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Institute for Clinical Research and Health Policy Studies

Program on Equity in Science and Health

The Program on Equity in Science and Health, directed by Dr. Karen Freund, addresses research disparities in health care, and diversity in the biomedical workforce.  Research on equity in science seeks to understand the factors associated with promoting and achieving diversity in biomedical careers.  This includes understanding the factors associated with the recruitment, promotion and retention of women and minority faculty in academic biomedical careers.  Research includes observations studies to understand the factors associated with promotion and advancement in biomedical careers, as well as intervention to address these issues.  The Program also addresses disparities in the delivery of health care, with major focus on care to women and minority communities.  Disparities in care are well documented in multiple racial and ethnic minority groups.  Conditions in common between women and men have also demonstrated gender disparities in outcomes.  Our recent research focuses on interventions to reduce and eliminate these disparities.

Active Studies

Cancer Health Disparities Network (CDRN) Cohort

The aim of this study is to evaluate the feasibility of recruiting, collecting survey and biospecimen data, and following a cohort of 450 diverse individuals from underserved populations from various geographic areas of the United States.  This study proposes to establish the Cancer Disparity Research Network (CDRN) Cohort, a resource for studies of factors related to cancer incidence among underserved populations. The CDRN Cohort will pool data and initiate new studies not previously undertaken in underserved populations. Targeted underserved populations that will compose the CDRN cohort will be recruited by research teams from the following study sites:

  • The Ohio State University Comprehensive Cancer Center (100 residents of Appalachia)
  • University of Illinois at Chicago (100 Hispanics)
  • Fox Chase Cancer Center (Philadelphia, PA) (100 African Americans)
  • University of Pennsylvania (50 African Americans)
  • Tufts Medical Center (100 Asians)

The Ohio State University Comprehensive Cancer Center is the Coordinating Center for the CDRN cohort feasibility study. The goals of the Tufts study site are to:

  • Recruit 100 Asians to the CDRN cohort
  • Collaborate with the CDRN Coordinating Center to refine study procedures, forms, questionnaires, and process for collecting and mailing biospecimen data.
  • Interact with the other cohorts/study sites to conduct two pilot studies: 
  1. Determine the impact of the Affordable Care Act (ACA) on cancer prevention and screening behaviors; and
  2. Explore the response to chronic stress (telomere length and Tumor Necrosis Factor (TNF) and C-reactive protein (CRP) concentrations) with the characteristics of cancer risk profiles for each of the populations and the cohort as a whole.

Insurance Instability and Disparities in Chronic Disease Outcomes

Racial and ethnic health disparities in the processes and outcomes of chronic disease care are pervasive, well documented, and consistently linked to health insurance coverage.  Insurance instability (the frequency of switches in insurance coverage or gaps without coverage), may contribute to disparities in outcomes of chronic disease care.  With the explicit goal of reducing disparities, Massachusetts (MA) Health Insurance Reform has now extended comprehensive health insurance coverage to 98% of the state’s residents, with disproportionately greater gains in coverage among racial/ethnic minorities and the poor.  To examine if MA insurance reform has lessened health disparities through increased insurance stability, our specific aims are:

  • To examine changes in insurance instability pre- and post-reform, overall and comparing racial/ethnic specific minority populations to whites.  We hypothesize that (a) Insurance instability decreased in the post-reform period and (c) Insurance instability decreased more for racial/ethnic minorities.
  • To examine whether patients receiving care post-insurance reform had better processes of chronic disease management and improved health outcomes, compared with patients receiving care pre-insurance reform, and whether such patterns vary by race/ethnicity.  We hypothesize that improvements in processes and outcomes of chronic disease management were greater among racial/ethnic minorities who benefited the most from insurance reform, resulting in reduced disparities.
  • To assess whether patients with more favorable insurance stability had better processes of chronic disease care and improved health outcomes compared to patients with less favorable insurance stability, and whether racial/ethnic minority patients experienced disproportionately greater gains. We hypothesize that greater insurance stability will be associated with improved processes and outcomes of chronic disease management, resulting in reduced disparities.

