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Feasibility of a resorbable anterior cervical graft containment plate.

In this article we review the background of anterior cervical plating for one- and two-level diskectomy for degenerative disease and provide background justification for the design and testing of a cervical plate composed of a resorbable material. The design of the plate is discussed with special reference to modifications of implant design and implant tools compared with metallic plates that are necessary because of the different mechanical properties of the less rigid material. Our cadaveric and animal in vivo testing methodologies are described and a novel testing method for reliably quantifying graft containment is also described. Data from a representative sample are presented. Advantages and disadvantages of resorbable plating are discussed.

Absorbable Implants↗

[Reconstruction of orbital floor defect with polylacticglycolide acid/recombinant human bone morphogenetic protein 2 compound implanted material in sheep].

OBJECTIVE: To study the effect and safety of polylacticglycolide acid copolymer (PLGA) and recombinant human bone morphogenetic protein 2 (rhBMP-2) as implanted biomaterials for reconstruction orbital floor defects in sheep and find the relationship between implant materials degradation and orbital floor defects restoration. METHODS: Nine sheep (eighteen eyes) with orbital floor defect were divided into three groups randomly. Group A was the control without treatment. Group B was treated with PLGA and group C was received PLGA/rhBMP-2. Cosmetic appearances and complications were observed after surgery. CT scan, 3D reconstruction, defect area measurement and histological examination were performed on a week, three months and six months after operation. RESULTS: No complication was observed. The CT examinations showed that orbital floor defect in group C was almost disappeared by six months, however in group A and group B only partially orbital floor defect was repaired. Histological examinations showed that all materials were absorbed on six months. The orbit defects in group A were replaced by fiber tissue. The defect areas in group B were consisted of bone tissue in the peripheral and fiber tissue in the center. In group C the reconstructed areas were replaced by bone tissue, loose connective tissue and mucosal epithelia layers. CONCLUSION: The thick of 0.5 mm PLGA/rhBMP-2 sheet is a good substitute material of bone graft and may be used for orbital fracture defect reconstruction in clinic in the future.

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Adenoviral BMP-2 gene transfer in mesenchymal stem cells: in vitro and in vivo bone formation on biodegradable polymer scaffolds.

The aim of this study was to determine the feasibility of adenoviral gene transfer into primary human bone marrow osteoprogenitor cells in combination with biodegradeable scaffolds to tissue-engineer bone. Osteoprogenitors were infected with AxCAOBMP-2, a vector carrying the human BMP-2 gene. Alkaline phosphatase activity was induced in C2C12 cells following culture with conditioned media from BMP-2 expressing cells, confirming successful secretion of active BMP-2. Expression of alkaline phosphatase activity, type I collagen and mineralisation confirmed bone cell differentiation and maintenance of the osteoblast phenotype in extended culture for up to 6 weeks on PLGA porous scaffolds. In vivo implantation of adenoviral osteoprogenitor constructs on PLGA biodegradeable scaffolds, using diffusion chambers, also demonstrated bone cell differentiation and production of bone tissue. The maintenance of the osteoblast phenotype in extended culture and generation of mineralised 3-D scaffolds containing such constructs indicate the potential of such bone tissue engineering approaches in bone repair.

Absorbable Implants↗

Novel intrathecal delivery system for treatment of spinal cord injury.

A novel, localized method for potential delivery of therapeutic agents to the injured spinal cord was investigated. The strategy consists of a polymeric drug solution that gels after injection into the subarachnoid space (SAS). By dispersing therapeutic agents in the polymeric solution, a method is provided for localized delivery to the spinal cord. To determine whether intrathecal injection of this drug delivery system (DDS) would affect cerebrospinal fluid (CSF) flow, a spinal canal model was built using dimensional analysis. Blocking up to 52% of the modeled subarachnoid space of the spinal canal caused minimal pressure differences (9.22 +/- 1.45 Pa), suggesting that implantation of a DDS would not subject the spinal cord to increased pressure. The safety of the DDS was also assessed in vivo by injecting collagen into the SAS of Sprague Dawley rats. Controls received injections of artificial CSF (aCSF). Collagen or aCSF was injected at the T2-T3 spinal level of both uninjured rats and rats injured with a 20g compression clip. The injected collagen persisted in the SAS for at least 8 weeks post-implantation and did not elicit an inflammatory reaction in either uninjured or injured animals. Long-term functional behavior was evaluated with the Basso, Beattie, and Bresnahan (BBB) scale weekly for 8 weeks. Functional behavior was similar in the collagen and aCSF groups, also indicating that the DDS was safe. This minimally invasive DDS may provide an alternative, safe method to deliver therapeutic agents intrathecally.

