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Chronic runny nose (chronic rhinitis)

The main forms of chronic rhinitis (rhinitis chronica) - catarrhal, hypertrophic and atrophic - are a nonspecific dystrophic process of the mucous membrane and, in some cases, the bone walls of the nasal cavity.

The disease is common.

E and l about g and I and patogenesis. The occurrence of chronic rhinitis is usually associated with discirculatory and trophic disorders in the nasal mucosa, which can be caused by factors such as frequent acute inflammation in the nasal cavity (including various infections), irritating environmental influences (most often dust gas), dryness or humidity, air temperature fluctuations, etc. An important role in the etiology of chronic rhinitis can be played by common diseases - cardiovascular, kidney, dysmenorrhea, frequent coprostasis, alcoholism, as well as local processes - narrowing or obstruction of the choan adenoids, purulent discharge in sinusitis, etc. Hereditary prerequisites can be important in the etiology of the disease. malformations and defects of the nose. In a number of cases, chronic rhinitis is a symptom of another disease, for example, chronic purulent sinusitis (sinusitis, frontitis, ethmoiditis), a foreign body of the nose, etc., which is important to consider in the diagnosis and treatment.

The effects of dust on the nasal mucosa can be different. Mineral and metal dust has solid pointed particles that traumatize the mucous membrane; flour, chalk, cotton, wool and other dust consists of soft particles, which, although they do not injure the mucous membrane, but, covering its surface, lead to the death of cilia of the ciliated epithelium and can cause its metaplasia, disrupt the outflow from mucous glands and goblet cells. Accumulations of dust in the nasal passages can cement and form nasal stones (rhinolitis).

Vapors and gases of various substances have a chemical effect on the nasal mucosa, causing first its acute, and then chronic inflammation. Irritating, toxic effects are exerted by some occupational hazards: mercury vapor, iodine, formalin, nitric, sulfuric, hydrochloric acids, etc., radiation exposure.

Thus, the combined effect of certain exogenous and endogenous factors over a period of time can lead to the appearance of some form of chronic rhinitis. Prevention of this disease includes the rehabilitation of the paranasal sinuses and nasopharynx, the treatment of common diseases, the improvement of working conditions, the introduction of personal protective measures in the presence of harmful effects in the workplace, and hardening of the body. For the purpose of early detection of the disease, a routine examination is performed by an otorhinolaryngologist.

K l and n and with to and to kartin and. Chronic catarral rhinitis (rhinitis cataralis chronica). The main symptoms of a chronic runny nose in its catarrhal form - difficulty in nasal breathing and discharge from the nose (rhinorrhea) - are mild. Significant respiratory failure through the nose usually occurs periodically, often in the cold, however, congestion in one half of the nose is more constant. When lying on its side, nasal congestion is more pronounced in the half of the nose, which is lower, which is explained by the filling of the cavernous vessels of the underlying shells with blood, the tone of which is weakened in chronic rhinitis. Nasal mucosa; usually it is a little, but at process aggravation it becomes purulent and plentiful. With rhinoscopy, the pastiness and swelling of the mucous membrane, often with a cyanotic hue, and a slight thickening of it mainly in the region of the lower shell and the anterior end of the middle shell are determined; while the walls of the nasal cavity are usually covered with mucus. Violation of smell (hyposmia) is more often temporary, usually associated with an increase in the amount of mucus; complete loss of smell (anosmia) is rare.

Morphological changes in catarrhal rhinitis are mainly localized in the surface layers of the mucous membrane. Atrial fibrillation in one way or another loses cilia, which can be restored when the condition improves. In some places, the epithelial cover is broken or infiltrated by round-cell elements, the subepithelial layer is often swollen. The vessels of the mucous membrane of the nasal concha are dilated, their walls can be thinned.

To distinguish a simple catarrhal form of rhinitis from hypertrophic, anemization test is performed - grease the thickened mucous membrane with a vasoconstrictor (0.1% adrenaline solution, etc.); while a significant decrease in swelling of the mucous membrane indicates the absence of true hypertrophy. If the contraction of the mucous membrane is slightly expressed or it has not contracted at all, this indicates the hypertrophic nature of its swelling. It is necessary to monitor the condition of the paranasal sinuses in order to exclude the secondary (symptomatic) nature of rhinitis.

