Man is addicted to habits and a slight change in his/her daily routine frustrates and puts him/her at unease. Think about a baby who lives inside his/her mother’s womb for nine whole months and comes unto this world full of hopes and surprises! There would be a change in temperature, environment and what not-being brought into this world, the newborn is now faced with the challenges of accommodating from intra-uterine to extra-uterine. According to the World Health Organization (WHO) the early newborn period is most critical for survival of a neonate (the period right from birth up to 28 days of age) and the child is probably at the highest risk of death during this period in a world where close to 10 million deaths occur every year in kids younger than 5 years old. Almost two-thirds of such deaths happen in the neonatal period where one-third of them happen during the first day of life of the neonate, almost half within 3 days and nearly three-quarters within first week of life. Developing countries contribute to a majority of such deaths with almost 34 of every 1000 live births leading to death and our country has seen a steady decline in the number of neonatal deaths from around 53 to only 22-28 per 1000 live births. Sub-Saharan Africa ranks highest in such deaths where the child’s day of birth is also its day of death unfortunately.
Death doesn’t occur all of a sudden mostly and there are multiple clinical signs that lead to the fatality. Fever is a common manifestation of diseases and requires immediate medical attention. Other signs include lethargy, poor sucking, increased respiratory rate (more than 60 beats per min), chest retractions and convulsions (sudden, abnormal electrical activity in the brain). Hence, the first 28 days are like a test to the child’s survival-it is of utmost importance to provide the best of feeding and care to maximize the neonate’s chances of survival and a healthy existence in this world. Developed by UNICEF and WHO the Integrated Management of Childhood Illness (IMCI) approach is understanding the various underlying causes of illness. This recognition of danger signs by the parent or any other caretaker helps in getting medical attention as early as possible. The reason why there is so much insistence is because a majority of neonatal deaths occur at home in which almost 75% can be prevented if there was timely action taken, the signs of an illness recognized by the parent/caretaker and there was no delay in the choice to go for medical action. Here, in this article we would be looking at the parent’s knowledge about the kid’s health, changes in health and the capacity to seek medical help in countries around the world.
Knowledge of Mothers Regarding their Neonate’s Health Status in Ethiopia
As per 2016 records, under-5 mortality rates were 67 deaths per 1,000 live births and most neonatal deaths occur at home showing that still most are unable to recognize and give treatment at the right time. Most children die due to lack of knowledge of the parent and the research here assesses the mother’s knowledge on neonatal danger signs and the reasons behind such poor knowledge for being unable to save her dying neonate!
368 mothers were selected to participate in the study of which 355 of them completed the interview. Mean age of the participants was 27.7, almost 60% of them were housewives and 234 (65.9%) of them gave birth at health institutions. It was reported that of the 355 participants, 281 (79.2%) of them had information about neonatal danger sign of which diarrhea (160 were aware), fever (136) and persistent vomiting (127) were more familiar with the participants. It was seen that 68.68% moms had good knowledge about neonatal danger signs-they were familiar with three or more signs of danger.
When asked about the place of care 78 mothers (33.8%) opted for home care of their sick neonate, 82 (32%) wanted to take them to health institutions, 56 (24.2%) wanted to take them to traditional healers and 15 (6.5%) did nothing. Home care was basically garlic, tenadam, a mix of lemon and ash applied on the neonate’s head for tonsils, matchstick for convulsion, tepid sponging for fever, sunlight exposure for jaundice and using coconut oil to rub all over the body for cold body. 118 mothers continued to breastfeed despite the presence of disease but 113 of them did not. The factors associated with the mom’s knowledge include the mom’s educational status, income, place of birth and source of information. Moms who gave birth in a health institution were 6.45 times likelier to take their neonates back to the institution and those who received a post-natal care (PNC) follow were 6.19 times likelier to go back to the hospital for a follow up. It was also seen that husband’s education status, husband occupation status, place of birth and PNC had a significant effect on the maternal practice for neonatal danger signs. The study clearly showed that educational qualification and work status clearly dominated the list of attributes that motivated women to seek the help of a health institution.
