Presented by P.

Jeevananth (for award of BHMS

Degree)

Guided by – Prof. Dr. Kannan, BHMS, (Sivaraj

Homeopathic Medical College.
The gastro intestinal tract (GI tract) consists of the:

• mouth (oral cavity)

• Oesophagus
• Stomach
• Small Intestine
• Large Intestine
• Rectum
• Anus
• Ingestion of pathogens may cause many different infections
• They may be confined to the gastro intestinal tract or start
spreading from there
• A wide range of microbial pathogens is capable of infecting
the gastro intestinal tract
• They are acquired by faecal – oral route, from faecaly
contaminated foods, fluids and finger
• For an infection to occur
–Pathogen must be ingested in sufficient number
–Or posses attributes to elude the host defences of the gastro intestinal
tract
• Saliva acts to flush away microbes that have transiently
settled on the mucosa.
• Lysozyme in saliva destroys bacteria.
• Stomach acidity and proteolytic enzymes destroy or
degrade many infectious agents.
• Bile secreted by the gallbladder is inhibitory to the
growth of many bacteria.
• Normal peristalsis forces organisms to move along the
GI tract and to be excreted with fecal matter.
• The mucosal layer protects epithelial cells.
• Organisms in the stomach are usually transient, and their
populations are kept low (103 to 106/g of contents) by acidity.
• The intestinal micro flora is a complex ecosystem containing
over 400 bacterial species.
• Anaerobes(Bacteroides, anaerobic streptococci, and
clostridia) outnumber facultative anaerobes(E coli).
• The flora is sparse in the stomach and upper intestine, but
luxuriant in the lower bowel.
• Bacteria occur both in the lumen and attached to the mucosa,
but do not normally penetrate the bowel wall .

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• Intestinal bacteria are a crucial component of the
enterohepatic circulation. (Enzyme : ß-glucuronidase,
sulfatase, and various glycosidases,Metabolites : bilirubin,
bile acids, cholesterol, estrogens, and metabolites of vitamin
D. conjugated with glucouranic acid, sulfate, taurine &
glycine)
• Antibiotics that suppress the flora can alter the fecal excretion
and hence the blood levels of these compounds.
• The flora also plays a role in fiber digestion and synthesizes
certain vitamins(Vitamin K).
• The intestinal micro flora may prevent infection by interfering
with pathogens.
• Antimicrobial substances such as bacteriocins or short-chain
fatty acids, which inhibit the growth of alien microorganisms.
• Antibiotics that upset the balance of the normal flora can favor
both infection by exogenous pathogens and overgrowth by
endogenous pathogens(Clostridium difficile).
• If the bowel wall is breached, enteric bacteria can escape into
the peritoneum and cause peritonitis and abscesses.(The
intestinal wall can be perforated by trauma (knife wounds &
gunshot wounds), by disease (appendicitis, penetrating
intestinal cancers), or by surgical procedures.)
• Worldwide: 1 billion episodes; 3 million to 5 million deaths
annually in children
•US: 1 to 2 episodes per year in children younger than 5 years;
300 to 400 deaths per year
Etiology
•Bacteria:
- Common: Campylobacter jejuni, Shigella spp., Salmonella
spp., E. Coli
- Less common: Yersinia enterocolitica, Bacillus cereus,C.
Difficile
- Rare:Vibrio spp., Staphylococcus aureus, Clostridium
perfringens, shigelloides, Aeromonas hydrophila
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• Viruses:
-Rotavirus, calicivirus, astrovirus, enteric adenovirus (types
40 and 41)
• Immunocompromised hosts may be infected with
cytomegalovirus (CMV), herpes simplex virus (HSV),
Cryptosporidium ovale.
• Protozoans:
–Entamoeba hisolytica
–Giardia lamblia
–Cryptosporidium parvum

