Analgesia Por Acupuntura
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“TÉCNICAS DE ANALGESIA Y ANESTESIA EN ATENCIÓN PRIMARIA”
ANALGESIA Y ACUPUNTURA Autores: Dr., Javier Álvarez Martínez, Dr. Antonio R. Romero Márquez
INTRODUCCION. NEUROFISIOLOGIA BASICA. CONCLUSIONES. ELECTROACUPUNTURA EN EL DOLOR.
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INTRODUCCIÓN. El abordaje, desde el punto de vista complementario, del dolor es uno de los temas más analizados por todas las medicinas no convencionales especialmente por la acupuntura. La demanda existente entre los pacientes de técnicas útiles que alivien síntomas no muy bien tratados o minimizados por la medicina convencional, es cada día más importante, las causas de la demanda son múltiples y radican en muy diferentes niveles, desde el propio individuo “doliente” hasta la sociedad en la que éste se desenvuelve. Esta sensación de “disconfort”, a la que denominamos dolor, asociada en muchas ocasiones a daño tisular, es uno de los síntomas más comunes asociado a la enfermedad y constituye un problema físico, psicológico y social que afecta de una forma peculiar y única, diferente para cada individuo, al normal desenvolvimiento de las actividades vitales básicas. El dolor pone en marcha repuestas nerviosas completas y complejas que activan reacciones reacciones de huida, huida, evitación, retirada y por supuesto, búsqueda de ayuda para evitarlo. La integración de la acupuntura en la medicina occidental, no obstante ser ésta una medicina profundamente científica practicada en una sociedad altamente desarrollada, desarrollada, no ha conducido conducido a la pérdida de sus características características diferenciales básicas relacionadas con sus peculiaridades a la hora de entender la fisiología y la patología humana. A pesar de que la Acupuntura sigue conservando estas peculiaridades (relacionando la salud y por tanto también la ausencia de dolor con el armonioso fluir del Qi) no no ha dejado de ser ser escudriñada por algunos fisiólogos y neurólogos occidentales en busca de posibles explicaciones a sus innegables y en muchas ocasiones potentes efectos analgésicos. Esta búsqueda sistemática ha llevado a algún autor como Bruce Pomeranz a afirmar que conocemos más acerca de los mecanismos de acción de la analgesia por acupuntura que sobre muchos fármacos de uso corriente. Desde la perspectiva neuroquímica, la puntura y estimulación de las agujas de acupuntura pone en marcha una cadena secuencial de acontecimientos: 1.
2.
3. 4.
Desencadenamiento de una reacción local a nivel cutáneo con aparición de micro corrientes eléctricas inducidas por la manipulación de una aguja metálica en un lecho acuoso y con iones. Interacción entre la aguja y el tejido conectivo periférico que conduce a la liberación local de factores de crecimiento, citoquinas, enzimas, etc., responsables de la activación de las vías de transmisión intercelulares. Aparición de reflejos autonómicos que mejoran la circulación sanguínea y producen una relajación muscular local. Aparición de mecanismos nerviosos tanto a nivel segmentario como no segmentario, de actividad neuroendocrina mediada por
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coagulante activa la llegada de células inmunitarias al lugar de la punción) Respuestas inmunes locales mediadas por la activación de los mastocitos y la liberación de histamina y leucotrienos.
6.
