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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

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


The classic classification is basically based on demonstration of two fused aortic cusps raloxifene 60mg with mastercard womens healthcare associates boca raton, whereas new classification on the orientation of the fused bicuspid aortic valve (modified with permission from Buchner et al cheap 60mg raloxifene women's health center flint mi. Frequently order raloxifene mastercard women's health clinic erina, the two commissures can be visualized only sideration of open heart surgery. Representative images showing additive benefit of transesophageal echocardiography for diagnosis of bicuspid aortic valve. Routine transthoracic echocardiography showed typical thickening and motion limitation of the mitral valve suggesting rheumatic involvement (A and B). Development of localized aortic dissection in a patient with bicuspid aortic valve. This 35-year-old gentleman without previous history of heart disease visited emergency department due to prolonged chest pain. Computed tomography revealed both pleural effusion with markedly dilated ascending aorta with maximal diameter of 65 mm (A). Transesophageal echocardiography showed bicuspid aortic valve without significant valvular dysfunction and localized intimal flap in the ascending aorta (arrow, B). Common association of aortic dilatation with signifcant ed with aortic aneurysm or dissection. Moreover, recent ad- tion is not correlated with severity of valvular dysfunction vances in molecular biology have demonstrated potential asso- 4 Bicuspid Aortic Valve: Unresolved Issues and Role of Imaging Specialists | Jae-Kwan Song. Development of aortic dissection after successful aortic valve replacement in a patient with bicuspid aortic valve. This gentleman underwent uneventful aortic valve replacement due to severe regurgitation in 2001. Five years later, sudden chest pain developed and computed tomography showed markedly dilated ascending aorta (up to 57 mm) with typical intimal flap involving both the ascending and descending aorta. Representative multidetector computed tomographic images of bicuspid aortopathy phenotypes using measurements of aortic dimensions in 10 different levels. If the aortic enlargement involves the tubular portion of the ascending aorta, it is classified as type 2, whereas in type 3, there is diffuse involvement of the entire ascending aorta and the transverse aortic arch. A indicates the aortic annulus; B, sinuses of Valsalva; C, sinotubular junction; D, tubular portion of the ascending aorta; E, proximal to the innominate artery (or common trunk in case of a bovine arch); F, distal to the innominate artery (or common trunk); G, proximal to the left subclavian artery; H, distal to the left subclavian artery; I, proximal descending aorta; and J, distal descending thoracic aorta at the level of the diaphragmatic hiatus (modified with permission from Kang et al. Standardiza- burden due to valvular dysfunction and protective effect of tion of the classifcation of bicuspid aortopathy phenotypes is surgical intervention. However, because progressive aortic dilatation occurs in dence of aortic dissection in these series has been re-confrmed many patients with normal valvular function, the hemody- by another registry data showing 0. It is obvious that aortic size and evidence dilation that correlate with specifc changes in valve morphol- of medial degeneration are limited risk stratifcation tools. Longitudinal patient registry with homogeneous and rigorous entry criteria follow-up is needed to determine whether an abnormal helical (i. Despite recent nosis or regurgitation), aortopathy (aortic dissection), and ac- advances in clinical cardiology, many challenging issues still quired complications (infective endocarditis), the late out- remain unresolved and elusive. A study of 85 autop- spectrum of valve dysfunction (mean age 35 ± 16 years) and the sy cases. Basso C, Boschello M, Perrone C, Mecenero A, Cera A, Bicego D, follow-up duration was 9 ± 5 years. An echocardiographic survey of primary was 96 ± 1% and the probability of aortic valve or aorta sur- school children for bicuspid aortic valve. Am J Car- these data support the notion held by many that eventually diol 2005;96:718-21. However, importantly, in both of these series, fatal 6 Bicuspid Aortic Valve: Unresolved Issues and Role of Imaging Specialists | Jae-Kwan Song 5. Bicuspid aortic valve: identifying knowledge gaps and rising to the valve disease. The bicuspid aortic valve: an