Microbiome and Allergy: New Insights and Perspectives.

The role of the microbiome in the molecular mechanisms underlying allergy has become highly relevant in recent years. Studies are increasingly suggesting that altered composition of the microbiota, or dysbiosis, may result in local and systemic alteration of the immune response to specific allergens. In this regard, a link has been established between lung microbiota and respiratory allergy, between skin microbiota and atopic dermatitis, and between gut microbiota and food allergy. The composition of the human microbiota is dynamic and depends on host-associated factors such as diet, diseases, and lifestyle. Omics are the techniques of choice for the analysis and understanding of the microbiota. Microbiota analysis techniques have advanced considerably in recent decades, and the need for multiple approaches to explore and comprehend multifactorial diseases, including allergy, has increased. Thus, more and more studies are proposing mechanisms for intervention in the microbiota. In this review, we present the latest advances with respect to the human microbiota in the literature, focusing on the intestinal, cutaneous, and respiratory microbiota. We discuss the relationship between the microbiome and the immune system, with emphasis on allergic diseases. Finally, we discuss the main technologies for the study of the microbiome and interventions targeting the microbiota for prevention of allergy.

Epithelial Barrier: Protector and Trigger of Allergic Disorders.

The epithelial barrier has classically been considered as the only first line of defense against irritants, pathogens, and allergens. However, it is now known to play an essential role in the immune response to exogenous agents. In fact, recent reports postulate the epithelial barrier hypothesis as a possible explanation for the increasing incidence and severity of allergic diseases. The epithelial barrier preserves the isolation of internal tissues from potential external threats. Moreover, a coordinated interaction between epithelial and immune cells ensures the unique immune response taking place in mucosal tissues, which is reported to be dysregulated in allergic diseases. We and others have demonstrated that in severe allergic phenotypes, the epithelial barrier undergoes several histological modifications, with increased infiltration of immune cells, leading to dysfunction. This is common in atopic dermatitis, asthma, and food allergy. However, the precise role of the epithelial barrier in mucosal biology during progression of allergic diseases is not well understood. In this review, we aim to compile recent knowledge regarding the histological structure and immunological function of the epithelial barrier and to shed light on the role of this compartment in the onset and progression of allergic diseases.

Microbiome and Allergy: New Insights and Perspectives

The role of the microbiome in the molecular mechanisms underlying allergy has become highly relevant in recent years. Studies areincreasingly suggesting that altered composition of the microbiota, or dysbiosis, may result in local and systemic alteration of the immuneresponse to specific allergens. In this regard, a link has been established between lung microbiota and respiratory allergy, between skinmicrobiota and atopic dermatitis, and between gut microbiota and food allergy.The composition of the human microbiota is dynamic and depends on host-associated factors such as diet, diseases, and lifestyle. Omics arethe techniques of choice for the analysis and understanding of the microbiota. Microbiota analysis techniques have advanced considerablyin recent decades, and the need for multiple approaches to explore and comprehend multifactorial diseases, including allergy, has increased.Thus, more and more studies are proposing mechanisms for intervention in the microbiota.In this review, we present the latest advances with respect to the human microbiota in the literature, focusing on the intestinal, cutaneous,and respiratory microbiota. We discuss the relationship between the microbiome and the immune system, with emphasis on allergic diseases.Finally, we discuss the main technologies for the study of the microbiome and interventions targeting the microbiota for prevention of allergy. (AU)

El papel del microbioma en los mecanismos moleculares de las enfermedades alérgicas se ha vuelto muy relevante en los últimos años.Cada vez más estudios sugieren que una composición alterada de la microbiota, o disbiosis, puede resultar en una alteración local ysistémica de la respuesta inmune a alérgenos específicos. En este sentido, se ha establecido un vínculo entre la microbiota pulmonar y laalergia respiratoria, así como la microbiota cutánea y el desarrollo de dermatitis atópica, y la microbiota intestinal y la alergia alimentaria.La composición de la microbiota humana es dinámica y depende de diversos factores asociados al huésped como la dieta, las enfermedadesy el estilo de vida, entre otros. Para el análisis y comprensión de la microbiota, las ómicas son las técnicas de elección. En las últimasdécadas, las técnicas de análisis de microbiota han tenido un gran avance y han aumentado la necesidad de múltiples enfoques paraexplorar y comprender las enfermedades multifactoriales, incluidas las enfermedades alérgicas. De esta manera, cada vez son más losestudios que proponen mecanismos de intervención sobre la microbiota de pacientes.En esta revisión, presentamos los últimos avances encontrados en la literatura sobre la microbiota humana, centrándose en las microbiotasintestinal, cutánea y respiratoria. Discutimos la relación entre el microbioma y el sistema inmunológico, con especial énfasis en lasenfermedades alérgicas. Finalmente, discutimos las principales tecnologías para el estudio del microbioma y los estudios de intervencióndirigidos a la microbiota propuestos para la prevención de alergias. (AU)

