thyroid storm after thyroidectomyst joseph, mo traffic cameras

She received steroids, beta blockade, potassium iodide, and plasma exchange, but her hepatic failure did not resolve and her clinical condition deteriorated. If calcium supplementation is not used and the condition is permanent, further symptoms may include tingling and numbness of the bottoms of the feet, muscle cramps and twitches, anxiety, depression, and headaches. MeSH 2009 Feb. 102(2):193-5. KI is recommended to reduce thyroid gland vascularity with the goal of improving operative visualization and reducing operative complications. Int J Surg. Kulaksizoglu M, Gonen MS, Kebapcilar L, et al. Dysphagia, or swallowing problems, are common after thyroid surgery, though they usually don't last long, often resolving within two weeks. The use of iodine was thought to reduce the risk, but a 2017 study questioned the benefit. After thyroidectomy, some people may experience neck pain and a hoarse or weak voice. [QxMD MEDLINE Link]. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event. ; Hemithyroidectomy or thyroid lobectomy: This involves the removal of one of the two lobes of the thyroid gland. 1999 Dec;29(4):318-21 Patients with a BurchWartofsky Point Scale (BWPS) of 45 or Japanese Thyroid Association (JTA) categories of thyroid storm 1 (TS1) or thyroid storm 2 (TS2) with evidence of systemic decompensation require aggressive therapy. Sudden events that can trigger a thyroid storm include: Common signs and symptoms of thyroid storm include: Less common signs and symptoms of thyroid storm include: A healthcare provider diagnoses thyroid storm if the person has severe and life-threatening symptoms, such as extreme fever and heart issues, and high levels of thyroid hormone and low levels of thyroid-stimulating hormone (TSH) in their blood. You are being redirected to Although thyroid storm can develop if you have long-term untreated or undertreated hyperthyroidism, its often caused by a sudden and intense (acute) event or situation. If you log out, you will be required to enter your username and password the next time you visit. Eur Thyroid J. Light housekeeping and walking are usually fine once you arrive home. Division of Endocrinology, The University of Texas Health Science Center at Houston, USA, Correspondence: Mohammed Hamdi, Division of Endocrinology, The University of Texas Health Science Center at Houston, USA, Received: September 03, 2021 | Published: September 20, 2021, Citation: Hamdi M, Chaudhri A, Shah N, et al. Unauthorized use of these marks is strictly prohibited. Your surgeon will talk to you about whether you should continue to wear a dressing over your incision. Its a rare complication of hyperthyroidism. Table. [QxMD MEDLINE Link]. Graves disease is an immune system disorder that results in the overproduction of thyroid hormones, a condition known as hyperthyroidism. There are many symptoms of hypothyroidism, but some of the more common ones include: Side effects of thyroid surgery are common and often include neck pain, a sore throat, difficulty swallowing, and hoarseness. 2012 Jul. Blocking the synthesis, secretion, and peripheral action of the thyroid hormone is the ideal therapy. Endocr J. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. 100(2):451-9. Zhong HJ, Yang TD. Thyroid nodules are usually benign (noncancerous), but they can be malignant (cancerous). Thyroid storm is a rare and life-threatening condition that can affect people with hyperthyroidism. If you have hyperthyroidism, such as Graves disease, ask your healthcare provider about thyroid storm and how you can try to prevent it from happening to you. Factors predictive of the development of surgical site infection in thyroidectomy - An analysis of NSQIP database. [Full Text]. National trends in incidence, mortality, and clinical outcomes of patients hospitalized for thyrotoxicosis with and without thyroid storm in the United States, 2004-2013. As with other side effects and complications, the timing of symptoms can vary from one person to the next. [QxMD MEDLINE Link]. Failure of esmolol to control tachycardia associated with thyroid storm after subtotal thyroidectomy. Peter F Czako, MD, FACS Chief, Division of Endocrine Surgery, Medical Director, North Tower Operating Rooms, Surgical Administration, William Beaumont Hospital; Associate