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00:00in the heart of liverpool okay let's go is an operating theater like no other
00:09doctors are the pinnacle of their profession ah big nest of vipers that's all totally abnormal
00:20fight to save lives are you all right buddy a bit of pain there yes down my face in neurosurgeon
00:28being able to change lives for the better there's no other job that i'd rather be doing it's high
00:34stakes surgery this is amazing i've not seen anything like this before ready study go if you
00:41cause an injury to the brain or the spinal cord you can't repair it that's it forever using
00:46groundbreaking technology making life or death decisions oh yes a sea of blood if we don't do
00:55anything should die he needs to wake up i think it's gone well it feels really good i love it
01:02when a plan comes together this is trauma room one
01:07the walton center in liverpool is one of the busiest neurosurgical hospitals in the uk
01:23carrying out 6 000 procedures every year
01:27today 34 year old milton needs urgent surgery to tackle a life-threatening condition
01:38i was getting severe headaches i was just in pain i couldn't walk straight and i was just throwing up
01:48a lot of stuff i went to a and e and that's when they admitted me and i was busy
01:54while in a and e doctors discovered a dangerous buildup of pressure in milton's skull
02:04the pressure meant he was at risk of brain damage or even death
02:10as an emergency measure to relieve the pressure doctors inserted a tube into milton's skull to drain away excess fluid
02:17fluid okay can you just confirm what you're having done today for us
02:23starting to reduce pressure from our brain yeah correct but it's not a permanent solution one two three
02:34and consultant neurosurgeon mr david lawson is about to operate
02:38it seems that there is some sort of mass
02:44or lesion in the back of his brain you can see this white mass here with a dark center and that
02:53shouldn't be there and it's causing problems with blocking the normal fluid drainage channels in the brain
03:01so he won't be able to talk he won't be able to move and within a relatively short time after that
03:16key functions within the brain are compromised and then his heart will stop beating and his breathing
03:24will also stop and he will die but the surgeons need to discover what the abnormal mass in milton's brain
03:32actually is it's some sort of tumor we think or potentially some sort of infection
03:41either way milton's life is at danger as a result of that
03:45mr lawson and neurosurgical registrar mr ahmad ali need to remove the mass immediately
03:57this operation is classed as a risky operator because above the tumor or the lesion whatever
04:03it's going to end up being our two big veins which drain the blood from the brain so we want to be very
04:08careful not to injure those and then the other thing is at the brain stem which is where a lot of our
04:13control centers for our breathing and our heart radial so um we want to be very careful not to go too
04:19far deep no problem it's all right start with yep thank you okay can i have a monopolar please
04:32the surgeon's first step is to open milton's skull
04:37about there there you
04:43we're drilling at the back of the skull
04:48whatever is underneath here is what we're trying to get to the bone in this region can be quite thick
04:59once they've accessed milton's brain the surgeons will be able to get to the abnormal mass
05:13over 50 000 spinal surgeries are performed in the uk every year and the walton center is one of the
05:25busiest spinal surgery centers in the country
05:31you've already marked her and everything okay perfect 40 year old annie from north wales has
05:38arrived at the hospital for urgent surgery to remove a lump from the back of her neck
05:45i've been having weakness and more so in my left arm for quite some time
05:50and a weird sensation of it being really cold it feels like you've got like a plastic skin all over
05:56the area that's not yours i had an mri scan and it was thought that it was going to be protruding discs
06:02pressing on the spinal cord happens to be a tumor
06:05i haven't got your signature there yeah it's right underneath the brain stem
06:10it's a real shock because suddenly oh you've got quite a big tumor that's pressing on your spinal cord
06:17if you don't get it seem to you're going to be paralyzed it's a big tumor between c naught and c1
06:26consultant neurosurgeon mr nish shriekandaraja is in charge of annie's case
06:33so this is how it should look if you look at the bottom end of the spine you've got spinal cord and
06:37a nice amount of white fluid around it you can see at the top end here that there's a tumor which
06:42shouldn't be there it's almost like a golf ball just completely pressing on the spinal cord
06:47where all the nerves are bundled up so that's why she's losing power in her arms and legs
06:54mr shriekandaraja plans to remove a portion of annie's spine
06:58so that he can reach and remove the tumor that's compressing her spinal cord
07:08without an operation the quality of annie's life will be severely limited
07:12the worst case scenario for her is that she becomes completely weak in her arms and legs
07:19and she's bed bound for the rest of her life yeah happy yeah but spinal surgery is a risky procedure
