Displaying publications 61 - 80 of 105 in total

  1. Abdulkarim, S.M., Ghazali, H.M.
    HyperDSC™(fast scan rate) was used to study the melting behavior of canola (CLO), sunflower (SFO), palm olein (PO), rice bran oils (RBO), and cocoa butter (CB), and was compared to the melting behaviors using conventional DSC. There was an increase in sensitivity with increase in scan rate. Slow scan rate (5 to 20C/min) gave low sensitivity, which increased when the scan rates were increased to 50, 100 and 200C/min. Peak resolution was affected by scan rate depending on the sample weight. Increase in the size of sample coupled with the use of fast scan rate decreased the peak resolution. Generally small sample sizes gave better peak resolution. Results of the effect of scan rate on glass transition (Tg) shows that Tg, which is a weak transition especially in crystalline and low amorphous materials was not detected using conventional scan rates (5 to 20oC/min). It was however detected using of hyperDSC™ scan rates (100 to 200oC/min). Increasing the scan rate resulted in an increase in the peak temperature and the elimination of shoulder peaks, which were caused due to the polymorphic behavior of the triacylglycerols in the oils. The increase in peak temperature caused a shift in the peak position towards a higher temperature value. There is a positive correlation between the peak temperature and scan rate. The correlation coefficients (r) for CLO, SFO, PO, RBO and CB were 0.96, 0.95, 0.97, 0.96 and 0.96 respectively.
    Matched MeSH terms: Shoulder
  2. Ho W, Lin Seow L, Musawi A
    J Clin Transl Res, 2018 May 28;4(1):70-74.
    PMID: 30873496
    Background: The purpose of the present study was to investigate the effect of different viscosities of polyvinyl siloxane (PVS) impression materials on the accuracy of the stone die produced.

    Methods: A three-unit bridge master model was fabricated using cold-cure acrylic resin. Four combinations of different viscosities of PVS impression materials - regular body (monophase) alone, light body with regular body, light body with heavy body, and light body with putty - were used to make an impression of the master model. Ten impressions from each group were taken and Type IV gypsum stone was used to generate the dies. The dies were measured at the inter-abutment distance, occlusogingival length, and shoulder width with a measuring microscope and were compared with the master model using one-way analysis of variance and Tukey (honest significant difference) test.

    Results: Differences were found for inter-abutment distance between the master model and the light body with regular body and light body with putty dies (both P < 0.02). A difference was found for shoulder width between the master model and the regular body alone die (P = 0.01). No differences were found for occlusogingival distance (all P > 0.08).

    Conclusion: Results suggested inter-abutment distance was most accurate when using a PVS light body combination. Occlusogingival length was accurate using any of the studied PVS combinations, and shoulder width was more accurate when using the regular body PVS.

    Relevance for patients: These results should be considered when choosing the viscosity of the PVS to use for producing impressions of high accuracy and fabricating a well-fitting fixed prosthesis.

