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2.
J Clin Neurosci ; 85: 1-5, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33581778

RESUMO

BACKGROUND: During the coronavirus 19 (COVID-19) pandemic, physicians have begun adapting their daily practices to prevent transmissions. In this study we aimed to provide surgical neuro-oncologists with practice guidelines during the COVID-19 pandemic based on objective data from a high-volume brain tumor surgeon at the current COVID-19 epicenter. METHODS: All outpatient visits and surgeries performed by the senior author during the COVID-19 pandemic were compared between the initial quarantine (3/23/20-5/4/20), the plateau period following quarantine (5/5/20-6/27/20), and the second peak (6/28/20-7/20/20). In-person and telemedicine visits were evaluated for crossovers. Surgeries were subdivided based on lesion type and evaluated across the same time period. RESULTS: From 3/23/20-7/20/20, 469 clinic visits and 196 surgeries were identified. After quarantine was lifted, face-to-face visits increased (P < 0.01) yet no change in telehealth visits occurred. Of 327 telehealth visits, only 5.8% converted to in-person during the 4-month period with the most cited reason being patient preference (68.4%). Of the 196 surgeries performed during the pandemic, 29.1% occurred during quarantine, 49.0% during the plateau, and 21.9% occurred in the second peak. No COVID negative patients developed symptoms at follow-up. 55.6% were performed on malignant tumors and 31.6% were benign with no difference in case volumes throughout the pandemic. CONCLUSIONS: Despite exceptional challenges, we have maintained a high-volume surgical neuro-oncology practice at the epicenter of the COVID-19 pandemic. We provide the protocols implemented at our institution in order to maximize neuro-oncology care while mitigating risk of COVID-19 exposure to both patients and providers.


Assuntos
/prevenção & controle , Controle de Doenças Transmissíveis/métodos , Oncologistas , Preferência do Paciente , Telemedicina/normas , Neoplasias Encefálicas/cirurgia , Humanos , Procedimentos Neurocirúrgicos , Pandemias/prevenção & controle , Cirurgiões
3.
Neurosurg Focus ; 50(2): E3, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33524946

RESUMO

OBJECTIVE: Adult glioblastoma (GBM) has proven refractory to decades of innovation. Oncolytic viral therapy represents a novel therapy that uses viral vectors as both a delivery and therapeutic mechanism to target GBM cells. Despite the growing body of basic science data supporting the feasibility of viral therapy to treat GBM, the reporting of clinical trial results is heterogeneous. Correspondingly, the aim of this study was to present a contemporary summary of the progress all clinical trials have made to date. METHODS: The ClinicalTrials.gov database was reviewed in August 2020 for all possible interventional clinical trials involving viral vector-based therapy to treat adult GBM. These were then screened against selection criteria to identify pertinent clinical trials. RESULTS: A total of 29 oncolytic viral therapy trials treating adult GBM were identified. The median start and expected completion years were 2014 and 2020, respectively. At the time of this writing, 10 (35%) trials were reported to have completed recruitment, whereas 7 (24%) were actively recruiting. The median target enrollment number was 36 (range 13-108), with the majority of trials being phase I (n = 18, 62%), and involving secondary GBM among other malignant glioma (n = 19, 66%). A total of 10 unique viral vectors were used across all trials, with the most common being adenovirus (n = 16, 55%). Only 2 (7%) phase I trials to date have reported outcomes on the ClinicalTrials.gov portal. Results of 12 additional clinical trials were found in academic publications, with median progression-free and overall survival times of 3 and 15 months, respectively, after the first viral dose at recurrence. The coordination of the large majority of trials originated from the US (n = 21, 72%), and the median number of testing sites per trial was 1 (range 1-15), via industry funding (n = 18 trials, 62%). CONCLUSIONS: There are multiple early-stage oncolytic viral therapy clinical trials for adult GBM currently active. To date, limited results and outcomes are promising but scarce. The authors expect this to change in the near future because many trials are scheduled to have either nearly or actually reached their expected recruitment completion time. How exactly oncolytic viral therapy will fit into the current treatment paradigms for primary and secondary GBM remains to be seen, and will not be known until safety and toxicity profiles are established by these clinical trials.

