Based on data from Anand SS, Wells PS, Hunt D, et al: Does this patient have deep vein thrombosis? Damage. With the occlusion, the result is slowed movement of blood through the vein. Common causes of asymmetric leg swelling that mimic DVT are, Obstruction of a lymphatic vessel in the pelvis, Popliteal bursitis (Baker cyst) that obstructs venous return, Abdominal or pelvic tumors that obstruct venous or lymphatic return. They include MRI venography using an intravenous contrast agent and direct MRI of thrombi using T1-weighted gradient-echo sequencing and a water-excitation radiofrequency pulse; theoretically, the latter test can provide simultaneous views of thrombi in deep veins and subsegmental pulmonary arteries (for diagnosis of pulmonary embolism). The interaction between the thrombus and the endothelium results in an irritated vein. On the other hand, oral factor Xa inhibitors and dabigatran attain a therapeutic effect within 2 to 3 hours of intake and there is no need to overlap these drugs with an injectable heparin. Damage to the intimal lining of blood vessels creates a site for clot formation. IVC filters reduce risk of acute embolic complications but can have longer-term complications (venous collaterals can develop, providing a pathway for emboli to circumvent the filter, and there is also an increased risk of recurrent DVT). Patients who may benefit from thrombolytics include those < 60 years with extensive iliofemoral DVT who have evolving or existing limb ischemia (eg, phlegmasia cerulea dolens) and do not have risk factors for bleeding. Merck & Co., Inc., Kenilworth, NJ, USA is a global healthcare leader working to help the world be well. D-Dimer is a byproduct of fibrinolysis; elevated levels suggest recent presence and lysis of thrombi. The three factors include: venous stasis, activation of blood coagulation, and vein damage. Prognosis is generally good with prompt, adequate treatment. Lifestyle. Acute DVT can be treated on an outpatient basis unless severe symptoms require parenteral analgesics, other disorders preclude safe outpatient discharge, or other factors (eg, functional, socioeconomic) might prevent the patient from adhering to prescribed treatments. Figure: one of the symptoms of DVT is leg ulceration, which may be precipitated by minor trauma, tends to be chronic, painful, and slow to heal, and often recurs Chronic thromboembolic pulmonary hypertension (CTPH) DVT is the primary cause of pulmonary embolism. (See also the American College of Chest Physicians recommendation, Antithrombotic Therapy for VTE Disease.). Complications of deep vein thrombosis. Definition, Etiology, Pathogenesis Top. Heart failure. This occurs due to an imbalance between the clotting factors and the clot busting factors. A deep vein thrombosis (DVT) is a blood clot that forms in the deep veins of the leg. If there is an occlusion or partial occlusion of the pulmonary artery or its branches, it will cause a pulmonary embolism. Treatment is with anticoagulants. Duration of treatment is typically 3 or 6 months, depending on the presence and nature of risk factors; certain patients require lifelong treatment. The causes of thrombosis include vessel wall damage, stasis or low flow, and hypercoagulability. Other risk factors include: obesity, neoplasm, surgery, immobility, acute infection, and being over 75 years of age. Extreme fear of loneliness is called monophobia. Because of the normal physiology of pregnancy, the central venous … This occurs when the clot loses its attachment to the inside of the vein, leaves the leg and lodges in the pulmonary artery, the main blood vessel to the lungs. Tenderness along distribution of the veins in calf or thigh, Calf swelling (> 3 cm difference in circumference between calves, measured 10 cm below tibial tuberosity), Cancer (including cases in which treatment was stopped within 6 months), Immobilization of lower extremity (eg, due to paralysis, paresis, casting, or recent long-distance travel), Surgery leading to immobility for > 3 days within the past 4 weeks. If pretest probability of DVT is low, DVT can be safely excluded in patients with a normal D-dimer level on a sensitive test. Typically, lower‐extremity thrombus develops in valve pockets of the calf veins. No single testing protocol is best; one approach is described in the figure One Approach to testing for suspected DVT. In addition, patients should have any age- and gender-appropriate cancer screening (eg, mammography, colonoscopy) that is due. Reduced blood flow. Deep vein thrombosis (DVT) or blood clot in the leg symptoms include swelling, warmth, redness, and pain in the leg with the blood clot. Probability equals the number of factors, subtracting 2 if another