All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance...

All Surgical Specialty Wound Class Review & Quiz

Bruce Ryon, RN, MS, PhD

Director, Performance Excellence

National Surgical Quality Improvement Program

[email protected]

mailto:[email protected]


Wound Class Review

Defined by the American College of Surgeons- Largely related to bacteria presence & activity


Wound Class Review

Defined by the CDC- Largely related to bacteria presence & activity

#1 - Clean- Any incision thru non-infected material NOT in major tracts


Wound Class Review



#2 - Clean, Contaminated- Baseline in GI, respiratory, reproductive, urinary tracts


Wound Class Review




#3 - Contaminated- Presence of contained acute inflammation (not chronic)- Dry, but not wet and active gangrene- Example: inflamed, non-perforated appendix


Wound Class Review




#3 - Contaminated- Presence of contained inflammation- Dry, but not wet and active gangrene- Example: inflamed, non-perforated appendix

#4 – Dirty/Infected- Incision into infected material- Spilled purulence or fecal material, wet gangrene - Example: perforated and inflamed appendix with presence

of purulence outside of appendix

Baseline Procedures & Wound Class

Non-tracts - 1

• Orthopedics – 1

• Breast – 1

• Vascular – 1

• Cardiovascular – 1

• Plastics – 1

• Hernia - 1

Tracts - 2

• Head & Neck – 2

• Thoracic (lung) - 2

• OB/GYN – 2

• Colorectal – 2

• Hepatobiliary – 2

• Urology – 2



Wound Class Simplified

Tract**2

Non-Tract*1

Acute Inflammation, dry (ischemic) gangrene, breaks in technique, spillage, true foreign bodies

3

Incision into pus, purulence, abscess, wet (infected) gangrene, old dead tissue

4

Clean Surgical Incision Site

1-11% wound infection risk

Potential or Pre-Infection

10-17% wound infection risk

Visually Active Infection

>27% wound infection risk

* Ortho, cardiac, vascular, plastics, hernia, breast, abdominal outside of tracts** Reproductive, urinary, renal, ear, nose, throat, pulmonary, colorectal, hepatobiliary

1 & 2 includes chronic inflammation at these sites, e.g., arthritic joint (1), colitis/Crohns (2)

HIGHEST WOUND CLASS ASSIGNED TO ALL PROCEDURES USING SAME INCISION


Wound Class Quiz

• 1st Slide – Kaiser San Francisco cases– Scenario explained with choices– Circulator recording marked by *asterisk– Think about the baseline of the procedure– Then think about anything that would

change that baseline

• 2nd Slide– Shows the answer in multiple asterisks– Note on key or important criteria

General Surgery


What is the wound class?

A patient under went a Whipple for cancer. Surgery included a cholecystectomy. Gallbladder was documented as having changes consistent with chronic cholecystitis.

1.Clean

2.Clean/contaminated

* 3.Contaminated

4.Dirty/Infected



A patient under went a Whipple for cancer. Surgery included a cholecystectomy. Gallbladder was documented as having changes consistent with chronic cholecystitis.

1.Clean

******* 2.Clean/contaminated *******

* 3.Contaminated

4.Dirty/Infected

Note: Chronic inflammation would not bump it to a 3



An 18 year old patient with extensive Crohns disease underwent a total colectomy with a colostomy.

1.Clean


* 3.Contaminated

4.Dirty/Infected



An 18 year old patient with extensive Crohns disease underwent a total colectomy with a colostomy.

1.Clean


3.Contaminated

4.Dirty/Infected

Note: Chronic inflammation would keep it at a 2 and not bump it to a 3



Patient underwent a breast biopsy. The operative report noted multiple areas of fatty necrosis on the large mass. There was also necrotic tissue around the mass.

1.Clean


3.Contaminated

* 4.Dirty/Infected



Patient underwent a breast biopsy. The operative report noted multiple areas of fatty necrosis on the large mass. There was also necrotic tissue around the mass.

1.Clean


******* 3.Contaminated *******

* 4.Dirty/Infected

Note: Necrotic, ischemic dead tissue, without infection is a 3



Patient underwent laparoscopic appendectomy. The pre op CT scan reported the appendix contained a fecalith. There was no mention of infection, rupture or inflammation on the operative report.

