HAH Enters the Digital Age!
As I deplaned at MIA this morning, we were immediately directed towards an escalator leading to the Skytrain. I stepped on to the elevator and the young man about 25 years old right in front of me fell down and dogpiled with the man next to him on top of my bag as I tried to pad his fall. At that point, his feet were up and his head down as I struggled to lift him up. He looked like a young healthy man and did not seem to be drunk after this short morning flight. As I helped him up his friend explained to me that it was his “first time”. I said “welcome to the United States of America!”. I only know of one escalator in Haiti – it is in the arrivals hall at PAP. Out of the many times I have arrived there it has only been working once.
This experience gave perspective to some of the things we have been trying to accomplish at Hôpital Adventiste – commonplace endeavors to take us up to the next level sometimes end up in a dogpile at the bottom of the escalator as we tumble over each other trying to communicate, understand and stand up again.
Scott Nelson demonstrating the new PACS
One such endeavor is our new PACS system. Some of you may not know what that is, and the rest of us who do, still might not know what those letters stand for…Picture Archiving and Communication System. Virtually all hospitals in the United States now have such systems which electronically store radiographic images. This technology is to the traditional x-ray what digital cameras are to film cameras. The way it works is by the use of a 14×17” digital detector which is the size of a standard x-ray cassette. X-rays out of any old, new, portable or stationary machine can be beamed through the patient onto the DR detector and voila! The image shows up on an adjacent computer via Bluetooth. It is then labeled, edited as necessary, and archived onto our server using an Agfa PACS database program.
No need for the old x-ray file system now that digital has arrived
The benefits of a digital system especially at a mission hospital are many. Film x-rays often require about $20 US of film and chemical per study. Bypassing the need for film allows us to more easily afford x-rays for people who cannot pay and yields more profit for the folks that can. If a poorly performed x-ray is taken then it can either be edited for clarity or retaken without wasting materials.
Calibrating the new machine
Gone is the day that you could not get an x-ray because the patient could not afford it and you did not want to put your hospital further in the lurch! Now we are lowering our prices, creating more accessibility for the common man, woman and child with an even better quality of care than before.
Immediate access to images in the clinic
Convenient access to images in the operating room
The reality of this system occurred over a cup of coffee early one morning on my way to work at LLUMC last November. I met with a friend who told me to let him know if I needed some financial support for a project in Haiti. I presented him this idea thinking that he may be able to provide a small jumpstart for this $95,000 project. Halfway through our cappuccinos he had heard enough of my enthusiasm to reach his hand across the table and shake on a promise to fund the whole project! Mike Haman director of our PACS at LLUMC used his VIP status with Agfa Healthcare to strike a 70% discount on the software and then put the whole system together, travel to Port au Prince and spend a week for installation and training.
New ID cards and medical record numbering to assure accurate data in PACS
Entering good data with consistent attention to spelling and details is where we began to stumble at the bottom of the escalator. We soon discovered that there were at least 7 existing medical record numbering schemes, with many patients having duplicate numbers. Continuing with this database nightmare would create chaos and frustration when searching for patient images. Fortunately, Jere Chrispens, our CEO is a seasoned IT executive who was able to come to the rescue. An eighth medical record numbering system was created with a consistent 7 digits to supplant all previous systems. It seemed like a simple scheme but various complexities arose which created moments of frustration amidst the joys of our new system. This has now led us to create a demographic database in order to avoid duplicate record numbers, have the consistent spelling of names, and contact patients when needed. These concepts don’t intrinsically exist in Haiti. But by padding the falls, communicating, and helping to lift each other up we are standing on the escalator and moving to the next level. Welcome to HAH!
We have the ability to print good quality paper copies when requested on an inexpensive laserjet printer
Radiologist Dr. Miot (L) with Chief Medical Officer Dr. Geneus (R)
Scott Nelson, MD
Total Joint Program Launched at HAH!
For me it was a historic day. Seeing people day after day here who are in pain, who have severe deformities, who are disabled, motivates me to work hard and continually try to improve. Malades (malade = patient in French) come to HAH with all types of orthopedic problems. Some of the most difficult to treat are hip problems. In 2010, it was 2 months after the earthquake that we received a beautiful C-arm, complements of our orthopedic colleagues back home. This enabled us to take care of many patients who had hip fractures that were nearly impossible to operate without x-ray guidance.
