110木村班GL念校.indd

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1 1

2 2012 2

3 ST 2013 acute coronary syndrome: ACS ST ST 3 3 ST ST 2012 ST percutaneous coronary interventionpci magnetic resonance imaging MRI universal definition 99 1) ST ST 12 ST ST

4 2012 ST ST I II IIa IIb III A400 B400 C Davies 2) Fuster 3) acute coronary syndromeacs ST ST-elevation acute myocardial infarctionstemi 4

5 ST

6 ) 1980 DeWood 5) Kodama 6) 92 Asakura 7) T vulnerable plaque 8,9) calcified nodule calcified nodule 10) positive remodeling T T 10) 11) optical coherence tomographyoct 12) 13) OCT fibrous cap thin fibrous cap fibroatheroma TCFA 14) 7) vulnerable patient 15) 40 16) 17) universal definition 1 2 1) 6

7 ST 2013 STEMI hypokinesis akinesis dyskinesis 18) dp/dt 19) 1 Frank-Starling 20) angiotensin converting enzymeace 21) BNP 22) STEMI 6 3) Hurler Fabry CO DIC 23) 17,24,25) 26,27) ,29) NIPPON DATA National Integrated Project for Prospective Obser vation of Non-communicable Disease And its Trends in the Aged 30) HDL 135 mmhg 85 mmhg 2 7

8 ) 32) ) 34) 35) 36) 37) ) 39) LDL 40,41) ) J-LITJapan Lipid Intervention Trial 43) 44) CKD 45) CKD 46) CKD 47) Ni-Hon-San 48) 49,50) 51) 52) ) ) ) STEMI 56) ) MIYAGI- AMI Registry ) OASIS ) 2005 HIJAMI ) MIYAGI-AMI Registry ) CCU ) 8

9 ST ) STEMIcoronary care unitccu 7 59) STEMI CCU STEMI ) STEMI 63,64) door-to-balloon time onset-to-device time onsetto-device time STEMI ) ACC/ AHA STEMI CCU ) STEMI STEMI STEMI 14 ventricular fibrillationvf VF 60 61) automated external defibrillatoraed 12 69) AED AED 62) AED 9

10 cardiopulmonary resuscitationcpr CPR CPR CPR 70,71) 2010 ILCOR CoSTR AHA CPR BLSbasic life support CPR AED STEMI 66-68,72) ,74) AED 1 mg/ ,74) 73,74) 10

11 ST IV. 14 STEMI 75-77) CI ) AHA CPR/ECC 2010 PCI 90 79) Watanabe TIMI ) Nakao 2 facilitated PCI TIMI 3 81) Kimura primary PCI 90 TIMI 3 68 primary PCI 43 82) 30 PCI 2 PCI 83, 84). AHA/ACC ST /PCI 2009 PCI primary PCI PCI PCI PCI 85) 11

12 2012 STEMI PCI CABG STEMI TIMI PCI 12 86,87) 12 CCU 24 CCU STEMI 12

13 ST ) STEMI STEMI PCI CABG CCU CCU 13

14 2012 STEMI ) 12 STEMI 30 PCI first medical contact ) STEMI 95-98) 20 14

15 ST ) 100) 97,98) Ca 101) 15

16 Bezold-Jarisch 90 mmhg III III Killip 102) thrill 4 23 III Killip 102) STEMI Stanford A 5 16

17 ST 2013 STEMI 103) 104,105) Thyperacute T T R ST Q STEMI 106) 510 V4R V4R 1mm 0.1mV ST ST 10 ST 107) STEMI ST ST 108,109) ST V1V4 ST V7V9 ST ST T ) ST 114) V1V3 ST QS ST avr ST PR avr ST PR WPWWolff- Parkinson-White 2 ST-T QRS 1mm ST V1V3 1mm ST QRS 5mm ST STEMI 115) V1 V3V4 ST qr V1 rr R 116) avr ST V1 ST 117). 12 Cabrera sequence 118) avl I avr avr III II Cabrera sequence 12 STEMI 119) STEMI 12 17

18 ,121) primary PCI PCI ) 12 STEMI ) STEMI 131) creatine kinaseckmbck-mb H-FABP TI T 6 STEMI I 132) CK 133,134) 135) STEMI CK CK 99 CK ESC/ACCF/AHA/WHF universal definition 136,137) 2 138) 2 139,140) H-FABP H-FABP H-FABP 2 141) 142) 18

