Health, both physical and mental is an important aspect of our lives. When the traditional western sciences do not have the desired results, then there is an entire range of alternative therapies. One of these is acupuncture / acupressure. This therapy is not in contradiction to modern day allopathic treatment, but an alternative and some times complementary therapy, to bring about a holistic approach in the line of treatment. Acupuncture is a philosophical approach towards treating both the body and the mind. “Mind over matter” is the under lying thrust to obtain positive results.

Definition of Acupuncture

The term acupuncture is derived from the Latin is words ocus – meaning needle and pungere meaning to puncture/penetrate. Acupuncture is an external treatment for internal disorders. The treatment is carried out by inserting acupuncture needles at various specific points all over the body. It is a drugless therapy. It is considered to be both a science and an art.

History of Acupuncture

Acupuncture is supposed to have been originated in India. The reference of Vedhan or Vyadhan indicates that the term “Soochee Shastra” means acupuncture and “Soochee Toda” means to prick or insert a needle. The Buddhist monks carried this from India, through Nepal to China, where along with Buddhism, this science was preserved and progressed.

The history of acupuncture in China dates back to the Neolithic Era (2500 BC), when stone needles were used in place of today’s finely manufactured ones. The reign of the Yellow Emperor of China saw the progression and preservation, observations and documentation of this drugless therapy.

The Nei Jing, the Yellow Emperor’s classic treatise on internal medicine, is the oldest medical book in China, having been written by numerous medical authors around 475 to 221 BC. The Nei Jing is divided into two parts. The first part, Su Wen (Essential Questions), is based on theory while the second part, Ling Shu (Spiritual Pivot) deals with practical application.

Although thousands of years old, the book remains the foundation for the theory and philosophy on which Chinese medicine was founded. In this ancient text, nine different types of needles are mentioned as being used for acupuncture treatments, each one with a different tip and a precise length and width. These were used for a variety of conditions from rheumatic diseases to paediatrics.

Acupuncture rapidly developed in China between 250 and 600 AD with additional books and charts being written to describe the channels and points for the treatment of an even greater number of conditions. Through the centuries, following the publication of these works, and with many of the traditions being passed from one generation to the next, acupuncture practice progressed.

In the Tang Dynasty (618-907AD) medical academies were established, and in about 1026 the Classic of the Bronze Man was created to illustrate the precise courses of the meridians, and the locations of the points. These two life- sized bronze figures were used for teaching and smaller replicas (in other materials) are still used today for training acupuncturist.

The Chinese define acupuncture as the art of healing. It is practically free of side effects commonly encountered in drug therapy. The most common side effect from acupuncture is a feeling of deep relaxation and an increased sense of well being. Acupuncture therefore is a simple, safe, effective and economical form of therapy.

The popular explanation offered for the discovery of acupuncture is a story of a warrior wounded by an arrow. The arrow was removed, the wound healed, and a disease in an unrelated part of the body was also cured. An arrow in the foot relieved headache. The cause and effect between the punctured points and the diseases it cured was worked out by observant physician and a series of points were charted.

Philosophy of Acupuncture

The Chinese believe that energy flows through the human body continuously; a vital motivating force which burns like fuel all through one’s life. It is called Qi or Chi, which means the vital energy. The Indian philosophers call its Prana or Prana Vayu. The Qi is omnipresent and universal in nature.

According to the philosophy of acupuncture the Chi flows in channels or meridians in our body. When there is any obstruction, impediment or hindrance in the smooth flow of this energy, there is “dis-ease”. The energy of this internal circuit cannot be created or eliminated, only transformed from one place to another. Depletion or reinforcement, where in balance, maintains growth and health; but imbalance results in ill health and absence of energy is death.

The edifice of Traditional Chinese Medicine (TCM) was built on careful clinical observations and presented within the framework of the all-embracing philosophical concepts of Yin and Yang. According to the Yin-Yang theory, the Universe was originally in a state of primordial chaos without force, form or substance. It then resolved into the negative (Yin) and the positive (Yang) forcers, and an order was established. It is therefore said, that a balance exists in the universe in its normal state, because Yin and Yang relate to each other in harmony. Natural disasters like floods, earthquakes, droughts and volcanic eruptions are brought about by an imbalance in the Yin and Yang forces. These forces are constantly interacting with each other. It is in fact, the dynamic balancing of this duality, which brings about both equilibrium and change.

