2024-03-29T12:29:46Z
https://azjp.journals.ekb.eg/?_action=export&rf=summon&issue=10649
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
CORRELATION OF METABOLIC ALTERATION IN MAGNETIC RESONANCE SPECTROSCOPY WITH EEG IN DIAGNOSIS OF CHILDHOOD EPILEPSY
Mahmoud Mohammed
Saber
Mohsen
TahaElkeie
Iman Ali
AbdElhameid
Mohamed Said
Abdul Aziz
Background: Epilepsy is a heterogonous group of disorders with multiple causes. It is a common neurologic condition worldwide. Up to 8% of the population will experience at least once seizure in their lifetime.
Objectives: The purpose of this study was to evaluate the potential benefits of MR Spectroscopic image in lateralization of epileptic foci in correlation with EEG and clinical features in the patients with epilepsy.
Methodology: Between December 2016 and August 2018, a total of 50 patients (28 male &22 female) having seizures were selected from the Neurology unite, Pediatric Department, Sayed Galal Hospital, Al Azhar University, underwent to routine video EEG& MRS examination.
Results: 36 patients (72% of total patient number) were found to have abnormal MRS finding. Seven patients (14%) have abnormal finding in both sides. 12 patients (24%) had abnormal data on right side. 17 patient (34%) had abnormal finding on left side. EEG was positive in 34 cases (68%), 14 case (28%) had bilateral findings;12 case (24%) had left sided and 8 cases (16%)had rt sided EEG findings. The temporal region was the commonest epileptogenic area in EEG&MRS. MRS sensitivity to EEG was (79.4%) and specificity was (43.75%) results were nearly consistent with EEG especially in cases with focal EEG discharges.
Conclusion: MRS is a very sensitive noninvasive guiding tool in predicting the lateralization related epilepsy mainly temporal lobe epilepsy rather than generalized epilepsy. It helps in detecting abnormal spectra of various brain metabolites before appearance of structural lesions.
Recommendation: MRS is a very sensitive noninvasive guiding tool in predicting the lateralization related epilepsy mainly temporal lobe epilepsy rather than generalized epilepsy. It helps in detecting abnormal spectra of various brain metabolites before appearance of structural lesions.
MRS
Epilepsy
EEG
2019
06
01
301
323
https://azjp.journals.ekb.eg/article_70123_305ba3b3089954d4514b0e975b2e2f63.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
MUCOCUTANEOUS MANIFESTATIONS ASSOCIATED WITH PEDIATRIC MALIGNANCIES
Khalid I
Shedeed
Hussein M
El Assal
Abdel Moneim A
Abdel Moneim
Mohamed D
El Harirri
Background: Skin lesions may help clinicians to diagnose and evaluate pediatric malignancies. However chemotherapy and radiotherapy have major role to fight cancer, they also have destructive side effect on skin and mucous membranes.
Aim of Study: to be aware of their side effects on skin apparatus and to clarify initial skin lesions that may precede appearance of neoplasm.
Methods: In this Prospective study, 199 patients diagnosed as malignancies in Pediatric oncology department at Nasser Institute Hospital and Benha University Hospitals during the period from November 2017 to May 2018. Complete clinical history was taken, systemic and local examination was carried for all the patients. Detailed dermatological examination was performed at initial presentation and when any mucocutaneous sign appeared. Biopsies taken when needed. Imaging of all positive signs to evaluate and follow up.
Results: 122 males (61.31%) compared to 77 females (38.69%). Hematological malignancies constitute 103(51.75%) and Non-Hematological 96 case (48.25%). The most prevalent sign was chemotherapy induced alopecia which found in 145(72.86%). Infections were the second in 23 cases (60.53%). Drug reaction, echymosis, radio-related dermatitis and oral mucositis found in 8(21.05%), 3(7.89%), 1(2.63%) and 6(15.79%) patients respectively. Some specific skin lesions precede the systemic appearance of the malignancies. Leukemia Cutis and Histiocytosis were encountered in our study in 1(2.63%) and 5(13.16%) respectively.
Conclusion: Alopecia found in 72.86%, Langerhans Cell Histiocytosis may presented with skin lesions initially, Neutropenic patients have higher risk to skin lesions.
