41. Wockhardt Hospital-Know Your Heart-Valve Disease Valve Disease. Rheumatic. · mitral valve disease · Aortic Valve Disease · Multiple Valve disease. - Non- Rheumatic. · Mitral Valve Prolapse, Flail Leaflet http://www.whhi.com/valve.htm

Valve Disease - Rheumatic - Non- Rheumatic :: Aortic Stenosis :: Aortic Regurgitation Valvular heart disease describes structural or functional abnormalities of single or multiple cardiac valves that results in alteration in blood flow across the valve. According to the causes it can be classified as: Rheumatic Rheumatic origin: Preceded by rheumatic fever Rheumatic fever Is an inflammatory disease, which occurs as a delayed sequel to pharyngeal infection with Beta hemolytic streptococci (Bacteria). This may lead to rheumatic heart disease if not treated properly on time. Rheumatic endocarditis Primarily affects the valve leading to fibrous thickening of the valve leaflets or even calcification leads to stenosis. Mitral and aortic valve commonly involved. Management: Antibiotics-Penicillin is the drug of choice. Salicylates and corticosteroids are also used. Non-Rheumatic Non-rheumatic origin: Caused by congenital malformations, bacterial endocarditis, syphilis etc.

42. WOCKHARDT HOSPITAL-Know Your Heart- Valve Disease mitral valve diseaseS 1. Mitral Stenosis Is the progressive thickening and contracture of mitral valve cusps(flaps) with narrowing of opening of the http://www.whhi.com/congenital.htm

Congenital Heart Diseases - Cynotic a. Tetrology Of Fallot b. Transposition of Great Arteries c. Uni Ventricular Heart - Acynotic a. Atrial Septal Defect b. Ventricular Septal Defect c. Patient Ductus Arteriosus d. Aortic Valvular Stenosis e. Mitral Valve Stenosis f. Pulmonary Stenosis g. Coarctation of Aorta Congenital Heart Disease is a structural malformation of heart or great vessels present at birth not necessarily detected at birth. Abnormalities in the heart and great vessels at birth maybe due to intrauterine development errors or to the failure of the heart and blood vessels to adapt to the extra uterine life (involution). Possible causes: :: Fetal and maternal infection occurring during first trimester (primarily rubella) :: Effects of drugs (lithium) and alcohol :: Maternal dietary deficiencies :: Genetic factors (trisomies) :: Maternal age greater than 40yrs :: Maternal insulin dependent diabetes :: Frequently associated with other congenital defects TYPES: Acyanotic Heart Disease Acyanotic Congenital heart disease: Bluish discoloration of the skin is usually absent.

43. Pulmonary Parenchymal Manifestations Of Mitral Valve Disease -- Woolley And Star The cardiac radiographic features of mitral valve disease are well known. The hallmark of mitral valve disease is pulmonary venous hypertension, http://radiographics.rsnajnls.org/cgi/content/full/19/4/965

HOME HELP FEEDBACK SUBSCRIPTIONS ... TABLE OF CONTENTS QUICK SEARCH: [advanced] Author: Keyword(s): Year: Vol: Page: This Article Abstract Figures Only Full Text (PDF) ... Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal ... Cited by other online articles PubMed PubMed Citation Articles by Woolley, K. Articles by Stark, P. Related Collections Chest Radiology Radiographics. RSNA SCIENTIFIC EXHIBIT Pulmonary Parenchymal Manifestations of Mitral Valve Disease Kevin Woolley, MD and Paul Stark, MD From the Department of Radiology, VA Palo Alto Health Care System and Stanford University School of Medicine, 3801 Miranda Ave, Palo Alto, CA 94304. Received May 26, 1998; revision requested July 20 and received September 1; accepted September 1. Address reprint requests to P.S. Abstract Top Abstract INTRODUCTION MITRAL STENOSIS MITRAL REGURGITATION CONCLUSIONS References Pulmonary parenchymal manifestations of mitral valve disease are the result of either pulmonary venous hypertension in mitral stenosis or abnormal regurgitant flow into pulmonary veins in mitral insufficiency. Typical radiographic findings in mitral

44. Pulmonary Parenchymal Manifestations Of Mitral Valve Disease -- Woolley And Star Pulmonary parenchymal manifestations of mitral valve disease are the result of either pulmonary venous hypertension in mitral stenosis or abnormal http://radiographics.rsnajnls.org/cgi/content/abstract/19/4/965

