{"paper_id":"ea260931-a419-49b0-9e68-fa3f85fb5b2f","body_text":"Przegl¥d menoP auzalny 3/2013\n216\nAddress for correspondence:\nMagdalena Lewicka MSC, PhD, Department of Obstetrics, Gynaecology and Obstetrical-Gynaecological Nursing, Medical University, Chodźki 6, 20-093 Lublin, \ne-mail: m.lewicka@umlub.pl\nSummary\nIntroduction: Women at the peri- and post-menopausal age who are qualified for surgical procedures for \ngynaecological reasons are exposed to specific emotional problems related with the necessity to perform the \nsurgery. Therefore, they often expect various types of support. A characteristic feature of this support is an \nexchange of emotions, information, instruments for action and tangible property. \nAim of the study: The objective of the study was to perform an analysis of the type of support expected \nduring the peri-operative period by women treated for gynaecological reasons. \nMaterial and methods: The study covered 232 women at the pre- and peri-menopausal age who received \nsurgical treatment for various gynaecological reasons. The study was carried out using an author-designed \nquestionnaire form. The results of the study obtained were analysed statistically. The p values p < 0.05 were \nconsidered statistically significant. \nResults: It was found out that respondents who had university education significantly more frequently \n(p < 0.05) expected information and instrumental support, compared to those with elementary/elementary \nvocational or secondary education level. In turn, patients who were married significantly more often expected \nemotional and information support, compared to those who were single. The respondents who had undergone \na surgical procedure with considerable tissue injury significantly more frequently (p < 0.05) expected material \nsupport than women who had undergone surgery with moderate tissue injury. \nConclusions: The education level and marital status of patients determined the expectations of support \nduring the peri-operative period, whereas patients’ age and category of surgical procedure did not have any \neffect on the expectations of support during this time. \nKey words: support, gynaecological surgery, peri-operative period.\nStreszczenie\nWstęp: Kobiety w wieku około- i pomenopauzalnym, które kwalifikowane są do operacji z powodów gine-\nkologicznych, narażone są na specyficzne problemy emocjonalne związane z koniecznością wykonania operacji, \ndlatego często oczekują różnego rodzaju wsparcia. Cechą charakterystyczną wsparcia jest wymiana emocji, \ninformacji, instrumentów działania oraz dóbr materialnych. \nCel pracy: Celem pracy było dokonanie analizy rodzaju oczekiwanego wsparcia w okresie okołooperacyjnym \nu kobiet leczonych z powodów ginekologicznych.\nMateriał i metody: Badaniami objęto 232 kobiety w wieku przed- i okołomenopauzalnym, leczone operacyj-\nnie z różnych powodów ginekologicznych. Badania przeprowadzono z zastosowaniem kwestionariusza ankiety \nTypes of support expected by women treated due to gynaecological reasons \nduring the peri-operative period \nTypy oczekiwanego wsparcia w okresie oko³ooperacyjnym u kobiet leczonych ginekologicznie\nMagdalena Lewicka1, Artur Wdowiak1, Magdalena Sulima1, Barbara Stawarz2, Szymon Bakalczuk3, \nGrzegorz Bakalczuk1\n1Department of Obstetrics, Gynaecology and Obstetrical-Gynaecological Nursing Faculty of Nursing and Health Sciences,  \n Medical University, Lublin; \n Head of Department: Prof. Henryk Wiktor, MD, PhD \n2Institute of Health Protection, Rev. Bronisław Markiewicz State Higher School of Technology and Economics, Jarosław; \n Head of Institute: Irena Brukwicka, MD, PhD \n3Non-Public Health Care Unit ‘Ovum Reproduction and Andrology’, Lublin\nPrzegląd Menopauzalny 2013; 3: 216–222\nDOI: 10.5114/pm.2013.36586\n\nPrzegl¥d menoP auzalny 3/2013\n217\nIntroduction\nWhile deciding about the scope of surgical treat-\nment of a woman it is necessary to consider medi-\ncal goals, eva luate the state of health, patient’s \nexpectations, and consent expressed by the woman \nto the type of surgery proposed [1-3]. According to \nFriebe [4], an acceptance and understanding by the \nwoman of the surgical procedure proposed is of great \nimportance in gynaecology. Pa tient’s knowledge about \nthe type of surgery, chances for its success and possible \ncomplications allow her to relatively precisely analyze \nthe risk, which is usually related with injury, as well as \nthe benefits of surgical treatment, and determines the \nemotional state of the patient. \nThe Expert Team of the Polish Gynaecological Asso-\nciation developed categorization of surgical procedures \nin gynaecology, taking into consideration the extent of \ntissue injuries. Four categories of surgical procedures in \ngynaecology were distinguished:\n•  category I – surgical procedures related with slight \ntissue injury; \n•  category II – surgical procedures related with moderate \ntissue injury; \n•  category III – surgical procedures associated with \nconsiderable tissue injury;\n•  category IV – surgical procedures related with \nextensive tissue injury [5].