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Enblad, Per
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Publications (10 of 54) Show all publications
Mogensen, S., Lubenow, N., Nilsson, P., Engquist, H., Knutson, F., Enblad, P., . . . Frykholm, P. (2017). An evaluation of the mixed pediatric unit for blood loss replacement in pediatric craniofacial surgery. Pediatric Anaesthesia, 27(7), 711-717.
Open this publication in new window or tab >>An evaluation of the mixed pediatric unit for blood loss replacement in pediatric craniofacial surgery
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2017 (English)In: Pediatric Anaesthesia, ISSN 1155-5645, E-ISSN 1460-9592, Vol. 27, no 7, 711-717 p.Article in journal (Refereed) Published
Abstract [en]

Background: Surgical correction for craniosynostosis is often associated with significant perioperative hemorrhage. We implemented a transfusion strategy with a strict protocol including transfusion triggers, frequent assessment of coagulation tests, and the use of a novel transfusion unit, the mixed pediatric unit. Aim: The aim of the study was to evaluate if the applied transfusion strategy could reduce total blood loss and number of blood donors. Methods: Children <1 year old admitted for craniosynostosis surgery were included for the study. On the day before surgery, an adult red blood cell unit was mixed with plasma and split into two mixed pediatric units-one intended for intraoperative use and the other saved for the postoperative period. A series of blood samples were obtained for standard coagulation parameters as well as thromboelastography to evaluate potential coagulopathy. Estimated blood loss, the number of additional standard packed red cell units opened in the first 24 h after surgery, the volume of fluid administered, and the total transfusion volumes were compared to a historical control group with similar age and characteristics. Results: Nineteen infants were included in the study group, and were compared to 21 historical controls. There was a significant reduction of intraoperative transfusion volume. Twelve patients were transfused postoperatively, but in 8 of these additional exposure to packed red cell donor blood was avoided by using the saved mixed pediatric unit. In the historical controls, a total of 10 packed red cell units were used in nine patients postoperatively. No additional transfusions of plasma, platelets, fibrinogen, or tranexamic acid were needed in either group, and the coagulation parameters including thromboelastography remained within their respective normal ranges in the study group. Conclusion: For craniofacial surgery in infants, moderate perioperative blood loss and avoidance of coagulopathy is possible when a multifactorial approach is implemented. In this setting, intraoperative, but not total perioperative blood loss was reduced with the studied protocol. The study indicates that there may be a role for mixed pediatric units to reduce exposure to multiple donors although the reduction in total donor exposure was not significant.

Keyword
craniosynostosis, blood loss, surgical, postoperative hemorrhage, blood transfusion, blood coagulation tests, thromboelastography, infants
National Category
Anesthesiology and Intensive Care Pediatrics
Identifiers
urn:nbn:se:uu:diva-330012 (URN)10.1111/pan.13140 (DOI)000405081500007 ()28436074 (PubMedID)
Available from: 2017-10-11 Created: 2017-10-11 Last updated: 2017-10-11Bibliographically approved
Abu Hamdeh, S., Marklund, N., Lannsjö, M., Howells, T., Raininko, R., Wikström, J. & Enblad, P. (2017). Extended anatomical grading in diffuse axonal injury using MRI: Hemorrhagic lesions in the substantia nigra and mesencephalic tegmentum indicate poor long-term outcome. Journal of Neurotrauma, 5(34), 341-352.
Open this publication in new window or tab >>Extended anatomical grading in diffuse axonal injury using MRI: Hemorrhagic lesions in the substantia nigra and mesencephalic tegmentum indicate poor long-term outcome
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2017 (English)In: Journal of Neurotrauma, ISSN 0897-7151, E-ISSN 1557-9042, Vol. 5, no 34, 341-352 p.Article in journal (Refereed) Published
Abstract [en]

