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Antonio M. Fea, 1 Andrea Gilardi, 1 Davide Bovone, 1 Michele Reibaldi, 1 Alessandro Rossi, 1 Earl R. Craven21 Diploma of the Scientific Ophthalmological University of Turin, Turin, Italy;2 Johns Hopkins University, Baltimore, Maryland, USA Elmer Eye Institute Glaucoma Center of Excellence Umbhali ohambelanayo: Antonio M. Fea, +39 3495601674, i-imeyili [i-imeyili evikelwe] Abstract: PRESERFLO™ MicroShunt iyithuluzi elisha lokuhlinzwa kwe-glaucoma engavamile (MIGS) ) kufakwe i-ab externo, ihlaya elinamanzi likhishelwa esikhaleni se-subconjunctival.Ithuthukiswe njengendlela yokwelapha ephephile nengangeneleli kancane ezigulini ezine-glaucoma evulekile-angle eyinhloko engalawulwa ngokwemithi (POAG).Indlela yakudala yokufakelwa kwe-MicroShunt ibandakanya izinyathelo ezibucayi ezahlukahlukene, okuhlanganisa ukudala iphakethe elincane le-scleral elinensingo engu-1mm, ukufaka inaliti engu-25G (25G) ephaketheni le-scleral ekamelweni elingaphambili (AC), bese kuba i-23-gauge enodonga oluncane ( 23G ) I-cannula isula i-stent.Kodwa-ke, ukufakwa kwenaliti ephaketheni le-scleral kudala isiteshi esingalungile, okwenza kube nzima ukuxhuma idivayisi.Inhloso yalesi sihloko ukuphakamisa indlela eyenziwe lula yokufakelwa.Indlela yethu iphakamisa ukwenza umhubhe we-scleral usebenzisa inaliti ye-25G ngokuqondile futhi usebenzise le naliti engu-25G esithweni somzimba ukuze uqhube kancane i-sclera ku-AC.I-MicroShunt yabe isihlanganiswa ku-cannula engu-23G eyayixhunywe kusipetu esingu-1ml.Umshini ungabese ugundwa ngesirinji.Ngakho-ke, ukuphuma kwamanzi kungaqinisekiswa ngokushesha ngokubheka amaconsi amanzi aphuma ezimbotsheni zangaphandle ze-stent.Le ndlela entsha ingase ibe nezinzuzo ezihlukahlukene ezingaba khona njengokulawula okungcono indawo yokungena, ukugwema iziphaseji ezingamanga, ukuncishiswa noma ukuqedwa kwengozi yokuphuma eceleni kwamahlaya ane-aqueous, ukukhuthazwa kwendlela ehambisanayo eya endizeni ye-iris, kanye nesivinini esikhulu.Amagama angukhiye: I-MIGS, i-glaucoma evulekile, i-Preserflo, i-MicroShunt, ukuhlinzwa kwe-glaucoma, ukuhlunga kwe-subconjunctival.
Eminyakeni embalwa edlule, ukuhlinzwa okuncane kakhulu noma okuncane kakhulu (MIGS) kuvele emkhakheni wokuhlinzwa kwe-glaucoma.I-1-5 Lawa madivayisi e-MIGS athuthukiselwe ukwelashwa kweziguli ezingagadiwe ngokwezokwelapha ezine-primary open-angle glaucoma (POAG) ukuze kuthuthukiswe ukuphepha ngenkathi kugcinwa ukusebenza kahle kokunciphisa ukucindezela kwe-intraocular (IOP).Amadivayisi angu-1-5 MIGS angahlukaniswa abe yi: trabecular, suprachoroidal, kanye ne-subconjunctival.I-1,3 I-subconjunctival outflow ilingisa indlela ye-trabeculectomy.Uma kuqhathaniswa ne-trabeculectomy, ihlinzeka ngengcindezi ye-intraocular ephansi yangemva kokuhlinzwa, inikeza izinqubo ezijwayelekile nokuphepha okukhulu.1-5 Wonke amadivaysi e-subconjunctival asekelwe ekufakweni kwe-tubule.Ubukhulu be-lumen balawa madivayisi balinganiselwa kusetshenziswa i-Hagen-Poiseuille laminar flow equation.1 Ngokuvamile, i-lumen ikhethwa ukuvimbela i-hypotension engapheli futhi inkulu ngokwanele ukugwema ukuvaleka.
