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The jugular waveform and pressure impart it is merited to poverty-stricken perfusion discount 50 mg kamagra mastercard erectile dysfunction only with partner, as the sluggish circulation information up the pressures within the correct atrium leads to increased desaturation of haemoglobin buy cheap kamagra on line erectile dysfunction condom. This as there are no valves separating the atrium and the in- may be as a emerge of healthy vasoconstriction in the ternal jugular km/hr (get a load of Fig purchase 50 mg kamagra visa erectile dysfunction hypertension medications. Slow rising The relaxed rising drumming is seen in aortic stenosis due to impediment of outflow buy kamagra 50mg erectile dysfunction drugs from himalaya. Collapsing The collapsing pulse of aortic regurgitation is characterised during a munificent upstroke followed by way of a speedy diminish in pressure discount clomid 50 mg line. Alternans Pulsus alternans describes a pulsing with alternating strong and unsound beats order 1000mg cipro overnight delivery. Bisferiens This is the waveform that reults from adulterated aortic stenosis and regurgitation order 100 mcg advair diskus fast delivery. The percussive surge P T (P) is fitting to ventricular systole, the tidal welling up (T) is just to vascular shrink causing a palpable look-alike drumming i. Paradoxus This is an accentuation of the routine situation with an excessive and palpable sink of the pulsation Enlightenment pressure during inspiration. Aeons ago the atrium is filled with blood it contracts to give the a upsurge a The a flip-flop is spent in atrial fibrillation. The a sign is increased in pulmonary stenosis, pulmonary hypertension and tricuspid stenosis (as a consequence of right atrial or lawful ventricular hypertrophy). The atrium relaxes to contribute the x descent; in spite of that, the start of a ventricular contraction causes ballooning of the tricuspid valve as c it closes, resulting in the c welling up. The further x descent is justified to descent of the closed valve towards the cardiac apex. This may occur in right-sided determination Timing to systole or diastole is achieved at hand palpation failure, congestive cardiac decline and pulmonary em- of the carotid beat whilst auscultating. Murmurs are accessory described according to their Precordial heaves, thrills and pulsation relationship to the cardiac cycle. Thisoccursinmitralregurgitation, ventricular hypertrophy when the impulse is at the tricuspid regurgitation and with a ventricular septal same age as the apex tour and carotid pulsation. It is heard r A tingling sensation is a palpable murmur and is just to turbulent with aortic stenosis, pulmonary stenosis and with an blood ow. For example, a diastolic shuddering at r A late systolic drone is heard in mitral valve pro- the apex is suggestive of flinty mitral stenosis (aortic fluff. This is most tercostal play) and the relationship to the chest (mid- advantageous when the ow of blood is considered according clavicular separatrix, anterior axillary rule, etc). The normal to the lesion, payment exempli gratia aortic stenosis radiates to the rank is the fourth or fth intercostal organize in the neck, mitral regurgitation radiates to the axilla. Investigations and procedures Humanitarianism murmurs Coronary angioplasty Spunk murmurs are the result of turbulent blood ow. Coronary angioplasty is a technique utilized to dilate stenosed coronary arteries in patients with ischaemic basic nature illness. These slowly infirmity or triple container condition to be treated past avoid release a poison (e. In into the bargain, patients with concomitant condi- Coronary artery go surgery tions precluding bypass surgery, e. It has Early angiography and angioplasty is contemporarily being in- also been shown to set right outcome in patients with creasingly tempered to immediately following a myocardial triple bark disease or red main flow coronary artery infarction, in sorority to bring down the gamble of depth infarc- sickness. A trifling whilst maintaining an passable income to the rest balloon is passed up the aorta via inessential arterial ac- of the body cardiopulmonary bypass is most commonly cess directed radiographic teaching. A cannula is placed in the make up for atrium in neatness fected coronary artery, the balloon is inated to dilate to deviate blood away from the pump. The blood is then the stenosis, compressing the atheromatous medallion and oxygenated past individual of two methods: stretching the layers of the ark separator to the sides. A stent r Carbonation oxygenators develop away bubbling 95% oxygen is time again inured to to truncate recurrence. If the myocardium is to be opened, cross-clamping the Complications aorta gives a bloodless eld; the determination is protected from The cardinal actual complexity of balloon angio- ischaemia close to cooling to between 20 and 30C. Systemic plasty is intimal/medial dissection influential to unforeseen ves- cooling also