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??????? Fuzy Background: Anaemia is common globally specially in developing countries where nutrient deficiencies are prevalent. It is just a common problem inside the outpatient collection but it’s always neglected and taken lightly which can trigger hyperdynamic blood flow disturbances and raise the rate of morbidity and mortality. Aim: To look for the prevalence of microcytic Hypochromic anaemia in medicine er casualty in academy instructing hospital.

Method: This is a descriptive cross-sectional study which has been done in the Academy Instructing Hospital by which 75 in the emergency room sufferers participated inside the study.

Your nutrition with the patients was evaluated with a questionnaire clarified by the patients. Chapter A single Introduction and Literature Assessment 1 . you Introduction Anaemia Anaemia is defined as the lowering of the oxygen-transporting capacity of blood, which will stems from a discount of the total circulating reddish colored cell mass to beneath normal portions. Blood haemoglobin level can be below 13. 5 g/dl in an mature male and below 14. 5 g/dl in an adult female. (1) Classification: Labeled according to: 1 . Causes: a. Not enough production of RBC. b. Blood loss anaemia: * Serious: due to severe hemorrhage. 5. Chronic: due to GIT bleeding, menorrhagia.. Excessive destruction of RBC (haemolysis). 2 . Morphology: a. Microcytic: * Iron deficiency. 2. Thalassemia. 5. Sideroblastic. b. Microcytic: 2. Folate deficiency. * B-12 deficiency. c. Normocytic: 5. Aplastic anaemia. * Myelodysplastic anaemia. There are numerous undiagnosed instances of anaemia that if left hidden can lead to a number of complications, these include: (2) 1 . Attacks: people with the anaemia are usually more susceptible to having infections coming from viruses and bacteria. installment payments on your Severe bleeding: if bleeding is serious, internal and excessive after that death may ensue if the blood transfusion is certainly not given and the cause of the bleeding is definitely not remedied.. Stroke: if haemoglobin is defective, it can damage the walls of the reddish blood vessels which can result in reducing or even obstructions in the mind, which can cause serious, deadly strokes. (2) Microcytic Hypochromic Anaemia Microcytic anemia is a blood disorder characterized by small red blood cells (erythrocytes) which have insufficient haemoglobin and hence have a lower ability to carry oxygen through the body. The red blood cells are small due to a failure of haemoglobin synthesis or insufficient quantities of haemoglobin readily available. (3) Classification: 1 . Flat iron deficiency anaemia. Sideroblastic anaemia. 3. Thalassemia. Iron deficiency anaemia Really estimated as the main reason behind anaemia influencing about 10% of the inhabitants in developed countries and 25-50% in developing countries. The prevalence of iron deficiency anemia in the United States was 2 percent in men, but was found to be more widespread in child-bearing women grow older. (4) Muscle building iron articles is about 2gm for females, and 6gm pertaining to males. Most of the iron inside the body is present in hemoglobin within erythrocytes (80%), with the remainder being present in myoglobin and iron made up of enzymes.

Flat iron is kept in liver, spleen organ, bone marrow and bone muscle. This iron storage space pool contains on average 15-20% of body building iron. (4) Iron is usually transported inside the plasma by simply an straightener binding healthy proteins called transferrin. In usual individuals, transferrin is about 33% saturated with iron. Nutritional iron can be obtained possibly from inorganic sources or perhaps animal sources. Dietary flat iron enters intestinal cells by means of specific transporters. The flat iron is then utilized by the cellular, stored as ferritin or transferred to the plasma. (4) Erythropoiesis is definitely the development procedure in which new erythrocytes are produced, by which each cellular matures in about seven days.

