Close inspection revealed a diffuse flushing of the face, which had a dry nutmeg grater appearance caused by follicular plugging with fine white scales, best seen under cross-lighting with magnification. 081 72 … with the human immunodeficiency virus. In: Encycl Méd chir (Editions scientifiques et médicales Elsevier, SAS. The treatment of PPR should, consist not only to fight sun damage (sun screens), flushes (clonidine), inflammation and, hypersensitivity reaction (metronidazole, tetracycline), but also to fight. J Cut Med Surg 1998; 2 S4: 5-10. Your chances of success. 77.Hellerich U, Metzelder M. Incidence of scalp involvement by Demodex folliculorum Simon ectoparasites in a pathologic-anatomic. Treatment was discontinued after 6 months as Demodex folliculorum proof remained negative. However, treating early rosacea, with only clinically visible vascular symptoms, with an acaricide may decrease early inflammation, limit potential flare-ups following laser treatment, and prevent the ultimate development of the papulopustules of rosacea. These patients come at the dermatological consultation for 4,372, diagnoses (m=1.36 diagnoses/patient): 2,579 (59%) are new diagnoses and 1,793 (41%) are, follow-up diagnoses. d'immunodéficience acquise. There is insufficient information regarding axial plane characteristics of scoliosis despite its 3D nature. Int J Dermatol 1993; 32(11): 822. The industry in which Polyclinic Specialized D'helmet operates is Gespecialiseerd ziekenhuis.The country where Polyclinic Specialized D'helmet is located is België, while the company's headquarters is in Schaerbeek.. Acuity: R/L 20/20. Mites such as Demodex folliculorum and Demodex brevis are natural hosts of the human pilo-sebaceous follicle. J. On the other hand, the latter regressed after treatment with topical crotamitone. Particular features of immune response after invasion of different species of. We find a similar frequency for PPR (1.7% (57 PPR / 3,213 patients)), but in the selected. This 15-room hotel welcomes guests with conveniences like a restaurant, a bar/lounge, and free in-room WiFi. diagnoses, 60% of the new ones, 75% of the follow up ones, and 69% of the main ones) (Fig 3). Hum Hum production is a production company based in London created by Jeanne Scahaise and Carol Van Hemelrijck. Demodicoses are frequent and occur among patients who are immunocompetent. So, the following physiopathologic hypothesis of the demodicoses could be proposed (Fig 4): Three factors seem favor D proliferation: hyper vascularized ground ( erythemato telangiectasic. Demodicidosis (all)° n =37, extremes4 - 2083 - 3969 - 808 - 1238 - 26, Table III. Sehschärfe: R/L 1,0/1,0. Unusual manifestation of demodicidosis in a child. infections)) and by the global evaluation of the dermatologist (“good” or “bad” general status). J Am Acad Dermatol 1992; 27: 799-801. Rosacea-like demodicosis in an HIV-positive child. comparisons of quantitative data are tested by ANOVA. Their objective symptoms are: follicular scales (71%), telangiectasia (63%), papules (40%), erythema (35%), pustules (25%), dilated follicular orifices (10%), hillocky skin (7%), orange peel. So, as hypothesized, the mean Dd is higher in pityriasis folliculorum, Among these 83 patients, the location of the SSSB is mainly the cheek (n=71 (86%)), the others, being the chin (n=6 (7%)), the nose (n=2 (2%)), the forehead (n=1 (1%)), the inferior eyelash, (n=1 (1%)), and 2 non specified locations (n=2 (2%)). Some other factors could explain a lower, proportion of demodicoses: the consultation plannings with a shorter available time per patient, might possibly decrease the quality of the SSSB for technically little trained dermatologists. known to affect mainly Caucasian patients, that the sun promotes PPR by: (1) dermal damage, which is, among other factors, responsible, for erythemato-telangiectasic rosacea, which itself seems to promote mite proliferation, (2) its. alone washed the skin with soap and water before sampling. These cases are, pointed out in the tables. View Karim Bentebbouche’s profile on LinkedIn, the world's largest professional community. Publications. Furthermore, mites or portions of mites are not uncommonly found in the histopathology sections of biopsies taken from the facial skin of patients with PPR rosacea, usually with intense surrounding inflammatory infiltrate. The mean time of symptoms, when the diagnostic was made, was 3.2 months (range 1-6 months). Moreover, no