發(fā)布時(shí)間：2018-06-10 06:47

  本文選題：甲狀腺激素 + 促甲狀腺激素��； 參考：《第四軍醫(yī)大學(xué)》2016年博士論文

【摘要】：甲狀腺激素對(duì)維持和調(diào)節(jié)細(xì)胞內(nèi)能量平衡十分關(guān)鍵,同時(shí)對(duì)糖脂代謝、血壓和身體成分都有著多重效應(yīng)。因此,將甲狀腺功能維持到正常狀態(tài)對(duì)于維持機(jī)體的正常功能十分重要。能夠影響體內(nèi)甲狀腺激素水平的因素有很多,環(huán)境中的碘的攝入和個(gè)體的遺傳因素在其中占了很大比例。近些年來,隨著全基因組關(guān)聯(lián)性研究(GWAS)在各種疾病和人體功能領(lǐng)域研究的應(yīng)用,人們對(duì)影響甲狀腺激素水平的遺傳因素有了更深的認(rèn)識(shí),很多能夠影響甲狀腺功能的單核苷酸多態(tài)性(SNP)位點(diǎn)進(jìn)入了人們的視野。代謝綜合征(Metabolic syndrome,MS),是以一系列心血管風(fēng)險(xiǎn)因子為代表的代謝紊亂癥候群,胰島素抵抗是其病理生理發(fā)展過程的核心特征。鑒于甲狀腺激素在能量代謝中的關(guān)鍵作用,其水平與各種MS相關(guān)參數(shù)亦會(huì)有相關(guān)性。很多研究已經(jīng)針對(duì)甲狀腺功能異常和MS組分的關(guān)系進(jìn)行了研究,甲狀腺功能亢進(jìn)和甲狀腺功能減退都已被證明與胰島素抵抗呈正相關(guān)。在過去的十年間,一些研究也對(duì)甲狀腺功能正常人群中的甲狀腺激素水平和MS及其組分的相關(guān)性進(jìn)行了研究,但這些結(jié)果并不一致。同時(shí),由于遺傳因素能夠影響甲狀腺功能,因此甲狀腺相關(guān)snp與機(jī)體代謝和疾病的研究也有很多,但在不同的人群中結(jié)果亦不盡相同。中國(guó)幅員遼闊,人口眾多,各地的地理環(huán)境不同,人口的遺傳學(xué)背景也難免具有差異。因此,本研究以陜西省流行病學(xué)調(diào)查人群為基礎(chǔ),為進(jìn)一步明確甲狀腺激素水平與ms及其組分的關(guān)系,分析相關(guān)snp對(duì)甲狀腺激素乃至ms的影響,我們進(jìn)行了如下五部分研究。第一部分西安人群正常甲狀腺激素水平參考值范圍的制定目的:在既往碘缺乏、目前碘超足量的西安地區(qū)建立甲狀腺激素水平的參考值范圍,同時(shí)探索影響甲狀腺功能的因素。方法:本研究納入的研究對(duì)象為2012年至2013年間,我科在西安地區(qū)進(jìn)行的流行病學(xué)調(diào)查的數(shù)據(jù)庫(kù)資料。共1286人參與了研究,其中717人被選擇作為參考值人群。研究共檢測(cè)了促甲狀腺激素(tsh)、游離t4(ft4)、游離t3(ft3)、t4、t3、甲狀腺過氧化物酶抗體(tpo-ab)和甲狀腺球蛋白抗體(tg-ab),同時(shí)還進(jìn)行了甲狀腺超聲的檢查。結(jié)果:新建立的甲狀腺激素水平參考值范圍為:tsh:0.43-5.51miu/l;ft4:11.0-20.4pmol/l,ft3:3.63-5.73pmol/l,t4:67.8-157mmol/l,t3:1.08-2.20mmol/l,與試劑供應(yīng)商提供的數(shù)據(jù)有所不同。ft3水平在不同年齡組間具有顯著的統(tǒng)計(jì)學(xué)差異(p0.05),而tsh、ft4、t4水平則在不同年齡間沒有顯著差異(p0.05)。男性的ft3、ft4和t3水平均高于女性(p0.05)。甲狀腺超聲異常組和抗甲狀腺自身抗體陽性組的tsh水平高于參考值人群。結(jié)論:我們的研究為中國(guó)西部人群診斷甲狀腺疾病提供了有意義的參考值范圍�？紤]到中國(guó)大部分內(nèi)陸地區(qū)都經(jīng)歷了一個(gè)從碘缺乏到碘超足量的轉(zhuǎn)變,我們建議在中國(guó)與西安有相似碘營(yíng)養(yǎng)狀況的地區(qū)都采用我們的參考值范圍。第二部分陜西人群正常范圍內(nèi)甲狀腺功能與代謝綜合征的橫斷面研究目的:通過橫斷面研究分析正常范圍內(nèi)甲狀腺激素水平與ms及其組分間的相關(guān)關(guān)系。方法:本部分的研究對(duì)象為2007年至2008年中國(guó)糖尿病及代謝紊亂研究中陜西省部分的人群。所有受試者均進(jìn)行了體格檢查、體脂百分比檢測(cè)、心電圖檢查,完成了ogtt試驗(yàn)或饅頭餐試餐試驗(yàn),檢測(cè)了血脂、血糖、胰島素、甲狀腺激素水平,完成了標(biāo)準(zhǔn)化的調(diào)查問卷。先將人群以甲狀腺功能分組,比較了亞臨床甲狀腺異常組與正常組間ms及其組分的差別,后將甲狀腺激素水平正常的人群按ft4水平三分位分組,比較各組間ms及相關(guān)組分的差異。最后以甲狀腺激素水平為自變量,ms組分為因變量,分別進(jìn)行了多元線性回歸和logistic回歸分析,分析甲狀腺激素和ms的相關(guān)關(guān)系。結(jié)果:研究共納入?yún)⑴c者2991名,其中亞臨床甲狀腺功能亢進(jìn)癥76名,亞臨床甲狀腺功能減退癥121名,亞臨床甲狀腺功能異常對(duì)總的ms發(fā)生率沒有統(tǒng)計(jì)學(xué)差異(p0.05)。在甲狀腺功能正常人群中,sbp、dbp、fbg、fins、aucglu、aucins、homa-ir、tc、ldl-c、tg等均隨ft4水平升高而升高,而hdl-c水平隨ft4水平升高而降低(p0.01);隨ft4水平的升高,ms和腹型肥胖、高血糖、高血壓、高tg和低hdl-c的發(fā)生率均逐步升高(p0.01)。logistic回歸結(jié)果顯示,與第一分位相比,ms在ft4、ft3第三分位發(fā)生風(fēng)險(xiǎn)較高(orft4:2.48,95%cift4:1.93-3.17;orft3:1.94,95%cift3:1.45-2.58),在ft3/ft4比值第三分位發(fā)生風(fēng)險(xiǎn)較低(or:0.52,95%ci:0.41-0.66);在tsh第三分位發(fā)生風(fēng)險(xiǎn)有升高趨勢(shì),但無統(tǒng)計(jì)學(xué)差異(or:1.26,95%ci:0.99-1.59)。結(jié)論:本次橫斷面研究結(jié)果顯示不同亞臨床甲狀腺功能異常狀態(tài)對(duì)總的ms發(fā)生率沒有顯著的影響。在甲狀腺功能正常人群中,ms與其相關(guān)組分與ft4、ft3水平呈正相關(guān),與ft3/ft4比值水平呈負(fù)相關(guān),與tsh水平無顯著相關(guān)性。第三部分:陜西人群正常范圍內(nèi)甲狀腺功能與代謝綜合征組分的隨訪研究目的:通過隨訪研究分析正常范圍內(nèi)甲狀腺功能與代謝綜合征組分的相關(guān)性。方法:本部分的基線研究對(duì)象為2007年至2008年中國(guó)糖尿病及代謝紊亂研究中陜西省部分的人群,2012年至2013年間對(duì)該部分人群進(jìn)行了5年后的隨訪。