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Bonvecchio E, Vailati D, Mura FD, Marino G. Nociception level index variations in ICU: curarized vs non-curarized patients - a pilot study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:57. [PMID: 39164731 PMCID: PMC11337812 DOI: 10.1186/s44158-024-00193-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 08/09/2024] [Indexed: 08/22/2024]
Abstract
PURPOSE Pain is a major physiological stressor that can worsen critical medical conditions in many ways. Currently, there is no reliable monitoring tool which is available for pain monitoring in the deeply sedated ± curarized critically ill patients. This study aims to assess the effectiveness of the multiparameter nociception index (NOL®) in the critical care setting. We compared NOL with traditionally used neurovegetative signs and examined its correlation with sedation depth measured by bispectral index (BIS®) electroencephalographic (EEG) monitoring. METHODS This retrospective monocentric cohort study was conducted in a general intensive care unit, including patients who required moderate-to-deep levels of sedation with or without continuous neuromuscular blockade. The performance of NOL was evaluated both in the entire studied population, as well as in two subgroups: curarized and non-curarized patients. RESULTS NOL demonstrated greater accuracy than all other indicators in pain detection in the overall population. In the non-curare subgroup, all indices correctly recognized painful stimulation, while in the patients subjected to neuromuscular blocking agent's infusion, only NOL properly identified nociception. In the former group, EEG's relation to nociception was on the border of statistical significance, whereas in the latter BIS showed no correlation with NOL. CONCLUSION NOL emerges as a promising device for pain assessment in the critical care setting and exhibits its best performance precisely in the clinical context where reliable pain assessment methods are most lacking. Furthermore, our research confirms the distinction between sedation and analgesia, highlighting the necessity for distinct monitoring instruments to accurately assess them.
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Affiliation(s)
- Emilio Bonvecchio
- ICU and Anaesthesia Department, Melegnano Hospital-ASST Melegnano and Martesana, Vizzolo Predabissi, Milan, Italy.
| | - Davide Vailati
- ICU and Anaesthesia Department, Melegnano Hospital-ASST Melegnano and Martesana, Vizzolo Predabissi, Milan, Italy
| | - Federica Della Mura
- ICU and Anaesthesia Department, Melegnano Hospital-ASST Melegnano and Martesana, Vizzolo Predabissi, Milan, Italy
| | - Giovanni Marino
- ICU and Anaesthesia Department, Melegnano Hospital-ASST Melegnano and Martesana, Vizzolo Predabissi, Milan, Italy
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Wang H, Wang Q, He Q, Li S, Zhao Y, Zuo Y. Current perioperative nociception monitoring and potential directions. Asian J Surg 2024; 47:2558-2565. [PMID: 38548545 DOI: 10.1016/j.asjsur.2024.03.090] [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: 12/08/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 06/05/2024] Open
Abstract
Perioperative nociception-antinociception balance is essential for the prevention of adverse postoperative events. Estimating the nociception level helps optimize intraoperative management. In the past two decades, various nociception monitoring devices have been developed for the identification of intraoperative nociception. However, each type of nociception monitoring device has advantages and disadvantages, limiting their clinical application in particular patients and settings. Therefore, this review aimed to summarize the information on nociceptor monitoring in current clinical settings, explore each technique's particularities, and possible future directions to provide a reference for clinicians and researchers.
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Affiliation(s)
- Haiyan Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, China
| | - Qifeng Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, China
| | - Qinqin He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, China
| | - Shikuo Li
- Department of Anesthesiology, Yan'an Hospital of Kunming City, Kunming Medical University, Kunming, Yunnan, China
| | - Yuyi Zhao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, China.
