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Wingert TEA, Hekmat D, Ayad I. Regional Anesthesia for Neonates. Neoreviews 2023; 24:e626-e641. [PMID: 37777613 DOI: 10.1542/neo.24-10-e626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.
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Affiliation(s)
- Theodora E A Wingert
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Diana Hekmat
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ihab Ayad
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
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2
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Kiblawi R, Beck C, Keil O, Schukfeh N, Hofmann AD, Ure BM, Kuebler JF. Laparoscopic versus Open Inguinal Hernia Repair Is Feasible in Infants with Caudal Anesthesia and Spontaneous Respiration. Eur J Pediatr Surg 2023; 33:26-34. [PMID: 36220133 DOI: 10.1055/a-1958-7989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Minimally invasive surgery (i.e., laparoscopy) and minimally invasive anesthesia (i.e., caudal anesthesia with spontaneous respiration) have separately shown benefits for inguinal hernia repair in infants, yet to what degree these techniques can be combined remains unknown. This study investigated whether laparoscopy impacts the feasibility of performing caudal anesthesia with spontaneous respiration in infants. METHODS Prospectively collected data of all infants less than 12 months old and over 3 kg weight who underwent laparoscopic indirect hernia repair (LAP) at our department from 2019 to 2021 were compared with a historical control-matched group of infants who underwent open repair (OPEN) from 2017 to 2021. We assessed the patients' characteristics, anesthesia, and surgical data as well as intra- and postoperative complications. RESULTS A total of 87 infants were included (LAP n = 29, OPEN n = 58). Caudal anesthesia with spontaneous respiration was feasible in 62.1% of cases (LAP n = 55.2%, OPEN n = 65.5%; nonsignificant). Neither group registered anesthetic intra- or postoperative complications. Sedatives were utilized in 97% of LAP patients versus 56.9% of OPEN patients (p < 0.00001). The airway was secured with a laryngeal mask in 89.7% of patients during LAP versus 41.4% during OPEN (p < 0.00001). No significant differences were found regarding the use frequency of opioids (48.3% LAP vs. 34.5% OPEN; nonsignificant) or neuromuscular blockers (6.9% LAP vs. 5.2% OPEN; nonsignificant). CONCLUSION This is the first comparative study on caudal anesthesia and spontaneous respiration in infants undergoing laparoscopic versus open inguinal hernia surgery. Laparoscopy increased the need for ventilatory support and sedatives but did not significantly impair the feasibility of caudal anesthesia and spontaneous respiration.
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Affiliation(s)
- Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Christiane Beck
- Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Oliver Keil
- Clinic for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | | | - Benno Manfred Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
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Derbyshire MC, Grant HM, Lam A, Banever GT, Brocks R, Pepper VK, Tashjian DB, Moriarty KP, Tirabassi MV. Subcutaneous Endoscopic-Assisted Ligation of the Internal Ring for Inguinal Hernia Repair in Neonates Under Spinal Anesthesia. J Laparoendosc Adv Surg Tech A 2022; 32:561-565. [PMID: 35501952 DOI: 10.1089/lap.2021.0624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: While laparoscopy is now widely accepted for inguinal hernia repair in infants, it traditionally has required general anesthesia. We sought to evaluate the safety of laparoscopic inguinal hernia repair in infants under spinal anesthesia. Materials and Methods: We performed a retrospective cohort study of all inguinal hernia repairs at a single institution between December 2011 and June 2019 in patients younger than 6 months of age. Four groups were compared: laparoscopic under general anesthesia, laparoscopic with spinal anesthesia, open with spinal anesthesia, and open under general anesthesia. Main outcome measures include operative time, cost, and postoperative outcomes. These were assessed using Kruskal-Wallis median comparison. Results: Of the 226 patients meeting inclusion criteria, 54% (122/226) of patients underwent general anesthesia, while 46% (104/226) had spinal. When compared to general anesthesia, spinal anesthesia was associated with significantly shorter procedure times (P < .01) and lower cost (P < .01) for both open and laparoscopic approaches. Complications were few and underpowered to calculate significance across each group. Conclusions: Laparoscopic inguinal hernia repair can be safely performed in infants under spinal anesthesia without significant compromise of early perioperative outcomes. Advantages may include shorter procedure time and lower cost.
