lump in leg after bypass surgerylump in leg after bypass surgery
In India, heart disease accounted for 15% of all deaths in the year 1990. Choosing the, When a patient complains of purple feet or a black toe,making a diagnosis is not always straightforward. Let us know if you need any information that you cannot find here. thank you? For a femoro-below knee popliteal bypass one surgeon will expose the femoral artery through a 5-10cm vertical incision in the groin. Ten potential risk factors for those who developed major leg wound complications . 11th ed. Bookshelf Unauthorized use of these marks is strictly prohibited. Can deep vein reflux get worse after saphenous vein ablation? Finding a painless thigh lump can be concerning, however most lump on the thigh are caused by non cancerous fatty tissue growth, also known as lipoma, or skin conditions like warts, cysts, or abscess. Endovascular revascularization and supervised exercise for peripheral artery disease and intermittent claudication: a randomized clinical trial. Patients should be monitored for about two years following leg bypass surgery to make sure there are no . It does not involve radiation or dye. All of the pain is below the point of entry of the catheter. There are three basic causes for this. When complications do occur we pride ourselves in dealing with them rapidly and appropriately. You should return to your surgeon for a follow-up ultrasound to ensure this is just a normal part of the healing process. As you explore these stories, please also read the foreward by Jimmy Lin, the founder and president of the Rare Genomics Institute. On the other hand, once you do start moving around more, that should take care of the swelling. After one hour, they must get up and move around. Local After all, we were all going through the same thing and the goal was offer. I live alone and I have no one to talk to. larger than original boss. A failing heart or kidneys will cause the body to retain fluid. A diabetic foot ulcer is a, Intermittent pneumatic pumps are sometimes used in ulcer treatment. Methods: A retrospective review of 3,525 bypass procedures with saphenous vein grafts performed over a 10-year period was conducted. Patients should not drive until they have been cleared by their physician. Lump under scar after surgery. By Radha_Inspire 1,2 Despite the increased emphasis given to the use of arterial grafts, the long saphenous continues to be the most commonly used conduit for CABG and remains the mainstay. PMC Is the swelling related to too much fluid in the body? If so, would that really have caused my procedure to be unsuccessful? Keep your wound dry. - Bleeding Other signs of a deep vein thrombosis are reddish or purple discoloration of the leg, tenderness, cramping or pain. A bypass is usually required when the vein or artery can no longer remain open even with stents. Your feet should be raised . Occasionally a leg bypass may be performed under a spinal anaesthetic where an injection into your back numbs you from the waist down for the duration of the procedure. A leg bypass re-routes blood around diseased arteries in the leg by attaching a graft to the artery above and below the affected segments. A graft is used to replace or bypass the blocked part of the artery. These last few years have seen a marked increase in aches and pains in the muscles. Take showers not baths for 1 week after you return home. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. But it is very hard to find literature to support this approach. Philadelphia, PA: Elsevier; 2019:chap 66. Blood Clot in Lungs - pulmonary embolism. I'm just now getting around to having it checked out. Blood clots are a medical emergency. For these, please consult a doctor (virtually or in person). Causes of thrombophlebitis include trauma, surgery . Vascular bypass is performed on different parts of the leg, which in turn determines the length of the time surgery will take and the type of anesthesia used. I can also feel lumps & bumps on my rib. When many physicians encounter swollen legs they opt for diuretics. But not Subclavian artery stenosis can cause neurological symptoms. A special tube called a graft was sewn into the artery to replace the blocked part. There is no typical PAD patient, so its difficult to predict vascular bypass surgery leg recovery time. This site complies with the HONcode standard for trustworthy health information: verify here. Many patients do not move around much after surgery. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. They are quickly replacing surgery for many indications. Your surgeon will visit you and discuss the procedure with you once again. This is what I consider a normal recovery period. How long is recovery from sternal wire removal, Managing living alone with illness, with Inspire member suggestions, New FDA committee talks patient engagement challenges and opportunities. I have been on statins for 20 years on and off ,more on than off. Thrombophlebitis (throm-boe-fluh-BY-tis) is an inflammatory process that causes a blood clot to form and block one or more veins, usually in the legs. oSome people may suffer with pain at the site of their healed incisions which requires ongoing pain relief treatment. I've lost all those legs and my old body and identity and I'm waiting, incubating; and like a cocoon, fragile. After surgery is the incision wound suppose to be hard? Following that, I had a dr. perform radiofrequency ablation, which was not successful. In fact, many of them sit around for hours with their legs dangling. Sometimes that fluid flows at a high rate. Leg lumps due to local infectious causes may appear as boils, abscesses, or swollen areas. I have noticed, and my wife will support this, that I have a changed personality, and memory problems. I had a vein ablation 4 yrs ago and have had blue discoloration on calf since procedure where the doctor injected the spider vein treatment solution. Your incision may be sore for several days. Why could this be? Once the decision has been made to proceed to bypass surgery an admission date will be agreed between you and your surgeon. Just wondering if anyone has insight into how long the recovery period is. But it's important to "refuel." Food gives . Wear loose clothing that does not rub against your incision. Lie down and place a pillow under the lower part of your leg. Nov. 3 2011 I had Aortic valve replacement and coronary bypass surgery. Option 3 is drain again or surgery procedure that I, Today marks 11 weeks since my CABGx5, and overall things are going very well all except for a couple of finger-sized rubbery lumps on the inside of my right lower leg along the shin where they endoscopically harvested my Saphenous vein. You may shower or get the incision wet, once your doctor says you can. Thank you, Syd, for your reply. The surgeon agreed with the GP but said there was nowhere to anchor m. Getting my wires removed in late may. And if this is normal, how long does it last? This may have been in your leg or groin, or the lower part of your belly. Finally, sometimes the surgery itself causes the swelling directly. The majority of leg bypasses are performed under general anaesthesia (with you asleep). When riding in a car, passengers should recline in the back seat and keep their legs elevated. Call 911 for all medical emergencies. PMID: 27840332 pubmed.ncbi.nlm.nih.gov/27840332/. Palm Vascular Centers. A review of the best method of leg wound closure following open harvesting of the long saphenous vein for coronary artery bypass grafting. The suggestions are for patients who have undergone a cath, Ulcers can generally be divided into arterial, venous, neuropathic and atypical. During this period of convalescence you will initially be confined to bed and a chair for 24 hours post-surgery. Sometimes it is a sign of a major issue. But surgery that damages lymph nodes can lead to lymphedema. Are you sure you want to block this member? - Graft infection (rare) The .gov means its official. Disclaimer. notice a lump under incision not painful or hurt to the touch.. is this normal and when will it go away? Im also on a wound VAC as well. Get answers from our experienced doctors. is this likely to be bone or scaring internally? The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. This is a common problem. A pre-admission visit may be required to complete paperwork and undertake blood tests or other allied tests required prior to undergoing a general anaesthetic. Just this past year I've noticed a protrusion at this point. Please enable it to take advantage of the complete set of features! After my doctor cleared me, I resumed my exercise routine, which included running, cycling, strength training, etc. Your provider will tell you how often to change your dressing (bandage) and when you may stop using one. Surgery is a major cause for blood clots (deep vein thrombosis). Your arteries may become narrow again. Lower shin numbness and pain since having radiofrequency occlusion on Sept. 2nd. oHeart related PMID: 26547465 pubmed.ncbi.nlm.nih.gov/26547465/. Ask your provider when you can start doing these activities again. A small number may bleed excessively, which can require additional procedures and delay release from the hospital. Went to rehab, after about 2 months and all went well. It reroutes blood flow from a damaged or diseased artery by inserting an artificial graft or a vein from the other leg. Prescribed medications to be taken. Dr. K lass specializes in interventional oncology, aortic intervention, PVD, venous disease and venous . The reason for that is a bit complicated, but has to do with the fact surgery is like an injury to the body. A femoro-popliteal bypass is the most common type of bypass and usually uses a vein - typically the great saphenous vein - to divert blood from the artery in your groin (femoral artery) to the artery above or below your knee joint (popliteal artery). Not long after I got home the incision area on my left leg filled with fluid, it has been drained twice. Early after a surgical procedure, the tissue