En cuanto a los mecanismos neuroquímicos que parecen estar implicados parecen no llegar nunca a su fin, de una forma comprensible y rápida podemos citar que la acupuntura pone en juego numerosas substancias: las tres endorfinas (dinorfina, encefalina y beta- endorfina), la colecistoquinina (C.C.K), el péptido intestinal vasocativo (V.I.P), la hormona adrenocorticotropa (A.C.T.H), la serotonina (5 HT), el gen liberador de calcitonina (C.G.R.P) …La interacción de estas substancias es relacionada ya no sólo con la analgesia acupuntural sino también con la mejoría de la homeostasia del individuo regulando el sistema endocrino, cardiovascular, inmunológico e incluso los componentes psico- emocionales del individuo. La acupuntura viene siendo usada desde hace más de dos mil años en China y Japón. Fue introducida en Europa por W. Rhijne en el siglo XVII tras su aprendizaje en Japón, y de forma progresiva y bastante lenta fue introduciéndose en Europa. Las primeras publicaciones sobre acupuntura europeas aparecen en el primer tercio del siglo XIX, Berlioz (1816) y Cloquet (1826) y comenzó a usarse de forma tímida especialmente en Francia donde alcanzó su máximo desarrollo en los años cincuenta del siglo XX. En 1972 la visita del presidente Richard Nixon a China y la llegada de grabaciones mostrando intervenciones quirúrgicas realizadas con hipoalgesia acupuntural le dio un respaldo importante a la técnica que comenzó a ser investigada y practicada de forma extensa. En 1980, la aparición de “Celestial lancets” el extraordinario texto de Lu y Needhan acaba de introducir de forma definitiva a la acupuntura dentro del marco académico occidental. En el momento actual el principal uso que la medicina occidental hace de la acupuntura está relacionado con el alivio del dolor en sus diversas modalidades. ALGUNOS ASPECTOS NEURO-FISIOLÓGICOS NEURO-FISIOLÓGICOS DEL DOLOR BÁSICOS EN ACUPUNTURA Podemos definir el dolor siguiendo a la Sociedad Internacional para el estudio del del dolor como “Experiencia “Experiencia desagradable, desagradable, sensorial y emocional, emocional, asociada a una lesión real o potencial que se describe como daño”. Esta experiencia presenta, al menos dos aspectos diferentes a tener en cuenta: Aspecto cognitivo. Relacionado con la localización, la duración y la intensidad del dolor Aspecto afectivo. Relacionado con la sensación subjetiva desagradable que acompaña al dolor y con el desencadenamiento de reacciones de huida, evitación, retirada y por supuesto búsqueda de ayuda para evitarlo. •
•
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•
Crónico. No siempre expresa una finalidad protectora. En muchas ocasiones, incluso sin la existencia de una lesión objetiva, el dolor se constituye como un importante factor de comunicación lleno de componentes emocionales y psicofisiológicos.
En su más amplio sentido, el término “dolor” se usa para expresar cualquier tipo de mal, independientemente de su significado médico …”es una decisión dolorosa”, “me duele mucho tu opinión”. Estas frases y muchas otras parecidas son utilizadas de forma continuada en todos los idiomas y completan el sentido emocional del dolor. El dolor pues, un fenómeno subjetivo básico en la conducta del hombre, existe una relación íntima entre el dolor y todas las emociones (explicable, en parte, por las conexiones anatómicas entre el córtex cerebral y el sistema límbico) permitiendo que la sensación de dolor pueda ser almacenada en la memoria y evocada como en relación con distintas emociones. Desde el punto de vista de sus causas primeras, el dolor se clasifica en: Nociceptivo. Por ejemplo el postquirúrgico o el asociado a la osteoporosis. Neuropático. La neuralgia postherpética. Psicógeno. Conversión histérica, somatizaciones. Mediado por la parte simpática del sistema nervioso. Por ejemplo la causalgia. •
• • •
Aunque lo frecuente es que cuando existe dolor crónico o prolongado en el tiempo, aparezca una superposición de varios de estos desencadenantes.
NEUROFISIOLOGÍA BÁSICA Un estudio en profundidad escapa del objetivo de este texto, simplemente se incidirá en aquellos aspectos relacionados con la recepción, la transducción, la conducción, la integración y la percepción de los estímulos dolorosos (con sus mecanismos de bloqueo, inhibición o activación) que parecen tener relación con los efectos analgésicos de la acupuntura. Clásicamente en la transmisión de dolor se diferencian cinco niveles diferentes. 1.- Nivel Periférico. Es el encargado de recibir, transducir y transportar la señal dolorosa desde la periferia hasta la médula espinal.
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En la epidermis existen receptores nerviosos, (fundamentalmente nociceptores polimodales y mecanorreceptores de umbral alto) que a través de un mecanismo de transducción son capaces de transformar el estímulo en un impulso nervioso capaz de atravesar las sinapsis sensitivo dendríticas por medio de un mecanismo eléctrico o neurohumoral.
