The document provides information about hypoglycemia including: 1. It defines hypoglycemia as a reduction in plasma glucose concentration that can induce symptoms like confusion or loss of consciousness. 2. The most common cause is medications used to treat diabetes like insulin and sulfonylureas. 3. Symptoms range from neurogenic symptoms like sweating to neuroglycopenic symptoms like weakness, and gestational hypoglycemia has certain features.

1. [0]
University of Baghdad
college of Medicine
Hypoglycemia
Endocrine module
Ahmad Dyia Sagban

2. [1]
Contents
1-Introduction …………………………………………….…. 2
2-Search board and discussion:
Signs and symptoms ...………………………………….. 3
Clinical presentation:
A. History …………...……………………………… 5
B. Physical examination ……………………………. 5
Diagnosis ……………………………………………….. 7
Treatment ……………………………………………….. 9
Etiology …...…...………………..…………………….. 11
Epidemiology ..………………………………………… 15
Prognosis …………………………………………...…. 16
Prevention …………………………………………….. 16
3-Summary.….……………………………………………... 18
4-References …………………………...…………………... 20

3. [2]
Introduction
Hypoglycemia is characterized by a reduction in plasma glucose concentration to
a level that may induce symptoms or signs such as confusion, loss of consciousness,
seizures, or death.
A feeling of hunger, sweating, shakiness, and weakness may also be present[1]
. This
condition typically arises from abnormalities in the mechanisms involved in
glucose homeostasis.
The most common cause of hypoglycemia is medications used to treat diabetes
mellitus such as insulin and sulfonylureas. [2][3]
Fig: 1

4. [3]
Signs and symptoms
The glucose level at which an individual becomes symptomatic is highly variable
(threshold generally at < 50 mg/dL). Carefully review the patient's medication and
drug history for potential causes of hypoglycemia (eg, new medications, insulin
usage or ingestion of an oral hypoglycemic agent, possible toxic ingestion).
The patient’s medical and/or social history may reveal the following:
 Diabetes mellitus, renal insufficiency/failure, alcoholism, hepatic
cirrhosis/failure, other endocrine diseases, or recent surgery
 Central nervous system: Headache, confusion, personality changes
 Ethanol intake and nutritional deficiency
 Weight reduction, nausea and vomiting
 Fatigue, somnolence
Neurogenic or neuroglycopenic symptoms of hypoglycemia may be categorized as
follows[28]
:
 Neurogenic (adrenergic) (sympathoadrenal activation) symptoms: Sweating,
shakiness, tachycardia, anxiety, and a sensation of hunger
 Neuroglycopenic symptoms: Weakness, tiredness, or dizziness; inappropriate
behavior (sometimes mistaken for inebriation), difficulty with concentration;
confusion; blurred vision; and, in extreme cases, coma and death.
Gestational hypoglycemia may have the following features[4]
:
 More frequent in women younger than 25 years
 More frequent in women with a preexisting medical condition
 Less frequent in women whose prepregnancy body mass index was ≥30
kg/m2
 Greater risk of preeclampsia/eclampsia in affected women.
In newborns, hypoglycemia can produce irritability, jitters, myoclonic jerks,
cyanosis, respiratory distress, apneic episodes, sweating, hypothermia,
somnolence, hypotonia, refusal to feed, and seizures or "spells." Hypoglycemia can
resemble asphyxia, hypocalcemia, sepsis, or heart failure.
Hypoglycemic symptoms can also occur when one is sleeping. Examples of
symptoms during sleep can include damp bed sheets or clothes from perspiration.
Having nightmares or the act of crying out can be a sign of hypoglycemia. Once

5. [4]
the individual is awake they may feel tired, irritable, or confused and these may be
signs of hypoglycemia as well.[5]
Long-term effects : Significant hypoglycemia appears to increase the risk of
cardiovascular disease.[6]
Fig: 2
Fig: 3

