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Even so buy anastrozole 1mg online, manipulation of the wound by cleansing or surgical excision can result in bacteremia buy anastrozole 1mg without a prescription. In the 1970s trusted 1mg anastrozole, before early excision became commonplace discount anastrozole 1mg amex, wound manipulation was associated with an overall 21% incidence of transient bacteremia (36). The incidence of bacteremia, which increased in proportion to the extent of burn and the vigor of the manipulation, provided the rationale for perioperative antibiotic administration as described above. The previously noted decrease in invasive bacterial burn wound infection stimulated Mozingo et al. The incidence of bacteremia was related to both the extent of burn and the time that had elapsed after the burn injury. Wound manipulation in patients with burns of less than 40% of the total body surface did not elicit bacteremia. In patients with more extensive burns, the incidence of bacteremia was 30% overall when wound manipulation occurred on or after the 10th post-burn day and rose to 100% in patients whose burns involved more than 80% of the total body surface (37). Those findings can justify omission of perioperative antibiotics for patients with burns of less than 40% of the total body surface, and perhaps even for those with more extensive burns who undergo excision prior to the 10th day after burn. Bacteremia may also occur in association with uncontrolled infection in other sites. In a critically ill burn patient with life threatening complications, recovery of multiple organisms from a single blood culture, or different organisms from successive blood cultures, indicate severe compromise of host resistance and should not be interpreted as contamination of the cultures. An antibiotic or antibiotics effective against all of the recovered organisms should be administered to such a patient at maximum dosage levels and the septic source of the blood- borne organisms should be identified and controlled. Historically, gram-negative septicemia and candidemia significantly increased mortality above that predicted on the basis of the extent of burn, but gram-positive septicemia had no demonstrable effect upon predicted mortality (38). Current techniques of wound care and improvements in general care of the burn patient have not only reduced the incidence of bacteremia but have also significantly ameliorated the comorbid effect of gram- negative septicemia (39). In a nine-year study, investigators compared 4059 paired aerobic and anaerobic cultures from burned patients and found only four anaerobic isolates (all Propionibacterium), none of which were associated with infection. However, they noted that 46 cultures with isolated bacteria, or 13% of those with identified bacteria, were found only in the anaerobic bottle. They concluded that detection of significant anaerobic bacteremia in burned patients is very rare, and anaerobic cultures are not needed for this purpose. However, anaerobic culture systems are also able to detect facultative and obligate bacteria; deletion of anaerobic culture medium may have deleterious clinical impact. In fact, traditional signs of infection such as elevation of white blood cells, increasing neutrophil content, or temperature elevation are not reliable (40). Other signs such as enteral feeding intolerance, thrombocytopenia, and increasing insulin resistance may be better signs of sepsis (41). Once the diagnosis of sepsis is secure, a clear source of infection from the burn wound, pneumonia, or bacteremia may still be elusive. This is usually associated with progression of multiple organ failure when a source is not Infections in Burns in Critical Care 369 identified and controlled. In fact, investigators have shown that 17% of burned patients who develop sepsis associated with multiple organ failure will not have a preceding diagnosis of infection (42). In this condition, a thorough search should be made for an infectious source, including careful and repeated examination of the wound. Other potential sources include the urinary tract, endocarditis, catheter related sepsis, and meningitis. If a source is still not found, it is conceivable that an overwhelming signal of inflammation from the wound could be the cause. It must be emphasized that this is a diagnosis of exclusion, and even after the diagnosis is made, the search for a source of infection must continue. Of late, investigators have been in search of genetic markers that herald the development of sepsis, which could be related to the condition described earlier. This early work signifies that slight genetic differences are likely to result in different responses to injury such as a burn. Identification of these alleles may eventually assist practitioners in the care of these patients who are at risk and even mandate treatment modifications. These initially present as papules with or without an erythematous rash that progress to vesicles and pustules. Crusted, shallow, serrated lesions at the margin of a healing or recently healed partial thickness burn, particularly in the nasolabial area, are typical of herpes simplex virus-1 infections. Titers for antibodies to cytomegalovirus and herpes simplex virus-1 may be found to increase, and intranuclear inclusion bodies in a biopsy specimen from the lesion may also be found. Excision is not required for the treatment of herpetic burn wound infections unless secondary invasive