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Pooled coronary flow changes over time (C) and summarized repayment/debt ratio (D cheap 80 mg super cialis otc, *p<0 cheap super cialis 80 mg mastercard. Our findings will shed new lights on adenosine-mediated coronary flow regulation under cardiac ischemic conditions and will be an important mechanistic basis for further in vivo studies buy 80 mg super cialis free shipping. Karen Martin and Amanda Ammer of the Imaging Center for their support, and Steve Tilley and C. Headrick, (2005) Mediators of coronary reactive hyperaemia in isolated mouse heart. Bagi, (2004) Nitric oxide and H2O2 contribute to reactive dilation of isolated coronary arterioles. Boegehold, (2007) Hydrogen peroxide-dependent arteriolar dilation in contracting muscle of rats fed normal and high salt diets. Beckman, (1996) Mechanisms of cerebral vasodilation by superoxide, hydrogen peroxide, and peroxynitrite. The cause of the long-term cardiac vulnerability, in subjects born of low birth weight, are not well understood. Using well-established rodent models of maternal protein restriction (which mimics maternal malnutrition during pregnancy) and bilateral uterine vessel ligation (which leads to uteroplacental insufficiency) we have stereologically examined the effect of intrauterine growth restriction on the number of cardiomyocytes formed within the heart of the offspring. Our findings demonstrate that intrauterine growth restriction can adversely impact on the complement of cardiomyocytes in the heart in early life. Since the proliferative capacity of cardiomyocytes is markedly attenuated postnatally, our findings provide a plausible explanation as to how intrauterine growth restriction leads to long-term vulnerability to cardiac disease. Keywords: intrauterine growth restriction, cardiomyocytes, stereology, developmental origins of disease. Introduction Convincing evidence from epidemiological and experimental studies demonstrate that growth in utero can program for long-term health and disease; with low birth weight associated with adverse long-term effects in the adult heart [1-3]. The cause of the long-term programming of cardiac disease in individuals who were born of low birth weight is the subject of intense research world-wide. Development of the heart The heart is the first organ to form in the embryo and this is a consequence of the increased oxygen and nutrient demands of growing tissues as the embryo develops. The human heart commences development in week 3 of gestation and is in a relatively mature form by 10 weeks of gestation [11, 12]. The formation of the multi- chambered heart is a complex process that involves formation of the linear heart tube, heart looping, formation of the cardiac chambers, and septation [13]. It involves an interplay of cellular proliferation and programmed cell death; processes that are tightly regulated by extracellular and intracellular factors [14]. The primitive heart tube is formed by 3 weeks in gestation and the heart undergoes rhythmic contractions by the end of the fourth of week of gestation. Early in gestation the developing heart undergoes a process of looping whereby the primitive chambers are brought into the spatial alignment of the mature heart. The heart then undergoes septal formation to initially divide the atria from the ventricles and then further division of the atria and ventricles. During this time there is also a spiralling division of the outflow tract of the heart to bring the aorta in alignment with the left ventricle and the pulmonary trunk in alignment with the right Medimond. All these processes take place by 10 weeks of gestation with the fetal heart in a relatively mature form by this gestational time point. In the last trimester of human pregnancy the cardiomyocytes undergo a process of maturation, whereby the cardiomyocytes exit the cell cycle and becoming terminally differentiated [15], in preparation for the hemodynamic transition at birth, when there is a marked increase both in heart rate and blood pressure. During this process, there is cytoplasmic myofibril assembly into sarcomeres and enhanced contractile activity within the cardiomyocytes [16]. Cell division is a rare event when cardiomyocytes have become differentiated [15]. In the human heart, most cardiomyocytes have become differentiated by birth or soon after birth; growth of the myocardium after this time is predominantly due to cardiomyocyte hypertrophy and extracellular matrix deposition [16]. Proliferation of cardiomyocytes is not precluded in the postnatal heart, although it is a relatively rare event with postnatal regenerative capacity markedly reduced [17, 18]. In the case of rodents the cardiomyocytes are still proliferating at the time of birth