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O'Hara J, Douglas C, Powell S, Wilson J. Tonsillectomy for recurrent tonsillitis: the NATTINA trial - Authors' reply. Lancet 2024; 403:1634. [PMID: 38677858 DOI: 10.1016/s0140-6736(24)00187-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/29/2024] [Indexed: 04/29/2024]
Affiliation(s)
- James O'Hara
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne NE2 4AX, UK; Department of Otolaryngology-Head and Neck Surgery, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK. james.o'
| | - Catriona Douglas
- Department of Otolaryngology-Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Steven Powell
- Department of Otolaryngology-Head and Neck Surgery, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Janet Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne NE2 4AX, UK
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Denton O, Wan Y, Beattie L, Jack T, McGoldrick P, McAllister H, Mullan C, Douglas CM, Shu W. Understanding the Role of Biofilms in Acute Recurrent Tonsillitis through 3D Bioprinting of a Novel Gelatin-PEGDA Hydrogel. Bioengineering (Basel) 2024; 11:202. [PMID: 38534476 DOI: 10.3390/bioengineering11030202] [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: 01/05/2024] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 03/28/2024] Open
Abstract
Acute recurrent tonsillitis is a chronic, biofilm-related infection that is a significant burden to patients and healthcare systems. It is often treated with repeated courses of antibiotics, which contributes to antimicrobial resistance. Studying biofilms is key to understanding this disease. In vitro modelling using 3D bioprinted hydrogels is a promising approach to achieve this. A novel gelatin-PEGDA pseudomonas fluorescens-laden bioink was developed and bioprinted in a 3D hydrogel construct fabricated using computer-aided design to mimic the tonsillar biofilm environment. The bioprinted constructs were cultured at 37 °C in lysogeny broth for 12 days. Bacterial growth was assessed by spectrophotometry. Cellular viability analysis was conducted using optical fluorescence microscopy (FDA/PI staining). A biocompatible 3D-printed bacteria-laden hydrogel construct was successfully fabricated. Bacterial growth was observed using optical fluorescence microscopy. A live/dead cellular-staining protocol demonstrated bacterial viability. Results obtained after the 12-day culture period showed higher bacterial growth in the 1% gelatin concentration construct compared to the 0% control. This study demonstrates the first use of a bacteria-laden gelatin-PEGDA hydrogel for biofabrication of a 3D-printed construct designed to model acute recurrent tonsillitis. Initiating a study with clinically relevant ex vivo tonsil bacteria will be an important next step in improving treatment of this impactful but understudied disease.
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Affiliation(s)
- Oliver Denton
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1XQ, UK
- Department of Otolaryngology/ENT Surgery, NHS Greater Glasgow and Clyde, Glasgow G51 4TF, UK
- Department of Medicine, University of Glasgow, Glasgow G12 8QQ, UK
| | - Yifei Wan
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1XQ, UK
| | - Laura Beattie
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1XQ, UK
| | - Téa Jack
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1XQ, UK
| | - Preston McGoldrick
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1XQ, UK
| | - Holly McAllister
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1XQ, UK
| | - Cara Mullan
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1XQ, UK
| | - Catriona M Douglas
- Department of Otolaryngology/ENT Surgery, NHS Greater Glasgow and Clyde, Glasgow G51 4TF, UK
- Department of Medicine, University of Glasgow, Glasgow G12 8QQ, UK
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK
| | - Wenmiao Shu
- Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1XQ, UK
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Richard K, Sanchez R, Amado B, Lubner R, Niconchuk J, Chen H, Phillips J, Kynes M, Belcher RH. Pediatric Otolaryngology Short-Term Mission Outcomes at a Surgical Mission Hospital in Guatemala. Otolaryngol Head Neck Surg 2024; 170:252-259. [PMID: 37466003 DOI: 10.1002/ohn.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/09/2023] [Accepted: 07/03/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE The frequency of humanitarian surgical mission trips has grown over recent decades. Unfortunately, research on patient outcomes from these trips has not increased proportionately. We aim to analyze the safety and efficacy of surgeries in a low- and middle-income country missions-based surgery center in Guatemala City, Guatemala, and identify factors that influence surgical outcomes. STUDY DESIGN Retrospective cohort study. SETTING Guatemalan surgery center is called the Moore Center. METHODS Pediatric patients underwent otolaryngology surgery between 2017 and 2019. All patients required follow up. We analyzed the effect of patient, surgical, and geographic factors on follow up and complications with univariate and multivariate analyses. RESULTS A total of 1094 otolaryngologic surgeries were performed between 2017 to 2019, which comprised 37.4% adenotonsillectomies, 26.8% cleft lip (CL)/cleft palate (CP) repairs, 13.6% otologic, and 20% "other" surgeries. Patients traveled on average 88 km to the center (±164 km). Eighty-nine percent attended their first follow up and 55% attended their second. The 11% who missed their first follow up lived farther from the center (p < .001) and had a higher ASA classification (p < .001) than the 89% who did attend. Sixty-nine (6.3%) patients had 1 or more complications. CL/CP surgery was associated with more complications than other procedures (p < .001). Of 416 tonsillectomies, 4 patients (1%) had a bleeding episode with 2 requiring reoperation. CONCLUSION This surgical center models effective surgical care in low-resource areas. Complications and follow-up length vary by diagnosis. Areas to improve include retaining complex patients for follow up and reducing complications for CL/CP repair.
