A strategy for urinary incontinence treatments deprescription

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Navarre Health Service, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estrategia para deprescripción de tratamiento en la incontinencia urinaria" ] ] "textoCompleto" => "Urinary incontinence (UI) is a medical condition that is becoming more prevalent due to demographic aging. Available drugs for UI treatment in Spain are: solifenacin, fesoterodine, tolterodine, oxybutynin, propiverine, trospium and mirabegron. There is no consistent evidence to support superiority of drug therapy over behavioral therapy for treatment of urgency UI.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> These drugs, except mirabegron, can cause anticholinergic effects<a class="elsevierStyleCrossRef" href="#bib0035">2</a> due to the anticholinergic burden (AB), which has been also associated with an increased risk of mortality,<a class="elsevierStyleCrossRef" href="#bib0040">3</a> while mirabegron may cause cardiovascular adverse events.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> So, non-pharmacological treatment is preferred in elderly.<a class="elsevierStyleCrossRef" href="#bib0030">1</a>Combination of UI drugs and all day long use of incontinence diapers is considered a therapeutic redundancy, increasing the risk of adverse effects without providing benefits. We developed a strategy in order to withdraw UI drugs in primary care setting including patients who met both criteria.We used an in-house developed computerized clinical decision support system called OBSERVA, which let us identify patients and created proposals for deprescription of UI treatments. The aim of this intervention was to promote the deprescription through shared-decision making. Proposals were presented to general practitioners (GP) with the following pop-up message in the electronic prescription:“Patient treated with UI drugs and all day long use of diapers. This drug provides low benefit and high risk of adverse events. Drug withdrawal is recommended”.This message displayed three options: reject, accept or postpone the proposal. When GP accepted, treatment discontinuation was automatically transferred to electronic prescription.Besides, educational outreach visits were provided by clinical pharmacists (CP) in health care centers.The impact of this deprescription strategy was evaluated 21 months after its implementation.The following data were collected: sex, age, UI treatment, date of regimen initiation and discontinuation and AB using Anticholinergic Cognitive Burden scale (ACB scale)<a class="elsevierStyleCrossRef" href="#bib0040">3</a> before and 21 months after the intervention.Statistical analysis was performed using IBM SPSS Statistics v25. Quantitative variables were described as mean and standard deviation (SD) or as median and 25th–75th percentiles. Qualitative variables were described as percentages. Results of AB before and 21 months after intervention were compared by Student's T-test.A total of 377 patients [median age: 84 (76–88) years] were included, and 391 proposals were sent. After 21 months, 66% of the deprescription proposals had been accepted, 26% rejected and 8% were pending review, which shows a great acceptance by GP, improving patients’ safety and reducing unnecessary expenses.Percentages of submitted proposals by drug were: solifenacin 25%, mirabegron 23%, tolterodine 21%, fesoterodine 19%, oxybutynin 10% and trospium 2%. After the intervention, the discontinued drugs were: mirabegron 26%, solifenacin 23%, fesoterodine 19%, tolterodine 19%, oxybutynin 11% and trospium 2%.The available evidence indicates that cumulative exposure to AB may result in an increased risk of cognitive impairments, dementia and falls.<a class="elsevierStyleCrossRefs" href="#bib0040">3–5</a> ACB scores greater than 3 are associated with cognitive impairment.<a class="elsevierStyleCrossRef" href="#bib0040">3</a> In our study the mean AB before the intervention was 3.8 (2.0) points, and it significantly decreased after intervention in those who discontinued the UI treatment. In patients with a rejected proposal, AB was significantly lower while for patients with pending proposals this was significantly higher (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In addition, inappropriate use of mirabegron was reduced.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Another aim was to increase GP awareness about AB and to promote safe use of drugs. It is encouraging to see that in patients whose proposals were read but rejected, a statistically significant decrease in AB was found while in patients whose proposals were not reviewed, it increased.Medication review by CP followed by feedback to prescriber has shown efficacy in reducing AB in elderly.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> Nevertheless, individual medication reviews require resources and time to reach all patients with inappropriate prescriptions. In this setting, electronic reminders supported by educational outreach visits can be an efficient way of addressing the problem. Our clinical support system, OBSERVA, enabled to easily reach target patients.The main limitation is that potential benefits of reducing the inappropriate prescription on clinically relevant endpoints (falls, dementia and cardiovascular events) were not evaluated but will be addressed in future studies.The deprescription strategy promoted by CP was well accepted by GP and led to a reduction of inappropriate prescriptions of UI drugs in patients using diapers.Ethics approvalEthical approval was received from the Clinical Research Ethics Committee of Navarre (Spain) on June 7, 2019. Number: Pyto2019/43Patient consentNot required. The requirement of patient consent was waived by the Clinical Research Ethics Committee of Navarre." "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethics approval" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Patient consent" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">State of the proposal \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean (SD) ACB before intervention \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean (SD) variation in ACB \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC 95% \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Accepted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">258 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.66 (2.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−1.62 (2.22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−1.89 to −1.35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rejected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.43 (1.92) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.33 (1.29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.14 to −1.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pending review \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.40 (2.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.43 (1.55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.21 to 1.30 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2584322.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Anticholinergic burden variation." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "EAU guidelines on assessment and nonsurgical management of urinary incontinence" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.K. 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Scientific letter

A strategy for urinary incontinence treatments deprescription

Estrategia para deprescripción de tratamiento en la incontinencia urinaria

Natalia Alzueta

Corresponding author

nalzueti@navarra.es

Corresponding author.

