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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 71-77

Quantifying variation in blood pressure measurement through different arm cuffs and estimating its impact on diagnosis of hypertension at community level


1 Department of Community Medicine, R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India
2 Department of Dentistry, R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India
3 Department of Community Medicine and Hospital Records, R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India

Date of Submission09-Nov-2016
Date of Acceptance28-Dec-2016
Date of Web Publication15-Jun-2017

Correspondence Address:
Badrinarayan Mishra
Department of Community Medicine, R. D. Gardi Medical College, Surasa, Agar Road, Ujjain - 456 006, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.208121

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  Abstract 

Aims: The aim of this study was to analyze does the difference in blood pressure (BP) measured by different arm cuffs has a clinical/diagnostic implication? Settings and Design: This study was a cross-sectional evaluation of sample rural population from Central India. Materials and Methods: Three different adult arm cuffs were used on a selected 394 rural population from 35 to 65 years age group to estimate BP. Their BP was taken on three different times of the day on three different occasions/days. Statistical Analysis: Basic sociodemographic profiles were expressed in frequency and percentages; relationships of hypertension (HTN) with sociodemographic and other risk factors were calculated by Chi-square test; variability in BP by different arm cuffs was expressed by mean, standard deviations, and ANOVA; and prevalence difference of HTN by different arm cuffs was expressed by frequency, percentage, paired t- test, and Chi-square test. Results and Conclusions: The routinely used small adult cuff was found appropriate in only 3.8% of cases studied, thereby highlighting the prevalence of under cuffing at 96.2%. The mean variation in systolic and diastolic BP recorded by using small adult arm cuff vs. medium arm cuff and small arm cuff vs. large arm cuffs were 5.9mm Hg/4.4mm Hg and 9mmHg/7.2mmHg respectively. These observations were both clinically and statistically significant. Our study reported an overestimation of 4.8% systolic and 15% diastolic HTN by the exclusive use of small adult arm cuff. The prevalence of systolic, diastolic, and both systolic and diastolic HTN in selected age group using the correct arm cuff was found to be 20.8%, 29.6%, and 37.5%, respectively. Thus, arm cuff mismatch was a prevalent cause in misdiagnosis of primary HTN in our study population.

Keywords: Arm cuffs, hypertension, miscuffing


How to cite this article:
Mishra B, Sinha ND, Ur Rehman H. Quantifying variation in blood pressure measurement through different arm cuffs and estimating its impact on diagnosis of hypertension at community level. J Health Res Rev 2017;4:71-7

How to cite this URL:
Mishra B, Sinha ND, Ur Rehman H. Quantifying variation in blood pressure measurement through different arm cuffs and estimating its impact on diagnosis of hypertension at community level. J Health Res Rev [serial online] 2017 [cited 2019 Dec 9];4:71-7. Available from: http://www.jhrr.org/text.asp?2017/4/2/71/208121




  Introduction Top


Hypertension (HTN) which has become an increasingly common health issue worldwide is as prevalent in developing countries as in developed ones. It is a major risk factor for heart attacks and strokes. Approximately 62% of cerebrovascular disease and 49% of ischemic heart disease are attributable to uncontrolled blood pressure (BP).[1] BP measurement is the basis for the diagnosis, management, treatment, epidemiology, and research of HTN. An accurate measurement is central to the success of all these activities.[2]

Recognizing the significance of this issue, the WHO on December 3, 2003, convened a meeting of experts regarding specifications for accurate and affordable BP monitoring devices (BPMDs). The expert committee stated that regardless of the type of BPMDs, appropriate cuff size is a prerequisite of accurate BP measurement.[1]

To obtain accurate BP reading, the cuff bladder should be at least as long as 80% of the middle of the upper arm and at least 40% of its width. Thus, the length-to-width ratio is 2:1 which is ideal, but a ratio >1.8:1 is considered feasible for BPMDs.[3],[4],[5] This means that thee cuff size will vary depending on the arm circumference. Hence, there is no universal cuff size which can fit to all. Unfortunately, adherence to these specifications is routinely flouted.