diagnosis is as likely as or more likely than deep venous thrombosis. Deep vein thrombosis (DVT) happens when the blood flow slows down and its platelets and plasma don't properly mix and circulate. Thrombosis of other deep veins (eg, the portal vein) is considered a separate disease entity. Diagnosis is by history and physical examination and is confirmed by objective testing, typically with duplex ultrasonography. Jugular vein suppurative thrombophlebitis (Lemierre syndrome), a bacterial (usually anaerobic) infection of the internal jugular vein and surrounding soft tissues, may follow tonsillopharyngitis and is often complicated by bacteremia and sepsis. With prompt diagnosis and treatment, the majority of DVT’s are not life threatening. The endothelium around valves responds by expressing adhesion molecules that attract leukocytes. Some evidence suggests that presence of hypercoagulability does not predict DVT recurrence as well as clinical risk factors. The need for additional tests (eg, D-dimer testing) and their choice and sequence depend on pretest probability and sometimes ultrasonography results. Deep vein thrombosis (DVT) is a serious condition that occurs when a blood clot forms in a vein located deep inside your body. Select patients may continue treatment with a low-molecular-weight heparin rather than switching to an oral drug, eg, patients with extensive iliofemoral DVT or selected patients with cancer. But it can occur at any age. With slowed movement, the result is a micro thrombi building up on the vasculature walls. When the legs are inactive or the pump is ineffective, blood pools by gravity in the veins. A pulmonary embolism (PE) occurs when a clot breaks loose and travels through the bloodstream to the lungs. DVT is most common in adults over age 60. An IVC filter is placed in the inferior vena cava just below the renal veins via catheterization of an internal jugular or femoral vein. Causes of DVT. The three factors include: venous stasis, activation of blood coagulation, and vein damage. The association is strongest for mucin-secreting endothelial cell tumors such as bowel or pancreatic cancers. A deep vein thrombosis (DVT) occurs when a blood clot forms in a vein deep inside your body. The accumulation of these micro thrombi continues to increase. A pulmonary embolism happens when a blood vessel in your lungs becomes blocked. Click below to consent to the use of this technology on this website. Pulmonary embolism can cause chest pain and difficulty breathing. The reason for this different approach is that when starting warfarin, it takes about 5 days to attain a therapeutic effect; hence, the need to overlap with rapidly acting heparin for 5 to 7 days. ; Valvular incompetence is the mechanism responsible for venous insufficiency development. Understanding the major causes of thrombosis can help people to take steps to reduce the risks that they face. D-Dimer testing is used when DVT is suspected; a negative result helps to exclude DVT, whereas a positive result is nonspecific and requires additional testing to confirm DVT. Ultrasound. About 50% of patients with DVT have occult PE, and at least 30% of patients with PE have demonstrable DVT. Common cause: An embolized clot from deep vein thrombosis (DVT) involving the lower leg. Clinical signs and symptoms of PE are rarely encountered together; the classic symptoms are as follows : 1. A deep vein thrombosis in the thigh carries a risk of pulmonary embolism (PE). Journal of the American Medical Association 279 (14):1094–1099, 1998. Patients with confirmed DVT and an obvious cause (eg, immobilization, surgical procedure, leg trauma) need no further testing. Testing to detect hypercoagulability is controversial but is sometimes done in patients who have idiopathic (or unprovoked) DVT or recurrent DVT, in patients who have a personal or family history of other thromboses, and in young patients with no obvious predisposing factors. Causes of Deep Vein Thrombosis (DVT) There are a variety of risk factors that contribute to the development of deep vein thrombosis: Surgery, particularly surgery of the hip or leg, or abdominal surgery; Trauma or bone fracture; A long period of bed rest or sitting for a long time (e.g., on an airplane or in a car) Cancer; Pregnancy Formation of a thrombus frequently accompanies phlebitis, which is an inflammation of the vein walls. A wandlike device (transducer) placed over the part of your body where there's a clot sends sound waves into the area. 2. Common long-term complications include venous insufficiency with or without the postphlebitic syndrome. DVT may occur in ambulatory patients or as a complication of surgery or major medical illness. Pulmonary embolism . The second portion of Virchow’s triad is hyper-coagulability. Symptoms can include pain, swelling, redness, and enlarged veins in the affected area, but some DVTs have no symptoms. However, thrombectomy, fasciotomy, or both are mandatory for phlegmasia alba dolens or phlegmasia cerulea dolens unresponsive to thrombolytics to try to prevent limb-threatening gangrene. IVC filters are sometimes used in situations where efficacy is not proven, for example, for the primary prevention of PE in patients after certain types of surgery or in patients with multiple severe injuries. Anyone can get DVT at any time, but there are risk factors that can increase your chances of developing this condition. Thrombi in subcutaneous veins just below the skin that are palpable (e.g., in a varicose vein) are classified as superficial venous thrombi (SVT); also referred to as superficial thrombophlebitis. The perforating veins valve normally functions by preventing the reflux of blood from the deep veins into the superficial veins. Deep vein thrombosis, commonly referred to as “DVT,” occurs when a blood clot or thrombus, develops in the large veins of the legs or pelvic area. It mainly affects the large veins in the lower leg and thigh, but can occur in other deep veins, such as in the arms and pelvis. Learn more about DVT of the upper extremity. This clinical syndrome has gained attention as one complication of DVT, pulmonary embolization, can be fatal. Deep vein thrombosis (DVT) refers to the development of a thrombus in the deep venous system (below the deep fascia) of the lower extremities or, less commonly, the upper extremities. Symmetric bilateral leg swelling is the typical result of use of drugs that cause dependent edema (eg, dihydropyridine calcium channel blockers, estrogen, high-dose opioids), venous hypertension (usually due to right heart failure), and hypoalbuminemia; however, such swelling may be asymmetric if venous insufficiency coexists and is worse in one leg. The trusted provider of medical information since 1899, Chronic Venous Insufficiency and Postphlebitic Syndrome. These thrombi disrupt the vascular integrity of the lower limbs and are the source of emboli that kill approximately 200,000 patients each year in the United States. It could break off and travel to your lung . Lower extremity DVT is much more likely to cause pulmonary embolism (PE), possibly because of the higher clot burden. Low-risk patients may have D-dimer testing, as a normal result essentially excludes deep venous thrombosis (DVT); others should have ultrasonography. Nursing Points General Thrombus v. Embolus Risk Factors Virchow’s […] Cigarette smoking (including passive smoking), Estrogen receptor modulators (eg, tamoxifen, raloxifene), Factor V Leiden mutation (activated protein C resistance), Myeloproliferative neoplasm (hyperviscosity), Lower extremity DVT most often results from, Impaired venous return (eg, in immobilized patients), Endothelial injury or dysfunction (eg, after leg fractures), Upper extremity DVT most often results from, Endothelial injury due to central venous catheters, pacemakers, or injection drug use. In phlegmasia alba dolens, a rare complication of DVT during pregnancy, the leg turns milky white. Inadequate anticoagulation in the first 24 to 48 hours may increase risk of recurrence or PE. Thrombus development is a local process. PATHOPHYSIOLOGY. Low-grade fever may be present; DVT may be the cause of fever without an obvious source, especially in postoperative patients. Deep venous thrombosis usually begins in venous valve cusps. Thrombi consist of thrombin, fibrin, and red blood cells with relatively few platelets (red thrombi); without treatment, thrombi may propagate proximally or travel to the lungs. Risk of venous insufficiency is difficult to predict. When present, symptoms and signs of DVT (eg, vague aching pain, tenderness along the distribution of the veins, edema, erythema) are nonspecific, vary in frequency and severity, and are similar in arms and legs. ; At 10 years of follow-up, the incidence of venous insufficiency is around 30%. 