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Reyna-Villasmil E, Briceño-Pérez C, Briceño-Sanabria JC. Ultrasonographic Diagnosis of Twin-to-Twin Transfusion Syndrome. Am J Perinatol 2024; 41:531-538. [PMID: 35263768 DOI: 10.1055/s-0042-1744259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Twin-twin transfusion syndrome (TTTS) is a typical complication of monochorionic twin pregnancies (MCTP). Placental vessels that communicate in the chorionic plate between donor and recipient, are responsible for the imbalance of blood flow. Circulatory imbalance causes hypovolemia in donor and hypervolemia in recipient fetus. In a typical case, recipient fetus develops polyhydramnios, weight gain, cardiomegaly and hydrops fetalis. In contrast, donor fetus develops oligohydramnios and fetal growth restriction. AIM The objective of this review is to evaluate in detail the main diagnostic aspects and add other important data for diagnosis of TTTS. SCIENTIFIC BASES The main diagnostic event for this condition is based on the ultrasonographic discovery of oligohydramnios-polyhydramnios sequence. Other useful elements for diagnosis, staging and prognosis are fetal urinary bladder visualization, urinary bladder volumen measurements, edema of subcutaneous and/or generalized tissue edema, Doppler flow velocity waves and cardiac evaluation. CONCLUSION Considerations regarding diagnosis of TTTS make it possible to emphasize that role of physicians treating patients with MCTP is to identify ultrasound sequence of oligohydramnios-polyhydramnios. Other ultrasonographic fetal data as fetal urinary bladder visualization, urinary bladder volumen measurements, edema of subcutaneous and/or generalized tissue edema, Doppler flow velocity waves and cardiac evaluation; may help diagnosis, staging and prognosis of TTTS. It is their responsibility to accurately assess severity, therapeutic possibilities and prognosis. KEY POINTS · The role of physicians treating patients with MCTP, regarding diagnosis of TTTS, must be to identify ultrasound sequence of oligohydramnios-polyhydramnios.. · Other ultrasonographic fetal data may help diagnosis, staging, and prognosis of TTTS as follows: fetal urinary bladder visualization, urinary bladder volume measurements, edema of subcutaneous and/or generalized tissue edema, Doppler flow velocity waves, and cardiac evaluation.. · It is physicians' responsibility to accurately assess severity, therapeutic possibilities, and prognosis of patients with MCTP and diagnosis of TTTS..
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Yan S, Wang Y, Chen Z, Zhang F. Chorionicity and neurodevelopmental outcomes in twin pregnancy: a systematic review and meta-analysis. J Perinatol 2023; 43:133-146. [PMID: 36333420 DOI: 10.1038/s41372-022-01534-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Through a systematic review and meta-analyses, we aimed to analyze the impact of chorionicity on neurodevelopment outcomes. STUDY DESIGN We conducted a comprehensive search strategy through Medline, Embase, Web of Science, and reference lists of the retrieved studies until August 2022. Studies that examined the association between chorionicity and children's neurodevelopment outcomes were included. RESULTS Twelve studies were included. Monochorionic (MC) twins increased the odds of neurodevelopment impairment, cerebral palsy compared to dichorionic (DC) twins. The differences in neurodevelopmental impairment and cerebral palsy between the two groups disappeared after excluding infants with twin-twin transfusion (TTTS). After fetoscopic laser surgery (FLS) for MC twins, there were no differences too. CONCLUSIONS Compared to DC twins, MC twins were associated with an increased risk of neurodevelopment impairment. MC twins complicated by TTTS were at high risk of neurologic disability, and FLS was an acceptable treatment modality for them.
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Affiliation(s)
- Shuhan Yan
- Medical College of Nantong University, Nantong City, Jiangsu Province, China
| | - Yuan Wang
- Medical College of Nantong University, Nantong City, Jiangsu Province, China
| | - Zhifang Chen
- Nantong Maternal and Child Health Hospital, Nantong City, Jiangsu Province, China
| | - Feng Zhang
- Medical College of Nantong University, Nantong City, Jiangsu Province, China.
