1.Disulfide bridge-targeted metabolome mining unravels an antiparkinsonian peptide.
Zhiwu TONG ; Xiahong XIE ; Huiming GE ; Ruihua JIAO ; Tingting WANG ; Xincun WANG ; Wenying ZHUANG ; Gang HU ; Renxiang TAN
Acta Pharmaceutica Sinica B 2024;14(2):881-892
Peptides are a particular molecule class with inherent attributes of some small-molecule drugs and macromolecular biologics, thereby inspiring continuous searches for peptides with therapeutic and/or agrochemical potentials. However, the success rate is decreasing, presumably because many interesting but less-abundant peptides are so scarce or labile that they are likely 'overlooked' during the characterization effort. Here, we present the biochemical characterization and druggability improvement of an unprecedented minor fungal RiPP (ribosomally synthesized and post-translationally modified peptide), named acalitide, by taking the relevant advantages of metabolomics approach and disulfide-bridged substructure which is more frequently imprinted in the marketed peptide drug molecules. Acalitide is biosynthetically unique in the macrotricyclization via two disulfide bridges and a protease (AcaB)-catalyzed lactamization of AcaA, an unprecedented precursor peptide. Such a biosynthetic logic was successfully re-edited for its sample supply renewal to facilitate the identification of the in vitro and in vivo antiparkinsonian efficacy of acalitide which was further confirmed safe and rendered brain-targetable by the liposome encapsulation strategy. Taken together, the work updates the mining strategy and biosynthetic complexity of RiPPs to unravel an antiparkinsonian drug candidate valuable for combating Parkinson's disease that is globally prevailing in an alarming manner.
2.Mechanism of Modified Erchentang on COPD Inflammation Based on TNF-α/TNFR1/RIPKs Pathway
Zhuang CHEN ; Gaoyang LIU ; Wenying XIE ; Lizhi SHANG
Chinese Journal of Experimental Traditional Medical Formulae 2024;30(9):40-47
ObjectiveBased on tumor necrosis factor alpha (TNF-α)/tumor necrosis factor receptor 1 (TNFR1)/receptor-interacting protein kinases (RIPKs) signaling pathway, this paper aims to study the effect of modified Erchentang on inflammation in rats with chronic obstructive pulmonary disease (COPD) and explore its mechanism of action. MethodA total of 60 SD rats were randomly divided into normal group, model group, high, medium, and low-dose groups (20, 10, 5 g·kg-1·d-1) of modified Erchentang, and Xiaokechuan group (3.5 mL·kg-1·d-1), with 10 rats in each group. The COPD rat model was established by cigarette smoke combined with lipopolysaccharide (LPS). The normal group and model group were given the same amount of normal saline for 21 days by gavage administration. The contents of TNF-α and TNFR1 in bronchoalveolar lavage fluid (BALF) of rats were detected by enzyme-linked immunosorbent assay (ELISA). Real-time fluorescence quantitative polymerase chain reaction (Real-time PCR) was used to detect mRNA expressions of RIPK1, RIPK3, and mixed lineage kinase domain-like (MLKL) in the lung tissue. The protein expressions of RIPK1, RIPK3, and MLKL in the lung tissue were detected by Western blot. The pathological changes in lung tissue were observed by hematoxylin-eosin (HE) staining. ResultCompared with the normal group, the contents of TNF-α and TNFR1 in BALF of the model group were significantly increased (P<0.01), and the mRNA and protein expression levels of RIPK1, RIPK3, and MLKL in the lung tissue were significantly increased (P<0.01). Compared with the model group, the contents of TNF-α and TNFR1 in BALF of high, medium, and low-dose groups of modified Erchentang and Xiaokechuan group were decreased (P<0.01). The mRNA and protein expression levels of RIPK1, RIPK3, and MLKL in the lung tissue were decreased to different degrees (P<0.05, P<0.01). ConclusionModified Erchentang can effectively improve the inflammatory response of lung tissue in COPD rats, and the mechanism may be by inhibiting the activation of the TNF-α/TNFR1/RIPKs signaling pathway.
