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Cardiopulm Phys Ther J. 2008 June; 19(2): 54–60.
PMCID: PMC2845223

Linda Crane Lecture 2008 “The Challenge for the Future: Five Steps to Improve Quality, Incorporate Prevention, Maintain Productivity, and Have Fun!”

Hillegass Ellen, PT, EdD, CCS, FAACVPR

An external file that holds a picture, illustration, etc.
Object name is cptj0019-0054-i01.jpgAs I was preparing for this presentation I was thinking about Linda and what the Linda Crane Award meant.

Linda had a lot of wonderful character traits, a serious dedication towards spe cialization and many strong beliefs for the direction of the profession which is what this Award should remind us to bring forward for future generations of PT. Since not everyone here knew Linda, I thought I would go through the ABCs characterizing Linda and talk to you about lasting impressions of one of my great mentors that exemplifies a true professional. These characteristics also exemplify the five steps I am utilizing in my presentation.

Linda was A: Able to communicate well with many different people: committee chairs, individuals representing many different PT communities, and was an active member of three different sections. She worked with other disciplines (RN, MD, etc), and with other faculty and brought a lot of people together.

Linda was also B: Being proactive; making strategic plans for light years ahead!

She was C: Collaborative and played nice in the sandbox (which not everybody always does), and she built sandcastles with other people. She was also C: Competency driven, insisting that the Cardiovascular and Pulmonary Section develop entry level competencies which I think was a driving force of the Section as no other section had competencies. Advanced level competencies followed soon after when specialization was being developed at that time.

Linda also was a team player and D: Divided up the work. Linda was someone who could accomplish more than any one else in less time than it took others.

She E: Excelled in her PT profession, and was one of the first three board certified clinical specialists, and was driven by competencies.

She always had F: Fun, and she believed in making everyone else experience fun.

Linda was a G: Go Getter and a H: Hard act to follow.

And she had I: Integrity, a character trait that best describes her.

So as I was developing my talk I reflected on all these things that characterized Linda to help me develop my goal for this presentation. My expected outcome is for each of you to leave here inspired….inspired to make a change: in your practice, in your professional contributions, or in your personal life. Hopefully you will leave this presentation with something that will make a difference in your practice or your life.

This presentation involves Five steps to improve quality, incorporate prevention, maintain productivity, and HAVE FUN (and don't forget the last one). I will discuss each of the five steps in detail and then summarize in the end.

  • The first step is to: Live in the Present, but look to the Future
  • Second, Practice with Competence
  • Third, Communicate your Competence
  • Fourth, Develop Efficiency in your Work
  • Fifth, Include HUMOR in all You Do

Step #1: Live in the Present But Look to the Future

We'll start with living in the present, but looking to the future. First of all, if we live in the present and we don't look to the future we are going to miss the boat. We currently have some form of direct access to physical therapy in approximately 40 states. As a result, our practice has totally changed. We have patients who may not have seen a physician about their symptoms prior to seeing a physical therapist, and these patients may have multiple co-morbidities. Their symptoms may not be physical therapy related, so PTs need to improve their initial assessments and assess all symptoms. We also now have “pay for performance” measures so PTs need to be better with documentation to benefit from pay for performance.1 Currently the only pay for performance measure PTs may utilize is fall risk assessment but there will be many others. We need to be looking to the future. What other pay for performance measures are going to be developed? We need to prepare ourselves for pay for performance measures as a standard. Additionally there are other changes going on in reimbursement on a daily basis. We can't live in the past where we received reimbursement for every service. We may need to look at fee for service and other ideas. We need to change the way we practice because reimbursement and access has changed.

There are other changes occurring in practice on a daily basis that PTs need to think about. We need to look at a holistic approach to our patients and not just that they are a patient with low back pain. They may be a patient with low back pain, high blood pressure, smoker and elevated cholesterol. We need to look at other things besides their presenting diagnosis.

