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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Continuous Spikes and (Landau-Kleffner syndrome): long-term follow-up and links with electrical Waves During Slow Sleep buy generic rumalaya online treatment centers for alcoholism. Electrical Status Epilepticus During Slow Sleep: status epilepticus during sleep (electrographic status epilepticus during Acquired Epileptic Aphasia and Related Conditions order rumalaya on line treatment of pneumonia. Felbamate in the treatment of tions and continuous spike and wave discharges in sleep generic rumalaya 60pills overnight delivery symptoms of diabetes. Surgical treatment of severe autis- computed tomography imaging in Landau-Kleffner syndrome. Landau- tion of children for epilepsy surgery: recommendations of the Subcommission Kleffner syndrome. Sign language in childhood epileptic aphasia Kleffner syndrome and continuous spike-wave discharge during sleep. A case of Landau-Kleffner syn- epilepsy) compared to children with absence epilepsy and healthy controls. Landau-Kleffner syndrome: consistent During Slow Sleep: Acquired Epileptic Aphasia and Related Conditions. This chapter reviews the neuro- physiology of reflex epilepsy from the available human and the seizures of reflex epilepsy are reliably precipitated by animal studies. Epilepsy (2) describes reflex epilepsies as epilepsies charac- terized by specific modes of seizure precipitation. The second model involves natu- occurring in generalized or in focal epilepsy syndromes (4). This technique also demonstrated that strychninization of Seizures triggered by factors such as alcohol withdrawal are auditory (13), gustatory (14), and olfactory cortex (15) pro- not included among reflex seizures. Arguing that no reflex arc the clinical seizures (chewing movements), which were is involved in reflex epilepsy, others proposed terms such as induced by photic stimulation in rabbits with strychnine sensory precipitation (6,7) or stimulus sensitive epilepsies (8). Most authorities retain reflex epilepsy to visual cortex may also occur in the fronto-rolandic areas dur- mean that a certain stimulus regularly elicits an observable ing seizures (17). Although some investigators restrict the term and demonstrated spread of the visual-evoked potential to the reflex epilepsy to cases in which a certain stimulus always brainstem reticular formation (19). Hunter and Ingvar (20) induces seizures (10), it may include cases in which sponta- identified a subcortical pathway involving the thalamus and neous seizures also occur or instances in which the epilepto- reticular system and an independent cortico-cortical system genic stimulus does not invariably induce an attack (11), for radiation of visual-evoked responses to the frontal lobe. The cats and monkeys, the fronto-rolandic region was also shown term epilepsy with reflex seizures, although more cumber- to receive spreading-evoked paroxysmal activity from audi- some, perhaps better reflects clinical reality and more accu- tory and other stimuli (21,22). The second approach, the study of naturally occurring or Reflex seizures have long fascinated epileptologists. Apart induced reflex seizures in genetically susceptible animals, has from epileptic photosensitivity to flickering light, cases of been pursued in domestic fowls and chickens with photosensi- reflex epilepsy are relatively rare and permit glimpses into the tivity (23,24), rodents susceptible to sound-induced convul- mechanisms of epileptogenesis and the organization of cogni- sions (25), the E1 mouse sensitive to vestibular stimulation tive function. The identification of a patient with reflex (26), and the Mongolian gerbil sensitive to a variety of stimuli epilepsy depends on the physicians awareness and on the (27,28). This use of the term psy- generate this abnormal activity but sends cortico-cortical visual chogenic seizures, common in European epileptology, does afferents to hyperexcitable frontal cortex, which is responsible not refer to nonepileptic events. Brain stem reticular activation depends initially on alumina cream model, with recruitment of group 2 neurons frontal cortical