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My name is Heather
and I'm gonna talk about skin and soft tissue infections in the emergency
department. And that's obviously
a huge topic that I can't possibly cover all of, so I chose some very specific
objectives that I'm gonna cover based on some cases that I saw
and I'd also like to thank Dr. John for joining us
He's a medical microbiologist and the medical director of infection control
and so hopefully he can answer questions people have about local antibiotic
resistance and antibiotic choices
so
the last four weeks I spent on HULC
and on HULC you do plastic surgery call, so
I saw a lot of soft-tissue infections on plastic surgery call, and it left me with
a lot of questions about what we do because
there's some differing opinions from
our point and the surgery
standpoint regarding antibiotics.
I want to talk with diagnosis of abscesses. MRSA coverage for
purulent skin and soft-tissue infections
antibiotics after I & D
primary organisms causing cellulitis
and the role of Ceftriaxone in treating moderate to severe cellulitis
so the first case I'm going to talk about
is a call I got from the community
about a twenty five-year-old male who presented complaining of left arm pain
and he admitted to injecting crystal *** into his forearm and thinks he might have missed
and he had - from what the Emerg doc told me - a large area of erythema and swelling
on his left forearm
The Emerg doc then texted me a picture to show me what he meant
and I 'll show you that in a minute
the community ER doc did a point of care ultrasound to confirm presence of
an access in that guy's forearm
how many call that's because he thought that the assets that he did see was
really deep and he didn't want to operate in top condition might benefit
from who are
so this is that the tree something
and he was right we ended up getting formal ultrasound and i cry and once you
are for uh...
and watched it
but it made me wonder
how much better if carol chase down ben our own clinical exam
when it comes to diagnosing abscesses
and that's actually a few papers at their but this time we can talk about
two of them
so this was our prospective study done in california on a hundred thirty-five
patients in academic to hospital
and they included any patients with a chief complaint of cellulase are assets
that have to be accurate sizing up the feeling unsafe and they can use oral sex
uh... and the residents and stopper provided with thirty minutes about some
training
tonight for a very between study some times it was as little as fifty minutes
sometimes it wasn't really a formal training period
and uh... they use the linear probe
when i was acting jones urgent care at
micron
uh... to use on that upsets benefits
they're not buy it
anyways this is that what the uh... defined as an abscess on ultrasound so
ananda collect or hydrochloric structure
with poorly defined borders it's usually spherical in shape
all about
uh... okay
soul poorly defined borders usually here comes the although it doesn't have to be
there it will not internal apples
and then this is an example of what they're looking for foresight latest and
not smart
primarily by koppel stoning
so that we have a steady work is that they were ordered to yes or no
assessment of an abscess
after their history and physical exam
and then they get their own point of character sounds it wasn't like that
and then they were recorded a revised castano a passion
all the patients with a free ultrasound assessment out yes i did find do you or
needle aspiration
uh... patience with the pre on south africa no
was up to physician proper and so after they get their ultrasonic make a
decision about what they wanted to do you think about how the patient followed
up at the base by phone district them with their patients products
or they could you an idea of illustration if they chose to him
and these were the results
system or miss priestly clinical exam was actually fairly sensitive or outside
so eighty six percent
just pretty good i think the specificity was a little bit lower at seventy
percent
and now when you add a point carol chase down into the picture
hymie subjectivity went up to ninety percent in specificity of eighty eight
percent
so much better
uh... so in this study point carrollton did increase the diagnostic accuracy
protection about substance
and in cases where ultrasound disagreed with the physical exam
uh... ultrasounds correct ninety four percent of the time
thank a good example of that was ibiza one-off case that they are reported but
one patient had a growing but it's not a growing up there so they put the
ultrasound probe on an oxygen tent yesterday lingers on
so not having to drink
because a supple sometime motion and lack of internal echoes
so i mean this was sent out of one but it's a disappointing
where option could be useful
twenty seven pieces we lost the plot i think about the function of this
been kinda marginalized population a lot of didn't have a phone number to follow
up
uh... there was no whining as i said
and we don't really know what happened to the patient-doctor variety
because after no winding up sorry because
they were followed up by foam show
i mean you're relying on occasion to tell you whether or not they're obsessed
with solves they weren't
didn't were subjected to repeat physical exam rope sound
obviously would have been accurately sound to heidi patients who had a
negative clinical assessment in a negative ultrasound
so they were sort of stock with that is there
cocom and also um...
