overall functioning that allows them to pursue valued life goals and that is reflected in their ... domains. Multitude of health indicators. More aggregated measures.
Oral Health-Related Quality of Life Principles and application Ziad D Baghdadi
Aims of the Lesson • Define HRQoL, giving historical relevant background • Explain the importance of HRQoL for • • • •
Health care Dental practice Research Community-based practice
• Describe how OHRQoL was used and is being used in research • Identify implications of OHRQoL research for health policy • Demonstrate the use of OHRQoL instruments in a study
Learning Objectives • Define HRQoL and OHRQoL and recognize the theoretical models underpinning the concepts • Assemble a timeline, which includes historical key developments of OHRQoL • Name 2 instruments used in measuring OHRQoL and identify 2 features of each instrument • Recognize that the relationships between SE and environmental factors and OHRQoL is not clear-cut • Support the inclusion of OHRQoL in dental practice, research, and community-based practice
What is Quality of Life? Aristotle • “…when it comes to saying in what happiness consists, opinions differ and the account given by the generality of mankind is not all like that of the wise. The former take it to be smoothing obvious and familiar, like pleasure or money or eminence and there are various other views, and often the same person actually changes his opinion. When he falls ill he says that it is health and when he is hard up he says it is money.” • George A Wells claimed that Pigou was the first to coin the term QoL in 1920 in a book on economics and welfare
A letter Jefferson wrote on July 6, 1787—eleven years before the Declaration of Independence—to his relative T.M. Randolph Jr.:
“With your talents and industry, with science and the steadfast honesty, which eternally pursues right regardless of consequences, you may promise yourself everything—but health, without which there is no happiness. An attention to health, then, should take place of every other object.” Thomas Jefferson 1787 American Founding Father, the principal author of the Declaration of Independence and the third President of the United States
Health World Health Organization
• Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
d on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
Oral Health Department of Health, England
• Oral Health is the standard of oral and related tissue health that enables individuals to eat, speak, and socialize without active disease, discomfort, or embarrassment, and that contributes to general wellbeing.
Department of Health. An Oral Health Strategy for England, London, DoH, 1994.
d on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
Quality of Life: Definition • QoL is the individual’s perceptions of his/her position in life in the context of culture and value systems in which he/she lives, and in relation to his/her goals, expectations, standards, and concerns (WHO 1995). • HRQoL is people’s subjective evaluation of the influences of their current health status, health care, and health promoting activities on their ability to achieve overall functioning that allows them to pursue valued life goals and that is reflected in their general wellbeing (Shumaker & Naughton 1995). • HRQoL is a dynamic construct affected by one’s ability to adapt to discrepancies between expected and experienced wellbeing (Padilla et al 1996)
Subjective Multidimensional Dynamic
Influences on QoL • Gender • Culture • Disease specific • Spiritual • Age
This paper examined the relationships of QoL to: 1. Socio-demographic characteristics (age, sex, income, education etc.) 2. Safety and security of place 3. Characteristics of people whose QoL excellent vs. poor 4. The changes between 2001 and 2004
History of HRQoL
35,000 yrs ago 14th -17th century
• 1940s – 1950s Studies on mortality and survival • 1960s – 1990s Shift of focus to health status, functional status, and other SINGLE dimension • 1990s Shift to patient-reported, multidimensional outcomes Patients’ perception adds an information that is not captured by physicians or ‘objective’ markers
Objective marker VS Patient-Reported Outcomes
Wiklund et al 1991
Exercise test Vs Physical functioning R = 0.40
“Objective” measure
© Pr Ingela Wiklund
“Subjective” measure
better HRQL
lower HRQL
Group health enrollees Cardiac arrest General population Moderate obesity Ulcerative colitis Myocardial inf arct
The condition impact on HRQoL is not always foreseeable and is not systematically correlated with the severity of the disease as perceived by the medical community
Angina Crohn's Hypothyroidism End-stage hemodialysis Rheumatoid arthritis Non-oxygen dependent COPD Physically disabled adults Back pain Chronic low back pain Oxygen dependent COPD Chronic pain non-responders Amyotrophic lateral sclerosis
0
5
10
15
20
25
Overall Sickness Impact Profile score
30
35
Single-item self-rating of oral health by patients compared with rating of clinicians
No.
