CT scanning - An educational update programme

CT scanning: An educational update 12 November 2013 Registered charity no: 215869

Venue: Stewart House, London 5 CPD credits

Welcome and thank you for coming to the ‘CT scanning: An educational update’ event organised by the British Institute of Radiology.

This booklet contains the abstracts and biographies for each speaker (where supplied).

This meeting has been awarded 5 RCR category I CPD credits. CPD certificates will be distributed by email within 2 weeks of the meeting after the online delegate survey has been completed.

Please complete the online delegate survey using the below link. We will use your valuable feedback to improve future conferences. https://www.surveymonkey.com/s/CT_scanning We hope you find the day interesting and enjoyable.

Lucy Hossen Meeting Organiser Radiation Protection Committee, BIR

We are most grateful to

for supporting this conference

Programme 09:30

Registration and refreshments

09:55

Welcome and introduction

10:00

Overview of use of CT in clinical practise

Nottingham University Hospitals NHS Trust

Dr Simon Hughes, 10:25

10:55

CT dosimetry Dr Elly Castellano, Consultant Clinical Scientist, Royal Marsden NHS Foundation Trust

Refreshments

CT scanners - basics of operation Dr Maria Lewis, Principal Physicist, Guy’s and St Thomas’ NHS Foundation Trust

11:15

11:30 Quality assurance Mr David Platten, Clinical Scientist,

Northampton General Hospital 11:55

IR(ME)R considerations Dr Matt Dunn, Head of Radiology Physics, Nottingham University Hospitals NHS Trust

12:20

Discussion

12:30

Lunch

Breakout group 1 - CT in radiotherapy 13:30 CT preparation for radiotherapy scanning Mrs Sairanne Wickers, Clinical Specialist in Radiotherapy Planning

(Breast and PET-CT), University College London Hospital 14:00 CT parameter selection and optimisation techniques

Dr Tim Wood, Radiation Protection and Diagnostic Imaging Physicist, Hull and East Yorkshire Hospitals NHS Trust

14:30 Coping with tumour motion in treatment planning Mr Neil Roberts, Advanced Practitioner (Pre-Treatment Lead),

St James’s Institute of Oncology

14:45 CT on the linac - use of cone beam CT in image guidance Mr Alan Needham, Radiotherapy Advanced Practitioner,

St James’s Institute of Oncology Breakout group 2 - CT for SPECT and PET 13:30 Patient preparation and examination technique Ms Catherine Murtagh, Senior Grade Radiographer,

Royal Marsden NHS Foundation Trust 14:00 CT parameter selection and optimisation techniques Mr Bruce Walmsley, Principal Physicist,

Guy’s and St Thomas’ NHS Foundation Trust 14:30 Putting the CT back into PET/CT - contrast, CT perfusion and beyond Mr Raymond Endozo, CT Lead and Research Radiographer,

University College Hospital 14:45 CT techniques in multi modality PET MPI - calcium score and

CT coronary angiography Ms Marguerite Du Preez, Radiographer,

University College Hospital 15:00

Refreshments

15:20

Case studies - linking the modalities Dr Bhuey Sharma, Consultant Radiologist, Royal Marsden NHS Foundation Trust

15:50

Discussionee

16:05

Close of meeting

Speaker profiles (where supplied) Dr Elly Castellano Consultant Clinical Scientist, Royal Marsden NHS Foundation Trust Dr Elly Castellano is a Consultant Clinical Scientist working at The Royal Marsden NHS Foundation Trust as head of the diagnostic radiology physics group. Elly was educated in physics and medical physics at the Universities of Oxford, Surrey and London. She trained at St Mary’s Hospital, London, in nuclear medicine, radiotherapy and diagnostic radiology physics, and thereafter specialised in the latter. She is a registered clinical scientist, chartered scientist and chartered radiation protection professional. She is a corporate member of the IPEM, a corporate member of the SRP, and a member of the BIR. She has chaired the CT Users Group, the Diagnostic Radiology Special Interest Group at IPEM and is currently Deputy Director of IPEM’s Science Board.

In addition to her clinical work Elly is active in research with over 20 publications to date. Her main research interests are in CT dosimetry and CT optimisation, although she has several published papers in the fields of mammography and fluoroscopy. She runs the advanced x-ray and CT imaging module of the MSc clinical sciences (medical physics) at King’s College, London, and lectures extensively in the UK and abroad. She is a contributing author to several text books and handbooks on CT and patient radiation dosimetry.

