56Debriefing

Grading:1++High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
RID: 1035Reference number 4995
Rose S;Bisson J;Wessely S;
Psychological Debriefing for preventing Post Traumatic Stress Disorder (PTSD)
2001John Wiley & Sons Ltdpgs
Study Type:Systematic Review
Patient---
Characteristics
Intervention---
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsNo evidence that single session debriefing reduces psychological distress nor prevents the onset of PTDS.
Quality
RID: 1036Reference number 4731
Scottish Intercollegiate Guidelines Network (SIGN);
Postnatal depression and puerperal psychosis
200260Scottish Intercollegiate Guidelines Networkpgs
Study Type:Systematic Review
Patient---
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
FundingClinical Resource and Audit Group of the Scottish Executive Health Department
ConclusionsSigns and symptoms of depression. Risk factors.
Quality
Grading:1+Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
RID: 1011Reference number 4918
Gamble JA;Creedy DK;Webster J;Moyle W;
A review of the literature on debriefing or non-directive counselling to prevent postpartum emotional distress
200218 1Midwiferypgs 72 79
Study Type:Systematic Review
Patient
Characteristics
Intervention
Comparisons
Study Length
Outcomes
Effect
FundingUnknown
ConclusionsThis systematic review looked at three RCTs. The two largest RCTs (n=1745 and n=872)indicate that a single debriefing session in the postnatal ward is of no statistically significant value in reducing psychololgical morbidity and may even be harmful. However the researchers conclude that there is insufficient evidence to draw conclusions about the effectiveness of debriefing followin childbirth because it is not clear that a standardised method
Quality+Unclear if standardised debriefing intervention was used
RID: 1028Reference number 4925
Midmer D;Wilson L;Cummings S;
A randomized, controlled trial of the influence of prenatal parenting education on postpartum anxiety and marital adjustment
199527 3Family Medicinepgs 200 205
Study Type:Randomised Controlled Trial
PatientPregnant women and their partners
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsEducational intervention of two classes (3 hours each) in the prenatal period significantly reduced state anxiety at 6 weeks (p < 0.05) and 6 months postpartum (p < 0.05).
Quality
Grading:2++High-quality systematic reviews of case–control or cohort studies High-quality case–control or
RID: 976Reference number 4923
Kennerley H;
Maternity blues: III. Associations with obstetric, psychological, and psychiatric factors
1989155 SepBritish Journal of Psychiatrypgs 367 373
Study Type:Cohort
PatientWomen assessed at 14–16 weeks prenatal, weeks 36–38 of pregnancy, 10 days postpartum, week 12 of puerperium
Characteristic
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsPostpartum blues associated with poor family and/or marital relationships (p < 0.05) anxiety (p < 0.001) and prenatal neuroticism score (p < 0.001). Type of delivery, obstetric morbidity, history of psychiatric illness were not associated with postpartum blues.
QualityProspective cohort study
RID: 987Reference number 4953
Kennerley H;Gath D;
Maternity blues. I. Detection and measurement by questionnaire
1989155Br J Psychiatrypgs 356 362
Study Type:Cohort
PatientNewly delivered women interviewed in the first ten days postpartum
Characteristics
Intervention
Comparisons49 symptoms of psychological state
Study Length
Outcomes---
Effect
Funding---
ConclusionsCluster analysis identified 7 symptoms associated with ‘primary blues’, namely; Tearfulness Fatigue Anxiety Feeling overemotional Changeability in mood Low spiritedness Forgetfulness/muddled thinking.
QualityProspective cohort study
Grading:2+Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance
RID: 1052Reference number 144
Ayers S;Pickering AD;
Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence
200128 2Birthpgs 111 118
Study Type:Cohort
PatientWomen at 36 months gestation, 6 weeks and 6 months postpartum
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
Conclusions2.8% of women fulfilled the criteria for PTSD at 6 weeks postpartum and this decreased to 1.5% at 6 months postpartum.
