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Clusters of cases have been noted with no obvious pre- Aetiology/pathophysiology cipitant discount malegra dxt plus online visa icd 9 code for erectile dysfunction due to diabetes. It occurs almost exclusively in heavy cigarette smokers and is therefore seen more in countries with high levels Pathophysiology of smoking malegra dxt plus 160 mg without prescription erectile dysfunction 40. There is segmental chronic inammatory The condition results from inammation within the inltration of the vessel walls with resultant obliteration walls of small blood vessels, predominantly capillaries of the lumen and secondary thrombosis. The condition starts with digital ischaemia, ulceration The inammation of the vessels increases permeability preceded by claudication in the feet, or rest pain in the resulting in a leaking of uid and cells from the circula- ngers or toes. IgA deposition within ankle pulses are usually absent but brachial and popliteal the glomeruli of the kidney causes a focal segmental pat- pulses are present. There may be a previous history of tern of glomerulonephritis with a resultant proliferation supercial thrombophlebitis. Investigations Clinical features Arteriography shows narrowing or occlusion of small This multisystem disorder may occur with simultaneous peripheral arteries with healthy main vessels. The rash characteristically affects the lower The condition remits with quitting smoking; nicotine limbs and buttocks, but is not always conned to these replacement therapy cannot be used but bupropion areas. Prostaglandin infusions, thrombolytic puric and then goes through the classic colour changes therapy, surgical sympathectomy and revascularistion of a bruise, lesions of varying ages are present at one procedures have been tried. Oedema of the face, dorsum of the hands and feet, perineum or foreskin may occur especially in young children Henoch Schonlein Purpura r Aself-limiting acute arthritis of large distal joints oc- Denition curs without articular damage with the patient com- A syndrome resulting from a vasculitis of small blood plaining of swollen, tender painful joints exacerbated vessels. Clinical features Symptoms are symmetrical with ngers affected more Complications than toes, it usually begins in a single digit and then Gastrointestinal complications include infarction and becomes more generalised. Renal failure may due to vasoconstriction progressing through cyanosis to occur in the acute phase, or may progress over many hyperaemia (white to blue to red). Investigations The diagnosis is clinical; erythrocyte sedimentation rate, Investigations white cell count and eosinophils may be raised. Urine Primary Raynaud s phenomenon must be distinguished microscopy should be performed looking for red and fromRaynaud ssyndromeoccurringwithconnectivetis- white blood cells, casts and protein. In more pain and rash may be achieved with nonsteroidal anti- severe cases calcium channel blockers such as nifedipine inammatory drugs. In severe cases prostacyclin infusions may be manifestations may be improved with the prompt use of required. Complications such as acute renal failure and intussusception should be managed promptly. Behcet s syndrome Prognosis Denition Inmostcasestheoverallprognosisisexcellent,thecourse Achronic,relapsingmultisystemvasculitischaracterised is variable with cases lasting between a few days and a by oral ulceration. Rarely it may continue for up to a year and there may be a course of relapse and remission. Denition An exaggerated vascular response to cold, causing a Sex spasm of the arteries supplying the ngers and toes. M > F Prevalence Geography Five to ten per cent of young women in temperate cli- Much more common in Turkey, Iran, China, Korea and mates. Patients demonstrate pathergy (a gered autoimmune reaction in a genetically susceptible papule or pustule forms at sites of skin puncture) this individual. Clinical features Management Patients have recurrent oral aphthous or herpetiform ul- Corticosteroids and immunosuppressive agents are used