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Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med 2023; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University, St. Louis, Missouri, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Penn State School of Medicine, State College, Pennsylvania, USA
- Hershey Medical Center, State College, Pennsylvania, USA
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Adventhealth Tampa, Tampa, Florida, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - James G Naples
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Health Science North Research Institute, Sudbury, Ontario, Canada
- Department of Emergency Medicine, Health Sciences North, Sudbury, Ontario, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Sharif
- Division of Critical Care and Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matt Siket
- Department of Emergency Medicine, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Emergency Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Suneel Upadhye
- Emergency Medicine, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
- Health Research Methods, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Etta Sundberg
- COO Royal Oasis Pool and Spas, Las Vegas, Nevada, USA
| | - Karen Tartt
- Absinthe Brasserie & Bar, San Francisco, California, USA
- St. George Spirits, San Francisco, California, USA
| | - Simone Vanni
- Department of Emergency Medicine, University of Florence, Firenze, Italy
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Du EH, Tenenbaum MN, Bhadelia RA, Sotman TE, Edlow JA, Selim MH, Chang YM. Major radiological outcomes of CTA head and neck performed for dizziness in a major academic Emergency Department. Neuroradiol J 2022:19714009221124304. [PMID: 36045600 DOI: 10.1177/19714009221124304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: Routine head and neck CTAs (CTAhead+neck) performed for dizziness in the Emergency Department (ED) has steadily increased, but its clinical utility is still poorly elucidated. Our purpose was to assess the radiologic outcomes of CTAhead+neck in ED dizziness patients.Methods: ED dizziness patients with CTAhead+neck from January 2010 through November 2019 were retrospectively identified and further stratified into central vertigo (CV), peripheral vertigo (PV), and non-specific dizziness (NSD) groups by final clinical diagnoses. Findings on CTAhead+neck (vessel stenosis >50%, occlusion, dissection, and infarct), and infarct on subsequent MRI if performed, were assessed. Differences in imaging findings were analyzed using chi-square or Fisher's exact tests.Results: Of 867 dizziness patients, 88 were diagnosed with CV, 383 with PV, and 396 with NSD. On CTAhead+neck, 11.4% of all patients had posterior CTA findings, including posterior occlusions (4.2%), dissections (1.2%), and infarcts (2.3%). CV patients had more posterior circulation findings (31.8%) versus PV (9.9%) and NSD (8.3%) patients (both p < 0.01). 21.6% of CV patients had acute infarcts on CT versus none for PV and 0.03% for NSD patients (both p < 0.01). On MRI, 46.6% of CV patients had acute posterior circulation infarcts versus none for PV and 0.3% for NSD patients (p < 0.01).Conclusion: Diagnostic yield for CTAhead+neck for dizziness patients is low except in central vertigo patients which constitute only 1/10th of CTAs performed. Our single institution results support that CTAhead+neck is likely low-yield in patients with high clinical suspicion for PV or NSD and further studies are needed to test this hypothesis.
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Affiliation(s)
- Elizabeth Hy Du
- Department of Radiology, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mary N Tenenbaum
- Department of Radiology, 21645Baystate Medical Center, Springfield, MA, USA
| | - Rafeeque A Bhadelia
- Department of Radiology, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Timothy E Sotman
- Department of Radiology, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jonathan A Edlow
- Department of Emergency Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Magdy H Selim
- Department of Neurology, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yu-Ming Chang
- Department of Radiology, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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Hiremath SB, Erdenebold UE, Kontolemos M, Miller W, Zakhari N. Association between vascular calcification in intracranial vertebrobasilar circulation and luminal stenosis. Neuroradiology 2022; 64:2285-2293. [PMID: 35551423 DOI: 10.1007/s00234-022-02974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/02/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The study aims to assess the correlation and association between calcium burden and luminal stenosis in the vertebrobasilar circulation. METHODS We evaluated 166 patients [mean age, 79.8 ± 8.8 (SD) with 93 males] with stroke symptoms. The calcification patterns were assessed on non-contrast CT (NCCT); quantitative calcium burden [Agatston-Janowitz (AJ) calcium score, volume, and mass] on the initial non-contrast phase of CT perfusion (CTP); and the qualitative and quantitative luminal stenosis on CT angiography (CTA) studies. We calculated the correlation coefficient and association between measures of calcium burden and luminal stenosis. RESULTS Two hundred twenty-eight of 498 arteries (45.8%) had detectable calcification on NCCT and measurable stenosis in 169 of 498 arteries (33.9%) on CTA. We found a moderate correlation between qualitative calcium burden and qualitative (0.51 for R1 and 0.62 for R2, p < 0.01) as well as quantitative luminal stenosis (0.67 for R1 and 0.69 for R2, p < 0.01). There was a moderate correlation of AJ score (0.66), volume (0.68), and mass of calcification (0.60, p < 0.01) with luminal stenosis measurements. The quantitative calcium burden and luminal stenosis showed statistically significant differences between different qualitative categories of calcium burden (p < 0.001 in both readers). However, severe stenosis was not seen even with the advanced circumferential wall calcification (mean stenosis of 35.3-40.7%). CONCLUSION Our study showed a moderate correlation between higher burden of vascular calcification and the degree of luminal stenosis. However, higher calcium burden and circumferential wall calcification were not associated with severe luminal stenosis.