bacterial infection occurs in the herpetic ulcers, in fact, no changes in mortality or length of stay was found in those with viral infections and those without (44). The cutaneous ulcerations of herpetic infections should be treated with twice-a-day application of a 5% acyclovir ointment to decrease symptoms. Identified viral infection is usually self-limited, but in severe cases, consideration can be given to systemic or topical treatment with acyclovir or ganciclovir. Systemic herpes simplex virus-1 infections involving the liver, lung, adrenal gland, and bone marrow, though rare, are typically fatal and justify systemic acyclovir treatment. The burn injury makes the patient fivefold more susceptible to the development of pneumonia because of mucociliary dysfunction associated with inhalation injury, atelectasis associated with mechanical ventila- tion, and impairment of innate immune responses (45) (Fig. However, with better microbial control of the burn wound, the route of pulmonary infection has changed from hematogenous to airborne, and the predominant radiographic pattern has changed from nodular to that of bronchopneumonia (46). Nonetheless, some investigators still report a pneumonia rate of 48% in severely burned patients treated in a burn center (47,48). They are also often intubated for airway control because of inhalation 370 Wolf et al. Note the denudation and hemorrhagic change in the trachea wall with erythema and soot. Similar inflammatory changes and edema in the distal airway predispose the patient to pneumonia. For this reason, we recommend that pneumonia in the severely burned must be confirmed with the presence of three conditions, signs of systemic inflammation, radiographic evidence of pneumonia, and isolation of a pathogen on quantitative culture of a bronchoalveolar lavage 4 specimen of 10 mL with greater than 10 organisms/mL of the return. Those patients with signs of sepsis and isolation of high colony counts of an organism on bronchoalveolar lavage without radiographic evidence of pneumonia are considered to have tracheobronchitis, which can become invasive with subsequent demise. These patients are then documented separately from those with pneumonia, but are treated similarly with systemic antibiotics directed at the organism isolated on culture. Organisms commonly encountered in the tracheobronchial tree include the gram- negatives, such as Pseudomonas and Escherichia coli, and on occasion the gram-positives such as S. When the diagnosis of pneumonia or tracheobronchitis is entertained, empiric antibiotic choice should include one that will cover both these types of organisms. We recommend imipenem and vancomycin given systemically until the isolates from the bronchoalveolar lavage are returned. The caveat to this is the finding of gram-negative organisms on routine surveillance cultures of the wound. Generally, microbes found on the wound do not reliably predict the causative agent of pneumonia, which requires separate microbial identification. Army Institute of Surgical Research indicates that identification of gram-negative organisms, particularly Pseudomonas and Klebsiella on the wound of a patient with pneumonia warrant presumptive antimicrobial coverage until the causative organism is determined.

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Eptifibatide cheap anastrozole 1mg otc, tirofiban generic anastrozole 1mg without prescription, and abciximab are beneficial for patients likely to receive percuta- neous intervention anastrozole 1 mg without a prescription. Indications for intervention for descending dissections acutely include occlu- sion of a major aortic branch with symptoms order anastrozole 1mg without a prescription. For example, paralysis may occur with oc- clusion of the spinal artery or worsening renal failure may occur in the case of dissection that involves the renal arteries. Once a descending dissection has been found, intensive medical management of blood pressure is imperative and should include agents that de- crease cardiac contractility and aortic shear force. Finally, patients with Marfan’s syndrome have increased complications with descending dissections and should be con- sidered for surgical repair, especially if there is concomitant disease in the ascending aorta as demonstrated by aortic root dilation to greater than 50 mm. Anemia, pain, and myocardial ischemia are also causes of tachycardia that should be considered when managing a new tachycardia. Patients with wide complex tachycardia suggestive of ventricu- lar tachycardia or known preexcitation syndrome should be treated with agents that de- crease automaticity, such as quinidine and procainamide. However, in patients with apparent ventricular tachycardia who have neither a history of ischemic heart disease nor preexcitation syndrome, adenosine may be a useful diagnostic agent to determine whether a patient has a reentrant tachycardia, in which case the drug may terminate it; an atrial tachycardia, in which case the atrial activity may be unmasked; or a true, preexcited tachy- cardia, in which case adenosine will have no effect. Although adenosine is not the recom- mended primary therapy for patients with wide complex tachyarrhythmia, patients with junctional tachycardia who have evidence of poor ventricular function or concomitant β- adrenergic blockade may be reasonable candidates for its use. The risk of rupture and subsequent management are related to the size of the aneurysm as well as symptoms