Self‐Care for the Prevention and Management of Cardiovascular Disease and Stroke
2017; Wiley; Volume: 6; Issue: 9 Linguagem: Inglês
10.1161/jaha.117.006997
ISSN2047-9980
AutoresBárbara Riegel, Debra K. Moser, Harleah G. Buck, Victoria Vaughan Dickson, Sandra B. Dunbar, Christopher S. Lee, Terry A. Lennie, JoAnn Lindenfeld, Judith E. Mitchell, Diane Treat‐Jacobson, David E. Webber,
Tópico(s)Cardiovascular Health and Risk Factors
ResumoHomeJournal of the American Heart AssociationVol. 6, No. 9Self‐Care for the Prevention and Management of Cardiovascular Disease and Stroke Open AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessResearch ArticlePDF/EPUBSelf‐Care for the Prevention and Management of Cardiovascular Disease and StrokeA Scientific Statement for Healthcare Professionals From the American Heart Association Barbara Riegel, PhD, RN, FAHA, Chair, Debra K. Moser, PhD, RN, FAHA, Vice Chair, Harleah G. Buck, PhD, RN, FAHA, Victoria Vaughan Dickson, PhD, RN, FAHA, Sandra B. Dunbar, PhD, RN, FAHA, Christopher S. Lee, PhD, RN, FAHA, Terry A. Lennie, PhD, RN, FAHA, JoAnn Lindenfeld, MD, FAHA, Judith E. Mitchell, MD, FAHA, Diane J. Treat‐Jacobson, PhD, RN, FAHA, David E. Webber, PhD and on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; and Council on Quality of Care and Outcomes Research Barbara RiegelBarbara Riegel , Debra K. MoserDebra K. Moser , Harleah G. BuckHarleah G. Buck , Victoria Vaughan DicksonVictoria Vaughan Dickson , Sandra B. DunbarSandra B. Dunbar , Christopher S. LeeChristopher S. Lee , Terry A. LennieTerry A. Lennie , JoAnn LindenfeldJoAnn Lindenfeld , Judith E. MitchellJudith E. Mitchell , Diane J. Treat‐JacobsonDiane J. Treat‐Jacobson , David E. WebberDavid E. Webber and on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; and Council on Quality of Care and Outcomes Research Originally published31 Aug 2017https://doi.org/10.1161/JAHA.117.006997Journal of the American Heart Association. 2017;6:e006997AbstractAbstractSelf‐care is defined as a naturalistic decision‐making process addressing both the prevention and management of chronic illness, with core elements of self‐care maintenance, self‐care monitoring, and self‐care management. In this scientific statement, we describe the importance of self‐care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self‐care behaviors such as diet and exercise, barriers to self‐care, and the effectiveness of self‐care in improving outcomes is reviewed, as is the evidence supporting various individual, family‐based, and community‐based approaches to improving self‐care. Although there are many nuances to the relationships between self‐care and outcomes, there is strong evidence that self‐care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self‐care in evidence‐based guidelines.Imagine a world in which cardiovascular disease (CVD) is not the No. 1 cause of death decade after decade because self‐care is pushed to the top of the hierarchy of best practices to managing health. Now, imagine the more probable scenario in which a "perfect storm" of an aging population,1 increased numbers of individuals with multiple CVD risk factors,2 and increased prevalence of people with multiple chronic conditions3, 4 converge to create a healthcare crisis5 because self‐care has been ignored. The latter scenario is the reality we are facing as fragmented, episodic, acute care remains a major focus of the healthcare system, whereas primordial and primary disease prevention fostered by optimal self‐care receive far less attention. The purpose of this scientific statement is to synthesize the evidence for the effectiveness of self‐care in preventing, delaying, and managing CVD and stroke. We delineate the self‐care skills and knowledge required to achieve these goals, discuss barriers to engagement in good self‐care, and present optimal strategies whereby healthcare providers and systems can support individuals and families as they engage in self‐care. Although our focus is on adults, we set the stage by describing the need for self‐care at all life stages.Self‐Care DefinedSelf‐care is fundamental to maintenance of health, and prevention and management of chronic illnesses.6, 7 The World Health Organization definition of self‐care7 and other recent definitions focus primarily on healthy people.8 In this article, we use a definition of self‐care from the Theory of Self‐care of Chronic Illness that addresses both the prevention and management of chronic illness, with core elements of self‐care maintenance, self‐care monitoring, and self‐care management.9 In this definition, self‐care is a process whereby individuals and their families maintain health through health‐promoting practices and managing illness. People who engage in self‐care maintenance adhere to those behaviors needed to maintain physical and emotional stability. Self‐care monitoring involves a process of observing oneself for changes in signs and symptoms—body listening. Self‐care management