Remote Telemetry Monitoring: Supporting Clinical Care and Clinical Leaders with a Simplified Operating Model

Remote Telemetry Monitoring: Supporting Clinical Care and Clinical Leaders with a Simplified Operating Model

Telemetry is widely-used by hospitals and health systems as a means of providing continuous cardiac monitoring for designated patients. While internal development of these programs has been the norm, the ongoing management of these internal programs has absorbed significant resources for many hospitals and hospital systems. As a result, health care organizations are increasingly turning to remote telemetry monitoring (RTM) services in an effort to decrease internal resource burdens while simplifying and enhancing care delivery. Marcia Murphy, Vice President of Clinical Operations and Nursing for Advanced ICU Care, sits down with to discuss this developing trend.

How have hospitals traditionally addressed cardiac monitoring in house?

In-patient cardiac monitoring is often relied upon by hospital bedside teams as a means of continuously evaluating hospital patients with certain medical conditions, those with cardiac-related co-morbidities, and individuals on specific medications who require that extra layer of observation. This monitoring is frequently provided to patients throughout the facility and is rarely restricted to a cardiac unit. Traditionally, a high-quality in-house program relies on trained technicians or nurses who are responsible for the real-time monitoring and interpretation of patient cardiac data transmitted via waveforms and the engagement of additional clinical personnel when changes or abnormalities are noted. In some instances, hospitals use an on-unit approach, while others use a centralized facility-specific approach. Both approaches can eat up significant management time and can create a wide range of clinical and administrative inefficiencies.

What are the potential limitations of such an in-house approach?

Launching and maintaining an on-site telemetry program is neither simple nor self-sustaining. Rather, programs can often pose a significant burden to clinical leadership who are more accustomed to supervising clinicians at the bedside than monitoring teams in a “clinical bunker”.  On-going management, supervision, and 24/7 staffing of the telemetry program includes continuous recruitment efforts, periodic training, and detailed direct management of an hourly workforce. In the case of an on-unit approach in which dedicated telemetry technicians are not assigned, the time available for continuous monitoring can vary and therefore the quality and consistency of monitoring can fluctuate. For example, nurses tasked with bedside patient responsibilities as well as telemetry monitoring can be inundated with perpetual tugs on their time, forcing difficult decisions regarding exactly where their bandwidth is best spent.

What does a remote telemetry monitoring model look like versus a build your own approach?

I feel that implemented appropriately, RTM delivers both the enhanced clinical benefits associated with a specifically trained and focused monitoring team as well as the elimination of the bulk of related administrative costs and headaches.  In addition, RTM can free up both budgeted headcount and space in the hospital.

With a partnered telemetry model, hospitals benefit from the same 24/7 continuous cardiac monitoring by certified technicians or nurses that one would expect in an in-house program. Utilizing telemetry monitoring systems that allow for remote patient observation, trained personnel can monitor hospitalized patients’ cardiac functions, review alerts and when necessary collaborate with bedside care teams to assess patients that require clinical attention. In these instances, recruiting, hiring, training, and productivity management for the monitoring personnel are all off-loaded to the selected clinical services partner.

Rather than working to sustain a fully staffed and well-managed telemetry program, a partnered solution allows hospital leadership to focus on clinical improvements and allows nurses to attend to patient care rather than the constant monitoring alerts. Further, working with a telemetry partner enables an on-demand monitoring resource supply that flexes based on a hospital’s census and patient risk profile. This approach assures that cardiac care is not constrained by staffing unavailability and, conversely, the risk of costly overstaffing and operational inefficiencies due to mis-estimated patient census expectations.

How have care teams traditionally reacted to the adoption of a RTM solution?

In my experience with Advanced ICU Care since we introduced our RTM services, client acceptance has generally been very positive. As with any change, the disruption of the status quo needs to be thought through and managed in advance. What I think is key to the success of our telemetry partnerships is building collaboration and ensuring that bedside nursing teams know what to expect and understand both the programmatic and personal benefits that come with such a program. In selecting an RTM solution, it is important for the bedside leadership team to screen for a partner that listens well and is focused on appropriate collaboration.