related to the aneurysm. When symptoms do occur, they are frequently related to mechanical complica- tions of the aneurysm causing compression of adjacent structures. This includes the trachea and esophagus, and symptoms can include cough, chest pain, hoarseness, and dysphagia. The risk of rupture is ~2–3% yearly for aneurysms <4 cm and rises to 7% per year once the size is greater than >6 cm. Beta blockers are recommended because they decrease contractility of the heart and thus decrease aortic wall stress, potentially slowing aneurys- mal growth. Individuals with thoracic aortic aneurysms should be monitored with chest imaging at least yearly, or sooner if new symptoms develop. Operative repair is indicated if the an- eurysm expands by >1 cm in a year or reaches a diameter of >5. Endovascular stenting for the treatment of thoracic aortic aneurysms is a relatively new procedure with limited long-term results available. The largest study to date included >400 patients with a variety of indications for thoracic endovascular stents. However, if the procedure was done emer- gently, the mortality rate at 30 days was 28%. At 1 year, data were available on only 96 of the original 249 patients with degenerative thoracic aneurysms. Ongoing studies with long-term follow-up are needed before endovascular stenting can be recommended for the treatment of tho- racic aortic aneurysms, although in individuals who are not candidates for surgery, stent- ing should be considered. Furthermore, this artery in the majority of the population arises from the right coronary artery. Thus, a patient who pre- sents as this one does with symptoms consistent with an acute coronary syndrome and V. Wellen’s T waves are deep symmetric T-wave in- versions that are seen in either significant left main coronary artery stenosis or proximal left anterior descending artery stenosis. Acute pericarditis is the most common disease of the pericardium and typically pre- sents as a sharp, intense anterior chest pain. It may be referred to the neck, arms, or left shoulder and may be pleuritic in nature. The pain is worse with lying supine and improved with sitting up and leaning forward. A pericardial friction rub is described as high-pitched, grating, or scratching and is heard throughout the cardiac cycle. An echocardiogram should be performed if there is suspicion of a possible effusion. Aspirin or nonsteroidal anti-inflammatory drugs in high doses are most commonly used. As this patient is in severe pain, reassurance only is not the best option but would be a possible treatment if panic attack were suspected. The other choices are utilized in the case of unstable angina and acute myocardial infarction and should not be utilized in this patient. Both heparin and reteplase would increase the risk of developing a hemorrhagic pericardial effusion. While all of the diagnoses listed are causes of sudden cardiac death in young indi- viduals, commotio cordis is the likely diagnosis because of the occurrence of the injury in relation to blunt trauma to the chest wall. In contrast to cardiac contusion (contusion cordis), the force of the injury is insufficient to cause cardiac contusion or injury to the ribs or chest wall. If the force were delivered during the upstroke of the T wave (10–30 msec before the peak), ventricular fibrillation would frequently result. A normal S2, the location of the murmur, the absence of radiation to the neck, and being loudest at the lower left sternal border make aortic sclerosis or aortic ste- nosis less likely. Maneuvers such as going from standing to squatting and passively raising the legs decrease the gradient across the outflow tract and intensity of the murmur due to in- creased preload. Amyl nitrate causes a decrease in systemic vascular resistance and arte- rial pressure. Right-sided murmurs, except for the pulmonic ejection “click” of pulmonary stenosis, usually in- crease in intensity during inspiration. Of the medications, only the thiazolidinediones improve insulin-mediated glucose uptake in the muscle and adipose tissue. The mechanism of ac- tion of metformin is uncertain, but it appears to work by reducing hepatic gluconeogen- esis and intestinal absorption of glucose. In a large trial of lifestyle modifications and metformin in the prevention of diabetes (Diabetes Prevention Program), subjects in the lifestyle arm of the trial had a more significant reduction in the incidence of diabetes than those assigned to metformin. In resource-poor settings and the developing world, life- style modifications have also been shown to be more cost-effective than metformin for preventing diabetes. Generally the recipients do well, with survival rates of 76% at 3 years and an average transplant “half-life” of 9. However, certain complica- tions are common with the necessary immunosuppression, including an increased risk of malignancy and infections. Additionally, patients are at risk of rejection of the trans- planted organ that can be acute or chronic. Chronic cardiac transplant rejection mani- fests as coronary artery disease, with characteristic long, diffuse, and concentric stenosis seen on angiography. It is thought that these changes represent chronic rejection of the transplanted organ. Common alternative diagnoses in this setting include exacerbations of congestive heart failure, myocarditis, and pulmonary embolism. This patient has atypical features of his chest pain for angina: lasting for more than minutes at a time, nonexertional.

