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An enlarged liver may originator torment and may be palpable unworthy of the costal lip in the straight upper quadrant purchase super levitra 80mg mastercard erectile dysfunction doctor in chennai. Aberrant hepatic arteries are also conceivable: the nobility hepatic part usually comes turned the tonier mesenteric purchase 80 mg super levitra with mastercard impotence due to alcohol, while the left branch day in and day out comes off of the leftist gastric artery discount super levitra 80mg mastercard erectile dysfunction under 35. The distal aimless of the hepatopancreatic ampulla and the infundibulum of the gallbladder are common sites on impaction of gallstones buy super levitra on line amex impotence of organic origin 60784. The blood then flows into the systemic group at places of portal-systemic anastomosis buy lipitor now, producing varicose veins buy domperidone from india. Caput medusae is caused at hand the veins of the anterior abdominal wall becoming dilated from portal hypertension cheap 400mg viagra plus mastercard. In nephroptosis, when a myself is standing, the ureter, which is of run-of-the-mill greatest extent (incompatible with in ectopic kidney), may mature coiled and/or kinked. A renal calculus (kidney stone) may contour and lodge in the calices of the kidneys, ureter (ureteric calculus), or urinary bladder. The calculi may obstruction the normal way of urine and cause disconnected woe referred to the lumbar and groin regions. Contraction of the psoas and iliacus (iliopsoas) causes pain from infirm viscera that lie against the posterior abdominal embankment. A psoas abscess may be produced end from tuberculosis in the lumbar sector, causing the spread of pus in every part of the precinct. Each anxiety supplies motor innervation to one hemidia- phragm; section of the dauntlessness results in unmitigated paralysis of the diaphragm ipsilateral to the lesion. Diagonal conjugate Medial representation Nobler gauge Sacral promontory Obstetric conjugate Pubic symphysis Cambered diameter Flat of least pelvic dimension Interspinous stretch, 10 cm Transverse diameter, 13. Android and anthropoid are most low-grade in males, android and gynecoid in drained females, and gynecoid and anthropoid in black females. Ischial barb Gynecoid Android Anthropoid Platypelloid © 2014 Lippincott Williams & Wilkins Pelvis and Perineum 3. This ease permits as much as a 10% to 15% proliferation in pelvic diameters (except the constant conjugate) and contributes to a lordotic posture. The pubococcygeus, the biggest section of the levator ani, is most commonly damaged, and the injury may margin to urinary incontinence. The obturator determination is defenceless to mayhem during surgery and may cause ordeal and sensory depletion in the adductor cell of the thigh. The collateral circulation in the pelvis allows exchange for ligation of the internal iliac artery to authority pelvic hemorrhage without completely interrupting the blood equip to pelvic structures. Obstacle of the ureters, such as from ureteric calculi, may genesis exertion and forbiddance of urinary flow. Obstacle most frequently occurs where the ureter is constricted: (1) at the connection of the ureter and the renal pelvis, (2) where the ureter crosses the pelvic lip, and (3) as it passes through the bladder close off. Injuries to the take down orientation of the anterior abdominal barrier may influence the distended bladder and superintend to the extravasation of urine. High- frequency electrical prevailing emitted toe the cysto- scope can be used to remove tumors from the bladder. The midget, distensible female urethra allows restful part of catheters and cystoscopes into the bladder; these characteris- tics also certify bladder infections more simple than in males. Sympathetic hypertrophy of the prostate is routine after middle age; it can restrain urination and escort to nocturia, dysuria, and pressure of urination. A culdoscope can be inserted Urethrovaginal fistula Vaginoperineal fistula into the vagina to scrutinize the ovaries or uterine tubes. A pelvic abscess in the rectouterine on can be drained before culdocentesis from top to bottom the vaginal fornix. An improve in intraabdominal force presses the uterus against the bladder; it may be in a less common position. Owing to the frequency of uterine and cervical cancer, hysterectomy, or excision of the uterus, is a somewhat normal system. Sympathetic trunk Lumbar splanchnic nerves Abdominal Spinal (rump completely) aortic ganglia T12 L2(3) plexus L3/L4 (A) Spinal close off via lumbar punching (anesthetizes from waist down intra- Pelvic splanchnic and subperitoneal nerves added somatic areas) First-rate and inferior hypogastric plexus Spinal (buttocks genealogy) ganglia, S2 S4 Uterovaginal plexus (intimate of Needle tip entering pelvic plexus) sacral canal Pelvic travail clue (B) Caudal Pudendal nerve epidural stump (anesthetizes sub- peritoneal extra somatic areas innervated by way of pudendal spirit) Key (C) Pudendal nerve obstruction Intraperitoneal viscera (anesthetizes Subperitoneal viscera tract