and they generally undergo the process of maturation in the first two weeks postnatally; in the first week of life they continue to proliferate and in the second week of life they undergo a process of maturation whereby they become binucleated [19, 20]. Hence, in the rodent heart, mature cardiomyocytes are easily identified as they are binucleated; this is not the case in the human heart where the majority of the cardiomyocytes remain mononucleated. Intrauterine growth restriction th Intrauterine growth restriction is defined as growth below the 10 percentile for gestational age. During pregnancy, the placenta is the key interface between the maternal and fetal circulation, with placental function directly influencing fetal growth. Placental insufficiency is largely due to an inadequate vascular adaptation at the uteroplacental interface, which leads to restricted delivery of oxygen and nutrients to the fetus and ultimately growth restriction as a result of hypoxia and hypoglycaemia. In general, placental insufficiency develops late in pregnancy, during the third trimester. Within our laboratories we have well-established models of early life growth restriction in rats, whereby growth restriction of the fetus is induced as a result of maternal protein restriction [10, 21-23] or bilateral uterine vessel ligation [9, 24-26]. The model of maternal protein restriction mimics malnutrition in pregnancy (where there is reduced protein and elevated starch content in the maternal diet) throughout pregnancy, whereas the bilateral uterine vessel ligation model is a model of late gestational placental insufficiency. The diets are semi-purified diets where all components of the low protein diet and the control diet are the same except for the casein and starch content; the starch content is elevated in the low protein diet and as a result the low protein diet and normal protein diets are close to isocaloric. The offspring exposed to maternal protein restriction exhibit symmetric growth restriction with an approximate 12 to 18% reduction in birth weight compared with control offspring exposed to a maternal normal protein diet. Bilateral uterine vessel ligation leads to asymmetric growth restriction of the offspring, with approximately 10 to 15% reduction in fetal body weight and litter size compared with controls. In the maternal protein restriction model we have stereologically counted the number of cardiomyocytes in the hearts of offspring at birth and at 4 weeks of age (in the left ventricle which is the dominant ventricle postnatally). In our placental insufficiency model we have counted the number of cardiomyocytes in the hearts at 7 days of age. Hence, as cardiomyocytes continue to proliferate in the rat heart in the first week of life, it appeared that there was catch-up hyperplasia of the cardiomyocytes in the early postnatal period. We have reported similar findings in lamb hearts in the early postnatal period [28] and in a rat vitamin D deficiency model [29]; the complement of cardiomyocytes in the left ventricle plus septum was directly proportional to heart size. In this series of experiments we used a cross-foster approach whereby offspring from a dam that had undergone bilateral uterine vessel ligation were cross-fostered onto another dam that had undergone bilateral uterine vessel ligation or onto a control dam [30]. We have previously shown that rat dams that have undergone bilateral uterine vessel ligation have impaired mammary development and thus reduced milk production during lactation [30]. This is indicative of catch-up hyperplasia of cardiomyocytes when nutrition was optimised in the immediate postnatal period, when the cardiomyocytes were still undergoing cell division. Interestingly, when we examined the nuclearity of the cardiomyocytes we found that at postnatal day 7 approximately 20 to 24% of the cardiomyocytes were mononucleated so they may still be capable of proliferation [8]. Unlike rodents, the majority of cardiomyocytes have ceased proliferating in the human heart at the time of birth; hence, they do not have the capacity to undergo catch-up cardiomyocyte hyperplasia after birth. However, it is important to note that this is not the case in the immature heart of the infant that is born prematurely. In these infants there may be a window of opportunity to stimulate cardiomyocyte growth and certainly our placental insufficiency cross-foster studies suggest that optimisation of nutrition after birth may be able to restore cardiomyocyte number to normal [8]. This, in turn, leads to a reduction in life-long cardiomyocyte functional reserve and leads to increased vulnerability to heart disease in adulthood. Birthweight and risk of cardiovascular disease in a cohort of women followed up since 1976.

