World Immunisation Week 24 – 30 April 2014; “Are you up-to-date?”

Back in 2012 I watched a BBC documentary ‘Ewan Macgregor: Cold Chain Mission’ http://www.unicef.org.uk/asp/cold-chain-ewan-mcgregor/index.asp. This filmed the actor’s mission as an ambassador of UNICEF to deliver vaccines, and immunise children in some of the world’s remotest places. This particular programme followed his journey to India and Nepal and highlighted the incredible journey he made trekking 2 days over the Himalaya whilst maintaining the ‘cold chain’ of the vaccines he was delivering to remote mountain villages. The cold chain is the essential system of transporting and storing vaccines within a safe temperature range (2°c to 8°c) from the place of manufacture to the point of administration. This ensures people receive an effective vaccine that has retained its viability by not being exposed to temperatures outside of this range. So you can only imagine how difficult this was given the circumstances of this trip!

A couple of things have stayed with me since watching this programme, namely;

• The complicated planning and effort it took the team to maintain the cold chain whilst trekking in the mountains, to preserve the efficacy of the vaccines they were delivering (without a vaccine fridge!). It really was a mission!

• The determination of these few health care workers to ensure even the remotest of children was protected against disease.

• The remoteness of where people live and their lack of basic medical care – to include limited access to vaccinations.

• The relief I saw in the parents as their children were immunised. They understood all too well the importance of immunisation, quoting that the measles vaccine being offered ‘will keep their children safe.’ I got the impression they had perhaps seen at first hand the devastating, sometimes fatal effect of measles infection in a child.

Immunisation is recognised as one of the most successful and cost effective health interventions ever introduced. It prevents 2 – 3 million deaths every year. New vaccines now protect against diseases such as pneumonia and rotavirus diarrhoea- two of the world’s biggest killers in children under 5. We also now have vaccines to protect against cervical cancer for adolescents and adults.

As highlighted in the BBC documentary, large numbers of people are not immunised, and for those who start but don’t finish immunisation schedules this is due to:

-inadequate supply of vaccines

-lack of heath care workers

-insufficient political and financial support

Here in the UK, we are extremely fortunate to have a system in place that is easy to access, evidence based, safe and funded by the NHS to ensure we are all protected against the most devastating ‘vaccine- preventable’ diseases. We now have a schedule that is started in pregnancy to protect pregnant women against influenza, and their babies, when born, from whooping cough – this continues through to the birth of their babies – the first few months of life, toddler age, pre-school age, on to teens and then later on in life above the age of 65 years.

We are very lucky indeed.

However, many people here in the UK are still not being vaccinated or are not up-to-date with the schedule. Unlike some other countries, we have robust systems in place to immunise our population, so why is this?

Lack of education about vaccination is one of the key reasons why adults consciously choose not to be vaccinated themselves, or not to vaccinate their children. Here in the UK, there have been many ‘scare’ stories and ‘controversies’ concerning immunisation that have influenced uptake of vaccinations and unfortunately we are now seeing the after effects of these, one being the recent measles outbreak.

A common misconception is that vaccines are unsafe. Remember they have been widely available for many years- some since the 19th century! They are thoroughly tested for safety before they are made routinely available, and each vaccine’s safety is then continually monitored even after it’s been made available. So in fact they are very safe and millions of children and adults are vaccinated every year without long term adverse effects.

I have at times consulted with students who at the age of 18yrs have never received a vaccine in their lifetime – as their parents did not consent to this. Fortunately, this happens infrequently and the person attending the appointment makes an informed choice, based on what they have read and what we discuss in the consultation, to complete a primary course of vaccinations, to ensure they have adequate immunity in their adult lives.

However, as more research and evidence becomes available, immunisation schedules change – so ‘lack of knowledge’ can be as a result of changes, rather than decision not to immunise. The schedule you received as a child may have changed by the time you reach adulthood. Some people also ‘miss’ receiving vaccinations due to illness on the day of vaccination.