  Materials and Methods Top


Aims

The reported study aimed at evaluating the true prevalence of the fallacy component arising out of arm cuff noncompliance and its impact on estimation of HTN.

Objectives

The prime objective was to estimate the true prevalence of HTN in general adult population at community level in rural India.

A couple of secondary objective which was explored in support of the primary one was as follows:

  1. To estimate the prevalence of miscuffing in relation to general adult community-based population
  2. The contribution of miscuffing in over and under diagnosis of HTN at community level
  3. To associate HTN with different risk factors
  4. To recommend appropriate monitoring method and instrumentation for BP measurement.


A cross-sectional study targeting the rural community was carried out from May 1 to July 30, 2012, in village Belakhadi of district Ujjain in the state of Madhya Pradesh in Central India. The target population was 35–65 years, the age at which most cases of primary HTNs are diagnosed. Thus, the participants were adults from the age group of 35–65 years from village Belakhadi who were found suitable as per the inclusion criteria.

Inclusion criteria

Permanent residents of village Belakhadi between 35 and 65 years of age of both sexes who gave valid informed written consent and were available at the time of visit for survey were included for the study purpose.

Exclusion criteria

People outside the age range, with mental disorders, serious illness, outstation on day of visits, and females at advanced pregnancy were kept out of the study.

An all-inclusive approach was adopted to select the sample individuals who gave valid informed written consent and found suitable for participation as per the inclusion guidelines.

Village Belakhadi had 246 households with a total population of 1236, consisting of 625 males and 611 females.[6] The expected population of study participants, i.e., from 35 to 65 years of age was estimated to reach 433 (35% of total population).[7]

Considering a dropout rate of 10%, the actual adjusted sample size was 390. The adopted all-inclusive technique provided a sample of 394, on which the study was carried out.

BP was recorded from each participant at three different times on three different occasions using three different arm cuffs. Data collection activities were divided into three phases each running over a fortnight. During the 1st fortnight morning, the 2nd fortnight afternoon, and in the 3rd fortnight evening, BP was documented.

Mid-arm circumference of study participants was recorded to specify BPMDs arm cuff requirement. This was done by measuring the midpoint between the tip of the acromion process and tip of ulnar process on the right arm of study participants by a standardized measuring tape.

Resting BP was measured in the sitting position during morning, afternoon, and evening as per the sequence mentioned earlier using a mercury column sphygmomanometer (by auscultatory method) with each of the three standard arm cuffs. From each participant, a total of nine readings were obtained, i.e., three reading on three different times and three reading each time, one each by three different cuffs.

Instruments in use

Equipment employed in the study includes calibrated mercury sphygmomanometer, three different BP cuffs, and a standard sixteenth measuring tape; all bearing ISI mark.

Sphygmomanometer was checked for the adequacy of calibration, i.e., resting level of the mercury meniscus at zero level and nonleaking of attachments such as valves, arm cuff, and manual pump.

The three different arm cuffs which were used in our study were small adult (12 cm × 22 cm), adult size (16 cm × 30 cm), and large adult (16 cm × 36 cm) against their respective arm size at 22–26 cm, 27–34 cm, and 35–44 cm.[8]

Besides this, additional information on different risk factors and demographic profiles of participants were also collected.

Statistical analysis

Basic sociodemographic profiles were expressed in frequency and percentages; relationships of HTN with sociodemographic and other risk factors were calculated by Chi-square test; variability in BP by different arm cuffs was expressed by mean, standard deviations, and ANOVA; and prevalence difference of HTN by different arm cuffs was expressed by frequency, percentage, paired t-test, and Chi-square test.

Clinical significance was considered for a change in BP ≥3 mm of Hg and statistical significance was fixed at a customary P<0.05.[9],[10],[11],[12]


  Results Top


The numbers of male and female participants were head-over-heel at 194 and 199, respectively. The trend of participants across different age groups was in accordance with the existing demographic structure, showing maximum representation(41.9%) in 35–45 age group and then gradually declining through (30.7%) in 46–55 age group and (27.4%) in 56–65 age category.[7] Married persons and persons from Hindu community dominated the studied population. Socioeconomic status “I” means the highest class whereas “V” means the lowest. As the result reflects, population under the study was mainly from middle and lower social strata.