19 ST 2013 X X X X X ,144) echo free space diastolic 19

20 2012 collapse Doppler intimal flap STEMI STEMI ) Killip 102) Killip IV a) mmhg 90 mmhg SHOCK Registry b) GRACE TIMI GRACE Killip ST STEMI 6 152,153) GRACE GRACE ) TIMI 8 155) GRACE TIMI simple risk indexcadillac simple risk index / ) CADILAC PCI Killip 3 PCI TIMI 7 157) STEMI 20

21 ST ) 159) L/ CO2 160) 161) 162) mmhg 30 mmhg50/ 100/ ) 24 mg mg 21

22 mg mg ) STEMI mg 81 mg mg 23 PCI 2 loading dose300 mg 172,173) 600 mg 174) 75 mg/ 85,175,176) ) PCI ACT TIMI 2 178) tpa 179,180) tpa APTT V ,182) 22

23 ST 2013 heparin-induced thrombocytopenia: HIT 183,184) immune-mediated HIT II HIT 1 HIT 185) HIT HIT 186) ) 2 192) PCI ) 194) PCI 195) ,197) VI. 38 PCI STEMI 6 5) Fabry Hurler 23

24 2012 CO DIC 23) Stanford A 39 STEMI Marfan B A X STEMI intimal flap CT intimal flap A 198) STEMI , 200) STEMI ) ) coronary artery bypass graftingcabg 201) intravascular ultrasound IVUSOCT ST universal definition 2 1) ) 202) Prizel ) ) 207,208) PCI 1970 universal definition 2 1) 24

25 ST ) 210) Ueda 211) STEMI A 212) 213) P- 214) ,216) 69 17) ) STEMI STEMI Ca STEMI ) Fabry 23) STEMI PCI 64,72) first medical contact door-to-needle time 30 PCI first medical contact door-to-device time 90 PCI PCI 3 PCI 217,218) PCI PCI PCI 60 PCI 60 94) 25

26 2012 PCI PCI STEMI 219) 60PCI 3 PCI 217,218) STEMI PCI PCI 219) 10 57,220) PCI universal definition STEMI ST 26

27 ST /110 mmhg ST PCI /kg TIMI 2 PCI 27

28 kg mL 1 PCI PCI PCI primary PCI 151a,217,218, ) ) STEMI PCI PCI 3 PCI PCI STEMI STEMI primary PCI 24 primary PCI PCI STEMI primary PCI 242,243) STEMI 244,245) 28

29 ST ) primary PCI no reflow ) TIMI 253) 254,255) no reflow STEMI a) ,247,248) 12 STEMI primary PCI 12 ST primary PCI 29

30 2012 PCI facilitated PCI rescue PCI facilitated PCI PCI PCI PCI rescue PCI PCI STEMI 2 PCI PCI PCI PCI systematic PCI systematic PCI 83,84) systematic PCI primary PCI 256,257) PCI PCI 83,84) PCI CABG STEMI CABG ,259) CABG CABG 258, ) 267) STEMI CABG 48 CABG 266,268) CABG primary PCI CABG 30

31 ST 2013 CABG CABG 151a, ) CABG CABG 272) ST 273) CK CK-MB MB ) rescue PCI 275) primary PCI TIMI PCI TIMI 2 TIMI 3 276) TIMI frame count 277) TIMI 3 no reflow 1/4 278) myocardial blush grade blush 279,280) 281) primary PCI ST reperfusion arrhythmiast myocardial stunning 282) 283) 284) remote ischemic conditioning 285) 31

32 ) 294, 295) STEMI PCI primary PCI ACC/ AHA /kg ACT ) 286) ACT APTT 287,288) 6 3 HIT 289) 10 HIT I II I II PF4HIT STEMI 296) HIT PCI 297) HIT 2011 HIT PCI PCI 0.1 mg/kg g/kg/ 10 ACT 4 ACT ) 4 0.7g/kg/ APTT APTT g/kg/ 10 Xa OASIS- 5 Fifth Organization to Assess Strategies in Ischemic Syndromes ST ST PCI 299) 32