Absorbable Implants↗

The current status of material used for depot delivery of drugs.

The ideal local antibiotic delivery system has not been created. Antibiotic-laden bone cement has become the gold standard in the treatment of infected orthopaedic implants and there are confirmatory laboratory and clinical data that support the use of these materials. Heat-stable antibiotics elute from antibiotic-laden bone cement and do not have a notable influence on the compressive strengths of bone cement if the antibiotics are used in appropriate amounts. If the proper antibiotic is chosen, placed in the appropriately porous materials in sufficient amounts, and implanted in bone, antibiotic levels in the surrounding bone are many times greater than can be achieved by safe systemic antibiotic doses. Although the materials that have been manufactured commercially have been used for over 30 years in Europe, until recently, they have not been available in the United States. Currently, there are five antibiotic-laden bone cement composites that have been approved by the FDA and that are available for clinical use. Studies are being done to search for biodegradable implants preferable to antibiotic-laden bone cement; however, these studies and the materials are still in early stages and development. Currently, there are no FDA-approved biodegradable materials available for use to treat infected orthopaedic implants. As new materials become available and their elution characteristics are recorded, it is important for surgeons to understand how the data were collected so they can have a clear understanding of the elution characteristics of the material used and how the material acts in different environments. Even with extensive historic, clinical, and research data that prove the effectiveness of antibiotic-laden cement, the ideal drug delivery system is neither agreed on nor available.

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Stabilization of anterior cervical spine with bioabsorbable polymer in one- and two-level fusions.

OBJECTIVE: We present our experience using a bioabsorbable polymer in the surgical management of one- and two-level degenerative disc disease of the cervical spine with anterior cervical discectomy and fusion. Twenty-six patients were treated at the University of California, San Diego Medical Center or the Veterans Affairs Medical Center in San Diego, CA. All cases were performed under the direction of a single neurosurgeon (WRT). METHODS: A retrospective review of patients' charts and imaging was performed to determine outcomes after anterior cervical spine operations. Specifically, we looked at the need for additional surgery, local reaction to the bioabsorbable polymer, fusion rate, and complications. Procedures involved the C3-C4, C4-C5, C5-C6, and/or C6-C7 levels, and fibular allograft was used in all but one case. The anterior cervical discectomy and fusion procedures with internal fixation were performed in 26 patients between March 2000 and November 2001. The patients were followed for up to 2 years after surgery (average, 14 mo). RESULTS: Radiographic fusion was achieved in 25 (96.2%) of 26 patients. Only one instance of treatment failure was encountered that required additional surgery and the placement of a titanium plate. There were no clinical signs or symptoms of reaction to the bioabsorbable material. CONCLUSION: The rates of fusion after single-level anterior cervical discectomy and fusion with internal fixation using bioabsorbable polymer and screws in this study match those using metallic implants, as previously reported in the literature, and are superior to those achieved with noninstrumented fusions. Preliminary results suggest that this newly available technology for anterior fusion is as effective in single-level disease as traditional titanium plating systems. The bioabsorbable material seems to be tolerated well by patients. A larger, randomized, controlled study is necessary to bring the results to statistical significance.

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Instrumented transforaminal lumbar interbody fusion with bioabsorbable polymer implants and iliac crest autograft.