, Carmen Fontela, Amaya Echeverría

Medicines Advice and Information Service. Navarre Health Service, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Urinary incontinence &#40;UI&#41; is a medical condition that is becoming more prevalent due to demographic aging&#46; Available drugs for UI treatment in Spain are&#58; solifenacin&#44; fesoterodine&#44; tolterodine&#44; oxybutynin&#44; propiverine&#44; trospium and mirabegron&#46; There is no consistent evidence to support superiority of drug therapy over behavioral therapy for treatment of urgency UI&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> These drugs&#44; except mirabegron&#44; can cause anticholinergic effects<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> due to the anticholinergic burden &#40;AB&#41;&#44; which has been also associated with an increased risk of mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> while mirabegron may cause cardiovascular adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> So&#44; non-pharmacological treatment is preferred in elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Combination of UI drugs and all day long use of incontinence diapers is considered a therapeutic redundancy&#44; increasing the risk of adverse effects without providing benefits&#46; We developed a strategy in order to withdraw UI drugs in primary care setting including patients who met both criteria&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We used an in-house developed computerized clinical decision support system called OBSERVA&#44; which let us identify patients and created proposals for deprescription of UI treatments&#46; The aim of this intervention was to promote the deprescription through shared-decision making&#46; Proposals were presented to general practitioners &#40;GP&#41; with the following pop-up message in the electronic prescription&#58;</p><p id="par0020" class="elsevierStylePara elsevierViewall">&#8220;Patient treated with UI drugs and all day long use of diapers&#46; This drug provides low benefit and high risk of adverse events&#46; Drug withdrawal is recommended&#8221;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This message displayed three options&#58; reject&#44; accept or postpone the proposal&#46; When GP accepted&#44; treatment discontinuation was automatically transferred to electronic prescription&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Besides&#44; educational outreach visits were provided by clinical pharmacists &#40;CP&#41; in health care centers&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The impact of this deprescription strategy was evaluated 21 months after its implementation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following data were collected&#58; sex&#44; age&#44; UI treatment&#44; date of regimen initiation and discontinuation and AB using Anticholinergic Cognitive Burden scale &#40;ACB scale&#41;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> before and 21 months after the intervention&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using IBM SPSS Statistics v25&#46; Quantitative variables were described as mean and standard deviation &#40;SD&#41; or as median and 25th&#8211;75th percentiles&#46; Qualitative variables were described as percentages&#46; Results of AB before and 21 months after intervention were compared by Student&#39;s <span class="elsevierStyleItalic">T</span>-test&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 377 patients &#91;median age&#58; 84 &#40;76&#8211;88&#41; years&#93; were included&#44; and 391 proposals were sent&#46; After 21 months&#44; 66&#37; of the deprescription proposals had been accepted&#44; 26&#37; rejected and 8&#37; were pending review&#44; which shows a great acceptance by GP&#44; improving patients&#8217; safety and reducing unnecessary expenses&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Percentages of submitted proposals by drug were&#58; solifenacin 25&#37;&#44; mirabegron 23&#37;&#44; tolterodine 21&#37;&#44; fesoterodine 19&#37;&#44; oxybutynin 10&#37; and trospium 2&#37;&#46; After the intervention&#44; the discontinued drugs were&#58; mirabegron 26&#37;&#44; solifenacin 23&#37;&#44; fesoterodine 19&#37;&#44; tolterodine 19&#37;&#44; oxybutynin 11&#37; and trospium 2&#37;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The available evidence indicates that cumulative exposure to AB may result in an increased risk of cognitive impairments&#44; dementia and falls&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#8211;5</span></a> ACB scores greater than 3 are associated with cognitive impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In our study the mean AB before the intervention was 3&#46;8 &#40;2&#46;0&#41; points&#44; and it significantly decreased after intervention in those who discontinued the UI treatment&#46; In patients with a rejected proposal&#44; AB was significantly lower while for patients with pending proposals this was significantly higher &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In addition&#44; inappropriate use of mirabegron was reduced&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Another aim was to increase GP awareness about AB and to promote safe use of drugs&#46; It is encouraging to see that in patients whose proposals were read but rejected&#44; a statistically significant decrease in AB was found while in patients whose proposals were not reviewed&#44; it increased&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Medication review by CP followed by feedback to prescriber has shown efficacy in reducing AB in elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Nevertheless&#44; individual medication reviews require resources and time to reach all patients with inappropriate prescriptions&#46; In this setting&#44; electronic reminders supported by educational outreach visits can be an efficient way of addressing the problem&#46; Our clinical support system&#44; OBSERVA&#44; enabled to easily reach target patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The main limitation is that potential benefits of reducing the inappropriate prescription on clinically relevant endpoints &#40;falls&#44; dementia and cardiovascular events&#41; were not evaluated but will be addressed in future studies&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The deprescription strategy promoted by CP was well accepted by GP and led to a reduction of inappropriate prescriptions of UI drugs in patients using diapers&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethics approval</span><p id="par0085" class="elsevierStylePara elsevierViewall">Ethical approval was received from the Clinical Research Ethics Committee of Navarre &#40;Spain&#41; on June 7&#44; 2019&#46; Number&#58; Pyto2019&#47;43</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Patient consent</span><p id="par0090" class="elsevierStylePara elsevierViewall">Not required&#46; The requirement of patient consent was waived by the Clinical Research Ethics Committee of Navarre&#46;</p></span></span>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41; variation in ACB&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Accepted&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;66 &#40;2&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;1&#46;62 &#40;2&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;1&#46;89 to &#8722;1&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Rejected&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;43 &#40;1&#46;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;0&#46;33 &#40;1&#46;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;0&#46;14 to &#8722;1&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Pending review&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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