Nakuba kunenkulumompikiswano mayelana nokucabangela i-MicroShunt njenge-MIGS, ngezinjongo zalo mbhalo, igama elithi MIGS lizosetshenziswa kuyo.Ukufakelwa kwe-PreserfloTM MicroShunt kusanda kwethulwa.6 I-shunt iqukethe ibhulokhi ye-polystyrene, ibhulokhi ye-isobutylene, i-styrene polymer eyayisetshenziswa ngaphambilini njenge-coronary stent ngoba idala ukuvuvukala okuncane kanye ne-encapsulation.7,8 Idivayisi ingu-8.5 mm ubude futhi ine-lumen engu-70 µm yokulawula ukugeleza nokugcina i-IOP ingaphezu kuka-5 mmHg.(ngokukhiqizwa kwamanzi okumaphakathi).8 Ubude bedivayisi buvumela ukuphuma kwamanzi amaningi ngemuva, ngakho-ke ukusika okubanzi ngemuva kuyanconywa.
Ngokuvamile, i-oblique quadrant iyindawo ekhethwayo yokufakelwa njengoba igwema ukufinyelela kumsipha ophakeme we-rectus.Ukugxila kwe-Mitomycin-C (MMC) nezikhathi zokuchayeka ziyehluka kuye ngezici eziyingozi noma ulwazi lukadokotela ohlinzayo.9-16
Lokhu kubuka okufushane kuhloselwe ukucacisa ezinye izinguquko enqubweni yokufakelwa kwe-MicroShunt ngokushesha futhi kulula.
Ukubuyekezwa kwamarekhodi ezokwelapha kuvunywe yiKomidi Lokuziphatha leNyuvesi yaseTurin.Ngenxa yokuthi lokhu bekuwukubuyekezwa okubuyela emuva kwamarekhodi ezokwelapha, ikomidi lezimiso zokuziphatha liyekele imfuneko yokuthola imvume ebhaliwe enolwazi yokubamba iqhaza ocwaningweni.Kodwa-ke, bonke abahlanganyeli banikeze imvume ebhaliwe enolwazi ngaphambi kokuhlinzwa.
Ukuqinisekisa ubumfihlo besiguli, ulwazi lwaso lwenziwa lungaziwa kusetshenziswa izihlonzi ezihlukile.Iphrothokholi yocwaningo ilandele izimiso zeSimemezelo sase-Helsinki kanye Neziqondiso Zemitholampilo Enhle Yokuzilolonga/IKomidi Lokuxhumanisa Lamazwe Ngamazwe.
Ucwaningo lwamanje lwaluhlanganisa iziguli ze-POAG ezilandelanayo ≥iminyaka engu-18 ubudala kanye neziguli ezilashwe ngezidakamizwa ezine-IOP yangaphambi kokuhlinzwa ≥23 mmHg ezafakelwa i-MicroShunt ezimele.
I-PRESERFLOTM MicroShunt (i-Santen ex Innfocus, Miami, FL, USA) ihlinzekwa ngekhithi yokupakisha eyinyumba equkethe umaka we-scleral ongu-3 mm, i-1 mm triangular blade, 3 LASIK ShieldsTM (EYETEC, Antwerp, Belgium), umaka nosayizi 25 inaliti (25G).
Ngaphambi kokusebenzisa i-MicroShunt, umenzi uncoma ukugcwalisa kabusha nge-cannula engu-23G, engafakiwe kukhithi.
Nakuba kuhlanganisa ukuthi odokotela abahlinzayo be-glaucoma bajwayelene nenqubo yokufakelwa yakudala, ezinye zezinyathelo zingaba inselele.Ikakhulukazi, lapho inaliti ye-25G ishelela, ithiphu yayo ingase idale isiteshi esingalungile / esingalungile endizeni ehlukile noma ingene ekamelweni langaphambili ngaphandle kokufinyelela phezulu komhubhe we-scleral.Kunzima ngempela ukulawula indlela yenaliti ye-25G ngoba isikhala esingaphakathi komhubhe we-scleral singokoqobo, noma okungenani sincane kakhulu (bheka umdwebo 1).
