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   Table of Contents - Current issue
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January-June 2021
Volume 13 | Issue 1
Page Nos. 1-71

Online since Wednesday, June 16, 2021

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EDITORIAL  

Artificial intelligence: Where do we stand? Highly accessed article p. 1
Alok Chandra Agrawal
DOI:10.4103/jotr.jotr_44_21  
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ORIGINAL ARTICLES Top

Is greater trochanteric pain syndrome influenced by pelvic anatomy? A radiological review Highly accessed article p. 3
Raviprasad Kattimani, Morgan Bayley
DOI:10.4103/jotr.jotr_42_20  
Introduction: Greater trochanteric pain syndrome (GTPS) is one of the common causes of hip pain, which can be difficult to treat. The incidence of GTPS is highest in the middle aged and the elderly. The iliotibial band (ITB) acts as a tension band over the concave lateral surface of the femur. We postulate that those with wider pelvic morphology have higher tension though the ITB which predisposes to developing GTPS. Aim of the Study: The aim of the study is to evaluate the relationship between pelvic anatomy and GTPS. Methodology: A total of 89 patients underwent steroid injection in a district general hospital for the clinical diagnosis of GTPS between February 2013 and December 2014. We performed a retrospective radiological analysis of their pelvic morphology. We measured intertrochanteric distance and the bispinal distance between both anterosuperior iliac spines on anteroposterior pelvis radiographs. A ratio of intertrochanteric to bispinal distance was calculated. Femoral neck angle and offset were also recorded. Student's t-test was used for statistical analysis. Results: The average intertrochanteric distance and bispinal distance of patients with GTPS and control group were 362 mm and 341 mm, respectively. Intertrochanteric to bi spinal average ratio of 1.06 was found in GTPS group compared to 1.04 in the control group. Patients with GTPS had more varus femoral necks and a larger femoral offset. Intertrochanteric distance, neck-shaft angle, and offset were also statistically significant. Conclusion: We postulate that risk factors for GTPS include female sex, increasing age, and a wider pelvis. To allow for magnification of radiographs, we would suggest the use of the intertrochanteric to bispinal ratio in assessing patients with suspected trochanteric bursitis. We believe a figure of >1.06 would be supportive of the condition.
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Epidemiological determinants of children's orthopedic care in rural central India p. 6
Deeptiman James, Manjulata Gajendran, Tapan Kumar Paraseth
DOI:10.4103/jotr.jotr_36_20  
Background: Musculoskeletal disorders of children in rural India are often highlighted through anecdotal reports of delayed presentations. This study was conducted to identify prevalence and factors that influenced children's orthopedic care in a secondary hospital in rural Central India. Methodology: A retrospective survey was conducted to identify the prevalence of musculoskeletal disorders and delayed presentation among children at our institution from July 2011 to June 2016. Actionable epidemiological determinants were identified with the Delphi method and a prospective cohort was analyzed for delayed presentation. Results: Among 2281 children 71% presented with trauma. The incidence of delayed presentation among the trauma cases was 28%. Remaining had neuromuscular (17%), infectious (3.75%), metabolic (1.5%), congenital (3.25%), and miscellaneous (3.5%) disorders. Delayed presentation in 19 children from a prospective cohort of 100 patients showed significant association with distance traveled to reach the clinic and poor transport infrastructure in rural areas (P = 0.025) but did not differ by socioeconomic scale (SES) (P = 0.085), lack of health insurance coverage (P = 0.348) or primary indigenous treatment (P = 0.535). In this cohort, 84% belonged to middle and low-SES families, 33% had insurance coverage, 79% received primary traditional remedies and 68% traveled from distant rural locations. Conclusions: Trauma care and neuromuscular diseases constituted the bulk of musculoskeletal disorders in children in this survey from rural India. Poor transport infrastructure led to delayed presentation in the prospective cohort but lower SES, lack of health insurance, and rampant primary indigenous treatment in rural areas are likely contributory factors.
