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The most common cause of secondary hypertension in children is renal parenchymal disease (60%–80%) often the result of reflux nephropathy erectile dysfunction dx code discount kamagra oral jelly 100mg amex, pyelonephritis and obstructive uropathy erectile dysfunction inventory of treatment satisfaction questionnaire order kamagra oral jelly cheap online. Renovascular hypertension (8%–10%) and coarctation of the aorta (2%) are less frequent erectile dysfunction treatment after prostatectomy discount kamagra oral jelly online american express. The long-term significance of blood pressure readings above the 95th percentile in an asymptomatic child remains uncertain erectile dysfunction testosterone injections order kamagra oral jelly with american express, since tracking of blood pressure as children grow older does not tend to be persistent. The positive predictive value of a blood pressure reading above the 95th percentile in a 10-year old body being at a hypertensive level at age 20 years is only 0. Nonetheless hypertensive children, as defined above, should be given a limited investigation for target organ damage and secondary causes. If these tests are negative, the children should be carefully monitored and given non-pharmacological therapy. Those with severe hypertension (levels above the 99th percentile) should be rapidly and completely evaluated and given appropriate pharmacological therapy. The elderly [46,47,48] About 55% of men and women aged 65–74 years have hypertension. Chronic renal disease or atherosclerotic renovascular disease are likely to be found. The elderly achieve even greater reductions in coronary disease and heart failure by effective therapy than younger hypertensives. The elderly may display two features that reflect age-related cardiovascular changes. Evaluation of hypertensive patients 45 • Pseudo-hypertension from markedly sclerotic arteries that do not collapse under the cuff, presenting much higher cuff pressures than are present within the vessels. If the arteries feel rigid but there are few retinal or cardiac findings to go along with marked hypertension, direct intra-arterial measurements may be needed before therapy. Women Women have lower systolic blood pressure levels than men during early adulthood while the opposite is true after the sixth decade of life. Diastolic blood pressure tends to be just marginally lower in women than men regardless of age. However, after the fifth decade of life, the incidence of hypertension increases more rapidly in women than men and the prevalence of hypertension in women is that in men during the sixth decade of life [49]. The effect of menopause on blood pressure is controversial, but postmenopausal women are more than twice as likely to have hypertension as premenopausal women. This may be attributed to estrogen withdrawal, overproduction of pituitary hormones, weight gain or a combination of other as yet undefined neurohormonal influences [50]. The effect of postmenopausal hormone replacement therapy on blood pressure is likely to be modest. All hypertensive women treated with hormone replacement therapy should have their blood pressure monitored closely at first and then at 6-month intervals. Patients with diabetes mellitus [51,52,53,54,55] the association of diabetes mellitus and hypertension is more than that predicted by chance. About 50% of type 1 patients and 80% of type 2 diabetes mellitus have hypertension. The development of hypertension increases all the microvascular and macrovascular complications of diabetes. The absence of nocturnal fall in blood pressure may reflect autonomic neuropathy or incipient diabetic nephropathy. When hypertensive, patients with diabetes mellitus may confront the following unusual problems [56,57,58]. In the Eastern Mediterranean Region, there has been a recent rapid increase in the prevalence of diabetes, particularly type 2. The prevalence rate in adults varies between 7% and 25% with an estimated 17 million people affected. Many countries in the Region are now reporting the onset of type 2 diabetes at an increasingly younger age, and in some countries type 2 is emerging in children. This might be related to the significant social and economic changes in the Region with rising rates of obesity, smoking and sedentary lifestyle [2]. Metabolic syndrome [59,60,61] Metabolic syndrome refers to a constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidaemia and insulin resistance. The National Cholesterol Education Program [62] defines the syndrome by the presence of three or more of the five risk factors given in Box 4. The prevalence of the condition is highly age dependent and is associated in men with a 4-fold increase in risk for fatal coronary artery disease and a 2-fold greater risk of cerebrovascular disease and all-cause mortality. The cornerstone of treatment is appropriate lifestyle changes but if blood pressure exceeds 140/90 mmHg pharmacological therapy is indicated. Associated impaired glucose tolerance, diabetes and lipid abnormalities are managed according to standard guidelines. The