The laborer class demonstrated the lowest prevalence of HTN and an across the group comparison observed a highly significant increase in prevalence when compared with the laborer group (P < 0.00). While HTN prevalence steadily and very significantly increased with increasing age, surprisingly, females showed higher and significant increase in the prevalence of HTN as compared to males (P < 0.05). On the basis of religion, Muslims had lowest prevalence and the difference in prevalence in different religious categories was found to be highly significant (P < 0.00).

Unmarried participants being from the younger age groups were found to have the lowest prevalence, the prevalence increased steadily and very significantly as we move across divorced, married, and widowed categories (P < 0.00).

Low prevalence of HTN was observed in participants with extremes of educational status, i.e. among graduates and illiterates as compared to persons from midlevel. These observations were also statistically highly significant (P < 0.00). Similar observations were reported across different SE groups.[13] Low HTN prevalence was reported in Class I and V whereas middle class showed significantly high prevalence of HTN (P < 0.00). These observations are presented in [Table 1].
Table 1: Association between socio-demographic profiles and hypertension

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The common and established risk factors such as family history, body mass index (BMI), physical activity, sleep, dietary intake, and addiction to alcohol and tobacco were assessed and their association with HTN is presented in [Table 2].
Table 2: Hypertension and associated risk Factors

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HTN was found in 148 (37.5%) study participants. Out of these 148 hypertensives, 128 had positive family history. The association of positive family history with HTN was found statistically significant (P<0.05).

There were approximately equal number of vegetarians and nonvegetarians in this study, i.e., 195 and 199 participants, respectively. However, prevalence of HTN was significantly higher among vegetarians as compared to nonvegetarians (P<0.05).

History of addiction was present in 157 persons. The addiction criteria were tobacco chewing, smoking, alcohol, and their combinations. However, HTN was noticed in significantly high number among nonaddicts (P<0.00).

Out of the 394 participants, 124 were into sedentary, 193 into moderate, and 77 into heavy physical activity groups. HTN was noted in significantly low number among heavy workers (P<0.00).

Out of 394 participants, 262 said that they had sound sleep during night. The sound sleepers had a very significant low prevalence of HTN as compared to persons with disturbed sleep (P<0.00).

According to BMI the study participants were divided into 4 groups, i.e., lean (<18), normal (18–25), preobese (25–30), and obese (>30) and their respective numbers from each categories were 24, 164, 155, and 51. Increase in BMI range from lowest to highest demonstrated a highly significant shift in prevalence in HTN (P<0.00).

The common risk factors associated with HTN are presented in [Table 2].

A participant when measured for BP by different cuff sizes gave different readings for both systolic and diastolic BPs. The mean and standard deviation of differences between these measurements has been plotted in [Table 3].
Table 3: Mean blood pressure variability with different arm cuff sizes

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The difference of mean between the average of systolic BPs taken by small cuff during morning, afternoon, and evening with that of average systolic BPs taken by large cuff size during the same time frames came out to be 9.01. Diastolic BP difference between the same variables was 5.91.

A similar comparison between the values of small- and medium-sized cuff yielded the difference of mean between measurements of systolic BP at 5.91 and for diastolic at 4.35.

The recorded mean differences for all the measurements against the small adult cuff were above the clinical significance level of ≥3 mm of Hg.[9],[10],[11],[12]P value for [Table 3] using ANOVA test was reported at <0.001, thus making it statistically highly significant.

Small-sized adult cuff stated that 101 participants had systolic BP exceeding the cutoff level of 140 mm of Hg while medium-sized cuff included only 85 such participants in this category and the large-sized cuff reduced it further to 72 participants.

