avoiding prescribing errors: a systematic approach

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10.14219/jada.archive.1996.0274 1996;127(5):617-623 JADA CL Marek approach Avoiding prescribing errors: a systematic jada.ada.org (this information is current as of December 4, 2014): The following resources related to this article are available online at http://jada.ada.org/content/127/5/617 in the online version of this article at: including high-resolution figures, can be found Updated information and services http://jada.ada.org/cgi/collection/practice_management Practice Management : subject collections This article appears in the following http://www.ada.org/990.aspx this article in whole or in part can be found at: of this article or about permission to reproduce reprints Information about obtaining are not endorsed by the ADA. prohibited without prior written permission of the American Dental Association. The sponsor and its products Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly on December 4, 2014 jada.ada.org Downloaded from on December 4, 2014 jada.ada.org Downloaded from

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Page 1: AVOIDING PRESCRIBING ERRORS: A SYSTEMATIC APPROACH

10.14219/jada.archive.1996.02741996;127(5):617-623JADA

CL MarekapproachAvoiding prescribing errors: a systematic

jada.ada.org (this information is current as of December 4, 2014):The following resources related to this article are available online at

http://jada.ada.org/content/127/5/617in the online version of this article at:

including high-resolution figures, can be foundUpdated information and services

http://jada.ada.org/cgi/collection/practice_managementPractice Management : subject collectionsThis article appears in the following

http://www.ada.org/990.aspxthis article in whole or in part can be found at: of this article or about permission to reproducereprintsInformation about obtaining

are not endorsed by the ADA. prohibited without prior written permission of the American Dental Association. The sponsor and its products

Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly

on December 4, 2014jada.ada.orgDownloaded from on December 4, 2014jada.ada.orgDownloaded from

Page 2: AVOIDING PRESCRIBING ERRORS: A SYSTEMATIC APPROACH

ARTICLE 2

AVOIDING PRESCRIBING ERRORS:A SYSTEMATIC APPROACHCINDY L. MAREK, R.PH., PHARM.D. CANDIDATE

With the number of prescription

and over-the-counter drugs grow-

ing every year, health profes-

sionals who write prescriptions

need to be particularly cautious

to avoid mishaps. The author

outlines eight pitfalls commonly

encountered when writing pre-

scriptions and urges dentists to

adopt a systematic approach

when prescribing medications.

ost dentists are very knowledgeable about the contraindica-tions, interactions and adverse effects of the medications that com-pose their own therapeutic arsenals. However, with the myriad ofdrugs available over the counter and by prescription, it is extremelydifficult for dental prescribers to be aware of every medication'spharmacological profile.When prescribing, practitioners often risk overlooking some de-

tail that may result in suboptimal treatment. At best, these pre-scribing errors may be an inconvenience to the patient. At worst,poor prescriber judgment may result in significant patient morbid-ity, or even mortality, and can damage the doctor-patient relation-ship, possibly to the point of litigation.

Health care providers are now charged by third-party payers,legislators and the public with the responsibility of maximizing pos-itive patient outcomes. At a conference on pharmaceutical care,Gerbino noted that, in today's litigious society, "thou shalt do noharm" has been replaced by "thou shalt be complete."' An importantaspect of this enhanced standard of care is the drive to improve theoverall quality of medication use. Practitioners now are expected touse medical history, concomitant disease states and other patient-specific factors when making pharmacotherapeutic decisions.

This article is intended to provide clinicians with a relativelysimple, systematic approach to establishing treatment regimensthat will allow for detection and avoidance of prescribing errors.

DRUG-RELATED PROBLEEMS

All medications, including over-the-counter products, have the po-tential to cause adverse events, the severity of which varies accord-ing to patient- and drug-specific factors. People with asthma whoare allergic to aspirin, for example, may experience an acute bron-chospasm after ingesting nonsteroidal anti-inflammatory agents,such as ibuprofen (Motrin, The Upjohn Co.). Prescribing ketoconazole

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(Nizoral, Janssen Pharmaceu-tica, Inc.) or erythromycin to pa-tients who take terfenadine (Sel-dane, Marion Merrell Dow, Inc.)may result in life-threateningventricular arrhythmias. Pa-tients who take carbamazepine(Tegretol, Basel Pharmaceu-ticals), primarily prescribed tocontrol epileptic seizures, mayexperience nausea, vomiting andcardiac dysrhythmias while re-ceiving a course of erythromycinfor an odontogenic infection.2

In 1993, antimicrobials andanalgesics were named in nearly40 percent ofthe adverse drug re-actions reported by the AmericanAssociation ofPoison ControlCenter's Toxic Exposure System.3Drugs from these two therapeuticclasses are among those pre-scribed most often by dentists.

