Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira

Al revisar los posibles mecanismos fisiopatológicos asociados a la aparición de la LRA, se observa una relación compleja entre factores vasculares, tubulares e inflamatorios. Dentro de las causas prerrenales y renales, la sobrecarga de volumen, el edema intersticial, la inflamación, las alteraciones...

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Autores:
Cruz Echeverry, Euclides José
Tipo de recurso:
Tesis
Fecha de publicación:
2023
Institución:
Universidad Tecnológica de Pereira
Repositorio:
Repositorio Institucional UTP
Idioma:
spa
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oai:repositorio.utp.edu.co:11059/14635
Acceso en línea:
https://hdl.handle.net/11059/14635
https://repositorio.utp.edu.co/home
Palabra clave:
610 - Medicina y salud::616 - Enfermedades
Terapia renal
Vena cava inferior
Medicina intensiva
Ultrasonography
Acute kidney injury
Critically ill patient
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openAccess
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Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0)
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dc.title.spa.fl_str_mv Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira
title Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira
spellingShingle Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira
610 - Medicina y salud::616 - Enfermedades
Terapia renal
Vena cava inferior
Medicina intensiva
Ultrasonography
Acute kidney injury
Critically ill patient
title_short Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira
title_full Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira
title_fullStr Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira
title_full_unstemmed Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira
title_sort Ultrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de Pereira
dc.creator.fl_str_mv Cruz Echeverry, Euclides José
dc.contributor.author.none.fl_str_mv Cruz Echeverry, Euclides José
dc.contributor.relatedperson.none.fl_str_mv Asesor Metodológico - José William Martinez
dc.contributor.subjectmatterexpert.none.fl_str_mv Andres Eduardo Bernal
Fernando Jose Villabona
dc.subject.ddc.none.fl_str_mv 610 - Medicina y salud::616 - Enfermedades
topic 610 - Medicina y salud::616 - Enfermedades
Terapia renal
Vena cava inferior
Medicina intensiva
Ultrasonography
Acute kidney injury
Critically ill patient
dc.subject.mesh.none.fl_str_mv Terapia renal
Vena cava inferior
Medicina intensiva
dc.subject.proposal.eng.fl_str_mv Ultrasonography
Acute kidney injury
Critically ill patient
description Al revisar los posibles mecanismos fisiopatológicos asociados a la aparición de la LRA, se observa una relación compleja entre factores vasculares, tubulares e inflamatorios. Dentro de las causas prerrenales y renales, la sobrecarga de volumen, el edema intersticial, la inflamación, las alteraciones en la microcirculación, la hipoperfusión en la médula renal, la necrosis tubular aguda, las nefrotoxinas y la obstrucción intratubular han sido factores frecuentemente descritos en la literatura (3–11). El conocimiento de la fisiopatología sigue siendo incompleto, especialmente, los procesos moleculares subyacentes que condicionan la lesión de las células del epitelio tubular, así como el mecanismo de reparación o mal adaptación, relacionados con fibrosis intraparenquimatosa y progresión a enfermedad renal crónica. En diferentes estudios realizados en modelos animales que fueron sometidos a inducción de sepsis y LRA, con posterior toma de muestras de biopsia renal, se evidenció que la necrosis tubular aguda fue relativamente infrecuente y cuando estaba presente, reflejaba una alteración de las variables macro circulatorias (ej. aumento del flujo plasmático renal) y micro circulatorias (caída de la presión intraglomerular por vasodilatación de la arteriola eferente inducida por óxido nítrico), lo cual orienta inicialmente a un posible origen funcional de la lesión renal (12,13).
publishDate 2023
dc.date.accessioned.none.fl_str_mv 2023-04-19T16:12:52Z
dc.date.available.none.fl_str_mv 2023-04-19T16:12:52Z
dc.date.issued.none.fl_str_mv 2023
dc.type.none.fl_str_mv Trabajo de grado - Especialización
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dc.identifier.instname.none.fl_str_mv Universidad Tecnológica de Pereira
dc.identifier.reponame.none.fl_str_mv Repositorio Institucional Universidad Tecnológica de Pereira
dc.identifier.repourl.none.fl_str_mv https://repositorio.utp.edu.co/home
url https://hdl.handle.net/11059/14635
https://repositorio.utp.edu.co/home
identifier_str_mv Universidad Tecnológica de Pereira
Repositorio Institucional Universidad Tecnológica de Pereira
dc.language.iso.none.fl_str_mv spa
language spa
dc.relation.references.none.fl_str_mv 1. Hoste, E. A., Kellum, J. A., Selby, N. M., Zarbock, A., Palevsky, P. M., Bagshaw, S. M., ... & Chawla, L. S. (2018). Global epidemiology and outcomes of acute kidney injury. Nature Reviews Nephrology, 14(10), 607- 625.
2. Vaara, S. T., Pettilä, V., Kaukonen, K. M., Bendel, S., Korhonen, A. M., Bellomo, R., ... & Finnish Acute Kidney Injury Study Group. (2014). The attributable mortality of acute kidney injury: a sequentially matched analysis. Critical care medicine, 42(4), 878-885.
3. Pickkers, P., Darmon, M., Hoste, E., Joannidis, M., Legrand, M., Ostermann, M., ... & Schetz, M. (2021). Acute kidney injury in the critically ill: an updated review on pathophysiology and management. Intensive care medicine, 47(8), 835-850.
4. Pakula, A. M., & Skinner, R. A. (2016). Acute kidney injury in the critically ill patient: a current review of the literature. Journal of intensive care medicine, 31(5), 319-324.
5. Chen, K. P., Cavender, S., Lee, J., Feng, M., Mark, R. G., Celi, L. A., ... & Danziger, J. (2016). Peripheral edema, central venous pressure, and risk of AKI in critical illness. Clinical Journal of the American Society of Nephrology, 11(4), 602-608.
6. Cruces, P., Salas, C., Lillo, P., Salomon, T., Lillo, F., & Hurtado, D. E. (2014). The renal compartment: a hydraulic view. Intensive care medicine experimental, 2(1), 1-9.
7. Salas, C., Cárcamo, C., & Cruces, P. (2013). Can acute renal failure be complicated by renal compartment syndrome? A new view of an old idea. Nefrología (English Edition), 33(5), 732-733.
8. Gnanaraj, J. F., Von Haehling, S., Anker, S. D., Raj, D. S., & Radhakrishnan, J. (2013). The relevance of congestion in the cardio-renal syndrome. Kidney international, 83(3), 384-391.
9. Legrand, M., Dupuis, C., Simon, C., Gayat, E., Mateo, J., Lukaszewicz, A. C., & Payen, D. (2013). Association between systemic hemodynamics and septic acute kidney injury in critically ill patients: a retrospective observational study. Critical care, 17(6), 1-8.
10. Le Dorze, M., Legrand, M., Payen, D., & Ince, C. (2009). The role of the microcirculation in acute kidney injury. Current opinion in critical care, 15(6), 503-508.
11. Basile, D. P. (2007). The endothelial cell in ischemic acute kidney injury: implications for acute and chronic function. Kidney international, 72(2), 151- 156.
12. Kosaka, J., Lankadeva, Y. R., May, C. N., & Bellomo, R. (2016). Histopathology of septic acute kidney injury: a systematic review of experimental data. Critical care medicine, 44(9), e897-e903.
13. Langenberg, C., Gobe, G., Hood, S., May, C. N., & Bellomo, R. (2014). Renal histopathology during experimental septic acute kidney injury and recovery. Critical care medicine, 42(1), e58-e67.
14. Vaara, S. T., Ostermann, M., Bitker, L., Schneider, A., Poli, E., Hoste, E., ... & Bellomo, R. (2021). Restrictive fluid management versus usual care in acute kidney injury (REVERSE-AKI): a pilot randomized controlled feasibility trial. Intensive care medicine, 47(6), 665-673.
15. Ostermann, M., Liu, K., & Kashani, K. (2019). Fluid management in acute kidney injury. Chest, 156(3), 594-603.
16. Prowle, J. R., & Bellomo, R. (2010). Fluid administration and the kidney. Current opinion in critical care, 16(4), 332-336
17. Damman, K., van Deursen, V. M., Navis, G., Voors, A. A., van Veldhuisen, D. J., & Hillege, H. L. (2009). Increased central venous pressure is associated with impaired renal function and mortality in a broad spectrum of patients with cardiovascular disease. Journal of the American College of Cardiology, 53(7), 582-588.
18. Marik, P. E., & Cavallazzi, R. (2013). Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Critical care medicine, 41(7), 1774-1781.
19. Au, S. M., & Vieillard-Baron, A. (2012). Bedside echocardiography in critically ill patients: a true hemodynamic monitoring tool. Journal of clinical monitoring and computing, 26, 355-360.
20. Schmidt, G. A., Koenig, S., & Mayo, P. H. (2012). Shock: ultrasound to guide diagnosis and therapy. Chest, 142(4), 1042-1048.
21. American College of Emergency Physicians. (2017). Ultrasound guidelines: emergency, point-of-care and clinical ultrasound guidelines in medicine. Ann Emerg Med, 69(5), e27-e54.
22. Levitov, A., Frankel, H. L., Blaivas, M., Kirkpatrick, A. W., Su, E., Evans, D., ... & Elbarbary, M. (2016). Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography. Critical care medicine, 44(6), 1206-1227.
