Smokeless Tobbacco Dr. Nida

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    tobacco in relation with oraltobacco in relation with oral

    cancers among the generalcancers among the general

    population in sohrab got ofpopulation in sohrab got ofKarachi.Karachi.

    Dr. Nida LiaquatDr. Nida LiaquatMSPH 2009-10MSPH 2009-10

    Health services academyHealth services academy

    ISLAMABADISLAMABAD

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    IntroductionIntroduction

    Cancers of the oral cavity are major cancer burden in Pakistan.Cancers of the oral cavity are major cancer burden in Pakistan.

    Tobacco use is a risk factor for oral cancers. Available evidenceTobacco use is a risk factor for oral cancers. Available evidencesuggests that the risk of oral diseases increases with greater usesuggests that the risk of oral diseases increases with greater use

    of smokeless tobacco.of smokeless tobacco. It's been medically proven that long-time use of chewing tobaccoIt's been medically proven that long-time use of chewing tobacco

    can lead to cancer .can lead to cancer .

    According to BBC, 4 in 10 of all cancers in India are oral cancersAccording to BBC, 4 in 10 of all cancers in India are oral cancers

    and this because of extensive use of smokeless tobacco andand this because of extensive use of smokeless tobacco andbetel quid.betel quid. [9][9]

    Smokeless tobacco delivers a high dose of nicotine. An averagedose from snuff is 3.6 milligrams (mg) and from chewing tobaccois 4.5 mg compared to 1 to 2 mg from one cigarette

    People are dying of oral cancers because ofignorance[5]

    Dr. Geoff Graig.

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    Global PerspectiveGlobal Perspective

    According to theAccording to the World Health OrganizationWorld Health Organization, of 267,000 newly diagnosed oral, of 267,000 newly diagnosed oralcancers worldwide, close to 40% (108,843 cases) occurred in India, Pakistan,cancers worldwide, close to 40% (108,843 cases) occurred in India, Pakistan,Bangladesh, and Sri Lanka. Furthermore, oral cancer incidence and mortality rates inBangladesh, and Sri Lanka. Furthermore, oral cancer incidence and mortality rates inSouth Asia are almost twice those of global rates.South Asia are almost twice those of global rates. [2][5][7][2][5][7]

    Currently 27,000 new cases of oral cancer were reported in the United States every

    year and 9,000 deaths from oral cancer.

    The World Health Organization predicts that tobacco deaths in India may exceed 1.5The World Health Organization predicts that tobacco deaths in India may exceed 1.5million annually by 2020million annually by 2020[4][4]

    Among women, chewing and poor oral hygiene explained 95% of oral cancer.Among women, chewing and poor oral hygiene explained 95% of oral cancer.[6][6]

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    PakistanPakistan

    Time trend analysis has suggested a rise in the incidence ofTime trend analysis has suggested a rise in the incidence of

    oral cavity cancers in Pakistanoral cavity cancers in Pakistan

    The incidence of oral cavity cancers in Karachi southThe incidence of oral cavity

    cancers in Karachi south

    district of Pakistan is the highest in the world.district of Pakistan is the hig

    hest in the world. [1][1]

    Oral cancer in Karachi has already reported an up toOral cancer in Karachi has already

    reported an up to200% increase in cases among lower socio-economic200% increase in cases among

    lower socio-economic

    strata between 1998 and 2002.strata between 1998 and 2002.

    In Pakistan and south Asian subcontinent the popularIn Pakistan and south Asian subcontinent the popular

    smokeless products are pan and chaalia with tobacco, Gutka,smokeless products are pan and chaalia with tobacco, Gutka,Naswar and tumbaku.Naswar and tumbaku.

    Use of Paan, chaalia, Gutka, Naswar, tumbaku are acceptableUse of Paan, chaalia, Gutka, Naswar, tumbaku are acceptable

    in Pakistan and is considered a normal cultural practice.in Pakistan and is considered a normal cultural practice.

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    RationalRational

    Incidence of oral cancers in Pakistan is increasing day by dayIncidence of oral cancers in Pakistan is increasing day by daybut there is dearth of research regarding behavioral changebut there is dearth of research regarding behavioral changeamong Pakistanis about smokeless tobacco.among Pakistanis about smokeless tobacco.

    People have wrong conceptions about smokeless tobacco. TheyPeople have wrong conceptions about smokeless tobacco. Theythink they dont smoke it; they dont swallow it so its harmless.think they dont smoke it; they dont swallow it so its harmless.

