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Urinary Calculi Imaging

http://emedicine.medscape.com/article/381993-overview#showall

Urinary Calculi Imaging
 Author: J Kevin Smith, MD, PhD; Chief Editor: Eugene C Lin, MD more...

Overview
Preferred examination
The goals of imaging of urinary calculi are to determine the presence of stones within the urinary tract, evaluate for complications, estimate the likelihood of stone passage, confirm stone passage, assess the stone burden, and evaluate disease activity.[1, 2, 3, 4, 5, 6, 7] Images of stone disease are provided below:

Magnified scout intravenous urogram shows a large, relatively lucent calculus in the lower pole of the right kidney.

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Urinary Calculi Imaging

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Scout intravenous urogram shows a smooth, dense, round calculus in the left kidney.

Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis.

Contrast-enhanced CT scan demonstrates an opaque staghorn calculus filling the left renal collecting system

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Urinary Calculi Imaging

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Intravenous urogram (10-min delay) Magnified view of the left ureterocele with a large stone in it.

Prone nonenhanced CT image shows that the stone in the left ureterovesical junction does not move to the dependent portion of the bladder. This finding indicates that it is still in the distal ureter at the ureterovesical junction and that it has not passed into the bladder.

Contrast-enhanced CT image of the right kidney shows a cluster of calyceal calculi without hydronephrosis.

When acute flank pain suggests the passage of a urinary stone, many methods of examination can be used.[8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19] Often, conventional radiography is initially used to screen for stones, bowel abnormalities, or free intra-abdominal air. Radiographs can also be used to monitor the passage of visible stones.

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renal failure. Pregnant or pediatric patients may be imaged with US first to avoid radiation exposure. those who are pregnant. intravenous contrast material may be needed to opacify the ureter. with Page 4 of 30 10/02/2014 15:30 . IVU is the traditional examination for the assessment of urinary stone disease.medscape. All of these methods have become less useful with the advent of more sensitive and specific nonenhanced computed tomography (CT) scanning. in rare cases. The rare false-negative finding is usually due to reader error or a protease-inhibitor CT-lucent stone. but it is of the same order of magnitude. As a result of the higher radiation dose of CT.[23] Limitations of techniques Because of the higher radiation dose with CT. it is now considered the examination of choice for the detection and localization of urinary stones. and complications of stone disease may result in severe infection. US is also helpful in problem solving. patients with spine injury). Almost all studies conducted to date show that IVU provides no additional clinically important information after nonenhanced CT is performed. In some cases. Ultrasonography (US) has limited sensitivity for smaller stones. It should be used mainly in patients who are young. conventional or digital radiography should be used to monitor the passage of stones if radiographic follow-up studies are indicated and if the stone is visible on conventional radiographs.Urinary Calculi Imaging http://emedicine. The radiation dose is generally smaller than that of CT. or those undergoing multiple examinations (eg. Falsepositive results are usually due to phleboliths adjacent to the ureter. 21] and in patients allergic to iodinated contrast material. death. and does not depict the ureters well. Ultrasonography (US) is useful in young or pregnant patients[20. or. and it does provide physiologic information related to the degree of obstruction. The pain may be some of the most severe pain that humans experience. When CT is available.[22] Passage of a urinary stone is the single most common cause of acute ureteral obstruction and affects as many as 12% of the population. conventional or digital radiography should be used to monitor the passage of stones if radiographic follow-up is believed to be indicated and if the stone is visible on conventional radiographs. Intravenous contrast is required.com/article/381993-overview#showall Intravenous urography (IVU) (excretory urography) provides important physiologic information regarding the degree of obstruction.

