4 diet tips to help you fight endometriosis

4 diet tips to help you fight endometriosis

Endometriosis is a challenging condition to deal with. Chronic pain has a physical and emotional toll on your well-being.

One in 10 women are affected by endometriosis and many do not have a diagnosis for 7-12 years, as endometriosis’ symptoms are similar to other gynecological conditions. Many women with endometriosis remain undiagnosed.

Fortunately, there are steps that can be taken to help with the pain of endometriosis and improve your quality of life. Simple changes in you diet can make you feel better.

Eating the right foods may provide some protection against endometriosis. The role of diet in endometriosis has been investigated in recent years due to the influence of diet on some of the processes linked to the disease, such as inflammation, prostaglandin metabolism, and estrogen activity.

Eat more fresh fruits and vegetables and less red meat

Add more fresh fruits and vegetables in your diet. Stocking your refrigerator with pre-washed and cut fruit and vegetables can help you eat more of both.

Cut down red meat. Research has shown a link between endometriosis and diets that are low in fruits and vegetables and high in red meat.

Some experts think the high amount of fat in meat like beef encourages your body to produce chemicals called prostaglandins, which may lead to more estrogen production. This extra estrogen could be what causes excess endometrial tissue to grow.

A higher intake of fresh fruit and green vegetables reduced the relative risk of endometriosis by 40 percent, while a high consumption of beef, other red meat, and ham increased relative risk by around 80 to 100 percent.

Boost omega-3 fatty acids intake

Eat more foods high in omega-3 fatty acids like salmon, mackerel, flaxseeds

and walnuts. A study showed that women who ate the highest amount of omega-3 fatty acids were 22% less likely to develop endometriosis compared to women who ate the least amount.

Reduce trans fats

Eat less trans fats. Research has shown that women who ate the most trans fats had a 48% higher risk of developing endometriosis than those who ate the least, so the type of fat you eat matters.

Avoid alcohol and caffeine

Drinking caffeinated coffee and soda seems to increase your chances of developing endometriosis, although researchers aren’t sure why. If you find that caffeine worsens your symptoms, switch to decaf.

Women who drink a lot of alcohol may be more likely to get endometriosis. Drinking might also make your symptoms worse. Alcohol raises estrogen levels, which could lead to more painful symptoms.

Can endometriosis cause leg pain?

Can endometriosis cause leg pain?

By I.Soussis MD

Experts have only recently begun to recognize how widespread leg pain may be in women with endometriosis. Usually endometriosis patients experience extremely painful, heavy periods, pain after or during sexual activity (called dyspareunia) and pelvic pain. When endometriosis growths though impact the nerves surrounding the pelvis, they can cause pain in the legs, hips and buttocks.

As many as 50 percent of women with endometriosis may experience some form of leg pain, according to a 2016 study. 

Diagnosing endometriosis-related leg pain can be tricky because of a wide range of other medical conditions that are better understood and easier to diagnose can also cause leg pain.

During regular menstruation, the uterus lining sheds and leaves the body through the vagina. This happens in response to changing hormone levels. When endometrial tissue grows outside the uterus, the cells still shed, but they cannot leave the body, causing painful symptoms.

In some cases, endometrial tissues grow in and around the many nerves that travel through the pelvis and hip. Abnormal growths can put pressure on the pelvic nerves. This may cause pain and numbness in the hips, buttock, and legs. 

Nearly all of the documented cases of leg pain associated with endometriosis involve abnormal growths on the sciatic nerve or one of its branches.The sciatic nerve is considered the largest and longest nerve in the human body. It begins in the lower back, runs through the pelvis, and down the leg into the foot, branching into several smaller nerves along the way. Pressure on this nerve can cause pain in the lower body.

The sciatic nerve provides sensation to most of the lower portion of the body. Pressure on the sciatic nerve can, therefore, cause a lot of different symptoms, most commonly pain, numbness, and tingling that radiates into the following areas: 

  • outside of the leg
  • back of the thighs and calf
  • knee
  • sole, heel, and top of the foot 
  • hips 
  • buttock

Everyday tips for finding relief include:

  • gentle stretching focusing on the buttocks, thighs, calf, and feet muscles
  • gentle exercise, such as yoga, swimming, or walking can often help ease inflammation. 
  • counter pain medications and pain-relieving topical treatments on painful areas can ease inflammation and pain. 