Clinical outcome after traumatic diffuse axonal injury (DAI) is difficult to predict. In this study, three magnetic resonance imaging (MRI) sequences were used to quantify the anatomical distribution of lesions, to grade DAI according to the Adams grading system, and to evaluate the value of lesion localization in combination with clinical prognostic factors to improve outcome prediction. Thirty patients (mean 31.2 years ±14.3 standard deviation) with severe DAI (Glasgow Motor Score [GMS] <6) examined with MRI within 1 week post-injury were included. Diffusion-weighted (DW), T2*-weighted gradient echo and susceptibility-weighted (SWI) sequences were used. Extended Glasgow outcome score was assessed after 6 months. Number of DW lesions in the thalamus, basal ganglia, and internal capsule and number of SWI lesions in the mesencephalon correlated significantly with outcome in univariate analysis. Age, GMS at admission, GMS at discharge, and low proportion of good monitoring time with cerebral perfusion pressure <60 mm Hg correlated significantly with outcome in univariate analysis. Multivariate analysis revealed an independent relation with poor outcome for age (p = 0.005) and lesions in the mesencephalic region corresponding to substantia nigra and tegmentum on SWI (p  = 0.008). We conclude that higher age and lesions in substantia nigra and mesencephalic tegmentum indicate poor long-term outcome in DAI. We propose an extended MRI classification system based on four stages (stage I—hemispheric lesions, stage II—corpus callosum lesions, stage III—brainstem lesions, and stage IV—substantia nigra or mesencephalic tegmentum lesions); all are subdivided by age (≥/<30 years).

Keyword
adult brain injury, axonal injury, head trauma, MRI, susceptibility weighted imaging
National Category
Clinical Medicine Neurology
Identifiers
urn:nbn:se:uu:diva-309038 (URN)10.1089/neu.2016.4426 (DOI)000391754800009 ()27356857 (PubMedID)
Available from: 2016-12-01 Created: 2016-12-01 Last updated: 2017-11-29Bibliographically approved
Johnson, U., Enquist, H., Lewén, A., Howells, T., Nilsson, P., Ronne-Engström, E., . . . Enblad, P. (2017). Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP. Acta Neurochirurgica, 159(6), 1065-1071.
Open this publication in new window or tab >>Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP
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2017 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 159, no 6, 1065-1071 p.Article in journal (Refereed) Published
Abstract [en]

Background Cerebral pressure autoregulation can be quantified with the pressure reactivity index (PRx), based on the correlation between blood pressure and intracranial pressure. Using PRx optimal cerebral perfusion pressure (CPPopt) can be calculated, i.e., the level of CPP where autoregulation functions best. The relation between cerebral blood flow (CBF) and CPPopt has not been examined. The objective was to assess to which extent CPPopt can be calculated in SAH patients and to investigate CPPopt in relation to CBF.

Methods Retrospective study of prospectively collected data. CBF was measured bedside with Xenon-enhanced CT (Xe-CT). The difference between actual CPP and CPPopt was calculated (CPPa dagger). Correlations between CPPa dagger and CBF parameters were calculated with Spearman's rank order correlation coefficient (rho). Separate calculations were done using all patients (day 0-14 after onset) as well as in two subgroups (day 0-3 and day 4-14).

Results Eighty-two patients with 145 Xe-CT scans were studied. Automated calculation of CPPopt was possible in adjunct to 60% of the Xe-CT scans. Actual CPP < CPPopt was associated with higher numbers of low-flow regions (CBF < 10 ml/100 g/min) in both the early phase (day 0-3, n = 39, Spearman's rho = -0.38, p = 0.02) and late acute phase of the disease (day 4-14, n = 35, Spearman's rho = -0.39, p = 0.02). CPP level per se was not associated with CBF.

Conclusions Calculation of CPPopt is possible in a majority of patients with severe SAH. Actual CPP below CPPopt is associated with low CBF.

