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As Brunswick (1988) notes in her longitudinal study of several hundred youths from central Harlem: "An often overlooked cornerstone of hard drug use among young black males is that it is not only and perhaps not primarily a consumption and/or recreational behavior discount lanoxin amex pre hypertension pathophysiology. It also serves economic functions of occupation and career for this group" (see also Johnson et al buy lanoxin in india arteria sacralis mediana. In a population subgroup in which employment opportunities are severely constrained order lanoxin with visa blood pressure chart girl, and at a life stage at which economic independence is expected and required, the drug economy is one of the relatively few high-wage options that seem wide open (Reuter et al. It is not known with certainty what distinguishes those who sell drugs in economically disadvantaged communities from the majority of their peers in these areas who, with similarly limited opportunities, shun drug involvement, or from those in the middle who use but do not sell drugs. The perception and fact of being socially distant from mainstream opportunities, at the same time needing money in order to survive, are important. But, in every ethnic group in subcommunities dominated by drug use and sales, families are the most important social unit—particularly so given the paucity of institutional infrastructure in most economically impoverished areas. Although drug users in poor minority subcommunities are predominantly from single-parent, female- headed households, the same is true of those adolescents who do not use drugs (Fitzpatrick, 1990). Whether or not there is an intact nuclear family, the most important family inhibitions against drug use (either through predisposition or through reinforcement) may be the active involvement of multiple adults—in the immediate or extended Copyright © National Academy of Sciences. Another unknown is how differential aspects of African-American, Puerto Rican, Mexican-American, and other cultures serve as barriers to or promoters of drug use, as mediating factors in the initiation and conduct of drug use, and potential influences on the routes by which users can become drug free. The results provide a textured picture of the differing contingencies that inner-city youths confront. Participation in street culture during leisure hours was highly correlated with marijuana use, especially in the toughest neighborhoods (Blount and Dembo, 1984). The correlation between respondent and peer group marijuana use was appreciably stronger in the tougher, more drug-involved neighborhoods. In other words, in tough neighborhoods, you are either with the pot smokers or not—it is rare to have close friends among abstainers and smokers at the same time. In contrast, alcohol use was not correlated with street culture—it cut across neighborhood differences, and the positive association between respondent and peer group alcohol use was about the same everywhere. The attitudes, peer group relations, and adult role models of nonusers, alcohol-only, and alcohol-and- marijuana users were consistently different. Beyond these differences, the need to choose starkly between friendships with tough kids—who are usually marijuana users—and friendships with nonusers was a fact of life in the toughest neighborhoods, one that youths in less combative zones—even in the inner city —could more readily finesse, and one that was not present with respect to alcohol, regardless of neighborhood. Relationships Among Risk Factors Young people who engage in one form of health-compromising behavior are often engaged in other problem behaviors (Jessor and Jessor, 1977). The co- occurrence of alcohol and other drug abuse with delinquency and criminal behavior is well established (Elliott et al. From the perspective of temporal order (and thus relevant to predispositions), the first involvement in delinquent activity usually predates illicit drug use. Early alcohol and drug use along with violent or predatory behavior and early and aggressive sexual behavior seem to be part of a general pattern of rebellion and nonconformity variously called a 'deviance syndrome," "antisocial personality," "conduct disorder," or "adolescent adjustment disorder. They found that 71 percent of the males and 52 percent of the females who were using multiple illicit drugs were sexually active, compared with 10 percent of the males and 3 percent of the females who were not using any drugs. Along similar lines were results of a study of nearly 1,000 adolescents in Los Angeles in grades 7-9 who were resurveyed in grades 10-12 (Newcomb et al. But only 22 percent of those with none of the risk factors identified (low grade point average, lack of religious participation, poor relationship with parents, early alcohol use, low self-esteem, lack of conformity, sensation seeking, perception of ease of obtaining drugs, perception of neutral or favorable norms concerning drug use) had used marijuana, compared with 94 percent of those with 7 or more risk factors. These results were consistent for all other drugs and for higher levels of consumption. Of youths in the sample with zero risk factors, however, less than 1 percent were daily marijuana users; of those with 7 or more risk factors, 56 percent were daily marijuana users. No single predisposing factor dominates these analyses; rather, movement toward drug problems seems to proceed by the accumulation of small and mutually supporting effects over time—throughout early childhood and into