4.
J Neurointerv Surg ; 2021 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-33593801

RESUMO

BACKGROUND: Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates. METHODS: An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature. RESULTS: One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%). CONCLUSIONS: UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

5.
World Neurosurg ; 2020 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-33346049

RESUMO

OBJECTIVE: Transradial access has been used increasingly for diagnostic cerebral angiography and neurointerventions. This requires development of a new skillset. Forming the Simmons catheter to catheterize the cerebral vessels is the most fundamental. Patient anatomy can complicate the formation of the Simmons catheter and the success of the procedure. The aim of this paper is to identify and describe the techniques that can be used transradially to facilitate the formation of the Simmons catheter for catheterization of the cerebral vessels. METHODS: We reviewed our series of 85 cerebral angiograms performed via a transradial approach at our institution between 2018 and 2019. We identified the techniques employed to form the Simmons catheter and compiled operative videos demonstrating each technique and its nuances. RESULTS: We have identified 7 techniques used to form the Simmons catheter from a right radial approach: in the ascending aorta, in the descending aorta, in the aortic arch, by deflecting the catheter off of the aortic valve with the glidewire in the common carotid artery, by deflecting the catheter off of the aortic valve with the glidewire in the descending aorta, and directly in the right or left common carotid arteries. We have identified that formation of the Simmons catheter from a left radial approach is most easily done in the descending aorta. CONCLUSIONS: Transradial artery access has become increasingly common in cerebral angiography and neurointerventions. We describe techniques used for the formation of the Simmons catheter, a fundamental skill necessary for transradial cerebral angiogram or neurointervention.

6.
Neurospine ; 2020 Nov 17.
Artigo em Inglês | MEDLINE | ID: mdl-33211950

RESUMO

Objective: Obesity has become a public health crisis and continues to be on the rise. An elevated BMI has been linked to higher rates of spinal degenerative disease requiring surgical intervention. Limited studies exist that evaluate the effects of obesity on peri-operative complications in patients undergoing anterior cervical discectomy and fusion (ACDF). Our study aims to determine the incidence of obesity in the ACDF population and the effects it may have on postoperative in-patient complications. Methods: The National Inpatient Sample was evaluated from 2004 to 2014 and discharges with International Classification of Diseases procedure codes indicating ACDF were identified. This cohort was stratified into patients with diagnosis codes indicating obesity. Separate univariable followed by multivariable logistic regression analysis were performed for the likelihood of peri-operative inpatient outcomes among the patients with obesity. Results: From 2004 to 2014 an estimated 1,212,475 ACDFs were identified in which 9.2% of the patients were obese. The incidence of obesity amongst ACDF patients has risen dramatically during those years from 5.8% to 13.4%. Obese ACDF patients had higher inpatient likelihood of dysphagia, neurological, respiratory, and hematologic complications as well as pulmonary emboli, and intraoperative durotomy. Conclusion: Obesity is a well-established modifiable comorbidity that leads to increased perioperative complications in various surgical specialties. We present one of the largest retrospective analyses evaluating the effects of obesity on inpatient complications following ACDF. Our data suggests that the number of obese patients undergoing ACDF is steadily increasing and had a higher inpatient likelihood of developing peri-operative complications.