ultrasound picked up a lot
abscesses that
or question of the clinton significance though
one of them was
happens the sea
so i don't know what i mean not could have potentially responded to truck
salam
but it was trained
and this is the second saying he's gonna talk about it very briefly because it's
very similar to the first study
but said they focused a little more patients but that clinical fail a dozen
no obvious that collection
and in this study point carol chan change management fifty six percent of
the cases
solan some republicans and it's actually pretty sensitive process detection
you're pretty good job
com without ultrasound
without a sound mixer clinical diagnosis batter
and that doesn't say anything about picking up on the weather makes the snow
comes back and say that but
uh... it does make our clinical
diagnosis better
so maybe the patients for whom this way
really provide about that would be people who work in a follow up so
mark's wife populations
citations i_v_ drug users homeless people
it might be a benefit to know right off the bat what you're dealing with 'cause
if they get worse they may not come back
one of the second back questions i have a back piece was
uh... whether or not by always needed here a camera say coverage for a
cure-all in skin infections
there's actually a lot of studies
i'm terrible at their site shows that she had to talk about briefly uh... one
was in the new england journal message without one because it's very
comprehensive
uh... and then the second one it shows because it was done here in london so it
probably has a lot of implications for
our local practice in
uh... sensitivities here
the in internal medicine study with a prospective prevalence study of adults
consumption factions and they looked at time of america to department eleven
u_s_ cities
excluded all terry *** abscesses
and swath of all the cure-all insights were culture
you can see that makes example than ever say access there
on four hundred and twenty-two patients were enrolled
and i say with a sladana fifty nine percent of their one copters
is pretty high only seven percent of the estimates were streptococcal
uh... interestingly only twenty seven percent of patience you came back
positive graham marcie and their wounds have risk factors for hospital acquired
anorexic
and that's that that was a clinical
uh... diagnosis so
these people i'm happy absence of state
uh...
a hospital mission in the past year or being on dialysis or how you're going
for you know things that you would associate with probably hospital choir
demonstrate
and ninety nine percent of the n_r_c_ by mercy street when they did you know
taking or characteristic of community-acquired
on the menu telemedicine study a hundred-percent respectable susceptible
to subtract
and ninety-five tyler susceptible to kinda makes about as we're gonna talk
about in a minute that's actually
a little bit different in london
fifty seven percent of haitians without mercy infection dot its products with no
emerson coverage
lucky no different than cocom between people
who had and i think that sent
huber heights at
and rock recovered at my favorite is those that
that may be an argument for saying that for a lot of patient i_d_ along with
probably sufficient to maybe not if needed antibiotics anyway
and that's of finding that's been
substantiated and other students as well
so
i guess that that articles that is comprehensive but it doesn't
really tell us around
about ever since he was optician factions here
uh... resistance house geographic variations
on the bacteria makeup dozens also
i looked at the study is licensed under
and this is just published this past year
so i'm sure a lot you probably heard about this study before so i'm not gonna
spend too long on it but some
was a prospective observation a study of the chief complaint of skinner
soft-tissue infection three academic emerges in london
and they excluded and the small number of patients that had
uh... abscesses that would be associated with different kinds of bacteria
so they included things everything from site latest too
uh... accesses to ulcers
uh... in baltimore md five patients and they
did two things they define connotation and infections connotation with people
who had
uh... nair serpro culture for embarrassing and then
infection was silent infection sites coptic progress there
and the film dimension of uh... predictor variables associated with a
mercy infection and holidays nation
wage
there's a bit overlap there but
and summary incarceration in the past year
known exposure generously competitive sports homelessness and previous access
in the past year
uh... were associate with uh... rustic condensation or action
uh... and become a m arce was the only orchid
deflated and twenty two percent cure-all instance optician factions
uh... but overall the seventeen percent a peaceful kaunas or infected with ***
icing
acquitted him
um seven one percent of the patients without marseille had community-acquired
n_r_c_'s that means that since the prospectus for hospital acquired at
marseilles subclinical
i'd i'd also sent eighty two percent of the addressee ice let's stop by gina
taking or characteristic of community park
and here are hundred-percent again were susceptible to spectra damp and cold
but only seven five percent versus applicant bison
uh... bell seventy percent patients
without our stake out its products and glamorous coverage but
as a doctor that with the new england comments and study at those if they were
assets is that doctoring it might not be that much of a difference
for some of them
so buy my ticket for those two studies is that a mercy is responsible for a lot
of grievance consumption factions and promise im not regular ones as well
but most of our citizens optician buttons on the people of any risk
factors
so it's been hard to decide who more interesting coverage it doesn't
i think that the bottom line is that empirical mercy coverage should be
considered and most
dream consumption patterns
the last question that i had it at that particular patient was whether or not we
e_t_'s xbox whereabouts asap ranking
i'm gonna talk about some
the uh...
