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Efficacy of non-selective beta-blockers as adjunct to acne vulgaris causes buy cleocin gel overnight delivery nadolol and sucralfate compared with ligation alone for the endoscopic prophylactic treatment for gastric variceal prevention of variceal re-bleeding: a prospective randomized bleeding: a randomized controlled trial skin care obagi discount cleocin gel 20 gm with amex. Harshal Rajekar skin care jakarta trusted 20gm cleocin gel, Professor acne icd 10 code order cleocin gel without prescription, Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India, Tel: +91-9923078668; E-mail: harshal rajekar@yahoo. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Portal hypertension is responsible for most of the complications that mark the transition from compensated to decompensated cirrhosis, namely variceal hemorrhage, ascites and hepatic encephalopathy. Gastroesophageal varices result almost solely from portal hypertension, although the hyperdynamic circulation contributes to variceal growth and rupture. Ascites results from sinusoidal hypertension (portal hypertension) and sodium retention, which is, in turn, secondary to vasodilatation and activation of neurohumoral systems. The hepatorenal syndrome results from extreme vasodilatation with extreme decrease in effective blood volume and maximal activation of vaso constrictive systems, renal vasoconstriction and renal failure, which is probably an indirect effect of the changes in splanchnic circulation. Spontaneous bacterial peritonitis, a frequent precipitant of the hepatorenal syndrome, most probably results from deficient immunity, resulting in pathological gut bacterial translocation. Hepatic encephalopathy results from portosystemic shunting and hepatic insufficiency leading to accumulation of neurotoxins, mainly ammonia, in the brain. As for any illness, prediction of death in cirrhosis is essential in its management; and the development of portal hypertension and its complications have important prognostic value. Keywords: Endopeptidase; Glucagon; Natriuretic peptide; Liver; patients with mild portal hypertension, then the risk of developing Isoenzymes varices is low [3]. Transient elastography has been extensively studied in the Introduction assessment of the degree of liver fbrosis; however, its role in identifying patients with portal hypertension and varices is Portal hypertension is a frequent complication of liver cirrhosis, controversial. Also known as fbroscan, it is a noninvasive tool in the which develops in many patients and plays a role in the development armamentarium of the clinician in measuring the degree of tissue of other complications of the disease. Tough it is efective in assessing the extent of fbrosis, its development of esophago-gastric varices which ofen bleed; and plays a efectiveness in assessing the degree of portal hypertension still needs role in the development of ascites, hepatorenal syndrome and hepatic large scale studies to precisely defne the role of fbroscan in the encephalopathy. Portal hypertension and resulting portosystemic assessment of portal hypertension [3,4]. In cirrhotic portal hypertension, the portal blood fow as well as the Assessment of degree of portal hypertension intrahepatic vascular resistance is increased. The increased intrahepatic vascular resistance has two components, A low platelet count may be a reliable method for diagnosing portal a fxed components and a functional component. However, recently the Portal is secondary to sinusoidal fbrosis and compression by regenerative Hypertension Collaborative Group showed that the measurement of nodules and relative obstruction to the terminal portal venules. This platelets was inadequate as a noninvasive method for diagnosing resistance at the level of the hepatic microcirculation (sinusoidal portal esophageal varices. The vascular tone is reduced by nitric oxide, prostacyclin and by variceal bleeding [3]. Such collateral vessels may also be seen as caput various drugs (nitrates, adrenolytic agents, and calcium channel medusa around the umbilicus, peri-stomal varices which may bleed, or blockers). In cirrhotics with portal hypertension, the hepatic vascular may be seen in and around the bile duct manifesting as portal resistance is increased because of an imbalance between vasodilatory biliopathy. Although ectopic varices can occur at several sites, they are and vasoconstrictor stimuli [3]. Hydrogen sulphide (H S), a gas2 most commonly found in the duodenum and at sites of previous bowel neurotransmitter with vasodilator activity, was found to be altered in surgery including stomas. In a review of 169 cases of bleeding ectopic cirrhosis, and there is abrogation of the relaxation produced by l varices, 17% occurred in the duodenum, 