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Veterinary Focus

Issue number 29.2 Other Scientific

Front line ultrasound imaging of the feline urinary tract

Published 17/10/2019

Written by Gregory Lisciandro

Also available in Français , Deutsch , Italiano and Español

Most practices will have access to an ultrasound machine; in this paper Greg Lisciandro discusses how a structured approach to abdominal scanning can help rapid identification of potential bladder abnormalities and related problems.


Key Points

Point-of-care ultrasound is gaining more and more use in first opinion veterinary medicine, and can be regarded as the clinician’s first-choice imaging method.

A structured approach to abdominal scanning should minimize the risk of missing important pathologies.

Assessment of bladder volume using ultrasound offers an indirect, non-invasive method for estimation of urine output, which can be important in managing critical cases.

Recording ultrasound findings using specific templates helps to emphasize the objectives whilst imaging, as well as chronicling patient data for future reference and comparison.


The well-defined point-of-care method for rapid ultrasound scanning of small animals, known as Global FAST or GFAST (Focused Assessment with Sonography in Trauma/Triage) is now widely used in the veterinary community. The technique includes protocols for abdominal scanning (AFAST), thoracic scanning (TFAST), and lung assessment (Vet BLUE, or veterinary Bedside Lung Ultrasound Examination). The idea behind GFAST was to develop a method for standardized ultrasound examination specifically tailored for veterinary patients that would answer clinical questions that might differ from what complete abdominal ultrasound and comprehensive echocardiography were trying to achieve. It should be emphasized that the AFAST, TFAST and Vet BLUE examinations are not the same as "flashing" the abdomen, thorax, and lungs.

The GFAST technique uses defined acoustic windows (i.e., views), which include target-organ interrogation and specific, standardized probe maneuvers. This article focuses on assessment of the feline urinary bladder and considers potential findings using the AFAST Cysto-Colic View (CC), including identification of free fluid and obvious, easily detected bladder abnormalities. The recording of findings on goal-directed templates gives value to the objective examination.

Firstly, however, a word of caution, the veterinary point-of-care ultrasound (V-POCUS) movement lends itself to "satisfaction of search error" through selective imaging (picking and choosing). Without following a standardized global protocol, the clinician will miss pathology and fail to integrate other important ultrasound findings 1 2 3 4 5. The idea is that the GFAST ultrasound approach serves as an extension of the physical exam, as it is designed as a standardized, achievable format for the non-specialist radiologist veterinarian, and is intended to be the clinician’s first-line choice of imaging modality, i.e., it is a quick assessment test.

This paper offers an introduction to first-line use of GFAST to assess feline lower urinary tract disease. The AFAST technique is used for general assessment of the abdomen, including a free-fluid scoring system, and is a target-organ approach involving the urinary bladder. A subsequent paper will focus on using the approach to assess patients with kidney disease. TFAST and Vet BLUE methods should also be employed when staging feline patients and for overall volume status. The GFAST approach should be part of the work-up for all cats with urinary tract signs and those with urinary obstruction, but using it as a first-line imaging test may also detect incidental and unexpected findings within the urinary tract.

The AFAST examination

Gregory Lisciandro

Ultrasound measurements offer a non-invasive option to calculate urinary bladder volume and, with serial measurements over time, estimation of urine output. This provides important clinical information, especially in cats at risk for, or in, renal failure.

Gregory Lisciandro

The external landmarks for the respective AFAST views that are part of the abdominal fluid scoring system are shown in Figure 1 and Figure 2. The standardized approach is necessary, beginning with the Diaphragmatico-Hepatic View (DH), followed by the least gravity-dependent Spleno-Renal View (SR) in right lateral recumbency (or the Hepato-Renal View (HR) in left lateral recumbency) followed by the Cysto-Colic View (CC) and then ending at the most gravity dependent Hepato-Renal Umbilical View (HRU) (or the Spleno-Renal Umbilical View (SRU) in left lateral recumbency). The standardized order ensures that the patient's thorax is first screened (i.e., with the DH view) for any obvious intrathoracic problems, such as pleural and pericardial effusion, that could increase patient risk when restrained. The final AFAST view ends at the most gravity-dependent region, the respective umbilical view, where abdominocentesis can be performed (after completing the AFAST) if effusion is detected.

