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By: Kelly C. Rogers, PharmD, FCCP

  • Professor, Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee

https://academic.uthsc.edu/faculty/KellyCRogers.html

Pannus (choice B) is featured in rheumatoid index virus 32 removal minocycline 50 mg fast delivery, hypogonadism antibiotic quiz discount minocycline 50mg otc, a sedentary lifestyle antimicrobial fogger minocycline 50 mg with visa, and glucocorti arthritis bacteria 5 letters buy 50 mg minocycline mastercard. Rheumatoid nodules (choice D) are found in extra coid therapy (seen in this patient). Choices A and C are congenital disorders that are not related to corticosteroid therapy. Choices B and E are acquired conditions but they are not related to corticosteroid therapy. She has problems chewing and swallowing and 1 A 4-year-old boy is brought to the physician by his parents loses her voice while talking. Physical examination reveals because he falls a lot, cannot jump, and tires easily. Laboratory studies would most likely examination reveals weakness in the pelvic and shoulder gir demonstrate serum autoantibodies directed against which of dles and enlargement of the child’s calf muscles. A biopsy of calf muscle (A) Acetylcholine receptor reveals marked variation in size and shape of muscle fibers. Which of the following (D) Dystrophin is the most likely cause of death expected in this patient She describes easy fatigability and can rise only with difculty from a squatting position. A muscle biopsy shows inltrates of B and T lymphocytes around blood ves sels and in connective tissue of the perimysium. Elevated serum levels of which of the following would be expected in this patient A muscle biopsy (C) Myotonic dystrophy displays massive accumulation of membrane-bound glycogen (D) Polymyositis and disappearance of the myolaments and other sarcoplas (E) Werdnig-Hoffman disease mic organelles. He cannot raise his arms and climbs the stairs only (C) Hurler syndrome with difculty. A muscle biopsy shows perivascular inltrates (D) Niemann-Pick disease of lymphocytes and plasma cells extending in between the (E) Pompe disease muscle bers. Immunouorescence reveals immune com plexes in the walls of intramuscular blood vessels. A muscle biopsy demonstrates lymphocytic inltration (B) Dermatomyositis with single-ber necrosis. In addition, muscle bers exhibit (C) Lambert-Eaton myasthenic syndrome basophilic granular material. An electron micrograph of the (D) Myasthenia gravis cytoplasmic material is shown. Laboratory studies demonstrate serum IgG autoan tibodies that recognize voltage-sensitive calcium channels in motor nerve terminals. He cannot open his hand for a handshake and cannot extend his arm after exing it. On physical examination, he has marked atrophy of leg and arm muscles, ptosis, and a xed facial expression. In the emergency room, the patient is noted (D) Myasthenia gravis to have hot dry skin with little sweating. Which of the following is the most likely diag (C) Lymphocytic inltration nosis Dystrophin-decient 14 A 22-year-old woman injured her leg in a motor vehicle muscle bers thus lack the normal interaction between the accident and subsequently suffers from weakness of her left sarcolemma and the extracellular matrix. A biopsy of the gastrocnemius muscle is obtained be responsible for the observed increased osmotic fragility of after 4 months (shown in the image). Which of the following dystrophic muscle, the excessive inux of calcium ions, and best characterizes this pathology The inammatory myopa thies represent a heterogeneous group of acquired disorders, all of which feature symmetric proximal muscle weakness, increased serum levels of muscle-derived enzymes, and non suppurative inammation of skeletal muscle. The most common morpho logic characteristics in the inammatory myopathies are (1) inammatory cells, (2) necrosis and phagocytosis of mus cle bers, (3) a mixture of regenerating and atrophic bers, (A) Autoimmune myopathy and (4) brosis. Dermatomyositis is distinguished from the (B) Compensatory