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Cortical and subcortical cluding multiple lesions due to Aspergillus dissemina- infarction with or without hemorrhage is a common a b Fig purchase 80 mg super cialis with amex. Solidly hypointense structure (a) with (d) fnding in Aspergillus infection explained by fungal in- 9 buy super cialis 80mg overnight delivery. Recognition Epidemiology of these radiological patterns in patients with cerebral aspergillosis is helpful in establishing an early diagnosis cheap 80mg super cialis amex. Candida albicans is part of the fora of mucous mem- Isolated meningitis due to Aspergillus infection is branes and the gastrointestinal tract of healthy indi- extremely unusual, being more ofen a complication of viduals. The gastrointestinal tract is the gateway for sys- other Aspergillus-related lesions. Spinal cord involve- temic infection in individuals with some predisposing ment has been reported very rarely. Clinically, the most rel- evant member of the genus is Candida albicans, which Candida meningitis may manifest spontaneously afer can cause numerous infections (candidiasis or thrush) iatrogenic inoculation most ofen catheter related. The severity of disease is dictated by the pseudohyphae, colonies of yeast enmeshed in fbrin dose of inoculum. Phagocytosis is the principal nonspe- and acute polymorph reaction primarily present as cifc mechanism protecting the host against Candida al- small hemorrhagic infarcts, progressing to microab- bicans infection. The hyphal form of candida can resist scess and later granulomatous abscess reaction. It is most common from rupture of true mycotic aneurysm or arteritis in neonates, where it usually shows an acute progres- with vascular invasion. In the rarer manifestation, in adults, the picture usually has a chronic and indolent course. The Gram stain is positive in only 30% within surrounding high signal on T2-weighted im- of cases. Such diminutive nodular or annular lesions in progressive encephalopathy associated with waxing and the transition from white matter to gray matter, and in waning signs and symptoms. Multiple microabscesses the basal nuclei, are compatible with microabscesses or are not infrequent but usually unrecognized and should noncaseous granulomas. Usually the microabscesses be considered in the diferential diagnosis of enceph- are observed in the territory of the anterior and middle alopathy in hospitalized patients with chronic disease, cerebral arteries, which might be explained simply by immunosuppression, and sepsis. Intravenous or intra- the relative extension of the vascular supply of these ter- ventricular administration of antifungal agents is sug- ritories; however, cerebellar involvement also has been gested. Even on histology, unless sus- pected and looked for, the Candida organisms may be 9. In immunocompetent patients, candidiasis Imaging may manifest as solid or abscess-like lesions giving rise to the diferential diagnosis of a pyogenic abscess. Meningeal enhancement may be primarily difuse or nodular enhancement in the Coccidioidomycosis is caused by a dimorphous fungus basal cisterns and may later progress to confuent difuse of the genus Coccidioides. Within the host, the inhaled enhancement patterns that represent focal collections of arthrospore develops into a globular structure (spher- the organism with surrounding infammation. This spherule is 20100 mm in diameter and later of meningeal enhancement the corresponding regions develops hundreds of endospores within a thick-walled on the nonenhanced T1-weighted images is isointense capsule. When the spherule ruptures, the tiny en- with brain and isointense to slightly hypointense rela- dospores are released continuing the infection cycle. The low sig- nal on the T2-weighted images is thought to represent ferromagnetic material within the fungus or simply re- 9. Cisternal involvement may lead to southwestern United States as well as in Central and vasculitis and thus territorial infarcts in the dependent South America. In addition to vasculitis, it has also been speculated that vasospasm may occur as a result of the infammatory process or di- 9. Typically those Manifestation infarcts involve the brain stem, cerebellum, thalamus, or basal ganglia. Cortical infarction seems to be an ex- Afer inhalation of fungus from dust, a pulmonary in- ceptionally rare manifestation. Approximately 40% Communicating hydrocephalus with or without of exposed individuals develop a fu-like picture with ventriculitis is an associated fnding that is observed in predominantly self-limited pulmonary symptoms, the up to 90% of the patients in later disease stages. The rate of disseminated disease mass lesions, hemorrhage, and calcifcation