January 1 2016, Friday

We wish all our readers a very Healthy & Happy New Year 2016...


Medicine is a rapidly changing field with many new researches and breakthroughs coming up every day, which shape day to day practice. The year 2015 too saw several advances in medicine and release of new and/or updated guidelines. Here is a quick snapshot of some researches that made the headlines in the year gone by. This by no means is a complete list. Our readers are welcome to add to this list…

• The landmark SPRINT or Systolic Blood Pressure Intervention Trial showed that a more intensive strategy of managing BP reduces the risk for death and cardiovascular events when compared with a strategy that lowers systolic blood pressure to the conventional target of 140 mm Hg. Treating high-risk hypertensive adults aged 50 years and older to a target of 120 mm Hg significantly reduced cardiovascular events by 30% and all-cause mortality by nearly 25%. The study funded by the National Institutes of Health (NIH) was stopped early because of the benefit of the intensive strategy.

• The FDA approved two new lipid lowering drugs, human monoclonal antibody PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors - alirocumab and evolocumab - for patients with familial hypercholesterolemia (FH) and for patients at high or very high risk for CV events who are unable to reach LDL targets despite maximally tolerated statin therapy.

The EMPA-REG OUTCOME study, a cardiovascular-outcomes trial, for the first time, showed superiority of the diabetic drug empagliflozin (Jardiance), sodium glucose cotransporter-2 (SGLT-2) inhibitor in reducing the rate of cardiovascular death, nonfatal MI, and nonfatal stroke among individuals with type 2 diabetes and established cardiovascular disease with 38% reduction in CV death and 32% reduction in all-cause mortality.

• The US Food and Drug Administration (FDA) approved the combination tablet valsartan/sacubitril (Entresto, Novartis) for the treatment of patients with heart failure. It is the first approved agent in the angiotensin receptor-neprilysin inhibitor (ARNI) class and exerts its effect within and beyond the renin-angiotensin system. Besides reducing heart failure deaths, Entresto also reduces heart failure hospitalizations.

• A head-to-head comparison of the everolimus-eluting stent with a bioresorbable scaffold (Absorb, Abbott Vascular) against a conventional everolimus-eluting cobalt-chromium stent (Xience, Abbot Vascular) in the ABSORB III trial, the two devices yielded similar rates of target lesion failure (TLF) at 1 year; 7.8% vs 6.1%, respectively. TLF is a composite end point that included cardiac death, target vessel MI, or ischemia-driven target lesion revascularization.

A novel oral anticoagulant (NOAC) reversal agent received FDA approval this year. The dabigatran reversal agent idarucizumab (Praxbind, Boehringer Ingelheim) is the first reversal agent approved specifically for dabigatran (Pradaxa Boehringer Ingelheim). In November, the New England Journal of Medicine published results of the factor Xa reversal agent andexanet alfa, which safely reversed the anticoagulant effect of apixaban and rivaroxaban in older volunteers.

• The Institute of Medicine (IOM) gave a new name to chronic fatigue syndrome, systemic exertion intolerance disease or SEID, highlighting the role of exertion in aggravating the symptoms. IOM also defined clear and simpler diagnostic criteria for SEID

o A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for > 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest
o Post-exertional malaise
o Unrefreshing sleep

Plus, at least one of the following: Cognitive impairment or orthostatic intolerance

• The FDA announced a new policy for blood donations by gay men overturning a lifetime ban that dates to 1983. It allows gay men to donate blood and excludes only those whose last sexual contact with another man occurred in the 12 months prior to donation. But, the ban remains in place for commercial sex workers and people who use injection drugs. People with hemophilia or related clotting disorders are also still barred from donating blood for their own protection due to potential harm from large needles used during the donation process.

• The American Cancer Society (ACS) updated its breast cancer screening guidelines for women at average risk of developing the disease. ACS now recommends that women should start annual screening with mammography at age 45, not 40 as recommended earlier. At age 55, women can transition to screening every 2 years instead of annually.

• An update of the American College of Obstetricians and Gynecologists (ACOG) cervical cancer screening guidelines recommends that women aged between 30 and 65 years and at "average risk" for cervical cancer should be co-tested with cytology and HPV testing every 5 years, or screening with cytology every 3 years. It does not recommend HPV co-testing for women younger than 30 years.

