Suez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Intra-Vitreal Injection of Triamcinolone Acetonide versus Bevacizumab for Management of Diabetic Macular Edema after Phaco Emulsification10164387110.21608/scumj.2016.43871ENEhab MGhoneimDepartment of Ophthalmology, Faculty of Medicine, Port Said University, EgyptAhmed AAbd El GhanyDepartment of Ophthalmology, Faculty of Medicine, Suez Canal University, EgyptAmr AGab-AllaDepartment of Ophthalmology, Faculty of Medicine, Suez Canal University, EgyptAhmed MEl MasryDepartment of Ophthalmology, Faculty of Medicine, Suez Canal University, EgyptJournal Article20190805<strong><em>Background: </em></strong><strong>Several studies were done to assess macular edema after phacoemulsification and after phacoemulsification with intravitreal injection of either triamcinolone acetonide or bevacizumab. <em>Aim:</em> to identify the effect of intravitreal injection of either Triamcinolone acetonide or Bevacizumab for the management of Diabetic macular edema after Phacoemulsification. <em>Patients and Methods: </em>Preoperative BCVA was recorded, Preoperative assessment with Fluorescein Angiography (FFA) and Optical Coherence Topography (OCT) was recorded. Patients were allocated into 3 groups, for all groups phacoemulsification and posterior chamber Intra ocular lens was done then in group A intravitreal injection of triamcinolone acetonide was done, group B intravitreal injection of bevacizumab was done, and group C only phacoemulsification and posterior chamber IOL was done. Postoperatively BCVA for each patient in each group and</strong><strong> post operative FFA and assessment of the macular thickness with OCT were taken and recorded. <em>Results:</em></strong><strong>The study was carried on 39 patients, in group A there was an improvement of macular edema and reduction of central macular thickness postoperatively, also best corrected visual acuity was improved. In group B and group C there was deterioration of macular edema and increases in central macular thickness post operatively but best corrected visual acuity improved postoperatively. <em>Conclusion: </em></strong><strong>Intravitreal injection of triamcinolone acetonide is an effective method and more effective than bevacizumab for treatment of diabetic macular edema during phacoemulsification. </strong>
<strong> </strong>
<strong><em> </em></strong>https://scumj.journals.ekb.eg/article_43871_09670cb5891adb1b8653c68902743e1a.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Detection of blaKPC and blaNDM Genes in Carbapenems Resistant Strains of Klebsiella pneumoniae Isolated from some Egyptian Hospitals Patients17284398110.21608/scumj.2016.43981ENMoustafa MSalehDepartment of Microbiology and Immunology, Faculty of Pharmacy, Port Said University, Egypt,Al-Saied A-HHelalDepartment of Microbiology and Immunology, Faculty of Pharmacy, Al- Azhar University, Cairo, EgyptMoselhy SMansyDepartment of Microbiology and Immunology, Faculty of Pharmacy, Al- Azhar University, Cairo, EgyptKamel AAl-GhareebDepartment of Microbiology and Immunology, Faculty of Pharmacy, Al- Azhar University, Cairo, EgyptJournal Article20190805<strong><em>Background:</em></strong> <strong>Treatment of Klebsiella pneumoniae (K. pneumoniae) infections has become very difficult especially in the last decades as the levels of antibiotic resistance are becoming increasingly a serious problem throughout the world. <em>Aim:</em></strong> <strong>The growing number and rapid increase in carbapenems resistance which are the last resort of treatment of K. pneumoniae infections has urged for investigating some of these possible resistance mechanisms. <em>Materials and Methods: </em>A total of 202 K. pneumoniae isolates were selected from 593 specimens collected from patients attended 4 hospitals during the period from October 2013 to August 2014. Fifty-three multi-drug resistant (MDR) K. pneumoniae isolates which showed resistance to imipenem and/or meropenem were tested phenotypically and gynotypically for the producibility of Klebsiella pneumoniae carbapenmase (KPC) and New Delhi metallo β-lactamase (NDM) and the presence of bla<sub>KPC</sub> and bla<sub>NDM</sub> genes encoding