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Introduction Vision impairment of some type is common in the general pediatric population and is one of the more prominent reasons for referral to buy generic xenical 120mg online weight loss drugs a health clinic buy xenical 120mg xenadrine extreme weight loss. These issues can result in social discount xenical 120 mg amex weight loss pills that work over the counter, behavioral buy xenical 60 mg online weight loss pills plexus, and educational difficulties, all of which can affect development. These problems tend to be more prevalent in the intellectually impaired population, both in adults [3] and in children, although exact statistics depends on the population studied. These anomalies con sisted primarily of refractive errors such as hyperopia and astigmatism, as well as K. Therefore the responsibility for the identification of patients with vision issues falls on the shoulders of the parents, caregivers, and health professionals. To this end, screening programs for school-age children to elucidate and eliminate causes of vision loss, such as amblyopia, have existed for many years [6]. In the last few years, the National Institutes of Health and other vision care orga nizations have tried to encourage pediatricians and primary care providers to screen children at earlier intervals for treatable causes of vision impairment, as previous studies have shown that pediatricians may not routinely test children prior to their starting school at age 5�6 years [7]. While it is more difficult to examine younger children, the benefits of early iden tification of vision abnormalities and their treatment are clear. These issues are more pressing in children with special needs, who may have multiple medical and educa tional issues. Even intellectually disabled adults who have a high incidence of visual problems are frequently unable to communicate their visual difficulties. Structured guidelines for screening and follow-up with optometric and ophthalmic professionals are essential to provide needed care to this community [8]. Furthermore, the need definitely exists for improved screening tools for testing and therapy in this special needs population. Down syndrome is one of the more common causes of neurodevelopmental disabilities and will be covered in greater depth later in this chapter. Furthermore, advances in techniques of in vitro fertilization and neonatology have led to the sur vival of younger, smaller babies who may be born in or prior to the seventh month of gestation. These babies also tend to have a significantly higher incidence of neu rologic, vision, and other sensory issues which require identification and treatment. Issues such as cortical visual impairment are prominent in this population, as will be described later in the chapter. Categorization of Visual Impairment There are varying definitions of the term blind and low vision. Occasionally different local definitions are used, such as the North American definitions. The North American system classifies legal blindness as best corrected vision in the better eye worse than 20/400 (6/60) or a visual field of less than 20fi. Severe vision impairment is defined as best corrected vision worse than 6/60 or 20/200 feet, but better than 20/400. The definition of moderate visual impairment is best corrected vision better than 6/60 or 20/200, but less than 6/18 or 20/60. There are numerous etiologies for impaired vision in patients with neurodevel opmental disorders and multiple methods of classification of visual impairment. Anatomic or Descriptive Classification Overall, uncorrected refractive errors are the most common cause of vision impair ment worldwide. Approximately 12 million children aged 5�15 years worldwide have impaired vision due to refractive disorders, which are correctable with spec tacles [10]. In addition to refractive errors, which are generally correctable with spectacles or vision aids, there are numerous causes of vision impairment depending on which aspect of the eye is affected [5]. Abnormalities of the cornea, such as keratoconus found in people with Down syndrome, can cause distortion of vision. However, anomalies of the lens, such as congenital cataracts or age-related cataracts, are the most common cause of decreased vision worldwide. Glaucoma in which increased intraocular pressure causes changes in the optic nerve and thereby affects the visual field used to be a very common cause of vision loss in the middle aged and elderly populations. Now with increased screening and earlier treatment with more successful regimens, glaucoma is no longer a primary cause of vision loss in the developed world. This demonstrates the efficacy of screening programs in early detection and treatment, in 280 K. Abnormalities of the cornea, lens, and glaucoma are areas where treatment is generally efficacious. Retinal abnormalities such as macular degeneration account for a significant amount of vision loss worldwide especially in the elderly, while infections or dys trophies affecting the retina are a cause of vision loss in children. While advances have been made in the treatment of the �wet� type of macular degeneration, there is no current medical treatment available for dry macular degeneration. Retinopathy of prematurity is treated with laser therapy or surgically if there is evidence of detach ments. These complicated procedures still have not been perfected and patients who have these levels of alterations to the retina often do not tend to recover full vision. Although effective treatments for reduction of scarring or severe detachment of the retina do not yet prevail and are a source of frustration for both physi cians and patients alike, nevertheless early detection of retinal abnormalities is still advised. This enables more effective counseling and allows patients to maintain more independence and a better quality of life. Intracranial, neurologic, or higher visual pathway disorders are a complex entity. Any severe insult along the visual pathway, such as tumors or cortical visual impairment due to hypoxia, can cause impairment of vision. An example of a descriptive classification summarizing some of the causes of decreased vision in children is presented in Table 18. The causes of decreased vision in children access the world vary according to region and socioeconomic status which determines availability of medical care. Hereditary retinal diseases are found throughout the world, whereas retinopathy of prematurity is only found in developed countries who have high levels of neonatal care.

