Self-Care Behaviors in Pregnant Women with Gestational Diabetes
Self-care Behaviors in Gestational Diabetes
DOI:
https://doi.org/10.31661/gmj.v13i.3235Keywords:
Gestational Diabetes; Self-care; Lifestyle; HyperglycemiaAbstract
Gestational diabetes (GD) is a type of diabetes that is considered a prevalent health issue that has been reported to represent an increasing trend in the past two decades. It is demonstrated that the prevalence of GD is irrespective of the country’s income status and is associated with complications of maternal and fetal due to maternal hyperglycemia. Although no specific treatment for GD has been established, various studies have suggested self-care as a potential strategy. Therefore, the current study aimed to review the effectiveness of self-care in pregnant women with GD. The findings revealed that increasing awareness of the pathophysiology and consequences of GD along with improving self-care behaviors such as monitoring blood glucose levels, changing lifestyle, and maintaining mothers’ health can potentially improve indicators related to diabetes. However, further studies with larger sample sizes and evaluation of related clinical/laboratory indicators in this content appear to be crucially required to confirm current understanding.
References
Mohebbi B, Tol A, Sadeghi R, Mohtarami SF, Shamshiri A. Self-management intervention program based on the health belief model (HBM) among women with gestational diabetes mellitus: A quazi-experimental study. Arch Iran med. 2019;22(4):168-73.
Rollo ME, Baldwin JN, Hutchesson M, Aguiar EJ, Wynne K, Young A et al. The feasibility and preliminary efficacy of an eHealth lifestyle program in women with recent gestational diabetes mellitus: a pilot study. Int jour env res pub health. 2020;17(19):7115.
https://doi.org/10.3390/ijerph17197115
PMid:32998401 PMCid:PMC7579575
McIntyre HD, Catalano P, Zhang C, Desoye G, Mathiesen ER, Damm P. Gestational diabetes mellitus. Nat Rev Dis Primers. 2019;5(1):47.
https://doi.org/10.1038/s41572-019-0098-8
PMid:31296866
Borgen I, Småstuen MC, Jacobsen AF, Garnweidner-Holme LM, Fayyad S, Noll J, Lukasse M. Effect of the Pregnant+ smartphone application in women with gestational diabetes mellitus: a randomised controlled trial in Norway. BMJ open. 2019;9(11):e030884.
https://doi.org/10.1136/bmjopen-2019-030884
PMid:31719080 PMCid:PMC6858205
Lefkovits YR, Stewart ZA, Murphy HR. Gestational diabetes. Medicine. 2019;47(2):114-8.
https://doi.org/10.1016/j.mpmed.2018.11.006
Hasan AK, Ali SH, Hussein WA. Impact of Serum level of L-Carnitine on Chitotriosidase in Women with Gestational Diabetes Compared to T2DM Pregnant & Non Pregnant Iraqi Women. Prof(Dr) RK Sharma. 2020;20(4):41075.
https://doi.org/10.37506/mlu.v20i4.1966
Moon JH, Jang HC. Gestational diabetes mellitus: diagnostic approaches and maternal-offspring complications. Diabetes Metab J. 2022;46(1):3-14.
https://doi.org/10.4093/dmj.2021.0335
PMid:35135076 PMCid:PMC8831816
Reece EA. The fetal and maternal consequences of gestational diabetes mellitus. J Matern Fetal Neonatal Med. 2010;23(3):199-203.
https://doi.org/10.3109/14767050903550659
PMid:20121460
Tu F, Fei A. Maternal and neonatal outcomes of singleton versus twin pregnancies complicated by gestational diabetes mellitus: A systematic review and meta-analysis. Plos one. 2023;18(1):e0280754.
https://doi.org/10.1371/journal.pone.0280754
PMid:36696415 PMCid:PMC9876238
McLean M, Chipps D, Cheung NW. Mother to child transmission of diabetes mellitus: does gestational diabetes program Type 2 diabetes in the next generation? Diabet Med. 2006;23(11):1213-5.
https://doi.org/10.1111/j.1464-5491.2006.01979.x
PMid:17054597
La Verde M, Torella M, Riemma G, Narciso G, Iavarone I, Gliubizzi L et al. Incidence of gestational diabetes mellitus before and after the Covid-19 lockdown: A retrospective cohort study. J Obstet Gynaecol Res. 2022;48(5):1126-31.
