Thursday, 11 January 2018

Tutorial 11th. January 2018


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17
EMQ. Cervical cancer staging
18
EMQ. Parvovirus
19
EMQ. Mental Capacity Act
20
EMQ. Confidentiality & consent
21
EMQ. Hepatitis B
22
EMQ. Clue cells, koilocytes etc.

17.         Cervical cancer staging
Lead-in.
The following scenarios relate to cervical cancer staging.
For each, select the most appropriate staging.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Scenario 1.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 2 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 2.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 3.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are not tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 4.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 3 cm in width. The resection margins are tumour-free. There is no evidence of extension outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 5.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 5 cm in width. The resection margins are tumour-free. She is nulliparous and wishes to retain her fertility.
Scenario 6.
A woman of 38 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 4 mm and 6mm in width. The resection margins are tumour-free. An MR scan shows involvement of the lymphatic nodes in the left of the pelvis.
Scenario 7.
A woman of 45 has carcinoma of the cervix. It extends into the parametrium, but not to the pelvic side-wall. It involves the upper 1/3 of the vagina. There is MR evidence of para-aortic node involvement.
Scenario 8.
A woman of 55 has carcinoma of the cervix. It extends to the pelvic side-wall. It involves the upper 1/3 of the vagina. She has a secondary on the end of her nose.
Scenario 9.
A woman of 55 has carcinoma of the cervix. It involves the bladder mucosa. 
Scenario 10.
A woman of 35 has a proven cancer of the cervix with extension into the right parametrium, but not to the pelvic side-wall. Left hydroureter and left non-functioning kidney are noted on IVP and there is no other explanation for the findings. Cystoscopy shows bullous oedema of the bladder mucosa.
Scenario 11.
A woman of 25 has a cone biopsy. It shows malignant melanoma. The lesion invades to a depth of 3 mm and is 5 mm in width. The margins of the biopsy are clear. There is evidence of lymphatic vessel involvement. There is no evidence of spread outside the uterus.
Option list.
Micro-invasive cervical cancer.
Stage Ia1
Stage Ia2
Stage Ia3
Stage Ib1
Stage Ib2
Stage Ib3
Stage IIa
Stage IIb
Stage IIc
Stage IIIa
Stage IIIb
Stage IIIc
Stage IVa
Stage IVb
Stage IVc
Stage Va
Stage Vb
Stage Vc
None of the above.
This question illustrates the problems surrounding staging. If you are not a cancer specialist, it is not something that you think about very often, if ever. So you have to put it into your list of things to revise in the days before the exam. If you haven’t started this list, do so now.

18.         EMQ. Parvovirus
Lead-in.
The following scenarios relate to parvovirus infection
Abbreviations.
PvB19:          parvovirus B19
PvIgG:           parvovirus B19 IgG
PvIgM:          parvovirus B19 IgM
Option list.
There is none: make up your own answers!
Scenario 1.
What type of virus is parvovirus?
Scenario 2.
Is the title B19 something to do with the American B19 bomber, its potentially devastating bomb load and the comparably devastating consequences of the parvovirus on human erythroid cell precursors?
Scenario 3.
PVB19 in the UK occurs in mini-epidemics at 3 – 4 year intervals, usually during the summer months.
Scenario 4.
Which animal acts as the main reservoir for infection?
Scenario 5.
What percentage of UK adults are immune to parvovirus infection?
Scenario 6.
What names are given to acute infection in the human?
Scenario 7.
What is the incubation period for parvovirus infection?
Scenario 8
What is the duration of infectivity for parvovirus infection?
Scenario 9.
What are the usual symptoms of parvovirus infection in the adult?
Scenario 10.
What is the incidence of parvovirus infection in pregnancy?
Scenario 11.
How is recent infection diagnosed?
Scenario 12.
How long does PvIgM persist and why is this important?
Scenario 13.
What is the rate of vertical transmission of parvovirus infection?
Scenario 14.