Phleboliths in the pelvis are usually located lower than and lateral to the ureter. the stone is relatively lucent. Cystine stones as small as 3-4 mm may be depicted. Typically. Calcium stones as small as 1-2 mm can be seen. 2 images are required. often. they are often difficult to distinguish from ureteral calculi. and the point at which the ureter crossing the iliac vessels. 29. but uric acid stones are usually not seen unless they have become calcified. and. However. These images should be obtained before contrast material is administered to prevent obscuring calcifications within the collecting system or calyceal diverticula. Stones are often found at key points of narrowing such as the ureteropelvic junction (UPJ). For its size. as shown in the image below. An addition site is on the right side where the ureter passes through the root of the mesentery. Conventional radiographs should include the entire urinary tract. 26. 30] Abdominal radiograph shows calcification filling the left collecting system. especially for small or nonobstructing stones. Because gonadal veins parallel Page 5 of 30 10/02/2014 15:30 . but they overlap with the ureter.Urinary Calculi Imaging http://emedicine. 27. 25. is often performed as a preliminary examination in patients with abdominal pain possibly resulting from urinary calculi. IVU is less sensitive than CT.medscape. This finding is consistent with a staghorn calculus. phleboliths are round or oval. 28.com/article/381993-overview#showall resultant risks of an allergic reaction or nephrotoxicity.[24. and they may demonstrate a central lucency. the ureterovesical junction (UVJ). Radiography Conventional radiography Conventional radiography.

and it can be used to confirm the relationship of stones to the kidneys.Urinary Calculi Imaging http://emedicine. compression of the abdomen and collimation is critical. Because stones are more visible with a lower peak kilovoltage (kVp).medscape. contrast enhancement may be needed to opacify the ureter and demonstrate the extraurinary location of phleboliths in the gonadal veins. IVU depicts anatomic abnormalities such as dilated calyces. if possible. Intravenous urography Intravenous urography. UPJ obstruction. Page 6 of 30 10/02/2014 15:30 . is useful for confirming the exact location of a stone within the urinary tract. Mild bowel preparation may be helpful for increasing the sensitivity of conventional radiography for small stones in patients undergoing screening or follow-up observation for stones. retrocaval ureter. Preinjection renal tomography may depict additional stones. and others that may predispose patients to stone formation or alter therapy. This view can also depict calcifications that are projected over the sacrum or transverse processes on the frontal view. Larger patients may require a higher peak kilovoltage for acceptable exposure and scatter. duplication. In this situation. maintaining a maximum of 60-80 kVp is best. An erect or posterior oblique radiograph obtained on the side of the calcification may help in distinguishing urinary stones from extraurinary calcifications. as shown in the images below. Because contrast agents can obscure stones in the collecting system. scouting the entire urinary tract prior to their administration is critical.com/article/381993-overview#showall the upper ureters. calyceal diverticula.

com/article/381993-overview#showall Magnified scout intravenous urogram shows a large. relatively lucent calculus in the lower pole of the right kidney.Urinary Calculi Imaging http://emedicine.medscape. After the intravenous injection. Page 7 of 30 10/02/2014 15:30 . Intravenous urogram. Scout intravenous urogram shows a smooth stone in the right kidney. contrast material in the collecting system obscures the calculus.

dilatation to the point of obstruction. which is often first indicated by blurring of the calyceal fornices. Delayed images may be needed to opacify to the point of the obstruction.Urinary Calculi Imaging http://emedicine. Contrast material in the collecting system obscures the stone. Extravasation of urine at the fornices may result in pyelosinus or pyelolymphatic extravasation. and the contrast may dissect into the perinephric space. false-positive findings result from extrarenal calcification. but may also be striated or occasionally not visible on radiographs. however. This may be prolonged and hyperopaque.[31] Other signs include delayed excretion. False positives/negatives Occasionally. or blunting of the calyceal fornices. Degree of confidence Although 90% of urinary calculi are opaque on abdominal radiographs. an obstructive nephrogram may be present. Immediately after the passage of a stone. residual mild obstruction or edema can be detected at the UVJ. Greater extravasation may outline the collecting system. with increasing opacity over time.com/article/381993-overview#showall Intravenous urogram obtained 5 minutes after the intravenous injection. The nephrogram of acute obstruction is usually homogeneous. US and CT are Page 8 of 30 10/02/2014 15:30 . the use of compression has been associated with forniceal rupture.medscape. In rare cases. compression may not be used to increase sensitivity for detection of low-grade obstruction. if the urine is not infected. When a stone causes acute obstruction. this is usually clinically insignificant. but using gravity to position the more opaque and more distal contrast material–laden-urine is also possible by placing the patient in a prone or erect position. but these are usually correctly identified with IVU. but they are not distinguished from non–stone-filling defects such as transitional cell carcinomas or blood clots. Approximately 10% of stones are radiolucent on conventional radiographs. When an acute urinary stone is the primary consideration. Lucent stones appear as filling defects on IVU. and the specificity is only approximately 70%. the sensitivity for the prospective identification of individual stones is only 5060%. A caveat is that the contralateral kidney may have an abnormality that requires ureteric compression for adequate examination.

