Method of autoblood preoperative preparation

FIELD: medicine.

SUBSTANCE: 2 blood samples are taken with interval 3 days against complex medicinal supplement under the following scheme. Therapy of the first exfusion day is characterized with single introduction of phetabolyl 0.4 mg/kg intramuscularly, 5% vitamin B1 - 50 mg intravenously, vitamin B12 - 500γ st. units intramuscularly, 5%vitamin C - 150 mg intravenously and 10 % aminoplasmal E - 250 ml intravenously drop-by-drop. The same day and the next two days imply intramuscular injection of ferrum lek 100 mg once, sorbypher 325 mg twice a day, folic acid - 5 mg 3 times a day. For the second day exfusion is accompanying with single subcutaneous introduction of epocryne in dosage 4 thausand UNITS. Then for the third day control inspection is carried out. The second day of exfusion implies single introduction of 5% vitamin B6 - 50 mg intravenously, 5% vitamin C - 150 mg intravenously, vitamin B12 - 500γ st.units intramuscularly and 10% aminoplasmal E - 250 ml intravenously drop-by-drop. This day and in the subsequent two - three days imply intramuscular introduction of ferrum lek 100 mg once, sorbypher 325 mg twice a day, folic acid - 5 mg 3 times a day. For the second day exfusion is accompanying with single subcutaneous introduction of epocryne in dosage 4 thausand UNITS. Then for the third day control inspection is carried out again. Since the first exfusion and before autoblood preparation nutritive supplement is carried out using module protein added to mix "Berlamine Modular" 50 g twice a day daily. After exfusion autoblood is divided on erythrocyte mass and fresh frozen plasma.

EFFECT: prevention of dangerous erythropoiesis and metabolic disorders.

1 ex, 3 cl

 

The invention relates to medicine, namely to transfusion medicine and anesthesiology, and can be used to ensure the optimization of preparation of the patient for surgical treatment of scoliosis in terms of preoperative autologous blood procurement.

Known methods of preoperative autologous blood procurement (ERB et al. The use of autohemotransfusions in a multidisciplinary hospital // Materials of international scientific-practical conference "Bloodless surgery on the threshold of XXI century". Moscow. 2000. P.85-87; Bjorn Lysander. Comparative evaluation of different methods of saving blood in surgery // in "Alternatives to blood transfusion in surgery", Supplement to the journal "Anesthesiol. and reanim.". M., 1999. S-93; Aria Shander. Anesthetic tactics and pharmacological means to limit perioperative blood loss // in "Alternatives to blood transfusion in surgery", Supplement to the journal "Anesthesiol. and reanim.". M., 1999. S-80; Jean-françois Baron "Pharmacological methods of stimulation of erythropoiesis - erythropoietin in combination with methods of saving blood" // in "Alternatives to blood transfusion in surgery", Supplement to the journal "Anesthesiol. and reanim.". M., 1999. S-80).

These methods require a long period of harvesting of the blood, which leads to a delay in surgical intervention and a significant increase from the shackles of hospital stay. In addition, long-term storage of blood components is accompanied by the development of degenerative changes in the blood Bank, which entails a violation of the oxygen-transport function of blood and the formation of cell microaggregates that may cause damage to the microcirculation system, primarily in the lungs. This fact is totally unacceptable in patients with scoliosis with the original cardio-respiratory disorders, due to the high risk of complications from cardiovascular and respiratory system.

Closest to the claimed method is preoperative autologous blood procurement of children for orthopedic operations: taking the blood is made preoperatively with 7-day intervals. The last blood donations in a week before surgery. The amount of blood equal to the weight of the child and the level of hematocrit (minimum hematocrit 0.34 l/l). On average, prepare to 2.29 dose of blood. All patients assigned Gelateria (Silvergleid A.J. Safety and effectiveness of preposit autologus transfusion in preterm and adolescent children // JAMA. 1987. N.257. P.3403-3404).

This method of preoperative preparation of blood provides the necessary amount of autologous blood for the upcoming surgical treatment. However, the method does not take into account the fact that the very process of autumnale with exusia the patient's blood volume to 10-15% of BCC is accompanied by a stress reaction of the body to the possible development of systemic neuroendocrine response caused by:

1. fluctuations in blood volume (CBV);

2. pain and emotional influences (especially in patients childhood and adolescence);

3. the metabolic response to stress (adrenal system activation, vasoconstriction, direct protein loss, increased catabolism, increased oxygen consumption).