Patients have seen good results when they eat:

  • fruits and vegetables rich in fiber and antioxidants (such as leafy green vegetables, berries, and citrus fruits).
  • lean meats and nuts that contain anti-inflammatory compounds, such as omega-3 (such as fish, walnuts, almonds, sesame seeds)

Also, when they avoid:

  • foods linked with inflammation (such as red meat, alcohol, heavily refined or preserved foods)

Drinking a lot of water also helps. Dehydration can intensify inflammation and pain throughout the whole body. Alternative therapies, such as acupuncture and massage therapy have proven to be effective for some endometriosis patients who experience leg pain.

Source: https://www.medicalnewstoday.com/articles/321457.php 


After endometriosis surgery chances of conception are high

After endometriosis surgery chances of conception are high

Women who have had surgery for deep infiltrating endometriosis and want to get pregnant have a reasonably high chance of conception, even after multiple failed in vitro fertilization (IVF) attempts, a new study suggests.

The study, “Pregnancy rates after surgical treatment of deep infiltrating endometriosis in infertile patients with at least 2 previous IVF / ICSI failures,” was published in the Journal of Minimally Invasive Gynecology.

Endometriosis can cause infertility, and there has been debate about how to manage this for people who want to get pregnant – specifically, whether it is better to try assisted reproductive techniques (eg IVF) before or after surgery.

In the new study, researchers looked at clinical data from the CIRENDO database, which records such data for people with endometriosis who are managed at one of several clinics in France.

The researchers specifically looked at patients younger than 43 who had undergone at least two previous IVF attempts, had endometriosis surgery, and stated a desire to become pregnant after surgery.

The researchers identified records for 73 patients matching these criteria and with at least one year’s worth of post-surgical data. Most of these patients had stage IV endometriosis; the average number of previous IVF attempts was 3.7.

At the time the data was available, 32 (43.8%) of the patients became pregnant, and 23 of these pregnancies had a live birth. The remaining pregnancies were ectopic (two), molar (one), or followed by an early miscarriage (six).

Of pregnancies, most occur after the introduction of medical assistance (eg IVF); seven of them (21.8%) occurred without additional medical intervention. The average time between surgery and conception was 11.1 months.

The researchers constructed statistical models in order to compare women who did get pregnant to those who did. They found three variables that were significantly associated with a lower likelihood of conception: having ovarian surgery, being 35 or older, and having a lower endometriosis stage.

Overall, this study shows a relatively high rate of pregnancies (and births) among women with endometriosis who have struggled with conception after undergoing surgery. This suggests that post-surgery pregnancy should be fully considered, even in cases that might seem to suggest otherwise.

The researchers said, “Many of our patients had four IVF procedures or were on the waiting list for oocyte donation and eventually had to undergo surgery to relieve their pain after giving up any hope of pregnancy. For these reasons, our results may encourage surgeons to do their best to maintain the uterus even in women who ‘have no hope of getting pregnant.’ ”

They concluded: “These encouraging results of experienced surgical teams working hand-in-hand with assisted reproductive techniques teams in multidisciplinary expert centers suggest that this is the way forward.”

Read more: https://www.jmig.org/article/S1553-4650%2819%2930413-3/fulltext

Source: www.endometriosisnews.com

OB-GYNs hesitate to talk about fertility

OB-GYNs hesitate to talk about fertility

Many OB-GYNs are uncomfortable counseling their patients on fertility at a time when more women are delaying pregnancy and needing their doctors to be more vigilant about this education, according to a new study.

“We found that most OB-GYNs don’t bring up fertility with every patient, often because they believe the patient would bring it up if she wanted to discuss it,” said Rashmi Kudesia, M.D., reproductive endocrinology and infertility specialist at Houston Methodist and CCRM Houston and lead author on the study, published in the Journal of Reproductive Medicine. “It’s a missed opportunity when OB-GYNs don’t start the conversation because many women are routinely exposed to conflicting information about fertility, leading many to believe that they’ll have no issues conceiving and delivering.”

In fact, 82% of OB-GYNs surveyed believe women receive mixed messages about their optimal fertility window, and 68% said women seem to believe they can indefinitely postpone making childbearing plans.

