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Oh GJ, Khalili A, Hammersmith KM, Nagra PK, Rapuano CJ, Syed ZA. Determinants of Clinical Outcomes After Infectious Scleritis. Cornea 2023:00003226-990000000-00360. [PMID: 37647147 DOI: 10.1097/ico.0000000000003373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE The aims of this study were to describe the clinical course of microbial infectious scleritis and identify factors associated with poor visual outcomes. METHODS Data from 26 eyes of 26 patients with culture-proven bacterial or fungal scleritis presenting at a single tertiary center from January 1, 2007, to July 1, 2021, were reviewed. Thirty-six variables were analyzed for associations with poor vision [best-corrected visual acuity (BCVA) <20/200] or loss of vision (no light perception vision or requirement for enucleation or evisceration) at final visit. RESULTS The mean age at initial presentation was 67.1 ± 14.0 (range: 34-92) years with a mean follow-up of 2.1 ± 2.2 (0.05-8.45) years. The mean presenting logarithm of minimal angle of resolution (logMAR) BCVA was 1.3 ± 1.0 (∼20/400) and mean final logMAR BCVA was 1.6 ± 1.2 (∼20/800). Fourteen eyes (53.8%) exhibited poor vision and 7 (26.9%) had loss of vision at final follow-up. History of necrotizing scleritis and poor presenting vision were associated with poor final vision (OR = 19.1; P = 0.017 and OR = 7.5; P = 0.047, respectively), whereas fungal scleritis was associated with loss of vision (odds ratio [OR] = 30.3, P = 0.013). Subconjunctival antimicrobial treatment was inversely associated with loss of vision (OR = 0.06, P = 0.023). There was no difference in vision between medical and combined medical-surgical management, although infection resolution time was shorter for combined intervention (16.8 ± 10.6 vs. 53.7 ± 33.8 days; P = 0.005). CONCLUSIONS Infectious scleritis is often successfully treated, but loss of vision or eye removal is common. Poor baseline vision, history of necrotizing scleritis, and fungal etiology were prognostic for worse clinical outcomes. Surgical intervention was associated with quicker resolution compared with medical treatment alone.
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Affiliation(s)
- Glenn J Oh
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Ashley Khalili
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
- Department of Ophthalmology, Northwell Health, Great Neck, NY
| | - Kristin M Hammersmith
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
| | - Parveen K Nagra
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
| | - Christopher J Rapuano
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
| | - Zeba A Syed
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Cornea Service, Wills Eye Hospital, Philadelphia, PA; and
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Dalal S, Murthy SI, Deogaokar K, Joseph J, Roy S. Successful Management of Extensively Drug Resistant Pseudomonas aeruginosa-Infectious Scleritis after Pterygium Surgery. Ocul Immunol Inflamm 2023:1-5. [PMID: 37433154 DOI: 10.1080/09273948.2023.2232037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/26/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION AND PURPOSE We report a case of extensively drug-resistant (XDR) Pseudomonas aeruginosa (PA) scleritis after pterygium surgery. METHODS Case report. RESULTS A 58-year-old farmer presented with a 40-day history of severe pain, swelling, and blurred vision after a pterygium excision was performed at another institute. The patient was on multiple medications with no relief. The examination showed a nasally located scleral thinning in his right eye, with ulceration and infiltrates. Microbiology revealed Pseudomonas aeruginosa, which showed intermediate sensitivity to colistin only. The patient was administered topical (0.19%) and intravenous colistin and dexamethasone. There was a rapid reduction in symptoms, and the lesions healed over the next 2 months. CONCLUSIONS To the best of our knowledge, this is the first case report of XDR-PA scleritis. We suggest the possibility of evolving drug resistance caused by the iatrogenic use of antibiotics during the early stages of the disease course.
