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Chemistry and Function of Glycosaminoglycans in the Nervous System. ADVANCES IN NEUROBIOLOGY 2023; 29:117-162. [DOI: 10.1007/978-3-031-12390-0_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Kormanyos Z, Reinert JP, Brady P. Heparin infusions in aneurysmal subarachnoid hemorrhages: clinical considerations for use beyond anticoagulation. Expert Rev Clin Pharmacol 2022; 15:1415-1421. [DOI: 10.1080/17512433.2022.2148654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Justin P. Reinert
- The University of Toledo, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Paul Brady
- Mercy Health St. Vincent Medical Center, Toledo, OH, USA
- The Neuroscience Institute at Mercy Health, Toledo, OH, USA
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Monsour M, Croci DM, Agazzi S. Microclots in subarachnoid hemorrhage: an underestimated factor in delayed cerebral ischemia? Clin Neurol Neurosurg 2022; 219:107330. [PMID: 35700661 DOI: 10.1016/j.clineuro.2022.107330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 12/01/2022]
Abstract
Subarachnoid hemorrhage has a poor prognosis due to the wide array of associated complications such as vasospasm, early brain injury, cortical spreading depression, oxidative stress, inflammation, and apoptosis. Each of these complications increases the risk of delayed cerebral ischemia (DCI), but recent research has suggested microclots play a substantial role in DCI incidence. This review will focus on the underlying inflammatory and coagulative mechanisms of microthrombosis while also outlining the current literature relating microclot burden to DCI. With a better understanding DCI pathophysiology as it relates to microthrombosis, more effective therapies can be developed in the future to improve clinical outcomes of SAH.
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Affiliation(s)
- Molly Monsour
- University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
| | - Davide Marco Croci
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA.
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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Ye F, Keep RF, Hua Y, Garton HJL, Xi G. Acute micro-thrombosis after subarachnoid hemorrhage: A new therapeutic target? J Cereb Blood Flow Metab 2021; 41:2470-2472. [PMID: 33993796 PMCID: PMC8393286 DOI: 10.1177/0271678x211013595] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Microthrombi formation in the brain following subarachnoid hemorrhage (SAH) has been recognized and suspected to contribute to cerebral ischemia. A recent study found that ultra-early cerebral micro-thrombosis occured four hours after experimental SAH. The number of thrombotic microvessels correlated with brain-blood barrier disruption and neuronal injury. If acute cerebral micro-thrombi also occur in humans, is it time to develop a therapy with systemic thrombolysis for SAH patients?
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Affiliation(s)
| | | | | | | | - Guohua Xi
- Guohua Xi, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI 48109-2200, USA.
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Liu W, Ye Q, Xi W, Li Y, Zhou X, Wang Y, Ye Z, Hai K. The ERK/CREB/PTN/syndecan-3 pathway involves in heparin-mediated neuro-protection and neuro-regeneration against cerebral ischemia-reperfusion injury following cardiac arrest. Int Immunopharmacol 2021; 98:107689. [PMID: 34153666 DOI: 10.1016/j.intimp.2021.107689] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Heparin, a commonly used anticoagulant, has been found to improve cerebral ischemia-reperfusion injury (CIR-CA) following cardiopulmonary resuscitation (CPR). Here, we aimed to explore the role of pleiotrophin (PTN)/syndecan-3 pathway in heparin therapy for CIR-CA. MATERIALS AND METHODS The CA-CPR model was constructed in Sprague-Dawley (SD) rats, which were treated with low molecular weight heparin, and the neurological changes and brain histopathological changes were evaluated. For in-vitro experiments, the ischemic injury model of primary neurons was established by oxygen and glucose deprivation (OGD), and the neuron regeneration was detected via the Cell counting Kit-8 (CCK8) method, flow cytometry and microscopy. CREB antagonist (KG-501), ERK antagonist (PD98059) and si-PTN were used respectively to inhibit the expression of CREB, ERK and PTN in cells, so as to explore the role of heparin in regulating neuronal regeneration. RESULTS Compared with the sham rats, the neurological deficits and cerebral edema of CA-CPR rats were significantly improved after heparin treatment. Heparin also attenuated OGD-mediated neuronal apoptosis and promoted neurite outgrowth in vitro. Moreover, heparin attenuated CA-CPR-mediated neuronal apoptosis and microglial neuroinflammation. In terms of the mechanism, heparin upregulated the expression of ERK, CREB, NF200, BDNF, NGF, PTN and syndecan-3 in the rat brains. Inhibition of ERK, CREB and interference with PTN expression notably weakened the heparin-mediated neuroprotective effects and restrained the expression of ERK/CREB and PTN/syndecan-3 pathway. CONCLUSION Heparin attenuates the secondary brain injury induced by CA-CPR through regulating the ERK/CREB-mediated PTN/syndecan-3 pathway.
