Labelling For maintaining sample identity generic loratadine 10 mg, proper labelling of samples is vital cheap 10mg loratadine, together with preventing loss of readability of labels or their separation from samples buy loratadine 10mg line. Write directly onto sample tubes or keep labels as close to the specimen as possible. Double labelling is advisable, for example, directly label the sample or sample tube and also the bag in which the sample is placed. This helps prevent confusion and possible errors when multiple samples are received at the same laboratory. The most durable tags are those made of soft metal that can be inscribed with a pencil. Waterproof paper can also be used when dealing with specimens from marine environments. Information marked on carcase tags should include: name, address and telephone number of the person submitting the carcase collection site date reference number whether the animal was found dead or euthanised (plus method of euthanasia) brief summary of clinical signs. Tissue samples taken into plastic bottles should be labelled on the outside of the bottle or a piece of masking tape placed around the tube. The label should include: date type of animal from which the sample came the type of tissue reference number. Do not insert tags into bottles or bags with samples as they may contaminate the sample. Preservation of specimens Chill or freeze all specimens depending on the length of time it will take for them to reach a diagnostic laboratory (understanding that chilled is preferable), unless they are chemically fixed, in which case samples can be kept at ambient temperature. Freezing can damage tissue or kill pathogens and hence reduce options for diagnosis. However, if samples must be held for more than a few days they should be frozen on the day of collection to minimise decomposition. Chapter 2, Field manual of wildlife diseases: general field procedures and diseases of birds. Where samples need to be chilled or frozen an understanding of the concept of the ‘cold-chain’ is required. This refers to the need for samples to remain at the desired temperature and not to experience cycles of change (e. The requirements for sample packaging and shipment vary between countries and diagnostic laboratories. It is, therefore, essential to contact the laboratory that will analyse samples to find out any specific shipping requirements as early as possible in the procedure. This will help with processing samples upon their arrival at the laboratory and reduce the risk of sample quality being compromised. Transporting and/or shipping samples must not pose a biosecurity or human health risk. Seek advice from veterinary authorities about safety and regulations for transporting and shipping samples. The most important considerations for successful sample transport and shipment are: prevent cross-contamination between specimens prevent decomposition of the specimen prevent leakage of fluids preserve individual identity of specimens properly label each specimen and the package in which they are sent. Prevent breakage and leakage Isolate individual specimens in their own containers and plastic bags. Protect samples from direct contact with coolants such as dry ice or freezer blocks. Ensure that if any sample breaks or leaks the liquid does not leak to the outside of the package by containing all materials inside plastic bags, or other leak-proof containers, where possible. Containing specimens The plastic bags for containing specimens need to be strong enough to resist being punctured by the materials they hold and those adjacent to them. Polystyrene boxes within cardboard boxes are useful for their insulating and shock absorbing properties. If polystyrene boxes are not available, sheets of this material can be cut to fit inside cardboard boxes with a similar effect (though the package is less leak-proof). The strength of the cardboard box needs to be sufficient for the weight of the package. If hard plastic or metal insulated boxes are used for transport, cardboard boxes around them can be used for protection and to attach labels. It is possible to make ice packs by freezing water inside a plastic bottle that is sealed (not filled completely and taped closed to prevent the top coming off in transit) and then placed in a sealed plastic bag to further prevent leakage. If frozen carcases are being transported they can act as a cool pack for other samples sent in the same container. When using ice packs they should be interspersed between samples to achieve a uniform temperature throughout. When submitting dead fish for post mortem examination they should be wrapped in moist paper to prevent them drying out and then refrigerated but not frozen. Fish decay very quickly but a fish refrigerated soon after death may be held for up to twelve hours before examination and sample fixation. Keeping samples frozen Dry ice (solid carbon dioxide) or in some circumstances liquid nitrogen can be used to ship frozen specimens. The gaseous carbon dioxide given off by dry ice can also damage some disease agents and this must be considered before using it for tissue transport. As the volume of both dry ice and liquid nitrogen expand as they change to gas, specialist containers that allow for this expansion are needed for their transportation. Note: Shipment of formalin, dry ice, liquid nitrogen and alcohol is regulated in many countries and must be cleared with a carrier before shipping. Samples preserved in formalin, other chemical fixative or alcohol can be transported without chilling. Shipping It is important to pack any space within packages with a substance such as newspaper which will prevent movement of containers, act as a shock absorber and may also soak up any potential leakages. Packaging and labelling Packaging and labelling of specimens must conform to the regulations of the country from which the package is sent and also those of the country in which it will be received (if it is being sent to a laboratory in another country). It is important to mark the outside of the package with the required labelling regarding the type of specimen being transferred and where necessary the method of cooling (e. Advice from national authorities about permit requirements must be sought prior to collection and transportation of samples. Carriers Samples should be shipped where possible by carriers that can guarantee 24-hour delivery to the diagnostic laboratory. Where possible arrange for collection of sample packages from the point of origin to avoid delays. When shipping arrangements have been made, contact the diagnostic laboratory to provide them with further details including estimated time of arrival and any shipping reference numbers. Chapter 3, Field manual of wildlife diseases: general field procedures and diseases of birds. Detailed field observations during the course of an outbreak and information about events preceding it, may provide valuable data on which to base a diagnosis and corrective actions. It is important for the information gatherer to keep an open mind about the potential cause of the problem. Some information which may seem irrelevant in the field may become very important when piecing together the events leading up to an outbreak. A thorough chronology of events is key to diagnosis and disease control operations, and is almost impossible to obtain some time after the outbreak has occurred. A key concept is that of explaining to the diagnostician how the affected individuals relate to the whole population at risk. As an example, 100% of the dead animals may be adult males but the population present (i. How to record data It is important to record as much relevant information as possible as soon as events unfold. Photographs and video footage can quickly convey specific information such as land use, landscape, environmental conditions, gross lesions and the appearance of clinical signs in sick animals. Sources of information may include local people, landowners and agencies working in the area preceding or during an outbreak. Information should be passed to the diagnosticians as soon as possible, updating them as appropriate. Which data to collect Checklist 3-3 provides a summary of the information to collect at a suspected outbreak.