No. of patient ratings identical to clinician rating
No. of higher clinician ratings
No. of lower clinician ratings
Excellent
142 (18%)
84
0
58
V. Good
228 (29%)
62
118
48
Good
244 (31%)
45
150
49
Fair
130 (17%)
33
90
7
Poor
32 (4%)
7
25
0
Total
776
231 (30%)
383 (49%)
162 (21%)
Patient Rating
Scientists, just like the rest of humanity, carry out their day to day affairs within a framework of pre-suppositions, called a paradigm, about what constitutes a problem, a solution and a method. At any given time a particular scientific community will have a prevailing paradigm that shapes and directs work in the field. People become very attached to their paradigms and scientific revolutions always involve intellectual bloodshed. Thomas Kuhn, The Structure of Scientific Revolutions, 1962
References to quality of life 1966-74 40 references 1986 – 99 more than 10,000 references NOW in PubMed more than 215,000 OHRQoL 1739
2013
More aggregated measures
Health-adjusted life years (HRQoL combined with life expectancy) summarizing overall health
HRQoL Indexes
Generic health status profiles
Disease specific scales Do not cover all health domains More disaggregate measures
Multitude of health indicators
National Research Council 2011
HALE is meant to measure not just how long people live, but the quality of their health through their lives (Health Canada 2013) QALY (Quality-Adjusted LifeYear) = quality of life + quantity of life lived
Domains addressed by 2 HRQoL indexes
• • • • • •
SF-6D (stands for short form 6D) Physical function Role limitation Social function Pain Mental health Vitality SF-6D describes 18,000 health states in all
HUI3 (Health Utilities Index Mark 3) • • • • • • • •
Vision Hearing Speech Dexterity Emotion Cognition Self-care Pain HUI2 and HUI3 describe 1,000,000 health states
Horsman et al 2003
Generic
Importance of content validity Generic SF-36
36 items 8 domains
Functional Digestive Disorders Quality of Life (FDDQoL)
Irritable Bowel Syndrome
• 1. Physical functioning
• 3. Sleep
• 4. General health
• 7. Emotional role functioning • 8. Mental health
8 domains • 2. Anxiety
• 3. Bodily pain
• 6. Social role functioning
43 items • 1. Daily activity
• 2. Physical role functioning
• 5. Vitality
Specific
Sleep and diet disturbances (83%)
• 4. Diet • 5. Abdominal discomfort
• 6. Coping with disease • 7. Control of disease • 8. Stress
OHRQoL: Definition, theoretical model, and dimension • In 1976 Cohen and Jago advocated the development of sociodental indicators to measure OHRQoL (Cohan & Jago 1976) • It includes how oral health affects • • • • •
Aspects of social life Self-esteem Social interaction School performance Job performance
• OHRQoL reflects people’s comfort when eating, sleeping, and engaging in social interaction; their self-esteem; and their satisfaction with respect to oral health (U.S. Department of Health and Human Services 2000) • It is the result of interaction between and among oral health conditions, social factors, contextual factors, and the rest of the body (Locker et al 2005)
Traditional model of disease development (Bio-Medical Model) Disease (Pathology)
Pathogen
Modifiers Lifestyles Individual susceptibility
Biopsychosocial model of illness
Pathogen
Psychosocial factors Attitudes Behavior Quality of Life
Illness (well-being)
Wilson and Cleary Model for Health-Related Quality Life. Symptom amplification Personality/Motivation Values Preferences
Psychological support Social support Economic support
Wilson, I.B., & Cleary, P.D (1995). Linking Clinical Variables with Health-Related Quality of Life: A Conceptual Model of Patient Outcomes. JAMA. 273, 59–65.
Audience!
