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By L. Kamak. Air Force Institute of Technology.

Registration and certification of traditional healers buy cheap top avana 80 mg line impotence nasal spray, as is required for their western allopathic counterparts purchase top avana 80 mg fast delivery impotence from diabetes, have been proposed as a solution and may contribute to a reduction in the incidence of poisoning. The best of drugs, in the hands of the irresponsible or ignorant, is potentially dangerous. It may be necessary to alert the public, by means of a media campaign, to the hazards of self-medication with traditional herbs known to have deleterious side effects. Although it is not possible to say if the South African experience holds true for other African states, it would be surprising if the effects on traditional medical practice of cultural disruption occasioned by urbanisation, political unrest, war or climate change would not be felt throughout the continent. These findings are a cause for concern and further toxicological studies are necessary before the species concerned can be prescribed with confidence. Quality assurance Quality assurance of medicines rests on the establishment of standards relating to their identity, purity and potency. This constitutes the first step 110 | Traditional medicine in the process of bringing traditionally used plant species from the field into the clinic, dispensary and hospital. Similar programmes have been undertaken in Mozambique, Zambia, Zimbabwe, Botswana and Malawi. Primarily a disease of the rural poor in Africa, Plas- modium falciparum malaria causes more deaths than any other infectious agent in young African children and is responsible for almost 40% of these deaths. The efficacy of such remedies has been demonstrated by the successful development of modern antimalarials from traditionally used Cinchona and Artemisia spp. Twenty years later, Africa’s fragile oral knowledge systems are threatened by war, famine, political instability and urbanisation (with concomitant loss of the ‘ecosystem generation’). Unsustainable harvesting practices, delib- erate habitat destruction and climate change threaten the survival of the plant species on which Africa’s traditional healers depend. The greatest threat to traditional medical practice, however, is the burgeoning global population, whose growth and consumption of natural resources places plant diversity at risk in most parts of the world. The quantity of wild plant material exported from Africa and destined for the international pharma- ceutical trade is enormous, but pales into insignificance compared with that required by the trade in crude drugs used in traditional medical practice, within individual states or across regional borders. This has resulted in a disregard for traditional conservation practices and ‘an opportunistic scramble for the last bag of bark, bulbs or roots’. High rates of unemployment and low levels of formal education have also given rise to an increasing number of medicinal plant vendors, plying their trade in the marketplace (Figure 5. The period 2001–10 has been declared the Decade of African Traditional Medicine and an Africa Health Strategy (2007–15) has been formulated, focusing on the strengthening of health systems for equity and development in Africa. Conclusion There is no doubt that Africa’s rich botanical biodiversity and well-estab- lished traditional medical systems can be harnessed for the provision of better healthcare throughout the continent. The neces- sary expertise and infrastructure do not exceed the capabilities of the average African university School of Pharmacy. Toen wy in Oktober omtrent den Coperbergh quamen, weird door alle man ‘tselvs op d’omliggende bergen (tot voorraad vant geheele jaar) ingesamelt ‘t welck zy gelijk d’Indianers den betel of areck gebruijcken, synde seer vroolijk van humeur, meest alle avonden in haer ‘tsamenkomst. The Traditional Medical Practitioner in Zimbabwe: His principles of practice and pharmacopoeia. Manchester: Manchester University Press in association with the International African Institute, 1986: 50–86. Riding the wave: South Africa’s contri- bution to ethnopharmacological research over the last 25 years. Policy and public health perspectives on tradi- tional, complementary and alternative medicine: an overview. In: Bodeker, G, Burford G (eds), Traditional, Complementary and Alternative Medicine: Policy and public health perspectives. Manchester: Manchester University Press in association with the International African Institute, 1986. The professionalisation of indigenous medicine: a comparative study of Ghana and Zambia. Manchester: Manchester University Press in association with the International African Institute, 1986: 117–135. Manchester: Manchester University Press in association with the International African Institute, 1986: 151–62. Report of the Inter-Regional Workshop on Intellectual Property Rights in the Context of Traditional Medicine. Proceedings of an International Workshop on Traditional Knowledge, Panama City, 21–23 September 2005. A review of the taxonomy, ethnobotany, chemistry and pharmacology of Sutherlandia frutescens (Fabaceae). Galanthamine: a randomised double-blind, dose comparison in patients with Alzheimer’s disease. Antidiabetic screening and scoring of 11 plants