7.
Childs Nerv Syst ; 2020 Nov 24.
Artigo em Inglês | MEDLINE | ID: mdl-33236183

RESUMO

BACKGROUND: Atypical teratoid/rhabdoid tumor (ATRT) is a rare and largely pediatric diagnosis, with poor survival. Diagnosis below the age of 3 years is characteristically seen as a poor prognostic sign. However, elucidating if clinical differences exist within this niche age group has never been attempted before. Correspondingly, we sought to characterize clinical profile of ATRT diagnoses before the age of 3 years based on separate ages of diagnosis. METHODS: All pediatric ATRT patients aged < 3 years in the US National Cancer Database (NCDB) between 2005 and 2016 were retrospectively reviewed. Age groups were divided based on diagnoses at ages 0-1 years in group 1, 1-2 years in group 2, and 2-3 years in group 3. Data were summarized, and overall survival (OS) was modeled using Kaplan-Meier and Cox regression analyses. RESULTS: A total of 354 ATRT diagnoses were made before the age of 3 years, with surgery used in 316 (89%) cases, chemotherapy in 242 (68%) cases, and radiation therapy in 118 (33%) cases. In terms of diagnosis age, there were 153 (43%) in group 1, 137 (39%) in group 2, and 64 (18%) in group 3. With respect to OS, median value was 9.9 months in group 1, 28.4 months in group 2, and 15.9 months in group 3. Upon multivariate analysis, receiving radiation therapy was the only parameter shared amongst all three groups as independently prognostic of longer OS (HR 0.53, P = 0.01 in group 1; HR 0.34, P < 0.01 in group 2; HR 0.31, P < 0.01 in group 3). In group 1, surgery (HR 0.47, P < 0.01) and chemotherapy (HR 0.44, P < 0.01) were also independently prognostic of longer OS. In group 3, multiple socioeconomic parameters were identified to independently predict longer OS. There were no additional predictive parameters identified in group 2. CONCLUSION: Although ATRT diagnosed before the age of 3 is typically viewed a poor prognostic age category, our findings demonstrate that the clinical profile of this pediatric niche is highly heterogeneous based on age of diagnosis. Survival of only those diagnosed between 0 and 1 years is independently prognosticated by all three treatment modalities; patients diagnosed between 1 and 2 years trend towards longest survival, and socioeconomic parameters are most influential in those diagnosed between 2 and 3 years.

9.
J Neurooncol ; 149(3): 533-542, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33057919

RESUMO

PURPOSE: Magnetic resonance-guided laser interstitial thermal therapy (LITT) has been increasingly used to treat a number of intracranial pathologies, though its use in the posterior fossa has been limited to a few small series. We performed a multi-institutional review of targets in the posterior fossa, reporting the efficacy and safety profile associated with laser ablation in this region of the brain. METHODS: A retrospective review of patients undergoing LITT in the posterior fossa was performed from August 2010 to March 2020. Patient demographic information was collected alongside the operative parameters and patient outcomes. Reported outcomes included local control of the lesion, postoperative complications, hospital length of stay, and steroid requirements. RESULTS: 58 patients across four institutions underwent LITT in the posterior fossa for 60 tumors. The median pre-ablation tumor volume was 2.24 cm3. 48 patients (50 tumors) were available for follow-up. An 84% (42/50) overall local control rate was achieved at 9.5 months median follow up. There were two procedural complications, including insertional hemorrhage and laser misplacement and 12/58 (21%) patients developed new neurological deficits. There was one procedure related death. The median length of hospital stay was 1 day, with 20.7% of patients requiring discharge to a rehabilitation facility. CONCLUSIONS: LITT is an effective approach for treating pathology in the posterior fossa. The average target size is smaller than what has been reported in the supratentorial space. Care must be taken to prevent injury to surrounding structures given the close proximity of critical structures in this region.

