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INFLAMMATORY DISORDERS. Objectives  Explain dermatitis and psoriasis  Discuss the education plan for a client with inflammatory disorders  List drugs.

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Presentation on theme: "INFLAMMATORY DISORDERS. Objectives  Explain dermatitis and psoriasis  Discuss the education plan for a client with inflammatory disorders  List drugs."— Presentation transcript:


2 Objectives  Explain dermatitis and psoriasis  Discuss the education plan for a client with inflammatory disorders  List drugs used for treatment of inflammatory disorders  Identify foods causing allergies  Identify topical drugs used for the client with disorders of the skin  Discuss components of a client education plan for the self-use of topical medications

3 DERMATITIS  Contact dermatitis from tape.  Poison ivy dermatitis.

4 CONTACT DERMATITIS  PATHOPHYSIOLOGY: -direct contact with agents in the environment that a person is hypersensitive to -epidermis becomes inflamed and damaged by the repeated contact -soaps, industrial chemicals, plants,etc.


6 SIGNS AND SYMPTOMS -lesions at the point of contact. -burning, pain, itching, and swelling. -red with papules -small, raised, solid skin lesions less than 1 cm. in diameter

7 ASSESSMENT  SUBJECTIVE DATA -history of the pt.’s activities -ask for a log of the past 48 hours before the s/s developed.

8 ASSESSMENT  SUBJECTIVE DATA  -tried a new soap.  -traveling and using different personal items.  -working with plants or flowers.  -severe itching.  -difficulty moving the affected area.

9 ASSESSMENT  OBJECTIVE DATA:  -erythema.  -papules /vesicles that generally ooze and  weep a clear fluid.  -scratch marks.  -edema of the area.

10 DIAGNOSTIC TESTS -health history to identify the agent. -intra-dermal skin testing. -elimination diets are used to identify food allergies. -elevated serum IgE levels and eosinopilia.

11 NURSING DIAGNOSES  Impaired skin integrity, related to scratching  Pain, related to pruritis

12 TREATMENT  MEDICAL MANAGEMENT  -identify the cause of the hypersensitive  reaction.  -treat symptomatically  -swelling, itching, discomfort.  -oral antihistamines  -corticosteroids topically.  -prophylactic treatment for asthma

13 NURSING INTERVENTIONS -protect the inflamed area from further harm. -rest the affected area. -wet dressings (Burrow’s solution) -use medical aseptic technique when applying the corticosteroids to the open lesions. -provide a cool environment with humidity. -cold compresses -deceases the circulation and cause vasoconstriction -this relieves the pruritis

14 NURSING INTERVENTIONS, CONT. -daily baths with an application of oil. -cut the fingertips -decreases excoriation from scratching - wear mittens or gloves). -clothing should be lightweight and loose.

15 TEACHING -keep a history of possible predisposing offensive agents. -avoid the causative agent once it has been identified. -avoid any rubbing of the area -any excessive heat -any soaps -these can all cause itching which could easily re-open the wound

16 PROGNOSIS  -removal of the offensive agent results in full  recovery  -if there is a recurrence, then the pt. may need  to be desensitized.


18 Inflammatory Disorders of the Skin  Dermatitis venenata, exfoliative dermatitis, and dermatitis medicamentosa  Etiology/pathophysiology Dermatitis venenata: -Contact with certain plants Exfoliative dermatitis: -Ingestation of heavy metals, antibiotics, aspirin, codeine, gold, or iodine Dermatitis medicamentosa: -Hypersensitivity to a medication

19 DERMATITIS VENENATA -Contact with certain plants - poison oak /poison ivy. -Mild-severe erythema with pruritis -Body undergoes a sensitizing antigen formation on first exposure -Lymphocytes to release irritating chemicals - inflammation - edema - vesiculation

20 EXFOLIATIVE DERMATITIS -Ingestation of heavy metals, or by antibiotics, - - aspirin, codeine, arsenic, mercury gold or iodine. -Skin sloughs off -swollen/reddened  -severe pruritis  -fever -Patients are hospitalized -Treatment is individualized.

21 EXFOLIATIVE DERMATITIS -Cause should be removed and treated -Prevent secondary infections -Avoid further irritation. -Maintain fluid balance.

