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Jiang SW, Flynn MS, Kwock JT, Liu B, Quow K, Blanchard SK, Breglio KF, Fresco A, Jamison MO, Lesesky E, Bellet JS, Green CL, Shearer SM, Nicholas MW. Quality and Perceived Usefulness of Patient-Submitted Store-and-Forward Teledermatology Images. JAMA Dermatol 2022; 158:1183-1186. [PMID: 35895039 PMCID: PMC9330374 DOI: 10.1001/jamadermatol.2022.2815] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patient-submitted images vary considerably in quality and usefulness. Studies that characterize patient-submitted images in a real-life setting are lacking. Objective To evaluate the quality and perceived usefulness of patient-submitted images as determined by dermatologists and characterize agreement of their responses. Design, Setting, and Participants This survey study included patient images submitted to the Department of Dermatology at Duke University (Durham, North Carolina) between August 1, 2018, and December 31, 2019. From a total pool of 1200 images, 10 dermatologists evaluated 200 or 400 images each, with every image being evaluated by 3 dermatologists. Data analysis occurred during the year leading up to the article being written. Main Outcomes and Measures The primary outcomes were the responses to 2 questions and were analyzed using frequency counts and interrater agreement (Fleiss κ) to assess image quality and perceived usefulness. We performed a random-effects logistic regression model to investigate factors associated with evaluators' decision-making comfort. We hypothesized that most images would be of low quality and perceived usefulness, and that interrater agreement would be poor. Results A total of 259 of 2915 patient-submitted images (8.9%) did not depict a skin condition at all. The final analysis comprised 3600 unique image evaluations. Dermatologist evaluators indicated that 1985 images (55.1%) were useful for medical decision-making and 2239 (62.2%) were of sufficient quality. Interrater agreement for a given image's diagnostic categorization was fair to substantial (κ range, 0.36-0.64), while agreement on image quality (κ range, 0.35-0.47) and perceived usefulness (κ range, 0.29-0.38) were fair to moderate. Senior faculty had higher odds of feeling comfortable with medical decision-making than junior faculty (odds ratio [OR], 3.68; 95% CI, 2.9-4.66; P < .001) and residents (OR, 5.55; 95% CI, 4.38-7.04; P < .001). Images depicting wounds (OR, 1.75; 95% CI, 1.18-2.58; P = .01) compared with inflammatory skin conditions and that were in focus (OR, 5.56; 95% CI, 4.63-6.67; P < .001) had higher odds of being considered useful for decision-making. Conclusions and Relevance In this survey study including 10 dermatologists, a slight majority of patient-submitted images were judged to be of adequate quality and perceived usefulness. Fair agreement between dermatologists was found regarding image quality and perceived usefulness, suggesting that store-and-forward teledermatology initiatives should consider a physician's individual experiences and comfort level. The study results suggest that images are most likely to be useful when they are in focus and reviewed by experienced attending physicians for wound surveillance, but dermatologists may be burdened by irrelevant or unsuitable images.