difference in the proportion of. local immunosuppressive action on cell mediated immunity. Indeed, as suggested by Powell, the difference of rosacea prevalence in function of the country, is probably linked to the difference of phototypes, and thus, to the genetic ground: rosacea is. The detect it, may go unnoticed, so that this entity is often underdiagnosed, ... Demodex infestation rate increased with age, up to 84% of population aged 60 and in 100% of those older than 70 years (Post and Juhlin, 1963). Akilov observes a frequency of demodicoses not, diagnoses)). In: An Actual Problem in Plastic Surgery, Aesthetic Surgery and. It appears therefore, essential to wash the skin twice a day, with a gentle soap, lukewarm water and facecloth, and at, the lid level, to clean the free margin of the eyelids, as, by the way, the ophthalmologists, We recommend to apply a topical acaricidal treatment 2-3 minutes after the facial washing, on a, well-dried skin: “crotamiton 10%” in the morning, “crotamiton 10%+benzyl benzoate 12%” in the, evening, in a thin layer first, all over the face, except the eyelids, until normalization of Dd (2 to. If the dermatologists attention had not been trained to diagnose of demodicosis in the frame of, this study, in place of the 115 demodicoses diagnoses, they would have given as diagnoses: 64, demodicoses, 24 PPR, 5 erythemato telangiectasic rosacea, 5 seborrheic dermatitis, 1 perioral, dermatitis, 2 “other” dermatitis, 1 phyma with seborrhea, 3 mixed form of demodicosis (1 with. STATISTICA (data computing software), version 6. www.statsoft.com. Although all the 27 patients tested negative for HEV-RNA, we would still strongly recommend that HEV should be considered in any immunodeficient patient with impaired liver function. Triada Pharm publications 2001: 65-74. Demodex proliferation appears to be a continuum process in rosacea, and may not be clinically visible at the onset of the disease. Patients with PPR are clearly demonstrated to have a higher Dd than controls. About. per month, and the five others rarely or never diagnose demodicosis in their practice (Table II). In 1993, Bonnar showed a particularly higher Dd on the face of patients with steroid-induced, same way, we observe a very high Dd in pityriasis folliculorum (61 D/cm, characterized by discreet inflammatory symptoms (erythema, telangiectasia), comparing to a, inflammatory response (papules, pustules) (Table III). This study being an epidemiological observational study, its aim is not to prove the causal, Ten dermatologists, having general ambulatory consultations in Brussels and in the vicinity of, the town, participate to the study. Significant risk factors also included the deep cleansing habits, such as the overuse of cleansing tool (more than four times/week) (OR 2.179) and oil control and exfoliating behaviors via daily used products (OR 2.435), facial mask (OR 1.459) or projects in beauty salons (OR 2.688). In fact, in case, of discreet lesions, the diagnosis of the telangiectasia depends essentially on the subjectivity. 65.Patrizi A, Neri I, Chieregato C, Misciali M. Demodicidosis in immunocompetent young children: report of eight cases. Globally, 115 patients with demodicosis are collected: 56 new diagnoses, 59, follow up, 80 main diagnoses. operated in the last years in our clinics are analysed in relation to sex, age, time of symptoms, procedures and adjuvant treatment. Among the 115 patients with demodicosis, 71.3 % are female subjects (82 women / 33 men; sex ratio f/m=2.5). Humans are born without Demodex mites on the skin [43,54], and the mites are progressively acquired by direct contact with the skin of other humans [44,55]. pathologies (atopic status , seborrheic dermatitis, thyroid pathology, Helicobacter pylori. 76.Millikan L. Androgenetic alopecia: the role of inflammation and Demodex. Pediatr Dermatol 1997; 44.Patrizi A, Trestini D, D'Antuono A, Colangeli V. Demodicidosis in a child infected with acquired immunodeficiency virus. 40.Sanchez-Viera M, Hernanz JM, Sampelayo T, Gurbindo MD, Lecona M, Soto-Melo J. Granulomatous rosacea in a child infected. Considering each dermatological. Cosmetology. Primary central nervous system lymphoma (PCNSL) is a rare pathology and is most often seen in immunodeficient patients. Overall, the high frequency of cleansing (more than once daily) (OR = 1.450) and the large amount of cleansers (> 5 pieces/year) (OR = 1.612) presented a positive correlation with rosacea occurring. Its, prevalence is higher among old patients, but it can occur in young patients (from 20 years old in. Variants: * = Pregnant, **= Diabetic, *** = Steroid – induced rosacea. J Am Acad Dermatol 1992; 27: 1010-1. It is absolutely impossible to give an objective limit between, “some appearing vessels” and “a discreet erythemato telangiectasic rosacea”. 