List dimensions of quality of life that mentioned in the video. https://www.youtube.com/watch?v=O0qhuu4Ipj0
Common Risk Factors Approach Cohen 2012
COMMON RISK FACTORS
GENERAL DISEASES
TOBACCO
CVD ALCOHOL
ORAL DISEASES PERIODONTAL DISEASES
CANCER DIABETES RESPIRATORY
POOR DIET
ORAL CANCER
DENTAL CARIES
•
Characteristics of the individuals Demographics; Psych (depression, resilience); Medical history
Biological/Genetics (Type/extent of defect)
OHRQoL
Symptoms Functional wellbeing Oral health
Environment • Access/utilization—payer source, Income • Caregiver characteristics (children QoL) • Education, Family structure
General QoL
Sischo & Broder 2011
• • •
Theoretical Model for OHRQoL
The relationships between biological variables and HRQoL outcomes are not direct, BUT moderated by a variety of personal, social, and environmental variables.
• Pain • Bleeding gums • Spaces between teeth
• Anxious • Attractive • Unhappy
• School • Job
Social/ Emotional
Environment
Dimensions of OHRQoL
Oral Health
OHRQoL
Function
Treatment expectations
• Chewing • Talking
• Satisfaction
UNDP Administrator Helen Clark (the 37th Prime Minister of New Zealand) • “Oral diseases are obstacles to development. Something as preventable as tooth decay can impair people’s ability to eat, interact with others, attend school, or work. These consequences all detract from human wellbeing, economic potential, and development progress.”
Side event on Global Oral Health, NN High Level Meeting on Non-Communicable Diseases, 2012
Secretary of the U.S. Dept of Health, Donna E Shalala • “Oral health problems can lead to needless pain and suffering, causing devastating complications to an individual’s wellbeing, with financial and social costs that significantly diminish quality of life and burden American society.”
In her forward to the Surgeon General’s report on oral health, “Healthy People 2010”
OHRQoL = f [P + S + (P × S)] OHRQoL is a function of the person (P), the situation (S), and the interaction between the person and the situation (P × S)
Inglehart & Bagramian 2002
OHIP-Oral Health Impact Profile GOHAI-General Oral Health Assessment Index CPQ-Child Perception Questionnaire DIDL-Dental Impact on Daily Living Strauss et al 1993 Dental Impact Profile Cushing et al 1986 Social impacts of dental disease
1980
Cohen & Jago 1976
Reisine 1984
Atchison et al 1990 GOHAI
1990
McGrath & Bedi 2000 OH-QoL UK
Leao & Sheiham 1996 DIDL Slade & Spencer 1994 OHIP
Broder et al 2004 COHIP
2000
Slade 1997 OHIP-14
2010 Jokovic & Locker 2002 COHQOL (CPQ)
Criteria for Development of QoL Measurements
Comprehensive (content validity)
Credibility (face validity)
Includes appropriate components of health
Appears sensible and interpretable
Accuracy (criterion validity) Consistently reflects true clinical status of patients
Criteria for Development of QoL Measurements
Sensitivity to change (discriminant validity) Detects smallest clinical important differences
Biological sense (construct validity) Matches hypothesized expectations when compared with other indirect measures
2
OHRQoL: Importance & scope • OHRQoL research includes
• Patients with oral cancer (ship 2002) • Toddlers with ECC (Filstrup et al 2003) • Children with craniofacial anomalies (Border 2007)
• Appropriate treatment care has been re-defined to focus on a person’s social and emotional experience and physical functioning • It gives patients more active role as members of the treatment team • It gives evidence to health practices • It is a valuable health outcome in case of chronic non-curable diseases • It can be useful in measuring the impact of oral health disparities on overall health and QoL • It has health policy implications
OHRQoL: Considerations for use
Generic
Diseasespecific
Generic • General • Less sensitivity to disease symptoms and impacts • Higher floor effects (i.e. no impact) • Less responsive to intervention
Disease-specific • Specific conditions • More sensitivity to disease symptoms and impacts • Lower floor effects (i.e. no impact) • Have effective evaluative properties (to detect response to intervention)
OHRQoL: Considerations for use • Parent(s) • Teacher • Caregiver
Proxy
Direct
Children
Adults
Michigan Oral Health-Related QoL Scale Version PG (parent/guardian)
• My child has difficulty chewing •
Strongly disagree………….strongly agree
• My child has difficulty biting hard • My child’s teeth are sensitive to hot or cold • My child’s teeth are sensitive to sweet food • My child is happy with teeth
Version C (child)
• Do your teeth hurt now? •
Yes
No
• Do your teeth hurt when you eat something sweet? • Do you like your teeth? • Are you happy with your teeth and smile? • Do kids make fun of your teeth?