07:28there's two important vessels that go down the side of the spine that supply blood to the brain
07:33so they're called the vertebral arteries and if you injure them then basically it could end up
07:38giving a stroke to the patient as well so you have to be very cautious in your approach and respect the
07:44anatomy there's a high risk of paralysis when you're working at the top end of the spine because it's all
07:49the nerves that supply your arms and your legs you only go there when essentially you've got a gun to
07:55your head and you have no other choice okay so that's c3 we're just going from there to there
08:05bipolar to me mr shriekandaraja and consultant neurosurgeon mr matthew stavell begin
08:16there's a lot of muscles on the back of the neck with a lot of good blood supply so it can bleed quite a lot
08:20if we are unfortunate enough to go into an artery she doesn't get blood to her brain and then the
08:30stroke may happen could i have a um another blunt hook please annie's future is on the line
08:50the walton center in liverpool one of the busiest neurosurgical hospitals in the uk
09:05carries out 6 000 elective and emergency procedures every year
09:12earlier today 34 year old milton was rushed to the hospital for urgent surgery
09:16okay right have we got enough exposure the pressure in milton's skull has been pushed
09:25dangerously high by an unidentified mass it could be a life-threatening tumor or the result of infection
09:35mr lawson and mr arley need to take it out
09:38we've removed this bit of bone at the back of the head where we expect the top of the tumor or
09:47infected area to be and then if we go into the brain a bit not too far i hope we'll find what it
09:53is we're looking for and that will tell us at least what we're dealing with jameson scissors right hand
09:59and of the number seven please yeah this is a very delicate part of the operation so you have to be
10:10very careful thank you if the pressure around that region increases during surgery or you interrupt a
10:19key blood vessel or blood supply to that region of the brain the patient can end up with deficits like
10:26stroke and they may even die mr lawson proceeds with extreme caution
10:42so you see the swollen bit of cerebellum here and you can see some blood vessels and it looks
10:47dusky and bruised up here and then you see this sort of bobbly like material and that is abnormal
10:56it looks more like tumor than infection but i i may be wrong it's it's you can't tell at this stage
11:06very easily okay can i have bipolar please
11:12and jameson scissors
11:16okay so that's for a quick smear please a smear or sample is prepared for the team in the hospital's
11:22laboratory to analyze do you see the way it's moving as a block at the moment
11:31i wouldn't dream of trying to guess what this is
11:34the weight to find out exactly what the mass is continues
11:5640 year old annie has a golf ball sized tumor in her neck that if left unchecked could leave her paralyzed
12:04so you have a blunt hook normal blunt hook mr shrie kandaraja and mr stovall are carefully working
12:14their way towards the spinal cord where the tumor is located
12:20the back of the spine you're protected by rings of bone this is one of the smallest rings at the top end
12:27that we're removing carefully
12:35bone removed time to tackle the tumor
12:41this is that kind of high risk low reward section now yeah two please i'll do it with my right hand
12:47and give us more expression more space i'm going to make it bleed though but the tumor is close to
12:54blood vessels that carry essential oxygen and nutrients that allow annie's nervous system to function
13:02function we're trying to get a good exposure on the left hand side because that's where the tumor is
13:06but the vessels are saying hello to us over there
13:15there's a serious bleed uh flow steel another patty
13:22patty to me i'm almost there almost ready ready one second no not ready i'm gonna get this right out
13:29patty where's the patty bleeding could cause annie to have a stroke
13:38the team has to stop it fast got it that's fine got it whenever you get an issue in surgery you have
13:48to remain uh completely calm so my first thing i always do is i'll take a breath just uh order my
13:55thoughts so the first thing you've got to do is gain control of yourself before you can control the situation
14:01yeah yeah ready
14:08lovely that's a bit of a warning shot it's telling us to behave
14:16okay another hitch please bleed stopped the surgeons can now see what they're dealing with
14:21so matt i think that's the tumor there i think so yeah yeah it's nice to see it yeah it's nice when
14:31you can see your enemy completely
14:34tumor located now to take it out there's two parts to this tumor one's outside of the spinal cord
14:43and one part of it is inside the spinal cord there's a big component just outside the spinal cord
14:48pushing on it so we're taking that component out now
14:58there's the root there
15:06number eight
15:07so every time you go into it matt it'll bleed
15:29this is tenacious beating
15:31it's another unwelcome bleed
15:33you agree with what we're doing nish yeah
15:41once again annie's at risk of having a stroke
15:47the walton center serves the northwest of england and north wales
