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Esophageal squamous cell carcinoma: possible factors o Alcohol o Tobacco o Nutritional exposure Nitrosamines: bush teas containing tannin and/or diterpene phorbol esters o Nutritional deficiencies (riboflavin 5 mg selegiline visa symptoms for diabetes, niacin purchase selegiline 5 mg on line treatment kidney failure, iron) o Chronic esophagitis o Achalasia o Previous lyle-induced injury o Tylosis o Plummer Vinson (Paterson-Kelly) syndrome First Principles of Gastroenterology and Hepatology A generic selegiline 5mg with visa treatment 7th feb cardiff. This has led to several theories concerning certain environmental agents that may be important etiologically (Table 3) buy discount selegiline 5 mg on-line symptoms uterine prolapse. In North America, squamous cell carcinoma is associated with alcohol ingestion, tobacco use and lower socioeconomic status. Characteristically these cancers, similarly to adenocarcinoma, extend microscopically in the submucosa for substantial distances above and below the area of the gross involvement. They also have a propensity to extend through the esophageal wall and to regional lymphatics quite early. Furthermore, they usually produce symptoms only when they have become locally quite advanced. For these reasons approximately 95% of these cancers are diagnosed at a time when surgical cure is impossible. In most studies, the mid-esophagus is the most common site of origin; however, others have reported distal cancers to be most common. Other symptoms include odynophagia, chest pain (which may radiate to the mid-scapular region), hoarseness (due to recurrent laryngeal nerve involvement) and blood loss. Pulmonary complications due to either direct aspiration or esophagorespiratory fistulas are also quite common during the course of the disease. Hepatomegaly or enlarged cervical or supraclavicular lymph nodes may be detected in cases of disseminated metastases. Barium swallow is usually diagnostic, although small cancers can be missed in up to 30% of cases. Endoscopy with multiple directed biopsies combined with brush cytology is required to confirm the diagnosis. This should be followed by careful attempts to stage the disease prior to deciding on therapeutic intervention. Endoscopic ultrasound appears promising in accurately assessing depth of tumor involvement and presence or absence of enlarged mediastinal lymph nodes. Barium swallow radiograph in a patient with adenocarcinoma of the distal esophagus. When similar lesions are in mid or proximal esophagus, they usually are squamous cell cancers. Shaffer 78 Treatment results of squamous cell carcinoma of the esophagus are discouraging. These tumors are quite radiosensitive; however, most centers give radiotherapy to patients who have advanced unresectable tumors or other health problems that make them poor surgical candidates. In the few reports where radiotherapy is used as the primary mode of therapy in patients who might otherwise be considered surgical candidates, the five-year survival rate is as high as 17%, which compares quite favorably to surgical results. Both forms of treatment have significant morbidity, but the surgical mortality following esophageal resection is 510%. Controlled trials are needed, but in only a small proportion of the total population of esophageal cancer patients is cure a realistic goal. New regimens that combine radiotherapy and chemotherapy, with or without surgery, are currently being evaluated and show promise in improving cure rates and disease-free survival. Both radiotherapy and palliative surgery can be used in this setting; however, other modalities are often necessary. The dysphagia can be relieved with peroral dilation, but in many patients this becomes exceedingly difficult as the disease progresses. If this is the case, a prosthetic device can sometimes be placed across the tumor to maintain luminal patency. These stents can work quite well, although tube blockage, tube migration, erosion through the esophageal wall and sudden massive aspiration are important complications. These prosthetic devices are the best treatment for an esophagorespiratory fistula. Photodynamic therapy and radiofrequency ablation are two relatively new minimally invasive treatment modalities for palliating esophageal cancer. The former involves using a photosensitizing compound that accumulates in cancer cells, which leads to their destruction when they are exposed to light of a certain wavelength. The caring physician must also provide emotional support, nutritional support and adequate pain therapy for these unfortunate patients. Webs and Rings Webs are thin, membrane-like structures that project into the esophageal lumen. They are covered on both sides with squamous epithelium and are most commonly found in the cervical esophagus. Webs are usually detected incidentally during barium x-rays and rarely occlude enough of the esophageal lumen to cause dysphagia. In some instances postcricoid esophageal webs are associated with iron deficiency and dysphagia the so-called Plummer-Vinson or Paterson-Kelly syndrome. This syndrome is associated with increased risk of hypopharyngeal cancer and should be managed