scholarly journals Extended-spectrum and Metallo-beta lactamase enzymes mediated resistance in Pseudomonas aeruginosa in clinically isolated specimens

2021 ◽  
Vol 48 (2) ◽  
Author(s):  
Farooq Ali ◽  
◽  
Seema Kamal ◽  
Qismat Shakeela ◽  
Shehzad Ahmed ◽  
...  
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Health Concern ◽  
Diffusion Method ◽  
Multiple Drug ◽  
Beta Lactamase ◽  
Age Group ◽  
Female Population ◽  
Extended Spectrum ◽  
Sensitivity Pattern ◽  
Wide Range

Pseudomonas aeruginosa is one of the leading opportunistic pathogens, frequently highlighted for the production of Extended-Spectrum Beta-Lactamase (ESBL) and Metallo-beta Lactamase (MBL) enzymes. This is believed to be the primary inhabitant of soil due to its adaptive nature and can survive in aquatic and even in a toxic environment. The current study aimed to screen ESBL, MBL producing, and Multiple Drug Resistant (MDR) strains of P. aeruginosa. Clinical specimens collected from patients were screened for the presence of P. aeruginosa. After identification, all the isolates were tested for the sensitivity pattern following the Kirby-Bauer disc diffusion method. The presence of ESBL and MBL enzymes were detected following DDST and IMP-EDTA detection tests, respectively. The sample size used in the study was 1369, and colonies for P. aeruginosa were obtained from 126 (9.20%) samples of culture media. 54.76% (69/126) of the positive cases were detected in the female population, whereas 45.24% (57/126) in the male population. High-frequency rate (n=43/126) was detected in the age group ≥31 year, followed by 21-30 (n=35/126), and 11-20 (n=34/126) age group, the minimal frequency (n=14/126) was detected in age group 0-10. The sensitivity pattern showed that the majority of the isolates were resistant, but class carbapenem (imipenem, meropenem), aminoglycosides (amikacin, gentamicin, tobramycin), and other antibiotics like sulbactam- Cefoperazone, tazobactam-piperacillin, tigecycline, and Fosfomycin exhibited the best efficacy against P. aeruginosa. It is concluded that the emergence of resistance due to ESBL and MBL enzymes in P. aeruginosa is directly linked with a public health concern because these strains are almost resistant to a wide range of antibiotics, and only limited antibiotics are potent against these organisms.

scholarly journals Extended Spectrum Beta Lactamase and Metallo Beta Lactamase producing Pseudomonas aeruginosa at Tertiary care Hospital of Nepal

2018 ◽  
Vol 5 ◽  
pp. 45-50
Author(s):  
Pallavi Shrestha ◽  
Saroj Sharma ◽  
Roshani Maharjan
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Male Patient ◽  
Diffusion Method ◽  
Care Hospital ◽  
Beta Lactamase ◽  
Age Group ◽  
Extended Spectrum Beta Lactamase ◽  
Extended Spectrum ◽  
Esbl Producers ◽  
Disk Test

Objective: To assess the prevalence of Extended spectrum beta lactamase (ESBL) and Metallo beta lactamase (MBL) producing Pseudomonas aeruginosa from pus samples. Methods: A cross-sectional study was conducted at Kanti Children’s Hospital, Kathmandu, Nepal during which 316 pus samples were collected and tested using standard microbiological procedures. Antibiotic Susceptibility Test (AST) was done by Kirby-Bauer disk diffusion method and the detection of ESBL and MBL production were done using Ceftazidime/clavulanic acid combined disk test and Imipenem- Ethylenenediaminetetraacetic acid combined disk test respectively as per CLSI guideline 2014. Results: The prevalence rate of P. aeruginosa was found to be 7.9% in pus samples. Out of 25 P. aeruginosa isolates 9(36%) were ESBL producers and 2(8%) were MBL producers. ESBL producers were predominant in the age group 2-3 years (33.3%) and in male patient (55.6%). Out of 2 MBL producing P. aeruginosa, 1(50%)was isolated from the age group below 2 years and male patient and 1(50%) from the age group 8-9 years and female patient. 96% of isolates showed sensitive to Polymyxin B. Conclusion: The study showed increasing trend of ESBL and MBL production in P. aeruginosa so constant survey of prevalence of ESBL and MBL producing isolates is essential to control and manage spread of these isolates in different units of health institutions.

