By O. Orknarok. American Public University.

Granulomatous infections Generally round or oval quality 20mg erectafil erectile dysfunction 35 years old, well-circumscribed Histoplasmosis discount 20mg erectafil with visa erectile dysfunction treatment massachusetts, tuberculosis purchase erectafil 20 mg without prescription erectile dysfunction after radiation treatment for rectal cancer, coccidioidomyco- (Figs C 8-2 and C 8-3) nodules. Several round lesions, many with cavitation, are seen throughout the lungs in this intravenous drug abuser with staphylococcal tricuspid endocarditis. Bilateral diffuse intermediate-sized nodules Fig C 8-2 24 along with patchy consolidation at the lung bases. Varicella (chickenpox) nodules often calcify 1 year or more after the initial infection (see Fig C 17-5). Paragonimus westermani Well-circumscribed cystic masses that have a Characteristic appearance of multiple ring opacities (Fig C 8-6) predilection for the periphery of the lower lobes. Multiple ill-defined and occasio- throughout the lungs that developed in a patient who nally confluent nodules throughout the lungs in a young child had undergone a renal transplant 3 months earlier and with severe combined immunodeficiency disease. The cysts are thin walled, and most have a prominent crescent-shaped opacity along one side of their borders, the characteristic ring shadow of paragonimiasis. Bronchioloalveolar Poorly defined nodules scattered throughout Other presentations include a single well- (alveolar cell) carcinoma both lungs. Lymphoma Multiple nodules that often have fuzzy outlines Manifestation of secondary disease. Pulmonary arteriovenous Sharply defined, round or oval, often slightly Diagnosis requires identification of the feeding fistulas lobulated nodules that predominantly involve artery and the draining vein. The lesions may change in third of the fistulas are multiple (arteriography of size between the Valsalva and the Mueller both lungs required if surgical resection is contem- maneuvers. Wegener’s granulomatosis Round, fairly well-circumscribed nodules that Cavitation (thick walled with irregular, shaggy (see Fig C 11-14) may simulate metastases. Rheumatoid necrobiotic Smooth, well-circumscribed nodules that Rare manifestation of rheumatoid lung disease nodules predominantly occur in peripheral subpleural that tends to wax and wane in relation to the acti- (Fig C 8-10) locations. Cavitation is common (thick walled vity of the rheumatoid arthritis and the presence of with smooth inner margins). Amyloidosis Multiple nodules that may cavitate and show Discrete masses of amyloid may develop in the rare calcification or ossification. The nodular parenchymal form of the disease has a better prognosis than the tracheobronchial (obstructive) or diffuse interstitial types (see Fig C 4-27). Pulmonary hematomas Unilocular or multilocular, round or oval Result from hemorrhage into pulmonary paren- (see Fig C 6-14) nodules that are occasionally huge. May peripheral subpleural locations deep to areas of communicate with the bronchial tree (air-fluid maximum trauma. Multiple well-circumscribed, rounded nodules of varying size in a patient with subcutaneous rheumatoid nodules. Usually associated with a (Fig C 8-12) nodules that may simulate metastatic disease. Pulmonary ossification Small, densely calcified or ossified nodules Primarily a manifestation of mitral stenosis (or throughout the lungs. Pneumoconiosis (progressive Conglomerate masses that predominantly Masses represent confluence of individual silicotic massive fibrosis) involve the upper lobes and are usually irregular nodules, sometimes associated with superimposed (Figs C 8-13 and C 8-14) and ill defined with peripheral stranding. They typically develop in the mid-zone or periphery of the lung and tend to migrate toward the hilum. Polyarteritis Poorly defined nodules that are often associated The pulmonary manifestations typically show with patchy consolidations. The angiographic demonstration of multiple arterial aneurysms in one or more abdominal organs is considered virtually diagnostic of this disease. Mucoid impactions Multiple (more commonly single), round, oval, Usually associated with hypersensitivity broncho- (see Fig C 6-18) or elliptical opacities caused by plugs in dilated pulmonary aspergillosis in patients with asthma or bronchi. Non- Fig C 8-14 segmental areas of homogeneous density in both upper Progressive massive fibrosis in silicosis. Granulomatous infections Generally round or oval, well-circumscribed Histoplasmosis, tuberculosis, coccidioidomycosis, (Fig C 9-2) nodules. Calcification is common in histoplasmosis, tuberculosis, and coccidioi- domycosis; cavitation is common in coccidioi- domycosis. Hematogenous metastases Various patterns (from diffuse micronodular Nodules typically vary in size in the same patient. Ground-glass opacification, with peripheral solitary nodule, Focal “pneumonia,” a (Fig C 9-5) areas of increased density representing ele- miliary pattern, or thin-walled cystic lesions. Multiple cavitating nodules Fig C 9-2 (Nocardia) in a young immunocompromised man. Multiple intermediate-sized nodules in a feeding vessel sign (vessel leading directly to the nodule) in patient with persistent and