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Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolao

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Non-invasive diagnostic tools in the field of head and neck oncology : A liquid biopsy for head and neck cancers

The development of a liquid biopsy for head and neck cancers via  ScienceDirect Publication: Oral Oncology Publication ...

Τρίτη, 22 Νοεμβρίου 2016

The "True Triangle" in cleft lip repair: A novel technique

The "True Triangle" in cleft lip repair: A novel technique: Abdullah I Al Atel



Saudi Journal of Oral Sciences 2014 1(2):114-116



The aim of this short communication is to describe the True Triangle (TT) technique for the repair of unilateral cleft lip (CL). A total of 309 patients were operated using the TT technique. The final cleft lip repair results showed positive outcomes. Conclusion: This technique may overcome some of the drawbacks of the previously described surgical techniques used for CL repair.




Given the complex nature of cleft lip (CL) and the esthetic and functional characteristics associated with its repair, new surgical techniques may bring small changes in the CL repair. [1] This short communication describes the use of a "true triangle" for the surgical repair of CL.

This technique practiced in the last 6 years in the Oral and Maxillofacial Surgery Department at Prince Sultan Military Medical City, Riyadh, Saudi Arabia. A total of 309 patients were operated using the True Triangle (TT) technique (Al- Atel Technique) to repair the CL; the final cleft lip repair results showed positive outcomes.


  The True Triangle Cleft Lip Repair Technique (Al Atel Technique) Top


Surgical markings

The technique uses 24 unique surgical points and in keeping with other techniques these points are marked on the patient using methylene blue [Figure 1]. The points can be described as those on the medial lip (non-cleft side). Nasal floor, and medial lip (non-cleft side)
Figure 1: Surgical anatomical points of the flap design for the TT technique

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  • (Point 1) base of columella
  • (Point 2) at lip-collumella crease
  • (Point 3) at lip-collumella crease to mirror (point 2) relation to (point 1)
  • (Point 4) at mid of philtrum (tubercle), near the vermillion cutaneous junction
  • (Point 5) at peak of cupids bow
  • (Point 6) at peak of cupids bow, mirror point 5 relation to point 4 and 1 mm above the vermillion cutaneous junction
  • (Point 7) is 2 mm superior to (Point 6) and forms the base of triangle at non-cleft side
  • (Point 8) is the apex of the triangle as points 6, 7, and 8 form a triangle with 2 mm base
  • (Point 9) is 1 mm below the vermillion cutaneous junction and forms the base of triangle with point 11
  • Points 6 and 9 form a line perpendicular to the vermillion cutaneous junction and pass through the peaks of the cupids bow
  • (Point 10) at mid of vermillion form apex of triangle with points 9 and 11
  • (Point 11) at the vermillion mucus junction
  • (Point 12) commissure of non cleft side


Nasal floor (Non-cleft side)

  • (Point 13) at sub alare medial side
  • (Point 14) at sub alare lateral side, on the curve of the alar-lip junction


Lateral lip (Cleft side)

  • (Point 15) at sub-alare lateral side, on the curve of alar-lip junction
  • (Point 16) at sub-alare medial side
  • The distance between points 2 and 13 (nasal sell at non-cleft side) equal the distance between points 3 and 16 (nasal sell at cleft side)
  • (Point 17) medial tip of advancement flap
  • (Point 18) peak of cupids bow at cleft side (1 mm above the white roll )
  • (Point 19) is 2 mm superior to point 18 and forms with point 18 the base of the triangle
  • (Point 20) apex of the triangle
  • (Point 21) is 1 mm below vermillion cutaneous junction
  • (Point 22) midpoint of vermillion forming the apex of the triangle, base is formed by points 21, 23
  • (Point 23) vermillion mucus junction
  • (Point 24) commissure cleft side


The distance between points 5 and 12 (peak of cupids bow and commissure at non-cleft side) equals the distance between points 24 and 18 (peak of cupids bow and commissure at cleft side).

