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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 1. - Me and My Op
RADIO 4
TUESDAY 28/08/07 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
SUE JAMES
SYLVIA RISLEY
JIG PATEL
JEAN OSMOND
CATHERINE BONNER
IAN BECKINGHAM
KEITH GIRLING
SUE HALL
ANNE GALLAGHER
PRODUCER:
HELENA SELBY
NOT CHECKED AS BROADCAST
PORTER
Seven million surgical procedures are performed on the NHS every year. Over the next half hour I'll be accompanying two patients on their journeys through the operating theatre, and talking to some of the staff - nurses, surgeons, anaesthetists and a hospital administrator - responsible for looking after them.
I'll be following Sylvia Risley as she undergoes a knee replacement.
CLIP
PORTER
It's refreshing to see that even in the days of GPS type mapping of the knee you still resort to the hammer and chisel.
SURGEON
Oh it's great.
PORTER
Of course and a saw.
And later on I'll be watching as Jean Osmond undergoes keyhole surgery to deal with troublesome gallstones.
CLIP
SURGEON
Right so are we going to time out?
NURSE
Yeah.
SURGEON
Okay this is Jean Osmond.
NURSE
Jean Osmond, S642192. Date of birth: 03.02.57.
SURGEON
Operation: Laparoscopic Cholecystectomy to remove the gall bladder.
NURSE
Okay.
PORTER
But first, how long should patients like Sylvia and Jean expect to have to wait for their operations? Sue James is Chief Executive of Walsall Hospitals NHS Trust.
JAMES
It's changed hugely. When I was a younger manager I was managing waiting lists of four years for certain procedures. Now in Walsall - and we're particularly on the leading edge of this - the maximum wait for anything other than orthopaedic surgery is eight weeks and in fact most of our patients are seen within well short of eight weeks.
PORTER
Patients under the choose and book scheme, they have a choice of which hospital they go to, and one of the things that might influence them might be MRSA rates in the hospital, the success rate or failure rate of the surgeon doing their operation, can we access that sort of information to make that choice?
JAMES
The information is really I think in its infancy at the moment. A lot of the websites that you look at, like NHS Choice or other websites that are supposed to be designed to help patients choose, have very, very bland broadly based information on which don't help about particular surgeons, they don't help about particular procedures in terms of survival rates and things like that. And part of the reason for that is it is actually very, very difficult to select out a consultant based on the outcomes of operations because clearly measuring outcome can be quite a subjective thing. If, for example, a patient has a hip replacement and that patient is 85 and already sort of quite slow on their feet and whatever the outcome for them may be just that they don't really want to be terribly mobile but they do want to be pain free, whereas a patient of 45 may want to go climbing Everest.
PORTER
So if that sort of information isn't out there to make an informed choice how do they choose your hospital because you're competing with other hospitals in your area for their business effectively?
JAMES
Yes and I think still the age old approach of asking your GP - clearly GPs have a knowledge of all the local hospitals, they have a knowledge of and many of the surgeons who operate in the hospitals and if you can ask your GP - well doctor would you send a member of your family to Walsall Manor Hospital - hopefully he'd say yes or she'd say yes - and that's always a very good acid test as far as I'm concerned.
PORTER
And presumably patients are very interested in proximity as well.
JAMES
Oh yes I mean the decisions are not really made on clinical grounds, I think they're made on the grounds of is there a bus route there, can my family park when they come and see me - and then obviously once they get into hospital, because many waiting list patients it's the first time they've ever come into hospital, and once they've been in then things for the future around how good the food was, how nice the staff were, do really begin to play a role. So actually as well as asking your GP it's often useful to ask around your neighbours and your friends and see what their experience has been.
RISLEY
I had the left one done two years ago.
PORTER
And that went well?
RISLEY
Yeah.
PORTER
So you're about to have your right knee done.
RISLEY
Right knee done by the same doctor. I think I've got faith in him.
PORTER
You don't seem worried at all. How long have you been waiting for the operation?
RISLEY
I haven't been waiting long but he knew I needed it done because he wanted to do two knees together two years ago and I got frightened - I thought ooh, I kept waking up and I said no I can't have two done together. But now I wish I had have done, it would have been finished with.
PORTER
Hindsight's a wonderful ...
