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Medical Instructor, College of Osteopathic Medicine of the Pacific, Northwest

Incidence of breast cancer in such mothers is relatively Readymade: No preparation needed allergy medicine reviews over the counter discount loratadine 10 mg amex. It is perhaps because of this factor also that It is inexpensive allergy medicine loratadine side effects purchase loratadine with a visa, costing virtually nothing and thus incidence of respiratory and gastrointestinal infections economical for individual family allergy ucla purchase loratadine 10 mg otc, community and the in breastfed infants is far less than that reported in nation. It contributes to reduction in infant morbidity and Breastfed babies have seven times less chances of an mortality. Its secretory IgA provides Exclusive breast milk: Breastfeeding should be started protection against respiratory and gastrointestinal within frst half to one hour after birth and continued infections. It contains lactoferrin, a substance that exclusively up to the age of six months. Timeline 14th days of birth Soon after birth Cues do point out that the baby is hungry and needs onwards feeding. Composition Rich in fat, protein, Richer in fat, protein, Breastfeeding should be given at least 8–10 times in 24 lactose and vitamins, immunoglobulins, hours till lactation is established (1–2 weeks). Te so-called test-feed involves weighing the baby before z Macrophages: Detecting, engulfng and destroying pathogens and after the mother has nursed him. This may cause undue anxiety to her, gastrointestinal tract, especially against Gram-positive bacteria. Correct position consists in Growth factors: supporting infant’s whole body so that it faces the mother Epidermal growth factor. Good attachment (laching) of infant’s mouth on mother’s z Amylase: Digestion of polysaccharides. It should be exclusive (no other food or water be given) Essentials in proper positioning of infant Box 12. Factors causing improper attachment include: Markers of adequate milk supply: A contented baby 187 z Inverted nipple is a good guide as regards the adequacy of milk supply. Te most reliable criterion of adequate supply of Basic Principles of Breastfeeding breast milk and growth of the baby is the weight gain. No prelacteal feeds: As a rule of the thumb, no prel- A baby who gains less than 500 g in any four week acteal feeds (not even honey or the so-called gutti) period in frst three months of life or 200 g in any four should be given to the neonate. Prelacteal feeds are weeks period in second three months is likely to be known to: malnourished later. Working woman and expressed breast milk: In case z Enhance risk of infections of a working mother, her expressed milk can be spoon- z Decrease suckling, stimulation and milk production fed to the baby in her absence. Te mothers should z Contribute to poor attachment be conversant with the technique of expressing milk. Ten Exclusive breast milk: Breastfeeding should be started the breast and areola should be squeezed between within frst half–one hour after birth and continued fngers and thumbs and the milk is collected in a exclusively up to the age of six months. Te container should be stored in a z During these six months, the infant should not be cool place. Technique of expressing milk is described breastfeeding can maintain hydration, urine out- later in this very chapter. Common Breastfeeding Problems Complementary feeds: After six months, breastfeeding Inverted or Retracted Nipples plus complementary feeding need to be continued upto two years. Since these may cause difculty in breastfeeding, the Hygiene: Breastfeeding should be done in a clean and mother is advised to manually stimulate, stretch and roll safe manner as possible. Art of feeding: Mother should be well conversant with Situations warranting temporary avoidance Box 12. In Mother One breast at a time: At least one breast should be z Chronic diseases such as active tuberculosis, leprosy, malignancy, completely emptied at every, sitting. Many authorities advocate continuing breast- should be after the frst breast is completely emptied. Those on heavy metals, phenobarbital, hydantoin, steroids, minutes in the subsequent days. Failure to do so may cause regurgitation, vomiting, z Inborn errors such as phenylketonuria, galactosemia or lactose and even abdominal pain.

