eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Phencyclidine

Patrick L West, MD, Clinical Instructor, Medical Toxicology Fellow, Department of Emergency Medicine, Oregon Health and Sciences University; Staff Physician, Department of Emergency Medicine, Portland Veterans Affairs Medical Center
Nathanael J McKeown, DO, Assistant Professor, Oregon Health and Science University; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center, Oregon Health and Science University

Updated: Jan 21, 2009

Introduction

Background

Phencyclidine (PCP) was originally developed for use as a general anesthetic for surgery under the trade name Sernyl in the 1950s. Its use was discontinued in humans in 1965 because it often produced postanesthetic delirium with psychotic features, dysphoria, and occasionally extreme agitation. PCP under the name Sernylan was used as a veterinary anesthetic until 1978, after which time it became illegal to use altogether. 

In the 1960s, people began illegally manufacturing phencyclidine in laboratories, and, by the late 1970s, it became a popular street drug. Common street names include angel dust, peace pill, crystal joint, hog, rocket fuel, KJ, elephant tranquilizer, supergrass, boat, tic-tac, zoom, wet, embalming fluid, and wack. PCP is a white crystalline powder that is available in liquid, tablet, or powder forms. It can be snorted, ingested orally, or injected intravenously. It also can be smoked as a "joint" or "wet" when sprinkled on cigarettes or applied to mint or marijuana leaves. PCP is often taken in conjunction with other co-ingestants, including ethanol and marijuana.

Pathophysiology

PCP, also known as 1-(1-phenylcyclohexyl-piperidine), is classified as a dissociative anesthetic. PCP acts mainly in the CNS, producing both stimulation and depression. Its sympathomimetic effects are thought to be due to weak reuptake inhibition of norepinephrine and dopamine. PCP also exerts some cholinergic and anticholinergic effects and has some other actions at nicotinic and opioid receptors.

The dissociative properties of PCP are believed to be due to its actions as a glutamate antagonist at the N -methyl-D-aspartate (NMDA) receptors. NMDA antagonists have been known to produce behavioral effects similar to those observed in schizophrenia, and they are used to induce an animal model of schizophrenia for research. PCP also affects the actions of dopamine, which may cause the psychomotor effects seen with PCP.

Clinical effects occur within minutes and usually last several hours. These symptoms may last up to 48 hours in the event of significant overdose. However, even more prolonged effects may be seen in chronic users either from enterohepatic recirculation or from delayed release of PCP from lipid stores. Because PCP is fat soluble, it accumulates in adipose tissue and the brain. Recurrent and fluctuating symptoms occur as PCP is remobilized from lipid stores, which can occur days, weeks, or months after the initial use.¹ The half-life of PCP is estimated at 17.4 hours; however, half-lives of 1-4 days have been reported.² PCP is primarily metabolized in the liver.

Frequency

United States

• The 2006 National Survey on Drug Use and Health, polling adults older than 12 years, found  a lifetime prevalence of 2.7% of the population trying PCP. In the last year, 0.1% (an estimated 187,000 people) had tried it, and in the last month, 30,000 had used PCP.³  
• The 2007 Monitoring the Future Survey of high school seniors showed 2.1% using PCP once in their lifetime (down from 2.2% in 2006), 0.9% had used PCP at least once in the last year (up from 0.7% in 2006), and 0.5% (up from 0.4% in 2006) had used PCP at least once in the last 30 days.⁴
• The 2007 Monitoring the Future Survey also showed 21% of high school seniors felt PCP was "very easy" or "fairly easy" to obtain (down from 23.1% in 2006 and down from the high of 31% in the early 1990s).
• However, in their 2006 report, the American Association of Poison Control Centers only reported a total of 303 individual exposures to PCP and 208 hospital visits for PCP.⁵

Mortality/Morbidity

Doses of 20 mg or more of PCP may cause prolonged coma, seizures, and even death. One death has been reported from an ingestion of 150-200 mg in an acute overdose. The AAPCC reported one death and 19 major outcomes from PCP in 2006.⁵  

Morbidity and mortality are usually associated with rhabdomyolysis, renal failure, hypertensive crises, accidental trauma, and self-destructive behavior.

Race

According to the Drug Abuse Warning Network (DAWN) report of 2004, of all PCP-related ED visits in 2002, 43% of abusers were black, 30% were white, and 12% were Hispanic.⁶

Sex

Nationally, patients presenting to the ED for PCP intoxication are more likely to be male (64%) than female (36%).