6. [5]
Clinical presentation
1-History:
The patient's medication and drug history should be reviewed carefully for potential
causes of hypoglycemia. Inquire if the patient is taking any new medications. A
history of insulin usage or ingestion of an oral hypoglycemic agent may be known,
and possible toxic ingestion should be considered. Injecting a shot of insulin and
skipping a meal or overdosing insulin is the most common cause in patients with
diabetes.
The medical history may include diabetes mellitus, renal insufficiency/failure,
alcoholism, hepatic cirrhosis/failure, other endocrine diseases, or recent surgery.
However, obtaining an accurate medical history may be difficult if the patient's
mental status is altered. Central nervous system (CNS) symptoms include
headache, confusion, and personality changes.
The social history may include ethanol intake and nutritional deficiency.
Review systems for weight reduction, fatigue, somnolence, nausea and vomiting,
and headache. Look for other symptoms suggesting infection.
2-Physical Examination:
Physical findings are nonspecific in hypoglycemia and generally are related to the
central and autonomic nervous systems. Assess vital signs for hypothermia,
tachypnea, tachycardia, hypertension, and bradycardia (neonates).
The head, eyes, ears, nose, and throat (HEENT) examination may indicate blurred
vision, pupils normal to fixed and dilated, icterus (usually cholestatic due to hepatic
disease), and parotid pain (due to endocrine causes).
Cardiovascular disturbances may include tachycardia (bradycardia in neonates),
hypertension or hypotension, and dysrhythmias. Neurologic conditions include
coma, confusion, fatigue, loss of coordination, combative or agitated disposition,
stroke syndrome, tremors, convulsions, and diplopia.
Respiratory disturbances may include dyspnea, tachypnea, and acute pulmonary
edema. Gastrointestinal disturbances may include nausea and vomiting, dyspepsia,
and abdominal cramping.

7. [6]
The patient's skin may be diaphoretic and warm or show signs of dehydration with
decrease in turgor.
Symptoms of hypoglycemia are fewer in elderly persons and they frequently appear
at a lower threshold of plasma glucose than in younger persons.
Fig: 4

8. [7]
Diagnosis
The glucose level that defines hypoglycemia is variable. In diabetics a levels below
3.9 mmol/L (70 mg/dL) is diagnostic.[1]
] In adults without diabetes, symptoms related to low blood sugar, low blood sugar
at the time of symptoms, and improvement when blood sugar is restored to normal
confirm the diagnosis, This is known as the Whipple's triad.[7]
Otherwise a level below 2.8 mmol/L (50 mg/dL) after not eating or following
exercise may be used.[1]
In newborns a level below 2.2 mmol/L (40 mg/dL) or less than 3.3 mmol/L (60
mg/dL) if symptoms are present indicates
hypoglycemia.[8]
Other tests that may be useful in determining the cause include insulin and C
peptide levels in the blood.[3]
Hyperglycemia, a high blood sugar, is the opposite condition.
Throughout a 24‑hour period blood plasma glucose levels are generally maintained
between 4–8 mmol/L (72 and 144 mg/dL).[9]
Although 3.3 or 3.9 mmol/L (60 or 70 mg/dL) is commonly cited as the lower limit
of normal glucose, symptoms of hypoglycemia usually do not occur until 2.8 to 3.0
mmol/L (50 to 54 mg/dL).[10]
In cases of recurrent hypoglycemia with severe symptoms, the best method of
excluding dangerous conditions is often a diagnostic fast. This is usually conducted
in the hospital, and the duration depends on the age of the patient and response to
the fast. A healthy adult can usually maintain a glucose level above 50 mg/dL (2.8
mM) for 72 hours, a child for 36 hours, and an infant for 24 hours. The purpose of
the fast is to determine whether the person can maintain his or her blood glucose as
long as normal, and can respond to fasting with the appropriate metabolic changes.
At the end of the fast the insulin should be nearly undetectable and ketosis should
be fully established. The patient's blood glucose levels are monitored and a critical
specimen is obtained if the glucose falls. Despite its unpleasantness and expense, a
diagnostic fast may be the only effective way to confirm or refute a number of
serious forms of hypoglycemia, especially those involving excessive insulin.
The precise level of glucose considered low enough to define hypoglycemia is
dependent on (1) the measurement method, (2) the age of the person, (3)
presence or absence of effects, and (4) the purpose of the definition. While there

