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V. Arokkh, M.A., M.D., Ph.D.

Associate Professor, Florida State University College of Medicine

Internal consistency has been ade- quate and consistent across studies (Melka women's health clinic toronto birth control buy generic cabergoline 0.25 mg on line, Lancaster women's health clinic keesler afb cabergoline 0.5 mg order amex, Bryant uc davis women's health center best order for cabergoline, & Rodriguez, 2011; Spaapen, Waters, Brummer, Stopa, & Bucks, 2014; Wiltink et al. Items are rated from 1 (almost never, 0–10%) to 5 (almost always, 91–100%), yielding a total from 36 to 180, with higher scores indicating greater degrees of impairment in emotion regulation. It is used extensively in psychiatric research as a predic- tor of psychopathology, in treatment trials as a mediator variable, and as a primary outcome variable. Capacity for Mentalization and Reflective Functioning “Mentalization”—the ability to infer and reflect on one’s own and others’ mental states—is a form of mental activity considered to be imaginative (because when we mentalize, we are “imagining” what others think or feel). Mentalization is primarily preconscious, typically occurring outside the focus of attention, and aims at under- standing and interpreting the behavior of self and others in terms of mental states (e. This capacity enables individuals to use ideas to experience, describe, and express internal life; to regulate their own affects and develop a coherent sense of self; and to make accurate inferences regarding the mental states of others. It allows them to distinguish between internal and external reality and between mental and emotional processes and real- world interactions. Mentalization is supported by several cognitive skills, including understanding of emotional states and the ability to think implicitly about others’ states of mind. Allen, Fonagy, and Bateman (2008) have described mentalization as a Profile of Mental Functioning—M Axis 89 means through which we “keep in mind the mind,” “understand misunderstandings,” “see [ourselves] from the outside and the other from the inside,” and “[attribute] a quality of mind to things or develop a mental perspective” (p. The construct of reflective functioning represents the operationalization of the capacity to mentalize— the way, in other words, that we measure mentalization. The capacity for mentalization and reflective functioning reflects the ability to symbolize affectively meaningful experience (i. It may be appar- ent in verbal behavior but can also be manifested in more subtle and indirect ways, nonverbally and via the body. The capacity to represent experience—a crucial aspect of mentalization—enables individuals to use ideas to experience, describe, and express internal life and to make accurate inferences regarding the mental states of others. The foundation for mentalization and reflective functioning is laid early in life, as dyadic interactions with caregivers are encoded and internalized. The “psychological self” develops as a child experiences a caregiver who thinks of the child as an indi- vidual with mental states. Thus the capacity to develop a mentalizing stance depends greatly on parental mentalizing capacities. The parents must be able to take the child’s perspective and, appreciating the inherent separateness of minds populated by differ- ent contents, treat the child as a “psychological agent” whose actions are motivated by mental states. This parental capacity includes the ability to make sense of the infant’s powerful affect states and other aspects of his or her nonverbally expressed internal world. Parents who cannot reflect empathically on the inner experience of their child and respond accordingly deprive the child of a nuclear psychological experience necessary to build a cohesive sense of self. Attuned care- giving, in contrast, fosters the elaboration, differentiation, and integration of affective self-states, setting the stage for the capacity to experience one’s own and others’ sub- jectivity. Awareness that other people accurately attend to and respond to one’s experi- ence gradually builds in the infant the ability to reflect on these experiences through using language (i. Individuals at this level can comprehend and reflect on internal mental states (e. They are highly capable of distinguishing inner from outer reality; have psychological insight into their own motives, affects, and behaviors; and can think about self and others in subtle and sophisticated ways. They also show a capacity to construct representations of internal mental states using both overt and subtle cues (e. Emotions are experienced and represented in complex and nuanced ways, in the context of social-emotional relationships and behavior patterns. Internal representations are used to modulate and inhibit impulses and to allow adaptive, appropriate expression of impulses. Individuals at this level are generally able to understand and reflect on their own behavior and reactions in terms of mental states (e. In situations of conflict or intensity, however, there is a notable decline from usual levels of awareness of mental states of self and others, with difficulties in per- ceiving and representing emotions in the moment. They may have a limited ability to elaborate on a feeling in its own right, and tend toward external justifications; wishes and feelings may be acted out (i. Individuals at this level are unable to infer, understand, or reflect upon their own affective experiences or to symbolize others’ mental states. They have severe dif- ficulties distinguishing between internal and external reality and between men- tal and emotional processes and real-world interactions; it seems that what exists in the mind must exist “out there,” and vice versa.