Epithelial Barrier: Protector and Trigger of Allergic Disorders

The epithelial barrier has classically been considered as the only first line of defense against irritants, pathogens, and allergens. However,it is now known to play an essential role in the immune response to exogenous agents. In fact, recent reports postulate the epithelialbarrier hypothesis as a possible explanation for the increasing incidence and severity of allergic diseases.The epithelial barrier preserves the isolation of internal tissues from potential external threats. Moreover, a coordinated interaction betweenepithelial and immune cells ensures the unique immune response taking place in mucosal tissues, which is reported to be dysregulatedin allergic diseases.We and others have demonstrated that in severe allergic phenotypes, the epithelial barrier undergoes several histological modifications,with increased infiltration of immune cells, leading to dysfunction. This is common in atopic dermatitis, asthma, and food allergy. However,the precise role of the epithelial barrier in mucosal biology during progression of allergic diseases is not well understood.In this review, we aim to compile recent knowledge regarding the histological structure and immunological function of the epithelialbarrier and to shed light on the role of this compartment in the onset and progression of allergic diseases (AU)

La barrera epitelial se ha considerado clásicamente sólo como la primera línea de defensa contra los irritantes, patógenos y alérgenos,pero ahora sabemos que el epitelio también desempeña un papel esencial en la respuesta inmunológica frente los agentes exógenos.De hecho, informes recientes postulan la hipótesis de la barrera epitelial como una posible explicación de la creciente incidencia y lagravedad de las enfermedades alérgicas.La barrera epitelial preserva el aislamiento de los tejidos internos de las posibles amenazas exteriores. Se sabe que las células epiteliales,además de un papel meramente protector, también tienen una función esencial en el desarrollo de la respuesta inmune en las mucosas,favoreciendo un ambiente tolerogénico. Sin embargo, en enfermedades alérgicas, estas características se ven afectadas como demuestrauna repuesta exagerada ante antígenos inocuos. De hecho, en los fenotipos alérgicos graves, la barrera epitelial experimenta variasmodificaciones histológicas que se asocian con pérdida de integridad y aumento de los infiltrados celulares, lo que conduce a una disfunciónde la misma. Este proceso es común en la dermatitis atópica, el asma y/o la alergia alimentaria. Aunque todavía no se conoce bien lafunción exacta de la barrera epitelial en la biología de la mucosa durante las enfermedades alérgicas.En esta revisión, pretendemos recopilar los conocimientos recientes sobre la estructura histológica y la función inmunológica de la barreraepitelial, y arrojar luz sobre el papel de este compartimento en la aparición y la progresión de las enfermedades alérgicas (AU)

Difference in patterns of prescribing antidepressants known for their weight-modulating and cardiovascular side effects for patients with obesity compared to patients with normal weight.

BACKGROUND: Patients with depression and comorbid obesity may be more prone to weight modulating and cardiovascular side effects of selected antidepressants (AD). It is important to ascertain whether these AD prescriptions differ by patient weight status. METHODS: Canadian Primary Care Sentinel Surveillance Network (CPCSSN) electronic medical records were used. Participants were adults with depression prescribed an AD in 2000-2016, with weight categories established before the first prescription. Logistic regression and mixed effects models were applied to examine associations between obesity and AD prescribing, adjusted for sex, age, and comorbidities. Machine learning algorithm random forest (RF) was used to evaluate the importance of weight in predicting prescribing patterns. RESULTS: Of 26,571 participants, 72.4% were women, mean age was 38.9 years (standard deviation (SD)=14.2) and mean BMI 27.0 kg/m2 (SD = 6.5); 9.5% had ≥ 1 comorbidity. Patients with obesity, compared to normal weight patients, were more likely to receive bupropion (adjusted odds ratio (aOR) 1.24, 95%CI: 1.09,1.42), fluoxetine (aOR 1.14, 95%CI: 0.97,1.34), and amitriptyline (aOR 1.13, 95%CI: 0.93,1.36), and less likely to receive mirtazapine (aOR 0.55, 95%CI: 0.44,0.68) and escitalopram (aOR 0.88, 95%CI: 0.80, 0.97). RF analysis showed that weight was among the most important predictors of prescribing patterns, equivalent to age and more important than sex. CONCLUSIONS: AD prescribing patterns for patients with obesity appear to be different for selected AD types, including AD known for their weight-modulating and cardiovascular side effects. Longitudinal studies are needed to examine whether these prescribing patterns are associated with significant health outcomes.

