Indian J Sex Transm Dis Indian J Sex Transm Dis
Official Publication of the Indian Association for the Study of Sexually Transmitted Diseases
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   Table of Contents - Current issue
January-June 2021
Volume 42 | Issue 1
Page Nos. 1-89

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Male circumcision and Sexually transmitted Infections – An update p. 1
Kajal S Mehta, Yogesh S Marfatia, Apexa P Jain, Dhiral J Shah, Disha S Baxi
Role of male circumcision (MC) as a tool to prevent sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) was assessed. An attempt was made to search articles related to association between MC and STIs/HIV. A thorough search was carried out to find out quality articles published in indexed specialty journals. Centers for Disease Control and Prevention and World Health Organization (WHO) sites were also referred. Warm and moist environment of area under foreskin facilitates some pathogens to persist and replicate. Further, the thinness of foreskin predisposes it to minor trauma and abrasions that facilitate the entry of pathogens. MC reduces HIV infection risk by 50%–60% over time and reduces the risk of men acquiring herpes simplex virus-2 and human papillomavirus (HPV) that can cause penile and other anogenital cancers, by 30%. There is no significant reduction in risk of acquiring syphilis, but reduced risk of acquisition of Haemophilus ducreyi is reported. MC is reported to be beneficial in conditions such as traumatic injury, Balanitis Xerotica Obliterans, refractory balanoposthitis, and chronic, recurrent urinary tract infections. MC also reduces the chances of penile carcinoma by facilitating improved penile hygiene, lowering HPV/HIV transmission rates, and reducing chronic inflammatory conditions such as phimosis and balanitis. MC has been recommended by the WHO and UNAIDS in 2007 as an additional HIV prevention intervention in settings of high HIV prevalence. MC is an important adjunct to safe sex education, condom use, and vaccination (HPV) in reducing the global burden of HIV/STIs-related morbidity and mortality.
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A study of biophysical profile of inguinal skin: An implication for health and disease p. 7
Puneet Bhargava, Heena Singdia, Shivi Nijhawan, Deepak K Mathur, Rishi K Bhargava
Context: Inguinal skin is prone to various infectious dermatological conditions such as erythrasma, intertrigo, hidradenitis suppurativa, folliculitis, dermatophytic infection, and various sexually transmitted diseases, as compared to the skin elsewhere. Aim: Our study attempts to compare the biophysical profile parameters (BPPs) of the genital skin with that of the rest of the body, while taking skin of the upper back as control. It also attempts to find out if there is a difference in BPPs of the two sites and that how the change in the BPPs, bring about change in microbiome and make inguinal skin more prone to infections. Materials and Methods: This was a hospital-based comparative study conducted over 976 patients (600 males and 376 females) of age group 18–60 years, where BPP parameters such as hydration, skin pH, transepidermal water loss (TEWL), and sebum content were measured over the skin of the upper back and right inguinal region, and the results were summarized and presented as proportions (%). Chi-square test was used to compare abnormal findings. P ≤ 0.05 was taken as statistically significant. MedCalc 16.4 version software was used for all statistical calculations. Results: Significant difference was noted in skin pH and TEWL, where P value came out to be <0.05, which was statistically significant, whereas there was minimal difference in sebum content and skin hydration in both the areas, in males and females. Conclusion: Raised skin pH disturbs organization of lipid bilayers (disturbed barrier), decreases lipid processing (impaired SC cohesion), and increases serine protease activity (reduced AMP). Increased TEWL (defect in physical barrier) and decreased hydration predispose the genital skin to infections. Use of pH buffered solutions (3–4), barrier repair creams containing ceramides, and barrier protective creams with dimethicone can help prevent these inguinal dermatoses.
