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Clozapine concentrations may be increased; dosage reduction may be necessary in patients with clinically important renal impairment. Gelenberg AJ, Doller JC. Clozapine versus chlorpromazine for the treatment of schizophrenia: preliminary results from a double-blind study. J Clin Psychiatry. Hyperglycemia, sometimes severe and associated with ketoacidosis, hyperosmolar coma, or death, reported in patients receiving atypical antipsychotic agents, 331 332 333 including clozapine. repaglinide

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Clozapine REMS Program. Clozapine and the Risk of Neutropenia: A Guide for Healthcare Providers. Phoenix, AZ; 2015 Sep. Hamilton D. Clozapine: a new antipsychotic drug. Arch Psychiatr Nurs. The active component of Clozapine Orally Disintegrating Tablets is clozapine. Monitor neonates that have been exposed to antipsychotic drugs during the third trimester of pregnancy for symptoms of agitation, hypertonia, tremor, somnolence, respiratory distress, and feeding difficulties. Novel antipsychotics: comparison of weight gain liabilities.

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Crismon ML, Ereshefsky L, Sakland SR. A comparison of clozapine absorption in the postprandial versus fasting states. Pharm Res. Benign ethnic neutropenia BEN is a condition observed in certain ethnic groups whose average ANC values are lower than “standard” laboratory ranges for neutrophils. It is most commonly observed in individuals of African descent approximate prevalence of 25-50% some Middle Eastern ethnic groups, and in other non-Caucasian ethnic groups with darker skin. BEN is more common in men. Patients with BEN have normal hematopoietic stem-cell number and myeloid maturation, are healthy, and do not suffer from repeated or severe infections. They are not at increased risk for developing Clozaril-induced neutropenia. Additional evaluation may be needed to determine if baseline neutropenia is due to BEN. Consider hematology consultation before initiating or during Clozaril treatment as necessary.

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McClellan J, Stock S, the American Academy of Child and Adolescent Psychiatry AACAP Committee on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. J Am Acad Child Adolesc Psychiatry. 2013; 52: 976-90. Clozapine concentrations may be increased in patients with clinically important hepatic impairment. 1 See Special Populations under Dosage and Administration. Black JL, Richelson E. Antipsychotic drugs: prediction of side-effect profiles based on neuroreceptor data derived from human brain tissue. Mayo Clin Proc. See FDA-approved patient labeling Patient Information and Instructions for Use.

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Menon MK, Gordon LI, Fitten J. Interaction between clozapine and a lipophilic α 1-adrenergic agonist. Life Sciences. Naheed M, Green B. 2001. My daughter has bipolar 1 and schizophrenia which I am told in combination is called "schizo-affective disorder. All medicines may cause side effects, but many people have no, or minor, side effects. Lab tests, including complete blood cell counts and heart function, may be performed while you use Clozaril and for at least 4 weeks after you stop taking it. These tests may be used to monitor your progress or check for side effects. Be sure to keep all doctor and lab appointments. Stimmel GL. Schizophrenia. In: Herfindal ET, Gourley DR, Hart LL, eds. Clinical Pharmacy and Therapeutics. Sixty-two percent of the patients were diagnosed with schizophrenia, and the remainder 38% were diagnosed with schizoaffective disorder. Only about one-fourth of the total patient population 27% was identified as “treatment-resistant” at baseline. There were more males than females in the study 61% of all patients were male. The mean age of patients entering the study was 37 years of age range 18 to 69. Most patients were Caucasian 71% 15% were Black, 1% were Asian, and 13% were classified as being of “other” races. Compton DR, Johnson KM. Effects of acute and chronic clozapine and haloperidol on in vitro release of acetylcholine and dopamine from striatum and nucleus accumbens. J Pharmacol Exp Ther. Wilk S, Stanley M. Clozapine concentrations in brain regions: relationship to dopamine metabolite increase. Eur J Pharmacol. Seizures have occurred with clozapine treatment. The risk is dose-related. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.

