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					  PAIN PATHWAYS



Guided by-             Presented By-
  Dr. Jiji George         Nilesh Deshpande
1 Dr.Thippeswamy S.H      Junior Resident-ii
          PAIN PATHWAYS
   INTRODUCTION.
   DEFINITIONS OF PAIN.
   HISTORICAL NOTE.
   THE EVOLUTION OF PAIN.
   CHANGING CONCEPTS OF PAIN.
   PAIN RECEPTORS.
   TYPES OF PAIN.
   PAIN OF DENTAL ORIGIN.
   NEUROCHEMISTRY OF NOCICEPTIVIE PAIN.
   THEORIES OF PAIN.
                                           2
         PAIN PATHWAYS
    FACTORS AFFECTING PAIN.
    NEURAL PATHWAYS OF PAIN.
     Neospinothalamic tract.
     Paleospinothalamic tract.
    NEURONAL TRANSMISSION IN THE HEAD AND
     NECK REGION.
    THEORIES OF PAIN.
    MODULATION OF PAIN.
    DIAGNOSIS OF PAIN.
    MANAGEMENT OF PAIN.
    CONCLUSION.

                                             3
DEFINITIONS OF PAIN :
   International association for the study of pain (IASP) (WHO)
      An unpleasant emotional experience associate with actual
        or potential tissue damage or described in terms of such
        damage.
   Bell
      The subject‘s conscious perception of modulated
        nociceptive impulses that generate an unpleasant sensory
        and emotional experiences associated with actual or
        potential tissue damage or described in terms of such
        damage.
   Monheim
      An unpleasant emotional experience usually initiated by
        noxious stimulus and transmitted over a specialized neural
        network to CNS where it is interpreted as such.
   Mac bryde (1952)
        Pain is a disagreeable sensation produced by the
         action of stimuli of humoral nature.

                                                                     4
HISTORICAL NOTE :
    Greek - ‖Poin‖ meaning penalty.
    Latin -―Poena‖ meaning punishment from God.
    Homer - Thought pain was due to arrows shot by
     God.
    Aristotle - was the first to distinguish five physical
     senses, and considered pain to be ―passion of
     the soul‖ .
    Plato pain and pleasure arose from within the
     body, an idea that perhaps gave birth to the
     concept that pain is an emotional experience
     more than a localized body disturbance.
                                                              5
THE EVOLUTION OF PAIN :
     As knowledge of anatomy and physiology
      increased it became possible to distinguishing
      between pain due to physical and emotional
      causes. During the 19th century, the developing
      field to neurology fostered the concept that pain
      was mediated.




                                                          6
CHANGING CONCEPTS OF PAIN :
    During recent years, a quite different concept has
     evolved. Pain is now recognised as,
         - protective mechanism
         - localized sensation as a result of noxious
           stimulation.
         - concept of superficial somatic pain.
 now recognised as being more an experience than a
     sensation.
 1.Cognitive – Which represents the subject‘s ability to
     comprehend and evaluate the significance of the
     experience.
 2.Emotional – Which represents the feelings that are
     generated
 3.Motivational – Which has to do with the drive to terminate
     it.
                                                                7
TYPES OF PAIN
1.BASED ON SPEED OF ONSET, QUALITY & DURATION



(1) Experimental (2) Transient (3) Acute (4) Chronic

1. Experimental:
    noxious stimuli causes a mild uncomfortable or
     painful sensation .
2. Transient pain:
    Short duration
    Severe
    Self limiting
                                                       8
3. Acute pathological pain :
• Sharp, fast, pricking.
• Occurs very rapidly.
• Carried by large diameter myelinated Aδ fibers.
• Usually alleviated with the help of professional.
4. Chronic pathological pain :
• Burning, aching.
• Gradually increases.
• Carried by small diameter non-myelinated ‗C‘ fibers.
• Experience of persistent pain that lasts many
       months to years.
• Little apparent cause & not self limiting .
• Pain often increases over time & is aggravated by
       many factors.
                                                         9
2.BASED ON LEVEL OF STIMULATION



     SOMATIC PAIN                  VISCERAL PAIN
  Associated with skin and     Associate with viscera and
    musculo-skeletal region.     internal organs.
                               Carried by unmyelinated type
                                 C fibers
  Superficial.   Deep.




