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Murr AT, Sweeney C, Lenze NR, Farquhar DR, Hackman TG. Implementation and Outcomes of ERAS Protocol for Major Oncologic Head and Neck Surgery. Laryngoscope 2024; 134:732-740. [PMID: 37466306 DOI: 10.1002/lary.30904] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/11/2022] [Revised: 06/28/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols have been developed and successfully implemented for many surgical specialties, demonstrating reductions in length of stay, post-operative complications, and resource utilization. Currently, there are few documented applications of ERAS protocols in head and neck surgery. Additional description of head and neck surgery protocol design, implementation, and outcomes will help advance postoperative care. METHODS An ERAS protocol was designed for patients undergoing glossectomy and primary or salvage laryngectomy with or without free flap reconstruction. Following successful protocol implementation, patient outcomes and perioperative metrics were retrospectively reviewed and compared between patients prior to and following the ERAS protocol. RESULTS Global comparison of ERAS and control group did not show statistically significant differences in measured perioperative outcomes. There were no statistically significant differences between the ERAS and control groups in age, sex, BMI, surgery type, or cancer stage. The ERAS protocol was associated with reduced variability in hospital length of stay (LOS), demonstrated through tighter interquartile ranges. For patients undergoing salvage laryngectomy, the ERAS protocol was associated with a significant reduction in 30-day readmission rates. Although not statistically significant, the median length of stay in the step-down unit (ISCU) and hospital was lower for specific patient groups. CONCLUSION The implementation and evaluation of the ERAS protocol demonstrated improvement in select patient outcomes as well as areas for process improvement. This study demonstrates the insights that arise from review of this protocol even for an institution with perceived standardized procedures for major oncologic head and neck surgeries. LEVEL OF EVIDENCE 3 Laryngoscope, 134:732-740, 2024.
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Affiliation(s)
- Alexander T Murr
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Craig Sweeney
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Nicholas R Lenze
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Douglas R Farquhar
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Trevor G Hackman
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
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Murr AT, Lenze NR, Weiss JM, Grilley-Olson JE, Patel SA, Shen C, Chera BS, Zanation AM, Thorp BD, Sheth SH. Sinonasal Squamous Cell Carcinoma Survival Outcomes Following Induction Chemotherapy vs Standard of Care Therapy. Otolaryngol Head Neck Surg 2022; 167:846-851. [PMID: 35259033 PMCID: PMC9630958 DOI: 10.1177/01945998221083097] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 11/16/2022]
Abstract
Objective To compare oncologic outcomes in sinonasal squamous cell carcinoma (SNSCC)
treated with standard of care (SOC) definitive therapy, consisting of
surgery or chemoradiotherapy, vs induction therapy followed by definitive
therapy. Study Design Retrospective review. Setting Academic tertiary care hospital. Methods The medical records of patients with biopsy-proven SNSCC treated between 2000
and 2020 were reviewed for demographics, tumor characteristics, staging,
treatment details, and oncologic outcomes. Patients were matched 1-to-1 by
age, sex, and cancer stage according to treatment received. Time-to-event
analyses were conducted. Results The analysis included 26 patients with locally advanced SNSCC who received
either induction therapy (n = 13) or SOC (n = 13). Baseline demographics,
Charlson Comorbidity Index, and median follow-up time were well balanced.
Weekly cetuximab, carboplatin, and paclitaxel were the most common induction
regimen utilized. Tolerance and safety to induction were excellent.
Objective responses were observed in 11 of 13 patients receiving induction.
No difference in disease-free survival was found between the induction and
SOC groups at 1 or 3 years. However, when compared with SOC, induction
therapy resulted in significant improvement in overall survival at 2 years
(100% vs 65.3%, P = .043) and 3 years (100% vs 48.4%,
P = .016) following completion of definitive therapy.
Two patients in the SOC group developed metastatic disease, as compared with
none in the induction group. Conclusions Induction therapy was safe and effective. When compared with SOC, induction
therapy improved 3-year overall survival.
