29,602 research outputs found

    Clinical dilemmas in acute neurological disorders

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    This thesis introduces the evolving landscape of acute neurology and the challenges it presents to clinicians in the emergency department (ED).In Chapter 2, the focus is on mild traumatic brain injury (mTBI) in patients on anticoagulation therapy. The study, involving 905 patients, reveals that delayed intracranial hemorrhage within 24 hours is very rare after a normal cranial CT, suggesting that routine hospitalization may be unnecessary.Chapter 3 delves into alcohol intoxication as a stroke mimic, especially in posterior circulation cases. The study, involving 974 patients, emphasizes considering measuring blood ethanol levels in patients with a possible stroke of the posterior circulation presenting after working hours. Nevertheless, elevated blood ethanol levels should not withhold clinicians from administering reperfusion therapy.Chapter 4 explores the association between low blood pressure and outcomes after acute ischemic stroke (AIS). Analyzing data from 2124 patients, the study finds that low systolic blood pressure is linked to increased in-hospital mortality and complications, urging clinicians to investigate potential underlying conditions.In Chapter 5, the focus shifts to AIS patients with active cancer undergoing endovascular treatment. The study, involving 2583 patients, indicates that despite technical success, those with active cancer experience significantly worse outcomes and an increased risk of recurrent stroke after EVT. Still, about a quarter of the patients regained functional independence, and the risk of other complications was not increased.This thesis collectively highlights the importance of nuanced decision-making in acute neurology, offering insights into specific clinical dilemmas and proposing considerations for optimized patient care

    Risk factors and management of intraprocedural rupture during coil embolization of unruptured intracranial aneurysms: role of balloon guiding catheter

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    IntroductionIntraprocedural rupture (IPR) is a serious complication of endovascular coil embolization of unruptured intracranial aneurysms (UIAs). Although outcomes after IPR are poor, methods to prevent subsequent neurological deterioration have not yet been investigated. We evaluated the risk factors and management strategies for IPR, particularly the role of balloon guiding catheters (BGCs) in rapid hemostasis.MethodsWe retrospectively reviewed all UIA cases treated with coil embolization at three institutions between 2003 and 2021, focusing on preoperative radiological data, operative details, and outcomes.ResultsIn total, 2,172 aneurysms were treated in 2026 patients. Of these, 19 aneurysms in 19 patients (0.8%) ruptured during the procedure. Multivariate analysis revealed that aneurysms with a bleb (OR: 3.03, 95% CI: 1.21 to 7.57, p‚ÄČ=‚ÄČ0.017), small neck size (OR: 0.56, 95% CI: 0.37 to 0.85, p‚ÄČ=‚ÄČ0.007), and aneurysms in the posterior communicating artery (PcomA) (OR: 4.92, 95% CI: 1.19 to 20.18, p‚ÄČ=‚ÄČ0.027) and anterior communicating artery (AcomA) (OR: 12.08, 95% CI: 2.99 to 48.79, p‚ÄČ<‚ÄČ0.001) compared with the internal carotid artery without PcomA were significantly associated with IPR. The incidence of IPR was similar between the non-BGC and BGC groups (0.9% vs. 0.8%, p‚ÄČ=‚ÄČ0.822); however, leveraging BGC was significantly associated with lower morbidity and mortality rates after IPR (0% vs. 44%, p‚ÄČ=‚ÄČ0.033).DiscussionThe incidence of IPR was relatively low. A bleb, small aneurysm neck, and location on PcomA and AcomA are independent risk factors for IPR. The use of BGC may prevent fatal clinical deterioration and achieve better clinical outcomes in patients with IPR

    Atuação do enfermeiro de suporte imediato de vida na dor torácica: realidades do interior norte de Portugal

