266 results found
Garner A, Dandridge O, Amis A, et al., 2021, Bi-Unicondylar Arthroplasty: A Biomechanics and Clinical Outcomes Study, Bone & Joint Research, ISSN: 2046-3758
Garner AJ, Dandridge OW, van Arkel RJ, et al., 2021, The compartmental approach to revision of partial knee arthroplasty results in nearer-normal gait and improved patient reported outcomes compared to total knee arthroplasty, Knee Surgery Sports Traumatology Arthroscopy, ISSN: 0942-2056
PURPOSE: This study investigated the gait and patient reported outcome measures of subjects converted from a partial knee arthroplasty to combined partial knee arthroplasty, using a compartmental approach. Healthy subjects and primary total knee arthroplasty patients were used as control groups. METHODS: Twenty-three patients converted from partial to combined partial knee arthroplasty were measured on the instrumented treadmill at top walking speeds, using standard gait metrics. Data were compared to healthy controls (n = 22) and primary posterior cruciate-retaining total knee arthroplasty subjects (n = 23) where surgery were performed for one or two-compartment osteoarthritis. Groups were matched for age, sex and body mass index. At the time of gait analysis, combined partial knee arthroplasty subjects were median 17 months post-revision surgery (range 4-81 months) while the total knee arthroplasty group was median 16 months post-surgery (range 6-150 months). Oxford Knee Scores and EuroQol-5D 5L scores were recorded at the time of treadmill assessment, and results analysed by question and domain. RESULTS: Subjects revised from partial to combined partial knee arthroplasty walked 16% faster than total knee arthroplasty (mean top walking speed 6.4 ± 0.8 km/h, vs. 5.5 ± 0.7 km/h p = 0.003), demonstrating nearer-normal weight-acceptance rate (p < 0.001), maximum weight-acceptance force (p < 0.006), mid-stance force (p < 0.03), contact time (p < 0.02), double support time (p < 0.009), step length (p = 0.003) and stride length (p = 0.051) compared to primary total knee arthroplasty. Combined partial knee arthroplasty subjects had a median Oxford Knee Score of 43 (interquartile range 39-47) vs. 38 (interquartile range 32-41, p < 0.
Preston B, Harris S, Villet L, et al., 2021, The medial condylar wall is a reliable landmark to kinematically align the femoral component in medial UKA: an in-silico study, KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY, ISSN: 0942-2056
Garner AJ, Edwards TC, Liddle AD, et al., 2021, The revision partial knee classification system: understanding the causative pathology and magnitude of further surgery following partial knee arthroplasty., Bone Jt Open, Vol: 2, Pages: 638-645
AIMS: Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics. METHODS: Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system. RESULTS: Four classes were proposed: PR1, where no bone-implant interfaces are affected; PR2, where surgery does not include conversion to total knee arthroplasty, for example, a second partial arthroplasty to a native compartment; PR3, when a standard primary total knee prosthesis is used; and PR4 when revision components are necessary. Round one resulted in 92% inter-rater agreement (Kendall's W 0.97; p < 0.005), rising to 93% in round two (Kendall's W 0.98; p < 0.001). Round three demonstrated 97% agreement (Kendall's W 0.98; p < 0.001), with high intra-rater reliability (interclass correlation coefficient (ICC) 0.99; 95% confidence interval 0.98 to 0.99). Round four resulted in 80% agreement (Kendall's W 0.92; p < 0.001). CONCLUSION: The RPKC system accounts for all procedures which may be appropriate following partial knee arthroplasty. It h
Edwards TC, Patel A, Szyszka B, et al., 2021, Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty., Archives of Orthopaedic and Trauma Surgery, ISSN: 0344-8444
INTRODUCTION: Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty. MATERIALS AND METHODS: Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety. RESULTS: Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and r
Dandridge O, Garner A, Amis A, et al., 2021, Variation in the patellar tendon moment arm identified with an improved measurement framework, Journal of Orthopaedic Research, ISSN: 0736-0266
The mechanical advantage of the knee extensor mechanism depends heavily on the patellar tendon moment arm (PTMA). Understanding which factors contribute to its variation may help improve functional outcomes following arthroplasty. This study optimized PTMA measurement, allowing us to quantify the contribution of different variables. The PTMA was calculated about the instantaneous helical axis of tibiofemoral rotation from optical tracked kinematics. A fabricated knee model facilitated calculation optimization, comparing four data smoothing techniques (raw, Butterworth filtering, generalized cross-validated cubic spline-interpolation and combined filtering/interpolation). The PTMA was then measured for 24 fresh-frozen cadaveric knees, under physiologically based loading and extension rates. Combined filtering/interpolation enabled sub-mm PTMA calculation accuracy throughout the range of motion (root-mean-squared error 0.2 mm, max error 0.4 mm), whereas large errors were measured for raw, filtered-only and interpolated-only techniques at terminal flexion/extension. Before scaling, the mean PTMA was 46 mm; PTMA magnitude was consistently larger in males (mean differences: 5 to 10 mm, p < .05) and was strongly related to knee size: larger knees have a larger PTMA. However, while scaling eliminated sex differences in PTMA magnitude, the peak PTMA occurred closer to terminal extension in females (female 15°, male 29°, p = .01). Knee size accounted for two-thirds of the variation in PTMA magnitude, but not the flexion angle where peak PTMA occurred. This substantial variation in angle of peak PTMA has implications for the design of musculoskeletal models and morphotype-specific arthroplasty. The developed calculation framework is applicable both in vivo and vitro for accurate PTMA measurement.
