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Erschienen in: Diabetologia 9/2009

01.09.2009 | Article

Glucose challenge test screening for prediabetes and undiagnosed diabetes

verfasst von: L. S. Phillips, D. C. Ziemer, P. Kolm, W. S. Weintraub, V. Vaccarino, M. K. Rhee, R. Chatterjee, K. M. V. Narayan, D. D. Koch

Erschienen in: Diabetologia | Ausgabe 9/2009

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Abstract

Aims/hypothesis

Diabetes prevention and care are limited by lack of screening. We hypothesised that screening could be done with a strategy similar to that used near-universally for gestational diabetes, i.e. a 50 g oral glucose challenge test (GCT) performed at any time of day, regardless of meal status, with one 1 h sample.

Methods

At a first visit, participants had random plasma and capillary glucose measured, followed by the GCT with plasma and capillary glucose (GCTplasma and GCTcap, respectively). At a second visit, participants had HbA1c measured and a diagnostic 75 g OGTT.

Results

The 1,573 participants had mean age of 48 years, BMI 30.3 kg/m2 and 58% were women and 58% were black. Diabetes (defined by WHO) was present in 4.6% and prediabetes (defined as impaired glucose tolerance [2 h glucose 7.8–11.1 (140–199 mg/dl) with fasting glucose ≤6.9 (125 mg/dl)] and/or impaired fasting glucose with plasma glucose 6.1–6.9 mmol/l [110–125 mg/dl]) in 18.7%. The GCTplasma provided areas under the receiver-operating-characteristic curves of 0.90, 0.82 and 0.79 for detection of diabetes, diabetes or prediabetes, and prediabetes, respectively, all of which were higher than GCTcap, random and capillary glucose, and HbA1c (p < 0.02 for all). The performance of GCTplasma was unaffected by time after meals or time of day, and was better in blacks than whites, but otherwise comparable in men and women, and in groups with differing prevalence of glucose intolerance. GCTplasma screening would cost approximately US$84 to identify one person with previously unrecognised diabetes or prediabetes.