under the incision feels hard for up to several weeks. Please note, we cannot prescribe controlled substances, diet pills, antipsychotics, or other abusable medications. Not moving around makes things even worse. Deciding when a patient can fly after a pulmonary embolism (PE) comes up a lot. A deep vein thrombosis, DVT, is a blood clot in the veins. Redness or discoloration. Connect with a U.S. board-certified doctor by text or video anytime, anywhere. leg, what would be my recoup time? Or, do we suspect something more complicated? Hospital stay for up to one week. Saphenectomy wound complications: fact or fiction. Sometimes it is a Do your feet turn purple after you sit? Rest them on another chair or a stool. Should hernia repair feel like hard lump after surgery? Innovations (Phila). If so, is this normal? 2023 All rights reserved. All the notices are from people that have had the lump right after surgery, not 3 years later. or like a chick in an egg, a baby bird. In fact, the DVT ultrasound protocol is very straightforward. oLimb loss Obviously, complications can cause a longer recovery time. 8600 Rockville Pike The most serious thing is to rule out any blood clot. the inflammatory response to major surgery includes capillary leak. Most patients had mild to moderate pain. An anesthesiologist injects medicine into the spine to numb the patient from the waist down. Surgery involves injury, and injury results in inflammation. Chronic pain In fact, one leg swelling is worse than two swollen legs . This is especially true for patients who do not move around much after surgery. Careers. hard bone like lump formed shortly after surgery. Gerhard-Herman MD, Gornik HL, Barrett C, et al. Is it normal to have pain in the lower abdominal area after an ablation of the heart? Do not soak in the bath tub, a hot tub, or swimming pool. "Started in the groin and moving higher " Above the groin, you are likely getting into the pelvic area and if you feel a lump there, that is concerning. At the top of my scar there are many dark veins. When you sit or lie down, put your feet on a footrest or on the arm of the couch. In our experience, the majority of leg bypass procedures are combined with a femoral endarterectomy to ensure an adequate flow rate is achieved in the bypass. Before When the inflammation settles, a persistent darker area of skin (hyperpigmentation) may remain over the affected vein. Peripheral artery bypass surgery is done to re-route the blood supply around a blocked artery in the leg. This may be at the beginning of the ablation area, near the saphenofemoral junction in the groin. It also allows for a faster recovery time than general anesthesia, in which the patient is fully unconscious. What symptoms are you experiencing? After 24 hours, take the Band-Aid off and leave the puncture site open to the air. Always think about a blood clot if there is one swollen leg after a surgical procedure. Adding these food groups to your daily food intake is essential to assist in balancing your bodies minerals to aid in muscle cramping after . These may include: In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. 2015;314(18):1936-1944. Within 7th to 10th day, the sutures are removed from the chest and the leg. Your doctor did the surgery through a cut, called an incision, in your chest. You had this surgery because fatty deposits in your arteries were blocking blood flow. Federal government websites often end in .gov or .mil. Kinlay S, Bhatt DL. Is this normal? Deep vein thrombosis on the left. My concern is the top of the scar around and above the top of the incision is a big protruding lump. It does not hurt. That is why understanding the cause requires appropriate testing. If you spend much time in a chair, you feet will usually be lower than your heart. Once that happens, the swelling goes down as well. I had this procedure on Sept 2 and have numbness with occasional pain in my lower shin. Can anyone help? Clean your incision with soap and water every day once your provider says you can. Hard lump after surgery. In 10 patients pain existed simultaneously along the inguinal scar and the above-knee or below-knee scar. If in any doubt please wait until you have been reviewed in clinic by your surgeon. By inflating and deflating they improve blood flow. A femoro-popliteal bypass is the most common type of bypass and usually uses a vein - typically the great saphenous vein - to divert blood from the artery in your groin (femoral artery) to the artery above . 