ARADyAL: The Spanish Multidisciplinary Research Network for Allergic Diseases.

Thematic cooperative health research networks (RETICS) are organizational structures promoted by the Instituto de Salud Carlos III of the Spanish Ministry of Science with the objective of carrying out cooperative research projects addressing challenges of general interest for society as a whole in the field of health care. The RETICS of Asthma, Adverse Drug Reactions, and Allergy (ARADyAL) received funding in 2016 for a 5-year program (2017-2021). ARADyAL integrates basic and clinical research in the areas of allergy, immunology, genetics, nanomedicine, pharmacology, and chemistry, with special interest in research on new biomarkers and the design and evaluation of new interventions for allergic patients with severe phenotypes. The consortium comprises 28 groups across Spain, including 171 clinical and basic researchers, 17 clinical groups that cover more than 10 000 000 patients of all ages from urban and rural areas and 11 basic groups active mostly at universities and research institutes. ARADyAL has proposed a research program organized into 3 different areas focusing on precision medicine, as follows: Program 1, Mechanisms and prediction of adverse drug reactions and allergic diseases; Program 2, Toward a precise diagnosis of allergic diseases; and Program 3, Predicting interventions in allergic diseases. There is also 1 common program dedicated to training. The network has a Steering Committee and an External Advisory Scientific Committee, which advise the global network coordinator, who has recognized expertise in the field. ARADyAL is a unique meeting point for clinicians and basic scientists who are already working in allergy.

ARADyAL: The Spanish Multidisciplinary Research Network for Allergic Diseases

Thematic cooperative health research networks (RETICS) are organizational structures promoted by the Instituto de Salud Carlos III of the Spanish Ministry of Science with the objective of carrying out cooperative research projects addressing challenges of general interest for society as a whole in the field of health care. The RETICS of Asthma, Adverse Drug Reactions, and Allergy (ARADyAL) received funding in 2016 for a 5-year program (2017-2021). ARADyAL integrates basic and clinical research in the areas of allergy, immunology, genetics, nanomedicine, pharmacology, and chemistry, with special interest in research on new biomarkers and the design and evaluation of new interventions for allergic patients with severe phenotypes. The consortium comprises 28 groups across Spain, including 171 clinical and basic researchers, 17 clinical groups that cover more than 10 000 000 patients of all ages from urban and rural areas and 11 basic groups active mostly at universities and research institutes. ARADyAL has proposed a research program organized into 3 different areas focusing on precision medicine, as follows: Program 1, Mechanisms and prediction of adverse drug reactions and allergic diseases; Program 2, Toward a precise diagnosis of allergic diseases; and Program 3, Predicting interventions in allergic diseases. There is also 1 common program dedicated to training. The network has a Steering Committee and an External Advisory Scientific Committee, which advise the global network coordinator, who has recognized expertise in the field. ARADyAL is a unique meeting point for clinicians and basic scientists who are already working in allergy. (AU)

