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Garg A, Roeder H, Leira EC. In-hospital outcomes and recurrence of stroke during pregnancy and puerperium. Int J Stroke 2023; 18:445-452. [PMID: 35838335 DOI: 10.1177/17474930221116209] [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]
Abstract
BACKGROUND There are limited data regarding the best management and outcomes of acute stroke during pregnancy and the puerperium. METHODS Pregnancy-related hospitalizations with age > 18 years were identified from the Nationwide Readmissions Database 2016-2018. The study cohort consisted of all patients with acute stroke and a 5% random sample of the remaining non-stroke hospitalizations. Logistic regression and survival analyses were used to compare the in-hospital outcomes and readmissions in patients with and without acute stroke. RESULTS There were 11,829,044 pregnancy-related hospitalizations, of which 4057 had acute stroke. The mean ± SD age of the study cohort was 29.0 ± 5.7 years. Among patients with acute ischemic stroke, 60 (3.7%) patients received intravenous thrombolysis and 112 (6.8%) patients underwent endovascular thrombectomy. Among patients with intracranial hemorrhage, 205 (10.5%) patients underwent ventriculostomy and 18 (0.9%) patients underwent decompressive craniotomy. Patients with stroke had longer length of stay (mean: 10.7 vs 2.7 days), higher in-hospital mortality (4.6% vs 0.0001%) and were less likely to discharge home (73.0% vs 98.6%). Non-elective readmission within 90 days of discharge occurred in 14.8% of patients with stroke versus in 3.9% of patients without stroke. Readmissions due to cerebrovascular events occurred in 2.3% of patients with stroke versus in 0.007% of patients without stroke within 1 year of discharge, with mean ± SD time to readmission 66.2 ± 78.0 days. CONCLUSION Stroke is a serious complication of pregnancy, associated with high morbidity and mortality. Recurrence of stroke occurs in a small proportion of patients, and the risk is highest during the initial 3 months.
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Affiliation(s)
- Aayushi Garg
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hannah Roeder
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Enrique C Leira
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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King CJ, Ngo TH, Constante M. Meningovascular Neurosyphilis Presenting as Multiple Ischemic Infarcts in a Young Adult. Cureus 2023; 15:e36405. [PMID: 37090294 PMCID: PMC10115213 DOI: 10.7759/cureus.36405] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/25/2023] Open
Abstract
Neurosyphilis occurs when the spirochete Treponema pallidum invades the cerebrospinal fluid (CSF). Clinical presentation depends on an individual's immune response and invasion location, with all possible involvement of meningeal, vascular, and/or parenchymatous tissues. Meningovascular neurosyphilis occurs when both the meninges and vasculature are affected and can lead to headaches, photophobia, neck stiffness, cranial nerve palsies, and/or ischemic brain infarctions due to infectious arteritis. The following report describes the rare case of a 32-year-old male patient presenting with multiple ischemic brain infarctions of varying ages. The stepwise diagnostic approach as described allowed the medical team to reach the final diagnosis of meningovascular neurosyphilis with concomitant acquired immunodeficiency syndrome (AIDS). This case emphasizes the importance of maintaining high clinical suspicion in all young adult patients who present with acute neurological deficits.
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Affiliation(s)
| | - Teresa H Ngo
- Neurology, Western University of Health Sciences, Pomona, USA
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Pierre K, Perez-Vega C, Fusco A, Olowofela B, Hatem R, Elyazeed M, Azab M, Lucke-Wold B. Updates in mechanical thrombectomy. Explor Neurosci 2022; 1:83-99. [PMID: 36655054 PMCID: PMC9845048 DOI: 10.37349/en.2022.00007] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 01/01/2023]
Abstract
Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.