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Affiliation(s)
- Alexander T Murr
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nicholas R Lenze
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jared M Weiss
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Juneko E Grilley-Olson
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shetal A Patel
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Colette Shen
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Bhishamjit S Chera
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam M Zanation
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brian D Thorp
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Siddharth H Sheth
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Murr AT, Lumley CJ, Feins RH, Hackman TG. Evaluation of a 3D-Printed Transoral Robotic Surgery Simulator Utilizing Artificial Tissue. Laryngoscope 2021; 132:1588-1593. [PMID: 34882806 PMCID: PMC9177903 DOI: 10.1002/lary.29981] [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: 06/15/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Transoral robotic surgery (TORS) poses challenges for operators in training, with limited robot access on a platform requiring distinct surgical skills. Few simulators exist, and current virtual reality training modules exclude head and neck simulations. This study evaluates the construct validity for a novel low-cost TORS simulator. STUDY DESIGN Single institution prospective observational study. METHODS Using 3D-printed oral cavity structures and replaceable artificial tissue components, a modular TORS simulator was constructed for short-duration hands-on simulations with the da Vinci SI robot. Sixteen surgeons of differing robotic skill levels, no experience (novice), prior experience, and formal robot training, participated in simulated tonsil and tongue base tumor resections. Video recordings of each participant were graded by a blinded robotically trained surgeon using a 35-point Global Evaluative Assessment of Robotic Surgery (GEARS) criterion adapted for the TORS simulator. RESULTS Operators reporting formal robotic training or prior robot experience achieved significantly higher mean total GEARS scores compared to novice operators (32 vs. 20.5; P < .001). Overall, mean total GEARS scores correlated with reported experience level; novice operators scored 54% of total points at 19 (4.5), operators with prior experience scored 82.3% of total points at 28.8 (2.6), and robotically trained operators scored 97.1% of total points at 34 (1.7). CONCLUSION With a GEARS criterion, our simulator successfully differentiated novice from experienced and robotically trained operators of the da Vinci SI robot during simulated tonsillectomy and base of tongue resections. These findings support the construct validity of this prototype simulator and offer a foundation for further testing of predictive validity. LEVEL OF EVIDENCE 2 Laryngoscope, 2021.
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Affiliation(s)
- Alexander T Murr
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Catherine J Lumley
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Richard H Feins
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Trevor G Hackman
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
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Murr AT, Bacon DR, Onuorah PC, Zeatoun A, Morse JC, Miller C, Thorp BD, Zanation AM, Ebert CS, Kimple AJ, Senior BA. Effect of nasal suction catheter use on aerosol generation during endoscopic sinus surgery. Int Forum Allergy Rhinol 2021; 11:1494-1496. [PMID: 34021534 DOI: 10.1002/alr.22812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/05/2021] [Accepted: 04/14/2021] [Indexed: 01/05/2023]
Affiliation(s)
- Alexander T Murr
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel R Bacon
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Princess C Onuorah
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Abdullah Zeatoun
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Justin C Morse
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Craig Miller
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brian D Thorp
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam M Zanation
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Charles S Ebert
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam J Kimple
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brent A Senior
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Murr AT, Canfarotta MW, O'Connell BP, Buss E, King ER, Bucker AL, Dillon SA, Rooth MA, Dedmon MM, Brown KD, Dillon MT. Speech Recognition as a Function of Age and Listening Experience in Adult Cochlear Implant Users. Laryngoscope 2021; 131:2106-2111. [PMID: 34043247 DOI: 10.1002/lary.29663] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 09/03/2020] [Revised: 05/04/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES/HYPOTHESIS Speech recognition with a cochlear implant (CI) tends to be better for younger adults than older adults. However, older adults may take longer to reach asymptotic performance than younger adults. The present study aimed to characterize speech recognition as a function of age at implantation and listening experience for adult CI users. STUDY DESIGN Retrospective review. METHODS A retrospective review identified 352 adult CI recipients (387 ears) with at least 5 years of device listening experience. Speech recognition, as measured with consonant-nucleus-consonant (CNC) words in quiet and AzBio sentences in a 10-talker noise masker (10 dB signal-to-noise ratio), was reviewed at 1, 5, and 10 years postactivation. RESULTS Speech recognition was better in younger listeners, and performance was stable or continued to improve through 10 years of CI listening experience. There was no indication of differences in acclimatization as a function of age at implantation. For the better performing CI recipients, an effect of age at implantation was more apparent for sentence recognition in noise than for word recognition in quiet. CONCLUSIONS Adult CI recipients across the age range examined here experience speech recognition benefit with a CI. However, older adults perform more poorly than young adults for speech recognition in quiet and noise, with similar age effects through 5 to 10 years of listening experience. LEVEL OF EVIDENCE 3 Laryngoscope, 131:2106-2111, 2021.