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Gender difference in health-related quality of life of adolescent idiopathic scoliosis patients between the 2nd and 5th year of bracing treatment using scoliosis research society-22 questionnaire p. 11
Wai-Wang Chau, Alec Lik-Hang Hung, Bobby Kin-Wah Ng
DOI:10.4103/jotr.jotr_37_20  
Background: Offering brace for moderately suffering adolescent idiopathic scoliosis (AIS) patients is a recognized intervention to control further curve progression, and the treatment period varies from each patient. Some AIS patients required to wear longer than expected with different clinical reasons. Health-related quality of life (HRQOL) of AIS patients who have undergone bracing from the 2nd year to 5th year has not been discussed. The aim of this study is to evaluate the HRQOL of patients who have undergone bracing between their 2nd to 5th year of treatment using Scoliosis Research Society-22 (SRS-22) questionnaire. Materials and Methods: One hundred and twenty-six AIS patients who were under brace treatment completed SRS-22 questionnaire at their 2nd, 3rd, 4th, and 5th year on brace. Five SRS-22 domain scores (function, pain, self-image, mental health, and satisfaction with management) collected longitudinally were compared among the 4-time points. Gender-specific analysis was performed to look for any difference between boys and girls. Results: Mean numbers of months among visits were 8.99 (between 2nd and 3rd), 8.42 (between 3rd and 4th), and 7.89 (between 4th and 5th). Function, pain, and satisfaction with management scores were significantly decreased in the 3rd year during bracing and increased steadily afterward. Gender-specific analysis showed female patients experienced similar changes in function, pain and satisfaction at the 3rd year. Conclusions: Function, pain, and satisfaction scores were much affected at the 3rd year and recovered afterward. Gender difference was found and the same significant changes were found in female patients but not in male patients.
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The coronal and sagittal parameters before and after posterior spinal fusion with all pedicle screw construct in adolescent idiopathic scoliosis (AIS) patients and comparing their health-related outcomes through SRS-22 questionnaire p. 17
Wai-Wang Chau, Bobby Kin-Wah Ng, Alec Lik-Hang Hung
DOI:10.4103/jotr.jotr_43_19  
Background: Sagittal balance in severe androgen insensitivity syndrome (AIS) patient has been difficult to study due to problems with imaging technique. Abnormal sagittal profiles have been frequently observed in AIS patients presenting as cervical kyphosis, thoracic hypokyphosis, and positive sagittal vertical axis (SVA) off set. The significance of these changes is not understood in these patients. The purpose of this study is to assess the sagittal profile of AIS patients before and after surgery. Subjects and Methods: Changes in curve correction in both coronal and sagittal planes before and after surgery. Curve type, Cobb angles, sagittal parameters, and fusion level were analyzed with conventional parameters. Patient outcomes were measured using mobile device friendly Scoliosis Research Society-22 questionnaire online. Results: Fourteen patients were recruited. Average age was 16 years (13–36). Postoperation and final follow-up Cobb angles were reduced to 27°, 26°, and 16° and 29°, 28°, and 16°, respectively. In the sagittal plane, the Cobb angles pre- and postoperation and final follow-up are as follows: Cervical lordosis (36.7, 39.1, and 41.9), thoracic kyphosis (33.1, 35.8, and 39.1), lumbar lordosis (51.1, 45.2, and 54.2), SVA (1.3, 1.6, and 0), pelvic tilt (19, 21, and 18), sacral slope (47, 46, and 55), and pelvic tilt (43.7, 45, and 43.5). “Function”, “satisfaction,” and “mean” were significantly improved over the period, particularly between the last seen visit and before surgery. Conclusions: Abnormal coronal and sagittal parameters and their changes after surgery are reported in AIS patients. Patients expressed significant improvements in their function abilities and satisfied with clinical management, as well as their general quality of life.
