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									                              Nutrition and Blood

9.1: Drugs used in anaemias

Iron deficiency anaemia:
Treatment with an iron preparation is only justified in the presence of a
demonstrable iron deficiency state.
Before starting treatment it is important to exclude any serious underlying
cause of the anaemia.
Iron salts should be given by mouth unless there are good reasons for using
another route.
Choice of preparation is usually decided by incidence of side effects and cost.

Iron salt                   Amount                          Content of ferrous iron
Ferrous Fumarate            200mg                           65mg
Ferrous Gluconate           300mg                           35mg
Ferrous Sulphate            300mg                           60mg
Ferrous Sulphate dried      200mg                           65mg

When haemoglobin is in normal range treatment should be continued for a
further three months to replenish iron stores.
The incidence of side effects due to ferrous sulp hate is no greater than with
other iron salts when compared on the basis of equivalent amounts of
elemental iron. If side effects occur the dose may be reduced or another salt
may be used but improved tolerance may simply be due to lower content of
elemental iron.
  Oral Iron              Notes           Form               Dose
  First Choice           Datasheets are not necessarily the brand kept
  Ferrous Sulphate       Best absorbed 200mg tabs           Refer to BNF
                         on an empty
                         maybe taken
                         after food to
                         reduce GI
  Pregaday               Ferrous         100mg iron/        1 once daily
  Datasheet              Fumarate and    350mcg folic
                         Folic acid      acid
  Second choice
  Ferrous Fumarate                        322mg tabs          See BNF
                                          elemental iron)
                                          210mg tabs
                                          elemental iron)
                                          syrup (45mg
                                          elemental iron)
  Ferrous Gluconate                       300mg tabs          See BNF
                                          (35mg iron)
  Sodium Feredetate      Sytron           190mg/5ml           See BNF
  Datasheet                               liquid (27.5mg)
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Parenteral iron
Iron may be administered parenterally as iron dextrose or iron sucrose.
Parenteral iron is generally reserved for use when oral therapy is
unsuccessful, if there is continued blood loss or malabsorption.
Anaphylactoid reaction can occur and test doses should be given.

     Parenteral iron       Notes              Form              Dose
     First Choice          Oral iron not to be given until 5 days after injection
     Venofer               May be given                         Calculated
     Datasheet             by slow IV or                        according to
                           IV infusion                          body weight
                                                                and iron deficit
                                                                See data sheet
     Second choice         Oral iron not to be given until 5 days after injection
     CosmoFer              May be given                         Calculated
     Datasheet             by deep IM                           according to
                           slow IV or IV                        body weight
                           infusion                             and iron deficit
                                                                See data sheet

Drugs used in megaloblastic anaemia:
Most megaloblastic anaemias result from a lack of either Vit B12 or a folate. It
is essential to establish in every case which deficiency is present and the
underlying cause. In emergencies it is sometimes necessary to administer
both substances while results are awaited.

                           Notes              Form              Dose
     Hydroxocobalamin                         1mg inj           See BNF
     Folic acid            Should never       400mcg and        See BNF
     Datasheet             be given alone     5mg tabs
                           for pernicious     2.5mg/5ml
                           anaemia or         liquid
                           other Vit B12

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Drugs used in hypoplastic, haemolytic and renal anaemias:
See NICE TA 142 and CG39
                            Notes            Form                  Dose
     Epoetin Beta           See              500, 1000,            See BNF
     (NeoRecormon,          MHRA/CHM         2000, 3000,
     Eprex)                 advice and       4000, 5000,
     Datasheet              CSM advice –     6000, 10,000,
                            pure red cell    20,000,
                            aplasia,         30,000,
                            tumour           50,000, 60,000
                            progression      and 100,000
                            and Hb conc      units inj
     Darbepoetin Alfa                        10, 15, 20, 30,       See BNF
     (Aranesp)                               40, 50, 60, 80,
     Datasheet                               100, 150, 300
                                             and 500mcg
     Epoetin Alfa (Eprex)   Sc injection is  1000, 2000,           See BNF
     Datasheet              contraindicated 3000, 4000,
                            in patients with 6000, 8000,
                            chronic renal    10,000 and
                            failure          40,000 units inj

