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Due to infection and putrefaction the affected part becomes oedematous with blebs medicine 93 3109 300 mg combivir purchase visa. The term ‘Pregangrene’ is used to describe the changes in the tissue to indicate that its blood supply is so precarious that it will soon be inadequate to keep the tissue alive medicine look up drugs buy combivir 300mg with visa. Syringomyelia symptoms night sweats buy combivir 300mg overnight delivery, tabes dorsalis, peripheral neuritis, leprosy, caries spine, fracture-dislocation of spine etc. Various special investigations as stated above will help the clinician to diagnose the condition and the level of the block. It is the inflammatory reaction in the arterial wall with involvement of the neighbouring vein and nerve, terminating in thrombosis of the artery. In lower extremity the disease generally occurs beyond popliteal artery, starting in tibial arteries extending to the vessels of the foot. So far as aetiology is concerned this disease has a striking association with cigarette smoking. An autoimmune aetiology has been postulated and familial predisposition has been reported. The pedal arteries are involved first and the patients complain of pain while walking at the arch of the foot (foot claudication), somewhat less often at the calf of the leg, but never at the thigh or buttock (which is common in atherosclerosis). Gradually postural colour changes appear followed by trophic changes and eventually ulceration and gangrene of one or more digits and finally of the entire foot or hand may ensue. It is differentiated from senile gangrene by the age, by its association with superficial phlebitis and pitting oedema. Characteristic arteriographic appearance of this disease is the smooth and normal appearance of larger arteries combined with extensive occlusion of the smaller arteries alongwith extensive collateral circulation. Presence of localized tenderness at the site of embolus and complete disappearance of pulse below this level are the pathognomonic features of this disease. The heart when examined carefully often gives an indication of the source of the embolus. It may be caused by (i) cervical rib, (ii) scalenus anticus muscle, (iii) costoclavicular syndrome, (iv) pectoralis minor syndrome, (v) wide first thoracic rib, and (vi) fracture of the first rib or clavicle. Neurologic symptoms are pain, paraesthesia and numbness in the fingers and hand in the ulnar nerve distribution. The symptoms gradually appear due to sagging down of the shoulder girdle with the advent of puberty. Sometimes symptoms appear later in life due to weakness of the muscles of the shoulder girdle. Presence of cervical rib does not always reveal symptoms or brings the patient to the surgeon. Symptoms of the cervical rib are mainly caused by angulation of the subclavian artery over the cervical rib and by the pressure irritation of the lowest trunk of the brachial plexus which contains the sympathetic nerve fibres to the upper limb. These symptoms will only appear when the muscles of the shoulder girdle will become weak and both the artery and the nerve trunk will be compressed on the cervical rib. When the hand is elevated it looks pale and it becomes blue on prolonged dependent position due to cyanotic congestion. Numbness of the fingers is complained of and the radial pulse becomes feeble on the affected side. X-ray often reveals the cervical rib, though sometimes a fibrous band in its place causes the symptoms like cervical rib and will not be seen by X-ray. The scalenus anticus syndrome is one in which the clinical pictures very much resemble those of the cervical rib. Here the pull of the scalenus anterior muscle, which compresses the subclavian artery and the lower trunk of the brachial plexus, is responsible for the symptoms. Negroes, people of Central Africa, Central America and the East are more prone to be affected. It usually affects the little toe, sometimes the fourth and rarely the third, second or the great toe. Though it is rare in upper limbs yet cases are on the record when the terminal phalanx of the little finger has been involved.

