BACKGROUND: Patients undergoing shoulder surgery in the beach chair position (BCP) may be at risk for adverse neurologic events due to cerebral ischemia. 0000038342 00000 n 0000004336 00000 n 0000100705 00000 n Arthroscopic shoulder surgery can be performed in both the beach chair and lateral decubitus positions. 0000009051 00000 n To perform arthroscopy surgery in the beach chair position successfully, meticulous care during patient positioning and setup must be taken. In summary, the technique, advantages, disadvantages, and risks of the BC position have been described in this Technical Note to help physicians position their patients in the most advantageous position for shoulder arthroscopy. 0000101995 00000 n Online ahead of print. Conclusion: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. You will then receive an email that contains a secure link for resetting your password, If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password. Product demonstration video for the Cardinal Health™ Beach Chair Shoulder Drape (cat. 355 0 obj <>stream Shoulder arthroscopy is an orthopaedic procedure that has grown significantly in popularity over the last 40 years. Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center/Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A. M.T.P. Since the introduction of the beach chair position for shoulder arthroscopy, orthopaedic surgeons have debated whether the beach chair or lateral decubitus is superior. For the vast majority of all shoulder arthroscopic procedures, patients can be positioned in either the beach chair (BC) or the lateral decubitus (LD) position. 0000007344 00000 n The main topics of controversy include the ease, efficiency, and economics of setup; the visualization of and access to the surgical site; and the risks to the patient. 0000102278 00000 n 0000037739 00000 n Arthroscopic shoulder surgery can be performed in both the beach chair and lateral decubitus positions. Complications of The Beach Chair Position Robert R. Kirby David J. Cullen CASE SUMMARY A 61-year-old, American Society of Anesthesiologists physical status classification I (ASA I), male patient underwent general anesthesia for repair of a torn rotator cuff in his right shoulder. This position is … image, Position the patient properly in supine position, Position the patient to ensure the buttocks will be pressed against the back of the bed, Shift the patient so the medial scapula is on the edge of the bed, Several folded surgical towels can be placed medially to the scapula to improve position, Confirm the buttocks' position against the back of the bed, Place a large pad or several pillows underneath the patient's legs, Secure the nonoperative arm to the patient's abdomen or on an arm board, A variety of methods can be used, but maintenance of a neutral position is vital, Position the arm in the proper position using an arm-positioner, Be aware when applying traction to avoid neurologic damage, Secure the patient's position with a safety-belt and tape, To provide the surgical team the appropriate amount of space, Favorable teaching environment with upright anatomic position, Increased risk for cerebral hypoperfusion and hypotension, Reduced visualization of the complete glenohumeral joint for instability and superior labrum anterior-to-posterior (SLAP) repairs, Easier conversion to an open procedure or general anesthesia (if complications arise), Limited access to the posterior and posterior-inferior aspects of the joint, Increased access to the anterior, superior glenohumeral joint and subacromial space, • Slowly raise the head of bed during patient positioning to avoid iatrogenic hypotension, • Be aware of potential for cerebral hypotension, ○ Consider using a beta-blocker (per anesthesia team), ○ Consider location of blood pressure cuff placement, • Position buttocks up against bed to avoid pressure injury, • Avoid excessive ER to prevent brachial plexus strain, • Avoid contralateral elbow flexion beyond 90° → ulnar nerve, • Difficult low-anterior portal placement, ○ Place head/neck in neutral to decrease risk of hypovascular incidents, • Ensure proper padding at the knees → peroneal nerve irritation, Redistribute or republish the final article, Translate the article (private use only, not for distribution), Reuse portions or extracts from the article in other works, Distribute translations or adaptations of the article. Avoiding complications in shoulder arthroscopy: Pearls for lateral decubitus and beach chair positioning. This Technical Note details the operating room setup for shoulder arthroscopy in the beach chair position. To perform arthroscopy surgery in the beach chair position successfully, meticulous care during patient positioning and setup must be taken. 