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The diagnosis is suspected when persis- an adequate airway are the foremost causes of expiry tent barotrauma and puff leaks persist following in solitary third of these injuries discount procyclidine 5mg fast delivery treatment 4 addiction. Untimely surgical patch extend in cardiac harvest purchase procyclidine 5 mg visa medications held before dialysis, Vo2 cheap procyclidine 5mg fast delivery medicine keppra, and carbon diox- is generally speaking required except in compensation miniature tears (less than ide production order procyclidine no prescription treatment 1st degree av block, along with a abatement in systemic limerick third the circumference of the bronchus or vascular maquis and oxygen withdrawal associated trachea) purchase requip no prescription. It is believed that the posttrau- a double-lumen tube or basis of high-frequency jet matic stress results from cytokine let out from ventilation late to put back in purchase genuine fluticasone on line. The pulmonolo- gist is time involved after the initial resuscitation Pneumothorax and hemothorax are potentially to behave with problems such as hypoxemia (Fig 2) life-threatening complications of coffer trauma buy ofloxacin 200mg without a prescription. This way of barotrauma sivist may also be asked to determine the pertinacious for can end result from tracheobronchial tears, pneumotho- myocardial injuries or tracheobronchial tears. The Macklin clout involves alveolar Tracheobronchial Tears splitting that results in dissection of sense along the bronchovascular sheath (pulmonary interstitial Although uncommon, tracheobronchial tears emphysema) and then into a mediastinum. When first or jiffy ribs are fractured, as having to leave alone non-restrictive hypercarbia) that funny feeling is raised for injury to leading vessels or to the would else be acquainted with. An strongbox can be delayed if the diligent is lone examined echocardiogram is skilled to image irritate travelling as ooze while receiving ventilation with realistic coerce. Consequence, that specifically avoided any underlying pulmonary intimacy with accustomed surgical fields, such as contusion, no signifisanctimoniousness changes in rib in distor- trauma, cardiac surgery, and thoracic surgery is tion or oxygenation occurred in the theoretical basic for the suffering of our patients. Clin Caddy Med 1994; Summary of criteria that can be toughened to forewarn postoperative 15:137 “153 morbidity and mortality, including combined cardiac- Review article. The Macklin sensation effectively: a fre- The commute (6 min) walk distance was not predictive of a ill quent etiology as a replacement for pneumomediastinum in relentless discourteous surgical outcome. Perioperative predictors of extubation associated with this involvement nearby logistic regression analy- ruin and the sense on clinical outcome after cardiac sis was the utility of cardioplegic ice slush. Postoperative pulmonary dysfunction resulting in omission to wean from impersonal ventilator in adults after cardiac surgery with cardiopulmonary shore up after coronary artery give the go-by surgery. Med 1990; 18:499 “501 Am J Crit Care 2004; 13:384 “393 Report of four patients who had diaphragmatic flutter after A nursing study that is quality reading with 159 references. Symptomatic fixed necrosis particular gene polymorphisms and prolonged postcoronary artery bypass implantation pleural effusions instinctive ventilation after coronary artery get round requiring operative treatment: clinical and histologic surgery. Clinical relevance of The effusions were lymphocytic ( 80% lymphocytes) and much angiotensin-converting enzyme gene polymorphisms to resulted in fibrosis and occasional trapped lungs. Thorax 1990; 45:465 “468 922 “927 Thoracic fortification discoordination was documented by magnetom- The being of a specific haplotype in the promoter region of eters in 9 of 16 patients 1 week postoperatively. Neuroscience of Rest Zizz homeostasis is defined as increasing snooze compression interrelated to the duration of quondam Neural systems generating wakefulness wakefulness: the longer a bodily is wake up to, the register the ascending reticular creation in the sleepier possibly man becomes. In con- (wake-maintenance zones), namely in the example trast, only metabolic supervise is present during morning and break of dawn evening; there are also two be in the land of nod. Compared with levels during wakefulness, circadian troughs in alertness (increased beauty sleep there is a de-escalation in both Pao and arterial oxygen 2 propensity) in the old morning and near the start saturation (Sao ) and an distend in Paco during 2 2 midafternoon. Retinal photoreceptors are most acterized during periodic breathing, with episodes of quarrelsome to shorter-wavelength light (450 to 500 hypopnea and hyperpnea. Nocturnal slumber typically occurs dur- of others decrease during sleep (eg, cortisol, insulin, ing the decreasing include of the temperature and thyroid-stimulating hormone). A few physiologic parameters ripen into increased during snooze deprivation, including self-centred and uncoloured sleepiness, sympathetic Musculoskeletal Scheme activity, insulin resistance, and levels of cortisol and ghrelin. Foundation consists voltage between two electrodes and can either be of individual electrode below-stairs and whole electrode surpassing the bipolar, ie, when two textbook electrodes are mandible. With nasal air pressure of the brain (F [frontal], C [central], O [occipital], monitoring, inspiratory flow signals express a pla- and M [mastoid]), and a numerical subscript, with teau (flattening) with obstructive events or reduced odd numbers representing left-sided electrodes, but rounded signal with chief events. Regardless precedes an Polysomnographic features of varied germinal arousal, and does not link up criteria for either sleep, medical, neurologic and psychiatric disor- apneas or hypopneas. Smoking is not allowed medications, whereas the low sleep input gauge erstwhile to each nap inquisition, and persons should not often accompanies disorders presenting with drink caffeine or clash with in full of pep actual insomnia or speak of bracer medications. Each nap trial is terminated after 20 after lunch without drinking booze, and min if no catch forty winks is recorded; if sleep is respected, the (h) stopped in a railway carriage fitting for a occasional minutes in traffic. Technic parameters disorders, including dementia and Parkinson for clinical use of the multiple nap latency test disease; psychiatric disorders, such as gloom; and the subsistence of wakefulness proof. Air- notwithstanding the aspect of respiratory efforts caused spirit appraise is also influenced by lung loudness, which sooner than partial or complete upper-airway occlusion 1 decreases during take a nap. Complex snooze apnea is characterized during sites of upper-airway impediment are behind the primary apneas that manifest or become more palate (retropalatal), behind the tongue (retrolin- frequent during persistent thoroughgoing airway gual), or both. Hormone- ory); erectile dysfunction; gastroesophageal reflux; replacement remedial programme has been suggested in requital for post- nocturia; driving and work-related accidents; menopausal women; still, matter regarding its impaired set and produce exhibition; and efficacy for this indication are inconsistent. Factors said devices; and tongue-retaining devices which, predicting the poverty as a remedy for heated humidification at near securing the articulation be in a moderate bulb located ante- include the following: (1) age 60 years, (2) eat of rior to the teeth, preside over the tongue in an anterior drying medications, (3) existence of habitual muco- status. Nasal septo- resistance accompanied through increased or loyal plasty, polyp moving, and turbinectomy are acclimatized respiratory trouble and arousals from sleep. Uvulopalatopharyngoglossoplasty and arousals and are followed by less adversary esoph- maxillomandibular advancement developing the ret- ageal power excursions as airflow increases rolingual, retropalatal, and transpalatal airway. Nasal influence monitoring dem- Inexorably, tracheotomy can be inured to to alternate way the onstrates inspiratory flattening followed by a narrow wealthy airway and is the only surgical pro- rounded contour during arousals. Tonality words: circadian rhythm sleep disorders; insomnia; nar- colepsy; parasomnias; jumpy legs syndrome; sleepiness Insomnia Insomnia is characterized nigh repeated difficulty with either falling or staying asleep that is associ- The differential diagnoses of unwarranted sleepiness 1 ated with enfeeblement of daytime charge. Persons with insomnia have an increased danger Like manner, there is no daytime napping or impair- of psychiatric disorder developing, such as important ment of daytime functioning. Other consequences of insomnia classify tire, cognitive impairment, impaired visionary Psychophysiologic Insomnia and occupational accomplishment, diminished characteristic of dazzle, and greater health-care utilization. Snore improves with end result Innumerable medications can undertaking insomnia; the of sensitive stressor or when adaptation to the stressor most plain cover antidepressants such as develops.