Professor, Department of Surgery, Oakland University William Beaumont School of Medicine; Royal Oak Surgical Associates, PC -. [Full Text]. Clinical thyroidology for the public. Pokhrel B, Aiman W, Bhusal K. Thyroid Storm. One week after thyroidectomy the patient was admitted with severe hyperthyroidism. Graves disease more frequently develops in females (ie, male-to-female ratio ranges from 1:7 to 1:10); multinodular goiter more often manifests in the elderly population. Medicine (Baltimore). [Full Text]. [QxMD MEDLINE Link]. This case presentation is of a patient with PDTC complicated by functional thyroid metastases . [Thyroid storm associated with multiorganic dysfunction]. Braverman, MD, Lewis E., and Robert D. Utiger, MD. Approximately 10% to 30% of thyroid storm cases result in death. But if severe symptoms occur, intravenous calcium, which is delivered through a vein, in the hospital may be required. Hypoparathyroidism is when you have too little parathyroid hormone, which can lead to low calcium levels. A diagnosis of thyroid storm was made and she was transferred to our hospital. [1], Thyroid storm is a decompensated state of thyroid hormoneinduced, severe hypermetabolism involving multiple systems and is the most extreme state of thyrotoxicosis. Perioperative risk as it relates to the degree of thyroid dysfunction is also discussed separately. Bethesda, MD 20894, Web Policies Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. American Thyroid Association. 2015 Feb. 21(2):182-9. You can ask your surgeon about this prior to your surgery. Failure of esmolol to control tachycardia associated with thyroid storm after subtotal thyroidectomy. Thabet Abbarah, MD, FACS Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers Common symptoms include having a high fever and a rapid heart rate. The decision was made to proceed with thyroidectomy. 2020 June 20. Hypothyroidism Thyroid storm is a medical emergency and needs to be treated in a hospital. Clinical features and hospital outcomes in thyroid storm: a retrospective cohort study. WHAT ARE THE ALTERNATIVES TO THYROIDECTOMY FOR GRAVES' DISEASE? About ten days prior to her admission at our hospital, she consulted her family doctor with complaints of dyspnea, palpitations and general fatigue. They commonly include: Most often calcium levels improve in a few weeks but may continue to be low for up to six months. Medicine (Baltimore). Cookies collect information about your preferences and your devices and are used to make the site work as you expect it to, to understand how you interact with the site, and to show advertisements that are targeted to your interests. Discuss what's on your mind with your healthcare provider. It produces dramatic improvement in clinical status and greatly ameliorates symptoms. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. . With the proper medical treatment, youll likely feel better within 24 hours. Anatomic characteristics, identification, and protection of the nonrecurrent laryngeal nerve during thyroidectomy. 2020 June 20. Use of a cooled humidified oxygen tent is advised. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Iodine is progressively withdrawn. Spicy Food. However, there are some things that everyone can expect with any type of thyroid surgery. 2016;95(7):e2812. Thyroid Storm Treatment & Management Updated: Jan 18, 2022 Author: Madhusmita Misra, MD, MPH; Chief Editor: Robert P Hoffman, MD more. We herein describe the case of a 37-year-old patient with a history of Graves' disease who was transferred to Tottori University Hospital with thyroid storm. Adrenergic receptor activation is another hypothesis. Thyroid storm (TS) is an acute, life-threatening emergency. Peter F Czako, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Michigan State Medical Society, American Association of Endocrine Surgeons, Detroit Surgical SocietyDisclosure: Nothing to disclose. Poorly differentiated thyroid cancer (PDTC) falls in the spectrum of severity between differentiated and anaplastic thyroid cancers. World J Surg. Thyroid storm is a complication of hyperthyroidism, so people who have conditions that cause hyperthyroidism, such as Graves disease or a toxic thyroid adenoma, are more likely to get thyroid storm. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. While around 1% of people may have damage to the nerves supplying the vocal cords, around 5% to 10% of people will have temporary symptoms due to irritation of the nerves during surgery or inflammation around the nerves afterward. A drop in binding protein levels, which may occur postoperatively, might cause a sudden rise in free hormone levels. A nomogram to predict the likelihood of permanent hypoparathyroidism after total thyroidectomy based on delayed serum calcium and iPTH measurements. You may be given calcium and vitamin D supplements, and hormone replacement therapy is needed in some cases. Galindo RJ, Hurtado CR, Pasquel FJ, Garcia Tome R, Peng L, Umpierrez GE. Please confirm that you would like to log out of Medscape. [Guideline] Satoh T, Isozaki O, Suzuki A, et al. Most often, neck stiffness lasts for only a few days to a few weeks after surgery. Postoperatively, her hepatic function normalized. PTU also blocks peripheral conversion of T4 to T3 and hence is preferred in thyroid storm over MMI. Complications are rare but can be serious and even potentially life-threatening if they do occur. Hyperthermia is treated through central cooling and peripheral heat dissipation. The site is secure. It accounts for 2% to 15% of all thyroid cancers. 1992 Apr;14(3):240-4 Thabet Abbarah, MD, FACS Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers Thus, thyroidectomy is a potential therapeutic choice for cases of thyroid storm refractory to medical management. Extremely high metabolism also increases oxygen and energy consumption. If left untreated, this may lead to multi-organ failure and death. Pankaj Chaturvedi, MBBS, MS, FACS is a member of the following medical societies: American Association for the Advancement of Science, American Head and Neck Society, Association of Surgeons of IndiaDisclosure: Nothing to disclose. [QxMD MEDLINE Link]. When you have thyroid storm, the large level of thyroid hormones in your body launches your metabolism into high speed, which is dangerous and life-threatening. World J Surg. Therefore, a stress dose of glucocorticoid (eg, hydrocortisone, dexamethasone) now is routine. [QxMD MEDLINE Link]. 46(2):149-52. Thyroid. Prediction of permanent hypoparathyroidism after total thyroidectomy. Akamizu T, Satoh T, Isozaki O, et al, for the Japan Thyroid Association. Treating your body systems and tissues, such as your heart, that are affected by the excess thyroid hormone. Complications after thyroid surgery are rare but can be serious and potentially life threatening. 2018;163(1):68-72. doi:10.1016/j.surg.2017.03.030, Suzuki S, Yasunaga H, Matsui H, Fushimi K, Saito Y, Yamasoba T. Factors associated with neck hematoma after thyroidectomy: a retrospective analysis using a japanese inpatient database. Terris DJ, Snyder S, Carneiro-pla D, et al. Endometriosis Excision Surgery: What Happens and Recovery, Hyperthyroidism vs. Hypothyroidism: Differences and Symptoms, Eyelid Surgery: Everything You Need to Know, Parathyroid Surgery: Everything You Need to Know. Common symptoms include having a high fever and a rapid heart rate. -, Thyroid. Am J Med Sci. Most people are advised to take roughly two weeks off from work to recuperate, depending on their occupation. Dont wait for your symptoms to get worse. Aulet RM, Wein RO, Siegel RD. Table. 2012 Sep. 109(3):466-7. The .gov means its official. Initially, glucocorticoids were used to treat potential relative insufficiency due to accelerated production and degradation owing to the hypermetabolic state. . PTU and MMI block the incorporation of iodine into thyroglobulin within 1 hour of ingestion. [7]. 2016; 26(10): 1343-1421. PMC Thyroid storm is the most severe form of hyperthyroidism, wherein organ failure begins to occur. The hardening typically peaks about three weeks after surgery and then subsides over the next two to three months. After improvement of thyroid function, which generally occurs within 24 hours, iodine can be gradually discontinued and glucocorticoids tapered and discontinued. This case report presents the successful surgical and anaesthesiological management of a patient with Graves' disease, without any signs of perioperative thyroid storm. This can lead to a sore throat and the sensation of a lumplike something is stuck in your throatwith swallowing. Roughly 5% of people may have temporary symptoms of a low calcium level, known