33 ST 2013 OASIS-6 STEMI 300) primary PCI 175) III Xa Xa STEMI 301) 172,176, ) 2012 J-AMI STEMI 300 mg/ 75 mg/ 304) STEMI 172,176,302,304,305) 600 mg ACC/AHA mg ) ACC/AHA STEMI ACC/AHA 1 85) j-cypher ) ) 12 2 dual anti-platelet therapy DAPT proton pump inhibitorppi 311,312) PPI PPI ) PPI PPI ) PPI H2 319) DAPT III primary PCI 320) 321) 33

34 2012 A reperfusion injury salvage kinase 0.025g/kg/ 3 HayashiKasama ST 322,323) J-WIND-ANP 569 PCI 0.025g/kg/ 3 CK ) ATP KATP KATP NO PCI Ito PCI 4 mg 24 6 mg/ no reflow 325) Ishii primary PCI mg TIMI frame count ST resolution 326) Iwakura 327) PCI TIMI 3 no reflow 328) 329) 2 mg 30 J-WIND-KATP 0.067mg/kg g/kg/ CK 324) AMISTAD 330) 331) primary PCI 332,333) EPO-AMI 34

35 ST 2013 II 334) STEMI PCI 282,335) 336) 337) STEMI 624 PCI 2 338,339) PCI 338,340) 273,341) 342) 340) ST PCI TIMI 0 343) primary PCI 344) primary VF 345) STEMI mg/ dl ) mg/dl ) Cigarroa 5 mlkg300 ml/ mg/dl 348) Gurm /Cockcroft-Gault 349) ) risk-benefit IABP 351,352) 35

36 ) N- 356) 357) 358) PCI ) 362) 363) 364) ) STEMI CCU CCU 1962 Day 365 Kansas Bethany Philadelphia Presbyterian Toronto 1968 coronary care unit CCU cardiac care unit circulatory care unit CCU chest pain unit chest pain center 366,367) CCU 368) CCU PCI CABG 300 CCU 369) CCU 370) Swan- Ganz 371) 372,373) CCU 36

37 ST 2013 CCU 369) Swan-Ganz pulmonary capillary wedge pressure: PCWP cardiac indexci 48 CK ,374,375) CCU PCI 1 376) PCI 6 79) 377) VII. 67 CCU 2 CK 2 PCI 800 kcal/ 6 g/ 378) 1 CCU ) 381) 382) 200 mg/dl 383,384) 385) CCU 386) Foley 387) 388) 37

38 ) 390) A CCU CCU 391) 3 PCI 396) no reflowpci CCU :. Killip 145) CKD T I brain natriuretic peptidebnp N NTproBNPST STEMI 392,393) primary PCI 394,395) STEMI primary PCI 20 STEMI STEMI primary PCI STEMI REACH 397) primary PCI 38

39 ST 2013 STEMI ,398) 2448 ACE ) mg/ STEMI 171,293,400) 75 mg/ 300 mg/ 171) STEMI PCI PCI 300 mg 75 mg/ 302) ) ACC/AHA 12 39

40 ,303,304) ,305) 401) DAPT2 402) PT-INR 2.0 LDL ) MUSASHI- AMI 406) LDL IVUS ESTABLISH 407) JAPAN-ACS 408) Extended- ESTABLISH 409) LDL LDL 410,411) Ca STEMI Ca 412,413) 414) 415) 416) 198 mg/dl DIGAMI 40

41 ST mg/dl mg/dl 417) 162 mg/dl GIK CREATE-ECLA 24 GIK 155 mg/dl 135 mg/dl 418) ) NICE-SUGER mg/dl180 mg/ dl 144 mg/dl 383) 40 mg/dl p p = ) 41

42 2012 VF VFprimary VF ) ) VF VF secondary VF VF PCI ICUCCU VF VF VF VF ISIS-3 345) III 428) VF 429) VF 162) ISIS-4 4 VF VF VT 1 2 cardiopulmonary resuscitationcpr AHA ACLS ) J J CPRVFVT 2 CPR 1mg CPR3 CPR AHA ) 300 mg 5 mg/kg QT torsades de pointes K VF VT 431,432) VF VF VT 433,434) 42