cers. Colchicine may be of benet for ery- ular disease (uveitis), skin lesions (erythema nodosum), thema nodosum and arthralgia. A thin section a few mil- limetres around and underneath the resulting defect Nomenclature and description is taken, divided into pieces, and cut as a fresh frozen specimen. If tumour is seen at a particular margin re- The cornerstone of dermatological diagnosis is accu- section is continued at the appropriate margin, and rate observation and description of lesions and rashes. Dermatological procedures Skin grafts r Shaveortangential excision: This procedure slices a Skin grafts are sections of skin that are completely de- surface growth off using a blade, often to remove a tached and transferred to cover large areas of skin defect. The recipient site requires a good blood supply, as the r Punch biopsy: Under local anaesthesia a full thickness graft has no supply of its own. Ifaverylargedefectneeds are scraped off with a special tool and the area is cau- covering, the graft can be meshed. Repeated treatment may be take up a blood supply more easily than full thickness required. The area heals often leaving a small hypopig- grafts, but tend to shrink and have abnormal pigmen- mented mark. Lightfreezingcausesapeeling,moderate dermis, are used mainly in reconstructive surgery. They leave a donor site, which requires closure by su- r Mohs surgery: This is a technique used in the re- tures, limiting the size of the graft. Erythroderma Intense and widespread reddening of the skin due to dilation of blood vessels, often with exfoliation. Excoriation Stripping of the skin usually by scratching as a result of intense itching of the skin. May be a primary lichenoid disease or a secondary lichenication due to repeated excoriation as seen in chronic eczema. Macule Describes a skin lesion that is at, often well circumscribed with alteration of colour. Skin aps Geography Mayoccur anywhere, but higher incidence in urban Skin aps differ from skin grafts in that they are taken areas. The coverage can thus be thicker and stronger than grafts, and can be applied to avascularareassuchasexposedbone,tendonsandjoints. Aetiology/pathophysiology Flaps may be transferred whilst maintaining their orig- The term atopy is a disease resulting from allergic inal vascular attachments (pedicle aps), or may be re- sensitisation to normal environmental constituents anastamosed to local blood supply (free aps). The underly- ing cause and mechanisms in eczema have yet to be fully elucidated; however, dry skin (xerosis) is an important Scaly lesions contributor. There appear to be genetic and immuno- logical components to allergic sensitisation (see also page 498). Offspring of one atopic parent have a 30% risk of Atopic eczema being atopic, which rises to 60% if both parents are Denition atopic. Achronic inammatory skin disorder associated with r Chromosome studies suggest that atopic tendency atopy, causing dry, scaly, itchy lesions. More common in children with peak onset usually 2 18 Serum IgE is elevated in 85% of individuals and higher months. It is thought that the high frequency of secondary Sex infectionisacombinationofthelossofskinintegrityand M = F deciency of local antimicrobial proteins. These are erythematous and r Antibiotics are used for secondary bacterial infection. Lesionsmayweepand r Wetwraps consist of the application of topical agents have tender tiny blisters termed vesicles especially when under bandages to facilitate absorption. The distribution is age depen- may be administered in this way or coal tar may be dent: used as a keratolytic in lichenied skin. If steroids are r Babies develop eczema predominantly on the face and appliedunderwetwrapsthedose/potencymustbede- head; this may resolve or progress by 18 months to the creased as increased absorption may result in systemic childhood/adult pattern. Complications r Topical tacrolimus, an immunosuppressant, is being Staphylococcus aureus is found on the skin of 90%, which increasingly used in children prior to the use of high- may result in acute infection (impetigenised eczema).

