Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
On Sep 2018




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On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
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My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : LC13 - LC16 Full Version

Factors Facilitating Hand Hygiene Practices in Eateries of Coimbatore: A Cross-sectional Study


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/50506.15259
Gaayathri Krishnan, Dharaniya Rathinasabapathy, Ganesh Kumar Natarajan, Dipika Balasubramanian, Dinesh Shankar, LEaswar, L Firthous Fathima, AM Gayathiri

1. Ex-MBBS Student, Department of Community Medicine, PSG IMSR, Chennai, Tamil Nadu, India. 2. Ex-MBBS Student, Department of Community Medicine, PSG IMSR, Coimbatore, Tamil Nadu, India. 3. Ex-MBBS Student, Department of Community Medicine, PSG IMSR, Coimbatore, Tamil Nadu, India. 4. Ex-MBBS Student, Department of Community Medicine, PSG IMSR, Coimbatore, Tamil Nadu, India. 5. Ex-MBBS Student, Department of Community Medicine, PSG IMSR, Coimbatore, Tamil Nadu, India. 6. Ex-MBBS Student, Department of Community Medicine, PSG IMSR, Coimbatore, Tamil Nadu, India. 7. Ex-MBBS Student, Department of Community Medicine, PSG IMSR, Coimbatore, Tamil Nadu, India. 8. Ex-MBBS Student, Department of Community Medicine, PSG IMSR, Coimbatore, Tamil Nadu, India.

Correspondence Address :
Dr. Gaayathri Krishnan,
17, Residency Dhanam [1b] Mandavel Ipakkam, Mandaveli, Chennai-600028, Tamil Nadu, India.
E-mail: gaays30@gmail.com

Abstract

Introduction: Improper hand hygiene practices and eating at unsanitary eateries are a major cause for many of the life-threatening diseases. Although studies done in the past have focused on the hand hygiene of the restaurant staff, the customers’ hand hygiene, which is equally, if not more important, has not been studied in detail.

Aim: To assess the factors facilitating hand hygiene for the customers as well as the general hygiene in the eateries of Coimbatore, Tamil Nadu, India.

Materials and Methods: A cross-sectional study was done in the eateries of Coimbatore in June 2017, after obtaining clearance from Institutional human ethics committee. A list of eateries was collected from a food delivery application and 30 of them were chosen by systematic random sample. The restaurants were further categorised into low, medium and high-price ranged eateries based on the price of a standard food item (coffee). As a mystery client, the restaurants were inspected and observations were noted in a hidden checklist, which was constructed for the purpose of this study. The checklist consisted of three major categories, the washing area (9 marks), the customer (7 marks) and the general hygiene of the restaurant (7 marks). There were 23 items in the checklist and each item, if present, was awarded a score of 1. No negative scoring was done. Hence, the maximum score an eatery could get was 23 and minimum was zero. ANOVA test was applied to compare the scores of different types of eateries.

Results: The mean and standard deviation hygiene scores of the low, medium and high-cost eateries were 7.7±4.05, 11±6.02 and 14±5.43, respectively. There was a significant difference in the (hygiene and sanitation) scores between low, medium and high-cost eateries (p-value=0.04). It was found that in lower priced restaurants, most of the restaurants failed to provide adequate facilities for hand hygiene. Medium and high price range eateries were similar in the fact that they scored better with regard to general hygiene and wash area facilities. Although none of the restaurants scored a full mark higher price ranged eateries had better wash area facilities. Customer hand hygiene practices were found to be subpar in all the three categories, even though facilities were present in some medium and high-end eateries.

Conclusion: It was noticed that in some of the lower end restaurants, facilities for hand hygiene were not adequate. It was also found that if adequate facilities for hand hygiene were present in a restaurant, there was a higher chance of a customer to utilise that. This was found to be true especially in higher priced restaurants. Hence, the importance of hand hygiene and awareness among customers should be emphasised.

Keywords

Customers, Hand washing, Health, Restaurants

Less than 200 years back, public knowledge regarding the spread of disease and hand hygiene practices was minimal, if at all existent. It was not until 1846, that a prominent Hungarian physician by the name of Dr. Ignaz Semmelweis, also known as the ‘saviour of mothers’ and the ‘Father of infection control’, discovered the importance of hand washing after drawing up the connection between the lack of hand hygiene practices in doctors and the alarming death rate of new mothers due to puerperal fever (1).

The Centre of Disease and Control (CDC) instituted national guidelines pertaining to hand wash and emphasised the importance of hand hygiene in breaking the chain of transmission of diseases, following a breakout of food borne illnesses in the United States in the 1980s (2). Within India, where communicable disease runs rampant, hand wash has been found to be a simple, cost-effective way in reducing overall mortality and morbidity from simple diseases.

Diarrhoeal diseases represent a major health problem in developing countries. It is estimated roughly that death due to diarrhoeal diseases are about two million annually (1.7-2.5 million deaths), and stands third among all causes of infectious disease related deaths worldwide (3).