11.
Cureus ; 12(9): e10416, 2020 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-33062532

RESUMO

Introduction Growth of surgical caseload among specialties with a large contribution margin is an important financial objective for hospitals. In this study, we examined the diversity of referral patterns to a neurosurgeon over an eight-year interval and examined practice attributes related to surgical growth. Methods The electronic records of all patients undergoing an intracranial surgical procedure between August 2011 and August 2019 by an academic neurosurgeon were reviewed retrospectively. The Herfindahl-Hirschman index (HHI) was used to assess the distribution of referrals among community physicians who referred such patients; a value of HHI <0.15 indicates diversity. The yearly HHI trend was evaluated using meta-regression. Results The neurosurgeon's brain surgery caseload progressively increased on an annual basis from 1.4 to 12.5 cases per week between 2012 and 2018. Among the 1540 cases referred by 1775 different physicians, 78% were from three counties in southeast Florida and 8.1% from two counties in southwest Florida. The HHI declined between 2013 and 2018 by 0.023 per year (0.0046 standard error [SE], p = 0.0073) with the estimated value 0.0063 (0.0014 SE) < 0.15 in 2018 (p < 0.0001). The findings indicate that the base of referring physicians was highly diverse and that growth in caseload was accompanied by significantly less concentration of referrals. Conclusion Surgical growth in the neurosurgeon's practice resulted from a small number of referrals from many physicians, not from many referrals from a small number of physicians. Few physicians referred a sufficient number of patients to warrant attribution of the referral itself to personal knowledge of their patients' eventual outcomes. Rather, factors promoting timely access to patient care appear to have been the driving force for growth.

12.
Neurosurg Clin N Am ; 31(4): 537-547, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32921350

RESUMO

Laser interstitial thermal therapy is a minimally invasive surgical alternative to craniotomy that uses laser light through a fiber optic probe placed within a target lesion to create thermal tissue damage, resulting in cellular death. It is used in neuro-oncology to treat inaccessible lesions and obviate morbidity in high-risk patients. Overall complication rates and outcome measures are comparable with those seen in radiation and/or craniotomy. Laser interstitial thermal therapy can be an effective option for recurrent brain metastases. Prospective, randomized trials must be performed to evaluate the efficacy of laser interstitial thermal therapy as a primary treatment for brain metastases.

13.
World Neurosurg ; 144: e926-e933, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32992058

RESUMO

BACKGROUND: The coronavirus disease 2019 pandemic has led to sweeping changes in residency programs across the world, including cancellation of elective cases. The effects of safety measures on neurosurgical training remain unclear. To understand how neurosurgical residents have been affected, we analyzed the operative experience in the months leading up to and during the pandemic. METHODS: The resident and institutional case totals were tallied for a single residency program in Miami-Dade County from January 1, 2019 to June 30, 2020. A matched cohort analysis was performed before and during the pandemic to assess the effects on resident surgical training. RESULTS: The case totals for all levels of training were lower when restrictions were placed on elective surgeries. An average of 11 cases was logged in April 2020, a decrease from 26 cases in April 2019 (95% confidence interval, 8.7-22; P < 0.01). An average of 20 cases was logged in May 2020, a decrease from 25 cases in May 2019 (95% confidence interval, 1.2-8.8; P = 0.01). In April and May 2020, 299 (66%) and 148 (50%) fewer cases had been performed at our institution compared with April and May 2109. CONCLUSIONS: Operative experience was reduced for residents during the months when the performance of elective cases was restricted. Our data suggest experience in some areas of neurosurgery were more affected than were others, and residents at different levels of training were also affected differently. However, the extent of the coronavirus disease 2019 pandemic on neurosurgical training is unlikely to be understood in the short term.

