Definition of Diagnosis Error

Edward Winslow edbjwinslow at GMAIL.COM
Tue Jan 31 21:12:04 UTC 2017


This is a fascinating thread! I count 16 unique contributors to this one.

I think that Bob is asking what the definition of diagnostic error is, in
order to try to use Dx Error in some form of Root Cause Analysis to help
decide what caused the Dx. Error. Many of us have then tried to classify
different types of Dx. Error: missed, wrong, delayed, and over among
others, which I think are right on track, but may be outside the scope of
the reason for Bob's question.

Mark Gusack's note is fascinating and touches on the results of screenings,
which today's VA study on Low Dose CT for lung cancer screening brought up
(there is a potential for many diagnostic errors here).

I have had difficulty finding the answer to Mark's first question ("What is
a Diagnosis"). When I was a medical student, I fell in love with Raymond
Adams' definition in Harrison's Textbook of Medicine: "*Diagnosis is the
mental act of selecting the one explanation most compatible with all the
facts of clinical observation".*  This leaves us wondering how many parts
of clinical observation are complete, thorough and accurate.

The National Academy definition is purposefully vague, and may not help Bob
for his immediate quest. I wonder if we don't put diagnostic error as one
of the questions in the RCA of an adverse outcome (death, prolonged
hospitalization, slow return to work, ...).




On Tue, Jan 31, 2017 at 10:44 AM, HM Epstein <hmepstein at gmail.com> wrote:

