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Preplanned Studies: Impact of Whole Lung Lavage on Pneumoconiosis Patients — China, 2018–2022

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  • Summary

    What is already known about this topic?

    The application of whole lung lavage (WLL) for the clinical treatment of pneumoconiosis is prevalent in China. Several scholars have reported success in the treatment of early-stage pneumoconiosis. Nonetheless, the overall efficacy of WLL in the management of pneumoconiosis remains ambiguous.

    What is added by this report?

    The preliminary evaluation of the effects of WLL on pneumoconiosis patients was conducted using follow-up data from 2020 to 2022, after controlling for confounding factors via propensity score matching. While the study found that WLL may improve some pneumoconiosis symptoms, no significant enhancements were observed in overall health status or quality of life.

    What are the implications for public health practice?

    The findings of this research indicate limited efficacy of WLL in treating patients with pneumoconiosis, thereby suggesting that it should not be utilized as a standard treatment procedure for this condition.

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  • Funding: Occupational population survey in key industries (102393220020090000017)
  • [1] Wang HQ, Dai HP, He JY, Lyu X, Zhang XR, Li T. Epidemiological characteristics of pulmonary tuberculosis in patients with pneumoconiosis based on its social determinants and risk factors in China: a cross-sectional study from 27 provinces. Chin Med J (Engl) 2022;135(24):2984 − 97. http://dx.doi.org/10.1097/CM9.0000000000002486CrossRef
    [2] Occupational Lung Disease Group of Labor Hygiene and Occupational Diseases Branch of Chinese Preventive Medicine Association. Consensus of Chinese experts on pneumoconiosis treatment (2018). J Environ Occup Med 2018;35(8):677 − 89. (In Chinese). 
    [3] Gao W, Wu J, Qiu CW, Yang CM. Mid-term therapeutic effects of bilateral synchronous massive whole lung lavage on lung functions of 39 patients with coal worker’s pneumoconiosis. J Prev Med Inf 2016;32(6):515 − 5. (In Chinese). 
    [4] Sun ZP, Li BP, Gao LN, Ji YR, Zhou YZ, Hou BW, et al. Comparative analysis of quality of life in patients with pneumoconiosis before and after whole-lung large-volume lavage. Occup Health 2021;37(13):1834 − 9. (In Chinese). 
    [5] The State Council. Opinions of the State Council on the implementation of the healthy China initiative [Internet]. China: The State Council. 2019. http://www.gov.cn/zhengce/content/2019-07/15/content_5409492.htm. [2023-6-16]. (In Chinese). http://www.gov.cn/zhengce/content/2019-07/15/content_5409492.htm
    [6] Ministry of Human Resources and Social Security, National Health Commission. Notice of the two departments on work-related injury insurance in key industries of pneumoconiosis [Internet]. China: Ministry of Human Resources and Social Security. 2019. http://www.gov.cn/fuwu/2019-12/10/content_5459923.htm. [2023-6-16]. (In Chinese). http://www.gov.cn/fuwu/2019-12/10/content_5459923.htm
    [7] Zhang YM, Zhang HT, Wang CY, Wang W, Wu J, Wang C. Long-term therapeutic effects of whole lung lavage in the management of silicosis. Chin J Ind Hyg Occup Dis 2012;30(9):690 − 3. (In Chinese). 
    [8] Wu CL, Yu JX, Xie LS. meta analysis on the effects of the whole lung lavage in treating pneumoconiosis. Occup Health Damage 2019;34(5):273 − 9. (In Chinese). 
    [9] Yi J, Wang SP. Clinical application and research progress of whole lung lavage. Int J Respir 2015;35(19):1517 − 20. (In Chinese). 
    [10] Liu CP. Complications and life quality survey of 995 cases simultaneous large volume bilateral lungs lavage. World Latest Med Inf 2019;19(58):15 − 6,30. (In Chinese). 
  • FIGURE 1.  Flowchart of enrolled patients.

    Abbreviation: PSM=propensity score matching.

    TABLE 1.  Comparison of pneumoconiosis-related symptoms between the control group and the lavage group — China, 2018–2022 (n=514).