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Affiliation(s)
- Shivaprakash B Hiremath
- Department of Radiology, Division of Neuroradiology, University of Ottawa, The Ottawa Hospital Civic and General Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Undrakh-Erdene Erdenebold
- Department of Radiology, Division of Neuroradiology, University of Ottawa, The Ottawa Hospital Civic and General Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Mario Kontolemos
- Department of Radiology, Division of Neuroradiology, University of Ottawa, The Ottawa Hospital Civic and General Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - William Miller
- Department of Radiology, Division of Neuroradiology, University of Ottawa, The Ottawa Hospital Civic and General Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Nader Zakhari
- Department of Radiology, Division of Neuroradiology, University of Ottawa, The Ottawa Hospital Civic and General Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
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Guarnizo A, Farah K, Lelli DA, Tse D, Zakhari N. Limited usefulness of routine head and neck CT angiogram in the imaging assessment of dizziness in the emergency department. Neuroradiol J 2021; 34:335-340. [PMID: 33487089 PMCID: PMC8447815 DOI: 10.1177/1971400920988665] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To assess the usefulness of head and neck computed tomography angiogram for the investigation of isolated dizziness in the emergency department in detecting significant acute findings leading to a change in management in comparison to non-contrast computed tomography scan of the head. METHODS Patients presenting with isolated dizziness in the emergency department investigated with non-contrast computed tomography and computed tomography angiogram over the span of 36 months were included. Findings on non-contrast computed tomography were classified as related to the emergency department presentation versus unrelated/no significant abnormality. Similarly, computed tomography angiogram scans were classified as positive or negative posterior circulation findings. RESULTS One hundred and fifty-three patients were imaged as a result of emergency department presentation with isolated dizziness. Fourteen cases were diagnosed clinically as of central aetiology. Non-contrast computed tomography was positive in three patients, all with central causes with sensitivity 21.4%, specificity 100%, positive predictive value 100%, negative predictive value 92.6% and accuracy 92.8%. Computed tomography angiogram was positive for angiographic posterior circulation abnormalities in five cases, and only two of them had a central cause of dizziness, with sensitivity 14.3%, specificity 97.7%, positive predictive value 40%, negative predictive value 91.46% and accuracy 92.1%. CONCLUSION Both non-contrast computed tomography and computed tomography angiogram of the head and neck have low diagnostic yield for the detection of central causes of dizziness, However, non-contrast computed tomography has higher sensitivity and positive predictive value than computed tomography angiogram, implying a lack of diagnostic advantage from the routine use of computed tomography angiogram in the emergency department for the investigation of isolated dizziness. Further studies are required to determine the role of computed tomography angiogram in the work-up of isolated dizziness in the emergency department.
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Affiliation(s)
- Angela Guarnizo
- Department of Radiology, University of Ottawa, The Ottawa Hospital, Canada
| | - Kevin Farah
- Department of Radiology, University of Ottawa, The Ottawa Hospital, Canada
| | - Daniel A Lelli
- Department of Medicine, Division of Neurology, University of Ottawa, The Ottawa Hospital, Canada
| | - Darren Tse
- Department of Otolaryngology, Head and Neck Surgery, University of Ottawa, The Ottawa Hospital, Canada
| | - Nader Zakhari
- Department of Radiology, University of Ottawa, The Ottawa Hospital, Canada
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NIRLU L, POPESCU LG, ALBEȘTEANU AC, SAGLAM AO, STAVRICĂ AG, ONOSE G. Diagnostic particularities and multimodal therapeutic and rehabilitation approches to a complex case of post ischemic stroke with dyshphagia and dysphonia, associating Millard-Gubler and Wallenberg syndromes- case report. BALNEO 2019. [DOI: 10.12680/balneo.2019.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction. Millard-Gubler syndrome (MGS), also known as the ventral pontine syndrome or hemiplegic syndrome, is one of the classical crossed syndromes characterized by a unilateral lesion of the basal portion of the caudal part of the pons. MGS manifests as ipsilateral palsy of CN VI and VII with contralateral hemiplegia.
Wallenberg syndrome or lateral medullary syndrome, is characterized by the triad of Horner's syndrome, ipsilateral ataxia and contralateral hypoalgesia. Other clinical symptoms may include difficult swallowing, slurred speech, vertigo, nausea, vomiting, dyspnea, tachycardia, headaches and muscular hypertonia.