mechanisms until a seizure is about to begin, at and evoked change in neuronal activity surrounding the which point the cortex can no longer control reticular activa- seizure focus as factors in seizure occurrence, spread, and tion. For primary read- imbalance between excitatory and inhibitory neurotransmitter ing epilepsy he observed that seizure evocation would depend amino acids (34) similar to those described in feline generalized on involvement of the multiple processes used for reading, an penicillin epilepsy and in human epilepsy (35). Studies in photosensitive patients suggested that the functional complexity of the epileptogenic who are also pattern-sensitive suggest that generalized seizures tasks leads to seizure precipitation. The recruitment that pro- Wieser proposed a neurophysiologic model for critical duces these seizures, however, need not be confined to physi- mass (9), referring to the group 1 and group 2 epileptic neu- cally contiguous brain tissue or fixed neuronal links. Instead, rons of the chronic experimental epileptic focus described by it may depend on activity of a function-related network of Wyler and Ward (43). Group 1 neurons produce abundant, both established and plastic links between brain regions, mod- spontaneous, high-frequency bursts of action potentials. These two Group 2 neurons have a variable interspike interval, and their approaches share much common ground. Moreover, these Disorders of cortical development may be present in some properties are influenced by external stimuli that can pro- patients with reflex seizures. The stimuli effective in eliciting reflex seizures techniques or may only be found in a surgical pathology spec- would act on this population of neurons, recruiting them into imen (4952). Chapter 24: Epilepsy with Reflex Seizures 307 Recent detailed studies on subjects known to have visually photic stimulus and on the patients degree of photosensitivity, induced seizures examined whether color modulation could be the clinical response ranges from subtle eyelid myoclonus to a an independent factor in human epileptic photosensitivity. Among photosensitive epilepsy patients sensitive to flash and Pure photosensitive epilepsy is typically conceptualized as a pattern stimulation, 25/43 were sensitive to color stimulation, variety of idiopathic generalized epilepsy, but cases occur in particularly at frequencies below 30 per sec. As in more typical photosensitive sub- tion, plays a role at lower frequencies (5 to 30 Hz). Another, jects, environmental triggers include television and video dependent on single-color light intensity modulation corre- games. Many of these patients have idiopathic photosensitive lates to white light sensitivity and is activated at higher fre- occipital lobe epilepsy, a relatively benign, age-related syn- quencies. The visual stimulus triggers initial visual symp- patients with light-induced seizures only, patients with photo- toms that may be followed by versive movements and motor sensitivity and other seizure types, and asymptomatic individu- seizures; however, migraine-like symptoms of throbbing als with isolated photosensitivity. Kasteleijn-Nolst Trenite (58) headache, nausea, and sometimes vomiting are common and has shown that more than half of known photosensitive can lead to delayed or incorrect diagnosis. Photosensitive epilepsy may Photosensitivity with be classified into two major groups, depending on whether the Spontaneous Seizures seizures are induced by flickering light. Further classification of photosensitive epilepsy into sub-groups is as follows: Jeavons and Harding (65) found that about one third of their Seizures induced by flicker photosensitive patients with environmentally precipitated Pure photosensitive epilepsy including idiopathic photo- attacks also had spontaneous seizures similar to those of pure sensitive occipital epilepsy photosensitive epilepsy. Photosensitive benign myoclonic epilepsy may also begin in Pure Photosensitive Epilepsy infants, with a generally good prognosis though the events may be overlooked by the parents for some time before diagnosis Pure photosensitive epilepsy is characterized by generalized (70).

