The adenoid is a component of Waldeyer’s ring and plays an important immunological role in childhood. Santorini first described about nasopharyngeal lymphoid aggregates and named it as Luschka tonsil in 1724.The term adenoid was coined by Wilhelm Meyer in 1868. Adenoid is a secondary lymphoid organ, lies in the mucosa of the upper part of the roof and posterior wall of nasopharynx in the midline. Growth continues rapidly during infancy and plateaus between 2 and 14 years of age largest in volume at 7 years. Regression of the adenoid occurs rapidly after 15 years of age in most children (2) . Pathological enlargement of adenoid tissue causes nasal obstruction, mouth breathing, snoring, otitis media with effusion, recurrent infections and obstructive sleep apnea (1). There is a characteristic facial appearance in children with adenoid hypertrophy. The so-called "adenoid facies" has classical appearance that include :a) open mouth b) crowding of upper teeth c) Short upper lip d) High arched palate e) Pinched nose f) hypoplastic maxilla g) narrow alveolus. Lateral projections of the neck (plain x-ray) using low-dose film (soft tissue technique) will visualize the posterior wall and roof of the nasopharynx and diagnostic nasal endoscopy are helpful in diagnosing adenoid hypertrophy. Clinical grading of adenoid size by Clemens et al. Grade Description Grade I Adenoid tissue filling 1/3 rd of the vertical portion of the choanae Grade II Adenoid tissue filling from 1/3 rd to 2/3rdof choanae Grade III From 2/3rd to nearly complete obstruction of the choanae Grade IV Complete choanal obstruction Adenoidectomy with or without tonsillectomy is one of the most common surgeries in pediatric patients significantly improves quality of life. Several techniques and instruments including curettage, microdebridement, laser, coblation and suction electrocautery can be used for surgery (4). Techniques and instruments have been changing over the years. Most techniques of adenoidectomy concentrate on removing predominantly the midline mass of adenoid tissue. An ideal adenoidectomy in children should attain direct visualization, ease of procedure, short operating time, minimal blood loss, suitable cost, cure of symptoms and more importantly complete adenoid resection without complications. Conventional curettage adenoidectomy has been the standard technique for decades. The adenoid tissue is curetted using a St. Clair Thompson adenoid curette. However, it is a blind procedure and may lead to incomplete removal, excessive bleeding and injury to surrounding structures such as the Eustachian tube. Endoscopic assisted adenoidectomy is an excellent, safe and thorough technique in endoscopic nasal surgery. They provide atraumatic dissection with minimal bleeding which enables decreased surgical time and faster postoperative healing and also avoids eustachian tube injury. The use of rigid endoscope-allows better visualization ensuring complete removal of adenoid tissue situated even high up in nasopharynx without damaging surrounding structures. POWERED INSTRUMENTATION -refers to motor driven instruments that deliver continuous suction to surgical site while providing cutting action. MICRODEBRIDER-is a powered rotatory shaving device with irrigating blades of different angles-0,15,45,60 degrees, precisely resects the tissue minimising inadvertent mucosal trauma thereby minimizing bleeding. Suction and shaving action of microdebrider, drawing the loose tissue into window,can remove the tissue down to less avascular plane, as opposed to pushing and cutting action of curette which may leave behind the bleeding tissue.Irrigation while using micro debrider-aids in quicker hemostasis. Figure 1: Microdebrider with IPC,hand piece with angled blades This study was conducted to compare conventional curettage adenoidectomy with endoscopic-assisted powered adenoidectomy in terms of surgical and functional outcomes. AIM AND OBJECTIVES Aim:To compare the efficacy and safety of conventional adenoidectomy and endoscopic-assisted powered adenoidectomy. Objectives • To compare operative time • To compare intraoperative and postoperative bleeding • To compare postoperative recovery time and eustachian tube scarring • To evaluate residual adenoid tissue • To assess Eustachian tube function using tympanometry • To compare postoperative pain and symptom relief measured on visual analog scale