with bougienage, iron replacement and careful follow-up. Esophageal webs may also form after esophageal injury, such as that induced by pills or lye ingestion, and have also been reported in association with graft-versus-host disease. The lower esophageal or Schatzkis ring is also a membrane-like structure, but unlike webs is lined by squamous epithelium on its superior aspect and columnar epithelium inferiorly. Few produce sufficient luminal obstruction to cause dysphagia (yet a lower esophageal ring is a common cause of dysphagia). When the lumen is narrowed to a diameter of 13 mm or less, the patient will experience intermittent solid-food dysphagia or even episodic food-bolus obstruction. Treatment of a symptomatic Schatzkis ring involves shattering the ring with a large-diameter bougie or a balloon dilator. Shaffer 79 treatment with a proton pump inhibitor has been shown to decrease the recurrence of symptomatic Schatzkis rings. Diverticula Pharyngoesophageal diverticula are outpouchings of one or more layers of the pharyngeal or esophageal wall and are classified according to their location. Zenkers diverticulum forms because of decreased compliance of the cricopharyngeal muscle, which results in abnormally high pressures in the hypopharynx during deglutition. In addition to pharyngeal-type dysphagia, Zenkers diverticulum may be associated with effortless regurgitation of stagnant, foul-tasting food, as well as aspiration. Most surgeons will either resect the diverticulum or suspend it (diverticulopexy) so that it cannot fill. In many cases, particularly if the diverticulum is small, cricopharyngeal myotomy alone will alleviate symptoms. Once the cricopharyngeal myotomy has been performed, the patient has lost an important defense mechanism to prevent the aspiration of refluxed material.

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Laboratory Examination A labaratory exam is only warranted when the sexual desire problem is clearly generalized purchase selegiline 5mg 300 medications for nclex. Total T is measured by radioimmunoassay which is a validated generic selegiline 5mg on-line symptoms 5 days post embryo transfer, standar- dized purchase selegiline 5mg amex treatments yeast infections pregnant, and reproducible assay selegiline 5mg for sale medicine 5513. Segraves and Balon estimate that 200350 ng/dL of T is required for normal sexual function and that above 450 ng/dL, it is difcult to demonstrate a relationship between testosterone and sexual activity. Measurement of T is best performed in the morning because of the diurnal variation in blood levels. Male Hypoactive Sexual Desire Disorder 85 men, mean serum T levels decrease by $30% between ages 25 and 75. Origin, Production, and Control Testosterone in men derives mostly from the testis but a small amount comes from the adrenal cortex. In older men, the function of both the testes and the hypothala- mic-pituitary axis are diminished and for both reasons, the output of T is less (24). About 56 mg of T is secreted daily into the plasma of men, usually in a pulsatile manner every 6090 min, and in a diurnal rhythm in which peak levels occur during the morning (although less pronounced in older men) (25). In addition to intraday uctuations, there is a wide range of normal levels between different individuals. Effects on Sexuality The sex-related impact of T in men has been demonstrated in two groups: (a) those who have been deprived of this hormone in a signicant manner and who are hypogonadal as a result (the most extreme example of which is men who have been castratedphysically or chemicallyfor any reason and in varying degrees) and (b) those who are generally healthy (including their hormone levels, otherwise referred to as eugonadal). The inuence of androgens on sexual desire is particularly prominent and was summarized by Bancroft (26; pp. From his studies on hypogonadal men, he concluded that within 34 weeks of androgen withdrawl: (i) sexual inter- est declines as measured by the frequency of sexual thoughts (ii) sexual activity appears to diminish (as a result of decreased sexual desire) but is more difcult to assess because of the confounding effects of a sexual partner, and (iii) the capacity for ejaculation disappears. When androgen replacement is given, these phenomena are reversed within 710 days. Fantasy (or imagery)-associated erections and nocturnal erections are both androgen-dependent, and cease as a result of androgen withdrawal. The fact that only certain aspects of erectile function are affected suggests that the impact in this area is indirect, that is, on the mans central nervous system rather than directly on his genitalia. Male Hypoactive Sexual Desire Disorder 87 described as performance anxiety superimposed on a biogenic desire disorder (27; p. Segraves and Balon summarize the impact of the therapeutic use of T in eugonadal men by saying that a relatively low level. Changes in Effects with Age The mystery of what happens to T as men age is not easy to unravel and possibly involves three separate issues: changes in production, carrier proteins, and recep- tor sensitivity. The decrease in normal levels of T with age (described previously) seems partly