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Mesbah N, Marsousi V, Eslamian L, Montazerlotfelahi H, Shamshirsaz AA, Hessami K, Jamal A, Noorzadeh M, Naemi M, Ghaemi M. Infantile neurodevelopmental outcome after fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome: the first prospective experience from Iran. BMC Pregnancy Childbirth 2022; 22:458. [PMID: 35650560 PMCID: PMC9158318 DOI: 10.1186/s12884-022-04793-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022] Open
Abstract
Objective We sought to evaluate the neurodevelopmental outcomes at 12 months of age among infants with twin-to-twin transfusion syndrome (TTTS) undergoing fetoscopic laser photocoagulation (FLP). Materials and methods In this prospective longitudinal study, neurodevelopmental assessment was performed among the infants at the corrected age of 12 months, who were diagnosed with TTTS and treated by FLP. The Ages and Stages Questionnaire (ASQ) was filled out by parents. In the next step in infants with abnormal ASQ, motor and cognitive developments were evaluated by Bayley’s infant and toddler development scoring system (Bayley 3-Third edition). Results In 39 FLP procedures the rate of live birth of at least one twin was 73.8%. Four neonatal deaths were recorded, three of which were due to prematurity and one was due to heart anomaly. The ASQ was normal in 89.7% (35/39) of the infants (group I), 5.1% (2/39) had minor neurodevelopmental impairment (NDI) (group II), and 5.1% (2/39) had major NDI (group III). The 4 infants with abnormal ASQ had Bayley examination which showed two with mild to moderate cerebral palsy and two had delayed verbal skills and autistic spectrum disorder. No significant difference was noted between survivors with and without NDI with respect to donor or recipient status, birth weight, gestational age at birth, Quintero stage of TTTS. In addition, the relationship between gestational age at the time of undergoing FLC and NDI was not significant. Conclusion In our population, minor and major neurodevelopmental impairment were seen in 10.2% of the infants. This information is useful for counseling our couples in this population prior the procedure.
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Affiliation(s)
- Nazila Mesbah
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Vajiheh Marsousi
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Laleh Eslamian
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hadi Montazerlotfelahi
- Department of Pediatrics, Imam Ali Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kamran Hessami
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ashraf Jamal
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Noorzadeh
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Naemi
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Marjan Ghaemi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Hessami K, Nassr AA, Sananès N, Castillo J, Castillo HA, Sanz Cortes M, Espinoza J, Donepudi RV, Sun RC, Krispin E, Belfort MA, Shamshirsaz AA. Perinatal risk factors of neurodevelopmental impairment after fetoscopic laser photocoagulation for twin-twin transfusion syndrome: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:658-668. [PMID: 34097320 DOI: 10.1002/uog.23706] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Monochorionic twins with twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) are at increased risk of neurodevelopmental impairment (NDI). This meta-analysis aimed to identify the prevalence of and perinatal risk factors for NDI in TTTS survivors treated with FLP. METHODS We performed a search in PubMed, EMBASE, Scopus and Web of Science, from inception to 13 February 2021, for studies evaluating perinatal risk factors for NDI in children diagnosed prenatally with TTTS managed by FLP. Data on severity of TTTS at the time of diagnosis, defined according to the Quintero staging system, FLP-related complications and perinatal outcomes were compared between children with a history of TTTS treated with FLP with and those without NDI, which was defined as performance on a cognitive or developmental assessment tool ≥ 2 SD below the mean or a defined motor or sensory disability. A random-effects model was used to pool the mean differences or odds ratios (OR) with the corresponding 95% CIs. Heterogeneity was assessed using the I2 