1.Clean


* 3.Contaminated

4.Dirty/Infected



Patient underwent laparoscopic appendectomy. The preop CT scan reported the appendix contained a fecalith. There was no mention of infection, rupture or inflammation on the operative report.

1.Clean


* 3.Contaminated

4.Dirty/Infected

Note: Fecalith contained within GI tract w/o infection or inflammation is a 2



Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation”.

* 1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation”.

* 1.Clean


******* 3.Contaminated ********

4.Dirty/Infected

Note: Acute inflammation is a 3



Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation with exudates”.

1.Clean


3.Contaminated

* 4.Dirty/Infected



Patient underwent a laparoscopic appendectomy. The operative report states “injected appendix without perforation with exudates”.

1.Clean



* 4.Dirty/Infected

Note: Exudates outside of non-perforated injected appendix is a 3



Patient underwent a laparoscopic appendectomy. The operative report states “acute appendix with perforation”.

1.Clean

* 2.Clean/contaminated

3.Contaminated

4.Dirty/Infected



Patient underwent a laparoscopic appendectomy. The operative report states “acute appendix with perforation”.

1.Clean


3.Contaminated

******* 4.Dirty/Infected *******

Note: Perforated appendix assumes infected contents have spilled into abdominal cavity



Patient underwent an exploratory laparoscopic for possible small bowel obstruction. The procedure performed was terminal ileum resection. The operative report states “necrotic cecum and appendix”.

1.Clean


3.Contaminated

* 4.Dirty/Infected



Patient underwent an exploratory laparoscopic for possible small bowel obstruction. The procedure performed was a terminal ileum resection. The operative report states surgeon found a “necrotic cecum and appendix”.

1.Clean



* 4.Dirty/Infected

Note: Necrosis, ischemic dead tissue, is generally not infected



With a patient in significant abdominal pain, a preop CT scan indicated patient had SBO (small bowl obstruction). An ex-lap was performed and adhesion lysis freed up a SBO.

1.Clean


3.Contaminated

4.Dirty/Infected



With a patient in significant abdominal pain, a preop CT scan indicated patient had SBO (small bowl obstruction). An ex-lap was performed and adhesion lysis freed up a SBO.

******* 1.Clean *******


3.Contaminated

4.Dirty/Infected

Note: Bowel was never incised, therefore surgery is on par with hernia repair



Patient underwent a rectopexy procedure (rectal prolapse) where a portion of the rectum was resected. The anastamosis was checked for patency/leaks by rigid sigimoidoscopy.

1.Clean


3.Contaminated

* 4.Dirty/Infected



Patient underwent a rectopexy procedure (rectal prolapse) where a portion of the rectum was resected. The anastamosis was checked for patency/leaks by rigid sigimoidoscopy.

1.Clean


3.Contaminated

* 4.Dirty/Infected

Note: Anal & rectum procedures are 2, unless infection present, e.g. abscess/fistula

Vascular Surgery



Patient had necrotic foot d/t complications from peripheral ischemia r/t 150 pack years of smoking. Surgeon performed below knee amputation where the incision was clean without infection.

1.Clean


3.Contaminated

* 4.Dirty/Infected



Patient had necrotic foot d/t complications from peripheral ischemia r/t 150 pack years of smoking. Surgeon performed below knee amputation where the incision was clean without infection.

******* 1.Clean ********


3.Contaminated

* 4.Dirty/Infected

Note: Incision was in a clean area, therefore on par with ortho baseline surgery



Long term diabetic patient had infected gangrenous below-the-knee-amputation stump after vascular grafts failed to improve leg perfusion. Surgeon performed above the knee amputation AKA where the initial incision expressed lymphatic pus. AKA surgery successful.

1.Clean


* 3.Contaminated

4.Dirty/Infected



Long term diabetic patient had infected gangrenous below-the-knee-amputation stump after vascular grafts failed to improve leg perfusion. Surgeon performed above the knee amputation (AKA) where the initial incision expressed lymphatic pus. AKA surgery successful.

