What is new in management of Surgical Infection

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What is new in management of Surgical Infection

• Prof. Ravi Kant

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Contents

• Introduction
• Types of surgical infections
• Definition of SSI
• Types SSI
• Recent management of SSI
• sepsis
• Peritonitis

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Soft tissue/wound Infictions.

• Third most reported nosocomial infections
• 16 of all reported nosocomial infections
• Most common surgical patient nosocomial infection
  (38)

4
Soft tissue/wound Infictions.

• 2/3 involved surgical incision
• 1/3 deep structures accessed by incision
• Deaths in patients with nosocomial infections77
  related to infection.

EWMA Journal 2005 5(2) 11-15.
5
Introduction

• lt 1900 70-80 mortality for wound infection
• gt1900 Ignaz Semmelweis and Joseph Lister
  antiseptic surgery

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Introduction

• Surgery, trauma, non-trauma local invasion can
  lead to bacterial insult.
• Once present, bacteria, initiate the host defense
  processes.
• Inflammatory mediators (kinins, histamine, etc.)
  PMNs arrive, etc.

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Introduction

• Surgical infections
• surgical wound itself or in
• other systems in the patient.
• They can be initiated not only by damage to the
  host but also by changes in the hosts
  physiologic state.

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Infections

• Two main types
• Community-Acquired
• Hospital-Acquired

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Community-Acquired

• Skin/soft tissue
• Cellulitis Group A strep
• Abcess/furuncle Staph aureus
• Necrotizing Mixed
• Hiradenitis suppurativaStaph aureus
• Lymphangitis Staph aureus

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Cellulitis
11
Furuncle
12
Necrotizing
13
Hiradenitis
14
Lymphangitis
15
Breast Abscess
16
Peri-rectal abscess
17
Gas Gangrene
18
Paronychia
19
Diabetic foot infection
20
Biliary Tract

• Usually result from obstruction
• Usual suspects
• E. coli, Klebsiella, Enterococci
• Acute Cholecystitis
• GB empyema
• Ascending cholangitis

21
Community-Acquired

• Viral
• Hepatitis
• HIV/AIDS
• Tetanus

22
Hospital-Acquired

• Post-operative
• At the surgical site
• Systemic.

23
Infected Vascular Graft

• Inguinal incision is independent risk factor
• Length of case and blood loss
• Prosthetic grafts 10-20
• S. Aureus

24
Gas gangrene

• Beta hemolytic strept
• Clostridial perfringes (gram pos rods) rare
• 50 polymicrobial
• Rapid lysis of tissues with relatively little
  response from host
• Endotoxin

25
Gas gangrene

• Aggressive debridement antibiotics
• Repeat antibiotics

26
Catheter Sepsis

• 80 of cases, colonized catheters had been
  inserted by inexperienced and experienced
  residents
• Key is to identify before sepsis develops
• Stapylococcus epidermis, S. Aureus, yeast

27
Burn Infections

• Necrotic tissue readily colonized
• High bacteria counts are NOT
• a reliable indication of an infected burn
• Histological examination to determine
  invasiveness
• TX debridement and antibiotics

28
Hospital-Acquired

• Pulmonary
• Pneumonia
• Non-ventilator associated
• Ventilator associated
• Aspiration

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Hospital-Acquired

• Urinary Tract
• Diagnosis
• Usual suspects
• Pseudomonas, Serratia, other

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Hospital-Acquired

• Foreign-body associated
• Sites
• Catheters
• Lines
• Prosthetics/grafts

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Hospital-Acquired

• Wound infection SSI.

32
Surgical wounds are healing by

• 1) Primary intention
• 2) Secondary intention
• 3) Delayed primary intention

33
Incidence of SSIs ?closure/delayed closure of an
infected wound
Opening and re-closure times Re-infection rate
Opening and re-closure at once  50
Opening and re-closure after two days 20
Opening and re-closure after four days 5
Opening and re-closure after nine days 10
Gottrup, F. Wound healing and principles of
wound closure. In Holström H, Drzewieck KT
(Eds). The Scandinavian Handbook of Plastic
Surgery. Malmoe Studenterliteraturen, 2005
34
Definition of SSI

• The CDC lt 30 days of surgery (or within a year
  in the case of implants)

Mangram . Guideline for prevention of
surgical site infection, 1999. Infect Control
Hosp Epidemiol 1999
35
classificationincisionalsurgical site infections

• Superficial
• Deep
• Organ/space

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superficial incisional surgical site infections

• lt 30 days of procedure
• involve only the skin or subcutaneous tissue
  around the incision.