22 DERMATITIS MEDICAMENTOSA -Medication causes a hypersensitive reaction -Any drug can cause a reaction -penicillin, codeine, and iron.

23 DERMATITIS MEDICAMENTOSA  Signs and symptoms - mild to severe erythema -pruritus. -vesicles/eruptions -respiratory distress -especially with medicamentosa



26 ASSESSMENT  SUBJECTIVE: -Complaints of pruritis/burning pain in the involved area  OBJECTIVE: -Lesions are white in the center/red on the periphery. -Vesicles -Severe dyspnea caused by respiratory distress

27 DIAGNOSTIC TESTS  Patient history.  A laboratory exam for serum IgE and eosinopilia.


29 NURSING DIAGNOSES  Impaired skin integrity, related to crusted, open lesions  Risk for infection, related to break in skin  Deficient knowledge, related to the cause and spread of the disease

30 TREATMENT  -Therapeutic baths  -Administration of corticosteroids.  -Treatment is directed at the cause.

31  NURSING INTERVENTIONS:  Dermatitis venenata- -Wash the affected area immediately after contact with the offending allergen -Cool, open, wet dressings to the lesions -Calamine lotion

32 NURSING INTERVENTIONS -Therapeutic baths with colloid solution, lotions, and ointments - alleviates the itching -Emotional support - the physical appearance is difficult for both the patient/family to accept.

33 NURSING INTERVENTIONS Dermatitis medicamentosa -center around the causative drug and discontinuation -if the drug cannot be identified -no drugs should be given -lesions will disappear after the medication has been stopped -PCP must be notified for further orders

34 TEACHING -Wear a medical alert bracelet/necklace showing the name of the allergen -Inspect the lesions daily -exudate, size, and body part. -Fever -have the pt. check his temperature -Medical asepsis/aseptic hand washing technique

35 TEACHING -Appropriate application of topical meds -Keep the involved areas dry when giving care -Own personal items that are not to be shared – -linens, towels, comb, etc. -Family must be involved with the teaching

36 PROGNOSIS  Full recovery  -when the offending agent is gone

37 Inflammatory Disorders of the Skin  Urticaria (Wheals/Hives)  Etiology/pathophysiology Allergic reaction -release of histamine in an antigen-antibody reaction -drugs -food -insect bites -inhalants -emotional stress -exposure to heat or cold

38 Inflammatory Disorders of the Skin  Clinical manifestations/assessment Pruritus Burning pain Wheals/ hives - release of histamine - capillaries to dilate - increased permeability


40 ASSESSMENT  SUBJECTIVE: -pruritis -edema -burning pain -shortness of breath.

41 ASSESSMENT  OBJECTIVE DATA: -Wheals of varying shapes and sizes -pale centers/red edges -Intense scratching -Respiratory status may be compromised.

42 Inflammatory Disorders of the Skin Diagnostic tests -Health history -Allergy skin test -IgE (serum immunoglobulin E) - check for its elevation.


44 TREATMENT  Medical management/nursing interventions -Identify and alleviate cause. -Antihistamine (Benadryl). -Therapeutic bath. -Epinephrine. -Teach patient possible causes. -Teach preventive measures.

45 TEACHING.  Signs and symptoms of a anaphylactic reaction.  -shortness of breath  -wheezing  -cyanosis

46 PROGNOSIS  Full recovery when the obnoxious agent is removed/avoided.  Patient must comply with the treatment regimen.

47 Inflammatory Disorders of the Skin  Angioedema  Etiology/pathophysiology -form of urticaria -subcutaneous tissue -same offenders as urticaria -eyelids, hands, feet, tongue, larynx, GI, genitalia, or lips -angioedema is a local edema of an entire area rarely occurs in more than a single area at one time

48 Inflammatory Disorders of the Skin  Angioedema  Clinical manifestations/assessment -burning /pruritus -lesions that are normal on the outer skin -edema -acute pain -in the GI tract -respiratory distress -in the larynx -edema of an entire area -eyelid, feet, lips, etc.


50 DIAGNOSTIC TESTS -patient history. -history of allergies are more likely to have angioedema.

51 TREATMENT  Medical management/nursing interventions -cold compresses. -antihistamines -epinephrine -corticosteroids -assess respiratory function for s/s of distress.