innervated on Somatic structures pudendal irritate) © 2014 Lippincott Williams & Wilkins Pelvis and Perineum 3. Abdominal tubal ligation is done from stem to stern a supra- pubic gash, while laparoscopic tubal ligation is done with a laparoscope. The blastocyst may root in the mucosa of the uterine tube (usually the ampulla), resulting in an ectopic tubal pregnancy. During resection of the rectum in males, the plane of the rectovesical septum is followed to avoid invoice to the prostate and urethra. The median episiotomy incises the perineal body, while a mediolateral episiotomy avoids the perineal heart. Straddle injuries cause break-up of the spongy urethra and urine extravasa- tion in the bulb of the penis, allowing urine to become a member of the superficial perineal span. Internal hemorrhoids are prolapses of rectal mucosa contain- ing the dilated veins of the internal rectal venous plexus. The glands may be infected because of blockage of the duct or a pathogenic creature; they are the purlieus of origin of most vulvar adenocarcinomas. To raise pain during childbirth, pudendal tenacity block anesthesia may be performed around injecting an anesthetic representative into the tissues adjacent the daring. The duration is also second-hand to mark slaughter of all or portion of the vertebral consummate by way of transecting the pedicles. Vertebral committee Vertebral foramen (vertebral canal Pedicle in the articulated vertebral column) 2 Vertebral 1 clever Lamina Spinous system © 2014 Lippincott Williams & Wilkins Subsidize 4. Rupture of the transverse ligament of the axis sets the dens free, causing atlantoaxial subluxation, which may lead to spinal rope or brainstem compression. Separation of the dens is typically less fatal, as the transverse ligament holds the fractured dens in place.


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The nucleophilic numbered receptor subtypes can be conveniently dis- oxygen of the serine reacts with the carbonyl carbon of tinguished order 80mg super levitra with visa impotence male. The latter intermediate is expeditiously hydrolyzed to erol (which can galvanize protein kinase C) discount super levitra 80mg otc impotence over 40, and stimula- release acetic acid and regenerate the dynamic enzyme best order super levitra erectile dysfunction pills gnc. These receptors are generally the sound process takes less 150 microseconds purchase super levitra 80mg erectile dysfunction ultrasound protocol, one of responsible owing activating calcium-dependent responses 10 mg cialis free shipping, the fastest enzymatic reactions known buy generic nifedipine 20mg. The split of potassium channels hy- in the body purchase alli visa, the most distinguished being the cholinergic perpolarizes the membrane potential and decreases the neuroeffector junction. Rectangular district represents the active center of the brane impermeant because they employ the quaternary enzyme with its anionic and esteratic sites. It is a tertiary amine that crosses membranes rela- linkage is broken, choline is liberated, and an acetylated tively easily. Finally, the cornea of the vision, and it can crucifix the blood-brain bar- acetylated middle undergoes hydrolysis to outspoken the rier. Muscarine is an alkaloid with no therapeutical profit by, but it can put together risky cholinomimetic stimulation following inges- tion of some types of mushrooms. This manifest selection for nonspecific cholinesterase) has a widespread distribu- muscarinic receptors can be attributed to the greater ac- tion, with enzyme extraordinarily plentiful in the liver, cessibility and copiousness of these cholinoreceptors where it is synthesized, and in the plasma. It does, anyhow, Cardiovascular Effects be occupied in an urgent post in the metabolism of such clini- cally eminent compounds as succinylcholine, pro- Coarse doses of muscarinic agonists affirmed intravenously caine, and numerous other esters. In fact, precise lofty doses of a the denial vasculature is not innervated during choliner- muscarinic agonist can cast mortal bradycardia and gic neurons, and the physiological chore of the en- A-V impediment. No matter how, effects on ventricular province, but they can offer activation of these receptors sooner than directly acting choli- adversative inotropy of the atria. Contraction of the iris sphincter decreases the di- This confusing effect is produced when the diminish ameter of the learner (miosis). Contraction of the tortuous in blood load produced past stimulation of endothe- fibers of the ciliary muscle, which encircles the lens, re- lial muscarinic receptors, as described earlier, triggers duces the tension on the suspensory ligaments that nor- the activation of a restitutory sympathetic reflex mally tour of duty and flatten the lens, allowing the extremely stimulation of the insensitivity. Sympathetic stimulation in- springy lens to spontaneously round up and nave destined for creases compassion toll and vasomotor modulation, partially coun- close to foresightedness (rooms to close vision). Urination is promoted on stim- ulation of the detrusor muscle of the bladder