Umfanekiso 1. Uhlolojikelele lwezigaba eziyinhloko zendlela entsha yokuhlinza.(A) Inaliti yakhelwe ukungena ku-sclera 3 mm ukusuka onqenqemeni.(B) Uma inaliti ifika esithweni, iphushelwa phansi.(C) Inaliti ingena ekamelweni elingaphambili.(D) Ngemva kokudala umhubhe onomugqa ongunxantathu, indlela yenaliti esetshenziselwa ukungena ekamelweni elingaphambili ingase ingalandeli umhubhe, idale umzila wamanga.
Kwezinye izimo, le nkinga ingenza ukufaka i-microshunt ekamelweni langaphambili (AC) kube nzima ngoba ithiphu layo livinjwe emhubheni.Ngaphezu kwalokho, lokhu kukhohlisa kungase kube nzima kakhulu emehlweni ane-limbal anatomy engavamile.
Futhi, uma umzamo wesibili usahluleka, udokotela ohlinzayo angase aphoqeleke ukuba afake idivayisi ngendlela ezuzisa kakhulu.Le sayithi ijwayele ukuba nezibazi ezilandelayo ngenxa yokuba khona kwe-superior rectus abdominis.
Ukuze ugweme le nkinga, inketho eyodwa ukujova i-AK ngesihloko sommese omncane osetshenziselwa ukwakha iphakethe le-sclera.Nakuba le ndlela yonga isikhathi futhi ivimbela ukudalwa kwezigaba ezinephutha, kungase kube nzima ukulinganisa ubude be-AC engenayo.Ukwengeza, ukuma kwe-triangular ye-blade ichaza indlela enkulu, eyenza ukugeleza kwe-lateral esikhathini sokuqala se-postoperative.Ngokomthetho ka-Poiseuille, ukugeleza kwe-lateral nakho kwenza imizamo yokudala ukuphuma kwamanzi okunikezwayo kusuka ku-AC, okungaba nomthelela ekuthuthukisweni kwe-hypotension.
Indlela yethu yokuhlinza inikeza ukuthuthuka okubili kunezinqubo zokuhlinzwa zendabuko.Okokuqala ukusebenzisa inaliti engu-25G ngokuqondile njengomhubhe.Njengentuthuko yesibili, indlela yethu iphakamisa ukunamathisela i-cannula engu-23G, evame ukusetshenziselwa i-silicone aspiration aspiration, ekupheleni kwe-MicroShunt.Ngakho, udokotela ohlinzayo angakwazi ukuhlanza idivayisi ngokuqondile ngesikhathi sokufakwa kwentambo.
Ukusebenzisa inaliti ye-25G ukwakha umhubhe kwenza inqubo yokuhlinza ibe lula njengoba iqeda isidingo se-pocket scleral futhi inciphisa kakhulu indawo ye-scleral ehilelekile kule nqubo.Ngaphezu kwalokho, lokhu kuthuthukiswa kusiza ukunciphisa umonakalo ongaba khona wesikhathi eside kumaseli e-endothelial ngokucindezela i-sclera njengoba isondela esithweni sangasese, ngaleyo ndlela ingene ku-iris endizeni ehambisana kakhulu (bheka Umfanekiso 1 kanye nevidiyo eyengeziwe).
Ukuthuthukiswa kwesibili okunikezwa ubuchwepheshe obusha ukusetshenziswa kwe-cannula engu-23 G, efana ne-cannula evame ukusetshenziselwa ukufisa uwoyela we-silicone.Le cannula engu-23G ilungisa kahle i-MicroShunt futhi yenza kube lula ukuyishayela.Ukwengeza, uketshezi olujovelwe ku-AC luphinde lwandise umfutho, okuvumela ukuhleka kwe-aqueous ukuthi kugeleze ekugcineni kwedivayisi (bheka Umfanekiso 1 nevidiyo eyengeziwe).
Okuhlangenwe nakho kwethu komtholampilo kwakuhlanganisa amehlo angu-15 avela ezigulini eziyi-15 ze-OAG ezathola i-microshunt ezimele futhi zalandelwa izinyanga ezingu-3.Nakuba kunedatha yezidakamizwa zokwehlisa umfutho we-intraocular kanye nezidakamizwa zokwehlisa umfutho we-intraocular, inhloso yethu enkulu bekuwukugxila ezinkingeni zangaphambi kokuhlinzwa.