Keyword
cerebral blood flow, autoregulation, CPP, subarachnoid haemorrhage
National Category
Clinical Medicine
Research subject
Neurosurgery
Identifiers
urn:nbn:se:uu:diva-294191 (URN)10.1007/s00701-017-3139-7 (DOI)000401117700016 ()28361248 (PubMedID)
Available from: 2016-09-21 Created: 2016-05-18 Last updated: 2017-06-13Bibliographically approved
Vlachogiannis, P., Hillered, L., Khalil, F., Enblad, P. & Ronne, E. (2017). Interleukin-6 levels in cerebrospinal fluid and plasma in patients with severe spontaneous subarachnoid hemorrhage. Paper presented at 28th International Symposium on Cerebral Blood Flow, Metabolism and Function / 13th International Conference on Quantification of Brain Function with PET, APR 01-04, 2017, Int Soc Cerebral Blood Flow & Metab, Berlin, GERMANY. Journal of Cerebral Blood Flow and Metabolism, 37, 496-496.
Open this publication in new window or tab >>Interleukin-6 levels in cerebrospinal fluid and plasma in patients with severe spontaneous subarachnoid hemorrhage
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2017 (English)In: Journal of Cerebral Blood Flow and Metabolism, ISSN 0271-678X, E-ISSN 1559-7016, Vol. 37, 496-496 p.Article in journal, Meeting abstract (Other academic) Published
Place, publisher, year, edition, pages
Sage Publications, 2017
National Category
Endocrinology and Diabetes Hematology Neurology
Identifiers
urn:nbn:se:uu:diva-331037 (URN)000400157400728 ()
Conference
28th International Symposium on Cerebral Blood Flow, Metabolism and Function / 13th International Conference on Quantification of Brain Function with PET, APR 01-04, 2017, Int Soc Cerebral Blood Flow & Metab, Berlin, GERMANY
Note

Supplement: 1, Meeting Abstract: PS06-089

Available from: 2017-10-11 Created: 2017-10-11 Last updated: 2017-10-11
Ljunghill Hedberg, A., Pauksens, K., Enblad, P., Söderberg, J., Johansson, B., Kayhty, H. & Sjölin, J. (2017). Pneumococcal polysaccharide vaccination administered early after neurotrauma or neurosurgery. Vaccine, 35(6), 909-915.
Open this publication in new window or tab >>Pneumococcal polysaccharide vaccination administered early after neurotrauma or neurosurgery
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2017 (English)In: Vaccine, ISSN 0264-410X, E-ISSN 1873-2518, Vol. 35, no 6, 909-915 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Pneumococcal vaccination is recommended to lower the risk of posttraumatic meningitis, and early vaccination may be of importance. After both trauma and central nervous system injury, immune suppression may occur, which could affect T-cell function and the response to T-cell dependent vaccines. We therefore aimed to investigate the response to early vaccination with a T-cell independent pneumococcal polysaccharide vaccine (PPSV). Methods: Thirty-three patients with basilar skull fracture and 23 patients undergoing transsphenoidal pituitary gland surgery were vaccinated with PPSV within 10 days after neurotrauma or neurosurgery. Twenty-nine neurosurgical patients vaccinated >= 3 weeks after neurotrauma or neurosurgery served as controls. Serotype-specific anti-polysaccharide binding IgG antibody levels to serotypes 4, 6B, 9V, 14, 18C, 19F and 23F were determined by enzyme immunoassay. Results: The vaccination was safe and a highly significant antibody response was found against all serotypes in all groups (p < 0.001 for each of the serotypes). There were no differences between groups or in the group by time interaction in any of the serotypes. After early and late vaccination, protective levels were found in >80% for serotypes 9V, 14, 18C, 19F and 23F and in 70% and 50% for serotypes 6B and 4, respectively. Conclusion: Patients vaccinated with PPSV within 10 days after neurotrauma or neurosurgery respond similarly to those vaccinated after >= 3 weeks, indicating that PPSV can be administered early after neurotrauma or neurosurgery.

