It's usually caused by bacteria. Biopsy of respiratory mucosa Infective endocarditis can occur at any age. It may cause fever, heart murmurs, petechiae, anemia, embolic phenomena, and endocardial vegetations. For most patients and procedures, a single dose shortly before the procedure is effective. The ESC criteria are similar to the modified Duke criteria but include expanded imaging results as major criteria as follows: Vegetation, abscess, pseudoaneurysm, intracardiac fistula, valvular perforation or aneurysm, or new partial dehiscence of prosthetic valve identified by echocardiography, Abnormal activity around a prosthetic valve (implanted > 3 months earlier) detected by PET/CT or single-photon emission computed tomography (SPECT)/CT with radiolabeled leukocytes, Paravalvular lesions identified by cardiac CT. Fever is almost always present initially, and patients appear toxic; sometimes septic shock Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. -UA The overall heart rate is 64 beats per minute. -shunts For more information, check out our privacy policy. -Renal toxicity secondary to medication (Vanco/Gent), -Effects up to 50% It may cause fever, heart murmurs, petechiae, anemia, embolic read more . -Hx Rheumatic Heart disease For gastrointestinal, genitourinary, and musculoskeletal procedures on areas involving infected tissue, antibiotics should be selected based on the known organism and its sensitivities. Endocarditis is inflammation of the endocardium which mainly affects the heart valves. -Degenerative Heart Disease -Valve Rupture 3. -HACEK However, bacteria on the skin or in the mouth, throat or gut (intestines) may enter the bloodstream and cause endocarditis under the right circumstances. CORRECT: Splinter hemorrhages in nail beds and a report of fever are findings associated with infective endocarditis. A client has developed atrial fibrillation, which has a ventricular rate of 150 beats per minute. -CXR The diagnosis of infective endocarditis is usually based on a constellation of clinical findings rather than a single definitive test result. -Rapid damage of cardiac structure -> heart failure If a patient has a valve what should you add to their empirical Tx? NURSING ACTIONS 9. o [ pediatric abdominal pain ] Instruct clients to take the medication with food. Infective endocarditis is definitively diagnosed when microorganisms are seen histologically in (or cultured from) endocardial vegetations obtained during cardiac surgery, embolectomy, or autopsy. Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts. Infective endocarditis occurs most often on the left side (eg, mitral or aortic valve). 3. May have a fever for a few days -Antifungal = Amphotericin. Spelman D, et al. Often, no source of infection or portal of entry is evident. She attended meetings about missionary programs whenever she could. What diagnostic test do you expect the physician to order in order to confirm the presence of infective endocarditis? Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. A. Local cardiac consequences include myocardial abscess, conduction system abnormalities, and sudden, severe valvular regurgitation. Many different things can cause germs to get into the bloodstream and lead to endocarditis. -Empyema In addition, antibiotic prophylaxis is not recommended for patients with valvular heart disease who are at high risk of IE for nondental procedures (e.g., TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection. Antibiotics should not be given until adequate blood cultures (minimally, generally 2 or 3 samples from different sites over 1 hour) have been obtained. The image on the left shows an Osler node (tender and erythematous nodule) on the thumb. information is beneficial, we may combine your email and website usage information with Chu VH, et al. This nursing test bank set includes 220 NCLEX-style practice questions that cover topics like dysrhythmias, EKG interpretation, heart failure, myocardial infarction, hematologic disorders, and more. 3. Synergistic Combination of Abx are used in what situations? C You must sign in or sign up to start the quiz. If endocarditis is suspected, 3 blood samples for culture (20-mL each) should be obtained, ideally > 6 hours apart (if presentation suggests acute bacterial endocarditis, 2 cultures within the first 1 to 2 hours). Complications and outcome of infective endocarditis. A nurse assesses the client for: A nurse is watching the cardiac monitor, and a clients rhythm suddenly changes. Monitor blood