STIKep PPNI Jawa Barat, Bandung - INDONESIA

National Cheng Kung University Hospital - TAIWAN

Bandung, 16th – 17th July, 2018

Conference Book
International Conference on Health Care
and Management
“Evidence to inform action on supporting and implementation of
SDGs”

Secretary Office :
STIKep PPNI Jawa Barat (Intitute of Nursing Science PPNI West Java)
Jalan Ahmad IV No. 32 Cicendo, Bandung 40173
West Java – Indonesia
Phone: +62 22 6121914
E-mail: [email protected]
Website: www.icon-stikepppni.org

National Cheng Kung University Hospital

No.138, Sheng Li Road,Tainan, Taiwan 704, R.O.C.
Tel：886-6-2353535
E-mail：[email protected]
Conference Book International Conference on Health Care and
Management:
“Evidence to inform action on supporting and implementation of SDGs”
Bandung, 16th – 17th July, 2018

This book published by:

STIKep PPNI Jawa Barat (Intitute of Nursing Science PPNI West Java)
Jalan Ahmad IV No. 32 Cicendo, Bandung 40173
West Java – Indonesia
Phone.: +62 22 6121914
E-mail: [email protected]
Website: www.icon-stikepppni.org

National Cheng Kung University Hospital (NCKUH)

No.138,Sheng Li Road,Tainan, Taiwan 704, R.O.C.
Tel：886-6-2353535
E-mail：[email protected]

Chief Editor:
Linlin Lindayani, Ph.D

Member:
Irma Darmawati, M.Kep.,Ns.Sp.Kep.Kom
Heni Purnama, MNS
Conference Book – Table of Contents
International Conference on Health Care and Management-2018

Welcome Message............................................................................................................................... 4
Conference Committee ....................................................................................................................... 8
Conference Program ......................................................................................................................... 10
Presentation Schedule ...................................................................................................................... 14
Speaker Biographic............................................................................................................................ 30
Information .......................................................................................................................................... 43
Welcome Message

Assalamualaikum Warahmatullahi Wabarakatuh

Dear honorable guests,

Sustainable Development Goals (SDGs) as an agreement of
sustainable development objectives agreed by all countries at
the 2015 UN sessions. Each country including Indonesia has an
obligation to implement this joint development plan by applying
universal, integration and inclusive principles by ensuring that no
one missed or “No-one Left Behind”
Indonesia has Nawa Cita or 9 priority agenda which should
synergize with SDGs and can be used as health program
application in Indonesia to also achieve SDGs.

On behalf of the organizing committee and the Nursing Society of Indonesia, I am

glad to invite you to join ICHM 2018 (International Conference on Health Care and
Management) in Bandung, Indonesia on July 16-17, 2018.

The conference is expected to reveal some solutions for evidence-based health care
and scientific facts to be discussed by various viewpoints from diverse speakers from
around the world with the title “Evidence to inform action on supporting and
implementation of SDGs. Through the International Conference is expected to
improve health services, especially in the field of nursing in Indonesia to improve the
human development index.

We hope all participant could benefit from the exciting program and will surpass your
expectation and that will be an inspiring event.

Warm regards,

Dhika Dharmansyah
Conference chair
 Assalamu’alaykum Wr.Wrb
Good morning and best wishes for all of us.