> May I add one to your list, Peter, based on personal experience and dozens
> of patient stories I've collected to date?
>
> No diagnosis: when the physician tells the patient that they are healthy
> when they're not, or that the tests are all negative but chooses not to
> continue to search for an underlying cause of symptoms, or throws up his
> hands and tells the patient, "It's all in your head."
>
> This diagnostic error is most often found amongst patients with long
> diagnostic journeys.
>
> Best,
> Helene
>
> *Sent from my iPhone*
>
>
>
> On Jan 19, 2017, at 11:22 PM, Elias Peter <pheski69 at GMAIL.COM> wrote:
>
> I think these are treatment errors, not diagnostic errors.  Diagnosis and
> treatment are linked but not identical, in that a diagnosis (whether
> correct or not) can be followed by no treatment, or by some combination of
> correct/incorrect treatment.
>
> I have always thought of diagnostic accuracy using the following schema:
>
>
>    - Correct diagnosis: making the diagnosis of something that is present
>    and is causing the signs or symptoms being evaluated.
>    - Incomplete diagnosis: making the diagnosis of something that is
>    present, but missing other pertinent diagnoses.
>    - Irrelevant diagnosis: making the diagnosis of something that is
>    present, but is not related to the signs or symptoms being evaluated. This
>    includes things often called incidentalomas or red herrings.
>    - Incorrect diagnosis: diagnosing something that is not present. Over
>    diagnosis, for example diagnosing a breast cancer that would never have
>    caused clinical illness based on an abnormal mammogram, is one form of
>    incorrect diagnosis. Another form is mislabeling: diagnosing a condition
>    that is not present, such as diagnosing viral pleurisy in a patient with
>    pulmonary embolus.
>
>
> I do not consider these to be mutually exclusive.
>
> Peter E;ias, MD
>
> On 2017.01.19, at 4:10 PM, Kohn, Michael <Michael.Kohn at UCSF.EDU> wrote:
>
> Dear colleagues,
>
> There are two general categories of diagnostic error:1) failing to treat
> the patient for something he or she has, and 2) treating for something he
> or she doesn't have.
>
> For the emergency physician, discharging a chest-pain patient who turns
> out to have a myocardial infarction is a diagnostic error, but so is
> admitting a chest-pain patient who turns out to have esophageal reflux,
> even if we are willing to make 10 of the second type of error (unnecessary
> hospitalization) in order to avoid one of the first type of error
> (“missing” an MI).
>
> Of course, we can make both types of error simultaneously -- treating the
> chest-pain patient with thrombolytics for MI when he turns out to have
> aortic dissection.
>
> Best,
>
> Michael
>
> Michael A. Kohn, MD, MPP
>
> Associate Professor
>
> Epidemiology and Biostatistics
>
> (Email created using voice recognition.  Please excuse transcription
> errors.)
> ------------------------------
> *From:* Bob Latino [blatino at RELIABILITY.COM]
> *Sent:* Thursday, January 19, 2017 2:07 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
> I believe it safe to say, it is more plausible to start with what is
> known, before addressing what is unknown. This seems to be the fastest way
> to reduce the impact to the patient.
>
>
> I am just trying to get a grasp of a starting point for this group.
> Perhaps I am not aware of ongoing, macro efforts by this group to getting a
> hold on the scope and magnitude of the problem?
>
>
> In my world, the Dx Error is not the problem, it is a cause category.  An
> undesirable outcome has to result, as a result of a Dx Error related
> issue.  An undesirable outcome could be death, harm, near miss or high
> risk.  Initially we would be less concerned with Dx Errors where these
> outcomes did not occur (or were not known at all).
>
>
> Off the top, wouldn't we be most concerned with the known Dx Error cases
> that resulted in death and/or harm?  From an analytical standpoint,
> wouldn't that be a good starting point to collect data and then try to sort
> the causes of these Dx cases into manageable and definitive sub-categories?
>
>
> Where is the starting point to formulate a plan to act on for this massive
> issue?
>
> Once again, thanks for your patience with this outsider who has an
> annoying, 'questioning attitude'.
> ------------------------------
> *From:* Koppel, Ross J <rkoppel at SAS.UPENN.EDU>
> *Sent:* Thursday, January 19, 2017 3:11 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
> May I add that in so many cases we never ever realize there was an error.
> Patients get better...die...something else become more prominent... we need
> to focus on the effects of the meds...hidden by polypharmacy...by age....etc
>
>
>
>
> Ross Koppel, PhD, FACMI
> Sociology Dept,
> LDI Senior Fellow, Wharton
> Affiliate Faculty, Medical School
> UNIVERSITY OF PENNSYLVANIA
> Rkoppel at sas.penn.edu
> Also, Prof of Biomedical Informatics
>  SUNY Buffalo
>
>
> -------- Original message --------
> From: "Ely, John" <john-ely at UIOWA.EDU>