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Affiliation(s)
- Kelsey Richard
- Medical Doctorate Program, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Barbara Amado
- Centro Quirugico Pediatrico Moore, Guatemala City, Guatemala
| | - Rory Lubner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Niconchuk
- Department of Anesthesia, Pediatric Division, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James Phillips
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Vanderbilt Children's Hospital, Nashville, Tennessee, USA
| | - Matthew Kynes
- Department of Anesthesia, Pediatric Division, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan H Belcher
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Vanderbilt Children's Hospital, Nashville, Tennessee, USA
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Wilson JA, Fouweather T, Stocken DD, Homer T, Haighton C, Rousseau N, O'Hara J, Vale L, Wilson R, Carnell S, Wilkes S, Morrison J, Ah-See K, Carrie S, Hopkins C, Howe N, Hussain M, Lindley L, MacKenzie K, McSweeney L, Mehanna H, Raine C, Whelan RS, Sullivan F, von Wilamowitz-Moellendorff A, Teare D. Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation. Health Technol Assess 2023; 27:1-195. [PMID: 38204203 PMCID: PMC11017150 DOI: 10.3310/ykur3660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Background The place of tonsillectomy in the management of sore throat in adults remains uncertain. Objectives To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways. Design This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation. Setting The study took place at 27 NHS secondary care hospitals in Great Britain. Participants A total of 453 eligible participants with recurrent sore throats were recruited to the main trial. Interventions Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity. Main outcome measures The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms. Results There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it. Limitations The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial. Conclusions The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective. Trial registration This trial is registered as ISRCTN55284102. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Janet A Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Haighton
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - James O'Hara
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Wilson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | | | - Kim Ah-See
- Department of Otolaryngology Head and Neck Surgery, NHS Grampian, Aberdeen, UK
| | - Sean Carrie
- Ear, Nose and Throat Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Claire Hopkins
- Ear, Nose and Throat and Head and Neck Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicola Howe
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Kenneth MacKenzie
- Department of Ear, Nose and Throat Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Lorraine McSweeney
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | - Christopher Raine
- Ear, Nose and Throat Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ruby Smith Whelan
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Frank Sullivan
- Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews, UK
| | | | - Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Reference rate for post-tonsillectomy haemorrhage in Australia—A 2000–2020 national hospital morbidity database analysis. PLoS One 2022; 17:e0273320. [PMID: 36006990 PMCID: PMC9409536 DOI: 10.1371/journal.pone.0273320] [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: 04/07/2022] [Accepted: 08/06/2022] [Indexed: 11/19/2022] Open
Abstract
This study aims to provide a national benchmark rate of post-tonsillectomy haemorrhage (PTH) in Australia. Using data from Australia’s National Hospital Morbidity Database (NHMD) from 1 July 2000 to 30 June 2020, we have conducted a nation-wide population-based study to estimate a reference rate of PTH. Outcomes of interest included the overall rate and time-trend of PTH, the relationship between PTH rates with age and gender as well as the epidemiology of tonsillectomy procedures. A total of 941,557 tonsillectomy procedures and 15,391 PTH episodes were recorded for the study period. Whilst the incidence of tonsillectomy procedures and the number of day-stay tonsillectomy procedures have increased substantially over time, the overall rate of PTH for all ages has remained relatively constant (1.6% [95% CI: 1.61 to 1.66]) with no significant association observed between the annual rates of PTH and time (year) (Spearman correlation coefficient, Rs = 0.24 (95% CI: -0.22 to 0.61), P = 0.3). However, the rate of PTH in adults (aged 15 years and over) experienced a statistically significant mild to moderate upward association with time (year) Rs = 0.64 (95% CI: 0.28 to 0.84), P = 0.003. Analysis of the odds of PTH using the risk factors of increasing age and male gender showed a unique age and gender risk pattern for PTH where males aged 20 to 24 years had the highest risk of PTH odds ratio 7.3 (95% CI: 6.7 to 7.8) compared to patients aged 1 to 4 years. Clinicians should be mindful of the greater risk of PTH in male adolescents and young adults. The NHMD datasets can be continually used to evaluate the benchmark PTH rate in Australia and to facilitate tonsillectomy surgical audit activities and quality improvement programs on a national basis.