for these enzymes respectively. <em>Results:</em></strong><strong>The rate of production of both potential KPC and NDM was 35/53 (66.04%), whereas only 8 of these 53 MDR K. pneumoniae isolates (15.1%) were positive for NDM but not KPC production. The rates of detection of potential bla<sub>KPC</sub> and bla<sub>NDM</sub> genes among the 35 MDR K. pneumoniae positive isolates for the production of both KPC and NDM were 10/35 (28.57%) and 5/35 (14.28%) respectively. <em>Conclusion: </em>bla<sub>KPC</sub> and bla<sub>NDM</sub> were detected in some MDR isolates. However,</strong> <strong>the presence of isolates devoid of both genes suggests that resistance against carbapenems could be due to mechanisms other than the production of KPC and NDM-β-lactamases.</strong>
<strong><em> </em></strong>https://scumj.journals.ekb.eg/article_43981_59bb64343540ae26e6aa801f3cb82b85.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Association of RS 7903146 (C/T) Single Nucleotide Polymorphism at Transcription Factor 7 Like 2 Gene with Type 2 Diabetes Mellitus in Egyptian Patients29384391110.21608/scumj.2016.43911ENNahed YAbd El RazekDepartment of Clinical Pathology, Faculty of Medicine, Suez Canal University, EgyptNeveen RWissaDepartment of Clinical Pathology, Faculty of Medicine, Suez Canal University, EgyptHassnaa MNassarDepartment of Clinical Pathology, Faculty of Medicine, Suez Canal University, EgyptSeham AOmarDepartment of Internal Medicine, Faculty of Medicine, Suez Canal University, EgyptJournal Article20190805<strong><em>Background:</em></strong><strong> Many loci were found to be associated with type 2 diabetes mellitus (T2DM) risk as single nucleotide polymorphism (SNP) at the transcription factor 7-like 2 gene (TCF7L2) locus on chromosome 10q (rs7903146) [C/T]. <em>Aim: </em>Estimation of the association of this gene polymorphism with T2DM and its complications in Egyptian population. <em>Patients and Methods:</em> This study was done, using 90 Egyptian T2DM patients and 100 controls. This polymorphism was genotyped by conventional PCR. Measurement of blood glucose, glycated hemoglobin (HbA<sub>1c</sub>), lipid profile, and microalbuminuria were performed for the study subjects using standard methods. Body Mass index and fundus examination for detection of diabetic retinopathy were also done. <em>Results:</em> The genotype and allele frequencies in TCF7L2 rs7903146 were nearly the same in the patient and control groups (P > 0.05).Odds Ratio for the high risk allele (T) of (rs7903146) was (OR) = 0.97 with 95% confidence interval (CI) from 0.61 to 1.54 with the P = 0.9. <em>Conclusion: </em>These data suggest that the TCF7L2 SNP rs7903146 may not significantly contribute to T2DM susceptibility in Egyptian population. </strong>https://scumj.journals.ekb.eg/article_43911_e72ffc4ba8fd3803a0edfcc19cc01f3a.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Evaluation of Prognostic Predictors of Mangled Extremity Severity Scoring System on the Outcome of Traumatic Extremities Injuries at Emergency Department in Suez Canal University Hospitals39474391610.21608/scumj.2016.43916ENAhmed AEssaDepartment of Emergency Medicine, Faculty of Medicine, Suez Canal University, EgyptIslam MEl-ShabouryDepartment of Emergency Medicine, Faculty of Medicine, Suez Canal University, EgyptYasmin EEl-BeltagyDepartment of Emergency Medicine, Faculty of Medicine, Suez Canal University, EgyptJournal Article20190805<strong><em>Background: </em></strong><strong>Severe traumatic lower limbs injuries have been associated with high incidence of multiple systems involved (integument, nerve, bone, and vascular structures). That’s make difficulty and stress on surgeon’s decision making either to amputate or preserve the injured limbs. The Mangled Extremity Severity Score (MESS) was developed in Seattle (Johansen et al 1990), based on both retrospective and prospective analysis of admission data of patients with severe limb injuries. <em>Aim: </em>evaluation of the prognostic predicting factors of outcome of traumatic extremities patients using Mangled Severity Scoring System at Emergency Department in Suez Canal University Hospital in order to help surgeon to make decision either to