Many malades come to HAH to be seen by the orthopedic team
Soon after, we were able perform hemiarthroplasties (partial hip replacements usually used for femoral neck fractures in the elderly). But the option of doing total hip replacements had continued to be an elusive dream, until today. We had to renovate our operating room, we had to get air handlers and filtration system working properly, we had to find implants which tend to be way out of the budget for our patient population, and we had to find a committed surgeon. Starting a joint replacement program was one of my major goals during this 6-month period of time that Marni and I are living in Haiti. That finally materialized due to the generosity of Renovis (total hip implant company) and Dr. Mark Mildren.
Instrumentation used for total hip replacement surgery
Over the past few weeks we called some of the patients on our total hip waiting list that was started in 2011. The list is huge. There are people that are in their 30’s and 40’s some younger some older that have been suffering from hip problems for years. One patient had an acetabular fracture several days before the 2010 earthquake but was unable to get treatment because of the thousands of victims crowding the hospitals. Beyond that he did not even go to the hospital because he was afraid they would just amputate his leg. He has been walking with a crutch for more than 8 years. Finally, we can take care of him. Another man had a femoral neck fracture in the earthquake and told me about how he looked for treatment all over the city, but no one could take care of it. He got the idea to come to “Diquini” (address of our hospital) and we did a hemiarthroplasty. I looked at his record and amazingly my operative note was there. Several years later he started having pain and needs to have a conversion to a total hip arthroplasty as expected. Many of our patients with hip problems are quite young, mostly due to accidents causing femoral head or acetabular fractures. Some others have untreated childhood hip disorders or avascular necrosis.
L to R: Drs Scott Epperly, Mark Mildren, Scott Nelson and Paul Kim
Due to the young age of our patients it is particularly important to use the highest quality implants since a failed hip replacement down the road would be quite a disaster. We have spoken to several companies about donating implants but nothing worked out until recently when I spoke to Renovis a company based in Redlands. They have top quality implants and were willing to donate them for the cause. I would like to give a big shout out to this company not only because of their high-quality product, but for their can-do attitude, customer service, and the relative simplicity of the process for donating the implants.
Hip implants donated by Renovis, a Redlands, CA orthopedic company
Mark Mildren (seen in action in cover photo) is a total joint specialist from Eugene, Oregon. He finished his residency at Loma Linda University in 2016 and subsequently did a fellowship. He came to Haiti with me as a resident in 2015. Those years that many of us spent training Mark to become an orthopaedic surgeon are now paying off! It is exciting to see him supersede me, operate as an attending and take the lead on cases. It was important to find someone committed to more than just a one-time visit. Ideally, we would like to perform total joint replacement surgery here every 3 months and have a couple of surgeons that each come twice a year. Mark is building his practice, paying off loans, and has 3 kids and a wife. But since he still drives the beat-up Hyundai that was given to him by a fellow resident who was buying a new car, he has the freedom to do this sort of stuff. Even though he is an attending now, he had an overnight layover at LAX on his way down here and sat in the terminal all night to save money.
Frist total hip arthroplasty performed at HAH safely returns to postoperative holding area
Special thanks to Dr Scott Epperly, orthopedic surgery resident from Loma Linda University and Dr Paul Kim, anesthesiologist from Redlands, CA for their assistance facilitating this program. Stay tuned for total knee replacement! Hopefully coming later this year…
Scott Nelson, MD
What’s Happening at HAH?
I would like to give you a brief update on what is going on at Hôpital Adventiste d’Haiti (HAH). Because of your support and generosity, we are on schedule to accomplish unprecedented goals this year. There are dedicated people from Haiti and the United States working at HAH, creating an exciting synergy that is unique amongst healthcare institutions in the country.
The new outpatient clinic (pictured below), which is a $1.6 million USD project, is scheduled to start July 1, 2018. The existing dilapidated structure (pictured above) that houses the administration and central storage depot will be demolished. These services must be relocated inside the hospital. Renovations are currently underway to accommodate this, as well as to install a CT scanner and PACS (digital x-ray archival system). Repairs to the plumbing and electrical infrastructure are also in progress. We have a great team consisting of Dan Brown from Maine, who is our facilities manager, local workers, professional health care architects and a construction company.
