Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-3_15-cv-08017/USCOURTS-azd-3_15-cv-08017-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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WO NOT FOR PUBLICATION 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Patricia J. Palmer, 

Plaintiff, 

v. 

Carolyn W. Colvin, 

Defendant. 

No. CV-15-08017-PCT-JJT

ORDER 

 At issue is the denial of Plaintiff Patricia J. Palmer’s Application for Disability 

Insurance Benefits (DIB) by the Social Security Administration under the Social Security 

Act. Plaintiff filed a Complaint on February 13, 2015, asking this Court to review the 

denial of her benefits. (Doc. 1.) The Court has reviewed the briefs (Docs. 11, 13) as well 

as the Administrative Record (Doc. 10) and now affirms the Administrative Law Judge’s 

decision (R. at 14–30) as upheld by the Appeals Council (R. at 1–6). 

I. BACKGROUND 

 Plaintiff filed an application for DIB on October 5, 2011, alleging disability 

beginning March 7, 2011. (R. at 17.) After Plaintiff’s application was denied initially and 

on reconsideration, Plaintiff requested a hearing, which an Administrative Law Judge 

(ALJ) held on September 5, 2013. (R. at 17.) On September 17, 2013, the ALJ issued a 

decision denying Plaintiff’s application. (R. at 14–30.) After the ALJ denied Plaintiff’s 

request, the Appeals Council (AC) denied Plaintiff’s request for review of the ALJ’s 

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decision on December 15, 2014, making the ALJ decision the final decision of the 

Commissioner of Social Security. (R. at 1–6.) The present appeal followed. 

 A. Medical Evidence 

 1. Treating Physicians 

 a. Dr. Kazmi 

Plaintiff began seeing Dr. M.A. Kazmi in June 2011 (R. at 328) and continued to 

regularly see him through September 2012 (R. at 318–40, 366–87, 450). Plaintiff also 

later sought treatment from Dr. Kazmi in September 2013. (R. at 482–86.) Plaintiff 

initially reported that she was experiencing constant, all-over muscle pain that increased 

with activity and that she was having trouble sleeping. (See, e.g., R. at 328, 457.) She also 

reported numbness in her feet. (R. at 319, 321, 457.) In later appointments with 

Dr. Kazmi, Plaintiff began complaining of leg pain, blurred vision, dizziness, and 

constant fatigue. (R. at 371, 373, 457.) 

 In 2011, Dr. Kazmi conducted various clinical tests. Electromyography (EMG) 

and nerve conduction velocity (NCV) testing showed pathology near to or at Plaintiff’s 

neck. (R. at 379.) Upon examination of Plaintiff’s cervical MRI, Dr. Kazmi determined 

Plaintiff had mild multilevel degenerative disc disease, no stenosis (compression of spinal 

nerve), and no other abnormalities. (R. at 325, 379.) Dr. Kazmi also performed 

neurologic exams, and Plaintiff’s results were normal as to her nerves, motor strength, 

coordination, and gait and station. (See, e.g., R. at 325, 457.) Dr. Kazmi ordered an MRI 

of Plaintiff’s brain, and the results were normal. (R. at 333.) Over the course of 

Dr. Kazmi’s treatment of Plaintiff, he made the following assessments: specified 

idiopathic peripheral neuropathy; acquired spondylolisthesis (displacement of vertebra) 

L5 on S1 (determined after review of x-rays); restless leg syndrome; periodic limb 

movement disorder; insomnia; fibromyalgia/myofascial spasm; anemia; lumbago (lower 

back pain); GERD; and other disorders of the ankle and foot joint. (R. at 277, 323, 328–

29, 373, 452–53, 458.) 

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 Dr. Kazmi completed a functional capacity report dated August 23, 2011, in which 

he found Plaintiff suffered from fibromyalgia, spondylolisthesis (lumbar), and chronic 

pain. (R. at 278, 282.) He indicated Plaintiff could do activities such as sitting, standing, 

and walking for only one to three hours in an eight-hour workday for a period of 12 

months. (R. at 279–80.) 

