UHM 2018, Vol. 45, No.

1 – ANALYSIS OF PRESSURE TEST FAILURES IN TAIWAN

Research Report
Analysis of factors related to failure in the pressure test:
a six-year experience in Taiwan
Wei-Shih Tseng, MD 1,2; Man-Yuan Huang, MPH 1; Hui-Chieh Lee, MD 1;
Wen-Shyan Huang MD 1,3; Bor-Hwang Kang, MD 1,4
1 Department of Diving and Hyperbaric Medicine, Zuoying Branch of Kaohsiung Armed Forces General Hospital,
Kaohsiung, Taiwan
2 Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
3 Department of Surgery, Division of Plastic Surgery, Zuoying Branch of Kaohsiung Armed Forces General Hospital,

Kaohsiung, Taiwan
4 Department of Otorhinolaryngology Head & Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung,

Taiwan
CORRESPONDING AUTHOR: Bor-Hwang Kang – bhkang@vghks.gov.tw

_____________________________________________________________________________________________________________________________________________________________________

ABSTRACT
Introduction: The Republic of China Navy instituted the
pressure test as one of the selection tools for diving troops
and submarine crews. We analyzed factors associated with
failure in the pressure test.
Methods: This was a retrospective cohort study designed
to investigate pressure test failure in Navy recruits between
January 2010 and August 2015. The recruits received
pressurization in a hyperbaric chamber to a simulated depth
of 112 feet of seawater (fsw) at a rate of 25 fsw/minute.
Data describing trainee demographics, disease history, causes
and depth of failure, as well as type of injury, were extracted
from case notes and facility databases for statistical analysis.
Results: Of 3,608 trial cohorts, there were 435 failures,
with an overall failure rate of 12.06%. About 95% of these
failure trials were within a simulated depth of 60 fsw. Fifty-
seven (57) failures did not record causes of failure. Among
the other 378 failures, the most commonly identified
causes were ear barotrauma (365 trials, 96.56 %) and sinus
barotrauma (10 trials, 2.65%). Statistical analysis revealed
that recent upper respiratory tract infection, allergic rhinitis,
and cigarette smoking were all significantly associated
with higher incidence of middle ear barotrauma.
Conclusions: Our results suggest that pressure testing
to a depth of 60 fsw is effective in disqualifying personnel
entering diving and submarine service. Recent infection of the
upper respiratory tract, allergic rhinitis and cigarette smoking
are risk factors for middle ear barotrauma, resulting in
failure of the pressure test.
INTRODUCTION
Pressure testing is part of the selection protocol for
trainees entering submarine service in the United States.
The test examines whether a trainee could smoothly
undertake the pressurization process. Failure during
the pressure test is the leading cause for exclusion of
Navy trainees. The most common cause of failure in
these individuals is middle ear barotrauma (MEB) [1].
MEB is a mechanical tissue damage following failure
to equalize middle ear pressure with pressure changes
in the surrounding environment. The middle ear cavity
connects with the nasopharynx via the Eustachian tube
(ET). In clinical hyperbaric oxygen (HBO2) therapy,
a treatment that requires pressurization and admini-
stration of 100% oxygen, some risk factors of ET dys-
function are associated with MEB. These risk factors
include upper respiratory tract infection (URI), allergic
rhinitis, adenoid hypertrophy, smoking tobacco, and
other factors [2-5].
The pressure test has been adopted by the Republic of
China (ROC) Navy for personnel selection and used for
more than four decades in Taiwan. The testing facility
is located in the Zuoying Branch of Kaohsiung Armed
Forces General Hospital within a Navy base in southern
Taiwan. As the main provider of the pressure test for the
ROC Navy, about 600 recruits receive the pressure test
each year at this facility. Here, we report our six-year
experience concerning incidences of test failure, causes
and depth of failure, as well as degree of MEB if present.

