Saint James Academy

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CHRONIC KIDNEY DISEASE

A Case Study Presented to the

Faculty of Senior High School Department
Saint James Academy
Ibaan, Batangas

In Partial Fulfilment
of the Requirements for
General Biology 2

GUTIERREZ, Yna Marie Z.

2020

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I. Medical History

Patient M is a teacher who has been living her life normally as an educator, youth
leader and family woman, until year 2004 when she was admitted to Mary Mediatrix
Medical Center of Lipa City and was diagnosed with kidney complication. This is a
struck of bad luck that leads to her medication and in the year 2005 she's living her life
with the disease, undergoing two to three times dialysis per week. She comes from a
family history of high blood pressure and hypertension. High blood pressure and diabetes
are the leading causes of kidney failure. This is what led to her diagnosis of end-stage
kidney disease at a very young age of 27.
Her symptoms were subtle. She had fluid retention in her hands and feet causing
them to swell. She went on dialysis three times a week for 3 ½ hours in the evenings. She
was hooked up to a machine that removed the waste and extra water build up from her
body and helped to control her blood pressure. She went through the process of getting on
the kidney transplant waiting list. In the meantime, she worked a full-time job as a
teacher in a catholic school, took care of her home and family. Then after years, they
have found her a haploidentical person who donated his left kidney. The kidney
transplant surgery was successful to her and for the donor. She bounced back quickly and
had a lot of energy.
But three years later she started having light diarrhea, which lasted for three days.
When the patient called her doctor, he said to come into his office immediately; then he
admitted her to the hospital for emergency dialysis treatment. Her kidneys failed again.
She couldn't work, and went from 150 pounds to 110 pounds at 5'4". Currently, she still
having three times per week of Dialysis in Mary Mediatrix Medical Center.

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II. Laboratory

Urinalysis or Urine tests. Analyzing a sample of urine may reveal abnormalities

that point to chronic kidney failure and help identify the cause of chronic kidney disease.

September 17,2005
Macroscopic Microscopic
Color Light yellow RBC 12-15 / HPF
Transparency Cloudy WBC Many / HPF
Specific Gravity 1.015 Epithelial Cells Moderate
Reaction 6.0 Mucus Threads Few
Chemical Tests Bacterial Many
Sugar Negative Crystals
Albumin Trace A. Urates Many
Special Tests A. Phosphate
Foam’s test Calcium Coxalate
Ketone Others
Pregnancy test
Analysis and Interpretation:
Laboratory results revealed that there is presence of albumin in the blood and no sugar present.

September 16,2005
Macroscopic Microscopic
Color Light yellow RBC 2-3 / HPF
Transparency Slightly cloudy WBC 2-3 / HPF
Specific Gravity 1.020 Epithelial Cells Few
Reaction 5.0 Mucus Threads Occasional
Chemical Tests Bacterial Few
Sugar +2 Crystals
Albumin +3 C. Urates Moderate
Special Tests B. Phosphate
Foam’s test Cast Coarse granular 3-5 / LPF
Ketone Others Waxy cast 2-4 / PLF
Analysis and Interpretation:
Laboratory results revealed that there is presence of albumin and sugarin the urine.

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Hematology test include tests on the blood, blood proteins and blood-producing
organs. These tests can evaluate a variety of blood conditions including infection,
anemia, inflammation, hemophilia, blood-clotting disorders, leukemia and the body's
response to chemotherapy treatments

September 15,2005
Result Normal Analysis
WBC 10.4 4.0-11.0x10^9 /L Normal
RBC 2.36 4.0-6.0x10^12 /L Result was below normal. This indicates
alteration in erythropoietin production
secondary to renal malfunction.
HGB 70 120-180 g/L Result was below normal. This shows the
decrease in the oxygen carrying capacity of
the blood secondary low hematocrit.
HCT 0.224 0.370-0.540 Result was below normal, thus showing
anemia related to insufficient RBC
production.
MCV 94.8 20-100fL Normal
MCH 29.6 27-31pg Normal
MCHC 312 320-360 g/L Result was below normal
RDW 15.2 11.5-15.0% Normal
Differential count
Bands 01 2-6% Result was below normal
Segmented 93 50-70% Result was above normal
Lymphocytes 05 20-44% Result is above the normal range, indicating
bacterial infection.
Monocytes 01 2-9% Result was below normal