“It isn’t unusual for women to believe that assisted reproductive technologies like IVF are their safety net because they hear so many success stories,” Kudesia said. “The reality is that IVF only has a 5% success rate for women in their mid-40s.”

Kudesia and her co-authors found that OB-GYNs were more likely to provide fertility counseling to married women between the ages of 27-40. For all age groups, single and lesbian women were less likely to receive fertility counseling than married women. It was also found that the 117 physicians who participated provided more counseling on contraception than fertility in nearly all age and relationship status groups.

“The results tell me that regardless of current relationship status or future plans for pregnancy, women need to bring up fertility at their next well-woman exam or ask for a referral to a fertility specialist,” Kudesia said. “Women who want to wait several years and even those who think they don’t want kids at all should still talk to their doctor about fertility so that they can make an informed decision about what is best for them.”

Source: https://www.houstonmethodist.org/newsroom/research-shows-ob-gyns-hesitate-to-talk-about-fertility/

Read more: http://www.reproductivemedicine.com/toc/auto_abstract.php?id=24782

Vaping may harm fertility in young women

Vaping may harm fertility in young women

E-cigarette usage may impair fertility and pregnancy outcomes, according to a mouse study published in the Journal of the Endocrine Society.

Many young and pregnant women are using e-cigarettes as a safer alternative to smoking, but little is known about the effects on fertility and pregnancy outcomes.

E-cigarettes are driving increases in tobacco product use among youth. According to the Centers for Disease Control and Prevention, the number of middle and high school students using e-cigarettes rose from 2.1 million in 2017 to 3.6 million in 2018 — a difference of about 1.5 million youth.

“We found that e-cigarette usage prior to conception significantly delayed implantation of a fertilized embryo to the uterus, thus delaying and reducing fertility (in mice),” said the study’s corresponding author, Kathleen Caron, Ph.D., of University of North Carolina at Chapel Hill, N.C. “We also discovered that e-cigarette usage throughout pregnancy changed the long-term health and metabolism of female offspring — imparting lifelong, second-generation effects on the growing fetus.”

In this study, researchers used a mouse model to examine whether e-cigarette exposure impairs fertility and offspring health. After exposure to e-cigarette vapor, female mice showed decreased embryo implantation and a significant delay in the onset of pregnancy with the first litter. Female offspring exposed to e-cigarettes in utero also failed to gain as much weight as control mice by the 8.5-month mark.

“These findings are important because they change our views on the perceived safety of e-cigarettes as alternatives to traditional cigarettes before and during pregnancy,” Caron said.

Read more: https://academic.oup.com/jes/advance-article/doi/10.1210/js.2019-00216/5560172

Source: https://www.endocrine.org/news-room/2019/vaping-may-harm-fertility-in-young-women

Breastfeeding for cancer prevention

Breastfeeding for cancer prevention

One of the many benefits of breastfeeding is that it can lower a mother’s risk of some cancers.

Most people know there are many benefits to breastfeeding. We’ve probably all heard that it’s the best source of nutrition for most babies and provides many health benefits for infants.

The health benefits for women who breastfeed, however, are less commonly known. In addition to lowering a mother’s risk for type 2 diabetes and high blood pressure, breastfeeding can also lower a mother’s risk of breast and ovarian cancers.

A recent study found that only about 1 in 4 people think that a woman is less likely to develop breast cancer later in life if she breastfeeds. It’s important to know that breastfeeding helps not only the baby’s health but also the mother’s health too.

The American Academy of Pediatrics (AAP) recommends that infants be exclusively breastfed for about the first 6 months of life with continued breastfeeding after the introduction of solid foods for 1 year or longer.

Although most infants receive some breast milk, most are not exclusively breastfed or continue to breastfeed as long as recommended. Four out of 5 infants start out breastfeeding, but only 1 in 4 infants are still exclusively breastfed at 6 months.

Breastfeeding is important for overall health. Infants that are breastfed have a lower risk of asthma, obesity, ear and respiratory infections, sudden infant death syndrome, and gastrointestinal infections such as diarrhea.

One reason breastfeeding lowers the risk of cancer may be that when a woman is breastfeeding, she experiences hormonal changes that may delay the return of her menstrual periods. This reduces her lifetime exposure to hormones such as estrogen, which are linked to an increased risk of breast and ovarian cancers.