Ladies and gentlemen, in such a great and happy day, let’s praise and
thank to Allah Swt who has given us grace and mercy to all of us to
gather in this International Conference on Health Care Management
event today.
First of all, we would like to gratitude and appreciate highly to national
Cheng Kung University Hospital has given the opportunity and confidence to our institution
STIKep PPNI Jabar for the second time in collaboration to organize International Conference
on Health Care Management with theme: “Evidence to inform action on supporting and
implementation of SDGs”. This event is one of follow up The memorandum of Understanding
between NCKUH with STIKep PPNI Jabar.
STIKep PPNI Jabar is as a nursing education institution carry out the mandate to create
professional nurse, we must implement all TRIDHARMA University activities in academic
atmosphere that aims to broaden and improve nursing and existence of nurse profession
capacity in nation developing continually.
As we know the university academic quality is determined by its researches and graduates
result quality. The research work results may be either a right against managing intellectual
wealth equity as well as scientific work which is able to be publicized through scientific
journals and scientific gathering forums of the same scientist background both in national
and international level.
Nevertheless, the publishing of journal researches is published by its university. Nowadays,
it is irregular because there are both financial and scientific manuscript availability
drawbacks. Scientific regular manuscripts are very limited because manuscript contributor is
only from its university as well.
The high education Research and technology ministry data in 2017, it stated that there were
an increase of research work publishing done by practitioners, academicians and
researchers of Indonesian. The amount of Indonesian research publishing on international
journal certifiable indexed Scopus tended to increase. The high education Research and
technology ministry data on December 1st 2017 noted that Indonesia scientific research
publishing reached 14.100 journals. Meanwhile, on October 1st 2017 there were as many as
12.098 journals.
However, internally nurse profession scientific research journals are still less of publishing. It
is alleged to the low of quantity and quality publishing about nursing. One of the drawbacks
is rarely the interaction between nursing scientists and experts in scientific conferences.
Some efforts are carried out by STIKep PPNI to encourage and to accelerate sharing
knowledge amongst the nursing experts. Accordance to the goals, National Cheng Kung
University Hospital Taiwan and STIKep PPNI have made MoU and held as this International
conferences organizer. Hopefully, it is able to bridge all stakeholders, practitioners, and
academicians in supporting the quality of the human resources especially, nurses and health
workers as well.
The honourable ladies and gentlemen,
Nowadays, in the global era, the transformation runs rapidly and consequently it makes the
knowledge based society. Information and communication technology development are very
important in on its role in manifesting society development based on the knowledge. The
higher education of society will be higher of health service quality demands specially nurse.

Accordance to the effort, this International conference aims to,

1. Facilitate the knowledge sharing between health experts and nurses to encourage
the goal of health human resource quality.
2. Produce health scientific and nursing articles deserve to be published on
international scopus indexed journal.
3. Make communication networking amongst Universities, research institution, nurse
practitioners, and other stakeholders.

I truly believe that all participants through the 2 days in international conference, our goals
above are able to be manifested well.

Finally, I would like to thank to all of participants diligently and with spirit of attending this
international conference on health care management.

Wish the conference is able to be knowledge sharing event and delightful and successful as
well, the conference will be enlightened and interchange will do great help for us after
attending this conference, especially STIKep PPNI Jabar and generally for all profession
nurses to provide health services to communities, aamiin ya robbal alamin.

Wassalamu’alaykum Wr.wb.
Kindest regards,

The Dean of STIKep PPNI Jabar

 Excellencies, Distinguished Delegates, Ladies and Gentlemen,
Selamat Siang,

I’m ChyunYu Yang, the superintendent of National Cheng Kung

University Hospital in Tainan, Taiwan.
On behalf of our hospital, it is my pleasure and privilege to
welcome all of you to participate in the international conference
on health care and management 2018.
To our eminent speakers and delegates who have come from
UK, Netherland, Korea, Japan, Thailand, Singapore, Taiwan, and
Indonesia, I bid you a very warm welcome to Bandung. We are indeed honoured to
have you here with us. We have about 1.000 participants from different place in
Indonesia and countries gathered here today, making our conference a truly
meaningful one.

This is our second time collaborate with STIKEP PPNI Jawa Barat to hold an
international conference. Last year, we have very successful conference with the
theme focus on infection control and disaster management.
And this year, our conference theme is “evidence to inform action on supporting and
implementation of SDGs”.

The Sustainable Development Goals (SDGs) known as the global goals, are a
universal call to action to end poverty, protect the planet and ensure that all people
enjoy peace and prosperity. Goal 3 addresses all major health priorities and calls for
improving reproductive, maternal and child health; ending communicable diseases;
reducing non-communicable diseases and other health hazards; and ensuring
universal access to safe, effective, quality and affordable medicines and vaccines as
well as health coverage.
However, the world seems still far from ending maternal mortality, with more than
303,000 deaths in pregnancy or childbirth occurring annually. NCDs are also a
growing problem, causing 40 million deaths in 2015.
But, All in all, we can take comfort in the fact that SGDs indicators are moving in the
right direction .Yet we still have plenty of work to do.

I wish in the next two day and a half, we have the opportunity - and indeed the
responsibility - to prepare and add knowledge related the current situation and
progress reflection of SDGs.
In closing, I encourage delegates to participate actively in the interesting discussions
over the next two days. I wish everyone a successful and fruitful conference.