is used by people as they respond to signs and symptoms when they occur.Similar self‐care activities are important whether one is concentrating on the prevention or management of CVD or stroke. With the onset of CVD or stroke, there are several additional elements of self‐care that need to be incorporated into the health regimen. Categorically, these self‐care behaviors can be mapped with key elements of the Theory of Self‐care of Chronic Illness.9 Based on current evidence‐based guidelines and complementary reviews, self‐care maintenance, monitoring, and management of the common CVDs of hypertension,10, 11, 12, 13 heart failure (HF),6, 14, 15, 16 stroke,17, 18, 19 atrial fibrillation (AF),20, 21, 22 coronary artery disease,23, 24 and peripheral artery disease25 are presented in Table 1.Table 1. Self‐Care of Common Cardiovascular Disorders Using the Middle‐Range Theory of Self‐Care NomenclatureHypertensionHeart FailureStrokeAtrial FibrillationCoronary Heart DiseasePeripheral Artery DiseaseSelf‐care maintenanceContinued cardiovascular health behaviorsSmoking cessationXXXXXXMaintain normal body mass indexXXXXXXRoutine physical activityXXXXXXMaintain healthy dietXXXXXXMaintain low cholesterolXXXXXXMaintain normal blood pressureXXXXXXMaintain normal fasting plasma glucoseXXXXXXReduce dietary sodium intakeXXXXXXDecrease alcohol useXXXXXXGaining knowledgeSeek information about the conditionXXXXXXDetermine where to get more informationXXXXXXUnderstand self‐care requirementsXXXXXXAdherence to condition‐specific treatmentsTake medications as prescribedXXXXXXKnow normal and side effects of treatmentsXXXXXXUnderstand why treatment is prescribedXXXXXXLearn how to adjust to specific dietary recommendationsAttend cardiac/other rehabilitationXXXKeep schedule appointments and contact providers as neededXXXXXXSelf‐care monitoringKnow common signs and symptomsXXXXXKnow signs and symptoms of worsening disease (eg, stroke or heart failure)XXXXXXKnow signs and symptoms of complications (eg, bleeding from anticoagulation)XXXXXRoutine (daily) blood pressure measurementXXXRoutine (daily) weight measurementXXXEstablish routine for monitoring signs and symptomsXXXXXXSelf‐care managementDistinguish among cardiovascular symptoms and non–life‐threatening conditionsXXXXXXHave a plan of what to do when signs and/or symptoms occurXXXXXXFurther reduce dietary sodiumXXIncrease diureticXTake nitroglycerinXAdjust anticoagulationXEvaluate the effectiveness of treatmentXXXXXXKnow when and which provider to call when signs and/or symptoms occurXXXXXXJohn Wiley & Sons, LtdOf 8760 hours in a year, patients spend only around 10 hours or 0.001% of their time with healthcare providers, meaning all other health maintenance, monitoring, and management activities are done by individuals or patients and their families as self‐care activities outside of the clinical or hospital setting. The basic self‐care activities important in CVD and stroke prevention and management are captured in the American Heart Association (AHA) "Life's Simple 7" (ie, smoking cessation, maintenance of body mass index [BMI], physical activity, healthy diet, maintaining low cholesterol, maintaining normal blood pressure [BP], and maintaining normal fasting plasma glucose).8 These behaviors have been shown to reduce incident stroke,26 HF,27 venous thromboembolism,28 and chronic kidney disease,29 and even incident cognitive impairment30 and non‐CVD.31Self‐Care as a Decision‐Making ProcessSelf‐care is most commonly understood as a naturalistic decision‐making process in which persons engage for the purpose of maintaining health and managing acute and chronic illness.9, 32, 33, 34, 35 Self‐care decision making is a complicated process. Better understanding of the nature of self‐care decision making will help clinicians understand how to better teach self‐care to their patients and to understand how self‐care fails and how to improve it. Naturalistic decision making has been used to explain the process of self‐care in individuals with CVD, most commonly HF, as well as other chronic illnesses.35, 36, 37, 38The naturalistic decision‐making framework explains that, in real‐world settings, people make decisions that are meaningful and familiar to them.39 These real‐world decisions are complex; they involve uncertainty, ambiguity, dynamically evolving conditions, missing information, time stress, and high stakes. These decisions may also have ill‐defined, shifting, or competing goals and involve multiple individuals. The naturalistic decision‐making process explains how individuals make decisions given this complexity and how they develop the skills necessary to succeed when faced with similar situations.40 Naturalistic decision making emphasizes how individuals use their experience and personal values in decision making.39 Experience emerges from situational awareness,41 or perception of the situation, as well as comprehension of the significance of a specific situation. One's