9. [8]
is no disagreement as to the normal range of blood sugar, debate continues as to
what degree of hypoglycemia warrants medical evaluation or treatment, or can
cause harm.[11,12,13]
Deciding whether a blood glucose in the borderline range of 45–75 mg/dL (2.5–4.2
mM) represents clinically problematic hypoglycemia is not always simple. This
leads people to use different "cutoff levels" of glucose in different contexts and for
different purposes. Because of all the variations, the Endocrine Society
recommends that a diagnosis of hypoglycemia as a problem for an individual be
based on the combination of a low glucose level and evidence of adverse effects.[7]
Glucose concentrations are expressed as milligrams per deciliter (mg/dL or mg/100
mL) in Lebanon, the United States, Japan, Portugal, Spain, France, Belgium, Egypt,
Saudi Arabia, Colombia, India and Israel, while millimoles per liter (mmol/L or
mM) are the units used in most of the rest of the world. Glucose concentrations
expressed as mg/dL can be converted to mmol/L by dividing by 18.0 g/dmol (the
molar mass of glucose). For example, a glucose concentration of 90 mg/dL is 5.0
mmol/L or 5.0 mM.
The circumstances of hypoglycemia provide most of the clues to diagnosis.
Circumstances include the age of the person, time of day, time since last meal,
previous episodes, nutritional status, physical and mental development, drugs or
toxins (especially insulin or other diabetes drugs), diseases of other organ systems,
family history, and response to treatment. When hypoglycemia occurs repeatedly,
a record or "diary" of the spells over several months, noting the circumstances of
each spell (time of day, relation to last meal, nature of last meal, response to
carbohydrate, and so forth) may be useful in recognizing the nature and cause of
the hypoglycemia.

10. [9]
Treatment
Treatment of some forms of hypoglycemia, such as in diabetes, involves
immediately raising the blood sugar to normal through the ingestion of
carbohydrates, determining the cause, and taking measures to hopefully prevent
future episodes. However, this treatment is not optimal in other forms such as
reactive hypoglycemia, where rapid carbohydrate ingestion may lead to a further
hypoglycemic episode.
Blood glucose can be raised to normal within minutes by taking (or receiving) 10–
20 grams of carbohydrate.[14]
It can be taken as food or drink if the person is
conscious and able to swallow. This amount of carbohydrate is contained in about
3–4 ounces (100–120 ml) of orange, apple, or grape juice although fruit juices
contain a higher proportion of fructose which is more slowly metabolized than pure
dextrose, alternatively, about 4–5 ounces (120–150 ml) of regular (non-diet) soda
may also work, as will about one slice of bread, about 4 crackers, or about 1 serving
of most starchy foods. Starch is quickly digested to glucose (unless the person is
taking acarbose), but adding fat or protein retards digestion. Symptoms should
begin to improve within 5 minutes, though full recovery may take 10–20 minutes.
Overfeeding does not speed recovery and if the person has diabetes will simply
produce hyperglycemia afterwards. A mnemonic used by the American Diabetes
Association and others is the "rule of 15" – consuming 15 grams of carbohydrate
followed by a 15-minute wait, repeated if glucose remains low (variable by
individual, sometimes 70 mg/dL).[15]
If a person is suffering such severe effects of hypoglycemia that they cannot (due
to combativeness) or should not (due to seizures or unconsciousness) be given
anything by mouth, medical personnel such as paramedics, or in-hospital personnel
can establish IV access and give intravenous dextrose, concentrations varying
depending on age (infants are given 2 ml/kg dextrose 10%, children are given
dextrose 25%, and adults are given dextrose 50%). Care must be taken in giving
these solutions because they can cause skin necrosis if the IV is infiltrated, sclerosis
of veins, and many other fluid and electrolyte disturbances if administered
incorrectly. If IV access cannot be established, the patient can be given 1 to 2
milligrams of glucagon in an intramuscular injection. More treatment information
can be found in the article diabetic hypoglycemia. If a person is suffering less
severe effects, and is conscious with the ability to swallow, medical personal such
as EMT-B's may administer gelatinous oral glucose.