September 15,2005
Test Result Unit Normal Results Unit Normal Analysis and
values conv. values Interpretation

Creatinine 674 umol/L 53.0 1.30 11.50 mg/dl 0.6 1.3 Result was above normal
high thus showing inability of
the kidney to excrete
nitrogenous waste.
Sodium 133 mmol/ 136 148 122.00 mEq/ 136 148 Result was below normal
low L dl thus showing the fluid
and electrolyte
imbalance.
Potassium 2.5 low mmol/ 3.65 5.20 6.30 mEq/ 3.60 5.20 Result was below normal
L dl thus showing the fluid
and electrolyte

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imbalance.

III. Anatomy and Physiology

The kidney is a bean-shaped organ that clear harmful substance in your body by
filtering your blood. It is like a water purification plant that helps clean the drinking water
for a city. It also regulates pH, volume, pressure, osmolality as well as produce
hormones. The kidneys are located between the T12 and L3 vertebrae, and they're
partially protected by ribs 11 and 12- which are the floating ribs. The kidneys are roughly
the size of a fist and are retroperitoneal, meaning they sit behind the peritoneal membrane
alongside the vertebral column. Like all solid organs, kidneys are enclosed in a fibrous
capsule that provides protection. The right kidney is pushed down by the liver so its sits
slightly lower that the left kidney.

In the middle of each kidney there is an indentation that forms the renal hilum.
This is the entry and exit point for the ureter renal artery and renal vein, lymphatics, and
nerves go into and come out of the kidney. The continuous pale outer tissues of the
kidney are known as the renal cortex, which surrounds the inner renal medulla. The shape

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and interaction of the renal medulla and cortex cause the medulla to take on triangular
shapes known as renal pyramids.

Found within the renal cortex and medulla is the nephron, the kidney’s
microscopic functioning unit. The nephron serves as the body’s filter and removes toxins
and wastes from the blood. Each kidney has roughly 1.25 million nephrons that total a
length of more than 145 km. The nephron has two primary structures: the renal corpuscle
and the renal tubule. The renal corpuscle (in the cortex) filters blood at the glomerulus
into Bowman’s capsule. The glomerulus is a capillary network and is enveloped by
Bowman’s capsule, which is the start of the nephron’s waste collection system. The two
are separated by a thin epithelial wall. It is within the glomerulus where the blood
pressure forces fluid and dissolved solutes out of an arteriole and into Bowman’s capsule.
The fluid and solutes forced from the blood are called filtrate and drain into the proximal
convoluted tubule. Damage to the barrier between the glomerulus and Bowman’s capsule
will lead to Chronic Kidney Disease.

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IV. Pathophysiology

Secondary Hypertension
↓
Arteriosclerotic lesions of the afferent and efferent arterioles
↓

Falling glomerular filtration rate

Decrease capability of the kidneys to excrete waste products

Due to hypertension, there are lesion to the afferent and efferent arterioles
decreasing the effectiveness of the filtration of blood in the glomerular that leads to the
decrease capability of the kidney to properly excrete waste products.

Chronic kidney disease is initially described as diminished renal reserve or renal

insufficiency, which may progress to renal failure (end-stage renal disease). Initially, as
renal tissue loses function, there are few noticeable abnormalities because the remaining
tissue increases its performance (renal functional adaptation).

