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Patients presenting with acute or subacute graft thrombo ses (< 1 4 days) are finest handled with catheter-directed throm bolysis. For sufferers with lengthy standing grafts that fail, willpower of the factors respon sible might require reestablishing sufficient move to visualize the graft angiographically. In circumstances of early graft failure, exami nation of angiographic studies might provide clues previously overlooked, similar to stenosis of an inflow vessel, poor or inad equate distal runoff, or the presence of a venous aspect branch that was not sutured. Unfortunately, presently tools to deal with continual venous illness are limited in the United States. A retrograde, by way of the con tralateral common femoral vein, or an antegrade approach by way of the popliteal vein is a potential choice. When placing patients on a lytic infu sion, low-dose heparin (600 to 800 unit/hour) should also be administered concurrently. If the lesion is immune to balloon dilation alone, directional or laser atherectomy may show helpful for salvaging the graft. Likewise, although stents have been advocated by some to be used in failing vein grafts, their utility has not been studied in any formal trials to date. In basic, we extremely advocate the use of embolic protection when performing atherectomy and even cutting balloon angioplasty in old bypass grafts. Such widespread application necessitates improvement of standardized pointers for training and credentialing to make certain that patients will receive optimal care. Until the cognitive, clin ical, and procedural skills are integrated rou tinely into formal cardiology fellowship applications, additional training is important. In particular, caro tid revascularization includes interventional skills, gear, and medical management expertise that differ significantly from these used in o ther vas cular distribu tions. Moreover, it includes treatment of a uniquely delicate organ system, whereby minor errors or complications can have catastrophic effects. Experienced operators have been shown to have improved outcomes in carotid stenting. As a result of these considerations, a j oint committee, including the societies of each specialty involved, has pro posed minimal coaching requirements that cowl proficiency within the cognitive, technical, and medical abilities necessary to safely perform carotid stenting. Effectiveness-based guidelines for the prevention of heart problems in women-20 1 1 up date: a guideline from the American Heart Association. Heart illness and stroke statistics-20 1 2 replace: a report from the American coronary heart associa tion. Heart illness and stroke statistics-2008 replace: a report from the American Heart Asso ciation Statistics Committee and Stroke Statistics Subcommittee. Carotid intima-media thick ness is related to untimely parental coronary coronary heart disease: the Framingham Heart Study. Successful carotid endarterectomy for cerebrovas cular insufficiency Nineteen-year follow-up. Beneficial impact of carotid endarterectomy in symptom atic sufferers with high-grade carotid stenosis. A report of the American College of Cardiol ogy Task Force on Clinical Expert Consensus Documents. Progression of hu man carotid and femoral atherosclerosis: a prospective observe up examine by magnetic resonance vessel wall imaging. Secondary prevention and mortality in peripheral artery illness: National Health and Nutrition Examination Study, 1999 to 2004. Undertreatment of dyslipidemia in periph eral arterial illness and other high-risk populations: an alternative for cardiovascular disease discount. What the million hearts initiative means for stroke: a presidential advisory from the American Heart Association/American Stroke Association. Trends in incidence, life time threat, severity, and 30-day mortality of stroke over the previous 50 years. Executive Committee for the Asymptomatic Carotid Atherosclero sis Study Endarterectomy for asymptomatic carotid artery stenosis. Analysis of pooled data from the randomised managed trials of endarterectomy for symptomatic carotid stenosis.