a study that would be a bunch of things and then i think they came out of the
same here
that was not written included in the studies so
so any else emergency medicine and they looked at six thirty a son
three or six years and and of your cities one had not liking officially
over
when only bought fifty patients
and one had patients to as part of their treatment got half lax by fifty-two
percent absences grammar say-so
uh... it's been a vote
limitation
study i guess and then three a cohort studies
uh... and other three
basically all of them found that there was no difference in resolution
after hiding for an infection traditions getting antibiotics to expand our a c is
resisting
races with two experts is susceptible
which would imply that sam
it doesn't really matter wouldn't treat them
so and also it stays there is no different in resolution print products
personal enterprise or
and rocks that were effective against infection
after him
but that doesn't answer a lot of questions so
begin keys out who had overlying slightly this big event
what if we tried to
treat patients with a product summers is susceptible to without include her
success rate
improve search that success rates
so this study looked at bats uh...
okay nothing here
so as a retrospective cohort study of community-acquired addresses consumption
actions done in arkansas they only included patients and their study you
culture positive for
uh... included everything from closer buffet latest europe's crisis
excluded anything really minor likened the taiko
a mix of anything major with an underlying disorder like osteomyelitis
and they define treatment failure as infection worst thing after two days in
greater than one of requiring a second i n t
hospital admission
and use guns optician faction
or microbiological earlier which was
culture of them are safe from a wound after they completed antibiotics
they're on
time zero
from whether to day started with the time at which c_i_d_ was performed
for most of them
but twenty percent of the patients didn't get ninety so that time zero was
when there will be sculpture
so they could set eighty percent had a ninety
there'd be field and five percent of the activity by a group in thirteen percent
of the united inspected
which was a significant
so active in charge for antibiotic sam
about how to activity against them
so it's a despot reading and i say accessing with antibiotics after
redeeming current treatment failure
but twenty percent in getting ninety
i guess the bottom line is that and i say offices may benefit
antibiotics
but there's been no large randomized double-blind placebo-controlled trial
done
so it's really still up to a clinical
pulses
one of those slightly
which is always the request
do you know what
field
i don't want and i don't think it's set in in the safe zone recall reading
so i don't know the answer
so the second case that sound
and at rocketmail wednesday
i helped me
thirty nine-year-old mail
them he presented
to community emerge complaining about brad and people attacked the past three
days and sounds kinda like the last night
no-show associated with that
here even on a patient's attract some for three days in the community
uh... stab route
still feels unwell
is there a team of spreading
and this is what it looked like
so you can see the different lines where people are kind of dog things over the
past few days and continues to spread beyond borders
and that made me question um... in this era
community-acquired i must say
uh... are we still looking at the same bacteria causing diffuse non-political
slightly this and there's two studies that have come out recently looking up
at
well review and the studies sick
so uh...
this size study looked at the role of the day he would extra causing if he's
not culture posts lately smacking stark two years ago
scissor prospective study at a california
uh... county hospital
and they had to nine forty patients with diffuse an on-call triple slightly
events
so not associated with some kind of he really important that you could culture
on the excluded people you had uh... here neal carryover orbital agreed
locations
anybody you could have had an opportunistic infection like nature
people future pena
uh...