experience with the situation, each option, and past response create a set of patterns that include relevant actions and expected outcomes associated with each possible response.36 In this way, past experience and personal values lead to the actions taken in specific situations.42Section SummarySelf‐care is defined as a naturalistic decision‐making process addressing both the prevention and management of chronic illness, with core elements of self‐care maintenance, self‐care monitoring, and self‐care management.The Coming Chronic Disease Healthcare CrisisWorldwide, we are experiencing an unprecedented increase in the age of the population attributed to decreased fertility, particularly in developed countries, and increased life expectancy.43 Life expectancy increased globally by 20 years from 1950 to 2000 and is expected to increase by another 10 years by 2050.43 By 2050, the population aged ≥60 years will double; 25% of the population will be >60 years of age; 20% >65 years of age; and close to 5% will be >85 years of age.2 By most projections, an increase in morbidity affected years will accompany the increase in life expectancy. Aging is a major risk factor for noncommunicable chronic conditions, particularly CVD and stroke, so this "silver tsunami"44 will result in huge numbers of elderly individuals with multiple chronic conditions.4 By 2050, the number of people with chronic conditions will escalate by 40%, and the number of older people with disabilities from chronic conditions will double.44 Currently, at least 66% of all deaths worldwide are attributable to noncommunicable diseases, the most common of which is CVD, and this percentage is projected to increase in coming years.CVD is the primary cause of death in men and women in the United States and worldwide.45, 46 Multiple lines of research convincingly demonstrate that preventing CVD is economically, socially, and humanly superior to even the best medical treatment of manifest CVD.47, 48, 49 Using sophisticated modeling, 1 group compared CVD prevention versus treatment for a population aged 30 to 84 years with risk‐factor levels, event rates, current behavior patterns, levels of treatment, and mortality rates resembling those of the US population. In the target population, 44% of all deaths were attributable to heart disease. Management of CVD risk factors before an event would have prevented or postponed 33% of these deaths. This compared with prevention of only 8% of deaths if "perfect care" was used during an acute event. These data provide strong support for the importance of self‐care in preventing CVD and further events.47Section SummaryA globally aging population will result in huge numbers of elderly individuals with multiple chronic conditions, including CVD and stroke, by 2050.A Life Course Approach to CVDBy the time CVD is manifest, it usually has been a silent condition for years.50 Thus, it is essential that self‐care of CVD risk factors is addressed as early as possible, not waiting for the emergence of overt CVD. Many advocate taking a "life course" approach to the prevention of chronic illnesses beginning with primordial prevention, because it is clear that the seeds of most noncommunicable diseases are planted very early in the life course.44, 51, 52Epidemiological data suggest that events in the perinatal period, and possibly even in the periconception period, are associated with an increased risk of chronic diseases in later life.53 This "fetal programming," also known as "developmental origins of health and disease," describes the process whereby a nutritional or endocrine event during a critical period of development results in an increased later risk of chronic disease.54, 55 Low‐birth‐weight (LBW) infants have a higher risk for coronary heart disease, cerebrovascular disease, metabolic syndrome, type 2 diabetes mellitus, and hypertension as adults than normal‐birth‐weight infants56, 57, 58 that is not explained by lifestyle factors such as smoking, diet, employment, alcohol, or exercise.57, 59 LBW may be caused by fetal, placental, or maternal factors, but, in many cases, the cause is not identified.A number of potentially modifiable maternal risk factors have been associated with LBW, including young or old age ( 35 years), low BMI (<20 kg/m2), alcohol or drug use, smoking, and poor nutrition. Preeclampsia is associated with LBW and a higher risk of stroke, hypertension, and obesity as well as evidence of widespread vascular dysfunction in the offspring.60, 61, 62, 63 Maternal obesity also predicts childhood obesity in the offspring.53 Even maternal exercise during gestation may influence cardiometabolic status in the fetus and infant.64 An intriguing study from the Helsinki Birth Cohort 1934–1944 reported that offspring of women who were preeclamptic compared with those of women with normotensive pregnancies have an increased risk for adulthood abnormalities in adaptive functioning, mental well‐being, and later