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Rao R, Rajappa G, Sandhya BK, Srinidhi HS, Pagadala T, Likitha S. To compare the efficacy of three techniques in reducing etomidate-induced myoclonus - A randomised controlled trial. Indian J Anaesth 2025; 69:282-288. [PMID: 40161910 PMCID: PMC11952170 DOI: 10.4103/ija.ija_948_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 12/27/2024] [Accepted: 12/28/2024] [Indexed: 04/02/2025] Open
Abstract
Background and Aims Etomidate is the preferred induction agent in haemodynamically unstable patients. Preventing etomidate-induced myoclonus (EIM) is important. The objective of this study was to compare the efficacy of three techniques of etomidate administration in preventing EIM. Methods This randomised, controlled study included 296 patients. General anaesthesia (GA) was induced with etomidate as per the randomly allocated groups: control (C), priming (P), slow (S), and priming with slow injection (T). The incidence, time of onset, and grade of myoclonus were noted. The grade of pain on injection and the effect on various haemodynamic parameters were noted. The Kruskal-Wallis, Fisher's exact, and Chi-square tests were used for statistical analysis. P < 0.05 was considered to be statistically significant. Results The study shows that the incidence of myoclonus was highest amongst Group C (73.0%), followed by Group P (52.7%), Group S (48.6%), and Group T (37.8%) (P = 0.001). Priming with a slow technique was most effective in preventing EIM and lowering the intensity of myoclonus. The incidence of grade 3 myoclonus was 5 (6.76%) in Group T when compared to 39 (52.7%) in Group C (mean difference [MD] =36.96, 95% CI: 7.45, 55.94; P = 0.0001). Conclusion We observed that the priming and slow injection techniques were similar in reducing the incidence of EIM. However, the combination of priming and slow technique was the most effective.
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Affiliation(s)
- Ridhi Rao
- Department of Anaesthesiology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Geetha Rajappa
- Department of Anaesthesiology, Ramaiah Medical College and Hospitals, New BEL Road, MSRIT Post, Bengaluru, Karnataka, India
| | - B K Sandhya
- Department of Anaesthesiology, Ramaiah Medical College and Hospitals, New BEL Road, MSRIT Post, Bengaluru, Karnataka, India
| | - H S Srinidhi
- Department of Anaesthesiology, Ramaiah Medical College and Hospitals, New BEL Road, MSRIT Post, Bengaluru, Karnataka, India
| | - Teja Pagadala
- Department of Anaesthesiology, Ramaiah Medical College and Hospitals, New BEL Road, MSRIT Post, Bengaluru, Karnataka, India
| | - S Likitha
- Department of Anaesthesiology, Ramaiah Medical College and Hospitals, New BEL Road, MSRIT Post, Bengaluru, Karnataka, India
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Luo HR, Chen AD, Lin JF, Ye P, Chen YJ, Lin MX, Chen PZ, Chen XH, Zheng XC. Effect of etomidate added to propofol target-controlled infusion in bidirectional endoscopy: A randomized clinical trial. World J Gastrointest Endosc 2025; 17:100722. [PMID: 39989856 PMCID: PMC11843041 DOI: 10.4253/wjge.v17.i2.100722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Revised: 01/06/2025] [Accepted: 01/18/2025] [Indexed: 02/13/2025] Open
Abstract
BACKGROUND Propofol has been widely used in bidirectional gastrointestinal endoscopy sedation; however, it frequently leads to cardiovascular adverse events and respiratory depression. Propofol target-controlled infusion (TCI) can provide safe sedation but may require higher dosages of propofol. On the contrary, etomidate offers hemodynamic stability. AIM To evaluate the effect of different dose etomidate added to propofol TCI sedation during same-visit bidirectional endoscopy. METHODS A total of 330 patients from Fujian Provincial Hospital were randomly divided into three groups: P, 0.1EP, and 0.15EP. Patients in the P group received propofol TCI only, with an initial effect-site concentration of the propofol TCI system of 3.0 mg/mL. Patients in the 0.1EP and 0.15EP groups received 0.1 and 0.15 mg/kg etomidate intravenous injection, respectively, followed by propofol TCI. RESULTS Patients in the 0.15EP group had higher mean blood pressure after induction than the other groups (P group: 78 mmHg, 0.1EP group: 82 mmHg, 0.15EP group: 88 mmHg; P < 0.05). Total doses of propofol consumption significantly decreased in the 0.15EP group compared with that in the other groups (P group: 260.6 mg, 0.1EP group: 228.1 mg, 0.15EP group: 201.2 mg; P < 0.05). The induction time was longer in the P group than in the other groups (P group: 1.9 ± 0.7 minutes, 0.1EP group: 1.2 ± 0.4 minutes, 0.15EP group: 1.1 ± 0.3 minutes; P < 0.01). The recovery time was shorter in the 0.15EP group than in the other groups (P group: 4.8 ± 2.1 minutes, 0.1EP group: 4.5 ± 1.6 minutes, 0.15EP group: 3.9 ± 1.4 minutes; P < 0.01). The incidence of hypotension (P group: 36.4%, 0.1EP group: 29.1%, 0.15EP group: 11.8%; P < 0.01) and injection pain was lower in the 0.15EP group than in the other groups (P < 0.05). Furthermore, the incidence of respiratory depression was lower in the 0.15EP group than in the P group (P < 0.05). Additionally, the satisfaction of the patient, endoscopist, and anesthesiologist was higher in the 0.15EP group than in the other groups (P < 0.05). CONCLUSION Our findings suggest that 0.15 mg/kg etomidate plus propofol TCI can significantly reduce propofol consumption, which is followed by fewer cardiovascular adverse events and respiratory depression, along with higher patient, endoscopist, and anesthesiologist satisfaction.