_____________________________________________________________________________________________________________________________________________________________

KEYWORDS: navy; pressure test; hyperbaric; middle ear barotrauma

Copyright © 2018 Undersea & Hyperbaric Medical Society, Inc. 33

 UHM 2018, Vol. 45, No. 1 – ANALYSIS OF PRESSURE TEST FAILURES IN TAIWAN
METHODS
Training facility
Pressure testing was conducted in a multiplace hyper-
baric chamber at Zuoying Diving Medical Center,
operated with a simulated depth to 112 feet of seawater
(fsw), with air as the breathing gas.
Medical screening
Recruits enrolling in the pressure test were candidates
of Navy diving or submarine troops. Medical screening
included a physical exam, laboratory tests, self-reported
medical history questionnaire, and a review of personal
history. Prior to testing, each candidate received expla-
nations about the chamber environment, test procedure,
hazards, contraindications to enrollment, emergency
actions to take if needed, and training in middle ear
pressure equalization techniques. The entire medical
record of each candidate was reviewed by diving medi-
cal officers in the Zuoying Diving Medical Center. The
record had to include a report of a normal chest
X-ray within one year.
Pressure test
After informed consent, candidates underwent the
pressure test, pressurized at a rate of 25 fsw/minute, to
reach a simulated depth of 112 fsw. There was a one-
minute stay at 112 fsw, followed by decompression at a
rate of 10 fsw/minute. Candidates were allowed to abort
during the test; those who did want to terminate were
brought out through the transfer chamber. Failure or
disqualification is defined as a candidate withdrawing
from the pressure test for any reason. All can-
didates were examined by otoscope to evaluate
degree of MEB and observed for 10 minutes for any
neurologic signs, pains or other symptoms of decom-
pression sickness/arterial gas embolism.
Data collection and analysis
Results of the pressure test – causes of failure, depth
attained and degree of MEB – were recorded on site.
The modified Teed classification was used for grading
severity (Table 1) [6].
Data, including basic demographic information,
self-reported medical history, pressure test results,
physical exam, and X-ray for each candidate, were
retained in facility databases.
A few of the candidates were females from military
intelligence units. Because of this, their personal iden-
34
__________________________________________________________________________
TABLE 1: The modified Teed classification
of middle ear barotrauma [6]
grade tympanic membrane and middle ear findings
0 normal
1 TM injection or retraction
2 slight hemorrhage in the TM
3 gross hemorrhage in the TM
4 hemotympanum
5 TM perforation
__________________________________________________________________________
TM = tympanic membrane
tification numbers and genders were concealed, and
gender variant was not available for statistical analysis.
Data were expressed as percentages for categorical
variables and mean ± standard deviation (SD) for con-
tinuous variables. Age and body mass index (BMI) were
converted into categorical variables for analysis. Statis-
tical analysis was performed using SPSS software ver-
sion 22 (SPSS Inc., Chicago, Illinois, U.S.). T-tests and
chi-square/Fisher exact tests were used to evaluate the
distributions of continuous and categorical variables,
respectively. Binary logistic regression was used to in-
spect the correlation of risk factors and MEB, and the
results were presented as odds ratios (OR) with 95%
confidence interval (CI). A two-tailed P-value < 0.05
was considered to indicate statistical significance.
RESULTS
Figure 1 is a flowchart of this study. Between January
2010 and August 2015, 3,612 Navy recruits, potential
candidates for diving and submarine units, received
pressure tests. Four subjects self-withdrew from the
test, stating they had no desire to enter the chamber.
Final numbers included 3,608 subjects who underwent
full testing. Of these 3,173 subjects passed the pres-
sure test; 435 failed, with a total failure rate 12.06%.
Characteristics of the subjects are shown in Table 2.
The average age was 23 ± 4 (range 17-47), with the
20-29 age group being the most numerous. The disquali-
fied rate was lowest in the 40-49 age group (8.7%) and
highest among the age group of < 20 (13.97%). However,
the difference was not statistically significant. Average
BMI was 23.0 ± 2.7 kg/m2 (range 14.7-34.7), with the
majority of candidates having normal BMI (18.5 ≤
BMI <24). The disqualified rate ranged from 11.57% in
the normal BMI group to 16.42% in the underweight
group. The difference was not statistically significant.
Tseng W-S, Huang M-Y, Lee H-C, et al.
 UHM 2018, Vol. 45, No. 1 – ANALYSIS OF PRESSURE TEST FAILURES IN TAIWAN

___________________________________________________________________________________________________________________________________________________________

FIGURE 1. Flowchart of the present study. See text for detail.