\nWomen at the peri- and post-menopausal age who \nare qualified for surgical procedures for gynaecological \nreasons, apart from the symptoms directly related \nwith menopause, are exposed to specific emotional \nproblems associated with the necessity to perform the \nsurgery, and therefore, often expect various types of \nsupport. \nSocial support is a multi-dimensional concept, \nwhich may be variously defined. Sęk [6, 7] considers \nit as assistance available to an individual in difficult \nsitua tions, possible to obtain due to interactions with \nothers, which is a consequence of the affiliation of an \nindividual to society. A characteristic feature of support \nis an exchange of emotions, information, instruments \nfor action and material goods. Such an exchange may \nbe one-sided or mutual, and its supporting-supported \ndirection may be constant or alternating. It is important \nthat this exchange accurately meets the demands of \nthe person who is in a difficult situation [8, 9]. \nIrrespective of different opinions concerning the \ntype of support, the following types are distinguished: \n•  Emotional support – consists in passing on supporting, \nreassuring emotions, which are the manifestation of \nconcern and positive attitude towards the supported \nperson in order to create the sense of affiliation, \ncare and increase self-esteem. Due to the emotional \nsupport those who suffer may release themselves \nfrom own tensions and negative feelings, may \nexpress their anxiety, concerns, and sadness. Also, an \nadequate behaviour of the supporting person releases \nthe sense of hopefulness. \n•  Informative support – consists in the exchange \nand provision of information and giving advice, \nwhich favour better understanding of the situation, \nown position in life and problems. Provision of \nfeedback information concerning the effectiveness \nof undertaking by the supported person of various \npreventive measures, and sharing own experience \nwith an individual experiencing similar problems also \nplays an important role. Informative support responds \nto the need for understanding the sense of critical \nevents and their causes. \n•  Instrumental support – consists in passing on \ninformation pertaining to specific ways of conduct, \nand may take the form of the modelling of effective \nremedial behaviours. \n•  Tangible (material) support – consists in the provision \nof direct assistance, in the form of a loan, gift or \nservice. Such a form of support may be, for example, \nacting on behalf of those in need: feeding, provision \nof shelter, residence, conveying financial support for \nliving, provision with pharmaceuticals and medicinal \nproducts [6-8, 10].\nThe category of support may be considered and \nmeasured from structural or functional perspectives. \nSocial structural support covers the category of the \nstructure of interpersonal relationships. It enables an \nobjective evaluation of mutual relationships between \nvarious types of social bonds. Social functional support \nmakes it possible to evaluate whether these bonds fulfil \ntheir specified functions. Therefore, a division was made \ninto perceived social support and received social support.\nwłasnego autorstwa. Uzyskane wyniki badań poddano analizie statystycznej. Przyjęto 5-procentowe ryzyko błę-\ndu wnioskowania, p < 0,05 uznano za istotne statystycznie.\nWyniki: Stwierdzono, że badane z wykształceniem wyższym istotnie częściej (p < 0,05) oczekiwały wsparcia \ninformacyjnego i instrumentalnego aniżeli pacjentki z wykształceniem podstawowym lub zawodowym oraz \nśrednim. Z kolei badane zamężne istotnie częściej oczekiwały wsparcia emocjonalnego i informacyjnego ani-\nżeli pacjentki samotne. Badane, u których wykonano operację ze znacznym urazem tkanek, istotnie częściej \n(p < 0,05) oczekiwały wsparcia rzeczowego aniżeli kobiety poddane operacji z miernym urazem tkanek.\nWnioski: Wykształcenie i stan cywilny pacjentek warunkowały oczekiwanie wsparcia w okresie okołoope-\nracyjnym, natomiast wiek pacjentek i kategoria zabiegu operacyjnego nie warunkowały takiego oczekiwania.\nSłowa kluczowe: wsparcie, operacje ginekologiczne, okres okołooperacyjny.