Conclusions/interpretation

GCT screening for prediabetes and previously unrecognised diabetes would be accurate, convenient and inexpensive. Widespread use of GCT screening could help improve disease management by permitting early initiation of therapy aimed at preventing or delaying the development of diabetes and its complications.
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Literatur
1.
Zurück zum Zitat Saaddine JB, Cadwell B, Gregg EW et al (2006) Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002. Ann Intern Med 144:465–474PubMed Saaddine JB, Cadwell B, Gregg EW et al (2006) Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002. Ann Intern Med 144:465–474PubMed
2.
Zurück zum Zitat Hoerger TJ, Segel JE, Gregg EW, Saaddine JB (2008) Is glycemic control improving in U.S. adults? Diabetes Care 31:81–86PubMedCrossRef Hoerger TJ, Segel JE, Gregg EW, Saaddine JB (2008) Is glycemic control improving in U.S. adults? Diabetes Care 31:81–86PubMedCrossRef
3.
Zurück zum Zitat Absetz P, Valve R, Oldenburg B et al (2007) Type 2 diabetes prevention in the “real world”: one-year results of the GOAL implementation trial. Diabetes Care 30:2465–2470PubMedCrossRef Absetz P, Valve R, Oldenburg B et al (2007) Type 2 diabetes prevention in the “real world”: one-year results of the GOAL implementation trial. Diabetes Care 30:2465–2470PubMedCrossRef
4.
Zurück zum Zitat Phillips LS, Branch WT Jr, Cook CB et al (2001) Clinical inertia. Ann Int Med 135:825–834PubMed Phillips LS, Branch WT Jr, Cook CB et al (2001) Clinical inertia. Ann Int Med 135:825–834PubMed
5.
Zurück zum Zitat Holman RR (1998) Assessing the potential for alpha-glucosidase inhibitors in prediabetic states. Diabetes Res Clin Pract 40(Suppl):S21–S25PubMedCrossRef Holman RR (1998) Assessing the potential for alpha-glucosidase inhibitors in prediabetic states. Diabetes Res Clin Pract 40(Suppl):S21–S25PubMedCrossRef
6.
Zurück zum Zitat Weyer C, Bogardus C, Mott DM, Pratley RE (1999) The natural history of insulin secretory dysfunction and insulin resistance in the pathogenesis of type 2 diabetes mellitus. J Clin Invest 104:787–794PubMedCrossRef Weyer C, Bogardus C, Mott DM, Pratley RE (1999) The natural history of insulin secretory dysfunction and insulin resistance in the pathogenesis of type 2 diabetes mellitus. J Clin Invest 104:787–794PubMedCrossRef
7.
Zurück zum Zitat Butler AE, Janson J, Bonner-Weir S, Ritzel R, Rizza RA, Butler PC (2003) Beta-cell deficit and increased beta-cell apoptosis in humans with type 2 diabetes. Diabetes 52:102–110PubMedCrossRef Butler AE, Janson J, Bonner-Weir S, Ritzel R, Rizza RA, Butler PC (2003) Beta-cell deficit and increased beta-cell apoptosis in humans with type 2 diabetes. Diabetes 52:102–110PubMedCrossRef
8.
Zurück zum Zitat Nichols GA, Alexander CM, Girman CJ, Kamal-Bahl SJ, Brown JB (2006) Treatment escalation and rise in HbA1c following successful initial metformin therapy. Diabetes Care 29:504–509PubMedCrossRef Nichols GA, Alexander CM, Girman CJ, Kamal-Bahl SJ, Brown JB (2006) Treatment escalation and rise in HbA1c following successful initial metformin therapy. Diabetes Care 29:504–509PubMedCrossRef
10.
Zurück zum Zitat Pi-Sunyer X, Blackburn G, Brancati FL et al (2007) Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care 30:1374–1383PubMedCrossRef Pi-Sunyer X, Blackburn G, Brancati FL et al (2007) Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care 30:1374–1383PubMedCrossRef
11.
Zurück zum Zitat Cowie CC, Rust KF, Ford ES et al (2009) Full accounting of diabetes and pre-diabetes in the U.S. population in 1988–1994 and 2005–2006. Diabetes Care 32:287–294PubMedCrossRef Cowie CC, Rust KF, Ford ES et al (2009) Full accounting of diabetes and pre-diabetes in the U.S. population in 1988–1994 and 2005–2006. Diabetes Care 32:287–294PubMedCrossRef