worsening symptoms of cough, several nodules (arrows). Several cavitating nodules Fig C 9-4 (arrows) in both lower lobes with irregular thickening of the Kaposi’s sarcoma. Innumerable, bilateral, poorly defined walls in a patient with metastatic squamous cell cancer of the peribronchovascular micronodules, some of which exhibit lungs. The mass in the left lower lobe also contains solid elements, consistent with the diagnosis of bronchoialveolar carcinoma with adenocarcinoma features. Pulmonary arteriovenous Sharply defined, round or oval, often slightly Diagnosis requires identification of the feeding fistulas lobulated nodules that predominantly involve artery and the draining vein. Wegener’s granulomatosis Round, fairly well-circumscribed nodules that Cavitation (thick walled with irregular, shaggy (Fig C 9-8) may simulate metastases. Multiple pulmonary nodules on a study obtained some of which contain air-fluid levels. Cavitation is common (thick walled the rheumatoid arthritis and the presence of with smooth inner margins). Amyloidosis Multiple nodules that may cavitate and show Discrete masses of amyloid may develop in the rare calcification or ossification. Pulmonary hematomas Unilocular or multilocular, round or oval Result from hemorrhage into pulmonary paren- nodules that are occasionally huge. May peripheral subpleural locations deep to areas of communicate with the bronchial tree (air- maximum trauma fluid level). Usually associated with a (Fig C 9-10) nodules that may simulate metastatic disease. Pneumoconiosis (progressive Conglomerate masses that predominantly Masses represent confluence of individual silicotic massive fibrosis) involve the upper lobes and are usually irregular nodules, sometimes associated with superimposed (Fig C 9-11) and ill defined with peripheral stranding. They typically develop in the mid-zone or periphery of the lung and tend to migrate toward the hilum. Two large, pleural-based nodules (large arrows) are seen at the level of the left upper lobe. The nodules are associated with marked posterior left-sided pleural thickening (small arrows).

Advancing the Colon Segment to the Neck Be certain to enlarge the diaphragmatic hiatus (see Fig purchase erectafil 20mg amex erectile dysfunction meaning. The most direct route to the neck follows the course of the original esopha- geal bed in the posterior mediastinum order generic erectafil from india erectile dysfunction medication otc. Place several studies between the proximal end of the colon transplant and the distal end of the esophagus; then draw the colon up into the neck by withdrawing the esophagus into the neck order erectafil without prescription erectile dysfunction cialis. This brings the colon into the posterior mediastinum behind the arch of the aorta and into the neck posterior to the trachea. If there is no constriction in the chest along this route, the ster- num and clavicle at the root of the neck are also not likely to Fig. Before closing the anterior portion of the of adjacent sternal manubrium to be certain there is no anastomosis, ask the anesthesiologist to pass a nasogastric obstruction at that point. Obtain a sterile plastic Retrosternal Passage of Colon Transplant sheath such as a laser drape and suture the end of this plastic When the posterior mediastinum is not a suitable pathway cylinder to the termination of the rubber catheter. Insert the for the colon or if the esophagus has not been removed, make proximal end of the colon into this plastic sheath and suture a retrosternal tunnel to pass the colon up to the neck. By withdrawing the cath- left lobe of the liver is large or if it appears to be exerting eter through the thoracic cavity into the neck, the colon with pressure on the posterior aspect of the colon transplant, liber- its delicate blood supply can be delivered into the neck with- ate the left lobe by dividing the triangular ligament. If the xiphoid process curves posteri- nal cavity lies in a straight line and there is no surplus of orly and impinges on the colon, resect the xiphoid. Leaving redundant colon in the thorax Enter the plane just posterior to the periosteum of the ster- may produce a functional obstruction to the passage of food. Start the dissection with Metzenbaum scissors; then Then suture the colon to the muscle of the diaphragmatic insert one or two fingers of the right hand. Finally, pass the hiatus with interrupted sutures of atraumatic 4-0 Tevdek at entire hand just deep to the sternum up to the suprasternal intervals of about 2 cm around half the circumference of the notch. This helps maintain a direct passageway from the segment so the mesentery enters from the patient’s left side. Be sure not to pass the needle deep Resect the medial 3–4 cm of clavicle using a Gigli saw. Then to the submucosa of the colon, as colonic leaks have been rongeur away about 2 cm of adjacent sternal manubrium to reported to result from this error. Pass Dissecting the Cervical Esophagus a long sponge holder into the retrosternal tunnel from the Change the position of the patient’s left hand, which is sus- neck down into the abdomen and suture the proximal end of pended from the ether screen. Turn the head pass the colon into the substernal tunnel while