Iron overload:
                        Notes               Form                     Dose
  Deferasirox                               125mg,250mg,500mg        See BNF
  Datasheet                                 dispersible tabs
  Deferiprone                               500mg tabs               See BNF
  Datasheet                                 100mg/mL oral
  Desferrioxamine                           500mg vial               See BNF

Drugs used in platelet disorders
                            Notes             Form                 Dose
     Anagrelide                               500mcg caps          See BNF

Refer to BNF for drug risk in G6PD deficiency.

Drugs used in neutropenia:
                            Notes             Form                   Dose
     Lenograstim                              13.4million units      See BNF
     (Granocyte)                              (105mcg)
     Datasheet                                33.6 million units
                                              (263mcg) inj
     Filgrastim                               30 million units       See BNF
     (Neupogen)                               (300mcg), 60
     Datasheet                                million units
                                              (600mcg) inj
     Pegfilgrastim                            10mg/ml                See BNF
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9.2 Fluids and electrolytes

Oral Potassium       See NPSA – Risk alert - safety of KCl in NHS

                       Notes                       Form             Dose
  Sando-K              K+ 12mmol,                  Effervescent     See BNF
  Datasheet            Cl- 8mmol                   tabs
                       May curdle enteral
  Kay-Cee-L            1mmol/ml K+ and Cl-         syrup            See BNF
                       Should be used if
                       enteral feeding
  Slow K               8mmol K+ and                tabs             See BNF
  Datasheet            Cl-
                       Avoid unless other
                       preparations are

Potassium removal:

                          Notes                    Form             Dose
   Calcium Resonium       It is advisable to       Powder or        See BNF
   Datasheet              prescribe lactulose      enema kit
                          alongside this if oral

Sodium salts:

                            Notes              Form               Dose
     Slow sodium            10mmol             600mg tabs         See BNF
     Datasheet              Sodium and

Oral rehydration:

                            Notes              Form               Dose

     Dioralyte                                 Blackcurrant,      See BNF
     Datasheet                                 citrus or

Oral bicarbonate

                            Notes              Form               Dose

     Sodium bicarbonate                        500mg caps,        See BNF
                                               600mg tabs

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Intravenous Rehydration:

Intravenous Sodium chloride
Sodium chloride 0.45%                500ml
Sodium chloride 0.9%                 100ml, 250ml, 500ml and 1000ml
Sodium chloride 1.8%                 500ml
Sodium chloride 5%                   500ml
Intravenous Glucose
Glucose 5%                           100ml, 250ml, 500ml, 1000ml
Glucose 10%                          500ml
Glucose 20%                          500ml
Glucose 50%                          500ml
Intravenous Glucose and Sodium Chloride
Glucose 4% & Sodium Chloride 0.18% 500ml and 1000ml
Glucose 5% & Sodium Chloride 0.9%    500ml and 1000ml
Plasma and Plasma substitutes
Dextran 40                           500ml
Dextran 70                           500ml
Volplex (Gelatin)                    500ml
Voluven (Etherified Starch)          500ml
Infusions with Potassium Chloride
Sodium chloride 0.9% &Potassium      1000ml (20mmol KCL)
Chloride 0.15%                       500ml (10mmol KCL)
Sodium chloride 0.9% &Potassium      500ml (20mmol KCL)
Chloride 0.3%
Sodium chloride 0.9% &Potassium      500ml (40mmol KCL)
Chloride 0.6%
Glucose 5% &Potassium Chloride       1000ml (20mmol KCL)
Glucose 5% &Potassium Chloride       500ml (20mmol KCL)
Glucose 5% &Potassium Chloride       500ml (40mmol KCL)
Potassium Chloride, Sodium chloride and Glucose
Glucose 4%, sodium chloride 0.18%    500ml (10mmol KCL)
and potassium chloride 0.15%         1000ml (20mmol KCL)
Glucose 4%, sodium chloride 0.18%    500ml (20mmol KCL)
and potassium chloride 0.3%
Other Infusions
Sodium lactate                       500ml and 1000ml
Sodium Bicarbonate 1.26%, 1.4%,      500ml polyfuser
2.74%, 4.2% and 8.4%

See NPSA alerts: IV infusion in children, Injectable medicines, Epidural
injections/infusions and Potassium chloride.