    Oral cancers are a major cancer burden in Pakistan. They shareOral cancers are a major cancer burden in Pakistan. They sharea common risk factor profile including regular consumption ofa common risk factor profile including regular consumption ofproducts of betel, areca with tobacco. People of Pakistanproducts of betel, areca with tobacco. People of Pakistan

    considered it a normal cultural practice.considered it a normal cultural practice.

    As a dentist I used to see a lot of patients with complicationsAs a dentist I used to see a lot of patients with complicationsarising out of habit like Gutka eating, keeping tobacco quid inarising out of habit like Gutka eating, keeping tobacco quid inmouth and Naswar. So I thought this awareness build up study.mouth and Naswar. So I thought this awareness build up study.

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    Carcinogens of smokelessCarcinogens of smokeless

    tobaccotobacco

    Tobacco when kept in mouth leaches out carcinogens, which act

    on oral mucosa causing neoplastic changes.

    Tobacco contains potent carcinogens are as follows:

    Formaldehyde

    N-nitrosamines

    Arsenic

    Nicotine and metabolites of these substances

    Polycyclic aromatic hydrocarbonsHydrogen cyanide

    Benzopyrene

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    Aims and Objectives:Aims and Objectives:

    Aim:Aim:

    To decrease morbidity and mortality associated with oralTo decrease morbidity and mortality associated with oralcancers among smokeless tobacco users.cancers among smokeless tobacco users.

    Objectives:Objectives:

    To determine the socio-demographic and cultural contextTo determine the socio-demographic and cultural contextof Gutka and Paan consumption.of Gutka and Paan consumption.

    To assess knowledge of the respondents about risk of oralTo assess knowledge of the respondents about risk of oralcancers posed by the use of smokeless tobacco.cancers posed by the use of smokeless tobacco.

    To identify the adverse effects of smokeless tobacco onTo identify the adverse effects of smokeless tobacco onoral cancers among 18 to 65 years old population inoral cancers among 18 to 65 years old population insohrab got of Karachi during three months study duration.sohrab got of Karachi during three months study duration.

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    MethodologyMethodology

    Study Design:Study Design: Cross sectional descriptive study.Cross sectional descriptive study.

    Study PopulationStudy Population:: Male and females aged 18-65 yearsMale and females aged 18-65 yearsliving in sohrab got of Karachi.living in sohrab got of Karachi.

    Study area:Study area: Sohrab got of KarachiSohrab got of Karachi Study time periodStudy time period:: 3 months3 months Sampling technique:Sampling technique:

    In sohrab got mohallas will be selected by simple randomIn sohrab got mohallas will be selected by simple randomsampling and then houses will be selected by systemicsampling and then houses will be selected by systemic

    random sampling. After selecting the houses all householdrandom sampling. After selecting the houses all householdhaving person aged 18-65 years and is regular user ofhaving person aged 18-65 years and is regular user ofsmokeless tobacco will be enrolled till the sample size issmokeless tobacco will be enrolled till the sample size iscompleted. Door of the house will be knocked and if thecompleted. Door of the house will be knocked and if theperson of that house fulfils the criteria he/she will beperson of that house fulfils the criteria he/she will beincluded in study.included in study.

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    MethodologyMethodology

    Sample size:Sample size:

    According to study conducted by Agha khan university.According to study conducted by Agha khan university.PrevalencePrevalence

    of smokeless tobacco among adults is 37.8%.of smokeless tobacco among adults is 37.8%.

    (Adults = above 18)(Adults = above 18)n =n = P (1-p)P (1-p)

    ee22

    n=n= 0.378 (1- 0. 378)0.378 (1- 0. 378)

    (0.05)(0.05)22

    n= 94 = 95n= 94 = 95

    Estimated sample size is 95.Estimated sample size is 95.

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    Study PopulationStudy Population

    Inclusion Criteria:Inclusion Criteria:

    Male and female aged 18-65 years who areMale and female aged 18-65 years who areregular users of smokeless tobacco for moreregular users of smokeless tobacco for more

    than six months.than six months.Those who give verbal and written consent.Those who give verbal and written consent.

    Exclusion Criteria:Exclusion Criteria:

    Those who dont give verbal consent.Those who dont give verbal consent.

    Those who are below 18 or above 65.Those who are below 18 or above 65.

    Those who are not regular users of smokelessThose who are not regular users of smokelesstobacco.tobacco.

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    VariablesVariables

    AgeAge Education of the subjectsEducation of the subjects.. Oral hygieneOral hygiene

    DietDiet Socio-economic groupSocio-economic group GenderGender EthnicityEthnicity

    Mother tongueMother tongue occupationoccupation ReligionReligion

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    Ethical considerationEthical consideration

    Written/verbal consent will be takenWritten/verbal consent will be taken

    from the study participants. Thefrom the study participants. The

    information obtained through theinformation obtained through the

    questionnaire will be kept secure andquestionnaire will be kept secure and

    will not be disclosed to anyone, andwill not be disclosed to anyone, and

    it will be used for research andit will be used for research andacademic purpose only.academic purpose only.

