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UNIVERSITY OF SANTO TOMAS

FACULTY OF PHARMACY
DEPARTMENT OF MEDICAL TECHNOLOGY
Principles and Strategies of Teaching in Health Education

NAME Decapia, Alessandra Caranina N.


COURSE/YEAR/SECTION 2A-MT

GROUP NUMBER Group 6

COURSE/SUBJECT Parasitology

TOPIC Entamoeba coli and Entamoeba histolytica

OBJECTIVES:

Topic: Parasitology (Entamoeba coli and Entamoeba histolytica)


COGNITIVE a. To provide a sufficient background knowledge about parasites for one to
OBJECTIVE be able to recognize and identify them particularly Amoebas and its species
Entamoeba coli and Entamoeba histolytica
b. To enable the students to understand better and differentiate Entamoeba
coli and Entamoeba histolytica from each other
c. To give essential information about Entamoeba coli and Entamoeba
histolytica for one to assess and evaluate the diseases they can cause
AFFECTIVE a. To enable the students to be aware and accept the conditions presented
OBJECTIVE by the amoebas Entamoeba coli and Entamoeba histolytica
b. To provide a learning environment where the teacher and the students
can both cooperate and participate in the discussion regarding parasites
particulary Entamoeba coli and Entamoeba histolytica
PSYCHOMOTOR a. To allow the students to apply the knowledge about the diagnosis of the
OBJECTIVE diseases caused by Entamoeba coli and Entamoeba histolytica
b. To demonstrate the treatment and prevention of the diseases caused by
Entamoeba coli and Entamoeba histolytica and consequently, allow the
students to do the proper action promptly during critical cases
UNIVERSITY OF SANTO TOMAS
FACULTY OF PHARMACY
DEPARTMENT OF MEDICAL TECHNOLOGY
Principles and Strategies of Teaching in Health Education

NAME Decapia, Alessandra Caranina N.


COURSE/YEAR/SECTION 2A-MT

GROUP NUMBER Group 6

COURSE/SUBJECT Parasitology

TOPIC Entamoeba coli and Entamoeba histolytica

I. OVERVIEW AND DEFINITION

A. Amebas
Amebas are animated bits of naked protoplasm, familiar to every freshman biology
student who peers through a microscope with appropriate marvelings at the
simplicity of animal life in its most primitive state. The vast majorities are free-living
animals inhabiting soil, water, and decaying organic matter everywhere, and play an
important role in the control of bacteria in some of these situations. In view of their
wide adaptability and the frequent contamination of food or drinking water by their
cysts, it is not surprising that some species of them have adapted themselves to
living out the active phase of their lives in the intestines of animals. The majority
even of these are harmless commensals, content to use the intestine as a haven of
refuge where food is abundant and enemies scarce, but a few have developed a
taste for live meat, and have taken to feeding upon the wall of the intestine that
shelters them.

The amebas belong to the subphylum Sarcodina, class Rhizopodea, and order
Amoebida. The members of this order are characterized by having lobelike
pseudopodia and no tests or shells.
B. Entamoeba species

Entamoeba species possess a vesicular nucleus that has a small endosome at or


near the center. Chromatin granules are arranged around the periphery of the
nucleus, and in some species, also around the endosome. The cytoplasm contains a
variety of food vacuoles, often with particles of food being digested, usually bacteria
or starch grains. On the ultrastructural level, the outer membrane possesses a “fuzzy
coat”, and the cytoplasm contains numerous vesicles, sometimes considered
exocytotic because of their accumulation at the uroid (temporary posterior end).
Golgi bodies and mitochondria are evidently absent. Curious, small helical bodies
bodies can be seen widely distributed in the cytoplasm of some trophozites. These
bodies are 0.3 µm to 1.0 µm in length, contain up to 40 distinct ribonucleoproteins,
and following encystment become crystallized into chromatoid bodies or bars that
stain darkly with basic dyes. Chromatoidal bars may be blunt rods or splinter shaped,
according to species, and in some species they are noticeable only in young cyst. As
cyst ages, the bars evidently are disassembled and disappear. Differentiation
between the Entamoeba species is based on a number of factors and
characteristics. Size, number of nuclei and the general morphology of the nuclei i.e.
peripheral chromatin and density of the karyosome are the most important factors.
Other characteristics such as motility are useful but impractical as most stool
specimens are received fixed. An identification should not be based on only one
characteristic, but on that of "the whole picture".