HOME HELP FEEDBACK SUBSCRIPTIONS ... TABLE OF CONTENTS QUICK SEARCH: [advanced] Author: Keyword(s): Year: Vol: Page: This Article Figures Only Full Text Full Text (PDF) ... Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal ... Cited by other online articles PubMed PubMed Citation Articles by Woolley, K. Articles by Stark, P. Related Collections Chest Radiology Radiographics. RSNA SCIENTIFIC EXHIBIT Pulmonary Parenchymal Manifestations of Mitral Valve Disease Kevin Woolley, MD and Paul Stark, MD From the Department of Radiology, VA Palo Alto Health Care System and Stanford University School of Medicine, 3801 Miranda Ave, Palo Alto, CA 94304. Received May 26, 1998; revision requested July 20 and received September 1; accepted September 1. Address reprint requests to P.S. Pulmonary parenchymal manifestations of mitral valve disease are the result of either pulmonary venous hypertension in mitral stenosis or abnormal regurgitant flow into pulmonary veins in mitral insufficiency. Typical radiographic findings in mitral

45. Genetic Link Suggested In Deaths From Cardiac Valve Diseases ? Deaths from cardiac valve diseases appear to run in families, suggesting a The seconddegree relatives of those who died of mitral valve disease also http://www.news-medical.net/?id=6026

46. Mitral Valve Disease In Norfolk Terriers At The College Of Veterinary Medicine, Clinical Studies on mitral valve disease in Norfolk Terriers at Washington State University College of Veterinary Medicine. http://www.vetmed.wsu.edu/researchVCS/NorfolkStudy/index.asp

Washington State University Home Mitral Valve Disease in Norfolk Terriers As of July 27, 2005 enrollment in this study is closed. Please check back at a later date. Although breeders, owners and veterinarians who work with Norfolk Terriers are suspicious that an increased prevalence of mitral valve disease (MVD) exists in this breed, there have been no published studies to characterize MVD in the Norfolk. The goal of this study is to identify the prevalence, progression, pathology and potentially the genetic basis of mitral valve disease in the Norfolk Terrier. These questions will be answered by three specific aims: Aim 1: Determine the incidence, progression and type of mitral valve disease in the Norfolk Terrier by echocardiography (ultrasound exam of the heart). Aim 2: Aim 3: Determine if a pattern of inheritance for mitral disease is identifiable in the Norfolk Terrier. This information will benefit the breeder, veterinarian and pet owner by providing the information necessary to make informed medical and breeding decisions. We welcome your participation in the study and thank you for your commitment to the Norfolk Terrier. We hope that we will provide you with valuable information for your pet and your breed.

47. Valve Disease : Epilepsy.com/Professionals is a major complication of native mitral valve disease. Mitral valve prolapse (MVP), often asymptomatic, occurs in 57% of the adult population, http://professionals.epilepsy.com/page/cardiac_valve.html

Search epilepsy.com/professionals: WHO IS EPILEPSY.COM DONATE PROFESSIONAL FORUM CO-EXISTING DISORDERS ... RESOURCE LIBRARY Valve disease Co-Existing Disorders Cardiac Disorders Valve disease Author: J Boggs Cerebral thromboembolism, which may precipitate seizures, is a major complication of native mitral valve disease. The Framingham Study estimated up to an 18-fold increased risk of thromboembolism if atrial fibrillation occurred with mitral disease. The most common valve disease precipitating cerebral thromboembolism is mitral stenosis. Indeed, cerebral thromboembolism may be the presenting manifestation in more than 10% of patients with mitral stenosis. Mitral regurgitation is less likely to result in embolic events, although concomitant mitral stenosis increases the risk of complications from mitral regurgitations. Mitral valve prolapse (MVP), often asymptomatic, occurs in 5-7% of the adult population, and therefore is commonly cited as a cause for many medical disorders, including epilepsy and stroke. Some patients with MVP and no other risk factors have recurrent cerebral ischemic events, suggesting a possible causal relationship.