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Affiliation(s)
- Simon W Jiang
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - M Seth Flynn
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Jeffery T Kwock
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Krystina Quow
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Sarah K Blanchard
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Kimberly F Breglio
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Amber Fresco
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Megan O'Brien Jamison
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Erin Lesesky
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Jane S Bellet
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina.,Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Sabrina M Shearer
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Matilda W Nicholas
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
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Sarver MM, Breglio KF, Olsen EA. Ataxia-telangiectasia mutated (ATM) gene mutation in a patient with primary cutaneous marginal zone lymphoma. JAAD Case Rep 2022; 23:73-75. [PMID: 35445145 PMCID: PMC9014317 DOI: 10.1016/j.jdcr.2022.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Breglio KF, Sarver MM, Hall RP, Marano AL. SARS-CoV-2 infections in patients with autoimmune blistering disorders: a case series and retrospective analysis. JAAD Int 2022; 7:38-43. [PMID: 35098172 PMCID: PMC8784432 DOI: 10.1016/j.jdin.2022.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 12/15/2022] Open
Abstract
Background Autoimmune blistering disorders (AIBDs) are rare, potentially life-threatening conditions often requiring immunosuppression. Throughout the SARS-CoV-2 pandemic, infection risk and mortality in patients with AIBDs are unknown. Objective We report the outcomes of SARS-CoV-2 infections in patients with AIBDs and determined if patients on rituximab have an increased risk of SARS-CoV-2 infection. Methods We examined clinical outcomes in 10 patients with AIBDs who developed SARS-CoV-2 infections at an American hospital. We performed a retrospective analysis of 132 patients with AIBDs enrolled in a clinical trial. Results Patients with severe SARS-CoV-2 (n = 4) or death (n = 2) trended to be older. These patients had higher mortality than the national average (20% vs 1.6%). Our cohort included 52 patients with a history of rituximab treatment, 35 of whom were immunosuppressed by rituximab during the pandemic, and 45 patients never treated with rituximab. We found no difference between the rates of SARS-CoV-2 positivity in patients with AIBDs immunosuppressed by rituximab and those not on rituximab (9.1% vs 12.1%). Limitations Testing for SARS-CoV-2 was performed on demand rather than surveillance. Overall transmission varied over time, and outcomes depended on accepted treatments. The small sample size of our cohort limits the generalizability of our results. Conclusion This study suggests that rituximab does not increase the risk of SARS-CoV-2 test positivity in patients with AIBDs. However, these results should be interpreted with caution due to our relatively small sample size.
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Affiliation(s)
- Kimberly F. Breglio
- Duke Dermatology Department, Duke University Hospital, Durham, North Carolina
| | - Melissa M. Sarver
- Duke School of Medicine, Duke University Hospital, Durham, North Carolina
| | - Russell P. Hall
- Duke Dermatology Department, Duke University Hospital, Durham, North Carolina
| | - Anne L. Marano
- Duke Dermatology Department, Duke University Hospital, Durham, North Carolina
- Correspondence to: Anne L. Marano, MD, Duke Dermatology Department, Duke University Hospital, 234 Crooked Creek Parkway Suite 300, Durham, NC 27713.
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Breglio KF, Vinhaes CL, Arriaga MB, Nason M, Roby G, Adelsberger J, Andrade BB, Sheikh V, Sereti I. Clinical and Immunologic Predictors of Mycobacterium avium Complex Immune Reconstitution Inflammatory Syndrome in a Contemporary Cohort of Patients With Human Immunodeficiency Virus. J Infect Dis 2021; 223:2124-2135. [PMID: 33104218 PMCID: PMC8205640 DOI: 10.1093/infdis/jiaa669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/20/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND People with human immunodeficiency virus (HIV) can present with new or worsening symptoms associated with Mycobacterium avium complex (MAC) infection shortly after antiretroviral therapy (ART) initiation as MAC immune reconstitution inflammatory syndrome (MAC-IRIS). In this study, we assessed the utility of several laboratory tests as predictors of MAC-IRIS. METHODS People with HIV with clinical and histologic and/or microbiologic evidence of MAC-IRIS were identified and followed up to 96 weeks post-ART initiation within a prospective study of 206 ART-naive patients with CD4 <100 cells/µL. RESULTS Fifteen (7.3%) patients presented with MAC-IRIS within a median interval of 26 days after ART initiation. Patients who developed MAC-IRIS had lower body mass index, lower hemoglobin levels, higher alkaline phosphatase (ALP), and increased CD38 frequency and mean fluorescence intensity on CD8+ T cells at the time of ART initiation compared with non-MAC IRIS patients. A decision tree inference model revealed that stratifying patients based on levels of ALP and D-dimer could predict the likelihood of MAC-IRIS. A binary logistic regression demonstrated that higher levels of ALP at baseline were associated with increased risk of MAC-IRIS development. CONCLUSIONS High ALP levels and increased CD8+ T-cell activation with low CD4 counts at ART initiation should warrant suspicion for subsequent development of MAC-IRIS.
