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Sexually Transmitted Diseases (STDs)
 

 

Couple 2   Diseases & Related Conditions   STD Sym......................................
Bacterial Vaginosis Hepatitis (Viral)
Chlamydia infection Herpes (Genital)
Gonorrhea, Syphilis STDs & HIV/AIDS

Pelvic Inflammatory Disease (PID)

Human Papilloma Virus (HPV)

Trichomoniasis

Other STDs
Pregnancy & Infertility 
STDs and Pregnancy
STDs and Infertility

 

Bacterial Vaginosis

 
Bacterial Vaginosis (BV)

Bacterial vaginosis (BV) is the name of a condition in women where the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of certain bacteria.  It is sometimes accompanied by discharge, odor, pain, itching, or burning.

How common it is?

Bacterial vaginosis (BV) is the most common vaginal infection in women of childbearing age.  In the United States, BV is common in pregnant women.

How this happens?

The cause of BV is not fully understood. BV is associated with an imbalance in the bacteria that are normally found in a woman's vagina. The vagina normally contains mostly "good" bacteria, and fewer "harmful" bacteria. BV develops when there is an increase in harmful bacteria.

Not much is known about how women get BV. There are many unanswered questions about the role that harmful bacteria play in causing BV. Any woman can get BV. However, some activities or behaviors can upset the normal balance of bacteria in the vagina and put women at increased risk including: 

  • Having a new sex partner or multiple sex partners
  • Douching (a liquid that a woman squirts into her vagina, may be for hygiene)

It is not clear what role sexual activity plays in the development of BV. Women do not get BV from toilet seats, bedding, swimming pools, or from touching objects around them. Women who have never had sexual intercourse may also be affected.

Signs & symptoms of BV

Women with BV may have an abnormal vaginal discharge with an unpleasant odor. Some women report a strong fish-like odor, especially after intercourse. Discharge, if present, is usually white or gray; it can be thin. Women with BV may also have burning during urination or itching around the outside of the vagina, or both. However, most women with BV report no signs or symptoms at all. BV can increase a woman's susceptibility to other STDS such as HIV, Herpes, Chlamydia, and Gonorrhea.

Complication of BV

In most cases, BV causes no complications. But there are some serious risks from BV including:

  • Having BV can increase a woman's susceptibility to HIV infection if she is exposed to the HIV virus.
  • Having BV increases the chances that an HIV-infected woman can pass HIV to her sex partner.
  • Having BV has been associated with an increase in the development of an infection following surgical procedures such as a hysterectomy or an abortion.
  • Having BV while pregnant may put a woman at increased risk for some complications of pregnancy, such as preterm delivery.
  • BV can increase a woman's susceptibility to other STDs, such as herpes simplex virus (HSV), chlamydia, and gonorrhea.
BV in Pregnancy 

Pregnant women with BV more often have babies who are born premature or with low birth weight (low birth weight is less than 5.5 pounds).

The bacteria that cause BV can sometimes infect the uterus (womb) and fallopian tubes (tubes that carry eggs from the ovaries to the uterus). This type of infection is called pelvic inflammatory disease (PID). PID can cause infertility or damage the fallopian tubes enough to increase the future risk of ectopic pregnancy and infertility. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube which can rupture.
Diagnosis/Detection

A health care provider must examine the vagina for signs of BV and perform laboratory tests on a sample of vaginal fluid to look for bacteria associated with BV.

Treatment of BV

Although BV will sometimes clear up without treatment, all women with symptoms of BV should be treated to avoid complications. Male partners generally do not need to be treated. However, BV may spread between female sex partners.

Treatment is especially important for pregnant women. All pregnant women who have ever had a premature delivery or low birth weight baby should be considered for a BV examination, regardless of symptoms, and should be treated if they have BV. All pregnant women who have symptoms of BV should be checked and treated.

Some physicians recommend that all women undergoing a hysterectomy or abortion be treated for BV prior to the procedure, regardless of symptoms, to reduce their risk of developing an infection.