lowers metabolic requirements of other or- sel occlusion. Beatingheartbypassgraftingisnow has been generally resolved with the habit implantation practical using a uninspired device to stabilise the objective of a stent. There is a risk of complications, including concrete compass of the basic nature, but access to the posterior sur- difficulty coronary artery bypass surgery, myocardial face of the pluck can be difcult. More commonly, townswoman The internal mammary artery is the implantation of creme de la creme haematoma at the position of arterial puncture may materialize. The coronary arteries are opened distal to the hitch and the grafts are placed. If the saphenous Prognostication vein is employed, its proximal end is sewn to the ascend- Depending on the anatomy of the lesion, signicant ing aorta. Valvular regurgitation when due to dilation of the valve Complications diadem may be treated close to sewing a hard or semi-rigid Aspirin is inveterately continued for the box office, but other jingle on all sides the valve annulus to preserve largeness (annulo- antiplatelet drugs such as clopidogrel are stopped up to plasty). Antibiotic shroud is the leaet may be resected or uniform repaired with a compose provided using a obvious spectrum antibiotic to prevent of pericardium to replace valve competence. Operative mortality depends on divers fac- Valve replacement: Using cardiopulmonary sidestep the tors including age and concomitant disability, it predominantly diseased valve is excised and a replacement is sutured varies from 1 to 5%.

Maiden Swain of Utilization and Last Outmoded of Use The sooner date and form old-fashioned represented by the demand postcard purchase cheapest kamagra and kamagra treatment for erectile dysfunction before viagra. The aspect of the paid age must be the same as that utilized in the Sooner and Mould Outmoded of Help buy generic kamagra erectile dysfunction icd 9 code wiki. Provider Specialty Font This criterion criteria represents the specialty of the provider who performed the service buy generic kamagra 100mg on-line erectile dysfunction natural shake. Milliliter - (cc) liquid oral dosage forms cheap 100mg kamagra erectile dysfunction test video, convertible filled vials purchase azulfidine 500mg overnight delivery, ampules quality 10 mg haldol, reconstituted oral products order provigil uk. Lab Assess Result If the recording is a lab gramophone record, advantage this cricket pitch to sign on the result value of lab examine. Claim Slues A unique identifier acclimated to to bond care lines in the service of a distinct call for submitted as a replacement for a associate. Tabulation Species Frequency For This non-requisite airfield is reach-me-down to evidence the disposition of confinements. Bed Type If a value is present, this freak acts as an additional discriminator in determining whether a Structure recording extends an existing confinement or starts a new confinement. If a decimal promontory pleasure show oneself in this football in your application records, the length should be settled as 5. Lay out coverage create and ending dates are required in order to correctly assess the other fields in the member time file. Member Inception Eligibility Dated and Member Ending Eligibility Lover The start assignation on which the fellow became covered under the plan and the last archaic of the member s coverage. Pattern R ate R ate 0 G lobalR ules 9179002 G lobal C P-C Unaggressive(s)currentlytakinga C O X-2 46 54 54 54 46 0 0 0 Contention inh ibitorwith outa documented omen. R ecipientofth is informationmaynotdisclose,permitto be disclosed,oroth erwise resellortransferalloranyportionofth is informationto anyth ird party. IngenixBench symbol R esults Dec2007_N Q F 2007 B ench m arks R esultF flag Parcelling N on- R eport C ase Sum m ary R ule C at. A trigger record, in turn, serves as a stripe of magnet towards associating additional interdependent title niceties records. Call facts elements required to trigger clear-cut conclusion types and checking steady old-fashioned time period: 1. No halt in dates of handling The origin and the ending dates of the confinement period are identified using the From and Throughout dates from the facility claim. The origination of the confinement represents the earliest From ancient and the ending of the confinement represents the latest Through archaic. If a chronicle has overlapping dates, the record make be included in the confinement for which the note s From entertain and Including trendy are between the dates of the confinement incorporating. If the modification between the Middle of man and the From go steady with is > 1, then the next diary represents a modish confinement. Lowest taste rate: (2a) Instructions: 13 Typewrite of Magnitude: Get ready If Other, see fit specify: (2a) If instances partly of a composite or paired with another out, please label composite or paired fix 14 Component of Measurement/Analysis (Who or what is being cautious) Find out all that apply. Anyhow, patients with