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The pericardium considerably affects the left ven tricular diastolic pressure-volume relationship in the dog. Right ventricular infarction: clinical prognosis and differentiation from cardiac tamponade and constriction. Acute alterations in left ventricular diastolic cham ber stiffness: role of the "erectile" impact of coronary arterial strain and circulate in regular and damaged hearts. Effects of coronary venous pressure on left ventricular diastolic chamber distensibility. The pacing thallium take a look at reex amined: correlation of pacing-induced hemodynamic changes with the quantity of myocardium at risk. Sensitivity of end-systolic pres sure-dimension and pressure-volume relations to the inotropic state in people. Comparison of left and proper ventricular end-systolic pressure-volume relations in conges tive heart failure. Increased regional myo cardial stiffness of the left ventricle throughout pacing-induced angina in man. Altered left ventricular dia stolic properties during pacing-induced ischemia in dogs with coro nary stenosis: potentiation by caffeine. Hemodynamic determi nants of the time-course of fall in canine left ventricular stress. Analysis of left ventricular strain dur ing isovolumic relaxation in coronary artery disease. Assessment of mitral annulus velocity by Doppler tissue imaging in the analysis of left ven tricular diastolic function. N ew insights into regional systolic and diastolic left ventricular function a quantitative approach. D eterminants of left ventric ular early-diastolic lengthening velocity: unbiased contributions from left ventricular leisure, restoring forces, and lengthening load. Tissue Doppler imag ing constantly detects myocardial abnormalities in sufferers with hypertrophic cardiomyopathy and offers a novel means for an early diagnosis before and independently of hypertrophy. Continuous wave D oppler echocardiography for noninvasive assessment of left ventricular dP/dt and leisure time fixed from mitral regurgitant spectra in sufferers. Noninvasive measure ment of price of left ventricular leisure by Doppler echocar diography: validation with simultaneous cardiac catheterization. Preload dependence of Doppler-derived indexes of left ventricular diastolic operate in people. Simultaneous assessment of left ventricular systolic and diastolic dysfunction during pacing induced ischemia. Improved left ventricular diastolic filling in sufferers with coronary artery disease after percutaneous translumi nal coronary angioplasty. Effects of verapamil on left ventricular systolic perform and diastolic filling in patients with hypertrophic cardio myopathy. Regional diastolic dysfunction in coronary artery illness: scientific and therapeutic implications. Diastolic Relaxation of the Heart: Basic Research and Soc Echocardiogr 2003; 1 6: 724-73 1. Left ventricular regional leisure and its nonuniformity in hypertrophic nonobstructive cardiomyopathy. Utility of Doppler echocardiography and tissue Doppler imaging within the estimation of diastolic operate in heart failure with regular ej ection fraction: a comparative Doppler-conductance catheter examine. Exercise echocardiography: detection of wall motion abnormalities during ischemia. Heart failure with preserved ej ection fraction: pathophysiology, diagnosis, and therapy. As a relatively inelas tic sac, it contributes to maintenance of normal atrial and ventricular compliance and optimal ventricular form, offers safety towards extreme ventricular-atrial valve regurgitation, and limits extreme acute dilation or mismatch between right- and left-side chamber volume.

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In such instances, an try at inner iliac artery revas cularization and/or mesenteric revascularization should be strongly considered13 (see also Chapters 34 and 46). C overage of bilateral internal iliac arteries is possible if enough col lateralization exists. Up to 5 0 % of sufferers undergoing inner iliac embolization will report signs including buttock claudication and erectile dysfunction (2 0%). If a limb kink or ste nosis is suspected, the delivery stiff wire can be exchanged for a floppy wire, which will enable the endograft to take its final resting conformation. Pressure gradient can then be measured throughout the suspected stenosis and if important mean stress drop is discovered (> lO mmHg) the section should be handled. Placement of a large balloon expandable stent with vital radial pressure, similar to a Palmaz stent, at the suspected steno sis can generally broaden the narrowing and prevent cata strophic acute endograft limb thrombosis. In excessive cases, conversion to an aorto-uniiliac and femoral crossover ought to be considered. C ontrol of the femoral arteries and enough arterial for ward flush before arterio tomy closure is really helpful to keep away from embolization. Weak femoral pulses as a result of suspected arterial dissec tions discovered on angiograms should be aggressively treated with stent coverage. Iliac artery rupture may be handled with additional graft or coated stent deploy ment. Renal Artery Patency Proximal migration or inaccurate deployment of the endo graft, particularly in a hostile aortic neck, could inadvertently cover partially or fully the renal or mesenteric arteries. In such circumstances, the graft can sometimes be pulled downward utilizing an inflated compliant balloon. This maneuver is how ever hazardous when coping with very short necks since the graft may actually " fall" into the aneurysm sac. It can also be harmful and damage the aortic wall and renal ostia when suprarenal fixation is current. A glidewire and catheter can be used by way of a brachial artery method to create a path in between graft materials and the aortic wall main into the renal artery. The wire is then replaced with a stiffer wire, corresponding to a Rosenwire, and a delivery sheath is superior to the renal artery. Placement of a