Object. The purpose of this study was to evaluate the clinical and radiographic results in 31 patients from one center who underwent instrumented transforaminal lumbar interbody fusion (TLIF) for primarily degenerative indications. Methods. Bioabsorbable polymer spacers manufactured with a copolymer of 70:30 poly(L-lactide-co-D,L-lactide) and filled with iliac crest autograft bone were used for the TLIF procedure. In this paper the details of this procedure, intermediate (1- to 2-year) clinical and radiographic outcomes, and the basic science and rationale for the use of bioabsorbable polymers are discussed. At a mean of 18.4 months of follow up, 30 patients (96.8%) were judged to have attained solid fusions and 25 patients (81%) had good to excellent results. Three patients (9.7%) experienced complications, none of which were directly or indirectly attributable to the use of the bioabsorbable polymer implant. Only one implant in one patient (3.2%) demonstrated mechanical failure on insertion, and that patient experienced no clinical sequelae. Conclusions. This is the first clinical series to be published in which the mean follow-up duration equals or exceeds the biological life expectancy of this material (12-18 months). Both the clinical and radiographic results of this study support the use of interbody devices manufactured from biodegradable polymers for structural interbody support in the TLIF procedure.

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In vivo absorption of porous apatite- and wollastonite-containing glass-ceramic.

The behavior of porous apatite- and wollastonite-containing glass-ceramic (AW) in the bone marrow cavity was investigated. Cylinders of porous AW (4 mm in diameter and 20 mm long, mean porosity of 70% and mean pore diameter of 200 microm) were implanted into the bone marrow cavity of rabbit femurs, and analyzed by chronological radiograms and by scanning electron microscopy one, three, six, and 12 months later. The pores of porous AW are interconnected and homogeneously distributed, and its compressive strength is nearly equal to that of human cancellous bone. Bone formed in the pores at the center of the material by one month and bonded to the material directly. The volume of newly formed bone in the material pores reached a peak at three months, and decreased gradually after six months. The trabecular structures of AW were gradually remodeled by newly formed bone, while AW-bone bonding was maintained during bone remodeling and material absorption. AW was absorbed continuously, and at six and 12 months the residual material corresponded to about 64 and 30% of the starting material, respectively. Porous AW may therefore be useful as an absorbable bone substitute.

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Electrically conductive biodegradable polymer composite for nerve regeneration: electricity-stimulated neurite outgrowth and axon regeneration.

Normal and electrically stimulated PC12 cell cultures and the implantation of nerve guidance channels were performed to evaluate newly developed electrically conductive biodegradable polymer composites. Polypyrrole (PPy) doped by butane sulfonic acid showed a significantly higher number of viable cells compared with PPy doped by polystyrenesulfonate after a 6-day culture. The PC12 cells were left to proliferate for 6 days, and the PPy-coated membranes, showing less initial cell adherence, recorded the same proliferation rate as did the noncoated membranes. Direct current electricity at various intensities was applied to the PC12 cell-cultured conductive membranes. After 7 days, the greatest number of neurites appeared on the membranes with a current intensity approximating 1.7-8.4 microA/cm. Nerve guidance channels made of conductive biodegradable composite were implanted into rats to replace 8 mm of sciatic nerve. The implants were harvested after 2 months and analyzed with immunohistochemistry and transmission electron microscopy. The regenerated nerve tissue displayed myelinated axons and Schwann cells that were similar to those in the native nerve. Electrical stimulation applied through the electrically conductive biodegradable polymers therefore enhanced neurite outgrowth in a current-dependent fashion. The conductive polymers also supported sciatic nerve regeneration in rats.

Absorbable Implants↗

Poly-L-lactic acid: an overview.

In August 2004, the US Food and Drug Administration approved a poly-L-lactic acid (PLLA)-based injectable medical device for restoration and/or correction of the signs of facial fat loss (lipoatrophy) in people with human immunodeficiency virus. As a result, the properties of the PLLA microparticles have received considerable interest from the medical community. Polylactides have a long-standing history of safe use in medical applications, such as pins, plates, screws, intra-bone and soft-tissue implants, and as vectors for sustained release of bioactive compounds. The L-isomer of polylactic acid is a biodegradable, biocompatible, biologically inert, synthetic polymer. Putatively, PLLA microparticles initiate neocollagenesis as a result of a normal foreign-body reaction to their presence. The build-up of collagen over time creates volume at the site of injection, while the PLLA microparticles are metabolized to carbon dioxide and water and expelled through the respiratory system.