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Affiliation(s)
- Hui-Rong Luo
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou 350000, Fujian Province, China
| | - An-Di Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Jing-Fang Lin
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Peng Ye
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Ying-Jie Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Ming-Xue Lin
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Pin-Zhong Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Xiao-Hui Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
| | - Xiao-Chun Zheng
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350000, Fujian Province, China
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Chen L, Zhou P, Li Z, Wu Z, Zhai S. Comparative efficacy and safety of 20 intravenous pharmaceutical intervention for prevention of etomidate-induced myoclonus: a systematic review and Bayesian network meta-analysis. Front Pharmacol 2025; 15:1507616. [PMID: 39917325 PMCID: PMC11799762 DOI: 10.3389/fphar.2024.1507616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Accepted: 12/27/2024] [Indexed: 02/09/2025] Open
Abstract
Objective To compare the efficacy and safety of pharmaceutical interventions to prevent etomidate-induced myoclonus (EIM), providing the optimal intervention for clinical practice. Methods PubMed, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Chinese National Knowledge Infrastructure, WanFang database, and SinoMed database were searched from the inception to sixth May 2024. We included randomized controlled trials (RCTs) comparing intravenous pharmaceutical interventions to prevent EIM with placebo, no intervention, or another pharmaceutical intervention. Results Forty-eight RCTs involving 4,768 participants randomly assigned to 20 intravenous pharmaceutical interventions and normal saline were included. Granisetron (odds ratio [OR]: 0.01, 95% confidence interval [CI]: 0.00 to 0.06; one study, moderate certainty) and oxycodone (OR: 0.01, 95% CI: 0.00 to 0.05; three studies, low certainty) was found to be the most effective intervention in reducing the risk of EIM and ranked highest in terms of surface under the cumulative ranking values (94.4% and 89.7% probability), followed by sufentanil (76.5% probability) and remifentanil (74.8% probability). Further subgroup analysis of EIM at mild, moderate-to-severe levels highlighted granisetron and oxycodone as the favorable interventions for reducing EIM. For safety outcomes, the synthesized results indicated that opioids were associated with a higher risk of adverse events (AEs), while no severe AEs were observed. Conclusion Moderate-to-low certainty evidence indicated that granisetron and oxycodone may represent the optimal intervention for reducing the risk of overall and moderate-to-severe EIM with a reasonable safety profile, providing the potential interventions for clinical practice. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=291275.
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Affiliation(s)
- Lu Chen
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Pengxiang Zhou
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Ziyang Wu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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Gao L, Lu X, Tan A, Liufu J, Xu Y, Wei L. Effect of Pretreatment with a Small Dose of Esketamine on Myoclonus Induced by Etomidate: A Randomized Controlled Trial. Drug Des Devel Ther 2024; 18:5773-5779. [PMID: 39664969 PMCID: PMC11633297 DOI: 10.2147/dddt.s495130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2024] [Accepted: 11/29/2024] [Indexed: 12/13/2024] Open
Abstract
Background Etomidate has been observed to precipitate myoclonus in patients undergoing induction of general anaesthesia. This study was designed to investigate the effect of pretreatment with a small dose of esketamine on the incidence of myoclonus induced by etomidate. Methods One hundred adult patients, who were scheduled to undergo selective operations with general anesthesia, were randomly divided into two groups, with one group receiving esketamine (Group E) and the other receiving normal saline (Group C). The group receiving esketamine (Group E) was administered an injection of 0.15 mg/kg of esketamine, while the control group (Group C) was given an equivalent volume of normal saline two minutes before the administration of 0.3 mg/kg of etomidate. The primary objective was to determine the incidence of etomidate-induced myoclonus. Secondary endpoints included the severity of etomidate-induced myoclonus and changes in haemodynamic variables at various time intervals. Additionally, the incidence of adverse effects such as dizziness, bradycardia, hypotension and hallucination were recorded from the administration of esketamine or normal saline to the injection of etomidate. Results The incidence of myoclonus was significantly lower in Group E (20%) than in Group C (62%). Compared with the control group, the esketamine group also experienced a reduction in the moderate and severe of myoclonus. However, there was no statistically significant difference between the two groups for mild etomidate-induced myoclonus. The haemodynamic data (mean arterial pressure and heart rate) showed no statistically significant differences between two groups at the three time points. The incidence of dizziness, bradycardia, hypotension and hallucination was similar in both groups. Conclusion Pretreatment with 0.15 mg/kg esketamine prior to anaesthesia induction with etomidate was observed to markedly reduce the incidence and severity of myoclonus, while having no effect on mild etomidate-induced myoclonus and maintaining a stable haemodynamic status.