The degree and duration of metabolic disorders depends on the adequacy of treatment in the period of preoperative autologous blood procurement and the type of pathology.

Objective: to ensure the safety of preoperative autologous blood procurement, to reduce terms of preparation, notice of the occurrence of the stress response of the organism.

When the task has a positive therapeutic effect, which is that through the use of complex medical training (apocrine, ferum Lek, sorbifer, b vitamins, ascorbic acid, folic acid, retabolil), parenteral administration of amino acids (aminoplasmal 10%) and conducting nutritional support using protein module to mix Bersamin Modular" manages to achieve a high degree of recovery of erythropoiesis and protein metabolism that allows in a short time (6 days) to prepare 4 doses of autologous blood components - 2 doses of the erythrocyte is Noah mass, and 2 doses of FFP without prejudice to the health of the patient. The method can significantly reduce the time of stay of the patient in the hospital, to prevent the development of severe complications associated with transfusion of drugs homologous blood during surgery and in the postoperative period, the development of which requires significant additional costs, and therefore when using the method has an economic effect.

The technical result is achieved due to complex drug protect the body against stress response. Expose blood is considered quite a safe procedure for most patients. However, it is important to note that the possible reactions during blood sampling may include: hypotension, vasovagal symptoms, ischemic manifestations in the brain and disorders of cardiac rhythm. Thus, it is necessary compensation exposuremanager blood volume equivalent to the volume of fluid fluids (crystalloids) and the implementation of mandatory monitoring of blood pressure, ECG, pulse oximetry.

The amount of blood that can be expositive autodoor, depends on the mass of circulating red blood cells and on the ability to quickly restore volume remote erythrocytes. In turn, the ability to quickly restore the red cell mass may be limited by the production of endogenous erythropoietin (who). Apocrine - recombinant human erythropoietin indistinguishable from natural glycoprotein hormone erythropoietin man as the biological activity and immunological. His appointment during the harvesting of blood seeks to reduce or prevent the development of anemia. The effect of EPO therapy is very often limited by the depletion of iron, so iron preparations (ferum Lek, sorbifer) leads to a more fast and adequate supply of iron cells Eritrea that gives increased eritropoeticescoe reaction.

B vitamins, folic acid are stimulators of protein biosynthesis. Ascorbic acid has strong antioxidant effect.

Any stressful situation causes shifts metabolism toward increased catabolism, which, in turn, is accompanied by the human protein-amino acid, carbohydrate, fat metabolism, water and electrolyte balance, metabolism of biologically active endogenous regulators of homeostasis, which is especially dangerous in patients with reduced body weight, which constitute a risk group in terms of the occurrence of intra - and postoperative complications. Of course preoperative stress, harvesting autologous blood determine the increasing needs of the body for energy substrates. There is no doubt that the decree which authorized the situation providing metabolic protection and compensation increased basal metabolic rate should be carried out with the help of clinical nutrition, warning immunity, synthesis of enzymes and hormones that are biochemically active substances. Restore the protein balance is impossible without amino acids, the use of which enables not only the substitution of nutritional therapy, but also to influence biochemical processes in the body 1-2 hours after their application. The advantages of the solution Aminoplasmal 10% include: content of 20 amino acids, 100 g, which accounted for 41% indispensable that you need for lightweight protein synthesis in the body of the patient; conservation of amino acid homeostasis, full body, good tolerance by patients.

The introduction of a 10% glucose solution has becomesvery effect in terms of increasing the body's needs in glucose.

The purpose of prolonged anabolic action, and promote protein synthesis is assigned retabolil.

In addition to therapeutic diet that the patient receives in the hospital, you must use Nutrilite, namely protein module registered in the Russian Ministry of health mixture Bersamin modular ("Berlin Chemie"), which contains high-quality non-genetically modified soy protein (50 grams of a mixture contains by 43.6 g of protein), a balanced amino acid composition (18 amino acids, including essential amino acids), allows the velocity the amount of injected protein without significantly increasing the volume of enteral nutrition.