We will assess the processes and outcomes of care for six highly prevalent, chronic conditions before and after the implementation of MA Health Insurance Reform: diabetes, hypertension, hyperlipidemia, congestive heart failure, asthma, and chronic obstructive pulmonary disease.  We will utilize existing electronic medical records on over 110,000 subjects from Boston Medical Center and eight of its affiliated federally qualified Community Health Centers, the largest safety net institution in New England that serves African American and Hispanic communities, and Tufts Medical Center, which serves a large Asian American community in Boston’s Chinatown.  When the study is completed, we will provide empiric data on the direct impact of insurance reform and insurance instability on health disparities in multiple populations.

Partners on this project include Multi- Principal Investigator Dr. Nancy Kressin (Boston Medical Center), Dr. Amresh Hanchate, co-Investigator (Boston University School of Medicine), Dr. Norma Terrin, co-Investigator (Tufts Research Design Center/Biostatistics Research Center), and Dr. Tracy Battaglia, co-Investigator (Boston Medical Center).  This work is supported by the National Institute on Minority Health and Health Disparities.

Dr. Amy LeClair’s Studies

30-Day Readmissions at Tufts Medical Center

This is a qualitative study to examine the medical and socioeconomic factors contributing to 30-day readmissions. The data collection for adults is currently complete. We are now piloting this study with the pediatric department to understand unique factors in the pediatric patient populations. 
CTSA Consortium SRC pilot study 

This NCATS funded study assesses the implementation and use of in the recommended Scientific Review Committee (SRC) process developed by the SRC Working Group. Scientific review is distinct but complementary to IRB review. The goal of the SRC is to review studies for scientific merit and feasibility. This pilot study is attempting to implement this review process at 10 CTSA hubs and assess the barriers and facilitators to its implementation and use. 
Stakeholder and Community Engagement (SCE) in Early Stage (T1) Translational Science 

Four CTSA hubs have come together to develop a framework for stakeholder engagement in the early stages of translational science. 
Together for Child Wellness

With support from the Deborah Munroe Noonan Memorial Research Fund, this study aims to understand the barriers and facilitators to diagnosis and treatment of Autism Spectrum Disorder (ASD) in children from Chinese immigrant families. Chinese children with ASD tend to be diagnosed later than their non-Chinese peers and experience significant delays in linking to care. By understanding the perspectives of both parents and providers we hope to inform an intervention to address these delays in a culturally competent and relevant manner. 

Dr. Elena Byhoff’s Studies

Screening for Social Determinants of Health in Massachusetts 

Health Centers are nonprofit organizations that provide health and other related services to residents in medically underserved areas. Social Determinants of Health (SDH) are defined as the circumstances, in which people are born, grow up, live, and work. There is a well-documented relationship between SDH and health outcome. Despite the prevalence of unmet social needs that disproportionately impact health when compared to other aspects of medical care, we understand relatively little about how best to recognize and address such needs. Even less is known about the landscape of current SDH screening practices. Our proposed study will address this gap by characterizing SDH screening practices in health centers throughout Massachusetts. By understanding and comparing current practices across all health centers in the state, we can identify heterogeneity in screening, which can facilitate targeted improvement in practices across the state.

Completed Studies

Longitudinal Follow-up to the National Faculty Survey

In 1995, over 1,900 academic faculty from 24 medical school completed the National Faculty Survey (NFS).  Under the leadership of Phyllis Carr MD as PI, the NFS collected information about demographics, professional goals, academic environment, perceptions of bias, discrimination, and harassment, compensation, and work/life balance.  The original survey provided seminal data on recruitment, promotion and retention of women and underrepresented minority faculty in academic medicine.

In 2011- 2012, we invited 1,300 faculty members from the original survey to complete a follow up survey.  The data serves as the first longitudinal follow up of a nationally representative sample of faculty in medical schools.  The specific aims of the project are:

  • To measure longitudinal career outcomes for women compared with men, and under-represented minority women faculty compared with majority women, along the following domains:
    • Satisfaction with academic career
    • Compensation
    • Productivity, including grants and publications
    • Academic rank
    • Retention
  • Identify how individual (e.g., hours of work, family responsibilities), institutional environment (e.g., support, work environment) and factors that intersect the individual and institution (e.g., racial discrimination, sexual harassment) are associated with career advancement outcomes form women compared with me, and for under-represented minority women compared with majority women.

We also conducted key informant interviews with administrative faculty at the medical schools to collect information regarding institutional policies and practices that differentially facilitate or impede faculty advancement based on gender or under-represented racial/ethnic minority status.