Specific goals for this world immunisation week are:

 

  1. 1.      For you to know what vaccines are available to protect you against disease
  2. 2.      Check your vaccination status. Perhaps print off the UK schedule and check on behalf of members of your family. Make sure they are all ‘up-to-date’ – remember schedules do change…
  3. 3.      Book an appointment at SHS for any vaccines you think are missing

Young people attending Universities and Higher Education are known to be at ‘higher risk’ for certain infections, including meningitis C and mumps/measles. These infections are spread through respiratory contact- coughing and sneezing, so easily transmitted. By ensuring that you are up-to-date with your immunisations you will protect both yourself and others, via ‘herd immunity’. Herd immunity is ‘the indirect protection from infection of susceptible members of the population, and the protection of the population as a whole, which is brought about by the presence of immune individuals.’ No vaccine is 100% effective- measles vaccine is 90-95% effective, and some people are unable receive a live vaccine like MMR, e.g. the immunocompromised, so by you making sure that you’re up-to-date with your vaccinations you will be giving yourself the best protection available and also contributing to increased herd immunity in the population around you for those who most need protection.

So, are YOU ‘Up-To-Date’?

You need to ensure you have received the following vaccines:

Number of Injections

Vaccine

5

Tetanus, Diphtheria and Polio

2

combined Measles, Mumps and Rubella

1

(2 as from August 2104)

Meningitis C

3

HPV- Gardasil (females under 18 yrs only)

Annual

Influenza vaccine – ‘at risk’ groups only

 

Remember, you are able to find out if you have missed any of your immunisations by checking:

-Your GP immunisation records

-Your parent’s records

-Your school, as some immunisations are given in schools and not documented in your GP records

If you find you are not ‘up-to-date’ with your immunisations schedule, we encourage you to come in to SHS so we may help you complete your schedule.

If you are planning a trip abroad, especially to ‘high risk’ destinations, please always check you are ‘up-to-date’ with your travel immunisations at least 6-8 weeks before you travel.

We have a safe and adequate supply of vaccines in the practice and we take care of the cold chain, so all you need to do is book an appointment with one of the nurses either by phone or online, and they will then administer any free NHS vaccines you are missing.

You haven’t got to cross the Himalaya to receive a life protecting immunisation; you can have them here at SHS, but if you do intend to cross the Himalaya, please ensure you are also up-to-date with your travel immunisations as well!

 Useful Links:

UK Immunisation Schedule:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/227651/8515_DoH_Complete_Imm_schedule_A4_2013_09.pdf.

 

Measles Outbreak:

http://www.nhs.uk/Conditions/vaccinations/Pages/measles-outbreak-advice.aspx.

http://www.bbc.co.uk/news/health-22277186.

 

History of vaccination, ‘From antiquity to the present day…’

http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1279889314367.

 

Travel Immunisations:

http://www.fitfortravel.nhs.uk/home.aspx.

 

World Health Day 7th April 2014: safer travel for all Bristol students

World Health Day is celebrated on 7 April every year to mark the anniversary of the founding of the World Health Organization in 1948. Each year a theme is selected that highlights a priority area of public health. In past years themes as diverse as road safety, climate change and high blood pressure have been chosen. The topic for 2014 is vector-borne diseases, which could be of great personal relevance to a large number of students who make international journeys whilst they are studying at the University of Bristol.

Vectors are organisms that transmit pathogens and parasites from one infected person (or animal) to another. Vector-borne diseases are illnesses caused by these pathogens and parasites. Vector-borne diseases account for a massive 17% of the estimated global burden of all infectious diseases.

The most well known and deadly vector-borne disease is of course Malaria but the world’s fastest growing vector-borne disease is Dengue with a 30-fold increase in disease incidence over the last 50 years. Others you may have heard of are Yellow Fever and Schistosomiasis. Vector borne diseases are most commonly found in tropical areas and places where access to safe drinking-water and sanitation systems is problematic. However, globalization of trade and travel and environmental challenges such as climate change and urbanization are having an impact on transmission of vector-borne diseases, and causing their appearance in countries where they were previously unknown.

 

So World Health Day 2014 has a particular relevance for people on the move, which includes many UoB students. Large numbers of you will travel to countries where vector borne diseases pose a threat. This includes some of our International Students who return home during the course of their degree. Many of the risks of global travel can be minimized by precautions taken before, during and after travel. Whether you are a student planning an exciting trip during one of the university holidays, or whether you are an International Student intending on going home during your degree, it is important that travellers to developing countries consult a travel medicine clinic well in advance of the intended journey. We run travel clinics at Students’ Health service, which are open to our International Students too.

