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Glu Mal Lac Suc For ascending infections in the male the differential diagnosis should include testicular torsion and in the female endometriosis muscle relaxer 7767 buy 100 mg tegretol free shipping, endometritis spasms youtube generic tegretol 100mg visa, Figure 9 muscle relaxant 5658 buy cheap tegretol 200mg online. Management the therapy for gonorrhea is antibiotics; however spasms mouth order 100mg tegretol overnight delivery, many gonococcal strains are resistant to penicillins, tetracyclines, spectinomycin, and fluoro quinolones. Since the early 1990s the fluoroquinolones have been widely used for the treatment of gonorrhea because of their efficacy, and conven ience as a single-dose, oral therapy. Currently only the cephalosporins are still recommended for the treatment of gonorrhea. Recommended antibiotic therapy for Neisseria gonorrhoeae Uncomplicated gonococcal infections of the cervix, urethra, and rectum* Recommended regimens Ceftriaxone 125 mg in a single intramuscular. Information regarding management of these infections in patients with documented severe allergic reactions to penicillin or cephalosporins is available at. Some evidence indicates that cefpodoxime 400 mg and cefuroxime axetil 1 g might be oral alternatives. Information on treatment for other gonococcal infections and associated conditions can be found at. Gonorrhea can also be spread vertically from the body and how does it spread a) within the mother to baby during delivery. Neisseria species are capnophilic, gram-negative what is the disease pathogenesis? In the genitourinary tract gonococci encounter (diplococci) where their adjacent sides are various innate antimicrobial factors such as flattened giving them a coffee bean appearance. What is the typical clinical presentation and composed of polymers of the structural protein what complications can occur? The most common organism to adhere tightly to epithelia and symptom is a thin, purulent, and unpleasant facilitate uptake by various types of host cell. This results in bilateral conjunctivitis observing intracellular (neutrophils) gram (ophthalmia neonatorum), which can lead to negative diplococci on smears of urethral blindness. However, ophthalmia subjecting oxidase-positive and catalase-positive neonatorum, which is caused by Neisseria gram-negative diplococci to carbohydrate utilization gonorrhoeae or Chlamydia trachomatis, is notifiable tests. The antimicrobial peptide cathelicidin protects the urinary tract against invasive Ganz T. The innate and early immune response to pathogen Neisseria-host-cell communication. Curr Opin Microbiol, challenge in the female genital tract and the pivotal role of 2003, 6: 43?49. Limited local and systemic antibody responses to protein to porin: a molecular mechanism of serum resistance of Neisseria gonorrhoeae during uncomplicated genital infections. Innate immune defences anisms of serum resistance of Neisseria gonorrhoeae and group B in the human endometrium. The PilC adhesin of the Neisseria type defences in the urinary tract: cathelicidin and beyond. J Immunol, 2005, uniqueness of the genital tract: challenge for vaccine develop 174: 7995?8002. While treating A Gram stain of his urethral exudate reveals this patient?s gonorrhea infection, treatment must neutrophils with intracellular gram-negative also be given for which one of the following? Use of selective culture media to suppress the growth of other bacteria and fungi while allowing gonococci 4. A Gram stain of the discharge shows the presence of gram-negative diplococci and numerous C. The lab reports the isolation of of the four sugars tested on an acid production panel. The presence of intracellular gram-negative cocci in diplococci that utilize glucose. A 22-year-old sexually active female from New England presents with fever and right knee swelling. Which of the following statements about gonorrhea She also has had a recent bout of cervicitis. Case 25 Neisseria meningitidis A 19-year-old college student was in his usual state of health until the evening before admission, when he went to bed with a headache. He told his room-mate that he felt feverish, and on the following morning his room-mate found him in bed, moaning and lethargic. He was taken to the emergency room, where he appeared toxic and drowsy but oriented. He had an impressive, nonblanching purpuric rash, most prominent on the trunk, wrists, and legs (Figure 1). Legs of patient showing a purpuric rash typical patient was started on intravenous ceftriaxone. Causative agent the patient has bacteremia (meningococcemia) caused by Neisseria meningitidis (often termed the meningococcus). This bacterium is one of the three principal causes of bacterial meningitis, the other two being Streptococcus pneumoniae (Sp) and Haemophilus influenzae serotype b (Hib). However, the introduction of conjugate vaccines for immunization of infants has reduced invasive disease caused by Sp and Hib significantly. The cocci are found in pairs where their adjacent sides are flattened giving them a coffee bean appearance (Figure 3). Neisseria species are oxidase-positive (Figure 4), catalase-posi