    Matched MeSH terms: Shoulder
  3. Yeak RD, Daud H, Nizlan NM
    Chin. J. Traumatol., 2019 Jun;22(3):182-185.
    PMID: 31060897 DOI: 10.1016/j.cjtee.2019.03.004
    Acromioclavicular joint (ACJ) injury is a common shoulder injury. There are various techniques of ACJ reconstruction. Superficial infection after ACJ reconstruction is not an uncommon complication. However, osteomyelitis post ACJ reconstruction has never been highlighted as a possible complication. Our patient is a 31-year-old male who sustained a Rockwood 5 ACJ dislocation and had anatomical ACJ reconstruction with autogenous gracilis and semitendinosus graft. Our technique involved the anatomical reconstruction of the ACJ and the coracoclavicular ligament with the usage of two bioscrews and the temporary stabilisation of the ACJ with two k-wires. As in any orthopaedic surgery, infection is often disastrous especially when the surgery involves implants. It can be disastrous with high morbidity to the patient as well as a costly complication to treat. Therefore, we wish to highlight this case as despite its rarity, osteomyelitis can be devastating to the patient and should be prevented if possible.
    Matched MeSH terms: Shoulder Dislocation
  4. Teo Chuun, B., Dian Darina Indah, D., Darliana, M.
    This study is aimed at seat design optimization for high-speed train based on the Malaysians sitting anthropometry
    data focusing on seat fit parameters. An analysis of anthropometry data composed of 15 dimensions that are
    required in seat design was done with 50 male subjects. These data were collected through direct measuring
    methods with standard equipment. According to the Malaysian automotive seat fit parameters, the backrest width,
    backrest height, cushion width, and cushion length were established based on these anthropometric dimensions:
    interscye breadth (5th percentile female and 95th percentile male), hip breadth (95th percentile female), sitting
    shoulder height (5th percentile female), and buttock-popliteal length (5th percentile female), respectively. This
    study uses the CATIA software to design and analyse the proposed seat design. The fit parameters proposed for the
    new design are seat height, 380mm; cushion width, 450mm; backrest width, 450mm and backrest height, 850mm.
    The CATIA human activity analysis (based on Rapid Upper Limb Analysis, RULA) was also executed. From the study,
    the new conceptual seat design gives the most optimized fit when compared to the current seat.
    Matched MeSH terms: Shoulder
  5. Kongcharoensombat W, Wattananon P
    Malays Orthop J, 2018 Nov;12(3):1-5.
    PMID: 30555639 DOI: 10.5704/MOJ.1811.001
    Introduction: The anterolateral acromion approach of the shoulder is popular for minimally invasive plate osteosynthesis (MIPO) technique. However, there are literatures describing the specific risks of injury of the axillary nerve using this approach. Nevertheless, most of the studies were done with Caucasian cadavers. So, the purpose of this study was to evaluate the risk of iatrogenic axillary nerve injury from using the anterolateral shoulder approach and further investigate the location of the axillary nerve, associated with its location and arm length in the Asian population that have shorter arm length compared to the Caucasian population. Materials and Methods: Seventy-nine shoulders in fourty-two embalmed cadavers were evaluated. The bony landmarks were drawn, and a vertical straight incision was made 5cm from tip of the acromion (anterolateral approach), to the bone. The iatrogenic nerve injury status and the distance between the anterolateral edge of the acromion to the axillary nerve was measured and recorded. Results: In ten of the seventy-nine shoulders, the axillary nerve were iatrogenically injured. The average anterior distance was 6.4cm and the average arm length was 30.2cm. The anterior distance and arm length ratio was 0.2. Conclusion: Our results demonstrated that the recommended safe zone at 5cm from tip of acromion was not suitable with Asian population due to shorter arm length, compared to Caucasian population. The location of axillary nerve could be predicted by 20% of the total arm-length.
    Matched MeSH terms: Shoulder
  6. Usman J, McIntosh AS, Quarrie K, Targett S
    J Sci Med Sport, 2015 Sep;18(5):529-33.
    PMID: 25156881 DOI: 10.1016/j.jsams.2014.07.020
    Shoulder injuries in rugby union football have been the focus of few in-depth studies, despite their frequency and severity. The study's objective was to describe the incidence, patterns and mechanisms of shoulder injuries in rugby.
    Matched MeSH terms: Shoulder/injuries*
  7. Joseph LH, Hussain RI, Pirunsan U, Naicker AS, Htwe O, Paungmali A
    Acta Orthop Traumatol Turc, 2014;48(2):169-74.
    PMID: 24747625 DOI: 10.3944/AOTT.2014.3184
    The aim of this study was to investigate the intra- and inter-rater reliability of ultrasonography (US) to measure anterior translation of the humeral head (ATHH) among healthy subjects and patients with sacroiliac joint dysfunction.
    Matched MeSH terms: Shoulder Joint/ultrasonography*
  8. Henry LJ, Jafarzadeh Esfehani A, Ramli A, Ishak I, Justine M, Mohan V
    Asia Pac J Public Health, 2015 Mar;27(2):NP1785-92.
    PMID: 23417907 DOI: 10.1177/1010539513475657
    This study investigated the patterns of ongoing work-related musculoskeletal disorders (WRMDs) and exposure risk to musculoskeletal injuries for various body regions among palm plantation workers. Standard Nordic Musculoskeletal Questionnaire (SNMQ) was used to assess the prevalence of musculoskeletal disorders symptoms. The Quick Exposure check (QEC) was used to assess the exposure risk of farmers to WRMDs. The common pattern of WRMDs was back pain (40%), followed by shoulder pain (19%). The QEC revealed high exposure risk for neck (56%), followed by back (45.6%). The results from the SNMQ showed that 58% reported pain in 1 region, followed by 2 regions (10.7%) and 3 regions (3.6%). Back pain and shoulder pain were found to be common among workers in palm plantation occupation. Nevertheless, the neck region appeared to have the highest risk of exposure to injuries.
    Matched MeSH terms: Shoulder Pain/epidemiology
  9. Kwan MK, Chan CY
    Eur Spine J, 2016 10;25(10):3065-3074.
    PMID: 27021616
    PURPOSE: To investigate whether an optimal upper instrumented vertebra (UIV) tilt angle would prevent 'lateral' shoulder imbalance or neck tilt (with 'medial' shoulder imbalance) post-operatively.