Another study in Ethiopia on 400 mothers/caregivers had a response rate of 94.7% and the participants’ mean age was between 25 and 34 years. Almost 64% were illiterate mothers with only 7.5% completing secondary education. Almost 40% infants were between 9 and 24 weeks of age, 32% were between 8 and 16 weeks of age and only 5.5% were aged less than one week during the study period. 67.5% infants were delivered at the hospital and only 6.6% of them were delivered at home. Of the study group almost 92.8% of them reported that they take their children to the health care center and among the rest who don’t almost 34% reported high treatment cost followed by lack of money (30%) as the reason behind it. When the study group tried to categorize the mother’s knowledge about their neonate’s risk as adequate and inadequate it was observed that almost two-thirds (65.3%) of them had inadequate knowledge as they were not even able to identify more than three symptoms among the 13 symptoms of illness of newborns and young infants.
Knowledge of Mothers Regarding their Neonate’s Health in India
Neonatal mortality rates (NMR) have dropped significantly in our country with Uttarakhand having a minimum of 11 and Haridwar having maximum NMR of 50. In Dehradun, neonatal mortality rate is 32 per 1000 live births. The survival of the child depends on the mother’s health alongside her knowledge and skills as a mom is the ‘one’ person who has constant contact with the child monitoring his/her actions and health.
The baby is said to be in danger when any of the following signs are experienced: movement only when stimulated, temperature below 35.5 °C and above 37.5 °C, respiratory rate over 60 breaths per minute, history of convulsions and history of feeding difficulty. The study conducted in Dehradun included 100 mothers for sampling but only 53 of them reported neonatal danger signs and were monitored for their observation and handling practices. Results showed that:
Knowledge of Mothers Regarding their Neonate’s Health in Saudi Arabia
Infant mortality rate in Saudi Arabia is pretty low-11 deaths per 1000 live births as per 2015 results. Under-five mortality rates in this country has reached Millennium Development Goal-4 target still infant mortality rates remains higher compared to many other countries. A community-based study was conducted in Riyadh city of this country regarding a mother’s knowledge about WHO guidelines on neonate danger signs. Primary health care centers (PHCC) are located all over the city and they provide free care to most of the residents there. Sample data of all the mothers who delivered a baby or nursed a baby (as in the case of caregivers such as grandmothers, grandfathers, fathers or nannies) in the past two years were taken from these health care centers. Face to face interviews were conducted with the mothers-the mother’s knowledge and her response on the neonate’s danger signs was collected, all the participants were asked to list the signs that they found threatening to the neonate’s life, recall any signs of danger that they personally experienced with the neonate, the time from noticing any danger to presenting it at the health facility, care received at the society and outcome of the neonate’s illness.
A total of 1428 women who were in the age group of 20-60 years were included in the study. 98% neonates were cared by their mothers, 33% had education up to degree level and 37% had secondary education. 87% women had attended antenatal care and 45% had 4 or more children. Results showed that:
Mother’s Knowledge & Practice about Neonatal Danger Signs & Associated Factors: http://www.jbiomeds.com/biomedical-sciences/mothers-knowledge-and-practice-about-neonatal-danger-signs-and-associatedfactors-in-wolkite-town-gurage-zone-snnpr-ethiopia-2017.php?aid=21314
Neonatal Danger Signs: Attitude & Practice of Post-natal Mothers: https://www.omicsonline.org/open-access/neonatal-danger-signs-attitude-and-practice-of-postnatal-mothers-2167-1168-1000401.php?aid=89908
Mother’s & Caregiver’s Knowledge on Neonate’s Danger Signs: https://www.hindawi.com/journals/bmri/2019/1750240/
Parents’ Knowledge of Danger Signs & Health Seeking Behavior in Newborn & Young Infant Illness in Southwest Ethiopia: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6308740/
Metabolic syndrome (MetS) is a cluster of metabolic disorders that increase the risk of cardiovascular disease when present in combination with each other. The disorders that elevate the risk include hypertension, central obesity, glucose intolerance and serum lipid disorders. While these conditions are good enough to put the individual in a high-risk category for heart problems there is a greater chance that the individual could suffer from cardiovascular issues when they occur in together. There has been an increasing concern regarding MetS as more than 23% of the adult population seems to be affected making them susceptible to diabetes, cardiovascular disease, stroke and diseases related to fatty build-up in artery walls. So, when we look at the risk factors behind this disease its none other than obesity, overweight, physical inactivity, genetic factors and ageing.