48. HSC News Details than twoand-a-half times more likely to die of mitral valve disease. The second-degree relatives of those who died of mitral valve disease also were 67 http://uuhsc.utah.edu/pubaffairs/news_detail.cfm?ID=28998

49. NursingCenter - Professional Development - CE Article $16.95, Recognizing aortic and mitral valve disease Recognizing aortic mitral valve disease. Article. TODD, BARBARA A. RN, CRNP, APRN, BC, MSN; http://www.nursingcenter.com/prodev/ce_article.asp?tid=587426

50. YourHeart | Patient Information | Anatomy/Treatment | Mitral Valve Disease mitral valve disease. Where is the Mitral Valve? The mitral or bicuspid valve lies between the left atrium and left ventricle and consists of two leaflets http://www.yourheart.org.uk/mitral.php

Search for Home About Us Patient Information Discussion Forum ... Sitemap Anatomy / Treatment Heart CHD / Angina Myocardial Infarction Iscaemic Heart Disease ... Aortic Valve Disease Mitral Valve Disease Pulmonary Valve Disease Tricuspid Valve Disease Endocarditis Pericarditis ... Useful Organisations You are here: Home Patient Information Anatomy / treatment Mitral Valve Disease Where is the Mitral Valve? The mitral or bicuspid valve lies between the left atrium and left ventricle and consists of two leaflets or cusps. The valve may become damaged or diseased causing stenosis and/or regurgitation of the valve. Both of these complications may prevent the valve from functioning correctly. What is Mitral Stenosis? The mitral valve may become narrowed or 'stenotic' causing the valve not to open fully. This will obstruct the forward flow of blood into the left ventricle from the left atrium. What are the causes of Mitral Stenosis? Mitral stenosis is nearly always a consequence of: Rheumatic fever and rheumatic heart disease Calcification of the valve - this can occur with an increase in age Both of these cause the valve leaflets and the support mechanisms (chordae tendineae) holding it in position to thicken and become rigid. This prevents the leaflets from opening properly and the free flow of blood from the left atrium to the left ventricle.

51. YourHeart | Patient Information | Anatomy/Treatment | Mitral Valve Disease How is mitral valve disease Diagnosed? Listening through a stethoscope When blood passes through What Treatment is available for mitral valve disease? http://www.yourheart.org.uk/mitral02.php

Search for Home About Us Patient Information Discussion Forum ... Sitemap Anatomy / Treatment Heart CHD / Angina Myocardial Infarction Iscaemic Heart Disease ... Aortic Valve Disease Mitral Valve Disease Pulmonary Valve Disease Tricuspid Valve Disease Endocarditis Pericarditis ... Useful Organisations You are here: Home Patient Information Anatomy / treatment How is Mitral Valve Disease Diagnosed? Listening through a stethoscope - When blood passes through a narrowed or leaky valve, the resulting noise is a heart murmur that can be heard through a stethoscope when placed on the chest. An electrocardiogram (ECG) will identify atrial fibrillation. An echocardiography (Echo) confirms severity of regurgitation and left atrium enlargement. It may yield additional information as to the cause of the disease. Chest X ray will show enlargement of the atrium caused by its thickening and dilatation and evidence of pulmonary congestion. Cardiac catheterisation (angiogram) can detect mitral regurgitation and stenosis. However it is generally performed to detect any co-existing coronary disease that may be evident by any symptoms of angina. What Treatment is available for Mitral Valve Disease?

52. Northwestern Memorial Hospital - Exceptional Care In The Heart Of Chicago mitral valve disease is the most common form of heart valve disease affecting 5 There are two general forms of mitral valve disease mitral stenosis and http://www.nmh.org/nmh/heart/heartvalvedisease/mitralvalve.htm