Age

According to a national survey in 2006, 2.7% of the population aged 12 years and older reported using PCP at least once.

Clinical

History

Because of the numerous routes of administration, variations in dosage, and possibility of co-ingestants, PCP produces a wide variety of physical and behavioral effects. Most commonly, witnesses may report agitation, bizarre actions, or violent behavior. Users of PCP often appear to be having a psychotic episode and may or may not report to the physician that they have taken the drug.

Physical

Based on a study by McCarron et al in which 1,000 patients presenting with acute phencyclidine intoxication were evaluated, clinical effects ranged from lethargy and coma to extreme agitation and psychosis.⁷
 
Common physical examination findings include the following:

• Nystagmus (horizontal, vertical, or rotary) - Often considered a hallmark of PCP intoxication (57-89%)
• Hypertension (57%)
• Acute brain syndrome involving confusion, amnesia, disorientation, and violence (37%)
• Agitation and violent behavior (35%)
• Tachycardia (30%)
• Bizarre behavior including public nudity (29%)
• Hallucinations and delusions (19%)
• Miosis - Often reported with a blank stare
• Rare findings - Usually only seen with high doses
  • Seizures (3.1%)
  • Dystonia
  • Ataxia
  • Apnea (often seen with co-ingestants)
  • Catatonia
  • Coma - PCP coma usually presents with nystagmus and the absence of respiratory depression. Unlike opioid-induced coma, it does not improve with naloxone.
  • Hypertensive crisis
  • Myocardial infarction (non-Q wave, cardiac enzyme leak)
  • Intracranial and subarachnoid hemorrhage
• Other manifestations include the following:
  • Hyperthermia, hyperreflexia, and muscle rigidity have been reported.
  • Rhabdomyolysis with or without acute renal failure may also occur.

Differential Diagnoses

Other Problems to Be Considered

Lysergic acid diethylamide toxicity
Plant poisoning, mescaline
Malignant hyperthermia
Serotonin syndrome

Workup

Laboratory Studies

• The diagnosis of PCP intoxication is a difficult one to make without some sort of history of drug use from the patient. It should be considered in patients with bizarre behavior, hypertension, and nystagmus, or coma unresponsive to naloxone in a substance abuse case.
• Exposure to PCP can be confirmed by qualitative urine toxicology screening. Serum screening for PCP is not useful clinically because the test is not readily available. In addition, quantitative serum PCP level does not correlate with the symptoms.
• A fingerstick should be performed in all patients with altered mental status, as hypoglycemia can cause symptoms consistent with PCP intoxication. In addition, McCarron et al found that 20% of patients with acute PCP intoxication were hypoglycemic on presentation.⁷
• No laboratory tests are specific for PCP intoxication, but, in addition to hypoglycemia, elevations in WBC count and BUN and creatinine levels may be seen.
• Serum creatine phosphokinase and urine myoglobin levels should also be measured to rule out rhabdomyolysis, especially in the patients with severe agitation.
• Consider an arterial blood gas (ABG) measurement to assess for hypoxemia and metabolic acidosis in unresponsive patients.
• Urine pregnancy tests are indicated for female patients of childbearing age.
• False-positive results on a quantitative drug screen for PCP vary based on the actual test used. (Consult the laboratory for a list of confounders. Reported confounders include dextromethorphan, diphenhydramine, methadone, ibuprofen, metamizol, chlorpromazine, and venlafaxine.) If contaminants are a concern gas chromatography–mass spectroscopy (GC-MS) confirmatory test can be ordered.

Imaging Studies

• No imaging studies are necessary for the evaluation of acute PCP intoxication.
• Consider a CT scan of the head to rule out an intracranial cause for altered mental status.
• Consider specific imaging to evaluate traumatic injuries associated with PCP intoxication.

Procedures

• For patients who are unable to protect their airway or have evidence of respiratory compromise, endotracheal intubation and mechanical ventilation may be needed.
• Consider lumbar puncture in patients with altered mental status and fever in whom the diagnosis is unclear.

Treatment

Prehospital Care

• Evaluate and stabilize the patient's airway, breathing, and circulation (ABCs) including cervical spine immobilization if traumatic injury is suspected.
• Physical restraints may be required to prevent self-injury and to protect the medical staff. These patients should be monitored closely due to several death reports of PCP-intoxicated patients while being physically restrained.
• Chemical restraints may also be used. Establish intravenous access and administer benzodiazepines for patients with severe agitation. Intramuscular benzodiazepines are an alternative if intravenous access is unobtainable.