However purchase loratadine 10 mg line, students are not required to complete all four levels of one particular foreign language course cheap loratadine 10mg without prescription. However purchase 10mg loratadine amex, in certain cases (for example, the student is repeating his academic year and needs only several units to graduate), the Dean can recommend that the student register for units below the minimum number required. Students need to accumulate only a specific number of the outstanding units for graduation purposes. However if the School wishes to accredit only one course at the diploma level for unit exemption for one course at the degree level, the said course at the diploma level must be equivalent to that at the degree level and carry the same number of units or more. If the student has completed Industrial Training while pursuing the programme of study at the diploma level, he/she must have at least one year’s work experience. In addition, the student should also submit a report on their work performance and the type of work performed. Dean’s List Guidelines (i) Students who achieve academic excellence at the end of a semester will be placed in the Dean’s List. University Courses University courses are offered to students as part of the requirement for graduation. Compulsory (10 units) a) Malay Language 108 b) English Language c) Islamic and Asian Civilisations d) Ethnic Relations 2. Note: To obtain credit units for Bahasa Malaysia courses, a minimum grade of a ’C’ is required. English Language Courses (as compulsory English Language units) The English Language courses offered as University Courses are as follows:- Course Academic School No. English Language Courses (as compulsory English Language/ Option/Skills units) The following courses may be taken as university courses to fulfil the compulsory English Language requirements or as skills/option courses: Course Code/ Academic School No. Students are not allowed to register for more than one foreign language course per semester. They must complete at least two levels of a foreign language course before they are allowed to register for another foreign language course. However, students are not required to complete all four levels of one particular foreign language course. Students who sign up for this package will obtain one (1) extra unit upon graduation. Students taking the minor package have to begin with level 100 and then proceed to the subsequent levels. The wisdom to comfort and counsell all our patients towards well being, peace and harmony regardless of their social status, race and religion. The ability to understand that our profession is sacred, dealing with your most precious gifts of life and intellect. We promise to devote our lives in serving Mankind, poor or rich, literate or illiterate, irrespective of race and religion with patience and tolerance, with virtue and reverence, with knowledge and vigilance, and with Your love in our hearts. If there is any other information that you think should be included in the guidebook, please suggest in the space below. The Statistician 32 (1983) 307-317 © 1983 Institute of Statisticians Measurement in Medicine: the Analysis of Method Comparison Studies† D. The use of correlation, regression and the difference between means is criticized. A simple parametric approach is proposed based on analysis of variance and simple graphical methods. Frequently, however, we cannot regard either method as giving the true value of the quantity being measured. In this case we want to know whether the methods give answers which are, in some sense, comparable. For example, we may wish to see whether a new, cheap and quick method produces answers that agree with those from an established method sufficiently well for clinical purposes. Yet few really answer the question “Do the two methods of measurement agree sufficiently closely? We will restrict our consideration to the comparison of two methods of measuring a continuous variable, although similar problems can arise with categorical variables. Comparison of means Cater (1979) compared two methods of estimating the gestational age of human babies. He divided the babies into three groups: normal birthweight babies, low birthweight pre-term (< 36 weeks gestation) babies, and low birthweight term babies. For each group he compared the mean by each method (using an unspecified test of significance), finding the mean gestational age to be significantly different for pre-term babies but not for the other groups. His criterion of agreement was that the two methods gave the same mean measurement; “the same” appears to stand for “not significantly different”. By his criterion, the greater the measurement error, and hence the less chance of a significant difference, the better. Correlation The favourite approach is to calculate the product-moment correlation coefficient, r, between the two methods of measurement. The correlation coefficient in this case depends on both the variation between individuals (i. In some applications the “true value” will be the subject’s average value over time, and short-term within-subject variation will be part of the measurement error. In others, where we wish to identify changes within subjects, the true value is not assumed constant. The correlation coefficient will therefore partly depend on the choice of subjects. For if the variation between individuals is high compared to the measurement error the correlation will be high, whereas if the variation between individuals is low the correlation will be low. This can be seen if we regard each measurement as the sum of the true value of the measured quantity and the error due to measurement. We have: 2 variance of true values = σT 2 variance of measurement error, method A = σA 2 variance of measurement error, method B = σB In the simplest model errors have expectation zero and are independent of one another and of the true value, so that 2 2 variance of method A = σA + σT 2 2 variance of method B = σB + σT 2 covariance = σT (see appendix) Hence the expected value of the sample correlation coefficient r is 2 σ T ρ = 2 2 2 2 (σ A + σT )(σ B + σT ) 2 2 2 2 2 Clearly ρ is less than one, and it depends only on the relative sizes of σT , σA and σB. If σA and σB 2 are not small compared to σT , the correlation will be small no matter how good the agreement between the two methods. In the extreme case, when we have several pairs of measurements on the same individual, 2 σT = 0 (assuming that there are no temporal changes), and so ρ = 0 no matter how close the agreement is. They concluded that the two methods did not agree because low correlations were found when the range of cardiac output was small, even though other studies covering a wide range of cardiac output had shown high correlations. In fact the result of their analysis may be 308 explained on the statistical grounds discussed above, the expected value of the correlation coefficient being zero. Their conclusion that the methods did not agree was thus wrong - their approach tells us nothing about dye-dilution and impedance cardiography. As already noted, another implication of the expected value of r is that the observed correlation will increase if the between subject variability increases. Diastolic blood pressure varies less between individuals than does systolic pressure, so that we would expect to observe a worse correlation for diastolic pressures when methods are compared in this way. It is not an indication that the methods agree less well for diastolic than for systolic measurements. This table provides another illustration of the effect on the correlation coefficient of variation between individuals. Correlation coefficients between methods of measurement of blood pressure for systolic and diastolic pressures Systolic pressure Diastolic pressure sA sB r sA sB r Laughlin et al. A further point of interest is that even what appears (visually) to be fairly poor agreement can produce fairly high values of the correlation coefficient. They concluded that because the correlation was high and significantly different from zero, agreement was good. However, from their data a baby with a gestational age of 35 weeks by the Robinson method could have been anything between 34 and 39. For two methods which purport to measure the same thing the agreement between them is not close, because what may be a high correlation in other contexts is not high when comparing things that should be highly related anyway. It is unlikely that we would consider totally unrelated quantities as candidates for a method comparison study. The correlation coefficient is not a measure of agreement; it is a measure of association. At the extreme, when measurement error is very small and correlations correspondingly high, it becomes difficult to interpret differences. It is difficult to imagine another context in which it were thought possible to improve materially on a correlation of 0. Regression Linear regression is another misused technique in method comparison studies.