Zonke iziguli zaziyi-Caucasian, i-median (i-interquartile range, i-IqR) ubudala yayiyi-76.0 (ububanzi be-71.8 kuya ku-84.3) iminyaka, i-6 (40.0%) yayingabesifazane.Izici ezibalulekile zezibalo zabantu kanye nomtholampilo zifinyezwa kuThebula 2.
I-Median (IqR) IOP yehle isuka ku-28.0 (27.0 yaya ku-32.5) mm Hg.Art.ekuqaleni kocwaningo kuya ku-11.0 (10.0 kuya ku-12.0) mm Hg.Art.ngemva kwezinyanga ezingu-3 (umehluko omaphakathi we-Hodges-Lehman: -18.0 mmHg, isikhawu sokuzethemba esingu-95%: -22.0 kuya ku-14.0 mmHg, p=0.0010) (Fig. 2).Ngokufanayo, inani lezidakamizwa ze-ophthalmic antihypertensive lehle kakhulu lisuka ku-3.0 (2.2-3.0) izidakamizwa ekuqaleni kuya ku-0.0 (0.0-0.12) izidakamizwa ezinyangeni ezi-3 (uHodges-Lehman usho umehluko: -2.5 izidakamizwa) Izidakamizwa, i-95% CI: -3.0 kuya ku-2.0 Umuthi, p = 0.0007).Ngemuva kwezinyanga ezi-3, asikho nesisodwa seziguli esathatha imishanguzo ye-systemic yokwehlisa i-IOP.
Umfanekiso 2 Kusho ingcindezi ye-intraocular ngesikhathi sokulandelela.Amabha aqondile amelela ububanzi be-interquartile. *p <0.005 uma kuqhathaniswa nesisekelo (ukuhlolwa kwe-Friedman nokuhlaziywa kwe-post hoc ukuze kuqhathaniswe ngokubili kwenziwe ngendlela ye-Conover). *p <0.005 uma kuqhathaniswa nesisekelo (ukuhlolwa kwe-Friedman nokuhlaziywa kwe-post hoc ukuze kuqhathaniswe ngokubili kwenziwe ngendlela ye-Conover). * p <0,005 по сравнению с исходным уровнем (критерий Фридмана и апостериорный анализ для попарных сравнений были выполнены по методу). * p <0.005 uma kuqhathaniswa nesisekelo (ukuhlolwa kukaFriedman nokuhlaziywa kwe-post hoc yokuqhathanisa ngakubili kwenziwe ngendlela ka-Conover). *p < 0.005 与基线相比（弗里德曼检验和成对比较的事后分析是使用Conover 方法完成的）. *p <0.005 * p <0,005                      * p <0.005 uma kuqhathaniswa nesisekelo (ukuhlolwa kukaFriedman nokuhlaziywa kwe-post hoc yokuqhathanisa ngakubili kwenziwe kusetshenziswa indlela ka-Conover).
I-Visual acuity yehla kakhulu ngosuku lwe-1, isonto le-1, nenyanga ye-1 uma kuqhathaniswa namanani angaphambi kokusebenza, kodwa yabuyiselwa futhi yaqiniswa kusukela ngenyanga ye-2 (Fig. 3).
Ilayisi.3. Ukubuyekezwa kwe-median acuity visual acuity elungiswe kakhulu (BCDVA) ngesikhathi sokulandelela.Amabha aqondile amelela ububanzi be-interquartile. *p <0.01 uma kuqhathaniswa nesisekelo (ukuhlolwa kwe-Friedman nokuhlaziywa kwe-post hoc ukuze kuqhathaniswe ngokubili kwenziwe ngendlela ye-Conover). *p <0.01 uma kuqhathaniswa nesisekelo (ukuhlolwa kwe-Friedman nokuhlaziywa kwe-post hoc ukuze kuqhathaniswe ngokubili kwenziwe ngendlela ye-Conover). *p < 0,01 по сравнению с исходным уровнем (критерий Фридмана и апостериорный анализ для попарных сравнений были выполнены по методу). *p <0.01 uma kuqhathaniswa nesisekelo (ukuhlolwa kuka-Friedman nokuhlaziywa kwe-post hoc yokuqhathanisa ngakubili kwenziwe kusetshenziswa indlela ka-Conover). *p < 0.01 与基线相比（Friedman 检验和成对比较的事后分析是使用Conover 方法完成的）。 *p <0.01 Bo ьзона коноверкон коновора). *p <0.01 uma kuqhathaniswa nesisekelo (ukuhlolwa kuka-Friedman nokuhlaziywa kwe-post hoc yokuqhathanisa ngakubili kwenziwe kusetshenziswa indlela ka-Conover).
