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Staged diabetes management a systematic approach - part 10 pps

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Set short- and long-term goals weight control, exercise, food plan, medications, monitoring Determine SMBG and HbA1c targetsRecord current medications Address lifestyle changes such as a

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Check all that apply

7

9 At which point are patients referred for diabetes education?

Who provides diabetes education?

Newly Diagnosed type 1 Newly Diagnosed type 2 Type 1 Continuing Education Type 2 Continuing Education Impaired Glucose Tolerance Inpatient

Gestational Diabetes

At Onset of Complications Pre-conception Counseling Other

SECTION FOUR: DIABETES EDUCATION SERVICES

1 Do you have a diabetes education curriculum in place in your facility? Yes No.

1 If yes, please describe or attach summary.

2 What diabetes patient education materials do you use?: ADA Drug Co IDC

1 IHS In House Ministry of Health Other

Figure A.1 (continued)

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SECTION FIVE: SYSTEM ASSESSMENT

1 Is there a diabetes committee or team? Yes No

Will this committee/team be responsible for the implementation of SDM?

2 How will you evaluate success of the SDM program?

a) What process/outcome inidcators will you use?

b) How often will you measure outcomes? _

3 Are you currently auditing diabetes care?

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What strengths does your community bring to the diabetes program?

Do you have the following processes to enhance your diabetes care in place?

How will you involve/inform others of the SDM program, its content and implementation process

9

Diabetes Flowsheet on chart Case Reviews/Grand Rounds Diabetes Support Group(s)

Patient Satisfaction Survey Rapid HbA1c available at time

of patient visit Foot Care Clinic

Community Awareness Program

Figure A.1 (continued)

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8 What questions do you have to assist you with the Site Preparation or training for SDM?

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1 Site Name

2 Abstraction Date:(mm/dd/yy)

3 Abstractor Name: _

4 Abstractor Title: _

5 Patient Gender: 1  Female 2  Male

6 Patient Date of Birth:(mm/dd/yy)

7 Pre-Diabetes:

Type of glucose abnormality diagnosed

1  Impaired Glucose Tolerance

2  Impaired Fasting Glucose

12 Visit Date: (mm/dd/yy) _

13 Blood Pressure Date: (mm/dd/yy) _

14 Most Recent Blood Pressure Systolic _ :

15 Most Recent Blood Pressure Diastolic _ :

16 Most Recent HbA 1c Date:(mm/dd/yy)

17 Most Recent HbA 1c Value: _

18 HbA 1c Lab Normal Range:

19 Total Serum Cholesterol Date: (mm/dd/yy) _

20 Total Serum Cholesterol Value:

21 LDL Date: (mm/dd/yy) _

22 LDL Value: _

SDM Patient Chart Audit Form

Figure A.2 SDM patient chart audit form

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23 HDL Date: (mm/dd/yy) _

24 HDL Value:

25 Serum Triglyceride Value: (mm/dd/yy) _

26 Serum Triglyceride Value: _

27 Gross Protein Present :

34 Foot Exam Date: (mm/dd/yy) _

35 Tobacco Status Documented:

1  Not documented

3  Previous tobacco user

2  Yes, documented in chart

36 If smoker, was referral for Tobacco Cessation made?:

0  Not documented

1  Yes

37 Retinal Exam Date: (mm/dd/yy) _

38 Metabolic syndrome: is patient diagnosed with any type of Metabolic Syndrome in addition

to the above diabetes types?