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9.3: Intravenous nutrition
See NICE guidelines for nutrition support in adults.

Parenteral feeding should only be considered if feeding via the GI tract is
contra-indicated. Per-oral, nasogastric, feeding gastrostomy and feeding
jejunostomy routes should be considered before parenteral feeding is

Other factors to be considered before parenteral feeding is commenced
include the following:

Are nutritional needs greater than normal due to infection or severe

Energy requirements and catabolism increase during illness, especially if
there is infection, fever, major trauma or severe pre-existing malnutrition.
These increased requirements must be provided by the parenteral nutrition.

Composition of the feeds
The total daily nutritional requirements are provided in a single infusion bag
providing 2 – 3 litres of volume daily.

Glucose is considered the most suitable source of carbohydrate for i/v use,
despite its irritant effect on veins and occasional need for exogenous insulin to
control hyperglycaemia. Glucose is a normal body constituent and has a
greater protein sparing effect than lipid. Long-term provision of excess
glucose may lead to fatty infiltration of the liver.

Lipid emulsions provide fatty acids particularly the essential fatty acids linoleic
and linolenic acids, and are a high calorific source in a relatively small volume
(500ml Intralipid® 20% providing 1,000 kcal). Lipid alone is inefficient at
inhibiting protein breakdown for gluconeogenesis.

       Amino acids
Nitrogen is usually provided by solutions of synthetic L -amino acids. The
amino acid solutions must provide the essential amino acids (as
approximately 40% of the total amino acid content) and sufficient non-
essential amino acids to meet nitrogen requirements.

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All electrolytes, trace elements, water-soluble and lipid soluble vitamins must
also be provided.

Route of administration
Parenteral nutrition solutions are hypertonic. To prevent the development of
thrombophlebitis, solutions are usually administered via a central venous
catheter which allows rapid dilution of the hypertonic solution with blood in the
right atrium or superior vena cava.

The central venous feeding line is for feeding only. No IV drugs should
be given via the feeding line, or blood withdrawn.

Peripheral veins may be used for the administration of specifically formulated
regimens. These regimens tend to have a lower tonicity than conventional

Despite the relatively lower tonicities, thrombophlebitis still occurs and the site
of administration must be changed at least once every 48 hours, even if the
vein is still patent. The integrity of the peripheral site may be prolonged by the
application of a glyceryl trinitrate patch (5mg) above the cannula (between the
hand and the cannula). Despite this intervention, the site still needs to be
changed every 48 hours. Peripheral parenteral nutrition is therefore only
suitable for short-term therapy (7-14 days).

All parenteral nutrition solutions are delivered using a volumetric pump.

Potential complications

1.       Infection

Parenteral nutrition solutions are an ideal medium for the culture of bacteria
and fungi. Consequently strict aseptic technique must be maintained duri ng
line management and solution changes. The feeding line must be reserved
for the parenteral nutrition only.

2.       Air embolism

The catheter tip (usually positioned within the right atrium or superior vena
cava) is subjected to negative intra-thoracic pressure. To avoid air embolism
the extension tubing must be atraumatically clamped when solutions are

3.       Metabolic

Parenteral feeding is unphysiological and patients so fed are liable to develop
metabolic complications more readily than if fed by the GI tract (e.g.
hyperglycaemia, hyperchloraemic acidosis, deficiency and excess states if not
managed properly). The patient must be monitored closely.

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The actual frequency at which measurements are made is dependent upon
the patient’s nutritional state, the underlying disease, the patient’s stability and
complications. Generally the frequency of monitoring can be reduced as the
patient’s condition improves.