In fact. 46. 38. CT is faster and no contrast agent is needed in most patients.[56. helical CT is considerably more effective than IVU. however.Urinary Calculi Imaging http://emedicine. 49. 58] Page 9 of 30 10/02/2014 15:30 . 33. 54. 41. 57. 39] Helical CT scans frequently depict non-obstructing stones that are missed on intravenous urography (IVU). 45. 37. if possible. 47. much of the ureter cannot be visualized with US. 48. 34. in most studies. pure matrix stones may demonstrate soft-tissue opacity on CT scans. the entire abdomen should be scanned during a single breath hold to prevent section misregistration. 52] Helical CT is important to avoid missing stones because of section misregistration.[43] Technique Because stones in the collecting system may be obscured by contrast material. nonenhanced CT. helical CT is the most sensitive radiologic examination for the detection. is usually performed.[44.[40. 36. and indinavir stones appear lucent. 35. as shown in the images below.[42] However.5:1 or less is preferred. localization. therefore. although some radiologists choose to use a pitch of as much as 2:1. 55] The kidneys and. Computed Tomography With a sensitivity of 94-97% and a specificity of 96-100%. 41] Rarely. and characterization of urinary calcifications. A 5-mm helical technique with a pitch of 1. IVU added little or no information. helical CT is better than US or IVU in detecting other causes of abdominal pain.[53. all other stones appear opaque on CT scans.com/article/381993-overview#showall effective tools in making this distinction. which may depict only a filling defect). 50. 51. In addition. CT easily differentiates between non-opaque stones and blood clots or tumors (compared with IVU.[32.medscape.

Urinary Calculi Imaging http://emedicine. Axial nonenhanced CT image at the level of the kidneys shows bilateral renal calculi. and moderate perinephric fluid. CT can be performed much more rapidly than urography and without the use of intravenous contrast material. Page 10 of 30 10/02/2014 15:30 .medscape. right hydronephrosis. No significant hydronephrosis is identified.com/article/381993-overview#showall Axial nonenhanced CT section at the level of the kidney demonstrates an attenuating proximal ureteral calculus (arrow). Axial nonenhanced CT image of the urinary bladder demonstrates an attenuating calculus at the right ureteropelvic junction.

minimizing the radiation dose is critical.com/article/381993-overview#showall Nonenhanced CT image of the pelvis shows dilatation of the distal left ureter and mild periureteral fluid near the left ureterovesical junction. Nonenhanced CT image of the pelvis shows a small attenuating stone at the left ureterovesical junction.8-4.006 Gy for 4-image IVU compared with 0.[60] At the authors' institution.0046 Gy for nonenhanced CT. Reported radiation doses for CT are 2. However. To discern between phleboliths and Page 11 of 30 10/02/2014 15:30 . the uterine dose is approximately 0.medscape. approximately 12% (10-20%) of patients who undergo nonenhanced CT for possible urinary stones receive intravenous contrast material for further evaluation.[59] A fairly high level of noise as a result of the inherently high contrast levels is tolerable in most patients.Urinary Calculi Imaging http://emedicine.3-1.5 mSv compared with 1. Because patients with stones are often young and because stone disease may recur.5 mSv for a 3-image IVU.

