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At some sites with highly experienced interpreting physicians natural pet medicine order cheap brahmi line, interpretation is typically limited to the axial images with sparing use of additional views in selected cases treatment herniated disc 60caps brahmi for sale. Based on a quick look, one can quickly ascertain how good the study is technically. We also ensure that the "optimal" phase was selected because occasionally multiple phases need to be processed and viewed. Scroll through the heart in a global sense with analysis of chamber size, and a look for any abnormalities including the pericardium and the paracardiac regions. Scroll through the coronary arteries, and look for the origin of each vessel and its branching pattern. Vessels such as the sinoatrial nodal branch and atrioventricular nodal branch are often best seen on the axial images. We follow each coronary artery to look at lumen diameter and determine the presence or absence of calcified or noncalcified plaque. Axial images also define the presence and extent of calcification, although a wide window often is needed in the presence of extensive calcification. The limitation of axial images is that one may need to look at 200 to 350 individual slices to get through a single vessel, such as the left anterior descending coronary artery. Vessels with off-axis courses, such as the right coronary artery, are best defined when one is looking beyond the axial plane. Our experience is that referring physicians desire threedimensional maps to correlate with what they typically see on classic catheter angiography. Although we typically scroll through the classic axial display interactively, other physicians believe that reading studies can be noninteractive, and that there are no data to prove otherwise. Although most physicians review the axial images as slabs in the plane acquired, one helpful hint is to draw a line through the plane of the aortic valve, and scroll up and down through this plane. This practice often provides a perfect en face display of the proximal coronary arteries. A, On a single axial image, one can define the vessel (arrow), but would need a series of individual images to delineate its course. With isotropic data, the individual cardiac chambers, aorta, and pulmonary vasculature can benefit from these displays, and they are routinely used. Whether it is for suspected aortic dissection or suspected pulmonary embolism, these displays are essential. On most workstations, the thickness of the reconstruction can be interactively adjusted. One issue with coronal and sagittal reconstruction and evaluation of the coronary arteries is that because the vessels have a nonlinear pathway, only short segments can be analyzed at a time. B, Multiplanar reconstruction in the orthogonal plane displays only various oblique cross sections of the artery. Changing the angle can be done interactively, but potentially results in more room for error and less than ideal image displays. If there is a suspect area on the axial views, the coronal or sagittal view may help clarify and quantify this potential narrowing. Coronal and sagittal imaging may be useful, but it depends on the vessel tracking capabilities of the workstation. Ideally, a specific point is selected, and viewing is adjusted from that perspective. The oblique planes are valuable for additional viewing of selected suspicious areas, which often arise after review of the axial images. With coronal, sagittal, and oblique images, one needs to be cautious in grading stenosis and not be fooled by partial averaging. We do not attempt to grade stenosis based only on these images because of this pitfall. We have found that these reconstructions are best for larger vessels, as discussed previously. Many sites now do preprocessed batched coronal and sagittal images at 1- to 3-mm intervals. Curved Planar Reconstruction As discussed, the limitations with coronal and sagittal reconstruction largely involve the inability to track the complex courses of the coronary arteries. Currently, most vendors have designed software that makes the process more robust and easier to use, and requires minimal user interaction. One simply picks a start and an end point, and the computer automatically tracks the vessel. The vessel is laid out like a string or piece of spaghetti, and the user can rotate the plane to look at the vessel and analyze it from multiple perspectives. The vessel path is calculated as a central line through the vessel, which is also crucial in avoiding errors in analysis. In cases where there is a gap or stenosis in the vessel, dropping additional seed points can be done to help with vessel tracking. The ability to lay out a vessel without the worry of partial averaging is important not only when trying to define the presence of stenosis, but also for calculating the degree of stenosis. A, When the entire volume is volume rendered, vessels are clearly defined and separated because the three-dimensional relationships are maintained. It is important to be careful with these programs because there are many potential sources of error, but at least they are a guide, and in the future they should be more robust. With poor opacification, automated vessel extraction programs have issues and result in errors of omission and commission. In the coronary arteries measuring 