MEDIC ST 5016AHO - Human Reproductive Health Part 1
Teaching Hospitals - Semester 1 - 2014
General Course Information
Course Code MEDIC ST 5016AHO Course Human Reproductive Health Part 1 Coordinating Unit Medical School Group Term Semester 1 Level Undergraduate Location/s Teaching Hospitals Contact attachments, common program & research Prerequisites Year 4 MBBS Exam Restrictions Available to MBBS students only Course Description The clinical attachments are a program of clinical education through a selection of placements so that students will be competent in history-taking, patient examination and management. This includes problem formulation, investigations, treatment (pharmacological and non-pharmacological), counselling, good communication skills, the practice of empathetic medicine, and a sound knowledge base that allows diagnosis and management of common disorders to be carried out under appropriate supervision. Some students will have the opportunity to undertake their training for an extended period of time in a rural or remote setting.
Course Coordinator: Associate Professor Paul DugganCourse Coordinator
Name Phone Location Associate Professor Paul Duggan +61 8 8313 7619 email@example.com Women’s and Children’s Hospital
Additional Acacdemic Staff
Name Phone Location Professor Jodie Dodd +61 8 81617619 Jodie.firstname.lastname@example.org Women’s & Children’s Hospital Dr Rosalie Grivell +61 8 81617619 Rosalie.email@example.com Women’s & Children’s Hospital Dr Louise Hull +61 8 81617619 Louise.firstname.lastname@example.org Women’s & Children’s Hospital Professor Ben Mol +61 8 81617619 Ben.email@example.com Women’s & Children’s Hospital & Lyell McEwin Hospital Professor Gus Dekker +61 8 81829306 Gus.firstname.lastname@example.org Lyell McEwin Hospital Dr Alphonse Roex +61 8 81829306 Alphosne.email@example.com Lyell McEwin Hospital Professor Robert Norman +61 8 82224816 Robert.firstname.lastname@example.org Royal Adelaide Hospital
Name Phone Location Jacki Smith +61 8 81617619 Jacki.email@example.com Women’s & Children’s Hospital Mary Paleologos +61 8 81617619 Mary.firstname.lastname@example.org Women’s & Children’s Hospital Kelly Fulton +61 8 8133 2124 Kelly.email@example.com Lyell McEwin Hospital
The full timetable of all activities for this course can be accessed from Course Planner.
Course Learning OutcomesOn successful completion of this course the student will be able to:
1. Demonstrate knowledge of:
1.1. the physiology and pathology of the female reproductive system in childhood, adult life and old age.
1.2. the physiology of pregnancy, parturition and the puerperium and its effect on medical and surgical disorders.
1.3. the diagnosis and management of simple gynaecological disorders and an understanding of the principles and essential features of more complex gynaecological conditions.
1.4. the application of the principles of evidence based medicine in obstetrics and gynaecology
1.5. the epidemiology of the major health and social problems related to obstetrics and gynaecology.
1.6. the embryology, developmental, physiological, biochemical, anatomical, endocrinological, immunological, morphological, pathological and psychological aspects underpinning obstetrics and gynaecology.
1.7. the pharmacology of drugs commonly used during pregnancy and in gynaecology.
1.8. the cultural, legal and social variation in attitudes towards obstetrics and gynaecology.
1.9. the effect of the woman’s social circumstances on pregnancy or a gynaecological condition.
1.10. the effect of drugs (prescribed or other) on pregnancy or gynaecological conditions
2. Demonstrate competence in the performance of:
2.1 an interview that considers the special physical, psychological and social characteristics required to take a full history relevant to human sexuality, obstetrics and gynaecology.
2.2 a physical examination which will take into account the special problems encountered in human sexuality, obstetrics and gynaecology, in order to confirm or refute an hypothesis or diagnosis.
2.3 counselling of a woman, her partner and family about common problems in human sexuality, obstetrics and gynaecology.
2.4 the provision of specific advice to the woman of the arrangements necessary for the woman to be confined in the appropriate setting including referral to a Specialist Obstetrician for further management if risk factors have been identified
2.5 the provision of specific advice to the woman on the potential hazards of drugs to the conceptus.
2.6 the requesting of appropriate laboratory, psychological or social data in order to reach an appropriate diagnosis.
2.7 observation and recording of the progress of labour, delivery and the early puerperium.