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Wolters EC, Hurwitz TA, Mak E et al. Clozapine in the treatment of parkinsonian patients with dopaminomimetic psychosis. Neurology. In man, Clozaril tablets 25 mg and 100 mg are equally bioavailable relative to a Clozaril solution. Going on 7 years we have had no success with any of the medications she has tried since day one. We were so-o-o-o hopeful to start Clozaril and went through all of the trouble of weekly blood tests etc. Potent CYP3A4 inducers: Concomitant use generally not recommended. 1 If concomitant use necessary, monitor for decreased efficacy of clozapine and consider increasing clozapine dosage. Parkinson's disease symptoms. Clozaril is the least likely to worsen Parkinson's symptoms; but, unfortunately, there is a small chance about 2% that your white blood cell cells that fight infection count will drop. For this reason, your doctor will likely perform frequent blood tests to make sure your white stay at a certain level. Claas FHJ. Drug-induced agranulocytosis; review of possible mechanisms, and prospects for clozapine studies. Psychopharmacology. Undesirable changes in lipid parameters observed in patients treated with some atypical antipsychotics, including clozapine. 1 Clinically important elevations in serum total cholesterol and triglyceride concentrations have occurred in clozapine-treated patients. If you are feeling depressed or experiencing any of the mentioned mental disturbances, talk to your doctor right away. There is likely a remedy that will make you feel better. Cohen S, Chiles J, MacNaughton A. Weight gain associated with clozapine. Am J Psychiatry. Check with your pharmacist about how to dispose of unused medicine. Patients initiating or continuing treatment with clozapine must have a baseline blood ANC before initiating clozapine therapy and regular ANC monitoring during treatment. 1 See Severe Neutropenia under Cautions. Reduce the dose gradually over a period of 1 to 2 weeks if termination of Clozaril therapy is planned and there is no evidence of moderate to severe neutropenia. Smego RA Jr, Durack DT. The neuroleptic malignant syndrome. Arch Intern Med. avlocardyl

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Kane J, Honigfeld G, Singer J et al. Clozapine for the treatment-resistant schizophrenic: a double- blind comparison with chlorpromazine. Arch Gen Psychiatry. Disclaimer: Every effort has been made to ensure that the information provided by Multum, Truven Health Analytics, Inc. Sokoloff P, Giros B, Martres MP et al. Molecular cloning and characterization of a novel dopamine receptor D3 as a target for neuroleptics. Nature. Please refer to the for information on shortages of one or more of these preparations. Bablenis E, Weber SS, Wagner RL. Clozapine: a novel antipsychotic agent. DICP. Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during the first few days of treatment. Jeste DV, Wyatt RJ. Clozapine and tardive dyskinesia. Arch Gen Psychiatry. Consider the risk of exacerbation of psychosis when discontinuing or changing treatment with antipsychotic medications during pregnancy and postpartum. Unit dose blister packages of 40 5 cards of 8 tablets each. Clozapine is available only through a shared REMS program, the Clozapine REMS program, that ensures appropriate monitoring and management of patients with severe neutropenia. 1 395 400 406 407 408 See Restricted Distribution Program under Dosage and Administration. Hu XT, Wang RY. Haloperidol and clozapine: differential effects on the sensitivity of caudate-putamen neurons to dopamine agonists and cholecystokinin following one month continuous treatment. Brain Res. Chiu E, Burrows G, Stevenson J. Double-blind comparison of clozapine with chlorpromazine in acute schizophrenic illness. Aust NZ J Psychiatry. Lipsitz L. Orthostatic hypotension in the elderly. N Engl J Med. Marder SR, Essock SM, Miller AL et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry. The orally disintegrating tablets in a blister pack should be left in the unopened blister until the time of use. Just prior to use, peel the foil from the blister and gently remove the orally disintegrating tablet. Do not push the tablets through the foil, because this could damage the tablet. The absence of a warning for a given drug or combination thereof in no way should be construed to indicate that the drug or combination is safe, effective, or appropriate for any given patient. Drugs.

