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--> 00:04.561\n大家好，\n\n00:04.961 --> 00:06.662\n今天我来讲一下。\n\n00:07.607 --> 00:12.008\n肺源性心脏病的病理机制与临床管理。\n\n00:16.333 --> 00:18.833\n那么今天将分为六个大点来讲。\n\n00:19.184 --> 00:20.833\n首先先看第一点，\n\n00:21.384 --> 00:23.934\n疾病的概述与流行病学。\n\n00:27.475 --> 00:27.825\n那么，\n\n00:28.225 --> 00:33.525\n肺性心脏病它的核心病理机制那么是肺动脉高压。\n\n00:34.424 --> 00:39.875\n它长期的超负荷会导致右心室壁增厚，\n\n00:40.025 --> 00:42.525\n增加0.5.1.2公分。\n\n00:43.075 --> 00:43.525\n那么，\n\n00:43.525 --> 00:45.325\n正常的右心室壁厚度呢，\n\n00:45.325 --> 00:47.025\n是0.3.0.5公分。\n\n00:47.424 --> 00:47.875\n那么，\n\n00:47.875 --> 00:52.575\n最终肺动脉高压长期就会引发一个右心的衰竭。\n\n00:54.312 --> 00:58.111\n第二就是急性或者慢性形态学的差异。\n\n00:59.012 --> 01:03.212\n急性肺心病表现为右心室的急性扩张，\n\n01:03.762 --> 01:07.061\n那么舒张末期的容积增加40%，\n\n01:07.561 --> 01:11.412\n慢性则呈现一个典型的血行性的改变。\n\n01:12.337 --> 01:13.837\n右室壁肥厚，\n\n01:14.038 --> 01:15.688\n伴心肌纤维化，\n\n01:17.237 --> 01:19.388\n然后是血流动力学的对比，\n\n01:20.138 --> 01:25.938\n急性型肺动脉收缩压会骤升至50.70mmHg，\n\n01:26.638 --> 01:29.688\n慢性型它是呈一个渐进性的升高，\n\n01:30.288 --> 01:32.888\n年均增长2.5mmHg。\n\n01:34.148 --> 01:38.197\n右室射血分数会下降至35%以下，\n\n01:38.398 --> 01:40.248\n提示了一个代偿。\n\n01:43.869 --> 01:47.018\n那么看一下全球疾病负担的分析。\n\n01:49.377 --> 01:53.527\n那么CPD就是主导的一个疾病谱，\n\n01:54.178 --> 01:58.953\n全球有3.8亿的Co pd患者中，\n\n01:58.953 --> 02:01.727\n32%会发展为一个肺源性的心脏病，\n\n02:02.377 --> 02:05.678\n占了一个慢性肺心病病因的82%，\n\n02:05.977 --> 02:06.553\n这个呢，\n\n02:06.553 --> 02:10.527\n是O2024年一个呼吸疾病报告的数据。\n\n02:11.378 --> 02:14.091\n那么年龄性别分布的特征中，\n\n02:14.091 --> 02:18.277\n50岁以上人群占百分比是87%，\n\n02:18.977 --> 02:19.727\n男性。\n\n02:19.848 --> 02:21.598\n患病率是女性的2.3倍，\n\n02:21.947 --> 02:25.197\n但女性死亡率高达到了18%，\n\n02:25.947 --> 02:29.397\n与合并哮喘比例达到41%相关，\n\n02:30.298 --> 02:32.647\n还有就是区域流行病学的差异。\n\n02:33.632 --> 02:37.382\n发展中国家发病率是发达国家的1.8倍，\n\n02:38.332 --> 02:42.981\n那么亚洲地区年均增长率达到3.2%，\n\n02:43.531 --> 02:46.882\n和PM2.5暴露水平是呈一个正相关的。\n\n02:52.093 --> 02:56.044\n然后看一下病因病理机制的解析。\n\n03:03.652 --> 03:05.352\n那么急性的病因，\n\n03:05.552 --> 03:08.652\n它比如就是有一个血栓和栓塞。\n\n03:09.651 --> 03:11.951\n那么栓子来源与病理特征，\n\n03:12.552 --> 03:15.302\n深静脉血栓占了肺栓塞。