17% in the jejunum or ileum, cysteine thru H S production [3]. In Neutral endopeptidase, in cirrhotics, degrades atrial natriuretic the review, 26% bled from peri-stomal varices and a few from peptide and bradykinin and generates endothelin-1, which contributes infrequent sites such as the ovary and vagina. Dilatation of veins in the peri-choledochal plexus of Petren and The increase in portal blood fow is caused by splanchnic arteriolar para-choledochal plexus of Saint may give rise to portal biliopathy in vasodilatation. Gut congestion may also refect in Earlier research focused on circulating vasodilator substances of the reduced delivery of hepatotrophic factors to the liver, and relative splanchnic origin such as glucagon, vasoactive intestinal peptide, bile growth hormone insensitivity may also be seen. Glucagon excess accounts for 30-40% of the splanchnic vasodilation Portal hypertension leads to the development of porto-systemic in cirrhotic portal hypertension, and thus somatostatin may be useful collaterals and diversion of portal fow from the gut to the systemic in the treatment of variceal bleeding [6]. Portal hypertension seems to be the common denominator resultant vasoconstriction in the intrahepatic portal vasculature. States of homeostasis and anti increased portal blood fow and hyperdynamic circulationon [6]. Varices and Variceal Bleeding Although commonly seen in Childs C cirrhotics, both have been described in isolated portal hypertension without cirrosis [2,7,8]. A The natural history and prognosis is quite diferent in patients who hyperdynamic circulation has been a common denominator in both have never bled, patients having acute variceal bleed, and patients who the conditions, though the exact mechanism hasn?t been completely have survived a bleeding episode. Variceal stage Aim of therapy Nomenclature No varices To prevent development of varices Preprimary prophylaxis Small varices (? The predictive value of initial endoscopy should undergo endoscopic surveillance at 1-year noninvasive methods such as fbroscan, spleen size, portal vein intervals. The size and variceal wall thickness, the presence of endoscopic stigmata such as red signs (an area where the variceal wall is thin and Preprimary prophylaxis weakened), the severity of the liver disease, and the portal pressure are Tere is no efective treatment to prevent development of varices determinants of risk of variceal bleeding [7,8]. High been disappointing with unacceptable adverse efects and limited risk varices were identifed as large (>5 mm) varices with at least one of efcacy [7]. Surveillance endoscopy may be repeated every two years in patients without varices. In those with small varices and a high risk factor like Patients with small varices having red signs or small varices with alcoholic cirrhosis, decompensated cirrhosis or those with red signs at decompensated liver disease should be ofered? However, it does not prolong survival and has its own disadvantages of cost and encephalopathy. The efcacy of beta-blockers is clinically monitored by a decrease in the resting heart Management of Acute Variceal Bleeding rate >25% but not <55 beats/min. Only 20% to 30% of subjects achieve The management of acute variceal bleeding includes hemodynamic these endpoints, and 15% to 20% of subjects cannot tolerate therapy resuscitation, general treatments, prevention of complications, and and require discontinuation. Antibiotic prophylaxis is inhibitors and sucralfate reduce esophageal ulceration [8]. Other indicated as it signifcantly reduces episodes of infective complications, measures like using multi-banders and increasing the interval between which are common and gravely afect prognosis [8]. Pharmacotherapy Nitrates, short-acting (nitroglycerin) or long-acting (isosorbide Terlipressin is the only drug shown to improve survival in patients mononitrates) reduce portal blood fow, but the efect on intrahepatic with acute variceal bleeding and therefore should be the drug of choice resistance is not impressive, and nitrates are no longer recommended [8]. If these drugs are not available, then vasopressin with transdermal Combination therapy with beta blockers and nitrates cannot be nitroglycerin may be used. A recent meta-analysis showed that pharmacotherapy by itself, may be as efective as endoscopic therapy in Somatostatin has been compared to terlipressin in efcacy, and no reducing rebleeding rates and all-cause mortality, but diferences were found for failure to control bleeding, rebleeding, and pharmacotherapy plus endoscopic intervention is more efective than mortality [8]. In a landmark article published by Bosch et al two endoscopic intervention alone [9]. During continuous infusion of Gastric Varices somatostatin, wedged hepatic venous pressure and estimated