According to researchers a human milk complex of alpha-lactalbumin and oleic acid (HAMLET) induces apoptosis only in tumour cells, while normal differentiated cells are resistant to its effects, thus providing safe and effective protection against the development of breast cancer. The longer a mother breastfeeds and the more children she breastfeeds in her life, the higher the protection she gets. Breastfeeding for as few as 3 months is associated with reduced ovarian cancer risk. If the mother breastfeeds for at least 13 months, the risk of getting ovarian cancer is 63% lower.

Source: https://blogs.cdc.gov/cancer/2019/08/01/breastfeeding-for-cancer-prevention/




Individualised approach to ‘fertile windows’ could help couples understand when pregnancy is likely to occur

Individualised approach to ‘fertile windows’ could help couples understand when pregnancy is likely to occur

Only 13% of women having menstrual cycles that last 28 days, according to a new study led by UCL and Natural Cycles, a contraceptive app.

The study, published in Nature Digital Medicine is one of the biggest overviews of menstrual cycles to date and analysed data over 600,000 menstrual cycles and 124,648 women from Sweden, USA and the UK. It could help couples better understand when pregnancy is likely and unlikely to occur.

Researchers set out to investigate menstrual cycle characteristics and associations with age, BMI and body temperatures. The findings show an average cycle length is 29.3 days and only around 13% of cycles are 28 days in length. Across the study, 65% of women had cycles that lasted between 25 and 30 days.

The menstrual cycle begins and ends with menstrual bleeding and is divided by ovulation into two phases: the follicular and luteal phases. Researchers found the average follicular phase length was 16.9 days and the average luteal phase length was 12.4 days. The average cycle length decreased by 0.18 days and average follicular phase length decreased by 0.19 days per year of age from 25 to 45 years. The average variation of cycle length for obese women was 0.4 days or 14% higher. Cycle length variability was observed to a lesser extent in non-obese and underweight women.

Co-author, Professor Joyce Harper (UCL Institute for Women’s Health), said: “Our study is unique in analysing over half a million cycles and re-writing our understanding of the key stages. Traditionally studies have concentrated on women who have approximately 28 day cycles and these studies have formed our understanding of the menstrual cycle.

“For the first time our study shows that few women have the text book 28 day cycle, with some experiencing very short or very long cycles. We studied all women who used the app.

“We also demonstrate that ovulation does not occur consistently on day 14 and therefore it is important that women who wish to plan a pregnancy are having intercourse on their fertile days. In order to identify the fertile period, it is important to track other measures such as basal body temperature as cycle dates alone are not informative.”

Co-author, Dr Simon Rowland, Head of Medical Affairs at Natural Cycles, said: “Given the variations in cycle length and follicular phase length that we have described, especially for cycles outside the average range (25-30 days), an individualised approach to identify the fertile window should be adopted.

“Apps giving predictions of fertile days based solely on cycle dates could completely miss the fertile window and it is therefore unsurprising that several studies have shown that calendar apps are not accurate in identifying the fertile window.

“Besides the potential benefits to the individual, fertility awareness apps and the associated databases of fertility data provide a unique opportunity to examine a large number of menstrual cycles in order to improve understanding.”

Data was collected from women using the app between September 2016 and February 2019 aged 18 to 45 and had a BMI between 15 and 50 and had not been using hormonal contraception within the 12 months prior to registration. Users who stated at registration that they had a pre-existing medical condition (polycystic ovarian syndrome, hypothyroidism or endometriosis) or who had menopausal symptoms were excluded.

The authors note the main limitation of this study is that the study population is derived solely from users of the app who may not be representative of the wider population. In particular, only 8% of women in our study were obese compared to 15% of women in the general population.

Professor Harper added, “The widespread use of mobile phone apps for personal health monitoring is generating large amounts of data on the menstrual cycle. Provided that the real-world data can be validated against traditional clinical studies done in controlled settings, there is enormous potential to uncover new scientific discoveries.

“This is one of the largest ever analyses of menstrual cycle characteristics. These initial results only scratch the surface of what can be achieved. We hope to stimulate greater interest in this field of research for the benefit of public health.”

Read more: https://www.nature.com/articles/s41746-019-0152-7

Source: https://www.ucl.ac.uk/news/2019/aug/individualised-approach-fertile-windows-could-benefit-many-women

What is endo belly and why does it occur?