https://doi.org/10.1111/jog.15205
PMid:35199420 PMCid:PMC9115303
Sweeting A, Wong J, Murphy HR, Ross GP. A clinical update on gestational diabetes mellitus. Endocrine rev. 2022;43(5):763-93.
https://doi.org/10.1210/endrev/bnac003
PMid:35041752 PMCid:PMC9512153
Borgen I, Garnweidner-Holme LM, Jacobsen AF, Bjerkan K, Fayyad S, Joranger P et al. Smartphone application for women with gestational diabetes mellitus: a study protocol for a multicentre randomised controlled trial. BMJ open. 2017;7(3):e013117.
https://doi.org/10.1136/bmjopen-2016-013117
PMid:28348183 PMCid:PMC5372027
Mirfeizi M, Tourzani ZM, Jafarabadi MA, Hanjani SM, Hasanzad M. Health Education in Gestational Diabetes Mellitus and Quality of Life. J of Midwifery & Reprod Health. 2017;5(4):1066.
Allehdan SS, Basha AS, Asali FF, Tayyem RF. Dietary and exercise interventions and glycemic control and maternal and newborn outcomes in women diagnosed with gestational diabetes: Systematic review. Diabetes Metab Syndr. 2019;13(4):2775-84.
https://doi.org/10.1016/j.dsx.2019.07.040
PMid:31405707
Carolan-Olah M, Duarte-Gardea M, Lechuga J. A systematic review of interventions for Hispanic women with or at risk of Gestational diabetes mellitus (GDM). Sex Reprod Health. 2017;13:14-22.
https://doi.org/10.1016/j.srhc.2017.02.006
PMid:28844353
Care D. Standards of medical care in diabetes 2012. Diabetes care. 2012; 35 (Suppl 1):11-63.
https://doi.org/10.2337/dc12-s011
PMid:22187469 PMCid:PMC3632172
Haron Z, Sutan R, Zakaria R, Abdullah Mahdy Z. Self-care educational guide for mothers with gestational diabetes mellitus: A systematic review on identifying self-care domains, approaches, and their effectiveness. Belitung nurs j. 2023;9(1):6-16.
https://doi.org/10.33546/bnj.2396
PMid:37469635 PMCid:PMC10353652
Kapur A. Links between maternal health and NCDs. Best Practice & Research Clinical Obstetrics & Gynaecology. 2015;29(1):32-42.
https://doi.org/10.1016/j.bpobgyn.2014.04.016
PMid:25199858
Care D. Care in Diabetesd2018. Diabetes care. 2018;41(1):S137-S43.
https://doi.org/10.2337/dc18-S013
PMid:29222384
Lim S, Takele WW, Vesco KK, Redman LM, Hannah W, Bonham MP et al. Participant characteristics in the prevention of gestational diabetes as evidence for precision medicine: a systematic review and meta-analysis. Commun Med. 2023;3(1):137.
https://doi.org/10.1038/s43856-023-00366-x
PMid:37794119 PMCid:PMC10551015
Madan S, Kurian N, Nagpal N. Gestational Diabetes-An Endocrinologist's Perspective. Series Endo Diab. 2023:5(1):22-24.
https://doi.org/10.54178/jsedmv5i1004
Retnakaran R, Ye C, Hanley AJ, Connelly PW, Sermer M, Zinman B. Treatment of Gestational Diabetes Mellitus and Maternal Risk of Diabetes After Pregnancy. Diabetes care. 2023;46(3):587-92.
https://doi.org/10.2337/dc22-1786
PMid:36602334
Martín-Estal I, Castorena-Torres F. Gestational diabetes mellitus and energy-dense diet: what is the role of the insulin/IGF axis? Fron Endocrinol. 2022;13:916042.
https://doi.org/10.3389/fendo.2022.916042
PMid:35813659 PMCid:PMC9259869
Goyal A, Gupta Y, Singla R, Kalra S, Tandon N. American diabetes association "standards of medical care-2020 for gestational diabetes mellitus": a critical Appraisal. Diabetes Ther. 2020;11:1639-44.
https://doi.org/10.1007/s13300-020-00865-3
PMid:32564336 PMCid:PMC7376815
Castillo WC, Boggess K, Stürmer T, Brookhart MA, Benjamin DK, Funk MJ. Association of adverse pregnancy outcomes with glyburide vs insulin in women with gestational diabetes. JAMA pediat. 2015;169(5):452-8.
https://doi.org/10.1001/jamapediatrics.2015.74
PMid:25822253
Nethery EM. Gestational diabetes screening changes and impacts on diagnosis. University of British: Columbia; 2022.