Place, publisher, year, edition, pages
ELSEVIER SCI LTD, 2017
Keyword
Pneumococcal polysaccharide vaccine, Neurotrauma, Neurosurgery
National Category
Infectious Medicine Immunology in the medical area
Identifiers
urn:nbn:se:uu:diva-319568 (URN)10.1016/j.vaccine.2016.12.065 (DOI)000394196000010 ()28069358 (PubMedID)
Available from: 2017-04-06 Created: 2017-04-06 Last updated: 2018-01-13Bibliographically approved
Nyholm, L., Howells, T. & Enblad, P. (2017). Predictive Factors That May Contribute to Secondary Insults With Nursing Interventions in Adults With Traumatic Brain Injury. Journal of Neuroscience Nursing, 49(1), 49-55.
Open this publication in new window or tab >>Predictive Factors That May Contribute to Secondary Insults With Nursing Interventions in Adults With Traumatic Brain Injury
2017 (English)In: Journal of Neuroscience Nursing, ISSN 0888-0395, E-ISSN 1945-2810, Vol. 49, no 1, 49-55 p.Article in journal (Refereed) Published
Abstract [en]

Background: Nursing interventions pose risks and benefits to patients with traumatic brain injury at a neurointensive care unit. Objectives: The aim of this study was to investigate the risk of inducing high intracranial pressure (ICP) related to interventions and whether intracranial compliance, baseline ICP, or autoregulation could be used as predictors. Methods: The study had a quantitative, prospective, observational design. Twenty-eight patients with TBI were included, and 67 interventions were observed. The definition of a secondary ICP insult was ICP of 20 mm Hg or greater for 5 minutes or more within a continuous 10-minute period. Results: Secondary ICP insults related to nursing interventions occurred in 6 patients (21%) and 8 occasions (12%). Patients with baseline ICP of 15 mm Hg or greater had 4.7 times higher risk of developing an insult. The predictor with the best combination of sensitivity and specificity was baseline ICP. Conclusions: Baseline ICP of 15 mm Hg or greater was the most important factor to determine the risk of secondary ICP insult related to nursing intervention.

Keyword
neurointensive care, nursing implications, nursing interventions, secondary insults
National Category
Neurology Nursing
Identifiers
urn:nbn:se:uu:diva-316018 (URN)10.1097/JNN.0000000000000260 (DOI)000392410200012 ()28060220 (PubMedID)
Funder
Swedish Research Council
Available from: 2017-02-24 Created: 2017-02-24 Last updated: 2017-11-29Bibliographically approved
Rostami, E., Engquist, H., Howells, T., Ronne-Engström, E., Nilsson, P., Hillered, L. T., . . . Enblad, P. (2017). The Correlation between Cerebral Blood Flow Measured by Bedside Xenon-CT and Brain Chemistry Monitored by Microdialysis in the Acute Phase following Subarachnoid Hemorrhage. Frontiers in Neurology, 8, Article ID 369.
Open this publication in new window or tab >>The Correlation between Cerebral Blood Flow Measured by Bedside Xenon-CT and Brain Chemistry Monitored by Microdialysis in the Acute Phase following Subarachnoid Hemorrhage
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2017 (English)In: Frontiers in Neurology, ISSN 1664-2295, E-ISSN 1664-2295, Vol. 8, 369Article in journal (Refereed) Published
Abstract [en]

Cerebral microdialysis (MD) may be used in patients suffering from subarachnoid hemorrhage (SAH) to detect focal cerebral ischemia. The cerebral MD catheter is usually placed in the right frontal lobe and monitors the area surrounding the catheter. This generates the concern that a fall in cerebral blood flow (CBF) and ischemic events distant to the catheter may not be detected. We aimed to investigate if there is a difference in the association between the MD parameters and CBF measured around the MD catheter compared to global cortical CBF and to CBF in the vascular territories following SAH in the early acute phase. MD catheter was placed in the right frontal lobe of 30 SAH patients, and interstitial glucose, lactate, pyruvate, glycerol, and lactate/pyruvate ratio were measured hourly. CBF measurements were performed during day 0-3 after SAH. Global cortical CBF correlated strongly with CBF around the microdialysis catheter (CBF-MD) (r = 0.911, p ≤ 0.001). This was also the case for the anterior, middle, and posterior vascular territories in the right hemisphere. A significant negative correlation was seen between lactate and CBF-MD (r = -0.468, p = 0.009). The same relationship was observed between lactate and CBF in anterior vascular territory but not in the middle and posterior vascular territories. In conclusion, global CBF 0-3 days after severe SAH correlated strongly with CBF-MD. High lactate level was associated with low global CBF and low regional CBF in the right anterior vascular territory, when the MD catheter was placed in the right frontal lobe.