QualityProspective cohort study
RID: 1053Reference number 4950
Ballinger CB;Buckley DE;Naylor GJ;Stansfield DA;
Emotional disturbance following childbirth: clinical findings and urinary excretion of cyclic AMP (adenosine 3′5′cyclic monophosphate)
19799 2Psychological Medicinepgs 293 300
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
ComparisonsPostpartum blues women and non postpartum blues women
Study Length
Outcomes---
Effect
Funding---
ConclusionsPoor family relationships (p < 0.001), problems in marital relationship (p < 0.01), problems in sexual relationship associated with postpartum blues (p < 0.05).
QualityProspective cohort study
RID: 1063Reference number 4916
Czarnocka J;
Prevalence and predictors of post-traumatic stress symptoms following childbirth
200039 1British Journal of Clinical Psychologypgs 35 51
Study Type:Cohort
PatientPostpartum women within 72 hours post-delivery and 6 weeks postpartum
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
Conclusions3% of women fulfilled the criteria for PTSD at 6 weeks postpartum. PTSD was associated with unplanned pregnancy (p < 0.01), no partner present at birth (p < 0.001), past mental health problems (p < 0.05), trait anxiety p < 0.001) and episiotomy during childbirth (p < 0.05). PTSD was not associated with pain relief breech presentation, type of delivery, vaginal tear, use of induction, nature of onset of labour, method of monitoring process.
QualityProspective cohort study
RID: 1014Reference number 4920
Hapgood CC;
Maternity blues: Phenomena and relationship to later post partum depression
198822 3Australian & New Zealand Journal of Psychiatrypgs 299 306
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
ComparisonsAssessment of mood (depression, tearfulness, anxiety, irritability) 34 weeks pre-natally. Postpartum: daily for 14 days, 6 weeks, 3 months, 6 months and 12 months
Study Length
Outcomes---
Effect
Funding---
ConclusionsAge, race, marital status, and socio-economic status were not risk factors for postpartum blues. Postnatal depression associated with blue symptom of lability.
QualityProspective cohort study
RID: 1021Reference number 4581
Kendell RE;Chalmers JC;Platz C;
Epidemiology of puerperal psychoses
1987150British Journal of Psychiatrypgs 662 673
Study Type:Cohort
Patient120 psychiatric admissions to hospital within 90 days postpartum
Characteristics
Intervention
ComparisonsTemporal relationship between psychiatric admissions and psychosis admissions
Study Length
Outcomes---
Effect
Funding---
ConclusionsThere were 120 psychiatric admission within 90 days postpartum from 54 087 births. The distribution of admissions was studied in an 8 year period from 1972–1979. The analysis commenced 2 years before birth and 2 years postpartum. Psychosis admission peaked in the first month fell thereafter but remained significantly higher for 2 years compared with 2 year prenatal period.
QualityRetrospective cohort study
RID: 1031Reference number 4955
O’Hara MW;Schlechte JA;Lewis DA;Varner MW;
Controlled prospective study of postpartum mood disorders: psychological, environmental, and hormonal
1991100 1Journal of Abnormal Psychologypgs 63 73
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
ComparisonsPostpartum blues women and non postpartum blues women
Study Length
Outcomes---
Effect
Funding---
ConclusionsPersonal and family history of depression (p < 0.01), social adjustment (p < 0.01), stressful life events(p < 0.05), and levels of free and total estriol (p < 0.05). Age, education and parity were not associated with postpartum blues.
QualityProspective cohort study
RID: 1032Reference number 4578
Pfuhlmann B;Stober G;Franzek E;Beckmann H;
Cycloid psychoses predominate in severe postpartum psychiatric disorders
199850 2–3Journal of Affective Disorderspgs 125 134
Study Type:Cohort
PatientWomen with severe postpartum psychiatric disorders admitted within 6 months postpartum
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsExtensive case notes were made on all women followed by an extensive interview on the course of the illness to obtain a lifetime-diagnosis according to ICD-10 and Leonhard’s classification. The illness began in the first week in the majority of women (56%). According to Leonhard’s classification cycloid psychosis accounted for 54% of diagnosis, manic depression for 13%, schizophremnias for 10% and monopolar depression for 8%.
