pediagenosis: Organ
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Showing posts with label Organ. Show all posts

Tuesday, September 21, 2021

Motility of Small Intestine

Motility of Small Intestine

Motility of Small Intestine

MOTILITY AND DYSMOTILITY OF SMALL INTESTINE
MOTILITY AND DYSMOTILITY OF SMALL INTESTINE


The digestive status (fed versus fasting) is a key component of small bowel motility. Fasting small intestinal motility follows four cyclic phases, referred to as the migratory motor complex. The migratory motor complex consists of waves of electrical activity that sweep through the intestine every 90 to 120 minutes. In addition to facilitating the transport of indigestible substances from the stomach to the colon, the migratory motor complex also transports bacteria from the small intestine to the large intestine and inhibits the reflux of colonic bacteria to the terminal ileum. It has thereby been termed the “intestinal housekeeper.”

Lymph Drainage of Small Intestine

Lymph Drainage of Small Intestine

Lymph Drainage of Small Intestine

Lymph Drainage of Small Intestine


The lymph vessels of the small intestine begin with the central lacteals of the villi. At the base of the villi, each central lacteal joins with lymph capillaries, draining the nearby intestinal crypts. These lymph capillaries form a fine network within the lamina propria, in which the first lymphatic valves are already encountered. Many minute branches emerge from this network, penetrating through the muscularis mucosae into the submucosa, which hosts a sizable network of lymphatic vessels. The vessels of this network have conspicuous valves that prevent retrograde motion of the lymphatic fluid once it is inside the vessels. Progressively larger lymph vessels, receiving additional lymph from the layers of the muscularis mucosae and from the serosa and subserosa, pass toward the attachment of the mesentery to the small intestine. Within the mesentery, the lymph vessels travel alongside arteries and veins. These larger lymph vessels have been referred to as chyliferous vessels or lacteals because they transport emulsified fat absorbed from the intestines and appear as milky-white threads after the ingestion of fat-containing food. Lymph fluid traveling through these vessels encounters several juxtaintestinal (within the mesentery, alongside the intestines) superior mesenteric lymph nodes, which number some 100 to 200 and constitute the largest aggregate of lymph nodes in the body. They increase in number and size toward the root of the mesentery. In the root of the mesentery, larger lymphatic branches are situated, which lead into the central group of superior mesenteric nodes in the area where the superior mesenteric artery arises from the aorta.

Blood Supply of Small Intestine

Blood Supply of Small Intestine

Blood Supply of Small Intestine

Blood Supply of Small Intestine


For the typical pattern of arterial branching of the small intestines, please refer to Plates 1-1 and 1-2. In this section, we will describe the variations concerning the origin, course, anastomoses, and distribution of the vessels supplying the small intestine. These variations are so frequent that conventional textbook descriptions are inadequate for anyone attempting procedures in the area. Typically, the superior mesenteric artery supplies almost all of the small intestine aside from the proximal duodenum, which receives blood from the supraduodenal and superior pancreaticoduodenal arteries. These arteries are branches of the gastroduodenal artery, a branch of the common hepatic artery, which is itself a branch of the celiac trunk.

Structure of Small Intestine

Structure of Small Intestine

Structure of Small Intestine

MUCOSA AND MUSCULATURE OF DUODENUM
MUCOSA AND MUSCULATURE OF DUODENUM


The freely mobile portion of the small intestine, which is attached to the mesentery, extends from the duodenojejunal flexure to the ileocolic orifice, where the small intestine joins the large intestine. This portion of the small intestine consists of the jejunum and the ileum. They run imperceptibly into each other, the transition being marked by a gradual change in the diameter of the lumen and by several structural alterations.

Topography and Relations of Small Bowel

Topography and Relations of Small Bowel

Topography and Relations of Small Bowel

Topography and Relations of Small Bowel


The small intestine consists of a retroperitoneal portion, the duodenum, and a mesenteric portion made up of the coils of the jejunum and ileum. The total length of the mesenteric portion of the small intestine varies considerably. The average for adults is roughly 5 m. The proximal jejunum forms approximately two fifths of the mesenteric portion, and the ileum forms the remaining three fifths. The jejunum commences at the duodenojejunal flexure on the left side of the second lumbar vertebra or, occasionally, somewhat more cranially. The ileum terminates when it joins the large intestine in the right iliac fossa. Although the division between the jejunum and ileum is not grossly visible (the appearance of the arteries and histologic structure can be used to distinguish the two regions), the coils of the jejunum tend to be on the superior left side of the abdomen and those of the ileum on the inferior right side.