Its been found that certain MetS features such as excessive adiposity, dyslipidaemia and glucose intolerance are strongly associated with depression-a health condition that now exists as the fourth biggest cause of disease burden in the world. Women are the primary victims of this condition though these days increasing number of men silently suffer from its effects. Depression involves change in mood and cognitive function besides being linked to a proinflammatory process that increases the risk of being affected by cardiovascular disease. There is a widespread prevalence of an activated peripheral immune system in these adults with overproduction of proinflammatory cytokine that has the potential to increase the risk of depressive symptoms. As it is now evident that both MetS and depression are commonly present bearing increased public health implications there has been interests shown in finding out an association between them. Depression involves dysregulation of the adrenocortical and autonomic nervous systems both of which increase the risk of MetS by supporting abdominal fat accumulation and insulin resistance. MetS is generally linked to increased levels of inflammatory cytokines and leptin resistance and c-reactive protein (CRP) is one of the commonly present inflammatory markers in subjects with MetS.
Health experts have come up with various proposals for controlling MetS occurrence the most common of which includes lifestyle changes (that includes diet modifications and exercises) and drug therapy. The Mediterranean diet has been generally prescribed as the best weight loss approach that’s beneficial for both MetS and depression. But we do have questions arising on how weight loss can have a positive effect on the mind in terms of reducing symptoms of depression. The study below exactly deals with this concern-it uses a subsample of the RESMENA-S study that tries to reduce MetS using a hypocaloric diet for a period of six months. It was generally assumed that the this diet does have a positive effect on depressive symptoms as well and the research team tried to understand the process through which it happens.
The study included 93 subjects (52 men and 41 women) aged around 50 years with a BMI around 36 kg/m2 diagnosed with MetS. Six months after following the hypocaloric diet 26 participants were eliminated due to different reasons and 7 of the 67 participants who did complete the study did not finish the Beck Depression Inventories (BDI) and hence, the study was left with not more than 60 participants who were able to complete the BDI in three visits (at baseline, after two months and end of six months). All the participants were put into either of the two groups randomly-control group or the RESMENA diet. All the participants were requested to carry on with their regular physical activity schedules and their performance was measured using a 24-hour physical activity questionnaire at the beginning and end of study. The research team measured serum glucose, total cholesterol, HDL-cholesterol, triglycerides and free fatty acids serum concentration.
Depression symptoms were analysed thrice over the course of the study (at baseline, after two months and at the end of the study) using a Spanish version of the BDI. A score of ≥10 reflects moderate depressive symptoms.
Results showed that:
A Decline in Inflammation is Associated with Less Depressive Symptoms after a Dietary Intervention in Metabolic Syndrome Patients: https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-13-36
Systematic Inflammation is Associated with Depressive Symptoms Differentially by Sex and Race: A Longitudinal Study of Urban Adults: https://www.nature.com/articles/s41380-019-0408-2
Postnatal depression was the only type of depression known to the world two decades back and those women suffering from antenatal depression were simply told that it’s just their hormone calling for attention. It’s been observed that 1 in every 10 women will be depressed at any point of time during pregnancy while 1 of every 30 women will be depressed during pregnancy and after delivery. Pregnancy, as we all know, is the most joyous period in a woman’s life as the pregnant woman experiences the peak of womanhood looking forward to the birth of her loving child. But according to some pregnant women who experience prenatal depression, the same pregnancy term instead of being filled with happiness and excitement turns out into a period of despair and gloom. There are various causes including physical, emotional and hormonal effects that can raises the risk of prenatal depression but this has dangerous consequences on the newborn, child and adult health outcomes putting the individual at a higher risk of common disorders.
Disasters of Depression in Pregnant Women
Depression as such is one of the highly common mental disorders that’s 50% more common in women than men. Almost 10-15% of women in developed countries and 20-40% of women in developing countries experience depression during pregnancy or after childbirth. Such depressions in pregnant women could have debilitating health outcomes when it is not stopped at the right time. Beyond affecting the immediate family, it also affects the society. Pregnancy is the period during which the woman undergoes numerous hormonal changes, her nutrient requirements vary and the mind goes through a sea of conflicting emotions simultaneously. We often hear elderly people advice the pregnant lady to eat for two as she is carrying another human inside but dietary guidelines don’t support this. Still, nutrient requirements increase to meet the needs of the developing fetus and the mother as well and fulfilling these requirements prepares the woman for a healthy delivery and a healthy baby thereafter. But depression brings about changes in her nutrient intakes which finally affects the health of the baby and the mother. Generally, these women eat fewer macronutrients (with the exception of fats), their nutrient levels are lower (with the exception of phosphorus) than recommendations and there are also theories that while these women have sufficient intake of macronutrients they witness a decrease in micronutrient intake.