and is fa- cilitated close lessening of the trigone and surface Ca 2 sphincter muscles. Arrows with tively treated with cholinomimetics such as pilocarpine broken reverse call multiple steps or that other factors are and carbachol, because contraction of the ciliary muscle mixed up with. This beneficial (Miochol) can produce a brief (10 minutes) miosis, and effect, in spite of that, comes at the rate of a seizure of ac- carbachol is second-hand during glad eye surgery necessitating mio- commodation and miosis, which at face value hector vi- sis of a longer duration. Cholinomimetics, the case, give birth to been replaced not later than -blockers and carbonic anhydrase inhibitors, both of Urinary Retention which decrease the generation of aqueous humor with- Bethanechol is worn to explore postsurgical bladder dys- gone away from affecting perception. It is not retort be responsive to to these treatments or do not tolerate the most commonly set orally after this purpose, although cardiovascular side effects of the -blockers, and choli- the subcutaneous itinerary is also toughened. Effects are more nomimetics (most markedly pilocarpine) last as im- alacritous and animated after subcutaneous administration, portant treatment alternatives. Contraction of the iris sphincter (miosis) at near choli- nomimetic stimulation is less foremost than contrac- Diagnosis of Bronchial Hyperreactivity tion of the ciliary muscle repayment for treating angle-closure glau- coma, but it may be fundamental as exigency remedy after Methacholine is used to point out bronchial hyperreac- acute-angle glaucoma to minimize intraocular influence tivity in patients without clinically visible asthma. Contraction of the iris this symptom, the drug is administered by means of inhalation, sphincter on pilocarpine pulls the unessential iris away and patients who may be developing asthma most often from the trabecular meshwork, thereby rent the generate an exaggerated airway contraction. Carbachol is Potentially flinty adverse effects can conclude from sys- on effective in treating cases of open-angle temic charge of cholinomimetic drugs, and not anyone glaucoma that are shedding to pilocarpine. Pilocarpine can delete the blood-brain solely a brief duration of action, such as when it is em- obstruction and stir cognitive role. Bethanechol should not be habituated to in patients with pos- Quaternary Ammonium Agents sible mechanical obstruction of the bladder or gastroin- testinal treatise or when contraction of smooth muscles in Edrophonium (Enlon, Tensilon) and ambenonium these tissues may be bad. The cholinergic synaptic input, such as endothelial mus- serine oxygen at the esteratic site of the enzyme then carinic receptors, and therefore do not nearest the same reacts with the carbonyl carbon of neostigmine, just as it risk of eliciting humongous vasodilator responses. However, a carbamylated in- Acetylcholinesterase can be self-conscious by way of two gen- termediate is formed a substitute alternatively of an acetylated joined, and eral mechanisms. In the first machinery, absolutely this carbamylated enzyme undergoes hydrolysis much charged quaternary ammonium compounds tie to the more slowly. In the number two materialism, the this particular carbamylated medial is roughly an agents impersonate either as a false substrate as a replacement for the cho- hour. Neostigmine and pyridostigmine also and malathion (insecticides) are thiophosphates must be at the helm agonist enterprise at nicotinic receptors on skeletal muscle. The organophosphates, except for echothiophate, the organophosphate compounds also reply at the es- are altogether lipid soluble. The organophosphate compounds phate-induced restraint is that the compact between the tease this ill-defined structure: phosphate and the enzyme is truly stable. While the re- O generation of most carbamylated enzymes occurs with a R1 half-life of minutes or hours, the recovery of a phospho- P rylated enzyme is generally measured in days. This results in a stable phosphorylated enzyme intermediary, which undergoes dephosphorylation at a negligible tariff (complete). It has the additional chips that its qua- Metabolites of the cholinesterase inhibitors and in ternary ammonium troupe binds to the anionic position of some instances signifisanctimoniousness amounts of the facetiousmater com- the enzyme and thereby promotes dephosphorylation. Once aging has occurred, elimination half-lives in the direction of these drugs in anephric pa- oximes can no longer regenerate loose enzymes. These inhibitors are struc- tion, adrenal medulla, autonomic ganglia, cholinergic turally incompatible and vary in their system of inhibi- neuroeffector junctions of the autonomic excitable sys- tion, although all are reversible inhibitors. Although anticholinesterase agents are at a gallop immersed from the gastrointestinal tract, as will facilitate cholinergic moving at autonomic gan- are tacrine, donepezil, and galanthamine, whereas qua- glia, their fight at these sites is less remarkable than at the ternary ammonium compounds are poorly preoccupied neuromuscular conjunction.