14.
J Neurointerv Surg ; 2020 Aug 25.
Artigo em Inglês | MEDLINE | ID: mdl-32843358

RESUMO

BACKGROUND: Many neurointerventionalists have transitioned to transradial access (TRA) as the preferred approach for neurointerventions as studies continue to demonstrate fewer access site complications than transfemoral access. However, radial artery spasm (RAS) remains one of the most commonly cited reasons for access site conversions. We discuss the benefits, techniques, and indications for using the long radial sheath in RAS and present our experience after implementing a protocol for routine use. METHODS: A retrospective review of all patients undergoing neurointerventions via TRA at our institution from July 2018 to April 2020 was performed. In November 2019, we implemented a long radial sheath protocol to address RAS. Patient demographics, RAS rates, radial artery diameter, and access site conversions were compared before and after the introduction of the protocol. RESULTS: 747 diagnostic cerebral angiograms and neurointerventional procedures in which TRA was attempted as the primary access site were identified; 247 were performed after the introduction of the long radial sheath protocol. No significant differences in age, gender, procedure type, sheath sizes, and radial artery diameter were seen between the two cohorts. Radial anomalies and small radial diameters were more frequently seen in patients with RAS. Patients with clinically significant RAS more often required access site conversion (p<0.0001), and in our multivariable model use of the long sheath was the only covariate protective against radial failure (OR 0.061, 95% CI 0.007 to 0.517; p=0.0103). CONCLUSION: In our experience, we have found that the use of long radial sheaths significantly reduces the need for access site conversions in patients with RAS during cerebral angiography and neurointerventions.

15.
World Neurosurg ; 144: 94-98, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32841795

RESUMO

BACKGROUND: To our knowledge, we report the first case of a cholangiocarcinoma brain metastasis successfully treated with magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy. CASE DESCRIPTION: In 2017, a 71-year-old man was diagnosed with unresectable intrahepatic cholangiocarcinoma. In August 2018, a brain MRI scan was performed after a transient episode of altered mental status and revealed a subcentimeter enhancing lesion in the deep white matter of the right cerebellum. Due to lack of symptoms and the small size of the lesion, it was initially observed. However, a follow-up MRI scan at 2.5 months demonstrated increased lesion size with worsening perilesional edema. Given the rarity of cholangiocarcinoma brain metastases and the deep location, the patient underwent stereotactic needle biopsy to confirm the diagnosis followed by laser ablation as a primary treatment for the metastasis. The patient tolerated the surgery well with no complications, and the postoperative course was uneventful. At 16 months postablation, there has been no recurrence or disease progression. CONCLUSIONS: Although prognosis for these tumors is poor, our result suggests that laser ablation can be an effective treatment for this rare entity and is a representative example of the expanding indications for laser interstitial thermal therapy.

17.
World Neurosurg ; 144: 125-135, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32730974

RESUMO

BACKGROUND: Lung carcinoma metastasizing to a skull base meningioma remains an extremely rare phenomenon, with only 3 studies reported. Furthermore, no documented cases have been reported in the petroclival region. Thus, we have presented the first 2 cases of tumor-to-tumor metastasis (TTM) in which a petroclival lesion, initially thought to be purely meningioma, was also found to contain metastatic lung adenocarcinoma. CASE DESCRIPTION: We present the cases of 2 patients with a known history of lung adenocarcinoma and stable petroclival meningioma who had presented with new-onset neurologic deficits. Repeat imaging studies for both patients found an increased lesion size and peritumoral enhancement; thus, both patients underwent emergent craniotomy for complete lesion resection. Intraoperatively, both lesions had zones of markedly different tumoral texture. On histologic analysis, both lesions showed metastatic lung adenocarcinoma contained within the primary petroclival meningioma. CONCLUSION: Skull base TTM is a rare entity for which no specific management guidelines have been created. Therefore, even if the imaging characteristics suggest a more benign process, skull base TTM should remain high on the differential diagnosis for patients with a known primary cancer and new-onset, rapidly progressive, neurologic deficits. Close clinical follow-up with short-interval repeat imaging in this subset of patients might prevent misdiagnosis and facilitate prompt treatment.