    METHODS: The mean follow-up for 60 AIS (Lenke 1 and Lenke 2) patients was 49.3 ± 8.4 months. Optimal UIV tilt angle was calculated from the cervical supine side bending radiographs. Lateral shoulder imbalance was graded using the clinical shoulder grading. The clinical neck tilt grading was as follows: Grade 0: no neck tilt, Grade 1: actively correctable neck tilt, Grade 2: neck tilt that cannot be corrected by active contraction and Grade 3: severe neck tilt with trapezial asymmetry >1 cm. T1 tilt, clavicle angle and cervical axis were measured. UIVDiff (difference between post-operative UIV tilt and pre-operative Optimal UIV tilt) and the reserve motion of the UIV were correlated with the outcome measures. Patients were assessed at 6 weeks and at final follow-up with a minimum follow-up duration of 24 months.

    RESULTS: Among patients with grade 0 neck tilt, 88.2 % of patients had the UIV tilt angle within the reserve motion range. This percentage dropped to 75.0 % in patients with grade 1 neck tilt whereas in patients with grade 2 and grade 3 neck tilt, the percentage dropped further to 22.2 and 20.0 % (p = 0.000). The occurrence of grade 2 and 3 neck tilt when UIVDiff was <5°, 5-10° and >10° was 9.5, 50.0 and 100.0 %, respectively (p = 0.005). UIVDiff and T1 tilt had a positive and strong correlation (r2 = 0.618). However, UIVDiff had poor correlation with clavicle angle and the lateral shoulder imbalance.

    CONCLUSION: An optimal UIV tilt might prevent neck tilt with 'medial' shoulder imbalance due to trapezial prominence and but not 'lateral' shoulder imbalance.

    Matched MeSH terms: Shoulder/physiopathology*
  10. Amir D, Yaszay B, Bartley CE, Bastrom TP, Newton PO
    Spine, 2016 Jul 15;41(14):1122-7.
    PMID: 26863257 DOI: 10.1097/BRS.0000000000001497
    STUDY DESIGN: Retrospective review of prospective data.

    OBJECTIVE: To determine if surgically leveling the upper thoracic spine in patients with adolescent idiopathic scoliosis results in level shoulders postoperatively.

    SUMMARY OF BACKGROUND DATA: Research has shown that preoperatively tilted proximal ribs and T1 tilt are more correlated with trapezial prominence than with clavicle angle.

    METHODS: Prospectively collected Lenke 1 and 2 cases from a single center were reviewed. Clinical shoulder imbalance was measured from 2-year postoperative clinical photos. Lateral shoulder imbalance was assessed utilizing clavicle angle. Medial imbalance was assessed with trapezial angle (TA), and trapezial area ratio (TAR). First rib angle, T1 tilt, and upper thoracic curve were measured from 2-year radiographs. Angular measurements were considered level if ≤ 3° of zero. TAR was considered level if ≤ 1 standard deviation of the natural log of the ratio. Upper thoracic Cobb at 2-years was categorized as at or below the mean value (≤ 14°) versus above the mean.

    RESULTS: Eighty-four patients were identified. There was no significant difference in the percentage of patients with a level clavicle angle or TAR based on first rib being level, T1 tilt being level, or upper thoracic Cobb being at/below versus above the mean (P shoulders or clavicles. Trapezial prominence was impacted by leveling T1 and the first rib and by minimizing the upper thoracic curve. How to achieve laterally balanced shoulders postoperatively remains unclear.