RISLEY
I would have been that bit younger as well.
PORTER
Hindsight's a wonderful thing isn't it.
RISLEY
I know it's true.
PORTER
I overheard you a moment ago saying that you'd been a bit worried leading up to the operation.
RISLEY
Yeah, I don't know why, I just got a bit - I had a sister-in-law who had an operation last year and she had a stroke going through it and somebody else I know and I've been a bit, you know...
PORTER
A bit scared by ...
RISLEY
Scared of them things, you know.
PORTER
... having the operation and the complications.
RISLEY
Is that going to happen to me yeah. Yeah but at the moment I think oh well it's got to be done, it's got to be done.
PORTER
Well it's only about 20 minutes away now.
RISLEY
Ah that's not bad is it.
PORTER
Orthopaedic surgeon Mr Jig Patel will be doing the operation. Sylvia has been put to sleep and has just arrived in Jig's theatre at London's University College Hospital.
PATEL
Antibiotics are on board. And we've just set the patient up so that we can do the operation in the appropriate position. And we're going to get [indistinct word], that's our computer gizmo, which will hopefully make us do a better job or equally as good a job.
BONNER
I'm Dr Catherine Bonner and I'm a consultant anaesthetist at UCH.
PORTER
Catherine, this is the lull before the storm.
BONNER
Not for us.
PORTER
No, the surgeon's about to start the operation. The patient's comfortably asleep. But your job's not over by any means is it, just starting.
BONNER
No. I mean this lady has already developed a profoundly slow heartbeat which we have to treat - dangerously slow. And a lot of these patients, very few of them, aren't on a whole cocktail of drugs associated with their heart or diabetes ...
PORTER
Because the sort of people who are coming in for knee replacements tend to be older and going to have more trouble.
BONNER
Yeah. And during the operation we never leave the operating theatre because ...
PORTER
There's quite a lot of trauma going on - in a minute Mr Patel's going to be sawing into the leg, what about blood loss and things?
BONNER
Blood loss because of the tourniquet is not too bad so we don't need to worry too much about blood loss but on some operations we do obviously and we monitor that all the time. And we have to give painkillers during the operation.
PORTER
That might come as a surprise to people, thinking once they're able to sleep they won't need pain relief.
BONNER
No part of the painkillers during the operation are to ensure that the patient wakes up comfortable. We have a variety of painkillers that we give during operations and - so in fact we - it's always nice when somebody comes up to me and says don't you find your job boring because if I can make it look boring I'm doing a very good job.
PORTER
So most patients the first thing they will remember probably might be the recovery room ...
BONNER
It's recovery yes.
PORTER
... but you'd make sure they're responding to you in here before you send them to recovery.
BONNER
Yes, I make sure that they're totally safe before I take them to recovery.
PORTER
And what can you do to ensure that those first few hours or 12 hours or day or two even after the operation are relatively pain free?
BONNER
Well we are very good at this these days, as I say we start the painkillers right at the beginning of the operation and we make sure the patient wakes up comfortable. Mr Patel puts a lot of local anaesthetic into the wound and I always tell the patients when all this wears off then they'll be given a patient controlled analgesic - analgesia machine - which they then deliver their own analgesic to themselves.
PORTER
And that's working how - that's a drip or ...?
BONNER
It comes in a drip and they just press the little plunger and it gives them a milligram of morphine. In fact in the olden days when patients used to have to ring the bell, get the nurse, the nurse had to then double check the morphine and it was an hour before they got any morphine, they used to require much more. With the PCA it delivers it instantly intravenously and they really require very little painkiller.
PORTER
So that's patient controlled analgesia - PCA? And what stops them giving too much?
BONNER
There's a cut out.
PORTER
So you can only give so much ...
BONNER
Yeah they can't overdose themselves. And obviously on the ward respiratory rate, pain relief, are all very carefully monitored.
PORTER
I asked Sue James what the chances are of a patient like Sylvia waking up on a mixed ward? Something that certainly bothers my patients - particularly the women.
JAMES
Yes, it is our ladies that worry about that. The only areas in the hospital where there is a chance that you might wake up in a bed next to a patient of the opposite sex are areas like the intensive care unit, the high dependency unit and in fact the emergency admissions unit, everywhere else - all our wards are managed in bays and the bays are single sexed bays. So you won't actually wake up in bed next to somebody of the opposite sex.
