Medical Specialties Commons^™

Prenatal Risk For Asd: Fetal Cortisol Exposure Predicts Child Autism-Spectrum-Disorder Symptoms, Sheena Ram, Mariann A. Howland, Curt A. Sandman, Elyssia Poggi Davis, Laura M. Glynn

Psychology Faculty Articles and Research

The etiology of autism spectrum disorder (ASD) is multifactorial, complex, and likely involves interactions among genetic, epigenetic, and environmental factors. With respect to environmental influences, a growing literature implicates intrauterine experiences in the origin of this pervasive developmental disorder. In this prospective longitudinal study, we examined the hypothesis that fetal exposure to maternal cortisol may confer ASD risk. In addition, because ASD is four times more prevalent in males than in females, and because sexually dimorphic responses to intrauterine experiences are commonly observed, we examined whether or not any associations differ by fetal sex. Maternal plasma cortisol was measured at …

Prenatal Risk For Autism Spectrum Disorder (Asd): Fetal Cortisol Exposure Predicts Child Asd Symptoms, Sheena Ram, Mariann A. Howland, Curt A. Sandman, Elyssia Poggi Davis, Laura M. Glynn

Psychology Faculty Articles and Research

The etiology of autism spectrum disorder (ASD) is multifactorial, complex, and likely involves interactions among genetic, epigenetic, and environmental factors. With respect to environmental influences, a growing literature implicates intrauterine experiences in the origin of this pervasive developmental disorder. In this prospective longitudinal study, we examined the hypothesis that fetal exposure to maternal cortisol may confer ASD risk. In addition, because ASD is four times more prevalent in males than in females, and because sexually dimorphic responses to intrauterine experiences are commonly observed, we examined whether or not any associations differ by fetal sex. Maternal plasma cortisol was measured at …

Strategies And Challenges Associated With Recruiting Retirement Village Communities And Residents Into A Group Exercise Intervention, Rachel L. Duckham, Jamie L. Tait, Caryl A. Nowson, Kerrie M. Sanders, Dennis R. Taaffe, Keith D. Hill, Robin M. Daly

Research outputs 2014 to 2021

BACKGROUND: Randomized controlled trials (RCTs) provide the highest level of scientific evidence, but successful participant recruitment is critical to ensure the external and internal validity of results. This study describes the strategies associated with recruiting older adults at increased falls risk residing in retirement villages into an 18-month cluster RCT designed to evaluate the effects of a dual-task exercise program on falls and physical and cognitive function.

METHODS: Recruitment of adults aged ≥65 at increased falls risk residing within retirement villages (size 60-350 residents) was initially designed to occur over 12 months using two distinct cohorts (C). Recruitment occurred via …

Mechanical Suppression Of Osteolytic Bone Metastases In Advanced Breast Cancer Patients: A Randomised Controlled Study Protocol Evaluating Safety, Feasibility And Preliminary Efficacy Of Exercise As A Targeted Medicine, Nicolas H. Hart, Daniel A. Galvão, Christobel Saunders, Dennis R. Taaffe, Kynan T. Feeney, Nigel A. Spry, Daphne Tsoi, Hilary Martin, Raphael Chee, Tim Clay, Andrew D. Redfern, Robert U. Newton

Research outputs 2014 to 2021

BACKGROUND: Skeletal metastases present a major challenge for clinicians, representing an advanced and typically incurable stage of cancer. Bone is also the most common location for metastatic breast carcinoma, with skeletal lesions identified in over 80% of patients with advanced breast cancer. Preclinical models have demonstrated the ability of mechanical stimulation to suppress tumour formation and promote skeletal preservation at bone sites with osteolytic lesions, generating modulatory interference of tumour-driven bone remodelling. Preclinical studies have also demonstrated anti-cancer effects through exercise by minimising tumour hypoxia, normalising tumour vasculature and increasing tumoural blood perfusion. This study proposes to explore the promising …

Making Prescriptions “Talk” To Stroke And Heart Attack Survivors To Improve Adherence: Results Of A Randomized Clinical Trial (The Talking Rx Study), Ayeesha Kamran Kamal, Wardah Khalid, Abdul Muqeet,, Anum Jamil,, Kashfa Farhat, Sehar Rahim Ali Gillani, Maryam Zulfiqar, Mehreen Saif, Aliya Amin Muhammad, Fabiha Zaidi, Saleem Sayani, Salim S. Virani

