1. with this distinction but evaluating the potential for aggressiveness of the tumor (e.g., tumor invasion, mitotic count and Ki-67 labeling index) may still be useful. Retro-chiasmal lesions almost always give rise to homonymous field defects with only one, exception. . Questions with answers: Identifier: 926-4: Title: Release Hallucinations: Ocular Movements: Normal: Creator: Shirley H. Wray, M.D., Ph.D., FRCP, Professor of Neurology Harvard Medical School . Wilbrands knee is composed of fibers originating in the inferonasal retina which after traversing via the optic nerve and crossing in the chiasm go anteriorly into the contralateral optic nerve up to 4 mm before passing posteriorly to the optic tract. What field defect results when a stroke affects the occipital lobe but spares the anterior portion of the occipital lobe? 9. When an altitudinal visual field defect is a presenting feature, besides the usual vascular and compressive causes, optic neuritis should be remembered in the list of differential diagnoses. Fig. Unspecified diagnosis codes like H53.439 are acceptable when clinical information is . Cushing syndrome describes the assortment of physiologic changes that occurs with elevated serum cortisol levels. Adenoma cells stain on immunohistochemistry based on the type of hormone they secrete. Use to remove results with certain terms (This rule does not apply to optic tract lesions that are suspected when the homonymous hemianopia is associated with a RAPD on the side of the hemianopia and bilateral optic nerve pallor). when looking at the lid color, you notice they are red, inflamed, and a little crusty. Most patients show improvement of visual acuity, visual fields, or both following surgical treatment. An altitudinal visual field defect is a condition in which there is defect in the superior or inferior portion of the visual field that respects the horizontal midline. Tell the patient to fixate on a central spot. [11] Mutations in the aryl hydrocarbon receptor interacting protein (AIP) gene are associated with an increased risk of aggressively invasive growth hormone-secreting pituitary adenomas. Some common types of visual field defects and their more common differentials are outlined below. [5], Cushing disease is a subset of Cushing syndrome that is caused by excess production of ACTH from a corticotroph adenoma. Driving and reading regular-sized print can be difficult. What are the monocular VF defect patterns? 2. In the example provided in Fig. The VF defect is a homonymous hemianopia with sparing of the temporal crescent on the same side as the hemianopia. Certain patterns of visual field loss help to establish a possible underlying cause. The stimulus size is kept the same, but the brightness varies. The most nasal retinal fibers have unpaired cortical representation, which is situated in the most anterior part of the contralateral parieto-occipital sulcus. the types and severity of visual field defects in the Optic Neu-rititsTreatmentTrial(ONTT) . It is a defect surrounded by normal visual field. [28] Patients may experience overlapping images or divergent images corresponding to esodeviation, exodeviation, or hyperdeviation. Because more fibers in the optic tract come from the opposite eye (crossed fibers), a relative afferent pupillary defect (RAPD) is often observed in the eye contralateral to an optic tract lesion (see discussion later in this chapter). 2. Pain is often unilateral, throbbing, worse with exertion, and accompanied by symptoms read more (which may cause transient homonymous hemianopia). 3.3 Interpretation of a Visual Field Defect, 3.3.1 Understanding a Humphrey Visual Field Printout. This superior wedge shaped area of vision loss is called a "pie in the sky.". We report a case of bilateral superior altitudinal hemianopsia (BSAH) secondary to pituitary microadenoma related inferior optic chiasm damage. Bilateral superior altitudinal hemianopia is an uncommon clinical presentation of ischemic stroke. The visual field of each eye overlaps centrally. An embolic infarction of either a distal MCA or PCA branch can result in exclusive ischemia of the tip of the occipital lobe, thereby producing only a small homonymous hemianopia if there is inadequate collateral circulation. Bilateral homonymous hemianopias A Homonymous hemianopia denser superiorly (pie in the sky), 1. The homogenicity of the images suggests the relative solidity of the tumor. If binocular, does the defect respect the vertical meridian? 12. 