covered stent avoids leaks through the stent cells behind the endograft materials. Thus, an access is maintained behind the endograft always; in case of accidental renal artery coverage, a balloon could be superior over the wire. This maneuver will present enough space for wire entry to the renal arteries from a brachial approach. Subse quently, a coated stent can be delivered to preserve renal artery perfusion in " chimney" configuration. If these maneuvers fail, open revasculariztion of the renal artery should be initiated. Type I endoleaks must be handled when recognized since they preserve a pressurized aneurysm sac leaving the patient vulnerable to aneurysm rupture. If the endoleak persists, a proximal or distal endograft extension could be added in circumstances where the touchdown zone permits it, with out obstructing aortic branch arteries. The stent will apply a high radial pressure over the endograft in order to get hold of a seal. Presence of a giant lumbar artery, accent renal artery, or inferior mesenteric artery may end in retrograde filling of the aneurysm sac. The collateral vessels feeding the sac usually thrombose when anticoagulation is reversed. Large patent inferior mesenteric arteries, giant accent renal arteries, or other aortic branches arising from the aneurysmal sac ought to however be embolized earlier than endograft deployment. Contrast flush between the modular component or graft materials can be identified on the angiogram. In order to clearly determine a type lil endoleak, the flush catheter can be brought down into the endograft and a focused angiogram obtained that can reveal the distinction blush. The modular graft junction may be ballooned again, and if unsuccessful, or if graft material is damaged, the leak should be coated and relined with an extra endograft. However, the sac continues to enlarge without any obvious radiographically demonstrable leak. Routine surveillance is needed to moni tor aortic reworking, graft migration, in addition to progression of persistent endoleaks, and development of recent endoleaks.

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This is caused by a continued proliferation of the lung mesenchymal cells and altered extracellular matrix remodelling, preventing the traditional thinning of the lung tissue and the air�blood barrier. Because of their role in selling lung maturation, synthetic glucocorticoids are given clinically to ladies at risk for preterm labour, which has led to a marked improve in the survival of premature babies. A mechanism leading to reduced lung enlargement and lung hypoplasia in fetal sheep throughout oligohydramnios. Determinants of the first inspiratory volume and practical residual capability at delivery. Spontaneous breathing patterns of very preterm infants handled with continuous optimistic airway strain at birth. The role of amilorideblockable sodium transport in adrenaline-induced lung liquid reabsorption within the fetal lamb. Effects of beta-adrenergic blockade on lung liquid secretion during fetal asphyxia. Pulmonary air flow and mechanics of breathing in first minutes of life, together with onset of respiration. The position of lung inflation and sodium transport in airway liquid clearance during lung aeration in new child rabbits. Chapter 12 Question 1 How many kidneys have most individuals had over their life course Answer 1 Six, consisting of the two pronephroi and two mesonephroi that mostly disappear during fetal growth and two metanephroi that become the adult kidneys. Answer 2 Nephron quantity in the end determines renal perform, though prerenal, renal and postrenal issues can all affect obvious perform. Chapter 13 Question 1 Describe the secondary changes that happen to a fetus throughout a interval of intrauterine retention. Answer 1 After an intrauterine dying, there may be a interval of intrauterine retention of the fetus before delivery. Signs of maceration embody blistering and slippage of the pores and skin, generalised discolouration and increased laxity of the skull bones. The fetal brain-to-liver weight ratio could provide useful info regarding intrauterine development standing at time of demise; nevertheless, adjustments should be made for weight modifications to avoid mistaking postmortem fetal weight loss brought on by maceration for intrauterine progress restriction. Effects of intrauterine retention and postmortem interval on body weight following intrauterine death: implications for assessment of fetal development restriction at post-mortem. Answer 2 the range of imaging modalities and techniques embody postmortem skeletal survey. When three-dimensional (3D) volumetric imaging sequences have been obtained, the images can be reconstructed in nonanatomical planes. The limitations to this method embody e20 Self-Assessment lack of resolution for smaller fetuses and poor ossified bony detail, which may be of specific curiosity when a identified musculoskeletal disorder is current. Volume rendered imaging methods allow a 3D skeleton of the deceased to be reconstructed and can permit for improved evaluation of some fractures (particularly useful when differentiating skull fractures from sutures). It can obtain high-resolution imaging all the way down to a similar scale as gentle microscopy and supply information on the bony micro-architecture (when used without contrast) and glorious delicate tissue differentiation (when used with contrast). Limitations embrace restricted availability and the flexibility to image entire fetuses conforming under a sure size (because of the image detector dimensions). Question three Describe the function of placental examination in the investigation of an intrauterine fetal dying. Organ weights and ratios for postmortem identification of fetal progress restriction: utility and confounding elements. Stillbirth and intrauterine fetal dying: function of routine histopathological placental findings to decide cause of death. Answer 3 After an intrauterine death