在這兩次流行病學(xué)調(diào)查,所有受試者均進(jìn)行了體格檢查、體脂百分比檢測(cè)、心電圖檢查,完成了ogtt試驗(yàn)或饅頭餐試餐試驗(yàn),檢測(cè)了血脂、血糖、胰島素、甲狀腺激素水平,完成了標(biāo)準(zhǔn)化的調(diào)查問卷。以ms相關(guān)參數(shù)的變化值為自變量,甲狀腺激素水平的變化值為因變量,進(jìn)行了多元線性回歸分析,分析ms相關(guān)參數(shù)的變化與甲狀腺激素水平變化間的相關(guān)關(guān)系。結(jié)果:本研究共納入符合條件的隨訪對(duì)象668人。多元線性回歸分析結(jié)果顯示,腰圍、體脂百分比、bmi及l(fā)dl-c的變化與ft3的變化呈正相關(guān)(p0.05);體脂百分比、sbp、dbp、tc、ldl-c及fbg的變化與ft4的變化呈正相關(guān);腰圍、bmi的變化量與ft3/ft4比值的變化量呈正相關(guān)(p0.05),而體脂百分比、sbp、hdl-c和fbg的變化量與ft3/ft4比值的變化量呈負(fù)相關(guān);代謝參數(shù)的變化與tsh的變化的相關(guān)性均無統(tǒng)計(jì)學(xué)意義(p0.05);腰圍、sbp、dbp的改變與t3的改變呈正相關(guān)(p0.05);bmi、tc、tg改變與t4的改變呈負(fù)相關(guān)(p0.05)。結(jié)論:本次隨訪研究結(jié)果顯示部分代謝相關(guān)指標(biāo)的變化與ft3、ft4、ft3/ft4比值、t3和t4的變化有相關(guān)性,而與tsh的變化無顯著相關(guān)性。提示代謝參數(shù)的變化可能會(huì)導(dǎo)致甲狀腺激素水平在正常范圍內(nèi)波動(dòng)。第四部分陜西人群甲狀腺相關(guān)基因多態(tài)性與甲狀腺功能的相關(guān)性目的:在陜西省人群中評(píng)價(jià)甲狀腺相關(guān)基因多態(tài)性與甲狀腺激素水平的關(guān)系。方法:本部分的研究對(duì)象為2007年至2008年中國(guó)糖尿病及代謝紊亂研究中陜西省部分的人群,利用massarray分子量陣列技術(shù)對(duì)甲狀腺相關(guān)遺傳多態(tài)性位點(diǎn)rs10032216、rs753760、rs10799824、rs2046045和rs2235544的基因型分布情況進(jìn)行檢測(cè)。比較不同位點(diǎn)各基因型之間甲狀腺激素和tsh水平的差異。并以各snp位點(diǎn)的等位基因?yàn)樽宰兞?甲狀腺激素和tsh水平為因變量,利用多元線性回歸分析不同等位基因與甲狀腺激素和tsh水平的相關(guān)性。結(jié)果:本研究共納入研究對(duì)象2486人。dio1基因rs2235544位點(diǎn)次要等位基因a的攜帶者ft4和t4水平隨堿基a的出現(xiàn)而升高,ft3和ft3/ft4比值水平隨堿基a的出現(xiàn)而降低(p0.05)。在nr3c2基因rs10032216位點(diǎn)、pde8b基因rs2046045位點(diǎn)、pde10a基因rs753760位點(diǎn),tsh水平隨次要等位基因的出現(xiàn)而降低(p0.05)而ft3、ft4、ft3/ft4比值、t3、t4水平在不同基因型間均無統(tǒng)計(jì)學(xué)差異(p0.05)。capzb基因rs10799824位點(diǎn),tsh、ft3、ft4、ft3/ft4比值、t3、t4水平在不同基因型間均無統(tǒng)計(jì)學(xué)差異(p0.05)。結(jié)論:在中國(guó)陜西漢族人群中,dio1基因rs2235544位點(diǎn)與循環(huán)中ft3、ft4水平有顯著相關(guān)性,nr3c2基因rs10032216位點(diǎn)、pde8b基因rs2046045位點(diǎn)、pde10a基因rs753760位點(diǎn)與血清中tsh水平顯著相關(guān),而capzb基因rs10799824位點(diǎn)與甲狀腺激素和tsh水平無相關(guān)性。第五部分陜西人群dio1基因多態(tài)性與代謝綜合征的相關(guān)性分析目的:在陜西省人群中評(píng)價(jià)甲狀腺1型脫碘酶dio1基因多態(tài)性與ms及其組分間的關(guān)系。方法:本部分的研究對(duì)象為2007年至2008年中國(guó)糖尿病及代謝紊亂研究中陜西省部分的人群,通過massarray分子量陣列技術(shù)對(duì)dio1基因rs2235544的基因型分布情況進(jìn)行檢測(cè)。應(yīng)用病例對(duì)照研究,選取人群中ms患者和健康對(duì)照,比較各組間基因型分布的差異。利用pearson卡方檢驗(yàn)分析病例組和對(duì)照組基因型頻率的差別,應(yīng)用logistic回歸分析rs2235544位點(diǎn)與ms及其組分間的相關(guān)關(guān)系,應(yīng)用協(xié)方差分析比較代謝相關(guān)參數(shù)在不同基因型間的差別,應(yīng)用多元線性回歸分析該位點(diǎn)與代謝相關(guān)參數(shù)的相關(guān)性。結(jié)果:dio1基因rs2235544位點(diǎn)次要等位基因a在ms組的發(fā)生率較高,和對(duì)照組相比具有統(tǒng)計(jì)學(xué)差異(p0.01)。logistic回歸分析結(jié)果顯示,在顯性模型中,等位基因a的顯性基因型c/a-a/a與ms的患病率顯著相關(guān)(or=1.38,p=0.039)。協(xié)方差分析結(jié)果顯示,tg在不同基因型間具有統(tǒng)計(jì)學(xué)差異(p=0.045),而其他參數(shù)在不同基因型間無統(tǒng)計(jì)學(xué)差異(p0.05)。對(duì)rs2235544位點(diǎn)的加性模型進(jìn)行多元線性回歸,結(jié)果顯示校正了性別和年齡后,空腹胰島素(fins)和homa-ir與等位基因a的出現(xiàn)呈正相關(guān),且具有統(tǒng)計(jì)學(xué)意義(p0.05)。在分別進(jìn)一步校正bmi和homa-ir后,其正相關(guān)的統(tǒng)計(jì)學(xué)意義消失(p0.05)。結(jié)論:在陜西人群中,DIO1基因rs2235544位點(diǎn)多態(tài)性與MS發(fā)生風(fēng)險(xiǎn)的增加明顯相關(guān),其機(jī)制可能與胰島素抵抗增強(qiáng)有關(guān)。然而,該觀點(diǎn)還需要在其他人群中進(jìn)行驗(yàn)證。