integrated phenotypic classifcation with bicuspid aortic valve. Bicuspid aortic valves with different aortic valve confguration and aortopathy pattern might represent different spatial orientations of the leafets are distinct etiological entities. Morphology of bicuspid aortic valve in children aorta with bicuspid aortic valve: a phenotypic classifcation with potential and adolescents. Aortic involvement in patients with a bicuspid aortic evaluation of ascending aortic systolic fow patterns. Association of tory of asymptomatic patients with normally functioning or minimally dys- aortic dilation with regurgitant, stenotic and functionally normal bicuspid functional bicuspid aortic valve in the community. Outcomes in adults with bicuspid aortic proportion to coexistent valvular lesions. Yasuda H, Nakatani S, Stugaard M, Tsujita-Kuroda Y, Bando K, patterns in surgical management of bicuspid aortopathy: a survey of 100 car- Kobayashi J, Yamagishi M, Kitakaze M, Kitamura S, Miyatake K. Failure to prevent progressive dilation of ascending aorta by aortic valve re- 35. Bicuspid aortic valve phenotype and placement in patients with bicuspid aortic valve: comparison with tricuspid aortopathy: nomenclature and role of aortic hemodynamics. Phenotypic heterogeneity of bicuspid aortopathy: a potential frequency of familial clustering of congenital bicuspid aortic valve. When placed within the target lesion, the stent graft provides an alternative conduit for blood flow within the patient’s vasculature by excluding the lesion from blood flow and pressure. The stent graft system is composed of 2 main components: the implantable Valiant thoracic stent graft and the disposable Captivia delivery system. The stent graft is preloaded into the delivery system, which is inserted endoluminally via the femoral or iliac artery and tracked through the patient’s vasculature to deliver the stent graft to the target site.

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Therapeutic interchange of clevidipine for sodium nitroprusside in cardiac surgery quality raloxifene 60mg womens health nurse practitioner jobs. Hydroxycobalamin/sodium thiosulfate ine: its use in the short-term treatment of hypertension as a cyanide antidote buy raloxifene cheap online women's health social justice issues. Hypertensive sure level purchase raloxifene with american express women's health clinic warilla, blood pressure variability, smoking, and emergencies are associated with elevated markers of stroke risk in Japanese men: the Ohasama study. Am J inflammation, coagulation, platelet activation and fbrino- Hypertens 2012;25:883-91. Functional the diagnosis and treatment of aortic diseases: Document magnetic resonance signal changes in neural struc- covering acute and chronic aortic diseases of the tho- tures to baroreceptor reflex activation. Proc Natl Acad Sci refractory hypertension causing severe hypotension and U S A 2002;99:7816-7. Neurocrit by-day variability in blood pressure measured at home and Care 2008;9:167-76. Effect of nitroprusside on study of sodium nitroprusside use and assessment of regional myocardial blood flow in coronary artery disease. Blood pressure value of the variability in home-measured blood pres- variability and outcome after acute intracerebral haemor- sure and heart rate: the Finn-Home Study. Effects of cysteine on amino metoprolol alone in patients with acute myocardial infarc- acid concentrations and transsulfuration enzyme activi- tion. An estimation of the hepatic blood are alleviated by betaine supplementation in rats. Assessment and man- ment of cerebrovascular diseases with particular agement of blood-pressure variability. Risk factors promoting Principles of Diagnosis and Management in the Adult, 3rd hypertensive crises: evidence from a longitudinal study. Effects of rapid blood pres- olol and labetalol for the treatment of perioperative sure reduction on cerebral blood flow. Impaired baroreflex sensi- tivity predicts outcome of acute intracerebral hemorrhage. A study of regional autoreg- ulation in the cerebral circulation to increased perfusion Rodriguez-Luna D, Pineiro S, Rubiera M, et al. Treatment of acute severe hypertension: current pressure reduction and clinical outcomes in acute intrace- and newer agents. Which one of the following is the best treatment goal intracerebral hemorrhage with 5-mm midline shift. Metoprolol intravenous push every 4 hours Questions 8 and 9 pertain to the following case. A 52-year-old man with no signifcant medical history has a family history signifcant for diabetes and hypertension. Chest radiography is grossly symptoms include