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EBM PEARLS: Resuscitation of Preterm Neonates


EBM PEARLS: Resuscitation of Preterm Neonates

Dear all;
I wanted to participate in this festival with this case.. I want the discussion to be interactive between us.. so I would really appreciate your participations (especially guys from Research Group of Hakeem).. after all I'm still a beginner in these matters
I will be starting with a case scenario.. after that we will discuss what is the best research question and how can we search for the best evidence.. and after we have found it, we will start our apprasial.. deal??
okay then let's start with the case scenario:

You were in a Pediatric ICU elective.. while doing the usual work with the attending, you were called to attend an urgent C-section for a pregnant women in her 30 week gestation age.. you run to the OR and you are so excited.. the delivery is done and the preterm baby in not responding.. the attending started resuscitating the baby and got him to respond and you took him to the PICU… now during you observation you did not noticed what gas the attending used to resuscitate the baby.. You asked the attending if you should use Normal Room Air "as you read once" or 100% Oxygen "as you heard once" in your resuscitation, and he answers that you should look it up yourself if you really wanted it to stick to your brain.. Now you get soooooo eager to investigate this info using EBM…
Now the first step would be to put a question to use in your search.. what would the question be

??

A photo album only shows the happy memories, not the bad ones.. but in fact, these bad moments are the ones that take us from one happy snapshot to another

dr-dark angel's picture
by
السنة السادسة

I think the PICO could be:

P: preterm neonate, resuscitation
I: 100% oxygen
C: oxygen on room air
we can consider it as therapy --> we have to search in cochrane, but I'm not going to do that now because I'm not sure about the PICO Embarrased Rolling Eyes

thanks for the PEARL Eye-wink

Dr.TH's picture
Dr.TH

Go on Ayman ..
"حيو"Eye-wink
Green Wave's picture
Green Wave

Quote:
P: preterm neonate, resuscitation
I: 100% oxygen
C: oxygen on room air
O: More survival , Less complications

(preterm neonate)+ (resuscitation)+ (100% oxygen) vs (oxygen + room air)+(survival) + (complication*)

I'll start searching , then tell u what I need to change in my Q
Let's make a race Surprised Cool
dr.napoleon's picture
dr.napoleon
طالب دراسات عليا

Quote:
P: preterm neonate, resuscitation
I: 100% oxygen
C: oxygen on room air
O: More survival , Less complications

(preterm neonate)+ (resuscitation)+ (100% oxygen) vs (oxygen + room air)+(survival) + (complication*)

I'll start searching , then tell u what I need to change in my Q
Let's make a race Surprised Cool
dr.napoleon's picture
dr.napoleon
طالب دراسات عليا


فتت بالحيط مع السؤال المجعلك ..
لذلك جربت دور على كل topic لحال ..
بلشت ب preterm neonate ..طلعلي 1 review و 3 clinical trials .. بال Cochrane
2 من 3 بس بتتحدث عن استخدام الأوكسجين

Resuscitation of preterm neonates by using room air or 100% oxygen.
Wang CL, Anderson C, Leone TA, Rich W, Govindaswami B, Finer NN
2008

Room Air or Oxygen for Resuscitation of Preterm, Very Low Birthweight (VLBW) Neonates
Wang C
2007

ما لي مسجل بال Cochrane لذلك ما حطولي ال abstract .. فأخذت العناوين وبوشي على ال Google
وإذ >>>>>
http://www.medscape.com/viewarticle/584486 للأول
http://www.nature.com/jp/journal/v29/n8/full/jp200934a.html للثاني

رح نزل ملخص كل واحد وناقشو على حدى

تنويه: أكيد بعرف أنو المرحلة الثانية هي الاستعانة بال Pubmed ..بس سبحان الله ، البروكسي يلي حاطو فتح مليون موقع محجوب ،وسكر ال Pubmed Evil Shocked

dr.napoleon's picture
dr.napoleon
طالب دراسات عليا

Initiating delivery room stabilization/resuscitation in very low birth weight (VLBW) infants with an FiO2 less than 100% is feasible

Abstract
Background:
Oxygen exposure during delivery room (DR) resuscitation, even when brief, is potentially toxic. A practice plan (PP) was introduced for very low birth weight (VLBW) infants less than or equal to1500 g as follows: initial FiO2 from 0.21 to 1.0 using blenders, oxygen guided by oximetry to maintain saturation between 85% to 95% from birth.

