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Diabetes Management After Bariatric Surgery

Cpe Monthly: Bariatric Surgery In Diabetes Management - Today's Dietitian Magazine

Cpe Monthly: Bariatric Surgery In Diabetes Management - Today's Dietitian Magazine

CPE Monthly: Bariatric Surgery In Diabetes Management Suggested CDR Learning Codes: 4140, 5125, 5190 Suggested CDR Performance Indicators: 8.1.5, 8.3.1, 8.3.6 Take this course and earn 2 CEUs on our Continuing Education Learning Library The latest National Health and Nutrition Examination Survey data indicate that between 2009 and 2010, roughly 35% of adults (78 million) and 16.9% of children and adolescents (12.5 million) were obese.1 Excess weight is associated with an increased prevalence of type 2 diabetes, and both diabetes and obesity are associated with an increased risk of mortality and higher health care costs.2 Since obesity is considered a modifiable risk factor for diabetes, preventing it is ideal, but treatment for those who are currently obese is critical. Diet, exercise, and medications are the cornerstones of therapy for type 2 diabetes, but outcomes remain disappointing.3 Fewer than 50% of people with moderate to severe diabetes achieve and maintain therapeutic thresholds for glycemic control. Diet, exercise, and behavioral therapy are first-line treatment modalities for obesity, but results also are inadequate.4 In addition, many diabetes medications (eg, insulin, sulfonylureas, thiazolidinediones) promote weight gain, further exacerbating obesity among people with diabetes.5 This continuing education course reviews the research on bariatric surgery as a treatment option for type 2 diabetes. The course reviews the types of interventions, remission rates, and the mechanisms for diabetes resolution and outlines practical applications for dietitians. The choice of surgery type for a particular patient often is discussed with diabetes resolution in mind. Because diabetes is one of the primary reasons patients elect to have bariatric surgery, surgeons typi Continue reading >>

Metabolic And Bariatric Surgery And Type 2 Diabetes

Metabolic And Bariatric Surgery And Type 2 Diabetes

Did You Know? Someone in the world dies from complications associated with diabetes every 10 seconds. Diabetes is one of the top ten leading causes of U.S. deaths. One out of ten health care dollars is attributed to diabetes. Diabetics have health expenditures that are 2.3 times higher than non-diabetics. Approximately 90 percent of type 2 diabetes mellitus (T2DM), the most common form of diabetes, is attributable to excessive body fat. If current trends continue, T2DM or pre diabetic conditions will strike as many as half of adult Americans by the end of the decade. (according to the United HealthGroup Inc., the largest U.S. health insurer by sales). The prevalence of diabetes is 8.9 percent for the U.S. population but more than 25 percent among individuals with morbid obesity. Metabolic and bariatric surgery is the most effective treatment for T2DM among individuals who are affected by obesity and may result in remission or improvement in nearly all cases. Type 2 Diabetes Mellitus (T2DM) Type 2 diabetes(T2DM) is the most common form of diabetes, accounting for approximately 95 percent of all cases. Obesity is the primary cause for T2DM and the alarming rise in diabetes prevalence throughout the world has been in direct association increase rates of obesity worldwide. T2DM leads to many health problems including cardiovascular disease, stroke, blindness, kidney failure, neuropathy, amputations, impotency, depression, cognitive decline and mortality risk from certain forms of cancer. Premature death from T2DM is increased by as much as 80 percent and life expectancy is reduced by 12 to 14 years. Current therapy for type 2 diabetes includes lifestyle intervention (weight-loss, appropriate diet, exercise) and anti-diabetes medication(s). Medical supervision and strict adh Continue reading >>