3.CT-guided hook-wire localization of ≤10 mm pulmonary ground-glass nodules via different path ways before video-assisted thoracoscopic surgery:a comparative study
Xingxiong ZOU ; Junjie XIA ; Hongwei LI ; Junqiang YANG ; Yu QIU ; Ming YANG ; Wenjun LI ; Wenying XIE ; Huihong XUE ; Jingxiu YOU ; Mi GA ; Juan WANG
Journal of Interventional Radiology 2024;33(8):884-890
Objective To compare the clinical safety and efficacy of CT-guided hook-wire localization of≤10mm pulmonary ground-glass nodule(GGN)via different path ways before video-assisted thoracoscopic surgery(VATS).Methods The clinical data of a total of 128 patients with 10 mm pulmonary GGN,who received CT-guided hook wire localization before VATS at The Third Hospital of Mianyang of China between July 2018 and March 2023,were retrospectively analyzed.According to the puncturing localization path way mode,the patients were divided into vertical puncturing group(n=88)and non-vertical puncturing group(n=40).The number of puncturing times,the time spent for puncturing localization,the success rate of puncture,the operation time of VATS,and puncture-related complications of the two groups were recorded.Results No statistically significant differences in the gender,age,smoking history,GGN location,puncture position,nodule size,density characteristics of GGN,emphysema,and nodules-pleura distance existed between the two groups(all P>0.05).Compared with non-vertical puncturing group,in vertical puncturing group the number of puncturing times was smaller,the time spent for localization was shorter,the incidence of pneumothorax was lower,and the operation time of VATS was shorter,the differences in all the above indexes between the two groups were statistically significant(all P<0.05);and the subgroup analysis of patients whose GGN was overlapped with rib shadow obtained the same results.Binary logistic regression analysis revealed that non-vertical puncturing and the number of puncturing times were the independent risk factors for the occurrence of pneumothorax.Conclusion CT-guided hook-wire localization of≤10mm pulmonary GGN before VATS is clinically safe and effective.Under the condition when the lesion can be localized within the range of 2.0cm and the shadow overlapping of GGN with the rib and blood vessel can be effectively avoided,vertical puncturing path way mode should be preferred,which can effectively reduce the incidence of pneumothorax and shorten the operation time of VATS.
4.Summary of the best evidence for exercise management in adolescents with type 2 diabetes mellitus
Feng MIAO ; Anwei XIE ; Xuan ZHAO ; Yiming ZHANG ; Mengwei YAN ; Hongqing GUO ; Jie GU ; Wenying YAO
Chinese Journal of Modern Nursing 2024;30(9):1143-1150
Objective:To systematically retrieve, evaluate and summarize the best evidence of exercise management for adolescents with type 2 diabetes mellitus (T2DM), so as provide reference for medical and nursing staff to guide patients and their families to exercise.Methods:Clinical decisions, recommended practices, evidence summaries, guidelines, expert consensuses, and systematic reviews on exercise management of adolescents with T2DM were electronically searched on BMJ Best Practice, UpToDate, Registered Nurses' Association of Ontario, National Guideline Clearinghouse, National Institute for Health and Clinical Excellence, Scottish Intercollegiate Guidelines Network, International Society for Pediatric and Adolescent Diabetes, Medlive, Joanna Briggs Institute Evidence-Based Health Care Center Database, Cochrane Library, PubMed, Web of Science, Embase, China National Knowledge Infrastructure, WanFang Data, Chinese Biology Medicine Disc, VIP and other databases. The search period was from database establishment to March 2023. After independent literature screening and quality evaluation by two researchers, evidence was extracted, summarized, and graded based on the theme.Results:A total of 10 articles were selected, including three guidelines, three systematic reviews, three expert consensuses, and one evidence summary. Finally, 22 pieces of best evidence of exercise management for adolescents with T2DM were summarized from seven aspects, including contraindications to exercise, exercise form, exercise intensity, exercise frequency, precautions, weight loss goals, family participation.Conclusions:This study summarizes the best evidence for exercise management in adolescents with T2DM. It is recommended that clinical medical and nursing staff should carry out personalized exercise management suitable for patients based on the wishes and preferences of patients and families, actual clinical situations, and support for exercise resources.