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In vitro and in vivo behavior of self-reinforced bioabsorbable polymer and self-reinforced bioabsorbable polymer/bioactive glass composites.

The aim of this study was to investigate the in vitro and in vivo properties and degradation of (1) self-reinforced (SR) lactide copolymer, P(L/DL)LA 70:30, and (2) SR composites of the same polylactide and bioactive glass 13-93. The following three polymer and polymer-bioactive glass samples were studied: SR-PLA70, SR-PLA70 + BaG15s, and SR-PLA70 + BaG20c. In vitro behavior was studied in a phosphate-buffered saline for 87 weeks at 37 degrees +/- 1 degrees C and a pH of 7.4 +/- 0.2. In vivo behavior was studied by implanting the rods in the dorsal subcutaneous tissue of rats (SR-PLA70 + BaG20c) or rabbits (SR-PLA70 and SR-PLA70 + BaG15s) for 48 weeks. The degradation of the specimens was evaluated by measuring the changes in mechanical properties, crystallinity and molecular weight of polymer, water absorption, weight loss, and structural changes. Results showed that the addition of bioactive glass filler modified the degradation kinetics and material morphology.

Absorbable Implants↗

Magnetic resonance imaging evaluation of biodegradable transfemoral fixation used in anterior cruciate ligament reconstruction.

PURPOSE: The study was designed to evaluate bioabsorbable transfemoral fixation in anterior cruciate ligament (ACL) reconstruction using hamstring tendon as graft. Magnetic resonance imaging (MRI) was used to assess the continuity of the bioabsorbable implant at different stages of the patients' rehabilitation. TYPE OF STUDY: Retrospective case series. METHODS: Forty-nine patients underwent ACL reconstruction performed by a single surgeon. The graft, a tensioned quadrupled semitendinosus tendon, was fixed proximally using a bioabsorbable TransFix implant (Arthrex, Naples, FL). The patients underwent an accelerated rehabilitation program and were assessed clinically at regular intervals postoperatively using MRI, with specific attention focused on the implant. RESULTS: The average time from surgery to MRI was 28 weeks (range, 4 to 54 weeks). All implants were fully visible with no evidence of resorption. Five implants were fractured at an average of 20 weeks postoperatively (range, 9 to 47 weeks). Three implants showed deformation but no definite fracture at an average of 14 weeks (range, 12 to 17 weeks). This amounts to 16% of implants with fractures or deformation, many close to the period of theoretical graft incorporation. All patients were clinically stable with no symptoms or signs or instability on clinical review and all had returned to preinjury sporting activities. CONCLUSIONS: Transfemoral biodegradable implants have the potential to fracture or deform during their postoperative course in tensioned hamstring tendon ACL reconstruction. Although no apparent detrimental effect was found in our series, further research is needed on this device before it can be recommended for ACL reconstruction. We also question the idea that rigid fixation for the ACL graft for the entire healing process is required. LEVEL OF EVIDENCE: Level IV, retrospective case series.

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Local delivery of minocycline and systemic BCNU have synergistic activity in the treatment of intracranial glioma.

Minocycline, a tetracycline derivative, has been shown to inhibit tumor angiogenesis through inhibitory effects on matrix metalloproteinases. Previous studies have shown this agent to be effective against a rodent brain tumor model when delivered intracranially and to potentiate the efficacy of standard chemotherapeutic agents. In the present study, the in vivo efficacy of intracranial minocycline delivered by a biodegradable controlled-release polymer against rat intracranial 9L gliosarcoma was investigated to determine whether it potentiates the effects of systemic 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU). Minocycline was incorporated into the biodegradable polymer polyanhydride poly[bis(p-carboxyphenoxy)propane-sebacic acid] (pCPP:SA) at a ratio of 50:50 by weight. The release kinetics of minocycline from the polymer were assessed. For the efficacy studies, female Fischer 344 rats were implanted with 9L glioma. Treatment with minocycline delivered by the pCPP:SA polymer at the time of tumor implantation resulted in 100% survival in contrast to untreated control animals that died within 21 days. Treatment with the minocycline-polymer 5 days after tumor implantation provided only modest increases in survival. The combination of intracranial minocycline and systemic BCNU extended median survival by 82% compared to BCNU alone (p < 0.0001) and 200% compared to no treatment (p < 0.004). We conclude that local intracranial delivery of minocycline from biodegradable controlled-release polymers inhibits tumor growth and may have clinical utility when combined with a chemotherapeutic agent.