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Affiliation(s)
- Samruddhi Dalal
- Cornea Service, The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Somasheila I Murthy
- Cornea Service, The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Ketan Deogaokar
- Cornea Service, The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Joveeta Joseph
- Jhaveri Microbiology Center, L. V. Prasad Eye Institute, Hyderabad, India
- The Ramoji Foundation Centre for Ocular Infections, L. V. Prasad Eye Institute, Hyderabad, India
| | - Sanhita Roy
- The Ramoji Foundation Centre for Ocular Infections, L. V. Prasad Eye Institute, Hyderabad, India
- Brien Holden Eye Research Centre, Hyderabad Eye Research Foundation, L V Prasad Eye Institute, Hyderabad, India
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Dutta Majumder P, Agarwal S, Shah M, Srinivasan B, K P, Iyer G, Sharma N, Biswas J, McCluskey P. Necrotizing Scleritis: A Review. Ocul Immunol Inflamm 2023:1-15. [PMID: 37279404 DOI: 10.1080/09273948.2023.2206898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 06/08/2023]
Abstract
Necrotizing scleritis is the most destructive and vision-threatening form of scleritis. Necrotizing scleritis can occur in systemic autoimmune disorders and systemic vasculitis, as well as following microbial infection. Rheumatoid arthritis and granulomatosis with polyangiitis remain the commonest identifiable systemic diseases associated with necrotising scleritis. Pseudomonas species is the most common organism causing infectious necrotizing scleritis, with surgery the most common risk factor. Necrotizing scleritis has the highest rates of complications and is more prone to secondary glaucoma and cataract than other phenotypes of scleritis. The differentiation between non-infectious and infectious necrotizing scleritis is not always easy but is critical in the management of necrotizing scleritis. Non-infectious necrotizing scleritis requires aggressive treatment with combination immunosuppressive therapy. Infectious scleritis is often recalcitrant and difficult to control, requiring long-term antimicrobial therapy and surgical debridement with drainage and patch grafting due to deep-seated infection and the avascularity of the sclera.
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Affiliation(s)
| | - Shweta Agarwal
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Mauli Shah
- Department of Uvea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Bhaskar Srinivasan
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Priyadarshini K
- Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Geetha Iyer
- CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Namrata Sharma
- Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jyotirmay Biswas
- Department of Uvea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Peter McCluskey
- Save Sight Institute, The University of Sydney, Sydney, Australia
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Santos MC, Paley GL, El Sayyad F, Sollenberger EL, Huang AJW. Subconjunctival triamcinolone injection for infectious necrotizing scleritis. Ocul Surf 2022; 26:97-99. [PMID: 35952987 DOI: 10.1016/j.jtos.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/26/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Matthew C Santos
- John F. Hardesty Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, St. Louis, MO, United States
| | - Grace L Paley
- John F. Hardesty Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, St. Louis, MO, United States
| | - Fouad El Sayyad
- John F. Hardesty Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, St. Louis, MO, United States
| | - Eric L Sollenberger
- John F. Hardesty Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, St. Louis, MO, United States
| | - Andrew J W Huang
- John F. Hardesty Department of Ophthalmology & Visual Sciences, Washington University School of Medicine, St. Louis, MO, United States.
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Pseudomonas aeruginosa Scleritis following Pterygium Surgery with Mitomycin C or Beta Irradiation: Three-Case Report. Case Rep Ophthalmol Med 2022; 2022:8000944. [PMID: 35572053 PMCID: PMC9098351 DOI: 10.1155/2022/8000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/30/2022] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose To report three cases of culture-positive Pseudomonas aeruginosa scleritis following pterygium surgery. Patients and Methods. A retrospective study of all patients of Pseudomonas aeruginosa scleritis after pterygium surgery presented from May 2017 to May 2020 was performed. Patient demographics and clinical characteristics included age, gender, time between prior surgery and onset, adjunctive therapy, risk factors, initial visual acuity, final visual acuity, clinical features, medical treatment, and surgical intervention were analyzed. Results Three eyes of three patients with clinical characteristics and laboratory-confirmed Pseudomonas aeruginosa scleritis were identified. Two patients were related with mitomycin C application after pterygium surgery, and only one had beta irradiation. Antibiotic administration and scleral debridement were required in 3 patients. One eye was enucleated. Final visual outcomes of two patients were improved. Conclusions Pseudomonas aeruginosa scleritis after pterygium surgery is a crucial ophthalmic disease. An early diagnosis with a prompt intensive antibiotic treatment in combination with surgical interventions may improve visual outcome.