Partners on this project include Multi- Principal Investigator Dr. Phyllis Carr (Massachusetts General Hospital), Dr. Norma Terrin, co-Investigator (Research Design Center/Biostatistics Research Center), Dr. Samantha Kaplan, co-Investigator (Boston University), and Dr. Anita Raj, co-Investigator (University of California, San Diego).  Dr. Carr was the Principal Investigator of the 1995 survey.  This work is supported by the National Institute of General Medical Sciences.

The National Patient Navigation Research Program

Dr. Freund serves as Chair of the Design and Analysis Committee of the National Patient Navigation Research Program (PNRP), an NCI funded cooperative group to conduct a controlled trial on the impact of patient navigation on timely cancer care in vulnerable populations.   The PNRP looks at the impact of patient navigation interventions to reduce or eliminate cancer health disparities. The Avon Foundation provides additional support for the secondary analyses of the Patient Navigation Research Program (PNRP). Current research questions addressed through this initiative include:

  • The impact of comorbidities on cancer care and patient navigation
  • The influence of household size and composition on delays in cancer care, and the ability of navigation to ameliorate their impact
  • Whether patient navigators with personal experience with cancer care are more effective in their position than navigators without cancer treatment experience
  • Understanding which tasks that navigators perform are associated with best practices and more timely care for their patients
  • The impact of patient navigation on the quality of breast cancer treatement
  • The impact of patient navigation for patients with abnormal Pap tests.
  • The impact of patient navigation in women with abnormal breast cancer screening

Patient Navigation Research Program Database

The national Patient Navigation Research Program recruited nearly 10,000 subjects with abnormal cancer screening, and over 2000 subjects with incident cancer and precancerous lesions into a controlled trial of patient navigation compared with the control of usual care.  Subjects were predominantly from under-insured and minority populations.  Subjects were recruited from nine centers (comprised of 21 local community health centers or ambulatory care sites).  We collected clinical and patient navigation information for eligible participants 18 years and older who had an abnormal breast, cervical, colorectal, or prostate concerning screening result.  Clinical information included type of screening abnormality, type and stage of cancer, dates and types of clinical services, and clinical outcomes.  Patient navigation information barriers identified as part of the care delivery process, activities to address the barriers, and services provided are also in the database.  Other information included race/ethnicity, gender, primary language, and health insurance coverage.

Program Director

Karen Freund, MDKaren Freund, MD, MPH

Karen M. Freund, MD, MPH is Vice Chair for Quality Improvement and Faculty Affairs in the Department of Medicine at Tufts Medical Center. She is trained and board certified as a general internist and primary care physician, and is also board certified in preventive medicine. She joined Tufts Medical Center in 2012 and maintains an active practice in general medicine. Dr. Freund is a national expert in women’s health and health care to minority and low-income populations. She has an active research program with over 120 publications. She is recognized for her skills in mentorship and oversees mentorship programs within the department for medical educators and clinician scientists.

Faculty

Elena ByhoffElena Byhoff, MD, MSc

Elena Byhoff, MD, MSc is an Assistant Professor in the Department of Medicine at Tufts Medical Center and Tufts University School of Medicine. Her primary research focuses on how social determinants of health impact health and health care across the life course. She is interested in identifying primary care-based interventions to reduce health disparities in vulnerable populations. Dr. Byhoff received her MD from the University of Pennsylvania School of Medicine. She trained in primary care internal medicine at the Hospital of the University of Pennsylvania and completed the Robert Wood Johnson Clinical Scholars Program at the University of Michigan.

 

Amy LeClairAmy LeClair, PhD, MPhil

Amy LeClair, PhD, MPhil is an Assistant Professor in the Department of Medicine at Tufts Medical Center and Tufts University School of Medicine. She is a medical sociologist who employs qualitative and mixed methods to health services research with disadvantaged populations. She holds an MPhil in Modern Society & Global Transformations from Cambridge University and received her PhD in Sociology from New York University. She completed a NIMHD post-doctoral training fellowship in mental health services research at Rutgers University’s Institute for Health, Healthcare Policy and Aging Research. She is currently working on a number of projects related to health disparities and stakeholder engagement, and co-teaches Health Services Research in the CTSI graduate program.

