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DIABETES MELLITUS

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DIABETES MELLITUS STATE UNIVERSITY OF NEW YORK AT STONY BROOK 1 YEAR NURSING PROGRAM SUMMER 2008 HNI 364 What is it? A laboratory test also known as the Hemoglobin ... – PowerPoint PPT presentation

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Title: DIABETES MELLITUS


1
DIABETES MELLITUS
  • STATE UNIVERSITY OF NEW YORK AT STONY BROOK
  • 1 YEAR NURSING PROGRAM
  • SUMMER 2008 HNI 364

2
Case Study Diabetes Mellitus
  • The story of patient S.S.

3
Who is S.S.? Case History
  • White female, 5 tall, 87 lbs.
  • Active, thin 14 year-old
  • General good health, occasional cold/flu
  • Never been hospitalized
  • Family history maternal grandmother has
    hyperthyroidism

4
History of Present Illness (HPI)
  • Late fall, Mrs. S. noticed that S.S. was pale and
    less active
  • S.S. felt tired and began to avoid friends and
    activities (wanted to resign from cheerleading!)
  • S.S. was constantly hungry, but still thin.
  • S.S. noticed she had to use the bathroom after
    almost every class.
  • S.S. was irritable, had difficulty concentrating
  • Due to these symptoms, Mrs. S. took S.S. to
    family physicians

5
S.S.s current status
  • S.S. has lost 7 lbs in last week, despite eating
    5-6 meals /day.
  • Skin is pale and dry
  • VS are within normal limits, but respirations and
    ulse rates are higher than on previous physical
    exams.
  • Voiding lg. amounts of urine q 1-2 hrs
  • Constantly hungry, thirsty, fatigued
  • Fasting glucose level 396 mg/dl
  • Urine acetone

6
S.S. is diagnosed with Type 1 diabetes and
hospitalized to regulate her insulin!
7
Conclusions
  • S.S. and her family demonstrated technical
    competence and understanding in
  • Blood glucose monitoring
  • Urine testing
  • Diet activity
  • Sick day management
  • Reason for urine testing

8
S.S. released from hospital!!
9
Question 1A
  • What was the most likely cause of S.S.s polyuria
    and weight loss before her hospitalization?

10
No insulin formed by pancreas
Diabetes Type 1
No uptake of glucose by bodys cells
Accumulation of glucose in bloodstream (Hyperglyc
emia)
Increased solute concentration in blood due to
excess glucose
Polyuria
H20 moves from high to low solute concentration
from cells to intravascular space
Body excretes excess H20, glucose, and
electrolytes in urine
Cell dehydration
11
Why did S.S. lose weight?
  • When your body cannot utilize glucose for
    energy it will begin to breakdown adipose tissue
    or fat and use that for energy, which explains
    the weight loss.

12
Question 1B
  • What are normal blood glucose levels?

13
Normal blood glucose
  • Normal blood glucose levels, before meals, should
    be less than 100 mg/l.
  • Normal blood glucose levels, 2 hours after meals,
    should be less than 140 mg/l.
  • Realistic target levels for people on medication
    is 70 140 before meals and less than 180 after
    meals.

14
Question 2
  • Compare and contrast the signs and symptoms of
    diabetic ketoacidosis and insulin shock. Explain
    why each occurs.

15
The DIFFERENCES betweenketoacidosis insulin
shock
16
Lab tests
  • Ketoacidosis
  • High blood glucose levels (gt 250 mg/dL)
  • Accumulation of ketones in urine and blood
  • Insulin shock
  • Low blood glucose levels (lt 45 mg/dL)

17
Symptoms
  • Ketoacidosis
  • Extreme thirst
  • Dehydration
  • Dry mouth
  • Frequent urination
  • Fatigue
  • Nausea/Vomiting
  • Difficulty breathing
  • Difficulty concentrating
  • Insulin shock
  • Confusion
  • Difficulty concentrating
  • Irritability
  • Weakness
  • Tremors
  • Anxiety
  • Hunger

18
Hyperglycemia
19
(No Transcript)
20
Whats the deal with ketoacidosis?
  • When the body cannot use glucose for energy due
    to the lack of insulin, the glucose is converted
    into fat for energy.
  • Excess fat is broken down by the liver and
    produces ketone bodies, which end up in the urine
    (ketouria).
  • Polyuria further increases the concentration of
    ketone bodies in the urine.
  • Breakdown of protein in the body also produces
    ketone bodies, contributing to ketoacidosis.