hepatic Gastric varices develop in about 20% of patients with portal blood fow decreased by, respectively, 17. Gastric varices are less likely to bleed, but bleeding form recently been found that higher doses i. Whereas somatostatin induced long-lasting efects on portal Similar to esophageal varices larger varices, decompensated liver pressure, the results of octreotide were far more inconsistent. Although disease and red signs are high risk factors for bleeding from gastric bolus octreotide markedly reduced portal pressure, continuous varices. On the Tere has been no randomized trial assessing the efcacy of beta other hand, octreotide consistently prevented postprandial splanchnic blockers in the primary prophylaxis of gastric variceal bleed, but the hyperemia in patients with portal hypertension. Endoscopic therapy for gastric varices is successful therapy can be maintained for 5 days to prevent early rebleeding. Embolization of the glue may occur during cyanoacrylate injection of gastric varices [10]. The exacerbation of portal hypertensive fewer adverse events and improved mortality [8]. Additionally, gastropathy afer variceal ligation is related to increased vascular sclerotherapy, but not band ligation, may induce an increase in portal congestion of the gastric mucosa. Emergency endoscopic therapy can be done at the time of efectively achieves hemostasis and eradication of varices, there was a diagnostic endoscopy, soon afer admission. Also the bleeding and the patient is stable, however, endoscopic treatment can technical complexity of snaring precludes it from being a widely be delayed. It has recently been shown that cyanoacrylate glue injection may be superior to and more efective Current recommendations include combination of the two than beta-blocker treatment for the prevention of gastric variceal approaches, as early administration of a vasoactive drug facilitates rebleeding and improving survival [11].

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In all known tapeworm infection skin care blog cheap 20gm cleocin gel mastercard, except in certain varieties of sparganosis acne mask cheap cleocin gel 20 gm without prescription, in which exposure in topical skin care professionals cleocin gel 20gm low price, the portal of entry is mouth hence acne at 30 cheap cleocin gel line, strict care not to swallow raw or inadequately, cooked beef, pork or fish or food or water contaminated with faeces or vermin, will ensure protection of the individuals. Digestive system may be absent, or when present it is rudimentary and without anus. The body is divided into three main body regions; this are Head (scolex): attachment organ and may have grooves, suckers, and rostellum armed with hooklets; this varies with species. B: Infection persists as long as the scolex and the neck region remain attached to the intestinal wall. The entire body is covered with active homogenous, elastic, resistant and continuous cuticle/integument from one proglottid to the next through out the entire body. Elaborate and well developed reproductive system with complete set of male and female genital organs which are found in a single worm. Taenia saginata (Beef tape worm) Geographical Distribution World wide distribution where cattle are raised and beef is eaten raw or under cooked. Habitat Adult: In small intestine of man Larvae: In muscular tissues of cattle Eggs: In faeces of man or in gravid segments. Colour: ivory white Scolex (head): quadrate, with four suckers, no looks, no rostellum Strobila : 1000-2000 proglottides Parasitology 118 Mature Proglottides: Broader than long Genital pores are arranged irregularly alternate on the lateral margin of each segment Gravid proglottide Detach when fully develop and pass through the anus independently. Larvae: Known as Cysticercus bovis Found in skeletal and muscular tissues of cattle Has four suckers and no rostellum and hooklets Egg (Embryophore): identical with the egg of T. Shell:-Thick, Smooth, brown, radially straited (embryophore) Content: A round granular mass enclosed by a fine membrane with six hooklets Stains red (acid fast) in Ziehl-Neelsen staining technique, this character helps to differentiate from T. Egg(hexacanth embryo>larva(Cysticercus bovis) >Adult Parasitology 119 Man acquires infection from raw or under cooked infected meat. Following ingestion, the larvae become attached to the wall of the small intestine with its suckers. Proglottides are formed from the neck region and the larvae grow into a long adult tapeworm. When fully developed the gravid segments become detached and the eggs are discharged only after the gravid segments have been separated from the worm. Gravid segments containing eggs and eggs from ruptured segments are passed in the faeces. The embryos escape from the eggs and pass