Pigtail plastic stents are used to remove the intra-abdominal drainage during procedures such as endoscopic retrograde cholangiopancreatography (ERCP) [8]. A few studies have also reported titanium as a potential allergen. Eczema most severe around the implant site, 3. does it exst? Y. Nakashima, D. H. Sun, M. Trindade, W. Maloney, S. Goodman, and D. Schurman, Induction of macrophage C-C chemokine expression by titanium alloy and bone cement particles, Journal of Bone and Joint Surgery, vol. Metal allergy and metal sensitivity are often used interchangeably in everyday conversations. The skin (or other tissue) that comes in contact with the offending metal becomes red, itchy, and irritated. The site is secure. A. Serati, B. Sharif-Kashani, Z. H. Ahmadi et al., Removing an entrapped pigtail catheter by re-enforcing a traditional method, Tanaffos., vol. Patch testing is the gold standard to determine sensitization, and this review provides a list of standard allergens to test for different implants. Nickel is one of the most common allergens, and can cause local contact dermatitis characterized by itching and skin reddening. Nickel-stented patients: difference in restenosis rate between "allergic patients with restenosis (. The patient had undergone a laparoscopic removal of the eight clips used in her past surgery, and since then, her symptoms have resolved. While the words "hypersensitivity" and "allergy" are often used interchangeably, they're not really the same. By clicking Accept, you consent to the use of ALL the cookies. 4143, 2011. M. Goutam, C. Giriyapura, S. K. Mishra, and S. Gupta, Titanium allergy: a literature review, Indian Journal of Dermatology, vol. Between 10% and 15% of the general population is sensitive or allergic to nickel. Disclaimer. The challenge with metal hypersensitivity is that the diagnosis is not always 100% certain. doi: 10.7759/cureus.30625. Stainless steel screws are commonly used for internal fixation in an array of podiatric procedures. doi:10.1016/j.jaip.2020.12.068, Wang Y, Dai S. Structural basis of metal hypersensitivity. Type I hypersensitivity reaction may manifest as anaphylaxis causing urticarial plaques or papules on the skin [3]. Patch tests positive or strongly positive for one of the metals in the alloy, 5. Cookies collect information about your preferences and your devices and are used to make the site work as you expect it to, to understand how you interact with the site, and to show advertisements that are targeted to your interests. There are more than 28 million surgical procedures with up to 1500 cases of retained foreign bodies estimated in the United States per year [13]. 12, no. official website and that any information you provide is encrypted = Reference; s/p = status post; TKA = total knee arthroplasty. -, J Bone Joint Surg Am. The patients preop white blood cell (WBC) count was 5.2K/L, absolute neutrophil count was 3281 cells/L, and absolute lymphocyte count was 1284 cells/L. A case by Little et al. This causes type IV hypersensitivity reaction through sensitization of T lymphocytes and macrophages. If you have a known hypersensitivity to metal and are scheduled to undergo a total knee replacement, it is not clear if starting with a ceramic or titanium appliance is the best option. Plaintiffs claim that they have suffered from serious injuries during or after a surgery because of misfired staples from a defective surgical stapler. Nam D, Li K, Riegler V, Barrack RL. Common symptoms of MHS reactions include localized pain, swelling, redness, warmth, loosening, draining, itching/burning, and implant instability. Dermatol Ther (Heidelb). 2005 Jan;87(1):28-36 The pigtail catheter in the cecum was removed carefully, and the foreign body was measured 10.0cm in length and 0.3cm in diameter. Total knee arthroplasty (TKA) is generally a very successful surgery, and the vast majority of people who undergo it are satisfied with the results. No metal allergy was found in 10 patients with very late in-stent restenosis. After all, surgical staplers, along with staples, have been heavily marketed as time savers and are said to be more convenient compared to stitches when it comes to wound closure. Runny nose. This review provides an update of the current knowledge in this field and should be valuable to health care providers who manage patients with conditions related to this field. Medical ID Cards to Identify Metal Implants for the TSA, Trapeziectomy: Everything You Need to Know, Removing Pins and Other Surgical Implants, Problems With Metal-on-Metal Hip Replacements, Causes and Risk Factors of Contact Dermatitis, Why the Material Used for Hip Replacement Implants Matters, Allergy in total knee arthroplasty: a review of the facts, Metal hypersensitivity reactions to orthopedic implants, Biological responses to metal implants: 2019. Sneezing. eCollection 2022. Bioact Mater. As these cases are reported with metal implants including clips used in surgery, these allergic reactions can also be expected with staples. 