BJA Advance Access originally published online on December 23, 2005
British Journal of Anaesthesia 2006 96(2):195-200; doi:10.1093/bja/aei301
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Anaesthesia for brachytherapy—5
yr of experience in 1622 procedures
Klinische Abteilung für Anästhesie und Allgemeine Intensivmedizin B, Medizinische Universität Wien, Währinger Gürtel 18-20, AKH, A-1090 Wien, Austria
Present address: Abteilung für Anästhesiologie und Intensivmedizin, Marienkrankenhaus Soest, Widumgasse 5, D-59494 Soest, Germany
* Corresponding author: DEAA, Klinische Abteilung für Anästhesie und Allgemeine Intensivmedizin B, Medizinische Universität Wien, Währinger Gürtel 18-20, AKH, A-1090 Wien, Austria. E-mail: burkhard.gustorff{at}meduniwien.ac.at
Accepted for publication October 21, 2005.
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Abstract |
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Background. Brachytherapy presents the anaesthetist with unique problems. Information on anaesthesia for brachytherapy, however, is limited. The aim of this paper is to report on our experience involving a large number of brachytherapy procedures.
Methods. A retrospective analysis of records of 1622 anaesthetic procedures in 952 patients is presented. Records were analysed in respect of patient data, tumour localization, brachytherapy treatment and the type and duration of anaesthetic procedures.
Results. More than one-third of patients were at high risk (ASA III or IV) and 40% were more than 60 yr. Repetitive treatments were performed on half of the patients. Breast cancer was the most common indication. The average duration of anaesthesia for pelvic brachytherapy was more than 3 h, with a high degree of variability. Regional anaesthesia was used in 30% of all cases and was the predominant technique for pelvic brachytherapy. Spinal catheter techniques represented a high proportion of those receiving regional anaesthesia. Complications resulting from regional and general anaesthesia were minor and no serious incidents occurred.
Conclusions. Based on a large number of procedures, this study gives an example of anaesthetic management in brachytherapy. A substantial minority of patients would be considered high risk for surgical intervention. Regional anaesthesia was the principal technique used when dealing with tumours of the lower body.
Keywords: anaesthesia, conduction; anaesthesia, general; anaesthesia, spinal; analgesia; analysis, retrospective; complications; therapy, brachytherapy
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Introduction |
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Brachytherapy, the implantation of radioactive sources in or near tumours, has acquired an important role in the treatment of a variety of cancers and presents the anaesthetist with numerous challenges, which differ somewhat from the conditions encountered in surgical patients in the operating theatre. Firstly, patients scheduled for brachytherapy are often elderly with coincidental diseases that may preclude major surgery1 and confer a high risk of perioperative complications.2 3 Secondly, intracavity and interstitial brachytherapy is extremely painful and requires both analgesia and immobilization. After removal of the applicators, however, no further analgesia is required. The duration of brachytherapy procedures is highly variable. Imaging of the applicator requires the additional procedures of X-ray, computed tomography (CT) and, increasingly, magnetic resonance imaging (MRI). Additionally, computer based planning of brachytherapy is an important part of the whole procedure while the applicator is in situ. All these procedures lead to a prolongation of each treatment episode. Thirdly, a brachytherapy treatment session can take place in more than one location, i.e. the operating theatre, the radiology units for X-ray, CT or MRI and the radiotherapy room for the brachytherapy itself. To perform and monitor general anaesthesia is challenging under these conditions.
Literature on analgesia and anaesthesia in brachytherapy has increased over the last years but is still limited.1 4 5 There is discussion of the ideal way to provide both analgesia and immobilization.4 6 7 General considerations on this issue have been published recently in a review on analgesia for pelvic brachytherapy, where the options of anaesthesia techniques in this field1 are discussed. This review gave rise to letters summarizing the importance of anaesthesia for brachytherapy and the need for data.6 7 Here we have reviewed our anaesthesia records for 1622 procedures for brachytherapy over a period of 5
yr.