analysis of factors related to failure in the pressure test:

a six-year experience in Taiwan
(N = 3,612 subjects)

exclusion: 4 subjects with no intention

study population for failure of pressure test:

(N = 3,608)

success failure
(N = 3,173) (N = 435)

failure with certain causes 57 subjects excluded with

(N = 378) undocumented causes

middle ear barotrauma sinus barotrauma other causes

(N = 365) (N = 10) (N = 3)

___________________________________________________________________________________________________________________________________________________________

Candidates who smoked cigarettes had a higher failure
rate than those who did not smoke (19.81% vs. 11.58%,
P = 0.001). The subjects with recent upper respiratory
tract infection (URI) had a higher failure rate than those
without URI (26.67% vs. 11.29%, P < 0.001). The data
also showed that candidates with allergic rhinitis had a
higher failure rate than those without (21.63% vs.
11.13%, P < 0.001).
As shown in Table 3, 378 failures had documented
causes of failure. The most commonly identified causes
of failure in the pressure test were MEB (365 subjects,
96.56 %) and sinus barotrauma (10 subjects, 2.65%). Three
failures self-withdrew during the test; two felt discom-
fort psychologically and were presumed to be claustro-
phobic. The other withdrew due to fear of a pressure-
related accident as a result of recent eye surgery, which
was not disclosed to medical officers during review
of his medical history.
Figure 2 shows the cumulative failure rate as a
function of the increase in pressure. About 95%
(349/368) of these failures occurred within a simulated
depth of 60 fsw, which is the current depth used for
the pressure test by the United States Navy [7]. Four
candidates completing the 112-fsw pressure test were
disqualified due to a Grade 4 MEB upon eardrum
inspection.

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 UHM 2018, Vol. 45, No. 1 – ANALYSIS OF PRESSURE TEST FAILURES IN TAIWAN

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TABLE 2: Characteristics of the study subjects

____________________ pressure
variables test ____________________ P-value 3
total qualified disqualified
n n % n %
_______________________________________________________________________________________________________________________________

total 3608 3173 87.94 435 12.06

age, years 1 0.598
(23 ± 4, 17 - 47)
<20 401 345 86.03 56 13.97
20-29 2858 2516 88.03 342 11.97
30-39 150 134 89.33 16 10.67
40-49 23 21 91.30 2 8.70
_______________________________________________________________________________________________________________________________

BMI 2
(23.0 ± 2.7, 14.7 - 34.7) 0.326
<18.5 (underweight) 134 112 83.58 22 16.42
18.5 ≤ BMI <24 (normal) 2195 1941 88.43 254 11.57
24 ≤ BMI <27 (overweight) 835 733 87.78 102 12.22
≥ 27 (obese) 283 244 86.22 39 13.78
_______________________________________________________________________________________________________________________________

cigarette smoking 0.001

with 207 166 80.19 41 19.81
without 3401 3007 88.42 394 11.58
_______________________________________________________________________________________________________________________________

recent URI <0.001

with 180 132 73.33 48 26.67
without 3428 3041 88.71 387 11.29
_______________________________________________________________________________________________________________________________

allergic rhinitis <0.001

with 319 250 78.37 69 21.63
without 3289 2923 88.87 366 11.13
_______________________________________________________________________________________________________________________________

BMI = body mass index; URI = upper respiratory tract infection

1 176 values were missed in the variable of age. 2 in kg/m2, 161 values were missed in the variable of BMI.
3 chi-square test, P < 0.05

__________________________________________________________________________
The degree of MEB was classified by the modified
TABLE 3: Causes of pressure test failure 1
Teed scale, and the results are shown in Table 4. The
subjects %
distributions of each degree of MEB in different depth
middle ear barotrauma 365 96.56
ranges are also shown. A total of 365 subjects reported
sinus barotrauma 10 2.65
ear discomfort. Of these, 317 subjects had documented
other 2 3 0.79
degrees of MEB. Six subjects did not have documented
Total 378 100.00 depth when MEB occurred. More than 85% of these fail-
__________________________________________________________________________

1 57 subjects without failure causes reported.
2 Three persons self-withdrew during the test.
See text for details.
ures (270/317) had Grade 0 or Grade 1 injury. Grade 2,
3 and 4 injuries accounted for 11.04%, 2.52% and 1.26%,
respectively. There was no incidence of ear perfora-
tion, a Grade 5 injury, during the study period. Grade 3
or 4 injury was seen only at depths deeper than 20 fsw.