statistic. RESULTS Nine studies with a total of 1499 TTTS survivors were included. The overall incidence of NDI was 14.0% (95% CI, 9.0-18.0%). The occurrence of NDI in TTTS survivors was associated with later gestational age (GA) at FLP (mean difference, 0.94 weeks (95% CI, 0.50-1.38 weeks); P < 0.0001, I2 = 0%), earlier GA at delivery (mean difference, -1.44 weeks (95% CI, -2.28 to -0.61 weeks); P = 0.0007, I2 = 49%) and lower birth weight (mean difference, -343.26 g (95% CI, -470.59 to -215.92 g); P < 0.00001, I2 = 27%). Evaluation of different GA cut-offs showed that preterm birth before 32 weeks was associated with higher risk for NDI later in childhood (OR, 2.25 (95% CI, 1.02-4.94); P = 0.04, I2 = 35%). No statistically significant difference was found between cases with and those without NDI with respect to Quintero stage of TTTS, recipient or donor status, development of postlaser twin anemia-polycythemia sequence, recurrence of TTTS and incidence of small- for-gestational age or cotwin fetal demise. CONCLUSIONS TTTS survivors with later GA at the time of FLP, earlier GA at delivery and lower birth weight are at higher risk of developing NDI. No significant association was found between Quintero stage of TTTS and risk of NDI. Our findings may be helpful for parental counseling and highlight the need for future studies to understand better the risk factors for NDI in TTTS survivors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K Hessami
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - N Sananès
- Department of Maternal-Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - J Castillo
- Department of Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - H A Castillo
- Department of Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - R V Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - R C Sun
- Doernbecher Children's Hospital, Oregon Health & Science University, Division of Pediatric Surgery, Portland, OR, USA
- Division of Pediatric Surgery, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - E Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Fetal Center, Houston, TX, USA
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Cunningham T, Anthony Canedo D, Ibanez D, Arroyo Papel L, Dungo N, Cordero A, Graves K. Perioperative Care of Patients Diagnosed With Twin-to-Twin Transfusion Syndrome Undergoing Laparoscopic-Assisted Fetoscopic Placental Laser Photocoagulation. AORN J 2021; 113:361-372. [PMID: 33788229 DOI: 10.1002/aorn.13354] [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: 11/14/2019] [Revised: 08/11/2020] [Accepted: 08/21/2020] [Indexed: 11/06/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a condition that results in unbalanced blood flow between two fetuses. Patients diagnosed with TTTS can experience maternal or fetal morbidity and mortality. Depending on the severity of TTTS, laser ablation of placental anastomoses may be the most effective treatment. The preferred treatment method requires percutaneous entry to the uterus; however, some patient circumstances (eg, placenta location) require a laparoscopic-assisted procedure. During the preoperative appointments, clinicians assess the condition of the fetuses and patients may participate in genetic counseling. Intraoperative care involves an interdisciplinary team that may include a pediatric general surgeon, maternal-fetal medicine specialists, an RN circulator, a scrub person, and an anesthesia professional. Perioperative nurses should have knowledge of the pathophysiology of TTTS, including its natural progression. They also should understand preoperative and intraoperative patient care requirements to provide safe and effective care for patients undergoing laparoscopic-assisted fetoscopic placental laser photocoagulation procedures.
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Abstract
With the increasing rate of twin pregnancies due to increase in maternal age and use of assisted reproduction, it is important to be aware of unique diseases which occur specifically to twin pregnancies, especially in monochorionic twin pregnancies. These entities include twin to twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion, cotwin demise, and conjoined twins. Early evaluation and documentation are imperative to guide management which ultimately leads to better patient outcomes.