Here allergy symptoms muscle aches 10 mg loratadine purchase amex, therefore allergy treatment portland maine best order for loratadine, the focus in z National Malaria Eradication Program z National Family Welfare/Planning Program an integrated manner is on main causes of morbidity and z National Tuberculosis Control Program mortality as also the overall health of the child allergy shots headaches loratadine 10 mg buy on line. Improvement of case management skills of health pro- z National Program for Prevention of Visual Impairment and viders through provisions of locally adapted guidelines Control of Blindness and training activities to promote their use. Provision of essential drug supplies required for z 20-Point Program efective case management of childhood illness. Optimization of family and community practices in rel- z National Diabetic Control Program ation to child health, particularly care-seeking behavior. Major Components Steps of Management Improvement in case-management skills of health Step 1: Check-up to identify the illness staf through appropriate guidelines. Step 2: Classifcation of illness according to color- Improvement in the overall health system. Such a focus on hospitals is the outcome as emergency (requiring urgent intervention and of inappropriate health care practices that have developed emergency measures). Show mothers how to breastfeed, and how to maintain Only a limited number of carefully-selected clinical lactation even if they should be separated from their infants. Give newborn infants no food or drink other than breast milk, the signs, the child is assigned to color-coded classifcation, unless medically indicated. Give no artifcial teats or pacifers (also called dummies or Guidelines address most but not all health problems. Foster the establishment of breastfeeding support groups and drugs and encourage active participation of caretakers refer mothers to them on discharge from the hospital or clinic. Infectious diseases, Intestinal parasitic (both protozoal and helminthic) infestations, Dental caries, Skin diseases, Fig. Te philosophy behind this new Promotion of positive health strategy is that hospitals set the standards for primary care Prevention of disease and act as the major providers and trendsetters, thereby Timely diagnosis, treatment and follow-up infuencing the behavior of the health providers and Health education to inculcate awareness about good the community. What is practiced in hospitals is viewed and bad health by community at large as the right thing to do. Health appraisal Te movement that took of in 1991 in 12 countries Remedial measures and follow-up has now become global. Experience has shown that Prevention of communicable diseases the following benefts in such hospitals are immediate, Healthful environment obvious and substantial: Nutritional services Decrease in infection rate. Mental health Easing of the hospital burden due to vast savings on Dental health infant formula purchase. Eye health Reduction in nursing load as rooming in and demand Ear health Health education feeding make nursery care easier. Education of handicapped children In India, hospitals are still in the stages of joining this School health record. Te procedure consists of a candidate hospital An important component of school health program improving practices to the point that it follows the ten steps is training the teachers in the basic concepts of hygiene, faithfully. Training the health care providers for successful nutrition, prevention and early detection of morbidities. Teachers can also act as liaison agents between children Besides promotion of breastfeeding, baby-friendly and health care providers. Etiology includes: Te baby-friendly hospital initiative has proved an initial Biologic causes step to make hospital facilities more friendly to mother, z Psychiatric disorders baby and child. Sound health and its care picked up Prevention lies in improvement of family life, better during these years have a great bearing on the individual, schooling and social welfare services. Like adults, children too watch it for entertainment, information, reassurance and comfort after stressful Parents must use their balanced judgment in choosing experience, overcoming boredom, etc. Now, he is able to draw preventive as well as curative activities for preschool conclusion from certain programs. Tere is a considerable children has been called the under-fves or young child improvement in memory for program contents. He, therefore, becomes overworked rural mother cannot carry her healthy 6 months choosy too. Tey constitute 17% of the country’s total and reduction in activity, resulting in obesity. Te under-fves clinic is usually located in a village, a Secondly, common illnesses of this age group—say slum or a labor colony.