21
What causes insulin shock?
  • Too much insulin in the blood due to overdose
    during an insulin shot.
  • Since insulin is responsible for uptake of
    glucose into bodys cells, too much insulin
    results in too little blood glucose.
  • Immediate intake of sugar will counteract insulin
    shock.

22
Similarities between ketoacidosis insulin shock
  • Both ketoacidosis and insulin shock are severe,
    emergency situations.
  • If left unaddressed they can both lead to coma.
  • The best way to prevent either one is to
    constantly monitor blood glucose levels.

23
Question 3 Why must insulin be injected?
Discuss the various types of insulin, their time
of onset, peak of action and duration of action.
Do persons with Type II diabetes ever require
insulin injections? If so, when and why?
24
Why must insulin be injected?
  • Insulin is a protein made up of two peptide
    chains linked together by disulfide bonds.
  • Proteins are broken down and digested by
    proteases (i.e. pepsin in the stomach trypsin
    in the small intestines)
  • If taken orally, insulin will therefore be broken
    down and deactivated, never reaching the blood
    stream
  • Insulin must be injected SQ to provide a more
    direct route of entry into the blood stream

25
Types of Insulin
  • Rapid (Quick-acting)
  • -Insulin Lispro
  • Short Acting
  • -Regular (R)
  • Intermediate-Acting
  • -NPH (N) or Lente (L)
  • Long-Acting
  • -Ultralente (U)
  • Pre-mixed

26
Rapid Insulin
  • Onset 5-15 minutes
  • Peak of Action 1 hour after injection
  • Duration of Action 3-4 hours

27
Short-Acting (Regular) Insulin
  • Onset 30-45 minutes
  • Peak of Action 2-3 hours after injection
  • Duration of Action 5-8 hours

28
Intermediate-Acting Insulin
  • Onset 2-4 hours
  • Peak of Action 4-10 hours after injection
  • Duration of Action 10-16 hours

29
Long-acting Insulin
  • Onset 6-10 hours
  • Peak of Action has a peak, but top speed
    looks like its normal speed
  • Duration of Action 20 hours

30
Pre-mixed Insulin
  • Onset 30 minutes
  • Duration 16-24 hours

31
Figure 2. Onset of action, peak, and
duration of action of exogenous insulin
preparations. (Neutral protamine Hagedorn
NPH) Reprinted with permission from the
American Diabetes Association's Clinical
Education Program "Insulin Therapy for the 21st
Century."
32
Do persons with Type II Diabetes ever require
insulin injections? If so, when why?
  • Type II diabetes occurs when the body produces
    enough insulin, but the ability to process use
    this insulin is lost (the body becomes resistant)

33
Type II Diabetes Insulin Requirements
  • Injections of insulin should mimic normal release
    patterns of the body
  • Long-acting insulin is usually injected 1-2x a
    day
  • In addition, short-acting or rapid-acting insulin
    is injected at mealtimes

34
Question 4Goal for a nutrition program for
children with Type 1 Diabetes
  • Maintain blood glucose levels without causing
    excessive hypoglycemia
  • When hypoglycemia occurs bring levels up to 80
    mg/dl
  • Foods low on glycemic index do not produce
    drastic changes in blood glucose levels i.e.
    whole grains, oranges and peanuts

35
  • DIET
  • - gt 50 calories from carbohydrates (1300
    kcal/day)
  • - 10-15 calories from protein (260-390
    kcal/day)
  • - 30-35 calories from fats (780-910 kcal/day)

36
Tips to help when eating out
  • keep a count of calorie intake
  • eat slowly
  • eat same portions as you would at home
  • order foods that are not breaded or fried
  • choose healthy alternatives
  • carry diabetes kit with you.
  • if rapid acting insulin is taken, try to delay
    injection until meal is served
  • talk to doctor about how to adjust insulin
    regimen when eating out

37
5A How do you prepare the injection? Why?
  • NPH (intermediate-acting) and regular
    (shortacting) are commonly mixed to produce
    differently-timed pharmacologic actions with a
    single injection.