This dynamic concept is the key – stone of the entirety of Chinese philosophy and of Chinese medicine. Yin is conceptualised as being cold, dark and female. Yang is warm, light and male. Yin is passive and signifies that which is deep and hidden. Yang is active, and signifies that which is above the surface. Since Yin and Yang are constantly changing their relationship to each other, one cannot exist materially or conceptually without the other. Thus there is no night without day, no inside without outside, and no virtue without vice. Yet nothing is absolutely Yin or absolutely Yang. In every Yin there is always some Yang, in every Yang there is always some Yin. As man is made out of the same elements as the Universe, he is subject to the same laws; the Universe being the macrocosm, man the microcosm.

Within our body, Yin and Yang must be in complete balance before chi can get our vital functions to function properly. These vital functions which encompass the whole person are spiritual, mental physical and emotional. Since “dis-ease” is caused by the imbalance of Yin and Yang, “homeostasis” is restored and maintained by needling of selected acupuncture points. In the process of undergoing acupuncture treatment, the mind plays a very important part. You think you are becoming well and so you become. It’s all within oneself, inside oneself. In order to obtain the very best results, it is very important that a rapport be established between the patient and the acupuncturist. The patient needs to have a very positive and unbiased mind to the line of treatment. It is not the needle, but the person behind the needle who initiates the cure. Acupuncturists therefore prefer being referred to as healers.

How Acupuncture works

Whether acupuncture works or not, is no longer the question today. The only question is how it works. Doctors trained in the schools of western medicine are sceptical and cynical about the seemingly lack of scientific explanation. Allopathy has, for its base, anatomy and physiology. Acupuncture on the other hand, is rooted in philosophy. The effects observed on needling are both subjective and objective.

Subjective effects could be, slight pain at the site of needling, an appearance of a peculiar sensation called deqi – a combination of numbness, heaviness slight soreness, distension, radiation of one or more of the above sensations.

Objective effects produced by needling can be listed as: -

a) Analgesic (Pain relieving) Effect: This is achieved by raising of the pain threshold. This is the physiological basis of acupuncture anaesthesia.

b) Sedation: Some people may even fall asleep during treatment and wake up refreshed. These effects are utilised in the acupuncture treatment of insomnia, migraine, anxiety, addictions, mental disorders and behavioural problems.

c) Homeostatic or Regulatory Effect: This means adjustment of the internal environment of the body towards a state of normal balance. Very often the same set of points may be used for treating opposite disorders like high and low blood pressure, diarrhoea and constipation etc.

d) Immunity-enhancing Action: Acupuncture contributes to increasing the body resistance to disease.

e) Psychological effect: Acupuncture has a calming and tranquilizing action, apart from mere sedation. A person’s mind is a warehouse of emotions and is the root cause of many emotional problems, which sometimes manifest in various forms.

f) Motor recovery: Even late cases of motor paralysis respond well to acupuncture therapy.

Theories of acupuncture

There are various theories that explain the mechanism of acupuncture:

  • i. Neurological theory
  • ii. Humoral theory
  • iii. Traditional Chinese theory

I. Neurological Theory

a) Gate Control theory: This theory was formulated in 1965 by Ronald Meltzac of McGill University, Montreal and Patrick D. Wall of University College, London. According to them, all pain impulses are controlled, modulated and modified by a functional gate located in the spinal cord. Under normal circumstances, this gate stays open, allowing pain impulses an easy passage. The passage of pain impulse passes from one end of nerve roots to the brain instantaneously – that is how the patient feels the pain.

After insertion of acupuncture needle a second stream of impulses is generated, which are non painful in character and travel faster than the pain impulses. When both these impulses reach the gate of the spinal cord the immediate reaction is a closure of the gate causing an elevation in the pain threshold, so no pain is felt.

b) Thalamic Integration Theory: This theory was formulated by Professor Chang, from the Shanghai Institute Of Physiology. According to this theory, there are four gates, one each at the spinal cord, brain stem, cerebral cortex and thalamus that are involved in the inhibitory inter- action between the different impulses arising from the site of pain and the point of needle insertion.

c) Cortical Inhibitory Surround Theory: This theory has been proposed by scientists from the Soviet Union. They state that when the body is needled, the focus of excitation is set up at the point where it is cortically represented. This action produces inhibition in the surrounding area to that point, resulting in analgesia in the appropriate region.

d) Reflex Theory: Felix Mann from the University College of London has put forth this theory. He states that if the internal organ can project its image upon the surface, the external affection should reflect upon the internal organs. Acupuncture, he says, acts essentially by means of simple reflex action called cuteno-visceral reflex.