Through this method erythrocytes will be continuously produced in the reddish colored bone marrow of large our bones, at a rate of around 2 mil per second in a healthier adult. The blood’s red colorization is due to the spectral properties of the hemic iron ions in hemoglobin. The red blood of an normal adult individual male retail outlet collectively regarding 2 . a few grams of iron, symbolizing about 65% of the total iron within the body. (5)(6) Causes: * Poor consumption. * Decreased absorption (celiac disease, gastrectomy). * Improved demand in growing teenagers and being pregnant. * Blood loss from GIT due to: * Hookworm pests. Erosions associated with NSAID, peptic ulcer or neoplastic disease. * Hemorrhoid distress. * Blood loss from infrequent or excessive menstruation. Symptoms and indications (7) Symptoms may include: 5. Fatigue. * Shortness of breath * Lightheadedness. 5. Palpitations. 5. Dizziness. 2. Chest pain. 5. Blurred vision. * Sleeping disturbance. Symptoms may include: * Rapid heart rate. * Low blood pressure. * Rapid breathing. * Light conjunctiva. * Cold pores and skin. * Growth of the spleen organ. Diagnosis of straightener deficiency anaemia: * Finish blood count number and color: with straightener deficiency anaemia red blood cells happen to be smaller and paler in color than normal. Hematocrit: This is the percentage of blood vessels volume made-up by red blood cells. Normal amounts are generally 41% for mature women and 47% for men. These beliefs may change depending on your actual age. * Haemoglobin: Lower than usual hemoglobin levels indicate anemia (12-16 g/dl in an mature male and 13. 7-17. 5 g/dl in an adult female). 5. Ferritin: This protein helps store iron in your body, and a low level of ferritin usually indicates a minimal level of kept iron. Some tests might be done to discover the actual cause, like: * Endoscopy: Often to look for bleeding from a hiatal hernia, a great ulcer or the stomach. Colonoscopy: To rule out lower intestinal sources of blood loss. * Ultrasound: Women might also have a pelvic ultrasound to look for the source of excess menstrual bleeding, such as uterine fibroids. (8)(9) Sideroblastic anaemia It is a disease in which the bone fragments marrow produces ringed sideroblasts rather than healthy and balanced red blood cells (erythrocytes). [10] In Sideroblastic anemia, the body offers iron obtainable but are unable to incorporate it into hemoglobin, which blood need to travel oxygen efficiently.

Sideroblasts happen to be atypical, irregular nucleated erythroblasts (precursors to mature reddish blood cells) with lentigo of flat iron accumulated in perinuclear mitochondria. [11] Sideroblasts are seen in aspirates of bone marrow. Causes: 5. Failure to fully form heme molecules, This leads to deposits of iron in the mitochondria that form an engagement ring around the center of the expanding red bloodstream cell. * Toxins: lead, copper or perhaps zinc poisoning * Drug-induced: ethanol, isoniazid, chloramphenicol, cycloserine, Oral Contraceptives 2. Nutritional: pyridoxine (Vitamin B6) or birdwatcher deficiency 5. Diseases: Arthritis rheumatoid, or multiple myeloma Innate: ALA synthase deficiency (X-linked, associated with ALAS2)[12] Symptoms and signs: 2. Pale epidermis, eyelids and lips. 5. Fatigue and weakness. * Dizziness. 5. Enlarged liver and/or spleen organ. Diagnosis: Ringed sideroblasts are seen in the bone tissue marrow. Laboratory findings: 2. Increased ferritin levels 5. Normal total iron-binding ability * Hematocrit of about 20-30% * Serum Iron: Substantial * Substantial transferrin vividness * The mean corpuscular volume or perhaps MCV is generally normal or perhaps low. * With lead poisoning, observe coarse basophilic stippling of red blood cells upon peripheral bloodstream smear 2. Specific check: Prussian Blue stain of RBC in marrow.

Displays ringed sideroblasts. * may also cause microcytic hypochromic low blood count. (12) Thalassemia It is a number of inherited autosomal recessive blood vessels disorders that originated in the Mediterranean area. In Thalassemia the hereditary defect, which may be either mutation or deletion, leads to reduced rate of synthesis, or no activity of one of the globins restaurants that make up hemoglobin. This can trigger the formation of abnormal hemoglobin molecules, thus causing anemia, the characteristic presenting symptom of the Thalassemia. (13) Symptoms and signs: * Fatigue and some weakness. * Shortness of breath. * Paler appearance. Frustration. * Discolored discoloration in the skin. 2. Facial cuboid deformities. 2. Slow expansion. * Stomach swelling. * Dark urine. (14) Prognosis: * Bloodstream tests. * Prenatal screening process. (14) Lab findings: 2. A low degree of red blood cells 2. Smaller than anticipated red blood cells 5. Pale red blood * Red blood that are different in size and shape 2. Red blood cells with uneven hemoglobin distribution, that gives the skin cells a bull’s-eye appearance beneath the microscope. (14) 1 . 2 Literature Review A study was done in Italy about frequency and occurrence and types of gentle anaemia inside the elderly.