The areolas are still some- areolas are still laterally positioned allergy shots cpt code buy cheap loratadine online, but the medial quadrants are fuller what large allergy quinoa 10 mg loratadine order free shipping, due to the redistribution of most of the peripheral periareo- and appear more normal allergy shots weight loss loratadine 10 mg order without prescription, and the defect is disguised lar skin in order to reduce the vertical scar and perform a small refinement at the submammary sulcus k F i g. Satisfactory form and vol- ume of the breasts that appear to be proportionate to the patient’s body habitus 282 E. Fortunately, I have encountered few cases of such failures and complications, probably because of my almost manic attention and precision to the smallest detail, notwith- standing the time I spend in the operating room. This last aspect has been often criticized by many because it is very costly; however, this apparent expense id offset by achieving a satisfying solution with only one surgical procedure, thus reducing the risks of probable and possible future costly revisions. Since the patient lived in a different town (a fact that some- times compromises the possibility of postoperative follow-ups) 7 Surgical Failures and Complications and because patients do not always comprehend or cannot understand the significance of certain symptoms or clinical This type of malformation is considered a true surgical chal- information and do not promptly report those problems to the lenge by many plastic surgeons because it is considered a surgeon, the initial complication which could be promptly reconstructive rather than aesthetic surgery; therefore, a cer- treated may become a severe complication that compromises tain percentage of failures and/or complications that will the final result. Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 283 In this particular case, which presented a good postopera- In selected cases it may even solve the malformation tive result, the complication occurred 1 month after the last problem without the use of a mammary prosthesis. The patient underestimated a pro- technique is a potential optimal solution and undoubtedly gressive capsular contracture and failed to report this to her offers advantages for younger patients with respect to avoid- parents and doctor until a fistula occurred with consequent ance of problems and inconveniences arising from prosthesis cutaneous erosion and prosthetic exposure. The patient underwent explantation of the left prosthesis, The disadvantages and limitations of this technique total circumferential capsulotomy and partial peripheral cap- mostly concern the following: sulectomy in the inferior quadrants, enlargement of the pros- thetic pocket, lipofilling to obtain softness in the fibrotic • The necessity of repeated surgical operations whose num- capsule, and folding of a glandular capsular flap from the bers are not foreseeable although they are performed subareolar region to cover the deep cutaneous breach, which under local anesthesia and in an outpatient setting was then repaired at its borders and sutured with intradermal • The presence of fat tissue, not always available when and superficial stitches. This has Therefore I believe, together with my fellow surgeons, that taught me how important it is for the surgeon to conduct a this interesting and useful technique cannot and should not sub- thorough psychological examination of the patient to antic- stitute completely the different techniques thus far employed to ipate possible postoperative behaviors. We must also correct tuberous deformity [10–25], but it could certainly help, emphasize from the beginning the consequences and risks and make the final result easier to achieve and safer, with or, that certain behaviors will have on the outcome, without even better whenever possible, without a prosthesis. Bibliography Never overestimate a patient’s ability to understand that which is obvious to the surgeon. Lippincott Co, Philadelphia, pp 1–13 No plastic surgeon is ever safe from such frustrating 3. Muti E (1996) Personal approach to surgical correction of the extremely hypoplastic tuberous breast. Gasperoni C, Salgarello M, Gargani G (1987) Tubular breast defor- Infections: If we exclude the possibility that I encountered mity: a new surgical approach. Aesthetic Plast Surg 14:93–100 In this chapter I have attempted to concisely share my expe- 8. Aesthetic Plast Surg 19:421–425 Today, however, there is a new approach already under 10. Lambrinaki N, Ioannidou-Mouzaka L (2003) Aesthetic reconstruc- Plast Reconstr Surg 65(2):217–225 tion of the tuberous breast deformity. Aesthetic Plast Surg 27:85–93 the tuberous breast deformity: a 10-year experience. Servaes M, Mahaudens P, Sinna R, Vanwijck R, Denoel C (2011) Piccin Nuova Libraria S. Aesthetic Plast Surg 6:445–449 Gynecomastia Carlo Cavina The word “gynecomastia” literally means female breast. Much has been increase in volume of the male breast, which thus resembles written about the etiology of gynecomastia and its correla- a feminine breast [1]. This has been ancient times, thus represents by far the most common described in detail in several chapters of internal medicine benign condition of the male breast. Typical patients are teenagers and young tias into true or false only in relation to a fatty or glandular adults in whom the temporarily modest increase in volume component as the cause of the increased volume. It seems of the breast (normal at their age) does not cease, gets worse, more correct to speak about gynecomastia in a broad sense and in the end stabilizes over time. Patients are often initially (increase in volume of the male breast), specifying and defin- referred to their pediatrician or family doctor and have ing the type: glandular, adipose, or mixed. Gynecomastia can already been fully investigated (clinically and with labora- be a symptom of diseases resulting in a general endocrine tory tests) in the search for some cause of hormonal imbal- imbalance, and therefore they can sometimes be cured sim- ance. They are subsequently referred to us because surgery is ply by an appropriate medical therapy [2]. Sometimes, although the possibil- be neglected as an expression of minor importance in rela- ity is rarer, a patient suffering from gynecomastia is directly tion to the complexity and severity of an underlying disease referred to us, requesting surgical correction. Often, on the basis of we order laboratory tests and an endocrine consultation to unknown etiology, it represents itself as a pathological con- rule out other causes before evaluating surgery. Finally, there dition, not linked to other diseases; it can thus be defined as are neglected cases whereby correction may be required in idiopathic gynecomastia.