Objective:
To determine whether the initiating FiO2 could be safely lowered, and by doing so whether the number of infants with a PaO2 >80 mm Hg could be minimized on admission, as well as lowering oxygen requirement at 24 h.

Methods:
In all, 53 infants admitted between June 2006 and June 2007 were evaluated and compared with 47 infants from 2004 managed with 100 % oxygen (historical comparison group (HC)).

Result:
Stabilization/Resuscitation included intubation (n=28) and continuous positive airway pressure (CPAP) (n=25); no cardiopulmonary resuscitation (CPR). The heart rate increased rapidly in all cases. The initiating FiO2 decreased from 0.42 to 0.28 over 12 months (P=0.00005); 14 (26%) were resuscitated with room air. Correspondingly, the pH increased from 7.24 to 7.30 (P=0.002) and PCO2 decreased from 53 to 41 (P=0.001). A comparison of infants during the PP with the HC revealed that 36/53 versus 21/47 had an initial PaO2 <80 mm Hg (P=0.02); the median PaO2, that is, 64 versus 86 and saturation, that is, 95% versus 99% on admission were significantly lower. The median FiO2 at 24 h was 0.25 versus 0.40.

Conclusion:
DR resuscitation of VLBW infants can be initiated with less oxygen even with room air without concomitant overt morbidity. This change was associated with more infants with an initial PaO2 <80 mm Hg and lower saturation values on admission as well as a lower FiO2 requirement at 24 h.
Keywords:

delivery room resuscitation, supplemental oxygen, room air, premature infants, pulse oximetry

منستنتج (بقراءة أولية وسطحية) انو الاثنين مثل بعضهم ،وأنو ما في مشكلة نبلش بoxygen on room air ، وجسب الحالة منرجع منتصرف ..

أما الثاني :

dr.napoleon's picture
dr.napoleon
طالب دراسات عليا


[

b]Resuscitation of Preterm Neonates by Using Room Air or 100% Oxygen
[/b]

لاحظوا أنو عنوان البحث يتطابق تماماً مع طلبنا Surprised (وبعد شوي منشوف أنو حتى العمر هو نفسو المطلوب)

Wang CL, Anderson C, Leone TA, Rich W, Govindaswami B, Finer NN
Pediatrics 2008;121:1083-1089
Summary
The authors note that previous studies have demonstrated that room air was effective in resuscitation of term newborns, and post-hoc analyses suggested that the benefit might extend to preterm newborns as well. The current standard of care is to resuscitate preterm newborns with oxygen; however, most clinicians set a goal of having the infant reach a targeted oxygen saturation percentage, rather than using a pre-set percentage of oxygen in the inhaled gas.

الشباب شافوا انو Room Air Oxygen منيح لل Term neonates وحابين يعرفوا إذا هالنتيجة الإيجابية رح تشمل الأولاد الأكثر عجلة بالخروج

The authors conducted a prospective, randomized study conducted at 2 California hospitals. The authors noted that healthy newborns have a slow increase in oxygen saturations, up to 90% by 5 minutes after birth, with preterm infants taking a median of 8 minutes to reach 90% saturation when not resuscitated. The authors randomized resuscitated preterm infants (from 23 to 31 weeks' gestation, inclusive) in this study, 1-to-1, to resuscitation by room air or by 100% oxygen. Pulse oximeter saturations were measured on each infant from 30 seconds of life onward.
In the group randomized to oxygen, the infants were resuscitated with 100% oxygen, and weaned if pulse oximeter saturations were ≥ 95% at 5 minutes of life. The other group was resuscitated with room air (21% oxygen). The concentration of oxygen was increased immediately to 100% if the infants required chest compressions or resuscitation medications or if they experienced low heart rates at predetermined cutoff time points.

The goals for the room air group were 70% saturation at 3 minutes and 85% at 5 minutes. If the infants were not at these goal saturations at the time cutoffs, the percent oxygen was increased in 25-percentage-point jumps. The analyses included 18 infants resuscitated with room air and 23 resuscitated with 100% oxygen.