Development of Small Intestine

Development of Small Intestine

Development of Small Intestine

Development of Small Intestine


The small intestine includes the duodenum, jejunum, and ileum. During development of the gastrointestinal system, the duodenum comes from the distal portion of the foregut, whereas the jejunum and ileum come entirely from the midgut. The duodenum moves to the right of the midline as the stomach rotates and shifts to the left side of the abdomen during weeks 4 to 6 of fetal life. As development proceeds, the common bile duct moves to the posterior side of the gut tube as the stomach rotates and the liver enlarges. One aspect of duodenal development that is clinically important is that during weeks 5 and 6, the epithelial lining of the duodenum, derived from the endoderm, proliferates to the point that it completely blocks the lumen of the duodenum. However, the lumen of the duodenum typically recanalizes so that the fetus can begin swallowing amniotic fluid. If the lumen of the duodenum does not recanalize or opens incompletely, duodenal atresia or stenosis will occur. As a region of gut that links the foregut and midgut, the duodenum is supplied by branches of both the celiac and superior mesenteric arteries. The descending and horizontal portions of the duodenum are the regions where this anastomosis occurs, and these are also the regions in which atresia or stenosis is most likely to be manifested.

Physiology of Gastroenteric Stomas

Physiology of Gastroenteric Stomas

Physiology of Gastroenteric Stomas

Physiology of Gastroenteric Stomas


Creation of a well-constructed ostomy by a highly skilled surgeon at the site of an anastomosis or as a cutaneous stoma that preserves normal digestive functions can result in an excellent quality of life for a patient undergoing resection of portions of the digestive system. Technical risks associated with the creation of any stoma include anastomotic leak, dehiscence, and stricture. The size of the anastomosis varies with the organs involved and the desired outcome of the procedure, but it is important to note that while stricture-related closure is always a risk, larger stomas are not always better. Cutaneous ostomies have an additional risk of prolapse, bleeding, and peristomal ulceration. Evaluation of ostomy function and anatomy may require skilled radiologic assessment with barium studies, CT studies, or endoscopy, or a combination of these studies. Endoscopic evaluation also provides the potential for therapeutic interventions to correct stomal problems, including dilatation and placement of self-expanding stents.

Abdominal Wounds: Blast Injuries

Abdominal Wounds: Blast Injuries

Abdominal Wounds: Blast Injuries

Abdominal Wounds: Blast Injuries


Abdominal wounds and blunt trauma are common acute injuries encountered in emergency settings. The depth and severity of a penetrating wound cannot be determined by history or physical examination alone. After stabilizing the airway, breathing and circulation, emergency cross-sectional imaging is essential as the operating room is being prepared and surgical expertise recruited. Broad-spectrum intravenous antibiotics should be hung on admission as the patient is prepped for operation. If extensive intraabdominal bleeding is occurring, laparotomy should be done as early as possible. Exploration must be thorough, and all perforations must be closed. Diversion of the fecal stream is often advised when there has been peritoneal soiling. In extensive damage, resection is necessary. In addition to customary preoperative and postoperative measures, oxygen, continuous gastroduodenal suction, multiple drains, and broad-spectrum antibiotic therapy are essential.

Cancer of Peritoneum

Cancer of Peritoneum

Cancer of Peritoneum

Cancer of Peritoneum


Primary malignant tumors of the peritoneum (meso-theliomas or endotheliomas) are rare, but secondary malignant tumors are relatively common. Tumor cell spread into the peritoneum occurs by direct extension, hematogenous spread, or lymphatic spread. Once the peritoneum has been invaded, dissemination of malignant cells throughout the peritoneal cavity and implantation diffusely throughout the peritoneal surfaces can occur rapidly. Epithelial primary carcinomas commonly metastasize to the peritoneum (e.g., adenocarcinomas of the stomach, intestine, ovaries, and, less commonly, lung and breast). Melanomas also frequently metastasize to the digestive system, including the mesentery. Malignant neoplasms of the retroperitoneal connective, nervous, or muscular tissue, as well as sarcomas and teratomas, although rare, invade the peritoneum or become metastasized within it.