Thank you.
Conference Committee

Steering Committee : H. Oman Fathurohman

H. Wawan Arif Sawana., S.Kp
Dr. Hj. Tri Hapsari. R. A., S.Kp., M.Kes
Drs. Sutjahyo., M.M
H. Husen BSC., MM
Advisor : Ns. Diwa Agus Sudrajat., M.Kep
Chair : Dhika Dharmansyah, Ners., M.Kep
General Secretary : Irma Darmawati., M.Kep.,Sp.Kep. Kom
Dian Anggraini., Ners., M.Kep
Finance : Hj. Imas Tjutju, AMK.,S.Pd
Fitria Agustina., Amd
Tati Apriliawati., S.Pt
Programs : Dewi Srinatania., S.Kp.,M.Kep
Heni Purnama., MNS
Gina Nurdina., S.Kep., Ners
Lia Juniarni., M.Kep., Sp. Kep.J
Nyayu Nina Putri C ., Ners., M. Kep
Scientific : Dewi Marfuah., Ns., M.Kep
Susy Puspasari., Ners., M.Kep
Wini Hadiyani., S.Kp., M.Kep
Vita Lucya, Ners., M.Kep
Nunung Nurhayati.,Ns., M.Kep
Tri Antika., Ners., M.Kep
Bhakti Permana., M.Si., M.Kep
Rizal., Ilbert.,SS., MM
IT Administrator : Rena Ratna Nur Syamsiah, AMD
Yuda Gumelar, S.Ip.,MPd
Deni Firmansyah., S.Sos
Public Relation and : Suci Noor Hayati., Ners., M.Kep
Sponsorship Eva Supriatin., S.Kp., M.Kep
Masdum Ibrahim., S.Kep., Ners
Ade Supriadi, S.Pd.,M.Si
Linlin Lindayani., MSN
Accomodation, Logistik, and : Agus Hendra., S.Kp., M.Kep
Documentation Ns. Herdiman., M.Kep
Wagino
Budi Gunawan, SE
Ribut Sarimin, M.Kes
Hj. Yuyu Yulipah, AMK.,S.Pd
General Committee : Asep Haedar
Djudju
Adjum
Dahlan
Edi
Security : Asep Supriyadi
Diki
Uu
Siswo
Poster Presentation
ICHM 2018
EFFECTIVENESS OF OXYGEN ACTIVITY THERAPY LOW FLOW
SYSTEM BINASAL KANUL WITH SOW FOWLER POSITION TO
REDUCE PAIN IN PATIENTS OF ACUTE CORONER SIDE
IN ULIN RSUD
1
Mariani, 2Hamzah, 3Solikin
1,3
University of Muhammadiyah Banjarmasin, South Kalimantan, Indonesia
2
Department of Anesthesiology, Soetomo, Dr. General Hospital
Corresponding Email: [email protected]

ABSTRACT

Background: Coronary Heart Disease is a heart disease caused by the narrowing of coronary
arteries due to atherosclerosis or spasm or both. Acute Coronary Syndrome (SKA) is a
serious disease which threatens someone’s life, it can cause sudden death. Objectives: The
purpose of this study is to analyze the effectiveness of Oxygen Therapy Action Method of
low flow system binasal kanul with semi fowler position to reduce chest pain in patients with
Acute Coronary Syndrome at Ulin Hospital. Methods: The research method used Queasy
Experimental Designs using nonequivalent control group design. The experimental group and
control group treatments were measured before and after treatment. Results: Pain rate in
patients with Acute Coronary Syndrome with oxygen action method of low flow system
binasal kanul p value 0,000 and level of pain in patients with acute coronary syndrome with
semi fowler position p value 0.000. Conclusions: This research needs to be refined and
developed to improve the reference in developing the concept of how to reduce the scale of
pain in patients with Acute Coronary Syndrome using non-pharmacological therapy. The
results of this study measures oxygen therapy method low flow binasal kanul system with
semi fowler position effective against reducing chest pain in patients with Acute Coronary
Syndrome.

Keywords: ACS, Binasal cannula, Semi-Fowler.