Allison BrownAlison Brown, MS, PhD

Dr. Brown is a TL1 post-doctoral research fellow whose research interests and experience include the intersection of epidemiology, clinical and community initiatives to address racial/ethnic health disparities in the U.S.  In May 2017, Alison graduated from Tufts University's Friedman School of Nutrition Science and Policy where her research focused on exploring the ethnic heterogeneity of the U.S. Black population and how this diversity relates to hypertension risk and diet quality.  During her fellowship year, Alison will broaden her understanding of health science research as it relates to health disparities and how health insurance stability influences the management of diabetes among various racially and ethnically diverse patients. 

Dr. Jana LearyJana Leary, MD

Dr. Leary is an Assistant Clinical Professor of Pediatrics and pediatric hospitalist at the Floating  Hospital for Children at Tufts Medical Center.  During her time as faculty, she has been particularly interested in new faculty mentorship, systems improvement, patient safety, and improving transitions of care for hospitalized children. She currently co-leads the new faculty collaborative mentorship group for her division of pediatric hospital medicine, is a TL1 research fellow at the Tufts CTSI, pursuing her Masters degree in clinical and translational science at the Sackler School of Graduate Biomedical Sciences.  Her current research focuses on predictors of readmission in the pediatric and medically complex populations.  She hopes to utilize these predictors to develop targeted strategies to improve transitions of care for vulnerable pediatric patients. 

Staff

  • Grace Yoon, BA

  • Grace Yoon, BA completed her undergraduate work at Northeastern University, where she majored in Asian Studies and minored in Biology. She completed a clinical research co-op at the Hong Kong Polytechnic University in the Fall of 2015. She is interested in helping communities in crisis, such as immigrant populations. She volunteers at the Asian Taskforce to End Domestic Violence (ATASK) and Boston Area Rape Crisis Center (BARCC). Grace is fluent in English, Korean, and Japanese and speaks basic Mandarin and Spanish. She has a black belt in Tae Kwon Do and likes to travel.

    Former Staff

  • Carolyn Luk, BA
  • The program highly values collaborative research partnerships.  Current collaborations include the following:

    Collaborations within Tufts Medical Center

    • The Center for Health Solutions – Susan Parsons, MD, MRP, Laurel Leslie, MD, and Carolyn Leung Rubin, EdD
    • The Research Design Center/Biostatistics Research Center – Norma Terrin, PhD
    • Lahey Clinic Medical Center – Zoher Ghoghawala, MD

    Community Partnerships

    • Addressing Disparities in Asian Populations through Translational Research (ADAPT)
    • Asian Women for Health and the Asian Breast Cancer Project – Chien Chi Huang, MS
    • Greater Boston Chinese Golden Age Center

    Academic Partnerships

    • Boston University/ Boston Medical Center, Women’s Health Unit – Tracy Battaglia, MD, MPH, Bonnie Sherman, PhD, Sharon Bak, MPH, Ann Han, MPH
    • Boston University/ Boston Medical Center, Health Disparities/Equity Unit – Nancy Kressin, PhD, Amresh Hanchate, PhD
    • Boston University/ Boston Medical Center, Obstetrics and Gynecology – Samantha Kaplan, MD, Rebecca Perkins, MD, MSc
    • Boston University/ Boston Medical Center, Pediatrics – Natalie Pierre Joseph, MD
    • Texas A&M University – Carrie Byington, MD
    • Massachusetts General Hospital – Phyllis Carr, MD
    • University of California, San Diego – Anita Raj, PhD
    • Ohio State University – Electra Paskett, PhD
    • University of Arizona – Elizabeth Calhoun, PhD
    • University of Illinois, Chicago – Julie Darnell, PhD

    Boston Breast Cancer Equity Coalition logo.In the City of Boston, inequities in breast cancer mortality have persisted among Black, non-Hispanic women compared to women of other racial/ethnic groups. The inequity is especially striking given that Black women in Boston receive mammography screening at the same rates as Boston White women and had a lower incidence of breast cancer than other women during this time period. Building on past efforts to address these cancer mortality inequities, the Dana-Farber Cancer Institute and the Boston Public Health Commission convened a meeting of a group of stakeholders in early 2014. From this stakeholder group, the Boston Breast Cancer Equity Coalition was formed. The coalition is comprised of a diverse group of multidisciplinary stakeholders. Members include oncology and primary care clinicians, patient navigators, public health policy makers, advocates, researchers and patients. The coalition members have determined that the immediate next steps are additional data collection and analyses (a “deep dive” of the data) to more fully understand causes of these inequities. For mor information, please visit https://www.bostonbcec.org/.