2.8 the maintenance of the dignity and privacy of the woman
2.9 the formulation of a plan for care of the patient(s).
University Graduate Attributes
This course will provide students with an opportunity to develop the Graduate Attribute(s) specified below:
University Graduate Attribute Course Learning Outcome(s) Knowledge and understanding of the content and techniques of a chosen discipline at advanced levels that are internationally recognised. All of the above The ability to locate, analyse, evaluate and synthesise information from a wide variety of sources in a planned and timely manner. All of the above An ability to apply effective, creative and innovative solutions, both independently and cooperatively, to current and future problems. All of the above Skills of a high order in interpersonal understanding, teamwork and communication. 2 A proficiency in the appropriate use of contemporary technologies. All of the above A commitment to continuous learning and the capacity to maintain intellectual curiosity throughout life. All of the above An awareness of ethical, social and cultural issues within a global context and their importance in the exercise of professional skills and responsibilities. All of the above
Required ResourcesThere are no required resources. Recommended resources will be advised as appropriate.
Recommended ResourcesGeneral Texts suitable for student purchase
Obstetrics & Gynaecology. An evidence-based guide. Abbott Jason, Bowyer Lucy, Finn Martha. (2nd ed) 2014 Elservier.
Hacker and Moore’s Essentials of Obstetrics and Gynaecology. Hacker, Gambone and Moore. (5th edn). 2010 Saunders Elsevier. ISBN 978 1 4160 5940 0.
A student consult titles with online and print access. Medical student level (USA curriculum).
Obstetrics and Gynaecology Impey and Child. (4th edn) .Wiley-Blackwell 2012. ISBN 978 0 470 65519 1Accompanying website with extra resources. Written for medical students (UK curriculum).
Gynaecology by Ten Teachers. Monga, Ash & Dobbs, Stephen (Ed) (2011) 19th edition, Hodder Arnold UK
Obstetrics by Ten Teachers. Monga, Ash & Dobbs, Stephen (Ed) (2011) 19th edition, Hodder Arnold UK Both books have free web resources.
Essentials of Obstetrics and Gynaecology. O’Reilly, Bottomley and Rymer. (2nd ed), 2012. Saunders Elsevier.
Electronic Based Reference
Cochrane Library - access via http://www.thecochranelibrary.com/view/0/index.html or type “Cochrane Library” in to the library catalogue and follow the links.
Sexual Health Website - www.mshc.org.au
Global Library of Women's Medicine free electronic O & G textbook website at www.glowm.com
Perinatal Practice Guidelines website – http://www.health.sa.gov.au/ppg/
Now also a free app – search app store for “practices guideline reader”. The correct spelling is essential.
LACTMed : http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Online LearningOn line Lectures: http://www.intellilearn.com/
Learning & Teaching Activities
Learning & Teaching ModesThere are numerous teaching and learning methods used, with the emphasis on active learning methods including, but not limited to: case based learning, large group lectures, seminars, tutorials and clinics and other sessions in hospital. There will be self-directed research and/or study, case presentations, and critical analysis.
Attendance at antenatal clinics, conduct of normal labour and delivery and observation of abnormal cases gives insight into the spectrum of common conditions, most of which will be met at some time in practice.
Students’ personal cases and deliveries require detailed observation of antenatal, labour and postnatal care and infant care. Adequate postnatal care includes observation of lactation, involution and the psychological development of the mother-child relationship.
Students are rostered to the labour ward four times during their rotation. These are all day sessions and include weekend and after-hours work. They aim to provide students with the opportunity to conduct spontaneous vaginal deliveries with the help of the midwifery staff in charge.
Students are rostered to attend gynaecological outpatient sessions where there will be the opportunity to take a history and examine outpatients with the Consultant/Registrar attending the Clinic. Students should clerk patients being admitted for elective gynaecological surgery, with the opportunity to attend theatre sessions when a patient they have clerked is having an operation. Students should also attend enough other theatre sessions to ensure a familiarity with the commonly performed gynaecological procedures. The postoperative progress of the patient(s) who have been clerked should be followed and the pathology reports should be examined before discharge
Students will have weekly neonatal tutorials and will also be rostered to follow the neonatal registrar for one morning. It is expected that students will be able to demonstrate skills in the examination of the normal neonate and knowledge of common problems that occur in the neonatal period.