The regular insulin is prepared first to
prevent it from becoming contaminated with the
intermediate-acting insulin (NPH).
38
Steps To Preparing Injection
  • Check the patient's name, medication, dosage,
    route and time of administration.

Carefully verify insulin labels.   Roll the NPH
vial between hands to resuspend the insulin
preparation.   If vial did not have cap on top,
wipe off with an alcohol swab. Verify dosage a
second time.
39
Steps To Preparing Injection (Cont.)
  • Take insulin syringe and aspirate volume of air
    equivalent to the dose of insulin to be withdrawn
    from the intermediate-acting (NPH) insulin
    first.
  • DO NOT LET THE TIP OF NEEDLE TOUCH THE INSULIN.
  • Remove syringe from vial without aspirating the
    insulin.
  •  

With the same syringe inject air equal to the
dose of insulin to be withdrawn from the
short-acting (regular) insulin.
40
Steps To Preparing Injection (Cont.)
  • Withdraw the correct dose into the syringe (10
    units of regular). Verify again that the correct
    dose has been withdrawn.
  •  
  • Place the needle of the syringe back into the NPH
    vial and withdraw the correct dose (10 units).
    Verify that the correct dose has been withdrawn.
  •  
  • The total amount of insulin in the syringe should
    be the sum of the two types (20 units).
  • Because short acting insulin was mixed with
  • intermediate-acting insulin, which reduces
  • the action of the faster-acting insulin,
    administer
  • the mixture within 5 minutes of preparation.

41
What Type of Syringe would you use?
  • A 50 or 100 unit Insulin syringe would be used
  • Insulin is measured in units (check the insulin
    bottle)
  • syringe measuring cc's or mL's cannot be used

Since the total amount to be given is 20 units,
a low dose 50 unit syringe is appropriate, but a
100 unit syringe may also be used.  
42
What sites could you use for the injection?
  • Insulin should be administered subcutaneously
  • There are 4 main sites
  • abdomen, posterior arms, anterior and lateral
    thighs and posterior hips
  • The insulin is absorbed faster in the abdomen and
    the rate of absorption decreases in the arms,
    thighs and hips

43
Education
  • Teach the patient what treatments are used, how
    the treatments work and how to administer the
    drugs
  • The patient should be aware of the effects of
    continuously injecting into the same site
  • They should know that it is important to rotate
    the injection site
  • They shouldnt inject into a limb that is to be
    exercised because it will be absorbed faster and
    may result in hypoglycemia.

44
Question 5 Lipodystrophy and What are some of
the long term complications of diabetes and why
do they occur?
  • Researchers J Strasheim M. Valerio
  • Ppt. Preparer Stefany Cimino
  • Presenter Nancy Yang

45
Lipodystrophy Localized Disturbance of Fat
Metabolism Below Skin Surface
  • Causes Not Rotating Insulin Injection Sites
  • 2 Forms
  • Lipoatrophy
  • Lipohypertrophy

46
Lipoatrophy Loss of Subcutaneous Fat Under the
Skin Surface Resulting in Small Dents
  • Appears as Slight Dimpling
  • Appears as Pitting (more serious)

47
Lip hypertrophy Buildup of Fat Below the Skin
Surface Causing lumps
  • Appears as Fibro-Fatty Masses.
  • Absorption is Delayed at these Sites.
  • Avoid these Sites Until Hypertrophy Disappears.

48
Question 5d
  • What are Some of the Long Term Complications of
    Diabetes and Why Do They Occur?

49
Diabetes Long Term Complications
  • Affects the Metabolism of Every Cell in the Body
  • Adversely Affects the Bodys Blood Supply
  • Can Lead to Life-Threatening and Disabling
    Complications Over Time
  • Therapeutic Management can Prevent or Delay the
    Onset of Various Complications

50
3 General Categories of Long Term Diabetes
Complications
  1. Macrovascular Disease
  2. Microvascular Disease
  3. Neuropathy

51
Macrovascular Disease
  • Atherosclerotic Changes in Larger Blood Vessels
  • Diabetics are more Prone to Develop than
    non-diabetics, but No clear-cut explanation Why
  • There is No Direct Link Between Hyperglycemia and
    Artherosclerosis
  • Diabetes is Seen as an Independent Risk Factor

