Comparator: teaching as usual
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Aghili et al. 2012
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To evaluate whether virtual patient simulations improve clinical reasoning skills of medical students.
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RCT
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6th years. N=52 (29 IG, 23 CG)
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Data gathering, ideas about patient management
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Diagnostic test (using patient cases)
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ñ Intervention produced significantly greater improvement in data gathering and ideas about patient management compared to teaching as usual (d=1.55).
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Moderate (6)
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Kalet et al. 2007
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To assess the impact of individual WISE-MD modules on clinical reasoning skills.
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RCT
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Clinical years. N=96 (52 IG, 44 CG)
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Data gathering, ideas about patient management
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Script concordance test
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ñ Intervention produced significantly greater improvement in data gathering and ideas about patient management compared to teaching as usual (d=0.25).
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Moderate (9)
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Lehman et al. 2015
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Investigated the effect of Virtual Patients combined with standard simulation-based training on the acquisition of clinical decision-making skills and procedural knowledge, objective skill performance, and self-assessment.
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RCT
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3rd & 4th years. N=57 (30 IG, 27 CG)
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Ideas about diagnoses, ideas about patient management, knowledge
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Key feature problems
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ñ Intervention produced significantly greater improvement in ideas about diagnoses and patient management, and knowledge compared to teaching as usual (d=1.91).
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High (13)
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Plackett et al. 2020
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To assess the feasibility, acceptability and potential effects of eCREST — the electronic Clinical Reasoning Educational Simulation Tool.
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Feasibility RCT
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5th & 6th years. N=264 (137 IG, 127 CG)
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Data gathering, flexibility in thinking about diagnoses (reported separately)*
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Virtual patient case & Diagnostic Thinking Inventory (DTI)
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ñ Ability to gather essential information (data gathering; d=0.19) significantly improved after intervention compared to teaching as usual
ó There was no significant difference between groups in relevance of history taking (data gathering; d=-0.13) and flexibility in diagnoses (d=0.20).
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High (11)
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Kim et al. 2018
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To explore how students use and benefit from virtual patient cases.
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Non-randomised trial
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3rd years. N=255 (129 IG, 126 CG)
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Ideas about diagnoses, knowledge
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Standardised patient (actor)
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ó Ideas about diagnoses and knowledge did not significantly improve compared to teaching as usual (voluntary access to cases) (d=0.09).
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Moderate (8)
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Comparator: tutorial covering the same case
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Botezatu et al. 2010
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To explore possible superior retention results with Virtual Patients versus regular learning activities, by measuring the differences between early and delayed assessment results.
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RCT
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4th & 6th years. N=49 (25 IG, 24 CG)
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Data gathering, ideas about diagnoses, ideas about patient management
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Virtual patient cases
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ñ Intervention produced significantly greater improvement in data gathering, ideas about diagnoses and patient management compared to tutorial (average effect size across 5 dimensions, d=1.57).
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Moderate (6)
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Devitt & Palmer 1998
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To evaluate the intervention by assessing whether it expanded students’ knowledge base, improving data-handling abilities and clinical problem-solving skills.
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RCT
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5th years. N=71 (46 IG, 25 CG)
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Problem-solving skills
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Multi-step clinical problem (patient case)
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ó Intervention produced non-significantly greater improvement in problem-solving skills compared to tutorial (d=0.50).
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Moderate (6)
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McCoy 2014
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This study investigates the utility of Virtual Patients for increasing medical student clinical reasoning skills, collaboration, and engagement.
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Randomised crossover trial
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1st years. N=108 (54 IG, 54 CG)
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Ideas about diagnoses
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Diagnostics competency task (using patient cases)
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ò Intervention significantly lowered ideas about diagnoses compared to tutorial (d=-0.59).
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Moderate (9)
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Raupach et al. 2009
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To explore whether students completing a web based collaborative teaching module show higher performance in a test aimed at clinical reasoning skills than students discussing the same clinical case in a traditional teaching session.
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RCT
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4th years. N=143 (72 IG, 71 CG)
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Data gathering, ideas about diagnoses, Ideas about patient management
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Key feature problems
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ó Intervention did not significantly improve data gathering, ideas about diagnoses and patient management compared to tutorial (d=0.03)
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High (10)
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Kamin et al. 2003
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To determine whether critical thinking differs among groups receiving the same case with the same facilitator in one of three formats.
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Non-randomised trial
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3rd years. N=65 (25 IG- virtual, 20 – IG video, 20 – CG – text)[iv]
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Critical thinking
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Students’ critical thinking during discussions of patient cases
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ñ Intervention produced significantly better critical thinking than the tutorials with either text-based cases (average effect size across 5 dimensions of critical thinking, d=2.20) or video modality (average effect size across 5 dimensions of critical thinking, d=2.72).