Are women with parvovirus infection who are asymptomatic less likely to pass the virus to their fetuses?
Scenario 15.
To what degree is parvovirus infection teratogenic?
Scenario 16.
What proportion of pregnancies infected with parvovirus are lost?
Scenario 17.
What is the timescale for the onset of hydrops?
Scenario 18.
Laboratories are advised to retain bloods obtained at booking for at least 2 years for possible future reference. True or false?
Scenario 19.
What ultrasound features would trigger consideration of cordocentesis?
Scenario 20.
Must suspected parvovirus infection be notified to the authorities?  Yes or No.
Scenario 21.
Possible parvovirus infection does not need to be investigated after 20 week’s gestation.  True or false?
Scenario 22
If serum is sent to the laboratory from a woman with a rash in pregnancy for screening for rubella, the laboratory should automatically test for parvovirus infection too.  True or false?

19.         EMQ. Mental Capacity Act
Lead-in.
The following scenarios relate to the Mental Capacity Act 2005.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
CAD:     Court-appointed Deputy.
COP:     Court of Protection.
FGR:      fetal growth restriction.
LPA:      Lasting Power of Attorney.
PoA:      Power of Attorney.
Option list.
A.        Yes
B.         No
C.         True
D.        False
E.         Does not exist
F.         The husband
G.        A parent
H.        The child
I.           the General Practitioner
J.          the Consultant
K.         the Registrar
L.          The Consultant treating the patient
M.      A Consultant not involved in treating the patient
N.        The Medical Director
O.        A person with Powers of Attorney
P.         The sheriff or sheriff’s deputy
Q.        Balance of probabilities
R.         Beyond reasonable doubt
S.         None of the above.
Scenario 1.
A person with LPA is normally not a family member.
Scenario 2.
A Sheriff’s Deputy is normally not a family member.
Scenario 3.
A person with PoA can consent to treatment for the patient who lacks capacity.
Scenario 4.
A Court-appointed Deputy can consent to treatment for the patient who lacks capacity, but must go back to the Court of Protection if further consent is required for additional treatment.
Scenario 5.
A person with PoA can authorise withdrawal of all care except basic care in cases of individuals with persistent vegetative states.
Scenario 6.
An advance decision can authorise withdrawal of all but basic care in cases of persistent vegetative states.
Scenario 7
A person with PoA cannot overrule an advance direction about withdrawal or withholding of life-sustaining care.
Scenario 8
A woman is seen in the antenatal clinic at 39 weeks’ gestation. Her blood pressure is 180/110 and she has +++ of proteinuria on dipstick testing. She has mild epigastric pain. A scan shows evidence of FGR with the baby on the 2nd. centile. Doppler studies of the umbilical artery are abnormal and a non-stress CTG shows loss of variability and variable decelerations. She is advised that she appears to have severe pre-eclampsia and is at risk of eclampsia and of intracranial haemorrhage. She is told of the associated risk of mortality and morbidity. She is also advised that the baby is showing evidence of severe FGR and has abnormal Doppler studies and CTG which could lead to death or hypoxic damage. She declines admission or treatment. She says she trusts in God and wishes to leave her fate and that of her baby in His hands. She is seen by a psychiatrist who assesses her as competent under the MCA and with no evidence of mental disorder. The obstetrician wants to apply to the COP for an order for compulsory treatment. Can he do this?
Scenario 9
A woman is admitted at 36 weeks’ gestation with evidence of placental abruption. She is semi-comatose and shocked. There is active bleeding and the cervical os is closed. Fetal heart activity is present but with bradycardia and decelerations. The consultant decides that Caesarean section is the best option to save her live and that of the baby. When reading the notes, the registrar comes across an advance notice drawn up by the woman and her solicitor. It states that she does not wish Caesarean section, regardless of the risk to her and the baby. The consultant tells the registrar that they can ignore it now that she is no longer competent and get on with the Caesarean section for which she will be thankful afterwards. The registrar says that the advance notice is binding. Who is correct?