There can be hemodynamic and symptomatic benefit as well as improvement in left ventricular function and dimension with surgical correction of functional mitral regurgitation in heart failure; however menstruation lasting 3 weeks generic cabergoline 0.25 mg buy on-line, thus far no significant mortality benefit has been demonstrated menopause gift basket order 0.5 mg cabergoline visa. In systolic heart failure pregnancy 5 weeks 6 days quality 0.25 mg cabergoline, in order to maintain stroke volume the left ventricle cavity size increases and becomes more spherical, thus increasing wall stress, as dictated by the Laplace law. Left ventricular reconstruction surgeries were initially developed as an alternative to cardiac transplantation. The procedures were devised to restore normal left ventricular geometry to reduce wall stress and increase cardiac efficiency. A ventriculotomy is created in the true aneurysm, and the opening is closed with a Dacron or pericardial patch. Ventricular reconstruction does not have a demonstrated significant survival benefit in heart failure. Cardiomyoplasty is also known as dynamic cardiomyoplasty, in which the latissimus dorsi is wrapped around the heart and paced. This procedure has been abandoned in heart failure because there was high surgical mortality and no significant survival benefit. The concept of ventricular restraint with cardiomyoplasty was translated into using man-made materials in lieu of muscle to constrain the left ventricle to prevent left ventricular dilatation. Currently, there is insufficient evidence regarding the role of various types of stem cells in cardiac regeneration and modifying systolic heart failure; however, further clinical trials may provide additional mechanistic insights and clinical evidence. Essentially, it partitions the distal chamber of the infarcted ventricle from the ventricular chamber and thus reduces the left ventricular volume. Patient with advanced heart failure have limited medical options, which include inotropic agents; however, the long-term use of these medications is associated with a 50% mortality at 6 months. However, there is a discrepancy between the limited availability of donor organs and the ever-increasing number of patients with heart failure. In 2015, about 5,000 heart transplants were performed worldwide, with 2,600 in the United States. Despite the increasing prevalence of heart failure and, resultantly, the number of patients who would benefit from heart transplantation, the donor volume has remained flat. Similarly, for those patients with advanced age and comorbid conditions, cardiac transplantation is often not an option to address advanced heart failure. The durability of this device was also a critical limitation, with the valve and motor failure occurring after 12 months of support. The classifications are many and can be based on site of support (either left ventricular, right ventricular, or biventricular support), duration of support (temporary versus permanent), or type of device (continuous versus pulsatile flow). In those patients with acute cardiogenic shock and multisystem organ failure whose condition does not allow for evaluation of transplant eligibility because of unclear neurologic status and reversibility of myocardial and end-organ function. Devices designed for this group of patients are those that are easily and quickly implantable and cost-efficient. These patients have irreversible ventricular failure and meet standard criteria for heart transplantation. Positive outcomes with this clinical application have been important for expanding the field of mechanical circulatory support. Thus, it is critical for patients to undergo neuropsychiatric evaluation for assessment of compliance, substance use, social support, and health literacy. The rotor in these devices rotates at a set constant speed and acts to unload the left ventricle. Given that there is continuous flow, the main contribution of pulsatility is from the native left ventricle. It has an electromagnetically powered impeller that spins on a blood-lubricated ruby bearing. The pump itself weighs about 10 oz, has an implant volume of 63 mL, and generates up to 10 L of flow per minute. The axial flow design and the absence of blood sac eliminate the need for venting, which was required for the first generation of implantable pumps, thus reducing the size of the percutaneous driveline and also eliminating the need for internal one-way valves. It is unique in that its small size allows for implantation within the pericardial space, obviating the need for the creation of a peritoneal pocket.