explained by a decrease in function of both testicular tissue (Leydig cells) and the pituitary-hypothalamic axis. A third issue is the possible decline in the level of sensitivity of T receptors (especially those in the central nervous system) which might explain both reduced sexual desire in the aging male and the need for large doses of T in treating hypogonadal states in older men. In a very informative study of men presenting to a clinic because of sexual disorders and who were later found to be hyperprolactinemic, Schwartz et al. Even more striking (and a sobering lesson to those who are not exible in their approach to treating sexual problems in men), sex therapy administered before the hyperprolactinemia was discovered, actually resulted in improvement! Some view sexual difculties from primarily a biomedical perspective and regard sex as natural. Because the reex pathways of sexual functioning are inborn does not mean that they are immune from disruption due to impaired health, cultural condition- ing, or interpersonal stress (30; p. Others look at sexuality and see the absence of intimacy as being crucial to understanding the psychological origins of many sexual difculties (11,32). Likewise, the patients past may not have included the experimental love and sexual relationships of adolescence in which so much learning takes place about oneself and others. Tiefer wrote that the primary inuences on womens sexuality are the norms of the culture, those internalized by women themselves and those enforced by institutions and enacted by signicant others in womens lives (5; p. Male Hypoactive Sexual Desire Disorder 89 even as the word natural is applied to men, it does not explain the contribution to sexual problems of either intimacy issues or cultural variations in sexual behavior. The social and cul- tural environment determines sexual expression and the meaning of sexual experience (31). Nevertheless, the observation is at least noteworthy, and beyond that, may be etiologically meaningful. Segraves and Segraves reported on 906 subjects (including 374 men) who had been recruited for a pharmaceutical company study of sexual disorders (20). Almost half (47%) had a secondary diagnosis of erectile impairment and a few (n 3) had retarded ejaculation (patients with premature ejaculation were excluded from the study). Schiavi reviewed 2500 charts of individuals and couples referred between 1974 and 1991. Together with colleagues, Schiavi also examined the psychobiology of a group of sexually healthy men aged 4574 living in stable sexual relationships (36; pp. One of the issues considered was a comparison of men with and without a sexual dysfunction. Sexual Difculties in a Partner Sexual difculties in a partner, for example, intercourse-related pain experienced by a woman, may result in profound change in the level of sexual desire in the other person. Case Study Rob and Melissa (not their real names), both 23 years old and university stu- dents, were referred because intercourse had not yet occurred in their 3- month-old marriage. History from both, plus her pelvic exam, revealed a diagnosis of vaginismus uncomplicated by vaginal pathology. Conventional treatment of vaginismus was successful in a technical sense (intercourse took place), but Melissa was cha- grined to nd that it was not as pleasurable as she anticipated (12). From the time of Robs initial attempt to insert even part of his penis, he was concerned over her report of intercourse-related pain, and found that his sexual desire had diminished considerably when compared with the pre-treatment level. He found that in general, he was thinking much less about sexual matters, and when he and Melissa were sexual together, his erections were less than full and he was unable to ejaculate in her vagina. His sexual desire slowly returned (but not to the pre-treatment level) as he accepted her reassurance that her intercourse pain was progressively diminishing. Her continuing lack of physical pleasure in intercourse (she looked forward to the closeness) seemed to impede the recovery of his own desire. One study indicated that did not predict sexual dysfunction in a clinical sample of adult men asking for treatment of this disorder (37). Case Study Alan and Amy (not their real names), both 32 years old; were referred by their family physician because of Alans low level of sexual desire which had been a problem for most of the 7 years of their marriage. Their rst 6 months together (they had lived in separate cities before marrying) were sexually harmonious but difculties became apparent after that time. They explained that nowadays they would go to bed at different times, and that he would hardly touch her. Six months prior to the rst visit, she discovered magazines in the back of his car which depicted men dressed as women. Alan asked Amy if he could do the same when they were sexual together, that is, be dressed as a woman. They were referred for care to a psychiatrist who specialized in treating couples where one partner had a paraphilia. Examples of psychological factors include: adopting the patient role as an asexual person, altered body image, mood difculties, and fear of death or rejection by a partner.