2. They make up 30-50% of pituitary adenomas and are the most common clinically functional adenomas. A patient with altitudinal visual loss is more likely to have a carotid or cardiac embolic source compared with patients with diffuse or constricting patterns of vision loss. 1. Special attention should be directed to the horizontal and vertical axes of the visual field to see if there is a change in vision across an axis. 4, 5 However, acute-onset inferior altitudinal VFD is a hallmark of AION. Hypercortisolism now most commonly results as a result of iatrogenic therapeutic modalities. Incomplete homonymous hemianopias may help localize the lesion based on their congruity: These tumors are the most common causeof optic chiasm compression in adults. Pituitary adenomas, which grow upward from the pituitary stalk, compress the chiasm from below, which preferentially involves the inferior, nasal, and macular nerve fibers. [6], Most pituitary adenomas are soft, well-circumscribed lesions that are confined to the sella turcica. It can quickly establish the pattern of visual field loss in the ill, poorly attentive, or elderly patient who requires continued encouragement to maintain fixation and respond appropriately. Lesions of the optic tract cause a contralateral homonymous hemianopia, which may or may not be congruent. Temporal retina in the left eye ([3green] in Fig. Rates must be under: They commonly occur in adults around 40-50 years old but can occur in all ages. Retro-chiasmal lesions normally cause homonymous visual field defects; the only exception is the temporal crescent or half moon syndrome, caused by a lesion in the anterior part of the contralateral parieto-occipital sulcus. What are the findings of bilateral occipital lobe lesions? Characterization of the visual field defect often allows precise localization of the lesion along the visual pathways. 1. Optic neuropathies typically produce nerve fiber bundle defects within the central 30 degrees of the visual field. Mammosomatotroph adenomas in addition to expressing GH, also express PRL, though at a lesser extent. The nasal fibers of the ipsilateral eye (53% of all fibers) cross in the chiasm to join the uncrossed temporal fibers (47% of all fibers) of the contralateral eye. 3.18). Tell the patient to fixate on a central spot. (B) Automated perimetry in the right eye is normal; left eye shows an inferior altitudinal defect. The far periphery can be assessed by finger wiggle. The laboratory tests may vary depending on the clinical presentation. 2012. If the middle cerebral artery is patent when the PCA is occluded, this focal area of the occipital lobe may be spared. [5] While both medications have similar mechanisms of action, the other medication may be tried if there is a minimal response from the first drug. 3.15, Fig. The tip of the occipital lobe, where the macular central homonymous hemifields are represented, often has a dual blood supply from terminal branches of the posterior cerebral artery and of the middle cerebral artery. Goldmann visual field showing a bitemporal hemianopsia. Treatment for the nonarteritic read more or Leber hereditary neuropathy Leber hereditary optic neuropathy Hereditary optic neuropathies result from genetic defects that cause vision loss and occasionally cardiac or neurologic abnormalities. 13. 15. Silent-type III pituitary adenomas can be clinically aggressive but has good treatment response to radiation and temozolomide. In interpreting a visual field test, you need to ask the following questions (Fig. 6. Philadelphia, Wolters Kluwer, 2017. If it respects the vertical meridian, is the defect bitemporal (temporal side of the vertical meridian in each eye) or homonymous (on the same side of the vertical meridian in each eye)? [7], Pituitary adenomas usually occur in adults; they rarely occur in childhood. Is the test normal? Having a high basal hormonal level postoperatively was predictive of recurrence in functional adenomas, but there are no known predictive factors for recurrence in nonfunctioning adenomas. Cover one of the patients eyes. Occlusion of the PCA often results homonymous hemianopia of the contralateral visual field with macular sparing. Gittinger JW. defect in the affected eye was diffuse visual field loss (48%), followed by altitudinal defects (15%), central or cecocentral scotoma (8.3%), arcuate or double arcuate (4.5%), hemianopic defects (4.2%). A recorded number of 0 indicates that the patient could not detect even the brightest stimulus at that point. Some patients with complete bitemporal hemianopsia will complain of a complete loss of depth perception. 3. Although the anatomical presence of Wilbrands knee is debated, junctional scotomas are observed clinically. While the patient is asked to fixate on a central target, a white or colored circular stimulus is slowly moved from the periphery toward the center of the screen until the patient reports seeing the stimulus. Right RAPD Somatotroph Adenomas (Growth Hormone Adenomas), Findings associated with endocrine disturbance, No Ophthalmologic Involvement/No Surgery/Medical Therapy. What are the findings of a parietal lobe lesion? What are the findings of a left optic tract lesion? 