23. Quiñones, M. A., Douglas, P. S., Foster, E., Gorcsan, J., Lewis, J. F., Pearlman, A. S., ... & Weitz, H. H. (2003). ACC/AHA clinical competence statement on echocardiography: a Report of the American College of Cardiology/American Heart Association/American College of Physicians– American Society of Internal Medicine Task Force on Clinical Competence Developed in Collaboration with the American Society of Echocardiography, the society of cardiovascular anesthesiologists, and the society of pediatric echocardiography. Journal of the American College of Cardiology, 41(4), 687-708.
24. Mayo, P. H., Beaulieu, Y., Doelken, P., Feller-Kopman, D., Harrod, C., Kaplan, A., ... & Vignon, P. (2009). American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest, 135(4), 1050-1060.
25. Wong, A., Galarza, L., Forni, L., De Backer, D., Slama, M., Cholley, B., ... & Duška, F. (2020). Recommendations for core critical care ultrasound competencies as a part of specialist training in multidisciplinary intensive care: a framework proposed by the European Society of Intensive Care Medicine (ESICM). Critical Care, 24(1), 1-6.
26. Wong, A., Robba, C., & Mayo, P. (2022). Critical care ultrasound. Intensive Care Medicine, 48(8), 1069-1071.
27. Akkaya, A., Yesilaras, M., Aksay, E., Sever, M., & Atilla, O. D. (2013). The interrater reliability of ultrasound imaging of the inferior vena cava performed by emergency residents. The American journal of emergency medicine, 31(10), 1509-1511.
28. Fields, J. M., Lee, P. A., Jenq, K. Y., Mark, D. G., Panebianco, N. L., & Dean, A. J. (2011). The interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients. Academic Emergency Medicine, 18(1), 98-101.
29. Beaubien‐Souligny, W., Benkreira, A., Robillard, P., Bouabdallaoui, N., Chassé, M., Desjardins, G., ... & Denault, A. (2018). Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: a prospective observational cohort study. Journal of the American Heart Association, 7(19), e009961.
30. Bhardwaj, V., Vikneswaran, G., Rola, P., Raju, S., Bhat, R. S., Jayakumar, A., & Alva, A. (2020). Combination of inferior vena cava diameter, hepatic venous flow, and portal vein pulsatility index: venous excess ultrasound score (VEXUS score) in predicting acute kidney injury in patients with cardiorenal syndrome: a prospective cohort study. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 24(9), 783.
31. Beaubien-Souligny, W., Rola, P., Haycock, K., Bouchard, J., Lamarche, Y., Spiegel, R., & Denault, A. Y. (2020). Quantifying systemic congestion with point-of-care ultrasound: development of the venous excess ultrasound grading system. The Ultrasound Journal, 12, 1-12.
32. Gupta, S., & Tomar, D. S. (2020). VEXUS—The Third Eye for the Intensivist?. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 24(9), 746.
33. Aslaner, Mehmet Ali, et al. "Accuracy of Multi-organ Point-of-Care Ultrasound for Acute Kidney Injury Etiologies." Ultrasound in Medicine & Biology 48.10 (2022): 2009-2018.
34. Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., ... & Tomlanovich, M. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England journal of medicine, 345(19), 1368-1377.
35. Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., ... & Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181-1247.
36. Neyra, J. A., Li, X., Canepa-Escaro, F., Adams-Huet, B., Toto, R. D., Yee, J., & Hedayati, S. S. (2016). Cumulative fluid balance and mortality in septic patients with or without acute kidney injury and chronic kidney disease. Critical care medicine, 44(10), 1891-1900.
38. Zhang, L., Chen, Z., Diao, Y., Yang, Y., & Fu, P. (2015). Associations of fluid overload with mortality and kidney recovery in patients with acute kidney injury: a systematic review and meta-analysis. Journal of critical care, 30(4), 860-e7.
39. Ogbu, O. C., Murphy, D. J., & Martin, G. S. (2015). How to avoid fluid overload. Current opinion in critical care, 21(4), 315.
41. Cecconi, M., De Backer, D., Antonelli, M., Beale, R., Bakker, J., Hofer, C., ... & Rhodes, A. (2014). Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive care medicine, 40, 1795-1815.
40. Boyd, J. H., Forbes, J., Nakada, T. A., Walley, K. R., & Russell, J. A. (2011). Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Critical care medicine, 39(2), 259-265.
42. Lang, R. M., Badano, L. P., Mor-Avi, V., Afilalo, J., Armstrong, A., Ernande, L., ... & Voigt, J. U. (2015). Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. European Heart Journal-Cardiovascular Imaging, 16(3), 233-271.
43. De Backer, Daniel, and David Fagnoul. "Intensive care ultrasound: VI. Fluid responsiveness and shock assessment." Annals of the American Thoracic Society 11.1 (2014): 129-136.
44. Evans, David, et al. "Volume responsiveness in critically ill patients: use of sonography to guide management." Journal of Ultrasound in Medicine 33.1 (2014): 3-7.
45. Levy, Bernard I., et al. "Non-invasive ultrasonic cardiac output measurement in intensive care unit." Ultrasound in medicine & biology 11.6 (1985): 841-849.
46. Orso, D., Paoli, I., Piani, T., Cilenti, F. L., Cristiani, L., & Guglielmo, N. (2020). Accuracy of ultrasonographic measurements of inferior vena cava to determine fluid responsiveness: a systematic review and meta-analysis. Journal of intensive care medicine, 35(4), 354-363.
47. Goldhammer, E., Mesnick, N., Abinader, E. G., & Sagiv, M. (1999). Dilated inferior vena cava: a common echocardiographic finding in highly trained elite athletes. Journal of the American Society of Echocardiography, 12(11), 988-993.
48. Taniguchi, T., Ohtani, T., Nakatani, S., Hayashi, K., Yamaguchi, O., Komuro, I., & Sakata, Y. (2015). Impact of body size on inferior vena cava parameters for estimating right atrial pressure: a need for standardization?. Journal of the American Society of Echocardiography, 28(12), 1420-1427.
49. Rudski, Lawrence G., et al. "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography: endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography." Journal of the American society of echocardiography 23.7 (2010): 685-713.
50. Beigel, Roy, et al. "Noninvasive evaluation of right atrial pressure." Journal of the American Society of Echocardiography 26.9 (2013): 1033-1042.
51. Airapetian, N., Maizel, J., Alyamani, O., Mahjoub, Y., Lorne, E., Levrard, M., ... & Slama, M. (2015). Does inferior vena cava respiratory variability predict fluid responsiveness in spontaneously breathing patients?. Critical Care, 19(1), 1-8.
53. Akoglu, Ebru Unal, et al. "Respiratory variability of inferior vena cava at different mechanical ventilator settings." The American Journal of Emergency Medicine 48 (2021): 96-102.
54. Yao, B., Liu, J. Y., Sun, Y. B., & Zhao, Y. X. (2019). The value of the inferior vena cava area distensibility index and its diameter ratio for predicting fluid responsiveness in mechanically ventilated patients. Shock, 52(1), 37-42.
55. Long, E., Oakley, E., Duke, T., & Babl, F. E. (2017). Does respiratory variation in inferior vena cava diameter predict fluid responsiveness: a systematic review and meta-analysis. Shock: Injury, Inflammation, and Sepsis: Laboratory and Clinical Approaches, 47(5), 550-559.
56. Preau, S., Bortolotti, P., Colling, D., Dewavrin, F., Colas, V., Voisin, B., ... & Saulnier, F. (2017). Diagnostic accuracy of the inferior vena cava collapsibility to predict fluid responsiveness in spontaneously breathing patients with sepsis and acute circulatory failure. Critical care medicine, 45(3), e290-e297.
57. Zhang, Z., Xu, X., Ye, S., & Xu, L. (2014). Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta analysis. Ultrasound in medicine & biology, 40(5), 845-853
58. De Vecchis, R., Ariano, C., Fusco, A., Ciccarelli, A., Cioppa, C., Giasi, A., ... & Cantatrione, S. (2012). Ultrasound evaluation of the inferior vena cava collapsibility index in congestive heart failure patients treated with intravenous diuretics: new insights about its relationship with renal function: an observational study. Anatolian Journal of Cardiology/Anadolu Kardiyoloji Dergisi, 12(5).
59. Orde, Sam, et al. "Pearls and pitfalls in comprehensive critical care echocardiography." Critical Care 21.1 (2017): 1-10.
60. Via, G., Tavazzi, G., & Price, S. (2016). Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view. Intensive care medicine, 42, 1164- 1167.