The finding is consistent with fornix rupture. as often seen on plain radiographs. this finding differentiates it from a calculus. The excretory phase image through the kidneys shows extravasation of contrast material in and near the renal pelvis and surrounding the proximal ureter.5:1. a 5-mm helical scan is obtained through the area of concern. Contrast-enhanced CT section reveals a dense calculus in the right kidney. 100-150 mL of a lowosmolar oral and rectal contrast agent is used.[63] In this situation.com/article/381993-overview#showall urinary stones. 50 mL of low-osmolar contrast agent should be administered. Soft tissue around the rim of a calculus can differentiate it from a phlebolith.medscape. but the hydronephrosis has resolved. Fewer contrast-enhanced studies are needed with increasing experience. A phlebolith may have a comet tail of soft tissue extending from it. and a 5-mm helical CT scan is obtained with a pitch of 1. routine abdominal and/or pelvic CT should be performed. Axial contrast-enhanced CT scan. phleboliths do not have radiolucent centers.[61] On CT scans. Patient selection determines the number of examinations needed. which is opacified. as shown in the images below. Page 12 of 30 10/02/2014 15:30 . After 3-5 minutes. are required to evaluate pain not related to stones.[43.Urinary Calculi Imaging http://emedicine. 62] When contrast-enhanced scans.

Contrast-enhanced CT image of the lower abdomen shows a tiny. Page 13 of 30 10/02/2014 15:30 .Urinary Calculi Imaging http://emedicine. A Foley catheter balloon is visible in the bladder.com/article/381993-overview#showall Axial contrast-enhanced CT image through the ureterovesical junction confirms the stone within a left ureterocele. left ureteral calculus. obstructing.medscape.

com/article/381993-overview#showall Contrast-enhanced CT image shows a patchy area of hypo-opacity consistent with pyelonephritis.[64] CT findings CT may depict the following:       Stones in the ureter Enlarged kidneys Hydronephrosis (83% sensitive. 94% specific) Perinephric fluid (82% sensitive. a repeat scan through the UVJ in the prone position may be helpful. 66] Page 14 of 30 10/02/2014 15:30 . 93% specific) Soft-tissue rim sign (good positive predictive value with a positive odds ratio of 31:1). see the image below.Urinary Calculi Imaging http://emedicine. Stones at the UVJ may be difficult to distinguish from stones that have already passed into the bladder.medscape. If the distinction changes therapy.[65. Stones that have already passed into the bladder will drop into a dependent location. 93% specific) Ureteral dilatation (90% sensitive.

Conventional radiography may be helpful in visualizing larger stones. and as with the obstruction. and bladder radiographs fail to depict the stone.com/article/381993-overview#showall Nonenhanced CT image shows an obstructing left proximal ureteral calculus with a slight soft-tissue rim around the stone (ie. If contrast material is administered. However. the usefulness of IVU is limited. Approximately 40-55% of stones are not visible on abdominal radiographs. Almost no stones with attenuation values of less than 200 HU are visible. this finding has been seen with proven ureteral calculi and is often absent in patients without stones. These indicate that significant obstruction is not present.Urinary Calculi Imaging http://emedicine. rim sign). a delayed or hyperattenuating nephrogram may also be visible on CT scans if the ureter has an obstruction. the amount of fluid is correlated with the likelihood of stone passage. Considerable overlap exists in the CT attenuation values of calcium stones. once they are identified on CT scans. and repeat CT scans are usually required if passage of the stone is to be followed. calcium stones usually demonstrate attenuation higher than 700 HU. ureter. If kidney. CT may be needed to follow its passage. For this reason. Page 15 of 30 10/02/2014 15:30 . Normal hyperattenuating renal pyramids sometimes are seen. The amount of perinephric fluid is correlated with the degree of obstruction seen on IVU. to provide a baseline to follow passage of the stone. Cystine and urate stones have an attenuation of 100-500 HU.medscape.