2019
06
01
324
342
https://azjp.journals.ekb.eg/article_70181_afc498d7ec7effe3538af5ebbaa83459.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
ASSOCIATION BETWEEN TRANSIENT TACHYPNEA OF THE NEWBORN AND WHEEZING SYMPTOMS IN INFANCY
Mohamed M.
Diaa Aldeen
Ahmad M.
Ismael
Mohamed M.
Abd Elmohsen
Background: Transient tachypnea of the newborn (TTN) has rare complications during the acute period and has a good prognosis. In addition it is generally believed that TTN does not lead to any long-term sequelae. However, in limited studies, the frequency of wheezing attacks and asthma was found to be increased in patient who had TTN diagnosis in the neonatal period in comparison to patients who had no respiratory problem in neonatal period.
Objectives: The aim of this study was to determine the association between TTN and the development of wheezing in early life.
Patients and Methods: This was a prospective study. It included 115 full term infants. It carried out in the NICU of Bab Alsharyia University Hospital. Follow up of all cases after parental consent from February 2017 to July 2018 for 18 month. Where 100 cases complete the follow up with regular assessment in the outpatient clinic for any symptoms of respiratory distress and clinical examination and attacks of wheeze or need for hospital admission, 15 cases missed the study period.
Results: Our study revealed that 63 (63%) out of 100 studied cases developed wheezy chest during the follow up period. The studied cases were male gender 35(55.6%) and smoking history especially the father 56 (88.9%) were risk factors for the development of wheeze in the studied cases with statistical significance (p<0.05). There was no statistical significant correlation between wheezy and non-wheezy groups regarding maternal history (bronchial asthma, hypertensive and DM). There was a positive correlation regarding hospital admission 63(100%) after neonatal period in studied cases with statistical significance difference in the wheezy group (P-value of 0.001).
Conclusion: The risk factors to developed wheezing symptoms in diagnosed term infant with TTN include male gander, smoking history of father. There is no correlation between maternal bronchial asthma of diagnosed term infant of TTN and development of wheezing symptoms
2019
06
01
343
355
https://azjp.journals.ekb.eg/article_70182_91231fa6afdc4a6e4b8e4e5e49ef11b2.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
IMPACTS OF PHOTOTHERAPY ON IMMUNOLOGICAL STATUS OF NEWBORN WITH HYPERBILIRUBINEMIA
Osman Khairy
Osman El-Sayed
Sherif Mostafa
Kamal Reda
Ahmed Yousef
Al Sawah
Mamdouh
Atia Mohmed
Mohammed
Abdel Karem
Background: Neonatal jaundice in the first week of life is a common problem in the newborn; it is due to an imbalance of bilirubin production and its elimination which can lead to significantly elevated levels of circulating bilirubin (hyperbilirubenemia).
Aim of the Work: The aim of this study was to evaluate the effect of phototherapy on the immunological status of newborn.
Patients & Methods: This is a prospective randomized simple descriptive follow up study that was conducted on 75 jaundiced neonates ≥37 weeks admitted to the neonatal intensive care unit (NICU) of Al Hussein University Hospital in a period from October 2016 to September 2018. Our cases were divided into three groups according to level of billrubin and type of phototherapy: Group (1) 25 neonates with billrubin level 16-18 mg/dL under single phototherapy, Group (2) 25 neonates with billrubin level >18 to 22 mg/dL under double phototherapy, Group (3) 25 neonates with billrubin level >22 mg/dL under intensive phototherapy and 25 apparently healthy neonates with physiological jaundice as control group. The history, general and local examinations and specific investigations were done by measuring IL6, IL10, CD19, CD4 and CD8.
Results: There is no difference between demographic data and level of IL6, IL10, CD19, CD4 and CD8 on all studied groups and there is significant increase between control group and groups exposed to single, double, intensive phototherapy in IL6 only and there are no changes in IL10 levels and CD19, CD4, CD8 percent after exposure to phototherapy
Conclusion: Phototherapy used in treatment of neonatal hyperbilirubinemia can affect the level of cytokines IL6 and no effect on IL10 or B19 and CD4, CD8.