13.
Zurück zum Zitat Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH (2004) Opportunistic screening for diabetes in routine clinical practice. Diabetes Care 27:9–12PubMedCrossRef Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH (2004) Opportunistic screening for diabetes in routine clinical practice. Diabetes Care 27:9–12PubMedCrossRef
14.
Zurück zum Zitat Leiter LA, Barr A, Belanger A et al (2001) Diabetes screening in Canada (DIASCAN) study: prevalence of undiagnosed diabetes and glucose intolerance in family physician offices. Diabetes Care 24:1038–1043PubMedCrossRef Leiter LA, Barr A, Belanger A et al (2001) Diabetes screening in Canada (DIASCAN) study: prevalence of undiagnosed diabetes and glucose intolerance in family physician offices. Diabetes Care 24:1038–1043PubMedCrossRef
15.
Zurück zum Zitat Twigg SM, Kamp MC, Davis TM, Neylon EK, Flack JR (2007) Prediabetes: a position statement from the Australian Diabetes Society and Australian Diabetes Educators Association. Med J Aust 186:461–465PubMed Twigg SM, Kamp MC, Davis TM, Neylon EK, Flack JR (2007) Prediabetes: a position statement from the Australian Diabetes Society and Australian Diabetes Educators Association. Med J Aust 186:461–465PubMed
16.
Zurück zum Zitat The DECODE Study Group on behalf of the European Diabetes Epidemiology Group (1999) Glucose tolerance and mortality: comparison of WHO and American Diabetic Association diagnostic criteria. Lancet 354:617–621CrossRef The DECODE Study Group on behalf of the European Diabetes Epidemiology Group (1999) Glucose tolerance and mortality: comparison of WHO and American Diabetic Association diagnostic criteria. Lancet 354:617–621CrossRef
17.
Zurück zum Zitat Meigs JB, Nathan DM, D'Agostino RB Jr, Wilson PWF (2002) Fasting and postchallenge glycemia and cardiovascular disease risk: the Framingham Offspring Study. Diabetes Care 25:1845–1850PubMedCrossRef Meigs JB, Nathan DM, D'Agostino RB Jr, Wilson PWF (2002) Fasting and postchallenge glycemia and cardiovascular disease risk: the Framingham Offspring Study. Diabetes Care 25:1845–1850PubMedCrossRef
18.
Zurück zum Zitat Sorkin JD, Muller DC, Fleg JL, Andres R (2005) The relation of fasting and 2-h postchallenge plasma glucose concentrations to mortality: data from the Baltimore Longitudinal Study of Aging with a critical review of the literature. Diabetes Care 28:2626–2632PubMedCrossRef Sorkin JD, Muller DC, Fleg JL, Andres R (2005) The relation of fasting and 2-h postchallenge plasma glucose concentrations to mortality: data from the Baltimore Longitudinal Study of Aging with a critical review of the literature. Diabetes Care 28:2626–2632PubMedCrossRef
19.
Zurück zum Zitat DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845PubMedCrossRef DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845PubMedCrossRef
20.
Zurück zum Zitat CDC Diabetes Cost-Effectiveness Study Group (1998) The cost-effectiveness of screening for type 2 diabetes. JAMA 280:1757–1763CrossRef CDC Diabetes Cost-Effectiveness Study Group (1998) The cost-effectiveness of screening for type 2 diabetes. JAMA 280:1757–1763CrossRef
21.
Zurück zum Zitat Schulze MB, Hoffmann K, Boeing H et al (2007) An accurate risk score based on anthropometric, dietary, and lifestyle factors to predict the development of type 2 diabetes. Diabetes Care 30:510–515PubMedCrossRef Schulze MB, Hoffmann K, Boeing H et al (2007) An accurate risk score based on anthropometric, dietary, and lifestyle factors to predict the development of type 2 diabetes. Diabetes Care 30:510–515PubMedCrossRef
22.