Figure 1. AFAST landmarks on a cat in right lateral recumbency. The cat is sedated in preparation for an elective ovariohysterectomy; for the ultrasound scan the cat would generally not be sedated and not shaved, but the shaved abdomen helps better show the anatomical landmarks. DH = Diaphragmatico-Hepatic View; SR = Spleno-Renal View; CC = Cysto-Colic View HRU = Hepato-Renal Umbilical View© Dr. Gregory Lisciandro, Hill Country Veterinary Specialists,, Spicewood, Texas
Figure 2. AFAST landmarks on a cat in left lateral recumbency. HR = Hepato-Renal View; DH = Diaphragmatico-Hepatic View; CC = Cysto-Colic View; SRU = Spleno-Renal Umbilical View© Dr. Gregory Lisciandro, Hill Country Veterinary Specialists,, Spicewood, Texas

The AFAST target-organ approach

Table 1. Questions to be asked with the AFAST Cysto-Colic View.
Question Notes
Is there any free fluid in the abdominal (peritoneal) cavity? Yes or No
How much free fluid in the abdominal cavity using the AFAST-applied Fluid Scoring System?
Score 0, ½ (≤ 5 mm) or
 1 (> 5mm)
What does the urinary bladder look like? Unremarkable or abnormal
What does the urinary bladder lumen look like? Unremarkable or abnormal
What does the urinary bladder wall look like? Unremarkable or abnormal
Is the patient intact reproductively? Yes or No
Could I be misinterpreting an artifact or pitfall for pathology?

Know pitfalls and artifacts

AFAST allows for sonographic assessment of easily recognized urinary tract-related conditions. The sonographer merely has to decide whether the urinary bladder is unremarkable or abnormal, and when abnormal, direct further imaging and a more streamlined approach for definitive diagnosis. Achievable abnormal AFAST findings are detailed in (Table 1). The normal appearance of the bladder and abdominal urethra are demonstrated in Table 2.

Table 2. It is vital that the clinician is familiar with the normal appearance of the feline bladder and abdominal urethra before identifying potential abnormalities.


                                                                           Normal abdominal urethra


Both the bladder and urethra should be easy to recognize during AFAST. The feline species has a significant track of abdominal urethra that may be imaged and marked by calipers. Intra-abdominal fluid-associated urethral distension may be readily appreciated if present.© Dr. Daniel Rodriguez, DACVR, Mexico City, Mexico – Focused Ultrasound Techniques for the Small Animal Practitioner, Wiley 2014

                                                                                      Normal urinary bladder


The feline urinary bladder is generally ovalshaped, with a normal wall thickness < 2.3 mm, independent of the degree of distension 6. The bladder wall should be smooth and uniform with sonographic striation seen as a hyperechoic, hypoechoic, hyperechoic pattern.

The AFAST is performed by fanning (interrogating in longitudinal planes) followed by rocking cranially and returning to the starting point at each of the respective views. Therefore the Cysto-Colic (CC) view interrogates the urinary bladder in longitudinal planes while searching for free fluid in the gravity-dependent region termed the Cysto-Colic Pouch. Note that the feline urethra differs from that of dogs, in that it has a substantial length which may be imaged intra-abdominally. The Spleno-Renal (SR) and Hepato-Renal (HR) views provide soft tissue information on the left and right kidneys and are used to search for free retroperitoneal and peritoneal fluid, and are also important for complete first-line evaluation of the feline urinary tract. This part of the assessment (which can be performed with the animal standing or in lateral or sternal recumbency) will be covered in the subsequent paper.

The AFAST CC view allows the urinary bladder to be surveyed for not only the presence, but also the degree, of sediment, which is especially helpful in urinary tract disease and urinary obstructed felines. Monitoring the amount of sediment can be helpful to assess the subsequent response to therapy (including dietary interventions), and – in cats with urinary obstruction – the degree of sediment helps determine the need for bladder lavage. Other possible findings include the presence of thrombi (blood clots), cystic calculi, bladder wall abnormalities and the location of a urinary catheter when placed. Table 3 illustrates some of the most useful normal and abnormal findings that can be detected using this technique.

Table 3. Ultrasound findings of the feline urinary bladder and urethra.