In case of diastolic BP, recordings over 100 mm of Hg were taken as cutoff for diastolic HTN.[12] The distribution of recordings above this cutoff level by different arm cuff sizes was 176 by small-sized cuff, 132 by medium cuff, and 104 for large cuff.

Analysis of these variants by paired t-test showed there was significant variation in number of cases detected with systolic HTN and highly significant variation in number of cases detected with diastolic HTN using different cuffs as evident by paired t-test [Table 4].
Table 4: Differences in prevalence in hypertension by different arm cuffs

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Only 15 (3.8%) out of 394 of the studied population were found suitable for the adult small arm cuff thereby yielding a miscuffing (under cuffing in this case) prevalence of 96.2%. If the correct arm cuff as determined by the individuals' mid-arm circumference was used, the prevalence of systolic and diastolic HTN would be 20.81% (n = 82) and 29.69% (n = 117), respectively. However, when this practice was flouted and the usual routine small adult cuff was used, we encountered the corresponding readings at an alarmingly higher level, i.e., 25.63% (n = 101) and 44.67% (n = 176), respectively (P =0.00). On the contrary, the reading by medium and large cuffs showed no significant differences (P at 0.34 and 0.45, respectively). These observations have been presented in [Table 5].
Table 5: Hypertension prevalence by recommended standard cuffs and reported errors by flouting this practice

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  Discussion Top


Summary of key findings

  • It was observed that the prevalence of HTN in female, nonaddicts, vegetarians, and Muslims was very significantly associated
  • Arm bladder cuff-mismatch, exclusively under cuffing, was reported in 98.2% of cases. Use of small adult arm cuff was associated with clinical and highly significant statistical overreporting of HTN.


Strengths and weakness of the study

Recording of BP at home ambiance by single trained observer in plain cloth was designed to comprehend apprehension and white coat effect. Multiple BP recordings by standardized single set of equipment on three different occasions on different dates and times were supposed to yield a fairly accurate recording.

We acknowledge sample size and sampling unit as a weakness. Although an all-inclusive sampling technique was adopted, it was limited to the population of a single village. A bigger population or even the same population but having representative samples from multiple villages could have been more scientific and idealistic.

The pandemicity of HTN is established beyond doubts, so also many of its contributing factors. Still research in differing conditions at regular intervals is necessary to affirm them or ascertain any variations.

An effort was made to explore few of these out in a challenging and naive surrounding. In rural India, especially from the Western part of central provinces, such type of studies is far and few. The populous of Malwa region of West-Central India where the concluded study was carried out has documented anthropometric superiority.[14]

We observed some established factors getting affirmation, a couple of them getting challenged, and some new observations being made.

The sociodemographic factors getting affirmation were age, marital status, socioeconomic status, education, and occupation. Significantly increased prevalence of HTN with these factors is well supported by literature.[1],[15],[16]

Among different risk factors, positive family history, level of physical activities, BMI, and duration of sleep were observed to be strongly associated with HTN. Similar observations relating to risk factor were reported by other sources.[1],[15],[16]

Sociodemographic factor getting challenged was significantly high association of HTN with female sex. Most studies associate male with HTN than females.[1],[15],[16] This observation could be attributed to social customs such as veil system, consumption of high-fat diet, imposed restriction on female from outdoor activities thereby making them sedentary, and easy going carefree attitude of males that puts female to additional psychological stress in managing their home needs further probing.[17],[18],[19]

The new observation that was encountered was significantly high prevalence of HTN in Muslim community. As to our knowledge, no other Indian studies have put Muslims at the receiving end. It might be associated with high consumption of fat and meat.[17],[18],[19] This hypothesis needs further testing.

In the risk factor category, surprisingly, vegetarians and nonaddicts showed significantly increased prevalence. High prevalence in vegetarians could be due to increased consumption of oils and fats especially saturated fat as their diet is dominated by deep fried items and generous use of butter.[19] Decreased prevalence in addicts is a point to ponder.

The main focus of the study was to evaluate the prevalence of miscuffing and its contribution or erroneous BP reading.