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Methods |
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The Clinical Department of General Anaesthesia and General Intensive Care B provides anaesthesia on a daily basis for brachytherapy conducted by the Department of Radiotherapy and Radiobiology, both in the Medical University of Vienna. We retrospectively reviewed all the anaesthesia records of patients who underwent anaesthesia for brachytherapy in this department over a period of 5
yr. The following data were collected and presented as summary statistics [mean (SD), median (range) or as proportions as appropriate]:
- Age, sex and ASA status.
- Localization and type of cancer.
- Type of brachytherapy: high dose rate, pulse dose rate and number of treatment sessions.
- Duration of anaesthesia in minutes measured from the first procedure undertaken by the anaesthetist to the end of the anaesthetist's attendance.
- Type of general anaesthesia: total i.v. anaesthesia (TIVA), inhalation anaesthesia or balanced anaesthesia and medication used: anaesthetic agents, opioids, neuromuscular blocking agents, other sedatives.
- Type of airway devices used: face mask, cuffed oropharyngeal airway (COPA), laryngeal mask, tube and the need for fibre-optic intubation.
- Anaesthesia-related complications during general anaesthesia: cardiovascular incidents such as bradycardia (heart rate <60 beats min–1), hypotension (blood pressure <30% of pretreatment value), hypertension (blood pressure > 30% of pretreatment value); nausea and vomiting.
- Type of regional anaesthesia: spinal anaesthesia, combined spinal and epidural (CSE) techniques, epidural anaesthesia.
- Details of spinal anaesthesia technique: single shot, catheter techniques, number of re-injections, continuous spinal anaesthesia via spinal catheter.
- Upper level of sensory block of regional anaesthesia.
- Change of anaesthetic technique from regional to general anaesthesia or change within regional anaesthesia techniques.
- Anaesthesia-related complications during regional anaesthesia: cardiovascular incidents as mentioned above, distribution of regional anaesthesia above T6.
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Results |
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Patient details and number of treatment sessions
During 5
yr of brachytherapy 952 patients, 860 female and 92 male, were treated. The distributions of age and ASA status are given in Table 1. The median age was 71 yr with a range from 2 to 97 yr. Thirty patients were more than 80 yr and 40% of the patients were more than 60 yr of age. About 11% of the patients were classified as ASA I (normal healthy patient), because these patients were without systemic disease. Most of the patients were classified ASA II with about one-third classified ASA III or IV.
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The type and localization of the treated tumours are given in Table 2. The majority of the patients suffered from breast cancer (70.1%), followed by tumours of the female genital organs (16.8%) and prostate cancer (3.9%). Most of the patients (56.7%) underwent a single treatment, for example, single brachytherapy of the female breast as a booster treatment after repeated radiotherapy (Table 3). All other patients had multiple treatments. On average patients receiving three or more treatments were at higher risk (ASA III and ASA IV) and were older than patients who received one or two therapeutic procedures (Table 3). Because of multiple sessions received by the 952 patients, a total of 1622 anaesthetic procedures was performed. Anaesthesia was given for 1468 (91.4%) treatments in high dose rate brachytherapy and in 154 (8.6%) patients anaesthesia was given for pulse dose rate brachytherapy (Table 4).
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Type and duration of anaesthetic procedures
Anaesthesia was performed for the induction and the withdrawal of brachytherapy manoeuvres. General anaesthesia was performed in 1055 (65%) of the treatments. Regional anaesthesia, with or without the additional use of sedatives, was used in 567 (35%) of procedures. Local anaesthesia was not used. The distribution of anaesthetic procedures, duration of anaesthesia related to the localization of the cancer and the number of ASA III and ASA IV patients are given in Table 4. A higher proportion of patients scheduled for regional anaesthesia were ASA III or IV and underwent longer procedures than patients who received general anaesthesia. Some of the procedures involved only the removal of the applicators and resulted therefore in anaesthesia of relatively short duration (Table 4). In general, in our department regional anaesthesia was preferred for brachytherapy for the treatment of cancer in female genital organs, rectum and prostate (Table 4). In 46 patients (7.5% of total procedures) scheduled for pelvic brachytherapy where regional anaesthesia would have been possible, general anaesthesia was chosen. Decisions to choose general anaesthesia instead of regional anaesthesia were made on the basis of medical considerations (e.g. coagulation disorders, low platelets, increased temperature) and the patient's wishes (e.g. incomplete distribution of regional anaesthesia in a former procedure, panic attack during a former procedure).