signifcant shortness of breath, which is normal. Bedside echocardiography reveals depressed systolic signs include pain 1/10, blood pressure 228/134 mm Hg, heart function, and chest radiography reveals volume over- heart rate 86 beats/minute, respiratory rate 20 breaths/ load. Patient has the diagnosis of chronic hypertension mm Hg (ideally less than 100 mm Hg) within minutes and some part of the medication adherence process C. Esmolol 50-mcg/kg/minute continuous intravenous infectious, that is the underlying trigger for the infusion patient’s emergency. However, there is a lack of evidence-based guidelines to assist in planning the management of affected pregnancies. The purpose of this Good Practice guidance is to provide a summary of current expert opinion as an interim measure, with the hope that these opinions will be supplemented by objective evidence in due course. One-third of these deaths are a result of myocardial infarction/ischaemic heart disease and a similar number of late deaths are associated with peripartum cardiomyopathy. Other significant contributors (5–10% each) are rheumatic heart disease, congenital heart disease and pulmonary hypertension. With the current increase in older mothers, obesity, immigration and survival of babies operated on for congenital heart disease, the need to identify women at risk of heart disease and to plan their careful management will also inevitably increase. Unfortunately, many of these risk factors are becoming increasingly common, and most women affected will be asymptomatic before pregnancy, with no history of heart disease. The key component of good management is therefore a high index of suspicion for myocardial infarction in any pregnant woman presenting with chest pain. All women with chest pain in pregnancy should have an electrocardiogram interpreted by someone who is skilled at detecting signs of cardiac ischaemia and infarction and, if the pain is severe, they should have computerd tomography or a magnetic resonance imaging scan of the chest. It usually presents in late pregnancy or early in the puerperium, but it can occur up to 6 months after delivery. Peripartum cardiomyopathy should be considered in any pregnant or puerperal woman who complains of increasing shortness of breath, especially on lying flat or at night. As 25% of affected women will be hypertensive, it can be confused with pre-eclampsia. All such women should have an electrocardiogram, a chest X-ray and an echocardiogram. Many of these women will never have undergone medical screening and some will be unaware that they have valvular heart disease. This highlights the need for a particularly careful cardiovascular assessment at the beginning of pregnancy of all women not born in a country where there is effective medical screening in childhood, including auscultation of the heart. Mitral valve stenosis (the most common lesion and the one that carries the highest risk) is a difficult clinical diagnosis and there should be a low threshold for echocardiography. Aortic dissection (diagnosed by computed tomography scan) is the most common serious complication of Marfan syndrome. Congenital heart disease is one of the most common congenital abnormalities and the majority of those affected will survive to adulthood, in large part because of the development of effective corrective/palliative surgery over the last 30 years.

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Farquhar discount raloxifene 60 mg free shipping 36 menstrual cycle, Clomiphene and other antioestrogens for ovulation induction in polycystic ovarian syndrome buy 60 mg raloxifene visa women's health nutrition tips. Abd Elaal buy discount raloxifene 60mg women's health center roseville ca, Minimal stimulation or clomiphene citrate as frst-line therapy in women with polycystic ovary syndrome: a randomized controlled trial. Chakravarty, Comparative evaluation of pregnancy outcome in gonadotrophin-clomiphene combination vs clomiphene alone in polycystic ovarian syndrome and unexplained infertility-A prospective clinical trial. Insler, Classifcation of amenorrhoeic states and their treatment by ovulation induction. Ghayaty, Combined metformin-clomiphene in clomiphene-resistant polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials. Grottum, Polycystic ovarian syndrome: a follow-up study on fertility and menstrual pattern in 149 patients 15-25 years after ovarian wedge resection. Scottish Intercollegiate Guidelines Network, Management of obesity: A national clinical guideline. Sleeve Gastrectomy: Balancing the Risks of Surgery with the Benefts of Weight