MISCELLANEOUS Impact of Voiding and Incontinence Symptoms on Health-Related Quality of Life in Serbian Male Population Uros Babic,1* Milena Santric-Milicevic,2,3 Zorica Terzic,2,3 Aleksandar Argirovic,5 Dejan Kojic,4 Mihailo Stjepanovic,1 Dejan Lazovic,1 Vesna Bjegovic-Mikanovic,2,3 Vinka Vukotic,3,4 Purpose: To investigate the impact of lower urinary tract symptoms on health-related quality of life (QoL) in Serbian population considering socio-demographic characteristics, habits, and health status. Materials and Methods: The study was conducted in the Primary Healthcare Center «Novi Beograd», Serbia. The study included 1424 male participants, aged 40 years and above. QoL was assessed by using the -36Item Short Form Health Survey (SF36-) questionnaire, while voiding and incontinence symptoms were measured using the International Continence Society Male Short Form (ICS male SF) questionnaire. Results: Voiding and incontinence symptoms significantly correlate with all domains of QoL. Voiding and incontinence symptoms have a high influence on general health, social functioning, physical functioning and body pain. After adjusting for age and education, voiding and incontinence symptoms had a similar influence on QoL. In the multivariate model the influence of cardiovascular diseases and income on QoL was lower than voiding and incontinence symptoms.. Conclusion: Voiding and incontinence symptoms affect QoL domains differently. Incontinence symptoms have a greater impact on QoL than voiding symptoms. Keywords: urinary incontinence; quality of life; cultural characteristics; psychology; male. INTRODUCTION The world statistics is showing the high prevalence of Lower Urinary Tract Symptoms (LUTS) such as urine storage, voiding and post-micturition(1) among older population.(2) A prediction is that even a greater portion of persons will be affected with LUTS due to population aging. Only storage symptoms are estimat- ed to affect 1.6 billion, while overactive bladder will affect additional 546 million individuals by 2018 due to population growth and the overall ageing of the worldwide population.(3) LUTS influence normal dai- ly activities and all domains of health related quali- ty of life (HRQoL).(4) Therefore, LUTS is related to significant healthcare costs, absenteeism, low work productivity and sexuality dissatisfaction, leading to sleep disorders, limited mobility, loneliness, anxie- ty and depression.(5,6) All that makes LUTS a signifi- cant clinical and public health management issue.(2,7) The incidence of having ‘at least one’ storage LUTS is high, ranging from 43% in Canadian men, and 45% of Korean men to 48% of men in The European Pro- spective Investigation into Cancer and Nutrition (EPIC) study and 69.4% of men in the epidemiology of lower urinary tract symptoms (EpiLUTS) study.(8-11) LUTS can be divided into three categories: storage, voiding and post-micturition.(7) Storage symptoms are nocturia, urgency, increased micturition frequency and urinary in- 1 Clinical Center of Serbia, Belgrade, Serbia. 2 Institute of Social Medicine, Belgrade, Serbia. 3 Faculty of Medicine, University of Belgrade, Belgrade, Serbia. 4 Clinical Center “Dr Dragisa Misovic-Dedinje”, Belgrade, Serbia. 5 Clinical Center “Zemun”, Belgrade, Serbia. *Correspondence: Clinic of Urology, Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia. Tel: +38 163 63305600. E-mail: urosb2001@yahoo.com. Received: December 2014 & Accepted: March 2015 continence. Voiding symptoms are weak stream, inter- mittent flow, hesitancy and straining. Post-micturition symptoms are a sensation of incomplete emptying and a post-micturition dribble. Voiding and post-micturition symptoms are not as prevalent as storage symptoms, as epidemiology studies report that storage and voiding symptoms occur most often together in 18-21% men.(8,9) Many people are not aware of the significance of those symptoms and tolerate and neglect LUTS con- sidering this condition as a result of ageing.(5) Benign prostatic hyperplasia (BPH), urethral stenosis and hy- permobility and detrusor overactivity, bladder stones or bladder tumors usually cause LUTS in men. In addition, various system conditions like hyperten- sion, diabetes mellitus, cardiovascular disease, met- abolic syndrome, obesity, dyslipidemia, hyperinsu- linemia are known to influence LUTS occurrence.(12) Serbia is one of the oldest populations in Europe Re- gion, with standardized death rate per 100,000 popula- tion due to diseases of genitourinary system that vary from 14 in 2001 to 19 in 2011.