18.
J Neurooncol ; 148(3): 501-508, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32627128

RESUMO

PURPOSE: Extent of resection remains a paramount prognostic factor for long-term outcomes for glioblastoma. As such, supramaximal resection or anatomic lobectomy have been offered for non-eloquent glioblastoma in an attempt to improve overall survival. Here, we conduct a propensity-matched analysis of patients with non-eloquent glioblastoma who underwent either lobectomy or gross total resection of lesion to investigate the efficacy of supramaximal resection of glioblastoma. METHODS: Patients who underwent initial surgery for gross total resection or lobectomy for non-eloquent glioblastoma at our tertiary care referral center from 2010 to 2019 were included for this propensity-matched survival analysis. Propensity scores were generated with the following covariates: age, location, preoperative KPS, product of perpendicular maximal tumor diameters, and product of perpendicular FLAIR signal diameters. Inverse probability of treatment weighting (IPTW) with generated propensity scores was used to compare progression-free survival and overall survival. RESULTS: Sixty-nine patients were identified who underwent initial resection of glioblastoma for non-eloquent glioblastoma from 2010 to 2019 (GTR = 37, lobectomy = 32). Using IPTW, overall survival (30.7 vs. 14.1 months) and progression-free survival (17.2 vs. 8.1 months were significantly higher in the lobectomy cohort compared to the GTR group (p < 0.001). There was no significant difference in pre-op or post-op KPS or complication rates between the two groups. CONCLUSION: Our propensity-matched study suggests that lobectomy for non-eloquent glioblastoma confers an added survival benefit compared to GTR alone. For patients with non-eloquent glioblastoma, a supramaximal resection by means of an anatomic lobectomy should be considered as a primary surgical treatment in select patients if feasible.

19.
World Neurosurg ; 141: 373-376, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32634635

RESUMO

BACKGROUND: Idiopathic intracranial hypertension (IIH), or pseudotumor cerebri, is a rare disorder marked by an increase of cerebrospinal fluid pressure that may cause severe headaches, papilledema, vision loss, and other symptoms. IIH is typically treated with shunts, but shunts are prone to malfunction and infection, resulting in many patients experiencing recurrent headaches after treatment. CASE DESCRIPTION: A 41-year-old woman with IIH presented with a history of severe headaches and seizures with documented elevated intracranial pressure (opening pressure 250 mm H2O). After failure of several medical treatments, the patient was offered surgery for symptomatic relief. Given the patient's ventricular anatomy and preference, IIH was treated with endoscopic third ventriculostomy rather than a conventional shunt. CONCLUSIONS: Reported resolution of the patient's headaches and improved quality of life following the procedure indicated that endoscopic third ventriculostomy can be used to treat IIH if ventricles are not completely slitlike. Additionally, we present a review of all previously reported cases in which endoscopic third ventriculostomy was used for the treatment of IIH.

20.
Neurosurgery ; 2020 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-32687191

RESUMO

BACKGROUND: Evolving requirements for patient and physician safety and rapid regulatory changes have stimulated interest in neurosurgical telemedicine in the COVID-19 era. OBJECTIVE: To conduct a systematic literature review investigating treatment of neurosurgical patients via telemedicine, and to evaluate barriers and challenges. Additionally, we review recent regulatory changes that affect telemedicine in neurosurgery, and our institution's initial experience. METHODS: A systematic review was performed including all studies investigating success regarding treatment of neurosurgical patients via telemedicine. We reviewed our department's outpatient clinic billing records after telemedicine was implemented from 3/23/2020 to 4/6/2020 and reviewed modifier 95 inclusion to determine the number of face-to-face and telemedicine visits, as well as breakdown of weekly telemedicine clinic visits by subspecialty. RESULTS: A total of 52 studies (25 prospective and 27 retrospective) with 45 801 patients were analyzed. A total of 13 studies were conducted in the United States and 39 in foreign countries. Patient management was successful via telemedicine in 99.6% of cases. Telemedicine visits failed in 162 cases, 81.5% of which were due to technology failure, and 18.5% of which were due to patients requiring further face-to-face evaluation or treatment. A total of 16 studies compared telemedicine encounters to alternative patient encounter mediums; telemedicine was equivalent or superior in 15 studies. From 3/23/2020 to 4/6/2020, our department had 122 telemedicine visits (65.9%) and 63 face-to-face visits (34.1%). About 94.3% of telemedicine visits were billed using face-to-face procedural codes. CONCLUSION: Neurosurgical telemedicine encounters appear promising in resource-scarce times, such as during global pandemics.

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