The phase difference in the spin of protons in moving blood compared with nonmoving protons within a magnetic gradient is called the “spin phase shift” and is proportional to the velocity of the moving protons women's health quinoa recipes cabergoline 0.5 mg purchase. A phase-encoded image is constructed women's health clinic doncaster 0.5 mg cabergoline free shipping, with the gray level of each pixel coded for velocity pregnancy 9 weeks 3 days buy cabergoline once a day. Phase-contrast velocity mapping could be considered analogous to pulse wave Doppler echocardiography. It can be used to measure blood velocity and hence quantify cardiac output, shunts, and valve dysfunction. There are, however, limitations, given that the accuracy of this method is highly dependent on factors such as flow pattern, flow velocity, size, and tortuosity of the vessel. Flow-related signal loss can be a result of loss of phase coherence that can occur in cases of significant flow acceleration and even in higher orders of motion present in complex flow patterns. A number of parallel imaging techniques make use of multiple receiving body coils to fasten the acquisition times. Gadolinium significantly shortens the relaxation time of nearby protons, thereby increasing their signal intensity. Prevalence of adverse reactions is approximately 2% and includes transient headache, nausea, vomiting, local burning or cool sensation, and hives. However, gadolinium has been linked to a severe and rapidly progressive form of systemic sclerosis called nephrogenic systemic fibrosis, which appears to be related to extracellular accumulation of gadolinium after its administration in patients with end-stage renal disease. The enclosed space of the magnet poses problems for many patients, even those who do not have a history of claustrophobia. The study can usually be successfully completed with the help of clear communication with the patient before and during the procedure and/or with light oral sedation (e. All metal items, jewelry, and nylon undergarments should be removed for reasons of safety and possible image degradation. Phased array body coils are placed on the patient’s torso over the imaging area of interest. Some of these coils, for example, enable performance of 3D cardiac cine examinations with full-ventricle coverage in a single breath- hold. The net result is not only better image quality but also reduced exam time for the patient. Use of vector cardiogram allows the R–R interval to be registered as a 3D spatial vector that varies in magnitude and direction throughout the cardiac cycle. The aorta may be highly tortuous and should be imaged in multiple planes, with double-oblique measurements performed from true short-axis cuts using reconstructed images. Intramural hematoma can be considered as the forme fruste of aortic dissection because of the spontaneous rupture of vasa vasorum within the media of the aortic wall. Because of the short T1-relaxation time of fresh blood, differentiation from the adjacent mediastinal fat may be difficult. Intramural blood can be best detected on fat- saturated T1-weighted gradient echo or black-blood techniques. Furthermore, on spin-echo (“black-blood”) imaging, the intramural hematoma may be isointense (acute) or hyperintense (subacute) relative to skeletal muscle. Penetrating aortic ulcers appear as deep ulcerations of an aortic atheroma that extend through the intima to disrupt the underlying media and cause bulging of the outer aortic contour. They commonly appear at the isthmus beyond the left subclavian artery and in the distal descending thoracic aorta near the diaphragm. If acute, there may be evidence of intramural bleeding in the rim adjacent to the ulcer. Tears are usually found in the area of the ligamentum arteriosum and diaphragmatic hiatus and are characterized by a localized saccular aneurysm, with or without associated periaortic hematoma. Special imaging sequences using T2-weighting and short-tau inversion recovery for fat suppression allow assessment of wall edema and wall thickening/inflammation, respectively. As a result, small changes in myocardial mass and/or volume can be detected over time or because of therapy. Manual or semiautomated tracing of the endocardial borders at end diastole and end systole is later performed off-line, and ventricular volumes and ejection fraction are calculated. As mentioned before, development of multichannel phase-array coils has enabled parallel imaging and significant improvements in temporal resolution and scan times.

Diseases

• Canavan leukodystrophy
• Immunodeficiency, secondary
• Situs inversus viscerum-cardiopathy
• Doxorubicin-induced cardiomyopathy
• Short rib syndrome Beemer type
• Learman syndrome
• Negative rheumatoid factor polyarthritis
• Ahumada-Del Castillo syndrome
• Antisocial personality disorder
• Blepharo facio skeletal syndrome