1. Entamoeba histolytica
This is a single celled parasitic animal, i.e., a protozoa, that infects predominantly
humans and other primates. Diverse mammals such as dogs and cats can
become infected but usually do not shed cysts (the environmental survival form
of the organism) with their feces, thus do not contribute significantly to
transmission. The active (trophozoite) stage exists only in the host and in fresh
feces; cysts survive outside the host in water and soils and on foods, especially
under moist conditions on the latter. When swallowed they cause infections by
excysting (to the trophozoite stage) in the digestive tract.
(Trichrome stain of Entamoeba histolytica
trophozoites in amebiasis)

2. Entamoeba coli
Entamoeba coli (along with Endolimax nana, Ent. hartmanni, Ent. polecki, and
Iodamoeba buetschlii) are generally considered nonpathogenic and reside in the
large intestine of a human host. Both cysts and trophozoites of these species are
passed in stool and considered diagnostic. Cysts are typically found in formed
stool, whereas trophozoites (the active stage) are typically found in diarrheal
stool. Colonization of the nonpathogenic amebae occurs after ingestion of mature
cysts in fecally-contaminated food, water, or fomites (i.e., inanimate objects or
substances capable of transferring pathogens).

II. DISTRIBUTION AND INCIDENCE (EPIDEMIOLOGY)

A. Entamoeba histolytica

In the United States, immigrants from and travelers to developing countries are
those most likely to develop amebiasis. A total of 2970 cases of amebiasis in the
United States were reported to the Centers for Disease Control and Prevention in
1993; 33% of the patients were Hispanic immigrants and 17% immigrants from
Asia or the Pacific Islands. Travelers to the tropics are at a low but definite risk
for acquiring amebic infection. One study of 2700 German citizens returning from
tropical areas demonstrated a 0.3% incidence of E. histolytica infection.
Residents of institutions for the mentally retarded are also at increased risk for
amebic colitis and liver abscess. Men who have sex with men were in the past
predominantly infected with the nonpathogenic ameba E. dispar, but recently
invasive amebiasis has been seen in this group (with and without HIV infection).

A total of 113 mentally retarded patients residing in a mental institution in


Metropolitan Manila, Philippines, were screened for the presence of Entamoeba
histolytica based on microscopy and polymerase chain reaction (PCR). Anti-E.
histolytica antibodies were also screened in 97 serum samples collected using
immunofluorescence antibody (IFA) test. Parasitological examination showed E.
histolytica/Entamoeba dispar in 43 cases (38.05%), while PCR detected 74
cases (65.48%) positive for E. histolytica and 6 cases (5.30%) positive for E.
dispar. Interestingly, these 6 samples were coinfected with E. histolytica. IFA test
revealed that 80.41% (78/97) of the respondents possessed significant antibody
titers for intestinal infection of E. histolytica. Of this number, there were 5 patients
negative in IFA test but positive in PCR. The genetic diversity of E. histolytica
isolates was also investigated by analyzing polymorphism in the serine-rich gene
by nested PCR on DNA directly extracted from stool specimens. A combination
of the nested PCR results and the AluI digestion of the PCR products examined
yielded six distinct DNA banding patterns among the 74 stool isolates. An
apparent clustering of E. histolytica strains was observed in patients living in
different residential cottages of the institution. These results indicate the high
prevalence of E. histolytica in an institution for the mentally retarded in the
Philippines.

B. Entamoeba coli

Until more recently, Entamoeba coli was considered to be entirely nonpathogenic


and was of interest to the clinician only because of its morphologic similarities to
Entamoeba histolytica that might result in misdiagnosis. In 1991, several case
reports from northern Europe appeared, however, that implicated Entamoeba coli
as a possible cause of infectious diarrhea. Two cases of diarrhea associated with
Entamoeba coli have been described in children.

III. MORPHOLOGY

A. Entamoeba histolytica

E. histolytica exists in the body as the fragile motile trophozoite and the hardy
infective cyst. The cysts typically measures 10 - 20 microns with 4 nuclei and
rounded or cigar shaped chromatoidal bars. An immature cyst may have a
vacuole and fewer nuclei. The only infective stage of E. histolytica is the mature
cyst. The trophozoite of E. histolytica possesses one nuclei with a fine even
peripheral chromatin. The punctate karyosome is usually central but maybe off
center. The cytoplasm usually contains little debris with a fine outer membrane. It
usually measures from between 12 and 20 microns.