Emergency Department Care

• After addressing and stabilizing the ABCs, treatment of PCP intoxication starts with initial supportive measures (IV, O₂, cardiac monitor). ECG may be indicated to assess for dysrhythmias.
• Obtain a fingerstick to rule out hypoglycemia.
• Place patients in a dark, quiet room under continuous observation to minimize environmental stimuli.
• Consider activated charcoal for oral ingestions and co-ingestions. Multiple doses of charcoal may be beneficial in the case of large overdose. Only one dose of sorbitol should be given, usually with the initial dose. Clinicians should be aware that inappropriate administration of activated charcoal can convert relatively benign exposure (eg, mild PCP intoxication) into a very serious condition (eg, aspiration pneumonia).
• Extreme violent psychotic behavior requires sedation with parenteral benzodiazepines. Seizures should be treated with benzodiazepines.
• Haldol (haloperidol) should be reserved for patients with mild, predominately psychotic symptoms, with normal vital signs. 
• Butyrophenones (haloperidol, droperidol) and phenothiazines (eg, chlorpromazine) should be avoided in moderate and severe intoxications because they can lower seizure threshold, cause dystonic reactions, induce hypotension, and worsen anticholinergic symptoms, including hyperthermia.
• Hyperthermia may be treated by conventional cooling methods.
• Rhabdomyolysis is treated with intravenous hydration, urine alkalinization, and osmotic/diuretic agents. Possible caveat: There is a theoretical, but clinically unproven, concept of increased PCP reabsorption secondary to the urine alkalinization.
• For hypertensive emergencies, try to control agitation first with parenteral benzodiazepines. For persistent hypertension, intravenous nitroprusside is the agent of choice. Because of the theoretical concept of unopposed alpha effect (worsening of hypertension) and the availability of other antihypertensive agents (eg, calcium-channel blockers, intravenous nitroglycerin), pure beta-blockade should be avoided. Even labetalol, which has both alpha- (weak) and beta-blocking abilities, can be given only after alpha-blockade with phentolamine is achieved.
• New research is focused on the development of antibodies to neutralize the toxic effects of PCP.
• Acute PCP toxicity can usually be managed conservatively with an observation period of a few hours. More serious ingestions may require admission to an intensive care unit for days to weeks.

Consultations

Consult with a board-certified medical toxicologist or a local poison control center for further recommendations.

Medication

The goals of pharmacotherapy are to relieve the toxic effects of PCP, reduce morbidity, and prevent complications.

GI decontaminant

These agents prevent further absorption of adsorbable toxins from the GI tract. They are most beneficial if administered within 1-2 h of ingestion.

Activated charcoal (Liqui-Char)

Because PCP undergoes enterohepatic recirculation, may be indicted if clinically feasible. Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.

Dosing

Adult

1 g/kg PO/NG (30-100 g usual dose) typically as a mixture with 70% sorbitol or similar cathartic; may administer 0.5 g/kg PO/NG as repeat dose if desired

Pediatric

<2 years: 1 g/kg PO/NG (15-30 g usual dose); may administer 0.5 g/kg PO/NG as repeat dose prn; coadministration with cathartic not recommended
>2 years: Administer as in adults

Interactions

May inactivate syrup of ipecac if used concomitantly; effectiveness of other medications decrease with coadministration; do not mix charcoal with sherbet, milk, or ice cream (decreases absorptive properties of activated charcoal)

Contraindications

Documented hypersensitivity; poisoning or overdose of mineral acids and alkalies; unprotected airway with absent gag reflex

Precautions

Pregnancy

Precautions

Protect airway to reduce risk of aspiration; not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administration; after emesis with ipecac, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black; if comatose, administer via nasogastric tube

Benzodiazepines

Indications include agitation, violent behavior, psychosis, seizures, and muscular rigidity.

Diazepam (Valium)

Enhances GABA transmission. Appears to act on part of the limbic system, the thalamus and hypothalamus, to induce a calming effect. Rapidly distributes to other body fat stores. Twenty minutes after initial IV infusion, serum concentration drops to 20% of C_max.
Individualize dosage and increase cautiously to avoid adverse effects.