hypertrophy other myopathies. Patients with inammatory myopathies have increased serum levels of creatine kinase and (E) Target bers other muscle enzymes. Elevated serum alkaline phosphatase (choice A) is associated with liver and bone disease. Alpha 15 A 28-year-old man begins a program of vigorous body fetoprotein and carcinoembryonic antigen (choices B and C) building. Elevated blood urea-nitrogen (choice exhibit which of the following adaptive cellular changes It is caused by circulating antibodies to myoblasts the acetylcholine receptor at the myoneural junction (motor endplate). The clinical severity of the condition is variable, and 1 the answer is D: Respiratory insufciency. The other choices are not muscular dystrophy is a severe, progressive, X-linked, inher related to myasthenia gravis. Diagnosis: Myasthenia gravis the weakness is noted mainly around the pelvic and shoul der girdles (proximal muscle weakness) and is relentlessly 5 the answer is C: Thymectomy. Up to due to abundant replacement of muscle bers by broadipose 40% of patients with thymoma develop myasthenia gravis, and tissue) of the calf muscles eventually develops. Other patients usually wheelchair bound by the age of 10 years and bedrid with myasthenia gravis have thymic hyperplasia, and in such den by age 15 years. The most common causes of death are cases, thymectomy is often an effective treatment. Acetylcho complications of respiratory insufciency caused by muscular line receptors have been demonstrated on the surface of some weakness or cardiac arrhythmia due to myocardial involve thymic cells in both thymoma and thymic hyperplasia. The other choices are not complications of Duchenne of the other choices are curative for myasthenia gravis. Duchenne muscular dystrophy is caused by mutations of a large gene on the short arm of 6 the answer is D: Polymyositis. This gene codes for dystrophin, direct muscle cell damage produced by cytotoxic T cells. There is a frequent associa 304 Chapter 27 tion between polymyositis and anti-Jo-1, an antibody against 10 the answer is A: Carnitine palmityl transferase defciency. An inammatory myopathy indistinguishable from have muscular pain, which may progress to myoglobinuria. Biopsy specimens show no microscopic abnormali associated with an inltrate of cytotoxic T lymphocytes. Dermatomyositis is an Diagnosis: Carnitine palmityl transferase deciency immune-mediated microangiopathy that leads to obliteration of capillaries, ischemic injury, and muscle damage. Glycogen-storage diseases ouorescence demonstrates that the walls of many capillar are autosomal recessive, inherited, metabolic disorders char ies contain C5b-9 proteins. The rst acid When dermatomyositis occurs in a middle-aged man, it is maltase deciency to be recognized, described by Pompe, associated with an increased risk of epithelial cancer, most is the most severe form and occurs in the neonatal or early commonly carcinoma of the lung. These patients have severe hypotonia and this and inclusion body myositis have only a chance associa areexia. Lambert-Eaton myasthenic syndrome and cardiomegaly and die of cardiac failure, usually within (choice C) is also seen in patients with lung cancer, but as with the rst 2 years of life. Many tissues are affected, but the most the other incorrect choices, it is not associated with a skin rash signicant involvement is in skeletal and cardiac muscle, the or muscle inammation. The serum creatine Diagnosis: Dermatomyositis kinase level is only slightly to moderately increased. Hurler syndrome (choice C) is an inherited defect in mucopolysac 8 the answer is C: Lambert-Eaton myasthenic syndrome. Glycogen accumulation is not a feature bert-Eaton syndrome is a paraneoplastic disorder that mani of the other choices. Also termed myasthenic–myopathic syndrome, the disease is usually associated with small cell car 12 the answer is C: Inclusion body myositis. The pathologic cinoma of the lung, although it may also occur in patients features of inclusion body myositis resemble those of poly with other malignant diseases.