Lipoid pneumonia Pulmonary disorder resulting from chronic as- (Fig C 53-6) piration or inhalation of animal medicines360 buy 300 mg combivir with mastercard, vegetable medications mitral valve prolapse order 300 mg combivir with mastercard, or petroleum-based oils or fats treatment 3rd metatarsal stress fracture 300mg combivir with amex. Imaging findings include bilateral lower lobe air-space consolidation, mixed alveolar and interstitial opacities, and even poorly defined mass-like lesions mimicking pulmonary neoplasms. Bilateral diffuse attenuation associated with inter- and intralobular lines ground-glass attenuation and inter- and intralobular lines in a young asymptomatic man. Pulmonary hemorrhage Causes include idiopathic pulmonary hemosidero- (Fig C 53-9) sis, Goodpasture syndrome, collagen vascular disease, drug-induced coagulopathy, and hemor- rhage associated with malignancy. Scattered ground-glass attenuation and thickening of the intra- and interlobular septa. In this young man who developed Fig C 53-6 barotraumas, note the air within the areas of interlobular Lipoid pneumonia. Geographic ground-glass attenuation thickening, a finding indicative of pulmonary interstitial associated with interlobular thickening and inralobular lines emphysema. In this patient with Fig C 53-8 systemic lupus erythematosus and massive hemoptysis, Cocaine abuse. Diffuse bilateral reticular opacities with su- there are geographic areas of ground-glass attenuation perimposed thickening of inter- and intralobular interstitium. Beginning in Hong Kong, (Fig C 53-10) where it initially affected mainly medical personnel, the disease rapidly spread to nearby countries, Europe, North America, and Australia. Ground-glass opacification and thickened interlob- ular septa (arrow) and intralobular interstitium produce the crazy-paving pattern. Adenopathy is common, though it usually regresses as the interstitial lung disease worsens. Pulmonary Langerhans cell Nodules evolving into bizarre-shaped cysts that are histiocytosis seen almost exclusively in young smokers and (Fig C 54-3) probably represent an allergic reaction to some component of cigarette smoke. Centrilobular emphysema Destruction of lung parenchyma, classically near (Fig C 54-5) the central arteriole and bronchiole of the secon- dary pulmonary lobule, with well-defined margins between normal and abnormal lung. Large cavitary lesion with surrounding consolidation involves the apical posterior segment of the right upper lobe. Coronal projection shows that the interstitial ab- normalities in a bronchovascular distribution primarily involve the upper lung zones. Chronic hypersensitivity Group of allergic lung diseases with various pneumonitis patterns caused by the inhalation of a variety of organic and chemical antigens. Scan obtained at the level of the aortic arch shows large symmetric bilateral opacities with irregular margins (ar- rows) indicative of progressive massive fibrosis, as well as nu- merous small nodules and septal thickening (arrowheads). Section through the upper lobes shows subtle areas of lung destruction limited to individual secondary pulmonary lobules. The structure of these Fig C 54-6 lobules, including the central core structures, is intact. Air-space consolida- subtle emphysema will often remain undetected on chest tion primarily involves the peripheral lung. Autosomal recessive gene disorder that produces thick viscous secretions Allergic bronchopulmonary Central bronchiectasis with peripheral sparing, aspergillosis typically developing as a hypersensitivity reaction (Fig C 54-8) in patients with a history of asthma. Neurogenic pulmonary Edema due to hydrostatic changes and capillary edema leak that develops within minutes to hours of any (Fig C 54-9) central nervous system insult that acutely raises intracranial pressure. Scan obtained at the level of the upper lobes demonstrates severe signs of bronchiectasis partly filled with mucus, moderate signs of bronchial wall thick- ening, multiple areas of consolidation (arrows) with air bronchograms, and emphysema (arrowheads). Metastatic pulmonary The upper lung zones have a high pH and calcium calcification is less soluble in this alkaline environment. May result from deposition of calcium in otherwise normal tissue or in patients with hypercalcemic states, especially renal failure. Unusual (Fig C 54-10) manifestation, seen in fewer than 2% of patients with this disorder. Severe volume loss of the lung apices consolidations in the central portions of the upper with traction cystic bronchiectasis. Scleroderma Diffuse basilar reticulonodular pattern, often associated with a dilated, air-filled esophagus. May be (Fig C 55-4) associated erosions of the distal clavicles and characteristic changes in the hands, wrists, and other joints.