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Micro-Core decompression combined with intralesional zoledronic acid as a treatment of osteonecrosis of femoral head: A novel technique p. 21
Muhammed Ashraf, Jyothis George, I Ibad Sha
DOI:10.4103/jotr.jotr_46_20  
Background: Avascular Necrosis / Osteonecrosis of the femoral head is a debilitating condition affecting the hip joint and is one of the most common causes of total hip replacement. The available treatments include pharmacological and surgical options with Total hip arthroplasty (THA) being the mainstay of treatment. We here is studying a novel technique of combining micro core decompression with intra-lesional bisphosphonate as a treatment for osteonecrosis of the hip. Materials and Methods: A prospective study of 19 hips was done. There were 11 males and 4 females ranging 42 - 63 years. Four hips were stage I, ten hips were stage IIA, three hips were stage IIb and two hips were stage III. 16 hips (40%) had stage IIb and 24 hips (60%) had stage III ONFH. The minimum period of follow up was 24 months. All patients were assessed according to the Harris Hip Score (HHS). The operative procedure include decompressing the avascular area with drilling then injecting the zoledronic acid locally. Results: The mean preoperative modified Harris Hip Score in stage I (n=4), stage IIa (n=10), stage IIb (n=3) and Stage III (n=2) were 81.9, 72.7, 68.8 and 59.2 respectively. The mean postoperative modified Harris Hip Score at two years in stage I, stage IIa, stage IIb and Stage III were 97.3, 91.1, 88.4 and 82.5 respectively. Conclusion: We found that the use of micro core-decompression with intra-lesional bisphosphonate will provide higher chances towards hip preservation especially in late cases or cases with larger lesions where core decompression may not be successful.
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Seasonality in pediatric and adolescent orthopedic fractures – An experience from central India p. 26
Ravi Kant Jain, Rajeev Shukla, Ram Dogne, Vishal Singh Champawat
DOI:10.4103/jotr.jotr_42_19  
Background: Incidence of childhood fractures varies from 1.2% to 5%. Very few studies have considered environmental variables which may influence incidence of fractures, that too in pediatric age group. According to literatures incidence of fracture is found to be higher in summers as compared to winters. Aims and Objectives: To study the seasonal variation of pediatric and adolescent orthopedic fractures at our institute in Central India. Materials and Methods: Data of orthopaedic trauma in patients of age 0-18 years were collected from the institutional database of a tertiary care hospital for the period 2007–2017. Basic demographic characteristics, time and date of injury, nature of injury and outcome data were recorded and tabulated according to age, sex, month/season, part of body injured, and then analyzed for the patterns of injury. Results: A total of 3260 pediatric orthopedic trauma cases were included in study. Most of the injuries were seen in 6–15 years' age group (64%), most common mode of injury was fall while playing. There was a male preponderance to fractures (73% males vs. 27% females). Trauma mostly occurred during summers (48%) followed by rainy season (30%) and least during winter season (22%). Injury to spine was seen in 31 (0.95%) patients, upper limb injuries were seen in 1799 (55.18%) patients, and lower limb injuries were seen in 1430 (43.86%) patients. Conclusion: This study concludes that there exists vast variation in the incidence of fractures in the pediatric and adolescent fractures with maximum fractures being reported in the summer season, then rainy season, and least in the winter season. Health-care professionals and parents should be educated about injury prevention strategies, and also, there should be commitment for more health-care personnel and resources at trauma centers during the summer season to deal with increased patient load efficiently.
