Wound Complications from Surgeries Pertaining to the Achilles Tendon

2008 ◽  
Vol 98 (2) ◽  
pp. 95-101 ◽  
Author(s):  
Amol Saxena ◽  
Nicola Maffulli ◽  
Aidan Nguyen ◽  
Albert Li
Keyword(s):  
Rheumatoid Arthritis ◽  
Achilles Tendon ◽  
Wound Complication ◽  
Wound Complications ◽  
Fisher Exact Test ◽  
Exact Test ◽  
Additional Surgery ◽  
Tendon Surgery ◽  
Keloid Formation ◽  
Age Range

Background: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. Methods: We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation. Results: A total of 219 surgical cases were available for review (140 males and 70 females; mean ± SD age at the time of surgery, 46.5 ± 12.6 years; age range, 16–75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after their wound complications; some had simple granuloma excision, and one necessitated a flap. Patients with risk factors such as diabetes mellitus, smoking, and rheumatoid arthritis necessitating corticosteroid therapy were more likely to have a wound complication (Fisher exact test, P = .03). Conclusions: Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed manner. Absorbable and nonabsorbable sutures can be implicated. (J Am Podiatr Med Assoc 98(2): 95–101, 2008)

Intramuscular versus ultrasound-guided intratenosynovial glucocorticoid injection for tenosynovitis in patients with rheumatoid arthritis: a randomised, double-blind, controlled study

2016 ◽  
Vol 76 (4) ◽  
pp. 666-672 ◽  
Author(s):  
Mads Ammitzbøll-Danielsen ◽  
Mikkel Østergaard ◽  
Viktoria Fana ◽  
Daniel Glinatsi ◽  
Uffe Møller Døhn ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Isotonic Saline ◽  
Group Versus ◽  
Controlled Study ◽  
Fisher Exact Test ◽  
Double Blind ◽  
Exact Test ◽  
Patient Reported ◽  
Registration Number

ObjectiveThe aim of this study was to compare the efficacy of intramuscular versus ultrasound (US)-guided intratenosynovial glucocorticoid injection in providing disease control after 2, 4 and 12 weeks in patients with rheumatoid arthritis(RA) with tenosynovitis.MethodsFifty patients with RA and tenosynovitis were randomised into two double-blind groups: (A) ‘intramuscular group’, receiving intramuscular injection of betamethasone and US-guided intratenosynovial isotonic saline injection and (B) ‘intratenosynovial group’ receiving saline intramuscularly and US-guided intratenosynovial betamethasone injection. All patients were in stable disease-modifying anti-rheumatic drug treatment prior to and during the study. Patients were excluded, and considered non-responders, if any treatments were altered during the follow-up period. ‘US tenosynovitis remission’, defined as US tenosynovitis grey-scale score ≤1 and colour Doppler score=0, was assessed at week 4 (primary outcome), and weeks 2 and 12, using non-responder imputation for missing data.ResultsUS tenosynovitis remission at week 4 was achieved in 25% (6/24) in the ‘intramuscular group’ versus 64% (16/25) in the ‘intratenosynovial group’, that is, a difference of −39 percentage point (pp) (CI −65pp to −13pp), Fisher exact test p=0.001. Corresponding values for the ‘intramuscular group’ versus the ‘intratenosynovial group’ at 2 and 12 weeks were 21% (5/24) versus 48% (13/25), that is, a difference of −27pp (CI −53pp to −2pp), p=0.072 and 8% (2/24) versus 44% (11/25), that is, difference of −36pp (−58pp to −13pp), p=0.003. Most US, clinical and patient-reported scores improved more in the ‘intratenosynovial group’ at all follow-up visits.ConclusionsIn this randomised double-blind clinical trial, patients with RA and tenosynovitis responded significantly better to US-guided intratenosynovial glucocorticoid injection than to intramuscular glucocorticoid injection, both at 4 and 12 weeks follow-up.Trial registration numberEudraCT nr: 2013-003486-34.

scholarly journals A comparative study between conventional skin sutures, staples adhesive skin glue for surgical skin closure

