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Okello I, Stephens CQ, Kakembo N, Kisa P, Nimanya S, Yap A, Wesonga AS, Naluyimbazi R, Kayima P, Ssewanyana Y, Ozgediz D, Sekabira J. Efforts to improve outcomes among neonates with complex intestinal atresia: a single-center low-income country experience. Pediatr Surg Int 2024; 40:70. [PMID: 38446259 PMCID: PMC10917857 DOI: 10.1007/s00383-024-05639-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Intestinal obstruction caused by intestinal atresia is a surgical emergency in newborns. Outcomes for the jejunal ileal atresia (JIA), the most common subtype of atresia in low-income countries (LIC), are poor. We sought to assess the impact of utilizing the Bishop-Koop (BK) approach to JIA in improving outcomes. METHODS A retrospective cohort study was performed on children with complex JIA (Type 2-4) treated at our national referral hospital from 1/2018 to 12/2022. BK was regularly used starting 1/1/2021, and outcomes between 1/2021 and 12/2022 were compared to those between 1/2018 and 12/2020. Statistical significance was set at p < 0.05. RESULTS A total of 122 neonates presented with JIA in 1/2018-12/2022, 83 of whom were treated for complex JIA. A significant decrease (p = 0.03) was noted in patient mortality in 2021 and 2022 (n = 33, 45.5% mortality) compared to 2018-2020 (n = 35, 71.4% mortality). This translated to a risk reduction of 0.64 (95% CI 0.41-0.98) with the increased use of BK. CONCLUSION Increased use of BK anastomoses with early enteral nutrition and decreased use of primary anastomosis improves outcomes for neonates with severe JIA in LIC settings. Implementing this surgical approach in LICs may help address the disparities in outcomes for children with JIA.
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Affiliation(s)
| | - Caroline Q Stephens
- Department of Surgery, Center for Health Equity and Anesthesia, University of California - San Francisco, San Francisco, USA.
| | - Nasser Kakembo
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Phyllis Kisa
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Ava Yap
- Department of Surgery, Center for Health Equity and Anesthesia, University of California - San Francisco, San Francisco, USA
| | | | | | - Peter Kayima
- Mulago National Referral Hospital, Kampala, Uganda
| | | | - Doruk Ozgediz
- Department of Surgery, Center for Health Equity and Anesthesia, University of California - San Francisco, San Francisco, USA
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Muacevic A, Adler JR. A Case of Jejunal Atresia Associated With Heterotrophic Pancreas and Meckel's Diverticulum. Cureus 2022; 14:e32766. [PMID: 36694481 PMCID: PMC9858787 DOI: 10.7759/cureus.32766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Apart from meconium ileus, amniotic fluid plug syndrome, malrotation of the gut, Hirschprung's disorder, trauma, and other rare causes, bowel atresia is one of the most common causes of bowel obstruction in newborns. Jejunal atresia can affect multiple lengths of the bowel. The higher the level of atresia, the greater the severity. The outcome of bowel atresia related to surgical repair is favorable. In general, both mortality and morbidity are affected by affiliated medical conditions such as preterm birth, cystic fibrosis, and other congenital anomalies; the sophistication of the lesion; and surgical complications. We present the case of a one-day-old baby who had two episodes of bilious vomiting with abdominal distension within 10 minutes of birth. The baby was advised to undergo ultrasonography of the abdomen and pelvis for further evaluation, and the findings were reported.