    Matched MeSH terms: Shoulder/surgery*
  11. Singh S, Yong CK, Mariapan S
    J Shoulder Elbow Surg, 2012 Dec;21(12):1706-11.
    PMID: 22819577 DOI: 10.1016/j.jse.2012.04.004
    To perform closed manual reduction of acute anterior shoulder dislocation using the traction-countertraction technique requires sedation (TCTS) and the participation of 2 people. We studied the modified Milch (MM) technique, a positional reductive maneuver that requires 1 operator, without patient sedation or analgesia.
    Matched MeSH terms: Shoulder Dislocation/therapy*
  12. Mansor A, Arumugam K, Omar SZ
    PMID: 20042263 DOI: 10.1016/j.ejogrb.2009.12.003
    To determine if shoulder dystocia can be predicted in babies born weighing 3.5 kg or more.
    Matched MeSH terms: Shoulder*
  13. Omar N, Abidin FZ, Das S, Abd Ghafar N, Haji Suhaimi F, Abd Latiff A, et al.
    Morphologie, 2010 May;94(305):36-9.
    PMID: 20359930 DOI: 10.1016/j.morpho.2010.03.001
    The latissimus dorsi is a muscle of the back which forms the posterior fold of the axilla and its tendon twists to insert into the floor of the intertubercular sulcus of the humerus. Occasionally, the muscle has a muscular slip which crosses the axilla to insert into the pectoralis major. This muscular slip is often termed as "axillary arch." In the present study, we report bilateral axillary arch detected in a 45-year-old male cadaver. The average vertical length of the axillary arch measured 7 cm. The average maximum width of the uppermost, middle and lower part of the arch measured 2, 3.5 and 3.2 cm, respectively. The presence of the axillary arch is an uncommon finding in humans, considering the fact that it is solely found in the animals who prefer to hang on the trees. A histological study of the axillary arch was also performed and it showed skeletal muscle fibres which was uniformly arranged. The presence of the axillary arch may assist in the adduction of the shoulder. It may also compress the axillary vessels and nerves thereby causing resultant symptoms. Prior anatomical knowledge of the presence of axillary arch may be helpful for surgeons performing radical dissection of the axillary lymph nodes and ligation of axillary vessels, clinicians diagnosing abduction syndromes and interventional radiologists interpreting axillary mass in day to day clinical practice.
    Matched MeSH terms: Shoulder/anatomy & histology
  14. Miswan MF, Saman MS, Hui TS, Al-Fayyadh MZ, Ali MR, Min NW
    J Orthop Surg (Hong Kong), 2017 01;25(1):2309499017690317.
    PMID: 28215115 DOI: 10.1177/2309499017690317
    INTRODUCTION: We conducted a study to elucidate the correlation between the anatomy of the shoulder joint with the development of rotator cuff tear (RCT) and glenohumeral osteoarthritis (GHOA) by using acromioglenoid angle (AGA).

    MATERIALS AND METHODS: The AGA is a new measured angle formed between the line from midglenoid to lateral end of the acromion with the line parallel to the glenoid surface. The AGA was measured in a group of 85 shoulders with RCT, 49 with GHOA and 103 non-RCT/GHOA control shoulders. The AGA was compared with other radiological parameters, such as, the critical shoulder angle (CSA), the acromion index (AI) and the acromiohumeral interval (AHI). Correlational and regression analysis were performed using SPSS 20.

    RESULTS: The mean AGA was 50.9° (45.2-56.5°) in the control group, 53.3° (47.6-59.1°) in RCT group and 45.5° (37.7-53.2°) in OA group. Among patients with AGA > 51.5°, 61% were in the RCT group and among patients with AGA < 44.5°, 56% were in OA group. Pearson correlation analysis had shown significant correlation between AGA and CSA ( r = 0.925, p < 0.001). It was also significant of AHI in RCT group with mean 6.6 mm (4.7-8.5 mm) and significant AI in OA group with mean 0.68 (0.57-0.78) with p value < 0.001 respectively.

    CONCLUSION: The AGA method of measurement is an excellent predictive parameter for diagnosing RCT and GHOA.

    Matched MeSH terms: Shoulder Joint*
  15. Labao HC, Faller EM, Bacayo MFD
    Ann Glob Health, 2018 08 31;84(3):474-480.
    PMID: 30835403 DOI: 10.29024/aogh.2331
    BACKGROUND AND PURPOSE: Musculoskeletal disorders (MSDs) are alarmingly high among migrant workers in Malaysia. MSDs are the most prevalent occupational-related conditions in most parts of the world affecting function, productivity and overall health-related quality of life. Therefore, this study aims to determine the profile of Filipino migrant workers in Malaysia and their various musculoskeletal complaints.