The objectives with this study were to estimate the prevalence and incidence of mild level anemia and to assess the frequency of low blood count types in the elderly. Style and Strategies: This was a prospective, population-based study in all residents 66 years or perhaps older in Biella, Italy. Results: Blood vessels test outcome was available for examination from 8, 744 aged. Hemoglobin focus decreased and mild anemia increased progressively with increasing age. Slight anemia (defined as a hemoglobin concentration of 10. 0-11. 9 g/dL in women and 10. 0-12. 9 g/dL in men) affected 11. % with the elderly within the analysis, while the estimated frequency in the entire population was 11. 1%. Before hemoglobin determination, most mildly frail individuals perceived themselves while non-anemic. Persistent disease anemia, Thalassemia characteristic, and suprarrenal insufficiency were the most recurrent types of mild anemia. (15) Research was required for emergency keep, Mulago Hospital, Uganda. Anaemia is a common injury in Africa, with prevalence including 21. 1% to 64. 4% 16-21 and a significant impact on morbidity and fatality. 22, 3 in people with AIDS low haemoglobin levels will be associated with poor outcomes. 4-27 However , anaemia in Africa has multiple causes, with infectious diseases such as HIV, tuberculosis and malaria adding significantly to the anaemia burden. 28 Hookworm is a key contributor to anaemia and even light hookworm loads will be associated with low haemoglobin amounts, 29-33 though Lewis ou al. reported that hookworm was not a common cause of anaemia among medical patients in Malawi. In a cross-sectional descriptive study 395 patients were recruited by systematic random sampling and the socio-demographic qualities and specialized medical details gathered.

A complete bloodstream count and peripheral film examination had been done and stool examined for hookworm ova.. With the patients 255 (64. 6%) had anaemia. The frequency was bigger among guys (65. 8%) than females (63. 7%). Fatigue (odds ratio (OR) 2 . 1, confidence time period (CI) 1 . 37 , 3. 24), dizziness (OR 1 . sixty four, CI 1 ) 07 , 2 . 44), previous bloodstream transfusion (OR 2 . 83, CI 1 ) 32 , 6. 06), lymphadenopathy (OR 2 . 99, CI 1 . 34 , 6. 66) and splenomegaly (OR five. 22, CI 1 . 80 , 15. 28) had been significantly connected with anaemia. Splenomegaly, low physique mass index (BMI) (&lt, 19) and being HIV positive had been independently associated with anaemia.

The commonest type of anaemia was Hypochromic microcytic (34. 1%). Just 10. 6% of anemic patients had hookworm infestation. (34) A report was done in north Vietnam was proposed to assess the prevalence of iron insufficiency and anemia and affiliated risk factors in a community-based sample of women living in a rural region of southwest Vietnam. A cross-sectional review, comprised of drafted questionnaires and laboratory examination of hemoglobin (Hb), ferritin, transferrin receptor, and chair hookworm egg count, was undertaken, plus the soluble transferrin receptor/log ferritin index was calculated. Of 349 non-pregnant women, thirty seven. 3% had been anemic (Hb &lt, 12 g/dL), and 23. 10% were iron deficient (ferritin &lt, 15 ng/L). Hookworm infection was present in 80. 15% of girls, although weighty infection was uncommon (6. 29%). Flat iron deficiency was more prevalent in anemic than non-anemic ladies (38. 21% versus 16. 08%, S &lt, zero. 001). Ingestion of various meats at least three times a week was more prevalent in non-anemic women (51. 15% vs 66. 67%, P sama dengan 0. 042). Mean ferritin was reduced anemic females (18. 99 versus 35. 66 ng/mL, P &lt, 0. 001). There was no evidence of a difference in frequency (15. twenty percent versus 18. 23%, S = 0. 629) or perhaps intensity (171. 7 vs . 129. 93 eggs/g, P = zero. 412) of hookworm disease between frail and non-anemic women. (35) In the United States research was done to determine the prevalence of iron deficit and straightener deficiency low blood count in the US human population. A total of 24 894 persons outdated 1 year and older evaluated in the third National Into the Nutrition Exam Survey (1988-1994). Iron deficiency, defined as having an unusual value no less than 2 of three laboratory tests of iron status (erythrocyte protoporphyrin, transferrin saturation, or serum ferritin), and flat iron deficiency low blood count, defined as iron deficiency in addition low hemoglobin.