1.Clean


* 3.Contaminated


Note: Incision cut into infected material


Orthopedics



THA for osteoarthritis of left hip. Bone was very good with advanced wear of both surfaces. No evidence of any other disease process.

1.Clean


3.Contaminated

4.Dirty/Infected



THA for osteoarthritis of left hip. Bone was very good with advanced wear of both surfaces. No evidence of any other disease process.

******* 1.Clean ********


3.Contaminated

4.Dirty/Infected

Note: Ortho cases are a baseline 1 wound class



Left knee several years status post total knee arthroplasty with rotating platform, status post arthroscopy with aspirate confirming coagulase negative staphylococcal infection.

1.Clean


3.Contaminated

* 4.Dirty/Infected



Left knee several years status post total knee arthroplasty with rotating platform, status post arthroscopy with aspirate confirming coagulase negative staphylococcal infection.

1.Clean


3.Contaminated


Note: Presence of infection = 4



Open left tib/fib fracture with intramedullary rod fixation, locked proximally and distally. Irrigation/debridement of devitalized tissue d/t compound fracture.

1.Clean


* 3.Contaminated

4.Dirty/Infected



Open left tib/fib fracture with intramedullary rod fixation, locked proximally and distally. Irrigation/debridement of devitalized tissue d/t compound fracture.

1.Clean



4.Dirty/Infected

Note: Presence of devitalized (necrotic) tissue = 3



Diagnostic arthroscopy, extensive washout, debridement of lateral portal. Extensive grade 3-4 arthritis in all three compartments. No evidence of intra-articular pus. The lateral portal had some soft tissue necrosis which was debrided.

1.Clean


3.Contaminated

4.Dirty/Infected



Diagnostic arthroscopy, extensive washout, debridement of lateral portal. Extensive grade 3-4 arthritis in all three compartments. No evidence of intra-articular pus. The lateral portal had some soft tissue necrosis which was debrided.

1.Clean



4.Dirty/Infected

Note: Presence of devitalized (necrotic) tissue = 3



Incision and drainage of bilateral lower extremity amputation stumps with gas gangrene bilateral, but no significant collection of any pus seen on the dressings. Wound was very large and necrotic tissue was sharply debrided.

1.Clean


3.Contaminated

4.Dirty/Infected



Incision and drainage of bilateral lower extremity amputation stumps with gas gangrene bilateral, but no significant collection of any pus seen. Wound was very large and necrotic tissue was sharply debrided.

1.Clean



or ******* 4.Dirty/Infected *******Note: Depends of type of necrosis and if gas gangrene was emanating from debrided tissue.


OB/GYN



Laparoscopic total abdominal hysterectomy.

* 1.Clean


3.Contaminated

4.Dirty/Infected



Laparoscopic total abdominal hysterectomy.

* 1.Clean


3.Contaminated

4.Dirty/InfectedNote: Hysterectomies are a baseline GYN procedure = 2



19 Y female patient with undesired pregnancy at 18w underwent a D&E with IUD insertion. No unusual findings intraop.

1.Clean


* 3.Contaminated

4.Dirty/Infected



19 Y female patient with undesired pregnancy at 18w underwent a D&E with IUD insertion. No unusual findings intraop.

1.Clean


* 3.Contaminated

4.Dirty/InfectedNote: D&E, D&C’s & IUD insertion w/o inflammation or infection are baseline = 2



Patient underwent lap ovarian cystectomy with lysis of adhesions (LOA) to gain clear access to ovaries. A small hemorrhagic cyst on the left ovary was evacuated. Obliteration of cul de sac consistent with stage 4 endometriosis.

* 1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent lap ovarian cystectomy with lysis of adhesions (LOA) to gain clear access to ovaries. A small hemorrhagic cyst on the left ovary which was evacuated. Obliteration of cul de sac consistent with stage 4 endometriosis.

******* 1.Clean *******


3.Contaminated

4.Dirty/InfectedNote: Cystectomy that does not incise ovarian tract = 1, LOA = 1

Cystectomy that does incise ovarian tract = 2



Patient underwent a Cesarean section with prolonged labor (> 20 hours), ruptured over 18 hours, thick meconium, no s/sx of infection.