Zurück zum Zitat Aekplakorn W, Bunnag P, Woodward M et al (2006) A risk score for predicting incident diabetes in the Thai population. Diabetes Care 29:1872–1877PubMedCrossRef Aekplakorn W, Bunnag P, Woodward M et al (2006) A risk score for predicting incident diabetes in the Thai population. Diabetes Care 29:1872–1877PubMedCrossRef
23.
Zurück zum Zitat Heikes KE, Eddy DM, Arondekar B, Schlessinger L (2008) Diabetes Risk Calculator: a simple tool for detecting undiagnosed diabetes and pre-diabetes. Diabetes Care 31:1040–1045PubMedCrossRef Heikes KE, Eddy DM, Arondekar B, Schlessinger L (2008) Diabetes Risk Calculator: a simple tool for detecting undiagnosed diabetes and pre-diabetes. Diabetes Care 31:1040–1045PubMedCrossRef
24.
Zurück zum Zitat Saudek CD, Herman WH, Sacks DB, Bergenstal RM, Edelman D, Davidson MB (2008) A new look at screening and diagnosing diabetes mellitus. J Clin Endocrinol Metab 93:2447–2453PubMedCrossRef Saudek CD, Herman WH, Sacks DB, Bergenstal RM, Edelman D, Davidson MB (2008) A new look at screening and diagnosing diabetes mellitus. J Clin Endocrinol Metab 93:2447–2453PubMedCrossRef
25.
Zurück zum Zitat McCance DR, Hanson RL, Charles M-A et al (1994) Comparison of tests for glycated haemoglobin and fasting and two hour plasma glucose concentrations as diagnostic methods for diabetes. BMJ 308:1323–1328PubMed McCance DR, Hanson RL, Charles M-A et al (1994) Comparison of tests for glycated haemoglobin and fasting and two hour plasma glucose concentrations as diagnostic methods for diabetes. BMJ 308:1323–1328PubMed
26.
Zurück zum Zitat Rohlfing CL, Little RR, Wiedmeyer H-M et al (2000) Use of GHb (HbA1c) in screening for undiagnosed diabetes in the U.S. population. Diabetes Care 23:187–191PubMedCrossRef Rohlfing CL, Little RR, Wiedmeyer H-M et al (2000) Use of GHb (HbA1c) in screening for undiagnosed diabetes in the U.S. population. Diabetes Care 23:187–191PubMedCrossRef
27.
Zurück zum Zitat Motala AA, Omar MAK (1992) The value of glycosylated haemoglobin as a substitute for the oral glucose tolerance test in the detection of impaired glucose tolerance (IGT). Diab Res Clin Prac 17:199–207CrossRef Motala AA, Omar MAK (1992) The value of glycosylated haemoglobin as a substitute for the oral glucose tolerance test in the detection of impaired glucose tolerance (IGT). Diab Res Clin Prac 17:199–207CrossRef
28.
Zurück zum Zitat Kilpatrick E, Maylor PW, Keevil BG (1998) Biological variation of glycated hemoglobin: implications for diabetes screening and monitoring. Diabetes Care 21:261–264PubMedCrossRef Kilpatrick E, Maylor PW, Keevil BG (1998) Biological variation of glycated hemoglobin: implications for diabetes screening and monitoring. Diabetes Care 21:261–264PubMedCrossRef
29.
Zurück zum Zitat Edelstein SL, Knowler WC, Bain RP et al (1997) Predictors of progression from impaired glucose tolerance to NIDDM: an analysis of six prospective studies. Diabetes 46:701–710PubMedCrossRef Edelstein SL, Knowler WC, Bain RP et al (1997) Predictors of progression from impaired glucose tolerance to NIDDM: an analysis of six prospective studies. Diabetes 46:701–710PubMedCrossRef
30.
Zurück zum Zitat Mannucci E, Bardini G, Ognibene A, Rotella CM (1999) Comparison of ADA and WHO screening methods for diabetes mellitus in obese patients. Diabetic Med 16:579–585PubMedCrossRef Mannucci E, Bardini G, Ognibene A, Rotella CM (1999) Comparison of ADA and WHO screening methods for diabetes mellitus in obese patients. Diabetic Med 16:579–585PubMedCrossRef
31.
Zurück zum Zitat Barzilay JI, Spiekerman CF, Wahl PW et al (1999) Cardiovascular disease in older adults with glucose disorders: comparison of American Diabetes Association criteria for diabetes mellitus with WHO criteria. Lancet 354:622–625PubMedCrossRef Barzilay JI, Spiekerman CF, Wahl PW et al (1999) Cardiovascular disease in older adults with glucose disorders: comparison of American Diabetes Association criteria for diabetes mellitus with WHO criteria. Lancet 354:622–625PubMedCrossRef