QualityRetrospective cohort study
RID: 1046Reference number 4931
Wijma K;Soderquist J;Wijma B;
Posttraumatic stress disorder after childbirth: a cross sectional study
199711 6Journal of Anxiety Disorderspgs 587 597
Study Type:Cohort
PatientPostpartum women 1 month to 13 months post-delivery
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
Conclusions1.7% women had symptoms of acute PTSD. PTSD was associated with primiparous women ((p = 0.003) and having received psychological counselling (p = 0.003). PTSD was not associated with age, education level, civil status, presence of partner at birth.
QualityProspective cohort study
RID: 1047Reference number 4579
Wisner KL;Peindl K;Hanusa BH;
Symptomatology of affective and psychotic illnesses related to childbearing
199430 2Journal of Affective Disorderspgs 77 87
Study Type:Cohort
PatientPrimary DSM-III Axis 1 diagnosis of non-psychotic affective disorders, psychotic affective disorders and non-affective psychosis
Characteristic
Intervention
Comparisons21 post-partum psychotic 92 post-partum non-psychotic 96 control psychotic women 553 control women non-psychotic
Study Length
Outcomes---
Effect
Funding----
ConclusionsSymptom patterns in women with childbearing-related onset illness and non-childbearing- related onset illness. Analysis of 64 components showed that women with childbearing related psychosis reported higher frequency of suicidal ideation (p = 0.002) and a higher score on the factor cognitive disorganization (p < 0.001). Increased motor activity was greater in childbearing related psychosis (p < 0.001).
QualityRetrospective cohort study
Grading:2Case–control or cohort studies with a high risk of confounding bias, or chance and a significant
RID: 1054Reference number 4914
Barnett B;Parker G;
Possible determinants, correlates and consequences of high levels of anxiety in primiparous mothers
198616 1Psychological Medicinepgs 177 185
Study Type:Cohort
PatientPostpartum women 89 women with high anxiety 29 women with moderate anxiety 29 women with low anxiety
Characteristic
Intervention
ComparisonsObstetric, social and baby obstetric variables
Study Length
Outcomes---
Effect
Funding---
ConclusionsHigh anxiety levels were associated with postpartum blues (p < 0.001), depression (p < 0.001) and migrant status (p < 0.01). No association found with age, social class, social support, or prior obstetric history.
QualityProspective cohort study
RID: 1056Reference number 209
Canals J;Esparo G;Fernandez-Ballart J;
How anxiety levels during pregnancy are linked to personality dimensions and sociodemographic factors
200233 2Personality & Individual Differencespgs 253 259
Study Type:Cohort
PatientPregnant and then postpartum women
Characteristics
Intervention
ComparisonsAnxiety before conception, in the 1st, 2nd and 3rd trimester, 3 days after delivery and 1 month after delivery
Study Length
Outcomes---
Effect
Funding---
ConclusionsState anxiety peaked at day 3 following delivery and decreased at 1 month (although not statistically significant).
QualityProspective cohort study
RID: 1058Reference number 46
Cox JL;Connor Y;Kendell RE;
Prospective study of the psychiatric disorders of childbirth
1982140British Journal of Psychiatrypgs 111 117
Study Type:Cohort
PatientPregnant and then postpartum women
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsAnxiety increased during pregnancy (from 2nd to 3rd trimester), peaked at the first postpartum interview (within 10 days postpartum). At 3–5 months postpartum, anxiety fell to its lowest level.
QualityProspective cohort study
RID: 1062Reference number 4915
Creedy DK;Spochet IM;Horsfall J;
Childbirth and the development of acute trauma symptoms: incidence and contributing factors
200027 2Birthpgs 104 111
Study Type:Cohort
PatientPostpartum women assessed at 4–6 weeks postpartum
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
Conclusions5.6% women had symptoms of acute PTSD. PTDS was associated with emergency caesarian section (p = 0.0001), forceps delivery section (p = 0.0001), high delivery pain section (p = 0.0001), vacuum delivery section (p = 0.003).
