The Virtual Doctor in the Room: How Tele-Trach Evolved as a Catalyst for Safety and Quality

A tele-tracheostomy performed at the bedside in the Intensive Care Unit at Mount Sinai Queens Hospital on a patient who had been ventilated for respiratory failure.

It’s been five years since the COVID-19 pandemic’s first cases, and much has changed in the world of medicine. Virtual care, also known as telehealth, became routine, among other virtual adaptations such as iPad hook-ups to IV poles to connect families to say goodbye, and even Zoom classrooms.

A lesser-known adaptation, the tele-consult, allowing a doctor at one hospital to oversee and guide care at another hospital, came about as hospitals swelled with patients and doctors were spread thin.

Dhruv Patel, MD

Dhruv Patel, MD, Director of Quality and Associate Director of the Transplant Intensive Care Unit at The Mount Sinai Hospital within Mount Sinai’s Institute for Critical Care Medicine, was part of a team that helped to make this innovation possible.

In his role at the Institute, he oversees percutaneous tele-tracheostomies from his office at The Mount Sinai Hospital. A percutaneous tracheostomy is a minimally invasive procedure done with a needle that punctures the skin, which is performed at the bedside to create an opening in the windpipe to facilitate breathing.

“The capacity to beam into another hospital to oversee and guide a tracheostomy made a world of difference during the pandemic when we had large volumes of very sick patients on ventilators for prolonged periods,” says Dr. Patel.

“During the pandemic, we performed three times as many tracheostomies, as respiratory failure among infected patients became extremely common. This allowed for faster and less invasive bedside procedures, while avoiding the necessity to transfer critically ill and vulnerable patients to the operating room,” says Dr. Patel. The Institute has continued to train all critical care specialists to become proficient at performing bedside percutaneous tracheostomy.

Leveraging the tele-consult has presented an important training opportunity, says I. Michael Leitman, MD, FACS, Dean for Graduate Medical Education at the Icahn School of Medicine at Mount Sinai. Dr. Leitman, Professor of Surgery and Medical Education, oversees Mount Sinai’s resident training program, which is the largest in the county.

“The introduction of telemedicine and the ability now to do tele-consults at the bedside provides an important advantage for an attending to supervise residents and attending doctors as they round on critical, complex cases,” says Dr. Leitman.

Nazia Mashriqi, MD, MBA, ICCM Site Director at Mount Sinai Queens, performs approximately 30 tracheostomies annually.

“Even though we aren’t seeing many critical COVID-19 patients, we are still performing bedside percutaneous tracheostomies quite often for patients who require prolonged assistance of a mechanical ventilator for other respiratory illnesses, such as the flu or pneumonia. With Dr. Patel tele-consulting and present in the room as we perform these procedures, we can ensure a critical layer of oversight and safety,” says Dr. Mashriqi, who is also part of the Institute’s team. “The procedure is somewhat straightforward, but at the same time, proficiency is key to avoid complications of bleeding due to trauma to nearby tissues. We use multiple layers of visualization including ultrasound and bronchoscopy to enhance the safety of the bedside procedure,” says Dr. Patel, noting that the procedure is now rarely performed in the operating room.

Mount Sinai’s Institute for Critical Care Medicine oversees critical care at seven of Mount Sinai’s eight hospitals in New York, providing highly specialized, life-saving care for patients experiencing the most serious diseases and injuries, and those recovering from complex surgeries.

The Institute’s System Director, Roopa Kohli-Seth, MD, says the team provides care for more than 10,000 patients annually.

“Our critical care teams care for the sickest of patients at Mount Sinai’s hospitals, and the capacity to tele-consult and advise from afar has given us an important advantage in saving lives and ensuring both quality and safety. We see this as a great win for our patients and patient safety overall,” says Dr. Kohli-Seth.

 

Certified Nurses at Mount Sinai: Representing a Commitment to Excellence and to Their Profession

Nursing Certification is an important, independent validation of specialized nursing knowledge and expertise that meet or exceed professional standards. In fact, empirical evidence shows an association between nursing certification and better patient outcomes, as well as lower rates of falls, hospital-acquired infections, and central line-related bloodstream infections.

Across the Mount Sinai Health System, an impressive near 50 percent of nurses have earned board certification in their chosen specialties. Their patients, families, colleagues, and teams are the direct beneficiaries of nursing expertise that is recognized as meeting or exceeding the highest professional standards.