Absorbable Implants↗

Mechanical properties and remodeling of hybrid cardiac constructs made from heart cells, fibrin, and biodegradable, elastomeric knitted fabric.

Hybrid cardiac constructs with mechanical properties suitable for in vitro loading studies and in vivo implantation were constructed from neonatal rat heart cells, fibrin (Fn), and biodegradable knitted fabric (Knit). Initial (2-h) constructs were compared with native heart tissue, studied in vitro with respect to mechanical function (stiffness, ultimate tensile strength [UTS], failure strain epsilon(f), strain energy density E) and compositional remodeling (collagen, DNA), and implanted in vivo. For 2-h constructs, stiffness was determined mainly by the Fn and was half as high as that of native heart, whereas UTS, epsilon(f), and E were determined by the Knit and were, respectively, 8-, 7-, and 30-fold higher than native heart. Over 1 week of static in vitro culture, cell-mediated, serum-dependent remodeling was demonstrated by a 5-fold increase in construct collagen content and maintenance of stiffness not observed in cell-free constructs. Cyclic stretch further increased construct collagen content in a manner dependent on loading regimen. The presence of cardiac cells in cultured constructs was demonstrated by immunohistochemistry (troponin I) and Western blot (connexin 43). However, in vitro culture reduced Knit mechanical properties, decreasing UTS, epsilon(f), and E of both constructs and cell-free constructs and motivating in vivo study of the 2-h constructs. Constructs implanted subcutaneously in nude rats for 3 weeks exhibited the continued presence of cardiomyocytes and blood vessel ingrowth by immunostaining for troponin I, connexin 43, and CD-31. Together, the data showed that hybrid cardiac constructs initially exhibited supraphysiologic UTS, epsilon(f), and E, and remodeled in response to serum and stretch in vitro and in an ectopic in vivo model.

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The effects of low-intensity ultrasound on peripheral nerve regeneration in poly(DL-lactic acid-co-glycolic acid) conduits seeded with Schwann cells.

This study attempted to improve the efficacy of peripheral nerve regeneration, using the stimulus of low-intensity ultrasound (US) on poly(DL-lactic acid-co-glycolic acid) (PLGA) nerve guidance conduits seeded with Schwann cells. The possible differences between the ultrasonic effects of biodegradable and nonbiodegradable materials used as conduits were also investigated, by comparison with a group of silicone conduits. The PLGA conduits were seeded with or without Schwann cells (6 x 10(3) cells). All conduits were implanted 10 mm into right sciatic nerve defects in rats and underwent 12 ultrasonic treatment sessions over 2 weeks. Ultrasound was applied at a frequency of 1 MHz and an intensity of 0.2 W/cm2 spatial average temporal peak (SATP) for 5 min/day. Histologic analysis was used to evaluate the recovery of the nerve after 6 weeks. Ultrasonically stimulated animals, especially those whose PLGA conduits, seeded with Schwann cells, exhibited considerably more myelinated axons with a larger mean area at the midconduit of the implanted grafts than those in any other group. Ultrasonic stimulation of a silicone conduit induced the generation of mass fibrous tissues that covered the nerve conduits and retarded axon regeneration. These results showed that ultrasonic stimulation may directly stimulate the seeded Schwann cells within the PLGA conduits to regenerate nerves. Nevertheless, the applying of US may not allow incorporation with the silicone rubber as a material from which to form nerve guidance conduits.

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Chondral lesions after arthroscopic meniscus repair using meniscus arrows.