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McLean JE, Hill CJ, Riddick JB, Folsom CR. Investigation of Adult Post-Tonsillectomy Hemorrhage Rates and the Impact of NSAID Use. Laryngoscope 2022; 132:949-953. [PMID: 34473351 DOI: 10.1002/lary.29844] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/14/2021] [Accepted: 08/20/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES/HYPOTHESIS Tonsillectomy is one of the most common ambulatory surgeries performed in the United States, yet the incidence of post-tonsillectomy hemorrhage (PTH) in adults remains unclear. In addition, any association between non-steroidal anti-inflammatory drugs (NSAIDs) and PTH in adults is currently unknown. The aim of this study is to examine the incidence and management of adult PTH at a single academic center and to assess for any association between NSAID use and PTH in adults. STUDY DESIGN Retrospective chart review. METHODS We conducted a retrospective chart review of adult tonsillectomies performed at our institution between January 1, 2012, and December 30, 2019. Demographics, past medical history, medications, NSAID use, surgical indication, bleeding events, and interventions were documented. The rate of PTH was calculated, logistic regression was performed to assess for any predictive factors, and odds ratios were calculated for NSAID use and PTH. RESULTS A total of 1,057 adult tonsillectomies were performed within the aforementioned time period. A total of 126 patients experienced 163 bleeding events for a postoperative hemorrhage rate of 11.9%. Most were controlled with bedside interventions, while 29 (23%) bled more than once. The hemorrhage rate for those who were not prescribed NSAIDs postoperatively (n = 625) was 11.7%, compared to 12.6% for those who did receive NSAIDs postoperatively (n = 432), which was not significantly different (adjusted odds ratio 1.01, 95% confidence interval 0.69-1.49; P = .95). CONCLUSIONS This retrospective cohort study of 1,057 adult patients found the incidence of PTH to be 11.9%. This study found no association between the use of NSAIDs and the rate of PTH, although a higher-powered study is needed. LEVEL OF EVIDENCE 3 Laryngoscope, 132:949-953, 2022.
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Affiliation(s)
- James E McLean
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Christopher J Hill
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Jeanelle B Riddick
- Clinical Investigations Department, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
| | - Craig R Folsom
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, U.S.A
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Should there be a body mass index eligibility cutoff for elective airway cases in an ambulatory surgery center? A retrospective analysis of adult patients undergoing outpatient tonsillectomy. J Clin Anesth 2021; 72:110306. [PMID: 33905901 DOI: 10.1016/j.jclinane.2021.110306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/30/2021] [Accepted: 04/18/2021] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVE It is unclear what the body mass index (BMI) should be when performing surgery involving the airway at an outpatient surgery facility. The objective of this study was to evaluate the association of Class 3 obesity versus a composite cohort of Class 1 and 2 obesity with same-day hospital admission following outpatient tonsillectomy in adults. DESIGN Retrospective cohort study. SETTING Multi-institutional. PATIENTS Patients undergoing outpatient tonsillectomy. INTERVENTION None. MEASUREMENTS We used the National Surgical Quality Improvement Program (NSQIP) to analyze association of BMI to same-day admission and 30-day readmission following outpatient tonsillectomy from 2017 to 2019. We looked at six BMI cohorts: 1) ≥30 and < 40 kg/m2 (reference cohort), 2) ≥20 and < 30 kg/m2, 3) <20 kg/m2, 4) ≥40 and < 50 kg/m2, 5) ≥50 and < 60 kg/m2, and 6) ≥60 kg/m2. We used multivariable Poisson regression with robust standard errors and controlled for various confounders to calculate risk ratios (RR) and 99% confidence intervals (CI). MAIN RESULTS There were 12,287 patients included in the final analysis, at which 697 (5.7%) and 283 (2.3%) had a same-day admission or 30-day readmission, respectively. On Poisson regression with robust standard errors, the relative risks for BMI ≥40 kg/m2 and < 50 kg/m2, ≥50 kg/m2 and < 60 kg/m2, and ≥ 60 kg/m2 (BMI ≥30 kg/m2 and < 40 kg/m2 was the reference group) were 1.31 (99% CI 1.03-1.65, p = 0.03), 1.99 (99% CI 1.43-2.78, p = 0.002), and 1.80 (99% CI 1.00-3.25, p = 0.07), respectively. Furthermore, Class 3 obesity was not associated with 30-day readmission. CONCLUSION These results contribute data that may help practices - especially freestanding ambulatory surgery centers - decide appropriate BMI cutoffs for surgery involving the airway. Whether this is considered clinically significant enough to rule out eligibility will differ from practice-to-practice and will depend on surgical volume, resources available and financial interests.
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