Figure A.2 (continued)

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Set short- and long-term goals (weight control, exercise, food plan, medications, monitoring) Determine SMBG and HbA1c targets

Record current medications Address lifestyle changes such as activity level and smoking cessation Educate about preventive care (foot, eye, dental)

Plan contraception and pregnancy with women of childbearing age Refer patient to registered dietitian for nutrition recommendations (exercise plan) and instruction Refer patient to diabetes educator for self-management training, BG and urine ketone monitoring and record-keeping instructions

Plan follow-up schedule with patient Refer patient for special services as necessary

Medical History

Symptoms/laboratory tests at diagnosis Previous and current diabetes therapy and control (SMBG and HbA1c) Weight history/especially previous diets

Nutrition and exercise pattern assessment Medications: assess those that may affect BG (b -blockers, steroids, thiazides) Growth and development in children and adolescents

Acute or chronic complications including hypoglycemia/hyperglycemia; neuropathy; sexual dysfunction; retinopathy; nephropathy; foot problems; cardiovascular disease; gastrointestinal symptoms

Prior or current infections including skin, dental, genitourinary History of other conditions, including endocrine and eating disorders Smoking and/or alcohol use

Lifestyle, cultural, psychosocial, abuse, occupational, and economic issues Previous education about diabetes

Determine body mass index (BMI  weight/height 2  kg/m 2 )

BP (sitting and standing) Examinations: funduscopic; dental; thyroid; cardiovascular; abdominal; neuro/vascular; feet; insulin injection sites

Growth and development in children (plot on growth charts) Sexual maturation in children

Fasting (preferred) or casual plasma glucose, if there is a question as to the validity of SMBG results

or for meter quality assuarance Hemoglobin A1c (HbA1c) Fasting lipid profile within 6 months of diagnosis Urinalysis (urine culture if sediment)

Urine microalbumin (timed or random albumin/creatinine ratio) if dip stick negative for proteinuria; after 5 years of duration in postpubertal type 1; at diagnosis and then annually in type 2

Serum creatinine in adults; in children if proteinuria present Thyroid functions in all type 1, in type 2 when thyroid disease is suspected Other lab assessments as indicated by history (chem profile, CBC) EKG (adults)

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Follow-up Visit

Every 1–2 months during adjust phase; every 3–4 months during maintain phase

Interim History

Note current stage (food plan, oral agent, etc., particularly self-adjustment of insulin/oral agent)

Review current medications and illnesses

Review SMBG and HbA1c targets

Discuss episodes of hypoglycemia/hyperglycemia (frequency, cause, severity, symptoms, treatment)

Address presence of intercurrent illness/ketonuria

Assess nutrition; exercise; lifestyle changes; psychosocial issues; complications

Evaluate patient’s adherence issues

Assess sexual activity beginning with puberty

Birth control/pregnancy planning for women of childbearing age

Review record book

Assess frequency of monitoring; SMBG ranges; patterns of hypoglycemia/hyperglycemia; validate

meter accuracy annually; response to exercise; illness

If memory meter used, compare with record book or download into computer for analysis

Determine body mass index (BMI  weight/height 2  kg/m 2 )

BP (sitting and standing)

Examinations: funduscopic; dental; thyroid; cardiac; abdominal; neuro/vascular; feet; injection sites

for patients on insulin

Growth and development in children (plot on growth charts)

Sexual maturation in children

Examine previous abnormal findings

Fasting (preferred) or casual plasma glucose, if there is a question as to the validity of SMBG results

or for meter quality assurance

HbA1c

Management Plan

Refer patient to diabetes educator and/or regisitered dietitian for review of self-management and/or

medical nutrition therapy as indicated

Consult with specialists as indicated (ophthalmologist, nephrologist, neurologist, podiatrist)

Yearly Check-Up

Complete eye examination with dilation by ophthalmologist: annually after 5 years duration in

post-pubertal type 1; at diagnosis and then annually in type 2

Lipid profile: every 5 years if normal; annually if abnormal

Albuminuria: each visit

Urine microalbumin (time or random albumin/creatinine ratio) if dip stick negative for proteinuria:

after 5 years duration in postpubertal type 1; at diagnosis and then annually in type 2

Thyroid: age 18 if growth problems, enlarged thyroid, or symptoms; age 18 if suspected problem s

EKG: all adults

Foot examination (pulses, nerves and inspection)

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Patients with BMI  25 kg/m 2

have a higher risk of adverse effects on health BMI is defined as body weight (kg) divided by height squared (m2) (BMI kg/m 2

)

1 meter  39.37 inches, 1 kilogram  2.2 pounds

Figure A.5 BMI chart

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Patient experiencing hypoglycemia

BG 70 mg/dL (3.9 mmol/L) with symptoms

Is patient unconscious or having a seizure?