I also think it’s important to reinforce the fact that the bedside nurse’s voice ultimately leads on all care-related decisions. RTM is a supportive function intended to allow bedside nurses to focus on the treatment of their individual patients more closely which should be viewed as a positive benefit. Just as with any introduction of new methods or processes into the delivery of patient care, there will be a smoother implementation and improved synergy among stakeholders with proper communication that reinforces how the telemetry process adds additional support for the bedside care team.

How does remote telemetry monitoring lessen the resource burden on care teams?

At the end of the day the primary goal of telemetry monitoring is to ensure that hospitals and health systems are offering outstanding care 24/7 to some of their most at-risk patients throughout the facility. With RTM dedicated remote telemetry technicians make this possible by allowing bedside care teams to make care and treatment for patients with urgent needs their top priority. This is accomplished by removing the distraction of the bedside caregiver’s valuable time driven by simultaneously managing all cardiac monitor alarms. Having all readings monitored in a central place around the clock allows bedside nurses to be more focused on their patients and their care delivery and diminishes false alarms and the alarm fatigue frequently experienced on units outfitted with telemetry infrastructure. These high-quality, remote telemetry programs include trained telemetry technicians that provide real-time interpretation and immediate notification to the appropriate nurse or physician. Ultimately, remote telemetry monitoring allows a nursing staff to focus on our number one goal: providing the very best possible patient care.

Breaking IN to Correctional Healthcare

Breaking IN to Correctional Healthcare

Part One of a Three-Part Series

A career in correctional nursing could challenge your preconceptions.

When asked by others about my career, I typically respond by stating that I am a medical recruiter for correctional and detention facilities. After the initial confusion wears off, I am then faced with numerous questions such as, “What is it like working in a prison and is it safe,” or “I never knew there was a medical department in a prison!” Explaining what I do to those who have never worked in correctional healthcare can be quite challenging.

Prior to starting my corrections career in 2009, I asked some of those same questions. I was hired as a Human Resources Manager for a new prison and was responsible for the recruitment and hiring of more than 400 positions.  The positions involved areas such as security, academic and vocational instructors, faith-based programs, substance abuse and mental health counselors, and multiple other healthcare positions. At that point in my career, I was unaware of the resources available to inmates in support of their rehabilitation, treatment and education.  These were tools that could provide them hope and prepare them to be successful upon release.

In correctional healthcare there are many opportunities to provide a helping hand, but the benefits of that help extend beyond just the recipient. Correctional nurses find this field very gratifying because of the immediate impact they can have on an inmates’ health. Our nurses are able to educate and inspire inmates to make positive changes to their health because for some the treatment received at a facility is the first medical care they have received in some time.  For this reason, inmates are appreciative of the care and have a high respect for the nursing staff.

Correctional nursing is not for everyone, but those that venture into this field discover just how fulfilling it can be and that they could not imagine doing anything else. I recently spoke to some of my nursing colleagues about their experiences.  It was gratifying to hear statements such as, “We work side by side with security to meet our daily medical goals and take care of our patients;” “There’s always a new experience each day and it’s never boring;” and “We’re able to continually learn and enhance our skills and gain new ones that help us in overcoming obstacles.” Hearing this it dawned on me that although the correctional environment is unique, our goal as medical professionals is the same – to provide a high level of patient care to those entrusted to us.

As a medical recruiter in the correctional healthcare industry, I am aware of the challenges we face in finding the right candidate to fill a need. Therefore, I keep the following in mind:

WE start with one person to help make a change, WE treat others as WE want to be treated, WE show kindness and compassion toward others, WE expand on someone’s strengths instead of their weaknesses, WE educate and teach those who crave personal growth and WE celebrate when someone overcomes hardships and finds success.

Correctional healthcare upholds these beliefs by providing a healthy foundation for our inmates and the surrounding community. To correctional medical staff, these characteristics are a way of life “behind the gate.” It’s not about just showing up to get a job done, it’s about fulfilling a purpose and making a difference to those around you!

Tune in for Sherry Cameron’s podcast with Andrew Bennie – available on Spotify starting November 5th!

Working as a Certified Pediatric Emergency Nurse

Working as a Certified Pediatric Emergency Nurse

The nursing field is filled with various specialties. And that’s a good thing, as while working in emergency would be too stressful for one nurse, it is the perfect fit for another.