The method allows for the procurement of the required number of components autologous blood for surgical treatment of scoliosis in the absence of dangerous disorders of erythropoiesis, metabolism and metabolic disorders at the stage of harvesting autologous blood and thus to avoid serious complications of the operational period, associated with the use of donor blood components, and the process of preoperative autologous blood procurement, the treatment of which requires significant additional costs.

The problem is solved due to the fact that they have 2 intake autologous blood with an interval of 3 days on the background of a comprehensive medical support under the scheme: on the first day of exfuze once imposed retabolil 0.4 mg/kg intramuscularly, vitamin B1 5% - 50 mg intravenously, vitamin B12 500γ intramuscularly, vitamin C 5% - 150 mg intravenously, aminoplasmal 10% 250 ml intravenous drip, on the first day of exfuze and in the next two days - ferum Lek 100 mg intramuscularly 1 time, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day, on the second day after exposee once imposed apocrine dose of 4 so U subcutaneously; in the second day of exfuze once imposed vitamin B6 5% - 50 mg intravenously, vitamin C 5% - 150 mg intravenously, vitamin B12 500γ intramuscularly, aminoplasmal 10% 250 ml intravenous drip, the day of the second exposee and beyond the two or three days - ferum Lek 100 mg intramuscularly 1 time, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day; on the second day after exposee enter apocrine dose of 4 so UNIT 1 subcutaneously; on the first day of exfuze and prior to the completion of autologous blood procurement spend nutritional support using protein module to mix Bersamin Modular" 50 grams 2 times a day every day. On the third day after exposee check-up examination. After exposee of autoblood prepare blood components - red blood cell mass and fresh frozen plasma.

The method is as follows.

All the patients before planned autumnale is a complete clinical and paraclinical examination: anthropometry, biochemical analysis of blood serum concentration of bilirubin, total protein, urea, glucose and electrolytes), analysis of hemostasis (PETIT, the concentration of fibrinogen, clotting time, duration of bleeding, platelet count), complete blood count, urinalysis.

From the functional tests required are: ECG, radiography of the chest. Additional tests include an ultrasound of the heart, kidneys, liver and spirography.

Following are absolute contraindications to preoperative harvesting autologous blood in children and adolescents:/p>

1. Severe cardiovascular diseases.

2. Blood diseases, anemia.

3. Acute infection.

4. Hypoproteinemia of any etiology.

Relative contraindications include:

1. The reduced body weight.

2. The age of 10.

3. Poor venous access.

4. The positive reaction to HsAg.

After examination in the absence of contraindications for patients based on individual program autodeal:

1. First exposio autologous blood is conducted from the cubital vein in a volume of 10 ml/kg (10-13% BCC) in a plastic bag with preservative. Next, carry out the separation of blood fractions RBC mass and NWS. The harvested blood components are stored in accordance with order No. 363 MOH, 2000, governing the operation of blood transfusion stations using lemakonov firm "TURUMO".

2. The compensation amount eksponirovannoi blood spend the equivalent amount of plasma-inflammatory drugs: crystalloids in the volume of 6 ml/kg of 10% glucose solution 10 ml/kg

3. On the day of exfuze once imposed retabolil 0.4 mg/kg intramuscularly, vitamin B1 5% - 50 mg intravenously, vitamin B12 500γ intramuscularly, vitamin C 5% - 150 mg intravenously, aminoplasmal 10% 250 ml intravenous drip, the day of exfuze and in the next 2-3 days - ferum Lek 100 mg intramuscularly 1 time, sorbifer 325 mg 2 times a day, folic sour is 5 mg 3 times a day; on the second day after exposee assigned apocrine dose of 4 so UNIT 1 subcutaneously.

4. Patients are prescribed nutritional support using protein module to mix Bersamin Modular" 50 g 2 times a day.

5. On the 3rd day after the first exposee blood under laboratory control scheme: biochemical analysis of blood serum concentration of total protein, urea, glucose and electrolytes), analysis of hemostasis (PETIT, fibrinogen concentration, platelet count), complete blood count, urinalysis. The minimum acceptable hemoglobin level before the second exusia blood is 120 g/l, color index - 0,9; hematocrit - 36.