16:09liverpool-based rob is having surgery to tackle a condition that's been blighting his life for years
16:14it's probably been about five and a half year journey
16:21first started off with some light tingling down my right arm so i thought i'd done something to my arm
16:27but then said well no it's actually your spine squeezing on the nerves
16:33when it's really bad it's like being electrocuted neck shoulder to arm every 10 minutes
16:38so fingers crossed this will be a game changer today
16:52consultant neurosurgeon mr narendra rath is preparing to operate
16:58so we've got robert today who's a 55-year-old gentleman the condition he has got is the cervical
17:03stenosis or tightness of the channel through which the nerve travels
17:11rob is one of 1.6 million people in the uk who have spinal stenosis
17:18mr rath will be performing endoscopic or keyhole surgery
17:23we're looking at the mri scan of robert the channel you see here which i call the slip roads
17:29of the motorway is free whereas this one appears to be narrow so we will be putting a camera through
17:38the back of the neck and shave the part of the bone off so that the nerve becomes free
17:48white screen can go backwards please it's a complex procedure
17:53preparation for the operation is key it has to be spot on check please
18:07again that's why we make sure that my angle of the surgery is right because a one degree two
18:14degree difference of angle on the top will make a big difference in the bottom so getting it right
18:20from the beginning is very very important right oh let's do it
18:30i do a lot of my cases endoscopically the main advantage of it is minimal tissue damage and because
18:37it's a very small incision which is less than a centimeter it would also mean that there is less
18:44chances of infection other advantages are that because of minimally invasive nature of it the
18:51recovery is very quick but inevitably there's some risk surgery comes with a risk nerve root injury
19:00paralysis the other risk is the dural injury that is the bag of fluid in which the nerves are floating or
19:06in this case the cord is floating can cause injury okay happy everyone okay to start knife please
19:24just want to make sure there is on the bone yeah i think it's very important to be meticulous
19:29the pilot in a in a plane for example he carries the life of so many passengers with us so in me i
19:37have to carry the responsibility of that patient whom i'm operating on so being meticulous and being
19:42precise and doing it in a planned way is the key to success yeah that's done yeah so that has gone down now
19:51what we are doing right now is creating the path for the surgery mr rath is creating a channel through
20:03the muscle and fat in rob's neck that feels like bone to me yeah just creating enough space
20:12the main concern is muscle and stripping bleeding bleeding bleeding could cause paralysis this area of
20:25the neck is always very prone to bleeding
20:31and rob has developed a bleed once it starts bleeding then it's difficult to control it
20:37the possibility of a pain-free future for rob depends on mr rath
20:59surgeons mr lawson and mr ali are attempting to remove an abnormal mass inside 34 year old milton's brain
21:08the hole in the skull is this bit here there's a little bit of normal brain there
21:16but basically squeezing out is this mass the mass is causing the pressure inside milton's skull to rise
21:25to dangerous levels the brain is under quite a bit of pressure looking at this coming out to meet us
21:32but the surgeons don't know yet whether it's a tumor or something else
21:38trying to take out as much as we safely can bipolar please
21:44whatever the mass is it's putting milton's life at risk
21:48but the operation to remove it also presents danger
21:52we're in a part of the brain called the cerebellum top of the center is away from the brain stem
21:58so the cerebellum is like this and then right in front of it is the brain stem and we're coming in from
22:03the back like that the brain stem is the bit where if you damage that patients can lose the ability to
22:09breathe lose the ability to control their own heart rate lose consciousness
22:12the brain stem is proceeding with extreme caution mr lawson starts to remove the mass
22:20pulse
22:30pulsing like jellyfish
22:31straight micro scissors thank you forceps right hand thank you
22:40good
22:48okay there we go
22:50got it thank you with the mass out mr lawson hands to mr ali
22:59armad is now doing very important bit of the operation he's closing and that doesn't sound
23:08like much but it's critical to how well the patient does afterwards we have to stop the fluid that the
23:14brain floats in leaking out because then he might get meningitis and we don't want milton getting
23:19meningitis and the chances of infection are also governed by how well the wound is closed
23:25so these things make it critical
23:28while mr ali closes oh hello it's david lawson here neurosurgery down in theater seven
23:33hiya i was wondering if we had a smear result from milton mr lawson chases pathology okay
23:44okay we'll we'll need to wait and see what's going on
23:46the wait for milton's results continues
24:03in liverpool the walton center is at the cutting edge of life or death procedures