QualityProspective cohort study
RID: 1009Reference number 264
Davidson JR;
Post-partum mood change in Jamaican women: A description and discussion on its significance
1972Vol. 121 565British Journal of Psychiatrypgs 659 663
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
ComparisonsPostpartum blues women and non postpartum blues women
Study Length
Outcomes---
Effect
Funding---
ConclusionsMultiparous women had greater incidence of postpartum blues (p < 0.05).
QualityProspective cohort study
RID: 1010Reference number 4917
Ehlert U;Patalla U;Kirschbaum C;Piedmont E;Hellhammer DH;
Postpartum blues: Salivary cortisol and psychological factors
199031 3Journal of Psychosomatic Researchpgs 319 325
Study Type:Cohort
PatientPostpartum blues women and non postpartum blues women
Characteristics
Intervention
Comparisons12 psychological factors
Study Length
Outcomes---
Effect
Funding---
ConclusionsTrait-anxiety (p < 0.005), passive coping strategies (p < 0.01),, marital dissatisfaction (p < 0.005), or non acceptance of their roles as mothers (p < 0.05) associated with postpartum blues.
QualityProspective cohort study
RID: 1012Reference number 4919
Gard PR;
A multivariate investigation of postpartum mood disturbance
1986148British Journal of Psychiatrypgs 567 575
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
ComparisonsPostpartum blues women and non postpartum blues women
Study Length
Outcomes---
Effect
Funding---
ConclusionsPrimiparous women had greater incidence of postpartum blues (p < 0.05).
QualityProspective cohort study
RID: 1015Reference number 173
Hau FW;Levy VA;
The maternity blues and Hong Kong Chinese women: an exploratory study
200375 2Journal of Affective Disorderspgs 197 203
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
ComparisonsPostpartum blues women and non postpartum blues women
Study Length
Outcomes---
Effect
Funding---
ConclusionsSymptoms peaked on day 5. Women aged 35–39 had a lower incidence of postpartum blues compared with women aged 18–34 (p < 0.05). Parity, education level and marital status not associated with postpartum blues.
QualityProspective cohort study
RID: 1065Reference number
Ijuin T;Douchi T;Yamamoto S;Ijuin Y;Nagata Y;
The relationship between maternity blues and thyroid dysfunction
1998pgs
Study Type:Case-Control
PatientRecruited subjects from 279 women using Okano self rating scale Normal delivery
Characteristics
Intervention
ComparisonsMaternity blue scores at 37 weeks prenatally, 5 days and 1 month postpartums
Study Length
Outcomes---
Effect
Funding---
ConclusionsResolution of low mood/high anxiety/mild depression at 1 month.
Quality
RID: 1017Reference number 4921
Ijuin T;Douchi T;Yamamoto S;Ijuin Y;Nagata Y;
The relationship between maternity blues and thyroid dysfunction
199824 1Journal of Obstetrics & Gynaecology Researchpgs 49 55
Study Type:Case-Control
PatientRecruited subjects from 279 women using Okano self rating scale Normal delivery
Characteristics
Intervention
ComparisonsMaternity blue scores
Study Length
Outcomes---
Effect
Funding---
ConclusionsResolution of low mood/high anxiety/mild depression at 1 month.
Quality
RID: 985Reference number 4951
Kendell RE;Mackenzie WE;West C;McGuire RJ;Cox JL;
Day-to-day mood changes after childbirth: further data
1984145Br J Psychiatrypgs 620 625
Study Type:Cohort
PatientPostpartum women mood tested to day 10
Characteristics
Intervention
ComparisonsPersonality types: neuroticism, psychoticism, extraversion, lying
Study Length
Outcomes---
Effect
Funding---
ConclusionsDepression, tears and lability peaked on day 5 falling to day 10. Eysenck Personality Questionnaire showed neuroticism is associated with high score in symptoms on day 5 (depression p < 0.01, lability p < 0.01).