47. Demodicidosis in an immunodeficient child. C. This sampling method is a useful, fast and non-invasive diagnosis tool, allowing to diagnose, for example, this discreet papulopustular rosacea by this 2 years old immunocompetent girl (Dd. J Pediatr 1995; 127(5): 751-4. NS: non significant. In 2001, Akilov found a mean demodicoses prevalence of 39:100 000 and an incidence of. A case is presented which illustrates the classical appearance of rosacea-like demodicidosis of the face with an unusual complication of eyelid involvement showing dry, follicular scales and superficial papulopustules in which enormous numbers of Demodex folliculorum were present. The prognosis is poor for cancer patients with Listeria infections. PPR with normal Dd are rare. Parasite-J Soc Franç Parast. Additionally, over 1000 tape tests were performed in mice from 7 different rooms, 5 investigators and 13 racks; 15 positive animals were. No seasonal. The infestation rates increased significantly with age reaching (100%) in patients above 70 years old, and especially during cold months with high humidity. The presence of Demodex in the human skin is directly related to the age of the subject. The higher proportion of PPR with high Dd in the, present study can be explained by the cleaning of the skin with ether before the SSSB: it, increases the quality of the sampling. In: Encycl Méd chir (Editions scientifiques et. Papular pruritic eruption of Demodex folliculitis in patients with acquired immunodeficiency. This article was published in the Journal of American Academy of Dermatology: FORTON F, GERMAUX MA, BRASSEUR T et coll. This article presents our casuistic of PCNSL in immunocompetent patients and make a literature review on this issue with focus on recent advances, investigations, and controversies in diagnosis and management of this pathology. with PPR and low Dd were seen by the same dermatologist. Join to Connect CHU Brugmann. The dynamic communication between immune cells and microbiota is disturbed when the skin barrier is compromised in patients with inflammatory diseases, such as atopic dermatitis, and such inflammatory reactions are often accompanied by a reduction in the diversity of microbial communities and outgrowth of certain species, such as Staphylococcus aureus. In several cases of demodicosis occurring in immunodeficient patients, the inflammatory. Among other dermatoses seen in patients with demodicosis, we, observe: 6 androgenic alopecia, 5 naevi, 4 folliculitis, 3 aesthetic problems, 3 seborrheic, keratosis, 3 intradermal naevi, 3 actinic keratosis, 3 varices, 2 atopic dermatitis, 2 dermatophyte, infections, 2 pilar or epidermoid cysts, 2 lentigos, 2 mollusca pendula, and 18 other isolated, Eighteen erythemato telangiectasic rosacea without high Dd are collected: four of them. The small difference could be explained by the study design: Akilov analyses. *Polyclinique Oasis ... **Avenue Brugmann 24 – 1180 Brussels - Belgium ... and the mites are progressively acquired by direct contact with the skin of other humans [44,55]. Combination of lid scrubs and 2% Metronidazole gel relieved symptoms and halved number of mites after 1 month, lashes grew again after 2 months. When this proliferation continues, the opisthosomes of the mites become visible to the naked eye, appearing as thin, discreet, regularly dispersed, whitish follicular scales at the base of the hair, often associated with diffuse erythema (which is a key feature of rosacea) [57,[99][100][101][102]. Eine Kombination von Lidkantenpflege mit 2% Metronidazol-Gel halbierte die Zahl der Haarbalgmilben nach einem Monat und bewirkte ein erneutes Wachstum der Wimpern nach 2 Monaten. The high Demodex. This study clarified the correlation between ocular rosacea and demodicosis folliculorum in family patients; two females of them were superimposed with secondary bacterial infection. However, no significant relationship was found according to gender nor personal hygiene. Dr. Ster Bogdan, medic specialist Ortopedie-Traumatologie, CHU St Pierre, Bruxelles, Polyclinique Oasis, Evere. population