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Continued How Are These Mental Disturbances Treated? Concomitant use of Clozapine Orally Disintegrating Tablets with other drugs metabolized by CYP2D6 can increase levels of these CYP2D6 substrates. Use caution when coadministering Clozapine Orally Disintegrating Tablets with other drugs that are metabolized by CYP2D6. It may be necessary to use lower doses of such drugs than usually prescribed. However, if the inducer is necessary, it may be necessary to increase the Clozaril dose. Orlistat and Rosuvastatin Calcium. Determine baseline CBC and ANC before initiation of therapy. FDA approved a shared REMS for clozapine to ensure that the benefits outweigh the risks. The REMS consists of the following: elements to assure safe use and implementation system. See the FDA REMS page or the ASHP REMS Resource Center . Also see Restricted Distribution Program under Dosage and Administration. Invernizzi R, Morali F, Pozzi L et al. Effects of acute and chronic clozapine on dopamine release and metabolism in the striatum and nucleus accumbens of conscious rats. Br J Pharmacol. Severe allergic reactions rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue; agitation; burning, numbness, or tingling; calf or leg pain or tenderness; chest pain; confusion; dark urine; decreased coordination; delirium; fainting; fast or difficult breathing; fast or irregular heartbeat; fever, chills, or sore throat; increased hunger, thirst, or urination; involuntary movements of the tongue, face, mouth, or jaw eg, tongue sticking out, puffing of cheeks, mouth puckering, chewing movements; loss of appetite; new or worsening mental or mood changes; numbness of an arm or leg; obsessive-compulsive symptoms eg, washing hands or checking doors continuously; persistent cough; restlessness; seizures; severe headache, dizziness, or vomiting; severe or persistent nausea or constipation; severe stomach pain; shortness of breath; sluggishness; stiff muscles; sudden, unusual weight gain; swelling of the hands, ankles, or feet; symptoms of a stroke eg, one-sided weakness, slurred speech; tremor; trouble swallowing; trouble urinating; uncontrolled muscle movements; unusual bruising or bleeding; unusual tiredness or weakness; vision changes; vomiting; yellowing of the skin or eyes. Use caution when administering concomitant medications that prolong the QT interval or inhibit the metabolism of clozapine. Mechanism of clozapine-induced neutropenia not known; risk is not dose-dependent. 1 Risk of neutropenia appears greatest during first 18 weeks of therapy and declines thereafter. 1 Not known whether concurrent use of other drugs known to cause neutropenia increases the risk or severity of clozapine-induced neutropenia. 1 See Interactions. Dosing regimens for each treatment group were determined by individual investigators and were individualized by patient. Pope HG Jr, Cole JO, Choras PT et al. Apparent neuroleptic malignant syndrome with clozapine and lithium. J Nerv Ment Dis. Discontinue promptly and obtain cardiac evaluation if myocarditis or cardiomyopathy suspected. 1 Generally should not rechallenge patients with clozapine-related myocarditis or cardiomyopathy unless benefit outweighs risks of recurrence; however, may consider rechallenge in consultation with a cardiologist, after a complete cardiac evaluation and with close monitoring. United States and its territories. Indications, uses and warnings on Drugs. Clozapine Orally Disintegrating Tablets and is associated with an increase in the risk of serious and potentially fatal infections. Risk of neutropenia appears greatest during the first 18 weeks on treatment and then declines. The mechanism by which clozapine causes neutropenia is unknown and is not dose-dependent. price for lumigan 50mg

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Approximately 88% of patients from the clozapine and chlorpromazine groups completed the 6-week trial. At the end of 6 weeks, 30% of the clozapine group responded to treatment, and 4% of the chlorpromazine group responded to treatment. Clozaril may lower the ability of your body to fight infection. Avoid contact with people who have colds or infections. Tell your doctor right away if you notice any signs of infection like fever, sore throat, rash, chills, mouth or nose sores, or unusual tiredness or weakness. Combination treatment with clozapine and paroxetine in schizophrenia: safety and tolerability data from a prospective open clinical trial. Use caution when administering concomitant medications that prolong the QT interval or inhibit the metabolism of Clozaril. Salzman C. Mandatory monitoring of side effects the “bundling” of clozapine. N Engl J Med.

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Pi EH, Simpson GM. Atypical neuroleptics: clozapine and the benzamides in the prevention and treatment of tardive dyskinesia. Mod Probl Pharmacopsychiat. Dibenzodiazepine-derivative; atypical or second-generation antipsychotic agent. They had attempted suicide within the three years prior to their baseline evaluation. C interrupt therapy and obtain ANC. Do not suddenly stop taking Clozaril. You may have an increased risk of side effects. If you need to stop Clozaril or add a new medicine, your doctor will gradually lower your dose. Sarafoff M, Davis L, Ruther E. Clozapine induced increase in human plasma norepinephrine. J Neural Transm. Roubicek J, Major I. EEG profile and behavioral changes after a single dose of clozapine in normals and schizophrenics. Biol Psychiatr. buy hydrochlorothiazide in new zealand

