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Nanthini S<br />ThyeCheeKeong<br />Lynette Lee<br />NurNadiatulAsyikin<br />NursheilaIzrin<br />Oon Li Keat<br />HurulAini...
	History<br /><ul><li>Mr. M
25 year old motorcyclist
Thrown off in a collision with a lorry
Brought to A&E unit in a hospital</li></li></ul><li>		On examination<br />No head and spinal injury<br />Stabilized<br />V...
	Question 1:<br />In the Accident & Emergency Room while waiting to be admitted to the ward, describe FIVE (5) other proce...
Continuation of the primary survey<br />Disability (D) of the central nervous system<br />Basic neurologic assessment with...
Continuation of the primary survey<br />Exposure/Environmental control/X-Rays (E)<br />Full exposure of the patient<br />A...
IMAGING<br />
X-rays:<br />Cervical spine: lateral view of C1-T1<br />Chest : Anteroposterior view<br />Pelvis : Anteroposterior view<br...
Adjunct to primary survey<br />Vital signs <br />Oxygen saturation e.g. pulse oxymetry, blood gases<br />Electrocardiograp...
Secondary survey<br />Complete history and physical examination<br />Each region of the body to be fully examined:<br />Ch...
Head<br />Check for bruising, swellings<br />Look for signs of basal skull fracture:<br />Battle’s sign<br />Racoon’s eyes...
Chest<br />Respiratory distress - Grunting, stridor<br />Bruising and skin imprinting<br />Mediastinal shift<br />Penetrat...
Abdomen and pelvis<br />External injuries<br />Abdominal distension by gas or fluid<br />Tenderness and guarding<br />Blee...
Limbs<br />Check the neurovascular status of each limb<br />Analgesia – orthopaedic injuries are extremely painful<br />Co...
Name of procedure and Purpose<br />
Skeletal traction of left proximal tibia<br />Purpose:<br /><ul><li>To reduce a fracture or dislocation
To prevent or reduce muscle spasm
To immobilize a joint or part of the body
To treat joint pathology</li></li></ul><li>PRIOR TO APPLICATION<br /><ul><li>Ensure adequate analgesia / sedation
Place patient in supine position
Record baseline neurovascular observations:
Pulses
Skin colour and temperature
Capillary refill time
Movement of joints
Swelling and sensation
Observe affected limb for any:
Wounds
Swelling
Infection
Soft tissue damage</li></li></ul><li>Principles of Skeletal Traction<br />Align the distal to the proximal fragment<br />R...
LOCAL ANAESTHESIA<br />Inject local anaesthetic into the skin, subcutaneous tissue, and periosteum of both sides, making s...
Bohler’s Stirrup<br />
Cord/ Rope is then attached to the pin’s holder and passed over a pulley, and fixed to a weight. <br />The weight may pull...
Complications<br /><ul><li>Due to procedure itself
Infection of the pin tract
Injury to common peroneal</li></ul>	nerve<br /><ul><li>Excessive traction
Due to prolonged bed rest
Thromboembolism
Decubiti
Pneumonia
Atelectasis</li></li></ul><li>Compartment Syndrome<br />
9) The problem you suspected in QXN (8), describe 4 other symptoms and/or signs would you look for ?<br />6 “P”s?<br /> us...
Symptoms<br />Pain out of proportion to apparent injury (early and common finding)<br />Persistent deep ache or burning pa...
Signs<br />Pain with passive stretch of muscles in the affected compartment (early finding)<br />Tense compartment with a ...
Late signs<br />Pallor from vascular insufficiency (uncommon)<br />Muscle weakness (onset within approximately two to four...
10) What first aid in the ward can you immediately give after you suspect the problem in QXN 8?<br />relieving all externa...
Capillary blood flow becomes compromised at 20 mmHg.<br /> • Pain develops at pressures between 20 and 30 mmHg.<br /> • Is...
<ul><li>11) Describe the pathophysiology of the problem you suspected in QXN 8?</li></ul>Compartment Syndrome<br />
Compartment Syndrome<br />Anatomy<br /><ul><li> Muscle groups -including the nerves and blood vessels that flow through th...
a tough membrane (fascia) that does not readily expand-this area is called a “compartment”</li></li></ul><li>PATHOPHYSIOLO...
