Abstract
SARS-CoV-2 (COVID-19) infection can be associated with significant medical complications. This risk could be even higher in psychiatric patients due to an increased risk of medical co-morbidity. In addition, psychiatric patients are also vulnerable to acquiring SARS-CoV2 infection due to homelessness, living in crowded areas, and poor adherence to recommended preventive measures. This retrospective study aims to compare two groups of patients, namely COVID-19 positive inpatient psychiatric patients with and without preexisting medical comorbidity on specific clinical and socio-demographic features and more importantly how many patients in the two groups subsequently developed medical complications. All COVID-19 positive psychiatric patients who were admitted to acute psychiatric inpatient units over a one-year period during the peri-pandemic phase were included for this study. Data was collected from the electronic medical records of 174 patients admitted to the inpatient psychiatric facility between January and December 2020.
Among the COVID-19 positive patients, twenty individuals out of eighty-nine in the WC (with pre-existing medical comorbidity) group and two individuals out of eighty-five in the WOC (without pre-existing medical comorbidity) group developed COVID-related pneumonia. Ten WC patients and two WOC patients required supplemental oxygen, while only one patient in the WC group developed critical illness and required ventilatory support. The WC group had longer stay in both psychiatric and medical units compared to the WOC group. Consistent with existing literature that patients with comorbid medical condition are higher risk of COVID-19 complications, this study replicates the finding that in psychiatric inpatients pre-existing comorbid medical conditions create a higher risk of experiencing COVID-19 related medical complications. More interestingly, however that increased risk of developing new medical complications was not significantly different from the published rates observed in the general population which is surprising given how vulnerable psychiatric patients are, both medical, psychiatrically and psychosocially. In fact, in some ways and for reasons as yet unclear, the medical complication rate was slightly better in the WC compared to published data in the general population groups.
Keywords: SARS-CoV-2, COVID-19, Medical complications, Inpatient psychiatric patients, Comorbidity
1. Introduction
In 2020, COVID-19 ranked as the third leading cause of death in the US, following heart disease and cancer. It has contributed to the deaths of approximately 377,883 individuals, accounting for 11.3% of all deaths by that year [1]. According to the CDC (Center for Disease Control), the severity of COVID-19 infection varies across the general population, with approximately 81% experiencing mild to moderate symptoms, 14% experiencing severe symptoms, and 5% classified as critical cases. Among COVID-19 cases in the US, 19% required hospitalization, and the overall fatality rate was 2.7% [2]. The CDC has identified older age (over 65) as a high-risk factor for COVID-19 related medical complications. However, individuals of any age with comorbid conditions such as chronic obstructive pulmonary disease (COPD), heart disease, diabetes mellitus, and obesity are also at an increased risk of developing severe illness from COVID-19. Additional comorbidities that may place patients at a higher risk include asthma, cerebrovascular accidents (CVAs), hypertension, immunocompromised states, and smoking [3]. It is worth noting that these comorbidities are widely prevalent among patients with psychiatric disorders particularly those with chronic and sever mental illnesses. Despite this, psychiatric patients have not received the same level of attention in the public health management.
Psychiatric patients face a higher risk of homelessness, increased medical comorbidity, living in high-density urban areas, and poor adherence to recommended preventive measures [[4], [5], [6]]. Such factors can make psychiatric patients more vulnerable both for acquiring COVID-19 infection and subsequent medical complications. Moreover, comorbid medical conditions are common among psychiatric patients at baseline even before contracting Covid-19 infection (pre-existing), due to personal, disease-related, and treatment-associated risk factors [4]. Additionally, substance use disorder is prevalent in this population, which can further increase complications and the severity of COVID-19 infection. For instance, patients diagnosed with schizophrenia have higher rates of alcohol, nicotine, and illicit drug use compared to the general population [6,7]. It is estimated that 68% of psychiatric patients suffer from comorbid medical conditions, and 28% of those with a medical disorder have a comorbid mental health condition [8,9]. For example, in a study analyzing death records of 608 seriously mentally ill patients in Ohio public mental health hospitals, it was discovered that almost a quarter of the deceased (24%) had obesity (BMI>30), 22% suffered from hypertension, 12% had diabetes, 10% had COPD and related conditions, and 5% had asthma [10]. Research evidence indicates an excess mortality rate in psychiatric patients, with the leading cause of death being comorbid heart disease [10].