or a complicated supply, the placenta should all the time be sent for histopathological examination. Features identified within the placenta (either at gross examination or at microscopic examination of placental samples taken by the pathologist) might assist to clarify the cause of a baby born in unexpectedly poor situation and could also be medicolegally relevant to the defense of medical care provided to the mother during the peripartum period. One recent large research of 1064 intrauterine fetal deaths discovered that around one third of instances during which the placenta was submitted for examination had the reason for dying assigned to abnormalities of the placenta, twine or membranes. The significance of placental lesions is still the subject of a lot debate, and when the trigger of dying is unknown, placental lesions of unknown significance could additionally be present. Placental pathologies subsequently characterize the single largest reason for intrauterine fetal dying, and placental histologic examination offers the highest yield of all elements of investigations after death, including the bodily post-mortem and histopathology of the body viscera.

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The dynamic response traits of such a system are decided largely by the pure frequency and the diploma of damping that the system possesses. The physical coun terpart of this augmentation is that the sensing membrane of the strain transducer vibrates with increasing vitality and violence. The identical mechanism underlies the fracture of a crystal glass when an opera singer vocalizes the appro priate input frequency. As an analogy to further help the reader perceive the importance of damping, contemplate the simple case of a weight suspended from a spring. If the weight is dis placed and then launched, the stretched spring recoils in order that the load moves previous its original place and then oscillates up and down. In the absence of frictional forces (damping), the oscillation would proceed indefinitely at a frequency decided by the stiffness of the spring and an amplitude decided by the mass of the load. This sec ond necessary consequence of damping-reduction of the natural frequency of a system-is not widely appreciated. If we continue with our analogy, think about that the spring and its weight are suspended in a jar of syrup or honey; the spring will clearly vibrate with lesser amplitude of vibration and lesser frequency than before. Further damping at this point merely slows the return of the burden to its equilibrium position, thereby miserable the frequency response charac teristics of the system. Therefore, damping helps to stop overshoot artifacts ensuing from resonance of the system, but at the price of diminished frequency response. Linearity Linearity is a further crucial element of recording sys tems, and it exists when the relationship between the input signal and the output sign is of the primary order. At a heart price of 1 20 bpm, the fundamental frequency is 2 Hz and the tenth harmonic is 20 Hz. Wood and colleagues6 and Gleason and Braunwald7 found that frequency response was flat to < 10 Hz with small-bore (6F) catheters attached to standard strain gauge manometers. To ensure a excessive frequency-response vary, the strain measurement system must be arrange in such a method that it has the highest possible pure frequency in addition to optimum damping. The natural frequency is immediately proportional to the lumen radius of the catheter system. It is inversely pro portional to the length of the catheter and related tubing and to the square root of the catheter and tubing compli ance and the density of fluid filling the system. The excessive est pure frequency is obtained by utilizing a short, wide-bore, stiff catheter connected to its transducer with out intervening tubing or stopcocks and filled with a low-density liquid from which small air bubbles, which enhance compliance, have been excluded. Such a system is impractical for routine use, but deviation from it happens solely at a big sacrifice. Accordingly, it is important to introduce damping into the system to hold the frequency response flat because the frequency of the enter signal approaches the natural frequency of the strain measurement system. Damp ing could additionally be introduced by interposing a damping needle between the catheter and manometer6 and gradually quick ening it until optimal damping is obtained, by filling the manometer or tubing with a viscous medium corresponding to Reno grafin (a radiographic distinction agent), or by any of several different methods. By altering the traits of the system mentioned within the earlier part, a cause able compromise between frequency response, damping, and practicality may be achieved for each laboratory. This method may be used for measuring the dynamic response characteristics of a strain measurement system. The transducer used ought to be of the low-volume-displacement sort (small chamber capacity) to improve frequency response. The syringe plunger is eliminated, and the barrel is mounted in a vertical posi tion, pointing downward, in order that the catheter enters from below. The manometer and catheter are full of saline resolution, care being taken to avoid even small air bubbles, and the catheter is flushed till the catheter tip and holes are submerged in approximately 30 mL of saline solution. The plunger is slowly inserted into the syringe, producing an upward deflection of the strain trace on the oscilloscope of the recording equipment. When the trace involves relaxation at the prime of the oscilloscope, the recorder is turned on at speedy paper speed and the plunger is all of a sudden withdrawn. The mathematical foundation for evaluation of such a shock excitation has been 2 described by Wiggers and Fry4 and could also be summarized as follows: the frequency of the after-vibrations produced by shock excitation is the damped pure frequency of the system.