 At appointments in May and July of 2012, Plaintiff reported increased pain in her 

feet, specifically her toes. (R. at 452, 454–56.) She also stated that her worst pain was in 

her lower back and arms and that she had pain and stiffness in her legs and hands. (R. at 

452.) 

 Dr. Kazmi conducted several more tests in May 2012. After conducting a bilateral 

lower extremity nerve conduction study, he found the results were abnormal (R. at 462–

66), and recommended an EMG and MRI of the lumbar spine (R. at 462). Plaintiff’s July 

2012 lumbar spine MRI showed the following: grade 1 anterior spondylolisthesis of L5 

over S1 with associated bilateral pars (small segment of bone joining the facet joints in 

the back of the spine) defects; moderate bilateral neural foraminal stenosis at L5-S1 

secondary to disc bulge and anterior spondylolisthesis; and asymmetrical left paramedian 

disc protrusion at L3-4 that abuts the thecal sac and causes mild central stenosis and mass 

effect on the left L4 nerve root. (R. at 467–68.) 

 Over a year later, Plaintiff saw Dr. Kazmi on September 11, 2013, and complained 

of constant pain, especially in her neck, back, and shoulders. (R. at 482.) She continued 

to experience numbness and pain in her legs and feet. (R. at 482.) She stated her pain 

increased with prolonged activity and sitting. (R. at 482.) Dr. Kazmi noted that Plaintiff 

had more than 20 trigger points suggesting fibromyalgia. (R. at 482.) Dr. Kazmi referred 

Plaintiff to a neurologist and rheumatologist for more a specific diagnosis and for her 

fibromyalgia, respectively. (R. at 483.) 

 Over the course of Plaintiff’s treatment, Dr. Kazmi prescribed her numerous 

medications including Cymbalta (for depression/anxiety), Effexor (for 

depression/anxiety), Nexium (for acid reflux), Synthroid (for hypothyroidism), 

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temazepam (for insomnia), trazodone (for depression/anxiety), Ultram (for pain), and 

Vicodin, and referred her for physical therapy. (See, e.g., R. at 319–20, 367, 370, 384.) 

While Plaintiff sometimes reported the medications relieved her pain (R. at 369, 457), she 

continually reported that generally, medications did not alleviate her pain or help her 

sleep. (R. at 319, 321, 323, 325, 328.) 

 b. FPS Medical Center, Ltd. 

Plaintiff sought treatment from FPS Medical Center, Ltd. from January to 

September of 2011. (R. at 255–77, 284–317.) Plaintiff reported experiencing constant 

pain in her chest and arms. (See, e.g., R. at 258, 305, 313.) An MRI of Plaintiff’s cervical 

spine showed mild multilevel degenerative disc disease. (R. at 275.) Plaintiff continually 

reported that her pain was gradually worsening, and she also began to experience pain in 

her legs. (See, e.g., R. at 262.) In May 2011, Plaintiff was diagnosed with myalgia and 

myositis, and was referred to a neurologist and rheumatologist. (R. at 264.) Plaintiff was 

also diagnosed with benign hypertension (R. at 264) and hypothyroidism (R. at 299). In 

July 2011, Plaintiff also began reporting constant groin discomfort. (R. at 269.) 

 c. Mohave Arthritis 

Plaintiff obtained treatment from Dr. Burhan Chinikhanwala at Mohave Arthritis 

from June to October 2011. (See R. at 341–65.) Plaintiff initially reported that she had 

been experiencing achiness and pain in her arms, hands, and neck during the previous 

eight to nine months, and also experienced associated numbness and headaches. (R. at 

345.) Although Dr. Chinikhanwala reported Plaintiff did not have any significant arthritic 

or neurological symptoms (R. at 341, 343, 354), he determined Plaintiff suffered from 

neuropathy, arthralgia (joint pain), myalgia, degenerative arthritis of her hands, back, and 

neck, and carpal tunnel (R. at 341, 346, 354). 

