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megajunk

Please help me decipher this DBQ for Back (Thoracolumbar Spine) Conditions

Question

I recently (October 2018) made my first claim and was examined and rated @ 10% for Tinnitus.  Immediately afterwards, I received a letter from the VA stating that they had made an appointment for me for back pain that was from a claim in March of 2000.  (I left the USAF in January, 2000).  This is the result of that C&P exam.

I was also sent a letter about foot pain that I had claimed in 2000.  I ended up filling out more paperwork to explain condition, and sending in medical records from private doctors.  I believe that they combined the foot pain, and the back pain into one claim.

I cannot see anything on eBenefits regarding the status these claims since they are so old (that's what they told me). 

I am also soliciting opinions as to what the effective date for these claims would be.  

Please let me know what you think regarding this DBQ from a C&P exam:

Thank you VERY much!   

Thanks!

 

mhv_Xxxxxxxx_.pdf

Edited by megajunk
Reduce size of 1st post. Added file of back C&P exam results

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22 hours ago, megajunk said:

I recently (October 2018) made my first claim and was examined and rated @ 10% for Tinnitus.  Immediately afterwards, I received a letter from the VA stating that they had made an appointment for me for back pain that was from a claim in March of 2000.  (I left the USAF in January, 2000).  This is the result of that C&P exam.

I was also sent a letter about foot pain that I had claimed in 2000.  I ended up filling out more paperwork to explain condition, and sending in medical records from private doctors.  I believe that they combined the foot pain, and the back pain into one claim.

I cannot see anything on eBenefits regarding the status these claims since they are so old (that's what they told me). 

I am also soliciting opinions as to what the effective date for these claims would be.  

Please let me know what you think regarding this DBQ from a C&P exam:

Thank you VERY much!

    *************************************************************************
 LOCAL TITLE: COMPENSATION & PENSION EXAM                        
STANDARD TITLE: C & P EXAMINATION NOTE                          
DATE OF NOTE: DEC 21, 2018@09:30     ENTRY DATE: DEC 21, 2018@16:02:11                      
     URGENCY:                            STATUS: COMPLETED                     


                      Back (Thoracolumbar Spine) Conditions
                        Disability Benefits Questionnaire

    Name of patient/Veteran:   Xxxxxxxx XXXX
    
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes   [ ] No
    

    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS


    1. Diagnosis
    ------------
    Does the Veteran now have or has he/she ever been diagnosed with a
    thoracolumbar spine (back) condition?
    [X] Yes   [ ] No

    Thoracolumbar Common Diagnoses:
        No response provided.

          Diagnosis #1:  THORACOLUMBAR STRAIN.
          ICD code:  48532005
          Date of diagnosis:  Uncertain
          
    2. Medical history
    ------------------
    a. Describe the history (including onset and course) of the Veteran's
    thoracolumbar spine (back) condition (brief summary):
       -- relates -- "I had to change really heavy parts in the bottom load of
       the air craft while I was in the military. They had these monorails but
       they didn't always work so we had to pick them up a lot of times. I can
       remember having back pain and having physical therapy in the Air Force 
and
       having to go to traction but that's all I can remember about what they
       did.  Since then I have always had back pain, upper and lower back. I 
have
       pain all the time, especially if I try to stand up for ten or more
       minutes. I can try to lean against something and put pressure and that
       seems to help. At night when I am sleeping it will wake me up with pain
       and I have to roll out of bed and walk around for a minute. I have just
       been living with the pain."

       
       
    b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?
    [X] Yes   [ ] No
        If yes, document the Veteran's description of the flare-ups in his or 
her
        own words:
           see History
           

    c. Does the Veteran report having any functional loss or functional
    impairment of the thoracolumbar spine (back) (regardless of repetitive use)?
    [X] Yes   [ ] No
        If yes, document the Veteran's description of functional loss or
        functional impairment in his or her own words.
           see History
           

    3. Range of motion (ROM) and functional limitation
    --------------------------------------------------
    a. Initial range of motion
    
       [ ] All normal
       [X] Abnormal or outside of normal range
       [ ] Unable to test (please explain)
       [ ] Not indicated (please explain)
       
           Forward Flexion (0 to 90):           0 to 60 degrees
           Extension (0 to 30):                 0 to 30 degrees
           Right Lateral Flexion (0 to 30):     0 to 30 degrees
           Left Lateral Flexion (0 to 30):      0 to 30 degrees
           Right Lateral Rotation (0 to 30):    0 to 30 degrees
           Left Lateral Rotation (0 to 30):     0 to 30 degrees