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A 42-year-old premenopausal woman history of prostate cancer had his prostate recently underwent partial mastectomy and removed 10 years ago discount 1mg anastrozole with amex. His prostate-specific radiation therapy for a small tumor in her antigen levels have begun to rise again discount anastrozole 1 mg mastercard, and he breast generic anastrozole 1 mg with amex. There were no lymph nodes involved purchase 1mg anastrozole fast delivery, complains of back pain, suggesting metastatic and the tumor was estrogen-receptor positive. Which of (A) Anastrozole the following is a concerning side effect of (B) Leuprolide tamoxifen? A 56-year-old woman with a significant (E) Hypotension smoking history was diagnosed with small-cell lung cancer 2 years ago and was successfully treated. Streptozocin is toxic to b cells of the islets of Langerhans in the pancreas and is therefore used in the treatment of insulinomas. Melphalan is a derivative of nitrogen mustard used to treat multiple myeloma, melanoma, and carcinoma of the ovary. Vinca alkaloids such as vinblastine block chromosomal migration and cellular differentiation. Leuprolide is used to treat hormone-sensitive prostate cancer, and tamoxifen is used to treat breast cancer. Paclitaxel is often used in the treatment of breast as well as ovarian and lung cancer. Its main toxicity is myelosuppression and peripheral neuropathy that usually manifests as numbness and tingling in the distal extremities. Blood in the urine can indicate hemorrhagic cystitis, a complication of cyclophosphamide use. Shortness of breath can result from pulmonary fibrosis secondary to busulfan or bleomycin use. Etoposide is used in the treatment of small-cell lung carcinomas as well as tes- ticular tumors. Before using this agent, a thorough cardiac evaluation is required, including an echocardiogram or nuclear medi- cine scan of the heart. Bleomycin is included in the treatment of metastatic testicular neoplasms and can cause pulmonary fibrosis. Busulfan can also cause pulmonary fibrosis; however, it is not used in the treatment of testicular neoplasms. Cisplatin is highly emetogenic and can cause nephrotoxicity as well as ototoxicity. Aminoglutethimide is an inhibitor of steroid synthesis used in Cushing syndrome as well as some cases of breast cancer. Dactinomycin is a pro- tein synthesis inhibitor used to treat such pediatric tumors as rhabdomyosarcoma and Wilms tu- mor. Anastrozole is an aromatase inhibitor used to inhibit estrogen synthesis in the adrenal gland, a principle source in postmenopausal women. Hydroxyurea is used in the treat- ment of some leukemias as well as myeloproliferative disorders. Many traditional chemotherapy agents inhibit cell cycle progression at vari- ous check points. Temozolomide is an orally active alkylating agent related to dacarbazine used along with radiation for the treatment of glioblastoma multiforme and other high-grade astrocy- tomas. Thioguanine and mercapto- purine are purine analogues that are used primarily in acute lymphoblastic leukemia. Cisplatin is also often used with radiation in tumors of the lung, head, and neck. Anastrozole is used in breast cancer in postmenopausal women to decrease estrogen levels. Tamoxifen is also used in breast cancer to inhibit estrogen-mediated gene transcription. Patients with estrogen receptor-positive tumors benefit from tamoxifen adjunct treatment. It, however, carries a risk of thromboembolism as well as the potential to develop en- dometrial cancer. Many tra- ditional chemotherapeutic agents are associated with myelosuppression, and in fact, that is the mechanism for the effects against leukemias. The antibiotic chloramphenicol has been associ- ated with both myelosuppression and aplastic anemia. Toxicology is concerned with the deleterious effects of physical and chemical agents (includ- ing drugs) in humans (Table 13-1). Toxicity refers to the ability of an agent to cause injury; hazard refers to the likelihood of injury. Occupational toxicology is concerned with chemicals encountered in the workplace (there are over 100,000 in commercial use). Ecotoxicology is concerned with the toxic effects of physical and chemical agents on populations and organisms in a defined ecosystem. The dose–response relationship implies that higher doses of a drug or toxicant in an individ- ual result in a graded response and that higher doses in a population result in a larger per- centage of individuals responding to the agent (quantal dose–response). Risk is defined as the expected frequency of occurrence of unwanted effects of a physical or chemical