Emergency physicians (EPs) rarely find out what happens to patients after the patients leave thei... more Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call "outcome feedback." Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs' perception of the current and potential role of outcome feedback in EM. We surveyed practising French- and English speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback. Of the 297 physicians surveyed, 231 (77.8%) respond ed. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is "essential" (62.6%) or "beneficial" (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (...
We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial ... more We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral. A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED. Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, ...
Emergency physicians (EPs) rarely find out what happens to patients after the patients leave thei... more Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call "outcome feedback." Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs' perception of the current and potential role of outcome feedback in EM. We surveyed practising French- and English speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback. Of the 297 physicians surveyed, 231 (77.8%) respond ed. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is "essential" (62.6%) or "beneficial" (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (...
We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial ... more We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral. A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED. Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, ...
To identify historical and clinical findings at emergency department presentation associated with... more To identify historical and clinical findings at emergency department presentation associated with severe H1N1 outcome in children presenting with influenza-like illness. Multicentre retrospective case-control study. 79 emergency departments of hospitals associated with the Pediatric Emergency Research Networks in 12 countries. 265 children (<16 years), presenting between 16 April and 31 December 2009, who fulfilled Centers for Disease Control and Prevention criteria for influenza-like illness and developed severe outcomes from laboratory confirmed H1N1 infection. For each case, two controls presenting with influenza-like illness but without severe outcomes were included: one random control and one age matched control. Severe outcomes included death or admission to intensive care for assisted ventilation, inotropic support, or both. Multivariable conditional logistic regression was used to compare cases and controls, with effect sizes measured as adjusted odds ratios. 151 (57%) of...
To assess the effectiveness of nurse-initiated administration of oral corticosteroids before phys... more To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED. A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4. One-to-one periods (physician-initiated and nurse-initiated) were analyzed from September 2009 through May 2010. In both phases, triage nurses initiated bronchodilator therapy before physician assessment, per Pediatric Respiratory Assessment Measure score. We reviewed charts of 644 consecutive children aged 2 to 17 years for the following outcomes: admission rate; times to clinical improvement, steroid receipt, mild status, and discharge; and rate of return ED visit and subsequent admission. Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1-50; P = .04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36-0.87). Efficiency gains were made in time to steroid receipt (median difference: 44 minutes; 95% CI: 39-50; P &amp;amp;amp;amp;amp;amp;lt; .001), time to mild status (median difference: 51 minutes; 95% CI: 17-84; P = .04), and time to discharge (median difference: 44 minutes; 95% CI: 17-68; P = .02). No differences were found in return visit rate or subsequent admission. Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.
The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and i... more The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma. This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;comprehensive therapy,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; i.e., albuterol via metered dose inhaler (MDI) with oral and ICS. The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;intensive…
Emergency physicians (EPs) rarely find out what happens to patients after the patients leave thei... more Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call "outcome feedback." Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs' perception of the current and potential role of outcome feedback in EM. We surveyed practising French- and English speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback. Of the 297 physicians surveyed, 231 (77.8%) respond ed. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is "essential" (62.6%) or "beneficial" (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (...
We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial ... more We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral. A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED. Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, ...
Emergency physicians (EPs) rarely find out what happens to patients after the patients leave thei... more Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call "outcome feedback." Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs' perception of the current and potential role of outcome feedback in EM. We surveyed practising French- and English speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback. Of the 297 physicians surveyed, 231 (77.8%) respond ed. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is "essential" (62.6%) or "beneficial" (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (...
We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial ... more We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral. A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED. Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, ...
To identify historical and clinical findings at emergency department presentation associated with... more To identify historical and clinical findings at emergency department presentation associated with severe H1N1 outcome in children presenting with influenza-like illness. Multicentre retrospective case-control study. 79 emergency departments of hospitals associated with the Pediatric Emergency Research Networks in 12 countries. 265 children (<16 years), presenting between 16 April and 31 December 2009, who fulfilled Centers for Disease Control and Prevention criteria for influenza-like illness and developed severe outcomes from laboratory confirmed H1N1 infection. For each case, two controls presenting with influenza-like illness but without severe outcomes were included: one random control and one age matched control. Severe outcomes included death or admission to intensive care for assisted ventilation, inotropic support, or both. Multivariable conditional logistic regression was used to compare cases and controls, with effect sizes measured as adjusted odds ratios. 151 (57%) of...
To assess the effectiveness of nurse-initiated administration of oral corticosteroids before phys... more To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED. A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4. One-to-one periods (physician-initiated and nurse-initiated) were analyzed from September 2009 through May 2010. In both phases, triage nurses initiated bronchodilator therapy before physician assessment, per Pediatric Respiratory Assessment Measure score. We reviewed charts of 644 consecutive children aged 2 to 17 years for the following outcomes: admission rate; times to clinical improvement, steroid receipt, mild status, and discharge; and rate of return ED visit and subsequent admission. Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1-50; P = .04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36-0.87). Efficiency gains were made in time to steroid receipt (median difference: 44 minutes; 95% CI: 39-50; P &amp;amp;amp;amp;amp;amp;lt; .001), time to mild status (median difference: 51 minutes; 95% CI: 17-84; P = .04), and time to discharge (median difference: 44 minutes; 95% CI: 17-68; P = .02). No differences were found in return visit rate or subsequent admission. Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.
The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and i... more The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma. This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;comprehensive therapy,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; i.e., albuterol via metered dose inhaler (MDI) with oral and ICS. The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;intensive…
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