OHRQoL: Considerations for use • OHRQoL surveys can be used to examine trends in oral health and population-based needs assessment • Example • Locker (2007) found that children from low-income families in Canada have poor OHRQoL than children from high-income families (indicating socioeconomic disparity) • Makhiji et al (2006) found that OHRQoL is strongly associated with sociodemographic factors (race, education, transportation difficulties) for elderly patients in Alabama
• The relationship between sociodemographic factors and OHRQoL is NOT clear-cut (Sischo & Broder 2011)
• Extent/type of medical conditions are associated with low OHRQoL and, therefore, included in the theoretical model • Example • Mulligan et al (2008) found that women with HIV have lower OHRQoL • Mehrsted et al (2008) found individuas with dental anxiety/fear have lower OHRQoL • The greater the DMFS, the lower the OHRQoL (Kim et al 2009)
• This assessment may inform health practitioners of specific areas of focus from the patients’ perspectives
• Characteristics of the individual (self-concept, psychological well-being) are considered as mediating factors in OHRQoL and, therefore, included in the theoretical model • Example • Barbosa and Gaviao (2008) found that the relationship between clinical variables and OHRQoL is mediated by various personal, social, and environmental factors
• By identifying groups who are vulnerable for low OHRQoL, investigators can use data from survey research to create programs to improve oral health and elevate OHRQoL
OHRQoL: Considerations for use • OHRQoL is being recently used to measure efficaciousness of treatment to improve care • Example • Broder is currently examining changes in OHRQoL following surgical interventions among school-aged children with cleft conditions in 6-center NIDCR-supported project (Sischo & Broder 2011) • Hyde et al (2006) found that rehabilitative dental treatment improved welfare reciepients’ OHRQoL and employment outcome
• The use of OHRQoL as an evaluative measure outcome is • Congruent with patient-centered care • Providing evidence that costs associated with treatment protocols are worth the expense • Assisting patients (and families) in treatment decision-making
• The multidimensional nature of OHRQoL is useful in identifying atrisk populations and developing interventions that care for the WHOLE person • Example • Turner et al (2006) found that cognitive-behavioral therapy (CBT) for patients with chronic TMJ disorder pain reduces pain and depression at one year CBT includes instruction and practice in progressive relaxation and abdominal/diaphragmatic breathing, as well as discussions of fear avoidance, identification and challenging of negative thoughts in response to pain, relapse prevention, and dealing with setbacks
• OHRQoL can help assess clinically meaningful change • It helps identify whether a statistically significant difference between experimental and comparison groups has clinical meaningfulness • It helps identify whether a statistically significant difference at the group level has relevance for clinically meaningful change at the individual level
There is a dearth of published studies assessing meaningful change in the oral health arena (Wyrwich et al 2005, Sischo & Broder 2011)
• Sloan et al (2002) emphasized the importance of incorporation of QOL assessment (and assessing clinical significance) in the treatment of patients with neoplastic diseases
OHRQoL: Implications • Using the association between oral health conditions and QoL can be an effective mechanism to communicate with policymakers to reveal the importance of oral health and equal access to care (Al Shamrany 2006) • Measuring the impact of health services (such as treatment of dental caries through community health centers) before and after treatment may improve evidence-based decision-making related to treatment needs, effectiveness, and policy perspectives
• Decayed, missing, and filled teeth (DMFT) scores are used as a common measurement of dental health • Politicians may get a better sense of the need for providing oral health care to underserved populations if they realize that these scores translate into impaired QoL for a child A child with high DMFT score may be malnourished because of inability to eat or unable to sleep through the night or concentrate in school due to associated pain
• NIH and NIDCR are supporting Centers for Research to Reduce Oral Health Disparities • CRROHD is studying the effect of ECC on young children’s OHRQoL (Cunnion et al 2010)
• NIH has incorporated HRQoL into its roadmap • There are 3 NIDCR-funded projects examining OHRQoL acroos lifespan from childhood to old age, across geographic regions (urban, rural, international), and for chronic conditions • NIDCR supports research that examines correlates of OHRQoL (e.g. body image, health beliefs) and research that seeks to uncover social determinants of oral health
• By measuring OHRQoL, oral health professionals can enhance evidence-based care • Practitioners Engaged in Applied Research and Learning Network is completing longitudinal protocols to compare objective (clinical ratings) and subjective assessments (patient OHRQoL ratings) to measure treatment outcomes • PEARL’s aim is to elucidate the interrelationships among oral healthcare and QoL factors, and to exemplify how patients are an invaluable source of information regarding treatment protocols, outcomes, and how oral health is related to QoL