Garner A, Dandridge O, Amis A, et al., 2021, Partial and combined partial knee arthroplasty: greater anterior-posterior stability than posterior-cruciate retaining total knee arthroplasty, The Journal of Arthroplasty, ISSN: 0883-5403
BackgroundLittle is known regarding anterior-posterior stability after anterior cruciate ligament–preserving partial (PKA) and combined partial knee arthroplasty (CPKA) compared to standard posterior cruciate–retaining total knee arthroplasty (TKA).MethodsThe anterior-posterior tibial translation of twenty-four cadaveric knees was measured, with optical tracking, while under 90N drawer with the knee flexed 0-90°. Knees were tested before and after PKA, CPKA (medial and lateral bicompartmental and bi-unicondylar), and then posterior cruciate–retaining TKA. The anterior-posterior tibial translations of the arthroplasty states, at each flexion angle, were compared to the native knee and each other with repeated measures analyses of variance and post-hoc t-tests.ResultsUnicompartmental and bicompartmental arthroplasty states had similar laxities to the native knee and to each other, with ≤1-mm differences throughout the flexion range (P ≥ .199). Bi-unicondylar arthroplasty resulted in 6- to 8-mm increase of anterior tibial translation at high flexion angles compared to the native knee (P ≤ .023 at 80-90°). Meanwhile, TKA exhibited increased laxity across all flexion angles, with increased anterior tibial translation of up to 18 ± 6 mm (P < .001) and increased posterior translation of up to 4 ± 2 mm (P < .001).ConclusionsIn a cadaveric study, anterior-posterior tibial translation did not differ from native laxity after PKA and CPKA. Posterior cruciate ligament–preserving TKA demonstrated increased laxity, particularly in anterior tibial translation.
Ponniah HS, Ahmed M, Edwards T, et al., 2021, How to prioritise patients and safely resume elective surgery during the Covid-19 pandemic, Publisher: OXFORD UNIV PRESS, ISSN: 0007-1323
Abel R, Behforootan S, Boughton O, et al., 2021, Ultrasound and Bone Disease: A Systematic Review, World Journal of Surgery and Surgical Research
Stoddart J, Dandridge O, Garner A, et al., 2021, The compartmental distribution of knee osteoarthritis – a systematic review and meta-analysis, Osteoarthritis and Cartilage, Vol: 29, Pages: 445-455, ISSN: 1063-4584
ObjectivesFor a population with knee osteoarthritis (OA), determine: 1) the prevalence of single compartmental, bicompartmental and tricompartmental OA, 2) the prevalence of isolated medial tibiofemoral, lateral tibiofemoral, or patellofemoral OA, and combinations thereof.MethodsPubMed and Web of Science databases, and reference lists of identified studies, were searched to find studies which reported on the compartmental distribution and prevalence of knee OA. Two independent reviewers assessed studies against pre-defined inclusion criteria and prevalence data were extracted along with subject characteristics. The methodological quality of each included study was assessed. A random-effects model meta-analysis was performed for each OA category to estimate the relative prevalence of OA in the knee compartments amongst people with knee OA.Results16 studies (3,786 knees) met the inclusion criteria. High heterogeneity was measured. Normalised for knees with OA, estimated prevalence rates (95% CI) were: single compartmental 50% (31.5–58.3%), bicompartmental 33% (23.1–37.2%) and tricompartmental only 17% (8.8–24.8%). Isolated medial tibiofemoral OA, isolated patellofemoral OA, and combined medial tibiofemoral and patellofemoral OA were more common than tricompartmental disease, occurring in 27% (15.2–31.1%), 18% (9.9–22.7%) and 23% (14.1–27.3%) of people respectively. Single/bicompartmental patterns of disease involving the lateral tibiofemoral compartment were less common, summing to 15% (8.5–18.7%).ConclusionThree-quarters of people with knee OA do not have tricompartmental disease. This is not reflected in the frequency with which partial and combined partial knee arthroplasties are currently used.Trial registration numberPROSPERO systematic review protocol (CRD42019140345).KeywordsGonarthrosisUnicompartmentalBicompartmentalPrevalenceEpidemiology