Beginning last December, Marni and I are spending 6 months working full time in Haiti until June. The impetus for this was partially based on the need for surgical leadership. Alex Coutsoumpos MD (general surgery) has been at HAH full time for the last two years and has moved to Florida. In addition, I have risked my reputation to raise money from all of you and want to make sure every penny is aspirated out of your donor’s dollar in regards to the upcoming building project.
With our decision to move to Haiti several serendipitous events occurred. Most notably, Jere Chrispens a seasoned CEO and IT expert from Loma Linda has decided to join us for this venture and will serve as interim CEO of HAH. His leadership will be key to helping create sustainability while maintaining our mission focus.
L to R: Scott Nelson, Jere Crispens
With pledges, cash on hand, and matching funds, we are in a strong financial position for the outpatient clinic building project. I would like to express a special gratitude to some donors who have already given their entire 5-year pledge. The option of paying these pledges ahead of schedule is helpful as it mobilizes matching funds, and gives an immediate tax deduction to the donor.
Once again, I thank all of you for your generosity and assure you that lives are being changed in amazing ways. This would not be possible without your help.
Scott Nelson, MD
Big Day In The OR/Day 6
The first case of the day was a left tibial plateau fracture sustained in a motorcycle accident a few days ago. After touring the orthopedic ward at the University Hospital downtown yesterday we are once again reminded that trauma, particularly the musculoskeletal variety, remains a neglected epidemic in developing countries like Haiti causing more than five million deaths each year, roughly equal to the number of deaths from HIV/AIDS, malaria and tuberculosis combined.
Comminuted, intra-articular fracture of the proximal left tibia
From L to R, Drs Francel Alexis, Eldine Jacques and Noam Bor applying an external fixation frame across the knee joint of the young man with the proximal tibia fracture. The fixation was augmented with several percutaneous screws.
Postop AP C-arm image showing acceptable restoration of the knee joint line
The next case was a 13 y/o girl with severe bowlegs secondary to rickets These deformities are never purely one dimensional and are always multiplanar which complicates the reconstruction
The surgery was long and complicated. First both femurs were osteotomized (broken), straightened then the rotation normalized. Both “broken” femurs had the correction stabilized with locked intramedullary nails.
Then Taylor Spatial Frames were applied to both lower legs and the tibias osteotomized. The tibial deformities will be corrected progressibly over time as previously described.
We have all been once again greatly impressed with the resilience of the Haitian people. Barely a teenager, this young lady withstood a 6 hour surgery with nary a complaint.
The next and last case of the day was the older sister of the patient I just finished describing above who had similar, but not as severe, bowleg deformities secondary to rickets.
Two sisters with bowleg deformities secondary to rickets
No femoral osteotomies were required in the older sister, but the Taylor Spatial Frame application on the tibias was very similar to the younger sister’s surgery. It is estimated that the correction in both girls will take approximately 3 months before the hardware could be removed.
Orthopedic surgeon Francel Alexis (L) and surgical tech JJ (R) pose at the conclusion of the older sister’s surgery
Day Of Rest/Day 5
Since Hopital Adventiste is a Seventh-day Adventist sponsored facility, no elective surgery is performed on the 7th day Sabbath. Obviously, this mandate is set aside when it comes to emergent cases that present to the trauma bay. Around midnight this morning we were awakened by the Chief of Surgery, Dr Alex Coutsoumpus, who informed us that there was a gentleman admitted to the hospital who presented with a severe crush injury to his left hand sustained while unloading grain from a ship.
Unfortunately, the patient presented with most of his hand missing including the thumb, index, middle and ring fingers. The small finger was the only digit that remained viable. The small white tubes are Penrose drains that will be removed in a couple of days.
We got back to bed around 2 am and slept well until rising to attend the Sabbath service down the road from the hospital. All of the service was conducted in French but we were inspired by the boisterous which was boisterous and heartfelt. When we first arrived the Sabbath School was in full swing and lesson study was a cacophony of loud and enthusiastic discussion (click on audio clip below) which apparently didn’t seem to distract from the overall experience for most worshipers.
The Adventist church we attended is known as the “Sinai Temple” which amused our guests from Israel
After church we navigated through the streets to return to the relative safety of the HAH campus. Note the “no guns allowed” graffic.