simultane- slightly to the right and make an incision along the anterior ously drawing the sutures in a cephalad direction. Be vicular head if it is performed on the side opposite the domi- careful not to damage the left or the right recurrent laryngeal nant hand. After dissecting the esophagus free down into the the colon segment is good, perform the esophagocolonic superior mediastinum, extract the thoracic esophagus by anastomosis as above. Cyanosis indicates venous obstruction, which anastomosis and leave them in place 7–10 days. Close the thoracoabdominal inci- transplant to a point about 6–7 cm above the cut end of the sion as illustrated in Figs. Colon Interposition, Short Segment Esophagocolonic Anastomosis Perform an end-to-side esophagocolonic anastomosis at a In rare cases of benign peptic stricture of the lower esopha- point about 4 cm below the proximal end of the colon using gus, it is impossible to dilate the stricture, even in the operat- a technique similar to that described in Figs. If the exploration appears satisfactory, close the opening in the colon about 1 cm away from the circular stapled anastomosis using a 55-/3. Jejunum Interposition Incision and Mobilization Although Polk advocated mobilizing the esophagogastric junction through an upper midline abdominal incision, we prefer the left sixth-interspace thoracoabdominal incision with a vertical midline abdominal component. This is because the jejunal interposition operation is performed pri- marily in patients who have had multiple failed previous operations for reflux esophagitis. The Collis-Nissen gastro- plasty combined with dilatation of the esophageal stricture suffices in most patients. This leaves a few of the most advanced cases that require a colon (short segment) or jeju- num interposition. The combined thoracoabdominal incision provides superb exposure and makes this operation as safe as possible. It should be emphasized that creating a jejunal segment is much more difficult than the short-segment colon interposi- tion. When performing the thoracoabdominal incision, incise the diaphragm with electrocautery in a circumferential fash- ion, as depicted in Fig. Dissect the left lobe of the liver carefully away from the anterior wall of the stomach; in doing so, approach the dis- section from the lesser curvature aspect of the stomach. At the same time, incise the gastrohepatic omentum by proceed- ing up toward the hiatus. It may also be difficult pulmonary ligament, resect the diseased esophagus down to to free the upper stomach from its posterior attachments to the esophagogastric junction and replace the missing esoph- the pancreas. Careful dissection with good exposure from agus with a short isoperistaltic segment of colon to extend the thoracoabdominal incision should make it possible to from the divided esophagus to a point about one-third the preserve the spleen from irreparable injury. Freeing the esophagus in the middle colic artery, and only the distal portion of the the upper abdomen may be expedited by first dissecting the transverse colon and the splenic flexure need be employed. The esoph- Resection of Diseased Esophagus agocolonic anastomosis may be sutured in an end-to-end After the esophagus has been freed from its fibrotic attachments fashion, an end-to-side fashion, or even by a stapling tech- in the mediastinum and upper stomach, select a point near the nique. The latter involves inserting a proper circular stapling esophagogastric junction for resection. If the upper stomach cartridge (generally 28 or 25 mm) into the open proximal has been perforated during this dissection and the perforation end of the colonic segment. If the upper stom- between the end of the esophagus and the side of the colon ach is not excessively thickened, apply a 55- or 90-mm linear by the usual circular stapling technique. Transect the gaging the instrument, explore the anastomosis visually and esophagogastric junction just above the stapling device. A technique similar to that described in Deliver the transected esophagus into the chest and select the Figs. If the point of division of the esophagus is not higher than the Pass the nasogastric tube through this anastomosis down to the inferior pulmonary vein, jejunal interposition is a good method lower end of the jejunal graft. If the esophagus must be transected stapled esophagojejunostomy by the technique described in at a higher level, use a short segment of colon for the interposi- Fig s. The mal margin of the stomach in an area of stomach that is rela- graft of jejunum may be lengthened safely if its circulation can tively free of fibrosis and that permits the vascular pedicle to be boosted by creating microvascular anastomoses from a tho- be free of tension. This may be done by the same suture tech- racic artery and vein to the upper end of the graft. The appearance of the vidualize the dissection according to the conditions completed anastomosis is shown in Fig. First, try to stretch the proximal jejunum in a cephalad direction to determine where the greatest mobility Jejunojejunostomy is located. Be certain to leave intact at least the first major Reestablish the continuity of the jejunum by creating a func- jejunal artery to the proximal jejunum.

