Dissolve Discomfort Instantly: Herbal Sublingual Films as A Natural Cure for Acidity

Aniket Thul, Pooja Rasal, Shruti Naik, Sneha Nishad, Onkar Shepal,

doi:10.5281/zenodo.17263993

Review Paper | Open Access
Volume 02 | Issue 10 | Article Id IJSRT/250309066

Dissolve Discomfort Instantly: Herbal Sublingual Films as A Natural Cure for Acidity
Aniket Thul* Pooja Rasal Shruti Naik Sneha Nishad Onkar Shepal
S.N.D College of Pharmacy, Babhulgaon, Yeola India [423401]

Abstract

Acidity, often experienced as heartburn or a burning sensation in the chest, is a common symptom of gastroesophageal reflux disease (GERD)—a condition that affects millions worldwide. While conventional medicines are available, many come with side effects or don’t always provide complete relief. That’s where herbal remedies, combined with modern drug delivery technologies, are beginning to show great promise.One such innovation is herbal sublingual films (HSFs)—thin strips that dissolve under the tongue, allowing herbs to quickly enter the bloodstream without going through the digestive system. This not only speeds up relief but also makes it easier for people who have trouble swallowing pills.This article takes a closer look at how these herbal films are made, what ingredients they contain (such as licorice, amla, and aloe vera), and how they work. It also discusses the science behind their design—like the use of natural polymers and specialized techniques to ensure strength, flexibility, and quick drug release.Additionally, the review compares how fast and effectively herbal extracts are absorbed when taken under the tongue versus traditional oral methods. It also explores exciting future directions—like combining multiple herbs, using smart materials, and incorporating artificial intelligence to fine-tune the film formulation.With continued research and proper safety checks, herbal sublingual films could soon become a trusted and widely used solution for managing acidity and related digestive issues—bringing the best of both herbal wisdom and modern science together.

Keywords

Herbal sublingual films, GERD, Acidity treatment, Novel drug delivery system (NDDS), Sublingual absorption, Herbal formulation, Fast-dissolving films

Introduction

Gastroesophageal reflux disease (GERD) is a widespread gastrointestinal (GI) condition and is among the most frequently observed disorders in clinical settings [1,2]. The hallmark symptoms of GERD include heartburn and acid reflux, which are commonly reported by affected individuals [3,4]. Numerous studies conducted worldwide have investigated its occurrence and found a particularly high prevalence in Western countries [5]. In the United States, it has been documented that around 44% of adults report experiencing heartburn at least once per month, 14% on a weekly basis, and 7% suffer from it daily [6]. Novel Drug Delivery SystemA Novel Drug Delivery System (NDDS) encompasses a range of innovative methods, formulations, and technologies developed to facilitate the controlled and targeted transport of therapeutic agents within the body, with the aim of achieving desired clinical outcomes. These systems are designed to ensure that drugs reach specific targets efficiently while maintaining effective therapeutic levels [7]. Ongoing research in this field has focused on the development of platforms such as liposomes, nanoparticles, niosomes, transdermal systems, implants, microencapsulation, and polymer-based carriers [7]. Among these, sublingual drug delivery has gained attention for its ability to offer fast absorption and bypass the gastrointestinal tract and liver metabolism. The effectiveness of sublingual administration depends on several factors, including the chemical properties of the drug, the formulation design, and the permeability of the sublingual mucosa [8]. This review primarily addresses the drug characteristics and formulation strategies necessary for effective sublingual delivery. When administered via this route, the drug is placed under the tongue and absorbed directly into the bloodstream through the tissues located beneath the tongue’s surface [9]. Role of Herbal Medicine in Gastrointestinal Disorders Polyphenols, a group of plant-derived compounds, are widely recognized for their antioxidant capacity and potential health-promoting effects. A significant subgroup of these compounds, flavonoids, is abundantly found in various fruits, vegetables, teas, and medicinal herbs. Evidence suggests that both polyphenols and flavonoids may play a beneficial role in the management of GERD by reducing inflammation, counteracting oxidative stress, and enhancing mucosal protection [10,11]. When integrated into diet or therapeutic strategies, these naturally occurring antioxidants may complement conventional GERD treatments by enhancing efficacy and minimizing side effects. The strong anti-inflammatory and antioxidant actions of flavonoids make them particularly promising for GERD therapy. Research has indicated that oxidative stress is a major factor in mucosal injury and inflammation, which in turn worsens GERD symptoms [12]. Plant-based antioxidant compounds like flavonoids and polyphenols may help alleviate GERD symptoms by mitigating oxidative stress within the esophageal lining [13,14]. For instance, common foods such as onions and apples, rich in the flavonoid quercetin, have demonstrated the ability to reduce esophageal inflammation and suppress pro-inflammatory cytokines, including tumor necrosis factor-alpha (TNF-α) [13,14].