After church then lunch we embarked on Scott’s infamous “Death March” consisting of a 7 mile hike up into the hills in 90 degree heat and seemingly close to 100% humidity. Survivors from L to R are: Noam Bor, Saif Zaman, Jim Matiko, Scott Nelson, Peter Nelson, Alex Nelson, Roosevelt and Mark Eidelman.
In in the afternoon we all drove downtown to visit a large trauma hospital in the midst of Port au Prince. There we had the opportunity to review some of the xrays of patients awaiting operative intervention
This young man with an open tibia fracture and subsequent external fixation begged me to take his photo. He had already been in the hospital for over two months and seemed perpetually optimistic.
The Haitian’s are very resourceful people demonstrated by the use of the homemade traction setup with the the recycled plastic bottle weight lying dysfunctional on the bed
Hospital mini-ambulance
We stopped off to view the ruins of the Cathedral of Our Lady of the Assumption. The church was built between 1884 and 1914 and was destroyed in the January 12, 2010 earthquake.
Francel, Saif and Scott posing outside of the Cathedral of Our Lady of the Assumption
View from the patio at Hôtel Montana in Port-au-Prince
After dinner we wound our way back to the hospital through the streets of Port au Prince in a thunderstorm which clogged the roadways with debri rendering progress virtually impossible. Still 3 miles from HAH, we elected to abandon the vehicles and walk the remaining distance through the chaos on the streets finally getting to bed around 1 AM. Not much rest on “Rest Day.”
Taylor Spatial Frames/Day 4
We spent time sorting through and organizing gear in the new orthopedic equipment room. Again, we were expecting to have a much bigger task in front of us but Elaine Lewis and JJ had performed wonders prior to our arrival so all that was left was taking care of a few small details.
A portion of the well-stocked and organized orthopedic equipment room adjacent to the main operating theater
We performed several smaller cases and 2 relatively big ones. The first big case was a young man with skeletal dysplasia with resultant marked bowleg deformities requiring application of bilateral Taylor Spatial Frames.
25 y/o male with severe bilateral bowleg deformities secondary to skeletal dysplasia
The Taylor Spatial Frame (TSF) is an external device for limb correction, lengthening and/or straightening that is based on the Ilizarov Method. This device and technique is a mainstay of pediatric musculoskeletal deformities at Hopital Adventiste. This external fixator takes advantage of the body’s natural ability to grow healthy new bone tissue and gives the surgeon the ability to accurately move bones to their correct precise anatomic alignment. The TSF fits around the patient’s limb and is attached to the bone with pins or wires that extend from the rings, through the skin and bone to the other side.
The Team working on applying the Taylor Spatial Frame to both lower legs
To be more specific, the TSF is a circular, metal frame with two rings that connect with six telescopic struts that can be independently lengthened or shortened relative to the rest of the frame. This allows for six different axes of movement, which gives the TSF the ability to correct difficult congenital deformities and trauma cases.
These larger, bilateral cases often benefit from two “subteams” to divide and conquer the load by working simultaneously. From L to R: Noam Bor, Jim Matiko, Francel Alexis, Mark Eidelman, Saif Zaman, JJ, Scott Nelson
When using the TSF, the surgeon inputs information about the patient’s original bone deformity into an advanced web-based computer application. This information is then interpreted by the software and a day-by-day treatment plan is created. The software also creates an image of the patient’s deformity on-screen and shows how the bones should be moving each day, until the bones are completely set in proper alignment. The patient then makes daily adjustments to the struts, depending on the prescribed course of treatment. As the adjustments are made, the rings are repositioned with respect to each other, moving bones in the directions necessary for treatment.
Our patient’s computer deformity profile pictured in the left image depicts the marked bowleg and internal rotation deformity on the right leg and the projected correction in the image on the right
The second big case involved a young man who underwent intramedullary nailing of a right femur fracture sustained in a motorcycle accident 3 years ago. Unfortunately the patient developed a marked extension contracture of the knee (couldn’t flex greater than 15 degrees) secondary to postoperative adhesions.
An extension contracture of the knee is a well known complication following femoral fractures. Traditional management consists of a quadricepsplasty which is comprised of a controlled, sequential release of the soft tissue structures, primarily the quadriceps muscle.
The Team performing a quadricepsplasty
This procedure can be seemingly somewhat barbaric as the incision is usually lengthy accompanied by a great deal of blood loss and frustration on the part of the surgeon secondary to slow progress.