the adolescent window of onset. The movement is a general drift toward adolescent problem behavior of various kinds and away from prosocial pursuits. If this drift across a continuum into increasingly problematic areas is indeed the principal type of causal process predisposing toward drug use, and particularly toward the higher (and more diversified) levels of consumption that mark abuse and dependence, then a preventive approach that attends systematically to a broad range of variables across a span of childhood years would be highly attractive. It is similar in this regard to the gradual accumulation of risk for heart disease and cancer from the cumulative effects of relatively innocuous discrete acts and gradually changing behavior patterns. This is not to say that more tightly focused studies should not be undertaken, but that such studies are best viewed as leading toward results that can be incorporated into larger-scale multivariate studies. There are needs for refinement of risk-factor research in several directions, but one in particular deserves emphasis here: methodological investment in improving techniques of measurement, particularly of environmental factors. A major reason for improved measurement is to avoid statistical biases (descriptive and inferential) in multivariate analyses. For example, factors such as personality traits are generally measured by multi-item scales administered to the individual and scored to identify the extent of individual variation from population parameters. In contrast, factors such as neighborhood quality, which urban researchers find can vary literally by the block in many areas, are usually measured at the level of the census tract or larger geographic swaths, using such proxies as average housing cost or population density, aggregated into quartiles, or loose "urbanicity" measures based on proximity to traditional city cores. This model suggests that socialization deficits in early childhood lead young people to affiliate with peers opposed to traditional institutions (such as school), a tendency that culminates in social alienation and trouble with the law (and other conventional institutions of society) in late adolescence and adulthood. This model parallels the logical progression of drug use to abuse to dependence, in that a relatively small proportion of youths who embark on the path of drug use continue on to dependence. If parenting practices to which the child is subject do not improve, these patterns of poor family bonding become more violent and reciprocal as the child grows beyond preschool. Although family economic conditions do not directly determine parenting practices, high levels of stress and disorganization degrade parenting performance, and these levels of stress are more common when family economic resources are scarce and when the neighborhood environment is itself impoverished and disorganized. In the second stage, poor socialization in the family leads to emotional and conduct problems in school grades 1-3. Peers and teachers respond antagonistically to poorly socialized behavior, and the child in turn is beset by social isolation or rejection, anxiety, insecurity, and continued conflicts with authority. The course of this second stage is obviously affected by the ability of the classroom teacher to adapt to poorly socialized children and educe not simply a modicum of compliance but rather positive bonding with the school, its staff, and other students. In the third stage, middle to late elementary grades 3-6, persistent problems in social adaptation result in decreased learning and poor grades. Deficient academic performance in turn creates isolation from and rejection by more academically competent peers; problems in adaptation to school transform into active alienation from school. It is among these youths that the early onset of tobacco or alcohol use, and in some instances marijuana as well, will occur. In the fourth stage, junior high school continuing on into high school, students disaffected from schooling firmly withdraw their efforts from academic or any other school-organized pursuits, become more overtly rebellious, and associate with each other in increasing opposition to academically competent and socially conventional peers, who reciprocate the hostility. An increasingly exclusive association with alienated peers intensifies into a school-oppositional peer group culture (Willis, 1977), characterized by expressive rejection of the conventional social norms and values, continuing academic failure, alcohol and drug use, delinquent activities, sexual behavior resulting in pregnancy, and a higher probability of early school exit. Interventions that assume school-based peer ties and adult-student solidarity will not be appropriate to committed members of the school-oppositional culture. Interventions that work as a reinforcer or accelerator of antidrug trends in the school-solidary culture may have null or even rebound effects in the school- oppositional one. In most schools, oppositional norms characterize a marginalized, limited proportion of students. In some, these hold the allegiance of a large fraction or even the majority, for example, in "special schools" for disciplinary problems, schools for emotionally disturbed youths, and schools that experience drop-out rates prior to high school graduation of 50 percent or higher (Lorion et al. The school-oppositional culture is resilient, a bed of resistance or rebellion that responds strongly to attempts to affect it; it "pushes back" in ways that rebound into the larger society.