[Abstract]:Thyroid hormones are crucial for maintaining and regulating energy balance in cells, and have multiple effects on glycolipid metabolism, blood pressure and body composition. Therefore, the maintenance of thyroid function to normal state is important for maintaining the normal function of the body. There are many factors that can affect the level of thyroid gland hormone in the body. In recent years, with the application of whole genome association study (GWAS) in the research of various diseases and human functions, people have a deeper understanding of the genetic factors affecting the thyroid hormone levels and a lot of single nucleotide polymorphisms (SNP) that can affect the thyroid function. Metabolic syndrome (MS) is a metabolic disorder characterized by a series of cardiovascular risk factors. Insulin resistance is the core feature of its pathophysiological process. In view of the key role of thyroid hormone in energy metabolism, its level is also associated with various MS related parameters. Many studies have studied the relationship between abnormal thyroid function and MS components. Hyperthyroidism and hypothyroidism have been shown to be positively related to insulin resistance. In the past ten years, some studies have also shown the levels of thyroid hormones and MS and their components in normal thyroid function population. The results are not consistent, but the results are not consistent. At the same time, because genetic factors can affect thyroid function, there are many studies on thyroid related SNP and body metabolism and disease, but the results are not the same in different populations. China has a vast territory, a large population, different geographical environment and population genetics. The background is also unavoidable. Therefore, based on the epidemiological survey of Shaanxi Province, to further clarify the relationship between thyroid hormone level and MS and its components, the effects of SNP on thyroid hormone and MS are analyzed. We have carried out the following five parts. Part one, normal thyroid hormone levels in Xi'an population Objective: to establish the range of reference values of thyroid hormone levels in the past iodine deficiency and the current iodine excess in Xi'an, and to explore the factors affecting the thyroid function. Methods: the object of this study was the database of epidemiological surveys conducted in the Xi'an area from 2012 to 2013. A total of 1286 people were involved in the study, of which 717 were selected as a reference group. A total of thyroid stimulating hormone (TSH), free T4 (FT4), free T3 (FT3), T4, T3, thyroid peroxidase antibody (TPO-Ab) and thyroglobulin antibody (tg-ab) were detected. Thyroid hormone water was also examined at the same time. Results: newly established thyroid hormone water The range of reference values was tsh:0.43-5.51miu/l; ft4:11.0-20.4pmol/l, ft3:3.63-5.73pmol/l, t4:67.8-157mmol/l, t3:1.08-2.20mmol/l, and the data provided by the Reagent Suppliers had significant statistical differences between different age groups (P0.05), while TSH, FT4 and T4 levels were not significantly different between different ages (P0.05). Men's FT3, FT4, and T3 levels were higher than women (P0.05). The TSH levels in the thyroid ultrasound group and