In the past, discussions of ad-verse drug reactions primarilyfocused on drug-drug interac-tions, allergic reactions and in-adequate monitoring of medica-tions that have narrow thera-peutic windows. While adversereactions such as these are im-portant contributors to poortreatment outcomes, they com-prise only some of the potentialcomplications that can arise inpharmacotherapy.

In 1990, Strand and col-

leagues identified eight majordrug-related problems encoun-tered when prescribing medica-tions.4 By definition, a drug-related problem exists when apatient experiences or is likelyto experience a medical condi-tion having a possible relation-ship with drug therapy (Box).4

This article will review each ofthe medication-related problemsconceptualized by Strand and col-leagues, with emphasis on pre-venting prescribing errors occa-sionally seen in clinical dentistry.Suggestions ofhow to avoid drugerrors and improve treatmentoutcomes also will be offered.By understanding and keep-

ing in mind these eight drug-related problems, practitionerscan raise the standard of pa-tient care in their dental prac-tices and avoid both the legaland medical ramifications of in-correct prescribing (Table).

UNTREATEDINDICATIONS

The patient has a medical condi-tion that requires drug therapy,but the patient is not receivingmedication for that condition.

In clinical practice, this prob-lem often occurs in the context ofantibiotic premedication. A pa-tient may have a congenital or

newly acquired condition that re-quires premedication, but thepractitioner does not prescribean antibiotic before performingan invasive procedure. To avoidthis potentially serious oversight,update each patient's health histo-ry frequently, thoroughly question-ing the patient about his or herpast and recent medical history.

Treatment of odontogenic in-fections also creates opportuni-ties for this problem to develop.A newly developed intraoral ab-scess often contains a mixture ofaerobic and anaerobic microbes.5Usually, these infections will re-spond to penicillin VK. In somecases, however, penicillin maybecome less effective as the in-fection progresses and theanaerobic bacteria (such as bac-terioides, fusobacteria) begin topredominate at the foci.5(p75' Totarget these microbes, dentistscan prescribe metronidazole(500 milligrams taken orallythree times a day) in addition tothe penicillin. Metronidazole-penicillin therapy can be espe-cially helpful for patients whoare at increased risk of antibiot-ic-associated colitis. This combi-nation also is a successful alter-native to clindamycin therapy,which typically is prescribed forsevere odontogenic infections.

IMPROPER DRUGSELECTION

The patient has a condition forwhich the incorrect drug hasbeen prescribed (this includesprescribing an expensive drugwhen a less costly alternativewould be equally effective).

Situations in which thisdrug-related problem is of con-cern include- prescribing a fluoroquinoloneor tetracycline derivative to ayoung child or a pregnant pa-tient;

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TABLE

- giving naproxen to a personwho has an aspirin allergy;- using doxycycline to treat os-teomyelitis.

The complications that canarise from such improper drug

selection are common knowl-edge, and yet such oversightscontinue to occur. Before pre-scribing any medication, healthcare providers should check tobe sure that they have not over-

looked the obvious. The medi-cation prescribed should be ap-propriate given the patient's di-agnosis, age and allergy status.The practitioner must verifythat the patient is not pregnant

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before prescribing any medica-tions that could cause terato-genic effects.A less obvious but clinically

significant issue arises whenpractitioners prescribe one drugwhen a lower-priced alternativeexists. For example, appropriate-ly prescribed antimicrobial com-binations can be cost-effective. Aregimen of metronidazole com-bined with penicillin VK is aboutone-sixth the price of an equiva-lent course of clindamycin.