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A partir de esta sinopsis dos tipos de fibras transportan, a diferente velocidad, los impulsos hasta llegar a las astas posteriores de la médula espinal donde se produce la conexión con la segunda neurona Las fibras son: •
•
Tipo “C”, diámetro, 2m/s) Tipo “Aδ” velocidad 30m/s)
son amielínicas, amielínicas, pequeñas, pequeñas, menores menores de 1 µ de con velocidad de conducción muy lenta. (0.5mielinizadas, de calibre variable (1 a 5 µ) cuya de conducción es proporcional al calibre.(12 a
A través de la anestesia local podemos demostrar que las fibras de tipo C, cuando son estimuladas responden con un dolor intenso, prolongado, de gran imprecisión topográfica, el paciente localiza el lugar del dolor con la mano abierta y haciendo movimientos circulares señalando una zona corporal extensa, que se acompaña de sensación de calor o prurito. Por el contrario las fibras de tipo A δ transmiten el dolor con sensación de punzada de forma, presión o frío permitiendo permitiendo que éste pueda pueda ser localizado localizado con gran precisión,
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2.- Nivel Segmentario. Cada nervio espinal ofrece inervación sensitiva a un territorio o zona segmentaria de piel, denominada dermatoma. Un dermatoma es el área de la piel inervada por una raíz o nervio dorsal de la médula espinal. Los nervios cutáneos son los que llegan a la piel, recogiendo la sensibilidad de ésta. Cada nervio cutáneo se distribuye en un dermatoma. De cada segmento medular surgen un par de raíces posteriores o sensitivas y un par de raíces anteriores o motoras, que se unen lateralmente a nivel del foramen intervertebral para formar un nervio espinal mixto. Cada uno de éstos inerva un dermatoma, por lo que la superficie corporal puede considerarse un
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Este mosaico aparece reflejado por una serie de zonas corporales diferenciadas unas de otras. En las figuras que se pueden consultar, estas zonas aparecen perfectamente definidas, si bien esto no es necesariamente cierto, ya que las ramas distales de los nervios invaden los territorios contiguos, lo cual se demuestra en que la pérdida de un nervio espinal no siempre significa la pérdida total de la sensibilidad cutánea. Cada unidad espinal tiene una topografía única la cual se mantiene a través de todo el sistema sensorial, desde la periferia hasta el córtex sensorial. las estructuras faciales y de la parte anterior del cráneo están inervadas por el nervio trigémino, la parte posterior de la cabeza por el segundo par cervical (C2); el cuello por el tercer par cervical (C3); los hombros por el cuarto par cervical (C4); el área del deltoides por el quinto par cervical (C5); la cara radial del antebrazo y el pulgar por el sexto par cervical (C6); el índice y los dedos
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y D4 son vías de conducción de impulsos nociceptivos provenientes del corazón y del pulmón; las dorsales D6, D7 Y D8 refieren a los órganos localizados en la parte superior del abdomen, mientras que las últimas dorsales y las lumbares superiores corresponden a las vísceras del abdomen inferior. Esto se pone de manifiesto en la localización del dolor referido, esto es, cuando el dolor visceral se refleja a la superficie del cuerpo, y en general la persona afectada se señala el dermatoma a partir del cual se originó embriológicamente el órgano visceral.
El dolor visceral, con frecuencia se localiza en dos áreas de superficie corporal al mismo tiempo, a causa de la doble transmisión del dolor a través de la vía visceral referida y de la vía parietal directa. Estímulos originados en el peritoneo parietal (generalmente por inflamación visceral) visceral) y son generalmente
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El modelo citoarquitectónico propuesto por Rexed en 1952 ha sido aceptado por la mayoría de los neurofisiólogos modernos. Rexed dividió la sustancia gris medular en diez capas o láminas enumerándolas del I al X en números romanos. Las láminas I a VI están en el asta posterior, las láminas del VII al IX se encuentran en la región intermedia y el asta anterior de la médula, la lámina X y última se encuentra rodeando el canal central medular. Hay por parte de algunos autores una clara tendencia a intentar deducir que tales láminas tienen funciones fisiológicas únicas únicas y exclusivas, pero un un análisis cuidadoso revela un patrón funcional de tendencias generales en vez de un patrón de exclusividad. Las fibras aferentes (nociceptivas) procedentes del territorio cutáneo terminan en las láminas I,II (sustancia gelatinosa gelatinosa de Rolando) Rolando) y V. Las fibras aferentes finas procedentes de las visceras, los músculos y otros tejidos profundos tienden a eludir la lámina II y a terminar en las láminas I, V y X.