Perceptual Changes Perceptual changes in psychotic subjects may affect various sensory modalities and their subjective interpretation breast cancer slogans cheap 0.5 mg cabergoline with amex. People in psychotic states may have a derealized experi- ence of the environment breast cancer 0-9 cabergoline 0.25 mg order with amex, in which the world is apprehended through a veil or fog women's health clinic parramatta 0.5 mg cabergoline purchase mastercard. At the other extreme, there may be heightened sensory awareness of the outside world and of sensory changes. Colors may appear more vivid, and spatial relationships distorted, such that stepping off a curb into the street may feel like leaping off a cliff. Sounds from the environment may mix with speech perception, such that one is uncertain whether one is hearing the wind or voices whispering. The person’s attention may be drawn to fragments of the perceptual frame, such that ambient stimuli that would ordinarily go unnoted are now the focus of attention. At first these sensory changes may not be related to the self, but they inevitably take on personal meaning for the psychotic individual. In psychosis, however, voices are better understood as arising from a noncohesive self, and not necessarily as the voice of an alternative self. Critical voices mock, degrade, and insult the person; threatening ones predict harm or punishment; command hallucinations often instruct self-harm or sui- cide, and, less often, destruction or harm of others. Locutions are typically in the sec- ond person (insulting or commanding), or third-person comments about the patient. Voices are typically felt as omnipotent and omniscient and frighteningly beyond the patient’s control. In a minority of cases, voices depart from these patterns, at which point differen- tial diagnosis becomes more important. Voices that are positive and supportive, telling the person that he or she is special or has religious significance, may be more indica- tive of mania (see pp. Voices capable of conversation (such that talking back alters a voice’s message) may be more indicative of dissociative identity disorder (see p. Symptom Patterns: The Subjective Experience—S Axis 149 Cognitive Dysfunctions Formal Thought Disorder People suffering from psychosis may have trouble maintaining a focused, organized, goal-directed train of thought. They may experience thought blocking, when no thought seems to come, and at other times may feel swamped by a flood of pres- sured thoughts. They may have trouble accessing words when they attempt to express thoughts or feelings, and may lose track of the main idea they wish to express. They may express themselves in concrete or idiosyncratic phrases, images, and metaphors not easily understood by others. For example, the answer to the question “What do a bus and a bicycle have in common? A patient may report never feeling fully awake, and complain of mental fatigue, clouded thinking, and lack of pleasure. To compensate for this, a new interest in metaphysical, philosophical, or religious themes may take hold, at times accompanied by the belief that the patient is seeing more deeply into events than the average person. Positive Cognitive Symptoms Disorders of Thought Content There is a wide spectrum of severity. At the mild end are idiosyncratic beliefs, preoc- cupations, and magical thinking, which may occur in the prodromal period leading up to frank psychosis. Delusions often arise in the context of the psychotic person’s attempts to find an explanation for anomalous experiences, such as hallucinations, or to express sentiments too powerful and conflicted to be easily put into socially con- sensual language. Early on, there may be a state of “delusional mood,” a vague sense or anxious expectation that something is about to happen, that significant change is afoot. This may be followed by a delusion, which brings some cognitive “order” to the emotional chaos by bringing some closure or meaning to particular intrapsychic themes of importance to the patient. In ideas of reference, an otherwise normal perception is interpreted as having personal significance (e. A person might say, “When I walked down the block, it seemed that the cars on the block had been arranged in a special pattern to send a message to me. They may be quite elaborate, as in this example: “When he looked at me angrily, his eyes were spinning in his head [illusion]; later, his buddies were following me in their cars, and I could tell for sure because as they drove by, the car wheels were spinning—just like his eyes! One of them drove right past me, and I could tell right away—he didn’t look at me! For example, a man with a disturbance in his self-experience, who reported hearing his own thoughts aloud, concluded that the government had advanced spy technology that could read his thoughts from a distance, and then that spy agents were playing his thoughts back to him through tiny speakers hidden along the sidewalk, so as to drive him mad into revealing what the government thought he knew about a terrorist operation.