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spelling Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0)Manifiesto (Manifestamos) en este documento la voluntad de autorizar a la Biblioteca Jorge Roa Martínez de la Universidad Tecnológica de Pereira la publicación en el Repositorio institucional (http://biblioteca.utp.edu.co), la versión electrónica de la OBRA titulada: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ La Universidad Tecnológica de Pereira, entidad académica sin ánimo de lucro, queda por lo tanto facultada para ejercer plenamente la autorización anteriormente descrita en su actividad ordinaria de investigación, docencia y publicación. La autorización otorgada se ajusta a lo que establece la Ley 23 de 1982. Con todo, en mi (nuestra) condición de autor (es) me (nos) reservo (reservamos) los derechos morales de la OBRA antes citada con arreglo al artículo 30 dehttps://creativecommons.org/licenses/by-nc-nd/4.0/http://purl.org/coar/access_right/c_abf2info:eu-repo/semantics/openAccessCruz Echeverry, Euclides JoséAsesor Metodológico - José William MartinezAndres Eduardo BernalFernando Jose Villabona2023-04-19T16:12:52Z2023-04-19T16:12:52Z2023https://hdl.handle.net/11059/14635Universidad Tecnológica de PereiraRepositorio Institucional Universidad Tecnológica de Pereirahttps://repositorio.utp.edu.co/homeAl revisar los posibles mecanismos fisiopatológicos asociados a la aparición de la LRA, se observa una relación compleja entre factores vasculares, tubulares e inflamatorios. Dentro de las causas prerrenales y renales, la sobrecarga de volumen, el edema intersticial, la inflamación, las alteraciones en la microcirculación, la hipoperfusión en la médula renal, la necrosis tubular aguda, las nefrotoxinas y la obstrucción intratubular han sido factores frecuentemente descritos en la literatura (3–11). El conocimiento de la fisiopatología sigue siendo incompleto, especialmente, los procesos moleculares subyacentes que condicionan la lesión de las células del epitelio tubular, así como el mecanismo de reparación o mal adaptación, relacionados con fibrosis intraparenquimatosa y progresión a enfermedad renal crónica. En diferentes estudios realizados en modelos animales que fueron sometidos a inducción de sepsis y LRA, con posterior toma de muestras de biopsia renal, se evidenció que la necrosis tubular aguda fue relativamente infrecuente y cuando estaba presente, reflejaba una alteración de las variables macro circulatorias (ej. aumento del flujo plasmático renal) y micro circulatorias (caída de la presión intraglomerular por vasodilatación de la arteriola eferente inducida por óxido nítrico), lo cual orienta inicialmente a un posible origen funcional de la lesión renal (12,13).TABLA DE CONTENIDO INTRODUCCIÓN.............................................................................................................................. 3 PREGUNTA DE INVESTIGACIÓN, HIPÓTESIS Y OBJETIVOS............................................ 6 Hipótesis ........................................................................................................................................ 6 Objetivo principal .......................................................................................................................... 6 Objetivos específicos................................................................................................................... 6 MARCO TEÓRICO .......................................................................................................................... 7 METODOLOGÍA............................................................................................................................. 15 Diseño del estudio...................................................................................................................... 15 Población a estudio.................................................................................................................... 16 Criterios de inclusión.................................................................................................................. 16 Criterios de exclusión................................................................................................................. 16 Intervenciones realizadas ......................................................................................................... 16 Resultado primario ..................................................................................................................... 16 PROTOCOLO DE LA TOMA DE DATOS Y MEDICIONES ................................................... 17 Procedimiento para la toma de los datos ............................................................................... 17 Protocolo mediciones ultrasonográficas de VCI.................................................................... 19 Mediciones registradas y cálculos derivados (figura 2)........................................................ 21 ANÁLISIS ESTADÍSTICOS.......................................................................................................... 23 RESULTADOS ............................................................................................................................... 24 Características y datos generales............................................................................................ 24 Mediciones de la VCI................................................................................................................. 28 DISCUSIÓN..................................................................................................................................... 34 FORTALEZAS DEL ESTUDIO.................................................................................................... 41 LIMITACIONES DEL ESTUDIO .................................................................................................. 42 RECOMENDACIONES ................................................................................................................. 43 CONCLUSIONES........................................................................................................................... 