As a result of the changes occurring I want to encourage you to start identifying for risk for disease or presence of disease prior to developing any exercise interventions. Additionally PTs should incorporate prevention in all interventions. Let's begin by understanding what is meant by identifying risk. Cardiovascular disease is the number one killer of all individuals in the United States; not breast cancer, colon cancer, AIDS, or even COPD.2 PTs need to improve their assessments by identifying risk for cardiovascular disease, particularly if patients are coming in without physician referral and particularly if part of their treatment involves developing exercise interventions. Assessment for other cardiovascular diseases such as cerebral vascular accidents (stroke), peripheral arterial disease, hypertension, congestive heart failure, deep vein thrombosis should also be included. And, the literature and clinical practice also tells us that diabetes is another key risk for cardiovascular disease. In fact, prevalence of heart disease is so high in diabetics that we often should think of a diagnosis of diabetes as equal to a diagnosis of heart disease. Physical therapists need to stop treating patients that are diabetic as if they just have diabetes. PTs need to be saying “this patient probably also has cardiovascular disease.”

PTs need to include the risk for or presence of falls in the initial assessment. Assessing for falls is a 2008 pay for performance measure. What is going to happen in the future? Maybe assessing for hypertension is going to be a pay for performance measure. Shouldn't we therefore be taking blood pressures of all our patients and get ready for pay for performance?

What about the assessment of risk for or presence of pulmonary disease or dysfunction or even COPD? How many PTs look at smoking history of patients? Smoking affects wound healing, exercise tolerance, risk of infection in addition to being a risk factor of pulmonary and cardiovascular disease. Who fares better with endurance activities; the smoker or the nonsmoker? PTs should be including questions about the patient's smoking history in the history and physical assessment. In addition, questions should be asked about occupational exposures that can also affect the lungs. Lastly, questions related to whether or not the patient experiences sleep apnea should be included. There is a relationship triad between sleep apnea, obesity, and hypertension.3 Obese patients coming in with low back pain who also have hypertension, may be at risk for sleep apnea.

Assessment of risk for cardiovascular disease should be an assessment all physical therapists should include in their initial evaluation of every patient. Cardiovascular disease is the number one killer of both men and women in the United States.2 In addition, the cardiovascular disease mortality trends for men and women show that more women than men are dying of cardiovascular disease. The deaths in thousands are going down for men, however the trend for women is that death from cardiovascular disease is not decreasing in women. You may ask “Why is that?” The answer is twofold: women often do not have the same symptoms as men, and the interventions for cardiovascular disease do not demonstrate the same outcomes in women.

Women often do not present with the typical angina, which is chest discomfort radiating down their left arm or into the jaw. Women often present with different symptoms such as nausea, indigestion, pain/pressure between shoulder blades, and/or fatigue.4 Are you looking for those symptoms when women come in? Are you assessing for these symptoms in the obese, diabetic patients, patients with low back dysfunction, or patients with total joint replacement? All patients could be experiencing symptoms of coronary disease but may not be recognizing these symptoms as symptoms of underlying cardiovascular disease, particularly women.

By the time women are diagnosed with cardiovascular disease, the treatment (angioplasty, coronary artery bypass surgery, or medication) often does not improve the patient's symptoms or disease as well as in men.5 Therefore, assessment of coronary artery disease symptoms in women is different than men, and interventions do not work as well in women.

Let's look at other statistics to justify why we should assess for risk of disease in our initial assessment: 6,7

  • Over 43 million or 24% of population have high blood pressure. Are you looking at all patients' blood pressure?
  • Only one quarter of all children and adolescents with high BP have been diagnosed with the condition.8
  • Over 5 million Americans suffer from heart failure.
  • Adults with diabetes are 2-4 times more likely to have heart disease or suffer a stroke.9 Do you assess for glucose intolerance in the patient history? Are you assessing for diabetes? Are you treating these individuals as if they are at risk for cardiovascular disease?
  • The absolute risk of CV death was 3 times higher for men with diabetes than men without diabetes.10,11
  • Complications from DVT blood clots kill up to 200,000 people in US/year and the complications from DVT blood clots contribute to more deaths each year than AIDS and breast cancer combined.12 Are you looking at risk for DVT? There are multiple risk factors for DVT which include smoking, immobility, long air flights, recent surgery. Assessment for DVT may be a pay for performance assessment in the future.
  • 13.5 million Americans have COPD.
  • 15 million Americans are undiagnosed or in the early stages of COPD (1 in 18). Therefore, do you look at smoking history, and the potential to possibly have COPD which could affect outcomes of treatment.
  • 90% of falls are due to chronic diseases and associated with mobility impairments and with unsafe environments.
  • Obesity is present in 20% of school age children according to NIH statistics.
  • The prevalence of overweight and obese is highest overall in the Southern region of the country and next the Midwest. West Virginia and Mississippi have more than 30% of the population with a BMI >30.

