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All females in child bearing age (11-60 years old) scheduled for I-131 thyroid therapy: 1 indomethacin 50 mg arthritis in neck whiplash. Document pregnancy test results (or tubal ligation/hysterectomy/menopause) on the thyroid information sheet c buy indomethacin 25mg cheap arthritis knee treatment swelling. Check that the patient has not been on thyroid medication or had contrast studies for the past 6 weeks indomethacin 75mg discount rheumatoid arthritis diet nightshades. Make the patient aware that I is eliminated by the saliva 75 mg indomethacin with mastercard hip pain arthritis vs bursitis, sweat glands, and kidneys, and that his/her urine will be radioactive for a few days. Advise the patient to avoid close contact with small children for a few days, and to discontinue breastfeeding. Clear liquids only for 4 hours before and one hour after radioiodine administration. If the technologists is unable to answer any questions the patient may have, contact the radiologist to do so. A copy of the prescription should be available at the time the dose is administered, and 2. Some radioactive iodine is excreted in your urine, and a little is excreted in your saliva and perspiration, requiring some precautions to avoid spreading any significant radiation to by-standers. Most patients experience no side effects from this treatment, and only one in ten to one in twenty require a second treatment. After thyroid function becomes normal, nearly all patients will later go on to develop an underactive thyroid, requiring life-long thyroid hormone pills for replacement; your physician will check for this periodically. If any tenderness of the gland develops in the week after treatment, aspirin, ibuprofen or Tylenol will usually provide sufficient relief; if not, call your physician. Food and Fluids: It is preferable to not eat for four hours before and for one hour after radioiodine treatment to enhance absorption from your stomach. Following therapy, drink at least 2 quarts of liquids (8 glasses) per day for the first three days to hasten excretion of the radioiodine. Time and Distance: For two days, you should minimize the length of time in contact with others and try to maintain a prudent distance from them in order to reduce their exposure to your radioactivity. Sleep in a separate bed (at least 6 feet separation) for the first two (2) days after your treatment. Remain at least six (6) feet away from children and pregnant women for two (2) days. Do not nap with children or hold an infant or child for more than several minutes (<30 min/day) for 14 days.. Radioiodine is secreted into the breast milk and can damage the infant’s or child’s thyroid gland. Have the sole use of a bathroom; if not possible, wipe the seat of the toilet after each use. If you have plans to use commercial transportation over the next several weeks, you may need to present this note. If you have any questions or concerns after therapy, please contact Huntsville Hospital’s Radiologist and ask to speak with the Radiologist in Nuclear Medicine. Follow-up: It is important that you see your physician within the first 4-8 weeks after treatment and regularly thereafter in order to evaluate your response to your radioiodine therapy. The accumulation of Tl in a parathyroid adenoma is non-specific and is most likely related to the cellularity and/or vascularity of the lesion. The double-phase sestamibi study is based on the time dependence of localization within the thyroid and parathyroid tissue. An initial image represents the "thyroid phase" and is used mainly as an anatomical reference for the delayed image. Over time, there is decreased uptake in the thyroid gland and persistent uptake in parathyroid adenomas. Taillefer R, Boucher Y, Potvin C Lambert R: Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study). Additional Information: The patient should be able to remain still for 30 minutes. Photopeak and window settings predetermined for Tc 140 keV, 15- 201 20%) and Tl (80 keV, 30%). Collect 20-minute Tl images at 60 seconds/image on the computer and four 5- minute images on the camera. Dynamic mode of data collection is used so that the data still may be salvaged even though patient movements may occur. Smooth all images (9-point smoothing) to reduce the effects of statistical variations. Examine the images carefully and select a region of thyroid that is comparable in 99m 201 the Tc and T1 images. Using a region of interest over this area, determine average count in this area for each image. Time interval between administration and scanning: 15 minutes and 2 hours Patient Preparation: Check that the patient is not pregnant or breast feeding. At 10-15 minutes post-injection, acquire digital images: view of neck and upper chest with head and neck extended. Calculation of parathyroid adenoma/normal thyroid tissue uptake ratio on both early and delayed images may sometimes be useful. Timing is important; the patient will undergo radioguided parathyroidectomy using a hand held probe, ideally 2. Time interval between injection and procedure: 10-15 minutes Patient Preparation: 1. Patient must be positioned for all views with head straight and a roll under the shoulders to extend the neck. Procedure may be performed regardless of medications after consultation with nuclear medicine physician. Interpretation: Activity on the subtraction images should represent pathological parathyroid tissue. Parathyroid imaging using simultaneous double-window 99m 123 acquisition of Tc-sestamibi and I. Rationale: The physiologic basis for this study is that intravenously administered macroaggregated albumin, which are larger than 10 microns in diameter, will be mechanically trapped in the pulmonary capillary bed. A normal perfusion lung scan effectively rules out the diagnosis of pulmonary embolus. If the lung scan is abnormal then the chest radiograph as well as another nuclear medicine study, the ventilation lung scan, may be used to evaluate the probability of pulmonary embolus versus that of parenchymal lung disease. The diagnostic considerations are that pulmonary embolus will cause an abnormal area of pulmonary perfusion with a relatively normal pulmonary ventilation. Pneumonia and chronic lung disease cause matching ventilation and perfusion abnormalities in the same pulmonary regions.