different bugs involved so animal or human bodies
underlying uh...
uh... disorder only cost you my latest
and they also excluded people that have at soft-tissue infection warfarin
tightness in the past year because
the way that they determined he would have been telling elects rapids by doing
serology is so that would have potentially interfered with uh...
and the way that they figured out who had
which organisms and on culture ble slightly this was a bit of around that
way so they looked at and t streptomycin
always partisan in tds p antibody is measured at baseline and then to the
topics leader
so if yes all measures um...
uh... those antibodies are antibodies to group a strep groups he struck a group
ki strap
and a_t_p_ are antibodies to complete
cell
they also um...
sorry should say that um... typically infection
your add traders should rise within the to meet and start to decline two three
six months later so it should be parent who has an infection because they're yet
to be a certain amount of rise and then they should be about the upper limit of
normal for adults
on the second tighter
uh... and only two to five percent of normal adult about tigers over the
number that day
uh... how the store permanent normal
they also are a look at what cultures what kind of capture the people who had
group b_ strep
because they weren't using
uh... antibodies that could
but the crew constructed
so
their secondary outcome was looking at response to beat a lock
uh... now with a high-stakes testing clinical improvement after greater than
forty eight hours to treat them
bikes at sorry there so
the physicians were asked to use gram-positive they lacked camps for the
most part b
complied with that so
uh... more stations eighty three percent were treated with sap is all in
uh... most of the rest were treated with oxox ellen
and then a handful of patience toppings like antes up track some opulent
uh... picked hazel
uh...
dot response to be lack tams could only
be done because they weren't determining without what treatment so that response
could only be measured in people who were not covered for accuracy
they only measured response to be talking to people who've gotten one dogs
or less i've ever read say covering it biotic so they could get one two oh
seven am i say active antibiotic in the emergency department about the senate
so there was tampering efficient schools
and sixty nine cases had to be dropped
and they couldn't be assessed for every piece of religion because they were lost
to follow-up
so they might have completed their initial hospital stay in forty eight
hours or whatever so they could be assessed for being a lot to respond to
that because they never showed up to get the repeat serology done
we don't know
what they were infected with
comes to a hundred and uh... soni nine people how to complete a violation
and i turned thirty one of those were positive for being with stratton
so everybody was has us from a collector response but they had to drop a
significant number of people who were on a valuable because some they got less
than forty eight hours of june and i need a lot kami
or discharged early
uh... or they got more than a dozen each product of my state
so you can see that
the people who actually
uh... worries that serbia lack of response
largely it was successful serb were very few treatment gillis even in the group
that
wasn't positive for beating elixir
but there were a lot of other valuable haitians
cell at the end down seventy three percent percentage in tel aviv inlex
japan faction
and ninety six percent responded to new york times
successfully
i mean not
includes the group of people accept negative
there's obviously some issues um...
with interpretation of this study so
posit serology does include cortex and so some east
and purchase could've been nam
point microbial
there was a very large and a valuable group of patients
and i don't know dr dot correct me if i'm wrong but i don't think that
serology doesn't
that serology doesn't necessarily mean that infections of a cut they beat you
extrapolate is caused by something else that has provided a portal of entry in
the skin orbiting with extra
maybe that wasn't the original
pathogen
so even in the air up to be a part of our sleeping kuelen except maybe still
the most common cause and if he's not culture bles like this
this is a study that came out seeing here
with kind of a conflicting point of view
and uh...
this is a systematic review of these judges say latest within tax kids
economist similar group of people
uh...