52
Macrovascular Examples
  1. Coronary Artery Disease (CAD)
  1. Peripheral Vascular Disease (PVD)

53
Coronary Artery Disease
  • Artherosclerotic Changes in Coronary Arteries
  • Leads to MI and an Increased Chance of a 2nd MI

54
Peripheral Vascular Disease
  • Atherosclerotic Changes in Large Blood Vessels of
    Lower Extremities
  • Decreased Peripheral Pulses
  • Intermittent Claudication
  • Increased Chance of Gangrene, Amputation

55
Microvascular Disease
  • Changes Unique to Diabetics
  • Characterized by Capillary Basement Membrane
    Thickening
  • Increased Blood Glucose Levels React through a
    Series of Biochemical Responses to Thicken the
    Basement Membrane

56
Microvascular Examples
  • Diabetic Retinopathy
  1. Neuropathy

57
Diabetic Retinopathy
  • Changes in Small Blood Vessels in Retina

58
Neuropathy Conditions Affecting the Nerves
  • Renal Disease
  • Foot and Leg Problems

59
Renal Disease
  • Diabetics comprise 25 of the patients with
    End-Stage Renal Disease (ESRD) requiring dialysis
    or transplantation
  • Diabetics have a 20-40 chance of developing
    Renal Disease
  • Type I Diabetics show signs after 15-20 years
  • Type II Diabetics show signs within 10 years of
    diagnosis

60
Renal Disease After Onset
  • The Kidneys filtration mechanism is stressed,
    allowing blood proteins to leak into urine
  • Kidney Blood Vessel Pressure Increases-thought to
    serve as the stimulus for development of
    Nephropathy
  • As Renal failure progresses, catabolism of
    insulin decreases, and frequent hypoglycemic
    episodes result, requiring a change in insulin

DIABETIC NEPHROPATHY
61
Foot and Leg Problems
  • 50-75 of all Lower Extremity Amputations are
    performed on Diabetics
  • Increased risk of foot infections

62
Three Contributing Factors
  • Neuropathy
  • PVD
  • Immunocompromised Status

63
Neuropathy
  • Loss of pain and pressure sensation, increased
    dryness and fissuring due to decreased sweating

64
PVD
  • Poor Circulation in lower extremities, causes
    poor wound healing and increased risk of gangrene

65
Immunocompromised Status
  • Hyperglycemia Impairs the ability of specialized
    Leukocytes to destroy bacteria
  • Decreased Resistance to Infections

66
Prevention
  • Daily Foot Checks

67
What will you teach Ms. S.S. regarding the
following situations she may encounter ?
68
Question 6A.
  • Physical education classes
  • and
  • cheerleading practice

69
Physical education classes and cheerleading
practice
  • Exercise is an important part of any diabetes
    treatment plan.
  • Exercise can actually increase your bodys
    insulin sensitivity, which means your body
    requires less insulin to guide sugar into your
    cells.

70
Before and after physical education/ cheerleading
practice
  • Check glucose levels
  • You're good to go.
  • For most people, this is a safe pre-exercise
    blood sugar range.
  • Eat a healthy meal
  • Hydrate yourself

100-200 mg /dL
71
Bring snacks and enough water or Gatorade-type
drinks to physical education or cheerleading
  • If blood sugars are low try
  • ½ cup of juice or
  • few pieces of candy

72
If you feel lightheaded or dizzy at any time
  • Take a break
  • Eat and drink something to bring up glucose levels

73
Always take breaks to hopefully avoid feeling
lightheaded, dehydrated or dizzy
  • Check glucose levels after
  • if planning on exercising long

30 minutes
74
Wear cotton socks
75
Wear appropriate footwear(i.e. no flip flops or
sandals)
  • You need support and cushion
  • Check feet daily, especially plantar surface
    (bottom of foot)

76
What will you teach Ms. S.S. regarding the
following situations she may encounter
77
Question 6B.
  • Illness e.g. colds and the flu, episodes of
    diarrhea and vomiting?

78
Diabetes management
  • Creating your
  • sick-day plan

79
  • Diabetes management can be especially challenging
    when you're struggling with a cold or other
    illness.

80
  • Proper planning can help you prevent
    complications.