Friday Afternoon Tutorials
Members of the academic and visiting staff will run whole-of-class tutorials in weeks 3-8 in selected topics, between 2:00pm and 5:00pm in the seminar room in the Robinson Institute, 55 King William Rd North Adelaide. The tutorials will be interactive.
Students will be provided with an iPad for use during the 9 weeks of their attachment. iPads have been especially configured for the course. They may also be used to undertake on-line written assessments.
On Line Chapters
A series of on line chapters covering some core topics in Obstetrics and Gynaecology is available through the Intellilearn web site. Students will be automatically enrolled at the beginning of the term and must register with the site.
The site includes optional multi-choice questions based on these topics. There is no restriction on the number of attempts at the MCQ's, which are intended to stimulate students’ thinking about the topics.
eMedici now includes case material and related formative assessment in Obstetrics and Gynaecology.
MyUni course in Human Reproductive Health
Every student is automatically enrolled in the course in Human Reproductive Health in the My Uni web site. This site is under review for 2013 and will predominantly be used for formative on-line and summative on-line assessments.
The information below is provided as a guide to assist students in engaging appropriately with the course requirements.Workload for the individual students will vary from week to week but students can assume that on average they will work a 45 hour week which will include clinic sessions, lectures (both delivered and online), seminars, tutorials and private study. After hours and weekend work may also be required to meet clinical requirements.
Learning Activities SummaryThe thematic structure of the Year 5 MBBS Program will be provided and discussed at the start of the program and is discussed in detail in the student handbook (provided to students on the first day of their rotation). Please note that the following applies only to the metropolitan students undertaking Human Reproductive Health. Students attached to the Discipline of Rural Health undergo separate orientation and clinical learning opportunities.
Week Topic Lecture Week 1 Warm up week Introduction to the course including whole-of-class tutorials covering the basicsand including small group clinical skillssessions. Weeks 2 - 9 Students are allocated to specific hospital-based attachments and have individual learning timetables for the clinical component of the course. On line lectures are available in Intellilearnand additional on line resources areavailable in eMedici and MyUni, includingaccess to on line formative assessments.A separate lecture timetable for Friday afternoon tutorials held in the RobinsonInstitute seminar room will be announced. Week 9 Summative assessment week Assessment of knowledge, reasoning and clinical skills will be undertaken from mid week onwards in week 9.
Specific Course RequirementsAll students will be allocated to Lyell McEwin Hospital or the Women’s and Children’s Hospital in the metropolitan area. Although allocated to one hospital all students should expect to travel to other hospitals (Modbury, The Queen Elizabeth Hospital, Royal Adelaide Hospital) and places for specialty sessions.
All students require a current National Criminal History Record Check for children and vulnerable adults. A Criminal History Check is valid for 3 years and students MUST have the original with them on the first day of term.
All students will be required to do some after-hours and weekend work (see above). Any other requirements will be advised.
Small Group Discovery ExperienceNot applicable
The University's policy on Assessment for Coursework Programs is based on the following four principles:
- Assessment must encourage and reinforce learning.
- Assessment must enable robust and fair judgements about student performance.
- Assessment practices must be fair and equitable to students and give them the opportunity to demonstrate what they have learned.
- Assessment must maintain academic standards.
Assessment Task Assessment Type Weighting Learning outcome(s) being addressed Clinical tasks requiring mastery to be completed by week 7 Summative and formative 20% 1 and 2 Clinical reasoning written examination week 9 Summative 30% 1 Multiple choice written examination week 9 Summative 25% 1 OSCE examination week 9 Summative 25% 2
Assessment Related Requirements“Clinical tasks requiring mastery” is a hurdle requirement, which must be completed satisfactorily in order to pass the course. Failure to complete all components will result in a Fail No Submission report to the MBBS Board of Examiners.
Assessment DetailFormative Assessment
In addition to informal feedback in tutorials and clinical sessions, formative on-line MCQ’s and SCT’s are available in the “Assessment” section of the MyUni course, on the MBBS Script Concordance Test web site, and in the Intellilearn and eMedici modules.