Often we see people eating according to their mood. We indulge in sweets when we are happy or even refrain from eating when we are sad. Some people cope up with sorrows in life by eating tubs of cheesy fries and it has been shown that mental health of women affects their nutritional intake and also impacts the fetus. Depressed women are at an increased risk of giving birth to neonates with low birth weight (LBW) (this is a leading cause of neonate mortality and morbidity), preterm birth or with an Apgar score of 1-5 some five minutes after birth. Women around the world suffer from antenatal depression with each of them experiencing different outcomes.
A Study on Antenatal Depression in Pakistani Pregnant Women
Pakistan has a maternal mortality rate of 260 for every 1,00,000 live births with almost 18-80% pregnant women suffering from antenatal depression. The study aimed at measuring association of depression with maternal dietary intake and neonate outcomes. Participants were pregnant women aged between 18 and 49 years at the start of their second trimester and having normal nutrient intakes. The study group ensured that those with depression, chronic diseases such as diabetes, anemia, BP and CHD or belonging to the high-risk pregnancy category were excluded from the study. Information about the participants such as demography, husband’s employment, gestational age and expected delivery date was collected using questionnaires. The Edinburgh Postnatal Depression Scale (EPDS) was used to measure the participant’s state of mind. Of the 94 participants who were cleared for the study 12 of them were excluded following no-show during follow up and finally the study was carried out with a sample size of 82.
An EPDS score of 9 indicated absence of depression, a score of 9-12 indicated moderate depression and a score of more than 13 indicated severe depression. Maternal intake was noted using a 24-hour dietary recall and a Food Frequency checklist at the start of the study and the same was repeated at the 36th week of gestation to analyze poor maternal nutrient intake. Food items were classified and their frequency of consumption (between never and 6+ times in a week) was noted. Each of the participants were questioned on their methods of preparation, portion sizes consumed and the types of snacks eaten. The 24-hour dietary recall was used to calculate macronutrient intake. The Healthy Eating Index (HEI) was used to score the 24 h recall with the overall score being reduced to 50 with the score split based on the type of food consumed-total fruit (5 score), whole fruit (5 score), total vegetables (5 score), greens and beans (5 score), whole grain (10 score), dairy (10 score), total protein foods (5 score) and seafood and plant proteins (5 score). Following dietary guidelines protocol to the dot yielded full score, a score ≥40 indicated good diet, a score between 25 and 40 was rated as moderate and a score below 25 was considered poor diet. Cut off points for carbohydrate and protein intake were ≥175 g and ≥71 g while it was ≥55 g for fats. Height, weight and BMI measurements of all the participants were taken and each of them was classified as underweight, normal weight, overweight or obese based on WHO guidelines. Information on the newborn was acquired in the form of fetal growth retardation (FGR), low (score of 6 or less) Apgar score and low birth weight (LBW) scores (<2500 g).
While mean age of the participants was 29 years almost 51% of them were between 24-29 years and 66% of them were between 151 and 160 cm. Mean weight of moms was 70 kg and BMI was 26.6. Results showed that there was a mean difference of only one HEI between depressed and non-depressed women as depressed antenatal women were consuming 151 kcal lesser than non-depressed women at the start. But at the end of the study, there was a difference of 5 HEI between depressed and non-depressed antenatal women. Depressed women ate almost 321 kcal lesser than non-depressed women by the end of cohort. At baseline, the type and quantity of foods consumed by both categories (depressed and non-depressed) of women were almost similar. While consumption of cereal, beans and lentils remained almost constant even after succumbing to antenatal depression usage of eggs decreased drastically (by almost 43% initially up to 75% later). Though 85% women were drinking milk at the start of the study it dropped to 65% later. Similar changes were seen in fruits and vegetables intake too. 60% of depressed antenatal women consumed one serving of fruit at baseline but the figures decreased to 37% by the end of cohort. Sadly, none of them were having green leafy vegetables even once a week. It was seen that almost 62% of poor dietary intake was due to antenatal depression. Protein and fat intake in antenatal depressed women decreased to less than 71g and 55g at the end of cohort.