In recognition of National Certified Nurses Day, Wednesday, March 19, Mount Sinai would like to shine a spotlight on some of our nurses who have earned their specialty certification. Along with their fellow certified nurses, they represent a commitment to excellence and their profession that is synonymous with Mount Sinai Nursing.

I’m proud to be certified in Medical Surgical Nursing. I believed that obtaining certification demonstrates commitment and dedication to professional growth and maintaining the best evidence-based practices. Encouraging other nurses to become certified is something I truly believe in. It’s not just a title, it’s a commitment to excellence.

Emmy Lou C. Adonay, RN, BSN-BC, Mount Sinai Queens

Carla Alves-Miraldo, MS, MSN-Ed, RN, CHPN, KP6 Palliative Care Unit, The Mount Sinai Hospital

Becoming a Certified Hospice and Palliative Care Nurse is a reflection of my commitment to ensuring every patient receives comfort, dignity, and compassionate care during life’s most challenging moments. This certification is more than a title—it represents my dedication to guiding patients and families with expertise, empathy, and unwavering support. I stand proud of my certification because it allows me to be a source of comfort, an advocate for quality of life, and ensure that no one faces their journey alone. Being a certified palliative care nurse is not just my profession—it is my passion and my purpose.
Obtaining and maintaining this certification provides me the opportunity to achieve professional and personal growth. Being a certified Critical Care Registered Nurse (CCRN) validates and demonstrates my expertise in advanced knowledge and skills caring for critically ill patients while developing wisdom of practice in the critical care fields. This allows me to share my knowledge and skills to elevate the standard of patient care within the nursing units, as well as at the organizational level to promote patient outcomes in Mount Sinai.

Keiko Iwama, PhD, MSN, RN, CCRN,Mount Sinai Morningside

Odeisha Maitland, DNP, FNP, RN-BC, Mount Sinai Brooklyn

Being a certified nurse is not just a title; it is a profound commitment to excellence in patient care and a testament to my dedication to ongoing professional development. Achieving certification demonstrates my expertise and the trust that patients and colleagues place in my abilities. It embodies my passion for delivering exceptional health care and my unwavering responsibility to uphold the highest standards of our profession. Ultimately, being a certified nurse is both an honor and a defining aspect of my identity in the health care field, empowering me to make a meaningful impact on the lives of others every day.
As an ED nurse, you never know who’s going to walk through the door. All we can do is prepare and improve our practice. Being certified is just that; It means I stay ready and inspire my team to do the same.

Cynthia Mendez, RN, MSN, CEN, Senior Clinical Nurse, Department of Emergency Medicine, The Mount Sinai Hospital

Jay Rodriguez Reyes, RN, BSN, AMB-BC, Ambulatory

In the ever-evolving health care landscape, certification is not just a title but a commitment to excellence, professional growth, and improved patient outcomes. Earning certification in Ambulatory nursing validates our expertise, knowledge, and dedication to the highest standards of patient care. To those considering certification, take that step. Invest in yourself, in your patients, and in the future of the nursing profession. Because when we grow as professionals, everyone benefits.
Being a certified nurse at Mount Sinai represents a deep commitment to professional growth and ensuring the highest standard of care for my patients. It reflects my expertise and dedication, particularly in specialized fields like vascular access and infusion therapy. After 25 years at Mount Sinai, these certifications reinforce my passion for nursing and the responsibility I feel in continually advancing my skills to best serve those who rely on me.

Lynette Joy Romanovitch, BSN, RN, CRNI, VA-BC, Vascular Access Service RN, Institute for Critical Care Medicine, The Mount Sinai Hospital

Elvira Solis MSN, RN, CCRN, Mount Sinai Queens

Certification means a lot to me in different perspectives, although we will say it is a validation of my knowledge and skills and my practice, embodying excellence, lifelong learning, and commitment in excellence in care.  As a Certified Critical Care Nurse, I am committed to so many duties and responsibilities. My commitment to providing excellence in care means I have an advance knowledge and skills to provide effective and safest care to my patients. I must ensure the excellence in practice is backed up with evidence-based. My commitment to life-long learning and professional development is not to myself alone but also to  support my team through peer-to peer teaching onsite and online. I take pride of being a role model to my colleague and a “Go to Person” especially in some challenging cases and situations.
Being wound care certified fills me with pride because it reflects my commitment to providing the highest level of care to my patients. This certification represents my dedication to continuous learning and staying up to date with the latest techniques and best practices in wound healing. Knowing I can make a tangible difference in someone’s recovery, while ensuring their comfort and well-being, gives me a strong sense of purpose in my work.