II. Humoral Theory

Humoral theory is based on the various chemical mechanisms involved in acupuncture.

a) Shanghai Theory: Although Gate Control Theory is a good explanation of acupuncture analgesia, it cannot prove all the therapeutic aspects of acupuncture. Research in China has proved that when needling is done, some immune inflammatory reactions take place at the site of the needling. Substances like histamine, adrenalin, acetycholin, serotonin, endorphin and some others, which are found in the human blood stream, are the humoral factors involved in acupuncture mechanism.

b) Endorphin Release Theory: Dr Bruce Pomeranz, Professor of Neurology at Toronto University, explains that the analgesic effect of acupuncture is due to release of hormone called endorphin, after needling. Endorphin, like morphine has the tendency of binding onto the opiate receptors of pain cells in the brain.

III. Traditional Chinese Theory

The Chinese believed that as long as the flow of energy is free, and Yin and Yang are balanced, the person is healthy. Obstruction to the flow of energy results in disease, and by inserting a needle at a particular point, there is a correction to all irregularities. Energy flows through meridians or pathways in the body. There are twelve meridians connect various organs in the body. Each solid organ (Yin) is connected to a hollow organ (Yang). An imbalance in one organ is reflected in its coupled organ. There is an interlacing network, which traverses all over the body, carrying vital energy to all parts of the body. This is the basic theory of traditional Chinese medicine.

Thus what began as a story long ago about an injury to a warrior by an arrow and subsequent relief from pain in another part of the body, acupuncture has become popular the world over during the past few decades. Acupuncture is one of the most thoroughly researched and documented alternative medical practices.

An important factor in promotion of acupuncture in the west occurred in 1971. A famous American commentator James Reston was visiting China. He had an acute attack of appendicitis, which resulted in an emergency surgery. Two days after the surgery, he was suffering from postoperative abdominal pain, which was treated by acupuncture – at points near the knees and elbows. He was surprised by the level of relief and was instrumental in gathering tremendous public and profession attention.

Effectiveness of Acupuncture

Acupuncture is effective in various disorders, which have been categorised in three major categories.

I. Painful
Pain is the main syndrome of this category. This includes headaches, migraine, trigeminal neuralgia, low backache, sciatica, arthritis, tennis elbow, cervical spondylosis, muscular spasms, intercostal neuralgia, dysmenorrhoea, frozen shoulder etc.

II. Psychosomatic
This includes insomnia, fatigue, sexual disturbance, gastritis, constipation, irritable bowel syndrome, stress related discomforts like anxiety, depression, certain allergies, certain gynaecological problems, bronchial asthma, addictions, enuresis, eczema etc.

III. Musculo – skeletal
This includes facial paralysis, Bell’s palsy, stroke-causing paralysis of lower upper body, peripheral neuropathies, etc.

Limitations or Contraindications of Acupuncture

There are some disorders, which do not respond to or are adversely affected by acupuncture. In these conditions, it is advisable to avoid acupuncture and recommend patient to seek other course of treatment. The following are the disorders and conditions, which might not respond effectively to acupuncture:

1. Cancer and other malignant diseases -
Acupuncture has no curative effect on malignant disorders. However, secondary effects such as severe pain, loss of appetite, mental depression, and lack of sleep can be effectively and safely managed with acupuncture

2. Mechanical obstructions -
If there is a mechanical obstruction like a twisted loop of intestine, severed tendon, or some object is stuck in the throat, eye, ear etc, these will have to be removed mechanically.

3. Clear indications for surgery -
Fractured bone, dislocated joint, a bleeding wound, congenital defects are some examples where surgery is clearly indicated.

4. Fulminating infections -
Antibiotics are preferred in such cases. Acupuncture may be combined with drug therapy to relieve symptoms.

5. Pregnancy -
In the first trimester and the last trimester of pregnancy, it is best to avoid acupuncture, as needling may cause abortion or premature delivery. However, acupuncture is effective as means of relieving the pain of childbirth or to carry out a caesarean section.