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Affiliation(s)
- Alexander T Murr
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Michael W Canfarotta
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Brendan P O'Connell
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Emily Buss
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - English R King
- Department of Audiology, University of North Carolina Health Care, Chapel Hill, North Carolina, U.S.A
| | - Andrea L Bucker
- Department of Audiology, University of North Carolina Health Care, Chapel Hill, North Carolina, U.S.A
| | - Sarah A Dillon
- Department of Audiology, University of North Carolina Health Care, Chapel Hill, North Carolina, U.S.A
| | - Meredith A Rooth
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Matthew M Dedmon
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Kevin D Brown
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Margaret T Dillon
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
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Murr AT, Lenze NR, Gelpi MW, Brown WC, Ebert CS, Senior BA, Thorp BD, Kimple AJ, Zanation AM. Quantification of Aerosol Concentrations During Endonasal Instrumentation in the Clinic Setting. Laryngoscope 2021; 131:E1415-E1421. [PMID: 33017067 PMCID: PMC7675733 DOI: 10.1002/lary.29122] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/17/2020] [Accepted: 08/31/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Recent anecdotal reports and cadaveric simulations have described aerosol generation during endonasal instrumentation, highlighting a possible risk for transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) during endoscopic endonasal instrumentation. This study aims to provide a greater understanding of particle generation and exposure risk during endoscopic endonasal instrumentation. STUDY DESIGN Prospective quantification of aerosol generation during office-based nasal endoscopy procedures. METHODS Using an optical particle sizer, airborne particles concentrations 0.3 to 10 microns in diameter, were measured during 30 nasal endoscopies in the clinic setting. Measurements were taken at time points throughout diagnostic and debridement endoscopies and compared to preprocedure and empty room particle concentrations. RESULTS No significant change in airborne particle concentrations was measured during diagnostic nasal endoscopies in patients without the need for debridement. However, significant increases in mean particle concentration compared to preprocedure levels were measured during cold instrumentation at 2,462 particles/foot3 (95% CI 837 to 4,088; P = .005) and during suction use at 2,973 particle/foot3 (95% CI 1,419 to 4,529; P = .001). In total, 99.2% of all measured particles were ≤1 μm in diameter. CONCLUSION When measured with an optical particle sizer, diagnostic nasal endoscopy with a rigid endoscope is not associated with increased particle aerosolization in patient for whom sinonasal debridement is not needed. In patients needing sinonasal debridement, endonasal cold and suction instrumentation were associated with increased particle aerosolization, with a trend observed during endoscope use prior to tissue manipulation. Endonasal debridement may potentially pose a higher risk for aerosolization and SARS-CoV-2 transmission. Appropriate personal protective equipment use and patient screening are recommended for all office-based endonasal procedures. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E1415-E1421, 2021.
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Affiliation(s)
- Alexander T. Murr
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
| | - Nicholas R. Lenze
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
| | - Mark W. Gelpi
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
| | - William C. Brown
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
| | - Charles S. Ebert
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
| | - Brent A. Senior
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
| | - Brian D. Thorp
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
| | - Adam J. Kimple
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
| | - Adam M. Zanation
- Department of Otolaryngology/Head and Neck SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaU.S.A.
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Salger SA, Reza J, Deck CA, Wahab MA, Baltzegar DA, Murr AT, Borski RJ. Enhanced biodiversity of gut flora and feed efficiency in pond cultured tilapia under reduced frequency feeding strategies. PLoS One 2020; 15:e0236100. [PMID: 32702020 PMCID: PMC7377384 DOI: 10.1371/journal.pone.0236100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 06/30/2020] [Indexed: 02/01/2023] Open
Abstract
Feed constitutes 50-70% of total production costs of tilapia, one of the most widely cultured finfishes in the world. We evaluated reduced-feeding strategies for improving production efficiency of Nile tilapia (Oreochromis niloticus). In a 12-week pond trial, fish were fed daily, every other day, every third day, or not at all. Ponds were fertilized to enhance natural foods. In a fifth group fish were fed daily without pond fertilization. Fish fed daily with or without pond fertilization and fish fed every other day had higher specific growth rates, survivability, and net production than the other two treatments. Fish feed efficiency and benefit to cost ratio was highest for treatments fed in a pulsatile manner (i.e. fed every other day or every third day) with fish fed on alternate days providing the best net return among all groups. Fish fed on alternate days had more moderate gene expression levels of intestinal nutrient transporters which may allow for a more balanced and efficient nutrient uptake. Fecal microbe analyses identified 145 families of prokaryotic and 132 genera of eukaryotic organisms in tilapia. The highest diversity of prokaryotes was found in fish fed either every other day or daily in fertilized ponds and the highest diversity of eukaryotes was found in fish fed every other day. These studies indicate feeding Nile tilapia on alternate days along with weekly pond fertilization has no deleterious effects on growth, survivability, or production versus daily feeding regimes, but enhances feed efficiency by 76% and provides the greatest net return on investments. Our studies also suggest for the first time that combining alternate-day feeding with pond fertilization produces the greatest microbial biodiversity in the intestine that could contribute to enhanced feed efficiency and overall health of tilapia.
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Affiliation(s)
- Scott A. Salger
- Department of Biological Sciences, North Carolina State University, Raleigh, North Carolina, United States of America
| | - Jimi Reza
- Department of Fisheries Management, Bangladesh Agricultural University, Mymensingh, Bangladesh
| | - Courtney A. Deck
- Department of Biological Sciences, North Carolina State University, Raleigh, North Carolina, United States of America
| | - Md. Abdul Wahab
- Department of Fisheries Management, Bangladesh Agricultural University, Mymensingh, Bangladesh
- WorldFish, Dhaka, Bangladesh
| | - David A. Baltzegar
- Department of Biological Sciences, North Carolina State University, Raleigh, North Carolina, United States of America
- Genomic Sciences Laboratory, North Carolina State University, Raleigh, North Carolina, United States of America
| | - Alexander T. Murr
- Department of Biological Sciences, North Carolina State University, Raleigh, North Carolina, United States of America
| | - Russell J. Borski
- Department of Biological Sciences, North Carolina State University, Raleigh, North Carolina, United States of America
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