scholarly journals Presence of different beta-lactamase classes among clinical isolates of Pseudomonas aeruginosa expressing AmpC beta-lactamase enzyme

2010 ◽  
Vol 4 (04) ◽  
pp. 239-242 ◽  
Author(s):  
Supriya Upadhyay ◽  
Malay Ranjan Sen ◽  
Amitabha Bhattacharjee
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Treatment Options ◽  
Clinical Isolates ◽  
Diffusion Method ◽  
Beta Lactamase ◽  
Beta Lactam ◽  
Disk Diffusion Method ◽  
Extended Spectrum Beta Lactamase ◽  
Extended Spectrum ◽  
Enzyme Detection

Introduction: Infections caused by Pseudomonas aeruginosa are difficult to treat as the majority of isolates exhibit varying degrees of beta-lactamase mediated resistance to most of the beta-lactam antibiotics. It is also not unusual to find a single isolate that expresses multiple β-lactamase enzymes, further complicating the treatment options. Thus the present study was designed to investigate the coexistence of different beta-lactamase enzymes in clinical isolates of P. aeruginosa. Methodology: A total of 202 clinical isolates of P. aeruginosa were tested for the presence of AmpC beta-lactamase, extended spectrum beta-lactamase (ESBL) and metallo beta-lactamase (MBL) enzyme. Detection of AmpC beta-lactamase was performed by disk antagonism test and a modified three-dimensional method, whereas detection of ESBL was done by the combined disk diffusion method per Clinical and Laboratory Standards Institute (CLSI) guidelines and MBL were detected by the Imipenem EDTA disk potentiation test. Results: A total of 120 (59.4%) isolates were confirmed to be positive for AmpC beta-lactamase. Among them, 14 strains (7%) were inducible AmpC producers. Co-production of AmpC along with extended spectrum beta-lactamase and metallo beta-lactamase was reported in 3.3% and 46.6% isolates respectively. Conclusion: The study emphasizes the high prevalence of multidrug resistant P. aeruginosa producing beta-lactamase enzymes of diverse mechanisms. Thus proper antibiotic policy and measures to restrict the indiscriminative use of cephalosporins and carbapenems should be taken to minimize the emergence of this multiple beta-lactamase producing pathogens.

scholarly journals Extended Spectrum Beta Lactamase (ESBL) Producing Klebsiella pneumoniae , a therapeutic challenge.

2015 ◽  
Vol 13 (1) ◽  
pp. 22-25
Author(s):  
Raina Chaudhary ◽  
Sabita Bhatt Bhatt ◽  
Eva Piya
Keyword(s):  
Klebsiella Pneumoniae ◽  
Multidrug Resistant ◽  
Diffusion Method ◽  
Clinical Samples ◽  
Gram Negative Bacteria ◽  
Beta Lactamase ◽  
Esbl Producer ◽  
Extended Spectrum Beta Lactamase ◽  
Extended Spectrum ◽  
Sensitivity Pattern

Introduction: Klebsiella pneumoniae is one of the most common Gram negative bacteria encountered byclinicians worldwide as a cause of infections in human. Most of the infections are acquired in hospital settingtherefore, it is reported to be the amongst the 10 most common nosocomial pathogen in various studies. Nowadays,Klebsiella pneumoniae infections are complicated by increase in Extended Spectrum Beta Lactamase (ESBL)producing isolates. Therefore, this study is being conducted with the objective to fi nd out the prevalence ofESBL producing Klebsiella pneumoniaein various clinical samples and to fi nd out there sensitivity pattern.Methods: A total of 100 Klebsiella pneumoniae were isolated from various samples during the period of April2013 to November 2013 in Microbiology Unit of Shree Birendra Hospital. All the isolates were identifi ed withtheir sensitivity pattern according to standard methodology. Combination disc diffusion method was followedfor identifi cation of ESBL.Results: Out of total 100 isolates of Klebsiella pneumoniae21% were ESBL producer.ESBL producer isolatesshowed 100% sensitivity to Imepenem followed by Amikacin 57.1% and Chloramphenicol 47.6%. All theESBL isolates were resistant to both Cefotaxime and Ceftazidime.Conclusions: ESBL producer Klebsiella pneumoniae isolates were multidrug resistant. Continuous surveillanceand timely intervention with discouraging the use of cephalosporin group of antibiotics is mandatory.doi:  http://dx.doi.org/10.3126/mjsbh.v13i1.12996 

scholarly journals Prevalence of Escherichia coli and Klebsiella pneumoniae, Producing Extended-Spectrum Beta-Lactamase (ESBLs) from Clinical Specimen in Khuzestan, Iran