Scenario 10
An 8 year old girl is admitted with abdominal pain. Appendicitis is diagnosed with peritonitis and surgery is advised. The parents decline treatment on religious grounds. Can the consultant in charge overrule the parents and give consent?

20.         Confidentiality & consent.
Lead-in.
The following scenarios relate to confidentiality.
For each, select the number that best fits the scenario.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
This EMQ has not option list. This is to make you decide your answers. Send them to me and I’ll send my version including what I think an option list might have looked like.
Scenario 1.
A 15-year-old girl attends the TOP clinic requesting TOP. She is assessed as Fraser competent. After full discussion arrangements are made for her admission for TOP. She does not wish her parents to be informed. Her mother attends clinic 1 hour after the child has left. She demands full information about her daughter. The consultant has delegated you to deal with her. Which option best fits the action you will take?
Scenario 2.
A 17-year-old A-level student attends the gynaecology clinic requesting TOP. She is accompanied by her 30-year-old mathematics teacher, who is her lover and wishes to give consent. Which option best fits the action you will take?
Scenario 3.
A 12-year-old girl attends the gynaecology clinic with her mother seeking contraceptive advice. She has an 18-year-old boyfriend whom the parents like and she wishes to start having sex. Which option best fits the action you will take?
Scenario 4.
A 15-year-old girl who is Fraser competent is referred to the gynaecology clinic with a complaint of vaginal discharge. She reveals that she has been having consensual sexual intercourse for six months with her 18-year-old boyfriend. She asks for advice about suitable contraception as she is happy in the relationship and wants to continue to have sex. Which option best fits the action you will take?
Scenario 5.
You are the new oncology consultant and have just operated on the wife of a local General Practitioner for suspected ovarian cancer. The diagnosis is confirmed and you proceed with appropriate surgery. On completion of the operation you go to the surgeon’s room for a coffee. The senior consultant anaesthetist who was not involved in theatre but is the Medical Director and tells you he is a close friend of the woman, asks what the diagnosis and prognosis are. Which option best fits the action you will take?
Scenario 6.
You are phoned by a doctor looking for information about his wife’s results from the booking clinic she attended two weeks ago. He says that she has given consent for disclosure. She has given a history of 2 terminations but no other pregnancies. She is Rhesus negative, but has Rhesus antibodies. Which option best fits the action you will take?
Scenario 7
You are phoned by a doctor looking for information about his wife’s results from the booking clinic she attended two weeks ago. He says that she has given consent for disclosure. Her serology tests have proved +ve for syphilis. You have spoken to the consultant bacteriologist who says that they have run confirmatory tests and they are +ve too. He is sure the woman has active syphilis. Which option best fits the action(s) you will take?
Scenario 8
A 15-year-old girl attends the TOP clinic requesting TOP. She is assessed as Fraser competent. After full discussion arrangements are made for her admission for TOP. She does not wish her parents to be informed despite your best efforts to persuade her. Who will give consent for the procedure?
Scenario 9
An immature 15-year-old girl attends the gynaecology clinic requesting TOP. She is accompanied by her 25-year-old sister who is a lawyer with whom she has been staying since she knew she was pregnant. She does not want her parents to be informed. The girl is assessed as not Fraser competent. The sister says that she is happy to act in loco parentis and to give consent. Which option best fits the action(s) you will take?
Scenario 10
A 25-year-old woman with Down’s syndrome attends the clinic accompanied by her mother. She has menorrhagia and copes badly with the hygiene aspects. The menorrhagia is bad enough for her now to be on treatment for iron-deficiency anaemia. She has tried all the standard medical methods. To complicate the problem, she has become close friends with a young man she has met at College, to which she travels independently each weekday. Her mother fears that she may already be involved in sexual activity and cannot get an accurate answer from her about it. The mother is keen for her to have hysterectomy to deal with both problems. If you agree that the surgery is appropriate, who can give consent?