pressure. Complications of endocarditis may include: You can take the following steps to help prevent endocarditis: Certain dental and medical procedures may allow bacteria to enter your bloodstream. -Large Emboli of valve = > 10 mm, Patients at high risk for Endocarditis that need Prophylaxis Abx, -HX of IE information and will only use or disclose that information as set forth in our notice of In addition, the nurse needs to be aware of the causes, risk factors, and management of endocarditis, specifically infective endocarditis.. You know that this is a common finding in patients with infective endocarditis and is known as? I will only wash my hands with soap and water., C. I will inform my dentist about my history of endocarditis prior to any invasive procedures., D. I will avoid eating fish and organ meats.. Maternal newborn practice test B with rationa, Trauma: Exemplar 32.C Posttraumatic Stress Di. -Mitral Valve prolaps Symptoms of endocarditis can vary from person to person. Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). -can result from fluid accumulation in the pericardial sac. -Strep gallolyticus -Fungal Endocarditis, MC Organism that cause Native Valve Endocarditis, - + Rheumatoid Factor Antibiotic retreatment may be effective, but surgery may also be required. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. This lining is called the endocardium. Patients who use illicit intravenous drugs have a much higher incidence of right-sided endocarditis (about 30 to 70%). (For typical regimens, see table Some Antibiotic Regimens for Endocarditis Some Antibiotic Regimens for Endocarditis in the United States . Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. -Poor dentition/ dental infection/dental procedure information submitted for this request. The nurse responds that this procedure may stimulate the: A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. Prolonged infection may cause splenomegaly or clubbing of fingers and toes. 5. Accessed April 12, 2022. a. Valvular disease i. Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium. Bacteria, fungi or other germs get into the bloodstream and attach to damaged areas in the heart. 2022-06-22; what do these words have in common solver . However, the incidence of staphylococcal and enterococcal endocarditis has been increasing, and streptococcal endocarditis has been decreasing. -Prosthetic heart valve 2. Cerebral emboli occur in 33% of patients. Endocarditis occurs when bacteria or other germs enter the bloodstream and travel to the heart. 1. C. A 63 year old female who is newly diagnosed with hyperparathyroidism and is taking Aspirin. or For smaller children, the dose will vary according to the child's weight. Hello, Nitroglycerin administer during MI attack pattern is changed. Bicuspid aortic valves -Eikenella species Juni 22, 2022 We may earn a small commission from your purchase. Endocarditis also may result from asymptomatic bacteremia, such as typically occurs during invasive dental, medical, or surgical procedures. -Start after Blood cultures have been drawn at least 2 sets prefer 3 When endocarditis is present and no prior antibiotic therapy was given, all 3 blood cultures usually are positive because the bacteremia is continuous; at least one culture is positive in 99%. Empiric antibiotic regimens should reflect local patterns of infection and antibiotic resistance; however, typical examples of broad-spectrum antibiotic coverage may include, Native valves: Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours (not to exceed 2 g per dose), Prosthetic valve: Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours (not to exceed 2 g per dose) plus gentamicin 1 mg/kg IV every 8 hours plus either cefepime 2 g IV every 8 hours or imipenem 1 g IV every 6 to 8 hours (maximum dose 4 g per day). Institute antibiotic therapy as soon as possible to minimize valvular damage. Pericardial fluid can be sent to the laboratory for culture and sensitivity. Mayo Clinic. Negative blood culture results may indicate suppression due to prior antimicrobial therapy, infection with organisms that do not grow in standard culture media, or another diagnosis (eg, noninfective endocarditis, atrial myxoma with embolic phenomena, vasculitis). Prosthetic valves and other intracardiac devices are a particular risk. Copyright 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. Our online community of patients, survivors and caregivers is here to keep you going no matter the obstacles. Strokes can be Ischemic (80%), typically resulting read more , toxic encephalopathy (due to infective microemboli), and, if a mycotic CNS aneurysm ruptures, brain abscess and subarachnoid hemorrhage. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. N Engl J Med 380:415424, 2019. Monitor liver and kidney function levels. infective endocarditis ati quizletsouthwest cargo phone number. Closed on Sundays. The nurse assesses this rhythm to be: While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. If endocarditis persists in a patient with a newly inserted central venous catheter, that catheter should also be removed. Late-onset infections are caused mainly by contamination with low-virulence organisms during surgery or by transient asymptomatic bacteremias, most often with streptococci; S. epidermidis; diphtheroids; and the fastidious gram-negative bacilli, Haemophilus species, Actinobacillus actinomycetemcomitans, and Cardiobacterium hominis. Question 26 on exam 4: Inform clients that the medication can cause GI distress. In addition, length of hospital stay was shortened in the patients switched to oral therapy. Major predisposing factors are congenital heart defects Overview of Congenital Cardiovascular Anomalies Congenital heart disease is the most common congenital anomaly, occurring in almost 1% of live births ( 1). Some organisms (eg, Coxiella burnetii, Bartonella species, Chlamydia psittaci, Brucella species) require serodiagnosis; others (eg, Legionella pneumophila) require special culture media or polymerase chain reaction (eg, Tropheryma whippelii). There is also an increased risk in patients with indwelling intravascular catheters. Monitor for reoccurrence of manifestations after the procedure. -Radiates to Axilla -After 3 seta of blood cultures are drawn Infective endocarditis (IE) is an uncommon but life-threatening infection. Weakness-40% All Rights Reserved. The major goals of therapy for infective endocarditis are to eradicate the infectious agent from the thrombus and to address the complications of valvular infection. It can cause severe valvular insufficiency, congestive heart failure, and myocardial abscess, The microorganisms that most commonly produce endocarditis are S aureus, Streptococcus viridan, group A, C, and G streptococci, and enterococci, What is the HACEK group of microorganisms, Haemophilus (Haemophilus influenzae, Haemophilus parainfluenzae), cardiac conditions are associated with an increased risk of IE. Accessed May 6, 2022. However, a recent multicenter, randomized, non-blinded study of uncomplicated left-sided endocarditis found that switching to oral antibiotics (after a minimum of 10 days of parenteral therapy) to be non-inferior to continued parenteral therapy. Educate the client about the importance of taking medications as prescribed. A patient being treated for infective endocarditis is complaining of very sharp radiating abdominal pain that goes to the left shoulder and back. Anticoagulation should be withheld in patients with cerebral emboli, because it increases the risk of hemorrhagic transformation. The image on the left shows multiple Roth spots or retinal hemorrhages. -Azithromycin/Clarithromycin. Give antimicrobial prophylaxis for patients at high risk of an adverse outcome from infective endocarditis, including those with prosthetic heart valves or heart valve repair, previous infective endocarditis, certain congenital heart diseases, or who are heart transplant recipients with valvulopathy. Find more information on our content editorial process. 4. information highlighted below and resubmit the form. J Am Coll Cardiol 77(4):e25e197, 2021. doi: 10.1016/j.jacc.2020.11.018. The nidus for infection is usually a sterile fibrin-platelet vegetation formed when damaged endothelial cells release tissue factor. Computerized tomography (CT) scan or magnetic resonance imaging (MRI). -Brain, Liver, Lung, Spleen, soft tissue People with the highest risk for poor outcomes from IE may be prescribed antibiotics (IE prophylaxis) prior to certain dental procedures to reduce their risk of developing it. A, B, D (Listen for murmur or friction rub. DOI: 10.1056/NEJMoa1808312. The middle cerebral artery is involved most often. CLIENT EDUCATION It depends on the type of germs causing the infection and whether there are other heart problems. -Prosthetic Valve Endocarditis, -Aortic valve > mitral valve - IVDU )}$ The germs enter the bloodstream and travel to the heart. the unsubscribe link in the e-mail. J Am Coll Cardiol 77(4):e25e197, 2021. doi: 10.1016/j.jacc.2020.11.018, IV antibiotics (based on the organism and its susceptibility), Sometimes valve debridement, repair, or replacement, Dental evaluation and treatment (to minimize oral sources of bacteremia), Removal of potential source of bacteremia (eg, internal catheters, devices), Withholding anticoagulation in patients with cerebral embolism. This patient with infective endocarditis has multiple Osler nodes (tender, erythematous nodules on the toes). 