Mangram . Guideline for prevention of
surgical site infection, 1999. Infect Control
Hosp Epidemiol 1999
37
Deep incisional surgical site infections

• lt 30 days of procedure (or one year in the case
  of implants)
• are related to the procedure
• involve deep soft tissues, such as the fascia and
  muscles.

Mangram . Guideline for prevention of
surgical site infection, 1999. Infect Control
Hosp Epidemiol 1999
38
ASEPSIS WOUND SCORING SYSTEM

• Wilson AP, Lancet 1986

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Southampton wound scoring system

• Bailey IS, BMJ 1992 304 469-71

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Risk Factors

• Surgical factors
• Patient-specific factors
• local
• systemic

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Factors influencing SSIsPatient Risk Factors

• Local
• High bacterial load
• Wound hematoma
• Necrotic tissue
• Foreign body
• Obesity

• Systemic
• Advanced age
• Shock
• Diabetes
• Malnutrition
• Alcoholism
• Steroids
• Chemotherapy
• Immuno-compromise

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Factors influencing SSIs

• Antibiotics
• Prophylactic
• Therapeutic

46
Factors influencing SSIs

• Surgical Risk Factors
• Type of procedure
• Degree of contamination
• Duration of operation
• Urgency of operation
• skin preparation
• operating room environment
• Antibiotic prophylaxis

EWMA Journal 2005 5(2) 11-15.
47
Berard F, Gandon J, Ann Surg 1964
48
Reduce hemoglobin A1c levels to lt7 before
operation

• Evidence
• Class II data
• References
• Anderson DJ, Kaye KS, Classen D, et al.
  Strategies to prevent surgical site infections in
  acute care hospitals. Infect Control Hosp
  Epidemiol 2008

49
Smoking cessation 30 d before operation

• Evidence
• Class II data
• References
• Anderson DJ, Kaye KS, Classen D, et al.
  Strategies to prevent surgical site infections in
  acute care hospitals. Infect Control Hosp
  Epidemiol 2008

50
Remove hair only if it will interfere with the
operation hair removal by clipping immediately
before the operation or with depilatories no
pre- or perioperative shaving of surgical

• Evidence
• Class I data
• References
• Kjønniksen I. Preoperative hair removal
• a systematic literature review. AORN J 2002

51
Use an antiseptic surgical scrub or alcohol-based
hand antiseptic for preoperative cleansing of the
operative team members hands and forearms

• Evidence
• Class II data
• References
• Anderson DJ. Strategies to prevent surgical site
• infections in acute care hospitals. Infect
  Control Hosp Epidemiol 2008

52
Prepare the skin around the operative site with
an appropriate antiseptic agent, including
preparations based on alcohol, chlorhexidine, or
iodine/iodophors

• Evidence
• Class II data
• References
• Anderson . Strategies to prevent surgical site
• infections in acute care hospitals. Infect
  Control Hosp Epidemiol 2008

53
Administer prophylactic antibiotics for most
clean-contaminated and contaminated procedures,
and selected clean procedures use antibiotics
appropriate for the potential pathogens

• Evidence
• Strong Class I data
• References
• Springer R. The Surgical care improvement
  project-focusing on infection control.Plast Surg
  Nurs 2007

54
Administer prophylactic antibiotics within1 h
before incision (2 h for vancomycin and
fluoroquinolones)

• Evidence
• Strong Class II data
• References
• Springer R. The Surgical care improvement
  project-focusing on infection control.Plast Surg
  Nurs 2007

55
Use higher dosages of prophylactic
antibioticsfor morbidly obese patients

• Evidence
• Limited Class II data
• References
• Springer R. The Surgical care improvement
  project-focusing on infection control.Plast Surg
  Nurs 2007

