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Phillips N, Eapen N, Wilson CL, Nehme Z, Babl FE. Prehospital use of spinal precautions by emergency medical services in children and adolescents. Emerg Med Australas 2024. [PMID: 39363781 DOI: 10.1111/1742-6723.14499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/20/2024] [Accepted: 08/25/2024] [Indexed: 10/05/2024]
Abstract
OBJECTIVES Limited evidence exists to guide the management of children with possible spinal injuries in the prehospital setting. As a first step to address this, we set out to describe the epidemiology and management of children <18 years presenting with possible cervical spinal injuries to EMS in Victoria, Australia. METHODS Retrospective case record review of all children with concerns of head or neck trauma and/or documented cervical spine collar use presenting to the statewide Ambulance Victoria (AV) EMS service, Victoria, Australia, between 1 July 2019 and 30 June 2020. Demographic, clinical features, mechanism of injury and spinal immobilisation practices were extracted. RESULTS 2100 children were included; 61% were male and the median age was 13 years (interquartile range: 9-15). Over half of the children were transported to suburban (32.2%) and rural/regional (22.9%) EDs, with 37.5% taken to designated trauma centres. The most common mechanisms of injury were sports/activity, motor vehicle accidents and falls in 35.4%, 27.9% and 26.3%, respectively. Spinal precaution use was recorded in 93.7% of cases; cervical collar use was the most common procedure recorded (87.1%). Younger age groups were less likely to have spinal precautions initiated; 51% of children aged 0-3 years, compared to 96.3% of children aged 12 and older (odds ratio = 23.8; 95% confidence interval = 14.5-37; P < 0.001). CONCLUSIONS Prehospital spinal precautions were initiated commonly in children, with use increasing with age, and most were transported to suburban, regional and rural hospitals, not trauma centres. These data will inform the integration of emerging paediatric-specific evidence into prehospital guidelines to risk stratify children.
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Affiliation(s)
- Natalie Phillips
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical Medical and Process Engineering, Queensland University of Technology, Brisbane, Queensland, Australia
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Centre for Child Health Research, University of Queensland, Brisbane, Queensland, Australia
| | - Nitaa Eapen
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Catherine L Wilson
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Centre for Research and Evaluation Ambulance Victoria, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Franz E Babl
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
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McDonald N, Kriellaars D, Pryce RT. Patterns of change in prehospital spinal motion restriction: A retrospective database review. Acad Emerg Med 2023; 30:698-708. [PMID: 36734048 DOI: 10.1111/acem.14678] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute management of trauma patients with potential spine injuries has evolved from uniform spinal immobilization (SI) to spinal motion restriction (SMR). Little research exists describing how these changes have been implemented. This study aims to describe and analyze the practice of SMR in one emergency medical services (EMS) agency over the time frame of SMR adoption. METHODS This was a retrospective database review of electronic patient care reports from 2009 to 2020. The effects of key practice changes (revised documentation and a collar-only treatment option) were analyzed in an interrupted time series using the rate of SI/SMR as the primary outcome. Secondary outcomes included patient age, sex, acuity, mechanism of injury, treatment provided, cervical collar size, and positioning. These were assessed for changes from year to year by Poisson regression. Associations between patient and treatment characteristics were investigated with binomial logistic regression. RESULTS There were 25,747 instances of SI/SMR included. Among all patients, the median age was 40 (interquartile range 24-56), 58% (14,970) were male, and 20% (5062) were high-acuity. The rate of SI/SMR declined from 31.2 to 12.7 treatments per 100 trauma calls per month. The proportion of high-acuity patients increased by 9.6% per year on average (95% CI 8.7%-10.0%). When first available, collar-only treatment was provided to 47% of patients, rising by 6.3% per year (95% CI 3.2%-9.5%) to 60% in 2020. Collar-only treatment (compared to board-and-collar) was more likely to be applied to low-acuity patients (as compared to high): odds ratio 3.01 (95% CI 2.64-3.43). CONCLUSIONS This study shows decreasing SI/SMR treatment and changing patient and practice characteristics. These patterns of care cannot be attributed solely to formal protocol changes. Similar patterns and their possible explanations should be investigated elsewhere.