OHRQoL to Assess Treatment Needs • QoL can give the patient a voice to assess his/her needs assessment • Health needs assessment is a systematic approach attempting to ensure that the health service uses its resources to improve the health of the population in the most efficient way (Tsakos 2008)
Normative VS Needs Assessment Normative Need • Identifies diseases and impairments (based on clinical indices) without considering the subjective perceptions of the subject
Needs Assessment • Focus on effectiveness of interventions that will bring about health again
Shortcomings of Normative Measures • Lack of objectivity and reliability • Neglect psychosocial aspect • No consideration for health behaviors • Unrealistic as it ignores limited resources • Serious conceptual limitations • “Clinical measures tell us nothing about the functioning of the oral cavity or the person as a whole” (Locker 1989) • “---essential for measuring disease…but not for health and treatment need” (Sheiham et al 1982)
Some people with oral impacts are denied treatment and some of those without oral impacts are treated.
Key Factors of Socio-Dental Approach to Needs Assessment • • • •
Clinical dental measures Subjective perceptions (OHRQoL) Behavioral propensity Evidence-based interventions • (Gherunpong et al 2006)
An OHRQoL measure for Needs Assessment
The Child Oral Impacts on Daily Performance (ChildOIDP)
Eating food Speaking clearly Cleaning mouth Sleeping Smiling, laughing, showing teeth without embarrassment • Maintain usual emotional state without being irritable • Carrying out school work • Enjoying contact with other people • • • • •
Gherunpong et al 2004
Impairments
no No intervention
Sheiham & Tsakos 2007
yes
no Perceived impacts
Normative Treatment Need
yes
Perceived impacts on QoL
Investigation Counseling
yes
no Dental Health Edu & Prom
Impact related need Propensity for treatment
Model for Needs Assessment
Propensity related need
Low
Initially planned treatment + DHE/OHP
Medium
High
Most appropriate (evidencebased) treatment
Normative Need
100 children
Impact-Related Need
30.2
PropensityRelated Need
Low
Med-low
Med-high
High
1.5
8.9
18.9
0.9
PRN: Oral hygiene dental attendance Patient cooperation
Total number examined 1126
Gherunpong et al 2006
Orthodontic Treatment Needs
Prosthodontic Treatment Needs
Normative Need
324
Impact Related Need
80
Propensity Related Need
Total number of patients examined 1029
Good
Poor
64
16 Ryu et al 2008
This will decrease the number of dental clinicians needed per 100,000 adults from 115 (NN) to 30 (IRN) to 25 (PRN)
Conclusion • OHRQoL has a multitude of substantive applications for the field of dentistry, healthcare, and dental research • Patient-oriented outcomes like OHRQoL will enhance understanding of the relationship between oral health and general health • OHRQoL research can be used to inform public policy and help eradicate oral health disparities
Oral-Health Related Quality of Life in Children Effects of Dental Treatment Case Study
Oral-Health-Related Quality of Life OHRQoL is that part of a person’s quality of life that is affected by this person’s oral health. Person functioning (biting, chewing, speaking) Sensations of pain/discomfort Psychological Appearance and self-esteem Social well-being
Inglehart 2006
OHRQoL measures provide Information of the impact of oral conditions on people’s lives Ways of determining whether clinical interventions are efficacious Usual developmental sequence:
Conceptual development
Item pool, reduction, psychometric testing
Theory, models
Development
Range of settings and populations Field testing, validation
Short-form versions
Routine clinical and HSR usage
Desired endpoint
Optional but desirable
Thomson 2011
OHRQoL Parental-Caregivers Pereception Questionnaires (P-CPQ) Family Impact Scale (FIS) PCPQ subscales (domains)
FIS subscales (domains)
• Oral symptoms (e.g. pain)
• Family/parental activity
• Functional limitations (e.g. Difficulty eating)
• Parental emotions • Family/financial conflict
• Emotional well-being (e.g. Avoid smiling) • Social well-being (e.g. Being teased)
Jokovic et al 2003
Total number of items 33
OS 6 items FL Oral health status in general
Effects of oral health on general wellbeing
Full
P-CPQ
8 items
EWB 9 items
SWB 10 items Jokovic et al 2003
Total number of items 16
OS
4 items FL Oral health status in general
Effects of oral health on general wellbeing
Short
P-CPQ
4 items
EWB 2 items
SWB 6 items Thomson et al 2012
Total number of items 14
FA
5 items PE Oral health status in general
Effects of oral health on general wellbeing
Full
FIS
4 items
FC 4 items
FC 1 items Jokovic et al 2003
Total numbers of items 9
FA
4 items PE Oral health status in general
Effects of oral health on general wellbeing
Short
FIS
2 items
FC 2 items
FC 1 items Thomson et al 2012
Pre-Operative General Questions Global Transition Items •
How would you rate the health of your child’s teeth, lips, jaws and mouth?