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An echocardiogram (four-chamber and parasternal long-axis views) from a patient with a hypertrophic cardiomyopathy fever after antibiotics for sinus infection cheap minocycline 50 mg without prescription. If the effusion is large enough or accumulates rapidly yeast infection 9 months pregnant buy minocycline 50 mg overnight delivery, the elevated intrapericardial pressure can prevent normal lling of the left and right ven tricles n-922 antimicrobial buy minocycline 50 mg low cost. Even if the ven tricles contract normally infection endocarditis buy generic minocycline 50 mg online, inadequate lling can lead to extreme reduction in the amount of blood expelled by the ventricles with each heartbeat (stroke volume), which can lead to profound hypotension. Echocardiography has emerged as the best test for rapidly determining whether a signicant peri cardial effusion is present. In general, abnormal valve function can be classied as stenosis, in which forward ow of blood through the valve is restricted. The pericardial effusion (*) is identied as a dark echo-free area surrounding the heart due to abnormal uid accumulation. Generally, the severity of valve steno sis or regurgitation is assessed by echocardiography Doppler evaluation. Valvular regurgitation produces a high-velocity jet that can be identied within the chamber into which the blood leaks back. For example, mitral regurgitation can be identied by a high-velocity jet within the left atrium and the area of the high-velocity jet correlates roughly with the severity of the valvular abnormality. Aortic Valve Narrowing of the aortic valve is one of the most common valvular abnor malities encountered clinically. Normally, the aortic valve has three leaets, but in some patients only two leaets are present. During childhood and early adulthood, the valve functions normally, but a harsh murmur due to turbulent blood ow during ventricular contraction (systole) is often heard. However, in the fth or sixth decade of life, progressive turbulent ow often leads to thickening of the aortic valve leaets, stenosis of the aortic valve, and reduction in stroke volume. In this case, progressive calcication of the leaets presents as aortic stenosis in the seventh or eighth decade. On echocardiography, the aortic valve appears “bright” or echogenic as a result of calcium deposi tion that almost completely reects the ultrasound signal (Figure 7–16). Aortic stenosis produces a high-velocity jet across the aortic valve into the Normal Aortic stenosis Figure 7–16. Echocardiographic images of a normal aortic valve and an aortic valve asso ciated with severe aortic stenosis. Although both aortic valves have three leaets, in the patient with aortic stenosis the leaets are calcied. The velocity of the jet can be used to estimate the severity of the gradient; the normal velocity of blood at the aortic valve is 1 m/s, but in severe aortic stenosis, velocities of 4–5 m/s can be measured at the aortic valve. In general, the higher the velocity recorded across the aortic valve, the larger the pressure gradient between the left ventricle and the aorta and the more severe the aortic stenosis. If the aortic valve does not close normally, blood from the aorta can leak back into the left ventricle. This condition is called aortic regurgita tion, in which blood ows backward from the aorta into the left ventricle. Aortic regurgitation can develop with infection of the aortic valve (endo carditis), in the presence of a bicuspid aortic valve, or with any process that causes enlargement of the aortic root (and consequent enlargement of the ring that provides the support for the valve leaets). The turbulent ow from aortic regurgitation occurs in diastole, and consequently a murmur is heard during diastole. Doppler echocardiography is useful for evaluating the severity of aortic regurgitation. Aortic regurgitation is recorded as a turbulent jet within the left ventricle, emanating from the aortic valve dur ing diastole (Figure 7–17). During diastole, a large turbulent jet is present (arrows), emanating from the aortic valve. A parasternal long-axis view of a patient with severe mitral stenosis due to rheumatic heart disease. During systole, the mitral valve is closed and blood is expelled through the open aortic valve (single arrow). During diastole, opening of the mitral valve is restricted, and a characteristic bowing of the mitral valve (arrows) is observed. Mitral stenosis is