Surgical technique

While a detailed description of the surgical technique is beyond the scope of this short communication the technique utilizes marking skin and subcutaneous incisions, incision of the orbicularis oris muscle, tip rhinoplasty, closure of the nasal layer of the alveolar cleft, and location of the nasal floors followed by closure of the orbicularis oris muscle and skin closure. This is then followed by mucosal closure and finally active placement of the alar base and placement of the nasal sell. The repair diagrams for the rectangular shape of philtrum [Figure 2]a and shield type of philtrum [Figure 2]b are shown in this communication. At the time of preparation of this communication, 309 patients had been operated on using this technique. The pre and post-operative pictures are shown below [Figure 3]a-f. The detailed outcome as well as patient and parent satisfaction from the technique are beyond the scope of this communication.
Figure 2: (a) The True Triangle lip repair diagramming in the case of rectangular shape of philtrum where the cutback (the arrow) is used. (b) The True Triangle lip repair diagramming in the case of Shield type of philtrum where the rotation part (the arrow) is used

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Figure 3: (a) Right CL pre-operative. (b) Same patient one month post operative CL repair with TT CL repair technique. (c) Same patient Three months post operative. (d) Six months post operative, CL repair with TT CL repair technique. (e) One year post operative. (f) One year post operatively, notice the nostril near symmetrical result

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  Discussion Top


This technique is a combination of Millard [2] or Mohler [3] technique, depending on the philtrum shape of the non-affected side of the cleft, in addition to creating a modified true triangle used by Noordhoff. [4] 

The purpose of using the rotation flap is to get the lengthening effect. The back cut is used to get the lengthening effect advocated by Mohler [3] , and it is used in rectangular-shape philtrums. The back cut and its associated lengthening effect has also been previously used by Randall. [5]

The two true triangles drawn at medial and lateral side of the cleft are placed 1 mm above the vermillion border to avoid the resultant irregular white roll which could result when the triangle is placed at the vermillion border. The triangle at the medial side of the cleft where the triangle base is 2 mm or less to avoid the obvious notching or discrepancy effect noted in Millard's technique [2] corrected by Thompson [6] and Fisher. [7] The triangle is directed toward the collemella, unlike Fisher (2005) where the triangle is directed medially in a horizontal direction. [7] 

This technique may overcome some of the drawbacks of the previously described surgical techniques used for CL repair.

 
  References Top

1.Atack NE, Hathorn IS, Semb G, Dowell T, Sandy JR. A new index for assessing surgical outcome in unilateral cleft lip and palate subjects aged five: Reproducibility and validity. Cleft Palate Craniofac J 1997;34:242-6.  Back to cited text no. 1
    
2.Millard DR Jr. A primary camouflage in the unilateral harelook. In Transactions of the International Congress of Plastic Surgeons. Baltimore, MD, Williams & Wilkins; 1957. p. 160.  Back to cited text no. 2
    
3.Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg 1987;80:511-5.  Back to cited text no. 3
    
4.Noordhoff MS, Chen YR, Chen KT, et al. The surgical technique for the complete unilateral cleft lip-nasal deformity. Operat Tech Plast Reconstr Surg 1995;2:167-74.  Back to cited text no. 4
    
5.Randall P. A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull 1959;23:331-47.  Back to cited text no. 5
    
6.Thomson HG. Unilateral cleft lip repair. Oper Tech Plast Reconstr Surg 1995;2:175-81.  Back to cited text no. 6
    
7.Fisher DM. Unilateral cleft lip repair: An anatomical subunit approximation technique. Plast Reconstr Surg 2005;116:61-71.  Back to cited text no. 7
    


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Below is an alphabetical list of the educational picture slideshows available on eMedicineHealth. Each slideshow covers a medical or health topic and includes images, illustrations, or pictures and summary information discussing the topic. Scroll through each slide by clicking on the Next button. At the end of each slideshow you'll find links to additional related information on the topic.