2021 ◽  
Vol In Press (In Press) ◽  
Author(s):  
Sahar Besharati Zadeh ◽  
Pegah Shakib ◽  
Mohammad Reza Zolfaghari ◽  
Ahmad Farajzadeh Sheikh
Keyword(s):  
Escherichia Coli ◽  
Antibiotic Resistance ◽  
Klebsiella Pneumoniae ◽  
Clinical Specimen ◽  
Diffusion Method ◽  
Beta Lactamase ◽  
Extended Spectrum Beta Lactamase ◽  
E Coli ◽  
Extended Spectrum ◽  
Sensitivity Pattern

Background: A major problem in the treatment of the infectious diseases healthcare centers is extended-spectrum beta-lactamase (ESBL)-producing bacteria. Objectives: The aim of present study was to identify the antibiotic sensitivity pattern and prevalence of the blaCTX, blaTEM, and blaSHV genes in Escherichia coli and Klebsiella pneumoniae strains. Methods: In this study, E. coli and K. pneumoniae specimens were collected in Shushtar hospitals, Khuzestan (southwest Iran), from March to October 2015. Sensitivity antibiotic pattern performed by disc diffusion method. Double disc synergy test (DDST) done for identifying ESBLs isolates and PCR for blaTEM, blaSHV, and blaCTX-M genes. Results: One hundred E. coli and 30 K. pneumoniae isolates were collected from different specimens. The highest rates of antibiotic resistance related to cefotaxime and aztreonam in E. coli and K. pneumoniae. ESBL-harboring K. pneumoniae and E. coli were 13.5 and 28%, respectively. Overall, bla TEM was the most prevalent ESBL gene. Conclusions: In this study, the rate of antibiotic resistance was high, and due to the carrying of coding genes on mobile genetic elements and the ability of these elements to carry genes that create resistance to other antibiotic families, identification and isolation of these isolates are essential to find effective antibiotics and eliminate the infection.

scholarly journals High Carrying Rate of Extended-Spectrum Beta-Lactamase (ESBL) Producing Enterobacteriaceae by Slaughterhouse Workers in Lomé, Togo in 2019

2020 ◽  
pp. 30-41
Author(s):  
Amivi Mawussi Godonou ◽  
Fifonsi Adjidossi Gbeasor-Komlanvi ◽  
Novissi Tsogbale ◽  
Fiali Lack ◽  
Sika Dossim ◽  
...  
Keyword(s):  
Clavulanic Acid ◽  
Health Concern ◽  
Diffusion Method ◽  
Food Chains ◽  
Beta Lactamase ◽  
Bacterial Strains ◽  
Carriage Rate ◽  
Extended Spectrum Beta Lactamase ◽  
Extended Spectrum