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Affiliation(s)
- Wenxun Liu
- Ningxia Medical University, Yinchuan 750004, Ningxia, China; Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China; Ningxia Anesthesia Clinincal Medical Research Center, Yinchuan 750002, Ningxia, China
| | - Qingshan Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China; Ningxia Anesthesia Clinincal Medical Research Center, Yinchuan 750002, Ningxia, China
| | - Wenhua Xi
- Ningxia Medical University, Yinchuan 750004, Ningxia, China
| | - Yan Li
- Ningxia Medical University, Yinchuan 750004, Ningxia, China
| | - Xiaohong Zhou
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China
| | - Yun Wang
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China; Ningxia Anesthesia Clinincal Medical Research Center, Yinchuan 750002, Ningxia, China
| | - Zhenhai Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China
| | - Kerong Hai
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China; Ningxia Anesthesia Clinincal Medical Research Center, Yinchuan 750002, Ningxia, China.
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Hvas CL, Hvas AM. Hemostasis and Fibrinolysis following Aneurysmal Subarachnoid Hemorrhage: A Systematic Review on Additional Knowledge from Dynamic Assays and Potential Treatment Targets. Semin Thromb Hemost 2021; 48:356-381. [PMID: 34261149 DOI: 10.1055/s-0041-1730346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mortality after aneurysmal subarachnoid hemorrhage (aSAH) is augmented by rebleeding and delayed cerebral ischemia (DCI). A range of assays evaluating the dynamic process of blood coagulation, from activation of clotting factors to fibrinolysis, has emerged and a comprehensive review of hemostasis and fibrinolysis following aSAH may reveal targets of treatment. We conducted a systematic review of existing literature assessing coagulation and fibrinolysis following aSAH, but prior to treatment. PubMed, Embase, and Web of Science were searched on November 18, 2020, without time boundaries. In total, 45 original studies were eventually incorporated into this systematic review, divided into studies presenting data only from conventional or quantitative assays (n = 22) and studies employing dynamic assays (n = 23). Data from conventional or quantitative assays indicated increased platelet activation, whereas dynamic assays detected platelet dysfunction possibly related to an increased risk of rebleeding. Secondary hemostasis was activated in conventional, quantitative, and dynamic assays and this was related to poor neurological outcome and mortality. Studies systematically investigating fibrinolysis were sparse. Measurements from conventional or quantitative assays, as well as dynamic fibrinolysis assays, revealed conflicting results with normal or increased lysis and changes were not associated with outcome. In conclusion, dynamic assays were able to detect reduced platelet function, not revealed by conventional or quantitative assays. Activation of secondary hemostasis was found in both dynamic and nondynamic assays, while changes in fibrinolysis were not convincingly demonstrable in either dynamic or conventional or quantitative assays. Hence, from a mechanistic point of view, desmopressin to prevent rebleeding and heparin to prevent DCI may hold potential as therapeutic options. As changes in fibrinolysis were not convincingly demonstrated and not related to outcome, the use of tranexamic acid prior to aneurysm closure is not supported by this review.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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Zeyu Zhang, Yuanjian Fang, Cameron Lenahan, Sheng Chen. The role of immune inflammation in aneurysmal subarachnoid hemorrhage. Exp Neurol 2020; 336:113535. [PMID: 33249033 DOI: 10.1016/j.expneurol.2020.113535] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease, which mainly caused by the rupture of an intracranial aneurysm. Clinical trials have demonstrated that cerebral vasospasm (CVS) is not the sole contributor to delayed cerebral ischemia (DCI) and poor outcomes in patients with aSAH. Currently, accumulating evidence suggests that early brain injury (EBI), which occurs within 72 h after the onset of aSAH, lays the foundation for subsequent pathophysiological changes and poor outcomes of patients. The pathological mechanisms of EBI mainly include increased intracranial pressure, oxidative stress, neuroinflammation, blood-brain barrier (BBB) disruption, cerebral edema and cell death. Among them, the brain immune inflammatory responses involve a variety of immune cells and active substances, which play an important role in EBI after aSAH and may be related to DCI and long-term outcomes. Thus, attention should be paid to strategies targeting cerebral immune inflammatory responses. In this review, we discuss the role of immune inflammatory responses in the occurrence and development of aSAH, as well as some inflammatory biomarkers related to CVS, DCI, and aSAH outcomes. In addition, we also summarize the potential therapeutic drugs that target cerebral immune inflammatory responses for patients with aSAH in current research.