index of suspicion should be high in any hypertensive patient whose body mass index exceeds 27 kg/m2. The impact of sleep apnoea on the cardiovascular system is probably related in large part to its association with elevated blood pressure. Episodes of apnoea with repeated oxygen desaturation have been shown to stimulate strong sympathetic nervous system discharges that directly elevate blood pressure. Other contributory factors for hypertension include the commonly associated obesity, impaired glucose tolerance and sleep deprivation. Other cardiovascular conditions associated with obstructive sleep apnoea include arrhythmias, myocardial ischaemia and failure and stroke. Renal transplantation [3] the prevalence of hypertension in patients receiving kidney allografts probably exceeds 65%. Nocturnal hypertension, a reversal of diurnal blood pressure rhythm, can present in renal transplant patients and they may need ambulatory blood pressure monitoring to evaluate overall blood pressure control. The mechanisms of hypertension in transplant patients are multifactorial and include vasoconstriction and structural vascular changes induced by calcineurin-inhibiting immunosuppression drugs (cyclosporine and tacrolimus), effect of steroid therapy, impairment of renal function that leads to salt and water retention and the occasional development of renal artery stenosis. Perioperative hypertension [7,66,67] Perioperative hypertension is defined as the presence of high blood pressure immediately before, during or after surgery that may require some attention to minimize risk to the patient. This situation may be encountered as a result of: • previously unrecognized hypertension • recognized but uncontrolled hypertension • effect of stress and pain • failure to take oral medications in the immediate post-surgical period. Treatment of hypertension Goals of therapy [3,5,68,69] the ultimate goal in treatment of the hypertensive patient is to achieve the maximum reduction in the long-term total risk of cardiovascular morbidity and mortality. This requires: • treatment of all reversible risk factors identified including smoking, dyslipidaemia and diabetes mellitus; • appropriate management of associated clinical conditions such as congestive heart failure, coronary artery disease, peripheral vascular disease and transient ischaemic attacks; • achieving office blood pressure values <130/80 mmHg for patients with diabetes mellitus or chronic renal disease. When home or ambulatory pressure measurements are used to evaluate the efficacy of treatment, daytime values around 10–15 mmHg lower for systolic blood pressure and 5–10 mmHg lower for diastolic blood pressure are the goal values. Because most patients with hypertension, especially those aged 50 years, will reach the diastolic blood pressure goal once the systolic blood pressure is at goal, the primary focus should be on achieving systolic blood pressure goal. Treating systolic and diastolic blood pressure to target is associated with a decrease in cardiovascular complications. This includes 35%–40% mean reduction in stroke incidence, 20%–25% mean reduction in myocardial infarction and >50% mean reduction in heart failure. There are several strategies for achieving therapeutic goals: lifestyle modifications, pharmacological modifications and general strategies for hypertensive therapy. Lifestyle modifications Adoption of healthy lifestyles by all individuals is critical in the prevention of high blood pressure and an indispensable part of the management of those with hypertension. Lifestyle modifications decrease blood pressure, enhance antihypertensive drug efficacy and decrease cardiovascular risk. Patients with prehypertension and no compelling indication (including heart failure, prior myocardial infarction or stroke, high coronary risk status, diabetes mellitus, chronic renal disease) respond well to lifestyle modifications and usually do not need drug therapy. For all other abnormal blood pressure categories, drug therapy is indicated if goal blood pressure is not achieved by lifestyle modification alone. Treatment of hypertension 50 Clinical guidelines for the management of hypertension Table 6. Cessation of smoking [70,71,72] this is probably the single most powerful lifestyle measure for the prevention of non-cardiovascular and cardiovascular diseases, including stroke and coronary heart disease. Although any independent chronic effect of smoking on blood pressure is small and smoking cessation does not lower blood pressure, total cardiovascular risk is greatly increased by smoking. In addition, smoking may interfere with the beneficial effects of some antihypertensive agents such as adrenergic blockers. When necessary, nicotine replacement or buspirone therapies should be considered since they appear to be safe in hypertension and to facilitate smoking cessation. Attainment of ideal body weight is by no means necessary to produce lower blood pressure. Many hypertensive patients have much more than 10 kg of excess adiposity and many of them would no longer be hypertensive if they lost even this amount of body fat.

