Accordingly order diltiazem overnight delivery medicine quizlet, both pressure and oxygenation of the blood in the left coronary artery decreases causing inadequate oxygen delivery to the myocar- dium purchase on line diltiazem symptoms zoloft. Over time order generic diltiazem from india medicine 5277, in an attempt to increase oxygen delivery, the left coronary vessels dilate and collaterals form to the right coronary system, which arises normally from the aorta. However, since the left coronary arises from the low- pressure pulmonary artery and the right coronary from the high-pressure aorta, collateral flow from the right coronary system passes into the left coronary sys- tem and then retrogrades through the left main coronary artery to the pulmonary artery. These collaterals effectively bypass the myocardial tissue and create a pulmonary artery steal from the coronary artery with resultant ischemia of the left ventricular myocardium, which leads to progressive left ventricular dysfunction and dilation in most cases. Felten Presentation/Clinical Manifestations Patients with an anomalous coronary artery that passes between the two great vessels may present with chest pain, dizziness, palpitations, or syncope during or immedi- ately after exercise. As mentioned above, the course of the coronary between the great vessels results in diminished coronary flow to the myocardium during exercise. This diminished flow can result in relative ischemia of that part of the heart, with resultant pain, ventricular arrhythmias (tachycardia or fibrillation), or diminished myocardial contractility. Ultimately, if the ischemia is significant enough, the patient will experience a sudden and dramatic drop in cardiac output. However, the majority of patients experience symptoms during exercise that lead them to seek medical attention. It should also be noted that many of the victims of sudden death have been athletes, so it is important that all individuals being evaluated for participation in sports be asked about the history of chest pain, dizziness, palpitations, syncope, or other symptoms associated with exer- cise. Those individuals who have a positive history should undergo further evaluation for potential anomalous coronary artery. It is interesting to note that there are patients who present with anomalous coronary between the great vessels as an incidental find- ing, apparently having had no previous symptoms. It is unclear why individuals with the same anatomic abnormalities can have such disparate outcomes. The presentation of anomalous left coronary artery arising from the pulmonary artery is quite different. Symptoms typically develop within the first 2–3 months of age, corresponding with the normal fall in pulmonary vascular resistance and resul- tant reversal of flow from the left coronary into the pulmonary artery. They may also be noted to have transient respira- tory distress, appear pale and sweaty, and may appear syncopal. It is thought that these symptoms are related to myocardial ischemia and associated angina. Signs and symptoms include the failure to thrive, tachypnea, lethargy, tachycardia, and diaphoresis. On examination, these patients may have poor perfusion, a murmur of mitral insufficiency, a gallop rhythm, or hepatomegaly. A small number of individuals improve with time and escape diagnosis as an infant. They may have transient shortness of breath and chest pain with exercise and continue to be at risk for sudden death. Chest Radiography Plain film X-rays are not useful in the diagnosis of an anomalous coronary artery arising from the wrong aortic sinus. Patients with anomalous origin of the left coronary artery from the pulmonary artery have X-ray findings consistent with dilated cardiomyopathy, 26 Congenital Abnormalities of Coronary Arteries 309 namely, cardiomegaly with left atrial and ventricular enlargement, and associated pulmonary edema. Echocardiography Echocardiography is the mainstay for the diagnosis of anomalous coronary arteries. An echocardiogram is recommended for all patients who present with syncope or chest pain associated with exercise to evaluate for the possibility of anomalous coronary arteries, as well as other cardiac abnormalities. It is important that Doppler color flow interrogation of the coronary arteries also be performed. Color flow can help to demonstrate the origins of the coronary arteries from the aortic sinuses and can also help to show a coronary artery passing between the two great vessels. The coronary flow can also be identified by Doppler color flow in the pul- monary artery as an abnormal diastolic flow signal at the point where the anoma- lous coronary artery enters. Echocardiography can also demonstrate other important findings in patients with anomalous coronary arteries, including ventricular size and function, the presence of atrioventricular valve insufficiency, and the presence of other congenital heart disease. Cardiac Catheterization Cardiac catheterization is typically only used in the diagnosis of anomalous