Therefore, PTs should know the risk factors of cardiovascular disease and assess all patients for the presence of these risk factors. The risk factors include:

  • Elevated blood pressure. Did you know that the NHLBI guidelines for blood pressure now say that 120/80 is NOT normal?13 The guidelines state that ≥ 120 systolic and ≥ 80 diastolic is considered to be prehypertension. Individuals with BPs between 120 and 139 systolic and 80-89 diastolic should initiate lifestyle modification no matter what age to begin to reduce their risk for all cardiovascular diseases.
  • Smoking history
  • Elevated cholesterol
  • Family history (mother or/father younger than age 60 at first onset)
  • STRESS (actually it is the personality characteristics of anger and hostility)
  • Lack of regular physical activity
  • Diabetes
  • Obesity
  • Male (females are = males after menopause)
  • Age

Did you know in Ireland smoking has been banned in all public places in the entire country, including in all the bars? Ireland's rate of heart attacks fell by one tenth in the year following introduction of nationwide ban on workplace smoking.

Your concern is one of productivity in the workplace, and you wonder how you continue to maintain productivity yet add risk assessment during your patient assessment. You can start by asking simple questions regarding the patient's risk for heart disease, stroke, etc. Or, you can add it to their initial history and physical survey instrument or initial assessment form. You can even add a list of questions on a separate form. There are also risk factor profiles that are found both on line and from national professional organizations (for example the American Heart Association, etc). In addition, there are many resources on the web that provide specific risk factor assessments, including:

As professionals who are looking to the future, you should start by becoming familiar with these resources and use some of these simple ways to assess for risk for disease of your patients including diabetes, hypertension, coronary disease, DVT, heart failure, pulmonary disease, etc.

Next, as a health care professional, you should incorporate prevention into your exercise assessment and your plan of care. You may choose to refer your patients to appropriate professionals or to educational resources. You might also provide resources in your practice to encourage your patients to make lifestyle changes, including talking to them about blood pressure, or dietary changes like lowering saturated fat in their diets. You could also begin to develop exercise interventions as part of the treatment programs to make a change in the patient's low level of physical activity.

There is a lot of evidence based medicine in practice that supports identifying for risk of disease and initiating lifestyle modification in published guidelines that as a professional you should read.1316 The American Heart Association published guidelines for women in 2007 to lower their risk of cardiovascular disease. In addition, the American Heart Association and the American College of Sports Medicine published guidelines for physical activity for older adults in 2007. Review these current guidelines and implement the recommendations into your patients' plan of care.

Prevention is not only good to incorporate into your treatment plan for your patients, but it can be fun, too. You may even incorporate prevention into your OWN lifestyle. Some of the latest research has shown that red wine can actually improve your cholesterol levels.16 In addition, there's also research that shows dark chocolate lowers your blood pressure. Just one square (6.43 g) of dark chocolate a day reduces blood pressure by a few mm Hg in healthy people with above-optimum blood pressure.17 Therefore, a little red wine, a little dark chocolate might be great therapeutic lifestyle interventions to lower your BP and cholesterol.

To summarize looking to the future, incorporate prevention in your interventions. If risk factors are identified during the initial assessment, then you should address those risk factors in your interventions. You might provide educational resources, provide referral to other healthcare practitioners, or provide additional resources to address the identified risks.

Step #2 is to Practice with Competence

One way to practice with competence is to start monitoring vital signs including HR, BP, SpO2 (in pulmonary and CHF patients) and symptoms at rest and with activity during all initial assessments. Don't wait until your patient experiences chest pain and then measure their HR and BP! Document vital signs all the time. Other ways to practice with competence include:

  • Measuring BMI or waist circumference during every initial assessment
  • Develop exercise interventions to increase regular physical activity
  • Evaluate outcomes and make changes if necessary

“WHY should I measure vital signs?” everyone always asks. Students often say “My Clinical Instructor doesn't monitor vital signs so why should I?” My answer is always because our practice it is part of what demonstrates our competence. In addition, the APTA Guide to Physical Therapist Practice documents the practice of PT should include vital sign monitoring.18 The guide says “during your initial assessment every patient should receive a systems review.” During the systems review, one should evaluate:

  • The Cardiovascular-Pulmonary system
  • Blood Pressure
  • Heart Rate
  • Respiratory Rate
  • Edema
  • The Musculoskeletal system
  • Gross ROM
  • Gross Strength
  • Gross Symmetry
  • Height and Weight (gives you BMI!!!!!)***

How many PTs actually measure these on all patients?