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Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing. Rudolf J, Grond M, Neveling M et al. Clozapine-induced agranulocytosis and thrombopenia in a patient with dopaminergic psychosis. J Neural Transm. Severity Scale score of at least 4 moderately ill. Laboratories International SRL May, 2016. Honigfeld G, Patin J, Singer J. Clozapine: antipsychotic activity in treatment-resistant schizophrenics. Adv Ther. If NMS occurs, immediately discontinue therapy and initiate supportive and symptomatic treatment. 1 Careful monitoring recommended if therapy is reinstituted following recovery; the risk that NMS can recur must be considered. Check with your doctor right away if you are having convulsions seizures difficulty with breathing, fast heartbeat, high fever, high or low blood pressure, increased sweating, loss of bladder control, severe muscle stiffness, unusually pale skin, or tiredness. These could be symptoms of a serious condition called neuroleptic malignant syndrome NMS. More than 80% of patients completed the 6-week trial. The following adverse reactions have been identified during post-approval use of clozapine. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. If clozapine is discontinued because of moderate to severe neutropenia, monitor ANC according to neutropenia monitoring recommendations. 1 Monitor ANC if fever occurs during the 2 weeks after clozapine discontinuance. Sassim N, Grohmann R. Adverse drug reactions with clozapine and simultaneous application of benzodiazepines. Pharmacopsychiatry. Choc MG, Hsuan F, Honigfeld G. Single- vs multiple-dose pharmacokinetics of clozapine in psychiatric patients. Pharm Res. Inactive Ingredients are colloidal silicon dioxide, lactose, magnesium stearate, povidone, starch corn and talc.

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Gullion G, Yeh HS. Treatment of clozapine-induced agranulocytosis with recombinant granulocyte colony-stimulating factor. J Clin Psychiatry. Neumayer JL. Neuroleptics and anxiolytic agents. In: Foye WO, ed. Principles of medicinal chemistry. Macfadden W. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. Wilmington, DE: AstraZeneca Pharmaceuticals; 2004 Apr 22. From the FDA website. The most serious adverse reactions include agranulocytosis, seizure, cardiovascular effects, and fever. Raptopoulos P, Gaind R. Clozapine Leponex in schizophrenia: therapeutic efficacy and side-effects. Generally, patients responding to Clozaril should continue maintenance treatment on their effective dose beyond the acute episode. bupropion

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Food and Drug Administration. Alert for healthcare professionals: clozapine marketed as clozaril. Rockville, MD; undated. From the FDA website. However, this increase is not clinically significant. Clozapine Orally Disintegrating Tablets must remain in the original package until used by the patient. Loosdrecht AA, Faber HJ, Hordijk P et al. Clozapine-induced agranulocytosis: a case report. Immunopathophysiological considerations. Neth J Med. Clozaril. Novartis Pharmaceuticals Corporation December, 2005.

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Lieberman JA, Johns CA, Kane JM et al. Clozapine-induced agranulocytosis: non-cross-reactivity with other psychotropic drugs. J Clin Psychiatry. Wirshing WC, Phelan CK, Van Putten T et al. Effects of clozapine on treatment-resistant akathisia and comcomitant tardive dyskinesia. Am J Psychopharmacol. Postmarketing, very rare events of ventricular tachycardia, cardiac arrest, and QT prolongation which may be associated with Torsades de pointes have been observed, although there is no conclusive causal relationship to use of this drug. Sangal R, Dimitrijevic R. Neuroleptic malignant syndrome: successful treatment with pancuronium. JAMA. Gerson SL, Lieberman JA, Friedenberg WR et al. Polypharmacy in fatal clozapine-associated agranulocytosis. Lancet. Rapidly and extensively distributed into human body tissues; 2 16 43 metabolites also appear to be extensively distributed. Clozapine-associated eosinophilia without organ involvement also may occur and can resolve without intervention. 1 In such cases, may continue clozapine therapy with careful monitoring. 1 If total eosinophil count continues to increase over several weeks in the absence of systemic disease, base decision whether to interrupt clozapine therapy and rechallenge after the eosinophil count decreases on the overall clinical assessment, in consultation with an internist or hematologist. 1 Successful rechallenge after discontinuance of clozapine, without recurrence of eosinophilia, reported. MacAllister CG, Rapaport MH, Pickar D et al. Effects of short-term administration of antipsychotic drugs on lymphocyte subsets in schizophrenic patients. Arch Gen Psychiatry. There have not been sufficient numbers of geriatric patients in clinical studies utilizing Clozapine Orally Disintegrating Tablets to determine whether those over 65 years of age differ from younger subjects in their response to Clozapine Orally Disintegrating Tablets. WebMD User Reviews should not be considered as medical advice and are not a substitute for professional medical advice, diagnosis, or treatment. Never delay or disregard seeking professional medical advice from your physician or other qualified healthcare provider because of something you have read on WebMD. You should always speak with your doctor before you start, stop, or change any prescribed part of your care plan or treatment. WebMD understands that reading individual, real-life experiences may be a helpful health information resource but they are never a substitute for professional medical advice from a qualified healthcare provider. Neutropenia may be mild, moderate, or severe see Tables 2 and 3. To improve and standardize understanding, “severe neutropenia” replaces the previous terms severe leukopenia, severe granulocytopenia, or agranulocytosis. norethisterone purchase mastercard