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Siyotula T, Arnold M. An analysis of neonatal mortality following gastro-intestinal and/or abdominal surgery in a tertiary hospital in South Africa. Pediatr Surg Int 2022; 38:721-729. [PMID: 35235014 DOI: 10.1007/s00383-022-05100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Thirty-day, 6-month and 12-month post-operative mortality and assessment of factors associated with 30 day post-operative mortality were ascertained. METHOD A retrospective medical record audit for neonates who underwent gastrointestinal or abdominal wall surgery within the neonatal period at a tertiary free standing paediatric hospital during the 12-year period from 1 January 2007 to 31 December 2018. RESULTS The 30-day post-operative mortality rate was 83/762 (11%). Mortality resulted from: sepsis (74%), palliation due to ultra-short bowel length (12%), ventilation-associated pneumonia (10%), associated congenital cardiac lesions (3%) and intestinal failure-associated liver disease (1%). Surgery for necrotizing enterocolitis had the greatest 30-day post-operative mortality (28%). Most neonates (69%) who died were prematurely born. Mean age at surgery was ten days and mean age at death was six days. Abdominal compartment syndrome was noted post operatively in 15% patients. Risk factors for sepsis included central line-associated bloodstream infections (65%), respiratory tract infections (41%) and surgical complications [anastomotic breakdown (7%) and wound infection (24%)]. Mortality in patients from referral hospitals more than an hour's drive away was high (15/39, 38%). CONCLUSION Mortality is double that of high-income countries, although significantly lower than most African settings. Strategic quality-improvement interventions are required to optimize outcomes.
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Affiliation(s)
- Thozama Siyotula
- Division of Paediatric Surgery at Red Cross War Memorial Children's Hospital, University of Cape Town, Klipfontein Rd, Rondebosch, Cape Town, 7700, South Africa.
| | - Marion Arnold
- Division of Paediatric Surgery at Red Cross War Memorial Children's Hospital, University of Cape Town, Klipfontein Rd, Rondebosch, Cape Town, 7700, South Africa
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Joda AE, Abdullah AF. Outcomes of end-to-side oblique anastomosis as a surgical technique for jejuno-ileal atresia. Updates Surg 2019; 71:587-593. [DOI: 10.1007/s13304-019-00666-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 06/22/2019] [Indexed: 10/26/2022]
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Sharma N, Memon MA, Sharma S, Sharma M, Chaurasia B, Verma SR. Transanastomotic tube in intestinal atresia: How beneficial are they? Afr J Paediatr Surg 2019; 16:29-32. [PMID: 32952137 PMCID: PMC7759087 DOI: 10.4103/ajps.ajps_101_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Intestinal atresia requires multiple surgeries and long hospital stay. We tried managing these cases by primary anastomosis with transanastomotic tube (TAT) for early feeding. AIMS The aim of the study was to analyse the outcomes in patients of intestinal atresia who underwent primary anastomosis with a TAT. MATERIALS AND METHODS The records between June 2014 and November 2017 were analysed. Those with incomplete data or unclear final outcome were excluded. Patients managed by primary anastomosis with TAT (Group A) or without TAT (Group B) were included. The TAT was kept for 6 weeks. Oral feeds were started after 2 weeks in all the cases. P < 0.05 was considered as statistically significant. RESULTS Forty-eight cases were included. There were two duodenal atresia, 29 jejunal atresia and 17 ileal atresia. The mean age at surgery was 2 days (range: 1-16 days). There were 42 cases in Group A (with TAT) and six in Group B (without TAT). The average duration of start of feeds was 78 h (range: 72-96 h) in Group A and 402 h (range: 360-504 h) in Group B (P = 0.01). The mean duration of hospital stay was 7 days (range: 5-15 days) and 27 days (range: 19-48 days) in Group A and B, respectively (P = 0.02). The overall survival was 38 (91%) and 3 (50%) in Group A and B, respectively (P = 0.01). Reexploration was required in 2/42 and 2/6 cases in Group A and B, respectively (P = 0.4). Total parental nutrition was required in 2/42 and all cases in Group A and B, respectively. CONCLUSION Primary repair in intestinal atresia with a TAT is a practical option. The overall outcome is better.