are seen less is about 5% of symptomatic patients, and meningitis frequently. Multifocal vague white matter lesions have occurs in about half of those cases with increased risk in also been described. Coccidioidomycotic parenchymal pregnant women, children, and old people, as well as in abscesses are exceptional. Although the disease may be controlled with chronic antifungal therapy, relapse afer withdrawal of Zygomycosis (mucormycosis) is caused by several gen- therapy is common. The fungi can usually be cultivated Imaging from the oral cavity, nasal fossa, and pharynx of healthy individuals. In immunodefciency they multiply and the Imaging shows a similar pattern to aspergillosis, but spores germinate, forming hyphae, which become inva- usually with even greater extent of damage to the ce- sive and can spread. Typically confuent regions of hyperin- tense signal on T2-weighted images in the basal por- 9. Usu- Zygomycosis is a worldwide polymorphic disease and is ally those lesions are associated with vascular involve- closely linked to the occurrence of diabetes mellitus in ment, including obstruction of the cavernous sinuses about 75% of the patients especially in diabetic ketoacido- and even of the carotid arteries, revealing thrombosis sis. Other predisposing conditions include hematological or wall enhancement, probably due to local infamma- malignancies, neutropenia, immunosuppressive medi- tory involvement. The manifestations of zygomycosis can be classifed into several forms with rhinocerebral mucormycosis being a typical one. Histoplasma capsulatum is a fungus found in several re- gions of the world, above all in some regions of North 9. The fungi are abundant in the droppings of birds and bats and are released into the air as spores that Orbital extension from the ethmoid sinuses produces can be inhaled, causing pulmonary involvement. Its symptoms vary greatly, but ofen so rapid that imaging does not ofer much beyond the disease is usually restricted to the lungs and rarely demonstrating the extent of involvement. While most presents systemic dissemination in immunocompetent reports suggest intracranial involvement to be almost individuals. Exposure to Histoplasma capsulatum is invariably fatal, a relatively high survival rate of 70% has very common in this region and usually follows a be- been reported afer timely medical or surgical interven- nign clinical course. This is in contrast to pyogenic and tuber- ternal meningitis or, more rarely, by the occurrence of cular abscesses where restricted difusion is observed in parenchymal granulomas (histoplasmomas) that may the lesion center; however, heterogeneity of difusion in mimic neoplasms. Histoplasmomas may present as fungal infection has been described (Mueller-Mang single ring-enhancing lesions in brain parenchyma en- et al. Neuroradiology culosis, neurosarcoidosis, and parasitic infections, but 49:651657 Parasitic Infections 10 Christoph Stippich Contents 10. Stippich fections through contaminated needles, transfusion, or Stationary parasites are in permanent contact with organ transplantation have also been reported. Diapla- the host, whereas temporary parasites attack the cental infection of the fetus is possible. The cycle parenchyma Toxoplasma gondii forms cysts preferen- of life of most parasites is very complex including tially in the brain, heart, and peripheral muscles where changes between diferent hosts (intermediate and the parasites may persist infectious over several years.

Arsenic was gone; patulin was gone; but salmonellas were now present in the prostate buy discount super cialis 80 mg on-line. He had his new refrigerator best 80 mg super cialis, and patulin was still Negative buy 80mg super cialis overnight delivery, so he could eat a few more fruits. Rhizopus (fungus) was growing in his prostate and Peyers patches (the lymph nodes of the intestine). His next blood test showed exceptionally good results in spite of his poor condition. And deep inside, patulin fungus was again growing, as was Aspergillus mycelium, conidia and three other aspergillus varieties. Two weeks later, he appeared more bowed and shuffling than ever but still walked unassisted. His doctor at home, where the test was done, was calling him ur- gently for treatment. Six days later he arrived in a wheelchair, just a wispy shadow of his former self. He was given Lugols again to be taken four times a day for salmonella every- where. She related that he wanted to die on a piece of family propertymountainous landfar from his city home. He got out of the wheel- chair, began to cook for himself, went for walks on trails and enjoyed each sunrise and sunset. Later, as I absorbed this miracle I wondered: Was it his toxic home that he