Decreased renal function interferes with the kidneys’ ability to maintain fluid and
electrolyte homeostasis. The ability to concentrate urine declines early and is followed by
decreases in ability to excrete excess phosphate, acid, and potassium. When renal failure
is advanced (GFR ≤ 15 mL/min/1.73 m2), the ability to effectively dilute or concentrate
urine is lost; thus, urine osmolality is usually fixed at about 300 to 320 mOsm/kg, close to
that of plasma (275 to 295 mOsm/kg), and urinary volume does not respond readily to
variations in water intake.

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V. Pharmacologic Treatment/ Surgical Treatment

Depending on the underlying cause, some types of kidney disease can be treated.
Often, though, chronic kidney disease has no cure. Treatment usually consists of
measures to help control signs and symptoms, reduce complications, and slow
progression of the disease. For treating complication, treatments may include:

 High blood pressure medications.

 Medications to lower cholesterol levels.
 Medications to treat anemia.
 Medications to relieve swelling.
 Medications to protect your bones.
 A lower protein diet to minimize waste products in your blood

If your kidneys can't keep up with waste and fluid clearance on their own and you
develop complete or near-complete kidney failure, you have end-stage kidney disease. At
that point, you need dialysis or a kidney transplant.

Dialysis artificially removes waste products and extra fluid from your blood when
your kidneys can no longer do this. In hemodialysis, a machine filters waste and excess
fluids from your blood. In peritoneal dialysis, a thin tube (catheter) inserted into your
abdomen fills your abdominal cavity with a dialysis solution that absorbs waste and
excess fluids. After a period of time, the dialysis solution drains from your body, carrying
the waste with it.

A kidney transplant involves surgically placing a healthy kidney from a donor

into your body. Transplanted kidneys can come from deceased or living donors. You'll
need to take medications for the rest of your life to keep your body from rejecting the
new organ. You don't need to be on dialysis to have a kidney transplant.

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VI. Palliative Care/ Rehabilitation

With a serious illness like chronic kidney disease, a palliative care should be
offered. Palliative care is a specialized type of medical care that can help people living
with CKD by alleviating pain, other symptoms and stress at the same time they are
receiving treatment to cure their disease. The goal of palliative care is to improve quality
of life for both the patient and the family. Palliative care puts control back in the hands
of the patient and family, and it can extend patients’ lives.”

When a person has a CKD, they already know that they need to take special care
of their body. Managing care and treatment for kidney disease can be a round-the-clock
effort that can put enormous physical and emotional strain on both the patient and the
family. A palliative care offer people with CKD an extra layer of support.

Manage pain and other conditions related to CKD. Palliative care is provided
alongside curative treatment. A palliative care team will work to provide relief from
conditions related to kidney disease, including high blood pressure, heart disease,
diabetes, and kidney failure.

Help with communication with other doctors and evaluating treatment options
Palliative care can help make critical decisions about treatment options including dialysis
and kidney transplant. The palliative care team can help the patient understand and decide
whether to go on dialysis.

Explain what to expect throughout the illness. The palliative care team will spend
as much time to help a patient and his/her family members to better understand the
condition and treatments.

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Help a patient cope with worry, stress or depression. The burden of CKD and
kidney failure can be heavy. Palliative care provides emotional support for both patients
and their families. The palliative care team can often provide additional therapies,
including massages, talk therapy, and relaxation techniques, to ease emotional and
spiritual stress.

VII. References

https://www.hse.ie/eng/health/az/c/chronic-kidney-disease/

https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-
20354521

https://www.manilatimes.net/2019/06/26/lifestyle-entertainment/life-times/health-
wellness/tips-to-prevent-control-chronic-kidney-disease/574740/

https://europe.nephroconferences.com/events-list/anatomy-physiology-of-kidney

https://www.emsworld.com/article/10876397/exploring-chronic-kidney-disease

https://www.kidney.org/atoz/content/palliative-care-helps-patients-kidney-disease

https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/diagnosis-
treatment/drc-20354527

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MEASLES

A Case Study Presented to the

Faculty of Senior High School Department
Saint James Academy
Ibaan, Batangas

In Partial Fulfilment
of the Requirements for
General Biology 2

GUTIERREZ, Yna Marie Z.