 

‘Golden age’ of antibiotics ‘set to end’

My last blog ‘More to pharmacies than meet the eye’ highlighted the increased services pharmacies now provide and that they are an excellent first ‘port of call’ for advice and treatment options if you are feeling unwell with a minor illness. At the same time as writing this, another article in the BBC health news caught my attention that somewhat relates to this blog- that of the growing threat of antibiotic resistant infections. http://www.bbc.co.uk/news/health-25654112.

England’s Chief Medical Officer Dame Sally Davies described the growing resistance to antibiotics as a ‘ticking time bomb’ and said ‘the danger ranked alongside terrorism on the list of national threats’. It has been described as a ‘global issue,’ and, rather alarmingly, a threat to mankind with ‘the prospect of a return to the pre-antibiotic era.’ As a nurse and prescriber, I find it extremely hard to imagine a time when we no longer have life- saving treatments available to us that we have relied upon for so many years. Most of us have been born into a world containing antibiotics. Penicillin went into widespread use in the 1950s, but infectious agents are older than humanity and continually evolving. Two bacterial infections that illustrate the problem are:

1. Multi-drug resistant (MDR) tuberculosis (TB). Of note, TB is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent. In 2012, 8.6 million people fell ill with TB and 1.3 million died from TB (WHO).

2. Infections from enterobacteriaceae e.g. E. coli- which can cause urinary tract infections (UTIs), cystitis and kidney infections. UTIs are common in general practice, accounting for 1-3% of all consultations. Almost half of all women report at least one UTI sometime during their lifetime, and after an initial UTI, 20% to 30% of women experience a recurrence. This is a common infection we see in female student patients at SHS.

We are also seeing alarming increases worldwide in gonorrhoea infections; this is again becoming extremely difficult to treat due to resistance to antibiotics.

So what is causing this problem?

Inappropriate use and prescribing of antibiotics is causing the development of resistance.

Inappropriate use includes:

  • not completing a course of antibiotics as prescribed
  • skipping doses of antibiotics
  • not taking antibiotics at regular intervals
  • saving some for later

Inappropriate prescribing includes:

  • unnecessary prescription of antibiotics
  • unsuitable use of broad-spectrum antibiotics
  • wrong selection of antibiotics and inappropriate duration or dose of antibiotics

Make antibiotic prescribing a priority in primary care by:

  • developing an antibiotic stewardship tool for prescribers

Within Bristol, we have ‘antimicrobial prescribing guidelines’ for the community as a tool to refer to and follow, ‘to provide a simple, best clinical judgment approach to the treatment of common infections; to promote the safe, effective and economic use of antibiotics and to minimise the emergence of bacterial resistance in the community.’

Frequently, patients who I see in my appointments ask for ‘antibiotics’ for their sore throat, colds and other minor illnesses. The majority of these illnesses we see in general practice are caused by viruses. Antibiotics will only treat bacterial infections, not viruses, so rest assured that careful clinical reasoning lies behind a decision not to prescribe antibiotics. If you are prescribed antibiotics, please take note of the ‘appropriate use’ points as above.

Remember the pharmacy is there for advice, treatment and referral if you do develop a minor illness. The patient.co.uk website is also an excellent source of information for patients and health care professionals alike http://www.patient.co.uk/.

 

More to Pharmacies than meets the eye

Did you know that perhaps one in seven GP appointments could be dealt with by pharmacies? This equates to 40million appointments per year. You may think of your local pharmacy as just a place to pick up your prescriptions or toiletries – but there is more to a pharmacy than meets the eye.

A recent article in the BBC health news

http://www.bbc.co.uk/news/health-25744060. highlighting the services pharmacies now provide, struck a chord with me. Having qualified as an independent nurse prescriber in 2011, many of the consultations I now deal with involve minor illness – i.e. sore throats, coughs, colds, sinusitis etc… Interestingly numerous student patients who present have not self treated by taking any over the counter medicines to help ease their symptoms. For those that are unsure about what to take, many have not consulted with a pharmacist for advice. In reality, after careful assessment, the majority of minor illness we see in general practice tends to be of viral origin – so antibiotics are not indicated – advice is then to take regular ‘over the counter’ medications i.e. paracetamol, ibuprofen (if safe to take) rest and fluids. These medications can be bought very cheaply from your local pharmacy.