Clinical Management Of Type 2 Diabetes Mellitus After Bariatric Surgery

Clinical Management Of Type 2 Diabetes Mellitus After Bariatric Surgery

Clinical Management of Type 2 Diabetes Mellitus after Bariatric Surgery Lipid and Metabolic Effects of Gastrointestinal Surgery (R Cohen, Section Editor) Topical Collection on Lipid and Metabolic Effects of Gastrointestinal Surgery Bariatric surgery has emerged as an effective treatment for type 2 diabetes in the setting of obesity, with recent clinical trials demonstrating biochemical remission (i.e., euglycemia) in up to 40% of subjects at 3years post-surgery. Conversely, these trials also highlight that a significant proportion of individuals undergoing bariatric surgery experience residual diabetes (i.e., they do not achieve remission or experience diabetes recurrence). The management of residual diabetes following surgery requires personalized attention, yet limited evidence exists on which to base clinical decisions. Hence, we aim to review the evidence that does exist and propose clinical management strategies in patients with persistent hyperglycemia following bariatric surgery. Bariatric surgeryResidual diabetesClinical managementDiabetes non-remissionDiabetes therapies This article is part of the Topical Collection on Lipid and Metabolic Effects of Gastrointestinal Surgery This is a preview of subscription content, log in to check access Vishesh Khanna declares no conflict of interest. Sangeeta R. Kashyap reports grants from Ethicon, Covidien, and Janssen. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors. Papers of particular interest, published recently, have been highlighted as: Of importance Of major importance Maruthur NM. The growing prevalence of type 2 diabetes: increased incidence or improved survival? Curr Diabetes Rep. 2013;13(6):78694. CrossRef Googl Continue reading >>

Medical Management Of Diabetes After Bariatric Surgery - Em|consulte

Medical Management Of Diabetes After Bariatric Surgery - Em|consulte

Medical management of diabetes after bariatric surgery Prise en charge mdicale et nutritionnelle aprs chirurgie bariatrique dans le diabte , A.Pradignac a , F.Luca a , L.Meyer a , S.Rohr b aService de Mdecine Interne, Endocrinologie, Nutrition, Hpital de Hautepierre, Avenue Molire, BP 83049, 67098 Strasbourg Cedex, France bService de Chirurgie Gnrale et Digestive, Hpital de Hautepierre, Avenue Molire, BP 83049, 67098 Strasbourg Cedex, France Several studies indicate that bariatric surgery frequently leads to resolution or improvement of type 2 diabetes in overweight patients. However, the medical postoperative management requires lifelong counselling, monitoring and nutrient supplements in patients in remission as well as in patients who continue to be diabetic. The aim of such management is to avoid nutritional deficiencies, and to delay diabetes relapse by optimizing the control of risk factors. To this end, diet and pharmacological prescriptions, including vitamin and mineral supplements, are indispensable, despite the fact that specific recommendations, until now, have been lacking for these particular patients. The full text of this article is available in PDF format. La chirurgie bariatrique est une procdure thrapeutique entranant une rmission frquente du diabte de type 2. Une prise en charge mdicale et nutritionnelle est ncessaire au trs long cours dans le but de limiter la reprise pondrale, de corriger les dficits nutrimentiels et de prvenir la rapparition du diabte. Il nexiste pas de recommandations spcifiques concernant le diabtique et, par dfaut, il convient dextrapoler les recommandations gnrales concernant les modalits de suivi et de supplmentation nutritionnelle auxquelles il faut adjoindre des modifications hygino-dittiques plus appropries au diabte en p Continue reading >>