In this study, all infants in the room air group required an increase in percent oxygen used for resuscitation before the 3-minute mark. In one third of these patients (n = 6), the oxygen concentration was increased directly to 100% due to low heart rates. Both groups reached the target heart rate of 100 beats per minute at the same time, however. The authors also evaluated several secondary outcomes and found no differences in rates of intraventricular hemorrhage, retinopathy, chronic lung disease, or necrotizing enterocolitis, with 1 subject death in each of the 2 groups.

The authors thought that their targeted saturations, 70% at 3 minutes and 85% at 5 minutes, were conservative and within margins of safety. The authors conclude, however, that they were unable to reach those targets when resuscitation was initiated with 21% oxygen or room air. They recommend that 21% oxygen should not be used for resuscitation of preterm infants outside of future clinical trials.
Viewpoint

The authors point out the limited sample size of this study, a fact that limits interpretation of the secondary outcomes more than the primary outcome. With 100% of room air infants failing to meet goals, one can feel better about the small sample size. However, given the severity of the side effects that may follow in preterm infants, a much larger trial would be needed to prove that the 21% oxygen concentration of room air did not result in worse outcomes.

بالأخير ، طلعت نتيجة معاكسة تماماً (خلينا نركز عالتاريخ ، وعلى تساؤل الباحثين استناداً على أبحاث شبيهة بالأول) ، ومو بس هيك ،كمان نصحوا بعدم استخدام Room air للإنعاش حتى بغير أبحاث ، مع لفت النظر أنو العينة كانت صغيرة ولا بد من تلافي هالنقطة بالأبحاث القادمة ..

آسف للعجقة ، بس حبيت حط كل شي صار معي من الألف إلى الياء ،وبالتفصيل الممل حتى يبين الخطوة الصح من الغلط ..

ترقبوا الحلقة الثانية من البحث في ال Pubmed بعد التخلص من البروكسي اللعين Evil (يلي طلعت روحي لدبرتو Laughing out loud )
Eye-wink

dr.napoleon's picture
dr.napoleon
طالب دراسات عليا


(preterm OR premature OR neonate OR birth) AND (resuscitation OR rehabilitation) AND (oxygen OR room air OR 100% oxygen)
أو
(preterm OR premature OR neonate OR birth) AND (resuscitation OR rehabilitation) AND (oxygen OR room air) AND (100% oxygen)

بعد إعداد هذا السؤال النموذجي (الذي لا يصنعه إلا معلمين Cool ) حصلت على ما يلي :

Question 1: is room air better than 100% oxygen for the resuscitation of the depressed full-term newborn?
http://www.ncbi.nlm.nih.gov/pubmed/20040687

Use of oxygen for resuscitation of the extremely low birth weight infant.
http://www.ncbi.nlm.nih.gov/pubmed/20100772
Pediatrics. 2010 Feb;125(2):389-91. Epub 2010 Jan 25. Shocked

[Air or oxygen for neonatal resuscitation at birth?]
http://www.ncbi.nlm.nih.gov/pubmed/19481912
Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full-term or near-term newborns. Results of recent meta-analysis of trials that compared ventilation with room air versus pure oxygen at birth suggest current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large-scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations.
2009 Aug;16(8):1194-201. Epub 2009 May 29.
Sad