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Tinnitus

1. Chadha NK, Gordon KA, James AL, Papsin BC. Tinnitus is prevalent in children with cochlear implants. International Journal of Pediatric Otorhinolaryngology. 2009;73:671-675. [abstract]

2. Akdogan O, Ozcan I, Ozbek C, Dere H. Tinnitus after cochlear implantation. Auris Nasus Larynx. 2009;36:210-212. [abstract]

3. Pan T, Tyler RS, Ji H, Coelho C, Gehringer AK, Gogel SA. Changes in the tinnitus handicap questionnaire after cochlear implantation. American Journal of Audiology. 2009;18:144-151. [abstract]

4. Andersson G, Freijd A, Baguley DM, Idrizbegovic E. Tinnitus distress, anxiety, depression, and hearing problems among cochlear implant patients with tinnitus. Journal of the American Academy of Audiology. 2009;20:315-319. [abstract]

5. Rothholtz VS, Tang Q, Wu EC, Fine EL, Djalilian H, Zeng F-G. Exploring the parametric space of tinnitus suppression in a patient with a cochlear implant. Laryngoscope. 2009;119.

6. Di NW, Cianfrone F, Scorpecci A, Cantore I, Giannantonio S, Paludetti G. Transtympanic electrical stimulation for immediate and long-term tinnitus suppression. International Tinnitus Journal. 2009;15:100-106.[abstract]

7. Litre CF, Theret E, Tran H et al. Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus. Brain Stimulation. 2009;2:132-137. [abstract]

8. Evans RW, Ishiyama G. Migraine with transient unilateral hearing loss and tinnitus. Headache: The Journal of Head & Face Pain. 2009;49:756-759. [abstract]

9. Pirodda A, Brandolini C, Raimondi MC, Ferri GG, Borghi C. Tinnitus as a warning for preventing vasovagal syncope. Medical Hypotheses. 2009;73:370-371. [abstract]

10. Anderson JE, Teitel D, Wu YW. Venous hum causing tinnitus: case report and review of the literature. Clinical Pediatrics. 2009;48:87-89. [abstract]

11. Liess BD, Lollar KW, Christiansen SG, Vaslow D. Pulsatile tinnitus: a harbinger of a greater ill? Head & Neck. 2009;31:269-273. [abstract]

12. Singh DP, Forte AJ, Brewer MB, Nowygrod R. Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus. Journal of Vascular Surgery. 2009;50:183-185. [abstract]

13. Delgado F, Munoz F, Bravo-Rodriguez F, Jurado-Ramos A, Oteros R. Treatment of dural arteriovenous fistulas presenting as pulsatile tinnitus. Otology and Neurotology. 2009;30:897-902. [abstract]

14. Cowley PO, Jones R, Tuch P, McAuliffe W. Pulsatile tinnitus from reversal of flow in an aberrant occipital artery: Resolved after carotid artery stenting. American Journal of Neuroradiology. 2009;30:995-997. [abstract]

15. Stimmer H, Borrmann A, Loer C, Arnold W, Rummeny EJ. Monaural tinnitus from a contralateral inferior colliculus hemorrhage. Audiology & Neurotology. 2009;14:35-38. [abstract]

16. Latifpour DH, Grenner J, Sjodahl C. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. International Tinnitus Journal. 2009;15:94-99. [abstract]

17. Department of Health. Provision of services for adults with tinnitus: a good practice guide. 2009. [full text]

18. DH. Tinnitus Map of Medicine care pathway. 2010. [Full text]

19. BTA. Tinnitus: guidelines for primary care. 2010. [Full text]

20. Schneider P, Andermann M, Wengenroth M et al. Reduced volume of Heschl's gyrus in tinnitus. NeuroImage. 2009;45:927-939. [abstract]

21. Landgrebe M, Langguth B, Rosengarth K et al. Structural brain changes in tinnitus: grey matter decrease in auditory and non-auditory brain areas. NeuroImage. 2009;46:213-218. [abstract]

22. Melcher JR, Levine RA, Bergevin C, Norris B. The auditory midbrain of people with tinnitus: Abnormal sound-evoked activity revisited. Hearing Research. 2009;257:63-74. [abstract]

23. Lanting CP, de KE, van DP. Neural activity underlying tinnitus generation: Results from PET and fMRI. Hearing Research. 2009;255:1-13. [abstract]

24. Kaltenbach JA. Insights on the origins of tinnitus: an overview of recent research. Hearing Journal. 2009;62:26-31. [Full text]

25. Shulman A, Goldstein B, Strashun AM. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. International Tinnitus Journal. 2009;15:5-50. [abstract]