Scenario 11
A 25-year-old woman with Down’s syndrome is admitted from College after collapsing. The clinical features are of ectopic pregnancy and she states that she has UPSI with her boyfriend of six months. She has tachycardia and hypotension and it is felt that she should have urgent surgery. You reckon that she is not competent to consent for surgery. Who can give consent?
Scenario 12
A 25-year-old woman with Down’s syndrome is admitted from College after collapsing. The clinical features are of ectopic pregnancy and she states that she has UPSI with her boyfriend of six months. She has tachycardia and hypotension and it is felt that she should have urgent surgery. You reckon that she is not competent to consent for surgery. What limits are there on the surgery?
Scenario 13.
You are the SpR on call and are asked to see a 10-year-old child in the A&E department. She has been brought because of vaginal bleeding. She is accompanied by her parents who give a story of her injuring herself falling of her bike. Examination shows vaginal bleeding and you think the hymen looks torn. You suspect sexual abuse and don’t believe the parents’ story. When this is discussed with the parents they say it is impossible and that they do not want involvement of police or social workers. What action will you take? 
Scenario 14.
You are the SpR in theatre with your consultant. Mrs Mary White, age 45, has been listed for abdominal hysterectomy and bilateral salpingo-oophorectomy – she has a long history of menorrhagia that has not responded to conservative measures. Her mother had ovarian cancer diagnosed at 55 and died from the disease 3 years later. A 10 cm., solid tumour of the left ovary is found on opening the abdomen. Which of the following options is the correct course of action?
A
close the abdomen, see her to explain the findings and book a follow-up appointment in the gynaecological clinic to discuss further management
B
close the abdomen, arrange to see her to explain the findings and refer to the gynaecological oncologist to discuss further management
C
continue with the operation, but don’t remove the left ovary
D
continue with the operation, removing the uterus and both ovaries and tubes
E
continue with the operation, removing the uterus and both ovaries and tubes and obtaining peritoneal washings
F
ask the gynaecological oncologist to attend to perform definitive surgery on the basis that the cyst is likely to be malignant
G
phone the legal department for advice
H
phone the Court of Protection for advice
Scenario 15.
You are an SpR in theatre with your consultant.
Mrs Mary White, age 45, has been listed for abdominal hysterectomy and bilateral salpingo-oophorectomy – she has a long history of menorrhagia that has not responded to conservative measures. Her mother had ovarian cancer diagnosed at 55 and died from the disease 3 years later.
You perform examination under anaesthesia prior to the abdomen being opened. You find a 10 cm., mass to the left of the uterus. It feels solid. There is no evidence of ascites or other pathology.
 Which of the following options is the correct course of action?
A
Cancel the operation and arrange review in the gynaecology department in 6 weeks
B
Cancel the operation and arrange review by the oncology team
C
Cancel the operation and arrange an urgent scan
D
Continue with the planned procedure
E
Ask the gynaecological oncologist to attend theatre to examine the patient and advise
F
Perform laparoscopy to identify the nature of the mass
G
Phone the legal department

21.         EMQ. Hepatitis B
Topic. Hepatitis B and pregnancy.
Lead-in.
These scenarios relate to hepatitis and pregnancy.
Instructions.
For each scenario, select the most appropriate option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
CNP:           Handbook of Obstetric Medicine. 5th. Edition. Catherine Nelson-Piercy. CRC Press. 2015. 
HAV:           hepatitis A virus
HBcAg:       hepatitis B core antigen
HBeAg:       hepatitis B e antigen
HBsAg:       hepatitis B surface antigen
HBcAb:       antibody to hepatitis B core antigen
HBeAb:      antibody to hepatitis B e antigen
HBsAb:       antibody to hepatitis B surface antigen
HBIG:         hepatitis B immunoglobulin
HBV:           hepatitis B virus
HBcAg:       hepatitis B core antigen
HBeAg:       hepatitis B e antigen
HBsAg:       hepatitis B surface antigen
HBcAb:       antibody to hepatitis B core antigen
HBeAb:      antibody to hepatitis B e antigen
HBsAb:       antibody to hepatitis B surface antigen
HBIG:         hepatitis B immunoglobulin
HCV:           hepatitis C virus
HEV:           hepatitis E virus
HSV:           herpes simplex virus
VT:              vertical transmission
Option list.