> Date: 1/19/17 1:44 PM (GMT-05:00)
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Definition of Diagnosis Error
>
> Rather than trying to define diagnostic error in a single sentence I think
> we should focus on the dimensions of diagnostic error and there are a lot
> of dimensions.  I agree with David that diagnostic error has a “truly
> massive scope” that is probably too massive to allow a one-sentence
> definition.  I also agree that the IOM definition is probably the best
> effort at a one-sentence definition, but only the first half.  The second
> half is an important problem.  A life-threatening problem.  But it’s not a
> diagnostic error.  It’s a communication error.  An extremely important
> communication error, but including it in the definition confuses the
> fundamental meaning of diagnostic error. Here are some of the dimensions:
>
>
> 1.  Do we want a conceptual definition or an operational definition?  If
> you do research, you need an operational definition.
> 2.  Should we define diagnostic error according to what it is (Graber,
> Singh, Schiff:  missed, delayed, wrong, missed opportunity, wrong process)
> or according to what it is not (IOM: failure to establish an accurate and
> timely diagnosis).
> 3.  Was there fault (i.e., missed opportunity) or no fault?
> 4.  If there was fault, were there mitigating circumstances (difficult
> diagnosis, difficult patient, difficult environment, new disease (HIV in
> the early 80’s, first cases of Legionnaires))?
> 5.  If there was fault, whose fault was it (physician, patient, NIH for
> not funding research on better tests or diagnostic strategies, hospital
> administrator who failed to adequately staff the emergency room or buy
> better diagnostic equipment)?
> 6.  If there was fault, who determined that there was fault and how did
> they determine it?
> 7.  Was it a near miss and what are the different kinds of near misses?
> 8.  Was it overdiagnosis and what are the kinds of overdiagnosis?
> 9.  What does timely mean as in “timely diagnosis”?
> 10.  What is the seriousness of the error (from trivial to serious)?  When
> we talk about diagnostic errors, we only think of the devastating ones, but
> most are trivial and occur every day in everyone’s practice (Pareto
> Principle).
> 11.  What is the seriousness of the patient harm (from nonexistent to
> death)?  You can have serious errors that are associated with zero patient
> harm, or even patient benefit.
> 12.  How do screening errors relate to diagnostic error?
> 13.  How do we decide if it was an error?
> 14.  What about errors that benefit the patient (e.g., failing to diagnose
> breast cancer or prostate cancer in which the treatment is worse than the
> disease)?
> 15.  How to detect and measure errors?  Can we measure errors without
> defining them?
> 16.  What causes diagnostic errors?
> 17.  How can we prevent diagnostic errors?
> 18.  What is the opposite of diagnostic error?
> 19.  What is our certainty about the correct diagnosis (definitive test,
> patient course, autopsy diagnosis, surgical diagnosis)?  All of these could
> be wrong and even if we never have anything definitive, there is still a
> correct diagnosis out there (what God knows)?
> 20.  Response to error (e.g., apology, root cause analysis, malpractice
> suit, forgiveness)
> 21.  Communication problems (physician-patient, physician-physician,
> physician-nurse)
> 22.  Treatment issues as they relate to the diagnostic process.  Treatment
> issues as they relate to diagnostic error.
> 23.  Whose perspective are we using when trying to define diagnostic
> error?  Patient, physician, lawyer, nurse, administrator, researcher?
>
>
> And there are many other dimensions and subcategories of these.  I think
> it would be useful to develop a taxonomy of these dimensions and illustrate
> how they are interrelated.  It would help us pigeon hole the causes,
> interventions, research, journal articles, discussions, etc.  We could
> organize our efforts and prioritize them using the taxonomy.  I have
> started to work on this.  I have lots of categories and subcategories.  I’m
> up to 6 pages so far.  But it needs input from others.  (Let me know if
> interested.)
>
>
> John Ely, MD
> University of Iowa
>
>
>
>
> *From:* David Newman-Toker [mailto:toker at JHU.EDU <toker at JHU.EDU>]
> *Sent:* Thursday, January 19, 2017 8:37 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
> Your logic is totally appropriate, but the availability of data does not
> allow us to achieve the level of precision (yet) that I suspect you desire.
> The IOM/NAM definition is of a problem with truly massive scope, although
> that scope is, as yet, not defined with much precision. We suspect there
> are at least 12 million such errors each year in the US… possibly more.
> Serious harms (disability/death) probably affect hundreds of thousands.
> The parts of that problem that are worth solving and can be solved in the
> relatively near future are smaller in scope.
> In my view, it is easier to have the larger superset of these problems be