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Laferrière-Langlois P, Morisson L, Jeffries S, Duclos C, Espitalier F, Richebé P. Depth of Anesthesia and Nociception Monitoring: Current State and Vision For 2050. Anesth Analg 2024; 138:295-307. [PMID: 38215709 DOI: 10.1213/ane.0000000000006860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Anesthesia objectives have evolved into combining hypnosis, amnesia, analgesia, paralysis, and suppression of the sympathetic autonomic nervous system. Technological improvements have led to new monitoring strategies, aimed at translating a qualitative physiological state into quantitative metrics, but the optimal strategies for depth of anesthesia (DoA) and analgesia monitoring continue to stimulate debate. Historically, DoA monitoring used patient's movement as a surrogate of awareness. Pharmacokinetic models and metrics, including minimum alveolar concentration for inhaled anesthetics and target-controlled infusion models for intravenous anesthesia, provided further insights to clinicians, but electroencephalography and its derivatives (processed EEG; pEEG) offer the potential for personalization of anesthesia care. Current studies appear to affirm that pEEG monitoring decreases the quantity of anesthetics administered, diminishes postanesthesia care unit duration, and may reduce the occurrence of postoperative delirium (notwithstanding the difficulties of defining this condition). Major trials are underway to further elucidate the impact on postoperative cognitive dysfunction. In this manuscript, we discuss the Bispectral (BIS) index, Narcotrend monitor, Patient State Index, entropy-based monitoring, and Neurosense monitor, as well as middle latency evoked auditory potential, before exploring how these technologies could evolve in the upcoming years. In contrast to developments in pEEG monitors, nociception monitors remain by comparison underdeveloped and underutilized. Just as with anesthetic agents, excessive analgesia can lead to harmful side effects, whereas inadequate analgesia is associated with increased stress response, poorer hemodynamic conditions and coagulation, metabolic, and immune system dysregulation. Broadly, 3 distinct monitoring strategies have emerged: motor reflex, central nervous system, and autonomic nervous system monitoring. Generally, nociceptive monitors outperform basic clinical vital sign monitoring in reducing perioperative opioid use. This manuscript describes pupillometry, surgical pleth index, analgesia nociception index, and nociception level index, and suggest how future developments could impact their use. The final section of this review explores the profound implications of future monitoring technologies on anesthesiology practice and envisages 3 transformative scenarios: helping in creation of an optimal analgesic drug, the advent of bidirectional neuron-microelectronic interfaces, and the synergistic combination of hypnosis and virtual reality.
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Affiliation(s)
- Pascal Laferrière-Langlois
- From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Louis Morisson
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Sean Jeffries
- Department of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Catherine Duclos
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Fabien Espitalier
- Department of Anesthesia and Intensive Care, University Hospitals of Tours, Tours, France
| | - Philippe Richebé
- From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
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Oh SK, Won YJ, Lim BG. Surgical pleth index monitoring in perioperative pain management: usefulness and limitations. Korean J Anesthesiol 2024; 77:31-45. [PMID: 36926752 PMCID: PMC10834712 DOI: 10.4097/kja.23158] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/16/2023] [Accepted: 03/16/2023] [Indexed: 03/18/2023] Open
Abstract
Surgical pleth index (SPI) monitoring is a representative, objective nociception-monitoring device that measures nociception using photoplethysmographic signals. It is easy to apply to patients and the numerical calculation formula is intuitively easy to understand; therefore, its clinical interpretation is simple. Several studies have demonstrated its efficacy and utility. Compared with hemodynamic parameters, the SPI can detect the degree of nociception during surgery under general anesthesia with greater accuracy, and therefore can provide better guidance for the administration of various opioids, including remifentanil, fentanyl, and sufentanil. Indeed, SPI-guided analgesia is associated with lower intraoperative opioid consumption, faster patient recovery, and comparable or lower levels of postoperative pain and rates of adverse events compared with conventional analgesia. In addition, SPI monitoring allows for the degree of postoperative pain and analgesic requirements to be predicted through the SPI values immediately before patient arousal. However, because patient age, effective circulating volume, position, concomitant medication and anesthetic regimen and level of consciousness may be confounding factors in SPI monitoring, clinicians must be careful when interpreting SPI values. In addition, as SPI values can differ depending on anesthetic and analgesic regimens and the underlying disease, an awareness of the effects of these variables with an understanding of the advantages and disadvantages of SPI monitoring compared to other nociception monitoring devices is essential. Therefore, this review aimed to help clinicians perform optimal SPI-guided analgesia and to assist with the establishment of future research designs through clarifying current usefulness and limitations of SPI monitoring in perioperative pain management.