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Clinical manifestations Intestinal schistosomiasis is caused by all human Schistosoma except S buy cheap selegiline 5 mg on-line silent treatment. It affects the large bowel buy cheap selegiline 5mg on line treatment group, the liver(in the intestinal form) buy selegiline 5 mg with visa treatment viral conjunctivitis, distal colon and rectum generic 5mg selegiline amex medications affected by grapefruit, and manifestations are dependent on the stages of st infection. Swimmers itch (stage of Invasion): This is the first clinical sign of acute infection appearing soon after exposure, usually with in 24 48 hrs, and characterized by itching at sites of cercarial entry commonly known as swimmers itch. Patient may have generalized lymphadenopathy, hepatosplenomegally, urticaria and leucocytosis with marked eosinophilia. Severity depends on intensity of infection, and tends to be mild in indigenous population. The clinical picture represents the effect of the pathologic lesions caused by the eggs on the urinary and gastrointestinal systems. Thus urinary and intestinal Schistosomiasis are different in their manifestations, as described below. They may have intestinal polyps, and progressive fibrosis of the intestinal wall leading to formation of strictures but intestinal obstruction is very rare. Moreover, granulomatous hepatitis followed by progressive peri-portal fibrosis (also called pipe stem fibrosis) may develop resulting in portal hypertension with associated splenomegally, ascites and esophageal varices that occasionally may bleed. Chronic infection leads to obstructive uropathy, hydronephrosis, chronic pyelonephritis, renal failure and contraction of the bladder. Laboratory Diagnosis Identification of the characteristic ova In stool or urine by Direct smear method; easy but light infection can be missed Sedimentation / Concentration method In rectal snip/bladder biopsy sample if it cannot be detected in the stool or urine. Design appropriate methods of prevention and control of cestodes Cestodes or tapeworms are segmented worms. As each proglottid matures, it is displaced further back from the neck by the formation of new, less mature segments. Eggs deposited on vegetation can persist for months or years, until ingested by cattle. Embryo 53 Internal Medicine from cattle intestine migrates to the muscle and transform into cysticercus. Diagnosis: The diagnosis is reached by demonstrating the eggs or proglottids in the stool. Etiology: The adult tapeworm resides in the upper jejunum, similar to taenia saginata. Its scolex attaches to intestinal wall by both sucking disk and two rows of hooklets. Clinical features : Mostly patients are asymptomatic; but they could have epigastric discomfort, nausea and weight loss. When infected with cysticerica (cysticercosis), they are distributed all over the body. Diagnosis is difficult in cysticercosis, which is done by different clinical and laboratory criteria. Hatching of eggs occurs in the small intestine where they penetrate the villus and become cysticercoid. Since this tapeworm consumes a lot of vitamin B12 and interferes with its absorption, it can cause vitamin B12 deficiency; and some patients develop megaloblastic anemia. Diagnosis: Diagnosis is reached by demonstration of characteristic eggs in the stool. B further reading Module on intestinal parasitosis, by Health Science College, Hawassa University 55 Internal Medicine 3. List the etiologies & animal reservoirs of the different types of leishmaniasis 4. Refer suspected cases of leishmaniasis to hospitals for investigation & treatment 12. Design appropriate methods of prevention andcontrol of leishmaniasis Definition: is an infectious disease caused by the protozoa called Leishmania Classification of leishmaniasis There are three major clinical forms of leishmaniasis: Visceral leishmaniasis Cutaneous leishmaniasis Mucocutaneous leishmaniasis Etiologic Agents The different clinical forms of leishmaniasis (listed above) are caused by different species of leishmanial parasites which are listed under each of these diseases. The parasites are seen in two forms Leishmanial form:- ( amastogote ) this is non flagellate form seen in man and extra human vertebrate reservoir Leptomonad forms (also called promastigotes) are flagellated forms The parasite is transmitted by the bite of vectors of the species phlebotomus, Sand flies 56 Internal Medicine Life Cycle of Leshimaniasis Transmitted by the bite of an infected female phlebotomine