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    A dor tor√°cica (DTC) aguda √© o sintoma comum de S√≠ndrome Coron√°rio Agudo (SCA), que mais frequentemente leva as pessoas a procurarem cuidados de emerg√™ncia no mundo. Dois ter√ßos das mortes por eventos coron√°rios agudos ocorrem por arritmias fatais, em ambiente pr√©-hospitalar. O reconhecimento r√°pido de sintomas √© mandat√≥rio para redu√ß√£o da mortalidade. O Enfermeiro SIV tem um papel fundamental na a determina√ß√£o do diagn√≥stico c√©lere e, no tratamento adequado da pessoa com SCA. Objetivos: Visando conhecer a atua√ß√£o do enfermeiro Suporte Imediato de Vida (SIV) nas ocorr√™ncias de DTC, na pessoa com suspeita de SCA, relativamente √†s ambul√Ęncias SIV de dois distritos do interior norte de Portugal, delinearam-se como objetivos espec√≠ficos: (i) Analisar as ativa√ß√Ķes das ambul√Ęncias SIV para ocorr√™ncias de DTC, na pessoa com suspeita de SCA, relativamente √†s caracter√≠sticas sociodemogr√°ficas e geogr√°ficas; (ii) Identificar o perfil de risco cardiovascular (verific√°vel) nas ocorr√™ncias de DTC, da pessoa com suspeita de SCA, por ambul√Ęncias SIV; (iii) Identificar os fatores de risco cardiovasculares (FRCV) modific√°veis (verific√°veis) nas ocorr√™ncias de DTC, da pessoa com suspeita de SCA, por ambul√Ęncia SIV; (iv) Conhecer os tempos de resposta do pr√©-hospitalar nos diferentes momentos do socorro, nas ocorr√™ncias de DTC, na pessoa com suspeita de SCA; (v) Analisar a atua√ß√£o do Enfermeiro tendo por base, a utiliza√ß√£o do protocolo da DTC e, complementares, por ambul√Ęncia SIV; (vi) Verificar a melhoria de sintomatologia decorrente da atua√ß√£o do enfermeiro SIV em ocorr√™ncia de DTC, da pessoa com suspeita de SCA; (vii) Identificar epis√≥dios de complica√ß√Ķes ocorridas durante a atua√ß√£o do enfermeiro SIV, em situa√ß√Ķes de DTC, na pessoa com suspeita de SCA. Metodologia: Foi realizado um estudo retrospetivo, anal√≠tico transversal, de cariz quantitativo, envolvendo uma amostra por conveni√™ncia de 75 ativa√ß√Ķes para DTC, com suspeita de SCA, nas ambul√Ęncias SIV do interior norte de Portugal, no per√≠odo compreendido entre 01 junho de 2017 e o 31 de dezembro de 2018. A recolha de dados foi efetuada atrav√©s de um IRD concebido para o efeito. Resultados: √Č predominante o sexo masculino, nas ativa√ß√Ķes de DTC, com suspeita de SCA, sendo a idade m√©dia de 65,90 anos na SIV 1 e, na SIV 2 de 72,33 anos. Na SIV 2 verificou-se que, entre o sexo masculino e a idade, existe rela√ß√£o estat√≠stica significativa (p=0,013), apresentando este uma idade inferior ( ŐÉ =70 anos sexo masculino; ŐÉ =81,50 anos sexo feminino). A maioria dos atendidos tem doen√ßa cardiovascular pr√©via e/ou j√° sofreu um EAM. Nos FRCV a HTA √© prevalente (62,7%), seguida da dislipidemia, onde 83% dos atendidos apresentam 2 ou mais. Os tempos de resposta do pr√©-hospitalar, na DTC com suspeita de SCA, observaram-se longos, sendo o tempo total de miss√£o, desde a ativa√ß√£o at√© √† chegada ao SU (T5), de 95,83 minutos na SIV 1 e, 95,22 minutos na SIV 2, n√£o tendo rela√ß√£o estat√≠stica significativa. Sobre os tempos de resposta no EAMCSST, a m√©dia de ambas as SIV, no tempo total de miss√£o (T5) foi de 131 minutos, sendo o tempo recomendado ultrapassado em 11 minutos tendo em conta as guidelines. O protocolo da DTC foi o mais utilizado, sendo a queixa mais comum a dor/desconforto e o aperto, de apresenta√ß√£o retrosternal ou epig√°strico, sem irradia√ß√£o e, inferior a 2 horas. Pela realiza√ß√£o de ECG observou-se a ocorr√™ncia de EAMCSST em 10,6%, sendo encontrada uma rela√ß√£o estatisticamente significativa entre as altera√ß√Ķes do ECG e a ambul√Ęncia SIV (p=0,028). A medica√ß√£o mais utilizada foi o DNI, a AAS a Morfina, apresentando melhoria de sintomas a maioria. O acompanhamento do enfermeiro SIV foi habitual, sendo 14,66% transportados para hospitais com capacidade de cateterismo, atrav√©s da VVC, sem se registarem complica√ß√Ķes nas ocorr√™ncias. Conclus√£o: Os tempos de resposta do pr√©-hospitalar s√£o mais elevados que a bibliografia encontrada, pelas dist√Ęncias a percorrer, em particular no EAMCSST (T5), onde √© superior 11 minutos relativamente ao recomendado. O enfermeiro SIV desempenha um papel preponderante na presta√ß√£o de cuidados √† pessoa com DTC e suspeita de SCA, sendo determinante para a defini√ß√£o do diagnostico precoce e, na melhoria