6. Ask the patient to signal detection of the white dot by pressing a buzzer. A variety of retinal or more central pathologies can cause visual field deficits that are limited to particular regions of visual space. [33], Macroadenomas are more obviously seen, as they extend beyond the anatomical borders of the sella. Please confirm that you are a health care professional. The life-threatening emergency associated with pituitary apoplexy is adrenal crisis, as well as other acute endocrine abnormalities. 3.25). o [teenager OR adolescent ], Loss of all or part of the superior or inferior half of the visual field; does not cross the horizontal median, More common: Ischemic optic neuropathy, hemicentral retinal artery occlusion Central Retinal Artery Occlusion and Branch Retinal Artery Occlusion Central retinal artery occlusion occurs when the central retinal artery becomes blocked, usually due to an embolus. Management of pituitary adenomas depends on the size of the tumor, its secretory function (as well as what type of hormone is secreted), and its impact on the patient's vision. The most nasal retinal fibers have unpaired cortical representation, which is situated in the most anterior part of the contralateral parieto-occipital sulcus. ABSTRACT Postsynaptic fibers from the lateral geniculate nucleus form the optic radiations, which separate into the inferior fibers (temporal lobe) and the superior fibers (parietal lobe) as they progress posteriorly toward the occipital cortex (Fig. In children, somatotrophic adenomas have more obvious signs as they may develop physical features that may lead to earlier detection. Occipital Lobe: Sparing the Temporal Crescent. Lesions of the lateral geniculate nucleus typically cause a contralateral homonymous hemianopia. Heteronymous altitudinal visual field defects comprises of a superior hemifield defect in one eye and a inferior hemifield defect in the other. Signs that you may have a visual field defect include: Bumping into things Knocking over objects when reaching Having difficulty reading Getting into a car accident In the example provided in Fig. 7. Present stimuli consisting of dots of white light projected one at a time onto the screen, randomly presented (not moving). Pearls Similar to bitemporal hemianopia, the presenting ocular manifestation is dependent on the type of tropia involved. 3.3.3 Interpreting the Visual Field Test We report a patient who had an ischemic stroke with a pure bilateral superior altitudinal hemianopia resulting from bilateral ischemia in the optic radiation. 3.2 Techniques to Evaluate the Visual Field 12. 3.4 Topographic Diagnosis of Visual Field Defects. The result is a completely blind region of the patient's vision at the point of fixation. 100 to 110 degrees temporally. 3.29). Visual Field Defects Symptoms Vision loss in one eye may indicate a problem in the eye, whereas the same visual field defect in both eyes may signal a problem in the brain. 3.21 show different homonymous hemianopias. Cortisol and other glucocorticoids have many systemic effects, which include immunosuppression, diabetes due to increased gluconeogenesis, hypertension caused by partial mineralocorticoid effects, osteoporosis from inhibition of bone formation and calcium resorption, elevated intraocular pressure (IOP), among many others. In this case report, a woman presented with seizures secondary to haemorrhagic infarction of the anterior part of the parieto-occipital sulcus. 4. And these will respect the horizontal midline. The nasal fibers of the ipsilateral eye (53% of all fibers) cross in the chiasm to join the uncrossed temporal fibers (47% of all fibers) of the contralateral eye. The diagnosis is confirmed by CT or MRI. Visual fields should be tested monocularly given that the overlap in binocular fields may mask visual field defects. Neuro-ophthalmology Illustrated-2nd Edition. A contralateral homonymous hemianopia that is small and centrally located. 3.25). The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. Because the symptoms in males are more subtle, pituitary adenomas tend to be detected later in males than in females. Altitudinal hemianopia comprises defective vision in the upper or lower horizontal half of the visual field. If the presenting symptom is sudden monocular visual loss, a pituitary adenoma may be acutely missed, as other more common etiologies are evaluated. Most ophthalmologic complaints are secondary to mass effects caused by macroadenomas. Lesions of the optic radiations typically produce a contralateral homonymous hemianopia, worse superiorly when the lesion is in the temporal lobe and worse inferiorly when the lesion is in the parietal lobe. Liu L, Liu ZX, Liu YS, Liu JF, Zeng Y, Zeng ZC, Wang M, Wang H, Zeng CM, Jiang XJ, Chen X, Yang SG. 3. Relative to the point of fixation: The upper visual field falls on the inferior retina (below the fovea). 