Recommendations: Avoid unnecessary exposure to phototherapy to avoid possible immunological impacts on immune systems.
phototherapy
Immunological Status
Hyperbilirubinemia
2019
06
01
356
371
https://azjp.journals.ekb.eg/article_70189_d06d781ce40c02704a249f5a873045eb.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
MANAGEMENT OF CROUP AT ASSIUT UNIVERSITY CHILDREN HOSPITAL
Khalid
A. Sanousy
Elsayed
K. Abd-Elkarim
Eman
FA Gad
Mary
F. Rasmy
Background: Croup or laryngotracheobronchitis is a respiratory condition that is usually triggered by an acute viral infection. We aim by this study to evaluate management of Croup in Assiut University Children Hospital, trying to find any defects and suggest methods of their correction.
Patients and Methods: This prospective study was done on 170 cases of children having croup in Assiut University Children Hospital, through a period of six months from start of October 2017 to the end of March 2018.
Results: Management of croup in Assiut University Children Hospital is compatible with the international guidelines but there are some defects including:
1. Doing x-ray for some cases without a need.
2. Abuse of antibiotics in many patients.
3. Rushing to admission of the cases without acute management.
4. No waiting for two hours after adrenaline use before deciding discharge to home.
5. No repeating of adrenaline nebulization before deciding admission for the cases.
Conclusion: Management of croup in Assiut University Children Hospital is compatible with the international guidelines but there are some defects.
2019
06
01
372
387
https://azjp.journals.ekb.eg/article_70221_68fa2ab15065ee7ad2ae16f600384729.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
Coproantigen versus microscopic examination for diagnosis of Gardia Lamblia and Entameba Histolytica infection in children in Banha Teaching Hospital
Gehan
F. Oreby
Abeer El Sayed
Hamed
Sahar H.
Quashwa
Lubna
Y. Mousa
Background: Giardia lamblia (G. lamblia) and Entamoeba histolytica (E. histolytica) are of the most common protozoan enteric pathogen in humans. Their laboratory diagnosis mainly consists of direct microscopic examination of stool specimen for trophozoites and/or cysts. However, due to intermittent fecal excretion of the parasite, the patient may be misdiagnosed and infecting others. Recently, immunological testing of stool (coproantigen) for E histolytica G lamblia has been reported as a more sensitive mean for their diagnosis.
Aim of Work: Evaluation of the efficacy of coproantigen detection by ELISA technique in comparison to direct microscopical examination for diagnosis of Entamoeba histolytica and/or Giardia lamblia.
Patients and Methods: One hundred ten children were included in this simple comparative study. They were divided into three groups:
- Group (1) included 40 children with dysentery their stools were examined for E. histolytica,
- Group (2) included 40 children with abdominal complaints their stools were examined for G. lamblia,
- Group (3) included 30 normal children their stools were examined for detection of both E histolytica and G. lamblia
Results: Group (1) by microscopic examination 35% were positive for trophozoites and/or cysts and 65% were negative while by Coproantigen test 47.5% were positive and 52.5%were negative[sensitivity 73%, specificity 100% and NPV 80.7%].
Group (2) by microscopic examination 27.5%were positive for trophozoites and/or cysts and 72.5% were negative while by Coproantigen test 37.5% were positive and 62.5% were negative [sensitivity 73.3%, specificity 100%,PPV 100% and NPV 86.2%]
Group (3) For E. histolytica :by microscopic examination 30% were positive for trophozoites and/or cysts and 70% were negative while by Coproantigen test 23.3% were positive and 76.7% were negative[sensitivity 100%, specificity 91.6% ,PPV 77.7% and NPV 100%]
For G. lamblia: by microscopic examination 16.6% were positive for trophozoites and/or cysts and 83.4% were negative (while by Coproantigen test 26.6% were positive and 73.4% were negative [sensitivity 62.5%, specificity 100% , PPV 100% and NPV 89.2%].