36 Tseng W-S, Huang M-Y, Lee H-C, et al.

 UHM 2018, Vol. 45, No. 1 – ANALYSIS OF PRESSURE TEST FAILURES IN TAIWAN

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FIGURE 2: Cumulative percentage of failure as a function

of the increase in pressure (the depths in seawater)

cumulative percentage of failure

depth

____________________________________________________________________________________________________________________________

TABLE 4: Modified Teed classification of middle ear barotrauma 1

______________________________________
grade _____________________________________
0 1 2 3 4 5 total
subjects (%)
depth (D, fsw) 133 (41.96) 137 (43.22) 35 (11.04) 8 (2.52) 4 (1.26) 0 (0) 317
____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________
0< D ≤10 58 62 5 0 0 0 125
____________________________________________________________________________________________________________________________
10< D ≤20 42 40 16 0 0 0 98
____________________________________________________________________________________________________________________________
20< D ≤30 9 14 7 1 0 0 31
30< D ≤40 7 8 2 2 0 0 19
____________________________________________________________________________________________________________________________

40< D ≤50 4 4 3 3 0 0 14
____________________________________________________________________________________________________________________________

50< D ≤60 2 3 1 0 0 0 6
____________________________________________________________________________________________________________________________

60< D ≤70 3 2 1 0 0 0 6
____________________________________________________________________________________________________________________________

70< D ≤80 3 0 0 1 0 0 4
____________________________________________________________________________________________________________________________

80< D ≤90 2 0 0 0 0 0 2
____________________________________________________________________________________________________________________________

90< D ≤100 0 1 0 0 0 0 1
____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________
100< D ≤112 1 0 0 0 4 0 5
undocumented 2 3 0 1 0 0 6
____________________________________________________________________________________________________________________________