43 ST ,436) VF VT CPR VF VT VF VT CPR CPR percutaneous cardiopulmonary support systempcps CPR percutaneous cardiopulmonary support system PCPS PCI 437) STEMI VF VT intra-aortic balloon pumpingiabpextracorporeal membrane oxygenationecmo PCI 43

44 2012 VT 30 VT 30 VT VT VT 170bpm VT VT 438,439) wide-qrs tachycardia 12 wide-qrs tachycardia VT wide-qrs tachycardia VT VT VT VF VT 100J VT 430,440) VT AHA ) 2 VT 125 mg mg mg mg 24 VT VF 125 mg mg/24 VT ) VT VT 44

45 ST 2013 VT 431,432,445) mg/kg mg/kg/ torsades de pointes mg/kg mg/kg/ STEMI VT VF electrical storm ) IABP PCl 449,450) VT 451) VT VF ph CAST Ic 452) STEMI Ic AIVR 12 VF 344,453) AIVR VF ) 45

46 2012 STEMI ,455) ) 454) 456) 200 J J 430) Ca 457) 458) 459) 2008 ESC 121) 2011 ACCF/ AHA/HRS 460) 2 10 mg 1 1 mg mg/kg mg/kg/ 10.1mL/ kg 1 mg/kg mmhg 50/ 461) 462) Ca 60 6 ACE 455) CAPRICORN ) VF PEA 464) 465,466) 467) PEA ) PEA STEMI Ca 46

47 ST mg 5 3 mg 210g/ 210 g/kg/ 469). STEMI 614 STEMI 469). 470) 3 QRS 210g/ 210g/ kg/ 3 STEMI Mobitz II 2 STEMI 2 1 Mobitz I 2 STEMI ). STEMI 47

48 2012 His- Purkinje STEMI 1 474) ) 1 476) STEMI ) 1 extension Killip 102,478) STEMI 29,145,155,479) Swan-Ganz 480) Forrester 200 PCWPCI 4 hemodynamic subset 481) 48

49 ST 2013 ACE ARB IABP PCPS Nohria Nohria-Stevenson 482,483) Forrester 4 X 484) Swan-Ganz Swan-Ganz 5 485) 49

50 2012 primary PCI 486,487) noninvasive positive pressure ventilationnppv ) pressure support ventilation : PSV positive end expiratory pressurepeep bilevel positive airway pressure : BiPAP continuous positive airway pressurecpap 491) 492) 35 mg 493) mmhg 20 mg V2 494) A ANP ) PCI PAMI-II PCI IABP 498) PCI 3 IABP 50

51 ST ) 15g/kg/ IABP PCI CABG 500) 90mmHg30mmHg 20mL/ STEMI ) 30 X 502) Swan-Ganz 515g/kg/ 215g/kg/ g/kg/ IABP 503) PCPS 504,505). 2g/kg/ 2g/kg/ 5g/kg/ 1 2g/kg/ PDE- III STEMI ) PCI CABG SHOCK p ,151a) ESC IABP 2 51

52 ) multiple organ failuremof systemic inflammatory response syndromesirs IAPB 507,508) ESC IABP Impella 509) 510) ACE 49 STEMI ,512) V4R 1mm ST Kussmaul 511) 513,514) Swan-Ganz 10mmHg PCWP 5mmHg y noncompliant PCWP 15mmHg PCWP 18mmHg ml IABP 515) 516,517) CABG 52

53 ST ) STEMI 369,518a) STEMI 1 518b) Swan-Ganz IABP STEMI SHOCK Registry ) STEMI 1 53

54 b) GUSTO-I 520,521) 35 GUSTO-I SHOCK Registry ,522) ) 40 Doppler Swan-Ganz STEMI , ) ST-T PEA Q ,530) ,531) 525,526) STEMI ) PCI 54

55 ST CABG IABP 533,534) 521, ) Daggett 543) infarct-exclusion 544) 545,546) 547) blow-out mmHg 548) IABPPCPS ) 552) oozing sutureless 553) 55

56 ,555) 556,557) IABP STEMI IABP PCPS 1 left ventricular assist devicelvad PCPS STEMI ImpellaIABP 509) STEMI CK-MB MBH-FABP ST ST T pseudo-normalization 558) 7 PCI ,29) ,524) 20 primary PCI 6 181,241) 559) 56