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• Several enterotoxin-producing bacteria cause diarrheal
diseases
• The diarrheal disease caused by Vibrio cholerae and
enterotoxigenic strains of E. coli has three main
characteristics.
–First, there is intestinal fluid loss that is related to the action of an
enterotoxin on the small bowel epithelial cells.
–Second, the organism itself does not invade the mucosal surface;
rather, it colonizes the upper small bowel, adhering to the epithelial
cells and elaborating the enterotoxin.
–Third, the fecal effluent is watery and often voluminous, so that the
diarrhea can result in clinical dehydration.
• Cholera is a potentially epidemic and life-
threatening secretory diarrhea
•
Characterized by numerous, voluminous watery
• stools, often accompanied by vomiting
Stool volume can exceed 1 L/h, with daily fecal
• outputs of 15 to 20 L if the patient is kept
hydrated.
Cholera flourishes in communities with inadequate
clean drinking water and sewage disposal

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 Structure and Classification of Antigenic Types

• Vibrios are Gram-negative, highly motile curved rods with a

single polar flagellum.
• They tolerate alkaline media that kill most intestinal
commensals, but they are sensitive to acid.
• Numerous free-living vibrios are known, some potentially
pathogenic.
• Until 1992, cholera was caused by only two serotypes, Inaba
(AC) and Ogawa (AB), and two biotypes, classical and El Tor,
of toxigenic O group 1 V. cholerae.
• In 1992, cholera caused by serogroup O139 emerged in
epidemic proportions in India and Bangladesh.

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• Vibrio Cholerae are sensitive to acid, and most die in the
stomach.
•
Surviving virulent organisms may adhere to and colonize the
small bowel, where they secrete the potent cholera enterotoxin
• (CT, also called “choleragen”).

This toxin binds to the plasma membrane of intestinal epithelial

cells and releases an enzymatically active subunit that causes
a rise in cyclic adenosine 51-monophosphate (cAMP)
production.
•
The resulting high intracellular cAMP level causes massive
secretion of electrolytes and water into the intestinal lumen.

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• Gastric acid, mucus secretion, and intestinal motility are the prime
nonspecific defenses against V cholerae.

• Breastfeeding in endemic areas is important in protecting infants from

disease.
•
Disease results in effective specific immunity, involving primarily
secretary IgA, as well as IgG antibodies, against vibrios.

Epidemiology
•
Cholera is endemic or epidemic in areas with poor sanitation; it occurs
sporadically or as limited outbreaks in developed countries.
Long-term convalescent carriers are rare.
•
• The diagnosis is suggested by strikingly severe, watery
diarrhea.
• For rapid diagnosis, a wet mount of liquid stool is examined
microscopically.
• Other methods are
–the slide agglutination test of colonies with specific antiserum
–fermentation tests (oxidase positive); and enrichment in peptone broth
followed by fluorescent antibody tests.
–More recently the polymerase chain reaction (PCR) and additional
genetically-based rapid techniques have been recommended for use in
specialized laboratories.
Clinical Manifestations
• Escherichia coli is a common member of the normal flora of
the large intestine.
• Depending on the virulence factors they possess, virulent
Escherichia coli strains cause either
–noninflammatory diarrhea (watery diarrhea or rice water stools)
–inflammatory diarrhea (dysentery with stools usually containing blood,
mucus, and leukocytes).
• These are Gram-negative bacilli of the family
Enterobacteriaceae.
• Three groups of E coli are associated with diarrheal
diseases.
• Strains producing enterotoxins are enterotoxigenic E coli
(ETEC).
–There are numerous types of enterotoxin.
–Some of these toxins are cytotoxic, damaging the mucosal cells,
–whereas others are merely cytotonic, inducing only the secretion of
water and electrolytes.
• A second group of E coli strains have invasion factors and
cause tissue destruction and inflammation resembling the
effects of Shigella(EIEC).
• A third group of serotypes, called enteropathogenic E coli
(EPEC), are associated with outbreaks of diarrhea in
newborn nurseries, but produce no recognizable toxins or
invasion factors.
Noninflammatory Diarrheas Caused by Enterotoxigenic
Escherichia Coli
Clinical Manifestations
–The diarrheal disease caused by ETEC is characterized by a rapid
onset of watery, non bloody diarrhea of considerable volume,
accompanied by little or no fever
–Other common symptoms are abdominal pain, malaise, nausea, and
vomiting.
–Diarrhea and other symptoms cease spontaneously after 24 to 72
hours.
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 – ETEC organisms are Gram-negative, short rods not visibly different
from E coli found in the normal flora of the human large intestine.
– Virulence-associated fimbriae are too small to be seen by light
microscopy.
– Escherichia coli serotypes are specific O-group/H-antigen
combinations.

