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Lenart EK, Byerly SE, Gross MG, Ali YM, Evans CR, Easterday TS, Howley IW, Kerwin AJ, Fischer PE, Filiberto DM. Clinical Implications of Over- and Under-Triage Using Need for Trauma Intervention and Cribari Indices. Am Surg 2024:31348241246181. [PMID: 38613475 DOI: 10.1177/00031348241246181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2024]
Abstract
BACKGROUND Need for Trauma Intervention (NFTI) score was proposed to help identify injured trauma patients while minimizing under (UT) and over triage (OT). Using a national database, we aimed to describe UT and OT of NFTI vs standard Cribari method (CM) and hypothesized triage sensitivity remains poor. METHODS The 2021 Trauma Quality Improvement Program (TQIP) database was queried. Demographics, mechanism, verification level, interfacility transfer (IF), and level of activation were collected. Patients were stratified by both NFTI [+ vs -] and CM [Injury severity score (ISS) < 15 vs > 15]. UT was defined as NFTI + or ISS >15 without full trauma activation. RESULTS 1,030,526 patients were identified in TQIP. 84,969 were UT and 97,262 were OT using NFTI while 94,020 were UT and 108,823 were OT using CM. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NFTI is 49%, 89%, 45%, and 90%, respectively vs 43%, 87%, 39%, and 89% of CM, respectively. Age was higher in the UT group using both scores (52 vs 42, P < .0001 and 54 vs 42, P < .0001, respectively). Using MLR, level 2 and 3 verification, blunt mechanism, female, IF, and older age were associated with UT in both NFTI and CM. Level 1 verification, penetrating mechanism, male, no IF, and younger age were associated with OT. CONCLUSIONS Current prehospital triage criteria have poor sensitivity for identifying severely injured trauma patients by both NFTI and CM. UT increases as age of the patient increases. Further studies are needed to improve triage.
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Affiliation(s)
- Emily K Lenart
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya E Byerly
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Megan G Gross
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yasmin M Ali
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cory R Evans
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Thomas S Easterday
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac W Howley
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andy J Kerwin
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter E Fischer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dina M Filiberto
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
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Gross MG, Filiberto DM, Lehrman BH, Lenart EK, Easterday TS, Kerwin AJ, Byerly SE. Outcomes and Predictors of Delayed Intervention After Renal Trauma. Am Surg 2024:31348241246164. [PMID: 38605637 DOI: 10.1177/00031348241246164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Historically, a zone II hematoma mandated exploration after penetrating trauma, but this has been challenged given potentially higher nephrectomy rates and the advent of therapeutic endovascular and endoscopic interventions. We hypothesized penetrating mechanism was not a predictor for delayed intervention in the modern era. METHODS This single-center, retrospective study included renal trauma patients from 3/2019 to 6/2022. Our institutional practice is selective exploration of zone II hematomas for active bleeding and expanding hematoma only, regardless of mechanism. Descriptive statistics and multivariable logistic regression (MLR) were performed. RESULTS One-hundred and forty-four patients were identified, with median age 32 years (IQR:23,49), 66% blunt mechanism, and injury severity score 17(IQR:11,26). Forty-three (30%) required operative intervention, and of the 20 that had a zone II exploration, 3 (15%) underwent renorrhaphy and 17 (85%) underwent nephrectomy. Penetrating patients more frequently underwent immediate operative intervention (67%vs10%,P < .0001), required nephrectomy (27%vs5%,P = .0003), and were less likely to undergo pre-intervention CT (51%vs96%,P < .0001) compared to blunt patients. Delayed renal interventions were higher in penetrating (33%vs13%,P = .004) with no difference in mortality or length of stay compared to blunt mechanism. Ureteral stent placement and renal embolization were the most common delayed interventions. On MLR, the only independent predictor for delayed intervention was need for initial operative intervention (OR 3.803;95%CI:1.612-8.975,P = .0023). Four (3%) required delayed nephrectomy, of which only one underwent initial operative intervention without zone 2 exploration. CONCLUSIONS The most common delayed interventions after renal trauma were renal embolization and ureteral stent. Penetrating mechanism was not a predictor of delayed renal intervention in a trauma center that manages zone II retroperitoneal hematomas similarly regardless of mechanism.
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Affiliation(s)
- Megan G Gross
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science University, Memphis, TN, USA
| | - Dina M Filiberto
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science University, Memphis, TN, USA
| | - Benjamin H Lehrman
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science University, Memphis, TN, USA
| | - Emily K Lenart
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science University, Memphis, TN, USA
| | - Thomas S Easterday
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science University, Memphis, TN, USA
| | - Andrew J Kerwin
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science University, Memphis, TN, USA
| | - Saskya E Byerly
- Department of Surgery, Division of Trauma & Surgical Critical Care, University of Tennessee Health Science University, Memphis, TN, USA
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Falcon AK, Caballero LM, Filiberto DM, Lenart EK, Easterday TS, Bhatt MN, Mitchell EL, Byerly S. Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis. Am Surg 2024:31348241241645. [PMID: 38527489 DOI: 10.1177/00031348241241645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
BACKGROUND Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. METHODS Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. RESULTS A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. CONCLUSION Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.