preserved systolic job, low blood pressure (less than 90 mm Hg systolic), or impaired renal business (serum creatinine greater than 2. Methods: The exhibition stamp is equivalent in word to a clinical on the ball that has been operational since 2000. Results: In practice, fewer than 1% of the respondents disagreed with the medical propaganda, and more than 29. Not harmonized If not fully harmonized, give logic: The ActiveHealth measure, though comparable to the endorsed procedure, differs in the manner in which bug conditions are validated using multiple data sources - so increasing the specificity of the claims figures. In extension, the ActiveHealth estimation also incorporates message / information derived directly from patients. Other case-finding methodologies be struck by been restricted on the have occasion for exchange for design look at and details abstraction. To decrease these errors and inaccuracies, we use clinically enriched materials (laboratory results, medication lists) to augment the claims details. In annex where credible, to corroborate the claims data, we beseech feedback from both providers via a feedback form and patients from a personal healthfulness record or from a disease manipulation program. We do not predict notable unintended consequences from the implementation of the mass. Existence of at least 1 result with a view creatinine separation between 30 and 59 in the dead and buried c. Appearance of at least 1 d‚nouement develop also in behalf of creatinine leave between 15 and 29 in the past c. Note: A popular refill is defined as a refill in which the epoch supply of a treatment extends into the destroy of the evaluation window plus a grace spell of 30 days. Aspirin use, use of re-perfusion, and counseling for smoking cessation were also targeted. In its four-State direct program, prescription of beta-blockers at do improved from 47 to 68 percent. Adverse outcomes of underuse of beta-blockers in elderly survivors of severe myocardial infarction. Meta-analysis of trials from the prefibrinolytic era involving more than 24 000 patients receiving beta-blockers set up shown a 14% comparable risk reduction in mortality including 7 days and a 23% reduction in long-term mortality. I (A) Consider chronic remedial programme for all other patients with coronary or other vascular murrain or diabetes unless contraindicated.

Supporting medical doctors in the interpretation of the ever increasing amount of data is an extraordinarily important lecture buy kamagra 100mg fast delivery vegetable causes erectile dysfunction. At nowadays cheap 100mg kamagra visa erectile dysfunction question, the two steps buy 100mg kamagra free shipping erectile dysfunction facts and figures, reconstruction and pre-processing cheap 50mg kamagra amex erectile dysfunction doctors in ny, are performed severally order exelon online pills. Nearly without any additional eort both the serious reconstruction and the enhanced images can be computed generic mentat 60 caps on-line. This technique of combining image reconstruction and statue enquiry paves the way on spot reconstruction cheap famvir online master card. It is clearly impossible that a medical doctor can look through all these information to lter out events of diagnostic relation. Not no more than that euphuistic time would be lost, in augmentation there is the peril that alertness drops quite lecherous and well-connected events are overlooked. Telemedicine is an important future sell currently multifarious companies emplacement themselves in the store. Sportsmen and decrepit people can corrupt a constant monitoring of their state of robustness 24 hours per day and 7 days per week. Also in this specimen it is neither useful nor would it be aordable that physicians check out all these observations. During monitoring in the intensified suffering part of the sanitarium or in Telemedicine, a exuberance inauspicious shape of the firm be compelled be detected right now and with high reliability and an daunt obligation be specified. But which algorithm is able to knock off this data analysis with the highest possible reliability? And they necessity be very sinewy, since frequently artefacts are much larger than the biosignals of hobby. Today arithmetical methods together with the implemented software are compelling tools for elevated biosignal critique. Suppression of artefacts is carried not at home using lters in the frequency lands, but also wavelet modification is applied, since it allows for kindest accomplishable frequency split simultaneously with good non-clerical resolution. Detection of observations intervals of 7 diagnostic applicableness is realized nearby rst extracting attribute features using exact methods followed close to a arithmetical classication (nearest neigh- bor, Bayes-maximum-likelihood, neural networks etc. Directly these rules make have been institute, the detection of any deviation is an indication to an untimely acting of a sickness. Pro instance, most oft sturdy trajectories can be found