Diseases

• AREDYLD syndrome
• Cramp fasciculations syndrome
• Costocoracoid ligament congenitally short
• Hypertrichosis brachydactyly obesity and mental retardation
• Neuroectodermal endocrine syndrome
• Idiopathic infection caused by BCG or atypical mycobacteria
• Tunglang Savage Bellman syndrome
• Galactorrhea
• Cystin transport, protein defect of
• Congenital mitral malformation

Older studies found that about 80%–90% of recurrent cystitis is due to reinfection allergy symptoms cough treatment generic loratadine 10 mg on line, of which about a third arose from the same organism invading the urothelium again [26] allergy testing los angeles cheap 10 mg loratadine fast delivery. They account for 1%–3% of all general practitioner consultations in the United Kingdom [28] and 0 allergy symptoms from eggs purchase cheap loratadine on line. However, pathogenic bacteria must gain access to the bladder, generally from neighboring sites. Other colonization sites include the perineum, vaginal vestibule, urethra, and paraurethral tissues. Traditionally, uropathogens are required to ascend the urethra, against the stream of urine, to colonize the bladder [34]. Urinary incontinence generally predisposes healthy postmenopausal women to develop recurrent cystitis [36]. The use of incontinence pads is associated with a significant increase in the incidence of symptomatic cystitis in the elderly [37]. However, just because bacteria gain access to the bladder, cystitis does not necessarily result. The bacteria must attach to the urothelial cells to begin the inflammatory process (see the succeeding text for more detail). This study showed no difference in the virulence of the strains between the asymptomatic and symptomatic group nor any difference in resistance to antibiotics; thus, the authors suggested that host factors may be more important than bacterial virulence. Most important is the hydrokinetic or “washout” effect, in which diuresis and voiding act to dilute the bacterial load and wash away infecting organisms. In a 1969 study, 40% of women with bacteriuria became free of infection spontaneously within 12 months [40], while a 1971 study demonstrated that the urine of 80% of women with simple infections became sterile on placebo alone [41]. Thus, the risk of infection will depend on the size of the bacterial load, the multiplication rate of the organism, the urinary residual, the frequency of voiding, and the volume of fluid intake. Extremes of urine pH, high osmolality, and high urea concentration tend to be protective [42], which is why historically urine has been used as an antiseptic. Urea is the principal antibacterial electrolyte in urine, and its effect is also modulated by 878 concentration and pH [43]. The acquisition of iron is also an important requirement for bacterial virulence, because bacteria need iron to grow. Epithelial Factors The inner (luminal) surface of the urothelium is lined by uroplakin membrane proteins that lie within the plasma membrane of the superficial urothelial cells (also known as umbrella cells). They form a permeability barrier, to prevent the resorption of urine solutes across the urothelium but also to limit the availability of receptors for bacterial adherence factors [48]. The urothelium is also coated by a proteoglycan mucin layer, which further reduces permeability. This acts to oppose bacterial colonization, partly due to the high negative charge of the sulfated and carboxylated glycosaminoglycans [49]. Soluble factors normally found in the urine, such as Tamm–Horsfall protein, also protect the bladder. This mucoprotein is shed from the renal tubular cells and is excreted in the urine. However, if the uropathogens are able to adhere to the urothelium, then the acute pathogenic cycle of bladder infection can begin. Immunologic Factors The fact that recurrent cystitis affects 20%–30% of women suggests that some women do not develop long-lasting protective adaptive immunity following their initial infection [52]. Secretory immunoglobulin A (IgA) is synthesized by plasma cells within the lamina propria of the bladder wall and hence provides a degree of humoral immunity. In addition, a significant proportion of IgA originates in the urethra and this may help prevent ascending infection [54]. This inhibits further invasion of the microorganism, induces the production of antimicrobial peptides, and initiates apoptotic pathways, so that infected cells are exfoliated and pro-inflammatory chemokines are released, triggering neutrophil accumulation [42]. Despite these defense mechanisms, some bacteria are able to attach and invade the epithelium, which in turn releases antimicrobial molecules like cathelicidin or defensins.