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Affiliation(s)
- Kevin Pierre
- Department of Radiology, University of Florida, Gainesville, FL 32608, USA
| | - Carlos Perez-Vega
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Anna Fusco
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Bankole Olowofela
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Rami Hatem
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mohammed Elyazeed
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Mohammed Azab
- Biomolecular Sciences Graduate Program, Boise State University, Boise, ID 83725, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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Sebök M, van Niftrik CHB, Winklhofer S, Wegener S, Esposito G, Stippich C, Luft A, Regli L, Fierstra J. Mapping Cerebrovascular Reactivity Impairment in Patients With Symptomatic Unilateral Carotid Artery Disease. J Am Heart Assoc 2021; 10:e020792. [PMID: 34102856 PMCID: PMC8477889 DOI: 10.1161/jaha.121.020792] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Comprehensive hemodynamic impairment mapping using blood oxygenation‐level dependent (BOLD) cerebrovascular reactivity (CVR) can be used to identify hemodynamically relevant symptomatic unilateral carotid artery disease. Methods and Results This prospective cohort study was conducted between February 2015 and July 2020 at the Clinical Neuroscience Center of the University Hospital Zurich, Zurich, Switzerland. One hundred two patients with newly diagnosed symptomatic unilateral internal carotid artery (ICA) occlusion or with 70% to 99% ICA stenosis were included. An age‐matched healthy cohort of 12 subjects underwent an identical BOLD functional magnetic resonance imaging examination. Using BOLD functional magnetic resonance imaging with a standardized CO2 stimulus, CVR impairment was evaluated. Moreover, embolic versus hemodynamic ischemic patterns were evaluated on diffusion‐weighted imaging. Sixty‐seven patients had unilateral ICA occlusion and 35 patients unilateral 70% to 99% ICA stenosis. Patients with ICA occlusion exhibited lower whole‐brain and ipsilateral hemisphere mean BOLD‐CVR values as compared with healthy subjects (0.12±0.08 versus 0.19±0.04, P=0.004 and 0.09±0.09 versus 0.18±0.04, P<0.001) and ICA stenosis cohort (0.12±0.08 versus 0.16±0.05, P=0.01 and 0.09±0.09 versus 0.15±0.05, P=0.01); however, only 40 (58%) patients of the cohort showed significant BOLD‐CVR impairment. Conversely, there was no difference in mean BOLD‐CVR values between healthy patients and patients with ICA stenosis, although 5 (14%) patients with ICA stenosis showed a significant BOLD‐CVR impairment. No significant BOLD‐CVR difference was discernible between patients with hemodynamic ischemic infarcts versus those with embolic infarct distribution (0.11±0.08 versus 0.13±0.06, P=0.12). Conclusions Comprehensive BOLD‐CVR mapping allows for identification of hemodynamically relevant symptomatic unilateral carotid artery stenosis or occlusion.
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Affiliation(s)
- Martina Sebök
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Christiaan Hendrik Bas van Niftrik
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Sebastian Winklhofer
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neuroradiology University Hospital ZurichUniversity of Zurich Switzerland
| | - Susanne Wegener
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neurology University Hospital ZurichUniversity of Zurich Switzerland
| | - Giuseppe Esposito
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Christoph Stippich
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Neuroradiology and Radiology Schmieder Clinic Allensbach Germany
| | - Andreas Luft
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neurology University Hospital ZurichUniversity of Zurich Switzerland.,Cereneo Center for Neurology and Rehabilitation Vitznau Switzerland
| | - Luca Regli
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
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Wiśniewski A, Karczmarska-Wódzka A, Sikora J, Sobczak P, Lemanowicz A, Filipska K, Ślusarz R. Hypercoagulability as Measured by Thrombelastography May Be Associated with the Size of Acute Ischemic Infarct-A Pilot Study. Diagnostics (Basel) 2021; 11:712. [PMID: 33921178 DOI: 10.3390/diagnostics11040712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/09/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Thromboelastography (TEG®) measures coagulation function in venous blood. Previous studies have reported that this device providing an integrated data on dynamics of clot formation may be useful for predicting clinical outcome in ischemic stroke. We investigated whether a hypercoagulability detected by thrombelastography may be associated with larger size of acute ischemic infarct. Methods: We included 40 ischemic stroke subjects with large artery atherosclerosis or small-vessel disease to a cross-sectional pilot study. Thrombelastography parameters related to time of clot formation (R- reaction time, K-clot kinetics), clot growth and strengthening (angle-alpha and MA-maximum amplitude) and lysis (Ly30) were performed within first 24 h after the onset of stroke. A volume of ischemic infarct was assessed on the basis of diffusion-weighted imaging (DWI) sequence of magnetic resonance imaging. Results: In the entire group, we reported that subjects with a large ischemic focus (>2 cm3) had a higher diameter of a clot (measured as MA) than subjects with a small ischemic focus (p = 0.0168). In the large artery atherosclerosis subgroup, we showed a significant correlation between MA and size of acute infarct (R = 0.64, p = 0.0138), between angle (alpha) and size of acute infarct (R = 0.55, p = 0.0428) and stroke subjects with hypercoagulability (MA > 69 mm) had significantly higher probability of a larger size of acute ischemic focus compared to normalcoagulable subjects (5.45 cm3 vs. 1.35 cm3; p = 0.0298). In multivariate logistic regression hypercoagulability was a predictor of a large size of ischemic infarct (Odds ratio OR = 59.5; 95% confidence interval (CI) 1.08–3558.8; p = 0.0488). Conclusions: We emphasized that thrombelastography, based on the parameters related to clot strength, may have clinical utility to identify the risk of the extensive ischemic infarct.