What is endo belly and why does it occur?

Severe bloating in women with endometriosis, also known as “endo belly” is often painful and uncomfortable and takes a toll on self-image.

Endo belly is a complex situation as endometriosis is a complex disease. Even a CT scan, cannot reveal the cause why it is happening. 

There are a few theories: 

  • Endometriosis causes adhesions that can reduce the mobility of the bowel. 
  • Endometriosis lesions can flare at different parts of the menstrual cycle, which can cause an immune response, which includes swelling.
  • The ectopic endometrial tissue growing on other organs, at the time of  menstruation is also bleeding internally, and the body gets inflamed. 
  • Endometriosis patients can be more sensitive in regards to how their intestines and gut process food. Endo belly could be a side effect of the intestines working overtime.

There is no proven explanation on what causes bloating with endometriosis, so there is no official cure for endo belly.

1. Make sure it is only endo belly

Several diseases and conditions are marked by severe swelling. Women with endo are more prone to Small Intestinal Bacterial Overgrowth (SIBO), which is often characterized by painful bloating, constipation, and painful bowel movements. Fibroids or cysts may also lead to bloating as well as Irritable Bowel Syndrom. 

2. Track food and water 

Log food and water intake. It helps you to identify patterns. Get advice from a dietitian/nutritionist about food that your body reacts to.

Nutritionists and wellness advocates recommend mindful eating, which includes sitting upright at the table for meals and undistracted consumption with thorough chewing. All of this helps support digestion and reduce bloating risk.

3. Check your gut 

Try an anti-inflammatory diet. The best way to find your version of this diet is to start with an elimination diet, slowly add things back in, and note when endo belly occurs. Eliminate those foods. Your dietitian can help you through this process.

The following are regularly recommended to endo patients: generally eliminate alcohol, gluten, dairy, eggs, soy, red meat, preservatives, artificial sugars, and caffeine. 

Women report positive experiences with the keto diet and low-carb diets, but also with natural remedies like drinking fresh celery juice first thing in the morning.  

There’s no one diet for endometriosis. You have to see what’s best for you and what you react to.

4. Check your hormones

Endometriosis comes with hormonal imbalance. Keeping blood sugar balanced will help support proper hormone balance. Make an appointment with an endocrinologist. Acupuncture may help balance hormones, it has been found to release norepinephrine and put us in a state of rest and digest, which is when our body can begin healing itself.

5. Workout 

Many women are afraid to workout when they are in pain, but exercising will actually decrease the pain over time, because it helps with the circulation of the blood, reduce stress, and maintain nutrient and oxygen flow to the whole body. Gentle twisting motions will aid in circulation and movement through the abdominal region and help with pain as well as bloating.

6. Get enough sleep

The body repairs itself during deep sleep. Sleep deprivation can cause hormonal and metabolic changes and increase pain and stress responses (and thus bloating), and women with endo often struggle with insomnia. Popular sleep inducing recommendations include lavender scents, blue light phone filters in the evenings, eliminating electronics after a certain time, and chamomile teas. 

7. Limit the stress

Stress fuels endometriosis and its symptoms, and endometriosis creates physical and mental stress, so the cycle needs to be slowed as much as possible. Breathing exercises, physical and emotional therapy, and exercise have been essential for many endo women.

Sources: https://www.endofound.org/endo-belly 



Image: https://www.instagram.com/p/Bfbd_88gkng/ 


Stinging nettle reduces size of lesions in rat model of endometriosis

Stinging nettle reduces size of lesions in rat model of endometriosis

Treatment with the aerial parts of the stinging nettle (Urtica dioica L.), a plant used in traditional medicine, reduced the size of endometrial lesions in a rat model of endometriosis,according to the results of a new study.

The study, “Bioactivity-guided isolation of flavonoids from Urtica dioica L. and their effect on endometriosis rat model,” were published in the Journal of Ethnopharmacology.

U. dioica L., commonly known as the stinging nettle, is a medicinal herb that has been used traditionally for centuries. U. dioica leaves and roots are used as a blood purifier, an emmenagogue (herbs that stimulate blood flow in the pelvic area and uterus), and a diuretic as well as to treat menstrual hemorrhage, rheumatism, and eczema.