Cara J. Szeglin, BSN, RN, CPEN, a Clinical Ladder III Staff Nurse at NewYork-Presbyterian Morgan Stanley Children’s Hospital, is one of these nurses who thrives working with emergency patients. She took time from her schedule to answer our questions about what it’s like to work as a Certified Pediatric Emergency Nurse (CPEN).

How long have you been a CPEN? What drew you to get that certification?

Cara with BCEN Board of Directors Chairperson-Elect Kyle Madigan, MSN, RN, CEN, CFRN, CTRN, CCRN, CMTE right after she received BCEN’s 2019 Distinguished CPEN Award
(Photo courtesy of Brian McCarthy)

I became CPEN-certified in November 2014. By this point, I had been an emergency nurse for about seven years. The first year was with only adult patients, the next two years with adult and pediatric patients, and the last four years were solely pediatric emergency patients. 

When I applied to sit for the CPEN, I had reached a point in my career where I felt like my education and pediatric emergency experience were enough for me to be ready. The Board of Certification for Emergency Nursing (BCEN) recommends nurses have two years of practice in their specialty. Passing BCEN’s Certified Pediatric Emergency Nurse (CPEN) examination proved to myself, my place of employment, and to my patients that I was indeed an expert in my field.     

Why do you enjoy working as a CPEN?

I absolutely love working in pediatric emergency care as a CPEN. I still cannot believe I get to do my job because it is just so much fun. The pediatric patients are great, the parents and guardians are grateful, and my co-workers are amazing. 

Some of the greatest moments I have as a Certified Pediatric Emergency Nurse are when a patient comes in sick or injured, and their guardians and the patient can be confused, worried, upset, and experiencing a host of other emotions, and as a CPEN, I’m able to anticipate what the plan of care should be and I know how to tell them what’s happening and what to expect in a way they will understand. You know by their questions if they understand or if they need you try to explain it another way. I always tell them it is all right to ask questions — as many as they like — and as a CPEN, I feel confident I know the answers or know how to get them and explain them.

The biggest thing about being a CPEN is that you have gained their trust because you are an expert professional who is going to give their loved one the very best care.

What are some of the biggest challenges to being a CPEN?

I have known some extraordinary pediatric emergency nurses who just needed a motivating nudge to get their nerve up to take the exam and get board certified. When I first started nursing and heard about the CPEN, I thought “Those are the elite people. I want to be them one day.” And then when I passed the exam, I said “What took me so long?”

What are some of the greatest rewards?

As a CPEN, I’m part of the care plan for my patients. Before I became a CPEN, fully understanding the rationale of why providers were requesting what they were ordering and engaging with the whole team had really been a challenge for me. Earning the CPEN has helped me find my voice and offer suggestions instead of just accepting all orders as they are. I love being able to constructively question the providers and asking for rationales.

Being a CPEN has boosted my confidence — I am a valued member of the care team who needs to know what is going on and why and whose voice needs to be considered when the care plan is being discussed. This also means I’m better able to ensure that my patients and their families know what the plan is and understand why. 

If nurses reading this are interested in becoming CPENs, what would you say to them?

The CPEN is for nurses who want to demonstrate their expertise in treating infants and children in emergency settings. The exam covers the most common pediatric illnesses and clinical issues of all kinds, including trauma, respiratory and cardiac issues, plus less common things that you still need to know because you never know what might come through your doors. The BCEN website contains all the information you need to apply for the exam, how to schedule a test date (which you can do all over the country throughout the year), plus a lot of helpful resources. 

I studied for the CPEN exam just as hard or probably even harder than I had for the nursing boards. A key part was scheduling a test date along with a pediatric emergency nursing friend of mine — so there was no backing out. We studied together, supported each other, and passed on the same day together! Each of us study and learn in different ways.

What else is important for readers to know?

There are so many good things, rewarding things about being a nurse, especially pediatric emergency care. There are days when everything seemed to go so smoothly and you excelled at everything you did. And then there are the days when something came through the doors totally unexpected, and you only hope you can hold it together until the end of your long shift so you can cry about it on the way home. The same can be said for all specialties of nursing. But you pull it together and show up for work the next shift, with the same level of care, dedication, and enthusiasm because being a nurse is the best career

I love being a CPEN, and I hope that readers can feel my passion and get motivated to become certified themselves, and if they are already certified, I hope that this inspires them to seek out other nurses and start being a mentor for them!