Dr Matt Dunn Head of Radiology Physics, Nottingham University Hospitals NHS Trust Matthew Dunn is currently the Head of Radiology Physics at Nottingham University Hospitals NHS Trust. He is a Radiation Protection Adviser to a range of NHS and independent healthcare providers and a Medical Physics Expert in diagnostic radiology. He has a research interest in the physics and clinical application of computed tomography.

Ms Marguerite Du Preez Radiographer, University College Hospital I am a qualified Radiographer with a B.Radiography degree from the University of Pretoria in South Africa (2000) and a B.Tech in nuclear medicine (2002). I joined the clinical team at the Institute of Nuclear Medicine at University College London Hospital in 2009. I am involved in all aspects of the clinical and research PET/CT imaging, with a special interest in cardiac PET/CT and coronary CT angiography.

Currently I’m completing my masters in radiography with specialisation in nuclear medicine on ‘comparison of 82Rubidium myocardial blood flow quantification with coronary calcium score for evaluation of coronary artery stenosis’.

Mr Raymond Endozo CT Lead and Research Radiographer, University College Hospital I have more than 10 years’ experience in radiography and author of more than 20 scientific publications and conferences. I graduated from the Philippines specialising in intervention CT. I came to UCLH in 2006 as a Radiographer and I am currently a CT Lead and Research Radiographer. I developed my skills to exploit PET/CT as a powerful platform for novel experimental medicine molecular imaging across cancer, lung fibrosis as well as cardiology. I developed the 1st imaging for PET/CT in man in Europe using PET tracer rubidium 82 in tumour angiogenesis and 1st Hybrid Cardiac imaging at the Institute of Nuclear Medicine. I have analysed images measuring cancer heterogeneity, texture characterisation on cardiac CT of hypertrophic cardiomyopathy patients and developed protocol for 64 trials that include PET/CT components.

Dr Maria Lewis Principal Physicist, Guy’s and St Thomas’ NHS Foundation Trust Maria Lewis previously worked for IMPACT, the UK’s national group for CT scanner evaluations. She has over 20 years’ experience teaching on technical aspects of CT, particularly dose issues, to physicists, technologists, radiographers and radiologists.

Maria currently works in the Medical Physics Department of Guy’s & St Thomas’ Hospitals on the application of CT perfusion in colorectal cancer. She also acts as an adviser on CT projects to KITEC, the UK’s centre for the evaluation of medical imaging technology based at King’s College Hospital, London.

Ms Catherine Murtagh Senior Grade Radiographer, Royal Marsden NHS Foundation Trust Catherine Murtagh is a Senior Grade Radiographer, who works at the Nuclear Medicine and PET/CT department at the Royal Marsden Hospital in London. She has a BSc in radiography from University College Dublin and a post graduate diploma in nuclear medicine from Trinity College Dublin. She has experience lecturing on the post graduate Msc in medical imaging in association with Trinity College and at the technologist sessions at the EANM conference in Barcelona 2009 and Milan 2012. She was awarded first in the technologist exam at the EANM Birmingham, 2011.

Mr Alan Needham Radiotherapy Advanced Practitioner, St James’s Institute of Oncology Alan is a Clinical Radiographer with over 25 years’ experience spent at a number of UK departments, initially in London but more recently in the Radiotherapy Department at the Leeds Cancer Centre (formerly Cookridge Hospital). For most of his career Alan specialised in pre-treatment aspects of the radiotherapy workflow, with a particular interest in CT and virtual simulation technologies.

More recently he has undertaken a period as Research Lead Radiographer at Leeds with responsibilities for implementation of SABR and other advanced treatment and imaging modalities.

Mr David Platten Clinical Scientist, Northampton General Hospital David Platten studied physics at University College London and then took a masters course in medical physics at the University of Birmingham. His career in medical physics began with a training post at North Staffordshire Hospital, after which he decided to specialise in diagnostic radiology. He worked at St George’s Hospital in London for six years, three of which were spent with the UK Department of Health’s ImPACT group. Whilst at ImPACT he gained a great deal of experience in the physics and technology of CT scanners and authored some of the group’s evaluation reports. David currently works in the Imaging Section of the Medical Physics Department of Northampton General Hospital. He is a corresponding member of IPEM’s Diagnostic Radiology Special Interest Group.