Presentation Typically starts as vesicles which rapidly break down to buy discount xenical 60 mg on-line weight loss pills 1 form honey coloured crusts; less commonly purchase xenical 60mg visa weight loss agents, there may be just a glazed erythema buy discount xenical 60 mg online weight loss pills similar to adderall. Sites usually involved are the face and neck but it can spread extensively over the body xenical 60 mg without a prescription weight loss naturally. If the lesions are widespread, treat with oral anti staphylococcal antibiotics such as fucloxacillin or clarithromycin. Impetiginised eczema Secondary infection, most commonly with Staphlococcus aureus or streptococcal isolates, can occur in the broken skin caused by scratching in atopic eczema. Miliaria rubra (prickly heat) occurs deeper in the epidermis and results in itchy red plaques. Advice to parent/carer � avoid excess heat which predisposes to the condition � avoid excessive soap usage Miliaria � cotton clothing or breathable fabrics should be worn � cool water compresses will soothe infamed areas. Koplik spots on the buccal mucosa are diagnostic at this stage (these look like grains of salt on a red base). Around day 4, a red macular rash will appear behind the ears and spread to the face, trunk and limbs. Immunisation can prevent measles but the disease is becoming more � malnourished individuals common with reduced uptake of vaccination. A barrier moisturiser such as zinc and castor oil cream should then be applied to the area covered by the nappy. Disposable nappies are more suitable than towelling ones while skin is affected as they are more effective at drawing liquid away from the skin. Traffc light If the rash does not improve after taking these simple measures, a weak topical steroid such as 1% hydrocortisone (see section 07) can be applied twice a day for 3�5 days. Napkin dermatitis (nappy rash) the common type of nappy rash is an irritant contact dermatitis, caused by urine and faeces being held next to the skin under occlusion. Bacteria in the faeces break down the urea in the urine into ammonia which irritates the skin. Presentation the rash will be patchy and tends to involve the skin in contact with the nappy (buttocks, genitalia, thighs); the skin folds may be spared. Rubella (German measles) Rubella, caused by a rubivirus, is a common viral illness in children. Presentation After an incubation period of 14fi21 days, a macular rash begins on the face and neck. If itch keeps the patient awake at night, a sedating night-time antihistamine can be prescribed. Advice to patient If there is a family pet (cat or dog) and fea bites are suspected, the animal, rather than the human, should be treated. Bites (insect) the presentation of the bite will help determine the causative insect. If there are groups or rows of 3 or 4, think of fea bites; bed bug bites produce single very large lesions on the hands or face, with new lesions usually being found each morning. Numerous other insects can bite humans, including midges, mosquitoes, fies, wasps, tics, bees, ants, moths and butterfies, centipedes, ladybirds and spiders. These drugs are only effective when the virus is replicating so should only be given in the early phase of the disease (within 48 hours of the rash appearing). Adequate analgesia, such as paracetamol or co-dydramol (adults only), is important. Traffc light In children, hospitalisation may be considered in cases of severe infection. Presentation the rash is made up of small umbilicated vesicles or grouped �punched out� erosions which are painful rather than itchy. Uraemia (also seen in 80% of patients on maintenance haemodialysis) Check creatinine and urea. Obstructive jaundice (may occur in patients with primary biliary cirrhosis before jaundice occurs) Check liver function tests and autoimmune profle. Thyroid disease Both hypo and hyperthyroidism: check T4 and thyroid stimulating hormone levels. Lymphoma Especially in young adults, check for enlarged lymph nodes clinically and on chest x-ray. Psychological Presentation Look for evidence of depression, anxiety or emotional upset. In generalised pruritus, the patient presents with itchy skin all over with no visible rash but may have evidence of excoriation due to scratching. Traffc light the patient often feels dirty and may describe a feeling of something crawling under the skin. Encourage frequent use of emollients and encourage patting (not rubbing) skin dry after bathing. Traffc light A frequent accompanying feature of urticaria is angioedema, in which oedema develops in the subcutaneous tissues around the eyes, lips, mouth and in the pharynx. Urticaria (acute) Urticaria refers to a group of disorders caused by the release of chemicals such as histamine from the mast cells in the skin. Presentation the skin itches or stings, with the development of weals which are frst white, then turn red. The weals can vary from a few millimetres to several centimetres in diameter and can become very extensive, developing in many sites at once. Burrows are most often found on the hands and feet in the sides of the fngers and toes and web spaces. In infants, burrows are often present on the palms of the hands and soles of the feet. It is important to take the time to explain to the patient exactly how to use the treatment, and explanatory treatment sheets are also useful.