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Affiliation(s)
- Neil McDonald
- Applied Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Winnipeg Fire Paramedic Service, Winnipeg, Manitoba, Canada
| | - Dean Kriellaars
- College of Rehabilitation Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob T Pryce
- Department of Kinesiology and Applied Health, Gupta Faculty of Kinesiology, University of Winnipeg, Winnipeg, Manitoba, Canada
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Häske D, Blumenstock G, Hossfeld B, Wölfl C, Schweigkofler U, Stock JP. The Immo Traffic Light System as a Decision-Making Tool for Prehospital Spinal Immobilization. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:753-758. [PMID: 35978468 PMCID: PMC9853232 DOI: 10.3238/arztebl.m2022.0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 01/24/2022] [Accepted: 07/21/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Spinal injuries are difficult injuries to assess yet can be associated with significant neurological damage. To avoid secondary damage, immobilization is considered state of the art trauma care. The indication for spinal immobilization must be assessed, however, for potential complications as well as its advantages and disadvantages. METHODS This systematic review addressing the question of the correct indication for spinal immobilization in trauma patients was compiled on the basis of our previously published analysis of possible predictors from the Trauma Registry of the German Society for Trauma Surgery. A Delphi procedure was then used to develop suggestions for action regarding immobilization based on the results of this review. RESULTS The search of the literature yielded 576 publications. The 24 publications included in the qualitative analysis report of 2 228 076 patients. A decision tool for spinal immobilization in prehospital trauma care was developed (Immo traffic light system) based on the results of the Delphi procedure. According to this system, severely injured patients with blunt trauma, severe traumatic brain injury, peripheral neurological symptoms, or spinal pain requiring treatment should be immobilized. Patients with a statistically increased risk of spinal injury as a result of the four cardinal features (fall >3m, severe trunk injury, supra clavicular injury, seniority [age >65 years]) should only have their spinal motion restricted after weighing up the pros and cons. Isolated penetrating trunk injuries should not be immobilized. CONCLUSION High-quality studies demonstrating the benefit of prehospital spinal immobilization are still lacking. Decision tools such as the Immo traffic light system can help weigh up the pros and cons of immobilization.
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Affiliation(s)
- David Häske
- Center for Public Health and Health Services Research, University Hospital of Tübingen, and German Red Cross Emergency Services Reutlingen,*Center for Public Health and Health Services Research University Hospital of Tübingen Osianderstr. 5 72076 Tübingen, Germany
| | - Gunnar Blumenstock
- Institute of Clinical Epidemiology and Applied Biometry, University Hospital of Tübingen
| | - Björn Hossfeld
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital of Ulm
| | - Christoph Wölfl
- Department for Orthopedic Surgery, Trauma and Sports Traumatology – Hand and Plastic Surgery, Musculoskeletal Center Neuwied, Marienhaus Hospital Neuwied
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Trauma Center, Frankfurt am Main
| | - Jan-Philipp Stock
- Department for Anesthesiology, Intensive Care Medicine, Emergency Medicine, Pain Therapy and Palliative Care, am Steinenberg Hospital, Reutlingen: Jan-Philipp Stock
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Ms R, Riffelmann M, Kunze-Szikszay N, Lier M, Schmid O, Haus H, Schneider S, Jf H. Vacuum mattress or long spine board: which method of spinal stabilisation in trauma patients is more time consuming? A simulation study. Scand J Trauma Resusc Emerg Med 2021; 29:46. [PMID: 33706791 PMCID: PMC7953765 DOI: 10.1186/s13049-021-00854-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spinal stabilisation is recommended for prehospital trauma treatment. In Germany, vacuum mattresses are traditionally used for spinal stabilisation, whereas in anglo-american countries, long spine boards are preferred. While it is recommended that the on-scene time is as short as possible, even less than 10 minutes for unstable patients, spinal stabilisation is a time-consuming procedure. For this reason, the time needed for spinal stabilisation may prevent the on-scene time from being brief. The aim of this simulation study was to compare the time required for spinal stabilisation between a scoop stretcher in conjunction with a vacuum mattress and a long spine board. METHODS Medical personnel of different professions were asked to perform spinal immobilizations with both methods. A total of 172 volunteers were immobilized under ideal conditions as well as under realistic conditions. A vacuum mattress was used for 78 spinal stabilisations, and a long spinal board was used for 94. The duration of the procedures were measured by video analysis. RESULTS Under ideal conditions, spinal stabilisation on a vacuum mattress and a spine board required 254.4 s (95 % CI 235.6-273.2 s) and 83.4 s (95 % CI 77.5-89.3 s), respectively (p < 0.01). Under realistic conditions, the vacuum mattress and spine board required 358.3 s (95 % CI 316.0-400.6 s) and 112.6 s (95 % CI 102.6-122.6 s), respectively (p < 0.01). CONCLUSIONS Spinal stabilisation for trauma patients is significantly more time consuming on a vacuum mattress than on a long spine board. Considering that the prehospital time of EMS should not exceed 60 minutes and the on-scene time should not exceed 30 minutes or even 10 minutes if the patient is in extremis, based on our results, spinal stabilisation on a vacuum mattress may consume more than 20 % of the recommended on-scene time. In contrast, stabilisation on a spine board requires only one third of the time required for that on a vacuum mattress. We conclude that a long spine board may be feasible for spinal stabilisation for critical trauma patients with timesensitive life threatening ABCDE-problems to ensure the shortest possible on-scene time for prehospital trauma treatment, not least if a patient has to be rescued from an open or inaccessible terrain, especially that with uneven overgrown land.