Conclusion: Coproantigen ELISA technique is a rapid and effective method with high sensitivity and specificity for diagnosis of E. histolytica and G. lamblia
2019
06
01
388
402
https://azjp.journals.ekb.eg/article_70222_d14a7d5d3205291bc508bfcdb73773f5.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
EVALUATION OF SERUM IRON AND TRANSFERRIN IN IDIOPATHIC NEPHROTIC SYNDROME PATIENTS ATTENDING AL-HUSSEIN PEDIATRIC NEPHROLOGY CLINIC
Ahmed Elsayed
Darwish
Moftah
Mohamed Rabeea
Nayera Mahmoud
Al-Akkad
Gamal Zakariya
El-Morsi
Background: Nephrotic syndrome is characterized by excessive urinary excretion of albumin and other intermediated-size plasma proteins such as transferrin.. Excessive urinary losses of transferrin can produce low serum transferrin level that may lead to low plasma iron concentration and consequently the development of iron resistant microcytic hypochromic anemia.
Aim of the Work: To evaluate changes in serum iron and transferrin and the relationship between the serum and urinary transferrin in the active and remission state of nephrotic syndrome
Patients & Methods: The present work included fifty children with idiopathic nephrotic syndrome (INS), divided into 2 groups: group A (25 cases in activity) and group B (25 cases in remission). These two groups were age and sex matched with a mean age of (7.74 ± 2.45). All patients in this work were clinically evaluated together with routine laboratory investigations. Levels of serum albumin, urinary alb. /creatinine, serum iron, serum ferritin, serum transferrin and urinary transferrin were measured.
Results: This work shows that the level of hemoglobin, MCV, HCT were statistically significantly lower in the cases in active state than cases in remission. The mean serum iron, serum ferritin and serum transferrin were significantly lower in the cases in active state than in the cases in remission .The mean urinary transferrin was statistically significantly higher in the cases in active state than in the cases with remission.
Conclusion: Urinary transferrin can be considered a reliable parameter for early prediction of iron deficiency anemia in children with active nephrotic syndrome.
Hemoglobin (HG)
Mean corpuscular volume (MCV) Albumin/creatinine ratio (alb. /creat) iron deficiency anemia
serum iron
transferrin
2019
06
01
403
424
https://azjp.journals.ekb.eg/article_70223_8144c5ec5dfcdef54b6d37ad0ed4da2b.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
ASSESSMENT OF RIGHT & LEFT VENTRICLES BY 4D SPECKLE TRACKING BEFORE & AFTER TRANSCATHETER CLOSURE OF ATRIAL SEPTAL DEFECTS IN CHILDREN
Islam Saad
Ibrahim Mohammed
Hassan Ali
Hassan
Hassan Saad
Abu Saif
Hala Mounir
Agha
Ibrahim Mohamed
Abu Farag
Introduction: Myocardial strain and strain rate are more accurate than velocities as indices of ventricular contractility, perhaps by eliminating translational artifact, Strain rate values appeared to be dependent on pressure overload but less dependent on volume overload compared to strain.
Aim of the Work: The goal of this study was to analyze the acute changes in longitudinal strain and strain rate for both RV & LV walls& for early detection of Ventricular dysfunction through regular follow up,also to measure children mental health symptoms before &after transcatheter closure of Atrial septal defect.
Methodology: prospective analytical study for 32 patients in the Pediatric Cardiology Division of Specialized Pediatric Hospital, Cairo University with haemodynamically significant Atrial septal defect (ASD) before & 6 months after transcatheter closure of ASD from September 2016 to September 2018, & using Spence Children Anxeity Scale (SCAS) to measure children mental health.