Chronic hypertrophic rhinitis (rhinitis chronica hipertrophica). The main signs of the hypertrophic form of the common cold are constant difficulty in nasal breathing, mucous and mucopurulent discharge, overgrowth and thickening of the nasal mucosa, mainly the entire lower conch and to a lesser average, i.e. in places of localization of cavernous tissue. However, hypertrophy can occur in other parts of the nose, in particular on the vomer at its posterior edge, in the anterior third of the nasal septum. The surface of hypertrophic areas may be smooth, bumpy, and the areas of the posterior or anterior ends of the shell may be coarse-grained. The mucous membrane is usually hyperemic, full-blooded, slightly cyanotic or purplish-cyanotic, gray-red, covered with mucus. If the mucopurulent discharge is localized under the middle shell, inflammation of the maxillary, ethmoid, or frontal sinuses should be excluded; if it is located in the olfactory fissure, then, possibly, the sphenoid sinus or posterior ethmoid cells are involved in the process. The posterior ends of the lower shells are usually thickened, often squeezing the pharyngeal mouth of the auditory tubes, thereby causing eustachitis (otosalpingitis). A sharp thickening of the anterior sections of the inferior concha can compress the opening of the lacrimal-nasal canal, which causes lacrimation, inflammation of the lacrimal sac and conjunctivitis. Hypertrophied lower concha often presses on the nasal septum, which can reflexively cause headaches and nervous disorders.

The decrease in the sense of smell at first has the character of a respiratory hypo- or anosmia, however, gradually due to atrophy of the olfactory receptors, essential (irreversible) anosmia occurs, and at the same time, the taste decreases slightly. Nasal congestion causes a change in the timbre of the voice - a closed nasal (rhinolalia clausa) appears. The morphological picture with this form of the common cold is characterized by hypertrophy of the mucous membrane, glands and, in rare cases, bone tissue of the nasal concha; the epithelial layer is loosened, in some places the cilia are absent. The function of the ciliary apparatus may be impaired to varying degrees.

In some patients, polypous degeneration of the mucous membrane is fixed, more often in the region of the middle shell; congestive edema may also occur in the posterior ends of the lower nasal concha. The formation of polyps and puffiness is facilitated by allergization of the body. Localization of polyps in the upper parts of the nasal cavity may not affect respiratory function until the polyps descend into the respiratory region of the nose, while olfactory function in these cases is often impaired immediately. Polypous and edematous thickening has a wide base, polypous hypertrophy can gradually transform into nasal polyps. To clarify the diagnosis in these cases, feel with a button probe after preliminary anemization of the nasal concha. Using this technique, you can also determine the presence of bone hypertrophy of the lower or middle shell, which sometimes occurs with a hypertrophic form.

The most convincing and complete data can be obtained with endoscopy using an operating microscope or using endonasal microendoscopes.

Atrophic rhinitis (rhinitis atrophica). A simple chronic atrophic process in the nasal mucosa can be diffuse and limited. Often there is a slight atrophy of the mucous membrane, mainly the respiratory region of the nose, this process is sometimes called subatrophic rhinitis in practice. The occurrence of an atrophic process in the nose is usually associated with prolonged exposure to dust, gases, steam, etc. Mineral dust (silicate, cement), tobacco, etc. have a particularly strong effect. Often atrophic rhinitis develops after surgery, such as extensive conchotomy, or after a nose injury. Sometimes the cause of the disease can be associated with constitutional and hereditary factors.

In childhood, the atrophic process is sometimes the result of infectious diseases such as measles, flu, diphtheria, scarlet fever.

D and a g n about with t and to and. Common symptoms of the disease include scanty viscous mucous or mucopurulent discharge, which usually adheres to the mucous membrane and dries, resulting in the formation of crusts. Periodic difficulty in nasal breathing is associated with accumulation in the general nasal passage, most often in its anterior crust.

Patients complain of dry nose and pharynx, a decrease in one degree or another of smell. Crusts in the nose often cause itching and difficulty breathing, so the patient tries to remove them with his finger, which leads to damage to the mucous membrane, usually in the anterior part of the nasal septum, the introduction of germs here and the formation of ulcerations and even perforation. In connection with the rejection of the crusts, small bleeding often occurs, usually from the Kisselbach zone.