Resuscitation of preterm neonates by using room air or 100% oxygen. Surprised
* Pediatrics. 2008 Jun;121(6):1257.
http://www.ncbi.nlm.nih.gov/pubmed/18519476
Abstract
OBJECTIVE: In this study of preterm neonates of <32 weeks Surprised , we prospectively compared the use of room air versus 100% oxygen as the initial resuscitation gas. METHODS: A 2-center, prospective, randomized, controlled trial of neonates with gestational ages of 23 to 32 weeks who required resuscitation was performed. The oxygen group was initially resuscitated with 100% oxygen, with decreases in the fraction of inspired oxygen after 5 minutes of life if pulse oxygen saturation was >95%. The room air group was initially resuscitated with 21% oxygen, which was increased to 100% oxygen if compressions were performed or if the heart rate was <100 beats per minute at 2 minutes of life. Oxygen was increased in 25% increments if pulse oxygen saturation was <70% at 3 minutes of life or <80% at 5 minutes of life. RESULTS: Twenty-three infants in the oxygen group (mean gestational age: 27.6 weeks; range: 24-31 weeks; mean birth weight: 1013 g; range: 495-2309 g) and 18 in the room air group (mean gestational age: 28 weeks; range: 25-31 weeks; mean birth weight: 1091 g; range: 555-1840 g) were evaluated. Every resuscitated patient in the room air group met rescue criteria and received an increase in the fraction of inspired oxygen by 3 minutes of life, 6 patients directly to 100% and 12 with incremental increases. Pulse oxygen saturation was significantly lower in the room air group from 2 to 10 minutes (pulse oxygen saturation at 3 minutes: 55% in the room air group vs 87% in the oxygen group). Heart rates did not differ between groups in the first 10 minutes of life, and there were no differences in secondary outcomes. CONCLUSIONS: Resuscitation with room air failed to achieve our target oxygen saturation by 3 minutes of life, and we recommend that it not be used for preterm neonates.

طلع بالأخير نفس البحث يلي طلع معنا بالطريقة المجعلكة Laughing out loud

إن شاء الله ما تكون عجقت الصفحة زيادة Embarrased .. بس عن جد في مشكلة بصياغة الكلمات المفتاحية للبحث ..(بدي درس خصوصي منكم بحثي، ومستعد لأي ثمن Cool وأي عزيمة بالمحل يلي بتطلبوه Cool )

dr.napoleon's picture
dr.napoleon
طالب دراسات عليا


برافو دكتور سامر ودكتور تحسين .. Impressive....
مشان السؤال البحثي جميع الطرق يلي ذكرتوها ممتازة.. لح نبلش بالـ PICO:

P (Problem/Population/Patient): Preterm Neonates.
I (intervention): 100% Oxygen.
C (Comparison): Room Air.
O (Outcome): Resuscitation.

هلق أنا ماني متأكد بس أنا فكرت بان يكون الانعاش هو النتيجة.. بس بنفس الوقت حسيت انو هو المشكلة كمان.. على كل بيضل هاد مجال للجدل.. واذا حدا من البحثي بيفيدنا برأيه بكون ممنونEmbarrased .

استراتيجية البحث:
متل ما قلتو.. بما انو أنا عم دور على دليل طريقة معالجة فالمكان الاول للبحث هو Cochrane.. أنا استخدمت الطريقة التالية:

(Preterm Neonate*) AND (Resuscitat*) AND (Oxygen*) AND (Room Air)

البحث في Cochrane لن يأتي بأي systematic review.. لكن سنجد 2 RCTs.. كلاهما تحتاجان إلى تسجيل في الموقع للحصول عليهما.. لذا المكان الاخر هو PubMed (لا تكون كسلان وقيم البروكسي شوي وبلاه الفيس بوك هلقEye-wink ).. باستخدام الاستراتيجية السابقة سنجد البحث التالي:

Resuscitation of Preterm Neonates by Using Room Air or 100% Oxygen

وهي المقالة الاخيرة يلي اتحدث عنها سامر... وهي المقالة يلي حابب ناقشها لأنو مناقشتها شوي بتفوت بالحيط.... على كل بإمكانكم انكم تدوروا عليها بالطريقة السابقة أو أي طريقة ممكن تلاقوها مناسبة...
المرحلة الثانية من النقاش حتكون قراءة البحث وتقييمه.. على اعتبار أنو هي RCT فانا ما باخود فيها حتى اعملها Appraisal... مشان هيك بدي منكم تقرؤوا البحث وتبدؤوا بأول خطوات التقييم الملخصة بـ RVRA... ويلي بيسبق الو نجمة وسكرة Laughing out loud Eye-wink ....

اذا في حدا ما قدر يجيب البحث فهي الرابط:
http://pediatrics.aappublications.org/cgi/content/full/121/6/1083

dr-dark angel's picture
dr-dark angel
السنة السادسة


سبقتك Cool كل المصادر عم ترجعنا على نفس المقالة ..
بالنسبة لقراءة البحث وتقييمه ، سامحنا الليلة ، بكرا إن شاء الله Eye-wink

dr.napoleon's picture
dr.napoleon
طالب دراسات عليا

Ok. To appraise the article we should check the RVRA:

R= relevance .. the title & the abstract tell us if the article is relevant or not.