agent. Hazard is defined as the ability of a toxicant to cause harm in a specific setting; it relates to the amount of a physical or chemical agent to which an individual will be exposed. This value, based on animal studies, is used for chemicals for which a full dose–response curve for toxicity in humans is unknown or unat- tainable. Acute exposure resulting in a toxic reaction represents a single exposure or multiple exposures over 1–2 days. Chronic exposure resulting in a toxic reaction represents multiple exposures over longer peri- ods of time. Delayed toxicity represents the appearance of a toxic effect after a delayed interval following exposure. Endogenous glutathione plays a central role in detoxication of these reactive species either directly, or coupled to superoxide dismutase and glutathione peroxidase (Fig. Superox- ide dismutase coupled to catalase is also involved in detoxication pathways (Fig. Air pollutants enter the body primarily through inhalation and are either absorbed into the blood (e. Air pollutants are characterized as either reducing types (sulfur oxides) or oxidizing types (nitrogen oxides, hydrocarbons, and photochemical oxidants). Carbon monoxide is a colorless, odorless, nonirritating gas produced from the incomplete combustion of organic matter. It is the most frequent cause of death from poisoning (see Ta- ble 13-2 for threshold limit values). Carbon monoxide competes for and combines with the oxygen-binding site of hemoglobin to form carboxyhemoglobin, resulting in a functional anemia. The binding affinity of carbon monoxide for hemoglobin is 220 times higher than that of oxygen itself. Carboxyhemoglobin also interferes with the dissociation in tissues of the remaining oxyhemoglobin.

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For example buy discount anastrozole 1mg, a person may for mute individuals anastrozole 1mg generic, and closed-captioning systems aspirate by accidentally drawing material from that help the hearing impaired enjoy television the stomach into the lungs order anastrozole 1 mg line, and a physician can shows and videos generic anastrozole 1mg without a prescription. Down syndrome), a malformation sequence of events, or a field defect, in which all the defects are aspiration, joint See arthrocentesis. An cylic acid, now the common name for this anti- example of association involves a feature on the sur- inflammatory pain reliever. For example, “She assayed this operation nonprofit association of accredited medical schools for the first time and was understandably nervous. Symptoms performed by a terminally ill patient, with assistance include shortness of breath, cough, wheezing, and from a physician, a family member, or another indi- chest tightness. Many allergens and irritants can precipi- assistive device A device that is designed, made, tate attacks of asthma. Avoidance of precipitating or adapted to help a person perform a particular factors can be helpful. For example, canes, crutches, walkers, wheel- lifestyle changes, activity reduction, allergy shots, chairs, and shower chairs are all assistive devices. It primarily affects chil- device that helps a disabled person to function more dren and young adults because of their high levels easily in the world. Examples of assistive technology of physical activity, but it can occur at any age. Other features include difficulty swal- can be minimized by warming up before strenuous lowing and slowed growth. With astigma- tism, light rays entering the eye are not uniformly atelectasis, secondary Partial or complete col- focused on the retina. Significant astigmatism can cause atelectasis may occur when full chest expansion is headaches, eye strain, and seriously blurred vision. Athelia tends to refractive errors such as nearsightedness and far- occur on one side (unilaterally) in children with the sightedness. Astigmatism is corrected with slightly Poland syndrome and on both sides (bilaterally) cylindrical lenses that have greater light-bending with certain types of ectodermal dysplasia. Use of these also occurs in association with progeria (premature lenses elongates objects in one direction and short- aging). See also amastia; amazia; Poland syn- ens them in the other, much like looking into a dis- drome; progeria. The location of the tumor depends on the age such as the coronary, carotid, and vertebral arter- of the person. In adults, astrocytomas most often ies, that have experienced the occlusive effects of arise in the cerebrum, whereas in children, they may atherosclerosis. Atherectomy may be accomplished arise in the brain stem, cerebrum, and cerebellum. Athetosis is