Introduction: Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL) represent a real public health concern because of their spread. The role of agri-food chains in transmitting of digestive ESBL-producing bacterial strains in the community, was demonstrated but little work was done in our settings (Togo, west Africa). The aim of this study was to estimate the rate of digestive carrying ESBL producing enterobacteriacae in slaughterhouse workers in Lomé, Togo. Material and Methods: This was a cross-sectional study carried out in three slaughterhouses in Lomé. Fresh stools of 60 slaughterhouse workers and socio-demographic data were collected during the period of September to October 2019 after obtaining the consent of each participant. The bacterial strains of interest were isolated on the selective medium Purple Bromocresol + Ceftazidime at 6µg/l. UriselectÒ and API 20E media were used for identification. Antibiotic susceptibility test was performed in Mueller-Hinton agar plate diffusion method (Kirby Bauer technic) and according to CASFM-EUCAST recommendations. Results: The digestive carriage rate of ESBL producing enterobacteriacae among professionals of three slaughterhouses of Lomé was 80% (n=48/60). Escherichia coli was the main bacteria 78.2% (n = 43/55) followed by Klebsiella pneumoniae 16.4% (n = 9/55) and Enterobacter cloacae 5.4% (n = 3/55). The antibiotic profile of ESBL producing enterobacteriacae showed resistance to Amoxycillin + Clavulanic Acid (26%), Ticarcillin + Clavulanic Acid (86%), Piperacillin + Tazobactam (14%), Cefoxitin (7%) Ciprofloxacin (63%), Levofloxacin (49%), Nalidixic Acid (42%), Chloramphenicol (33%), Gentamicin (21%), Sulfamethoxazole-Trimetoprim (93%). These bacteria were 100% sensitive to Imipenem, Ertapenem, Amikacin and Fosfomycin. Conclusion: This study revealed a very high carriage rate of ESBL producing Enterobacteriacae among Slaughterhouse Workers in Lomé. It confirmed the major potential role of the agri-food chains in the spread of ESBL producing bacteria in the Community.

scholarly journals Coproduction of Extended Spectrum, AmpC and Metallo β- Lactamases in Pseudomonas aeruginosa Isolates from a Super Speciality Center

2021 ◽  
Vol 10 (10) ◽  
pp. 176-184
Author(s):  
Ashna Bhasin Poonam Loomba ◽  
Abha Sharma Bibhabati Mishra ◽  
Ashish Bajaj
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Treatment Options ◽  
Multidrug Resistant ◽  
Clinical Isolates ◽  
Diffusion Method ◽  
Beta Lactamase ◽  
Beta Lactam ◽  
Disk Diffusion Method ◽  
Extended Spectrum Beta Lactamase ◽  
Extended Spectrum

Pseudomonas aeruginosa (P. aeruginosa) is one of the leading causes of hospital as well as community acquired infections. They’re strenuous to treat as most of isolates exhibit various degrees of beta- lactamase mediated resistance to majority of the beta-lactam antibiotics. Single isolate can express multiple β- lactamase enzymes, further limiting the treatment options. Therefore, this study was outlined to research the coexistence of various beta-lactamase enzymes in clinical isolates of P. aeruginosa. The aim of the study was to detect the co-prevalence of Extended Spectrum Beta lactmases (ESBL), AmpC and Metallo β-Lactamases (MBL) in Pseudomonas aeruginosa isolates from a superspeciality center. Fifty clinical isolates of P. aeruginosa were tested for the presence of AmpC beta-lactamase, extended spectrum beta- lactamase (ESBL) and metallo beta-lactamase (MBL) enzyme. Discernment of AmpC beta-lactamase was performed by disk antagonism while ESBL detection was done by the combined disk diffusion method as per Clinical and Laboratory Standards Institute (CLSI) guidelines and MBL were detected by the Imipenem EDTA disk potentiation test. Eleven of 50 (22%) isolates were confirmed to be positive for AmpC and Extended spectrum beta lactamases. Co-production of AmpC along side ESBL and MBL was reported in 12 % isolates. The study shows the high prevalence of multidrug resistant P. aeruginosa producing beta-lactamase enzymes of diverse mechanisms. Consequently, formulation of a correct antibiotic policy and taking measures to restrict the indiscriminative use of cephalosporins and carbapenems should be taken to mitigate the emergence of this multiple beta-lactamase producing pathogens.

Multidrug-resistant Pseudomonas aeruginosa isolated from ear and wound swabs in some selected hospital laboratories in Sokoto Metropolis, Nigeria

2020 ◽  
Vol 3 ◽  
pp. 31-35
Author(s):  
A. I. Umar ◽  
I. Garba ◽  
M. L. Jidda ◽  
A. M. Ganau ◽  
A. S. Fana ◽  
...  
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Antimicrobial Agents ◽  
Opportunistic Infections ◽  
Antibiotic Sensitivity ◽  
Diffusion Method ◽  
Resistance Pattern ◽  
Multiple Drug ◽  
Drug Resistant ◽  
Sensitivity Testing ◽  
Wide Range

