SweetSue's Class Notes

overlord said:
I am not sure on iPad, with google Chrome on windows I right click directly on the pic. from the pop-up I choose copy image address and then paste into the insert photo.

I tried copying the url from the address bar and got an error.
Click to expand...

Yeah, that's what I got too. It may be something they have to work out. How ironic....:laughtwo: They did all this because there was so much trouble loading into the gallery from devices. Trouble I never had, and still don't, but now I can't figure out how to post them clean from my device. Lol! Have you seen how many pictures I post?
 
I'm so glad I have Carnival at my disposal, and that you've been such a good friend, and a good sport.
 
Alright as far as the gallery page I did this:

1) I choose the "gallery embed"
2) Found Photo
3) right clicked the photo and choose "copy image address"
4) I closed out the "gallery embed" by clicking the "x" in the top right corner
5 I opened "insert Photo" and pasted
6) Then clicked "insert"

Here is another one same method


full


Not real hard, but you may need to go to your app store and download chrome to your iPad
 
I may do that tomorrow. More change. Oh yeah. Hahahaha!

I get no option to get the address. There was a moment it flashed up, but I can't remember how to do that again. Lol! It's late. I'll come back to it after my lunch date tomorrow with a friend who happens to work with a gentleman who studies cannabinoids. Small world. I've yet to meet the young man.

Thank you for all your help. You've been so thoughtful.
 
SweetSue said:
I may do that tomorrow. More change. Oh yeah. Hahahaha!

I get no option to get the address. There was a moment it flashed up, but I can't remember how to do that again. Lol! It's late. I'll come back to it after my lunch date tomorrow with a friend who happens to work with a gentleman who studies cannabinoids. Small world. I've yet to meet the young man.

Thank you for all your help. You've been so thoughtful.
Click to expand...


Your welcome, i need to get sleep for work in the morning anyway..

See you later
 
When I get home from my lunch date I'll load Chrome in and dive in with both feet.
: )
 
I don't see any edit button this morning. As a matter of fact, no options other than script. Lol! Fun times ahead for us eh m'lord. Did you get some sleep? I think I got four hours. A nap is in order later. Lol!
 
Oh...... The compose bar is back. Poor Duggan, I'll swing by. He has issues with change.

Thank God I took up daily meditation last month. Lol!
 
You too. I have a friend bringing me lunch, so I've a bus to catch.
 
This post was simply to see if the platform would take the entire narrative as one post.

Dr. Michele Sexton

[video=youtube;BuW-ro3rCHg]https:/www.youtube.com/watch?v=BuW-ro3rCHg[/video]

United In Compassion 2017 conference

Opiate Tapering - Cannabis as a Substitute for Prescribed Pain Medications: Theory and Practice

Dr. Michele Sexton

Dr. Sexton, in her own words (from her LinkedIn page):

"I have background in midwifery, botanical medicine, naturopathic medicine, women's health, basic science, clinical research, guitar-playing and rock climbing. I was in private practice as a midwife for 10 years, and now am a doctor of naturopathic medicine (ND)- this is different from homeopathy, but includes it. My research background is in analytical chemistry, and the molecular imaging of two proteins that are upregulated in neuroinflammation: TSPO and CB2. My post-doctoral work was with LCMS analysis of endogenous cannabinoids, and monocyte activation. I conducted a pilot study looking at the effects on some immune parameters of Cannabis use in patients with Multiple Sclerosis. I am currently involved in building the clinical database on the topic of clinical Cannabis use. I am investigating the areas of Cannabis use in neurology, specifically multiple sclerosis, parkinson disease, epilepsy, women's health and for adjunctive therapy in oncology. I am embarking on the journey of product development to combine strategies for integrative, scientifically-based cannabinoid medicines.

Specialties: My clinical practice is specialized in complementary neurology, neuroinflammation and neurological disease, and women's health, particularly the perimenopause. I am also adept at managing and treating chronic disease and pain syndromes. I continue to pursue 'alternative' healing modalities, especally as they apply to chronic illness, healing the whole person! Body/mind medicine"

She has a long list of accomplishments and qualifications to back up her presentation.