Recent evidence unequivocally confirms that the presence of comorbid medical conditions significantly increases the risk of experiencing complications related to COVID-19 across all patient populations. The severity of COVID-19 infection is influenced by various factors, including individual immune responses and underlying health conditions. In a small percentage of COVID-19 patients, the illness can become severe and critical [11]. It is natural to question how psychiatric patients, who are already at a heightened risk of medical comorbidities and also vulnerable to acquiring COVID-19, would respond in the face of the potentially devastating health consequences associated with COVID-19. Specifically, it is important to understand what would be the interplay between COVID-19 and pre-existing comorbidities in the context of having a psychiatric disorder and how this might impact the overall morbidity and mortality rates among psychiatric patients.
We aimed to investigate the rates of COVID-19-related medical complications in acute psychiatric patients. Specifically, this retrospective study aims to compare two groups of patients, namely COVID-19 positive inpatient psychiatric patients with and without preexisting medical comorbidity on specific clinical and socio-demographic features and more importantly how many patients in the two groups subsequently developed medical complications. The study sample were those patients who were COVID-19 positive and were admitted to acute psychiatric inpatient units over a one-year period during the peri-pandemic phase. By identifying potential high-risk factors in COVID-19-positive psychiatric patients, we aimed to facilitate the early identification of individuals at risk and provide necessary medical monitoring and treatment measures. This is important for reducing the risk of serious medical complications, both for inpatients and patients living in the community. By recognizing, monitoring and taking necessary precautions, and ensuring timely referrals for treatment, we may be able to minimize the occurrence of or progression to severe medical complications.
2. Materials and methods
This retrospective review utilized data from three psychiatric inpatient facilities within the Valleywise Health Comprehensive Healthcare System in Maricopa County, Arizona. Approval for the study (Protocol ID: 2020-096) was obtained from the Valleywise Health Institutional Review Board, along with waivers of informed consent and HIPAA authorization. The study initially included all psychiatric inpatients aged 18 years or older who were admitted between January and December 2020 and subsequently tested positive for SARS-CoV-2 infection. To study the natural course of COVID-19 recovery, patients who received monoclonal antibodies or specific anti-COVID-19 therapies were excluded. Patients who were determined to have been reinfected with COVID-19 were also excluded, as their medical course presents unique characteristics that may not be easily generalized. The medical records of all eligible patients (those who tested positive for COVID-19 by PCR test) were reviewed to determine their inclusion or exclusion based on the aforementioned criteria and to collect data for the study. The collected data included patients' demographic details, medical history, medical risk factors, medical conditions, COVID-19 related symptoms, laboratory reports, and other clinical data relevant to ventilatory care (if applicable) and length of stay. The SARS-CoV-2 PCR positive patient group was divided into two categories: those with pre-existing major comorbid medical conditions (WC group) and those without such conditions (WOC group), and their data were compared. Major medical conditions included were hypertension, heart disease, chronic obstructive pulmonary disease (COPD), cardiovascular accident (CVA), asthma, diabetes, and obesity defined as a BMI >30. The authors also reviewed recent research study results on mild and-moderate COVID-19 patients in the general population to compare their clinical and demographic characteristics, disease course, and outcomes with those of the psychiatric inpatient study patients.
3. Statistical analysis
Demographics, psychiatric diagnoses, major clinical features, and severity of COVID-19 positivity for all patients were tabulated and compared between the WC and WOC groups using descriptive statistics and measures of central tendency, such as the mean, median and range values. Categorical variables were analyzed using chi-square tests, while Wilcoxon rank-sum tests were employed for continuous variables to compare between groups. Clinical symptoms, disease-related outcomes, and medical complications were also compared between the WC and WOC groups. The level of significance was set at p=<0.05. SAS 9.4 software (SAS Inc., Cary, NC) was utilized for all analyses.
4. Results
4.1. Demographic and clinical characteristics
The study included a total of 174 patients, with 89 patients (51%) belonging to the group with at least one major medical co-morbidity (WC group), and 85 patients (49%) without major comorbid medical illness (WOC group). Table 1 provides a summary of the demographic and clinical characteristics, including psychiatric diagnoses, of the study sample. WOC patients had a median age of 33 years, while the WC group had an older median age of 42 years (P < 0.001). WC patients also had a higher BMI compared to WOC patients (P < 0.001). Thus, the WC group tended to have higher risk for having or developing comorbid medical conditions. Other demographic and clinical features such as gender, ethnicity, marital status, smoking status, substance use disorders, and psychiatric diagnoses were generally similar between the two patient groups and did not show any significant differences (See Table 1).