 d. True Rehab 

Per Dr. Kazmi’s physical therapy referral with a start date of December 20, 2011 

and end date of July 3, 2012 (R. at 440), Plaintiff received treatment at True Rehab, but 

only for one month – from May to June 2012 – for her lower back pain (see R. at 439–

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48). On June 28, 2012, Plaintiff indicated her pain had increased, and she did not feel 

physical therapy had helped her pain and numbness. (R. at 447.) She stated she “just 

need[s] to have a MRI.” (R. at 447.) Plaintiff was then discharged. (R. at 447.) 

 e. Dr. Livingstone 

Dr. Franklin Livingstone conducted an electrodiagnostic evaluation, including 

EMG and NCV testing, on June 7, 2013. (R. at 477–81.) He found no evidence of lumbar 

radiculopathy, myopathy, or motor neuron disease, but did find evidence of a mild degree 

of sensory peripheral neuropathy of bilateral lower extremities. (R. at 477.) 

Dr. Livingstone also found moderate to severe myofascial pain in the L4 to S2 paraspinal 

muscles, which he attributed to a muscular disorder. (R. at 477.) 

 f. Dr. Alvarado 

Dr. Andres Alvarado saw Plaintiff on September 9, 2013. (R. at 486.) Plaintiff 

reported that her bladder control and back pain were worsening. (R. at 486.) Dr. Alvarado 

referred Plaintiff to another doctor for consideration of surgical options. (R. at 486.) 

 g. Rheumatology and Arthritis Consultants 

Plaintiff was seen at Rheumatology and Arthritis Consultants on October 8, 2013 

and November 6, 2013. (R. at 487–97.) At the October appointment, Dr. Rajitha 

Premaratne found Plaintiff suffered from polymyalgia – an inflammatory disorder 

causing muscle pain and stiffness – and that Plaintiff had 18/18 positive tender points. 

(R. at 491.) Dr. Premaratne noted this was consistent with Plaintiff’s underlying 

fibromyalgia diagnosis. (R. at 491.) The doctor also noted Plaintiff had myofascial pain 

syndrome with 18/18 tender points, indicating Plaintiff had fibromyalgia. (R. at 491.) 

Plaintiff sought treatment again in November for joint pain and swelling. (R. at 487–88.) 

 h. Mental Health Treatment 

Plaintiff obtained mental health treatment at Mohave Mental Health Clinic from 

November 2011 to February 2012. (R. at 388–438.) Plaintiff was diagnosed with 

adjustment disorder with anxiety and was referred for more services. (R. at 405.) 

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 2. State Agency Reports 

In the ALJ’s written decision dated September 17, 2013, he states he considered 

all of the State agency physicians’ reports and cites exhibits 2A, 4A, and 13F. (R. at 24.) 

Exhibit 2A is the May 2012 disability determination explanation at the initial level, in 

which a doctor determined that based on his review of the medical record, Plaintiff could 

perform light work and was not disabled. (See R. at 55–66.) Exhibit 4A is the September 

2012 disability determination explanation at the reconsideration level, in which another 

doctor again determined Plaintiff was not disabled. (See R. at 68–82.) Exhibit 13F is a 

one-page Disability Determination Services case analysis dated March 22, 2013, that 

states that Plaintiff’s record was reviewed, and she was found to have the residual 

functional capacity for light work and could perform her previous work. (R. at 476.) 

 B. Hearing Testimony 

 1. Plaintiff’s Testimony 

On September 5, 2013, Plaintiff testified before the ALJ to the following (R. at 

31–49): 

 Plaintiff is 51 years old and has a GED. (R. at 37.) Plaintiff last worked in 2011 as 

a waitress and bartender for approximately two months. (R. at 34–35.) After making 

mistakes on a patron’s order because she was in pain and could not concentrate, 

Plaintiff’s supervisor sent her home. (R. at 35.) Plaintiff did not attempt to obtain work 

thereafter because her doctor had instructed her not to work. (R. at 35.) Plaintiff 

previously worked as a machine operator for seven years. (R. at 37.) 