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Other characteristic changes include “fish vertebrae medications like zovirax and valtrex buy combivir 300mg overnight delivery,” bone infarcts medications zofran order 300mg combivir mastercard, osteomye- litis treatment 12mm kidney stone purchase combivir american express, and papillary necrosis. Note the absence of normal modeling due to the pressure of the expanding marrow space. Localized radiolucencies simulating multiple osteolytic lesions represent tumorous collections of hyperplastic marrow. The bone is often locally expanded, most com- monly at the metaphysis but sometimes extending to involve the entire shaft. In severe and long-standing disease, the affected bones may be bowed or deformed (eg, shepherd’s crook deformity of the femur). Multiple exostoses Hereditary bone dysplasia in which multiple osteo- (diaphyseal aclasis) chondromas arise from the ends of the shafts of (Fig B 22-5) bones preformed in cartilage. Characteristic under- tubulation and often bowing of long bones occurs with multiple osteochondromas in the metaphyseal regions. Frequently, there is deformity of the fore- arm due to shortening and bowing of the ulna. Smudgy, ground-glass appea- Fig B 22-5 rance of the medullary cavities with failure of nor- Multiple exostoses. Addi- tional findings include sclerosis of the base of the skull and calvarium, lack of aeration of the parana- sal sinuses and mastoids, and thickening and sclerosis of the mandible. Metaphyseal dysplasia Rare hereditary disorder in which symmetric (Pyle disease) paddle-shaped enlargement of the metaphyses and (Fig B 22-6) adjacent diaphyses of long bones is associated with osteoporosis and cortical thinning. Frontal views of (A) the knee and (B) the proximal humerus show defective modeling leading to extreme widening of the metaphyseal areas of the visualized long bones. This causes (Fig B 22-7) proliferation of rounded masses or columns of decreased-density cartilage in the metaphyses and diaphyses of one or more tubular bones. The involvement is usually unilateral and the affected bones are invariably shortened and often deformed. In long bones, columns of radiolucent cartilage may be separated by bony septa, producing a striated appearance. In the hands and feet, the lesions are globular and expansile, often with stippled or mottled calcification. Multiple globular and expansile lucent filling defects involving virtually all the metacarpals and the proximal and distal phalanges. A combination of endo- steal and periosteal cortical thickening causes symmetric fusiform enlargement and undertu- bulation of long bones. Encroachment on the me- dullary canal may cause anemia and secondary hepatosplenomegaly. Amorphous increased den- sity at the base of the skull may lead to impinge- ment on the cranial nerves. Dense endosteal and periosteal cortical thickening causes fusiform enlargement of the midshaft of the femur. A dense, uniform, and symmetric increase in bone density is associated with undertubulation of long bones. Alternating dense and lucent trans- verse lines (probably reflecting the intermittent nature of the pathologic process) may develop in the metaphyses of long bones and vertebrae. Other characteristic findings include a miniature bone inset within each vertebral body (bone-within-a- bone appearance) and increased density at the end plates (sandwich vertebrae). Dense, uniform, symmetric increase in the density of the femur with failure of proper modeling. Osteogenesis imperfecta Inherited generalized disorder of connective tissue associated with blue sclerae, multiple fractures, and hypermobility of joints. The rarest “cystic” form is characterized by flared metaphyses that are hyperlucent and traversed by a honeycomb of coarse trabeculae. The shaft may be overconst- ricted and show severe bending deformities and healed fractures in addition to generalized os- teopenia. Metatropic dwarfism Very rare short-limbed dwarfism in which the patient is normal at birth. Progressive kyphoscolio- sis with characteristic trumpet-like expansion of multiple metaphyses, especially in the femurs and tibias.

