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Triple endoscopy of upper and lower airway and upper aerodigestive tract order 50mg pletal with mastercard muscle spasms xanax withdrawal, with biopsy of any suspicious lesions cheap pletal 100mg on-line muscle relaxant end of life. Measurement and biopsy cheap pletal 50mg muscle relaxant pregnancy, if indicated quality pletal 50 mg muscle relaxant pharmacology, of any cervical or supraclavicular nodes should be performed. Brain metastases are rare and are seen mainly in patients with nasopharyngeal cancer. Depending on tobacco and alcohol history, a second cancer of the head and neck, esophagus, or lung may occur in up to 20% of patients at some time in the course of their disease, especially if they continue to smoke and drink. Primarily surgery for early-stage cancer, sometimes involving radical neck node dissection and/or postoperative radiotherapy. In more advanced stages, head and neck cancers are treated with multimodality therapy, using chemotherapy or targeted agents in combination with radiotherapy. For cancer of the larynx, vocal cord preservation with chemotherapy and radiotherapy is preferred whenever possible. Cessation of smoking and alcohol consumption is essential to decrease the occurrence of second primary cancers in the head and neck region. Which chemotherapeutic agents are used in the treatment of squamous cell cancers of the head and neck? Response rates for these agents vary depending on the agent, schedule, tumor type/location, previous treatment, and patient performance status. Combination chemotherapy regimens usually show higher initial response rates but have yet to show an increase in survival rates. In families with these mutations, generally over half of the female relatives have breast or ovarian cancer that is usually multifocal and has early age of onset. Patients with these gene mutations have a cumulative lifetime risk of developing breast cancer ranging up to 87%. The two surgical options are modified radical mastectomy or breast conservation surgery (lumpectomy) followed by radiation therapy. In both types of surgery, axillary node staging with sentinel node biopsy or axillary node dissection is performed. Lumpectomy followed by radiotherapy is used if complete excision is possible and radiation therapy can be delivered to the tumor bed. Modified radical mastectomy is performed if tumor mass is large relative to breast size, the cancer is multifocal, or radiation therapy is not technically feasible. If the tumor is large or has unfavorable prognostic characteristics on the preliminary biopsy, preoperative (neoadjuvant) chemotherapy may be administered, followed by surgery. After the operation, adjuvant therapy with chemotherapy, hormone therapy, and/or trastuzumab, or combination therapy may be given to help eradicate any possible micrometastases in the circulation. The types of agents chosen will depend on tumor characteristics that include estrogen and progesterone receptor status and Her2/neu status. Patient-specific factors such as menopausal category, age, and comorbidities are also important in the choice of adjuvant therapy. Local radiation therapy is administered to patients whose tumors are at high risk for local recurrence. When is radiation therapy given to the chest wall and regional lymph nodes after breast cancer surgery? For high-risk patients for recurrence identified by: & Lumpectomy as procedure for initial treatment & Four or more axillary nodes positive for cancer & Extracapsular nodal extension & Large (>5 cm) primary tumor & Positive or very close tumor resection margin 150. With either systemic chemotherapy or hormone therapy, depending on hormone receptor status, location of metastases, and patient characteristics, reserving surgery and radiotherapy for local control. Trastuzumab, an antibody against the Her2/neu receptor, may be added for patients whose tumors are Her2/neu-positive. In postmenopausal women with hormone-positive breast cancers, aromatase inhibitors such as anastrozole may be more effective than tamoxifen, and the addition of letrozole after 5 years of adjuvant tamoxifen may offer additional benefit. Paclitaxel, docetaxel, doxorubicin, epirubicin, vinorelbine, cyclophosphamide, methotrexate, fluorouracil, and capecitabine. These agents are used singly or in combination in the treatment of advanced or metastatic breast cancer. If the tumor overexpresses the Her2/neu oncogene, trastuzumab or lapatinib may be added to improve the effectiveness of chemotherapy. How effective are chemotherapy agents in the treatment of metastatic breast cancer? The survival rates depend more on the site of the metastatic disease than on the treatment, with visceral disease faring more poorly than bony or soft tissue metastases. Most patients receive more than one treatment regimen, because the median time to failure of most programs is about 6 months. Newer drugs that target growth factor pathways in breast cancer are currently in development. For early-stage disease, treatment options include radiation therapy or surgery with postoperative radiation therapy plus chemotherapy. For locally advanced disease, the treatment is radiation therapy combined with chemotherapy. What are the 5-year survival rates, relative to stage, for carcinoma of the cervix? What are the 5-year survival rates for the various grades and stages of endometrial cancer?