A pharmacist can deal with and advise on cold and flu symptoms.

The Pharmacy Voice chief exec states that ‘Pharmacy is the third largest health profession (in the health sector) after medicine and nursing, yet people still don’t really know who we are and what we do’.

Pharmacists have been given increasing responsibility within the NHS, and many professionals, like myself, can also now prescribe ‘prescription only medicines’; medicines that only a Doctor might previously have prescribed for you. They are also able to sell Pharmacy ‘P’ medications i.e. antibiotics eye drops for eye infections, emergency contraception, vaginal thrush treatment; and provide stop smoking advice, pregnancy testing and sexual health screening.

 

‘Community pharmacies are perfectly capable of taking the strain from GP and A+E departments that are bursting at the seams.’ One out of every four people who go to A&E could have been treated elsewhere in the community, or could have self-treated. Your local pharmacy can help treat common illnesses.

Please pick up this leaflet from SHS or download from the following: http://www.bristolccg.nhs.uk/media/25934/feelingunwell_choosewell.pdf.

 

Self-injury awareness day

March 1st marks ‘self-injury awareness day’, a global movement signified by the wearing of an orange ribbon, which aims to increase the awareness of self-injury and challenge many of the misconceptions surrounding this.

What is self-injury? Self-injury, also known as ‘self-harm’ or ‘cutting’, describes how someone intentionally inflicts physical injury to their own body without any suicidal intent. It can take on any form, whether it is cutting, head banging, hair pulling, burning, recreational drug or alcohol abuse, non-lethal drug overdoses or taking excessive risks to personal safety.  It affects people regardless of age, gender or ethnicity, although it is known to be particularly common in younger people.  Due to the shame and self-hatred often associated with self-harm, many sufferers will go to great lengths to hide scars, making it difficult to identify those needing help, and also to estimate how prevalent this is.  Research suggests that at least ten percent of 15-16 year olds have self-harmed at some point in their lives.

Why do people self-injure? Self-injury is recognised as a coping mechanism for overwhelming emotional distress relating to current traumas or difficulties from the past.  The distress might be grief, anger, loneliness, emptiness, anxiety or self-hatred and sufferers may describe how the ‘real pain’ of self-harm numbs their emotional turmoil, and in some cases acts as a way of avoiding attempting suicide. Over time self-injury might become a person’s ordinary response to everyday stressors, sometimes increasing the frequency and severity of injury.

What to do if you are self-harming? GPs are well placed to provide confidential advice and support, put you in touch with local and national self- injury organisations (see below) and check for any underlying depression/ anxiety or eating disorder symptoms. The Student Counselling Service is also somewhere safe and non judgmental to go to.

Is there treatment for self-harm?  Yes there can be, and the aim of treatment may be to both minimise harm from acts of self-injury and to help the sufferer find new coping mechanisms and develop problem-solving skills.  Strategies to minimise harm include recognising triggers for self-injury, learning less dangerous ways/locations for cutting, carrying dressings and understanding the dangers associated with certain medications. However, stopping the self harm is not necessarily the aim of treatment, which may be more directed towards underlying issues.

Talking therapy (e.g. cognitive behavioural therapy/ dialectical behavioural therapy), creative therapy, support networks and the promotion of the development of self-help skills all help in supporting a sufferer to learn new coping mechanisms.  If self-harm is part of an underlying mental health illness, specific treatment for that condition may be warranted.

I am worried that my friend is self-harming?  It is upsetting to discover a friend is self-harming but it is important to provide non-judgmental support and acceptance, acknowledging that they are distressed. Encouraging them to talk to health care professionals or contact a local support group will show them that you care. Asking a person to stop self-harming will not help the situation as you are asking them to take away their coping strategy.

Will I/my friend get better?  There are no quick fixes for self-harm, but by getting a person the right support and treatment, they will start to learn new ways to deal with their emotional distress.