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Traditionally, surfactant was given after the toddler was intubated and mechanical ventilated. Recent studies have demonstrated the security of administering surfactant on spontaneously respiration infants receiving noninvasive support. Trials are underway investigating the efficacy of the much less invasive surfactant administration. Other noninvasive air flow strategies can be found, although most of them are used after mechanical ventilation to stop extubation failure. Synchronising the inflations of the ventilator to the breaths of the infants (triggered ventilation) is now used in most neonatal centres and has shortened the period of air flow. For synchronisation, a flow sensor is positioned proximal of the patient at the endotracheal tube. New technology and the usage of microprocessors has led to the availability of many different modes which are more sophisticated and will probably reduce the ventilation-induced lung damage. This matrix layer is situated adjacent to the ventricle and serves as a supply of neuronal and glial precursor cells. After the initial diagnosis, progression may happen over the following 3 to 5 days. This is caused by an impaired drainage of medullary veins in the white matter adjacent to the haemorrhage. The second element consists of diffuse white matter damage with loss of premyelinating oligodendrocytes and astrogliosis but with out necrosis or glial scars. Within the spectrum of preterm white matter harm, the diffuse sort represents the mildest type and the cystic form essentially the most extreme. These mechanisms usually happen simultaneously and trigger excitotoxicity and free radical assault, which can result in dying of premyelinating oligodendrocytes. The preterm white matter is especially susceptible to ischaemia due to the presence of arterial border zones within the deep (periventricular) white matter and an impaired autoregulation of cerebral blood move. Other threat elements are related to infection and irritation, both prenatally in case of maternal intrauterine infection and postnatally in case of sepsis, necrotising enterocolitis and ventilation-induced lung harm. In cases with antenatal onset, cysts may be current at birth or develop within the first week. In case of a perinatal insult, cysts normally develop after 2 to 3 weeks, though for smaller and localised cysts, this will take longer (4�6 weeks). Preterm white matter injury is associated with an increased risk for impaired motor and cognitive outcomes. However, its capability to predict different long-term outcomes as neurocognitive and behavioural impairments for the person affected person is limited. The latter happens in the case of severe supratentorial brain lesions that are related to a slower growth of cerebellar volumes. This contains not only motor disabilities but in addition cognitive, behavioural and emotional deficits. Long-Term Follow-Up in in Extreme Preterm Children Most neonatal care centres provide structured follow-up assessments of the youngsters born preterm. Monitoring their growth is crucial for analysis and additional enchancment of care to improve our understanding of particular risk components for impairment and for early detection of developmental problems that necessitate early intervention and the supply of ongoing support for kids with particular wants. Since the mid-1990s, a quantity of large national population-based and multicentre studies on the long-term neurodevelopmental end result have been carried out. Of observe, impairment rates differ among studies because of differences in patients or inclusion standards (gestational age selected), time interval and perinatal or neonatal management, in consequence measures and definitions of severity of impairment, as well as in timing and protocol of follow-up. Neurodevelopmental follow-up at 2 years of age revealed that 49% (138 of 283) of youngsters had impairment, including 23% (64 of 283) with severe impairment. However, regardless of significant advances in care, the proportion of children with severe impairments remained unchanged. Moderate to severe impairments in children born between 23 and 25 weeks, at 26 weeks, and between 27 and 32 weeks of gestation have been, respectively, 55% (6 of 11), 21% (4 of 17) and 16% (26 of 167).