tive, and produce acid from sugars by oxidation. Their habitat is the mucous membranes of mammals and many species are commensals of these surfaces. However, it has been reported to colonize the mucosae of the endocervix, urethra, and anus. Neisseria species have a typical gram-negative envelope (Figure 5) but the Figure 3. The cell surface is decorated with pili, which are hair-like projections composed of polymers of the structural protein pilin (PilE). Pili mediate initial attachment to nasopharyngeal epithelium and enable the bacterium to resist phagocytosis. These truncated genes are termed pilus porin core polysaccharide lipid A outer membrane periplasmic space lipoprotein peptidoglycan layer cytoplasmic membrane Figure 5. By recombination of pilS sequences into the pilE gene the bacterium can express a high number of antigenically dis tinct pili. They also dictate the tissue tropism of the meningococcus and its ability to invade epithelial cells. There are three or four genes encoding Opa pro teins and they undergo phase variation such that a neisserial population will contain bacteria expressing none, one or several Opa proteins. There are two hypervariable domains within the extracellular portion of the molecule that give rise to new Opa variants as a result of point mutation and by mod ular exchange of domains between different Opa proteins. These hyper variable domains are also the sites of interaction with cellular receptors. The Opa proteins of the meningococcus can be divided into two major groups based on the cellular receptors to which they bind. The porin proteins that form channels that traverse the outer membrane are thought to play several roles in pathogenesis. For example, when meningococci are apposed to the host cell membrane, PorB appears to be able to translocate into the eukaryotic cell membrane and affect the matu ration of phagosomes. An important virulence determinant of the meningococcus is the produc tion of a capsule. Noncapsulate strains rarely cause invasive disease and are often found colonizing the nasopharynx of asymptomatic carriers. Although there are 13 different types of capsule only five commonly cause invasive disease, A, B, C, Y, and W-135. However, recently there have been outbreaks of invasive disease caused by serogroup X in West Africa. This property contributes to its ability to replicate on mucosal surfaces, intracellularly, and in the blood. Entry and spread within the body the nasopharyngeal epithelium is induced to take up the meningococci by receptor-mediated endocytosis and the bacteria pass through the cells into the subepithelial space where infection is established. From this site the meningococci may seed the bloodstream where production of capsule is important for survival and from there to the meninges and many other sites including joints and the skin. An essential step in the formation of membrane protrusions appears to be the phosphorylation of cortactin because it controls the polymerization of cortical actin. Spread from person to person the meningococcus is spread horizontally (person to person) by respira tory droplets or direct contact.

Effects of resistance weight training stimuli on metabolically determined blood fow in in patients with chronic heart failure spasms jaw muscles purchase 400mg tegretol visa. Light-to-moderate document: use of sildenifl (Viagra) in patients with alcohol consumption and prognosis in patients with left cardiovascular disease muscle relaxant jaw clenching order 200mg tegretol. Effects of exercise training in patients geographical location on impotence and quality of life spasms quadriceps purchase tegretol 400 mg line. Effects of physical training in chronic psychological correlates: results of the Massachusetts heart failure muscle relaxant abuse tegretol 200mg fast delivery. Triggering myocardial infarction by sexual by physical training in chronic heart failure assessed by activity. Physical training in patients with stable chronic heart failure: effects on cardiorespiratory 83. Overall cardiovascular profle of ftness and ultrastructural abnormalities of leg muscles. Exercise training in patients with heart hypotensive effects of nitric oxide donor drugs in failure: a randomised, controlled trial. Specifc psychological intervention independent risk factor for mortality in chronic heart reduces depression and pain after urgent coronary failure. Effects of treating depression and low management of patients with chronic heart failure. Specialist nurse intervention in myocardial infarction: the Enhancing Recovery chronic heart failure: from research to practice. Evidence for left ventricular ventricular mechanoenergetics in Ca2+ overload failing dysfunction in patients with obstructive sleep apnoea in rat hearts. Left ventricular systolic dysfunction in to prevent the readmission of elderly patients with patients with obstructive sleep apnoea syndrome. Prolonged benefcial effects of a home positive airway pressure in patients with chronic heart based intervention on unplanned readmissions and failure and obstructive sleep apnoea. Impact of a comprehensive heart pressure on cardiovascular outcomes in heart failure failure management