depressive symptoms, all of which might affect self‐care in adulthood.65, 66Other periods during the life course are receiving increased attention for the appearance of risk factors that must be addressed early. For example, pregnancy is considered a "natural stress test" that uncovers risk for future CVD among mothers.67 Women with hypertension or preeclampsia during pregnancy have more than double the risk for a future CVD or cerebrovascular disease death or diagnosis than women who do not have these conditions during pregnancy.68 LBW among offspring or delivery of a preterm baby place the mother at increased risk for CVD.52 Early self‐care during this window of opportunity could stave off the development of CVD.Maternal risk factors place infants and adolescents at higher than normal risk for early development of CVD risk factors and higher risk of early disease.69 Thus, self‐care must address maternal risk factors for LBW, primordial prevention (eg, not starting smoking, avoiding overweight, being active, eating a heart healthy and low‐sodium diet), and the early appearance of cardiometabolic risk factors in LBW offspring. For example, childhood obesity is rising as are other risk factors, such as sedentary lifestyle, and early self‐care intervention to prevent or manage these risk factors is needed. Primordial prevention of CVD risk factors is best addressed with multifaceted, population‐based strategies involving increased education beginning in elementary schools or earlier, improvements in environmental infrastructure (eg, more sidewalks, parks, recreation centers, and easier access to healthful food choices), and regulatory initiatives (eg, tighter control of tobacco products, reduction in use of simple sugars and trans fats in foods). Such strategies are particularly important because, as this review highlights, it may be that only through primordial prevention will we achieve a marked reduction in the incidence and prevalence of CVD.Failure of Routine Care to Promote Self‐CareTeaching and supporting self‐care should be a major activity in our healthcare system. Yet, complexities in its conceptualization and practice result in underappreciation of self‐care by clinicians and healthcare systems. As a consequence, clinicians have not emphasized self‐care, and the vast majority of people do not perform self‐care behaviors well.16, 70, 71Self‐care research and clinical efforts have been hindered by the perceptions of both patients and providers that pharmacological interventions are more effective than lifestyle change.72, 73 Widespread failure of clinicians to follow, or give more than token attention to, CVD prevention guidelines has resulted in little change or worsening in CVD risk factors over time in many countries and points to a compelling need for a greater emphasis on self‐care.74 Further evidence of this failure is evident in practice‐based approaches to CVD risk reduction.75, 76 Some reasons for the lack of effectiveness of clinical efforts to influence CVD risk include the limited training of providers about patient education and use of effective behavior change strategies, lack of time for patient encounters, lack of support in the clinic environment for a self‐care–based approach, growth of healthcare systems focusing on care of acute events with little appreciation of the chronicity of most conditions, and better reimbursement for treatment than for prevention.77Our clinical and societal focus on an illness‐ or disease‐driven model of episodic care has resulted in what Goldman et al call "investing in sickness rather than health."49 This investment and our changing demography have resulted in people living longer with multiple chronic conditions that are not well controlled because self‐care is at the heart of control of chronic illnesses.Section SummaryThe seeds of most noncommunicable diseases such as CVD are planted very early in the life course, requiring a massive shift in the focus on treatment of acute events to an early emphasis on self‐care.Self‐Care BehaviorsIn this section, we address self‐care behaviors at the individual, family, and community levels. The roots of health lie in behavior, genetics, social circumstances, health care, and environmental exposures.78 Inadequate or unavailable medical therapy is thought to contribute little (around 10%) to illness and disease, whereas the predominant force is behavior, contributing ≈40% to overall health.78 Other determinants of health include genetics and stress. Social circumstances and environment contribute another ≈20% to health.78 Thus, it is clear that improving self‐care at the individual, family, and community levels could produce a major impact in health.Individual‐Level Self‐Care BehaviorsAutonomy, understanding self‐care, and self‐responsibility.Our healthcare system is built on the assumption that individuals seeking care will comply with healthcare providers' recommendations. Accountability is fostered in the context