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Rapid Response Systems: A Review of the Evidence

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Textbook of Rapid Response Systems

Abstract

Long before the development of the Rapid Response System (RRS) concept, nurses and physicians have been aware that patients rarely deteriorate suddenly. Once practitioners started to ask questions such as “What is happening in the minutes, hours and even days before a patient deteriorates to a cardiorespiratory arrest?” or “Is there something we can do to intervene?” the steps towards creating a new patient safety and quality initiative began. Several studies sought to identify the antecedents to these events and define what might be the most predictive signs and symptoms to watch for. The results of these inquires were then linked to an intervention where a team can be summoned based on these changes in a patient’s condition to attempt to halt the progression to a more severe situation or even an arrest. This idea has matured from the early Medical Emergency Teams (METs) piloted in Australia and the US to more comprehensive and diverse systems that include Rapid Response Teams (RRTs), Critical Care Outreach Teams (CCOTs) and other strategies to bring additional resources to the bedside of a patient developing a critical illness. While this strategy makes intuitive sense and has strong face validity, is it supported by the evidence? Do RRSs improve patient safety and quality of care and are they cost-effective? In this chapter we will review the published literature for RRSs to try and address these questions.

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References

  1. Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence‑Based Medicine. 3rd ed. Edinburgh: Churchhill Livingstone; 2005:169.

    Google Scholar 

  2. Sax FL, Charlson ME. Medical patients at high risk for catastrophic deterioration. Crit Care Med. 1987;15(5):510–515.

    Article  CAS  PubMed  Google Scholar 

  3. Schein RM, Hazday N, Pena M, Robin BH, Sprung CL. Clinical antecedents to in‑hospital cardiopulmonary arrest. Chest. 1990;98(6):1388–1392.

    Article  CAS  PubMed  Google Scholar 

  4. Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrests. JAMA. 1991;265(21):2815–2820.

    Article  CAS  PubMed  Google Scholar 

  5. Daffurn K, Lee A, Hillman KM, Bishop GF, Bauman A. Do nurses know when to summon emergency assistance? Intensive Crit Care Nurs. 1994;10(2):115–120.

    Article  CAS  PubMed  Google Scholar 

  6. Smith AF, Wood J. Can some in‑hospital cardio‑respiratory arrests be prevented? A prospective survey. Resuscitation. 1998;37(3):133–137.

    Article  CAS  PubMed  Google Scholar 

  7. Buist MD, Jarmolowski E, Burton PR, Bernard SA, Waxman BP, Anderson J. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary‑care hospital. Med J Aust. 1999;171(1):22–25.

    CAS  PubMed  Google Scholar 

  8. Hillman KM, Bristow PJ, Chey T, Daffurn K, et al. Antecedents to hospital deaths. Intern Med J. 2001;31(6):343–348.

    Article  CAS  PubMed  Google Scholar 

  9. Hodgetts TJ, Kenward G, Vlachonikolis IG, et al. Incidence, location and reasons for avoidable in‑hospital cardiac arrest in a district general hospital. Resuscitation. 2002;54(2):115–123.

    Article  PubMed  Google Scholar 

  10. Kause J, Smith G, Prytherch D, et al. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia, New Zealand, and the United Kingdom ‑ the ACADEMIA study. Resuscitation. 2004;62(3):275–282.

    Article  PubMed  Google Scholar 

  11. Nurmi J, Harjola VP, Nolan J, Castren M. Observations and warning signs prior to cardiac arrest. Should a medical emergency team intervene earlier? Acta Anaesthesiol Scand. 2005;49(3):702–706.

    Article  CAS  PubMed  Google Scholar 

  12. Hillman K, Bristow PJ, Chey T, et al. Duration of life‑threatening antecedents prior to intensive care admission. Intensive Care Med. 2002;28:1629–1634.

    Article  PubMed  Google Scholar 

  13. Franklin C, Mathew J. Developing strategies to prevent in‑hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22(2):244–247.

    Article  CAS  PubMed  Google Scholar 

  14. McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? J R Coll Physicians Lond. 1999;33(37):255–259.

    CAS  PubMed  Google Scholar 

  15. Goldhill DR, White SA, Sumner A. Physiological values and procedures in the 24 h before ICU admissions from the ward. Anaesthesia. 1999;54(6):529–534.