Why else should we monitor vital signs? Because hypertension is a major risk factor for stroke, CAD, and renal failure. We should be assessing all patients for hypertension. Hypertension is defined as BP > 140 systolic and >90 diastolic pressure. At least 65 million adults or 1 in 4 has high blood pressure. As I said before, pre-hypertension is defined as 120-139/80-89 and should be treated with lifestyle interventions. There is a high prevalence of elevated BP which is undetected in the general population13 and there is a high prevalence of high BP in our adolescent population.8 Therefore, someone in your clinic should be taking BPs of all patients coming into your clinic.

Monitoring HR (with palpation) may detect irregular heart rhythms (most commonly we see atrial fibrillation in the elderly) and monitoring HR may also detect abnormal HR responses. We should be discussing the patient's aerobic condition with their physician as well as their functional status, and this can be done by documenting abnormal HR responses to activities. Resting heart rates also provide great information. A high resting HR in the older population has also been associated with an increased risk for diabetes and mortality.19,20

Body mass index (BMI) or waist circumference and waist to hip ratio is something that should be measured and documented on all your patients. Begin documenting that your patient is obese by documenting BMI which may be why the patient takes longer to achieve the outcomes you expect or why they might not achieve the outcomes you would like them to achieve. There is new evidence regarding the measurement of waist circumference (WC) as a better indicator than BMI in identifying women at risk for diabetes and cardiovascular disease (CVD).2123 In addition, waist-to-hip ratio appears to be more sensitive than body mass index (BMI) at predicting risk of subsequent coronary disease.23 We also know that clinical outcomes differ with obese patients. One study showed that individuals with a BMI ≥ 30, had poorer outcomes post total knee replacement.24 PTs should start documenting when an obese patient has a poor outcome, it may be due to their obesity and possibly responses to exercise. If you don't document their BMI or waist to hip ratio, that means you haven't looked at it and cannot use it as a reason for poor outcomes.

We also want to start to develop exercise interventions to improve fitness, reduce risk of disease, and encourage compliance. Recent evidence discovered that cardiorespiratory fitness and short term complications improved in patients undergoing bariatric surgery in patients who performed exercise intervention prior to surgery. The results showed that if this population increased their fitness prior to their bariatric surgery they had fewer complications after surgery.25 This could be justification for another program to add to our practice. After all, in our clinical experience, who does better postsurgical intervention? Those who have been in better shape before surgery often have easier postsurgery recuperation.

If we are going to develop exercise programs to improve fitness for our patients we should be performing an exercise tolerance assessment. The six minute walk test is a valid outcome measurement for exercise tolerance assessment.26 Perform a six minute walk test on your patients with low back dysfunction, your patients who are obese or who are post total hip or total knee surgery. There are even 3 minute walk tests that are valid.27 There is a wealth of evidence on the efficacy of the six minute walk test utilized on a variety of populations. Six minute walk tests demonstrate more observable, CHANGE with exercise interventions that increases the validity of our documentation of improvement in exercise tolerance.

PTs also need to use more measurable testing methods in our strength testing. More formal strength testing may demonstrate improvement after a one to two week strengthening program more than the traditional manual muscle test. Sometimes you may be performing strengthening exercises for a week and you may not see a change in the MMT. However, if they were performing strengthening with weights, they probably have changed the amount of repetitions or weight lifted in one week. Measurable change in strength is more easily observed when utilizing weights a patient can lift or number of repetitions or 1 Repetition max.28

We also need to be determining outcomes and measuring progress towards outcomes as a way to practice with competence. PTs should include exercise interventions to address endurance impairments in ALL populations no matter the diagnosis. In addition, outcomes are easier to document if you use formalized assessment of endurance and strength.