56
Carefully handle tissue, eradicate dead space,
and adhere to standard principles of asepsis

• Evidence
• Class III
• References
• Anderson DJ. Strategies to prevent surgical site
  infections in acute care hospitals. Infect
  Control Hosp Epidemiol 2008

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Redose prophylactic antibiotics with short
half-lives intraoperatively if operation is
prolonged (for cefazolin if operation is gt3 h) or
if there is extensive blood loss

• Evidence
• Limited Class I, Class II data
• References
• Scher K. Studies on the duration of antibiotic
  administration for surgical prophylaxis Am Surg
  1997

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Maintain intraoperative normothermiac

• Evidence
• Class I some contradictory Class II data
• References
• Sessler DI, Akca O. Nonpharmacological prevention
  of surgical wound infections.
• Clin Infect Dis 2002

59
Discontinue prophylactic antibiotics within 24 h
after the procedure (48 h for cardiac surgery
liver transplant procedures) discontinue
prophylactic antibiotics after skin closure

• Evidence
• Class I
• meta-analyses support single dose regimens for
  prophylaxis
• References ASHP Therapeutic guidelines on
  antimicrobial prophylaxis in surgery. Am J Health
  Syst Pharm 1999

60
Maintain serum glucose levels lt200 mg/dL on PO

• Evidence
• Class II data
• References
• Anderson DJ. Strategies to prevent surgical site
  infections in acute care hospitals. Infect
  Control Hosp Epidemiol 2008

61
Monitor wound for the development of SSI
postoperative days 1 and 2d

• Evidence
• Class III data
• References
• Anderson DJ. Strategies to prevent surgical site
  infections in acute care hospitals. Infect
  Control Hosp Epidemiol 2008

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Treatment of SSI

• opening the wound ID .
• For most patients who have had their wounds
  opened and adequately
• drained, antibiotic therapy is unnecessary.

Stevens DL. Prguidelines for the diagnosis and
management of skin and soft-tissue infections.
Clin Infect Dis 2005actice
63
Treatment of SSI

• o use antibiotics only when there are
• significant systemic signs of infection
  (temperature higher than
• 38.5Cor heart rate greater than 100 beats/min)
  
• erythema extends more than 5 cm from the
  incision.
• Stevens DL. Prguidelines for the diagnosis and
  management of skin and soft-tissue infections.
  Clin Infect Dis 2005actice

64
Sepsis

• Sepsis Commonly called a "blood stream
  infection.
• The presence of bacteria (bacteremia) or other
  infectious organisms or their toxins in the blood
  (septicemia) or in other tissue of the body.

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Sepsis

• Sepsis may be associated with clinical symptoms
  of systemic (bodywide) illness, such as fever,
  chills, malaise , low blood pressure, and mental
  status changes.
• Sepsis can be a serious situation, a life
  threatening disease calling for urgent and
  comprehensive care.

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Sepsis, Septic shock

• Signs of
• Increased C.O.
• Altered O2 SATURATION.
• Metabolic acidosis (usually)
• Can lead to ---Death.

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Sepsis

• Sepsis remains a major clinical problem for 21st
  century
• marginal improvement in the mortality
• antibiotics are cornerstone
• 10 improvement in mortality

Mac Arthur RD et al.Adequacy of early empiric
antibiotic treatment in severe sepsis experience
from MONARCS trial . Clin Infect Dis
200438(2)284-88
68
Endothelial injury
Cytokines Release TNF , IL1 IL6,10 Protease
,PG PAF
Tissue factor
Coagulopathy
Fibrin clot
Inhibit activity Protein C Antithrombin III
Suppress fibrinolysis
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The aim

• Sepsis is condition diagnosed on the bases of
  clinical laboratory parameters
• increased level of inflammatory mediators
  reflects global dysregulation of immune response
  
• Examine the latest evidence for the use of
  immuno-modulating drugs obtained from human
  clinical trials

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• immune response is multi-faceted
• Aim

Eliminate invading object
Maintain homeostasis
Limit tissue damage
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Sepsis And host response

• More than adequate or
• Inadequate.