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A total of 84 patients 4 finished the trial cheap 60pills rumalaya fast delivery in treatment, compared to the placebo group (53 discount rumalaya 60pills amex medications ending in ine,85%) cheap rumalaya online master card medicine university, the treatment group (77,78%) 5 showed improvement in symptoms (133). Although a pilot study has indicated some 30 beneficial effects (157), further studies were unable to establish a dose response 31 relationship (158). Additional studies could not prove a beneficial effect on skin barrier 32 function (159). A further study compared a 16 topical preparation of Mahonia aquifolium, Viola tricolor and Centella asiatica with the 17 vehicle cream in 88 patients and could not find significant differences (165). A subgroup 18 analysis revealed superiority of the plant preparation under dry and cool weather conditions. It was demonstrated that so called phytocosmetic creams containing a mixture 21 of plant extracts may also contain triamcinolone acetonide as an active ingredient (168). Serious adverse effects including fatal hepatitis have been reported 39 by independent investigators following these trials (171, 174-176). The authors assessed most studies at high risk of bias and found substantial 10 inconsistency between studies. A similar result was achieved by the 12 systematic review of Tan and co-workers (181). Patients were 36 recruited via press advertisement and finally 30 subjects participated. The data suggest a beneficial effect of autologous blood 2 therapy with respect to the signs score. Large case series illustrating the therapeutic benefits 25 of homeopathy have been published as papers or books (190, 191). Greater degrees of improvement in anxiety scores, tactile defensiveness 2 and coping index were reported by parents of children in the active group. Furthermore 3 clinical signs such as scaling and excoriation improved significantly in the massage group. A further 5 small cross-over trial in 8 children compared massage with essential oils (aroma therapy) to 6 conventional massage (196). Both treatment groups improved significantly without 7 significant differences between groups. Given the small sample size, conclusions on the 8 beneficial effects of additional aroma therapy cannot be drawn. Similarly, a smaller study of 49 patients comparing vitamin E plus 2 vitamin B2 to vitamin E or vitamin B2 alone revealed a superiority of the combination 3 treatment with respect to the physicians assessed overall usefulness and global rating 4 (208). A Hungarian study compared multi-vitamin supplementation in 2090 7 pregnancies to trace element supplementation in 2032 pregnancies over a 17 month period 8 (206). Although this 9 unexpected result could be a chance finding as suggested by the authors, detailed studies 10 in the prospective setting are needed. The severity score increased in both 12 study groups without significant differences. The median 14 severity score increased in the pyridoxine group whereas an improvement was observed in 15 the placebo group. Thereby vitamin D supplementation showed statistically significant improvement in 18 clinical scores in 20 i. Vitamin 20 D supplementation of mothers during lactation did also not improve facial eczema in 164 21 children studied (217). Dietary 4 regimens involving strong restrictions can lead to harmful sequels in terms of 5 malnourishment. Therapeutic procedures involving organic material from plants or animals 6 can be associated with severe toxic or allergic reactions. Interventions including patient education, eczema action 5 plans, and a quick return for a follow-up visit improve adherence (221). The reason for 6 treatment failure in more than one-half of patients referred to specialist centers is that the 7 treatment is not being administered. Doctors often have insufficient time to educate patients 8 and their caregivers about the correct application of ointments and creams, and this 9 adversely affects compliance. Many countries have patient organizations and support 10 groups that provide useful supplementary literature (222). The itch-scratch cycle is especially vulnerable to psychological influences and 15 can show a tendency to self-perpetuation (227-229). One study of a psychological 21 intervention used biofeedback and hypnotherapy as relaxation techniques versus 22 discussion only. Three of the four educational studies identified significant improvements in 23 disease severity in the intervention groups. The fourth trial evaluated long-term outcomes 24 and found a statistically significant improvement (P < 0. The psychological and educational interventions were delivered by nurses or 28 multidisciplinary teams (234). In conclusion, patient 32 education appears to be effective in improving QoL and in reducing the perceived severity 33 of skin disease (236-238). Another publication stated that there is currently only limited 12 research evidence on the effect of educational and psychological approaches when used 13 alongside medicines for the treatment of childhood eczema (233). It is well possible that 14 there is limited research activity in this area of intervention, thus providing limited evidence 15 of the measurable effects of interventions. These differ in 19 number and certification of the educators, number of participants, age of patients, teaching 20 techniques, duration and frequency of interventions (233, 250). For example, 22 while the intervention by Staab (237) entailed 2-h sessions, involving a trained 23 multidisciplinary team, once a week for 6 weeks, the intervention by Shaw et al (251) 24 involved a trained medical student running a single 15-min session.