Table 1.
Demographic and clinical characteristics.
| Demographic Details | All patients (N = 174) | WOC (N = 85) | WC (N = 89) | P* | |
|---|---|---|---|---|---|
| Age [M, MD (R)] | 41.51, 38 (18–87) | 36.72, 33 (19–83) | 46.08, 42 (18–87) | <0.001 | |
| BMI [M, MD (R)] | 27.69, 26.05 (16.9–50.46) | 24.29, 24 (18.46–29.6) | 30.93,30.96 (16.9–50.46) | <0.001 | |
| BMI>30 N (%) | 52 (29.82) | 20 (23.52) | 32 (35.95) | ||
| Sex N (%) | Female | 46 (26.44) | 20 (23.53) | 26 (29.21) | 0.3954 |
| Male | 128 (73.56) | 65 (76.47) | 63 (70.79) | ||
| Marital status N (%) | Partnered | 18 (10.34) | 10 (11.76) | 8 (8.99) | 0.5478 |
| Single | 156 (89.66) | 75 (88.24) | 81 (91.01) | ||
| Accommodation N (%) | Homeless | 32 (18.39) | 17 (20) | 15 (16.85) | 0.287 |
| HPL | 142 (81.60) | 68 (80) | 74 (83.14) | ||
| Ethnicity/Race N (%) | AA | 29 (16.67) | 13 (15.29) | 16 (17.98) | 0.4900 |
| Asian | 5 (2.87) | 4 (4.71) | 1 (1.12) | ||
| Hispanic | 40 (22.99) | 18 (21.18) | 22 (24.72) | ||
| White | 100 (57.47) | 50 (58.82) | 50 (56.18) | ||
| Smoker N (%) | Current | 76 (43.68) | 33 (38.82) | 43 (48.31) | 0.2070 |
| Non-smoker | 98 (56.32) | 52 (61.18) | 46 (51.69) | ||
| SUD N (%) | Meth | 51 (29.31) | 26 (30.59) | 25 (28.09) | 0.1445 |
| Cocaine | 6 (3.45) | 6 (7.06) | 0 (0) | ||
| Opioid | 14 (8.05) | 9 (10.59) | 5 (5.62) | ||
| ETOH | 18 (10.34) | 10 (11.76) | 8 (8.99) | ||
| Cannabis | 67 (38.51) | 40 (47.06) | 27 (30.34) | ||
| Psychiatric diagnosis N (%) | Schizophrenia | 45 (25.86) | 22 (25.88) | 23 (25.84) | 0.777 |
| SAD | 58 (33.33) | 33 (38.82) | 25 (28.08) | ||
| BPAD | 46 (25.43) | 22 (25.88) | 24 (26.96) | ||
| MDD | 12 (6.89) | 3 (3.52) | 9 (10.11) | ||
| Other | 13 (7.4) | 5 (5.88) | 8 (8.98) | ||
M = mean, MD = median, R = range, AA = African American, N = number of patients, HPL: has some form of place to live, % = percent, SUD = substance use disorder, Other = cognitive Disorder, anxiety disorder, psychosis NOS. WC=With comorbidity WOC = without comorbidity, SAD = schizoaffective disorder, BPAD = bipolar affective disorder. MDD = Major Depressive Disorder * Wilcoxon rank-sum test based 2-tail P-values for continuous variables and Chi-square 2-tail P-values comparing patients with and without comorbidities.
In terms of ethnicity, the majority of the study participants were Caucasian (57%, n = 100), followed by Hispanic (22.98%, n = 40), Black (16.66%, n = 29), and Asian/Pacific Islander (2.87%, n = 5). Among these ethnic groups, approximately half of the Caucasian patients (50), 55% of Hispanic individuals (22), 55% of Black patients (16), and one patient from the Asian/Pacific Islander group had pre-existing physical illnesses. Regarding psychiatric diagnoses observed in the study population, the most common were schizoaffective disorder (n = 58, 33%), bipolar disorder (n = 46, 26%), schizophrenia (n = 45, 26%), and major depressive disorder (n = 12, 7%). Sixty percent of the patients had a secondary diagnosis of a substance use disorder. Table 1 shows the groups demographics and any differences between the two groups.