Shared Decision Making Q&A

Shared Decision Making Q&A

Shared Decision Making (SDM) is a client-centered health care model in which clients are active participants in their own medical care and their own health.1,2 With the support of the health care provider (HCP), who gives adequate and accurate information when engaging with the client, the client can make better informed decisions based on his or her issues, goals, preferences, values and treatment options. The client and HCP maintain open and respectful dialogue with each other in order to improve clinical care and health outcomes for the patient.1,2,3,4

Drs. Nicole Lassiter, Amy Marowitz, Jane Houston, and Megan Garland offer insight on the Shared Decision Making model and the health care provider and client relationship.

Q: Are there any guidelines for HCPs? 

A: There are many. For example, the Agency for Healthcare Research and Quality provides the SHARE approach.5 A humanistic approach to communication is also encouraged, whereby the HCP sincerely strives to convey compassion, and empathy with the client.6

Q: What are three basic components of SDM?

A: Collaboration between provider and client, education on care options based on the evidence, and incorporation of the client’s values and preferences in the collaborative process.1,2,3

Q: What is the HCP’s role in making medically indicated recommendations in the SDM model? 

A: When there is clear evidence that one care option would result in better outcomes, it is the HCP’s duty to explain such recommendations. This is often referred to as “directive counseling,” which is an integral component of informed consent. “Directive counseling” is not forced or coercive. When multiple, reasonable options seem equivalent in terms of outcomes, the HCP should offer those reasonable options.7

Q: What are some risks of strained communication between the HCP and the client? 

A: Strained communication between the client and HCP may arise when the client refuses or decides against a recommended treatment, or chooses a treatment not recommended.7 The evidence indicates that poor communication between client and HCP can lead to suboptimal clinical care and poor health care outcomes. Thus, striving to maintain a respectful, supportive relationship with the client improves clinical care and improved health care outcomes.3,4,7

Q: What if the evidence and the HCP’s clinical experience strongly support the recommendation, then shouldn’t the HCP do everything reasonable to lead the client to that choice? 

A:  When the HCP believes that the choice will help the client and decrease risks, it is essential that the HCP make strong recommendations and provide necessary information for the client to understand the risks and benefits. Yet, it is ultimately the client’s decision.2,7 It is the HCP’s duty to continue to provide informative, respectful, professional care. According to current professional guidelines, true SDM and informed consent must still occur when an adult client, who is capable of making a decision, maintains the right to make their own decisions about their own health.2,7

Q: Are there ever any situations in which coercion is acceptable? 

A: No. The HCP should not coerce, threaten, or force the client.2,7

Q: Isn’t the HCP at legal and professional risk if the client refuses a recommended treatment or intervention? 

A: Without attempting to provide legal advice, it seems reasonable that if the client is not incapacitated, it is the HCP’s duty to recognize the client as an autonomous individual. When an honest, trusting, and supportive relationship is maintained with the client, much literature indicates that this may reduce litigious situations.2,3,7

Q: How should the HCP collaborate with a client who is refusing a medically indicated treatment?

A: The HCP should strive to sincerely listen to and take into consideration the following: The client’s concerns, life experience, history, thoughts and feelings, and her value system.1,2,3,7 The HCP should also integrate the strength of the evidence, the level of maternal and fetal risk, the acuteness of the situation, and the client’s level of understanding of the factors. Under these circumstances, the HCP’s efforts to give the best result will hopefully have maximum chance of success.2,7

Q: What if an adverse outcome occurs after client refusal of a recommended treatment? 

A: All supportive means should be taken and resources made available for both the HCP and the client including but not limited to debriefing and counseling support.2,7 A contemporaneous record of all the relevant details should be made and carefully preserved. 

Disclaimer: The statements in this blog are not intended to be legal advice.  We also note that laws may be different from state to state.


1. ACNM Position Statement. [ACNM]. (2016, December). Shared decision-making in midwifery care. 

2. Kotaska, A. (2017). Informed consent and refusal in obstetrics: A practical ethical guide. Birth (Berkeley, Calif.), 44(3), 195-199. doi:10.1111/birt.12281 

3. American Congress of Obstetricians and Gynecologists (2019). “Partnering with patients to improve safety.” ACOG Committee Opinion Number 490.