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To find out what to do if someone has collapsed and is not responding and may be in cardiac arrest order 60pills rumalaya with visa medicine in the middle ages, see page 53 discount rumalaya 60 pills treatment urinary incontinence. For information on Heartstart order rumalaya american express medicine clip art, a course in emergency life-support skills, see page 58. You may need to have one or more of these treatments, depending on the type of arrhythmia you have. Medicines Medicines are used in three main ways: to stop an arrhythmia (this is called rhythm control or chemical cardioversion) to prevent an arrhythmia, and to control the rate of an arrhythmia (rate control). Medicines to prevent arrhythmias and to control the rate of arrhythmias are usually taken as tablets. Pill in the pocket Most people who take medicines to prevent arrhythmias have to take their medicine every day. However, if you Heart rhythms | 33 only very rarely have an arrhythmia, your doctor may give you a prescription for a particular dose of one or more medicines which you take if you ever get the arrhythmia again. You should only use this method if your doctor has advised you to and has given you a prescription for it. It stimulates the vagus nerve a nerve that is responsible for slowing the heart rate normally. It involves taking a deep breath and pushing down into your abdomen as if you were constipated. Cardioversion can be a successful treatment for various types of tachycardias, particularly atrial fibrillation and atrial flutter. A doctor or specialist nurse then applies one or more controlled electrical shocks to the chest wall, using a defibrillator machine. Sometimes it is successful to start with, but the fast heart rhythm may come back again within hours, weeks or months after cardioversion. If an arrhythmia does come back again, your cardiologist may decide to repeat the cardioversion. Heart rhythms | 35 Catheter ablation this treatment may be used if you get repeated episodes of abnormal fast heart rhythms and your medicine has not had much effect on them. You will be asked not to eat or drink anything for a few hours before the procedure. Most people need only a local anaesthetic and sedation when they have this treatment. At the end of the catheter there are small electrodes that detect which parts of the heart tissue are causing unwanted electrical impulses. Radio-frequency energy can be used to destroy particular areas of heart tissue to prevent the abnormal heart rhythms from happening 36 | British Heart Foundation and to restore a normal rhythm. While you are having the catheter ablation, you may feel like you are having palpitations, and the procedure can make some people feel a bit dizzy. When the catheters are inserted, you may feel a sensation in your chest, but this should not be painful. How long you need to rest for will depend on how your puncture wound (where the catheters were inserted) is, and how much sedation you have had. Catheter ablation is a very successful treatment for certain types of fast heart rhythms, and has a relatively low risk of complications. The success rate depends on which type of arrhythmia you have, where the extra electrical pathways are, and how many you have. Some people who have catheter ablation treatment may not be completely cured, but may have fewer and shorter episodes of arrhythmias after the treatment. Major complications are rare but the risks should all be explained to you before you agree to have the treatment. Your cardiologist will be able to discuss with you how high this risk is in your particular case. These can help to detect the areas of the heart that need 38 | British Heart Foundation ablation, but sometimes the person needs to have treatment to stop an arrhythmia during the procedure. Also, having a catheter ablation does mean that you are exposed to some radiation. I was started on medicines that helped control my symptoms but they didnt completely disappear. My cardiologist suggested I had a procedure called catheter ablation, and I can honestly say it was the best thing I have ever done. Ive been able to enjoy sports without any restrictions and have even represented Great Britain for my age group in a number of swimming, cycling and running events. This does not cause the heart to stop beating altogether, and rarely causes symptoms. Some heart blocks can cause a bradycardia (a slow heart rhythm), but others dont. Other symptoms are feeling dizzy, extremely tired, confused or breathless, and fluid retention (when there is too much fluid in the body). In some people, these heart blocks are always there, while in others they are paroxsysmal (which means that they come and go). Treatment If you do need to have treatment, the type of treatment 42 | British Heart Foundation will depend on your heart rate and symptoms, and on what has caused the heart block. If they dont have any symptoms from this, their condition may be stable and they may not need a pacemaker. If the normal rhythm hasnt recovered a few weeks after your heart attack, you may need to have a permanent pacemaker fitted. Bundle branch blocks A bundle branch block is when the electrical impulses travel through the ventricles more slowly than normal, due to a block in the electrical pathway. Other causes of right bundle branch block include coronary heart disease, or a problem with the structure of the heart such as a hole in the heart, and some lung conditions.