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Affiliation(s)
- Nitin Sharma
- Department of Paediatric Surgery, CM Hospital, Pt JNM Medical College and Associated Dr BRAM/DKS Hospital, Raipur, India
| | - M Amin Memon
- Department of Paediatric Sugery, Pt JNM Medical College and Associated Dr BRAM/DKS Hospital, Raipur, India
| | - Shipra Sharma
- Department of General Surgery, Pt JNM Medical College and BRAM Hospital, Raipur, India
| | - Mini Sharma
- Department of Community Medicine, Pt JNM Medical college, Raipur, India
| | - Basant Chaurasia
- Department of Anaesthesia, CM Hospital and Associated Medical College, Bhilai, Chhattisgarh, India
| | - Sewak Ram Verma
- Department of Anaesthesia, CM Hospital and Associated Medical College, Bhilai, Chhattisgarh, India
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Abstract
BACKGROUND Intestinal atresia is a common cause of neonatal intestinal obstruction. Previous reports from Nigeria have indicated a high mortality rate. This is a report of current outcome review from one tertiary center. PATIENTS AND METHODS A retrospective analysis of infants managed for jejunoileal atresia in 10 years (2005-2014). The information retrieved from patients' records was analyzed using SPSS 17. RESULTS There were 38 patients (19 boys and 19 girls) aged 1-28 days (median 4 days). Twenty-four patients (63.2%) presented after 48 h of life. Twenty-five (65.8%) had jejunal atresia and 13 (34.2%) had ileal atresia. Six patients had associated anomalies. The most common atresia was type III (39.5%, 15 patients). Twenty-eight (73.7%) patients had a resection of the atresia and anastomosis and others had enterostomies. Total parenteral nutrition and neonatal intensive care support were not available during the period of the study. Bowel function was established within 1 week and 27 (71.1%) patients commenced oral feeding. Twenty-six (68.4%) patients had postoperative complications resulting in prolonged hospital stay of 2-44 days (median = 13). Mortality was 34.2% (13 patients). Factors that significantly affected mortality were intestinal necrosis at presentation, postoperative complications, and severe malnutrition. CONCLUSION Intestinal atresia is still associated with unacceptably high morbidity and mortality, due to late presentation, and lack neonatal intensive care services and parenteral nutritional support. Efforts need to be intensified to address these factors to improve outcome.
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Affiliation(s)
- Tunde Talib Sholadoye
- Department of Surgery, Division of Paediatric Surgery, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria
| | - Philip Mari Mshelbwala
- Department of Surgery, Division of Paediatric Surgery, University of Abuja, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Emmanuel Adoyi Ameh
- Department of Surgery, Division of Paediatric Surgery, National Hospital, Abuja, Nigeria
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Ekenze SO, Modekwe VO, Ajuzieogu OV, Asinobi IO, Sanusi J. Neonatal surgery in a developing country: Outcome of co-ordinated interdisciplinary collaboration. J Paediatr Child Health 2017; 53:976-980. [PMID: 28600851 DOI: 10.1111/jpc.13610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 03/17/2017] [Accepted: 04/08/2017] [Indexed: 11/29/2022]
Abstract
AIM Neonatal surgery in low-income and middle-income countries has a poorer outcome when compared with high-income countries. This study evaluated the management challenges and outcomes of neonatal surgery before and after the introduction of focused interdisciplinary team management in 2013. METHODS We retrospectively analysed neonatal surgery undertaken at two referral hospitals in Enugu, south-eastern Nigeria from January 2011 to November 2015. Cases managed prior to July 2013 (group A) were compared with those managed from July 2013 (group B). RESULTS There were 91 cases (group A, 47; group B, 44). The common neonatal conditions were oesophageal atresia (21), anorectal malformation (18) and intestinal atresia (18). The surgical conditions, birthweight, age at presentation and associated anomalies did not differ in the two groups. The treatment was also similar except in oesophageal atresia, where cardiac banding was added to the temporary gastrostomy in late presenting cases with undernutrition in group B. Postoperative complications occurred in 43 (47.3%) cases (group A, 55.3%; group B, 38.6%; P > 0.05), and the overall mortality was 33 (35.3%: group A, 48.9%; group B, 22.7%: P < 0.05). Causes of mortality were unremitting sepsis (group A, 11; group B, 5), anaesthesia complications (group A, 5; group B, 0) and respiratory complication (group A, 7; group B, 5). Delayed presentation, inadequate facilities and defective health insurance scheme were challenges in the two groups. CONCLUSION Despite the persisting challenges, co-ordinated team management may result in the modest improvement of outcomes of neonatal surgery in our setting. Addressing these challenges may further improve outcomes.