was getting away from? She kept her hair Iron 93 67 59 Sodium 138 136 133 dye and eyebrow pencil, Potassium 4. It has more hidden wisdom than we can understand; at the very least, a terminally ill patient should leave the dwelling where the disease was ac- quired. Three weeks earlier, his right arm began hurting and a bump arose on his forearm about half way up to the elbow. He slept most of the time (16-18 hours a day), the rest of the day he was dizzy and felt cold. A visit to the doctor at that time, March 9, got him a blood test and a di- agnosis of Epstein-Barre virus. He must have been suffering from certain parasites and pollutants for many years, perhaps from age four when he had Kawasaki disease. Creatine is made by the body from arginine and glycine and also requires methionine. Was he Brians arm in July not getting enough of these amino acids or was a parasite inhibiting their formation? It is normal to be high when your bones are growing, and Brian had grown 6 inches during the past year, but still, 378 is too high. The doctor had given an ominous prognosis: it was better to amputate than try to treat; this variety of cancer was lethal in children. On July 6 his family started him on our parasite killing recipe, using the book as guide. On July 10, another visit to his doctor brought only dire predictions if the surgery were not carried out quickly. These were Brians initial test results using the Syncrometer: isopropyl alcohol Positive. He was referred to the isopropyl alcohol list in The Cure For All Cancers; he agreed to be meticulous about compliance. Evidently he had killed the flukes and their stages already with the parasite program. A home air test (dust sample) was Positive for freon in liv- ing room and Brians bedroom. The parents planned to immediately move the refrigerator outdoors while finding a new non-freon replacement. They would make a homeopathic dilution of it (one part per million) and give Brian tsp. The final solution should not be more than 10 minutes old before Brian drank the tsp. New tests showed solvents Negative; Mucor Negative; copper still Positive at bone and parathyroid; mercury Positive at bone and parathyroid; freon still Positive at bone and parathyroid. The blood test (July 14) showed considerable improvement from the one done in March, especially in alk phos, creatinine level, and thyroid function (T4). Brians arm pain had not returned; the lump was visibly smaller, nearly normal-feeling. His new Syn- crometer tests showed: isopropyl and wood alcohol Negative; copper Posi- tive at bone and parathyroid; mercury Positive at bone; Penicillium spores (fungus) Positive at bone; Mucor and yeast fungi Negative at bone; freon Positive at bone and parathyroid. His household water continued to be Positive for copper; the plumbing had not yet been done. Final Syncrometer testing showed: Penicillium spores Negative at bone, mercury Negative at bone. They informed me that a second X-ray had been taken August 30, showing that the top part of the tumor was gone; the base was still there, maybe even larger, according to his doctor. The doctor now advised to keep doing whatever it is we are doing, something seems to be working and scheduled another X-ray for thirty days hence. The tumor had decreased in size again and texture appeared more bone-like; nevertheless, the doctor referred them to an orthopedic surgeon. Their regular doctor appointment had been on October 9, the doctor had compared all three X-rays stating he didnt usually see tumors do this, didnt usually see them get smaller, they usually get bigger. Nevertheless, the doctor recommended a total surgical bone biopsy in order to see it himself. They had become way too relaxed about all Brians instructions; he was consuming cold cereals and soda pop (they contain traces of isopropyl alcohol antiseptic). He was to continue the maintenance parasite program once a week and give away his dog. He was reminded to boil all dairy products, avoid afla- toxins, stay away from salad bars (Salmonella, etc. The doctor was delighted, exclaiming it was like a ferocious beast had attacked but then decided to run away. We didnt actually see Brian and his family again till February 28 of the next year. This time we used coenzyme Q10 in 4 massive doses of 3,000 mg taken four days apart. Now we know he must remove the composites as well and even make a dedicated search for tattoos before he can be free of their toxicity. His last X-ray was taken on April 1: His doctor had come into the room and said, Well, its all gone now. After all, two radiologists knew exactly what it was, and two other doctors agreed. Summary: Of course, we know that the last quote, its gone now, should be changed to its gone for now.