Keyword
Xenon-CT, cerebral blood flow, lactate, microdialysis, subarachnoid hemorrhage
National Category
Neurosciences
Identifiers
urn:nbn:se:uu:diva-330939 (URN)10.3389/fneur.2017.00369 (DOI)000407574600001 ()28824527 (PubMedID)
Available from: 2017-10-07 Created: 2017-10-07 Last updated: 2018-01-13Bibliographically approved
Howells, T., Johnson, U., McKelvey, T., Ronne-Engström, E. & Enblad, P. (2017). The effects of ventricular drainage on the intracranial pressure signal and the pressure reactivity index. Journal of clinical monitoring and computing, 31(2), 469-478.
Open this publication in new window or tab >>The effects of ventricular drainage on the intracranial pressure signal and the pressure reactivity index
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2017 (English)In: Journal of clinical monitoring and computing, ISSN 1387-1307, E-ISSN 1573-2614, Vol. 31, no 2, 469-478 p.Article in journal (Refereed) Published
Abstract [en]

In subarachnoid hemorrhage (SAH) patients intracranial pressure (ICP) is usually monitored via an extraventricular drain (EVD), which can produce false readings when the drain is open. It is established that both the ICP cardiac pulse frequency and long term trends over several hours are often seriously corrupted. The aim of this study was to establish whether or not the intermediate frequency bands [respiratory, Mayer wave and very low frequency (VLF)] were also corrupted. The VLF range is of special interest because it is important in cerebral autoregulation studies. Using a pattern recognition algorithm we retrospectively identified 718 cases of EVD opening in 80 SAH patients. An analysis of differences between closed and open-drain periods showed that ICP amplitude decreased significantly in all of the three lower frequency bands when the EVD was open. A similar analysis of systemic arterial pressure signal revealed similar changes in the same frequency bands that were positively correlated with the ICP changes. Therefore we concluded that the changes in the ICP signal represented real, physiological changes and not artifact. Pressure reactivity index (PRx) values were also computed during closed and open-drain periods. We found a small but statistically significant decrease during open-drain periods. Based on analysis of the change in the PRx distribution during open drainage we concluded that this decrease also represented physiological changes rather than artifact. In summary the ICP respiratory, Mayer wave, and VLF frequency bands are not corrupted when the EVD is open, and it safe to use these for autoregulation studies.

Keyword
Intracranial pressure, Subarachnoid hemorrhage, Cerebral autoregulation, Vascular pressure reactivity, Clinical monitoring
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-321426 (URN)10.1007/s10877-016-9863-3 (DOI)000396348800028 ()26987656 (PubMedID)
Available from: 2017-05-16 Created: 2017-05-16 Last updated: 2017-05-16
Widén, J., Eriksson, B.-M., Ronne-Engström, E., Enblad, P. & Westman, G. (2017). Ventriculostomy-related infections in subarachnoid hemorrhage patients - a retrospective study of incidence, etiology, and antimicrobial therapy. Acta Neurochirurgica, 159(2), 317-323.
Open this publication in new window or tab >>Ventriculostomy-related infections in subarachnoid hemorrhage patients - a retrospective study of incidence, etiology, and antimicrobial therapy
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2017 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 159, no 2, 317-323 p.Article in journal (Refereed) Published
Abstract [en]