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Alcohol interventions for trauma patients treated in emergency departments and hospitals: A cost benefit analysis purchase lanoxin line prehypertension statistics. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence purchase lanoxin 0.25mg fast delivery blood pressure jumps from high to low. Alcohol screening and intervention in trauma centers: Confidentiality concerns and legal considerations buy cheap lanoxin online blood pressure kit cvs. Safety and efficiency of an anti-(+)-methamphetamine monoclonal antibody in the protection against cardiovascular and central nervous system effects of (+)-methamphetamine in rats. Help-seeking for alcohol-related problems: Social contexts surrounding entry into alcoholism treatment or Alcoholics Anonymous. Individual differences in prefrontal cortex function and the transition from drug use to drug dependence. Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey. The effects of negative life events on alcohol consumption among older men and women. Journals of Gerontology: Series B: Psychological Science and Social Science, 50(4), S205-S216. Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders. Social networks and methadone treatment outcome: the costs and benefits of social ties. Opiate withdrawal using clonidine: A safe, effective, and rapid nonopiate treatment. Designing a smoking cessation intervention for the unique needs of homeless persons: A community-based randomized clinical trial. Effects of behavioral skills training and schedule of nicotine gum administration on smoking cessation. Dysfunction of the prefrontal cortex in addiction: Neuroimaging findings and clinical implications. Cigarette smoking and panic attacks among young adults in the community: the role of parental smoking and anxiety disorders. The accuracy of self-reported smoking: A systematic review of the relationship between self-reported and cotinine- assessed smoking status. Provider, patient, and family perspectives of adolescent alcohol use and treatment in rural settings. A pilot study comparing motivational interviewing and an educational intervention in patients with schizophrenia and alcohol use disorders. Neuropsychological functioning and outcomes of treatment for co-occurring depression and substance use disorders. Barriers to alcoholism treatment: Reasons for not seeking treatment in a general population sample. Adolescent alcohol use is a risk factor for adult alcohol and drug dependence: Evidence from a twin design. Nutrition education is positively associated with substance abuse treatment program outcomes. Services for perinatal women with substance abuse and mental health disorders: the unmet need. Substance abuse treatment for women: Changes in the settings where women received treatment and types of services provided, 1987-1998. Drug treatment outcomes for adolescents with comcorbid mental and substance use disorders. Perceptions of need and help received for substance dependence in a national probability survey. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Outcomes of implementing patient centered medical home interventions: A review of the evidence from prospective evaluation studies in the United States. Mechanisms involved in the neurotoxic, cognitive, and neurobehavioral effects of alcohol consumption during adolescence. Screening and intervention for alcohol and illicit drug abuse: A survey of internal medicine housestaff. Treatment of smokers with co-occurring disorders: Emphasis on integration in mental health and addiction treatment settings. Associations between duration of illicit drug use and health conditions: Results from the 2005-2007 National Surveys on Drug Use and Health. Lifetime tobacco, alcohol and other substance use in adolescent Minnesota twins: Univariate and multivariate behavioral genetic analyses. Pharmacodynamics of a monoclonal antiphencyclidine Fab with broad selectivity for phencyclidine-like drugs. The five-year diagnostic utility of "diagnostic orphans" for alcohol use disorders in a national sample of young adults. Do medical marijuana laws increase marijuana use: Replication study and extension. Computer- facilitated substance use screening and brief advice for teens in primary care: An international trial. Sexual abuse correlates: Similarities between male and female adolescents in chemical dependency treatment. Primary care provider screening for diabetes and assessment of cardiometabolic risk. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Seeking drug treatment for OxyContin abuse: A chart review of consecutive admissions to a substance abuse treatment facility in Kentucky. Affordable care organizations: Improving care coordination for people with Medicare. Affordable insurance exchanges: Seamless access to affordable coverage - overview. Essential health benefits: A set of health care service categories that must be covered by certain plans, starting in 2014. Genetic and environmental contributions to alcohol dependence risk in a national twin sample: Consistency of findings in women and men. Correlates of perceiving a need for treatment among adults with substance use disorder: Results from a national survey. 