QualityProspective cohort study
RID: 986Reference number 4952
Kendell RE;McGuire RJ;Connor Y;Cox JL;
Mood changes in the first three weeks after childbirth
19813 4J Affect Disordpgs 317 326
Study Type:Cohort
PatientMood ratings scales completed daily to 21 days postpartum
Characteristics
Intervention
ComparisonsSymptoms of tears, happiness, depression, anxiety, irritability, lability
Study Length
Outcomes---
Effect
Funding---
ConclusionsDepression postpartum (p < 0.001), tears and lability peaked on day 5 postpartum.
QualityProspective cohort study
RID: 1024Reference number 277
Klompenhouwer JL;
The clinical features of postpartum psychosis
199510 7European Psychiatrypgs 355 367
Study Type:Cohort
Patient250 puerperal psychosis admissions derived from 238 patients (12 patients admitted twice) within 3 months postpartum
Characteristic
Intervention
ComparisonsAuditive hallucination, Optic hallucination, Misrecognition Mania, Depression, Formal thought disorder, Persecurtary delusions, Delusions of grandeur, Nihilistic delusions, Thematic delusions, Retardation, stupor, Agitative behavior and speech, Number of
Study Length
Outcomes---
Effect
Funding---
ConclusionsProminent symptoms of puerperal psychosis were depersonalization, misrecognisation, themic delusions and kaleidoscopic picture (rapid shifts in the level of confusion, mood and psychotic symptoms).
QualityRetrospective cohort study
RID: 990Reference number 4956
Levy V;
The maternity blues in post-partum and post-operative women
1987151Br J Psychiatrypgs 368 372
Study Type:Cohort
Patient37 postpartum women, 28 women post major surgery, 22 women post minor surgery
Characteristics
Intervention
ComparisonsChildbirth, major surgery, minor surgery mood comparison
Study Length
Outcomes---
Effect
Funding---
ConclusionsPostpartum symptoms peaked on days 3–4, and declined on days 5 and 6. Symptoms in the surgical groups declined progressively to day 6, without showing a peak.
QualityProspective cohort study
RID: 1029Reference number 261
Nott PN;
Hormonal changes and mood in the puerperium
1976128 AprBritish Journal of Psychiatrypgs 379 383
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
ComparisonsPostpartum blues women and non postpartum blues women
Study Length
Outcomes---
Effect
Funding---
ConclusionsPrimiparous women had greater incidence of postpartum blues (9:4).
QualityProspective cohort study
RID: 988Reference number 4954
O’Hara MW;Schlechte JA;Lewis DA;Wright EJ;
Prospective study of postpartum blues. Biologic and psychosocial factors
199148 9Arch Gen Psychiatrypgs 801 806
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsPostnatal depression was positively associated with postpartum blues (p < 0.01).
QualityProspective cohort study
RID: 977Reference number 4926
Pitt B;
Maternity blues.
1973Vol. 122 569British Journal of Psychiatrypgs 431 433
Study Type:Cohort
PatientPostpartum women on wards (7th and 10th day)
Characteristics
Intervention
ComparisonsPostpartum blues women and non postpartum blues women
Study Length
Outcomes---
Effect
Funding---
Conclusions‘Blues rating’ and Maudsley Personality Inventory used to measure neuroticism and extraversion. 50% of 100 women diagnosed with postpartum blues. Anxiety (p <0.001) and confusion (p<0.05) were significantly associated with postpartum blues.
QualityProspective cohort study
RID: 1553Reference number 250
Sholomskas DE;Wickamaratne P;
Postpartum onset of panic disorder: A coincidental event?