General anaesthesia
All types of general anaesthesia, that is, TIVA (55% of general anaesthesia), balanced anaesthesia (15% of general anaesthesia) or inhalation anaesthesia with or without analgesic supplement under spontaneous breathing (30% of general anaesthesia) were used. The type of anaesthesia and medication used was dictated by the location of the tumour and the proposed duration for the application of the hollow needles. Remifentanil was used in 68% and fentanyl in 11% of general anaesthetics. Neuromuscular blocking drugs were used only in 7% of general anaesthetics. The tracheas of all patients with a bronchial tumour were intubated and these patients underwent anaesthesia with a neuromuscular block and mechanical ventilation of the lungs. All of the common airway devices, i.e. tracheal tube (10% of general anaesthesia cases), face mask (48%), laryngeal mask (10%) and COPA (5%) were used. Fifty percent of the patients treated for oropharyngeal tumours required tracheal intubation using a fibre-optic laryngoscope.
Complications of general anaesthesia were documented in 369 patients (35%). Complications were dominated by cardiovascular incidents, that is, hypotension in 134 (33%) and bradycardia in 221 patients (20%). Bradycardia was reported mainly when remifentanil was used (211 patients). Postoperative nausea was reported in 10 patients and vomiting in 4 patients (1.3%). Two patients developed laryngospasm which was treated without sequalae. No life threatening complications occurred.
The use of postoperative analgesia was documented in 114 general anaesthesia patients (11%). Metamizol was used in 73 patients; diclofenac in 11 patients; tramadol in 14 patients; piritramid in 12 patients: in 11 patients a combination of non-opioids and opioids was used.
Regional anaesthesia
Anaesthesia for brachytherapy to the female genital organs, rectum and prostate was dominated by regional anaesthetic techniques (Table 4). Single shot spinal anaesthesia was performed in 30% (n=171), a spinal catheter was used in 52% (n=295) and in 1% (n=5) of the treatments the spinal catheter was used connected to a pump for continuous infusion. Combined spinal/epidural (CSE) was performed in 7% (n=38) of cases and an epidural catheter only was used in 10% (n=58) of cases. In 105 patients (18.5% of regional anaesthetics) midazolam was given i.v. after regional anaesthesia and cardiovascular stability had been established.
The number of injections given through the spinal catheters is given in Table 5. In 40% of the cases it was not necessary to re-inject using the spinal catheter, because the first injection outlasted the treatment time required for brachytherapy. The longer the duration of treatment, the higher was the number of injections (Table 5). In total, 295 spinal catheter treatments were performed. Bupivacaine 0.5% was used for the first dose in all cases and in most cases for subsequent injections: in 5% of the subsequent injections mepivacaine 1% and in 2.5% lidocaine 1% were used. When epidural catheters were used, more than one dose of local anaesthetic was used in 46% of the cases, regardless of whether CSE or an epidural catheter alone was used. When more than one dose was required the average total number of doses required was three. The local anaesthetic of choice was bupivacaine 0.5%, which was used initially, apart from the test dose with lidocaine 1%, in all cases. After this, ropivacaine 0.2% was used for top-up doses in 20% of cases. We did not use opioids such as morphine or fentanyl as an addition to local anaesthetics for regional anaesthesia. The upper level of anaesthesia was between T3 and T6 in 29% of regional anaesthetics, between T7 and T10 in 61% and below T10 in 10%.