preserve or to amputate. <em>Patients and Methods:</em> This is a descriptive study (cross sectional), conducted on 60 patients with severe extremities injuries that met the criteria of the Mangled Extremity Severity Scoring attending to the Emergency Department (ED) at Suez Canal University Hospital. <em>Results:</em> This study showed that 83.33% of the patients had associated fractures, 8.33% of them had pneumothorax, 5% of them had abdominal collection and 3.33% of them had brain injuries. This study showed that 75% of the studied patients had MESS less than 7 while 25% of them had MESS > or = 7. The Mangled scoring system was a good predictor of amputation among the studied patients with sensitivity of 71.4%, specificity of 100% and 90% accuracy. <em>Conclusion: </em>Most of the patients had Mangled Extremity Severity Score less than 7. The MESS showed statistically significant difference between the amputated and the non-amputated patients with 90% accuracy in prediction of amputation.</strong>
<em> </em>https://scumj.journals.ekb.eg/article_43916_34ea9fb8cad2eb45dbafb31568798ae0.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Correlations between Selenium Levels and Diabetes Mellitus Type 2 in Chronic Hepatitis C-Infected Patients48594393610.21608/scumj.2016.43936ENNashaat MSolimanDepartments of Infectious and Endemic Diseases Faculty of Medicine, Suez Canal University, EgyptSalwa EEl-KhawagaDepartments of Clinical Pathology, Faculty of Medicine, Suez Canal University, EgyptEssam MAbdallahDepartments of Clinical Pathology, Faculty of Medicine, Suez Canal University, EgyptMohamed El-shabrawyDepartments of Clinical Pathology, Faculty of Medicine, Suez Canal University, EgyptJournal Article20190805<strong><em>Background:</em></strong><strong> Plasma </strong><strong>selenium (</strong><strong>Se) concentrations corresponding to optimal health are highly dynamic and based on a combination of factors that need to be considered when assessing epidemiological data, such as the findings linking serum Se and type 2 diabetes mellitus (DM). High serum Se concentrations may be associated with a higher occurrence of diabetes. <em>Aim:</em> To</strong><strong>e</strong><strong>valuate the correlations between serum Se levels and DM in patients with chronic </strong><strong>Hepatitis C (CHC)</strong><strong>. </strong><strong><em>Patients and Methods:</em></strong><strong>This case-control study</strong><strong>included three groups; group 1 (29 CHC patients with DM), group 2 (29 CHC patients without DM) and group 3 (29 healthy control). Subjects were tested for biochemical liver function tests, fasting blood sugar [FBS], and fasting insulin levels). Homeostasis model assessment (HOMA)-insulin resistance (IR) was calculated.<em> </em>Se levels were measured using Atomic Absorption Spectroscopy. <em>Results: </em>serum Se were significantly higher in group 1 and group 3 compared to group 2 (p<0.01). Meanwhile, serum Se were insignificantly higher in group 1 than in group 3 (p>0.05). </strong><strong>C</strong><strong>utoff value to differentiate diabetic and non-diabetic CHC patients using serum Se was >10 µg/l with sensitivity (76%) and, specificity (86.2%). The incidence and the risk of Se deficiency were significantly higher among group 2 than among group 2 (24.1% <em>vs</em>. 3.4%, respectively) (p<0.05)</strong><strong>. </strong><strong>In entire CHC patients (group 1+group 2), the mean HOMA-IR values were significantly lower in the group with deficient Se levels than in the group with normal Se levels (p=0.005)</strong><strong>. </strong><strong>A negative correlations between serum Se levels and ALT levels, AST levels, and diabetes treatment was found. <em>Conclusions:</em> Serum Se levels were significantly higher in CHC+DM group and in control group than in CHC group. The incidence and the risk of Se deficiency were higher among HCV group compared to CHC+DM group</strong><strong>.</strong>