5.Effect of Modified Erchentang on Bronchioles of Rats with Chronic Obstructive Pulmonary Disease by HMGB1/RAGE/NF-κB Signaling Pathway
Lizhi SHANG ; Yaoyang LI ; Shu JI ; Wenying XIE ; Haofan SHANG ; Zhuang CHEN ; Gaoyang LIU ; Qi WANG
Chinese Journal of Experimental Traditional Medical Formulae 2023;29(6):44-54
ObjectiveTo study the effect of modified Erchentang on the expression of key molecules in the high mobility group Box 1 protein (HMGB1)/receptor for advanced glycation endproduct (RAGE)/nuclear factor-κB (NF-κB) signaling pathway in bronchioles of rats with chronic obstructive pulmonary disease (COPD), to explore the mechanism of modified Erchentang against bronchiolar inflammation of COPD rats via HMGB1/RAGE/NF-κB signaling pathway. MethodSixty SD rats were randomly divided into normal group, model group, modified Erchentang low-, medium- and high-dose groups (5, 10, 20 g·kg-1·d-1) and ethyl pyruvate (HMGB1 inhibitor) group, with 10 in each group. The COPD rat model was prepared by cigarette smoke combined with tracheal injection of lipopolysaccharide (LPS). After modeling, the modified Erchentang groups were given corresponding drugs (ig) and Ringer's solution (4 mL, ip), while the EP group was treated with equal volume of normal saline (ig) and EP (0.04 g·kg-1·d-1, ip). The normal group and the model group received equal volume of normal saline (ig) and Ringer's solution (ip) for 21 consecutive days. The contents of HMGB1, chemokine (C-X-C motif) ligand 1 (CXCL1), CXCL2 and monocyte chemotactic protein-1 (MCP-1) in bronchoalveolar lavage fluid (BALF) were detected by enzyme-linked immunosorbent assay (ELISA). The mRNA expressions of HMGB1, RAGE and NF-κB p65 were determined by Real-time polymerase chain reaction (Real-time PCR), and the protein expressions of HMGB1, RAGE, p-NF-κB p65, and alpha-smooth muscle actin (α-SMA) in bronchioles tissue of rats were determined by immunohistochemistry (IHC). ResultCompared with the conditions in the normal group, the forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and FEV1/FVC in the model group were decreased (P<0.01) while the contents of HMGB1, CXCL1, CXCL2 and MCP-1 in BALF were increased (P<0.01). And the model group presented higher mRNA expressions of HMGB1, RAGE and NF-κB p65 (P<0.01) and protein expressions of HMGB1, RAGE, p-NF-κB p65 and α-SMA (P<0.05, P<0.01) than the normal group. Compared with the model group, the modified Erchentang medium- and high-dose groups had increased FEV1/FVC (P<0.05, P<0.01), lowered contents of HMGB1, CXCL1, CXCL2 and MCP-1 in BALF (P<0.05, P<0.05), and reduced mRNA expressions of HMGB1, RAGE and NF-κB p65 (P<0.05, P<0.01) and protein expressions of HMGB1, RAGE, p-NF-κB p65 and α-SMA (P<0.05, P<0.01). ConclusionModified Erchentang can resist bronchiolar inflammation of COPD rats. The mechanism may be related to down-regulating the mRNA expressiona of HMGB1 and RAGE, inhibiting the activity of NF-κB, and reducing the release of HMGB1, CXCL1, CXCL2 and MCP-1, thus suppressing the inflammatory injury and abnormal repair of bronchioles.