4. ACNM Position Statement. [ACNM]. (2016, February). Creating a culture of safety inmidwifery care. 

5. Agency for Healthcare Research and Quality (2016). The SHARE Approach: Essential steps of shared decisionmaking. AHRQ Pub. No. 14-0026-2-EF.

6. Kunneman, M., Gionfriddo, M. R., Toloza, F. J. K., Gärtner, F. R., Spencer-Bonilla, G., Hargraves, I. G., . . . Montori, V. M. (2019). Humanistic communication in the evaluation of shared decision making: A systematic reviewdoi:

7. American Congress of Obstetricians and Gynecologists (2016). “Refusal of medically indicated treatment during pregnancy.” ACOG Committee Opinion Number 664.

Maximize Your Income as a Travel Nurse: Useful Tips

Maximize Your Income as a Travel Nurse: Useful Tips

My first experience looking for a job as a nurse and attempting to understand compensation variability within the profession was both intimidating and stressful. After graduating from one of the best undergraduate nursing programs in the country, gaining clinical experience from top healthcare facilities and enduring the NCLEX and licensure, I assumed that finding a job would be a fairly straightforward process. Instead, I found myself scouring job boards, Googling for any new grad opportunity I could find, combing through Craigslist and blindly emailing the few contacts I had. 

After a discouraging months-long search, I finally landed an inpatient opportunity as a pediatric nurse, but the experience was so painful that doing it again seemed unthinkable. So two years ago, when I had the opportunity to join the team at Trusted Health and to help other nurses avoid a similar ordeal, I jumped at the chance. 

Today, along with a team of Nurse Advocates, I help nurses find new opportunities, maximize their income, and ultimately, build their careers. After helping hundreds of nurses navigate the job market, I’ve discovered a variety of strategies for any nurse looking to understand how they can grow their skills and increase their earning potential… all things I wish I’d had known at the outset of my career! Read on for three of my top tips.  

Experiment with different income streams

One of the tactics I often recommend to the nurses who are looking to maximize their earning potential is to combine different types of opportunities, such as a per diem and a part-time role or travel nursing contract. While many nurses are familiar with this concept, most have questions about how to make it work on a practical level. 

The key is to find a per diem role that offers maximum flexibility. If you’re restricted by a specific shift or weekend requirement, it’s likely going to be tricky to make both work. But, if you only need to work one to two days per month and are able to plan ahead, you can easily schedule around a part-time or travel position which may not be as flexible. 

While combining two types of clinical opportunities, such as per diem and travel nursing, can be a great financial decision, it’s important not to overdo it. Be sure to consider the proximity of the two roles and how that will affect your ability to balance both and have downtime in-between shifts. I also encourage nurses to schedule time off or a vacation in between opportunities — particularly if they are working in two similar care  settings — to avoid burnout. 

Understand the salary landscape

The nursing industry suffers from a serious lack of transparency when it comes to compensation, especially for travel opportunities. Compensation information is often obscure and can vary by agency, plus most recruiters can only speak to the compensation trends across their open roles. Given how great the variances are geographically, by specialty, and care setting, it’s important to do your research. One great resource is a recent report from Trusted, which provides a comprehensive look at the salary landscape for travel nurses. 

Some of the findings are what you might expect: cities like San Francisco, New York and Los Angeles lead in terms of pay, but there are nuances. While that big paycheck may not stretch very far in SF and NYC once you factor in cost of living, LA actually offers a pretty good bang for your buck. In fact, the average gross weekly pay for travel nurses in LA is 60% higher than the average for local residents. 

St. Louis also emerged as a place where travel nurse salaries really stretch. While St. Louis might not top many nurses’ wish lists the same way that California or Hawaii often do, it has the advantage of its central location. So in addition to its low cost of living, it also may be a place you could potentially commute to for travel shifts while maintaining a per diem role elsewhere. 

In general, I always encourage travel nurses to keep their minds open to locations that not be as obviously appealing. Rural or less-populated states often have a need for travel nurses that outstrips their supply, and as a result, are willing to pay top dollar. Alaska and South Dakota, for example, rank among the top five states in terms of pay, offering 9 and 6 percent above the national average respectively. It’s also worth noting that less obvious choices can sometimes make for surprisingly fun places to live. I frequently hear anecdotes from nurses who go to small towns with low expectations, only to find that they really enjoy the setting and lifestyle. 