The surgeons pictured may seem overly triumphant in this image but gaining an increase of flexion from 15 to 90 degrees involved a great deal of effort accomplished with tedious incremental steps over 2 hour time span
New Team Members/Day 3
We performed several small surgeries today including a bilateral 8-plate application for pediatric lower extremity angular deformities, a Girdlestone procedure (femoral head resection) in a paralytic patient, debridement of chronic tibial osteomyelitis and removal of a tibial external fixator with debridement of infected pin tract sites. We also slogged through another clinic which is always a challenge primarily due to language barriers and xray logistics.
The highlight of the day was the arrival of two new team members from Israel, Drs Noam Bor and Mark Eidelman from Israel. Dr Bor is the Head of the Pediatric Orthopedic Unit at Central Emek Hospital in Afula. Dr Eidelman is the Director of Pediatric Orthopedics at the Meyer Children’s Hospital in Haifa.
Scott Nelson (L) is giving Drs Noam Bor (L) and Mark Eidelman (R) the royal tour of the new operating rooms
Collaboration with international team members on overseas trips like this is one of the outstanding fringe benefits. Not only do our perspectives get changed as we entertain new ways of addressing problems, we make new friends that enrich our lives for years to come.
It didn’t take long for the new team members to get to work. Mark’s enthusiasm and Noam’s introspective comments have been greatly appreciated by all.
Cinic & First Case/Day 2
Day 2 of the Fall, 2015 Orthopedic Surgical trip from Loma Linda University.
There are no two ways about it, clinic is long and hard. This young man was one of the last patients to be seen but he couldn’t take the delay any longer without a nap. Haitian patients rarely complain about the wait, they are some of the most longsuffering souls on the planet.
One of the inefficiencies in the clinic is that we typically sort through a group of patients, order their xrays then go view the images en masse on a digital machine apart from the clinic area. We discuss the patients and frequently formulate a treatment plan in that room then go back to the clinic to present options to the patient and/or family.
Today also happened to be clubfoot cast change day at HAH. There are a couple of well-trained cast technicians who are very skilled in the Ponsetti technique for conservative clubfoot management.
At the end of clinic we had 3 cases scheduled which we were anticipating as we had never operated in the new theater before. The first was a 3 y/o with bilateral hip dysplasia. Here Scott (R) and Saif (L) are viewing images on the C-arm monitor after performing bilateral hip arthograms.
The arthrograms demonstrated that this little boy’s hip sockets were too “vertical” thereby not providing enough coverage for the femoral heads. Because of this finding it was elected to proceed with bilateral pelvic osteotomies to correct the deformities.
Orthopedic surgery resident Saif Zaman trying out the new scrub sink
As we were scrubbing for our case, a New Haitian life came to fruition as in the room next to ours, Dr Coutsoumpos assited one of the local obstetricians in the delivery of a baby girl
At this point, we must acknowledge Dr Maria Adrian, anesthesiologist extraordinaire who frequently travels from the Dominican Republic to join the team, more about this amazing woman in a post to come.
Scott and Saif performing a Dega opening wedge pelvic osteotomy
Bilateral iliac bone grafts in place rendering the hip sockets more horizontal providing better femoral head coverage
Haitian technique for applying protective postoperative hip spica cast
Team photo at the end of the case. From L to R, Maria Adragon, Saif Zaman, Scott Nelson and Francel Alexis, HAH Chief of Orthopedic Surgery. The following two cases, a fracture/dislocation of the foot and a postoperative tibial wound infection, went well and we left the operating theater at around 9pm and went home for dinner. It was a good day.
Arrived Safely/Day 1
Due to spotty and slow internet access, reports from our Fall trip will be delayed and sporadic. This has been an exciting trip for us so far and hopefully will be encouraging to the many supporters who read this blog as we witness the incredible progress that has been made to date.
Three of us (Scott, Peter and Jim) left LAX at 11:35 Monday evening and took the red-eye to Miami where we met the rest of the team, Alex and Saif. After a brief layover, enhanced by a tasty breakfast at the American Airlines Admiral’s lounge, we took the close to two hour flight to Port au Prince.
View of Hispaniola from Boeing 767-300
Clearing immigration was a breeze but clearing customs was problematic once again as two of us had our baggage searched because the phrase “medical supplies” triggered a search for contraband medication.