2019 ◽  
Vol 6 (3) ◽  
pp. 775 ◽  
Author(s):  
Ananda B. B. ◽  
Vikram J. ◽  
Ramesh B. S. ◽  
Hosni Mubarak Khan
Keyword(s):  
Length Of Hospital Stay ◽  
Controlled Study ◽  
Wound Complications ◽  
Fisher Exact Test ◽  
Skin Closure ◽  
Chi Square ◽  
Exact Test ◽  
Tissue Glue ◽  
Randomized Controlled ◽  
Post Operative Pain

Background: The signature of a surgeon is ‘scar’. Skin closure technique should be technically easy, acceptable, speedy and economical. Sutures and staples remain the mainstay of techniques. However, the use of GLUE is increasing in clinical practice. Authors compared all the three techniques in terms of time efficacy, post-operative pain, wound complications, cosmesis and cost-effectiveness.Methods: A 2-year prospective randomized controlled study was conducted on 90 healthy patients comparing tissue glue, staplers and sutures in primary wound closures following elective surgeries in the Department of General Surgery at BRAMC (October 2015 to October 2017).Results: The patients in the three groups were analyzed using chi-square, ANOVA, Fisher Exact test, and results were formulated. Staples consumed less time for application with a mean of 53.3 seconds when compared to glue (103.97 seconds) and sutures (294.97 seconds). Glue gave best results in terms of less post-operative pain. Mean VAS score calculated at 12,24,48,72 hrs was 63.13,42.10,16.94,7.27 and at 7 days was 4.73. The wound ASEPSIS score calculated on 3rd, 5th, and 7th day. Cosmesis score on 7th day, 1st month and 5th month was calculated using modified hollander and VAS cosmesis scale. Mean score with glue was 5.83,88.90 and 96.13 respectively. Cost of material including length of hospital stay for glue was also effective with 3.47 days on an average. All the above proved statistical significance.Conclusions: Staples application is faster, consumes less significant time than glue and sutures. Skin glue gives the best results in terms of less post-operative pain, wound asepsis, better cosmesis and cost-effectiveness. The concept of tissue glue is a safe, attractive, and effective alternate over other conventional methods of wound closures following elective surgeries.

scholarly journals MICROBE PATTERN AND RISK FACTORS OF DEEP NECK ABSCESS PATIENTS IN ATMA JAYA HOSPITAL

2021 ◽  
Vol 20 (1) ◽  
pp. 26-32
Author(s):  
Kendrick Klaudius Hartedja ◽  
Ricky Yue ◽  
Lucky H. Moehario
Keyword(s):  
Risk Factors ◽  
Oral Hygiene ◽  
Fisher Exact Test ◽  
Main Concern ◽  
Chi Square ◽  
Exact Test ◽  
Neck Abscess ◽  
Deep Neck Abscess ◽  
Male Patients ◽  
Age Range

Introduction: Deep neck abscess is a pus accumulation in the space and tissue of the cervical fascia caused by an infection and has the potential for several complications. Appropriate use of antibiotics can prevent these complications, but long culture time has been a main concern. Diabetes and oral hygiene are identified as commonly found risk factors for deep neck abscess. This study aims to analyze patients’ characteristics and the usage of antibiotics in treating deep neck abscess patients in Atma Jaya Hospital as well as assessing the effect of diabetes and oral hygiene as the causes for deep neck abscess. Methods: This was a cohort retrospective, descriptive analytic study. The samples were from 23 deep neck abscess patients undergoing treatment in Atma Jaya Hospital and met the inclusion and exclusion criteria. Chi square and Fisher exact test were used to determine the significance effect of diabetes and higiene oral in relation to deep neck abscess. Results: There were more male patients than female patients with age range 20-30 years old. Streptococcus viridans and Streptococcus pyogenes were the most common bacteria causing deep neck abscesses. Metronidazole, gentamicin and ceftriaxone were the most widely used antibiotics and it had shown great compatibility to fight against germs found in this disease. Statistical test results on the effect of oral hygiene oral to submandibular abscesses, peritonsillar, and Ludwig’s angina were p(AS)=0.605, p(AP)=1.000, and p(LA)=1.000, while of diabetes were p(AS)=0.685, p(AP)=0.657, and p(LA)=1.000. Conclusion: Deep neck abscess tends to occur in male patients of productive age. Metronidazole, gentamicin and ceftriaxone were the recommended empiric antibiotics. There was no significant relationship between oral hygiene and diabetes on the occurrence of deep neck abscesses.