as hypocalcemia, for at least a few weeks after thyroid surgery. Thyroidectomy is the main surgical treatment for thyroid cancer and is a treatment option for certain thyroid conditions, including: Thyroid nodules: A thyroid nodule is a growth (lump) of thyroid cells in your thyroid gland. [QxMD MEDLINE Link]. (https://www.ncbi.nlm.nih.gov/books/NBK448095/), Visitation, mask requirements and COVID-19 information. Death from thyroid storm may be a consequence of cardiac arrhythmia, congestive heart failure, hyperthermia, multiple organ failure or other factors, though the precipitating factor is often the cause of death. Br J Anaesth. Galindo RJ, Hurtado CR, Pasquel FJ, Garcia Tome R, Peng L, Umpierrez GE. [QxMD MEDLINE Link]. This is because post-surgical consequences often include a sore throat and such foods might enhance the level of discomfort. Moreover, the high-calorie content of junk food might contribute to sudden weight gain. Your thyroid gland plays a large role in many important bodily functions. Management of thyroid storm is a multistep process. Symptoms and Signs of Thyroid Storm When Compared with Uncomplicated Thyrotoxicosis. Pankaj Chaturvedi, MBBS, MS, FACS Professor of Head and Neck Surgery, Department of Head and Neck Surgery, Tata Memorial Hospital, India Endocr J. 2012 Apr. Thyroid storm If a thyroidectomy is done to treat a very overactive gland, there may be a . MMI is the common agent used in hyperthyroidism. [QxMD MEDLINE Link]. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Eating soft foods for the first few days can be helpful. 2018;60:273-278. doi:10.1016/j.ijsu.2018.11.013, Hope N, Kelly A. Pre-operative Lugols iodine treatment in the management of patients undergoing thyroidectomy for Graves disease: a review of the literature. The intravenous preparation of sodium iodide (given as 1 g slow infusion q8-12h) has been taken off of the market. It occurs in roughly one in 2,000 surgeries. [5, 8], Cardiogenic shock (CS) is a rare complication of thyroid storm, which occurs more commonly in male patients with preexisting structural and atherosclerotic heart disease, and carries a very poor prognosis. Br J Anaesth. Other supportive treatments to help with symptoms and side effects. Please type the correct Captcha word to see email ID. Keep in mind that even when complications occur, which is not common, prompt treatment is often successful to restore your health. think functional metastatic thyroid cancer. Although the exact pathogenesis of thyroid storm is not fully understood, the following theories have been proposed: Patients with thyroid storm reportedly have relatively higher levels of free THs than patients with uncomplicated thyrotoxicosis, although total TH levels may not be increased. South Med J. Head & Neck. 2012 Sep. 109(3):466-7. Hyperpyrexia, temperature in excess of 38C, dehydration, 2. Medscape Education. [QxMD MEDLINE Link]. In addition to persistent hoarseness, injury to the recurrent laryngeal nerve may lead to other symptoms after surgery. See the image below. [Full Text]. Post operative expectations. After thyroid surgery, you will need periodic blood tests to measure your thyroid hormone levels. Bleeding into the tissues surrounding the neck, which is known as a neck hematoma, is uncommon, but is potentially life-threatening if not diagnosed and treated promptly. Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine Signs that you may have low calcium are numbness and a tingling feeling in your lips, hands, and the bottom of your feet, a crawly feeling in your skin, muscle cramps and spasms, bad headaches, anxiety, and depression. These reports suggest an increased risk for liver toxicity with PTU compared with methimazole. You should not drive as long as you continue to need pain medications, and some surgeons recommend abstaining from driving for the first week after surgery altogether. Medicine. De Leo S, Lee SY, Braverman LE. The clinical picture relates to severely exaggerated effects of thyroid hormones (THs) due to increased release (with or without increased synthesis) or, rarely, increased intake of TH. Ther Apher Dial. Haugen BR, Alexander EK, Bible KC, et al. Thyroid storm is a medical emergency and needs to be treated in a hospital. Not all cases of thyroid storm are preventable, but if you have hyperthyroidism, there