coro- nary artery when other imaging modalities are inconclusive. Coronary angiography may help in demonstrating the anomalous origin of a coronary artery, but proving 310 R. Hemodynamic evaluation performed at cardiac catheterization can be useful in the management of certain patients with anomalous coronary arteries to evaluate cardiac output, filling pres- sures, and measurement of shunts, but in most cases these measurement are not necessary. Treatment/Management The treatment of an anomalous coronary passing between the great vessels or of anomalous origin of the left coronary from the pulmonary artery is predominately surgical. In the case of an anomalous coronary passing between the great vessels, surgical reimplantation of the abnormal coronary into the correct sinus can some- times be performed if the anomalous coronary artery arises as a separate origin from the abnormal sinus. In cases where a portion of the anomalous coronary courses in the wall of the aorta, the coronary may be “unroofed” such that the intra- mural portion of the coronary is opened to the lumen of the aorta so as to widen the origin and minimize tension or compression effects that may result from the coro- nary passing between the two great vessels. In the case of anomalous left coronary from the pulmonary artery, several surgical approaches have been used historically. If adequate collaterals have formed, one straightforward approach is to ligate the anomalous origin from the pulmonary artery to eliminate the pulmonary–coronary steal. This procedure has also been performed in association with a bypass graft to augment coronary flow if collaterals were not sufficient. Currently, however, the most accepted approach is direct excision and reim- plantation of the anomalous coronary from the pulmonary artery into the aorta. In these cases, an aortopulmonary window can be created and a baffle placed in the pulmonary artery to tunnel coronary flow from the aorta (Takeuchi procedure). It is generally accepted that surgical intervention should be undertaken in these patients at the time of presentation. Patients with significant cardiac dysfunction or heart failure may require acute medical management of these symptoms before proceeding to surgery. Long-Term Follow-Up and Prognosis It remains unclear as to what extent surgical intervention in cases of anomalous coronary passing between the great vessels minimizes the risk of sudden death. It is widely felt, though, that surgical intervention should be undertaken in any patient with the finding of an anomalous left coronary between the great vessels. The finding of an anomalous right coronary passing between the great vessels is more controversial, but surgical intervention is frequently undertaken, particularly in patients who are symptomatic in any way. Patients with a coronary arising from the pulmonary artery generally have significant improvement in their ventricular 26 Congenital Abnormalities of Coronary Arteries 311 function following coronary reimplantation, with some eventually returning to normal myocardial function. However, patients with significant myocardial injury at presentation often continue to have cardiac dysfunction and remain at increased risk for cardiac issues, including sudden death. Following surgical intervention for anomalous coronary arteries, some may benefit from medical therapy to improve cardiac function, such as diuretics and afterload-reducing agents.
There is a marked tendency to recurrence; in a few cases this may be at regular intervals buy genuine diltiazem on line medications requiring central line. Depressive psychosis Manic-depressive psychosis or reaction Endogenous depression Monopolar depression Involutional melancholia Psychotic depression Excludes: circular type buy generic diltiazem symptoms of breast cancer, if previous attack was of manic type (296 diltiazem 180 mg cheap symptoms for hiv. Bipolar disorder, now depressed Excludes: brief compensatory or rebound mood swings (296. The delusions are mostly of grandeur [the paranoiac prophet or inventor], persecution or somatic abnormality. Affective symptoms and disordered thinking, if present, do not dominate the clinical picture and the personality is well preserved. The rare cases in which several persons are affected should also be included here. Paranoia querulans Sensitiver Beziehungswahn Excludes: senile paranoid state (297. They should not be used for the wider range of psychoses in which environmental factors play some [but not the major] part in aetiology. Psychogenic depressive psychosis Reactive depressive psychosis Excludes: manic-depressive psychosis, depressed type (296. Psychogenic confusion Psychogenic twilight state Excludes: acute confusional state (293. Such states are particularly prone to occur in prisoners or as acute reactions to a strange and threatening environment, e. Where there is a diagnosis of psychogenic paranoid psychosis which does not specify "acute" this coding should be made. Responses to auditory and sometimes to visual