Chronic Peritonitis

Chronic Peritonitis

Chronic Peritonitis

Chronic Peritonitis


Tuberculous peritonitis can occur at any age but is seen more commonly in young adults and children, patients undergoing dialysis, or immunocompromised patients such as those with acquired immunodeficiency syndrome. It is practically always secondary to some other focus in the body, the most frequent sources of infection being tuberculous lesions in the bowel, mesenteric glands, and fallopian tubes. In the course of general miliary tuberculosis, the tuberculous peritonitis may occur as an acute infection; much more commonly, however, it appears as a chronic condition that manifests itself in one of two main forms: (1) exudative or moist and (2) plastic or dry. In the first variety, the exudation is marked and the abdominal cavity becomes filled with a thin ascitic fluid; numerous tubercles, about the size of a pinhead or larger, appear on the peritoneal surfaces. In the second variety, the exudate is dense and rich in fibrin, formation of adhesions occurs most readily, and the viscera become matted together; the peritoneum is studded with tubercles, which, however, may be covered by deposits of fibrin; the omentum is often greatly thickened and rolled up. Caseous necrosis of tuberculous lesions may lead to formation of fistulous tracts. The two varieties may occur together, giving rise to the so-called encysted or encapsulated form characterized by loculated collections of fluid encysted by the dense adhesions.

Monday, September 20, 2021

TRAUMA

TRAUMA

TRAUMA

TRAUMA


Nonobstetric lacerations of the vaginal wall or introitus are most often the result of sexual trauma (consensual or otherwise). This may occur from intercourse (80%), saddle or water-skiing injury, sexual assault, or penetration by foreign objects. A rape injury, in particular, may be a potentially serious one, because it is often associated with psychological trauma (rape trauma syndrome), damage to adjacent vital organs, and even surgical shock. This is especially true when the injury occurs in a child. Inspection of the vestibule and vagina in such a case often reveals a jagged laceration, which has ruptured the hymen, torn the labia minora, and extended down the perineum toward the anus. Usually, the external genitalia are also badly damaged, with contusions and abrasions as far as the medial surfaces of the thighs. In more severely traumatized victims, the tears may compromise the integrity of the urethra, bladder, and rectum or breach the peritoneum. Such individuals may be brought into the hospital in a state of profound shock requiring immediate blood and fluid replacement before definitive surgical treatment can be instituted. In adults, common sites of lacerations are the vaginal wall, the lateral fornices, and the cul-de-sac. Rape injuries are dangerous in elderly, postmenopausal women who, because of vulvar and vaginal atrophy and the attendant increased fragility of the vaginal wall, are predisposed to more extensive damage. In younger women, the trauma to the vagina from rape is usually not so grave, although during pregnancy and in the immediate post-partum period, the tissues are vascular, delicate, and liable to injury.

TOXIC SHOCK SYNDROME

TOXIC SHOCK SYNDROME

TOXIC SHOCK SYNDROME

Toxic shock syndrome (TSS) is an uncommon, potentially life-threatening condition caused by toxins produced by an infection with Staphylococcus aureus. Toxic shock syndrome is rare, being seen in only 1 to 2/100,000 women 15 to 44 years old (last active surveillance done in 1987).

TOXIC SHOCK SYNDROME


Toxic shock syndrome requires infection by S. aureus and is associated with the use of super-absorbency tampons, or prolonged use of regular tampons, or barrier contraceptive devices. Although most commonly associated with prolonged tampon use, about 10% of TSS cases are associated with other conditions, including postoperative staphylococcal wound infections and nonsurgical focal infections. Postpartum cases (including transmission to the neonate) have been reported. Even the use of laminaria to dilate the cervix has been reported to be associated with rare cases. Overall, the prevalence of toxic shock syndrome appears to have declined with newer menstrual hygiene products and awareness of more appropriate use patterns.