4. Although the anatomical presence of Wilbrands knee is debated, junctional scotomas are observed clinically. The ability of the patient to perform the test can be evaluated by measurements of reliability reported on the printout. Central, Cecocentral, Paracentral, Arcuate/Sector, Nasal Step, Altitudinal, Enlarged blind spots, Temporal Crescent Defect. 4. It may be unilateral or bilateral; unilateral field defect is prechiasmal. The trusted provider of medical information since 1899. 3. Results must be interpreted critically (reliability and repeatability) and in conjunction with other clinical signs, symptoms and examination findings. [25] When a filter is placed in front of one eye and a moving object at a constant distance away is viewed, the person perceives the object as having depth, when in reality it is moving in the same plane. The pattern on the devia- . [46], Moreover, the visual outcome is also affected by the preoperative peripapillary retinal nerve fiber layer thickness- for example, preoperative temporal peripapillary retinal nerve fiber layer thickness 60 m and inferior peripapillary retinal nerve fiber layer thickness 105 m are associated with postoperative visual field index > 90% and a postoperative visual acuity of at least 20/25, respectively.[47]. [43] The outcome is affected by the severity of symptoms - for example, sudden ophthalmoplegia due to pituitary apoplexy would have a different result than a slow-growing prolactinoma. Mslman AM, Cansever T, Ylmaz A, Kanat A, Oba E, avuolu H, Sirinolu D, Aydn Y. Surgical results of large and giant pituitary adenomas with special consideration of ophthalmologic outcomes. Because this is not an autoimmune process, the hyperthyroid state induced by these adenomas is not associated with thyroid eye disease. 3. Thieme. What field defects results from ischemia limited to of the tip of an occipital lobe? Patients with acute optic neuritis typically present with acute loss of vision. Transcription factors are helpful in determining if the tumor is actually two or more separate tumors in the same area, or if the tumor actually co-expresses two different pituitary hormones. - hypothyroidism . Bowtie atrophy of the right optic nerve 2. difficulty . 13. Mostly temporal pallor of the left optic nerve from atrophy of the temporal retina in the left eye. Scotoma - this is a type of visual field defect. A follow-up of 52 patients. 5. Personnier C, Cazabat L, Bertherat J, Gaillard S, Souberbielle JC, Habrand JL, Dufour C, Clauser E, SainteRose C, Polak M. Clinical features and treatment of pediatric somatotropinoma: case study of an aggressive tumor due to a new AIP mutation and extensive literature review. For example, a small detachment in the inferior retina results in a small superior visual field defect, while a large temporal detachment causes extensive nasal field loss. The lesion may be anywhere along the optic pathway; retina to occipital cortex. Deep lesions of the parietal lobe often impair optokinetic nystagmus when stimuli are moved in the direction of the damaged parietal lobe. The code is valid during the fiscal year 2023 from October 01, 2022 through September 30, 2023 for the submission of HIPAA-covered transactions. The patient should perform the task equally well in all four quadrants. Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. 3. [5], Thyrotrophic tumors can be treated with octreotide due to the presence of somatostatin receptors on the tumor. 3.1). The numeric grid just to the right of the measurements of reliability is a presentation of the threshold level in decibels for all points checked in the patients visual field. Ask the patient to signal detection of the white dot by pressing a buzzer. She later presented with right-sided visual disturbance; her examination confirmed temporal crescent syndrome. The optic nerve in altitudinal visual field loss may show sector or diffuse edema, be normal, or show optic atrophy. [24], Pituitary adenomas that compress on the chiasm can often produce a slow decrease in visual function. Some atrophy is reported to be present in approximately 50% of pituitary lesions with visual field defects. Octreotide has the most effect on tumor shrinkage, and pegvisomant has no effect on tumor size or growth hormone secretion but may have better effect on the overall systemic effects of elevated growth hormone. Nasal half of the macula of the right eye ([1red] in Fig. The altitudinal defect can be . Complete homonymous hemianopias may occur with any lesion of the retrochiasmal visual pathways and do not allow precise localization of the lesion along the retrochiasmal visual pathways. The main symptom of hemianopia is losing half of your visual field in one or both eyes. If it respects the vertical meridian, is the defect bitemporal or homonymous? [33], Microadenomas are best seen on unenhanced T1-weighted coronal or sagittal scans. Octreotide therapy for thyroid-stimulating hormone-secreting pituitary adenomas. Bone window scans help assess erosions and extensions into the sphenoid sinus. If it is homonymous, is the defect complete or incomplete? 