2. Concept of Sublingual Drug Delivery System

[Fig1]: Sublingual Drug Delivery System [15]

In below [Fig2], The oral mucosa is composed of squamous epithelial cells and contains mucous glands. The structure of the buccal and sublingual mucosal tissues is similar in nature. For a drug to be effectively absorbed via the sublingual route, it must permeate through the buccal mucous membrane, primarily through a diffusion-driven process such as osmosis, which plays a key role in controlling both intestinal and sublingual retention of the drug [16].

Mechanism of drug absorption from the sublingual [16].

[Fig 2]: Mechanism of drug absorption from sublingual [16]

Herb / Product	Botanical Source	Role in Acidity / GERD	Reference
Deglycyrrhizinated Licorice (GutGard®)	Glycyrrhiza glabra	Phase III RCT: improved heartburn/regurgitation; QoL improvements by day?7 over 28?days	[17]
Aloe vera syrup	Aloe barbadensis Miller	Pilot RCT: 10?mL/day for 4?weeks reduced frequency of heartburn, regurgitation, nausea; well?tolerated	[18]
Artemisia asiatica extract (DA?5204)	Artemisia asiatica	RCT: 4?weeks healing similar to PPI; significantly fewer residual lesions (p<0.001)	[19]
Opuntia–Olea extracts (Mucosave®)	Opuntia ficus?indica, Olea europaea	RCT: 2?months; 56.5% reduction in GERD?HRQoL, 59.1% drop in symptom scores; fewer heartburn/regurgitation episodes	[20]
Myrtus communis extract (Myrtle)	Myrtus communis	6-week RCT in adults: symptom reduction; also studied in children with improved appetite post?treatment	[21]
Melatonin (oral & sublingual)	endogenous pineal hormone	Trial: 4–8 weeks melatonin alone or with PPI; improved heartburn, epigastric pain, enhanced LES tone and mucosal protection	[22]
Marine alginate (alginate formulations)	brown seaweed-derived alginate	Alginate forms acid “raft” to reduce reflux; multiple RCTs show better symptom relief vs placebo or antacids	[23]
Slippery elm	Ulmus rubra inner bark	Case series & formula use: mucilage forms protective layer over mucosa; associated with 60–80% reduction in GI pain	[24]
Marshmallow root (Althaea officinalis)	Althaea officinalis	Reduce inflammation and support tissue healing (pre?clinical evidence)	[25]

3. Herbal Remedies for Acidity:

4. Factors affecting the sublingual absorption [26,27]

Solubility in Salivary Secretions:
For a drug to be effectively absorbed through the sublingual route, it must dissolve well in the aqueous environment of the oral cavity and also exhibit good lipid solubility. In essence, the drug should possess both hydrophilic and lipophilic properties (i.e., be biphasic) to facilitate efficient absorption.

Binding Affinity to Oral Mucosa: Drugs that strongly adhere to the oral mucosal surfaces tend to show reduced systemic bioavailability. The sublingual epithelium, which is about 100–200 μm thick, is thinner than the buccal epithelium, promoting quicker absorption. Additionally, the thin tissue allows the drug to disperse effectively in small volumes of saliva.
pH and pKa Compatibility with Saliva: The typical pH of saliva is around 6.0, which favors the uptake of drugs that remain unionized at this pH. Drugs with a pKa value above 2 (for acids) or below 10 (for bases) are more likely to be absorbed through the oral mucosa under such conditions.
Drug Lipophilicity: Sublingually administered drugs require slightly higher lipid solubility compared to drugs absorbed through the gastrointestinal tract. This facilitates passive diffusion through the mucosal barrier, leading to efficient and rapid absorption.
Thickness of Oral Epithelial Mucosa: The sublingual mucosal tissue, being relatively thin (100–200 μm), offers less resistance to drug penetration. As a result, drugs can be effectively absorbed even in small quantities of saliva due to enhanced permeability.
Blood Flow: Good blood circulation under the tongue helps the drug quickly enter the bloodstream. If blood flow is reduced (for example, from smoking or cold temperatures), absorption slows down.
Drug Properties: The chemical nature of the drug matters. Drugs that are small in size, more fat-soluble (lipophilic), and stable in saliva tend to absorb better under the tongue.
Time of Contact: The longer the drug stays under the tongue without being swallowed, the better the chance it has to absorb fully. Talking, eating, or swallowing too soon can lower its effectiveness.