1 48 subjects did not have documented degree of middle ear barotrauma

Tseng W-S, Huang M-Y, Lee H-C, et al. 37

 UHM 2018, Vol. 45, No. 1 – ANALYSIS OF PRESSURE TEST FAILURES IN TAIWAN
Binary logistic regression was applied to analyzing
factors associated with MEB, as shown in Table 5.
Cigarette smoking (OR = 2.19, 95% CI = 1.51, 3.19,
P < 0.001), recent URI (OR = 2.72, 95% CI = 1.84,
4.03, P < 0.001), and allergic rhinitis (OR = 2.20,
95% CI = 1.60, 3.04, P < 0.001) were significantly cor-
related with higher incidence of MEB.
DISCUSSION
The purpose of this study was to determine the fail-
ure rate, depth and causes of failure, as well as factors
associated with MEB in navy recruits during the pres-
sure test. The main findings showed that there was an
overall test failure rate of 12.06%, with 95% of these
failures occurring at depths equal to or shallower than
60 fsw. The main cause of failure during pressure test
was MEB, and the known risk factors of ET dysfunc-
tion, such as cigarette smoking, recent URI and allergic
rhinitis were associated with higher test failure rate.
O’Donnell et al. [1] reported an 11.23% (321/2859)
failure rate of students ranging in age from 17-59, with
a median age of 22 during the pressure test. We showed
similar findings in the present study, with a 12.06%
(435/3608) failure rate in a group of navy recruits,
ranging from 17-47 years old, with a median age of 23.
During the pressure test, the most common cause of
failure was MEB, which accounted for 86.92% (279/321)
failures reported in a previous study [1] and
96.56% (365/378) in ours.
Recent studies have shown MEB had a wide-ranging
incidence of 8.9%-66.7% in individuals receiving HBO2
therapy [8-11], and most MEB (49.7%-60.2%) occurred
during the first session [9,10,12]. The relatively low
incidence of MEB in our study might be due to the
fact that these recruits were selected candidates for
navy submarine and diving troops and who were
young, with generally good health.
It is controversial as to whether age is a risk factor
for pressure equalization and MEB [8,11-14]. Several
studies reported that age greater than 60 years old was
an independent risk factor of cessation of HBO2 therapy
due to MEB [10,12, 4]. On the other hand, Fitzpatrick,
et al. [13] and Hadanny, et al. [11] found that younger
people (< 40 years in Fitzpatrick’s study and < 16 years
in Hadanny’s study, respectively) were at higher risk of
MEB. Some studies have suggested that females have in-
creased risk for MEB [10,11,13,14]. A prospective study
by Bessereau, et al. [8] reported that age (mean age 37.5 ±
38
__________________________________________________________________________
TABLE 5: Factors associated with middle ear barotrauma 1
______ middle
variables ear barotrauma ______
OR 95%CI P-value
age, years 0.99 0.95 - 1.02 0.347
BMI 1.02 0.98 - 1.06 0.463
cigarette smoking 2.19 1.51 - 3.19 <0.001
URI 2.72 1.84 - 4.03 <0.001
allergic rhinitis 2.20 1.60 - 3.04 <0.001
__________________________________________________________________________
BMI = body mass index; URI = upper respiratory tract infection
1 by binary logistic regression analysis
20.5 years) and female gender did not serve as risk factors
for MEB. In this present study, we found that there was
no association between age and risk of MEB (OR=0.99;
95% CI 0.95 to 1.02; P=0.347). However, because of
our mostly male population and a concentrated age
distribution (17-47 years), there was insufficient data
in our study to determine whether age or gender were
risk factors for MEB.
In the present study, we found that there was no sig-
nificant correlation between BMI and MEB (OR=1.02;
95% CI 0.98 to 1.06; P=0.463). Similar to that of concen-
trated age distribution, 87.9% of our navy recruits had
BMI between 18.5 to 27. BMI lower than 18.5 or greater
than 27 accounted for only 3.9% and 8.2% of the popu-
lation, respectively. The relationship between BMI and
incidence of MEB remains an issue to be determined.
Cigarette smoking, URI and allergic rhinitis are well-
known risk factors of ET dysfunction and MEB [2-5].
In our study, recruits with one or more of the above-
mentioned risk factors had a higher rate of MEB than
those without any risk factor: The odd ratios were all
greater than 2 and were statistically significant. However,
there were no significant differences in the failure
rate between recruits with one risk factor only and
those with two risk factors (data not shown).
The underwater task or submarine escape training
requires compression and decompression processes.
The pressure test serves as a measure mainly to screen
out those unable to equalize middle ear pressure. Ac-
cording to Boyle’s law of physics, the volume of a gas
shrinks proportionally to the increase in pressure. Ear
discomfort or pain may be noted with a descent from
the surface to 6.6 fsw, which causes approximately a 17%
reduction in the middle ear air volume if the ET is ob-
structed [15]. As seen in Figure 2 and Table 4, about 70%
