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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atopic dermatitis &#40;AD&#41; is the most frequent inflammatory dermatosis&#46; Up to 20&#37; of patients have moderate to severe disease&#46; Of these&#44; 20&#37;&#8211;43&#37; may experience ocular symptoms&#44; including conjunctivitis&#44; keratitis&#44; and blepharitis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Dupilumab is the first monoclonal antibody approved for the treatment of moderate to severe AD&#46; It binds to the common alfa subunit of interleukins &#40;IL&#41; 4 and IL-13&#44; leading to a reduction in Th2-mediated inflammation and an improvement in epidermal barrier function&#46; Although it is expected that control of AD could also improve ocular manifestations&#44; in clinical trials&#44; IL-4&#47;IL-13 blockade with dupilumab is associated with a greater frequency of ocular manifestations than observed in the control group&#44; which received placebo &#40;incidence of 5&#37;&#8211;28&#37;&#44; according to dose&#44; compared with 1&#37;&#8211;8&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Two basic clinical patterns of ocular involvement associated with the use of dupilumab have been reported&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Nonspecific conjunctivitis&#44; associated with dots on the cornea in the lower third and evaporative dry eye &#40;lacrimal secretion is quantitatively normal but of a lower quality&#41;&#46; This form can respond to measures to hydrate the ocular surface&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Follicular conjunctivitis&#44; more specific&#44; generally bilateral and of a mild to moderate severity&#44; associated with pruritus&#44; burning sensation&#44; and increased tear production&#46; It is characteristic of limbal hyperemia and can be accompanied by blepharitis&#46; This form is refractory to humectants and requires topical anti-inflammatory treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">The cause of ocular manifestations associated with dupilumab is unknown&#44; although the mechanism could be inflammatory and specific to AD&#44; given that administration in patients with asthma or nasal polyposis has not been associated with an increased risk of conjunctivitis&#46; The risk factors for its development include severe AD&#44; personal history of conjunctivitis&#44; and low serum levels of dupilumab&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is postulated that inhibition of IL-4&#47;IL-13 itself could increase the activity of OX40L&#8212;which participates in the development of atopic keratoconjunctivitis&#8212;and also reduce the number of intraepithelial goblet cells&#59; this would explain the lower proportion of mucin observed&#44; in turn impacting tear quality&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">For diagnosis of dupilumab-associated conjunctivitis&#44; it is essential to obtain a detailed clinical history&#44; and findings of the eye examination &#40;exudate&#44; pruritus&#44; and concurrent symptoms&#41; and slit lamp assessment&#44; to be performed by ophthalmologists&#46; Differential diagnosis with other forms of conjunctivitis is essential&#44; particularly&#44; infectious forms&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The therapeutic recommendations are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Following approval of dupilumab in Europe&#44; an increase in the number of patients with drug-related ocular manifestations could be expected&#46; It would be desirable to raise awareness of this potential issue&#44; and put in place measures for their prevention and management&#46; Prior ophthalmological assessment is recommended before administration of the drug&#44; along with active screening for this possible side effect&#44; as well as the development of new therapeutic algorithms&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts ofinterest</span><p id="par0045" class="elsevierStylePara elsevierViewall">J&#46;M&#46; Carrascosa has received speaker and consultant fees from Sanofi and fees as an investigator in clinical trials from Sanofi&#44; Lilly&#44; Leo-Pharma&#44; Pfizer&#44; and Amgen&#46; M&#46; Munera-Campos has participated in and received fees as an investigator in clinical trials from Lilly&#44; Leo-Pharma&#44; and Pfizer&#46;</p></span></span>"
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                  \t\t\t\t">Stabilization of the lacrimal film&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Artificial tears &#40;carmellose sodium 0&#46;5&#37;&#44; trehalose 3&#37;&#44; and&#47;or sodium hyaluronate 0&#46;15&#37;&#8211;4&#37;&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Commercialized</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rehydration of the ocular surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sensitization to preservatives</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">May resolve nonspecific forms of conjunctivitis&#44; associated with evaporative dry eye&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Anti-inflammatory treatments</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fluorometholone 0&#46;1&#37;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Commercialized</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower risk of glaucoma or cataracts compared with other topical corticoids &#40;minimal penetration of the ocular anterior chamber&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sensitization to preservatives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Care should be taken regarding the possibility of glaucoma and&#47;or cataracts with chronic use &#40;class adverse effect&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">Tacrolimus &#40;concentrations of 0&#46;03&#37; and 0&#46;1&#37;&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Commercialized&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decrease in conjunctival inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Compassionate use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Magistral formulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does not increase the risk of glaucoma or cataracts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ocular irritation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ciclosporin &#40;concentrations of 0&#46;05&#37;&#8211;2&#37;&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marketed at 0&#46;1&#37; &#40;therapeutic indication in severe keratitis in adults with xerophthalmia&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decrease in conjunctival inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Compassionate use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Magistral formulation at other concentrations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does not increase the risk of glaucoma or cataracts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ocular irritation&#44; local burning sensation&#44; or pain on application&nbsp;\t\t\t\t\t\t\n
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Resident’s Forum
RF-Conjuntivitis Associated With Dupilumab in Atopic Dermatitis
FR-Conjuntivitis asociada a dupilumab en dermatitis atópica
M. Munera-Campos
Autor para correspondencia
monicamunera@hotmail.com

Corresponding author.