The student’s final grade in this attachment is determined as follows:
Clinical tasks requiring mastery
Some clinical tasks are important but are not readily assessed in an OSCE. At the start of rotation students are given a list of tasks which must be completed in a satisfactory manner. Students are required to have their observed performance of the mandatory clinical tasks signed off by an appropriate assessor (a medical graduate or graduate midwife, dependent on the task).
ALL “clinical tasks requiring mastery” must be satisfactorily completed. Failure to satisfactorily complete all tasks will result in a Fail grade (Band E) for the course regardless of satisfactory completion of the other assessment tasks.
Written assessment is in Week 9.
An on line examination comprising single best answer Multiple Choice Questions will be held at the end of term.
All written assessments will be sat on-line.
The OSCE will be a 5-station examination usually to be held on the last day of term (Friday week 9). Each question will be of 6 minutes duration plus 1 minute reading time. The OSCE stations cover a range of clinical skills including history taking, examination, requesting and interpretation of investigations, diagnosis, management, explanation and counselling. Questions may be in obstetrics, gynaecology and neonatology. Stations will be standardised by the use of surrogate patients and anatomical simulations, where applicable.
SubmissionAssessment in Human Reproductive Health comprises:
1. Clinical Portfolio 20% (week 7). This is a hurdle requirement = must pass to pass the course
2. Clinical Reasoning Examination 30% (week 9)
3. MCQ examination 25% (week 9)
4. OSCE examination 25% (week 9).
A Clinical Portfolio is a record of your clinical experiences in HRH. There are three components to the Clinical Portfolio:
A case summary of a normal labour and normal or assisted vaginal delivery including management of the third stage of labour, that you have personally attended and been involved in. You are required to produce written evidence that you have undertaken this task, including delivery of the placenta.
A case summary of your involvement in the postpartum care of a woman and her baby on the antenatal ward and/or on a domiciliary visit.
A Clinical Core Competencies Document (see below).
You are required to submit via MyUni no later than 5pm Friday of week 7 a fully completed written clinical portfolio in the required format as detailed in MyUni unless otherwise arranged with the course coordinator or their designated person. It is recognized that completing all components by the due date may be difficult for some people. It is your responsibility to request help before the due date.
An assessor (qualified doctor or midwife) who is able to attest that you have performed the task to a satisfactory standard must sign the clinical competency document:
Competency Date Print Name of Assessor Signature of Assessor Measurement of symphysial-fundal height in third trimester Column cell Column cell Measurement of blood pressure in third trimester of pregnancy Column cell Column cell Detection of the fetal heart using a portable Doppler device in the third trimester Column cell Column cell Detection of fetal lie and presentation in third trimester Column cell Column cell Location of the uterine cervix with a speculum * Column cell Column cell
Inspection of a Caesarean section wound
Column cell Column cell Examination of a well term neonate Column cell Column cell
One patient per student
NO “BUDDYING” OF CASES IS PERMITTED.
You are required to provide the patient’s initials, UR number and clinical location for each case. We will randomly check a sample of patients to confirm your participation was as stated in your portfolio. DO NOT plagiarise or copy the work of another person.
Clinical portfolios submitted late or incomplete without permission will receive 0 marks. The clinical portfolio is a hurdle requirement. A member of the academic staff will mark the clinical portfolio. It is necessary to pass the clinical portfolio in order to pass the course. For the purposes of grading, the percentage marks awarded for each component of the clinical portfolio appear in the table below:
Marks available How marked Case summary of a normal labour 8% The examiner will award between 0-8 marks for this component. A score of 5 is required to pass this component. Case summary of your involvement in postpartum care 8% The examiner will award between 0-8 marks for this component. A score of 5 is required to pass this component. Clinical Core Competencies 4% Satisfactory completion of all tasks = 4 marks, anything less = zero marks Total 20 %
It is necessary to pass EACH of the three components in order to pass the clinical portfolioWe will undertake random checks to confirm that you have attended delivery suite and the postnatal wards as claimed.
Candidates who fail the clinical portfolio will receive an “E” band in the course.
Summative written assessments
Summative written assessment is held in week 9. The written assessment comprises a Clinical Reasoning Examination and a single best answer Multiple Choice Question (MCQ) examination. You will undertake these assessments on line and using the iPad that was provided to you at the start of the course. For security reasons, you will be required to hand in the loan iPad immediately on completion of the written examinations.