through the intestinal wall into a blood vessel. Through the blood circulation they are carried to muscles and develop into infective cystic larvae called cysticercus bovis. TheScientific Book Center, Cairo) Parasitology 120 Pathogenicity: Causes taeniasis Major symptoms are loss of appetite, weight loss, hunger, acute intestinal obstruction, eosinophilia, and discomfort by the crawling of segments through the anus. Avoid eating raw or insufficiently cooked meat which may contain infective larvae. Identifying gravid segments and scolex recovered from clothing or passed in faeces. Owing to the inherent problem of missing many infections during routine stool examination. Estimates made by different investigators of the prevalence Parasitology 121 of taeniasis in Ethiopia vary widely, from 2% -16% to over 70% (Kloos H et al, 1993, Yared M et al 2001). Taeniasis is so common in the country and the tradition of self-treatment is so well developed that most people do not use the health services for diagnosis and treatment. Instead, Ethiopians use about dozens of traditional plant medicines, including Kosso (Hagenia abyssinica). Enkoko (Embelia schimperi), and Metere (Glinus lotoides) upon noticing proglottids in the feces or when experimenting abdominal discomfort, usually every 2 months (Shibru T, 1986). Taenia solium (Pork tape worm) Geographical Distribution:-Widely distributed where human faeces reach pigs and pork is eaten raw or insufficiently cooked. Habitat: Adult: In the small intestine of man Larva: In muscular tissues of pig Egg: In the faeces of man and in gravid segment. Larvae: Known as Cysticercus cellulosae Found in skeletal and muscular tissues of pig Has four sucers, rostellum and two raws of hooklets Egg (embryophore): -morphologically identical with the egg of T. Size: 31-43 (m Shape: -Round Colour: Shell-dark yellowish-brown, content light yellowish gray. Shell: -Thick, Smooth, brown, radially straighten (embryophore) Content: A round granular mass enclosed by a fine membrane with 6 hooklets. Does not stains red (acid fast) in Ziehl-Neelsen staining technique Life Cycle: the life cycle of T. Egg(hexacanth embryo) >larva(Cysticercus cellulosae) >Adult Parasitology 123 Man acquires infection from eating raw or under cooked pork that develops into adult in the intestine or from contaminated food or drink with faeces containing the eggs and develops into larval stage in visceral organs. Mode of Transmission can be Eating raw or under cooked pork meat Eggs in food or drink Internal autoinfections Pathology: Taeniasis and cysticercosis Major symptoms are as a result of the adult worm. These include abdominal pain, loss of appetite, and infection with larvae cause cystic nodules in subcutaneous and muscles. Treating infected person, providing health education and adequate sanitary facilities Laboratory Diagnosis 1. Detecting eggs in the faeces which is morphologically indistinguishable from the egg of Taenia saginata. Parasitology 124 Relevance to Ethiopia the parasite has not been reported from Ethiopia. Habitat: Adult: small intestine of man, rat and mice Cysticercoid larvae: in the intestinal villi of man, rat and mice. Eggs: In the faeces of man, rat and mice Morphology: Adult Size: 10-44 mm Scolex with 4 suckers, short retractile rostellum with single crown of hooklets. Stroblia: 100-200 proglottides, the size is inversely proportional to the number of worms present in the intestine of their host. Mature Segment: Unilateral common genital pore 80-180 eggs in gravid segment Egg: Size: 35-50? Colour: colour less or very pale gray Content: Rounded mass (embryo) with six refractile hooklets arranged in fan shaped. Egg(hexacanth embryo) >Cysticercoide larvae> Adult Eggs are the infective stages which are ingested contaminated hands, food and drink. When fully mature, the larvae rupture out of the villi into the lumen of the intestine. They attach to the intestinal wall by their scolex and grow rapidly into mature tapeworms. Some of the eggs are passed in the faeces while others remain in the intestine to cause internal autoinfection. Symptoms of infection are rarely detected except in children when many tapeworms may cause abdominal pain, diarrhoea, anorexia and lassitude. Some times adult worms in the faeces Hymenolepis diminuta (Rat tape worm) Geographical Distribution: Cosmopolitan with sporadic human infection in the world. Habitat: Adult: Ileum of rat, mice and rarely man Larva: body cavity of insects (fleas and cockroaches) Egg: In the faeces of rat, mice and man Morphology: Adult 20-60 cm Scolex with 4 suckers and retractile rostellum without hook-lets. Colour: Transparent or pale yellow Stroblia: 800-1000 segments Egg Yellow-brown or bile pigmented. Egg(hexacanth embryo) >Cysticercoide larvae>Adult Eggs in the faeces of the