6. The second exposio autologous blood is conducted from the cubital vein in a volume of 10 ml/kg (10-13% BCC). Collect blood in a plastic bag with preservative. Next, carry out the separation of blood into fractions. The harvested blood components are stored in accordance with order No. 363 MOH, 2000, governing the operation of blood transfusion stations using lemakonov firm "TURUMO".

7. The compensation amount eksponirovannoi blood spend plazmozameschayuschie fluids: crystalloids in the volume of 6 ml/kg of 10% glucose solution 10 ml/kg

8. In the second day of exfuze appoint one vitamin B6 5% - 50 mg intravenously, vitamin C 5% - 150 mg intravenously, vitamin B12 500γ intramuscularly and is Anaplasma 10% 250 ml 1 intravenous drip, on the day of exfuze and in the next 2-3 days - ferum Lek 100 mg intramuscularly 1 time, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day; apocrine assigned on the second day after exposee dose of 4 so UNIT 1 subcutaneously; ongoing nutritional support using protein module to mix Bersamin Modular" 50 g 2 times a day.

An example of the clinical use of the method.

Patient W. born in 1990 (15 years old) was admitted to the hospital of Novosibirsk research Institute of traumatology and orthopedics 21.10.05. In the clinic according to the established procedure performed, a complete clinical and radiographic examination. Clinical diagnosis: Idiopathic is not complicated by progressive subcompensated mobile left lumbar lordoscoliosis IV degree. In the study of respiratory function indices spirometry correspond to the age norm - 2300 ml In x-ray examination of the chest pathological changes of the lungs and the mediastinum was not detected. Data ECG - sinus rhythm with a frequency of 83 min, impaired intraventricular conduction on the right leg of the bundle of his. Ultrasound of the heart - mitral valve prolapse I degree. Ultrasound of internal organs, ultrasound of the kidneys without pathology. The patient weight - 43 kg Allergological anamnesis is not burdened. A General analysis of blood, urine, biochemical and is Aliza within conditional rules: erythrocytes 4,0· 1012/l, hemoglobin - 134 g/l, colour index of 1.00, platelets 272·109/l, hematocrit 42%, ESR 9 mm/h, the formula blood without features, duration of bleeding 1 min, clotting time 4 min 12 sec, total protein, 76 g/l, urea 6.5 mmol/l, total bilirubin of 15.9 mmol/l, serum potassium 4.1 mmol/l, serum sodium 143 mmol/l, blood glucose 4.7 mmol/l, prothrombin index 94%, fibrinogen 3.1 g/L. HELL systolic and 110 mm Hg, BP diastolic 65 mm Hg, heart rate is the heart rate of 80. The patient examined by a pediatrician, contraindications for surgery and preoperative autologous blood procurement not identified. The estimated volume of intraoperative blood loss of 1000 ml (30% BCC).

24.10.2005 made the first fence autologous blood from the cubital vein in a volume of 400 ml (10 ml/kg, which corresponded to 13% BCC) in a plastic bag with preservative. Then spent the separation of blood fractions RBC mass and NWS. The harvested blood components stored in accordance with order No. 363 MOH, 2000, governing the operation of blood transfusion stations using lemakonov firm "TURUMO". The compensation amount eksponirovannoi blood held solution "Acesol" (200 ml) and 10% glucose solution, 400 ml. Assigned and entered - retabolil 0.4 mg/kg intramuscularly 1 time, vitamin B1 5% - 50 mg 1 time intravenously, vitamin B12 500γ 1 times intramuscularly vitamin C 5% - 150 mg 1 time intravenous, aminoplasmal 10% 250 ml 1 intravenous drip, ferum Lek 100 mg intramuscularly 1 time (further 25.10.05; 26.10.05), sorbifer 325 mg 2 times a day (and then 25.10.05; 26.10.05), folic acid 5 mg 3 times a day (and then 25.10.05; 26.10.05); 21.10.2005 assigned apocrine dose of 4 so UNIT 1 subcutaneously. With 20.10.2005 assigned patient nutritional support using protein module to mix Bersamin Modular" 50 grams 2 times a day every day. During blood sampling, and implementation of comprehensive drug therapy the patient's condition did not suffer, the level of arterial pressure did not change significantly HELL systolic 110-100 mm Hg, BP diastolic 65-70 mm Hg, heart rate 96 HR in minutes