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Affiliation(s)
- Kimberly F Breglio
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Bahia, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Bahia, Brazil
| | - María B Arriaga
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Bahia, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Martha Nason
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gregg Roby
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joseph Adelsberger
- Leidos Biomedical Research Inc, Fredrick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Bahia, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Bahia, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
- Curso de Medicina, Universidade Salvador, Laureate Universities, Salvador, Bahia, Brazil
| | - Virginia Sheikh
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Helm MF, Breglio KF, Straight C, Maczuga SA, Marks VJ, Foulke GT. Prevalence of hemophagocytic lymphohistiocytosis with dermatomyositis, other rheumatic diseases, and lymphoma. Int J Dermatol 2020; 60:e78-e79. [PMID: 33502779 DOI: 10.1111/ijd.15122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/08/2020] [Accepted: 07/15/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Matthew F Helm
- Department of Dermatology, Penn State Health, Hershey, PA, USA
| | | | | | | | - Victor J Marks
- Department of Dermatology, Geisinger Medical Center, Danville, PA, USA
| | - Galen T Foulke
- Department of Dermatology, Penn State Health, Hershey, PA, USA
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Hsu DC, Breglio KF, Pei L, Wong CS, Andrade BB, Sheikh V, Smelkinson M, Petrovas C, Rupert A, Gil-Santana L, Zelazny A, Holland SM, Olivier K, Barber D, Sereti I. Emergence of Polyfunctional Cytotoxic CD4+ T Cells in Mycobacterium avium Immune Reconstitution Inflammatory Syndrome in Human Immunodeficiency Virus-Infected Patients. Clin Infect Dis 2019. [PMID: 29538651 DOI: 10.1093/cid/ciy016] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Immune reconstitution inflammatory syndrome (IRIS) is an aberrant inflammatory response in individuals with advanced human immunodeficiency virus (HIV) infection, after antiretroviral therapy (ART) initiation. The pathogenesis of Mycobacterium avium complex (MAC)-associated IRIS has not been fully elucidated. Methods We investigated monocyte and CD4+ T-cell responses in vitro, tumor necrosis factor (TNF) expression in tissues, and plasma cytokines and inflammatory markers, in 13 HIV-infected patients with MAC-IRIS and 14 HIV-uninfected patients with pulmonary MAC infection. Results Prior to ART, HIV-infected compared with HIV-uninfected patients, had reduced TNF+ monocytes (P = .013), although similar cytokine (interferon gamma [IFN-γ], TNF, interleukin 2 [IL-2], and interleukin 17 [IL-17])-expressing CD4+ T cells. During IRIS, monocyte cytokine production was restored. IFN-γ+ (P = .027), TNF+ (P = .004), and polyfunctional CD4+ T cells (P = 0.03) also increased. These effectors were T-betlow, and some expressed markers of degranulation and cytotoxic potential. Blockade of cytotoxic T-lymphocyte associated protein 4 and lymphocyte activation gene-3 further increased CD4+ T-cell cytokine production. Tissue immunofluorescence showed higher proportions of CD4+ and CD68+ (monocyte/macrophage) cells expressed TNF during IRIS compared with HIV-uninfected patients. Plasma IFN-γ (P = .048), C-reactive protein (P = .008), and myeloperoxidase (P < .001) levels also increased, whereas interleukin 10 decreased (P = .008) during IRIS. Conclusions Advanced HIV infection was associated with impaired MAC responses. Restoration of monocyte responses and expansion of polyfunctional MAC-specific T-betlow CD4+ T cells with cytotoxic potential after ART initiation may overwhelm existing regulatory and inhibitory mechanisms, leading to MAC-IRIS.