For example purchase 50mg pletal visa spasms stomach area, a clini cian might decide to generic 100mg pletal fast delivery spasms throat treat with antibiotics if the probability of streptococcal pharyngitis in a patient with a sore throat is > 25% (Figure 1–10A) buy cheap pletal 100mg xanax muscle relaxant qualities. Use of the nomogram shown in Figure 1–7 indicates that the posttest probability would be 55% (Figure 1–10B); thus discount pletal 50mg on-line muscle relaxant 751, ordering the test would be justiﬁed, 18 Pocket Guide to Diagnostic Tests A C B D Treatment threshold 0 Probability of disease (%) 100 Figure 1–9. Using the same nomogram, the posttest probability after a negative test would be 33% (Figure 1–10C). Therefore, ordering the throat culture would not be justi ﬁed because it does not affect patient management. Decision Analysis Up to this point, the discussion of diagnostic testing has focused on test characteristics and methods for using these characteristics to calculate the probability of disease in different clinical situations. Although useful, these methods are limited because they do not incorporate the many outcomes that may occur in clinical medicine or the values that patients and clini cians place on those outcomes. To incorporate outcomes and values with characteristics of tests, decision analysis can be used. Decision analysis is a quantitative evaluation of the outcomes that result from a set of choices in a speciﬁc clinical situation. Although it is infrequently used in routine clinical practice, the decision analysis approach can be helpful to address questions relating to clinical decisions that cannot easily be answered through clinical trials. Diagnostic tests provide more information when the diagnosis is truly uncertain (pretest probability about 50%, as in Part B) than when the diagnosis is either unlikely (Part A) or nearly certain (Part C). To complete a decision analysis, the clinician would proceed as follows: (1) Draw a decision tree showing the elements of the medical decision. The results obtained from a decision analysis depend on the accuracy of the data used to estimate the probabilities and values of outcomes. Figure 1–11 shows a decision tree in which the decision to be made is whether to treat without testing, perform a test and then treat based on the test result, or perform no tests and give no treatment. The clinician begins Outcomes Disease Treat, Disease +, No test p Treat No 1– p disease Treat, Disease –, No test Test + Treat, Disease +, Test done Sens Disease 1–Sens Test – p Don’t treat, Disease +, Test done Test 1–p Test + Treat, Disease –, Test done No 1– Spec disease Spec Test – Don’t treat, Disease –, Test done Disease Don’t treat, Disease +, No test p Don’t treat No 1– p Disease Don’t treat, Disease –, No test Figure 1–11. Generic tree for a clinical decision where the choices are (1) to treat the patient empirically, (2) to do the test and then treat only if the test is positive, or (3) to withhold therapy. The square node is called a decision node, and the circular nodes are called chance nodes. Diagnostic Testing and Medical Decision Making 21 the analysis by building a decision tree showing the important elements of the decision. In this case, all the branch probabilities can be calculated from (1) the probability of disease before the test (pretest probability), (2) the chance of a positive test result if the disease is present (sensitivity), and (3) the chance of a negative test result if the disease is absent (speciﬁcity). After the expected value (expected utility) is calculated for each branch of the decision tree, by multiplying the value (utility) of the outcome by the probability of the outcome, the clinician can identify the alternative with the highest expected value (expected utility). When costs are included, it is pos sible to determine the cost per unit of health gained for one approach com pared with an alternative (cost-effectiveness analysis). This information can help evaluate the efﬁciency of different testing or treatment strategies. Although time-consuming, decision analysis can help structure com plex clinical problems and assist in difﬁcult clinical decisions. Evidence-Based Medicine Evidence-based medicine is the care of patients using the best available research evidence to guide clinical decision making. It relies on the identiﬁcation of methodologically sound evidence, critical appraisal of research studies for both internal validity (freedom from bias) and external validity (applicability and generalizability), and the dissemination of accurate and useful summaries of evidence to inform clinical decision making. Systematic reviews can be used to summarize evidence for dissemination, as