Sylvia Springer-Fahie, RN-BC, DNP, MSN, BSN, WCC, The Mount Sinai Hospital

A Look Back at the Pandemic, and Views on the Future

In early 2020, Mount Sinai treated the first COVID-19 patient. Shortly after that, New York State declared a state of emergency, and COVID-19 cases started to rise. Mount Sinai staff are coming together to share their experiences of overcoming the pandemic in a look back video, “COVID-19 Five Years Later: Reflecting. Learning. Advancing.”

“We stood at the edge of the worst health care crisis in modern memory,” said David L. Reich, MD, President and Chief Operating Officer of The Mount Sinai Hospital, who narrates the video. “And no one knew. Over the next eight weeks, over 18,000 New Yorkers would die of COVID-19—one every five minutes, over 350 every day.”

A timeline takes us through those challenging times, featuring the resilience of front-line staff in the face of what seemed like a never-ending flow of patients, while ICU beds filled up. The video, too, takes us through how scientists and researchers were working nonstop to understand the virus, and coming up with various ways to treat and test for COVID-19.

Five years since the pandemic was officially declared, the Mount Sinai Health System is able to reflect on what it achieved and learned since.

Measles Is Back—Here’s What to Know

Once thought eradicated from the United States, measles is beginning to spread in communities with low vaccination rates. Texas is experiencing a measles outbreak affecting a growing number of people, a majority of them children, with one dead. In New York City, two people are reported to have contracted measles, as well as three in New Jersey. A number of other states have also reported cases, though the outbreaks are small.

Measles is a highly contagious virus with symptoms that start with fever, red eyes, cough, and progress to a rash and red spots on the skin. Without vaccination, measles can be dangerous and deadly, especially among children under five.

Jennifer Duchon, MD, MPH, DrPH

In this Q&A, Jennifer Duchon, MD, MPH, DrPH, Associate Professor of Pediatrics at the Icahn School of Medicine at Mount Sinai, discusses measles and the importance of vaccines.

What do we know about the current measles outbreak?

The current outbreak in Texas likely began with an unvaccinated individual contracting measles after travelling to a region where the disease is active, bringing it back with them, and spreading it in a community with low vaccination rates. One child died. Based on the statistics, we know that if this epidemic spreads, we expect many more children with severe complications and additional deaths.

If measles was eliminated, why has it come back?

Measles was considered eliminated from the United States in 2000. That doesn’t mean we don’t have outbreaks or cases; it means there has been no sustained transmission of measles in a particular region (such as the United States) for 12 months or more.

How contagious is measles?

Measles is a highly infectious viral infection spread through coughing and sneezing. One person with measles will spread it to 12 to 18 other susceptible people after a very short period of contact. To prevent an epidemic, about 95 percent of a specific community needs to be vaccinated. In the region of Texas where the virus is currently spreading, vaccination rates are much lower than the national average, making it extremely difficult to contain.

Could the New York region experience a measles outbreak?

Yes, absolutely. New York State, as a whole, has a robust vaccine coverage. But in some areas, such as parts of Brooklyn and Rockland County, vaccine coverage hovers anywhere from 60 to 80 percent. In 2019, New York had a similar measles epidemic that encompassed parts of New York City and Upstate NY.

Why is it important to be vaccinated?

There is no cure or treatment for measles; however, it is extremely preventable with vaccination. Vaccines vary in what they do in terms of efficacy. Some vaccines will prevent you from getting a very severe form of the disease, some prevent you from getting the disease altogether.

The measles vaccine is one of the most effective vaccines in terms of preventing people from contracting the disease. If you received one vaccine, there is about a 93 percent certainty that you won’t contract the disease. If you got two doses—as recommended—that goes up to 97 percent.