Practitioners also must en-sure that they are prescribingthe most efficacious medicationavailable. For example, a bacte-riostatic antibiotic is not the op-timal choice when treating a pa-tient who has poorly controlleddiabetes. Likewise, using tetra-cyclines to premedicate a pa-tient at risk of infective endo-carditis6 or prescribing a third-generation oral cephalosporin totreat a typical odontogenic in-fection does not meet the stan-dard of care in either situation.A common error in clinical

practice is to ignore an unfa-miliar medication. New drugscontinually are being developedand approved for use. To keepup with available options, pre-scribers must have access to up-dated drug references. Ideally,these texts should include infor-mation about both over-the-counter medications and pre-scription drug products.

Clinicians who keep abreastof the primary literature, be-come familiar with new medica-tions and factor cost into the se-lection of pharmacotherapeuticregimens for their patients willbe best equipped to provide op-timal patient care.

SUBTHERAPEUTICDOSAGE

The patient has a medical con-

dition that is being managedwith an inadequate amount ofthe correct drug.

The optimal dosage and du-ration of therapy for most drugsused in clinical dentistry hasbeen well-defined. It is widelyaccepted, for example, thatantimicrobial regimens shouldcontinue at least 48 hours afterthe resolution of symptoms7-generally a minimum of sevento 10 days. Underdosing candelay the desired outcome, re-sulting in increased morbidity,unnecessary discomfort and pa-tient dissatisfaction.

To optimize pharmacothera-py, dental practitioners must befamiliar with the pharmacoki-netic properties of absorption,distribution, metabolism andexcretion of the medicationsthey prescribe. An infectionmay be unresponsive to thera-peutic regimens that fail toachieve the necessary drug con-centration at the infection site,even if the correct drug hasbeen prescribed.5'05 lo Acci-dently writing a penicillin pre-scription for "q.d." (every day)instead of "q.i.d." (four times aday) can have disastrous conse-quences for both the patientand the dentist.

Prescribing antibiotics forprophylaxis also poses the riskof administering a suboptimaldosage. In cases that requirepremedication, the practitionermust take care to correctly cal-culate the initial and follow-updoses of antibiotics. He or shealso must do the utmost to en-sure that the patient does nottake the medication at thewrong time. This typically re-quires explicit instructionsabout when to take the medica-tion. Instructions that read "sixhours later" are ambiguous andcan be interpreted by the pa-

tient to mean six hours afterthe scheduled appointment orsix hours after the appointmentis completed or even six hoursafter the patient returns home.Any of these interpretationsleads to the follow-up dosebeing ingested past the timewhen the antibiotic has themost benefit. According to theAmerican Heart Association6and American Dental Associa-tion8 standards, the patientshould be instructed to take thefollow-up dose "six hours afterfirst dose."

FAILURE TO RECEIVEDRUG

The patient has a medical prob-lem that is the result of not re-ceiving the intended drug.

Patients fail to receive medi-cations for a variety of reasons.Noncompliance may result frompatient misunderstanding, pov-erty or apathy. It is estimatedthat between 14 and 21 percentof all prescriptions written bypractitioners are never filled.9Good communication betweenthe dentist and the patient canhelp to identify and eliminatepotential compliance problems.

It is necessary for health carepractitioners to explain the pur-pose of the prescription to elicitpatient compliance. This be-comes especially importantwhen antibiotics are prescribedfor prophylaxis. I have spokenwith many patients who do notunderstand the relationship be-tween dental procedures and"heart infections" and, as a con-sequence, they often view pre-medication as an unnecessaryinconvenience and expense.

In addition to providing pa-tient education about pre-scribed drug regimens, it is im-portant that practitioners besensitive to cost issues and the

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impact they can have on patientcompliance. It is not unusual fora patient to present a prescrip-tion to the pharmacist, only tofind that he or she cannot affordto pay for the medication. Thissituation often occurs at a timewhen the writer of the prescrip-tion cannot be contacted to rec-ommend a less expensive alter-native.