BV is treatable with antibiotics prescribed by a health care provider. Two different antibiotics are recommended as treatment for BV: metronidazole or clindamycin. Either can be used with non-pregnant or pregnant women, but the recommended dosages differ. Women with BV who are HIV-positive should receive the same treatment as those who are HIV-negative.

BV can recur after treatment.

Prevention of BV

BV is not completely understood by scientists, and the best ways to prevent it are unknown. However, it is known that BV is associated with having a new sex partner or having multiple sex partners.

The following basic prevention steps can help reduce the risk of upsetting the natural balance of bacteria in the vagina and developing BV:

  • Be abstinent.
  • Limit the number of sex partners.
  • Do not douche.
  • Use all of the medicine prescribed for treatment of BV, even if the signs and symptoms go away.
 

Gonorrhea

 
Gonorrhea

Gonorrhea is a sexually transmitted infection commonly manifested by urethritis, cervicitis, proctitis, salpingitis, or pharyngitis. Infection may be asymptomatic.

This is caused by a bacterium and can grow easily in the warm, moist areas of the reproductive tract, including the cervix (opening to the womb), uterus (womb), and fallopian tubes (egg canals) in women, and in the urethra (urine canal) in women and men. The bacterium can also grow in the mouth, throat, eyes, and anus.

How common it is? 

Gonorrhea is a very common infectious disease. CDC* estimates that, annually, 820,000 people in the United States get new gonorrhea infections and less than half of these infections are detected and reported to CDC. CDC estimates that 570,000 of them were among young people 15-24 years of age. In 2011, 321,849 cases of gonorrhea were reported to CDC.

Any sexually active person can be infected with gonorrhea. It is a very common STD. In the United States, the highest reported rates of infection are among sexually active teenagers, young adults, and African Americans.

How it happens?

People get gonorrhea by having sex with someone who has the disease. 'Having sex' means anal, vaginal, or oral sex. Gonorrhea can still be transmitted via fluids even if a man does not ejaculate. Gonorrhea can also be spread from an untreated mother to her baby during childbirth.

People who have had gonorrhea and have been treated may get infected again if they have sexual contact with a person infected with gonorrhea.

Symptoms of Gonorrhea

Some men with gonorrhea may have no symptoms at all. However, common symptoms in men include a burning sensation when urinating, or a white, yellow, or green discharge from the penis that usually appears 1 to 14 days after infection. Sometimes men with gonorrhea get painful or swollen testicles.

Most women with gonorrhea do not have any symptoms. Even when a woman has symptoms, they are often mild and can be mistaken for a bladder or vaginal infection. The initial symptoms in women can include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods. Women with gonorrhea are at risk of developing serious complications from the infection, even if symptoms are not present or are mild.

Symptoms of rectal infection in both men and women may include discharge, anal itching, soreness, bleeding, or painful bowel movements. Rectal infections may also cause no symptoms. Infections in the throat may cause a sore throat, but usually cause no symptoms.

Complication of Gonorrhea

Untreated gonorrhea can cause serious and permanent health problems in both women and men.

In women, gonorrhea can spread into the uterus (womb) or fallopian tubes (egg canals) and cause pelvic inflammatory disease (PID). The symptoms may be mild or can be very severe and can include abdominal pain and fever. PID can lead to internal abscesses (pus-filled pockets that are hard to cure) and chronic (long-lasting) pelvic pain. PID can damage the fallopian tubes enough that a woman will be unable to have children. It also can increase her risk of ectopic pregnancy. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube.

In men, gonorrhea can cause a painful condition called epididymitis in the tubes attached to the testicles. In rare cases, this may prevent a man from being able to father children.

If not treated, gonorrhea can also spread to the blood or joints. This condition can be life-threatening.

Gonorrhea & HIV

Untreated gonorrhea can increase a person's risk of acquiring or transmitting HIV-the virus that causes AIDS.

Gonorrhea  in Pregnancy

If a pregnant woman has gonorrhea, she may give the infection to her baby as the baby passes through the birth canal during delivery. This can cause serious health problems for the baby. Treating gonorrhea as soon as it is detected in pregnant women will make these health outcomes less likely. Pregnant women should consult a health care provider for appropriate examination, testing, and treatment, as necessary.