B. Entamoeba coli

The trophozoite and cyst of E. coli are both slightly larger than E. histolytica. The
trophozoite measuring from 18 to 28 microns and larger has 1 nucleous
containing a large diffuse karyosome. The peripheral chromatin is usually dense
and irregular. The cytoplasm is usually rough with few to many ingested debris.
In the wet mount it is usually impossible to differentiate between E. coli
trophozoites and those of E. histolytica. A stained smear is required. The cysts
measures from 12 to 25 microns and typically contains 8 nuclei with very diffuse
karyosomes. The cyst may also contain chromatoidal bars with very irregular
fragmented ends. Due to the size of the cyst and its density in a permanent
stained smear it usually shrinks considerably. Hypernucleation is possible with as
many as 16 or more nuclei present in one cyst.

Comparison of Entamoeba coli and Entamoeba histoytica

Entamoeba Histolytica Entamoeba coli


Trophozoite
Size (range) 25 µm (15-60) 25 µm (15-40)
Motility Active, directional, Sluggish, nondirectional,
progressive nonprogressive
Pseudopodia Fingerlike, explosive Short, blunt, broad, slow
Nucleus (stained) Delicate envelope & Coarse envelope &
chromatin; central chromatin, eccentric
endosome endosome

Cyst
Size (range) 12 µm (10-20) 17 µm (10-33)
Inclusions
Glycogen Diffuse Ill defined
Chromatoidal bars In young cysts; rounded In young cysts; splintered
ends ends
Number of nuclei 1-4 1-8
IV. HABITS, BIOLOGY AND LIFE CYCLE

A. Entamoeba histolytica

Like most other parasitic amebas, Entamoeba hitolytica is normally an


inhabitant of the large intestine, frequently invading the appendix and
occasionally venturing into the lower part of the small intestine. Although
amebic ulcers may be found anywhere along the 6 feet of the large intestine
from ileocecal valve to anus, they are most frequent at the opposite end, in
the sigmoidal flexure and rectum. These are the regions where the contents
of the intestine are usually allowed a temporary halt in their otherwise rough
and restless journey through the alimentary canal.

Inside humans, Entamoeba histolytica lives and multiplies as a trophozoite.


Trophozoites are oblong and about 15–20 µm in length. In order to infect
other humans they encyst and exit the body. The life cycle of Entamoeba
histolytica does not require any intermediate host. Mature cysts (spherical,
12–15 µm in diameter) are passed in the feces of an infected human. Another
human can get infected by ingesting them in fecally contaminated water, food
or hands. If the cysts survive the acidic stomach, they transform back into
trophozoites in the small intestine. Trophozoites migrate to the large intestine
where they live and multiply by binary fission. Both cysts and trophozoites are
sometimes present in the feces. Cysts are usually found in firm stool,
whereas trophozoites are found in loose stool. Only cysts can survive longer
periods (up to many weeks outside the host) and infect other humans. If
trophozoites are ingested, they are killed by the gastric acid of the stomach.
Occasionally trophozoites might be transmitted during sexual intercourse.

B. Entamoeba coli

Infection and migration to the large intestine in the case of Entamoeba coli
are identical to those of E. histolytica. The octanucleate metacyst produces 8
to 16 metacystic trophozoites, which first colonize the cecum and then the
general colon. Infection is by contamination; in some areas, of the world it
nearly reaches 100%. Obviously, this widespread infection is a reflection of
the level of sanitation and water treatment. Because Entamoeba coli is a
commensal, no treatment is required. However, infection with this ameba
indicates that opportunities exist for ingestion of E. histolytica or other
parasites transmitted in a manner similar to E. coli.

Entamoeba coli are a monogenetic organism. Three distinct morphological


forms exist airing the life cycle-Trophozoite, Pre-cystic stage and Cystic
stage.
Irophozoite of E. coli is about 20 to 30 in diameter with a range from 10 to 50.
Trophozoite is unicellular. The cytoplasm is differentiated into outer narrow
ectoplasm which is not so prominent and inner granular, vacuolated
endoplasm containing bacteria and debris inside food vacuoles.