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Moderate (6)
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Middeke et al. 2018
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To compare a Serious Game, the virtual A&E department ‘EMERGE’ to small-group problem-based learning (PBL) regarding student learning outcome on clinical reasoning in the short term.
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Non-randomised trial
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5th years, N=112 (78 IG, 34 CG)
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Data gathering, ideas about diagnoses, ideas about patient management (reported separately)
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Key feature problems & virtual patient cases
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ñ Intervention produced significantly better clinical reasoning skills compared to tutorial (d=0.47) when measured on key features test and for some domains measured by the virtual patient cases – final diagnosis (ideas about diagnoses),
therapeutic interventions (ideas about patient management), physical examination, instrumental examination (data gathering)
ó There was no significant difference between groups in history taking (data gathering), laboratory orders and patient transfer (ideas about patient management).
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Moderate (6)
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Comparator: text-based cases
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Basu Roy & McMahon 2012
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To explore video-based cases comparative impact on students’ critical thinking.
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Randomised crossover trial
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2nd years. N=28 (14 IG, 14 CG)
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Critical thinking
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Proportion of deep utterances and superficial utterances during discussions of patient cases
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ò Intervention produced significantly lower odds of deep thinking compared to text-based cases (d=-0.23).
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Moderate (9)
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Kahl et al. 2010
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To explore whether the addition of systematic training in iterative hypothesis testing may add to the quality of the psychiatry course taught to fifth year medical students.
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RCT
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5th years. N=72 (36 IG, 36 CG)
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Ideas about diagnoses
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Standardised patient (actor)
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ñ Intervention produced significantly greater improvements in ideas about diagnoses compared to using text-based cases with examination of real patients (d=1.17).
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Moderate (7)
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Ludwig et al. 2018
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To test the hypothesis that repeated testing with video-based key feature questions produces superior retention of procedural knowledge related to clinical reasoning compared to repeated testing with text-based key feature questions.
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Randomised crossover trial
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4th years. N=93
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Data gathering, ideas about diagnoses, ideas about patient management, knowledge
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Key feature problems
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ñ Intervention produced significantly greater improvements in data gathering, ideas about diagnoses and patient management and knowledge compared to using text-based cases (d not possible to calculate).
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Moderate (6)
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Sobocan et al. 2017
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To determine the educational effects of substituting p-PBL sessions with VP on undergraduate medical students in their internal medicine course.
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RCT
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3rd years. N=34 (17 IG, 17 CG)
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Knowledge and flexibility in thinking
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DTI
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ó Intervention did not significantly improve knowledge and flexibility in thinking compared to text-based cases (d=0.25).
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Moderate (7)
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Comparator: N/A
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Chon et al. 2019
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To test the effect of a serious game simulating an emergency department (“EMERGE”) on students’ declarative and procedural knowledge
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Single group pre & post comparison
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Clinical years. N=140
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Data gathering, ideas about diagnoses, ideas about patient management, (reported separately)
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Patient case
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ñ Diagnostic questions (data gathering; d=0.77), choosing the correct order of diagnostic procedures (ideas about diagnoses; d=0.65) and treatment suggestions improved (ideas about patient management; d=0.82) after using intervention.
ó There was no significant difference between groups in diagnostic accuracy (ideas about diagnoses; d=0.08).
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Moderate (5)
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Isaza-Restrepo et al. 2018
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To present evidence regarding the effectiveness of a low-fidelity simulator: Virtual Patient
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Single group pre & post comparison
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1st-5th years. N=20
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Data gathering, ideas about diagnoses, ideas about patient management
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Standardised patient (actor)
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ñ Data gathering, ideas about diagnoses and patient management, and presentation of a case significantly improved after using intervention (average effect size across 5 dimensions from 3 evaluators, d=1.41).
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Moderate (6)
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Kleinart et al. 2015
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To examine whether the use of ALICE has positive impact on clinical reasoning and is a suitable tool for supporting the clinical teacher.
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Single group pre & post comparison
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3rd years. N=62
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Ideas about diagnoses, ideas about patient management
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Patient cases
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ñ Ideas about diagnoses and patient management significantly improved after using intervention (d=0.92).
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Low (3)
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Watari et al. 2020
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To clarify the effectiveness of VPSs for improving clinical reasoning skills among medical students, and to compare improvements in knowledge or clinical reasoning skills relevant to specific clinical scenarios.
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Single group pre & post comparison
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4th years. N=169
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Data gathering, ideas about diagnoses, ideas about patient management
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Multiple-choice question (MCQ) quiz (using patient cases)
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ñ Data gathering, ideas about diagnoses and patient management significantly improved after using intervention (d=1.39).
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Low (3)
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Wu et al. 2014
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To examine the effectiveness of a computer-based cognitive representation approach in supporting the learning of clinical reasoning.
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Single group pre & post comparison
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3rd-5th years. N=50
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Problem-solving
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Concept maps
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ñ Problem-solving significantly improved after using intervention (d=1.17).
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Moderate (5)
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