scholarly journals AB0024 ASSOCIATION OF IL6 RS1800795 BUT NOT IL6R RS2228145, RS4845618 AND STAT4 RS7574865 POLYMORPHISMS WITH CHLAMYDIA-ASSOCIATED RHEUMATOID ARTHRITIS

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1315.2-1315
Author(s):  
T. Zybalova ◽  
V. Yagur ◽  
R. Goncharova ◽  
N. Soroka ◽  
N. Dostanko ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Chlamydial Infection ◽  
Blood Donors ◽  
Statistical Significance ◽  
Diagnostic Odds Ratio ◽  
Fisher Exact Test ◽  
Bonferroni Correction ◽  
Research Support ◽  
Exact Test ◽  
Healthy Donors

Background:Rheumatoid arthritis (RA), associated with Chlamydial Infection, has some clinical and immunological particulars that interfere with the early diagnosis and require significant changes in treatment strategy [1].Objectives:To estimate the distribution of some non-HLA genetic markers such as STAT4 rs7574865, IL6 rs1800795, IL6R rs2228145 and rs4845618 in Chlamydia positive and negative RA patients and healthy controls.Methods:We examined 380 healthy blood donors and 187 RA patients classified according to the ACR/EULAR 2010 criteria for RA [2]. Twenty-three of the RA patients were positive for Chlamidia trachomatis (n=17) or Chlamidia pneumonia (n=6) persistence. DNA from peripheral blood samples was extracted by phenol-chloroform method. SNPs were genotyped by the real-time PCR with fluorescent probes. Statistical significance of SNPs’ frequency was estimated by two-way Fisher exact test (F, p2-t) with Bonferroni correction for multiple comparisons (pcor). Moreover, diagnostic odds ratio (dOR), the likelihood ratio of positive (LR+) and negative (LR–) tests and corresponding confidence intervals (CI) were calculated.Results:We revealed statistically significant increase of genotype СС frequency (IL6 rs1800795) in Chlamydia-associated RA (60.9%) vs healthy donors (20.7%): p2-t=0.000065; pcor=0.00026; dOR=5.95 (CI95%2.53-13.94); LR+=2.94 (CI95%1.90-3.29); LR–=0.49 (CI95%0.28-0.75) as well as in Chlamydia-associated RA (60.9%) vs Chlamydia-negative RA (23.9%): p2-t=0.00051; pcor=0.002; dOR=4.99 (CI95%2.04-12.16); LR+=2.56 (CI95%1.60-3.57); LR–=0.51 (CI95%0.29-0.78). Significant differences in STAT4 rs7574865, IL6R rs2228145 and IL6R rs4845618 distribution between studied groups were not found.Conclusion:Our data suggest the association between СС genotype of IL6 rs1800795 and Chlamydia-associated RA.References:[1]Soroka N.F. Rheumatoid Arthritis, associated with Chlamydial infection // Healthcare 2009; 1: 5-9.[2]Aletaha D. et al. 2010 Rheumatoid arthritis classification criteria// Arthritis Rheum 2010; 62 (9): 2569-81.Disclosure of Interests:Tatiana Zybalova: None declared, Viktor Yagur: None declared, Roza Goncharova: None declared, Nikolaj Soroka Grant/research support from: JSC BIOCAD, Natalia Dostanko: None declared, Valery Apanasovich: None declared, Anastasiya Tushina: None declared

A Method for Combined Percutaneous and Open Surgical Repair of Achilles Tendon Ruptures: A Report of Three Cases