For example, minocycline isroughly 10 times the price ofdoxycycline, yet offers no thera-peutic advantage in dentistry.2'10For uncomplicated odontogenicinfections, a 10-day course ofamoxicillin and clavulanatepotassium (Augmentin, Smith-Kline Beecham Pharmaceu-ticals), 500 mg, is priced at about$80, while an equivalent regi-men of penicillin VK will usuallycost the patient less than $10.10

Successful drug therapy alsohinges on the practitioner'sknowledge of the pharmacoki-netic principles of drug absorp-tion, distribution, metabolismand excretion. In addition to un-derstanding the properties ofthe medications they prescribe,dentists also must understandthe potential of other drugs toimpair therapy. Medicationslike H2-antagonists (Zantac,Glaxo Pharmaceuticals; Taga-met, SmithKline BeechamPharmaceuticals; Pepcid, Merck& Co., Inc.), antacids and pro-ton-pump inhibitors (Prilosec,Astra Merck Group; Prevacid,TAP Pharm) raise the pH of thegastric secretions and inhibitabsorption of oral ketoconazole(Nizoral). Ketoconazole tabletsmust have an acidic gastric en-vironment, or a low pH, to facil-itate tablet dissolution and sys-temic absorption. Clorazepate, abenzodiazepine often prescribedfor anxiety, must be hydrolyzedin acidic media to form the ac-

tive derivative, N-desmethyld-iazepam.2 In both instances,therapeutic failure may resultin patients who are taking medi-cations that raise gastric pH lev-els, even though they took theketoconazole or chlorazepate asinstructed.

EXCESS OF CORRECTDRUG

The patient has a medical con-dition that is being treated withan excess of the correct drug.

Drug accumulation can pro-duce toxic complications andtypically is a problem when thedrug dose or dosing interval isnot adjusted in the presence of

It is important thatpractitioners be sen-sitive to cost issuesand the impact theycan have on patientcompliance.

metabolic or excretory organdysfunction.

The total daily dosage of an-tibiotics such as tetracycline,amoxicillin and ampicillin mustbe adjusted downward in pa-tients who have renal failure.2 Itis important to remember thatthe degree of renal failure is notalways measurable by creati-nine clearance values alone.Dentists should consult with thepatient's nephrologist when pre-scribing medications to a patientwith significant renal disease.New guidelines regarding

acetaminophen use have beenpublished after the lay press re-ported several deaths secondaryto Tylenol (McNeil ConsumerProducts Co.) ingestion.2 Aceta-minophen in doses greater than140 mg/kilogram is considered

hepatotoxic in all patients.Patients who consume largeamounts of alcohol experience ahigher incidence of acetamin-ophen-induced hepatotoxicity.2Prescribers must decrease totaldaily doses of acetaminophen orchoose another analgesic for pa-tients at risk for hepatotoxicity,such as those who have a historyof alcohol abuse or those who aretaking hepatic enzyme inducersor other hepatotoxic medica-tions. The practitioner alsoshould be mindful of the amountof acetaminophen contained incommonly used acetaminophen-narcotic combinations.

The dosage of highly lipo-philic or highly protein-bounddrugs also must be reduced inthe elderly to avoid possibleoverdosage. With age comes apredictable decline in both renaland hepatic function necessitat-ing a reduced dosage of antibi-otics and analgesics.11 Prescrip-tions should never exceed thetotal recommended daily dosefor any patient, and practition-ers must be cognizant of theage-related drug distributionchanges in the elderly.

Clinicians also must use carewhen prescribing medicationsfor pediatric patients. Drug ref-erences generally provide pedi-atric doses in terms of eithermilligram per kilogram perdose or milligram per kilogramper day. Practitioners must becareful to correctly convertpound weight to kilogramweight by dividing the weightexpressed in pounds by 2.2.Overdosage also can occurwhen the prescriber uses themilligram per kilogram per dayamount as the "per-dose"amount, which results in thepatient receiving the recom-mended total daily dose at eachdosing interval.

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ICLINICA[ PAACIIC

ADVERSE DRUGREACTION

The patient has a medical con-dition that is the result ofeithera dose-related or idiosyncraticadverse drug reaction.