    SymptomsThe first surveySecondary follow-up survey
    Control group
    n (%)
    Lavage group
    n (%)
    χ2PControl group
    n (%)
    Lavage group
    n (%)
    χ2P
    Cough2.0790.3544.2650.119
    No51 (9.9)38 (7.4)113 (22.0)135 (26.3)
    Mild310 (60.3)319 (62.1)313 (60.9)310 (60.3)
    Moderate and severe153 (29.8)157 (30.5)88 (17.1)69 (13.4)
    Expectoration13.959<0.0011.0030.606
    No102 (19.8)60 (11.7)166 (32.3)181 (35.2)
    Mild280 (54.5)323 (62.8)270 (52.5)260 (50.6)
    Moderate and severe132 (25.7)131 (25.5)78 (15.2)73 (14.2)
    Chest tightness2.6610.2640.2550.880
    No64 (12.5)48 (9.3)164 (31.9)157 (30.5)
    Mild295 (57.4)310 (60.3)258 (50.2)261 (50.8)
    Moderate and severe155 (30.2)156 (30.4)92 (17.9)96 (18.7)
    Chest pain5.7360.0574.5780.101
    No199 (38.7)170 (33.1)336 (65.4)329 (64.0)
    Mild197 (38.3)234 (45.5)118 (23.0)141 (27.4)
    Moderate and severe118 (23.0)110 (21.4)60 (11.7)44 (8.6)
    Dyspnea0.4390.8034.3700.112
    No131 (25.5)129 (25.1)176 (34.2)208 (40.5)
    Mild222 (43.2)232 (45.1)230 (44.7)212 (41.2)
    Moderate and severe161 (31.3)153 (29.8)108 (21.0)94 (18.3)
    Hemoptysis0.9570.3280.3240.569
    No460 (89.5)450 (87.5)486 (94.6)490 (95.3)
    Yes54 (10.5)64 (12.5)28 (5.4)24 (4.7)
    Note: The categories for cough severity include mild (intermittent cough not affecting daily activities), moderate, and severe (frequent or violent cough disrupting daily activities and rest). Expectoration is categorized as mild (sputum volume of 10–50 mL during day and night), moderate, and severe (sputum volume exceeding 50 mL during day and night). Chest tightness ranges from mild (intermittent discomfort) to moderate and severe (persistent tightness restricting breathing). Chest pain and dyspnea are classified as mild (occurs during physical activities), moderate, and severe (manifests during daily activities and rest).
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    TABLE 2.  Comparative analysis of quality-of-life differences between the two patient groups across two surveys — China, 2018–2022 (n=514).

    Quality of lifeGroupLevelThe first survey Secondary follow-up survey P
    Mobility, n (%)Control groupNo problems302 (58.8)365 (71.0)<0.001
    Moderate problems206 (40.1)140 (27.2)
    Extreme problems6 (1.2)9 (1.8)
    Lavage groupNo problems322 (62.6)388 (75.5)<0.001
    Moderate problems189 (36.8)123 (23.9)
    Extreme problems3 (0.6)3 (0.6)
    Self-care, n (%)Control groupNo problems405 (78.8)426 (82.9)0.083
    Moderate problems106 (20.6)82 (16.0)
    Extreme problems3 (0.6)6 (1.2)
    Lavage groupNo problems386 (75.1)442 (86.0)<0.001
    Moderate problems125 (24.3)70 (13.6)
    Extreme problems3 (0.6)2 (0.4)
    Usual activities, n (%)Control groupNo problems251 (48.8)317 (61.7)<0.001
    Moderate problems232 (45.1)173 (33.7)
    Extreme problems31 (6.0)24 (4.7)
    Lavage groupNo problems264 (51.4)349 (67.9)<0.001
    Moderate problems221 (43.0)143 (27.8)
    Extreme problems29 (5.6)22 (4.3)
    Pain/discomfort, n (%)Control groupNo problems118 (23.0)233 (45.3)<0.001
    Moderate problems352 (68.5)255 (49.6)
    Extreme problems44 (8.6)26 (5.1)
    Lavage groupNo problems147 (28.6)234 (45.5)<0.001
    Moderate problems330 (64.2)268 (52.1)
    Extreme problems37 (7.2)12 (2.3)
    Anxiety/depression, n (%)Control groupNo problems219 (42.6)292 (56.8)<0.001
    Moderate problems214 (41.6)193 (37.5)
    Extreme problems81 (15.8)29 (5.6)
    Lavage groupNo problems217 (42.2)313 (60.9)<0.001
    Moderate problems210 (40.9)176 (34.2)
    Extreme problems87 (16.9)25 (4.9)
    Health status self-score $(\bar x \pm s )$Control group/59.1±17.368.7±15.8<0.001
    Lavage group/59.0±17.269.3±16.3<0.001
    Note: “/” means health status self-score did not differentiate levels.
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Impact of Whole Lung Lavage on Pneumoconiosis Patients — China, 2018–2022

