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Chandrasinghe PC, Siriwardana RC, Kumarage SK, Munasinghe BNL, Weerasuriya A, Tillakaratne S, Pinto D, Gunathilake B, Fernando FR. A novel structure for online surgical undergraduate teaching during the COVID-19 pandemic. BMC Med Educ 2020; 20:324. [PMID: 32962691 PMCID: PMC7506821 DOI: 10.1186/s12909-020-02236-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/09/2020] [Indexed: 05/22/2023]
Abstract
BACKGROUND The Covid-19 pandemic necessitated the delivery of online higher education. Online learning is a novel experience for medical education in Sri Lanka. A novel approach to undergraduate surgical learning was taken up in an attempt to improve the interest amongst the students in clinical practice while maximizing the limited contact time. METHOD Online learning activity was designed involving medical students from all stages and multi consultant panel discussions. The discussions were designed to cover each topic from basic sciences to high-level clinical management in an attempt to stimulate the student interest in clinical medicine. Online meeting platform with free to use basic plan and a social media platform were used in combination to communicate with the students. The student feedback was periodically assessed for individual topics as well as for general outcome. Lickert scales and numeric scales were used to acquire student agreement on the desired learning outcomes. RESULTS A total of 1047 student responses for 7 questionnaires were analysed. During a 6-week period, 24 surgical topics were discussed with 51 contact hours. Eighty-seven per cent definitely agreed (highest agreement) with the statement 'students benefitted from the discussions'. Over 95% have either participated for all or most sessions. A majority of the respondents (83.4%) 'definitely agreed' that the discussions helped to improve their clinical sense. Of the total respondents, 79.3% definitely agreed that the discussions helped to build an interest in clinical medicine. Around 90% agreed that both exam-oriented and clinical practice-oriented topics were highly important and relevant. Most widely raised concerns were the poor Internet connectivity and limitation of access to the meeting platform. CONCLUSION Online teaching with a novel structure is feasible and effective in a resource-limited setting. Students agree that it could improve clinical interest while meeting the expected learning outcomes.
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Affiliation(s)
- P C Chandrasinghe
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka.
| | - R C Siriwardana
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - S K Kumarage
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - B N L Munasinghe
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - A Weerasuriya
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - S Tillakaratne
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - D Pinto
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - B Gunathilake
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - F R Fernando
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
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Siriwardana RC, Kumarage SK, Gunathilake BM, Thilakarathne SB, Wijesinghe JS. Local infiltration versus laparoscopic-guided transverse abdominis plane block in laparoscopic cholecystectomy: double-blinded randomized control trial. Surg Endosc 2019; 33:179-183. [PMID: 29943054 DOI: 10.1007/s00464-018-6291-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 06/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Transverse abdominal plane block (TAP) is a new technique of regional block described to reduce postoperative pain in laparoscopic cholecystectomy (LC). Recent reports describe an easy technique to deliver local anesthetic agent under laparoscopic guidance. METHODS This randomized control trial was designed to compare the effectiveness of additional laparoscopic-guided TAP block against the standard full thickness port site infiltration. 45 patients were randomized in to each arm after excluding emergency LC, conversions, ones with coagulopathy, pregnancy and allergy to local anesthetics. All cases were four ports LC. Interventions-Both groups received standard port site infiltration with 3-5 ml of 0.25% bupivacaine. The test group received additional laparoscopic-guided TAP block with 20 ml of 0.25% bupivacaine subcostally, between the anterior axillary and mid clavicular lines. As outcome measures the pain score, opioid requirement, episodes of nausea and vomiting and time to mobilize was measured at 6 hourly intervals. RESULTS The two groups were comparable in the age, gender, body mass index, indication for cholecystectomy difficulty index and surgery duration. The pain score at 6 h (P = 0.043) and opioid requirement at 6 h (P = 0.026) was higher in the TAP group. These were similar in subsequent assessments. Other secondary outcomes were similar in the two groups. CONCLUSION Laparoscopic-guided transverses abdominis plane block using plain bupivacaine does not give an additional pain relief or other favorable outcomes. It can worsen the pain scores. Pre registration: The trial was registered in Sri Lanka clinical trial registry-SLCTR/2016/011 ( http://www.slctr.lk/trials/357 ).