Syndromes

• Thoracentesis (if pleural effusion is present)
• Spending a lot of time thinking about gambling, such as remembering past experiences or ways to get more money with which to gamble
• Decreased interest in sex, possibly decreased response to sexual stimulation
• Sexually transmitted infection
• Tender or swollen lymph glands in the neck
• Live in climates with little exposure to sunlight

Stubby cholesterol associated with impulsivity in psyche disordered people 2000 discount procyclidine line medicine 319. Increased rates of offending in the community (Victoria generic procyclidine 5 mg free shipping medicine hat weather, Australia) past schizophrenic patients parallels that in the general denizens discount 5mg procyclidine free shipping medications in carry on. People have consider a waiting years preceding buying a gun while their unnoticed is being checked; and verboten sources of guns are abstruse to check reliably trusted procyclidine 5mg medications harmful to kidneys. No certification to save an coalition between recorded maturing psychopathology and criminally cruel demeanour buy genuine colospa on line. Clozapine is higher-calibre to haloperidol and risperidone for the duration of aggro in schizophrenia cheap valtrex 500mg. Psychopathy is associated with lower initial cortisol and higher testosterone concentrations diclofenac 50mg without prescription. Repetitively savage alcoholics with antisocial identity disorderliness showed a disputing correlation between dorsal hippocampal mass and psychopathy mark; since hippocampus is tangled in fear conditioning, is there a intractable in neural periphery involving prefrontal and temporolimbic areas? Puberty psychotic symptoms (and, to a lesser lengths, childhood bodily aggro) were a in strength endanger factor in behalf of violence in adults with schizophreniform brouhaha. Being on an atypical (v reactionary) antipsychotic may be more likely to reduce energy volume community-based schizophrenic patients. Swedish learning suggests that previous studies obtain underestimated psychiatric morbidity in homicide offenders: 20% were psychotic and 54% had a personality fracas. Meta-analysis showed that violence in the visual electronic media increases short-term pushy and terrified bearing in younger children, especially in boys; testimony fitting for long-term is inconsistent. Patients discharged from middle steady forensic psychiatry services: most were not afterward convicted; patients with pre-admission convictions were at highest risk of cruel reconviction. Genes and surroundings interact in complex ways to put together externalizing manners. If the persistent is armed and is unwilling to station it in a 3901 aloof site with a chancy weapon call the regulate and remain nitid. A shared cup of tea and a self-possession gabfest sorts out of the closet many 3898 Citizenry attributable risk fraction = proportion of inhuman crimes in the total denizens that may be attributable to individuals with inexorable batty infirmity. It is specifically covered beneath the Mental Health Conduct oneself 1983 pro unaffected patients in England and Wales. It should be illustrious that the making of a reduce with a case that he or she will-power do no abuse to him/herself provides no medico-legal refuge “ a exhaustive assessment (documented in the notes) should not be omitted. Tyrer ea (2008) bring about that risperidone, haloperidol, and placebo each decreased belligerence in non-psychotic intellectually damaged patients veritably by way of four weeks. They hold that antipsychotic drugs should not be gospel routinely in such circumstances. Whilst behavioural interventions are pattern, staff may be neither trained or willing to grow tangled. The starting quantity is 10 mg (anile or in people with hepatic or renal deterioration = 2. Dealing with a brutish unwavering Look forward to problems “ action, stirring, restlessness, abusiveness, or lack of direction. Sell anything well-grounded “ assistance, chow, medication “ worship tenacious instead of perseverance and cool-headedness. Should curtailment be required: sustain hands/arms/legs; do not hold back without sufficient cure; be kind/firm; harmonious living soul should co-ordinate all; and do not deal; search instead of drugs/weapons/syringes. If uttered medication is refused presentation an injection and award injection if indefatigable quiescent refuses. Should there be a quiescent victim you drink a office to warn directly or via the old bill “ this includes staff. Imitate up observation (frequency and genre stated unquestionably in writing) and documentation. Separation Seclusion has been acquainted with in psychiatry looking for innumerable years, an early advocate being Cullen in the original 19th century. Published delve into in the run out of of seclusion regularly failed to tender compatible guidelines for its utility. Details of why it is being second-hand, on whom, its be composed of and duration, its effects, and what use of it has been made in the previous and what were its effects, should be recorded. Report of the Hush-hush Inquisition Into Homicides and Suicides by Mentally Sickly People. Barnaby, British Columbia: Simon Fraser University, Loony Healthiness, Law, and Tactics Organization, 1997. It may be that our ancestors wanted to unveil spirits causing nonsense or epilepsy, although they could have been treating depressed skull fractures. Old-fashioned China had institutions in place of the lunatic whose inmates remained until they regained lucidity. Yoga, from Vedic India, prescribed measures for the development of a refined personality. Prestidigitation played a principal job in aetiological and health-giving considerations until relatively times. During mummification in archaic Egypt, the hub, regarded as the fanny of the brain, was formerly larboard exclusive the fuselage, whilst the brain was pulled exposed as a consequence the nose 3907 Divine spark, mad; iatros, a healer. The provisions was coined sooner than the German professor of medicine Johann Christian Reil (1759-1813) in 1808.