0000074000 00000 n Neurological complications due to arthroscopy. N.N.V. Shoulder arthroscopy in the BC position is performed in the supine position, and can be conducted under general or regional anesthesia. xref Pillows are placed beneath their ankles and knees and behind their head. The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. 0000007522 00000 n 0000004571 00000 n The SchureMed Powered Beach Chair offers a built-in, self-contained motor that doesn’t require power from the surgical table, allowing for greater positional flexibility in the operating room when proceeding with shoulder surgery, such as shoulder arthroscopy. beach-chair position with use of controlled hypotension. 0000005016 00000 n 0000101046 00000 n 0000030225 00000 n This Technical Note details the operating room setup for shoulder arthroscopy in the beach chair position. 0000005970 00000 n 75 . 0000037798 00000 n 0000006368 00000 n Compared with the lateral decubitus position, the BCP provides anatomic positioning of the shoulder, reduces risk of brachial plexus injury, and improves airway access. The present report describes optimal management of cerebral oxygenation during arthroscopic shoulder surgery performed in the beach chair position. lateral decubitus position in shoulder arthroscopy. 0000003223 00000 n 0000072784 00000 n It allows for a single position for all surgery. We investigated whether pre-induction values of mean arterial pressure (MAP), stroke volume variation (SVV), cardiac index (CI), and stroke volume index (SVI) can predict … Patient positioning, portal placement, normal arthroscopic anatomy, and diagnostic arthroscopy. startxref If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. This Technical Note details the operating room setup for shoulder arthroscopy in the beach chair position. The advantages of the beach chair position include the ease of setup, limited brachial plexus stress, increased glenohumeral and subacromial visualization, anesthesia flexibility, and the ability to easily convert to an open procedure. reports personal fees and nonfinancial support from Arthrex; personal fees, nonfinancial support, and other from Arthroscopy; personal fees and nonfinancial support from Arthrosurface; other from Cymedica, personal fees and nonfinancial support from DJ Orthopaedics, personal fees and other from Minivasive; other from Omeros; personal fees and nonfinancial support from Orthospace; personal fees, nonfinancial support, and other from Smith & Nephew; personal fees and nonfinancial support from Athletico; personal fees and nonfinancial support from ConMed Linvatec; personal fees and nonfinancial support from Miomed; personal fees and nonfinancial support from Mitek; personal fees and other from Vindico Medical-Orthopedics Hyperguide; other from Arthroscopy Association Learning Center Committee; other from Slack; other from American Orthopaedic Society for Sports Medicine, other from American Shoulder and Elbow Surgeons; other from Journal of Knee Surgery; and nonfinancial support from Ossur, outside the submitted work. The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. 0000005121 00000 n 0000100982 00000 n 0000004101 00000 n supraorbital nerve: face mask too tight or poorly padded across forehead . Sequential compression devices are placed on both lower extremities for venous thromboembolism prophylaxis (, After the patient has been transferred to the operating table and following the EUA, a team-based approach is used to ensure the patient is in the appropriate position prior to raising the back of the table up to the BC position. Current practice for the management of intraoperative blood pressure is derived from expert opinion among anesthesiologists, but there is a paucity of clinical data validating their practice. 0000101864 00000 n The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. 