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However buy loratadine 10mg low cost, the rash may come and go for days or even weeks purchase 10 mg loratadine fast delivery, when the person is exposed to sunlight or heat buy loratadine 10mg line. However, children with sickle cell anemia, chronic anemia, or a weakened immune system may become seriously ill and require medical care when infected with parvovirus B19. People can also become infected by touching these secretions and then touching their mouth, eyes, or nose. Wash hands thoroughly with soap and warm running water after touching secretions from the nose or mouth. If you do not know whether you are immune (have had fifth disease in the past), call your healthcare provider for advice and whether a blood test is needed. About 50% of women have already had fifth disease (are immune), so they and their babies are not at risk. Even if a woman is susceptible and gets infected with parvovirus B19, she usually experiences only mild illness. Likewise, her unborn baby usually does not have any problems caused by parvovirus B19 infection. Rarely, parvovirus B19 infection will cause the unborn baby to have severe anemia and the woman may have a miscarriage. This occurs in fewer than 5% of all pregnant women who are infected with parvovirus B19 and happens more commonly during the first half of pregnancy. There is no evidence that parvovirus B19 infection causes birth defects or mental retardation. If you think your child Symptoms has Fifth Disease: Your child may have a sore throat or a low-grade fever. The rash often begins on the cheeks and moves to the arms, upper body, buttocks, and legs. However, the rash may come and go for weeks, Childcare and School: when your child is in the sunlight or heat. If your child is infected, it may take 4 to 21 days for No, if other rash-causing symptoms to start. Call your Healthcare Provider ♦ If your child has a weakened immune system, sickle cell anemia, or other blood disorders and has been exposed to someone with fifth disease. Spread can occur when people do not wash their hands after using the toilet or changing diapers. Giardia can be present in feces for several weeks or months after symptoms have stopped. Persons with diarrhea should be excluded from childcare until they are free of diarrhea for at least 24 hours. Children who have Giardia in their feces but who have no symptoms do not need to be excluded. No one with Giardia should use swimming beaches, pools, water parks, spas, or hot tubs for 2 weeks after diarrhea has stopped. Wash hands thoroughly with soap and warm running water after using the toilet and changing diapers and before preparing or eating food. Staff should closely monitor or assist all children, as appropriate, with handwashing after children have used the bathroom or been diapered. In the classroom, children should not serve themselves food items that are not individually wrapped. If you think your child Symptoms has Giardiasis: Your child may have gas, stomach cramps, bloating, and  Tell your childcare diarrhea. If your child is infected, it may take 1 to 4 weeks (usually 7 to 10 days) for symptoms to start. School: Call your Healthcare Provider No, unless the child is not feeling well and/or ♦ If anyone in your home has symptoms. Your child may beaches, pools, water become dehydrated due to vomiting or diarrhea. Prevention  Wash hands after using the toilet and changing diapers and before preparing food or eating. Haemophilus influenzae type b (Hib) can cause a number of serious illnesses, but it is not related to influenza or “stomach flu”. Cellulitis - A tender, rapid swelling of the skin, usually on the cheek or around the eye; may also have an ear infection on the same side; also a low-grade fever. Epiglottitis - Fever, trouble swallowing, tiredness, difficult and rapid breathing (often confused with viral croup, which is a milder infection and lasts longer). Invasive disease most commonly occurs in children who are too young to have completed their vaccination series. A person can also get infected from touching these secretions and then touching their mouth, eyes, or nose. All children between the ages of 2 months and 5 years who are in a licensed childcare setting are required to have Hib vaccine or they must have a legal exemption. Type b If you think your child Symptoms has Hib: Your child may have a fever with any of these conditions. The infection occurs most commonly in children less than 10 years of age and most often in the summer and fall months. Blister-like rash occurs in the mouth, on the sides of the tongue, inside the cheeks, and on the gums. Blister-like rash may occur on the palms and fingers of the hands and on the soles of the feet. The disease is usually self- limited, but in rare cases has been fatal in infants. It also is spread through droplets that are expelled from the nose and mouth of an infected person during sneezing and coughing and by direct contact with respiratory secretions. Wash hands thoroughly with soap and warm running water after using the bathroom, after changing diapers, after handling anything soiled with feces or secretions from the nose or mouth, and before preparing food or eating. Staff should closely monitor or assist all children, as appropriate, with handwashing after children have used the bathroom or been diapered. Disease If you think your child Symptoms has Hand, Foot, and Mouth Disease: Your child may have a runny nose, low-grade fever, and sometimes a sore throat. Childcare and School: If your child is infected, it may take 3 to 6 days for symptoms Yes, until fever is gone to start. This includes toilets (potty chairs), sinks, mouthed toys, and diaper changing areas. There are two other kinds of lice that infest people, but they do not live on the head. Head lice are very small (less than 1/8" long, about this size [--]), brownish-colored insects that live on human heads and lay their eggs (nits) close to the scalp. The eggs are tiny (about the size of the eye of a small needle) and gray or white in color. Look for: 1) crawling lice in the hair, usually few in number; 2) eggs (nits) glued to the hair, often found behind the ears and at the back of the neck; and 3) scratch marks on the head or back of the neck at the hairline. Children do not need to be sent home immediately if lice are detected; however they should not return until effective treatment is given. Removing the nits (nitpicking) is an essential part of the treatment for controlling the spread of head lice. The nits are glued onto the hair shaft as they are laid and require effort to remove. To remove the nits, use a metal nit comb, cat flea comb, or your fingernails to slide eggs off the hair shafts, or use scissors to cut the hair shafts that have nits glued to them. If all nits within ½" of the scalp are not removed, some may hatch and the child will be infested again. Bedding, when not in use for naptime, can be stored in individual plastic bags or storage boxes. When a child returns from a sleepover, check the child’s head and launder any bedding that they brought home. Clothing or backpacks that cannot be washed or dried, linens, and stuffed toys can be dry cleaned or sealed in plastic bags for 2 weeks.