PATHOPHYSIOLOGY<br />↑ Compartmental volume<br /> (↑ fluid content)<br />↓ Compartment volume <br />(constriction of the c...
Compartment Syndrome:Sequela After Initial Injury<br />Tissue damage- irreversible tissue death within 4-12 hours<br />per...
Muscle infarcted<br />Replaced by inelastic fibrous tissue<br />( Volkmann’s ischaemic contracture)<br />Necrosis of <br /...
12) If the problem still continues despite first aid in QXN 10, elaborate what would you do?<br />
Fasciotomy<br />Fasciotomy -definitive and only treatment for acute compartment syndrome (ACS) <br />If intra-compartment ...
Cross section of a forearm.Palm up.<br />
the thick, fibrous bands that line the muscles are filleted open,<br /> allowing the muscles to swell and relieve the pres...
Hyperbaric oxygen -considered as an adjunct treatment after surgery to promote healing  and reducing repetitive surgery<br...
13) You did a secondary survey, he complained of pain in left hip; you found he was tender in the left iliac region.What i...
Anatomy of the pelvic bone<br />
14) What did the investigation in Figure 2 show ? <br />( 1 mark )<br />ISOLATED FRACTURE OF LEFT ILIUM WITH INTACT PELVIC...
15) IN THE SAME NIGHT after admission to A&E ( 10 HOURS after admission ), his pulse rate became 140 beats a minute and bl...
16) Name 3 investigations / actions / procedures you would do to stabilize the above situation.( 3 marks)<br />Resuscitati...
17) Name 3 investigations / monitoring procedures to help you know that you really stabilized the above problem adequately...
The intended operation on the femur was delayed…<br />On DAY 3 after the accident, the patient was noted to have ↓ level o...
Name 1 diagnosis you suspect & what other 4 symptoms and/or signs would you look for<br />
Fat Embolism<br />Presence of fat globules obstructing arteries in the lung parenchyma & peripheral circulation after long...
GURD’s Criteria for Diagnosis<br />Major<br />Axillary or subconjunctivalpetechiae<br />Hypoxaemia PaO2 <60mmHg<br />CNS d...
4 Symptoms and/or Signs<br />Respiratory distress: SOB<br />CNS abnormalities: Confusion, restlessness, coma<br />Changes ...
Elaborate what investigations would you do?<br />
Clinically: <br />	-tachycardia>110bpm, tachypnea>30bpm,  pyrexia>38.5◦<br />	_ confused / restless<br />	- petechiae<br /...
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Cpc orthopaedics

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Cpc orthopaedics

  1. 1. Nanthini S<br />ThyeCheeKeong<br />Lynette Lee<br />NurNadiatulAsyikin<br />NursheilaIzrin<br />Oon Li Keat<br />HurulAini<br />CPC OrthopaedicsWITH PROF. RAZIF ALI<br />
  2. 2. History<br /><ul><li>Mr. M
  3. 3. 25 year old motorcyclist
  4. 4. Thrown off in a collision with a lorry
  5. 5. Brought to A&E unit in a hospital</li></li></ul><li> On examination<br />No head and spinal injury<br />Stabilized<br />Vital signs stable<br />Initial assessment:<br />closed fracture of his left femur<br />closed distal extraarticular fracture of his right radius<br />soft tissue injury of his right shoulder<br />Decision was made for:<br />internal fixation of his left femur<br />closed reduction and POP of his right radial fracture as a semi emergency.<br />
  6. 6. Question 1:<br />In the Accident & Emergency Room while waiting to be admitted to the ward, describe FIVE (5) other procedures / actions you would do as part of treatment or investigation not mentioned above?<br />(10 marks)<br />
  7. 7. Continuation of the primary survey<br />Disability (D) of the central nervous system<br />Basic neurologic assessment with AVPU score:<br />A – Alert<br />V – Responds to verbal stimuli<br />P – Responding to painful stimuli<br />U – Unconscious<br />Pupil size, inequality and reactivity to light<br />GCS score<br />