Consider the patient's lifestyle when developing interventions. Since the internet, the blackberry, the cell phone, etc. the population has become extremely inactive, demonstrates increased obesity, and decreased flexibility PTs should be addressing their patient's lifestyle and incorporating exercise programs to reduce their risk for development of disease. PTs should also incorporate flexibility into the exercise programs.

In summary, practicing with competence includes monitoring of vital signs and measuring for BMI or waist circumference, as well as developing exercise programs to improve fitness. One should also incorporate more formal exercise tolerance assessment and strength assessment to demonstrate improvement in outcomes with interventions, including interventions that improve lifestyle.

Step #3 Communicate Your Competence

The ways to communicate your competence include: communicate your expertise with GOOD DOCUMENTATION, communicate with all participants in the patient's health care and collaborate and communicate with others. Communication should include expected outcomes and progress made relative to the outcomes. In addition, the development of appropriate outcomes is essential for communication. Lastly, we should communicate evidence of practice.

What is good documentation? First of all, we, as PTs may understand our abbreviations, but others outside our field may not. A big caution for PTs is to watch your abbreviations! In addition, PTs should be documenting initial vital signs prior to something happening. Red flag items in the patient's history and systems review that may affect outcomes should also be documented. These red flag items include:

  • Smoking history
  • BMI/waist circumference
  • All co-morbidities!

Documentation of medical necessity should also be included in the patient's chart. Any abnormalities in the patient's history or physical exam, including abnormal resting BP or abnormal BP response to activity should be documented. Identify abnormal responses or findings, which is your justification for monitoring the patient with activities. Document when you have contacted the physician and notified the physician of the abnormalities. The goal is for the patient to exercise independently, so we need to be recording information that identifies the patient demonstrates abnormalities and requires closer monitoring by medical professionals. For example, your assessment is that the patient requires monitoring with progressive activity. MD notified of patient's abnormal resting BP. The goal is independence in a home exercise program.

Communication should be with all participants in the patient's health care, including the physician, insurance company, family/caregiver, and the patient.

If one of your problems with “time management” is that documentation is taking a long time, then you may need to invest in improving your technology and change the way that you document. Technology has provided tools to improve communication. Review ways to improve communication and documentation including “thinking outside the box.”

Therefore, communicate expected outcomes and progress made relative to the outcomes with good documentation, realistic outcomes, and realistic time frames and also look at all other impairments that may be affecting your outcomes. Include justification for differences in outcomes and time to achieve improved function.

You also need to start reading current evidence, and not just attending conferences to get the current evidence. There are lots of different ways to get current evidence, including pod casts, reader feeds, etc. Once identified, you can then use evidence to guide your interventions, documentation, or justification Other ways to identify current evidence include the use of the APTA's website which has Open Door and Hooked On Evidence. You might also collect reader feeds (RSS Feeds) or subscribe to Evidence Express from Evidence in Motion and have the information highway come to you.

In summary, communicate your competence and stay competent by staying current with the evidence.

Step # 4 Develop Efficiency in your Practice

PTs often hear they need to be more productive. However, maybe it's not productivity that is the problem, but rather the need to develop efficiency in practice. Productivity is related to the concept of efficiency. Productivity is the amount of output produced relative to the amount of resources (time and money) that go into the production. Efficiency is the value of output relative to the cost of inputs used. Productivity improves when the quantity of output increases relative to the quantity of input. Efficiency improves, when the cost of inputs used is reduced relative to the value of output.2932

Therefore, is the emphasis on productivity because payment for services is decreasing? If so, we need to look at reimbursement issues. We may need to look at other populations to attract to practice. There may be many other patients we could attract to our practices that we haven't thought about. We may need to look outside the reimbursement box and look at fee for services. We also may need to look at pay for performance opportunities and maybe lobby for pay for performance measures that are pertinent to the way we practice. And, then there are other ways to improve income to practice which include pro bono work, etc. Again, we may need to look outside the box.

Productivity can be increased in a variety of ways. We know with automation and computerization we could improve our notes and documentation. Therefore, if we improve our technology or our knowledge of available technology we may be able to improve our productivity, especially with our written communication. We may also need to look at less obvious techniques such as alternative ergonomic designs and/or worker comfort. In Japan the Shiseido Corporation looked at utilizing perfuming or deodorizing the air conditioning system of the workplace. Maybe aromatherapy could be may utilized in the clinics. Others have looked at worker fitness and worker satisfaction as factors improving productivity. Again, look outside your box. Maybe we should have fitness clubs, or challenges for losing weight, healthier eating, etc. Think about having staff luncheons where you communicate with each other and have fun. Get together on the weekend and have a walk for health or a fun run.