5. Herbal sublingual flims: formulation and development

MATERIALS:

Material Type	Examples	Function	Recent References
Film-Forming Polymers	- Hydroxypropyl methylcellulose (HPMC) - Pullulan - Sodium alginate - PVA - Chitosan	Provides film structure, flexibility, and integrity	[28]
Plasticizers	- Glycerol - Propylene glycol - PEG-400	Improves film elasticity, reduces brittleness	[28]
Superdisintegrants	- Crospovidone - Croscarmellose sodium	Enhances rapid disintegration in saliva	[28]
Herbal Extracts	- Licorice (Glycyrrhiza glabra) - Ginger (Zingiber officinale) - Amla (Emblica officinalis)	Active pharmaceutical ingredient with anti-acid, antioxidant, or soothing properties	[29]
Sweeteners	- Mannitol - Xylitol - Sucralose	Masks bitter taste of herbal extracts	[29]
Saliva Stimulating Agents	- Citric acid - Malic acid	Promotes saliva production, improving film dissolution and absorption	[30]
Surfactants	- Poloxamer 188 - Tween 80	Enhances solubility and spreadability of actives	[30]
Preservatives	- Sodium benzoate - Methylparaben	Prevents microbial contamination in film during storage	[31]

Formularion: [32,33]

Methodology (Solvent Casting)

1. Selection of Herbal API (Active Ingredient Choose herbs with proven anti-acid or gastroprotective activity. Common choices: Glycyrrhiza glabra (Licorice), Zingiber officinale (Ginger), Foeniculum vulgare (Fennel), Aegle marmelos, Mentha piperita.)
2. Extraction of Herbal API

Extract active compounds using techniques like cold maceration, Soxhlet extraction, or hydroalcoholic extraction.

1. Selection of Film-Forming Polymer

Common polymers: HPMC (Hydroxypropyl methylcellulose), PVA (Polyvinyl alcohol), Pullulan, or Sodium alginate.

1. Plasticizer Addition

Add plasticizers like Glycerol or PEG 400 (typically 10–20% of polymer weight) to enhance flexibility and prevent brittleness.

1. Sweetener and Flavoring Agents

Add natural sweeteners (Stevia, Sucralose) and flavors (peppermint oil, orange oil) for patient compliance.

1. Preparation of Casting Solution

Mix extract, polymer, plasticizer, sweetener, and solvent (usually water or hydroalcoholic). Stir well to form a homogeneous solution

1. Casting and Drying

Pour the solution into a Petri dish or teflon plate and allow to dry at controlled temperature (40-50°C) in a hot air oven

1. Film Cutting and Packing

Cut dried film into uniform dimensions (e.g., 2x2 cm). Store in moisture-resistant packaging.

1. Evaluation

Perform tests like:

Folding endurance

Disintegration time

Surface pH

Content uniformity

In vitro release study

METHODS:

Fast-dissolving films can be made using the following processes:

Solvent casting
Semi solid casting
Solid dispersion extrusion
Hot melt extrusion method
Rolling method

Solvent casting technique

Water-soluble polymers are first dissolved in water, while the drug and additional excipients are dispersed in an appropriate solvent. These two solutions are then combined and thoroughly stirred. The resulting mixture is poured into a Petri dish, allowed to dry, and subsequently cut into films of uniform size.

[Fig3]: Solvent casting technique [38]

Semi-solid casting technique

In the semisolid casting technique, a solution of a water-soluble film-forming polymer is initially prepared. This is then blended with a solution of an acid-insoluble polymer—such as cellulose acetate phthalate or cellulose acetate butyrate—previously dissolved using ammonium or sodium hydroxide. A suitable quantity of plasticizer is added to the mixture to develop a gel-like mass. This gel is then spread into films or ribbons using heated rollers. The resulting film typically has a thickness between 0.015 and 0.05 inches. An optimal ratio of 1:4 between the acid-insoluble polymer and the film-forming polymer is maintained.

