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2016-11-22T23-05-36Z
Source: International Journal of Research in Medical Sciences
Mahim Mittal, Ashutosh Kumar Mall, Yash Gopal Sharma.
Background: Vertical Transmission is still not an uncommon mode of HIV transmission. HIV and its treatment can also affect maternal and fetal outcomes. We aimed to study incidence and factors of MTCT and maternal and fetal outcomes with the current standard of care. Methods: It was an observational study, at BRD medical college Gorakhpur. Pregnant, HIV positive females consenting for the study were enrolled. Follow up was up to 6 months post-delivery. Infant testing for transmission was done at 6 months. Results: A total 35 HIV positive pregnant female were studied. Follow up could be completed in only 29 patients. Four (13.79%) infants had HIV DNA detectable in whole blood at 6 months. Transmission was 16.6% in group taking ART for 3 months, 25% in mixed feeding group vs. 12% in exclusive breast feeding and 16.6% in NVD group vs. 9% in LSCS. Incidence of Preterm delivery was higher in group who took ART for longer duration. IUGR was present in 10/29 (27%) and growth failure in 12/29 (41%) infants. Conclusions: Longer ART duration and cesarean section delivery were more effective in preventing MTCT. Even exclusive breast feeding could result in MTCT. HIV exposure in utero may lead to IUGR. ART has no deleterious or positive effect on fetal growth but may be associated with preterm delivery. Better patient education will probably lead to earlier diagnosis and initiation of therapy to prevent transmission, and also to better fetal and infant outcomes.
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2016-11-22T23-05-36Z
Source: International Journal of Research in Medical Sciences
Esakkiammal N., Renu Chauhan.
Background: The cervical vertebrae are smallest of all the vertebrae present in the vertebral column. It is characterized by a foramen in each transverse process. The foramen transversarium (FT) of 6th to 1st cervical vertebrae transmits vertebral vessels and sympathetic nerves. Presence of another foramen apart from FT in the transverse process of cervical vertebrae is called accessory FT. Anatomical knowledge of these variations are helpful for conducting cervical spinal surgeries by the surgeons in order to prevent injury to vertebral vessels and sympathetic nerves. Methods: The present study was conducted in the department of anatomy, UCMS and GTB Hospital, Delhi, India. A total number of 241 dried cervical vertebrae were collected from the bone bank of the Department of Anatomy. Presence of any variation from the normal anatomy of the cervical vertebrae were noted and photographed. Results: Out of 241 cervical vertebrae (typical and atypical), the accessory FT was noted in typical cervical vertebrae only. Accessory FT was seen in 37 (27.6%) vertebrae, out of 134 typical cervical vertebrae. These accessory FT were either bilateral complete in 4 (2.9%) or incomplete 9 (6.7%) or unilateral complete 6 (4.5%) and unilateral incomplete 12 (8.9%) were observed. Six (4.5%) typical cervical vertebrae showed presence of complete accessory FT on one side and incomplete accessory FT on the other side in the same vertebra. Conclusions: Knowledge of variations of the presence of accessory FT in the typical cervical vertebrae is not only important to anatomist but also to radiologist in identifying the presence of duplicate vertebral artery and hence helping the neuro surgeons in preventing accidental bleeding from the vertebral artery while performing surgery on the cervical spine.
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2016-11-22T23-05-36Z
Source: International Journal of Research in Medical Sciences
Aniruddha A. Malgaonkar, S. Kartikeyan.