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Affiliation(s)
- Zeyu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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Albanna W, Merkelbach L, Schubert GA, Stoppe C, Heussen N, Riabikin A, Wiesmann M, Blume C, Jablawi F, Schiefer J, Clusmann H, Neuloh G. Risk of postprocedural intracerebral hemorrhage in patients with ruptured cerebral aneurysms after treatment with antiplatelet agents. J Neurol Sci 2020; 420:117219. [PMID: 33162063 DOI: 10.1016/j.jns.2020.117219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Endovascular treatment of ruptured cerebral aneurysms frequently requires antiplatelet medication to prevent thromboembolism. This might raise concern regarding the risk of postprocedural hemorrhage (pH), e.g. from placement of intracranial probes. We explored the risk of PH associated with standard antiplatelet therapy (sAP: acetylsalicylic acid, and/or clopidogrel) in the context of aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed a total of 146 consecutive cases with cerebral aneurysms treated between 1/2011-12/2015, and distinguished between minor (0.5 cm3) - 4 cm3) or major (> 4 cm3) PH occurring within four weeks after intervention. A separate analysis included hemorrhages related to placement of intracranial probes and drainages in the subgroup of 99 cases with such surgical interventions (pPH). Clinical outcome was assessed via Glasgow Outcome Scale (GOS) twelve months after aSAH. RESULTS A total of 49 cases (33.6%) in the overall sample sustained PH, there were 19 cases of pPH. Multifactorial analyses yielded sAP as an independent predictor for minor, but not major PH (p < 0.001 vs. p = 0.829), with comparable results for pPH (p = 0.001 vs. p = 0.184). sAP did not influence the clinical outcome in either group. CONCLUSIONS sAP was associated with a higher rate of minor PH and, more specifically, of minor pPH. However, it was neither accompanied by the occurrence of major hemorrhages nor by unfavorable clinical outcome. Future prospective studies should confirm these observations and hemorrhage risks associated with extended anticoagulation regimes after complex interventions and intra-arterial vasospasm therapy should be explored in order to facilitate interdisciplinary decision-making in aSAH.
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Affiliation(s)
- Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Germany.
| | | | | | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Germany
| | - Nicole Heussen
- Department of Medical Statistics, RWTH Aachen University, Germany; Medical School, Sigmund Freud Private University, Vienna, Austria
| | - Alexander Riabikin
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Germany
| | | | - Fidaa Jablawi
- Department of Neurosurgery, Justus-Liebig-University, Giessen, Germany
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Germany
| | - Georg Neuloh
- Department of Neurosurgery, RWTH Aachen University, Germany
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Ali D, Barra ME, Blunck J, Brophy GM, Brown CS, Caylor M, Clark SL, Hensler D, Jones M, Lamer-Rosen A, Levesque M, Mahmoud LN, Mahmoud SH, May C, Nguyen K, Panos N, Roels C, Shewmaker J, Smetana K, Traeger J, Shadler A, Cook AM. Stress-Related Gastrointestinal Bleeding in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Observational Study. Neurocrit Care 2020; 35:39-45. [PMID: 33150575 DOI: 10.1007/s12028-020-01137-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/OBJECTIVE Stress-related mucosal bleeding (SRMB) occurs in approximately 2-4% of critically ill patients. Patients with aneurysmal subarachnoid hemorrhage (aSAH) have a (diffuse) space-occupying lesion, are critically ill, often require mechanical ventilation, and frequently receive anticoagulation or antiplatelet therapy after aneurysm embolization, all of which may be risk factors for SRMB. However, no studies have evaluated SRMB in patients with aSAH. Aims of the study were to determine the incidence of SRMB in aSAH patients, evaluate the effect of acid suppression on SRMB, and identify specific risk factors for SRMB. METHODS This was a multicenter, retrospective, observational study conducted across 17 centers. Each center reviewed up to 50 of the most recent cases of aSAH. Patients with length of stay (LOS) < 48 h or active GI bleeding on admission were excluded. Variables related to demographics, aSAH severity, gastrointestinal (GI) bleeding, provision of SRMB prophylaxis, adverse events, intensive care unit (ICU), and hospital LOS were collected for the first 