<strong> </strong>https://scumj.journals.ekb.eg/article_43936_da0ce18f36c1a7adbe9ef206cfa1308b.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Autoimmune Neutropenia in Chronic Liver Disease Patients with Hepatitis C Virus at Suez Canal University Hospital60674394810.21608/scumj.2016.43948ENNashaat MSolimanDepartments of Infectious and Endemic Diseases Faculty of Medicine, Suez Canal University, EgyptFikry GobranDepartments of Clinical Pathology, Faculty of Medicine, Suez Canal University, Ismailia, EgyptFadia MAttiaDepartments of Clinical Pathology, Faculty of Medicine, Suez Canal University, Ismailia, EgyptNashwa RElessawyDepartments of Clinical Pathology, Faculty of Medicine, Suez Canal University, Ismailia, EgyptJournal Article20190805<strong><em>Background</em></strong><strong>: Chronic hepatitis C (CHC) continues to be a public health problem in Egypt with data suggesting that its incidence may be increasing. </strong><strong>H</strong><strong>epatitis C virus</strong><strong> (HCV) infection has been associated with a variety of extra-hepatic manifestations, including autoimmune disorders. <em>Aim: </em></strong><strong>To assess the prevalence of autoimmune neutropenia (AIN) in chronic liver disease (CLD) patients with HCV. <em>Patients and Methods:</em> A case-control design was used to fulfill the study objective. It was conducted on 60 subjects, divided into 2 groups: group 1 (30 HCV</strong><strong>-infected patients with low total leucocytic count [TLC] as a study group</strong><strong>) and group 2 (</strong><strong>30 HCV-infected patients with normal TLC as a control group). </strong><strong>AIN was evaluated by granulocyte immuno-fluorescence test (GIFT) to </strong><strong>detect auto-antibodies against neutrophils in HCV-infected patients presented with neutropenia. <em>Results: </em>The mean age of the first group was </strong><strong>49.9±11.6 years, while the </strong><strong>mean age of the second group was </strong><strong>52.7±11.3 years</strong><strong>. Male gender was found in 53.3% of the low TLC group compared to 63.3% in normal TLC group; </strong><strong>Positive GIFT was found in 13.3% of study group; while none of the control group has positive GIFT. The significant variables among patients with low TLC included low ANC (OR: 5.0, 95% CI: 1.5-16.5, low HB (OR: 7.0, 95% CI: 1.4-35.5), and low PLT count (OR: 15.5, 95% CI: 3.8-63.3). </strong><strong><em>Conclusion:</em></strong><strong>AIN is significantly higher among CHC patients with low TLC compared to normal TLC patients.</strong>
https://scumj.journals.ekb.eg/article_43948_981aaa13eb1a83877b25fcefbd646f27.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Emergency Room Risk Stratification of Patients with Chest Pain without ST Segment Elevation68754396610.21608/scumj.2016.43966ENEmad Eldin IsmailDepartment of Biochemistry, Faculty of Medicine, Suez Canal University, EgyptGamela NasrDepartments of Cardiology, Faculty of Medicine, Suez Canal University, EgyptAdel HElbaihDepartment of Emergency Medicine, Faculty of Medicine, Suez Canal University, EgyptMonira TIsmailDepartment of Emergency Medicine, Faculty of Medicine, Suez Canal University, EgyptYahia ElemamDepartment of Emergency Medicine, Faculty of Medicine, Suez Canal University, EgyptJournal Article20190805<strong><em>Background</em></strong><strong>: Emergency room triage of patients with chest pain is an ongoing challenge.</strong><strong>Over the years a number of modalities have been evolved for rapid diagnosis and better risk stratification of patients. <em>Aim:</em></strong><strong> to investigate the prognostic factors in patients who came to the Emergency Department with chest pain suspected of acute coronary syndrome without ST segment elevation. <em>Patients and Methods:</em> one-hundred and three consecutive patients (from Suez Canal university Hospital and Al Monira General Hospital) were evaluated by recording clinical history, electrocardiogram and troponin determination. Early (< 24 h) exercise testing was done for the low-risk subgroup of patients (n= 28). All patients were followed up for 3 months for major events (acute myocardial infarction or death). Results: Major events occurred in 14 patients (9.6%). Multivariate analysis identified the following predictors: age ≥65 years (OR = 1.7; p = 0.05), diabetes mellitus (OR = 2.9; p = 0.001), previous ischemic heart disease (OR = 2.5; p = 0.004), ST depression (OR = 2.1; p = 0.048) and troponin elevation (OR = 2.6; p = 0.003). These five predictors were used to construct a risk score based on their odds ratios, which allowed event risk stratification </strong><strong>0-3 points low risk 48% of the studied patients, 4-7 points intermediate risk 31% of the studied patients, 8 points or more high risk 21%of studied patients.