PORTER
What about patient dignity - a lot of patients are worried about preserving their dignity - presumably that's important to you?
JAMES
Absolutely. We've just been mounting a campaign actually at the hospital around the whole patient experience and we've been looking at patient dignity as a key part of that because it is very easy for nurses, particularly the younger generation, to not remember that patients are people first and patients second and so we're very cautious about making sure, for example, that their privacy is protected at all times. We now have notices on our curtains saying please knock before entering, which sounds a bit bizarre on a curtain, but the point is if a curtain's shut it's usually because there's something private going on behind it and the last thing you want is a junior doctor or a nurse to fling them open and march in. We always make a point of asking patients what they'd like to be called, before we start treating them, so that we're not over familiar or over formal, it's very much their call. And when a patient goes to theatre, I mean clearly we need to have access to their whole body but they are still a patient even if they're unconscious and unaware of what's going on. And the nurses in theatre have a particular role in protecting of the unconscious patient.
PORTER
Hospital administrator Sue James.
Back at UCH Mr Jig Patel is halfway through giving Sylvia a new knee. He's using a computer system that helps him put the replacement joint linings in the optimum position. The computer uses beams of light to work out the shape and movement of the knee and helps the surgeon align the new components for the best result. Think of it as a sort of GPS guided carpentry and you won't be far wrong - although older technologies are still required.
It's refreshing to see that even in the days of GPS type mapping of the knee we still resort to the hammer and chisel.
PATEL
Ah it's great.
PORTER
Of course and the saw.
PATEL
All joint replacements in this country are undertaken with antibiotics. Pretty much most of the joint replacements - in fact all the joint replacements we do in this hospital are undertaken in a laminar air flow theatre. And what that means is that there is a canopy around us here which sends out a column of filtered air and it pushes the air out and this is filtered clean air and then it's filtered out through the doors. So hopefully with the antibiotics and the laminar air flow infection rates should be less than 1%.
PORTER
Because if you presumably get an infection the orthopaedics ...
PATEL
It's a disaster, it's a disaster, that's why we get absolutely paranoid in the operation room - everyone is paranoid about introducing infection into the patient, which is a disaster. But thankfully it's pretty rare. Well it's there, when it's a problem it becomes a chronic problem but certainly we're lucky in pretty low numbers here.
JAMES
I think patients do get a very distorted view of these infections. For an example, on the MRSA infection a lot of people say to me oh I don't want to come in hospital because I may get MRSA. If you're coming in for an elective operation last year we had four patients who got MRSA while they were in for an elective operation, so that's a 1 in 6,000 chance of getting it. So hopefully that puts it into a bit more perspective. And as far as C. Difficile is concerned most patients who get C. Difficile are very elderly poorly patients with chest infections or other sorts of infections - emergency problems - who very often get drugs which then create the environment in which C Difficile can develop. So again it's very, very rare indeed for a patient who's coming for waiting list surgery to get that infection.
PORTER
And the other complication that presumably is deep vein thrombosis - blood clots - in the calf is a particular problem with orthopaedics, it's a problem with all types of surgery.
PATEL
It's a problem with all types of surgery but particularly with hip and knee surgery and what we do for our patients is we give them heparin and that's what all our patients use in this hospital. On the wards we give them elastic stockings called TED stockings which are very useful and some of our patients also get calf pumps and foot pumps as well. And hopefully with that with relatively short anaesthetic times and early mobilisation of our patients hopefully we can keep the blood flowing rather than getting it static and hopefully that will reduce our risk of developing clots.
PORTER
And how likely are they in a patient like this, having this sort of procedure?
PATEL
If you look very, very, very carefully it's about 20% in the calf but the reality is that clinically significant, i.e. you've picked it up on a scan, clots are in the region of about 1 in 20 - they're pretty rare, it's pretty low.
PORTER
We'll go back to UCH to find out how Sylvia's operation is getting on a bit later. But first it's off to Nottingham where Jean Osmond is about to have her gallbladder removed by surgeon Mr Ian Beckingham using a keyhole technique known as laparoscopic cholecystectomy.
ANAESTHETIST
I'm going to drift you off to sleep alright? It's just fresh air coming through this mask. Alright, you'll just find yourself being a little bit more light headed over the next couple of minutes, alright?