2 to 5 mm, if the center-line trace is inaccurate, it could result in the overestimation of stenosis. A center-line error is most likely to occur in the presence of extensive coronary artery calcification. With dense calcification, rotation of the vessel 360 degrees helps with determining whether the calcification is mainly eccentric and representing positive remodeling or causing a critical stenosis. Some newer software versions allow the computer to segment the vessels automatically without user interaction. This may work well in selected cases, but careful attention to recognize incorrect tracking is crucial. After analysis using multiple postprocessing tools, we are able to define correctly a greater than 70% stenosis in the left anterior descending artery, which was stented. Although most sites use some type of three-dimensional imaging for selected cardiac applications, experts have yet to reach consensus as to whether this practice is mandatory or necessary in all cases. Postprocessing with three-dimensional imaging is an essential part of every examination, providing crucial information not revealed by other interpretative methods. Depending on the view and parameters, the left anterior descending artery, circumflex artery, and ramus intermedius can look occluded or patent. The displayed pixel intensity represents only the material with the highest intensity. A high-intensity material, such as calcification, would obscure information from an intravascular contrast agent. This limitation can be partially overcome with use of nonlinear transfer functions or, more practically, through volume editing. Use of the highest intensity of the image in effect also selects the "noisiest" background voxels, and decreases the visibility of vessels in brightly enhancing structures, such as the cardiac chambers and pulmonary arteries. A normal small vessel passing obliquely through a volume may have a "string of beads" appearance because it is only partially represented by voxels along its length. Soft plaque is overlooked, however, unless it creates significant lumen narrowing. One must adjust the slab thickness carefully to see the vessel in full view, but one must be careful not to overlook lesions, especially very proximal lesions. Even when the study looks normal, another display technique should be used for confirmation. The key difference between thresholding classification and percentage classification is that, in thresholding, it is assumed that each voxel contains either all or none of a particular tissue type, and no mixtures of tissues. In percentage classification, it is assumed that a voxel can contain one or more tissue types, and the amount of each tissue is a continuum between 0% and 100%. Percentage classification is possible to approximate more closely true voxel content in voxels containing tissue mixtures, or volume averaging.

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The presenting lower urinary tract symptoms can be exacerbated or entirely caused by a bacterial infection fungal nail treatment cheap brahmi 60 caps online, and effective treatment with appropriate antibiotics may be all that is required medications dogs can take purchase brahmi. If it proves necessary to proceed to urodynamic studies, it is important to ensure that there is not an infection already present, which would lead to unrepresentative findings and the risk of an ascending urinary infection of the upper tracts. It is designed to help us take a closer look at your fluid intake and output, and leakage if any. The patient is asked to record on a standard time sheet the volume of all fluid consumed and of all urine passed, as well as indicating any episodes of urgency and incontinence. The value of this simple, noninvasive tool is often overlooked, which is unfortunate as, if filled in conscientioualy, it provides a good indication of fluid input and a natural volumetric record of bladder function. Please write the time you got up and time you went to bed at the top and bottom of the chart for each day. This allows us to see the difference between what is happening during the day and during the night. It is now widely used as an outcome measure in the evaluation of clinical practice and in research trials. There are many disease-specific questionnaires to assess women with urinary incontinence. Pad test so that they can objectively evaluate the effectiveness of any therapy, for example in women undergoing bladder training for detrusor over-activity. In addition, they can also aid diagnosis for conditions such as nocturnal polyuria. In addition to the standard volumetric information, the patient may be asked to quantitate incontinent episodes, note associated or provocative activities, and state the number of pads used per day. The objective demonstration of leaking is essential in reaching a diagnosis of urinary incontinence. A pad test provides a simple, non-invasive, objective method for detecting and quantifying urinary leakage. To obtain a representative result, especially for those who have variable or intermittent urinary incontinence, the test should be as long as possible in circumstances that approximate those of everyday life. It should be conducted in a standardized fashion so that results are comparable and reproducible. This allows the effect of treatment to be objectively assessed in a non-invasive manner. She then