View author affiliation

Summary

What is already known about this topic?

The application of whole lung lavage (WLL) for the clinical treatment of pneumoconiosis is prevalent in China. Several scholars have reported success in the treatment of early-stage pneumoconiosis. Nonetheless, the overall efficacy of WLL in the management of pneumoconiosis remains ambiguous.

What is added by this report?

The preliminary evaluation of the effects of WLL on pneumoconiosis patients was conducted using follow-up data from 2020 to 2022, after controlling for confounding factors via propensity score matching. While the study found that WLL may improve some pneumoconiosis symptoms, no significant enhancements were observed in overall health status or quality of life.

What are the implications for public health practice?

The findings of this research indicate limited efficacy of WLL in treating patients with pneumoconiosis, thereby suggesting that it should not be utilized as a standard treatment procedure for this condition.

  • 1. National Institute of Occupational Health and Poison Control, Chinese Center for Disease Control and Prevention, Beijing, China
  • Corresponding author:

    Huanqiang Wang, wanghq@niohp.chinacdc.cn

  • Funding: Occupational population survey in key industries (102393220020090000017)
  • Online Date: September 22 2023
    Issue Date: September 22 2023
    doi: 10.46234/ccdcw2023.160
  • Whole lung lavage (WLL) is a surgical procedure utilized in China to treat pneumoconiosis, despite the scholarly debate surrounding its efficacy. The National Institute for Occupational Health and Poisoning Control, part of the Chinese Center for Disease Control and Prevention (China CDC), conducted a comprehensive study on pneumoconiosis patients’ health-seeking behaviors across 27 provincial-level administrative divisions (PLADs) over a three-year period, from January 2018 to December 2020. Utilizing baseline data, follow-up patient information, and WLL-related data, a retrospective cohort study was undertaken to evaluate WLL’s impact and gauge the changes in pneumoconiosis-related symptoms and patient quality of life. The study, empowered by propensity score matching (PSM), contrasted 514 patients in both the control and lavage groups. The data illustrated that the patients in the lavage group displayed a marked improvement in expectoration symptoms and self-care than those in the control group. However, this study suggests that while WLL can alleviate some pneumoconiosis symptoms, it offers no significant enhancement to a patient’s overall health status or quality of life.

    The present study utilized data from a survey on health-seeking behaviors and a subsequent follow-up survey of pneumoconiosis patients across 27 PLADs in China. The investigation was conducted by the National Institute for Occupational Health and Poisoning Control, affiliated with China CDC (1).

    The initial health-seeking behavior survey, undertaken from January 2018 to December 2020, involved studying 9,934 pneumoconiosis patients. Of these, 8,198 valid questionnaires were collected, resulting in a questionnaire recovery rate of 82.5%.

    The research group subsequently executed a second telephone follow-up survey from 2020 to 2022. This included the 8,198 pneumoconiosis patients from the initial survey. As of November 2022, follow-up communication had been completed with 5,561 patients. However, the remaining 2,637 patients, who were still being followed up, were not included in the current study due to timing constraints.

    The follow-up survey amassed a total of 4,644 valid questionnaires, yielding a questionnaire recovery rate of 83.5%. Tragically, the survey revealed that 232 pneumoconiosis patients passed away during the second follow-up.

    The current study finally selected 514 cases, both from the control group (those who had not received WLL treatment prior to the first survey) and the lavage group (those who had received WLL treatment prior to the first survey). A PSM technique was used to match the baseline data from the first survey of 4,412 surviving pneumoconiosis patients with valid questionnaires; 3,322 did not receive WLL before the first survey, and 1,090 received WLL before the first survey (Figure 1).