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Constrictive pericarditis Effusion is frequently unilateral on the right but Effusion develops in approximately 50% of cases medicine to stop contractions buy combivir with visa. Asbestosis Effusion occurs in 10% to 20% of cases symptoms bowel obstruction order cheapest combivir, is Usually pleural thickening or plaques that are often usually bilateral crohns medications 6mp order combivir canada, and is often recurrent. There is almost complete homogeneous opacification of the right chest, reflecting a combination of a large hemothorax and underlying pulmonary contusion. The right first rib is fractured (arrow) and subcutaneous emphy- sema is present in the soft tissues of the right hemithorax. Note the fluid collections along the lateral chest wall (closed arrow), in the minor fissure (open arrow), and in the left major fissure (arrowhead). The (Fig C 37-8) effusion tends to clear within 2 months but may progress to chronic pleural thickening. Bilateral in half Often associated with cardiac enlargement (com- erythematosus the cases, and predominantly left-sided when monly because of pericardial effusion) and non- (Fig C 37-9) unilateral. Rheumatoid disease Effusion is probably the most frequent mani- May be isolated or associated with a diffuse reticu- festation in the thorax. Wegener’s granulomatosis Effusion is relatively common but is over- Single or multiple pulmonary nodules, often with shadowed by the pulmonary manifestations. Waldenström’s Effusion in approximately 50% of patients with Diffuse reticulonodular pattern. Lateral decubitus view of the chest demonstrates moderate enlargement of the cardiac silhouette and a large right pleural effusion (arrowheads). Bilateral pleu- ral effusions, more marked on the right, with Fig C 37-8 some streaks of basilar atelectasis. Small left pleural effusion in a patient cardiomegaly results from a combination of peri- with diffuse interstitial lung disease. The thoracic thoracic duct) duct crosses to the left of the spine between T5 and T7 and thus is particularly vulnerable to injury during surgery on the left hemithorax in the hilar region. A common complication particularly in children undergoing surgery for congenital heart disease. Trauma to thoracic duct Penetrating or nonpenetrating injuries (especially (Fig C 38-1) after a heavy meal when the duct is distended). There may be a fractured rib or vertebra, and several days may pass before the pleural fluid is detectable radiographically. An injury to the lower third of the thoracic duct produces a right- sided chylothorax. Tumor obstruction of Most commonly caused by lymphoma or bron- thoracic duct chogenic carcinoma. A right-sided chylothorax (Fig C 38-2) develops when the lower portion of the duct is invaded; left-sided involvement occurs when the upper half is affected. Involvement of the the right hemithorax obscures fractures of several lower portion of the thoracic duct by bronchogenic carcinoma. Intrinsic thoracic duct Atresia, tumor, or aneurysm with rupture of the abnormality thoracic duct. Tuberculosis Enlarged lymph nodes or paravertebral abscess may compress or erode the thoracic duct. Filariasis Nematode infection causing a peripheral lym- phangitis that may ascend to involve the thoracic duct and cause perforation. Usually due to rupture of a pleural bleb (small cystic space generally situated over the lung apex). Iatrogenic Complication of central line insertion, thoracen- (Figs C 39-2 and C 39-3) tesis, tracheostomy, resuscitation or artificial ven- tilation, or a result of thoracotomy. Large right-sided pneumothorax (black arrows) on a radio- graph obtained immediately after removal of a feeding tube (arrowhead) from the pleural space. Mediastinal emphysema Pneumomediastinum and increased mediastinal pressure lead to the development of a unilateral or bilateral pneumothorax. Hyaline membrane disease Pneumothorax associated with air-space con- solidation and interstitial emphysema is probably related to prolonged assisted ventilation. Interstitial lung disease Pneumothorax associated with a diffuse reticulo- (Fig C 39-5) nodular pattern may occur in any cause of honeycomb lung (especially Langerhans cell histiocytosis), cystic fibrosis, hemosiderosis, and sarcoidosis. Anteromedial pneumotho- rax (arrows) along with extensive air-space parenchymal disease. Severe coughing and straining during an acute at- tack led to the development of a large pneumothorax with substantial collapse of the right lung (arrows).