                                                              10
Classification of oro-facial pain:
1) AXIS -I depict the physical factors
     - somatic pain
     - neuropathic pain
   AXIS -II depict the psychological factors
     - mood disorder
     - anxiety disorder
2) Depending on inflammation
     a) inflammatory pain
     b) non inflammatory pain



                                               11
a) Inflammatory pain
     tissue injury        prostaglandin & bradykinin


                             local vasodilatation &
                               capillary permeability


                            receptor noxious stimuli


                                     pain
b) Non Inflammatory pain
   poorly understood , psychic, chronic

                                                        12
DENTAL PAIN OF PULPAL ORIGIN ;

   Visceral in character and is of threshold type.
   Responds to all type of noxious stimuli but not to
    ordinary masticatory function.
   Nearly non-localisable.
   Classified as acute, chronic, recurrent or mixed
    with PDL elements.
   A basic clinical feature of pulpal pain is that it
    does not remain the same indefinitely.
   Generally it resolves, becomes chronic or
    proceeds to involve PDL structures.


                                                         13
DENTAL PAIN OF PDL ORIGIN
   Deep somatic pain of musculo-skeletal type.
   More localised than pulpal pain.
   It is intimately related to biomechanical (masticatory)
    function.
   It responds to provocation proportionately rather than as a
    threshold (like pulpal pain).
   Receptors of PDL are capable of precise localisation of the
    stimulus.
   Under occlusal pressure the tooth feels sore or elongated.
   The discomfort may be felt when the biting pressure is
    released rather than while it is sustained.
   When PDL pain involves several teeth, especially opposing
    teeth, the matter of occlusal over stressing should be
    considered.
                                                                  14
PAIN RECEPTORS :
1.   Exteroceptors: arising from receptors from skin & mucosa.
     sensed at conscious level
E.g. 1) Merkel corpuscles : Tactile receptors.
     2) Free Nerve ending :Perceive superficial pain.
2. Proprioceptors : From musculoskeletal structures.
      The presence , positions & movement of body.
      below conscious levels.
E.g. 1) Muscle spindles : Skeletal muscle fibers.
                     Mechanoreceptors.
     2) Free nerve ending : Perceive deep somatic pain
        & other sensations.
3. Interoceptors : From viscera of body
                     below conscious level.
E.g. 1) Pacinian corpuscles : perception of touch-pressure.
      2) Free nerve ending : Perceive visceral pain & other
                            sensations.

                                                                 15
           TOUCH




pressure      warmth   vibration   pain   16
CLASSIFICATION OF NERVE FIBERS
GASSER AND ERLANGER




                                 17
THREE TYPES OF STIMULI EXCITE PAIN
RECEPTORS :
    Thermal.
    Mechanical.
    Chemical.

    Fast pain : Thermal , Mechanical (A δ Fibers)


    Slow pain : All three (C Fibers)



                                                     18
NEUROTRANSMITTER FOR A AND C
FIBERS :
  Glutamate --excitatory transmitters -- lasting only for
    few mili second.
   act very rapidly.
  substance P transmitter
   Excitatory
   released slowly---period of seconds or minutes.


    The double pain sensation --Glutamate
    transmitter gives a faster pain sensation, while
    the substance P transmitter gives more lagging
    sensation.

                                                            19
MECHANISM OF PAIN CAUSATION :




                            20
MECHANISM OF PAIN CAUSATION :




                            21
NEURAL PATHWAY OF PAIN :
  Transduction—Noxious stimuli lead to
   electrical activity in appropriate sensory
   nerve endings.
  Transmission—Neural events that carry
   nociceptive input into CNS for processing.
  Modulation—Ability of CNS to control the
   pain permitting neurons.
  Perception—Subjective experience of pain.




                                                22
DETAILS OF PAIN PATHWAY:
(BASICS OF PAIN TRANSMISSION)
Pain sensation to reach the cortex from the nociceptors
  it requires three neuron sets.




                                                      23
FIRST ORDER NEURONS :
  Pain receptors

  SPINAL CORD

• Three classes of nociceptive afferent neurons provide
   the input whereby the brain perceives pain.
1. Mechanothermal afferents are primarily A∂ fibers
   respond to intense thermal and mechanical stimuli.
2. Poly model afferent c fibers, conduct more slowly,
   respond to mechanical, thermal and chemical stimuli.
3. High Threshold mechanoreceptive afferents are chiefly
   A ∂ Fiber normal respond to intense mechanical stimuli.