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Other publications buy 60pills rumalaya overnight delivery medications japan, including the Expert Patients Programme11 rumalaya 60pills for sale medicine 75 yellow, a special interest in epilepsy order 60pills rumalaya fast delivery medications you cannot eat grapefruit with. Because of the potential problems of diagnosis, it is recommended that a consultant neurologist, or other Table 2. The following checklist for the first review of the patient by the primary Role expansion, More effcient use of healthcare team, after the diagnosis of epilepsy has been made, may be helpful18:. People Find out what the patient knows and fill in the gaps with chronic epilepsy often have significant comorbidity requiring psychological support and the input Provide addresses of patient organisations of mental health and social care services. Uncoordinated care can lead to inconsistent advice for patients, Discuss contraception and pregnancy with women inappropriate and unnecessary investigations and interventions, and delays in diagnosis and initiation Agree a timetable for follow-up. Improved integration of care is key to improving the quality, safety and efficiency of health services for people with chronic disease. This would help to alleviate the mismatch which could occur when the persons epilepsy footprints. Epilepsy nurse specialists are integral to effective integrated care, evaluating need and access to multi- be encouraged to manage their epilepsy more effectively through the Expert Patients Programme11. To date, the impact of nurse intervention on health Controlled epilepsy outcomes such as impact on unplanned admissions, seizure outcome and cost is largely unexplored, but It is generally accepted that those no longer experiencing seizures can be returned to primary care it is widely acknowledged that epilepsy specialist nurses enhance the integration of epilepsy care and with provision for re-referral when necessary. The strategic vision of one such model into electronic patient records to facilitate teaching and to guide the review process. People with stable epilepsy and those with complex care needs will be stepped down into the community service, allowing greater access to allied health professionals and improved communication Those not under current review across services. More responsive and proactive care should result in reduced unplanned admissions due There may be problems in attempting to review all people with epilepsy, particularly those who have not to epilepsy. It is anticipated that delivering care in the context of integrated health and social care provision been reviewed for some years. The best time to anxiety and depression), while offering improved psychosocial support, and better access to employment offer a review may be when a prescription is due21. In keeping with the goal of person-centred medicine, advice and local support networks. The correctness of the diagnosis Integral to effective integrated care is timely sharing and dissemination of clinical information. Improved integration across primary, secondary and tertiary care and social services should result in improved sharing of information and ultimately improved patient experience It has been shown that reviewing people with epilepsy in general practice, reducing polytherapy and changing treatment, can improve seizure control in over one-quarter of patients, and reduce side effects Specialist care in almost one-quarter21. In many cases, however, re-referral to specialist care for these alterations may be more appropriate. After diagnosis, 2040% of people with epilepsy will need follow-up in a specialist centre24. A Cochrane Review found only one study Those with continuing seizures should benefit from continuing secondary care, with additional investigating the benefit of clinics held at a specialist epilepsy unit25. Nevertheless, and the patient may need to try second-line or experimental drugs, or be assessed for epilepsy surgery several studies have shown that neurology opinions may contribute useful advice to, or change the or neurostimulation20. All people with epilepsy should be able to consult a tertiary care specialist diagnosis in, patients previously under the care of non-neurologists26,27, and the Association of British (via the secondary care specialist) should the circumstances require this19. Suggested criteria for referral Neurologists states that neurologists who specialise in epilepsy (or other conditions) are better at managing to tertiary care are: those conditions than neurologists without such a specialism28. Transition from paediatric to adolescent services is a major milestone for an adolescent with a chronic illness such as epilepsy, with adjustments in their care and social needs as well as an Controlled epilepsy evolving relationship with their parents and clinicians. Although transfer and transition are often used Although those adults who become seizure free will probably not need ongoing secondary care, interchangeably, transition is a more dynamic process implying a planned and structured move from it is important that re-referral can be swiftly instigated should seizures recur, or circumstances change paediatric to adult care, involving preparation and discussion with the young person, while transfer often (e. In children a regular structured review, occurring at least yearly, should Specialist epilepsy care should provide provision for special groups. Such services could conceivably be held either in the community or in specialist units and funding may come from either hospital Trusts Accident and emergency care or Clinical Commissioning Groups. The guidelines of healthier and safer lifestyles and use scarce health services more efficiently. Improved partnership stress that information on how to recognise a seizure and first-aid for seizures should be provided between the individual and clinician in devising a care plan should help to increase treatment adherence. Once epilepsy is diagnosed, seizures and syndromes should be classified using a multi-axial Self-management programmes. Managing epilepsy in general practice: the dissemination and uptake of a free audit package, and collated results from 12 practices in England and Wales. In response to ever increasing burdens on our healthcare system and the wide variability in the quality 35. Self-management for people with poorly controlled epilepsy: Participants through improved self-management and improves the quality of life of those with epilepsy. Developing an evidence-based epilepsy risk assessment ehealth solution; from poorly supported and implemented. The National Sentinel Clinical Audit of Epilepsy-Related Death: Epilepsy death in the shadows. Expert Patients Programme: A new approach to chronic disease management for the 21st century. Guidelines for the appointment of general practitioners with special interests in the delivery of clinical services. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. A real puzzle: the views of patients with epilepsy about the organisation of care. The impact of health information technology on collaborative chronic care management. Influence of obtaining a neurological opinion on the diagnosis and management of hospital inpatients. The charitys founding fathers were pioneers of their time, providing employment and a safe place to live for people with a much stigmatised condition.