Objective: Pseudomonas aeruginosa is a metabolically versatile bacterium that can cause a wide range of severe opportunistic infections in patients with serious underlying conditions and can be found in most communities in Nigeria. The study was to determine the prevalence, resistance pattern and distribution of multiple drug resistant P. aeruginosa (MDR-PA) isolated from ear and wound specimens in patients attending Specialist Hospital Sokoto and Maryam Abacha Women and Children Hospital Sokoto. Materials and Methods: A total of 150 samples were analysed by standard bacteriological methods. Screening for MDR-PA was carried out by antibiotic sensitivity testing using disc diffusion method with ceftazidime (30 µg), ofloxacin (5 µg), cefuroxime (30 µg), cloxacillin (30 µg), amoxicillin (30 µg), ceftriaxone (30 µg), imipenem (10 µg), gentamycin (10 µg) and colistin (10 µg) discs on Mueller Hinton agar. Results: Of a total of 55 (36.7%) isolates of P. aeruginosa strains were obtained, 30 (54.5%) isolates were resistant to imipenem, 31 (56.3%) were resistant to ofloxacin, 44 (80.0%) to gentamycin, 53 (96.3%) to ceftazidime and cefuroxime, 50 (90.9%) to ceftrizone, 54 (98.1%) to cloxacillin and amoxycillin and lastly 15 (27.2%) to colistin. All the isolates were multi drug resistant, this probably due to improper use or over the counter purchase of antibiotics without professional oversight. Conclusion: Almost all the isolates were resistant to all the antibiotics used including colistin. There is need to improve on the public health awareness on the indiscriminate use of antimicrobial agents as it is one of the major ways microbes develop resistance to them.

scholarly journals Multi-drug Resistant and Extended Spectrum β-lactamase Producing Salmonella Species Isolated from Fresh Chicken Liver Samples

2020 ◽  
Vol 18 (1) ◽  
pp. 23-27
Author(s):  
S. Adhikari ◽  
S. Khadka ◽  
S. Sapkota ◽  
B.R. Sharma ◽  
A. Ghimire ◽  
...  
Keyword(s):  
Meat Products ◽  
Chicken Liver ◽  
Health Concern ◽  
Diffusion Method ◽  
Beta Lactamase ◽  
Drug Resistant ◽  
Global Public Health ◽  
Disk Diffusion Method ◽  
Extended Spectrum Beta Lactamase ◽  
Extended Spectrum

Background Emergence of antibiotic resistance among microbes contaminating the fresh meat products is a global public health concern as they can be easily transmitted to humans through their consumption and contact. Objective The current study was conducted to determine the distribution of antimicrobial resistance among Salmonella species isolated from fresh chicken liver samples with special emphasis on extended spectrum beta-lactamase (ESBL) production. Method A total of 200 fresh chicken liver samples were cultivated for the isolation of Salmonella and further subcultivated to detect extended spectrum beta-lactamase production among them. Antimicrobial susceptibility testing (AST) was done by disk diffusion method using a panel of 7 antimicrobials. Result Out of 200 samples analyzed, 61 (30.5%) samples harbored Salmonella species out of which 15 (7.5%) samples showed the presence of Salmonella Typhi. A significant association was noted in the incidence of Salmonella with various factors pertaining to the butchers, such as age, sex, literacy rate, practices of washing knives and chopping board, wearing aprons and gloves and type of water used (p < 0.05). Salmonella isolates were highly sensitive to amikacin (82.0%) and least sensitive to tetracycline (3.3%). All the isolates were resistant to colistin. Sixty (98.4%) isolates were identified as multi-drug resistant (MDR). The total number of extended spectrum beta-lactamase producers reported among Salmonella isolates was 29 (47.5%). Conclusion The results indicate that the fresh chicken liver samples sold in Bharatpur Metropolis are reservoirs of multi-drug resistant Salmonella, including extended spectrum beta-lactamase producers, that could potentially be transmitted to the humans by direct contact or through inadequate cooking.

scholarly journals Detection of extended spectrum beta-lactamase genes in Pseudomonas aeruginosa isolated from patients in rural Eastern Cape Province, South Africa