    Figure 1. 

    Flowchart of enrolled patients.

    Abbreviation: PSM=propensity score matching.

    This study utilized PSM to create control and lavage groups from the pool of surveyed pneumoconiosis patients in each medical institution. The final control and lavage groups each included 514 patients. Factors used for matching consisted of gender, age, body mass index (BMI), patients’ source, annual family income, pneumoconiosis stage and type, presence of tuberculosis, self-reported health status, medications for pneumoconiosis, oxygen therapy, and practice of breathing exercises, all of which are crucial influencers on pneumoconiosis patients’ decision to undergo WLL and their overall health condition. The Nearest Neighbor Matching method was applied in a 1∶1 matching ratio with a caliper value of 0.01. The basic information of the two groups of patients is shown in Supplementary Tables S1S2. The study referenced the European EQ-5D-3L scale to describe patient quality of life. To compare pneumoconiosis-related symptoms and quality of life differences between the two groups, the t-test, chi-squared test or Fisher’s exact probability method was implemented, while paired t-test and paired chi-squared test were used to assess differences between initial and follow-up surveys for both groups. All analyses used SPSS software (version 26.0, SPSS Inc, Chicago, IL, USA). The accepted statistically significant level was set at 0.05 (two-tailed)。Ethical approval for this research was granted by the Ethics Committee of the National Institute for Occupational Health and Poison Control, China CDC (Approval No: 201720). Written informed consent was obtained from all participants.

    Following PSM, a total of 514 patients were found in each of the control group and the lavage group. The average age in both groups was found to be 53.3 years, with a standard deviation of 9.7 and 8.3, respectively, a difference which was not considered statistically significant (t=−0.052, P=0.959). The average interval between the two surveys was found to be approximately 1.9 years in both groups, with a standard deviation of 0.9 and 0.8, respectively, revealing no significant statistical difference (t=0.799, P=0.424).

    In the initial survey, a notable statistical difference was detected regarding expectoration symptoms between the two groups (P<0.001). The percentage of patients exhibiting no expectoration was lower in the lavage group than in the control group (11.7% vs. 19.8%). Conversely, the patient percentage with minimal expectoration was higher than in the control group (62.8% vs. 54.5%). However, in the subsequent follow-up survey, no meaningful difference in expectoration symptoms was found between the groups (P=0.606) (Table 1).

    SymptomsThe first surveySecondary follow-up survey
    Control group
    n (%)
    Lavage group
    n (%)
    χ2PControl group
    n (%)
    Lavage group
    n (%)
    χ2P
    Cough2.0790.3544.2650.119
    No51 (9.9)38 (7.4)113 (22.0)135 (26.3)
    Mild310 (60.3)319 (62.1)313 (60.9)310 (60.3)
    Moderate and severe153 (29.8)157 (30.5)88 (17.1)69 (13.4)
    Expectoration13.959<0.0011.0030.606
    No102 (19.8)60 (11.7)166 (32.3)181 (35.2)
    Mild280 (54.5)323 (62.8)270 (52.5)260 (50.6)
    Moderate and severe132 (25.7)131 (25.5)78 (15.2)73 (14.2)
    Chest tightness2.6610.2640.2550.880
    No64 (12.5)48 (9.3)164 (31.9)157 (30.5)
    Mild295 (57.4)310 (60.3)258 (50.2)261 (50.8)
    Moderate and severe155 (30.2)156 (30.4)92 (17.9)96 (18.7)
    Chest pain5.7360.0574.5780.101
    No199 (38.7)170 (33.1)336 (65.4)329 (64.0)
    Mild197 (38.3)234 (45.5)118 (23.0)141 (27.4)
    Moderate and severe118 (23.0)110 (21.4)60 (11.7)44 (8.6)
    Dyspnea0.4390.8034.3700.112
    No131 (25.5)129 (25.1)176 (34.2)208 (40.5)
    Mild222 (43.2)232 (45.1)230 (44.7)212 (41.2)
    Moderate and severe161 (31.3)153 (29.8)108 (21.0)94 (18.3)
    Hemoptysis0.9570.3280.3240.569
    No460 (89.5)450 (87.5)486 (94.6)490 (95.3)
    Yes54 (10.5)64 (12.5)28 (5.4)24 (4.7)
    Note: The categories for cough severity include mild (intermittent cough not affecting daily activities), moderate, and severe (frequent or violent cough disrupting daily activities and rest). Expectoration is categorized as mild (sputum volume of 10–50 mL during day and night), moderate, and severe (sputum volume exceeding 50 mL during day and night). Chest tightness ranges from mild (intermittent discomfort) to moderate and severe (persistent tightness restricting breathing). Chest pain and dyspnea are classified as mild (occurs during physical activities), moderate, and severe (manifests during daily activities and rest).