Solid dispersion extrusion

In this approach, the drug is combined with immiscible components through an extrusion process to form solid dispersions. These dispersions are then shaped into films using molds or dies.

[Fig 4]: Solid dispersion extrusion [39]

Hot melt extrusion method

In the hot melt extrusion technique, the drug is initially blended with solid carriers. This blend is then heated and melted using an extruder fitted with temperature control units. The molten mixture is subsequently shaped into films using specialized dies. Hot melt extrusion offers several advantages, including:

Fewer processing steps
Improved uniform distribution of the drug
A solvent-free (anhydrous) procedure

[Fig5]: Hot melt extrusion method [40]

Rolling method

In the rolling method, a drug-loaded solution or suspension is applied onto a carrier material. The solvent used is typically water or a combination of water and alcohol. The coated film is then dried as it passes over rollers and subsequently cut into specific shapes and dimensions.

[Fig6]: Rolling method [41]

EVALUATION PARAMETERS:

Thickness

The thickness of the film was assessed at multiple points using a digital Vernier Caliper with a least count of 0.01 mm. Measurements were taken from three distinct spots on the film, and the average value along with the standard deviation was calculated.

Weight Variation

The prepared film was sectioned into 4 cm² pieces from three different areas. Each section was weighed individually, and the variation in weight was then determined.

Folding Endurance

To evaluate folding endurance, the film was repeatedly folded at the same point until it broke. The total number of folds the film could withstand before tearing was recorded as the folding endurance.

Tensile Strength

Tensile strength refers to the maximum force a film can endure before breaking. It was determined by dividing the applied force at the point of rupture by the film’s cross-sectional area.

Percentage Elongation

When a film is subjected to stress, it undergoes stretching, referred to as strain. Strain is calculated by dividing the change in the film’s length by its original length. An increase in plasticizer concentration typically results in greater film extensibility.
Formula:
Percentage Elongation = (L × 100) / Lo
Where:

L = Extension in length

Lo = Original length of the film

Strain Evaluation

Strain occurs as a result of mechanical stress causing the film to stretch. It is expressed as the ratio of the film's deformation to its original length. Films with higher plasticizer levels tend to stretch more before breaking.

Drug Content Uniformity

To assess drug uniformity, a 2 × 2 cm film sample was homogenized in 100 mL of simulated saliva fluid at pH 6.8, with continuous shaking for 30 minutes. A 10 mL aliquot was then diluted to 50 mL using the same medium. The absorbance of this solution was measured using a UV-visible spectrophotometer. Each formulation was tested in triplicate, and the average result was recorded.

Surface pH

A small volume (0.5 mL) of distilled water was applied to the film placed in a petri dish and allowed to sit for 30 seconds. The surface pH was then measured by placing the pH meter’s electrode in contact with the film for 1 minute to allow for stabilization. Measurements were repeated three times per formulation, and the mean value was taken.

In Vitro Dissolution Studies

The dissolution behavior of the fast-dissolving films was examined using the USP type II paddle method. The test was conducted in 300 mL of simulated salivary fluid (pH 6.8) maintained at 37?±?0.5?°C. The dissolution medium was continuously stirred at a speed of 100 rpm. At intervals of 30 seconds, small portions were removed and immediately replenished with an equal volume of fresh medium to maintain consistent conditions. The concentration of the drug in each collected sample was analyzed using a UV spectrophotometer. A release profile was then constructed by plotting the percentage of drug released against time.

Ex Vivo Permeation Study Using Porcine Buccal Mucosa

Permeation assessment was conducted using a modified Franz diffusion cell with an internal diameter of 2.5 cm. Fresh buccal tissue was collected from the cheek pouch of a pig shortly after sacrifice at a local abattoir. The tissue was carefully trimmed and rinsed with isotonic phosphate buffer solution (pH 6.6) before being used. This mucosal membrane served as the barrier between the donor and receptor compartments of the diffusion cell.The receptor chamber contained 200 mL of phosphate buffer (pH 7.4), maintained at 37?±?0.2?°C and stirred with a magnetic bead at 50 rpm to simulate physiological conditions. A pre-weighed 2 × 2 cm film sample was gently placed on the mucosal surface, which had been moistened with a few drops of artificial saliva to mimic oral conditions. Then, 1 mL of simulated saliva (pH 6.8) was added to the donor chamber.Samples were withdrawn from the receptor chamber at predetermined time intervals and replaced with fresh buffer to maintain constant volume. The amount of drug that permeated through the tissue was determined by measuring absorbance using a UV-Visible spectrophotometer, and the results were expressed as a percentage of total drug permeated over time.