Although som e of the following sym ptom s m ay be m ore appropriately associated with a serious solvent m isuse problem discount 10 mg loratadine with visa, their absence does preclude experim ental or sporadic use loratadine 10 mg amex. Surveys of newspaper reports indicate that butane gas is implicated in most of the recorded deaths “… followed by aerosols and typewriter correcting fluid discount loratadine 10 mg line. With solvent use, there is the potential for dependence but the reality is that, for most young people, solvent use happens within the context of the peer group and is not sustained. Long-term, habitual use of solvents will see the development of tolerance and an increase in the amount of solvents inhaled. Side effects from regular use may include: y Disturbed sleep patterns y Loss of appetite y Loss of weight y ‘Glue sniffer rash’ due to the ongoing application of plastic bags to the face, especially around the nose and mouth Side effects from long-term use include: y Depression y Being moody and suspicious y Being forgetful with a diminished ability to concentrate which will obviously impact on school performance59 These problem s will tend to clear up for m ost young people shortly after the solvent use ceases. In term s of withdrawals, sym ptom s m ay include: y Sleep disturbance y Nausea and stomach cramps y General irritability y Facial tics60 The other risks associated with solvent m isuse relate to behavioural problem s which arise from use or which can be exacerbated by use. As with alcohol, the disinhibiting qualities of volatile substances will im pact on judgem ent and self-control and this m ay prom ote aggressive and violent behaviour. Regular use m ay also feature theft of either solvent based products or of m oney to purchase such products. A young person m ay start to encounter problem s in school in term s of both attendance and a deterioration in perform ance, in som e cases leading to early school leaving. All of these issues can contribute to fam ily disruption as parents and siblings attem pt to deal with an intoxicated child and the attendant problem s detailed here. Someone found guilty of such an offence under Section 74 of the 1991 Child Care Act maybe fined up to B1,270, imprisoned for twelve months or both. Risk can be reduced by looking at the consequences and dangers of solitary use and in some circumstances it “… may be appropriate to advise teenagers about first aid procedures in the event of an accident involving one of a group of solvent abusers. The fam iliarity of m any of the products m isused can m ean that adults, whether in the hom e, at school or in a retail setting m ay not be as proactive in securing and lim iting access to them as they would with substances or products which present m ore obvious risks to the health and safety of young people. This m ay be an area that can be addressed in a school’s substance use policy through a section detailing: y How products will be securely stored y How limited access to products will be maintained y How products which do not have a legitimate use within the school are not permissible y Use of solvent free products where possible 44 Drug Facts Cannabis The use of cannabis is well-established throughout the time of human civilisation, with archaeological evidence pointing to its cultivation in a Neolithic settlement in Taiwan. However, as with all psychoactive substances, it has the potential for m isuse and causing harm to those who use it: “… a cannabis dependence syndrom e m ay occur in long-term regular users and, internationally, it has been suggested that one in ten of those who ever use cannabis will m eet the criteria for cannabis dependence. Cannabis takes the form of one of the following: 45 Drug Facts 1 Herbal cannabis (marijuana, grass, weed, ganja) consisting of the dried leaves and female flower heads. Desired Effects Cannabis is a sedative with hallucinogenic properties whose mood altering effects depend on the strength of the cannabis, the length of time it has been stored (potency is effected by time and exposure to light and air), the amount used, the way it is taken and the experience, mood and expectations of the user. This is particularly apparent in relation to visual images/colours and music/sounds arising from the hallucinogenic effects of cannabis leading to the intensification of ordinary sensory experiences such as eating, watching films and listening to music. W hether or not cannabis is central to any branch of m usic appreciation or creativity is a m oot point. However, it is worth considering that the pharm acological im pact of any drug is m ediated by the expectations of the user and the setting or environm ent within which it is used. For exam ple, in the 1950s, when heroin use am ongst jazz m usicians was reaching crisis proportions, it was said that “jazz was born in a whiskey barrel, grew up on m arijuana and is about to expire on heroin,”77 neatly capturing the changing prim acy of position for different substances in jazz and in turn reflecting changing social conditions and habits. Signs and symptoms of use Signs and symptoms of cannabis use include: y Bloodshot eyes y Giggling, especially in early stages of use y Increased appetite, also known as the “munchies” y “Bomb” burns on clothes – small multiple burn marks caused by falling bits of burning cannabis resin or ash y Paraphernalia associated with making cannabis joints including:  Torn off pieces of cardboard from cigarette boxes, filter paper packets or other cardboard items used to make a “roach” – a type of filter  Bits of loose cigarette tobacco around the home  Unstained loose cigarette filters – discarded when the tobacco from the manufactured cigarette is used to make a joint Short-term risks Unpleasant side-effects of occasional cannabis use include anxiety and panic reactions. Heart rate increases within 15-30 minutes of inhalation and remains raised for two hours or more. This cardiovascular effect of cannabis is similar to the effects of exercise and probably does not constitute a significant risk in healthy adolescents and young adults. Aside from tobacco and alcohol, cannabis is judged the least dangerous substance on the list. Perceptions of cannabis and the am ount of risk arising from its use have fluctuated throughout history. In the 1930’s an Am erican anti-drugs leaflet described it as “… the killer Drug M arihuana – a powerful narcotic in which lurks M urder! Because cannabis is fat-soluble, it persists in all parts of the body, including the brain, for up to four weeks after a single dose. This results in a general slowing of inform ation processing, leading to sluggish m ental perform ance. In relation to the first concern: “Public health researchers in the Netherlands now believe that there is ‘converging evidence’ to show that cannabis is a risk factor for schizophrenia … [warning] that cannabis approxim ately doubles the risk of schizophrenia and that the risk increases in proportion to the am ount of drug used. It stem s from the observation m ade in m any retrospective studies that those who use heroin and cocaine have also generally used cannabis first. Cannabis is thought to have sim ilar addictive properties to alcohol but a lesser level of risk than nicotine or heroin. Legal Status Cannabis is governed by the Misuse Of Drugs Act 1977 (schedule 1) and is therefore illegal to grow, produce, supply or possess. It is also an offence to allow a premises to be used for cultivating, supplying or smoking cannabis. It had som e lim ited deploym ent as a therapeutic drug; prescribed by practitioners working in m arriage guidance and psychotherapy94 because of its em pathogenic qualities – the ability to prom ote feelings of contentm ent and ‘connectedness’. Physical description Ecstasy comes in tablet form with different