    Tufts Breast Cancer Training Program to Reduce Health Disparities

    Led by Drs. Karen Freund and Susan Parsons and supported by the Komen for the Cure Foundation, this training program provides a cadre of master’s and doctoral students with a broad understanding of Asian, specifically Chinese, breast cancer health disparities to conduct clinical and translational research to address the needs of Chinese American breast cancer patients and survivors. Asian Americans are the only racial/ethnic group in which cancer is the leading cause of death, and breast cancer is the most common type of cancer in Asian women. Tufts University School of Medicine and Tufts Medical Center (Tufts MC) sits within Boston Chinatown and provides care for this vibrant community, and for the surrounding Chinese immigrant communities in Quincy and Malden, MA, who use Chinatown as their cultural hub. This training program is in partnership with Tufts Cancer Center, Tufts Clinical Translational Science Institute (CTSI) and Tufts Sackler School of Graduate Biomedical Sciences.

    List of Trainees – Tufts Breast Cancer Training Program
    • Angie Mae Rodday, PhD, MS (2015)
    • Research Project: Assessing the Relationship between Self-Efficacy and Socio-economic Status Using the Communication and Attitudinal Self-Efficacy General Scale

    • Jinghui Dong, PhD (2015-)
    • Research Project: Impact of Patient Navigation of Patient Acceptance of Recommended Breast Cancer Treatment

    • Kimberly Esham, MD
    • Research Project: Uncharted Waters: Course and Correlates of Migratory Newly Diagnosed Breast Cancer Patients
    Former Trainees – Program on Equity in Health and Science
    • Aysha Almas, MBBS, FACP
    • Anthony Kulukulualani, MD candidate
    • Andre Vogel, Brown University undergraduate student

    Karen Freund, MD, MPH

    1. American Cancer Society – “What Does the End of Cancer Look Like?
    2. The Week – “Is your doctor a woman? She’s probably being paid less.” 
    3. Science 2.0 – “Why Do Women Lag in Academic Medicine Leadership Positions?” 
    4. Presentations:
      • 2016.11.16 Boston Chinese Evangelical Church – Community Cancer Talk: “How to Keep Healthy”
      • 2016.12.09 Tufts MC Cancer Center Grand Rounds – “Addressing Cancer Disparities”
      • 2016. 9.30 American Cancer Society – “Patient Navigation to Eliminate Cancer Disparities”
      • 2016.8.3 Academic Partnership webinar – “Solutions to Gender Disparities in Research and Academic Careers in Medicine and Science”
      • 2016.7.10 QuantiaMD webinar – “Patient Navigation”
      • 2017.4.20 SGIM Special Symposium – “Maintaining Resilience and Grit in a General Medicine Research Career”
      • 2017.4.21 SGIM Oral presentation – “Racial Differences in Insurance Stability after Health Insurance Reform”
      • 2017.9.27 AACR Poster presentation – “The Impact of Insurance and Insurance Stability on Cancer Screening Behaviors”

    Elena Byhoff, MD, MSc

    1. News-Medical.net – “New study explores why cost of dying higher for African Americans and Hispanics
    2. Science Daily – “Two kinds of Medicare, two kinds of patients? Findings may mean a lot for health policy
    3. Consumer Reports – “Can You Rely on Your State’s Medical Board?
    4. Presentations:
      • 2016.12.18 CCHERS presentation – “Michigan to MA: Screening for Social Determinants of Health in Community Health Centers”
      • 2016.12.06 ICRHPS Grand Rounds – “Michigan to MA: Screening for Social Determinants of Health in Community Health Centers”
      • 2017.4.19 SGIM Poster presentation – “Patient Characteristics Associated with Leaving a Usual Source of Care Despite Improved Insurance Coverage After Massachusetts Health Reform”