Background: Street children are underprivileged urban children who suffer poverty, deprivation of education, vulnerability to various types of abuse, lack of supervision by adults, and with varying status of street-based existence and contact with their families. The study compares the socio-demographic and health profiles of children in a NGO-run Open House and street children. Methods: Respondents satisfying intake criteria were interviewed using a pre-tested questionnaire and their height and weight were measured and the data were statistically analysed. Results: 72% were aged between 12-16 years. Their occupations included rag picking, unorganised labour, street vending, cleaning vehicles, hotel work and begging. The reasons for street living were parental abuse, poverty, parental death, or peer pressure. Between the two groups of children, there were significant differences in frequencies of genital lesions (p=0.014; OR=0.465), injuries (p=0.01; OR=0.5), scabies (p=0.01; OR=0.31), and pyoderma (p=0.03; OR =0.38). A majority from both groups chewed tobacco regularly, some were addicted to more than one substance and had started using addictive substances due to peer pressure or to alleviate depression. Conclusions: Multi-pronged interventions ought to focus on improving income levels and housing of impoverished families, curbing parental abuse, and providing educational and health care facilities, establishing more number of drop-in Open Houses, providing avenues for legal income, and educating on the hazards of promiscuity and substance abuse.
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2016-11-22T23-05-36Z
Source: International Journal of Research in Medical Sciences
Smiti Sripathi, Anurag Ayachit, Rebin Bos.
Background: Patients with high division of the median nerve proximal to carpal tunnel, or bifid median nerve, may present with carpal tunnel syndrome (CTS). Ultrasound (US) measurements indicative of CTS in this subset of patients differ from those in patients with non-bifid median nerve. The objectives were to evaluate the parameter ∆CSA [difference between the maximum cross-sectional area of bifid median nerve within carpal tunnel (CSAc) and outside tunnel (CSAp)] in the diagnosis of CTS, to compare sensitivity and specificity of ∆CSA with nerve conduction velocity studies (NCS), and to compare the cross-sectional area (CSAc, CSAp & ∆CSA) of bifid median nerve in CTS patients with that in asymptomatic controls. Methods: 20 wrists with bifid median nerves and symptoms suggestive of CTS were included in the study group. Nerve conduction velocity studies (NCS) were performed in all cases. 4 wrists of asymptomatic age-matched subjects had bifid median nerves and normal NCS and were included in the control group. High resolution ultrasonography was performed for all wrists and findings documented. Statistical Analysis: Receiver Operating Characteristics curves were used to obtain the level of significance (p-value) and assessment of correlation between ∆CSA and NCS findings. Results: There was significant correlation between ∆CSA and NCS. A cut-off value of 2.3mm2 gave the best calculated sensitivity (76.9 %) and specificity (100%). Conclusions: CSA criteria for diagnosing CTS in patients with bifid median nerves are different from those in patients with non-bifid median nerve. ∆CSA is a sensitive and specific parameter for confirming the diagnosis of CTS in patients with bifid median nerve with sensitivity approaching that of NCS.
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2016-11-22T23-05-36Z
Source: International Journal of Research in Medical Sciences
Abhinay Indrakumar, Ganesh S. Mandakulutur, Keerthi R. Banavara.
Background: It is estimated that 990000 new gastric cancer (GC) cases occur in the world annually. The aim of this study was to examine the accuracy of laparoscopy in staging patients with gastric cancer in comparison with preoperative computed tomography (CT) examination and to determine the influence of staging laparoscopy on treatment decisions in gastric cancers. Methods: This was a prospective study conducted in a tertiary care hospital between August 2014 and February 2016. Thirty patients out of a series of 60 patients with gastric adenocarcinoma underwent a preoperative staging CT followed by a staging laparoscopy. The strengths of the agreement between the CT stage, the laparoscopic stage, and the final histopathological stage were determined by the weighted Kappa statistic (Kw). The number of patients with treatment decision-changes was counted. Results: The strengths of agreement between the CT stage and the final histopathological stage were Kw- 0.314 (95% confidence interval [CI]; 0.03-0.66; P≥0.0001) for T stage and 0.00 (95% CI; 0.0-0.00) for M stage, compared with 0.668 (95% CI; 0.39-0.98; P≥0.0001) and 1.00 (95% CI; 1.0-1.0; P≥0.0001) for the laparoscopic T and M stages, respectively. Unsuspected metastases that were not detected by CT, were found in 12 patients at laparoscopy, all of whom had T3 or T4 locally advanced tumors evident on CT. Conclusions: Preoperative laparoscopic staging of gastric cancer is indicated for potential surgical candidates with locally advanced disease in the absence of metastases on CT and influences treatment decision making apart from preventing unnecessary laparotomies.