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Inadequate Host response

• Stimulation by Levamisole
• Pro inflammatory Cytokine interferon y
• Anti- prostaglandins (immunosuppressive mediators

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IL-10

• IL- 10 administration improves survival following
  endotoxin challenge
• Live candida - block IL-10- improves survival

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More than adequate host response

• Anti-inflammatory cyotkines like Interleukin 10
• Agents to neutralise tumor necrsois factor or
  interlekin -1

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Severity assessment

• PAC- initially
• Ultra low frequency ossillations in CO/global end
  diastolic vol -severity high
• Lactate levels good severity predictor
• Low exogenous clearance very early predictor of
  mortality
• C reactive protein high risk of organ failure/
  too slow to monitor

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Management of Sepsis

• Hemodynamic, respiratory stability
• Source control in sepsis
• Early enteral feed/intensive insulin therapy
• stress ulcer prophylaxis, and deep vein
  thrombosis
• Daily hemodalysis better survival

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Early goal-directed therapy (EGDT)

• Oximetric central venous catheters were placed to
  measure central venous pressure
• (CVP) CvO2
• 500-mL aliquots of isotonic crystalloid were
  given by bolus infusion to achieve a central
  venous pressure greater than 8 mm Hg.

Rivers E, Nguyen B, Havstad S, et al. Early
goal-directed therapy in the treatment of severe
sepsis and septic shock. N Engl J Med 2001
78
Early goal-directed therapy (EGDT)

• Mean arterial pressure was maintained at 65 mm Hg
  or higher with vasopressors.
• If the CvO2 saturation was still less than 70,
  blood was transfused to a hematocritof 30.
• If the CvO2 saturation was still less than 70,
  dobutamine was started.

Rivers E, Nguyen B, Havstad S, et al. Early
goal-directed therapy in the treatment of severe
sepsis and septic shock. N Engl J Med 2001
79
Early goal-directed therapy (EGDT)

• Mortality was significantly lower among patients
  randomized to EGDT (48.2 versus
• 33.3, P 5 .01).

Rivers E, Nguyen B, Havstad S, et al. Early
goal-directed therapy in the treatment of severe
sepsis and septic shock. N Engl J Med 2001
80
Sepsis

• it is complex process and the goal of immune
  therapy is identifying critical point of response
  to modulate it

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TNF

• TNF is an important mediator of sepsis
• Serum level correlate with outcome
• Immunotherapy
• - Antibodies
• - Blocking receptor

Calandra T et al.Prognostic values of tumor
necrosis factor/cachectin,interlukin-1,interferon-
alpha and interferon gamma in the serum of
patients with septic shock. J Infec Dis
1990161982-87
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Blockade of tumor necrosis factor

• Improves outcome in E. coli septicemia.
• But increased mortality with cecal ligation and
  puncture.

84
TNF antibody

• NEROCEPT
• reduction of mortality 1st 3 days - dose
  dependant
• INTERSEPT
• -reduce progression of sepsis
• - rapid resolution of shock

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TNF antireciptor

• Recombinant receptor
• - dose dependant increase in mortality
• - deleterious effect in human clinical trial
  

Fisher CJ et al.Treatment of septic shock with
the tumot necrosis factor receptor.Fc fusion
protein .N Engl J Med 19963341697-702
86
Steroids

• Most widely known and used immunotherapy
• Blunt potent anti-inflammatory
• Action
• Prevent complement activation
• inhibit nitrous oxide synthatase
• Decrease proinflammatory cytokines
• inhibit neutrophil aggregation
• stabilise lysosomal membrane

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• 1960-90S No advantage
• 1997 increase mortality with high dose
• Beneficial for patient with adrenal
  insufficiency
• Currently 2nd generation trials
• - low physiological dose
• - long duration
• - vasopressor dependant pt
• - no difference among corticotrophic
• dependant or non dependant

Minneci PC et al Meta analysisthe effect of
steroids on survival shock during sepsis depend
on the dose. Ann Intern Med 200414147-57
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• Inhibit thrombin and factor Xa
• low during sepsis d/t
• - impaired synthesis
• - consumption by DIC
• - degradation by elastase