Loss. Kashyap, Bariatric Surgery or Intensive Medical Therapy for Diabetes after 5 Years. Aboulghar, Gonadotrophin-releasing hormone antagonists for assisted conception: a Cochrane review. Prevention and treatment of moderate and severe ovarian hyperstimulation syndrome: a guideline. A randomized controlled trial: effect on hormonal levels and follicular development. Zegers-Hochschild, Addition of neither recombinant nor urinary luteinizing hormone was associated with an improvement in the outcome of autologous in vitro fertilization/ intracytoplasmatic sperm injection cycles under regular clinical settings: a multicenter observational analysis. Balen, Hypothalamic-pituitary, ovarian and adrenal contributions to polycystic ovary syndrome. Coutifaris, In vitro fertilization in the polycystic ovary syndrome patient: an update. Centre for Clinical Effectiveness, Critical Appraisal Templates, Southern Health, Editor. The Royal Australian College of General Practitioners, Clinical guideline for the diagnosis and management of early rheumatoid arthritis. National Health and Medical Research Council, Clinical practice guideline for the prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to Australian hospitals. Category 3 ■ Yes ■ No 10 Do you have high blood 6 Has anyone noticed that you quit breathing pressure? Final result: 2 or more positive categories indicates a high Scoring categories: likelihood of sleep disordered Category 1 is positive with 2 or more positive responses to questions 2-6 ■ breathing. Adverse effect An adverse event for which the causal relation between the drug/intervention and the event is at least a reasonable possibility. Aerobic exercise/activity Any physical activity that produces energy by combining oxygen with blood glucose or body fat. Algorithm A fow chart of the clinical decision pathway described in the guideline, where recommendations are presented in boxes, linked with arrows. Anovulation A condition in which the ovary does not produce and release an egg each menstrual cycle. Anxiety When fears or thoughts that are chronic (constant) and distressing interfere with daily living. Assess In this guideline, assess refers to the process of identifying the severity of the condition Blood pressure Blood pressure is the pressure of the blood in the arteries as it is pumped around the body by the heart. Body image the way a person may feel, think and view their body including their appearance. Clinical impact the potential beneft from application of the recommendations in the guideline on the treatment or treatment outcomes of the target population. Clinical question One of a set of questions about an intervention or process that defne the content (guideline development) of the evidence reviews and subsequent recommendations in the guideline. Clomiphene citrate sensitive When the patient is able to ovulate and conceive with clomiphene citrate treatment. Cochrane review Cochrane Reviews are systematic summaries of evidence of the effects of healthcare interventions. Cochrane Reviews are prepared using Review Manager (RevMan) software provided by the Collaboration, and adhere to a structured format that is described in the Cochrane Handbook for Systematic Reviews of Interventions. Co-morbidity the presence of one or more diseases or conditions other than those of primary interest. In a study looking at treatment for one disease or condition, some of the individuals may have other diseases or conditions that could affect their outcomes. Confdence interval A range of values for an unknown population parameter with a stated ‘confdence’ (conventionally 95%) that it contains the true value. The interval is calculated from sample data, and generally straddles the sample estimate. The ‘confdence’ value means that if the method used to calculate the interval is repeated many times, then that proportion of intervals will actually contain the true value. Congenital adrenal Congenital adrenal hyperplasia is a condition where the enzyme needed by the hyperplasia adrenal gland to make the hormones cortisol and aldosterone is lacking and thus the body produces more androgen and causes male characteristics to appear early or inappropriately. Consensus methods Techniques that aim to reach an agreement on a particular issue. Formal consensus methods include Delphi and nominal group techniques, and consensus development conferences. In the development of clinical guidelines, consensus methods may be used where there is a lack of strong research evidence on a particular topic. Expert consensus methods will aim to reach agreement between experts in a particular feld.