Mr Neil Roberts Advanced Practitioner (Pre-Treatment Lead), St James’s Imstitute of Oncology Neil has worked as a Therapy Radiographer at The Leeds Cancer Centre (formally St James’s Institute of Oncology) since graduating from The University of Leeds in 2001. He has held various positions in the Radiotherapy Department including a secondment to the Yorkshire Cancer Research Network.

His role as Pre-Treatment Lead Radiographer has involved advancing practice at Leeds through the development of a radiographer led IV contrast service for CT planning, the introduction of multi-modality imaging studies in CT, MRI and PET. In addition Neil played a key role in implementing the Lung SABR service at Leeds, one of the first centre’s in the UK to do so.

Dr Bhuey Sharma Consultant Radiologist, Royal Marsden NHS Foundation Trust Dr Bhupinder Sharma graduated from the University of Southampton Medical School in 1993 with biomedical sciences (1st class honours) and bachelor of medicine degrees. He realised the importance of combining radiological and nuclear medicine techniques in the early 1990’s whilst a junior doctor at the Hammersmith Hospital, becoming one of the first dual trained radiology-nuclear medicine specialists in the UK.

Appointed Consultant Radiologist with a specialist PET interest at the Royal Marsden Hospital in 2002, his research, clinical and educational focus is combined morphologic and functional imaging. Dr Sharma is the Lead RMH Radiologist for the weekly lymphoma and lung MDTs (commenced by Dr Sharma in 2002), and involved with the weekly breast MDT and a number of tumour types. Teaching and lecturing extensively on a yearly basis, including the organisation of a novel new national multiparametric imaging course for non-radiologists. Dr Sharma has written numerous book chapters and widely published, including 1st author papers in Nature Reviews Clinical Oncology, papers in Annals of Oncology and a number of radiology journals.

Mrs Sairanne Wickers Clinical Specialist in Radiotherapy Planning (breast & PET-CT), University College London Hospital After qualifying as a Therapeutic Radiographer in 2002, I specialised in radiotherapy planning in 2005. My current role is Clinical Specialist in Radiotherapy Planning (breast & PET-CT).

Mr Bruce Walmsley, Principal Physicist, Guy’s and St Thomas’ NHS Foundation Trust Bruce has over 20 years’ experience working as a Clinical Scientist, started in nuclear medicine and eventually migrating to diagnostic radiology and radiation protection. He lectures at both undergraduate and post graduate level on subjects in radiation protection and diagnostic radiology, especially CT and SPECT/CT. He has also presented talks on SPECT/CT nationally at the CT User Group and BNMS and internationally at the 2008 Asia Oceania congress of nuclear medicine in Delhi. He currently helps provide a diagnostic radiology service to several CT scanners used at Guy’s and St Thomas’ and other south London hospitals. This service also includes hybrid PET/CT and SPECT/CT systems which incorporate a range of CT systems from the simple single slice slow rotation scanners to fully diagnostic CT scanners. Bruce has worked closely with nuclear medicine staff to develop and optimise the CT protocols used on these scanners and assess the doses delivered to patients as a result.

Dr Tim Wood Radiation Protection and Diagnostic Imaging Physicist, Hull and East Yorkshire Hospitals NHS Trust Tim works as a Radiation Protection and Diagnostic Imaging Physicist in the Radiation Physics department, Hull and East Yorkshire Hospitals NHS Trust, and is also a current member of the IPEM Diagnostic Radiology Special Interest Group.

Tim is currently leading a number of projects investigating the development, implementation and optimisation of X-ray imaging techniques in radiotherapy.

Other interests include the physics, technology and clinical application of computed tomography and digital X-ray imaging, including mammography.

Abstracts (where supplied) CT scanners - basics of operation Dr Maria Lewis The principle of CT imaging relies on measuring the transmission of kilovoltage x-rays through various angles around a patient. The reconstructed images provide ‘attenuation maps’ displaying the various linear attenuation coefficients of the anatomical structures in the body. The attenuation coefficients are converted to CT numbers (in Hounsfield units) and displayed on the monitor as varying shades of grey.