Itching may be relieved by systemic antihistaminics Prognosis and/or local application of calamine lotion allergy treatment center st louis generic loratadine 10 mg without a prescription, potassium Chickenpox carries allergy vacuum cleaner order loratadine with american express, as a rule allergy forecast phoenix az loratadine 10 mg sale, favorable prognosis. It is the most common and the most infectious of the viral Steroids are, as a rule, contraindicated. It is characterized by catarrhal symptoms followed Children sufering from chickenpox must be restrained by a typical rash, the so-called measly rash. In healthy children, it Acyclovir (Zovirax) claims to accelerate rate of clinical generally runs a more or less benign course. Te peak incidence evidence becomes available for its utility in routine in the developing world is in the age group 1–5 years. One cases of chickenpox, its administration should be attack confers nearly lifelong immunity. Transmission is by indirect or direct contact and droplet infection, portal of entry being respiratory tract. Te period of infectivity is 4 days prior to and 5 days after the appearance of the rash. Pathological changes are essentially limited to superfcial blood vessels of skin and mucus membrane, forming the so-called inclusion bodies. Te infection is highly contagious with secondary attack rates as high as over 90% in susceptible (unimmunized) household contacts. Either no medicines or the ones which are supposed to cause greater eruption are preferred by the folklore. Harm- ful practices such as fomentation with hot bricks, instilling cow milk drops in nostrils and eyes, and giving a purge in order to bring the rash out fully are common. Clinical Features Te average incubation period is 11 days, the variation being between 10 days and 12 days provided that onset is ascribed to the frst prodromal symptoms. Prodromal (Catarrhal) phase of 3–5 days is characterized by upper respiratory catarrh (rhinorrhea, dry cough), fever, malaise, conjunctival congestion and photophobia. Teir frst appearance, usually on second or third day, is over the buccal mucosa, opposite the frst or second lower molar, and then at other sites in the mouth. With the appearance of rash, fever tends to observed in only a small proportion of cases. Even 10–20 days after the onset, complement-fxation antibodies in meaningful titer may be detected. Differential Diagnosis At times, another supposedly viral infection of infant and toddlers, roseola infantum (roseola subitum, ffth disease), may be confused with measles. Te pink macular rash of this infection usually appears on trunk, neck and proximal areas of the extremities only. It lasts for just 24 hours as against measles in which the rash lasts for 4–7 days. Frequency of complications is relatively higher in Infectious mononucleosis (glandular fever) is charac- such cases with guarded prognosis. Then petechial and other signs of the disease, such as it spreads to neck, trunk and limbs during the meningitis, toxemic state of the patient, etc. The rash starts fading from third to fourth day, Miliaria rubra (prickly heat, sudamina and heat rash) disappearing in the order of appearance. It is usu- superficial skin of face followed by that of trunk and ally seen in summer. Kawasaki disease, over and above the rash, is accom- It takes 10–14 days for the pigmentation to fade. Infrequently, measles may be Complications complicated by bleeding from different sites and a Te potential dangers of measles lie in its complications purpuric rash (hemorrhagic measles). Convalescent phase is marked by disappearance of fever, other constitutional symptoms and the rash. Treatment Clinical picture in a partially immune child may be of No specifc treatment is available. In case of superadded bacterial infec- Maintenance of proper fuid and dietary intake tions, a sharp leucocytosis often occurs. Vitamin A administration to reduce the morbidity Measles-specifc IgM antibody appears 3 days after the from measles rash and persists for 30–60 days following the rash. Transmission is by drop- z Otitis media tops the list of respiratory complications. Te virus enters the host z Tracheobronchitis, laryngotracheobronchitis, bronchiolitis, bron- through the upper respiratory route.

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Testimonials:

Kasim, 33 years: You also have an analgesic effect with a positive action on the autonomic nervous sys- tem, in particular on the parasympathetic nervous system, thus producing an inhibition of muscle tone and better tro- pism of the tissues. As a consequence, their endocardial activation is via muscle-to-muscle conduction and thus is much slower.