           If abnormal, does the range of motion itself contribute to a
           functional loss? [ ] Yes (please explain)   [X] No

       Description of pain (select best response):
         Pain noted on exam but does not result in/cause functional loss
         
         If noted on exam, which ROM exhibited pain (select all that apply)?
           Forward Flexion
           
       Is there evidence of pain with weight bearing? [X] Yes   [ ] No
       
       Is there objective evidence of localized tenderness or pain on palpation
       of the joints or associated soft tissue of the thoracolumbar spine 
(back)?
       [ ] Yes   [X] No
       
    b. Observed repetitive use
    
       Is the Veteran able to perform repetitive use testing with at least three
       repetitions? [X] Yes   [ ] No
          Is there additional loss of function or range of motion after three
          repetitions? [ ] Yes   [X] No

    c. Repeated use over time
    
       Is the Veteran being examined immediately after repetitive use over time?
       [ ] Yes   [X] No
       
           If the examination is not being conducted immediately after 
repetitive
           use over time:
           [ ] The examination is medically consistent with the Veteran's
               statements describing functional loss with repetitive use over
               time.
           [ ] The examination is medically inconsistent with the Veteran's
               statements describing functional loss with repetitive use over
               time.  Please explain.
           [X] The examination is neither medically consistent or inconsistent
               with the Veteran's statements describing functional loss with
               repetitive use over time.
               
       Does pain, weakness, fatigability or incoordination significantly limit
       functional ability with repeated use over a period of time?
       [ ] Yes   [ ] No   [X] Unable to say w/o mere speculation
           If unable to say w/o mere speculation, please explain:

           Exam was not conducted under stated condition
           
           

    d. Flare-ups
    
       Is the exam being conducted during a flare-up? [X] Yes   [ ] No
       
       Does pain, weakness, fatigability or incoordination significantly limit
       functional ability with flare-ups?
       [X] Yes   [ ] No   [ ] Unable to say w/o mere speculation
           Select all factors that cause this functional loss:
             Pain
             
           Able to describe in terms of range of motion: [ ] Yes   [X] No
              If no, please describe:
              No change in ROM
              
              

    e. Guarding and muscle spasm
    
       Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
       (back)? [ ] Yes   [X] No
       

    f. Additional factors contributing to disability
    
       In addition to those addressed above, are there additional contributing
       factors of disability?  Please select all that apply and describe:
         Interference with sitting, Interference with standing
         
    4. Muscle strength testing
    --------------------------
    a. Rate strength according to the following scale:
    
       0/5 No muscle movement
       1/5 Palpable or visible muscle contraction, but no joint movement
       2/5 Active movement with gravity eliminated
       3/5 Active movement against gravity
       4/5 Active movement against some resistance
       5/5 Normal strength
       
       Hip flexion:
         Right: [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         Left:  [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         
       Knee extension:
         Right: [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         Left:  [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         
       Ankle plantar flexion:
         Right: [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         Left:  [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         
       Ankle dorsiflexion:
         Right: [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 
0/5
         Left:  [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         
       Great toe extension:
         Right: [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         Left:  [X] 5/5   [ ] 4/5   [ ] 3/5   [ ] 2/5   [ ] 1/5   [ ] 0/5
         
    b. Does the Veteran have muscle atrophy?
       [ ] Yes   [X] No
       
    5. Reflex exam
    --------------
    Rate deep tendon reflexes (DTRs) according to the following scale:
    
       0  Absent
       1+ Hypoactive
       2+ Normal
       3+ Hyperactive without clonus
       4+ Hyperactive with clonus

       Knee:
         Right: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
         
       Ankle:
         Right: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
         
    6. Sensory exam
    ---------------
    Provide results for sensation to light touch (dermatome) testing:
    
       Upper anterior thigh (L2):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
         
       Thigh/knee (L3/4):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
         
       Lower leg/ankle (L4/L5/S1):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
         
       Foot/toes (L5):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
         
    7. Straight leg raising test
    ----------------------------
    Provide straight leg raising test results:
       Right: [X] Negative   [ ] Positive   [ ] Unable to perform
       Left:  [X] Negative   [ ] Positive   [ ] Unable to perform