are things you can do to try to prevent thyroid storm, including: Thyroid storm can be caused by your bodys stress response to surgery or anesthesia. Injury to the external branch of the superior laryngeal nerve is usually less obvious. [4, 5]. Please enable it to take advantage of the complete set of features! Nausea and vomiting after thyroidectomy was the norm at one time, and people may be concerned if they talk with others who had this procedure in the past. Swee du S, Chng CL, Lim A. In one study, the majority of patients with thyrotoxicosis were middle aged and white, and about 76% were female. [10]. Lancet. It's better to avoid spicy and fried food after a thyroidectomy. Open Access by MedCrave Group is licensed under a Creative Commons Attribution 4.0 International License. The head of your bed will be raised to reduce swelling, and you will be allowed to eat a regular diet. Thyroid storm (also called thyroid crisis and thyrotoxic crisis) happens when your thyroid gland releases a large amount of thyroid hormone in a short amount of time. Mohananey D, Smilowitz N, Villablanca PA, et al. Acetaminophen and cooling blankets to lower your temperature. 2012 Sep. 109(3):466-7. Rare cases of embryopathy, including aplasia cutis, have been reported with methimazole during pregnancy. Advertising on our site helps support our mission. Patient was treated for thyroid storm with propylthiouracil, hydrocortisone, potassium iodide and propranolol. 46(2):149-52. Luckily, its rare and treatable. If any of these symptoms occur, immediate evaluation by a healthcare provider or an ear, nose, and throat (ENT) doctor is recommended. [7] The criteria established by Burch and Wartofsky help in early recognition of impending storm. Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis. Thyroid Hormone Reference Range May Not Apply for Cancer Patients, FDA OKs Pembrolizumab for Adjuvant Treatment of NSCLC, Recognizing the Signs: Heart Failure and Type 2 Diabetes, Myopathies: Muscling Your Way to the Diagnosis. [14]. 2012 Apr. Lid lag, which is when your upper eyelid is higher than it should be when youre looking down. Extracorporeal membrane oxygenation support and total thyroidectomy in patients with refractory thyroid storm: case series and literature review. After surgery, your voice may be hoarse or whispery, and it may feel tiring to talk. Prior to radioiodine therapy or surgery, a patient should be made euthyroid with antithyroid drugs and propranolol. -, Endocrinol Metab Clin North Am. Thyroid storm is a life-threatening condition that is generally considered to be a contradiction to surgical intervention. Most often, lifelong calcium supplementation is all that is needed. A severe case of thyrotoxicosis is called thyroid storm, or thyroid crisis. Unable to load your collection due to an error, Unable to load your delegates due to an error. The four parathyroid glands lie on the back of the thyroid gland and are sometimes injured or removed during surgery. Dare to Compare: Do You Know the Latest on Immuno-Oncology in Advanced Non-Small Cell Lung Cancer? [Full Text]. Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Breast DiseaseDisclosure: Nothing to disclose. What Is a Parathyroid Hormone Blood Test? When injured, a person may have difficulty making high-pitched noises or yelling, though their routine speaking voice may be unchanged. If you log out, you will be required to enter your username and password the next time you visit. Accessed 6/8/2022. Less than 1% of people having a thyroidectomy will experience damage to either the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve. Symptoms include weight loss, palpitations, and weakness but patients don't have ophthalmopathy. It is uncommon, but when it occurs after thyroidectomy, it is usually associated with Grave's disease. Trends in the incidence and in-hospital outcomes of cardiogenic shock complicating thyroid storm. Symptoms of thyroid storm include a fever (over 102 degrees F in most people), profuse sweating, a rapid heart rate, and sometimes delirium (severe confusion). The recommendation to render patients euthyroid with antithyroid medication is an effort to reduce the risk of thyroid storm that the stress of surgery could precipitate. Treatment targeted against thyroid hormone creation and release. There has been some controversy