Las Redes Temáticas de Investigación Cooperativa en Salud (RETICS) son unas estructuras organizativas promovidas por el Instituto de Salud Carlos III del Ministerio de e Sanidad, Consumo y Bienestar Social con el objetivo de llevar a cabo proyectos de investigación colaborativos que aborden desafíos de interés general para la sociedad en el campo de la salud. La RETICS de Asma, Reacciones Adversas a Fármacos y Alérgicas (ARADyAL) comenzó en 2016 y fue financiada por un periodo de 5 años (2017-2021). ARADyAL integra la investigación básica y clínica en diferentes áreas de conocimiento, alergia, inmunología, genética, nanomedicina, farmacología y química, con especial interés en la investigación de nuevos biomarcadores, y el diseño y evaluación de nuevas estrategias de intervención para pacientes alérgicos con fenotipos graves. El consorcio está compuesto por 28 grupos de toda España, que incluyen 171 investigadores clínicos y básicos: 17 grupos clínicos que cubren a más de 10.000.000 de pacientes de todas las edades y de áreas tanto urbanas como rurales; 11 grupos básicos que desarrollan sus actividades principalmente en universidades e institutos de investigación. ARADyAL propone un programa de investigación organizado en tres áreas diferentes centradas en la medicina de precisión: Programa 1. Mecanismos y predicción de reacciones adversas a medicamentos y enfermedades alérgicas; Programa 2. Hacia un diagnóstico preciso de enfermedades alérgicas; y Programa 3. Predicción de intervenciones en enfermedades alérgicas. Además, hay un programa transversal dedicado a la formación. La red cuenta con un Comité de Dirección y un Comité Científico Asesor Externo, que asesoran a la coordinadora de la red la cual tiene experiencia reconocida en el campo. ARADyAL es un punto de encuentro único para médicos y científicos básicos que ya están trabajando en alergias.

Flower-like Mn-Doped Magnetic Nanoparticles Functionalized with αvß3-Integrin-Ligand to Efficiently Induce Intracellular Heat after Alternating Magnetic Field Exposition, Triggering Glioma Cell Death.

Despite the potential of magnetic nanoparticles (NPs) to mediate intracellular hyperthermia when exposed to an alternating magnetic field (AMF), several studies indicate that the intracellular heating capacity of magnetic NPs depends on factors such as cytoplasm viscosity, nanoparticle aggregation within subcellular compartments, and dipolar interactions. In this work, we report the design and synthesis of monodispersed flowerlike superparamagnetic manganese iron oxide NPs with maximized SAR (specific absorption rate) and evaluate their efficacy as intracellular heaters in the human tumor-derived glioblastoma cell line U87MG. Three main strategies to tune the particle anisotropy of the core and the surface to reach the maximum heating efficiency were adopted: (1) varying the crystalline anisotropy by inserting a low amount of Mn2+ in the inverse spinel structure, (2) varying the NP shape to add an additional anisotropy source while keeping the superparamagnetic behavior, and (3) maximizing NP-cell affinity through conjugation with a biological targeting molecule to reach the NP concentration required to increase the temperature within the cell. We investigate possible effects produced by these improved NPs under the AMF (f = 96 kHz, H = 47 kA/m) exposure in the glioblastoma cell line U87MG by monitoring the expression of hsp70 gene and reactive oxygen species (ROS) production, as both effects have been described to be induced by increasing the intracellular temperature. The induced cell responses include cellular membrane permeabilization and rupture with concomitant high ROS appearance and hsp70 expression, followed by cell death. The responses were largely limited to cells that contained the NPs exposed to the AMF. Our results indicate that the developed strategies to optimize particle anisotropy in this work are a promising guidance to improve the heating efficiency of magnetic NPs in the human glioma cell line.

Strong and frequent T-cell responses to the minor allergen Phl p 12 in Spanish patients IgE-sensitized to Profilins.

BACKGROUND: Profilins are dominant pan-allergens known to cause cross-sensitization, leading to clinical symptoms such as pollen-food syndrome. This study aimed to determine the T-cell response to Phl p 12 in profilin-sensitized patients, by measuring the prevalence, strength and cross-reactivity to clinically relevant profilins. METHODS: The release of Phl p allergens from pollen was determined by mass spectrometry and immunochemistry. T-cell responses, epitope mapping and cross-reactivity to profilins (Phl p 12, Ole e 2, Bet v 2 and Mal d 4) were measured in vitro using PBMCs from 26 Spanish grass-allergic donors IgE-sensitized to profilin. Cross-reactivity was addressed in vivo using 2 different mouse strains (BALB/c and C3H). RESULTS: Phl p 12 and Phl p 1 are released from pollen simultaneously and in similar amounts. Both T-cell response frequency (17/26 donors) and strength were comparable between Phl p 12 and Phl p 1. T-cell cross-reactivity to other profilins correlated with overall sequence homology, and 2 immunodominant epitope regions of Phl p 12 were identified. Data from mice immunized with Phl p 12 showed that cross-reactivity to Bet v 2 was mediated by conserved epitopes and further influenced by additional genetic factors, likely to be MHC II. CONCLUSION: The strength, prevalence and cross-reactivity of T-cell responses towards Phl p 12 are comparable to the major allergen Phl p 1, which supports the hypothesis that T cells to Phl p 12 can play an important role in development of allergic symptoms, such as those associated with pollen-food syndrome.