Absorption Kinetics: Sublingual vs. Oral Route

The way a drug is delivered into the body plays a crucial role in how quickly and effectively it works. Two commonly used methods for delivering drugs systemically are the sublingual and oral routes. These methods differ significantly in how the body absorbs the drug, mainly because of their unique anatomical and physiological pathways.

Sublingual Route

In the sublingual method, the drug is placed beneath the tongue, where it dissolves and is absorbed directly into the bloodstream through the mucous membrane, which is rich in blood vessels.This route allows the drug to skip the liver's initial metabolic processing, known as the first-pass effect, resulting in quicker action and better bioavailability.

Key Absorption Features:

Fast absorption due to thin membrane and dense blood flow.
The drug reaches systemic circulation through lingual veins, avoiding liver metabolism.
Best suited for lipophilic (fat-soluble), low-dose, and potent drugs.

Oral Route

With oral administration, the drug is swallowed and absorbed through the digestive tract, primarily in the stomach and small intestine.However, this route exposes the drug to the digestive system and the liver’s first-pass metabolism, which can reduce how much of the active drug enters the bloodstream.

Key Absorption Features:

Slower absorption because of digestion and intestinal movement.
Absorption can be influenced by stomach pH, food intake, digestive enzymes, and the drug’s solubility.
Suitable for many drug types, although some may degrade before they can be fully absorbed.

Comparison: Sublingual vs. Oral Route

Parameter	Sublingual Route	Oral Route
Absorption Site	Under the tongue (sublingual mucosa)	Stomach and small intestine
Onset of Action	Fast (1–10 minutes)	Slower (30–90 minutes)
Bioavailability	Higher (bypasses liver metabolism)	Lower (due to liver processing)
Stability in GIT	Not affected by gastric conditions	Can be degraded by stomach acid or enzymes
Ease for Patients	High (no swallowing needed)	High (common, but depends on dosage form)
Ideal Drug Type	Small, fat-soluble, potent molecules	Wide range, including water-soluble drugs
First-Pass Metabolism	Avoided	Present

Advantages and Challenges Of Flims [51]

Advantages of Films

Suitable for patients with swallowing difficulties, including children, the elderly, and individuals with psychiatric conditions who may resist conventional tablets.
Provides more accurate and convenient dosing compared to liquid formulations, especially in outpatient settings.

Eliminates the need for water, making it ideal for mobile patients or those in situations where water is not readily available.
Enhanced palatability and mouthfeel improve patient acceptance, especially among children, by avoiding the typical bitterness associated with many oral medications.
Rapid disintegration and absorption facilitate a faster therapeutic effect due to quicker onset of action.
Certain drugs can be absorbed directly through the oral mucosa, including the mouth, pharynx, and esophagus, leading to enhanced bioavailability as saliva carries the drug to the stomach.
Combines the advantages of liquids with the stability of solid dosage forms, offering ease of storage and handling.
By promoting pregastric absorption, it can enhance drug bioavailability and allow lower dosing, which may reduce the risk of adverse effects and improve overall therapeutic efficacy.

Challenges:

Sublingual drug delivery may not be ideal for long-term use since it can interfere with normal activities like eating, drinking, and speaking.
This route is generally unsuitable for sustained-release formulations due to the limited surface area and short retention time under the tongue.
Patients are advised to avoid smoking during sublingual therapy, as nicotine-induced vasoconstriction can reduce blood flow and diminish the drug’s absorption and effectiveness.

10. Future Prospects and Research Directions of Herbal Sublingual Films for Acidity

1. Enhanced Bioavailability through Novel Herbal Delivery

Future Prospect: Herbal sublingual films (HSFs) offer a promising alternative for delivering herbal anti-acid agents with improved bioavailability by bypassing hepatic first-pass metabolism.
Research Direction: Investigate pharmacokinetic profiles of various herbal extracts (e.g., Glycyrrhiza glabra, Amla, Fennel) when administered sublingually compared to oral routes.