3 Moreover, DVT is a common post-operative complication, 4 and a serious threat to the patient's general recovery. It can also develop in deep veins of the upper extremities (4 to 13% of DVT cases). Virchow’s triad was developed to help identify the factors that were present in those patients who were developing DVTs. Kearon C, Aki EA, Ornelas J, et al: Antithrombotic therapy for VTE disease (Chest Guideline and Expert Panel Report). Identify the pathophysiology of chronic … The … Introduction. (i) Anatomy: The venous anatomy of the leg predisposes itself to the formation of thrombosis: low flow areas such as soleal sinuses, valve pockets and at venous confluences are common sites of clot formation. Common causes of calf pain that mimic acute DVT include, Venous insufficiency and postphlebitic syndrome, Cellulitis that causes painful erythema of the calf, Ruptured popliteal (Baker) cyst (pseudo-DVT), which causes calf swelling, pain, and sometimes bruising in the region of the medial malleolus, Partial or complete tears of the calf muscles or tendons. The signs and symptoms of VTE are nonspecific and common in pregnancy. It can result in long-term complications that include postthrombotic syndrome (PTS) adding to its morbidity. Preventive treatment is required for bedbound patients with major illness and/or those undergoing certain surgical procedures. Three mechanisms predispose to DVT, they are collectively described as the Virchow's triad. © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA), © 2021 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, Excessive loss of lung tissue due to surgery, One approach to testing for suspected deep venous thrombosis, Doppler Ultrasound of a Patient with a Thrombus in Femoral Vein, Probability of Deep Venous Thrombosis Based on Clinical Factors, Journal of the American Medical Association, Musculoskeletal and Connective Tissue Disorders, One Approach to testing for suspected DVT. Calf discomfort elicited by ankle dorsiflexion with the knee extended (Homans sign) occasionally occurs with distal leg DVT but is neither sensitive nor specific. Causes are pregnancy, obesity, smoking, medications, and prolonged sitting. When DVT does not grow, it can be cleared naturally and dissolved into the blood (fibrinolysis). Each can also influence the others in ways that enhance or reduce thrombotic prop … Male sex. Upper extremity DVT most commonly affects the subclavian, axillary, and jugular … Although the exact cause of deep vein thrombosis remains unclear, there are mechanisms believed to play a significant role in its development. When the legs are inactive or the pump is ineffective, blood pools by gravity in the veins. It is thought to occur when there is an increased amount of tissue activation factor present, and a decreased amount of plasma antithrombin or fibrinolysins. Thus, in lower limb deep vein thrombosis, the affected leg is usually swollen with the circumference of the calf larger than the unaffected side. Venous stasis occurs when blood flow is reduced, when veins are dilated, and when skeletal muscle contraction is reduced. A deep vein thrombosis (DVT) is a blood clot that forms in a vein deep inside your body. For patients who are to start an oral factor Xa inhibitor (edoxaban) or dabigatran etexilate, the oral agent is started on the day after the 5 to 7 days of injectable heparin is completed. DVT typically presents in the lower limb, although it can also rarely occur in the upper limb. Deep Vein Thrombosis (DVT) is a condition wherein a blood clot or thrombus is formed in a deep vein. In patients with DVT, there is a potential to develop chronic venous insufficiency, also known as post-phlebitic syndrome. 1. These micro thrombi are not washed away by the pressure of the blood on the vein walls because of the obstruction. Surgery is rarely needed. A deep vein thrombosis in the thigh carries a risk of pulmonary embolism (PE). This irruption stimulates the production of inflammation markers. Pathophysiology of DVT formation. General supportive measures include pain control with analgesics, which may include short (3- to 5-day) courses of a nonsteroidal anti-inflammatory drug (NSAID). Most of the time, deep vein thrombosis (DVT) doesn’t cause any further problems. Here is some information about the leading causes of thrombosis in the United Kingdom. Diagnosis of VTE by physical examination is frequently inaccurate, even though one study found that 80% of pregnant women with DVT experience pain and swelling of the lower extremity. In this Assignment, you explore the epidemiology, pathophysiology, and clinical presentation of CVI and DVT. This causes a blood clot, in this case in a deep vein, which prevents deoxygenated blood from returning to the heart. Alternatively, anticoagulation may be initiated with selected direct oral anticoagulants (rivaroxaban or apixaban) without first giving an injectable heparin; however, use of these drugs may be limited due to higher cost compared to warfarin. January 3, 2012. About 10-20% of thromboses extend proximally, and a further 1-5% go on to develop fatal pulmonary embolism. Risk of recurrent DVT is lowest for patients with transient risk factors (eg, surgery, trauma, temporary immobility) and greatest for patients with persistent risk factors (eg, cancer), idiopathic DVT, or incomplete