The histological picture is characterized by thinning of the own tissue of the nasal mucosa, a decrease in the number of glands and their hypoplasia. The multilayer cylindrical epithelium also becomes thinner, its cilia are absent in many places. Metaplasia of the cylindrical epithelium into the flat is observed. With anterior and posterior rhinoscopy, depending on the severity of atrophy, more or less dilated nasal passages are seen, reduced in the volume of the shell, covered with a pale, dry, thinned mucous membrane, in which there are crusts or viscous mucus in places. Usually, with anterior rhinoscopy, after removal of the crusts, the posterior wall of the nasopharynx can be seen.

In the differential diagnosis, one should bear in mind the possibility of localizing a tuberculous process in the area of ​​the nasal septum, in which a granulating ulcer and perforation are formed that capture only the cartilaginous part, as well as a syphilitic process in the bone part on the border with the cartilage.

Treatment. With various forms of chronic rhinitis, it includes:

• elimination of possible endo- and exogenous factors that cause and maintain a runny nose;

• drug therapy for each form of rhinitis;

• surgery according to indications;

• physiotherapy and climatotherapy.

Elimination of the reasons supporting the chronic inflammatory process in the mucous membrane of the nasal cavity serves as a priority in the treatment of the common cold. Among them, chronic inflammation of the paranasal sinuses is often found. In such cases, the pathological discharge periodically or constantly flows into the nasal cavity and, being an extreme irritant, causes and supports chronic rhinitis. After a sanitizing operation on the affected sinus, rhinitis usually stops or its treatment becomes more effective. Active therapy of common diseases (obesity, kidney disease, heart disease, etc.), improvement of hygienic conditions at home and at work (elimination or reduction of dust and gas contamination, etc.) also make it possible to treat rhinitis with great success.

In chronic catarrhal colds, astringents are prescribed: 3-5% protargolum solution (collargolum) - 5 drops in each half of the nose 2 times a day or lubricate the mucous membrane with cotton wool wound onto the probe and moistened with a 3-5% lapis solution.
Treatment with one of these drugs is carried out for 10 days. At the same time, it is possible to recommend thermal procedures on the nose - currents of UHF or microwaves and endonasal ultraviolet radiation through a tube, endonasal helium-neon laser. Subsequently, alternating courses of agitation in the nose of drops of peloidin (extract from therapeutic mud), inhalation of balsamic solutions (Shostakovsky balm, diluted 5 times with vegetable oil, eucalyptus, etc.). When crusts appear, switch to an infusion of only isotonic sodium chloride solution with hydrocortisone into the nose. Patients with chronic catarrhal runny nose may be advised to periodically stay in a dry, warm climate.

Treatment for chronic hypertrophic rhinitis, as a rule, includes methods by which the volume of thickened sections of the mucous membrane of the nasal cavity is steadily reduced and nasal breathing is restored. The criterion for a rational choice of the treatment method in each case is the degree of hypertrophy of the nasal concha (usually the lower and less than the middle) and sometimes other parts of the nasal mucosa, as well as the degree of violation of nasal breathing.

In case of slight hypertrophy, when after anemization (lubrication with a vasoconstrictor drug) the mucous membrane contracts and nasal breathing improves, the most sparing surgical interventions are effective: cauterization with chemicals (lapis, trichloroacetic and chromic acids), galvanic caustics (these methods are used less and less), submucosal ultrasonization nasal concha, their laser destruction or submucosal vasotomy. Severe hypertrophy and significant respiratory failure through the nose, when nasal breathing does not improve after anemia, as a rule, partial resection of the hypertrophic nasal concha is indicated - gentle conchotomy. This intervention can be performed not only in the hospital, but also in the outpatient operating room, provided that good home care and outpatient care are organized, as well as in the absence of aggravating factors (general illnesses, old age, etc.). Before surgery, the patient is examined: a clinical study of blood (including bleeding and coagulation time), urine, examination by a therapist, find out if there are any carious teeth, boils, etc. Sometimes, before an operation, it is necessary to carry out one or another treatment of a general disease, remove a carious tooth, etc.