program on hospital readmission with and without Cheyne?Stokes respiration. Prevention of hospitalisations for heart on left ventricular function in congestive heart failure. Autonomic modulation of heart rate integrated heart failure management: the Auckland Heart during obstructive versus central sleep apnoeas in Failure Management Study. Major depression and survival in pressure airway pressure on cardiac sympathetic tone in congestive heart failure. Depressed mood and chronic heart supplemental oxygen administration in congestive heart failure. Randomised morbidity in patients with left ventricular dysfunction trial of effects of calcium antagonists compared with after myocardial infarction. Results of the Survival diuretics and beta-blockers on cardiovascular morbidity and Ventricular Enlargement Trial. Morbidity and development of heart failure in asymptomatic patients mortality in patients randomised to double-blind with reduced left ventricular ejection fractions. N Engl J treatment with a long-acting calcium-channel blocker Med 1992;327:685?91. Major outcomes in high-risk hypertensive study of the impact of cardilol on morbidity and patients randomized to angiotensin-converting-enzyme mortality in patients with left ventricular dysfunction after inhibitor or calcium channel blocker vs diuretic: the myocardial infarction. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular 134. Lancet and the development of heart failure in asymptomatic 2001;357(9266):1385?90. Effects of carvedilol, a vasodilator beta blocker, in patients with congestive heart failure due 135. Effects of different blood pressure-lowering regimens on major cardiovascular 124. Prevention of heart failure by events: results of prospectively designed overviews of antihypertensive drug treatment in older persons with randomised trials. Effects of nebivolol on left based blood pressure lowering regimen on cardiac ventricular function in elderly patients with chronic heart outcomes among patients with cerebrovascular disease. Randomized incidence of heart failure in patients with coronary heart trial to determine the effect of nebivolol on mortality and disease. Effect of enalapril on survival in patients with reduced left ventricular ejection fraction 154. N Engl J Med 1991;325: hospitalization of initiating treatment for chronic heart 293?302. Eplerenone, a selective aldosterone blocker, in blind placebo-controlled study of quinapril. J Am Coll patients with left ventricular dysfunction after myocardial Cardiol 1993;22:1557?63. Withdrawal enzyme inhibitor, lisinopril, on morbidity and mortality of digoxin from patients with chronic heart failure in chronic heart failure. The effect of carvedilol on morbidity and mortality in patients with chronic heart 159. Sex-based metoprolol on clinical outcomes in patients with chronic differences in the effect of digoxin for the treatment of heart failure in the Carvedilol Or Metoprolol European heart failure. Valsartan, captopril, or both in with impaired and preserved left ventricular ejection myocardial infarction complicated by heart failure, fraction. Increased mortality after dronedarone with chronic heart failure and reduced left-ventricular therapy for severe heart failure. Vasodilator and inotropic drugs for the Results of a Veterans Administration Cooperative Study. Comparative systemic and regional enalapril with hydralazine-isosorbide dinitrate in the effects of dopamine and dobutamine in patients with treatment of chronic congestive heart failure. Effect of amlodipine levosimendan compared with dobutamine in severe low on survival. Cardiac-resynchronization therapy trial of levosimendan on clinical status in acutely for prevention of heart-failure events. Circulation trial of cardiac resynchronization in mildly symptomatic 2005;112:3363. Effect of oral milrinone on for an implantable cardioverter-defbrillator, and mildly mortality in severe chronic heart failure. Long-term comparison of the implantable in patients with advanced severe heart failure. Continuous home ambulatory in patients with myocardial infarction and reduced intravenous inotropic drug therapy in severe heart failure: ejection fraction. J Thorac Cardiovasc backup pacing in patients with an implanted defbrillator: Surg 1998;115(2):381?6, discussion 387?8. Effcacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left 201. Effects of multisite biventricular pacing in ventricular dysfunction: comparison with a series patients with heart failure and intraventricular conduction of large dyskinetic scars. Dynamic cardiomyoplasty: expectations with or without an implantable defbrillator in advanced and results. Ventricular resynchronisation on morbidity and mortality in Heart containment as an adjunctive procedure in ischaemic Failure. Noninvasive support device in advanced heart failure patients not ventilation in acute cardiogenic pulmonary edema: requiring concomitant valve surgery. Noninvasive bypass surgery with or without surgical ventricular ventilation in acute cardiogenic pulmonary edema. Mechanical cardiac-support devices?dreams device as a bridge to patient and myocardial recovery. Randomized Evaluation of Mechanical on venous tone in patients with acute pulmonary edema. Assistance for the Treatment of Congestive Heart Failure Circulation 1976;54:335?7. 