    8. Radiculopathy
    ----------------
    Does the Veteran have radicular pain or any other signs or symptoms due to
    radiculopathy?
    [ ] Yes   [X] No
    
    9. Ankylosis
    ------------
    Is there ankylosis of the spine? [ ] Yes   [X] No

    10. Other neurologic abnormalities
    ----------------------------------
    Does the Veteran have any other neurologic abnormalities or findings related
    to a thoracolumbar spine (back) condition (such as bowel or bladder
    problems/pathologic reflexes)?
    [ ] Yes   [X] No

    11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
    -----------------------------------------------------------------------
    a. Does the Veteran have IVDS of the thoracolumbar spine?
       [ ] Yes   [X] No
       

    12. Assistive devices
    ---------------------
    a. Does the Veteran use any assistive device(s) as a normal mode of
       locomotion, although occasional locomotion by other methods may be
       possible?
       [ ] Yes   [X] No
       

    b. If the Veteran uses any assistive devices, specify the condition and
       identify the assistive device used for each condition:
       No response provided.
       
    13. Remaining effective function of the extremities
    ---------------------------------------------------
    Due to a thoracolumbar spine (back) condition, is there functional 
impairment
    of an extremity such that no effective function remains other than that 
which
    would be equally well served by an amputation with prosthesis? (Functions of
    the upper extremity include grasping, manipulation, etc.; functions of the
    lower extremity include balance and propulsion, etc.)
    
       [X] No

    14. Other pertinent physical findings, complications, conditions, signs,
        symptoms and scars
    ------------------------------------------------------------------------
    a. Does the Veteran have any other pertinent physical findings,
       complications, conditions, signs or symptoms related to any conditions
       listed in the Diagnosis Section above?
       [ ] Yes   [X] No
       
    b. Does the Veteran have any scars (surgical or otherwise) related to any
       conditions or to the treatment of any conditions listed in the Diagnosis
       Section above?
       [ ] Yes   [X] No
       
    c. Comments, if any:
       No response provided
       
    15. Diagnostic testing
    ----------------------
    a. Have imaging studies of the thoracolumbar spine been performed and are 
the
       results available?
       [ ] Yes   [X] No
       
    b. Does the Veteran have a thoracic vertebral fracture with loss of 50
       percent or more of height?
       [ ] Yes   [X] No
       
    c. Are there any other significant diagnostic test findings and/or results?
       [ ] Yes   [X] No
       
    16. Functional impact
    ---------------------
    Does the Veteran's thoracolumbar spine (back) condition impact on his or her
    ability to work?
       [X] Yes   [ ] No
       
           If yes describe the impact of each of the Veteran's thoracolumbar
           spine (back) conditions providing one or more examples:
              unable to do strenuous activities
              
              
    17. Remarks, if any:
    --------------------
     -- "Correia" 
       
     -- Is there evidence of pain on passive ROM testing? No 
     -- Is there evidence of pain when the joint is used in 
        non-weight bearing? No 
     -- If yes, is the opposing joint undamaged?
    
    


****************************************************************************


                                 Medical Opinion
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  Xxxxxxxx XXXX
    
    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS


    MEDICAL OPINION SUMMARY
    -----------------------
    RESTATEMENT OF REQUESTED OPINION: 

    a. Opinion from general remarks: 
    -- Does the Veteran have a diagnosis of (a) back pain 1995 that is at least
    as 
    likely as not (50 percent or greater probability) incurred in or caused by 
    (the) motor vehicle accident and complaints of back pain during service?

    b. Indicate type of exam for which opinion has been requested: Back

    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
    CONNECTION ] 

    a. The condition claimed was at least as likely as not (50% or greater
    probability) incurred in or caused by the claimed in-service injury, event 
or
    illness.   

    c. Rationale: 
    -- C-file review:
    -- no date on note; c/o right upper back pain x 10 days; dx MS strain, right
    upper back/shoulder; tx provided
    -- 04/10/1996 c/o severe back pain x two weeks; dx recurrent musculoskeletal
    pain
    -- 05/03/1995 s/p MVA; activated airbag; dx negative exam, no injuries 
noted,
    minor MS aches
    -- 05/01/1995 c/o right upper back pain x 10 days; dx MS strain right upper
    back/shoulder' tx provided

    -- condition was first noted in the military as documented;
    noted condition is still present during C&P Exam

    *************************************************************************

Thanks!