stimuli are abnormal and there are usually severe problems in the understanding of spoken language. Speech is delayed and, if it develops, is characterized by echolalia, the reversal of pronouns, immature grammatical structure and inability to use abstract terms. There is generally an impairment in the social use of both verbal and gestural language. Problems in social relationships are most severe before the age of five years and include an impairment in the development of eye-to-eye gaze, social attachments, and cooperative play. Ritualistic behavior is usual and may include abnormal routines, resistance to change, attachment to odd objects and stereotyped patterns of play. The capacity for abstract or symbolic thought and for imaginative play is diminished. Performance is usually better on tasks involving rote memory or visuospatial skills than on those requiring symbolic or linguistic skills. Usually this loss of speech and of social competence takes place over a period of a few months and is accompanied by the emergence of overactivity and of stereotypies. In most cases there is intellectual impairment, but this is not a necessary part of the disorder. The condition may follow overt brain disease--such as measles encephalitis--but it may also occur in the absence of any known organic brain disease or damage. Symptoms may include stereotyped repetitive movements, hyperkinesis, self-injury, retarded speech development, echolalia and impaired social relationships. Such disorders may occur in children of any level of intelligence but are particularly common in those with mental retardation. Atypical childhood psychosis Excludes: simple stereotypies without psychotic disturbance (307. Neurotic disorders are mental disorders without any demonstrable organic basis in which the patient may have considerable insight and has unimpaired reality testing, in that he usually does not confuse his morbid subjective experiences and fantasies with external reality. Behavior may be greatly affected although usually remaining within socially acceptable limits, but personality is not disorganized. The principal manifestations include excessive anxiety, hysterical symptoms, phobias, obsessional and compulsive symptoms, and depression. Other neurotic features such as obsessional or hysterical symptoms may be present but do not dominate the clinical picture. In the conversion form the chief or only symptoms consist of psychogenic disturbance of function in some part of the body, e. In the dissociative variety, the most prominent feature is a narrowing of the field of consciousness which seems to serve an unconscious purpose and is commonly accompanied or followed by a selective amnesia. There may be dramatic but essentially superficial changes of personality sometimes taking the form of a fugue [wandering state]. If the anxiety tends to spread from a specified situation or object to a wider range of circumstances, it becomes akin to or identical with anxiety state, and should be classified as such (300. Unwanted thoughts which intrude, the insistency of words or ideas, ruminations or trains of thought are perceived by the patient to be inappropriate or nonsensical. The obsessional urge or idea is recognized as alien to the personality but as coming from within the self. Obsessional actions may be quasi-ritual performances designed to relieve anxiety, e. Attempts to dispel the unwelcome thoughts or urges may lead to a severe inner struggle, with intense anxiety. Anankastic neurosis Compulsive neurosis Excludes: obsessive-compulsive symptoms occurring in: endogenous depression (296. Anxiety is also frequently present and mixed states of anxiety and depression should be included here. Anxiety depression Reactive depression Depressive reaction Neurotic depressive state Excludes: adjustment reaction with depressive symptoms (309. It may follow or accompany an infection or exhaustion, or arise from continued emotional stress. If neurasthenia is associated with a physical disorder, the latter should also be coded. Depersonalization may occur as a feature of several mental disorders including depression, obsessional neurosis, anxiety and schizophrenia; in that case the condition should not be classified here but in the corresponding major category. It may occur as a feature of severe mental disorder and in that case should not be classified here but in the corresponding major category. Patients with mixed neuroses should not be classified in this category but according to the most prominent symptoms they display. The personality is abnormal either in the balance of components, their quality and expression or in its total aspect. Because of this deviation or psychopathy the patient suffers or others have to suffer and there is an adverse effect upon the individual or on society. It includes what is sometimes called psychopathic personality, but if this is determined primarily by malfunctioning of the brain, it should not be classified here but as one of the nonpsychotic organic brain syndromes (310).