, J.M. Carrascosa
Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
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    "titulo" => "RF-Conjuntivitis Associated With Dupilumab in Atopic Dermatitis"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atopic dermatitis &#40;AD&#41; is the most frequent inflammatory dermatosis&#46; Up to 20&#37; of patients have moderate to severe disease&#46; Of these&#44; 20&#37;&#8211;43&#37; may experience ocular symptoms&#44; including conjunctivitis&#44; keratitis&#44; and blepharitis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Dupilumab is the first monoclonal antibody approved for the treatment of moderate to severe AD&#46; It binds to the common alfa subunit of interleukins &#40;IL&#41; 4 and IL-13&#44; leading to a reduction in Th2-mediated inflammation and an improvement in epidermal barrier function&#46; Although it is expected that control of AD could also improve ocular manifestations&#44; in clinical trials&#44; IL-4&#47;IL-13 blockade with dupilumab is associated with a greater frequency of ocular manifestations than observed in the control group&#44; which received placebo &#40;incidence of 5&#37;&#8211;28&#37;&#44; according to dose&#44; compared with 1&#37;&#8211;8&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Two basic clinical patterns of ocular involvement associated with the use of dupilumab have been reported&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Nonspecific conjunctivitis&#44; associated with dots on the cornea in the lower third and evaporative dry eye &#40;lacrimal secretion is quantitatively normal but of a lower quality&#41;&#46; This form can respond to measures to hydrate the ocular surface&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Follicular conjunctivitis&#44; more specific&#44; generally bilateral and of a mild to moderate severity&#44; associated with pruritus&#44; burning sensation&#44; and increased tear production&#46; It is characteristic of limbal hyperemia and can be accompanied by blepharitis&#46; This form is refractory to humectants and requires topical anti-inflammatory treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">The cause of ocular manifestations associated with dupilumab is unknown&#44; although the mechanism could be inflammatory and specific to AD&#44; given that administration in patients with asthma or nasal polyposis has not been associated with an increased risk of conjunctivitis&#46; The risk factors for its development include severe AD&#44; personal history of conjunctivitis&#44; and low serum levels of dupilumab&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is postulated that inhibition of IL-4&#47;IL-13 itself could increase the activity of OX40L&#8212;which participates in the development of atopic keratoconjunctivitis&#8212;and also reduce the number of intraepithelial goblet cells&#59; this would explain the lower proportion of mucin observed&#44; in turn impacting tear quality&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">For diagnosis of dupilumab-associated conjunctivitis&#44; it is essential to obtain a detailed clinical history&#44; and findings of the eye examination &#40;exudate&#44; pruritus&#44; and concurrent symptoms&#41; and slit lamp assessment&#44; to be performed by ophthalmologists&#46; Differential diagnosis with other forms of conjunctivitis is essential&#44; particularly&#44; infectious forms&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The therapeutic recommendations are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Following approval of dupilumab in Europe&#44; an increase in the number of patients with drug-related ocular manifestations could be expected&#46; It would be desirable to raise awareness of this potential issue&#44; and put in place measures for their prevention and management&#46; Prior ophthalmological assessment is recommended before administration of the drug&#44; along with active screening for this possible side effect&#44; as well as the development of new therapeutic algorithms&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts ofinterest</span><p id="par0045" class="elsevierStylePara elsevierViewall">J&#46;M&#46; Carrascosa has received speaker and consultant fees from Sanofi and fees as an investigator in clinical trials from Sanofi&#44; Lilly&#44; Leo-Pharma&#44; Pfizer&#44; and Amgen&#46; M&#46; Munera-Campos has participated in and received fees as an investigator in clinical trials from Lilly&#44; Leo-Pharma&#44; and Pfizer&#46;</p></span></span>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Decrease in conjunctival inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Compassionate use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Magistral formulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does not increase the risk of glaucoma or cataracts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ocular irritation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ciclosporin &#40;concentrations of 0&#46;05&#37;&#8211;2&#37;&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marketed at 0&#46;1&#37; &#40;therapeutic indication in severe keratitis in adults with xerophthalmia&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decrease in conjunctival inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Compassionate use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Magistral formulation at other concentrations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does not increase the risk of glaucoma or cataracts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ocular irritation&#44; local burning sensation&#44; or pain on application&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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