> bigger, rather than smaller, and for the individual problems to be true
> subsets.
> There are many of us seeking to break the problem into bite-size chunks,
> and to measure those chunks (and eventually the larger problem), more
> systematically.
> If we all keep working in that direction, eventually we will get there. In
> the meantime, we need some “early wins” on a manageable subset so that
> people can see this as a tractable problem.
> David
>
>
>
>
>
>
> *David E. Newman-Toker, MD PhD*
> Professor of Neurology, Ophthalmology, & Otolaryngology
>
>
> *Director, Division of Neuro-Visual & Vestibular Disorders*
>
> *http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/*
> <http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/>
>
> *Director, Armstrong Institute Center for Diagnostic Excellence*
>
> *http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/*
> <http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/>
>
>
> Johns Hopkins University School of Medicine
> Johns Hopkins Hospital; CRB-II, Room 2M-03 North
> 1550 Orleans Street; Baltimore, MD 21231
> Email: toker at jhu.edu
>
>
> Administrator: Doug Montague (410) 955-2536; dmontag6 at jhu.edu
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>
> *From:* Bob Latino [mailto:blatino at reliability.com
> <blatino at reliability.com>]
> *Sent:* Thursday, January 19, 2017 9:27 AM
> *To:* David Newman-Toker <toker at jhu.edu>; Society to Improve Diagnosis in
> Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *Subject:* RE: [IMPROVEDX] Definition of Diagnosis Error
>
>
> My purpose is seeking clarification is because I don't see unity in
> purpose within the various Diagnosis Error communities, on a common
> definition.  If the problem cannot be uniformly defined, how can it be
> solved?  In order to solve such a massive issue, there has to be an
> identified scope of the problem.  To me, these definitions vary widely in
> scope.  If I can't determine scope, I can't determine magnitude of the
> problem.
>
>
> I see many, many discussions about proposed solutions, but I have not seen
> much about breaking the 'problem' down into its manageable components, and
> determining systemic causes that are actionable.
>
>
> I'm from the investigative community and just trying to look at how this
> Community is going about identifying the specific root causes of diagnosis
> error and acting on those evidence-based deficiencies?
>
>
> I am not from the clinical community, so my interest is in just seeing
> what reasoning process/pattern is being used to methodically solve this
> problem, that affects every user of the U.S. healthcare system.
>
>
> I am just a lurker and certainly not an SME like the majority of
> participants on this forum.  I am just trying to keep up with the
> conversation:-)
>
>
> Thanks for your patience with my questions.
>
>
> *Robert J. Latino, CEO*
> Reliability Center, Inc.
> 1.800.457.0645 <(800)%20457-0645>
> blatino at reliability.com
> www.reliability.com
> <image002.jpg>
> <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>
>
>
> *From:* David Newman-Toker [mailto:toker at jhu.edu <toker at jhu.edu>]
> *Sent:* Thursday, January 19, 2017 9:07 AM
> *To:* Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>; Bob Latino <blatino at reliability.com>
> *Subject:* RE: [IMPROVEDX] Definition of Diagnosis Error
>
>
> Dear Bob,
> I think that is the wrong way to think about it. Going forward, the
> IOM/NAM definition should be thought of as *THE* definition of diagnostic
> error.
> There will be different ways to operationalize that definition, and there
> will remain some differences of opinion over how best to do that.
> However, we cannot keep re-litigating the definition ad infinitum. There
> is no “right” answer or true consensus, so the IOM/NAM has settled the
> matter for us.
> David
>
>
>
>
>
>
> *David E. Newman-Toker, MD PhD*
> Professor of Neurology, Ophthalmology, & Otolaryngology
>
>
> *Director, Division of Neuro-Visual & Vestibular Disorders*
>
> *http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/*
> <http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/>
>
> *Director, Armstrong Institute Center for Diagnostic Excellence*
>
> *http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/*
> <http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/>
>
>
> Johns Hopkins University School of Medicine
> Johns Hopkins Hospital; CRB-II, Room 2M-03 North
> 1550 Orleans Street; Baltimore, MD 21231
> Email: toker at jhu.edu
>
>
> Administrator: Doug Montague (410) 955-2536; dmontag6 at jhu.edu
>
> Confidentiality Notice: The information contained in this email is
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>
>
>
> *From:* Bob Latino [mailto:blatino at RELIABILITY.COM
> <blatino at RELIABILITY.COM>]
> *Sent:* Thursday, January 19, 2017 6:17 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
> So, based on all of this feedback, it is safe to state that there is no
> singular, universally accepted definition for Diagnosis Error?
>
>
> *Robert J. Latino, CEO*
> Reliability Center, Inc.