It often results from an immune-incompetent recipient’s inability to defend against transfused lymphocytes menstruation blood clots order on line cabergoline. Transfusion services may favor X-ray irradiators women's health center john muir 0.5 mg cabergoline purchase fast delivery, as the Federal requirements for having an irradiator with gamma irradiation are quite extensive due to fear of terrorists being able to weaponize the Cobalt or Cesium source atraso menstrual 02 dias 0.25 mg cabergoline buy with amex. Currently, many hospitals provide 100% leukoreduced products, but implementation is not yet universal. The most common indications for washed products include: history of anaphylactic reactions (removal of allergenic plasma proteins); prevention of hyperkalemia in newborns and small children (removal of potassium present in the plasma); and removal of antibodies (e. Although questionable, it is generally accepted that patients with complete IgA defciency plus the presence of anti-IgA should also receive washed products with the goal of removing as much IgA as possible. Current guidelines recommend washing the product 6 times for suffcient IgA removal. For platelets, washing will both reduce the number of platelets, as well as activate them, leading to degranulation, and thus, washing platelet products may lead to an inferior product with questionable beneft. The antibody screen is positive and additional testing demonstrates the presence of anti-k. This donor is not required to go through the standard donor screening and testing process B. Family members are not allowed to donate blood components due to the risk of alloimmunization Concept: The patient has an antibody against a high incidence antigen. Although directed donations are usually discouraged, family members are a good resource for compatible blood in these situations. The pathophysiologic mechanism involves the proliferation of viable donor lymphocytes in the recipient, due to the recipient being unable to mount an immune response against donor lymphocytes. The minimum required dose of gamma radiation is 2500 cGy (25 Gy) to the center of the blood product bag, and 1500 cGy (15 Gy) to the remainder of the blood product bag (Fig. In the case of rare blood, family members should be encouraged to donate for the patient (Answer E). Nonetheless, they have to go through the standard screening process and testing as with any other allogeneic blood donors (Answer A). The antibody screen is positive at the immediate spin phase; antibody identifcation shows that he has anti-M. Typically, anti-M is a naturally occurring alloantibody that is detected at room temperature. In the setting of open heart surgery, the reactivity of the antibody can become stronger as the patient is cooled down during the surgery. Use a blood warmer for the case Concept: Anti-M is usually not clinically signifcant. One can perform a thermal amplitude test to determine the temperature range over which the antibody reacts. If, for example, the antibody does not react above 32°C, the anesthesiologist may choose to cool the patient down only to 32°C (rather than 30°C). Also, since about 20% of blood donor red cells do not express the M-antigen, it may be possible to provide M-negative red cell units for the surgery. Once the patient is off bypass and back to 37°C, the anti-M would not be expected to bind red cells; thus, M-antigen untested units (but crossmatch compatible) may be transfused. A similar situation occurs when a patient has hemolysis due to a cold autoantibody. If transfusion is clinically indicated, then transfusion via a blood warmer should be given. In patients with severe life- threatening hemolysis due to this condition, therapeutic plasma exchange may be considered. During plasma exchange, a blood warmer for both draw and return lines, as well as heating up the room to 37°C, should be considered. Having the patient move to a warmer climate will have no effect on the cooling 174 8. AdulT TrAnsfusion—PrinciPles And PrAcTice of the bypass circuit for surgery (Answer D). Similarly, warming up the operating room or using a blood warmer will also not affect the cooling of the bypass circuit (Answers B and E). The clinical team is considering a diagnosis of acute chest syndrome, and consults transfusion medicine about treatment options. Proceed with an automated red cell exchange to increase hematocrit to 30% and reduce HbS to less than 30% D.

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Vandorn, 45 years: The R-value is within normal limits, suggesting that the patient has adequate levels of coagulation factors and would therefore not beneft from additional plasma transfusions (Answers A and B). The protein component of enteral or parenteral nutrition appears to be the major macronutri- ent enhancing systemic clearance of affected drugs in patients transitioned from the “unfed” to the “fed” state. The busy physician who does not have the time to perform a neurologic examination should refer the patient to a neurologist or orthopedist.

Masil, 30 years: Another substantial example of nutritional immunity can be found in investiga- tions on murine Plasmodiun infections, mimicking human malaria [65,66]. For example, an instrument/questionnaire designed to measure Infant mortality should contain item content that reflects the construct of infant survival. The titer is the reciprocal of the highest dilution in which agglutination (not including weak reaction or reaction <1+) was observed.

Fedor, 23 years: If there are hypoactive reflexes in the lower extremities, consider the possibility of cauda equina tumor or tabes dorsalis. They have a number of advantages: Handwheel valves • The regulator assembly is manufactured in a clean Large nitrous oxide cylinders for use on cylinder manifolds environment and is much less prone to particulate and carbon dioxide cylinders of size F and G are ftted contamination. If there is a high thrombosis risk, then cover with low-molecular-weight heparin from 2 days after stopping warfarin, with the last dose ≥24h pre-procedure.