almost always due to rheumatic heart disease related to untreated streptococcal infections (see Chapter 5) and can be identied by restricted opening of the mitral valve leaets on echocardiography (Figure 7–18). Of all the valvular lesions, mitral stenosis is the least com monly encountered in developed countries but still remains a common problem in many parts of the developing world. Mitral regurgitation is much more commonly observed than mitral stenosis and can be due to severe mitral valve prolapse, endocarditis of the mitral valve, myocardial ischemia, or rheumatic valvular disease. Like aortic regurgitation, Doppler techniques are used to identify the high-velocity turbulent jet. However, in mitral regurgitation, the high-velocity jet is observed in the left atrium, emanates from the mitral valve, and occurs during ventricular contraction (systole). An example of an echocardiogram from a patient with mitral regurgitation is shown in Figure 7–19. A wide necked jet that encompasses a larger portion of the left atrium is character istic of severe mitral regurgitation. Tricuspid Valve In tricuspid regurgitation, a regurgitant jet is present in the right atrium, emanating from the tricuspid valve (Figure 7–20). A high-velocity jet is observed in the left atrium (arrows), emanating from the mitral valve. A wide necked jet that lls a large portion of the left atrium suggests severe mitral regurgitation. Doppler evaluation of the tricuspid valve is frequently used to assess right-sided cardiac pressures. The relative pres sure difference between two chambers can be estimated by using a simpli ed formula of the Bernoulli equation: 2 P = 4V where P is the pressure difference in mm Hg and V is the velocity between two cardiac chambers in m/s. Figure 7–21 shows a Doppler signal from the tricuspid valve in a patient with severe tricuspid regurgitation. Using the simplied Bernoulli equation, the difference between right atrial pressure and right ventricular pressure reaches 56 mm Hg during systole. In transesophageal echocardiography, the trans ducer can be placed on a probe designed to enter the esophagus. In intracar diac echocardiography, the transducer can be placed on a catheter designed to enter the heart itself via one of the central veins (usually the femoral vein) and advanced via the inferior vena cava into the heart. Imaging from a trans ducer located adjacent to the heart (transesophageal echocardiography) or from inside the heart (intracardiac echocardiography) produces images with exquisite detail and resolution. In tricuspid regurgitation, the high-velocity ow is recorded during systole and not in dias tole (Dias). Since the jet of tricuspid regurgitation is owing away from the transducer, a negative signal is recorded (contrast this to the normal mitral inow signal shown in Figure 7–10). The simplied Bernoulli equation can be used to estimate the pressure difference between the right ventricle and right atrium from the peak velocity recorded from the tricuspid regurgitation signal (3. Electrocardiographic classication of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology. Material is presented in tabular format, and contents are listed in alphabetical order by disease topic. Abbreviations used throughout this section include the following: N = Normal Abn = Abnormal Pos = Positive Neg = Negative ^ Increased or high v Decreased or low Occ = Occasional 487 488 Pocket Guide to Diagnostic Tests Contents (Tables) Pages 8–1. Acid–base disturbance: Laboratory characteristics of primary or single acid–base disturbance. Hepatitis B virus infection: Common serologic test patterns and their interpretation. Pulmonary function tests: Interpretation in obstructive and restrictive pulmonary diseases. Partial Unmeasured Acute Primary Compensatory Arterial Serum [K+] Anions Disturbance Change Response pH (meq/L) (Anion Gap1) Clinical Features Normal None None 7. Variable, but Thalassemias Abnormal red cell morphology, normal to Asian, African, or Mediterranean descent. Variable, but Sideroblastic High serum iron, high transferrin saturation, Dimorphic red cell population with hypo usually < 32 anemia erythroid hyperplasia with ring sideroblasts in chromic red cells on blood smear. Numerical Score Child-Turcotte-Pugh scoring system Parameter 1 2 3 Ascites None Slight Moderate to severe Encephalopathy None Slight to moderate Moderate to severe Bilirubin, mg/dL <2. Over 800 mutations have been considered diagnostic of a cystic ing 1 in 2500 births.