resolution of past DVT (residual thrombus). Deep vein thrombosis (DVT) is a condition that occurs when a blood clot forms in a vein deep inside a part of the body. This site complies with the HONcode standard for trustworthy health information: Alterations in blood flow : Venous stasis is a major risk factor for the development of thrombosis. Treatment of lower and upper extremity DVT is generally the same. The three factors include: venous stasis, activation of blood coagulation, and vein damage. Tenderness, swelling of the whole leg, > 3 cm difference in circumference between calves, pitting edema, and collateral superficial veins may be most specific; DVT is likely with a combination of ≥ 3 in the absence of another likely diagnosis (see table Probability of Deep Venous Thrombosis). For patients who are to start warfarin, warfarin is started within 24 to 48 hours after the start of the injectable heparin. Venous thromboembolism (VTE), a disease that includes deep venous thrombosis (DVT) and pulmonary embolism (PE), is associated with high mortality, morbidity, and costs. Immobilization for more than 3 days may also increase the risk of DVT development. Diagnosis is typically by ultrasonography with Doppler flow studies (duplex ultrasonography). The superficial femoral and popliteal veins in the thighs and the posterior tibial and peroneal veins in the calves are most commonly affected. Depending on how likely you are to have a blood clot, your doctor might suggest tests, including: 1. These thrombi disrupt the vascular integrity of the lower limbs and are the source of emboli that kill approximately 200,000 patients each year in the United States. Deep vein thrombosis of the lower limb is also seen in a quarter of patients with acute myocardial infarction, and more than half of patients with acute ischaemic stroke. Symptoms and signs are nonspecific, so clinicians must be alert, particularly in high-risk patients. We evaluated the effects of diabetes on the risks of developing deep-vein thrombosis (DVT) and pulmonary embolism (PE) in a nationwide, population-based cohort study in Taiwan. Get medical help as soon as possible if you think you have DVT. Prevent the clot from getting bigger. In addition, elevation of legs (supported by a pillow or other soft surface to avoid venous compression) is recommended during periods of inactivity. [2, 3] No single physical finding or com… Thus, a negative D-dimer test can identify patients who have a low probability of DVT and do not require ultrasonography. It can also be called venous thrombosis, thrombophlebitis, phlebothrombosis. Which of the following is a likely cause of acute cor pulmonale rather than chronic cor pulmonale? DVT usually can be treated with drug therapy. Tenderness - Occurs in 75% of patients 4. Continuing or intrinsic risk factors include: A history of DVT. Some DVTs may cause no pain, whereas others can be quite painful. The following modalities are used (for a more complete discussion, see DVT Prevention). Venous gangrene may result. Treatment is aimed primarily at PE prevention and secondarily at symptom relief and prevention of DVT recurrence, chronic venous insufficiency, and postphlebitic syndrome. However, a positive test result is nonspecific; because levels can be elevated by other conditions (eg, liver disease, trauma, pregnancy, positive rheumatoid factor, inflammation, recent surgery, cancer), further testing is necessary. Lower-limb deep venous thrombosis (DVT) affects between 1% to 2% of hospitalized patients. DVT is the primary cause of pulmonary embolism. It begins by platelet adherence to the endothelium. Deep vein thrombosis (DVT) is the formation of a thrombus (blood clot) in a deep vein, usually in the legs, which partially or completely obstructs blood flow. Ultrasonography identifies thrombi by directly visualizing the venous lining and by demonstrating abnormal vein compressibility or, with Doppler flow studies, impaired venous flow. Click here for Patient Education Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. We do not control or have responsibility for the content of any third-party site. Leg pain - Occurs in 50% of patients but is nonspecific 3. Risk factors for postphlebitic syndrome include proximal thrombosis, recurrent ipsilateral DVT, and body mass index (BMI) ≥ 22 kg/m2. For example, a highly sensitive test is enzyme-linked immunosorbent assay (ELISA), which has a sensitivity of about 95%. Upper extremity DVT occasionally occurs as part of superior vena cava (SVC) syndrome (compression or invasion of the superior vena cava by a tumor and causing symptoms such as facial swelling, dilated neck veins, and facial flushing) or results from a hypercoagulable