26. Schutte NS, Noble W, Malouff JM, Bhullar N. Evaluation of a model of distress related to tinnitus. International Journal of Audiology. 2009;48:428-432. [abstract]

27. Hesser H, Pereswetoff-Morath CE, Andersson G. Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology. 2009;54:381-390.[abstract]

28. Argstatter H, Krick C, Bolay HV. Music therapy for chronic tinnitus. Heidelberg treatment model. Psychotherapeut. 2009;54:17-26. [abstract]

29. Lugli M, Romani R, Ponzi S, Bacciu S, Parmigiani S. The windowed sound therapy: A new empirical approach for an effective personalized treatment of tinnitus. International Tinnitus Journal. 2009;15:51-61.[abstract]

30. Langguth B, Salvi R, Elgoyhen AB. Emerging pharmacotherapy of tinnitus. Expert Opinion on Emerging Drugs. 2009;14:687-702. [abstract]

31. Campbell KCM. Emerging pharmacologic treatments for hearing loss and tinnitus. ASHA Leader. 2009;14:14-18. [Full text]

32. Hesser H, Westin V, Hayes SC, Andersson G. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress. Behaviour Research & Therapy. 2009;47:523-528. [abstract]

33. Hesser H, Andersson G. The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. International Journal of Audiology. 2009;48:295-299. [abstract]

34. Shulman A, Goldstein B. Subjective idiopathic tinnitus and palliative care: a plan for diagnosis and treatment. Otolaryngologic Clinics of North America. 2009;42:15-38. [abstract]

35. Forti S, Costanzo S, Crocetti A, Pignataro L, Del BL, Ambrosetti U. Are results of tinnitus retraining therapy maintained over time? 18-month follow-up after completion of therapy. Audiology & Neuro-Otology. 2009;14:286-289. [abstract]

36. Bessman P, Heider T, Watten VP, Watten RG. The tinnitus intensive therapy habituation program: a 2-year follow-up pilot study on subjective tinnitus. Rehabilitation Psychology. 2009;54:133-138. [abstract]

37. Gudex C, Skellgaard PH, West T, Sorensen J. Effectiveness of a tinnitus management programme: A 2-year follow-up study. BMC Ear, Nose and Throat Disorders. 2009;9. [Full text]

38. Henry J, Zaugg T, Myers P, Kendall C, Turbin M. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health. 2009;11:33-48. [abstract]

1. Hazell JW, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol. 1990;19:1-5. [Abstract]

2. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol. 2000 Mar;11(3):162-77. [Abstract]

3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

4. Cannon SC Pathomechanisms in channelopathies of skeletal muscle and brain. Annu Rev Neurosci. 2006;29:387-415. [Abstract]

5. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audiol. 1994;28:125-129. [Abstract]

6. Baguley DM, Jones S, Wilkins I, Axon PR, Moffat DA. The inhibitory effect of intravenous lidocaine infusion on tinnitus after translabyrinthine removal of vestibular schwannoma: a double-blind, placebo-controlled, crossover study. Otol Neurotol. 2005;26:169-176. [Abstract]

Eggermont JJ. Cortical tonotopic map reorganization and its implications for treatment of tinnitus. Acta Otolaryngol Suppl. 2006;9-12. [Abstract]

Hoke ES, Muhlnickel W, Ross B, Hoke M. Tinnitus and event-related activity of the auditory cortex. Audiol Neurootol. 1998;3:300-331. [Abstract]

Mirz F, Pedersen B, Ishizu K et al. Positron emission tomography of cortical centers of tinnitus. Hear Res. 1999;134:133-144. [Abstract]

Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95:10340-10343. [Abstract]

Norena AJ, Eggermont JJ. Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus. Neuroreport. 2006;17:559-563. [Abstract]

Schlee W, Hartmann T, Langguth B, Weisz N. Abnormal resting-state cortical coupling in chronic tinnitus. BMC Neurosci. 2009;10:11. [Full text]

Schlee W, Mueller N, Hartmann T, Keil J, Lorenz I, Weisz N. Mapping cortical hubs in tinnitus. BMC Biol. 2009;7:80. [Full text]

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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