This prospective comparative study was conducted in the Department of ENT, Government General Hospital, Kurnool, after obtaining Institutional Ethics Committee approval (IEC No: 87/2022). The study duration was two years. Sample Size 100 in which the subjects are randomly divided into two groups,where • Group A (n = 50): Conventional curettage adenoidectomy • Group B (n = 50): Endoscopic-assisted powered adenoidectomy using microdebrider Inclusion Criteria • Children of both sexes aged 5–15 years • Children with symptoms of adenoid hypertrophy such as nasal obstruction, mouth breathing, snoring • Adenoid hypertrophy confirmed by X-ray nasopharynx and diagnostic nasal endoscopy • Children weighing more than 20kg • Children with hemoglobin more than 10g% Exclusion Criteria • Bleeding disorders • Craniofacial anomalies • Middle ear infection • Immunodeficiency • Previous adenoidectomy Methodology Hundred consecutive cases between the age of 5-15,admitted in department of ENT,Government general hospital,Kurnool and requiring adenoidectomy fulfilling the inclusion and exclusion criteria were included in the study. All subjects including their parents were counselled about the nature of the study and informed and written consent taken. On admission, the subjects underwent a baseline evaluation including symptom analysis ,diagnostic nasal endoscopy and impedance audiometry preoperatively.The grade of adenoid hypertrophy was assessed using the scale described by Clemens and Mcmurray where adenoids are graded according to the extent of vertical height of choana filled by adenoid tissueAll the cases were randomized into two groups consecutively. Group A consisted of cases undergoing Conventional Adenoidectomy using Curettage method Group B undergoing Endoscopic Assisted Powered adenoidectomy. Figure 2: Impedance audiometry All surgeries were performed by a single surgeon under General anaesthesia using oral endo-tracheal intubation and a throat pack. In group A ,Conventional adenoidectomy was performed by using St.Clair Thompson’s Adenoid curette with guard and without guard. After Curettage, postnasal pack was kept till hemostasis is achieved. Figure 3: Conventional curettage adenoidectomy In group B,endoscopic assisted powered adenoidectomy was performed using the 0 degrees 2.7mm/4mm Hopkin’s rigid endoscope which is introduced intranasally and the nasopharynx is visualised for adenoid hypertrophy.Medtronic straightshot M5 microdebrider,powered by integrated power console(IPC) system was used. The nasal cavities were decongested by using merocele soaked in 4% lignocaine with 1:10,000 adrenaline. Mouth gag was applied. Microdebrider with irrigating blades of different angles 0, 15, 45 and 60 or special adenoid blade was used. The special adenoid blade is longer, and has a window on convex side for use transorally to adapt to the roof of nasopharynx. Endoscope and debrider were passed through the same nostril or the endoscope through one nostril and debrider through the other. In some cases endoscope was passed through nose and debrider through the oral cavity with angled blade. The adenoidectomy was started high in the nasopharynx from upper limit of adenoid tissue, which often cannot be reached by conventional curette.Resection was continued in side to side fashion on an even level until the inferior edge of adenoid was reached. The cutting and aspirating action of the shaver and simultaneous irrigation removes both adenoid tissue and the blood, thus providing a clear view. Better control of the depth of removal of adenoid is achieved thus avoiding damage to underlying structures. Hemostasis is achieved by using postnasal pack. Figure 4: Endoscopy The cases in two groups were compared preoperatively in grade of adenoid hypertrophy,impedance audiometry. Intraoperatively the parameters compared were mean operative time,intraoperative bleeding.postoperatively the grade of residual adenoid tissue,relief of symptoms at 1week and 2 weeks,mean recovery time,relief of pain postoperatively,postoperative impedance audiometry,snoring scores and eustachian tube scarring. The completeness of adenoid removal was assessed by nasal endoscopy at the end of the procedure in both groups. Post operatively, the patient was assessed for post operative symptomatic relief using visual analog scale (VAS).Institutional Ethics Committee Approval No: IEC/87/2022 ANALYSIS OF STATISTICS The patients details were entered in MS Excel sheet and analysed. The study used both descriptive and inferential statistics. Descriptive statistics include frequency and percentage for categorical data, and, mean and standard deviation for continuous data. Inferential statistics include the Pearson Chi-square test and Fisher’s exact test for significance (only for 2x2 tables) for categorical data while independent sample t-test to compare continuous data of groups and to find significance. The results are interpreted and graphical representation is shown wherever necessary.