performs 30 minutes of moderate exercise, such as stair climbing and walking. The remaining 15 minutes are spent performing more provocative exercises, including coughing vigorously, bending over, hand washing and running. However, the short period of study and lack of a standardized bladder volume before starting the test mean that there is a significant falsenegative rate. Long-term protocols also exist in which the patient is given several pre-weighed pads to be worn at home for periods of 12, 24 or 48 hours. The used pads are collected in sealed plastic bags and reweighed at the end of the specified period to determine total urine loss. The extended pad test is particularly useful to confirm or refute leakage in those patients complaining of incontinence that has not been demonstrated on urodynamic studies. Recent studies have shown that pad tests bare little relationship to the underlying urodynamic diagnosis but there is a positive relationship with symptom severity. Traditionally, doctors have categorized the severity of a condition using objective clinical measures. Two major types of QoL questionnaire are available: generic questionnaires, which can be used across a range of medical conditions, and disease-specific questionnaires, which focus on the likely impacts of a particular disorder. It is very important that any questionnaires used for this form of assessment have been subjected to rigorous reliability testing and validation in order to derive meaningful data from them. Quality of life assessment is particularly useful in determining the response of patients to treatment. At the end of the test, patients are asked to void and then each vaginal swab is removed. Blue on the lower vaginal swab may represent urethro-vaginal reflux or contamination from the test. Blue on the mid-vaginal swab may be indicative of a urethrovaginal fistula and on the upper vaginal swab could suggest a vesico-vaginal fistula. During the instillation of methylene blue into the bladder, it is important to ensure that there is no contamination of dye on to the labia or vagina as this will give false-positive results from the test. Indications Uroflowmetry should be regarded as a screening test for voiding difficulty in all women with symptoms of lower urinary tract dysfunction. It is important to appreciate that urinary flow is dependent upon a number of factors, including detrusor contractility, neurological co-ordination of sphincter relaxation and outflow patency. Uroflowmetry on its own cannot successfully distinguish between the causes of voiding dysfunction. Methods There are several different physical principles that can be utilized to provide an accurate assessment of flow. A known amount of power is required to keep a rotating disc spinning at a constant rate. The flow rate is proportional to the amount of extra power that is required to keep the disc spinning at a constant rate. As urine accumulates in the container, the electrical capacitance of the dipstick changes and from this the rate of flow can be calculated. It should be noted that the environment in which the woman performs the flow rate recording will have a considerable influence on the results. It is important that every effort is made to make the patient feel as comfortable and relaxed as possible, and that privacy and dignity are maintained at all times. Uroflowmetry Uroflowmetry is the simplest and one of the most useful investigations in the assessment of voiding dysfunction. It consists simply of measuring urinary flow over time and allows a rapid and non-invasive analysis of the normality or otherwise of flow rate. When combined with the measurement of residual urine volume by ultrasound or catheterization, it provides information on the efficiency of micturition in emptying the bladder. One or more symptoms of voiding disorder are commonly described in women complaining of urinary tract disorders, and it is important to diagnose or eliminate voiding difficulty. Both surgical treatment of urodynamic stress incontinence and drug treatment for detrusor over-activity have the potential to cause voiding difficulty. The maximum flow rate is partially dependent on the voided volume, as this determines how distended the bladder muscle fibres are. For this reason, small voided volumes of less than 150 mL are insufficient to obtain an accurate impression of flow, and the test needs to be repeated. The third major factor to consider when interpreting flow rate is the pattern of flow, in particular whether flow is continuous or intermittent. A normal flow curve is bell-shaped and characterized by a rapid rise to maximal flow. A prolonged, intermittent flow curve is suggestive of voiding dysfunction, with the patient using abdominal straining to achieve bladder emptying. If flow is intermittent, the time intervals between flow episodes are not included. Time to maximum flow: elapsed time from onset of flow to maximum flow rates are higher in women than in men for a comparable voided volume. Age and parity have not been shown to have a significant effect on urine flow rates in asymptomatic women. As might be expected, there is a progressive decline in flow rate with increasing grades of pelvic floor prolapse, especially uterine prolapse and cystourethrocele. Altered detrusor function influences flow rate by determining the contractile force with which urine is expelled.