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Affiliation(s)
- Seok Kyeong Oh
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Young Ju Won
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Peng K, Karunakaran KD, Green S, Borsook D. Machines, mathematics, and modules: the potential to provide real-time metrics for pain under anesthesia. NEUROPHOTONICS 2024; 11:010701. [PMID: 38389718 PMCID: PMC10883389 DOI: 10.1117/1.nph.11.1.010701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 02/24/2024]
Abstract
The brain-based assessments under anesthesia have provided the ability to evaluate pain/nociception during surgery and the potential to prevent long-term evolution of chronic pain. Prior studies have shown that the functional near-infrared spectroscopy (fNIRS)-measured changes in cortical regions such as the primary somatosensory and the polar frontal cortices show consistent response to evoked and ongoing pain in awake, sedated, and anesthetized patients. We take this basic approach and integrate it into a potential framework that could provide real-time measures of pain/nociception during the peri-surgical period. This application could have significant implications for providing analgesia during surgery, a practice that currently lacks quantitative evidence to guide patient tailored pain management. Through a simple readout of "pain" or "no pain," the proposed system could diminish or eliminate levels of intraoperative, early post-operative, and potentially, the transition to chronic post-surgical pain. The system, when validated, could also be applied to measures of analgesic efficacy in the clinic.
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Affiliation(s)
- Ke Peng
- University of Manitoba, Department of Electrical and Computer Engineering, Price Faculty of Engineering, Winnipeg, Manitoba, Canada
| | - Keerthana Deepti Karunakaran
- Massachusetts General Hospital, Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, United States
| | - Stephen Green
- Massachusetts Institute of Technology, Department of Mechanical Engineering, Boston, Massachusetts, United States
| | - David Borsook
- Massachusetts General Hospital, Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, United States
- Massachusetts General Hospital, Harvard Medical School, Department of Radiology, Boston, Massachusetts, United States
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van Rijbroek LS, Noordergraaf GJ, de Man-van Ginkel JM, van Boekel RLM. The association of hemodynamic parameters and clinical demographic variables with acute postoperative pain in female oncological breast surgery patients: A retrospective cohort study. Scand J Pain 2024; 24:sjpain-2023-0066. [PMID: 38460147 DOI: 10.1515/sjpain-2023-0066] [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: 05/25/2023] [Accepted: 01/03/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES Appropriate administration of intraoperative analgesia is an essential factor in care and reasonable recovery times. Inappropriate intraoperative analgesia puts the patient at risk of acute postoperative pain (APOP). The absence of an objective standard for intraoperative nociceptive monitoring complicates pain care. Heart rate (HR) and mean arterial blood pressure (MABP) have been suggested as useful parameters during general anesthesia for nociceptive monitoring. However, studies focusing on whether intraoperative heart rate variability (HRv) and mean arterial blood pressure variability (MABPv) during general anesthesia can accurately monitor nociception in patients have remained inconclusive. The current study aimed to (1) identify the association of intraoperative heart rate and blood pressure variability in patients undergoing low-risk surgery with the incidence of APOP in the immediate postoperative setting and (2) evaluate the associations of clinical demographic factors with the incidence of APOP. METHODS A retrospective observational cohort study was conducted. The outcome was moderate-to-severe APOP, defined as a numeric rating scale score of ≥ 4. HRv, MABPv, and potential confounders, such as age, body mass index, duration of surgery, smoking, depression, preoperative use of analgesics, and type of surgery, were used as independent variables. RESULTS Data from 764 female oncological breast surgery patients were analyzed. No statistically significant association of HRv and MABPv with APOP was found. Lower age was associated with higher odds of APOP (odds ratio [OR] 0.978, p = 0.001). Increased length of surgery (OR 1.013, p = 0.022) and a history of depression were associated with increased odds of APOP (OR 2.327, p = 0.010). The subtype of surgery was statistically significantly associated with APOP (p = 0.006). CONCLUSIONS Our results suggest that heart rate and blood pressure variability intraoperatively, in female patients undergoing low-risk surgery, are not associated with, and thus not predictive of, APOP in the immediate postoperative setting.