Allergen manufacturing and quality aspects for allergen immunotherapy in Europe and the United States: An analysis from the EAACI AIT Guidelines Project.

Adequate quality is essential for any medicinal product to be eligible for marketing. Quality includes verification of the identity, content and purity of a medicinal product in combination with a specified production process and its control. Allergen products derived from natural sources require particular considerations to ensure adequate quality. Here, we describe key aspects of the documentation on manufacturing and quality aspects for allergen immunotherapy products in the European Union and the United States. In some key parts, requirements in these areas are harmonized while other fields are regulated separately between both regions. Essential differences are found in the use of Reference Preparations, or the requirement to apply standardized assays for potency determination. As the types of products available are different in specific regions, regulatory guidance for such products may also be available in one specific region only, such as for allergoids in the European Union. Region-specific issues and priorities are a result of this. As allergen products derived from natural sources are inherently variable in their qualitative and quantitative composition, these products present special challenges to balance the variability and ensuring batch-to-batch consistency. Advancements in scientific knowledge on specific allergens and their role in allergic disease will consequentially find representation in future regulatory guidelines.

Defective positioning in granulomas but not lung-homing limits CD4 T-cell interactions with Mycobacterium tuberculosis-infected macrophages in rhesus macaques.

Protection against Mycobacterium tuberculosis (Mtb) infection requires CD4 T cells to migrate into the lung and interact with infected macrophages. In mice, less-differentiated CXCR3+ CD4 T cells migrate into the lung and suppress growth of Mtb, whereas CX3CR1+ terminally differentiated Th1 cells accumulate in the blood vasculature and do not control pulmonary infection. Here we examine CD4 T-cell differentiation and lung homing during primary Mtb infection of rhesus macaques. Mtb-specific CD4 T cells simultaneously appeared in the airways and blood ∼21-28 days post exposure, indicating that recently primed effectors are quickly recruited into the lungs after entering circulation. Mtb-specific CD4 T cells in granulomas display a tissue-parenchymal CXCR3+CX3CR1-PD-1hiCTLA-4+ phenotype. However, most granuloma CD4 T cells are found within the outer lymphocyte cuff and few localize to the myeloid cell core containing the bacilli. Using the intravascular stain approach, we find essentially all Mtb-specific CD4 T cells in granulomas have extravasated across the vascular endothelium into the parenchyma. Therefore, it is unlikely to be that lung-homing defects introduced by terminal differentiation limit the migration of CD4 T cells into granulomas following primary Mtb infection of macaques. However, intralesional positioning defects within the granuloma may pose a major barrier to T-cell-mediated immunity during tuberculosis.

Profilin, a Change in the Paradigm.

Profilin is a protein that is present in all eukaryotic cells and is responsible for cross-reactivity between pollen, latex, and plant foods. It has been classically acknowledged as a minor or nearly irrelevant allergen, although recent data are changing this conception. The objective of this manuscript is to provide a comprehensive review of published data on the role of this ubiquitous allergen in pollen, latex, and plant food allergy. The patterns of recognition of this minor allergen follow a north-south gradient. Although present in all pollens and vegetables, profilin is significantly associated with allergy to grass pollen and to Cucurbitaceae fruits. Heb v 8, the latex profilin, is usually a marker of profilin allergy in plant food-allergic patients, although it has no clinical relevance in latex allergy. Sensitization to profilin jeopardizes the diagnosis of pollen allergy and selection of immunotherapy, and although component-resolved diagnosis can identify its impact, there are no tailored treatments available. In recent years, several new publications have shown how profilin should be taken into account and, under certain circumstances, considered a marker of severity, an allergen capable of inducing respiratory symptoms, and, in its natural purified form, a potential candidate for etiological treatment of food allergy. Current data on profilin strongly support the need for a shift in the previously accepted paradigm for this allergen. More research should be done to assess the real clinical impact of sensitization in specific populations and to develop therapeutic strategies.