Who is at risk?

Any sexually active person can be infected with gonorrhea. Anyone with genital symptoms such as discharge, burning during urination, unusual sores, or rash should stop having sex and see a health care provider immediately.

Also, anyone with an oral, anal, or vaginal sex partner who has been recently diagnosed with an STD should see a health care provider for evaluation.

Some people should be tested for gonorrhea even if they do not have symptoms or know of a sex partner who has gonorrhea. Anyone who is sexually active should discuss his or her risk factors with a health care provider and ask whether he or she should be tested for gonorrhea or other STDs.

People who have gonorrhea should also be tested for other STDs.

Diagnosis/Detection
  • Observation of gram-negative intracellular diplococci in a urethral smear obtained from a male or an endocervical smear obtained from a female, or 
  • Isolation of typical gram-negative, oxidase-positive diplococci by culture (presumptive Neisseria gonorrhoeae) from a clinical specimen, or 
  • Demonstration of N. gonorrhoeae in a clinical specimen by detection of antigen or nucleic acid.

Most of the time, a urine test can be used to test for gonorrhea. However, if a person has had oral and/or anal sex, swabs may be used to collect samples from the throat and/or rectum. In some cases, a swab may be used to collect a sample from a man's urethra (urine canal) or a woman's cervix (opening to the womb).

Case Classification

Probable: demonstration of gram-negative intracellular diplococci in a urethral smear obtained from a male or an endocervical smear obtained from a female. 
Confirmed: a person with laboratory isolation of typical gram-negative, oxidase-positive diplococci by culture (presumptive Neisseria gonorrhoeae) from a clinical specimen, or demonstration of N. gonorrhoeae in a clinical specimen by detection of antigen or detection of nucleic acid via nucleic acid amplification (e.g., PCR) or hybridization with a nucleic acid probe.

Treatment option

Gonorrhea can be cured with the right treatment. It is important to take all of the medication prescribed to cure gonorrhea. Medication for gonorrhea should not be shared with anyone. Although medication will stop the infection, it will not repair any permanent damage done by the disease. Drug-resistant strains of gonorrhea are increasing, and successful treatment of gonorrhea is becoming more difficult. If a person's symptoms continue for more than a few days after receiving treatment, he or she should return to a health care provider to be reevaluated.

If a person has been diagnosed and treated for gonorrhea, he or she should tell all recent anal, vaginal, or oral sex partners so they can see a health care provider and be treated. This will reduce the risk that the sex partners will develop serious complications from gonorrhea and will also reduce the person's risk of becoming re-infected. A person with gonorrhea and all of his or her sex partners must avoid having sex until they have completed their treatment for gonorrhea and until they no longer have symptoms.

Prevention of Gonorrhea

Latex condoms, when used consistently and correctly, can reduce the risk of getting or giving gonorrhea. The most certain way to avoid gonorrhea is to not have sex or to be in a long-term, mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

 

Syphilis

 
What is Syphilis?

Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. Syphilis can cause long-term complications and/or death if not adequately treated.

How common it is?

CDC estimates that, in 2013 there were 56,471 reported cases of syphilis in the United States, including 17,535 cases of primary and secondary (P&S) syphilis. In 2013, half of all P&S syphilis cases were reported from 29 counties and 2 cities. The incidence of P&S syphilis was highest in women 20 to 24 years of age and in men 20 to 29 years of age. Reported cases of congenital syphilis in newborns increased from 2012 to 2013, with 322 new cases reported in 2012 compared to 350 cases in 2013.Between 2012 and 2013, the number of reported P&S syphilis cases increased 10.9 percent.In 2013, 75% of the reported P&S syphilis cases were among men who have sex with men (MSM).