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In this first unit general concepts on the pharmacodynamics and pharmacokinetics of drug consumption are addressed order 0.25mg lanoxin otc hypertension 39 weeks pregnant. The characteristics of the main psychoactive substances and their psychoactive effects and mechanisms are also presented discount 0.25 mg lanoxin amex blood pressure garlic. Greeks and Romans deified wine with the figures of Dionysus and Bacchus order lanoxin 0.25mg overnight delivery heart attack reasons, respectively. Historically, drugs have been linked to magical-religious rituals, celebrations and social events. Some of these substances are natural in origin, as is the case with tobacco or cannabis. Others are the result of chemical processes carried out using natural products, like what occurs with alcoholic beverages, which are obtained from the fermentation or distillation of grain or fruit juice. There has also been a differentiation between soft and hard drugs, although currently that distinction is rarely used because of its scant utility and the fact that it can give rise to the erroneous interpretation that so-called soft drugs are not quite detrimental to health. The first group includes alcohol, opiates and psychotropic drugs such as hypnotics, anxiolytics and antipsychotics. In the third group, consisting of psychedelic drugs, are hallucinogens, cannabis, synthetic drugs and solvents. Central Nervous System Depressants a) Alcohol b) Hypnotics: Barbiturates and non-barbiturates c) Anxiolytics: diazepam d) Narcotic analgesics: i. We understand drug use to be drug consumption that does not negatively impact health. Drug consumption becomes abusive at the appearance of dependence, which is defined as the set of physiological, behavioral and cognitive manifestations in which the use of a drug is a priority for the individual. This term is usually linked to tolerance, or the need to consume more of a substance to achieve the effects of previous consumption. It is a cluster of symptoms that affect an individual who is suddenly deprived of any toxin or drug on which he/she is physically dependent and which previously had been consumed on a regular basis. The quantity of symptoms, as well as their intensity and duration will depend on the type of drug, the length of time the person has consumed the substance and his/her physical and psychological state at the time of withdrawal. Physical dependence is a state of adaptation of the organism to the presence of the drug and is manifested by the appearance of intense physical discomfort (tremors, chills, insomnia, vomiting, pain in the muscles and bones, etc. This same physical discomfort occurs when the substance?s action on the organism is influenced by drugs designed to block its effects. Psychological dependence refers to the situation in which a person feels an emotional need and urge to consume a drug on a regular basis in order to feel good, be satisfied (obtain pleasure or avoid discomfort) although he/she does not need the substance physiologically. There are the so-called non-toxic addictions which involve dependency behavior with an evident syndrome of psychological withdrawal. There is, for example, addiction to gambling or pathological gambling and others such as technological addictions (internet, mobile, and video games), addiction to shopping, exercise or sex. These addictive behaviors share, if not all, some of the characteristics mentioned so far, with the peculiarity that there is not a mediating substance that produces physical changes in the subject. Effects of Drugs 4 Jose Pedro Espada and Daniel Lloret Irles As already mentioned, drugs act on the central nervous system (i. The physiological correlates and effects vary according to each substance; there are specific mechanisms that involve precise receptors for each substance type. In this section we present some common aspects to the physiological effects of drugs. When a substance enters the body it first affects the neuronal receptors, which are structures located within a neuron or in its membrane and are characterized by selective binding to a substance and the physiological effect that accompanies the union. The presence of a drug in the body affects the presynapse, altering the production/ release of neurotransmitters. During the next step, the drug affects the synapses, by increasing the presence of neurotransmitters in the synaptic space. There can be a reuptake inhibition, blockade of reuptake channels, or inhibition of degradation. The activity of the drug in the body over a period of time comprises the processes of absorption, distribution, localization in tissues, biotransformation and excretion. Physical dependence emerges as the need to maintain certain levels of a substance in the body. Therefore, it involves the development of a drug- organism link and neuroadaptation process. Central Nervous System