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Overnight treatment for sinus infection from mold cheap minocycline 50mg amex, room tem perature hold of whole blood followed by 42-day storage of red blood cells in additive solution-7 antimicrobial mouthwash brands minocycline 50mg fast delivery. Packed red blood cell trans fusion in the intensive care unit: Limitations and conse quences antibiotic resistance news article buy minocycline 50 mg free shipping. A multicenter antibiotics for dogs for skin infection discount minocycline 50 mg without a prescription, ran domized, controlled clinical trial of transfusion requirements in critical care. Transfusion in the patient with sickle cell disease: A critical review of the litera 68 ture and transfusion guidelines. Clinical practice guideline: Red blood cell transfusion in adult trauma and criti cal care. Appropriateness of allogeneic red blood cell transfusion: the international consen sus conference on transfusion outcomes. Cryoprecipitate-reduced plasma: Ratio nale for use and efficacy in the treatment of thrombotic throm bocytopenic purpura. Coagulation parame ters in apheresis and leukodepleted whole-blood plasma during storage. How we treat: Manage ment of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol. Fresh frozen plasma transfu sion in critically ill medical patients with coagulopathy. The bioequivalence of frozen plasma prepared from whole blood held overnight at room temperature compared to fresh-frozen plasma prepared within eight hours of collection. Four-factor pro thrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: A phase 3b, open-label, non-inferiority, randomised trial. How we treat management of war farin-associated coagulopathy in patients with intracerebral hemorrhage. Massive transfusion and coagulopathy: Pathophysiology and implications of clini cal management. Toward rational fresh frozen plasma transfusion: the effect of plasma transfusion on coagulation test results. Indications for early fresh frozen plasma, cryoprecipitate, and platelet transfusion in trauma. Better hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. Five-day stabil ity of thawed plasma: Solvent/detergent-treated plasma com parable with fresh-frozen plasma and plasma frozen within 24 hours. The impact of plasma preparations and their storage time on short-term posttransfu sion mortality: A population-based study using the Scandina vian Donation and Transfusion database. Evaluation and comparison of coagulation factor activity in fresh-frozen plasma and 24 hour plasma at thaw and after 120 hours of 1 to 6 C storage. Paucity of studies to support that abnor mal coagulation test results predict bleeding in the setting of invasive procedures: An evidence-based review. Coagulation factor levels in plasma frozen within 24 hours of phlebotomy over 5 days of storage at 1 to 60 C. A randomized trial of washed red blood cell and platelet transfusions in adult leuke mia. Clinical effectiveness of leucoreduced, pooled donor platelet concen trates, stored in plasma or additive solution with and without pathogen reduction. Platelet transfusion for patients with cancer: Clinical practice guidelines of the American Society of Clinical Oncology. Relationship between platelet count and bleeding risk in thrombocytopenic patients. Platelet immunopa thology and therapy: A Canadian Blood Services research and development symposium. Secondly, because this document has amazing tools that can allow you quick access to just the information you want to see, you will want to read pages 17-19 which are the instructions of those shortcuts and features. The contents of this e-Book are evidence based and substantiated by extensive research published in medical and scientific journals. In addition, the references contained in the excerpts from these studies 1 consist of thousands of additional studies that also corroborate that evidence. To the best of my knowledge, this is the most extensive expose on vaccines to date and the first presented in this easy to search and share electronic format. If you have looked at the number of pages this contains and have concluded that you could never have the time to read it, sit tight because over the next few pages, I will describe the many shortcuts to get you to exactly the information you are most interested in. For those that don’t even want to attempt to read this, I at least want you to see what it contains. Read the whole introduction and then go to page 30 and scroll through the Table of Contents. The take-away you will get, is that there is such a massive amount of credible science that contradicts what we are being told and the current vaccine status quo, that we have to open an honest and unbiased investigation into the entire matter. For those currently supporting the vaccine agenda, I challenge you to read this with an open mind and contrast it with what you currently know and believe. We face a crisis of unprecedented proportions We are facing an unprecedented crisis in our nation and the Western world. There has been a meteoric rise in the rates of autism, developmental delays, learning disabilities, allergy, asthma, autoimmune diseases and more in the way of chronic and debilitating diseases. And tragically, we are losing a large portion of the next generation of children to neurological, neurodevelopmental, behavioral and learning disabilities. And, those statistics show that these developmental delays including behavioral and learning disabilities are continuing