\n\n03:16.294 --> 03:17.944\n的90%，\n\n03:19.143 --> 03:21.994\n那么新鲜的血栓含有红细胞，\n\n03:22.143 --> 03:23.994\n还有纤维蛋白复合物。\n\n03:24.244 --> 03:27.544\n平均长度是15.20cm，\n\n03:27.794 --> 03:30.244\n可以完全阻塞一个肺动脉的主干。\n\n03:32.242 --> 03:34.742\n血流动力学骤变的机制，\n\n03:35.591 --> 03:39.242\n肺动脉压6小时内可以升至60mmHg。\n\n03:40.063 --> 03:42.563\n那么正常是小于等于25mmHg，\n\n03:43.363 --> 03:47.514\n血管截面积减少大于50%时，\n\n03:47.863 --> 03:51.164\n那么右室的后负荷会增加200%，\n\n03:51.613 --> 03:54.014\n导致一个急性的右心扩张。\n\n03:55.037 --> 03:59.938\n还有就是一个细胞因子风暴级的级联反应。\n\n04:02.438 --> 04:04.087\n血栓释放了五羟色胺，\n\n04:04.087 --> 04:05.337\n还有血栓素A2，\n\n04:05.837 --> 04:07.787\n引发了肺血管痉挛，\n\n04:08.287 --> 04:11.888\n使肺血管阻力在两小时内增加4倍，\n\n04:12.138 --> 04:14.087\n形成了一个恶性的循环。\n\n04:17.359 --> 04:18.709\n看一下慢性进展，\n\n04:18.709 --> 04:20.510\n它一个三阶段的模型，\n\n04:21.660 --> 04:23.035\n首先是第一期，\n\n04:23.035 --> 04:24.760\n一个是支气管病变期。\n\n04:25.817 --> 04:27.417\n大约是5.10年，\n\n04:28.467 --> 04:33.518\n那么慢性阻塞性肺病患者EVO one每年下降60.80ml，\n\n04:34.368 --> 04:36.717\n气道阻力增加了三倍，\n\n04:37.417 --> 04:41.167\n肺泡壁毛细血管床减少了40%，\n\n04:41.917 --> 04:46.967\n那么其由此就是启动了一个缺氧性的一个肺血管的收缩。\n\n04:48.246 --> 04:49.096\n2期呢，\n\n04:49.096 --> 04:50.696\n是一个肺动脉高压期，\n\n04:51.196 --> 04:52.746\n大约在3.5年，\n\n04:53.645 --> 04:55.145\n持续的缺氧，\n\n04:55.346 --> 04:56.446\n它会激活，\n\n04:56.446 --> 04:56.746\nHi,\n\n04:56.846 --> 04:57.571\n一阿尔法，\n\n04:57.571 --> 04:59.846\n还有ET水平增高5倍，\n\n05:00.795 --> 05:01.895\n肺血管中。\n\n05:03.052 --> 05:05.451\n层厚度增加200%，\n\n05:05.802 --> 05:10.052\n那么平均肺动脉压达40.55mmHg。\n\n05:12.368 --> 05:14.967\n第三期是一个右心失代偿期，\n\n05:15.317 --> 05:16.667\n大约一到两年。\n\n05:17.794 --> 05:21.544\n右室游离壁厚度大于5公5mm。\n\n05:22.382 --> 05:27.282\n舒张末容积指数大于等于85ml每平方米，\n\n05:27.532 --> 05:31.382\n还有就是B、NP水平大于500匹克每毫升，\n\n05:31.933 --> 05:35.333\n最终会出现一个肝颈静脉反流征的阳性。\n\n05:40.587 --> 05:43.736\n后是一个血管重构的分子机制，\n\n05:44.786 --> 05:46.712\n首先就前面说的，\n\n05:46.712 --> 05:51.736\n缺氧会诱导一个缺氧诱导因子一阿尔法调控网络，\n\n05:51.986 --> 05:57.286\n一个HIF一尔法在氧分压小于60mmHg时会激活。\n\n05:58.312 --> 06:01.111\n上调的V、EG、F表达3倍，\n\n06:02.011 --> 06:04.161\n促进了平滑肌细胞的增殖，\n\n06:04.611 --> 06:08.161\n血管壁增厚达到了150.200μm。\n\n06:09.279 --> 06:11.579\n还有就是甲通道异常的机制。\n\n06:12.627 --> 06:13.278\n那么。