    Article  CAS  PubMed  Google Scholar 

  16. Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient‑at‑risk team: identifying and managing seriously ill ward patients. Anaesthesia. 1999;54(2):853–860.

    Article  CAS  PubMed  Google Scholar 

  17. Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinically abnormal observations and subsequent in‑hospital mortality: a prospective study. Resuscitation. 2004;62(2):137–141.

    Article  PubMed  Google Scholar 

  18. Santiano N, Young L, Hillman K, et al. Analysis of medical emergency team calls comparing subjective to “objective” call criteria. Resuscitation. 2009;80(1):44–49.

    Article  PubMed  Google Scholar 

  19. Hodgetts TJ, Kenward G, Vlachonikolis IG, Payne S, Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation. 2002;54(2):125–131.

    Article  PubMed  Google Scholar 

  20. Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of a Modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. Br J Anaesth. 2000;84:663P.

    Google Scholar 

  21. Lee A, Bishop G, Hillman K, Daffurn K. The medical emergency team. Anaesth Intensive Care. 1995;23:183–186.

    CAS  PubMed  Google Scholar 

  22. Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care. 1997;8:100.

    Google Scholar 

  23. Goldhill DR, McNarry AF. Physiological abnormalities in early warning scores are related to mortality in adult in‑patients. Br J Anaesth. 2004;92(6):882–884.

    Article  CAS  PubMed  Google Scholar 

  24. Goldhill DR, McNarry AF, Mandersloot G, McGinley A. A physiologically‑based early warning score for ward patients: the association between score and outcome. Anaesthesia. 2005;60(6):547–553.

    Article  CAS  PubMed  Google Scholar 

  25. Sharpley JT, Holden JC. Introducing an early warning scoring system in a district general hospital. Nurs Crit Care. 2004;9:98–103.

    Article  PubMed  Google Scholar 

  26. Gardner‑Thorpe J, Love N, Wrightson J, Walsh S, Keeling N. The value of Modified Early Warning Score (MEWS) in surgical in‑patients: a prospective observational study. Ann R Coll Surg Engl. 2006;88:571–575.

    Article  CAS  PubMed  Google Scholar 

  27. Harrison GA, Jacques T, McLaws ML, Kilborn G. Combinations of early signs of critical illness predict in‑hospital death ‑ the SOCCER study (signs of critical conditions and emergency responses). Resuscitation. 2006;71:327–334.

    Article  PubMed  Google Scholar 

  28. Jacques T, Harrison GA, McLaws ML, Kilborn G. Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting. Resuscitation. 2006;69:175–183.

    Article  PubMed  Google Scholar 

  29. Subbe CP, Hibbs R, Williams E, Rutherford P, Gemmel L. ASSIST: a screening tool for critically ill patients on general medical wards. Intensive Care Med. 2002;28(Suppl 1):S21.

    Google Scholar 

  30. Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. Q J Med. 2001;94(10):521–526.

    CAS  Google Scholar 

  31. Subbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of introducing the Modified Early Warning score on clinical outcomes, cardio‑pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia. 2003;58(8):797–802.

    Article  CAS  PubMed  Google Scholar 

  32. Haines C, Perrott M, Weir P. Promoting care for acutely ill children. Development and evaluation of a pediatric early warning tool. Intensive Crit Care Nurs. 2006;22(2):73–81.

    Article  PubMed  Google Scholar 

  33. Monaghan A. Detecting and managing deterioration in children. Paediatr Nurs. 2005;17(1):32–35.

    PubMed  Google Scholar 

  34. Duncan H, Hutchison J, Parshuram CS. The pediatric early warning system score: a severity of illness score to predict urgent medical need in hospitalised children. J Crit Care. 2006;21(13):271–279.

    Article  PubMed  Google Scholar 

  35. Subbe CP, Gao H, Harrison DA. Reproducibility of physiological track‑and‑trigger warning systems for identifying at‑risk patients on the ward. Intensive Care Med. 2007;33(4):619–624.

