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Pelvic and Lower Extremity Veins: Contrast-enhanced Three-dimensional MR Venography with a Dedicated Vascular Coil-Initial Experience¹

¹ From the Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland. From the 1998 RSNA scientific assembly. Received April 30, 1999; revision requested June 16; revision received August 2; accepted August 12. Address correspondence to J.F.D., Department of Diagnostic Radiology, University Hospital Essen, Hufelandstrasse 55, D-45122 Essen, Germany (e-mail: debatin@uni-essen.de).

	Abstract

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To assess the performance of three-dimensional (3D) magnetic resonance (MR) venography of the pelvis and lower extremities in patients without acute deep venous thrombosis by using a lower extremity vascular coil and pedal injection of paramagnetic contrast material.

MATERIALS AND METHODS: Conventional and MR venography were performed in 35 legs in 25 patients referred for evaluation of varicosities (n = 8) and postthrombotic changes (n = 7) and assessment of the great saphenous veins prior to bypass surgery (n = 10). Injection of 120 mL of diluted (1:15) gadopentetate dimeglumine into a pedal vein was performed manually at a rate of 1 mL/sec, and 3D gradient-recalled echo data sets of the upper and lower veins were collected. Conventional and MR venographic images were analyzed separately in a blinded fashion.

RESULTS: MR image quality was comparable to that of conventional venograms. Varicose changes of the great and small saphenous veins (sensitivity, 94% [44 of 47]; specificity, 96% [89 of 93]) were assessed as reliably as their status before bypass surgery (sensitivity, 98% [53 of 54]; specificity, 92% [47 of 51]). Postthrombotic changes were diagnosed with a sensitivity of 100% [13 of 13] and a specificity of 98% [88 of 90].

CONCLUSION: Direct 3D MR venography comprehensively displays the lower extremity venous system and permits assessment of postthrombotic and varicose changes and the bypass suitability of the saphenous vein.

Index terms: Extremities, MR, 44.121412, 44.12142, 45.121412, 45.12142, 46.121412, 46.12142 • Magnetic resonance (MR), comparative studies, 93.124, 93.129412, 93.12942 • Magnetic resonance (MR), vascular studies, 93.129412, 93.12942 • Veins, abnormalities, 93.751, 93.753 • Veins, extremities, 93.751, 93.753, 93.91 • Veins, MR, 93.129412, 93.12942 • Venography, 93.124

	Introduction

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Conventional venography of the lower extremity veins continues to be used for a number of indications, including (a) exclusion of deep venous thrombosis, (b) monitoring of postthrombotic changes, (c) depiction of venous malformations, (d) preoperative imaging prior to saphenous venous stripping, and (e) determination of suitability of the saphenous vein to serve as a coronary bypass vessel. Beyond exposure to ionizing radiation, venography is not without risk: Complications associated with the use of iodinated contrast material are reported to occur in 2%–5% of patients (1–4). Their effect is augmented by the high number of young patients undergoing venography.

Magnetic resonance (MR) imaging has long been used for evaluation of the deep venous system (5–9). In the pelvic region, two-dimensional (2D) time-of-flight techniques were shown to be even more accurate than was conventional venography (10). Lengthy acquisition times coupled with the technique's inability to reliably display small deep veins in the calf or the superficial veins (11) have limited its clinical use. On the basis of the concept underlying fast contrast material–enhanced three-dimensional (3D) MR angiography, we developed a technique capable of depicting the venous vasculature from the ankle to the inferior vena cava. After a pedal injection of contrast material, two large-volume 3D data sets were collected during the intravenous phase of the T1-shortening extracellular contrast material.

The purpose of this study was to determine the diagnostic accuracy of contrast-enhanced 3D MR venography in assessing the deep and superficial veins from ankle to pelvis with the combined use of a dedicated vascular coil and a pedal injection of diluted paramagnetic contrast material. Patients with acute deep venous thrombosis were not included in this preliminary study. Conventional venography served as the standard of reference.