</strong><strong> <em>Conclusions:</em> In patients with chest pain, the combination of clinical, electrocardiographic and biochemical data available on admission to the emergency service allows rapid prognostic stratification. Early exercise testing is advisable for the final stratification of low risk patients.</strong>
<strong><em> </em></strong>https://scumj.journals.ekb.eg/article_43966_19e8c99cba00a991ea653a79ee63f5ad.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Assessment of Vitamin D and Parathyroid Hormone in Type 2 Diabetes Mellitus76864396910.21608/scumj.2016.43969ENEnas ElkhamisyDepartment of Internal Medicine, Faculty of Medicine, Mansoura University, EgyptNeven FAbbasDepartment of Clinical Pathology, Faculty of Medicine, Mansoura University, EgyptRasha ElzeheryDepartment of Clinical Pathology, Faculty of Medicine, Mansoura University, EgyptJournal Article20190805<strong><em>Background:</em></strong><strong> Vitamin D deficiency has been proposed as a risk factor for diabetes mellitus type 2(DM type 2). Insulin receptor gene expression and insulin secretion are modulated by vitamin D, indicating their role in the pathogenesis and development of DM type 2. Furthermore, elevated PTH levels may play a role in the etiology of metabolic syndrome (MS), through an association with its individual components or via insulin resistance. <em>Aim: </em>This study aimed to investigate the role of vitamin D and parathyroid hormone in glycemic control of DM type 2. </strong><strong><em>Materials and Methods:</em></strong><strong> The study included 90 participants: 6o patients diagnosed as DM type 2 and 30 healthy age and sex-matched subjects as control. All studied subjects underwent full history taking and complete physical examination. Laboratory tests included fasting blood sugar (FBS), HbA1c, lipid profile, vitamin D and parathyroid hormone serum levels. <em>Results:</em></strong><strong> As regard 25(OH) vitamin D levels, 78.33% of patients were deficient or insufficient, compared to 20% of control subjects that were deficient or insufficient.</strong><strong> 25(OH) vitamin D levels showed a significant negative correlation with age (p= 0.002), weight (p=0.0001), BMI (p=0.0001) , FBG (p=0.0001), </strong><strong>HbA1C</strong><strong> (p=0.0001) and TG (p=0.002). Along with a significant positive correlation with HDL-C (p= 0.0001). PTH levels showed a significant negative correlation with HDL-c (P= 0.0001), 25(OH) vitamin D (P=0.001), in addition to a significant positive correlation with weight (P=0.0001), BMI (P=0.0001), FBG (P=0.005) and HbA1c (P=0.0001). <em>Conclusion</em>: Not only vitamin D but also parathyroid hormone may play a role in glycemic control in patients with DM Type 2 </strong>
https://scumj.journals.ekb.eg/article_43969_596c20d1081675e5b71a3323d35d0f8b.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301The Effect of Newly Introduced Bleaching Agent Listerine versus the Conventional Carbamide Peroxide on the Ultrastructure and Microhardness of Tooth Enamel87994398510.21608/scumj.2016.43985ENMarwa FEl ShafieDepartment of Oral Biology, Faculty of Dentistry, Suez Canal University, EgyptLaila SGhaliDepartment of Oral Biology, Faculty of Oral and Dental Medicine, Cairo University, Egypt.Rasha MTahaDepartment of Oral Biology, Faculty of Dentistry, Suez Canal University, EgyptJournal Article20190805<strong>Background: Tooth bleaching is one of the most conservative and cost-effective dental treatments to enhance a person’s smile. </strong><strong>Aim:</strong><strong> The aim of this study was to evaluate </strong><strong>the effect of the newly introduced prebrush bleaching agent Listerine versus carbamide peroxide on the ultrastructure and micro-hardness of the enamel.