6.Anti-inflammatory Mechanism of Modified Erchentang on Chronic Obstructive Pulmonary Disease Through Jagged1/Notch1/Hes1 Signaling Pathway
Lizhi SHANG ; Shu JI ; Yaoyang LI ; Wenhao HU ; Wenying XIE ; Zhuang CHEN ; Gaoyang LIU ; Haofan SHANG ; Hongwei WANG
Chinese Journal of Experimental Traditional Medical Formulae 2023;29(9):109-118
ObjectiveTo observe the effect of modified Erchentang on the expression of key molecules in the Jagged1/Notch1/Hes1 signaling pathway in lung tissues of rats with chronic obstructive pulmonary disease (COPD) and explore its anti-inflammatory effect and molecular mechanism on COPD through the Jagged1/Notch1/Hes1 signaling pathway. MethodSixty SD rats were randomly divided into normal group, model group, low-, medium-, and high-dose modified Erchentang groups (5, 10, 20 g·kg-1), and γ-secretase inhibitor DAPT group (0.02 g·kg-1), with 10 rats in each group. The COPD model was induced in rats by cigarette smoking combined with intratracheal instillation of lipopolysaccharide (LPS). Rats were treated with corresponding drugs by gavage, while those in the normal group and the model group were treated with the same amount of normal saline by gavage. The serum levels of Notch1, soluble intercellular adhesion molecule-1 (sICAM-1), activated leukocyte cell adhesion molecule (ALCAM), and soluble vascular adhesion molecule-1 (sVCAM-1) were detected by enzyme-linked immunosorbent assay (ELISA). The mRNA expression of Jagged1, Notch1, and Hes1 was detected by Real-time fluorescence quantitative polymerase chain reaction (Real-time PCR). The protein expression of Jagged1, Notch1, Notch1 intracellular domain (NICD1), and Hes1 in lung tissues of rats was detected by immunohistochemistry (IHC). ResultCompared with the normal group, the model group showed increased serum content of Notch1, sICAM-1, ALCAM, and sVCAM-1 (P<0.01), increased mRNA expression of Jagged1, Notch1, and Hes1 in lung tissues (P<0.01), and increased protein expression of Jagged1, Notch1, NICD1, and Hes1 (P<0.01). Compared with the model group, the medium- and high-dose modified Erchentang groups and the DAPT group showed decreased serum content of Notch1, sICAM-1, ALCAM, and sVCAM-1 (P<0.05, P<0.05), down-regulated mRNA expression of Jagged1, Notch1, and Hes1 (P<0.05, P<0.01), and reduced protein expression of Jagged1, Notch1, NICD1, and Hes1(P<0.05, P<0.01). ConclusionModified Erchentang may inhibit the inflammatory response in the lung of COPD rats, and its mechanism may be related to the resistance of inflammatory injury in the lung by decreasing the mRNA expression of Jagged1, Notch1, and Hes1 and inhibiting the release of Notch1, sICAM-1, ALCAM, and sVCAM-1.
7.Modified Erchentang Alleviates Inflammation in Chronic Obstructive Pulmonary Disease via Midkine/Notch2/Hey1 Signaling Pathway in Rats
Wenhao HU ; Lizhi SHANG ; Wenying XIE ; Yaoyang LI ; Gaoyang LIU ; Zhuang CHEN
Chinese Journal of Experimental Traditional Medical Formulae 2023;29(16):12-21
ObjectiveTo investigate the molecular mechanism of the anti-inflammatory effect of Erchentang in the lung tissue of the rat model of chronic obstructive pulmonary disease (COPD) via the heparin-binding factor (Midkine)/transmembrane receptor protein (Notch2)/Hey1 signaling pathway. MethodSixty SD rats were randomized into normal group, model group, modified Erchentang (5, 10, 20 g·kg-1·d-1) groups, and Notch1 pathway inhibitor (γ-secretase inhibitor, DAPT, 0.02 g·kg-1) group, with 10 rats in each group. The rat model of COPD was established by cigarette smoke combined with lipopolysaccharide (LPS). After the modeling, the rats were administrated with corresponding drugs by gavage, and those in the normal and model groups were administrated with normal saline by gavage for 21 days. The levels of Midkine, cytokine-induced neutrophil chemoattractant-1 (CINC-1), macrophage-derived chemokine (MDC), chemokine ligand 5 (CXCL5), neutrophil elastase (NE), and nuclear factor-kappa B (NF-κB) p65 in bronchoalveolar lavage fluid (BALF) were determined by enzyme-linked immunosorbent assay (ELISA). Real-time fluorescence quantitative polymerase chain reaction (Real-time PCR) and immunohistochemistry were respectively employed to determine the mRNA and protein levels of Midkine, Notch2, and Hey1 in the lung tissue. ResultCompared with the normal group, the modeling increased the levels of Midkine, CINC-1, MDC, CXCL5, NE, and NF-κB p65 in BALF (P<0.01) and up-regulated the mRNA and protein levels of Midkine, Notch2, and Hey1 in the lung tissue (P<0.01). Compared with the model group, medium- and high-dose modified Erchentang and DAPT lowered the levels of Midkine, CINC-1, MDC, CXCL5, and NF-κB p65 in BALF (P<0.01) and down-regulated the mRNA levels of Midkine, Notch2, and Hey1 (P<0.01). ConclusionModified Erchentang may inhibit the inflammation in COPD rats by down-regulating the expression of Midkine, Notch2, and Hey1 and reducing the content of Midkine, CINC-1, MDC, and CXCL5.