Mean gestational age (born 2 days earlier), weight (200 g less) and low (0.5lower) Apgar score were low among neonates of depressed antenatal women compared to non-depressed women. FGR, preterm birth and poor Apgar score was predominantly seen among neonates of depressed antenatal women but not LBW and in this, 60% of FGR and poor Apgar score and 54% of preterm births could be attributed to antenatal depression. The study clearly reveals the impact of depression on the nutrient intake of pregnant women and dietary intake must be an important topic of discussion during nutrition counseling in the absence of which birth of a healthy baby and survival of a healthy mother both remain questionable.
Effect of Antenatal Depression on Maternal Dietary Intake & Neonatal Outcome: https://nutritionj.biomedcentral.com/articles/10.1186/s12937-016-0184-7
The Interplay between Maternal Nutrition and Stress during Pregnancy: https://www.karger.com/Article/PDF/457136
Do you remember the boy in the ad with a milk moustache? Then you are probably an 80s or 90s kid who has grown up seeing and hearing about the goodness of consuming dairy and its benefits on bone health-in those days dairy products were the magicians who could provide individuals with stronger bones and muscles. But today, the effects of dairy have been made dark and twisted with the food group being beneficial or harmful depending on the people’s intake and needs. While it might not be the best way to a healthy body dairy indeed is the simplest way to equip yourself with calcium, vitamin D and proteins to enable optimal functioning of the heart, muscles, bones and overall body. Kids are constantly forced to drink between 2 and 3 glasses of milk for sufficient calcium levels and one should also not forget the fact that bones become stronger only up to the age of 3 after which bone mass starts deteriorating. Hence, parents insist that their children consume dairy products like milk, cheese, yoghurt and cottage cheese for maintaining bone density and reducing risk of fracture.
Fermented foods are the recent health craze and fermented dairy foods are no exception. Cheese and yoghurt are fermented foods that are a part of the Mediterranean diet, a diet that’s acclaimed for its protective nature against cardiovascular diseases (CVD). Dairy products have the capability to provide up to 60% of the recommended daily allowance (RDA) of calcium and fermented dairy products are an excellent source of vitamin K. We have studies showing that fermented dairy products show beneficial effects on blood lipid profiles and the risk of heart disease compared to regular dairy products as they deliver probiotics that benefit the gut microbiota. The human gut has been the centre of attraction these days as they seem to regulate whole body health. Still, there are not many research studies providing insightful data on the benefits of fermented dairy foods.
Cardiovascular Benefits of Fermented Dairy Products on Australian Population
Type 2 diabetes mellitus (T2DM) and CVD are spreading like forest fire worldwide and researchers are trying various means to curb their rise. Of late, there has been an increasing interest in the relationship between dairy consumption, specifically fermented dairy foods, and its effect on T2DM and CVD risk.
We have meta-analysis from cohort studies showing that yogurt consumption has a positive effect on T2DM. Yet another meta-analysis of 29 cohort studies showed that consumption of fermented dairy products (such as milk products, cheese and yogurt) was inversely associated with CVD risk. There are not many studies that focus on middle-aged people as study participants and the Australian study discussed below examines the association between fermented dairy products and T2DM and CVD risk in Australian women.
The Australian Longitudinal Study on Women’s Health (ALSWH) is a population-based cohort study examining the health and well-being of >58,000 Australian women. The current study included data from 1946-1951 age cohort and these women were surveyed every 2-3 years since the start of ALSWH in 1996. Information on dietary intake was first collected in survey 3 in 1991 and this was used as a baseline for the present study. Surveys 5-7 once again included dietary intake. After implementing various exclusion criteria, the study was left with 7633 participants in the T2DM subcohort and 7679 participants in the CVD subcohort. T2DM and CVD was self-reported and during every survey, women were asked whether they were diagnosed or treated for diabetes and coronary heart disease (CHD) in the past 3 years. In the present study, CVD was defined as the sum of CHD and stroke and incidence was defined as the onset of T2DM and CVD at surveys 4-8.