can evidence-based synopses of current research. Systematic reviews often use meta-analysis: statistical techniques to combine evidence from different studies to produce a more precise estimate of the effect of an intervention or the accuracy of a test. Clinical practice guidelines are systematically developed statements intended to assist practitioners in making decisions about health care. Clin ical algorithms and practice guidelines are now ubiquitous in medicine, developed by various professional societies or independent expert panels. Their utility and validity depend on the quality of the evidence that shaped the recommendations, on their being kept current, and on their acceptance and appropriate application by clinicians. Although some clinicians are concerned about the effect of guidelines on professional autonomy and indi vidual decision making, many organizations use compliance with practice guidelines as a measure of quality of care. Because treatment decisions have not always integrated the best medi cal knowledge and patient values, there has been growing interest in shared decision making. Shared decision making is a process by which physicians provide patients with evidence-based health information, elicit patient values, and then collaborate to reach a mutually acceptable decision. In this regard, evidence-based medicine is used to complement, not replace, clinical judgment tailored to individual patients. Computerized information technology provides clinicians with infor mation from laboratory, imaging, physiologic monitoring systems, and many other sources. Computerized clinical decision support has been increasingly used to develop, implement, and reﬁne computerized protocols for speciﬁc processes of care derived from evidence-based practice guide lines. It is important that clinicians use modern information technology to deliver medical care in their practice. Ethical, legal, and social concerns about expanded newborn screening: Fragile X syndrome as a prototype for emerging issues. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening.
The last observation carried forward approach was used for Table 3 Subject demographics subjects that made at least one follow-up visit but that did not Treatment Placebo complete the study (lost to buy 50mg pletal free shipping infantile spasms 9 month old follow-up) to generic 50 mg pletal free shipping muscle relaxant allergy minimize missing Age buy pletal 100 mg on-line spasm, years 9 discount pletal 50mg free shipping muscle relaxant tincture. Female (%) 9 (35) 12 (48) Weight, kg (lbs) 23±11 (51±25) 25±11 (55±25) Results Breeds Subject recruitment began in August 2014 at eight veterinary Pure (%) 15 (58) 13 (52) Mixed (%) 11 (42) 12 (48) clinics in the Saint Louis, Missouri metropolitan area, and Affected joint the ﬁnal evaluation was completed in August 2015. A total Stiﬂe/knee (l, r, bilateral) 7 (1, 4, 2) 17 (6, 7, 4) of 51 dogs between the ages of 3 years and 14 years with Hip (l, r, bilateral) 13 (4, 3, 6) 8 (2, 1, 5) suboptimal joint function were enrolled in the study and Shoulder (l, r, bilateral) 2 (2, 0, 0) 1 (0, 1, 0) Elbow (l, r, bilateral) 6 (3, 2, 1) 4 (2, 1, 1) underwent randomization. Of these subjects, 12% (6/51) Note: Except where indicated otherwise, values are reported as mean were from site 1, 20% (10/51) were from site 2, 12% (6/51) ± standard deviation (n=51). Absolute treatment effect is the net difference of treatment versus placebo for the change in mean treatment effect from P=0. A clinical comparison of valid subjects (exclud baseline expressed in percentage. Negative values indicate superior ing noncompliance) was also carried out to obtain mean improvement in the treatment group. Absolute treatment effect is the net difference of abnormalities in any of the clinical chemistry parameters treatment versus placebo for the change in mean treatment effect from baseline expressed in percentage. Subject dog owners reported that the indicate superior improvement in the treatment group, whereas positive treatment was well tolerated by their pets. P-values were determined by repeated measures analysis of variance and Discussion represent treatment versus placebo. The sizeable improvements noted by the dog owners 5 could not be fully corroborated by the veterinarian assess ments of mobility and lameness (w and t), which improved –5 by an average of 11. This disagreement may be a consequence of the differ –15 ence in precision between the two instruments. It is also possible that the disagree for those that suffer from the debilitating conditions. This ment in instruments arises from the inherent design of the trial was designed to evaluate the efﬁcacy, safety, and questionnaires. Evidence