de sintomas, dando resposta √†s necessidades e ao risco imediato da pessoa, procurando evitar fatalidades.Acute chest pain (aCP) is a common symptom of Acute Coronary Syndrome (ACS), which often leads people to seek emergency care worldwide. Two-thirds of deaths from acute coronary events occur due to fatal arrhythmias in the pre-hospital setting. Rapid recognition of symptoms is essential for reducing mortality. The Immediate Life Support (ILS) Nurse plays a crucial role in rapidly diagnosing and appropriately treating individuals with ACS. Objectives: Understand the role of Immediate Life Support (ILS) nurses in aCP incidents in individuals with suspected ACS reharding the ILS ambulances of two districts in the north of Portugal, specific objectives were outlined: (i) Analyze the activations of ILS ambulances for aCP incidents in individuals with suspected ACS, considering sociodemographic and geographic characteristics; (ii) Identify the cardiovascular risk profile (verifiable) in aCP incidents in individuals with suspected ACS attended by ILS ambulances; (iii) Identify modifiable cardiovascular disease (CAD) risk factors (verifiable) in aCP incidents in individuals with suspected ACS attended by ILS ambulances; (iv) Understand the pre-hospital response times, at different stages of assistance, in aCP incidents in individuals with suspected ACS; (v) Analyze nurse‚Äôs actions based on the application of the aCP and other complementary protocols by ILS ambulances; (vi) Assess symptoms improvement resulting from the ILS nurse's interventions, in aCP incidents, in individuals with suspected ACS; (vii) Identify complications that occurred during the ILS nurse's intervention, in aCP incidents in individuals with suspected ACS. Methodology: An observational, cross-sectional, retrospective quantitative study was conducted, involving a convenience sample of 75 aCP missions with suspected ACS, attended by ILS ambulances in northern Portugal between June 1, 2017, and December 31, 2018. Data collection was carried out using a proper designed data collection form. Results: Male patients was predominant in aCP activations with suspected ACS, with an average age of 65.90 years for ILS ambulance 1 and 72.33 years for ILS ambulance 2. In ILS ambulance 2, a statistically significant relationship was observed between male gender and age (p=0.013), with males being younger (‚ȧ70 years for males; ‚ȧ81.50 years for females). The majority of patients have cardiovascular disease (CVD) and/or had already suffered a myocardial infarction (MI). Among CVD risk factors, hypertension (62.7%) was prevalent, followed by dyslipidemia, where 83% of those treated have 2 or more risk factors. Pre-hospital response times for aCP, with suspected ACS were long, with a total mission time from activation to arrival at the Emergency Department (ED) (T5) of 95.83 minutes for ILS ambulance 1 and 95.22 minutes for ILS ambulance 2, not having a statistically significant relationship. As for response times in ST-segment elevation myocardial infarction (STEMI), the average total mission time (T5), for both ILS ambulances was 131 minutes, exceeding the recommended time by 11 minutes, according to guidelines. The aCP protocol was the most frequently used, with the dominant complaint being acute chest pain or discomfort, epigastric pain, without radiation and occurring within less than 2 hours. ECG changes consistent with STEMI were observed in 10.6% of cases, with a statistically significant relationship between ECG changes and the ILS ambulance (p=0.028). The most commonly used medications were nitrate, aspirin, and morphine, with the majority of patients experiencing symptom improvement. ILS nurse monitoring was routine, with 14.66% of patients being transported to hospitals with primary angioplasty capability, via coronary fast- track system, with no complications or incidents reported. Conclusion: Pre-hospital response times were higher than those reported in the literature, primarily due to the distances to be covered, especially in STEMI cases (T5), where it exceeds the recommended time by 11 minutes. The ILS nurse plays a crucial role in providing care to individuals with aCP and suspected ACS, contributing significantly to early diagnosis and symptom improvement, addressing the individuals‚Äô immediate needs and risks, striving to prevent fatalities