Operations in the nasal cavity are usually performed under local anesthesia with premedication, for which seduxen, promedol, atropine, luminal, etc. are used depending on the severity of the operation. For superficial analgesia, the mucous membrane is lubricated three times with 10% lidocaine solution or 2% dicaine solution; 4 drops for each milliliter of anesthetic are usually added to dicaine. One of the most powerful anesthetics is injection of ultracain. With intolerance to these drugs, lidocaine or general anesthesia is prescribed.

Chemical substances need to be cauterized carefully so as not to damage the surrounding tissue, after anemia and local anesthesia. A thin layer of cotton wool is tightly wound around the tip of the probe without the formation of a brush at its end.

After wetting with a 30–40% lapis solution, the cotton wool is slightly squeezed out on the edge of the bubble, then the probe is inserted along the general nasal passage to its posterior part, touched with the tip of the probe (cotton) to the lower edge of the lower nasal concha and lubricated as a line to the front end of the concha. A narrow white strip of coagulated mucous membrane is formed.

Make one or two such strips on the lower shell and, if necessary, on the middle. In this case, you must ensure that

there was a burn of the mucous membrane of the nasal septum, otherwise adhesions (synechia) between the shell and the septum may develop. Trichloroacetic and chromic acids are used concentrated (without dilution); cauterizing effect of their deeply penetrating. These acids are taken with a button probe without cotton wool. Cauterization substances may not be in liquid form, but crystalline, soldering them to the red-hot tip of the probe. If acid gets on the skin or the surrounding mucous membrane, immediately moisten these places with 2% sodium bicarbonate solution, neutralize lapis with an isotonic sodium chloride solution. To prevent synechia during burns of opposite sections of the mucous membrane of the nasal septum, a plastic film (washed X-ray film) is introduced into the general nasal passage. Improving nasal breathing depends on the degree of wrinkling of the mucous membrane and expansion of the nasal passages during healing of the burn surface. Caustics with chemicals gives a positive effect with slight hypertrophy of the turbinates and is rarely used.

Electrocautery is carried out with a special tool - a galvanocauter, with the help of which a deeper destruction of the thickened mucous membrane is performed. The tip heat (kauter) of this instrument is adjusted to red heat, which contributes to blood coagulation during caustic. Инструмент вводят по нижнему носовому ходу до заднего отдела нижней носовой раковины в холодном состоянии, прижимают каутер к нижнему краю раковины, включают накал и медленно ведут каутер по раковине кпереди до переднего ее конца. После прижигания назначают вливание масляных капель в нос. Больной нуждается в больничном листе на 3—5 дней. Носовое дыхание обычно улучшается через 2—3 нед.

Для ультразвуковой дезинтеграции применяют генератор ультразвука с набором специальных волноводов. После аппликационной анестезии слизистой оболочки носовой раковины в ее толщу вводят во включенном состоянии волновод и проводят его на необходимую глубину. Экспозиция воздействия определяется индивидуально. Эффект основан на физическом явлении кавитации, приводящем к рубцеванию кавернозной ткани и расширению просвета носовых ходов.

Подслизистую вазотомию (предложена С.3.Пискуновым) при кавернозной форме гипертрофии нижних носовых раковин (гипертрофия кавернозной ткани) выполняют под местной анестезией: смазывание слизистой оболочки 5 % раствором кокаина или 2 % раствором дикаина в сочетании с инфильтрацией вдоль всей нижней носовой раковины 1—2 % раствором новокаина или 1 % лидокаина (без сосудосуживающих средств). В области переднего конца нижней носовой раковины до кости делают разрез размером 2—3 мм, с помощью распатора, введенного через этот разрез, слизистую оболочку отсепаровывают на всем протяжении по верхней и при необходимости и нижней поверхности. В результате разрушается расположенная внутрислизисто-кавернозная ткань, после чего происходит рубцевание раковины и уменьшение ее объема с сохранением покровного эпителия. Вмешательство может быть особенно эффективным при его сочетании с латероконхопексией нижних носовых раковин. После предварительной анестезии с помощью мягкого зажима или киллиановского зеркала нижняя носовая раковина сублюксируется, г.е. надламывается у основания и приподнимается, а затем отводится максимально латерально к боковой стенке носа. После операции проводят тампонаду полости носа эластичными тампонами (рис. 6.2). Последующее рубцевание кавернозной ткани уменьшает объем раковины и увеличивает просвет носовых ходов, оставляя неповрежденной функциональную поверхность раковины.