A.       
acyclovir 
B.       
divorce
C.       
HBcAg +ve
D.       
HBeAg +ve
E.        
HbsAg +ve
F.        
HBsAg +ve; HBsAb –ve;  HBcAb –ve; HBeAg +ve
G.       
HBsAg +ve; HBsAb –ve on two tests six months apart
H.       
HBsAg -ve; HBsAb -ve on two tests six months apart
I.         
HBsAg -ve; HBsAb +ve; HBcAb –ve
J.         
HBsAg -ve; HBsAb +ve; HBcAb +ve
K.        
HBsAg -ve; HBsAb +ve
L.        
HBsAg +ve; HBcAg +ve
M.     
HBV vaccine
N.       
HBIG
O.      
HBV vaccine + HBIG
P.        
immune as a result of infection
Q.      
immune as a result of vaccination
R.       
not immune
S.        
chronic carrier of HBV infection
T.        
10%
U.       
30%
V.       
50%
W.     
60%
X.        
70-90%
Y.        
soap and boiling water
Z.        
10% dilution of bleach in water
AA.   
10% dilution of formaldehyde in alcohol
BB.   
ultraviolet irradiation
CC.   
yes
DD.  
no
EE.    
HAV
FF.     
HBV
GG.  
HCV
HH.  
HEV
II.       
HSV
JJ.       
none of the above
Scenario 1.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she has an acute HBV infection?
Scenario 2.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of infection?
Scenario 3.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of HBV vaccine?
Scenario 4.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 9 months ago. What results on routine blood testing would show that she is a chronic carrier of HBV infection?
Scenario 5.
Testing shows that he is positive for HBsAg, positive for HBcAb but negative for IgM HBcAb. What does this mean in relation to his HBV status?
Scenario 6.
Testing shows that he is negative for HBsAg, positive for HBcAb and positive for HBsAb.
What does this mean in relation to his HBV status?
Scenario 7.
How common is chronic HBV carrier status in UK pregnant women?
Scenario 8.
What is the risk of death from chronic HBV carrier status?
Scenario 9.
A primigravid woman at 8 weeks gestation is found to be non-immune to HBV. She has recently married and her husband is a chronic carrier. What should be done to protect her from infection?
Scenario 10.
A woman is a known carrier of HBV. What is the risk of vertical transmission in the first trimester?
Scenario 11.
What is the risk of the neonate who has been infected by vertical transmission becoming a carrier without treatment?
Scenario 12.
Should antiviral maternal therapy in the 3rd. trimester be considered for women with HBeAg or high viral load?
Scenario 13.
How effective is hepatitis B prophylaxis for the neonate in preventing chronic carrier status as a result of vertical transmission?
Scenario 14.
Can a woman who is a chronic HBV carrier breastfeed safely?
Scenario 15.
Hepatitis B infection is the most dangerous of the viral hepatitis infections in pregnancy.
Scenario 16.
A pregnant woman who is not immune to HBV has a partner who is a chronic carrier. Can HBV vaccine be administered safely in pregnancy?
Scenario 17.
A pregnant woman who is not immune has a partner with acute hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How should she clean the surface to ensure that she gets rid of the virus?
Scenario 18.
Is it true that the presence of HBeAg in maternal blood is a particular risk factor for vertical transmission? Not really a scenario, but never mind!
Scenario 19.
Does elective Cs before labour and with the membranes intact reduce the vertical transmission rate?
Scenario 20.
Which hepatitis virus normally produces a mild illness, but represents a major risk to pregnant women, with a mortality rate of up to 5%?