Sharma AK, Singh S, Singh H, Mahajan D, Kolli P, Mandadapu G et al. Deep Insight of the Pathophysiology of Gestational Diabetes Mellitus. Cells. 2022;11(17):2672.
https://doi.org/10.3390/cells11172672
PMid:36078079 PMCid:PMC9455072
Trout KK, Compher C, Durnwald CP. 753-P: Protein vs Carbohydrate in Gestational Diabetes. Diabetes. 2019;68(Supplement_1):753.
https://doi.org/10.2337/db19-753-P
Plows JF, Stanley JL, Baker PN, Reynolds CM, Vickers MH. The pathophysiology of gestational diabetes mellitus. Int j mol sci. 2018;19(11):3342.
https://doi.org/10.3390/ijms19113342
PMid:30373146 PMCid:PMC6274679
Parrettini S, Caroli A, Torlone E. Nutrition and metabolic adaptations in physiological and complicated pregnancy: focus on obesity and gestational diabetes. Front Endocrinol. 2020;11:611929.
https://doi.org/10.3389/fendo.2020.611929
PMid:33424775 PMCid:PMC7793966
Zehravi M, Maqbool M, Ara I. Correlation between obesity, gestational diabetes mellitus, and pregnancy outcomes: an overview. Int J Adolesc Med Health. 2021;33(6):339-45.
https://doi.org/10.1515/ijamh-2021-0058
PMid:34142511
Permana PA, Menge C, Reaven PD. Macrophage-secreted factors induce adipocyte inflammation and insulin resistance. Biochem Biophys Res Commun. 2006;341(2):507-14.
https://doi.org/10.1016/j.bbrc.2006.01.012
PMid:16427608
Zhang Z, Wu Y, Zhong C, Zhou X, Liu C, Li Q et al. Association between dietary inflammatory index and gestational diabetes mellitus risk in a prospective birth cohort study. Nutrition. 2021;87:111193.
https://doi.org/10.1016/j.nut.2021.111193
PMid:33774421
Jafari Khorchani M, Samare-Najaf M, Abbasi A, Vakili S, Zal F. Effects of quercetin, vitamin E, and estrogen on Metabolic-Related factors in uterus and serum of ovariectomized rat models. Gynecol Endocrinol. 2021;37(8):764-8.
https://doi.org/10.1080/09513590.2021.1879784
PMid:33525940
Kawai T, Autieri MV, Scalia R. Adipose tissue inflammation and metabolic dysfunction in obesity. Am J Physiol Cell Physiol. 2021;320(3):C375-C91.
https://doi.org/10.1152/ajpcell.00379.2020
PMid:33356944 PMCid:PMC8294624
Qiu C, Sorensen TK, Luthy DA, Williams MA. A prospective study of maternal serum C-reactive protein (CRP) concentrations and risk of gestational diabetes mellitus. Paediatr Perinat Epidemiol. 2004;18(5):377-84.
https://doi.org/10.1111/j.1365-3016.2004.00578.x
PMid:15367325
Wolf M, Sauk J, Shah A, Smirnakis KV, Jimenez-Kimble R, Ecker JL, Thadhani R. Inflammation and glucose intolerance A prospective study of gestational diabetes mellitus. Clin Diabetol. 2004;5(2):85-94.