VAGINITIS III—CHEMICAL, TRAUMATIC

VAGINITIS III—CHEMICAL, TRAUMATIC

VAGINITIS III—CHEMICAL, TRAUMATIC

VAGINITIS III—CHEMICAL, TRAUMATIC


Some vaginal inflammations, in addition to those due to direct bacterial invasion, are caused by the ill-advised introduction of foreign objects or substances. Vaginal douches and solutions have been used for a variety of gynecologic conditions, and an incalculable number of proprietary douche powders or fluids have been devised to alleviate or cure different types of real or perceived disturbances. Although it is doubtful that the brief contact of the vaginal epithelium with the materials contained in a commercial douche produces a salutary effect other than a cleansing one, the practice continues to be widespread. When homemade solutions or other agents are used, the risk is increased. The danger of such a procedure is the possibility of producing a chemical burn, with marked redness, swelling, and ulceration of the vaginal walls. Under these circumstances, a purulent exudate soon appears, and the patient suffers from intense local pain. Such accidents were particularly perilous when, during early pregnancy, various solutions were used to induce abortion. Even with the availability of elective pregnancy terminations, cases of this nature are still encountered. If the immediate damage has not been too severe, the inflammation may subside spontaneously or with mild palliative therapy, but if a necrotizing drug has been applied, adhesions may form that scar or occlude the vagina and cause dyspareunia.

VAGINITIS II—VENEREAL INFECTIONS

VAGINITIS II—VENEREAL INFECTIONS

VAGINITIS II—VENEREAL INFECTIONS

VAGINITIS II—VENEREAL INFECTIONS


In clinical practice an occasional case is seen in which the differential diagnosis of a lesion in the lower genital tract involves the exclusion of syphilis. In the female, primary lesions occur more often on the external genitalia and less frequently in the vagina or on the cervix. If in the vagina, a chancre is most likely to be near the vestibule, with no predilection for anterior, posterior, or lateral walls. It has the characteristic raised, indurated border surrounding a shallow ulceration. Because the disease is often in the lower third of the vagina, associated inguinal lymphadenopathy may be present. Although routine serologic tests are frequently negative at this stage, dark-field examination should lead to the proper diagnosis, and a biopsy can rule out other granulomas, carcinoma, or various infections. The mucous patches of late syphilis also occur in the vagina as well as on the external genitalia. They are white, vesicular lesions, which may coalesce and break down to form shallow ulcers and are not to be confused with the firm, raised condylomata lata, which are also late manifestations of syphilis. At this stage, a positive serologic test should indicate the probable diagnosis; a dark-field examination of scrapings is usually positive for Treponema pallidum. The Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR) tests are good screening tests and the fluorescent treponemal antibody absorption or microhemagglutination T. pal-lidum tests are specific treponemal antibody tests that are confirmatory or diagnostic. Screening for HIV infection should also be strongly considered.

VAGINITIS I—TRICHOMONAS, MONILIA, BACTERIAL VAGINOSIS

VAGINITIS I—TRICHOMONAS, MONILIA, BACTERIAL VAGINOSIS

VAGINITIS I—TRICHOMONAS, MONILIA, BACTERIAL VAGINOSIS

VAGINITIS I—TRICHOMONAS, MONILIA, BACTERIAL VAGINOSIS


The vaginal flora has many different types of bacteria, some of which, like lactobacilli, are necessary for normal vaginal metabolism and for maintenance of the vaginal pH at the normal level of 3.8 to 4.2. Also present in numbers, which may be altered by such conditions as age, debility, systemic disease, ovulation, menstruation, and pregnancy are a variety of potentially pathogenic organisms. Among these are streptococci, staphylococci, colon bacilli, and fungi.