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Some fundamental points concerning catheterization in such sufferers have been reviewed in Chapter 9, and a number of the interventional strategies have been reviewed in Chapter 3 5. This article presents a series of real-world profiles illustrating a few of these primary rules. Pulse oximetry confirmed an arterial oxygen satura tion of 90% to 9 1 % at baseline, falling to mid-80s throughout a stress check. Transthoracic echo demonstrated valvar pulmo nary stenosis with a peak instantaneous gradient of approxi mately 1 1 5 mmHg. Oxygen saturation in the pulmonary veins was 96% (room air) with a simultaneous aortic saturation of 8 9 %, defining a right- to-left shunt. There was no mitral stenosis, obstruc tion of the left ventricular ou tflow, or aortic arch. A Berman catheter was positioned in the right ventricle and a proper ventricular angiogram was obtained. The pulmonary valve was dilated with the Inoue balloon technique-techniques of balloon valvular dilation range, with some operators preferring the relative ease and simplicity of the Inoue balloon methodology, while others prefer a higher sense of waist and compliance assessment that can be afforded by standard single- and double-balloon dilation (see Chapters 33 and 40). An Inoue balloon was selected with a maximum in flation diameter a couple of millimeters bigger than the measured diameter of the valve annulus, however was ready with solely enough quantity to broaden to the size of the annulus. The Inoue balloon was straightened and launched via a l 4F sheath on the femoral vein. A side-arm valve was added to the again of the catheter, and a pressure transducer was hooked up to the aspect port of the valve. Pullback 2, recognized that the systolic gradient was located throughout the ventricular chamber, on the subvalvar degree. The pa tient was hydrated intravenously and started on an intrave nous beta-blocker infusion. Over 10 to quarter-hour, systemic arterial oxygen saturations rose to the mid-90s (%), because the gradient fell; over the next 6 weeks, the peak instan taneous gradient by Doppler decreased even further, sys temic arterial saturations normalized, and oral beta-blo cker therapy was discontinued. In adults and in youngsters, the size of the valve annulus is such that a double-balloon method is often required to get hold of enough dilating drive and diameter. The Inoue balloon (see earlier discussion) could be chosen to suit bigger diameters and is variable in its inflation dimension, so that a larger inflation measurement can be used without needing to change the catheter. The angiogram demonstrated filling of the descending aorta from intercostal and internal mammary collaterals. A stiff wire with a hand-formed loop was superior through the pigtail catheter around the arch to the ascend ing aorta, and the pigtail catheter was eliminated. Blood strain in the proper arm was 1 65/9 0, with no palpable femoral pulses and a blood stress of 75/40 within the lower extremities. There was an apical click on, a soft systolic mur mur, and a diastolic decrescendo murmur. Under intravenous propofol sedation, sheaths had been placed in the femoral artery and vein. The pigtail catheter was removed, and the long sheath was superior by way of the co arctation to the ascending aorta. At the treating center, pre dilation of the coarctation website, to allow assessment of aortic compliance, was not carried out. A balloon-dilatable Palmaz iliac stent Qohnson & j ohnson) was mounted on a 1 0-mm balloon catheter and advanced through the sheath to the level of the coarctation site. The sheath was withdrawn into the de scending aorta, and an angiographic inj ection was carried out through the aspect port of the Mullins sheath to help position the stent. There was a small residual gradient across the stent, but the ascending aortic pressure was markedly lowered, and the descending aortic stress increased to the traditional vary. Because of the small preliminary diameter of the coarctation phase, we elected to do full dilation in two phases. For recurrent coarctation after surgical repair in children, nevertheless, balloon angioplasty is accepted as the procedure of selection, when possible. Stenting is generally not used in youthful children given their development potential, however has turn into widely accepted in older youngsters, in addition to in adults with coarctation.

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