    Article  PubMed  Google Scholar 

  36. Polderman K, Christiaans HMT, Wester JP, Spijkstra JJ, Girbes ARJ. Intra‑observer variability in APACHE II scoring. Intensive Care Med. 2001;27(9):1550–1552.

    Article  CAS  PubMed  Google Scholar 

  37. Gao H, McDonnell A, Harrison DA, Moore T, et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at‑risk patients on the ward. Intensive Care Med. 2007;33(4):667–679.

    Article  PubMed  Google Scholar 

  38. Bell MB, Konrad D, Granath F, Ekbom A, Martling CR. Prevalence and sensitivity of MET‑criteria in a Scandinavian university hospital. Resuscitation. 2006;70(1):66–73.

    Article  PubMed  Google Scholar 

  39. Cretikos M, Chen J, Hillman K, Bellomo R, Finfer S, Flabouris A. MERIT study investigators. The objective medical emergency team activation criteria: a case‑control study. Resuscitation. 2007;73(1):62–72.

    Article  PubMed  Google Scholar 

  40. Smith GB, Prytherch DR, Schmidt PE, Featherstone PI, Higgins B. A review, and performance evaluation, of single‑parameter “track and trigger” systems. Resuscitation. 2008;79(1):11–21.

    Article  PubMed  Google Scholar 

  41. Smith GB, Prytherch DR, Schmidt PE, Featherstone PI. Review and performance evaluation of aggregate weighted “track and trigger” systems. Resuscitation. 2008;77(2):170–179.

    Article  PubMed  Google Scholar 

  42. Smith GB, Prytherch DR, Schmidt P, Featherstone PI, et al. Hospital‑wide physiological surveillance. A new approach to the early identification and management of the sick patient. Resuscitation. 2006;71(1):19–28.

    Article  PubMed  Google Scholar 

  43. Watkinson PJ, Barber VS, Price JD, Hann A, et al. A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients. Anaesthesia. 2006;61(11):1031–1039.

    Article  CAS  PubMed  Google Scholar 

  44. Tarassenko L, Hann A, Young D. Integrated monitoring and analysis for early warning of patient deterioration. Br J Anaesth. 2006;97(1):64–68.

    Article  CAS  PubMed  Google Scholar 

  45. Hunt EA, Zimmer KP, Rinke ML, et al. Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children’s center. Arch Pediatr Adolesc Med. 2008;162(2):117–122.

    Article  PubMed  Google Scholar 

  46. Jones D, Bates S, Warrillow S, Goldsmith D, et al. Effect of an education programme on the utilization of a medical emergency team in a teaching hospital. Intern Med J. 2006;36(4):231–236.

    Article  CAS  PubMed  Google Scholar 

  47. DeVita MA, Schaefer J, Lutz J, Wang H, Dongilli T. Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Qual Saf Health Care. 2005;14(5):326–331.

    Article  CAS  PubMed  Google Scholar 

  48. Wallin CJ, Meurling L, Hedman L, Hedegård J, Felländer‑Tsai L. Target‑focused medical emergency team training using a human patient simulator: effects on behaviour and attitude. Med Educ. 2007;41(2):173–180.

    Article  PubMed  Google Scholar 

  49. Cretikos MA, Chen A, Hillman KM, Bellomo R, Finfer S, Flabouris A. MERIT Study Investigators. The effectiveness of implementation of the medical emergency team (MET) system and factors associated with use during the MERIT study. Crit Care Resusc. 2007;9(2):205–212.

    Google Scholar 

  50. Buist M, Bellomo R. MET. The emergency medical team or the medical education team? Crit Care Resusc. 2004;6:88–91.

    CAS  PubMed  Google Scholar 

  51. MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a cluster‑randomised controlled trial. Lancet. 2005;365(9477):2091–2097.

    Article  Google Scholar 

  52. Priestley G, Watson W, Rashidian A, et al. Introducing critical care outreach: a ward‑ randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004;30(7):1398–1404.

    Article  PubMed  Google Scholar 

  53. Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009;37(1):148–153.