Home About Us Jobs Directions ... Contact Us Northwestern Memorial Hospital Logo Physician Finder Hospital Guide Health Information Healthcare Professionals Navigation Exceptional Care in the Heart of Chicago About Us Bluhm Cardiovascular Institute Special Needs Visitor Information Parking Options Clinical Centers Atrial Fibrillation Coronary Disease Heart Failure Heart Valve Disease ... Women's Cardiovascular Health Specialists Cardiac Behavioral Medicine Cardiovascular Anethesiologists Cardiovascular Radiologists Cardiologists ... Vascular Surgeons Latest News In the News Viewpoint Innovations Cardiovascular Support Groups ... Cardiovascular Institute Center for Heart Valve Disease Mitral Valve Mitral valve disease is the most common form of heart valve disease affecting 5 percent of the population in the United States resulting in over 500,000 hospital admissions per year. There are two general forms of mitral valve disease: mitral stenosis and mitral regurgitation. Mitral stenosis is when a valve becomes thickened and narrowed, often with calcium buildup, obstructing blood flow through the valve. This causes increased back pressure of blood in the lungs and congestive heart failure. Mitral stenosis occurs less commonly than mitral regurgitation in the United States, but when it does occur it is usually a manifestation of rheumatic heart disease which occurs in some people with a childhood history of rheumatic fever. Mitral regurgitation is much more common, and refers to a valve that leaks blood backward in the heart from the left ventricle into the left atrium. This causes an increased workload on the heart and, when it becomes severe, congestive heart failure. Mitral regurgitation is classified into four types: ischemic, degenerative, rheumatic and infectious. Ischemic and degenerative (or myxomatous) mitral regurgitation account for most cases of mitral valve disease and occur with almost equal frequency in the U.S. Each of the different classifications of mitral valve disease demand specialized techniques to treat them.

53. The Health Library — Cardiovascular mitral valve disease. Diseases of the Mitral ValveTexas Heart Institute Mitral Valve Prolapse What You Should Know American Academy of Family http://healthlibrary.stanford.edu/resources/internet/bodysystems/cardio_valve.ht

Diseases and Disorders Use these links to jump directly to your topic of interest in Cardiovascular: Heart Diseases: Angina Arrhythmia Congenital Heart Disease Coronary Artery Disease ... Other Heart Diseases Vascular Diseases: Aneurysms Aortic Diseases Hypertension (High Blood Pressure) Hypotension (Low Blood Pressure) ... Venous Diseases Cardiovascular Disease Treatment: Medication Surgery Heart Transplantation Other Topics: General Cardiovascular Anatomy Cholesterol Diagnostic Procedures ... Homocysteine Heart Valve Diseases (Jump to: Overviews Aortic Valve Disease Mitral Valve Disease Pulmonary Valve Disease ... Tricuspid Valve Disease Overviews Valve Disease:Texas Heart Institute Valve Disease:Cleveland Clinic Heart Center Heart Valve Diseases: MedlinePlus See also Congenital Heart Disease Aortic Valve Disease Diseases of the Aortic Valve:Texas Heart Institute Aortic Valve Calcification (Sclerosis): Mayo Clinic Aortic Valve Regurgitation:WebMD Aortic Valve Stenosis:WebMD Mitral Valve Disease Diseases of the Mitral Valve:Texas Heart Institute Mitral Valve Prolapse: What You Should Know: American Academy of Family Physicians Mitral Valve Prolapse: A Patient Guide:Heart Information Network Mitral Valve Prolapse:Cleveland Clinic Heart Center ... Mitral Valve Stenosis:WebMD Pulmonary Valve Disease Diseases of the Pulmonary Valve:Texas Heart Institute Pulmonary Stenosis:Merck Manual Tricuspid Valve Disease Diseases of the Tricuspid Valve:Texas Heart Institute Tricuspid Valve Disease:Cleveland Clinic Heart Center Tricuspid Regurgitation:Merck Manual Tricuspid Stenosis:Merck Manual Heart Valve Repair and Replacement

54. UpToDate Transesophageal Echocardiography For Evaluating Mitral Valve Disease Transesophageal echocardiography for evaluating mitral valve disease. Nelson B Schiller, MD Elyse Foster, MD. UpToDate performs a continuous review of http://patients.uptodate.com/topic.asp?file=echo_ima/8204&title=Antiphospholipid

55. Mitral Valve Disease BACK TO LINKS. related terms mitral valve disorder, mitral valve malformation, mitral dysplasia, mitral systolic murmur. What is mitral valve disease? http://www.btca.com/Health/articles/HCmitralvalve.htm

BULL TERRIER CLUB OF AMERICA, INC. BTCA EVENTS AWARDS CLUBS ... BACK TO LINKS related terms: mitral valve disorder, mitral valve malformation, mitral dysplasia, mitral systolic murmur What is mitral valve disease? The heart consists of 4 chambers - 2 atria and 2 ventricles. The atrioventricular (AV) valves ensure that the blood flows from the atria to the ventricles when the heart beats. A defect in the mitral valve (the left atrioventricular valve) causes backflow of blood into the left atrium, or mitral regurgitation. Less commonly, a narrowing or stenosis of the valve can be identified. Because of the leaky valve, the heart is less efficient at pumping blood to the body. Mitral valve insufficiency is the most common acquired cardiac disease in older dogs, affecting over one third of dogs greater than 10 years of age. In some breeds however, mitral insufficiency develops at a much younger age, due to an inherited predisposition for this disorder. In some breeds, abnormal development (dysplasia) of the valve has been identified in the embryo.