1996 ◽  
Vol 17 (4) ◽  
pp. 217-220 ◽  
Author(s):  
Behiç Tanil Esemenli ◽  
Hakan Gündeş ◽  
Mete Mecikoğlu
Keyword(s):  
Surgical Treatment ◽  
Achilles Tendon ◽  
Surgical Repair ◽  
Functional Results ◽  
Wound Complication ◽  
Wound Complications ◽  
Distal Stump ◽  
Open Surgical Repair ◽  
Tendon Ruptures

Surgical treatment of Achilles tendon ruptures provides excellent functional results in active individuals, although it carries an incidence of wound complications. After experiencing a 25% wound complication rate with the traditional techniques in Achilles tendon ruptures, we modified the Bosworth technique by passing the gastrocsoleus flap percutaneously through the distal stump. This modification eliminated one third of the distal incision, which appears to be the most vulnerable part. We performed the operation in three consecutive cases. At 2-year follow-up there were no wound complications and no reruptures.

Comparison of Wound Complications Between Two Closing Techniques Following Total Hip Arthroplasty Via the Direct Anterior Approach

2019 ◽  
Vol 03 (04) ◽  
pp. 191-196
Author(s):  
Maria Opanova ◽  
Ian Hasegawa ◽  
Emily Unebasami ◽  
Cera-Nicole Tollefsen ◽  
Sean Saito ◽  
...  
Keyword(s):  
Total Hip Arthroplasty ◽  
Hip Arthroplasty ◽  
Anterior Approach ◽  
Direct Anterior Approach ◽  
Wound Complications ◽  
Fisher Exact Test ◽  
Total Hip ◽  
Additional Surgery ◽  
Increased Risk ◽  
First 90 Days

AbstractA higher rate of wound complications has been reported in the direct anterior approach (DAA) for total hip arthroplasty (THA), reportedly due to the location of the incision and poor surgical site exposure techniques. Therefore, the purpose of this study was to compare wound complications within the first 90 days between a zipper closing method (ZM) and subcuticular monocryl with dermabond skin closure (SMD). A total of 294 patients (352 hips) were closed using the SMD and 166 patients (206 hips) were closed via the ZM. All THAs via the DAA and postoperative care were performed based on the current standard of care for the treatment of symptomatic hip osteoarthritis, established by a single, high volume surgeon from 2016 to 2018. Any wound complications during the first 90 days were noted. Independent t-tests determined differences in descriptive variables. Additionally, a Fisher Exact test was performed to compare wound complication rate between groups (p < 0.05). Surgical time was significantly shorter for ZM (p < 0.001) for both unilateral and bilateral groups compared with SMD. Overall, there were four complications occurring in 558 cases (0.7%), with two cases (0.36%) requiring additional surgery. No wound complications were present in the SMD and four wound complications (1.9%), two requiring surgery, were reported for the ZM (χ2 [1, N = 558] = 6.884, p = 0.009). While no wound complications were reported in the SMD group, the ZM group sustained four wound complications, two of which required additional surgery. Two of these wound complications occurred within the first 14 cases following implementation of the ZM, perhaps indicating a short learning curve. The ZM is a quicker, perhaps easier closure method yet the added expense for materials and suggested increased risk for wound complications may moderate the enthusiasm of the ZM compared with the sutures following THA via the DAA.

scholarly journals Patterns and Associated Risk of Perioperative Use of Anti-Tumor Necrosis Factor in Patients with Rheumatoid Arthritis Undergoing Total Knee Replacement

2013 ◽  
Vol 40 (5) ◽  
pp. 617-623 ◽  
Author(s):  
Beverly K. Johnson ◽  
Susan M. Goodman ◽  
Michael M. Alexiades ◽  
Mark P. Figgie ◽  
Ryan T. Demmer ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Tumor Necrosis Factor ◽  
Tumor Necrosis ◽  
Joint Infection ◽  
Self Report ◽  
Fisher Exact Test ◽  
Site Infection ◽  
Exact Test ◽  
Total Knee ◽  
Necrosis Factor