    Table 1.  Comparison of pneumoconiosis-related symptoms between the control group and the lavage group — China, 2018–2022 (n=514).

    A comparative analysis of pneumoconiosis symptoms before and after the initial and follow-up surveys indicates a significant statistical variation in the severity of the identified eight symptoms across the two groups (P<0.05). We noted a reduction in the proportion of patients in the highest severity level of each symptom and conversely, observed an increased proportion of patients without the said symptoms in both groups (Supplementary Table S3).

    The initial and subsequent surveys did not reveal any statistically significant disparities in the five elements of self-reported quality of life and health status among pneumoconiosis patients across both groups (P>0.05) (Supplementary Table S4).

    Upon comparing the quality of life before and after initial and follow-up surveys, no statistically significant changes were observed in the self-care of pneumoconiosis patients from the control group (P=0.083). Conversely, the differences within the lavage group were statistically significant (P<0.001), exemplified by an increased proportion of patients reported to have “no problem” in terms of self-care (Table 2). The average variation in self-reported health status between the two surveys was 9.6±16.7 in the control group and 10.3±18.5 in the lavage group. This difference, however, did not reach statistical significance (t=−0.678, P=0.498).

    Quality of lifeGroupLevelThe first survey Secondary follow-up survey P
    Mobility, n (%)Control groupNo problems302 (58.8)365 (71.0)<0.001
    Moderate problems206 (40.1)140 (27.2)
    Extreme problems6 (1.2)9 (1.8)
    Lavage groupNo problems322 (62.6)388 (75.5)<0.001
    Moderate problems189 (36.8)123 (23.9)
    Extreme problems3 (0.6)3 (0.6)
    Self-care, n (%)Control groupNo problems405 (78.8)426 (82.9)0.083
    Moderate problems106 (20.6)82 (16.0)
    Extreme problems3 (0.6)6 (1.2)
    Lavage groupNo problems386 (75.1)442 (86.0)<0.001
    Moderate problems125 (24.3)70 (13.6)
    Extreme problems3 (0.6)2 (0.4)
    Usual activities, n (%)Control groupNo problems251 (48.8)317 (61.7)<0.001
    Moderate problems232 (45.1)173 (33.7)
    Extreme problems31 (6.0)24 (4.7)
    Lavage groupNo problems264 (51.4)349 (67.9)<0.001
    Moderate problems221 (43.0)143 (27.8)
    Extreme problems29 (5.6)22 (4.3)
    Pain/discomfort, n (%)Control groupNo problems118 (23.0)233 (45.3)<0.001
    Moderate problems352 (68.5)255 (49.6)
    Extreme problems44 (8.6)26 (5.1)
    Lavage groupNo problems147 (28.6)234 (45.5)<0.001
    Moderate problems330 (64.2)268 (52.1)
    Extreme problems37 (7.2)12 (2.3)
    Anxiety/depression, n (%)Control groupNo problems219 (42.6)292 (56.8)<0.001
    Moderate problems214 (41.6)193 (37.5)
    Extreme problems81 (15.8)29 (5.6)
    Lavage groupNo problems217 (42.2)313 (60.9)<0.001
    Moderate problems210 (40.9)176 (34.2)
    Extreme problems87 (16.9)25 (4.9)
    Health status self-score $(\bar x \pm s )$Control group/59.1±17.368.7±15.8<0.001
    Lavage group/59.0±17.269.3±16.3<0.001
    Note: “/” means health status self-score did not differentiate levels.

    Table 2.  Comparative analysis of quality-of-life differences between the two patient groups across two surveys — China, 2018–2022 (n=514).