Early CT scanners acquired data at a rate of one slice per rotation with typical slice widths of 5 – 10 mm. Modern multi-slice scanners can acquire up to 320 simultaneous 0.5 mm slices resulting in faster acquisition times and improved spatial resolution with consistent image quality for reconstructions performed in any plane.

Three scanning modes are available on CT scanners: axial, helical and cine. The most commonly used is the helical mode where the couch moves at a given speed through the gantry as the attenuation data is acquired. This allows faster volume coverage and the acquisition of a volume of data from which slices can be reconstructed at arbitrary positions along the scan axis.

Until recently, the reconstruction method used in CT scanning was filtered back projection with a number of specific reconstruction kernels (from smooth to sharp) available on the scanners for different imaging tasks. In the last few years the increasing speed of computers has allowed the implementation of iterative reconstruction methods in CT with potential for dose and artefact reduction.

CT dosimetry Dr Elly Castellano The learning objectives of this talk are to: • • • • •

Identify the dose indices used for CT dosimetry Understand how the dose indices behave with changes in scan settings Understand how the dose indices relate to actual patient dose Appreciate how CT doses compare to radionuclide doses in nuclear medicine Appreciate how CT doses compare to imaging and treatment doses in radiotherapy

Quality assurance Mr David Platten This talk will describe the quality assurance tests for CT scanners recommended by the Institute of Physics and Engineering in Medicine’s report 91. The methods to perform the tests will be described and practical tips given to help obtain reliable results. Reasons for results changing relative to baselines will be given.

IR(ME)R considerations Dr Matt Dunn The IR(ME)R 2000 regulations place a number of obligations on healthcare providers using ionising radiation for imaging procedures carried out for medical diagnosis or as part of treatment. The use of diagnostic CT scanners with radiotherapy, nuclear medicine and PET modalities requires employers to consider the following elements of IR(ME)R. • • • • • •

Standard operating protocols Referral, justification and authorisation of imaging exposures Practitioner and operator entitlement Staff training Optimisation and monitoring of exposures (DRL’s) Expert advice (MPE)

This presentation will highlight the requirements in these areas and the issues to be resolved to achieve compliance.

CT preparation for radiotherapy scanning Mrs Sairanne Wickers This presentation aims to be a lively and informative session, with lots of pictures and case studies and welcomes active discussion.

Topics to be covered: • • • • • • • • • •

Patient positioning: the challenges of the CT aperture The radiotherapy couch - indexing and reproducibility IV contrast Bowel and bladder prep Breast mark-up PET-CT planning - intercepting diagnostic pathways Oral preparation for head and neck Steroid use in paediatrics – appetites and tight masks Healing v’s timely treatment Avoiding GA - role of play specialists

CT parameter selection and optimisation techniques Dr Tim Wood Imaging plays a fundamental role at all stages of the patient pathway in a modern radiotherapy centre, be it the initial diagnosis, CT planning scans or verification imaging. However, the vast majority of these examinations will involve the use of ionising radiation, which means their use must be carefully considered to ensure images of sufficient quality are obtained. In the UK, the Ionising Radiation (Medical Exposure) Regulations place a responsibility on all duty holders to ensure every exposure is kept ‘as low as reasonably practicable consistent with the intended purpose’; this does not mean driving doses down to artificially low levels, but finding the point that gives images fit-for-purpose.

It is therefore important to understand how each imaging modality works and what technology is available to optimise radiation dose to the patient.

The purpose of this talk is to outline the various options that can be used on modern CT and cone beam CT equipment to assist with the optimisation of the each individual examination, such as automatic exposure controls and iterative reconstruction. General optimisation strategies will then be discussed, along with the concept of radiotherapy imaging reference levels.

Coping with tumour motion in treatment planning Mr Neil Roberts Accurate tumour target definition is essential for improvements in the therapeutic ratio for organ-preserving treatment. In recent years the array of technology dedicated to assessing and managing tumour motion has markedly increased. With this technology and a national expectation to account for tumour motion in radiotherapy treatment (NICE, 2012) come the challenges of advancing planning and treatment techniques.

This talk will highlight how some of this technology is shaping practice to cope with tumour motion in radiotherapy planning; it will identify pitfalls involved in this area and provide an overview of current developments around tumour motion management.