11. [10]
One situation where starch may be less effective than glucose or sucrose is when a
person is taking acarbose. Since acarbose and other alpha-glucosidase inhibitors
prevents starch and other sugars from being broken down into monosaccharides
that can be absorbed by the body, patients taking these medications should consume
monosaccharide-containing foods such as glucose tablets, honey, or juice to reverse
hypoglycemia.
Fig: 5

12. [11]
Etiology
Causes of hypoglycemia are varied, but it is seen most often in diabetic patients.
Hypoglycemia may result from medication changes or overdoses, infection, diet
changes, metabolic changes over time, or activity changes; however, no acute cause
may be found. Other causes include alimentary problems, idiopathic causes,
fasting, insulinoma, endocrine problems, extrapancreatic causes, hepatic disease,
post bariatric surgery, and miscellaneous causes.
Fasting hypoglycemia
Nesidioblastosis is a rare cause of fasting hypoglycemia in infants and an extremely
rare cause in adults. This condition is characterized by a diffuse budding of insulin-
secreting cells from pancreatic duct epithelium and pancreatic microadenomas of
such cells.
Causes of fasting hypoglycemia usually diagnosed in infancy or childhood include
inherited liver enzyme deficiencies that restrict hepatic glucose release
(deficiencies of glucose-6-phosphatase, fructose-1,6-diphosphatase,
phosphorylase, pyruvate carboxylase, phosphoenolpyruvate carboxykinase, or
glycogen synthetase).
Inherited defects in fatty acid oxidation, including that resulting from systemic
carnitine deficiency and inherited defects in ketogenesis (3-hydroxy-3-
methylglutaryl-CoA lyase deficiency) cause fasting hypoglycemia by restricting
the extent to which nonneural tissues can derive their energy from plasma free fatty
acids (FFA) and ketones during fasting or exercise. This results in an abnormally
high rate of glucose uptake by nonneural tissues under these conditions.
Several cases of nesidioblastosis were reported recently after gastric bypass
surgery.
Drags:
Ethanol (including propranolol plus ethanol), haloperidol, pentamidine, quinine,
salicylates, and sulfonamides ("sulfa drugs") have been associated with
hypoglycemia. Other drugs that may be related to this condition include oral
hypoglycemics, phenylbutazone, insulin, bishydroxycoumarin, p-aminobenzoic
acid, propoxyphene, stanozolol, hypoglycin, carbamate insecticide, disopyramide,
isoniazid, methanol, methotrexate, tricyclic antidepressants, cytotoxic agents,

13. [12]
organophosphates, didanosine, chlorpromazine, fluoxetine, sertraline,
fenfluramine, trimethoprim, 6-mercaptopurine, thiazide diuretics, thioglycolate,
tremetol, ritodrine, disodium ethylenediaminetetraacetic acid (EDTA), clofibrate,
angiotensin converting enzyme (ACE) inhibitors, and lithium.
A study by Fournier and colleagues indicates that treatment for pain with the opioid
analgesic tramadol increases a patient’s risk of being hospitalized for
hypoglycemia. Information from the United Kingdom Clinical Practice Research
Datalink and the Hospital Episode Statistics database was analyzed for 28,110
patients who were newly prescribed tramadol and 305,924 individuals who were
newly prescribed codeine, all for noncancer pain, with 11,019 controls also
included in the study. Using case-control, cohort, and case-crossover analysis, the
investigators found that tramadol increased the risk of hospitalization for
hypoglycemia by more than three-fold, with the risk particularly elevated in the
first 30 days of treatment. The actual risk was small, however, occurring in about
7 patients per 10,000 annually.[16,17]
A study by Eriksson et al indicated that in patients with type 2 diabetes undergoing
second-line treatment, the combination of metformin and sulfonylurea carries a
greater risk for severe hypoglycemia, cardiovascular disease, and all-cause
mortality than does the combination of metformin and dipeptidyl peptidase-4
inhibitor (DPP4i).[18]
Similarly, a study by Gautier et al found that patients with type 2 diabetes treated
with metformin plus insulin secretagogues (such as sulfonylurea or glinide) were
more likely to experience hypoglycemia than were those treated with metformin
plus DPP4i while starting insulin. Both groups achieved similar glycemic
control.[19]
Surreptitious sulfonylurea use/abuse :
Factitious hypoglycemia or self-induced hypoglycemia can be seen in healthcare
workers or in relatives who care for diabetic family members at home. (see Type
1 Diabetes Mellitus and Type 2 Diabetes Mellitus for further discussion,
including the diagnostic use of C-peptide levels and hemoglobin A1C).
Exogenous insulin:
Surreptitious use of insulin may be seen, typically among those likely to have
access to insulin. Measurement of insulin level along with C-peptide is very crucial
in making this diagnosis.