This is done by multiplying the number of deaths averted with the survival rate of any other cause of mortality for that year and age group purchase malegra dxt plus 160 mg overnight delivery erectile dysfunction treatment scams. This figure is also supplemented by the added population from averted deaths in previous years buy malegra dxt plus 160 mg with mastercard erectile dysfunction lexapro, who survive all other mortality causes year on year. The additional population is multiplied by age-group and country specific employment rates, as well as an experience factor. The savings rate, capital depreciation rate, and capital share are assumed to be constant across years and exogenous to the model. The prevalence of age-standardized adjusted diabetes projections comes from the Global Status Report on Noncommunicable Diseases 2014, which provided the prevalence rate of raised blood glucose for 18 years of age and older in the year 2014. Using the International Diabetes Federation s diabetes prevalence rates for 2015 and 2040, a constant growth rate gives projections for 2015 through to 2040 with growth rates ranging from 0. Medical costs are applied to diabetics 15 years of age and over while the loss of income and tax loss are only accounted for 20- to 65-year-old diabetics. The method also assumes that an individual driven to early retirements from diabetes does so at the beginning of the year. A constant growth rate between the two years provides the medical cost associated with all other years of analysis. The loss in tax revenue is calculated as that year s tax that would have been paid had the individual not been removed from the workforce due to diabetes. This the lost tax revenue is calculated at the average income level tax rate by country. One strong assumption made is that the country-specific tax rate is constant across all years. First, the 2015 and 2040 population statistic was disaggregated by age bracket using the average rates from the available six countries; second, prevalence rates by age group from the Global Status Report on Noncommunicable Diseases 2014 began at 18-years-old while the closest sub- population available is from 15+-years-old. The economic costs is the difference in income between employment and unemployment. The summation of these economic burdens gives the lower bound estimate of total economic burden due to diabetes morbidity. The diabetes morbidity burden is scaled up to the four non-communicable diseases using relationships derived in the mortality analysis. The projections for all other years is then scaled back to 2015 by 6 Where disability benefit information is available, disability benefit should also be considered to be an economic burden to the economy. An implicit assumption that results from this method is that those countries with higher diabetes morbidity costs will also have higher cardiovascular diseases, chronic respiratory disease, and cancer prevalence rates. A particularly interesting outcome of a reduction in diabetes prevalence is that the cost curve associated with diabetes morbidity can be bent. The first scenario reduces the diabetes prevalence, beginning at the year 2015, by three percent on the status quo prevalence, with this three percent discounted by five percent each year. Furthermore, the reduction is compounded so that the reductions in one year is added to the proportion of reduction in every year following. The second scenario uses the same method, however, the initial reduction begins at six percent. It is well known that disease is not impartial and that the less educated are encumbered by more than their equal share of the disease burden. The less educated tend to earn lower wages while the assumption states that an individual cured of a disease would on average earn the expected wage of an economy. Among the costs not calculated in this study are the loss of income (and productivity) for those who are withdrawn from the labor force to look after diabetic family members. Temporary disability, as in the case where a diabetic is withdrawn from the workforce for a short period, is not accounted. The lack of inclusion for this form of income may cause overestimation in the lost income estimates. However, the households with diabetics receiving remittances may use this income to ease the burden of diabetes i. These remittances, used to ease financial burden associated with disease, can then be considered an indirect cost of morbidity. O) Papua New Guinea Samoa 35 Solomon Islands Tonga Vanuatu Source: International Health Metric and Statistics. The burden and costs of chronic diseases in low-income and middle-income countries. An estimation of the economic impact of chronic noncommunicable diseases in selected countries World Health Organization Working Paper, 1-21. The Economic Costs of Noncommunicable Diseases in the Pacific Islands: A Rapid Stocktake of the Situation in Samoa, Tonga, and Vanuatu. The costs and affordability of drug treatments for type 2 diabetes and hypertension in Vanuatu. The fetal and infant origins of adult disease: the womb may be more important than the home. Maternal and child undernutrition: global and regional exposures and health consequences. Global, regional, and national age sex specific all-cause and cause-specific mortality for 240 causes of death, 1990 2013: a systematic analysis for the Global Burden of Disease Study 2013. Mortality displacement of heat- related deaths: a comparison of Delhi, Sao Paulo and London. Determinants of Tobacco Consumption in Papua New Guinea: Challenges in Changing Behaviours. Changing patterns of under- and over-nutrition in South African children future risks of non-communicable diseases Annals of Tropical Peadiatrics, 25(1), 3-15. Public health impact of global heating due to climate change: potential effects on chronic non-communicable diseases. The 2006 California heat wave: impacts on hospitalizations and emergency department visits. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes a meta-analysis. Evidence for impaired insulin production and higher sensitivity in stunted children living in slums. A survey of macro damages from Non-communicable chronic diseases: another challenge for global governance. Socioeconomic status and obesity in adult populations of developing countries: a review. The World Health Report 2001: Mental Health: New Understanding, New Hope: World Health Organization. Human Thermal Environments: The Effects of Hot, Moderate, and Cold Environments on Human Health, Comfort and Performance (2nd ed. Effect of socioeconomic deprivation on waiting time for cardiac surgery: retrospective cohort study. The link between childhood undernutrition and risk of chronic diseases in adulthood: a case study of Brazil. Forum Leaders Statement on Non-Communicable Diseases: Pacific in an Crisis, Leaders Declare: Secretariat of the Pacific Islands Community. Prevention and Control of Noncommunicable Diseases Regional Committee 51st Session, Manila, Philippinesn 18-22 September (Vol.