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Affiliation(s)
- Liangliang Gao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, People’s Republic of China
- The First Affiliated Hospital of Anhui Medical University, Hefei, People’s Republic of China
| | - Xinyu Lu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, People’s Republic of China
| | - Aiping Tan
- Department of Anesthesiology, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, People’s Republic of China
| | - Jiaying Liufu
- Department of Anesthesiology, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, People’s Republic of China
| | - Yidan Xu
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, People’s Republic of China
| | - Lei Wei
- Department of Anesthesiology, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, People’s Republic of China
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Shan G, Lu H, Dai F, Liu Y, Yin D, Cao H. Low-dose nalmefene pretreatment reduces etomidate-induced myoclonus: A randomized, double-blind controlled trial. Medicine (Baltimore) 2023; 102:e35138. [PMID: 37682124 PMCID: PMC10489433 DOI: 10.1097/md.0000000000035138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND This study compared the effectiveness of nalmefene and fentanyl in reducing the incidence and severity of etomidate-induced myoclonus. METHODS One hundred fifty patients were randomized to receive 0.25ug/kg of nalmefene, 1ug/kg of fentanyl, or the same volume of normal saline 3 minutes prior to etomidate-induced anesthesia. The primary observational indexes were the severity level and incidence of etomidate-induced myoclonus, and the secondary observational index included blood pressure, heart rate, and the incidence of adverse effects from anesthesia induction to resuscitation, such as cough, chest wall rigidity, dizziness, nausea, pain after awakening, and intraoperative awareness. RESULTS The incidence of myoclonus was significantly lower in the nalmefene group (8.0%) than in the fentanyl group (32.0%) (P = .003) and in the normal saline group (72.0%) (P = .000). The severity level of myoclonus in the nalmefene group was significantly lower than the fentanyl group (P = .001) and normal saline group (P = .000). Meanwhile, the incidences of cough and chest wall rigidity during anesthesia induction were significantly lower in the nalmefene group compared with the fentanyl group (P = .003, P = .027). There were no statistically significant differences in heart rate and mean arterial pressure among the 3 gruops (P > .05). There was no difference in the incidence of adverse effects among the 3 groups during recovery from anesthesia (P > .05). CONCLUSION Intravenous injection of 0.25ug/kg of nalmefene 3 minutes prior to etomidate is more effective in preventing etomidate-induced myoclonus during general anesthesia than 1ug/kg of fentanyl.