IMPERFORATE HYMEN, HEMATOCOLPOS, FIBROUS HYMEN

IMPERFORATE HYMEN, HEMATOCOLPOS, FIBROUS HYMEN

IMPERFORATE HYMEN, HEMATOCOLPOS, FIBROUS HYMEN

IMPERFORATE HYMEN, HEMATOCOLPOS, FIBROUS HYMEN


An imperforate hymen is the most commonly encountered anomaly resulting from abnormalities in the development or canalization of the müllerian ducts. It is caused by failure of the endoderm of the urogenital sinus and the epithelium of the vaginal vestibule to fuse and perforate during embryonic development. In addition to primary amenorrhea and coital dysfunction, an imperforate hymen may also be associated with endometriosis, vaginal adenosis, infertility, chronic pelvic pain, long-term sexual dysfunction, and hematocolpos. The hymen, located at the junction of the vagina and the vestibule, is the product of the combined embryo- logic fusion of the urogenital sinus and the müllerian ducts. As the urogenital sinus advances upward like a diverticulum from the outside, it envelops the column of müllerian cells, which has already moved nearly four-fifths of the distance from the cervix down to the vestibule. The infoldings of the sinus at the point of union form the lateral walls of the hymen, but the posterior or dorsal portion is a composite of sinus cells externally and müllerian cells internally. The superficial epithelium of the hymen, as of the vagina and cervical portio vaginalis, is derived entirely from the epithelium of the urogenital sinus, which pushes up the vaginal tube and undergoes differentiation into the stratified squamous layer. The opening of the vagina may occur independently of the formation of the hymen.

CONGENITAL ANOMALIES

CONGENITAL ANOMALIES

CONGENITAL ANOMALIES

CONGENITAL ANOMALIES


The müllerian ducts first appear between the seventh and eighth weeks of embryonic life as invaginations of the coelomic epithelium overlying the genital folds. These ducts migrate caudally in the developing embryo, cross toward the midline, and fuse to form the anlage of the uterus, cervix, and upper three-quarters of the vagina. The unfused, cranial portions of the müllerian ducts develop into the fallopian tubes. The caudal fused column of cells moves further downward to join the urogenital sinus, which pushes in from the perineal surface. With the sloughing of the internal core of the cell column to form the vagina, the process is completed in 5 to 6 weeks, although full differentiation takes several weeks longer.

The majority of congenital anomalies of the uterus and vagina are caused by a failure of the müllerian ducts to fuse completely or to develop after fusion. The most extreme anomaly results from complete lack of union of the ducts as a result of inhibition in growth at a very early stage. (The HOX genes have been shown to play key roles in body patterning and organogenesis, and in particular during genital tract development.) The result of this failure of fusion in the adult is the complete absence of the uterus and vagina, but with a normal ovary (because it is derived from a different embryonic source). The fallopian tube may be well developed or rudimentary. The tube is connected near the midline to a small bulb of fibrous tissue attached anteriorly to the bladder peritoneum and posteriorly to the peritoneum of the rectosigmoid. This bulb, which has its counterpart on the opposite side, represents the abortive attempt to form a uterus and may occasionally contain an endometrial lining. Because the vagina is absent, drainage of menstrual flow is impossible, and blood is retained within the genital tract or must drain into the peritoneal cavity. The external genitalia and the vaginal vestibule are normally developed, distinguishing this condition from pseudohermaphroditism. Vaginal atresia is often unrecognized until the occurrence of amenorrhea after puberty or dyspareunia after marriage. Above the vestibular dimple, between bladder and rectum, a potential space filled with loose areolar connective tissue may be found, which can be opened surgically. The term Mayer-Rokitansky-Küster-Hauser syndrome is sometimes applied to these cases of vaginal atresia, usually with absent cervix and uterus.

A less extreme degree of failure in müllerian fusion leads to a double vagina. In such instances the ducts have fused incompletely and have progressed independently to maturity. In the perineal view, the longitudinal septum dividing the vaginal compartments extends outward from the vestibule separating the two cervices. A longitudinal section through the vagina shows the appearance of the same anomaly from above, each uterus having its own fallopian tube and ovary, and each theoretically fertile. The partial septate vagina is a milder degree of congenital malformation, which is caused by a failure of the core of solid müllerian epithelium to slough completely at its lowermost portion. The frequent occurrence of vaginal anomalies with other congenital malformations in the genitourinary tract results from their common embryonic heritage. The possibility of associated lesions in the upper urinary tracts should always be investigated.

Incomplete canalization of the müllerian tubercle and sinovaginal bulb can result in a transverse vaginal septum. These patients will have a normal-appearing introitus leading to a foreshortened blind vaginal pouch. After puberty, a large hematocolpos or hematometrium may result from this outflow obstruction. Partial septa have been reported in women exposed in utero to diethylstilbestrol (DES).


VAGINA—CYTOLOGY

VAGINA—CYTOLOGY

VAGINA—CYTOLOGY

VAGINA—CYTOLOGY


The superficial cells of the vaginal epithelium are under the influence of ovarian hormones, changing in character over the course of a woman’s lifetime and the phases of the reproductive cycle. These variations are largely dependent upon the amount of circulating estrogen.