Thyme is also used to generic xenical 120mg fast delivery weight loss resorts alleviate chronic gastritis cheap xenical 120mg fast delivery weight loss zanesville ohio, lack of appetite xenical 60 mg amex weight loss 30 10 weight loss for life, enteritis order 60mg xenical amex weight loss pills from doctor, dyspepsia, griping (the sharp pains and grumbling usually associated with trapped gas or diarrhea), indigestion, irritable bowel and colic. Thyme is considered a reliable antispasmodic that has been used to ease convulsions, stomach cramps, epilepsy, menstrual cramps and spasm-induced coughing and diarrhea. As a "nervine" with sedative properties, Thyme is believed to be a good tonic that stimulates and tones up the nervous system, alleviating such nervous disorders as neurasthenia (a functional neurosis marked by intense nervous irritability and weakness), depression, nightmares, nervous exhaustion, insomnia and melancholy. The astringent tannins in the herb cause proteins in the skin tissue to cross-link, forming a barrier to infection. It is potent germicidal properties clean tissue and may be best known commercially as an ingredient in Listerine Antiseptic Mouthwash. Used externally, Thyme is helpful for tumors, dental decay, plaque, thrush, tonsillitis, halitosis, deep wounds, and bruises and as an ingredient in relaxing baths, which alleviates nervous exhaustion. It is said to be effective for destroying skin parasites, such as scabies, crabs and lice. Precautions: Pregnant and nursing women should not use Thyme, as it is a uterine stimulant. Habitual and excessive usage (many times the recommended dosage) is not recommended, as it may cause gastric irritation, and those who are allergic to members of the mint family (Thyme, basil, sage, marjoram, etc. Never drink Witch Hazel purchased from the drug store; it contains an alcohol that is not intended for internal use. Plant Description: Witch Hazel is a deciduous shrub or small tree that is native to the eastern seaboard of the United States, grows in damp woods from Canada to Georgia, and extends to Nebraska. It is cultivated elsewhere for its autumn-blooming flowers and the tree is considered endangered in Minnesota. It is a twisted shrub that grows from five to fifteen feet in height with leathery leaves that are shiny green on top and a dull gray on the bottom. The tree stands out in the forest in the autumn, because as other trees begin to lose their leaves, Witch Hazel is covered with golden yellow, threadlike flowers, thus making it appealing to landscapers as an ornamental plant. History: Centuries ago, Native Americans drank Witch Hazel tea as a general tonic and used it as a gargle for mouth and throat irritations. The tribes introduced and shared the numerous medicinal applications of Witch Hazel to the European settlers, who promptly adopted it into their own daily lives. The name, Witch Hazel, was given to the shrub by the English settlers, who attached their own lore to the American species. Back home in England, the forked twigs of various European trees had been used as divining rods to locate water and minerals, and the twisted, bent branches of the Witch Hazel actually referred to an Anglo-Saxon word meaning, "To bend" and not at all to magic or broomsticks. In the nineteenth century, an alcoholic extract of Witch Hazel was one of the most popular herbs in the United States; it was a distillation of the bark, twigs and leaves, mixed with alcohol and water. Witch Hazel steam baths were also considered very beneficial in helping to loosen heavy phlegm and coughing it up. Witch Hazel was officially listed in the United States Pharmacopoeia, and it is still one of the commonest home remedies in America. The bark, leaves and twigs of the plant are used medicinally for internal and external ailments, and its non-toxic, astringent qualities are highly prized in many cosmetics and pharmaceuticals as soothing ointments and after-shave lotions, etc. Some of the constituents in Witch Hazel include beta-ionone, gallic acid, isoquercitrin, kaempferol, myrcetin, phenol, quercetin, quercetrin, essential oils, saponins, tannins, bitters and resin. Medical Uses: Witch Hazel is a wonderful astringent, and that quality is applied both externally and internally. It is effective in stopping bleeding with a unique kind of astringency whose main focus of action is on the venous system, acting to restore