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In some patients no specific pathologic findings are found purchase generic malegra dxt plus online drugs used for erectile dysfunction, especially if death is from cardiovascular collapse malegra dxt plus 160mg with mastercard erectile dysfunction studies. Sudden vascular collapse usually is attributed to vessel dilation or cardiac arrhythmia, but myocardial infarction may be sufficient to explain the clinical findings ( 78). The diagnosis of anaphylaxis is clinical, but the following laboratory findings help in unusual cases or in ongoing management. A complete blood count may show an elevated hematocrit secondary to hemoconcentration. Blood chemistries may reveal elevated creatinine phosphokinase, troponin, aspartate aminotransferase, or lactate dehydrogenase if myocardial damage has occurred. Acute elevation of serum histamine, urine histamine, and serum tryptase can occur, and complement abnormalities have been observed (79). Plasma histamine has a short half-life and is not reliable for postmortem diagnosis of anaphylaxis. Mast cell derived tryptase with a half-life of several hours, however, has been reported to be elevated for up to 24 hours after death from anaphylaxis and not from other causes of death. Serum tryptase may not be detected within the first 15 to 30 minutes of onset of anaphylaxis; therefore, persons with sudden fatal anaphylaxis may not have elevated tryptase in their postmortem sera (80). Together the postmortem serum tryptase and the determination of specific IgE may elucidate the cause of an unexplained death. Serum should be obtained antemortem and within 15 hours of postmortem for tryptase and specific IgE assays, with sera frozen and stored at -20 C ( 80,81). Classic anaphylaxis occurs when an allergen combines with specific IgE antibody bound to the surface membranes of mast cells and circulating basophils. This leads to the initiation of a signal transduction cascade mediated by lyn and syk kinases, analogous to that induced by T-cell and B-cell receptors. Anaphylactoid (pseudoallergic) reactions are not IgE antibody/antigen mediated, but are induced by substances acting directly on mast cells and basophils causing mediator release. Histamine is a preformed and stored vasoactive mediator in mast cell and basophil cytoplasmic granules. These membrane-derived mediators also cause bronchoconstriction, mucus secretion, and changes in vascular permeability. Platelet-activating factor can alter pulmonary mechanics and lower blood pressure in animals ( 87), as well as activate clotting, and produce disseminated intravascular coagulation ( 88). In humans it causes bronchoconstriction if inhaled and causes a wheal and flare reaction when injected into human skin. Its release also has been reported in cold urticaria, but whether platelet-activating factor participates in anaphylaxis remains speculative ( 89). Hypotension occurs by nitric oxide increasing vascular permeability and causing smooth muscle relaxation ( 94,95,96 and 97). Chemotactic mediators attract eosinophils and neutrophils prolonging the inflammatory response. In summary, anaphylactic and anaphylactoid events occur as a result of multimediator release and recruitment with a potential for a catastrophic outcome. When sudden collapse occurs in the absence of urticaria or angioedema, other diagnoses must be considered, although shock may be the only symptom of Hymenoptera anaphylaxis. The most