    • This research involved the selection of lavage and control groups through PSM for the purpose of comparing differences in pneumoconiosis-related symptoms and quality of life. These two groups of pneumoconiosis patients exhibited similar baseline characteristics, allowing for a preliminary evaluation of the effects of WLL on these patients. The intent was to stimulate thought and inform future empirical studies focusing on the long-term efficacy of WLL for pneumoconiosis patients. The Consensus of Chinese Experts on Pneumoconiosis Treatment (2018) purports that while WLL significantly improves clinical symptoms in the short term, current evidence does not substantiate a marked therapeutic impact on lung function and pulmonary fibrosis. As WLL is an invasive treatment, it is currently not upheld as a standard treatment for pneumoconiosis (2). The results from the study’s initial survey are presented herewith.

      The survey data revealed a 17.8% prevalence rate for WLL use among participants, signaling its considerable utilization as a nonstandard treatment technique. Earlier studies typically gauged the efficacy of WLL via self-regulated pre-and post-surgical evaluations, concluding that WLL might have a positive impact on alleviating short-term pneumoconiosis symptoms (34). Nonetheless, the present research suggests that both patient groups exhibited improved health status. This improvement may be attributable to recent enhancements in national support policies for individuals with pneumoconiosis and the survivor effect (56). Therefore, when assessing WLL’s impact on pneumoconiosis patients, mere self-comparisons before and after the treatment may not accurately reflect the reality of their condition.

      In studies involving control groups, the influential confounding factors affecting the health condition of patients with pneumoconiosis were either not adjusted or only a few were accounted for. Despite this, these studies generally concluded that WLL had short-term beneficial effects on the patients’ health (78). Before adjusting for confounders, WLL was linked to improvements in numerous respiratory symptoms and quality of life. WLL typically targets patients with relatively mild conditions that are more likely to tolerate the procedure, introducing potential selection bias in the outcomes (910). In our study, however, we employed a large sample size and controlled for the principal factors that may influence both the patients’ decision to undergo WLL and their health conditions. Using PSM, we equalized the baseline characteristics of both patient groups. This approach allowed us to evaluate the effects of WLL on pneumoconiosis patients more accurately.

      The findings of the study indicate that WLL yielded a moderate effect on alleviating expectoration symptoms when juxtaposed with the control. However, there was no significant improvement in symptoms such as coughing, chest tightness, chest pain, and dyspnea in comparison to the control. This finding is consistent with the underlying mechanism that WLL works by cleansing the respiratory tract and pulmonary sputum of patients with pneumoconiosis, thus aiding those with substantial sputum stasis that is challenging to expectorate. In terms of quality of life assessment, WLL only significantly enhanced the self-care abilities of the pneumoconiosis patients contrasted with the control. However, no notable improvements were evident in the remaining four aspects and the overall health status compared with the control group.

      This study indicates that WLL has a modest impact on pneumoconiosis patients and should not be considered a standard treatment. However, this research primarily assessed the influence of whole lung lavage based on patients’ subjective experiences of symptoms and quality of life, without incorporating objective measurements, such as chest imaging and lung function. This omission represents a limitation. Future research on the use of WLL in pneumoconiosis treatment should endeavor to provide stronger evidence by choosing indicators that can objectively assess disease severity, progression, and patient quality of life. It should also account for potential confounding factors, such as the quality of WLL operation, patients’ dust exposure history, medication therapies, and other treatment modalities. A systematic evaluation of WLL’s long-term efficacy using standardized methodologies is recommended to fairly assess WLL’s cost-effectiveness for pneumoconiosis patients.

      The current study inadequately addresses the potential influence of varied WLL procedure quality across different medical institutions on patient outcomes. Furthermore, the research does not provide detailed information regarding the dust exposure history and work type of participants, likely influencing the assessed impact of WLL on pneumoconiosis patients. Additionally, potential disparities in data collection methods could introduce bias as the initial questionnaire involved face-to-face interviews, whereas the secondary follow-up predominantly used telephone interviews. Consequently, the potential for information bias is apparent in the comparison of the two surveys’ results.

    • No conflicts of interest.

    • The participants in the study and the members of the survey teams in each of the 27 regional centers, and the project development and management teams.

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