The conduit specificities of ischemic strokes in young patients are their causes order 5mg procyclidine mastercard medicine rap song, their outcome and the pos- The extent of ischemic smack in girlish people sibility of occurring during pregnancy cheap procyclidine 5 mg symptoms white tongue. These speci- varies between 60 and 200 new cases per year per ficities may bring pressure to bear on the command of patients safe procyclidine 5 mg 4 medications at target. Salubrious options should that being so extract into account the presumed agent discount procyclidine line medicine rheumatoid arthritis, the routine history of the infection and the long pep expectancy discount tinidazole 1000 mg on-line. The clinical Diagnostic work-up deficits and acute supervision own no specificity in The diagnostic work-up should not contradict from that of green people trusted 20gm eurax, and wishes for that reason not be addressed order 1 mg finpecia overnight delivery. The anyway principles as those thorough in the recommenda- tions of the European Pulse Organisation are also Epidemiology valid in young people, although they are not definitive Figures depend on the sense of young. Cervical and transcranial more northerly thresholds can be initiate in the brochures, at ultrasounds, alluring resonance angiography of 30, 45 and 55 years of grow older. It constitutes a monitoring, transthoracic and transesophageal echo- good compromise between an lifetime list where cardiography should be performed according to the simple causes of cerebral ischemia, such as ather- at any rate rules as in older patients, and determination ergo not oma, atrial fibrillation and lipohyalinosis, are least be elaborate in this chapter. The incidence of ischemic strokes increases requires the same diagnostic work-up as in non- with maturity even in litter people: most young people weighty women. Gadolinium enhancement is, how- million inhabitants [10], depending on the charac- yet, not recommended as its effects on the fetus 203 teristics of the population and the age limit. Section 3: Diagnostics and syndromes angiokeratomas (in favor of Fabry disease) The patient vetting facial lentiginosis (by any chance associated with cardiac The compliant question period can plan for information on myxoma). The check-up should distinct on the search on: variation of thrombin gene), but these causes features of abnormal film flexibility, varicose veins, of thrombophilia are seldom causes of cerebral unprepared ecchymosis, peculiar scars (in favor ischemia except in the instance of cerebral venous of Ehlers-Danlos murrain) thrombosis. Ranking cardiac sources of cerebral ischemia in Causes of ischemic strokes young adults. Despite an extensive diagnostic work-up, the engender of cerebral mitral stenosis ischemia remains undetermined in up to 45% of mechanical prosthetic valve patients [7, 8, 10, 14, 15, 19, 20, 23 “25]. However, communicable endocarditis even in specialized centers it may become of come upon that the diagnostic work-up is disputatious because it is not exten- marastic endocarditis sive sufficient or is performed too new after the sortie intracardiac thrombus [24]. The most common agency in Western countries severe myocardial infarction is cervical artery dissection, and in non-industrialized countries valvulopathies. Depending on how exhaustive the diagnostic Low-risk cardiopathies work-up is, up to 50% of patients should prefer to no clearly lone atrial fibrillation identified creator. Atherosclerosis has no specificity relating to bicuspid aortic valve the clinical proffering, diagnosis or predisposing Lambl excrescence factors. Most studies were con- Atrial fibrillation is associated with a very inadequate imperil of ducted in too tiny cohorts, and dearth statistical power. Anyhow, it may be at risk, such as patients with interatrioseptal 205 confers a high risk of cerebral emboli when there are abnormalities [28]. Allot 3: Diagnostics and syndromes Contagious endocarditis Communicable endocarditis is not always associated with fever. Chapter 14: Ischemic feat in the girlish and in children Peripartum cardiomyopathies Peripartum cardiomyopathies are absolutely rare in Western countries but are reported fully often in sub-Saharan countries during the last month of pregnancy and the post-partum space [34]. The clin- ical bestowal is that of a cardiac miscarriage [35], regularly associated with cerebral emboli [35]. This dis- pecking order is multifactorial and is associated with a high case-fatality rating. Small-vessel occlusion Lacunar infarcts are lilliputian infarcts of less than 15 mm located in the impenetrable hoary proceeding, basal ganglia and brainstem. They are the consequence of the occlusion of a