Objective.The patterns and risks of perioperative use of anti-tumor necrosis factor (anti-TNF) medication in patients with rheumatoid arthritis (RA) are not well studied. We examined the patterns of perioperative anti-TNF use and risk of postoperative adverse events (AE) in patients undergoing total knee replacement (TKR).Method.Retrospective cohort study with followup. RA cases within a TKR registry were identified by ICD-9 code (714.0) or self-report. Mailed questionnaires queried anti-TNF use and duration of RA. AE were determined by chart review and patient self-report, and included surgical site infection, pulmonary embolus, deep venous thrombosis, pneumonia, and any infection or re-operation within 6 months.Results.There were 268 TKR cases with RA. The stop time for anti-TNF preoperatively correlated with dosing schedule; restart time was after wound healing. There were 7 surgical site infections (3%), one (0.4%) of which was a deep joint infection in bilateral TKA requiring explant. The anti-TNF group had 3.26% (3/92) local site infection versus 2.10% (3/143) in the group without anti-TNF and this difference was not statistically significant (Fisher exact test, p = 0.68). The one deep joint infection was in the anti-TNF group. Six-month AE rate was 7.61% in the anti-TNF group versus 6.99% in the group without anti-TNF (Fisher exact test, p = 1.0).Conclusion.There was a low risk of infection and perioperative adverse events in patients with RA receiving anti-TNF therapy who were undergoing TKR. This raises the question whether it is necessary to stop anti-TNF for a long period prior to surgery. Given the possible risks associated with stopping anti-TNF, including worsening of disease, further study is needed to determine optimal perioperative use of anti-TNF among patients with RA undergoing TKR.

Venous Thromboembolism and High Grade Gliomas

1993 ◽  
Vol 70 (03) ◽  
pp. 393-396 ◽  
Author(s):  
Mandeep S Dhami ◽  
Robert D Bona ◽  
John A Calogero ◽  
Richard M Hellman
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Medical Center ◽  
Significant Risk ◽  
Bleeding Complications ◽  
Fisher Exact Test ◽  
High Grade ◽  
Chi Square ◽  
Exact Test ◽  
High Grade Gliomas

SummaryA retrospective study was done to determine the incidence of and the risk factors predisposing to clinical venous thromboembolism (VTE) in patients treated for high grade gliomas. Medical records of 68 consecutive patients diagnosed and treated at Saint Francis Hospital and Medical Center from January 1986 to June 1991 were reviewed. The follow up was to time of death or at least 6 months (up to December 1991). All clinically suspected episodes of VTE were confirmed by objective tests. Sixteen episodes of VTE were detected in 13 patients for an overall episode rate of 23.5%. Administration of chemotherapy (p = 0.027, two tailed Fisher exact test) and presence of paresis (p = 0.031, two tailed Fisher exact test) were statistically significant risk factors for the development of VTE. Thrombotic events were more likely to occur in the paretic limb and this difference was statistically significant (p = 0.00049, chi square test, with Yates correction). No major bleeding complications were seen in the nine episodes treated with long term anticoagulation.We conclude that venous thromboembolic complications are frequently encountered in patients being treated for high grade gliomas and the presence of paresis and the administration of chemotherapy increases the risk of such complications.

Electronic cigarettes: How confident and effective are allergists, pulmonologists, and primary care physicians in their practice behavior?

2020 ◽  
Vol 41 (3) ◽  
pp. 192-197
Author(s):  
Sherry S. Zhou ◽  
Alan P. Baptist
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Electronic Cigarettes ◽  
The United States ◽  
Fisher Exact Test ◽  
Exact Test ◽  
Knowledge And Beliefs ◽  
Tobacco Cigarette ◽  
Number Of Patients ◽  
Personal Use