The history of polio vaccines dates back carefully monitored and tested by the Centers for to the 1950s diltiazem 60mg overnight delivery medications 7 rights, when they were developed and Disease Control and Prevention order diltiazem mastercard medicine 10 day 2 times a day chart, the U discount diltiazem 60mg without prescription medicine naproxen 500mg. Jonas Salk introduced the first one that Drug Administration, the National Institutes of was widely used as a polio vaccine as a shot in Health, and other federal agencies. Hilary Koprowski introduced an oral polio labs and animals and three phases of testing in vaccine that people swallowed. All tissues and cells that dures, early vaccines were used on monkeys, are used to grow and produce any vaccine must be chimpanzees, guinea pigs, mice, and rabbits. Basically, the two kinds of durable plays a role in causing cancer, including in those power of attorney are one for health care deci- who got virus-contaminated polio vaccines (in the sions and one for ﬁnancial decisions. Also, the legal document can give or deny this agent the right to admit the ill person to power of attorney A legal arrangement that a psychiatric facility, the right to authorize psychi- gives an assigned individual the right to sign atric medications and treatments, and the right to checks, give medical consent, and conduct other decide about nursing home placement. Special business for a person with a terminal illness such as instructions can also be included in the document. A durable power of attorney can be Those who do assign someone durable power of exercised in the event that the ill person becomes attorney for health care may want to update it mentally incapacitated or unconscious. In most occasionally because laws regarding durable power states, this power can be assigned to anyone older of attorney are subject to frequent change. The basic plan is that this person will then have the right to sign on the person’s behalf if that becomes necessary. The goal is to pre- pregnancy The period during which a woman vent legal, ﬁnancial, and medical matters from carries a developing fetus. The doctor who is supervising wants it to go into effect or when the ill person the pregnancy should be informed of all perti- becomes incompetent. Two physicians’ agreement is the pregnant woman may not have tested posi- required to declare incompetence in a patient. The most important prevention message is this: avoiding sexual contact with other people is the only sureﬁre way to prevent getting a sexually prevention messages Public service announce- transmitted disease. The goal is to convey to sexually active people that they need to • Have a mutually monogamous sexual relation- make certain behavior changes if they are cur- ship with an uninfected partner. Risk of acquiring ners should make sure that a new condom is used for sexually transmitted diseases also increases with each separate act of intercourse. Department of Health • Avoid douching, which removes some of the and Human Services of the Centers for Disease Con- vagina’s normal bacteria, thus heightening the trol and Prevention. Ideally, those who are drug risk of sexually associated problems such as bac- users will seek help in a drug-treatment program. Lymphoma is a cancer of the vaccination is a good idea for anyone being evalu- lymphatic system. For example, genital the ﬁrst federal privacy standards to protect patients’ herpes outbreaks are often preceded by prodromal medical records and other health information took symptoms. The regulation proﬁles of behavior Epidemiological researchers covers health plans, health care clearinghouses, and often study various groups of people to determine health care providers who electronically conduct what sorts of lifestyles appear to contribute to the such transactions as enrollment, billing, and eligibil- spread of certain diseases. Certain small health plans have an transmitted diseases, proﬁles of behavior can spot- extra year to comply, but most health insurers, light groups whose needs should be addressed pharmacies, doctors, and other health care providers insofar as disseminating information on transmis- had to meet the April 14, 2003, deadline. Criminal prostatitis An inflammation of the prostate penalities apply for actions such as knowingly gland. Penalties range up to $50,000 and Causes one year in prison for certain offenses; up to By far, the most common type of prostatitis is non- $100,000 and up to five years in prison for bacterial. The others—chronic and acute bacterial offenses committed under false pretenses; and up prostatitis—stem from bacteria. Inﬂammation of to $250,000 and up to 10 years in prison for the prostate gland as a result of infection is com- offenses committed with intent to sell, transfer, or mon in men 50 and younger. A man who has nonbacterial prostatitis has pain (perineal, suprapubic, or low back) and urinary proctitis An inﬂammation of the rectum that is symptoms (frequent irritation, difﬁculty in urinat- characterized by diarrhea, bleeding, and unproduc- ing). Chronic prostatitis often causes recurrent uri- tive straining to have a bowel movement. This nary tract infections, low back pain, urination occurs in ulcerative colitis and sometimes in Crohn’s problems, pain after ejaculation, penile pain, disease and can also result from other conditions. Researchers in a review experiences