from prior studies Veterinary Medicine: Research and Reports 2016:7 submit your manuscript| The authors would also like to thank United the trial had a somewhat limited enrollment (51 sub Pet Group for providing the bottled tablets used in the jects); however, there was a fairly low drop-out rate (9. The other authors report no con (and concurrent sizes) of dogs enrolled in the study, as ﬂicts of interest in this work. Prevalence of hip dys of additional objective measures of joint function (eg, plasia in dogs according to ofﬁcial radiographic screening in Croatia. Incidence of canine hip Further research is warranted to validate the use of serum dysplasia: a survey of 272 cases. Clinical validity of outcome pain mea function, it is important for dog owners to have treatment sures in naturally occurring canine osteoarthritis. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Efﬁcacy of an equine joint ers for osteoarthritis caused by fragmented medial coronoid process in supplement, and the synergistic effect of its active ingredients (chelated trace dogs. Power of treatment success deﬁnitions nuclear cells: increased suppression of tumor necrosis factor-α levels when the Canine Brief Pain Inventory is used to evaluate carprofen after in vitro digestion. Guidance brand eggshell membrane effective in the treatment of pain associated for Industry: Estimating the Maximum Safe Starting Dose in Initial Clini with knee and hip osteoarthritis: results from a six-center, open-label cal Trials for Therapeutics in Adult Healthy Volunteers. Effects of natural eggshell membrane Evaluation of a nutraceutical joint supplement in camels. Veterinary Medicine: Research and Reports Dovepress Publish your work in this journal Veterinary Medicine: Research and Reports is an international, Visit. The manuscript management system is com pletely online and includes a very quick and fair peer-review system. Additionally, a significant treatment response from baseline was also observed for composite stiffness at both 10 days and 30 days (22. There were no adverse events or serious adverse events reported during the study and the treatment was reported to be well tolerated by study participants. There was also a meaningful reduction in the amount of analgesic consumed on a weekly basis, which further enhanced patients’ safety. Masini Keywords Knee, Osteoarthritis, Supplement, Egg Shell Membrane, Glycosaminoglycans 1. The pain associated with these maladies can be quite debilitating and few treatment options exist outside of easing symptoms. Eggshell membrane is primarily composed of fibrous proteins such as Collagen Type I . However, egg shell membranes have also been shown to contain other bioactive components, namely glycosaminoglycans. The single-center trial reported here was designed to evaluate the efficacy of this natural arthritis treatment in an Italian population and to confirm the results found previously in the U. Clinic visits were scheduled for subjects at study initiation and at 10 days and 30 days following the onset of treatment. Treatment compliance was checked at clinic visits by patient interview and by counting the number of unused doses of the study medications. Patients All subjects 18 years of age or older who were seeking relief of mild to moderate pain due to osteoarthritis of the knee were considered for enrollment in the study.
In most cases avoidance ered discount 100mg pletal mastercard 3m muscle relaxant, especially in patients with a reasonable of contact sports until the cyst heals is sufﬁcient buy pletal 100mg mastercard spasms right before falling asleep. Patients should always be referred back to generic 100mg pletal otc muscle relaxants quizlet their Benign bone tumours oncologist for further management cheap 50mg pletal with visa vascular spasms, which will usually include radiotherapy to the site of the Osteochondromas (exostoses) metastasis to prevent recurrence. Most are solitary and are small bony outgrowths Hamartomata from the shaft of a long bone with a small cartilage these are lesions of bone which are developmental cap. If the lesion is large in a solitary osteochondroma is low (probably <1 or symptomatic, there is a small risk of fracture. Fibrous dysplasia Aneurysmal bone cysts this is a developmental abnormality of bone where these can look very similar to simple bone cysts, the bone does not form properly and is weaker than but can also arise in axial bones. Stress fractures are common and in severe spontaneous resolution can occur, most will cases the bones can be bowed and deformed. Radiologically they can be indistinguishable from X-rays typically show a ground-glass appearance an osteosarcoma and biopsy should always be 94 Neoplastic conditions of