Scenario 21.
A pregnant woman has a history of viral hepatitis and informs the midwife at booking that she is a carrier and that she has a significant risk of cirrhosis and has been advised not to drink alcohol. Which is the most likely hepatitis virus?
Scenario 22.
Which hepatitis virus is an absolute contraindication to breastfeeding after appropriate treatment of the infected mother and prophylaxis for the baby?
Scenario 23.
Which hepatitis virus is linked to an increased risk of obstetric cholestasis?

22.         EMQ. Clue cells, koilocytes etc.
Lead-in.
The following scenarios relate to genital infection.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
Ct:                     Chlamydia trachomatis
FPA:                  Family Planning Association
HSV:                 Herpes simplex virus
LGV:                 lymphogranuloma venereum
Ng:                    Neisseria gonorrhoeae
Tv:                    Trichomonas vaginalis
Option list.
A
Actinomyces
B
Bacterial vaginosis
C
Bacteroides
D
Chlamydia trachomatis
E
Chlamydial infection of the genital tract
F
Herpes Simplex
G
Human Papilloma Virus
H
Lymphogranuloma venereum
I
Monilia
J
Neisseria gonorrhoeae
K
Trichomonas vaginalis
Scenario 1.                
Which option or options from the option list best fit with “clue cells”
Scenario 2.                
Which option or options from the option list best fit with “fishy odour”?
Scenario 3.                
Which option or options from the option list best fit with “flagellate organisms”?
Scenario 4.                
Which option or options from the option list best fit with “inflammatory smear”?
Scenario 5.                
Which option or options from the option list best fit with “koilocytes”?
Scenario 6.                
Which option or options from the option list best fit with “non-specific urethritis in the male”?
Scenario 7.                
Which option or options from the option list best fit with “strawberry cervix”?
Scenario 8.                
Which option or options from the option list best fit with “thin grey/ white discharge”?
Scenario 9.                
Which option or options from the option list best fit with “white, curdy discharge”?
Scenario 10.            
Which option or options from the option list best fit with “frothy yellow discharge”?
Scenario 11.            
Which option or options from the option list best fit with “protozoan”?
Scenario 12.            
Which option or options from the option list best fit with “obligate intracellular organism”?
Scenario 13.            
Which option or options from the option list best fit with “blindness”?
Scenario 14.            
Which option or options from the option list best fit with “LGV”?
Scenario 15.            
Which option or options from the option list best fit with “multinucleated cells”?
Scenario 16.            
Which option or options from the option list best fit with “serotypes D–K”?
Scenario 17.            
Which option or options from the option list best fit with “serovars L1-L3”?
Scenario 18.            
Which of the following are true in relation to Amsel’s criteria?
A
used for the diagnosis of bacterial vaginosis
B
used for the diagnosis of trichomonal infection
C
clue cells present on microscopy of wet preparation of vaginal fluid
D
flagellate organism present on microscopic examination of vaginal fluid
E
pH ≤ 4.5
F
pH > 4.5
G
thin, grey-white, homogeneous discharge present
H
frothy, yellow-green discharge present
I
fishy smell on adding alkali (10%KOH)
J
fishy smell on adding acid (10%HCl)
K
koilocytes present
L
absence of vulvo-vaginal irritation
Scenario 19.            
Which of the following are true in relation to Nugent’s Amsel’s criteria?
A
used for the diagnosis of bacterial vaginosis
B
used for the diagnosis of trichomonal infection
C
clue cells present on microscopy of wet preparation of vaginal fluid
D
pH ≤ 4.5
E
pH > 4.5
F
count of lactobacilli
G
count of Gardnerella and Bacteroides
H
count of white cells
Scenario 20.            
Garnerella vaginallis can be cultured from the vagina of what proportion of normal women?
A
< 10%
B
11 - 20%
C
21 - 30%
D
31 - 40%
E
41 - 50%
F
> 50%





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