Dirty endoscopes, particularly duodenoscopes used in endoscopic retrograde cholangiopancreatography topped the list of health technology hazards in ECRI Institute's Top 10 list for 2016. Poorly cleaned flexible endoscopes prior to disinfection can increase the risk of transmitting infections. Outbreaks of multidrug resistant bacteria have been linked to duodenoscopes despite following proper reprocessing instructions.

• The WHO issued “Early Release Guideline” on when to start antiretroviral therapy and on pre-exposure prophylaxis (PrEP) for HIV. The two major recommendations are: Initiation of antiretroviral therapy (ART) in adults with HIV irrespective CD4 cell count, use of daily oral pre-exposure prophylaxis (PrEP) as a prevention option for people at substantial risk of acquiring HIV infection. The comprehensive guidelines are expected to be released in 2016.

Immunotherapy has been identified as the game changer for oncology with studies demonstrating cancers like non-small cell lung cancer (NSCLC), breast cancer, multiple myeloma responding to immune checkpoint inhibitors. Earlier in the year, FDA approved Opdivo (nivolumab) to treat patients with advanced squamous NSCLC whose disease progressed during or after platinum-based chemotherapy. In October, FDA expanded the use of Opdivo to also treat patients with non-squamous NSCLC.

• The FDA approved new formulations for delivering carbidopa/levodopa for patients with Parkinson’s disease. Rytary is an extended-release capsule formulation of carbidopa-levodopa for the for the treatment of Parkinson's disease (PD), postencephalitic parkinsonism and parkinsonism that may follow carbon monoxide intoxication or manganese intoxication. Duopa, enteral suspension for the treatment of motor fluctuations for people with advanced Parkinson's disease and is administered using a small, portable infusion pump that delivers carbidopa and levodopa directly into the small intestine for 16 continuous hours via a percutaneous endoscopic gastrostomy procedure with jejunal extension.

• The American Heart Association (AHA) new guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) emphasize on quick action, proper training, use of technology and more teamwork - from bystanders to dispatchers, emergency responders to healthcare providers - to increase survival from cardiac arrest. The new compression rate is 100–120 a minute, while earlier it was “at least 100.” The new compression depth is 2–2.4 inches for adults and adolescents; it had been “at least 2 inches.

The WHO report classifying red meat and processed meat as carcinogenic created controversy and panic. The International Agency for Research on Cancer (IARC), the cancer research agency of WHO classified the consumption of red meat as ‘probably carcinogenic’ to humans and processed meat as ‘carcinogenic’ to humans. Eating 50 gm portion of processed meat daily increases the risk of colorectal cancer by 18%. However, the WHO later tried to ease the panic by emphasizing that the findings only confirmed recommendations made back in 2002, which advised people to reduce their consumption of these products to reduce the risk of cancer.

• The American Academy of Pediatrics (AAP) endorsed a recommendation for early introduction of peanut-containing foods in to the diets of infants at high risk of peanut allergies. This current consensus statement from 10 medical organizations in Europe and the United States is based on findings of the Learning Early about Peanut Allergy (LEAP) randomized trial, which found that the early introduction of peanuts into the diet of high-risk infants lowered their likelihood of being allergic to them.

Ocrelizumab, a second-generation monoclonal antibody targeting B-cells has been a major advance in multiple sclerosis. Although not available for marketing, it has shown encouraging results in clinical trials (OPERA I and II, ORATORIO) for both relapsing-remitting and primary progressive multiple sclerosis.

• Many other guidelines have been released: pediatric pulmonary HT (AHA/ATS), pediatric perioperative anesthesia (AAP), thyroid nodule diagnosis & management (ATA), polymyalgia rheumatic (EULAR/ACR), rheumatoid arthritis (ACR)


Breaking News

Five-year national biotech strategy unveiled

Intending to establish India as a world class bio-manufacturing hub, the Centre on Wednesday unveiled the country's National Biotechnology Development Strategy 2015-2020 that would work to turn this sector into a $100 billion industry by 2025 with focus in areas of healthcare, food and nutrition, clean energy and education. Under this five-year strategy, the Centre will launch a major mission, backed with significant investments, for the creation of new biotech products, create a strong infrastructure for R&D and empower India's human resources scientifically and technologically. The strategy was unveiled by the Union minister of science and technology Harsh Vardhan who said his ministry had come out with it after consulting all stakeholders (scientists, academicians and industry)… (ET Healthworld)