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Affiliation(s)
- Roessler Ms
- Department for Anaesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075, Göttingen, Germany.
| | - M Riffelmann
- Praxis Schmallenberg, Obringhauser Strasse 4, 57392, Schmallenberg, Germany
| | - N Kunze-Szikszay
- Department for Anaesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - M Lier
- Department for Anaesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - O Schmid
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Eichsfeld Clinic, Windische Gasse 112, 37308, Heilbad Heiligenstadt, Germany
| | - H Haus
- Department for Anaesthesiology, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - S Schneider
- Department of Medical Statistics, University Medical Center Göttingen, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - Heuer Jf
- Department of Anaesthesiology, Intensive-Care-, Emergency- and Pain-Medicine, Augusta Krankenanstalt Bochum, Bergstrasse 26, 44791, Bochum, Germany
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Evidence for the use of spinal collars in stabilising spinal injuries in the pre-hospital setting in trauma patients: a systematic review. Eur J Trauma Emerg Surg 2020; 48:647-657. [PMID: 33346863 PMCID: PMC8825572 DOI: 10.1007/s00068-020-01576-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/07/2020] [Indexed: 11/04/2022]
Abstract
Purpose Spinal collars were introduced in 1967 into the management of spinal trauma care as it was thought that this technique of immobilisation would prevent any further neurological or spinal damage in high-risk patients. The aim of this systematic review was to determine whether the use of spinal collars in the pre-hospital trauma patient was recommended by published literature. Methods A systematic search of the literature was conducted between 1990 and 2020, screening PubMed, Medline, Science Direct and Google Scholar. The consequent findings were then qualitatively synthesised with the aim of effectively evaluating the evidence to resolve the discrepancy between current practice and literature. Results Of the nine eligible studies, six deemed that spinal collars should not be used in pre-hospital trauma patients with the remaining three reporting uncertainty if spinal collars were best practice. Our results suggest that there is a discrepancy between current guidance and practice in that although the guidelines recommend the use of spinal collars in the pre-hospital setting the majority of the studies were against the use of spinal collars. Importantly, none of the studies reported any benefits of spinal collars. Conclusion Our study shows a disparity between current guidelines and the published literature and warrants further direct research to obtain a more comprehensive view of the use of spinal collars in a pre-hospital setting.
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Häske D, Lefering R, Stock JP, Kreinest M. Epidemiology and predictors of traumatic spine injury in severely injured patients: implications for emergency procedures. Eur J Trauma Emerg Surg 2020; 48:1975-1983. [PMID: 33025171 PMCID: PMC9192373 DOI: 10.1007/s00068-020-01515-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/25/2020] [Indexed: 10/30/2022]
Abstract
PURPOSE This study aimed to identify the prevalence and predictors of spinal injuries that are suitable for immobilization. METHODS Retrospective cohort study drawing from the multi-center database of the TraumaRegister DGU®, spinal injury patients ≥ 16 years of age who scored ≥ 3 on the Abbreviated Injury Scale (AIS) between 2009 and 2016 were enrolled. RESULTS The mean age of the 145,833 patients enrolled was 52.7 ± 21.1 years. The hospital mortality rate was 13.9%, and the mean injury severity score (ISS) was 21.8 ± 11.8. Seventy percent of patients had no spine injury, 25.9% scored 2-3 on the AIS, and 4.1% scored 4-6 on the AIS. Among patients with isolated traumatic brain injury (TBI), 26.8% had spinal injuries with an AIS score of 4-6. Among patients with multi-system trauma and TBI, 44.7% had spinal injuries that scored 4-6 on the AIS. Regression analysis predicted a serious spine injury (SI; AIS 3-6) with a prevalence of 10.6% and cervical spine injury (CSI; AIS 3-6) with a prevalence of 5.1%. Blunt trauma was a predictor for SI and CSI (OR 4.066 and OR 3.640, respectively; both p < 0.001) and fall > 3 m for SI (OR 2.243; p < 0.001) but not CSI (OR 0.636; p < 0.001). Pre-hospital shock was predictive for SI and CSI (OR 1.87 and OR 2.342, respectively; both p < 0.001), and diminished or absent motor response was also predictive for SI (OR 3.171) and CSI (OR 7.462; both p < 0.001). Patients over 65 years of age were more frequently affected by CSI. CONCLUSIONS In addition to the clinical symptoms of pain, we identify '4S' [spill (fall) > 3 m, seniority (age > 65 years), seriously injured, skull/traumatic brain injury] as an indication for increased attention for CSIs or indication for spinal motion restriction.