In most cases, immunity from the measles vaccine is lifelong. Unlike vaccines for COVID-19 or the flu, you don’t need booster shots or updated annual vaccinations for measles. If you are a health care worker or work with vulnerable people, such as the elderly or immunocompromised individuals, you may be required to have proof of two vaccines.

Is it true that vitamin A can provide protection from measles?

No, that data comes from outbreaks primarily in under-resourced countries where vitamin A deficiency is rampant because of malnutrition. In children who are malnourished, measles can affect the immune system in such a way that they become much more vulnerable to other diseases, and vitamin A can help prevent complications like blindness and death in those children. Vitamin A cannot prevent or treat measles.

What can I do to keep my children safe?

Vaccinate them. Any child one year or older should get the first dose of the vaccine, and a second dose at age four to six, preferably before they start school. The vaccine is not as effective on children under one year old. If you have an infant, it is important that all members of the family who are one year or older are vaccinated to protect them. In very special circumstances, where an infant could be at high risk, such as international travel, we can give the vaccine as early as six months of age. If you have questions, talk to you pediatrician.

What else would you like people to know?

The famous children’s book author, Roald Dahl, who wrote Charlie and the Chocolate Factory, lost his young daughter to measles in 1962, before an effective measles vaccine was available. In 1986, after the current vaccine was well established and part of the recommended vaccine schedule for kids, there was a measles outbreak in England due to low vaccination rates. Roald Dahl couldn’t understand why. He wrote a letter to the public describing that situation and urging people to get vaccinated. This happened back in 1986, and history is repeating itself now. This is a completely preventable disease in terms of outbreaks and morbidity and mortality. People don’t have to get this disease.

Mount Sinai COVID-19 Innovations: Improving Care After the Pandemic

Before COVID-19 was even formally recognized as a pandemic, David L. Reich, MD, President of The Mount Sinai Hospital, was hearing from his anesthesiologist peers in Europe about a terribly problematic “respiratory disease” with a high mortality rate.

“This trusted source was telling me that people were getting very ill, and hospitals were becoming instantaneously overwhelmed with patients requiring intensive care,” said Dr. Reich, who is also Chief Clinical Officer of the Mount Sinai Health System.

“It got me thinking: if we fell into a crisis like that, do we have the structure to transform our hospital from the normal state where 15 to 20 percent of patients require ICU-level care, to one that is nearly 100 percent ICU and the next level down—intermediate care beds?” he said.

As Dr. Reich and Mount Sinai started to make contingency plans for the arrival of COVID-19 in New York City, he realized tackling a pandemic required creative and innovative solutions. Over the course of the COVID-19 pandemic—declared as such in 2020—Mount Sinai created various capabilities to tackle the crisis.

Dr. Reich discusses some of the things that were done at Mount Sinai to help provide relief to patients, the community, and the staff during the pandemic, and how those things have changed since.

David Reich, MD, President of The Mount Sinai Hospital

Clinical Command Center

Prior to the pandemic, a new Clinical Command Center was tasked with finding ways to streamline various operations across hospitals in the Mount Sinai Health System.

At the start of the pandemic—even before social distancing became common policy—various leaders from within the Health System were meeting regularly on how to empower the Clinical Command Center to address the mounting cases of COVID-19.
As New York City was overwhelmed by patients requiring hospital care during the first wave of COVID-19, the Clinical Command Center helped bring patients to unique and temporary care locations, said David L. Reich, MD (right), seen visiting the patient care tents set up in Central Park, hours prior to the arrival of the first patient.
Under the guidance of the Clinical Command Center, respiratory therapists supervised medical volunteers to deploy ventilators to sites and areas with the greatest need.
Centralizing patient admission and intake protocol within the Clinical Command Center enabled patients to be seamlessly moved from one hospital to another during the pandemic.

Mount Sinai built upon the spirit of collaboration developed during the pandemic to expand the Clinical Command Center, and it has since taken on additional responsibilities to improve care to the community, said Dr. Reich.

During the pandemic, we needed to be able to move patients around seamlessly among hospitals, especially as one or more hospitals exceeded their capacity to provide care. Many things are involved in moving a patient from one hospital to another, and with hospitals traditionally managing their own admitting offices and with individual intake protocols, there were opportunities for miscommunication and inefficiency at a time when that would have cost lives.