tone, health and vigor throughout the system. The tannin called hamamelitannin has been shown to constrict blood vessels and stem bleeding. Internally, it is one of best remedies for stopping excessive menstruation, hemorrhages from the lungs, stomach, nose, uterus, kidneys and rectum (including bleeding piles). The same astringent properties are also effective in easing diarrhea, dysentery and mucous discharges, including female congestive conditions of the uterus, cervix and vagina (vaginitis and prolapsus). Witch Hazel is a painkiller and antiseptic that will help to kill bacteria and is used as an effective gargle for sore throats and to keep wounds clean and combat infection. Witch Hazel is an anti-inflammatory and anesthetic that is included in several over-the-counter preparations (Preparation H and Tucks) that reduce swelling and soothe the discomforts resulting from rectal and vaginal surgery and stitches. It also helps to relieve the pain and inflammation of hemorrhoids and soothes minor burns, sunburn (Eucarin), sores, and inflamed eyes, bedsores, oozing skin disease, eczema and wounds. Witch Hazel may also be used to ease the inflammation of sore muscles or inflamed, irritated sensitive tissues. It helps to smooth wrinkles, cleanse and tone the skin and prevent oily buildup on the tissues of the skin. Its antiseptic properties help to keep skin clear of pimples and acne and heal wounds. Applied topically, Artemisia aids in healing wounds, skin ulcers, blemishes and insect bites. Plant Description: Wormwood is a native of Eurasia (Europe and Siberia) and North Africa, and the plant has been naturalized in North America where it occurs as a casual weed. It is a perennial root, which arises to a height of two to three feet with leafy, flowering stems. History: the name of the botanical genus, Artemisia, is derived from Artemis, the Greek name for Diana, who is said to have found the plants and delivered their powers to Chiron, the centaur, and the ancient Greeks claimed that the plant counteracted the poisons of hemlock and toadstools. The name, wormwood, is derived from the Anglo-Saxon wermode or wermut, meaning preserver of the mind, since the herb was thought to enhance mental functions and which accounts for its use in treating nervous temperament and melancholia. The major constituent of Wormwood is a volatile oil, dark green or blue in color, with a strong odor and bitter taste.

Level 10) * On successful commissioning buy xenical 60mg without a prescription weight loss tips for women, the pay in the Pay matrix of the Officer commissioned shall be fixed in first Cell of Level 10 and the period of training shall not be treated as commissioned service and arrears on account of admissible allowances purchase xenical 60 mg mastercard weight loss pills yellow jackets, as applicable generic 120mg xenical free shipping weight loss pills appetite suppressant, for the training period shall be paid to buy xenical 120mg overnight delivery weight loss pills venom hyperdrive 30 cadets. In the case of allowances specific to Defence Forces, the rates of these allowances would be enhanced by 25% automatically each time the Dearness Allowance payable on the revised pay band goes up by 50% (GoI letter no. No disability award shall be payable in cases where the degree of disablement is less than 20%. Disability due to alcoholism, drug addiction and due to the diseases of pre enrolment origin will not qualify for disability benefit and Ex-Gratia Grant. Disability due to alcoholism, drug addiction and due to the diseases of pre-enrolment origin will not qualify for disability benefit and Ex-Gratia Grant. Library of Congress Control Number: 2004108494 Previous editions copyrighted 2001, 1997, 1992, 1987 by Elsevier. It would be difficult to imagine how one could write down chemical and mathematical formulas and equations without using abbreviations or symbols. In medicine, they are used as a convenient shorthand in writing medical records, instructions, and prescriptions, and as space-saving devices in printed literature. Some actually save space in print, such as acronyms for the names of institutions and organizational units, as well as being convenient to use. Abbreviations and acronyms used in medicine can be grouped into two broad categories. The first consists of official abbreviations and symbols used in chemistry, mathematics, and other sciences, and