Adults with congenital heart disease have a high prevalence of PTSD

A new study published in the American Journal of Cardiology suggests that adults with congenital heart disease (ACHD) may be at increased risk for post-traumatic stress disorder (PTSD). In the study of 134 outpatients with ACHD, 21% had global PTSD symptoms and 11% had symptoms directly related to their cardiac condition, as measured with two validated mental health scales. The strongest factors associated with PTSD were having comorbid depressive symptoms (P<0.001) and an earlier year for their most recent cardiac surgery (P<0.03)… (Medscape)



Specialty Updates 

• For patients with type 1 diabetes, having celiac disease increases the risk of developing autoimmune thyroid disease at some point in life, suggested a new cohort study published online in Diabetes Care.
• Night-shift workers who drive home after a night's work may be at higher risk of crashing due to drowsy driving, suggested a small study published in the Proceedings of the National Academy of Sciences.
• The offspring of parents with rheumatoid arthritis (RA) are at increased risk for many long-term morbidities, and particularly autoimmune diseases, suggested a large Danish cohort study published online in Annals of the Rheumatic Diseases.
• Palbociclib, a new oral drug found effective in combating breast cancer both alone and in combination with endocrine therapy, also has potential to combat other types of cancer, suggested a literature review and additional original research published in JAMA Oncology.
• A combination of the anti-B-cell drug rituximab and intravenous immune globulin (IVIG) therapy led to long-standing remission and prevented recurrence of pemphigus vulgaris, suggested a new study reported in a letter to the editor in the December 31 issue of the New England Journal of Medicine.
• Cannabidiol, a derivative of medical marijuana effectively reduces seizure frequency and is safe for most children and young adults who have epilepsy, reported a new study published in The Lancet Neurology.
• Cardiovascular-specific mortality is increased in patients undergoing vascular surgery who develop acute kidney injury (AKI), suggested a retrospective study published online in JAMA Surgery.
• High doses of vitamin D3 (cholecalciferol) appear to be safe and tolerable in patients with multiple sclerosis (MS), suggested a single-center, randomized, double-blind pilot study published online in Neurology.



Why do we apply holy ash?

Bhasma is the holy ash produced from the Homa, the sacrificial fire, wherein special wood along with ghee and other herbs are offered as a part of pooja. By the time a Bhasma is formed, no trace of original matter remains in the ash. Ash obtained from any burnt object is not bhasma. The ritual involves worshipping the deity by pouring ash as abhishek and then distributing it as Bhasma, which is then applied on the forehead (usually), upper arms, chest, or rubbed all over the body. Some consume a pinch of Bhasma when they receive it. The word Bhasma is derived from “bha” or "bhartsanam" ("to destroy") and "sma" or "smaranam" ("to remember"). It denotes "that by which our sins are destroyed and the Lord is remembered". Bhasma is also called vibhuti, which means glory. Bhasma is associated with Lord Shiva who applies it all over His body.

Spiritually, the Homa is the offering of oblations into the fire with sacred chants and signifies offering or surrender of the ego and egocentric desires into the fire of knowledge. The resultant ash signifies the purity of the mind. The fire of knowledge burns the oblation and wood signifying ignorance and inertia respectively. The application of ash implies that one should burn false identification with the body.

Bhasma has medicinal values in Ayurveda. It is supposed to be the strongest of all Ayurveda preparations. According to Ayurveda, a Bhasma is formed when the matter is converted into non matter by the process of homa. The non matter is the spirit or the energy of the matter being processed with strong healing powers. It has the same significance as any ‘potentised’ medicine in homoeopathy. It absorbs excess moisture from the body and prevents colds and headaches.

When applied with a red spot at the centre, the mark symbolizes Shiva–Shakti (the unity of energy and matter that creates the entire seen and unseen universe). The Upanishads say that the famous Mrityunjaya Mantra should be chanted whilst applying ash on the forehead.