Background: There has been a striking increase in electronic cigarette (EC) use in the United States. The beliefs and practices toward ECs among physicians are unknown. Objective: The purpose of this study was to investigate EC practice patterns among allergists, pulmonologists, and primary care physicians. Methods: An anonymous survey was sent to physicians. The survey contained 32 questions and addressed issues related to demographics, cessation counseling behaviors, personal use, and knowledge and beliefs about ECs. Statistical analysis was performed by using analysis of variance, the Pearson χ2 test, Fisher exact test, and logistic regression. Results: A total of 291 physicians completed the survey (222 primary care physicians, 33 pulmonologists, and 36 allergists) for a response rate of 46%. The allergists asked about tobacco cigarette use as frequently as did the pulmonologists and more than the primary care physicians (p < 0.001), but they rarely asked about EC use. The pulmonologists scored highest on self-reported knowledge on ECs, although all the groups answered <40% of the questions correctly. The allergists did not feel as comfortable about providing EC cessation counseling as did the pulmonologists and primary care physicians (p < 0.001). All three groups were equally unlikely to recommend ECs as a cessation tool for tobacco cigarette users. Conclusion: Allergists lacked knowledge and confidence in providing education and cessation counseling for EC users. As the number of patients who use these products continues to increase, there is an urgent need for all physicians to be comfortable and knowledgeable with counseling about ECs.

Perbedaan Kontaminasi Bacteria Staphylococcus sp di Denominasi Uang Kertas Rupiah di Warung Jalan Adi Sucipto Kota Pontianak

2018 ◽  
Vol 1 (2) ◽  
pp. 166
Author(s):  
Sutriswanto Sutriswanto ◽  
Sugito Sugito
Keyword(s):  
Research Method ◽  
Sampling Technique ◽  
Cluster Sampling ◽  
Fisher Exact Test ◽  
Infectious Agents ◽  
Exact Test ◽  
Purposive Sampling ◽  
Paper Money

Abstract: Staphylococcus is a cause of infection. Infection can be transmitted from a source by an indirect through fomite. Paper money can act as transmission of infectious agents, money acts as a fomite. Smaller denominations of value have higher contamination. This study aims to analyze differences in contamination bacterial Staphylococcus sp on denomination of paper money Rp.2.000, 5.000, Rp.10,000 and Rp.20.000 that currently shop on Adi Sucipto street town Pontianak. The research method used in this research is in the form of difference and the sample in this research is denomination of paper money curently with sampling technique using cluster sampling. Checkup of Staphylococcus spon denomination of paper money using rinse method. On these result of study, denomination of paper money Rp.2.000 that is contaminated staphylococcus sp is 80%, denomination of paper money Rp.5.000 that is contaminated staphylococcus sp is 70%, denomination of paper money Rp.10.000 and Rp.20.000 that is contaminated staphylococcus sp is 80%. The data from result of study has been obtained were analyzed statistically by using fisher exact test, the result of p (0,477) >α (0,05) which mean as H1 is rejected. So it can be concluded there is no difference of contamination bacteria staphylococcus sp on denominations of paper money rupiah.Abstrak: Staphylococcus merupakan penyebab terjadinya infeksi. Infeksi dapat ditularkan dari suatu sumber dengan mekanisme tidak langsung melalui fomite. Uang kertas dapat bertindak sebagai transmisi agens infeksius ,uang berperan sebagai fomite. Pecahan uang yang lebih kecil nilainya memiliki kontaminasi yang lebih tinggi. Penelitian ini bertujuan untuk menganalisis perbedaan cemaran bakteri Staphylococcus sp pada pecahan uang kertas Rp.2.000, 5.000, Rp.10.000 dan Rp.20.000 yang beredar di warung jalan Adi Sucipto kota Pontianak. Metode penelitian yang digunakan dalam penelitian berbentuk komperatif dan sampel pada penelitian ini adalah pecahan uang kertas rupiah dengan.teknik pengambilan sampel menggunakan purposive sampling. Pemeriksaan Staphylococcus sp pada pecahan uang kertas rupiah menggunakan metode rinse. Pada hasil penelitian pecahan uang kertas Rp.2.000 yang tercemar staphylococcus sp adalah 80%, pecahan uang kertas Rp.5.000 yang tercemar staphylococcus spadalah 70%, pecahan uang kertas Rp.10.000 dan Rp.20.000 yang tercemar staphylococcus spadalah 50%. Berdasarkan data dari hasil penelitian yang telah didapat dianalisis menggunakan uji statistik fisher exact, didapatkan hasil p (0,477) >α (0,05) yang diartikan sebagai H1 ditolak. Sehingga dapat disimpulkan tidak ada perbedaan cemaran bakteri staphylococcus sp pada pecahan uang kertas rupiah.

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