logos and in different colours. The various designs and colours appearing on the tablets have no intrinsic significance as to the quality of the tablet and, in many respects, this feature of their production reflects the perceived value and importance of labels and branding. Obviously, as an illicit drug, there is no trade-marking, copyright or quality control involved in the production and distribution of ecstasy. Obviously, the more tablets taken in one episode the higher the potential for risk; to address this, ecstasy users may initially take half a tablet to see how they respond to it. Desired effects The sought after effect is that of feeling content, relaxed and happy with a warm friendly feeling towards others. Users may have increased self-awareness and increased perception of visions and music; however, no true hallucinations occur at “normal dose” levels. Signs and symptoms of use The following are associated with ecstasy use: y Hyperactivity and boundless energy y Unusual confidence y Very talkative y Sweating y Dry mouth/thirsty y Dilated pupils y Tremors and palpitations y Jaw stiffness/teeth grinding Short-term risks One of the main fears about to ecstasy relates to heat stroke or hyperthermia which has been linked to deaths in the past. Death can subsequently occur due to m uscle breakdown, clotting inside the body and kidney failure. It is not known why som e individuals have such an extrem e reaction and why others do not. In som e cases, contrary to this advice, large volum es of fluid have been ingested 50 Drug Facts quickly leading to water intoxication. The effect of Vasopressin is fluid overload after excess water consum ption because the kidneys do not function, resulting in cerebral oedem a (swelling of the brain), com a and death. Other short term risks m ay include y Inexperienced users finding the initial ‘rush’ frightening which can lead to panic y A rise in blood pressure, pulse and temperature y Convulsions, stroke and severe chest pains y Emotional openness and enhanced sexual desire may lead to unsafe sexual practices, however, male sexual performance is impaired as a side-effect of ecstasy use. Long-term risks Psychiatrists report that regular ecstasy use is associated with chronic psychiatric symptoms, including y Psychotic episodes y Panic disorder y Depersonalisation (a feeling of floating outside of one’s body) which may continue after drug use has stopped. However, it is still unclear whether such experiences reflect pre-existing conditions, triggered by ecstasy or if the use of the substance is the cause of the problems. It is not considered a drug of addiction but given its stimulant/amphetamine qualities it does have the “… potential to cause psychological dependence. Its use has been predominantly associated with affluence but in recent times an increase in availability coupled with a decrease in price has seen cocaine start to make inroads into new European markets not defined by wealth and high-living. In Ireland it has been suggested that cocaine use is more prevalent in those individuals who report problem drug-taking and whose poly-drug use has extended from opiates to include cocaine. In recent years the purity of the cocaine sold in Ireland is believed to have fallen from 62% to around 38%. By snorting, cocaine is conveyed directly into the bloodstream via the mucous membranes of the nose and throat where it dissolves. Cocaine is m ade into crack by dissolving the powder in water and heating it, norm ally with the addition of baking soda. Apart from being sm oked in a pipe, the base form of cocaine (referred to as freebase, which has been washed with ether or am m onia to m ake the coke sm okeable) can be ‘chased’† on silver foil, sim ilar to the way heroin is sm oked or sprinkled into joints/hand-m ade cigarettes to m ake a m ore efficient form of ‘charlie spliff’. This com bination converts into cocaethylene in the body which lasts longer in the brain and is m ore toxic than either drug alone. Desired Effects The desired effects of cocaine use include: y Feelings of euphoria, increased self-worth and emotional disinhibition y Increased energy y Increased mental activity and alertness y Lack of appetite y A heightened sense of pleasure112 Sm oking crack produces sim ilar effects.

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This is a common error and may invalidate the results of the experiment or portray them in a misleading manner purchase 10 mg loratadine free shipping. It should be used when deal- ing with ordinal variables or when the data are highly skewed buy 10mg loratadine with amex. The mode is the most common value or the one value with the largest number of data points discount 10mg loratadine with amex. It is used for describing nominal and ordinal data and is rarely used in clinical studies. The stan- dard error of the mean is a measure that describes the dispersion of a group of samples. It should be given whenever there is either a large spread of data values with many outliers or when the range is asymmetrical about the value of central tendency. The lowest quarter of values lie below the lower quartile or 25th percentile, the Review of basic statistics 101 lower half below the 50th percentile, and the lowest three-quarters below the upper quartile or 75th percentile. The interquartile range is the range of values from the 25th to the 75th percentile values. It is the average of the squares of the difference between each value and the mean or the sum of the squares of the difference between each value and the mean divided by n (the number of data points in the sample). Populations and samples A population is the set of all possible members of the group being studied. The members of the population have various attributes in common and the more characteristics they have in common, the more homogeneous and therefore restrictive the population. An example of a fairly restricitive population would be all white males between 40 and 65 years of age. With a restrictive population, the generalizability of the population is often a problem. The less the members of the sample have in common, the more generalizable the results of data gath- ered for that population. For example, a population that included all males is more generalizable than one that only includes white males between 40 and 65 years of age. An example could be all white males available to the researcher on a given day for a study. Reasons to use a sample rather than the entire population include convenience, time, cost,andlogistics. The sample may or may not be representative of the entire population, an issue which has been discussed in the chapter on sources of bias (Chapter 8). Histograms or frequency polygons show how many subjects in a sample or population (the y-axis) have a certain characteristic value (the x-axis). When plotted in this manner, we call the graph a distribution of values for the given sample. By definition, a symmet- rical distribution is one for which the mean, median, and mode are identical. They are said to be skewed to the right (positive 102 Essential Evidence-Based Medicine Fig. Skew should be discussed when presenting and evaluating data and the range of the data given in addition to the standard measures of central tendency and dispersion. One clue to the presence of skewed data is if twice the standard deviation is larger than the mean. The mathematical measures used to describe data are different for skewed distributions than for symmetrical ones. Abraham de Moivre, a French mathematician, discovered it about 50 years before Gauss published his thesis. It is a special case of a symmetrical distribution, and it describes the frequency of occurrence of many naturally occurring phenomena. For the purposes of most statistical tests, we assume normality in the distribution