7, no. Read the article to learn more about what triggers this side effect and how you can ask help from your doctor to avoid any complications after your surgery. J Am Acad Orthop Surg. N Y State Dent J. The abdominal pain is associated with titanium allergy reaction from previously inserted titanium-based surgical clips. This category only includes cookies that ensures basic functionalities and security features of the website. The Opioid Epidemic. *List may not be exhaustive. However, in chronic cases of months to years after the operation, a CT scan is usually performed to rule out malignant tumors and possible fistula formations [13]. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. Allergy symptoms, which depend on the substance involved, can affect your airways, sinuses and nasal passages, skin, and digestive system. Some orthopedic implants contain small amounts of nickel, and there's been a concern that this may be an issue for nickel-sensitive people. Immune response differences in degradable and non-degradable alloy implants. ASTM = American Society for Testing and Materials. 2013, no. Pain around the site of orthopedic implants has many causes. Please enable it to take advantage of the complete set of features! By postoperative day 6, the patients symptoms of abdominal distension resolved and her RLQ pain also diminished. eCollection 2022. The authors declare that they have no competing interests. Lump in left groin associated with shooting pain, Bilateral MOM hip resurfacings (34 mo apart). Akashi Y, Shimoo Y, Hashiguchi H, Nakajima K, Kokubun K, Matsuzaka K. Materials (Basel). The https:// ensures that you are connecting to the doi: 10.1371/journal.pone.0272283. The most common symptoms for patients with MHS-associated failures are localized soft tissue reaction including delayed wound healing and/or recurrent wound issues. The patient also started having low-grade fever, nausea, vomiting, joint pain, diffuse rash, and fatigue. apr18 1, article bcr2013009070, 2013. Cutaneous reactions to metal implants, orthopedic or otherwise, are well documented in the literature. Telephone: 1.800.234.1826 A number of studies also suggest a conversion to suturing in place of surgical stapling in order to avoid allergic reactions and other potential complications after surgery. Additionally, standard surgical instruments such as electrodes, drains/catheters, retractors, or clamps can be left unrecognized after operations, especially in the abdominal space [13]. Hypoallergenic knee replacement materials are available. Cara Beth Lee, MD, is a board-certified Orthopedic Surgeon with over 20 years of practice experience and subspecialty expertise in hip preservation surgery, focusing on patients with pre-arthritic hip disorders. If surgery is needed, the implant would be removed and replaced with a special implant made of ceramic or titanium. Keywords: Reactions to metals in knee replacements happen when the immune system overreacts or launches a defensive assault on the artificial joint and surrounding tissues, triggering local inflammation. This corrosion causes the formation of metal ions that ultimately trigger the inflammatory immune response. It explores the causes and symptoms of a reaction and what to do if you suspect one. 18, no. Painful cramps. Plastic used if the patient is allergic to metals found in other medical staples. Six metal surgical clips removed from the RUQ via fluoroscopic guidance. Thanks so much Craig, that is good to hear! 426431, 2018. 2019;10(2):63-70. doi:10.5312/wjo.v10.i2.63, Kahlenberg CA, Nwachukwu BU, McLawhorn AS, Cross MB, Cornell CN, Padgett DE. With prosthetic knees, stainless steel used to build the appliance contains around 10% nickel. If you or a loved one have any of these latter, more severe symptoms, these are indicators of when to go to the ER for an allergic reaction . Metal allergies are becoming more recognized within the surgical field. Most of the usage of titanium is in the form of titanium dioxide. Dermatitis. An Investigation into the Potential of Turning Induced Deformation Technique for Developing Porous Magnesium and Mg-SiO. and transmitted securely. It is based on symptoms that are associated with allergies in the form of rashes, urticarial, pruritus, swelling in the region of the orofacial, erythema of facial as well as oral, eczematous lesions in the area of the cheeks. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. The MELISA test has been known to be a more sensitive test to metal allergy but lacks specificity in the proliferation of lymphocytes [3]. All of her symptoms were initially suspected due to the infections mentioned above, and she was placed on various antibiotic therapy regimens consisting of ciprofloxacin, amoxicillin/clavulanate potassium, and sulfamethoxazole/trimethoprim. Symptoms of a Reaction Unfortunately, the symptoms of metal implant sensitivity and allergy are not well defined. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Red, swollen, watery eyes -- a condition known as allergic conjunctivitis. 5, no. None had issues despite confirmed allergy to one of the metals in their device (6-year follow-up). Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. 155162, 1999. 201207, 2012. Throughout this article, we do the same. M. Hosoki, K. Nishigawa, T. Tajima, M. Ueda, and Y. Matsuka, Cross-sectional observational study exploring clinical risk of titanium allergy caused by dental implants, Journal of Prosthodontic Research, vol. It helps to understand what happens when your body comes in contact with a metal to which you're allergic. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The patient contacted our department the next morning, and the case and CT findings were reviewed. The patient initially had intermittent RLQ abdominal pain accompanied by nonspecific symptoms. You can find out more about our use, change your default settings, and withdraw your consent at any time with effect for the future by visiting Cookies Settings, which can also be found in the footer of the site. Sensitization to implant components is associated with joint replacement failure: identification and revision to nonallergenic hardware improves outcomes. The case also unfolds rare differential diagnoses to keep in mind when encountering a patient with abdominal pain and associated nonspecific symptoms. However, while both are in the "allergy family," there is an important difference worth clarifying. 1, pp. The striking features of titanium include its stability with increased resistance to corrosion and its biocompatibility to diverse materials [3]. With her history of allergy to other metals in the past, a titanium allergy was suspected at this visit, and the patient promptly underwent a titanium skin patch test that turned out positive. Sinus Issues. Normal pelvic radiography. The CT impressions showed no signs of bowel obstruction or colitis; however, it was evident that a portion of a pigtail drainage catheter was lodged within the cecum (Figure 2). Cardiac stents and patches are often made of Nitinol, a composite of nickel and titanium. 2013 Jun-Jul;79(4):38-43. American Association of Hip and Knee Surgeons. The site is secure. 2023 Mar 20;16(6):2463. doi: 10.3390/ma16062463. Revision to titanium alloy with ceramic-on-ceramic bearing led to symptom resolution. Contact Dermatitis. eCollection 2023 Jun. Allergy to a metal screw is very rare, so consider other issues first. This resulted in approximately 75lbs. Martinez JS, Peterson S, Hoel CA, Erno DJ, Murray T, Boyd L, Her JH, Mclean N, Davis R, Ginty F, Duclos SJ, Davis BM, Parthasarathy G. PLoS One. She also reported low-grade fever, nausea, vomiting, joint pain, bloody diarrhea, and inability to keep her food down. Craig Payne said: . But sometimes issues do arise. eCollection 2022 Jun. She reported a complete resolution of all symptoms one-month postsurgery. When hardware issues become apparent, one of the first questions patients ask themselves is: Am I allergic to the hardware? In this post, we are going to talk about allergies as they relate to spinal hardware. does it exst? Would you like email updates of new search results? ABG = Anatomique Benoist Giraud; Co = cobalt; Cr = chromium; F = female; Fe = iron; M = male; Mo = molybdenum; Ni = nickel; OA = osteoarthritis; PCA = porous coated monatomic; Ref. In most instances, these screws and plates do not create symptoms and remain permanently in the foot. In most cases, patients have no issues with the hardware. Diagnosis of metal hypersensitivity in total knee arthroplasty: a case report. There is also tissue response to implants, such as the hyperplastic lesions of the soft tissues. Sun et al., Suspected allergy to titanium after anterior cervical discectomy and fusion using a Zero-P device: a case report, British Journal of Neurosurgery, pp. The patient had delayed hypersensitivity reaction to nickel in the past with erythematous rash formation and severe itching. The best way to avoid postoperative issues is to routinely ask patients prior to surgery if they have any known MHS including problems with cosmetic jewelry. DHT is typically diagnosed by excluding all other causes of post-operative knee pain, such as: It is only after these causes are excluded that metal sensitivity is explored. 