traditionally used in South Africa. In vitro antiplasmodial activity of medicinal plants native to or naturalised in South Africa. The distribution of mesembrine alkaloids in selected taxa of the Mesembryanthemaceae and their modification in the Sceletium derived ‘kougoed’. Antimycobacterial activity of 5 plant species used as traditional medicines in the Western Cape Province (South Africa). Uses and abuses of in vitro testing in ethnopharmacology: visualizing an elephant. A pharmacognostical study of 26 South African plant species used as traditional medicines. The African cherry (Prunus africana): can lessons be learned from an over- exploited medicinal tree? Acute toxicity associated with the use of South African traditional medicinal herbs. Clinical and analytical aspects of pyrrolizidine poisoning caused by South African traditional medicines. Screening of medicinal plants used in South African traditional medicine for genotoxic effects. Searching for a Cure: Conservation of medicinal wildlife resources in east and southern Africa. In: Bodeker G, Burford G (eds), Traditional, Complementary and Alternative Medicine: Policy and public health perspectives. In: Bodeker G, Burford G (eds), Traditional, Complementary and Alternative Medicine: Policy and public health perspectives. An Africa-wide Overview of Medicinal Plant Harvesting, Conservation and Health Care. A brief overview of other similar traditional medicine practices is also included. All healthcare providers, particularly those who practise in areas with substantial Chinese immigrant populations, will find it useful to have some background knowledge of this topic. Written in the form of a discourse between Huangdi and his ministers on the nature of health, it contains a wealth of knowledge, including aetiology, physiology, diagnosis, therapy and prevention of disease, as well as an in-depth investigation of such diverse subjects as ethics, psychology and cosmology.

Its effects on intestinal • Betahistine is used in vertigo order 80 mg top avana with visa erectile dysfunction doctor dublin, tinnitus and hearing loss motility result in numerous alterations in drug absorption order top avana online now erectile dysfunction cpt code, associated with Ménière’s disease. Phenothiazines barium to reach the caecum and decreases the number of used as anti-emetics include prochlorperazine, trifluoper- films required; azine, perphenazine and chlorpromazine. They are least effective in the treatment of motion sick- • symptoms of reflux oesophagitis may be improved, as it ness. All of them carry a risk of extrapyramidal disturbances, prevents nausea, regurgitation and reflux. These effects are more common in females and in in the management of acute nausea and vomiting due to cyto- the young. They are treated by stopping metoclopramide and toxic chemotheraphy, although they offer little advantage for giving benztropine or diazepam acutely if necessary (see also delayed emesis, occurring secondary to cytotoxic chemother- Chapter 21). It may be peripheral at abdominal visceral afferent neurones, or central within the Mechanism of action area postrema of the brain, or a combination of both. Metoclopramide increases the amount of acetylcholine Examples include ondansetron, granisetron, dolasetron and released at post-ganglionic terminals. It also decreases the sensitivity of the visceral nerves that carry impulses from the gut to the emetic centre. In an Pharmacokinetics attempt to reduce side effects and increase efficacy, a number Metoclopramide is well absorbed orally and is also given by of analogues, including nabilone, have been synthesized. There is some evidence that opioid pathways Glucocorticosteroids are not suitable for maintenance treatment are involved in these actions. Benzodiazepines given before treatment with cytotox- pository or enema preparations are as effective as systemic ics reduce vomiting, although whether this is a specific anti- steroids. Drugs currently available in this group are sulfasalazine, mesalazine, balsalazide and olsalazine. Although usually well tolerated, and Crohn’s disease include kinins and prostaglandins. The the adverse effects of sulfasalazine are nausea, vomiting, latter stimulate adenylyl cyclase, which induces active ion epigastric discomfort, headache and rashes (including toxic secretion and thus diarrhoea. All of the adverse effects associated with thromboxane A2 and prostacyclin by the gut increases during sulphonamides can occur with sulfasalazine, and they are disease activity, but not during remission. Toxic effects on red cells lates influence the synthesis and metabolism of these are common (70% of cases) and in some cases lead to haemoly- eicosanoids, and influence the course of disease activity. Temporary oligospermia with life-saving) and other non-specific treatment, glucocorticos- decreased sperm motility and infertility occurs in up to 70% of teroids, aminosalicylates and immunosuppressive drugs are males who are treated for over three years. Prednisolone and hydrocorti- ate sulfasalazine and in men who wish to remain fertile. Topical therapy in the form of a rectal drip, foam or enema of Key points hydrocortisone or prednisolone is very effective in milder Aminosalicylates and blood dyscrasias attacks of ulcerative colitis and Crohn’s colitis; some systemic • Any patient who is receiving