Langenbecks failure buy discount erectafil 20mg on-line erectile dysfunction neurological causes, the anastomosis should be taken apart and done over erectafil 20 mg sale erectile dysfunction zocor, Arch Surg buy erectafil erectile dysfunction ed natural treatment. A prospective, con- trap of fuzzy thinking, which would permit acceptance of an trolled study of prophylactic drainage after colonic anastomoses. Practical experience of a no abdominal drainage policy in patients undergoing liver resection. The uses and abuses cellulitis, some surgeons believe the inflamed areas should of drains in abdominal surgery. This chapter provides an illustrated glossary of com- mon instruments and their names. Use this as a general guide and then learn the terms used in your own institutions. Instruments used during open surgery are shown first, followed by instruments used during laparoscopic surgery. The important characteristics are the length, the delicacy of the tips, curved versus straight (curved is more versatile), and whether the serrations extend all the way down to the hinge of the clamp Fig. This is a port designed to allow the surgeon to perform laparoscopic procedure through a single incision. It gives the surgeon the ability to use multiple instruments with maximal maneu- verability through adjustable cannulas all within a low-profile mallea- ble port Fig. This device seals vessels by a combination of pressure and monopolar elec- trocautery. It is also crucial to know if the This cannot be more true than in healthcare—no surgical surgeon was able to place the aortic clamp in the usual intervention can be considered completed until the operative infrarenal position or whether suprarenal clamping was note is done. The operative note is an essential part of the necessary to allow for the construction of the proximal patient’s medical care and records. Such details are essential for the proper standard of care in all hospitals accredited by The Joint planning and selection of the most appropriate treatment Commission or other international hospital accreditation option in the typically challenging reoperative situation. Most hospitals delineate in their bylaws or Trying to tackle this problem without knowing such details policies and procedure manuals their expectations for prompt can further complicate the management of such patient and accurate documentation of operative procedures. Not ful- Similarly consider a patient with Crohn’s disease requir- filling such documentation represents a deviation from the ing a second or third operation to manage yet another com- standards of care. It is very important to provided to the patient and reflects the quality of care deliv- know what was done or resected in the prior procedures and ered. Its value may not be immediately apparent, particularly the length of the remaining small bowel to select the most to the harried surgical resident. Such need may arise when the origi- may vary depending on the extent of the procedure. For nal healthcare provider is no longer available and a different example, the coding for skin grafting will depend on the sur- healthcare provider is going to assume care of that patient. Similarly, reimbursement for stab phle- Similarly if another operation becomes needed in the future, bectomy of varicose veins will vary depending on whether the pertinent details of what was performed during that oper- the number of phlebectomy sites performed is greater or less ation cannot be undervalued. Consider a patient with an aortic graft infection or aorto- For reimbursement purposes, the procedure must be indi- duodenal fistula. This patient will require an operation to cated and must have been performed and clearly docu- correct the problem; and, like all reoperations in the same mented. Thus, in the case cited, it is very important If the charts are audited for billing and the documentation to know the location and configuration of the aortic anasto- does not reflect the billing submitted, the surgeon will be mosis, whether it was performed using an end-to-end or required to pay back what was not properly documented even if it was performed, along with whatever fines may be deemed necessary. Hoballah may be the surgeon’s best ally or his worst foe depending on The operative note should clearly indicate that a the documentation level. Adverse events can occur during an “time-out” was performed to confirm the patient identity, operation in the best of hands. It should clarify the avoidance of describing them in the operative note and clari- position of the patient for the operation