to increase at alarming rates. And, all of the learning and behavioral 2 conditions have a prevalence much higher in boys. In addition, all across the spectrum, the rates of allergy, asthma and autoimmunity are nearing epidemic proportions. Autism Spectrum Disorder (Autism), is just one of those many conditions that are affecting our children. Compare that to rates of autism estimated at 1 in 10,000 in the 1950s and 1960s, 1 in 5,000 in the 1970s and increasing to 1 in 300 in the 1990s. Many experts believe at the current trajectory, somewhere between the years 2025 and 2032, 1 in 2 boys will be autistic!! And, that is not even considering the crippling rates of other intellectual disabilities just mentioned. This chart published in Nature the International Weekly Journal of Science, shows the rate increases up to 2011, when the rates were 1 in 68. As just mentioned, the rates as of 2014 were 1 in 45 and the projections for when the 2018 rates come out may be as high as 1 in 25. It is estimated that it takes between two and three million dollars to raise an autistic child. And as the proportions of autistic children continue to increase, the cost over the next thirty years of raising millions of young people on the spectrum will be astronomical! Just doing some simple math let’s take just boys, since the prediction of 1 in 2 becoming autistic is only for boys. If we reach a point (heaven forbid), where 1 in 2 boys are autistic, conservatively using today’s birth numbers of 1 million boys, and the current cost of an estimated of $60,000 annually to raise an autistic child to age 40, that amounts to an annual expenditure of 60 billion dollars at today’s cost! Add girls in to the equation and that expenditure climbs to around 80 billion dollars (since autism is 3-4 times more prevalent in boys, fewer girls are affected). Over 40 years (without inflation factored in), that amounts to 3 trillion, 200 billion dollars (3,200,000,000,000)! In addition, consider that as the years elapse, most likely many more boys and girls will be born annually than at the current birth rates. And, to make matters even worse, this calculation doesn’t even take into effect the added costs involved for children with other neurodevelopmental delays, learning or behavioral problems, chronically ill with allergies, asthma and autoimmune disorders. In addition, can you imagine the impact on us socially, on militarily readiness and on the affected children and families themselves What about our intellectual capacity to churn out scientists, inventors and business innovators for the years to come

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Approach to antimicrobial use and resistance in animals buy discount minocycline 50mg the patient with peripheral neuropa Parkinsonism Relat Disord 2005;11:327–330 antibiotics for uti with birth control discount minocycline 50 mg otc. Biol Psychiatry 2005;57:788– lin-associated glycoprotein paraprotein-associated peripheral 792 antimicrobial cleaner order 50mg minocycline amex. Special Writing Group of the Committee on atric disorders associated with streptococcal infections—anes Rheumatic Fever infection movies discount 50 mg minocycline fast delivery, Endocarditis, and Kawasaki Disease of the thetic implications and literature review. Paediatr Anaesth Council on Cardiovascular Disease in the Young of the Ameri 2006;16:573–577. Treatment of Sydenham’s chorea with intravenous immuno Pediatrics 2008;122:273–278. Arch Dermatol 1983;119: treatment preserves sensory nerve action potentials and motor 215–221. 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Recovery of splenic dulating effects of synchronised plasmapheresis and intrave infarction with anti-platelet treatments and platelet-apheresis in nous bolus cyclophosphamide in systemic lupus erythematosus. Gaubitz M, Seidel M, Kummer S, Schotte H, Perniok A, Ozawa N, Kitagawa M, Murashima A. Prospective randomized trial of sis during pregnancy in a high-risk patient with essential two different immunoadsorbers in severe systemic lupus ery thrombocythemia. J Thromb Throm lupus erythematosus: different techniques and their current role bolysis 2006;22:165–167. Pilot clinical study of agement: outcomes and lessons from 3 decades of splenectomy Adacolumn cytapheresis in patients with systemic lupus ery for myelofibrosis with myeloid metaplasia at the Mayo Clinic. Four pregnancies in two severe central nervous system neuropsychiatric systemic lupus patients with essential thrombocythaemia—a case report. A single institutional experience with and pulse cyclophosphamide in severe systemic lupus erythem 43 pregnancies in essential thrombocythemia. Improvement of platelet function fol sis in therapy-refractory disseminated discoid lupus erythema lowing plateletpheresis in patients with myeloproliferative dis tosus. J Clin Apher 1998;13: Ticlopidine and clopidogrel-associated thrombotic thrombocy 163–166. Therapeutic thrombocytapheresis: a review of 132 Matsumoto M, Uemura M, Fujimura Y. Am J patient with previous clopidogrel-induced thrombotic thrombo Hematol 1996;52:310–312. Egypt J topenic purpura/haemolytic uraemic syndrome associated with Immunol 2006;13:95–99. Clopidogrel-induced throm A case of early onset cyclosporine-induced hemolytic uremic botic thrombocytopenic purpura-hemolytic uremic syndrome syndrome resulting in renal graft loss. Transplantation 1999; vention of recurrent stroke in black patients: a randomized 67:539–544. 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