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Since the late 1980s impotence young males purchase cheapest kamagra oral jelly, both rates have remained tracking erectile dysfunction juicing purchase kamagra oral jelly 100 mg overnight delivery, and the school environment play a signi relatively stable (Kaufman & colleagues impotence cures buy kamagra oral jelly amex, 2001) erectile dysfunction treatments that work 100 mg kamagra oral jelly with mastercard. Student grade retention is associated with 1970s, it would seem logical to assume that the prob continued academic struggles, increased behavioral lem is being adequately addressed. Students who have been western states, dropout rates remain higher than in retained are three times as likely to drop out of school, other areas of the country. Students coming from low and the likelihood of dropping out increases with income families are still significantly more likely to multiple retentions. The dropout rates for African Educational tracking (grouping students based on American and white youths have decreased, and academic ability) also influences dropping out. Demands They are less likely to take college preparatory classes for higher academic standards in our high schools, and more likely to drop out of high school. Finally, the increased competition in the workplace, and an school environment also has a significant influence. For increase in the number of minority students (who are students who are at risk for dropping out, school is more likely than their peers to drop out) maintain often perceived as an unwelcoming place. According to Eckstrom and colleagues (1986), vidual student and for society as a whole. Dropouts dropouts have fewer study aids in their homes, have generally have low-level academic skills, difficulty less opportunity for non-school learning, are less finding employment and an adequate income, and less likely to have both parents living at home, have chance of receiving additional education that may be mothers who have less formal education and who are necessary to remain competitive in the job market more likely to be working, and have parents who are (Rumberger, 1987). They are also less likely to vote less involved in their child’s school experience. Additionally, Protective Factors; Retention and Promotion; School individuals who drop out of school are more likely Refusal; Self-Concept and Efficacy; Substance Abuse; Suspension to commit a crime and to live in poverty (Blackorby & colleagues, 1991). A look at the problem of high school dropout multifaceted; therefore, there is not a simple, one among students with mild handicaps. Teachers College Record, 87, school—the means for reaching this goal are not 356–373. School dropout rates: Are we sure they are understand how to support student persistence. Dropout a multitude of levels, integrating services in ways that rates in the United States, 2000: Statistical analysis are tailored to individual needs. Consequences of dropping out of school: Findings • Identifying at-risk students early from high school and beyond. Students are more likely to stay in school if they experience academic success and are reinforced for school attendance. While there is a growing understanding of both used for clinical, research, and educational purposes. The relative infancy of this classification sys school dropouts becomes increasingly urgent. It was developed as a variant of the “Mental Childhood, or Adolescence with criteria available for Disorders” section of the sixth edition of the World more than 40 mental health diagnoses. However, few changes were made to improve diagnostic decision making within a comprehensive the specificity of diagnostic definitions as narrative evaluation to guide treatment planning and deve descriptions of symptoms remained. Axis I: Clinical Disorders and Other Conditions Impairment” or “Learning Disabilities. Axis V: Global Assessment of Functioning this manual to improve understanding of children’s social–emotional behavior in an effort to ultimately this system helps to capture the complexity of create learning environments that meet the child’s mental health conditions and the diversity of contexts mental health and academic needs. Because of the extensive multimethod assessment framework within this classi research that was generated by the diagnostic criteria fication system. In order to meet diagnostic definitions, symptoms A three-stage evidence-based process involving and behaviors must typically persist across time and thorough literature reviews, reanalyses of extant data impair the functioning of the individual. Carlson and schools an avenue for resolving disputes and com See also Individuals With Disabilities Education Act plaints. The diagnostic and In addition to an impartial due-process hearing, statistical manual of mental disorders (2nd ed. The diagnostic and Mediation is available whenever a hearing is reques statistical manual of mental disorders (3rd ed. Due process is the fundamental principles of justice as opposed to a specific rule of law. Whenever a 178———Dyslexia complaint has been received, the parents involved time with parents before educational planning meetings have an opportunity for an impartial due-process to explain procedures and evaluation results so that hearing or mediation. When possible, unless the parents agree otherwise, the child involved the number of people at meetings should be limited in the dispute will