NO

Is patient confused or combative,

requiring assistance in treatment?

Patient usually able to self-treat

Assess cause and determine level of

hypo-glycemia; identify individual symptoms; discuss

preventive measures and review annually with

patient and significant others

Sypmtoms

Mild: shaking; sweating; tachycardia; dizziness;

hunger; blurred vision; irritability Moderate: confusion; tiredness; yawning; poor coordination; headache; double vision;

Treatment for Severe Hypoglycemia

Subcutaneous or IM glucagon: ½ cc (0.5 mg) for age 5; 1 cc (1.0 mg) for age 5

If glucagon not available, call 911 for emergency assistance; health professionals may administer 50% D/W; 5–25 cc IV

Follow-up

Assess cause of hypoglycemia; make appropriate adjustments in treatment plan; report episode to clinician

Treatment for Moderate Hypoglycemia

Fruit juice or glucose gel (30 g)

If patient refuses or is unable to swallow, administer subcutaneous or IM glucagon

Treatment for Mild to Moderate Hypoglycemia

NO

YES YES

Figure A.6 Hypoglycemia/Treatment DecisionPath

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Do not delay meals or snacks Eat extra food or adjust insulin for planned exercise

Be aware of warning signs and treat promptly Always carry food to treat hypoglycemia Anticipate schedule changes

Always eat carbohydrates when consuming alcohol

Make sure friends, co-workers, teachers, and room-mates are aware of causes, symptoms and treatment

Have glucagon available for severe hypoglycemia; review instructions periodically; check expiration dates

For Nocturnal Hypoglycemia with Insulin Therapy

Measure BG before evening snack; if

100 mg/dL (5.6 mmol/L) may increase snack Measure BG at 3 AM; if less than target may need to adjust insulin, time of administration,

or stage of therapy Adjust SMBG targets if persistent nocturnal hypoglycemia

Recommendations

Review SMBG targets and adjust higher (100–160 mg/dL [5.6–8.9 mmol/L]) if necessary

Treat earliest symptoms immediately SMBG at least 4 times/day Treat any BG 70 mg/dL (3.9 mmol/L) in adults; 80 mg/dL (4.4 mmol/L) in children/ elderly; 60 mg/dL (3.3 mmol/L) in pregnancy

Patient previously treated for hypoglycemia

Assess potential cause; consider time of day and

activity when hypoglycemia occurred (occurs

most often before meals, during or after exercise,

and at peak times of insulin action)

Begin preventive measures based on cause

Assess Hypoglycemia Unawareness

Experienced most by type 1 patients; may occur

if BG levels are maintained at or below normal

glucose levels, or with increasing duration of

diabetes; SMBG target may need to be adjusted

higher

Rare in type 2 unless on b-blockers or with

autonomic neuropathy

Rare in gestational diabetes

Occurs over time, due in part to loss in ability

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Type of diabetes (diagnosis data)

Diabetes treatment regimen (medications,

medical nutrition therapy)

Medical history (HTN, lipids, complications)

HbA1c/ketones/SMBG data

SMBG/HbA1c targets

Prescription for BG testing, if needed

Diabetes education indicated

Obtain Referral Data

Readiness to learn/barriers to learning

Lifestyle (work, school, food and exercise

Achieve self-management knowledge/skills/

behavior (SMBG, medications, nutrition,

exercise)

Plan

Teach initial education topics

Establish 3 behavior change goals with patient

(exercise, nutrition, medications, monitoring)

Move to Diabetes Education/Follow-Up

Document and communicate education delivered

and behavior change goals in writing to referral

Behavior Change Goals

Goals must be specific, reasonable, and measurable

Establish a time frame and evaluation points Document goals for the patient record and give copy to patient