Challenges in the implementation of EAACI guidelines on allergen immunotherapy: A global perspective on the regulation of allergen products.

Regulatory approaches for allergen immunotherapy (AIT) products and the availability of high-quality AIT products are inherently linked to each other. While allergen products are available in many countries across the globe, their regulation is very heterogeneous. First, we describe the regulatory systems applicable for AIT products in the European Union (EU) and in the United States (US). For Europe, a depiction of the different types of relevant procedures, as well as the committees involved, is provided and the fundamental role of national agencies of the EU member states in this complex and unique network is highlighted. Furthermore, the regulatory agencies from Australia, Canada, Japan, Russia, and Switzerland provided information on the system implemented in their countries for the regulation of allergen products. While AIT products are commonly classified as biological medicinal products, they are made available by varying types of procedures, most commonly either by obtaining a marketing authorization or by being distributed as named patient products. Exemptions from marketing authorizations in exceptional cases, as well as import of allergen products from other countries, are additional tools applied by countries to ensure availability of needed AIT products. Several challenges for AIT products are apparent from this analysis and will require further consideration.

Profilin, a change in the paradigm

Profilin is a protein that is present in all eukaryotic cells and is responsible for cross-reactivity between pollen, latex, and plant foods. It has been classically acknowledged as a minor or nearly irrelevant allergen, although recent data are changing this conception. The objective of this manuscript is to provide a comprehensive review of published data on the role of this ubiquitous allergen in pollen, latex, and plant food allergy. The patterns of recognition of this minor allergen follow a north-south gradient. Although present in all pollens and vegetables, profilin is significantly associated with allergy to grass pollen and to Cucurbitaceae fruits. Heb v 8, the latex profilin, is usually a marker of profilin allergy in plant food-allergic patients, although it has no clinical relevance in latex allergy. Sensitization to profilin jeopardizes the diagnosis of pollen allergy and selection of immunotherapy, and although component-resolved diagnosis can identify its impact, there are no tailored treatments available. In recent years, several new publications have shown how profilin should be taken into account and, under certain circumstances, considered a marker of severity, an allergen capable of inducing respiratory symptoms, and, in its natural purified form, a potential candidate for etiological treatment of food allergy. Current data on profilin strongly support the need for a shift in the previously accepted paradigm for this allergen. More research should be done to assess the real clinical impact of sensitization in specific populations and to develop therapeutic strategies (AU)

La profilina es una proteína presente en todas las células eucariotas, siendo responsable de la reactividad cruzada entre polen, látex y alimentos vegetales. Ha sido reconocida clásicamente como un alérgeno menor o irrelevante; sin embargo, datos recientemente publicados están modificando esta interpretación. El objetivo de este manuscrito es realizar una revisión comprensiva de la literatura sobre el papel de este ubicuo alérgeno en el polen, látex y los alimentos vegetales. El patrón de reconocimiento de este alérgeno menor sigue un gradiente de norte a sur, y a pesar de estar presente en todos los pólenes y vegetales, está significativamente asociado al polen de gramíneas y a las frutas de la familia Cucurbitaceae. Heb v 8, la profilina del látex, es habitualmente un marcador de alergia a profilina en pacientes alérgicos a vegetales pero sin relevancia clínica en la alergia a látex. La presencia de la sensibilización a profilina dificulta el diagnóstico de alergia a pólenes y la selección de la inmunoterapia, y a pesar de que el diagnóstico por componentes puede identificar su impacto, no existen tratamientos personalizados disponibles. En los últimos años, diversas publicaciones nuevas han demostrado como la profilina debe ser tenida en cuenta y considerada bajo determinadas circunstancias, como un marcador de gravedad, como un alérgeno capaz de inducir síntomas respiratorios, y en su forma natural purificada, como un potencial candidato para realizar un tratamiento etiológico para tratar la alergia a alimentos. El conocimiento actual sobre la profilina impulsa la necesidad de cambiar el concepto que previamente se tenía sobre este alérgeno. Sería preciso investigar más para valorar el impacto clínico real de esta sensibilización en poblaciones específicas y desarrollar estrategias terapéuticas (AU)

Predictive biomarkers in allergen specific immunotherapy

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