27.10.2005 St laboratory control: erythrocytes 3,9·1012/l, hemoglobin - 128 g/l, colour index of 0.98, platelets 242·109/l, hematocrit 37%, erythrocyte sedimentation rate of 12 mm/h, the formula blood without features, total protein 66 g/l, urea 8.5 mmol/l, total bilirubin of 12.0 mmol/l, serum potassium 4.3 mmol/l, serum sodium 145 mmol/l, blood glucose 5.0 mmol/l, prothrombin index 97%, fibrinogen 3.0 g/l, urine analysis without pathology, ECG data without dynamics, HELL systolic and 110 mm Hg, BP diastolic 70 mm Hg, the heart rate HR 84 in minutes

27.10.2005 St conducted a second exposio autologous blood in a volume of 400 ml (10 ml/kg, which corresponded to 13%BCC). Blood is collected in a plastic bag with preservative with the separation of blood into fractions harvested blood components stored in accordance with order No. 363 health Ministry from 2000, the Compensation amount eksponirovannoi blood held plazmozameschayuschim solutions "Acesol" in the volume of 200 ml and 10% glucose solution, 400 ml. 27.10.2005 St assigned and entered: vitamin B6 5% - 50 mg 1 time intravenous vitamin C 5% - 150 mg 1 time intravenously, vitamin B12 500γ 1 times intramuscularly, aminoplasmal 10% 250 ml 1 intravenous, ferum Lek 100 mg intramuscularly 1 time (further 28.10.05; 29.10.05; 30.10.05), sorbifer 325 mg 2 times a day (and then 28.10.05; 29.10.05; 30.10.05), folic acid 5 mg 3 times a day (and then 28.10.05; 29.10.05; 30.10.05); 28.10.05 assigned apocrine dose of 4 so UNIT 1 subcutaneously; continued nutritional support using protein module to mix Bersamin Modular" 50 grams 2 times a day every day. The second exfuze of blood was carried out with stable hemodynamics - AD 115 mm Hg systolic, BP diastolic 70 mm Hg, heart rate heart rate 88 / min, any complications are not registered. Thus, for the task ahead was harvested 2 doses of erythrocyte mass (150 ml and 170 ml) and 2 doses of FFP (250 ml and 270 ml). Surgery performed 02.11.2005 in full with intraoperative blood loss 850 ml, without complications.

1. The way preoperative ranging ovci autologous blood through the fence, recovery of blood counts, wherein spend 2 blood sampling with an interval of 3 days on the background of a comprehensive medical support under the scheme: on the first day of exfuze - once imposed retabolil 0.4 mg/kg intramuscularly, vitamin B1 5% - 50 mg intravenously, vitamin B12 500γ intramuscularly, vitamin C 5% - 150 mg intravenously, aminoplasmal 10% 250 ml intravenous drip, on the first day of exfuze and in the next two days - ferum Lek 100 mg intramuscularly 1 time, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day, on the second day after exposee once imposed apocrine dose of 4 so U subcutaneously; in the second day of exfuze once imposed vitamin B6 5% - 50 mg intravenously, vitamin C 5% - 150 mg intravenously, vitamin B12 500γ intramuscularly, aminoplasmal 10% 250 ml intravenous drip, the day of the second exposee and in the next two or three days - ferum Lek 100 mg intramuscularly 1 time, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times per day; on the second day after exposee enter apocrine dose of 4 so UNIT 1 subcutaneously; on the first day of exfuze and prior to the completion of autologous blood procurement spend nutritional support using protein-module to a mixture of Beremin Modular" 50 g 2 times a day.

2. The method according to claim 1, characterized in that on the third day after exposee check-up examination.

3. The method according to claim 1, Otley is audica fact, after exposee of autoblood prepare blood components - red blood cell mass and fresh frozen plasma.



 

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28 cl, 4 tbl, 13 ex

FIELD: medicine, neurology.