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Among the many causes are multiple sclerosis cheap 50mg indomethacin mastercard arthritis diet alkaline, lateral medullary syndrome cheap indomethacin 75mg with amex arthritis lab test, cavernous sinus thrombosis discount 50 mg indomethacin with amex arthritis mutilans symptoms, syringomyelia order 50 mg indomethacin visa rheumatoid arthritis gerd, sympathectomy, cervical plexus/stellate ganglion/interscalene block, thoracostomy, neck trauma, goitre, carcinoma of thyroid, cervical rib (pulling on stellate ganglion), Klumpke’s paralysis, neurofibromatosis type I, cluster headache (the combination = Horton’s headache), middle ear infection, Pancoast tumour of lung apex, carotid artery dissection (Horner’s syndrome contralateral to hemiparesis: disrupted carotid sympathetic plexus), and thoracic aortic aneurysm (including dissecting). It is not appropriate to rely on psychological tests to make a psychiatric diagnosis. Medically ill patients tend to score high on Hy (hysteria) and Hs (hypochondiasis) scales. Finish with a formulation, a brief summary of the case, differential diagnosis, prognosis, and plan of management, noting positive points only. Interviewing ‘Most mental disorders affect the young and are chronic, recurring illnesses that last a lifetime’. The interview is a deliberate, non-haphazard process, demanding an understanding of psychopathology and psychodynamics (vide infra). Psychopathology may be more obvious with the patient in a familiar environment rather than in the clinic; there may be an apparent ‘remission’ in hospital, followed by ‘relapse’ on discharge. Allow patient reveal private thoughts without feeling demeaned Patients vary in the degree and timing of revelation and concealment of factual material Some patients will be hostile, perhaps (but not always) because they are of involuntary legal status Good rapport imparts a therapeutic feel to the encounter Interviewer and interviewee should achieve a shared understanding Trainees should stick to a set order of questioning Flexibility, although not always desirable during a first session, is an acquired art Keep interruption to a minimum, and handle it tactfully when it happens Settings will vary: office, high security or general hospital ward, busy clinic, or, all too often, a window-seat or linen- cupboard Every effort should be made (comfort, lighting, etc. Extremely high prolactin levels may give a falsely low reading due to the ‘hook effect’ but dilution of the serum will reveal the hyperprolactinaemia. Macroprolactinaemia refers to high molecular weight complexed prolactin + IgG which is inactive – it does not require intervention but can be misleading: ‘apparent hyperprolactinaemia’ - after precipitation of IgG with polyethylene glycol the prolactin level can be measured accurately and shown to be normal. There will be many variables to contend with, such as lateness, privacy, and seating arrangements. Resistances May interfere with progress, even in the most motivated patient He may go silent, intellectualise, stick to symptoms or some other aspect of the history, or get annoyed He may continue talking or asking questions of you He may be seductive or resort to lateness39 Do not take over the interview for the patient. Explain to him how matters are progressing from your viewpoint rather than interpreting in an analytical sense. Experience, especially under supervision, with a wide range of patients is important. Defence mechanisms are unconscious psychic 41 activities used to reduce anxiety and eliminate conflict. They are deemed abnormal if used too often, if 42 43 they are used inappropriately (avoidance of reality testing ), or if they fail to work. Simply knowing that ones delusion is not shared by others does not lead to insight. Martindale (1987) discussed the excessive use of defence mechanisms within the families of patients with Huntington’s disease and amongst those professionals caring for them. He argued that genetic counselling was not offered to these people and that this might help to spread the condition through to the next generation. Mothers who smother their offspring with love may in fact harbour hateful feelings for them at an unconscious level. For example, in introjection (another’s qualities taken as part of self) a person might assume aspects of the deceased in order to mitigate loss. Regression - vide supra - reversion to earlier developmental level of functioning; common during admission to