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Wiśniewski A, Sikora J, Karczmarska-Wódzka A, Sobczak P, Lemanowicz A, Zawada E, Masiliūnas R, Jatužis D. Unfavorable Changes of Platelet Reactivity on Clopidogrel Therapy Assessed by Impedance Aggregometry Affect a Larger Volume of Acute Ischemic Lesions in Stroke. Diagnostics (Basel) 2021; 11:405. [PMID: 33673437 DOI: 10.3390/diagnostics11030405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 01/01/2023] Open
Abstract
Background: High on-treatment platelet reactivity or its equivalent—resistance to the antiplatelet agent—significantly reduces the efficacy of the therapy, contributing to a negative impact on stroke course. Previous studies demonstrated that aspirin resistance is associated with a larger size of acute ischemic infarct. Due to the increasing use of clopidogrel in the secondary prevention of stroke, we aimed to assess the impact of clopidogrel resistance on the size and extent of ischemic lesions, both acute and chronic. Methods: This prospective, single-center and observational study involved 74 ischemic stroke subjects, treated with 75 mg of clopidogrel. We used impedance aggregometry to determine platelet reactivity 6–12 h after a dose of clopidogrel as a first assessment and 48 h later as the second measurement. A favorable dynamics of platelet reactivity over time was the decrease in the minimum value equal to the median in the entire study. The volume of acute ischemic infarct was estimated within 48 h after onset in diffusion-weighted imaging and fluid-attenuated inversion recovery sequences of magnetic resonance and the severity of chronic vascular lesions by Fazekas scale. Results: Subjects with mild severity of chronic vascular lesions (Fazekas 1) exhibited a significant decrease of platelet reactivity over time (p = 0.035). Dynamics of platelet reactivity over time differed between subjects with large, moderate, mild and insignificant size of acute ischemic lesion (Kruskall-Wallis H = 3.2576; p = 0.048). In multivariate regression models, we reported unfavorable dynamics of platelet reactivity alone and combined with a high initial value of platelet reactivity as independent predictors of higher risk of a significant ischemic infarct volume (OR 7.16 95%CI 1.69–30.31, p = 0.008 and 26.49 95%CI 1.88–372.4, p = 0.015, respectively). Conclusions: We emphasized that unfavorable dynamics of platelet reactivity over time during clopidogrel therapy in acute phase of stroke affect the volume of acute infarct and the severity of chronic vascular lesions.
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Abstract
We present a case of a young man who developed bilateral basal ganglia infarct after intranasal use of cocaine. Cerebral ischemic infarcts are a known complication of cocaine use. This complication is rare and has been reported in the past with cocaine and concomitant use of other drugs such as heroin and amphetamines.