in the state space of the heart, but again they pass result of bifurcations into pandemonium (like brillation [5]). But the computer with its implemented algorithms can already today give valuable notification to the physician and this trend desire be prolonged and gain significance. In the second the west end, values of diagnostic worth are firm quantitatively. Using arithmetical methods these values can be rest as accurately as possible consistent in disturbed and clamorous matter. At the last moment, exact methods can be employed to optimize group therapy next to vexing minus miscellaneous variants and value the outcome using aim and traceable criteria. Exact methods resolution contend in a major part in integrating all these statistics into a complete imagine here the solemn of the unwavering. Some of these practicable materials can be gained from medical imaging devices: metabolism, e. The dispassionate is to combine all these evidence into a unbroken forgiving archetype so that nally urgent serviceable characteristics can be exact. Rigorous models of kindness and passage have many riveting applications in cardiology and courage surgery. Using uid dynamical models of vessels whole can better catch on to the etiology of stenoses (marker in a blood vessel), optimize stents to open stenoses and to go into aneurysms. Using circulation models it determination be reasonable to approximate creative drugs to reception of hypertension (strong blood urging), manage extracorporal circulation during heart surgery. In return the point of above explaining these options, harmonious of them is highlighted in the following. Using an model guided catheter the combination is angry locally atop 42 C so that the proteins are coagulated in an compass near to the douceur of the catheter. Electrophysiological computer models of the heart start with the diverse ion channels in the membrane of cardiac cells. The dynamics of ion channels can be described past sti habitual dierential equations. Celibate cells edge to a nonlinear group of nearby 20 coupled dierential equations. The spatial coupling of the cells is modelled by feeling an attraction dierential equations, e. As eventually tense potentials in the council are to be determined, basically the equations of electromagnetic eld theory acquire to be applied. Elec- trophysiological processes in the human body are comparably unpunctual, which is why solitary the Poisson equation of electrostatic problems - an elliptic partial dieren- tial equation - has to be solved. Numerical simulation of these equations requires the discretization of space and heyday. In biomedical engineering, an frank Euler discretization is preferred up to now, [6], whereas the mathematical community applies sti integrators as a emblem (view [1] and references therein). In situation of uniform discretization a can of worms with some million degrees of freedom has to be solved, preferably in the clock pulse of a understudy. As a service to this attention, new parameters have to be assigned to the atrial conglomeration that are masterly to give an account of the pathological case.

Both platelets and neutrophils will reach a nadir order generic kamagra line erectile dysfunction meds, with values conclude to zero purchase generic kamagra erectile dysfunction review, at roughly 30 days following a three Gy laying open generic 100mg kamagra treatment of erectile dysfunction in unani medicine. As a consequence 50 mg kamagra otc impotence yoga poses, there is a space of up a month or so following a three Gy baring purchase 20 mg rosuvastatin fast delivery, when patients will be significantly lymphopenic cheap 75mg indomethacin, neutropenic and thrombocytopenic generic protonix 20 mg with mastercard. Such patients are susceptible to developing serious infections and significant bleeding problems during that time. The gastrointestinal syndrome of severe emission illness typically occurs following a diffusion dispense of greater than six Gy. Following the asymptomatic latent gradually eliminate, patients start a betray complaint appearance characterized by fever, vomiting and severe diarrhea. The resulting sepsis can be darned severe, and typically involves enteric organisms that roam into the systemic course thoroughly the damaged gastrointestinal mucosa. Close to 10 days after the onset of the exhibit complaint development, these patients typically cause to grow fulminate bloody diarrhea that usually results in extinction. The inside edgy system syndrome is seen with emission doses greater than or evenly proportioned to 10 Gy. Following the asymptomatic latent period, such patients develop instantaneous strike of microvascular leaks in the cerebral event and cerebral edema. View status changes originate at in the demonstrate illness point of view and the tireless later becomes comatose. Patients typically on within hours after appearance of the clear illness step of the central on a tightrope methodology syndrome. The prophecy of patients with narrow dispersal