52 TEACHING  -wear a medical alert bracelet or necklace.  -prevent recurrent episodes.

53 PROGNOSIS  -With treatment,the prognosis is excellent


55 Inflammatory Disorders of the Skin  Eczema (atopic dermatitis)  Etiology/pathophysiology -Allergen causes histamine to be released -antigen-antibody reaction -Primarily occurs in infants. -chocolate, orange juice, eggs, wheat.


57 ASSESSMENT -Papules/vesicles -edged with redness -ruptures -discharges a yellow, thick exudate -dries, becomes crusted -infected -skin becomes shiny, de-pigmented -dry scales.

58 ASSESSMENT  SUBJECTIVE: -pruritis -scratching -children are more fussy/irritable -anorexic. -skin is tender to the touch. -family history of allergies -asthma is often associated with children who have eczema.

59 ASSESSMENT -Papules and vesicles -scalp, forehead, cheeks, neck, and extremities. -Erythematic/dryness of area. -Pruritis.

60 Inflammatory Disorders of the Skin  Eczema (atopic dermatitis)  Diagnostic tests Health history (heredity is a primary factor). Diet elimination. Skin testing and IgE serum tests.  Medical management/nursing interventions Reduce exposure to allergen Hydration of skin Topical steroids Lotions—Eucerin, Alpha-Keri, Lubriderm, or Curel 3-4 times/day

61 ECZEMA (atopic dermatitis)

62 NURSING DIAGNOSES  Impaired skin integrity, related to open lesions  Risk for situational low self-esteem, related to change in body image  Risk for infection, related to open lesions

63 NURSING INTERVENTIONS - therapeutic baths -occlusive preparations -wet dressings -maximizes the hydration of the skin -topical steroids -lesions healed-lotions are used -Eucerin, Alpha Keri, Lubriderm, Curel - apply 3-4 times/day.

64 NURSING INTERVENTIONS -monitor emotions -anger, depression anxiety, embarrassment, guilt, etc. -encourage the pt. to verbalize his feelings -use effective listening skills -open-ended questions.



67 Inflammatory Disorders of the Skin  Acne vulgaris Etiology/pathophysiology - Occluded oil glands ( the sebaceous glands) -The cause is unknown -Androgens increase the size of the oil gland -It primarily occurs in adolescents -Influencing factors -Diet -Stress -Heredity -Overactive hormones

68 Inflammatory Disorders of the Skin  Acne vulgaris  Clinical manifestations/assessment -Tenderness and edema -Oily, shiny skin -Pustules -Comedones -blackheads - the effect of oxygen on sebum, not dirt -Scarring from traumatized lesions


70 ASSESSSMENT  SUBJECTIVE DATA: -how is the acne affects his/her lifestyle. -face and chin. -lesions increase with emotional upsets/ stress

71 ASSESSMENT  OBJECTIVE: Note the presence of edema in the involved area.

72 DIAGNOSTIC TESTS  Diagnostic tests Blood samples for androgen level Health history Inspection of lesion

73 NURSING DIAGNOSES  Impaired skin integrity, related to occluded oil glands  Situational low self-esteem, related to physical appearance  Social isolation, related to decreased self-esteem

74 Inflammatory Disorders of the Skin  Acne vulgaris  Medical management/nursing interventions Keep skin clean Keep hands and hair away from area Wash hair daily Water-based makeup Topical therapy Benzoyl peroxide, vitamin A acids, antibiotics, sulfur- zinc lotions Systemic therapy Tetracycline, isotretinoin (Accutane)




78 NURSING INTERVENTIONS -Adolescents may not comply with long-term treatment regimens. -Evaluate the pt.’s understanding/reaction to his acne disorder. -What does acne mean to the pt.? -Focus on: -skin care -compliance -emotional support

79 NURSING INTERVENTIONS -Prevention -identification of factors that directly increase acne -Cleanliness decreases infection/promotes healing. -The skin should be washed 2-3 times/ day with a medicated soap -Improvement is slow so compliance is hard.


81 NURSING INTERVENTIONS -Often it takes 3 weeks of treatment -Family support -Primary cause for low self-esteem -Not comparing oneself with others -Give positive reinforcement -Focus on his strengths

82 TEACHING -Both the physical and emotional needs of the pt. -Diet, hygiene, stress reduction, makeup, and medications. -Coping skills. -Adolescent should talk about his feelings -decreases any long-term effects that acne may have on his personality.