1975 Nov 15;4(5993):376-8 Dental implants; Metal allergy; Orthopedic surgery; Patch testing; Titanium. It is important to diagnose RFB promptly and remove it as soon as possible due to life-threatening complications such as gastrointestinal bleeding, intestinal obstruction, and perforation [13]. A decision was made to remove all the metal surgical clips laparoscopically via fluoroscopic guidance (Figure 1). Metal Allergy to Surgical Plates, Screws, and Implants, Hip Replacement Loosening Symptoms and Causes, Problems With Metal-on-Metal Hip Replacements, What Causes Metal Implants to Break Inside the Body, Trapeziectomy: Everything You Need to Know, What to Expect When Getting Your Ears Pierced, Allergic Reactions and Sensitivities Caused by Synthroid, Causes and Risk Factors of Contact Dermatitis, Metal hypersensitivity and total knee arthroplasty. 2022 Oct 24;14(10):e30625. Accessibility Proper history taking, appropriate physical exams, and specific diagnostic modalities can identify rare causes of chronic abdominal pain. In fact, they are the subjects of recently filed complaints in the surgical stapler lawsuit. Would you like email updates of new search results? She was diagnosed with pneumonia twice followed by two sinusitis episodes from January 2020 to March 2020. Adhesive allergy; Contact dermatitis; Joint failure; Joint replacement; Metal allergy; Methyl methacrylate; Nickel; Rash; Surgical implant. Healthcare providers now believe that the term, "iodine allergy" should no longer be used because it is inaccurate. He exhibited allergic symptoms (eczema) after orthopedic surgery. The signs and symptoms of a late infection present a challenge in the setting of a bioabsorbable interference screw. 2019 Nov;10:02758. doi:10.3389/fimmu.2019.02758, Faschingbauer M, Renner L, Boettner F. Allergy in total knee replacement. Clinic Locations. Orthopade. By Jonathan Cluett, MD Symptoms of metal allergy and sensitivity. The titanium screws used in the orthopedic surgery that he underwent were removed 1 year later, but the eczema remained. V. Vijayaraghavan, A. V. Sabane, and K. Tejas, Hypersensitivity to titanium: a less explored area of research, J Indian Prosthodont Soc., vol. or can an allergic reaction occur from these - Answered by a verified Doctor . -, Br Med J. The patient did not report any screening for immunodeficiency in the past. FOIA Cobalt and chromium may be found not only in the appliance but also in bone cements used to set the prosthetic. Please use this form to submit your questions or comments on how to make this article more useful to clinicians. On this site, Dr. Sinicropi periodically provides assessments and commentary on specific procedures that individuals have undergone. AAAAI 2009: Half of Physicians Fail to Prescribe EpiPen for Patients With History of Anaphylaxis, Contact Allergens Lurk in Diabetes Devices, New Guidance on Alpha-Gal Syndromes GI Implications: What to Know. People with known metal allergies or sensitivities should tell their surgeon prior to knee replacement surgery. 2021;9(8):3109-3117.e1. She was tested for Clostridium difficile infection and showed positive toxin B results confirming the diagnosis. Allergy in total knee replacement. This rapid expansion of titanium-containing products has increased percutaneous and permucosal exposure of titanium to the population. Other case reports by Shi et al., Tawil et al., and Towers et al., mentioned hypersensitivity reactions due to titanium in different surgical procedures such as anterior cervical discectomy, dental implants, and spinal fixation devices. Many types of metallic implants can cause cutaneous allergic reactions, from orthopedic and dental implants to cardiac stents and pacemakers. Metal screws and plates are often used in surgery to fix fractures, fuse joints, or stabilize bones that have been cut (osteotomies) in the foot and ankle. Patients can present with atopic dermatitis, pruritus, edema, urticaria, impaired healing fractures, pain, and necrosis of implants [3]. 2007 Jan;42(1):93-7. doi: 10.1016/j.jpedsurg.2006.09.056. 