Encourage rewards for progress

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Follow-up diabetes education indicated

Obtain Referral Data

Type of diabetes (diagnosis data)

Diabetes treatment regimen (medications,

medical nutrition therapy)

Medical history (HTN, lipids, complications)

HbA1c/ketones/SMBG data

Summarize progress; document and

communicate in writing to referral source

Follow-Up

Education: annual visits

Diabetes Complications and Treatment

CVD: antihypertensives Dyslipidemia: lipid-lowering agents Retinopathy: laser therapy Nephropathy: nutritional interventions Neuropathy: pharmacologic agents Foot Problems: ulcer treatment

Diabetes Education Goals

SMBG/HbA1c in target Achieve self-management knowledge/skills/ behavior (SMBG, medications, nutrition, exercise)

Consider addressing adherence issues, updating education plan, or setting new behavior change goals; document and communicate education delivered and new goals in writing to referral source

Education: within 3 months

Figure A.9 Diabetes Education/Follow-up DecisionPath

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Initial Visit

Follow-up Visits

General Information

Diabetes pathophysiology (definition and causes of

hyperglycemia, type 1 vs type 2)

Interaction of food/exercise/medication

Insulin resistance/obesity (type 2)

Target goals (SMBG, HbA1c, weight)

Medication administration/adjustment

SMBG technique/record-keeping

Daily schedule (testing, medication, meals, snacks)

Hypoglycemia signs (dizziness, sweating, confusion,

loss of consciousness)

Hyperglycemia signs (fatigue, acetonic, polyuria,

polydipsia, polyphagia)

Prevention/treatment of hypoglycemia/hyperglycemia

Emergency phone numbers

Patient education materials

Insulin storage Syringe/lancet disposal Hypoglycemia/glucagon use Urine ketone monitoring (type 1) Medical identification

Add for Insulin Pump Users

Pump operation and care Site care (change site every 24–48 hours) Use of algorithm for bolus/basal ratio Record-keeping

New topics based on assessment

Review first-visit topics/re-educate as needed

Check SMBG skills/meter accuracy

Precautions when driving

Illness management

Benefits/responsibilities of self-care

Added for Insulin Users

Pattern control Compensatory/anticipatory insulin adjustments Hypoglycemia unawareness

Review injection technique Travel/schedule changes and effect on insulin

Added for Insulin Pump Users

Review hypoglycemia signs (dizziness, sweating, confusion, loss of consciousness)

Unexplained hyperglycemia (causes, recognition, treatment)

Exercise (insulin adjustments, pump care) Problem-solving skills

Add as Needed

Foot/skin/dental care Recognition of complications (numbness, persistent ulcers, blurry vision, frequent urination)

Healthy lifestyle (weight management, exercise, tobacco and alcohol use, stress management) Travel/schedule changes

Sexuality (impotence, contraception, pregnancy planning)

Psychological adjustments Community diabetes resources

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Nutrition intervention indicated

Obtain Referral Data

Type of diabetes (diagnosis data)

Diabetes treatment regimen (medications,

medical nutrition therapy)

Medical history (HTN, lipids, complications)

HbA1c/ketones/SMBG data

Weight goals/eating disorders

Psychosocial issues (denial, anxiety,

Achieve desirable body weight (adults)

Normal growth and development (children)

Consistent carbohydrate intake

Establish adequate calories for growth and

development/reasonable body weight

Set meal/snack times

Integrate insulin regimen with medical

nutrition therapy (insulin users)

Set consistent carbohydrate intake

Encourage regular exercise

Establish adequate calories for pregnancy/

lactation/recovery from illness

Move to Nutrition Education/Follow-Up

Document and communicate medical nutrition

therapy and education delivered in writing to

referral source

Follow-Up

Nutrition: within 1 month

Diabetes Complications and Treatment

CVD: antihypertensives Dyslipidemia: lipid-lowering agents Retinopathy: laser therapy Nephropathy: nutritional interventions Neuropathy: pharmacologic agents Foot Problems: ulcer treatment