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Affiliation(s)
- Allison K Falcon
- Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Ladd M Caballero
- Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Dina M Filiberto
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Emily K Lenart
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Thomas S Easterday
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Maunil N Bhatt
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Erica L Mitchell
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Saskya Byerly
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
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Spoor K, Cull JD, Otaibi BW, Hazelton JP, Chipko J, Reynolds J, Fugate S, Pederson C, Zier LB, Jacobson LE, Williams JM, Easterday TS, Byerly S, Mentzer C, Hawke E, Cullinane DC, Ontengco JB, Bugaev N, LeClair M, Udekwu P, Josephs C, Noorbaksh M, Babowice J, Velopulos CG, Urban S, Goldenberg A, Ghobrial G, Pickering JM, Quarfordt SD, Aunchman AF, LaRiccia AK, Spalding C, Catalano RD, Basham JE, Edmundson PM, Nahmias J, Tay E, Norwood SH, Meadows K, Wong Y, Hardman C. Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study. Trauma Surg Acute Care Open 2024; 9:e001159. [PMID: 38464553 PMCID: PMC10921525 DOI: 10.1136/tsaco-2023-001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/25/2023] [Indexed: 03/12/2024] Open
Abstract
Objectives There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence IV.
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Affiliation(s)
- Kristen Spoor
- Prisma Health Upstate, Greenville, South Carolina, USA
| | - John David Cull
- Surgery, Prisma Health Upstate, Greenville, South Carolina, USA
| | - Banan W Otaibi
- Pennsylvania State University, Hershey, Pennsylvania, USA
| | | | - John Chipko
- Research Medical Center, Kansas City, Missouri, USA
| | | | - Sam Fugate
- University of Kentucky HealthCare, Lexington, Kentucky, USA
| | | | - Linda B Zier
- Medical Center of the Rockies, Loveland, Colorado, USA
| | - Lewis E Jacobson
- Trauma Department, St. Vincent Indianapolis Hospital, Indianapolis, Indiana, USA
| | - Jamie M Williams
- Trauma Department, St. Vincent Indianapolis Hospital, Indianapolis, Indiana, USA
| | | | | | - Caleb Mentzer
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Edward Hawke
- Spartanburg Regional Health System, Spartanburg, South Carolina, USA
| | | | | | | | | | - Pascal Udekwu
- Surgery, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | | | | | | | | | - Shane Urban
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Anna Goldenberg
- Trauma, Acute Care Surgery, and Surgical Critical Care, Cooper University Hospital Regional Trauma Center, Camden, New Jersey, USA
| | | | | | | | - Alia F Aunchman
- University of Vermont Medical Center, Burlington, Vermont, USA
| | | | - Chance Spalding
- Trauma and Acute Care Surgery, Grant Medical Center, Columbus, Ohio, USA
| | - Richard D Catalano
- Loma Linda University Adventist Health Sciences Center, Loma Linda, California, USA
| | | | | | | | - Erika Tay
- Texas Health Presbyterian Hospital, Dallas, Texas, USA
| | | | | | - Yee Wong
- Premier Health Partners Inc, Dayton, Ohio, USA
| | - Claire Hardman
- Wright State Physicians, Department of Surgery, Dayton, Ohio, USA
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Easterday TS, Moore J, Redden MH, Feliciano DV, Henderson VJ, Humphries T, Kohler KE, Ramsay PT, Spence SD, Walker M, Wyrzykowski AD. Percutaneous Tracheostomy under Bronchoscopic Visualization Does Not Affect Short-Term or Long-Term Complications. Am Surg 2017. [DOI: 10.1177/000313481708300723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Percutaneous tracheostomy is a safe and effective bedside procedure. Some advocate the use of bronchoscopy during the procedure to reduce the rate of complications. We evaluated our complication rate in trauma patients undergoing percutaneous tracheostomy with and without bronchoscopic guidance to ascertain if there was a difference in the rate of complications. A retrospective review of all tracheostomies performed in critically ill trauma patients was performed using the trauma registry from an urban, Level I Trauma Center. Bronchoscopy assistance was used based on surgeon preference. Standard statistical methodology was used to determine if there was a difference in complication rates for procedures performed with and without the bronchoscope. From January 2007, to April 2016, 649 patients underwent modified percuteaneous tracheostomy; 289 with the aid of a bronchoscope and 360 without. There were no statistically significant differences in any type of complication regardless of utilization of a bronchoscope. The addition of bronchoscopy provides several theoretical benefits when performing percutaneous tracheostomy. Our findings, however, do not demonstrate a statistically significant difference in complications between procedures performed with and without a bronchoscope. Use of the bronchoscope should, therefore, be left to the discretion of the performing physician.
