Posts filed under 'Brain'

What is a Brain Bleed?

On July 21st, 2017

Neuron blood flow as brain circulation with cells flowing through veins and human circulatory system representing a medical health care symbol relating to stroke or neurology issues.

A brain bleed is another phrase for a brain hemorrhage and it is a type of stroke that occurs when an artery in a person’s brain bursts, which creates a bleeding throughout surrounding cranial tissues.

Brain hemorrhages amount to around 13% of all strokes and it begins from some form of trauma that creates swelling called a cerebral edema. Blood will collect in these places of swelling into what is known as a hematoma, and when this happens not enough blood flow will occur throughout the entire brain, which also kills brain cells.

Brain bleeds are a very serious issue and they can occur just about anywhere within your cranial cavity. Here are some of the condition’s main causes:

  1. The most common way that brain bleeds occur is through an injury or some form of physical head trauma.
  2. Another very common cause is high blood pressure, which can weaken the blood vessel walls within your brain. This is one of the most preventable causes that can be easily treated.
  3. An aneurysm is when a blood vessel wall in the brain swells, weakens and then eventually bursts into the brain creating a stroke.

  4. Also bleeding or blood disorders like sickle cell or hemophilia can create brain bleeds.
  5. Lastly liver disease and brain tumors are major causes associated in general with increased bleeding.

Many times it can be hard to distinguish the exact symptoms of brain bleeding, and that’s mainly because the symptoms can vary. It will mostly depend on the exact location of the brain bleeding, as well as the severity and amount of tissue affected. Symptoms develop both over time as well as appear suddenly.

Here’s a list of common symptoms:

  • Severe headaches
  • Seizures with no prior history
  • Nausea
  • Lethargy
  • Vision changes
  • Tingling/numbness
  • Difficulty speaking or comprehending speech
  • Difficulty swallowing
  • Difficulty reading/writing
  • Hand tremors
  • Loss of coordination/balance
  • Loss of consciousness
  • Weakness in a leg/arm

Many times doctors will use CT scans or MRIs to reveal blood accumulation and internal bleeding, and sometimes eye exams are done to show if there is any swelling within the optic nerves.

Procedures vary for each patient with brain bleeds. Surgery is sometimes needed to alleviate bleeding and swelling. Almost always, treatment comes along with prescribed medications including diuretics, painkillers and corticosteroids in order to control seizures and reduce swelling.

If you feel as though you may be suffering from some of these symptoms then there are several next steps of treatment available for you. Your doctor can then determine which part of your brain is being affected based upon your personal symptoms.

Dr. Todd Kuether has been serving the Portland community for over 10 years now, providing surgery and consultations for brain and spine injuries. Contact our office to schedule an appointment.

Entry Filed under: Brain Comments

What Is Brain Swelling?

On March 31st, 2017

Brain swelling is a dangerous condition that increases pressure inside the skull. Swelling may be in one area or throughout the brain. There are different causes and treatments for brain swelling. In some cases, a neurosurgeon will recommend surgery to relieve pressure.

Treatment may involve medication, surgery or another option. A quick diagnosis is essential for recovery.

Brain swelling goes by several names: brain edema, cerebral edema and elevated intracranial pressure. Pressure in the skull slows or stops blood from flowing. Blood carries oxygen to the brain. Without blood and oxygen, cells die and the brain is damaged.

How Is Brain Swelling Treated?

What Is Brain SwellingMost instances of swelling in the brain require immediate medical attention. Some cases require little more than time, rest and monitoring. For example, a minor concussion may cause slight swelling that will resolve on its own over several days.

Only a professional can evaluate a brain injury and recommend treatment. Treatment relieves swelling and treats the causes of the condition. Quickly reducing swelling is important to keep blood and oxygen flowing to the brain. Delaying treatment increases the chance of brain damage.

Possible therapies for brain swelling include:

Surgery: A neurosurgeon may recommend an operation to relieve pressure in the skull. Sometimes, the brain surgeon removes part of the skull. This procedure is called decompressive craniectomy. The neurosurgeon might also repair the cause of the swelling, including correcting a damage vein or artery.

Ventriculostomy: A surgeon uses this procedure to drain fluid from the brain, relieving pressure. This operation involves cutting the skull and inserting a tube. Fluid drains through the tube.