Chandran M, Phillips SA, Ciaraldi T, Henry RR. Adiponectin: more than just another fat cell hormone? Diabetes care. 2003;26(8):2442-50.
https://doi.org/10.2337/diacare.26.8.2442
PMid:12882876
Fasshauer M, Blüher M, Stumvoll M. Adipokines in gestational diabetes. Lancet Diabetes Endocrinol. 2014;2(6):488-99.
https://doi.org/10.1016/S2213-8587(13)70176-1
PMid:24731659
Qiu C, Williams MA, Vadachkoria S, Frederick IO, Luthy DA. Increased maternal plasma leptin in early pregnancy and risk of gestational diabetes mellitus. Obstet Gynecol. 2004;103(3):519-25.
https://doi.org/10.1097/01.AOG.0000113621.53602.7a
PMid:14990416
Farina A, Eklund E, Bernabini D, Paladino M, Righetti F, Monti G, Lambert-Messerlian G. A first-trimester biomarker panel for predicting the development of gestational diabetes. Reprod sci. 2017;24(6):954-9.
https://doi.org/10.1177/1933719116675057
PMid:27837083
Moradi F, Ghadiri-Anari A, Enjezab B. COVID-19 and self-care strategies for women with gestational diabetes mellitus. Diabetes & Metabolic Syndrome: Clin Res Rev. 2020;14(5):1535-9.
https://doi.org/10.1016/j.dsx.2020.08.004
PMid:32947751 PMCid:PMC7837010
Shan Y, Chen J, Zhou S, Wen G. Nursing Interventions and Care Strategies for Patients with Coronary Heart Disease: A Comprehensive Review. Galen Med J. 2023;12:e2994-e.
https://doi.org/10.31661/gmj.v12i.2994
PMid:38774841 PMCid:PMC11108677
Karavasileiadou S, Almegewly W, Alanazi A, Alyami H, Chatzimichailidou S. Self-management and self-efficacy of women with gestational diabetes mellitus: a systematic review. Global Health Action. 2022;15(1):2087298.
https://doi.org/10.1080/16549716.2022.2087298
PMid:35867537 PMCid:PMC9310944
Elamurugan S, Arounassalame B. What do mothers know about gestational diabetes: knowledge and awareness. Indian J Obstet Gynecol Res. 2016;3(4):393-6.
Al-Hashmi I, Hodge F, Nandy K, Thomas E, Brecht M-L. The effect of a self-efficacy-enhancing intervention on perceived self-efficacy and actual adherence to healthy behaviours among women with gestational diabetes mellitus. Sultan Qaboos Univ Med J. 2018;18(4):e513.
https://doi.org/10.18295/squmj.2018.18.04.014
PMid:30988972 PMCid:PMC6443280
Chahed S, Lassouad L, Dardouri M, Mtiraoui A, Maaroufi A, Khairi H. Impact of a tailored-care education programme on maternal and neonatal outcomes in pregnant women with gestational diabetes: a randomized controlled trial. Pan Afr Med J. 2022;43:1.
https://doi.org/10.11604/pamj.2022.43.128.34084
PMid:36762155 PMCid:PMC9883796
Karbalai Harafteh F, Karami Mohajeri Z, Kia S. The Effect of Self-care Training on Perceived Stress, Health Literacy, and Self-care Behaviors in Women with Gestational Diabetes. Commun Health J. 2020;14(2):30-9.
Khadivzadeh T, Hoseinzadeh M, Azhari S, Esmaily H, Akhlaghi F, Sardar MA. Effects of self-care education on perceived stress in women with gestational diabetes under insulin treatment. Evid Based Care. 2015;5(3):7-18.
Kordi M, Banaei M, Asgharipour N, Mazloum SR, Akhlaghi F. Prediction of self-care behaviors of women with gestational diabetes based on Belief of Person in own ability (self-efficacy) Iran J Obstet Gynecol. Infertil. 2016;19(13):6-17.
Kolivand M, Keramat A, Rahimi M, Motaghi Z, Shariati M, Emamian M. Self-care education needs in gestational diabetes tailored to the Iranian culture: a qualitative content analysis. Iran J Nurs Midwifery Res. 2018;23(3):222.
https://doi.org/10.4103/ijnmr.IJNMR_108_17
PMid:29861762 PMCid:PMC5954645
Zandinava H, Shafaei FS, Charandabi S-A, Homayi SG, Mirghafourvand M. Effect of educational package on Self-Care behavior, quality of life, and blood glucose levels in pregnantwomen with gestational diabetes: A randomized controlled trial. Iran Red Crescent Med J. 2017;19(4): e44317.