24:1040 year old annie has a tumor on her spine
24:13it's compressing her nerves and could leave her paralyzed
24:21going party
24:24but before the surgeons can remove the tumor they must stop a bleed that's putting annie's brain at risk
24:32party to me place your finish quick quick happy to that tell me when you're ready
24:38party to me buddy to me
24:43the blood vessel bleeding is not great you can't see what you're doing the patient needs their blood
24:51and then if you block it or injure it you'll get a stroke and the second one ready to go go for it
24:57a combination of tiny surgical patches another one and a blood clotting agent stop the bleed
25:09there we go there we go this budget gave us a bit of a warning
25:21with the bleeding under control the surgeons can start to remove the tumor that's causing annie to lose
25:27the feeling in her arms
25:30bipolar so the key is to get out as much as you can so it basically frees up the spinal cord
25:36maybe i'll cut a bit smaller for sure sharp the curve scissors
25:41i'm trying to transect it here
25:44but the tumor has attached itself to both the outside and inside of annie's spinal cord
25:50uh curve micro it's just a bit more outside the spinal coverings than inside than i was
25:57i personally was expecting
26:01just go for it matt cut across i'll come this way i'll come down actually
26:08that's it yeah by further
26:11so now this is the uh outside part of the tumor and now we're going to go inside the leathery sack
26:20of the spinal cord to have a look for it inside and take out that part as well so we're attacking
26:25it from two angles and then i think we should be winning hopefully it's just trying to make sure we
26:32don't leave any tumor behind that we can easily get and now we're going to do the last little five percent
26:41so there's another decision to make i wonder if we take those nerve rudits
27:11you have nerves coming out along your spinal cord
27:17some of these nerves are basically more important than others and luckily for us this nerve at the
27:22top wasn't too important it's not providing it for example the power to your hand or your legs
27:28it's just providing sensation at the back of the neck because the tumor is originating from this nerve
27:34itself you've got to cut the actual nerve and by cutting the nerve you're basically sacrificing
27:40its function but because she'll only maybe be slightly numb in her neck that's it that's a sacrifice
27:45for me worth taking for the patient in order to take out the tumor completely so these are the nerve
27:50roots we're just cutting through the rootlets rootlets sorry yeah
27:54now let's see if we can get that tumor out
28:04there's some tumor there on yeah on please on
28:09scissors please
28:11after more than two hours of surgery the team extracts the remains of the tumor tumor
28:24the thing we've taken out most of the tumor now we're just making it look a bit more pretty
28:29i think bipolar that man and then we're done
28:38i think that's pretty good that's great i think it looks great man
28:46we're very happy
28:50but before they can claim complete success the surgeons must wait for annie to wake up
28:59and then we're going to be able to get out of the room
29:04and then we're going to be able to get out of the room
29:06and then we're going to be able to get out of the room
29:09earlier today 55 year old rob was taken into theater
29:13for an operation to prevent him from losing the sensation in his arms
29:20where are we here we are
29:21sections of bone in rob's spine are compressing the nerves in his spinal cord
29:29mr rath is using keyhole technology to cut the bone away
29:39but mr rath is working hard to control the bleed
29:42the joys of doing it through a keyhole is you can specifically see where it is bleeding
29:52and you can stop it there and then
29:56by cauterizing or heating and sealing the areas that are bleeding he stems the flow
30:01so now we understand which gap we need to go into to free the nerve so slowly we are making progress
30:24the part of rob's spine compressing his nerves begins to emerge
30:27so slowly it will come you need to keep the tip please
30:33yeah see that now this is bone yeah this is c7 so this is all needs to go to free the nerve up
30:42mr rath is operating within millimeters of the spinal cord
30:46that transmits commands from rob's brain to the rest of his body
30:51so there's a lot of hand and eye coordination in these procedures
30:55normally i use everything in my right hand but i have developed the skill to use my left hand for this procedure
31:08okay burr please cutting now
31:16okay
31:17now we can see the channel and the nerve
31:23this is the important part of it because we need to make sure that it's done very carefully
31:39scissors please
31:48so now i'm going to just go and and just take a bite
31:58here we are that's divided three bites nice in yeah okay so now we have defined where we wanted
32:08to go what we are going to do is create the channel and then shave off this area a bit more
32:13to make the nerve completely free
32:18if mr rath can free the nerve rob can return to a life without pain and with the full use of his hands
32:24hands and fingers
32:25seven days ago milton had an abnormal mass removed from his brain
32:42into the mouth and uh...