83 PROGNOSIS  Prognosis is good.  Lasting psychological effects can occur from the scarring that may result.  In rare cases, eczema may develop from taking med: for acne, such as isotretinoin.

84 Psoriasis

85 Etiology/pathophysiology Noninfectious. Skin cells divide more rapidly than normal -normal– skin replaced every 28 days -psoriasis-skin replaced every 7 days. -occur at any age. -hereditary. -at the epidermis. -no known predisposing factors. -severe scaling is the result of the rapid cell division.

86 ASSESSMENT  SUBJECTIVE: -pruritis. -feelings of depression, frustration, loneliness. -people may stare at them.

87 ASSESSMENT  Clinical manifestations/assessment -raised, erythematous, circumscribed, silvery, scaling plaques -scalp, elbows, knees, chin, and trunk -primary lesion is papular.

88 DIAGNOSTIC TESTS  -no special tests.  -observation of the patient/symptoms.

89 TREATMENT  Goal-slow the proliferation of the epithelial layers of the skin. Topical steroids Keratolytic agents -occlusive wet dressings to decrease inflammation Tar preparations Salicylic acid Reduces shedding of the outer layer of skin Photochemotherapy PUVA Oral psoralen Ultraviolet light

90 NURSING DIAGNOSES  Impaired skin integrity, related to proliferation of epithelial cells  Situational low self-esteem, related to appearance  Social isolation, related to decreased self-esteem

91 NURSING INTERVENTIONS  -Administration of the treatment modality.  -Rest  -Promote psychological well-being  -counseling, exercise, etc.  -Focus on positive attributes.  -Medical asepsis.  -Conceal obvious lesions.

92 TEACHING  -Nature of the disease  -Treatments  -Compliance with medical care.  -Disease is not CURABLE  -Patient needs to understand this.

93 PROGNOSIS  -Chronic disease.  -Clinical course is variable  -less than 50% will have a prolonged remission.  -Severity:  -cosmetic problem to a life-threatening  emergency

94 Systemic Lupus Erythematosus (SLE)  Etiology/pathophysiology Autoimmune disorder - antibodies against its own cells Inflammation of almost any body part. Skin, joints, kidneys, and serous membranes Affects women more than men -9 times more women than men Contributing factors Immunological, hormonal, genetic, and viral. Origin still remains a mystery.

95 SLE  -Disease of exacerbations and remissions  -triggered by contributing factors.  -Inflammatory lesions  -affect several organ systems  -skin, joints, kidneys, and serous membranes.  -T-suppressor cells decrease

96 SLE  Clinical manifestations/assessment Erythema butterfly rash over nose and cheeks Alopecia Butterfly rash - occurs in 10-50% of patients Photosensitivity Organic brain syndrome

97 SLE Polyarthralgias and polyarthritis -90-95% of patients Pleuritic pain Pleural effusion Pericarditis Vasculitis Oral ulcers Anemia -most common.

98 SLE Neurological signs (seizures) Renal disorders Hematological disorders


100 Figure 3-11 Systemic lupus erythematosus (SLE) flare. (From Habif, T.P., et al. [2005]. Skin disease: diagnosis and treatment. [2 nd ed.]. St. Louis: Mosby.)

101 SLE Diagnostic Tests Antinuclear antibody (ANA) DNA antibody Complement CBC Erythrocyte sedimentation rate (ESR) Coagulation profile Rheumatoid factor

102 DIAGNOSTIC TESTS  Rapid plasma reagin  Skin and renal biopsy  C-reactive protein (CRP)  Coomb’s test  LE cell prep (lupus erythematosus)  Urinalysis  Chest x-ray

103 NURSING DIAGNOSES  Impaired skin integrity, related to skin rash, hair loss, skin atrophy, discoid lesions involving other parts of the body.

104 NURSING DIAGNOSES  Disturbed body image, related to baldness, skin pattern pathologies

105 TREATMENT GOALS: -Relief /managaement of symptoms. -Inducement of remission. -Prevention of complications. -Suppression of inflammation.