References/ literature available:

 

  1. Life Signs Self-Injury Fact Sheet for Health Care Workers- www.lifesigns.org.uk
  2. Information resource pack- Bristol Crisis Service for Women –www.selfinjurysupport.org.uk
  3. NHS self injury fact sheet- http://www.nhs.uk/conditions/self-injury/pages/introduction.aspx
  4. MIND- ‘understanding self-harm’- http://www.mind.org.uk

 

Support Groups

Self Injury Self Help- support groups for women and men who self-injure in the Bristol area. www.sishbristol.org.uk

TESS- Bristol Crisis Support for Women, text or email support service for girls and women who self-injure- up to age 25.  www.selfinjurysupport.org.uk, or text 07800472908

MIND- for information sheets/ advice about local resources- www.mind.org.uk

 

 

Eating Disorders Awareness Week; 24 February 2014.

Beat, the Eating Disorders Charity, is running a national awareness week called ‘Sock it to Eating Disorders’ this week. It is a light hearted way to bring people together, do a bit of fundraising, and raise the profile of a devastating group of conditions.

As a GP at Students’ Health I deal with such conditions most weeks, and one can become too focussed on the medical aspects, so it’s good to stop and think occasionally about what these illnesses mean to the people who suffer from them, and their friends and families. And nothing brings that home like the Beat “Lasting Memories” page, which reminded me of the immense impact that such a potentially fatal condition can have.

What a long list of lost young people, mainly women, and so many aged around 18-20, like the students I look after every day. The messages left by family and friends are heart breaking, and this online wall of memorials is a sobering reminder of why I and my colleagues spend so much time and energy improving and developing local services for Eating Disorders in Bristol.

We have made it so much easier in the last 2 or 3 years to get help that hopefully such memorials will become rare, and fewer families will be turned upside down by such tragic deaths.

Here at Students’ Health Service we really do want to help you if you have, or think you might have, an eating disorder, so please do come and see any of the GPs, and talk about referral onto First Step, the new Bristol-wide community based service for assessment and therapy. First Step is led by a clinical psychologist, and you can have your appointment in the same building as the GP practice, no need to go to hospital. The average waiting time for an appointment with them is about 3 weeks, not long at all, so don’t hesitate if you are suffering… come and talk to us.

 

http://www.b-eat.co.uk/support-us/get-involved/lasting-memories/

 

http://www.awp.nhs.uk/news-publications/trust-news/2013/july/another-step-forward-in-eating-disorders-support-for-bristol/

Think about sex day; Valentine’s Day 2014!

Are you thinking about sex? Maybe. Studies tell us that on average you will do 19 times a day if you’re a man, and 10 times a day if you’re a woman!

It’s normal!

What sort of thoughts? The more graphic thoughts I will leave to your imagination but there are numerous reasons why people will think about sex.

Let’s think of some of the less positive thoughts that may cause distress:-

- Sex is always painful

- I’m not getting enough sex

- I love sex but I’m not sure I’m any good

- Have a caught an STI (sexually transmitted infection)? HIV? Other?

- Sex brings back awful memories for me

- Where shall I get condoms/emergency contraception/sexual health checks from?

- Am I big enough?

- Do my genitals look odd? Am I normal? Is that a wart?

- Fears of pregnancy?

- I’m embarrassed to get help or ask advice

 

Please don’t sit alone worrying about these things. Often the worry is needless and reassurance is all that is required, but if not, help is out there.

If you’re not sure about what to do about your worry then preferably ask a health professional e.g. GP/practice nurse/local sexual health clinic. Book an appointment with us. Another alternative is to do your own research in books or on the internet but please take care that you use reputable sites.

Sex is normal. Thinking about sex is normal. Do it as often as you like. If you have sex make sure you do it safely.

The most important part is to not be shy or embarrassed but to come and ask. Remember we nearly all do it, think about it and worry about it at some time. If we didn’t then none of us would be here of course!

See below for some great helpful websites and resources

 

http://www.national-awareness-days.com/think-about-sex-day.html

 

Sexual health – Live Well – NHS Choices

FPA – the sexual health charity | FPA

http://www.brook.co.uk

Symptom Checker, Health Information and Medicines Guide | Patient.co.uk | Patient.co.uk

Find Sexual health information and support services – NHS Choices

 

Have a good day!

Love Hearts …or Love Hurts?

Roses are red and violets are blue,

No one in the bar was as gorgeous as you.