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Affiliation(s)
- Lieselotte S van Rijbroek
- Department of Anesthesiology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Gerrit J Noordergraaf
- Department of Anesthesiology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Janneke M de Man-van Ginkel
- Nursing Science, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
- Nursing Science, Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Regina L M van Boekel
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Won YJ, Oh SK, Lim BG, Kim YS, Lee DY, Lee JH. Effect of surgical pleth index-guided remifentanil administration on perioperative outcomes in elderly patients: a prospective randomized controlled trial. BMC Anesthesiol 2023; 23:57. [PMID: 36803564 PMCID: PMC9936695 DOI: 10.1186/s12871-023-02011-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/03/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND During general anesthesia, the surgical pleth index (SPI) monitors nociception. The evidence of SPI in the elderly remains scarce. We aimed to investigate whether there is a difference in perioperative outcomes following intraoperative opioid administration according to the surgical pleth index (SPI) value versus hemodynamic parameters (heart rate or blood pressure) in elderly patients. METHODS Patients aged 65-90 years who underwent laparoscopic colorectal cancer surgery under sevoflurane/remifentanil anesthesia were randomized to receive remifentanil guided by SPI (SPI group) or conventional clinical judgment based on hemodynamic parameters (conventional group). The primary endpoint was intraoperative remifentanil consumption. Secondary endpoints were intraoperative hemodynamic instability, pain score, fentanyl consumption and delirium in the post-anesthesia care unit (PACU), and perioperative changes in interleukin-6 and natural killer (NK) cell activity. RESULTS Seventy-five patients (38, SPI; 37, conventional) were included in the study. The SPI group consumed significantly more remifentanil intraoperatively than the conventional group (mean ± SD, 0.13 ± 0.05 vs. 0.06 ± 0.04 μg/kg/min, P < 0.001). Intraoperative hypertension and tachycardia were more common in the conventional group than in the SPI group. Pain score in the PACU (P = 0.013) and the incidence of delirium in the PACU were significantly lower in the SPI group than the conventional group (5.2% vs. 24.3%, P = 0.02). There was no significant difference in NK cell activity and interleukin-6 level. CONCLUSIONS In the elderly patients, SPI-guided analgesia provided appropriate analgesia with sufficient intraoperative remifentanil consumption, lower incidence of hypertension/ tachycardia events, and a lower incidence of delirium in the PACU than the conventional analgesia. However, SPI-guided analgesia may not prevent perioperative immune system deterioration. TRIAL REGISTRATION The randomized controlled trial was retrospectively registered in the UMIN Clinical Trials Registry (trial number: UMIN000048351; date of registration: 12/07/2022).
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Affiliation(s)
- Young Ju Won
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
| | - Seok Kyeong Oh
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308, Republic of Korea.
| | - Young Sung Kim
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
| | - Do Yeop Lee
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
| | - Jae Hak Lee
- grid.411134.20000 0004 0474 0479Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Gurodong-Ro 148, Guro-Gu, Seoul, 08308 Republic of Korea
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Bertolizio G, Garbin M, Ingelmo PM. Evaluation of Nociception during Pediatric Surgery: A Topical Review. J Pers Med 2023; 13:260. [PMID: 36836492 PMCID: PMC9964458 DOI: 10.3390/jpm13020260] [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: 01/02/2023] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
The association between intraoperative nociception and increased patient's morbidity is well established. However, hemodynamic parameters, such as heart rate and blood pressure, may result in an inadequate monitor of nociception during surgery. Over the last two decades, different devices have been marketed to "reliably" detect intraoperative nociception. Since the direct measure of nociception is impractical during surgery, these monitors measures nociception surrogates such as sympathetic and parasympathetic nervous systems responses (heart rate variability, pupillometry, skin conductance), electroencephalographic changes, and muscular reflex arc. Each monitor carries its own advantages and disadvantages. The manuscript aims to give an overview of the most up-to-date information available in the literature on current nociceptor monitors available in clinical practice, with particular focus on their applications in pediatrics.
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Affiliation(s)
- Gianluca Bertolizio
- Department of Pediatric Anesthesiology, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada
- Research Institute, McGill University Health Center, Montreal, QC H4A 3J1, Canada
| | - Marta Garbin
- Department of Clinical Sciences, Université de Montréal, St-Hyacinthe, QC J2S 2M2, Canada
| | - Pablo M. Ingelmo
- Department of Pediatric Anesthesiology, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada
- Research Institute, McGill University Health Center, Montreal, QC H4A 3J1, Canada
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Alan Edwards Center for Research on Pain, McGill University, Montreal, QC H3A 2B4, Canada
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