4.2. Comorbid medical illness
Table 2 provides a listing of the major medical illnesses observed in the entire sample and specifically within the WC group. The most prevalent comorbidities in this study were obesity and hypertension. Hypertension was found in 46 patients (26.43%) of the total sample and in 51.68% of the WC group. Obesity, based on BMI criteria, was present in 52 individuals, accounting for 29.82% of the total sample and 58.42% of the WC group. Coronary artery disease was identified in six patients (3.44%) of the total sample and in 6.74% of the WC group. Cerebrovascular accidents (CVA) was noted in five patients (2.87%) of the total sample and in 5.61% of the WC group. Chronic obstructive pulmonary disease (COPD) was observed in eight individuals (4.59%) of the total sample and in 8.98% of the WC group. Asthma was diagnosed in 21 patients, accounting for 12.06% of the total sample and 23.59% of the WC group. Similarly, diabetes type II was found in 21 patients, representing 12.06% of the total sample and 23.59% of the WC group.
Table 2.
Comorbid medical condition.
| Comorbid Medical Condition | All patients (n = 174, %) | WC (%) |
|---|---|---|
| Obesity | 52 (29.82) | 58.42 |
| Hypertension | 46 (26.43) | 51.68 |
| Coronary Artery Disease | 6 (03.44) | 6.74 |
| Cerebrovascular Accidents (CVA) | 5 (02.87) | 5.61 |
| COPD | 8 (04.59) | 8.98 |
| Asthma | 21 (12.06) | 23.59 |
| Diabetes Type ll | 21 (12.06) | 23.59 |
4.3. Physical symptoms and severity of COVID infection
Among the WOC group patients, 14 individuals (16.47%) presented fever and chills during their psychiatric hospitalization, while in the WC group, this number was 10 (11.23%) (Table 3). Other physical symptoms were more frequently observed in the WC group compared to the WOC group. Specifically, 46 patients in the WC group had a cough (51.69%), 24 individuals reported shortness of breath (26.97%), 34 patients experienced myalgia (38.2%), 18 patients had diarrhea (20.22%), 14 participants complained of nausea (15.73%), and 19 patients reported loss of taste (ageusia) (21.35%). In comparison, in the WOC group, 25 patients had a cough (29.41%), 13 individuals complained of shortness of breath (15.29%), 22 patients reported myalgia (25.88%), 13 patients had diarrhea (15.29%), 5 individuals experienced nausea (5.88%), and 9 patients complained of loss of taste (ageusia) (10.59%). The patients in the WC group had a significantly higher prevalence of cough compared to the WOC group. Other symptoms, such as fever, chills, headache, shortness of breath, fatigue, myalgia, diarrhea, nausea, vomiting, anosmia, and ageusia, did not show significant differences between the groups.
Table 3.
Clinical symptoms and severity.
| Clinical presentation | All patients (n = 174) | WOC (n = 85) | WC = 89 | P* |
|---|---|---|---|---|
| Fever | 24 (13.79) | 14 (16.47) | 10 (11.23) | 0.319 |
| Chills | 18 (10.34) | 10 (11.76) | 8 (8.99) | 0.548 |
| Headache | 50 (28.74) | 23 (27.06) | 27 (30.34) | 0.633 |
| Cough | 71 (40.8) | 25 (29.41) | 46 (51.69) | 0.003 |
| SOB | 37 (21.26) | 13 (15.29) | 24 (26.97) | 0.060 |
| Fatigue | 36 (20.69) | 17 (20) | 19 (21.35) | 0.826 |
| Myalgia | 56 (32.18) | 22 (25.88) | 34 (38.2) | 0.082 |
| Diarrhea | 31 (17.82) | 13 (15.29) | 18 (20.22) | 0.395 |
| Nausea | 19 (10.92) | 5 (5.88) | 14 (15.73) | 0.037 |
| Vomiting | 12 (6.9) | 5 (5.88) | 7 (7.87) | 0.606 |
| Anosmia | 19 (10.92) | 9 (10.59) | 10 (11.24) | 0.891 |
| Ageusia | 28 (16.09) | 9 (10.59) | 19 (21.35) | 0.706 |
N = number of patients, % = percentage, WC=With comorbidity, WOC = without comorbidity. * Chi-square 2-tail P-value comparing frequency of clinical presentation between patients with and without comorbidities.