Most pathogenic organisms that cause diarrhoea are transmitted by the faecal-oral route. Faecal-oral transmission may be water borne, food borne or direct transmission which implies an array of other faecal-oral routes such as via fingers, fomites or dirt which may be ingested by people (4). A review of food borne disease outbreaks in India from 1980-2016 showed Staphylococcus sp, E. coli, Yersinia enterocolitica and Norwalk-like virus as some important microbial pathogens responsible for food borne gastroenteritis (5).

Eating out has become an integral part of life for many Indians. According to a survey by the National Restaurant Association of India (NRAI), notably, Indian consumers are eating out almost 6-7 times every month (6). As such, the chances of acquiring a food borne illness is higher.

Of the 9040 food borne disease outbreaks that were reported to the CDC from 1998 to 2004 (7), 4675 (52%) were associated with restaurants or delicatessens (including cafeterias and hotels). One in 10 people or 600 million people in the world are susceptible to illness following consumption of food that has been contaminated, according to the WHO. It was noted that the mortality rate, due to these illnesses, was around 420,000 annually, often resulting in the loss of 33 million healthy life years-Disability Adjusted Life Years (DALYs) (8). Diarrhoeal diseases are the most frequent illness resultant from the eating of infected food, causing 550 million people to fall ill and 230 000 deaths every year (8).

Cultural differences also play a part in the spread of communicable diseases. In India, Africa and the middle-east, the practice of eating with hands is quite common. The people of these regions may be at greater risk of contracting food borne related illnesses as opposed to their western counterparts.

Unclean hands are a major cause of the spread of diarrhoeal diseases in developing countries. The microbiota in our hands is very complex and varied. There are two categories of microbes that reside in our hands, the first type being resident flora- those that are present in our hands and help fight germs. Transient microbes, the second type, most of which are pathogenic, are those that colonise the superficial layers of the skin and can be eliminated by hand wash practices (4).

No part of the human body is free from microbes, so to say, microbes as part of the human body, is constant. Transient microbes, however, change according to the environmental conditions. Some of the microorganisms found are Acinetobacter, Aerococcus, Bacillus, Clostridium, Corynebacterium, Micrococcus, Staphylococcus and Streptococcus Spp, and Candida and Malassezia Spp; almost all of which are transmitted by faeco-oral route of transmission (4).

A study in Dhaka revealed a 2.6-fold reduction in diarrheal episodes in the intervention area following the practice of regular hand washing with soap and water (9). In one meta-analysis, hand washing with soap has been shown to reduce diarrhoea risk by 31% and acute respiratory infection risk by 21% (10). Washing with soap is more effective at hand decontamination than washing with water alone (11),(12),(13).

Thus, this study focussed more on the factors facilitating hand hygiene in customers rather than the food handlers, who are equally if not more important in the chain of transmission of disease. It was assumed, that there was no difference among the mean (sanitation and hygiene) scores of low, medium and high price range eateries.

Material and Methods

This cross-sectional study was conducted in eateries of Coimbatore, for a period of one month in June 2017, regarding factors facilitating hand hygiene, after obtaining clearance from the institutional human ethics committee (Project no. 17/155). Using a popular food delivery application, as a reference search engine, 30 eateries inside Coimbatore Corporation, using Systematic Random Sampling (SRS) were selected at random. According to the cost of a standard food item (coffee), the eateries were categorised into low (Rs. 10-Rs. 30), medium (Rs. 30-Rs. 70) and high (more than Rs. 70).

Inclusion criteria: Only those restaurants and bakeries which sold coffee, the standard food item which was used to classify restaurants as low, medium and high price range were selected.

Exclusion criteria: Those restaurants, not selling coffee or selling coffee out of our price range, were excluded.

Study Procedure

Mystery clients are defined by the Pathfinder International tool series as trained people (usually community members) who visit program facilities in the assumed role of clients, and then report (by completing a survey or through an interview) their experience (14). As a ‘mystery client’, using a hidden checklist, all 30 restaurants under survey were visited, and the facilities available for hand hygiene, the general hygiene of the restaurant and whether the customers used the available facilities were observed in the pretence of drinking a cup of coffee.

A checklist, created for the purpose of this study, was used in which the responses were marked in binary form- a ‘yes’ response scored 1 and a ‘no’ scored 0. The checklist was divided into 3 main headings with sub-questions under each- the wash area (9 marks), the customer (7 marks) and the general hygiene of the restaurant (7 marks). The maximum score an eatery could get was 23 and the minimum was 0 [Appendix1].

Statistical Analysis

The cumulative scores of the eateries in the low, medium and high-price range eateries were taken and compared the means and standard deviations with each other. The scores were entered and analysed using ‘R’ software, version 7.5 and the ANOVA test was applied to see the differences between the scores of different types of eateries. Pearson correlation test was also used.

Results

The mean hygiene scores of the low, medium and high-cost eateries were 7.7±4.05, 11±6.02 and 14±5.43, respectively (Table/Fig 1). Here, the 2 degree of freedom (dfs) were calculated as difference among all of the sample size (n=30; df =27) and within the groups (low, medium and high; n=3, df=2).