> 1.800.457.0645 <(800)%20457-0645>
> blatino at reliability.com
> www.reliability.com
> <image004.jpg>
> <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>
>
>
> *From:* Tom Benzoni [mailto:benzonit at GMAIL.COM <benzonit at GMAIL.COM>]
> *Sent:* Wednesday, January 18, 2017 2:18 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
> The major class missing is the largest.
> "Irrelevant"
> Tom
>
>
> On Jan 18, 2017 12:54, "Mark Graber" <mark.graber at improvediagnosis.org>
> wrote:
>
>
>
>
>
> I've used the missed - wrong - delayed categories, which were originally
> created by the Australian Patient Safety Foundation decades ago.  These
> categories are useful in clarifying what things we're talking about in
> regard to diagnostic error.  The classification isn't perfect, because
> there will be overlap in the cases where a diagnosis is initially
> mis-labeled, but then correctly diagnosed later on (so originally wrong,
> but ultimately delayed).  Other limitations include the need to have some
> near-gold-standard way of knowing the correct diagnosis, and the fact that
> the categorization can only be done reliably in retrospect.
>
>
> None of the other definitions are perfect either, but they are all useful,
> and highly complementary, depending on your goals.  For performance
> improvement research, the definitions that focus more on the DIAGNOSTIC
> PROCESS are especially useful:  Gordy Schiff's definition centers on
> identifying breakdowns in the process, and Hardeep Singh's definition
> centers on finding 'missed opportunities'.
>
>
> The IOM definition is the only patient-focused definition; it starts off
> as another 'label' failure, but then includes that key process step of
> communicating the diagnosis to the patient.
>
>
> A paper by David Newman-Toker is attached that provides more detail for
> anyone interested, and also attached are the attributions for these 4
> definitions.
>
>
>    Mark
>
>
> Mark L Graber, MD FACP
> President, Society to Improve Diagnosis in Medicine
> Senior Fellow, RTI International
> Professor Emeritus, Stony Brook University
>
>
>
>
> On Jan 18, 2017, at 8:17 AM, Tom Benzoni <benzonit at GMAIL.COM> wrote:
>
>
> There are too many flaws in the definition to give it credibility.
>
>
> Tom
>
>
> On Jan 18, 2017 8:33 AM, "Bob Latino" <blatino at reliability.com> wrote:
>
> Is this IOM Definition of Diagnosis Error an accepted definition by SIDM?
>
>
> What is Diagnostic Error?
> The Institute of Medicine recently defined diagnostic error as the failure
> to (a) establish an accurate and timely explanation of the patient’s health
> problem(s) or (b) communicate that explanation to the patient. Simply put,
> these are diagnoses that are missed altogether, wrong, or should have been
> made much earlier.
>
> These categories overlap, but examples help illustrate some differences:
> *A missed diagnosis *refers to a patient whose medical complaints are
> never explained. Many patients with chronic fatigue, or chronic pain fall
> into this category, as well as patients with more specific complaints that
> are never accurately diagnosed.
>
> *A wrong diagnosis* occurs, for example, if a patient truly having a
> heart attack is told their pain is from acid indigestion. The original
> diagnosis is found to be incorrect because the true cause is discovered
> later.
>
> *A delayed diagnosis* refers to a case where the diagnosis should have
> been made earlier. Delayed diagnosis of cancer is by far the leading entity
> in this category. A major problem in this regard is that there are very few
> good guidelines on making a timely diagnosis, and many illnesses aren’t
> suspected until symptoms persist, or worsen.
>
>
>
>
> *Robert J. Latino, CEO*
> Reliability Center, Inc.
> 1.800.457.0645 <(800)%20457-0645>
> blatino at reliability.com
> www.reliability.com
> <image001.jpg>
> <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>
>
>
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>
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>
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>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?
> SUBED1=IMPROVEDX&A=1
>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?
> SUBED1=IMPROVEDX&A=1
>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?
> SUBED1=IMPROVEDX&A=1
>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?
> SUBED1=IMPROVEDX&A=1 or send email to: IMPROVEDX-SIGNOFF-REQUEST@
> LIST.IMPROVEDIAGNOSIS.ORG
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/




-- 
*Edward B, J. Winslow, MD, MBA*
Home 847 256-2475; Mobile 847 508-1442
edbjwinslow at gmail.com
winslowmedical.com

"The only thing new in the world is the history that you don't know"
       Harry S. Truman, 33rd President of US (1945-1953)


"... it can be argued that underinvestment in assessing the past is likely
to
lead to faulty estimates and erroneous prescriptions for future action."
        Eli Ginzberg, 1997






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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