The Year In Medicine 2015: News That Made Difference

Advances in Telemedicine Policy

In May, eight states joined the interstate compact of the Federation of State Medical Boards. Seven states were enough to set in motion the compact, an agreement designed to make it easier for physicians to be licensed in multiple states — an important step in making telemedicine workable and accessible. In addition, a majority of states now have telemedicine parity laws, which require private insurers to cover remote consultations the same way they cover in-person medical visits. Many of these states also mandate telemedicine coverage by their Medicaid programs and, in some cases, by their state employee health insurance plans. Earlier in the year, telemedicine — in which clinicians encounter patients remotely via real-time audio and/or video — got a big boost when the Obama administration waived burdensome Medicare restrictions. A survey released by the National Business Group on Health found that telemedicine services will be offered in health insurance plans sponsored by 74% of large employers during the next year in states where it is legal... (Medscape)


Legal Quote

Indian Medical Association vs VP Shantha & Ors on 13 November, 1995, 1996 AIR 550, 1995 SCC (6) 651

“There may be cases which do not raise such complicated questions and the deficiency in service may be due to obvious faults which can be easily established such as removal of the wrong limb or the performance of an operation on the wrong patient or giving injection of a drug to which the patient is allergic without looking into the outpatient card containing the warning [as in Chinkeow v. Government of Malaysia, (1967) 1 WLR 813 P.C.] or use of wrong gas during the course of an anesthetic or leaving inside the patient swabs or other items of operating equipment after surgery.”


The switch from trivalent to bivalent oral polio vaccine

18th December, 2015

For successful implementation

• tOPV supplies to be regulated and removed after switch (Manufacturers, CDSCO, CDL Kasauli)
• bOPV supplies to be secured (Manufacturers, CDSCO, CDL Kasauli)
• bOPV testing to be fast tracked (CDL Kasauli)
• Communication planning for open market (IMA/IAP)
• tOPV removal to be validated(CDSCO, IAP, IMA)


IMA Satyagraha


IMA Poll



New drug price caps to help save up to 20% 

The revision in the National List of Essential Medicines (NLEM) by the government last week is expected to translate into savings of 10-20% for patients at the therapy level on widely used antibiotics, anti-infectives, cardiac and respiratory medicines. The overall coverage of new medicines being added to the NLEM will be nearly Rs 8,000 crore in the organized pharma retail market, valued at Rs 95,000 crore (moving annual total)…(ET Healthworld)


Industry urges govt to allow practices of small gifts, CMEs & free samples to doctors in revised UCPMP

Even as the Department of Pharmaceuticals (DoP) is in the final stage of preparations to make the Uniform Code of Pharmaceuticals Marketing Practices (UCPMP) compulsory for pharma companies, the pharmaceutical industry in the country has asked the government to allow the companies to continue with some of its long standing practices like small gifts and free supply of physician samples to the doctor fraternity. The industry has urged the government that certain long standing industry initiatives like providing small gifts of utility (less than Rs.1,000 of product value) to medical practitioners, CMEs on new drug and novel innovations for three years that better existing therapies, free supply of physician samples that also function as starter doses for poor patients should be allowed to continue. Besides, the industry has also urged the government that the MCI guidelines, the CBDT circular of 1st August 2012 and the UCPMP should be suitably aligned to ensure these provisions are recognised and accepted… (Pharmabiz - Ramesh Shankar)


End of Ebola transmission in Guinea

WHO has declared the end of Ebola virus transmission in the Republic of Guinea. Forty-two days have passed since the last person confirmed to have Ebola virus disease tested negative for the second time. Guinea now enters a 90-day period of heightened surveillance to ensure that any new cases are identified quickly before they can spread to other people… (WHO Africa Region)