Study Looks At Insulin Requirements After Bariatric Surgery

Study Looks At Insulin Requirements After Bariatric Surgery

Major clinical trials, most notably Cleveland Clinics STAMPEDE (Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently), have demonstrated that Roux-en-Y gastric bypass surgery improves glycemic control in insulin-requiring patients with type 2 diabetes (T2D), even resulting in remission in many cases months to years after surgery. However, the perioperative insulin dose needed in this population had not been well studied until now. Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services Policy Cleveland Clinic researchers recently presented the results of a retrospective study comparing pre- and post-operative insulin regimens and dosages in patients with T2D who had undergone gastric bypass during a four-year period. The study, presented as an abstract and eposter at the recently concluded American Association of Clinical Endocrinologists (AACE) 25th Annual Scientific & Clinical Congress ,1 found that on average, patients required an 86 percent post-operative reduction in their total daily dose of insulin within two days of surgery. Our study results demonstrated the drastic insulin dose reduction needed immediately after bariatric surgery, which will hopefully help guide inpatient diabetes management in this population, says M. Cecilia Lansang, MD, MPH, director of Cleveland Clinics Inpatient Diabetes Service and chair of the Diabetes Care Committee. The study was driven by nurse practitioner leaders, who recognized the challenges related to glycemic control following bariatric surgery, especially on post-op days one and two. Since there arent any guidelines right now to treat post-bariatric surgery patients with insulin, everyone was Continue reading >>

Diabetes Remission, Glycemic Control After Bariatric Surgery

Diabetes Remission, Glycemic Control After Bariatric Surgery

Objective Eligibility criteria for bariatric surgery in diabetes include BMI 35 kg/m2 and poorly controlled glycemia. However, BMI does not predict diabetes remission, and thus, predictors need to be identified. Research Design and Methods Seven hundred twenty-seven patients were included in a database merged from the Swedish Obese Subjects (SOS) study and two randomized controlled studies, with 415 surgical and 312 medical patients in total. Bariatric operations were divided into gastric only (GO) and gastric plus diversion (GD). Results Sixty-four percent of patients in the surgical arm and 15.0% in the medical arm experienced diabetes remission (P < 0.001). GO yielded 60% remission, and GD yielded 76% remission. The best predictors of diabetes remission were lower baseline glycemia and shorter diabetes duration. However, when operation type was considered, GD predicted a higher likelihood of remission and greater weight loss. Patients in remission (responders) lost more weight (25% vs. 17%) and waist circumference (18% vs. 13%) and experienced better insulin sensitivity than nonresponders. Conclusions Surgery is more effective than medical treatment in achieving diabetes remission and tighter glycemic control. Shorter diabetes duration, lower fasting glycemia before surgery, and GD versus GO procedures independently predict higher rates of remission, whereas baseline HbA1c and waist circumference predict improved glycemic control. The results show the advantage of an early operation together with better controlled glycemia on diabetes remission independently of BMI. The prospective, controlled Swedish Obese Subjects (SOS) study showed that the short-term rate of remission of diabetes after bariatric surgery is 72% compared with 21% in subjects treated with conventio Continue reading >>

Hypoglycemia After Gastric Bypass: An Emerging Complication

Hypoglycemia After Gastric Bypass: An Emerging Complication

Bariatric surgery, though beneficial, is associated with complications, one of which is post-gastric bypass hypoglycemia (PGBH).1 The mean time from gastric bypass to documented hypoglycemia is about 28 months.2 PGBH is probably more common than initially thought. In older reports, the prevalence was only 0.1% to 0.36%.1,3 In contrast, in a mail survey in 2015,4 one-third of bariatric surgery patients reported symptoms that raised the suspicion of hypoglycemia. Those with suspicious symptoms were more likely to have undergone Roux-en-Y surgery, to have had no preoperative diabetes, to have had a longer interval since surgery, and to be female. Restricting the suspicion of postprandial hypoglycemia to those who reported more serious symptoms, including needing third-party assistance, the prevalence was 11.6%. Kefurt et al5 followed Roux-en-Y patients who wore a continuous glucose monitor for 86 months after surgery and found that 38% had hypoglycemia; however, symptoms of hypoglycemia were not discussed. Thus, the exact prevalence is currently unknown. But as time goes by and more procedures are performed, the incidence will likely rise. OBESITY IS ON THE RISE, AND SO IS WEIGHT-LOSS SURGERY Obesity is rampant, and its prevalence continues to rise. In 2011–2012, more than two-thirds of adults in the United States were reported as obese.6 Complications of obesity such as cardiac disease, diabetes, and cancer lead to increased mortality risk.7 Obesity is difficult to reverse, as many people fail to lose weight with diet, exercise, and pharmacotherapy. Given the difficulty of losing weight and the complications that arise from obesity, bariatric surgery has become increasingly popular. Not only do patients lose significantly more weight with bariatric surgery than with con Continue reading >>