Excellent Very good Good Fair
Poor
•
How much is your child’s overall wellbeing affected by the condition of his/her teeth, lips, jaws and mouth?
Not at all Very little Some A lot Very much
P-CPQ items Examples •
During the last 3 months, how often your child had: –
Pain in the teeth, lips, jaws or mouth
•
Never Once or twice Sometimes Often Every day or almost every day Don’t know
During the last 3 months, because of his/her teeth, lips, mouth or jaws, how often has your child: –
Missed school (e.g., due to toothache or emergency dental appointment)
Never Once or twice Sometimes Often Every day or almost every day Don’t know
FIS items Examples •
During the last 3 months, because of your child’s teeth, lips, mouth or jaws, how often have you or another family member –
Felt guilty
•
Never Once or twice Sometimes Often Every day or almost every day Don’t know
During the last 3 months, because of your child’s teeth, lips, mouth or jaws, how often have you or another family member –
Caused financial difficulties for your family
Never Once or twice Sometimes Often Every day or almost every day Don’t know
Post-Operative General Question •
Since the operation to fix his/her teeth, is your child’s overall quality of life
Much improved A little improved The same A little worse
Much worse
Methods
Study Design • Pre-treatment P-CPQ and FIS
• Dental treatment under GA 3-4 weeks
• Post-treatment P-CPQ and FIS
Analyses
Analyses
Cross-sectional construct validity
Examining the association between means of pretreatment scores and the rating of the pre-treatment global transition item (Kruskal-Wallis)
Cronbach’s alpha Internal consistency
More than 0.9 Excellent 0.7 – 0.9 Good 0.6 – 0.7 Acceptable 0.5 – 0.6 Poor Less than 0.5 Unacceptable
Interclass Correlation Coefficient (ICC) Test-retest reliability
0 no agreement 1 perfect agreement
Analyses
Resposnsiveness
Effect size
ES
Subtracting post-treatment scores from pretreatment scores (paired t-test)
Dividing the mean of change scores by the SD of the pre-treatment scores
Less than 0.2 small change 0.2 – 0.7 moderate change Above 0.7 large change
Results
How much is the child’s wellbeing affected by oral health?
Reponsiveness 25
20
Large Effect size descriptors
15
Large 10
Large Large Moderate
5
0 P-CPQ
FIS
OS
FL
Pretreatment
Posttreatment
EWB
SWB
Cronbach’s Alpha & ICC
Alpha
ICC
0.81
0.93
OS
0.61
0.91
FL
0.61
0.93
EWB
0.49
0.76
SWB
0.66
0.86
FIS
0.67
0.84
P-CPQ+FIS
0.84
0.94
P-CPQ
Conclusions
✓
1
✓
2
✓
3
Test – retest reliability is strong
✓
4
This instrument can be used for children with severe caries
✓
5
Validity and responsiveness in other groups need to be explored
Dental treatment associated with positive effects on quality of life P-CPQ and FIS are valid and responsive
This is an example text. Go ahead and replace it This is an example text. Go ahead and replace it
THANK YOU!
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