Details of the recommended regimens, monitoring parameters or advice about
any aspect of parenteral nutrition can be obtained from your ward pharmacist,
Pharmacy Broomfield (4174 or 4175), the dietetic department (4132) or ward
dietician. See intranet for further contact details.

9.4: Foods for Special Diets and Nutritional Support

Enteral nutrition    See Rapid response report – NG tubes and neonatal
NG tubes

Enteral feeding can be defined as nutrition provided via the gastrointestinal
tract. It includes nutrition taken orally or administered by enteric tube,
although the term is generally reserved to refer to the latter.

Tube feeding should be considered in patients with a functioning gut who are
unwilling or unable to meet their requirements orally.

In practice the decision to tube feed is made by the clinician in consultation
with the dietician. Each patient should be considered individually taking t he
clinical condition, treatment plan and nutritional state into account.

A wide range of commercially prepared nutritionally complete feeds are
available. These are produced in liquid or powder form and are packaged in
easybags, cans or sachets

Standard feeds

Standard feeds contain whole protein as their nitrogen source, with
carbohydrate and hydrolysed fat as the energy sources. Standard feeds are
low in lactose, low residue and have a relatively low osmolarity. Their energy
content is 1 kcal/ml, and is suitable for most patients. The feeds are available
with or without dietary fibre.

High energy/high nitrogen feeds

These feeds provide 1.5 – 2 kcal/ml and have higher nitrogen content than
standard feeds. These feeds therefore are hypertonic, thus should initially be
administered with caution.

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Elemental and Semi-elemental (peptide) feeds

In most patients whole protein feeds are well tolerated even in the presence of
a degree of gut malfunction. However with severe gut impairment these may
be indicated.

Choice of feeding regimen

When the decision to feed has been made the patient’s feeding regimen
should be determined by the dietician. There are a number of factors, which
need be considered including gut function, fluid requirements, energy and
nitrogen requirements, electrolyte status and trace element status.

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Monitoring is vitally important to detect any potential feeding complications
and to assess the efficacy of the nutritional regimen. Prior to feeding, and
regularly throughout the feeding period, patients should undergo nutritional
assessment by the dietician. The measurements made and their frequency
will depend on the individual patient, their stability, and the stage of feeding.
Obviously the critically ill patient will require much closer monitoring than the
stable home fed patient.

Home enteral nutrition

Home enteral nutrition is a rapidly expanding field with larger and larger
numbers of patients being supported at home.

Successful home feeding relies on careful co-ordination of various factors
including patient education, supply and delivery of equipment and follow up
nutritional care.

At present all feeds are available in the community on prescription (FP10
(HP)), however the feeding equipment is not and funding needs to be
established. Generally both feed and feeding equipment are delivered direct
to the patient’s home/nursing home.

The aim of home enteral feeding should be to optimise the patient’s quality of
life whilst minimising the inconvenience caused by the feeding regimen.

Discontinuing tube feeding

Whenever possible nutritional support should be phased out gradually once
normal eating has resumed or improved. To ensure that an adequate intake
is maintained, close dietetic involvement continues to be required. Patients in
whom tube feeding is discontinued may benefit from sip feeding in addition to
normal diet until an adequate diet is taken. Many patients leaving hospital are
still on an inadequate intake and regular follow up in outpatient clinics or the
community is advisable.

Please contact Nutrition and Dietetics with any queries:

Extension 4552 or 4132 (see intranet for further contact details)

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1.       High energy products

Maxijul supersoluble powder
Calogen (plain, strawberry)

2.       High protein products

Fresubin Protein Energy

3.       Semi-elemental and Elemental products

Fresenius Survimed OPD
Elemental 028 unflavoured*
Elemental 028 Extra*

4.       Supplementary nutrition

Resource shake                                  Provide extra
Prosure – pancreatic cancer patients
Fresubin Energy Fibre drink                     Nepro (renal patients)

5.       Enteral tube feeds                        Fresubin original 500ml, 1000ml,
Fresubin 1000 complete - 1000ml                    Fresubin original fibre - 500ml,
Fresubin 1200 complete – 1000ml                    1000ml, 1500ml
Fresubin energy - 500ml, 1000ml                    Nutrison conc - 500ml
Fresubin energy fibre 500ml, 1000ml                Nutrison low sodium 1000ml
Fresubin HP energy 500ml,1000ml                    Nutrison soya – 1000ml

6.    Fluid restriction high calorie supplement

7.     Paediatric products
See Mid Essex Formulary for Infant formula milk products for prescribing
advice and also the Position Statement on the use of Soya protein for Infants .