Step #5: Include Humor in all You Do

If we added humor in our workplace we might find a happier population of workers! Don't forget to have fun in all you do! Laughter has healing properties for all!

Use inspiration to motivate by identifying words to live by:

Laugh often, long and loud.

Laugh until you Gasp for Breath.

Keep only Cheerful friends.

The Grouches pull you down.

Other ways to add humor and fun include:

  • Get outside and enjoy the great weather.
  • Celebrate EVERY DAY and EVERY Holiday. Examples include:
    • Feb 5 International Pancake Day
    • Jan 3rd 2008 Drinking Straw Day
    • Sat, Jan 12th Penguin Awareness Day
    • Feb 27 Inconvenience Yourself Day
  • Party with your friends…but remember only Moderate Consumption: 1-2 glasses/day of wine or 7-14 glasses/week decreases your risk of coronary artery disease, however don't take all your consumption at once.
  • Enjoy Life
  • Enjoy the Scenery Around You
  • Take Vacations
  • Turn up the volume of the radio or CD in car and sing to your favorite songs OR have a Karaoke party with your IPOD!!!!
  • Have a “favorite website” day at work and discuss this at lunch and communicate with other workers
  • Have a “bring a joke” day for your patients for other employees
  • Have “dress in costume” days
  • Enjoy the simple things
  • Learn how to chill
  • Hug therapy. Give people hugs

Keep a positive outlook on life. Some resources are:

  • The Power of Positive Thinking by Norman Vincent Peale
  • Change the Way you See Everything: Through Asset-Based Thinking by K D Cramer and H Wasiak
  • If You're Not Happy You're Doing It Wrong: The ABC's of Life by Randolf W Ek
  • Life is Short…Wear Your Party Pants by Loretta Laroche

Ten Simple Truths That Lead to an Amazing Life were identified in the book written by Loretta Laroche that give many ideas to lead a happy life:

  • Say Yes to Stress (Resilience)
  • If not now, when? (Live in the Moment)
  • The Light IS at the end of the Tunnel (Optimism)
  • It is what it is! (Acceptance)
  • Laugh it up! (Humor)
  • Put a spin on it (Creativity)
  • Too much of a good thing can be too much! (Moderation)
  • Just Show up! (Responsibility)
  • But what does it all mean? (Meaning)
  • Join the Party! (Connection)

Other words to live by:

Life isn't about waiting for the storm to pass…

It's about learning to dance in the rain.

There is evidence in the literature regarding the use of humor. Humor has been shown to improve immune function, increase pain tolerance, and decrease the stress (catecholamine) response.33 Therefore, part of your therapeutic interventions may include a humor video while your patient is receiving therapeutic exercise. In addition, humor and laughter may influence health as humor is a stimulus that helps people laugh and feel happy and laughter is the psycho-physiological response.33


Keep Learning….

Learn more about the computer, crafts, gardening,


Never let the brain idle.

An idle mind is the devil's workshop.

And the devil's name is Alzheimer's.

Other wisdom:

The tears happen.

Endure, grieve, and move on.

The only person, who is with us our entire life,

is ourselves.

Be ALIVE while you are alive.

In Summary the five steps to remember from this presentation include:

  • Live in the Present, but look to the Future
  • Practice with Competence
  • Communicate your Competence
  • Develop Efficiency in your Work
  • Include HUMOR in all You Do

And always remember….

Life is not measured by the number of BREATHS

we take….

But by the MOMENTS that take our breath away….

Thank you for this honor. I would also like to recognize all who have helped me along the way…. In my professional career and in my personal life. “No man is an Island” and No WOMAN is an Island either….

Thanks go to my family, which is my support system, and all my mentors, some of whom are the most memorable and respected individuals you have ever met. These mentors include Linda Crane, Michael Pollock, Nancy Humber-stone, Gary Dudley, Randy Ice, and many others. Thanks also go to my colleagues and friends including Dianne Jewell and Joanne Watchie and the faculty, staff, and students at North Georgia College and State University.


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