state or subclavian vein compression at the thoracic outlet. WebMD explains what causes it, as well as the symptoms and how you can prevent it. PATHOPHYSIOLOGY. They can also occur in the pelvis and arm. Using Virchow's triad as framework, it is clear that alterations in any of its components (blood composition, the vessel wall, and blood flow) can influence the propensity for the development of venous thromboembolism. The causes of the condition are many, for example, trauma, prolonged periods of immobility, and advanced age. Venous Insufficiency. Introduction, Symptoms and Treatment of Type 1 Diabetes, Symptoms and Diagnosis of Rheumatoid Arthritis. If ultrasonography does not reveal evidence of DVT, a normal D-dimer level helps exclude DVT. Last full review/revision Dec 2019| Content last modified Dec 2019. It is preferable and safer to prevent DVT than to treat it, particularly in high-risk patients. Less common causes: Tissue fragments; Lipids; Foreign body; Air bubble; Amniotic fluid; Risk Factors Dilated collateral superficial veins may become visible or palpable. Contrast venography was the definitive test for the diagnosis of DVT but has been largely replaced by ultrasonography, which is noninvasive, more readily available, and almost equally accurate for detecting DVT. Pathophysiology and Diagnosis of Deep Venous Thrombosis Bruce R. Line Lower-limb deep venous thrombosis (DVT) affects be- tween 1% to 2% of hospitalized patients. Pathophysiology may involve complete stasis of venous and arterial blood flow in the lower extremity because venous return is occluded or massive edema cuts off arterial blood flow. A blood clot is a clump of blood that’s turned to a solid state. Venous status, damage to the vessel, and hypercoagulability cause the blood to pool so blood can not move the way that it should so more clots form. Vein damage is the third component of Virchow’s triad. Dyspnea - 82% 2. (For details on drugs and their complications, see Drugs for Deep Venous Thrombosis), All patients with DVT are given anticoagulants. Thrombolytic drugs, which include alteplase, tenecteplase, and streptokinase, lyse clots and may be more effective than anticoagulation alone in selected patients, but the risk of bleeding is higher than with heparin. The most commonly associated risk factor for the development of DVT is the patient having a past medical history of DVT. Deep vein thrombosis (DVT) is a serious condition that occurs when a blood clot forms in a vein located deep inside your body. VTE affects 1/1000 patients, costs $13.5 billion annually to treat, and claims 100,000 lives annually in the US. An IVC filter may help prevent PE in patients with lower extremity DVT who have contraindications to anticoagulant therapy or in patients with recurrent DVT (or emboli) despite adequate anticoagulation. A deep vein thrombosis (DVT) is a blood clot that forms in the deep veins of the leg. Also, IVC filters can dislodge or become obstructed by a clot. Causes of a thrombus (blood clot) include slow blood flow, an injury to the lining of a vein, or having blood with an increased tendency to clot. Thrombus development is a local process. Causes of DVT. Deep Vein Thrombosis and Pulmonary Embolism (DVT/PE) are often underdiagnosed and serious, but preventable medical conditions. Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. Although most DVT is occult and resolves spontaneously without complication, death from DVT-associated massive pulmonary embolism (PE) causes as many as 300,000 deaths annually in the United States. Anatomy and Pathophysiology. Age over 60 years. Deep vein thrombosis of the lower limb normally starts in the calf veins. Venography may be indicated when ultrasonography results are normal but pretest suspicion for DVT is high. Virchow's triad (venous stasis, vessel wall injury, and hypercoagulability) summarizes the mechanisms by which acquired and inherited risk factors (Table 10‐1) predispose to VTE. Deep vein thrombosis (DVT) is the formation of a blood clot in a vein deep under the skin. Symptoms of pulmonary embolism, if it occurs, may include shortness of breath and pleuritic chest pain. Deep vein thrombosis (DVT) is a medical condition that occurs when a blood clot forms in a deep vein. Therefore, early detection and systematic management of DVT and related complica- The test is > 90% sensitive and > 95% specific for femoral and popliteal vein thrombosis but is less accurate for iliac or calf vein thrombosis. Lower-limb deep venous thrombosis (DVT) affects between 1% to 2% of hospitalized patients. Treatment for a dislodged filter is removal, using angiographic or, if necessary, surgical methods. 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