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Affiliation(s)
- Sebastian O Ekenze
- Sub-Department of Paediatric Surgery, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Victor O Modekwe
- Sub-Department of Paediatric Surgery, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Obinna V Ajuzieogu
- Department of Anaesthesia, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Isaac O Asinobi
- Neonatology Unit, Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Jubril Sanusi
- Nursing Services Division, University of Nigeria Teaching Hospital, Enugu, Nigeria
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Cairo S, Kakembo N, Kisa P, Muzira A, Cheung M, Healy J, Ozgediz D, Sekabira J. Disparity in access and outcomes for emergency neonatal surgery: intestinal atresia in Kampala, Uganda. Pediatr Surg Int 2017; 33:907-915. [PMID: 28677072 DOI: 10.1007/s00383-017-4120-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND/AIM Intestinal atresia is one of the leading causes of neonatal intestinal obstruction (NIO). The purpose of this study was to analyze the presentation and outcome of IA and compare with those from both similar and high-income country settings. PATIENTS AND METHODS A retrospective review of prospectively collected data from patient charts and pediatric surgical database for 2012-2015 was performed. Epidemiological data and patient characteristics were analyzed and outcomes were compared with those reported in other LMICs and high-income countries (HICs). Unmet need was calculated along with economic valuation or economic burden of surgical disease. RESULTS Of 98 patients, 42.9% were male. 35 patients had duodenal atresia (DA), 60 had jejunio-ileal atresia (JIA), and 3 had colonic atresia. The mean age at presentation was 7.14 days for DA and 6.7 days for JIA. Average weight for DA and JIA was 2.2 and 2.12 kg, respectively. All patients with DA and colonic atresia underwent surgery, and 88.3% of patients with JIA had surgery. Overall mortality was 43% with the majority of deaths attributable to aspiration, anastomotic leak, and sepsis. 3304 DALYs were calculated as met compared to 25,577 DALYs' unmet. CONCLUSION Patients with IA in Uganda present late in the clinical course with high morbidity and mortality attributable to a combination of late presentation, poor nutrition status, surgical complications, and likely underreporting of associated anomalies rather than surgical morbidity alone. LEVEL OF EVIDENCE Level IV, Case series with no comparison group.
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Affiliation(s)
- Sarah Cairo
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA.
| | - Nasser Kakembo
- Department of Surgery, Mulago-Makerere University Teaching Hospital, Kampala, Uganda
| | - Phyllis Kisa
- Department of Surgery, Mulago-Makerere University Teaching Hospital, Kampala, Uganda
| | - Arlene Muzira
- Department of Surgery, Mulago-Makerere University Teaching Hospital, Kampala, Uganda
| | - Maija Cheung
- Department of Pediatric Surgery, Yale School of Medicine, New Haven, USA
| | - James Healy
- Department of Pediatric Surgery, Yale School of Medicine, New Haven, USA
| | - Doruk Ozgediz
- Department of Pediatric Surgery, Yale School of Medicine, New Haven, USA
- Global Partners in Anesthesia and Surgery (GPAS), Kampala, Uganda
| | - John Sekabira
- Department of Pediatric Surgery, Yale School of Medicine, New Haven, USA
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Ekenze SO, Ajuzieogu OV, Nwomeh BC. Challenges of management and outcome of neonatal surgery in Africa: a systematic review. Pediatr Surg Int 2016; 32:291-9. [PMID: 26783085 DOI: 10.1007/s00383-016-3861-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Disparity still exists in the outcome of neonatal surgery between high-income countries and low-income and middle-income countries. This study reviews publications on neonatal surgery in Africa over 20 years with a focus on challenges of management, trends in outcome, and potential interventions to improve outcome. METHODS We did a literature review by searching PubMed and African Index Medicus for original articles published in any language between January 1995 and September 2014. A data extraction sheet was used to collect information, including type of