32.
Zurück zum Zitat Chang C-J, Wu J-S, Lu F-H, Lee H-L, Yang Y-C, Wen M-J (1998) Fasting plasma glucose in screening for diabetes in the Taiwanese population. Diabetes Care 21:1856–1860PubMedCrossRef Chang C-J, Wu J-S, Lu F-H, Lee H-L, Yang Y-C, Wen M-J (1998) Fasting plasma glucose in screening for diabetes in the Taiwanese population. Diabetes Care 21:1856–1860PubMedCrossRef
33.
Zurück zum Zitat Schmidt MI, Duncan BB, Vigo A et al (2003) Detection of undiagnosed diabetes and other hyperglycemia states. Diabetes Care 26:1338–1343PubMedCrossRef Schmidt MI, Duncan BB, Vigo A et al (2003) Detection of undiagnosed diabetes and other hyperglycemia states. Diabetes Care 26:1338–1343PubMedCrossRef
34.
Zurück zum Zitat Johnson SL, Tabaei BP, Herman WH (2005) The efficacy and cost of alternative strategies for systematic screening for type 2 diabetes in the U.S. population 45–74 years of age. Diabetes Care 28:307–311PubMedCrossRef Johnson SL, Tabaei BP, Herman WH (2005) The efficacy and cost of alternative strategies for systematic screening for type 2 diabetes in the U.S. population 45–74 years of age. Diabetes Care 28:307–311PubMedCrossRef
35.
Zurück zum Zitat Zhang P, Engelgau MM, Valdez R, Cadwell B, Benjamin SM, Narayan KMV (2005) Efficient cutoff points for three screening tests for detecting undiagnosed diabetes and pre-diabetes: an economic analysis. Diabetes Care 28:1321–1325PubMedCrossRef Zhang P, Engelgau MM, Valdez R, Cadwell B, Benjamin SM, Narayan KMV (2005) Efficient cutoff points for three screening tests for detecting undiagnosed diabetes and pre-diabetes: an economic analysis. Diabetes Care 28:1321–1325PubMedCrossRef
36.
Zurück zum Zitat Hoerger TJ, Hicks KA, Sorensen SW et al (2007) Cost-effectiveness of screening for pre-diabetes among overweight and obese U.S. adults. Diabetes Care 30:2874–2879PubMedCrossRef Hoerger TJ, Hicks KA, Sorensen SW et al (2007) Cost-effectiveness of screening for pre-diabetes among overweight and obese U.S. adults. Diabetes Care 30:2874–2879PubMedCrossRef
37.
Zurück zum Zitat Abdul-Ghani MA, Williams K, Defronzo RA, Stern M (2007) What is the best predictor of future type 2 diabetes? Diabetes Care 30:1544–1548PubMedCrossRef Abdul-Ghani MA, Williams K, Defronzo RA, Stern M (2007) What is the best predictor of future type 2 diabetes? Diabetes Care 30:1544–1548PubMedCrossRef
38.
Zurück zum Zitat Abdul-Ghani MA, Abdul-Ghani T, Ali N, Defronzo RA (2008) One-hour plasma glucose concentration and the metabolic syndrome identify subjects at high risk for future type 2 diabetes. Diabetes Care 31:1650–1655PubMedCrossRef Abdul-Ghani MA, Abdul-Ghani T, Ali N, Defronzo RA (2008) One-hour plasma glucose concentration and the metabolic syndrome identify subjects at high risk for future type 2 diabetes. Diabetes Care 31:1650–1655PubMedCrossRef
39.
Zurück zum Zitat Chemistry/Therapeutic Drug Monitoring Survey (2008) College of American Pathologists (Northfield, IL, USA). Available from www.cap.org, accessed 15 May 2009 Chemistry/Therapeutic Drug Monitoring Survey (2008) College of American Pathologists (Northfield, IL, USA). Available from www.​cap.​org, accessed 15 May 2009
40.
Zurück zum Zitat Park Y-W, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB (2003) The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988–1994. Arch Intern Med 163:427–436PubMedCrossRef Park Y-W, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB (2003) The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988–1994. Arch Intern Med 163:427–436PubMedCrossRef
41.