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People may remain confused and unable to store memories for some time after the injury spasms pain rib cage proven 100 mg tegretol. It can last from a few minutes to several weeks or months muscle relaxant liquid form order 100 mg tegretol mastercard, depending on the severity of brain injury spasms sentence tegretol 200mg otc. The best way to learn about the injury is to ask family members muscle relaxant walgreens order tegretol 100mg on line, friends, or medical personnel who may have objective information. Research has found very few ways to restore the brain?s natural ability to learn and remember. Memory and Moderate to Severe Traumatic Brain Injury 87 Using compensatory strategies is the best way to tackle memory problems and still get things done. This approach uses memory devices that we all use to make up for limited memory storage in the brain (e. When you write down information or enter it into a phone or computer, you may actually strengthen the memory trace in your brain, and the information will always be available for you if you need it. For example, make a checklist of bills that you need to pay each month and the dates on which they are due. College students can contact the Disability Supports Services office at their school to receive assistance with note-taking and other services to support learning. The Vocational Rehabilitation services available in every state may be able to supply job coaching or counseling to assist workers who need memory supports, and may provide additional help to college students. Source: Our health information content is based on research evidence and/or professional consensus and has been reviewed and approved by an editorial team of experts from the Traumatic Brain Injury Model System. The contents of this fact sheet do not necessarily represent the policy of Department of Health and Human Services, and you should not assume endorsement by the Federal Government. For many, this role is new and comes expect from a team of with a lot of questions. They can?t see because their eyes are closed, and they may not respond to sound, touch, or pain. They can?t communicate, follow commands, show emotions, or engage in purposeful behaviors. As with a coma, people in a vegetative state can?t show emotions or engage in purposeful behaviors. They may have some awareness of themselves or their surroundings but not all the time. People in a minimally conscious state may engage in purposeful behaviors from time to time. For example, they may follow a simple command, look at people or objects around them, or keep their eyes focused on people or objects that are moving. They may show appropriate emotional responses or try to communicate through gestures or talking. During this stage, they may be able to Model System program is answer simple questions correctly by saying or gesturing responses like yes? and no. When people regain consciousness, they may enter a post-traumatic confusional state. People in Rehabilitation Research, this state are confused and have problems forming new memories. Typically, people can?t remember where they and Human Services? are or what happened. People in this state may also do unsafe things, like pull on feeding and breathing. In the acute care setting, doctors and other health care professionals first address life-threatening injuries. The following is an overview of the health care team members who will likely be involved. Examples include trauma surgeons, neurosurgeons, orthopedic surgeons, and plastic surgeons. Because they interact frequently with the patient and family, they are often the first line? of communication, education, and support for families. They may also perform bedside evaluations to guide diagnosis and monitor neurological recovery. They determine whether a person needs a breathing tube or machine to help them breathe. They may also help determine whether a feeding tube is needed to provide nutrition. They may also provide education to the medical team and sometimes directly to families. They can explain the purpose of the medications being given and provide information on medication side effects. They also direct and oversee a team of brain injury rehab specialists, including physical therapists, occupational therapists, and/or speech therapists. These services help prevent muscle loss and keep the range of motion in arms and legs. Doctors can also use the results of these tests to help determine if surgery is needed. Severe Traumatic Brain Injury: What to Expect in the Trauma Center, Hospital, and Beyond 2 90? Neurological monitoring/neuromonitoring: Devices such as intracranial pressure monitors track the amount of pressure in the brain and help manage brain swelling. These devices require placing a tube in the brain that is attached to wires and a monitoring screen. If needed, the tube device can be used to drain excess fluid and relieve excess pressure in the brain. Neuromonitoring also helps diagnose and treat hydrocephalus (an excess of fluid buildup in