Depressants Alcohol the two main types of alcohol based on their chemical composition are: methyl alcohol (methanol), which is the simplest of the alcohols and is used as a solvent, antifreeze and in industrial applications; and ethyl alcohol (ethanol), which is what alcoholic beverages contain. Ethyl alcohol is obtained through the fermentation of sugars from different plants. After the distillation process, the amount of alcohol can be concentrated and significantly increased. From a physical standpoint, the short term effects of alcoholic beverage intake are impaired balance, movement, speech and vision, hurried and unintelligible expression, decreased ability to concentrate, drowsiness, and despondency, irritability, nausea, vomiting and/or headaches. Among the consequences at the physical level the following stand out: ? Alcoholic dependency syndrome or alcoholism. In the case of mothers who consume alcohol, a condition known as fetal alcohol syndrome appears. Children with this syndrome show morphological changes in the head, skeleton, heart and genitals, as well as mental retardation in approximately 50% of cases. When ingested in higher quantities, it brings about greater motor incoordination, aggression and loss of consciousness. It is estimated to affect between 50% and 70% of alcoholics (Caballeria, Caballeria y Pares, 1996). Thus, Pons y Berjano (1999) note that about half of suicide attempts in women and two thirds in men occur under the influence of alcohol. According to Romero (1994), up to 60% of traffic accidents occur from the following combination: young people- alcohol - weekend. The alcohol abuse is 7 Basic Concepts in Drug Addiction often associated with abuse, domestic violence and couple breakup (Carvalho et al. In the long run, individuals addicted to alcohol often lose their jobs (Moreno, Portus and Arias, 1995). It has also been observed that the intensity of alcohol consumption is one of the variables related to the use of other illegal drugs, such that the earlier the consumption of alcoholic beverages begins, the more substances will be used later (Secades, 1996). Adverse effects of alcohol in the juvenile population the negative repercussions of alcohol poisoning are numerous. Among the negative consequences that young people may specifically suffer the following stand out: ? School problems: alcohol consumption among boy and girl students has consequences that directly impact on their academic performance. Among the students who have never repeated a course there is a higher proportion of abstainers than among repeaters. Jacobson, Aldalna and Beaty (1994) affirm that 25% of teens had been drinking before their last sexual experience.

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Naive B cells make IgM antibodies that typic- ally bind with low a?nity to epitopes order lanoxin master card blood pressure extremely low. A particular epitope stimulates division of B cells with relatively higher-a?nity IgM antibodies for the epitope generic lanoxin 0.25 mg mastercard arteria spanish. As the stimulated B cell clones divide rapidly generic lanoxin 0.25mg with visa arteria epigastrica cranialis superficialis commissura labiorum dorsalis, they also mu- tate their antibody-binding regions at a high rate. Mutant lineages that bind with higher a?nity to the target antigen divide more rapidly and outcompete weaker-binding lineages. This mutation and selection pro- duces high-a?nity antibodies,typically of type IgA or IgG. Natural antibodies from di?erent B cell lineages form adiverseset thatbindswithlowa?nity to almost any antigen. By contrast, in vivo inoculations with several di?erent patho- gens showed that the initial binding by natural antibodies lowered the concentrations of pathogens early in infection by one or two orders of magnitude. Poor binding condi- tions cause low-a?nity binding to be highly speci?c because detectable bonds form only between the strongest complementary partners. By contrast, favorable binding conditions cause low-a?nity binding to de- velop a relatively broad set of complementary partners, causing rela- tively low speci?city. Early stimulation of B cells appears to depend on the equilibrium binding a?nity for antigens. By contrast, competition between B cell clones for producing a?nity-matured anti- bodies appears to depend on the dynamic rates of association between Bcellreceptors and antigens. The sixth section compares the cross-reactivity of an in vivo, poly- clonal immune response with the cross-reactivity of a puri?ed, mono- clonal antibody. Polyclonal immune responses raise antibodies against many epitopes on the surface of an antigen. Cross-reactivity declines lin- early with the number of amino acid substitutions between variant anti- gens because each exposed amino acidcontributes only a small amount to the total binding between all antibodies and all epitopes. By contrast, amonoclonal antibody usually binds to a single epitope on the antigen surface. Cross-reactivity declines rapidly and nonlinearly with the num- ber of amino acid substitutions