Section of Neurology

Background: We developed and tested the effectiveness of a tailored health information technology driven intervention: "TalkingPrescriptions" (Talking Rx) to improve medication adherence in a resource challenged environment.
Methods: We conducted a parallel, randomized, controlled, assessor-blinded trial at the Aga Khan University (AKU), Karachi, Pakistan. Adults with diagnosis of cerebrovascular accident (CVA) or coronary artery disease (CAD) diagnosed least one month before enrollment, on anti-platelets and statins, with access to a mobile phone were enrolled. The intervention group received a) Daily Interactive Voice Response (IVR) call services regarding specific statin and antiplatelet b) Daily tailored medication reminders for statin and antiplatelet …

Retinopathy Of Prematurity: A Major Review And Situation Analysis In Egypt, Ihab S. Othman

Journal of Medicine in Scientific Research

Retinopathy of prematurity (ROP) remains a major cause of childhood blindness in developing countries. As childhood and neonatal mortality in Egypt has shown tremendous improvement over the past two decades, it is expected to encounter an increasing number of cases of blindness from ROP in surviving infants unless strict guidelines and cooperation between different involved departments are explicitly set. In this review article, the author highlights the studies conducted and published risk factors, recommends protocols for early diagnosis, and describes management strategies to lessen or prevent blindness related to ROP.

Osteochondral Autologous Transplantation As A Treatment Of Osteochondral Defects Of The Talus, Sameh S. Alsafty

Journal of Medicine in Scientific Research

Background For many years, osteochondral defects of the talus has been known as a symptomatic lesion that causes pain, recurrent synovitis, altered joint mechanics, and obstruction from loose bodies. It is a probable precursor of ankle osteoarthritis. Arthroscopic procedures, such as debridement, retrograde drilling, and bone grafting have a great advantage in treating small defects. An open method can be considered for treatment of large osteochondral lesions and unstable osteochondral defect lesions. Objective To present the functional results after autologous osteochondral transplantation in 12 patients using open surgical technique by antromedial approach and antrolateral approach for the ankle according to …

Epidural Bupivacaine And Dexmedetomidine Versus Bupivacaine And Opioids For Lower Vascular Surgery, Amir S. M. Melika, Ashraf Abd El Hameed Mahmoud Soliman

Journal of Medicine in Scientific Research

Objective The purpose of this study was to assess dexmedetomidine as an adjuvant to bupivacaine as a good alternative to other adjuvants like fentanyl in epidural anesthesia. Patients and methods Ninety patients between the age of 40 and 60 years with American Statistical Association status I–III planned for elective lower abdomen surgery were enrolled in a double-blind comparative study. Patients were randomized to one of three group: group A (n = 30) patients received bupivacaine, group B (n = 30) patients received bupivacaine and fentanyl, and group D (n = 30) patients received bupivacaine and dexmedetomidine. Result …

Psychological Respect For Patients With Breast Cancer Using Radial Incision Which Gives Better Cosmetic Outcome After Conservative Breast Surgery, Adel K. Barsoum, Hytham R. Yassin

Journal of Medicine in Scientific Research

Background Breast cancer is considered as one of the most common cancers affecting women, and remains one of the world's biggest killers. Once diagnosed as a breast cancer patient, a woman can be exposed to psychological trauma that is manifested as stress, anxiety, and even depression. Since surgery is the most important part of breast cancer management protocol, the first time a woman looks to her body after surgery can be harmful. Despite this gloomy picture, there have been some dramatic modifications recently in the treatment of breast cancer, especially in early detected tumors. One of them is the clear …

Transcription Factor 7-Like 2 Rs7903146 Polymorphism And Therapeutic Response To Sulfonylureas In Patients With Type 2 Diabetes, Ashraf A. Ismail, Ghada A. Omar, Ghada S. Mohamed, Ola Sayed M. Ali