                                                                             Table 3.1. Sediment

Sediment is usually easy to identify using AFAST. Normal feline urine may have some degree of echogenicity (unlike the dog, where only anechoic is considered normal) because cats concentrate their urine. Often the echogenicity is due to lipid droplets; this can be normal. Urinalysis is required to definitively determine whether the urine is normal or abnormal.

This  image shows the urinary bladder and a small degree of free fluid in the Cysto-Colic Pouch where the urinary bladder wall and abdominal muscle meet (anechoic triangulation). The bladder lumen has marked slice-thickness artifact that mimics sediment. Turning down the gain, ballottement, and changing the patient position are maneuvers to better differentiate one from the other. Clinicians should be aware that slice-thickness artifact can be mistaken for sediment or other pathology.

                                                                         Table 3.2. Sediment – Linear strands and septa


In this view the sediment is organized with linear strands of debris; in more severe cases actual septa form. In urinary obstructed cats, the finding of either linear strands or septa still carries a good prognosis 6.
© Focused Ultrasound Techniques for the Small Animal Practitioner, Wiley 2014

                                                                            Table 3.3 Sediment – Sand


Different degrees of mineralized urine sediment can develop in cats. In this image the "sand" is great enough to cause distal acoustic shadowing. Clean distal acoustic shadowing is a hallmark for mineralization; small mineralized foci may be detected using color Doppler and the "twinkle artifact" 7 8.
© Focused Ultrasound Techniques for the Small Animal Practitioner, Wiley 2014

                                                                           Table 3.4 Cystoliths (cystic calculi)


There is a single cystolith visible in this scan; note the suspect is within the urinary bladder lumen and has clean acoustic shadowing. Again care is needed; air-filled small intestine and colon can mimic cystic calculi. Ultrasound is comparable in accuracy to double contrast cystography for detection of uroliths 9.

There are multiple cystoliths present in this image. Note the suspects are within the urinary bladder lumen and each has clean acoustic shadowing. Clean distal acoustic shadowing is a hallmark for mineralized calculi but radiography can be used to confirm AFAST sonographic suspicions.
A loop of gas-filled intestinal tract can mimic a cystolith, as shown here. Ballottement and changing patient position can better differentiate one from the other sonographically

                                                                           Table 3.5 Thrombus (blood clot)

Echogenic material in the bladder lumen can be due to a thrombus (blood clot). To differentiate between a neoplastic mass and a thrombus, apply color Doppler – a thrombus or blood clot should not demonstrate blood flow

                                                                           Table 3.6 Bladder mass

A bladder wall mass: to differentiate between a mass (pulsatile flow) and a thrombus (no flow) apply color Doppler (see “Thrombus” above). Note that slice-thickness artifact may be mistaken for a mass effect if the clinician makes a hasty interpretation of the scan.

                                                                            Table 3.7 Bladder wall irregularities

An example of polypoid cystitis, showing as irregularities to the bladder wall. Remember that normal wall thickness in a moderately distended bladder is < 2.3 mm 6.

                                                                           Table 3.8 Free peritoneal fluid 

The presence of small volumes of free intra-abdominal fluid (ascites) may be easily recognized in the Cysto-Colic (CC) Pouch, the most gravity-dependent region. This is also where sediment and cystoliths will settle within the urinary bladder lumen 

                                                                            Table 3.9 Urinary catheter

A urinary catheter may be imaged directly or (if having difficulty) located by moving the catheter while imaging, or gently flushing the catheter with sterile saline. It is seen as a hyperechoic (bright white) “equal sign” or parallel lines for near and far walls of the urinary catheter and/or shadowing.

                                                                           Table 3.10 Cystocentesis


The needle may be tracked using ultrasound while performing cystocentesis. Ultrasound-guided procedures are becoming standard of care in human medicine because they limit complications 10.