VULVA AND VAGINA HISTOLOGY

VULVA AND VAGINA HISTOLOGY

VULVA AND VAGINA HISTOLOGY

VULVA AND VAGINA HISTOLOGY


The vagina is lined by squamous epithelium and capable of dilation and constriction as a result of the action of its supporting muscles and erectile tissue. The three principal layers are easily recognized in the cross section through the vaginal wall. The epithelial surface is composed of stratified squamous epithelium divided into basal cell, transitional cell, and spinal or prickle cell layers, also referred to as basalis, intraepithelial, and functionalis. The superficial cells contain keratin but normally show no gross cornification in women of reproductive age. The epithelium is slightly thicker than the corresponding structure in the cervix and sends more and larger papillae into the underlying connective tissue, giving the basement membrane an undulating outline. These papillae are more numerous on the posterior wall and near the vaginal orifice. Beneath the epithelium, which has a thickness of 150 to 200 m, a dense connective tissue layer known as the lamina propria is supported by elastic fibers crossing from the epithelium to the underlying muscle. These elastic fibers, here and throughout the pelvis, are critical to pelvic support and function. The lamina propria becomes less dense as it approaches the muscle, and in this area it contains a network of large, thin-walled veins, giving it the appearance of erectile tissue. The smooth muscle beneath this layer is divided into internal circular and external longitudinal groups, the latter being thicker and stronger and continuous with the superficial muscle bundles of the uterus. No dividing membrane or fascia separates these two interlacing muscle groups. The adventitial coat of the vagina is a thin, firm, fibrous layer arising from the visceral or endopelvic fascia. In this fascia and in the connective tissue between it and the muscle runs another large network of veins and, in addition, a rich nerve supply. The Bartholin gland is situated just lateral to the vaginal vestibule and appears in cross section as a collection of small mucus-secreting glands lined by a single layer of columnar epithelial cells with basally placed nuclei. Occasionally, the columnar epithelium is stratified. The small glands tend to be oval and symmetric and are supported in a loose, vascular connective tissue. The main Bartholin duct is lined by columnar epithelium as it runs upward along the side of the vagina, but as it nears its opening in the midportion of the lateral wall of the vestibule, the epithelium takes on the stratified squamous characteristics of the vaginal epithelium. This transition accounts for the fact that malignant tumors of Bartholin gland may be of either the adenomatous or the squamous type.

FEMALE URETHRA

FEMALE URETHRA

FEMALE URETHRA

FEMALE URETHRA


The urethra, situated at the lowest portion of the bladder and passing downward and forward beneath the symphysis, varies from 3 to 5 cm in length and averages about 6 mm in diameter. The angle formed by the internal urethral orifice and the bladder at the bladder neck and surrounded by the intrinsic sphincter is critical to maintaining normal urinary continence; to with-stand the hydrostatic pressure of the bladder, this area is further supported by the fascia and tensing muscles of the pelvic diaphragm. Its mucosal surface is thrown into longitudinal folds by the constricting action of the external supporting structures. The most prominent of these longitudinal folds, situated on the posterior aspect of the urethra, is sometimes referred to as the urethral crest. The endopelvic fascia that covers the bladder is continuous over the entire urethra just below the mucosal layer, and contiguous to it is a thin layer of erectile tissue formed by the cavernous venous plexus. The muscular coats that surround the bladder also cover the urethra but become thinner as it passes down-ward toward the external meatus. The upper two-thirds of the urethra lie behind the symphysis pubis and are referred to as the intrapelvic urethra. It is this portion that passes through the musculofascial attachments forming the interlevator cleft. The perineal portion extends from the superior fascia of the urogenital diaphragm to the meatus. As it passes through the urogenital diaphragm, the urethra is surrounded by the sphincter urethrae membranaceae, the homologue of the muscle of the same name in the male but a far weaker and less important structure. Near the external meatus, the urethra is adjacent to the upper ends of the vestibular bulbs and the surrounding bulbocavernosus muscles. At its meatus, the urethra lies in the anterior vaginal wall between the folds of the labia minora 2 to 3 cm below the clitoris. Along its entire length, but especially in its perineal portion, the urethra is perforated by the openings of numerous small periurethral glands, the homologues of the prostatic ducts in the male.

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