and they look at studies that had you think a lot for easter punch biopsy to
try to culture
uh... people say latest where there wasn't anything that was cultura ball
so big and excluded similar people's so ocular oh dont genic armed factions
anything deep tissue are involving another organ which they defined as a
processor osteomyelitis
things that were thought to be contaminants like stop at the terminus
works for that
uh... man anything involving the skin break was excluded this fall
so in the and they were left with eight hundred any patients and total from
sixteen articles
two hundred and twenty seven have positive cultures
sixty five of which grew south korea's
thirty-five group group a strep
are very small number grew other id he lets wrap
the most
common utility celia is in this study was
actually south koreans
however most cultures yielded no organising
so vast majority yielded an organism
so maybe the real culprit is just more difficult to obtain holzer
some of the studies were altered so
who can really make any comments about
proportion of them that were immensely because it was before about
proportion would have been higher
i think that the bottom line is that even if they ripped me apart ever say
probably most oncall terrible slightly still cause they amass a single they
strap
select what they suggested that those articles is to start with the data
locked him in the drug coverage if treatment failure at two days
uh... adhesion st peters allergic to be a lot of times could maybe just start
with um... and on my sin
since that has some some anorexic coverage
i guess another approach is to treat people with breast actors are does more
that we can ill treatment abroad in their coverage berkeley
uh... again what's the threat research day wendy and he was talking about uh...
i his research of votes are factors independently associated with treatment
failure
which included are fever tree ***
leg ulcers
idea marilyn to demand a prior sale latest from the same area
so i guess that's another approach that we could do
philosopher snack when some whether or not uh... subtract them is a good choice
for moderate to severe slightly
it's kinda hard questions and sorry because there's no i i couldn't find any
studies directly assessing its efficacy in adults
and for those of you that had gone down
hope he'll know that our
surgical colleagues don't really agree with our use of soft rap song because it
doesn't
um... gram-positive properties
omitted third-generation cephalosporins
selfridge generations of course what i can suck theoretically should have
better grandpa's of coverage
so that's why i wanted to look into this
if the majority of slightly toasted stock left that meeting lets up and i
must say that might make more sense to choose something with better
gram-positive coverage
but us again talk about it
clinically that's not really how it turns out
this was done
a century uh... into microbial surveillance program
uh... study and i looked at about twelve thousand strains of stop instruct that
were obtained and canada and the u_s_ and then it
tested their sensitivity to suck tracks on a twelve other dynamics
food pretty big undertaking
is that samples price awaited from a bright someplace is unfortunately not to
skin
to cry take that into account to guess
and then they looked at susceptibility in vitro
so
almost a hundred percent of the analytics japanese study was susceptible
to subtract some
only sixty percent of staph aureus
some of which would've been a marseille society but for those present grinding
fifty three percent of coed negative stuff
for example stop epidermis
and that about ninety percent of irritants kirk streptococcal which i
think is a pretty low-key real instead
organism
for most people who are not suppressed
so we'd be just as a w doesn't necessarily translate to review wasn't
numbers might actually be lower in people
uh...
both amethyst anniversary strange for houston we wouldn't expect separate
happening actually got something
not all organism lives will be necessarily representative of those
found in assets to be honest i care because they were cultured from a
variety of different places
in-vitro
um... there's a
there's a few different studies that look at
and suffering compared to such try out some
in a clinical setting
romantic this one just as it was the most recent that i could find
and they compare diane subplots program and said to you
uh... its attacks on plus placebo
mistreatment of water to their site latest nipples
this is a randomized double-blind equivalence trial on a hundred and
thirty four pieces moderate to severe slightly this an australian
and uh... they define their saline says recent off onset soft-tissue working now
with more than one of pain
swelling limp and janice fever and all three shin with her with a discharge
c excluded patients that could
diskette oral antibiotics in the community treating physician
i'm anne nosocomial infections were excluded
anne patients there were really sick works great if the septic shock back to
me on
tom again mixed with aussie my latest
anne patients socially unsuitable for home treatment works for them as well
and patients without kidney or liver
um so they were handed my station sts you hands up two dash eighty plus
propensity cramped yelp or subtract sonogram ivy plus placebo yell
answer ends up taxing
i think one is yellow and when it's clear i can't remember which fights back
and he said look at seated around the banks of
i_d_ solution too
high ground and then they gave people pills that looked like carpentersent
and their hijab two points at which they assessed
work you work
uh... at the end of i_b_p_ repeat your was defined as resolution of signs and
symptoms needing no way to bright therapy or world fear appealable
and then they have reassess them in a one-month all of the set
and here was to find a snowbird parents at the same thing
so eighteen cases were considered and determine and that those were mostly
people
uh... you actually had exclusion criteria but can become apparent until
later
so they had an underlying often my letters or their true diagnosis with
d_d_t_ they were never expected to begin with
three patients were lost to follow-up
so at the end of the day i didn't thirteen cases were acquitted there when
the problem
here at the end of their people
ninety six percent
this of trucks and grouping eighty six percent of the answer
i was not significant difference between the two
thank your at one month was very somewhere again not stupid
the very same
so i guess the study was assigned to the first republican sarcasm absent a can
suck not so much d
efficacy except wrexham per se
it's not a canadian study
writers that might not represent
our bonds and resistance starbucks
and i wasn't really sure got this
was that isn't that i've seen that have been entertaining
care for example maybe catholic three doses buy these products mimicking
transition to peel
but the average on mean number of doses in inseparably seven of the setbacks in
six seemed like a lot me
uh... it's not really clear whether absences for
so this is um...