Nine percent of toddlers aged one to two years and 9% to 11% of adolescent ladies and women of childbearing grow older were flat iron deficient, of the, iron insufficiency anemia was found in 3% and 2% to 5%, respectively. These prevalences correspond to approximately 700000 toddlers and 7. almost 8 million females with iron deficiency, of the, approximately 240 000 small children and three or more. 3 , 000, 000 women include iron deficit anemia. Iron deficiency took place in no more than seven percent of teenagers or these older than 50 years, and in a maximum of 1% of teenage boys and teenage boys.

Among women of childbearing grow older, iron insufficiency was much more likely in individuals who are minority, low income, and multiparous. (36) Chapter Two Justification * Anaemia is common worldwide exclusively in expanding countries in which nutrient deficiencies are common. * Healthy iron insufficiency anaemia is usually difficult to control in Sudan due to poor socio-economic position and this contributes to the advancement of it. 5. Anaemia is a common problem in the outpatient set although it’s always neglected and considered lightly. 5. Undetected anaemia can cause hyperdynamic circulation disturbances and raise the rate of morbidity and mortality.

Section Three Objectives: General: 2. To determine the frequency of anaemia in medication emergency room (ER) casualty in academy teaching hospital. Particular: * To look for the prevalence of microcytic Hypochromic anaemia in medicine er casualty in academy instructing hospital. 5. To determine the finest age group from the sample size that reveals at the medicine emergency room. 5. To determine the quantity of meals each day in relation to the anaemia. * To determine the best gender risk group intended for the microcytic Hypochromic anaemia. Chapter Several Methodology 4. 1 Examine Design:

A cross-sectional detailed study. 4. 2 Analyze Period: The analysis was conducted in a period from the to begin October right up until the end of December. 5. 3 Analyze Area: The study was required for the emergency room of the School Teaching Clinic located in Al-sahafa East. some. 4 Examine Population: Patients present with the medicine er of the Schools Teaching Medical center were within the study through the study period 2011-2012. Patients present in the outpatient had been excluded. 5. 5 Factors: Background variables: * Kind of the low blood count. * Gender in relation to the anaemia. Causes in relation to the anaemia. 2. Age with regards to the anaemia. 4. six Sampling Strategy: Simple arbitrary sampling of 75 people was done based on: 2. Age among 16-45 years. * Unfavorable previous great anaemia. 2. No good blood disorder. * Not any pregnancy. 4. 7 Sample Size: Almost all patients had been willing to get involved. A total of 75 patients participated inside the study. 5. 8 Info collection Tactics and Tools: * a questionnaire which include demographic data, symptoms, health background, physical evaluation and healthy status has to each patient to be loaded by them or a great assistant. About enrolment of patients into the emergency room, a few ml of peripheral bloodstream will be accumulated in plastic container. * Liquid blood samples will be sent to the lab for screening of anemia and its specific morphology using full blood count test and platelet count. 5. 9 Info management and Analysis: To assess the gathered data, Statistical Package to get Social Sciences (SPSS exploration software) to be used. Used to compute the prevalence of low blood count, through a pre-coded system. four. 10 Ethical Consideration: 2. Ethical approval for the study was obtained from the moral committee with the University of Medical Sciences & Technology.

Verbal consent was taken from individuals beneath the study. 2. The information utilized in this analyze is confidential and only utilized for the purpose of this research. Section Five Recommendation 1 . Obligatory screening of blood pertaining to anaemia and microcytic Hypochromic anaemia. installment payments on your Investigation to get the causes of anaemia and follow-up. 3. Iron supplements below doctor’s pharmaceutical are recommended for patients with below three meals per day. 4. Education and spreading of awareness about the important sources of iron and harmful attributes of fizzy drinks, tea and coffee. Part Nine References: 1 . Mohammad Inam Danish.