common is vasovagal collapse after an injection or a painful stimulation. In vasovagal collapse, pallor and diaphoresis are common features associated with presyncopal nausea. Respiratory difficulty does not occur, the pulse is slow, and the blood pressure can be supported without sympathomimetic agents. Hereditary angioedema must be considered when laryngeal edema is accompanied by abdominal pain. This disorder usually has a slower onset, and lacks urticaria and hypotension, and there is often a family history of similar reactions. There is also a relative resistance to epinephrine, but epinephrine may have life-saving value in hereditary angioedema. Idiopathic urticaria occurring with the acute onset of bronchospasm in an asthmatic patient may make it impossible to differentiate from anaphylaxis. Similarly, a patient experiencing a sudden respiratory arrest from asthma may be thought to be experiencing anaphylaxis because of severe dyspnea and facial fullness and erythema. Many patients suffer from flush reactions that mimic anaphylaxis and may blame monosodium glutamate incorrectly. Excessive endogenous production of histamine may mimic anaphylaxis such as systemic mastocytosis, urticaria pigmentosa, certain leukemias, and ruptured hydrated cysts (98). Laboratory tests can help in the differential diagnosis; for example, blood serotonin and the urinary 5-hydroxy-indoleacetic acid level will be elevated in carcinoid syndrome. Measurement of plasma histamine levels may not be helpful because of its rapid release and short half-life. However, a 24-hour urine collection or spot sample for histamine or histamine metabolites can be helpful, because urinary histamine levels usually are elevated for longer periods. A subsequent study demonstrated an increase in C3a, a clearing product of C3 supporting activation of the complement cascade ( 107). Munchausen stridor patients can be distracted from their vocal cord adduction by maneuvers such as coughing. In vocal cord dysfunction patients, the involuntary vocal cord adduction can be confirmed by video laryngoscopy during episodes and absence of cutaneous signs ( 98,102,103). A history of recent antigen or substance exposure and clinical suspicion are the most important diagnostic tools. Skin-prick testing can be useful in predicting anaphylactic sensitivity to many antigens. Anaphylaxis has followed skin-prick testing with penicillin, insect sting extract, and foods. Passive transfer to human skin carries the risk for transmitting viral illnesses (i. Complement consumption has not yet been used routinely to define anaphylactic mechanisms. The only currently reliable test for agents that alter arachidonic acid metabolism such as aspirin and other nonsteroidal antiinflammatory agents and other suspected non IgE-mediated agents is carefully graded oral challenge with close clinical observation and measurement of pulmonary function, nasal patency, and vital signs, following informed patient consent. Substances that can directly release histamine from mast cells and basophils may be identified in vitro using washed human leukocytes or by in vivo skin testing. Concomitant therapy with b-adrenergic blocking drugs or the presence of asthma exacerbate the responses of the airways in anaphylaxis and inhibit resuscitative efforts ( 27,108,109,110 and 111). Furthermore, epinephrine use in patients on b-adrenergic blocking drugs may induce unopposed a-adrenergic effects, resulting in severe hypertension.