Wiik AV, Aqil A, Al-Obaidi B, et al., 2021, The impact of reducing the femoral stem length in total hip arthroplasty during gait, ARCHIVES OF ORTHOPAEDIC AND TRAUMA SURGERY, ISSN: 0936-8051
Riviere C, Sivaloganathan S, Villet L, et al., 2021, Kinematic alignment of medial UKA is safe: a systematic review, KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY, ISSN: 0942-2056
Logishetty K, Edwards TC, Subbiah Ponniah H, et al., 2021, How to prioritize patients and redesign care to safely resume planned surgery during the COVID-19 pandemic., Bone & Joint Open, Vol: 2, Pages: 134-140, ISSN: 2633-1462
AIMS: Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites. METHODS: A multidisciplinary surgical prioritization committee developed the SPAG, incorporating procedural urgency, shared decision-making, patient safety, and biopsychosocial factors; and applied it to 1,142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites, including one with access to a high dependency unit (HDU) or intensive care unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively. RESULTS: A total of 1,142 patients were included, 47 declined surgery, and 110 were deemed high-risk or requiring specialist resources. In the ten-week study period, 28 high-risk patients underwent surgery, during which 68% (13/19) of Priority 2 (P2, surgery within one month) patients underwent surgery, and 15% (3/20) of P3 (< three months) and 16% (11/71) of P4 (> three months) groups. Of the 1,032 low-risk patients, 322 patients underwent surgery. Overall, 21 P3 and P4 patients were expedited to 'Urgent' based on biopsychosocial factors identified by the SPAG. During the study period, 91% (19/21) of the Urgent group, 52% (49/95) of P2, 36% (70/196) of P3, and 26% (184/720) of P4 underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19. CONCLUSION: Our widely generalizable model enabled the restart of planned surgery during the COVID-19 pandemic, without compromising patient safety or excluding high-risk or complex cases. Patients classified as Urgent or P2 w
Logishetty K, Edwards T, Cobb J, 2021, How to prioritise patients and redesign care to safely resume planned surgery during the COVID-19 pandemic – a clinical validation study, Bone & Joint Open, ISSN: 2633-1462
Background and Purpose: Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites. Patients and Methods: A multidisciplinary Surgical Prioritisation Committee developed the SPAG, incorporating procedural urgency, shared decision making, patient safety and biopsychosocial factors; and applied it to 1142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites – including one with access to a High Dependency Unit (HDU) or Intensive Care Unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively. Results: 1142 patients were included, 47 declined surgery. 110 were deemed high-risk or requiring specialist resources. In the 10-week study period, 28 high-risk patients underwent surgery, during which 68% of Priority 2 (P2, surgery within 1 month) patients underwent surgery, and 15% of P3 (<3 months) and 16% of P4 (>3 months) groups. Of the 1032 low-risk patients, 322 patients underwent surgery. Twenty-one P3 and P4 patients were expedited to ‘Urgent’ based on biopsychosocial factors identified by the SPAG. During the study period, 91% of the Urgent group, 52% of P2, 36% of P3, and 26% of P4 underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19. Interpretation: Our widely generalisable model enabled the restart of planned surgery during the CO