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Affiliation(s)
- David Häske
- German Red Cross, Emergency Medical Service, Obere Wässere 1, 72764, Reutlingen, Germany. .,Center for Public Health and Health Services Research, University Hospital Tübingen, Tübingen, Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Jan-Philipp Stock
- Department of Anesthesiology, Intensive Care Medicine, Emergency and Pain Medicine, Klinikum am Steinenberg, Reutlingen, Germany
| | - Michael Kreinest
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
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Ladny M, Smereka J, Ahuja S, Szarpak L, Ruetzler K, Ladny JR. Effect of 5 different cervical collars on optic nerve sheath diameter: A randomized crossover trial. Medicine (Baltimore) 2020; 99:e19740. [PMID: 32311968 PMCID: PMC7220316 DOI: 10.1097/md.0000000000019740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There is considerable evidence that prolonged use of cervical collars potentially cause detrimental effects including increase in optic nerve sheath diameter (ONSD) among healthy volunteers. Different types of cervical collars immobilize cervical spine variably well and may presumably differently influence the venous compression and hence the intracranial pressure. We therefore aimed to evaluate the influence of cervical spine immobilization with 5 different types of cervical collars on ONSD measured noninvasively by ultrasound on healthy volunteers. METHODS We conducted a randomized crossover trial including 60 adult healthy volunteers. Control assessment of the optic nerve sheath thickness was performed in both sagittal and transverse planes. Patient was placed supine on a transport stretcher, cervical collar was placed, and ONSD measurement was performed after 5 and 20 minutes. During the next days, the procedure was repeated with random allocation of participants and random cervical collar. RESULTS Sixty healthy volunteers were included in our study. ONSD left diameter [mm] for the baseline was 3.8 [interquartile range (IQR): 3.65-3.93)] mm. Using AMBU after 5 min, ONSD was changed up to 4.505 (IQR 4.285-4.61; P < .001) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.73 (IQR: 4.49-4.895; P < .001) and 4.925 (IQR: 4.65-5.06; P < .001), respectively. Necklite reported the lower change in ONSD: 3.92 (IQR: 3.795-4; P = 1.0) mm in 5 minutes and 3.995 (IQR: 3.875 - 4.1; P = 1.0) mm in 20 minutes. ONSD right diameter [mm] for the baseline was 3.8 (IQR 3.675-3.9) mm. Using AMBU after 5 minutes, ONSD was changed up to 4.5 (IQR 4.21-4.6) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.705 (IQR 4.455-4.9) and 4.93 (IQR 4.645-5.075), respectively. Necklite reported the lower change in ONSD -33.9 (IQR 3.795-3.99) mm in 5 minutes and 3.995 (IQR 3.86-4.09) mm in 20 minutes. CONCLUSION We report significant increase of ONSD from the baseline after cervical collar placement among healthy volunteers at 5 minutes and 20 minutes interval. In addition, no significant difference was noted between ONSD measurements at 5 and 20 minutes. Clinicians should take proactive steps to assess the actual need of cervical collar case by case basis. Nonetheless, when needed, Necklite moldable neck brace seems to be a reasonable option.Registration: ClinicalTrials database (www.clinicaltrials.gov, NCT03609879).
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Affiliation(s)
- Michal Ladny
- Department of Trauma-Orthopedic Surgery, Solec Hospital, Warsaw, Poland
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland
| | - Sanchit Ahuja
- Department of Anesthesiology, Pain management and Perioperative Medicine, Henry Ford Health System, Detroit, MI
| | - Lukasz Szarpak
- Medical Simulation Center, Lazarski University, Warsaw, Poland
| | - Kurt Ruetzler
- Departments of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Jerzy Robert Ladny
- Clinic of Emergency Medicine, Medical University Bialystok, Bialystok, Poland
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Brown A, Low A. Self-extrication and selective spinal immobilisation in a polytrauma patient with spinal injuries. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620910845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Methods of extrication and spinal immobilisation following trauma remains controversial. There is a consensus shift towards encouraging patients to self-extricate from vehicles after collisions and reduced use of hard cervical collars. Difficulties in conducting randomised controlled trials in this area means that case reports are important in adding to the existing evidence base. This case of an 81-year-old female polytrauma patient suggests that self-extrication, and not using hard cervical collars is safe practice, even in the context of significant multi-level spinal injuries.
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Affiliation(s)
- Aidan Brown
- West Midlands Ambulance Service NHS Foundation Trust, Midlands Air Ambulance Charity, Brierley Hill, UK
| | - Adam Low
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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