Bariatric Surgery Leads To 3-year Resolution Of Diabetes In 24% To 38% Of Patients

Bariatric Surgery Leads To 3-year Resolution Of Diabetes In 24% To 38% Of Patients

Bariatric Surgery Leads to 3-Year Resolution of Diabetes in 24% to 38% of Patients Journal of Clinical Outcomes Management. 2014 July;21(7) Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes3 year outcomes. N Engl J Med 2014;370:200213. 1. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:156776. 2. Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:268393. 3. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:74152. 4. Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med 2012;367:695704. 5. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:75361. 6. Sjostrom L, Peltonen M, Jacobson P, et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA 2014;311:2297304. 7. Mingrone G, Panunzi S, DeGaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012;366:157785. 8. Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA 2013;309:22409. 9. The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361:44554. 1 Continue reading >>

Type 2 Diabetes Management In A Post-bariatric Surgery Patient

Type 2 Diabetes Management In A Post-bariatric Surgery Patient

Type 2 diabetes management in a post-bariatric surgery patient Type 2 diabetes management in a post-bariatric surgery patient A patient, aged 57 years, was admitted to the hospital to undergo gastric bypass surgery. He had a history of type 2 diabetes for ten years. Diabetes management in a pre-, post-bariatric surgery patient A patient, aged 57 years, was admitted to the hospital to undergo gastric bypass surgery. He had a history of type 2 diabetes for ten years. Pre-admission diabetes therapy included metformin 1000 mg at morning and bedtime, insulin glargine ( Lantus ) 70 units every day in the afternoon or evening, insulin aspart ( NovoLog ) 30 units plus sliding scale three times per day. The day prior to surgery, the patient reported taking metformin 1000 mg, insulin glargine 70 units, and insulin aspart 30 units with his evening meal. His hemoglobin A1c value was 8%, and it was taken just prior to surgery. The patient's blood glucose value on admission was 204 mg/dL. Throughout the surgery, blood glucose values ranged from 208 to 214 mg/dL. Throughout the day, the patient received a total of 8 units of insulin aspart in correction doses for noted hyperglycemia. The patient was instructed to take nothing by mouth on the day of surgery, and then was advised to start a bariatric clear liquid diet on post-operative day one, advancing as tolerated. This meal plan consisted of six small, liquid meals provided throughout the day with the goal of staying hydrated. On post-operative day two, blood glucose values ranged from 90 to 103 mg/dL. The patient continued to tolerate six small meals per day via a bariatric surgery diet.He was approved to dismiss from the hospital on post-operative day two. The patient was recommended to take a multivitamin with minerals daily aft Continue reading >>

Frontiers | The Impact Of Bariatric Surgery On Type 2 Diabetes Mellitus And The Management Of Hypoglycemic Events | Endocrinology

Frontiers | The Impact Of Bariatric Surgery On Type 2 Diabetes Mellitus And The Management Of Hypoglycemic Events | Endocrinology