Not all adverse drug reac-tions are preventable. Patientssuddenly may develop a rashwhen taking penicillin or experi-ence acute gastrointestinal dis-tress after taking a prophylacticregimen of erythromycin or anarcotic-containing analgesic.

Taking a thorough patienthealth and medication historycan sometimes prevent theseadverse effects. Certain non-steroidal anti-inflammatorydrugs, such as ibuprofen andnaproxen sodium, are less likelyto cause gastrointestinal dis-tress than aspirin.12 Hydroco-done is less likely to producevomiting than codeine and maybe better tolerated by patientswith a history of gastrointesti-nal intolerance to codeine."3

INTERACTIONS

The patient has a medical con-dition resulting from a drug-drug, drug-food, drug-disease ordrug-laboratory interaction.

Whenever patients are tak-ing two or more prescriptions orover-the-counter medications,the potential exists for a drug-drug interaction. While most in-teractions are mild to moderate,a small percentage are seriousor life-threatening. In the caseof drug interactions, a good of-fense is often the best defense.Health care providers shouldassume that the potential for aninteraction exists until provenotherwise.

Because new drug interac-tions are constantly beingdiscovered, a complete, comp-arative, comprehensive andup-to-date drug reference is in-

valuable in the clinical practicesetting. The USP Drug Infor-mation for the Health CareProfessional (Vol. 1) is pub-lished annually, with informa-tion updates available everymonth from the publishers, andis an excellent drug referencefor both general practitionersand specialists.2 This hardcovertext provides complete prescrib-

Patient selftreatmentand the pessibity ofsubstance abuse arefactors that must beconsidered whenissuing prescriptionsto patients.

ing information for both over-the-counter and prescriptionmedications as well as a uniquedental precaution section fordrugs that exhibit intraoral sideeffects or have an impact ondental management.

While drug-drug interactionsare commonly recognized as amedication-related problem, it isimportant to remember thatpharmaceutical products interactwith everything ingested by thepatient-not just with each other.A commonly cited drug-food

reaction is the chelation oftetracycline by dairy products.This chemical reaction with di-valent and trivalent cations pre-sent in dairy products, iron sup-plements and antacids renderthe drug unabsorbable by theintestinal mucosa."

Numerous medications, in-cluding benzodiazepines andnarcotics, interact with alcohol.Metronidazole is a useful anaer-obic antimicrobial agent that isstructurally similar to disulfi-ram (Antabuse, Wyeth-Ayerst

Laboratories), a drug used totreat alcoholism. Both thesemedications can produce severegastric distress, vomiting andhypotension when ingested withethanol.2"2

Dentists should be aware ofthe possible food-drug interac-tions of the pharmaceuticalsthey prescribe and should coun-sel patients to avoid ingestingfoods or beverages that maycause untoward effects whiletaking a medication.Many diseases alter drug

absorption, metabolism and ex-cretion. Patients who have ad-vanced HIV infection, short-bowel syndrome, gastroparesisor other diseases have difficultyabsorbing oral medications.Pulmonary, renal or hepatic dis-eases may interfere with themetabolization or excretion ofdrugs dependent on the involvedorgans for biotransformation.

While rarely a problem indental practice, drug-laboratoryinteractions can adversely af-fect medical therapy. Somemedications can skew the re-sults of laboratory tests; conse-quently, prescribers may incor-rectly initiate or alter therapy.For example, penicillins, ceph-alosporins and salicylates caninterfere with urine glucosetesting by detecting falsely ele-vated glucose levels.2

NO VALID INDICATION

Patient is taking a medicationfor no valid medical condition.

This category, also termedclinical abuse or misuse, in-cludes prescribed and over-the-counter medications as well asillegal substances of abuse.Patient self-treatment and thepossibility of substance abuseare factors that must be consid-ered when issuing prescriptionsto patients.

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A patient with a history ofsub-stance abuse should not be rou-tinely prescribed narcotics or ben-zodiazepines. The risk forrecidivism and drug-seeking be-havior generally precludes the useofthese centrally acting agents.

This drug-related problemalso can result when a patientdevelops symptoms after begin-ning a new medication regimen.Before changing the treatment,the prescriber first should ver-ify that a given complaint canbe attributed to the medication.