Fig. 6.2.

Подслизистая вазотомия нижней носовой раковины

.

а — линия разреза по переднему краю раковины: 6 — линия проведения острого распатора.

Радикальным методом восстановления носового дыхания при гипертрофическом рините является резекция гиперплазированных участков носовых раковин. Показанием к этой операции служит истинная гипертрофия нижних раковин, когда смазывание адреналином их поверхности не уменьшает достаточно объема раковин. Операцию осуществляют в поликлинической операционной или в стационаре. Во время операции удаляют лишь гипертрофированные, фиброзные или полипозно-измененные, участки носовых раковин. Неизмененные ткани раковин следует максимально щадить (рис. 6.3).

Операцию проводят в положении больных лежа на спине с приподнятым головным концом или в положении сидя в кресле.

А н е с т е з и я : смазывание слизистой оболочки 10 % раствором лидокаина или 2 % раствором дикаина в сочетании с инфильтрацией вдоль всей нижней носовой раковины 1—2 % раствором новокаина или 1 % лидокаина. С помошью мягкого зажима или киллиановского зеркала нижняя носовая раковина сублюксируется, т.е. надламывается у основания так, что устанавливается параллельно дну носа. Такое положение раковины является оптимальным для дальнейшего хода операции. На гипертрофированные участки нижней носовой раковины накладывают зажим, затем ножницами по зажиму или по компрессионной борозде после снятия зажима гипертрофированные участки раковины удаляют. Если имеется изолированная гипертрофия задних концов нижних носовых раковин, то возможна их резекция с помощью носовой петли. Не рекомендуется из-за опасности кровотечения отрывать участки слизистой оболочки.

В некоторых случаях, особенно при костной форме гипертрофического ринита (Б.С.Преображенский), оправдано проведение подслизистой конхотомии. Для этого по переднему краю нижней носовой раковины до кости делают разрез, с помошью распатора отсепаровывают слизистую оболочку, затем ножницами или конхотомом удаляют кость и укладывают на место отсепарованную слизистую оболочку.

После операции проводят тампонаду полости носа эластичными или марлевыми тампонами.

Утолщенный задний конец носовой раковины бывает легче снять носовой петлей (см.рис. 6.3, б). Следует иметь в виду, что конхотомию всегда необходимо выполнять щадяще, так как полное удаление раковины может привести к излишне широким носовым ходам. В послеоперационном периоде на раневой поверхности раковины восстанавливается мерцательный эпителий.

Лечение атрофического ринита в основном симптоматическое. Больной должен следить, чтобы в полости носа не скапливались корки и отделяемое. Для их удаления нужно систематически 1 или 2 раза в день орошать носовую полость с помощью пульверизатора изотоническим раствором натрия хлорида с добавлением в него йода (на 200 мл раствора 6—8 капель 10 % йодной настойки). Периодически применяют раздражающую терапию — смазывание слизистой оболочки носа

Fig. 6.3.

Резекция нижней носовой раковины

(щадящая нижняя конхотомия).

а —

удаление гипертрофированных участков с помощью ножниц

; 6 —

с помощью полипной петли

.

йод-глицерином1 раз в день в течение 10 дней, что усиливает деятельность желез и расширяет кровеносные сосуды слизистой оболочки. С этой же целью назначают внутрь 30 % раствор йодида калия по 8 капель 3 раза в день в течение 2—3 нед.