81
  • You don't feel well. Your temperature is high,
    you're tired and you've lost your appetite.
  • Having diabetes only adds to your concerns.

82
  • When you're sick, your body produces hormones to
    help fight the illness.
  • These hormones raise your blood sugar by
    preventing insulin from working effectively.
  • In people without diabetes, the additional sugar
    promotes healing.
  • But when you have diabetes, the fluctuations can
    result in potentially serious diabetes
    complications.

83
  • To prevent complications,
  • make a sick-day plan
  • part of your diabetes
  • management.

84
Start with your health care team
  • Talk to your doctor and other members of your
    diabetes care team about your sick-day plan.
  • Make sure your sick-day plan includes
  • What medications to take
  • How often to measure your blood sugar and urine
    ketones
  • How to adjust your insulin dosage, if you need
    insulin
  • How to manage any other conditions you may have
  • When to call your doctor
  • Also identify a loved one or friend who can
    contact your doctor or help you seek emergency
    care if you experience diabetes complications.

85
Keep close track of your blood sugar and urine
ketone levels
  • Continue taking your diabetes medication when
    you're sick, and remember to test your blood
    sugar often. You may need to adjust your insulin
    doses or other medications. Here are some general
    guidelines
  • Type 1 diabetes. Check your blood sugar and urine
    ketone levels every four hours.
  • Excessively high blood sugar can lead to
    ketoacidosis, especially in people who have type
    1 diabetes.  e conditions can be fatal.

86
  • Excessively high blood sugar can lead to
    ketoacidosis, especially in people who have type
    1 diabetes.  
  • These conditions can be fatal.

87
Stick to your diabetes meal plan
  • With a minor illness such as a cold, you may be
    able to stick to your diabetes meal plan which
    will help ensure blood sugar stability. Remember
    to check the sugar content of any
    over-the-counter medications you take. Many cough
    syrups and other liquid cold preparations are
    high in sugar.

88
If you have nausea, vomiting or diarrhea, you may
not be able to eat your regular foods. But it's
still important to get enough carbohydrates. Try
these foods, which contain about 10 to 15 grams
of carbohydrates each1 double-stick frozen
fruit pop
  • 1 cup milk
  • 1/2 cup fruit juice
  • 1/2 cup regular (not diet) soda
  • 6 saltine crackers
  • 3 graham crackers
  • 1 slice dry toast
  • 1/2 cup regular (not artificially sweetened)
    gelatin

89
  • In addition to sipping fruit juice or sweetened
    beverages, drink at least 8 ounces of water or
    other calorie-free liquid every hour you're
    awake.
  • If you're not able to keep anything down, it's
    especially important to monitor your blood sugar
    closely.

90
Know when to contact your doctor
  • Diabetes complications can quickly become
    dangerous.
  • Contact your doctor if
  • Your blood sugar level is higher than 300 mg/dL
  • Your blood sugar level is higher than 240 mg/dL
    for more than 24 hours
  • Your urine ketone level is moderate to high
  • You feel sleepier than usual or can't think
    clearly
  • You're unable to keep fluids down or vomit for
    more than six hours
  • You have diarrhea for more than six hours
  • You feel confused and can't think clearly
  • Your lips and tongue appear dry and cracked

91
Think prevention
  • High blood sugar can weaken your immune
    system. This makes you more likely to get a cold
    or the flu and more vulnerable to serious
    effects of common illnesses. To reduce the risk
    of getting sick, wash your hands often and avoid
    crowds during flu season.

92
Think prevention
  • Ask your doctor about
  • vaccination for flu
  • and
  • pneumococcal pneumonia.

93
  • If you do get sick,
  • feel confident in your ability
  • to manage your diabetes by following
  • your sick-day plan.

94
Infections
  • Respiratory Infections
  • People with diabetes face a higher risk for
    influenza and its complications, including
    pneumonia, possibly because the disorder
    neutralizes the effects of protective proteins on
    the surface of the lungs. In fact, deaths among
    people with diabetes increase by 5 - 15 during
    flu epidemics, and they are six times more likely
    to be hospitalized with complications from flu
    than non-diabetic patients who have flu. Everyone
    with diabetes should have annual influenza
    vaccinations and a vaccination against
    pneumococcal pneumonia.