INTRODUCTION
Coronary Heart Disease is a heart disease caused by the narrowing of coronary arteries due
to the process of atherosclerosis or spasm or both. Coronary heart disease causes problems in the
heart's organs and especially in the blood vessels. Acute Coronary Syndrome is a serious life-
threatening coronary disease because it can cause sudden death18
American Heart Association (AHA) data noted that every two minutes one person dies of
heart disease. Five of the 1000 hospitalized patients in some developing countries are estimated to
have cardiac arrest, and less than 20% of patients are unable to survive out of hospital11.
World Health Organization (WHO) data, the death of heart disease will continue to increase
worldwide. In total, by 2030 it is predicted there will be 52 million deaths per year or up 14 million
from 38 million by 2015. More than two thirds (70%) of the global population will die of heart 16.
The main symptoms of the most complained or felt by patients with coronary heart disease
are chest pain (angina) or discomfort in the chest. The pain is very severe, worsens, and lasts more
than 20 minutes. Pain can be accompanied by body weakness, nausea, shortness of breath, fatigue,
cold sweats or fainting. Pain or discomfort is very severe, worsens and lasts more than 20 13.
Poster Presentation
ICHM 2018

METHOD
This research is quantitative research with a design using Quasi-Experimental Designs
research method, this design has a control group, but it can not function to control the external
variables that influence the experiment implementation. This research uses nonequivalent control
group design. After the treatment, the results of the measurements of the two treatments can be
compared which is more effective.
The population in this study were all patients with Acute Coronary Syndrome (SKA) treated
in the Inpatient Heart Hospital (Alamanda) Hospital Ulin in November 2017.
Sample size from population got 36 people, as for Inclusion criteria:
1. Patients with Acute Coronary Syndrome (SKA)
2. The pain felt by the patient include scale 4 -9 (Medium/heavy)
3. Not with STEMI
4. Angiography has not been done
The samples were divided into two experimental groups namely Oxygen Therapy of cannula
and Semi-Fowler Position
The research instrument for the dependent variable is NRS (Numeric Rating Scale) scale,
pain measurement using NRS scale to assess the scale of pain in SKA patients. Results from NRS
Scale Assessment: score 0 included category no pain, score 1-3 included on the mild pain scale, score
4-6 including medium pain scale, score 7-9 including heavy pain category and ten very heavy or
unbearable pain. Assessment of pain is done pre and post actions to be performed, whether pain
decreases, pain unchanged or pain increases.
The data collected by the researcher in this research is related to the independent variable in
this research in the form of SOP process perform the action developed by the researcher.
The ethics of this study used patients with diagnoses of Acute Coronary Syndrome with
moderate pain scale treated in the Heart Room (Alamanda) of Ulin Banjarmasin Hospital, so it should
consider the ethical and humanist aspects. Previously, research should get ethical approval (ethical
clearance) from the Ethics Committee of Muhammadiyah University of Banjarmasin and Ethics
Committee at Ulin Banjarmasin Hospital. In addition to the principles of research ethics, researchers
also made informed consent given to the patient/family before the study was conducted.

RESULTS
Data collection was conducted from November third week until December fourth week 2017
At Ulin Hospital. This study uses 36 respondents; the sample is then divided into two intervention
groups that are 18 by using Oxygen Therapy Action Method of Low Flow System Binasal Kanul and
18 using Semi Fowler Position.

Univariate Analysis

Tabel.1 Distribution of Respondents by Sex and Age at Ulin Hospital (n = 36)

Characteristics Semi Fowler’s position Low flow

f % f %
Gender
a. Man 12 66,7 10 55,6
b. Woman 6 33,3 8 44,4
Total 18 100 18 100
Age
46- ≥64 18 100 18 100

Most of the respondents were gender and age, most respondents were 12 (66,7%) male for
Semi-Fowler and 10 (55,6%) for Oxygen, so total male respondents were 22 from 36 respondents,
Poster Presentation
ICHM 2018
while the respondent distribution based on age that respondents aged elderly s / d the end of the
average 46-≥65 for the position of semi-fowler and Oxygen total of 18 of 36 respondents.

Table 2. Pain Scale on Patients Given Oxygen Therapy Measures With Low Flow System
Binasal Kanul Method n = 18
Scale of Scale Before After
f % f %
Mild Pain 7 38,9 17 94,4
Medium Pain 11 61,1 1 5,6
Amount 18 100 18 100

Most of the pain scale in patients with Acute Coronary Syndrome at Ulin Hospital before
being administered was moderate pain category, i.e. 11 people (61.1%), and light category seven
people (38,9%). Whereas after being given Oxygen Therapeutic Measure With Low Flow System
Binasal Kanul Method, most of the patients had pain scale with the light category, that is 17 people
(94,4%) and moderate category as many as one person (5,6%).