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The stresses of starting a new job can make anyone feel tired and inefficient. In health care, this may impair the ability to learn at a time when there is most to learn, and increase the risk of error in a context where errors may lead to patient harm.
The aim of this study was to understand issues which influence anesthesia trainees' transition to a pediatric setting.
This qualitative study utilized in-depth semi-structured interviews to gather data from 31 anesthesia trainees who had commenced work at a tertiary children's hospital between 4 and 6 weeks previously. Data were examined using thematic analysis.
Two key themes were identified: feeling ineffective, which appeared to have both a cognitive component (feeling disoriented) and an emotional component (feeling useless), and feeling anxious or afraid. Trainees found the pediatric environment highly unfamiliar, which made them feel disoriented, inefficient, and at times incompetent. Many experienced difficulty identifying a useful role in a highly specialized area of practice, leading to loss of identity as an expert clinician. Many described an ever-present fear of making an anesthetic error or being unable to manage a rapidly evolving clinical situation. Some trainees developed a negative mindset, which was reinforced by subsequent perceived failures. Overall, these experiences impeded trainees' ability to concentrate and learn.
The impact of disorientation and anxiety on anesthesia trainees as they adapt to a highly specialized clinical environment such as a children's hospital should not be underestimated. Study findings illustrate the importance of helping new trainees to feel less afraid, more useful, and more realistic in assessing their own performance during the transition period.
Posterior spinal fusion to correct idiopathic scoliosis is associated with severe postoperative pain. Intrathecal morphine is commonly used for analgesia after adolescent posterior spinal fusion; however, anticipating and managing the increase in pain scores after resolution of analgesic effect of intrathecal morphine analgesia is challenging. In 2014, we developed a clinical protocol detailing both the administration of intrathecal morphine intraoperatively and the transition to routine, scheduled oral analgesics at 18 h postoperatively. The goal of our study was to examine the efficacy of our intrathecal morphine protocol vs epidural hydromorphone for postoperative analgesia after posterior spinal fusion.
Following IRB approval, we retrospectively identified developmentally intact children of ages 10–20 years in our electronic database with a diagnosis of idiopathic scoliosis who had undergone elective posterior spinal fusion surgery from June 2014 to April 2015. For the intrathecal morphine group, intrathecal morphine was administered in a dose of 12 μg·kg−1 (max 1000 μg) prior to incision. Postoperatively, all children in the intrathecal morphine group had an order to receive oral oxycodone (0.1 mg·kg−1, max 5 mg) starting at 18 h postintrathecal morphine injection. For the epidural hydromorphone group, catheters were placed by the surgeon and bolused with 5 μg·kg−1 hydromorphone (max 200 μg) and 1 μg·kg−1 fentanyl (max 50 μg), followed by a continuous infusion of 40–60 μg·h−1, and patient-controlled bolus doses of 5 μg with a lockout interval of 30 min. All patients in both groups had postoperative orders for acetaminophen, diazepam, and ketorolac.
During the study time period, 20 patients received intrathecal morphine and were successfully matched with 20 patients who received epidural hydromorphone. All patients in the intrathecal morphine group were transitioned to oral analgesics on the first postoperative day, without need for intravenous opioids after discharge from the postanesthesia care unit. Compared to the epidural hydromorphone group, the intrathecal morphine group reported lower pain scores in the postanesthesia care unit (difference in means −4.26 [95% CI −6.56, −1.96], P = 0.001) and first 8 h after surgery (difference in means −1.88 [95% CI −3.84, 0.082, P = 0.060) and higher pain scores on the 2nd postoperative day (difference in means 1.60 [95% CI 0.10, 3.10], P = 0.037). The documented time to ambulation and time of Foley catheter removal were statistically earlier in the intrathecal morphine group, and the hospital length of stay was significantly shorter (3.0 ± 0.5 days vs 3.5 ± 0.7 days; P = 0.03). Adverse events did not significantly differ between the groups.