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Evaluation of point of care serum cryptococcal antigen by lateral flow immunoassay for diagnosis of cryptococcosis and cryptococcal meningitis in HIV-positive patients p. 14
Ulka Kamble, KH Dheeresh, Kakasaheb Bhosale, MB Indu, Brijesh Sharma, Anuradha Chowdhary
Background: Cryptococcal meningitis (CM) is the initial acquired immunodeficiency syndrome (AIDS) defining illness in 2% of patients with CD4 levels <100/μL and a leading cause of mortality in AIDS in the developing world. It is the most common opportunistic infection of the central nervous system in AIDS in various Indian studies. Detection of serum cryptococcal antigen (SCRAG) is the most widely used diagnostic method for cryptococcosis.The presence of cerebrospinal fluid cryptococcal antigen (CSF CRAG) is diagnostic of CM. CRAG can be determined by latex agglutination (LAT), enzyme-linked immunosorbent assay and now, by lateral flow (LFA)immunoassay. LFA is a point of care test that rapidly detects CRAG. Aims and Objectives: This study compares LAT and LFA for the detection of serum CRAG and diagnosing CM. Materials and methods: Two hundred and ten patients of HIV/AIDS were submitted to SCRAG LFA by dipstick. A sample was also sent to laboratory for SCRAG by LAT. CSF examination was done for those who were positive for SCRAG LFA and those who had symptoms suggestive of meningitis. SCRAG by LFA was compared with SCRAG by LAT, CSF CRAG by LAT and LFA, CSF cryptococcal culture and CSF India ink examination for Cryptococcus. Results: Fifteen patients were found positive for SCRAG by LFA dipstick. All of them were also positive for SCRAG by LAT. Twelve of them had C. D4 count below below 100 cells/mm3. CSF CRAG was positive in all 12 SCRAG positive who were submitted to CSF examination. Conclusion: We found that serum detection of CRAG by LFA dipstick is as sensitive as CRAG detection in serum by LAT and CSF CRAG detection by LFA and LAT. It is thus a rapid test for diagnosing CM in HIV patients with low CD4 counts.
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Isolation, characterization and acyclovir susceptibility of herpes simplex virus isolates among immunocompromised patients Highly accessed article p. 19
Soumyabrata Nag, Mallika Sengupta, Soma Sarkar, Yogiraj Ray, Debprasad Chattopadhyay, Manideepa Sengupta
Introduction: Herpes simplex virus (HSV) Type 2 primarily causes genital herpes, while HSV Type 1 is responsible for oral and facial lesions. The objective of this study was to isolate and characterize HSV from herpetic lesions among human immunodeficiency virus (HIV) infected patients and to evaluate their acyclovir susceptibility pattern. Materials and Methods: Blister fluid and swabs from ulcers were collected from patients with clinical diagnosis of HSV infection among patients attending the HIV clinic of two tertiary care centers – Medical College, Kolkata, and School of Tropical Medicine, Kolkata. These samples were cultured in the Vero cell line. Growth of virus was noted by observing the characteristic cytopathic effect of HSV, which was further confirmed by immunofluorescence and polymerase chain reaction (PCR). These isolates were then subjected to the Vero cells with serial dilutions of acyclovir for determining the susceptibility pattern. Results: Among the 52 samples received, 8 (15.38%) showed growth of HSV. After confirmation by immunofluorescence and PCR, all seven isolates from genital samples were identified as HSV-2 and the lone isolate from oral lesion was confirmed as HSV 1. Out of the eight isolates, 25% showed resistance to acyclovir. The overall isolation rate was more from genital blister than genital ulcer which was 46.15% and 2.86%, respectively. Conclusion: HSV was isolated in 15.38% of cases of clinical herpes. There was a higher isolation rate of virus from blister fluid as compared to ulcer scrapings. Acyclovir resistance in 25% of cases is alarmingly high.