3.8). Because the spatial relationships in the retinas are maintained in central visual structures, a careful analysis of the visual fields can often indicate the site of neurological damage. 3.1). At present, The test involves the following steps: Bilateral hypertensive optic disc edema in the setting of Cushing's disease may mimic papilledema. They derive from Pit-1 lineage and can express thyroid-stimulating hormone (TSH), which induces the thyroid gland to produce thyroid hormone (thyroxine). Where is the lesion of a junctional scotoma? Thieme Thieme LH deficiency is manifested by decreased energy and libido in men due to decreased testosterone levels, and amenorrhea in premenopausal women. The visual loss can be due to a unilateral or bilateral optic neuropathy, bitemporal hemianopsia from chiasmal compression, or rarely homonymous hemianopsia from optic tract involvement. What is the visual field defect of a junctional scotoma? This non-invasive test examines your fields of vision, and it is important for identifying vision problems that could be signs of eye disease or conditions that affect the brain (like a stroke). 2. Lesion groups 1 and 2 result in a bowtie pattern of optic atrophy (Fig. A right RAPD (contralateral to lesion) because more fibers (53%) in the optic tract come from the opposite eyes nasal retina, having crossed in the chiasm. Two cases of generalised visual-field loss are presented, binocular loss in a girl with LCA and monocular loss in a boy with optic nerve hypoplasia. [40][41], The following are some of the indications for surgical debulking of a pituitary adenoma:[42][43][44][45], Surgical debulking in a timely fashion (within 6 months of onset of visual symptoms) has been shown to normalize or improve visual acuity as well as improve visual field with rare worsening or severe surgical complication. 1. 3.4). These tumors can also have decreased pituitary hormones, most commonly related to decreased LH. 1. Examination of the visual fields helps to localize and identify diseases affecting the visual pathways (Fig. 60 degrees nasally Bowtie atrophy of the right optic nerve from atrophy of fibers supplying the nasal half of the macula and nasal retina of the right eye. [3] Most prolactinomas are sparsely granulated; on histology these tumor cells are weakly acidophilic or chromophobic. Biousse V and Newman NJ. What are the findings of an occlusion of the posterior cerebral artery? Enter search terms to find related medical topics, multimedia and more. Is the test reliable (as indicated by the technician for Goldmann visual fields and by the reliability parameters for automated perimetry)? H53.439 is a billable ICD-10 code used to specify a medical diagnosis of sector or arcuate defects, unspecified eye. The link you have selected will take you to a third-party website. Medical treatment is considered the primary treatment for prolactinomas. In this case report, a woman presented with seizures secondary to haemorrhagic infarction of the anterior part of the parieto-occipital sulcus. Place the patients head on a chin rest in front of a computer screen. (This rule does not apply to optic tract lesions that are suspected when the homonymous hemianopia is associated with a RAPD on the side of the hemianopia and bilateral optic nerve pallor). Testing strategies for visual fields are discussed below. 2. Reddy R, Cudlip S, Byrne JV, Karavitaki N, Wass JA. As such, they tend to become symptomatic when they grow large enough to cause the associated neurological symptoms of pituitary tumors. Two patterns of visual field loss occur when the lesion is secondary to an ischemic lesion in the territory of the choroidal arteries (anterior or posterior) (Fig. The higher the number, the better the vision at that point in the field. There is no effective treatment. 6. 3.2 Techniques to Evaluate the Visual Field. Occipital Lobe: Sparing the Temporal Crescent 2. Place the patients head on a chin rest on the open side of a white hemispheric bowl. Central Retinal Artery Occlusion and Branch Retinal Artery Occlusion. Once the lesion is localized anatomically, a directed workup looks for an etiology. 