1. IMA Rare Blood Group Online Blood Bank Directory: ima-india.org/Rare
2. IMA Online TB Notification initiative: ima-india.org/tbnotify
3. IMA Online Events Reporting initiative: http://www.ima-india.org/ima/left-side-bar.php?scid=228
4. Performa for Hypertension Screening: http://module.ima-india.org/
5. IMA Online Sentinel Events Reporting Initiative: ima-india.org/sentinel
6. IMA Disease Notification: http://disnotif.ima-india.org/
7. IMA RISE and SHINE: http://imariseandshine.com/
8. IMA Slide Share: http://www.ima-india.org/ima/free-way-page.php?scid=287
9. I Pledge My Organ: http://module.ima-india.org/ipmo/
10. IMA Weekly Live: http://www.ima-india.org/imalive/
11. IMA/ART: http://ima-india.org/artbill
12. IMA/ Satyagraha: http://ima-india.org/satyagraha
13. IMA/ Daily Webcast: http://ima-india.org/ima/
14. CC SLIDES: http://www.ima-india.org/ima/left-side-bar.php?scid=417
15. NATCON Photos: IMA Natcon 2015 - Day 2 - Camera 1, IMA Natcon 2015 - Day 2 - Camera 2


All about alcohol dose and terminologies used
Dr K K Aggarwal

What is one peg of alcohol?

Definitions of a "standard drink" differ, both within and between countries.

• United States: 14-15 g alcohol (0.5 to 0.6 fl oz), equivalent to 12 oz beer, 5 oz wine, and 1.5 oz of 80 proof liquor
• Great Britain: 8 g alcohol
• Japan: 19.75 g alcohol
• India: 10 g alcohol
• Patiala peg: 20 g alcohol
• The National Institute on Alcohol Abuse and Alcoholism (NIAAA): 12 g of alcohol (equivalent to 360 mL (12 oz) of beer, 150 mL (5 oz) of wine, or 45 mL (1.5 oz) of 80 proof distilled spirits)
• Most countries: 8-12 g alcohol

Bioethical Issues In Medical Practice

Protecting the privacy and confidentiality of patients 

Smita N Deshpande 
Head, Dept. of Psychiatry, De–addiction Services 
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi 

You are a member of an informal discussion group of doctors who meet regularly to discuss difficult cases. At all these discussions, the conversation is frank and detailed, with all details of the patients, social situation, family issues etc. are discussed threadbare. Sometimes this discussion spills over into the hospital lifts, corridors and canteens. When these issues are really interesting, you discuss them at home with your spouse– a doctor– as well. Many times the name, address, and other details of patients are discussed as well.

a) Do such discussions breach medical confidentiality?
b) At which places should medical cases be discussed? 
c) Should interesting medical cases be discussed at home?

Any suggestions? Do write in! 
Adapted from: Bioethics Case Studies (AUSN and EEI, November 2013): http://www.eubios.info/ 

Responses received 
• Medical discussions of difficult cases are very important from the doctor’s point of view and also from the patient’s point of view. They should definitely be discussed at home, in medical get-togethers, but not in lifts, hotels and public places. Medical science is based on discussions and exploration of the knowledge what one has. Dr BR Bhatnagar

• As regards Bioethical issues as deliberated above, may I suggest to keep discussion anonymous, important material for discussion are clinical facts and not the identification of the patient. This way perhaps we may not breach the confidentiality issues. Dr VJ Mahhadik


Smoking makes you 5 years older 

Men have a greater chance of dying then women, and smoking increases any adult’s risk of death just as if five years were suddenly added to their age.

• For men who have never smoked, heart disease presents their greatest risk for death at any age, exceeding the odds of dying from lung, colon and prostate cancer combined.

• Male smokers face a lung cancer risk that is greater than the odds of heart disease taking their lives after age 60, and is tenfold higher than the chance of dying from prostate and colon cancer combined.

• The chances of dying from heart disease and breast cancer are similar for nonsmoking women until age 60, when heart disease becomes a greater risk.

• For female smokers, dying from lung cancer or heart disease is more likely than dying from breast cancer after age 40


WP(C) No.8706/2015 titled “Indian Medical Association Vs. Union of India & Anr (NCERT)” Delhi High Court, New Delhi 

Click here to read the proposed changes


IMA Live Webcast 

Click here


Inspirational Story

Four Burning Candles

In a room there were four candles burning. The ambiance was so soft you could hear them talking. The first one said, "I am PEACE, however nobody can keep me lit. I believe I will go out."