those designating weights and measures, whose exact form, capitalization, and punctuation have been determined by official governing bodies. Abbreviations in the second group, on the other hand, may appear in a variety of forms, the same abbreviation having a different number of letters, sometimes capitalized, at other times not, with or without punctuation. Editors of individual scientific publications make an effort to standardize the form of abbreviations and symbols in their journals and books, but they generally vary from one publication to another. This dictionary lists acronyms and abbreviations occurring with a reasonable frequency in the medical literature that were identified by a systematic scanning of collections of books and periodicals at the National Library of Medicine. Except as they take the form of Greek letters, pure geometric symbols are not included. Although we have attempted to be as inclusive as possible, a book such as this one can never be complete, in spite of the most diligent effort, and it is expected that some abbreviations and acronyms may have escaped detection and others may have been introduced since completion of the manuscript. This new fifth edition, although compiled with constant reference to its purpose as a convenient source for the most commonly used acronyms and abbreviations, has nonetheless grown by about 12,000 new entries. No matter what the imprint, however, the same care as always has been taken in the selection of entries and the verification of their accuracy. The familiar format of boldface acronyms and abbreviations followed by run-in meanings has been retained, allowing the book to be kept to a convenient size. New terms have been drawn especially from the areas of virology, clinical trials, new technology, and medical informatics. It is an unfortunate fact that the use of abbreviations, although a helpful time-saver, occasionally leads to ambiguity in interpretation. Even as this fifth edition is being prepared for publication, new acronyms and abbreviations are being added to the already existing body, so that no compilation can ever be complete. I invite you to submit your own suggestions for the next edition; this can be done over the Internet at. Einheit] 18 E exa [10 ] E stereodescriptor to indicate the configuration at a double bond [Ger. Hauch, breath]; deflection in the His bundle in electrogram [spike]; dose equivalent; draft [Lat. Immunit ts Einheit]; immunoelectrophoresis; infective endocarditis; information economics; information engineering; inner ear; intake energy; internal elastica; intraepithelial ie that is [Lat. Kapsel, capsule]; carrying capacity; cathode; coefficient; constant; constant improvement factor [in imaging]; electron capture; electrostatic capacity; equilibrium constant; ionization constant; kallikrein inhibiting unit; kanamycin; Kell factor; kelvin; kerma; kidney; Kilham [virus]; killer [cell]; kilo-; kilodalton; kinetic energy; Klebsiella; knee; lysine; modulus of compression; the number 1024 in computer core memory; potassium [Lat. As the stye grows, the eyelid becomes fi Eyelid tenderness Styes are caused by staphylococcal fi Sensitivity to light swollen and painful. While they fi watering of the eye produce no lasting damage, styes Chalazia (pleural) tend to be larger fi sensitivity to light can be quite painful. A yellowish bump sometimes develops months, though more often than not, in the affected area. Warm compress mation of a blocked meibomian Most styes swell for about 3 days before application may speed up the draining gland, usually on the upper eyelid. Contact details are at the end of this information sheet if you have any questions or concerns. A chalazion is a lump on the eyelid that is caused by inflammation of a tiny sweat gland within the skin. When the gland becomes blocked, it can rupture and the inflammation process begins. A chalazion is not a stye, which is an infection in the eyelash hair follicle root on the surface of the skin. An area on the upper lid becomes hard and swollen over a few weeks � this may be tender and the eye lid may appear red, if infected. The ophthalmologist (eye doctor) will examine the back of the eyelid and the eye itself. Instructions for hot spoon bathing: Have someone help you with this at home if possible. Keeping the eye closed raise the padded end to the affected eye, keeping it about an inch away from the eyelid.