	MATERIALS AND METHODS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Twenty-five patients (16 men, nine women; mean age, 51 years; age range, 21–78 years) were enrolled in the study and underwent both conventional and MR venography. Inclusion of patients was based on fulfillment of the following criteria: (a) referral to venography for assessment of postthrombotic changes (n = 7) or varicosities (n = 8) or for bypass surgery planning (n = 10); (b) ability and willingness to provide informed consent in accordance with regulations set forth by the institutional review board that approved this study; (c) lack of contraindications to MR imaging, such as a pacemaker or claustrophobia; and (d) availability of MR system time immediately following conventional venography. Since both legs were examined in patients undergoing venography prior to cardiac surgery, 35 legs were available for comparison.

Conventional Venography
Venograms were obtained with a standard fluoroscopy unit (Diagnost 92; Philips Medical Systems, Best, the Netherlands) by using a digital technique. Injection of 120 mL of diluted (2:1) iopromide (Ultravist 300; Schering, Berlin, Germany) was performed manually at a rate of 1 mL/sec as a split injection into a superficial vein on the dorsum of the foot. A tourniquet was fixed at the ankle to ensure filling of the deep venous system. Images of the calf and thigh were obtained with the patient in a semierect position; for imaging the pelvic veins, the patient was supine. Imaging was repeated without the tourniquet for display of the superficial venous system. Additional oblique projections were acquired as deemed necessary by the performing radiologist. To enhance examination comparability, the needle was left in place as the patient was transported to the MR suite.

MR Imaging
MR imaging was performed with a 1.5-T system (Signa EchoSpeed; GE Medical Systems, Milwaukee, Wis). Patients underwent imaging in a supine position, wrapped in a multichannel-quadrature phased-array peripheral vascular coil (Medical Advances, Milwaukee, Wis). The coil consisted of four circular arrays used for signal reception. The flexible design of the coil allowed for bilateral vascular imaging with high spatial resolution in close proximity to the anatomic region of interest. Each element covered a territory of 24 cm (total coverage, 96 cm) and could be activated separately or together. The coil was placed to encompass the veins from the pelvis to the ankle.

The imaging strategy was based on the acquisition of two 3D data sets, each time with the use of two adjacent coil elements extending over 48 cm. The two 3D acquisitions, each consisting of 48 contiguous coronal sections, were prescribed on the basis of transverse 2D time-of-flight images collected at 10-cm intervals through the pelvis, thighs, and lower limbs. Section thickness was adapted to ensure full coverage and ranged between 2.4 and 3.0 mm.

A 3D spoiled gradient-recalled echo (GRE) sequence was used with the following parameters: 5.2/1.5 (repetition time msec/echo time msec); inversion time, 28 msec; flip angle, 30°. A field of view of 48 x 36 x 12 cm combined with a matrix of 256 x 192 x 48 rendered an in-plane spatial resolution of 1.8 x 1.8 x 2.6 mm. Zero interpolation in all three planes improved the latter to 0.9 x 0.9 x 1.3 mm. Each image set was collected during 30 seconds, with the first set covering the pelvis and thighs and the second set covering the popliteal region to the ankle. To ensure complete filling of the deep and superficial venous system of the calf, the thigh region was imaged first. Table movement from the upper to the lower region was accomplished manually during the 10 seconds separating the two 3D acquisitions. To ensure some spatial overlap, the lower image set was offset by only 45 cm. Craniocaudal coverage thus extended over 90 cm.

Prior to pedal administration of contrast material, a tourniquet was placed around the ankle to ensure adequate filling of the deep venous system. Data acquisition was commenced following the administration of 40 mL of diluted (1:15) gadopentetate dimeglumine (Magnevist; Schering) in each leg. The contrast material was injected continuously throughout data acquisition at a rate of 1 mL/sec up to a total volume of 120 mL, which corresponds to 8 mL of gadopentetate dimeglumine in each leg. After administration of contrast material was complete, 3D imaging was repeated without the tourniquet for depiction of the superficial veins.

Maximum intensity projection images displaying the proximal and distal venous territories were rendered from the 3D data sets. Rotated maximum intensity projection displays extending from -60° to +60° were documented on film hard copy. To provide an overview, images of each territory were merged in the "multiple display" mode.