the brain) and can help determine if surgical placement of a more permanent pressure valve, called a shunt, is needed. A typical exam tests basic reflexes; doctors look at how the eyes react to light and they assess a person?s response to sound, voice, touch, and pain. Doctors also look for signs of purposeful behaviors, like following a moving object with the eyes. It may take weeks?or even months?for a doctor to determine how or if a person will recover over time. Most people progress through the stages of coma, vegetative state, minimally conscious state, emerged from minimally conscious state, and post-traumatic confusional state. Others progress more slowly and may remain in a state of impaired consciousness for months or years. It is often one of the first meaningful behaviors seen when a person moves from a coma or vegetative state to a minimally conscious state. For example, if a person can follow simple, one-step commands by 2?3 months after the injury, the better the outcome is likely to be. Among those with a prolonged time of impaired consciousness, younger people are more likely to return to living more independent, productive lives. An accurate diagnosis is also helpful for family members and decision makers as they sort through difficult decisions like whether to stop care. These could be about your loved one?s medicines, allergies, or other medical conditions. The more information you can provide, the better prepared the medical team will be in preventing new problems. Other family members and loved ones can support the legal decision maker during this tough and emotional time. If your loved one has an advance directive, discuss with the medical team his or her wishes about resuscitation. Severe Traumatic Brain Injury: What to Expect in the Trauma Center, Hospital, and Beyond 3 91? It might be helpful for you or someone else to become the legal guardian for your loved one. A guardian is someone the court assigns to manage personal, legal, and financial matters for a person who can?t make their own decisions.

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The stained cell pellet showed holiday and had had several infections during that time. He did not believe in the use of that is only observed in people with immunodeficiency. Over the past 4 days he had developed a dry On examination of his mouth, a purplish nodular cough, had noticed increasing shortness of breath, and swelling was visible (Figure 3) and this was biopsied had begun to feel feverish. The patient then were few physical signs but a chest X-ray showed was immediately treated with co-trimoxazole and highly widespread shadowing (Figure 1). What is the causative agent, how does it enter the body and matrix protein how does it spread a) within the body and b) from person to lipid bilayer p24 core protein gp120 from host envelope person? Three of the genes code for polyproteins that are cleaved to produce nine different proteins. The main proteins are: p24 (capsid protein), gp120 and gp41 (envelope glycoproteins that are involved in viral attachment and entry host gp41 into cells), reverse transcriptase, integrase, and protease. Since the virus may be present at high level in plasma, in the past blood products such as clotting factor concentrates have infected many hemophiliacs. And many more virions are necessary for infection than with other viral pathogens such as hepatitis B. It is thought that the mucosal surfaces have some protection through innate immunity and that small lesions in the mucosal cell wall are required for successful infection. The normal skin as well as the prepuce of the penis is enriched in dendritic cells (that in this location are referred to as Langerhans cells; Figure 6). Spread within the body Following initial infection, the virus passes into draining lymph nodes and Figure 6. East Asia 800 000 Caribbean Middle East & North Africa (620 000 960 000) 230 000 380 000 (210 000 270 000) (270 000 500 000) South & South-East Asia 4. Much of the data on the development of a host immune response and the mechanisms of pathogenesis have been derived from animal studies modeled on simian immunodeficiency virus in nonhuman primates. In fact, the neutralizing antibodies are thought to merely drive 6 weeks and then increase slightly during the generation of escape mutants in the gp120 hypervariable region, thus the chronic phase of infection (blue line). A pool of virus 500 104 infected cells remains during the chronic 400 phase during which there is clinical 300 103 latency. Chronic phase After the acute phase, the level of viremia settles to a particular point called the set point? or point of equilibrium, which varies from individual to indi vidual, and presumably represents the balance between production of new virus and control by the immune system. The length of this phase varies from person to person and dur ing this period there is a so-called clinical latency period, that is no symp toms (Figure 9), although the immune impairment progresses, sometimes associated with a variety of nonspecific symptoms and general malaise. Whether it becomes grossly infected itself and produces significantly large amounts of virus is