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Clinical profile and disease progression of HIV in adolescents and young adults in Vadodara, India p. 24
Geetika Madan-Patel, Vihang Mazumdar
Introduction: Adolescents are vulnerable to HIV for many reasons. Unfortunately, there are little data available on adolescents and young adults who have contracted HIV. Only few studies have been conducted in India with an aim to assess the clinical presentation, disease progression, and clinical profile of HIV in adolescents. Materials and Methods: There was a cohort study conducted at the antiretroviral therapy (ART) center at a teaching hospital in Western India. The study participants were kept under observation for 1 year. The end point of the cohort analysis was HIV disease progression. Patient details such as sociodemographic profile, CD4 counts at presentation, date of initiation of ART, WHO clinical stage of HIV at presentation, episodes of opportunistic infections, and laboratory investigations were recorded. Descriptive statistics and survival analysis were used for analyzing disease progression, improvement in health conditions, and factors affecting the same. Results: Of 155 participants, 100 were followed up till the end of the study. Seventy-two percent participants were adolescents and 53% were female. The mean age at presentation was 16.7 years, and the common modes of transmission were mother-to-child transmission (MTCT) (48%), heterosexual relationships (23%), and blood transfusion (12%). CD4 counts at presentation were <350 cells/mm3 among 70 participants. Among those infected through MTCT, the median survival duration was 15 years (95% confidence interval: 12.98–17.07). The risk of progression of the disease among young adults was thrice than that of adolescents (P < 0.05). Conclusion: HIV/AIDS screening and health services shall be tailored to address the special needs of adolescents and young adults. Teaching hospitals shall explore opportunities for student-involved longitudinal research studies to better understand the source of HIV infection, treatment seeking behavior, disease progression and outcome in a comprehensive manner.
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Virological outcome and frequency of low-level viremia in patients receiving generic dolutegravir-containing regimen at a large tertiary care clinic in Western India p. 31
Atul K Patel, Ketan K Patel, Sanjay Pujari, Jagdish K Patel, Ambuj Kumar
Background: Dolutegravir (DTG) is widely used for the management of naïve and treatment-experienced HIV-infected patients. Low-level viremia (LLV) is common in patients receiving nonnucleoside reverse transcriptase inhibitor- and protease inhibitor-containing regimens. However, the incidence of LLV associated with DTG-containing regimen is not well known. Objective: The objective of this study was to assess the virological response associated with DTG-containing regimens and explored frequencies of LLV and risk factors for the same. Methods: We performed a retrospective cohort study of HIV-infected patients receiving generic DTG-containing regimen from February 2017 to July 2019. All adult patients (≥18 years), who completed at least the first follow-up after initiating treatment, were included in this study. LLV was defined as plasma viral load between 20 and 200 copies/ml. Results: A total of 597 patients started DTG-containing regimen during the study period, of which 522 patients met the inclusion criteria. The study patients were categorized into five groups: naïve (n = 86), first-line failure (n = 32), second-line failure (n = 53), switch (n = 325), and HIV-2 (n = 26). Complete virological suppression at 6, 12, and 18 months was achieved in 78.5%, 81.1%, and 70.9% of the patients, respectively. Furthermore, 17.9%, 12.9%, and 23.3% of the patients had LLV at 6, 12, and 18 months, respectively. Persistent LLV was found in 2.9% of the patients. Overall, DTG was well tolerated and was discontinued in only three patients due to neuropsychiatric side effects. Conclusion: DTG is well tolerated and effective in suppressing HIV across all antiretroviral treatment categories. The rate of persistent LLV is low in DTG-containing therapy.