  8. 8. Continuation of the primary survey<br />Exposure/Environmental control/X-Rays (E)<br />Full exposure of the patient<br />Assess from head to toe for injuries not recognized and managed<br />Keep patient warm<br />
  9. 9. IMAGING<br />
  10. 10. X-rays:<br />Cervical spine: lateral view of C1-T1<br />Chest : Anteroposterior view<br />Pelvis : Anteroposterior view<br />Focused abdominal sonography for trauma (FAST) scan on ‘5Ps’:<br />Perihepatic – liver lacerations<br />Perisplenic – splenic lacerations and rupture<br />Pelvic – free fluid e.g. haematoma<br />Pleural – haemothorax, pneumothorax<br />Pericardial – pericardial effusion<br />
  11. 11. Adjunct to primary survey<br />Vital signs <br />Oxygen saturation e.g. pulse oxymetry, blood gases<br />Electrocardiography<br />Urine catheterization – hourly urine output<br />Nasogastric aspiration output<br />
  12. 12. Secondary survey<br />Complete history and physical examination<br />Each region of the body to be fully examined:<br />Chest<br />Abdomen<br />Pelvis<br />Limbs<br />Reassessment of all vital signs<br />
  13. 13. Head<br />Check for bruising, swellings<br />Look for signs of basal skull fracture:<br />Battle’s sign<br />Racoon’s eyes<br />Examine nose and ears for CSF leakage<br />Pupil size and responsiveness<br />
  14. 14. Chest<br />Respiratory distress - Grunting, stridor<br />Bruising and skin imprinting<br />Mediastinal shift<br />Penetrating injuries<br />
  15. 15. Abdomen and pelvis<br />External injuries<br />Abdominal distension by gas or fluid<br />Tenderness and guarding<br />Bleeding from urethral meatus<br />Presence of palpable bladder<br />PR exam: blood, high-riding prostate, anal tone<br />
  16. 16. Limbs<br />Check the neurovascular status of each limb<br />Analgesia – orthopaedic injuries are extremely painful<br />Correct obvious deformity by temporary splinting<br />
  17. 17. Name of procedure and Purpose<br />
  18. 18. Skeletal traction of left proximal tibia<br />Purpose:<br /><ul><li>To reduce a fracture or dislocation
  19. 19. To prevent or reduce muscle spasm
  20. 20. To immobilize a joint or part of the body
  21. 21. To treat joint pathology</li></li></ul><li>PRIOR TO APPLICATION<br /><ul><li>Ensure adequate analgesia / sedation
  22. 22. Place patient in supine position
  23. 23. Record baseline neurovascular observations:
  24. 24. Pulses
  25. 25. Skin colour and temperature
  26. 26. Capillary refill time
  27. 27. Movement of joints
  28. 28. Swelling and sensation
  29. 29. Observe affected limb for any:
  30. 30. Wounds
  31. 31. Swelling
  32. 32. Infection
  33. 33. Soft tissue damage</li></li></ul><li>Principles of Skeletal Traction<br />Align the distal to the proximal fragment<br />Remain constant<br />Allow for adequate exercise and diversion<br />Allow for optimum nursing care<br />
  34. 34.
  35. 35.
  36. 36.
  37. 37. LOCAL ANAESTHESIA<br />Inject local anaesthetic into the skin, subcutaneous tissue, and periosteum of both sides, making sure it goes under the periosteum.<br />
  38. 38. Bohler’s Stirrup<br />
  39. 39. Cord/ Rope is then attached to the pin’s holder and passed over a pulley, and fixed to a weight. <br />The weight may pull the patient out of the bed, thus need to exert countertraction by raising the foot off his bed.<br />
  40. 40. Complications<br /><ul><li>Due to procedure itself
  41. 41. Infection of the pin tract
  42. 42. Injury to common peroneal</li></ul> nerve<br /><ul><li>Excessive traction
  43. 43. Due to prolonged bed rest
  44. 44. Thromboembolism
  45. 45. Decubiti
  46. 46. Pneumonia
  47. 47. Atelectasis</li></li></ul><li>Compartment Syndrome<br />
  48. 48.