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– Escherichia coli diarrheal disease is contracted orally by ingestion of
food or water contaminated with a pathogenic strain shed by an
infected person.
– The pathogenesis of ETEC diarrhea involves two steps: intestinal
colonization, followed by elaboration of diarrheagenic enterotoxin(s)
– ST is actually a family of toxic peptides ranging from 18 to 50 amino
acid residues in length.
– They can stimulate intestinal guanylate cyclase, the enzyme that
converts GTP to cGMP.
– Increased intracellular cGMP inhibits intestinal fluid uptake, resulting
in net fluid secretion.
– The E coli LTs are antigenic proteins whose mechanism of action is
similar to that of Vibrio cholerae enterotoxin.
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 – This activates the adenylate cyclase, which produces excess
intracellular cAMP, which leads to hypersecretion of water and
electrolytes into the bowel lumen.
Host Defenses
– As in any orally transmitted disease, the first line of defense against
ETEC diarrhea is gastric acidity.
– Other nonspecific defenses are small-intestinal motility and a large
population of normal flora in the large intestine.
– intestinal secretory immunoglobulin (IgA) directed against surface
antigens such as the CFAs and against LT appears to be the key to
immunity from ETEC diarrhea.
– Human breast milk also contains nonimmunoglobulin factors
(receptor-containing molecules) that can neutralize E coli toxins and
CFAs.
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 – ETEC diarrhea is characterized by copious watery diarrhea with little
or no fever.
– The diarrheal stool yields a virtually pure culture of E coli.
– Since the disease is self-limiting, virulence testing of isolates and
serotyping is impractical except in an outbreak situation.
– Confirmation is achieved by serotyping, serologic identification of a
specific CFA on isolates, demonstration of LT or ST production, and
identification of genes encoding these virulence factors
• Control
– Escherichia coli diarrheal disease is best controlled by preventing
transmission and by stressing the importance of breast-feeding of
infants,
– The best treatment is oral fluid and electrolyte replacement
(intravenous in severe cases).
• Clinical Manifestation
– Diarrhea caused by the enteroinvasive, cytotoxic, and
enteropathogenic (EPEC) strains of E coli ranges from very mild to
severe.
– Illness is usually protracted and accompanied by fever.
– Infection with a few serogroups (O157, O26) is characterized by
bloody diarrhea (hemorrhagic colitis).
– Infection with the Shigella-like serogroups presents as bacillary
dysentery are recognized as primary causative organisms.
•
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 – Escherichia Coli strains belonging to the classic EPEC serogroups
(Table 25-2) bind intimately to the epithelial surface of the intestine,
– The lesion caused by EPEC consists mainly of destruction of
microvilli.
– Cell damage occurs in two steps.
• collectively termed attaching
• second is loss of microvilli which is the result of rearrangement of the host
cell cytoskeleton.
– Loss of microvilli leads to malabsorption and osmotic diarrhea.
– Diarrhea is persistent, often chronic, and accompanied by fever.
– The E coli strains associated with hemorrhagic colitis
(enterohemorrhagic E coli, or EHEC) most notably O157:H7, produce
relatively large amounts of the bacteriophage-mediated Shiga-like
toxin.
– This toxin is called Vero toxin (VT), or Vero cytotoxin after its cytotoxic
effect on cultured Vero cells.
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 – The Shigella-like E coli strains are highly virulent;
– oral exposure to a very small number of these invasive bacteria
causes severe illness.
– The site of the infection is the colon, where adherence is rapidly
followed by invasion of the intestinal epithelial cells
– An acute inflammatory response and tissue destruction produce
diarrhea with little fluid, much blood, and sheets of mucus containing
polymorphonuclear cells.