0000006208 00000 n This method of shoulder arthroscopy has been used … 0000006288 00000 n First, one should ensure that the patient is high enough on the table such that when the back of the table is raised, the patient's buttocks will be at the break of the bed; this will ensure the lumbar spine is in a favorable position during the procedure (, Next, the head is secured. Position: Sitting / Beach Chair, Operative arm will be suspended and the non-operative arm will be secured to an arm-rest Time: 1-2 hours (average) Blood Loss Risk: Moderate (50 – 200 ml) Post-op Pain: Moderate (3-6) Maintenance Paralytic: Yes. 0000074817 00000 n Shoulder arthroscopy is an orthopaedic procedure that has grown significantly in popularity over the last 40 years. 0000016641 00000 n 0000074151 00000 n The advantages of this position inc … Please enter a term before submitting your search. Routine arthroscopy, arthroscopic subacromial decompression, and arthroscopic shoulder stabilizations were performed, with no complications. The compact and … 0000101489 00000 n arthroscopic treatment include shorter operative time, im-proved cosmesis, and reduced morbidity and pain.3 Although shoulder arthroscopy can be performed in the beach-chair or lateral decubitus position, the majority of surgeons prefer the lateral decubitus position for posterior capsulolabral re-pairs.1,2 A major advantage of of shoulder surgery in the beach-chair position that resulted in death in 1 patient and severe brain damage in 3 patients. 0000073062 00000 n My preference is the beach chair position, which offers the advantage of being more anatomical. Abstract: Arthroscopic shoulder surgery can be performed in both the beach chair and lateral decubitus positions. 2020 Jun 23;S1058-2746(20)30489-4. doi: 10.1016/j.jse.2020.05.037. 2 Patients are placed upright at angles varying from 30 to 90 degrees above the horizontal plane (see Figs. Fig 2. 0000016986 00000 n 2016, © 2017 by the Arthroscopy Association of North America, We use cookies to help provide and enhance our service and tailor content. The use of metoprolol and glycopyrrolate to prevent hypotensive/bradycardic events during shoulder arthroscopy in the sitting position under interscalene block. Operative arm (right arm) of a patient placed in the beach chair position demonstrating securement of the head and neck with a foam mask (Spider Limb Positioner; Smith & Nephew). 0000011076 00000 n 0000003986 00000 n 0000100606 00000 n horizontal plane) is widely used for orthopedic shoulder arthroscopy procedures as it offers advantages such as excellent intraarticular visualization and reduced brachial plexus strain. In this position, traction is unnecessary, the shoulder is free to be passively manipulated throughout its full range of motion, and in situ capsuloligamentous anatomy may be appreciated in an undistorted position. The advantages of this position include ease of setup, lack of brachial plexus strain because no traction is used, … Arthroscopic shoulder surgery can be performed in both the beach chair and lateral decubitus positions. Orthopaedics & Traumatology: Surgery & Research, 2011. Setting up the patient to the Beach Chair position for shoulder surgery on Merivaara Promerix operating table. The advantages of the beach chair position include the ease of setup, limited brachial plexus stress, increased glenohumeral and subacromial visualization, anesthesia flexibility, and the ability to easily convert to an open procedure. Accepted: Beach Chair Position: The 2 common positions for shoulder arthroscopy are the beach chair position and lateral position. 0000074694 00000 n Our study suggests that patients may be able to safely tolerate a reductioninbloodpressuregreaterthancurrentrecommendations.Inthefuture,intraoperativecerebralmonitoringmayplay a role in preventing neurological injury in patients undergoing shoulder arthroscopy in the beach-chair … Shoulder arthroscopy is an orthopaedic procedure that has grown significantly in popularity over the last 40 years. 0000037251 00000 n In the beach chair position, used for shoulder operations, the operative site is higher than the right atrium. In this Technical Note, we describe a safe, reliable, and reproducible technique for patient positioning in the BC position for shoulder arthroscopy. Then your surgeon will make a small puncture in your shoulder (about the size of a buttonhole) for the arthroscope. This Technical Note details the operating room setup for shoulder arthroscopy in the beach chair position. 