1- The title is:

Quote:
Resuscitation of Preterm Neonates by Using Room Air or 100% Oxygen

2- The abstract, the objective:

Quote:
In this study of preterm neonates of <32 weeks, we prospectively compared the use of room air versus 100% oxygen as the initial resuscitation gas.

From 1 &2 --> the article is relevant.

------------------------
------------------------

V= validity .. if the article is valid, then it should start well, run well and finish well.

Start well: the article should achieve the 1st 3 Cs: control group, concealed randomization, comparability of groups.

- Control group: from results:

Quote:
Eighteen infants received room air and 23 infants received oxygen

.
That’s mean there were treatment and control groups.

- Concealment & Randomization:

Quote:
A total of 32 patients were enrolled at UCSD and 11 at Santa Clara Valley Medical Center

.

Quote:
Patients were included in the trial if any resuscitation was received

The previous information in my opinion tell us about concealment. Rolling Eyes

Quote:
When delivery was imminent, subjects were randomly assigned to 2 groups by using sealed envelopes.

That’s mean it was randomized and double blinded ( cuz neonates didn’t know the treatment they’ve received Cool ).

- Comparability of groups:

Quote:
No differences were seen between groups with respect to baseline characteristics, delivery room interventions (Table 2), or maternal factors.

So, the article started well Very Happy .. I’ll leave the rest to you Cool Eye-wink

Dr.TH's picture
Dr.TH


ما شاااااااااااااااااء الله شباب على الهمة Smiling

طريقة العمل تمام... مع اني مع أنه الresuscitation تكون بال P بس على كل المهم نكون عرفانين على شو رح ندور...

المشكلة أنه ما عم تقيمو systematic review (اختصاصي) بس مو مشكلة رح ساعد قدر الاستطاعة

تحسين التقييم لهلأ ممتاز...
بس في شغلة

Quote:
When delivery was imminent, subjects were randomly assigned to 2 groups by using sealed envelopes

الجملة تدل على concealed allocation

لكن سؤال هل برأيكم هناك blinding فكروا فيها منيح و بانتظار أجوبتكم...

dr.dado

Quote:
الجملة تدل على concealed allocation

إياد بس هنن بعد ما جمعوا الحالات .. قسموهم ل control و treatment بظروف مختومة يعني صرنا بال randomization وال blinding مو ؟ Rolling Eyes
يعني لو concealment المفروض يكون توزيع الظروف قبل التقسيم لمجموعتين Rolling Eyes
-----

Quote:
لكن سؤال هل برأيكم هناك blinding فكروا فيها منيح و بانتظار أجوبتكم...

قصدك أنه هنن لما بدهم يفتحوا الظروف حيعرفوا شو عم يعطوا كل وليد --> ما في blinding .. يعني المفروض يقولوا: أنها لأشخاص اللي وزعوا الظروف غير الأشخاص اللي عم يعملوا إنعاش لحتى تكون blinding صح ؟

Dr.TH's picture
Dr.TH


سؤال جيد dr.dado... أنا صار معي شوية مشاكل بمعرفة وجود الامور الثلاث Concealment/Blinding/Randomization...

هلق انا عندي وجهات نظر.. بس النية انو اترك النقاش مفتوح لأكبر عدد من المناقشات.. مشان هيك لح نحاول نبحث عن معلومات بتدل على وجود او عدم وجود هالامور الثلاث... مع انو ما شاء الله الشباب عم يكفوا ويوفوا..

Great job Dr.TH....Eye-wink

dr-dark angel's picture
dr-dark angel
السنة السادسة


ما شاء الله على هالنشاط Cool

Quote:
إياد بس هنن بعد ما جمعوا الحالات .. قسموهم ل control و treatment بظروف مختومة يعني صرنا بال randomization وال blinding مو ؟ Rolling Eyes
يعني لو concealment المفروض يكون توزيع الظروف قبل التقسيم لمجموعتين Rolling Eyes

حجاوب من بعد إذن إياد Eye-wink

concealment و blinding لهما نفس مفهوم "التعمية" للدكاترة والمرضى ولكن يختلفان بالمرحلة:
Concealment ملازمة لل randomization يعني التعمية في تقسيم المرضى للمجموعتين control or treatment وقبل البدء بإعطاء الدواء
وبهذا البحث تحقق هالشي بال sealed envelopes كما ذكر إياد.
أما الBlinding فهي التعمية أثناء إعطاء الدواء وبعدها, أي ما يعرفوا نوع الدواء يلي عم يعطى لكل مريض إن كان دواء الTraetment أم دواء الControl.