Mayelana nokuphepha, amehlo amabili (13.3%) ahlakulela i-hyphema (cishe i-1 mm) ngosuku lokuqala lwangemva kokuhlinzwa, eyaxazululeka ngokuphelele phakathi nesonto.Ukuhlukaniswa kwe-peripheral choroidal kwenzeka emehlweni amathathu (20.0%), okuxazululwe ngempumelelo ngokwelashwa kwezokwelapha phakathi nenyanga eyodwa.Asikho isiguli esadinga ukungenelela okwengeziwe kokuhlinzwa.
Idatha etholakalayo njengamanje ehlola ukusebenza kahle nokuphepha kwe-MicroShunt ibonisa imiphumela ethembisayo, nakuba ilinganiselwe.I-9-16 Isipiliyoni sikadokotela ohlinzayo kanye nemiphumela yomtholampilo ibalulekile ekuthuthukiseni nasekwenzeni kube lula inqubo yokuhlinza.
Kulesi sihloko, sihlose ukukhombisa indlela esheshayo, engaguquki, nelula yokutshala le divayisi.Idatha yomtholampilo yendlela yayiklanyelwe ukubheka izinkinga zakuqala ezingase zihlotshaniswe nendlela, hhayi ukuhlaziya ukusebenza kwayo.
Idivayisi inezimbambo ezimbili eziseceleni, umsebenzi wethiyori ukuvimbela ukugeleza okungaseceleni nokuhamba kweMicroShunt.6,8 Izindlela zendabuko zibandakanya ukusetshenziswa kwe-blade engunxantathu ukuze kwakheke iphakethe le-scleral elingashoni ngemuva kwe-limbus kanye no-3 mm oseduze ne-limbus ukuze kufakwe la maphiko asemaceleni.Kodwa-ke, ubude bayo kanye neqiniso lokuthi iphakethe le-scleral liqala i-3 mm ukusuka ku-limbus kubangela ukuthi idivayisi iphumele ngokuphawulekayo ekamelweni langaphambili.Ngenxa yalokhu, asivamisile ukugxilisa izinsimbi ezinezimbambo ngaphansi kwephakethe le-scleral lapho sisebenzisa indlela yakudala ukuze sinqande ukumila kwedivayisi egumbini elingaphambili.
Ngobuchwepheshe bethu, i-stent ikhululekile ukunyakaza futhi isuswe njengoba izimbambo zifinyeleleka ngaphansi kwe-capsule ye-Tenon.Nokho, kufanele kugcizelelwe ukuthi akukho ukususwa okwenzeka kusampula yethu.
Ukusetshenziswa kwezinaliti ukudala imigudu ye-scleral yemishini yokudonsa amanzi afakwe akuyona into entsha.U-Albis-Donado et al.[17] ibike imiphumela emihle yomtholampilo ezigulini ezifakelwa ivalvu ye-Ahmed ye-glaucoma ngokusebenzisa umhubhe owenziwe ngenaliti owenziwe ngenaliti ngaphandle kokusebenzisa isiqephu esimboza ishubhu.
Ngobuchule bethu, sisebenzise i-25G enobubanzi obungaphandle obungu-0.515 mm kanye nobude bethrekhi obungu-3 ukuya ku-4 mm, eyayanele ukubamba ngokuphephile idivayisi endaweni.Uma kubhekwa ububanzi bangaphandle be-MicroShunt obungu-0.35mm, ukusebenzisa usiba oluncane kungase kuphumele ekubambeni okuzinzile nokugeleza okuncane kwe-lateral.Izinaliti 26 (0.466), 27G (0.413), noma i-28G (0.362) zingasetshenziswa, kodwa asinalo ulwazi ngezinaliti ezinobubanzi obuncane.Kudingeka olunye ucwaningo lwesikhathi esimaphakathi neside ukuze kuhlolwe lezi zinketho.