2022 Dec 7;12(12):3074. doi: 10.3390/diagnostics12123074. MN We also use third-party cookies that help us analyze and understand how you use this website. Vomiting or diarrhea. Metals corrode in biologic systems, allowing for hapten formation. Contact Allergy to metals such as nickel, cobalt, and chromium is prevalent in the general population. Will my hardware set off a metal detector? Staged revision resulted in pain relief, but nerve palsy did not recover. Despite repeated attempts by researchers and clinicians to further understand this difficult area of medicine, the association between metal sensitivity and cutaneous allergic reactions remains to be fully understood. Patient satisfaction after total knee replacement: a systematic review. Hypersensitivity Reaction Post Laparoscopic Cholecystectomy Due to Retained Titanium Clips. [1] Metal allergy is mainly caused by prolonged or repeated skin exposure to consumer items such as jewelry, cell phones,[2] clothing fasteners,[3] and leather goods. government site. You will receive email when new content is published. To complicate things, patients may also develop delayed-type hypersensitivity reactions to metals (ie, in-stent restenosis, prosthesis loosening, inflammation, pain, or allergic contact dermatitis) following the insertion of intravascular stents, dental implants, cardiac pacemakers, or implanted gynecologic devices. This site needs JavaScript to work properly. We describe a 69-year-old male for whom significant pathologic findings around dental implants had never been observed. These symptoms can make your child feel bad, but it's not life-threatening. Unfortunately, the symptoms of metal implant sensitivity and allergy are not well defined. doi:10.5435/JAAOS-D-14-00290, Saccomanno MF, Sircana G, Masci G, et al. He exhibited allergic symptoms (eczema) after orthopedic surgery. When they do occur, however, the associated pain, swelling, inflammation, and decreased range of motion can significantly impair the implant function. He exhibited allergic symptoms (eczema) after orthopedic surgery. Allergic or sensitive to metal? Fortunately, allergic responses to surgical implants are infrequent. 2017;13(1):129. Polylactide-polyglycolide copolymer an absorbable material that is ideally used for plastic surgeries because of less scarring after healing. Most skin reactions are eczematous and allergic in nature, although urticarial, bullous, and vasculitic eruptions may occur. However, around 10% to 15% are not satisfied for various reasons, including persistent pain and the loss of joint flexibility. If a glass of milk or slice of pizza causes swollen lips, hives, or other symptoms, you may have an allergy to casein, a protein in milk. Although removal of offending. Iodine is essential for thyroid function, and an allergy to it would be life . On November 5, 2020, the embedded right colon foreign body was identified with fluoroscopic guidance (Figures 3(a) and 3(b)) and removed surgically (Figure 4). PMC Still, cases have been reported, and some people's symptoms have gone away after removal. Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. Conclusions: Some people are prone to developing a response to various metals, such as skin sensitivity to jewelry or watches. FOIA The most common metals used in orthopedic implants are: Solid metal implants include orthopedic plates and screws. The information contained herein is subject to change without notice. complete resolution; 2/17 awaiting revision; 3/17 coping well. Because this can involve another surgery that may be quite complicated, it should not be done without a thorough review of the pros and cons. Titanium hypersensitivity. Patients can also lower their risk for other complications after a surgery with staples by following postoperative care instructions from their surgeon. However, pre-surgical allergy testing cannot completely rule out a potential reaction. 29, no. The patient recovered well with no significant intraoperative or postoperative complications. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. After removal of dental implants, the eczema disappeared completely. Using skin patch tests and blood work, researchers identified metal sensitivity in nearly one-third of the study participants. It should NOT be regarded as diagnostic, treatment or any other type of specific medical advice to anyone. No difference in positive patch-test results between restenosis and nonrestenosis groups after stent implantation (9% vs 10%). Case presentation We present the case of a 52-year-old female patient with reoccured low back pain and sciatica after posterior lumbar decompression and fusion (PLDF) for her lumbar . Nasal congestion. 18 Patients: 3, pp. Titanium a strong metal that is known to hold fast to tissues and bone and tends to cause few problems for patients in surgeries. When they do occur, however, the associated pain, swelling, inflammation, and decreased range of motion can significantly impair the implant function. Please enter a Recipient Address and/or check the Send me a copy checkbox. 