Clinical Reasoning Examination
The Clinical Reasoning Examination (CRE) comprises 10 common case scenarios in Obstetrics and Gynaecology. You will be required to answer for each scenario a single best answer question in script concordance test format, and then to type your justification for selection of that answer using the iPad’s virtual keyboard.
The CRE examination will contribute 30% to your final grade in HRH.
An example of a CRE question including a marking template follows:
A 38-year-old G3P2 woman presents for routine antenatal clinic review at 32 weeks gestation. She feels well but you record a blood pressure of 150/100 mmHg.
If you were thinking of: And then you find: Pre-eclampsia Her booking BP at 9 weeks gestation was 120/70 mmHg
- Strongly negative
- Slightly negative
- No effect
- Slightly positive
- Strongly positive
In this option, the standard setting process may (generously) allow a borderline student to choose any of the options “No effect”; “Slightly positive” or “Strongly positive”. A borderline candidate would then be expected to score 1 mark for this question.
Justify your answer:(4 marks)
A complete answer may include all of the following:
A reasonable differential diagnosis (pre-eclampsia, pregnancy induced hypertension, white coat hypertension, measurement error) including that chronic essential hypertension though common in this age group.
The need to repeat BP after quiet resting before determining if it is truly elevated.
Additional information required in relation to risk factors that have not been provided in the scenario (new paternity, maternal obesity).
Need for additional investigations to confirm or refute primary hypothesis.
The examiners may determine that the borderline student would recognise that this is not essential (chronic) hypertension and that the BP would need to be repeated to confirm that the woman is truly hypertensive, and no more – and thus score 2 out of a possible 4 for this question.
Multiple Choice Examination (MCQ)
The MCQ examination will comprise a mixture of “core” questions and some more difficult “extension” questions. Standard setting for the MCQ is based on a different version of the modified Angoff standard setting process. In this version, examiners estimate for each question the probability of a borderline candidate answering the question correctly. The pass mark is the average of these estimates for the entire assessment. For example, if our examiners determined that a borderline student has a 60% chance of answering each question in the assessment correctly, the pass mark is 60%.
The MCQ examination will contribute 25% to your final grade in HRH.
The OSCE will be a multi-station examination usually to be held on the last day of term (Friday week 9). Each question will be of 5 minutes duration plus 1-minute of reading time. The OSCE stations cover a range of clinical skills including history taking, examination, requesting and interpretation of investigations, diagnosis, management, explanation and counseling. Questions may be in obstetrics, gynaecology and neonatology. Stations will be standardised by the use of surrogate patients and anatomical simulations, where applicable.
Each of the 5 stations will be scored out of 5 possible marks. Standard setting for the OSCE will follow the procedure described for the CRE.
The OSCE examination will contribute 25% to your final grade in HRH.
Academic Honesty and Copyright
All examination questions are copyright and may include material owned by other organisations. Examination questions are not to be copied or reproduced in any manner, including by memorisation. This includes copying for private study, which is also expressly forbidden. Breach of this rule is a serious breach of professional behaviour, and will result in referral for investigation through the university disciplinary process - see Academic Dishonesty Policy –http://www.adelaide.edu.au/policies/230/.
Please also note that if you copy and sell our questions you will be treated most severely - see Student Misconduct Rules
Grades for your performance in this course will be awarded in accordance with the following scheme:
NOG (No Grade Associated) Grade Description CN Continuing
Further details of the grades/results can be obtained from Examinations.
Grade Descriptors are available which provide a general guide to the standard of work that is expected at each grade level. More information at Assessment for Coursework Programs.In addition, students will receive a banded result upon completion of their attachment.
Five bands are available to determine the assessment for the Human Reproductive Health rotation in fifth year of MBBS. The Bands available for determining student performance are
A Above expected competency for Year 5
B Clearly at expected competency for Year 5
C Just reaches expected competency for Year 5
D Below expected competency for Year 5
E Far below expected competency for Year 5
Calculation of GradesA candidate MUST pass the core competencies (mastery) by the end of the course or will fail with an E. Otherwise, the calculation of grades is as follows:
Written and practical examinations are held at the end of the year to assess competence in the MBBS Program. Included in these exams will be some Obstetrics & Gynaecology questions.
Final results for this course will be made available through Access Adelaide.If a replacement or additional assessment is required, this will normally take the form of a clinical viva assessment, which may include an observed long case and oral assessment covering both the long case and a range of other topics.