Boughton O, Cobb J, owyang D, et al., 2021, Patient and Public Involvement Within Orthopaedic Research: A Systematic Review, Journal of Bone and Joint Surgery: American Volume, ISSN: 0021-9355
Caughie C, Bean P, Tiede P, et al., 2021, Dementia Worry and Neuropsychological Performance in Healthy Older Adults, ARCHIVES OF CLINICAL NEUROPSYCHOLOGY, Vol: 36, Pages: 29-36, ISSN: 0887-6177
Nemeth B, Marfurt K, Cobb J, et al., 2021, New and old standing special sections in Interpretation, INTERPRETATION-A JOURNAL OF SUBSURFACE CHARACTERIZATION, Vol: 9, Pages: 1F-1F, ISSN: 2324-8858
Mudunuru S, Cobb J, Navarrete J, et al., 2021, DIFFERENCES IN CLINICAL CHARACTERISTICS OF CALCIPHYLAXIS (CALCIFIC UREMIC ARTERIOLOPATHY) PATIENTS DEPENDING ON WARFARIN STATUS, Publisher: BMJ PUBLISHING GROUP, Pages: 670-670, ISSN: 1081-5589
Claudio-Gonzalez I, Navarrete J, Cobb J, 2021, D-DIMMER LEVELS IN END-STAGE RENAL DISEASE (ESRD) PATIENTS DURING COVID-19 PANDEMIC, Publisher: BMJ PUBLISHING GROUP, Pages: 665-665, ISSN: 1081-5589
Andrinas K, Craig W, Wax JR, et al., 2021, Use of ketamine infusion in post cesarean pain management in patients with opioid use disorder, Publisher: MOSBY-ELSEVIER, Pages: S346-S347, ISSN: 0002-9378
Wiley Z, Kubes JN, Cobb J, et al., 2021, Age, Comorbid Conditions, and Racial Disparities in COVID-19 Outcomes, JOURNAL OF RACIAL AND ETHNIC HEALTH DISPARITIES, ISSN: 2197-3792
Braysher E, Russell B, Collins SM, et al., 2021, Development of a reference material for analysing naturally occurring radioactive material from the steel industry, ANALYTICA CHIMICA ACTA, Vol: 1141, Pages: 221-229, ISSN: 0003-2670
Garner A, Dandridge O, Amis A, et al., 2021, The extensor efficiency of unicompartmental, bicompartmental and total knee arthroplasty, Bone and Joint Research, Vol: 10, Pages: 1-9, ISSN: 2046-3758
Aims: Unicompartmental (UKA) and bicompartmental (BCA) knee arthroplasty have been associated with improved functional outcomes compared to Total Knee Arthroplasty (TKA) in suitable patients, although the reason is poorly understood. The aim of this study was to measure how the different arthroplasties affect knee extensor function. Methods: Extensor function was measured for sixteen cadaveric knees and then re-tested following the different arthroplasties. Eight knees underwent medial UKA then BCA, then posterior-cruciate retaining TKA, and eight underwent the lateral equivalents then TKA. Extensorefficiency was calculated for ranges of knee flexion associated with common 46activities of daily living. Data were analyzed with repeated measures analysis of variance (=0.05). Results: Compared to native, there were no reductions in either extension moment or efficiency following UKA. Conversion to BCA resulted in a small decrease in extension moment between 70-90° flexion(p<0.05), but when examined in the context of daily activity ranges of flexion, extensor efficiency was largely unaffected. Following TKA, large decreases in extension moment were measured at low knee flexion angles(p<0.05), resulting in 12-43% reductions in extensor efficiency for the daily activity ranges. Conclusion: This cadaveric study found that TKA resulted in inferior extensor function compared to UKA and BCA. This may, in part, help explain the reported differences in 58function and satisfaction differences between partial and total knee arthroplasty.