6. Drugs -
Patients receiving drug treatment for certain diseases may suffer complications, due to the over correction of that condition, by the homeostatic action of needling. The action of acupuncture and the drug combined together may cause over-correction.

An abrupt fall of blood pressure may occur when the patient is taking medication and also undergoing acupuncture treatment for high blood pressure. In such cases, the BP needs to be monitored during the course of the treatment.

In the case of diabetes, it is possible that a hypoglycaemic state may occur. This is brought about by a patient taking acupuncture treatment for some ailment other than diabetes mellitus and continuing to take antidiabetic medication. Hence, it is prudent to ensure the medical history of the patient before onset of any acupuncture treatment.

7. Haemorrhagic diseases -
In haemorrhagic diseases, non-invasive methods (like laser therapy) are more useful.

8. Miscellaneous conditions -
Acupuncture might contra-indicate in case of persons with the following conditions:
a) Very old patients
b) Debilitated and dying patients
c) Patients under the influence of alcohol.
d) Patients who have just had an intensive emotional experience or after an immediate period of excitement (Sexual intercourse included)
e) Patients sweating profusely.
f) Immediately after a hot bath.

The acupuncturist must use a good judgement in selecting his or her cases for therapy: good judgement comes with experience and learning from one’s mistakes and from other mistakes (A master acupuncturist is one who has already made all the mistakes!!)

Complications due to acupuncture

Complications of acupuncture are called acupuncture accidents. These can occur from improper technique, lack of skill or failure to observe certain guidelines.

The following are common complications of acupuncture: -

1. Pain on insertion of needle.
Some degree of pain will always occur when points close to sense organs like the eyes, nose and ears are needled. However at the majority of other points, needling is relatively painless, if carried out expertly.

Causes of pain during needling: -
a. Bad acupuncturist (unskilful insertion)
b. Bad needle (blunt or hooked needle)
c. Bad posture (patient not correctly postured before needling)
d. Bad patient (e.g. tense and anxious patient)

2. Bleeding
Bleeding sometimes occurs on withdrawal of the needle. This may be considered as a complication. If bleeding occurs, massaging the point with a dry cotton swab will stop the bleeding and seal the wound. Slight bruising at the site of acupuncture is fairly common and has no dangerous implications.

3. Fainting
Common causes of fainting are nervous apprehension, tiredness, hunger, general weakness or painful insertion or excessive stimulation with the needles. This can be avoided by explaining the procedure of acupuncture to the patient, to allay his anxiety, to create a rapport with the patient, to insert one or two needles only in the first sitting, ensuring the patient has eaten something before the treatment starts, making the patient comfortable and relaxed.

4. The Forgotten Needle
This can occur in a busy clinic, especially in case of OPD patients coming for acupuncture treatment.

5. Bent, Broken or Stuck Needle
This can occur due to forcible insertion of the needle or may be due to the patient changing his posture after needling. If the broken part is visible above the skin surface it can be removed by forceps. If it lies at a deeper level, it will necessitate surgical removal.

6. Infection
This may occur due to improper hygiene of the acupuncturist, the needles he uses, the hygiene of the patient. However due precaution of sterilization and clean surroundings must be adhered to.

People have their own apprehensions, information, fear, regarding any procedure that involves needling. This is a genuine concern and the acupuncturist has to deal with it.

ACUPRESSURE

One of the ancillary techniques of acupuncture is acupressure. Acupressure is the ancient Chinese healing art of using applied pressure on specific points on the body to relieve common ailments and discomfort. Acupressure is based on the same concept of meridians and acu -points as acupuncture, but fingertip pressure is used rather than needles. The aim is also the same, to balance the flow of energy or chi within the meridians, creating healthy functioning of the internal organs and preventing or curing.

During treatment, the practitioner determines the correct points to use in relation to the ailment(s) and then places gentle pressure on the area(s) using the tips of the index finger or the thumb, or the edge of the fingernail. The pressure must be even and is most often applied in the direction of the flow of the meridian. Some small rotations may accompany the pressure.