associ- sels in the conjunctiva (ocular telangiectasia), and ated with several neurological disorders, such as cerebral palsy and Rett syndrome. Usually, when clots in veins break off socks and clothing, and it can be spread from per- (embolize), they travel first to the right side of the son to person through contact with these objects. It can be right to the left side of the heart, and then pass into treated with topical antifungal preparations. Once a clot known as tinea pedis, athlete’s foot is a form of is in the arterial circulation, it can travel to the ringworm. The atlantoaxial joint is a pivot type of atrioventricular Pertaining to the upper cham- joint. On both sides of the dermatitis is frequently associated with other aller- heart, the atrium is the chamber that leads to the gic disorders, especially asthma and hay fever. Muscle atresia Absence of a normal opening, or failure atrophy is a decrease in muscle mass, often due to of a structure to be tubular. For example, esophageal atresia is a birth defect in which part of the esopha- atropine A drug, made from the belladonna gus is not hollow, and with anal atresia, there is no plant, that is administered via injection, eye drops, hole at the bottom end of the intestine. Learning is most efficient when acuity is measured in order to determine a person’s a person is paying attention. Augmentative communication devices range from attention deficit hyperactivity disorder A dis- books of pictures or words that the patient can order in which a person is unable to control behav- show to express thoughts, to computers that are ior due to difficulty in processing neural stimuli, capable of synthesizing complex speech. Treatments include making adjust- aural vertigo, recurrent See Ménière’s dis- ments to the environment to accommodate the ease. Stimulants are the most common auricle 1 The principal projecting part of the ear, drugs used, although certain other medications can also known as pinna. An attenuated virus may be used to make a vaccine that is capable of stimulating an immune auricular fibrillation See fibrillation, atrial. Some, but not all, people with autism are fever, headache, cough, and abdominal pain. Autism is normally diagnosed before age may appear 1 to 2 days later, often beginning on 6, and it may be diagnosed in infancy in some cases. Swelling (edema) of the hands and feet The cause of autism is currently unknown, although may occur. Patients whose misdi- of encephalitis, and several genetic disorders, rected immune systems attack their own body tis- including Angelman syndrome and Rett syndrome. See also Asperger syndrome; elective mutism; fragile X syndrome; Landau-Kleffner syndrome; autologous In blood transfusion and transplan- Prader-Willi syndrome; Rett syndrome. Patients scheduled for non- autistic disorder Autism, particularly the most emergency surgery may be autologous donors by serious form of autism. An autologous graft is a graft (such autoantibody An antibody that is directed as a graft of skin) that is provided for oneself. Autoantibodies play a causative role in a number of diseases, such as automated external defibrillator A device that rheumatoid arthritis, systemic lupus erythematosus, automatically analyzes the heart rhythm and that— and Hashimoto disease. See also autoimmune if it detects a problem that may respond to an elec- disorder. The original autoclave was essen- (such as schools and airports), and serve a role in tially a pressure cooker in which steam tightened expanding the number of opportunities for life-sav- the lid. The neurologic disorders associated with automatism include narcolepsy and autoimmune disorder A condition character- some forms of epilepsy. The psychiatric conditions ized by autoimmunity in which a misdirected associated with automatism include schizophrenia immune system acts against the tissues of one’s own and fugue states. Autoimmune disorders typically feature thing “automatically” and not remembering after- inflammation of various tissues of the body and are ward how one did it or even that one did it. It is thought that the estrogen of nervous system has two divisions: the sympathetic females may influence the immune system to pre- nervous system, which accelerates the heart rate, dispose some women to autoimmune disorders. People normally have 22 pairs of autosomes (44 autosomes) in each cell, autoimmune thyroiditis See Hashimoto dis- together with 2 sex chromosomes, X and Y in a male ease. A nerve can be avulsed by appears in patients who have received one copy of a an injury, as can part of a bone.

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