Bladder obstruction, ascites and retroperitoneal effusion

Cats with urinary obstruction commonly have ascites associated with the obstruction 6 11 12 and retroperitoneal effusion. In the most detailed study to date (to the author's knowledge) ~ 60% of obstructed cats were positive for pericystic fluid (analogous to the AFAST CC View) and ~35% were positive for retroperitoneal effusion 6. It is important to be aware that the clinical course for the great majority of such cats is unaltered, in that with standard care the ascites and retroperitoneal effusion will resolve in time as the patient recovers 6. Sampling and testing the effusion may support a diagnosis of uroabdomen, but medical therapy, rather than surgical intervention, is appropriate in such cases. There is speculation as to why the effusion develops in such cases, but the author proposes that it is caused by tissue inflammation and backpressure of urine against the urinary bladder wall and renal capsule 13. Using the abdominal fluid scoring (AFS) system with the AFAST-applied technique provides not only an objective semi-quantification of the volume (usually scored between 0-4, although the system can be modified for smaller volumes), but also specifies positive and negative regions 1 14 15 16. The scoring system provides distinct advantages over use of subjective terms such as trivial, mild, moderate and severe (which have been employed to describe the fluid), and allows monitoring of affected cats as necessary, including during daily patient rounds and recheck evaluations. From the author’s experience, the free fluid usually resolves 24-36 hours after the obstruction is removed and the patient successfully resuscitated.

Gregory Lisciandro

Any urinary bladder scan should be surveyed for not only the presence, but also the degree, of sediment; this technique is especially helpful with urinary tract disease and obstructed cats. Monitoring the amount of sediment can aid assessing the subsequent response to therapy.

Gregory Lisciandro

Sampling accessible free fluid

When free fluid is detected on ultrasound scan and is safely accessible it must be sampled to accurately characterize it; fluid analysis and cytology should be performed to better direct care and diagnostics. When urinary tract rupture is suspected, it is helpful to compare serum creatinine or potassium levels to that of the effusion. Importantly, ultrasound cannot accurately characterize free fluid, and with larger volume effusions abdominocentesis is generally performed immediately after competing AFAST at its most gravity-dependent umbilical view, where free intra-abdominal fluid is pocketed.

Urinary bladder volume estimation

The use of longitudinal (sagittal) and transverse measurements with the AFAST CC view can provide estimations for urinary bladder volume and, with serial measurements over time, assessment of urine output 17. The bladder is measured in longitudinal orientation at its largest oval for the measurements of length (L) and height (H) in centimeters. The probe is then rotated 90 degrees for the measurement of width (W). The formula of L x H x W x 0.625 gives an estimation of the bladder volume in milliliters (Figure 3a) (Figure 3b). This provides an indirect non-invasive option to gain this important clinical information, especially in cats at risk for or in renal failure.

Figure 3. Urinary bladder measurements during AFAST at the Cysto-Colic View for bladder volume estimation. The bladder is measured in longitudinal orientation at its largest oval for length (L) and height (H) in centimeters (cm) (a). The probe is then rotated 90 degrees to transverse orientation for the largest oval to measure width (W) (b). The formula of L x H x W x 0.625 = estimation of urinary bladder volume in milliliters (mL) (18). The measurements here are 5.01 (cm) x 3.22 (cm) x 4.49 (cm) x 0.625 = 45.3 mL. These images were taken from a male cat with urinary obstruction; note that the bladder contains a substantial amount of sediment and that there is free intra-abdominal fluid adjacent to its apex in the Cysto-Colic Pouch. 

Bladder masses

A not-uncommon scenario in small animal practice is when the veterinarian detects a suspect bladder mass when performing cytocentesis on a cat. Such cases should be staged with GFAST, partly in order to provide a much better dialogue with the client. Two simple scenarios can illustrate the point:

(i) The clinician discovers a bladder mass during cystocentesis, aborts the procedure and returns to tell the client that there is bad news, i.e., that there is likely a neoplastic process, and that an expensive work-up is recommended. If the cat is stable, the client may opt to go home to "think about it", and does not return for the work-up. This leads to a setback in the veterinarian – client relationship and can leave the client guilt-ridden at home, wondering what the best option should be for their cat.

(ii) The clinician discovers a bladder mass but returns to the exam room having already performed a GFAST assessment. The dialogue may be more upbeat than the first scenario if the scan suggests that the mass appears to be localized, with no obvious renal pelvic dilation or masses detected, no liver masses, no lung masses (from a Vet BLUE scan) and no pleural or pericardial effusion. If the cat is cooperative, TFAST echo views may also allow detection of unremarkable heart chambers. The clinician can then recommend that appropriate further tests are the next step. Conversely, if serious findings are detected on the scan, such as lung nodules 18, then the clinician should move to discuss palliative care, helping both client and pet as best as possible. Using the GFAST approach, the veterinarian-client bond becomes even stronger.