The University places a high priority on approaches to learning and teaching that enhance the student experience. Feedback is sought from students in a variety of ways including on-going engagement with staff, the use of online discussion boards and the use of Student Experience of Learning and Teaching (SELT) surveys as well as GOS surveys and Program reviews.
SELTs are an important source of information to inform individual teaching practice, decisions about teaching duties, and course and program curriculum design. They enable the University to assess how effectively its learning environments and teaching practices facilitate student engagement and learning outcomes. Under the current SELT Policy (http://www.adelaide.edu.au/policies/101/) course SELTs are mandated and must be conducted at the conclusion of each term/semester/trimester for every course offering. Feedback on issues raised through course SELT surveys is made available to enrolled students through various resources (e.g. MyUni). In addition aggregated course SELT data is available.A student course evaluation is completed online by all students at the end of the rotation. SELTS of individual teaching are done on a regular basis.
- Academic Support with Maths
- Academic Support with writing and speaking skills
- Student Life Counselling Support - Personal counselling for issues affecting study
- International Student Support
- AUU Student Care - Advocacy, confidential counselling, welfare support and advice
- Students with a Disability - Alternative academic arrangements
- Reasonable Adjustments to Teaching & Assessment for Students with a Disability Policy
- LinkedIn Learning
Policies & Guidelines
This section contains links to relevant assessment-related policies and guidelines - all university policies.
MBBS Incident Reporting
- Academic Credit Arrangement Policy
- Academic Honesty Policy
- Academic Progress by Coursework Students Policy
- Assessment for Coursework Programs
- Copyright Compliance Policy
- Coursework Academic Programs Policy
- Elder Conservatorium of Music Noise Management Plan
- Intellectual Property Policy
- IT Acceptable Use and Security Policy
- Modified Arrangements for Coursework Assessment
- Student Experience of Learning and Teaching Policy
- Student Grievance Resolution Process
Students are to report incidents in the hospitals via the Clinical Education offices. The staff in these offices can debrief students, and also provide students with the University’s Incident Reporting form and the relevant Hospital form. See:
MBBS incidents will be flagged by the relevant School Health & Safety Officer and on the assignment of controls they will be compiled by the Faculty HSW Manager, and finally reported to the School of Medicine OHS Committee.
Clinical Education Offices
Modbury Hospital (MPH)
The MPH Clinical Education Office is situated on Level 5 of the Modbury Hospital main building.
Dr Wing Cheung (Senior Lecturer, Clinical Education)
Ms Danique Chadwick (Administrator)
Phone: 8161 2132
Royal Adelaide Hospital (RAH)
The RAH Clinical Education Office, is situated on Level 1 of the Eleanor Harrald Building, Frome Road.
Dr Jo Thomas (Senior Lecturer, Clinical Education)
Ms Ebony Dukic (Administrator)
Lyell McEwin Hospital (LMH)
The LMH Clinical Education Office is situated on Level 2 of the Education Centre in the Lyell McEwin Hospital.
Dr Jenny Cook-Foxwell (Senior Lecturer, Clinical Education)
Ms Donna Holloway (Administrator)
Dr Peak Mann Mah (Senior Lecturer, and Clinical Dean, LMH)
Mrs Liz Ziebarth (Administrator)
Phone: 8182 9433
The Queen Elizabeth Hospital (QEH)
The TQEH Clinical Education Office is situated on Level 2 of the Queen Elizabeth Hospital.
Dr Robin Limb (Senior Lecturer, Clinical Education
Ms Mary Denys (Administrator)
Phone: 8222 7480
The Women’s and Children’s Hospital (WCH)
The WCH Clinical Education Office, is situated on Level 2 of the Rieger Ward, in the Women’s and Children’s Hospital.
Ms Gemma Barnes (Clinical Studies Officer)
Phone: 8161 6346
Students are reminded that in order to maintain the academic integrity of all programs and courses, the university has a zero-tolerance approach to students offering money or significant value goods or services to any staff member who is involved in their teaching or assessment. Students offering lecturers or tutors or professional staff anything more than a small token of appreciation is totally unacceptable, in any circumstances. Staff members are obliged to report all such incidents to their supervisor/manager, who will refer them for action under the university's student’s disciplinary procedures.
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