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 – These defenses are frequently deficient or lacking in the infant and the
elderly, which is consistent with the epidemiology of EPEC illness.
– Infection with these pathogens often excites an inflammatory cell
response in the intestine, as is frequently reflected in the diarrheal
symptoms.
• Diagnosis
– Diagnosis is usually based on the symptomatology described above.
– Escherichia Coli serotyping is useful in chronic cases and in
outbreaks, because identification of the agent and its antibiotic
sensitivity pattern are valuable in these situations.
– Testing for specific EPEC virulence factors is usually impractical
because it can be done only in reference and specialized research
laboratories.
– Prevention and control are generally the same as for ETEC.
– Intervention of the fecal-oral transmission cycle is most effective in
institutional situations.
– Broad-spectrum antibiotics are recommended in chronic and/or life-
threatening cases.
• Clinical Manifestations
–Salmonellosis ranges clinically from the common Salmonella
gastroenteritis (diarrhea, abdominal cramps, and fever) to enteric
fevers (including typhoid fever)
–The most common form of salmonellosis is a self-limited,
uncomplicated gastroenteritis.
• Structure, Classification, and Antigenic Types
–Salmonella species are Gram-negative, flagellated facultatively
anaerobic bacilli characterized by O, H, and Vi antigens.,
–There are over 1800 known serovars which current classification
considers to be separate species.
– Both nonspecific and specific host defenses are active.
– Non-specific defenses consist of gastric acidity, intestinal mucus,
intestinal motility (peristalsis), lactoferrin, and lysozyme.
– Specific defenses consist of mucosal and systemic antibodies and
genetic resistance to invasion. Various factors affect susceptibility.
 – Salmonellosis should be considered in any acute diarrheal or febrile
illness without obvious cause.
– The diagnosis is confirmed by isolating the organisms from clinical
specimens (stool or blood).
• Control
– Salmonellae are difficult to eradicate from the environment.
– General salmonellosis treatment measures include replacing fluid loss
by oral and intravenous routes, and controlling pain, nausea, and
vomiting.
– Specific therapy consists of antibiotic administration.
• Clinical Manifestations
–Symptoms of shigellosis include abdominal pain, watery diarrhea, and/or
dysentery (multiple scanty, bloody, mucoid stools).
–Other signs may include abdominal tenderness, fever, vomiting,
dehydration, and convulsions.
• Structure, Classification, and Antigenic Types
–Shigellae are Gram-negative, nonmotile, facultatively anaerobic, non-
spore-forming rods.
–Shigella are differentiated from the closely related Escherichia coli on the
basis of pathogenicity, physiology (failure to ferment lactose or
decarboxylate lysine) and serology.
–The genus is divided into four serogroups with multiple serotypes: A (S
dysenteriae, 12 serotypes); B (S flexneri, 6 serotypes); C (S boydii, 18
serotypes); and D (S sonnei, 1 serotype).
 – Infection is initiated by ingestion of shigellae
– An early symptom, diarrhea (possibly elicited by enterotoxins and/or
cytotoxin), may occur as the organisms pass through the small
intestine.
– The hallmarks of shigellosis are bacterial invasion of the colonic
epithelium and inflammatory colitis.
– These are interdependent processes amplified by local release of
cytokines and by the infiltration of inflammatory elements.
• Host Defenses
– Inflammation, copious mucus secretion, and regeneration of the
damaged colonic epithelium limit the spread of colitis and promote
spontaneous recovery.
– The protective role of immune responses against the antigens is
unclear.
 – Shigellosis can be correctly diagnosed in most patients on the basis of
fresh blood in the stool.
– Neutrophils in fecal smears is also a strongly suggestive sign.
– Nonetheless, watery, mucoid diarrhea may be the only symptom of
many S sonnei infections, and any clinical diagnosis should be
confirmed by cultivation of the etiologic agent from stools.
• Control
– Prevention of fecal-oral transmission is the most effective control
strategy.
– Severe dysentery is treated with ampicillin, trimethoprim-
sulfamethoxazole, or, in patients over 17 years old, a 4-fluorquinolone
such as ciprofloxacin.
– Vaccines are not currently available, but some promising candidates
are being developed.
• Clinical Manifestations
–Campylobacter species cause acute gastroenteritis with diarrhea,
abdominal pain, fever, nausea, and vomiting.
• Structure
–Campylobacter species are Gram-negative, microaerophilic, non-