hospital. Counterphobic behaviour - approaches fear instead of avoiding it - the claustrophobic (fear of enclosed spaces) becomes an elevator mechanic. Intellectualisation - avoids facing up to feelings by hiding behind logic; unpleasant thoughts remain conscious whilst associated feelings remain unsconscious, a derivative of isolation of affect. Rationalisation – the giving of apparently logical reasons for beliefs or actions when really attempting to conceal true motives; the person who hits his wife avoids the painful reality that it was wrong to do so by deciding that she deserved it because of nagging! Substitution - replacement of a seriously dangerous impulse with something impersonal and less dangerous, e. Displacement of affect - the office boy who is annoyed by and hence hostile towards his boss beats his own wife up instead of the boss - not socially acceptable - also the basis of transference reactions. Sublimation - aggressive and sexual desires diverted into socially and personally more acceptable channels, e. Conversion - unconscious conflicts are given external expression in the form of physical ailments, such as hysterical paresis (hysterical conversion symptoms work via the voluntary nervous system, whereas the somatic symptoms of anxiety - such as palpitations - work via the autonomic nerves). A lack of concern, or la belle indifférence, may or may not be present in cases of conversion; anyway, it can also be found with general medical disorders, e. Patients who appear to have a paralysed limb may have normal deep tendon reflexes. Dissociation - occurs in hysterical amnesias, sleepwalking, loss of memory with running away (= fugue), and multiple personality - mental function(s) are split off from the rest of the personality. Retroflexion - either sexual feelings are turned inward leading to excessive love of self (narcissism after Narcissus) or hostility is turned inwards leading to depression or a poor self-image. Acting out - expressing unconscious conflicts in a manner not consciously recognised as such, e. Isolation and undoing - compulsive rituals of the obsessive-compulsive neurotic consist of impulses which have become separated from unacceptable impulses, e. Projective identification – described by Melanie Klein and extended by Wilfred Bion;(Meissner, 1999) good and bad aspects of self are split off and projected into someone or something (e. It is associated with release of tension or with gratification/satisfaction/pleasure. Denial - can accept at intellectual level that something has happened, such as a loss through death, but this is rejected emotionally; in delusional states intellectual acceptance is also forfeited so that the dead person 46 is believed to still live, despite irrefutable evidence. Splitting – strict separation of good and bad aspects of self or others in order to avoid having to cope with ambivalent feelings such as love and hatred. Did he see other doctors before and how did he get on, and why did he stop seeing them? Contact relatives as required, being careful not to contravene the trust placed in the relationship between doctor and patient. Does the information being collected constitute a true reflection of the client, and, if not, why not? The presenting complaint may be dealt with at the start or end of history- taking as seems appropriate. The patient may wish to take the lead here, or it may be necessary to get early information on his background in order to put the problem in perspective. He should know that it is from him that you want to hear the story, not just from the referring letter. How does he spend his average day, get on with other people, respond to adversity, seem to other people, see his role in life, and feel about his status? Most questions are best left open- ended, although clarification may sometimes necessitate the use of direct questioning. Sometimes it may be necessary to put mild pressure on the client to elicit his feelings. Estimate how much stress the patient can tolerate by close observation, and allow him to recover his composure before leaving. It keeps out the facts’: Lord Moran (Sir Charles Wilson) on Winston Churchill, November 10, 1953, in Moran. With the move of psychiatry into the community and the consequent dispersal of paper-based information the need for electronic information sharing is becoming more relevant, particularly regarding potential for self-harm, alerts (e. These may reveal much about resistances, personality, expectations, attendance, and compliance.