For example, laboratory testsshould be used to confirm anti-biotic-associated colitis beforeoral vancomycin is prescribedfor a patient who develops diar-rhea while taking clindamycinor any other antibiotic. Whilestool analysis may show thepresence of Clostridium difficile,the gold standard of diagnosis ispositive confirmation of an endo-toxin.14 Clinicians also shouldnote that with the advent ofvancomycin-resistant enterococ-ci, oral vancomycin has been re-placed by metronidazole as thedrug of choice in the treatmentof antibiotic-associated colitis.'4

Practitioners have both alegal and ethical responsibilityto prescribe drugs wisely, tak-ing into consideration individu-al patient history and thorough-ly evaluating any complaintfollowing treatment.

CONCLUSION

The categorization of drug-re-lated problems outlined in thisarticle is designed to help den-tal professionals develop a stan-dard of patient care that em-phasizes the prevention ofprescribing errors. In addition,the following suggestions willhelp the dentist apply theseconcepts to daily practice:- mentally review each of theeight drug-related problems be-fore issuing a prescription;- update the patient's medicaland drug history with eachvisit;- call the patient's physician orpharmacist when the patient isunsure of medications, dosagesor disease states;- encourage patients to carry awallet card listing the nameand dosage regimen of all theirmedications;- specifically question patientsabout use of over-the-counterand homeopathic remedies;- interact with pharmacists.These professionals have up-to-date information on all aspectsof drug therapy, including newproducts, drug interactions, dos-ing regimens and medicationcosts. This information will helpdental practitioners choose pa-tient-specific drug therapy,which will result in more posi-tive treatment outcomes. .

Ms. Marek is a clinical pharmacist, Uni-versity of Iowa College of Dentistry, and apharmaceutical doctoral candidate, Universityof Iowa College of Pharmacy, 306 DentalScience Building S, Iowa City, Iowa. 52242-1001. Address reprint requests to Ms. Marek.

1. Gerbino PP. The pharmacist's vital role:prevent drug misadventuring. Rutgers Uni-versity 40th annual conference pharmaceuti-cal care and patient outcomes: a model forchange. U.S. Pharmacist (hospital ed.)1991;16(11):58-68.

2. USP drug information for the health careprofessional. Vol. 1. 15th ed. Rockville, Md.:United States Pharmacopeial Convention,Inc.; 1995:646.

3. Pal S. Six drug classes cause most ADRs.U.S. Pharmacist (hospital ed.) 1995;20(5):16.

4. Strand LM, Morley PC, Cipolle RJ, Ram-sey R, Lamsam GD. Drug-related problems:their structure and function. DICP AnnPharmacother 1990;24:1903-7.

5. Topazian RG, Goldberg MH. Oral andmaxillofacial infections. 3rd ed. Philadelphia:Saunders;1994:75-110.

6. Dajani AS, Bisno AL, Chung KJ, et al.Prevention of bacterial endocarditis recom-mendations by the American Heart Associa-tion. JAMA 1990;264:2919-22.

7. Baker KA, Fotos PG. The management ofodontogenic infections: a rationale for appro-priate chemotherapy. Dent Clin North Am1994;38:689-706.

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9. Feldman JA, DeTullio PE. Medicationnoncompliance: an issue to consider in thedrug selection process. Hosp Forum 1994;29(3):204-11.

10. Denniston PL, Denniston PW, eds. 1994Physicians Gen Rx. Smithtown, N.Y.: DataPharnaceutica Inc.; 1994.

11. Wade VVE. Managing dosage alterationneeds in the elderly. Clinical Consult (clinicalnewsletter of the American Society ofConsultant Pharmacists) 1992;11(10):2.

12. Olin BR, ed. Drug facts and compar-isons. St. Louis: Facts and Comparisons Inc.;1995;251f, 248c.

13. Turturro MA, Paris PM, Yealy DM,Menegazzi JJ. Hydrocodone versus codeine inacute musculoskeletal pain. Ann Emerg Med1991;20:1100-3.

14. Reinke CM, Messick CR. Update onClostridium difficile-induced colitis, part 2.Am J Hosp Pharm 1994;51:1892-901.

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