Image Analysis
Conventional and MR venographic images were interpreted in a prospective and blinded fashion. To avoid interpretation errors related to well-documented interobserver variations (12), both imaging modalities were interpreted by the same experienced radiologist (W.W.). Conventional venograms were read first. After an interval of 10 weeks, MR venographic images were interpreted. To avoid any recognition bias, the studies were presented in a random order. Analysis of the results of both studies was based on all available images. In addition, 3D MR data sets were available on a workstation, which permitted interactive reformation. Conventional venography was used as the standard of reference.

For analysis, the venous system was divided into superficial and deep veins with the following segments: distal inferior vena cava; common iliac vein; external iliac vein; common femoral vein; proximal superficial femoral vein; distal superficial femoral vein; popliteal vein; anterior tibial vein; fibular veins; posterior tibial veins; great saphenous vein divided into superior, middle, and lower thirds; and small saphenous vein.

Each segment was characterized as (a) completely seen, (b) partially seen, or (c) not seen. The criteria included an intravascular filling defect affecting the deep venous system with surrounding contrast material without the presence of extensive formation of collateral vessels. Furthermore, each segment was assessed for the presence of acute thromboses. Weighted values were calculated to measure concordance between MR venography and conventional venography: poor,  = 0–0.20; fair,  = 0.21–0.40; moderate,  = 0.41–0.60; good,  = 0.61–0.80; excellent,  = 0.81–1.00. To determine statistical differences in vessel delineation, Wilcoxon signed rank test statistics were calculated.

Since postthrombotic changes generally extend over several deep venous segments, analysis was based on images obtained in the pelvic (common iliac vein, external iliac vein), thigh (common femoral vein, superficial femoral vein, popliteal vein), and calf (anterior or posterior tibial veins, fibular vein) regions. The diagnosis of postthrombotic syndrome was based on the presence of contour irregularities with partially or fully recanalized vessel lumen and/or the presence of deep or superficial collateral vessels.

Analysis of varicose changes was limited to the four superficial venous segments encompassing the great and small saphenous veins. The diagnosis of varicosities was based on the presence of dilatation of the vessel with a diameter exceeding 5 mm and/or serpiginous vessel morphology of extrafascial veins, including side branches and perforating veins.

Suitability for coronary bypass surgery was determined for only the great saphenous vein. Exclusion criteria for bypass surgery included a vessel diameter exceeding 5 mm (stem varicosity) or less than 3 mm, marked side branch varicosity, and/or nondepiction of the vessel.

	RESULTS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
We assumed that there were paired calf veins, so 585 venous segments potentially could be seen (Table 1). MR venography depicted 494 segments (completely seen, n = 399; partially seen, n = 95). Display of 20 segments was not possible for technical reasons: In three patients the superior acquisition volume was centered too low, which resulted in a failure to depict nine segments (inferior vena cava, n = 3; common iliac vein, n = 6). In another patient, a signal reception problem of the superior coil elements rendered all segments of the superior data set (n = 11) nondiagnostic.

Postthrombotic changes were identified on both MR and conventional venographic images in 13 of 103 possible regions involving the pelvis (n = 1), the thigh (n = 4), and the calf (n = 8). In an additional two regions read as normal on conventional venograms, postthrombotic changes were seen on MR venographic images. Thus, 3D MR venography reached sensitivity and specificity values of 100% (13 of 13) and 98% (88 of 90), respectively. Excellent correlation between MR venography and conventional venography regarding the presence of postthrombotic changes was evidenced by a value of 0.92 (95% CI: 0.87, 0.97).

Comparative analysis regarding the presence of varicose changes was based on 140 superficial venous segments. Varicose changes were depicted on both conventional and MR venographic images in 44 segments (great saphenous vein, n = 41; small saphenous vein, n = 3). Conventional venography depicted varicose changes in an additional three segments that were rated as normal at MR venography, whereas MR venography depicted varicosities in four segments that were not seen at conventional venography. Thus, MR venography reached sensitivity and specificity values of 94% (44 of 47) and 96% (89 of 93), respectively, for correct diagnosis of varicose changes, and the value of 0.89 (95% CI: 0.85, 0.93) helped to confirm excellent correlation with results from conventional venography.