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Vaginal discharge: The diagnostic enigma p. 38
Shaheen Siddiqua Amrin, G Jyothi Lakshmi
Background: Vaginal discharge is a common clinical problem with varied etiologies, most common being bacterial vaginosis which presents as homogenous gray discharge caused by overgrowth of facultative and anaerobic bacterial species, next common is vulvovaginal candidiasis characterized by pruritus and cottage cheese like discharge followed by vaginal trichomoniasis associated with copious yellow or green and frothy discharge. This necessitates the need to identify the specific cause of vaginal discharge. Aim: To determine the etiology of pathological vaginal discharges in women attending tertiary care hospital. Methodology: 698 sexually active females in age group of 15 to 65 years with complaints of vaginal discharge attending Department of Dermatology Venereology and Leprosy at a Tertiary care hospital from June 2017 to May 2018 participated in the study. After presumptive clinical diagnosis vaginal discharge was collected. Wet mounts and 10% KOH preparations were examined immediately. Identification of pathogens was done by Gram stain and culture. Results: 18.33% of 698 patients showed vulvovaginal candidiasis, 13.75% had bacterial vaginosis, 1.86% showed trichomoniasis. Gold standard was considered to be culture for candidiasis & trichomoniasis whereas for bacterial vaginosis it was Nugent's score. Conclusions: Vaginal discharge is of multiple yet specific etiologies hence simple and minimal tests like microscopy available in most laboratories (supported by culture wherever possible) would help in accurate diagnosis without over or under treatment of patient due to the empirical therapy. Syndromic management of STIs (WHO guidelines) should be used only in non-specific cases.
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Effectiveness and safety of oral acyclovir 1 g twice a day for 3 days in the management of genital herpes p. 46
Kaushal K Verma, Mahendra Sonune, Lalit Dar, Neetu Bhari, Banwari Lal Jangid
Context: Acyclovir is the most commonly used drug in genital herpes; however, with existing acyclovir regimens, the drug needs to be taken five times a day which is inconvenient for patients. Aims: The aim of the study was to evaluate the efficacy and safety of oral acyclovir 1 g twice a day for 3 days in genital herpes. Methods: The patients of genital herpes were treated with oral acyclovir 1 g twice a day for 3 days and followed up after day 3, 5, 7, and 10 to determine the response to therapy. The response was assessed by physicians' assessment of percentage healing of the ulcer and mean healing time as well as patients' assessment of improvement in the Visual Analog Scale (VAS). Results: Twenty-three patients of genital herpes were recruited of which 21 (91.3%) had recurrent episodes, whereas 2 (8.7%) patients had first episode. One patient was lost to follow-up and 22 were analyzed. Complete healing of ulcer was seen in 9 (40.9%), 17 (77.27%) and 20 (90.90%) patients after day 3, 5 and 7 following the treatment respectively, with a mean healing time of 4.91 ± 2.16 days. The mean healing time of recurrent disease was 4.67 ± 1.87 days. Complete improvement in VAS was seen in 9 (40.9%), 21 (95.45%) and 22 (100%) patients after day 3, 5 and 7 following the treatment respectively, with a mean time for complete improvement being 4.27 ± 1.16 days. There were no significant side effects of therapy. Conclusion: Acyclovir 1 g twice a day for 3 days is an effective treatment for genital herpes with advantages of comparable healing time and convenient dosage schedule.
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A randomized prospective study to assess health-related quality-of-life outcomes of antiretroviral therapy in human immunodeficiency virus-positive adults p. 50
Vikas Kumar, Jatinder Singh, Harpreet Singh
Introduction: Health-related quality of life (HRQOL) in human immunodeficiency virus (HIV)-positive individuals is substantially challenged due to disease, opportunistic infections, lifelong commitment, and tolerability to antiretroviral therapy (ART) and various social, physical, and psychological domains. Aim: This study was conducted to assess the magnitude of the impact on HRQOL in HIV-positive people from early access to ART. Settings and Design: This was a randomized, prospective, open-label study, conducted at the ART center attached to the Government Medical College, Amritsar. Subjects and Methods: This study comprised 240 HIV-infected adults in the age group >18 years who presented to the ART center. Approval from the Institutional Ethics Committee was obtained. Informed consent was taken from all the enrolled participants after explaining the study therapy and its benefits and side effects. Patients who presented early in their course of disease and had baseline CD4 count ≥350/mm3 were recruited in early arm and those with <350/mm3 or the development of symptomatic HIV-related disease in the late arm. Following stratification, both groups were 1:1 randomized by permuted block randomization. The primary objective was to assess HRQOL using the World Health Organization Quality of Life-HIV brief instrument (WHOQOL-HIV). Statistical Analysis Used: The summary domain and total HRQOL scores were calculated using method developed by the WHOQOL-HIV group. Unpaired t-test was applied for statistical analysis, with level of significance expressed as P < 0.05. Results: Out of the total 240 HIV-positive patients, 120 who met eligibility criteria were recruited for the final analysis. There was a significant difference between HRQOL score of Physical domains and Psychological domains, between early and late arms at baseline and at the end of 9 months. Conclusions: Quality of life is an important holistic measure for assessing the health of people living with HIV/AIDS.