2,500 review questions are now included on the Evolve companion website. one major and 2 minor criteria, Common Source of Bacteria for Endocarditid, -Staphylococcus aureus However, for high-risk patients who have an established GI or GU tract infection, or for those who receive antibiotic therapy to prevent wound infection or sepsis associated with a GI or GU tract procedure, the antibiotic regimen should include an agent active against enterococci, such as ampicillin or vancomycin. D. A 66 year old female who recently had an invasive dental procedure performed 1 month ago and is having a fever. Watch for indications of GI distress. -Abx administered Cutaneous manifestations include petechiae (on the upper trunk, conjunctivae, mucous membranes, and distal extremities), painful erythematous subcutaneous nodules on or near the tips of digits (Osler nodes), nontender hemorrhagic macules or papules on the palms or soles (Janeway lesions), and splinter hemorrhages under the nails. About 35% of patients have central nervous system (CNS) effects, including transient ischemic attacks Transient Ischemic Attack (TIA) A transient ischemic attack (TIA) is focal brain ischemia that causes sudden, transient neurologic deficits and is not accompanied by permanent brain infarction (eg, negative results on diffusion-weighted read more , stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Barrel chested or existing prosthetic valves Two parallel disks having equal diameters of 30cm30 \mathrm{~cm}30cm are maintained at 120C120^{\circ} \mathrm{C}120C and 34C34^{\circ} \mathrm{C}34C. You may want to request an endocarditis wallet card from the American Heart Association. -Group A hemolytic strep, Organisms that cause Late Prosthetic Valve Endocarditis, -staph aureus -and vascular phenonmen, Non-tender macular on the palms and soles Thank you! Use these questions to help you review for cardiovascular system disorders and as an alternative to Quizlet. All dental procedures that involve the manipulation of gingival tissue, the periapical region of teeth or the perforation of the oral mucosa. IE is uncommon, but people with some heart conditions have a greater risk of developing it. If surgery is necessary (due to heart failure or lack of therapeutic response), then valve repair is preferred over replacement to avoid future prosthetic valve infection due to any continued IV drug use. OR When bacteria are virulent or bacterial exposure is massive, ABE can affect normal valves. Infective endocarditis (IE) is an uncommon infectious disease with an annual incidence ranging from 3 to 7 per 100 000 person-years in the most contemporary population surveys. Image courtesy of CDC/Dr. The image on the right shows Janeway lesions (nontender and erythematous macules on the palm). IE occurs most frequently in patients with abnormal (leaky or narrow) heart valves, artificial (prosthetic) heart valve or in people who have a pacemaker lead. A. -Valve Rupture -Turbulent blood flow ->stenosis, regurgitation, congenital heart defects, Most common skin presentation of endocarditis, -Petechiae-most common peripheral lesions The lower chambers the right and left ventricles pump blood out of your heart. Almost any implanted foreign material (eg, ventricular or peritoneal shunt, prosthetic device) is at risk of bacterial colonization, thus becoming a source of bacteremia and hence endocarditis. There are different types of endocarditis, such as infective and non-infective endocarditis. Prosthetic valve endocarditis may be caused by MRSA or coagulase-negative staphylococci and vancomycin and gentamicin may be used for treatment, despite the risk of renal insufficiency. In what group and period of the periodic table is the element found? Home health services can be indicated if the client had surgery. 