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Cardiovascular complications of the 567 regional anaesthesia procedures were: hypotension (10%), bradycardia (10%), hypertension (1%), ventricular dysrhythmia (4 patients). Hypotension and bradycardia occurred simultaneously during nine procedures (1.6%). Nausea was rare (1% of regional anaesthetics). Postdural puncture headache occurred shortly after the removal of spinal or epidural catheters in two patients. No life threatening complications occurred.
Technical problems during siting of regional anaesthetics were documented in 23 patients (4%). These included multiple puncture attempts (4 patients) and puncture of the dura during epidural placement (3 patients). Bloody puncture (4 patients) and accidental removal of the inserted spinal catheter shortly after induction (2 patients) were reported.
A switch from regional anaesthesia to general anaesthesia was documented in 11 patients (1.9% of regional anaesthetics). In 7 patients regional anaesthesia produced insufficient analgesia, in two patients there was accidental removal of the spinal catheter, and there was one patient of catheter occlusion.
Postoperative analgesia was documented in 10 patients (1.7% of regional anaesthetics). In half of the cases metamizol was used, piritramide was given in one case and in four cases a combination of non-opioids and opioids was used.
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Discussion |
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We have reviewed 1622 anaesthetics used for brachytherapy. Our data identify the proportion of high risk patients, characterize the brachytherapy procedures (high dose rate or pulse dose rate) and frequency of repeated treatments and the tumour-associated duration of procedures and the type of anaesthesia. Here, the anaesthetic procedure of choice is regional anaesthesia for patients scheduled for pelvic brachytherapy and in cases of regional anaesthesia we report a particularly high proportion of spinal catheter techniques.
Brachytherapy covers all types of patients, from young healthy adults with localized tumours without systemic disease, as found in many breast cancer patients, to the elderly with important concomitant morbidity. Even small children are treated by brachytherapy to reduce radiation-induced complications and a few case reports have been published.8 9 In the patients reported here tumours affecting the breast (70%) and the female genital organs (17%) predominated. Our distribution of treated cancer types is in accordance with the incidence of cancer in Western Europe.10 Prostate carcinoma is a major indicator for brachytherapy in other clinics.4 5 11 Prostate carcinoma accounted for 3.9% of our patients (Table 2).
Multiple brachytherapy sessions are frequently required. Our 1622 anaesthetic procedures were performed on 952 patients. These data are in accordance with a report of 170 low-dose-rate intracavity brachytherapy procedures performed on 128 cervical carcinoma patients.2 In gynaecologic brachytherapy 95% of patients are treated more than four times.3 Our data indicate that ASA III or IV patients often receive repeated brachytherapy treatments such that about 40% of all anaesthetic procedures are carried out on ASA III or IV patients (Table 4). Our data are in line with the general appraisal of risk factors in brachytherapy patients,1 that is a large proportion of elderly patients with coincidental diseases which preclude major surgery.
Our data on general anaesthesia represented the broad range of general anaesthesia techniques. Most common airway devices were used. Anaesthetics and analgesics including short acting opioids were used for general anaesthesia according to clinical requirements. As there is a lack of previous reports, we cannot conclude whether our practice is representative of the anaesthetic management of brachytherapy. The choice of anaesthetic technique has been discussed in some recent publications. One report cites the use of sedation in 98% of cases3 whereas others have used general anaesthesia in 2312 to 85%2 of cases. There is increasing interest in the influence of the type of anaesthesia on the outcome of brachytherapy. In a retrospective review of 18 patients the radio-oncologists Lam and colleagues11 concluded that general anaesthesia is associated with a higher rate of anaesthesia-related complications than conscious sedation or local anaesthesia. However, the reported general anaesthesia complications were mild such as nausea and cystitis, whereas among five paracervical blocks one patient suffered from seizures. In another study there was no correlation between the type of anaesthesia and the rate of ‘acute complications’ during low-dose-rate intracavity brachytherapy in 128 patients.2 Our data do not support the superiority of any particular anaesthesia technique.