4.4. Length of stay
The duration of COVID symptoms was significantly higher among the WC patients compared to the WOC group. On average, the length of stay on the psychiatric unit was slightly longer for WC patients (mean: 50.18 days) compared to the WOC group (mean: 46.39 days). Patients who required supplemental oxygen or had medical instability were transferred to a medical unit, where the mean duration of stay was 6 days for WC patients and 3.5 days for those in the WOC group. However, there was no statistically significant difference in the length of stay on either the medical or psychiatry units between the two groups (Table 4).
Table 4.
Length of stay.
| Measures (mean, median (range) | All patients (N = 174) | WOC (N = 85) | WC (N = 89) | P* |
|---|---|---|---|---|
| Duration of COVID symptoms | 4.82, 3 (0–28) | 3.93, 2 (0–28) | 5.64, 3 (0–28) | 0.049 |
| Length of stay | 48.33, 29 (2–439) | 46.39, 28 (2–322) | 50.18, 30 (3–439) | 0.627 |
| Days in Medical Unit | 5.64, 5 (0–21) | 3.5, 3.5 (1–6) | 6, 5 (0–21) | 0.856 |
| Days in Psychiatry unit | 47.16, 30.5 (2–439) | 44.44, 28 (2–322) | 50.13, 32.5 (2–439) | 0.163 |
WC=With comorbidity, WOC = without comorbidity, * Chi-square 2-tail P-value.
4.5. Medical Complications from COVID-19
Out of the total sample of 174 patients, 20 (11.5%) were diagnosed with COVID pneumonia. Among them, 2 patients (2.35%) were from the WOC group, while 18 patients (20.23%) were from the WC group. The difference in the prevalence of COVID pneumonia between the two groups was statistically significant (P < 0.001), indicating a higher incidence in the WC group. In summary, the data reveals that the WC group had a higher incidence of total COVID pneumonia, pneumonia without hypoxia, and hypoxia with SpO2<92% compared to the WOC group. However, there were no significant differences between the two groups in terms of critically ill patients, ARDS (acute respiratory distress syndrome), or the need for ventilator support (Table 5).
Table 5.
Medical complications.
| Medical complications | All patients (N = 174) | WOC (n = 85) | WC (N = 89) | P* |
|---|---|---|---|---|
| Total COVID Pneumonia | 20 (11.5) | 2 (2.35) | 18 (20.23) | <0.001 |
| Pneumonia with no Hypoxia | 8 (4.6) | 0 (0) | 8 (8.99) | 0.008 |
| Hypoxia with SpO2<92% | 12 (6.9) | 2 (2.35) | 10 (11.24) | 0.039 |
| Critically ill/ARDS | 1 (0.57) | 0 (0) | 1 (1.12) | >0.999 |
| Ventilator Support | 1 (0.57) | 0 (0) | 1 (1.12) | >0.999 |
N = number of patients, % = percentage, WC=With comorbidity, WOC = without comorbidity, * Fisher's exact test 2-tail P-value.
5. Discussion
This study specifically focused on psychiatric patients who were admitted to the psychiatry unit and tested positive for COVID-19. These patients were not primarily admitted for the treatment of COVID infection but rather due to the severity of their mental illness. The COVID-positive cases were identified either during their inpatient stay or just before their admission. Notably, none of the psychiatric inpatients who tested positive for COVID-19 displayed severe symptoms of COVID-19 or experienced any related complications at the time of admission. All of these patients met the CDC criteria for mild to moderate COVID-19 (CDC 2020).