Assessment regarding suitability for bypass surgery was based on a potential of 105 great saphenous venous segments. At conventional venography, 54 segments were rated suitable for bypass surgery, whereas at MR venography 57 segments were found to be suitable (Table 2). MR venography displayed five segments that were not depicted at conventional venography. Of those, one segment was rated as suitable for bypass surgery, whereas four segments were not (too thin, n = 2; varicose changes, n = 2). MR venography failed to depict three segments visible at conventional venography. All three segments were considered too thin to serve as bypass vessels. Rating discrepancies occurred in three segments graded as suitable for bypass surgery at MR venography and not suitable owing to insufficient diameter (<3 mm) at conventional venography. By using conventional venography as the standard of reference, MR venography was characterized by sensitivity and specificity of 98% (53 of 54) and 92% (47 of 51), respectively. The excellent correlation of results between MR venography and conventional venography was evidenced by a value of 0.90 (95% CI: 0.85, 0.95).

	DISCUSSION

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

After the development of GRE techniques, time-of-flight venography quickly evolved as a clinically reliable method for detecting deep venous thrombosis (5–9). Although time-of-flight images can depict venous thrombosis in the femoral and trifurcation veins (10), lengthy acquisition times have limited its use mainly to the pelvis. Owing to in-plane flow saturation preventing reliable depiction of perforating veins that run in the horizontal plane, and the technique's lack of sensitivity to slow or retrograde flow, time-of-flight MR angiography has not been used for assessing varicose veins or postthrombotic changes.

Contrast-enhanced 3D MR venography overcomes the limitations inherent in time-of-flight imaging. Since it is not flow dependent, direct MR venography displays all vessels containing T1-shortening contrast material, regardless of the underlying flow characteristics. Thus, in-plane saturation is eliminated, and imaging along the vessel axis is possible (13). Perforating and superficial veins containing slowly or even retrogradely flowing blood are fully depicted. The underlying 3D data sets provide high spatial resolution, which permits delineation of very small vessels (14).

Contrast-enhanced 3D GRE MR imaging is used increasingly for assessment of the arterial vasculature (15–25). On the basis of the intravenous administration of T1-shortening paramagnetic contrast material into an antecubital vein, the technique exploits the short intraarterial phase of the extracellular agents (13). Implementation of a bolus chase concept permits imaging over two to three regions from the pelvis to the malleoli (26–28). Despite long imaging times, depiction of lower extremity veins after an antecubital injection of contrast material is not possible.

On the basis of this observation, we persued a direct injection approach for the MR-based assessment of the lower extremity veins. In conjunction with short repetition times and a dedicated peripheral vascular coil, direct injection of the contrast material results in sufficient signal-to-noise and contrast-to-noise ratios for high-resolution delineation of the entire venous system, including the small-caliber perforating veins. To avoid T2-shortening effects, the contrast material is diluted by a ratio of 1:15, thereby reducing the required amount of extracellular paramagnetic contrast material to 8 mL per leg. The isotonic nature of the injected volume eliminates all risk of thrombosis associated with conventional iodinated agents (3,4). Lack of nephrotoxic effects and low risk of anaphylactic reactions inherent to extracellular paramagnetic agents are additional factors contributing to the attractiveness of direct MR venography.

As with conventional venography, in MR venography the application of a tourniquet to the ankle permits select delineation of the deep venous system on a first image set. A second data set collected following removal of the tourniquet displays both the deep and superficial venous systems. Similar to injection at conventional venography, the direct injection into a pedal vein at MR venography results in complete filling, particularly of the superficial venous system. Since the dose of the heavily diluted contrast material is of no concern, a minimum volume of 40 mL of the diluted contrast material is injected prior to the collection of the first data set. Data collection times of merely 30 seconds for each 3D set, separated by a 10-second break for repositioning of the table, were short enough to prevent image contamination by arterial enhancement. The presented two-region imaging strategy was robust: Barring one technical failure to reconstruct, diagnostic image quality was achieved in all examined legs.