The mean age of Group A was 11.200 years and the standard deviation was 2.587 years. The mean age of Group B was 11.100 years and the standard deviation was 2.704 years. Overall, males constituted 55% and females constituted 45% of the total sample. In Group A, 50% were males while the remaining 50% were females. In Group B, 60% were males while 40% were females. In Group A, 78% of the patients had grade III adenoid hypertrophy and 22% had grade IV adenoid hypertrophy. In Group B, 68% of the patients had grade III adenoid hypertrophy and 32% had grade IV adenoid hypertrophy. The chi-square test revealed a non-significant association (X2 = 1.268; p=.368) indicating that the grade of adenoid hypertrophy was similar across patients in both groups. Figure 5: frequency distribution of grades of adenoid hypertrophy among groups The mean operative time for Group A was 7.32 minutes and that for Group B was 18.00 minutes. The standard deviations of groups A and B were 1.132 and 1.428 minutes respectively. The independent sample t-test revealed a significant difference (t= -41.421; p= .001). So, Group B had a higher mean operative time which is statistically significant. The mean bleeding (in ml) for groups A and B were 8.150 and 16.600 respectively. The standard deviations of groups A and B were 1.799 and 1.442 mL respectively. The independent sample t-test revealed a significant difference (t= - 25.872; p= .001), showing that Group B patients bled more than those of Group A. The same is significant statistically. In Group A, 26% had residual adenoid of grade I postoperatively and 74% had grade II. In Group B, 36% had no residual tissue, 54% had grade I residual adenoid tissue and 10% had grade II. The chi-square test revealed a significant association (X2 = 47.281; p= .001). This shows that tissue removal was significantly more complete in Group B than Group A. Table 1: Mean operative time and intraoperative bleeding in groups and independent sample t-test results Groups Mean SD t-value Operative time (in minutes) Group A 7.32 1.13 t= 41.421 p = .001 Group B 18.00 1.42 Bleeding (in ml) Group A 8.16 1.79 t= 25.872 p = .001 Group B 16.60 1.44 Table 2: Frequency and percentage distribution of Postoperative residual tissue (measured as grade of remnant adenoid tissue) in each group and chi- square test results Postop residual tissue/grade of adenoid Groups Chi-square Group A Group B None F 0 18 X2 = 47.281 p = .001 % 0.0% 36.0% I F 13 27 % 26.0% 54.0% II F 37 5 % 74.0% 10.0% Figure 6: Frequency distribution of Postoperative snoring score In Group A, no patient had relief of symptoms at week 1, while at week 2, 44% of patients had relief of symptoms and 56% did not. The chi-square test revealed a significant association (X2 = 28.205; p=.001FET) indicating a significant change in relief of symptoms during 1st week and 2nd week.In Group B, at week 1, 82% showed relief of symptoms and 18% did not. However, at 2 week all patients had relief of symptoms. The chi-square test revealed a significant association (X2 = 9.890; p= .003FET) indicating a significant change in relief of symptoms during 1st week and 2nd week. The mean and standard deviation of postop recovery time in Group A were 11.880 and 2.105 days respectively. The mean and standard deviation of postop recovery time in Group B were 6.580 and 1.601 days respectively. The independent sample t-test revealed a significant difference (t= 13.875; p= .001) which indicates that Group A patients took longer to recover. Table 3: Frequency and percentage distribution of Change in relief of symptoms with time in both groups and chi-square test results Groups Relief of symptoms Time Chi-square At 1 week At 2 weeks Group A Yes F 0 22 X2 = 28.205 p = .001FET % 0.0% 44.0% No F 50 28 % 100.0% 56.0% Group B Yes F 41 50 X2 = 9.890 p = .003FET % 82.0% 100.0% No F 9 0 % 18.0% 0.0% In Group A, 76% of the patients had type A curve and 24% had type B curve. In Group B, 72% of the patients had type A and 28% had type B. The chi-square test revealed a non-significant association (X2 = .208; p= .820) which indicates that patients had similar preoperative tympanogram curves irrespective of the groups. In Group A, 78% of the patients had postoperative tympanogram curve A and 22% had curve B. In Group B, 94% of the patients had postoperative tympanogram curve A and only 6% of had curve B. The chi-square test revealed a significant association (X2 = 5.316; p= .041) indicating that a higher number of patients in group A and group B had postoperative tympanogram A. In Group A, the chi-square test showed a non-significant association (X2 =.056; p= 1.00FET) indicating no significant change in tympanogram curve during preoperative and postoperative time period. However, in Group B, the chi-square test showed a significant association (X2= 8.575; p=.006FET) indicating a significant change from preoperative tympanogram curve to postoperative tympanogram curve among patients in Group B. Table 4: Frequency and percentage distribution of Change in tympanogram curve in each group by time and chi-square test results Groups Tympanogram curve Time Chi-square Preoperative Postoperative Group A Type A F 38 39 X2 = .056 p = 1.00FET % 76.0% 78.0% Type B F 12 11 % 24.0% 22.0% Group B Type A F 36 47 X2 = 8.575 p = .006FET % 72.0% 94.0% Type B F 14 3 % 28.0% 6.0% Figure 7: Frequency distribution of Change in tympanogram curve in each group by time In Group A, 46% of the patients had 8.00 on relief of symptoms, 38% had 6, 10% had 4, 4% had 2 and 2% had 0. In Group B., 50% had 2, 10% had 0, 30 had 4, 8 had 6 and 2% had 8. The chi-square test revealed a significant association (X2 = 57.209; p= .001) which indicates that a higher number of patients in group A had a score of 8.00 on relief of symptoms while a higher number of patients in group B had 2.00 on relief of symptoms. In Group A, 46% of the patients had a pain score of 8 on the visual analog scale and 54% had 6. In Group B, none of the patients had scores of 6 or 8, but 26% of the patients had a score of 0, 52% had 2 and 22% had 4. The chi-square test revealed a significant association (X2 = 100.000; p= .001) indicating that Group A patients had a higher pain score postoperatively than Group B patient Table 5: Frequency and percentage distribution of Relief of symptoms in each group and chi-square test results Relief of pain Groups Chi-square Group A Group B Zero F 1 5 X2 = 57.209 p = 0.001 % 2.0% 10.0% Two F 2 25 % 4.0% 50.0% Four F 5 15 % 10.0% 30.0% Six F 19 4 % 38.0% 8.0% Eight F 23 1 % 46.0% 2.0% The chi-square test revealed a significant association (X2= 7.527; p = .012FET) indicating that patients in group A were significantly prone to have Eustachian tube scarring than patient in group B. Table 6: Frequency and percentage distribution of Eustachian tube scarring in each group and chi-square test results Eustachian tube scarring Groups Chi-square Group A Group B Yes F 7 0 X2 = 7.527 p = .012FET % 14.0% 0.0% No F 43 50 % 86.0% 100.0%

Adenoid tissue plays an important role in the immun system.While there have been many indications for adenoidectomy, paediatric obstructive sleep apnoea,otitis media with effusion and pediatric chronic rhinosinusitis remain the major indications for the procedure.Nasal obstruction,mouth breathing and sleep disordered breathing were the predominant indications for adenoidectomy in this study. The main objective of adenoidectomy is complete removal of obstructing adenoid tissue while preserving surrounding structures.Traditionally adenoidectomy is done with a curette. The main disadvantage of this method is that it is relatively a blind technique that may injure the choanae and torus tubarius, the nasopharyngeal mucosa or may leave behind obstructing tissue, particularly at the eustachian tube orifices, high in the nasopharynx. This can lead to persistent nasal obstruction, otitis media and recurrent symptoms. Several techniques and instruments including endoscopic assisted curettage, microdebridement, laser, coblation and suction electrocautery can be used for surgery(4). Techniques and instruments have been changing over the years. The use of rigid endoscope has its advantages. It allows good visualization ensuring complete removal of adenoid tissue situated even high up in nasopharynx and intranasally without damaging surrounding structures. The microdebrider removes tissue along relatively avascular planes with continuous suction, resulting in reduced bleeding and better surgical field visibility. When used transnasally there is no need to extend the neck especially in patients with instability of cervical spine. The mean age of all 100 patients aged 5–15 years in Group A comprised 25 males (50%) and 25 females (50%) while group B comprised 30 males (60%) and 20 females (40%). The mean age of patients was 11.2 ± 2.587 years in group A and 11.1± 2.704 years in group B. There was no statistical difference between the two groups with respect to age and gender distribution between the two groups. The majority of the two groups showed grade III and IV adenoid hypertrophy.In group A , 78% of the patients had grade III adenoid hypertrophy and 22% had grade IV adenoid hypertrophy. In Group B, 68% of the patients had grade III adenoid hypertrophy and 32% had grade IV adenoid hypertrophy. There was no significant statistical difference between the two groups(p=.368) In this study, the mean operative time was significantly longer in group B (endoscopic assisted powered adenoidectomy) than group A (conventional) the mean operative time in group A was 7.32 min and in group B was 18 min. Datta et al. showed