Given the limited published research on the progression and complications of COVID-19 in psychiatric inpatients, our analysis went beyond comparing outcomes between patients with and without comorbid conditions within our sample. We also reviewed extant research on the course and outcome of mild to moderate COVID-19 cases in the general population. This allowed us to determine the similarities and differences in the course and outcome of COVID-19 infection between our inpatient psychiatric study patients and those with mild to moderate cases in the general population. In general, this study suggests that the symptoms of COVID-19 infection in psychiatric inpatients were mild to moderate and slightly better than and relatively fewer medical complications when compared to COVID-19 positive cases in the general population living in the community with no need of COVID-19 infection related hospitalization. From the available literature, it is important to highlight that even young individuals with mild to moderate symptoms who receive outpatient treatment can experience prolonged illness due to COVID-19 [12]. Surprisingly, in our study group, a significant proportion of patients (88.5%, n = 154) had mild to moderate symptoms, slightly more than the CDC's report of 80% in the general population, but experienced significantly fewer complications tha reported in the CDC data. Only 11.5% (n = 20) developed COVID pneumonia in the WC group and also severe illness in WC group was 6.9% (n = 12) requiring supplemental oxygen due to hypoxia, compared with the CDC's 2020 data of 14% developing severe illness. Additionally, one patient developed critical illness and required ventilator support, but ultimately recovered whereas CDC data of 2020 reports 5% developing critical illness in the general population. On average, the duration of COVID symptoms was around 4.8 days. Overall, these findings indicate a significantly less intense course of COVID symptoms and complications in our study patients than those reported in CDC data. studies of covid positive patients in the general population. Likewise, compared to specific studies of COVID-19 related physical symptoms and medical complications in more general populations [[13], [14], [15], [16]], our study subjects seemed to have less and milder COVID symptoms and less medical complications. This is counterintuitive as our subjects being psychiatrically ill are more vulnerable to medical comorbidities and complications. The reasons for such moderation is not clear and is beyond the scope of our study. Speculatively, we could suggest both underreporting of symptoms by patients, being in the hospital, routine laboratory testing, early recognition could all be responsible. Another intriguing but not proven explanation may be a potentially protective role of psychotropic medications which have been proposed to have favorable immune-modulatory effect [17,18].
In our study, the length of stay in the psychiatric facility was not influenced by a history of comorbid medical conditions. However, medical hospitalization duration was twice as long for patients with comorbidities, which is not surprising. It is reasonable to assume that patients with more medical conditions may have a more challenging medical admission compared to otherwise healthy individuals. A research study conducted by Levitt et al. also highlighted that psychiatric patients had higher rates of medical comorbidities compared to statewide data, although medical hospitalizations were infrequent in our study [19]. In addition, the length of stay was found to be longer for patients who tested positive for COVID-19 compared to those without infection. However, this extended duration was often attributed to factors unrelated to COVID illness. For instance, it could be due to patients refusing to adhere to an uninterrupted quarantine period, residential placements declining to admit COVID-positive patients until the completion of the quarantine period, patients' homes not being suitable for continued quarantine, or the presence of other residents at high risk of infection in the placement. These non-COVID-related factors contributed to the increased length of stay in these cases.
There are several limitations to our study. Firstly, it includes a relatively small sample size of only 172 patients, making it unlikely to be representative of larger and heterogenous samples of psychiatric patients with COVID illness in the community and long-term institutions, especially considering the overall high incidence of COVID-19 in the general population during the study period. Second, the retrospective nature of the study introduces many limitations on the data which is not entered by staff or providers keeping any research design or research goals in mind. Thirdly, the study sample was overrepresented by individuals of Caucasian ethnicity. It is worth noting that many studies conducted in the general population have shown that Caucasians are less susceptible to COVID-19 complications, mortality, and severity compared to other ethnic groups [20]. The overrepresentation of the Caucasian population in our study sample may have influenced the observed reduction in COVID-19-related complications. Finally, and as mentioned earlier, findings from hospitalized patients cannot be generalized to non-hospital, community populations.
In conclusion, COVID-19 positive psychiatric inpatients with pre-existing medical comorbidities exhibited more symptoms, more severity and needed more medical care than those without such pre-existing medical comorbidity. There was also suggestive data that our total sample of COVID-19 positive psychiatric inpatients, despite well-known demographic, psychosocial and medical risk factors tended to have milder and less COVID-19 related physical symptoms and medical complications when compared with available CDC data and several specific studies of COVID-19 positive patients in the general population. If replicated, the reasons for this are deserving of further study and may help us identify factors protective of COVID-19 symptoms and complications.
Funding/support
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
None.
Acknowledgements
We are thankful to Timothy Durr, MD student for helping to organize the data
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