\n\n06:14.111 --> 06:17.411\n甲通道一点五通道表达减少50%，\n\n06:17.761 --> 06:20.962\n那么膜电位会去极化至-30mV，\n\n06:21.761 --> 06:24.661\n触发了电压依赖性的钙通道开放，\n\n06:25.562 --> 06:28.361\n细胞内钙离子浓度会升高5倍。\n\n06:31.805 --> 06:36.605\n然后是一个基质金属蛋白酶的作用，\n\n06:36.605 --> 06:39.406\nMMP9活性增加的2.5倍，\n\n06:39.656 --> 06:45.105\n它会降解四型胶原血管基底膜完整性会被破坏，\n\n06:45.656 --> 06:51.205\n中层平滑肌细胞内膜迁移率会提高一个80%。\n\n06:57.135 --> 06:59.936\n那么第三就是一个临床表现与分期。\n\n07:04.957 --> 07:07.807\n先看一下代偿期隐匿症状的识别。\n\n07:09.993 --> 07:14.343\n那么劳力性的呼吸困难特征代偿期，\n\n07:14.343 --> 07:18.093\n患者活动后气促发生率高达78%，\n\n07:18.843 --> 07:21.394\n步行200米就会出现一个喘息，\n\n07:22.394 --> 07:25.593\n但是静息时症状可以自行缓解，\n\n07:25.894 --> 07:27.218\n容易被误诊，\n\n07:27.218 --> 07:29.394\n误认为是一个衰老的表现。\n\n07:30.523 --> 07:32.873\n还有就是剑突下搏动的体征，\n\n07:33.723 --> 07:36.449\n右心室肥厚患者中，\n\n07:36.449 --> 07:40.473\n63%可以触及一个剑突下异常的搏动。\n\n07:41.579 --> 07:46.229\n其幅度、搏动幅度和肺动脉压成一个正相关，\n\n07:46.579 --> 07:49.729\n是一个早期的筛查重要指标，\n\n07:50.979 --> 07:53.479\n还有就是夜间症状加重模式。\n\n07:55.671 --> 07:58.821\n32%患者出现了一个夜间阵发性的呼吸困难，\n\n07:59.522 --> 08:04.321\n和平卧位膈肌上抬、肺血容量增加有关，\n\n08:04.921 --> 08:08.821\n平均血氧饱和度下降8%.12%。\n\n08:11.972 --> 08:13.872\n后是一个失代偿期，\n\n08:13.872 --> 08:15.122\n多系统的表现，\n\n08:16.222 --> 08:18.072\n呼吸衰竭分级的表现。\n\n08:19.173 --> 08:23.972\n那么二型呼吸衰竭患者氧分压小于等于60mmHg，\n\n08:24.072 --> 08:27.423\n伴二氧化碳分压大于等于50mmHg，\n\n08:27.673 --> 08:28.997\n出现意识障碍，\n\n08:28.997 --> 08:30.722\n发生率是41%。\n\n08:31.585 --> 08:32.385\n血气P，\n\n08:32.385 --> 08:34.286\nH值小于7.25时，\n\n08:34.286 --> 08:35.835\n病死率会增加3倍。\n\n08:37.926 --> 08:40.226\n然后是一个右心衰竭的三联征，\n\n08:41.226 --> 08:42.375\n颈静脉怒张，\n\n08:42.926 --> 08:44.125\n肝大压痛，\n\n08:44.476 --> 08:45.651\n下肢水肿，\n\n08:45.651 --> 08:48.825\n构成了一个典型的右心衰竭三联针，\n\n08:49.276 --> 08:52.125\n那么中心静脉压正常是。\n\n08:53.726 --> 08:56.377\n会大于一个12cmH2O。\n\n09:00.750 --> 09:04.351\n另外一个多系统表现表现为一个肝肾综合征，\n\n09:04.601 --> 09:08.151\n它的机制就是有效循环血量减少，\n\n09:08.601 --> 09:10.450\n导致肾灌注不足，\n\n09:11.101 --> 09:15.151\n血清肌酐大于133μmol/L发生率。\n\n09:16.685 --> 09:16.935\n29%，\n\n09:17.585 --> 09:20.911\n合并腹水时白蛋白小于30g，\n\n09:20.911 --> 09:22.986\n每升者达83%。\n\n09:23.935 --> 09:26.486\n另外就是一个凝血功能异常的特征，\n\n09:27.385 --> 09:29.786\nDIC发生率有17%，\n\n09:30.335 --> 09:33.085\n表现为血小板小于100。