21 days of admission or until hospital discharge, whichever came first. Descriptive statistics were used to analyze the data. A multivariate logistic regression modeling was utilized to examine the relationship between specific risk factors and the incidence of clinically important GI bleeding in patients with aSAH. RESULTS A total of 627 patients were included. The overall incidence of clinically important GI bleeding was 4.9%. Of the patients with clinically important GI bleeding, 19 (61%) received pharmacologic prophylaxis prior to evidence of GI bleeding, while 12 (39%) were not on pharmacologic prophylaxis at the onset of GI bleeding. Patients who received an acid suppressant agent were less likely to experience GI bleeding than patients who did not receive pharmacologic prophylaxis prior to evidence of bleeding (OR 0.39, 95% CI 0.18-0.83). The multivariate regression analysis identified any instance of elevated intracranial pressure, creatinine clearance < 60 ml/min and the incidence of cerebral vasospasm as specific risk factors associated with GI bleeding. Cerebral vasospasm has not previously been described as a risk for GI bleeding (OR 2.5 95% CI 1.09-5.79). CONCLUSIONS Clinically important GI bleeding occurred in 4.9% of patients with aSAH, similar to the general critical care population. Risk factors associated with GI bleeding were prolonged mechanical ventilation (> 48 h), creatinine clearance < 60 ml/min, presence of coagulopathy, elevation of intracranial pressure, and cerebral vasospasm. Further prospective research is needed to confirm this observation within this patient population.
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Affiliation(s)
- Dina Ali
- University of Kentucky HealthCare, Lexington, USA.
| | | | - Joseph Blunck
- Saint Luke's Health System-Kansas City, Kansas City, USA
| | | | | | - Meghan Caylor
- Hospital of the University of Pennsylvania, Philadelphia, USA
| | | | | | | | | | | | | | | | - Casey May
- Ohio State Wexner Medical Center, Columbus, USA
| | | | | | | | | | | | | | - Aric Shadler
- University of Kentucky College of Pharmacy, Lexington, USA
| | - Aaron M Cook
- University of Kentucky HealthCare, Lexington, USA
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Dl-3-n-Butylphthalide promotes neovascularization and neurological recovery in a rat model of intracerebral hemorrhage. BMC Neurosci 2020; 21:24. [PMID: 32471341 PMCID: PMC7257157 DOI: 10.1186/s12868-020-00575-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/20/2020] [Indexed: 12/15/2022] Open
Abstract
Background Cerebral stroke occurs following ischemic and hemorrhagic lesions in the brain. Survival and recovery of stroke patients depend on the severity of the initial injury but also the therapeutic approaches applied for emergent lifesaving and continuing post-stroke management. Dl-3-n-Butylphthalide (NBP), an active compound derived from Chinese celery seeds, has shown clinical efficacy in the treatment of ischemic cerebral stroke. Results In the present study we explored the therapeutic effect of NBP in a rat model of intracerebral hemorrhage (ICH), focusing on its potential role in promoting neovascularization in the perihemorrhagic zone. ICH was induced in male Sprague-Dawley rats by unilateral injection of autologous blood into the globus pallidus, with sham-operated (Sham group), vehicle-treated (ICH) and NBP-treated (at 10 and 25 mg/kg/Bid, p.o., ICH + NBP10 and ICH + NBP25, respectively) groups examined behaviorally, macroscopically, histologically and biochemically at 1, 3, 7 and 15 days (d) post operation. Rats in the ICH + NBP10 and ICH + NBP25 groups showed reduced Longa’s motor scores relative to the ICH groups at the 3 and 7d time points, while the hematoma volume was comparable in the two NBP relative to the ICH groups as measured at 7d and 15d. In the perihemorrhagic zone, the numeric density of blood vessels immunolabeled by CD34, an angiogenic marker, was greater in the ICH + NBP10 and ICH + NBP25 than ICH groups, more so in the higher dosage group, at 1, 3, 7 and 15d. Levels of the vascular endothelial growth factor (VEGF) and angiopoietins-2 (Ang-2) proteins were elevated in the NBP groups relative to the sham and vehicle controls in immunoblotting of tissue lysates from the injection region. Conclusion These results suggest that NBP can alleviate neurological defects following experimentally induced local brain hemorrhage, which is associated with a potential role of this drug in promoting neovascularization surrounding the bleeding loci.
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