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This condition treatment kidney stones buy brahmi 60caps, characterized by progressive treatment centers for alcoholism discount brahmi 60caps visa, necrotic lung inflammation, is the form of tuberculosis most people associate with the disease. Treatment Administration of isoniazid and rifampin individually or combined, pyrazinamide, ethambutol, or streptomycin. The composition of these surface antigens is controlled genetically and can therefore change. Because of this, the organism is able to evade host antibodies that might otherwise attack it. However, if allowed to reach the bloodstream, certain strains of this organism that contain a surface antigen similar to that of red blood cells can evade host serum antibodies. Treatment Resistance to penicillin G and tetracyclines has led to using ceftriaxone and azithromycin combined with doxycycline. It resides on mucous membranes of the nasopharynx, oropharynx, and the anogenital region. It does not remain viable for long outside the human body and must be transferred sexually or by direct contact with infected respiratory secretions. It causes meningococcemia and the accompanying meningococcal meningitis, a devastating disease primarily of children and young adults. In most healthy individuals the organism produces a localized infection or no symptoms at all, but in the absence of an early antibody response, may result in fulminant sepsis and meningitis. Treatment Administration of penicillin G, 3rd generation cephalosporins, or chloramphenicol. However, its mycelia fragment into rod and coccus-like elements that contain no membrane-bound organelles. In the majority of cases, transmission is by inhalation of aerosol droplets leading to pulmonary nocardiosis (chronic pneumonia). Dissemination of the Because Nocardia species are weakly acid-fast, decolorization is done with a lower concentration of acid-alcohol. Treatment Differential Characteristics Norcardia asteroides is anaerobic, nonmotile, Gram-positive to Gram-variable, partially acid-fast rod. It reduces nitrate, does not Trimethoprim-sulfamethoxazole is the treatment of choice. It is of particular importance as a urinary tract pathogen because of its ability to produce urease (page 96). Urease splits urea, thus creating an alkaline environment and promoting the formation of kidney stones. Proteus septicemia is a potential complication of urinary tract infections and can be fatal in weakened individuals. It is negative for indole, esculin hydrolysis, and lactose and salicin fermentation. Treatment Administration of 1st, 2nd, or 3rd generation cephalosporins, carbapenems, fluoroquinolones, or extended spectrum penicillins. It has also been isolated from hospital sinks and tubs, dialysis equipment, contact lens solution, aerators, irrigation fluids, hot tubs, ointments, insoles of shoes, and even in soaps and cleaning solutions. While healthy individuals are less frequently affected by the organism, immunosuppressed patients are susceptible to a variety of serious infections. Among the nosocomial infections caused by this organism are pneumonia, wound sepsis, bacteremia, and urinary tract infections. Treatment Administration of ceftazidime individually or combined with aminoglycosides, extended spectrum penicillins, cefepime, fluoroquinolones, or ciprofloxacin. Salmonella enteritidis Salmonella Enteritidis (Class Gammaproteobacteria)3 typically resides in the gastrointestinal tract of humans and many other animals, including poultry, rodents, and wild birds. It is one of approximately 2,200 nontyphoidal Salmonella serotypes, all of which cause gastroenteritis in humans. Once through the hostile environment of the stomach, they are taken up by intestinal epithelial cells and are released into the underlying connective tissue where they begin to multiply. The mechanism by which diarrhea is induced is not fully understood, however, evidence suggests that it is due to the production of a choleralike or Shiga-like toxin. Salmonella Enteritidis is not well suited for intracellular conditions, therefore, except in cases where the host immune system has been compromised, gastrointestinal infections are generally short-lived. Lacking an appropriate host immune response, however, dissemination of the organism may occur, resulting in widespread systemic infection. Diagnostic procedures include aerobic and anaerobic blood culture, bone marrow culture, and stool culture. Because the vast number of strains differ primarily in antigenic structure, serogrouping by a reference laboratory is necessary for final identification. However, in disseminated Salmonella infections, third generation cephalosporins, ampicillin, or sulfamethoxazole with trimethoprim are used. Note the black colonies due to reaction of H2S (from sulfur reduction) and ferric citrate in the medium. It then enters the bloodstream where it produces acute bacteremia and subsequently infects the liver, spleen, bone marrow, and eventually the kidneys and gallbladder. This phase, accompanied by high fever and sometimes diarrhea, is long lasting and continuous (up to 8 weeks in untreated cases). In a small percentage of patients ("carriers"), the organism