The efficacy of intraoperative intrathecal morphine for postoperative analgesia in the posterior spinal fusion patient population has been shown previously; however, the pain and analgesic trajectory, including transition to other analgesics, has not previously been studied. Our findings suggest that for many patients, use of intrathecal morphine in addition to routine administration of nonopioid medications facilitates direct transition to oral analgesics in the early postoperative period and earlier routine ambulation and discharge of posterior spinal fusion patients.
Rhythmic oscillation in neurons can be characterized by various attributes, such as the oscillation period and duty cycle. The values of these features depend on the amplitudes of the participating ionic currents, which can be characterized by their maximum conductance values. Recent experimental and theoretical work has shown that the values of these attributes can be maintained constant for different combinations of two or more ionic currents of varying conductances, defining what is known as level sets in conductance space. In two-dimensional conductance spaces, a level set is a curve, often a line, along which a particular oscillation attribute value is conserved. In this work, we use modeling, dynamical systems tools (phase-space analysis), and numerical simulations to investigate the possible dynamic mechanisms responsible for the generation of period and duty-cycle levels sets in simplified (linearized and FitzHugh-Nagumo) and conductance-based (Morris-Lecar) models of neuronal oscillations. A simplistic hypothesis would be that the tonic balance between ionic currents with the same or opposite effective signs is sufficient to create level sets. According to this hypothesis, the dynamics of each ionic current during a given cycle are well captured by some constant quantity (e.g., maximal conductances), and the phase-plane diagrams are identical or are almost identical (e.g., cubic-like nullclines with the same maxima and minima) for different combinations of these maximal conductances. In contrast, we show that these mechanisms are dynamic and involve the complex interaction between the nonlinear voltage dependencies and the effective time scales at which the ionic current's dynamical variables operate.
The present study examines the extent to which distractors that signal the availability of monetary reward on a given trial affect eye movements. We used a novel eye movement task in which observers had to follow a target around the screen while ignoring distractors presented at varying locations. We examined the effects of reward magnitude and distractor location on a host of oculomotor properties, including saccade latency, amplitude, landing position, curvature, and erroneous saccades toward the distractor. We found consistent effects of reward magnitude on classic oculomotor phenomena such as the remote distractor effect, the global effect, and oculomotor capture by the distractor. We also show that a distractor in the visual hemifield opposite to the target had a larger effect on oculomotor control than an equidistant distractor in the same hemifield as the target. Bayesian hierarchical drift diffusion modeling revealed large differences in drift rate depending on the reward value, location, and visual hemifield of the distractor stimulus. Our findings suggest that high reward distractors not only capture the eyes but also affect a multitude of oculomotor properties associated with oculomotor inhibition and control.
To examine the effects of caffeine ingestion on physiological and perceptual responses in mentally fatigued individuals.
Eight male physically active subjects completed four cycling constant-workload tests in four experimental conditions at 80 % of maximal power output: control (C), mental fatigue (MF), mental fatigue plus caffeine ingestion (5 mg/kg) (MF-CAF), and mental fatigue plus placebo (MF-PLA). The mental fatigue was induced by a continuous performance task A-X version (AX-CPT). Before and after the AX-CPT, the profile of mood state (POMS) and blood samples for lactate measurement were collected. Oxygen consumption ( \( \dot{V}{\text{O}}_{2} \) ), rating of perceived exertion (RPE), and electromyography (EMG) activity were measured during the cycling test.
The time to exhaustion in C, MF, MF-PLA, and MF-CAF were 251 ± 30, 222 ± 23, 248 ± 28, and 285 ± 42 s, respectively. Delta values (corrected by C condition) were higher in MF-CAF than MF (P = 0.031). MF-CAF reported higher Vigor scores when compared with C (P = 0.046) and MF (P = 0.020). RPE at the first minute was significantly higher in MF-PLA than in C (P = 0.050); at the second minute, RPE was higher in MF-PLA than in C (P = 0.049) and MF-CAF (P = 0.048). EMG activity was not different between the conditions.