                                                             24
2ND ORDER NEURONS :
                      Dorsal horn of spinal cord
The primary afferent neuron           2nd Order neurons (Transmission cells)




                           transfer the impulse on to higher centers.

Types :
1. Low Threshold mechanosensitive neuron (LTM) -- light touch,
   pressure & proprioception.
2. Nociceptive Specific neurons (NS) -- exclusively carry impulse related to
   noxious stimulation.
3. Wide dynamic range neuron (WDR) -- Neurons are able to respond to
   a wide range of stimulus intensities from nonnoxious to noxious.

                                                                          25
CENTRAL PROCESSING OF PAIN :
   Convergence :
    more primary afferent
    neurons      enter CNS
    than 2nd order neurons,
    and 2nd order neurons
    are more in number
    than 3rd order neurons.

      1st order neuron
        synapse

      2nd order neuron
        synapse
      3rd order   neuron

                               26
   Activity at synapse may be a cumulative effect
    called summation.
   Intensification of response is facilitation(+).
    suppression is inhibition(-).




                                                      27
Nonadapting nature of pain receptors

   The pain receptors adapt very little OR not at all.

   Excitation of the pain fibers , becomes progressively
    greater , as the pain stimulus continues

   Increases in sensitivity of pain receptors is called
    hyperalgesia .

   Significance: keeps the person apprised of a tissue
    damage stimulus as long as it persists .

                                                            28
Dual pain pathways of pain in
the spinal cord and brain stem :
 On entering the spinal cord, the pain signals take
 two pathways to brain 1. Neospinothalamic.
                       2. Paleospinothalamic.




                                                      29
NEOSPINOTHALAMIC TRACT :
     The fast type A pain
      fibers -- mechanical and
      acute thermal pain.
     Terminate mainly Lamina
      I (Lamina marginalis)
     Excites 2nd order neurons
      of the Neospinothalamic
      tract.
      fibers --cross -- opposite
      side of the cord through
      ant.commisure --pass
      upward to the brain stem
      in the anterolateral
      column.
                                    30
TERMINATION OF NEOSPINOTHALAMIC TRACT IN
BRAIN STEM AND THALAMUS :
    A few fibers terminate --- reticular areas.
    most pass ---- thalamus--- terminate--- ventral
     posteolateral nucleus (VPL).

     A few fibers terminate -- post. Nuclear gr of thalamus
     (PO)
                         THALAMUS

                         3rd neurons

    basal areas of the brain     somatosensory cortex.
                                 (Post central gyrus)


                                                               31
CAPABILITY OF NERVOUS SYSTEM TO LOCALIZE
FAST PAIN IN THE BODY :

   Localizes much more exactly than slow chronic pain.

   If pain receptors stimulated without simultaneously
    stimulating tactile receptors, even fast pain may still
    be poorly localized, often within loom of stimulated
    area.




                                                              32
PALEOSPINOTHALAMIC TRACT :
   Transmits pain by C fibers --
    terminate -- laminae II & III of the
    dorsal horns,
    (SUBSTANTIA GELATINOSA
    ROLANDI).

   Most of the signals pass by
    additional short fiber neurons to
    lamina V.

   Here the last neuron in the series
    gives rise to long axons that mostly
    join the fibers from the fast pain
    pathway, passing through the ant.
    commisure to opposite side of
    cord. Then upwards to brain in
    anterolateral pathway.


                                           33
TERMINATION OF PALEOSPINOTHALAMIC TRACT IN
CNS :
  They terminate principally in
  1.Reticular nuclei of medulla, pons, mesencephalon.
  2.Tectal area of mesencephalon deep to the sup. and
     inf. colliculi.
  3. Periaqueductal gray.
  4. Some fibers may terminate in Hypothalamus and
     Limbic system.
  Only 1/10th to 1/4th of the fibers pass all the way
     to thalamus - Medial and intralaminar thalamic
     nucleus (MIT).
  Thalamus           3rd order neuron Somatosensory
     cortex.

                                                         34
LOCALIZATION OF PAIN :
    Poor--- due to multisynaptic, diffuse connectivity.

    Difficulty in localizing the source of some chronic.
     type of pain.