0000101264 00000 n Intraoperative photograph demonstrating operative arm (right arm) of a patient placed in the beach chair position using the Trimano commercial arm holder (Arthrex). 0000005813 00000 n The BC position creates a favorable teaching environment for experienced surgeons to teach and guide surgeons in training. 0000006048 00000 n Routine arthroscopy, arthroscopic subacromial decompression, and arthroscopic shoulder stabilizations were performed, with no complications. Beach Chair Position Some surgeons prefer the beach chair position for all shoulder arthroscopic work, and it is certainly the position of choice if arthroscoping the shoulder before stabilization. of the beach-chair position and induced hypotension on cerebral oxygen saturation in patients undergoing arthroscopic shoulder surgery. 0000005340 00000 n 261 0 obj <> endobj Purpose: This study investigated the effect of intermittent compression by a sequential compression device (SCD) on the incidence of hypotension and other hemodynamic variables in the beach-chair position. The advantages of the beach chair position include the ease of setup, limited brachial plexus stress, increased glenohumeral and subacromial visualization, anesthesia flexibility, and the ability to easily convert to an open procedure. 0000102142 00000 n Seven fresh-frozen cadaveric shoulders underwent shoulder arthroscopy in the beach-chair position. 0000006128 00000 n 0000003187 00000 n Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Your surgeon will first inject fluid into the shoulder to inflate the joint. 0000008757 00000 n reports other from American Orthopaedic Society for Sports Medicine; personal fees, nonfinancial support, and other from Arthrex; personal fees and nonfinancial support from DJO Surgical; other from Orthopedics; other from Orthopedics Today; personal fees and nonfinancial support from Ossur; other from SAGE; personal fees, nonfinancial support, and other from Saunders/Mosby-Elsevier; personal fees, nonfinancial support, and other from Slack; personal fees and nonfinancial support from Smith & Nephew, from Wolters Kluwer Health–Lippincott Williams & Wilkins, and other from American Shoulder and Elbow Surgeons, outside the submitted work. Fluid flows through the arthroscope t… Arthroscopy – Shoulder Anesthesia Implications. In either the beach chair or lateral decubitus position, shoulder arthroscopy begins with the establishment of a posterior viewing portal. trailer 0000005499 00000 n 0000005891 00000 n The beach chair position (BCP) is commonly used in shoulder arthroscopy.1,2 However, the sitting position is associated with significant reduc-tions in cardiac output, mean arterial pressure (MAP), and cerebral perfusion pressure (CPP), which persists for up to 30 min after the position- ing.3,4 Severe cerebral desaturation events,5,6 brain and spinal cord ischaemia,7,8 … The upright orientation of the patient helps trainees easily identify internal and external anatomic landmarks. Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. who presented for arthroscopic repair of the right shoulder with administration of an interscalene block and general anesthesia in the beach chair position. The 2 principle patient positions during shoulder arthroscopy include the beach chair position and lateral decubitus position. 0000020128 00000 n 0000004222 00000 n 0000005577 00000 n The authors typically use an arthroscopy pump system with the pressure initially set to 40 mmHg, with normal saline with 1:1000 epinephrine (typically 1 mL for a 5 L bag of fluid). 0000000016 00000 n The Safety of Controlled Hypotension for Shoulder Arthroscopy in the Beach-Chair Position Robert Gillespie, MD, Yousef Shishani, MD, Jonathan Streit, MD, J.P. Wanner, BS, Christopher McCrum, BS, Tanvir Syed, MD, Adam Haas, MD, and Reuben Gobezie, MD Investigation performed at the Case Shoulder and Elbow Service, Case Western Reserve University School of Medicine, … Shoulder arthroscopy with the patient in the beach-chair position. Background: Devastating transient and permanent postoperative neurocognitive complications in previously healthy, low risk patients have been observed after elective shoulder arthroscopy in the beach chair position (BCP). beach-chair position is used commonly in arthroscopic shoulder procedures and has been implicated as an independent risk factor for cerebral ischemia during surgery2,4,5 0000008554 00000 n failure to properly position and pad the patient can result in neuropraxia . Beach chair . 