    Cost-effectiveness of stepwise provisional versus systematic dual stenting strategies in patients with distal bifurcation left main stem lesions: Economic analysis of the EBC MAIN trial

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    \ua9 2024 BMJ Publishing Group. All rights reserved.Background In patients with distal bifurcation left main stem lesions requiring intervention, the European Bifurcation Club Left Main Coronary Stent Study trial found a non-significant difference in major adverse cardiac events (MACEs, composite of all-cause death, non-fatal myocardial infarction and target lesion revascularisation) favouring the stepwise provisional strategy, compared with the systematic dual stenting. Aims To estimate the 1-year cost-effectiveness of stepwise provisional versus systematic dual stenting strategies. Methods Costs in France and the UK, and MACE were calculated in both groups to estimate the incremental cost-effectiveness ratio (ICER). Uncertainty was explored by probabilistic bootstrapping. The analysis was conducted from the perspective of the healthcare provider with a time horizon of 1 year. Results The cost difference between the two groups was ‚ā¨-755 (‚ā¨5700 in the stepwise provisional group and ‚ā¨6455 in the systematic dual stenting group, p value<0.01) in France and ‚ā¨-647 (‚ā¨6728 and ‚ā¨7375, respectively, p value=0.08) in the UK. The point estimates for the ICERs found that stepwise provisional strategy was cost saving and improved outcomes with a probabilistic sensitivity analysis confirming dominance with an 80% probability. Conclusion The stepwise provisional strategy at 1 year is dominant compared with the systematic dual stenting strategy on both economic and clinical outcomes

    Elaboraci√≥n de manual de reconstituci√≥n, conservaci√≥n y administraci√≥n de medicamentos parenterales para los servicios de Hospitalizaci√≥n del Hospital General ‚ÄúHomero Castanier‚ÄĚ de la Ciudad de Azogues

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    El desarrollo de un manual para los procesos de reconstituci√≥n, conservaci√≥n y administraci√≥n de medicamentos parenterales es fundamental para garantizar la seguridad y eficacia de la atenci√≥n m√©dica. El objetivo principal del estudio fue elaborar un manual de reconstituci√≥n, conservaci√≥n y administraci√≥n de medicamentos parenterales para los servicios de hospitalizaci√≥n del Hospital General ‚ÄúHomero Castanier Crespo‚ÄĚ de la ciudad de Azogues. Se realizaron observaciones y evaluaciones exhaustivas para conocer las condiciones de la reconstituci√≥n, conservaci√≥n y administraci√≥n de dichos medicamentos. Esta etapa proporcion√≥ un enfoque claro para la elaboraci√≥n del manual, lo que permiti√≥ identificar √°reas de mejora y desaf√≠os asociados con las pr√°cticas existentes. El Hospital Homero Castanier Crespo se beneficiar√° de la implementaci√≥n exitosa del manual, ya que establece pautas basadas en evidencia y alineadas con est√°ndares nacionales e internacionales, sirve como punto de partida para estandarizar procesos, reducir riesgos y mejorar la seguridad del paciente al abordar espec√≠ficamente las √°reas de reconstituci√≥n, conservaci√≥n y administraci√≥n. El manual de reconstituci√≥n, conservaci√≥n y administraci√≥n de medicamentos parenterales se posiciona como un instrumento esencial para el logro de pr√°cticas seguras, coherentes y eficientes en la preparaci√≥n y administraci√≥n de terapias parenterales en el Hospital Homero Castanier de Azogues.The development of a manual for the processes of reconstitution, conservation and administration of parenteral drugs is essential to ensure the safety and efficacy of medical care. The main objective of the study was to develop a manual for the reconstitution, conservation and administration of parenteral drugs for the hospitalization services of the General Hospital "Homero Castanier Crespo" in the city of Azogues. Extensive observations and evaluations were carried out to assess the conditions of reconstitution, conservation and administration of these drugs. This stage provided a clear focus for the development of the manual, which made it possible to identify areas for improvement and challenges associated with existing practices. Hospital Homero Castanier Crespo will benefit from the successful implementation of the manual, as it establishes evidence-based guidelines aligned with national and international standards, serves as a starting point to standardize processes, reduce risks and improve patient safety by specifically addressing the areas of reconstitution, storage and administration. The manual for reconstitution, conservation and administration of parenteral drugs is positioned as an essential instrument for the achievement of safe, consistent and efficient practices in the preparation and administration of parenteral therapies at the Homero Castanier Hospital in Azogues.0000-0001-8937-619