remain in his or her current educa so that parents don’t feel overwhelmed (recommend tional placement. Another suggestion is to encourage parents to At least five business days prior to a hearing, each visit the program for the child so that parents can see party shall disclose to all other parties the evaluations more correctly what is being offered. It is also impor and recommendations that they intend to use at the tant to follow up with families that do not sign or do hearing. Any party to a hearing shall be accorded the not return signed educational plans, and find out why. The decision made in a hearing is final, except the most important role of the school psychologist that any parties involved in such hearings may appeal in due-process hearings is as an expert witness. If appealed, this preparing for the due-process hearing, the expert wit agency will conduct an impartial review of the deci ness needs to meet with the lawyer at least 1 week sion and will make an independent decision. Any before testimony and ask what the testimony will be party who does not have the right to an appeal and about, what questions will be asked, what questions any party aggrieved by the findings and decision has should be asked, and what testimony the other witnesses the right to bring a civil action with respect to the going to give. The first is to design in-service training programs to help staff learn to work more Dyslexia occurs as a result of deficits in under effectively with parents, become less defensive in standing speech sounds, and therefore results in prob responding to parental inquiries and complaints, and lems with accurate and fluent word recognition, poor become more skilled at respecting parents’ opinions. The disorder is often character and alert others in the system to potential problems. It has An important consideration is that staff and adminis been described as “an unexpected difficulty learning trators should become sensitized to parents’ anger to read despite having all the factors necessary to and learn not to take parents’ anger and frustration read–good thinking and reasoning skills and the abil personally, and if parents are angry, to include other ity to think creatively” (Campbell, 2003, p. These professionals outside the evaluation team to talk with children frequently have aural/oral, cognitive, fine them. Another suggestion is for staff to spend more motor, and executive functions that are normally Dyslexia———179 developed. Their cognitive abilities are often in able to learn by affecting cognitive, language, and the average to above average range (International other skills (Berninger, 2001). However, children and A common belief is that people with dyslexia read adults with dyslexia may also have specific impair and write letters backwards. A study investigating ments in other academic skills like writing and math letter orientation confusion in children with reading (Berninger, 2001). In early grade school, children may have quently than average readers in reception and difficulty reading words in isolation, make consistent production tasks, but this is not the sole problem or spelling errors such as letter reversals, rely on guess determinant of dyslexia (Terepocki & colleagues, 2002). As students reach middle for the diagnosis of dyslexia makes it difficult to deter school, they are often reading below grade level. They mine an exact prevalence of the learning disability may demonstrate difficulties, such as reversing letter (Padget, 1998). Dyslexia occurs fairly equally among sequences; be slow to learn prefixes, suffixes, and root males and females, and among different ethnic and words; may have trouble with word problems in math; socioeconomic backgrounds (International Dyslexia and may have difficulties with recall of facts and com Association, 2003). Some signs of the disorder may continue order have an increased risk of later having a reading to occur throughout the life span. Phonological culties with planning and organization can afflict disorders are manifested by errors in sound production, those with dyslexia from elementary school through use, representation, or substitutions and omissions of adulthood. As children, they may reading disorder are at an increased risk of having other have difficulty acquiring vocabulary, which results in disorders. For example, approximately 50% of those an inadequate vocabulary as they enter high school diagnosed with a learning or reading disorder have also and go on to college or careers. In middle school, high been diagnosed with attention deficit hyperactivity dis school, and into adulthood, the person may avoid writ order (International Dyslexia Association, 2003). They also may One fourth of all children with dyslexia have try to hide their reading disability or avoid written a parent who also has the disability. As adults, people with two parents that have the disability are at a greater risk dyslexia often work well below their intellectual for dyslexia (Berninger, 2001). Therefore it is important to culties and failures children with dyslexia experience, remember that when one refers to dyslexia they may which cause them to doubt their intelligence and be referring to any degree of reading difficulties. Phonological training investigated by a French neurologist, Dejerine, in should begin while the child is in kindergarten 1891. The use of functional brain imaging investiga (International Dyslexia Association, 2003).