Oxygen Therapy: A respirator can supply more oxygen to the blood and brain. This treatment may also help decrease swelling.

Lowering body temperature: A lower brain and body temperature can reduce swelling.

IV fluids: Physicians may use IV fluids and medications to keep blood pressure at a healthy level. If blood pressure falls too low, the brain won’t receive adequate blood.

Medication: Drugs can treat some causes of swelling. Medication dissolves clots and reduces swelling.

What Are the Symptoms of Brain Swelling?

Symptoms of brain swelling often begin suddenly. Many symptoms are comparable to those of other brain conditions. Call your physician or go to an emergency room if you have any of the following symptoms:

  • Trouble speaking
  • Seizures
  • Loss of consciousness
  • Inability to walk
  • Headache
  • Vision loss, changes
  • Memory loss
  • Neck pain, stiffness
  • Nausea
  • Dizziness
  • Irregular breathing

Call a Portland Brain Surgeon

Dr. Todd Kuether is an experienced neurosurgeon in Portland, Oregon. To make an appointment, please contact his office.

Entry Filed under: Brain Comments

How to Choose A Brain Surgeon

On March 17th, 2017

If you have recently learned that you need to undergo brain surgery, you’re likely experiencing a lot of emotions. Fear, anxiety, and stress are just some of the feelings that you may be processing right now and having to choose a brain surgeon adds another level of stress to the situation.

Here are some important facts you should consider when choosing a brain surgeon.

Find a surgeon who specializes in your condition

How to Choose A Brain SurgeonBrain surgery is highly focused and specialized. Look for a Portland brain surgeon who specializes in treating your condition or who has significant experience in working with patients with your medical issue.

The support staff and surgeon work as a unit. The surgeon’s team also needs to be experienced in your type of condition. These people include physical therapists, oncologists, anesthesiologists, nurses and more.

You’ll also want to know if your surgeon partners with other surgeons. There can be an advantage to choosing a doctor who collaborates with colleagues.

Understand the details, build rapport

Once you have chosen the surgeon and team of specialists who you will work with, get details on what the short- and long-term plan is for your treatment. Ask as many questions as you need to in order to prepare. Here some things to ask:

What can I expect on operation day?

Can you explain what will happen during the surgery?

What does long-term care look like?

Can I speak with other patients who have been through similar surgeries?

This will not only help you prepare, but it will probably give you a bit of peace of mind. The more you speak with your surgeon and their staff, the better. It’s important to establish a comfortable relationship with your doctor. If you’re unable to get answers to your questions, consider looking elsewhere for your care.

Choose a Portland Brain Surgeon

If you’re looking for a surgeon, contact our team at Kuether Brain and Spine. Dr. Kuether specializes in a variety of brain conditions. Contact us today for an appointment and evaluation.

Entry Filed under: Brain Comments

What Causes Brain Bleeding?

On October 10th, 2016

Brain bleeding, also called a brain hemorrhage, happens when an artery bursts. A burst artery in the brain is one type of stroke. A damaged artery bleeds into the tissues of the brain. Bleeding damages the brain by killing brain cells. This is a serious condition that requires the immediate attention of a brain surgeon. Brain surgery or other treatments can limit damage from a brain bleed.

Brain bleeding can be caused by chronic high blood pressure.

Chronic high blood pressure weakens blood vessel walls and may increase the risk of a brain bleeding.

What Causes Brain Bleeding?

Brain bleeds go by a few different names: cerebral hemorrhage, intracerebral hemorrhage and intracranial hemorrhage.

When the brain is injured, blood from the trauma causes swelling. The blood may form a mass. The mass, or hematoma, puts pressure on surrounding tissue. The swelling restricts blood flow. When brain cells don’t get enough blood, they die.

Bleeding can happen in several different areas: within the brain, beneath the brain membranes or beneath the skull.

Here are some of the most common causes of brain bleeds:

Brain tumors – These increase the risk of stress on blood vessels. Tumors can sometimes be removed by a neurosurgeon.

Head trauma – The  most common cause of bleeding in the brain for people under 50 years of age.

High blood pressure – A chronic condition that weakens blood vessel walls. Untreated, it may lead to brain hemorrhage.

Aneurysm – A weakening of blood vessel walls that begin to swell. Vessels may burst, leading to a stroke.