Dietary intake was noted down with the help of a food frequency questionnaire (FFQ) that collected information on dairy consumption that included yogurt, cheese (different types of cheese such as hard cheese, soft cheese, firm cheese, ricotta or cottage cheese and low-fat cheese) and milk (including reduced-fat milk, skim milk, soya milk and flavoured milk). All the participants were asked to mark down their frequency of intake of dairy products over the last 12 months through the use of a 10-point scale (which has measurements from never to ≥3 times/d with the intake converted to grams per day) with milk being the only exception here whose intake quantity was reported between none and ≥750 ml/d. All the dairy products were classified as yogurt, total cheese (all types of cheese), total fermented dairy (sum of yogurt and total cheese), total nonfermented dairy (all types of milk) and total dairy (sum of total fermented dairy and nonfermented dairy).
Women self-reported on height, weight and other body measurements; physical activity was calculated according to total metabolic equivalent (MET in min/wk) into ‘sedentary or low physical activity level’ (<600 MET min/wk), ‘moderate physical activity level’ (from 600 to <1200 min/wk) or ‘high physical activity level’ (≥1200 min/wk). BMI measurements were calculated and categorized as underweight (BMI <18.5), healthy weight (BMI from 18.5<25), overweight (BMI from 25-30) and obese (BMI ≥30).
The mean age of 8748 women enrolled in the study was 52.5 years and mean BMI was 26.8. Women belonging to the highest tertile of energy-adjusted total dairy intake were likelier to have a lower BMI, were higher educated, never smoked, rarely drank and were physically active. Above all, they had a lower intake of total energy with median intakes corresponding to 20 g/d for yogurt, 14 g/d for total cheese, 35 g/d for total fermented dairy, 202 g/d for nonfermented dairy and 369 g/d for total dairy. 7633 were diabetes-free at baseline and were followed-up for ≤15 years. During follow-up 701 (9.2%) T2DM cases were reported. Results showed that:
Fermented Dairy Intake & CVD Disease Risk in Men
Researchers at the University of Eastern Finland studied 2,000 men for their risk of CVD on consumption of fermented dairy products. All the participants’ dietary habits were assessed at the start of the study (1984-89) and followed up for around 20 years during which 472 of them experienced coronary heart disease event. All the participants were split into four groups depending on how much dairy (that is, fermented dairy products with less than 3.5% fat) they consumed and the researchers compared the groups with the highest and lowest consumption. Results showed that the incidence of coronary heart disease was 26% lower in the highest consumption group compared to the lowest consumption group, sour milk was the commonly used low-fat fermented dairy product and consumption of high-fat fermented dairy products such as cheese was not associated with coronary heart disease risk. On the other hand, increased consumption of non-fermented dairy products (such as milk whose intake was as high as 0.9 litre/day in some individuals) was associated with an increased risk of coronary heart disease. The practise of dairy consumption is changing all over the globe and in Finland (where this study happened) too people are moving away from the consumption of dairy products such as milk and sour milk to those fermented dairy products such as cheese, yogurt and others. Hence, men who eat plenty of fermented dairy products are at a reduced risk of CHD than men who eat less of these products.
A study comparing fermented and non-fermented dairy products in a Swedish cohort found that there was a 32% increased hazard in consuming non-fermented milk compared to fermented milk. In another crossover-controlled study yoghurt consumption increased HDL levels in 29 hypocholesterolaemic women and we have other studies showing that fermented dairy intake has positive or neutral effects on fasting plasma glucose levels. Many studies revolve around the hypothesis that fermented dairy products induce cardioprotective effects due to the intake of bacterial metabolites and probiotics. Fermented dairy seems to be way better in every way compared to non-fermented dairy and individuals should take greater care to consume such products.
Total Fermented Dairy Food Intake is Inversely Associated with Cardiovascular Disease Risk in Women: https://academic.oup.com/jn/article/149/10/1797/5514556
Fermented Dairy Products May protect Against Heart Attack, Study Suggests: https://www.sciencedaily.com/releases/2018/10/181030102828.htm
Dairy Fats and Cardiovascular Disease: Do We Really Need to be Concerned? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5867544/
Fermented Dairy Food & CVD Risk: https://pdfs.semanticscholar.org/336d/1c0782de6bcf3ee2056c0481119e088380a2.pdf
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