\n\n09:33.969 --> 09:35.294\n乘以十的9次方，\n\n09:35.294 --> 09:38.594\n每升纤维蛋白原小于1.5g，\n\n09:38.594 --> 09:41.619\n每升出血风险就会增加百分，\n\n09:41.770 --> 09:43.619\n就会增加1个4.6倍。\n\n09:49.432 --> 09:51.932\n然后是一个精准诊断路径，\n\n09:52.932 --> 09:55.481\n影像学的一个诊断金标准，\n\n09:56.331 --> 09:58.331\n超声心动图核心指标。\n\n09:59.346 --> 10:04.546\n右心室厚壁厚度大于5mm是诊断阈值，\n\n10:05.296 --> 10:07.596\n敏感性达到了87%。\n\n10:08.611 --> 10:10.286\n特异性92%，\n\n10:10.286 --> 10:14.062\n是评估右心重构的关键影像学证据。\n\n10:15.150 --> 10:17.099\n另外是肺动脉高压的特征，\n\n10:17.799 --> 10:21.849\n收缩期肺动脉压大于等于40mmHg，\n\n10:22.349 --> 10:25.849\n肺动脉内径大于等于25mm，\n\n10:26.599 --> 10:29.450\n提示了肺血管阻力显著增加。\n\n10:30.099 --> 10:32.299\n另外就是影像学的联合诊断，\n\n10:32.849 --> 10:34.950\nCT肺动脉造影显示。\n\n10:35.679 --> 10:39.229\n血管截面积大减少大于50%时，\n\n10:39.580 --> 10:45.479\n那么联合超声测得的右室和左室直径比大于1.0，\n\n10:46.030 --> 10:50.580\n那么诊断的准确率可以提升到95%。\n\n10:54.724 --> 10:57.125\n然后是一个血气分析和肺功能。\n\n10:58.174 --> 10:58.875\n首先，\n\n10:59.224 --> 11:04.474\n呼吸衰竭判定的标准就是静息状态下氧分压小于60mmHg。\n\n11:05.320 --> 11:08.171\n半二氧化碳分压大于50mmHg，\n\n11:08.471 --> 11:11.270\n氧合指数小于300mmHg，\n\n11:11.421 --> 11:13.570\n提示了存在一个二型的呼衰，\n\n11:14.971 --> 11:21.171\n还有就是肺功能的一个关键参数Feb比FBC\u003C70%，\n\n11:21.770 --> 11:24.971\n残气量比肺总量大于40%，\n\n11:25.270 --> 11:28.671\n提示了一个不可逆性的气流受限的特征。\n\n11:30.611 --> 11:33.010\n还有血气动态监测的价值，\n\n11:33.810 --> 11:37.085\n如果夜间血氧饱和度小于90%，\n\n11:37.085 --> 11:39.911\n持续时间大于30%的睡眠时间，\n\n11:40.310 --> 11:44.010\n那么预示五年生存率会下降40%，\n\n11:44.361 --> 11:47.661\n需要启动一个长期的氧疗干预。\n\n11:53.859 --> 11:56.008\n然后是一个综合治疗的策略，\n\n11:57.059 --> 11:59.758\n先是阶梯式的氧疗方案。\n\n12:01.513 --> 12:02.013\n那么，\n\n12:02.013 --> 12:05.039\n鼻导管氧疗它的参数控制呢，\n\n12:05.039 --> 12:08.064\n是初始氧流量在1.2L/min，\n\n12:08.064 --> 12:13.888\n维持氧饱和度在88%.92%。\n\n12:13.888 --> 12:16.888\nCo pd患者需要严格遵循低流量的原则，\n\n12:16.888 --> 12:18.963\n避免二氧化碳储留的加重。\n\n12:20.312 --> 12:22.937\n高流量湿化氧疗的应用，\n\n12:22.937 --> 12:27.961\n在急性期可以采用40.60L/min的高流量氧疗，\n\n12:28.512 --> 12:31.961\n那么氧浓度可以调节至50%，\n\n12:32.361 --> 12:34.711\n这样可以有效改善氧合指数。\n\n12:39.310 --> 12:40.036\n还有呢，\n\n12:40.036 --> 12:41.960\n就是机械通气过渡策略。\n\n12:42.760 --> 12:43.161\n当。