NICE (2012), QS17, Quality Standard for Lung Cancer, www.nice.org.uk CT on the linac - use of cone beam CT in image guidance Mr Alan Needham One of the most clinically significant developments within radiotherapy in recent years has been the addition of cone beam CT technology (CBCT) to the linear accelerator suite and the resulting ability to acquire volumetric imaging for verification at the point of treatment delivery.

Although CT data has been used for many years in simulation and planning of Radiotherapy, until recently the commonest modality used in image guided radiotherapy (IGRT) was that of planar imaging and the comparison of often low contrast megavoltage images with software generated DRRs.

CBCT, currently considered a gold standard in IGRT, enables treatment radiographers to make on-line clinical decisions based on soft tissue anatomy, to enact real time couch corrections and to calculate error trend analysis that together offer potential to improve accuracy, to reduce doses to surrounding healthy tissues and to enable dose escalation that might lead to better tumour control.

In this presentation I will briefly describe the components of the modern Cone Beam system along with basic principles relating to image reconstruction, quality assurance and issues of image quality. The clinical benefits of volumetric imaging will be discussed in comparison with planar imaging methods and through use of a range of clinical examples from a number of anatomical sites.

I will also discuss more recent advances in cone beam technologies, such as the development of 4D-CBCT and an ability to acquire intra-fractional images during VMAT treatment delivery.

Patient preparation and examination technique Ms Catherine Murtagh PET/CT and SPECT/CT scanning now contribute significantly to the diagnosis and treatment planning for the patient particularly in the oncology setting.

Through the superimposition of functional and anatomic images, the emerging single dataset has the advantage of precise localisation of the radiopharmaceutical distributions. This development in single session scanning is not without its drawbacks however. This review aims to outline how careful patient preparation and examination technique can contribute to improving diagnostic quality of images, reducing known pitfalls as well as contributing to patient safety and improving the patient experience in clinical practice.

The CT component to the PET/CT and SPECT/CT scan has a dual purpose. As well as providing anatomic information for localisation it also works as the attenuation correction for the PET and SPECT data. CT scans are more rapid than the conventional transmission sources. One pitfall of the SPECT/CT systems is that some incorporate a non-standard CT scanner, which doesn’t have the same imaging capabilities as stand alone scanners. This review will identify how in this case, in particular, patient preparation and examination technique will significantly impact in the resultant image.

Although software corrections can be introduced that will reduce the effects of some set-up errors, as operators, it is imperative that from the onset, there is accuracy in all technical aspects of scanning. This review will help to unveil a framework for PET and SPECT/CT imaging that will assist in achieving high quality diagnostic images without compromising the patient experience through careful attention to patient preparation and examination technique.

References: Christian PE, and Waterstram-Rich KM (2012) Nuclear Medicine and PET/CT, Technology and Techniques. 7th Edition. Elsevier Mosby.

Ganasegaran G et al. Patterns, variants, artefacts and pitfalls in conventional radionuclide bone imaging and SPECT/CT. Semin Nucl Med 2009 Nov; 39(6):380-95 Patton JA et al. SPECT/CT Physical Principles and Attenuation correction. J Nucl Med Technol 2008; 36:1-10 Van Dalen JA et al. Multimodality nuclear medicine imaging: artefacts pitfalls and recommendations. Cancer Imaging 2007; 7 (1):77-83 CT parameter selection and optimisation techniques Mr Bruce Walmsley CT used in hybrid imaging for PET or nuclear medicine has a range of possible uses and so therefore a range of dose and image quality levels that are necessary to achieve the diagnostic task. Very low dose and poor image quality scans are quite sufficient for attenuation correction of the SPECT or PET data.

But many hybrid systems offer the ability to do fully diagnostic quality CT scanning. In between the two extremes lies a near infinite combination of parameters that could achieve a suitable level of image quality at an acceptable dose for the intended purpose of localisation and/or characterisation that will inform the clinician and supplement the information obtained by the radionuclide scan. This talk will look at some of these possibilities and the choices that have to be made when setting the CT scan protocols for PET/CT and SPECT/CT. Putting the CT back into PET/CT - contrast, CT perfusion and beyond Mr Raymond Endozo The continuing advances in computed tomographic (CT) technology in the past decades have provided on-going opportunities to improve PET/CT image quality and clinical practice. Most contrast enhanced CT procedures map the anatomy and morphology of tumours with little or no information about their metabolism. Positron emission tomography (PET/CT) performed with PET tracers has proved valuable in providing important tumour-related quantitative metabolic information that is critical to diagnosis. Combined CECT and PET/CT is a unique combination of the cross-sectional anatomic information provided by CT and the metabolic information provided by PET, which are acquired during examination. It provides relevant information in the staging and therapy monitoring of tumours and others.