57 ST ,524,560) primary PCI PCI CABG 561,562) STEMI 563,564) STEMI ST ) STEMI 565) Q oozing rupture 528) STEMI 1 T T T 566) CK-MB Doressler 567) g g 568) 569,570) 57

58 2012 STEMI ,571,572) STEMI STEMI ) STEMI 561,573,574) 573,575) SAVE 574) Killip IIIIV 576) 577,578) STEMI ) STEMI MRIMRA CT 579) STEMI 580) PCI 75 mg/ mg/ 581) PT-INR 2 STEMI ,582) distal protection device 583,584) ) p ) 587) PT-INR ,589) 590) 58

59 ST ,589) STEMI 588) 586) STEMI risk area avr ST V ) ST ST ST ST QRS avr ST 1mm ST 2.5mm0.25mV V1 ST V4V6 septal Q Seg.6 591) V5V6 2mm ST 592,593) III ST II I avl ST 594,595) IaVL ST avl II ST III V1V3 ST IaVL ST 596,597) Seg.4AV 12 V3RV6RV7V9 598) V4R 1mm ST V4RST ) V4 V7 V8 V9 ST Q 599,600) 600) Q ST T 4 V7V9 ST 601) 12 1mm ST T Q 1 601) 59

60 2012 STEMI ST ST resolution ST resolution ST 602,603) ST resolution ST ST resolution 604) Q Q MRI Q 605) T 24 T Q T T Q T 606) Q Q R R 607) R Q 12 R Q R Q QRS 608) QRS CK CK-MB I T ) T ,614) I T ) 10 STEMI 139,140) 615) WPW ASE ) normokinesis 1 hypokinesis2 akinesis3 60

61 ST 2013 dyskinesis4 aneurysm ) CK ) 621) 622) ) IX STEMI 624) 201 Tl 625,626) 99m Tc sestamibi MIBI 99m Tc tetrofosmin 99m Tc ) 631) 17 Berman ) 5 uptake uptake50 99m Tc MIBI Tl 633) 634) 99m Tc quantitative gated SPECTQGS QGS 635) 123 I-BMIPP SPECT 636,637) 201 Tl 123 I-BMIPP 638,639) 123 I-BMIPP SPECT risk area 99m Tc pyrophosphate CK 640) 641) ) MRIcardiac MRI:CMR MRIT2 MRI late gadolinium MRI: LGE-MRI MRI ) ) thickeningradial shortening 2005 MRI reference standard 648) CMR 61

62 2012 T2 LGE-MRI CMR LGE-MRI MRI ) 652) CT single photon emission computed tomographyspect SPECT MRI SPECT CMR SPECT CMR SPECT 649) ) ,655) CMR 656) LGE-MRI 10 LGE-MRI 657,658) 659) LGE-MRI positron emission tomographypet 660) LGE-MRI 661) PCI CABG 1 LGE-MRI ) 663) 664,665) 666) LGE-MRI 667) PCI 2050 slow flowno flow MRI microvascular obstruction MO CMR perfusion MRI LGE- MRI MO perfusion MRI 12 early MO 668) MO LGE-MRI 1015 late MO persistent MO 668) MO T2 T2 669,670) ,672) 673) 62

63 ST 2013 STEMI ) STEMI 674) PCI CABG PCI ) ) 3 SYNTAX ) 4 CABG 3.3 PCI ) 3 PCI CABG CABG 48 CABG 266,268) 2 primary PCI PCI PCI CABG PCI primary PCI staged PCI 679) PCI ) STEMI 48 63

64 ,268) CABG 677,680,681) 682,683) 684) CABG 685) STEMI 5 686) 2013 ACCF/AHA 24 CABG 175) STEMI 29,414,687,688) STEMI ) 692) ST 687, ) 1mm ST 64

65 ST ) 697,698) wall motion score index 698,699) Doppler ) ) 709) STEMI ) ) 715). 716). 717,718) 719) 99m TC 201 Tl 201 Tl 99m Tc 720) 201 Tl SPECT 625,626) ) ATP 723,727) 201 Tl 50 uptake stunned myocardium 123 I-BMIPP 636,728,729) STEMI 123 I-BMIPP 637) MRI 654,662,730) 668,673,731) PET 65