 Plaintiff states that, at the present time, she cannot work due to the following: all 

over body pain; numbness and coldness in her feet; throbbing in her legs; burning and 

aching in her lower back; neck, arm, and shoulder pain if her arms are up too long; 

trouble squatting; and headaches. (R. at 35–36.) Plaintiff’s back has bothered her for a 

“long time,” becoming increasingly worse, and her other pains started about two and a 

half years ago. (R. at 42.) Plaintiff has problems moving her head in extreme positions. 

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(R. at 49.) She also has difficulty sleeping at night. (R. at 42.) Plaintiff takes several 

medications for her pain and medical issues. (R. at 40–41.) 

 Dr. Kazmi and Dr. Alvarado have told Plaintiff she may need operations on her 

cervical or lumbar spine due to loss of bladder control and weakened legs resulting from 

pinching of her spinal cord. (R. at 43–45.) Dr. Alvarado has also considered epidural 

injections for Plaintiff, but decided against them pending a clearer understanding of 

Plaintiff’s medical issues. (R. at 46.) Plaintiff was referred to a nerve conduction 

specialist, and has an appointment with Dr. Alvarado thereafter to determine next steps 

for her treatment. (R. at 44, 46–47.) 

 Plaintiff describes that, on a typical day, she wakes up at ten or eleven o’clock in 

the morning, makes breakfast, watches some television, makes lunch, and then may nap 

because she is tired. (R. at 38.) After her nap, she will watch more television with her 

fiancé and help her fiancé prepare dinner. (R. at 38.) Plaintiff tries to help with the 

laundry, but her fiancé does most of the household chores. (R. at 40.) 

 Plaintiff has no source of income. (R. at 36.) Plaintiff has lived with her fiancé and 

his mother for seven years. (R. at 36–37.) Although Plaintiff’s fiancé does not work, he 

receives disability and supports Plaintiff with that income. (R. at 37.) 

 2. Vocational Expert Testimony 

Sandra Beerready, a vocational expert (VE), also testified before the ALJ at the 

September 5, 2013 hearing. (R. at 50–53.) When the ALJ asked the VE whether a 

hypothetical individual – one with a high school education, who could lift and carry no 

more than 20 pounds occasionally or ten pounds frequently, who could only be on her 

feet for up to three hours and sitting for six hours in an eight-hour workday with time up 

on her feet limited to 30 minutes at a time, who could only occasionally bend, stoop, 

crouch, and crawl, who could not move her head in extreme positions, who would be 

limited to routine or repetitive tasks, who would be off task up to ten percent of the time, 

and who might miss work once a month – could perform any of Plaintiff’s past work, the 

VE said “no.” (R. at 50.) The ALJ then asked the VE to identify light, unskilled jobs the 

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hypothetical individual could perform, to which the VE responded the individual could 

work as a cashier and a small products assembler. (R. at 51.) When the ALJ asked the VE 

whether those jobs would still exist if the individual was off task 20 percent of the time or 

would miss work three or more times a month, the VE answered “no.” (R. at 51.) 

Plaintiff’s counsel also questioned the VE and asked whether, in the same 

hypothetical above, but with the addition of chronic pain that prohibited concentration on 

even simple repetitive tasks, there would be any gainful employment for the individual, 

and the VE said “no.” (R. at 52.) 

 C. The ALJ’s Opinion 

ALJ Mason D. Harrell, Jr. issued an opinion dated September 17, 2013, in which 

he concluded Plaintiff was not disabled under sections 216(i) and 223(d) of the Social 

Security Act. (R. at 26.) The ALJ began his analysis by stating his finding that Plaintiff 

met the insured status requirement and had not engaged in substantial gainful activity 

during the period from her alleged onset date of March 17, 2011 through her date last 

insured of December 31, 2013. (R. at 19.) The ALJ then listed degenerative disc disease 

of the spine, arthritis, and anxiety as severe impairments afflicting Plaintiff. (R. at 19.) 