Intro: "Dr. Sexton began her career as a home midwife and herbalist. She has a doctorate in Homeopathic Medicine, and completed a post- doctoral fellowship at the University of Washington in 2011. Her NIH-funded pre-doctoral and post-doctoral research was on the topic of Cannabinoids And Their Roles In Neural Inflammation And Neural Degradation.

The post-doctoral project investigated cannabis use and impact on endocannabinoidal and inflammatory markers In patients with Multiple Sclerosis.

Dr. Sexton is the Medical Director at the Center for the Study of Cannabis and Social Policy and serves as an editor and technical advisor for the American Herbal Pharmacopoeia Cannabis Monograph.

Her clinical practice, research, and teaching focus is on the medical use of cannabis across a wide range of conditions and age groups.

Dr. Sexton:
- Dr. of Naturopathic Medicine
- undergraduate work was in horticulture
- She was studying a protein that was upgraded in neural inflammation in undergraduate work. When she got to graduate work in Seattle she spent six years studying and ended up being steeped in the pharmacology of cannabinoids.
- Her clinical work became a cannabis speciality that grew out of her doctrinal and post-doctrinal work.
- In the early days she was seeing quite a few pain patients. Following that the children with seizure disorder took a lot of focus.
- Now she sees mostly pain patients.

The presentation:

[video=youtube;BuW-ro3rCHg]https:/www.youtube.com/watch?v=BuW-ro3rCHg[/video]

United In Compassion 2017 conference

Opiate Tapering - Cannabis as a Substitute for Prescribed Pain Medications: Theory and Practice

It's a public health imperative that we need a better response to pain. The cost of the ineffective use of opioids is tremendous financially, but that doesn't begin to describe the cost in loss of quality of life.

It's suggested that one in five live with chronic pain, which means we all deal with the effects of the disease. The likelihood exists that regardless of your personal situation, you know someone with chronic pain.

In states that had instituted medical cannabis laws there was an almost 25% drop in opioid-induced deaths. In 2016 a retrospective cross-sectional survey of patients with chronic pain that were using cannabis as part of their regimen showed they use for pain and it gives them pain control as well as the opportunity to cut back or eliminate opioid medications.

Patients reported
*65% decreased opioid use
* decreased side effects of medication
* improved quality of life.

Dr. Sexton has an ongoing cannabis use survey going on with Bastyr University.

Of participants identified as medical cannabis users only
- 61% used cannabis to manage pain
- The second and third noted reasons for using cannabis were anxiety and depression.
- This is significant because pain patients often have anxiety and depression.

They did another analysis of this data, asking if patients substituted cannabis for prescribed medications. The survey included 2864 people
- 46% responded affirmatively.
- The top medications they were substituting for were narcotics and opiates. The next two types of medications they were substituting for were anti-anxiety and anti-depression medications.
- Medical cannabis patients were 4.6 times more likely than non- medical cannabis users to substitute cannabis for pain medications.
- Women were 6 times more likely to be substituting cannabis for their prescribed pain medications.

OPIOID SPARING PHOTO

There's quite a bit of literature in how cannabis modulates pain. The molecular details and how the endocannabinoid system is involved.

When co-administered you'll get greater relief than if you administer opioids and cannabis separately, and at a lower dose. This is relevant because of opioid tolerance and the need to keep escalating the dose.
- All patients may not be able to get off opiates, but if you can reduce the opioid dose to the point where side effects are negligible you've done well.

META ANALYSIS PHOTO

META-analysis of animal studies and clinical studies shows a noticeable decrease in opiate requirements when co-administered with THC.

LIPID GATE FOR THE PERIPHERAL CONTROL OF PAIN (Journal of Neuroscience, November 12, 2016 34(46) 15184-15191

The role of the ECS in pain
- eCB1Rs are found in both neurons and non-neural cells.
- In pain the eCBR is transported from the Dorsal Root Ganglia out to the peripheral nerve terminals. They're synthesized in cell bodies of DRG neurons and are transported to peripheral nerve terminals, where they are localized appropriately to control pain initiation in response to agonist stimulation
Hohmann AG, Herkenham M. Cannabinoid receptors undergo axonal flow in sensory nerves. Neuroscience. 1999;92:1171–1175. doi: 10.1016/S0306-4522(99)00220-1. [PubMed] [Cross Ref]
- eCB2Rs are found primarily on immune cells, although there are some reports of them also in the DRG.
- eCB2Rs are also in the keratinocytes and in tissues at the surface of the skin, where we have our sensory input.
- The expression of these receptors is enhanced by injury and inflammation. You'll see an up regulation of these receptors.