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Acute coronary syndrome symptoms may include: tightness erectile dysfunction qof 100 mg kamagra oral jelly sale, pressure erectile dysfunction pills cheap purchase kamagra oral jelly 100mg with amex, heaviness otc erectile dysfunction pills walgreens buy cheap kamagra oral jelly line, fullness or squeezing in the chest which may spread to erectile dysfunction treatment center kamagra oral jelly 100 mg amex the neck and throat, jaw, shoulders, the back, upper abdomen, either or both arms and even into the wrists and hands dyspnoea, nausea/vomiting, cold sweat or syncope. Comments: the clinical, electrocardiogram and biochemical characteristics are important to enable early risk stratification. Source and reference attributes Submitting organisation: Acute coronary syndrome data working group Origin: National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand. Generally, external cause, place of occurrence and activity codes will be included in the string of additional diagnosis codes. Additional diagnoses give information on the conditions that are significant in terms of treatment required, investigations needed and resources used during the episode of care. Collection methods: An additional diagnosis should be recorded and coded where appropriate upon separation of an episode of admitted patient care or the end of an episode of residential care or attendance at a health care establishment. The additional diagnosis is derived from and must be substantiated by clinical documentation. Additional diagnoses are significant for the allocation of Australian Refined Diagnosis Related Groups. The allocation of patient to major problem or complication and co-morbidity Diagnosis Related Groups is made on the basis of the presence of certain specified additional diagnoses. Additional diagnoses should be recorded when relevant to the patient’s episode of care and not restricted by the number of fields on the morbidity form or computer screen. External cause codes, although not diagnosis of condition codes, should be sequenced together with the additional diagnosis codes so that meaning is given to the data for use in injury surveillance and other monitoring activities. Suburb/town/locality, Postcode—Australian, Australian state/territory, and Country, forms a complete geographical/physical address of a person. Data Element Concept: Person (address)—address line Value domain attributes Representational attributes Representation class: Text Data type: String Format: [X(180)] Maximum character length: 180 Data element attributes Collection and usage attributes Guide for use: A high-level address component is defined as a broad geographical area that is capable of containing more than one specific physical location. Some examples of a broad geographical area are: Suburb, town or locality Postcode—Australian or international State, Territory, local government area, electorate, statistical local area Postal delivery point identifier Countries, provinces, etc other than in Australia these components of a complete address do not form part of the Address line. When addressing an Australian location, following are the standard address data elements that may be concatenated in the Address line: Building/complex sub-unit type Building/complex sub-unit number 51 Building/property name Floor/level number Floor/level type House/property number Lot/section number Street name Street type code Street suffix code One complete identification/description of a location/site of an address can comprise one or more than one instance of address line. Instances of address lines are commonly identified in electronic information systems as Address-line 1, Address-line 2, etc. The format of data collection is less important than consistent use of conventions in the recording of address data. Where Address line is collected as a stand-alone item, software may be used to parse the Address line details to separate the sub components. Collection methods: the following concatenation rules should be observed when collecting address lines addressing an Australian location. Data Element Concept: Service provider organisation (address)—address line Value domain attributes Representational attributes Representation class: Text Data type: String Format: [X(180)] Maximum character length: 180 Data element attributes Collection and usage attributes Guide for use: A high-level address component is defined as a broad geographical area that is capable of containing more than one specific physical location. Some examples of a broad geographical area are: Suburb, town or locality Postcode Australian or international State, Territory, local government area, electorate, statistical local area Postal delivery point identifier Countries, provinces, etc. When addressing an Australian location, following are the standard address data elements that may be concatenated in the Address line: Building/complex sub-unit type Building/complex sub-unit number Building/property name Floor/level number 54 Floor/level type House/property number Lot/section number Street name Street type code Street suffix code One complete identification/description of a location/site of an address can comprise one or more than one instance of address line. Hence, address may be collected in an unstructured manner but should ideally be stored in a structured format. Where Address line is collected as a stand-alone item, software may be used to parse the Address line details to separate the sub-components. Data element attributes Collection and usage attributes Guide for use: A single address may have multiple address types associated with it. Collection methods: At least one address must be recorded (this may be an unknown Address type). Health care establishments should always attempt to collect the residential address of a person who is a health care client when a service is provided. Overseas address: For individuals record the overseas address as the residential address