Journal of Medicine in Scientific Research

Background Transcription factor 7-like 2 (TCF7L2) variations were related to a modified hypoglycemic reaction to sulfonylureas (SUs) in patients with type 2 diabetes mellitus (T2D). Aims The aim of the present work was to show the relationship between TCF7L2 rs7903146 polymorphism and the hypoglycemic reaction to SUs in T2D patients. Patients and methods We enlisted 54 already diagnosed T2D patients who were treated with SUs. Utilizing secondary SU treatment failure, defined as glycated hemoglobin more than 7%, they were divided into two groups: responders and nonresponders. We genotyped the TCF7L2 rs7903146 single-nucleotide polymorphism by utilizing TaqMan allelic discrimination assay-based real-time …

The Role Of Urinary Hepcidin In Early Detection Of Iron Deficiency Anemia, Aisha El Sheimy, Azza Omran, Fify Helmy, Hala I. Mouhamed, Sohaila Ali, Youssof Mohamed

Journal of Medicine in Scientific Research

Iron deficiency anemia (IDA) is one of the most severe and important nutritional deficiencies, especially in children all over the world. Iron deficiency may occur because of inadequate dietary intake, increase in physiological needs of the nutrient, and/or increased losses, which may lead to anemia. IDA has been associated with cognitive, motor, and behavioral impairment in children. The most commonly used tests to determine iron status include serum iron levels, ferritin, and others. However, these test have limited role in diagnosis of IDA. For this reason, there is great interest in investigating effective method for the diagnosis of IDA. The …

Renal Function And Diabetic Foot Ulcer, El-Saied Shaheen, Feisal Goda, Helmy M. Elshazly

Journal of Medicine in Scientific Research

Introduction Diabetic nephropathy has been identified as an essential risk factor for foot ulceration and amputation. Renal failure has been reported to independently predict the risk of nonhealing ischemic and neuroischemic foot lesions and major amputation. Objective In this study, we aimed at assessing the renal function of diabetic foot infected patients. Patients and methods We included 120 patients with type 2 diabetes mellitus, patients participated from the medical and surgical unit, Shebin El Kom Teaching Hospital, Egypt. They were divided into two main group; group 1 included 80 patients with an active diabetic foot ulcer (DFU) and group 2 …

Mitral Annular Calcification Predicts Coronary Artery Disease In End-Stage Renal Disease Patients On Hemodialysis, Amir S. Michael

Journal of Medicine in Scientific Research

Background Mitral annulus calcifi cation ( MAC) is a chronic, degenerative process of the fi brous support structure of the mitral valve. The reported prevalence of MAC is between 8 and 15%, but it signifi cantly increases with age and in patients with multiple cardiovascular risk factors or chronic kidney disease. Aim The aim of this study was to determine whether MAC predicts coronary artery disease in a group of end-stage renal disease patients. Patients and Methods Twenty-three patients with ESRD on hemodialysis referred for coronary angiography were prospectively studied. Results This study included 23 patients, MAC was seen in …

Anti-Acetylcholine Receptor Antibodies As A Diagnostic Marker For Myasthenia Gravis, Aisha El-Shimy, Hala I. Mohamed, Iman Kamel, Magdy Khalaf, Youssof Abd El Motamad

Journal of Medicine in Scientific Research

Background Myasthenia gravis (MG) is a common primary disorder of neuromuscular transmission, which is characterized by fluctuating weakness of a certain voluntary muscles, particularly those innervated by motor nuclei of the brain stem, that is, ocular and mastication muscles, and caused by antibodies binding to components in the neuromuscular junction. Most MG cases demonstrate elevated serum levels of acetylcholine receptor (ACh-R) antibodies, which cause partial or complete inhibition of receptor function and complement-mediated focal lysis of the postsynaptic membrane. ACh-R antibodies are detected in the serum of more than 80–90% patients with generalized MG, in ~50% with ocular myasthenia, and …

D-Dimer, Von Willibrand Factor, And Adamts13 In Renal Transplant Recipients, Ahmed Hassan, Azza A. I. Elmenyawi

Journal of Medicine in Scientific Research

Introduction Chronic kidney disease and renal transplants are associated with activation of coagulation. Microvascular thrombosis and fibrinolytic disorders have been recognized as main causes of allograft rejection in renal transplant recipients. Aims The aim was to evaluate D-dimer, Von Willibrand factor (VWF), and ADAMTS13 activity plasma levels in renal transplant recipients and investigate the association of these parameters and creatinine plasma levels, estimated glomerular filtration rate (eGFR), and time after transplantation. Participants and methods A total of 40 renal transplant recipients clinically stable at National Institute of Urology and Nephrology, 5–192 months after transplantation were enrolled in the study. Dimer, …