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    BudgetBudgetHeads # Unit cost (Rs) Duration total cost

    Datacollectors 4 300/person/day 15 days 18,000

    Data entry by PI 1

    Training of data

    collectors

    4 300/person/day 2 days 2400

    Stationary 2,000

    Questionnaire

    Printing of questionnaire 250 2Rs/questionnaire

    500

    Printing of consent form 250 2 Rs/consent form 500

    Transportation for data

    collection

    1 1500/day 15 days 22,500

    Pretesting

    Data collectors 2 400/person/day 2 days 800Transportation for

    pretesting2 1500/person/day 2 days 3000

    Administrative charges

    Mailing/post ing 2 500 1000

    Food expenses 5 200/person/day 15 days 15000

    Total 65,700

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    Work PlanWork Plan

    Effects of smokele

    #

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    ExpectedExpected

    RecommendationsRecommendations To discourage the consumption of chewing products of betel, arecaTo discourage the consumption of chewing products of betel, areca

    and tobacco is the first step towards the control of epidemic of oraland tobacco is the first step towards the control of epidemic of oralcancers in Pakistan and requires radical measures involving healthcancers in Pakistan and requires radical measures involving healthcare professionals, media, policy makers and the community.care professionals, media, policy makers and the community.

    Behavioral interventions are successful measures in reducing oralBehavioral interventions are successful measures in reducing oraluse of smokeless tobacco .use of smokeless tobacco .

    Instead of using smokeless tobacco, habit can be controlled byInstead of using smokeless tobacco, habit can be controlled byeating chew gums, saunf and so on.eating chew gums, saunf and so on.

    Warning signs should accompany sachets and advertisements ofWarning signs should accompany sachets and advertisements ofthese items, as used for cigarettes. Chaalia sponsored musicthese items, as used for cigarettes. Chaalia sponsored musicvideos showing TV stars using these products as a symbolicvideos showing TV stars using these products as a symbolicoffering should be counteredoffering should be countered

    Frequent consumption of fruit and vegetables, including carrots,Frequent consumption of fruit and vegetables, including carrots,fresh tomatoes and green peppers, was associated with reducedfresh tomatoes and green peppers, was associated with reducedrisk ofrisk oforaloral cancercancer [7][7]

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    ReferencesReferences1. 2006 Samia Mazahir et al; licensee BioMed Central Ltd.1. 2006 Samia Mazahir et al; licensee BioMed Central Ltd.

    .. Socio-demographic correlates of betel, areca and smokelessSocio-demographic correlates of betel, areca and smokeless

    tobacco use as a high risk behavior for head and neck cancers intobacco use as a high risk behavior for head and neck cancers ina squatter settlement of Karachi, Pakistan..6 pages.a squatter settlement of Karachi, Pakistan..6 pages.

    2.2. Kavita P. Ahluwalia, D.D.S., M.P.H.Kavita P. Ahluwalia, D.D.S., M.P.H.

    School of Dental and Oral Surgery, Columbia University, New York, New York.School of Dental and Oral Surgery, Columbia University, New York, New York.

    cancer. 2005 December 15; 104(12 Supply): 29592961.cancer. 2005 December 15; 104(12 Supply): 29592961.

    Assessing the Oral Cancer Risk of South-Asian Immigrants in New YorkAssessing the Oral Cancer Risk of South-Asian Immigrants in New YorkCityCity

    3. American Cancer Society.3. American Cancer Society. Cancer Facts & Figures 2008Cancer Facts & Figures 2008. Atlanta, GA.. Atlanta, GA.2008 copyright 2009 American Cancer Society, Inc.2008 copyright 2009 American Cancer Society, Inc.

    4. M Rani, S Bonu, P Jha, S N Nguyen and L Jamjoum4. M Rani, S Bonu, P Jha, S N Nguyen and L Jamjoum

    household survey smoking and chewing in a national crosshousehold survey smoking and chewing in a national crosssectionalsectional

    Tobacco use in India: prevalence and predictors ofTobacco use in India: prevalence and predictors ofsmokingsmoking

    and chewing in a national cross sectional household surveyand chewing in a national cross sectional household surveyReceived 22 April 2003Received 22 April 2003