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Clinicomycological study of vulvovaginal candidiasis p. 57
S Seeniammal, M Selvakumar, P Nirmaladevi
Background: Vaginal candidiasis is one of the most common vaginal infections in women of reproductive age group caused by Candida species of fungi, a normal inhabitant of vagina. Aims: The aim is to study the culture characteristics, species prevalence, and drug sensitivity of vulvovaginal candidiasis (VVC) among females with genital pruritus and discharge per vaginum who are proved to have Candida infection by a vaginal smear study. Materials and Methods: A prospective study was done on female patients aged 18 years attending the Sexually Transmitted Diseases Clinic of the Department of Dermato-Venereo-Leprology (DVL), Tirunelveli Medical College, with complaints of genital pruritus and vaginal discharge over a period of 1½ years from 2013 to 2015. After clinical examination, vaginal discharge was smeared for wet mount, potassium hydroxide mount, and Gram stain. Those with pseudohyphae were chosen for culture, speciation, and drug sensitivity. Results: The most common age group affected was 18–35 years. The most common predisposing factor was HIV infection-induced immunosuppression (48.7%), followed by antibiotic usage and diabetes mellitus. Clinical presentation of VVC was similar in HIV-positive and HIV-negative patients. Recurrent VVC makes up 12% of total cases with most common species being Candida albicans whereas Candida glabrata among the non-C. albicans. Drug sensitivity pattern of C. albicans showed the highest sensitivity to nystatin 85.7%, followed by triazoles (75%–85%) with ketoconazole being more resistant (40%–60%), and was similar in C. albicans and non-C. albicans. Limitations: Exclusion of unmarried and pregnant women and lack of follow-up were limitations in our study. Conclusions: According to our study, elimination of predisposing factors, speciation of fungus, and treatment based on drug sensitivity pattern will reduce the incidence of VVC.
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Assessment of self-reported adherence to ART and patient's virological/CD4 response in a tertiary care clinic and government free ART clinic p. 62
Rushin Patel, Amee Pandya, Ketan K Patel, Supriya Malhotra, Atul K Patel
Introduction: Treatment adherence to antiretroviral treatment (ART) is critical in reducing morbidity, mortality, and improving the survival in HIV patients. ART is a life-long commitment, and the variety of factors can influence treatment adherence. We studied the factors affecting treatment adherence in the private sector and public sector outdoor clinic in Ahmedabad, India. The primary objective of this study is to compare the level of adherence and factors that influence adherence to ART in patients attending government run free ART program and private setup. Methods: We conducted a cross-sectional study of 8 weeks among HIV-infected patients who were receiving ART from private clinic and free ART center from July 2019 to September 2019. We enrolled all consecutive patients >18 years of age attending both clinics. Statistical analysis was carried out using the SPSS software version 25.0. Multiple logistic regression was used to identify the factors that were independently associated with adherence to ART. Results: The study enrolled 306 patients, 151 (49.34%) from the outpatient department of private hospital, and 155 (50.65%) from the free ART center. Patients attending private clinics were more likely to have been diagnosed with HIV since ≥10 years compared to free ART center. Higher opportunistic infection rates were found in free ART center (64.51%). Treatment adherence was significantly lower in the patients attending free ART center (P = 0.004). Patients taking concomitant medications for other comorbid conditions (≥4 pills/day) were more likely to exhibit inadequate adherence ([odds ratio] 1.216, 95% confidence interval 1.0171–1.454). Univariate analysis showed that age, education, habits of alcohol, tobacco, number of pills, and duration of disease played a significant role in predicting adherence to ART (P < 0.05). Conclusions: Patients attending private clinic are surviving longer with HIV diagnosis, have fewer opportunistic infections, and have better treatment adherence compared to free ART clinic.