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12
Cuando un estímulo nociceptivo es de breve duración, algunos segundos, se produce la normal transmisión nerviosa fisiológica del mensaje. Cuando el estímulo dura minutos u horas hay variaciones de sensibilidad neuronal, sobretodo a causa de los mecanismos inflamatorios (participación de los receptores silentes) y por tanto, una ampliación del campo de acción del receptor. Cuando el estímulo dura días o meses, las lesiones nerviosas que se producen originan variaciones de la sensibilidad y de la organización somatotopográfica. En resumen, cuanto más se prolonga el estímulo nociceptivo, más cambios se producen en las vías de conducción nociceptiva, a esto se le denomina plasticidad neuronal. La transmisión de la información nociceptiva desde la médula espinal a los centros supremedulares, se encuentran bajo mecanismos de control, algunos de los cuales se encuentran localizados en la misma médula, siendo por tanto, controles segmentarios, entre ellos se encuentran los mecanismos de control presinápticos mediante los cuales, los impulsos conducidos por las fibras aferentes primarias activan interneuronas de la sustancia gris. El sistema de inhibición presináptico afecta a todas las fibras aferentes y actúa como mecanismo de autocontrol de los impulsos afrentes de fibras sensoriales complementarias.
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espino reticular, la formación reticular (FR), el Tálamo (núcleo intralaminar medial) y finalmente el cerebro.
Las fibras de gran calibre (A δ) que parten de los mecanorreceptores de
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El sistema nervioso autónomo o vegetativo es la parte del sistema nervioso central y periférico que se encarga de la regulación de las funciones involuntarias del organismo, mantiene la homeostasis interna y la respuesta a las variaciones del medio, tanto internas como externas.
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En el sistema nervioso parasimpático la fibra nerviosa preganglionar es larga con sinapsis en un ganglio distal o directamente en el órgano efector, siendo la fibra postganglionar corta.
Los nervios simpáticos tienen su origen en la médula espinal, entre los segmentos T1 y L2, de aquí y a través de los agujeros de conjunción se dirigen
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asegurar el impulso nervioso. Las neuronas postganglionares de la médula suprarrenal secretan sobretodo adrenalina y muy poca cantidad de noradrenalina.
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informaciones generadas generadas por los agentes agentes nocivos que llegan a la médula médula a través de los nociptores polimodales C. este es el mecanismo conocido como DNIC (controles inhibitorios difusos por agentes nocivos), un potente mecanismo de tipo opioide que aparece cuando la piel es punturada, tanto en puntos de acupuntura como fuera de los puntos descritos por la tradición médica china. El haz espinorreticular hace conexiones multisinápticas con la sustancia gris periacueductal antes de llegar a la formación reticular para posteriormente ascender hasta el tálamo
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5.- Nivel Superior. Córtex cerebral. A este nivel tomamos conciencia del dolor con sus “tonalidades afectivas”. El córtex tiene una acción bien conocida sobre la Formación Reticular y un control sobre el Núcleo Arqueado hipotalámico que a su vez se relaciona con la vía inhibitoria descendente a través de la substancia gris periacueductal Las estructuras del Córtex Cerebral que participan en los fenómenos dolorosos tienen como características principales: Existe una proyección cortical de los territorios cutáneos y viscerales, pudiendo existir fenómenos de convergencia e inhibición recíproca entre las fibras cutáneas y viscerales. Los potenciales evocados son modulados por sistemas inespecíficos talámicos, aunque existan también proyecciones reticulares extra-talámicas. El Córtex puede inhibir o activar diferentes núcleos talámicos y de la formación reticular mesencefálica. mesencefálica. El componente afectivo del dolor depende de una red muy elaborada de conexiones entre la Formación Reticular, el •
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Esta hipótesis explicaría bien el fenómeno de “rebote” (recrudecimiento inmediato del dolor) que se produce en la electroacupuntura. 6.2.- Estudios de Shui- Yin Lo publicados en 2006 parecen demostrar que la estimulación de puntos de acupuntura relacionados con los canales clásicos que pasan por la zona dolorosa (pero fuera de ella) producen una disminución de la temperatura local de la zona, objetivable de forma termografía. Además esta disminución se produce de forma exponencial y es proporcional a la cantidad de reacciones bioquímicas presentes en la zona. El autor, en sus conclusiones, afirma que no todo el efecto analgésico es explicable a través de mecanismos neurológicos, sino que parte de ese efecto está relacionado con mecanismos de tipo cuántico. La explicación posee una buena base física, pero en número de casos de la muestra, quince, hace necesarias posteriores confirmaciones.