of a variable. It is better defined by giving its properties: (1) The mean, median, and mode are equal so that we can say that the curve is symmetric around the mean and not skewed or has a skew = 0. There are specific numerical equivalents to the standard deviations of the nor- mal distribution, as shown in Table 9. The normal distribution is the basis of most statistical tests and concepts we will use in critical interpretation of the statistics used in the medical literature. Percentages Percentages are commonly used in reporting results in the medical literature. Percentage improvement or percentage of patients who achieve one of two dichotomous endpoints are the preferred method of reporting the results. A percentage is a ratio or fraction, the numer- ator divided by the denominator, multiplied by 100 to create a whole number. Obviously, inaccuracies in either the numerator or denominator will result in inaccuracy of the percentage. Percentofapercent will usually show a very large result, even when there is only a small absolute change in the variables. The second misleading technique is called the percentages of small num- bers, and can be misleading in a more subtle way. Twenty percent of ten subjects seems like a large number, yet represents only two subjects. For example, the fact that those two subjects had an adverse reaction to a drug could have occurred simply by chance and the percentage could be much lower (< 1%) or higher (> 50%) when the same intervention is studied in a larger sample of the population. To display these results properly when there are only a small number of subjects in a study, the percentage may be given as long as the overall numbers are also given with equal prominence. The best way to deal with this is through the use of confidence intervals, which will be discussed in the next chapter. Probability Probability tells you the likelihood that a certain event will or will not occur rel- ative to all possible related events of interest. Mathematically it is expressed as the number of times the event of interest occurs divided by the number of times all possible related events occur. This can be written as P(x) = nx/N where P(x)is the probability of an event x occurring in a total of N possible outcome events. This is calculated as P(head) = 1/2, or the outcome of interest (one head)/the total number of possible outcomes of the coin toss (one head plus one tail). Two events are said to be independent, not to be confused with the indepen- dent variable of an experiment, when the occurrence of one of the events does not depend on the occurrence of the other event. Since the probability of a head on one toss is 1/2, if the same coin is tossed again, the probability of flipping a head does not change. The probability will continue to be 1/2 no matter how many heads or tails are thrown, unless of course, the coin is rigged. Similarly, events are said to be dependent, not to be confused with the depen- dent variable of an experiment, if the probability of one event affects the out- come of the other. An example would be the probability of first drawing a red ball and then a yellow ball from a jar of colored balls, without replacing the one you drew out first. This means that the probabilities of selecting one or another colored ball will change each time one is selected and removed from the jar. Heads or tails obtained on the flip of a coin are mutually exclusive events as a coin will only land on the head or tail. Conditional probability allows us to calculate complex probabilities, such as the probability that one event occurs given that another event has occurred. If two events are mutually exclusive, the probability that either event occurs can be easily calculated. The probability that event a or event b occurs is simply the sum of the two probabilities. The probability of a head or a tail occurring when a coin is flipped is P(head) + P (tail), which is 1/2 + 1/2 = 1, or a certain event. Similarly, the probability that event a and event b occurs is the product of the two probabilities. The probability of getting two heads on two flips of a coin is P(head on 1st flip) × P(head on 2nd flip) which is 1/2 × 1/2 = 1/4. Determining the probability that at least one of several mutually exclusive events will occur is a bit more complex, but the above rules allow us to make this a simple calculation: P(at least one event will occur) = 1–P(none of the events will occur).

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Cocci petent hosts and paradoxically uncommon in dioides meningitis should be treated with amphoter immunosuppressed hosts cheap 10mg loratadine fast delivery. Also Mexico buy discount loratadine 10 mg, based budding yeast’’ in clinical specimens strongly Central and South America purchase loratadine 10mg otc. Infection rates are 1 5%, up to 100% schoolenvironments, coworkersinthesame office, for long term catheterization. Complications include young adults in dormitories, and recruits in train cystitis, prostatitis, pyelonephritis, and urosepsis ing centers. Education, isolation, tions (gloves, gowns, masks if risk of exposure of and surveillance are important. Transmission via respirator for personal protection) varicella, urine and feces unlikely tuberculosis. Identifi surface between the distal ulna and the carpal able risk factors and arthrocentesis are most helpful bones. Methylprednisolone 100 150 mg lection in subcutaneous tissues (particularly colder intra articularly once). Allopurinol chromatosis, diabetes, hypothyroidism, hypomagne alone can cause an abrupt decrease in serum uric acid semia, trauma, and symptoms! Joint protection (range of neous ulceration, visceral arteritis) motion exercises, orthotics, splints). Individual patients neurologic, and hematologic involvement, but usually have a fixed pattern of presentation. Terminate attacks early (place hands in hypertension (endothelin antagonists [Bosentan]) warm water). Common signs include dilated capil with inflammatory myositis, muscle biopsy consis lary loops, sclerodactyly, flexion contractures, hypo tent with inflammatory myositis. Loss tis, plantar fasciitis, tenosynovitis, dactylitis), nail of lumbar lordosis and thoracic kyphosis with changes (pits, onycholysis), pitting edema, and significant decreased range of motion and chest uveitis. Imaging reveals co existence of erosive expansion, positive Schober’s test and occiput to changes and new bone formation in the distal wall test. Extraarticular manifestations include joints with lysis of the terminal phalanges, fluffy anterior uveitis, C1 2 subluxation, restrictive lung periostitis, "pencil in cup" appearance, and the disease, aortic regurgitation, conduction abnorm occurrence of both joint lysis and ankylosis in the alities, and secondary amyloidosis. Back pain in young men raises possibility Onset Insidious Abrupt of ankylosing spondylitis. Failure to improve with Duration >3 months Shorter rest is sensitive for systemic conditions. Straight leg raising should be assessed bilaterally in sciatica or neurogenic claudication. The classic features are aching pain in the but cord(uppermotorneuron,usuallyaboveL1level). Symp tock and paresthesias radiating into the posterior toms include lower limb weakness, increased tendon thigh and calf or into the posterior lateral thigh and reflexes in legs, sensory loss usually 1 5 levels below lateral foreleg. Symptoms include lower limb weakness, tebra onanother, usually asa result ofrepeated stress depressed tendon reflexes in legs, and sacral paresthesia on pars interarticularis. Laminectomy, spinal fusion, through the annulus, due to intervertebral pressure trauma, Cushing’s syndrome, Paget’s disease, and and degeneration of the ligamentous fibers. Occurs acromegaly are also associated with spinal stenosis more commonly in younger