Zurück zum Zitat Herman WH, Brandle M, Zhang P, The Diabetes Prevention Program Research Group et al (2003) Costs associated with the primary prevention of type 2 diabetes mellitus in the Diabetes Prevention Program. Diabetes Care 26:36–47CrossRef Herman WH, Brandle M, Zhang P, The Diabetes Prevention Program Research Group et al (2003) Costs associated with the primary prevention of type 2 diabetes mellitus in the Diabetes Prevention Program. Diabetes Care 26:36–47CrossRef
42.
Zurück zum Zitat Zhang P, Engelgau MM, Valdez R, Benjamin SM, Cadwell B, Narayan KMV (2003) Costs of screening for pre-diabetes among U.S. adults. Diabetes Care 26:2536–2542PubMedCrossRef Zhang P, Engelgau MM, Valdez R, Benjamin SM, Cadwell B, Narayan KMV (2003) Costs of screening for pre-diabetes among U.S. adults. Diabetes Care 26:2536–2542PubMedCrossRef
43.
Zurück zum Zitat Troisi RJ, Cowie CC, Harris MI (2000) Diurnal variation in fasting plasma glucose: implications for diagnosis of diabetes in patients examined in the afternoon. JAMA 284:3157–3159PubMedCrossRef Troisi RJ, Cowie CC, Harris MI (2000) Diurnal variation in fasting plasma glucose: implications for diagnosis of diabetes in patients examined in the afternoon. JAMA 284:3157–3159PubMedCrossRef
44.
Zurück zum Zitat Narayan KMV, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF (2003) Lifetime risk for diabetes mellitus in the United States. JAMA 290:1884–1890PubMedCrossRef Narayan KMV, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF (2003) Lifetime risk for diabetes mellitus in the United States. JAMA 290:1884–1890PubMedCrossRef
45.
Zurück zum Zitat Thaler LM, El-Kebbi IM, Ziemer DC, Gallina DL, Dunbar VG, Phillips LS (1998) High prevalence of albuminuria among African-Americans with short duration of diabetes. Diabetes Care 21:1576–1577PubMedCrossRef Thaler LM, El-Kebbi IM, Ziemer DC, Gallina DL, Dunbar VG, Phillips LS (1998) High prevalence of albuminuria among African-Americans with short duration of diabetes. Diabetes Care 21:1576–1577PubMedCrossRef
46.
Zurück zum Zitat Erdman DM, Cook CB, Greenlund KJ et al (2002) The impact of outpatient diabetes management on serum lipids in urban African-Americans with type 2 diabetes. Diabetes Care 25:9–15PubMedCrossRef Erdman DM, Cook CB, Greenlund KJ et al (2002) The impact of outpatient diabetes management on serum lipids in urban African-Americans with type 2 diabetes. Diabetes Care 25:9–15PubMedCrossRef
47.
Zurück zum Zitat Keech S, Colquehoun D, Best J et al (2003) Secondary prevention of cardiovascular events with long-term pravastatin in patients with diabetes or impaired fasting glucose: results from the LIPID trial. Diabetes Care 26:2713–2721PubMedCrossRef Keech S, Colquehoun D, Best J et al (2003) Secondary prevention of cardiovascular events with long-term pravastatin in patients with diabetes or impaired fasting glucose: results from the LIPID trial. Diabetes Care 26:2713–2721PubMedCrossRef
48.
Zurück zum Zitat Herman WH, Hoerger TJ, Brandle M et al (2005) The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med 142:323–332PubMed Herman WH, Hoerger TJ, Brandle M et al (2005) The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med 142:323–332PubMed
49.
Zurück zum Zitat American Diabetes Association, NIH/NIDDK (2002) The prevention or delay of type 2 diabetes. Diabetes Care 25:742–749CrossRef American Diabetes Association, NIH/NIDDK (2002) The prevention or delay of type 2 diabetes. Diabetes Care 25:742–749CrossRef
Metadaten
Titel
Glucose challenge test screening for prediabetes and undiagnosed diabetes
verfasst von
L. S. Phillips
D. C. Ziemer
P. Kolm
W. S. Weintraub
V. Vaccarino
M. K. Rhee
R. Chatterjee
K. M. V. Narayan
D. D. Koch
Publikationsdatum
01.09.2009
Verlag
Springer-Verlag
Erschienen in
Diabetologia / Ausgabe 9/2009
Print ISSN: 0012-186X
Elektronische ISSN: 1432-0428
DOI
https://doi.org/10.1007/s00125-009-1407-7

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