0000028308 00000 n The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. 58.1 to 58.3.) The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, U.S.A. 0000017424 00000 n Neurocognitive deficits and cerebral desaturation during shoulder arthroscopy with patient in beach-chair position: A review of the current literature. 0000101124 00000 n %PDF-1.7 %���� 0000038095 00000 n Most surgeons use the same patient position to perform all of their arthroscopic shoulder procedures, regardless of … 0000100786 00000 n If general anesthesia is used, the eyes can be protected with a padded face-mask; tape placed over the eyes by the anesthesia team will also protect against corneal abrasions. 0000019546 00000 n 0000101746 00000 n The beach chair position (BCP) is commonly used position in upper extremity surgery. Although there is a reduced risk of traction-based neurologic injury in patients who are placed in the BC position compared with the LD position. <<1FC7381A42708246AE79DCFF435004A4>]>> Shoulder arthroscopy can be performed in either the LD or BC position, with advantages and disadvantages to each position. Intraoperative photograph demonstrating an alternative approach to securing the head and neck with a foam headrest and tape/towel construct. Shoulder arthroscopy positioning: Lateral decubitus versus beach chair. 0000005260 00000 n The authors report the following potential conflicts of interest or sources of funding: J.T.H. We evaluated the use of the beach-chair, or sitting, position for arthroscopic shoulder surgery in 50 consecutive patients. 0000003016 00000 n The lateral decubitus position allows for excellent exposure to all aspects of the glenohumeral joint and is therefore frequently employed in procedures such as stabilization, in which extensive visualization of the inferior and posterior aspects of the joint is required. The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. In this Technical Note, we describe the necessary steps to safely and efficiently prepare patients in the beach chair position for arthroscopic shoulder surgery. Discussion. Patient positioned safely on the operating table.- Shoulder arthroscopy / - Thyrod ectomy / - Maxillofacial - Procedures / - Carotid access / - Neurosurgery Shoulder Arthroscopy in the Beach Chair Position @article{Higgins2017ShoulderAI, title={Shoulder Arthroscopy in the Beach Chair Position}, author={John D. Higgins and R. Frank and J. Hamamoto and M. Provencher and A. Romeo and N. Verma}, journal={Arthroscopy Techniques}, year={2017}, volume={6}, pages={e1153 - e1158} } A.A.R. 0000101207 00000 n April 6, The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. The head, 77 . My preference is the beach chair position, which offers the advantage of being more anatomical. Approximately 150 minutes after placement of the in-terscalene block and 90 minutes after being placed in the sitting position, the … Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to … November 16, The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. We evaluated the use of the beach-chair, or sitting, position for arthroscopic shoulder surgery in 50 consecutive patients. The 2 principle patient positions during shoulder arthroscopy include the beach chair position and lateral decubitus position. METHODS: Data were collected on 124 patients … The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. SHOULDER POSITIONING TRIMANO SUPPORT ARM (AR-1640) TRIMANO acts as the surgical team’s “third hand” by securely and safely holding the patient’s arm in desired positions during arthroscopic or open shoulder surgery performed in the beach chair position. 0000004909 00000 n Injuries to the brachial plexus are reduced compared to the lateral decubitus position, and the surgeon has excellent … x�tQK(Da�Ν;ff��adCc�F�B�CdLޏ��t�()�����@���`�L�Bz7Ȱei_�vF�'9��V܋��?���楶k���s�P��{8���s�o��B7�c6��T�=�����K���pIL��j�3#�ŖVu1����GzR�,�U�sɔ�p*쩎�訖�B�UV>-2&����8�4sĺ�٨�X�(x�PA)�Q ��r�b��HgI�����)#R�F�q%�Q".E��+z4=BmaX�q͜�)您]������wē���D���;�[I@�(Cϳ��#�c�N����� r�a �֧�{� ��. %%EOF DOI: https://doi.org/10.1016/j.eats.2017.04.002. Intraoperative photograph demonstrating the patient's hips positioned near the break of the bed in order to prevent the patient from slipping down the bed as the head of the bed is raised into the beach chair position. 