Aptamil-Pepti                   Infasoy                         SMA Gold Prem 2
Nutramigen-1                    Wysoy*                          Premcare
Nutramigen-2                    Enfamil Lactofree               Infatrini RTF
Pepti-Junior                    SMA LF                          SMA High Energyrtf

Calogen                         Duocal*                         Peptamen*
  Items which are not routinely available from pharmacy. These items are only obtained for
specific patients, usually within 1 working day.
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8.       Gluten free products

See MEAPC guidance for the Prescribing of Gluten Free foods.

Gluten free meals can be ordered from the kitchens.

These should only be prescribed for patients with a clear diagnosis of coeliac
disease and dermatitis herpetiformis.
GPs should not prescribe GF foods for patients who simply believe that they
have intolerance to wheat, without any supporting diagnosis. When GF foods
are prescribed, the quantities given should be in accordance with the needs of
the patient and bearing in mind good nutritional practice. Many of these foods
are now available in supermarkets and can be purchased by patients.
It is not appropriate to supply large quantities of biscuits and cakes. Patients
who believe they have intolerance to wheat can purchase wheat-free foods
from supermarkets.
Gluten-free products are not wheat-free. However gluten-free/wheat-free
products are available (ask dietician for information).

9.       Thickening agents

Thick-n-Easy                                             Instant Carobel

10.      Enteral feeding equipment

Easy Bag giving set                                      Hydro bags

Enteral feeds and supplements should only be dispensed for patients going
home if the dietician endorses the prescription as TTA.
The dietician will liaise with the GP regarding continuation of supply.
Hypercalcaemia and hypercalciuria

                              Notes               Form             Dose

      Cinacalcet              See NICE            30mg,60mg,       See BNF
      (Only for secondary     TA117 and           90mg tabs
      hyperparathyroidism     MEAPC
      in end-stage renal      guidelines
      disease on dialysis.)

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9.6: Minerals/Vitamins

                         Notes            Form                Dose
     Calcium             Calcium preparations should be taken 4 hours
                         apart from bisphosphonates. If taking two tablets,
                         they should be taken at different times for
                         improved absorption.
     Calceos             Ca++ 500mg       Chewable tabs See BNF
     Datasheet           and Vit D 400
     Calfovit D3         Ca++ 1.2g and    Dispersible         See BNF
                         Vit D 800 IU     sachet
                         For patients
     Calcichew           For renal        Ca++ 500mg          See BNF
     Datasheet           patients as      chewable tabs
     Calcium 500         binding agents Ca++ 500mg            See BNF
                                          chewable tabs
     Calcium Sandoz      Ca++             syrup               See BNF

                         Notes               Form            Dose
     Magnesium                               2mmol/ml inj    See BNF

     Magnesium glycero   Unlicensed          tablets

                         Notes           Form               Dose
     Phosphorus          Datasheets are not necessarily the brand kept
     Phosphate Sandoz                    tablets            See BNF
     Phosphate                               100mmol/ l      See BNF

                         Notes       Form                    Dose
     Phosphate binding   SEE APPENDIX 1
     Sevelamer           Renagel             800mg tabs      See BNF

     Lanthanum           Fosrenol            500mg,          See BNF
     carbonate                               750mg, 1g
     Datasheet                               chewable

                         Notes           Form               Dose
     Zinc                Datasheets are not necessarily the brand kept
     Solvazinc           45mg Zinc       Effervescent       See BNF
     Datasheet                           tabs