BECKINGHAM
Right, shall we do a time out?
NURSE
Yeah.
BECKINGHAM
Okay this is Jean Osmond.
NURSE
Jean Osmond S642192. Date of birth: 03.02.57.
BECKINGHAM
Operatation laparoscopic cholecystectomy - removal of the gallbladder.
PORTER
So the basic principle of a laparoscopic cholecystectormy, as opposed to a conventional one, is what, what would surgeons have done 30 or 40 years ago?
BECKINGHAM
Thirty or forty years ago you'd end up with a large scar on your abdomen going from the middle to the lateral edge on the right side under the rib cage to access the gallbladder. And you'd be in hospital for about five to seven days afterwards and it would take you about four to six weeks to get over that operation. The advantage of keyhole is that everyone thinks it's about the cosmetic appearance but that's really the icing on the cake, the importance is that there's minimal trauma to the patient, so there's less stretching of the tissues, there's less pain afterwards so they need less analgesics and painkillers and we can choose the same operation with the same low complication rate or lower then it makes sense to do it that way and get them back to a faster recovery. Most patients will be back to normal activities after this operation in about two weeks.
PORTER
Jean's op should take less than 40 minutes and her gallbladder will be removed through a tiny incision just below her tummy button.
BECKINGHAM
Lights off.
PORTER
You're looking now at the picture from the camera on a big computer screen effectively here.
BECKINGHAM
Yeah and the real leap in laparoscopic surgery was in the early 1980s, before that the surgeon had to put his eye against what was essentially a small telescope to allow him to see in, nobody else could see in, one hand had to hold the laparoscope itself. By plugging a camera on to the end of a telescope we can put it on to a TV screen so that the assistants and nursing staff can see what's going on, someone else can be involved in the operation and I can use both hands to use my instruments and my assistant can hold the camera. And that made a leap from what had previously been just a diagnostic technique to becoming much more of a therapeutic technique.
PORTER
So diagnostic because it allowed us to have a look inside and see what was going on.
BECKINGHAM
That's right, yeah, to look and see but we couldn't really do very much other than very simple techniques. [Indistinct words] extremely complicated operations and just about every operation that you can conceive of has been done that way. We can record the operations, so that we can use them teaching and training and we can analyse the case after if we want to see where we could have changed the operation at all.
PORTER
So we've got the main camera in through the tummy button there or just below it, now you're putting in a collection of other little nick's in the skin and these are your instrument holes.
BECKINGHAM
That's right, these are what we call ports and they're little tubes that are like small cigar tubes, if you like, that go into the abdomen and allow us to introduce instruments backwards and forwards without making a fresh hole each time. And they stay in there and they've got special little ribs on them that prevent them moving backwards and forwards.
PORTER
You've got a great view here and it seems to be pretty easy to access but when you're sitting in the consulting room are there things that would make you think this patient's not suitable for this sort of technique?
BECKINGHAM
Nowadays virtually all patients are suitable for keyhole surgery. We used to have a long list of contraindications - overweight, chest problems, heart problems - but these in fact have become relative indications rather than contraindications.
PORTER
You're making it all look very easy here but you are manipulating tiny instruments, I mean they're basically a foot and a half long, these instruments, it reminds me of trying to break into your car and - in the old days when you used to have to use a coat hanger to try and lift up the knob on the door. Practise makes perfect I presume.
BECKINGHAM
It's too many years on the Nintendo, so you shouldn't discourage your children to do these things because it does have some benefits later in life.
GIRLING
I'm Keith Girling and I'm one of the consultant anaesthetists at Queen's.
PORTER
Keith, is it a challenge from an anaesthetic point of view to do an operation like this that might take anything up to an hour, maybe longer, and then the patient will be going home a few hours later?
GIRLING
Most of the patients that we do for day cases - laparo cholies - are pretty fit and well and so the anaesthetic challenge is relatively small, the challenge is in getting them comfortable and making sure that they're comfortable enough to cope at home.
PORTER
So what about sickness, one of the common complications of having an anaesthetic is that you feeling a bit sick and that can go on for a while, are the newer agents that we use these days better in that respect?