\n\nPrzegl¥d menoP auzalny 3/2013\n218\nPerceived support results from the knowledge and \nconvictions of an individual concerning from whom \nand where he/she may obtain assistance in a difficult \nsituation, whereas received support is objectively \nevaluated or subjectively reported by a recipient, \nas an actually received type and amount of support \n[7, 11]. These two types of support exert an effect \non the level of evaluation of stressful events, and \nmay be associated with a lower intensity of negative \nemotions, or contribute to an increase in the sense of \nown resourcefulness, effectiveness, and independence. \nIn the functional effect of support it is important to \nadjust received support to perceived support. According \nto Verheijden et al. [12], this type of support shows \na strong correlation with health. \nObjective\nThe objective of the study was to perform an analysis \nof the type of support expected during the peri-operative \nperiod among women treated for gynaecological \nreasons, according to socio-demographic variables and \ncategory of the surgical procedure. \nMaterial and methods\nThe study covered 232 women at the pre- and peri-\nmenopausal age who received surgical treatment due \nto various gynaecological reasons at the Chairs II and \nIII, Clinic of Gynaecology, Independent Public Clinical \nHospital No. 4 in Lublin, and the Gynaecology and \nOb stetric Ward with Outpatient Department at the \nCardinal Stefan Wyszyński Specialist Hospital in Lublin. \nConsent to the study was obtained from the Bioethical \nCommission at the Medical University in Lublin. \nThe study was conducted using a questionnaire form \ndesigned by the author for the needs of the presented \ninvestigations. The study was carried out in two stages: \non the day preceding the surgery and on the third \nday after the surgical procedure. On these days, the \nrespondents completed an identical questionnaire form. \nAll the women in the study expressed their voluntary \nconsent to complete the questionnaires, after being \ninformed about the use of the results of the study only \nfor scientific purposes and assurance of its anonymity. \nAmong patients who participated in the study there \nwere 74 (31.90%) patients aged 41-50, 80 women (34.48%) \naged over 50, and 78 (33.62%) respondents aged up to \n40. As many as 55 (23.7%) patients had elementary or \nelementary vocational education, 115 (49.6%) – secondary \neducation, and 62 (26.7%) – uni versity education. Among \nthe respondents, 157 (67.68%) women were married, \nwhile 75 (32.32%) patients were single. \nThe structure of the study group according to the type \nof surgical procedure was as follows: in the group of 167 \n(71.98%) patients in the study, a surgical procedure with \nconsiderable tissue injury was performed, whereas in 65 \n(28.02%) respondents the surgery was performed with \nmoderate tissue injury. Among the surgical procedures \nwith moderate tissue injury in 21 (32.31%) patients \nsurgical hysteroscopy was performed, in 13 (20.0%) \nsurgery due to vaginal prolapse, also in 13 (20.0%) \npatients diagnostic laparoscopy was performed. In \n10 (15.38%) patients amputation of the cervix was \nperformed, in 5 (7.69%) the Burch colposuspension, \nwhile in 3 (4.62%) – the Marshall-Marchetti-Krantz \n(MMK) colposuspension. In the group of patients who \nhad undergone surgery with considerable tissue injury, \nsimple abdominal hysterectomy was most frequently \nperformed – 68 (40.72%) patients, followed by surgical \nlaparoscopy – 31 (18.55%), myomectomy – 26 (15.57%), \nand partial or complete surgical removal of the uterine \nbody – in 20 (11.98%) patients. Surgical treatment of \nendometriosis was performed in 9 (5.39%) patients, \n10 (5.99%) respondents had undergone unilateral \nremoval of the uterine appendages, while bilateral \nremoval of the uterine appendages was performed in \n3 (1.80%) of the patients in the study. \nThe results of the studies obtained were analysed \nstatistically using chi-square (chi\n2) test for homogeneity \nby means of computer software STATISTICA 8.0 \n(StatSoft, Poland). The p values p < 0.05 were considered \nstatistically significant. \nResults \nTable I presents the relationship between the type \nof support expected during the peri-operative period \nand patients’ age. \nThe study showed that during the peri-operative pe-\nriod, patients aged 40 and under expected emotional, in-\nfor mative, instrumental and material support on a similar \nlevel as those aged 41-50, and also over 50. These \ndifferences were statistically insignificant (p > 0.05). The \nfact of performance of the procedure did not re sult in \nvariation in the support expected by