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Comparisons of health-related quality of life of adolescents with idiopathic scoliosis undergoing anterior spinal fusion with extrapleural and posterior lumbar spinal fusion with transpleural treatments using scoliosis research society-22 questionnaire p. 29
Bobby Kin-Wah Ng, Wai-Wang Chau, Anna C. N. Hui, C. Y. Wong, Francis K. Y. Shit
DOI:10.4103/jotr.jotr_45_19  
Background: Conventional posterior lumbar spinal fusion (PLSF) surgical treatment in severe adolescent idiopathic scoliosis (AIS) patients involved transpleural technique. AIS patients undergoing anterior spinal fusion (ASF) together with extrapleural treatments in the treatment of thoracolumbar scoliosis are well known for its effect in curve correction. Health-related quality of life (HRQOL) of patients after ASF and PLSF has yet to be explored. Subjects and Methods: Severe AIS patients underwent ASF with extrapleural or PLSF with transpleural treatments filled out Scoliosis Research Society-22 (SRS-22) questionnaire before and after surgery. HRQOL before and after surgery was compared. HRQOL between ASF and PLSF was also compared. Results: Twenty-eight patients (10 ASF extrapleural and 18 PLSF transpleural) filled out the SRS-22 questionnaire before and after surgery. No significant difference in function, pain, self-image, mental, satisfaction, and mean scores between ASF and PLSF. All mentioned domains and mean scores were significantly improved after surgery in both ASF and PLSF. Conclusions: Significant improvements in all HRQOL domains after either treatment after surgery were observed, while there was no difference when compared with each other postoperatively. ASF with extrapleural treatment provided same HRQOL as of PLSF.
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A novel technique of stabilization of supracondylar femoral dome osteotomy with proximal humeral locking plate for surgical management of genu valgum deformity p. 32
Mukul Mohindra, VK Gautam, Amit Meena, Navdeep Gupta, Jagannath Desai, Sumon Singphow Saikia
DOI:10.4103/jotr.jotr_47_20  
Background: Genu valgum is a common deformity in the developing world. When the patient presents after a second growth spurt, corrective surgery remains the only treatment option. Different types of osteotomies and fixation methods have been described in the literature, but the choice of the method remains debatable. We evaluated the outcome of the proximal humeral locking plate used for stabilization of supracondylar femoral dome osteotomy (DO). Methods: In this prospective study, we performed 39 osteotomies for genu valgum deformity on 24 patients who satisfied inclusion criteria (15 bilateral and 9 unilateral) between May 2015 and May 2017. The mean age was 13 years (11–20), 16 were male and 8 were female patients. All patients underwent supracondylar femoral DO and stabilization with the proximal humeral locking plate. Informed consent was obtained from all patients. All patients were evaluated preoperatively and postoperatively by using the Bostman knee score, intermalleolar distance (IMD), tibiofemoral angle (TFA), and lateral distal-femoral angle (LDFA). Patients with a minimum follow-up of 2 years were included in the study. Results: The preoperative LDFA was 73.4 ± 2.1 which improved to 87.2 ± 0.6 postoperatively while clinical and radiological TFA improved from 19.7 ± 21 and 21.4 ± 2.1 to 7.3 ± 0.8 and 8.6 ± 0.8, respectively. The mean Bostman score improved significantly. Two patients (2 limbs) had a good score (20–27), while the rest had an excellent score (28–30). IMD, TFA, and LDFA also improved statistically significantly (P < 0.001). All the patients were satisfied with the cosmetic correction. There were no implant failures, re-operations, and any loss of correction. Conclusion: This novel technique of stabilizing supracondylar femoral DO with the proximal humeral locking plate is cost-effective and has encouraging early results.