of keeping appointments and taking prescribed medications while following provider advice. The complex tasks of preventing chronic illnesses such as CVD and stroke commonly are addressed with provision of advice to "lose weight, get more activity, stop smoking" without provision of the knowledge, skills, and long‐term support needed for people to be successful with these self‐care behaviors. Training in self‐care is not common in the current healthcare system (for either providers or patients), and there is little time for development of strong and respectful patient‐provider partnerships.Given the lack of emphasis on self‐care in the healthcare system today, most patients expect that healthcare providers hold the responsibility for patients' health.79 Thus, both healthcare providers and patients will need a major change in expectations about their respective roles in the prevention and management of CVD and stroke. Recently, the National Academy of Medicine (formerly the Institute of Medicine) wrote a white paper, "Vital Directions for Health and Health Care," which addresses the major problems with healthcare systems today and changes that need to be made. One of their major focuses was "Empower People—Democratize Action for Health."78 With this focus comes the charge to develop a healthcare system in which patients and families are informed, empowered, and engaged in their own health care and that they are promoted as partners in making healthcare decisions and in ensuring that these decisions are commensurate with their goals for health and life.78Knowledge of health status.Knowledge of health status and awareness of risk is an essential first step in self‐care of CVD. Individuals need to understand their current health status and their risk for future conditions in order to engage in adequate self‐care. Such knowledge requires development of a partnership with all healthcare providers who are willing to promote self‐care by keeping patients informed about their health status, thoroughly explaining all risk factors, and providing patients with access to appropriate sources of further information (eg, reputable web sources, books, and media outlets).The "Know Your Numbers" campaign was designed to encourage people to determine their risk for CVD.80 Five risk factors are targeted: BP, total cholesterol, high‐density lipoprotein cholesterol, blood glucose, and BMI. The goal is for people to determine whether any of these factors are abnormal, allowing them to take appropriate action to reduce their risk for CVD. A similar campaign is used for people with pre–diabetes mellitus or type 2 diabetes mellitus.81 There have been no studies to determine the effectiveness of these specific campaigns; however, the "Know Your Numbers" program in Australia to increase BP awareness resulted in a majority of people with hypertension seeking medical follow‐up.82Diet.Self‐care related to diet differs from some other preventative lifestyle behaviors in that a new behavior is not required, such as exercise, but rather existing behaviors are modified. This can make dietary self‐care challenging because it involves changing habitual behaviors that are embedded in culture and may have social consequences. Equally challenging are what can appear to be frequent changes to dietary recommendations, which may be frustrating to those attempting to follow guidelines. This may be particularly true in respect to changes in long‐standing recommendations. One example is the change in current guidelines that no longer specify a maximum daily intake of dietary cholesterol, which people have spent the past 45 years struggling to limit.83 Thus, it is important that people have confidence that the recommendations they are given are worth the effort to follow. The recent switch in focus away from restriction of specific nutrients to promoting heart‐healthy dietary patterns84 may increase stability in recommendations and reduce future frustration. It is important to note, however, that the recommended dietary patterns are still intended to restrict intake of specific nutrients, namely added sugars, trans fats, saturated fats, and sodium, indicating that these nutrients continue to be implicated in development of CVD.Key components of current dietary recommendations84 center around eating a varied, nutrient‐dense diet that includes all vegetable subgroups: dark green, red and orange, legumes, and starchy. Also recommended are fruits, especially whole fruits, grains, particularly whole grains, fat‐free or low‐fat dairy, and protein from seafood, poultry, lean meats, eggs, nuts, seeds, and soy products. Unsaturated fat oils, such as soybean, corn, olive, canola, and safflower, are recommended.85 The 2 most commonly recommended diets that achieve these recommendations are the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean‐style diets.85 The recommendations can also easily be achieved with vegan or vegetarian diets as long as attention