43 MARCO BIOÉTICO ....................................................................................................................... 44 PRESUPUESTO............................................................................................................................. 45 CONFLICTO DE INTERESES..................................................................................................... 45 AGRADECIMIENTOS ................................................................................................................... 46 BIBLIOGRAFÍA.............................................................................................................................. 46EspecializaciónEspecialista en Medicina Crítica y Cuidado Intensivo58 Páginasapplication/pdfspaUniversidad Tecnológica de PereiraMedicinaFacultad de Ciencias de la SaludPereira610 - Medicina y salud::616 - EnfermedadesTerapia renalVena cava inferiorMedicina intensivaUltrasonographyAcute kidney injuryCritically ill patientUltrasonografía de la vena cava inferior como predictor de lesión renal aguda en el paciente críticamente enfermo: estudio en una uci de la ciudad de PereiraTrabajo de grado - Especializacióninfo:eu-repo/semantics/acceptedVersionhttp://purl.org/coar/resource_type/c_46echttp://purl.org/coar/resource_type/c_93fcTextinfo:eu-repo/semantics/report1. Hoste, E. A., Kellum, J. A., Selby, N. M., Zarbock, A., Palevsky, P. M., Bagshaw, S. M., ... & Chawla, L. S. (2018). Global epidemiology and outcomes of acute kidney injury. Nature Reviews Nephrology, 14(10), 607- 625.2. Vaara, S. T., Pettilä, V., Kaukonen, K. M., Bendel, S., Korhonen, A. M., Bellomo, R., ... & Finnish Acute Kidney Injury Study Group. (2014). The attributable mortality of acute kidney injury: a sequentially matched analysis. Critical care medicine, 42(4), 878-885.3. Pickkers, P., Darmon, M., Hoste, E., Joannidis, M., Legrand, M., Ostermann, M., ... & Schetz, M. (2021). Acute kidney injury in the critically ill: an updated review on pathophysiology and management. Intensive care medicine, 47(8), 835-850.4. Pakula, A. M., & Skinner, R. A. (2016). Acute kidney injury in the critically ill patient: a current review of the literature. Journal of intensive care medicine, 31(5), 319-324.5. Chen, K. P., Cavender, S., Lee, J., Feng, M., Mark, R. G., Celi, L. A., ... & Danziger, J. (2016). Peripheral edema, central venous pressure, and risk of AKI in critical illness. Clinical Journal of the American Society of Nephrology, 11(4), 602-608.6. Cruces, P., Salas, C., Lillo, P., Salomon, T., Lillo, F., & Hurtado, D. E. (2014). The renal compartment: a hydraulic view. Intensive care medicine experimental, 2(1), 1-9.7. Salas, C., Cárcamo, C., & Cruces, P. (2013). Can acute renal failure be complicated by renal compartment syndrome? A new view of an old idea. Nefrología (English Edition), 33(5), 732-733.8. Gnanaraj, J. F., Von Haehling, S., Anker, S. D., Raj, D. S., & Radhakrishnan, J. (2013). The relevance of congestion in the cardio-renal syndrome. Kidney international, 83(3), 384-391.9. Legrand, M., Dupuis, C., Simon, C., Gayat, E., Mateo, J., Lukaszewicz, A. C., & Payen, D. (2013). Association between systemic hemodynamics and septic acute kidney injury in critically ill patients: a retrospective observational study. Critical care, 17(6), 1-8.10. Le Dorze, M., Legrand, M., Payen, D., & Ince, C. (2009). The role of the microcirculation in acute kidney injury. Current opinion in critical care, 15(6), 503-508.11. Basile, D. P. (2007). The endothelial cell in ischemic acute kidney injury: implications for acute and chronic function. Kidney international, 72(2), 151- 156.12. Kosaka, J., Lankadeva, Y. R., May, C. N., & Bellomo, R. (2016). Histopathology of septic acute kidney injury: a systematic review of experimental data. Critical care medicine, 44(9), e897-e903.13. Langenberg, C., Gobe, G., Hood, S., May, C. N., & Bellomo, R. (2014). Renal histopathology during experimental septic acute kidney injury and recovery. Critical care medicine, 42(1), e58-e67.14. Vaara, S. T., Ostermann, M., Bitker, L., Schneider, A., Poli, E., Hoste, E., ... & Bellomo, R. (2021). Restrictive fluid management versus usual care in acute kidney injury (REVERSE-AKI): a pilot randomized controlled feasibility trial. Intensive care medicine, 47(6), 665-673.15. Ostermann, M., Liu, K., & Kashani, K. (2019). Fluid management in acute kidney injury. Chest, 156(3), 594-603.16. Prowle, J. R., & Bellomo, R. (2010). Fluid administration and the kidney. Current opinion in critical care, 16(4), 332-33617. Damman, K., van Deursen, V. M., Navis, G., Voors, A. A., van Veldhuisen, D. J., & Hillege, H. L. (2009). Increased central venous pressure is associated with impaired renal function and mortality in a broad spectrum of patients with cardiovascular disease. Journal of the American College of Cardiology, 53(7), 582-588.18. Marik, P. E., & Cavallazzi, R. (2013). Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Critical care medicine, 41(7), 1774-1781.19. Au, S. M., & Vieillard-Baron, A. (2012). Bedside echocardiography in critically ill patients: a true hemodynamic monitoring tool. Journal of clinical monitoring and computing, 26, 355-360.20. Schmidt, G. A., Koenig, S., & Mayo, P. H. (2012). Shock: ultrasound to guide diagnosis and therapy. Chest, 142(4), 1042-1048.21. American College of Emergency Physicians. (2017). Ultrasound guidelines: emergency, point-of-care and clinical ultrasound guidelines in medicine. Ann Emerg Med, 69(5), e27-e54.22. Levitov, A., Frankel, H. L., Blaivas, M., Kirkpatrick, A. W., Su, E., Evans, D., ... & Elbarbary, M. (2016). Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography. Critical care medicine, 44(6), 1206-1227.23. Quiñones, M. A., Douglas, P. S., Foster, E., Gorcsan, J., Lewis, J. F., Pearlman, A. S., ... & Weitz, H. H. (2003). ACC/AHA clinical competence statement on echocardiography: a Report of the American College of Cardiology/American Heart Association/American College of Physicians– American Society of Internal Medicine Task Force on Clinical Competence Developed in Collaboration with the American Society of Echocardiography, the society of cardiovascular anesthesiologists, and the society of pediatric echocardiography. Journal of the American College of Cardiology, 41(4), 687-708.24. Mayo, P. H., Beaulieu, Y., Doelken, P., Feller-Kopman, D., Harrod, C., Kaplan, A., ... & Vignon, P. (2009). American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest, 135(4), 1050-1060.25. Wong, A., Galarza, L., Forni, L., De Backer, D., Slama, M., Cholley, B., ... & Duška, F. (2020). Recommendations for core critical care ultrasound competencies as a part of specialist training in multidisciplinary intensive care: a framework proposed by the European Society of Intensive Care Medicine (ESICM). Critical Care, 24(1), 1-6.26. Wong, A., Robba, C., & Mayo, P. (2022). Critical care ultrasound. Intensive Care Medicine, 48(8), 1069-1071.27. Akkaya, A., Yesilaras, M., Aksay, E., Sever, M., & Atilla, O. D. (2013). The interrater reliability of ultrasound imaging of the inferior vena cava performed by emergency residents. The American journal of emergency medicine, 31(10), 1509-1511.28. Fields, J. M., Lee, P. A., Jenq, K. Y., Mark, D. G., Panebianco, N. L., & Dean, A. J. (2011). The interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients. Academic Emergency Medicine, 18(1), 98-101.29. Beaubien‐Souligny, W., Benkreira, A., Robillard, P., Bouabdallaoui, N., Chassé, M., Desjardins, G., ... & Denault, A. (2018). Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: a prospective observational cohort study. Journal of the American Heart Association, 7(19), e009961.30. Bhardwaj, V., Vikneswaran, G., Rola, P., Raju, S., Bhat, R. S., Jayakumar, A., & Alva, A. (2020). Combination of inferior vena cava diameter, hepatic venous flow, and portal vein pulsatility index: venous excess ultrasound score (VEXUS score) in predicting acute kidney injury in patients with cardiorenal syndrome: a prospective cohort study. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 24(9), 783.31. Beaubien-Souligny, W., Rola, P., Haycock, K., Bouchard, J., Lamarche, Y., Spiegel, R., & Denault, A. Y. (2020). Quantifying systemic congestion with point-of-care ultrasound: development of the venous excess ultrasound grading system. The Ultrasound Journal, 12, 1-12.32. Gupta, S., & Tomar, D. S. (2020). VEXUS—The Third Eye for the Intensivist?. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 24(9), 746.33. Aslaner, Mehmet Ali, et al. "Accuracy of Multi-organ Point-of-Care Ultrasound for Acute Kidney Injury Etiologies." Ultrasound in Medicine & Biology 48.10 (2022): 2009-2018.34. Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., ... & Tomlanovich, M. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England journal of medicine, 345(19), 1368-1377.35. Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., ... & Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181-1247.36. Neyra, J. A., Li, X., Canepa-Escaro, F., Adams-Huet, B., Toto, R. D., Yee, J., & Hedayati, S. S. (2016). Cumulative fluid balance and mortality in septic patients with or without acute kidney injury and chronic kidney disease. Critical care medicine, 44(10), 1891-1900.38. Zhang, L., Chen, Z., Diao, Y., Yang, Y., & Fu, P. (2015). Associations of fluid overload with mortality and kidney recovery in patients with acute kidney injury: a systematic review and meta-analysis. Journal of critical care, 30(4), 860-e7.39. Ogbu, O. C., Murphy, D. J., & Martin, G. S. (2015). How to avoid fluid overload. Current opinion in critical care, 21(4), 315.41. Cecconi, M., De Backer, D., Antonelli, M., Beale, R., Bakker, J., Hofer, C., ... & Rhodes, A. (2014). Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive care medicine, 40, 1795-1815.40. Boyd, J. H., Forbes, J., Nakada, T. A., Walley, K. R., & Russell, J. A. (2011). Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Critical care medicine, 39(2), 259-265.42. Lang, R. M., Badano, L. P., Mor-Avi, V., Afilalo, J., Armstrong, A., Ernande, L., ... & Voigt, J. U. (2015). Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. European Heart Journal-Cardiovascular Imaging, 16(3), 233-271.43. De Backer, Daniel, and David Fagnoul. "Intensive care ultrasound: VI. Fluid responsiveness and shock assessment." Annals of the American Thoracic Society 11.1 (2014): 129-136.44. Evans, David, et al. "Volume responsiveness in critically ill patients: use of sonography to guide management." Journal of Ultrasound in Medicine 33.1 (2014): 3-7.45. Levy, Bernard I., et al. "Non-invasive ultrasonic cardiac output measurement in intensive care unit." Ultrasound in medicine & biology 11.6 (1985): 841-849.46. Orso, D., Paoli, I., Piani, T., Cilenti, F. L., Cristiani, L., & Guglielmo, N. (2020). Accuracy of ultrasonographic measurements of inferior vena cava to determine fluid responsiveness: a systematic review and meta-analysis. Journal of intensive care medicine, 35(4), 354-363.47. Goldhammer, E., Mesnick, N., Abinader, E. G., & Sagiv, M. (1999). Dilated inferior vena cava: a common echocardiographic finding in highly trained elite athletes. Journal of the American Society of Echocardiography, 12(11), 988-993.48. Taniguchi, T., Ohtani, T., Nakatani, S., Hayashi, K., Yamaguchi, O., Komuro, I., & Sakata, Y. (2015). Impact of body size on inferior vena cava parameters for estimating right atrial pressure: a need for standardization?. Journal of the American Society of Echocardiography, 28(12), 1420-1427.49. Rudski, Lawrence G., et al. "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography: endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography." Journal of the American society of echocardiography 23.7 (2010): 685-713.50. Beigel, Roy, et al. "Noninvasive evaluation of right atrial pressure." Journal of the American Society of Echocardiography 26.9 (2013): 1033-1042.51. Airapetian, N., Maizel, J., Alyamani, O., Mahjoub, Y., Lorne, E., Levrard, M., ... & Slama, M. (2015). Does inferior vena cava respiratory variability predict fluid responsiveness in spontaneously breathing patients?. Critical Care, 19(1), 1-8.53. Akoglu, Ebru Unal, et al. "Respiratory variability of inferior vena cava at