that the average time of microdebrider assisted adenoidectomy was 39.3 min and the average time of conventional adenoidectomy was 29.3 min.Another study by Al-Mazrou reported the same showing that the average operative time for microdebrider assisted adenoidectomy was 6.1 min while for the conventional adenoidectomy it was 12.3 min.We attribute the increase in the operative time in the microdebrider assisted technique is quite explained by wise slow removal of the adenoid tissue and hemostasis which is time- consuming(8). Although the difference in time was statistically significant, the new technique only adds around 10 min to the mean operative time. In this study, bleeding intra-operatively was significantly less in group A (conventional) than group B (endoscopic assisted powered), the average in group A was 8.15 ml while in group B it was 16.6 ml. Intra-operative blood loss was more in group B because of increased operative time which leads to more time of exposure of the raw bleeding surface. However, Al-Mazrou et al. reported that blood loss was more in conventional adenoidectomy, as it was 22.1 ml while it was 8.2 ml in micro- debrider assisted adenoidectomy.Stanislaw et al. had also similar results, reporting 27 percent less blood loss in micro-debrider assisted adenoidectomy(12). Postoperative residual tissue measured as grade of remnant adenoid tissue showed that adenoid removal was almost complete in the endoscopic technique. In Group A,13 had residual adenoid of grade I postoperatively and 37 had grade II. In Group B, 18 had no residual tissue, 27 had grade I residual adenoid tissue and 5 had grade II. This also ensures the capability of endoscopic assistance to achieve the complete removal of adenoid tissue. Havas et al. reported residual adenoids in 39% of cases following the conventional method. The authors have often noted that the extent of resection after conventional adenoidectomy was incomplete. Endoscopic evaluation was therefore considered to be used to determine the extent of residual tissue(3). The nasopharynx can be clearly seen and the traces of adenoid tissue can be removed accurately under vision in endoscopic- assisted adenoidectomies. Thus, completeness is more in the endoscopic powered method. In this study, a significant difference in post-operative relief of symptoms was found between both groups with greater relief in endoscopic assisted powered adenoidectomy. Some studies also confirmed a similar result of less pain in the microdebrider assisted adenoidectomy group. In Group B, all patients had postop relief of symptoms at week 2. Further, In Group A and Group B, all the patients had postop relief of symptoms by 4 weeks. In Group A, 23 patients had a pain score of 8 on the visual analog scale and 27had 6. In Group B, none of the patients had scores of 6 or 8, but 13 patients had a score of 0, 26 had 2 and 11 had 4. This revealed a significant association indicating that Group A patients had a higher pain score postoperatively than Group B patients. Group A patients has more postoperative pain compared to those in group B. This was in agreement with the study performed by Lister et al. who reported significant less postoperative pain in the microdebrider group.There was a significant reduction in postop snoring which was analysed by score in group B compared to group A . Symptomatic relief in endoscopy assisted group were faster when compared with those who had conventional curettage(6). Regarding the recovery time after any surgery, there is no unified parameter to use and different parameters are used by different studies, that is why, the recovery time is difficult to define. Following the surgery, in the postoperative follow- up, the question was raised about “return to normal daily activities.” Regarding the recovery period, it was shorter for the endoscopic-assisted powered adenoidectomy and there was a statistically significant difference. An average of 7 days faster recovery was accomplished by the use of powered, which may favor an introduction to the newer methodology in current practices. In Group A, 38 patients had type A curve and 12 had type B curve. In Group B, 36 of the patients had type A and 14 had type B. In Group A, 39 patients had postoperative tympanogram curve A and 11 had curve B. In Group B, 47 of the patients had postoperative tympanogram curve A and only 3 of had curve B. The chi- square test revealed a significant association (X2 = 5.316; p= .041) indicating that a higher number of patients in group A and group B had postoperative tympanogram A .In a study by Somayaji et al., otoscopy findings showed varied appearance of TM. 24% (26 ears) showed air–fluid level and 17.6% (19 ears) had dull and retracted TM. Tympanogram results revealed pathological curves in 45 ears (25% Type B