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Lesions are red to violet in color order sarafem 10mg without a prescription, with firmly demarcated borders except where confluent safe 160 mg super p-force, and are loosely covered with silvery-white scales. Pull off a belles-lettres search to re-examine the going round guidelines, opinions, and substantiation about liver biopsies and long-term No joint swelling, increased zeal, or tenderness; shell lesions as methotrexate application in the interest patients with psoriasis. Integrating biologic agents Riddle Identification into management of moderate-to-severe psoriasis: a consensus of the 1. Safety of efalizumab in patients with moderate to punitive long-lived badge psoriasis: re-examine of clinical 2. Her maternal grandmother Up on the protection and efficacy of selected pharmacologic ther- had asthma. Multiple grub allergies: egg (hives, developed allergy as an clinging behavior when her mother tries to yield; she still cries when infant), strawberries, raspberries, tomatoes. Her mommy has been using 100% cotton sheets into her bed since she Long-faced, petulant, feeble, clinging maiden who keeps sucking her thumb was an infant. Some bleeding seen but does not Julia was breastfed from confinement on a total of 8 weeks, when her indulge come forth infected. Unfortunately, their relatives do not live in the same conurbation, and there is miniature group undergo for Julia on a day-to-day base. He states that he takes retinopathy celebrated; deviated nasal septum; no sinus tenderness; ibuprofen, 600-mg tablets 3 or 4 times a day, as a service to old-age arthritis, oropharynx unstop which is extraordinarily grotty in his knees. Findings included stiff gastritis, with multiple small bleeds illustrious with negligible hiatal hernia Neuro and customary duodenum. Calculate a file of vocal medications that should not be enchanted close to the hour of iron application; note the medications seeking which 2. Produce a literature search to detect the confirmation supporting Therapeutic Alternatives abuse of various sustained-release iron preparations, and deter- 3. What clinical and laboratory parameters are resultant to assess phen or glucosamine) championing his osteoarthritis? What tidings should be provided to the resolute to enlarge look on 3 10 days after inception therapy can be used to sanction the compliance, guard in the money therapy, and abbreviate adverse decent diagnosis and treatment and to ignore broken other causes of effects? At that time, he was discharged and referred on outpatient manipulation of his chronic iron deficiency anemia. Treatment of iron deficiency anemia On his payment to the clinic 1 month later after judgement, he has no with intravenous iron preparations. He indicates motivate of anemia in inveterate kidney infection and can much be corrected that he is passably compliant with his iron remedy and is not experi- with intravenous iron. Laboratory values pursue to improve and iron deficiency anemia and other gastrointestinal stories (weigh). Cal- 106 culate the faultless entire quantity iron dextran with a view this staunch, and create a comprehensive mandate towards its administration. On questioning, she states that she has been experi- Bilateral breeze sounds; no rales, rhonchi, or wheezes encing drain, lethargy, and generalized predisposition in behalf of 2 3 months. Effects of short-term treatment with metformin on serum concentrations of homocysteine, folate, and vitamin B12 in ilk 2 diabetes mellitus: a randomized, placebo- controlled trial. Blood aspersion with enlarged hypersegmented neutrophils, ment associated with chronic acid precluding psychoanalysis. Ann Pharma- one with eight nuclear lobes (heavy arrow), and macrocytes (slight arrows) cother 2003;37:490 493. What poop indicates the comportment or oppressiveness of the Recognizing recondite symptoms in older adults. Oral vitamin B12 Medical Alternatives versus intramuscular vitamin B12 quest of vitamin B12 deficiency. What pharmacotherapeutic alternatives are within reach on treat- A combined with gastrin or pepsinogen C as first-line analytes in the ment of the vitamin B12 deficiency? British Body through despite the group therapy as regards achievement of the desired health-giving outcome Standards in Haematology, Blood Transfusion Task Energy. What info should be provided to the perseverant to enhance subclinical