Medical Nutrition Therapy Guidelines

Total fat  30% total calories; less if obese and high LDL

Saturated fat 10% total calories; 7% with high LDL

Cholesterol 300 mg/day Sodium 2400 mg/day Protein reduced to 0.8 g/kg/day (~10% total calories) if macroalbuminuria

Calories decreased by 10–20% if BMI

Inactive women/obese adults/inactive adults

age 55: weight (lb)  10 kcal

Children/Method 1

First year: 1000 kcal/year Ages 1–10: add 100 kcal/year Age 11–15: boys add 200 kcal/year; girls add

100 kcal/year Age 15: Boys add for activity (23 kcal/lb very active, 18 kcal/lb normal, 16 kcal lb inactive); girls calculate as adult

Children/Method 2

First year: 1000 kcal Ages 1–3: add 40 kcal/inch Age 3: Boys 125 kcal  age; girls 100 kcal  age; add up to 20% kcal for activity

Figure A.11 Nutrition Education/Initial DecisionPath

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Follow-up nutrition education indicated

Obtain Referral Data

Type of diabetes (diagnosis data)

Diabetes treatment regimen (medications,

medical nutrition therapy)

Medical history (HTN, lipids, complications)

HbA1c/ketones/SMBG data

Nutrition adequacy/carbohydrate intake

Height/weight/BMI, see BMI Chart

Growth and development (children)

Progress toward weight goal

SMBG records

Progress toward BG/HbA1c goals

Incidence of hypoglycemia/hyperglycemia

Work/school/sports schedules

Exercise (times, duration, types)

Psychosocial issues (denial, anxiety,

Is any additional education needed?

Summarize progress; document and

communicate in writing to referral source

Follow-Up

Nutrition: annual visits

Diabetes Complications and Treatment

CVD: antihypertensives Dyslipidemia: lipid-lowering agents Retinopathy: laser therapy Nephropathy: nutritional interventions Neuropathy: pharmacologic agents Foot Problems: ulcer treatment

Nutrition Education Goals

SMBG/HbA1c in target Achieve desirable body weight (adults) Normal growth and development (children) Consistent carbohydrate intake

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Food components (carbohydrate, protein, fat)

Effect of food on BG levels (carbohydrates have

greatest effect)

Portion control (average servings, measuring,

estimating)

Realistic weight goals (achievable, maintainable)

Guidelines for fat intake

Guidelines for exercise

Guidelines for treatment of hypoglycemia

Individualize medical nutrition therapy

Synchronization of insulin with food Consistency in timing of meals and snacks Prevention and treatment of hypoglycemia (food or beverage choices and amounts)

Adjusting food intake/insulin for exercise

Review first visit topics and short-term goals

Carbohydrate counting

Nutrition management during short-term illness

Food nutrition labels/healthy food choices

Use of food with higher sugar content

Reset short-term goals

Food related questions/problem-solving

Pattern control for adjusting insulin/food Anticipatory insulin adjustments for changes in basic medical nutrition therapy

Travel/schedule changes; effect on insulin Review SMBG/food and insulin adjustments Food/insulin adjustments for short-term illness

Sources of carbohydrate/protein/fat; effects on BG/other health factors (blood lipids, CHD)

SMBG to problem solve/identify patterns related to food intake

Adjusting meal times or delayed meals Travel/schedule changes

Holidays/special occasions; restaurant/fast food choices Alcohol guidelines/effect on BG

Recipes/menu ideas/cookbooks Dietetic foods/sweeteners Exchanges and equivalencies Behavior modification/problem-solving tips Vitamin/mineral/nutritional supplements