14. [13]
Endogenous insulin or insulin-receptor–mediated hypoglycemia:
Sources of endogenous insulin include insulin-producing tumors of pancreas and
non–beta-cell tumors.
Insulin-producing tumors of pancreas:
Islet cell adenoma or carcinoma (insulinoma) is an uncommon and usually curable
cause of fasting hypoglycemia and is most often diagnosed in adults. It may occur
as an isolated abnormality or as a component of the multiple endocrine neoplasia
type I (MEN I) syndrome.
Carcinomas account for only 10% of insulin-secreting islet cell tumors.
Hypoglycemia in patients with islet cell adenomas results from uncontrolled insulin
secretion, which may be clinically determined during fasting and exercise.
Approximately 60% of patients with insulinoma are female. Insulinomas are
uncommon in persons younger than 20 years and are rare in those younger than 5
years. The median age at diagnosis is about 50 years, except in patients with MEN
syndrome, in which the median age is in the mid third decade of life. Ten percent
of patients with insulinoma are older than 70 years.
Non–beta-cell tumors:
Hypoglycemia may also be caused by large non–insulin-secreting tumors, most
commonly retroperitoneal or mediastinal malignant mesenchymal tumors. The
tumor secretes abnormal insulinlike growth factor (large IGF-II), which does not
bind to its plasma binding proteins. This increase in free IGF-II exerts
hypoglycemia through the IGF-I or the insulin receptors. The hypoglycemia is
corrected when the tumor is completely or partially removed and usually recurs
when the tumor regrows.
Reactive hypoglycemia:
Reactive hypoglycemia can be idiopathic, due to alimentary problems, or a result
of congenital enzyme deficiencies.
Alimentary hypoglycemia is another form of reactive hypoglycemia that occurs in
patients who have had previous upper gastrointestinal (GI) surgical procedures
(gastrectomy, gastrojejunostomy, vagotomy, pyloroplasty) and allows rapid
glucose entry and absorption in the intestine, provoking excessive insulin response
to a meal. This may occur within 1-3 hours after a meal. Very rare cases of

15. [14]
idiopathic alimentary hypoglycemia occur in patients who have not had GI
operations.
Congenital enzyme deficiencies include hereditary fructose intolerance,
galactosemia, and leucine sensitivity of childhood. In hereditary fructose
intolerance and galactosemia, an inherited deficiency of a hepatic enzyme causes
acute inhibition of hepatic glucose output when fructose or galactose is ingested.
Leucine provokes an exaggerated insulin secretory response to a meal and reactive
hypoglycemia in patients with leucine sensitivity of childhood.
Fig: 6

16. [15]
Epidemiology
The incidence of hypoglycemia in a population is difficult to ascertain. Patients and
physicians frequently attribute symptoms (eg, anxiety, irritability, hunger) to
hypoglycemia without documenting the presence of low blood sugar. The true
prevalence of hypoglycemia, with blood sugar levels below 50 mg/dL, generally
occurs in 5-10% of people presenting with symptoms suggestive of hypoglycemia.
Hypoglycemia is also a known complication of several medications, and the
incidence is difficult to determine with any certainty. In addition, this condition is
a known complication of many therapies for diabetes; therefore, the incidence of
hypoglycemia in a population of people with diabetes is very different from that in
a population of people without diabetes.[20,21,22,23,24,25]
Insulin-producing tumors are a rare but important treatable cause of hypoglycemia,
with an annual US incidence of 1-2 cases per million persons per year.
Reactive hypoglycemia is reported most frequently by women aged 25-35 years;
however, other causes of hypoglycemia are not associated with a sex predilection.
The average age of a patient diagnosed with an insulinoma is the early 40s, but
cases have been reported in patients ranging from birth to age 80 years.[26]