32:46like the brain and handlers need to run the nerve
32:47and the body and the body and ability to take 2 parts to bend and the mass to the pathology
32:50so if i can see it's going to be very carefully
32:51so if i can see it i'm gonna get into it
32:52has the results. This is his post-operative scan and you can see there's just a gap where this large
33:00lump was. Now this has in fact come back as something called a tuberculoma which is infection
33:10rather than tumour. But it's not great news, it does mean he has significant tuberculosis within
33:17his brain and that can kill you. Tuberculosis or TB is caused by bacteria, it usually spreads through
33:26the air. Most people think about TB being in your lungs and people coughing and spluttering and
33:33being shedding infection in the droplets that they cough up. He's not coughing, he's remarkably
33:40untroubled by this from a lung perspective but the organism has reached his brain and has caused a
33:48reaction within the brain and formed not quite an abscess but something more solid comprised of
33:56infected brain tissue and the reaction of the immune type cells within the brain and the organisms that
34:04they're trying to eradicate. But they haven't managed to and that's why he's got this lump.
34:11Come in.
34:16Hi Milton. Hi, are you all right?
34:18How are you doing now? Yeah, I feel better today.
34:21You feel a bit better. The infectious diseases team are now treating you for tuberculosis
34:28but they want us to get some more bacteria probably from your lymph gland to find out if any of the
34:35tuberculosis bacteria are resistant to certain antibiotics. It'll take a little bit of time to get
34:42the results from that but as soon as we know we'll tell you how long you actually need to be in hospital
34:48before you can go. But basically you're going in the right direction. I'm very pleased that you're
34:55doing this well. I don't know. And I bet you're desperate to get out.
35:0024 hours ago, 40-year-old Annie faced losing the use of her arms and legs.
35:19The worst case scenario was complete paralysis below the site of the tumour so my life would have been
35:25changed forever. That's it. So now this is the outside part of the tumour.
35:33But the surgeons removed a tumour that was compressing her spinal cord.
35:39Being able to do rare cases and complex cases for me especially, you know, it drives me forward.
35:45Certainly I think if you're a surgeon in this field, it's something which you need to embrace.
35:49Yeah, I love it. Today, Annie's recovering.
35:58I'm feeling tired, a bit battered and bruised but super successful outcome.
36:06I'm noticing temperature in this hand a lot more than I would have done.
36:12They had the aircon on last night on the wards and this arm would have been absolutely freezing when
36:20the tumour was there. But my whole body felt the same temperature.
36:25I want to get back to just normal what we've seen, normal life.
36:29This has been such a shock that there's going to be certain things that I'm just going to
36:33grab by the horns and just do now. When a patient is able to go home without
36:42that level of immobility they had before or they're able to go home with their pain significantly reduced,
36:49it's a priceless feeling for us as a surgeon. All we want is for our patients to get better.
36:57That's why we go into the job we do. The surgeons, well, I can't thank them enough, really.
37:05The outcome could have massively, significantly changed my life.
37:27Today, 55-year-old Rob is at the Walton Centre in Liverpool, having surgery to free trapped nerves in his spine.
37:37The nerve will be below, below this where I'm cutting.
37:41Mr Rath is using keyhole surgery to remove sections of bone and create space for the compressed nerves.
37:48Mr Rath. Okay, scissors please. Okay. So now we gently go, just below this is the spinal cord.
38:02And I'm just trying to take the tissue off from the top.
38:13He's working close to the spinal cord.
38:15So that white structure you see is the spinal cord.