study, demographics, number of cases, outcome, challenges, and suggestions to improve outcome. RESULTS A total of 51 studies from 11 countries met the inclusion criteria. The 16 studies in the first 10 years (1995-2004; group A) were compared with the 35 in the last 10 years (2005-2014; group B). Nigeria (n = 32; 62.7 %), South Africa (n = 7; 13.7 %), Tanzania (n = 2; 3.9 %), and Tunisia (n = 2; 3.9 %) were the predominant sources of the publications, which were retrospective in 38 (74.5 %) studies and prospective in 13 (25.5 %) studies. The mean sample size of the studies was 95.1 (range 5-640). Overall, 4849 neonates were studied, with median age of 6 days (range 1-30 days). Common neonatal conditions reported were intestinal atresia in 28 (54.9 %) studies, abdominal wall defects in 27 (52.9 %), anorectal malformations 25 in (49.0 %), and Hirschsprung's disease, necrotising enterocolitis, and volvulus neonatorum in 23 (45.1 %) each. Mortality was lowest (<3 %) in spina bifida and facial cleft procedures, and highest (>50 %) in emergency neonatal surgeries involving bowel perforation, bowel resection, congenital diaphragmatic hernia, oesophageal atresia, and ruptured omphalocele or gastroschisis. Overall average mortality rate was higher in group A than group B (36.9 vs 29.1 %; p < 0.001), and varied between the groups for some conditions. The major documented challenges were delayed presentation and inadequate facilities in 39 (76.5 %) studies, dearth of trained support personnel in 32 (62.7 %), and absence of neonatal intensive care in 29 (56.9 %). The challenges varied from country to country but did not differ in the two groups. CONCLUSION Improvement has been achieved in outcomes of neonatal surgery in Africa in the past two decades, although several of the studies reviewed are retrospective and poorly designed. Cost effective adaptations for neonatal intensive care, improved health-care funding, coordinated neonatal surgical care via regional centres, and collaboration with international partners are potential interventions that could help to address the challenges and further improve outcome.
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Affiliation(s)
- Sebastian O Ekenze
- Sub-Department of Pediatric Surgery, College of Medicine, University of Nigeria, Enugu Campus, 400001, Enugu, Nigeria.
| | - Obinna V Ajuzieogu
- Department of Anesthesia, University of Nigeria Teaching Hospital, Enugu, Nigeria
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The Combination of Gastroschisis, Jejunal Atresia, and Colonic Atresia in a Newborn. Case Rep Pediatr 2015; 2015:129098. [PMID: 26180651 PMCID: PMC4477220 DOI: 10.1155/2015/129098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/29/2015] [Accepted: 05/30/2015] [Indexed: 11/17/2022] Open
Abstract
We encountered a rare case of gastroschisis associated with jejunal atresia and colonic atresia. In our case, the jejunal atresia was not discovered for 27 days after the initial abdominal wall closure. The colonic atresia was not discovered for 48 days after initial repair of the gastroschisis secondary to the rarity of the disorder. Both types of atresia were repaired with primary hand-sewn anastomoses. Other than the prolonged parenteral nutrition and hyperbilirubinemia, our patient did very well throughout his hospital course. Based on our case presentation, small bowel atresia and colonic atresia must be considered in patients who undergo abdominal wall closure for gastroschisis with prolonged symptoms suggestive of bowel obstruction. Our case report also demonstrates primary enteric anastomosis as a safe, well-tolerated surgical option for patients with types of intestinal atresia.
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Akkoyun I, Erdoğan D, Cavuşoğlu YH, Tütün O. What is Our Development Progress for the Treatment Outcome of Newborn with Intestinal Atresia and Stenosis in a Period of 28 Years? NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2013; 5:145-8. [PMID: 23641378 PMCID: PMC3624717 DOI: 10.4103/1947-2714.107539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Ibrahim Akkoyun
- Department of Pediatric Surgery, Dr. Faruk Sükan Maternity and Children Hospital Konya, Ankara, Turkey. E-mail:
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