bone and soft tissue Chapter 12 Figure 12. If the patient also has cutaneous angi omas then this is Mafucci’s syndrome where the risk considered. Chondroblastoma Enchondromas this is a benign cartilage tumour which typically these are benign cartilage growths inside the bone. If an enchon droma is longer than 5cm and is symptomatic, this is a benign tumour typically arising eccentri then potential malignancy should be considered. Osteoid osteoma this is a bone-forming tumour that typically arises Ollier’s disease in the cortex of a long bone. The mid-tibia is the the patient suffers from multiple enchondromas most common site but any bone can be affected. The risk of the patient typically has a long history of pain, 95 Chapter 12 Neoplastic conditions of bone and soft tissue There is a 10–20% risk of local recurrence and a 1% risk of metastases developing, although these tend to behave very indolently. In some sites, excision and reconstruction may be appropriate and in others, such as the spine or pelvis, embolization, surgery and radiotherapy may be needed. Primary malignant bone tumours Osteosarcoma this is a malignant neoplasm arising from bone cells which are undifferentiated and capable of forming bone, cartilage and collagenous tissue. It is the most commonly occurring primary tumour of bone, with an incidence of 3 per million popula tion. It usually occurs under the age of 30, in boys more than in girls, and in cylindrical bones. It almost always affects the especially at night, almost completely relieved by metaphysis. X-rays tends to occur in ﬂat bones as well as long bones, show a central nidus with dense sclerosis around it and is then usually associated with Paget’s disease (Fig. The typical feature is a destructive lesion in the metaphysis—usually translucent and often with reactive periosteal new bone or rays of ossiﬁcation Osteoblastomas within the expanding tumour (‘sunburst effect’) these are slightly larger versions of the same lesion (Fig. Giant cell tumours Investigations these arise in the epiphysis after growth has ﬁn Staging is essential to assess both the local and ished and typically involve the knee region, with a distant extent of disease. As metastases tend to be lytic defect affecting either the femoral or tibial blood borne, lung metastases are the greatest risk. Biopsy is with obvious malignant cells showing mitoses, but essential to exclude a malignant tumour. Treatment often with areas of bone, cartilage and ﬁbrous is by detailed curettage and can be supplemented tissue, which may confuse the diagnosis. The with adjuncts such as phenol or cryotherapy fol tumour is usually highly vascular, but there may be lowed by either bone grafting or cementation. This variation in histological 96 Neoplastic conditions of bone and soft tissue Chapter 12 Figure 12. Patients with osteosarcoma arising after previous Treatment radiotherapy should be treated as a new primary Treatment now almost always commences with osteosarcoma, although they may not be able to chemotherapy. This has the advantage of immedi receive full doses of chemotherapy and surgery is ately treating the micro-metastases which are usually more difﬁcult. After 6–9 required but chemotherapy is not needed in most weeks, surgery is carried out. The tumours being reconstructed with a custom-built prosthesis usually present early and treatment is surgical; the and artiﬁcial joint if necessary. If the tumour is too extensive at the time of diagnosis and there this is a tumour which arises from chondroblasts is a poor response to chemotherapy, amputation and can only produce chondroid and collagen, may still be necessary. It at diagnosis, the prognosis is poor, but for those typically affects the bones of the trunk and the without detectable metastases, there is now a cure proximal ends of long bones. About two-thirds of the tumours occur in cylindrical bones, but the older the patient the more likely it is that the tumour arises in a ﬂat bone because it develops from red marrow. Radiological features the most striking feature is bone destruction and often a soft-tissue swelling. Occasionally, there are onion-skin layers of new bone formation around the lesion. At diagnosis, 25% of patients will have metastases, either in the lung, other bones or bone marrow. Occasionally, the centre of the tumour may be necrotic and liqueﬁed, resembling Figure 12. The tumour consists of round cells of uniform appearance—usually with areas of degeneration. The tumours have a characteristic t11:22 transloca surface (peripheral), sometimes in an osteochon tion on cytogenetic testing. The tumour may cause pain Treatment and a slowly increasing swelling, often over many Chemotherapy usually produces a dramatic years.