Sand fly, the leishmaniases are globally widespread diseases. Sand flies are primarily infected by animal reservoir hosts, but humans are also a reservoir for some forms. Animal Reservoirs: include Rodents - Commonly in East Africa, Ethiopia, the Sudan and Kenya and Canines - Mediterranean and Asia. As the sandfly feeds, promastigote forms of the leishmanial parasite enter the human host via the proboscis. Within the human host, the promastigote forms of the parasite are ingested by macrophage where they metamorphose into amastigote forms and reproduce by binary fission. They increase in number until the cell eventually bursts, then infect other phagocyctic cells and continue the cycle. The parasites are transformed inside the fly and delivered to a new host, and the life-cycle continues Fig 3. It is characterized by chronic irregular fever, profound wasting, debility and hepatosplenomegally. Epidemiology Visceral leishmaniasis affects many countries in Africa, mainly Ethiopia and the Sudan the Middle East, Southern soviet union, India and S. Transmission The commonest way of transmission is by inoculation of promastigotes into humans by the bite of sand flies which breed in termite hills and forests. The source of the aflagellate forms may be either humans or extra human vertebrate reservoirs, and the disease may have life cycles that involve humans and sand flies only, or humans, sand flies and extra human vertebrate reservoirs together. Pathogenesis The common site of entrance is the skin where primary cutaneous lesion appears at the sites of sand fly bite. Here a cellular reaction by lymphocytes and plasma cells develop around the amasitigote-filled histiocytes in the dermis. As immune response develops epitheloid and giant cells appear, to be followed in some by healing. In others usually 4-6 months later amastigotes escape to the blood in macrophages, hematogeneous spread occurs and colonize the cells of reticuloendothelial system, where they multiply further and released after rupture of the cells and transported to new cells. The cells affected include that of spleen, liver, bone marrow and lymphatic glands, where the parasite multiplies and cause overcrowding of cells and as a result these organs are enlarged. The liver with its Kuppfer cells packed with amastigotes is enlarged & progress to cirrhosis. Clinical Features Incubation period usually varies from weeks to months but can be as long as years. Diagnosis Definitive diagnosis is based on demonstration of the Parasite - Giemsa stained smear of peripheral blood (in Indian form) and tissue touch preparation of organ aspirates and examined by light microscopy. Following the bite of sand flies, leishmania multiply in the macrophages of the skin.

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A comparison of clinical features and mortality among methicillin-resistant and methicillin-sensitive strains of Staphylococcus aureus endocarditis order selegiline 5mg with visa symptoms youre pregnant. Mortality after Staphylococcus aureus bacteraemia in two hospitals in Oxfordshire purchase selegiline 5 mg with mastercard treatment 001, 1997-2003: cohort study cheap selegiline 5 mg free shipping medications pain pills. Mortality associated with in-hospital bacteraemia caused by Staphylococcus aureus: a multistate analysis with follow-up beyond hospital discharge generic 5 mg selegiline overnight delivery symptoms 9 weeks pregnant. Clinical and laboratory features of invasive community-onset methicillin-resistant Staphylococcus aureus infection: a prospective case-control study. Risk factors and mortality in patients with nosocomial Staphylococcus aureus bacteremia. Risk factors for nasal carriage of methicillin- resistant Staphylococcus aureus among patients with end-stage renal disease in Taiwan. Comparison of necrotizing fasciitis and sepsis caused by Vibrio vulnicus and Staphylococcus aureus. Community-associated strains of methicillin-resistant Staphylococcus aureus and methicillin-susceptible S. The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses. Staphylococcus aureus bacteremia after thermal injury: The clinical impact of methicillin resistance. Clinical and economic outcomes in patients with community-acquired Staphylococcus aureus pneumonia. The changing pattern of severe neonatal staphylococcal infection: a 10-year study. The impact of resistance to methicillin in Staphylococcus aureus bacteremia on mortality. Denite infective endocarditis: clinical and microbiological features of 155 episodes in one