17. [16]
Prognosis
The prognosis of hypoglycemia depends on the cause of this condition, its severity,
and its duration. If the cause of fasting hypoglycemia is identified and treated early,
the prognosis is excellent. If the problem is not curable, such as an inoperable
malignant tumor, the long-term prognosis is poor. However, note that these tumors
may progress rather slowly. Severe and prolonged hypoglycemia can be life
threatening and may be associated with increased mortality in patients with
diabetes.
If the patient has reactive hypoglycemia, symptoms often spontaneously improve
over time, and the long-term prognosis is very good. Reactive hypoglycemia is
often treated successfully with dietary changes and is associated with minimal
morbidity. Mortality is not observed. Untreated reactive hypoglycemia may cause
significant discomfort to the patient, but long-term sequelae are not likely.
A study by Boucai et al found that drug-associated hypoglycemia was not
associated with increased mortality risk among patients admitted to general wards.
This suggests that hypoglycemia may be a marker of disease burden and not a direct
cause of death. [27[
Prevention
The most effective means of preventing further episodes of hypoglycemia depends
on the cause [28[
.
The risk of further episodes of diabetic hypoglycemia can often (but not always) be
reduced by lowering the dose of insulin or other medications, or by more
meticulous attention to blood sugar balance during unusual hours, higher levels of
exercise, or decreasing alcohol intake.
Many of the inborn errors of metabolism require avoidance or shortening of fasting
intervals, or extra carbohydrates. For the more severe disorders, such as type 1
glycogen storage disease, this may be supplied in the form of cornstarch every few
hours or by continuous gastric infusion.

18. [17]
Several treatments are used for hyperinsulinemic hypoglycemia, depending on the
exact form and severity. Some forms of congenital hyperinsulinism respond to
diazoxide or octreotide. Surgical removal of the overactive part of the pancreas is
curative with minimal risk when hyperinsulinism is focal or due to a benign insulin-
producing tumor of the pancreas. When congenital hyperinsulinism is diffuse and
refractory to medications, near-total pancreatectomy may be the treatment of last
resort, but in this condition is less consistently effective and fraught with more
complications.
Hypoglycemia due to hormone deficiencies such as hypopituitarism or adrenal
insufficiency usually ceases when the appropriate hormone is replaced.
Hypoglycemia due to dumping syndrome and other post-surgical conditions is best
dealt with by altering diet. Including fat and protein with carbohydrates may slow
digestion and reduce early insulin secretion. Some forms of this respond to
treatment with a glucosidase inhibitor, which slows starch digestion.
Reactive hypoglycemia with demonstrably low blood glucose levels is most often
a predictable nuisance which can be avoided by consuming fat and protein with
carbohydrates, by adding morning or afternoon snacks, and reducing alcohol
intake.
Idiopathic postprandial syndrome without demonstrably low glucose levels at the
time of symptoms can be more of a management challenge. Many people find
improvement by changing eating patterns (smaller meals, avoiding excessive sugar,
mixed meals rather than carbohydrates by themselves), reducing intake of
stimulants such as caffeine, or by making lifestyle changes to reduce stress.
Fig: 7

19. [18]
Summary
Hypoglycemia is a reduction in plasma glucose concentration.
The most common cause of hypoglycemia is medications used to treat diabetes
mellitus such as insulin and sulfonylureas.
Hypoglycemic symptoms include:
o Neurogenic (adrenergic) (sympathoadrenal activation) symptoms:
Sweating, shakiness, tachycardia, anxiety, and a sensation of hunger
o Neuroglycopenic symptoms: Weakness, tiredness, or dizziness;
inappropriate behavior (sometimes mistaken for inebriation), difficulty
with concentration; confusion; blurred vision; and, in extreme cases,
coma and death.
The patient's medication and drug history should be reviewed carefully for potential
causes of hypoglycemia.
The glucose level that defines hypoglycemia is variable. In diabetics a levels
below 3.9 mmol/L (70 mg/dL) is diagnostic.
In adults without diabetes, symptoms related to low blood sugar, low blood sugar
at the time of symptoms, and improvement when blood sugar is restored to normal
confirm the diagnosis, This is known as the Whipple's triad.
Treatment of some forms of hypoglycemia, such as in diabetes, involves
immediately raising the blood sugar to normal through the ingestion of
carbohydrates, determining the cause, and taking measures to hopefully prevent
future episodes.
Causes of hypoglycemia are varied, but it is seen most often in diabetic patients.
Hypoglycemia may result from medication changes or overdoses, infection, diet
changes, metabolic changes over time, or activity changes.
The incidence of hypoglycemia in a population is difficult to ascertain.

20. [19]
The prognosis of hypoglycemia depends on the cause of this condition, its severity,
and its duration.
The most effective means of preventing further episodes of hypoglycemia depends
on the cause.
To prevent hypoglycemia should be:
1- Take sweets with you.
2- Have regular meals.
3- Check your blood sugar regularly.

21. [20]
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