(13) In 2013, the specif- ic mortality rate for males only was 32 per 100,000 population due to diseases of genitourinary system. (14) The same year, general practice services have reg- istered over 86000 cases with prostate hyperplasia or 15 per 1000 population(14) which is considerably higher than 12.5 per 1000 or over 71000 cases registered in Miscellaneous 2196 2012.(15) To our knowledge, there were no published HRQoL studies on persons with LUTS in Serbia. The aim of this study was to estimate the impact of void- ing and incontinence symptoms on quality of life (QoL) in urban male population considering socio-de- mographic characteristics, habits, and health status. MATERIALS AND METHODS Study Design and Population This is a descriptive study of HRQoL of series of male patients that have visited general practitioners at the Primary Healthcare Center “Novi Beograd” (PHC) of Belgrade (capital of Serbia) from December 2011 un- til May 2012 (six-month period). The study was car- ried out in the largest municipality of Belgrade (Novi Beograd) which accounts for 214,000 residents (2011 census).(16) The underlying reason for community based PHC approach is because persons with LUTS do not perceive LUTS as a health problem for a long time, but when they decide to seek help, they have to visit their general practitioner first (gate keeper).(17,18) Ac- cording to official statistics,(16) the study participants represent 2.8% of the total male population of 40 years or older residing at Novi Belgrade. Respondents’ age structure, marriage and education status, number of household members and weight profile appropriate- ly represent the population of the municipality.(14,15) However, risk behavior such as smoking and alcohol consumption was less frequent than reported by oth- er authors,(14,15) very likely because study respondents were those who visited general practitioners for a therapy or advice and being aware of their health sta- tus most of them have abandoned unhealthy life style habits. Diabetes mellitus in Serbia affects 8.6% of pop- ulation(14) while in our study 5.3% of respondents had diabetes mellitus. In addition, most of our respondents had cardiovascular diseases that are the most frequent non-communicable disease in Serbia.(14,15) Regarding all the above-mentioned points, our study population reasonably represents the population of Serbia as well. The study had two inclusion criteria, being male and aged 40 years or older. Patients with diagnosed cancer of any organ at any stage and diagnosed depression, or anxiety were excluded from the study. Participants who did not complete the questionnaires were also excluded. All eligible patients were informed orally and in writ- ten form about the purpose and ethical standards of the study and were kindly asked to voluntary participate in the study. All persons gave their informed consent prior their inclusion to study. This study has been approved by Ethics Committee of PHC Novi Beograd. A total of 1424 patients fulfilling criteria were included in the study and anonymously and properly completed three types of questionnaires. The response rate was 95% (1424/1500). Study Instruments The first questionnaire was about general socio-eco- nomic status (age, education, profession, employment, marital status, having children, apartment/house owner- ship, salary level), and general health data (body weight and height, daily smoking of 20 cigarettes and more, alcohol consumption, being diagnosed with angina pectoris, myocardial infarction, stroke and diabetes). The second questionnaire was the International Con- tinence Society Male Short Form (ICS male SF), in- tended for evaluating the occurrence of LUTS.(19) The questionnaire has been translated and culturally adapt- ed. Translation was done by two professional English translators. Firstly, the questionnaire was translated to Serbian language and then secondly, professional Eng- lish translator undertook a back translation to English language. The back translated questionnaire was com- pared to the original questionnaire and no significant differences were observed. A pilot study with five pa- tients was performed, and these patients evaluated the Serbian version of questionnaire. Minor changes were undertaking with by their suggestions. The question- naire contained voiding symptoms (5 questions) and in- continence symptoms (6 questions) domains. This