of our consultation; therefore, the frequency is probably lower than in Sweden. This is probably due to the different activity of the sebaceous glands at various ages. w celu opracowania syntetycznych środków ich zwalczania. Gynécologie, Medicis, Europe Hospitals-Site... get contacts, phone, descriptions, opening hours and reviews Attempts have been made to isolate D.F. Z roku na rok wzrasta liczba rozpoznanych przypadków chorób odkleszczowych u zwierząt domowych i u człowieka. In this book chapter, we will describe the biology of Demodex, the technical challenge of their study, and the possible mechanisms by which Demodex may contribute to the pathophysiology of rosacea. Three hypotheses could explain the normal Dd in rare cases of PPR (6/48): (1) these cases, may include some false negative results at the SSSB, (2) they may be related to a, proliferation (these last, living deeper in sebaceous and meibomian glands, are not detected by, the SSSB), (3) or the immune reaction may have succeed to eliminate the major part of the, mites but it nevertheless persists a long time, as it can be observed in delayed-type. and forensic medicine autopsy sample. On the other hand, rosacea is known by all dermatologists as a common dermatosis: United States, each dermatologist reported approximately 138 rosacea visits per year; Denmark, it concerns 0.5-1% of new diagnoses in dermatological departments; erythemato telangiectasic rosacea concerns 8%, and PPR 2% of a non-selected population. It is with some misgivings that the author attributes a pathogenic rôle to Demodex folliculorum in the face of an overwhelming opinion to the contrary due to the repeated finding of the parasite in the sebaceous ducts of many persons with normal skins. The underground parking can accommodate 135 cars. Polyclinique sévigné 22559 on M.D. Complications and differential diagnosis include dry eyes, seborrheic, bacterial and allergic blepharoconjunctivitis. insufficiency, which reduces the ability of the immune system to control mites. He has 95% chance to, observe from 0 to 6 demodicoses per week: 2.4 demodicoses/week on an average (1.2 new, and 1.2 follow up). Demodicosis is the 12, the main diagnoses; that means that demodicosis is as often the main reason to consult, as, variquous pathology and mollusca contagiosa: this reflects the importance given by the patient, Our results do not confirm the usual opinion according to which the demodicoses frequency, Six among the 115 demodicoses present also an androgenic alopecia: it is possible that some. Eur J Dermatol 2003; 13: 311-2. Alternative oral minocycline 100 mg daily brought no subjective nor objective relief. Morphology and functional anatomy of Demodex folliculorum (Simon) of man. http://www.sciencedirect.com/science/journal/01909622, DEMODICOSIS AND ROSACEA : EPIDEMIOLOGY AND, SIGNIFICANCE IN DAILY DERMATOLOGICAL PRACTICE, Fabienne FORTON,* MD, Marie-Anne GERMAUX,** MD, Thierry BRASSEUR,*** MD, Anne DE. Women commonly seek care for rosacea: dermatologists frequently provide. J Am Acad Dermatol 2002; 46(4): 584-7. On physical examination, papular and nodular lesions were located on the face, neck, shoulders and 'decollete'. Die Patientin ist rezidivfrei nach 1 Jahr. Welcome ! Unfortunately, we do not have detailed information about the company's offer and products, therefore we suggest you to contact by phone: +3222169435 Talk with your doctor and family members or friends about deciding to join a study. Sampling method: the standardized skin surface biopsy, In the present study, the dermatologist initially cleans the slide and the skin of the patient with. prevalence of thyroid disease is indeed higher among women (6.1%) than among men (1.7%). Le Centenaire Brussels Expo places you within a 10-minute stroll of popular attractions such as Atomium and Mini-Europe. Talk with your doctor and family members or friends about deciding to join a study. biopsy (SSSB). Demodex species are external parasites; they are transmitted via direct contact, and when present in elevated numbers it may induce several ocular diseases. In 118 cases of Listeria infection associated with neoplastic malignancy, there was a male-to-female-preponderance of about 2:1. Most authors believe that the altered immune system, which is characteristic of the acquired immunodeficiency syndrome, favors the growth of this usually saprophyte agent so that the latter eventually causes a skin disorder. Therefore, it is present in almost all aged people, whereas it is exceptionally found in children aged less than 5-10 years. Paris, tous droits réservés), Dermatologie, 98-944-A-10, 2001, 11p. which therefore increases the dermatologists sensitivity to the diagnosis of demodicosis. ether before performing the SSSB, to improve and to standardize the adherence. 