fermenting, motile rods with a single polar flagellum; they are oxidase-
positive and grow optimally at 37° or 42°C.
• Classification and Antigenic Types
–Campylobacter species have many serogroups, based on
lipopolysaccharide (O) and protein (H) antigens.
–C jejuni possesses several common surface-exposed antigens, including
porin protein and flagellin.
 – The bacteria colonize the small and large intestines, causing
inflammatory diarrhea with fever.
– Stools contain leukocytes and blood.
– The role of toxins in pathogenesis is unclear.
– C jejuni antigens that cross-react with one or more neural structures
may be responsible for triggering the Guillian-Barre syndrome.
• Host Defenses
– Nonspecific defenses such as gastric acidity and intestinal transit time
are important.
– Specific immunity, involving intestinal immunoglobulin (IgA) and
systemic antibodies, develops.
– Persons deficient in humoral immunity develop severe and prolonged
illnesses.
• Control
– Control depends on measures to prevent transmission from
animal reservoirs to humans.
• Vibrio parahaemolyticus and Yersinia enterocolitica are food
borne gram negative cause of diarrhea
• Clostridium perfringens and Bacillus cereus are spore
forming gram positive causes of diarrhea
Viral Diarrhea
• Over 3 million infants die of gastro entiritis each year, viruses
are the comenest causes
• Rota virus
• Replicating Rota virus cause diarrhea by damaging the
transport mechanism in the gut
• They can be seen in fecal particles under electron
microscope
 Clinical Manifestations
– Rotaviruses induce a clinical illness characterized by vomiting,
diarrhea, abdominal discomfort, fever, and dehydration
– It occurs primarily in infants and young children and may lead to
hospitalization for rehydration therapy
– Although milder gastroenteric illnesses that do not require
hospitalization are also common, most studies of clinical
manifestations of rotavirus-induced gastroenteritis rely on data from
hospitalized patients
– The duration of hospitalization ranges from 2 to 14 days with a mean
of 4 days
– The highest attack rate is usually among infants and young children 6
to 24 months old, and the next highest in infants less than 6 months
old
– Deaths from rotavirus gastroenteritis may occur from dehydration and
electrolyte imbalance.
 – Rotaviruses have a distinctive wheel-like shape
– Complete particles have a double-layered capsid and measure about
70 nm in diameter
– Within the inner capsid is the 37-nm core, which contains the RNA
genome
– Morphologically, rotaviruses resemble the reoviruses, coltiviruses and
orbiviruses
– The rotavirus genome contains 11 segments of double-stranded RNA
• Classification and Antigenic Types
– Most human rotaviruses share a common group antigen and are
designated group A rotaviruses,
– The non-group A viruses are divided into groups B, C, D, E, F, and G
on the basis of distinct group antigens
– The group A rotaviruses are the most important agents of severe
diarrhea in infants and young children and are prevalent worldwide.
 – The mechanism of immunity is not firmly established
– Serum antibody in volunteers was found to correlate with resistance to
rotavirus-induced illness
– Serotype-specific immunity may be of importance in protecting against illness
with individual serotypes, but this is still under investigation
• Diagnosis
– Because the clinical manifestations of rotavirus gastroenteritis are not distinct
enough to permit a specific diagnosis, specimens must be examined in the
laboratory
–
Laboratory diagnosis of rotavirus infections requires identifying the virus in feces
or rectal swab specimens
–
When the number of specimens is limited, the most rapid method of rotavirus
diagnosis in a hospital setting is by examination of a stool specimen by
negative-stain electron microscopy
–
Serologic evidence of rotavirus infection can be detected by various techniques,
such as ELISA immunofluorescence, neutralization, and complement fixation
– The primary aim of treatment of rotavirus gastroenteritis is the
replacement by the intravenous or oral route of fluids and electrolytes
lost by vomiting or diarrhea
– In patients with severe dehydration and shock, intravenous
rehydration is indicated for efficient replacement of fluid loss
– Virus-specific chemotherapy is not available
– An attenuated monovalent bovine rotavirus strain (serotype 6) or an
attenuated monovalent rhesus rotavirus strain (serotype 3) has been
administered orally to infants and young children as experimental
vaccines. Their efficacy has been variable
• Other viruses
• Other viruses causing damage includes
– calici viruses
– astro viruses
– adeno viruses
– parvo viruses
– and corona viruses
•