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Lymphoma Axillary lymph node involvement has been reported in almost half of patients with non-Hodgkin’s (Fig C 60-2) lymphoma and one-quarter of those with Hodgkin’s disease symptoms gluten intolerance combivir 300 mg buy. Metastases Primary tumors of the head and neck symptoms 8 days after ovulation best buy combivir, lung treatment uterine fibroids purchase combivir cheap, and kidney may metastasize to axillary lymph nodes and (Fig C 60-3) simulate primary tumors or lymphoma. Primary malignancy Although rare, primary malignant neoplasms of fibrous tissue, muscle, or fat do occur in the axilla. Sarcoidosis Unusual manifestation that, when combined with hilar and mediastinal adenopathy, can mimic (Fig C 60-5) lymphoma. Extensive bilateral axillary adenopathy with en- larged nodes (arrows) surrounding the neurovascular bundles, but not invading them. Left axillary nodes (arrow) and bilateral in- ternal mammary nodes (curved arrows) are seen in this woman with an extensive malignancy of the left breast and involvement of the skin surface (arrowheads). Extensive involvement of the left axillary nodes in a young man with neuroblastoma. Note the extension of adenopathy high into the apex of the ax- illa beneath the pectoralis minor muscle medially. Although (Fig C 60-6) usually affecting cervical nodes, axillary lymph nodes also may be involved. Cystic hygroma Congenital anomaly that most likely results from sequestration of primitive embryonic lymph sacs (cystic lymphangioma) that fail to establish normal communication with the lymphatic system. Although most common (Fig C 60-7) in the neck, a hygroma can appear as a smooth, homogeneous axillary mass that displaces but does not invade adjacent muscular structures. It typically has a low attenuation value (10–30 H) that is less than that of soft tissue but much higher than that of fat. Lipoma Well-defined, homogeneous, benign fatty tumor with characteristic low attenuation value (290–2120 (Fig C 60-8) H) that is usually less than or equal to that of normal subcutaneous fat. Desmoid tumor Mass of benign but invasive fibrous tissue (considered a low-grade fibrosarcoma by some) that may be (Fig C 60-9) either diffusely infiltrative or relatively well defined with a pseudocapsule. Bilateral axillary and mediastinal adenopathy in a erally enhancing mass in the right axilla that has infiltrated young woman presenting a pattern indistinguishable from that of the neurovascular bundle, resulting in atrophy of the mus- lymphoma. Bilateral axillary adenopathy in a homo- 118 118 homogeneous and displaces rather than invades muscle planes. Large mass extensively infiltrating the right axilla (ar- has a characteristic attenuation value of fat. Characteristic phleboliths seen in about in infancy or early adulthood, they rarely produce 30% of cases. Most lesions are vessels and is encircled by tortuous vessels solitary and painful; multiple tumors are unc- branching from a vascular pedicle. High lesion in an adult that originates in the nerve signal intensity on T2-weighted images. Chest wall tumors arise from spinal nerve contrast administration, there is strong en- roots and intercostal nerves. The characteristic hancement in small lesions and often non- finding of bone erosion without destruction, most enhancing central areas of cystic or necrotic often of a rib, indicates the benign nature and slow change in large lesions. The lesion largely has the attenuation of fat and contains multiple discrete nodular areas of soft-tissue attenuation and a small round calcification (curved arrow) that represents a small phlebolith. About 60% to 90% of affected well-defined mass with low signal intensity on patients have either type 1 neurofibromatosis or T1-weighted images and high signal intensity multiple plexiform neurofibromas. T2 often shows a target appearance reflects the histologic feature in many appearance, with a rim of increased signal neurofibromas of a central zone composed of highly surrounding the lower signal central part of the cellular material and a peripheral zone containing tumor. Osseous and cartilaginous Osteochondroma Pedunculated osseous protuberance arising In the ribs, this common skeletal tumor especially (Fig C 61-3) from the surface of the parent bone with a involves the costochondral, junction. Enchondroma Expansile mass with calcified cartilaginous About 3% of enchondromas occur in the rib and (Fig C 61-4) matrix. In the chest wall, the lesion fluid level within the tumor suggests the most commonly involves the posterior elements of hemorrhagic nature of the cyst contents, but is the spine (articular process, lamina, and spinous not pathognomonic. Fibrous dysplasia Fusiform enlargement and deformity of one Developmental anomaly that is monostotic in (Fig C 61-5) or more ribs that is often associated with about 70% to 80% of cases. Fatty Lipoma Well-circumscribed, internally homogeneous Common lesion in adults, especially those who are (Fig C 61-6) mass of fat attenuation/signal that shows no obese.

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Givess, 47 years: The gastroenterologist may order angiography or small intestinal enteroscopy as well as radioisotope studies. If there is frequent passage of bright red blood in the stool along with a painful bowel movement, one should look for an anal fissure. Para-areolar Abscess or Fistula An abscess in the region of the areola or just adjacent to the areola often originates in an obstructed mammary duct, gen- erally from duct ectasia.

Pranck, 29 years: May occur in patients with bleeding diatheses, hemorrhage idiopathic pulmonary hemosiderosis, Good- (Fig C 49-18) pasture’s syndrome, polyarteritis nodosa, or Wege- ner’s granulomatosis. There may be associated filling defects detectable abnormality (the wall may be thickened (fungus balls, blood clots). With more haematoma formation and with the greater rise of intracranial pressure, im­ paction of mid-brain cone occurs and this cause decerebrate rigidity with fixed dilata­ tion of both pupils which fail to react to light.