Blood vessel abnormalities – Malformations weaken the blood vessel walls. They can lead to stroke and brain hemorrhage.

Bleeding disorders – Hemophilia and sickle cell anemia are blood disorders that increase the risk of bleeding in the brain.

What Are the Symptoms of Brain Bleeding?

Signs of brain bleeding vary. The location and severity of the trauma affect the symptoms. Problems may appear suddenly or gradually. If you have any of the following symptoms, you should see your primary care doctor, neurosurgeon or, if it’s an emergency, call 911. While any of the following can indicate brain bleeding, they are also warning signs of other medical conditions.

  • A sudden, severe headache
  • A seizure
  • Sudden weakness in arms or legs
  • Severe nausea or vomiting
  • Decreased alertness
  • Sudden changes in vision
  • Tingling or numbness
  • Difficulty speaking or understanding speech
  • Difficulty swallowing
  • Difficulty with motor skills
  • Loss of balance
  • A sense of “metal” or abnormal taste in your mouth
  • Sudden loss of consciousness

Doctors use various tests to diagnose brain bleeding. These include CT scans and MRI scans. The bleeding may be stopped with medication or with surgery.

Recovery from a brain bleed depends on many variables including, a patient’s health and the severity and location of the hemorrhage.

Prompt medical attention is key to recovery. Patients who are treated quickly by a neurosurgeon decrease their risk of complications.

Dr. Todd Kuether is a neurosurgeon practicing in Portland, Oregon. He treats brain and spine injuries. Learn more by contacting his office.

 

Entry Filed under: Brain Comments

What is Aneurysm Clipping?

On October 5th, 2016

What is Aneurysm ClippingA cerebral aneurysm clipping is surgery to repair a weak spot on a brain blood vessel. A cerebral aneurysm is a bulge on an artery wall. A brain surgeon or neurosurgeon performs the operation. The surgeon begins the procedure by opening the skull. This is called a craniotomy. The doctor positions a clip across the weak spot of the vessel. The repair prevents the aneurysm from bleeding and causing more injury.

In his brain surgery practice in Portland, Oregon, Dr. Kuether repairs brain aneurysms. He may choose to perform clipping or a less invasive operation. When possible he uses a catheter to complete an endovascular repair. This type of surgery does not require opening the skull.

Sometimes clipping is the best option for patients. Here’s a more detailed overview of the operation.

What Is a Brain Aneurysm?

Doctors often describe a cerebral aneurysm as looking like a balloon filled with blood. Some of these bulges remain small and produce few or no symptoms. Possible symptoms include pain behind or above the eye, numbness or paralysis of the face and changes in vision. A bleeding aneurysm can cause severe pain, nausea, double vision and unconsciousness.

If you have any of these symptoms, you should see your doctor or go to the emergency room.

Why Do Surgeons Perform Aneurysm Clipping?

Clipping stops blood flow to the aneurysm. Unrestricted blood may enlarge the bulge causing the vessel to rupture. A burst aneurysm is a life-threatening injury. Clipping prevents rupture and may also reduce the size of the aneurysm. The larger the “balloon,” the more pressure it exerts on the surrounding tissue.

What Is Aneurysm Clipping?

The procedure is performed in a hospital under general anesthesia. The surgeon removes a section of the skull to find the aneurysm. The doctor then places a metal clip on the base of the bulge. The clip remains in place to prevent further enlargement and ruptures. The surgeon replaces the skull and closes the opening.

How Successful Is the Operation?

Clipping is effective at permanently repairing the artery. Patients and their doctors must weigh potential benefits against possible risks. The risks of aneurysm clipping are bleeding, infection and symptoms similar to stroke.

How Long Is Recovery?

Recovery varies depending on the patient’s health. If an aneurysm is repaired before it ruptures, a patient may be able to leave the hospital after a few days. If the aneurysm has broken, the hospital stay could stretch to two weeks or longer as medical staff closely watches for side-effects.

Skilled Portland Brain Surgery

Dr. Kuether is highly skilled and experienced in brain and spine surgery. He thoroughly evaluates a patient’s condition before recommending a carefully considered course of treatment. Please contact Dr. Kuether’s office to learn about becoming a patient.

 

Entry Filed under: Brain Comments

How Do I Prepare for Brain Surgery?