56. Valvular  Heart Disease essentially limits possible aetiologies to congenital and rheumatic. Aortic valve disease without mitral valve disease less likely to be rheumatic http://www.aic.cuhk.edu.hk/web8/valvular_heart_disease.htm

All these topics are covered in the Not so BASIC course. Click here for details Aortic regurgitation Aortic stenosis Mitral regurgitation Mitral stenosis Aortic regurgitation Aetiology rheumatic heart disease infective endocarditis trauma: surgical or blunt chest trauma bicuspid aortic valve VSD dilatation of aortic ring: syphilis, seronegative arthritides eg ankylosing spondylitis, Marfan’s, aortic dissection Coexisting aortic stenosis essentially limits possible aetiologies to congenital and rheumatic. Aortic valve disease without mitral valve disease less likely to be rheumatic Haemodynamics avoid bradycardia and increased SVR as both increase regurgitant flow and may precipitate cardiac failure tachycardia and low aortic diastolic pressure result in decreased coronary blood flow. Therefore the combination of ischaemic heart disease and AR problematic impaired contractility with chronic volume overload and increased sensitivity to myocardial depressants in severe cases relative inability to increase cardiac output resulting intolerance of sepsis, arrythmias Symptoms tend to occur late dyspnoea on exertion due to decreased forward flow orthopnoea, PND due to LVF

57. Cardiac Home The diagnosis and treatment of mitral valve disease is an integral part of the mitral valve disease and its complications, mitral prolapse syndrome, http://cardiac.um-surgery.org/clinics/03b_clinics.htm

UMHS Cardiac Surgery F7830 Mott Hospital Ann Arbor, Michigan 48109-0223 Phone: 734-936-4980 Cardiac Home Surgery Home Aortic Clinics Mitral Clinics ... Transplant, Artificial Devices Mitral Valve Clinic The diagnosis and treatment of mitral valve disease is an integral part of the delivery of heart care services. The University of Michigan Medical Center is a leader in the diagnosis and treatment of mitral valve disease. Mitral valve disease and its complications, mitral prolapse syndrome, mitral murmurs, congestive heart failure, shortness of breath, embolism, atrial fibrillation, etc. affect tens of thousands of patients each year. This interdisciplinary program was founded to provide these patients with services that their primary care physicians and cardiologists can not provide, including: provision of identified patients with a multi-disciplinary approach to the diagnosis and treatment of mitral valve disease evaluation of the etiology of mitral valve disease generation of research literature regarding mitral disease provision of patients and referring physicians with mitral valve disease education in the areas of effective diagnostic methods and treatment options available identification and targeting of adult patients at risk for and with mitral valve disease Comprehensive evaluation of patients with mitral valve disease is a frustrating problem in the practice of cardiology, internal medicine and family practice, as many physicians are not familiar with the scope of this disease. The establishment of this program is in keeping with current trends in medical care, which are focusing on timely, effective interdisciplinary approaches to the treatment of systemic diseases.

58. Mitral Valve Disease -- Cavalier King Charles Spaniel Health and severe genetic diseases of the Cavalier King Charles Spaniel mitral valve disease. http://www.cavalierhealth.org/mitral_valve_disease.htm