GIRLING
What we tend to do these days instead of using one drug, hoping it will cover all types of sickness, we tend to use a combination of different types of agent that work at different receptors that control the sickness response. So we know that people are sick after surgery for different reasons, some of them are sick because of the drugs that we give, some of them are sick because of the anaesthetic agents, some of them are sick because of the movement and the positioning and we use a combination of drugs to try and block the different responses.
PORTER
What about the effects of the general anaesthetic on the brain, when does the patient actually fully recover, when might they be able to do something like drive a car for instance?
GIRLING
If they were going home the same day we would not want them to drive on the day of the operation, we'd want them to be driven by somebody else or at least accompanied in their taxi. And really we would suggest to them that they shouldn't drive for 24 hours after the general anaesthetic. The agents these days are very good and they do allow you to wake up and feel very good very quickly but we know that your complex motor tasks ...
PORTER
There's still a drug there yes.
GIRLING
There's still a drug there and you're not quite as good as you think you are. So we would say 24 hours would be the time that you'd be able to drive again.
BECKINGHAM
Now we need to remove the gall bladder itself. So first of all I'm going to put a bag into the abdomen.
PORTER
One of the things that intrigues me about keyhole surgery is that eventually you've got to pull that gall bladder out through somewhere.
BECKINGHAM
Well for a gall bladder it's not so much of a problem, the standard gallbladder is about the size of a conference pear and of course contains fluid and stones. It's not usually packed full of stones, so we can extract some of the fluid to allow it to shrink down and use a special spreading machine to allow it to be removed through the 10 millimetre hole in the umbilicus there. When we're taking other organs out and we're now taking half a liver out laparoscopically we can use other techniques to remove it. So if we take a spleen, we took a three and a half kilogram spleen out the other day, by putting it into a bag and then morcellating the spleen into tiny little pieces then extracting it again through a small hole.
PORTER
And all the patient needs is a few stitches.
BECKINGHAM
Yes, we put a stitch in the umbilical wound because we've stretched that to remove the gallbladder it's slightly larger, so we always suture that to prevent a hernia later. And we use glue on the wounds so that there's no sutures to remove at any stage later and also it's a waterproof dressing so that the patient can shower the next day.
PORTER
Around half of patients undergoing this type of keyhole surgery go home the same day. Most will be back at work with in a week or two.
Nurse Sue Hall had a laparoscopic cholecystectomy six weeks ago.
HALL
I came in at eight o'clock, had the operation about nine and my children came to collect me at half past three because my husband was away at the time, which I found was quite amazingly quick.
PORTER
Well what used to be regarded as quite a major operation.
HALL
Well that's right, I mean I went back to work quite quickly but I'd only be going back now after six weeks ...
PORTER
If you'd had a conventional operation.
HALL
If I'd had it conventionally. So it was really quite good, I mean two weeks later and I didn't really believe that I thought I would go back to work but I have. And I started cycling again and did my normal 32 miles and I'm feeling fine and I'm not taking some of the medication that I needed before. So it's been really good and no problems whatsoever. The backup after the operation was good, I got phoned the next day and then a week later to make sure and they gave me all the instructions to do if I got any problems.
PORTER
As a nurse I'm interested, because you know a lot more about what goes on in hospitals than most people, was there anything that particularly worried you about coming in to have the operation?
HALL
I think a lot of people worry about the anaesthetic and I think that's majorly what I worried about, not the infection side or the actual operation but the anaesthetic, I think we all have qualms about going to sleep and being out of control of things. But ...
PORTER
Qualms of what, I mean what specifically was worrying you about the anaesthetic - the dangers or ...?
HALL
Yeah just really and truly waking up after it properly, you know, it's just a fear of going off to sleep not naturally, you know.
PORTER
But the surgery itself you weren't too worried by?
HALL
No, no because I knew what was going to happen, it was explained really well.
PORTER
A satisfied patient in Nottingham.
Meanwhile back in London orthopaedic surgeon Jig Patel is giving Sylvia Risley a new knee. But how long will her new joint last?
PATEL
It all depends on the age of the patient, the activity levels but generally I would say it would be disappointing if knees today didn't last more than 15 years.
PORTER
And you would hope that she would get back to normal activity, for a lady of her age, at what sort of stage, how long is the post operative recovery?