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Affiliation(s)
- Rohan C Siriwardana
- Department of Surgery, Faculty of Medicine Ragama, University of Kelaniya, Kelaniya, Sri Lanka.
| | - Sumudu K Kumarage
- Department of Surgery, Faculty of Medicine Ragama, University of Kelaniya, Kelaniya, Sri Lanka
| | - Bhagya M Gunathilake
- Department of Surgery, Faculty of Medicine Ragama, University of Kelaniya, Kelaniya, Sri Lanka
| | | | - Jeevani S Wijesinghe
- Department of Surgery, Faculty of Medicine Ragama, University of Kelaniya, Kelaniya, Sri Lanka
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Siriwardana RC, Niriella MA, Dassanayake A, Ediriweera D, Gunetilleke B, Sivasundaram T, de Silva J. Association of Serum Ferritin with Diabetes and Alcohol in Patients with Non-Viral Liver Disease-Related Hepatocellular Carcinoma. Liver Cancer 2017; 6:307-312. [PMID: 29234634 PMCID: PMC5704680 DOI: 10.1159/000477266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Non-alcoholic fatty liver disease is a leading cause for hepatocellular carcinoma (HCC) in Sri Lanka. Diabetes mellitus, alcohol abuse, and liver inflammation are known to increase the risk of HCC. The present study evaluates serum ferritin levels in a cohort of patients with non-viral HCC (nvHCC). METHODOLOGY Consecutive patients with nvHCC presenting to the Colombo North Liver transplant Service, Ragama, from January 2012 to July 2013 were investigated. All were negative for hepatitis B and C. At registration, 5 mL of serum was separated into plain tubes, stored at -80°C and analysed for ferritin using an enzyme-linked immunosorbent assay. Correlation between the serum ferritin and patient risk factors, liver status, and tumour characteristics were analysed. RESULTS There were 93 patients with nvHCC (median age 65 [12-82] years; 82 [88.2%] males). The median ferritin level was 246.2 μg/L, and 38 (40.86%) patients had elevated ferritin. Non-diabetics (median 363.5 mg/L, p = 0.003) and alcohol abusers (median 261.2 mg/L, p = 0.018) had higher ferritin levels. On multiple-variable analysis, being non-diabetic (p = 0.013) and alcoholic (p = 0.046) was significantly associated with high serum ferritin. No association was found with body mass index, tumour stage, size, macrovascular invasion, number of nodules, alpha-fetoprotein, bilirubin, international normalized ratio, and survival. CONCLUSION In patients with nvHCC, serum ferritin levels are higher in non-diabetics and alcoholics.
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Affiliation(s)
- Rohan C. Siriwardana
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka,*Dr. Rohan Siriwardana, Department of Surgery, Faculty of Medicine, University of Kelaniya, PO Box 6, Thalagolla Road, Ragama, GQ 11010 (Sri Lanka), E-Mail
| | - Madunil A. Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Anuradha Dassanayake
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Dileepa Ediriweera
- Department of ICT Centre, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Bhagya Gunetilleke
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Thenuka Sivasundaram
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Janaka de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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Siriwardana RC, Niriella MA, Dassnayake AS, Gunathillake B, de Silva HJ. Liver Transplantation for Non-Alcoholic Steatohepatitis Related Cirrhosis. Prog Transplant 2017; 27:107-108. [PMID: 28511575 DOI: 10.1177/1526924816677996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- R C Siriwardana
- 1 Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | | | - A S Dassnayake
- 1 Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - B Gunathillake
- 1 Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - H J de Silva
- 1 Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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Siriwardana RC, Liyanage CAH, Gunetilleke B, Niriella MA, de Silva J, Dassanayake AS, Jayatunge SP. Diffuse-Type Hepatoma: A Grave Prognostic Marker. Gastrointest Tumors 2017; 4:20-27. [PMID: 29071261 DOI: 10.1159/000460249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/07/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Data on diffuse-type hepatocellular carcinoma (HCC) are rare. HCC in Sri Lanka is rising, and the majority is related to nonalcoholic fatty liver disease. This study was planned to compare nodular- and diffuse-type HCC in this cohort. METHODS CT scans of 227 patients with HCC negative for infective hepatitis were analyzed and grouped as nodular and diffuse from July 2011 to July 2014. Diffuse-type cancer was defined as a tumor without convex/distinct margin, diffusely infiltrating the hepatic parenchyma. There were 45 (20%) cases. The baseline liver functions, etiology, treatment, and the outcome were compared with nodular-type cancers. Stage III diffuse cancers were matched with 2 stage III nodular cancers looking at the T stage and background liver. RESULTS There was no difference in the age (63 vs. 62 years, p = 0.937) and gender. Diffuse cancers had a low BMI (24 vs. 22, p = 0.009), a higher alpha fetoprotein (AFP) level (p < 0.001), a higher incidence of major vascular invasion (14 vs. 80%, p < 0.001), and a history of significant alcohol consumption (39 vs. 67%, p = 0.001). The baseline liver functions were similar in diffuse and nodular cancers. A large proportion (27 vs.77%, p < 0.001) of diffuse cancers were not candidates for active treatment. Overall survival was poor in the diffuse type (4.7 vs. 25 months, p < 0.001). Diffuse-type stage III cancers had a poor survival compared to matched nodular cancers (2.5 vs. 15.8 months, p = 0.001). CONCLUSION HCC without a background of infective hepatitis were common in our cohort. These tumors are associated with high AFP levels, major vascular invasion, and a poor prognosis.