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2020

I. Introduction

Measles is one of the most contagious infectious disease, and remains a leading
cause of death particularly among young children, especially in areas with low rates of
vaccination. The illness begins with fever, runny nose, and a cough. A few days later, a
characteristic rash begins to form all along the body, and the fever may reach a high of
104° Fahrenheit. Ear infections are a common problem for measles patients, and left
untreated, can lead to hearing loss. While most cases of measles are mild, resulting in
itching and discomfort, it can cause serious problems, such as pneumonia and
encephalitis (swelling of the brain).

Measles is caused by the measles virus of the genus Morbillivirus and family
Paramyxoviridae. The reason it so contagious is that it’s airborne, and spreads via tiny
liquid particles that get flung into the air when someone sneezes or coughs, and can live
for up to two hours in that airspace or nearby surfaces. If someone breath in the air or
touches a surface and then touches their eyes, or their mouths, they can become infected.

Once the measles virus gets onto the mucosa of an unsuspecting person, it quickly
starts to infect the epithelial cells in the trachea or bronchi. Measles virus uses a protein
on its surface called hemagglutinin, or just H protein, to bind to a target receptor on the
host cell which could be CD46, which is expressed on all nucleated human cells, CD150,
aka signaling lymphocyte activation molecule or SLAM, which is found on immune cells
like B or T cells and antigen-presenting cells, or nectin-4, a cellular adhesion molecule.
Once bound, the fusion, or F protein helps the virus fuse with the membrane and
ultimately get inside the cell. Wrapped on cell envelope, and send out as a newly made
virus. The measles virus spreads through local tissue in the lungs to the local lymph

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nodes. From there it continues to spread, eventually getting into the blood and spreading
to other organs.

The period of contagiousness is estimated to be from five days before the

appearance of the rash to four days afterward. One findings of measles are the presence
of spots, known as "Koplik spots," inside the mouth. These tiny pinpoint blue-white spots
begin as a few lesions on the inside of the cheeks.

II. Medical History

Patient C is a 16-year-old female student and living in San Agustin, Ibaan,

Batangas. She developed rhinorrhea and a mild non-productive cough for 8 days before
she was admission to the Sto. Rosario Hospital in January 9, 2020. Six days before
admission to the hospital, she developed a tactile fever and was taken to a local clinic.
She was prescribed a mucolytic and an antihistamine.

Despite this treatment, her cough worsened and her fever persisted. Three days
before admission to SRH, she developed a facial rash, which proceeded to spread to her
trunk, back and upper extremities.

Furthermore, she presented with a history of fever for 5 days which was insidious
in onset and was intermittent, associated with chills and rigor. History of vomiting was
also there for 5 days, which was non-projectile type with multiple episodes associated
with loose stools. She also got a headache. No history of abdominal distention or urinary
tract infection. History of rash was there for 3 days with severe itching. No history of
meningitis.

On the day before admission to SHR her fever and cough persisted, and she was
transferred to SHR for severe respiratory distress and potential need for mechanical
ventilation. She was diagnosed with measles. She had no medical or surgical history. She
did not take any medications. She had no known drug allergies. Her vaccination history
included: BCG vaccine; diphtheria, pertussis and tetanus vaccine; oral polio virus vaccine
(three doses); and hepatitis B vaccine (three doses).

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III. Laboratory

Measles is diagnosed primarily on the clinical and physical examination findings.

The appearance of the rash is characteristic, and when found in association with Koplik
spots inside the mouth, an experienced physician can diagnose measles.

A physical examination was undergo to patient C. The result tend to appear that
patient C has illnesss and she was uncomforatble because of her vital prodromal
sysmtoms. Canddiasis and Koplik spots was present in her body. Canddiasis are white
patches that was found in her tongue. While the Koplik spots she had in her mouth are 1-
2 mm, blue-gray macules on an erythematous base. The measles rash is a Maculopapular
Eythematous rash that involves the palms and soles. Lesion density is greatest about the
shoulders, where macular lesions may coalesce.