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It is most commonly found in middle-aged women 75mg indomethacin visa how to treat arthritis in dogs uk, although it can be seen in all age groups buy indomethacin 75mg amex yoga arthritis pain. Patients can present with a rubbery discount indomethacin 25mg without a prescription how does arthritis in neck feel, nontender goiter that may have “scalloped” borders cheap indomethacin 75 mg without prescription improving arthritis with diet. Iodine deficiency is exceedingly uncommon in the United States because of iodized salt. Patients with thyroid cancer usually are euthyroid and have a history of head and neck irradiation. Several different autoantibodies directed toward components of the thyroid gland will be present in the patient’s serum; however, of these, antithyroperoxidase antibody almost always is detectable (also called antimicrosomal antibody). On thyroid biopsy, lymphocytic infiltra- tion and fibrosis of the gland are pathognomonic. The presence of these autoantibodies predicts progressive gland failure and the need for hormone replacement. In a young woman with oligomenorrhea, pregnancy should always be the first diagnosis considered. Urine pregnancy tests are easily per- formed in the office and are highly sensitive. In this patient, the next most likely diagnosis is hypothalamic hypogonadism, secondary to her strenuous exercise regimen. These young women are at risk for osteo- porosis and should be counseled on adequate nutrition and offered combined oral contraceptives if the amenorrhea persists. The amount of hormone batch to batch and the patient dose response are believed to be more predictable than with other forms of hormone replacement, such as thyroid extract, which is made from desiccated beef or pork thyroid glands. There is no evidence that the natural hormone replacement is superior to the synthetic form. Other medications, especially iron- containing vitamins, should be taken at different times than levothy- roxine because they may interfere with absorption. Clinical Pearls ➤ The most common causes of oligomenorrhea are disorders of the hypo- thalamic-pituitary-gonadal axis, such as polycystic ovarian syndrome and hypothyroidism. Both hypothyroidism and hyperprolactinemia may cause hypothalamic dysfunction, leading to menstrual irregularities. This page intentionally left blank Case 13 A 49-year-old woman presents to the emergency room complaining of a 4-week history of progressive abdominal swelling and discomfort. She has no other gastrointestinal symptoms, and she has a normal appetite and normal bowel habits. Her medical history is significant only for three pregnancies, one of which was complicated by excessive blood loss, requiring a blood transfusion. She is happily married for 20 years, exercises, does not smoke, and drinks only occasionally. On pointed questioning, however, she does admit that she was “wild” in her youth, and she had snorted cocaine once or twice at parties many years ago. She is thin, her complexion is sallow, her sclerae are icteric, her chest is clear, and her heart rhythm is regular with no murmur. Her abdomen is distended, with mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, and a fluid wave. Her history reveals a blood transfusion with postpartum hemorrhage and cocaine use. Her abdomen is dis- tended, with mild diffuse tenderness, shifting dullness to percussion, and a fluid wave, consistent with ascites. Learn the complications of chronic hepatitis, such as cirrhosis and portal hypertension. Considerations This 49-year-old woman had been in good health until recently, when she noted increasing abdominal swelling and discomfort, indicative of ascites. The physical examination is consistent with ascites with the fluid wave and shift- ing dullness. Her laboratory studies are significant for hypoalbuminemia and coagulopathy (prolonged prothrombin time), indicating probable impaired hepatic synthetic function and advanced liver disease. She does have prior exposures, most notably a blood transfusion, which put her at risk for hepatitis viruses, espe- cially hepatitis C. Currently, she also has a low-grade fever and mild abdomi- nal tenderness, both signs of infection. Bacterial infection of the ascitic fluid must be considered, because untreated cases have a high mortality. Thus, paracentesis using a needle introduced through the skin into the peritoneal cavity can be used to assess for infection as well as to seek an etiology of the ascites. The most common causes of chronic hepatitis are viral infections, such as hepatitis B and C, alcohol use, chronic exposure to other drugs or toxins, and autoimmune hepatitis. Less common causes are inherited meta- bolic disorders, such as hemochromatosis, Wilson disease, or α1-antitrypsin deficiency. Hepatitis C infection is most commonly acquired through percutaneous exposure to blood. It also can be transmitted through exposure