and record a temporary accommodation address as their contact address in Australia. Comments: ‘No fixed address’ is coded as unknown because it (the concept) is not a type of address for a person but is an attribute of the person only i. It is not recommended that an implementation collects this attribute as an address type. A person not having a fixed address constrains the number of address types that can be collected i. However, if it is imperative that this occurs, it is suggested that code 9 be used. When recording the address for a health care provider or organisation, the business address should always be collected. In addition, other addresses may also need to be recorded for individuals and organisations. Data element attributes Collection and usage attributes Collection methods: Collect the data at the 4-digit level. Source and reference attributes Reference documents: Standard Australian Classification of Countries Edition 2, Catalogue number 1269. Data Element Concept: Administrative health region—region name Value domain attributes Representational attributes Representation class: Text Data type: String Format: [A(80)] Maximum character length: 80 Data element attributes Collection and usage attributes Guide for use: Administrative health regions are determined by the relevant state or territory. Data Element Concept: Administrative health region—palliative care strategic plan indicator Value domain attributes Representational attributes Representation class: Code Data type: Boolean Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Yes 2 No Data element attributes Collection and usage attributes Guide for use: A palliative care strategic plan may be an entire health region’s plan, or an aggregation of the region’s sub-units’ plans. The plan may be specifically for palliative care or a general health service plan that includes palliative care elements. The palliative care elements in the plan must include all of the following aspects: timeframe (the beginning and end-date in years), with a minimum time period of two years to demonstrate a strategic focus measurable objectives relating to: service access, quality, utilisation, responsiveness and evaluation demonstrated stakeholder involvement in plan development, such as the inclusion of a description of the consultation process in the strategic plan document demonstrated links with the National Palliative Care Strategy 65 implementation strategies (can include resources identified for service delivery) evidence of ongoing development in subsequent plans. A strategic plan typically has a mission statement, outlines a vision, values and strategies, and includes goals and objectives. A strategic plan may: serve as a framework for decisions; provide a basis for more detailed planning; explain the business to others in order to inform, motivate and involve; assist benchmarking and performance monitoring; stimulate change and become a building block for next plan. The plan will ideally address both palliative care at the specialist level and palliative care at the primary care. Data Element Concept: Episode of admitted patient care—patient election status Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Public 2 Private Collection and usage attributes Guide for use: Public patient: A person, eligible for Medicare, who receives or elects to receive a public hospital service free of charge. Includes: patients in public psychiatric hospitals who do not have the choice to be treated as a private patient. Also includes overseas visitors who are covered by a reciprocal health care agreement, and who elect to be treated as public patients. Private patient: A person who elects to be treated as a private patient and elects to be responsible for paying fees for the type referred to in clause 49 of the Australian Health Care Agreements (2003–2008). Clause 49 states that: Private patients, compensable patients and ineligible persons may be charged an amount for public hospital services as determined by (the state or territory). All patients in private hospitals (other than those receiving public hospital services and electing to be treated as a public patient) are private patients. Includes: all patients who are charged (regardless of the level of the charge) or for whom a charge is raised for a third party payer (for example, Department of Veterans’ Affairs and Compensable patients). Also includes patients who are Medicare ineligible and 71 receive public hospital services free of charge at the discretion of the hospital, and prisoners, who are Medicare ineligible while incarcerated. Data element attributes Collection and usage attributes Guide for use: Australian Health Care Agreements 2003–08 state that eligible persons are to be given the choice to receive, free of charge as public patients, health and emergency services. At the time of, or as soon as practicable after, admission for a public hospital service, the patient must elect in writing to be treated as either a public patient or a private patient this item is independent of the patient’s hospital insurance status and room type. Notes: Inability to sign: In cases where the patient is unable to complete the patient election form, the patient should be assumed to be a public patient. Compensation funding decisions: A patient may be recorded as a public patient as an interim patient election status while the patient’s compensable status is being decided. Inter-hospital contracted care: If the patient receives inter hospital contracted care the following guidelines can be used if no further information is available: If the patient received contracted care that was purchased by a public hospital then it will be assumed that they elected to be treated as a public patient. Context: Age is a core data element in a wide range of social, labour and demographic statistics. It is used in the analyses of service utilisation by age group and can be used as an assistance eligibility criterion.

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