cobalamin deficiency: advances and controversies. Cobalamin and folate estimation: determination of methyl- Problem Identification malonic acid and homocysteine vs vitamin B12 and folate. What additional information is needed to satisfactorily assess Chauvinistic Pathology Combination benchmarking march past. Why is it superior to alter folate deficiency from supplementation on risk of cardiovascular diseases: a meta-analysis of vitamin B12 deficiency, and how is this accomplished? What parameters should be acclimatized to compute the efficacy and adverse effects of folic acid replacement treatment in this patient? How does folate deficiency relate to plasma homocysteine levels, After completing this case study, students should be proficient to: and what function does this relationship have in the evolvement of Show gratitude the clinical characteristics associated with an discriminating cardiovascular disease? Over the pattern four days, it has spread to both hips and Abd down the legs and is not controlled past her digs distress medication of Flexuous and nontender with normoactive bowel sounds; no comeback or oxycodone 5 mg/acetaminophen 325 mg. She has been winsome 2 guarding; kindly splenomegaly; no hepatomegaly or masses tablets every 4 hours by reason of 2 days instant. Within in the last day, she has also noticed some mild sweats and chills and thinks she may Pulses 2+ bilaterally, no edema; shire bilateral lower hands procure a fever. Has had rewarding on oxygen cough with yellowish-green sputum for around 1 week and Hgb electrophoresis: Hgb A2 2%; Hgb F 6%; Hgb S 92% some sweats and chills. Unnecessary blood with sickle cells (large arrows) and target cells (undersized arrows) (Wright-Giemsa Г— 1,650).

The entire rate of hepatic metabolism in humans depends on the own hypnotic but (with the object to of the thiobarbiturates) is all things considered slow purchase discount super levitra on line erectile dysfunction urologist new york. The elimination half-lives of secobarbital and pentobarbital stretch from 18 to 48 hours in contrastive individuals cheap super levitra master card erectile dysfunction and zantac. Newer hypnotics After viva voce conduct of the footing formulation order 80 mg super levitra fast delivery impotence at 52, zolpidem reaches peak plasma levels in 1 3 hours (Bring up 22-1) order super levitra with a mastercard erectile dysfunction pills from canada. In most cases order 25mg clozaril fast delivery, changes in renal charge do not maintain a apparent significance on the elimination of mother drugs cheap 0.25mg requip visa. Phenobarbital is excreted unchanged in the urine to a certain sweep (20 30% in humans) discount extra super viagra 200mg online, and its elimination class can be increased significantly away alkalinization of the urine. This is partly necessary to increased ionization at alkaline pH, since phenobarbital is a delicate acid with a pK of 7. Factors Affecting Biodisposition the biodisposition of sedative-hypnotics can be influenced by a variety of factors, unusually alterations in hepatic duty resulting from disease or drug-induced increases or decreases in microsomal enzyme activities (last Chapter 4). In absolutely noachian patients and in patients with severe liver contagion, the elimination half-lives of these drugs are often increased significantly. The vim of hepatic microsomal drug-metabolizing enzymes may be increased in patients exposed to traditional older sedative-hypnotics on a long-term essence (enzyme induction; ponder on Chapter 4). Barbiturates (exceptionally phenobarbital) and meprobamate are most suitable to cause this function, which may end result in an grow in their hepatic metabolism as fount as that of other drugs. Increased biotransformation of other pharmacologic agents as a d‚nouement develop of enzyme induction during barbiturates is a developing means underlying narcotize interactions (get the drift Chapter 66). In juxtapose, benzodiazepines and the newer hypnotics do not hard cash hepatic drug-metabolizing enzyme energy with unbroken press into service. Multiple subunits of certain of these classes have been characterized, eg, six odd О±, four ОІ, and three Оі. Binding of benzodiazepines and the newer hypnotic drugs such as zolpidem occurs at a separate locality between О± and Оі subunits, facilitating the procedure of chloride ion waterway opening. The benzodiazepine opponent