of these failures occurred within 20-fsw limit. Nonethe-
Tseng W-S, Huang M-Y, Lee H-C, et al.
 UHM 2018, Vol. 45, No. 1 – ANALYSIS OF PRESSURE TEST FAILURES IN TAIWAN
less, 30% of failures occurred at deeper depths, which
might reflect that a partially obstructed ET may have
compensated the volume reduction initially but even-
tually failed. This phenomenon suggests that a pressure
test of an appropriate depth is needed to screen out
candidates with poor ability of pressure equalization.
The 112-fsw pressure test for ROC Navy, instituted
in 1975, was adopted from the U.S. Navy. More than
27,000 candidates have been screened since then.
Currently the U.S. Navy uses the 60-fsw pressure test
for submarine crew instead of the 112-fsw test [1,7].
Our present study shows approximately 95% of the
failures in the 112-fsw pressure test occurred at depths
equal to or shallower than 60 fsw. Only 19 (5.0%) candi-
dates failed the test at depths greater than 60 fsw. This
result suggests that the 60-fsw pressure test may be
efficient enough to screen out those not suitable to
participate in diving or submarine service. It should be
noted that four subjects completed the 112-fsw pres-
sure test despite having Grade 4 barotrauma, indicat-
ing some subjects may have higher tolerance for – or be
insensitive to – pain. Further, once middle ear effusion/
hemorrhage occurred, there would be volume compen-
_____________________________________________________________________________________________________________________________________________________________________
REFERENCES
1. O’Donnell SW, Horn WG. Initial review of the U.S. Navy’s
pressurized submarine escape training outcomes. Undersea Hyperb
Med. 2014; 41:33-40.
2. Fernau JL, Hirsch BE, Derkay C, Ramasastry S, Schaefer SE.
Hyperbaric oxygen therapy: effect on middle ear and Eustachian tube
function. Laryngoscope. 1992; 102: 48-52.
3. Miyazawa T, Ueda H, Yanagita N. Eustachian tube function and
middle ear barotrauma associated with extremes in atmospheric
pressure. Ann Otol Rhinol Laryngol. 1996; 105: 887-92.
4. Uzun C. Evaluation of predive parameters related to Eustachian
tube dysfunction for symptomatic middle ear barotrauma in divers.
Otol Neurotol. 2005; 26: 59-64.
5. Seibert JW, Danner CJ. Eustachian tube function and the middle
ear. Otolaryngol Clin North Am. 2006; 39: 1221-1235.
6. Beuerlein M, Nelson RN, Welling DB. Inner and middle ear
hyperbaric oxygen-induced barotrauma. Laryngoscope. 1997; 107:
1350-1356.
7. Navy U. US Navy Diving Manual, Rev 7. Washington, DC:
Department of the Navy. 2016.
8. Bessereau J, Tabah A, Genotelle N, Francais A, Coulange M,
Annane D. Middle-ear barotrauma after hyperbaric oxygen therapy.
Undersea Hyperb Med. 2010; 37: 203-208.
Tseng W-S, Huang M-Y, Lee H-C, et al.
sation by the fluid and less negative pressure to cause
pain. These above observations suggest that it would
not be necessary to bring candidates to deeper than 60
fsw, since very limited screening efficacy could be fur-
ther obtained, and greater danger might be encoun-
tered at deeper depths. Considering the efficacy and
safety of the pressure test, it would seem reasonable to
implement the 60-fsw pressure test for the ROC Navy.
CONCLUSION
Our results suggest that pressure testing to a depth
of 60 fsw is effective in disqualifying personnel who
are entering diving and submarine service. The most
common cause of pressure test failure is MEB. Recent
URI, allergic rhinitis and cigarette smoking are risk
factors for MEB, resulting in failure of the pressure test.
n
Acknowledgments
Supported by Ministry of National Defense-Medical Affairs
Bureau Research Program (MAB-104-102).
Authors declare no conflicts of interest exist
with this submission.
9. Lima MA, Farage L, Cury MC, Bahmad F, Jr. Middle ear
barotrauma after hyperbaric oxygen therapy - the role of insuflation
maneuvers. Int Tinnitus J. 2012; 17: 180-185.
10. Yamamoto Y, Noguchi Y, Enomoto M, Yagishita K, Kitamura K.
Otological complications associated with hyperbaric oxygen therapy.
Eur Arch Otorhinolaryngol. 2016; 273: 2487-2493.
11. Hadanny A, Meir O, Bechor Y, Fishlev G, Bergan J, Efrati S.
The safety of hyperbaric oxygen treatment--retrospective analysis in
2,334 patients. Undersea Hyperb Med. 2016; 43: 113-122.
12. Plafki C, Peters P, Almeling M, Welslau W, Busch R. Complica-
tions and side effects of hyperbaric oxygen therapy. Aviat Space
Environ Med. 2000; 71: 119-124.
13. Fitzpatrick DT, Franck BA, Mason KT, Shannon SG. Risk factors
for symptomatic otic and sinus barotrauma in a multiplace hyper-
baric chamber. Undersea Hyperb Med. 1999; 26: 243-247.
14. Ambiru S, Furuyama N, Aono M, Otsuka H, Suzuki T, Miyazaki M.
Analysis of risk factors associated with complications of hyperbaric
oxygen therapy. J Crit Care. 2008; 23: 295-300.
15. Edmonds C. Ear barotrauma. In: Edmonds C, Bennett M, Lipp-
mann J, Mitchell S, eds. Diving and Subaquatic Medicine.
Boca Raton: CRC Press, 2015: 81-102.
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