definitive hosts are ingested by the insect vectors and hatches releasing the oncosphere. In a survey of schoolchildren in 26 towns and villages in Harerge, only 1 case of H. Of 50 communities in the central and northern highlands, 78% had positive cases, with a mean prevalence of 12%. Among the general population of the Lake Zeway islands and the outpatients of Zeway Health Centre, H. Parasitology 130 Echinococcus granulosus (Hydatid worm) Geographical Distribution:-Common in sheep and cattle raising countries mainly in Kenya, Middle East, North and South Africa, India, Australia. Habitat Adult: mucus membrane of small intestine of carnivores such as dog, fox, Hydatid cyst/larvae: in the different body parts (liver, lung, brain, etc) of man and herbivorous animals. Egg: in the faece s of dog, fox, and jackals Morphology Adult Size: 3-6mm Scolex with 4 suckers, rostellum with two rows of hooklets. Egg: morphologically indistinguishable from the ova of Taenia species Size: 30-37? Carnivores such as dog, fox, jackles are the definitive hosts, man and herbivorous animals. Egg (hexacanth embryo) >Hydatid cyst(larvae) > Adult Man acquires infection from ingesting eggs in contaminated food, drink and fingers.

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A condensed tracing was used for conventional evaluation of motility disorders in the small intestine (148) acne zapper buy 20gm cleocin gel mastercard. For calculation of the motility index in the four segments studied skin care jakarta selatan purchase cleocin gel without a prescription, the following channels were used: channel 3 in the antrum acne conglobata purchase cleocin gel 20 gm overnight delivery, channel 5 in the proximal duodenum skin care for pregnancy discount 20gm cleocin gel fast delivery, channel 7 in the distal duodenum, and channel 8 in the jejunum. A long cluster of intestinal activity was defined as a sequence of pressure waves at the maximal contractile activity (10?14/min), lasting? Analysis of interdigestive motility and individual pressure waves was performed by inspection on the computer screen. Postprandial recordings were analyzed for motility index and propagated single contractions. Conventional evaluation of the condensed manometry data were performed by one of the investigators, who was blinded to patient group. Recordings with persistently low amplitude of contractions but with normal coordination patterns were considered to be myopathic-like. Diagnosis of bacterial overgrowth Aspirate from the jejunum was obtained at the manometry via the central lumen of the catheter and collected in a sterile glass tube. Identification of the microorganisms was based on colony characteristics, Gram staining, and biochemical and gas chromatographic tests. Cultures from jejunal aspirate were considered positive if the total count of colonic 5 bacteria was >10 colony-forming units/ml (104,149,150), whereas growth of upper respiratory tract flora was not regarded as positive. Biopsies were taken from the stomach during gastroscopy to verify whether the patients had atrophic gastritis or not. Variceal pressure measurements Variceal pressure measurements were performed in all 12 patients with esophageal varices with a noninvasive technique that employs a pressure sensitive capsule connected to an endoscope (Varipress?, Labotron, Barcelona, Spain) (72-74). The capsule is perfused with a constant flow of nitrogen; when applying it over the esophageal varix the pressure needed to perfuse the capsule equals the variceal pressure. Variceal pressure was calculated as the difference in pressure when the capsule was free in the esophageal lumen and when it was applied over a varix. Several recordings were obtained in each patient, and the results given represent the mean of at least three satisfactory tracings obtained in each patient. A schematic figure of the Varipress method is shown in Fig 2 and a typical registration is shown in Fig 3. For survival analysis, Kaplan-Meier estimates were calculated and formally tested with the log-rank test. In order to select independent predictors to survival stepwise Cox proportional hazard regression analysis were performed. Hazard ratios with 95% confidence intervals were calculated with Cox models for descriptive purpose. For comparison between two groups, Fisher nonparametric permutation test was used. In addition, Pearson correlation coefficient was calculated for descriptive purposes. All significance tests were performed two-sided and conducted at a 5% significance level. The registered alcohol consumption in Sweden has not changed much in the past decades whereas it has increased in Iceland (Figure 5) (152,153). Patients characteristics A total of 312 patients were eligible to be included in this study. Eight (3%) of the patients were diagnosed