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Anatomical considerations of intercondylar notch dimensions of femur in cadavers with intact anterior cruciate ligament p. 38
Alok Chandra Agrawal, J Rakshit, Harshal Sakale, Bikram Kar, Manish Raj
DOI:10.4103/jotr.jotr_27_21  
Background: The femoral intercondylar notch is an anatomic site of interest since it houses the anterior cruciate ligament which is one of the importantstructure stabilizing knee. The configuration of the intercondylar notch is related to the active functioning of the cruciate ligaments. Objective: The primary objective of the study was to measure the intercondylar notch dimensions of femur in cadavers with intact ACL and its correlation. Materials and Methods: The study was done on 30 cadaveric knees provided by department of Anatomy. The measurements of intercondylar notch like width at the base of the notch, width in the middle of the notch, width at the top of the notch, height of the notch were measured using a digital vernier callipers with knee in 90 degree flexion. Results: Among the 30 cadaveric knees whose intercondylar notch dimensions were measured, 20 were male and 10 were female. All the 30 knees were categorized into A-, U, and W-shaped notch knees. A shaped intercondylar notch was accounted for 13, U shaped 16 and W shaped 1 knee. There was a significant difference (P = 0.048) in notch width at base in A-, U-, and W-shaped notches. The highest is of W followed by A- and U-shaped notches. Conclusion: This study shreds light on the normal intercondylar notch dimensions of femur and its correlation with different notch shapes. This study would help for the comparison of notch dimensions and finding out the causal reason for ACL insufficiency.
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Role of platelet-rich plasma in painful early osteoarthritis knee and plantar Fasciitis: A prospective study p. 41
Karuna Shankar Dinkar, Rajat Kapoor, Vikas Kumar Mishra, Chandra Prakash Pal, Mohit Sharma, Rohit Yadav
DOI:10.4103/jotr.jotr_35_20  
Introduction: Plantar fasciitis and early osteoarthritis knee are the most common painful orthopedic conditions treated by orthopedic practitioners. This study is to assess the role of platelet-rich plasma (PRP) injection in the treatment of plantar fasciitis and early osteoarthritis knee. Aims and Objectives: To access the role of platelet-rich plasma in plantar fasciitis and early osteoarthritis knee. Materials and Methods: A prospective interventional study was conducted at our center between January 2016 to March 2017. Patients included were complaining of pain in knee for 3 months, Grade 1 to Grade 2 osteoarthritis, presenting with complaints of plantar heel pain, tenderness at the attachment of the plantar fascia. The details of the clinical assessment filled and baseline WOMAC score for osteoarthritis knee and analog pain scale for plantar fasciitis was recorded. We explained the procedure to the patients and informed consent were taken. 4 ml of PRP was injected in either condition. Patients were followed up for 6 months at 1, 2, 3, 4, 5, and 6 months. Visual analog scale (VAS) for the assessment of pain in plantar fasciitis and WOMAC score for early osteoarthritis knee was recorded for all patients at the last visit and compared. Results: In 15 patients with osteoarthritis of knee, the mean score for preinjection baseline was 29.4 ± 5.80, which showed improvement by 27% from baseline during the 1st month with a mean of 21.4S7 ± 5.475 and during 6th month with a mean of 22.47 ± 9.516 but it never reverted to baseline pre injection value. In 30 patients with plantar fasciitis, the results are statistically significant (P ≤ 0.05), and all the patients responded to the treatment. VAS score is statistically significant in comparison with baseline at all duration. Conclusion: In our study, PRP is significantly effective in reducing pain in early osteoarthritis knee and plantar fasciitis.
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CASE REPORTS Top

Digit transposition; A “spare-part” surgery in a mutilating hand injury p. 47
Kuldeep Nahar, Nikita Nahar
DOI:10.4103/jotr.jotr_49_19  
A young Male had a RTA, causing loss of whole of middle finger & crushed skin at dorsum of Index metacarpal bone with fracture of Proximal Phalanx of ring finger along with infected Palmar Lacerated wound. He presented it two weeks after the injury. Hand salvaging surgical procedure was done by transporting the index digit to middle finger metacarpal head and fixed with K wires, sacrificing distal two-third of the second nonviable metacarpal bone. Hand appears to be more functionally and esthetically viable along with avoiding multiple different surgeries, contractures, and stiffness of the joints.