US may be used initially in pregnant or pediatric patients. MRI may be a useful tool for problem solving. US. because any fetal damage is unlikely at the typical radiation doses. in those who have contraindications to the use of contrast media. and the radiation dose may be justified (especially if the clinical picture is confusing).[69] Usually. IVU can be used. especially in the first trimester. and the diagnosis may be difficult to establish with imaging because of the displacement and obscuration of organs by the enlarged uterus and fetus. but the views should be limited to scout and 10. Use of low-osmolar contrast agent also helps. Very poor renal function results in a failure to opacify the collecting system. As in pregnant patients.medscape. The patient can be premedicated with steroids and histamine blockers.05% of pregnancies. a pregnancy test should be performed prior to CT scanning or radiography. Radiation exposure should be minimized in pregnant women. Use of iodinated contrast agents should be avoided in patients who have had previous lifethreatening reactions. special concerns exist in patients who are pregnant. stone formation is a complication in as many as 0. Nonenhanced CT is usually sufficient with the aid of US and MRI as problem-solving tools. and in those with renal insufficiency. Nuclear scintigraphy may also be helpful in confirming obstruction.[20] Consider using US first in a pregnant patient. Patients may potentially sue for contrast material–related injuries if nonenhanced CT was available but not used.Urinary Calculi Imaging http://emedicine. however.[67] CT can also be useful. MRI. Pregnancy does not predispose patients to stone formation. and female patients should be questioned carefully. nephrotoxicity and allergy-like reactions are possible. in patients with renal insufficiency. but CT may be indicated to confirm or Page 16 of 30 10/02/2014 15:30 . nonenhanced CT is sufficient.to 30-minute images if possible. and scintigraphy can be useful as problem-solving tools. If needed. If contrast material is used for IVU or for problem solving with CT. Nonenhanced CT results are usually diagnostic. actions can be taken to decrease the risk of an adverse reaction in patients.[68] but if contrast material is needed. Minimize the dose by increasing the pitch and decreasing the milliamperage.com/article/381993-overview#showall Special concerns In the diagnosis and treatment of kidney stones.

especially if dilatation is present.com/article/381993-overview#showall diagnose urinary stone disease and exclude other pelvic pathology in pregnant women. 72] Magnetic Resonance Imaging Stones are not directly visible on MRIs because they produce no signal. Characteristics include red or dark patches on the skin. 80. or feet. False-negative results are primarily due to indinavir radiolucent stones and error. some patients with acute obstruction have little or no dilation. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. and muscle weakness. joint stiffness with trouble moving or straightening the arms. 74. Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ. they may be indirectly visualized as a filling defect in the ureter or collecting system on heavily T2-weighted images or on gadoliniumenhanced T1-weighted images. however. pain deep in the hip bones or ribs. burning.[77. 78. 81] In particular. legs. itching. hardening. However.Urinary Calculi Imaging http://emedicine. during pregnancy). Ultrasonography On sonograms. False-positive results are almost exclusively the result of a phlebolith adjacent to the ureter. yellow spots on the whites of the eyes. CT scans often suggest an alternative or additional diagnosis when renal stone disease is clinically suspected. 75.[82] Page 17 of 30 10/02/2014 15:30 . however. as noted in CT findings above. US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction). Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD).[71. 76] MRI can be useful as a problemsolving tool if the use of iodinated contrast material or radiation is contraindicated (eg. US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media. and tightening of the skin. US is often skipped in favor of nonenhanced CT. 79.[70] Degree of confidence Individual CT signs are associated with varying degrees of confidence.medscape. hands. stones are demonstrated as bright echogenic foci with posterior acoustic shadowing.[73. swelling. NSF/NFD is a debilitating and sometimes fatal disease.