patients in the age \ngroups compared. Also, during the post-operative period \nthe respondents aged 40 and under expected emotional, \ninformative, instrumental and material support on a level \nsimilar to those aged 41-50, and also over 50. These \ndifferences were statistically insignificant (p > 0.05). \nTable II presents an analysis of the relationship \nbetween the type of perceived support during the peri-\noperative period and the respondents’ education level. \nBased on the results of studies it was found that \nduring the pre-operative period the patients with uni-\nversity education significantly more frequently expec ted \ninformative support (69.35%) and instrumental support \n(25.81%), compared to those with secondary education \n(46.09% and 11.30%, respectively), and elementary or \nelementary vocational education level (41.82% and \n7.27%, respectively). The statistical analysis performed \n\nPrzegl¥d menoP auzalny 3/2013\n219\nshowed a statistically significant relationship between \nthe expectations of informative support (p < 0.02) and \ninstrumental support (p < 0.05) during the pre-operative \nperiod, and the respondents’ education level. However, \nno statistically significant difference was observed  \n(p > 0.05) between the expectations of emotional and \nmaterial support during the pre-operative period, accor-\nding to the respondents’ education level. The per centage \ndistributions determining the expectations of support \nduring the post-operative period did not con siderably \nchange according to the respondents’ edu cation level. \nAlso, during the post-operative period, women who \nhad university education more frequently expected \ninformative support (62.90%) and instrumental support \n(25.81%) than the respondents who had secondary \neducation (53.04% and 16.52%, respectively), and ele-\nmentary or elementary vocational education (41.82% \nand 12.73%, respectively). A statistically significant rela-\ntionship was confirmed between the expectations of \ninformative support (p < 0.05) and instrumental support \n(p < 0.05) during the post-operative period, and the \neducation level of the patients examined. However, no \nstatistically significant difference was found (p > 0.05) \nbetween expectations of social and material support \nTable I. Relationship between the type of expected support and the respondents’ age during the peri-operative period\nCategory \nof surgical \nprocedure\nSupport expected before surgery*\nemotional informative instrumental material\nn % n % n % n %\nup to 40 71 91.03 45 57.69 17 21.79 3 3.85\n41-50 67 90.54 32 43.24 4 5.41 1 1.35\nover 50 68 85.00 42 52.50 12 15.00 2 2.50\nχ\n2 1.268 2.265 3.007 0.147\np NS NS NS NS\nCategory \nof surgical \nprocedure \nSupport expected after surgery*\nemotional informative instrumental material\nn % n % n % n %\nup to 40 68 87.18 44 56.41 19 24.36 2 2.56\n41-50 64 86.49 44 59.46 10 13.51 3 4.05\nover 50 68 85.00 35 43.75 13 16.25 3 3.75\nχ\n2 0.589 1.898 1.740 0.159\np NS NS NS NS\n*the respondents provided more than one reply\nTable II. Relationship between the type of support expected during the peri-operative period and the respondents’ education level\nCategory of surgical procedure Support expected before surgery*\nemotional informative instrumental material\nn % n % n % n %\nelementary or elementary vocational 47 85.45 23 41.82 4 7.27 0 0.00\nsecondary 101 87.83 53 46.09 13 11.30 6 5.22\nuniversity 58 93.55 43 69.35 16 25.81 0 0.00\nχ2 3.598 7.899 6.448 1.287\np NS < 0.02 < 0.05 NS\nCategory of surgical procedure Support expected after surgery*\nemotional informative instrumental material\nn % n % n % n %\nelementary or elementary vocational 42 76.36 23 41.82 7 12.73 2 3.64\nsecondary 102 88.70 61 53.04 19 16.52 4 3.48\nuniversity 56 90.32 39 62.90 16 25.81 2 3.23\nχ2 4.228 6.517 6.210 1.278\np NS < 0.05 < 0.05 NS\n*the respondents provided more than one reply\n\nPrzegl¥d menoP auzalny 3/2013\n220\nduring the post-operative period, and the respondents’ \neducation level. \nTable III shows the relationship between the type of \nsupport expected during the peri-operative period and \nthe respondents’ marital status. \nMarital status considerably determined the respon-\ndents’ expectations of emotional and informative sup-\nport during the pre-operative period. Single women \n(unmarried, widowed, divorced) considerably less fre-\nquently expected emotional support (77.33%) and \ninformative support (38.67%), compared to the married \nwomen (94.77% and 57.32%, respectively). In both cases, \na statistically significant relationship was observed at \na level of p < 0.02 and p < 0.01, respectively. During the \npost-operative