It is noteworthy, that, although small in number, certain brachytherapy procedures are associated with high risk because of specific hazards met in the patients. Patients with oropharyngeal cancer (2.9% of our patients) often present a difficult airway. For example, more than half of our oropharyngeal cancer patients required fibre-optic intubation of the trachea. In future anaesthetists are likely to face further challenges as technical progress leads to more sophisticated imaging-guided interventions such as open MRI-guided brachytherapy,13 CT-guided interstitial brachytherapy of the lung14 and palliation of dysphagia by brachytherapy.15
Up until now there is very little information about regional anaesthesia in brachytherapy. There is a sole review of analgesia for pelvic brachytherapy only.1 The data presented here show that the choice of anaesthetic procedure correlates with the location of the tumours. Accordingly, regional anaesthesia in nearly all patients with lower body brachytherapy reflects the preference for regional anaesthesia in our department. This choice is influenced favourably by the availability on a daily basis of anaesthesia staff and standard anaesthesia equipment. Local anaesthesia was not performed. We used catheter techniques in 70% of all regional anaesthetics with a spinal catheter technique favoured in more than half of the regional anaesthetics. The need for top-up doses of local anaesthetic through the spinal catheter in more than 60% of the spinal catheter cases confirmed the rationale for this approach. Removal of the applicator after high dose rate brachytherapy is painful and requires complete anaesthesia until the end of the brachytherapy. It is important to attain a rapid onset of anaesthesia and this is facilitated by the use of spinal catheters rather than epidural catheters.
Hypotension and bradycardia occurred in about 10% of the patients having regional anaesthesia. This may be explained by the high proportion (29%) of the patients with an upper level of regional anaesthesia at or above T6 and this may be attributed to the predominant use of spinal catheters. There are specific complications reported with the use of spinal catheters16 17 and even a traumatic syrinx has been described.18 These complications may be related to catheter dimensions and the method of insertion.17 19
Local anaesthesia has been proposed for prostate and cervical brachytherapy, while it has been suggested that systemic non-steroid anti-inflammatory drugs and opioids could be used for intermediate pulse dose rate brachytherapy.6 However, the use of topical lidocaine for cervical brachytherapy resulted on average in pain on the visual analogue scale (VAS) of 49.9 mm (scale 0–100, 0=no pain, 100=worst possible pain).20 Local anaesthesia for prostate brachytherapy results in pain on the VAS between 30 and 45.4 5 21 These reports reveal that 9% of patients prefer general anaesthesia instead of local anaesthesia after the treatment.4 5 Moreover, local anaesthesia does not outlast the duration of the procedures reported here which lasted more than 3 h. We did not systematically interview our patients to obtain their satisfaction of the procedure. However, our data indicate that insufficient analgesia was the reason for a switch from regional anaesthesia to general anaesthesia in only 1.7% cases of regional anaesthesia. All other regional anaesthesia procedures seemed to have met the analgesic needs of the patients. We do not provide local anaesthesia for brachytherapy in our department.
This study is a retrospective review of records and is therefore limited in several respects. Complications of the anaesthetic procedures are likely to have been under-reported. For example, postpuncture headache was documented in two patients only. Cardiovascular complications of general anaesthesia and regional anaesthesia might have been expected in a higher proportion of cases. In addition, we did not perform systematic post-anaesthesia interviews on patient satisfaction. Incidences of post-puncture headache that might have emerged on the ward were not registered. Therefore we cannot provide proof that the high proportion of regional anaesthesia used for pelvic brachytherapy met with the approval of our patients. However, from clinical experience we are convinced that regional anaesthesia provides superior conditions for lower body brachytherapy for both patients and radiotherapists under the particular circumstances of a brachytherapy department.
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Acknowledgments |
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We highly appreciate Mrs Eileen Reynolds' enthusiasm in proof-reading the manuscript.