the anti thyroid autoantibody positive group were higher than those of the reference group. Conclusion: our study provides a meaningful reference range for the diagnosis of thyroid disease in Western China. From iodine deficiency to iodine excess, we suggest that we use our reference range in areas with similar iodine nutritional status in China and Xi'an. Second part of the cross-sectional study of thyroid function and metabolic syndrome in the normal range of Shaanxi population: a cross-sectional study of thyroid hormone levels and MS in the normal range Methods: the subjects of this part were the population of Shaanxi Province in the study of diabetes and metabolic disorders in China from 2007 to 2008. All the subjects performed physical examination, body fat percentage test, electrocardiogram examination, completed the OGTT test or steamed bread meal test, and tested the blood lipid, blood sugar, islet. A standardized questionnaire was completed for the level of thyroid hormone. First, the population was grouped with thyroid function, and the difference of MS and its components between the subclinical thyroidism group and the normal group was compared. Then the group with normal thyroid hormone level was divided into three subgroups at the level of FT4, compared with the MS and the related components in each group. Adenoid hormone level was the independent variable, MS group was divided into dependent variables, multiple linear regression and logistic regression analysis were carried out to analyze the correlation between thyroid hormone and MS. Results: the study included 2991 participants, including 76 subclinical hyperthyroidism, 121 subclinical hypothyroidism, subclinical thyroid dysfunction. There was no significant difference in the incidence of total MS (P0.05). In normal thyroid function population, SBP, DBP, FBG, fins, aucglu, AUCIns, HOMA-IR, TC, LDL-C, TG, etc. The incidence of P0.01.Logistic regression showed that the risk of MS at FT4, FT3 third division was higher (orft4:2.48,95%cift4:1.93-3.17; orft3:1.94,95%cift3:1.45-2.58), and the risk of ft3/ft4 ratio third was lower (or: 0.52,95%ci:0.41-0.66), and the risk of occurrence in TSH third was higher than that of the first division. There was no statistical difference (or:1.26,95%ci:0.99-1.59). Conclusion: the results of this cross-sectional study showed that different subclinical thyroid dysfunction had no significant influence on the incidence of total MS. In normal thyroid function population, MS and its related components were positively correlated with FT4, FT3 water level, and negative correlation with ft3/ft4 ratio, and TSH No significant correlation. Third part: follow up study of thyroid function and metabolic syndrome in the normal range of Shaanxi population. Follow up study to analyze the correlation between thyroid function and metabolic syndrome in normal range. Methods: this part of the baseline study was on diabetes and metabolism in China from 2007 to 2008. In the study of the disorder, some people from Shaanxi province were followed up for 5 years from 2012 to 2013. In these two