    Article  PubMed  Google Scholar 

  54. Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S. Pronovost PJl. Rapid response systems: a systematic review. Crit Care Med. 2007;35(5):1238–1243.

    Article  PubMed  Google Scholar 

  55. McGaughey J, Alderdice F, Fowler R, Kapila A, et al. Outreach and Early Warning System (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev. 2007;18:CD00552.

    Google Scholar 

  56. Ranji SR, Auerbach AD, Hurd CJ, O’Rourke K, Shojania KG. Effects of rapid response systems on clinical outcomes: systematic review and meta‑analysis. J Hosp Med. 2007;2(6):422–432.

    Article  PubMed  Google Scholar 

  57. Bellomo R, Goldsmith D, Uchino S, et al. A prospective before‑and‑after trial of a medical emergency team. Med J Aust. 2003;179(6):283–287.

    PubMed  Google Scholar 

  58. Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32(4):916–921.

    Article  PubMed  Google Scholar 

  59. Jones D, Bellomo R, Bates S, et al. Long‑term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care. 2005;9(6):R808–815.

    Article  PubMed  Google Scholar 

  60. Jones D, Opdam H, Egi M, et al. Long‑term effect of a medical emergency team on mortality in a teaching hospital. Resuscitation. 2007;74(2):235–241.

    Article  PubMed  Google Scholar 

  61. Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002;324(7334):387–390.

    Article  PubMed  Google Scholar 

  62. Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. Hospital‑wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008;300(21):2506–2513.

    Article  CAS  PubMed  Google Scholar 

  63. Bristow PJ, Hillman KM, Chey T, et al. Rates of in‑hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust. 2000;173(5):236–240.

    CAS  PubMed  Google Scholar 

  64. Kenwood G, Castle N, Hodgetts T, Shaikh L. Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004;61(3):257–263.

    Article  Google Scholar 

  65. DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004;13(4):251–254.

    Article  CAS  PubMed  Google Scholar 

  66. Jolley J, Bendyk H, Holaday B, Lombardozzi KAK, Harmon C. Rapid response teams: do they make a difference? Dimens Crit Care Nurs. 2007;26(6):253–260.

    Article  PubMed  Google Scholar 

  67. Dacey MJ, Mirza ER, Wilcox V, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007;35(9):2076–2082.

    Article  PubMed  Google Scholar 

  68. Garcea G, Thomasset S, McClelland L, Leslie A, Berry DP. Impact of a critical care outreach team on critical care readmissions and mortality. Acta Anaesthesiol Scand. 2004;48(9):1096–1100.

    Article  CAS  PubMed  Google Scholar 

  69. Tibballs J, Kinney S, Duke T, Oakely E, Hennessy M. Reduction of pediatric in‑patient cardiac arrest and death with a medical emergency team: preliminary results. Arch Dis Child. 2005;90(11):1148–1152.

    Article  CAS  PubMed  Google Scholar 

  70. Tibballs J, Kinney S. Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team. Pediatr Crit Care Med. 2009;10(3):306–312.

    Article  PubMed  Google Scholar 

  71. Brilli RJ, Gibson R, Luria JW, et al. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med. 2007;8(3):236–246.

    Article  PubMed  Google Scholar 

  72. Sharek PJ, Parast M, Leong K, et al. Effect of a rapid response team on hospital‑wide mortality and code rates outside the ICU in a children’s hospital. JAMA. 2007;298(19):2267–2274.

    Article  CAS  PubMed  Google Scholar 

  73. Zenker P, Schlesinger A, Hauck M, et al. Implementation and impact of a rapid response team in a children’s hospital. Joint Comm J Qual Saf. 2007;33(7):418–425.

    Google Scholar 

  74. Buist M, Harrison J, Abaloz E, Van Dyke S. Six‑year audit of cardiac arrests and medical emergency team calls in an Australian teaching hospital. BMJ. 2007;335(7631):1210–1212.

    Article  PubMed  Google Scholar 

  75. Jones D, Egi M, Bellomo R, Goldsmith D. Effect of the medical emergency team on long‑term mortality following major surgery. Crit Care. 2007;11(1):R12.