is paid to obtaining all essential amino acids and minerals.84, 85Although adherence to dietary recommendations has improved over the past 10 years, it still remains low at ≤60% of the population.84 Although considerable research has been conducted testing the effect of various diets on cardiovascular health, studies to promote dietary adherence are limited. In a recent review of dietary advice interventions for healthy adults to improve CVD risk factors, most interventions focused on nutrient reductions, such as fats or sodium, or nutrient increases, such as fruits, vegetables, or fiber.86 None focused on the currently recommended "whole diet" approach. Higher‐intensity interventions with more personal contact were more effective than low‐intensity interventions. Dietary advice appeared to be more effective for people with known or perceived risk for CVD who are more likely to be receptive to advice. Effectiveness of specific strategies was not identified in the review. In another recent review, strategies to change dietary behavior for prevention and management of chronic illness identified feedback, telephone follow‐up after education sessions, provision of nutritional tools such as menus, and contracting as the most promising interventions.87 However, none of the interventions was clearly superior, primarily because of the low quality of the studies.Published examples of how to apply current dietary guidelines are based on Western foods.84, 85 Cultural considerations are important when planning self‐care strategies for everyone given the multiplicity of cultures and the effect of culture on diet.88 For example, in many cases, the diets of first‐generation immigrants are more heart‐healthy than the typical Western diet on arrival in the United States, but gradually change to a more Western‐style diet over time.89 In this case, strategies are needed to promote adoption of healthy components of the Western diet, rather than the large portion sizes or commercially prepared and convenience foods. For immigrants who maintain a diet from their home culture, the underlying principles of the guidelines can be applied by focusing on the selection of comparable foods.Weight control.Maintaining a healthy body weight is an important self‐care behavior and current dietary guidelines emphasize the importance of weight control.84 This is achieved by consuming appropriate serving sizes of recommended foods to meet estimated caloric demand. Estimating and tracking caloric intake is difficult over the course of a typical day and therefore not a successful strategy for weight control. Fortunately, serving sizes for specific food categories are provided in the guidelines for each level of caloric intake. Estimating serving sizes can be quickly mastered after a brief period of measuring out portion sizes. Individual caloric need is based on activity level, indicating that self‐care strategies for increasing activity carry equal importance with diet in body weight maintenance.Weight loss for people who are obese has been a long‐standing recommendation for cardiovascular health.90 It should be noted that with the exception of bariatric surgery, no interventions have been associated with substantial weight loss sustained over time. So, setting initial weight loss targets of 5% to 10% can have a clinically significant impact on CVD risk.91 Self‐care for weight loss is rarely achieved alone. Most successful lifestyle interventions for weight loss require participation in a program, either individually or in a group, for ≥6 months.91 Long‐term weight maintenance may require an ongoing support system. Computer‐based interventions are an attractive alternative to in‐person programs for convenience and cost. However, the evidence suggests that, whereas these programs are better than passive interventions such as pamphlets or a manual, they are not equal in effectiveness to in‐person programs.92 However, the majority of these studies were not highly interactive, so it is possible that interventions that provide greater interaction may be equally effective to in‐person programs.Physical activity and exercise.Aerobic exercise is a self‐care behavior with incontrovertible health benefit, including systemic improvement in oxygen consumption, endothelial function, inflammation, BP, and insulin resistance as well as improvement in functional status, sleep quality, and quality of life.93 The importance of physical activity on mortality risk was highlighted in the Oslo II study.94 Elderly men who engaged in 30 minutes of physical activity 6 d/w had a 40% mortality risk reduction at 12‐year follow‐up—a benefit comparable to that observed with smoking cessation.There is increasing evidence that inactivity or sedentary behavior is independently associated with negative outcomes independent of overall exercise or physical activity levels. In patients with symptomatic chronic HF, phys
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