Many studies have assessed the biological activity of U. dioica, reporting antioxidant, antidiabetic, antiviral, [liver protective], antimicrobial, diuretic, anti-inflammatory, anti-hyperlipidemic (lowers the levels of fatty molecules), [antiparasitic], analgesic, anti-arthritic, anti-cancer, hypotensive (lowers blood pressure), and immunomodulatory activities,” they added.

In this study, a team of investigators from the Gazi University in Turkey evaluated the effects of U. dioica in the treatment of endometriosis, using a rat model of disease.

They started by inducing endometriosis in the animals by injecting womb cells from female rat donors into the abdominal walls of other female rats. Then they collected plant extracts containing chemical compounds found on the aerial parts of U. dioica, using three different reagents: methanol, ethyl acetate, and n-hexane.

In addition, in an attempt to isolate the specific compounds that might have relevant clinical activity, they used a technique called chromatography to obtain four different fractions (A, B, C, and D), each containing chemical compounds of different “weights,” found on plant extracts that had been obtained using methanol.

To assess the activity and effects of the different types of extracts and fractions, they then treated animals who had developed endometriosis with the different compounds, all administered orally, once a day, for four weeks, at a dose of 100 mg/kg.

In addition, some animals were treated with buserelin acetate (sold under the brand name Suprefact by Sanofi) — a medication to treat endometriosis — to be used as reference controls.

Results showed that animals treated with methanol plant extracts and those treated with buserelin acetate had a significant reduction in the size of endometrial lesions, compared to rats that had been treated with carboxymethyl cellulose (CMC; controls).

In addition, treatment with methanol plant extracts and with buserelin acetate significantly reduced the levels of two inflammatory markers — tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) — and those of a molecule that controls blood vessel growth, called vascular endothelial growth factor (VEGF), found on the fluid surrounding the lesions.

Analysis of the different fractions that had been obtained from methanol plant extracts revealed fraction C was the most active, having practically the same effects as the original extract at reducing the size of endometrial lesions and the levels of disease activity markers.

A subsequent analysis showed that fraction C contained six different compounds, all belonging to a class of chemicals known as flavonoids: rutin, isoquercetin, kaempferol-3-O-rutinoside, isorhamnetin-3-O-rutinoside, kaempferol-3-O-glucoside and isorhamnetin-3-O-glucoside. Flavonoids are natural substances found in plants and are known for their anti-oxidative, anti-inflammatory and anti-cancer properties.

Flavonoids act as antioxidants, arrest the cell cycle and some of them have been shown to decrease cytokine expression and secretion release,” the researchers said. Cytokines are molecules that mediate and regulate immune and inflammatory responses.

Therefore, flavonoids as cytokine modulators can be effective in the regression of endometriosis,” they concluded.

Read more: https://www.sciencedirect.com/science/article/pii/S0378874118326138?via%3Dihub

After 40 weeks of pregnancy, risk of stillbirth rises

After 40 weeks of pregnancy, risk of stillbirth rises

When pregnancies last for 40 weeks or longer, there is a significant additional risk of stillbirth and neonatal death, according to the results of a large review of studies.

The meta-analysis also found that prolonging pregnancy beyond 40 weeks did not reduce the risk for death in the baby’s first month of life (neonatal mortality).

Prolongation of pregnancy at term is a known risk factor for stillbirth. Currently women are routinely offered induction of labour after 41 weeks gestation to avoid stillbirth. But 1 in 3 stillbirths will happen prior to this gestational age.

The review, published in PLOS Medicine, combined data from 13 studies of stillbirth and neonatal death involving more than 15 million pregnancies.

The researchers found that stillbirths steadily rose with gestational age, from 0.11 per thousand births at 37 weeks to 3.18 per thousand at 42 weeks.

In mothers who continued their pregnancy to 41 weeks, there was a 64% increase in the risk of stillbirth compared to those who delivered at 40 weeks, with 1 additional mother having a stillborn baby for every 1,449 women.

Women need to be aware that there is a small but increasing risk after 40 weeks of gestation,” said the senior author, Shakila Thangaratinam, a professor at Queen Mary University of London. “But induction is a medical procedure that some mothers won’t want. We have to give mothers the information that empowers them to make a decision. We want to promote joint decision making between mother and doctor.”

Read more: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002838


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