1 Patients with MHS reactions to implants typically have prolonged eczematous dermatitis.8 Although the majority of MHS reactions are localized, more widespread inflammation has been reported. Itchy eyes, nose or roof of mouth. 145162, 2008. Jonathan Cluett, MD, is board-certified in orthopedic surgery. However, since all medical staples include a certain percentage of nickel, in some cases, patients can also suffer from titanium allergy reactions. Its symptomsitching, knee pain, skin rashes, joint stiffness, and swellingcan also have other causes, which makes this difficult to diagnose. When they do occur, titanium allergy symptoms can range from mild to severe and can include: loosening of the implants (or implant failure) rash or hives. Please confirm that you would like to log out of Medscape. To confirm, the patient was further ordered for memory lymphocyte immunostimulation assay (MELISA) that also showed equivocal results for titanium allergy. Based on the level and proportion of immune cells in the sampleincluding leukocytes, eosinophils, and basophilsthe healthcare provider can diagnose DHT with a relatively high degree of confidence. Diagnostic Value of Oral Provocation Tests in Drug Hypersensitivity Reactions Induced by Nonsteroidal Anti-Inflammatory Drugs and Paracetamol. Given the high numbers of joint replacements performed in the developed world, allergic reactions to orthopedic implants form the largest category of allergic responses. Surgical Staples Removal: Heres What You Should Know, FDA Finalizes Reclassification of Surgical Staplers from Class I to Class II. The patient started having another episode of intermittent right lower quadrant (RLQ) pain starting in January 2020. Results may vary from person to person. However, other metal ions as well as bone cement components can cause such hypersensitivity reactions. reports an 86-year-old woman who presented three years to postlaparoscopic cholecystectomy with subdiaphragmatic abscess due to titanium surgical clips used during the procedure [4]. Restenosis occurred predominantly in patients with negative patch-test reaction to nickel. July 9, 2021/ Erica Davies / Surgical Stapler Lawsuit / 0 comments. 2022 Dec 22;16(1):115. doi: 10.3390/ma16010115. government site. These screws normally contain 14% nickel, 20% . Titanium has been considered to be a non-allergenic material. The diagnosis of DHT can be difficult, in part because a hypersensitive reaction on the skin doesn't always cause a hypersensitive reaction on internal tissues, or vice versa. The patient has allergic symptoms reported from IV contrast, nickel, titanium, iodine, metoclopramide, and oxalate. For more information about spinal hardware, take a look at some of our previous blogs: Centennial Lakes Medical Center Metal allergies and sensitivities can be assessed using skin patch testing. document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() ); We care about your privacy. 1, pp. She reported symptoms including a low-grade fever, nausea, vomiting, diarrhea, and joint pain. We describe a case of chronic abdominal pain, which is potentially complicated by retained titanium surgical clips and subsequently a retained portion of a pigtail catheter. However, titanium staples are not made of pure titanium. But sometimes a child can have what's known as anaphylaxis . 2018 Oct;62(4):426-431. doi: 10.1016/j.jpor.2018.03.003. It's rare for someone to need their metal implants removed due to a metal allergy or sensitivity. When you visit the site, Dotdash Meredith and its partners may store or retrieve information on your browser, mostly in the form of cookies. It also sheds light on retained foreign bodies as a possible cause of abdominal pain in patients who have gone through various surgical procedures in the past. Bone Joint J. Surgical implants are essential elements of repair procedures to correct worn out joints, damaged spinal components, heart and vascular disease, and chronic pain. Pseudotumors posterior to joints (4 mo apart), Pain (15/17); lump (6/17); nerve irritation or palsy (5/17); dislocation (2/17); instability (2/17); rash (1/17); none (2/17). Fortunately, allergic responses to surgical implants are infrequent. Having a metal allergy or sensitivity doesn't mean getting a metal implant like a surgical screw, plate, or joint replacement is entirely off limits or that the body will reject it. Revision to conventional THR led to resolution of pain. Immunol Res. Symptoms controlled with repeated joint aspirations. These are not classic allergic responses in that they do not have the potential to cause body-wide symptoms including anaphylaxis, a severe and potentially life-threatening allergic reaction.
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