* 1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent a Cesarean section with prolonged labor (> 20 hours), ruptured over 18 hours, thick meconium, no s/sx of infection.

* 1.Clean

2.Clean/contaminated (baseline c-section)


4.Dirty/Infected

Note: Presence of possible non-sterile material not normally a part of organ flora



Patient underwent a Cesarean section d/t PROM and maternal temperature over 38C/100.4F, most likely due to chorioamnioitis perforation.

1.Clean

* 2.Clean/contaminated (baseline c-section)

3.Contaminated

4.Dirty/Infected



Patient underwent a Cesarean section d/t PROM and maternal temperature over 38C/100.4F, most likely due to chorioamnioitis perforation.

1.Clean

* 2.Clean/contaminated (baseline c-section)

3.Contaminated


Note: Presence of infected material from chorioamnioitis perforation



Patient underwent a lap fallopian tube ligation with Filshie clips placed with good blanching and completely encompassing the tubes. There was no bleeding on final inspection.

1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent a lap fallopian tube ligation with Filshie clips placed with good blanching and completely encompassing the tubes. There was no bleeding on final inspection.

******* 1.Clean ******* * 2.Clean/contaminated

3.Contaminated

4.Dirty/Infected

Note: the fallopian tubes were not incised or penetrated = 1



Patient underwent a fallopian tube ligation at the end of a Cesarean section, 3 cm segments of tubeligated with two free ties of plain gut and excised on both fallopian tubes. The lumina were visible and hemostasis was noted.

* 1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent a fallopian tube ligation at the end of a Cesarean section, 3 cm segments of tubeligated with two free ties of plain gut and excised on both fallopian tubes.

* 1.Clean


3.Contaminated

4.Dirty/Infected

Note: the fallopian tubes were incised = 2, the c-section = 2



Elderly patient underwent a colpocleisis le forte type as part of a joint general and gynecology surgery for a colovaginal fistula. Pus was found along abscess.

1.Clean


* 3.Contaminated

4.Dirty/Infected



Elderly patient underwent a colpocleisis le forte type as part of a joint general and gynecology surgery for a colovaginal fistula. Pus was found along abscess.

1.Clean


* 3.Contaminated


Note: ongoing infection = 4

Urology



The patient had a large exophytic tumor on the lower lateral portion of the right kidney. A hand port technique was used to excise the tumor and do the renorrhaphy.

* 1.Clean


3.Contaminated

4.Dirty/Infected



The patient had a large exophytic tumor on the lower lateral portion of the right kidney. A hand port technique was used to excise the tumor and do the renorrhaphy.

* 1.Clean


3.Contaminated

4.Dirty/Infected

Note: Incision into renal/urinary tract = 2



The patient had a very subtle firm nodule in the left testicle as well as palpable firm mass in his abdomen that could be felt while asleep under anesthesia. A left radical orchiectomy was performed in standard fashion.

* 1.Clean


3.Contaminated

4.Dirty/Infected



The patient had a very subtle firm nodule in the left testicle as well as palpable firm mass in his abdomen that could be felt while asleep under anesthesia. A left radical orchiectomy was performed in standard fashion.

* 1.Clean


3.Contaminated

4.Dirty/Infected

Note: Incision into reproductory tract = 2



The patient underwent a repeat transurethral resection of the prostate without difficulty. There was no evidence of any intravesical lesions. There was no evidence of any perforation or uncontrolled bleeding at any point.

* 1.Clean


3.Contaminated

4.Dirty/Infected



The patient underwent a repeat transurethral resection of the prostate without difficulty. There was no evidence of any intravesical lesions. There was no evidence of any perforation or uncontrolled bleeding at any point.

* 1.Clean


3.Contaminated

4.Dirty/Infected

Note: Incision into renal/urinary tract = 2



Patient underwent a vasectomy. The portion of vas outside the body was incised. The vas was clamped between two Mosquito clamps and the portion between the clamp was severed. The vas stumps proximal and distal were cauterized.