    The application and sustainable development of coral in traditional medicine and its chemical composition, pharmacology, toxicology, and clinical research

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    This review discusses the variety, chemical composition, pharmacological effects, toxicology, and clinical research of corals used in traditional medicine in the past two decades. At present, several types of medicinal coral resources are identified, which are used in 56 formulas such as traditional Chinese medicine, Tibetan medicine, Mongolian medicine, and Uyghur medicine. A total of 34 families and 99 genera of corals are involved in medical research, with the Alcyoniidae family and Sarcophyton genus being the main research objects. Based on the structural types of compounds and the families and genera of corals, this review summarizes the compounds primarily reported during the period, including terpenoids, steroids, nitrogen-containing compounds, and other terpenoids dominated by sesquiterpene and diterpenes. The biological activities of coral include cytotoxicity (antitumor and anticancer), anti-inflammatory, analgesic, antibacterial, antiviral, immunosuppressive, antioxidant, and neurological properties, and a detailed summary of the mechanisms underlying these activities or related targets is provided. Coral toxicity mostly occurs in the marine ornamental soft coral Zoanthidae family, with palytoxin as the main toxic compound. In addition, nonpeptide neurotoxins are extracted from aquatic corals. The compatibility of coral-related preparations did not show significant acute toxicity, but if used for a long time, it will still cause toxicity to the liver, kidneys, lungs, and other internal organs in a dose-dependent manner. In clinical applications, individual application of coral is often used as a substitute for orthopedic materials to treat diseases such as bone defects and bone hyperplasia. Second, coral is primarily available in the form of compound preparations, such as Ershiwuwei Shanhu pills and Shanhu Qishiwei pills, which are widely used in the treatment of neurological diseases such as migraine, primary headache, epilepsy, cerebral infarction, hypertension, and other cardiovascular and cerebrovascular diseases. It is undeniable that the effectiveness of coral research has exacerbated the endangered status of corals. Therefore, there should be no distinction between the advantages and disadvantages of listed endangered species, and it is imperative to completely prohibit their use and provide equal protection to help them recover to their normal numbers. This article can provide some reference for research on coral chemical composition, biological activity, chemical ecology, and the discovery of marine drug lead compounds. At the same time, it calls for people to protect endangered corals from the perspectives of prohibition, substitution, and synthesis