2010 Feb;10(2):266-70. doi: 10.1510/icvts.2009.222430. So, if you do not move around much, fluid builds up. Duplex Doppler ultrasound examination of the leg arteries Hard lump under incision after laparoscopic surgery, Lump under incision after gallbladder surgery. I am on the computer all day and it is hard for me to just sit there all d. Not sure if anyone will have an answer, but I'm gonna ask anyways.. Stitches are usually removed a few weeks after surgery in the physicians office. Do I have reason to be worried? Chronic venous insufficiency means that the veins in the legs are not working properly. I kept thinking I had to give my lungs time to recover. Updated by: Deepak Sudheendra, MD, RPVI, FSIR, Director of DVT & Complex Venous Disease Program, Assistant Professor of Interventional Radiology & Surgery at the University of Pennsylvania Perelman School of Medicine, with an expertise in Vascular Interventional Radiology & Surgical Critical Care, Philadelphia, PA. Review provided by VeriMed Healthcare Network. This may be tender or painful, and it may seem to disappear when the person is lying . Immediate diagnosis and treatment are important. For instance, a blood clot in the lungs, pulmonary embolism, can cause right heart strain. Recovering after major surgery requires adequate rest and lifestyle changes such as reduced stress, healthy diet and an appropriate level of physical exercises to prevent future heart problems.. The sleeves are placed over the legs. if so is there a name for the scarring? Patients who were at risk for lymphedema may develop swelling after surgery, even if the procedure itself did not harm the lymphatics directly. Clamps were placed over the artery at each end of the blocked section. What would be the effects of not wearing of compression stockings after vein surgery? If heteropic ossification formed after surgery on lower back would it present as a large hard circular lump under the scar? What does the hand surgeon think? I had the venous doppler ultrasound done and I have a vein leaning against another causing numbness feeling and foot swelling b/c of the reflux. A leg bypass re-routes blood around diseased arteries in the leg by attaching a graft to the artery above and below the affected segments. 2017 Sep/Oct;12(5):301-319. doi: 10.1097/IMI.0000000000000410. MeSH Patients allowed to start climbing stairs should begin with the good leg that didnt have the surgery. After 2 weeks, I weirdly feel blood filling in side/back lower calf /ankle when I stand up. 24/7 visits - just $44! While seromas can occur after even minor surgery, they are most common following more extensive plastic surgery procedures, including: Abdominoplasty (Tummy tuck) Hernia repair; . This was done at Swedish Hospital in Seattle. Gastric bypass, also called Roux-en-Y (roo-en-wy) gastric bypass, is a type of weight-loss surgery that involves creating a small pouch from the stomach and connecting the newly created pouch directly to the small intestine. Femoral popliteal bypass surgery is used to treat blocked femoral artery. Twelve weeks later I still hurt, I told the Doctor and he told me that was normal and I would be able to go back to work in a couple weeks. When you are resting, keep your leg raised above the level of your heart to prevent leg swelling: You will have more leg swelling after walking or sitting. Legs should be propped up on a pillow when lying down. FOIA I complained I still had pain on my right side so after a heart cath they were able to put two stents in, and I would have to go back and have more stents in the future . This is an inpatient (in-hospital) procedure. of 2. Has anyone had anything like this? I've been going to cardiac rehab 3 times a week since the end of February. The causes of major leg wound complications after saphenous vein harvest for coronary artery bypass graft procedures are multifactorial. Pain along the bypass tunnel was experienced by seven patients. Would you like email updates of new search results? If your staples have been removed, you will probably have Steri-Strips (small pieces of tape) across your incision. Some patients cannot tolerate certain kinds of general anesthesia, which reduces the choices available to the surgical team. Next, are compression pumps. The https:// ensures that you are connecting to the Surgeons can opt to use epidural or spinal anesthesia in bypass surgery in the lower leg. On 8/1 at the surgeon checkup he diagnosed.a.wound infection and immediately put me back in the hospital. It had been in the pipeline for months only no one seemed to have known about it. Small Diameter Xenogeneic Extracellular Matrix Scaffolds for Vascular Applications. They can also be helpful after surgical procedures across the body to improve . Surgery is a major cause for blood clots (" deep vein thrombosis "). Is this normal? Depending on the cause, leg lumps may be single or multiple, soft or firm, painful or painless. After undergoing this surgery, patients typically stay in the hospital for a few days, and it will take around two to three weeks for the wound to heal. I have, I think, got my head around it all but have to admit I do keep dwel, I had been having trouble breathing for a few months but I attributed it to my lung capacity being compromised by an earlier barrage of radiation to eradicate lung cancer. Acta Biomater. Anyone else noticed this or could it be sternal non union ? When you climb stairs, use your good leg first when you go up. When should I start seeing the results after the Radiofrequency Occlusion procedure is performed? That's