curve and 16.7% Type C curve). Sarafoleanu et al. in his study observed that 28.57% had retracted TM and 49.2% had middle ear effusion. Furthermore, tympanogram results showed pathologic curves in 98 cases (40.47% Type B curve and 37.30% Type C curve). In a similar study by Khayat and Dabbagh also, the otoscopic findings were varied with distorted cone of light, retraction of TM, and air bubbles(7). A study by Ajayan et al. conducted to study the effect of adenoidectomy with tonsillectomy in pediatric patients with OME, showed dull and retracted TM in 78.5% cases and air–fluid was seen only in 11.42%.In a study by Somayaji et al., the difference between the two techniques (one group for conventional adenoidectomy and another for microdebrider adenoidectomy) was statistically significant (P < 0.001). Furthermore, 69.1% and 17.2% with Type A tympanogram changed to Type C and Type B, respectively, in the immediate postoperative period. All the patients in Group A had Eustachian tube scaring while patients in Group B did not have. Pagella et al. recently introduced the transoral endonasal- controlled combined adenoidectomy (TECCA) method. The TECCA method can be used in patients with narrow nasal passages and reduces the risk of damaging the surrounding structures(9). Endoscopic assisted adenoidectomy versus conventional curettage adenoidectomy: a meta-analysis of randomized controlled trials by Liyun Yang, Yamin Shan, Shili Wang, Changping Cai and Hao Zhang included seven studies that all met the inclusion criteria (Songu et al. 2010; Al-Mazrou et al. 2009; Ozturk and Polat 2012; Stanislaw et al. 2000; Murray et al. 2002; Feng and Ying 2006; Zhang and Yang 2013). Five studies stated the total operative time, and the result of meta-analysis showed that endoscopic assisted adenoidectomy was better than conventional curettage adenoidectomy in this regard(10). The related shorter operative time could be explained by the endoscopic adenoidectomy is an operation to remove pathological tissues which clearly block the choana, and the shaver can reach them directly by using 0°, 30° endoscopy (Somani et al. 2010). Although the actual procedure time is not concerned, the total operative time the children spent is possible more important. This is specifically important in children with upper airway obstruction where the time taken to induce adequate anaesthesia and the time taken for the patient to emerge from anaesthesia was often long and unpredictable (Songu et al. 2010). Five studies selected reported blood loss, and the meta-analysis results demonstrated that the conventional curettage adenoidectomy caused greater blood loss than endoscopic assisted adenoidectomy. This is mainly related to direct visualization, treatment of the source of bleeding, the effect of a microdebrider depended on suction efficacy and hemostasis is noticeably shortened (Vokurka 2003). This reduction of blood loss is highly suitable for children because it reduces the risk of hemorrhage (Al-Mazrou et al. 2009) , conventional technique increases the risk of damaging the eustachian tube openings in the region of the nasopharynx (Viorel 2011) and leads to mild hearing loss (Capaccio et al. 2016). Furthermore, the adenoids may only be reduced, not completely removed. If the adenoids are not completely removed, they may continue to be re-grow and cause airway obstruction (Al-Mazrou et al. 2009). By contrast, endoscopic assisted adenoidectomy removes the tissues precisely and solves the nasopharyngeal obstruction completely. The results of meta-analysis suggest that the endoscopic assisted adenoidectomy is better than conventional curettage adenoidectomy in terms of total operative time, blood loss, and complications.

The surgical technique for adenoidectomy can have considerable influence on the intra operative bleeding, post operative pain and the recovery time.We prospectively compared and studied patients in whom we performed endoscopic assisted powered adenoidectomy and conventional adenoidectomy, reviewed its merits and demerits. Our experience with the microdebrider was supported by these studies, with respect to completeness of adenoid tissue removal to adequate depth and causing no damage to surrounding structures. The newer method of endoscopic-assisted powered adenoidectomy was found to be a safe and useful tool for adenoidectomy. Endoscopic-assisted powered adenoidectomy is superior to conventional curettage adenoidectomy in terms of • completeness of removal • postoperative recovery • symptom relief • middle ear function. It should be preferred wherever facilities and expertise are available. Ethics Approval Institutional Ethics Committee, Kurnool Medical College – IEC No: 87/2022 Conflict of Interest None Funding Nil

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