CONCLUSIÓN. Aunque los l os mecanismos de actuación de la acupuntura sobre el dolor no están absolutamente desentrañados sí parecen bien constatadas dos acciones
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2.- Nivel suprasegmentario. En este nivel la acción es doble: 2. A. Mecanismos de de tipo neuro- hormonal. Vía tálamo-hipotálamo, con liberación de β- endorfina y probablemente también de metencefalina y ACTH. ACTH. Existe un sistema de activación del sistema cerebral a las tensiones o estrés que crea un complejo de respuestas neuronales, hormonales e inmunológicas. Los centros hipotalámicos segregan hormona liberadora de corticotropina, CRF (corticotropin-releasing factor). Esta hormona o factor estimula a su vez la glándula pineal y le excita a que produzca hormona adenocorticotropina (ACTH), que llega, vía sanguínea hasta la corteza suprarrenal y hace que se libere cortisol. Este proceso se interrumpe cuando el exceso exceso de cortisol alcanza alcanza a sus receptores receptores cerebrales (receptores de glucocorticoides), frenando la producción de CRF. Las neuronas productoras de CRF situadas en el hipotálamo están reguladas principalmente por neuronas noradrenérgicas, originadas en el cerebro posterior. Estas neuronas de CRF y de noradrenalina sirven de estaciones centrales al estrés. Un grupo neuronal estimula al otro. El sistema cerebral del estrés marca el nivel de alerta y el tono emocional, dificulta la
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2 B.1. Efecto serotoninérgico. La serotonina o 5-hidroxitriptamina (5-HT), es una sustancia sintetizada en las neuronas serotoninérgicas del sistema nervioso central y en las células enterocromafines . Las neuronas productoras de serotonina se proyectan desde los núcleos de rafe, en el troncoencéfalo, hacia neuronas de diversas regiones del sistema nervioso central (la amígdala, el hipotálamo, áreas corticales cognitivas, etc), incluidas las que segregan noradrenalina y las que regulan su liberación. Se cree que un fallo en las vías dependientes de la serotonina podría amortiguar la señal de la noradrenalina. Estas vías serotoninérgicas que proceden de los núcleos del rafe en la protuberancia y se proyectan hacia la médula espinal regulan varias funciones vegetativas como las gastrointestinales) o se proyectan hacia la corteza cerebral y estructuras subcorticales regulando funciones cognoscitivas y afectivas. Existen pruebas evidentes, de la relación entre depresión y niveles bajos de serotonina.
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aminoácidos neutros tirosina, fenilalanina, leucina, isoleucina y valina compiten con el triptófano en el transporte a través de la Barrera hemato-encefálica. En pacientes con depresión endógena se constata disminución del triptófano libre plasmático, con triptófano total normal. Varios hechos avalan también la participación de mecanismos serotoninérgicos en los desórdenes por ansiedad, particularmente las denominadas crisis de ansiedad generalizada. Esta participación sería complementaria de la función noradrenérgica. Por un lado las neuronas noradrenérgicas del Locus Coeruleus recibirían un estímulo inhibitorio de fibras originadas en los núcleos serotoninérgicos del rafe, estímulo que tendría la función función de modular las respuestas de alarma alarma mediadas
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las emitidas por la serotonina, que viene a intensificar la reactividad plaquetaria ante otros estímulos químicos. No obstante una inhibición de las vías serotoninérgicas puede tener un efecto amortiguador en las señales noradrenérgicas, y que por tanto la inhibición de serotonina puede traer como consecuencia una disminución de la noradrenalina disponible, con los que al déficit de uno hay que añadirle el déficit del otro. Es, por tanto, un sistema controlado desde el córtex prefrontal, desciende, se
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riesgo de quemadura tanto de tipo ácido (por formación de ácido hidroclorhídrico), reacción que se produce en las proximidades del ánodo como alcalina, dado que en las proximidades del cátodo se produce la formación de ClNa. La ionización que se produce entre la aguja y los tejidos no sólo puede producir quemadura sino también, en casos extremos, rotura de la aguja con las consiguientes complicaciones. En tercer lugar el que el pulso negativo sea exponencial disminuye la posibilidad de generar tetania muscular.
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sensaciones experimentadas. Según las conclusiones estas sensaciones van a
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se origina el dolor produce la activación del “Control gate” de Melzack y Wall,
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intensidades variables. Con lo que el rango de estímulos asegura una
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riesgo de rotura de las mismas no es desdeñable, no olvidemos que,
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El aparato debe emitir una onda bipolar, que no se “agote” a lo
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Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Trusted by over 1 million members
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Trusted by over 1 million members
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Trusted by over 1 million members
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Trusted by over 1 million members
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Trusted by over 1 million members
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Trusted by over 1 million members
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Trusted by over 1 million members
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
Trusted by over 1 million members
Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.
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