Dosing

Adult

5-10 mg IV; repeat q5-10min prn; IM/PR may be used if IV not available

Pediatric

30 days to 5 years: 0.2-0.5 mg IV (slowly) q2-5min prn; not to exceed 5 mg
>5 years: 1 mg IV (slowly) q2-5min prn; not to exceed 10 mg

Interactions

Phenothiazines, barbiturates, alcohols, and MAO inhibitors increase CNS toxicity when administered concurrently

Contraindications

Documented hypersensitivity; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity); monitor for respiratory depression and propylene glycol toxicity with high or repeated doses

Lorazepam (Ativan)

Short-acting anxiolytic with relatively long half-life.
Increases transmission of GABA, a major inhibitory neurotransmitter in the brain.
May be used IV and is well absorbed after IM injection. Onset of action occurs within min of an injection, and effects peak 15-20 min after injection. Duration of action is 6-8 h. No active metabolites exist.

Dosing

Adult

1-4 mg IV/IM; may repeat q15min prn; not to exceed 8 mg
Status epilepticus: 0.05-0.1 mg/kg IV over 2-5 min; may repeat in 10-15 min prn; not to exceed 8 mg/dose

Pediatric

0.05-0.1 mg/kg IV slowly over 2-5 min, maximum 4 mg/dose

Interactions

Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAO inhibitors

Contraindications

Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease; monitor for respiratory depression and/or propylene glycol toxicity with high or repeated doses

Midazolam (Versed)

Used as alternative in termination of refractory status epilepticus. Because water soluble, takes approximately 3 times longer than diazepam to peak EEG effects. Thus, clinician must wait 2 min to fully evaluate sedative effects before initiating procedure or repeating dose. Has twice the affinity for benzodiazepine receptors than diazepam. May be administered IM if unable to obtain vascular access.

Dosing

Adult

0.01-0.05 mg/kg (usually 0.5-4 mg, not to exceed 10 mg) IV slowly over several min; may repeat q10-15min prn

Pediatric

<32 weeks: 0.5 mcg/kg/min IV infusion
>32 weeks: 1 mcg/kg/min IV infusion
Children: 0.05-0.2 mg/kg IV over 2-3 min, followed by 1-2 mcg/kg/min continuous infusion
Status epilepticus (refractory to standard therapy), >2 months and children: 0.15 mg/kg followed by continuous infusion of 1 mcg/kg/min, titrate upward q5min prn

Interactions

Sedative effects of midazolam may be antagonized by theophyllines; narcotics and erythromycin may accentuate sedative effects of midazolam due to decreased clearance

Contraindications

Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, pulmonary disease, renal impairment, and hepatic failure; monitor for respiratory depression with high or repeated doses

Antihypertensives

These agents are used for blood pressure control in hypertensive crises to minimize end-organ damage.

Nitroprusside (Nitropress)

Produces vasodilation and increases inotropic activity of the heart. At higher dosages, may exacerbate myocardial ischemia by increasing the heart rate.

Dosing

Adult

Begin infusion at 0.3-0.5 mcg/kg/min IV and use increments of 0.5 mcg/kg/min; titrate to desired effect; average dose is 1-6 mcg/kg/min
Infusion rates >10 mcg/kg/min may lead to cyanide toxicity

Pediatric

Administer as in adults

Interactions

Effects are additive when administered with other hypotensive agents

Contraindications

Documented hypersensitivity; subaortic stenosis; decreased cerebral perfusion; arteriovenous shunt or coarctation of aorta (eg, compensatory hypertension); atrial fibrillation or flutter

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in increased intracranial pressure, hepatic failure, severe renal impairment, and hypothyroidism; in renal or hepatic insufficiency, nitroprusside levels may increase and can cause cyanide toxicity at high infusion rates and when used in combination with a diuretic; sodium nitroprusside has ability to lower blood pressure and thus should be used only in patients with mean arterial pressures >70 mm Hg

Neuroleptics

These agents are used for acute psychosis when no contraindications are present.

Haloperidol (Haldol)

Butyrophenone noted for high potency and low potential for causing orthostasis. Downside is high potential for EPS and dystonia. Lowers seizure threshold and worsens anticholinergic symptoms, including hyperthermia. Should be reserved only for mild PCP intoxications with predominantly psychotic features and normal vital signs.
Parenteral dosage form may be admixed with 2 mg lorazepam for better anxiolytic effects.