A single nucleus lies inside the endoplasm. The nucleus is a ring like
structure with thick nuclear membrane lined with irregularly distributed
masses of chromatin and a large, irregular, eccentric karyosome.

Fine linin threads extend between nuclear membrane and karyosome.


Trophozoite bears one too many pseudopodia which are short, blunt and
granular Movement is sluggish and usually not directional. The parasite feeds
upon bacteria, vegetable cells and other faecal debris present in the large
intestine. Dobell (1938) reported that it may ingest R.B.C., occasionally. The
trophozoite reproduces by binary fission.

Trophozoite changes into spherical uninucleate precystic stage. The precystic


stage size ranges from 15 to 45 ц in diameter. It is similar to trophozoite
stage, except that it is non feeding stage and hence food inclusions are not
found in the endoplasm. Precystic stage changes into cystic stage.

The cysts are spherical or avoid with size ranging from 10 to 33 µ in


diameter. The cyst wall is thick. Immature cyst may have one-two or four
nuclei with eccentric kaiyosome .Occasionally, the cyst may bear 16 or even
32 nuclei. Glycogen vacuoles and chromatid bodies are seen in the
endoplasm up to binucleate stage after that they are consumed.

Matured cyst is the infective stage. Cyst formed in the large intestine is
discharged out о the host’s body through faeces. The cysts survive for 3-4
months outside the body of the host and are relatively more resistant to
desiccation as compared to those of E. histolytica. The survive rate of the
cyst is about 46 per cent.
V. DISEASE, PATHOGENESIS AND CLINICAL PRESENTATION

A. Entamoeba histolytica

Entamoeba histolytica is almost unique among amebas in its ability to hydrolyze


and invade host tissues. Tiny cytoplasmic extensions from the surface, as seen
in electron micrographs, are filopodia. These structures could have functions
related to pathogenesis, for example attachment to host cells, release of
cytotoxic substances, or contact cytolysis of host cells. Both E. histolytica and E.
dispar have galactose-specific membrane lectins that function in binding to host
cells, but only the E. histolytica lectin produces a host inflammatory response
through stimulation of host cytokine production. Such inflammation can easily
contribute to subsequent pathology.

In the majority of cases, amoebas remain in the gastrointestinal tract of the hosts.
Severe ulceration of the gastrointestinal mucosal surfaces occurs in less than
16% of cases. In fewer cases, the parasite invades the soft tissues, most
commonly the liver. Only rarely are masses formed (amoebomas) that lead to
intestinal obstruction. Fatalities are infrequent.

Sometimes, a granulomatous mass, called an ameboma, forms in the intestinal


wall and may obstruct the bowel. It is the result of cellular responses to a chronic
ulcer and often still contains active trophozoites. The condition is rare except in
Central and South America.

1. Nondysenteric infections

Although amebiasis is usually thought of as the cause of dysentery with blood


and mucus-containing stools, or of liver abscesses, these conditions are
actually the exception rather than the rule, and some workers have reported
that as many as 90% of the dysentery cases in temperate climates are
apparently symptomless.
2. Amebic dysentery

Although the small-race amebas appear to be harmless commensals, at least


in the majority of cases, the large race may, under favorable conditions, eat
into the tissues, first destroying the mucosa and then pushing deeper into the
submucosa where they spread out and produce flask-shaped ulcers.

3. Abscesses in liver, lungs, etc.

It is clear that invading amebas actively dissolving the tissues may frequently
be drawn into the portal circulation. Amebas which have escaped into the
blood stream are not necessarily halted in the liver but may be carried to any
part of the body. Lungs abscesses are fairly frequent; these are usually
caused by direct extension from a liver abscess through the diaphragm.

Hepatic amebiasis results when trophozites enter mesenteric venules and


travel to the liver through the hepatoportal system. They digest their way
through portal capillaries and enter the sinusoids, where they begin to form
abscessed. Lesions thus produced may remain at a pinpoint size, or they
may continue to grow, sometimes reaching the size of a grapefruit. The
center of the abscess is filled with necrotic fluid, a median zone consists of
liver stroma, and the outer zone consists of liver tissue being attacked by
amebas, although it is bacteriologically sterile. The abscess may rupture,
pouring debris and amebas into the body cavity, where they attack other
organs.