at autopsy (A) and were excluded from further analysis. Fifteen (5%) of the patients had portal vein thrombosis (T), without liver cirrhosis (7/15, 47% of these were diagnosed in association with a bleeding episode). In groups B and P the etiology of the cirrhosis was alcohol abuse in 54% of the patients (including those who were also infected with the hepatitis C virus. The incidence as well as the proportion of alcoholic etiology was fairly constant over time (Fig. Number of patients diagnosed for each year and the proportion of alcohol etiology. During follow-up, 46/84 (55%) group B patients 37 experienced at least one bleeding episode as compared to 26/197 (13%) of those in group P (p<0. Because of the different etiology of the portal hypertension compared to groups B and P, the T group was excluded from the further survival analysis. Use of prophylactic therapy In group P, only 128/197 (65%) were treated with primary prophylactic therapy. The majority 41/69 (60%) of the patients who did not receive primary prevention had small varices and were therefore judged as having a low risk of bleeding, or they were lost during follow-up due to alcohol or drug abuse. During follow-up, 26/197 (13%) patients in group P had a bleeding episode; 20/128 (16%) of the patients who received primary preventive therapy experienced variceal bleeding during follow-up. Four patients in group P died in the first bleeding and all had received primary preventive therapy, two of them pharmacological and two both pharmacological and endoscopic therapies. In group B, 8 of the 92 patients died in the first bleeding and 81 of the surviving 84 (96%) had secondary prophylactic therapy. There was no significant difference in bleeding rate during follow-up when comparing different primary or secondary preventive therapies when this was grouped into pharmacological, endoscopic and combined therapy, or when comparing those with alcoholic liver disease versus other etiologies. Patients characteristics Clinical characteristics of 1019 patients with liver cirrhosis are shown in Table 6. Mortality the frequency and cause of death, 1019 liver cirrhosis patients are shown in Table 7. Overall risk of cancer One hundred and ninety-three cancers were identified in the cohort of the 1019 patients. The standard incidence ratio for hepatocellular carcinoma was 267 as shown in Table 8. Standard incidence ratio for first cancer after diagnosis of liver cirrhosis Site of cancer Observed Expected Standard 95% I ncidence Confidence Ratio interval All sites 187 30. The risk for hepatocellular carcinoma is high and most of the patients are diagnosed shortly after the cirrhosis diagnosis after one year from diagnosis the risk is constant over the years. Conventional manometric evaluation In the 24 patients 10 (42%) demonstrated motor abnormalities. All of these alterations were neuropathic-like, and no myopathic-like manometry pattern was identified. Condensed manometry recording in a patient with liver cirrhosis and portal hypertension, exhibiting a high number of long clusters. There was no significant difference between patients with Child-Pugh score A or B when comparing any of the motility variables (data not shown). The following bacteria were cultured: Citerobacter, Escherichia coli, Enterobacter, Enterococci, and Klebsiella; one patient had two different bacterial strains (both Klebsiella and Enterococci). Variceal pressure There was no significant difference in the variceal pressures in patients with different etiologies for liver disease. There was a negative correlation between variceal pressure and motility index in the proximal duodenum postprandially (r =? There was no time trend in the incidence for neither of the countries during the study period and the incidence in Iceland has decreased by 27% compared to the period 1970-1990 (22). The lower incidence in Iceland is predominantly explained by lower prevalence of alcohol and hepatitis C cirrhosis than in Sweden. The mortality from liver cirrhosis is declining in most western countries in concert with reduction in alcohol consumption (11). We observed a declining incidence of liver cirrhosis in Iceland in spite the fact that alcohol consumption has been increasing in the last decades. Recent estimates of the total alcohol consumption that is the unregistered alcohol consumption in Iceland are not available. Comparisons with other epidemiological studies can be difficult because of different methods used. A study from Denmark demonstrated an incidence of liver cirrhosis over the period 2001-2005 to be 26. The alcohol consumption in Denmark has been stable over the past 30 year around 12 L per inhabitant which is also higher than in Sweden and Iceland as mentioned above (20).

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