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Older patients tend to acquire tears over time order raloxifene women's health yearly check up, without any inciting event or with relatively mild trauma purchase raloxifene 60 mg womens health hotline, during performance of usual activities purchase raloxifene master card menstruation 2 weeks apart. The type of tear may help determine whether it is more likely degenerative or traumatic in nature. While osteoarthritis is the more common name for this entity, osteoarthrosis is more technically precise since there is no classic inflammation. These latter disorders are non-occupational and are not included in this discussion. Thinning of the cartilage in the knee joint may lead to pain with movement and stiffness. A minority of cases occur after discrete significant trauma, most commonly fractures. Regular participation in programs stressing aquatic or gentle aerobic Copyright 2016 Reed Group, Ltd. Weight loss also is thought to be strongly indicated for patients who are either overweight or obese. The advantage of selective Cox-2 inhibitors is their lower risks of gastrointestinal side effects. Highly selected patients may be candidates for judicious use of low doses of opioids if this results in functional improvement. Osteoarthrosis: Role of Invasive Procedures Invasive procedures are not indicated in the management of most osteoarthrosis patients unless the condition is unable to be satisfactorily controlled with other non-invasive treatments. In such cases, intraarticular injections with glucocorticosteroid and viscosupplementation are sometimes utilized. In advanced cases, joint replacements and other surgical procedures are often performed. Osteochondritis dissecans most commonly occurs in teenagers, although it can occur in adults. Consequently, osteochondritis dissecans will not be addressed further in this guideline. The condition is painless at early stages, but when it advances, patients generally present with pain and limitation of motion. This condition most commonly affects the head of the femur, but it can affect any bone. Pain in the lower extremity is usually exacerbated by weight bearing and relieved with rest. Management of knee osteonecrosis is extrapolated from quality evidence for treatment of osteonecrosis of the head of the femur (see Hip and Groin Disorders guideline). Pain from dislocation is usually severe and associated with an inability to use the limb. Individuals with a congenital or inherited tendency to dislocate have usually dislocated their patella prior to reaching an employable age. The patella may dislocate with lesser force or stress over time, and recurrences are quite common. The patella may then be prone to recurrent dislocation after the initial dislocation, and a subjective feeling of instability may result. Some of these patients are thought to have degenerative joint disease that is focused on that aspect of the knee joint, although they may also have degenerative changes in other parts of the knee joint. Some patients may have muscle weakness that is present in one part of the quadriceps . When pain arises from arthrosis in the patellofemoral joint then treatment is comparable to other arthrosis reviewed above. However, when there is evidence of quadriceps muscle weakness, specific strengthening exercises for that muscle are usually prescribed. They are treated with surgical repair and rehabilitation; partial tears may be treated non-operatively. In some cases involving less trauma, rupture is believed to occur because of prior injury and weakness. Complete tears of the anterior cruciate ligament are usually surgically reconstructed, although non-surgical treatment with rehabilitation may be attempted. Complete tears of the posterior cruciate are usually treated with exercise, although sometimes they are treated surgically. By definition, these are high force injuries and may occur during sports, accidents, trips, slips or falls. The medial collateral ligament may be accompanied by a medial meniscal tear due to shared fibers in these two anatomical parts. Isolated complete tears of the medial collateral ligament are usually treated non-operatively. The following is a general summary of the recommendations contained in this guideline: Evaluation and Diagnostic Issues  the knee should be carefully evaluated with a history, physical examination, and focused diagnostic testing. A complete physical exam is recommended, since pain can be referred, particularly from the back or hip to the knee joint. The threshold for additional x-rays, particularly of the back and hip, should be low and may be indicated in certain situations. However, most knee arthrosis patients, particularly those without severe disease, do not require arthroplasty. Occupational Issues  Aside from knee fracture patients in whom prolonged time away from work is often required, or stress fracture patients in whom significant restrictions to limit forceful activity and weight bearing may be recommended, patients should be encouraged to return to normal activity or work as soon as possible. However, the more these activities are reduced, the greater the time generally required to rehabilitate the patient. However, results should be interpreted with caution, as patients’ efforts might be submaximal because of pain.