Effect Of Digital Wireless Technology On The Language Development Of Children With Cochlear Implants, Abir Omara, Azza Azzam, Azza Samy, Eman Ghorab, Iman El-Rouby, Soha Hamada

Journal of Medicine in Scientific Research

Introduction Hearing is the principal sensory modality by which language and speech are acquired. For that reason, a child with hearing loss whose family chooses an auditory approach for learning language must have as much exposure to high-quality auditory stimulation as possible. Both hearing aids and cochlear implants (CI) are best in quiet and close places, but not so good at a distance, in noise or when sounds bounce around. Children with CI have significant difficulty in hearing conversational speech in the presence of background noise. They may have difficulty understanding soft speech signals due to distance and reverberation. Assistive …

Post-Traumatic Multiplanar Knee Deformity Correction Using Taylor Spatial Frame Fixator, Sameh S. Alsafty

Journal of Medicine in Scientific Research

Background Multiplanar knee deformity needs correction in different axes; this can be achieved by the Ilizarov system, which utilizes the hinges and translation mechanism; this needs an effort or orientation and gradual correction. The Taylor spatial frame (TSF) fixator solves this problems; it consist of two rings or partial rings connecting by six telescopic struts at special universal joints. Patients and methods The study included six patients with complex post-traumatic knee deformity. They had genu varus, recurvatum, and shortening; two female individuals and four male individuals, with an age range from 16 to 20 years comprised our study sample. The …

Results Of Compression Plating Versus Locked Intramedullary Nailing Fixation In The Treatment Of Humeral Shaft Fractures In Adults, Ahmad Shawakat Rizk, Hassan Hussein Ahmad Abdallah, Mohammed Gamal El Din Al Ashahab, Said Ibrahim Said Abdelmotalb

Journal of Medicine in Scientific Research

Background Most humerus shaft fractures can be treated successfully using the conservative methods. When choosing surgical fixation, there is a debate between the use of plate and screws and intramedullary nails. Aims The aim of this study was to compare the results of the dynamic compression plate and the antegrade interlocked humeral nail in the fixation of humerus shaft fractures. Patients and methods A total of 40 patients were selected by a randomized method to be treated by either method; there were 20 patients in each group and patients were followed up for at least 6 months until union. Result …

Evaluation Of Knowledge, Attitude, And Practice Of Adverse Drug Reactions Reporting Among Doctors And Nursing Staff Of A Rural Tertiary Care Teaching Hospital Of Maharashtra, Sanyukta M. Patil, Satish E. Bahekar

Journal of Medicine in Scientific Research

Context The adverse drug reactions (ADRs) are of great concern for any health care set ups as they directly or indirectly cost in terms of disability, prolongation of hospital stay, or even death. Hence, regular and timely reporting of ADR is of great importance, especially in treating doctors and nursing staff. Aims The main aim of this study was to assess the knowledge, attitude, and practice (KAP) of ADR reporting among doctors and nurses of tertiary care teaching hospital. Settings and design This was a prospective, cross-sectional questionnaire-based study that included 50 doctors and 50 nurses from the clinical departments …

Effectiveness Of A Youth-Led Early Childhood Care And Education Programme In Rural Pakistan: A Cluster-Randomised Controlled Trial, Aisha Khizar Yousafzai, Muneera Rasheed, Arjumand Rizvi, Fariha Shaheen, Liliana A. Ponguta, Chin R. Reyes

Department of Paediatrics and Child Health

Background: The United Nation's Sustainable Development Goals encompass lifelong learning from birth to youth to adulthood (Goal 4) and economic opportunities for young people (Goal 8). The targets include improving access to quality early childhood care and education (ECCE) as well as learning and training opportunities for adolescents and youth. Cross-generational models for young children and youth may offer opportunities to address the interconnections between goals and targets for the next generation. We investigated whether an ECCE programme for young children (3.5-6.5 years) delivered by female youth (18-24 years) in rural Pakistan would be effective on children's school readiness.
Methods: …