38:23Any wrong move can cause damage to the cord or the nerve root, which you need to be very careful about.
38:28Try to be away from it, cause no damage to the cord.
38:33If he does damage the spinal cord, Rob could be paralysed.
38:39Here we are, yeah. That's the nerve coming out here.
38:42I just need to open this channel a bit more.
38:49It's a painstaking procedure.
38:55You have to have patience.
38:57Standing on that small two foot by two foot area and doing an operation for hours can be very difficult,
39:04and especially with all the protection we wear. So it takes a lot of concentration to do that.
39:10But thankfully we have got a, it's not me who's operating, it's the whole team operating.
39:15So where are we? Is there anything there? No.
39:26The nerve is free. And the disc which we had seen previously is not compressing the nerve.
39:32Perfect. Save that please. Thank you. Closing.
39:36All right. I'm done then, yeah?
39:48So we achieved what we want to achieve. We have freed the nerve up completely.
39:51Hopefully it will be pain-free after operation and go home today.
39:55A final post-operative assessment will see whether Rob will return to a pain-free life.
40:04Two weeks ago, 34-year-old Milton had an abnormal mass removed from his brain.
40:20The mass, diagnosed as tuberculosis, was causing the pressure in his skull to rise to dangerous levels.
40:28Now, with the mass removed and with the help of steroids and antibiotics,
40:33he's making a slow but steady recovery.
40:37I couldn't, I couldn't really see properly. I couldn't work properly.
40:41So I can see the progress. I can see the light at the end of the tunnel.
40:48I think Milton's doing really well. Psychologically it might be a bit difficult for him because
40:53he has to have treatment for several months. It's a long process.
40:59I think that does impinge on your general well-being. Hopefully he'll see the good side,
41:05which is he stays alive and he makes a recovery.
41:10Milton's recovery is continuing at the Royal Liverpool Hospital's infectious diseases unit,
41:15where he can receive specialist treatment.
41:20So I just want to be back to where things were, like before this brain surgery and that,
41:26to be able to just do my day-to-day life. So for now I'm just happy to be alive.
41:32I'm often operating on situations where I'm preventing somebody getting worse if I'm lucky.
41:44I don't always make them better. But if you see a definite improvement in somebody and you know that
41:52it will be long-lasting, it does make you feel as if the whole process has been worthwhile.
41:59And it gives you a sense of satisfaction and well-being.
42:13Less than six hours ago, 55-year-old Rob had surgery on his spine.
42:18Hospital too.
42:22Now his surgeon, Mr. Rath, is doing his rounds.
42:25Hi, Robert. How are you, mate?
42:28Oh, yeah. Good.
42:30Feeling all right?
42:31Thanks, Mr. Rath.
42:32Good? Yeah, yeah. A little groggy, but yeah.
42:34Mr. General, I see you sometimes makes you feel groggy.
42:36So everything went well?
42:37Yeah, perfect. Perfect. As per plan, as I said, we did it through a keyhole.
42:41The nerve was completely free. Yeah?
42:44Okay.
42:44So you should have a good result. Let's take a couple of steps then.
42:48Yeah, a little bit wobbly actually.
42:51Good, man. Fantastic.
42:55The hand's better. That was like, doing that. So that's a good sign.
43:02It's encouraging. I mean, people have been great here.
43:05Yeah, you put your faith in the team.
43:07Good. Come on, have a seat now.
43:08That's a bit ambitious.
43:10Yeah? Come on.
43:11Robert is doing very well. His pain is much, much better than what it was.
43:17I'm hoping that by the end of the day today, he'll be going home.
43:21Good, man. Good.
43:22Okay?
43:23All done, man. Thanks very much. Thanks for all your help.
43:26A bit of hospital taste and a bit of luck. Yeah.
43:30As a surgeon, that's the primary thing. A smile on his face makes the difference to me.
43:36If I can bring anything better for him, that's the whole aim of the surgery.
43:41It's an immense pleasure to bring some happiness to somebody. And I can't explain it by words.
43:46I think it's something you enjoy from inside.
43:59All right.
44:00I think everybody has been a pretty good in my specificway morning.
44:05I think I've got a great job.
44:10Everyone has beenocus, and I've got things down, and are the third time.
44:17If you like getting everything out of where you can come to my decisions.
44:21Transcription by CastingWords
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