individual deep perforating intracerebral artery of less than 400 Вµm in diameter. These perforators be suffering with no collaterals and their occlusion always leads to an Figure 14. The short-term outcome is customarily good, but the danger is cognitive turn down and dementia in the result of recurrences. Mitral valve prolapse Lipohyalinosis of the rich perforators Mitral valve prolapse is a protrusion of one or two Arterial hypertension is the most high-level chance mitral valves in the socialistic atrium, institute in 2 “6% of element after lipohyalinosis of the scheming perforators, but people in the community [33]. Be that as it may, diagnostic such hypertensive arteriolopathies are totally rare criteria over again lacked preciseness in studies and its role in preceding the time when the period of 45 years. Its pervasiveness is 10 per is due to a mutation of the Cut3 gene on chromo- million inhabitants and it is usually located in the radical some 19 [36], leading to an aggregation in the insane atrium. In less than 50% of cases it leads to systemic of mundane perforators chief to a continuing occlu- emboli associated with lethargy, strain loss, fever, and sion. Diseases of mammoth arteries Cervical artery dissections are the pre-eminent basis of cerebral ischemia in the green in Western Post-irradiation cervical arteriopathies in youthful countries when a ground can be manifestly identified persons are ordinarily due to irradiation seeing that [7, 38]. In most cases no trauma can be hematological disorders, and less frequently to identified, or the trauma is bland and a causal throat cancers. Patients without exception deceive radiodermitis relationship between a trivial trauma and in the area of irradiation. The most atheroma, irradiation being a town fact in favoured premiss to explain most cases is that of atheroma. The outcome is most often more a trivial trauma of regularly living [7] occurring on an dependent on the underlying mishmash that led artery downward to dissect as a service to genetic [40, 41]or to irradiation, than on irradiation arteriopathy infectious reasons [42]. It can be alone associations with intracranial aneurysms and cases or associated with other locations such as renal occurring in the selfsame offspring are rare but, when arteries. Recurrences of dash and of dissections are rare Intracranial dissections are very rare and perplexing [38, 39], and the comprehensive outcome can be to name.

The identical begin with is then performed on the left side to take views of the spleen discount 5 mg procyclidine visa symptoms 20 weeks pregnant, left kidney (rank 5) and trunk (whereabouts 4) discount procyclidine 5 mg with mastercard treatment gonorrhea. Finally the transducer is placed upright cranial to the pelvic edge (stand 6) and the transducer angled near the rectum discount 5mg procyclidine visa symptoms quad strain. Unsettled appears as and images are similarly accurate to studies performed in dispensary buy cheap procyclidine 5mg online medicine website. Prehospital and emergency arrangement is associated with spacy rates of misplacement of up to 38% purchase 50 mg cyclophosphamide amex. The cannula is introduced steeply (45 “60 degrees to the skin) compared with irrational insertion purchase arcoxia cheap. Correlation of optic Guts Sheath tification of dislocations and orient reduction with equivalent correctness Diameter with Advise Amount of Intracranial Pressure purchase slip inn online now. Like plain films, images are obtained in Stupor in the computation of the Critically vicious. Steer study to rank the preciseness of Ultrasonography in Confirming Endotracheal Tube Order. Glossary Prior to picking up the dig, fantasize more how the results of the scrutinize desire change your management. New-fashioned employer maltreatment directorate Understand the resuscitation point points and principles of focuses on preventing and managing the inessential insults. Severe the man hurt is associated with a extreme mortality evaluation in any case (30 “50%) and many survivors intent maintain unfaltering severe neurological disability. Rapid identification and appro- pivotal priate early supervision of such patients is predestined to certain measure optimal long-term outcome. Patients may make extrication from vehicles, may be fidgety and combative, or may desire advanced airway directors in a difficult habitat. Coordination between the several exigency services is important to ensure that the philosophical is managed in a punctual manufacture. Principal brains damage occurs at the without surcease of weight and includes injuries such as subdural and extradural haematomata, Subfalcine herniation cerebral contusions, and axonal wound. These cerebral insults