On May 13th, 2016

The prospect of undergoing brain surgery is scary. You’re facing the unknown. You probably feel vulnerable. Questions, important and trivial, fill your thoughts. Preparing for your procedure will empower you. By taking charge of those things you can control, you feel calmer and better able to cope.

Prepare for brain surgery by speaking frankly with your doctors.

Communicate openly with your neurosurgeon. Research your condition. Ask lots of questions. Arm yourself with information. If you have a thorough understanding of the surgery, you can partner with your medical team. A patient isn’t a passive subject. Actively participating in your care helps you stay strong through the procedure and during recovery.

Getting Cleared for Your Operation

Before brain surgery, patients complete a tried-and-true procedure to ensure they are medically fit for surgery. You will speak with your doctor about medications you take. You may be required to see an internist or specialist who will check your ability to withstand the stress of surgery.

If you have medical conditions that could complicate brain surgery, these may need to be resolved. For instance, those with heart disease may need further tests or treatments before undergoing brain surgery.

Coping With the Risks

Only you and your doctors can decide if surgery is right for you. If you’re undergoing elective surgery, you’ll have time to weigh the benefits against the risks. Every surgery has side-effects.

Ask your surgeon about the dangers of your procedure. Find out how many times the surgeon has successfully completed the same operation. You may get peace of mind by having legal documents, such as a living will or advanced directive, in place.

It may not be easy, but speak with family members about worst-case scenarios. Let key members know that you have an advanced directive. If it’s not possible to speak with those close to you, consult your lawyer and draw up the documents.

Find Comfort In the Familiar

Hospitals can be less than soothing. They are filled with strange equipment. Monitors beep when you’re resting. Compression sleeves suddenly inflate around your legs. Technicians come to poke, prod and peer. You’re tethered to poles with bags of blood and fluids.

Counteract the unfamiliar routines and contraptions by bringing a little bit of home to the hospital. Pack your favorite slippers, pillow, blanket or pajamas. Maybe you find comfort in a book, music or a photo of someone you love. Perhaps you have a lucky talisman, or a symbol of your faith. Whatever it may be, bring it with you if it helps you relax.

Your medical team will give you additional instructions to prepare for your procedure. Rely on your caregivers to help you while you’re in the hospital. Follow their recommendations for recovery.

Dr. Kuether is a skilled brain surgeon. If you have questions about your diagnosis, contact him at 503.489.8111. He is accepting new patients.

Entry Filed under: Brain,Surgery Comments

What Are Some Common Brain Tumor Symptoms?

On March 24th, 2016

Do you know the symptoms of a brain tumor? Some tumors produce no signs, and some common brain tumor symptoms are shared with other conditions. Tumors sometimes, but not always, require brain surgery.

Dr. Kuether is an experienced brain surgeon. He is always accepting new patients. Please contact our office at 503.489.8111 to schedule an appointment.

Headaches can be a symptom of a brain tumor.What Is a Brain Tumor?

A brain tumor is a mass of abnormal cells growing in the brain. Tumors grow at an uncontrollable rate. Normal cells age and die before new cells form to replace them. Tumor cells don’t die.

Tumors continue to increase in size as more tissue is added to the mass. There are benign and malignant tumors. Benign tumors are those that do not contain cancerous cells though they may cause health problems. Malignant tumors are those that are cancerous. Cancerous tumors generally grow faster than noncancerous ones.

Common Symptoms of Brain Tumors

A diagnosis usually begins with a doctor asking a patient to describe symptoms. If the signs are consistent with a brain tumor, the physician may recommend making an appointment with a neurosurgeon. The surgeon may advise brain surgery or another type of treatment.

If you have any of the following indications or suspect you have a brain tumor, see a doctor immediately.

Headaches: Pain is caused by pressure from the tumor on the brain’s nerves. The pain from a tumor is persistent, continuous and may be worse at night. Pain from a tumor may not respond to medication. Pain may be more severe during physical activities.

Seizures: A seizure is a sudden convulsion caused by abnormal electrical activity in the brain. Seizures usually happen quickly. Victims lose control of their bodies during an episode. A person suffering from a seizure may lose consciousness and be unable to control movements. After a seizure, pain, numbness or weakness may linger.

Drowsiness: As a tumor grows, a patient may feel drowsy and sleep more. As the tumor progresses, the sufferer may find it difficult to stay awake. Sometimes these tendencies progress until the person falls into a coma.