aminosalicylates must be absorption may occur. Prednisolone is preferred to hydrocortisone as it has less min- • If there is suspicion of blood dyscrasia, stop aminosalicylates. Also, it is important to remember that many drugs is activated in the intestine of patients with inflammatory can cause constipation (Table 34. This forms the rationale for the use of immuno- In general, patients with constipation present in two ways: suppressive agents in the group of patients who do not respond to therapy with aminosalicylates or glucocorticos- 1. General indications for their use include patients who may be due to decreased colon motility or to dyschezia, or have been on steroids for more than six months despite efforts to a combination of both. It is usually sufficient to reassure to taper them off, those who have frequent relapses, those with the patient and to instruct them in the importance of re- chronic continuous disease activity and those with Crohn’s establishing a regular bowel habit. Patients with ulcerative colitis combined with an increased fluid intake and increased may benefit from a short course of ciclosporin (unlicensed bulk in the diet. Patients with unresponsive or chronically active alternative, non-absorbed bulk substances such as inflammatory bowel disease may benefit from azathioprine or methylcellulose, ispaghula or sterculia are helpful. The mercaptopurine, or (in the case of Crohn’s disease) once- other laxatives described below should only be tried if weekly methotrexate (these are all unlicensed indications). Loaded colon or faecal impaction – sometimes it is nerosis factor (see Chapters 16 and 26) is licensed for the necessary to evacuate the bowel before it is possible to management of severe active Crohn’s disease and moderate to start re-education, particularly in the elderly or those who severe ulcerative colitis in patients whose condition has not are ill. In these cases, a laxative such as senna combined responded adequately to treatment with a glucocorticosteroid with glycerol suppositories is appropriate. Infliximab is also licensed for the management of refractory fistulating Crohn’s disease. It is usually given for a month, but no Iron preparations longer than three months because of concerns about develop- ing peripheral neuropathy. Antimotility drugs such as codeine and loperamide (see below) and antispasmodic drugs may precipitate paralytic ileus and megacolon in active ulcerative colitis; treatment of the inflammation is more logical. There is now a greater know- ledge of intestinal pathophysiology, and of outstanding import- Key points ance is the finding that the fibre content of the diet has a marked regulatory action on gut transit time and motility and Inflammatory bowel disease on defecation performance. Magnesium sulphate (Epsom salts) and other magnesium salts are useful where rapid bowel evacuation is required. Plant fibre Macrogols are inert polymers of ethylene glycol which Plant fibre is the portion of the walls of plant cells that resists sequester fluid in the bowel; giving fluid with macrogols may digestion in the intestine. The main effect of increasing the reduce the dehydrating effect sometimes seen with osmotic amount of fibre in the diet is to increase the bulk of the stools laxatives. It does not increase the Lactulose is a disaccharide which passes through the small effective caloric content of the diet, as it is not digested or intestine unchanged, but in the colon is broken down by absorbed. This By increasing the bulk of the intestinal contents, fibre slowly produces a laxative effect after two to three days. It is effective distends the wall of the colon, and this causes an increase in and well tolerated, but relatively expensive. The main result is a return of value in the treatment of hepatic encephalopathy, as it dis- the large bowel function towards normal. Similar results are courages the proliferation of ammonia-producing organisms obtained in diverticular disease in which there is colon and the absorption of ammonia. These agents were formerly believed to act by softening or The starting ‘dose’ of bran is a dessertspoonful daily and lubricating the faeces, but they act at least in part in a similar this can be increased at weekly intervals until a satisfactory manner to stimulant purgatives by inhibiting intestinal elec- result is obtained. Bran should be avoided in gluten enteropathy and is patients with faecal impaction, and it should not be given over contraindicated in bowel obstruction. However, 5g of magnesium sulphate due to the local irritant action of glycerol and are useful if a would be isotonic in only 130mL and acts within one to two rapid effect is required. Antibiotic treatment is indicated is not clear, but this effect is perhaps due to damage to the for patients with systemic illness and evidence of bacterial intrinsic nerve plexus of the colon. Two main types of drug may be employed, that either Some people, mainly women, take purgatives secretly. This decrease intestinal transit time or increase the bulk and viscos- probably bears some relationship to disorders such as anorexia ity of the gut contents. Codeine is widely used for this purpose in doses of • sodium depletion – hypotension, cramps, secondary 15–60mg. Morphine is also given, usually as a kaolin and hyperaldosteronism; morphine mixture.