  49. 49. 9) The problem you suspected in QXN (8), describe 4 other symptoms and/or signs would you look for ?<br />6 “P”s?<br /> use them as criteria is Not reliable<br />Only pain & paraesthesia useful<br />The rest are uncommon or late signs<br />Eg. Paralysis or even muscle weakness indicate irreversible muscle damage <br />
  50. 50. Symptoms<br />Pain out of proportion to apparent injury (early and common finding)<br />Persistent deep ache or burning pain<br />Paresthesias (onset within approximately 30 minutes to 2 hours of ACS; suggests ischemic nerve dysfunction)<br />
  51. 51. Signs<br />Pain with passive stretch of muscles in the affected compartment (early finding)<br />Tense compartment with a firm "wood-like" feeling<br />Diminished sensation (two point discrimination found to be earliest)<br />
  52. 52. Late signs<br />Pallor from vascular insufficiency (uncommon)<br />Muscle weakness (onset within approximately two to four hours of ACS)<br />Paralysis (late finding)<br />
  53. 53. 10) What first aid in the ward can you immediately give after you suspect the problem in QXN 8?<br />relieving all external pressure on the compartment. Any dressing, splint, cast, or other restrictive covering should be removed<br />Maintain perfusion: <br />Hypotension reduces perfusion, exacerbating tissue injury, and should be treated with intravenous isotonic saline.<br />The limb should not be elevated. Elevation can diminish arterial inflow and exacerbate ischemia [62].<br />Analgesics should be given and supplementary oxygen provided. Further research <br />
  54. 54.
  55. 55. Capillary blood flow becomes compromised at 20 mmHg.<br /> • Pain develops at pressures between 20 and 30 mmHg.<br /> • Ischemia occurs at pressures above 30 mmHg.<br />Traditional recommendations for decompression include absolute pressure readings above 30 mmHg [49], or above 45 mmHg [1].<br /> <br />The delta pressure is found by subtracting the compartment pressure from the diastolic pressure. Many clinicians use a delta pressure of 30 mmHg to determine the need for fasciotomy. Others use a difference of 20 mmHg [15].<br />
  56. 56. <ul><li>11) Describe the pathophysiology of the problem you suspected in QXN 8?</li></ul>Compartment Syndrome<br />
  57. 57. Compartment Syndrome<br />Anatomy<br /><ul><li> Muscle groups -including the nerves and blood vessels that flow through them- are covered by
  58. 58. a tough membrane (fascia) that does not readily expand-this area is called a “compartment”</li></li></ul><li>PATHOPHYSIOLOGY<br />complex pathophysiology<br />the final common pathway is cellular anoxia [15]<br />prerequisite for the development of increased compartment pressure is a fascial structure (prevents adequate expansion )<br />widely believed hypothesis : arteriovenous pressure gradient theory [2]<br />[2] Elliott, KG, Johnstone, AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003; 85:625.[15] Olson, SA, Glasgow, RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005; 13:436.<br />
  59. 59. PATHOPHYSIOLOGY<br />↑ Compartmental volume<br /> (↑ fluid content)<br />↓ Compartment volume <br />(constriction of the compartment)<br />↑ INTRACOMPARTMENTAL PRESSURE<br />Due to inelasticity of fascia<br />venous outflow is reduced (obstruction)<br />oedema<br />Inadequate venous drainage<br />But early-Lymphatic Drainage <br />compensate<br />Vascular congestion<br />Muscle and nerve ischaemia,necrosis<br />Further ↑ intracompartmentalpressure (venous pressure )<br />( arteriovenous pressure gradient)<br />↓ capillary perfusion<br />Compromise arterial circulation (late)<br />
  60. 60. Compartment Syndrome:Sequela After Initial Injury<br />Tissue damage- irreversible tissue death within 4-12 hours<br />permanent disabilities can develop from undiagnosed compartment syndrome<br /> Amputation- sometimes tissue beyond repair and only measure to prevent gangrene and death is amputation<br />
  61. 61. Muscle infarcted<br />Replaced by inelastic fibrous tissue<br />( Volkmann’s ischaemic contracture)<br />Necrosis of <br />the nerve and muscle <br />within the compartment<br />Vicious circle that <br />Ends after<br /> ~12 hours<br />Nerve<br />-capable to regenerate<br />
  62. 62. 12) If the problem still continues despite first aid in QXN 10, elaborate what would you do?<br />
  63. 63. Fasciotomy<br />Fasciotomy -definitive and only treatment for acute compartment syndrome (ACS) <br />If intra-compartment pressure > 40mmHg<br />Immediate open fasciotomy<br />Morbidity from delay is significant, so the operation should be performed immediately. <br />The wound should not be stitched until a post-surgical assessment has been done at 48 hours. <br /> subsequent skin grafts may be needed for successful healing<br />
  64. 64. Cross section of a forearm.Palm up.<br />
  65. 65.