Table 3. The pain scale in the patients given the semi-fowler position, n =18
Scale of Scale Before After
f % f %
Mild Pain 0 0 7 39,0
Medium Pain 18 100 11 61,0
Amount 18 100 18 100

Most of the pain scale in patients with Acute Coronary Syndrome at Ulin Hospital before
being given Semi Fowler's Position action was with moderate pain category, i.e., as many as 18
people (100%). After the Semi-Fowler Position, most patients had moderate-to-moderate pain scores
of 11 (61.0%) and light category of 7 (39.0%).
Normality test before and after is done (Semi-Fowler Position and Action of Oxygen
Therapy With Low Flow System Binasal Kanul Method) based on a test of normality Shapiro-Wilk.
Can be p-value value 0.000.

Bivariate Analysis

Tabel.4 Effectiveness of Semi-Fowler Position in Acute Coronary Syndrome at Ulin Hospital (n = 18)

Semi
Standar
Fowler Median Mean Rank p-value
Devition
position
Pre 6,00 0,00 1,056 0,000
Post 1,451 9,00 1,451

Before and after the provision of semi-fowler position in SKA patients in Ulin General
Hospital, median pre 6.00 average, mean rank pre 0.00 and standard deviation of 1.056. Average
median post 4,00, Mean Rank 0,00 and standard deviation 1,451, The result of statistical test got p-
value 0.000 which means p-value <0,05, so it can be concluded Semi Fowler's position effective in
reducing pain scale in a patient of Acute Coronary Syndrome.

Tabel.5 Effectiveness of Oxygen Therapy Action Methods Low Flow System Binasal Kanul in Acute
Coronary Syndrome at Ulin Hospital (n = 18)

Low flow Median Mean Rank Standard p-value

Poster Presentation
ICHM 2018
Division
Pre 6.00 0.00 1.056 0.000
Post 1.451 9.00 1.451

Before and after the administration of Oxygen Actions in patients with Acute Coronary Syndrome at
Ulin Hospital, median average pre 6.00, Mean Rank pre 0.00 and standard deviation of 1.056.
Average median post 4.00, Mean Rank 9.00 and standard deviation 1.451, The result of statistic test
got p-value 0.000 which mean p-value <0.05, so it can be concluded oxygen therapy action with a low
flow method bi-nasal system cannula is effective in reducing the scale of pain in patients with Acute
Coronary Syndrome.

Tabel.6 Effectiveness of Oxygen Therapy Methods Low Flow system Binasal Kanul with Semi-
Fowler position on reducing chest pain in patients with Acute Coronary Syndrome at Ulin Hospital (n
= 18)

Standar
Action Median Mean Rank p-value
Devition
Semi 4.00 3.89 1.056 0.043
fowler
Low flow 4.00 3.89 1.451

Provision of Oxygen Therapy Low Flow system Binasal Kanul method and semi-fowler
position to reduce chest pain in patients with Acute Coronary Syndrome, a median average of 4.00
and mean 3.89. The result of statistical test obtained p-value 0,043 which mean p value <0,05, so it
can be concluded oxygen therapy method low flow system binasal kanul with semi fowler position
effectively decrease chest pain in a patient of the acute coronary syndrome at RSUD.

DISCUSSION
Characteristics of Respondents
Age is a painting variable that affects pain, especially in children and the elderly.
Developmental differences, found among these age groups can affect how children and elderly act
against pain. Pain is not a part of the aging process that can not be avoided. In elderly people who
experience pain, need to do an assessment, diagnosis, and management aggressively17.
In general, men and women did not differ significantly in response to pain, pain tolerance for a long
time has been the subject of research involving men and women. However, tolerance to pain is
influenced by biochemical factors and is unique to each, regardless of sex17.