The majority of individuals with psoriasis can be treated with topical treatments discount xenical 60 mg overnight delivery weight loss pills sams club. Approximate age group It can occur at any age but often begins between the ages of 15 and Chronic plaque psoriasis: treatment depends on the type buy xenical 60mg lowest price weight loss over 60, size and 25 years purchase xenical 120mg with visa weight loss ads. Topical treatments include: emollient order xenical 120mg with amex weight loss xls, vitamin D analogues or vitamin D analogue in combination with a potent topical steroid; tar preparations; saliyclic acid ointments; dithranol. Guttate psoriasis: as the condition usually resolves spontaneously, reassurance is all that is needed. Traffc light If more than 30% of the body surface area is affected by chronic plaque psoriasis, referral to dermatology should be considered. Erythrodermic psoriasis, where the entire skin surface is infamed, must be referred to secondary care. Generalised pustular psoriasis is an acute form of the disease which develops rapidly and may be associated with withdrawal of systemic or potent topical steroids. Sheets of erythema studded with sterile pustules come in waves, with an associated fever or malaise. The pain often continues until healing occurs but may go on for months or even years in older people (post-herpetic neuralgia). Treatment If the patient is seen in the prodromal phase with pain or abnormal sensation, or within 48 hours of the blisters appearing, treat with a 7-day course of an oral antiviral agents such as Aciclovir, Valaciclovir or Famciclovir. Antiviral agents are only effective when the virus is replicating and should only be given in the early phase of the disease (within 48 hours of the rash appearing). Adequate analgesia is important, such as paracetamol 1g every 4 hours or co-dydramol 2 tablets 4 hourly (max 8 in 24hrs). In older people, prophylactic amitriptyline 10fi25mg at night, gradually increasing to 75mg, may help post-herpetic neuralgia if started as soon as the rash appears. Advice to patient Reassure the patient that shingles cannot be caught, but chickenpox can Shingles (herpes zoster) be contracted from a patient with shingles by someone who has never Shingles occurs in people who have previously had chickenpox. Traffc light If there is ophthalmic involvement, rapid referral to ophthalmology is Approximate age group required to minimise potential complications of shingles involvement Can occur at any age. The rash is usually unilateral with dermatomal distribution and a sharp cut off at or near the midline. It slowly increases in size and, over time, the centre may ulcerate and crust (rodent ulcer). On examination, if you stretch the skin you will see a raised rolled edge like a piece of string sitting around the edge. Well-differentiated tumours produce keratin, so the surface will be scaly or even horny and are often painful to touch. If the lesion is superfcial (that is, it has not invaded downwards into the dermis), excision is more likely to result in cure. Change or irregular colour Malignant melanoma Minor features (score 1 point) A malignant melanoma is a malignant tumour of the pigment-producing 1 point. Oozing or bleeding of the skin cancers as it has the capability to metastisise through the 1 point. Suspect melamona if any major feature is present or there is a total score Approximate age group of 2. All age groups, particularly in those with fair or red hair who burn rather than tan in the sun. If urinalysis identifes protein or blood in the urine, specialist help should be sought as the patient may require systemic steroids or cyclophosphamide. Where no cause can be found (idiopathic), the patient should be reassured that the condition is self limiting and should resolve within 3fi6 weeks. Vasculitis Advice to patient Vasculitis is an infammation of the blood vessels in the skin, usually due Bed rest will stop new lesions forming. Regular analgesia should be to the deposit of immune complexes in the walls of the vessels. Henoch-Schonlein purpura is a form of vasculitis and occurs mainly in the young (see section 05). Presentation the presentation will differ depending on the size and site of vessels involved. If the capillaries are involved, there will be a polymorphic rash with palpable purpura, as well as macules, papules, vesicles and pustules. Where there is arterial and venous involvement, there will be red, tender nodules or deep plaques in the subcutaneous fat. The condition is communicable from fve days before the rash develops until around six days after. The spots can be very itchy and secondary infection may lead to pock-like scarring. However, an antiseptic-based emollient may reduce the risk of secondary infection. In adults or immunocompromised patients, aciclovir, valaciclovir or famciclovir will reduce the severity of the attack. Traffc light Adults who contract chickenpox can become very unwell with more severe symptoms. Chickenpox (Varicella) Varicella zoster virus causes chickenpox and shingles (see section 04 for shingles). By the age of 10 years most children, particularly in urban communities, will have been infected. Treatment To treat effectively consider the following: � complete emollient therapy (see section 07) � for eczematous lesions, treat with topical steroid (see section 07) � if the itch is disturbing sleep, consider a sedative antihistamine � if there is infection, refer to impetiginised eczema (see this section). Local dermatology nurses and dermatology departments will help with education, support and long-term management.

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