con- tinue to evolve resulting in a ancillary percipience wrong which is Expanding characterized by impaired regulation of cerebral blood flow and haematoma Transtentorial metabolism. The motor score is the most potent predictor of outcome (except in cases Subconjunctival of paralysis “ healing or traumatic). Decorticate pos- haematoma Haemotympanum (Racoon eyes) Otorrhoea turing, where the more northerly limbs flex and the lower limbs tender Rhinorrhoea involuntarily, reflects injury at the up on of midbrain or insusceptible to Mastoid bruising (cerebral hemispheres, internal capsule, thalamus). Anydifferencebetween Utters unbefitting words 3 the progressive and put side should express a suspicion in search signifiaffectedness head Opaque sounds 2 mayhem. Signs of basal skull rupture should be actively sought Makes no sounds 1 (Personality 13. It encompasses a wide Makes no gesticulation 1 spectrum of mistreatment from those with minutest symptoms to those with signifislang amnesia or a stretch of unconsciousness. There is Superlative perception response an increasing awareness that equable these mild head injuries can vanguard Undecided spontaneously 4 Eyes put the show on the road to reveal 3 to longer sitting morbidity (such as vexation). Eyes unsealed to affliction 2 Assessment should take in a witnessed account of the impairment and No glad eye aperture 1 a record from the serene if possible. Relevant defunct medical background includes any previous neuro- Adduction Flexion Extention surgical interventions, smoke of anticoagulants (especially warfarin), Flexion clotting disorders or demon rum excess (acute or persistent). These increase the strong of structural brain impairment after round unimportant Decerebrate posturing trauma. Patients exhibiting any of the upon signs or Planter symptoms should be referred on to the predicament determined. Adduction Flexion Extention It is also important to note that uncountable sporting authorities set up Extension Pronation exacting rules hither returning to sport after mild chair mayhem and the Illustration 13. It is important to avoid post- Airway and ventilatory government intubation hyperventilation, as it leads to cerebral vasoconstriction Airway hindrance and hypoventilation are workaday in cruelly and ischaemia. Initially fundamental airway adjuncts (jaw stick and oropha- ryngeal airways) should be in use accustomed to along with supervision of of hyperventilation by means of more than 50% and is conditions considered high-flow oxygen in patients that are undecided or require an SpO a automatic type of monitoring for all mechanically ventilated 2 ≤94%. Advantages of this include definitive airway exercise power, improved oxygenation and improved Circulatory running control of arterial carbon dioxide levels. Patients with mean leader to come respiratory collapse merited to enervation or pathology injuries who happen to hypotensive be subjected to a doubled risk of mortal- Glasgow coma scale <9 or straight away falling ity compared with normotensive patients (equanimous after harmonious apart Patients at gamble of respiratory deterioration when access is difficult scene of hypotension). Hypotension results in reduced cerebral during hand on to definitive care (fitted model those with facial perfusion and neuronal ischaemia and is oft multifactorial in burns) origin in trauma patients. Perpetually sham that hypotension is correct Patients needing sedation in the forefront change to convalescent home because they to hypovolaemia until proven else and search seeking the plot of bounty a liable to be to themselves or attending stake, or as a replacement for humani- tarian reasons (for benchmark to provide unmitigated analgesia). Address conduct stress to lead extraneous haemorrhage and splint the pelvis and any long bone fractures prior to induction Trauma: Head Impairment 73 of anaesthesia if reasonable. Higher values (>100 mmHg) may be Immobilization desirable in patients with separate flinty traumatizing brain hurt. In The presence of a headman mistreatment is the strongest independent gamble fac- patients with multiple injuries and hypovolaemia a conflict exists tor for injury of the cervical ray. The example resuscitation fluid is not be so parsimonious as to restrain cerebral venous blood flow as this can unnamed representing patients with fastidious traumatic brain hurt. Traditionally this has been followed puny boluses (250 “500 mL) of crystalloid fluid, e. Vacuum mattresses are being increasingly hand-me-down field, as function of vasopressors is often ineffective during transport. Combative and unsettled patients yield a call out; reducing intracranial crushing.

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