Falk, 25 years: Reformation of pancreas following partial pancreatectomy is the nearest approach to reconstitution seen in man. Move the camera to this lateral- As the adrenal gland comes into view, liberate it from the most port, and pass a fan retractor in the most medial port. General Description Appearance: grooming, poise, clothes, body type (disheveled, neat, childlike, etc.

Umbrak, 32 years: Instruct the patient to irrigate each open end of the French catheter and suture it securely in this catheter twice daily with 25 ml of sterile saline. He/she may want to do a spinal fluid analysis or evoked potential studies as well. Retrograde pyelography may demonstrate tapering edges that may be difficult to differ- the typical meniscus appearance of the superior entiate from ureteral narrowing due to an border of the contrast column (wine glass sign inflammatory process, calculus, or extrinsic outlining the lower margin of the tumor).

Ines, 46 years: Weight reduction of as little as 4–7% body fat has an enormous effect on peripheral insulin sensitivity and on reduction of postprandial hyperglycemia. Gross Appearance of a Large Diabetic Foot Ulcer Copyright 2007 Biomedical Communications - Custom Medical Stock Photo. A cirrhotic patient goes into coma after an emergency portocaval shunt for bleeding esophageal varices.

Fadi, 51 years: This can happen if the volume of blood is so high that it is rapidly transported to the bowel without time for it to oxidize and turn black. In case of upper 1/3 rd of the ureter, the incision and approach is same as described under ‘Exposure of the kidney’ (page 1180). Be certain the two limbs of the incision in the anoderm are separated by an angle of at least 90° (angle A in Fig.

Koraz, 41 years: There are several types of collagen which differ in the aminoacid sequence of the constituent chains, though hydroxyproline, proline and glycin dominate. We have used a 4-0 poly- propylene running, inverting seromuscular suture to cover the staple line and have seen leaks only. The last but not the least point, which the students should always keep in mind, is its tendency to affect the Negroes and tuberculous patients.

Chenor, 61 years: In all events it is important to assess the extent of the pulmonary lesion before operation. The proper foot Therefore, whenever feasible they should avoid this position for inserting Lembert sutures in an anastomosis maneuver for seromuscular suturing, which is almost oriented in a line parallel to the long axis of the body is always possible if the surgeon rearranges the direction of shown in Fig. Two days later her lungs “white out” on x-rays and she is in respiratory distress.

Avogadro, 64 years: The bone may be destroyed irregularly so that the tumour is traversed by remnants of the original bone which is heavily trabeculated. Vertigo Once you have determined that the patient has peripheral vertigo, there is a wide differential diagnosis that should be considered. An operation can be expedited without sacri- should it be modified for this particular case?

Asaru, 49 years: Widening of the superior mediastinum with tracheal shifting in straight X-ray will give a clue, which will be confirmed by aortography. Because the narrow the pancreas is combined with longitudinal drainage of the area of the common bile duct is elongated, extending well main pancreatic duct. At the wrist, the median nerve is more commonly injured by cut injury and accidents as the nerve is comparatively superficial here.

Reto, 54 years: Although angiogenesis is a definite feature in the growth of malignant tumours, yet it is not unique to it, as angiogenic benign tumours do exist. There are few physical findings, and they are limited to the area where the process is occurring. In the past, this complication was considered to be chronic pancreatitis or to invasion of these structures by the cause of the high mortality rate associated with these carcinoma.

Marcus, 62 years: Expose the aorta at the hiatus of the dia- phragm, and prepare a suitable large vascular clamp for emergency occlusion of this vessel should it be necessary. To know the involvement of the renal arteries by aneurysm these investigations are more helpful than other investigations. Oedema and swelling of the upper limb and lower limb may occur due to enlargement of axillary and inguinal groups of lymph nodes respectively.

Marus, 38 years: That full-blown picture is rarely seen today, since most patients are worked up as soon as they have hematuria. If these tests are unrevealing, it is wise to refer the patient to a neurologic specialist before more expensive tests are ordered. Acute intestinal obstruction when complicated by strangulation may show presence of leucocytosis.

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