Проводят лечение вливанием капель 1—2 % масляного раствора цитраля, по 5 капель в каждую половину носа 2 раза в день в течение недели. В более тяжелых случаях периодически осуществляют тампонаду носа с индифферентными мазями (на сутки) и терапию, как при озене.
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Хронический насморк (хронический ринит)

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    Клиническая картина острого ринита Насморк острый - проявление катара верхних дыхательных путей или инфекций (чаще гриппа). У больного возникает сухость в носу, жжение в глотке, чиханье, тяжесть в голове. В дальнейшем - закладывание носа, обильные выделения, вначале светлые, затем слизистогнойные, головная боль, иногда боль в области придаточных пазух, глазниц, гнусавость, слезотечение,
  3. Насморк (ринит)
    Самой частой патологией у детей, особенно раннего возраста, является ринит (насморк). Он может быть острым и хроническим. Острый ринит представляет собой острое неспецифическое воспаление слизистой оболочки полости носа. Причины заболевания. Большое значение для возникновения острого ринита имеет понижение местной и общей реактивности организма и активации микрофлоры в полости носа. it
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  5. Хронический гломерулонефрит у детей. Острая и хроническая почечная недостаточность
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    Chronic tonsillitis (tonsillitis chronica) is a common infectious disease with the localization of a chronic focus of infection in the tonsils with periodic exacerbations in the form of tonsillitis. It is characterized by a violation of the general reactivity of the body, due to the ingestion of toxic infectious agents from the tonsils. Exacerbations of chronic tonsillitis (sore throat) when contagious
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    In recent years, due to the deteriorating environmental situation, the prevalence of smoking, and a change in the reactivity of the human body, there has been a significant increase in the incidence of chronic non-specific lung diseases (COPD). The term KNZL was adopted in 1958 in London at a symposium convened by the pharmaceutical group Ciba. He combined such diffuse diseases
  9. Acute runny nose (acute rhinitis)
    Acute rhinitis (rhinitis acuta) is an acute nonspecific inflammation of the nasal mucosa. This disease is among the most common in both children and adults. The clinic distinguishes: • acute catarrhal rhinitis (rhinitis cataralis acuta); • acute catarrhal rhinopharyngitis, usually in childhood (rhinitis cataralis neonatorum acuta); • sharp
  10. Chronic duodenitis. Chronic gastroduodenitis
    Chronic duodenitis (gastroduodenitis) is a disease characterized by a chronic inflammatory process in the mucous membrane of the duodenum (and stomach). ETIOLOGY. In the etiology of the disease, impairment of diet and lifestyle, disorder of the neuro-endocrine regulation of the function of the stomach and duodenum, as a result of which motor function
  11. CHRONIC OBSTRUCTIVE LUNG DISEASES / CHRONIC BRONCHITIS AND LUNG EMPHISEMA /
    Chronic obstructive pulmonary disease is a pathological condition characterized by the formation of chronic airway obstruction due to chronic bronchitis / chronic obstructive pulmonary disease and / or pulmonary emphysema / EL /. Chronic obstructive pulmonary disease is widespread. It is estimated that HB affects about 14–20% of the male and about 3–8% of the female adult population, but only
  12. Chronic duodenitis
    - An inflammatory disease of the duodenum. Classification of chronic duodenitis Due to occurrence: primary, secondary; morphology: chronic duodenitis without atrophy; хронический атрофический дуоденит; by activity: period of exacerbation, period of remission. Diagnostic criteria 1) Pain; 2) dyspeptic syndrome (nausea, vomiting, heartburn,
  13. Хронические ларингиты
    Картина хронических катаральных ларингитов сходна с острыми, но их симптомы могут быть сглажены, течение волнообразное, сочетаются, как правило с хроническим фарингитом. Причины - хронические воспалительные заболевания трахеи, бронхов, легких, синуиты, вазомоторный ринит, неблагоприятные факторы среды - частое или постоянное охлаждение, примеси в воздухе, злоупотребление алкоголем. У 100% курящих
  14. Chronic pancreatitis
    Clinic Chronic pancreatitis is a chronic inflammation of the pancreatic tissue leading to fibrosis, loss of exocrine tissue and, consequently, to gland dysfunction. The Marseille-Roman classification of chronic pancreatitis includes three types: 1. Chronic colifiable pancreatitis, accounting for 80% of all cases of chronic pancreatitis and arising from the background
  15. Chronic pneumonia
    Chronic pneumonia is a chronic nonspecific bronchopulmonary process, based on irreversible morphological changes in the form of deformations of the bronchi and pneumosclerosis in one or more segments and accompanied by relapses of inflammation in the lung tissue and / or bronchi. Essentially a similar definition is currently given by therapists. It is believed that under chronic pneumonia
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