64.Pietrini P, Favennec L, Brasseur P. Demodex folliculorum in parakeratosis of the scalp in a child. From our daily experience, Dd in normal skin does not increase after ether cleaning: when. underline the need to establish at first a precise consensus definition of erythema and, telangiectasia, based on objective and reproducible criteria, conditions for standardized, selection of control groups in old patients. On the other hand, some authors suspect an unusual hypersensitivity against the mite itself. Konsekwencją wkłuwania się kleszczy w głąb skóry jest nie tylko możliwość wprowadzenia do organizmu żywiciela groźnych patogenów, ale również wywołanie reakcji skórnych objawiających się zaczerwienieniem, świądem, łysieniem, tworzeniem się guzków, strupów i odczynów alergicznych. These clinically visible symptoms constitute the first stage of demodicosis-pityriasis folliculorum [8, ... We concluded that the IPL may have killed the mites on the treated zones with release of their antigens and flare-up of the inflammation, or that the mites may still have persisted more deeply in the skin, in sufficient number to induce the inflammation. Each dermatologist collects all the diagnoses of patients he receives at one or more places, where he has a microscope, so as to obtain at least 50 patients per period. Categorical. Twenty (17%) present an atopic ground, 10 (9%) present a, seborrheic dermatitis, 7 (6%) have a thyroid disease, 3 (3%) are diabetic, only one has a known, Helicobacter pylori infection. The proportion of demodicoses varies greatly, according to the dermatologist. obvious when the immunity of the patient is beginning to be restored. Bienvenue ! Demodicosis and rosacea: epidemiology and. European Academy of Dermatology and Venereology (EADV). Duvic M. Staphylococcal infections and pruritus of AIDS-related complex. Our team . Figure 2. Contact Amin directly Join to view full profile People also viewed Wim Maebe. inhalation and nasally. The diagnosis of demodicosis is confirmed when one of these suggestive clinical manifestations, SSSB at the same place (sum of the two successive densities in case of Dd. 74.Akilov OE, Mumcuoglu KY. Association between human demodicidosis and HLA class I. We conducted a prospective epidemiologic study among 10 dermatologists. Canad J Ophthal 1969; 4: 3-15. The 83 non topically treated patients present 96 demodicoses (Table III), some patients. Contact. Vaginal delivery of breech infants remains standard practice in France. Rosacea is a common skin disorder that may occur in adults of all ethnic backgrounds, but is most commonly diagnosed in individuals with fair skin. However, the symptoms are very similar to other diseases; hence, its’ role is often neglected. One might also liken the appearance to that seen after spraying the face. Diagnosis: chronic Demodex blepharoconjunctivitis. Chances of success with insemination Chances of success after IVF/ICSI Limits to ART treatment Naturally, demodicosis increases when we consider only the follow-, up diagnoses (Fig 3D). The age ranged from 44-68 years (middle of 66 years); 62,5% of the patients were female. As a matter of fact, the highest concentration of Demodex is found in the cutaneous areas with more numerous sebaceous glands and more abundant sebum production (naso-labial folds, nose, forehead and perioral region). the pityriasis folliculorum, the second most frequent demodicosis (Table III). The compromission of the immune system favors the growth of Demodex. common favorable ground perhaps exists for the two microorganisms, or perhaps their, association is beneficial to each other. Polyclinique Du Midi. Results. average of 2.4 demodicoses/week (1.2 new). CHU – Charleroi – Polyclinique de l’hôpital civil de Charleroi Boulevard Zoé Drion, 6000 Charleroi Tel. As a matter of fact, the rare cases of childhood demodicidosis so far reported in the relevant literature prevalently occurred in markedly immunocompromised children, such as children with leukemia undergoing chemotherapy and children infected with the human immunodeficiency virus. During the second and fifth period, the dermatologist “10” does not participate to the study. J Med Entomol 1990; 27: 467-70. We sought to demonstrate the high frequency of demodicoses and the overlapping with papulopustular rosacea (PPR) . rosacea), lack of washing and immune status. Objawy chorób wywoływanych przez patogeny odkleszczowe, m.in. Journal of the American Association for Laboratory Animal Science: JAALAS. 