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                                     9.6: Vitamins
                      Notes                     Form                           Dose
Vitamin B group       Datasheets are not necessarily the brand kept
Thiamine                                        100mg tabs                     See BNF
Pabrinex              IM injection is a fridge  VitB&C IM&IV Injection         See BNF
Datasheet             line                                                     Given as a pair

Pyridoxine                                         10mg, 20mg, 50mg            See BNF
Hydroxocobalamin      Brands are not available     1000mcg/ml                  See BNF
Datasheet             on NHS
Vitamin B compound                                 tabs                        See BNF
Vitamin C group
Ascorbic Acid                                      500mg tabs                  One daily

Vitamin D group
Calcitriol                                         250, 500 nanogram caps      See BNF
Alfacalcidol          The concentration of         250 nanogram                See BNF
Datasheet             Alfacalcidol in One-Alpha    1mcg caps
                      drops is 10 times greater    2microgram/1ml solution
                      than the former One-         (1 drop = 100
                      Alpha solution               nanograms)

Calceos               Ca++ 500mg and Vit D         Chewable tabs               See BNF
Datasheet             400 IU
Calfovit D3           Ca++ 1200mg & vit D 800      powder                      See BNF
Paricalcitol          Patient selector pathway     1mcg, 2mcg, 4mcg            See BNF
                                                   capsules 5mcg/ml
Vitamin E group
Alpha tocopheryl      Tabs are available on the 500mg/5ml suspension         See BNF
Datasheet             named patient basis
Vitamin K group       Anticoagulant guidelines
                      Tablets should be chewed or allowed to be dissolved in the mouth
Phytomenadione        Tablets are fat soluble   2mg/0.2ml and                See BNF
Datasheet                                       10mg/ml injection
                                                10mg tabs
Menadiol sodium       Tablets are water soluble 10mg tabs                    See BNF
phosphate Datasheet
Multivitamin          Abidec or Dalivit drops      Tabs/caps                   See BNF
                      for children                 Drops for paediatrics
Ketovite              Should be co-prescribed                                  Tabs: one tds
Datasheet             in order to administer                                   Liquid: 5ml
                      both water and lipid                                     daily
                      soluble vitamins
                      Vitamins & minerals
Forceval              Vitamins & minerals                                      One daily

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9.8: Metabolic disorders

                           Notes             Form           Dose
     Penicillamine         For Wilson’s      125mg and      See BNF
     Datasheet             disease           250mg tabs

See BNF for information on acute porphyrias.


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Appendix 1

    Phosphate binder therapy should only be initiated by the Nephrology Team

     Serum phosphate < 1.8mmol/L
     Serum corrected calcium 2.1 – 2.37 mmol/L
     Calcium /phosphate product < 4.4mmol/L
     iPTH 16.5 – 33 pmol/L

    Phosphate > 1.8mmol/L

    STEP 1
     Dietary Phosphate Restriction
     Calcium – containing Phosphate Binder (CALCICHEW)
     (With meals, up to a max 1500mg/day (2gm total elemental calcium intake)

     Calcium 500 tablets are also available as a non-chewable option

    Phosphate > 1.8mmol/L                     Patients with vascular and / or other soft tissue
    and / or                                  calcification
    (Calcium > 2.54mmol/ L)

    STEP 2
     Add non-calcium based phosphate binder SEVELAMER (RENAGEL)
     (May be used in combination with calcium-containing binder or as monotherapy)
     Maximum 15 tablets per day in 3 divided doses with meals

     Review of adequacy of dialysis

    Phosphate > 1.8 mmol/L
    And /or
    Calcium > 2.54 mmol/L

    STEP 3
     Use of non-calcium containing phosphate binder
     (available in 250, 500, 750 & 1000mg tablets)
     For use in patients with intolerance to Renagel
     Consider for use in patients with an unacceptably high tablet burden (taking multiple
     tablets of Calcichew/Renagel) leading to compliance problems
     For patients unable to swallow Renagel (Fosrenol is chewable)

    NOTE: Aluminium-containing binders should not be used routinely and may only be
    used for a course of 4 weeks.
    KDOQI (Kidney Disease Outcome Quality Initiative) Guidelines (2002)
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