Medical prognosis and management. Karachi start of cardiovascular diseases, 2010. 2 . Placed: http://www. vitalhealthzone. com/health/conditions/a/anaemia/06_complications_of_anaemia. code 3. Sited: http://www. websters-online-dictionary. org/definitions/microcytic+anemia 5. Vinay Kummar, Abul T. Abbas, Nelson Fausto. Standard pathology. eighth edition, 2007. 5. Laura Dean. Bloodstream Groups and Red Cellular Antigens. Nationwide Center to get Biotechnology Data (NCBI), Countrywide Library of Medicine, National Acadamies of Overall health, 2005. 6th. Kabanova T, Kleinbongard S, Volkmer T, Andree B, Kelm Meters, Jax TW.

Gene appearance analysis of human red blood cells. International Diary of Medical Sciences 6th, 2009 (4): 156″9. several. Sited: http://www. emedicinehealth. com/anemia/page3_em. htm 8. Marks PW. Anemia. Countrywide Heart, Chest, and Blood vessels Institute. Mayo Clinic, 2011 January 6th. 9. Rochester, Minn. Laboratory reference principles. Hematology group. Mayo Base for Medical Education and Research, 2011 January. twelve. Sideroblastic Anemias: Anemias Brought on by Deficient Erythropoiesis at Merck Manual of Diagnosis and Therapy Specialist Edition 10. “Sideroblast” at Dorland’s Medical Dictionary 12. Aivado Meters, Gattermann N, Rong A, et al.

X-linked sideroblastic anemia associated with a new ALAS2 mutation and sad skewed X-chromosome inactivation patterns. Blood Cellular material Mo, 2006. Dis. thirty seven (1): 40″5 13. Hemoglobinopathies and Thalassemias. 14.. mayonaise clinic personnel, thalassemia. Mayonaise Foundation to get Medical Education and Research (MFMER)., 1998-2012. 15. Mauro Tettamanti, Ugo Lucca, Francesca Gandini. Frequency, incidence and types of mild low blood count in the seniors. Haematol, 2010 November 1 ) 16. Adam I, Khamis AH, Elbashir MI. Prevalence and risk factors pertaining to anaemia in pregnant women of eastern Sudan. Trans 3rd there’s r Soc Trop Med Hyg 2005, 99(10): 739-743. several. Asobayire FS, Adou P, Davidsson D, Cook JD, Hurrell RF. Prevalence of iron deficiency with minus concurrent low blood count in population groups with high prevalences of malaria and other infections: a study in Cote d’Ivoire. Am J Clin Nutr 2001, 74(6): 776-782. 18. Charlton KE, Kruger Meters, Labadarios Deb, Wolmarans G, Aronson I. Iron, folate and cobalamin status associated with an elderly Southern region African population. Eur M Clin Nutr 1997, 51(7): 424-430. 19. Dicko A, Mantel C, Thera MOTHER, et ing. Risk factors for malaria infection and anemia intended for pregnant women in the Sahel area of Bandiagara, Mali. Acta Trop 2003, 89(1): 17-23. 0. Leenstra T, Kariuki SK, Kurtis JD, Oloo AJ, Kager PA, ter Kuile FO. Prevalence and intensity of anemia and flat iron deficiency: cross-sectional studies in adolescent schoolgirls in american Kenya. Eur J Clignement Nutr 2004, 58(4): 681-891. 21. Sserunjogi L, Scheutz F, Whyte SR. Postnatal anaemia: neglected problems and missed possibilities in Uganda. Health Policy Plan the year 2003, 18(2): 225-231. 22. Culleton BF, Manns BJ, Zhang J, Tonelli M, Klarenbach S, Hemmelgarn BR. Effect of anemia on hospitalization and mortality in more mature adults. Bloodstream 2006, 107(10): 3841-3846. twenty-three. Ma JZ, Ebben T, Xia H, Collins AJ.

Hematocrit level and linked mortality in hemodialysis patients. J Are Soc Nephrol 1999, 10(3): 610-619. twenty four. Elliott AM, Halwiindi W, Hayes RJ, et ing. The impact of human immunodeficiency virus in mortality of patients cared for for tuberculosis in a cohort study in Zambia. Trans R Soc Trop Mediterranean sea Hyg 95, 89(1): 78-82. 25.. Moore RD. Human immunodeficiency disease infection, anemia, and survival. Clin Contaminate Dis 1999, 29(1): 44-49. 26. O’Brien ME, Kupka R, Msamanga GI, Saathoff E, Seeker DJ, Fawzi WW. Low blood count is persistent predictor of mortality and immunologic progression of disease among women with HIV in Tanzania.