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Twin-to-Twin Transfusion Syndrome: Diagnostic Imaging and Its Role in Staving Off Malpractice Charges and Litigation. Diagnostics (Basel) 2021; 11:diagnostics11030445. [PMID: 33806678 PMCID: PMC8002196 DOI: 10.3390/diagnostics11030445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
The study aims to expound upon the imaging-based diagnostic methodologies aimed at identifying twin-to-twin transfusion syndrome (TTTS), a serious, somewhat rare prenatal condition that takes place in pregnancies where identical twins, or other multiples, share a placenta (monochorionic placenta), highlighting how medico-legal outcomes can be affected by provable compliance with consolidated diagnostic guidelines or best practices. It is of utmost importance to produce a prompt identification of TTTS instances; an early diagnosis is in fact critical in order to effectively treat and manage TTTS. By virtue of TTTS being a highly progressive condition, a delay in diagnosis can result in disastrous outcomes; just a few weeks delay in the diagnosis of TTTS can turn out fatal for one or both twins. Hence, most TTTS malpractice claims involve allegations of medical negligence, namely the failure to recognize the condition in a timely fashion, or to proceed with adequate diagnostic and therapeutic pathways. In that regard, case law databases have been pored over (Justia, Lexis, Leagle), and five significant court cases have been examined and discussed in an attempt to identify objective medico-legal standards and bring to the forefront relevant forensic dynamics. In fact, when health professionals are capable of proving adherence to guidelines or best practices, this can shield them from malpractice allegations and ensuing litigation.
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Jha P, Morgan TA, Kennedy A. US Evaluation of Twin Pregnancies: Importance of Chorionicity and Amnionicity. Radiographics 2020; 39:2146-2166. [PMID: 31697621 DOI: 10.1148/rg.2019190042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Tara A Morgan
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
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Korček P, Širc J, Straňák Z. Cerebral oxygenation reflects fetal development in preterm monochorionic and dichorionic twins. Early Hum Dev 2020; 144:105025. [PMID: 32298945 DOI: 10.1016/j.earlhumdev.2020.105025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cerebral oxygenation (crSO2) monitoring is increasingly used in high-risk infants. Monochorionic twins suffer from specific fetal pathologies that can affect cerebral hemodynamics. Limited data are available on crSO2 and blood flow patterns in this population after birth. OBJECTIVE To evaluate crSO2 changes in preterm monochorionic and dichorionic twins during the first 72 h of life. METHODS Near-infrared spectroscopy was used to measure crSO2 in 62 infants from 31 twin pregnancies <32 weeks of gestation. The study group was divided into 4 subgroups: donor (1) and recipient (2) monochorionic twins (with twin-twin transfusion syndrome), fetal growth restriction (FGR) infants (3) and twins without fetal compromise (4). RESULTS There was significant difference in birth weight (p < 0.001) among 4 subgroups. We observed significant variation in crSO2 among the subgroups using mixed model analysis (p < 0.001). The recipient twins exhibited the lowest crSO2 (mean ± SE) throughout the study period (76 ± 0.3%), whereas the FGR and donor twins presented with the highest values (86 ± 0.3% and 83 ± 0.4% respectively). We found no statistically significant differences in neonatal mortality and morbidity among subgroups. CONCLUSION Our study revealed significant correlation between crSO2 values postnatally and underlying fetal pathology in monochorionic and dichorionic preterm twins.
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Affiliation(s)
- Peter Korček
- Institute for the Care of Mother and Child - Neonatology, Podolské nábřeží 157/36, Prague 14700, Czech Republic; 3rd Faculty of Medicine - Charles University, Ruská 2411/87, Prague 10000, Czech Republic.
| | - Jan Širc
- Institute for the Care of Mother and Child - Neonatology, Podolské nábřeží 157/36, Prague 14700, Czech Republic; 3rd Faculty of Medicine - Charles University, Ruská 2411/87, Prague 10000, Czech Republic
| | - Zbyněk Straňák
- Institute for the Care of Mother and Child - Neonatology, Podolské nábřeží 157/36, Prague 14700, Czech Republic; 3rd Faculty of Medicine - Charles University, Ruská 2411/87, Prague 10000, Czech Republic
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Inter-foetus Membrane Segmentation for TTTS Using Adversarial Networks. Ann Biomed Eng 2019; 48:848-859. [DOI: 10.1007/s10439-019-02424-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/23/2019] [Indexed: 12/18/2022]
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