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Yu J, Syed ZA, Rapuano CJ. Infectious Scleritis: Pathophysiology, Diagnosis, and Management. Eye Contact Lens 2021; 47:434-441. [PMID: 34224444 DOI: 10.1097/icl.0000000000000813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Infectious scleritis (IS) is a rare and severe ocular disorder responsible for approximately 5%-15% of all scleritis cases. It is often associated with a poor prognosis due to its similar clinical presentation to autoimmune scleritis, resulting in a delayed diagnosis and treatment. Therefore, differentiating between infectious and noninfectious entities is critical. Several details extracted from the patient's history and clinical examination can raise suspicion for infection. The most common predisposing factor is previous ocular surgery, especially pterygium, cataract, and vitreoretinal surgeries. Ocular trauma, poor contact lens hygiene, "eye-whitening" procedures, and subtenon triamcinolone injections have also been implicated. Clinical features of infection include the presence of scleral necrosis, hypopyon, unifocal or multifocal scleral abscesses, and mucopurulent discharge. Thorough diagnostic testing is essential before excluding infection as a possibility. Empiric broad-spectrum topical and systemic antibiotic therapy should be initiated while awaiting laboratory results and adjusted accordingly. Most IS cases require both aggressive medical and surgical treatment, and various studies have reported favorable outcomes with this combination. At this time, there is no consensus on the management of this severe ocular condition, and future studies are needed to establish clear treatment guidelines.
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Affiliation(s)
- Julia Yu
- Cornea Service, Wills Eye Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Kim SJ, Kim SH, Choi Y, Choi SK, Park SW, Byon IS, Lee JJ. Infectious Scleritis Featuring Kissing Choroidal Detachment and Serous Retinal Detachment. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2021. [DOI: 10.3341/jkos.2021.62.3.400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Syed ZA, Rapuano CJ. Umbilical amnion and amniotic membrane transplantation for infectious scleritis and scleral melt: A case series. Am J Ophthalmol Case Rep 2021; 21:101013. [PMID: 33553804 PMCID: PMC7848434 DOI: 10.1016/j.ajoc.2021.101013] [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: 06/16/2020] [Revised: 10/13/2020] [Accepted: 01/11/2021] [Indexed: 01/04/2023] Open
Abstract
Purpose To report the outcomes of two cases of infectious scleritis with severe scleral thinning managed using combined mechanical debridement, cryopreserved umbilical amnion (UA) and amniotic membrane (AM) grafts, and antimicrobial therapy. Observations Two patients presented with severe infectious scleritis with progressive scleral melts secondary to Pseudomonas aeruginosa subsequent to pterygium surgery and intravitreal injection, respectively. Surgical debridement was followed by UA grafting, AM transplantation, and antimicrobial therapy. Epithelialization and vascularization were seen within 1-4 weeks post-operatively. At last follow up of 5-6 months, the structural integrity of the sclera remained preserved with no infection recurrence, graft necrosis, or wound dehiscence. Conclusions and importance This case series highlights the utilization of UA grafting along with AM transplantation and topical and systemic antibiotics to preserve the globe in cases of severe infectious scleritis.
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Affiliation(s)
- Zeba A Syed
- Cornea Service, Wills Eye Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher J Rapuano
- Cornea Service, Wills Eye Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Concha del Rio L, Ramirez-Dominguez C, Vanzzini-Zago V, Arellanes-Garcia L. Reply to editor comment on Alternaria chartarum sclerokeratouveitis: A new fungus cause. Taiwan J Ophthalmol 2021; 12:244-245. [PMID: 35813805 PMCID: PMC9262029 DOI: 10.4103/tjo.tjo_36_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/05/2021] [Indexed: 11/04/2022] Open
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Murthy SI, Sabhapandit S, Balamurugan S, Subramaniam P, Sainz-de-la-Maza M, Agarwal M, Parvesio C. Scleritis: Differentiating infectious from non-infectious entities. Indian J Ophthalmol 2020; 68:1818-1828. [PMID: 32823398 PMCID: PMC7690484 DOI: 10.4103/ijo.ijo_2032_20] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 12/04/2022] Open
Abstract
Scleritis is a rare painful ocular disorder, associated with severe ocular pain and tissue destruction. Although a majority of these cases are immune mediated and at least half of these are associated with systemic immune-mediated diseases, a smaller minority are due to infections of the sclera. The two conditions closely mimic each other, and a thorough knowledge of the subtle differences is necessary in order to reach a timely diagnosis. Diagnostic delay can lead to a poor outcome both due to the destruction caused by the uncontrolled infection and also due to propagation of the infection with the use of corticosteroids which may have been started for presumed immune mediated scleritis. In this review, we present the clinical features, etiological agents, and the differentiating features between immune and infectious scleritis. We also present diagnostic and management guidelines for managing scleral infection.