Research strongly suggests that antinociceptive endocannabinoid signaling is upregulated in both the CNS and peripheral nervous system during painful states.

DIFFERENTIAL MIGRATORY PROPERTIES....

One of the primary strategies in treating MS is to keep immune cells out of the brain. The ECS plays a part in the migration of immune cells. One of the experiments in Dr. Sexton' post-grad work was to see if cannabis users had any difference in the migratory capacity of their immune cells.
- They looked specifically at macrophages, isolated out of the blood.
- The study participants were all healthy subjects.
- They found that cannabis users had immune cells that didn't move around as much as those in subjects that didn't use cannabis.
- They were asking the macrophages to migrate in a chamber toward a chemo attractor.

They also showed a differential expression of eCBRs on immune cells.
- There's thought that immune cells can be an indicator, a mirror in many respects, to the health of the brain.
- The CNS and the immune system have a lot of cross talk.

CANNABIS USE BY INDIVIDUALS....

They also measured a global decrease in cytokine expression.
- Cytokines are inflammatory compounds that tell the rest of the body how to react to what's going on.
- Inflammation is a big problem in MS.
- They found that with all patients, those with or without MS, those that uses cannabis in any way had a reduced expression of these cytokine markers.

SUMMARY

In summary:
- Chronic pain is a problem.
- We know the ECS is involved in the pain processing.
- People are using cannabis to treat their pain.
- THC has an opioid-sparing effect. If used together you can reduce the opioid dose and still get pain relief.
- Cannabinoids have an effect on immune function.

The Endogenous Opioid System

This critical system has gotten a lot of bad press because of the misuse of opioid medications. The opioid system is the best-studied system in the body.

- There are three classes of endogenous opioids that our body produces, and three classes of opioid receptors.
- Just like the ECS, immune cells have opioid receptors and can produce opiates.
- By administering opiates we inhibit the immune response, probably directly through this opiate system.

OPIOID MEDICATIONS

Opioids are the drug of choice in conventional medicine, despite the fact that they increase pain by leading to tolerance, dependence, and hyperalgesia - amplified pain.
- They used to be reserved for end-of-life, in particular cancer patients.
- Suddenly they became overprescribed for all chronic pain, and that mushroomed into the current epidemic.

The pharmacologic effects of opioid medications are primarily through the mu opiate receptor.
- There's good evidence that simply by administering morphine, for example, we induce inflammation into the body.

PRESCRIPTION OPIOIDS, 2011 *No need for this one. *

TWENTY-FIVE YEAR.....

The Australian government, in assessing their own country's opioid problem, determined that the dramatic and alarming increase in prescribed opioids was due to the subsidy of longer-acting medications being prescribed for the treatment of non-cancer pain.

Opioid-induced hyperalgesia

OIH is alterations in pain perception caused by exposure to opioids.
- The condition is characterized by a paradoxical response, whereby the patient receiving opioids can actually become more sensitive to certain painful stimuli, known as allodynia.

Hyperalgesia = more pain
Allodynia = something that shouldn't be painful, like cold, feeling very painful to the patient.

Problems with opiate therapies:
- Tolerance: They may be on very high doses of opiates and still have relentless breakthrough pain.
- Dependance: They can't come off the opiate (opiate craving).
- Mechanical allodynia or hyperalgesia.
- Behavioral effects like catastropheizing, where the patient has to recall and retell everything that led up to this depressing state, every misstep by a medical professional involved in their treatment, and a litany of how everything is going wrong, and nothing will work out for them because nothing ever does.
- Chronic pain patients usually live with anxiety and depression as well.

PATIENT #1
* Female Age: 63
* Drug List: Methadone (10mg) x 8, Hydromorphone 4mg x 8, Xanax 1.5mg 1 - 2 times per month
* Pain Descriptor: numbness, tingling, tightness, and muscle spasm
* Gastrointestinal: Constipation
* Endocrine: Cold intolerance
* Psychiatry: sleep difficulty,vicious wake-sleep cycles; anxiety
* Musculoskeletal: joint pain, swelling, muscle pain
*Sleep: poor sleep initiation and maintainance.