Sancho, 59 years: However, it may not in a minority of patients, fewer than in β thalassaemia always be possible to recognise the combination of iron trait [4]. Tortuous signal voids (long arrows), representing dilated intercostal arteries to the post-coarctation aortic segment, are seen. If no cause is found for hypogonado- trophic hypogonadism, the likely cause is Kallman’s syndrome, especially if associated with anosmia.

Konrad, 38 years: On examination in follow-up in 24 hours the light, the right pupil is dilated as compared with (E) Immediate referral to an ophthalmologist the left. As the gastrocnemius contracts, traction on the apophysis causes micromotion between the apophysis and the body of the calcaneus, resulting in inflammation and arthritic type pain. Childhood-onset vasculitides • The primary vasculitides in children are rare but life-threatening conditions.

Kan, 43 years: It may also indicate following neck fexion and softening of the tube during inadequate cuff infation or defation caused by cuff anaesthesia. Death in aortic dissection results from vascular compromise, tamponade, or aortic rupture. Macallan and colleagues conducted a study in India to investigate the pathophysiology of wasting using 12C-labeled leucine [89].

Vigo, 24 years: When the history and monary sequestration following transfusion of blood examination of the blood flm do not reveal the cause, containing an anti‐neutrophil antibody, e. The risk of embolism is greatest in the early postoperative period, declines after 3 months, and is greater for mitral (7%) compared with aortic valves (3%). The roots of primary anterior teeth bend labially in the outlines of the crown, more widely on primary their apical one third to one half by as much as 10° second molars than the first molars (the opposite of (Appendix 9c).

Kirk, 39 years: There are two types of controller: conventional ‘high-suction’ and also ‘low-suction’. T is was secondary to recurrent bleed from previously clipped lef posterior communicating artery aneurysm (note the partially visualized streak artifact). A close working relationship between especially in the areas of therapeutic and operative primary care physicians, chest radiologists, thoracic procedures like carbon dioxide laser treatment of surgeons, and pulmonologists not only facilitates the spontaneous pneumothorax or diffuse bullous educational process but also ensures that patients emphysema, neodymium: yttrium-aluminum-garnet undergoing thoracoscopy are assessed from all laser vaporization of pleural malignant tumors, and perspectives.

Vak, 29 years: Individuals draw on various sources of efficacy information to increase exercise behavior, including mastery experiences (e. Unilateral jugular venous distention can be seen in patients with venous compression. Presents as small vesicles deep seated (appearing like “tapioca”) in clusters, occasionally bullae.

Yespas, 42 years: Shocks delivered during physical exertion noted to have gradually increasing heart rates and gradually decreasing V-V intervals suggest sinus tachycardia. Half of showing a large minimally enhancing mass in the anterior congenital cysts are incidentally detected whereas mediastinum inflammatory cysts occur in adults but are have cystic changes. For the clinical evaluation of proposed research intervention, the framework of guidelines is provided for the following areas: 1.

Rhobar, 64 years: Remember that the labial surface of an anterior tooth and the buccal surface of a posterior tooth are both referred to as facial surfaces. Rouleaux Concept: Based on the two different agglutination reaction patterns, 4+ cells compared to 2+, it is likely that antibodies to multiple antigens are present. Suggested Answer: Based on this study, the oR i had the highest accuracy for assessing osteo- porosis risk.

Stan, 26 years: This is a retrospective study of 45 knees treated with a modifed Elmslie-Trillat osteotomy for recur- rent instability or patellofemoral pain. As can be seen inPanelA, the default breath-hold time should be 10–12 s for scanning of the coronary arteries. Under stress, capacity for self-awareness, self-reflection, and self- examination may fluctuate or deteriorate, as may awareness of others’ subjective experience.

Riordian, 62 years: The done in suspected cases of lung cancer and this helps presence of hilar and mediastinal lymph nodes can in detecting asymptomatic distant metastases in the be detected though accurate classification of these lungs, liver and adrenals. It is also possible to derive normal ranges will more closely approximate to those that would be from data on patients, based on the assumption that the expected in an optimal state of health. Two con- study also demonstrated the linear relationship between firmatory tests are used to ensure proper placement.

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