  66. 66. the thick, fibrous bands that line the muscles are filleted open,<br /> allowing the muscles to swell and relieve the pressure within the compartment <br />Depending upon the amount of swelling (edema), a second operation may be required later to close the skin after the swelling has resolved.<br />If muscle necrosis, do debridement<br />
  67. 67. Hyperbaric oxygen -considered as an adjunct treatment after surgery to promote healing and reducing repetitive surgery<br />Treatment will also be directed to the underlying cause of the compartment syndrome <br />try to prevent other associated complications including kidney failure due to rhabdomyolysis<br />
  68. 68. 13) You did a secondary survey, he complained of pain in left hip; you found he was tender in the left iliac region.What investigation will you order ? ( 1 mark ) <br />ANTEROPOSTERIOR RADIOGRAPH OF PELVIS<br />VITAL SIGNS<br />
  69. 69. Anatomy of the pelvic bone<br />
  70. 70.
  71. 71.
  72. 72. 14) What did the investigation in Figure 2 show ? <br />( 1 mark )<br />ISOLATED FRACTURE OF LEFT ILIUM WITH INTACT PELVIC RING<br />
  73. 73. 15) IN THE SAME NIGHT after admission to A&E ( 10 HOURS after admission ), his pulse rate became 140 beats a minute and blood pressure became 70 / 40 mm Hg. He looked pale, there is pallor of conjunctivae and sweaty palms and forearms but he is still conscious. Explain briefly what pathophysiology may be happening here.(2 marks)<br />Tachycardia<br />Hypotensive<br />Anaemic<br />Sweaty palms<br />* HYPOVOLAEMIC SHOCK(CLASS III)<br />PELVIC FRACTUREBLOOD VESSEL INJURYBLEEDINGHYPO VOLAEMIC SHOCK<br />
  74. 74.
  75. 75.
  76. 76. 16) Name 3 investigations / actions / procedures you would do to stabilize the above situation.( 3 marks)<br />Resuscitation:<br />a)Vascular access:Insert TWO large bore cannula,Arterial line?<br />b)Blood investigation<br />c)Fluid therapy,oxygen<br />Stabilization of the fracture:<br />-pelvic binder/external fixator<br />Repeat FAST scan <br />Refer to orthopaedic team for further management of the fracture<br />
  77. 77. 17) Name 3 investigations / monitoring procedures to help you know that you really stabilized the above problem adequately.( 3 marks)<br />a)Vital signs,Pulseoxymetry and CVP monitoring if available<br />b)ABG<br />C)CBD-urine output monitoring<br />
  78. 78. The intended operation on the femur was delayed…<br />On DAY 3 after the accident, the patient was noted to have ↓ level of consciousness in the ward round<br />
  79. 79. Name 1 diagnosis you suspect & what other 4 symptoms and/or signs would you look for<br />
  80. 80. Fat Embolism<br />Presence of fat globules obstructing arteries in the lung parenchyma & peripheral circulation after long bone or other major trauma<br />More frequent in closed than in open #<br />Incidence ↑ with no. of # involved<br />Can occur in relation to other trauma<br />Pathogenesis: mechanical & biochemical theory<br />
  81. 81. GURD’s Criteria for Diagnosis<br />Major<br />Axillary or subconjunctivalpetechiae<br />Hypoxaemia PaO2 <60mmHg<br />CNS depression disproportionate to hypoxaemia<br />Minor<br />Tachycardia >110bpm<br />Pyrexia >38.5<br />Retinal emboli on fundoscopy<br />Fat globules in urine and sputum<br />Increased ESR, decreased haematocrit and platelet<br />For diagnosis, at least 1 MAJOR and 4 MINOR criteria must be present<br />
  82. 82. 4 Symptoms and/or Signs<br />Respiratory distress: SOB<br />CNS abnormalities: Confusion, restlessness, coma<br />Changes in V/S: ↑ temperature, ↑ PR<br />Petechiae: neck, chest, axilla, subconjunctiva<br />
  83. 83. Elaborate what investigations would you do?<br />
  84. 84. Clinically: <br /> -tachycardia>110bpm, tachypnea>30bpm, pyrexia>38.5◦<br /> _ confused / restless<br /> - petechiae<br />Lab Ix:<br /> - ABG (PaO2<60mmHg)<br /> - FBC: ↓ hematocrit, thrombocytopenia<br /> - LFT, RP, serum electrolytes, ↑ ESR<br /> - Urine & sputum for fat globules<br />
  85. 85. IMAGING<br />
  86. 86. Chest radiograph: may be normal / snow-storm appearance / diffuse, ground glass appearance<br />Head CT-evidence of microvascular injury<br />Spiral CT<br />Others:<br /> -ECG, TEE <br /> -D-dimers<br /> -ventilation/perfusion scan<br />
  87. 87.