    METHOD: This study utilized a quantitative, nonexperimental, cross-sectional research design. A total of 60 subjects were randomly selected after passing the study's sampling criteria. The Nordic Musculoskeletal Questionnaire (NMQ) was to used to determine common MSDs affecting the various regions in the body. The Demographic Pofile Sheet was provided to gather a subject's demographic characteristics.

    RESULTS: Filipino migrant workers mostly complain of pain in the low back area (60%) and shoulder pain (60%), followed by pain in the upper back (48.3%) and neck pain (45%) in the last 12 months. Household workers accounting for 73.3% of the subjects commonly complain of pain in the hips/thighs (78.9%), while workers in the service industry commonly complain of knee pain (39.1%).

    CONCLUSIONS: Results imply that Filipino migrant workers have a higher prevalence of shoulder and lower back pain in the last 12 months. Household workers are more susceptible to hip/thigh pain. Interventions focusing on ergonomics policy implementation, education on posture and lifting techniques and physical function is recommended. Further studies should consider the psychological and psychosocial aspects of migrant employment, which are known risk factors for MSDs.

    Matched MeSH terms: Shoulder; Shoulder Pain
  16. Amin NA, Nordin R, Fatt QK, Noah RM, Oxley J
    PMID: 25852937 DOI: 10.1186/s40557-014-0023-2
    OBJECTIVE: This study examined the relationships between psychosocial work factors and risk of WRMSDs among public hospital nurses in the Klang Valley, Malaysia.

    METHODS: We conducted a cross-sectional study among 660 public hospital nurses. A self-administered questionnaire was used to collect data on the occurrence of WRMSDs according to body regions, socio-demographic profiles, occupational information and psychosocial risk factors. 468 questionnaires were returned (response rate of 71%), and 376 questionnaires qualified for subsequent analysis. Univariate analyses were applied to test for mean and categorical differences across the WRMSDs; multiple logistic regression was applied to predict WRMSDs based on the Job Strain Model's psychosocial risk factors.

    RESULTS: Over two thirds of the sample of nurses experienced discomfort or pain in at least one site of the musculoskeletal system within the last year. The neck was the most prevalent site (48.94%), followed by the feet (47.20%), the upper back (40.69%) and the lower back (35.28%). More than 50% of the nurses complained of having discomfort in region one (neck, shoulders and upperback) and region four (hips, knees, ankles, and feet). The results also revealed that psychological job demands, job strain and iso-strain ratio demonstrated statistically significant mean differences (p shoulders and upper back) and region 4 (hips, knees, ankles, and feet). All demographic variables except for years of employment were statistically and significantly associated with WRMSDs (p