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Affiliation(s)
- Rohan C Siriwardana
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Chandika A H Liyanage
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Bhagya Gunetilleke
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Madunil A Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Janaka de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Anuradha S Dassanayake
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Subani P Jayatunge
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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Siriwardana RC, Niriella MA, Dassanayake AS, Liyanage CAH, Gunetilleke B, de Silva HJ. Recurrence of graft steatosis after liver transplantation for cryptogenic cirrhosis in recently commenced liver transplant program. Indian J Gastroenterol 2016; 35:222-4. [PMID: 27142096 DOI: 10.1007/s12664-016-0653-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 03/27/2016] [Indexed: 02/04/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) seems to recur in at least one third of patients transplanted for non-alcoholic steatohepatitis (NASH)-related cirrhosis. While, NASH recurrence does not seem to affect overall graft and patient survival up to 10 years, cardiovascular and infection-related morbidity and mortality seem to be increased in these patients. This report looks at the graft histology in patients who were transplanted for NASH-related cirrhosis after short-term follow up. We report a high prevalence of recurrent NAFLD in liver grafts post-transplant among five patients. The degree of steatosis noted among the recipients is alarming.
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Affiliation(s)
- Rohan C Siriwardana
- Hepato-Pancreatico-Biliary and Liver Transplant Unit Ragama, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka.
| | - Madunil Anuk Niriella
- Hepato-Pancreatico-Biliary and Liver Transplant Unit Ragama, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Anuradha Supun Dassanayake
- Hepato-Pancreatico-Biliary and Liver Transplant Unit Ragama, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | | | - Bhagya Gunetilleke
- Hepato-Pancreatico-Biliary and Liver Transplant Unit Ragama, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Hithanadura Janaka de Silva
- Hepato-Pancreatico-Biliary and Liver Transplant Unit Ragama, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
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Siriwardana RC, Niriella MA, Dassanayake AS, Liyanage C, Gunathilaka B, Jayathunge S, de Silva HJ. Clinical characteristics and outcome of hepatocellular carcinoma in alcohol related and cryptogenic cirrhosis: a prospective study. Hepatobiliary Pancreat Dis Int 2015; 14:401-5. [PMID: 26256085 DOI: 10.1016/s1499-3872(15)60343-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is becoming a leading cause of chronic liver disease. Hepatocellular carcinoma (HCC) is one of its complications. Although the pathophysiology is unclear, it is reasonable to expect that cryptogenic cirrhosis related HCC (cryptogenic HCC) behaves differently to other types of HCC. This study prospectively compared patients with cryptogenic HCC and those with HCC related to alcoholic cirrhosis. METHODS A total of 150 consecutive patients with HCC (89 cryptogenic HCC and 61 alcohol related HCC) referred to our unit over a 23-month period were studied. Their demographic data, liver function, tumor characteristics and outcomes were compared. RESULTS Alcohol related HCC was seen only in males. Compared with cryptogenic HCC, alcohol related HCC had significantly higher aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio (1.7 vs 1.4, P=0.002), model for end-stage liver disease score (13 vs 11, P=0.018) and Child's score (7 vs 6, P=0.037). No significant difference was seen in platelet counts, serum sodium and AST to platelet ratio index. Single nodular tumors were more common in cryptogenic HCC, while diffuse type tumors and macroscopic vascular invasion were common in alcohol related HCC. In patients who could not be offered any treatment because of advanced tumors or poor liver function, alcohol related HCC had a significantly lower median survival (5.3 months) compared with cryptogenic HCC (9.3 months, P=0.034). CONCLUSIONS Compared with cryptogenic HCC, alcohol related HCC had worse liver function and aggressive tumor morphology at presentation, and a higher proportion was untreatable. In patients who could not be treated, median survival was lower in patients with alcohol related HCC than in those with cryptogenic HCC.