The ALJ found that Plaintiff’s medically determinable impairment of hypothyroidism 

was non-severe. (R. at 19.) 

 Proceeding with the five-step inquiry, the ALJ found that the impairments or 

combination of impairments did not meet the severity of symptoms to meet or equal any 

of the medical listings. (R. at 19–20.) 

The ALJ then stated his finding that Plaintiff had the residual functional capacity 

(RFC) to perform light work as defined in 20 CFR 404.1567(b) except she could lift 

and/or carry 20 pounds occasionally and ten pounds frequently; she could be on her feet 

up to three hours in an eight-hour workday for 30 minutes at a time and she can sit for six 

hours in an eight-hour workday; she can occasionally bend, stoop, crouch, or crawl; she 

cannot move her head to extreme positions; she is limited to routine and repetitive tasks; 

she would be off task ten percent of the time; she would miss work once a month; and she 

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cannot climb stairs or ladders. (R. at 21–22.) The ALJ found that Plaintiff had stated she 

was able to do daily activities that were not limited to the extent one would expect given 

her complaints of disabling symptoms and limitations. (R. at 22.) The ALJ found that 

Plaintiff’s activities diminished the credibility of her allegations regarding her functional 

limitations. (R. at 22.) The ALJ also found the objective medical evidence did not support 

the alleged severity of symptoms. (R. at 24.) As to the medical opinions, the ALJ gave 

“little weight” to treating physician, Dr. Kazmi and “significant weight” to the opinions 

of the State agency medical/psychological consultants. (R. at 23.) 

 After determining Plaintiff’s RFC, the ALJ found that Plaintiff could not perform 

any past relevant work (R. at 24–25), but there were jobs in significant numbers in the 

national economy that Plaintiff could perform (R. at 25). The ALJ thus found Plaintiff 

was “not disabled.” (R. at 26.) 

II. LEGAL STANDARDS 

The district court reviews only those issues raised by the party challenging the 

ALJ’s decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The court 

may set aside the Commissioner’s disability determination only if the determination is 

not supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 

625, 630 (9th Cir. 2007). Substantial evidence is more than a scintilla, but less than a 

preponderance; it is relevant evidence that a reasonable person might accept as adequate 

to support a conclusion considering the record as a whole. Id. In determining whether 

substantial evidence supports a decision, the court must consider the record as a whole 

and may not affirm simply by isolating a “specific quantum of supporting evidence.” Id.

As a general rule, “[w]here the evidence is susceptible to more than one rational 

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be 

upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations omitted). 

 To determine whether a claimant is disabled for purposes of the Social Security 

Act, the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears the 

burden of proof on the first four steps, but the burden shifts to the Commissioner at step 

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five. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). At the first step, the ALJ 

determines whether the claimant is engaging in substantial gainful activity. 20 C.F.R. 

§ 404.1520(a)(4)(i). If so, the claimant is not disabled and the inquiry ends. Id. At step 

two, the ALJ determines whether the claimant has a “severe” medically determinable 

physical or mental impairment. 20 C.F.R. § 404.1520(a)(4)(ii). If not, the claimant is not 

disabled and the inquiry ends. Id. At step three, the ALJ considers whether the claimant's 

impairment or combination of impairments meets or medically equals an impairment 

listed in Appendix 1 to Subpart P of 20 C.F.R. Pt. 404 (Listing of Impairments). 