Front. Endocrinol., 01 March 2017 | The Impact of Bariatric Surgery on Type 2 Diabetes Mellitus and the Management of Hypoglycemic Events Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA Recent studies discussed the benefit of bariatric surgery on obese patients diagnosed with type 2 diabetes mellitus (T2DM). Several factors play an essential role in predicting the impact of bariatric surgery on T2DM, such as ABCD score (age, BMI, C-peptide, and duration of the disease), HbA1c, and fasting blood glucose, incretins [glucagon-like peptide-1 (GLP-1) and gastric inhibitory peptide (GIP)]. DiaRem score known to include factors such as age, HbA1c, medication, and insulin usage used to predict the remission of T2DM, but it has some limitations. An extensive literature search was conducted on PubMed and Google Scholar using keywords such as gastric bypass, T2DM, bariatric surgery, GLP-1, GIP, and post bariatric hypoglycemia. Restrictive-malabsorptive procedures are most effective in treating T2DM patients based on changes induced in appetite through regulation of gastrointestinal hormones, with decreased hunger and increased satiation. We provide a review of bariatric surgery influence on T2DM and management of post-intervention hypoglycemic events. Post-bariatric surgery hypoglycemia is a serious complication especially when patients develop life-threatening neuroglycopenia with loss of consciousness and seizure. The avoidance of this adverse event may be achieved by strict dietary modification including a restriction on carbohydrates as well as foods with high glycemic index. Further research will provide more information on post-bariatric surgery hyperinsulinemic hypoglycemia pathophysiology and management. Obesity is one of t Continue reading >>

Management Of Type 2 Diabetes After Gastric Bypass Surgery

Management Of Type 2 Diabetes After Gastric Bypass Surgery

You have reached the maximum number of saved studies (100). Please remove one or more studies before adding more. Management of Type 2 Diabetes After Gastric Bypass Surgery The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. ClinicalTrials.gov Identifier: NCT01213563 Information provided by (Responsible Party): Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information Gastric bypass surgery has been proposed as an effective treatment strategy for type 2 diabetes mellitus (T2DM), but thus far algorithms for the management of T2DM immediately after surgery have not been established. The investigators designed an algorithm to achieve good glycaemic control in patients with insulin-requiring T2DM upon discharge after gastric bypass surgery, and evaluated this algorithm for feasibility, efficacy, and safety. Drug: Actrapid insulin+Gloucose Drug: Actrapid insulin This is a prospective randomised controlled intervention study on obese human subjects with Type 2 Diabetes Mellitus undergoing obesity surgery (n=80). Patients will be recruited from those already due to undergo bariatric surgery within the context of the obesity clinic (Imperial College London). Patients will be randomised to either of two treatment protocols. Protocol A-Conservative Management: On admission to hospital all pre-operative oral antidiabetic agents and insulin are stopped and glucose monitoring is carried out every four hours at the same time as routine observations. Actrapid insulin is administered with glucose as per standard sliding scale (Appendix A). Continue reading >>

Treatment Of Diabetes Prior To And After Bariatric Surgery

Treatment Of Diabetes Prior To And After Bariatric Surgery

Go to: Introduction Type 2 diabetes (T2DM) is a major health problem with increasing incidence in the Western world as well as in developing countries. The disease is chronic and the treatment involves lifestyle changes, oral antidiabetic drugs, and/or injections of insulin or glucagon-like peptide-1 (GLP-1) analogs as well as treatment for any ongoing hypertension and/or hyperlipidemia. Although the mortality from cardiovascular disease in diabetes seems to decline over time, it is still at least double compared to that in a nondiabetic population.1 Diabetes is associated with obesity; the more obesity, the greater the risk for T2DM. Current recommendations for bariatric surgery are based on body mass index [(BMI), body weight (kg)/length (m2)]. Body mass index >25 is classified as overweight, and BMI >30 is classified as obesity. Similar to diabetes, obesity is also associated with increased risk of morbidity and mortality. The total risk of premature death has been reported to be increased at least two-fold in patients with obesity compared with normal-weight subjects.2 Moreover, the risk of death from cardiovascular disease has been reported to be increased three- and five-fold in obese women and men, respectively, and there is an increased risk for several types of cancer.3 Treatment modalities for obesity include lifestyle changes, diet regimens, pharmacological treatment, and bariatric surgery. Of these, surgery is the most efficient alternative and has been demonstrated to be associated with maintained weight reduction as well as with effects on obesity-associated conditions such as T2DM. Today, the most commonly used limits to qualify for bariatric (weight-reducing) surgery in Europe as well as in the United States are a BMI of 35 with comorbidity and 40 withou Continue reading >>

Medical Management Of Diabetes After Bariatric Surgery.