Caffeine ingestion increased approximately 14 % endurance performance after the induction of mental fatigue. This effect was accompanied by a tendency to improvement in mood state (i.e., vigor). Therefore, caffeine ingestion can promote a beneficial effect on endurance performance in mentally fatigued individuals.
The NF-κB signaling pathway regulates multiple cellular processes following exercise stress. This study aims to examine the effects of an acute lower-body resistance exercise protocol and subsequent recovery on intramuscular NF-κB signaling.
Twenty-eight untrained males were assigned to either a control (CON; n = 11) or exercise group (EX; n = 17) and completed a lower-body resistance exercise protocol consisting of the back squat, leg press, and leg extension exercises. Skeletal muscle microbiopsies were obtained from the vastus lateralis pre-exercise (PRE), 1-hour (1H), 5-hours (5H), and 48-hours (48H) post-resistance exercise. Multiplex signaling assay kits (EMD Millipore, Billerica, MA, USA) were used to quantify the total protein (TNFR1, c-Myc) or phosphorylation status of proteins belonging to the NF-κB signaling pathway (IKKa/b, IkBα, NF-κB) using multiplex protein assay. Repeated measures ANOVA analysis was used to determine the effects of the exercise bout on intramuscular signaling at each time point. Additionally, change scores were analyzed by magnitude based inferences to determine a mechanistic interpretation.
Repeated measures ANOVA indicated a trend for a two-way interaction between the EX and CON Group (p = 0.064) for c-Myc post resistance exercise. Magnitude based inference analysis suggest a "Very Likely" increase in total c-Myc from PRE-5H and a "Likely" increase in IkBα phosphorylation from PRE-5H post-resistance exercise.
Results indicated that c-Myc transcription factor is elevated following acute intense resistance exercise in untrained males. Future studies should examine the role that post-resistance exercise NF-κβ signaling plays in c-Myc induction, ribosome biogenesis and skeletal muscle regeneration.
The bilateral deficit phenomenon, characterized by a reduction in the amount of force from a single limb during maximal bilateral actions, has been shown in various movement tasks, contraction types and different populations. However, bilateral deficit appears to be an inconsistent phenomenon, with high variability in magnitude and existence, and seems to be plastic, as bilateral facilitation has also been shown to occur. Furthermore, many mechanisms underlying this phenomenon have been proposed over the years, but still remain largely unknown. The purpose of this review was to clarify and critically discuss some of the important issues relevant to bilateral deficit. The main findings of this review were: (1) bilateral deficit does not seem to be contraction-type dependent; however, it is more consistent in dynamic compared to isometric contractions; (2) postural stabilization requirements and/or ability to use counterbalances during unilateral actions seem to influence the expression of bilateral deficit to a great extent; strong evidence has been provided for higher-order neural inhibition as a possible mechanism, but requires further exploration using a lower limb model; biomechanical mechanisms, such as differences in shortening velocity between contraction modes and displacement of the force–velocity curve, seem to underlie bilateral deficit in ballistic and explosive contractions; (3) task familiarity has a large influence on bilateral deficit and thus adequate testing specificity is warranted in training/cross-sectional experiments; (4) the literature investigating the relationship between bilateral deficit and athletic performance and injury remains scarce; hence, further research in this area is required.
Spinal manipulative therapy (SMT) has been attributed with substantial non-specific effects. Accurate assessment of the non-specific effects of SMT relies on high-quality studies with low risk of bias that compare to appropriate placebos.
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By EMS1 Staff
TECH, Mich. — During a family mountain biking trip, an EMT had one of the most difficult calls unfold right in front of him.
Mario Calabria was biking with his family when his father fell off his bike, hit a tree and was knocked unconscious, reported Up Matters.
Calabria began to perform CPR after he was unable to find a pulse. He told his brother's girlfriend to call 911 and gave her a map so she could show their location to first responders.
Although Calabria managed to get a pulse, his father stopped breathing a second time. Soon after, EMTs and police officers arrived on scene and used an AED. Calabria's father was also intubated to avoid swelling in his airway. After five shocks, first responders were able to get a pulse.