After applying the ANOVA test, the p-value obtained by comparing the cumulative scores between the three categories of restaurant was found to be 0.04 and the F-value was 3.5273, which proved that the results were significant.

On correlating, the variables customer hand hygiene practices and the availability of adequate facilities showed that these two had a strong correlation (r=0.8, p=0.04).

None of the eateries ticked all the boxes on checklist with respect to hand hygiene facilities. In some of the lower end eateries, especially bakeries, facilities for hand washing was not provided. For example, with regard to availability of soap, 9 out of the 10 low-cost restaurants did not have a provision for soap since they did not have a wash area to begin with. Although higher priced eateries all had wash areas, only 6 out of 10 provided soap (Table/Fig 2).

Discussion

Hand washing is like a do-it-yourself vaccine. Good hand hygiene is an extremely simple but efficacious technique that has proven time and again to be a break in the chain of transmission of multiple infectious diseases. Although numerous studies have been done on the food handlers, it was pertinent to note that, the customers, who also play an important role in disease transmission hadn’t been studied about. Surprisingly, it was noted that many restaurants did not offer adequate facilities for hand hygiene and thus hindering the customers’ hand hygiene practices.

A meta-analysis conducted by Aiello AE et al., confirmed that, irrespective of the development status of a country, hand-hygiene interventions are efficacious for preventing gastrointestinal illnesses (10).

With the emergence of the Food Safety and Standards Authority of India (FSSAI) and new food safety regulations, a study conducted in Chennai, Tamil Nadu showed lacunae in the knowledge among food handlers. Manes MR et al., observed that the overall mean knowledge score was almost 50% and knowledge gaps related to hand hygiene, proper food cooking and holding temperatures, and cross contamination were identified (15). A similar study done in Chicago, revealed that the mean overall knowledge score regarding hand hygiene practices in food handlers, was only 72% and substantial knowledge gaps related to cross contamination, cooking, and holding and storage of food were identified (16). These data provide an insight on the targets for educational interventions to remedy knowledge gaps in food handlers in order to prevent food poisoning from restaurants. It is the responsibility of the restaurant and its staff to ensure a safe eating experience for their customers. Hence, a well-educated staff can be a key in ensuring the presence of adequate facilities.

With the availability of facilities, more people tended to utilise those studies. Lubya SP et al., in Bangladesh showed interventions that improve the presence of soap and water at the designated place to wash hands would be expected to improve hand washing behaviour and health (OR: 2.1) (17). Thus, a customer at a restaurant may feel inclined to wash their hands before dining if they see a wash area with adequate facilities. These findings are consistent with studies of handwashing in hospitals that concluded that hand hygiene was improved when equipment and supplies were present that made it easier to wash hands (17),(18),(19),(20),(21).

It is thus vital that not only the food handlers but also the customers should be educated on the importance of such a simple measure of personal hygiene which is not only efficient and cost effective but hardly takes two minutes of their time.

Addressing barriers to handwashing, including sink accessibility, availability of soap and clean water, are of utmost importance. Many of the eateries under the study did not even provide the bare requirement to practice hand hygiene like soap and clean water. Thus, it should be mandated that all eateries, no matter the price range, should provide adequate facilities for hand hygiene. Because, the provision of clean water and a simple soap by itself is a motivation for the customers to wash their hands. Hence, awareness among the customers should be increased as their hand hygiene, plays an essential role in interrupting the chain of transmission of disease.

Eating out has become a necessary evil in today’s world. However, it is practically impossible to carry soap and clean water wherever we go. Although customers could carry a pocket sized hand sanitizer with them, many fail to do so. Hence, it’s the responsibility of the restaurants to provide the means to promote healthy hand hygiene practices for their customers.

Limitation(s)

The sample size chosen for this study was limited and confounding variables like age, sex and socio-economic class of customers, etc., were not considered. Further studies with a larger sample size and these variables can be conducted in future.

Conclusion

It is vital that all restaurants provide facilities for hand hygiene. None of the restaurants that were visited was awarded a full score. Thus, there is scope for improvement in all eateries. It was noticed that in some of the lower end restaurants, facilities for hand hygiene were not adequate. It was also found that if adequate facilities for hand hygiene were present in a restaurant, there was a higher chance of a customer to utilise that. This was found to be true especially in higher priced restaurants. Carrying with them, a bottle of sanitizer or utilising the adequate facilities at restaurants can be a game changer in healthy living and prevention of infectious diseases. Hence, the importance of hand hygiene and awareness among customers should be emphasised.

Acknowledgement

Authors would like to thank their mentor Dr. M. Sivamani, Professor, Community Medicine, PSGIMS&R, for his constant support and guidance without which this project would not have been possible.

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DOI and Others

10.7860/JCDR/2021/50506.15259

Date of Submission: May 24, 2021
Date of Peer Review: Jun 21, 2021
Date of Acceptance: Jul 10, 2021
Date of Publishing: Aug 01, 2021

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

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• Plagiarism X-checker: Jun 05, 2021
• Manual Googling: Jul 09, 2021
• iThenticate Software: Jul 15, 2021 (10%)

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