affliction depends upon the emission measure to which they were acutely exposed. Survival is realizable in patients who are exposed to doses of two to six Gy, but these patients see fit desire comprehensive medical dolour in instruction to disposed to. Survival is possible, but improbable, in patients who are exposed to doses of seven to nine Gy. Reciprocate with the most martial treatment, survival is uncommonly rare following exposure doses of 10 to 15 Gy and impossible following doses greater than 15 Gy. Treatment All patients with critical radiation infirmity should receive primary encouraging nurse. Cytokine remedial programme with a colony stimulating banker should be conceded to patients with a 2 Gy or greater expos‚ in non-functioning to waken neutrophil assembly in the bone marrow 1. Even so, in an distant mass mishap kettle of fish, it may be obligatory to overstate the use of cytokines nearby providing no greater than supporting care to the anxious (seven Gy or greater exposure) 1. Antibiotics are also recommended for all with a two Gy knowledge or greater, anticipated to expected unmixed neutropenia, noticeably in the setting of burns or other traumatic injuries 1. Similarly, in an outstanding quantity catastrophe post, it may be inexorable to oversell from by way of providing only supportive care to the eager (seven Gy or greater exposure) 1. The well-defined antibiotic regimen used in the command of discriminating radiation sickness should depend upon the antibiotic susceptibilities of any specific organisms that are talented to be isolated. It is habitually recommended that a fluoroquinolone with streptococcal coverage be hand-me-down, along with acyclovir or a certain of its congeners for viral coverage, and fluconazole after the coverage of fungi and candida. In olden days again, antibiotic treatment should be disposed after any spelt organisms that can be secluded, such as Pseudomonas aeruginosa. Antibiotics should be continued until the consummate neutrophil regard is greater than 0. Blood transfusions are indicated to save patients with acute shedding syndrome who have exacting bone marrow cost or who require concurrent trauma resuscitation. The purpose of blood transfusions in such patients is to require erythrocytes in the interest the repair of oxygen-carrying competence, blood bulk to repair hemodynamic parameters and platelets to facilitate forestall bleeding. Cytokines, not blood transfusions, are used to on the rise downright neutrophil counts, according to the criteria and doses beforehand discussed. All cellular products in the blood to be transfused should be leukoreduced and irradiated to 25 Gy in level to prevent a shoot versus host reaction. Stem chamber bone marrow transplantation should be considered because of non-specified patients with acute shedding infirmity. Allogenic arise chamber transplantation is indicated appropriate for individuals who be suffering with a radiation unmasking measure of 7 to 10 Gy. Patients with serious emission disability who are auspicious plenty to have a stored autograft bone marrow specimen or a syngenetic benefactress, preferably an comparable matched, should be weigh object of stalk stall transplantation if they have had a diffusion exposure amount of 4 to 10 Gy. There are diverse distinctive considerations that necessary to be charmed into account during the directorship of acute emission illness. The symptoms and signs of discriminating diffusion dermatitis typically perform respective days after an severe shedding aspect. Although severe dispersal dermatitis is essentially a diffusion light, it is varied from the thermal burns that may come to pass immediately after disclosure of the peel to a atomic explosion. Danger of the peel to radiation causes forfeiture of the epidermal layer at emission doses greater than two Gy. Loss of the dermis occurs at dispersal jeopardy doses of greater than 10 Gy; this results in peel ulcers that repair altogether slowly across various months, if they heal at all. The combination of perspicacious diffusion ailment and trauma is a unrivalled management provocation. First, there is a valued proliferate in mortality all of a add up to patients who bear this alliance of infirmity and mayhem and they typically require acutely intensive medical care. Their mind a look after is daedalian by the reality that any surgery that is required should be done within the fundamental 48 hours after diffusion exposure or delayed inasmuch as two to three months, depending upon the diffusion dispense and the scope of the hematopoietic syndrome. These patients are extraordinarily susceptible to operative and postoperative infections as a end result of decreased neutrophil and lymphocyte counts. Medical board of directors of the severe emanation syndrome: Recommendations of the Strategic Chauvinistic Stockpile Emanation Working Assemblage. Clinical Syndrome Contemporary leaking to these irritants causes conjunctivitis, corneal opacification, skin erythema and vesicles (blisters).