While the rate of congenital syphilis (syphilis passed from pregnant women to their babies) has decreased in recent years,3 more cases of congenital syphilis are reported in the United States than cases of perinatal HIV infection. During 2011, 360 cases of congenital syphilis were reported, compared to an estimated 162 cases of perinatal HIV infection during 2010. 5 Congenital syphilis rates were 15.0 times and 3.5 times higher among infants born to black and Hispanic mothers (33.0 and 7.6 cases per 100,000 live births, respectively) compared to white mothers (2.2 cases per 100,000 live births).6

 

How this happens?

Syphilis is transmitted from person to person by direct contact with a syphilitic sore, known as a chancre. Chancres occur mainly on the external genitals, vagina, anus, or in the rectum. Chancres also can occur on the lips and in the mouth. Transmission of syphilis occurs during vaginal, anal, or oral sex. Pregnant women with the disease can transmit it to their unborn child.

Signs & symptoms of Syphilis

Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late complications if they are not treated. Although transmission occurs from persons with sores who are in the primary or secondary stage, many of these sores are unrecognized. Thus, transmission may occur from persons who are unaware of their infection. However, syphilis typically follows a progression of stages that can last for weeks, months, or even years:

Primary Stage

The appearance of a single chancre marks the primary (first) stage of syphilis symptoms, but there may be multiple sores. The chancre is usually firm, round, and painless. It appears at the location where syphilis entered the body. Possibly because these painless chancres can occur in locations that make them difficult to find (e.g., the vagina or anus), smaller proportions of MSM and women are diagnosed in primary stage than men having sex with women only. 3 The chancre lasts 3 to 6 weeks and heals regardless of whether a person is treated or not. However, if the infected person does not receive adequate treatment, the infection progresses to the secondary stage.

Secondary Stage

Skin rashes and/or mucous membrane lesions (sores in the mouth, vagina, or anus) mark the second stage of symptoms. This stage typically starts with the development of a rash on one or more areas of the body. Rashes associated with secondary syphilis can appear when the primary chancre is healing or several weeks after the chancre has healed. The rash usually does not cause itching. The characteristic rash of secondary syphilis may appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet. However, rashes with a different appearance may occur on other parts of the body, sometimes resembling rashes caused by other diseases. Sometimes rashes associated with secondary syphilis are so faint that they are not noticed. Large, raised, gray or white lesions, known as condyloma lata, may develop in warm, moist areas such as the mouth, underarm or groin region. In addition to rashes, symptoms of secondary syphilis may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The symptoms of secondary syphilis will go away with or without treatment, but without treatment, the infection will progress to the latent and possibly late stages of disease.

Latent and Late Stages

The latent (hidden) stage of syphilis begins when primary and secondary symptoms disappear. Without treatment, the infected person will continue to have syphilis infection in their body even though there are no signs or symptoms. Early latent syphilis is latent syphilis where infection occurred within the past 12 months. Late latent syphilis is latent syphilis where infection occurred more than 12 months ago. Latent syphilis can last for years.

The late stages of syphilis can develop in about 15% of people who have not been treated for syphilis, and can appear 10-20 years after infection was first acquired. In the late stages of syphilis, the disease may damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. This damage may be serious enough to cause death.

Neurosyphilis

Syphilis can invade the nervous system at any stage of infection, and causes a wide range of symptoms varying from no symptoms at all, to headache, altered behavior, and movement problems that look like Parkinson's or Huntington's disease.7 This invasion of the nervous system is called 'neurosyphilis.'

Note: Health departments report syphilis by its stage of infection, noting 'neurological manifestations,' rather than using the term neurosyphilis.3

Syphilis & HIV

Individuals who are HIV-positive can develop symptoms very different from the symptoms described above, including hypopigmented skin rashes. 8 HIV can also increase the chances of developing syphilis with neurological involvement.9

Genital sores caused by syphilis make it easier to transmit and acquire HIV infection sexually. There is an estimated 2- to 5-fold increased risk of acquiring HIV if exposed to that infection when syphilis is present.13

Ulcerative STDs that cause sores, ulcers, or breaks in the skin or mucous membranes, such as syphilis, disrupt barriers that provide protection against infections. The genital ulcers caused by syphilis can bleed easily, and when they come into contact with oral and rectal mucosa during sex, increase the infectiousness of and susceptibility to HIV. Studies have observed that infection with syphilis was associated with subsequent HIV infection among MSM.14,15