\n\n12:44.211 --> 12:46.762\n二氧化碳分压大于70mmHg，\n\n12:47.062 --> 12:50.161\n而且PH小于七点二五时，\n\n12:50.512 --> 12:56.961\n那么采用百pap无创通气IP可以设置为12.20cmH2O。\n\n12:58.085 --> 13:00.635\nEPP可以设置为4.8cmH2O，\n\n13:01.135 --> 13:04.385\n那么平均每天要使用大于等于16个小时。\n\n13:07.208 --> 13:09.408\n另外要注意并发症的预防要点，\n\n13:09.807 --> 13:11.708\n需要监测一个氧中毒，\n\n13:12.307 --> 13:14.458\n当氧浓度大于六十，\n\n13:14.557 --> 13:15.583\n60%，\n\n13:15.583 --> 13:18.007\n持续超过24小时时去警惕，\n\n13:18.607 --> 13:21.007\n需要我们定期的监测血气分析。\n\n13:21.658 --> 13:25.257\n另外还要当心一个鼻粘膜损伤的预防，\n\n13:25.357 --> 13:28.682\n那么这个时候就要就要加进行一个湿化，\n\n13:28.682 --> 13:31.507\n温度维持在37加减1°C，\n\n13:32.107 --> 13:34.307\n湿度要大于70%。\n\n13:36.632 --> 13:38.007\n那么药物治疗的话，\n\n13:38.007 --> 13:40.481\n首先看一下一个靶向药物新进展，\n\n13:41.281 --> 13:45.182\n那么就是PD 5 five一个抑制剂优化方案。\n\n13:46.182 --> 13:56.257\n西地那非20mg tid联合波生坦62.5mg bid可以使肺动脉收缩压下降15.25cm，\n\n13:56.257 --> 14:01.831\n水毫米水汞柱6分钟步行距离增加大于等于50米。\n\n14:02.599 --> 14:05.900\n还有就是内皮素受体拮抗剂的联用，\n\n14:06.500 --> 14:07.900\n比如一个安利生坦，\n\n14:08.049 --> 14:09.799\n还有马西坦坦方案，\n\n14:10.650 --> 14:11.599\n三个月后，\n\n14:11.650 --> 14:14.500\n它n tpro、BMP会下降40%，\n\n14:15.599 --> 14:18.700\nwho功能分级改善率都会提升68%。\n\n14:22.880 --> 14:25.367\n另外就是一个靶向药物的新进展，\n\n14:25.367 --> 14:29.979\n一个是新型的SGC刺激剂的应用，\n\n14:30.679 --> 14:35.780\n利奥西瓜1.5mgtid可以治疗一个顽固性的肺动脉高压，\n\n14:36.229 --> 14:40.330\n12周后肺血管阻力指数会下降350。\n\n14:41.732 --> 14:43.833\n新指数会提升0.8L。\n\n14:45.505 --> 14:46.056\n另外，\n\n14:46.255 --> 14:47.856\n药物副作用的管理，\n\n14:48.356 --> 14:53.106\n那么联合用药时需要定期监测一个肝功能、血红蛋白，\n\n14:53.455 --> 14:58.156\n还有就是一个血压控制目标要大于九十六十毫米汞柱。\n\n14:59.354 --> 15:00.005\n另外。\n\n15:00.969 --> 15:01.744\n肺动脉高压，\n\n15:01.744 --> 15:03.419\n一个外科干预的适应症。\n\n15:04.765 --> 15:06.091\n在终末区Co，\n\n15:06.091 --> 15:06.866\nOPD患者F，\n\n15:06.866 --> 15:07.716\nfe,\n\n15:07.716 --> 15:08.341\nV,\n\n15:08.341 --> 15:09.416\nY\u003C25%的预计值时，\n\n15:09.916 --> 15:11.390\n那么IP，\n\n15:11.390 --> 15:15.616\nF患者小于三十百分之30的预计值，\n\n15:16.416 --> 15:20.916\n还有供肺冷缺血时间需要小于6小时，\n\n15:21.216 --> 15:25.216\n那么术后一年生存率会达到85%。\n\n15:26.065 --> 15:28.466\n还有就是肺动脉血栓切除的指针，\n\n15:29.065 --> 15:31.265\n它包括一个CTEPH患者，\n\n15:31.466 --> 15:33.216\n他PB要大于500，\n\n15:33.616 --> 15:36.565\n还有近端血栓占比要大于50%，\n\n15:37.366 --> 15:39.716\n手术死亡率3.8%，\n\n15:40.166 --> 15:43.065\n术后五年生存率可以达到82%。