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Affiliation(s)
- Rohan C Siriwardana
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.
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Abstract
BACKGROUND Hepatic steatosis is a major concern in living donor liver transplantation. Factors affecting hepatic functional status after a donor right hepatectomy (with the middle hepatic vein included in the graft) with a focus on changes owing to steatosis were retrospectively studied. METHODS Donors (n = 325) were categorized into three groups: G0 (no steatosis, n = 178), G1 (< = 10% steatosis, n = 128) and G2 (>10% steatosis, n = 19). Donors with >20% steatosis were excluded. Changes in aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin levels and prothrombin time (PT) were assessed. Factors predicting steatosis were also assessed. A liver biopsy was performed on selected donors. RESULTS The ALT level rose until day 3 in G1 and day 6 in G2 (P < 0.05). The AST level rose until day 7 in G2 (P < 0.05) but stayed unchanged in G1. The bilirubin level was higher only on day 1 in G2 (P < 0.05). By day 30, no significant difference between any groups was noted. Receiver-operating characteristic (ROC) area under the curve for body mass index (BMI) on predicting steatosis was 0.75 [confidence interval (CI) = 69-80]. Among donors with a BMI > 23.5 kg/m(2), 75% had steatosis. Five donors had >20% steatosis and were not assessed. CONCLUSION Using a liver with up to 20% steatosis in right liver donation, even if the middle hepatic vein is included in the graft, is safe. For Asian donors, a BMI > 23.5 kg/m(2) is a guide in deciding whether to perform a liver biopsy for steatosis.
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Affiliation(s)
| | - See Ching Chan
- Department of Surgery, the University of Hong KongHong Kong, China,State Key Laboratory for Liver Research, the University of Hong KongHong Kong, China
| | - Kenneth SH Chok
- Department of Surgery, the University of Hong KongHong Kong, China
| | - Chung Mau Lo
- Department of Surgery, the University of Hong KongHong Kong, China,State Key Laboratory for Liver Research, the University of Hong KongHong Kong, China
| | - Sheung Tat Fan
- Department of Surgery, the University of Hong KongHong Kong, China,State Key Laboratory for Liver Research, the University of Hong KongHong Kong, China
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Siriwardana RC, Renuka S, Kumarage S. Laparoscopy as a diagnostic and therapeutic option in evaluating chronic unexplained right iliac fossa pain. Surg Endosc 2010; 24:2793-5. [PMID: 20376495 DOI: 10.1007/s00464-010-1049-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2009] [Accepted: 03/19/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management of chronic right iliac fossa (CRIF) pain is poorly documented in literature. No guidelines are available on the best therapeutic approach. METHOD Patients presenting from October 2007 to August 2009 with pain persisting or recurring in right lower abdomen over a period of 6 weeks or more were assessed. Severity of CRIF pain was documented using a ten-point visual analogue scale. Initial history and examination were followed by urine analysis, blood counts, X-ray and ultrasound scan of the abdomen. Full colonoscopy was performed in all negative cases. Diagnostic or therapeutic laparoscopy was offered to patients with normal initial investigations. The normal-looking appendix was removed in the absence of other positive laparoscopic findings. Patient's immediate complications, pain score at 8 weeks and histology of appendix were assessed. RESULTS Nineteen patients with median age of 43 years (range 32-52 years) underwent laparoscopy. All were female. Median pain score was 5 (range 4-6). During surgery, 12 (64%) had positive findings. Of these, 6 (30%) had adhesions, which were separated. Three patients with congested appendices were removed. One caecal perforation, tubal mass and ovarian cyst were treated laparoscopically. Seven (36%) patients who had macroscopically normal appendices underwent appendicectomy. There were no immediate postoperative complications. Significant improvement was seen in overall pain score after surgery (median 5, range 4-6 versus median 0, range 0-6; p = 0.001). However, only 57% of patients with normal appendix had improved pain scores (median 5, range 4-6 versus median 1, range 0-6; p = 0.12). All patients with positive laparoscopic findings improved after surgery. CONCLUSION Laparoscopy seems effective in evaluation and treatment of CRIF pain. The role of appendicectomy with normal-looking appendix needs further evaluation.
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