2. Development of Standardized Herbal Extracts

Future Prospect: Standardization ensures consistency in therapeutic efficacy and safety.
Research Direction: Focus on quantifying bioactive constituents (e.g., flavonoids, saponins, tannins) in sublingual film formulations and establishing dose-response relationships.

3. Polymer and Film Matrix Innovations

Future Prospect: Use of novel natural and semi-synthetic polymers to improve mucoadhesion, mechanical strength, and disintegration.
Research Direction:
- Explore biodegradable polymers like chitosan, sodium alginate, pullulan.
- Develop smart films with pH-sensitive release for acidic environments.

4. Patient-Centric Formulations

Future Prospect: HSFs will be highly suitable for pediatrics, geriatrics, and patients with dysphagia.
Research Direction: Clinical evaluation of patient acceptability, taste masking techniques, and improved palatability using natural sweeteners and flavors.

5. Controlled/Sustained Release Herbal Films

Future Prospect: Shift from immediate to controlled-release sublingual herbal films to provide prolonged relief from acid reflux.
Research Direction: Design multilayered or nano-embedded films using microencapsulation or nanoparticle-loaded herbal extracts.

6. Synergistic Polyherbal Formulations

Future Prospect: Combine multiple herbs with synergistic anti-ulcer, anti-inflammatory, and acid-neutralizing effects.
Research Direction: Study synergism using in vitro and in vivo models and optimize ratios for maximum therapeutic benefit.

7. In-vitro–In-vivo Correlation (IVIVC) and Pharmacodynamics

Future Prospect: Predicting human outcomes from lab data can speed up product development.
Research Direction:
Develop reliable in vitro dissolution models mimicking sublingual conditions.
Study pharmacodynamic effects on gastric acid suppression via animal models.

Regulatory and Safety Assessments

Future Prospect: Global acceptance and marketing of herbal sublingual films require thorough safety validation.
Research Direction: Conduct toxicological studies, long-term stability assessments, and regulatory pathway standardization (e.g., WHO, AYUSH, USFDA).

Technological Integration and AI in Formulation Design

Future Prospect: AI-driven formulation modeling to optimize film characteristics and predict stability.
Research Direction: Use machine learning algorithms for predicting disintegration time, drug release, and herbal compatibility.

Clinical Trials and Evidence-Based Validation

Future Prospect: To gain medical and public trust, clinical efficacy must be validated in large-scale human trials.

Research Direction: Conduct Phase I–III trials to evaluate safety, effectiveness, and patient outcomes in GERD and related disorders.

Promise and Path Forward in Herbal Novel Drug Delivery

Herbal sublingual films offer a modern approach to combining traditional plant-based remedies with advanced drug delivery technologies. By delivering therapeutic agents through the sublingual route, these films ensure faster absorption, greater bioavailability, and increased ease of use—making them especially effective for conditions like acidity, where prompt relief is crucial. What makes this delivery system promising is not just its rapid effectiveness but also its capacity to administer standardized herbal extracts in a simple and non-invasive form. Ongoing research into innovative polymers, multi-herb formulations, and user-friendly designs is expected to expand their potential in clinical use. Looking to the future, essential steps include thorough clinical testing, regulatory standardization, and the use of modern tools such as artificial intelligence to improve formulation strategies. With these developments, herbal sublingual films are well-positioned to become a validated and widely accepted solution for managing gastrointestinal conditions and may also pave the way for broader applications in herbal therapeutics.

CONCLUSION

Herbal sublingual films offer a modern, patient-friendly approach to managing acidity using the wisdom of traditional herbal medicine. By delivering natural anti-acid agents directly through the sublingual route, these films bypass the digestive system and liver, allowing for faster relief and improved absorption. Their ease of use especially for those who struggle with swallowing pills makes them a convenient and accessible option for people of all ages. With ongoing research into new herbal combinations, advanced film-forming materials, and controlled-release technologies, herbal sublingual films are poised to become a promising alternative in gastrointestinal health. As science continues to validate the benefits of these formulations, they hold great potential to bridge the gap between natural remedies and modern drug delivery systems.

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