Its flame rapidly diminishes and goes out completely. The second one says, "I am FAITH. Most of all I am no longer indispensable, so it does not make any sense that I stay lit any longer." When it finished talking a breeze softly blew on it putting it out.
Sadly, the third candle spoke in its turn. "I am LOVE. I have not gotten the strength to stay lit. People put me aside and don’t understand my importance. They even forget to love those who are nearest to them." And waiting no longer it goes out.

Suddenly a child entered the room and saw three candles not burning. "Why are you not burning you are supposed to stay lit till the end." Saying this, the child began to cry. Then the fourth candle said, "Don’t be afraid, while I am still burning we can re–light the other candles, I am HOPE.”

With shining eyes, the child took the candle of Hope and lit the other candles. The flame of Hope should never go out from our life and that each of us can maintain HOPE, FAITH, PEACE and LOVE. Hope never abandons you. You abandon hope. Consult not your fears but your hopes and your dreams. Think not about your frustrations, but about your unfulfilled potential. Concern yourself not with what you tried and failed in, but with what it is still possible for you to do.


eMedi Quiz 

All of the following conditions may predispose to pulmonary embolism except:
1. Protein S deficiency.
2. Malignancy.
3. Obesity.
4. Progesterone therapy.

Yesterday’s Mind Teaser: A 20-year-old man complains of difficulty in reading the newspaper with his right eye. Three weeks after sustaining a gunshot injury to his left eye. The most likely diagnosis is:
1. Macular edema.
2. Sympathetic ophthalmia.
3. Optic nerve avulsion.
4. Delayed vitreous hemorrhage.

Answer for Yesterday’s Mind Teaser: 2. Sympathetic ophthalmia.
Answers received from: Daivadheenam Jella, Dr Avtar Krishan
Answer for 30th December Mind Teaser: 1. The sample should be kept at 4°C.
Answers received from: Dr Bitaan Sen & Dr Jayashree Sen, Dr Poonam Chablani.


Reader’s Column
The National conference was wonderful.
Last year would be definitely reckoned as a Golden year in IMA.
Let's keep up the good work.
Best wishes to Dr SS Aggarwal and the new team.
Dr Sreejith N Kumar


A friend recently explained why he refuses to get to married. He says the wedding rings look like miniature handcuffs.


Press Release

Fight potbelly obesity in the up-coming year 

• Normal weight obesity is a new epidemic of the society
• Abdominal obesity is a risk factor for heart attacks and diabetes

Normal weight obesity is a new epidemic of the society. Most people measure obesity by calculating their BMI. However it has often been noticed that height and weight alone cannot be used to measure obesity.

As per Vedic Medicine, a person can have three personalities – Vata (Deer personality), Pitta (Lion personality) and Kapha (Elephant personality). People with Deer personality may have lower BMI and people with Elephant personality may have high BMI yet they may be defined as normal and not obese.

The current and the correct method for evaluating obesity is the presence of body fat, especially the fat in the tummy and around the abdomen. Any male with an abdominal circumference of more than 90 cm or female with one more than 80 cm can be said to be suffering from abdominal obesity. Abdominal obesity is a risk factor for future heart attack and diabetes.

Speaking about the dangers of pot-belly obesity, Dr S S Agarwal – National President and Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA and President HCFI in a joint statement said, ”People suffering from normal weight obesity have a normal BMI as per their age and height however they have an above normal abdominal circumference. Typically, these are the people who otherwise look normal but have a potbelly. A liver ultrasound in such individuals will show the presence of a fatty liver. It is extremely important that such people seek help from their doctor and make necessary lifestyle changes immediately to avoid developing life-threatening diseases in the future”.

Gaining weight is considered normal as along as a person gains height. Once the height stops increasing, the development of one’s organs also stops. This normally happens at the age of 16 in girls and 18 in boys. After this age the size of one’s liver, spleen or kidney cannot grow. The only thing, which continues to grow, is fat.

Up to 5 kgs of weight gain can occur because of muscle built-up. However after this, weight gain in those above the age of 16 (girls) and 18 (boys) is said to be fat unless proved otherwise. The leading cause for potbelly obesity is a diet rich in refined carbohydrates, which is found in white sugar, white maida (flour) and white rice.

Probably our ancestors knew that being Indian is risk for potbelly obesity, therefore, they had invented the ritual of not eating carbohydrates at least once in a week through the medium of fasting making the condition non existent in those times.

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