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Affiliation(s)
- Meagan C Derbyshire
- Department of Surgery, UMass Medical School - Baystate, Springfield, Massachusetts, USA
| | - Heather M Grant
- Department of Surgery, UMass Medical School - Baystate, Springfield, Massachusetts, USA.,Department of Surgery, Institute for Healthcare Delivery and Population Science, UMass Medical School - Baystate, Springfield, Massachusetts, USA
| | - Antonio Lam
- Department of Surgery, UMass Medical School - Baystate, Springfield, Massachusetts, USA
| | - Gregory T Banever
- Department of Surgery, UMass Medical School - Baystate, Springfield, Massachusetts, USA.,Department of Surgery, Baystate Children's Hospital, Springfield, Massachusetts, USA
| | - Rebecca Brocks
- Department of Pediatric Surgery and Liver Transplantation, CHU Sainte-Justine, Montreal, Canada
| | - Victoria K Pepper
- Department of Surgery, Baystate Children's Hospital, Springfield, Massachusetts, USA
| | - David B Tashjian
- Department of Surgery, UMass Medical School - Baystate, Springfield, Massachusetts, USA.,Department of Surgery, Baystate Children's Hospital, Springfield, Massachusetts, USA
| | - Kevin P Moriarty
- Department of Surgery, UMass Medical School - Baystate, Springfield, Massachusetts, USA.,Department of Surgery, Baystate Children's Hospital, Springfield, Massachusetts, USA
| | - Michael V Tirabassi
- Department of Surgery, UMass Medical School - Baystate, Springfield, Massachusetts, USA.,Department of Surgery, Baystate Children's Hospital, Springfield, Massachusetts, USA
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Grabowski J, Goldin A, Arthur LG, Beres AL, Guner YS, Hu YY, Kawaguchi AL, Kelley-Quon LI, McAteer JP, Miniati D, Renaud EJ, Ricca R, Slidell MB, Smith CA, Sola JE, Sømme S, Downard CD, Gosain A, Valusek P, St Peter SD, Jagannathan N'S, Dasgupta R. The effects of early anesthesia on neurodevelopment: A systematic review. J Pediatr Surg 2021; 56:851-861. [PMID: 33509654 DOI: 10.1016/j.jpedsurg.2021.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is growing concern regarding the impact of general anesthesia on neurodevelopment in children. Pre-clinical animal studies have linked anesthetic exposure to abnormal central nervous system development, but it is unclear whether these results translate into humans. The purpose of this systematic review from the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice (OEBP) Committee was to review, summarize, and evaluate the evidence regarding the neurodevelopmental impact of general anesthesia on children and identify factors that may affect the risk of neurotoxicity. METHODS Medline, Cochrane, Embase, Web of Science, and Scopus databases were queried for articles published up to and including December 2017 using the search terms "general anesthesia and neurodevelopment" as well as specific anesthetic agents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to screen manuscripts for inclusion in the review. A consensus statement of recommendations in response to each study question was synthesized based upon the best available evidence. RESULTS In total, 493 titles were initially identified, with 56 articles selected for full analysis and 44 included for review. Based on currently available developmental assessment tools, a single exposure to general anesthesia does not appear to have a significant effect on general neurodevelopment, although prolonged or multiple anesthetic exposures may have some adverse effects. Exposure to general anesthesia may affect different domains of development at different ages. Regional anesthetic techniques with the addition of dexmedetomidine and/or some intravenous agents may mitigate the risks of neurotoxicity. This approach may be performed safely in some patients and can be considered as an option in selected short procedures. CONCLUSION There is no conclusive evidence that a single short anesthetic in infancy has a detectable neurodevelopmental effect. Data do not support waiting until later in childhood to perform general anesthesia for single short procedures. With the complexities and nuances of different anesthetic methods, patients and procedures, the planning and execution of anesthesia for the pediatric patient is generally best accomplished by an anesthesiologist, ideally a pediatric anesthesiologist. TYPE OF STUDY Systematic review of level 1-4 studies. LEVEL OF EVIDENCE Level 1-4 (mainly level 3-4).
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Affiliation(s)
- Julia Grabowski
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University, 225 E. Chicago, Box 63, Chicago, IL 60611, United States.
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, United States
| | - L Grier Arthur
- Division of Minimally Invasive, Thoracic and General Surgery, St. Christopher's Hospital for Children, Philadelphia, PA, United States
| | - Alana L Beres
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California, Davis. Sacramento, CA, United States
| | - Yigit S Guner
- Department of Surgery, Children's Hospital of Orange County Division of Pediatric Surgery, University of California, Irvine, United States
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University, 225 E. Chicago, Box 63, Chicago, IL 60611, United States
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, Mc Govern Medical School at the University of Texas HSC, Houston, TX, United States
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States; Department of Preventive Medicine, University of Southern California Los Angeles, CA, United States
| | | | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children's Center, Roseville, CA, United States
| | - Elizabeth J Renaud
- Division of Pediatric Surgery, Hasbro Children's Hospital, Alpert Medical School at Brown University, Providence, RI, United States
| | - Robert Ricca
- Division of Pediatric Surgery, Naval Medical Center Portsmouth, VA, United States
| | - Mark B Slidell
- Section of Pediatric Surgery, Comer Children's Hospital, The University of Chicago Medicine, Chicago, IL, United States
| | - Caitlin A Smith
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, United States
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Stig Sømme
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY, United States
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States; Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, United States
| | - Patricia Valusek