SUBSTANCE: the present innovation deals with treating cerebrasthenic syndrome (CS) due to carrying out therapy at taking into account the data of a child's complex inspection. At bioelectric cerebral activity a rest being under 40 mcV and impossibility to reconstruct its background values after functional loadings during 3 min by EEG, deviation of cerebral neuromediator supply by 10% and more, affected fermentative activity along with decreased utilization of glucose and creatine phosphate synthesis according to electromagnetic cerebral scanning (EMS) data it is possible to establish CS as a result of oxygen-dependent cerebral hypoergia to introduce amino acids, enzymes, iron preparations, vitamins, hepatoprotectors during 1-mo-long period; then - nootropes and sedative preparations and then comes transcranial micropolarizations (TCMP) along the intake of antihypoxants and vitamin and microelements complexes. Such therapeutic courses should be repeated twice or thrice at interval being not less than 2 mo at keeping soft daily schedule. In case of analogous EEG alterations, the deficiency of initial pulse circulation in carotid and vertebral-basilary (VB) basin being not less than 10%, and during carrying out functional samples - up to 55-75% against the norm, the signs of venous outflow difficulties at REG and USDG, and decreased activity of neurons by above 20% according EMS data it is possible to state upon CS at VB failure and the risk for syncopic states; also, in therapy one should additionally apply vasoactive, spasmolytic and diuretic preparations for 1 mo, and after TCMP the course of resolution therapy should be conducted. In case of instability of vertebro-motor segments and ligamentous-muscular apparatus of cervical vertebrae and rotation subluxations C1 or C2 at wave deviation being above 0.2 mm according to EMS data, and at availability of vascular abnormality of brain or neck it is necessary to fulfill MRT at vascular program. In case of pronounced instability, and/or functional blocks at the level of C1-C5, and/or shifts of disks or vertebral bodies it is important to conduct manual therapy of cervical department at "soft techniques", except those at inborn abnormality of cranio-vertebral area. The innovation provides rapid and stable effect due to differentiating complex therapy at taking into account all the links of etiopathogenesis.

EFFECT: higher efficiency of therapy.

4 cl, 3 ex

FIELD: pharmaceutical industry, natural materials.

SUBSTANCE: invention relates to the development of preparations based on marine algae. The preparation comprises spirulina enriched with selenium in the concentration up to 50-800 mcg/g and at least one brown algae from the group comprising laminaria, zooster and focus taken in the amount 60% of the preparation mass, not less, and subjected for homogenization by destruction, hydrolysis and heating at temperature 65-75°C with particles sized mainly 5-45 mcm. Spirulina is enriched additionally with at least one trace element chosen from the group: vanadium, iron, zinc, molybdenum, chrome, manganese, silicon, cobalt and germanium. The preparation comprises preferably spirulina as green mass grown in medium enriched with selenium and at least one of abovementioned trace element or as powder. Except for, the preparation can comprise one component from the group comprising green mass or powder prepared from plant amaranth or extract prepared from plant stevia leaves. The preparation comprises preferably brown algae subjected for destruction by homogenization of milled material, or by cryodestruction at temperature (-106)-(-124)°C, or by cavitation treatment at the efflux rate 10-30 m/s. Brown algae are subjected for hydrolysis in acid medium at pH < 5 and then in alkaline medium at pH > 7. The preparation shows the enhanced assimilability of iodine, prolonged effect and expanded range of curative-prophylactic (functional) possibilities including antioxidant and immunomodulating effect, improved organoleptic indices and minimal contraindications.

EFFECT: valuable medicinal properties of preparation.

9 cl, 4 ex

FIELD: medicine.

SUBSTANCE: invention relates to polyvitamin composition comprising complex of vitamins A, B1, B2, B6, B12, C, E, nicotinamide and calcium pantothenate and, optionally, folic acid, biotin, chlorocalciferol, phytomenadione and sorbitol, lactose, lubricating agent, taste and/or odor corrector as special supplements, and, optionally, microcrystalline cellulose and/or aerosil, and to a method for its preparing. The composition shows the enhanced stability.

EFFECT: improved and valuable properties of composition.

19 cl, 1 tbl, 4 ex

FIELD: medicine.

SUBSTANCE: substance of invention includes application of ligand associated with carrier, where ligand is protein FasL, or Fas leukocyte receptor-directed antibody, to reduce leukocyte activity for extracorporal application. Besides, this invention provides method of leukocyte activity reduction my means of specified module.

EFFECT: damaging action of associated activated leukocytes is inhibited by inactivation module within minutes.

9 cl, 1 ex, 1 tbl, 1 dwg

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