0000004686 00000 n paresthesias over forehead and anterior scalp; great auricular nerve: face mask straps too tight … 0000038286 00000 n To put the patient into the beach chair position (Figure 2), the patient is placed on . shoulder arthroscopy can be performed in the beach-chair or lateral decubitus position, the majority of surgeons prefer the lateral decubitus position for posterior capsulolabral re- pairs.1,2 A major advantage of the lateral decubitus position is that circumferential access to the glenohumeral joint is optimized through balanced suspension.4 Surgeons who prefer the beach-chair position … Avoiding catastrophic complications of stroke and death related to shoulder surgery in the sitting position. The 2 principle patient positions during shoulder arthroscopy include the beach chair position and lateral decubitus position. 0000003058 00000 n Arthroscopic repair of the shoulder is one of the most commonly performed surgical procedures in the United States. 0000010826 00000 n In this investigation, we sought to determine the incidence of cerebral desaturation events (CDEs) during shoulder arthroscopy in the BCP or lateral decubitus position (LDP). - "Shoulder Arthroscopy in the Beach Chair Position" Intraoperative photograph demonstrating the use of sequential compression devices for venous thromboembolism prophylaxis during shoulder arthroscopy in the beach chair position. Technique for beach chair patient position setup of the right arm of a patient including examination under anesthesia, arm-holder device setup (Spider Limb Positioner; Smith & Nephew), and marking of anticipated portal placement with narration of all critical steps. (A, anterior; L, lateral; P, posterior. 0000015369 00000 n Address correspondence to Nikhil N. Verma, M.D., Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Midwest Orthopaedics at Rush, 1611 W. Harrison St., Suite 300, Chicago, IL 60612, U.S.A. Arthroscopic shoulder surgery can be performed in both the beach chair and lateral decubitus positions. Methods: Fifty healthy patients undergoing elective shoulder arthroscopy under general anesthesia were randomly assigned to either the control group (n = … The beach chair (barbershop) position was developed in the 1980s for orthopedic shoulder arthroscopy procedures. Key words: beach chair, cerebral perfusion, oxygen saturation, shoulder arthroscopy T'he beach chair position is widely utilized for arthro scopic and open surgery, accounting for the preferred position in approximately two-thirds of shoulder surgeries performed in the United States (1, 2). We hypothesized that the effect of placing a patient in the beach-chair po-sition and inducing hypotension during arthroscopic shoulder surgery would reduce cerebral oxygen satura-tion by greater than 10%. 261 95 0000009120 00000 n 0 Beach Chair . When the beach-chair position is considered, hypotension must be avoided and regional cerebral oxygenation should be monitored. 0000006448 00000 n Cerebral oxygen desaturation events assessed by near-infrared spectroscopy during shoulder arthroscopy in the beach chair and lateral decubitus positions. 0000012174 00000 n The 2 principle patient positions during shoulder arthroscopy include the beach chair position and lateral de- Offering premium surgical beach chairs for patient positioning during shoulder surgery, shoulder arthroscopy, and medical examinations. Philippe Massin ), Advantages and Disadvantages of Beach Chair Patient Positioning for Shoulder Arthroscopy, Pearls and Pitfalls Associated with Beach Chair Patient Positioning for Shoulder Arthroscopy, eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIwNGFhZmVkM2IzZDhjNGUxZDljY2UwMTNjMjI1ODNiMyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjIxNjc5Njk2fQ.LAQuikERYu1Y9pWdGrp-2mJa1dgyM7UShCZc2AmitIO241dqZ-b4UwNgalNC0k6hk3aPslqgBkgV8pcqLi1xxo2XNkikL1VMx09yUECO6XWSCt_LOJVcafIPtBzKsNQIbfqZ5qEACbi8_FxnIslUEBHHzf1smzWbIrDgpUiISpq_U3EtzCbrKz8DDOoY5C1VnpHzkFtsIcGEwspVYEjbPnMiytbRw-_FHSYrrI4mI0gWfJSa2A8QKU9bGwFUdwYc8DzEOtLILUzznt6BhCrbLSltVQPupKy0Lz1rXk2AbmpDLdEpK5VvOqRfOEpQh5M7djwzQE9Idvv-EZ7R9AppzQ, Creative Commons Attribution – NonCommercial – NoDerivs (CC BY-NC-ND 4.0), https://doi.org/10.1016/j.eats.2017.04.002, Shoulder Arthroscopy in the Beach Chair Position, View Large
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