    Matched MeSH terms: Shoulder
  17. Adib Asmawi Mohd Yusoff, Irniza Rasdi, Ahmed S. Mahmoud Ben Hameid, Karmegam Karuppiah
    Ergonomic is important in classroom. Sitting for protracted period in class may lead students to develop musculoskeletal disorders. Their physical health and performance in the class may increase by designing school furniture that match with human body. In Malaysia, there is a lack of ergonomic assessment for school environment especially in urban areas. The aim of this study is to determine the mismatch between the furniture dimension and anthropometric parameters among primary school children in Putrajaya. This is a cross-sectional study which involved 100, Year 1 and Year 6 primary school students randomly selected in Putrajaya. Five anthropometric measurements (popliteal height, buttock popliteal length, elbow height, shoulder height (sitting), hip breadth) as well as five furniture dimensions (seat height, seat depth, seat width, backrest height and seat to desk height) were measured. Instrument used is Martin type anthropometer set, SECA body meter, and SECA weighing scale. Calculation for determining mismatch between the furniture and anthropometric measures were calculated using a standard mismatch formula. There was 100% mismatch for seat height, seat depth, and seat to seat to desk height for Year 1. As for Year 6, mismatch was reported 100% for backrest height and seat to desk height. There were significance difference for parameters of popliteal height between Year 1 and Year 6 and between male and female of Year 1. There was a presence of mismatch between furniture dimension and children anthropometric measurement. Proposed dimension of furniture shows decrease in percentage of mismatch for the most parameter of anthropometric measurement.
    Matched MeSH terms: Shoulder
  18. Mirta Widia, Siti Zawiah Md Dawal, NukmanYusoff
    Extensive research has been carried out over the years to determine the maximum acceptable weight that a worker is capable of lifting in a given situation among the Occidental populations in the Europe and US. At present, there is a scarcity of studies in which lifting frequency is used as the measuring variable, especially in developing countries such as Malaysia. Therefore, the objective of this study is to determine the effects of lifting loads on the maximum acceptable frequency limit (MAFL), physiological response (muscle activity) and rating of perceived exertion (RPE) for asymmetric lifting and lowering tasks of Malaysian males.Ten male subjects are recruited in this study and they perform asymmetric lifting and lowering tasks repetitively for 30 minutes. Two lifting loads are considered (1) 1 kg and (2) 5 kg. Each of the subjects adjusts his frequency of lifting using a psychophysical approach. The subjects are instructed to perform the lifting and lowering task as fast as they could over duration of 30 minutes without exhausting themselves or becoming overheated. Electromyography (EMG) signals are recorded from four muscles (Right Erector Spinae (RES), Left Erector Spinae (LES), Right Trapezius p Descendenz (RTD) and Left Trapezius p Descendenz (LTD) and analysed in terms of the normalized MVC during asymmetric lifting and lowering tasks. The ratings of perceived exertion (RPE) for four body parts (arms, lower back, shoulders and entire body) are also collected after the subjects have completed the lifting and lowering task. The mean frequency of the lifting and lowering task obtained from the experiment is 13.41 and 9.66 times/minute for a lifting load of 1 and 5 kg, respectively. The results of the independent sample t-test show that load has a statistically significant effect on the maximum acceptable frequency limit (p < 0.05). However, it is found that even though there is an increase in muscle activity and RPE with an increase in lifting load, there is no significant difference in the overall mean muscle activity and RPE (p > 0.05). The percentage decrease in the maximum acceptable frequency for Malaysian males is higher than the Occidental populations for both of the loads investigated in this study.
    Matched MeSH terms: Shoulder
  19. Ng CK, Azuhairy A, Tan LH, Nordin A
    Malays Orthop J, 2015 Jul;9(2):51-53.
    PMID: 28435611 MyJurnal DOI: 10.5704/MOJ.1507.001
    Chondrosarcoma is the third most common primary tumour of the bone, after myeloma and osteosarcoma. Most of the chondrosarcoma grow slowly and rarely metastasize, and they have an excellent prognosis after adequate surgery. However most of them are chemo or radio-resistant. We report a case of primary chondrosarcoma of proximal humerus in a 36-year-old female who presented with a six years history of left shoulder swelling and restricted range of motion. Trucut biopsy showed a well-differentiated chondrosarcoma. The patient underwent forequarter amputation of left upper limb and was started on chemotherapy following operation.
    Matched MeSH terms: Shoulder
  20. Mohd Sallehuddin H, Zamzuri Z, Ariff MS, Mohd Shukrimi A, Mohamed Azril MA, Nazri MY
    Introduction: This is a cross-sectional study of 37 patients with AO type C (complete intra-articular) fractures of the distal radius, evaluating the functional, anatomical, and patient rated outcomes one year after primary fixation with a volar locking plate.

    Methods: Functional outcomes were assessed based on the grip strength, and the range of motion of forearm and wrist. Anatomical outcomes were assessed based on the radial inclination, radial height, volar tilt, and articular step or gap. Patient rated outcome was measured with a Disability of arm, shoulder and hand (DASH) questionnaire.

    Results: One year after surgery, 24 (64%) patients achieved good and excellent anatomical results, and DASH scores were acceptable in 73% of patients. Most of the patients had achieved 80% of their grip strength. The mean DASH score of 12.3 was comparable with other studies. Grip strength, radial inclination and volar tilt had a significant correlation with the DASH score.

    Conclusion: Volar locking plates can be used to achieve optimal reduction in all three parameters in the treatment of AO type C fractures of the distal radius. Versatile fracture fragment reduction and angular stability enable rehabilitation hence obtaining good functional outcomes.
    Matched MeSH terms: Shoulder
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