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Affiliation(s)
- Oscar Cisneros
- Internal Medicine, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
| | | | - Eric O Then
- Gastroenterology, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
| | - Razia Rehmani
- Neuroradiology, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
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Kim P, Langheinrich K, Cristiano B, Grigsby P, Oyoyo U, Kido D, Paul Jacobson J. Low thalamostriate venous quantitative susceptibility measurements correlate with higher presenting NIH stroke scale score in emergent large vessel occlusion stroke. J Int Med Res 2019; 48:300060519832462. [PMID: 30859887 PMCID: PMC7140206 DOI: 10.1177/0300060519832462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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] [Indexed: 01/28/2023] Open
Abstract
Objective Hyperacute stroke affects various patient subgroups who may benefit from
different management strategies. Magnetic resonance imaging (MRI)
quantitative susceptibility mapping (QSM) is a recent MRI technique for
measuring deoxyhemoglobin levels. The results of QSM thus have the potential
to act as a quantitative biomarker for predicting the success of
endovascular interventions. Methods Twenty-five patients with M1 occlusions were evaluated retrospectively. QSM
measurements were obtained based on susceptibility-weighted imaging
sequences from the most prominent veins in each of the four standard regions
of interest: the cortical and thalamostriate veins ipsilateral and
contralateral to the side of the stroke. The results were analyzed using
Wilcoxon’s signed rank test and compared with presenting National Institutes
of Health stroke scale (NIHSS) score. Results Cortical veins ipsilateral to the stroke showed the greatest elevation in
susceptibility compared with all other vein groups. Both ipsilateral and
contralateral thalamostriate vein susceptibilities showed strong inverse
correlation with presenting NIHSS score. Conclusion Thalamostriate vein susceptibility shows a strong inverse correlation with
presenting NIHSS in adult patients with hyperacute stroke who are selected
for endovascular intervention by advanced imaging.
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Affiliation(s)
- Paggie Kim
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | - Brian Cristiano
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Phillip Grigsby
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Udo Oyoyo
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Daniel Kido
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - J Paul Jacobson
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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Urban ETR, Bury SD, Barbay HS, Guggenmos DJ, Dong Y, Nudo RJ. Gene expression changes of interconnected spared cortical neurons 7 days after ischemic infarct of the primary motor cortex in the rat. Mol Cell Biochem 2012; 369:267-86. [PMID: 22821175 PMCID: PMC3694431 DOI: 10.1007/s11010-012-1390-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 07/07/2012] [Indexed: 12/11/2022]
Abstract
After cortical injury resulting from stroke, some recovery can occur and may involve spared areas of the cerebral cortex reorganizing to assume functions previously controlled by the damaged cortical areas. No studies have specifically assessed gene expression changes in remote neurons with axonal processes that terminate in the infarcted tissue, i.e., the subset of neurons most likely to be involved in regenerative processes. By physiologically identifying the primary motor area controlling forelimb function in adult rats (caudal forelimb area = CFA), and injecting a retrograde tract-tracer, we labeled neurons within the non-primary motor cortex (rostral forelimb area = RFA) that project to CFA. Then, 7 days after a CFA infarct (n = 6), we used laser capture microdissection techniques to harvest labeled neurons in RFA. Healthy, uninjured rats served as controls (n = 6). Biological interactions and functions of gene profiling were investigated by Affymetrix Microarray, and Ingenuity Pathway Analysis. A total of 143 up- and 128 down-regulated genes showed significant changes (fold change ≥1.3 and p < 0.05). The canonical pathway, "Axonal Guidance Signaling," was overrepresented (p value = 0.002). Significantly overrepresented functions included: branching of neurites, organization of cytoskeleton, dendritic growth and branching, organization of cytoplasm, guidance of neurites, development of cellular protrusions, density of dendritic spines, and shape change (p = 0.000151-0.0487). As previous studies have shown that spared motor areas are important in recovery following injury to the primary motor area, the results suggest that these gene expression changes in remote, interconnected neurons may underlie reorganization and recovery mechanisms.
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Affiliation(s)
- Edward T. R. Urban
- Department of Molecular & Integrative Physiology, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 3043, Kansas City, KS 66160, USA. Landon Center on Aging, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 1005, Kansas City, KS 66160, USA
| | - Scott D. Bury
- Landon Center on Aging, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 1005, Kansas City, KS 66160, USA
| | - H. Scott Barbay
- Landon Center on Aging, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 1005, Kansas City, KS 66160, USA
| | - David J. Guggenmos
- Department of Molecular & Integrative Physiology, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 3043, Kansas City, KS 66160, USA. Landon Center on Aging, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 1005, Kansas City, KS 66160, USA
| | - Yafeng Dong
- Department of Obstetrics and Gynecology, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 2028, Kansas City, KS 66160, USA
| | - Randolph J. Nudo
- Department of Molecular & Integrative Physiology, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 3043, Kansas City, KS 66160, USA. Landon Center on Aging, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 1005, Kansas City, KS 66160, USA. Intellectual & Developmental Disabilities Research Center, Kansas University Medical Center, 3901 Rainbow Boulevard, Mail Stop 3051, Kansas City, KS 66160, USA
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