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Mojisola C. Hosu ◽  
Sandeep D. Vasaikar ◽  
Grace E. Okuthe ◽  
Teke Apalata
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Antimicrobial Resistance ◽  
Multidrug Resistant ◽  
High Rate ◽  
Infection Prevention And Control ◽  
Beta Lactamase ◽  
Eastern Cape ◽  
Extended Spectrum Beta Lactamase ◽  
Extended Spectrum ◽  
Resistance Patterns

AbstractThe proliferation of extended spectrum beta-lactamase (ESBL) producing Pseudomonas aeruginosa represent a major public health threat. In this study, we evaluated the antimicrobial resistance patterns of P. aeruginosa strains and characterized the ESBLs and Metallo- β-lactamases (MBL) produced. Strains of P. aeruginosa cultured from patients who attended Nelson Mandela Academic Hospital and other clinics in the four district municipalities of the Eastern Cape between August 2017 and May 2019 were identified; antimicrobial susceptibility testing was carried out against thirteen clinically relevant antibiotics using the BioMérieux VITEK 2 and confirmed by Beckman autoSCAN-4 System. Real-time PCR was done using Roche Light Cycler 2.0 to detect the presence of ESBLs; blaSHV, blaTEM and blaCTX-M genes; and MBLs; blaIMP, blaVIM. Strains of P. aeruginosa demonstrated resistance to wide-ranging clinically relevant antibiotics including piperacillin (64.2%), followed by aztreonam (57.8%), cefepime (51.5%), ceftazidime (51.0%), piperacillin/tazobactam (50.5%), and imipenem (46.6%). A total of 75 (36.8%) multidrug-resistant (MDR) strains were observed of the total pool of isolates. The blaTEM, blaSHV and blaCTX-M was detected in 79.3%, 69.5% and 31.7% isolates (n = 82), respectively. The blaIMP was detected in 1.25% while no blaVIM was detected in any of the strains tested. The study showed a high rate of MDR P. aeruginosa in our setting. The vast majority of these resistant strains carried blaTEM and blaSHV genes. Continuous monitoring of antimicrobial resistance and strict compliance towards infection prevention and control practices are the best defence against spread of MDR P. aeruginosa.

scholarly journals Evaluation of extended spectrum beta lactamase enzymes prevalence in clinical isolates of Escherichia coli

2011 ◽  
Vol 2 (1) ◽  
pp. 8
Author(s):  
Ronak Bakhtiari ◽  
Jalil Fallah Mehrabadi ◽  
Hedroosha Molla Agamirzaei ◽  
Ailar Sabbaghi ◽  
Mohammad Mehdi Soltan Dallal
Keyword(s):  
Escherichia Coli ◽  
Disk Diffusion ◽  
Confirmatory Test ◽  
Diffusion Method ◽  
Multi Drug Resistance ◽  
Beta Lactamase ◽  
Disk Diffusion Method ◽  
Extended Spectrum Beta Lactamase ◽  
E Coli ◽  
Extended Spectrum

Resistance to b-lactam antibiotics by gramnegative bacteria, especially <em>Escherichia coli (E. coli)</em>, is a major public health issue worldwide. The predominant resistance mechanism in gram negative bacteria particularly <em>E. coli </em>is via the production of extended spectrum beta lactamase (ESBLs) enzymes. In recent years, the prevalence of b-lactamase producing organisms is increased and identification of these isolates by using disk diffusion method and no-one else is not satisfactory. So, this investigation focused on evaluating the prevalence of ESBL enzymes by disk diffusion method and confirmatory test (Combined Disk). Five hundred clinical samples were collected and 200 <em>E. coli </em>isolates were detected by standard biochemical tests. To performing initial screening of ESBLs was used from Disk diffusion method on <em>E. coli </em>isolates. A confirmation test (Combined Disk method) was performed on isolates of resistant to cephalosporin's indicators. Up to 70% isolates exhibited the Multi Drug Resistance phenotype. In Disk diffusion method, 128(64%) <em>E. coli </em>isolates which resistant to ceftazidime and cefotaxime while in Combined Disk, among 128 screened isolates, 115 (89.8%) isolates were detected as ESBLs producers. This survey indicate beta lactamase enzymes are playing a significant role in antibiotic resistance and correct detection of them in phenotypic test by using disk diffusion and combined Disk is essential for accurate recognition of ESBLs.

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