Results: the mean age was 6.01 ± 3.19 (range 3 to 9 ys), was BSA 0.73 ± 0.22 m2 (range 0.5 to 0.94m2) with female to male ratio 1.3/1. There was improvement of RVMPI(Myocardial Performance Index) and LVMPI after 6-month post ASD closure, RVMPI (0.46±0.069 before vs 0.38±0.053 after P <0.0001) LVMPI (0.49±0.12 before vs 0.38±0.08 after P <0.0001) .There was a significant improvement of LV End Diastolic Volume ( EDV), LV End systolic Volume (ESV) using 4D TomTec measures after device closure , LV EDV (32.96 ±10.99 ml before vs 44.024±14.9017 ml after P <0.0001) , LV ESV (15.16±6.08 ml before vs 21.76±8.34 ml after P <0.0001). There also was significant improvement of the LV Global Circumferential Strain( GCS) after device occlusion (-20.76 ±11.17 before vs -26.36±6.59) , & LV Global Longitudinal Strain(GLS) (-19.17± 3.67 before vs -22.36 ± 4.72) after device occlusion using 4D TomTec .4D RV volumes and strains are better predictors of the hemodynamic indices of RV dysfunction compared to conventional RV parameters . There was a significant decrease of the RV EDV (ml), 54.65±10.05 before vs 15.73 ± 8.67 after) & RV SV (25.15 ±6.36 before vs 20.06±7.2, after device occlusion) using 4D TomTec.
Tissue Doppler Imaging _ Myocardial Performance Index _ ASD _ Transcatheter closure_4D STE
2019
06
01
425
442
https://azjp.journals.ekb.eg/article_70224_5f5daf99e72013df4b743db2fa862382.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
A STUDY OF MONITORING & PREPARING AL-HUSSEIN UNIVERSITY HOSPITAL (PEDIATRIC DEPARTMENT) FOR BECOMING BABY FRIENDLY HOSPITAL
Mohammed
Salem Zayed
Mahmoud
Mohamed Rashad
Sherif
Mostafa Reda
Osama
Abdel Aziz Fakher
Background: Breastfeeding is known as the optimal and unique method of infant feeding that result in short and long-term benefits for infants, mothers, families, economy and the entire society. Recommended by international organizations such as WHO and UNICEF. Planning, implementation and evaluation of programmes like BFHI to promote appropriate infant feeding practices require detailed, current information about these practices in the target populations.
Objectives: The aim of this research is to evaluate and prepare Al-Hussein University Hospital (Pediatric department) to attain the designation of baby friendly hospital.
Subjects & Methods: A cross-sectional study (with intervention). The tools used were those developed by the UNICEF and WHO for monitoring Baby Friendly hospitals. The tools included the following: Hospital data sheet, mother interview sheets, staff interview sheet, observation forms, and summary sheet for the ten steps. (Annexes 1-5).
Answers of questionnaires and findings of monitoring forms were obtained from randomly selected 210 mothers having babies less than 6 months old delivered at Al-Hussein UH, and 50 medical staff who joined Pediatric department for 12 months or more. Questionnaires answers collected through 2 visits weekly to the Pediatric department over 6 months. The 1st monitoring reflects the weak points, which were: skin to skin contact with early initiation, exclusive breastfeeding, milk expression, positioning and attachment, the code, giving written information about where mothers can get advice about breastfeeding for follow up and deficient knowledge and practice of the staff. 20- Hours training courses were conducted for the relevant staff in the target areas during the intervention phase, then the post intervention Phase conducted (phase I was repeated) 2 month after the intervention.
2019
06
01
443
466
https://azjp.journals.ekb.eg/article_70225_1da8407c3e4a294bdea71b690ccda3df.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
ASSESSMENT OF NEUROPSYCHIATRIC COMORBIDITIES IN EGYPTIAN CHILDREN WITH EPILEPSY USING THE MINI-KID TOOL
Karima Abd El-Fattah
Bahgat
Hala Taha
Mohamed
Safeya Mahmoud
Yousef Mohamed
Background: Epilepsy is considered as one of the most common neurological diseases in children with an increased risk of multiple comorbidities.
Aim of the Work: The aim of this study is to determine the frequency of neuropsychiatric comorbidities in children with epilepsy & analyze the association between neuropsychiatric comorbidities in children with epilepsy with several risk factors.
Subjects & Methods: Mini International Neuropsychiatric Interview for children and adolescents (MINI-KID) (child version) was used to assess the neuropsychiatric disorders of 100 children with epilepsy (CWE) and 100 healthy children from the outpatient clinic and inpatient neurology unit of pediatric department of Al-Zahraa-university hospital. In addition, Vanderbilt Attention-Deficit Hyperactivity Disorder Diagnostic Parent Rating Scale (VADPRS) was used for confirming the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). Socio-demographic and clinical data were collected through detailed history taking from parents.