L to R: Jim Matiko (orthopedic surgeon), Alex Nelson (high school student), Scott Nelson (orthopedic surgeon), Peter Nelson (retired dentist) and Saif Zaman (orthopedic surgery resident)
Driving to Hopital Adventiste took much longer than usual due to a torrential downpour that flooded the the streets with debri washed down from the hills.
A classic Haitian meal of rice and beans was waiting for us when we arrived in our new home for the next week
In spite of being tired from the all-night flight, we were eager to view the new operating theater to see what progress has been made.
The nursing staff are making a concerted effort to maintain a clean environment in the new oprating theater
Our tour guide was Alex Coutsoumpos, MD, the new Chief of Surgery at Hopital Adventiste d’Haiti
Entrance to operating rooms 2 and 3
Fully operational operating room 1
Sterile processing department. Many of the rooms in the new operating theater have natural light which is a great improvement over the dark and gloomy environment that existed prior to the new rennovation.
Dirty room where contaminated instruments are cleaned then sent over to be autoclaved in the sterile processing department
The new break room with refrigerator and computer set up for future electronic medical records system
I was truly impressed with the organization of the new equipment room, thanks in large part to the efforts of JJ under the tutelage of former volunteer Elaine Lewis. Scott and I were prepared to dedicate hours to sorting through bins of instruments and supplies but much of the work had already been accomplished.
While on tour, we met Wintley Phipps, a well known gospel singer (second from R), who was filming a fundraising documentary sponsored by Florida Hospital in Orlando
We would be remiss to fail to acknowledge Dan Brown, the incredibly talented, always upbeat project manager for the restoration of Hopital Adventiste. Here he is pictured on the left pointing out some of the features of the new lab to Monty Jacobs from Florida Hospital.
One of the reasons that Scott’s retired dentist father, Peter Nelson (R), returned to HAH was to eplore the possibilites of establishing a dental clinic. Here is discussing options with project manager Dan Brown (L). The proposed site for the new polyclinic, including dentistry, is the building in background to the left of Dan.
First Cases In New OR!
The following post was written by Dr. Alex Coutsoumpos (far right in banner image above), a newly graduated general surgeon who, along with his family, has made a several year commitment to Hopital Adventiste d’Haiti. After months of anticipation, the big day has finally arrived and the first surgical case was successfully performed in the newly renovated operating theater.
For the past couple of weeks the halls of Hopital Adventist d’Haiti have been abuzz with excitement regarding all the visible changes going on at our hospital. Dan Brown, our facilities manager/construction extraordinaire, has been orchestrating simultaneous projects for the renovation of one hospital wing, building a new clinical laboratory and renovating the operating rooms. This past week one of those projects was completed.
On Thursday, October 8, 2015, the operating rooms were opened for surgery after a special prayer of dedication (see banner image above). This event would not have been possible if it were not for the operating room staff that tirelessly worked in between surgical cases to complete an inventory and organize a myriad of surgical items in preparation for the move to the new operating rooms over the last month and a half. The move itself occurred over a period of three days, in which new donated equipment was transported in from storage, old indispensable equipment was refurbished, surgical supplies stocked and the new space cleaned from top to bottom.
Drs. Thierry Rosarion (L) and Francel Alexis (R) perform a knee arthroscopy
Following the dedicatory service, Dr. Alexis, and his assistant, Dr. Thierry Rosarion completed the first two cases in the new operating rooms. The first case was a knee arthroscopy and the second case was a forearm debridement in a young child who had developed osteomyelitis after surgical repair for an ulnar fracture at an outside facility. Fortunately, both cases were completed without any major glitches.
The determined work of Dr. Elie Honorie, Dr. Scott Nelson, Dan Brown, Edward Martin, the hospital administration, the donors and the hospital staff is truly appreciated. Without this group of people the completion of this important project would not have been possible.
Dr. Alexis (center) performs a forearm debridement with the assistance of JJ Boyer (L) and anesthesiologist Dr. Elkine (R)
Though the hospital still faces many difficulties there is a burgeoning sense of optimism for the institution. Many staff members have approached the administration to share their words of affirmation for the work that is currently being done to improve the hospital and its future. For many, the opening of the new operating rooms is not a just a symbol of change to come, but the realization of a new chapter for the institution.
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