7. Modest elevations in prolactin however can occur without prolactin secreting tumor because of the effect of compression of the stalk (removing the inhibition from dopamine) and is called the stalk effect. These numbers are then converted to a gray scale representation of the field (upper right, Fig. 3. [5] While some forms of pituitary adenoma can be managed medically, most pituitary adenomas that have demonstrable visual field loss are treated surgically. Management of prolactinomas is often in conjunction with an endocrinologist in regards to medication administration and decisions regarding indication for surgical resection. Fixation Loss 20% ACTH triggers the adrenal glands to secrete cortisol. 6. Preoperative MRI evaluation of pituitary macroadenoma: imaging features predictive of successful transsphenoidal surgery. We do not control or have responsibility for the content of any third-party site. 3.10), which provides a gross picture of the size and severity of the field defects present. Rarely these cells will be strongly acidophilic and are classified as densely granulated prolactinomas. [36], Cabergoline is a newer medication that also binds to D2 dopamine receptors. In adolescents, elevated prolactin levels can delay puberty. This is often performed with the guidance of an endocrinologist. 2003. Pituitary or sella sequence magnetic resonance imaging (MRI) with and without contrast is the study of choice for most sellar and parasellar lesions, but high-resolution CTs with fine cuts (1.5-3 mm) have also been shown to be very helpful in the differential diagnosis especially if calcification is seen (e.g., craniopharyngioma or meningioma). The cytoplasm of these cells may be acidophilic, basophilic, or chromophobic, and is generally uniform in its appearance. An embolic infarction of either a distal MCA or PCA branch can result in exclusive ischemia of the tip of the occipital lobe, thereby producing a small homonymous scotomatous defect if there is inadequate collateral circulation (Fig. 6. 2012. Occipital Lobe: Bilateral _____________________________________________________. The tangent screen is rarely used and is primarily helpful for evaluating patients suspected of nonorganic constriction of the visual field (Fig. The patient. Tumor extension into the cavernous sinus can affect cranial nerves III, IV, V, or VI and produce a limited or total cavernous sinus syndrome. 14. 3.3 Interpretation of a Visual Field Defect Lateral Geniculate Nucleus If the middle cerebral artery is patent when the PCA is occluded, this focal area of the occipital lobe may be spared. When the macula . Sudden expansion of the pituitary mass into the cavernous sinus can cause sudden ophthalmoplegia and facial hypoesthesia due to compression of cranial nerves III, IV, V, and VI, with cranial nerve III being affected most commonly. A consistent difference in color perception (use a red object) across the horizontal or vertical meridian may be the only sign of an altitudinal or hemianopic defect, respectively. The patient sits 1m from a black screen (mounted on a wall) on which there are concentric circles. 8. The only constant symptom is painless vision loss. [19] Acromegaly most commonly occurs from DGSA. 7. Present stimuli consisting of dots of white light projected one at a time onto the inner surface of the bowl, usually moving from the unseen periphery into the patients field of view. 7. [5], Characteristically lesions at the level of the optic chiasm produce a bitemporal hemianopia. [6], In children who have bony epiphyses that have not yet closed, GH and IGF-I cause gigantism. Enter the email address you signed up with and we'll email you a reset link. [3] One review found an average incidence of 16.7% (14.4% in autopsy studies and 22.5% in radiologic studies). An embolic infarction of either a distal MCA or PCA branch can result in exclusive ischemia of the tip of the occipital lobe, thereby producing only a small homonymous hemianopia if there is inadequate collateral circulation. 5. Righi A, Agati P, Sisto A, Frank G, Faustini-Fustini M, Agati R, Mazzatenta D, Farnedi A, Menetti F, Marucci G, Foschini MP. It can quickly establish the pattern of visual field loss in the ill, poorly attentive, or elderly patient who requires continued encouragement to maintain fixation and respond appropriately. [6], There are many complications associated with excess growth hormone, including:[3][4][5]. Pituitary adenomas are a collection of tumors that arise from the pituitary gland. What field defects results from ischemia limited to of the tip of an occipital lobe? Is the test reliable (as indicated by the technician for Goldmann visual fields and by the reliability parameters for automated perimetry)? 3.26). Symptoms include night blindness and loss read more or another peripheral retinal disorder, chronic papilledema, following panretinal photocoagulation, central retinal artery occlusion Central Retinal Artery Occlusion and Branch Retinal Artery Occlusion Central retinal artery occlusion occurs when the central retinal artery becomes blocked, usually due to an embolus. 11.
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