to other body fluids, although this method is less effective. Risk factors for acquisition of hepatitis C include intravenous drug use, sharing of straws to snort cocaine, hemodialysis, blood transfusion, tattooing, and piercing. Most patients diagnosed with hepatitis C are asymptomatic, and report no prior history of acute hepatitis. The clinician must have a high index of suspi- cion and offer screening to those individuals with risk factors for infection. Approximately 70% to 80% of all patients infected with hepatitis C will develop chronic hepatitis in the 10 years following infection. Among those with cirrhosis, 1% to 4% annually may develop hepatocellular carcinoma. Therapy is directed toward reducing the viral load to prevent the sequelae of end-stage cirrhosis, liver failure, and hepatocellular car- cinoma. Currently, the treatment of choice for chronic hepatitis C is combi- nation therapy with pegylated alpha-interferon and ribavirin. However, the therapy has many side effects, such as influenzalike symptoms and depression with interferon, and hemolysis with ribavirin. The goal of interferon therapy for hepatitis C is preventing the complications of chronic hepatitis. Cirrhosis is the end result of chronic hepatocellular injury that leads to both fibrosis and nodular regeneration. With ongoing hepatocyte destruction and collagen deposition, the liver shrinks in size and becomes nodular and hard. Alcoholic cirrhosis is one of the most common forms of cirrhosis encountered in the United States. It is related to chronic alcohol use, but there appears to be some hereditary predisposition to the development of fibrosis, and the process is enhanced by concomitant infection with hepatitis C. Loss of functioning hepatic mass leads to jaundice as well as impaired synthesis of albumin (leading to edema) and of clotting factors (leading to coagulopathy).

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This structure refers to the three-dimensional structure of a single protein molecule generic indomethacin 25mg visa arthritis utensils, a spatial arrangement of the secondary structures discount 25mg indomethacin mastercard rheumatoid arthritis definition ppt. This structure refers to a complex of several protein molecules or polypeptide chains indomethacin 25 mg free shipping infective arthritis definition, usually called protein subunits in this context 25 mg indomethacin amex arthritis in flat feet, which function as part of the larger assembly or protein complex. Collagen and elastin are critical components of connective tissue such as cartilage; keratin is found in hard or filamentous structures such as hair and nails. Proteins that associate with the surfaces of membranes, usually through non-covalent charge–charge interactions, are referred to as peripheral; proteins within the hydrophobic interior of membranes (whose surface is generally made up of hydrophobic amino acids) are referred to as integral. Integral proteins are often transmembrane; that is, they span the membrane; examples are receptors and channels. Such proteins are generally amphipathic; they have both hydrophilic and hydrophobic regions that help orientate the molecule across the membrane. The formation of the α-helix is spontaneous and is stabilised by H-bonding between amide nitrogens and carbonyl carbons of peptide bonds spaced four residues apart. This orientation of H-bonding produces a helical coiling of the peptide backbone such that the R-groups of individual amino acids lie on the exterior of the helix and perpendicular to its axis. Amino acids such as A, D, E, I, L and M favour the formation of α-helices, whereas G (glycine) and P (proline) favour disruption of the helix. The disruption of the helix is important as it introduces additional folding of the polypeptide backbone to allow the formation of globular proteins. The folding and alignment of stretches of the polypeptide backbone alongside one another to form β-sheets is stabilised by H-bonding between amide nitrogens and carbonyl carbons. However, the H-bonding residues are present in adjacently opposed stretches of the polypeptide backbone, as opposed to a linearly contiguous region of the backbone in the α-helix. This is due to positioning of the α-carbons of the peptide bond, which alternates above and below the plane of the sheet. The amino acid sequence of a protein predisposes it towards its native conformation(s). Most (soluble) folded proteins have a hydrophobic core in which side-chain packing stabilises the folded state, and charged or polar side chains are placed on the solvent-exposed surface, where they interact with surrounding water molecules. It is generally accepted that minimising the number of hydrophobic side chains exposed to water is the principal driving force behind the folding process. The tertiary structure is fixed only when the parts of a protein are ‘locked’ into place by structurally specific