Lewy body dementia presents with parkinsonian signs order 100 mg pletal with mastercard bladder spasms 4 year old, fluctuating mental status discount 100 mg pletal free shipping spasms lung, and visual hallucinations and can be often misdiagnosed as Parkinson’s disease or primary psychosis generic pletal 100mg visa spasms heat or ice. Patients typically respond poorly to purchase 100mg pletal with mastercard muscle relaxant pregnancy category antipsychotic medications, with prominent extrapyramidal symptoms. At age 65, the prevalence is approximately 1–2% but increases each year thereafter, approaching 20–25% by age 85. When a demented patient has behavioral problems, what nonpharmacologic approaches are helpful? Cholinesterase inhibitors such as tacrine, donezepil, rivastagmine, and galantamine in general have minimal benefit in reversing dementia but are often given with the hope of slowing progression. Patients with mild-to-moderate dementia should be assessed for depression and treated appropriately. Severe agitation with delusions or hallucinations warrants a trial of an antipsychotic but adverse effects are common. Severe sleep disturbance that has not responded to nonpharmacologic measures warrants a trial of a nonbenzodiazepine hypnotic. Depression is commonly associated with cognitive difficulties (pseudodementia) and many patients in early stages of dementia become depressed. The differentiation of pseudodementia from true dementia can be a clinical challenge. Clues that depression is the cause of cognitive difficulties include decline over weeks to months rather than years and whether the patient has overt concern for their memory loss. Referral for complete neuropsychological testing can be helpful in elucidating the diagnosis in many cases. Treatment with antidepressants will significantly improve cognitive function in patients with pseudodementia, whereas truly demented patients may see improvements in overall function but will continue to have cognitive impairment. Current research, though, focuses on antihypertensive agents, omega-3 fatty acids, physical activity, and cognitive activities as possibly effective. What presenting features can lead to underdiagnosis or overdiagnosis of Parkinson’s disease? There are no blood tests or imaging studies for confirming the diagnosis, and other medical conditions present with similar features. For this reason, clinicians can easily underdiagnose or overdiagnose Parkinson’s disease, especially at early stages. Presenting features leading to underdiagnosis include: & Absence of resting tremor on initial presentation that occurs in 25% of patients with early Parkinson’s disease. Presenting features leading to overdiagnosis include: & Tremor related to other causes. The most commonly used are nonselective beta blockers (such as propanolol) and primidone. Surgical procedures may be tried in patients who had an unsatisfactory response to drug therapy, and after carefully weighing the benefit-to-risk ratio. Available surgical procedures include thalamotomy or placement of electrodes for high-frequency stimulation of the thalamus. Many patients fail to mention restless legs, periodic limb movements, or nocturnal myoclonus unless specifically questioned, and only describe “poor sleep. Evening treatment with a dopaminergic medication such as ropinirole is highly effective in many patients. What is the most effective treatment for patients who feel dizzy when they turn their head or roll over? This condition is attributed to the presence of free-floating calcium debris (dislodged from the utriculus) within the posterior semicircular canal. The diagnosis is confirmed by the Dix-Hallpike maneuver, which provokes similar symptoms and a typical nystagmus. The maneuvers encourage the migration of calcium debris from semicircular canals back to the utriculus. In an elderly patient who is incapable of giving even a decent medical history, how can one differentiate dementia and delirium? Interviewing family members or friends is also helpful in obtaining an accurate history in a confused patient. Among adults aged 57–64 years, 74% report sexual activity, declining to 26% among those aged 75–85 years. The urethral sphincter is activated by alpha1 receptors in the sympathetic nervous system. The detrusor muscle is inhibited by the sympathetic nervous system and activated by the parasympathetic system, largely through M2 and M3 muscarinic (cholinergic) receptors. How does this innervation affect the choice of pharmacologic treatments for urinary incontinence? For men with prostatic hypertrophy and a tendency to urinary retention, resting urethral sphincter pressure is usually high so alpha1 receptor blockers are used to reduce sphincter tone and facilitate emptying of the bladder. For patients with urge incontinence, anticholinergic medications with activity in blocking the M2 and M3 receptors are used to relax the bladder. The residual should be measured before bladder relaxant drugs are given because they are contraindicated if the residual volume > 200 mL. Besides infection risk, patients attached to an indwelling catheter remain in bed more than usual, which is highly detrimental in older patients. The indications for an indwelling catheter are urinary retention, severe pressure ulcers where healing is compromised by incontinence, or for hemodynamically unstable patients whose urinary output must be closely monitored. Is it true that clamping a Foley catheter before pulling it out helps “train the bladder”? There is no advantage to intermittently clamping the catheter for a day or two before removal. The alpha1 adrenergic antagonists improve bladder outlet obstruction by acting in the prostatic urethra, bladder neck, and prostate.
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