with a specificity as high as 90%. especially stones smaller than 2 mm. 87] Degree of confidence US is very insensitive for stones. as visualized with color Doppler on the symptomatic side. US is more dependent on the operator's ability and more time consuming. Doppler imaging may demonstrate a high resistive index in acute obstruction. confirming the obstruction with nuclear medicine studies is useful if the administration of iodinated contrast material is contraindicated. False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum. Nuclear Imaging Nuclear medicine studies may demonstrate the retention of activity in the cortex or collecting system when the obstruction is ongoing. 86. With US. 85. 84.[88. Renal function evaluation is not reliable in the presence of ongoing obstruction. Absence of the ureteral jet. Page 18 of 30 10/02/2014 15:30 . Nuclear medicine tests are useful in determining differential renal function for treatment planning and for assessing how much renal function might return after the obstruction is relieved.medscape. Occasionally. imaging findings may be normal with low-grade obstruction. Fowler et al suggest that US has a sensitivity as low as 24%. compared with nonenhanced CT. matrix or indinavir stones may have soft tissue echogenicity without shadowing.com/article/381993-overview#showall In addition. US does not provide direct physiologic information regarding the degree of obstruction. is presumptive evidence for a high-grade obstruction in a well-hydrated patient. False-positive findings may result from renal vascular calcifications. Conversely.[83. a kidney with very little function might be removed if very little function persists after a trial of drainage. Compared with nonenhanced CT.Urinary Calculi Imaging http://emedicine. 69] For example. US is good for characterizing lucent filling defects that are visualized as stones on IVU. but this may not occur immediately or after forniceal rupture. False positives/negatives US is fairly specific when stones are seen. estimations of stone size may not be accurate. stones at the UPJ. Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis. However. Furthermore. or stones in the mid ureter.

Associate Director of Radiology Medical Student Education.com/article/381993-overview#showall Contributor Information and Disclosures Author J Kevin Smith. Vice Chair for Veterans Affairs. MPH Professor of Radiology. American College of Radiology. University of Arkansas for Medical Sciences Page 19 of 30 10/02/2014 15:30 . Philip Kenney. Department of Radiology. MD.medscape. Chief of Abdominal Imaging. Department of Radiology. and Society of Radiologists in Ultrasound Disclosure: Nothing to disclose. Collat Jewish Family Service Disclosure: Nothing to disclose. MPH is a member of the following medical societies: American Institute of Ultrasound in Medicine. Nicole W Berland Outreach Support for Hurricane Relief. Coauthor(s) Mark E Lockhart. American Roentgen Ray Society. MD. American Roentgen Ray Society. MD. Chief of Service. Department of Radiology.Urinary Calculi Imaging http://emedicine. PhD Professor of Abdominal Imaging. Radiological Society of North America. Birmingham Veterans Affairs Medical Center J Kevin Smith. MD Professor of Radiology and Chairman. and Society of Uroradiology Disclosure: Nothing to disclose. International Society for Magnetic Resonance in Medicine.Radiological Society of North America. University of Alabama at Birmingham School of Medicine Mark E Lockhart. Association of University Radiologists. PhD is a member of the following medical societies: Alpha Omega Alpha. University of Alabama at Birmingham School of Medicine. MD. Society of Radiologists in Ultrasound.

American Institute of Ultrasound in Medicine. Peconic Bay Medical Center Steven Perlmutter. Robert M Krasny. ChB.Radiological Society of North America. MD Resolution Imaging Medical Corporation Robert M Krasny.Urinary Calculi Imaging http://emedicine. The School of Medicine at Stony Brook University. Virginia Mason Medical Page 20 of 30 10/02/2014 15:30 . Hutt Valley District Health Board. American Medical Association. Medical Director of Radiology. Teaching Coordinator for Cardiac Imaging. MB. Chief Editor Eugene C Lin. and Society of Uroradiology Disclosure: Nothing to disclose. MD. Medical Society of the State of New York. Radiological Society of North America. PhD Consulting Staff. American Roentgen Ray Society. FACR Associate Professor of Clinical Radiology. Association of University Radiologists. Association of University Radiologists. Bernard D Coombs. MD is a member of the following medical societies: Alpha Omega Alpha. American Roentgen Ray Society. New Zealand Disclosure: Nothing to disclose. MD. MD Attending Radiologist. Society of Breast Imaging. American College of Radiology.medscape. Radiology Residency Program. MD is a member of the following medical societies: American Roentgen Ray Societyand Radiological Society of North America Disclosure: Nothing to disclose. Association of Program Directors in Radiology. Department of Specialist Rehabilitation Services. FACR is a member of the following medical societies: American College of Radiology. Society of Nuclear Medicine. and Society of Uroradiology Disclosure: Nothing to disclose.com/article/381993-overview#showall Philip Kenney. Specialty Editor Board Steven Perlmutter.

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