fever and chills with urinary tract reported in August 2001 that routinely giving infection (or obstruction) symptoms, such as fre- antibiotics or alpha-blockers to men with chronic quent urination or difﬁculty urinating. However, some who has acute prostatitis may experience low back evidence supports using the two-glass test, and pain, perineal pain, joint pain, and malaise and will some small studies have shown that symptoms and probably feel very ill. Testing Also, some abacterial prostatitis patients ﬁnd relief Diagnosis of prostatitis is a matter of excluding pos- from pelvic pain via antioxidants (tomato extract, sibilities because prostate cancer, benign prostatic selenium, lycopene). In the largest prostate cancer enlargement, and prostatitis can coexist and symp- prevention study to date, the National Cancer Insti- toms may overlap. Enterococcus faecalis, Staphylococcus aureus, or coagu- The ﬁnal results will not be computed until the end lase-negative staphylococcus). Enrollment lasts from 2001 of a person with chronic prostatitis may show more through 2006. Chronic nonbacterial prostatitis yields sterile cultures—no Treatment bacteria or uropathogens. With acute chlamydia, gonorrhea, and nongonococcal urethri- prostatitis, the prostate is enlarged, indurated, and tis is initiated. Imaging may be necessary, if a Usually, for acute bacterial prostatitis, a doctor person is extremely ill, to rule out an abscess, which prescribes a 10- to 14-day regimen of antibiotics. For chronic nonbacterial prostatitis, a doctor There is not enough evidence of the accuracy of treats with several weeks of antibiotics (because of the gold standard four-glass test, long used to clas- the uncertainty of the cause of the prostatitis). To sify prostatitis as infectious, inﬂammatory, or non- ease irritation, the patient may try nonsteroidal inflammatory. Furthermore, studies that have anti-inﬂammatories, muscle relaxers, warm sitz examined currently used treatment methods are baths, normal sexual activity, and regular mild considered ﬂawed, and not one has been done in exercise, and should avoid spicy foods, caffeine, the United States. Some people believe that this kind of ﬁnasteride and other alpha-blockers, antiinﬂam- infection can be eradicated by repeated instances of matory medications, antibiotics, thermotherapy, ejaculation via masturbation, but this idea has not 180 psychiatric disorders been proved. There opportunistic infections, medication side effects, are a number of psychiatric disorders that are asso- and systemic illness. Doctors with delirium need to be treated in an intensive note that some people are so devastated by hearing care unit because they must be monitored care- the news of a sexually transmitted disease diagno- fully. Much depends on drawal, low oxygen concentration in the blood, the basic temperament of the individual, his or her electrolyte disorders, low blood sugar level, or medical history up to that point, and the particular low blood pressure. Psychiatric consultation is form of psychiatric distress, which can stem from recommended. Patients experiencing signs are in evidence, dextroamphetamine sulfate depression, for example, must be warned not to self- (dexedrine) or methylphenidate hydrochloride medicate without consulting their treating physician, (Ritalin) may be required. Also, caregivers should not let their own tions that sometimes result in distancing.
Incubation period—Usually 3–8 weeks order diltiazem 60 mg otc 7r medications, rarely as short as 9 days or as long as 7 years; depends on wound severity order diltiazem 60 mg with visa medicine reminder, wound site in relation to nerve supply and distance from the brain cheap 180mg diltiazem with amex treatment jalapeno skin burn, amount and strain of virus, protection provided by clothing and other factors. Period of communicability—In dogs and cats, usually for 3–7 days before onset of clinical signs (rarely over 4 days) and throughout the course of the disease. Longer periods of excretion before onset of clinical signs (14 days) have been observed with Ethiopian dog rabies strains. In one study, bats shed virus for 12 days before evidence of illness; in another, skunks shed virus for at least 8 days before onset of clinical signs. Susceptibility—All mammals are susceptible to varying degrees, which may be inﬂuenced by the virus strain. Humans are more resistant to infection than several animal species; a study in the Islamic Republic of Iran showed that, of those bitten by proven rabid animals and not treated, about 40% developed the disease. Preventive measures: Many preventive measures are possible at the level of the main animal main host(s) and transmitter(s) of rabies to humans. Educate pet owners and the public on the importance of restrictions for dogs and cats (e. Where dog control is sociologically impractical, repetitive total dog population immunization has been effective. Get physicians, veterinarians and animal control ofﬁcials to obtain/sacriﬁce/test animals involved in human and domestic animal exposures. If the biting animal was infective at the time of bite, signs of rabies will usually follow within 4–7 days, with a change in behaviour and excitability or paralysis, followed by death. All wild mammals that have bitten a person must be sacriﬁced immediately and the brain examined for evidence of rabies. In the case of bites by a normally