• Exotoxins produced causes botulism

–They are of three types food borne botulism, wound botulism and
infant botulism
–They cause flaccid paralysis leading to muscle weakness and
respiratory arrest
–Complete recovery may take months

• Five different entero toxins are produced by S.aureus

– Thier mechanism of action is not understood
– They affect the CNS and cause severe vomitting within 3-6 hrs
– Diarrhea is not a feature, recovered within 24 hrs
 Parasites and the Gastro Intestinal
tract
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• Three species are of particular importance
– Entamoeba hisolytica
– Giardia lamblia
– Cryptosporidium parvum

Entamoeba histolitica
–Common in subtropical and trophical countries
–Clinical manifestation vary from asymptomatic and severe diarrhea
–They can be diagonised by the presence of characteristic 4 nucleated
cysts
–They can be treated with Metronidazole

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 Pathogenesis of E histolytica infection.

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 Multiplication and life cycle of E histolytica.

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 – Preventive measures are limited to environmental and personal
hygiene
– Homeopathic drugs are essentially used to control the infection.
– The drug of choice is

– Calcarea Carbonica.

– Mercuris.

– Veratum album.

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 – It is the first intestinal microorganism to be viewed under the
microscope.

– Giardia infection may be asymptomatic or it may cause disease

ranging from a self-limiting diarrhea to a severe chronic syndrome.

– The length of the incubation period, usually 1 to 3 weeks, depends at

least partly on the number of cysts ingested.

– Signs and symptoms may include interference with the absorption of

fat and fat-soluble vitamins, retarded growth, weight loss, or a celiac-
disease-like syndrome

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 Giardia life cycle in humans

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 – Attention to personal hygiene is the key to preventing the spread of
giardiasis
– Controlling the spread of Giardia in drinking water should be possible
where community water treatment methods (e.g., disinfection and
filtration) are available
– The drug of choice for treating Giardia infections is quinacrine
hydrochloride
– This drug frequently causes dizziness, headache, and vomiting
– Metronidazole and furazolidone also may be used

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 • Is widely distributed in many animals Diarrhea
• ranges from moderate to severe
• Faecal examination is inadequate for
• identification Only immunocompromised patients
need treatment

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• The most important worms clinically known as nematodes
are
–Ascaris lumbricoides and Trichuiris trichura, in which the infection
occurs by swallowing the eggs
–Ancyclostoma duodenale and necator americanus, they infect by
active skin penetration by infective larvae
–The pinworm or threadworm Enterobius vermicularis is the
commenest intestinal nematodes and least pathogenic

• Other intestinal worms include

– Taenia saginata
– Hymenolipis nata
– Trichinella spiralis

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