https://doi.org/10.5812/ircmj.44317
Cao X, Wang Z, Yang C, Mo X, Xiu L, Li Y, Xiao H. Comprehensive intensive therapy for Chinese gestational diabetes benefits both newborns and mothers. Diabetes Technol Therapeut. 2012;14(11):1002-7.
https://doi.org/10.1089/dia.2012.0142
PMid:23046401
He R, Lei Q, Hu H, Li H, Tian D, Lai Z. The effect of health education combined with personalized psychological nursing intervention on pregnancy outcome of pregnant women with gestational diabetes mellitus. BioMed Res Internat. 2022;2022:3157986.
https://doi.org/10.1155/2022/3157986
PMid:35345524 PMCid:PMC8957459
Rokni S, Rezaei Z, Noghabi AD, Sajjadi M, Mohammadpour A. Evaluation of the effects of diabetes self-management education based on 5A model on the quality of life and blood glucose of women with gestational diabetes mellitus: An experimental study in eastern Iran. J prev med hyg. 2022;63(3):E442.
Xie Y, Zhao H, Zhao M, Huang H, Liu C, Huang F, Wu J. Effects of resistance exercise on blood glucose level and pregnancy outcome in patients with gestational diabetes mellitus: a randomized controlled trial. BMJ Open Diabet Res and Care. 2022;10(2):e002622.
https://doi.org/10.1136/bmjdrc-2021-002622
PMid:35383101 PMCid:PMC8984031
Al-Ofi EA, Mosli HH, Ghamri KA, Ghazali SM. Management of postprandial hyperglycaemia and weight gain in women with gestational diabetes mellitus using a novel telemonitoring system. J Internat Med Res. 2019;47(2):754-64.
https://doi.org/10.1177/0300060518809872
PMid:30442052 PMCid:PMC6381491
Kim Y-S, Kim H-S, Kim Y-L. Effects of a web-based self-management program on the behavior and blood glucose levels of women with gestational diabetes mellitus. Telemed and e-Health. 2019;25(5):407-14.
https://doi.org/10.1089/tmj.2017.0332
PMid:30036165
Murphy HR, Rayman G, Lewis K, Kelly S, Johal B, Duffield K et al. Effectiveness of continuous glucose monitoring in pregnant women with diabetes: randomised clinical trial. Bmj. 2008;337:a1680.
https://doi.org/10.1136/bmj.a1680
PMid:18818254 PMCid:PMC2563261
Ahmed RJ, Gafni A, Hutton EK, Hu ZJ, Sanchez JJ, Murphy HR, Feig DS. The cost implications of continuous glucose monitoring in pregnant women with type 1 diabetes in 3 Canadian provinces: a posthoc cost analysis of the CONCEPTT trial. Can Med Assoc J. 2021;9(2):E627-E34.
https://doi.org/10.9778/cmajo.20200128
PMid:34088734 PMCid:PMC8191590
Feig DS, Donovan LE, Corcoy R, Murphy KE, Amiel SA, Hunt KF et al. Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. The Lancet. 2017;390(10110):2347-59.
https://doi.org/10.1016/S0140-6736(17)32400-5
PMid:28923465
Paramasivam S, Chinna K, Singh A, Ratnasingam J, Ibrahim L, Lim L et al. Continuous glucose monitoring results in lower HbA1c in Malaysian women with insulin-treated gestational diabetes: a randomized controlled trial. Diabetic Med. 2018;35(8):1118-29.
https://doi.org/10.1111/dme.13649
PMid:29663517
Kestilä KK, Ekblad UU, Rönnemaa T. Continuous glucose monitoring versus self-monitoring of blood glucose in the treatment of gestational diabetes mellitus. Diabetes res clin practice. 2007;77(2):174-9.
https://doi.org/10.1016/j.diabres.2006.12.012
PMid:17234297
Wei Q, Sun Z, Yang Y, Yu H, Ding H, Wang S. Effect of a CGMS and SMBG on maternal and neonatal outcomes in gestational diabetes mellitus: a randomized controlled trial. Scientific reports. 2016;6(1):19920.
https://doi.org/10.1038/srep19920
PMid:26814139 PMCid:PMC4728693
Nagle C, Skouteris H, Morris H, Nankervis A, Rasmussen B, Mayall P, Kennedy RL. Primary prevention of gestational diabetes for women who are overweight and obese: a randomised controlled trial. BMC Pregnancy Childbirth. 2013;13:1-6.