Medical Management Of Diabetes After Bariatric Surgery.

1. Diabetes Metab. 2009 Dec;35(6 Pt 2):558-61. doi: 10.1016/S1262-3636(09)73465-2. Medical management of diabetes after bariatric surgery. Schlienger JL(1), Pradignac A, Luca F, Meyer L, Rohr S. (1)Service de Mdecine Interne, Endocrinologie, Nutrition, Hpital de Hautepierre, Avenue Molire, BP 83049, 67098 Strasbourg Cedex, France. [email protected] Several studies indicate that bariatric surgery frequently leads to resolution orimprovement of type 2 diabetes in overweight patients. However, the medicalpostoperative management requires lifelong counselling, monitoring and nutrientsupplements in patients in remission as well as in patients who continue to bediabetic. The aim of such management is to avoid nutritional deficiencies, and todelay diabetes relapse by optimizing the control of risk factors. To this end,diet and pharmacological prescriptions, including vitamin and mineralsupplements, are indispensable, despite the fact that specific recommendations,until now, have been lacking for these particular patients.Copyright 2009 Elsevier Masson SAS. All rights reserved. Diabetes Mellitus, Type 2/prevention & control Continue reading >>

Unveiling The “magic” Of Diabetes Remission After Weight-loss Surgery

Unveiling The “magic” Of Diabetes Remission After Weight-loss Surgery

An extraordinary thing happens to some patients with type 2 diabetes who undergo weight-loss surgery: Within days of the procedure, they improve their insulin production and need fewer or no diabetes medications. Although it’s well established that losing weight, especially around the waistline, improves pancreas function and insulin sensitivity, it generally takes 6 months to a year after bariatric surgery before a patient sheds a substantial number of pounds. Bruce M. Wolfe, MD, professor of surgery at Oregon Health and Science University School of Medicine, recalled one “remarkable” case in which a patient who required 400 daily units of insulin prior to gastric bypass surgery needed none on the day she was discharged from the hospital. Continue reading >>

Bariatric Surgery | Johns Hopkins Diabetes Guide

Bariatric Surgery | Johns Hopkins Diabetes Guide

Up to 55% of all patients diagnosed with diabetes are obese [11] . Of an estimated 225,000 bariatric surgeries performed per annum, 15- 30% have diabetes [11] . Bariatric surgery, especially Roux-en-Y gastric bypass, can result in the resolution of type 2 diabetes in 42-75% at up to 2 years after surgery [2] [1] . Diabetes-related mortality and all-cause mortality are significantly decreased after gastric bypass [2] . Eligibility for bariatric surgery is established according to National Institutes of Health guidelines: BMI 40 kg/m2 or a BMI 35 kg/m2 with an obesity- related comorbidity such as diabetes, hypertension, obstructive sleep apnea , obesity hypo-ventilation syndrome, Pickwickian syndrome, severe urinary incontinence, hyperlipidemia, debilitating osteoarthritis, nonalcoholic fatty liver disease, coronary artery disease, gastroesophageal reflux disease, and pseudotumor cerebri [12] . In February 2011, FDA approved use of laparoscopic adjustable gastric banding for BMI 30 kg/m2 with an obesity-related comorbidity in response to a study presented by the manufacturer that showed significant weight loss after the surgery for persons who were mildly obese. Specific coverage guidelines vary by insurance carrier (e.g. documentation of a failed trial of diet and exercise and performance of surgery at an American Society for Bariatric Surgery designated Center of Excellence). Glycemic control in immediate post-operative period (days 0-3) Insulin requiring patients often require significantly lower doses of insulin and oral hypoglycemic agents post-operatively due to decreased oral intake. With Roux-en-Y or BPD procedures, hyperglycemia may improve dramatically within several days, well before significant weight loss. Oral intake advanced according to institution or pro Continue reading >>

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