    Alison Brown, MS, PhD

    Tufts Nutrition – “Former FDA Commissioner Kessler Headlines 2017 Commencement"
    Tufts Nutrition –“Could community-based “Change Clubs” improve heart health in black women?”
    Tufts Nutrition – “Friedman Student Alison Brown Wins the 2014 Tufts University's Presidential Award”

    Amy LeClair, PhD, MPhil

    1. Presentations:

    1. 2017.4.19 SGIM Poster presentation – “Patients’ Perspectives on Reasons for Readmission”
    2. 2017.4.19-20 ACTS Poster presentation – “Stakeholder and Community Engagement in Early Stage Translational Science”
    3. 2017.4.21 ACTS Poster presentation – “Documenting ADAPT: The growth of a community-research collaborative”

      Jana Leary, MD

      • 1. Presentations:

        • 2017.4.19-20 ACTS Poster presentation – “Patients’ Perspectives on Reasons for Readmission"

      1U01TR002070-01, NIH/NCATS 09/01/2017-05/31/2022

      Translating Research into Practice: A Regional Collaborative to Reduce Disparities in Breast Cancer Care
      To implement scientific evidence and systems interventions in order to promote utilization of guideline concordant therapies, and ultimately reduce disparities in breast cancer care in Boston, MA and beyond.

      1K12HD092535-01, NIH/NIDCR 09/11/2017-08/31/2022
      Tufts BIRCWH Program (K12)
      The program seeks to support investigators through a mentored research and career development experience leading to an independent scientific career that will 1) benefit the health of women or advance research on sex/gender influences on health, and 2) encourage interdisciplinary research methodology. 

      R01 MD007735, NIMHD 2014/09/25-2018/05/31
      Insurance Instability and Disparities in Chronic Disease Outcomes
      To address the impact of insurance instability on continuity of care for chronic disease management focusing on racial and ethnic health disparities. 

      R01 MD007735-02S1, NIMHD
      2015/06/01-2018/05/31
      Gender Disparities in Stability of Insurance Coverage and Chronic Disease Management 
      To address the impact of insurance instability on continuity of care for chronic disease management focusing on gender health disparities.

      CRP-17-112-06-COUN, American Cancer Society 
      2012/07/01-2022/06/30
      Clinical Research Professorship
      This award recognizes Dr. Freund’s national leadership in cancer health disparities research, and supports her mentorship and research activities in cancer health disparities.

      GTDR15333918, Susan G. Komen Foundation
      2015/08/01-2018/07/31
      Tufts Breast Cancer Training Program to Reduce Health Disparities 
      To train students to conduct breast cancer health disparities research, focusing on Asian Americans.

      UL1TR00064, NCATS 2013/09/26-2018/04/30
      Tufts Clinical and Translational Science Institute (CTSI)
      To accelerate translational and interdisciplinary research across Tufts University and Tufts CTSI members.
      Role: Research Lead, ADAPT (Addressing Disparities in Asian Populations)

      KL2TR00063, NCATS
      2013/09/26-2018/04/30
      Tufts Clinical and Translational Science Institute (CTSI) Mentored Career Development
      To support junior investigators in developing their careers as clinical translational investigators.

      CE-1304-6173, PCORI 2013/10/01-2017/09/30
      Cervical Spondylotic Myelopathy Surgical Trial (CSM-S Trial)
      The goal of this study is to conduct a comparative effectiveness randomized clinical trial of two methods of neurosurgical intervention for cervical spondylotic myelopathy.

      Program on Equity in Science and Health
      800 Washington St., Box #63
      Boston, MA 02111

      35 Kneeland St., 11th Floor
      Boston, MA 02111

      Phone: 617-636-5065
      Fax: 617-636-8023

      Dr. Freud's is s a physician researcher at Tufts Medical Center in Boston.

      Program News

      Researchers find Massachusetts’ health reform law increased coverage without increasing “churn”; led to more women following up on cancer screenings.

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      Representatives from the Institute for Clinical Research and Health Policy Studies (ICRHPS) at Tufts Medical Center presented at the 2017 National SGIM and ACTS Annual Meeting.

      Program News

      At the 2017 National Society of General Internal Medicine (SGIM) meeting and the Association for Clinical and Translational Science (ACTS) meeting, Dr. Karen Freund’s research team and mentees had the opportunity to present their recent research topics and speak at the SGIM Special Symposium.

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