Common Usage of Acupressure / Acupuncture

A keen observation of features around us indicates the usage of acupressure (more common) and acupuncture unconsciously or sub unconsciously. We have often seen babies who wear anklets and wristbands around their ankles and wrists. There are important points of all meridians at the ankles and wrists and constant pressure by the anklets and wrist. Bands ensure stimulation of these points regularly and continuously. Bands around the navel exert pressure on the points, which help in the digestion, excretion and the urino – genital organs of the baby.

Massaging with oil is a form of total acupressure of all points in the body. The fontanelles (top of the head – the soft part of the head) of infants are often massaged with oil, resulting in the baby sleeping well. Here we have massaged the tranquillising and sedative point of the body.

The wooden kadaus – the footwear used by ancient rishis, saints, constantly exerted pressure on the web between the big toe and the second toe – a very important point to control hypertension.
Sitting cross-legged on the floor to have meals, automatically gave pressure to the points influencing stomach and digestion – one reason why our grand parents, and to a certain extent our parents, ate well and had the capacity to digest it too.

It has been observed that many tribals wear heavy anklets, toe rings, bangles, armbands, nose rings, earrings, etc. Closer observation reveals that all these ornaments serve some form of acupressure and acupuncture. Given the quality of food they eat, life style that the tribals have and the health that they possess, it is an eye opener to the effect acupressure /acupuncture has on our body (health). The pressure applied when placing the ‘bindi’ on the forehead or between the eyebrows-the point is important for headaches, endocrine disorders, migraine etc.

Auriculotherapy or the Chinese Ear Acupuncture Therapy. May be defined as that branch of acupuncture, which makes use of the external ear to diagnose as well as treat illness. The external ear is looked upon by the acupuncturist as a ‘switch-board’ for the rest of the body structures.

The above are a few observations where we find the usage of acupressure/acupuncture there may be many others in different parts of the world.

Frequently Asked Questions

There are certain frequently asked questions (FAQs) that come to mind whenever the topic of acupressure/acupuncture is discussed. Here are some of the FAQs:

1. What is the difference between acupressure/acupuncture?
The acu- point being the same, acupressure is manual stimulation of that point by thumb or fingers and acupuncture is needling the said point.

2. Where did this originate?
Acupuncture originated in India, but it was carried to China thro’ Nepal, by the Buddhist monks, and China developed and documented the science.

3. What factor determines the response of a patient to acupuncture?
The response of a patient to acupuncture depends on the severity of the illness, the chronicity of the ill-ness, the general health, constitution, emotional balance, diet, lifestyle along with a very open and unbiased receptive mind to the line of treatment. Mind over matter is the key to positive results.

4. How quickly can acupuncture treat on illness?
In this age of “instant gratification”, the “patient” needs to learn “patience”. The response varies from individual to individual. Those having good general vitality, children, less chronic an illness, often respond faster. And as reiterated, mind plays an important role.

5. Does acupuncture cure a problem permanently - or provide temporary relief?
Nothing in life is permanent - except perhaps death. Acupuncture does provide effective relief in many situations like low backache, cervical spondylitis, frozen shoulder etc. In some case it provides symptomatic relief and the patient might have to take treatment at regular intervals. If the working disability is reduced and emotional anxiety and distress is effectively managed, we have more than won the battle of life.

6. Is it effective as a single mode of treatment or in conjunction with other?
This depends on the illness or disease that the patient is suffering from. In a case of frozen shoulder, a single mode of treatment is effective.
If a person is suffering from hypertension the drug therapy and acupuncture therapy will have to be closely monitored.

7. Does it affect other simultaneous treatment?
It does not after the effect of any other simultaneous treatment.

8. Has acupuncture been given formal scientific recognition?
Yes, it has been given scientific recognition by the WHO and in many countries like Sri Lanka, Australia, UK, USA. In India, presently, the recognition of acupuncture is under the active consideration of the govt. The West Bengal Govt. has already recognised acupuncture in their state.

9. Which painful conditions can be treated by acupuncture?
Any discomfort where pain is the main syndrome – like – headaches, migraine, low backache, sciatica, tennis elbow, cervical, spondylosis, muscular spasms, etc. can be effectively treated by acupuncture.
10. Can it treat any other condition besides pain?
Yes, it can treat a large number of diseases like – asthma, sinusitis, constipation, menstrual problems, hypertension, facial paralysis, vertigo, stress related discomforts like anxiety, depression, insomnia, certain allergies, addictions, enuresis etc.