    Accepted 10 September 2003Accepted 10 September 2003

    http://tobaccocontrol.bmj.com/cgi/content/full/12/4/e4http://tobaccocontrol.bmj.com/cgi/content/full/12/4/e4

    http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://tobaccocontrol.bmj.com/cgi/content/full/12/4/e4http://tobaccocontrol.bmj.com/cgi/content/full/12/4/e4http://tobaccocontrol.bmj.com/cgi/content/full/12/4/e4http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776http://www.pubmedcentral.nih.gov/redirect3.cgi?&&auth=0vwBvE0px97IsHLFHy2nz0dyMqZEBBdx6afYKK5rT&reftype=publisher&artid=1618785&article-id=1618785&iid=136178&issue-id=136178&jid=319&journal-id=319&FROM=Article%7CFront%20Matter&TO=Content%20Provider%7CArticle%7CFree%20Access&rendering-type=normal&&http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16247776
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    5. D. Max Parkin, M,D Paola Pisani,PhD, J. Ferlay5. D. Max Parkin, M,D Paola Pisani,PhD, J. FerlayGlobal Cancer StatisticsGlobal Cancer Statistics

    C A C a n c e r J C l i n 1 9 9 9 ; 4 9 : 3 3 - 6 4C A C a n c e r J C l i n 1 9 9 9 ; 4 9 : 3 3 - 6 4

    6. Prabha BALARAM, ORAL CANCER IN SOUTHERN INDIA: THE INFLUENCE OF SMOKING,6. Prabha BALARAM, ORAL CANCER IN SOUTHERN INDIA: THE INFLUENCE OF SMOKING,DRINKING, PAAN-CHEWING AND ORAL HYGIENE DRINKING, PAAN-CHEWING AND ORAL HYGIENE 2002 Wiley-Liss, Inc2002 Wiley-Liss, Inc

    7. Carlo La Vecchia,7. Carlo La Vecchia, ORALORAL CANCER: EPIDEMIOLOGY, RISK FACTORS ANDCANCER: EPIDEMIOLOGY, RISK FACTORS AND

    PREVENTION. This is the html version of the filePREVENTION. This is the html version of the filehttp://mso.cinbo.org/documenti/allegati/slide/2005/24_26_Novembre/24_Novembre/Vecchia.ppthttp://mso.cinbo.org/documenti/allegati/slide/2005/24_26_Novembre/24_Novembre/Vecchia.ppt..

    8. ERNESLT. WYNDERM,. D., IRWIN8. ERNESLT. WYNDERM,. D., IRWINJ.J. BROSSP, H.D., AND RIVKAHkZ . FELDMANB,BROSSP, H.D., AND RIVKAHkZ . FELDMANB,A study of the etiological factors in cancer ofA study of the etiological factors in cancer ofthe mouththe mouth

    9. Sangeeta Darvekar Charitable Trust, a registered trust with registration no9. Sangeeta Darvekar Charitable Trust, a registered trust with registration noE/3092/Thane dated 30/4/03 presents an awareness program on Oral CancerE/3092/Thane dated 30/4/03 presents an awareness program on Oral Cancerand named it.and named it. Oral Cancer Awareness.orgOral Cancer Awareness.org

    10. Monika Arora Director ,HRIDAY-SHAN, Alternate Forms of Tobacco Use10. Monika Arora Director ,HRIDAY-SHAN, Alternate Forms of Tobacco Use

    11. Educational programs of the Texas AgriLife Extension Service are open to11. Educational programs of the Texas AgriLife Extension Service are open toall people without regard to race, color, sex, disability, religion, age, orall people without regard to race, color, sex, disability, religion, age, ornational origin. The Texas A&M University System, U.S. Department ofnational origin. The Texas A&M University System, U.S. Department ofAgriculture, and the County Commissioners Courts of Texas CooperatingAgriculture, and the County Commissioners Courts of Texas Cooperating

    12. Texas Department of Health - Public Health Region 7,Office of Tobacco12. Texas Department of Health - Public Health Region 7,Office of TobaccoPrevention & Control.Prevention & Control.

    13. Scott L. Tomar, DMD, DrPH,13. Scott L. Tomar, DMD, DrPH,Oral Health Effects of Smokeless Tobacco Use,Oral Health Effects of Smokeless Tobacco Use,University of Florida,CUniversity of Florida,C

    college of Dentistry.college of [email protected]@dental.ufl.edu

    http://mso.cinbo.org/documenti/allegati/slide/2005/24_26_Novembre/24_Novembre/Vecchia.ppthttp://mso.cinbo.org/documenti/allegati/slide/2005/24_26_Novembre/24_Novembre/Vecchia.pptmailto:[email protected]:[email protected]:[email protected]://mso.cinbo.org/documenti/allegati/slide/2005/24_26_Novembre/24_Novembre/Vecchia.ppt
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