 

It appears you received a favorable nexus and a rational was provided.

Now to see how you will be rated.

 

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I agree with doc25, this exam is mostly favorable with a nexus.  

However, your question on effective dates is more complex.  

The effective date of your disability is not included in this exam, but may be referenced in your other medical records which we did not read.  You see, your effective date is the later of "facts found" or date you applied.  

I have no idea what condition you were in during the 2000 to 2018 period.  Did you have medical flare ups, documented??  Were you in treatment for the condition?  What did it say on your exit exam??  Did you appeal the denial?  What were the reasons and bases for denial. 

    Since I dont know the answers to the questions I asked, I cant speculate on the effective date.  The date you applied may well be year 2000, per your post, but you still have to show you met the critieria for disability during the period 2000 to 2018, and I dont know what your symptoms were for that period.  

     However, if your back problem was the same in year 2000 as it was in 2018, and you were under treatment for it during that period, you should be able to argue for an eed.  But, if you applied in 2000, had no issues until 2018, it may be very difficult for you to get back pay for that period.  Remember, you are compensated for symptoms, not diagnosis, even tho you must have a diagnosis.  

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On these effective dates...question  

Does the VA go by there effective dates? they put up?

like when a veteran first files for his disability  lets say 1998, he gets denied and Appeals that decision and a year later 1999 is awarded Service connection at 0%.  then he  files for increase in 2000 and is given a 50% increase this is 2000 .

  and reopens his claim in 2002 files for increase and is awarded  a 10% increase and a 30% increase (40%increase) 

so now the veteran is at 90% combined rating...ok he is given TDIU P&T because he can't work due to his S.C. Disability's....would they go back to 1998 for his total effective date?

In other words after a Veteran first files for his disability ....does that start his  over all effective date? for increase along the way? or do they use the dates the veteran filed for the increases?  and not when he first filed?

or since the veteran reopen his claim  then that cancels out the 1998 effective date?

if the latter is true  then his effective date for the 50% would be 2000 and his 20 year protection would start this year  correct? (2019) and his TDIU P&T  20 year protection date would be 2022  correct?

Edited by Buck52

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As far as other documents related to the back pain claim, I have nothing.  I did not even remember making this "claim", exactly.  As I was out processing from the AF, I am sure someone at the hospital asked me about medical problems, and I told them I had back and foot pain.  I do not know if there was a claim filed at that time, or not.  I never thought about it again, until I got a letter asking about it, which only happened because I wanted to see about getting hearing aids, and that led to all of this.  So, I guess there must have been a claim filed, but I did not even realize it.

So, no, I never made any appeal, as I didn't know if (and still don't) if it was denied, or what.

Regarding my condition from 2000 to 2018, as I said (and she recorded) 

2. Medical history
    ------------------
    a. Describe the history (including onset and course) of the Veteran's
    thoracolumbar spine (back) condition (brief summary):
       -- relates -- "I had to change really heavy parts in the bottom load of
       the air craft while I was in the military. They had these monorails but
       they didn't always work so we had to pick them up a lot of times. I can
       remember having back pain and having physical therapy in the Air Force 
and
       having to go to traction but that's all I can remember about what they
       did.  Since then I have always had back pain, upper and lower back.
have
       pain all the time, especially if I try to stand up for ten or more
       minutes. I can try to lean against something and put pressure and that
       seems to help. At night when I am sleeping it will wake me up with pain
       and I have to roll out of bed and walk around for a minute. I have just
       been living with the pain."

Not sure if the above has any merit, or not.

The VA has never asked me for more information about my back, only the C&P.  They wanted all sorts of info on the foot pain, however.  

I did see a doctor about my back sometime around 2006.  I called them to get records, but they told me they'd already destroyed them all.

 

Thanks!  I appreciate your help!

 

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Some times a VA Doc will file the claim and not tell you  I had a VA  AUDIOLOGIST one time give me a Hearing test AND he submitted a claim  because I never did  anyway this may have happen to you with your conditions?

You need to request your C-FILE AND SEE WHAT RECORDS YOU HAVE IN IT  THESE RECORDS GOOD VERY WELL BE IN THERE? OR request all your service and medical records From NRPC in  St Louis.