It is selves but suspends them order top avana 80 mg erectile dysfunction statistics age, allowing us to experience conceptualized as a dialectic between the impres- the other in his or her own uniqueness purchase top avana discount erectile dysfunction clinics. This shifting back and forth al- By intentionally bringing into present con- lows for sudden insights on the nurse’s part, a new sciousness, and acknowledging what we believe to overall grasp, which manifests itself in a clearer, or be true, we can then attempt to hold any precon- perhaps a new,“understanding. A a dialogue with her unbracketed view (see Figure personal experience that helped me to grasp the 11–4). As I entered each new country, I experienced the In the next phase, objectivity is needed as the nurse excitement of the unknown. Standing time how alert, open, and other directed I was in outside the phenomenon, the nurse examines it this uncharted world as compared to my own daily through analysis. According to Husserl (1970), who is considered the father of modern phenomenology, the attitude desired is that of the perpetual beginner. Bracketing prepares the inquirer to enter the un- charted world of the other without expectations and preconceived ideas. Even temporarily letting go of that which shapes our own identity as the self, however, causes anxi- ety, fear, and uncertainty. Labeling, diagnosing, and routine add a necessary and very valuable pre- dictability, sense of security, and means of conserv- ing energy to our everyday existence and practice. Being open to the new and different is a necessary stance in being able to know of the other intuitively. Patterns and themes are reflective of ternalization of what others have come to know, and rigorously validated by the authentic experi- dynamically interrelates with the nurse’s human ca- ence (Figure 11–5). Through this interrelationship, the subjective and Nurse Complementarily objective world of nursing can be reflected upon by Synthesizing Known Others each nurse, who is aware of and values herself as a At this point the nurse personifies what has been “knowing place” (Figure 11–6). Zderad as a Succession Within the Nurse from “noetic locus,” a “knowing place” (1976, p. The coming together of a new overall grasp the nurse and the patient, the between in the lived sudden insights world, is nursing. Paterson and Zderad is: “Two or more persons The definition of community presented Subjective Objective by Drs. This is the pattern of the dialectic the recurrent pattern of nursing and is therefore process, which is reflected throughout Humanistic worth reflecting upon and valuing. In the dialectic process there is a Humanistic Nursing Theory, there is an inherent repetitive pattern of organizing the dissimilar into a obligation of nurses to one another and to the com- higher level (Barnum, 1990, p. That which enhances one of us, level, differences are assimilated to create the new. Through openness, sharing, and This repetitive dialectic process of humanistic caring, we each will expand our angular views, each nursing is an approach that feels comfortable and becoming more than before. Human beings, by virtue of their ability to self-observe, have the unique capacity to transcend themselves and reflect on their relationship to the universe. This paradigm speaks to the interactive dialogue Applications between two different human beings from which a unique yet universal instance of nursing emerges. I was experiencing His friend had just been diagnosed with a seri- what Dominic was expressing. At this time I was feeling his inadequacy, helplessness, and inability ous form of cancer. We talked, but there was the This insight brought a greater understanding awkwardness of not knowing what to say or what between Dr. Later that night, I was in my room all standing that brought them closer so that she alone. No longer having to be concerned about could endure with him in his fear-filled knowing my family and what they were struggling with, I and unknowing of dying. Then the evening nurse who had “Often after greeting me and saying what he been working with me over the last two days of needed he would fall asleep. I reevaluated his sleeping during my know how long, until I placed my other hand on visit. I to be with me in the known, and unknown; no longer made any move to leave before my time somehow she also conveyed a reassurance that I with him was up. I told him of this intention so did not have to go through what was coming, that he could relax more deeply. To give This ability to be with and endure with a pa- this gift of time and presence in the patient’s tient in the process of living and dying is fre- space, a person has to value the outcomes of quently taken for granted by us, yet it is what relating. Subsequently, the nurse was able to understand the patient’s intense fear of being The humanistic nursing approach is useful in clin- alone. In the process of supervision I try choices are humanizing, she began to explore the to understand the “call” of the nurse when she need for