Pulmonary amebiasis is the next most common secondary lesion. It usually


develops by metastasis from a hepatic lesion but may originate
independently. Most cases originate when a liver abscess ruptures through
the diaphragm. Other ectopic sites occasionally encounteres are the brain,
skin and penis (with the amebiasis possibly acquired venereally). Rare
ectopic sites include kidneys, adrenals, spleen, male and female genitalia,
and pericardium. As a rule all ectopic abscesses are bacteriologically sterile.
E. histolytica is capable of causing a spectrum of illnesses. Intestinal
conditions resulting from E. histolytica infection include the following:
• Asymptomatic infection
• Symptomatic noninvasive infection
• Acute proctocolitis (dysentery)
• Fulminant colitis with perforation
• Toxic megacolon
• Chronic nondysenteric colitis
• Ameboma
• Perianal ulceration

Extraintestinal conditions resulting from E. histolytica infection include the


following:
• Liver abscess
• Pleuropulmonary disease
• Peritonitis
• Pericarditis
• Brain abscess
• Genitourinary disease

B. Entamoeba coli

Entamoeba coli is usually found in Human gastrointestinal tract specifically


the large intestine as a commensal parasite. This microorganism is not
harmful and lives in the human GI tract. E. coli is a non-pathogenic amoeba
that is important in medicine because it can be confused with E. histolytica
during microscopic examination of stool samples.

E. coli lives inside the lumen of the large intestine in man. They never enter
into the mucosa or sub-mucosa layers or other tissues of the intestine. There
is no reliable evidence that it ever produces intestinal lession, although it has
been reported that E. coli occasionally ingest red blood cells.
In this way it is believed to exist as non-pathogenic endo-commensa.
However, Dey (1974) observed that a large population of E. coli inside the gut
lumen may cause dyspepsia, hyperacidity, gastritis and indigestion.

VI. MODES OF TRANSMISSION

A. Entamoeba histolytica
Since only the cysts can survive outside the body, these alone are concerned in
transmission. The trophozoites are rarely capable of passing through the human
stomach and intestine to reach their promised land in the colon. Since dysenteric
cases rarely pass cysts, they are not usually concerned in transmission; persons
who are cysts-passers with few or no symptoms are principally concerned. Even
the cysts probably find the stomach a dangerous hazard and, like typhoid
organisms, may cause infection more readily when ingested with water than with
food because of the greater rapidity with which they pass the stomach. It also
throws light on the relative frequency of amebic infections in individuals with
abnormally low stomach acidity.

Since amebic cysts survive for considerable periods outside the body if not
desiccated (up to 8 days in soil), it is obvious that if they get into drinking water or
moist foods, such as raw vegetables, they are in an advantageous position both
from the standpoint of length of life and of opportunities to “thumb a ride” into a
human alimentary canal. Polluted water is undoubtedly one of the most important
means of transmission, and wherever unprotected or untreated ground water is
used for drinking in areas where there is widespread soil pollution, amebic
infections will be common. Such conditions prevail over vast portions of the
tropics and in the rural areas of our own southern states.

B. Entamoeba coli

Infection to the new host occurs by consuming contaminated food and drinks.
The infective stage cysts are carried from faces to the food items through insects
and rodents. In the small intestine of the new host excystation occurs during
which a single multinucleate amoeba comes out through the cyst wall.
Multinucleate amoeba divide into as many immature amoebas as there are nuclei
in the cyst.

The young amoeba moves down to reach the caecum where they multiply in
number and become trophozoites.

VII. Diagnosis

A. Entamoeba histolytica
1. Identification
Human cases are diagnosed by finding cysts shed with the stool; various
flotation or sedimentation procedures have been developed to recover the
cysts from fecal matter; stains (including fluorescent antibody) help to
visualize the isolated cysts for microscopic examination. Since cysts are not
shed constantly, a minimum of 3 stools should be examined. In heavy
infections, the motile form (the trophozoite) can be seen in fresh feces.
Serological tests exist for long-term infections. It is important to distinguish
the E. histolytica cyst from the cysts of nonpathogenic intestinal protozoa by
its appearance.