Japanese university hospital. Infections caused by Staphylococcus aureus in a Veterans Afairs nursing home care unit: a 5-year experience. Pathogenic signifcance of methicillin resistance for patients with Staphylococcus aureus bacteremia. Methicillin resistance is not a predictor of severity in community-acquired Staphylococcus aureus necrotizing pneumoniaresults of a prospective observational study. Comparison of mortality risk associated with bacteremia due to methicillin-resistant and methicillin-susceptible Staphylococcus aureus. Morbidity and cost burden of methicillin- resistant Staphylococcus aureus in early onset ventilator-associated pneumonia. Clinical and economic outcomes for patients with health care-associated Staphylococcus aureus Pneumonia. Methicillin-resistant Staphylococcus aureus prolongs intensive care unit stay in ventilator-associated pneumonia, despite initially appropriate antibiotic therapy. Methicillin-resistant and susceptible Staphylococcus aureus bacteremia and meningitis in preterm infants. Nosocomial methicillin-resistant Staphylococcus aureus bacteremia: is it any worse than nosocomial methicillin-sensitive Staphylococcus aureus bacteremia? Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Changing trends in acute osteomyelitis in children: impact of methicillin-resistant Staphylococcus aureus infections. Mortality associated with nosocomial bacteremia due to methicillin-resistant Staphylococcus aureus. Costs and outcomes among hemodialysis-dependent patients with methicillin-resistant or methicillin-susceptible Staphylococcus aureus bacteremia. High incidence of methicillin-resistant Staphylococcus aureus sepsis and death in patients with febrile neutropenia at Royal Darwin Hospital. Nosocomial Staphylococcus aureus bacteremia among nasal carriers of methicillin-resistant and methicillin-susceptible strains. Clinical and epidemiological ndings in mechanically-ventilated patients with methicillin-resistant Staphylococcus aureus pneumonia. Hematogenous vertebral osteomyelitis due to Staphylococcus aureus in the adult: clinical features and therapeutic outcomes. Epidemiology and clinical characteristics of Staphylococcus aureus bloodstream infections in a tertiary-care center in Mexico City: 2003-2007. Bactericidal activity of oxacillin and glycopeptides against Staphylococcus aureus in patients with endocarditis: looking for a relationship between tolerance and outcome. Periprosthetic joint infection: the economic impact of methicillin-resistant infections. Clinical impact of methicillin-resistant Staphylococcus aureus bacteremia based on propensity scores. Costs of nosocomial pneumonia caused by meticillin-resistant Staphylococcus aureus. Hospital mortality for patients with bacteremia due to Staphylococcus aureus or Pseudomonas aeruginosa. Community-associated methicillin-resistant Staphylococcus aureus in pediatric patients. Staphylococcus aureus bacteraemia in a tropical setting: patient outcome and impact of antibiotic resistance. Methicillin-resistant Staphylococcus aureus bloodstream infection: risk factors and clinical outcome in non-intensive-care units. Emergence of a predominant clone of community-acquired Staphylococcus aureus among children in Houston, Texas. A prospective investigation of outcomes after hospital discharge for endemic, community-acquired methicillin-resistant and -susceptible Staphylococcus aureus skin infection. Is methicillin-resistant Staphylococcus aureus more virulent than methicillin-susceptible S. A comparative cohort study of British patients with nosocomial infection and bacteremia. Poststernotomy mediastinitis due to Staphylococcus aureus: Comparison of methicillin-resistant and methicillin-susceptible cases. Risk factors and costs associated with methicillin-resistant Staphylococcus aureus bloodstream infections. Resistance to methicillin and virulence of Staphylococcus aureus strains in bacteriemic cancer patients. Clindamycin treatment of invasive infections caused by community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus in children. Community- acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children. Predictive factors of meticillin resistance among patients with Staphylococcus aureus bloodstream infections at hospital admission. Clinical and economic impact of methicillin resistance in patients with Staphylococcus aureus bacteremia. Comparison of methicillin-resistant and methicillin-sensitive Staphylococcus aureus bacteremia.

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