106 SLE  Medical management/nursing interventions No cure -treat symptoms, induce remission, alleviate exacerbation. Medications Nonsteroidal ant-inflammatory agents. anti-malarial drugs (hydroxychloroquine). corticosteroids ( prednisone) -Peak amounts of steroids help to achieve remission Anti-neoplastic agents ( Imuran, Cytoxan). Topical corticosteroid creams are used for the rash.

107 MEDICATIONS  Anti-infective drugs  -treat/prevent infections  -specific agent depends on the infection site  -Cipro for a UTI.  Dialysis for pts. with renal involvement.  Lab Tests  -assess renal function (BUN/serum creatinine)  Analgesics  -pain  Diuretics  -fluid retention

108 TREATMENT Balance rest and exercise Balanced diet Avoid direct sunlight

109 NURSING INTERVENTIONS -Thorough assessment -multi-systemic disease. -Skin care -avoiding direct sunlight -protective clothing -sunscreen. -Balance rest and activity. -Recognize s/s of exacerbation -fever, rash, cough

110 NURSING INTERVENTIONS -Recognize the s/s of infection. -Reduce stress. -Balanced diet -Reduction of sodium intake.

111 NURSING INTERVENTIONS -emotional, psychosocial, and spiritual support. -activity level -prevention of infection -potential complications -information on living a normal life.

112 Pharmacology for the treatment of inflammatory skin disorders  Corticosteroids  Emollients  Antipsoriatics

113 Corticosteroids  -local inflammatory disorders  -Topical administration  -avoids systemic adverse effects  -the inflammatory site must be localized and  accessible  -effective and relatively safe form of therapy  -prescription and non-prescription products

114 NURSING INTERVENTIONS -Monitor site for healing- -increased use of topical steroids decreases vasoconstriction -decreases the absorption of the steroid -requires a higher amount/more frequent usage -Monitor for increased facial redness when decreasing the amount of topical steroid secondary to tolerance. -Skin atrophy, striae (stretch marks), steroid allergies or skin infections -Fungal infections will not resolve with the use of topical steroids

115 Emollients -Dry skin - infections, excessive bathing or strong soaps/detergents -pruritus, cracking, and predisposition to skin disorders -prevent the loss of additional skin moisture be forming a occlusive barrier on the skin surface -waxes, fats and/or oils -urea-enhances the skin’s ability to hold moisture -Oils, creams, lotions, bath oils -daily after showering of bathing -do not apply to skin lesions that are moist/exudative

116 Antipsoriatics Alefacept- -first antibiological therapy for moderate to severe chronic plague psoriasis -provides longer remissions the other treatments -adverse effects- serious infection Efalizumab - -immunosuppressive recombinant monoclonal antibody  -stimulates the bodies immune system’s ability to fight  disease  -adverse effects- thrombocytopenia, hypersensitivity,, headache,  fever, chills, nausea and myalgia

117 Food Allergies  Definition:  -Ingestion of food that the person’s immune system  incorrectly identifies as harmful  - 4% of adults have food allergies  -6-8% of children age 4 years of younger

118  -Immune system creates food specific antibodies.  -Antigens which are foreign substances (food)  -produces the immune response  -antibodies start destroying the antigens  -immune system discharges large amounts  of histamine and chemicals  -cause the allergic reaction


120 Allergic Reaction  Respiratory  -Tongue swelling, dyspnea  Gastrointestinal  -Nausea, abdominal pain, diarrhea  Skin  -Hives, rash  Cardiovascular  -Tachycardia, hypotension  Neurological  -Anxiety, loss of consciousness

121 Anaphylaxis  -Severe reaction to allergen  -Swelling of the lips, tongue, throat  -blocks the upper airway resulting in  suffocation  -Emergency situation

122  Common allergy foods:  -Eggs, peanuts, tree nuts, fish, shellfish, wheat,  soy  -Peanuts and tree nuts- severe reactions!  -0.6% of Americans are allergic to peanuts  -young children  -allergic to eggs, milk, peanuts, tree nuts and soy.  -outgrow their allergies  -usually be allergic to peanuts and tree nuts for the  rest of their life. 