Jared, 47 years: It disappears soon after cessation of Choice of Donor Blood phototherapy with no permanent sequelae Te donor blood should be fresh (less than 3 days old). Note the multiple areas of ecchymo- sis and contusion caused by minimal blunt force trauma.

Runak, 58 years: Symptoms in childhood psychiatric Pediatrician is the best person to motivate parents for this. Most commonly this would be due to bladder prolapse (cystocele, either central, paravaginal, or a combination).

Trano, 63 years: It has been ments are necessary to achieve facial balance in any specific described as the “polar bear” syndrome because of the defi- patient is the appreciation of malar–midface zonal deficien- ciency recession of the inferior orbital rim, which contributes cies. In addition, the study by Kahn and Stanton showed an increase in rates of incomplete bowel emptying and fecal incontinence (4% preoperatively vs.

Inog, 54 years: Fine needle aspiration of 154 parotid masses with his- tologic correlation: Ten-year experience at the university of Texas M. The two phenomena observed during this effort are a constriction of the urethral lumen by the striated urogenital sphincter and an elevation of the vesical neck, caused by contraction of the levator ani muscles, as described in the following texts.

Kulak, 50 years: If plasma sodium is 120–125 mEq/L, eforts should also be directed at fnding the etiologic fuid restriction usually resolves the problem. Influence of the site of stimulation on the resetting phenomenon in ventricular tachycardia.

Nefarius, 45 years: These catheters consist of fluid-filled balloons over the side holes, and the urethral pressures represent the average pressure measured over the length of the entire 482 balloon. The doctor responds to the crew’s request that any doctor aboard identify himself/herself, and provides treat- ment to the passenger.

Bufford, 28 years: The control of micturition and continence arise at three levels: suprapontine (thin line box), spinal (thick line box), and peripheral/infrasacral (dashed box). The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence Society.

Thorek, 26 years: However, the length of follow-up was not reported, and “objective cure” was said to be 61% compared to 100% for Burch; thus, little confidence can be placed in this study. Stippling defects represent abrasions that, unlike the irregular nature of the wound due to the location of the soot, cannot be wiped away.

Thorald, 24 years: The median basilic vein is generally superficial to the brachial artery pulsation, and the brachial vein lies deep in the vascular sheath alongside the artery. It has proven itself to be a reliable system, and it is the system that should be employed in research regarding pelvic organ support.

Ernesto, 31 years: Prominent Tese include pleuropulmonary involvement, peritonitis, collaterals in fanks and over back point to inferior vena subphrenic abscess, abscess-duodenum, fstula, hemobilia, cava obstruction. However, this bladder to sympathetic mechanism to suppress detrusor contractions during urine storage may be weak in humans, given that bilateral retroperitoneal lymph node dissection (involves destruction of sympathetic chains) has no discernible alteration of filling or storage function in humans.

Basir, 49 years: For this reason, point C, the lat- eral limit of the ellipse, usually is near the lateral border of the areola (Fig. The level of injury to the pelvic viscera is determined by the level at which fetal descent stops [12].

Tangach, 21 years: This dog sus- the irregular weathering marks on the surface of the bullet tained penetrating gunshot wounds during the attack. Atrioventricular pacing is often necessary to get the heart rate 80 to 100 beats/min, and supraventricular tachycardias generally require cardioversion.

Koraz, 53 years: Third-degree (complete) heart block occurring in the A-V node is relatively common. If the patient is signifcantly anemic and/or having large hematemesis, blood transfusion is usually needed.

Anog, 46 years: Within 2 weeks after the last laboratory test, all subjects competed in the National University Triathlon Championship. Do these simulated data provide evidence for us to conclude that a difference in the spinal canal cross-sectional area exists between a population of subjects with disc herniations and a population of those who do not have disc herniations?

Jaroll, 59 years: If the patient does receive treatment, remarries, or returns to her husband, the subsequent fertility rates are quite desponding. Subsequent stitches move posteriorly until the last stitch closest to the ischial spine is attached to the vagina nearest the apex, again using the previously placed marking sutures for guidance.

Leif, 40 years: Atrial pacing prolongs the P-R interval owing to A-V nodal delay but will not change the degree of preexcitation because the fiber takes off from the His–Purkinje system. Pelvic organ prolapse and incontinence in developing countries: Review of prevalence and risk factors.

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