It was observed that routinely used small adult cuff (in fact it is the only arm cuff provided as standard practice with all varieties of indirect PBMD in India) to be appropriate in only 3.8% of cases studied, thereby highlighting the prevalence of under cuffing at 96.2%. Many studies have reported high prevalence of miscuffing with great variability ranging from 30% to 67% or further higher.[2],[20],[21],[22],[23],[24] Most of these studies had taken hospital-based population as participants. The staggeringly high prevalence in our study might be due to its apparently healthy population drawn directly from a single village with similar customs, beliefs, dietary habits, and genetic composition.

Routine use of adult small arm cuff was observed to contribute to clinically significant overestimation of BP [Table 3]. Similar observations were reported by many other researchers.[3], 4, [9],[10],[11]

If the correct arm cuff as determined by the individuals mid-arm circumference was used, the general prevalence of HTN in the age specified population was 37.5% and systolic and diastolic HTN in particular was 20.81% (n = 82) and 29.69% (n = 117), respectively. These observations also found support from other studies.[3],[4],[9],[10],[11],[20],[21],[22],[23],[24],[25]

The difference in prevalence detected by routine small adult cuff and the other two cuffs was statistically very significant (P < 0.00), thereby putting them under scanner. When the same parameter was compared between the medium and large adult arm cuff, the reported difference became nonsignificant [Table 5]. We did not come across any reported research which had analyzed their information from this angle.

Recommendation

Indirect BPMDs are an important part of a doctor's routine practice and they are here to stay. Whatever may be their make and shape, all of them have a constant component, i.e., the arm cuff.

Studied literature points to wide and significant variability in arm cuff mismatch and its alarming consequences on indirect BP measurement. Even the mentioned dimensions on arm cuffs are not adhered to and most of them report a suboptimal length-to-width ratio (<1.8:1).[2] Hence, recommending a single arm cuff for all adults will be suicidal.

The results of the reported study further underline these issues and add to the pool of evidence in favor of discontinuation of the flatulent practice. As rightly pointed out by fellow researchers, it is high time to ensure an effective packaging of equipment with all available cuffs as a mandatory prerequisite and all relevant statutory bodies to enforce this.[2] Once the physicians have the options, definitely, they will be encouraged to use them.


  Conclusion Top


Arm bladder cuff mismatch; exclusively under cuffing was reported in 98.2% of cases. Use of small adult arm cuff was associated with clinical and highly significant statistical over reporting of HTN.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO; 2002.  Back to cited text no. 1
    
2.
Mishra B, Sinha ND, Gidwani H, Shukla SK, Kawatra A, Mehta S. Equipment errors: A prevalent cause for fallacy in blood pressure recording – A point prevalence estimate from an Indian health university. Indian J Community Med 2013;38:15-21.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Irving G, Holden J, Stevens R, McManus RJ. Which cuff should I use? Indirect blood pressure measurement for the diagnosis of hypertension in patients with obesity: A diagnostic accuracy review. BMJ Open 2016;6:e012429.  Back to cited text no. 3
    
4.
Oliveras Puig A, Dalfó-Pibernat A, Jdid Rosàs N, Mayor Isaac E, Pérez-Romero L, Gibert Llorach E, et al. Determination of arm circumference for correct measurement of blood pressure. Results of an intervention study. Hipertens Riesgo Vasc 2015;32:6-11.  Back to cited text no. 4
    
5.
Anast N, Olejniczak M, Ingrande J, Brock-Utne J. The impact of blood pressure cuff location on the accuracy of noninvasive blood pressure measurements in obese patients: An observational study. Can J Anaesth 2016;63:298-306.  Back to cited text no. 5
    
6.
Data from Demographic Surveillance Site for Palwa field practice area (2002 to 2015), mainlined at R D Gardi Medical College, Ujjain. Mp. India. [Unpublished Data].  Back to cited text no. 6
    
7.
Government of India. National Health Profile 2009. New Delhi: Ministry of Health and Family Welfare; 2010.  Back to cited text no. 7
    