إن شاء الله تكون توضحت الفكرة ...

pearls-5's picture
pearls-5
السنة السادسة

Quote:
حجاوب من بعد إذن إياد

ما بيطلع لل systematic review يحكوا بعد ال therapy Smiling

هذا كان قصدي تحسين... كان في تعمية قبل ما يدخلوا بمجموعتين... أما بعد فبنظري ليس من الممكن بهكذا دراسة أن تجرى تعمية.. لأنه ليست موضوع دواء وغفل متشابهين... ولكن إجراءين مختلفين.. و من الواضح أن من سيقوم به سيعلم أنه يجري 100% أوكسجين أو 21%... و بالتالي مو ممكن double blinding
ولكن طبعا الأطفال و ذووهم لا يعلمون الإجراء و بالتالي single blinding

dr.dado

Quote:
Smiling

آسف قصدي Eye-wink

dr.dado

Quote:
كان في تعمية قبل ما يدخلوا بمجموعتين

ليس randomization ولكن concealment

dr.dado

Quote:
إن شاء الله تكون توضحت الفكرة ...

تمام .. وضحت، شكراً جزيلاً دكتورة Eye-wink
أنا كنت فهمان الفكرة بشكل مختلف .. بس بإذن الله هلأ تمام .. شكراً
--------------
معناها متل ما قلتوا .. في concealment ، و randomization .. بس بقي ال blinding .. بركي برد بشوفها إذا ذكروها بالمقال Rolling Eyes

Dr.TH's picture
Dr.TH

Quote:
هذا كان قصدي تحسين... كان في تعمية قبل ما يدخلوا بمجموعتين... أما بعد فبنظري ليس من الممكن بهكذا دراسة أن تجرى تعمية.. لأنه ليست موضوع دواء وغفل متشابهين... ولكن إجراءين مختلفين.. و من الواضح أن من سيقوم به سيعلم أنه يجري 100% أوكسجين أو 21%... و بالتالي مو ممكن double blinding

عفواً إياد كنت فاتح الصفحة من فترة ..
تمام .. حلوة الفكرة اللي ذكرتها .. ما انتبهت Embarrased .. شكراً Cool Eye-wink

Dr.TH's picture
Dr.TH


ما شاء الله عليكم يا شباب.. والله نقاش مفيد أكثر من ما كنت متوقع.. والنقاش رهيب...

معناها هلق قررنا أنو في ببحثنا Start well... بس غالباً -مثل ما قال dr.dado- انو مافي Blinding او انو هيي بس single binding.. لآنو البحث يقارن طريقتين معالجة... والطريقتين ما بيحتملوا أنو يكون الطبيب معمى عنها....

طيب يالله نكمل بالتقييم... شو مشان الخطوة التانية... Run Well... يالله يا شباب بدنا يكون في مشاركة أكثر.... Laughing out loud Eye-wink Cool

dr-dark angel's picture
dr-dark angel
السنة السادسة


شو وينكم يا شباب... بردت الهمة؟؟؟؟Rolling Eyes Sad
يالله بدنا جواب على السؤال السابق.... مين الكفو؟؟؟؟؟

dr-dark angel's picture
dr-dark angel
السنة السادسة

Quote:
ما شاء الله عليكم يا شباب.. والله نقاش مفيد أكثر من ما كنت متوقع.. والنقاش رهيب...

إذا بتشاركنا بيصير النقاش أكثر إرهاباً Cool ( مشتقة من رهيب .. وجب التنويه Idea )
طيب هلأ عنا ال run well يلا مين رح يشفلنا ياها Laughing out loud

run well: we should check the 2nd 3 Cs: Co-intervention, Contamination, Compliance.

إذا لحقت اللي علي اليوم .. برجع للمشاركة Sad

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Dr.TH
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