Results: CWE had a significantly higher frequency of neuropsychiatric disorders (65%) compared to healthy control children (38%), 24% of CWE had multiple neuropsychiatric disorders compared to 10% in control group (p= <0.001). The younger the age at seizure onset (p=0.043), the longer the duration of epilepsy (p=0.017), the focal seizure (p=0.002), focal epilepsy type (p=0.003) and presence of environmental risk factors (p=0.005) the more the neuropsychiatric disorders among children with epilepsy.
Conclusion: Neuropsychiatric disorders are more common in children with epilepsy. Regular screening of children with epilepsy for neuropsychiatric comorbidities and health education programs for parents about the nature of the epilepsy disease and its comorbidities are highly recommended.
Epilepsy
neuropsychiatric comorbidities
MINI-KID
children
2019
06
01
467
483
https://azjp.journals.ekb.eg/article_70226_3be147ca08b851e41e1a35f8794a20f2.pdf
Al-Azhar Journal of Pediatrics
1110-7774
1110-7774
2019
22
3
COMPARISON BETWEEN WAIST CIRCUMFERENCE-TO-HEIGHT RATIO AND BODY MASS INDEX TO PREDICT ADIPOSITY IN SCH OOL AGED CHILDREN FROM 5 TO 15 YEARS
Mohamed Sayed
Ahmad Nagy
Raafat Abdel-Raouf
Mohamed Khattab
Fathy
Khalil Nawar
Kamel
Soliman Hammad
Mohamed
Hussein Meabed
Introduction: obesity is defined as a situation by which there is excess body fat leading to health impairment and waist circumference-to height ratio (WHtR) is a simple, easy, inexpensive, highly reproducible and accurate tool for prevention , control, and intervention against child hood obesity.
Aim of the Work: comparison between Waist circumference-to- Height Ratio (WHtR) and Body Mass Index (BMI) for prediction of overweight and obesity in school children aged 5 - 15 years.
Patients and Methods: A cross-sectional study was conducted on a sample of 1000 students who attended government schools conducted in the village “Qai” which is a rural area in Beni-Suef governorate. , during the first and the second school trimester between December 2017 and May 2018. Both sexes were included.
Results: in the present study, 1000 students, consisted of 506 female(50.6%) and 494 male(49.4%) with mean age ± SD 9.58 ± 2.24 years (range 5.1 – 15 years) and the overall prevalence of overweight and obesity according to BMI percentile was 34.6%, The overall prevalence of overweight was 17.7% more in girls than boys (9.6 % girls and 8.1% boys) and that of obesity was 16.9% more in girls than boys (9.7 % girls and 7.2 % boys) and hyperlipidemia in obese children was 32% , 7.7% of them had combined Hyperlipidemia, 14.2 % had hypertriglyceridemia & 10.1% had Hypercholesterolemia . the WHtR & BMI were highly sensitive as an indicator of adiposity, but WHtR was highly sensitive than BMI as WHtR showed that (Area Under Curve (AUC) = 0.986, sensitivity =94.87%, & specificity = 93.64 %) according to the Receiver Operating Characteristic (ROC) curve analysis for obese cases from normal with cut-off point > 0.47 for both sexes, and BMI showed that (AUC = 0.935, sensitivity = 85.13%, & specificity = 87.3%).
Conclusion: The prevalence of overweight and obesity is considerably high in Egyptian children and was more in girls than in boys and hyperlipidemia in obese children was found in 32% of obese children and WHtR & BMI are highly accurate indicators of adiposity in Egyptian school children . Our findings suggest that the WHtR is useful index for school screening and is particularly useful and superior on BMI and not dependent on Age & sex and is easier to use.
Recommendations: We believe that the WHtR should become a routine measurement in Egyptian school children to predict childhood adiposity to deal with it and further studies are required to validate cutoff values and the effectiveness of WHtR as anthropometric index to predict childhood adiposity.
Obesity
Waist Circumference-to-Height Ratio and Body Mass Index
2019
06
01
482
502
https://azjp.journals.ekb.eg/article_70227_ae6a69de6caeddb7c7ecf2f9f3d53ce6.pdf