in the target epitope because a small number of amino acids control most of the binding energy. The seventh section discusses the speci?city and cross-reactivity of Tcellresponses. The eighth section lists the ways in which hosts vary genetically in their responses to antigens. The germline genesthatcontribute to the T cellreceptor have some poly- morphisms that in?uence recognition, but the germline B cell receptor genes do not carry any known polymorphisms. Each speci?c subset of an antigenic molecule recognized by an antibody or a T cell receptor de?nes an epitope. For example, insulin, a dimeric protein with 51 amino acids, has on its surface at least 115 antibody epitopes (Schroer et al. Nearly the entire surface of an antigen presents many overlapping domains that antibodies can discriminate as distinct epitopes (Benjamin et al. Epitopes have approximately 15 amino acids when de?ned by spatial contact of antibody and epitope during binding (Benjamin and Perdue 1996). Almost all naturally occurring antibody epitopes studied so far are composed of amino acids that are discontinuous in the primary se- quence but brought together in space by the folding of the protein. The relative binding of a native and a mutant antigen to a puri?ed (monoclonal) antibody de?nes one common measure of cross-reactivity. C50mut is the concentration of the mutant antigen required to cause 50% inhibi- tion of the reaction between the native antigen and the antibody. Simi- larly, C50nat is the concentration of the native antigen required to cause 50% inhibition of the reaction between the native antigen and the an- tibody (self-inhibition). Then the relative equilibrium binding constant for the variant antigen, C50nat/C50mut,measurescross-reactivity (Ben- jamin and Perdue 1996). Site-directed mutagenesis has been used to create epitopes that vary by only a single amino acid. Studies di?er considerably in the methods used to identify the amino acid sites de?ning an epitope, the choice of sites to mutate, the amino acids used for substitution, and the calculation of changes in equilibrium binding constants or the free- energy of binding. Benjamin and Perdue (1996) discuss these general issues and summarize analyses of epitopes on four proteins. First, approximately 5 of the 15 amino acids in each epitope strongly in?uence binding. Certain substitutions at each of these strong sites can reduce the relative binding constant by two or three orders of magnitude. These strong sites may contribute about one-half of the total free-energy of the reaction (Dougan et al. Second, the other 10 or so amino acids in contact with the antibody may each in?uence the binding constant by up to one order of magni- tude. Third, the consequences of mutation at a particular site depend, not surprisingly, on the original aminoacidandtheamino acid used for substitution. Fourth, theoretical predictions about the free-energy consequences of substitutions based on physical structure and charge can sometimes be highly misleading. This problem often occurs when the binding location between the antibody and a particular amino acid is highly accessible to solvent, a factor that theoretical calculations have had di?culty incor- porating accurately. Fifth, antibodies raised against a particular epitope might not bind optimally to that epitope—the antibodies sometimes bind more strongly to mutated epitopes. In addition, antibodies with low a?nity for an antigen can have higher a?nity for related antigens (van Regenmortel 1998). Each antibody binding site de?nes a paratope, composed of the particular amino acids of that antibody that physically bind to a speci?c epitope. Approximately 50 variable amino acids make up the potential binding area of an antibody (van Regenmortel 1998). However, in both epitope and paratope, substitutions both in and away from the binding site can change the spatial conformation of the binding region and a?ect the binding reaction (Wedemayer et al. The antibody’s 50 or so variable amino acids in its binding region de?ne many overlapping groups of 15 amino acids. A paratope does not de?ne asinglecomplementary epitope; rather it presents certain molecular characteristics that bind antigenic sites with varying a?nity. First, an antibody can have two completely independent binding sites (paratopes) for unrelated epitopes (Richards et al. Bhattachar- jee and Glaudemans (1978) showed that two puri?ed mouse antibodies (M384 and M870) each bind methyl ? D-galactopyranoside and phos- phorylcholine at two di?erent sites in the antigen-binding region of the antibody. Second, an antibody presumably has many overlapping paratopes that can potentially bind to a variety of related or unrelated epitopes. I did not, however, ?nd any studies that de?ned for a particular antibody the paratope map relative to a set of variable epitopes. The potential distribution of paratopes may change as a B cell clone matures in re- sponse to challenge by a matching antigen—I take this up in the next section (4.

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