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It is applied to oozing surfaces buy generic super cialis 80mg on-line, including bone and areas of bleeding difficult to reach safe super cialis 80mg. Oxidized cellulose: Oxycel cheap super cialis 80mg with visa, Surgicel: made of cellulose, able to adsorb a large amount of blood, with blood make an artificial thrombus. Oxytocin: This is a hormone produced by pitutary gland, but is also prepared synthetically. Epinephrine: This hormone is secreted by the adrenal gland, is also prepared synthetically. Novel hemostatic agents: Indications: External bleeding where the conventional pressure dressings fail. HemCon: It is available as a chitosan-based product, made from shrimp shell polysaccharide + vinegar. Preparations for an operation Salus aegroti suprema lex esto = The well-being of the patient is the most important law. We can think of increased surgical morbidity (and accompanying cardiacvascular, hepatic, and renal diseases) as the age of the patient is increasing. Surgical indications, contraindications and risks Indications Proper evaluation of the surgical disease and risks: - Vital indications: These are involved in the case of life-saving procedures. The patient can be treated only with an operation (100% mortality without operation). Example: rupture of an abdominal aorta aneurysm - Absolute indications: These are involved in urgent procedures. Contraindications In the cases of vital and absolute indications: only in moribund patients. In the case of relative indication: decompensated accompanying diseases, does the surgery improve the survival? Surgical risks Surgical risks = risks of surgery itself + anesthesiological risks. The preoperative examinations must answer the questions of both surgeon and anesthesiologist, allowing them to give their agreed opinion in writing. Medium-risk surgery: Surgical interventions of medium severity can be classified here (the expected blood loss is less than 1000 ml), e. Operations in which 2 body cavities are opened at the same time are runnig with the highest risks. Oncological patients own problems - chemotherapeutic agents - radiotherapy (local inflammation) - decreased function of the immune system - paraneoplastic syndromes e. To have a safe general anesthesia, the patient should avoid eating (fasting 6 hours prior to surgery). Preoperative nutritional therapy First, you should consider the natural oral feeding. If it is not possible, then the nasogastric, duodenal or jejunal tubes are the most appropriate ways of feeding. The burned, tumorous, polytraumatized, and septic patients need the highst amount of energy. Slag deprivation - Diet: liquids for 2-3 days or a low-residue diet - Enema: In the case of major abdominal surgeries (or those operations which involve the intestinal system), there is a need to make the intestinal tract empty. Urinary catheter 67 It is needed in the case of long-lasted operations which are running with loss of a large amount of fluids. Thrombosis prophylaxis - Drugs: - Heparin derivatives: Na-heparin, Ca-heparin, low molecular weight heparins - Platelet aggregation inhibitors (e. Syncumar) - Physical: - early mobilization - compression (elastic bandages) - bed-side bicycle - keeping the lower extremities at a high level Psychic preparartion That is natural for the patient to fear of the operation and its unwanted consequences. He/she should carefully evaluate the indications and contraindications and choose the best possible intevention. Laparotomy on the anterior abdominal wall The direction of the incision can be: verical, transverse, or oblique. Vertical incisions: - upper, lower, middle, or total median laparotomy - paramedian laparotomy - vertical transrectal laparotomy - pararectal laparotomy Transverse incisions: - horizontal transrectal laparotomy - Pfannensteil incision Oblique incisions: - McBurney-incision - inguinal transmuscular laparotomy - paracostal laparotomy (Kocher incision) - subcostal laparotomy Vertical incisions Upper median laparotomy The incision is made from xyphoid process to the umbilicus. Advantages: insures a quick and wide exposure, quickly and easily can be elongated and closed. The advantages and disadvantages are the same as those for an upper median laparotomy. Advantage: from a small incision we can inspect both the upper and the lower part of the abdominal cavity. Total median laparotomy The incision is made from xyphoid process to the syphysis pubis. It gives an excellent exposure but injures the statistic of the abdominal wall significantly. It also makes the postoperative coughing difficult, increases the danger of pneumonia, and can cause constipation. About 2 cm right (an parallel) to the midline cut the skin, subcutaneous tissue and the anterior leaflet of the rectus sheath. Transrectal laparotomy About 2-3 cm right to the midline cut the skin, subcutaneous tissue, and the anterior leaflet of the rectus sheath. Due to the denervation of the muscles the abdominal wall becomes significanly weakened. Lateral transmuscular laparotomy The incision is made starting from a point located 2-3 cm lateral to the external edge of the rectus muscle. The longest incision of such starts at the lower edge of the 10 th rib and runs till the level of the anterior sup. The pararectal and an incision made alongside the semilunar line of Spiegel are not the ideal incisions because they weaken the abdominal wall significantly. In this way, the possibilties for postoperative sterile wound disruption and later hernia are less. Upper transverse laparotomy The incision is made at the area beween the xyphoid proc. This incision can be made larger by elongating it at both of its lateral sides (even up to the middle axillary lines). The innervations of these muscles are not injured and the wound heals with development of a strong scar. In upper abdominal surgeries we can combine the upper median incision with a transverse incision. Nowdays, with application of the laparoscopic cholecystectomy we can avoid the postoperative pain and complications of such this incision! Paracostal laparotomy Muscle-splitting incisions In these types of incisions the fibers of the abdominal wall muscles are not cut but separated from each other alongside their courses.

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