The doctor will ask about alcohol and medicine taken and whether the patient has thoughts about death or suicide purchase rumalaya 60 pills overnight delivery medical treatment. The doctor will also ask questions about family history: Have other family members had depression Talking Points: There are two common types of treatment for depression: Medicine order rumalaya uk medications information. If you are not feeling better after a few weeks buy 60 pills rumalaya mastercard pure keratin treatment, your doctor may have you try different medicines to fnd out what works best for you. Also, if one medicine does not work, you should ask your doctor if you can try another medicine. Never stop taking an antidepressant without talking to the doctor about how to do it safely. You should keep taking the medication, even if you are feeling better, to prevent the depression from returning. Although antidepressants are not habit-forming or addictive, suddenly ending an antidepressant can cause withdrawal problems or lead to a return of the depression. Some people, such as those with continual depression, may need to stay on the medication a longer time. You should not use alcohol or street drugs because they may cause the antidepressants not to work as well. The latest information on medications for treating depression is available on the U. This therapy helps you learn to change the way depression makes you think, feel, and act. Ask your doctor or psychiatrist which professional you should go to for talk therapy. In the meantime there are things you can encourage a person with depression to do Set realistic goals and take a reasonable amount of responsibility. The most important thing anyone can do for the depressed person is to help him or her get a diagnosis and treatment. You can encourage the person to stay with treatment until he or she feels better (it may take several weeks), or to talk to his or her doctor about a different treatment. Sometimes you might need to make an appointment and go with the depressed person to the doctor. It may also mean checking on whether or not the depressed person is taking medication. You should encourage the depressed person to follow the doctors advice about the use of alcohol while on medicine. Invite the person for walks, outings, to the movies, and other activities that they used to enjoy. Do not accuse the depressed person of faking illness or of laziness, or expect him or her to snap out of it. Keep that in mind, and keep telling the depressed person that, with time and help, he or she will feel better. But, we know from research that people with heart disease are more likely than healthy people to suffer from depression. Also, people with heart disease who are depressed have a greater risk of dying after a heart attack and stroke than those who are not depressed. Talking Points: Remember, depression can make it hard to function in everyday life. Depression makes it hard to care about taking medicine or to remember to take medicine. Making lifestyle changes such as increasing physical activity, eating healthy foods, and quitting smoking can seem impossible to someone suffering from depression. Depression may affect heart rhythm, increase blood pressure, and affect the bloods clotting ability. Despite research showing a link between depression and heart disease, depression often is not diagnosed and is left untreated. Persons with heart disease or stroke, their families and friends, and sometimes even their doctors may not see the signs of depression, or may mistake them for the usual feelings that are a part of heart disease or stroke. Doctors trained to see the signs of depression know the right questions to diagnose depression and can treat the person for it. But most people who survive a stroke become depressed because of the changes in their lives. How can they help people understand that depression is a real illness, but that there is hope for feeling better. People who have reduced blood fow to the heart during mental stress are more likely to have reduced blood fow to the heart during everyday activities. They are also more likely to have heart problems, such as angina and repeat heart attacks. Taking practical steps to maintain your health and outlook can reduce or prevent these effects. The following are some tips that may help you to cope with stress Get help from a mental health care provider if you are overwhelmed, feel you cannot cope, have suicidal thoughts, or are using drugs or alcohol to cope. Ask for help from friends, family, and community or religious organizations to reduce stress due to work burdens or family issues, such as caring for a loved one.


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