patients. Over95%ofherniateddiscs mity pain with walking, relieved with flexion, sit affect the L4 5 or L5 S1 interspace. Important to try to distinguish from or acetabular osteophytes, radiographic joint space periarticular structures (tendonitis, bursitis) narrowing. Among physical examination findings, synovitis makes the diagnosis of temporal arteritis less likely, while beaded, prominent, enlarged, and tender temporal arteries each increase the likelihood of positive biopsy results. While these findings increase the chance of having temporal arteritis, they are variably sensitive from 16% (beaded temporal artery) to 65% (any temporal artery abnormality). Need four of six criteria >14 mmol/L [>39 mg/dL] or Cr >132 mmol/L for diagnosis (sens 85%, spc 99. Upfront radiation improves progressive free Supportive measures only survival but not overall survival. About 10Â more fre intrathecal therapy (methotrexate, cytarabine, quent than primary brain tumors. Accordingly, carotid bruit cannot be used to rule in or rule out surgically amenable carotid artery stenosis in symptomatic patients. Asymptomatic preoperative bruits are not predictive of increased risk of perioperative stroke. Lacunes develop over hours or at most margins of the insula), or lentiform nucleus and sul a few days; large artery ischemia may evolve over cal effacement. Patients ment, coagulopathy), clinical (rapidly improving benefit more if treated early (<90 min) but benefit strokesymptoms,minor/isolatedsymptoms,seizure extends out to 6 h. Major risk is symptomatic brain at onset of stroke with residual impairment second hemorrhage(3 5%). Speech (‘Ka Ka Ka’’), coughing, swallowing Reflex gag reflex X Nucleus ambiguous, Jugular foramen Sensory sensation of palate dorsal motor vagal, Motor uvula and palate movement. Peripherallesions include aneurysm, tumor, meningitis, nasopharyngeal carcinoma, orbital lesions, and ischemic lesions (diabetes, hypertension). If all three divisions (V1 V3) get affected, the lesion is likely at the ganglion or sensory root level (trigeminal neuroma, meningioma). If only a single division is affected, the lesion is likely at the post ganglion level (e. Anadenomamaycompresstheopticchiasm inferiorly, causing superior bitemporal quadranopsia Related Topics and eventually complete bitemporal hemianopia Diplopia (p. Lacrimation intact but salivation and taste both affected if lesion distal to geniculate ganglion. Facial electroneurography) palsy, ear pain, and vesicles in external auditory mea tus may be present. Check with driving authority for drug induced etiologies include isoniazide, theophyl specific restrictions and legal requirements. If single line, oral hypoglycemic agents, carbon monoxide, unprovoked seizure, usually no driving restrictions and bupropion. Treat isoniazide seizure free interval before re instating driver’s induced seizures with pyridoxine; hypoglycemic sei license (varies with jurisdiction). Some places may zures with glucose Æ octreotide and glucagon; and also restrict driving for 6 months after antiepileptic carbon monoxide associated seizures with oxygen dose adjustments. Autonomic failure may be resulting in increased peripheral vascular resis assessed by heart rate variability testing tance and cardiac output. Medications include fludrocortisone syncope, weakness, fatigue, angina, orthostatic 0. Headaches may be classified as new headache, acute thunderclap headache, or chronic headache. Chronic headaches with high risk features above should be investigated with neuroimaging. Risk factors include acterize headaches (location, nature, intensity, radia obesity, history of frequent headache (>1 per week), tion, alleviation, and aggravation), precipitants caffeine consumption, and overuse of acute head (stress, food, physical activity), and any associated ache medications (analgesics, ergots, triptans). Neurological examination includ and chronic tension type headache ing visual fields and fundoscopy. Any 1 of N&V, photophobia, and phonophobia (>5x and up to 24Â per day) and are shorter 5. If can still hear (air conduction trating trauma), tumor (acoustic neuroma, menin >bone conduction), either normal or sensorineural gioma), infectious (viral cochleitis, meningitis, loss on that side. Individuals who per ceive the whispered voicerequire no further testing, while those unable to perceive the voice require audiometry. The ice test, sleep test, and response to anticholinesterase agents (especially the edrophonium test) are useful in confirming the diagnosis, and reduce the likelihood when results are negative. On examination, the diagnostic value of the classic combination of tremor, rigidity, bradykinesia is limited. Anticho exercises linergics have limited activity but can help with tremor and dyskinesia. Combinedusewithentacaponecanleadto width, coordination, and stability (see table more sustained levodopa levels.

The contribution of protein to energy needs may be significant during periods of energy restriction or following the utilization of the body’s limited endogenous carbohydrate stores buy loratadine 10mg with amex. Protein oxidation also has been shown to rise considerably in highly traumatized or septic individuals effective loratadine 10 mg, which results in large amounts of body protein loss cheap loratadine 10 mg visa; this loss can compro- mise recovery or even lead to death (see below) (Klein, 1990). It is much less in periods of chronic starvation because of various metabolic adaptations related to ketone utilization, or on protein-restricted diets. Whether glucose or fat is formed from the carbon skeleton of an amino acid depends on its point of entry into these two pathways. The carbon skeletons of other amino acids can, however, enter the pathways in such a way that their carbons can be used for gluco- neogenesis. This is the basis for the classical nutritional description of amino acids as either ketogenic or glucogenic (i. Some amino acids produce both products upon degradation and so are considered both ketogenic and glucogenic (Figure 10-3). It has been argued that the majority of hepatic amino acid catabolism is directed in an obligatory fashion to glucose synthesis (Jungas et al. This cycle also involves the peripheral synthesis of glutamine, an amino acid that is utilized in substantial quantities by the intestinal cells in which it is used for energy and for the synthesis of proline, citrulline, and nucleic acids. A significant proportion of the glucose synthesized in the liver is due to recapture and recycling via the liver of 3-carbon units in the form of lactate derived from anaerobic glucose breakdown in muscle (the Cori cycle). Hepatic gluconeogenesis also occurs via the glucose–alanine cycle (a direct parallel of the Cori cycle) and the glucose–glutamine cycle. Since the nitrogen donors may be either glucogenic or ketogenic amino acids, these cycles function as mechanisms for transporting nitrogen from the periphery to the liver as well as for glucose production. The cycle involving glutamine transport from the periphery to the gastrointestinal tract is also vital to the synthesis of arginine and proline and is critical to the preven- tion of the build up of excessive ammonia in the circulation. Nonprotein Pathways of Amino Acid Nitrogen Utilization Although in general the utilization of dietary amino acids is dominated by their incorporation into protein and their role in energy metabolism, amino acids are also involved in the synthesis of other nitrogenous com- pounds important to physiological viability as shown in Table 10-5. Some pathways have the potential for exerting a substantial impact on the utili- zation of certain amino acids, and may be of potential significance for the requirements for these amino acids. This is particularly true for glycine, which is a precursor