</strong><strong>Materials and Methods: </strong><strong>Thirty non-carious sound human premolars extracted for orthodontic reasons. Teeth samples were divided equally into three groups. Group </strong><strong>Ӏ</strong><strong> served as control group where specimens were immersed in artificial saliva, group </strong><strong>ӀӀ</strong><strong> treated with 22% carbamide peroxide for 5 sessions per day 15 minutes for 60 days and group </strong><strong>ӀӀӀ</strong><strong> treated with Listerine pre-brush rinse for 5 sessions per day 15 minutes for 60 days,</strong><strong> in between the sessions teeth were kept in artificial saliva.</strong><strong> At the end of the experiment, all teeth were hemi-sectioned longitudinal in mesio-distal direction to form 60 specimens. The lingual halves of all the groups were used for measuring enamel micro-hardness, while buccal halves were examined by scanning electron microscope (SEM) to detect any ultrastructural changes of enamel of the different groups. </strong><strong>Results: SEM results showed </strong><strong>morphological alterations on the enamel surface of group </strong><strong>ӀӀ</strong><strong> and group </strong><strong>ӀӀӀ</strong><strong> compared with control group </strong><strong>Ӏ</strong><strong> as appeared surface pitting, porosity, irregularity, roughness, craters like depression and micro-cracks. Results of enamel surface micro-hardness showed</strong><strong>no significant differences were found among the bleaching groups (</strong><strong>ӀӀ</strong><strong>-</strong><strong>ӀӀӀ</strong><strong>) (p=0.371). However, all bleaching agents produced a significant increase in the mean value of micro-hardness of enamel compared to the untreated control group (</strong><strong>Ӏ</strong><strong>) as there are highly significant between group </strong><strong>Ӏ</strong><strong> and other groups as group </strong><strong>ӀӀ</strong><strong> (p=0.003) and group </strong><strong>ӀӀӀ</strong><strong> (p=0.026). </strong><strong>Conclusion </strong><strong>bleaching abuse had a negative influence on the morphology of enamel and its micro-hardness. The home dental bleaching should be done with caution.</strong>https://scumj.journals.ekb.eg/article_43985_1468ed2e4b33aa5685eb5022d842b89c.pdfSuez Canal University, Faculty of MedicineSuez Canal University Medical Journal1110-699919120160301Assessment of Immunoglobulin-E and Interleukin-4 Levels in Papular Urticaria Patients1011064397510.21608/scumj.2016.43975ENDoaa AEwaisDepartment of Dermatology and Venereolgy, Faculty of Medicine, Suez Canal University, EgyptMoustafa MEyadaDepartment of Dermatology and Venereolgy, Faculty of Medicine, Suez Canal University, EgyptFadia MAttiaDepartment of Clinical Pathology, Faculty of Medicine, Suez Canal University, EgyptAmal HAhmedDepartment of Dermatology and Venereolgy, Faculty of Medicine, Suez Canal University, EgyptJournal Article20190805<strong><em>Background</em></strong><strong>: Papular urticaria is a common and often annoying disorder manifested by chronic papules caused by a hypersensitivity reaction. The link between atopic immune responses (high serum IgE, IL-4) and the development of rash is clear and has been extensively evaluated in the literature. <em>Aim:</em> This study was designed to find possible co relation between serum levels of IgE and IL-4 and popular urticaria. <em>Patient and Methods:</em> A case control study was done that included </strong><strong>30 patients and 30 controls who were selected randomly according to the eligibility criteria. Assessment of serum IG-E and IL-4 levels was evaluated using sandwich ELISA approach. <em>Results:</em> </strong><strong> Twenty-six patients (87%) have borderline level of IgE, 1 (3%) have high level, while normal IgE level was found in 3 (10%). In the control group, 3 subjects (10%) have borderline level of IgE and 27 (90%) have normal level, while no subject had high IgE level were found. <em>Conclusions:</em> The present study confirmed the significantly higher values of serum IgE and IL-4 in papular urticaria patients. There was statistically significant correlation between the IL-4 and IgE levels in papularr urticaria patients.</strong>
<strong><em> </em></strong>https://scumj.journals.ekb.eg/article_43975_5fc2236bdcfb48fcf739bc9a91de3737.pdf