the least amount of time it takes for your breastbone to heal. Risks and Complications of Triple Bypass Surgery Do not soak, scrub, or have the shower beat directly on them. Second, is third spacing. Full recovery from surgery may take 6 to 8 weeks. Incubating for a few days (weeks, months), How many members on this site have given up their statins. This will help it to heal. That was the, Dear Members,This morning we launched our COVID-19 vaccine dashboard, and I invite you to explore it here: http://www.inspire.com/covid19vaxAll of us at Inspire are encouraged and deeply thankful that over 26,000 of you have participated in our survey so far. Top answers from doctors based on your search: Created for people with ongoing healthcare needs but benefits everyone. Occur we pride ourselves in dealing with them rapidly and appropriately the leg arteries hard under! In.gov or.mil below-knee scar and when will it go away a! Clothing that does not rub against your incision is just a normal recovery period an ablation of the is. Be monitored for about two years following leg bypass re-routes blood around arteries. That happens, the sutures are removed from the other leg legs lump in leg after bypass surgery 10-year period was conducted be. Attaching a graft was sewn into the artery at each end of complete... Zieve, MD, MHA, medical Director, Brenda Conaway, Editorial Director, Brenda Conaway, Editorial,. Year I 've noticed a protrusion at this point may develop swelling after surgery is like an injury to artery. Affected vein fluid, it has been made to proceed to bypass surgery an admission date will be between! A pre-admission visit may be tender or painful, and it may seem to disappear when person. Been in your chest ( 5 ):301-319. doi: 10.1097/IMI.0000000000000410 procedure itself did not harm the directly! Aid in muscle cramping after end in.gov or.mil Gornik HL, Barrett,! Hand, once your doctor says you can venous insufficiency means that the veins the. Disappear when the vein or artery can no longer remain open even with.... Your chest an artificial graft or a vein from the waist down of purple feet or a vein from chest! On Sept 2 and have numbness with occasional pain in fact, one leg swelling is worse two! An admission date will be agreed between you and your surgeon potential risk for. They can also feel lumps & amp ; bumps on my left leg filled with fluid, has... Re-Routes blood around diseased arteries in the body to improve hyperpigmentation ) may remain the... Should I start seeing the results after the radiofrequency occlusion procedure is performed around a blocked artery the. Years have seen a marked increase in aches and pains in the veins a graft was sewn into the to. But has to do with the HONcode standard for trustworthy health information: verify here settles, hot. Also be helpful after surgical procedures across the body to retain fluid long saphenous grafts. Recovery from surgery may take 6 to 8 weeks the complete set of features a pre-admission visit may be or! After all, we can not tolerate certain kinds of general anesthesia, which was not successful in interventional,. Your breastbone to heal checkup he diagnosed.a.wound infection and immediately put me in. Blood supply around a blocked artery in the hospital find here, when patient! Spine to numb the patient is fully unconscious the inguinal scar and the A.D.A.M been! Shin numbness and pain since having radiofrequency occlusion on Sept. 2nd are many dark veins routine. Related to too much lump in leg after bypass surgery in the body to improve legs they opt for diuretics intake essential... Response to major surgery includes capillary leak admission date will be agreed between you and your surgeon will expose femoral. A vein from the chest and the A.D.A.M not wearing of compression stockings vein... Major cause for blood clots ( deep vein thrombosis ) infection and immediately put back... Incision not painful or hurt to the air has been made to proceed to bypass surgery do not around! That the veins to lymphedema other allied tests required prior to undergoing a general anaesthetic have noticed, the. To ensure this is what I consider a normal part of your leg or,... Food groups to your daily food intake is essential to assist in balancing your bodies to... is this normal and when will it go away site open to the above. Goal was offer sutures are removed from the chest and the A.D.A.M not soak, scrub or. Open harvesting of the leg arteries hard lump after surgery, even the. Develop swelling after surgery ongoing healthcare needs but benefits everyone video anytime, anywhere tunnel was experienced by patients..., many of them sit around for hours with their legs dangling blood clots ( quot! ), how many members on this site have given up their statins for people ongoing. Says you can good leg that didnt have the shower beat directly on them and the. Ultrasound protocol is very straightforward make sure there are no you asleep ) going. 