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Affiliation(s)
- Denise C Hsu
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland
| | - Kimberly F Breglio
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland
| | - Luxin Pei
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland
| | - Chun-Shu Wong
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Fundação José Silveira, Salvador, Bahia, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Bahia, Brazil.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Virginia Sheikh
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland
| | | | - Constantinos Petrovas
- Tissue Analysis Core Section, Vaccine Research Center, NIAID, NIH, Bethesda, Maryland
| | - Adam Rupert
- Functional Immunology Section, AIDS Monitoring Laboratory, SAIC-Frederick, National Cancer Institute, National Institutes of Health, Frederick, Maryland
| | - Leonardo Gil-Santana
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Fundação José Silveira, Salvador, Bahia, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Bahia, Brazil
| | - Adrian Zelazny
- Department of Laboratory Medicine, NIAID, NIH, Bethesda, Maryland
| | - Steven M Holland
- Laboratory of Clinical Infectious Diseases, NIAID Bethesda, Maryland
| | - Kenneth Olivier
- Pulmonary Clinical Medicine Section, National Heart, Lung, and Blood Institute
| | - Daniel Barber
- Laboratory of Parasitic Diseases, NIAID, NIH, Bethesda, Maryland
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland
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Breglio KF, Amato R, Eastman R, Lim P, Sa JM, Guha R, Ganesan S, Dorward DW, Klumpp-Thomas C, McKnight C, Fairhurst RM, Roberts D, Thomas C, Simon AK. A single nucleotide polymorphism in the Plasmodium falciparum atg18 gene associates with artemisinin resistance and confers enhanced parasite survival under nutrient deprivation. Malar J 2018; 17:391. [PMID: 30367653 PMCID: PMC6204056 DOI: 10.1186/s12936-018-2532-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/17/2018] [Indexed: 01/20/2023] Open
Abstract
Background Artemisinin-resistant Plasmodium falciparum has been reported throughout the Greater Mekong subregion and threatens to disrupt current malaria control efforts worldwide. Polymorphisms in kelch13 have been associated with clinical and in vitro resistance phenotypes; however, several studies suggest that the genetic determinants of resistance may involve multiple genes. Current proposed mechanisms of resistance conferred by polymorphisms in kelch13 hint at a connection to an autophagy-like pathway in P. falciparum. Results A SNP in autophagy-related gene 18 (atg18) was associated with long parasite clearance half-life in patients following artemisinin-based combination therapy. This gene encodes PfAtg18, which is shown to be similar to the mammalian/yeast homologue WIPI/Atg18 in terms of structure, binding abilities, and ability to form puncta in response to stress. To investigate the contribution of this polymorphism, the atg18 gene was edited using CRISPR/Cas9 to introduce a T38I mutation into a k13-edited Dd2 parasite. The presence of this SNP confers a fitness advantage by enabling parasites to grow faster in nutrient-limited settings. The mutant and parent parasites were screened against drug libraries of 6349 unique compounds. While the SNP did not modulate the parasite’s susceptibility to any of the anti-malarial compounds using a 72-h drug pulse, it did alter the parasite’s susceptibility to 227 other compounds. Conclusions These results suggest that the atg18 T38I polymorphism may provide additional resistance against artemisinin derivatives, but not partner drugs, even in the absence of kelch13 mutations, and may also be important in parasite survival during nutrient deprivation. Electronic supplementary material The online version of this article (10.1186/s12936-018-2532-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kimberly F Breglio
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA. .,Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Roberto Amato
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, UK
| | - Richard Eastman
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Pharath Lim
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Juliana M Sa
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Rajarshi Guha
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA.,Vertex Pharmaceuticals, Boston, MA, USA
| | - Sundar Ganesan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - David W Dorward
- Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Carleen Klumpp-Thomas
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Crystal McKnight
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Rick M Fairhurst
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - David Roberts
- Radcliffe Department of Medicine, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Craig Thomas
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD, USA
| | - Anna Katharina Simon
- Kennedy Institute of Rheumatology and Medical Research Council Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
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