period, married women also considerably \nmore often expected emotional support (91.72%) and \ninformative support (57.32%), compared to those who \nwere single (74.67% and 44.00%, respectively). During \nthe post-operative period a statistically significant \nrelationship was noted between the expectation of \nemotional support (p < 0.02) and informative support \n(p < 0.02), and the marital status of the women in \nthe study. Nevertheless, no statistically significant re-\nla tionship was observed (p > 0.05) between expec-\ntations of instrumental and material support, and \nthe respondents’ marital status, both during the pre-\noperative and post-operative periods. \nTable IV presents relationship between the type of \nsupport expected during the pre- and post-operative \nperiods, and the category of the surgical procedure. \nThe study showed that patients in whom surgery \nwas planned with moderate tissue injury slightly \nmore rarely expected emotional support (84.62%) \nand informative support (47.69%) during the pre-\nTable III. Relationship between the type of expected support and respondents’ marital status during the peri-operative period\nCategory \nof surgical \nprocedure\nSupport expected before surgery*\nemotional informative instrumental material\nn % n % n % n %\nsingle 58 77.33 29 38.67 11 14.67 2 2.67\nmarried 148 94.27 90 57.32 22 14.01 4 2.55\nχ\n2 8.457 10.569 0.259 0.477\np < 0.02 < 0.01 NS NS\nCategory \nof surgical \nprocedure \nSupport expected after surgery*\nemotional informative instrumental material\nn % n % n % n %\nsingle 56 74.67 33 44.00 12 16,00 4 5,33\nmarried 144 91.72 90 57.32 30 19,11 4 2,55\nχ\n2 8,598 7.458 3.569 2.659\np < 0.02 < 0.02 NS NS\n*the respondents provided more than one reply\nTable IV. Relationship between the type of support expected and category of surgical procedure during the peri-operative period\nCategory of surgical procedure Support expected before surgery*\nemotional informative instrumental material\nn % n % n % n %\nmoderate tissue injury 55 84.62 31 47.69 9 13.85 2 3.08\nconsiderable tissue injury 151 90.42 88 52.69 24 14.37 4 2.40\nχ2 2.585 3.569 1.741 0.879\np NS NS NS NS\nCategory of surgical procedure Support expected after surgery*\nemotional informative instrumental material\nn % n % n % n %\nmoderate tissue injury 53 81.54 30 46.15 24 36.92 8 12.31\nconsiderable tissue injury 143 85.63 79 47.31 57 34.13 37 22.16\nχ2 2.268 0.144 1028 6.598\np NS NS NS <0.05\n*the respondents provided more than one reply\n\nPrzegl¥d menoP auzalny 3/2013\n221\noperative period, compared to those in whom surgery \nwas planned with considerable tissue injury (90.42% \nand 52.69%, respectively). However, this difference \nwas statistically insignificant (p > 0.05), similar to the \nexpected instrumental and material support (p > 0.05). \nAlso, during the post-operative period, the women who \nhad undergone surgery with a moderate tissue injury \nslightly more rarely expected emotional support (81.54%) \nand informative support (46.15%), compared to the \nwomen who had undergone surgery with considerable \ntissue injury (emotional support – 85.63%, informative \nsupport – 47.31%). This difference was not statistically \nsignificant (p > 0.05). Nevertheless, during the post-\noperative period, a statistically significant relationship \nwas found (p < 0.05) between the category of surgical \nprocedure and expectation of material support in the \ngroup of patients. The respondents who had undergone \nsurgery with a considerable tissue injury significantly \nmore frequently expected material support (22.16%) \nthan those who had undergone surgical treatment \nwith moderate tissue injury (12.31%). However, among \nthe patients in the study, no statistically significant \ndifferences were observed (p > 0.05) between the ca-\nte gory of surgical procedure and expectations of \nemotional, informative and instrumental support during \nthe post-operative period. \nDiscussion\nWomen, irrespective of age, perceive gynaecological \nsurgical procedures as a form of mutilation, which is \nassociated with the violation of physical integrity, \ndisturbed body image, and decreased self-esteem. \nTherefore, during the peri-operative period, it is im-\nportant to identify patients with a low level of personal \nand social resources, in order to provide them with an \nadequate type of support [13-15].