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      Any clinical clinician such as MD ,Psychiatrist even a L.C.S.W. (Certified)can perform the Diagnostics Evaluation Employed by the the VA

      ...They just need to figure out your symptoms and put together a list of your symptom's that you possess or show from the evaluation...I am not 100% Sure just how they do this ?

      being I am not a Dr or clinical clinician 

      Once a Diagnoses of PTSD is given they try to set you up with a Therapist to help with your New dx And how to adjust or cope with the Anxiety and Depression the PTSD can cause.

        you learn the tools to cope with and depending how severe your symptoms are ? 

       They test /screen you with phychoeducational type therapy treatment usually at first.

       Warning  some of this therapy can be very rough on a Veteran  from holding on to guilt  from the trauma its self or you maybe in a  ''stuck point''from memories and guilt or from the stressor's or anything that reminds you of the trauma you endured.

      The therapy works  even if we think it don't,  I recommend Therapy for all PTSD Veterans  it could very well save your life once the correct therapy is in place and the Veteran makes all his Clinical Appointments.

      I still have Combat PTSD it probably will never be cured completely but we can learn the tools it takes to cope with this horrible diseases 

      even learning breathing techniques  Helps tremendously during a panic attact.

      I have guilt from the war in Vietnam  ( I ask my self what could I have done to make a better outcome/difference?..and also I am in what the therapist calls stuck points. working on that at present once a week for 90 minutes.  I am very fortunate to have the help the VA gives me and I am lucky I have not turned to alcohol or drugs to mask my problem.

      But I have put my family through a living hell with my angers of burst.and they all stood by me the whole time years and years of my family life was disrupted because of me and my children &spouse  never deserved it one bit.

      That's all I want to say about that.

      At least I am still around. and plan to be tell my old age dying day.
    • No timeframe gotta love that answer it’s even better when you ask 1800 people or call the board directly they’ll say you’ll know sooner then later. I had mine advanced and it was about 2 months later until I had the decision in my hand which seems forever but in the present system in 2016 lightning fast...
        • Thanks
    • I am serviced connected for ankylosing spondylitis back in 1985. I had a C&P exam on 7-7-19 since I am asking for an increase in my cervical, thoracic, and lumbosacral ratings. After speaking with the DAV to find out progress and info on my exam, the Rep. noted sort of what I expected. Radiculopathy was noted and ROM was 0-15 for cervical, and 0-25 for back. I am currently rated as Cervical 30%, Thoracic 10%, and Lumbosacral 40%. The main question that I have is relating to the thoracic 10% and lumbosacral 40%. I am confused on these two. Is Lumbosacral separate from the thoracic/others ? Since my back ROM is at 0-25, does this mean that my thoracic might increase from the 10% to a higher rating ? I am confused how they break down my ratings from cervical at 30%, Thoracic at 10%, and Lumbosacral at 40%. Also, with the radiculopathy, is this something that they will rate also ? I am currently at 90% total combined for all my disabilities. I hope this helps for someone to give me advice/answers.
      • 4 replies
    • Thank you @GeekySquid for your reply. 

       

      I have redacted personal information for my documents listed below. 

      I look forward to your reply. 

      HEADACHE STR 2006 copy_Redacted.pdf

      HEADACHE-DBQ.pdf

      Pages from Original Denial-Grant Reasons_Redacted.pdf
    • Hello Defenders of freedom!

      I have a question pertaining to this denial for headaches. The decision letter is quoted below. 

       

      3. Service connection for headaches.

      "We may grant service connection for a disability which began in military service or was caused by some event or experience in service.

      Your STRs are negative for any treatment of or diagnosis of headaches. On your post-deployment exam in 2005 you denied any headaches. On separation, you denied any headaches. VA treatment records are negative for any treatment of or diagnosis of headaches. On VA exam, the examiner stated there was no evidence of any residuals of a traumatic brain injury.

      We have denied service connection for headaches because the evidence of record fails to show this disability was incurred in or caused by military service."

      From my understanding these 3 points must be overturned to successfully win a CUE case:

       (1) either the correct facts, as they were known at the time, were not before the adjudicator or the statutory or regulatory provisions in existence at that time were incorrectly applied; 

      (2) the error must be undebatable and of the sort which, had it not been made, would have manifestly changed the outcome at the time of the prior determination

      and (3) a determination that there was CUE must be based on the record and law that existed at the time of the prior adjudication in question.  

      @Berta, or veterans out here who have knowledge/experience, tell me what facts you think would be needed to prove this denial for headaches was an error? 
      • 14 replies
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