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Affiliation(s)
- Thomas S. Easterday
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Joshuaw Moore
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Meredith H. Redden
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - David V. Feliciano
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Vernon J. Henderson
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Timothy Humphries
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Katherine E. Kohler
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Philip T. Ramsay
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Stanston D. Spence
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Mark Walker
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
| | - Amy D. Wyrzykowski
- Department of Surgery, Division of Trauma Surgery and Critical Care, Atlanta Medical Center, Atlanta, Georgia
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Easterday TS, Moore JW, Redden MH, Feliciano DV, Henderson VJ, Humphries T, Kohler KE, Ramsay PT, Spence SD, Walker M, Wyrzykowski AD. Percutaneous Tracheostomy under Bronchoscopic Visualization Does Not Affect Short-Term or Long-Term Complications. Am Surg 2017; 83:696-698. [PMID: 28738937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Percutaneous tracheostomy is a safe and effective bedside procedure. Some advocate the use of bronchoscopy during the procedure to reduce the rate of complications. We evaluated our complication rate in trauma patients undergoing percutaneous tracheostomy with and without bronchoscopic guidance to ascertain if there was a difference in the rate of complications. A retrospective review of all tracheostomies performed in critically ill trauma patients was performed using the trauma registry from an urban, Level I Trauma Center. Bronchoscopy assistance was used based on surgeon preference. Standard statistical methodology was used to determine if there was a difference in complication rates for procedures performed with and without the bronchoscope. From January 2007, to April 2016, 649 patients underwent modified percuteaneous tracheostomy; 289 with the aid of a bronchoscope and 360 without. There were no statistically significant differences in any type of complication regardless of utilization of a bronchoscope. The addition of bronchoscopy provides several theoretical benefits when performing percutaneous tracheostomy. Our findings, however, do not demonstrate a statistically significant difference in complications between procedures performed with and without a bronchoscope. Use of the bronchoscope should, therefore, be left to the discretion of the performing physician.
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Gracon ASA, Liang TW, Easterday TS, Weber DJ, Butler J, Slaven JE, Lemmon GW, Motaganahalli RL. Institutional Cost of Unplanned 30-Day Readmission Following Open and Endovascular Surgery. Vasc Endovascular Surg 2016; 50:398-404. [DOI: 10.1177/1538574416666227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Vascular surgical patients have a high rate of readmission, and the cost of readmission for these patients has not been described. Herein, we characterize and compare institutional index hospitalization and 30-day readmission cost following open and endovascular vascular procedures. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify inpatient open and endovascular procedures at a single institution, from January 2011 through June 2012. Variable and fixed costs for index hospitalization and unplanned 30-day readmissions were obtained using SAP BusinessObjects. Patient characteristics and outcome variables were analyzed using Student t tests or Wilcoxon rank-sum nonparametric tests for continuous variables and Fisher exact tests for categorical variables. Results: One thousand twenty-six inpatient procedures were included in the analysis. There were 605 (59%) open and 421 (41%) endovascular procedures with a 30-day unplanned readmission rate of 16.9% and 17.8%, respectively ( P = .679). The mean index hospitalization costs for open and endovascular procedures were US$27 653 and US$23 999, respectively ( P = .146). The mean costs for 30-day unplanned readmission for open and endovascular procedures were US$19 117 and US$17 887, respectively ( P = .635). Among open procedures, the mean cost for patients not readmitted was US$28 321 compared to US$31 115 for those readmitted ( P = .003). Among endovascular procedures, the mean cost for patients not readmitted was US$26 908 compared to US$32 262 for those readmitted ( P = .028). Conclusion: The cost of index hospitalization and 30-day unplanned readmission are similar for open and endovascular procedures. Readmitted patients had a higher mean index hospitalization cost irrespective of open or endovascular procedure.
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Affiliation(s)
- Adam S. A. Gracon
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
| | - Tiffany W. Liang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
| | | | - Daniel J. Weber
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
| | - James Butler
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
| | - James E. Slaven
- Department of Biostatistics, Indiana University School of Medicine, IN, USA
| | - Gary W. Lemmon
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
- Division of Vascular Surgery, Indiana University School of Medicine, IN, USA
| | - Raghu L. Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
- Division of Vascular Surgery, Indiana University School of Medicine, IN, USA
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Easterday TS, Gracon AS, Weber D, Slaven J, Lemmon G, Motaganahalli R. Quantifying Excess Cost Associated with Readmission for Surgical Site Infection Following Open Vascular Procedures Involving the Lower Extremity. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.07.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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