Materials and Methods
Having the patient’s consent and The Teaching Emergency Hospital “Bagdasar-Arseni” Ethics Committee N.O 20270 from the 26th of June 2019, the current case report presents a 67-year-old male patient from rural area with left hemiplegia (complete brachial and crural motor deficit), right eye abduction paresis, dysphagia, dysphonia, central facial palsy - all post acute ischemic stroke. The patient was also diagnosed with ischemic cardiomyopathy, atherosclerosis, alcoholism, type 2 diabetes with Insulin therapy and oral antidiabetic agent. The patient was admitted in the Neurorehabilitation Clinic of the Teaching Emergency Hospital „Bagdasar-Arseni” (TEHBA) Bucharest, Romania, associating severe alteration in self-care abilities, locomotor dysfunction, memory disorders, slurred speech, for specialized rehabilitation treatment and nursing.
Results. A case of rare pathology for which, unfortunately, there is a discrepancy between functional improvement and the poor motor control in the in the lower limbs (muscle force was 0-1 out of 5 on the Medicale Research Council scale), within an overall favorable evolution, including elements of the clinical status afferent to the two above mentioned syndromes.
Conclusions. Approaching such a clinical case has been a complex and extensive challenge for the entire neuromuscular recovery team and remains similar for any other squad. This pathology remains an issue that demands our earnest attention.
Key words: Millard-Gubler syndrome (MGS), Wallenberg syndrome, crossed syndromes, hemiplegia, neurorehabilitation, stroke
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Affiliation(s)
- Luminița NIRLU
- Teaching Emergency Hospital “Bagdasar-Arseni” (TEHBA), Bucharest, Romania
| | | | | | - Ali-Osman SAGLAM
- Teaching Emergency Hospital “Bagdasar-Arseni” (TEHBA), Bucharest, Romania
| | | | - Gelu ONOSE
- 1. Teaching Emergency Hospital “Bagdasar-Arseni” (TEHBA), Bucharest, Romania 2. University of Medicine and Pharmacy ”Carol Davila” (UMPCD), Bucharest, Romania
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Antipova D, Eadie L, Macaden A, Wilson P. Diagnostic accuracy of clinical tools for assessment of acute stroke: a systematic review. BMC Emerg Med 2019; 19:49. [PMID: 31484499 PMCID: PMC6727516 DOI: 10.1186/s12873-019-0262-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/20/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Recanalisation therapy in acute ischaemic stroke is highly time-sensitive, and requires early identification of eligible patients to ensure better outcomes. Thus, a number of clinical assessment tools have been developed and this review examines their diagnostic capabilities. METHODS Diagnostic performance of currently available clinical tools for identification of acute ischaemic and haemorrhagic strokes and stroke mimicking conditions was reviewed. A systematic search of the literature published in 2015-2018 was conducted using PubMed, EMBASE, Scopus and The Cochrane Library. Prehospital and in-hospital studies with a minimum sample size of 300 patients reporting diagnostic accuracy were selected. RESULTS Twenty-five articles were included. Cortical signs (gaze deviation, aphasia and neglect) were shown to be significant indicators of large vessel occlusion (LVO). Sensitivity values for selecting subjects with LVO ranged from 23 to 99% whereas specificity was 24 to 97%. Clinical tools, such as FAST-ED, NIHSS, and RACE incorporating cortical signs as well as motor dysfunction demonstrated the best diagnostic accuracy. Tools for identification of stroke mimics showed sensitivity varying from 44 to 91%, and specificity of 27 to 98% with the best diagnostic performance demonstrated by FABS (90% sensitivity, 91% specificity). Hypertension and younger age predicted intracerebral haemorrhage whereas history of atrial fibrillation and diabetes were associated with ischaemia. There was a variation in approach used to establish the definitive diagnosis. Blinding of the index test assessment was not specified in about 50% of included studies. CONCLUSIONS A wide range of clinical assessment tools for selecting subjects with acute stroke has been developed in recent years. Assessment of both cortical and motor function using RACE, FAST-ED and NIHSS showed the best diagnostic accuracy values for selecting subjects with LVO. There were limited data on clinical tools that can be used to differentiate between acute ischaemia and haemorrhage. Diagnostic accuracy appeared to be modest for distinguishing between acute stroke and stroke mimics with optimal diagnostic performance demonstrated by the FABS tool. Further prehospital research is required to improve the diagnostic utility of clinical assessments with possible application of a two-step clinical assessment or involvement of simple brain imaging, such as transcranial ultrasonography.
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Affiliation(s)
- Daria Antipova
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK.
| | - Leila Eadie
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK
| | - Ashish Macaden
- Department of Stroke and Rehabilitation, Raigmore Hospital, NHS Highland, Inverness, IV2 3UJ, UK
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK
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Ljunggren M, Persson J, Salzer J. Dizziness and the Acute Vestibular Syndrome at the Emergency Department: A Population-Based Descriptive Study. Eur Neurol 2017; 79:5-12. [DOI: 10.1159/000481982] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/03/2017] [Indexed: 11/19/2022]
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