  88. 88. What further treatment would this patient receive?<br />
  89. 89. Supportive Mx<br />Maintenance of adequate oxygenation & ventilation<br />Maintain stable hemodynamics<br />Fluids & blood products as clinically indicated<br />Prophylaxis of DVT & stress-related GI bleeding<br />Nutrition<br />
  90. 90. The right shoulder<br /> When En. M recovered from the operation and ICU, he began to ambulate. He complained of a right shoulder problem when examined as shown in Figure 3A and 3B<br />
  91. 91. Figure 3A<br />Figure 3B<br />
  92. 92. Question 21<br /> Name ONE clinical test which describe the method of examination shown in the figures<br />Shoulder impingement test<br />
  93. 93. Question 22<br /> Name TWO diagnoses possible for the above problem<br />1. Rotator cuff impingement<br />2. Rotator cuff tear<br />
  94. 94. The rotator cuff muscles<br />
  95. 95. Rotator cuff impingement<br /> “Mechanical impingement of rotator cuff tendon beneath the anteroinferior portion of the acromion, especially when the shoulder is placed in the forward-flex and internally rotated position.”<br />NeerCS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. Jan 1972;54(1):41-50.<br />
  96. 96. Neer’s classification<br />Stage I: oedema and haemorrhage<br />Stage II: fibrosis and tendinopathy<br />Stage III: partial or complete tear<br />
  97. 97. Clinical features<br />Pain<br />Gradual onset<br />In the anterolateral part of shoulder<br />On overhead movement<br />Worse at night<br />Associated with weakness and stiffness<br />Clicking or creaking sounds during movement<br />Joint instability<br />Positive Impingement test<br />Normal range of movement and strength<br />
  98. 98. Rotator cuff tear<br />Partial tears frequently occur with supraspinatus tendinitis<br />Complete tear may result from sudden shoulder strain or as complication of tendinitis or partial rupture<br />
  99. 99. Clinical features<br />History of trauma to the shoulder<br />Pain<br />Sudden onset<br />In anterolateral part of shoulder<br />Associated with gross weakness of abduction<br />Joint instability<br />Persistent painful arc of abduction<br />Decreased strength on involved muscle group<br />Decreased range of movement<br />
  100. 100. Conservative Treatment<br />NSAIDS<br />Rest, activity modification (avoid irritating activities)<br />Ice on affected area<br />Physical therapy for stretching/ ROM<br />Rotator cuff strengthening and scapular stabilization<br />
  101. 101. Physical therapy<br />Strengthening the rotator cuff tendons<br />Stretching and regaining lost motion caused by pain and inflammation<br />Allowing the humerus to be better positioned under the acromion, thus reducing compression of the bursa<br />
  102. 102. Examples of physical therapy<br />Cross arm push<br />External rotation on elastic resistance cord<br />
  103. 103. Surgical treatment<br />Arthroscopic subacromial decompression to expand the space between acromion and rotator cuff tendons<br />Rotator cuff repair in rotator cuff tears<br />
  104. 104. THANK YOU<br />QUESTIONS?<br />
  105. 105. HAPPY CHINESE NEW YEARANDHAPPY HOLIDAY!!<br />

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