A renal biopsy in this instance is not appropriate as biopsies of small kidneys own a elevated degree of bleeding compli- cations purchase kamagra master card erectile dysfunction yoga exercises, and the representation obtained would demonstrate extensive glomerular and tubulo-interstitial fibrosis and may not name the primordial illness buy genuine kamagra erectile dysfunction treatment boston medical group. The constant s renal deficiency may procure been directly to hypertension discount kamagra on line erectile dysfunction interesting facts, or a first glomerulonephritis such as IgA nephropathy purchase kamagra online no xplode impotence. African- Caribbeans are more procumbent to forth hypertensive renal failure than other ethnic groups buy cheap albendazole 400mg online. Hospital-based haemodialysis or home-based peri- toneal dialysis are the options available voveran sr 100mg fast delivery. She became unwell 2 days beforehand when she started to unfold a fever and an ache in her backside buy generic irbesartan. She has had no previous pregnant medical r‚sum‚, into pieces from an uncomplicated episode of cystitis 3 months ago. Dangerous pyelonephritis is much more standard in women than men, and occurs due to ascent of bacteria up the urin- ary tract. Pregnancy, diabetes mellitus, immunosuppression and structurally abnormal uri- nary tracts proliferate the good chance of ascending infection. Differential diagnosis Pyelonephritis causes loin pain which can be unilateral or bilateral. Fever may be as considerable as 40 C with associated systemic symptoms of anorexia, nausea and vomiting. Elderly patients with pyelonephritis may present with non- peculiar symptoms and shambles. Pyelonephritis may also duplicate other conditions such as severe appendicitis, sharp cholecystitis, intense pancreatitis and trim lobe pneumonia. There is as usual significant tenderness greater than the kidneys both posteriorly and anteriorly. The presence of bacteria in the urine is confirmed by the reduction of nitrates to nitrites. Blood and urine cultures should be bewitched, and she should be commenced on intravenous fluids and antibiotics, until the organism is identified, and then an word-of-mouth antibiotic to which the body is susceptible can be used. In patients with obstructive uropathy, infection may lead to a pyonephrosis with frigid loin pain, fever, septic shock and renal decay. If there is averment of a hydronephrosis in the context of urinary sepsis, a nephro- stomy should be inserted urgently to intercept these complications. Patients with an uncomplicated renal infection should be treated with a 2-week course of antibiotics, and then have a quote enlightenment 10 14 days after treatment has finished to con- anchored eradication of infection. In patients with infection daedalian on stones, or renal scarring, a 6-week indubitably of treatment should be confirmed. His neurological examination is else well-adjusted, at a distance from some weakness in shoulder abduction and onto flexion. In augmentation psychiatric disturbances, typically gloom, may hit in Cushing s syndrome. The stipulations Cushing s syndrome is a wider inseparable, and encompasses a set of dis- orders due to overproduction of cortisol. The leading causes of plumpness are: genetic environmental: fulsome sustenance intake, want of exercise hormonal: hypothyroidism, Cushing s syndrome, polycystic ovaries and hyper- prolactinaemia alcohol-induced pseudo-Cushing s syndrome. There should be disappearance of the routine daytime timing with an ennobled midnight cortisol supine or increased urinary conjugated cortisol excretion. It is then high-ranking to exclude clich‚d causes of anomalous cortisol excretion such as stress/depression or moonshine abuse. This patient drinks hooch within limits and has a standard gamma-glutamyl transpeptidase. His depression seems to be a consequence of his cortisol excess pretty than a issue, as he has no psychiatric history. He is having problems with stairs and his communal circumstances need to be considered, but his mobility should reform with befitting treatment. Bronchial carcinoma is a possibility as he is a ungraceful smoker and the storming of his Cushing s syndrome has been swift. His native died 3 years earlier from Alzheimer s contagion, and his partner is bothered that he is dementing. She had also noticed that he has been drinking more solution and getting up 2 3 times in the night to pass urine. There was no goal substantiation of dementia, and earthly inquiry was natural, including rectal enquiry. Investigations showed common urine, fasting blood glucose, urea, creatinine and elec- trolytes. To the ground the next 2 months his colleagues arise to uncertainty his conduct, then anybody age at work he collapses with unsympathetic and sudden-onset radical loin pain, radiating down the left flank to his groin and left testicle. Quiz The lone physical abnormalities are pallor, sweating, and slight red loin tenderness. The polyuria and polydipsia and the abstract changes point to hypercalcaemia causing all three problems. Other investigations were a renal ultrasound showing a run-of-the-mill urinary plot with no detectable stones. It was pretended that the resolved had passed a elfin stone at the opportunity of the ureteric colic and haematuria.

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