\nSalmon [16] emphasizes that social support is \nespecially important for hospitalized patients, because \nit serves as their protection against physiological and \nemotional stress responses. According to this researcher, \nthe obtaining of support from the medical staff and others \nis related with a lower level of anxiety and depression, \nand better adaptation after the surgery. Social support is \nan important factor which results in the restoration and \nincrease in the sense of coherence, and when provided by \na family or other social network, may help the patient to \nperceive her own situation as understandable, steerable \nand meaningful [17]. The studies by Łepecka-Klusek et al. \n[18] show that older women (aged > 49 years) significantly \nmore often than those younger (aged ≤ 49 years) expect \nsupport mainly from the medical staff, because in their \nopinion, they may less often count on support from their \nfamily than the younger patients. \nLindberg and Nolan [19] consider that it is important \nto provide women with adequate informative and emo-\ntional support during the period of decision making \nconcerning surgical treatment. The patients’ need for \nemotional support, to a great extent, is due to their \nbeing insufficiently informed about the goal of surgical \ntreatment and the surgical method [20]. The presented \nstudy shows that during the pre-operative period the \npatients expected emotional, informative, instrumental \nand material support on a similar level, irrespective of \ntheir age. In turn, considering the respondents’ edu-\ncation level, in own studies it was observed that during \nthe pre-operative period patients with university \neducation considerably more often expected informative \nand instrumental support, compared to those with \nelementary/elementary vocation or secondary edu ca-\ntion. Also, married women significantly more frequen-\ntly expected emotional and informative support than \nthose who were single. \nThe effect of social support on the self-reported \nand objective indicators of stress during the peri-\noperative period was investigated by Krohne and \nSlangen [21]. The results of the studies obtained \nshowed that patients who received high social support \nwere characterized by a lower level of anxiety, were \nadministered lower doses of anaesthetics, and the \nduration of their hospitalization was considerably \nshorter, compared to patients who received poor \nsupport during the peri-operative period. According \nto Chan et al. [22], during the post-operative period, \nthe obtaining of material and informative support is \nmore important for patients than emotional support. \nStudies conducted by Bunde et al. [23] showed that \npatients who had undergone hysterectomy received \nhigh emotional and material support from their \nclosest surroundings. However, despite this, the above-\nmentioned patients considerably more frequently \nsought for information and advice from other women \nwho had undergone a similar surgical procedure, than \nsought emotional support. The presented study shows \nthat age did not determine the type of expected support \nduring the post-operative period. Nevertheless, the \ntype of expected support depended on the education \nlevel and marital status of the women examined. In \nown studies, it was observed that during the post-\noperative period the patients with university education \nconsiderably more often expected informative and \ninstrumental support, compared to respondents with \nan elementary/elementary vocational or secondary \neducation level. In turn, married women significantly \nmore frequently expected emotional and informative \nsupport than women who were single. No significant \ndifferences were found between the category of the \nsurgical procedure and expectations of emotional, \ninformative, instrumental or material support in the \ngroup of patients examined, during the pre-operative \nand post-operative periods. \n\nPrzegl¥d menoP auzalny 3/2013\n222\nConclusions\n1.  Patients’ age did not determine the expectation of \nsupport during the peri-operative period.\n2.  The education level and marital status of patients \ndetermined expectation of support during the peri-\nope rative period. The respondents with university \nedu cation significantly more frequently expected \ninformative and instrumental support, compared to \npatients with elementary/elementary vocational or \nsecondary edu cation level. In turn, married women \nsignificantly more often expected emotional and \ninformative support than patients who were single. \n3.  The category of the surgical procedure did not \ndetermine the expected emotional, informative, \ninstru mental and material support during the pre-\noperative period. However, during the post-operative \nperiod, only material support was determined by the \ncategory of the surgical procedure. 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