behaving valuable pet or zoo animal, it may be appropriate to consider postexposure prophylaxis for the human victim, and, instead of sacriﬁcing the animal, hold it in quarantine for 3–12 weeks. If previously immunized, reimmunize and detain (leashing and conﬁnement) for at least 45 days. If such focal depopulation is undertaken, it must be maintained to prevent repopulation from the periphery. Although immune response has not been evaluated for antimalarials structurally related to chloroquine (e. If risk of exposure continues, single booster doses are given, or preferably serum is tested for neutralizing antibody every 2 years, with booster doses given when indicated. Sutures, if required, should be placed after local inﬁltration of antiserum (see 9b); they should be loose and not interfere with free bleeding and drain- age. Animal studies suggest that human disease caused by the Australian bat lyssavirus may be prevented by rabies vaccine and rabies immune globulin, and such post-exposure prophylaxis is recommended for persons bitten or scratched by any bat in Australia. Although rabies vaccine may not always be effective for the treatment of African bat lyssaviruses, it should be administered. If serum of animal origin is used, an intradermal or subcu- taneous test dose should precede its administration to detect allergic sensitivity. If sensitization reactions appear in the course of immunization, consult the health department or infec- tious disease consultants for guidance. If the person has had a previous full course of antirabies immunization with an approved vaccine, or had developed neutralizing antibodies after pre-exposure immunization (see 9A8) or after a postexposure regimen, only 2 doses of vaccine need to be given–one immediately and one 3 days later. Pregnancy and infancy are never contraindications to post-exposure rabies vaccination. Persons presenting even months after the bite must be dealt with in the same way as recent exposures. Factors to be considered in the initiation of post-exposure treat- ment are: nature of the contact; rabies endemicity at site of encounter or origin of animal; animal species involved; vaccination/clinical status and availability of animal for observation plus type of vaccine used; laboratory results of animal for rabies if available. Local reactions, such as pain, erythema, swelling or itching at the injec- tion site have been reported in 25% of those receiving 5 doses of 1. Mild systemic reactions of headache, nausea, muscle aches, abdominal pain and dizziness were reported in about 20%. These symptoms have responded to antihista- mines; a few have required corticosteroids or epineph- rine. Persons exposed to rabies who develop these symptoms should complete the required number of in- jections using a rabies vaccine prepared with another cell type. Newer commer- cially produced puriﬁed animal globulins, in particular equine globulin, have only a 1% risk of adverse reactions. The risk of contracting fatal rabies usually outweighs the risks of allergic reactions. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory case report required in most countries, Class 2 (see Reporting). Although transmission from a patient to attending personnel has not been documented, immediate attendants should be warned of the potential hazard of infection from saliva, and wear rubber gloves, protective gowns, and pro- tection to avoid exposure from a coughing patient. Epidemic (epizootic) measures: Applicable only to animals; a sporadic disease in humans. For protection of other domes- tic animals, use approved vaccines appropriate for each animal species. Disaster implications: A potential problem if the disease is freshly introduced or enzootic in an area where there are many stray dogs or wild reservoir animals. International measures: 1) Strict compliance by common carriers and travellers with national laws and regulations in rabies-free countries. Immu- nization of animals, certiﬁcates of health and origin, or microchip identiﬁcation of animals may be required. Vaccination Status Treatment Regimen* Not previously Wound All postexposure treatment to begin with immediate vaccinated cleansing thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as a povi- done-iodine solution should be used to irrigate the wounds. Previously Wound All postexposure treatment to begin with immediate vaccinated§ cleansing thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as a povi- done-iodine solution should be used to irrigate wounds. Strepto- bacillosis is caused by Actinobacillus muris (formerly Streptobacillus moniliformis or Haverhillia multiformis) and spirillary fever or sodoku by Spirillum minus (minor). Because of their clinical and epidemiological similarities, only streptobacillosis is presented in detail; variations mani- fested by Spirillum minus infection are noted in a brief summary. Identiﬁcation—An abrupt onset of chills and fever, headache and muscle pain, is followed within 1–3 days by a maculopapular rash most marked on the extremities. There is usually a history of a rat bite within the previous 10 days that healed normally. Bacterial endocarditis, peri- carditis, parotitis, tenosynovitis and focal abscesses of soft tissues or the brain may occur late in untreated cases, with a case-fatality rate of 7%–10%.
W. Barrack. Ashford University. 2019.
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