ques- tionnaire also had three additional questions, urination frequency during day and night, and overall impact of urinary problems on life. Responses were designed by five-point Likert scale type, where a lower grade rep- resented better condition. Two extracted components of total eleven questions explained 69.9% of variance. High reliability was observed in five items of voiding symptoms, Cronbach›s α = 0.893 (α if item deleted 0.860-0.886) and six items of incontinence symptoms, Cronbach's α = 0.894 (α if item deleted 0.862-0.894). The third questionnaire was The 36-Item Short Form Health Survey (SF-36) generic assessment domain for HRQoL, previously translated and adapted for Serbi- an population.(20) This questionnaire contains eight domains intended for evaluating physical health and mental functioning. The first four domains (physical functioning, role-physical, bodily pain and general health) were used to assess physical health from the patient›s point of view whilst others deal with vitali- ty, social functioning, role-emotional and mental health issues. Patients gave answers on numerical scale. An- swers were coded, and scores for the eight domains were calculated on a 0-100 scale. Higher scores rep- resented better results from patient›s point of view.(20) Statistical Analyses The results were presented as frequency with percent and mean ± SD. Principal components analysis with varimax rotation and reliability analysis were used for validation of ICS male SF questionnaire. Spearman correlation, Pearson correlation, Point bi-serial corre- lation were determined to assess relationship between patients characteristics (socio-demographic, health sta- tus, LUTS) and QoL. Linear regression modeling was applied to assess correlation of voiding and urinary symptoms with QoL. Modeling was done in several steps to avoid the influence of confounding factors. In the first step, only voiding and incontinence scores were entered as independent variables and the eight domains of the SF-36 as dependent variables. In the second step, voiding and incontinence symptoms were adjusted for age. Then, in the next step, urinary symptoms were ad- justed for age and education. In the fourth model, ad- justment was made for age and education and one of the following: morbidity, income, number of house- hold members and apartment/house ownership. In the final step, all predictors were entered into the model. In order to shorten the results, only standardized beta and P values of voiding and incontinence symptoms were presented, as well as r square. All data were ana- lyzed using Statistical Package for the Social Science (SPSS Inc, Chicago, Illinois, USA) version 15.0. All P values less than .05 were considered significant. RESULTS LUTS and Quality of Life-Babic et al. Vol 12 No 03 May-June 2015 2197 Participants were mostly males in their sixties and with secondary school or higher education. Two thirds had own apartments but one eight lived alone. More than 51% had 200€ net monthly incomes which is the min- imal income in 2012 in Serbia according to the Statis- tical office of the Republic of Serbia. Half respondents were either overweight or obese (according to Body Mass Index for adults). A quarter of them were smokers and alcohol consumers. One fifth of them had cardio- vascular diseases, in most cases angina pectoris (Ta- ble 1). Our study population had characteristics similar to the other those studies conducted in Serbia . Most participants (61.1%) claimed that voiding has no ef- fect on their QoL (Table 2). Average voiding (VS) and incontinence symptoms (IS) were low. Physical func- tioning and social functioning had the highest score, and general and mental health had the lowest average values (Table 2). VS and IS have a statistically sig- nificant relationship with SF-36 domains. Correlation coefficients are lower in some domains such as men- tal health, emotional health, and role physical. But, correlation coefficients of these variables are high- er than others in number of QoL domains (Table 3). All five steps of regression modeling are presented in Table 4, thus the first model is non-adjusted, the second is age, and education adjusted, third is age, education and morbidity adjusted. The fourth model is age, edu- cation and income adjusted model. The final model is age, education, morbidity, income, household member number and apartment ownership adjusted (Table 4). Voiding and incontinence symptoms