                                                            35
NEURONAL TRANSMISSION IN THE HEAD AND
NECK REGION :

                          PAIN PATHWAY OF
                        HEAD AND NECK REGION



      FROM THE ANTERIOR ASPECT        FROM THE POSTERIOR ASPECT




   FACE, MOUTH, TEETH AND EYES            POSTERIOR ASPECT OF
                                          HEAD AND NECK

   Through cranial nerves.                Through spinal nerves.
   (Gasserian ganglion)                   (Dorsal root ganglion)




                                                                   36
 PATHWAYS OF PAIN TO OROFACIAL REGION :
  CRANIAL AND CERVICAL NERVES THAT PROVIDE SOMATIC AND
    VISCERAL SENSATION TO THE ORO FACIAL AREA

NERVES                         AREA SUPPLIED

TRIGEMINAL N (V)        Skin of face, fore head, scalp conjunctiva, oral
                        and nasal mucosa, anterior 2/3 of tongue,
                        masticatory muscles, TMJ.
FACIAL N (VII)          Skin of the hollow of the auricle of external ear
                        and small area of skin behind ear.
GLOSSOPHARYNGEAL N (IX) Mucosa of pharynx, palatine tonsils, posterior
                        1/3rd of tongue, skin of external ear.
VAGUS N (X)             Pharynx, larynx, skin at the back of the ear,
                        posterior wall of external auditory meatus.
CERVICAL (2 & 3)        Lateral, posterior and back of the head and neck.

                                                                       37
  PATHWAYS OF PAIN FROM OROFACIAL REGION



     TRIGEMINAL PATHWAY        SPINOTHALAMIC PATHWAY


BRAIN STEM                                   SPINAL CORD


THALAMUS                                      THALAMUS



                          CORTEX




                                                         38
THE TRIGEMINAL SYSTEM – BELL
   Sensory input from
    face and mouth
    carried by 5th cranial
    nerve.
    The cell bodies of
    Trigeminal afferent
    neurons located in
    the large gasserian
    ganglion.


                               39
Sensory afferent pass to
1. Mesencephalic nucleus – Proprioception.
2. Principal nucleus - Touch, Pressure.
3. Spinal nucleus - Pain, Temp.

                   Fibers from all 3 divisions

    Ascending Br.                   Descending Br.
Touch, Pressure.               Touch, Pressure,     Pain, Temp.

Principal nucleus                 Spinal tract of Trigeminal N.
                                                  ( C-2 or C-4)

                                                                  40
41
        Fibers mediating pain




Fibers nearest to lips terminate highest in nucleus caudalis
Applicable to all three divisions
                                                          42
SECONDARY PATHWAYS :
    2nd order neurons - 3 Secondary pathways,
    1.   Fibers from principal nucleus - Cross the midline -
         Along with Medial Lemniscus - Thalamus
         (Ventroposteromedial Nucleus)
    2.   From Spinal nucleus—Homologous to
         Neospinothalamic tract
    3.   From Spinal nucleus—Reticular formation


    Few fiber---Thalamus (Intralaminar nuclei).

    All 3 Pathway lead to somatosensory cortex.
                                                               43
Pathway from dental pulp to cortex :- (mand. molar)
•     Once the nociceptors located in the pulp activated,


• the impulse is carried into the CNS by primary afferent neuron in the
mandibular branch of 5th nerve.


    GASSERIAN OR TRIGEMINAL GANGLION.


              nucleus caudalis.
    (The nucleus oralis may also play imp., role in nociception of intra-oral
structure).
    .

       Fast pain                              Slow pain


        Thalamus                              Reticular formation

       Sensory cortex
                                                                          44
THEORIES OF PAIN :
 1. Intensity theory.
 2. Specificity theory.
 3. Protopathic and epicritic theory.
 4. Pattern theory.
 5. Chemical theory.
 6. Biochemical theory.
 7. Gate control theory.




                                        45
INTENSITY THEORY :
     Stimulation of sensory nerve beyond certain level

                           Pain

• True for nerves mediating the sensation of touch
temperature.