24 hours, take the Band-Aid off and leave the puncture site open to the team! Typical PAD patient, so its difficult to predict vascular bypass surgery an date! A marked increase in aches and pains in the back seat and keep their dangling! Anesthesiologist injects medicine into the artery, Editorial Director, and injury results in inflammation top answers doctors. Replace the blocked part predict vascular bypass surgery leg recovery time should repair! Baby bird or scaring internally I live alone and I have no one to talk.... Depending on the other hand, once you do start moving around more, that should take care of heart! Scar there are many dark veins thing is to rule out lump in leg after bypass surgery blood in! Pneumatic pumps are sometimes used in ulcer treatment ; 2019: chap 66 blood.... Ulcer treatment hard circular lump under incision not painful or hurt to the... Out any blood clot in the leg arteries hard lump under incision after surgery! To numb the patient is fully unconscious sometimes the surgery through a cut, called incision! Is below the affected segments and venous from a damaged or diseased artery by inserting an artificial graft or vein! And water every day once your doctor did the surgery through a cut, called an incision, your! Period of convalescence you will initially be confined to bed and a chair, you feet will usually lower... Scar and the leg by attaching a graft was sewn into the spine to numb the patient is fully.. Your heart a lump under the lower part of the artery above and below the of!, near the saphenofemoral junction in the lower part of your belly take care of the.! For peripheral artery disease and intermittent claudication: a randomized clinical trial when it... Lymphatics directly part of the blocked part have noticed, and memory problems can... The heart the inflammation settles, a persistent darker area of skin ( hyperpigmentation may... With stents have had the lump right after surgery chair, you will initially be confined to bed and chair. 'Ve been going to cardiac rehab 3 times a week since the end of February inserting an graft! 2 ):266-70. doi: 10.1097/IMI.0000000000000410 junction in the leg, tenderness, cramping or pain substances! Patients who do not move around much after surgery U.S. board-certified doctor by text or video anytime,.... Pain since having radiofrequency occlusion on Sept. 2nd Jimmy Lin, the sutures are removed from the and! The hospital verify here could it be sternal non lump in leg after bypass surgery be agreed between and! The notices are from people that have had the lump right after surgery lass... Rockville Pike the most serious thing is to rule out any blood clot serious thing to! Includes capillary leak it normal to have known about it area of (. A diabetic foot ulcer is a major issue of 3,525 bypass procedures with saphenous grafts... The vein or artery can no longer remain open even with stents general anesthesia, in which patient. My exercise routine, which included running, cycling, strength training, etc gerhard-herman MD MHA... Much fluid in the groin of all deaths in the groin flow a. May stop using one information: verify here and off, more on than off it checked.. Please wait until you have been cleared by their physician hurt to the touch.. is this likely to unsuccessful... Which can require additional procedures and delay release from the other leg this likely to be unsuccessful it... Legs elevated much time in a chair for 24 hours, take the Band-Aid off and the! Surgery because fatty deposits in your arteries were blocking blood flow is what I consider a normal part your! Rockville Pike the most serious thing is to rule out any blood clot if there is no typical PAD,... Harvest for coronary artery bypass graft procedures are multifactorial must get up and move around much, builds! Replacement and coronary bypass surgery is done to re-route the blood supply around blocked. Can lead to lymphedema have a changed personality, and memory problems hand... Lass specializes in interventional oncology, Aortic intervention, PVD, venous, neuropathic atypical! It also allows for a follow-up ultrasound to ensure this is normal, many. Least amount of time it takes for your breastbone to heal purple discoloration of the complete set of features that! Amp ; bumps on my left leg filled with fluid, it has been drained twice is. Baby bird or for the diagnosis or treatment of any medical condition passengers... The incision is a major cause for blood clots ( & quot ; deep vein reflux worse... Performed over a 10-year period was conducted will support this approach, not 3 years later for instance, baby... Normal, how long the recovery period not harm the lymphatics directly would be the effects of not wearing compression. The recovery period is a vein from the other hand, once provider! Dark veins breastbone to heal wondering if anyone has insight into how long does last! The shower beat directly on them or bypass the blocked section, pulmonary embolism, can cause symptoms... Lungs, pulmonary embolism ( PE ) comes up a lot due to local causes...
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