8.
Smith L. New AHA recommendations for blood pressure measurement. Am Fam Physician 2005; 72:1391-8.  Back to cited text no. 8
    
9.
Lewis P, Naqvi S, Mandal P, Potluri P. LB03.04: Sphygmomanometer cuff construction and materials affect transmission of pressure from cuff to arterial wall. Finite element analysis of human pressure measurements and DICOM data. J Hypertens 2015;33 Suppl 1:e127.  Back to cited text no. 9
    
10.
Iyriboz Y, Hearon CM, Edwards K. Agreement between large and small cuffs in sphygmomanometry: A quantitative assessment. J Clin Monit 1994;10:127-33.  Back to cited text no. 10
    
11.
Ostchega Y, Hughes JP, Zhang G, Nwankwo T, Chiappa MM. Mean mid-arm circumference and blood pressure cuff sizes for U.S. adults: National Health and Nutrition Examination Survey, 1999-2010. Blood Press Monit 2013;18:138-43.  Back to cited text no. 11
    
12.
O'Brien E. Will mercury manometers soon be obsolete? J Hum Hypertens 1995;9:933-4.  Back to cited text no. 12
    
13.
Bairwa M, Rajput M, Sachdeva S. Modified Kuppuswamy's socioeconomic scale: Social researcher should include updated income criteria, 2012. Indian J Community Med 2013;38:185-6.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Ahmad SH. Anthropometric Measurements and Ethnic Affinities of the Bhil and Their Allied Groups of Malwa Area. London: Anthropological Survey of India; 1991.  Back to cited text no. 14
    
15.
Joffres MR, Hamet P, Rabkin SW, Gelskey D, Hogan K, Fodor G. Prevalence, control and awareness of high blood pressure among Canadian adults. Canadian Heart Health Surveys Research Group 1992;146:1997-2005.  Back to cited text no. 15
    
16.
Tolonen H, Koponen P, Naska A, Männistö S, Broda G, Palosaari T, et al. Challenges in standardization of blood pressure measurement at the population level. BMC Med Res Methodol 2015;15:33.  Back to cited text no. 16
    
17.
Malcolm SJ. A Memoir of Central India: Including Malwa, and Adjoining Provinces. Vol. 1. Parbury and Allen, Ny Public Library; 2015. p. 163-8.  Back to cited text no. 17
    
18.
Maheshwari G. Your Diet May Have An Answer for Cancer. The Tribune; 24 February, 2015.  Back to cited text no. 18
    
19.
Shanker MK. Caste and Ritual in a Malwa Village. The Journal of Asian Studies 1964;24:243-341.  Back to cited text no. 19
    
20.
Vinod CH, Misra BN, Kumthekar AA, Kawatra A. Calibration and cuffing issues concerning sphygmomanometer's in a tertiary health care centre. Indian J Prev Soc Med 2013;44:165-70.   Back to cited text no. 20
    
21.
Clark CE, Steele AM, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL. Interarm blood pressure difference in people with diabetes: Measurement and vascular and mortality implications: A cohort study. Diabetes Care 2014;37:1613-20.  Back to cited text no. 21
    
22.
Russell AE, Wing LM, Smith SA, Aylward PE, McRitchie RJ, Hassam RM, et al. Optimal size of cuff bladder for indirect measurement of arterial pressure in adults. J Hypertens 1989;7:607-13.  Back to cited text no. 22
    
23.
Pickering TG, Davidson K, Gerin W, Schwartz JE. Masked hypertension. Hypertension 2002;40:795-6.  Back to cited text no. 23
    
24.
Oliveira SM, Arcuri EA, Santos JL. Cuff width influence on blood pressure measurement during the pregnant-puerperal cycle. J Adv Nurs 2002;38:180-9.  Back to cited text no. 24
    
25.
O'Brien E, Petrie J, Littler W, de Swiet M, Padfield PL, Altman DG, et al. An outline of the revised British Hypertension Society protocol for the evaluation of blood pressure measuring devices. J Hypertens 1993;11:677-9.  Back to cited text no. 25
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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