and clarify whether fying how they were managed can reflect negatively on the the positioning was performed according to the expected surgeon when the case is being reviewed. The positioning will clarify how the arms were with hoarseness following a thyroidectomy or tongue placed, whether cushion pads were used to support bony deviation following a carotid endarterectomy. The operative prominences and protect for any skin ulcerations or nerve note should indicate whether key structures were identified compression or stretch in select positions. The following elements should what type of incision and the location of the incision. It is very important to clar- • The preoperative diagnosis ify and document the intraoperative findings in the operative • The name of the procedure note, especially if there were unexpected findings or if they • The postoperative diagnosis caused a change in the procedure or the original planned • The indication for the procedure intervention. The postoperative diagnosis will identify of dissection, the extent of the dissection, the steps until whether the operative findings were supportive or different the completion of the procedure, and finally the closure of from the preoperative diagnosis. Finally it is also important to comment on the The indication section is a very essential part of the patient’s condition upon the completion of the procedure. All operative note as it will reflect the thinking process and these elements are very essential as they provide a clear doc- frame of mind of the surgeon prior to the operation. It will umentation of the indication for what was performed and clarify the justification for the operation that will be used how it was conducted. Such documentation will allow other if the case is being audited for billing issues or for mal- healthcare providers to care for this patient in the future if the practice litigation. It will also allow the surgeon to clarify patient care was transferred to another location or to another the reasoning behind selecting one approach versus state or if the initial surgeon is no longer capable of provid- another. It should document that the case was discussed ing care or if the patient wishes to switch to another health- with the patient and that the procedure was explained to care provider. Such note will provide the necessary the patient along with its risks and benefits. It will further documents for billing and auditing purposes and for risk confirm that an informed consent was obtained and who management. Suppose you were to read the opera- tive note and should include several components. Would components include the time-out, anesthesia type, monitor- it provide sufficient level of detail that you could easily visu- ing lines, Foley catheters, position, prepping and draping, alize what was done and why? The details of the procedure performed will include information in the management of these patients (DeOrio the anatomic location, specimen resected, viability of rem- 2002). Having templates for dictations or to describe the nants, configuration of anastomoses, staples or hand sewn, operative notes allows the surgeon to use a systematic any testing of anastomosis, placement of drains and tubes, approach to the dictation that will not allow for missing any and finally the closure technique. How to prepare an appropriate In summary the operative note is a solid reflection of the operative note was rarely taught or instructed to the budding care provided. It is the responsibility of the surgeon to ensure surgical residents starting their surgical training. Such need that the essential elements of a surgical procedure are was identified and addressed by a book entitled Operative promptly documented in an accessible operative note. Dictations in General and Vascular Surgery, coedited by Carol Scott-Conner and Jamal J Hoballah (2011), which has served as a companion to Chassin’s textbook. This has been References a very useful educational resource to the surgical residents in training as a quick guide prior to performing a surgical pro- DeOrio J. The quality of the operative report for women American Board of Surgery examination. New York: Springer Science + tate the ability of the surgeon to maintain soft copies of all his/ Business Communication; 2011. Gouge Advances in diagnostic studies, perioperative management, Important concepts are resection with adequate margins and the techniques of esophageal surgery have greatly of normal esophagus and stomach, resection of the fibroareo- reduced mortality, morbidity, and length of hospital stay.