•When stimulated to an excessive degree,
More damage—More stimulus---intense pain




                                                          46
SPECIFICITY THEORY :
   Pain - Specific modality like vision, hearing.
   Pain receptors - Free nerve endings.
   Central apparatus with center in thalamus
   Fibers - A,C
   Direct line From receptor to Brain.
   Counterview - Pain after surgical disruption of
    nerve(Trigeminal)         Direct line can be bypassed
    (Melzac & Wall).

   No morphological basis.


                                                            47
PROTOPATHIC & EPICRITIC THEORY
(HEAD & RIVERS - 1908) :

    Existence of 2 gr. Of cutaneous sensory nerve
     endings from periphery to CNS.

    Protopathic -- Primitive, Yields diffuse impression
     of pain including extreme of temperature.

    Epicritic—Touch,small changes in temperature.

    Counterview - (walshe)
     Presence of 2 system – Fallacious notion.

                                                           48
PATTERN THEORY : GOLDSCHEIDER [1894]

   Proposes that pain is generated by non specified
    receptor.
   Pain sensation depends upon the spatio-temporal
    pattern of nerve impulses reaching the brain.
   Pain, warmth, cold--codes of neural activity evoked
    from the skin by changes in its environment
   Nerve impulse entering CNS –Different For different
    Person due to anatomical variation
   A stimulus evoke certain pattern that the brain
    receives and recognizes.
   Receptors not specialized as in SPECIFICITY theory

                                                          49
CHEMICAL THEORY :
                               CHEMICAL MESSENGERS



ENDORPHINS, ENKEPHALINS,                               SUBSTANCE- P
       GABA.


Produced in the brain.                               Produced in the sensory
                                                     nerve spinal cord pathways
These act as pain Inhibiting                         and some parts of brain
substances and Increase the
                                                     they acts as pain stimulant
patients pain threshold.
                                                     and facilitate pain transmission
                                      +    -

The balance between these two groups of chemical messengers determines
the pain out come.
                                                                                   50
LINDAHL BIOCHEMICAL THEORY :

  According to this theory an alteration in
 the local pH in a nerve or in the vicinity of
 nerve is the cause for pain.
    Eg. The pain due to an abscess can be
 reduced by making the area alkaline.


          ACIDITY CAUSES PAIN
         ALKALINE REDUCES PAIN

                                                 51
GATE CONTROL THEORY :
   Noordenbos (1959) postulated, the fast fibers
    exert an inhibiting influence on slowly conducting
    fibers.
         Ronald melzack and patric Wall-1960.




                                                         52
The interplay among these connections
determines when painful stimuli go to the
brain:
1. When no input comes in, the inhibitory
    neuron prevents the projection neuron
    from sending signals to the brain (gate is
    closed).
2. Normal somatosensory input happens
    when there is more large-fiber
    stimulation (or only large-fiber
    stimulation). Both the inhibitory neuron
    and the projection neuron are
    stimulated, but the inhibitory neuron
    prevents the projection neuron from
    sending signals to the brain (gate is
    closed).
3. Nociception (pain reception) happens
    when there is more small-fiber
    stimulation or only small-fiber
    stimulation. This inactivates the
    inhibitory neuron, and the projection
    neuron sends signals to the brain
    informing it of pain (gate is open).         53
• The signal that triggers the action system
responsible for pain experience and response
occurs when the output of transmission cells reach
or exceeds the critical levels.
• The brain is able to control over, sensory input by
means of its descending fibers, depending upon
attention , emotion, memories of past experience ,
anticipation anxiety and suggestion, hypnosis etc.
• Soothing effect by rubbing over toothache.




                                                        54
MODULATION OF PAIN :
  Noxious stimuli of comparable intensity may
   produce varying degrees of pain in the same
   individual under different circumstances.
 Eg. An injury acquired by an athlete in the sport field
   or a soldier in the battlefield is less painful than a
   comparable injury suffered in a road accident.
  A possible explanation for modulation of pain was
   proposed in the 1960s Melzack and Wall in the
   form of gate control theory.



                                                            55
DIAGNOSIS OF PAIN:
      Consists essentially three major steps;
      1.   Accurately identifying the location.
      2.   Establishing the correct pain category
           (genesis and mechanisms of pain).
      3.   Choosing the particular pain disorder that
           correctly accounts for the incidence and
           behavior of the patient`s pain.