interactions, involving charge–charge interactions (salt bridges), hydrogen bonds and the tight packing of side chains. The tertiary structure of extracellular proteins can also be stabilised by disulphide bonds; disulfide bonds are extremely rare in cytoplasmic proteins since the cytoplasm is generally a reducing environment. When proteins fold into their tertiary structures, there are often subdivisions within the protein, designated as domains, which are characterised by similar features or motifs. A protein domain is a part of the protein sequence and structure that can evolve, function and exist independently of the rest of the protein chain. The shortest domains, such as ‘zinc fingers’, are stabilised by metal ions or disulfide bridges. As they are self-stable, domains can be ‘swapped’ by genetic engineering between one protein and another, to make chimera proteins. These modifica- tions/additions to the protein occur following translation; they are termed post-translational modifications. A major function of lipoproteins is to aid in the storage and transport of lipid and cholesterol. Glycoproteins are either N-linked or O-linked, referring to the site of covalent attachment of the sugar moieties. The variability in the composition of the carbohydrate portions of many glycoproteins (and glycolipids) of erythrocytes determines blood group specificities. There are at least 100 blood group determinants, most of which are due to carbohydrate differences, the most common being A, B and O. High concentrations of solutes, extremes of pH, mechanical forces and the presence of chemical denaturants can do the same. A fully denatured protein lacks both tertiary and secondary structure, and exists as a ‘random coil’. Sev- eral neurodegenerative diseases are believed to result from the accumulation of misfolded (incorrectly folded) proteins. Aggregated proteins are associated with prion-related illnesses such as Creutzfeldt–Jakob disease, bovine spongiform encephalopathy (mad cow disease) and amyloid-related illnesses such as Alzheimer’s disease and familial amyloid cardiomyopathy or polyneuropathy, as well as intracytoplasmic aggregation diseases such as Huntington’s and Parkinson’s disease. These age-onset degenerative diseases are associated with the multimerisa- tion of misfolded proteins into insoluble, extracellular aggregates and/or intracellular inclusions, including cross-β-sheet myeloid fibrils. It is not clear whether the aggregates are the cause or merely a reflection of the loss of protein homeostasis, the balance between synthesis, folding, aggregation and protein turnover. Misfolding and excessive degradation lead to a number of pro- teopathy diseases, such as antitrypsin-associated emphysaema, cystic fibrosis and the lysosomal storage diseases, where loss of function is the origin of the disorder. The resulting mixture can be ultracentrifuged to fractionate the various cellular components into soluble proteins, membrane lipids and proteins, cellular organelles and nucleic acids. Precipitation (salting out) is often employed to concentrate the proteins from this lysate. Various types of chromatography can be used to isolate the protein(s) on the basis of their size, charge and binding affinity. The level of purification can be monitored using various types of gel electrophoresis, by spec- troscopy (if the protein has distinguishable spectroscopic features) or by enzyme assays (if the protein is an enzyme). Additionally, proteins can be isolated according to their charge, using electrofocusing. This form of haemoglobin is referred to as HbS; normal adult haemoglobin is referred to as HbA. Substitution of a hydrophobic (valine) for a polar residue (glutamic acid) results in haemoglobin tetramers that aggregate upon deoxygenation in the tissues. Aggregation results in deformation of the red blood cell into a sickle-like shape, making it relatively inflexible and unable to easily traverse the capillary beds. Although heterozygous individuals are clinically normal, their red blood cells can ‘sickle’ under very low oxygen pressure, for example at high altitudes. Heterozygous individuals exhibit phenotypic dominance, yet are recessive genotypically. The result of quantitative abnormalities in haemoglobin synthesis, in either the α-globin or β-globin chains. A large number of mutations have been identified lead- ing to decreased (α+β+)orabsent(α◦β◦) production of globin chains. The primary cause of the α-thalassemias is gene deletion, but for the β-thalassemias the mutations are more subtle, with some 170 different ones identified. Mutations that affect the structure and function of type I collagens result in numerous disease states. At least four bio- chemically and clinically distinguishable maladies have been identified as osteogenesis imperfecta, all of which are characterised by multiple fractures and resultant bone defor- mities.

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