different mechanical ventilator settings." The American Journal of Emergency Medicine 48 (2021): 96-102.54. Yao, B., Liu, J. Y., Sun, Y. B., & Zhao, Y. X. (2019). The value of the inferior vena cava area distensibility index and its diameter ratio for predicting fluid responsiveness in mechanically ventilated patients. Shock, 52(1), 37-42.55. Long, E., Oakley, E., Duke, T., & Babl, F. E. (2017). Does respiratory variation in inferior vena cava diameter predict fluid responsiveness: a systematic review and meta-analysis. Shock: Injury, Inflammation, and Sepsis: Laboratory and Clinical Approaches, 47(5), 550-559.56. Preau, S., Bortolotti, P., Colling, D., Dewavrin, F., Colas, V., Voisin, B., ... & Saulnier, F. (2017). Diagnostic accuracy of the inferior vena cava collapsibility to predict fluid responsiveness in spontaneously breathing patients with sepsis and acute circulatory failure. Critical care medicine, 45(3), e290-e297.57. Zhang, Z., Xu, X., Ye, S., & Xu, L. (2014). Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta analysis. Ultrasound in medicine & biology, 40(5), 845-85358. De Vecchis, R., Ariano, C., Fusco, A., Ciccarelli, A., Cioppa, C., Giasi, A., ... & Cantatrione, S. (2012). Ultrasound evaluation of the inferior vena cava collapsibility index in congestive heart failure patients treated with intravenous diuretics: new insights about its relationship with renal function: an observational study. Anatolian Journal of Cardiology/Anadolu Kardiyoloji Dergisi, 12(5).59. Orde, Sam, et al. "Pearls and pitfalls in comprehensive critical care echocardiography." Critical Care 21.1 (2017): 1-10.60. Via, G., Tavazzi, G., & Price, S. (2016). Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view. Intensive care medicine, 42, 1164- 1167.PublicationORIGINALTRABAJO DE GRADO.pdfTRABAJO DE GRADO.pdfapplication/pdf1276981https://dspace7-utp.metabuscador.org/bitstreams/c50eff79-0783-4907-a79e-cc3a86668830/downloadae15d0b5f71a3d8977b51d2b84c77ed3MD51LICENSElicense.txtlicense.txttext/plain; charset=utf-814828https://dspace7-utp.metabuscador.org/bitstreams/57a1aaac-4423-48c3-a568-45b1759b130c/download2f9959eaf5b71fae44bbf9ec84150c7aMD52TEXTTRABAJO DE GRADO.pdf.txtTRABAJO DE GRADO.pdf.txtExtracted texttext/plain103188https://dspace7-utp.metabuscador.org/bitstreams/c6a3f87c-23df-4196-80a1-e4f8f297698f/download0fe6dad1db1c6aaef8a1757571ee5dbfMD53THUMBNAILTRABAJO DE GRADO.pdf.jpgTRABAJO DE GRADO.pdf.jpgGenerated Thumbnailimage/jpeg7401https://dspace7-utp.metabuscador.org/bitstreams/1b557fa0-8bc6-4943-86ec-337b619c9ba2/downloadafbd036a2f0fe8079b01d8ee0d5bbd57MD5411059/14635oai:dspace7-utp.metabuscador.org:11059/146352024-09-05 17:06:58.943https://creativecommons.org/licenses/by-nc-nd/4.0/Manifiesto (Manifestamos) en este documento la voluntad de autorizar a la Biblioteca Jorge Roa Martínez de la Universidad Tecnológica de Pereira la publicación en el Repositorio institucional (http://biblioteca.utp.edu.co), la versión electrónica de la OBRA titulada: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ La Universidad Tecnológica de Pereira, entidad académica sin ánimo de lucro, queda por lo tanto facultada para ejercer plenamente la autorización anteriormente descrita en su actividad ordinaria de investigación, docencia y publicación. La autorización otorgada se ajusta a lo que establece la Ley 23 de 1982. Con todo, en mi (nuestra) condición de autor (es) me (nos) reservo (reservamos) los derechos morales de la OBRA antes citada con arreglo al artículo 30 deopen.accesshttps://dspace7-utp.metabuscador.orgRepositorio de la Universidad Tecnológica de 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luY29ycG9yYWRhIGVuIGxhcyBPYnJhcyBDb2xlY3RpdmFzLgoKYi4JRGlzdHJpYnVpciBjb3BpYXMgbyBmb25vZ3JhbWFzIGRlIGxhcyBPYnJhcywgZXhoaWJpcmxhcyBww7pibGljYW1lbnRlLCBlamVjdXRhcmxhcyBww7pibGljYW1lbnRlIHkvbyBwb25lcmxhcyBhIGRpc3Bvc2ljacOzbiBww7pibGljYSwgaW5jbHV5w6luZG9sYXMgY29tbyBpbmNvcnBvcmFkYXMgZW4gT2JyYXMgQ29sZWN0aXZhcywgc2Vnw7puIGNvcnJlc3BvbmRhLgoKYy4JRGlzdHJpYnVpciBjb3BpYXMgZGUgbGFzIE9icmFzIERlcml2YWRhcyBxdWUgc2UgZ2VuZXJlbiwgZXhoaWJpcmxhcyBww7pibGljYW1lbnRlLCBlamVjdXRhcmxhcyBww7pibGljYW1lbnRlIHkvbyBwb25lcmxhcyBhIGRpc3Bvc2ljacOzbiBww7pibGljYS4KTG9zIGRlcmVjaG9zIG1lbmNpb25hZG9zIGFudGVyaW9ybWVudGUgcHVlZGVuIHNlciBlamVyY2lkb3MgZW4gdG9kb3MgbG9zIG1lZGlvcyB5IGZvcm1hdG9zLCBhY3R1YWxtZW50ZSBjb25vY2lkb3MgbyBxdWUgc2UgaW52ZW50ZW4gZW4gZWwgZnV0dXJvLiBMb3MgZGVyZWNob3MgYW50ZXMgbWVuY2lvbmFkb3MgaW5jbHV5ZW4gZWwgZGVyZWNobyBhIHJlYWxpemFyIGRpY2hhcyBtb2RpZmljYWNpb25lcyBlbiBsYSBtZWRpZGEgcXVlIHNlYW4gdMOpY25pY2FtZW50ZSBuZWNlc2FyaWFzIHBhcmEgZWplcmNlciBsb3MgZGVyZWNob3MgZW4gb3RybyBtZWRpbyBvIGZvcm1hdG9zLCBwZXJvIGRlIG90cmEgbWFuZXJhIHVzdGVkIG5vIGVzdMOhIGF1dG9yaXphZG8gcGFyYSByZWFsaXphciBvYnJhcyBkZXJpdmFkYXMuIFRvZG9zIGxvcyBkZXJlY2hvcyBubyBvdG9yZ2Fkb3MgZXhwcmVzYW1lbnRlIHBvciBlbCBMaWNlbmNpYW50ZSBxdWVkYW4gcG9yIGVzdGUgbWVkaW8gcmVzZXJ2YWRvcywgaW5jbHV5ZW5kbyBwZXJvIHNpbiBsaW1pdGFyc2UgYSBhcXVlbGxvcyBxdWUgc2UgbWVuY2lvbmFuIGVuIGxhcyBzZWNjaW9uZXMgNChkKSB5IDQoZSkuCgo0LiBSZXN0cmljY2lvbmVzLgpMYSBsaWNlbmNpYSBvdG9yZ2FkYSBlbiBsYSBhbnRlcmlvciBTZWNjacOzbiAzIGVzdMOhIGV4cHJlc2FtZW50ZSBzdWpldGEgeSBsaW1pdGFkYSBwb3IgbGFzIHNpZ3VpZW50ZXMgcmVzdHJpY2Npb25lczoKCmEuCVVzdGVkIHB1ZWRlIGRpc3RyaWJ1aXIsIGV4aGliaXIgcMO6YmxpY2FtZW50ZSwgZWplY3V0YXIgcMO6YmxpY2FtZW50ZSwgbyBwb25lciBhIGRpc3Bvc2ljacOzbiBww7pibGljYSBsYSBPYnJhIHPDs2xvIGJham8gbGFzIGNvbmRpY2lvbmVzIGRlIGVzdGEgTGljZW5jaWEsIHkgVXN0ZWQgZGViZSBpbmNsdWlyIHVuYSBjb3BpYSBkZSBlc3RhIGxpY2VuY2lhIG8gZGVsIElkZW50aWZpY2Fkb3IgVW5pdmVyc2FsIGRlIFJlY3Vyc29zIGRlIGxhIG1pc21hIGNvbiBjYWRhIGNvcGlhIGRlIGxhIE9icmEgcXVlIGRpc3RyaWJ1eWEsIGV4aGliYSBww7pibGljYW1lbnRlLCBlamVjdXRlIHDDumJsaWNhbWVudGUgbyBwb25nYSBhIGRpc3Bvc2ljacOzbiBww7pibGljYS4gTm8gZXMgcG9zaWJsZSBvZnJlY2VyIG8gaW1wb25lciBuaW5ndW5hIGNvbmRpY2nDs24gc29icmUgbGEgT2JyYSBxdWUgYWx0ZXJlIG8gbGltaXRlIGxhcyBjb25kaWNpb25lcyBkZSBlc3RhIExpY2VuY2lhIG8gZWwgZWplcmNpY2lvIGRlIGxvcyBkZXJlY2hvcyBkZSBsb3MgZGVzdGluYXRhcmlvcyBvdG9yZ2Fkb3MgZW4gZXN0ZSBkb2N1bWVudG8uIE5vIGVzIHBvc2libGUgc3VibGljZW5jaWFyIGxhIE9icmEuIFVzdGVkIGRlYmUgbWFudGVuZXIgaW50YWN0b3MgdG9kb3MgbG9zIGF2aXNvcyBxdWUgaGFnYW4gcmVmZXJlbmNpYSBhIGVzdGEgTGljZW5jaWEgeSBhIGxhIGNsw6F1c3VsYSBkZSBsaW1pdGFjacOzbiBkZSBnYXJhbnTDrWFzLiBVc3RlZCBubyBwdWVkZSBkaXN0cmlidWlyLCBleGhpYmlyIHDDumJsaWNhbWVudGUsIGVqZWN1dGFyIHDDumJsaWNhbWVudGUsIG8gcG9uZXIgYSBkaXNwb3NpY2nDs24gcMO6YmxpY2EgbGEgT2JyYSBjb24gYWxndW5hIG1lZGlkYSB0ZWNub2zDs2dpY2EgcXVlIGNvbnRyb2xlIGVsIGFjY2VzbyBvIGxhIHV0aWxpemFjacOzbiBkZSBlbGxhIGRlIHVuYSBmb3JtYSBxdWUgc2VhIGluY29uc2lzdGVudGUgY29uIGxhcyBjb25kaWNpb25lcyBkZSBlc3RhIExpY2VuY2lhLiBMbyBhbnRlcmlvciBzZSBhcGxpY2EgYSBsYSBPYnJhIGluY29ycG9yYWRhIGEgdW5hIE9icmEgQ29sZWN0aXZhLCBwZXJvIGVzdG8gbm8gZXhpZ2UgcXVlIGxhIE9icmEgQ29sZWN0aXZhIGFwYXJ0ZSBkZSBsYSBvYnJhIG1pc21hIHF1ZWRlIHN1amV0YSBhIGxhcyBjb25kaWNpb25lcyBkZSBlc3RhIExpY2VuY2lhLiBTaSBVc3RlZCBjcmVhIHVuYSBPYnJhIENvbGVjdGl2YSwgcHJldmlvIGF2aXNvIGRlIGN1YWxxdWllciBMaWNlbmNpYW50ZSBkZWJlLCBlbiBsYSBtZWRpZGEgZGUgbG8gcG9zaWJsZSwgZWxpbWluYXIgZGUgbGEgT2JyYSBDb2xlY3RpdmEgY3VhbHF1aWVyIHJlZmVyZW5jaWEgYSBkaWNobyBMaWNlbmNpYW50ZSBvIGFsIEF1dG9yIE9yaWdpbmFsLCBzZWfDum4gbG8gc29saWNpdGFkbyBwb3IgZWwgTGljZW5jaWFudGUgeSBjb25mb3JtZSBsbyBleGlnZSBsYSBjbMOhdXN1bGEgNChjKS4KCmIuCVVzdGVkIG5vIHB1ZWRlIGVqZXJjZXIgbmluZ3VubyBkZSBsb3MgZGVyZWNob3MgcXVlIGxlIGhhbiBzaWRvIG90b3JnYWRvcyBlbiBsYSBTZWNjacOzbiAzIHByZWNlZGVudGUgZGUgbW9kbyBxdWUgZXN0w6luIHByaW5jaXBhbG1lbnRlIGRlc3RpbmFkb3MgbyBkaXJlY3RhbWVudGUgZGlyaWdpZG9zIGEgY29uc2VndWlyIHVuIHByb3ZlY2hvIGNvbWVyY2lhbCBvIHVuYSBjb21wZW5zYWNpw7NuIG1vbmV0YXJpYSBwcml2YWRhLiBFbCBpbnRlcmNhbWJpbyBkZSBsYSBPYnJhIHBvciBvdHJhcyBvYnJhcyBwcm90ZWdpZGFzIHBvciBkZXJlY2hvcyBkZSBhdXRvciwgeWEgc2VhIGEgdHJhdsOpcyBkZSB1biBzaXN0ZW1hIHBhcmEgY29tcGFydGlyIGFyY2hpdm9zIGRpZ2l0YWxlcyAoZGlnaXRhbCBmaWxlLXNoYXJpbmcpIG8gZGUgY3VhbHF1aWVyIG90cmEgbWFuZXJhIG5vIHNlcsOhIGNvbnNpZGVyYWRvIGNvbW8gZXN0YXIgZGVzdGluYWRvIHByaW5jaXBhbG1lbnRlIG8gZGlyaWdpZG8gZGlyZWN0YW1lbnRlIGEgY29uc2VndWlyIHVuIHByb3ZlY2hvIGNvbWVyY2lhbCBvIHVuYSBjb21wZW5zYWNpw7NuIG1vbmV0YXJpYSBwcml2YWRhLCBzaWVtcHJlIHF1ZSBubyBzZSByZWFsaWNlIHVuIHBhZ28gbWVkaWFudGUgdW5hIGNvbXBlbnNhY2nDs24gbW9uZXRhcmlhIGVuIHJlbGFjacOzbiBjb24gZWwgaW50ZXJjYW1iaW8gZGUgb2JyYXMgcHJvdGVnaWRhcyBwb3IgZWwgZGVyZWNobyBkZSBhdXRvci4KCmMuCVNpIHVzdGVkIGRpc3RyaWJ1eWUsIGV4aGliZSBww7pibGljYW1lbnRlLCBlamVjdXRhIHDDumJsaWNhbWVudGUgbyBlamVjdXRhIHDDumJsaWNhbWVudGUgZW4gZm9ybWEgZGlnaXRhbCBsYSBPYnJhIG8gY3VhbHF1aWVyIE9icmEgRGVyaXZhZGEgdSBPYnJhIENvbGVjdGl2YSwgVXN0ZWQgZGViZSBtYW50ZW5lciBpbnRhY3RhIHRvZGEgbGEgaW5mb3JtYWNpw7NuIGRlIGRlcmVjaG8gZGUgYXV0b3IgZGUgbGEgT2JyYSB5IHByb3BvcmNpb25hciwgZGUgZm9ybWEgcmF6b25hYmxlIHNlZ8O6biBlbCBtZWRpbyBvIG1hbmVyYSBxdWUgVXN0ZWQgZXN0w6kgdXRpbGl6YW5kbzogKGkpIGVsIG5vbWJyZSBkZWwgQXV0b3IgT3JpZ2luYWwgc2kgZXN0w6EgcHJvdmlzdG8gKG8gc2V1ZMOzbmltbywgc2kgZnVlcmUgYXBsaWNhYmxlKSwgeS9vIChpaSkgZWwgbm9tYnJlIGRlIGxhIHBhcnRlIG8gbGFzIHBhcnRlcyBxdWUgZWwgQXV0b3IgT3JpZ2luYWwgeS9vIGVsIExpY2VuY2lhbnRlIGh1YmllcmVuIGRlc2lnbmFkbyBwYXJhIGxhIGF0cmlidWNpw7NuICh2LmcuLCB1biBpbnN0aXR1dG8gcGF0cm9jaW5hZG9yLCBlZGl0b3JpYWwsIHB1YmxpY2FjacOzbikgZW4gbGEgaW5mb3JtYWNpw7NuIGRlIGxvcyBkZXJlY2hvcyBkZSBhdXRvciBkZWwgTGljZW5jaWFudGUsIHTDqXJtaW5vcyBkZSBzZXJ2aWNpb3MgbyBkZSBvdHJhcyBmb3JtYXMgcmF6b25hYmxlczsgZWwgdMOtdHVsbyBkZSBsYSBPYnJhIHNpIGVzdMOhIHByb3Zpc3RvOyBlbiBsYSBtZWRpZGEgZGUgbG8gcmF6b25hYmxlbWVudGUgZmFjdGlibGUgeSwgc2kgZXN0w6EgcHJvdmlzdG8sIGVsIElkZW50aWZpY2Fkb3IgVW5pZm9ybWUgZGUgUmVjdXJzb3MgKFVuaWZvcm0gUmVzb3VyY2UgSWRlbnRpZmllcikgcXVlIGVsIExpY2VuY2lhbnRlIGVzcGVjaWZpY2EgcGFyYSBzZXIgYXNvY2lhZG8gY29uIGxhIE9icmEsIHNhbHZvIHF1ZSB0YWwgVVJJIG5vIHNlIHJlZmllcmEgYSBsYSBub3RhIHNvYnJlIGxvcyBkZXJlY2hvcyBkZSBhdXRvciBvIGEgbGEgaW5mb3JtYWNpw7NuIHNvYnJlIGVsIGxpY2VuY2lhbWllbnRvIGRlIGxhIE9icmE7IHkgZW4gZWwgY2FzbyBkZSB1bmEgT2JyYSBEZXJpdmFkYSwgYXRyaWJ1aXIgZWwgY3LDqWRpdG8gaWRlbnRpZmljYW5kbyBlbCB1c28gZGUgbGEgT2JyYSBlbiBsYSBPYnJhIERlcml2YWRhICh2LmcuLCAiVHJhZHVjY2nDs24gRnJhbmNlc2EgZGUgbGEgT2JyYSBkZWwgQXV0b3IgT3JpZ2luYWwsIiBvICJHdWnDs24gQ2luZW1hdG9ncsOhZmljbyBiYXNhZG8gZW4gbGEgT2JyYSBvcmlnaW5hbCBkZWwgQXV0b3IgT3JpZ2luYWwiKS4gVGFsIGNyw6lkaXRvIHB1ZWRlIHNlciBpbXBsZW1lbnRhZG8gZGUgY3VhbHF1aWVyIGZvcm1hIHJhem9uYWJsZTsgZW4gZWwgY2Fzbywgc2luIGVtYmFyZ28sIGRlIE9icmFzIERlcml2YWRhcyB1IE9icmFzIENvbGVjdGl2YXMsIHRhbCBjcsOpZGl0byBhcGFyZWNlcsOhLCBjb21vIG3DrW5pbW8sIGRvbmRlIGFwYXJlY2UgZWwgY3LDqWRpdG8gZGUgY3VhbHF1aWVyIG90cm8gYXV0b3IgY29tcGFyYWJsZSB5IGRlIHVuYSBtYW5lcmEsIGFsIG1lbm9zLCB0YW4gZGVzdGFjYWRhIGNvbW8gZWwgY3LDqWRpdG8gZGUgb3RybyBhdXRvciBjb21wYXJhYmxlLgoKZC4JUGFyYSBldml0YXIgdG9kYSBjb25mdXNpw7NuLCBlbCBMaWNlbmNpYW50ZSBhY2xhcmEgcXVlLCBjdWFuZG8gbGEgb2JyYSBlcyB1bmEgY29tcG9zaWNpw7NuIG11c2ljYWw6CgppLglSZWdhbMOtYXMgcG9yIGludGVycHJldGFjacOzbiB5IGVqZWN1Y2nDs24gYmFqbyBsaWNlbmNpYXMgZ2VuZXJhbGVzLiBFbCBMaWNlbmNpYW50ZSBzZSByZXNlcnZhIGVsIGRlcmVjaG8gZXhjbHVzaXZvIGRlIGF1dG9yaXphciBsYSBlamVjdWNpw7NuIHDDumJsaWNhIG8gbGEgZWplY3VjacOzbiBww7pibGljYSBkaWdpdGFsIGRlIGxhIG9icmEgeSBkZSByZWNvbGVjdGFyLCBzZWEgaW5kaXZpZHVhbG1lbnRlIG8gYSB0cmF2w6lzIGRlIHVuYSBzb2NpZWRhZCBkZSBnZXN0acOzbiBjb2xlY3RpdmEgZGUgZGVyZWNob3MgZGUgYXV0b3IgeSBkZXJlY2hvcyBjb25leG9zIChwb3IgZWplbXBsbywgU0FZQ08pLCBsYXMgcmVnYWzDrWFzIHBvciBsYSBlamVjdWNpw7NuIHDDumJsaWNhIG8gcG9yIGxhIGVqZWN1Y2nDs24gcMO6YmxpY2EgZGlnaXRhbCBkZSBsYSBvYnJhIChwb3IgZWplbXBsbyBXZWJjYXN0KSBsaWNlbmNpYWRhIGJham8gbGljZW5jaWFzIGdlbmVyYWxlcywgc2kgbGEgaW50ZXJwcmV0YWNpw7NuIG8gZWplY3VjacOzbiBkZSBsYSBvYnJhIGVzdMOhIHByaW1vcmRpYWxtZW50ZSBvcmllbnRhZGEgcG9yIG8gZGlyaWdpZGEgYSBsYSBvYnRlbmNpw7NuIGRlIHVuYSB2ZW50YWphIGNvbWVyY2lhbCBvIHVuYSBjb21wZW5zYWNpw7NuIG1vbmV0YXJpYSBwcml2YWRhLgoKaWkuCVJlZ2Fsw61hcyBwb3IgRm9ub2dyYW1hcy4gRWwgTGljZW5jaWFudGUgc2UgcmVzZXJ2YSBlbCBkZXJlY2hvIGV4Y2x1c2l2byBkZSByZWNvbGVjdGFyLCBpbmRpdmlkdWFsbWVudGUgbyBhIHRyYXbDqXMgZGUgdW5hIHNvY2llZGFkIGRlIGdlc3Rpw7NuIGNvbGVjdGl2YSBkZSBkZXJlY2hvcyBkZSBhdXRvciB5IGRlcmVjaG9zIGNvbmV4b3MgKHBvciBlamVtcGxvLCBsb3MgY29uc2FncmFkb3MgcG9yIGxhIFNBWUNPKSwgdW5hIGFnZW5jaWEgZGUgZGVyZWNob3MgbXVzaWNhbGVzIG8gYWxnw7puIGFnZW50ZSBkZXNpZ25hZG8sIGxhcyByZWdhbMOtYXMgcG9yIGN1YWxxdWllciBmb25vZ3JhbWEgcXVlIFVzdGVkIGNyZWUgYSBwYXJ0aXIgZGUgbGEgb2JyYSAo4oCcdmVyc2nDs24gY292ZXLigJ0pIHkgZGlzdHJpYnV5YSwgZW4gbG9zIHTDqXJtaW5vcyBkZWwgcsOpZ2ltZW4gZGUgZGVyZWNob3MgZGUgYXV0b3IsIHNpIGxhIGNyZWFjacOzbiBvIGRpc3RyaWJ1Y2nDs24gZGUgZXNhIHZlcnNpw7NuIGNvdmVyIGVzdMOhIHByaW1vcmRpYWxtZW50ZSBkZXN0aW5hZGEgbyBkaXJpZ2lkYSBhIG9idGVuZXIgdW5hIHZlbnRhamEgY29tZXJjaWFsIG8gdW5hIGNvbXBlbnNhY2nDs24gbW9uZXRhcmlhIHByaXZhZGEuCgplLglHZXN0acOzbiBkZSBEZXJlY2hvcyBkZSBBdXRvciBzb2JyZSBJbnRlcnByZXRhY2lvbmVzIHkgRWplY3VjaW9uZXMgRGlnaXRhbGVzIChXZWJDYXN0aW5nKS4gUGFyYSBldml0YXIgdG9kYSBjb25mdXNpw7NuLCBlbCBMaWNlbmNpYW50ZSBhY2xhcmEgcXVlLCBjdWFuZG8gbGEgb2JyYSBzZWEgdW4gZm9ub2dyYW1hLCBlbCBMaWNlbmNpYW50ZSBzZSByZXNlcnZhIGVsIGRlcmVjaG8gZXhjbHVzaXZvIGRlIGF1dG9yaXphciBsYSBlamVjdWNpw7NuIHDDumJsaWNhIGRpZ2l0YWwgZGUgbGEgb2JyYSAocG9yIGVqZW1wbG8sIHdlYmNhc3QpIHkgZGUgcmVjb2xlY3RhciwgaW5kaXZpZHVhbG1lbnRlIG8gYSB0cmF2w6lzIGRlIHVuYSBzb2NpZWRhZCBkZSBnZXN0acOzbiBjb2xlY3RpdmEgZGUgZGVyZWNob3MgZGUgYXV0b3IgeSBkZXJlY2hvcyBjb25leG9zIChwb3IgZWplbXBsbywgQUNJTlBSTyksIGxhcyByZWdhbMOtYXMgcG9yIGxhIGVqZWN1Y2nDs24gcMO6YmxpY2EgZGlnaXRhbCBkZSBsYSBvYnJhIChwb3IgZWplbXBsbywgd2ViY2FzdCksIHN1amV0YSBhIGxhcyBkaXNwb3NpY2lvbmVzIGFwbGljYWJsZXMgZGVsIHLDqWdpbWVuIGRlIERlcmVjaG8gZGUgQXV0b3IsIHNpIGVzdGEgZWplY3VjacOzbiBww7pibGljYSBkaWdpdGFsIGVzdMOhIHByaW1vcmRpYWxtZW50ZSBkaXJpZ2lkYSBhIG9idGVuZXIgdW5hIHZlbnRhamEgY29tZXJjaWFsIG8gdW5hIGNvbXBlbnNhY2nDs24gbW9uZXRhcmlhIHByaXZhZGEuCgo1LiBSZXByZXNlbnRhY2lvbmVzLCBHYXJhbnTDrWFzIHkgTGltaXRhY2lvbmVzIGRlIFJlc3BvbnNhYmlsaWRhZC4KQSBNRU5PUyBRVUUgTEFTIFBBUlRFUyBMTyBBQ09SREFSQU4gREUgT1RSQSBGT1JNQSBQT1IgRVNDUklUTywgRUwgTElDRU5DSUFOVEUgT0ZSRUNFIExBIE9CUkEgKEVOIEVMIEVTVEFETyBFTiBFTCBRVUUgU0UgRU5DVUVOVFJBKSDigJxUQUwgQ1VBTOKAnSwgU0lOIEJSSU5EQVIgR0FSQU5Uw41BUyBERSBDTEFTRSBBTEdVTkEgUkVTUEVDVE8gREUgTEEgT0JSQSwgWUEgU0VBIEVYUFJFU0EsIElNUEzDjUNJVEEsIExFR0FMIE8gQ1VBTFFVSUVSQSBPVFJBLCBJTkNMVVlFTkRPLCBTSU4gTElNSVRBUlNFIEEgRUxMQVMsIEdBUkFOVMONQVMgREUgVElUVUxBUklEQUQsIENPTUVSQ0lBQklMSURBRCwgQURBUFRBQklMSURBRCBPIEFERUNVQUNJw5NOIEEgUFJPUMOTU0lUTyBERVRFUk1JTkFETywgQVVTRU5DSUEgREUgSU5GUkFDQ0nDk04sIERFIEFVU0VOQ0lBIERFIERFRkVDVE9TIExBVEVOVEVTIE8gREUgT1RSTyBUSVBPLCBPIExBIFBSRVNFTkNJQSBPIEFVU0VOQ0lBIERFIEVSUk9SRVMsIFNFQU4gTyBOTyBERVNDVUJSSUJMRVMgKFBVRURBTiBPIE5PIFNFUiBFU1RPUyBERVNDVUJJRVJUT1MpLiBBTEdVTkFTIEpVUklTRElDQ0lPTkVTIE5PIFBFUk1JVEVOIExBIEVYQ0xVU0nDk04gREUgR0FSQU5Uw41BUyBJTVBMw41DSVRBUywgRU4gQ1VZTyBDQVNPIEVTVEEgRVhDTFVTScOTTiBQVUVERSBOTyBBUExJQ0FSU0UgQSBVU1RFRC4KCjYuIExpbWl0YWNpw7NuIGRlIHJlc3BvbnNhYmlsaWRhZC4KQSBNRU5PUyBRVUUgTE8gRVhJSkEgRVhQUkVTQU1FTlRFIExBIExFWSBBUExJQ0FCTEUsIEVMIExJQ0VOQ0lBTlRFIE5PIFNFUsOBIFJFU1BPTlNBQkxFIEFOVEUgVVNURUQgUE9SIERBw5FPIEFMR1VOTywgU0VBIFBPUiBSRVNQT05TQUJJTElEQUQgRVhUUkFDT05UUkFDVFVBTCwgUFJFQ09OVFJBQ1RVQUwgTyBDT05UUkFDVFVBTCwgT0JKRVRJVkEgTyBTVUJKRVRJVkEsIFNFIFRSQVRFIERFIERBw5FPUyBNT1JBTEVTIE8gUEFUUklNT05JQUxFUywgRElSRUNUT1MgTyBJTkRJUkVDVE9TLCBQUkVWSVNUT1MgTyBJTVBSRVZJU1RPUyBQUk9EVUNJRE9TIFBPUiBFTCBVU08gREUgRVNUQSBMSUNFTkNJQSBPIERFIExBIE9CUkEsIEFVTiBDVUFORE8gRUwgTElDRU5DSUFOVEUgSEFZQSBTSURPIEFEVkVSVElETyBERSBMQSBQT1NJQklMSURBRCBERSBESUNIT1MgREHDkU9TLiBBTEdVTkFTIExFWUVTIE5PIFBFUk1JVEVOIExBIEVYQ0xVU0nDk04gREUgQ0lFUlRBIFJFU1BPTlNBQklMSURBRCwgRU4gQ1VZTyBDQVNPIEVTVEEgRVhDTFVTScOTTiBQVUVERSBOTyBBUExJQ0FSU0UgQSBVU1RFRC4KCjcuIFTDqXJtaW5vLgoKYS4JRXN0YSBMaWNlbmNpYSB5IGxvcyBkZXJlY2hvcyBvdG9yZ2Fkb3MgZW4gdmlydHVkIGRlIGVsbGEgdGVybWluYXLDoW4gYXV0b23DoXRpY2FtZW50ZSBzaSBVc3RlZCBpbmZyaW5nZSBhbGd1bmEgY29uZGljacOzbiBlc3RhYmxlY2lkYSBlbiBlbGxhLiBTaW4gZW1iYXJnbywgbG9zIGluZGl2aWR1b3MgbyBlbnRpZGFkZXMgcXVlIGhhbiByZWNpYmlkbyBPYnJhcyBEZXJpdmFkYXMgbyBDb2xlY3RpdmFzIGRlIFVzdGVkIGRlIGNvbmZvcm1pZGFkIGNvbiBlc3RhIExpY2VuY2lhLCBubyB2ZXLDoW4gdGVybWluYWRhcyBzdXMgbGljZW5jaWFzLCBzaWVtcHJlIHF1ZSBlc3RvcyBpbmRpdmlkdW9zIG8gZW50aWRhZGVzIHNpZ2FuIGN1bXBsaWVuZG8gw61udGVncmFtZW50ZSBsYXMgY29uZGljaW9uZXMgZGUgZXN0YXMgbGljZW5jaWFzLiBMYXMgU2VjY2lvbmVzIDEsIDIsIDUsIDYsIDcsIHkgOCBzdWJzaXN0aXLDoW4gYSBjdWFscXVpZXIgdGVybWluYWNpw7NuIGRlIGVzdGEgTGljZW5jaWEuCgpiLglTdWpldGEgYSBsYXMgY29uZGljaW9uZXMgeSB0w6lybWlub3MgYW50ZXJpb3JlcywgbGEgbGljZW5jaWEgb3RvcmdhZGEgYXF1w60gZXMgcGVycGV0dWEgKGR1cmFudGUgZWwgcGVyw61vZG8gZGUgdmlnZW5jaWEgZGUgbG9zIGRlcmVjaG9zIGRlIGF1dG9yIGRlIGxhIG9icmEpLiBObyBvYnN0YW50ZSBsbyBhbnRlcmlvciwgZWwgTGljZW5jaWFudGUgc2UgcmVzZXJ2YSBlbCBkZXJlY2hvIGEgcHVibGljYXIgeS9vIGVzdHJlbmFyIGxhIE9icmEgYmFqbyBjb25kaWNpb25lcyBkZSBsaWNlbmNpYSBkaWZlcmVudGVzIG8gYSBkZWphciBkZSBkaXN0cmlidWlybGEgZW4gbG9zIHTDqXJtaW5vcyBkZSBlc3RhIExpY2VuY2lhIGVuIGN1YWxxdWllciBtb21lbnRvOyBlbiBlbCBlbnRlbmRpZG8sIHNpbiBlbWJhcmdvLCBxdWUgZXNhIGVsZWNjacOzbiBubyBzZXJ2aXLDoSBwYXJhIHJldm9jYXIgZXN0YSBsaWNlbmNpYSBvIHF1ZSBkZWJhIHNlciBvdG9yZ2FkYSAsIGJham8gbG9zIHTDqXJtaW5vcyBkZSBlc3RhIGxpY2VuY2lhKSwgeSBlc3RhIGxpY2VuY2lhIGNvbnRpbnVhcsOhIGVuIHBsZW5vIHZpZ29yIHkgZWZlY3RvIGEgbWVub3MgcXVlIHNlYSB0ZXJtaW5hZGEgY29tbyBzZSBleHByZXNhIGF0csOhcy4gTGEgTGljZW5jaWEgcmV2b2NhZGEgY29udGludWFyw6Egc2llbmRvIHBsZW5hbWVudGUgdmlnZW50ZSB5IGVmZWN0aXZhIHNpIG5vIHNlIGxlIGRhIHTDqXJtaW5vIGVuIGxhcyBjb25kaWNpb25lcyBpbmRpY2FkYXMgYW50ZXJpb3JtZW50ZS4KCjguIFZhcmlvcy4KCmEuCUNhZGEgdmV6IHF1ZSBVc3RlZCBkaXN0cmlidXlhIG8gcG9uZ2EgYSBkaXNwb3NpY2nDs24gcMO6YmxpY2EgbGEgT2JyYSBvIHVuYSBPYnJhIENvbGVjdGl2YSwgZWwgTGljZW5jaWFudGUgb2ZyZWNlcsOhIGFsIGRlc3RpbmF0YXJpbyB1bmEgbGljZW5jaWEgZW4gbG9zIG1pc21vcyB0w6lybWlub3MgeSBjb25kaWNpb25lcyBxdWUgbGEgbGljZW5jaWEgb3RvcmdhZGEgYSBVc3RlZCBiYWpvIGVzdGEgTGljZW5jaWEuCgpiLglTaSBhbGd1bmEgZGlzcG9zaWNpw7NuIGRlIGVzdGEgTGljZW5jaWEgcmVzdWx0YSBpbnZhbGlkYWRhIG8gbm8gZXhpZ2libGUsIHNlZ8O6biBsYSBsZWdpc2xhY2nDs24gdmlnZW50ZSwgZXN0byBubyBhZmVjdGFyw6EgbmkgbGEgdmFsaWRleiBuaSBsYSBhcGxpY2FiaWxpZGFkIGRlbCByZXN0byBkZSBjb25kaWNpb25lcyBkZSBlc3RhIExpY2VuY2lhIHksIHNpbiBhY2Npw7NuIGFkaWNpb25hbCBwb3IgcGFydGUgZGUgbG9zIHN1amV0b3MgZGUgZXN0ZSBhY3VlcmRvLCBhcXXDqWxsYSBzZSBlbnRlbmRlcsOhIHJlZm9ybWFkYSBsbyBtw61uaW1vIG5lY2VzYXJpbyBwYXJhIGhhY2VyIHF1ZSBkaWNoYSBkaXNwb3NpY2nDs24gc2VhIHbDoWxpZGEgeSBleGlnaWJsZS4KCmMuCU5pbmfDum4gdMOpcm1pbm8gbyBkaXNwb3NpY2nDs24gZGUgZXN0YSBMaWNlbmNpYSBzZSBlc3RpbWFyw6EgcmVudW5jaWFkYSB5IG5pbmd1bmEgdmlvbGFjacOzbiBkZSBlbGxhIHNlcsOhIGNvbnNlbnRpZGEgYSBtZW5vcyBxdWUgZXNhIHJlbnVuY2lhIG8gY29uc2VudGltaWVudG8gc2VhIG90b3JnYWRvIHBvciBlc2NyaXRvIHkgZmlybWFkbyBwb3IgbGEgcGFydGUgcXVlIHJlbnVuY2llIG8gY29uc2llbnRhLgoKZC4JRXN0YSBMaWNlbmNpYSByZWZsZWphIGVsIGFjdWVyZG8gcGxlbm8gZW50cmUgbGFzIHBhcnRlcyByZXNwZWN0byBhIGxhIE9icmEgYXF1w60gbGljZW5jaWFkYS4gTm8gaGF5IGFycmVnbG9zLCBhY3VlcmRvcyBvIGRlY2xhcmFjaW9uZXMgcmVzcGVjdG8gYSBsYSBPYnJhIHF1ZSBubyBlc3TDqW4gZXNwZWNpZmljYWRvcyBlbiBlc3RlIGRvY3VtZW50by4gRWwgTGljZW5jaWFudGUgbm8gc2UgdmVyw6EgbGltaXRhZG8gcG9yIG5pbmd1bmEgZGlzcG9zaWNpw7NuIGFkaWNpb25hbCBxdWUgcHVlZGEgc3VyZ2lyIGVuIGFsZ3VuYSBjb211bmljYWNpw7NuIGVtYW5hZGEgZGUgVXN0ZWQuIEVzdGEgTGljZW5jaWEgbm8gcHVlZGUgc2VyIG1vZGlmaWNhZGEgc2luIGVsIGNvbnNlbnRpbWllbnRvIG11dHVvIHBvciBlc2NyaXRvIGRlbCBMaWNlbmNpYW50ZSB5IFVzdGVkLgo=

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