correlate signifi- cantly with all domains of QoL, measured through the SF-36 questionnaire. In the non-adjusted model void- ing symptoms highly correlated with physical function- ing and general health, while incontinence symptoms are correlated with physical functioning, body pain, general health and social functioning. After adjusting for age and education, standardized beta were lower in all domains, mostly in physical functioning. After adjusting for age, education and morbidity or income, coefficients were very similar as well after adjusting for all predictors (the previous including household members and apartment/house ownership) (Table 4). DISCUSSION This study is the first conducted in Serbia assessing the impact of voiding and incontinence symptoms on life quality in urban males of Belgrade. It is to emphasize that countries with limited health care resources, like Serbia, should take an advantage of QoL assessments in order to involve patients with certain health disor- ders in better understanding of their health problems and in decision making about potential treatments. Based on the results of our study, almost two-thirds of participants claimed that voiding has no effects to HRQoL. For the other third, we found a highly signif- icant statistical relationship between voiding and in- continence symptoms with all SF-36 HRQoL domains except mental health (perhaps because of exclusion of patients with mental illness from the study). Accord- ing to Serbian National Health Survey, 3.9% of males of 15 years and older had urinary incontinence.(21) Our study highlighted that voiding and incontinence symp- toms have higher influence on some domains like gen- eral health, social functioning, physical functioning and body pain than on role physical, vitality and role emo- tional, although effects were statistically significant. It is important to emphasize that incontinency had a high- er impact on role physical and social functioning than voiding symptoms. Same domains of HRQoL are asso- ciated with LUTS severity (social functioning, vitality and role physical).(6) Also, revealed a high correlation between LUTS intensity and HRQoL, especially on role physical, social functioning, vitality, mental health and general health domains.(22) In our study, explained variability was low as in other studies.(23,24) Similar to findings of other researchers(23,24) the intensity of void- ing or storage bother, had a significant correlation with HRQoL. Due to chronic character of these problems, our patients could have adapted to their difficulties, thus mental health was not as poor as was emotional role. One half of our study participants’ had salaries below minimum, which suggested difficult living conditions. Therefore reduced social functioning was expected. Experts agreed that it is difficult to determine normal voiding frequency. A majority of males without lower urinary tract symptoms in the USA, had a frequency of 7 voiding per day.(25) On the contrary, the Incontinence Society of Singapore claimed that normal 24-hour void- ing frequency was of 4 to 5 voiding.(26) Voiding frequen- cy is in direct correlation with ageing and it is expect- ed to increase during life.(22,27) In our study almost half Table 1. Demographic and clinical characteristics of the study participants. Variables n (%) Age, mean ± SD (min-max) 55.5 ± 10.1 (40-80) Married (or union) 982 (69.0) Number of household members 1 182 (12.8) 2-4 1116 (78.4) ≥ 5 126 (8.8) Education Basic 130 (9.1) High school 775 (54.4) College/Faculty 519 (36.9) Own apartment/house 968 (68.0) Income higher than 200 Euros 690 (48.5) Body Mass Index < 25 664 (46.6) 25-29.9 588 (41.3) ≥ 30 172 (12.1) Smoking 347 (24.4) Alcohol consumption 378 (26.5) Co-morbidity (all) 288 (20.2) Angina pectoris 211 (14.8) Myocardial infarction 19 (1.3) Stroke 13 (0.9) Diabetes mellitus 75 (5.3) Abbreviation: SD, standard deviation. LUTS and Quality of Life-Babic et al. Miscellaneous 2198 Table 2. Urinary status (ICS male SF) and Quality of life (SF-36). Questionnaire Variables No. % ICS male SF Voiding frequency during day 4 hours or more 658 46.2 3 hours 392 27.5 2 hours 245 17.2 every hour 129 9.1 Voiding frequency during night (time) None 587 41.2 Once 436 30.6 2 241 16.9 3 117 8.2 ≥ 4 43 3.0 Impact of voiding on life Not at all 870 61.1 Some 395 27.7 Quite 127 8.9 Much 32 2.2 Mean ± SD Median (min-max) Voiding symptoms 3.8±4.5 2 (0-20) Incontinence symptoms 3.2±4.4 1 (0-24) SF-36 Physical