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Disseminated violaceous plaques in a HIV-1-positive patient from eastern India: A manifestation of Kaposi's sarcoma p. 69
Sumit Sen, Subhadeep Mallick, Somnath Das, Jyoti Das, Surabhi Sharma, Subhasmita Baisya
Kaposi's sarcoma (KS) is an angioproliferative disorder primarily of viral etiology, though multiple cofactors are also responsible. Human herpes virus-8, a gamma herpes virus, is considered to be the causative agent. Acquired immunodeficiency syndrome-associated KS has different clinical pictures than those seen in other types of KS. As it progresses rapidly, early institution of highly active antiretroviral therapy (HAART) after proper diagnosis is expected. Though HAART has reduced the prevalence of KS in HIV disease, HAART has not eliminated the disease. Here, we report a case who is HIV 1 and hepatitis B surface antigen positive with numerous violaceous plaques over the face, upper extremities, and trunk along with oral mucosal involvement. He had received ten sessions of electron beam radiotherapy on the face, and the facial lesions have healed with residual hyperpigmentation.
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Bipolar herpes simplex infection in an human immunodeficiency virus-infected individual p. 72
Sonia Raghukumar, CB Ravikumar
Herpes simplex infection is the most common infection among the human immunodeficiency virus-infected individuals. However, the atypical manifestations of herpes simplex virus may confound even an astute physician. Hand involvement is rarely associated with genital herpes infection and the involvement of widespread areas healing with debilitating scarring is uncommon.
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A congenital syphilitic child to an adequately treated syphilitic mother p. 75
R Suganthy Rajakumari, Sudha R Gopinath, Nithya Mohan, Durgadevi Sathyamoorthy, Sundararaj Sumithra
A mentally ill antenatal mother of 34 weeks gestation was diagnosed as a case of latent syphilis of unknown duration and was treated adequately with benzathine penicillin. One month after last dose of penicillin she delivered a male baby without any clinical or radiological evidence of syphilis, but reactive RPR in 1:64 dilution. Baby was treated as per CDC guidelines. It is also the gestational age at which the mother was treated decides the outcome in child in addition to stage of syphilis. These reported congenital syphilis cases necessitates early screening and adequate treatment of syphilis mainly in pregnancy.
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Multiple opportunistic central nervous system coinfections in HIV: Diagnostic and therapeutic difficulties p. 78
Mandira Chakraborty, Manoj Kumar Gupta, Sukalyan Saha Roy, Partha Pratim Chakraborty
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High-risk male teenager with concurrent gonorrhea and syphilis infection: An alarming call p. 79
Elangbam Nelson Singh, Taniya Mehta, Puneet Bhargava
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Moth-eaten alopecia as a sole manifestation of secondary syphilis in an adolescent: Role of a dermatologist p. 81
Sonal Sachan, Prakriti Shukla, Swastika Suvirya, Parul Verma, Usha Chandra
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Utility of a rapid point of care test for screening of syphilis among high-risk and low-risk population at a tertiary care hospital p. 83
Bineeta Kashyap, Rituparna Saha, Vikas Saini, Chander Grover, Narendra Pal Singh
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Synchronous primary and secondary syphilis – An uncommon presentation p. 85
P Arunprasath, Mahadevan Krishnaswamy, Reena Rai
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Highly Active Anti-Retroviral Therapy, Pre- Exposure Prophylaxis, and assisted reproductive techniques for the conception of a seronegative baby in HIV sero-discordant couples: A retrospective analysis p. 87
Raj Harjani, Ritika Harjani Hinduja
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