8.Effect of Danggui Shaoyaosan on Improvement of Cognitive Ability of SAMP8 Mice and Its Mechanism via Regulating Ubiquitin Proteasome Pathway
Yunhui CHEN ; Jun XIA ; Wenying HUAI ; Dan LIU ; Tiane ZHANG ; Yan LI ; Yongmei XIE ; Songqi TANG ; Yu YOU ; Wei PENG
Chinese Journal of Experimental Traditional Medical Formulae 2022;28(24):8-16
ObjectiveTo investigate the mechanism of Danggui Shaoyaosan (DSS) in the improvement of the cognitive ability of SAMP8 mice with Alzheimer's disease (AD) via regulating the ubiquitin-proteasome pathway (UPP). MethodFifteen SAMR1 mice were used as a normal group, and 60 SAMP8 mice were randomly divided into a model group and DSS high, medium, and low-dose groups (57.6, 28.8, and 14.4 g·kg-1·d-1), with 15 mice in each group. Intragastric administration was conducted for eight continuous weeks. Place navigation and spatial capacity were evaluated by Morris water maze. Pathological structure changes in neurons in the hippocampal CA1 area was detected by hematoxylin-eosin (HE) staining. The protein expression levels of hippocampal β-amyloid protein(Aβ) and phosphorylation(p)-Tau were determined by immunohistochemical staining (IHC) and enzyme-linked immunosorbent assay (ELISA), and the mRNA and protein expression levels of hippocampal ubiquitin (Ub), ubiquitin ligase E3 (E3), 26S proteasome, ubiquitin carboxyl terminal hydrolase-1 (UCHL1), and UCHL3 were determined by real-time fluorescent quantitative polymerase chain reaction (Real-time PCR) and Western blot, respectively. ResultAs compared with the normal group, the escape latency was prolonged in the model group (P<0.05) with the reduced number of crossing platform quadrants and time ratio in the platform quadrant (P<0.05). The model group decreased neurons and condensed cell bodies in the CA1 area, and increased β-amyloid precursor protein (β-APP) and p-Tau positive cells (P<0.05). In the model group, the protein expression levels of Aβ and p-Tau were increased (P<0.05), the mRNA and protein expression levels of Ub were increased (P<0.05), and the mRNA and protein expression levels of E3, 26S proteasome, UCHL1, and UCHL3 were decreased (P<0.05). As compared with the model group, the escape latency was shortened in the DSS high and medium-dose groups (P<0.05) with an increased number of crossing platform quadrants and residence time ratio (P<0.05). The pathological changes in CA1 of each DSS group were significantly improved, and the number of β-APP positive staining cells decreased (P<0.05). The number of p-Tau positive staining cells decreased in the DDS medium and low-dose groups (P<0.05). The protein expression levels of Aβ and p-Tau in each DDS group decreased (P<0.05), and the mRNA expression level of Ub in each group decreased (P <0.05). The mRNA expression levels of 26S, E3, and UCHL3 in the DDS high and medium-dose groups increased (P<0.05), and the mRNA expression level of UCHL1 in the DDS medium-dose group increased (P<0.05). The protein expression level of Ub in each DDS group decreased, and the protein expression levels of 26S, E3, UCHL1+3 in the DDS high and medium-dose groups increased (P<0.05). ConclusionDSS can improve the cognitive ability of SAMP8 mice, and its mechanism may be related to the reduction of the abnormal deposition of Aβ and p-Tau via decreasing the expression of Ub and increasing that of E3, 26S, UCHL1, and UCHL3 in the UPP.