We did away with the barriers and empowered our nascent Clinical Command Center to centralize admitting work and transfer protocols across all of our hospitals in the system. We needed a centralized view that looked at bed capacity and management, resource needs, and medical and protective supplies. The aim was to operationalize a group with a cohesive view of a health system, rather than silos, each thinking for themselves rather than optimizing for the benefit of all.

And because we tore down those barriers, we were able to see who needed help and to fill that gap in any way necessary. For example, when the leadership team of Mount Sinai Brooklyn simultaneously fell ill from COVID-19, we sent the Vice President of Perioperative Services from The Mount Sinai Hospital and a senior nursing leader to Brooklyn to be temporary leadership.

Today, the Clinical Command Center continues to add additional functions to support health system experts. We’ve learned that there are some hospital functions that are better suited to being centralized, not just for cost savings but also from an effectiveness standpoint. And there are some functions that are better suited to sit within each site.

Testing Labs

At the height of the pandemic, city and state testing resources for COVID-19 were overwhelmed by the sheer volume of testing requirements. There was a pressing need for Mount Sinai Health System to establish its own high-capacity testing platform.

Mount Sinai tapped many of its own experts to launch its COVID-19 testing capabilities. Alberto Paniz-Mondolfi, MD, PhD, Director of Molecular Biology, was one of the key figures in launching a community testing program.

With all hands on deck and specialized equipment, Mount Sinai was able to bring its testing turnaround time down to under 24 hours.

As a result of a partnership with the Pershing Square Foundation, Mount Sinai was able to bring its testing capabilities to help schoolchildren return to classrooms, and help employees return to the workplace.

That testing program involved a simple, noninvasive saliva test. At its height, the program was collecting samples from more than 700 sites a day.
With the height of the pandemic over, the testing equipment and facilities have been repurposed toward the Mount Sinai Million Health Discoveries Program, a large-scale genetics study.

At the start of the pandemic, we needed to be able to do our own tests for COVID-19, rather than sending samples out to the city and state, because they had a six-day turnaround for results, which was impractical for the situation then.

Initially, we were using supplies from our basic science laboratories, but then Roche released a diagnostic platform that worked on one of our large-volume analyzers. Suddenly, we were able to achieve testing with a turnaround time under 24 hours that resulted in identifying which patients could be removed from isolation, saving precious personal protective equipment at a time of severe shortage.

And then, in December 2020, Bill Ackman, co-trustee of the Pershing Square Foundation, came to us and wanted to fund a project to bring kids back to schools. To do so, we needed a better testing mechanism. In partnership with Rockefeller University, we were able to implement a COVID-19 saliva testing program.

At the peak of the testing program, we were collecting from 700 sites a day, as far north as New Haven, Connecticut, and as far east as Montauk on Long Island to support employees of the Metropolitan Transportation Authority. We were also testing schoolchildren in Westchester County, NYC residents, multiple private businesses, and US Open tennis players and staff.

Now that the COVID-19 pandemic has receded, the equipment purchased using the Pershing Square Foundation grant is still being put to good use. Mount Sinai has a research study called the Mount Sinai Million Health Discoveries Program. When samples, such as blood, are collected from patients as part of their routine care, with their consent, researchers extract the DNA information as part of a genetic sequencing project. The massive database of genetic information will inform future diagnostic and therapeutic discoveries and help to design personalized treatment protocols.

Recharge Rooms

Being on the frontlines during the pandemic was hard. Members within the Mount Sinai Health System came up with the idea of creating a space for staff to take a break and unwind.

Various unused public and medical spaces were turned into “recharge rooms.” Even medical examination beds that were unused due to the pandemic could find new purpose to help staff relax.

The spaces were fitted with soft or dim lighting, calming colors, and even soothing sounds and scents to help staff take their minds off the stresses of the pandemic.

“It was important for our staff to be able to take a break from the crisis,” said David L. Reich, MD, President of The Mount Sinai Hospital.

Even for temporary structures and tents erected to handle the high volume of patients at the height of the pandemic, it was important to ensure front-line staff had a place to take breaks.

The outpouring of creativity during the pandemic was inspiring. “I hope we access that creativity again and again,” said Dr. Reich.

During the pandemic, our staff were very challenged by the high rates of patient mortality. It was a hard time. It was important for our staff to be able to take a break from the crisis, and people came up with the concept of recharge, or respite, rooms.