The effectiveness of Oxygen Therapy Action Method Low Flow system Binasal Kanul in pain
reduction in patients with Acute Coronary Syndrome at Ulin Hospital
Oxygen therapy is done to increase oxygen supply and reduce breathing work. Oxygen
therapy is used to create a balance between oxygen supply and oxygen demand. This imbalance will
cause organ dysfunction. Oxygen therapy can improve the outcome and save lives when used
appropriately and harmfully if used improperly17.
This study proved that the provision of oxygenation action With Low Flow System Binasal
Kanul method could reduce the scale of pain in patients with Acute Coronary Syndrome because this
alternative is beneficial for the patient's condition, this way is easy to do in the nursing environment.
Provided interventions provide comfort, improve mobility, change psychological responses, reduce
fear and give clients the power to control pain3.
Oxygen supplementation is the standard treatment for all patients present with acute
coronary syndromes, regardless of oxygen saturation level. Oxygen Therapy Low Flow system
Binasal Kanul method in the reduction of pain in patients with Acute Coronary Syndrome in this
study of oxygen therapy bi-nasal cannula low flow method by giving 1-3 liters with a concentration of
Poster Presentation
ICHM 2018
24-32% to 18 respondents. The advantage of using nasal cannula oxygen is a simple, inexpensive and
more often used tool for delivering oxygen.

Effectiveness Measures Semi-fowler position in pain reduction in patients with Acute Coronary
Syndrome at Ulin Hospital.
The simplest and most effective method to reduce the risk of decreasing chest wall
development is by setting the position at rest. The most effective position for patients with the
cardiopulmonary disease is to give a semi-fowler position with a degree of 30-45º14.
The semi-fowler position can increase oxygen and maximize ventilation efforts by
decreasing abdominal compression at the lung base. The semi-fowler position in the patient may also
support lung performance. The process of blood circulation is influenced by the position of the body
and changes in body gravity. Upright positions are also used to increase lung volume and reduce
respiratory work in patients19.
Giving a semi-fowler position with a slope of 45º helps the development of the chest in
patients with cardiopulmonary disorders can be effective in reducing pain in patients with Acute
Coronary Syndrome

The effectiveness of Fowler Position with Action of Oxygen Therapy With Low Flow System Bi-
nasal cannula Method for reducing pain in patients with Acute Coronary Syndrome at Ulin
Hospital
A decrease in cardiac output is associated with a reduction in cardiac contraction as a
priority because of the impact of the cardiac reduction in the rate of glomerular filtration rate resulting
in sodium retention causing ischemia in the myocardium, and this may adversely affect the patient
and also cause changes in tissue perfusion. Cardiac output is a disturbance in the breathing pattern that
can be bad for the patient21.
Semi Fowler's position causes decreased tension in the abdominal muscles, and the
abdominal mass drops down, reducing the pressure to the diaphragm and relieving chest compression.
At the time of inspiration, the pressure in the lungs is much lower than usual than the atmospheric
pressure, which results in more air intake into the lungs. Increased air entering the lungs, an increase
oxygenation, especially in semi-fowler position 30º14. semi-fowler position and action of oxygen
therapy low flow system binasal kanul method effective on decreasing the scale of pain in patients
with acute coronary syndrome.

CONCLUSION
Based on study, it can be concluded that Provision of Oxygen Therapy Low Flow system
Binasal Kanul method and semi-fowler position to reduce chest pain in patients with Acute Coronary
Syndrome, a median average of 4.00 and mean 3.89. The result of statistical test is p-value 0,043
which means p- value <0,05, so it can be concluded that oxygen therapy method of low flow system
bi-nasal cannula with semi-fowler position effectively decrease chest pain in patients with acute
coronary syndrome in rsud ulin

Suggestion
For Institution Hospital
Semi-fowler Position and Methods of low flow system bi-nasal cannula are applied in
reducing the scale of pain especially in patients with Acute Coronary Syndrome in care of nursing
care.

For Educational Institutions

As a reference in developing the concept of how to reduce the scale of pain in patients with
Acute Coronary Syndrome using non-pharmacological therapy and also efficient to develop nursing
interventions.

For Nurses
Poster Presentation
ICHM 2018
New knowledge that Semi Fowler's position and low flow bin canal method is effective in
reducing the scale of pain in patients with Acute Coronary Syndrome, may provide a solution in
treating pain in patients with Acute Coronary Syndrome.

For Further Research

This research can also be continued with larger sample, because this research is applicative
so it is worth to be developed again to enrich the repertoire of nursing science.

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