* 1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent a vasectomy. The portion of vas outside the body was incised. The vas was clamped between two Mosquito clamps and the portion between the clamp was severed. The vas stumps proximal and distal were cauterized.

* 1.Clean

******* 2.Clean/contaminated ********

3.Contaminated

4.Dirty/Infected

Note: Incision into reproductory tract = 2



The patient underwent a radical spermatic cord resection for recurrent phlegmon. The phlegmon was carefully delivered from the scrotum into the operative field and gently expressed through the incision.

1.Clean


3.Contaminated

4.Dirty/Infected



The patient underwent a radical spermatic cord resection for recurrent phlegmon. The phlegmon was carefully delivered from the scrotum into the operative field and gently expressed through the incision.

1.Clean


******* 3.Contaminated ********

4.Dirty/Infected* 2 or 3 wound class depends on if phlegmon was acute or chronic

Head and Neck



Tympanoplasty with R posterior perforation 30%. Thick tymapnosclerosis at the anterior border of perforation extending within the perforation forward.

1.Clean


3.Contaminated

4.Dirty/Infected



Tympanoplasty with R posterior perforation 30%. Thick tymapnosclerosis at the anterior border of perforation extending within the perforation forward.

******* 1.Clean *******


3.Contaminated

4.Dirty/Infected

Note: Ear drum not populated by friendly flora



Patient underwent myringotomy with insertion of tube for media otitis and eustachian tube dysfuntion.

1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent myringotomy with insertion of tube for media otitis and eustachian tube dysfuntion.

1.Clean


****** 3.Contaminated ******

4.Dirty/Infected

Note: Otitis media is an acute inflammation process.



Patient underwent thyroplasty with medialization for vocal cord paralysis.

1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent thyroplasty with medialization for vocal cord paralysis.

******* 1.Clean *********


3.Contaminated

4.Dirty/Infected

Note: Thyroid and surrounding tissue are clean tissue



Patient underwent nasal septoplasty w turbinate reduction and nasal closed reduction fracture without s/s of inflammation or infection.

1.Clean


* 3.Contaminated

4.Dirty/Infected



Patient underwent nasal septoplasty w turbinate reduction and nasal closed reduction fracture without s/s of inflammation or infection.

1.Clean


* 3.Contaminated

4.Dirty/Infected

Note: Baseline nasal surgeries are 2



Patient underwent thyroglossal duct cyst excision without s/s of inflammation or infection.

* 1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent thyroglossal duct cyst excision without s/s of inflammation or infection.

* 1.Clean


3.Contaminated

4.Dirty/Infected

Note: Baseline pharnyx surgeries = 2

Plastics



Patient with excess skin and adiposity of the abdomen underwent abdominoplasty with rectus plication, in addition to bilateral medial thigh lifts. Surgery was uncomplicated.

* 1.Clean


3.Contaminated

4.Dirty/Infected



Patient with excess skin and adiposity of the abdomen underwent abdominoplasty with rectus plication, in addition to bilateral medial thigh lifts. Surgery was uncomplicated.

******* 1.Clean *******


3.Contaminated

4.Dirty/Infected

Note: Baseline plastics procedures = 1



Patient underwent nail unit excision, distal phalanx shortening, and primary closure d/t lesion (nailfold melanocytic proliferation). No unusual findings during the case.

1.Clean


3.Contaminated

4.Dirty/Infected



Patient underwent nail unit excision, distal phalanx shortening, and primary closure d/t lesion (nailfold melanocytic proliferation). No unusual findings during the case.

******* 1.Clean *******


3.Contaminated

4.Dirty/Infected

Note: Baseline plastics procedures = 1



15 yo patient with underwent a vaginoplasty r/t adrenal hyperplasia. Case was completed without complication.

1.Clean


3.Contaminated

4.Dirty/Infected



15 yo patient with underwent a vaginoplasty r/t adrenal hyperplasia. Case was completed without complication.

1.Clean


3.Contaminated

4.Dirty/Infected

Note: Reproductory tract surgeries = 2



Debridement of surgical wound. Necrotic skin, soft tissue as well as muscle of right groin incision with lateral pockets composed of dead fat and seroma fluid. Cultures sent from the OR for aerobic and anaerobic cultures. No drains. No complications.