Meniscus repair using bioabsorbable devices has become popular in the last few years. Good clinical results have been reported and few complications have been published. This report describes the case of a 37-year-old male patient with a lateral meniscus repair using 4 Meniscus Arrows (Bionx Implants, Blue Bell, PA). Postoperatively, repeated episodes of intra-articular effusions have occurred. A second-look arthroscopy 8 months after the reconstruction showed that the meniscus tear had not healed and revealed the presence of chondral damage corresponding to the location of the arrows in the posterior area of the lateral femoral condyle. Surgeons using the Meniscus Arrow should be aware of this possible postoperative complication.

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Characteristics of cartilage engineered from human pediatric auricular cartilage.

In the repair of cartilage defects, autologous tissue offers the advantage of lasting biocompatibility. The ability of bovine chondrocytes isolated from hyaline cartilage to generate tissue-engineered cartilage in a predetermined shape, such as a human ear, has been demonstrated; however, the potential of chondrocytes isolated from human elastic cartilage remains unknown. In this study, the authors examined the multiplication characteristics of human auricular chondrocytes and the ability of these cells to generate new elastic cartilage as a function of the length of time they are maintained in vitro. Human auricular cartilage, harvested from patients 5 to 17 years of age, was digested in collagenase, and the chondrocytes were isolated and cultured in vitro for up to 12 weeks. Cells were trypsinized, counted, and passaged every 2 weeks. Chondrocyte-polymer (polyglycolic acid) constructs were created at each passage and then implanted into athymic mice for 8 weeks. The ability of the cells to multiply in vitro and their ability to generate new cartilage as a function of the time they had been maintained in vitro were studied. A total of 31 experimental constructs from 12 patients were implanted and compared with a control group of constructs without chondrocytes. In parallel, a representative sample of cells was evaluated to determine the presence of collagen. The doubling rate of human auricular chondrocytes in vitro remained constant within the population studied. New tissue developed in 22 of 31 experimental implants. This tissue demonstrated the physical characteristics of auricular cartilage on gross inspection. Histologically, specimens exhibited dense cellularity and lacunae-containing cells embedded in a basophilic matrix. The specimens resembled immature cartilage and were partially devoid of the synthetic material of which the construct had been composed. Analyses for collagen, proteoglycans, and elastin were consistent with elastic cartilage. No cartilage was detected in the control implants. Human auricular chondrocytes multiply well in vitro and possess the ability to form new cartilage when seeded onto a three-dimensional scaffold. These growth characteristics might some day enable chondrocytes isolated from a small auricular biopsy to be expanded in vitro to generate a large, custom-shaped, autologous graft for clinical reconstruction of a cartilage defect, such as for congenital microtia.

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Comparison of self-reinforced poly-L-lactide and steel wire in fixation of sternotomy in rabbits.

BACKGROUND AND AIMS: To investigate the healing of sternotomies fixed with biodegradable self-reinforced poly-L-lactide (SR-PLLA) wire and comparing it with steel wire fixation. MATERIAL AND METHODS: Sixteen rabbits (15 Chinchilla and one New Zealand White rabbit) were operated on. Two parallel holes of 1.5 mm in diameter were drilled in the sternum at the level of the second and third rib and similar holes of 0.8 mm were drilled at the level of the third and fourth rib. A transverse sternotomy was created between both drill hole pairs. The sternotomy with larger drill holes was fixed with 1.1-mm thick SR-PLLA wire. The sternotomy between the smaller drill holes was fixed using 2.0 steel wire. The animals were sacrificed at 2, 7, 26 and 52 weeks postoperatively and specimens were taken, radiographed and studied by both light and scanning electron microscopy. RESULTS: One rabbit died at four months postoperatively as a result of gastrointestinal problems. No other complications were seen. The SR-PLLA wire was slowly degraded. There was no disturbance of bone healing. The implants were surrounded by a fibrous tissue capsule, which also contained chronic inflammatory cells. Both SR-PLLA and steel wires provided sufficient fixation security. No differences in the healing of the sternotomies were observed between SR-PLLA and steel wire fixation. CONCLUSIONS: SR-PLLA wires are biocompatible and useful for sternotomy fixation. They may be suitable for use in clinical applications.

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