GFAST for assessing patient volume status

The feline species as a whole seems to be more susceptible to fluid volume overload, including cats with urinary obstruction 19; this may result in pulmonary edema, hepatic venous congestion, pleural or pericardial effusion, or any combination of the above 20. Obtaining a baseline GFAST on such patients on presentation is invaluable. The integration of findings during TFAST and Vet BLUE are helpful in determining if left- versus right-side volume overload is occurring. Moreover, and importantly, echo views are not needed in many patients, as the so-called "fallback views" can be sufficient. Left-sided congestive heart overload/failure results in cardiogenic lung edema and is either readily detected and scored using Vet BLUE or excluded 20 21 22. Right-sided congestive heart overload/failure results in hepatic venous congestion, which again can be readily detected by characterizing the size of the caudal vena cava and its associated hepatic veins. Moreover, pleural and pericardial effusion can occur concurrently with either condition and this can be assessed during TFAST 15 23 24 25 26. Integration of echo findings during TFAST, the characterization of the caudal vena cava, and lungs during Vet BLUE increase the probability of an accurate assessment 3.

Recording the results

Goal-directed templates are imperative to clearly convey objectives and for recording patient data that may be measured and compared initially and with future studies. Published examples may be accessed through the website 1 15 27 28.


Abdominal ultrasound scans using a standardized approach should be the clinician’s first-line imaging choice when presented with a cat that has potential bladder disease or abdominal trauma cases. Using the AFAST method, with defined acoustic windows with specific, consistent probe maneuvers allows targeted organ interrogation and should permit rapid assessment of cases and appropriate ongoing treatment as necessary.