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Affiliation(s)
- Guofa Shan
- Department of Anesthesiology, Funing People’s Hospital of Jiangsu, Yancheng, Jiangsu province, China
| | - Haixia Lu
- Department of Clinical Medicine, Medical School of Nantong University, Nantong, Jiangsu, China
- Department of Anesthesiology, Haian Chinese Medicine Hospital of Jiangsu, Nantong, Jiangsu Province, China
| | - Fang Dai
- Department of Anesthesiology, Funing People’s Hospital of Jiangsu, Yancheng, Jiangsu province, China
| | - Yan Liu
- Department of Anesthesiology, Funing People’s Hospital of Jiangsu, Yancheng, Jiangsu province, China
| | - Dekun Yin
- Department of Anesthesiology, Funing People’s Hospital of Jiangsu, Yancheng, Jiangsu province, China
| | - Hanzhong Cao
- Department of Clinical Medicine, Medical School of Nantong University, Nantong, Jiangsu, China
- Department of Anesthesiology, Nantong Tumor Hospital, Nantong University, Jiangsu Province, China
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Zhang KD, Wang LY, Zhang DX, Zhang ZH, Wang HL. Comparison of the Effectiveness of Various Drug Interventions to Prevent Etomidate-Induced Myoclonus: A Bayesian Network Meta-Analysis. Front Med (Lausanne) 2022; 9:799156. [PMID: 35559341 PMCID: PMC9086535 DOI: 10.3389/fmed.2022.799156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background Myoclonic movement is a very common but undesirable phenomenon during the induction of general anesthesia using etomidate. Such movement may cause unnecessary problems. Currently, there is an increasing number of drugs for preventing etomidate-induced myoclonus (EM). However, direct comparisons of various drugs are lacking, and this interferes with clinical decision-making. Our network meta-analysis (NMA) aimed to compare the efficacy of different drugs for the prevention of moderate-to-severe general myoclonus. Methods Using several biomedical databases, randomized controlled trials (RCTs) published in English from inception to August 22, 2021 were searched. Among the various interventions, we selected nine types of intervention drugs (dexmedetomidine, etomidate, lidocaine, NMDA receptor antagonist, κ opioid receptor agonist, μ opioid receptor agonist, muscle relaxant, gabapentin, and midazolam) for comparison, according to the number of studies. Bayesian NMA was performed using STATA16 and R softwares. The relative risk of EM was assessed using risk ratios (RRs) and the corresponding 95% confidence intervals (CI). Results A total of 31 RCTs (3209 patients) were included. NMA results showed that, compared with a placebo, etomidate (RR 4.0, 95%CI 2.1–7.8), κ opioid receptor agonist (RR 2.9, 95%CI 1.9–4.6), μ opioid receptor agonist (RR 3.1, 95%CI 2.3–4.3), NMDA receptor antagonist (RR 1.7, 95%CI 1.0–2.8), dexmedetomidine (RR 2.4, 95%CI 1.5–3.9), lidocaine (RR 2.1, 95%CI 1.2–3.9), and midazolam (RR 2.2, 95%CI 1.5–3.2) can significantly reduce the risk of EM. In contrast, the effects of muscle relaxants (RR 2.1, 95%CI 0.81–5.3) and gabapentin (RR 2.8, 95%CI 0.92–9.3) were inconclusive. Further subgroup analyses showed that preoperative low-dose etomidate, μ-opioid receptor agonist, and κ-opioid receptor agonist were significantly better than other interventions in the prevention of moderate to severe EM. Conclusion Preoperative use of small doses of etomidate or opioids may be the most effective way to avoid EM, especially moderate and severe EM, which makes anesthesia induction safer, more stable, and aligns better with the requirements of comfortable medicine. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], [CRD4202127706].
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Affiliation(s)
- Kang-Da Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, China
| | - Lin-Yu Wang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, China
| | - Dan-Xu Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, China
| | - Zhi-Hua Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, China
| | - Huan-Liang Wang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, China.,Shenzhen Research Institute of Shandong University, Shenzhen, China
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Nazemroaya B, Mousavi SM. Comparison of Premedication with Low-Dose Midazolam Versus Etomidate for Reduction of Etomidate-Induced Myoclonus During General Anesthesia for Electroconvulsive Therapy: A Randomized Clinical Trial. Anesth Pain Med 2020; 9:e94388. [PMID: 32280614 PMCID: PMC7118685 DOI: 10.5812/aapm.94388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 11/06/2019] [Accepted: 12/03/2019] [Indexed: 12/27/2022] Open
Abstract
Background A variety of anesthetics including methohexital, thiopental sodium, propofol, ketamine, and etomidate are used for electroconvulsive therapy (ECT), each accompanied by adverse effects that can cause unpleasant experiences for patients. Etomidate-induced myoclonus is among the adverse effects. We attempted to assess the effect of premedication with low-dose midazolam compared to etomidate on the reduction of this complication. Objectives This study was designed to compare the effectiveness of low-dose etomidate and low- dose midazolam to suppress etomidate-induced myoclonus in ECT. Methods This randomized double-blinded clinical trial was conducted on 132 patients who were candidates for ECT. They were divided into three groups of 44 patients to receive 0.015 mg/kg midazolam, 0.03 mg/kg etomidate, or placebo. Independent t-test and chi-square test were used for comparison of variables. Results The frequency of myoclonic movements during anesthesia was different between the three groups (P value < 0.001). Myoclonic movements were significantly lower in the midazolam group than in the placebo (P value < 0.001) and etomidate (P value = 0.002) groups. In addition, the intensity of myoclonic movements was significantly higher in the midazolam group than in the placebo and etomidate groups (P value < 0.001). Conclusions Low-dose midazolam (0.015 mg/kg) before anesthesia induction with etomidate was accompanied with significantly lower incidence and intensity of myoclonus than low-dose etomidate (0.03 mg/kg).
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Affiliation(s)
- Behzad Nazemroaya
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Corresponding Author: Assistant Professor, Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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