"At first, it was just me versus a massive heart attack," Calabria said. "Then I was surrounded with people who knew what they were doing … it was a team effort."
Calabria's father was loaded into an ambulance and later airlifted to a medical center. He was put into an induced coma; he was released from the hospital six days later.
Mario Calabria was biking with his family when his father fell off his bike, hit a tree and was knocked unconscious.
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Old timers may remember the heroin epidemic of the mid 1980s, the crack epidemic of the early 1990s and the rise of meth labs around 2000. More recently, synthetic drugs such as MDMA, bath salts and spice have received media coverage as ways for humans to drive themselves crazy.
But the current opioid crisis has really gotten everyone's attention. The depth and breadth of patients impacted by narcotic overdoses has been incredible. According to the U.S. Department of Health and Human Services, 78 Americans die each day from opioid-related overdoses. The effect is widespread, with the greatest numbers of deaths occurring in diverse states such as Massachusetts, Pennsylvania, Oklahoma and Colorado.
The supply of opioids on the black market has never been more plentiful. More than 650,000 opioid prescriptions are dispensed daily. Small "stamp bags" of heroin can cost as little as $10. Access to opioids is easy and recovery is difficult, because narcotic addiction has physiologic and psychological roots.
What is especially dangerous now to both users and first responders is the use of fillers that drug makers cut into or batch with heroin to increase sales. Everything from corn starch to rat poison has been used. Yet EMS and other public safety providers stand the risk of becoming ill when contacting substances such as carfentanil, which can be absorbed readily through air and skin contact. Carfentanil, which is intended for large animal sedation, is 10,000 times more potent than morphine and 100 times stronger than fentanyl, one microgram of carfentanil is enough to cause significant effects on humans and one milligram is enough to be lethal.
In September 2016, the U.S. Drug Enforcement Agency issued a critical statement to the public and law enforcement personnel warning of potentially disastrous effects after casual or unintended contact with carfentanil. There have been instances where police officers, firefighters and EMS personnel have been affected while operating at a scene where the drug was present.
Safety tips for EMS
Remember and follow these tips when operating on a scene where carfentanil, fentanyl and other such substances may be present:
1. Be aware of your surroundings
This may be obvious while on the scene of an overdose patient; in other situations, not so much. Unusual odors like vinegar may be present. Interior doors with padlocks and other security measures may be a sign of clandestine activity.
2. Think hazmat
If more than one person is experiencing signs and symptoms of an opioid overdose, it might be intentional. Or it might be an inadvertent exposure. Similar to a carbon monoxide situation, evacuate everyone out of a scene immediately. If powder is present on clothing, you may need a hazmat specialist to decontaminate the patient in order to avoid aerosolizing the product. NIOSH categorizes fentanyl as an incapacitating agent and describes the necessary PPE to prevent exposure.
3. Act as if you were operating within a crime scene
That means not disturbing or touching anything other than the patient. Do not stay within the scene any longer than you have to. Prevent others from entering the scene unless absolutely necessary.
4. If you or another responder begins to feel ill, STOP and seek care immediately
Carfentanil and fentanyl require large doses of naloxone as a reversal agent. There may not be enough naloxone on scene to administer to more than one patient, necessitating a multi-unit response or transport to an emergency department.
5. Scene safety is paramount for EMS providers
Knowing the potential lethality of these powerful drugs will help keep you safe form their effects the next time you're at work.
The management of pain after burn injuries is a clinical challenge magnified in patients with significant comorbidities. Presently, burn pain is treated via a wide variety of modalities, including systemic pharmacotherapy and regional analgesia. Although the latter can provide effective pain control in patients with burn injuries, it is relatively underused. Furthermore, the development of ultrasound guidance has allowed for novel approaches and sparing of motor nerve blockade with preference toward sensory-specific analgesia that has not been possible previously.
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Abdominal Imaging
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CNS Drugs
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Journal of Computer Assisted Tomography
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International Journal of Cancer
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Annals of Surgery
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Journal of Viral Hepatitis
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International Journal of Obesity
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World Journal of Emergency Surgery
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