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Method of meal planning that takes into account only

carbohydrate content of foods

May be used in people with type 1 diabetes, type 2

diabetes, and in pre-gestational and gestational diabetes

Individualize carbohydrate intake for each patient

15 g carbohydrate  1 carbohydrate choice

1 carbohydrate choice is provided in one serving of

food from the starch, fruit, or milk food exchange lists

“Simple” and “complex” carbohydrate absorption rates

are similar

Emphasize total carbohydrate content of foods, rather

than the source

Carbohydrate is the first and primary nutrient that

affects BG levels

Consistency of carbohydrate intake will promote

consistency in BG control

Serves as a guideline for how much carbohydrate to

consume at meals and snacks

Provides flexibility in food choices

Sugar (sucrose) affects BG levels in a similar way

as other carbohydrate foods Sugar and foods high in sugar must be counted into the food plan or substituted for other carbohydrate Foods that are high in sugar are often high in fat and low in nutrients, making them a source of “empty calories”

Sugar and foods high in sugar should not be aged, rather worked into the food plan appropriately

encour-Potential for weight gain if too many foods high

in fat are consumed Nutritional inadequacy of the diet if the food plan

is not well balanced with a variety of foods

May be be used to teach people how to make adjustments

in regular or rapid-acting insulin for adding or

subtracting food from their usual food plan

Normally 1 unit bolus insulin for each 15 g of

carbohydrate (or 1 carbohydrate choice)

Add 1 unit of short-acting insulin to cover 1 extra

carbohydrate choice to be eaten at that meal

Subtract 1 unit of short-acting insulin from usual dose if

1 less carbohydrate choice is to be eaten at that meal

Frequent monitoring and diligent record keeping are

For All Patients

Considerations

Additional Considerations

Figure A.14 Carbohydrate counting

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Carbohydrate Servings (15 g carbohydrate; 60–90 calories)

Starch Group

Bagel or English muffin

Bread, slice or roll

Hamburger or hot dog bun

Lima beans, cooked

Squash, winter, cooked

Taco shells, 6" across

Tortilla, 6" across

Waffles, 4½" across

Fruit Group

Banana Berries or melon Canned fruit in juice or water Dried fruit

Fresh fruit Fruit juice Grapes or cherries Raisins

Milk Group

Milk, skim or low-fat Yogurt, low-fat, artificially sweetened (6–8 oz) Yogurt, plain, low-fat (6–8 oz)

Meat and Meat Substitutes Servings (7 g protein; 5 g fat; 50–100 calories)

Meats

Beef, lamb, pork, seafood, ham, veal

Poultry with skin removed

Meats should be baked, broiled, roasted, or grilled

Average serving size is 3 oz

Meat Substitutes

Cottage cheese Cheese Egg Peanut butter Tuna or salmon packed in water

¼ cup

1 oz 1

Sour cream Sunflower seeds

½ cup

3 squares

1 half or 1 oz cup 1 2

½ cup cup

3 cups 1

½ cup

½ cup

1 cup 2 1 1

Excerpted from My Food Plan

© 2003 International Diabetes Center

Figure A.15 Food choices

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Exercise assessment indicated

Obtain Referral Data

Obtain Medical Clearance

Obtain Fitness Clearance

Start Exercise/Plan

Type of diabetes

Diabetes treatment regimen (medications,

medical nutrition therapy)

Medical history (HTN, lipids, complications)

HbA1c/ketones

SMBG/HbA1c targets

Avoid strenuous exercise if BP 180/100

mmHg; if active proliferative retinopathy or

recent laser therapy; if recent foot disease or no

feeling in extremities (neuropathy)

If HbA1c 6 percentage points above upper

limit of normal, measure change in BG during

test exercise

Perform stress EKG if pre-existing CHD; over

age 40; or over age 30 with 10 years duration

Fitness clearance obtained?

Does patient understand the role

of exercise in diabetes? Educate patient about benefits of exercise

Refer to exercise specialist to improve fitness for exercise

If micro- or macro-vascular disease, refer accordingly

If BG control problem, adjust medical nutrition therapy and/or medication to optimize control, then reassess for exercise

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