epidemiological surveys, all subjects performed physical examination, body fat percentage test, electrocardiogram examination, completed the OGTT test or steamed bread meal test, and detected blood lipids, blood sugar, insulin, thyroid gland. A standardized questionnaire was completed. The variation value of MS related parameters was the independent variable. The variation value of thyroid hormone level was the dependent variable. The multivariate linear regression analysis was carried out to analyze the correlation between the changes of MS related parameters and the changes of thyroid hormone levels. Results: the results were included in the eligible follow-up subjects. The results of multivariate linear regression analysis showed that the changes in waist circumference, body fat percentage, BMI and LDL-C were positively correlated with the changes of FT3, and the changes of body fat percentage, SBP, DBP, TC, LDL-C and FBG were positively correlated with the changes of FT4; the changes in waist circumference and BMI were positively correlated with the variation of ft3/ft4 ratio, and the percentage of body fat The change of BG was negatively correlated with the change of ft3/ft4 ratio, and there was no significant correlation between the changes of metabolic parameters and the changes of TSH (P0.05); the changes in waist circumference, SBP, DBP were positively correlated with the changes of T3; BMI, TC, TG changes were negatively correlated with the changes of T4. Conclusion: the results of this follow-up study showed partial metabolic related indicators. The changes in FT3, FT4, ft3/ft4, T3 and T4 were correlated, but there was no significant correlation with the changes of TSH. It was suggested that the changes in metabolic parameters may lead to the fluctuation of thyroid hormone levels in the normal range. Fourth the correlation of thyroid related gene polymorphisms in Shaanxi population and thyroid function: in Shaanxi province population The relationship between thyroid related gene polymorphism and thyroid hormone levels was evaluated. Methods: the subjects of this part were the population of Shaanxi province in the study of diabetes and metabolic disorders in China from 2007 to 2008. Massarray molecular weight array technique was used for thyroid related genetic polymorphisms rs10032216, rs753760, rs10799824, rs204. The genotypic distribution of 6045 and rs2235544 was detected. The differences in thyroid hormones and TSH levels between different genotypes of different loci were compared. The alleles of each SNP locus were taken as independent variables, thyroid hormones and TSH levels were the dependent variables, and the correlation of different alleles with thyroid hormones and TSH levels was analyzed by multiple linear regression. Results: the level of FT4 and T4 increased with the presence of base a, and the level of FT3 and ft3/ft4 decreased with the presence of base a (P0.05) in the study of the.Dio1 gene rs2235544 loci of the 2486 people, and the FT3 and ft3/ft4 ratio decreased with the presence of base a (P0.05). The level of FT3, FT4, ft3/ft4, T3, T4 