J Acquir Immune system Defic Syndr 2005, 40(2): 219-225. twenty seven. Sullivan PS, Hanson DL, Chu SY, Jones JL, Ward JW. Epidemiology of anemia in human immunodeficiency virus (HIV)-infected persons: comes from the multistate adult and adolescent variety of HIV disease surveillance project. Blood 1998, 91(1): 301-308. 28. Morris CD, Bird KVADRATMETER, Nell H. The haematological and biochemical changes in severe pulmonary tuberculosis. Q L Med 1989, 73(272): 1151-1159. 29. Akhwale WS, Lum JK, Kaneko A, ou al. Anemia and malaria at different altitudes inside the western highlands of Kenya. Acta Trop 2004, 91(2): 167-175. zero. Bates We, McKew T, Sarkinfada N. Anaemia: a useful indicator of neglected disease burden and control. PLoS Med 2007, 4(8): e231. 31. Stoltzfus RJ, Albonico M, Chwaya HM, ainsi que al. Hemoquant determination of hookworm-related loss of blood and its part in iron deficiency in African children. Am L Trop Scientif Hyg mil novecentos e noventa e seis, 55(4): 399-404. 32. Sturrock RF. Hookworm studies in Uganda: research at Teboke in Lango District. East Afr Mediterranean sea J 1966, 43(10): 430-438. 33. Tatala S, Svanberg U, Mduma B. Low dietary flat iron availability can be described as major reason behind anemia: a nutrition study in the Lindi District of Tanzania.

I am J Clin Nutr, 98, 68(1): 171-178. 34. Japheth E Mukaya, Henry Ddungu, Francis Ssali, Tim O’Shea, Mark A Crowther. Prevalence and morphological types of anaemia and hookworm pests in the medical emergency keep. SAMJ, H. Afr. mediterranean. J, 2009 December vol. 99 number 12 Shawl Town, 35. Sant- Rayn Pasricha, Sonia R. Caruana, Tran Q. Phuc, Gerard J. Casey, Damien Jolley. Anemia, Iron Deficiency, Meats Consumption, and Hookworm Disease in Women of Reproductive system Age in Northwest Vietnam. Am T Trop Mediterranean Hyg, 2008 March vol. 78 no . 3 375-381. 36. Anne C. Looker, Peter L. Dallman, Maggie D. Carroll, Elaine W.

Gunter, Clifford L. Johnson. Prevalence of Iron Deficiency in the United States. JAMA, 1997, 277(12): 973-976. Phase Ten Appendix 10. 1 ) Questionnaire: Healthy status: Frequency of microcytic Hypochromic anaemia in remedies emergency room in Academy Teaching hospital?????????????????: as well as /2011?.???: ______???: _____???: ________????: ________________????: ___________???????: ___________________________ , , , , , , , , , , , , , , , , , , , , , , , , , , 1 .???????????? _____________________________________. installment payments on your????????????????????? ____________________________________________________________________________________. three or more.????????????? ____________________________________. 5.????????????????? __________________________________. , , , , , , , , , , , , , , , , , , , , , ,?????????????????????????. 5.??????????. _____________ 5.???. ______________ 5.???????. ______________ 2.????????. ______________ *????????????? (???,??? ) ___________ *???????. _____________ 5.??????????. _____________ 5.???????????. _____________ *??????. _____________ *???????. _____________?????????????????????? _________________________.?????????????????,????????????.??? |???? |?????? |??????? |?????? |?? | | | | |???? | | | | |??? | | | | |??????? | | | | |??? | | | | |??? | | | | |????? | | | | |???????? (?????,???????,??? )| | | | |????????????? (???,???,???,??????? ). | | | | |??????? (???,???,???,???,??? )| | | | |????,????,????? )| | | | |??? | | | | |???? (???,??? )| | | | |???????? | | | | |?????????????????,????? ___________________________________________________________________________________. , , , , , , , , , , , , , , , , , , , , , , , , , -???????:???: ____??. _____?.???: ____??. _____?.???? ____??. _____?.???? _______________________.?????????? ______________________.???????? ____??. _____?.???? __________________________.???????: ______??. _____???.????,?????????? __________.?????,??????????? ___________.?????? ___________________.???????? ____??. ______?.???? ______________________.?????????? __________________.????????????????,??????? ________________________________________.?????????????????,??????? _______________________________________.

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