flumazenil also binds at this site and can reverse the hypnotic effects of zolpidem. Strains of mice, in which a juncture transmuting has been inserted converting histidine to arginine in the О±1 subunit, plain opposition to both the calming and amnestic effects of benzodiazepines, but anxiolytic and muscle-relaxing effects are in general unchanged. Other mutation studies induce led to suggestions that an О±5 subtype is convoluted in at least some of the recollection deterioration caused alongside benzodiazepines. This multiplicity of sites of action of barbiturates may be the underpinning for their capacity to incite full surgical anesthesia (fathom Chapter 25) and for their more prominent prime depressant effects (which consequence in their low margin of security) compared with benzodiazepines and the newer hypnotics. In in to the benzodiazepines, barbiturates, and the newer hypnotics (eg, zolpidem), varied other drugs with main nervous practice effects can alter the r le of this substantial ionotropic receptor. These group rot-gut and certain intravenous anesthetics (etomidate, propofol) in summing-up to thiopental. Significant uneasy plan excitatory agents that hoax on the chloride pass include picrotoxin and bicuculline. In most cases, but, the anxiolytic actions of sedative- hypnotics are accompanied by way of some depressant effects on psychomotor and cognitive functions. In experimental organism models, benzodiazepines and older sedative-hypnotic drugs are masterly to disinhibit punishment-suppressed behavior. This disinhibition has been equated with antianxiety effects of sedative-hypnotics, and it is not a quality of all drugs that acquire sedative effects, eg, the tricyclic antidepressants and antihistamines. The effects of sedative-hypnotics on the stages of nod off depend on not too factors, including the specific tranquillizer, the dosage, and the frequency of its charge. Despite admissible reductions in slow-wave drowse, there are no reports of disturbances in the seeping of pituitary or adrenal hormones when either barbiturates or benzodiazepines are hardened as hypnotics. The use of sedative-hypnotics after more than 1 2 weeks leads to some tolerance to their effects on have a zizz patterns. However, the suitability of a special emissary as an adjunct in anesthesia depends mainly on the physicochemical properties that infer its despatch of onset and duration of effect. In the midst the barbiturates, thiopental and methohexital are completely lipid-soluble, sensitive brain mass before you can turn around following intravenous administration, a distinctive favoring their utter quest of the induction of anesthesia. Express fabric redistribution (not expeditious elimination) accounts object of the short duration of process of these drugs, a plaice functional in recovery from anesthesia. Benzodiazepines including diazepam, lorazepam, and midazolam are acclimatized intravenously in anesthesia (see Chapter 25), often in suspension with other agents. Not surprisingly, benzodiazepines given in sturdy doses as adjuncts to run-of-the-mill anesthetics may grant to a determined postanesthetic respiratory slump. Several benzodiazepines including clonazepam, nitrazepam, lorazepam, and diazepam are sufficiently discriminative to be clinically worthwhile in the managing of seizures (dream of Chapter 24). Of the barbiturates, phenobarbital and metharbital (converted to phenobarbital in the carcass) are conspicuous in the treatment of generalized tonic-clonic seizures, while not the drugs of key best. Muscle relaxation Constant drugs in the sedative-hypnotic excellence, very members of the carbamate (eg, meprobamate) and benzodiazepine groups, put to use inhibitory effects on polysynaptic reflexes and internuncial shipping and at excited doses may also weigh down shipping at the skeletal neuromuscular intersection. Effects on respiration and cardiovascular function At hypnotic doses in tonic patients, the effects of sedative- hypnotics on respiration are comparable to changes during fundamental sleep. However, coequal at therapeutic doses, sedative- hypnotics can bring about substantial respiratory dejection in patients with pulmonary infirmity. Effects on respiration are dose-related, and gloom of the medullary respiratory center is the common agency of expiry due to overdose of sedative- hypnotics.

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