199354 12pgs 476 480
Study Type:Cohort
PatientPostparum women
Characteristics
Intervention
ComparisonsWomen with panic disorder Control women
Study Length
Outcomes---
Effect
Funding---
ConclusionsProbability statistics showed that onset of panic disorder was not a coincidental event (co-occurrence probability 0.0092).
QualityRetrospective cohort study
RID: 1041Reference number 4929
Sostek AM;Scanlon JW;Abrason DC;
Postpartum contact and maternal confidence and anxiety: A confirmation of short-term effects
19825Infant Behavior and Developmentpgs 323 329
Study Type:Cohort
PatientPostpartum women
Characteristics
Intervention
Comparisons6 women separated from baby for 1st 24 hours 28 women not separated from baby
Study Length
Outcomes---
Effect
Funding---
Conclusions1 month postpartum, women separated from baby had increased anxiety (p < 0.05).
QualityProspective cohort study
RID: 1044Reference number 254
Stein GS;
The pattern of mental change and body weight change in the first post-partum week
198024 3 Sup 4Journal of Psychosomatic Researchpgs 165 171
Study Type:Cohort
Patient18 primigravid women 19 multigravid women
Characteristics
Intervention
ComparisonsSymptoms of crying, depression, restlessness, dreaming, irritability, headache, exhaustion, anorexia, poor concentration
Study Length
Outcomes---
Effect
Funding---
Conclusions76% women experienced tearfulness (cf Pitt 1973: 50%). Depression, crying, headaches, dreaming, restlessness and irritability peaked around days 4–5. Severe postpartum blues occurred amongst women with a previous history of neurotic depression (p < 0.01), tearfulness in 3rd trimester (p < 0.01), no elation in 1st trimester (p < 0.02), previous postnatal depression (p
QualityProspective cohort study
RID: 1049Reference number 262
Yalom ID;Lunde DT;Moos RH;Hamburg DA;
Postpartum blues syndrome. A description and related variables
196818 1Archives of General Psychiatrypgs 16 27
Study Type:Cohort
PatientWomen assessed 1–3 weeks prior to birth, then daily for 10 days
Characteristics
Intervention
ComparisonsPostpartum blues women and non postpartum blues women
Study Length
Outcomes---
Effect
Funding---
ConclusionsPrimiparous women had greater incidence of tearfulness.
QualityProspective cohort study
Grading:4Expert opinion, formal consensus
RID: 1051Reference number 4913
ICEA position statement and review of postpartum emotional disorders
200318 3International Journal of Childbirth Educationpgs 35 43
Study Type:Reviews and Reports
Patient---
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsPostpartum blues can be improved by a new mother using good self-care techniques and making use of support systems. These include; good nutrition, regular physical activity and sleep, developing of a support system, having realistic expectations of motherhood, taking breaks to rest, practicing deep breathing, expressing and accepting negative feelings, structuring of the day, nurturing a sense of humour and postponing major life changes.
Quality
RID: 1549Reference number 5037
Jones HW;Venis JA;
Identification and classification of postpartum psychiatric disorders
200139 12J Psychosoc Nurs Ment Health Servpgs 23 30
Study Type:Reviews and Reports
Patient---
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsWomen with postpartum blues should be encouraged to seek further evaluation if symptoms persist beyond 7 to 10 days.
Quality
RID: 1037Reference number 4928
Seyfried LS;
Postpartum mood disorders
200315 3International Review of Psychiatrypgs 231 242
Study Type:Reviews and Reports
Patient---
Characteristics
Intervention
Comparisons---
Study Length
Outcomes---
Effect
Funding---
ConclusionsWomen with postpartum blues should be encouraged to seek further evaluation if symptoms persist beyond 7 to 10 days.
Quality

From: Appendix C, Clinical Evidence Extractions

Cover of Postnatal Care
Postnatal Care: Routine Postnatal Care of Women and Their Babies [Internet].
NICE Clinical Guidelines, No. 37.
National Collaborating Centre for Primary Care (UK).
Copyright © 2006, National Collaborating Centre for Primary Care.

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