9.Protective Effect of Danggui Shaoyaosan-contained Serum on Aβ1-40-injured PC12 Cells via Regulating UPP and Its Mechanism
Yunhui CHEN ; Jun XIA ; Xinglong LIU ; Wenying HUAI ; Dan LIU ; Tiane ZHANG ; Yongmei XIE ; Yu YOU ; Wen YUE ; Songqi TANG ; Wei PENG
Chinese Journal of Experimental Traditional Medical Formulae 2022;28(24):17-25
ObjectiveTo investigate the protective effect of Danggui Shaoyaosan (DSS)-contained serum on β-amyloid (Aβ)1-40-injured rat adrenal pheochromocytoma PC12 cells and its mechanism in regulating ubiquitin-proteasome pathway (UPP). MethodAβ1-40 was used to intervene PC12 cells to prepare the cell models of Alzheimer's disease (AD), and the experiment was divided into the blank, model, and DSS-contained serum high, medium, and low-dose groups (10%, 5%, and 2.5%). Cell viability and apoptosis were detected using cell counting kit-8 (CCK-8) method and flow cytometry, respectively. The content of Aβ and p-Tau protein was determined by enzyme-linked immunosorbent assay (ELISA). The ubiquitin (Ub), ubiquitin ligase E3 (E3), 26S proteasome, ubiquitin carboxyl terminal hydrolase1 (UCHL1), and UCHL3 protein expressions of UPP were displayed using immunofluorescence cytochemistry (ICC), and the mRNA and protein expression levels of Ub, E3-parkin, 26S, UCHL1, and UCHL3 were determined by real-time fluorescent quantitative polymerase chain reaction (Real-time PCR) and Western blot, respectively. ResultThe data of the CCK8 experiment verified that 5 μmol·L-1 and 48 hours were the optimal conditions for modeling Aβ1-40-injured PC12 cells. As compared with the blank group, the cell viability rate in the model group decreased (P<0.05) with an increased apoptosis rate (P<0.05), the content of Aβ and p-Tau contents was elevated (P<0.05), the mRNA and protein expression levels of Ub increased, and the mRNA and protein expression levels of 26S, E3, and UCHL1+3 decreased (P<0.05). As compared with the model group, the cell viability rate in the DSS-contained medium-dose group increased (P<0.05), whereas the apoptosis rate in each DSS-contained group decreased (P<0.05). The content of Aβ in each DDS-contained group decreased (P<0.05), and the content of p-Tau in the DDS-contained high and medium-dose groups decreased (P<0.05). The mRNA expression level of Ub decreased, and that of 26S increased in each DDS-contained group (P<0.05). The mRNA expression level of UCHL1 in the DDS-contained medium-dose group increased (P<0.05), and the mRNA expression levels of E3 and UCHL 3 in the DDS-contained high and medium-dose groups increased (P<0.05). The protein expression level of Ub in each DDS-contained group decreased, and the protein expression levels of 26S, E3, and UCHL1+3 in the DDS high and medium-dose groups increased. The DSS-contained serum medium-dose group exerted the optimal effect. ConclusionDSS-contained serum can increase cell viability rate, reduce cell apoptosis rate, eliminate Aβ and p-Tau protein deposits, and exert protective effects on Aβ1-40-injured PC12 cells. Its mechanism may involve UPP via decreasing the expression of Ub and increasing that of 26S, E3, UCHL1, and UCHL3.
10.High expression of FABP4 in colorectal cancer and its clinical significance.
Yan ZHANG ; Wenjia ZHANG ; Min XIA ; Zhujun XIE ; Fangmei AN ; Qiang ZHAN ; Wenying TIAN ; Tianyue ZHU
Journal of Zhejiang University. Science. B 2021;22(2):136-145
OBJECTIVES:
To investigate the relationship between the fatty acid-binding protein 4 (FABP4) and colorectal cancer (CRC).
METHODS:
Using an enzyme-linked immunosorbent assay (ELISA), we measured the expression of FABP4 in plasma of 50 patients who underwent surgery for CRC from October 2017 to May 2018 and 50 healthy controls. The content of the visceral fat area (VFA) as seen with abdominal computed tomography (CT) scanning was measured by ImageJ software. The expression levels of FABP4, E-cadherin, and Snail proteins in CRC and adjacent tissues were determined by immunohistochemistry.
RESULTS:
The mean concentration of plasma FABP4 of CRC patients was higher than that of the control group (22.46 vs. 9.82 ng/mL;
CONCLUSIONS
High LPA and VFA were risk factors for increased plasma FABP4 in CRC patients. FABP4 protein was highly expressed in CRC tissues and associated with TNM stage, differentiation, and lymph node metastasis of CRC. The level of FABP4 in CRC tissue was correlated with E-cadherin and Snail expression, suggesting that FABP4 may promote CRC progression related to epithelial-mesenchymal transition (EMT).

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