PATEL
Knee replacements are a very painful thing to go through, it takes at least six weeks of pain and swelling and limping around and hard work for the patient - physiotherapy and doing their exercises - before the swelling actually starts to settle and they're really happy with it. And by about three months they should be very happy, they should be walking pretty well.
PORTER
Sylvia's in the final stages of her op and her next port of call will be the recovery room under the watchful eye of Sister Anne Gallagher.
CLIP
GALLAGHER
Where's the pain?
PORTER
Sister what happens when the patient comes out of the theatre in recovery, why do we have a recovery room?
GALLAGHER
The recovery room is there basically to ensure the patient wakes up smoothly from their anaesthetic, so when they come in here we check their airway, breathing and circulation, pain, nausea and then that usually takes around about an hour to sort out.
PORTER
I mean this is traditionally the first thing the patient will remember about waking up, you're the first face they see.
GALLAGHER
But actually they don't remember a lot, if you actually speak to them on the ward they don't actually recognise you again, even though you may well have had a very coherent conversation with them down here or felt you had.
PORTER
And what sort of problems might you pick up in recovery?
GALLAGHER
Low temperature, low blood pressure, bleeding, sickness, pain.
PORTER
[Indistinct words], they're looked after, they're assessed, when you're happy that they're alright to go back to the ward the nursing staff will come and pick them up and that's often the first thing they'll remember is when they're back on the ward.
GALLAGHER
Sometimes even after that they still don't remember, especially with big operations, I've had friends that have been in and you've gone to see them and you go back the next day they don't even recall that you've been to see them on that day. It's quite amazing how much amnesia you do suffer from after your anaesthetic.
PORTER
Advances like keyhole surgery and modern anaesthetics mean that patients spend much less time in hospital than they used to. Average hospital stays have plummeted, and the likes of Sir Lancelot Spratt simply wouldn't recognise the wards of today. Sue James is Chief Exec of Walsall Hospitals NHS Trusts.
JAMES
Oh it's changed hugely, I think if you think back to the old films - the Carry On films - where there were loads of patients who were recovering from surgery on wards and there were all sorts of opportunities for high jinx going on, that sort of thing doesn't happen now. Patients are very often admitted on the day of surgery, rather than a day or so before, 80% of our patients are now having their surgery on a day case basis, so they sleep in their own bed the night after their surgery. Patients who do need to stay in, we keep them in as short as we possibly can because obviously people actually recover much more effectively if they're in their own home surroundings.
PORTER
I mean there's a vested interest on both sides - you need to move patients in and out of the facility quickly for efficiency and patients often want to go home as soon as they can. But it can be a bit conveyor belt like for some patients, do you get many patients complaining about the fact that they're in and out so quickly?
JAMES
No they complain about having to stay I think more often than being in and out so quickly. I think some of their relatives sometimes are worried about patients coming home because obviously they then have to take the responsibility of looking after them and we don't send anybody home if there's not a responsible adult who can stay with them for the 24 hours after surgery. But the majority of patients, if you give them a chance of sleeping in their own bed or sharing a ward with 28 other people, they very quickly plump for sleeping in their own bed.
PORTER
Sylvia Risley spent a week in hospital recovering from her knee replacement and the following week at home has been a bit uncomfortable, but she is doing well.
RISLEY
It seemed a bit strange first of all, coming home and getting about, I was a little bit worried about going home. The thing was really managing when I first got home but once I was there it was fine. A carer comes in of a morning, she washes me feet, creams them and then puts these horrible things on my legs and then does a little bit of work for me - washing up and making the bed - and so that is a help. They've give her for six weeks and then see if I need them after that. I was in quite a lot of pain afterwards and it still is painful but you know you expect it and you think oh I'll get on with it. But last night I was in a lot of pain, I didn't know what way to lay in bed, it was a nuisance but I'm getting there.
PORTER
And I am pleased to say that Jean Osmond has also made a speedy recovery following her gallbladder op in Nottingham. It must be very strange listening to your own operation on radio - still better than watching it on TV I suppose.
Next week's programme is all about irritable bowel syndrome . As many as one in five adults in the UK is thought to suffer from IBS to some degree. I'll be talking to some of the leading experts on the condition to discover the latest thinking on the causes, and the best ways to treat it.
ENDS
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