1.Clean


3.Contaminated

4.Dirty/Infected



Debridement of surgical wound. Findings: necrotic skin, soft tissue as well as muscle of right groin incision with lateral pockets composed of dead fat and seroma fluid. Cultures sent from the OR for aerobic and anaerobic cultures. No drains. No complications.

1.Clean


******* 3.Contaminated ******* or


Note: Dry necrotic skin = 3. PostOp labs indicate tissue was infected = 4



Quadriplegic patient underwent debridement and flap closure for a chronic left ischial pressure sore Stage IV with non-healing of wound Cultures of the wound have grown out multiple organisms.

1.Clean


3.Contaminated

* 4.Dirty/Infected



Quadriplegic patient underwent debridement and flap closure for a chronic left ischial pressure sore Stage IV with non-healing of wound Cultures of the wound have grown out multiple organisms.

1.Clean


3.Contaminated


Note: Infected wound = 4



30-year-old Asian female underwent scar revision by initial excision at Stage I with VAC dressing delay. She is 18 months status post chemical burn to her left upper trunk, neck and face. Previous skin grafting is noted to be extremely thick with some contracture bands along the neck.

1.Clean


3.Contaminated

4.Dirty/Infected



30-year-old Asian female underwent scar revision by initial excision at Stage I with VAC dressing delay. She is 18 months status post chemical burn to her left upper trunk, neck and face. Previous skin grafting is noted to be extremely thick with some contracture bands along the neck.

******* 1.Clean *******


3.Contaminated

4.Dirty/InfectedNote: Class 2 is reserved for baseline tracts where friendly flora is homeostatic.

Ophthalmology



57 year old male patient underwent cataract surgery. Case was completed without complication.

1.Clean


3.Contaminated

4.Dirty/Infected



57 year old male patient underwent cataract surgery. Case was completed without complication.

******* 1.Clean *******


3.Contaminated

4.Dirty/Infected

Note: Baseline eye surgeries = 1

Cardiac Vascular and Thoracic



76 year old male was with extensive CAD was brought into the OR for an internal mammary CABG procedure. There was dense pericarditis observed after the midsternotomy. Revascularization included LAD graft to LIMA and PDA was grafted with separate segment of RSVG.

1.Clean


3.Contaminated

4.Dirty/Infected



76 year old male was with extensive CAD was brought into the OR for an internal mammary CABG procedure. There was dense pericarditis observed after the midsternotomy. Revascularization included LAD graft to LIMA and PDA was grafted with separate segment of RSVG.

******* 1.Clean ******* if chronic pericarditis


******* 3.Contaminated ******* if acute pericarditis

4.Dirty/Infected



Aortic valve replacement and repair of the ascending thoracic aortic aneurysm with a 32 mm Terumo tube graft was completed on a 58 year old male. The pt was transferred to the CV ICU and a transesophageal echocardiography revealed (TEE) a well-seated valve without evidence of perivalvular leak.

1.Clean


3.Contaminated

4.Dirty/Infected



Aortic valve replacement and repair of the ascending thoracic aortic aneurysm with a 32 mm Terumo tube graft was completed on a 58 year old male. The pt was transferred to the CV ICU and a transesophageal echocardiography (TEE) revealed a well-seated valve without evidence of perivalvular leak.

******* 1.Clean *******


3.Contaminated

4.Dirty/Infected

Note: Baseline heart surgeries = 1



A wedge resection of the right upper lobe as well as mechanical pleurodesis was performed. The apex of the right lung was abnormal with multiple microscopic blebs, but no gross bullae.

* 1.Clean


3.Contaminated

4.Dirty/Infected



A wedge resection of the right upper lobe as well as mechanical pleurodesis was performed. The apex of the right lung was abnormal with multiple microscopic blebs, but no gross bullae.

* 1.Clean


3.Contaminated

4.Dirty/Infected

Note: Baseline lung surgeries = 2

All Surgical Specialty Wound Class Review & Quiz


Director, Performance Excellence

National Surgical Quality Improvement Program

[email protected]

mailto:[email protected]

All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance...

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