    Preparation and Evaluation of Telmisartan Solid Dispersion as Sublingual Tablets

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    Background: Telmisartan is an antihypertensive angiotensin II receptor antagonist drug commonly used to treat hypertension and renal disease. Based on the Biopharmaceutical Classification System.  It’s a Class II poorly soluble drug. Objective: To prepare a sublingual tablet by increasing the dissolution and solubility of Telmisartan utilizing the solid dispersion method. Methods: Three methods were obtained to prepare the solid dispersion of telmisartan: solvent evaporation, Kneading, and microwave method. Each method uses surplus as a hydrophilic carrier in different ratios of 1%, 2%, and 3%. Preparation of ternary solid dispersion by adding potassium carbonate salt to the binary solid dispersion. After that preparing the sublingual tablets by applying a direct compression method, using different types and ratios of superdisintegrants such as crospovidone, croscarmellose and sodium starch glycolate in 5% and 10%. Study the evaluation tests of sublingual tablets, such as friability, hardness, disintegration time and dissolution time. Results: The solid dispersion showed an improvement in solubility over the pure medication. The best result was obtained with the formula (Telmisartan, soluplus and k2co3 salt at 1:1:0.3 ratio) prepared by microwave method, in this method and the high ratio of soluplus, the solubility increased more than the solvent evaporation and kneading method. The selected tablet is prepared using crospovidone 10% as a superdisintegrant that appears disintegration time in 5 seconds and releases in 1 min in dissolution media. Conclusion: The solubility and dissolution of Telmisartan were improved by microwave-based ternary solid dispersion using hydrophilic carriers and salt in a ratio of 1:1:0.3 (drug: carrier: salt). The analysis exerts the increases in wettability, enhanced solubility, and dissolution due to conversion from crystal to amorphous state. Received May. 2023 Accepted Aug. 2023 Published Jan. 2024

    Pregnancy and cardiac disease

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    Effects of remnant cholesterol on the efficacy of genotype-guided dual antiplatelet in CYP2C19 loss-of -function carriers with minor stroke or transient ischaemic attack: a post-hoc analysis of the CHANCE-2 trialResearch in context

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    Summary: Background: The atherogenicity of remnant cholesterol (RC), a contributor to residual risk of cardiovascular events, has been underlined by recent guidelines. We aimed to evaluate the relationship between RC levels and the efficacy and safety of genotype-guided dual antiplatelet therapy in the CHANCE-2 trial. Methods: This post-hoc study used data from the CHANCE-2 trial, which was a randomised, double-blind, placebo-controlled trial of 6412 patients (aged >40 years) enrolled from 202 hospitals in China, between Sept 23, 2019, and March 22, 2021, who carried CYP2C19 loss-of-function alleles and had either an acute minor stroke or high-risk transient ischaemic attack (TIA), and could start treatment within 24¬†h of symptom onset. Participants received either (1:1) ticagrelor plus aspirin (control) or clopidogrel plus aspirin (intervention) and the effect of reducing the 3-month risk of any new stroke was assessed (ischemic or haemorrhagic, primary outcome). From the CHANCE-2 study population, we enrolled 5890 patients with complete data on RC. The cutoff point of RC for distinguishing patients with greater benefit from ticagrelor-aspirin versus clopidogrel-aspirin was determined with subpopulation treatment effect pattern plot. The primary efficacy and safety outcome was recurrent stroke and severe or moderate bleeding within 90 days, respectively. CHANCE-2 is registered with ClinicalTrials.gov, NCT04078737. Findings: The cutoff to define elevated RC was 0.91¬†mmol/L. Ticagrelor-aspirin versus clopidogrel-aspirin was associated with a reduced risk of recurrent stroke in patients with non-elevated RC levels (122 [5.3%] versus 179 [7.8%]; hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.54‚Äď0.85), but this benefit was absent in those with elevated RC levels (58 [8.4%] versus 48 [7.3%]; HR, 1.10; 95% CI, 0.73‚Äď1.65; P-interaction¬†=¬†0.03). When analyzed as a continuous variable, the benefit of ticagrelor-aspirin on recurrent stroke decreased as RC levels increased. The rates of severe or moderate bleeding between treatment groups were similar across RC categories (0.3% versus 0.3%, P-interaction¬†=¬†0.95). Interpretation: Our post-hoc findings suggest that RC could be a potential biomarker to discriminate patients who received more benefits from ticagrelor-aspirin versus clopidogrel-aspirin therapy in CYP2C19 loss-of-function carriers with minor stroke or TIA. These findings need to be validated in an independent study. Funding: The National Key Research and Development Program of China, Beijing Natural Science Foundation Haidian original innovation joint fund, Fund for Young Talents of Beijing Medical Management Center, the high-level public health talents, Training Fund for Open Projects at Clinical Institutes and Departments of Capital Medical University; and Salubris
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