123 -are hereditary -a child having allergies increases when both parents have allergies -allergic to the common foods eaten in their countries -rice allergies are common in Japan

124  Diagnosis  -family history of allergies  -food diary  -scratch test  -RAST (radioallergosorbant test)  -measures the presence f food-specific IgE  in the blood  -elimination of food from the diet  -food challenge  -capsules of different foods and a placebo  -ingested and then followed to see if an allergic  reaction occurs (rarely done)

125  Treatment-  -avoid foods that cause allergies  Prognosis  -not curable but manageable  -multiple medications being researched

126 Nursing Considerations  -Carefully reading food labels  -Inquire of the food ingredients when eating out.  -Counseling by a dietician on the foods that their  children need to avoid  -Medical alert bracelet with the name of food  allergy

127  Epinephrine injection  -carried at all times  - person, parents of children  - severe/ anaphylactic reaction to foods or medications  Epi-pen auto injection  -pre-measured epinephrine injection  - costs $50  Along with a Epi-pen the person should carry:  -food allergies  -3 emergency contacts  -Physicians name and telephone number  -description of how to treat the reaction

128 Pharmacology of skin disorders  Topical antiseptics/germicides  Topical Anti-Infectives  Topical Cortico-steroids  Topical Local Anesthetics  Topical Enzymes  Keratolytics

129 Topical Antiseptics and Germicides  Long history of usage  -spices, vegetable oils and extracts of trees/plants   -1800’s Pastuer, Koch  -substances that slowed or destroyed pathogenic  organisms  Definition:  -an agent that kills or inhibits the growth of  microorganisms that is applied to living tissue 

130  Types-  -Hibiclens  -Alcohol  -Phisohex  -Hydrogen  -Peroxide  -Iodine  -Mercurochrome  -Betadine  -Silver Nitrate  -Silvadene  -Dakin’s Solution  -Septi-Soft

131  Nursing implications-  -Specific to the type of antiseptic  -Observe for hypersensitivity  -Skin staining/bleaching

132 Topical Anti-infectives  -Prevent infection-minor skin abrasions  -treat superficial skin infections  -Several antibiotics are combined in a single  product  -produces a broad spectrum coverage for  multiple organisms

133  Types-  -Bacitracin  -Polymyoxin  -Neomycin  -Gentamycin  -Tetracycline  -Erythromycin 

134  Nursing Considerations  -hypersensitivity  -systemic absorption if applying to a  extensively damaged skin  -Neomycin -observe for changes in renal  function:  -decreased urine output  -elevated Creatine and BUN  - changes in hearing.

135 Topical Local Anesthetics  Inhibits the conduction of nerve impulses from sensory nerves  - reduces pain/pruritis  -insect bites, burns and plant allergies  -patches, ointments, creams, sprays, liquids of jelly  form  -Types- “caine”  -Lidocaine  -Benzocaine  -Tetracaine  -Cocaine 

136  Nursing Considerations  -absorbed systemically through damaged or  diseased skin  -local or systemic adverse effects  -if the medication is applied to a large area of  skin  -systemic hypersensitivity  -CNS stimulant  -hypotension  -slow heart rate  -possible cardiac arrest  -avoid in clients  -hypersensitivity to “caine” medications  -severely traumatized skin

137 Topical Enzymes  Remove dead tissue  -enhances the formation of new tissue  - promotes wound healing  Selectively digest dead tissue  Specifically digest protein of dead tissue  Destroys components of the necrotic tissue mass.

138  Types-  Collagenase (Santyl)  -digests collagen that 75% of skin tissue  Fibrinolysin/Desoxyribonuclease (Elase)  -dissolves the fibrin structure of blood clots/  DNA strands  - make up necrotic tissue.

139 Nursing considerations  Santyl-  The wound must be free of antiseptic/  antibacterial medications  Compatible with triple antibiotic medication  Apply Burrows solution to stop the enzymatic  action  Elase-  Observe for hypersenitivity/allergic reaction

140 Keratolytics  Remove excess keratin layer of skin -acne, warts, psoriasis, corns calluses and fungal infections  Breaks down the protein structure of the keratin layer -easier removal of the compacted cellular material  Types- Salicylic Acid, Lactic acid

141 Nursing Considerations  -Apply after bathing  -Soaked in water for several minutes  -Occlude with a dressing/plastic wrap after  applying medication  -Apply overnight and remove in the morning  -Repeated applications will probably control the  hyperkeratinic skin growth -occasional reapplications may be needed for reoccurrence

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