one of the say sit down looking adaptations of tracks on the internet
for selling us not in adults
like i said i could end
can find one but
the study was done in montreal
on treating kids as in patients with us construction factions using such craft
some
uh... peachtree tickets with moderate to severe slightly dismayed to find that
was the treating physician thought that they required antibiotics idly in the
emergency department
excluded any really sick kids talk to kids immune suppressed kids
uh... kids with any significant comorbidity works with it
kids away five unusual bugs so he will bites were excluded
anything really rapidly progressing threefold
was maybe not appropriate for a patient management
was excluded as well
so
uh... these contracts have tractable
and if they're panel urgent pickup clindamycin
very fewer than actually ended up getting commitments most of them concept
back from
and then they were stepped down to kaplan spiel
unicef track some group
and once they were not backgrounds lately has had decreased by seventy five
percent
or their stepped on the claim that he only planned the group and i was just a
position description that was rightly
unspecific and points that they were looking for
most of them got ended up going to stop at some condemning son
and it's only nine percent of them were successfully discharge from the day
treatment center after three days of therapy i could
onto killing two products and hope
there was a period of twenty one percent
uh... so by failure i mean they were ended up being admitted to hospital
but job only twelve percent of the total
uh... hot uncalled who uncomplicated slightly city of st
so dress for all the data for other issues and you can see that honesty impl
so
they revolution was deemed unsatisfactory active teachers
center there are the ones that
that field
okay to mention a slightly misleading going on for tracks and i have to be a
plan etc
um... that a lot of the others feel for other reasons sam parental capacity to
comply with teaching here
roundtrip
day treatment center treatment uh... or they had an upset that had to be dream
uh... other medical issues they needed to be a good or thank ab
obviously
kids might harbor different bacteria then it all some adults may be more
likely to happen i'd say
so it's hard to make generalizations i think
from the steady two adult population necessarily
there might be a lower threshold making two day i think it's a hospital
because they're feeling terribly than it would be for adults
it was hard for me driving conclusions from the literature that was available
at their
i think some treatment failures are really inevitable no matter what we used
uh... but it should be noted that none of the kids and how much else study had
about it calms the ones that failed management and end up being hospitalized
their oldest church you have no
a long time
morbidity
as a result
according to the study
although they installed the mob
for for very long so
we don't really how to better alternative i think because uh... it's
been shown that's excellent with the program is this probably quibble
interceptor some
really draw from that
uh... so in summary
quaker ultrasound improves diagnosis of access is in the emergency department
uh... empirical mercy coverage should be considered most cure-all instance
optician actions
uh... the land in starting an
showed an arson is a soap opera turning twenty two percent the back
uh... that included some
cultured
cellulitis withheld access that wasn't really sure what that meant
but sam
the rate of and i've seen on three oh one slightly sick on cultural sorry
latest it's not really known in london so
i can't really making
comments about that
it's not really clear whether absences benefit for me to right after my deep
and uh...
such acts in a similar rates of treatment failure himself
you know patient management sleepless
elected
colin susan wilson says
covers replace these in particular issue
answer
fish
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he requested to see if the dates
last night
obviously the resume
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do you think he goes he said
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haha uh...
you know with is sister
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says
the motivation for me
augments attracts
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and you know so that
cost-benefit signaling that and save plus for and sadistic sos expensive
imaginative transit
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inductive foods
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you know i realized that
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if you see
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