Having other STDs can also indicate increased risk for becoming HIV infected.14

Syphilis in Pregnancy 

The syphilis bacterium can infect the baby of a woman during her pregnancy. All pregnant women should be tested for syphilis at the first prenatal visit. The syphilis screening test should be repeated during the third trimester (28 to 32 weeks gestation) and at delivery in women who are at high risk for syphilis, live in areas of high syphilis morbidity, are previously untested, or had a positive screening test in the first trimester.10

Depending on how long a pregnant woman has been infected, she may have a high risk of having a stillbirth (a baby born dead) or of giving birth to a baby who dies shortly after birth; untreated syphilis in pregnant women results in infant death in up to 40 percent of cases. 6 Any woman who delivers a stillborn infant after 20 week's gestation should also be tested for syphilis.

An infected baby born alive may not have any signs or symptoms of disease. However, if not treated immediately, the baby may develop serious problems within a few weeks. Untreated babies may become developmentally delayed, have seizures, or die. All babies born to mothers who test positive for syphilis during pregnancy should be screened for syphilis and examined thoroughly for evidence of congenital syphilis.10

For pregnant women only penicillin therapy can be used to treat syphilis and prevent passing the disease to her baby; treatment with penicillin is extremely effective (success rate of 98%) in preventing mother-to-child transmission.11 Pregnant women who are allergic to penicillin should be referred to a specialist for desensitization to penicillin.

Diagnosis of Syphilis

The definitive method for diagnosing syphilis is visualizing the spirochete via darkfield microscopy. This technique is rarely performed today because it is a technologically difficult method. Diagnoses are thus more commonly made using blood tests. There are two types of blood tests available for syphilis: 1) nontreponemal tests and 2) treponemal tests.

Nontreponemal tests (e.g., VDRL and RPR) are simple, inexpensive, and are often used for screening. However, they are not specific for syphilis, can produce false-positive results, and, by themselves, are insufficient for diagnosis. VDRL and RPR should each have their antibody titer results reported quantitatively.  Persons with a reactive nontreponemal test should receive a treponemal test to confirm a syphilis diagnosis. This sequence of testing (nontreponemal, then treponemal test) is considered the 'classical' testing algorithm.

Treponemal tests (e.g., FTA-ABS, TP-PA, various EIAs, and chemiluminescence immunoassays) detect antibodies that are specific for syphilis. Treponemal antibodies appear earlier than nontreponemal antibodies and usually remain detectable for life, even after successful treatment. If a treponemal test is used for screening and the results are positive, a nontreponemal test with titer should be performed to confirm diagnosis and guide patient management decisions. Based on the results, further treponemal testing may be indicated. For further guidance, please refer to the 2010 STD Treatment Guidelines.10 This sequence of testing (treponemal, then nontreponemal, test) is considered the 'reverse' sequence testing algorithm.Reverse sequence testing can be more convenient for laboratories, but its clinical interpretation is problematic, as this testing sequence can identify individuals not previously described (e.g., treponemal test positive, nontreponemal test negative), making optimal management choices difficult.12

Special note: Because untreated syphilis in a pregnant woman can infect and possibly kill her developing baby, every pregnant woman should have a blood test for syphilis. All women should be screened at their first prenatal visit. For patients who belong to communities and populations with high prevalence of syphilis and for patients at high risk, blood tests should also be performed during the third trimester (at 28-32 weeks) and at delivery. For further information on screening guidelines, please refer to the 2010 STD Treatment Guidelines.10

All infants born to mothers who have reactive nontreponemal and treponemal test results should be evaluated for congenital syphilis. A quantitative nontreponemal test should be performed on infant serum and, if reactive, the infant should be examined thoroughly for evidence of congenital syphilis. Suspicious lesions, body fluids, or tissues (e.g., umbilical cord, placenta) should be examined by darkfield microscopy and/or special stains. Other recommended evaluations may include analysis of cerebrospinal fluid by VDRL, cell count and protein, CBC with differential and platelet count, and long-bone radiographs. For further guidance on evaluation of infants for congenital syphilis, please refer to the 2010 STD Treatment Guidelines.10