https://doi.org/10.1186/1471-2393-13-65
PMid:23497264 PMCid:PMC3669050
Hagobian TA, Phelan S, Gorin AA, Phipps MG, Abrams B, Wing RR. Effects of maternal lifestyle intervention during pregnancy on untreated partner weight: Results from fit for delivery study. Obesity. 2016;24(1):23-5.
https://doi.org/10.1002/oby.21368
PMid:26637985 PMCid:PMC4688135
Garnweidner-Holme L, Henriksen L, Torheim LE, Lukasse M. Effect of the pregnant+ smartphone app on the dietary behavior of women with gestational diabetes mellitus: secondary analysis of a randomized controlled trial. JMIR mHealth and uHealth. 2020;8(11):e18614.
PMid:33146620 PMCid:PMC7673980
Brown J, Alwan NA, West J, Brown S, McKinlay CJ, Farrar D, Crowther CA. Lifestyle interventions for the treatment of women with gestational diabetes. Cochrane Database Syst Rev. 2017;(5):14651858.
https://doi.org/10.1002/14651858.CD011970.pub2
PMid:28472859
Rasmussen L, Poulsen CW, Kampmann U, Smedegaard SB, Ovesen PG, Fuglsang J. Diet and healthy lifestyle in the management of gestational diabetes mellitus. Nutrients. 2020;12(10):3050.
https://doi.org/10.3390/nu12103050
PMid:33036170 PMCid:PMC7599681
Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer X et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. The J Clin Endocrinol Metab. 2008;93(12):4774-9.
https://doi.org/10.1210/jc.2008-0772
PMid:18826999 PMCid:PMC2626441
Seward MW, Simon D, Richardson M, Oken E, Gillman MW, Hivert M-F. Supporting healthful lifestyles during pregnancy: a health coach intervention pilot study. BMC Pregnancy Childbirth. 2018;18:1-11.
https://doi.org/10.1186/s12884-018-2010-z
PMid:30223779 PMCid:PMC6142676
da Silva SG, Hallal PC, Domingues MR, Bertoldi AD, Silveira MFd, Bassani D et al. A randomized controlled trial of exercise during pregnancy on maternal and neonatal outcomes: results from the PAMELA study. Int J Behav Nutr Phys Act. 2017;14(1):1-11.
https://doi.org/10.1186/s12966-017-0632-6
PMid:29273044 PMCid:PMC5741924
Stith BJ, Buls SM, Keim SA, Thung SF, Klebanoff MA, Landon MB et al. Moms in motion: weight loss intervention for postpartum mothers after gestational diabetes: a randomized controlled trial. BMC Pregnancy Childbirth. 2021;21(1):461.
https://doi.org/10.1186/s12884-021-03886-3
PMid:34187391 PMCid:PMC8240610
Galderisi S, Heinz A, Kastrup M, Beezhold J, Sartorius N. Toward a new definition of mental health. World psychiat. 2015;14(2):231.
https://doi.org/10.1002/wps.20231
PMid:26043341 PMCid:PMC4471980
Organization WH. The World Health Report 2001. Mental health: new understanding, new hope; 2001.
Horsch A, Gilbert L, Lanzi S, Gross J, Kayser B, Vial Y et al. Improving cardiometabolic and mental health in women with gestational diabetes mellitus and their offspring: study protocol for MySweetHeart Trial, a randomised controlled trial. BMJ open. 2018;8(2):e020462.
https://doi.org/10.1136/bmjopen-2017-020462
PMid:29487077 PMCid:PMC5855393
Ge L, Wikby K, Rask M. 'Is gestational diabetes a severe illness?'exploring beliefs and self-care behaviour among women with gestational diabetes living in a rural area of the south east of C hina. Aust J Rural Health. 2016;24(6):378-84.
https://doi.org/10.1111/ajr.12292
PMid:27087496
Nicklas JM, Miller LJ, Zera CA, Davis RB, Levkoff SE, Seely EW. Factors associated with depressive symptoms in the early postpartum period among women with recent gestational diabetes mellitus. Matern Child Health J. 2013;17:1665-72.
https://doi.org/10.1007/s10995-012-1180-y
PMid:23124798 PMCid:PMC3580121
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