I brought you home; I was over the moon,

In the morning I was singing a different tune…

 

Alcohol can contribute to risk-taking behaviour that can lead to unwanted pregnancies and sexually transmitted infections

A survey of 16 – 24-year-olds found that after drinking alcohol-

•             One in seven have had unsafe sex (i.e. not using a condom)

•             One in five had sex and later wished they hadn’t

•             One in 10 were unable to remember whether they had sex the night before

•             Many (40%) agreed that they would be more likely to have casual sex

 

Saint Valentine’s Day has long been associated with love, romance and gifts.

 

Will you receive a gift from your loved one……or is the relationship ‘complicated’?

And what if the gift you are given is an unwanted one that can cause ‘complications’…such as Chlamydia?

Most people with Chlamydia have no symptoms. It‘s the commonest Sexually Transmited Infection (STI) in the under 25’s with 1 in 20 people affected.

We are encouraging everyone under the age of 25 to take a combined Chlamydia and Gonorrhoea test if they have ever been sexually active.

This test should be repeated yearly and with any change in sexual partner. It’s a simple self-taken test on either a vaginal swab or urine specimen. The result can even be sent by text or email. Pop into the surgery to pick up a test kit from the office, or book in for a test.

 

You may also want to consider screening for blood borne infections (BBV) such as HIV, Hepatitis or Syphilis if you have had higher risk sexual partners.

This would include anyone who has injected drugs, paid for sex, men who have sex with men and their partners, and any partners from regions with a higher incidence of HIV (above 1%) such Sub-Saharan Africa.

You can call the office (0117 3302720 Option 2) and leave your details to arrange an asymptomatic sexual health appointment for BBV testing, and or book in for a Chlamydia and Gonorrhoea test.

So, wishing you a Happy and Healthy Valentine’s Day with no unwelcome gifts….

 

 

It’s Time to Talk about Mental Health! #TimetoTalk

This weeks blog is a quiz!

Time to stop the stigma surrounding mental ill health. See how much you know in the attached short quiz, via the link below. Scroll to the bottom of the linked page to see the Myth/ Fact quiz.

Then spread the word. It’s OK to talk about mental health!

http://www.time-to-change.org.uk/downloads

http://www.time-to-change.org.uk/

 

 

 

 

Figs, Chestnuts , Nutmegs, Baubles and Jingle berries!

Actually I am not talking about Christmas items, but some of the names given to testicles!

The Male Cancer website ‘Your Privates’, run by the charity Orchid, gives 33 different names to testicles- I challenge you to see if you can think of them all! (Some of the least rude answers are at the end!).

The website does, however, also have an important message to convey to all you men out there:

‘Get to know your Balls’………or whatever name you like to use for them.

Testicular cancer is the most common cancer in men aged between 15-45 years with just over approximately 2200 new cases a year. However, if found at an early stage cure rates of 98% are usually possible. Even when testicular cancer has spread to other areas of the body cure can still be achieved. Recent research has suggested that 96% of all men with testicular cancer should be cured.

So to assist early detection you need to be performing Testicular Self Examination, in other words getting to know what’s normal for you!

Testicular Self Examination

Perform Testicular Self Examination (TSE) about once a month.

The best time is after a warm bath or shower (so the scrotum is soft and relaxed)

Get to know your balls and if you find something abnormal, get it checked out. This may include a lump or a noticeable increase in size or weight of the testicle.

The website (link below) contains a video demonstrating TSE (under testicular health and awareness)

What to watch out for?

A lump can be felt in 97% of cases of testicular cancer, and in approximately 86% of cases this will be painless. However, also remember that only 4 in 100 lumps will be cancer. There are many other causes of lumps or swellings in the scrotum including infection (Epididymo-orchitis), fluid (Hydrocoele), varicose veins ( Varicocoele), and Epididymal cysts. Many of these can be easily diagnosed when examined by a doctor, but a simple painless Ultrasound Scan may sometimes also be required.

So grab those ‘crackers’ and add ‘Getting to know you Baubles’ to your New Years Resolution list alongside your regular Chlamydia test!

http://www.yourprivates.org.uk

Answers- acorns, baby-makers, back wheels, baubles, chestnuts, cods, conkers, cream crackers, doodads, figs, globes, goolies, hairy conkers, heirlooms, jingle berries, knackers, love apples, love nuts, love spuds, marble halls, meaty bites, nads, nobby halls, nuggets, nutmegs, nuts, plums, rocks.

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