1. In patients without prosthetic valves, recrudescence of endocarditis after 6 weeks usually results from a new infection rather than a relapse. History (symptoms usually present acutely): Through history, physical exam, blood cultures, and other selected labs, echocardiography, electrocardiography, and chest xray. \textbf{Juan los prefiere llevar. Completely repaired congenital heart defect with prosthetic material or device, during the first six months after the procedure -1 Major & 3 minor -Pulmonary Emboli Established infections often cause a normocytic-normochromic anemia, elevated white blood cell count, increased erythrocyte sedimentation rate, increased immunoglobulin levels, and the presence of circulating immune complexes and rheumatoid factor, but these findings are not diagnostically helpful. -involving right heart valves, assess for septic emboli or metastatic abscess -Coag neg staph, -Rapid onset sacramento obituaries 2021; apartments on aldine mail route Thomas F. Sellers via the Centers for Disease Control and Prevention Public Health Image Library. The most common cause is dilation of the read more is typical. Monitor heart rhythm as changes indicate improper positioning of the needle. The nurse should expect to observe: When ventricular fibrillation occurs in a CCU, the first person reaching the client should: What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Initially, 15% of patients have fever or a murmur, but eventually almost all develop both. Exam 1: Infective Endocarditis 42 terms Images Hodges09 Endocarditis NCLEX Questions 9 terms florahill10 Endocarditis (highlighted questions) 20 terms anna_heitz Recent flashcard sets immigrant history 22 terms Evelyn_Cunningham7 CM exam 6 - sepsis 30 terms asf140 3.2.2- Active Transport 6 terms Images EmilyHarman16 Sets found in the same folder Endocarditis usually involves the heart valves. (NOTE: When you hit submit, it will refresh this same page. -Immunological Phenomena -Bacteremia = delivers organism to the surface of the vale -Location -Fungal organism 21st ed. Use for phrases 3. -Septic PE Rarely, purulent meningitis occurs. 0 Essay(s) Pending (Possible Point(s): 0). Habib G, Lancellotti P, Antunes MJ, et al: 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Bicuspid aortic valve is the most common congenital cardiovascular abnormality. NURSING CONSIDERATIONS 9. Illustrated Study Guide for the NCLEX-RN ExamThe 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. Symptoms and signs vary based on the classification but are nonspecific. Cahill TJ, Baddour LM, Habib G, et al: Challenges in infective endocarditis. These symptoms may mean the infection is getting worse: There is a problem with Usually, the body's immune system destroys any harmful bacteria that enter the bloodstream. Give your best for a perfect score! It can include one or more heart valves, the mural endocardium, or a septal defect. Definition Endocarditis is inflammation of the inside lining of the heart chambers and heart valves (endocardium). Prophylaxis often involves use of amoxicillin/clavulanic acid instead of a cephalosporin. National Center Empirical Tx choices are based upon many variables -IVDU The physician suspects possible infective endocarditis. Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. -New onset valvular regurgitation, Vascular Phenomena of Minor Duke Criteria, -Arterial emboli As the nurse, it is important to know how to care for a patient with endocarditis. -Enterococci Endocarditis should be suspected in patients with unexplained fevers, night sweats, or signs of systemic illness. NOTICE TO ALL USERSPlease be aware that our test banks are ALWAYS FREE OF CHARGE, and NO REGISTRATION IS REQUIRED. *these clothing items. Diffuse glomerulonephritis may result from immune complex deposition. (expert opinion). A client is having frequent premature ventricular contractions. Monitor for reoccurrence of cardiac tamponade. -Janeway Lesions Accessed May 6, 2022. Native valve endocarditis is often treated with penicillin G and gentamicin for synergistic coverage of streptococci. Inflammatory cardiovasciular disorder diagnostic procedures, Inflammatory cardiovascular disorder- Nursing Care, Auscultate heart sounds. -Subcutaneous nodules, -Fever, Arthralgia In addition, it provides 10 critical thinking pathways for analyzing exam questions. The P waves and QRS complexes are regular. Prednisone: Glucocorticosteroid given to treat inflammation 1. -Myocardial abscess tides equities los angeles does dawn dish soap kill ticks does dawn dish soap kill ticks other information we have about you. The question was asking about the most important long term goal for a hypertensive patient. Contact Us, Hours Serial TEE enables diagnosis of complications that evolve