66 2012 PETSPECT 732,733). STEMI 688,734) 735,736) 737,738) 19,739) ) STEMI BNP 744) STEMI 745,746). BNP probnp N NT-proBNP 747) 1 748) BNP NT-proBNP 34 BNP 5 746) CRPC H-FABP ) STEMI 754) STEMI STEMI implantable cardioverter defibrillatoricd 755,756) 757) 66

67 ST 2013 ICD ) 758) ) QRS 762,763) T 764) ICD ) PCI STEMI 768,769) GRACE 152,153) TIMI 155) CADILLAC 157) STEMI ) 3 I phase I II phase II III phase III 3 STEMI QOL ) Taylor p p ) 1995 Lawler ) Haykowsky ) ACC/AHA ) ) STEMI AHA/ACCF ) 67

68 2012 STEMI QOL ) ) STEMI ) ) ) 9 21 PCI 770,772,780,789) 790,791) 2001 AHA 789) 2 STEMI ST T ST 9 68

69 ST ) ) Valsalva 369) STEMI 793) ) 6 780,789) STEMI 69

70 ) 2 STEMI 1 13 STEMI 787) 780,789) STEMI 70

71 ST ,795) STEMI 795) 3 796) ACC/AHA 795) ) Borg ,789) ,789,795) 798) STEMI 799) QOL 800) 801) ACC/AHA ) STEMI ) 71

72 2012 STEMI ) PCI PCI 612 PCI 802,803) ) 369,789,794) STEMI ACC/AHA ) ) ) 5METs 3METs3.06.0METs 6.1METs METs 6.1METs 3METs 6.1METs 805) 1 369) 72

73 ST ) AED 806) ) 5 5METs 807) ) 807) ) Q ) PCI 369) 811) PAMI-II PCI 2 812) STEMI ) QOL 369) STEMI 814) 369) SSRI 815,816) 1 STEMI STEMI ) social isolation 817) 818) 819) 820) STEMI 821) 822) QOL 818) 73

74 ) ) ) 74

75 ST

76 2012 *repetition maximum10 RM QOL ) AHA/ACCF ) VII

77 ST ) primary PCI 80 29,220,396) mg/ 176,302) DES PCI DAPT ) ACC/AHA/SCAI 832) FDA 833) DES 12 j-cypher ) ) ) 1 DAPT 830,831) DES PPI CYP2C19 313,317,835) PPI CYP2C19 836) 77

78

79 ST ) ) PCI ) ) 79

80 2012 ACC AHA ) ACC/AHA quality improvement : QI 842,844,845) 843) ACC/AHA STEMI 843) 1 ACC/ AHA 369,846) primary PCI STEMI ) ACCF/ AHA/SCAI PCI 400 PCI primary PCI PCI primary PCI 11 STEMI 308) CVIT 850) PCI J-PCI /National Clinical Database 851) 80

81 ST 2013 CCU CCU 6 58) 14 60,61) 181) ) ) STEMI AHA emergency cardiovascular care ECC CCU PCI STEMI 81

82 2012 ILCOR CoSTR 2005 AHA PCI 854) ) 3 STEMI CPR AED PADpublic access defibrillation 3 CCU PCI 2007 ACC/AHA 2008 ESC door-to-balloondtb 90 DTB Get With The Guidelines GWTG 2000 ACC/AHA 858,859) STEMI Community Education

83 83 ST 2013

84

85 85 ST 2013

86 Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation 2012; 126: Davies MJ, Thomas AC. Plaque fissuring--the cause of acute myocardial infarction, sudden ischaemic death, and crescendo angina. Br Heart J 1985; 53: Fuster V, Badimon L, Badimon JJ, et al. The pathogenesis of coronary artery disease and the acute coronary syndromes (1). N Engl J Med 1992; 326: Rentrop KP, Blanke H, Karsch KR, et al. Acute myocardial infarction: intracoronary application of nitroglycerin and streptokinase. Clin Cardiol 1979; 2: DeWood MA, Spores J, Notske R, et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med 1980; 303: Kodama K, Asakura M, Ueda Y, et al. The role of plaque rupture in the development of acute coronary syndrome evaluated by the coronary angioscope. Intern Med 2000; 39: Asakura M, Ueda Y, Yamaguchi O, et al. 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