support systems. This usually is connected own capability of being a “knowing place” and ex- to the “call” of the patient to him or her and some panding her angular view, she sought out the help issue that has arisen around the nurse’s not being of the nurse practitioner in our gynecology clinic. The original issue usually quite reserved and shies away from public that came up was that the nurse was very concerned forums, with encouragement she was able to share that the doctor on the interdisciplinary team, who the experience with this patient in a large public was also the patient’s therapist, was not giving the forum. She not only shared with other profession- patient the support that the nurse felt the patient als the role that she as a nurse played in the treat- was calling out for. This nurse and I explored her ment of this patient, but she also acknowledged perception that the patient did in fact seem to be herself in a group of professionals as a “knowing reaching out. The patient was told Patients call to us both verbally and nonverbally, that there were treatments to retard the disease but with all sorts of health-related needs. Given this, the doctor, tant to hear the calls and know the process that lets whose primary function is treatment and cure, was us understand them. In hearing the calls and feeling ill prepared to deal with this patient; it was searching our own experiences of who we are, our perhaps this sense of inadequacy that fostered personal angular view, we may progress as human- avoidant behavior on his part. In an effort to better understand why some patients With this clarified, the nurse and I began to explore stayed in the day hospital and others left prema- the nurse’s experience of hearing this call. The turely, the nursing staff of a psychiatric day hospi- nurse spoke of the pain of knowing that this young tal conducted a phenomenological study that woman would die prematurely. She spoke of how investigated the experiences of patients as they en- a friend, who reminded her of this patient, had tered and become engaged in treatment in a day also died and that when she associated the two she hospital system. The initial step in the process of preparing the As we explored the nurse’s angular view, we were nurses for this study was to expand their angular able to identify areas that were unknown. The nurse view by educating them in the phenomenological had difficulty understanding the need or the role of method and the unstructured interview style. In the patient’s relationship with her current order to promote the openness of the interviewers boyfriend. We worked on helping the nurse to to the experience of the patients, we used our group bracket her own thoughts and judgments, so that nursing meetings for the purpose of bracketing our she could be open to the patient’s experience of angular views. I became aware of a other’s experiences and points of view, we were common call being issued forth by nurses from my opening ourselves to the world of other possibilities own experiences as a nurse manager.

Ginseng may enhance the blood sugar-lowering effects of insulin or diabetic med- ications and may decrease the effect of blood-thinning drugs generic 80mg top avana otc erectile dysfunction kits. It is generally well tolerated cheap top avana 80mg mastercard erectile dysfunction 3 seconds, but there are some reports of nervousness, insomnia, and upset stomach. It is not recommended during pregnancy, breast-feeding, or by those with breast cancer. It is commonly used to support immune function, mental acuity, and athletic performance and to help reduce the effects of stress. Numerous studies have found that it can improve osteoarthritis symptoms (joint pain, mobility); it may also prevent the progression of the disease. Research supports benefits for chronic venous insufficiency, varicose veins, pre- vention of blood clots while flying, and reducing post-surgical edema. Unlike black and oolong tea, it is not fermented, which preserves the active constituents. It is used for heart health, cancer prevention, cervical dysplasia, weight loss, liver disease, and gum health. Research has demonstrated that it can improve the heart’s pumping action and is helpful in the treatment of congestive heart failure. It is generally well tolerated; side effects are minor and may include dizziness, upset stomach, headache, and skin rash. It has anti-cancer properties, aids in detoxification of estrogen, reduces the levels of free radicals, and protects liver func- tion. It has been shown in preliminary research to reduce estrogen-promoted cancers (cervical and breast). Many studies have shown that when combined with calcium, it can slow and even reverse bone breakdown; it also helps reduce the pain of fractures caused by osteoporosis. It is generally well tolerated; one study found that long-term use (three years) reduced levels of lymphocytes (white blood cells). Supplements of lecithin are broken down in the body into choline, which promotes methylation and is used to make acetylcholine, a nerve