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If the difference between them is higher than 20 mmHg a final assessment is performed by using an invasive pressure catheter order raloxifene 60 mg mastercard menopause gastro symptoms, inserted in the aorta in order to measure pressure difference at systolic peak between the aortic arch and the descending aorta order discount raloxifene line menopause vaginal odor. Doppler Eco-cardiography is frequently used for assessing peak velocity effective 60mg raloxifene menopause yeast infection, helpful for estimating pressure drop across the narrowed section. With the latter, the narrowed section is surgically removed and replaced with a patch. Value of the simulation data – significance and importance Simulation can provide details of pressure distribution at systole. High pressure at the ascending aorta, indicates significant occlusion, with resultant adverse pressure distribution along the vessel. Simulation data about pressure distributions can allow the cardiologist to make a judgement about the need for intervention. The future – implications of the simulation for the clinic Pressure information that informs clinical judgement is the main outcome of the simulation. This is not only relevant to native coarctation patients but also to patients that show a recurrent coarctation that has been repaired with either a stent or a patch. Acute aortic rupture or inadequate perfusion may cause a patient to become unconscious. Uncomplicated Type-B dissections, instead, are treated medically to reduce and control the blood pressure and heart rate. In the specific case analysed there was no critical pressure differential between the lumina. Simulations can help the clinicians in the planning of the surgical or endovascular treatment – they can be used to virtually simulate different interventional strategies before performing them on the actual patient. The future – implications of the simulation for the clinic the simulations could be used to support the clinical-decision making process, with two possible ways to do this. Firstly, for complex cases, simulations can be used for the virtual planning of the intervention on a patient-specific basis. Up to 50% of the medically treated dissections currently develop late-term complications that are difficult to be fixed in the chronic phase. This example highlights design/development/testing of a medically relevant device for clinical scanners that image flow. Preamble the fluid dynamics of the cardiovascular system are complicated, involving complex flow patterns, such as turbulence, vortices, jets etc. Diagnosis of cardiovascular diseases informed by flow, requires effective interpretation of complex flows acquired by medical imaging systems. Satisfactory imaging performance can only be assured if adequate validation has been performed against known reference flows, but in the domain of the cardiovascular circulation, such representative flows are not readily obtained. The flow inherent to a vortex ring was chosen as the candidate flow for such a device because it offers a degree of complexity similar to physiological flows but also demonstrates stable, predictable, reproducible and controllable behaviour. Fluid Dynamics the ring vortex is a toroidal fluid structure that is comprised of an annular vortex core, surrounded by a vortex atmosphere, the whole of which propagates along the direction of the ring axis. This is a common phenomenon, considered to be a fundamental flow in fluid dynamics. It possesses vorticity in which fluid particles move in circular paths within the toroidal volume. Inside the vortex atmosphere the fluid circulates along closed streamlines encompassing the toroidal core while interaction of the ring vortex structure as a whole with the remainder of the fluid is similar to that of flow past a corresponding solid body. The vortex ring has several characteristics that make it valuable as a reference flow for a flow phantom, since it is stable and can be controlled. By generating the ring in various ways, it can be produced in a range of sizes, travelling at distinct velocities. The behaviour of the ring vortex can be mathematically described by solution of the Navier-Stokes equation, and this is amenable to analytical solution under highly idealised conditions. This provides a reference by which to compare the interpretation of flows as measured by a clinical scanner. From the above description, the complexities of the fluid dynamics are readily apparent, and so it becomes a challenge to understand and communicate this 3D fluid phenomenon, exposing the features described above. Screenshots of numerical results do not do it justice, whereas interactive 3D visualisation yields a much improved appreciation of the intricacies of the flow. The 3D representation clarifies the composition of the ring vortex, which is important for both device design and testing. This is relevant to interpretation of the flow structure obtained by clinical imaging systems, which are configured to capture the passage of the ring vortex as it passes through the scanner’s field of view. Figure 10: the ring vortex is a toroidal structure composed of an annular vortex core, encompassed by a boundary that defines the vortex atmosphere. Use of the ring vortex flow as a calibration standard for the imaging community has been promoted through demonstration and presentation at conferences (and broader events) and through peer reviewed publication. This enables the non-specialist to readily grasp and appreciate the phantom concept. Its application in the sphere of ultrasound flow quantification is already beginning to highlight interesting facets relevant to the performance of such flow imaging technology. Furthermore, recent advancements in quantitative flow Ultrasound, are beginning to produce enhanced visualization of complex cardiovascular flow structures which frequently exploit sophisticated post-processing algorithms for particle velocimetry tracking and waveform analysis. This has already been identified as an important area for validation, and is readily addressed by the ring vortex phantom – this promises a rich relationship between scanner design and phantom validation in the future. Acceptance of the technology also brings new methods for recalibration of diagnostic flow quantification imaging technologies and protocols, with longer term implications for improved best practice and improved diagnostic accuracy. Furthermore this has implications for teaching, since it is already influencing undergraduate work at the University of Sheffield (eg.


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