functioning 69.5 ± 27.9 75 (0-100) Role-physical 56.7 ± 43.4 75 (0-100) Bodily pain 59.9 ± 27.4 52 (0-100) General health 53.8 ± 15.4 52 (0-100) Vitality 56.1±10.8 55 (20-100) Social functioning 62.2±22.6 62.5 (0-100) Role-emotional 58.3±43.7 66.6 (0-100) Mental health 50.4±6.8 52.0 (16-80) Abbreviations: SF-36, 36-Item Short Form Health Survey; ICS male SF, International Continence Society Male Short Form. SF-36 Domains Voiding Score Incontinence Score ≤ 1 2-5 ≥ 6 0 1-4 ≥ 5 Physical functioning 81.5 ± 23.7 65.5 ± 26.8 56.0 ± 27.3 81.9 ± 23.1 69.5 ± 25.6 50.2 ± 26.1 Role-physical 62.0 ± 44.7 57.8 ± 42.1 48.3 ± 41.5 64.5 ± 44.0 58.4 ± 42.4 42.8 ± 40.1 Bodily pain 68.0 ± 26.8 59.9 ± 27.8 48.5 ± 23.5 69.1 ± 26.8 61.9 ± 25.9 43.7 ± 21.8 General health 57.8 ± 14.3 55.2 ± 14.3 47.1 ± 15.5 57.8 ± 14.6 56.5 ± 14.0 44.8 ± 14.0 Vitality 58.3 ± 10.4 55.5 ± 11.1 53.4 ± 10.7 58.2 ± 10.2 57.0 ± 10.8 51.6 ± 10.5 Social functioning 68.8 ± 22.3 61.0 ± 22.4 53.9 ± 20.3 69.4 ± 22.2 64.3 ± 21.4 48.9 ± 18.3 Role-emotional 63.9 ± 44.0 59.6 ± 42.1 49.2 ± 43.2 65.7 ± 43.9 62.8 ± 41.3 58.3 ± 43.6 Mental health 50.0 ± 6.5 49.6 ± 7.1 51.6 ± 6.7 50.3 ± 6.3 49.7 ± 6.8 51.1 ± 7.3 Abbreviation: SF-36, 36-Item Short Form Health Survey. Table 3. Voiding score and incontinence score tertiles and quality of life measured by SF-36. LUTS and Quality of Life-Babic et al. Vol 12 No 03 May-June 2015 2199 Table 4. Multivariate regression analyses with SF-36 domains as dependents and voiding and incontinence symptoms as independents variables.* Regression Models Voiding Symptoms Incontinence Symptoms R2 Standardized β R2 Standardized β Model 1 no adjustment Physical functioning 0.188 -0.433 0.224 -0.473 Role-physical 0.024 -0.155 0.042 -0.206 Bodily pain 0.115 -0.339 0.137 -0.371 General health 0.148 -0.385 0.148 -0.385 Vitality 0.055 -0.235 0.065 -0.255 Social functioning 0.104 -0.322 0.139 -0.372 Role-emotional 0.028 -0.169 0.060 -0.244 Mental health 0.020 0.141 0.006 0.080 Model 2 adjusted for age and education Physical functioning 0.239 -0.345 0.264 -0.388 Role-physical 0.040 -0.111 0.053 -0.167 Bodily pain 0.153 -0.295 0.167 -0.325 General health 0.191 -0.327 0.185 -0.320 Vitality 0.098 -0.183 0.103 -0.197 Social functioning 0.142 -0.289 0.169 -0.340 Role-emotional 0.037 -0.145 0.064 -0.230 Mental health 0.044 0.110 0.035 0.031 NS Model 3 adjusted for age, education and morbidity Physical functioning 0.239 -0.348 0.264 -0.388 Role-physical 0.041 -0.104 0.054 -0.165 Bodily pain 0.153 -0.292 0.168 -0.322 General health 0.206 -0.309 0.205 -0.308 Vitality 0.100 -0.175 0.105 -0.194 Social functioning 0.145 -0.280 0.173 -0.335 Role-emotional 0.037 -0.143 0.064 -0.230 Mental health 0.055 0.095 0.048 0.022 NS Model 4 adjusted for age, education and income Physical functioning 0.239 -0.345 0.264 -0.388 Role-physical 0.040 -0.111 0.053 -0.168 Bodily pain 0.156 -0.295 0.169 -0.323 General health 0.207 -0.327 0.198 -0.315 Vitality 0.115 -0.182 0.118 -0.192 Social functioning 0.151 -0.289 0.175 -0.337 Role-emotional 0.040 -0.145 0.066 -0.228 Mental health 0.049 0.110 0.040 0.028 NS Model 5 adjusted for age, education, income, number of household members and own apartment Physical functioning 0.279 -0.341 0.271 -0.380 Role-physical 0.044 -0.101 0.057 -0.161 Bodily pain 0.163 -0.286 0.175 -0.312 General health 0.224 -0.307 0.220 -0.300 Vitality 0.130 -0.170 0.132 -0.180 Social functioning 0.165 -0.273 0.188 -0.322 Role-emotional 0.042 -0.137 0.068 -0.224 Mental health 0.062 0.096 0.055 0.021 NS Abbreviation: NS, not significant. *All P values for all models are less than .001. LUTS and Quality of Life-Babic et al. Miscellaneous 2200 of participants had normal voiding frequency (every 4 hours or more), while less than 30% had frequent uri- nation (every two hours or less). These results should be to considered with regard to the fact that voiding frequency during the day depends on liquid intake. The studies that explored correlation of lifestyle and LUTS, found that alcohol consumption correlated with urgency and voiding and incontinence symptoms.(12) Nocturia represents one or more than one voiding during night, interrupting sleep. However, some re- searches claim that nocturia is more than one voiding during the night.(28) EPIC study revealed that nocturia is the most frequent LUTS. Also according to results of the Boston Area Community Health (BACH) cohort study, more than 25% of males suffer from nocturia, where diabetes mellitus, cardiovascular disease, cere- brovascular disease, obesity and diuretics are predis- posing factors.