Abraham E et al.Efficacy and safety of tifacogen
in severe sepsis randomised controlled trial
.JAMA 2003290238-47
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APC action
Anti-inflammatory
Anticoagulant
APC

• inhibit transcription NF-kB reducing
  pro-inflammatory cytokines

• inactivate Va,VIIa
• Low level in sepsis
• cytokine-induced down-regulation of
  thrombomodulin

Esmon CT. Inflammation thrombosis mutual
regulation by protein C. Immunologist 1998684-89
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APC

• 48hrs /reduces mortalityiv 24 ug/ kg/hr x 96hrs
• Recombinant APC Dotrecogin alfa
• - Significant reduction of mortality
• - faster resolution cardiovascular
• respiratory dysfunction
• PROWESS ( protein c worldwide evaluation in
  severe sepsis)
• multicentre study,2001

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Vasopressor/ Inotropics

• The Surviving Sepsis guidelines recommended
• dopamine or norepinephrine as first line
  agents.
• Vasopressin should be considered an important
  adjunct vasopressor.
• Epinephrine may be considered as a second line
  agent.

Matthew C. Byrnes, MDa,b,, GregJ. Beilman, MDa
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INTENSIVE GLUCOSEMANAGEMENT

• Current international recommendations have been
  made to maintain blood glucose levels lower
  than150 mg/dL.
• Maintenance of blood glucose between 80 and 110
  mg/dL may carry a significant risk of
  hypoglycemia.

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• All of the mentioned immunotherapeutic
  strategies worked in animal models of sepsis but
  not always converted into patient
• Comorbidity
• Extreme ages
• organ dysfunction
• genetic polymorphism
• site of infection

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• cautious multi-centre studies !
• - differences resources
• - availability of intensive care bed
  

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• Only APC has been shown to improve outcome in
  septic patient
• low steroid dose also worthy , should not
  restricted to corticotrophin hypo-responsive
  patient
• Sprung CL et al.Influence of alterations in
  foregoing life sustaining treatment
  practices on a clinical sepsis
  trial.Critical Care Medicine 199725383-7

101

• most effective management of septic patient
  remains recognition support of organ dysfunction
• antibiotics remain the cornerstone of management

102

• Administration of AT III is not recommended in
  sepsis
• no significance difference in mortality
• increase risk of bleeding
• KyberSept trial randomised controlled
  clinical trial

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Peritonitis
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Classification

1. Primary peritonitis
2. Secondary peritonitis
3. Tertiary peritonitis

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Secondary peritonitis is the most common form
for surgeons
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Intra-abdominal sepsis...

• Diversion
• Nutrition
• Fluid Electrolytes
• ABG
• Antibiotics

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Diversion

• Small Bowel ileostomy
• Large bowel colostomy
• More important than antibiotics

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Nutrition

• Enteral or parenteral (TPN)

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Any Question?
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References

• Awad, S., Palacio, C., Subramanian, A., Byers,
  P., Abraham, P., Lewis, D., Young, E. (2009).
  Implementation of a methicillin-resistant
  staphylococcus aureus (MRSA) prevention bundle
  results in decreased MRSA surgical site
  infections. The American Journal of Surgery,
  198(5), 607-610. doi10.1016/j.amjsurg.2009.07.010
  
• Bratzler, D. (2006). The surgical infection
  prevention and surgical care improvement project
  Promises and pitfalls. The American Surgeon.
  72(11). 1010-1016. Retrieved from
  http//www.highbeam.com/TheAmericanSurgeon/publi
  cations.aspx
• Centers for Disease Control and Prevention.
  (2008). Surgical site infections, frequently
  asked questions. Retrieved from
  http//www.cdc.gov/ncidod/dhqp/FAQ_SSI.html
• Centers for Medicare Medicaid Services. (2008).
  Medicare and Medicaid move aggressively to
  encourage greater patient safety in hospitals and
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  wordTypeAllchkNewsType12C22C32C42C5int
  PageshowAllpYearyeardesccboOrderdate

111
References

• Chundamala, J., Wright, J. (2007). The
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• Kable, A., Gibberd, R., Spigelman, A. (2004).
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