presently unclear. Infected den dritic cells could also affect the early differentiation of Th0 cells into either Th1 or Th2 or indeed other subsets early in an immune response, thus disrupting all immune responses. A number of pathological changes also occur in primary and secondary lymphoid organs and tissues that contribute to immunodeficiency. Finally, Th2 and also Th1 cells help B cells to differentiate into antibody-producing plasma cells. Late effects include changes to stromal cell function and loss of tissue architecture. The bone marrow depression seen late in the disease is probably due to effects on stromal cells but the mechanism remains unclear. The inflammation leads to fibrosis and later in the disease breakdown in the structure of the lymph nodes including germinal centers. It more frequently presents on the skin of the patient but other common sites are the gums of the mouth. It is also essential to obtain a second blood sample from the same patient, just to confirm that the laboratory result belongs to the correct patient. Antibody tests are not immediately useful during the earliest phase of infection when antibodies are undetectable the so-called diagnostic win dow. The availability and standardization of tests for diagnosis and monitoring remain a problem in countries where the national health budget is limited. New equipment designed to cost a frac tion of that of commercial flow cytometers is available and is being tested. Enfuvirtide binds to the gp41 subunit of the viral envelope glycoprotein and prevents the conformational change required for viral fusion and entry into cells. Drug interactions and side effects also frequently limit the usefulness of combination therapy. National awareness at the governmental level of a country?s burden of infection is essential in encouraging acceptance of the problem by that country?s people. Microbicides A number of microbicides have been developed for use as topical products to prevent infection. Much of the initial effort focused on producing vaccines to generate neutralizing antibodies; however, those that have reached the stage of phase 3 clinical trials have all failed to prevent infection. The idea of these nonperfect? vaccines would be to reduce the initial burst of viremia and the frequency of latently infected cells instead of preventing infection. The aim is to increase the time to progression and to reduce transmission of the virus, which is most likely to occur during high viral load in either early or late infection. The main thymus and bone marrow; other mucosal surfaces proteins are: p24 (capsid protein), gp120 and especially the gut-associated lymphoid tissue; gp41 (envelope proteins that are involved in viral other secondary lymphoid tissues including attachment and entry into cells), and the enzymes other lymph nodes; and the lungs and the brain. These include a variety of bacterial, this period there is so-called clinical latency, that viral, and fungal infections and tumors such as is asymptomatic, although the immune Kaposi?s sarcoma and nonHodgkin?s lymphomas. Late effects include changes to stromal cell detecting specific antibodies, antigens, or both. Infection of humans has arisen through transfer of True (T) or False (F) for each answer statement, or by simian immunodeficiency viruses into the human selecting the answer statements which best answer the population. Which of the following statements regarding the infection of human immunodeficiency virus? Lymphadenopathy results from increased proliferation nucleoside analog reverse transcriptase inhibitor is of B cells and cytotoxic T cells. Successful therapy results in restoration of immune result in a number of different assays. Case 18 Influenza virus A 59-year-old woman went to see her doctor, as she had she was febrile (38. She initially noticed a through her nose, but there were no other abnormal nonproductive cough, and then she became abruptly physical signs. Since A throat swab was taken, broken off into viral transport then she had developed muscle aches all over her body, medium, and sent to the laboratory. Immunofluorescent especially in the legs, and her eyes had become watery staining with a monoclonal antibody against influenza A and painful to move. She was a nonsmoker, previously fit virus was positive, confirming a diagnosis of acute and well, and on no regular medication. Causative agent Influenza A virus belongs to the Orthomyxoviridae virus family (myxo = affin ity for mucin). Influenza type A viruses are widespread in nature, infecting many avian species, but also humans, pigs, horses, and occasion ally other species such as cats. Influenza B virus is an exclusively human pathogen, while influenza C viruses are not serious pathogens in humans. Influenza type A viruses are further subdivided into subtypes depending on the nature of their two external glycoproteins. When referring to an influenza A virus isolate, it is therefore necessary to specify precisely which subtype it is, for example influenza A/H1N1 or influenza A/H7N7. Entry and spread within the body Influenza virus enters via the nasal or oral mucosa.

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