The majority are slow growing cancers which can be successfully treated by adequate radical excision order generic erectafil on-line erectile dysfunction young age treatment. Microscopically four cell types can be identified — (i) mucin producing order discount erectafil line erectile dysfunction treatment ayurveda, (ii) squamous discount 20 mg erectafil overnight delivery erectile dysfunction treatment centers in bangalore, (iii) intermediate and (iv) clear cells. The intermediate is considered to be the precursor of the mucin producing and squamous cells. The low grade type presents as a well circumscribed mass having cystic areas with mucinous material. The high grade variety is grossly infiltrative and has less tendency to cyst formation. Soft cystic tumours are low grade malignant, whereas hard tumours are of high grade variety. The more malignant variety invades surrounding structures and is relatively fixed. This tumour is believed to arise from the ducts and is unique in being as common in submandibular gland as in the parotid gland. This tumour also occurs in the trachea, bronchi, paranasal sinuses, pharynx and lacrimal glands. The microscopic pattern of adenoid cystic carcinoma has certain well defined characteristics. Nests of columnar cells are seen arranged concentrically around a gland like space filled with mucin or mucohyaline material. But microscopic variations may occur in which pseudoglandular spaces do not occur and only small nests of highly infiltrative tumour cells are seen. Due to its affinity to invade perineural lymphatics, there may be areas of anaesthesia of the skin and high frequency of facial nerve paralysis. It may invade the medullary bone for many centimetres before showing significant bone resorption. Two-thirds of the tumours occur in women and are most common in 4th and 5th decades. Clinically it presents as round or ovoid encapsulated tumour which is usually solitary. This tumour is known for its highly cellular nature and relative absence of supporting stroma. The tumour cells are round or polygonal resembling serous cells of the salivary glands. Microscopically it shows well defined papillary structures and mucin in the stroma. This tumour is also rare, but it is seen in the submandibular gland where prognosis is even worse than that in the parotid. Pathologically this tumour is more or less similar to epidermoid carcinoma anywhere in the body with local invasion and spread to lymph nodes. In the submandibular gland the most common tumour is a metastatic carcinoma in the submandibular lymph nodes. It ultimately presents as a swelling on the lateral wall of the pharynx or posterior pillar of the fauces or as a swelling of the soft palate. If the growth is a slow growing one, it is usually a pleomorphic adenoma and no biopsy is required. If the growth is relatively rapid, it should be biopsied through a small incision on the posterior pillar of the fauces. Computed tomography often demonstrates the tumour with its size and anatomical position. Treatment is surgical excision of the tumour alongwith a margin of normal tissue and a covering- of connective tissue. It may require the mandible to be divided anterior to the mental foramen so that the angle may be retracted upwards. It may also require division of the styloid process between the origin of the stylopharyngeous and the styloglossus and stylohyoid muscles to facilitate dissection of the tumour under direct vision. There may be a history of a painless lump for quite a few years and recently the swelling has suddenly increased in size. When the tumour presents with clinical signs of malignancy, a fine-needle biopsy is almost always performed if the lump is easily accessible. In case of relatively inaccessible growth an open biopsy is performed for frozen section during the operation, followed by a radical excision. A few immediate reconstructive techniques have been used when facial nerve grafting is not possible. These techniques include immediate transfer of the masseter muscle to the paralysed comer of the mouth, use of dermal ligaments and modified tarsorrhaphy to support the paralysed eye lids. When a portion of the mandible has been excised, primary bone grafting may be used to replace the mandible. Other advanced parotid cancers that are clearly non-resectable may be controlled for many months by appropriate X-ray therapy. Infusion with cyclophosphamide (Cycloxan or Endoxan) by retrograde catheter into the superficial temporal artery has produced marked regression in certain cases of advanced parotid carcinoma. Radical excision of the submandibular gland with adjacent mandible, a portion of the mylohyoid muscle, a portion of the tongue and lymph node dissection of the neck are performed to give adequate removal of the growth alongwith a considerable margin of healthy tissue. Occasionally such removal may require sacrifice of the lingual and hypoglossal nerves. Patients with such tumours require full-thickness resection of portions of the hard and the soft palate. Hard palate defects may be managed by the use of dental prosthesis, whereas defects of the soft palate are managed by immediate reconstruction using a flap of mucosa and muscle from the posterior pharynx. When other connective tissue disease is present the condition is called secondary Sjogren’s syndrome. When only the clinical triad (as mentioned above) is present, it is called primary Sjogren’s syndrome. There is mucous gland metaplasia of the duct epithelium which may lead to formation of gelatinous saliva in some patients. In general hypergamma globulinaemia, eosinophilia, leukopenia and cryoglobulinaemia are often noticed as laboratory findings. This condition is regarded as an autoimmune disease and very much resembles Hashimoto’s disease of the thyroid. One can find autoantibodies such as rheumatoid factor, antinuclear factor and salivary duct antibody in the serum. Swelling of the salivary glands in the form of localised nodules should arouse suspicion and must be differentiated from malignancy.

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