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The patient is positioned in an applicator with (here) eight antennas that emit radio waves into the body trusted 160mg malegra dxt plus impotence tcm. By separate control of the individual antennas 160mg malegra dxt plus free shipping top erectile dysfunction pills, the interference eld can be adjusted to each individual patient, to locally apply high thermal energy to the tumor region only. The scientic question is: How should the antennas be tuned (in terms of amplitudes and phases) such that the tumor is heated within a temperature window between 42,5 and 45 C, but no healthy tissue. The impact of the dierent tuning parameters on the therapeutically eective temperature distribution is so complex that optimal therapy plans can be determined only via numerical simulation. The associated functional patient model here comprises Maxwell s equations for the description of the electric elds and the bio-heat-transfer equation which governs the heat distribution inside the body. The applied multigrid methods require computing times proportional to the number of nodes, which implies that adaptive methods are about a factor of 130 faster in this medically relevant example and at a comparable accuracy! In cranio-maxillo-facial surgery the mathematical model consists of the biomechanical dierential equations. They are to be solved numerically (by ecient multigrid methods) to permit a reliable prediction of the postoperative facial appearance assuming the operation went well as planned. On an intermediate time scale, it would be reasonable to open more space in public health to mathematics. The following lines of devel- opment can be foreseen: Radiology will more and more move on from mere 2D image interpretation to 3D model reconstruction. This requires substantial screening of individual im- age data by means of automated segmentation techniques. The corresponding increase of patient specic data will lead to a twofold development: (a) the build- up of centralized medical data bases in large hospitals, and (b) a population-wide introduction of (only personally disposable) individual data carriers (the elec- tronic patient ). Google-med may be a possible format of storing such data; it 17 will, however, need to be modied due to national dierences in health organi- sations and mentality as well as with respect to its non-guaranteed security of individual data. Provokingly, the function of an organ will not be fully understood, before it has been expressed by a realistic mathe- matical model covering both the healthy and the unhealthy case. Radi- ologists will certainly continue to bear the legal responsibility for the correctness of the interpretation of medical image data and the therefrom derived anatomi- cal models. However, in countries like Germany, insurance companies will need to include model assisted planning on the basis of geometrical 3D models and mathematical functional models into their catalogue of nancially supported ser- vices. Apart from medical indication, the new kind of planning tools is useful in view of an improved patient information as well as of education, documentation, and quality assurance. However, there is still a long way to go, until anatomically correct and medically useful functional models will be available even for the most essential body parts and the most frequent diseases. Within the German funding system, the corresponding research will, on a quite long run, remain dependent on public funding. In any case, political frames in health and research will need to be adjusted in close cooperation with selected medical doctors, engineers, and mathematicians! Pavarino: Adaptivity in Space and Time for Reaction-Diusion Systems in Electro- cardiology. Deuhard: Dierential Equations in Technology and Medicine: Compu- tational Concepts, Adaptive Algorithms, and Virtual Labs. Hochmuth: Multiscale abnalysis of thermoregulation in the human microvasular system. Dossel: Kausalitat bei der Entstehung, der Diagnose und der Therapie von Krankheiten aus dem Blickwinkel des Ingenieurs. Smoak: Anisotropy, ber curva- ture, and bath loading eects on activation in thin and thick cardiac tissue preparations: simulations in a three-dimensional bidomain model. Lamecker: Shape constrained automatic seg- mentation of the liver based on a heuristic intensity model. Louis: Combining Image Reconstruction and Image Analysis with an Application to Two-dimensional Tomography. Dossel: Multiple wavelets, rotos, and snakes in atrial brillation a computer simulation study. Laguna: Bioelectrical signal processing in cardiac and neu- rological applications. Zachow: Computergestutzte 3D-Osteotomieplanung in der Mund-Kiefer- Gesichtschirurgie unter Berucksichtigung der raumlichen Weichgewe- beanordnung. Technology Special Is- sue on Computer-Based Craniofacial Modelling and Reconstruction, pp. The members of the Committee responsible for the report were chosen for their special competences and with regard for appropriate balance. N01-0D-4-2139 between the National Academy of Sciences and the National Institutes of Health. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: x Leslie Biesecker, National Institutes of Health x Martin J. Blaser, New York University Langone Medical Center x Wylie Burke, University of Washington x Christopher G. Chute, University of Minnesota and Mayo Clinic x Sean Eddy, Howard Hughes Medical Institute Janelia Farm Research x Elaine Jaffe, National Cancer Institute x Brian J. Schwartz, University of Washington Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Dennis Ausiello, Harvard Medical School, Massachusetts General Hospital and Partners Healthcare and Queta Bond, Burroughs Welcome Fund.

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