Dichotomous Scoring Of Tdp-43 Proteinopathy From Specific Brain Regions In 27 Academic Research Centers: Associations With Alzheimer's Disease And Cerebrovascular Disease Pathologies, Yuriko Katsumata, David W. Fardo, Walter A. Kukull, Peter T. Nelson

Biostatistics Faculty Publications

TAR-DNA binding protein 43 (TDP-43) proteinopathy is a common brain pathology in elderly persons, but much remains to be learned about this high-morbidity condition. Published stage-based systems for operationalizing disease severity rely on the involvement (presence/absence) of pathology in specific anatomic regions. To examine the comorbidities associated with TDP-43 pathology in aged individuals, we studied data from the National Alzheimer’s Coordinating Center (NACC) Neuropathology Data Set. Data were analyzed from 929 included subjects with available TDP-43 pathology information, sourced from 27 different American Alzheimer’s Disease Centers (ADCs). Cases with relatively unusual diseases including autopsy-proven frontotemporal lobar degeneration (FTLD-TDP or FTLD-tau) …

Rheumatoid Meningitis Sine Arthritis., Cathy Lee-Ching, Lawrence C. Kenyon, Matthew Berk, Chantel Park

Department of Medicine Faculty Papers

Rheumatoid meningitis is a rare and very serious extra-articular manifestation of rheumatoid arthritis. We present a case of a 7()year-old female with no history of arthritis who developed stroke-like symptoms, seizures, psychosis and compulsive behavior. Serial brain magnetic resonance images (MRI) over four months demonstrated progressive interhemispheric meningeal thickening. She had mild lymphocytic pleocytosis on the cerebrospinal fluid analysis and serum anti-cyclic citrullinated peptide antibodies resulted positive in high titers. She underwent a brain biopsy showing necrotizing granulomas consistent with rheumatoid meningitis. Her symptoms resolved with treatment with glucocorticoids and cyclophosphamide. She has not been diagnosed with rheumatoid arthritis even …

An Evaluation Of The Impact Of Medication On Behavioral Intervention Effectiveness For Adults With Traumatic Brain Injury, Sulay Martinez

Capstone Projects

A systematic search of the literature was conducted to identify articles implementing both pharmacological and behavioral interventions with subjects with traumatic brain injury (TBI). Limitations of pharmacological interventions were evaluated and compared to the implications for behavioral interventions for adults with TBI. Results of this study indicate further research is necessary to adequately evaluate the effects of medication on behavioral intervention effectiveness for adults with TBI.

Stroke Outcomes With Vorapaxar Versus Placebo In Patients With Acute Coronary Syndromes: Insights From The Tracer Trial, Leo Ungar, Robert M. Clare, Fatima Rodriguez, Bradley J Kolls, Paul W. Armstrong, Philip Aylward, Claes Held, David J. Moliterno, John Strony, Frans Van De Werf, Lars Wallentin, Harvey D. White, Pierluigi Tricoci, Robert A. Harrington, Kenneth W. Mahaffey, Chiara Melloni

Gill Heart & Vascular Institute Faculty Publications

Background—Vorapaxar, a protease‐activated receptor‐1 antagonist, is approved for secondary prevention of cardiovascular events but is associated with increased intracranial hemorrhage.

Methods and Results—TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) was a trial of vorapaxar versus placebo among patients with acute coronary syndrome. Strokes were adjudicated by a central events committee. Of 12 944 patients, 199 (1.5%) had ≥1 stroke during the study period (median follow‐up, 477 days). Four patients had a single stroke of unknown type; 195 patients had ≥1 stroke classified as hemorrhagic or nonhemorrhagic (165 nonhemorrhagic, 28 hemorrhagic, and 2 both). …

Tumor Cell-Released Autophagosomes (Traps) Promote Immunosuppression Through Induction Of M2-Like Macrophages With Increased Expression Of Pd-L1., Zhi-Fa Wen, Hongxiang Liu, Rong Gao, Meng Zhou, Jie Ma, Yue Zhang, Jinjin Zhao, Yongqiang Chen, Tianyu Zhang, Fang Huang, Ning Pan, Jinping Zhang, Bernard A Fox, Hong-Ming Hu, Li-Xin Wang