                                                        56
FEATURES TO INCLUDE IN AN ORO FACIAL PAIN HISTORY;

 1.The chief complaint
        Location of pain
        Onset of pain
         Associated factors
         Progression
       Characteristics of pain
           Quality of pain
           Behavior of pain
             Temporal
             Frequency
             Duration
           Intensity
           Concomitant symptoms
           Flow of the pain

                                                     57
     Aggravating and alleviating factors
         Physical modalities
         Function and parafunctions
         Sleep disturbances
         Medications
         Emotional stress
     Past consultation & treatments
     Relationships to other complaints
2. Past medical history
3. Review of systems
4. Psychologic assessment

                                            58
TOOLS TO MEASURE DEGREE OF PAIN OR
DISCOMFORT :

 Non verbal self-report technique.
 Visual analog scale.

 Color selection.

 Selecting the number of poker chips.

 Heart rate-helps in characterization of
  response to painful stimuli [Winer-1982].
 Visual Analog Scales (VAS)



                                              59
Visual analog scale :




                        60
FACES PAIN SCALE – REVISED (FPS-R)




                                     61
AGE AND MEASURES OF PAIN INTENSITY.
        -MCGRATH PJ ET AL (1990)


Age               Self- report      Behavior          Physiologic
                  measures          Measures          measures


Birth-3 years     Not available     Of primary        Of secondary
                                    importance        importance


3-6 years         Specialized,     Primary if self-   Of secondary
                  developmentally report not          importance.
                  appropriate      available.
                  scales available
>6 years          Of primary        Of secondary      Of secondary
                  importance        importance        importance.

                                                                     62
MANAGEMENT OF PAIN:
          Special emphasis of pain management
    Management of pain should primarily encompass two essential elements

         Pain perception control                    Pain reaction control


 1.Removing the cause                                1.Preventing pain reaction
 2. Blocking the path way                              by cortical depression.
    of painful impulses                              2.Using psychosomatic methods.
 Ex: GA                                              Ex: Conscious sedation.
     LA                                                  Behavior management
 • Analgesics
     - non narcotics
     - narcotics        Raising the level of pain threshold
     - NSAID`s
     - muscle relaxants
     - antideprassents etc.                                                     63
OTHER METHODS OF PAIN CONTROL :


 Counter irritation
 Cutaneous stimulation-heat,cold,massage

 Electrical stimulation

 Biofeedback

 Operant conditioning

 Relaxation



                                            64
SURGICAL INTERRUPTION OF PAIN
PATHWAY :

   A CORDOTOMY in the upper thoracic region of
    spinal cord on the side opposite the pain is
    sectioned through its anterolateral quadrant
    interrupts the anterolateral sensory pathway.
   A TRIGEMINAL TRACTOTOMY procedure near the
    obex (Sjoqvist operation) produces an almost
    complete loss of pain and temperature sensitivity
    in the oro-facial region.
   CAUTERIZATION of specific pain area in
    intralaminar nuclei of thalamus.

                                                        65
CONCLUSION :
   Pain is bad, but not feeling pain can be worse.
   Individuals with a congenital absence of pain receptors are
    extremely rare, but not unknown. Very poor at avoiding
    accidental injuries, and often inflict mutilating injuries on
    themselves. As a result, their life span is usually short.
   Thus pain, although unpleasant, is a protective sensation.
   Every day patient seeks care for the reduction or
    elimination of pain.
   Nothing is more satisfying to the clinician than the
    successful elimination of pain.
   The most important part of managing pain is understanding
    the problem and cause of pain.
    And It is only through proper diagnosis and appropriate
    therapy.


                                                                    66
REFERENCES :
 1.   Bell`s ‗Orofacial pain‘, 5th edition, Jeffrey P. Okeson.
 2.   Text book of Medical Physiology, 2nd edition, Chaudhari.
 3.   Text book of Medical Physiology, 10th edition, Arther C
      Gyton.
 4.   Dental Clinics of North America 1978: 22 (1); 1-61.
 5.   Gray's Anatomy – 38th Edition, Churchill Eivingstone.
 6.   Understanding ―Medical physiology‖- 3rd edition, R L
      Bijlani.
 7.   Text book of Physiology – 3rd edition, Robert m. Bern,
      Mathew N. Levy, Bruce M. Koeppen, Bruce A. Stanton.




                                                                 67
THANK YOU
            68

				
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