Cavalier Health org serving the cavalier King charles spaniel HOME OVERVIEW ABOUT US BREEDERS ... HEALTH Clinics Updated: September 8, 2005 INSIDE TOPICS Breeders Questions for breeders Breeders' excuses Blood platelets ... Clinics Updated! Congestive heart Failure Corneal dystrophy Curly coat syndrome Cushing's disease ... Vision disorders CavalierHealth.org provides this information for your education only. Advice or suggestions found on this website are not meant to replace professional veterinary care. Consult your veterinarian before attempting to medically treat your dog or changing your dog's medical treatment. Mitral Valve Disease: Cavaliers' Deadly Curse I What It Is Diagnosis Breeders' Responsibilities In Depth: ... Resources In Short: Heart mitral valve disease (MVD) is the leading cause of death in Cavaliers throughout the world. It is a polygenetic disease which afflicts over half of all Cavalier King Charles Spaniels by age 5 years and nearly all Cavaliers by age 10 years, should they survive that long. What It Is MVD is a degeneration of the heart's mitral valve, one of four sets of valves in a dog's heart. As the mitral valve degenerates, the valve no longer fully closes after each pumping action, allowing some blood to flow backwards through them from the ventricle back into the atrium. As the condition worsens, more and more blood is able to backflow through the valve. In the final stages, the valve’s struts sometimes break, causing the valve to collapse completely. MVD results in congestive heart failure in the CKCS.

59. News Releases - November 25, 2004 - First-ever Canine Mitral Valve Disease Sympo Firstever canine mitral valve disease symposium inspires future direction mitral valve disease (MVD) is the most common cardiovascular disease in dogs http://www.boehringer-ingelheim.ca/news_releases/2004/2004-11-25.asp

contact Boehringer Ingelheim Canada Ltd/Ltee Public Relations First-ever canine mitral valve disease symposium inspires future direction for research, care and treatment - Global experts call for greater understanding and further collaboration to conquer cardiac condition in pet dogs - Ingelheim, Germany – 25 November 2004. Hundreds of thousands of dogs across the world die of canine mitral valve disease every year. Over 180 cardiologists, research experts and veterinarians from 17 countries recently convened in Paris during the first-ever International Canine Valvular Disease Symposium (ICVS 2004) to discuss the shortcomings in the management of this disease and propose solutions for improving the standard of care. Mitral valve disease (MVD) is the most common cardiovascular disease in dogs – reportedly responsible for an excess of 70 percent of all cases - yet, despite this prevalence, until now there has been no single forum that brings together the world’s experts in this key area of veterinary science. Throughout a highly scientific two-day programme, internationally renowned speakers from the USA, Canada and Europe shared their latest research results and hypotheses, sparking challenging debates related to the complex pathology, diagnosis and treatment of this condition. One of the highlights of the ICVS 2004 was the presentation identifying the synergies between the understanding of human heart disease and the canine condition. Professor Mark Starling, Medical Director of the Banner Baywood Heart Hospital, Arizona, USA provided an overview of his current work and findings in human mitral valve research, showing that sophisticated analyses of the sympathetic nervous system illustrate that the pathophysiology of canine and human mitral valve disease is quite similar.

60. Nursing: Closing In On Mitral Valve Disease Full text of the article, Closing in on mitral valve disease from Nursing, a publication in the field of Health Fitness, is provided free of charge by http://www.findarticles.com/p/articles/mi_qa3689/is_199904/ai_n8829242

@import url(/css/us/style1.css); @import url(/css/us/searchResult1.css); @import url(/css/us/articles.css); @import url(/css/us/artHome1.css); Advanced Search Home Help IN free articles only all articles this publication Automotive Sports 10,000,000 articles - not found on any other search engine. FindArticles Nursing Apr 1999 Content provided in partnership with 10,000,000 articles Not found on any other search engine. Featured Titles for AAACN Viewpoint ABNF Journal, The AIDS Treatment News AMAA Journal ... View all titles in this topic Hot New Articles by Topic Automotive Sports Top Articles Ever by Topic Automotive Sports Closing in on mitral valve disease Nursing Apr 1999 by Nagle, Beth McMahan O'Keefe, Lisa M Save a personal copy of this article and quickly find it again with Furl.net. It's free! Save it. FIND OUT HOW TO RECOGNIZE THE THREE TYPES AND TEACH YOUR PATIENT WHAT SHE NEEDS TO KNOW. Mitral valve disease is a common heart problem affecting people of all ages. Although it can follow a stable course for many years, mitral valve disease may lead to heart failure and other complications. In this article, we'll review three common mitral valve problems: prolapse, stenosis, and regurgitation. For a review of normal mitral valve physiology, see Going with the Flow.

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