Memory Loss: Loss of memory, particularly of short-term memory, is a common symptom of tumors.

Vision or Hearing Problems: A tumor may cause blurred or double vision. A sufferer may see flashing lights or experience deteriorating sight. Changes in pupil size or the appearance of the eyes can occur. Some people lose hearing on one side or hear ringing.

Mood Changes: Brain tumor patients often suffer from depression which tends to grow as the tumor progresses. Insomnia, low energy and thoughts of suicide may also be present.

Behavior Changes: In addition to anxiety, a brain tumor may cause significant changes in behavior. For instance, patients may get irritable and have trouble with written and spoken language.

Don’t ignore these health problems if you have any of them. These signs may be an indication of a brain tumor.

A tumor isn’t something you can identify yourself. If you suspect something is wrong, make an appointment to see a doctor. If you’re diagnosed with a brain tumor, consult a neurosurgeon who will advise you on a course of treatment.

Entry Filed under: Brain,Surgery Comments

How Exercise Boosts a Brain

On January 8th, 2016

Lots of thing can go wrong with the human brain. Like every other organ in the body, it can get sick or suffer from trauma. If you have an acute condition, such as a brain aneurysm, you’ll need a neurosurgeon to repair it. Brain tumors may require the attention of an oncologist. A chemical imbalance is often treated by a psychiatrist.

What if you don’t have a condition that needs treatment but you’re interested in keeping your brain healthy? A growing number of studies point to exercise as a way of keeping the brain healthier into old age. Here’s a rundown of two recent studies that could get you thinking about the role of exercise in brain health.

Exercise improves brain health as illustrated in this cartoon showing a cartoon brain lifting a barbell.Aerobic Fitness Linked to More Efficient Brains

A 2015 Japanese study of brain scans highlighted the connection between cardiovascular exercise and brains that age well. The study found that the brains of physically fit older men were nearly as nimble as those of younger people.

Previous studies have suggested the brains of older people, those past age 40 or so, had to work harder compared to younger people to complete certain mental tasks. These conclusions were based on activity observed during brain scans. Older people’s brains needed to access more areas of the brain than did younger people. For some tasks, younger people used only one side of the brain while both sides of the brain were engaged in older people.

The new study looked at brain scans of 60 men between the ages of 64 and 75. The men’s aerobic fitness was studied ahead of the test for mental acuity. The results suggested the most physically fit men had brains that were nearly as efficient as the brains of young people. The men who were less physically fit needed to use more of the brain to complete the mental exercises.

Build Better Brain Health by Pumping Iron

Many people have felt the positive effects of aerobic exercise on mood and mental clarity. It’s not just cardiovascular exercise that can lead to a healthier brain, though. A study published in October 2015 looked at the effects of weight training on brains.

In the study, 155 women aged 65 to 75 engaged in a yearlong program of exercise. Some of the women lifted weights twice a week, others lifted once a week and another group completed stretching and balance workouts each week. The women who trained twice a week with light weights had fewer and smaller brain lesions than those who completed stretching and balance-training workouts.

Lesions in the brain’s white matter begin appearing in middle age and multiply and grow bigger with age. Having numerous lesions has been associated with diminishing cognitive abilities including problems with memory.

Dr. Kuether is a neurosurgeon. He performs brain surgery in Portland, Oregon. For more information contact his office at 503.489.8111.

Entry Filed under: Brain Comments

An Overview of Brain Aneurysm Surgery

On November 9th, 2015

A brain aneurysm diagnosis can be terrifying. Even though a ruptured aneurysm is somewhat infrequent, it can still signify a very serious illness that can lead to disability and even death.

Brain Aneurysm SurgeryHere is an overview of what a brain aneurysm is and what the surgical treatment entails. Information about this condition can help ease fears and bring a sense of support during a challenging time.
What is a brain aneurysm?

Otherwise known as a cerebral aneurysm, this condition occurs when there is a bulging spot on the wall of a brain artery, which can be likened to a thin balloon. As time goes on, the blood flow within the artery will hit against the thin portion of the wall and aneurysms can form, causing significant wear on the arteries.

Once the artery wall becomes thinner, the blood flow causes the weakened wall to swell. The pressure can cause the aneurysm to burst and blood will flow around the brain. If this happens, surgery is often needed to fix it.