The ability to interactively reformat in any desired plane allowed delineation of a considerably greater number of venous segments at MR venography than at conventional venography. Unencumbered by the projectional nature of conventional venography, MR venography outperformed conventional venography, particularly in the pelvis. With MR venography, overlapping structures could be peeled away, which resulted in full depiction of the pelvic veins. The analysis revealed moderate to good correlation between conventional venography and MR venography for most other segments (Table 1). Differences in the interpretation of the calf veins largely reflect the blinded nature of the image analysis. Positive identification of calf veins, especially at conventional venography with its projection-related limitations, is not trivial and is associated with considerable intraobserver variability (12).

MR venographic assessment of postthrombotic changes (Figs 1, 2), varicosities (Figs 3, 4), and the bypass status of the superficial venous system (Fig 5) correlated well with conventional venographic assessment. The 3D nature of the underlying data sets allows for a complete evaluation of even the most complex varicosities, as illustrated in Figures 2 and 3. More complete depiction of the superficial veins even favors MR venography over conventional venography regarding assessment of bypass suitability and analysis for postthrombotic and varicose changes. In several instances, particularly those in which the vessel segment or associated change was seen at MR venography but not at conventional venography, discrepancies between MR venography and conventional venography likely reflect limitations of the latter.

View larger version (63K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. (a) Coronal maximum intensity projection image shows postthrombotic changes on the left side (arrow) in a 43-year-old man. (b) Coronal conventional venogram shows the changes (arrow) to equal advantage. The blood is shunted via the deep femoral vein from the popliteal vein into the left iliac venous system (arrowheads in a and b). On the patient's right side, an MR venographic image (GRE; 5.2/1.5; flip angle, 30°, not shown) illustrates a duplication of the superficial femoral vein.

View larger version (58K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. (a) Coronal maximum intensity projection image shows postthrombotic changes on the left side (arrow) in a 43-year-old man. (b) Coronal conventional venogram shows the changes (arrow) to equal advantage. The blood is shunted via the deep femoral vein from the popliteal vein into the left iliac venous system (arrowheads in a and b). On the patient's right side, an MR venographic image (GRE; 5.2/1.5; flip angle, 30°, not shown) illustrates a duplication of the superficial femoral vein.

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. (a) Coronal conventional venograms of the calf (left) and knee (right) regions in a 64-year-old man illustrate extensive postthrombotic changes with marked formation of collateral vessels involving the superficial venous system, which obscures delineation of the deep venous system. The upper portion of the conventional venogram of the knee region illustrates interruption of the popliteal vein with formation of collateral vessels into the thigh. (b) Coronal MR venographic image (GRE; 5.2/1.5; flip angle, 30°) permits select targeting of the deep venous system. The single deep vein, the fibular vein (arrowheads), is clearly identified as it merges into the popliteal vein, which is interrupted (arrow). Similar to findings on the conventional venogram, collateral vessels are seen as they drain the blood into the thigh. In addition, a strong caliber great saphenous vein with side branches was identified on the same select-targeted maximum intensity projection image (not shown).

View larger version (57K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. (a) Coronal conventional venograms of the calf (left) and knee (right) regions in a 64-year-old man illustrate extensive postthrombotic changes with marked formation of collateral vessels involving the superficial venous system, which obscures delineation of the deep venous system. The upper portion of the conventional venogram of the knee region illustrates interruption of the popliteal vein with formation of collateral vessels into the thigh. (b) Coronal MR venographic image (GRE; 5.2/1.5; flip angle, 30°) permits select targeting of the deep venous system. The single deep vein, the fibular vein (arrowheads), is clearly identified as it merges into the popliteal vein, which is interrupted (arrow). Similar to findings on the conventional venogram, collateral vessels are seen as they drain the blood into the thigh. In addition, a strong caliber great saphenous vein with side branches was identified on the same select-targeted maximum intensity projection image (not shown).

View larger version (65K): [in this window] [in a new window] [Download PPT slide]   Figure 3a. Varices in a 54-year-old woman who was obese and who was referred for assessment of the superficial venous system prior to bypass surgery. (a) Coronal MR venographic image (GRE; 5.2/1.5; flip angle, 30°) illustrates the deep and superficial venous systems from the level of the ankles to just below the aortic bifurcation. The inferior vena cava was inadvertently cut off owing to misplacement of the coil. Varicosity of the main stem of the great saphenous vein (arrows) is seen affecting the left great saphenous vein. The superior section of the right great saphenous vein was found suitable for bypass surgery. (b) Coronal conventional venograms obtained in the right extremity also show the right great saphenous vein to be suitable for bypass surgery.