(1) But, if we applied a stricter criterion (two or more voidings during night), 30% of our par- ticipants had nocturia. Similar results were obtained in cross-sectional study among elderly men in 21 general practices.(29) In EpiLUTS study, a majority of participants (92.8%) did not show any kind of bother. (3) In our study most of participants claimed no both- er or some bother (89%), which demonstrates a sim- ilar percentage of urinary bother in both populations. Aging and education are in positive correlation with LUTS intensity.(2,30-32) Our study population’s age and education level varied and it was necessary to adjust the relation of voiding and incontinence symptoms with them. The impact of voiding and incontinence symp- toms on QoL domains was still significant after adjust- ment for age and education and that was found in other studies as well.(31,32) Morbidity and LUTS are correlat- ed, especially in some chronic diseases such as diabe- tes mellitus, coronary artery disease and stroke. These morbidities have a negative impact on LUTS intensity because of vascular and neurological pathogenesis.(33) After adjustment for age, education and morbidity (dia- betes mellitus, cardiovascular and cerebrovascular dis- eases and asthma), no significant changes in regression coefficients were obtained in any specific QoL domains. It indicates that influence of urinary bother on QoL is higher than observed diseases. Other studies have sim- ilar results as our study, which confirms a high impact of LUTS on QoL, higher than many other conditions. (30,31) The BACH and UREPIC studies (the UREPIK survey collected information on this relationship in the Netherlands, Korea, France and the UK) showed that LUTS had a similar or higher effect on QoL as stroke, myocardial infarction and other life threatening dis- ease.(32) The same studies revealed that morbidity, ex- cepting myocardial infarction, had no influence on the mental component as QoL domain. A higher impact of LUTS on QoL than of diabetes mellitus, gout and hy- pertension was also confirmed by other researchers.(24) Age, education and income adjusted model, revealed that voiding and incontinence symptoms had a higher impact than income. The final model with addition- al adjustment for, household members, and apartment ownership did not change coefficients significantly. Study Limitations The findings of this study are limited to the one male com- munity in Belgrade. For better generalization, further studies should be conducted on a larger scale and should include possibility of comparing the QoL data between the patients with LUTS and patients with no symptoms. The questionnaires were self-administered by par- ticipants and data affected participant’s memory and perception to some extent, thus findings might be un- der or overestimated. This study, nonetheless, is an original attempt to assess the HRQoL of male adults with LUTS in Serbia. In line with that, in this study the ICS male SF questionnaire has been translated and culturally adapted for Serbian population, there- fore it provides a foundation for further research. The inclusion of general practitioners in the collec- tion of data has raised their awareness about the re- lationship between the quality of lofe and LUTS and might have enhanced their approach to clinical man- agement of LUTS for the better HRQoL of patients. CONCLUSION LUTS have a high impact on QoL. Incontinence symp- toms have higher impact on QoL than voiding symp- toms. Voiding and incontinence symptoms significant- ly affect different domains of QOl after adjustment for comorbidities, income and household characteristics. CONFLICT OF INTEREST None declared. ACKNOWLEDGEMENTS Authors were supported from the Ministry of Educa- tion, Science, and Technological Development of the Republic of Serbia (Grant No. 175087 and Contract No. 175042). We would also like to thank the manage- ment and general practitioners of the Primary Health- care Center “Novi Beograd” in Belgrade for their help. Special thanks to participants for their valuable input. REFERENCES 1. Irwin DE, Milsom I, Kopp Z, Abrams P, Artibani W, Herschorn S. Prevalence, severity, and symptom bother of lower urinary tract symptoms among men in the EPIC study: impact of overactive bladder. Eur Urol. 2009;56:14-20. 2. Irwin DE, Kopp ZS, Agatep B, Milsom I, Abrams P. 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