What are the symptoms?

Brain aneurysms that are unruptured often will not cause any symptoms. But, if the aneurysm is large enough, it can sometimes press on the brain or nerves which can cause neurological symptoms, including dilated pupils, blurred or double vision, pain above and behind the eye, nausea/vomiting, stiff neck, loss of consciousness, difficulty speaking, localized headache, weakness, or numbness.

What does the brain aneurysm surgery involve?

There are two common surgical approaches to repairing an aneurysm. The first method is when the doctor clips the aneurysm, which is completed through an open craniotomy. Here, the physician creates a hole in the skull to attend to the area where the aneurysm is located. The other way it can be treated is through endovascular repair, which is a less invasive method that involves inserting a coil or stent.

Patients who undergo the aneurysm clipping will be put under general anesthesia with a breathing tube. Then the scalp, skull, and coverings of the brain are opened. A metal clip is inserted at the neck of the aneurysm to prevent it from bursting.

Patients who have the endovascular repair will either have general anesthesia or a medicine to sedate them without putting them to sleep. A catheter is guided through the groin to an artery, then the blood vessel where the aneurysm is located. A contrast dye is injected through the catheter which allows the physician to look at the arteries and the aneurysm on a monitor.

Once it is located, thin metal wires are put into the aneurysm, which then coil into a mesh ball. Sometimes, mesh tubes are also put in to keep the coils secure. If blood clots form around the coil, it will prevent the aneurysm from bursting.

After the surgery is completed and deemed successful, it isn’t common to have a bleeding aneurysm again in the same area. Patients will likely need to be seen by a doctor every year to discuss progress and prognosis, but most of the time these surgical repairs can prevent further brain aneurysms.

For more information contact the office of Dr. Todd Kuether. Dr. Kuether performs brain surgery at Legacy Emanuel Hospital and Legacy Good Samaritan Hospital both located in Portland, Oregon. Dr. Kuether sees patients at his Emanuel Hospital location and also in Tualatin at Legacy Meridian Park.

Entry Filed under: Brain,Surgery Comments

Will Insurance Cover My Surgery?

On November 5th, 2015

Major surgery raises questions, such as concerns about your diagnosis and treatment. New patients may worry about paying for your care. You may be uncertain what your insurance covers. Most patients want to know what to expect from their insurance company before going into surgery.

Insurance Coverage for SurgeryDr. Kuether’s staff can help you understand your benefits. We accept most private insurance and worker’s compensation claims. No matter what your level of coverage, we can help you. We may be able to arrange discounts and payment plans.

Some types of brain and spine surgery are scheduled well ahead of time. If Dr. Kuether is treating you for carpal tunnel syndrome, neck pain or back problems, you’ll likely have time to investigate your coverage and get pre-approvals.

Speak with your insurance company to learn about your benefits. Your insurer will let you know what portion of your treatments are covered and what portion is your responsibility. If you have disability coverage, you may be able to collect benefits while you recover from surgery.

Ask your medical or disability insurance company the following questions before you schedule a surgery:

* What is my policy’s maximum payout? Does this procedure fall within that limit?
* Does my policy pay for post-surgery home health care or rehabilitation? What is my prescription drug benefit?
* What is my disability benefit? How much will I receive each week?
* How long after surgery until my disability coverage starts?

There are three basic types of health coverage. Each type handles patient care differently. Most plans require copayments and some have deductibles. Here’s an overview of how each type of insurance handles referrals.

* Health maintenance organizations: An HMO pays for medical care when you visit a doctor within the network. Most require a referral before seeing a specialist. You’ll have to pay your expenses if you visit a provider outside the network.

* Preferred provider organization: A PPO allows you to choose your doctors. If the doctor you see is not a preferred provider, you’ll pay more than if you see in-network physicians.

* Point of service: A POS generally requires a referral to see a specialist. You can visit an out-of-network doctor, but you’ll be responsible for a higher portion of your expenses.

A ruptured brain aneurysm is a life-threatening crisis that requires prompt treatment. If you have a health crisis, you won’t have time to query your insurance company. Insurance companies handle payment for emergency care differently.

We understand no one wants to worry about medical expenses when they need an operation. We’ll do our best to make it easier by helping you understand your plan and coverage.

Entry Filed under: Brain,Spine,Surgery Comments

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