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Clozapine-related eosinophilia has also occurred in the absence of organ involvement and can resolve without intervention. There are reports of successful rechallenge after discontinuation of clozapine, without recurrence of eosinophilia. In the absence of organ involvement, continue Clozaril under careful monitoring. If the total eosinophil count continues to increase over several weeks in the absence of systemic disease, the decision to interrupt Clozaril therapy and rechallenge after the eosinophil count decreases should be based on the overall clinical assessment, in consultation with an internist or hematologist. Myocarditis and cardiomyopathy have occurred with the use of Clozaril. These reactions can be fatal. Discontinue Clozaril and obtain a cardiac evaluation upon suspicion of myocarditis or cardiomyopathy. Generally, patients with a history of clozapine-associated myocarditis or cardiomyopathy should not be rechallenged with Clozaril. However, if the benefit of Clozaril treatment is judged to outweigh the potential risks of recurrent myocarditis or cardiomyopathy, the clinician may consider rechallenge with Clozaril in consultation with a cardiologist, after a complete cardiac evaluation, and under close monitoring. Neuroleptic malignant syndrome NMS is a possibly fatal syndrome that can be caused by Clozaril. Symptoms may include fever, stiff muscles, confusion, abnormal thinking, fast or irregular heartbeat, and sweating. Contact your doctor at once if you have any of these symptoms. Piscitelli SC, Frazier JA, McKenna K. Plasma clozapine and haloperidol concentrations in adolescents with childhood-onset schizophrenia: association with response. J Clin Psychiatry. When Clozapine Orally Disintegrating Tablets was administered after a high-fat meal, the C max of both clozapine and its active metabolite, desmethylclozapine, were decreased by approximately 20%, compared to administration under fasting conditions, while the AUC values were unchanged. This decrease in C max is not clinically significant. Therefore, Clozapine Orally Disintegrating Tablets can be taken without regard to meals. Monitor for adverse reactions. Consider reducing the Clozapine Orally Disintegrating Tablets dose if necessary. RxList is part of the WebMD Health Network. The opinions expressed in the WebMD User Reviews are solely those of the User, who may or may not have medical or scientific training, and do not represent the opinions of WebMD. These member reviews have not been reviewed by a WebMD physician or any member of the WebMD editorial staff for accuracy, balance, objectivity, or any other purpose except for compliance with our Terms and Conditions.

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Snyder SH, Banerjee SP, Yamamura HI et al. Drugs, neurotransmitters, and schizophrenia. Science. See USP Controlled Room Temperature. Boehm G, Racoosin JA, Laughren TP et al. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. can you buy omeprazole over the counter in canada

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Pentel PR, Benowitz NL. Tricyclic antidepressant poisoning: management of arrhythmias. Med Toxicol. Leadbetter RA, Vieweg V. Clozapine-induced weight gain. Am J Psychiatry. The dose of this medicine will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of this medicine.

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Clozaril is only available through a restricted program under a REMS called the Clozapine REMS Program because of the risk of severe neutropenia. Bess AL, Cunningham SR. Dear health care provider letter regarding revised prescribing information for Clozaril tablets. East Hanover, NJ: Novartis; 2005 Dec. Raja M, Raja S. Clozapine safety, 40 years later. Curr Drug Saf. The ANC is usually available as a component of the complete blood count CBC including differential, and is more relevant to drug-induced neutropenia than is the white blood cell WBC count. The ANC may also be calculated using the following formula: ANC equals the Total WBC count multiplied by the total percentage of neutrophils obtained from the differential neutrophil “segs” plus neutrophil “bands”.

Important information

This is not a complete list of all side effects that may occur. If you have questions about side effects, contact your health care provider. Call your doctor for medical advice about side effects. WILLWERTH Monday, Jul. 06, 1992 July 6, 1992. "". Time. Puopolo PR, Flood JG. Serum concentrations of clozapine and its major metabolites: effects of cotreatment with fluoxetine or valproate. Clozaril can cause sedation and impairment of cognitive and motor performance. Caution patients about operating hazardous machinery, including automobiles, until they are reasonably certain that Clozaril does not affect them adversely. These reactions may be dose-related. Consider reducing the dose if they occur.

Periodically monitor serum electrolytes during clozapine therapy. The use of clozapine is contraindicated in patients with myeloproliferative disorders, preexisting bone marrow depression, or a history of clozapine-induced agranulocytosis or severe granulocytopenia. The management of NMS should include 1 immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy, 2 intensive symptomatic treatment and medical monitoring, and 3 treatment of comorbid medical conditions. There is no general agreement about specific pharmacological treatments for NMS.

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