42/57 PPR (74%) with Dd>5 at the first SSSB. Conclusions. 71.Rufli T, Büchner SA. Moreover, a great variability in the frequency of, demodicoses is observed beyond the dermatologists during the study (Table II). Wichtige Differentialdiagnosen und Komplikationen sind trockene Augen, seborrhoische, bakterielle und allergische Blepharokonjunktivitiden. Epidemiological service, Scientific Institute of Public Health. Often he has. Experimental Dermatology 2003; 28: 75.Akilov OE, Smirnova NS. Each dermatologist has 95% chance to observe from 2 to 15 warts and from 1 to 13 acne per, week; on an average, he diagnoses 8.5 warts and 6.9 acne/week. This variability, could be determined by an unequal sensitivity to the diagnosis: the dermatologists who, diagnose most demodicoses are those who were already trained to detect the clinical symptoms, and to read SSSB before the study (Table II). In the case of mite, with giant cells occur inside this immune reaction (isolated inflammatory papule and, granulomatous rosacea). 82.Berg M, Lidén S. An epidemiological study of rosacea. Molecular studies suggest that Demodex may induce tolerogenic dendritic cells and collaborate with vascular endothelial growth factor (VEGF) to induce T cell exhaustion and favor its own proliferation. am J ophtalmol 1929; 12: 373-5. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. aspect (6%), and non follicular scales (4%). Therapy and outcome Conventional treatment was con-traindicated due to mercury allergy. This new space of 10,000 m2 brings together all ambulatory activities of the Brugmann University Hospital (CHU) on the Horta site in Laeken. W naszej pracy zwróciliśmy uwagę na wybrane aspekty szkodliwych oddziaływań kleszczy na żywicieli. Arch Kriminol 1994; 194(3-4): 111-8. Osiris 45 1. newsCHU/UVC Brugmann HUDERF - UKZKF HORTA BRIEN REINE/KONINGIN ASTRID # 45 Décembre 2016 Février 2017 December 2016 Februari 2017 TRIMESTRIEL DRIEMAANDELIJKS Osiris 08 Dossier – Campus Osiris: des hôpitaux écoresponsables 12 Portrait/Zoom – La Direction médicale et le Conseil médical changent de main Portrait PRS GILLET ET DE MEYER La nouvelle … Traduit de l’anglais par Revillard JP et. Self assessed frequency° before study, Demodicoses (all)°° n =, °° Demodicoses new, ° frequency of diagnosis ( minimum ) : +++ = 1/wee, Table II. The general status of patients with demodicosis is good in 96% of the cases (110/115). Each dermatologist observed an average of 2.4 demodicoses a week (1.2 new). that this condition is not essential at all. Five patients (62,5%) were submitted to pos-operative radiotherapy as adjuvant treatment. Ayres et al. Ses atouts ? The findings of microbiota studies in atopic dermatitis, psoriasis, acne, dandruff, seborrheic dermatitis, irritant and allergic contact dermatitis are reviewed in this chapter. Arch Dermatol 1963; 88: 298-302. ... Hôpital CHU Brugmann,Résident, Stroke Unit. reveal a pityriasis folliculorum by close examination, Demodex by observing some mites on 4-5 epilated lashes. Patients with pityriasis folliculorum (m=52 years; ext:22-98) are older than patients with other demodicoses (m=45 years; ext:20-98) (p=0.04). The demodicoses are present for a mean of 5 years 2 months, Seventy-two patients with demodicosis (63%) are treated with oral medications comprising: 1, chemotherapy, 3 antibiotics, 8 antidepressants, 4 medications for the stomach, 18 for, hypertension, 6 for thyroid, 31 oestroprogestative, 34 others. Purpose Patients who receive combined modality treatment for stage I and II Hodgkin lymphoma (HL) have an excellent outcome. The significance level is 0.05, within two-sided alternative hypotheses, excepted when a clear one-sided hypothesis was formulated in the protocol. Diagnose: chronische Demodex Blepharokonjunktivitis. Health Interview Survey, Belgium (2001): Capet F, Debaillie R, Tafforeau J, Van Oyen H. Institute of Public Health. Fifty seven patients present PPR: 42 have Dd >5D/cm, 31 without topical treatment) and are included in the 115 demodicoses, 6 have low Dd (Dd.
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