is harbored asymptomatically in the gallbladder and sloughed in the feces for up to a year or more. Diagnostic procedures include aerobic and anaerobic blood culture, 4 Abbreviated from Salmonella enterica subspecies Enterica serovar Typhi. Note the absence of black in the colonies due to weak (or lack of) sulfur reduction to H2S. Transmission is by direct person-to-person contact or ingestion of food or water contaminated by human feces. It is highly communicable and virulent; it can cause illness with as few as 200 organisms, but more typically with 103 organisms. This process combined with an acute immune response is responsible for the purulent bloody diarrhea characteristic of the disease. Note the colorless colonies due to inability to ferment lactose or reduce sulfur- both included in the medium. Treatment Administration of ampicillin, sulfamethoxazole with trimethoprim, or ciprofloxacin. Staphylococcus aureus Staphylococcus aureus (Phylum Firmicutes) is a normal human inhabitant, most commonly found in the nose, but also known to inhabit the skin and vagina. It is a common nosocomial pathogen that causes toxic shock syndrome, food poisoning, scalded skin syndrome, and abscesses virtually anywhere in the body. Factors that increase its virulence include: antiphagocytic proteins, lipase production (which aids entry through the skin), coagulase (which enhances the formation of abscesses), enterotoxins (which induce vomiting and diarrhea), and exotoxins (which destroy polymorphonuclear leukocytes, aid necrosis, and produce fever, chills, shock, and rash). It is a robust organism that resists cleaning solutions and antimicrobial agents, and can survive for weeks in the environment. Diagnostic procedures include Gram stain, appropriate-site aerobic culture, and teichoic acid antibody test. Most strains produce a slime layer that may enable them to attach to certain hospital apparati used in invasive procedures, thereby gaining entry to the body. Infections originating at the site of prosthetic implantation are frequently caused by S. Due to multiple antibiotic resistance and the generally weakened condition of a convalescing patient, disseminated S. The reservoir for this organism is believed to be the intestinal tracts of humans and animals, but it is often found in the vagina of pregnant women. The organism is typically acquired by the infant in utero through a damaged membrane, from the birth canal during childbirth, or from contact with contaminants after birth. Its virulence is attributable to a polysaccharide capsule which allows it to survive phagocytosis, multiply, and eventually spread by way of the bloodstream. Disseminated disease also causes pneumonia and septic shock, especially in the elderly and immunocompromised populations. Diagnostic procedures include appropriate-site aerobic culture and group B Streptococcus antigen test. Treatment Administration of penicillin G, amoxicillin, ampicillin, 1st generation cephalosporins, erythromycin, or vancomycin. The mutans group is one of five groups in the "viridans group," which also includes the "anginosus group," "bovis group," "mitis group," and "salivarius group.

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Neither of these situations changes the actual Gram reaction for the organism being stained symptoms of a stranger order brahmi once a day. A second source of poor Gram stains is inconsistency in preparation of the emulsion medications 3 times a day safe brahmi 60caps. Spreading them out across the slide makes it difficult to stain and decolorize them equally. Expect numerous Gram-positive bacteria (especially cocci) and some Gram-negative cells, including your own epithelial cells. In this slide, Gram-positive cocci predominate, but a few Gram-negative cells are visible, including Gram-negative rods (circled) and a Gram-negative diplococcus (arrow) on the surface of the epithelial cell. Older Gram-positive cultures may lose their ability to resist decolorization and give an artifactual Gram-negative result. Potassium hydroxide provides a nonstain test to confirm Gram reaction for particularly difficult species. Notice the virtual absence of any purple cells, a certain indication of over-decoloration. Also notice the variable quality of this stain-the epithelial cell to the left of center is stained better than the others. The solution has become viscous and stringy due to the release of chromosomal material from the cells. A this specimen is of a gum line direct smear; B Micrococcus roseus grown in culture. Notice their size relative to the epithelial cells, their lobed nucleus, and Gram-negative staining reaction. Notice its spherical nucleus and vacuolated cytoplasm (containing bacteria in the process of digestion). Also notice the Gram-positive cocci on its surface, probably caught in the act of being engulfed. Their columnar and irregular shape, nucleus, and cilia (what are left) provide clues to their identity. It is an important differential stain used to identify bacteria in the genus Mycobacterium, some of which are pathogens. Oocysts of coccidian parasites, such as Cryptosporidium and Isospora, are also acid-fast. Because so few organisms are acid-fast, the acid-fast