- Pediatric Surgical Associates, Ltd., Children's Minnesota, United States
| | | | - Narasimhan 'Sim' Jagannathan
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL, United States
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
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Hannan MJ, Parveen MK, Nandy A, Hasan MS. Use of Spinal Anesthesia in Pediatric Laparoscopic Appendectomies: Case Series. JMIRX MED 2021; 2:e25204. [PMID: 37725540 PMCID: PMC10414511 DOI: 10.2196/25204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/04/2021] [Accepted: 03/25/2021] [Indexed: 09/21/2023]
Abstract
BACKGROUND Owing to the widespread use of general anesthesia, administration of spinal anesthesia in pediatric patients is not widely practiced. Yet there is ample positive evidence demonstrating its safety, effectiveness, and success. OBJECTIVE The objective of this study is to compare postoperative patient comfort, length of hospital stay, and cost-effectiveness of pediatric laparoscopic appendectomies performed under spinal and general anesthesia with the usual standard-of-care procedures employed in the hospital. METHODS This is a case series of 77 consecutive pediatric laparoscopic appendectomies (involving 5-8-year-old children) that took place in a hospital in Chittagong, Bangladesh, in 2019. A total of 40 patients underwent spinal anesthesia and 37 patients underwent general anesthesia. Variables such as surgery and operation theater times, pain score, incidence of postsurgery vomiting, analgesic usage, discharge times, and hospital costs were recorded. Statistical analysis was used to analyze the data as a function of anesthesia type. RESULTS The probability of vomiting when using spinal compared to general anesthesia was lower within the first 5 hours (P<.001) and 6 hours (P=.008) postoperation. A significant difference (P<.001) was observed between the total costs of the two procedures, with spinal anesthesia being less expensive. Patients were more likely to be discharged the same day of the procedure when spinal anesthesia was used (P=.008). CONCLUSIONS Spinal anesthesia has many advantages compared to general anesthesia for pediatric laparoscopic appendectomies. Patient comfort is improved due to a significant decrease in vomiting. This allows for more rapid hospital discharges and substantial cost savings, without compromising the outcome of the procedure.
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Affiliation(s)
- Md Jafrul Hannan
- Department of Pediatric Surgery, South Point Hospital, Chittagong, Bangladesh
| | | | - Alak Nandy
- Department of Anesthesiology, Chattagram Maa-O-Shishu Hospital Medical College, Chittagong, Bangladesh
| | - Md Samiul Hasan
- Department of Pediatric Surgery, Dhaka Shishu Hospital, Dhaka, Bangladesh
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Abstract
Neuraxial (spinal and epidural) anesthesia has become commonplace in the care of neonates undergoing surgical procedures. These techniques afford many benefits, and, when properly performed, are extremely safe. This article reviews the benefits, risks, and applications of neuraxial anesthesia in neonates.
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Abstract
Spinal anesthesia (SA) is a valuable alternative to general anesthesia in infants, but laparoscopic surgery is considered a contraindication in this age group. We report 3 cases of SA for inguinal hernia repairs. The contralateral inguinal region was explored by laparoscopic port placement and pneumoperitoneum through the surgical site. Ages ranged from 5 to 15 weeks, postconceptual age from 46 to 55 weeks, and weights from 4.0 to 6.6 kg. Spinal anesthetics were supplemented with intravenous dexmedetomidine. One patient experienced hypertension and tachycardia during insufflation with brief supplemental use of sevoflurane. Opioids were spared in 2 patients. Pain scores were low throughout. SA as a primary anesthetic may be used in pediatric laparoscopic procedures.
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Eizaga Rebollar R, García Palacios MV, Morales Guerrero J, Torres Morera LM. Spinal Anesthesia for Pediatric Laparoscopic Hernia Repair: A Case Report. A A Pract 2019; 11:293-295. [PMID: 29851688 DOI: 10.1213/xaa.0000000000000810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spinal anesthesia is practical and safe in infants and toddlers and prevents perioperative complications including cardiorespiratory instability and apnea. Other perioperative advantages include reduced time from surgery completion to operating room exit and first feed. This article presents the case of an ex-premature infant who underwent laparoscopic inguinal hernia repair under spinal anesthesia. The infant remained calm and stable throughout the uneventful procedure and postoperative period. Spinal anesthesia may be feasible for laparoscopic herniotomy when pneumoperitoneum pressure and operative time are restricted to 8 mm Hg and 60 minutes, respectively, with sensory level at T10 or higher.
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Affiliation(s)
- Ramón Eizaga Rebollar
- From the Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
| | | | - Javier Morales Guerrero
- From the Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
| | - Luis Miguel Torres Morera
- From the Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
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Cartabuke RS, Tobias JD, Rice J, Tumin D. Current perioperative care of infants with pyloric stenosis: comparison of survey results. J Surg Res 2018; 223:244-250.e3. [DOI: 10.1016/j.jss.2017.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/26/2017] [Accepted: 10/12/2017] [Indexed: 01/12/2023]
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Anesthesia for Hypertrophic Pyloric Stenosis. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pyloric Stenosis. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kamata M, Cartabuke RS, Tobias JD. Perioperative care of infants with pyloric stenosis. Paediatr Anaesth 2015; 25:1193-206. [PMID: 26490352 DOI: 10.1111/pan.12792] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2015] [Indexed: 11/28/2022]
Abstract
Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.
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Affiliation(s)
- Mineto Kamata
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard S Cartabuke
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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