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Affiliation(s)
| | | | - S Balamurugan
- Department of Uvea, Aravind Eye Hospital, Pondicherry, India
| | | | | | | | - Carlos Parvesio
- Consultant Ophthalmologist, Moorfields Eye Hospital, Senior Lecturer, Biomedical Research Centre, Institute of Ophthalmology UCL Moorfields Eye Hospital, London, United Kingdom
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Concha Del Río LE, Ramirez-Dominguez C, Vanzzini-Zago V, Arellanes-Garcia L. Alternaria chartarum sclerokeratouveitis: A new fungus cause. Taiwan J Ophthalmol 2020; 11:190-192. [PMID: 34295628 PMCID: PMC8259522 DOI: 10.4103/tjo.tjo_17_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 02/10/2020] [Indexed: 11/16/2022] Open
Abstract
We report a case of Alternaria chartarum sclerokeratouveitis with an unfavorable response to treatment. To the best of our knowledge, there are no previous reports of this fungus invading the sclera. A 68-year-old diabetic farmer male patient presented with a 3-week history of pain and redness and a decrease in visual acuity occurring 5 days before admittance in the right eye. Examination revealed severe mixed hyperemia and a scleral calcified plaque with a surrounding area of ischemia and lysis. The cornea showed diffuse infiltrates, stromal edema, and hypopyon. Initial scrapings were negative, and empiric antibiotics were started. After a fungus was reported, topical and systemic antifungals were initiated, but there was no clinical response. The eye was enucleated. A slow-growing fungus A. chartarum, resistant to voriconazole, was isolated. Fungal etiology must be kept in mind when dealing with infectious scleritis. Despite treatment, the outcome of this case was unfavorable due to the slow-growing nature of the fungus and this strain's resistance to voriconazole.
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Affiliation(s)
- Luz Elena Concha Del Río
- Inflammatory Eye Diseases Clinic, Hospital Dr. Luis Sánchez Bulnes, Asociación Para Evitar La Ceguera En México, Mexico City, Mexico
| | - Carolina Ramirez-Dominguez
- Inflammatory Eye Diseases Clinic, Hospital Dr. Luis Sánchez Bulnes, Asociación Para Evitar La Ceguera En México, Mexico City, Mexico
| | - Virginia Vanzzini-Zago
- Inflammatory Eye Diseases Clinic, Hospital Dr. Luis Sánchez Bulnes, Asociación Para Evitar La Ceguera En México, Mexico City, Mexico
| | - Lourdes Arellanes-Garcia
- Department of Microbiology, Hospital Dr. Luis Sánchez Bulnes, Asociación Para Evitar La Ceguera En México, Mexico City, Mexico
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Park MH, Yoo WS, Kim HA, Chung I, Seo SW, Kim SJ. Clinical Features and Treatment Outcomes in Patients with Infectious Scleritis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.6.510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mi-Hwa Park
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
| | - Woong-Sun Yoo
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
| | - Hyun-A Kim
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
| | - Inyoung Chung
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
| | - Seong-Wook Seo
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
| | - Seong-Jae Kim
- Department of Ophthalmology, College of Medicine, Gyeongsang National University, Jinju, Korea
- Department of Ophthalmology, Gyeongsang National University Hospital, Jinju, Korea
- Health Science Institute, Gyeongsang National University, Jinju, Korea
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