11. Does acupuncture have side effects?
Ans. Acupuncture has relatively no side effects. The most common side effect is a feeling of deep relaxation and an increased sense of well-being.

12. Is the insertion of needles painful?
Acupuncture needles are very fine, about the size of a thick hair. They are solid and nothing is injected through them. Prior to needling, it is very important that the patient is relaxed and comfortable with the idea of needling. A rapport between the patient and the acupuncturist is a absolutely necessary. Insertion of needle causes very little or no pain.

13. Is there any bleeding with needles?
Bleeding sometimes occurs on withdrawal of the needle occurs on withdrawal of the needle. This may be considered a benign complication and has no dangerous implications.

14. How often are the needles used in acupuncture changed?
All acupuncturists need to carry out stringent sterilization procedures. Frequent change of needles is required for smooth and painless insertion of needles.

15. What treatments are available for patients who are apprehensive of needles?
Needless techniques like acupressure, laser acupuncture, TCNS (transcutaneous neuro-stimulation) are some of the other treatments available for patients who are apprehensive of needles.

16. What role can acupuncture play in childbirth?
Acupuncture has two main effects in childbirth; it can reduce pain; and it can stimulate the contractions of the uterus, which help to ensure a healthy delivery. Reduction of pain without the use of drugs is of special benefit, especially to the unborn child.

17. Can acupuncture be used to quit smoking?
Acupuncture treatment helps to reduce or even give up smoking. It makes the system more sensitive to toxins, and therefore may make patient feel repulsion to the smoke. The patient must be committed to quitting smoking as acupuncture treatment can only help to motivate the addict – it is not a miracle cure.

18. Is acupuncture helpful in sleeping problems?
It is important to understand that very often, sleeping problems are a result of stress. Dependence on sleeping pills whether physical or psychological can have ill effects on the patient’s body and mind. Acupuncture can play a positive role in helping to reduce the drug, while assisting in regulating the patient’s sleeping pattern. This may take 4-6 wks.

19. Is acupuncture effective in emotional problems?
The Chinese philosophy of health defines physical and mental problems as different manifestations of disharmony. Emotional imbalances, if untreated may eventually result in physical symptoms. The emotional imbalances are treated by rebalancing, removing blockages, and restoring the natural flow of energy and not by suppressing symptoms with potentially addictive drugs.

20. How long does the treatment last?
The duration of treatment is decided by the duration of the disease. The less chronic an illness, lesser are the number of sittings.

21. What are the limitations of acupuncture?
An ‘emergency’ patient needing life saving resuscitation, surgery, serious infection, any life- threatening condition, a mechanical obstruction requiring immediate surgery, pregnancy, a pace- maker in the heart etc are some limitations. In such conditions, acupuncture would normally be a useful supplement in improving the final outcome of the sickness, and curing the residual/chronic component of the sickness.

In the process of living in this fast paced, fast lane life style, stress in an importance feature, which has repercussion on both our physical and mental well being stress, can manifest itself into anxiety, depression, allergies, certain gynecological problems etc. Today, we all have to manage time, money, space, finances, resources, relationships, jobs, and even pain. Effective a management comes with a positive frame of mind and a positive outlook towards life.

Acupuncture and mental health

Mental health is an area of speciality of acupuncture. It plays a major role of soothing, sedating and tranquillising a person’s mind. There are points, which are mood elevators, which reduce sleep and stimulate appetite and enhance immunity since acupuncture/ acupressure is based on treating the complete person without differentiating between the physical and mental illness. Hence its effectiveness in treating problems of mental health is immense.

Mental health is an upcoming area in current research in acupuncture and its effectiveness. Acupuncture has proved to be effective in many mental disorders like depression, anxiety-related disorders, stress disorders, bi -polar disorder etc. We have tried to compile some resources available on the Internet in the context of acupuncture and mental disorders, to illustrate this. These resources have been attached with this dossier for the reference of the readers.

Compiled by Daya Patwardhan, with assistance from Madhura Lohokare, Pune.

Bibliography
Borwankar, Dr. Prabha. 1988. ‘Practical Approach to Acupuncture’, Popular Prakashan Pvt. Ltd., Bombay.
Jayasurya, Dr. Anton. 1996. ‘Clinical Acupuncture’, B. Jain Publishers (P) Ltd., New Delhi.

Internet Resources

 
     

 

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