Patient was surgically fused from the top of her cervical spine to the sacrum and had zero quality of life.
- Barely able to walk, and had to use a walker.
- Intense and unrelenting anxiety.
- Constant insomnia.
- Constipation.
- Her Morphine Equivalent Daily Dose was 1088. :straightface:
- She kept drugs on hand in case of an overdose.

How does hyperalgesia work?
- One method is by depressing dopamine transmission in a particular pathway in the brain.
- Dopamine is one of the body's pleasure neurotransmitters.
- If you over-agonize the MOR dopamine receptor you'll see the same loss of dopamergic function that is seen in inflammatory pain.
- Opioids depress immune function, by interfering with macrophage and T-cell function, since the immune cells express opioid receptors.
- By administering morphine you inhibit the production of natural endorphins and natural opiates, which are there for good cause - for pain relief and for modulating the immune system.

A paper in Proceedings of the National Academy of Sciences showed the mechanism of how morphine is actually prolonging and intensifying neuropathic pain by amplifying the NALP3, an inflammisome, a molecule that activates inflammation.

In May of 2017 in Frontiers of Immunology they reported on "Tool-like Receptor-Dependent Negative Effects of Opioids: A Battle between Analgesia and Hyperalgesia."

Toll-like receptors are typically activated by infectious agents or toxins produced by bacteria, but things in our bodies can also activate them, such as mechanical damage.
- It activates the immune response to come and clean up the problem.

- "Toll-like receptors are expressed on various types of cells, including those found in the CNS, and constitute a vital link between the immune system an the CNS."
- "TLR4 has been identified as a pain initiator."
- "using analgesics that will activate both the MOR and TLRs can worsen the general scenario."
- "TLRs expressed on neurons, glia, and other neuroimmune cells on-steroselectively by both active and inactive isomers of Morph and its opioid-inactive metabolite M3G."

We know precisely how opioids are contributing to pain.

Summary:
- There's an endogenous opiate system, present on our CNS cells and on immune cells.
- Administration of opioids has been shown to cause paradoxical pain.
- We know exactly what this happens at the cellular level.

NEURAL-IMMUNE REFLEX

The Neural-Immune Reflex

The natural flow is that the immune response should resolve itself. The body is designed and evolved to heal. The ECS is involved in the homeostasis of the immune system.
- If you don't get resolution you end up with chronic inflammation which is associated with chronic pain.

IMMUNE CELLS COMMUNICATE WITH.....

How it works:
- The body experiences injury or illness. (Pathogens or tissue damage)
- The body responds with pro-inflammatory cytokines, signaling in the brain and contributing to the pain experience.
- There should be a negative feedback loop (eCBs turning off the neurotransmitter dump) which will turn off the immune system response.
- This is the crosstalk in the body, the cytokines, immune system and endocannabinoid system working together to resolve pain. We call this the Neural Circuit

* Neural reflexes regulate immunity. * Our brain is involved in our immunity.

RETHINKING INFLAMMATION:....

What should happen in a normal reflex arc:
- The Vegas nerve communicates between the brain and the internal organs directly from the loco cerillas through a neurotransmitter called norepinephrine.
- Norepinephrine comes signalling down the Vegas nerve, communicating with T-cells, telling them to produce acetylcholine.
- Acetylcholine turns off the innate immune system. It's calling the immune cells home.

There's significant crosstalk between the ECS and the EOS. They both have some control on
- sedation
- hypnosis
- regulation of temperature
- analgesia
- intestinal motility
- pain

They're involved in common things happening within the body.
- Cannabinoids can enhance opiate potential and vice-versa.
- Administered together there's greater than additive effect.
- These two systems are co-localized in the brain and on immune cells.
- Beta endorphins can bind to some eCBRs and some cannabinoids can bind to opiate receptors.
- The cannabinoid and opioid receptors can join together in what's called heterodimerization, which can lead to different types of signaling.

EVALUATING THE CROSS-TALK

Dr. Sexton is doing a study of patients to evaluate the crosstalk between the ECS and EOS.
- They'll measure cytokines, the ECS, the EOS.
- They'll then administer chemovars of cannabis, both with and without CBD to measure changes in how these systems are talking to each other.