in different genotypes was not statistically different (P0.05).Capzb gene rs10799824 loci, TSH, FT3, FT4, and the ratio between the different genotypes. Conclusion: in the Han population of Shaanxi, Shaanxi, China There is a significant correlation between the rs2235544 locus and the level of FT3 and FT4 in the cycle. The nr3c2 gene rs10032216 site, the rs2046045 locus of the pde8b gene, the rs753760 locus of the pde10a gene and the TSH level in the serum are significantly related, while the capzb gene rs10799824 loci are not related to the thyroid hormone and the level. The fifth part of the Shaanxi population is polymorphic and generation. The correlation analysis of the Xie syndrome Objective: To evaluate the relationship between the polymorphisms of thyroid 1 deiodidan dio1 gene and MS and its components in the population of Shaanxi province. Methods: the object of this study was the population of Shaanxi Province in the study of diabetes and metabolic disorders in China from 2007 to 2008, and the dio1 gene was detected by massarray molecular weight array technology. The genotype distribution of rs2235544 was detected. A case-control study was used to select MS patients and healthy controls to compare the differences in genotype distribution among the groups. The difference between the genotype frequencies of the case group and the control group was analyzed by the Pearson chi square test, and the correlation between the rs2235544 site and the MS and its components was analyzed by logistic regression. Covariance analysis was used to compare the differences of metabolic parameters in different genotypes. The correlation between the site and metabolic parameters was analyzed by multiple linear regression. Results: the incidence of secondary allele A in the rs2235544 site of dio1 gene was higher in the MS group than in the control group (P0.01).Logistic regression score. The results showed that in the dominant model, the dominant genotype c/a-a/a of the allele A was significantly correlated with the prevalence of MS (or=1.38, p=0.039). The covariance analysis showed that TG had statistical differences between different genotypes (p=0.045), but the other parameters were not statistically different in different genotypes (P0.05). The additive model to the rs2235544 locus was the additive model. After multiple linear regression, the results showed that there was a positive correlation between fasting insulin (fins) and HOMA-IR and the occurrence of allele A after correction of sex and age, and had statistical significance (P0.05). The statistical significance of the positive correlation was disappeared after the further correction of BMI and HOMA-IR (P0.05). Conclusion: the rs2235544 position of DIO1 gene in the Shaanxi population. Point polymorphism is associated with an increase in the risk of MS, and its mechanism may be associated with increased insulin resistance. However, this view is also required to be verified in other populations.
【學(xué)位授予單位】：第四軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R589

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