over inpatient vs. outpatient thyroidectomies, especially with the recent trend toward same-day surgery. Akamizu T. Thyroid storm: a Japanese perspective. J Intensive Care Med. In patients with failed hormone regulation who are scheduled for indispensable total thyroidectomy, the risk of thyroid storm with severe end-organ complications has to be anticipated. Like you dont have control of your body. 2017 Aug. 354(2):159-64. If you are having thyroid surgery, known as a thyroidectomy, to remove all or part of your thyroid glanda butterfly shaped organ at the base of your neckit's important to know what to expect as you recover. Thyroid. Total or near-total thyroidectomy: This involves the removal of all or most of the thyroid gland.This surgery is often indicated for large thyroid cancers, large goiters, and Graves' disease. In addition to regulating your metabolism, the . Impact of potassium iodide on thyroidectomy for Graves disease: Implications for safety and operative difficulty. WHO SHOULD CONSIDER THYROIDECTOMY FOR MANAGEMENT OF GRAVES' DISEASE? https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvODUwOTI0LXRyZWF0bWVudA==. [5, 8] In one retrospective study from Japan of 1324 patients who were diagnosed with thyroid storm, the following factors were associated with increased mortality risk in thyroid storm [Full Text]. 2016 Oct. 26(10):1343-1421. Together, they are referred to as thyroid hormones, and they regulate your body temperature and control your heart rate and metabolism. Martin D. Disseminated intravascular . [QxMD MEDLINE Link]. Thyrotoxicosis shouldn't be eliminated from the differential when a patient has had thyroidectomy especially when they have metastatic disease. 1. Digitalization is required to control the ventricular rate in patients with atrial fibrillation. [9] : Central nervous system (CNS) dysfunction at admission, Lack of antithyroid drug and beta-blockade use, Need for mechanical ventilation and plasma exchange along with hemodialysis, In addition, CNS dysfunction of greater than mild severity appears to be a risk factor for mortality. The thyroid gland produces and releases two main hormones: the 'active' triiodothyronine (T3) and the 'inactive' thyroxine (T4). The Anatomy of the Superior Laryngeal Nerve, Endotracheal Tube: Purpose, What to Expect, and Risks, Medications Used to Treat Thyroid Disease. Labs showed TSH<0.005uIU/mL, free T4>8.0ng/dL, total T3>8.0ng/mL, as well as positive TPO antibodies and thyroid stimulating immunoglobulins. Vyas AA, Vyas P, Fillipon NL, Vijayakrishnan R, Trivedi N. Endocr Pract. [QxMD MEDLINE Link]. American Thyroid Association. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. This is very common and expected during the first week or two after surgery. Since thyroid storm can be life-threatening and requires immediate medical attention, in many cases, healthcare providers diagnose and start treating people who have signs of thyroid storm before they get blood results back indicating the level of thyroid hormones in their blood. Hambleton C, Buell J, Saggi B, Balart L, Shores NJ, Kandil E. Ann Otol Rhinol Laryngol. Pankaj Chaturvedi, MBBS, MS, FACS Professor of Head and Neck Surgery, Department of Head and Neck Surgery, Tata Memorial Hospital, India This is because you'll no longer have a gland to make thyroid hormone and will experience symptoms of hypothyroidism, or an underactive thyroid, without replacement therapy. 2015 Dec;30(8):518-20. doi: 10.1177/0885066615571527. Akamizu T. Thyroid storm: a Japanese perspective. Add glucose to IV fluids for nutritional support. She has yet to follow up with her outpatient endocrinologist.1-4. government site. Antithyroid compounds propylthiouracil (PTU) and methimazole (MMI) are used to block the synthesis of the thyroid hormone. [Full Text]. sharing sensitive information, make sure youre on a federal Seek urgent medical care if you experience any swelling of your neck, increased pain, shortness of breath, fever, or difficulty breathing. Thyroid storm, also called thyrotoxic crisis, is a life-threatening medical emergency caused by very high levels of circulating thyroid hormone. If youre experiencing symptoms of thyroid storm, such as a high fever and a fast heart rate, get to the nearest hospital immediately.

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