- The systems talk to each other.
- Hyperalgesia has an inflammatory component.
- It's believed that cannabinoids can help restore the Neural-Immune Reflex and restore some of the damage that's being done by chronic opiate administration.

NEUROPATHIC PAIN STUDIES

The Cannabis Medical Research Center(CMCR), UCSD studies on inhaled cannabis showed consistent and significant decrease in pain after inhaling cannabis.
- They used flower in a vaporizer.
- Cannabis often works more effectively than most add-on pain relievers.
- Cannabis is a rational choice as an add-on medication.

EFFICACY OF INHALED CANNABINOIDS

A study at UCSD by Mike Wallace on diabetic neuropathy pain compared three chemovars acquired from the U of Miss, meaning they were abysmally lacking in cannabinoids, and yet.....
- It's low-potency cannabis, around 4%, and it still showed efficacy.
- Surprisingly, when they titrated up there were more patients that experienced decreased pain relief.

** When you treat chronic pain it's important to find the sweet spot and stay there. **
- If you overshoot you disrupt the system and may experience less pain relief from cannabis then you'll get at a lower dose.
- Consider that most of the varietals in dispensaries are much higher than 15% and what this might be doing to disrupt pain management.
- Find the sweet spot and avoid the chance of having THC exacerbating pain.

INHALED CANNABIS FOR.....

COMPROMISED EXTERNAL VALIDITY (the comparison of what U of Miss offers and how they don't stack up to what the market is offering)
- You can go to NIDA's site and see the potency of the chemovars offered by U of Miss.
- The cannabis all the studies are being done with bears no real resemblance to what patients are actually using.
- This calls into question all of the "sanctioned" studies.

USE OF CANNABIS IN CLINICAL PRACTICE

Clinical Practice
Dr. Sexton prefers inhalation, with whole flower and a vaporizer.
- When a pain patient needs pain relief they need it immediately, and nothing beats inhalation for speedy delivery.
- Patients can self-titrate to find their optimal therapeutic dose with the least side effects.

* Vaporization reduces symptoms of chronic bronchitis seen in cannabis smokers Is this a real thing, or something the government spreads? I don't know anyone getting chronic bronchitis from smoking cannabis. As a matter of fact, I believe most of us don't get sick at all.
* Specifically, pinene may add to the analgesic effects and ameliorate some side effects of THC.

CANNABIDIOL

Cannabidiol
- There are no studies showing analgesic effects of CBD in humans.
- CBD has been shown to have anxiolytic effects.
- CBD has been shown to have anti-inflammatory effects.
- CBD has been shown to increase AEA (anandamide) levels.
- CBD decreases NALP3.
- CBD may modulate dopamine mechanisms in the ventral tegmental area (related to addiction).

There's a strong argument for including CBD in the regimen, but in her experience CBD will not offer pain relief, at least not for the complex pain she sees in her practice.

*****greatwolf would dispute that. *****

Most of the CBD products are being marketed at 5 mg doses, much, much lower than would be effective.
- When you formulate a cannabinoid medication you want lots of CBD and a small amount of THC. In other words, a CBD-rich medication with as much THC as is needed or tolerated.

Her basic protocol is to teach her patients how to shop for cannabis that will meet their needs.

ACDC is the first choice.
- It has a predictable high ratio of CBD to THC.

She also has them purchase a high THC chemovar so they can mix the chemovars and titrate the THC themselves.

Many patients come in proclaiming they have no intention of smoking cannabis or getting high.
- She respects their thoughts, and then it becomes an educational session as to how one can use cannabis without overwhelming euphoria.
- This isn't "smoking pot." It's the best delivery system for pain relief, and you won't get addicted and it won't destroy your life or kill you.

She compares it making enchilada sauce; you want two tablespoons of cumin (CBD) but start with just a pinch of red pepper (THC).
- You want clear-headed therapeutic efficacy.

The THC chemovar she suggests is the most popular in CA and along the west coast, and in Colorado identify this chemovar having an almost even ratio of the terpenes a-pinene and b-myrcene. This is not a common ratio of monoterpenes.
- Dr. Sexton believes it's the pinene in such high concentrations that may be having a pronounced effect on pain.
- There's evidence that a-pinene inhibits the breakdown of acetylcholine, a neurotransmitter that improves cognitive function.
- Acetylcholine is also involved in the neural-immune reflex.