stain is run only when infection by an acid-fast organism is suspected. It also can be performed on patient samples to track the progress of antibiotic therapy and determine their degree of contagiousness. In both protocols, the bacterial smear may be prepared in a drop of serum to help the "slippery" acidfast cells adhere to the slide. Principle the presence of mycolic acids in the cell walls of acid-fast organisms is the cytological basis for this differential stain. Mycolic acid is a waxy substance that gives acid-fast cells a higher affinity for the primary stain and resistance to decolorization by an acid alcohol solution. Staining by carbolfuchsin is further enhanced by steam heating the preparation to melt the wax and allow the stain to move into the cell. Acid alcohol is used to decolorize nonacid-fast cells; acid-fast cells resist this decolorization. Fluorescent dyes, such as auramine or rhodamine, are used in many clinical laboratories and are actually preferable to traditional carbolfuchsin stains for examination of direct smears because of their higher sensitivity. Acid alcohol is used for decolorization and potassium permanganate is the counterstain. It is not uncommon for brilliant green dye to stain more of a gray color, but it still contrasts with the carbolfuchsin of acid-fast positive cells. Capsule production increases virulence in some microbes (such as the anthrax bacillus Bacillus anthracis and the pneumococcus Streptococcus pneumoniae) by making them less vulnerable to phagocytosis. Principle Capsules are composed of mucoid polysaccharides or polypeptides that repel most stains. The capsule stain technique takes advantage of this phenomenon by staining around the cells. Typically, an acidic stain, such as Congo red or nigrosin that stains the background, and a basic stain that colorizes the cell proper, are used. This technique begins by spreading the cells in a film of an acidic stain and serum. Heat-fixing causes shrinkage of the cells, leaving an artifactual white halo around them that might be interpreted as a capsule when counterstained. In place of heat-fixing, cells may be emulsified in a drop of serum to promote adherence to the glass slide. Notice the lack of uniform capsule size, and even the absence of a capsule in some cells. The difference in cell size between the two photos is due to enlargement of the micrograph, not to the staining. Most members of Bacillus are soil, freshwater, or marine saprophytes, but a few are pathogens, such as B. Most members of Clostridium are soil or aquatic saprophytes or inhabitants of human intestines, but four pathogens are fairly well known: C. Principle An endospore is a dormant form of the bacterium that allows it to survive poor environmental conditions. Spores are resistant to heat and chemicals because of a tough outer covering made of the protein keratin. The keratin also resists staining, so extreme measures must be taken to stain the spore. Alternatively, malachite green can be left on the slide for 15 minutes or more to stain the spores. Malachite green is water-soluble and has a low affinity for cellular material, so vegetative cells and spore 52 A Photograph Atlas for the Microbiology Laboratory Spore producer Cells and spores prior to staining are transparent. Spore nonproducer A After staining with malachite green, cells and spores are green. Spores may be located in the middle of the cell (central), at the end of the cell (terminal), or between the end and middle of the cell (subterminal). Spores also may be differentiated based on shape-either spherical or elliptical (oval)- and size relative to the cell. Sporulation is done in response to nutrient depletion, and so is characteristic of older cultures. Because they are anaerobic, it is likely they are one or more species of Clostridium. Note the difference in morphology between the cell marked with the arrow and the others. Their irregular size and the presence of more than one per cell are clues that they are not endospores, but an endospore stain would remove any doubt. Presence and arrangement of flagella may be useful in identifying bacterial species. Various special flagella stains have been developed that use a mordant to assist in encrusting flagella with stain to a visible thickness. Most require experience and advanced techniques, and are typically not performed in beginning microbiology classes. This is due to the fragile nature of flagella, which can be broken from the cells during slide preparation. The flagella of this aquatic spirillum are barely visible at each end of the cell in this phase contrast micrograph. Again, not all cells have flagella because they were too delicate to stay intact during the staining procedure. The smaller cells are called "swimmers" and are the form seen when grown in a liquid medium. When transferred to a solid medium or under certain environmental conditions, swimmers differentiate into "swarmers. Simple wet mounts and the hanging drop technique allow observation of living cells to determine motility. The preparation may then be picked up, inverted so the cover glass is on top, and placed under the microscope for examination.

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