    Article  PubMed  Google Scholar 

  76. Ball C, Kirkby M, Williams S. Effect of the critical care outreach team on patient survival to discharge from hospital and re‑admission to critical care: non‑randomised population based study. BMJ. 2003;327(7422):1014–1016.

    Article  PubMed  Google Scholar 

  77. Leary T, Ridley S. Impact of an outreach team on re‑admissions to a critical care unit. Anaesthesia. 2003;58(4):328–332.

    Article  CAS  PubMed  Google Scholar 

  78. Mailey J, Digiovine B, Baillod D, Gnam G, Jordan J, Rubinfeld I. Reducing hospital standardized mortality rate with early interventions. J Trauma Nurs. 2006;13(4):178–182.

    PubMed  Google Scholar 

  79. Tolchin S, Brush R, Lange P, Bates P, Garbo JJ. Eliminating preventable death at Ascension Health. Joint Comm J Qual Saf. 2007;33(3):145–154.

    Google Scholar 

  80. K Lives Campaign. http://www.ihi.org/IHI/Programs/Campaign/Campaign; 2009 Accessed 05.01.09.

  81. Sebat F, Musthafa AA, Johnson D, et al. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years. Crit Care Med. 2007;35(11):2568–2575.

    Article  PubMed  Google Scholar 

  82. Chen J, Flabouris A, Bellomo R, Hillman K, Finfer S. MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. The Medical Emergency Team System and not‑for‑resuscitation orders: results from the MERIT study. Resuscitation. 2008;79(3):391–397.

    Article  PubMed  Google Scholar 

  83. Jones DA, McIntyre T, Baldwin I, Mercer I, Kattula A, Bellomo R. The medical emergency team and end‑of‑life care: a pilot study. Crit Care Resusc. 2007;9(2):151–156.

    PubMed  Google Scholar 

  84. Jones D, Baldwin I, McIntyre T, et al. Nurse’s attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care. 2006;15(6):427–432.

    Article  CAS  PubMed  Google Scholar 

  85. Galhotra S, Scholle CC, Dew MA, Mininni NC, Clermont G, DeVita MA. Medical emergency teams: a strategy for improving patient care and nursing work environments. J Adv Nurs. 2006;55(2):180–187.

    Article  PubMed  Google Scholar 

  86. Salamonson Y, van Heere B, Everett B, Davison P. Voices from the floor: nurses’ perceptions of the medical emergency team. Intensive Crit Care Nurs. 2006;22(3):138–143.

    Article  PubMed  Google Scholar 

  87. Thomas K, Vanoyen Force M, Rasmussen D, Dodd D, Whildin S. Rapid response team: challenges, solutions, benefits. Crit Care Nurse. 2007;27(1):20–27.

    PubMed  Google Scholar 

  88. Ward WJ. The business case for implementing rapid response teams [power point presentation]. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools Business Case for Implementing RRTs Presentation; 2009 Accessed 05.01.09.

  89. Lanser E. Outcomes and performance measurement. Redefining how healthcare is strategized and delivered. Healthc Exec. 1999;14(4):20–24.

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Departments of Anesthesiology, Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine, Meyer 297 600N Wolfe Street, Baltimore, MD, 21298, USA

    Bradford D. Winters

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  1. Bradford D. Winters
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  2. Julius C. Pham
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Correspondence to Bradford D. Winters .

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Editors and Affiliations

  1. , Department of Critical Care Medicine, University of Pittsburgh Medical Center, Dewey Street 125, Edgewood, 15218-1407, Pennsylvania, USA

    Michael A. DeVita

  2. Liverpool Hospital, Dept. Intensive Care, University of New South Wales, Locked Bag 7103, Liverpool, 1871, New South Wales, Australia

    Ken Hillman

  3. Dept. Intensive Care, Austin and Repatriation Medical Centre, Studley Road, Heidelberg, 3084, Victoria, Australia

    Rinaldo Bellomo

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Winters, B.D., Pham, J.C. (2011). Rapid Response Systems: A Review of the Evidence. In: DeVita, M., Hillman, K., Bellomo, R. (eds) Textbook of Rapid Response Systems. Springer, New York, NY. https://doi.org/10.1007/978-0-387-92853-1_7

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