As we had limited resources, there was an idea to turn unused public spaces, such as family rooms or certain physiotherapy rooms, into spaces where our staff could sit in a peaceful environment. Some of these rooms had music, lighting, and even scents designed to reduce stress. Others were places where individuals could enjoy some quiet contemplation.

Today, many of these rooms have gone back to their original use to support our patients and visitors. A time of great crisis can spark great creativity, and as we work to lower barriers among our hospitals, I hope we access that creativity again and again.

Pioneering Research Examines the Role of Your Gut in Multiple Sclerosis

Stephanie K Tankou, MD, PhD

Is a crucial cause of multiple sclerosis (MS) residing in your gut? Stephanie K Tankou, MD, PhD, Assistant Professor of Neurology at The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, is conducting research designed to prove that specific gut bacteria generate inflammation that underlies MS.

“At some point in our life, we can become exposed to various environmental stressors that can lead to profound changes in the gut microbe composition and put someone at risk for developing MS,” she says.

Trillions of microbes called the human microbiome are living in each human. The largest community of microbes, called the gut microbiome, exist in the gut. They are essential for the proper development of your immune system and your brain.

“Studies have shown that a disturbance in the normal composition of these gut microbes can lead to many diseases, including MS,” she says.

Within a healthy individual’s gut, there is a delicate balance of pro-inflammatory and anti-inflammatory bacteria. Conditions favoring an overgrowth of the pro-inflammatory bacteria can trigger inflammation in the gut leading to the breakdown of the gut barrier, also known as leaky gut. In individuals with a leaky gut, microbes in the gut can enter the bloodstream, where they will activate various immune cells, including inflammatory cells that will destroy myelin—a sheath that forms around nerves—in the brain and spinal cord of MS patients.

Several studies, including ones conducted at the Tankou Lab found that mice infused with gut microbes taken from MS patients develop more severe inflammation in the brain and spinal cord than mice that received gut microbes from healthy subjects.

“These results suggest that alterations found in the gut microbe composition of an MS patient significantly contributes to the disease,” she says. “So, the question is what changes do we need to introduce in the gut microbiome of MS patients to stop the disease?”

Dr. Tankou joined the Center staff in 2019. While she sees MS patients, she spends most of her time in her research lab.

“I became interested in the gut microbiome because one of the biggest hurdles we run into with MS, or any neurological disease, is we do not have access to the disease tissue, to the brain or the spinal cord,” she explains. “Consider the gut microbiome as a remote control for your brain. I can control the level of inflammation in the brain of my MS patients by changing the composition of their gut microbes.”

To further her theory, Dr. Tankou’s lab found that an antibiotic called vancomycin, when given orally to mice with an MS-like disease, suppresses inflammation in the brain and spinal cord. Her study showed that administering vancomycin orally causes significant changes in the mice gut microbe composition, leading to an increase in the abundance of anti-inflammatory bacteria in their gut, which decreased inflammation in the brain and spinal cord of these mice.

For her current, ongoing study, Dr. Tankou received funding from the Doris Duke Charitable Foundation to examine the impact of vancomycin on newly diagnosed MS patients between the ages of 18 and 50 who have not taken any MS treatment. Participants receive either vancomycin or a placebo as well as provide blood and stool samples.

“We are hopeful that vancomycin will cause a dramatic shift in the gut microbe composition of these MS patients that will suppress inflammation in the brain,” says Dr. Tankou. The findings from this vancomycin trial could lead to the development of the first “bugs as drugs” for the prevention and treatment of MS. “Bugs as drugs” refers to communities of gut derived bacteria with anti-inflammatory properties that can be used to suppress inflammation and disease progression in MS.

Dr. Tankou maintains that “bugs as drugs” will be safer than the current MS treatments approved by the Food and Drug Administration, which are all based on chemical structures and come with a range of side effects, whereas using microbes means nothing foreign will be introduced into patients. “We expect a new ‘bug as drugs’ therapy to be just as effective as drugs we are currently using,” she says.

The promise and hope that Dr. Tankou’s pioneering lab offers will position the Center as an institutional leader in understanding what causes MS, as well as developing novel microbiome-based therapies for preventing and treating all forms of the chronic disease.

By Kenneth Bandler, a multiple sclerosis patient, advocate, and member of The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Advisory Board

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