View larger version (54K): [in this window] [in a new window] [Download PPT slide]   Figure 3b. Varices in a 54-year-old woman who was obese and who was referred for assessment of the superficial venous system prior to bypass surgery. (a) Coronal MR venographic image (GRE; 5.2/1.5; flip angle, 30°) illustrates the deep and superficial venous systems from the level of the ankles to just below the aortic bifurcation. The inferior vena cava was inadvertently cut off owing to misplacement of the coil. Varicosity of the main stem of the great saphenous vein (arrows) is seen affecting the left great saphenous vein. The superior section of the right great saphenous vein was found suitable for bypass surgery. (b) Coronal conventional venograms obtained in the right extremity also show the right great saphenous vein to be suitable for bypass surgery.

View larger version (61K): [in this window] [in a new window] [Download PPT slide]   Figure 4a. Coronal right-sided (a) contrast-enhanced 3D MR venographic image (GRE; 5.2/1.5; flip angle, 30°) and (b) anterograde conventional venogram obtained in a 53-year-old woman. A varicosity (arrow) of the side branch of the great saphenous vein is identified in a. No such change is seen in b. (c) Coronal conventional retrograde press venogram helps to confirm the varicosity (arrow) visible in a.

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 4b. Coronal right-sided (a) contrast-enhanced 3D MR venographic image (GRE; 5.2/1.5; flip angle, 30°) and (b) anterograde conventional venogram obtained in a 53-year-old woman. A varicosity (arrow) of the side branch of the great saphenous vein is identified in a. No such change is seen in b. (c) Coronal conventional retrograde press venogram helps to confirm the varicosity (arrow) visible in a.

View larger version (66K): [in this window] [in a new window] [Download PPT slide]   Figure 4c. Coronal right-sided (a) contrast-enhanced 3D MR venographic image (GRE; 5.2/1.5; flip angle, 30°) and (b) anterograde conventional venogram obtained in a 53-year-old woman. A varicosity (arrow) of the side branch of the great saphenous vein is identified in a. No such change is seen in b. (c) Coronal conventional retrograde press venogram helps to confirm the varicosity (arrow) visible in a.

View larger version (62K): [in this window] [in a new window] [Download PPT slide]   Figure 5a. Coronary arterial disease in a 62-year-old woman referred for venography to assess the suitability of the great saphenous veins for coronary bypass grafts. (a) Coronal MR venographic image (GRE; 5.2/1.5; flip angle, 30°) fails to demonstrate the great saphenous vein on either side. Merely a side branch (arrow) is visible on the right side following bilateral stripping of the great saphenous veins. (b) Coronal conventional venograms on which the branch (arrows) is seen shows these findings to similar advantage.

View larger version (52K): [in this window] [in a new window] [Download PPT slide]   Figure 5b. Coronary arterial disease in a 62-year-old woman referred for venography to assess the suitability of the great saphenous veins for coronary bypass grafts. (a) Coronal MR venographic image (GRE; 5.2/1.5; flip angle, 30°) fails to demonstrate the great saphenous vein on either side. Merely a side branch (arrow) is visible on the right side following bilateral stripping of the great saphenous veins. (b) Coronal conventional venograms on which the branch (arrows) is seen shows these findings to similar advantage.

	Footnotes

 
Abbreviations: GRE = gradient-recalled echo 2D = two-dimensional 3D = three-dimensional

Author contributions: Guarantor of integrity of entire study, S.G.R.; study concepts and design, S.G.R.; definition of intellectual content, S.G.R., J.F.D.; literature research, S.G.R.; clinical studies, S.G.R.; experimental studies, S.G.R.; data acquisition and analysis, S.G.R., W.W.; statistical analysis, S.G.R.; manuscript preparation and editing, S.G.R., J.F.D.; manuscript review, J.F.D.

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