2. Causes
Amebiasis is transmitted by fecal contamination of drinking water and foods,
but also by direct contact with dirty hands or objects as well as by sexual
contact. The infection is "not uncommon" in the tropics and arctics, but also in
crowded situations of poor hygiene in temperate-zone urban environments. It
is also frequently diagnosed among homosexual men. All people are believed
to be susceptible to infection, but individuals with a damaged or undeveloped
immunity may suffer more severe forms of the disease. AIDS / ARC patients
are very vulnerable. E. histolytica cysts may be recovered from contaminated
food by methods similar to those used for recovering Giardia lamblia cysts
from feces. Filtration is probably the most practical method for recovery from
drinking water and liquid foods. E. histolytica cysts must be distinguished
from cysts of other parasitic (but nonpathogenic) protozoa and from cysts of
free-living protozoa. Recovery procedures are not very accurate; cysts are
easily lost or damaged beyond recognition, which leads to many falsely
negative results in recovery tests.

3. Symptoms
Minor infections(luminal amoebiasis) can cause symptoms that include:
• gas (flatulence)
• intermittent constipation
• loose stools
• stomach ache
• stomach cramping

Severe infections inflame the mucosa of the large intestine causing amoebic
dysentery. The parasites can also penetrate the intestinal wall and travel to
organs such as the liver via bloodstream causing extraintestinal amoebiasis.
Symptoms of these more severe infections include:
• anemia
• appendicitis (inflammation of the appendix)
• bloody diarrhea
• fatigue
• fever
• gas (flatulence)
• genital and skin lesions
• intermittent constipation
• liver abscesses (can lead to death, if not treated)
• malnutrition
• painful defecation (passage of the stool)
• peritonitis (inflammation of the peritoneum which is the thin membrane
that lines the abdominal wall)
• pleuropulmonary abscesses
• stomach ache
• stomach cramping
• toxic megacolon (dilated colon)
• weight loss.
B. Entamoeba coli

1. Identification
It is made by finding the characteristic cysts in an iodine stained, formol-ether
concentration method or by detecting the characteristic trophozoites in a wet
preparation or a permanent stained preparation.

2. Causes
Infection to the new host occurs by consuming contaminated food and drinks.
The infective stage cysts are carried from faces to the food items through
insects and rodents.

3. Symptoms

Symptoms are similar to the symptoms caused by the diseases associated


with it like dyspepsia, hyperacidity, gastritis and indigestion. These may
include bloating, belching, nausea, or heartburn.

VIII. PREVENTION AND TREATMENT

A. Entamoeba histolytica

To prevent spreading the infection to others, one should take care of personal
hygiene. Always wash your hands with soap and water after using the toilet and
before eating or preparing food. Amoebiasis is common in developing countries.
Some good practices, when visiting areas of poor sanitation:

• Wash your hands often.

• Avoid eating raw food.

• Avoid eating raw vegetables or fruit that you did not wash and peel
yourself.

• Avoid consuming milk or other dairy products that have not been
pasteurized.
• Drink only bottled or boiled water or carbonated (bubbly) drinks in cans or
bottles.

Appropriate chemotheraphy should be employed to destroy trophozoites, relieve


symptoms, and control secondary bacterial infections. The drug of choice for the
entire spectrum of symptoms is metronidazole or tinidazole. Complete bed rest
and a bland diet is recommended. In symptomless carriers, it is essential that the
trophozoites be destroyed since they are the precursors of cysts that pass out of
the host. For such patients, either iodoquinol or paromomycin are the drugs of
choice. To combat secondary bacterial infections, antibiotics such as tetracycline
are used in combination with metronidazole or tinidazole. Hepatic amoebiasis
also responds well to metronidazole.

B. Entamoeba coli

• Avoid drinking contaminated water; use bottled water while traveling if


possible
• If local water is to be drunk, purify it by (a) boiling it for more than 1
minute, (b) using 0.22 µm filtration, or (c) iodinating it with tetraglycine
hydroperiodide
• Avoid eating raw fruits and salads, which are difficult to sterilize; eat only
cooked food or self-peeled fruits if possible
• Wash uncooked vegetables and soak them in acetic acid or vinegar for
10-15 minutes

Since, Entamoeba coli is harmless, its treatment is not required from the
stand point of health, however arsenical compounds such as carbarsone
have been reported to be quite effective to kill the trophozoites.
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