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Complex regional pain syndrome type 1 of the upper limb following glass cut of the third finger in a patient p. 50
Mehpare Firat
DOI:10.4103/jotr.jotr_4_20  
Complex Regional Pain Syndrome (CRPS) is a chronic pain syndrome characterized with edema, autonomic dysfunction, and dystrophic changes. We present the case of CRPS in a 32-year-old male in whom the diagnosis was based on the bone scan; characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function. This disorder usually develops after minor trauma or surgery. Its diagnosis is very difficult and based on diagnostic criteria which have been changing over last years. However, there is no golden standard in the diagnosis of this entity. Three-phase bone scan is a widely used diagnostic modality which has been proved useful in CRPS. Multidisciplinary approach is necessary for proper and quick diagnosis.
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Bilateral, multiple, trigger digits in a 3-year-old child p. 54
Sumedh D Chaudhary, Sagar R Raghuwanshi
DOI:10.4103/jotr.jotr_82_20  
A trigger finger is characterized by clicking, catching, or loss of motion of the involved finger and is associated with dysfunction and pain. Trigger digits in the pediatric population are relatively uncommon and multiple, bilateral trigger digits in children are extremely rare. Patients may present with the classical triggering as seen in adults or with digits locked in flexion. In this paper, we are reporting a 3-year-old girl who presented with flexion deformity of multiple digits with involvement of left thumb, middle, ring finger, and right thumb. After a failed trial of conservative management, the patient underwent surgery. Complete correction could be achieved with open division of the A1 pulleys of the involved digits. There has been no recurrence even after 3 years postsurgery. We believe that open release gives satisfactory results even in multiple trigger digits and should be the preferred treatment, especially for children presenting with digits locked in flexion.
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Fracture-subluxation of the shoulder in children: A case series and literature review p. 57
Ganesh Singh Dharmshaktu, Navneet Adhikari, Pankaj Mourya
DOI:10.4103/jotr.jotr_25_20  
Glenohumeral dislocation in pediatric age is a rare injury. The proximal humerus fractures, on the other hand, are relatively common with the management ranging from conservative to operative fixation. Concomitant proximal humeral fracture and subluxation or dislocation of ipsilateral glenohumeral joint are the rarer events with very few reports available in the literature. We present a series of four pediatric cases (2 males and 2 females) of fracture dislocation of the shoulder with relevant details. All the cases suffered injuries following fall from tree and were managed by operative means in two while two were managed conservatively. Good functional outcome was noted in the mean follow-up of 10 months.
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Recurrent complex regional pain syndrome after minor hip surgery p. 61
Hüseyin Kaplan, Emel Güler, Mehmet Kirnap
DOI:10.4103/jotr.jotr_8_19  
Complex regional pain syndrome (CRPS) Type I, a chronic pain disorder, occurs in the sequel of certain predisposing conditions. Recurrence may be observed in 4%–10% of cases in the same or another limb. There are no specific parameters to prevent CRPS after surgery or trauma. However, some authors have reported several recommendations about surgical techniques and Vitamin C supplementation. We report a case who had CRPS Type I history before and developed recurrent CRPS Type I in the lower limb due to surgery for osteonecrosis of the hip. We observed significant improvement with physical therapy and medication.
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A case of neuroborreliosis: A challenge to physiatrist p. 64
Vinay Kanaujia, Shipra Verma, Raj Kumar Yadav, Binayak Patra
DOI:10.4103/jotr.jotr_29_20  
Lyme disease is a multisystem complex illness. Neuroborreliosis is a neurological manifestation of Lyme disease. Neuroborreliosis is not very common in India. Neuroborreliosis disease sequelae sometime resolves completely but in some cases it became chronic which ultimately impairs the quality of life. Early diagnosis, medical management, and proper rehabilitation protocol improve the outcome of the disease. This case report demonstrates medical and rehabilitation management of neuroborreliosis in a middle-aged female, a native of Garhwal, Uttarakhand, with some atypical presentation.
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LETTERS TO EDITOR Top

extending assistance to the internally displaced victims of humanitarian emergencies in Iraq: World health organization p. 69
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/jotr.jotr_26_19  
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Multifocal skeletal tuberculosis with atypical imaging feature p. 71
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/jotr.jotr_29_18  
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