for six nitrogenous compounds, as shown in Table 10-5. Its utilization in the synthesis of creatine (muscle function), heme (oxygen transport and oxidative phosphorylation), and glutathione (protective reactions which are limited by the amount of available cysteine) is not only of physiological importance, but can also involve substantial quantities of the amino acid. For example, in the absence of a dietary source of creatine, adults require at least 1. In premature infants, mainly fed human milk, there is evidence that the glycine supply may be a primary nutritional limitation to growth (Jackson, 1991). This so-called dispensable amino acid is then needed in the diet for optimum growth and may be termed “conditionally indispensable. These may be important nutritional con- siderations in individuals consuming marginal amounts of proteins of plant origin and undoubtedly have an impact on overall amino acid utilization when protein intake is very low. Clinical Effects of Inadequate Protein Intake As outlined above, protein is the fundamental component necessary for cellular and organ function. Not only must sufficient protein be pro- vided, but also sufficient nonprotein energy (i. Similarly, unless amino acids are present in the diet in the right balance (see later section, “Protein Quality”), protein utilization will be affected (Duffy et al. Hypoalbuminemic malnutrition has been described in hospitalized adults (Bistrian, 1990) and has also been called adult kwashiorkor (Hill, 1992). Clearly, protein deficiency has adverse effects on all organs (Corish and Kennedy, 2000). Furthermore, protein deficiency has been shown to have adverse effects on the immune system, resulting in a higher risk of infections (Bistrian, 1990). It also affects gut mucosal function and permeability, which, in turn, affects absorption and makes possible bacterial invasion from the gut, which can result in septicemia (Reynolds et al. Protein deficiency has also been shown to adversely affect kidney function, where it has adverse effects on both glomerular and tubular function (Benabe and Martinez-Moldonado, 1998). Total starvation will result in death in initially normal-weight adults in 60 to 70 days (Allison, 1992). For comparison, protein and energy reserves are much smaller in premature infants, and survival of 1,000-g neonates is only about 5 days (Heird et al. Clinical Assessment of Protein Nutritional Status No single parameter is completely reliable to assess protein nutritional status. Borderline inadequate protein intakes in infants and children are reflected in failure to grow as estimated by length or height (Jelliffe, 1966; Pencharz, 1985). However, weight-height relationships can be distorted by edema and ascites (Corish and Kennedy, 2000). Mid-upper arm parameters such as arm muscle circumference have been used to measure protein status (Young et al. The triceps skinfold is reflective of energy nutritional status while the arm muscle circumference (or diameter) is reflective of protein nutritional status (unless a myopathy or neuropathy is present) (Patrick et al. In addition, urinary creatinine excretion has been used as a reflection of muscle mass (Corish and Kennedy, 2000; Forbes, 1987; Young et al. The most commonly used methods to clinically evaluate protein status measure serum proteins; the strengths and weaknesses of these indicators are summarized in Table 10-6. In practical terms, acute protein depletion is not clinically important as it is rare, while chronic deficiency is important. Serum proteins as shown in Table 10-6 are useful, especially albumin and transferrin (an iron-binding protein). Due to their very short half-lives, prealbumin and retinol binding protein (apart from their dependence on vitamin A status) may reflect more acute protein intake than risk of protein malnutrition (which is a process with an onset of period of 7 to 10 days (Ramsey et al. Hence, albumin and transferrin remain the best measures of protein mal- nutrition, but with all of the caveats listed in Table 10-6. In protein malnutrition, the skin becomes thinner and appears dull; the hair first does not grow, then it may fall out or show color changes (Pencharz, 1985). Over a longer period of time, assessment of changes in lean body mass reflects protein nutritional status. The clinical tools most available to assess lean mass are dual emission x-ray absorptiometry and bioelectrical impedance (Pencharz and Azcue, 1996). This section reviews some of the possible indicators used or proposed for use in analyses estimating human protein requirements. Factorial Method The factorial method is based on estimating the nitrogen (obligatory) losses that occur when a person is fed a diet that meets energy needs but is essentially protein free and, when appropriate, also relies on estimates of the amount of nitrogen that is accreted during periods of growth or lost to mothers during lactation. The major losses of nitrogen under most con- ditions are in urine and feces, but also include sweat and miscellaneous losses, such as nasal secretions, menstrual losses, or seminal fluid. This is where the factorial method has its greatest weakness, since the relationship between protein intake and nitrogen retention is somewhat curvilinear; the efficiency of nitrogen retention becomes less as the zero balance point is approached (Rand and Young, 1999; Young et al. Additionally, in order to utilize the factorial approach when determining the protein requirement for infants and children, their needs for protein accreted as a result of growth must be added to their maintenance needs. Nitrogen Balance Method This classical method has been viewed by many as theoretically the most satisfactory way of determining the protein requirement. Nitrogen balance is the difference between nitrogen intake and the amount excreted in urine, feces, skin, and miscellaneous losses. As discussed below, nitro- gen balance remains the only method that has generated sufficient data for the determination of the total protein (nitrogen) requirement. It is assumed that when needs are met or exceeded adults come into nitrogen balance; when intakes are inadequate, negative nitrogen balance results. In determining total protein (nitrogen) needs, high-quality proteins are utilized as test proteins to prevent negative nitrogen balance resulting from the inadequate intake of a limiting indispensable amino acid. A significant literature exists regarding the methods and procedures to use in deter- mining nitrogen balance amount (Manatt and Garcia, 1992; Rand et al. Limitations of the Method The nitrogen balance method does have substantial practical limita- tions and problems. First, the rate of urea turnover in adults is slow, so several days of adaptation are required for each level of dietary protein tested to attain a new steady state of nitrogen excretion (Meakins and Jackson, 1996; Rand et al. Second, the execution of accurate nitro- gen balance measurements requires very careful attention to all the details of the procedures involved. Since it is easy to overestimate intake and underestimate excretion, falsely positive nitrogen balances may be obtained (Hegsted, 1976). Indeed, an overestimate of nitrogen balance seems con- sistent throughout the literature because there are many observations of quite considerable apparent retention of nitrogen in adults (Oddoye and Margen, 1979). A third limitation of the nitrogen balance method is that since the requirement is defined for the individual, and studies rarely provide exactly the amount of protein necessary to produce zero balance, individuals must be studied at several levels of protein intake in the region of the requirement so that estimates of individual requirements can be interpolated (Rand et al.

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