Treatment of Syphilis

There are no home remedies or over-the-counter drugs that will cure syphilis, but syphilis is easy to cure in its early stages. A single intramuscular injection of long acting Benzathine penicillin G (2.4 million units administered intramuscularly) will cure a person who has primary, secondary or early latent syphilis. Three doses of long acting Benzathine penicillin G (2.4 million units administered intramuscularly) at weekly intervals is recommended for individuals with late latent syphilis or latent syphilis of unknown duration. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.

Selection of the appropriate penicillin preparation is important to properly treat and cure syphilis. Combinations of some penicillin preparations (e.g., Bicillin C-R, a combination of benzathine penicillin and procaine penicillin) are not appropriate treatments for syphilis, as these combinations provide inadequate doses of penicillin.16

Although data to support the use of alternatives to penicillin is limited, options for non-pregnant patients who are allergic to penicillin may include doxycycline, tetracycline, and for neurosyphilis, potentially probenecid. These therapies should be used only in conjunction with close clinical and laboratory follow-up to ensure appropriate serological response and cure.10

Persons who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed. Persons with syphilis must notify their sex partners so that they also can be tested and receive treatment if necessary.

Who are at risk?

Any person with signs or symptoms of primary infection, secondary infection, neurologic infection, or tertiary infection should be tested for syphilis.

Providers should routinely test persons who,

  • are pregnant;
  • are members of an at-risk subpopulation (i.e., persons in correctional facilities and MSM);
  • describe sexual behaviors that put them at risk for STDs (i.e., having unprotected vaginal, anal, or oral sexual contact; having multiple sexual partners; using drugs and alcohol, and engaging in commercial or coerced sex);
  • have partner(s) who have tested positive for syphilis;
  • are sexually active and live in areas with high syphilis morbidity.

Does Syphilis recur?

Syphilis does not recur. However, having syphilis once does not protect a person from becoming infected again. Even following successful treatment, people can be re-infected. Patients with signs or symptoms that persist or recur or who have a sustained fourfold increase in nontreponemal test titer probably failed treatment or were reinfected. These patients should be retreated.

Because chancres can be hidden in the vagina, rectum, or mouth, it may not be obvious that a sex partner has syphilis. Unless a person knows that their sex partners have been tested and treated, they may be at risk of being reinfected by an untreated partner. For further details on the management of sex partners, refer to the 2010 STD Treatment Guidelines.10

Prevention of Syphilis

Correct and consistent use of latex condoms can reduce the risk of syphilis only when the infected area or site of potential exposure is protected. However, a syphilis sore outside of the area covered by a latex condom can still allow transmission, so caution should be exercised even when using a condom. For persons who have latex allergies, synthetic non-latex condoms can be used but it is important to note that they have higher breakage rates than latex condoms.17 Natural membrane condoms are not recommended for STD prevention. 18 Other individual-based interventions, such as the use of microbicide or male circumcision, do not prevent syphilis.19

The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Partner-based interventions include partner notification - a critical component in preventing the spread of syphilis. Sexual partners of infected patients should be considered at risk and provided treatment per the 2010 STD Treatment Guidelines.10

Transmission of an STD, including syphilis, cannot be prevented by washing the genitals, urinating, and/or douching after sex. Any unusual discharge, sore, or rash, particularly in the groin area, should be a signal to refrain from having sex and to see a doctor immediately.

Avoiding alcohol and drug use may also help prevent transmission of syphilis because these activities may lead to risky sexual behavior. It is important that sex partners talk to each other about their HIV status and history of other STDs so that preventive action can be taken.

Reference

1. Peterman, T.A., et al., The changing epidemiology of syphilis. Sex Transm Dis, 2005. 32(10 Suppl): p. S4-10.

2.            Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2002 Atlanta, GA: U.S. Department of Health and Human Services, 2003.

 

 

 

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