Systemic examination shows regular pulse of 102 per minute, blood pressure of
100/70mm Hg. Cardiac examination was normal. Respiratory examination showed
bilateral extensive crackles. Abdomen was soft with mild splenomegaly. Central nervous
system examination was normal. From the history and clinical examination, it was
thought of differential diagnosis like malaria, leptospirosis, dengue fever, typhoid, drug
allergy, atypical measles and infectious mononucleosis.

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IV. Anatomy and Physiology

Measles is a virus a hull of protein, RNA, plus some more proteins for reproduction.
It cannot reproduce by itself; it needs a host cell to do so. To understand measles the
researcher should first know the immune system.

The measles virus enters humans through the nose, mouth, or eyes. The measles
infection starts in the lungs. Measles is especially good at infecting the body’s first line of

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defense, macrophages, powerful guard cells that protect the lungs from intruders. They
enter a cell and take it over. The virus reprograms the cell and transforms it into a
dangerous virus production center. Once a cell is filled with viruses, they leave the
crippled cell and begin the cycle over again. But the immune system has powerful
weapons against virus infections: natural killer cells. These cells basically patrol the body
and check other cells for infections. If they find an infected cell, they order it to commit
suicide. After a period of fighting and dying, macrophages alert the brain of the immune
system: the dendritic cells. Its job is to collect samples of intruders, travel to the lymph
nodes and then activate the heavy weapon but the measles virus infects the dendritic cells
and uses them to enter

deeper into the body. The infected cells travel to the next lymph node to alert other
immune cells. Once it arrives, the measles virus spreads around the virgin T and B cells
and infect them. It attacks the very system that evolved to fight it. Now, things happen
very fast. The lymph system spreads the virus everywhere and it enters the bloodstream,
infecting cell while travelling. Measles infects organs like the spleen, the liver, the
intestines, and, most importantly, the lungs. The symptom ranges a very high fever,
headache, sickness, bronchitis, and, of course, a rash.

In the lungs, the immune system was doing okay. But not, millions of viruses
attack a second time and kill countless cells, wiping out the defense systems. In this
phase, the infected person starts coughing out millions of measles viruses. Measles is so
contagious at this stage that almost everyone you meet who isn’t vaccinated will be
infected. Without the protective army in the lungs, other bacteria or viruses that would
usually not stand a chance can enter the lungs and develop into harmful parallel
infections that can cause pneumonia, the most common way to die from measles. The
body’s immune system is now seriously wounded. Various protective systems are hurt
and disrupted. The virus spread everywhere, infecting the skin all over the body.

In some cases, the measles virus reaches the brain and causes a brain infection. If
it does so, the chances of dying are between 20 to 40 percent, and there may be long-term
damage. But the body is far from giving up at this stage, and it fights back aggressively.
Some dendritic cells survive long enough to activate the anti-virus forces of the body.

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Plasma cells in the lymph nodes start producing billions of antibodies, tiny proteins that
mark infected cell for destruction. Killer T cells flood the body and kill infected cells left
and right. After 2 to 3 weeks, the body usually gets the upper hand and overwhelms the
infection. But the immune system is now seriously weakened.

V. Pathophysiology

Virus enters respiratory tract and

replicates

Spread to lymph nodes followed by

primary viremia

Spread to GI tract, liver, CNS and

thymus. Also proliferates in
endothelial cells of vessels,
macrophages and white cells
(mainly monocytes)

These phases stimulate cell-

mediated and humoral immunity-
the rash represents clean-up of
infected cells, especially those in
capillaries by T-Cellls

After viral infection is controlled an

immunodeficiency state ensues for
months (Observed as secondary
bacterial
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Central Nervous System

complications

Measles is caused by a paramyxovirus and is a human disease. It is extremely

communicable; the secondary attack rate is > 90% among susceptible people who are
exposed. Measles is spread mainly by secretions from the nose, throat, and mouth during
the prodromal or early eruptive stage. Communicability begins several days before and
continues until several days after the rash appears. Measles is not communicable once the
rash begins to desquamate.