Dosing

Adult

0.5-5 mg IV (unlabeled use), may be repeated q30min
2-5 mg IM q1-8h; not to exceed 100 mg/d

Pediatric

<3 years: Not established
3-12 years: 0.5 mg IV/IM
>12 years: Administer as in adults

Interactions

May increase tricyclic antidepressant serum concentrations and hypotensive action of antihypertensive agents; phenobarbital or carbamazepine may decrease effects of haloperidol; haloperidol coadministration with anticholinergics may increase intraocular pressure; encephalopathylike syndrome associated with concurrent administration of lithium and haloperidol

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; bone marrow suppression; severe cardiac or liver disease; severe hypotension; hyperthermia; seizures

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Severe neurotoxicity manifesting as rigidity or inability to walk or talk may occur in patients with thyrotoxicosis also receiving antipsychotics; if IV/IM, watch for hypotension; caution in those with CNS depression, subcortical brain damage, or cardiac disease; if history of seizures, benefits must outweigh risks; significant increase in body temperature may indicate intolerance to antipsychotics (discontinue if this occurs)

Follow-up

Further Inpatient Care

• Any patient with evidence of unrelenting agitation, hypertensive crisis, hyperthermia, seizures, respiratory depression, rhabdomyolysis, or severe traumatic injuries should be admitted to the hospital, and possibly to an intensive care setting if indicated.
• Consider a psychiatric evaluation for substance abuse counseling and/or suicidal ideations.

Further Outpatient Care

• Consider referral to a drug rehabilitation program. Repeated use of PCP can result in addiction, and abrupt discontinuation of the drug can produce withdrawal symptoms, including craving, confusion, and depression.²

Complications

• Chronic PCP toxicity results in cognitive deficits and mood disorders. Patients can develop speech impediments and also suffer from dysphoria, depression, anxiety, and psychosis.
• Occult traumatic injuries must be ruled out. Perform a thorough physical examination on all patients under the influence of PCP.

Prognosis

• Patients who present with rhabdomyolysis, renal failure, seizures, hyperthermia, hypertensive crises, and traumatic injuries tend to have worse outcomes.

Patient Education

• For excellent patient education resources, visit eMedicine's Poisoning - First Aid and Emergency Center, Mental Health and Behavior Center, and Substance Abuse Center. Also, see eMedicine's patient education articles Drug Dependence & Abuse, Poisoning, Club Drugs, and Activated Charcoal.
• Also visit the following Web sites: www.streetdrugs.org, National Institute on Drug Abuse, and The Partnership for a Drug-Free America.

Miscellaneous

Medicolegal Pitfalls

• The acute toxicity of PCP is often misdiagnosed because of its similarity to schizophrenic episodes. In fact, PCP-induced psychosis may respond to antipsychotics, which may further confound the diagnosis.
• Do not rely on the urine toxicology screen to diagnose acute PCP intoxication. Chronic PCP users can have positive test results for weeks after their last use. Cases of false-positive results for PCP have also been reported with many agents, including diphenhydramine (Benadryl) and dextromethorphan, agents in over-the-counter cough formulations that can produce clinical effects similar to PCP when taken in high doses.
• Failure to diagnose or address CNS infection, hypoglycemia, hyperthermia, traumatic injuries, or rhabdomyolysis is medical malpractice.

References

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Keywords

phencyclidine toxicity, PCP, PCP overdose, phencyclidine overdose, angel dust, peace pill, crystal joint, supergrass, wack, rocket fuel, KJ, illy, elephant tranquilizer, embalming fluid

Contributor Information and Disclosures

Author

Patrick L West, MD, Clinical Instructor, Medical Toxicology Fellow, Department of Emergency Medicine, Oregon Health and Sciences University; Staff Physician, Department of Emergency Medicine, Portland Veterans Affairs Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Nathanael J McKeown, DO, Assistant Professor, Oregon Health and Science University; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center, Oregon Health and Science University
Nathanael J McKeown, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Lance W Kreplick, MD, MMM, FAAEM, FACEP, Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC
Lance W Kreplick, MD, MMM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Fred Harchelroad, MD, FACMT, Chair, Department of Emergency Medicine, Director of Medical Toxicology, Department of Emergency Medicine, Associate Professor, Allegheny General Hospital
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Nicole S Johnson, MD, and Mark A Silverberg, MD, to the development and writing of this article.

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