\n\n15:46.984 --> 15:47.708\n还有就是，\n\n15:47.708 --> 15:49.633\n房间隔造口术评估，\n\n15:50.283 --> 15:56.583\n适用于WHO的一个心功能分级4级RAP≥20mmHg的患者，\n\n15:56.833 --> 16:00.133\n造口直径8.10mm，\n\n16:00.484 --> 16:01.184\n术后。\n\n16:02.765 --> 16:06.140\n那个SCO two要维持在85%，\n\n16:06.140 --> 16:09.414\n30天的生存率可以提升至71%，\n\n16:10.265 --> 16:13.215\n还有就是术后康复监测指标，\n\n16:13.864 --> 16:16.164\n肺移植后需要监测。\n\n16:16.164 --> 16:16.414\nFEB.\n\n16:17.398 --> 16:19.499\nTRC血栓切除后，\n\n16:19.499 --> 16:22.523\nD机体需要小于500μg/L。\n\n16:26.882 --> 16:29.232\n最后讲一下预后管理与预防，\n\n16:30.132 --> 16:33.083\n首先是一个长期随访指标系统，\n\n16:33.583 --> 16:36.932\n首第一个是一个6分钟步行监测试验。\n\n16:38.078 --> 16:40.177\n那么需要每三个月评估一次，\n\n16:41.127 --> 16:43.578\n还有就是BNP的一个动态评估。\n\n16:46.439 --> 16:48.263\nBP如果大于100匹克每毫升，\n\n16:48.263 --> 16:50.564\n提示右心功能会失失代偿。\n\n16:51.351 --> 16:51.702\n嗯。\n\n16:52.395 --> 16:54.745\n还有就是一个生活质量的多维评估，\n\n16:55.495 --> 16:58.846\n采用SGRQ问卷评估，\n\n16:59.296 --> 17:02.245\n症状维度权重占40%，\n\n17:02.695 --> 17:05.145\n活动能力占35%，\n\n17:05.446 --> 17:07.595\n社会影响占25%，\n\n17:07.845 --> 17:09.845\n总分大于五十分，\n\n17:09.845 --> 17:10.995\n需要心理干预。\n\n17:11.645 --> 17:14.446\n还有就是综合预警模型的构建。\n\n17:18.094 --> 17:19.194\n最后谢谢各位。\n\n","v0d47cg10004d768jmqljhtcqqooq80g",1049,696,"2026-01-26 13:09:48","肺源性心脏病病理机制与临床管理 | 病因、诊断与治疗策略  ","肺源性心脏病, 病理机制, 临床管理, 肺动脉高压, 右心衰竭, 慢性阻塞性肺病, 呼吸系统疾病, 心血管并发症  ","本文深入解析肺源性心脏病的病理机制，包括肺动脉高压与右心衰竭的发展过程，并提供最新的临床管理策略，涵盖诊断方法、药物治疗及综合干预措施，帮助改善患者预后。","2026-06-11 13:36:26",[37],{"menuId":38,"menuName":39,"parentId":17,"orderNum":40,"path":41,"component":42,"isFrame":43,"isCache":44,"menuType":45,"visible":26,"status":17,"createDept":6,"remark":24,"createTime":46,"children":47,"columnImage":48,"columnLogo":49,"uncheckedLogo":6,"checkedLogo":6,"isHot":17,"isHome":17,"forceLogin":17,"color":6,"seoTitle":50,"seoKeywords":51,"seoDescription":52,"contentNum":6,"promotionalPoster":53,"menuFrame":7,"innerLink":7,"parentView":7,"routeName":54,"routerPath":41,"componentInfo":42},"1986622624134549505","科普视频",3,"video","/video.html","1","0","T","2025-11-07 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