This study was performed to investigate the incidence and etiology of ventriculostomy-related infections (VRIs) in patients with subarachnoid hemorrhage (SAH) and to assess adherence to local clinical guidelines regarding empirical antimicrobial therapy and diagnostic routines. A total of 191 consecutive SAH patients treated in the neuro-intensive care unit of Uppsala University Hospital between 2010 and 2013 were included retrospectively. Information regarding cerebrospinal fluid samples, bacterial cultures, ventriculostomy treatment, patient characteristics, and antibiotic treatment were collected from electronic patient records. Eleven patients developed VRI, resulting in an incidence of 5.8% per patient, 5.4% per ventriculostomy catheter, and 4.1 per 1000 catheter days. Coagulase-negative staphylococci caused nine cases of VRI and Klebsiella pneumoniae and Staphylococcus aureus caused one each. Empirical VRI therapy was initiated on 97 occasions in 81 subjects (42.4%). Out of the 11 patients with VRI, four did not receive empirical antibiotic therapy before the positive culture result. The clinical actions performed after analysis of CSF samples were in line with the action suggested by the local guidelines in 307 out of 592 cases (51.9%). The incidence of VRI in our cohort was comparable to what has previously been reported. Coagulase-negative staphylococci was the most common agent. Our study demonstrates the difficulty in diagnosing VRI in SAH patients. Improved adherence to clinical guidelines could to some extent reduce the use of empirical antibiotic treatment, but better diagnostic methods and routines are needed.

Keyword
Ventriculostomy, Meningitis, Subarachnoid hemorrhage, Antimicrobial therapy
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-317591 (URN)10.1007/s00701-016-3039-2 (DOI)000393022200018 ()27928632 (PubMedID)
Available from: 2017-03-24 Created: 2017-03-24 Last updated: 2017-11-29Bibliographically approved
Blomquist, E., Ronne Engström, E., Borota, L., Gál, G., Nilsson, K., Lewén, A., . . . Enblad, P. (2016). Positive correlation between occlusion rate and nidus size of proton beam treated brain arteriovenous malformations (AVMs). Acta Oncologica, 55(1), 105-112.
Open this publication in new window or tab >>Positive correlation between occlusion rate and nidus size of proton beam treated brain arteriovenous malformations (AVMs)
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2016 (English)In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 55, no 1, 105-112 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Proton beam radiotherapy of arteriovenous malformations (AVM) in the brain has been performed in Uppsala since 1991. An earlier study based on the first 26 patients concluded that proton beam can be used for treating large and medium sized AVMs that were considered difficult to treat with photons due to the risk of side effects. In the present study we analyzed the result from treating the subsequent 65 patients.

MATERIAL AND METHODS: A retrospective review of the patients' medical records, treatment protocols and radiological results was done. Information about gender, age, presenting symptoms, clinical course, the size of AVM nidus and rate of occlusion was collected. Outcome parameters were the occlusion of the AVM, clinical outcome and side effects.

RESULTS: The rate of total occlusion was overall 68%. For target volume 0-2cm(3) it was 77%, for 3-10 cm(3) 80%, for 11-15 cm(3) 50% and for 16-51 cm(3) 20%. Those with total regress of the AVM had significantly smaller target volumes (p < 0.009) higher fraction dose (p < 0.001) as well as total dose (p < 0.004) compared to the rest. The target volume was an independent predictor of total occlusion (p = 0.03). There was no difference between those with and without total occlusion regarding mean age, gender distribution or symptoms at diagnosis. Forty-one patients developed a mild radiation-induced brain edema and this was more common in those that had total occlusion of the AVM. Two patients had brain hemorrhages after treatment. One of these had no effect and the other only partial occlusion from proton beams. Two thirds of those presenting with seizures reported an improved seizure situation after treatment.

CONCLUSION: Our observations agree with earlier results and show that proton beam irradiation is a treatment alternative for brain AVMs since it has a high occlusion rate even in larger AVMs.

National Category
Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-254040 (URN)10.3109/0284186X.2015.1043023 (DOI)000367007700015 ()25972265 (PubMedID)
Available from: 2015-06-04 Created: 2015-06-04 Last updated: 2017-12-04Bibliographically approved
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