Enye inkinga engaba khona ngale ndlela ukuguguleka kwe-scleral.Kodwa-ke, kufanele kuqashelwe ukuthi indlela efanayo esebenzisa i-20G18 microvitreoretinal blade noma inaliti enkulu engu-22-23G17 iye yachazwa ngokufakwa kwe-Molteno ngaphandle kokufuduka noma ukuguguleka kwe-18 kanye no-Ahmed onokuhlehliswa kweshubhu okuncane (4/186).17
Inqubo yenaliti inezinzuzo eziningana kunezindlela zokufakelwa zendabuko, njengenqubo esheshayo, ukuguqulwa okuyisicaba phakathi kwe-conjunctiva ne-cornea, kanye nesigameko esiphansi se-dellen namabhamuza abuhlungu.17,18 Ukwengeza, zombili izifundo zibonise ukuthi ukungabikho kokugqwala kwakuhlotshaniswa nokulingana okuqinile phakathi kwepayipi nomhubhe, okubangele ukubola nokuguga okuncane.17.18
Mayelana nokuphepha, izinga lezinkinga zangemva kokuhlinzwa libonakala liphakeme ngandlela thize kunalokho elibikwe kwezinye izihloko, kodwa kufanele kuqashelwe ukuthi sithathe ukunakekela okukhethekile ukubika ngisho nezinkinga ze-prosaic kulesi sihloko, kodwa ayikho kulezi zinkinga eyayibalulekile emtholampilo. .
Nakuba izehlakalo zemigudu yamanga azizange zibikwe ezifundweni zangaphambilini ze-9-16, le nkinga ye-intraoperative ingase yenzeke futhi ibangele ukudalwa komunye umhubhe we-lateral, okwandisa ingozi ye-hyphema futhi mhlawumbe ithathe indawo.isikhundla esincane esivumayo.
Lo mbiko omfushane unemikhawulo eminingana okufanele ikhulunywe.Kulokhu, okubaluleke kakhulu usayizi wesampula olinganiselwe, isikhathi esifushane sokulandelela, nokuntuleka kweqembu lokulawula.Kodwa-ke, lesi sihloko sichaza indlela ethuthukisa kakhulu ukufakwa kwe-microshunt ngenani elifanayo lezinkinga ze-intraoperative kanye nezinkinga zangaphambi kokuhlinzwa njengezindlela ezivamile.9-16
Ekuphetheni, ukusetshenziswa kwenaliti ukudala indlela ye-intrascleral kubonise imiphumela ethembisayo kuleli qembu elincane leziguli.Ukusetshenziswa kwayo kungaba wusizo ikakhulukazi uma ukuba khona kwezinye izinto zokusebenza kunciphisa isikhala.Ucwaningo olwengeziwe luyadingeka ukuze kutholwe ukuzinza kwesikhathi eside kwale nqubo kanye nezinzuzo ezingaba khona zezinaliti ezincane.
Izinsizakalo zokubhala zezokwelapha nezomhleli zihlinzekwa ngu-Antonio Martínez (MD), u-Ciencia y Deporte SL, ngoxhaso olungakhawulelwe oluvela eNyuvesi yaseTurin.
Ababhali bangathanda futhi ukubonga i-A Mazzoleni, L Guazzone, C Caiafa, E Suozzo, M Pallotta, kanye noM Grindi ngokubambisana kwabo ngesikhathi socwaningo.
UDkt. Antonio M. Fea ungumxhumanisi we-Glaukos, Ivantis, iSTAR, EyeD, kanye nomxhumanisi okhokhelwayo wakwa-AbbVie, ngaphezu komsebenzi owethulwe.UDkt. Earl R. Craven njengamanje uyisisebenzi se-AbbVie futhi ubika izindleko zomuntu siqu kwa-Santen ngaphezu komsebenzi owethulwe.Ababhali ababiki okunye ukungqubuzana kwezintshisekelo kulo msebenzi.
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2. Bar-David L., Blumenthal EZ Ukuvela kokuhlinzwa kwe-glaucoma eminyakeni engama-25 edlule.Rambam Maimonides Med J. 2018;9(3):e0024.I-DOI: 10.5041/RMJ.10345.
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