Articles, Abstracts, and Reports

BACKGROUND: Tumor-associated macrophages (TAMs) facilitate tumor progression via establishment of an immunosuppressive tumor microenvironment (TME). However, it is poorly understood how tumor cells could functionally modulate TAMs. Our previous work indicated that tumor cell-released autophagosomes (TRAPs), a type of LC3-II

METHODS: TRAPs isolated from multiple murine tumor cell lines and pleural effusions or ascites of cancer patients were incubated with bone marrow-derived macrophages (BMDMs) and monocytes, respectively. Cellular phenotypes were examined by flow cytometry, ELISA and quantitative PCR. TRAPs treated BMDMs were tested for the ability to suppress T-cell proliferation in vitro, and for promotion of tumor growth in vivo. …

Evidence For Minimal Cardiogenic Potential Of Stem Cell Antigen 1-Positive Cells In The Adult Mouse Heart., Lauren E Neidig, Florian Weinberger, Nathan J Palpant, John Mignone, Amy M Martinson, Daniel W Sorensen, Ingrid Bender, Natsumi Nemoto, Hans Reinecke, Lil Pabon, Jeffery D Molkentin, Charles E Murry, Jop H Van Berlo

Articles, Abstracts, and Reports

No abstract provided.

Transgenic Mice Overexpressing Human Tnf-Α Experience Early Onset Spontaneous Intervertebral Disc Herniation In The Absence Of Overt Degeneration., Deborah J. Gorth, Irving M. Shapiro, Makarand V. Risbud

Department of Orthopaedic Surgery Faculty Papers

There is a well-established link between cytokine expression and the progression of intervertebral disc degeneration. Among these cytokines, interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) are the most commonly studied. To investigate whether systemic hTNF-α overexpression affects intervertebral disc health, we studied the spine phenotype of Tg197 mice, a widely used hTNF-α transgenic line. These mice were studied at 12-16 weeks of age using comprehensive histochemical and immunohistological analysis of the spinal motion segment. Micro-CT analysis was performed to quantify vertebral trabecular bone architecture. The Tg197 mice evidenced spontaneous annular tears and herniation with increased vascularity in subchondral bone and …

Fly Control To Prevent Diarrhoea In Children, Jai K. Das, Yousaf Bashir Hadi, Rehana Salam, Mehar Hoda, Zohra S. Lassi, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background:
Diarrhoeal disease accounts for millions of child deaths every year. Although the role of flies as vectors of infectious diarrhoea has been established, fly control is not often mentioned as an approach to decrease childhood diarrhoea. Theoretically, fly control for decreasing diarrhoea incidence can be achieved by intervening at four different levels: reduction or elimination of fly breeding sites; reduction of sources that attract houseflies; prevention of contact between flies and disease-causing organisms; and protection of people, food, and food utensils from contact with flies.
Objectives:
To assess the impact of various housefly control measures on the incidence of …

A Us Hospital Budget Impact Analysis Of A Skin Closure System Compared With Standard Of Care In Hip And Knee Arthroplasty., Kay Sadik, Jana Flener, Jeanine Gargiulo, Zachary D. Post, Steven Wurzelbacher, Andrew Hogan, Sarah Hollmann, Nicole Ferko

Department of Orthopaedic Surgery Faculty Papers

Background: Medicare's mandatory bundle for hip and knee arthroplasty necessitates provider accountability for quality and cost of care to 90 days, and wound closure may be a key area of consideration. The DERMABOND

Methods: A 90-day economic model was developed assuming 500 annual hip/knee arthroplasties for a typical US hospital setting. In current practice, wound closure methods for the final skin layer were set to 50% sutures and 50% staples. In future practice, this distribution shifted to 20% sutures, 20% staples, and 60% Skin Closure System. Health care resources included materials (eg, staplers, steri-strips, and traditional/barbed sutures), standard or premium …

Women Are Being Cut During Childbirth Without Need Or Consent, Molly Cora Enking

Capstones

An episiotomy, a surgical cut used to enlarge the vaginal opening during childbirth, can be extremely painful, hard to recover from and can increase the risk of severe complications. In 2018, episiotomies are rarely necessary, but at some U.S. hospitals they happen much more than they should. And in the course reporting this story, New York City News Service found that it is common for doctors to cut women without the mother’s consent.

https://medium.com/@mollyenking/women-are-being-cut-during-childbirth-without-need-or-consent-7677de7eddae