VI. Pharmacologic Treatment/ Surgical Treatment

There's no specific treatment for an established measles infection. However, some

measures can be taken to protect vulnerable individuals who have been exposed to the
virus.

Post-exposure vaccination. Nonimmunized people, including infants, may be

given the measles vaccination within 72 hours of exposure to the measles virus to provide
protection against the disease. If measles still develops, the illness usually has milder
symptoms and lasts for a shorter time.

Immune serum globulin. Pregnant women, infants and people with weakened
immune systems who are exposed to the virus may receive an injection of proteins
(antibodies) called immune serum globulin. When given within six days of exposure to
the virus, these antibodies can prevent measles or make symptoms less severe.

Fever reducers. You or your child may also take over-the-counter medications
such as acetaminophen (Tylenol, others), ibuprofen (Advil, Children's Motrin, others) or
naproxen (Aleve) to help relieve the fever that accompanies measles.

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Don't give aspirin to children or teenagers who have measles symptoms. Though
aspirin is approved for use in children older than age 3, children and teenagers recovering
from chickenpox or flu-like symptoms should never take aspirin. This is because aspirin
has been linked to Reye's syndrome, a rare but potentially life-threatening condition, in
such children.

Antibiotics. If a bacterial infection, such as pneumonia or an ear infection,

develops while you or your child has measles, your doctor may prescribe an antibiotic.

Vitamin A. Children with low levels of vitamin A are more likely to have a more
severe case of measles. Giving vitamin A may lessen the severity of the measles. It's
generally given as a large dose of 200,000 international units (IU) for children older than
a year.

VII. Palliative Care/ Rehabilitation

In most circumstances, contacts who are not immune to measles should be

excluded from childcare, preschool, school and work for 18 days after the last contact
with an infectious person. Where the contact with an infectious person occurs in an early
childhood education and care services or primary school setting, or if the contact is
immune-suppressed, advice on the exclusion period should be sought from the
Communicable Disease Control Branch of SA Health. A contact is any person who has
been close enough to an infected person to be at risk of having acquired the infection
from that person.

Measles is best prevented by the measles, mumps and rubella (MMR)

combination vaccine or the measles, mumps, rubella and varicella (MMRV) combination
vaccine. Almost all people who have 2 doses of a measles-containing vaccine will be
protected against measles.

If an unimmunized child aged 6 months of age or older or adult has contact with
measles, the infection may be prevented by immediate vaccination (within 72 hours of

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first contact with an infectious person) with a measles-containing vaccine (unless

contraindicated). If it is more than 3 days (73 hours) and within 6 days (144 hours) since
the first exposure, immunoglobulin (a solution containing human antibodies that is made
from human blood products) may prevent infection.

If the infant is less than 6 months old and is in contact with measles, the risk of
developing measles can be reduced by giving immunoglobulin within 6 days (144 hours)
of first contact. The MMR vaccine should then be given as close as possible to 12 months
of age, but at least 5 to 6 months after giving immunoglobulin. The measles-mumps-
rubella-varicella (MMRV) vaccine due at 18 months of age should still be given at that
time.

Adults born during or since 1966 are very likely to be susceptible to measles.
Unless they have had a medically confirmed infection with measles, they should ensure
that they have had 2 documented doses of a measles containing vaccine.

VIII. References

https://study.com/academy/lesson/measles-virus-structure-and-function.html

https://www.uptodate.com/contents/measles-clinical-manifestations-diagnosis-treatment-and-
prevention

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800572/

https://www.msdmanuals.com/professional/pediatrics/miscellaneous-viral-infections-in-
infants-and-children/measles#v1022944

https://www.mayoclinic.org/diseases-conditions/measles/diagnosis-treatment/drc-20374862

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