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References |
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1 Smith MD, Todd JG, Symonds RP. Analgesia for pelvic brachytherapy. Br J Anaesth 2002; 88: 270–6
2 Wollschläger K, Connell PP, Waggoner S, Rotmensch J, Mundt AJ. Acute problems during low-dose-rate intracavitary brachytherapy for cervical carcinoma. Gynecol Oncol 2000; 76: 67–72[Medline]
3 Petereit DG, Sarkaria JN, Chappell RJ. Perioperative morbidity and mortality of high-dose-rate gynecologic brachytherapy. Int J Radiat Oncol Biol Phys 1998; 42: 1025–31[CrossRef][ISI][Medline]
4 Wallner K. Prostate brachytherapy under local anesthesia; lessons from the first 600 patients. Brachytherapy 2002; 1: 145–8[Medline]
5 Mueller A, Wallner K, Corriveau J, Arthurs S, Gwinn M, Sutlief S. A reappraisal of local anesthesia for prostate brachytherapy. Radiother Oncol 2003; 67: 309–12[Medline]
6 Fitz-Henry J, Chan S. Analgesia for pelvic brachytherapy. Br J Anaesth 2002; 89: 342
7 Appadurai IR, Hanna L. Analgesia for pelvic brachytherapy. Br J Anaesth 2002; 89: 342
8 Gustorff B, Lierz P, Felleiter P, Knocke TH, Hoerauf K, Kress HG. Ropivacaine and bupivacaine for long-term epidural infusion in a small child. Br J Anaesth 1999; 83: 673–4
9 Kozek-Langenecker SA, Marhofer P, Sator-Katzenschlager SM, Dieckmann K. S(+)-ketamine for long-term sedation in a child with retinoblastoma undergoing interstitial brachytherapy. Paediatr Anaesth 2005; 15: 248–50[Medline]
10 Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005; 55: 74–108
11 Lam ST, Cho PS, Marks RJ, Narayanan S. Detection and correction of patient movement in prostate brachytherapy seed reconstruction. Phys Med Biol 2005; 50: 2071–87[Medline]
12 Lim KH, Lu JJ, Wynne CJ, et al. A study of complications arising from different methods of anesthesia used in high-dose-rate brachytherapy for cervical cancer. Am J Clin Oncol 2004; 27: 449–51[Medline]
13 Kettenbach J, Köstler W, Rücklinger E, et al. Percutaneous saline-enhanced radiofrequency ablation of unresectable hepatic tumors: initial experience in 26 patients. Am J Roentgenol 2003; 180: 1537–45
14 Ricke J, Wust P, Wieners G et al. CT-guided interstitial single-fraction brachytherapy of lung tumors: phase I results of a novel technique. Chest 2005; 127: 2237–42
15 Homs MY, Steyerberg EW, Eijkenboom WM, et al. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004; 364: 1497–504[CrossRef][Medline]
16 Chan BO, Paech MJ. Persistent cerebrospinal fluid leak: a complication of the combined spinal-epidural technique. Anesth Analg 2004; 98: 828–30
17 Gosch UW, Hüppe M, Hallschmid M, Born J, Schmucker P, Meier T. Post-dural puncture headache in young adults: comparison of two small-gauge spinal catheters with different needle design. Br J Anaesth 2005; 94: 657–61
18 Harney D, Victor R. Traumatic syrinx after implantation of an intrathecal catheter. Reg Anesth. Pain Med 2004; 29: 606–9[Medline]
19 Deusch E, Benrath J, Weigl L, Neumann K, Kozek-Langenecker SA. The mechanical properties of continuous spinal small-bore catheters. Anesth Analg 2004; 99: 1844–7
20 Chen HC, Leung SW, Wang CJ, et al. Local vaginal anesthesia during high-dose-rate intracavitary brachytherapy for cervical cancer. Int J Radiat Oncol Biol Phys 1998; 42: 541–4[CrossRef][ISI][Medline]
21 Smathers S, Wallner K, Simpson C, Roof J. Patient perception of local anesthesia for prostate brachytherapy. Semin Urol Oncol 2000; 18: 142–6[Medline]
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