20 C.F.R. § 404.1520(a)(4)(iii). If so, the claimant is automatically found to be disabled. 

Id. If not, the ALJ proceeds to step four. Id. At step four, the ALJ assesses the claimant’s 

residual functional capacity and determines whether the claimant is still capable of 

performing past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If so, the claimant is not 

disabled and the inquiry ends. Id. If not, the ALJ proceeds to the fifth and final step, 

where he determines whether the claimant can perform any other work based on the 

claimant’s residual functional capacity, age, education, and work experience. 20 C.F.R. 

§ 404.1520(a)(4)(v). If so, the claimant is not disabled. Id. If not, the claimant is disabled. 

Id.

III. ANALYSIS 

Plaintiff argues that the ALJ committed legal error by failing to consider her 

fibromyalgia. (Doc. 11, Pl’s Br. at 3.) Plaintiff does not state at what step of the five-step 

determination her contention arises from. The Court understands Plaintiff to dispute the 

ALJ’s findings at step two of the five-step process because the ALJ did not list 

fibromyalgia as a severe medically determinable physical impairment, but did consider 

fibromyalgia in the remainder of his opinion. (See R. at 19–24.) 

 The Court considers the harmless error doctrine when reviewing an ALJ’s 

decision. The doctrine provides that the Court need not remand or reverse an ALJ’s 

decision if it is clear from the record that the error is “inconsequential to the ultimate 

nondisability determination.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008). 

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When, at step two, an ALJ errs by failing to find an alleged impairment “severe,” such 

error is harmless so long as the ALJ considered the limitations of the impairment in the 

remainder of the analysis. See Lewis v. Astrue, 498 F.3d 909, 911 (9th Cir. 2007) (“The 

decision reflects that the ALJ considered any limitations posed by bursitis at Step 4. As 

such, any error that the ALJ made in failing to include bursitis at Step 2 was harmless.”)

 Here, the ALJ found in favor of Plaintiff at step two and proceeded through the 

entire sequential analysis, carefully considering Plaintiff’s testimony and the medical 

evidence in assessing her RFC. (See R. at 19–24.) The ALJ considered the opinion of 

Plaintiff’s treating physician, Dr. Kazmi, and noted his diagnosis that Plaintiff had 

fibromyalgia. (R. at 23.) The ALJ also found Plaintiff’s allegations were less then fully 

credible (R. at 21), and then properly weighed the remaining evidence, including the 

specific medical reports, in detail (see R. 21–24). Plaintiff argues that the ALJ did not 

consider certain clinical test reports and medical records, including those from Dr. 

Premaratne, which provide evidence of Plaintiff’s fibromyalgia. (Pl’s Br. at 3.) The Court 

notes that Dr. Premaratne’s report is dated October 8, 2013, and thus was not available 

when the ALJ issued his decision on September 17, 2013, but that the AC did consider 

the report. (See R. at 4.) Moreover, Dr. Premaratne’s report states Plaintiff has “18/18 

tender points positive,” and otherwise merely reiterates Dr. Kazmi’s previous 

fibromyalgia diagnosis, which the ALJ considered. (R. at 491.) 

 Plaintiff does not dispute that the ALJ adequately accounted for all credible 

limitations resulting from her alleged fibromyalgia. Plaintiff has also not set forth, and 

there is no evidence in the record of, any limitations that the ALJ failed to consider. 

Plaintiff has thus failed to show that finding her alleged fibromyalgia severe at step two 

would have had any effect on the ultimate disability determination. Accordingly, even if 

the ALJ erred by failing to find Plaintiff’s alleged fibromyalgia severe at step two, the 

error is harmless and provides no basis for remand or reversal. See Tommasetti, 533 F.3d 

at 1038. 

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IT IS THEREFORE ORDERED affirming the September 17, 2013 decision of 

the Administrative Law Judge, (R. at 14–30), as upheld by the Appeals Council on 

December 15, 2014, (R. at 1–6). 

IT IS FURTHER ORDERED directing the Clerk of Court to enter final 

judgment consistent with this Order and close this case. 

Dated this 25th day of February, 2016. 

 

 Honorable John J. Tuchi 

 United States District Judge 

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