She tells her patients this is their introductory package, and encourages them to shop around for other chemovars once they get familiar.
- If this mix doesn't work they'll talk about other beneficial terpenes and explore other options.

She suggests the patients use oral administration, starting at 1-2 mg of THC.
- Begin with an inhalation and follow that up with an edible and you'll get instant relief as well as long-term relief.

Follow-Up of Patient #1
* Two-month follow-up: MEDD 368 (down from 1088)

* Four-month follow-up:
- Has been able to return to PT.
- Opiate taper has remained constant (hasn't been able to get completely off).
- Xanax unchanged. Still has some anxiety.
- Continues to use cannabis for sleep.
- Her "relief scores" are 70-80%. She still has pain, but it doesn't affect her the way it used to. Cannabis removes you from the pain expression.

As Dr. Sexton puts it, you may still have pain, but it'll be an altered perception of your pain. You may see that the sky is blue because you're not so focused on your pain.

SUMMARY

In summary:
- Inhaled cannabis has demonstrated efficacy for neuropathic pain.
- There have been no formal trials for CBD for pain.
- Inhalation allows for whole plant administration and rapid effects that are pharmacokinetically reproducible across patients.
- Patient responses are highly variable. The majority respond to quite a low dose for their pain while others will require higher doses.

Take the whole patient package into account - diet, lifestyle, exercise - an inclusive treatment overview. Take natural steps to support your ECS.

Considerations for pain patients

Morphine effects
- impaired osteoblast function
- decreased sex steroids
- Acetylcholine signaling disrupted
- cognitive function impaired
- bowel function disrupted

Integrated Care
- diet
- nutrients
- exercise
- mental health
- mindfulness
- acupuncture
- massage
- PT
- Osteopathy

Tapering ideally includes a coordination of all medical teams. This is something that will effect the entire program. The doctor that prescribes the medication is the one who should be removing it or overseeing the weaning off.

In an ideal world you shoot for a 10% reduction per week. No more than that.
- Some patients can do it, others can't.
- Alcohol use can be a concern, disrupting the sleep cycle and exacerbating the pain.
- Suggest replacing the alcohol with cannabis. It'll be more effective and non-toxic.

Other support active therapies
* Dose escalation of CBD: 200mg TID
* Curcumin has been shown to attenuate morphine withdrawal in rats. 1000 mg BID
- It's also an anti-inflammatory.
* Theanine, a compound from green tea has a calming effect. (for anxiety)
* Lithium orotate (for sleep and anxiety)
* Omega-3 fatty acids
* EXERCISE
* Body work

- Consider the patient preference. How are they most likely to use cannabis?
- Start a patient resistant to inhalation on edibles, explaining the delayed effects and inconsistent results you'll possibly get.
- Most patients find their way to inhalation for the relief factor.
- Cannabis doesn't potentiate the opioids by increasing their blood levels, so using cannabis with your opioids won't be a threat to your life.
- When you're trying to taper off opioids use cannabis whenever you feel pain. The goal is opiate elimination.
- If the patient is starting with pain in the morning, start the day with cannabis and get the pain under control. Some patients set their alarms for 4 AM to take an opiate so they can go back to sleep and wake up with less pain. Not a way to live.
- Inhale first with an edible follow-up for longer relief.
- Some patients will be able to get off opioids, others won't, but will be able to taper the opiates down and get better pain relief.

The significance of ongoing research:
- To help to make sure the medical community keep from making the same mistakes they made with opiates pharmacy, which is unchecked prescribing with adverse effects of epic proportions.
- Support federal guidelines for opiate tapering.
- Provide a rational alternative to opioid medications.
- Address the gaps in medical education by providing CME to physicians for evidence-based practice.
- Allow for physician participation in the treatment plan of using cannabis.

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I've been in and out all day and I didn't think to check what I just posted. Lol! Hold on, let me try one.

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Apparently not. They have a lot on the plate, and I know this is a top priority. I haven't loaded Chrome in yet. I'm hoping I don't have to.
 
I don't mind the information showing, except that it's clutter no one needs.
 
overlord said:
You managed to do it in the previous post
Click to expand...

You are so right. :hug:

I'm sure it's being worked out. Things are bound to fall in and out, aren't they? This is my first such experience.
 

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