chemical essential for proper brain function. Some research supports benefits for liver disease; lowering homocysteine; and the treatment of bipolar, Alzheimer’s, and other neurological disorders. It may raise blood pressure, lower testosterone in men, and have estrogenic effects; it is not recommended during pregnancy, breast-feeding, or for use by those with cancer. Research supports benefits for prevention of prostate cancer and pre-eclampsia, and treatment of asthma; it may also help prevent macular degeneration, cataracts, and heart disease. Regular supplement use has been shown to prevent cold sores; it may also prevent genital herpes flare-ups. Supplements have been shown to help shorten the time needed to fall asleep, improve sleep quality, and help with disrupted sleep cycles (such as with travellers and shift workers). It may also help in the treatment of depression, seasonal affective disorder, anxiety, schizophrenia, cluster headaches, and to improve quality of life in cancer patients. It is well tolerated and does not cause next-day drowsiness; it is not recommended dur- ing pregnancy or breast-feeding. It may be helpful for osteoarthritis, recovery from sports injuries, and for growth of nails and hair, although research is preliminary. Research supports its use for the treatment of viral and alcoholic hepatitis, and liver cirrhosis. Preliminary research suggests that it might protect the liver against drug-induced toxicity caused by acetaminophen (Tylenol) and phenytoin (Dilantin). It is not recommended for use by those with organ transplants or those taking immune-suppressant drugs; use only under doctor’s su- pervision if pregnant, lactating, diabetic, or if you have an immune disorder. Preliminary research suggests benefits for allergies; topical products are used to relieve the pain of osteoarthritis. It may be more beneficial when combined with pygeum and/or saw palmetto, and is generally well tolerated. Research shows that supplements can help improve memory, mental function, and depression in the elderly, and it is useful in the treatment of Alzheimer’s. It is well tolerated, but may cause mild upset stomach; it may enhance the effect of blood-thinning drugs and supplements, requiring dosage adjustments. Several studies have found benefits with beta-sitosterol (a phytosterol) for reducing symp- toms of prostate enlargement. Phytostanols are added to foods (margarine spreads and salad dressings) and sold as supplements; studies have shown that phytostanols and stanol esters can lower cholesterol levels. It may enhance the effects of blood-thinning drugs and supplements so dosage adjustments may be necessary; it is not recommended during pregnancy or breast-feeding. They are also present in some fermented dairy foods (live culture yogurt), although potency and stability is questionable. They provide many health benefits by protecting against infection by harmful bacteria (yeast and bacteria), aiding in detoxification, producing vitamins, aiding digestion, and supporting immune function. Research supports benefits for travellers’ diarrhea, constipation, irritable bowel, ulcerative colitis, eczema, aller- gies, and tooth decay. They also improve immune function, reduce cholesterol, prevent and treat yeast infections, and enhance ulcer treatment. Choose products that are tested for potency and stability, and made from human strains. Studies have found it beneficial for improving symptoms of an enlarged prostate; it may also be beneficial for prostatitis (prostate infection). It is often combined with saw palmetto or nettle root, which are also beneficial for reducing prostate symptoms, and is very well tolerated. Recent research has focused on its isoflavones, which work as phytoestrogens, with possible benefits for menopause. It may help reduce cholesterol levels and protect against osteoporosis by re- ducing bone loss. It is not recommended during pregnancy, breast-feeding, or for use by those with breast or uterine cancer. It may enhance the effect of blood-thinning drugs, so dosage adjustments may be necessary. It promotes relaxation without sedation, normalizes stress hormones, and reduces stress-related eating. Studies have demonstrated benefits for reducing fatigue and enhancing mental function. Preliminary research suggests that it may help with altitude sickness and may aid cancer chemotherapy by pro- tecting the liver against drug-induced damage. Research shows that supplements can benefit those with depression, os- teoarthritis, liver disease, and fibromyalgia. It may also reduce depression associated with Parkinson’s disease, and is generally well tolerated, but may cause mild upset stomach. It is not recommended for those with bipolar disorder; use cautiously with other antidepressant products. Studies show that it can help reduce an enlarged prostate and improve urinary symptoms, similarly to prescription drugs, but it is better tolerated. It may also be helpful for the treatment of prostatitis, and is generally well tolerated.

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