during treatment, such as increasing vegetation size or abscess formation. -Procedures on infected skin I have corrected the choices. The image on the right shows a close up of a Roth spot with central clearing. -Hemodialysis This content does not have an Arabic version. )* Previous coronary artery bypass graft surgery Acute bacterial endocarditis (ABE) usually develops abruptly and progresses rapidly (ie, over days). Written by American Heart Association editorial staff and reviewed by science and medicine advisers. -Erythema marginatum Infective endocarditis (IE) is a lethal disease if not promptly treated with antibiotics, either in association with surgery or not. Antibiotics should be broad spectrum to cover all likely organisms, typically including sensitive and resistant staphylococci, streptococci, and enterococci. Even toothbrushing and chewing can cause bacteremia (usually due to viridans streptococci) in patients with gingivitis. -Intracranial hemorrhage, Immunological Phenomena of Minor Duke Criteria, -Glomerulonephritis The nurse determines that the client is experiencing: A nurse is viewing the cardiac monitor in a clients room and notes that the client has just gone into ventricular tachycardia. This photo shows conjunctival hemorrhages in a patient with infective endocarditis. Show this card to your dentist, pediatrician, family doctor or other health care professional. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. 4. Blood cultures may require 3 to 4 weeks of incubation for certain organisms; however, some proprietary, automated culture monitoring systems can identify positive cultures within a week. It can cause severe valvular insufficiency, congestive heart failure, and myocardial abscess What infectious agents cause IE Saturday: 9 a.m. - 5 p.m. CT Prosthetic cardiac valves -New onset valvular regurgitation, Persistent infection that would need surgery for IE, -Blood Culture remains positive for 5-7 days -Aortic >mitral Advise all providers, including dentists, of history of endocarditis so that antibiotic prophylaxis is prescribed if needed. All the best! How many cases of I.E. Use the ATI Active Learning Template: System Disorder to complete this item. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. Prednisone: Nursing considerations/client teaching, NURSING CONSIDERATIONS Pets and Your Health / Healthy Bond for Life, La Iniciativa Nacional de Control de la Hipertensin, American Heart Association wallet card (PDF), Prevention of Infective Endocarditis Wallet Card (PDF). Common in IV drug users or clients who have cardiac malformation. Vegetations may result in valvular incompetence or obstruction, myocardial abscess, or mycotic aneurysm. Ibuprofen: Nursing considerations/client teaching. A. Join the nursing revolution. -Cefazolin/Ceftriaxone IV, Prophylactic Tx if unable to take penicillin due to allergy, -Clindamycin Educate the client and family about the illness, and encourage them to express their feelings. If you're at risk of endocarditis, tell your health care providers. The nurse interprets this rhythm as: A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. Delete ( ) unnecessary commas. A nurse is caring for a client with unstable ventricular tachycardia. SBE often develops on abnormal valves after asymptomatic bacteremia due to periodontal, gastrointestinal, or genitourinary infections. Risk factors for developing IE include: Heart valve disease Click here for an email preview. -Recent Procedures -Acute needs immediate Abx A, C, F, G For question no 48, I think Cardiac tamponade includes jugular vein distention decreased urine output, not increased urine output as indicated in your answers. -Strep Viridans After starting therapy, patients with penicillin-susceptible streptococcal endocarditis usually feel better, and fever is reduced within 3 to 7 days. -results in Endocarditis, -Renal infarct or abscess Symptoms and signs of valvular insufficiency may be a first clue. Without early identification and treatment, a myriad of intracardiac and far-reaching extracardiac complications can develop. Earned Point(s): 0 of 0, (0) -Tetralogy of Fallot Early surgery in these patients decreases the risk of embolic events. It has sensitivity of 90 to 100%. Treatment consists of a prolonged course of antimicrobial therapy (1 Treatment references Infective endocarditis is infection of the endocardium, usually with bacteria (commonly, streptococci or staphylococci) or fungi.
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