Embrace the art of negotiation 

Broadly speaking, the characteristics that make a good nurse — selflessness, empathy and putting the needs of others first — are antithetical to negotiating savvy. It’s also not a skill taught in most nursing programs. As a result, it can feel taboo to nurses to have hard conversations about money.  Fortunately, being informed can be just as effective as possessing those natural negotiating skills.

When you find a travel role you’re interested in, do your diligence to understand what compensation you should expect and whether it’s being offered by multiple agencies.  Compensation and contract terms can often vary widely. To make an informed decision about the role, it’s important to understand the complete compensation package, which, in addition to salary, includes stipends and reimbursements.

While most of us don’t choose nursing for the money, that doesn’t mean you shouldn’t go after the pay you deserve. I know firsthand that travel nurses can be some of the hardest working and most experienced professionals in healthcare, and I hope these insights are helpful for anyone looking for ways to maximize their income!

 Another important variable? Understanding how the length of your contract impacts your compensation. While longer contracts should generally mean higher compensation, it is important to find out if there is the possibility of an extension bonus. Even if you plan to stay for a longer period of time, it might benefit you  to sign an initial contract first and later extend. And if an employer isn’t willing or able to budge on compensation, see if you can stipulate that your hours are guaranteed in your contract, thereby ensuring that your salary doesn’t vary if you’re called off shifts.

Sarah Gray is the Founding Clinician at Trusted Health, the career platform for the modern nurse. She is a graduate of the University of Pennsylvania’s Nursing School and began her nursing career at UCSF Benioff Children’s Hospital. Prior to moving away from the bedside, she was a Clinical Nurse III and an Evidence Based Practice Fellow, and served on multiple hospital-wide committee boards. At Trusted, she utilizes her clinical insight and passion for innovation to change how nurses manage their careers and solve for inefficiencies within healthcare staffing.

5 Characteristics A Nurse Entrepreneur Should Have

5 Characteristics A Nurse Entrepreneur Should Have

Have you noticed that nurse practitioners are becoming more common in this country?

We are providing patients with essential medical services. We, as nurse practitioners, are able to offer diagnostic and treatment services for a wide range of illnesses. While many nurse practitioners might be happy at an office that is run by someone else, there are some who consider becoming an entrepreneur.

Starting your own nurse practitioner practice can be lucrative and gives you an opportunity to help those patients in need, but you should understand what you are getting into. I personally have been providing patients with care at my clinic for many years and the knowledge I have acquired is invaluable. If you are considering becoming a nurse entrepreneur, be sure to learn more about the top characteristics that others in the industry possess. This way, you can do a more thorough analysis of yourself.

1. The Ability To Be In Control

In one scientific publication, it was found that one of the most important traits for a nurse entrepreneur is the ability to be and remain in control over any type of situation. When you become an entrepreneur and start your own nurse practice, you need to be in charge of various aspects all at once. You need to be a leader and have the ability to recognize situations that may spiral out of control quickly – and then take charge to avoid such problems. For me, the ability to act fast and be in control at all times is critical to the success of my practice.

2. The Ability To Analyze A Situation And Know When It’s Okay To Take A Risk

Another critical characteristic lies in your ability to take risks at the right times. There are many risks that have to be taken to succeed in the business world. Understanding how these risks will play out and when it is appropriate to take such a risk is critical. I often find myself taking risks, but only when I am able to understand how my decisions might play out.

3. A Need For Achievement

You should have a desire for achievement. Once you have established your new office, you need to recognize the fact that there is always room to grow. You should know how to set goals – both short term and long-term goals. You should also know how to continue striving toward those goals, ultimately ensuring a consistency in achievements reached.

4. Innovation

Innovation – the ability to adapt to new things – is a characteristic that is now more critical than ever before in a nurse practitioner. You should be able to adapt to the latest technological advancements that have been made. Plus, you need to be able to accept new changes in the industry and ensure you always have the latest treatments for patients. 

5. Ambiguity Tolerance

Finally, ambiguity tolerance is another characteristic that you definitely need. As a nurse practitioner, there will be times where the result of something you strived for turns out as a disappointment. You should be able to bounce back and avoid thinking negatively about such events.


As a nurse entrepreneur, I have a lot of responsibilities. Understanding what it takes is important. I believe that the characteristics outlined in this post are crucial to nurse practitioners who are looking to take the entrepreneurial route.  

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