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  2. Lisciandro SC. Focused or COAST3 – Urinary Bladder. In: Lisciandro GR (ed). Focused Ultrasound Techniques for the Small Animal Practitioner. Ames: Wiley-Blackwell; 2014;99-109.
  3. Lisciandro GR, Armenise AA. Focused or COAST3: Cardiopulmonary resuscitation (CPR), Global FAST (GFAST3), and the FAST-ABCDE Exam. In: Lisciandro GR (ed), Focused Ultrasound Techniques for the Small Animal Practitioner. Ames: Wiley-Blackwell; 2014;269-285.
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  5. Ha YR, Toh HC. Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review. J Intensive Care 2016; 4:54. doi: 10.1186/s40560-016-0172-1.
  6. Nevins JR, Mai W, Thomas E. Associations between ultrasound and clinical findings in 87 cats with urethral obstruction. Vet Radiol Ultrasound 2015;56(4): 439-447.
  7. Gliga ML, Chirila CN, Podeanu DM, et al. Twinkle, twinkle little stone: an artifcat improves the ultrasound performance! Med Ultrason 2017;19(3):272-275.
  8. Simon JC, Sapozhnikov OA, Krieder W, et al. The role of trapped bubbles in kidney stone detection with the color Doppler ultrasound twinkling artifact. Phys Med Biol 2018;63(2):0205011. doi: 10.1088/1361-6560/aa9a2f.
  9. Weichselbaum RC, Feeney DA, Jessen CR, et al. Urocystolith detection: comparison of survey, contrast radiographic and ultrasonographic techniques in an in vitro bladder phantom. Vet Radiol Ultrasound 1999;40(4):386-400.
  10. Peabody CR, Manadavia D. Deep needle procedures: improving safety with ultrasound visualization. J Patient Saf 2017;13(2):103-108.
  11. Hall J, Hall K, Powell LL, et al. Outcome of male cats managed for urethral obstruction with decompressive cystocentesis and urinary catheterization: 47 cats (2009-2012). J Vet Emerg Crit Care 2015;25(2):256-262.
  12. Reineke EL, Thomas EK, Syring RS, et al. The effect of prazosin on outcome in feline urethral obstruction. J Vet Emerg Crit Care 2017;27(4):387-396.
  13. Cooper ES, Owens TJ, Chew DJ, et al. A protocol for manging urethral obstruction in male cats without uerthral catheterization. J Am Vet Med Assoc 2010;237(11): 1261-2166.
  14. Lisciandro GR, Lagutchik MS, Mann KA, et al. Evaluation of an abdominal fluid scoring system determined using abdominal focused assessment with sonography for trauma in 101 dogs with motor vehicle trauma. J Vet Emerg Crit Care 2009;19(5):426-437.
  15. Lisciandro GR. Abdominal and thoracic focused assessment with sonography for trauma, triage, and monitoring in small animals. J Vet Emerg Crit Care 2011;21(2):104-122.
  16. Lisciandro GR, Fosgate GT, Romero LA, et al. Abdominal FAST (AFAST) and abdominal fluid scores in adult and juvenile cats. Abstract, J Vet Emerg Crit Care 2015;25(S1):S8.
  17. Lisciandro GR, Fosgate GT. Use of AFAST Cysto-Colic View urinary bladder measurements to estimate urinary bladder volume in dogs and cats. J Vet Emerg Crit Care 2017;27(6):713-717.
  18. Kulhavy DA, Lisciandro GR. Use of a lung ultrasound examination called Vet BLUE to screen for metastatic lung nodules in the emergency room. Abstract, J Vet Emerg Crit Care 2015;25(S1);S14.
  19. Ostroski CJ, Drobatz KJ, Reineke EL. Retrospective evaluation of and risk factor analysis for presumed fluid overload in cats with urethral obstruction: 11 cases (2002-2012). J Vet Emerg Crit Care 2017;27(5):561-568.
  20. Ward JL, Lisciandro GR, Keene BW, et al. Accuracy of point-of-care lung ultrasound (Vet BLUE protocol) for the diagnosis of cardiogenic pulmonary edema in dogs and cats with acute dyspnea. J Am Vet Assoc 2017;250(6):666-675.
  21. Lisciandro GR, Ward JL, DeFrancesco TC, et al. Absence of B-lines on lung ultrasound (Vet BLUE protocol) to rule out left-sided congestive heart failure in 368 cats and dogs. Abstract, J Vet Emerg Crit Care 2016;26(S1):S8.
  22. Lisciandro GR, Fulton RM, Fosgate GT, et al. Frequency and number of B-lines using a regionally-based lung ultrasound examination in cats with radiographically normal lung compared to cats with left-sided congestive heart failure. J Vet Emerg Crit Care 2017;27(3):267-277.
  23. Lisciandro GR, Lagutchik MS, Mann KA, et al. Accuracy of Focused Assessment with Sonography for Trauma (TFAST) to detect pneumothorax in 145 dogs with blunt and penetrating trauma. J Vet Emerg Crit Care 2008;18(3):258-269.
  24. Lisciandro GR. Evaluation of initial and serial combination focused assessment with sonography for trauma (CFAST) examinations of the thorax (TFAST) and abdomen (AFAST) with the application of an abdominal fluid scoring system in 49 traumatized cats. Abstract, J Vet Emerg Crit Care 2012;22(S2):S11.
  25. Lisciandro GR. The use of the diaphragmatico-hepatic (DH) views of the abdominal and thoracic focused assessment with sonography for triage (AFAST/TFAST) examinations for the detection of pericardial effusion in 24 dogs (2011-2012). J Vet Emerg Crit Care 2016;26(1):125-131.
  26. McMurray J, Boysen S, Chalhoub S. Focused assessment with sonography in nontraumatized dogs and cats in the emergency and critical care setting. J Vet Emerg Crit Care 2016;26(1):64-73.
  27. Lisciandro GR. The Thoracic FAST3 (TFAST3) Exam. In: Lisciandro GR (ed), Focused Ultrasound Techniques for the Small Animal Practitioner. Ames: Wiley-Blackwell; 2014;140-165.
  28. Lisciandro GR. The Vet BLUE Lung Scan. In: Lisciandro GR, (ed). Focused Ultrasound Techniques for the Small Animal Practitioner. Ames: Wiley Blackwell; 2014;166-187.
Gregory Lisciandro

Gregory Lisciandro

Dr. Lisciandro qualified from Cornell University, completed a rotating internship in small animal medicine and surgery at The Animal Medical Center, New York Read more

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