Ng KCG, Bankes M, El Daou H, et al., 2021, Cam osteochondroplasty for femoroacetabular impingement increases microinstability in deep flexion: A cadaveric study, Arthroscopy: The Journal of Arthroscopy and Related Surgery, Vol: 37, Pages: 159-170, ISSN: 0749-8063
Purpose: The purpose of this in vitro cadaveric study was to examine the contributions of each surgical stage during cam femoroacetabular impingement (FAI) surgery (i.e., intact cam hip, T8 capsulotomy, cam resection, capsular repair) towards hip range of motion, translations, and microinstability.Methods: Twelve cadaveric cam hips were denuded to the capsule and mounted onto a robotic tester. Hips were positioned in several flexion positions: Full Extension, Neutral 0°, Flexion 30°, and Flexion 90°; and performed internal-external rotations to 5-Nm torque in each position. Hips underwent a series of surgical stages (T-capsulotomy, cam resection, capsular repair) and was retested after each stage. Changes in range of motion, translation, and microinstability (overall translation normalized by femoral head radius) were measured after each stage.Results: For range of motion, cam resection increased internal rotation at Flexion 90° (ΔIR = +6°, P = .001), but did not affect external rotation. Capsular repairs restrained external rotations compared to the cam resection stage (ΔER = –4 to –8°, P ≤ .04). For translations, the hip translated after cam resection at Flexion 90° in the medial-lateral plane (ΔT = +1.9 mm, P = .04), relative to the intact and capsulotomy stages. For microinstability, capsulotomy increased microinstability in Flexion 30° (ΔM = +0.05; P = .003), but did not further increase after cam resection. At Flexion 90°, microinstability did not increase after capsulotomy (ΔM = +0.03; P = .2, d = .24), but substantially increased after cam resection (ΔM = +0.08; P = .03), accounting for a 31% change with respect to the intact stage.Conclusions: Cam resection increased microinstability by 31% during deep hip flexion relative to the intact hip. This suggests that iatrogenic microinstability may be due to separation of the labral seal and resected contour of the femoral head.
Truong AD, Auld SC, Barker NA, et al., 2020, Therapeutic plasma exchange for COVID-19-associated hyperviscosity, TRANSFUSION, Vol: 61, Pages: 1029-1034, ISSN: 0041-1132
Canovas R, Cobb J, Brozynska M, et al., 2020, Genomic risk scores for juvenile idiopathic arthritis and its subtypes, ANNALS OF THE RHEUMATIC DISEASES, Vol: 79, Pages: 1572-1579, ISSN: 0003-4967
Cobb J, 2020, Highlights of the World Nuclear Performance Report 2020, ATW-INTERNATIONAL JOURNAL FOR NUCLEAR POWER, Vol: 65, Pages: 551-554, ISSN: 1431-5254
Hull S, Stevens R, Cobb J, 2020, Masks are the New Condoms: Health Communication, Intersectionality and Racial Equity in COVID-times, HEALTH COMMUNICATION, Vol: 35, Pages: 1740-1742, ISSN: 1041-0236
Schellenberg M, Hawley L, Biswas S, et al., 2020, Complications Following Brachial Arterial Catheterization in the Surgical Intensive Care Unit, AMERICAN SURGEON, Vol: 86, Pages: 1260-1263, ISSN: 0003-1348
Wiik AV, Nathwani D, Akhtar A, et al., 2020, The unicompartmental knee is the preferred side in individuals with both a unicompartmental and total knee arthroplasty, Knee Surgery Sports Traumatology Arthroscopy, Vol: 28, Pages: 3193-3199, ISSN: 0942-2056
PurposeTo determine the preferred knee in patients with both one total and one unicompartmental knee arthroplasty.MethodPatients simply with a unicompartmental (UKA) and total knee arthroplasty (TKA) on contralateral sides were retrospectively screened from three senior knee surgeon’s logs over a 15 year period. Patients safe and free from other diseases to affect gait were approached. A total of 16 patients (mean age 70 ± 8) agreed to ground reaction force testing on an instrumented treadmill at a fair pace and incline. A gender-ratio identical group of 16 healthy control subjects (mean age 67 ± 10) and 16 patients with ipsilateral medial knee OA (mean age 66 ± 7) were analysed to compare.ResultsRadiographically the mode preoperative Kellgren–Lawrence knee grade for each side was 3. Postoperatively, the TKA side had a mean coronal femoral component alignment of 7° and a mean tibial coronal alignment of 89° with a mean posterior slope of 5° in the sagittal plane. The UKA side had a mean coronal femoral component alignment of 7° and a mean tibial coronal alignment of 86° with a mean posterior slope of 4° in the sagittal plane. In 7 patients, the TKA was the first procedure, while 6 for the UKA and 3 done simultaneously. Gait analysis demonstrated in both walking conditions the UKA limb was the preferred side through all phases of loading (p < 0.05) and nearer to normal than the TKA limb when compared to healthy controls and patients with knee OA. The greatest difference was observed between the transition of weight acceptance and midstance (p = 0.008), when 22% more load was taken by the UKA side.ConclusionBy using a dynamic metric of an everyday activity, a distinct gait difference between differing arthroplasty types were established. A more natural loading pattern can be achieved with unicompartmentals as compared to total knees.Level o
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