CT techniques in multi modality PET MRI - Calcium score and CT coronary angiography Ms Marguerite Du Preez Coronary hybrid imaging is not only the fusion of different imaging modalities, but also the fusion of people (Nuclear Medicine Physicians, radiologists, nuclear medicine technologists and radiographers). Myocardial perfusion PET/CT is a functional image modality used to identify coronary ishaemia, while coronary calcium score and coronary CT angiography are anatomical image modalities used to identify soft and calcified plaque in the coronary arteries and determine the relevance of the stenosis. Cardiac hybrid imaging creates a ‘one stop shop’ experience for the patient while making a functional and anatomical diagnosis on coronary artery disease. There are some limitations to the CT aspect of coronary hybrid imaging and I will be discussing these limitations and how to overcome them and create optimised low radiation protocols in our clinical practice.

Case studies - linking the modalities Dr Bhuey Sharma A clinical case oriented approach will be used to illustrate principles of multiparametric imaging – regarding anatomical and functional datasets, strengths and limitations and the importance of technically optimal quality datasets. Examples will be shown from a large number of clinical situations, including a wide range of tumour types and haematological malignancies (including breast cancer, lymphoma, lung cancer, GI malignancies and gynaecological malignancy) and numerous modalities including PET, PET/CT, CT, WB-DWI, MRI and PET-MRI amongst others.

References: Sharma B, Constantinidou A, Martin A, Stanway S, Johnston S. Imaging in Oncology: over a century of key advances. Nature Reviews Clinical Oncology 9, 728-737 (December 2012), doi:10.1038/nrclinonc.2012.195 Constantinidou A, Martin A, Sharma B, Johnston SR. Positron emission tomography/computed tomography in the management of recurrent/metastatic breast cancer: a large retrospective study from the Royal Marsden Hospital. Ann Oncol. 2011 Feb;22(2):307-14.

Martin A, Cunningham D, Sharma B. Positron emission tomography/CT in the management of lymphoma. Imaging 2013;22:20110086. doi:10.1259/ imaging.20110086.

Sharma B, Martin A, Zerizer I. Positron Emission Tomography – Computed Tomography in Liver Imaging. Seminars in Ultrasound, CT and MRI. Semin Ultrasound CT MR. 2013 Feb;34(1):66-80. doi: 10.1053/j. sult.2012.11.006.

Handbook of Metastatic Breast Cancer. 2nd Edition. 2011. SRD Johnston & C Swanton. PET/CT and Breast Cancer. Invited Chapter. Dr Sharma and Dr Afaq.

ISBN-10: 184848115. ISBN-13: 978 1841848112

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FORTHCOMING EVENTS THE JOURNEY FROM RESEARCH TO PUBLICATION 14 NOVEMBER 2013 LONDON THE FUTURE OF RADIOLOGY IN THE NHS: TOP TOPICS FOR INTERVIEWS 15 NOVEMBER 2013 LONDON Stereotactic ablative body radiotherapy: Current status and developments 12 December 2013 london Wessex Branch meeting: Pushing the boundaries of radiology 13 december 2013 southampton north branch meeting: contrast study day and essential physics for FRCR 23-24 january 2014 liverpool radiology errors 31 january 2014 london Scottish Branch meeting: Recent advances in diagnostic imaging 14 february 2014 glasgow 3rd annual spect/ct symposium: current status and future directions of spect/ct imaging 24 february 2014 london Multi-parametric imaging of prostate cancer can it facilitate a paradigm shift in management?

28 february 2014 london biological optimisation of radiotherapy 13 march 2014 london Paediatric body mri 1 april 2014 london BIR management course for radiology SpRs and new consultants 2 may 2014 london Radiotherapy: Meeting the current workforce challenges for patient care 19 may 2014 london VISIT: WWW.BIR.ORG.UK FOR MORE INFORMATION AND TO REGISTER!

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