95
Infections
  • Urinary Tract Infections
  • Women with diabetes face a significantly higher
    risk for urinary tract infections, which are
    likely to be more complicated and difficult to
    treat than in the general population.

96
6C Glycosylated Hemoglobin testing
97
Introduction
  • Hemoglobin on red blood cells combine with blood
    glucose to make glycosylated hemoglobin
  • Red blood cells store glycosylated hemoglobin
    slowly over their 120-day life span

98
What is it?
  • A laboratory test also known as the Hemoglobin
    A1C
  • Analyzes the concentration of glycosylated
    hemoglobin within the bodys circulation
  • Determines blood glucose levels

99
  • High blood glucose levels
  • Result in red blood cells storing large amounts
    of glycosylated hemoglobin
  • Normal or near normal blood glucose levels
  • Result in normal or near normal amounts of
    glycosylated hemoglobin

100
Why is it important?
  • High Glycosylated Hemoglobin puts you at risk
    for
  • eye disease
  • kidney disease
  • nerve damage
  • heart disease and stroke
  • especially true if the glycosylated hemoglobin
    remains high for a long period

101
How is the glycosylated hemoglobin test used?
  • Diagnostic tool used by doctors for diabetic
    patients since 1976
  • Offers a good estimate of disease management over
    a 2 to 3 month period, in contrast to other tests
    that give a onetime snapshot

102
  • Used in the routine monitoring of patients with
    diabetes mellitus
  • How well patient is responding to treatment
  • Low test values reduce risk for having
    complications from diabetes mellitus

103
How is the test performed?
  • Venipuncture
  • Some may feel moderate pain, or only a prick or
    stinging sensation.
  • Afterward, there may be some throbbing

104
Examples of glycosylated hemoglobin
  • A glycosylated hemoglobin level of 7 is
    considered to be good
  • 6 Very Good
  • 8 Not too bad
  • 10 Not good
  • 13 Dangerous

105
Benefits S.S. will derive from having the test
done
  • safely monitor her blood glucose levels
  • newly diagnosed pts may have to monitor levels
    closely over several 2-3 week periods

106
Disadvantages to using this test
  • Results require interpretation by a physician
    with knowledge of persons clinical condition
  • False high or low may result
  • Some medical conditions such as splenectomies
    falsely increase levels

107
Any Questions?
108
References
  • Potter, P.A., Perry, A.G. (2009). Fundamentals
    of Nursing (7th edition). St. Louis, MO Mosby,
    INC.
  • Smeltzer, S.C Bare, B.G. (1996).
    Medical-Surgical Nursing (8th edition).
    Philadelphia, PA Lippincott-Raven Publishers.
  • McCance, Huether et al. Pathophysiology. 4th
    Edition.
  • Abraham , E.C., Schwartz, M.K., (1985)
    Glycosylated Hemoglobins Mehtods of Anmalysis
    and Clinical Applications..
  • http//www.fda.gov/diabetes/glucose.html
  • http//www.endocrinologist.com
  • http//healthlibrary.epnet.com
  • http//www.healthatoz.com
  • http//www.labtestsonline.org/understanding/analyt
    es/a1c/test.html
  • http//www.nlm.nih.gov/medlineplus/ency/article/00
    3640.htm
  • http//www.mdconsult.com/
  • http//mayoclinic.com/

109
Question Intorduction .PPT Creator Sharon Jaffin Presenter Renee Brown
1 Alexis Galetta Kim Barressi 2Nicole Cariello Cynthia McCreight Sharon Jaffin Linda Rampil
3 Ron Casella Natalie De Roche 4Amar Singh Christina DeRosa Christina Barbuto Emily Gerbert Bridget Erwin Jennifer Dixon
5 Jamie Strasheim Marisol Valerio 1st ½ of Q5 Christine Abrams Kevin Budway
5 Jamie Strasheim Marisol Valerio 2nd ½ of Q5 Stef Cimino Nancy Yang
6 Katrina Stephano Karen Broomes-James Melinda Torey Q6 AB Ari Vigborn Stefanie Florio
6 Katrina Stephano Karen Broomes-James Melinda Torey Q 6 Finalization of .PPT Marissa Gonzalez Renee Brown
Game Alex Nee Marissa Lutzer Ashley Taylor Rose Massana
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