Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_04-cv-01018/USCOURTS-azd-2_04-cv-01018-0/pdf.json

Parties Involved:
Teresa Padilla
Plaintiff
Social Security Administration
Defendant

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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Teresa Padilla,

Plaintiff, 

vs.

JoAnne Barnhart, Commissioner, Social

Security Administration,

Defendant. 

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No. CIV 04-1018-PHX-DKD

ORDER

Plaintiff Teresa Padilla appeals from the Commissioner of the Social Security

Administration’s decision to adopt the Administrative Law Judge’s ("ALJ") ruling denying her

claim for disability benefits for two and one half years before October 2, 2000, the date the ALJ

found her to be disabled. Pending before this Court are Plaintiff’s Motion for Summary

Judgment or Motion to Remand to the Commissioner (Doc. #8-1, 8-2), filed September 2, 2004,

and Defendant’s Cross Motion for Summary Judgment (Doc. #16), filed November 16, 2004.

This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). The parties have consented to

Magistrate Judge jurisdiction under 28 U.S.C. § 636(c).

PROCEDURAL HISTORY

Plaintiff suffers from bilateral carpal tunnel syndrome, mild on the left and resolved on

the right, status post-decompression surgery, adhesive capsulitis of the right shoulder, status

post-arthroscopy, and degenerative arthritis of the left shoulder. Plaintiff can no longer work

in her past profession as a hairstylist and has not engaged in substantial gainful activity since

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May 22, 1998. Plaintiff filed for a period of Disability Benefits and Supplemental Security

Income (SSI) on April 18, 2000 alleging disability onset beginning May 1, 1998. These claims

were denied June 12, 2000. On August 14, 2000, Plaintiff filed for Disabled Widow’s

Insurance Benefits beginning May 22, 1998. This claim was denied December 21, 2000. A

timely hearing request was filed on June 8, 2001 and a hearing held at which Plaintiff amended

the claim with respect to the SSI and Disability Insurance Benefit to reflect a disability onset

date of May 22, 1998. 

Plaintiff received a partially favorable judgment granting Disability Insurance Benefits

under section 216(I) and 223 of the Social Security Act, Disabled Widow's Insurance Benefits

under section 202(e), and SSI benefits as of October 2, 2000. However, from May 22, 1998 to

October 1, 2000, the ALJ found that despite her inability to do her past work as a hairdresser,

Plaintiff was able to perform sedentary work and retained Residual Functional Capacity

("RFC") to perform other work existing in significant numbers in the national economy.

Plaintiff then requested a review by the Social Security Administration Commissioner to

remand or reverse the ALJ’s decision denying her benefits from May 22, 1998 to October 1,

2000. Plaintiff’s review was denied on April 13, 2004.

Treating Physicians

In May 1998, Plaintiff first complained to Dr. Kim Lucas, her primary care physician,

of pain and numbness located in her upper right extremity. Dr. Lucas placed her on a no-work

status, and referred her to Dr. Conklin, a hand, wrist, and upper extremity surgeon. After

referral from Dr. Lucas, an EMG nerve test was conducted and found to be consistent with a

diagnosis of moderately severe carpal tunnel syndrome (TR 212). Plaintiff received

conservative treatment, including physical therapy, without success (TR 335).

On April 7, 1999, operated on by Dr. Conklin, Plaintiff underwent an invasive procedure

receiving debridement and subacromial arthroscopic decompression with open Mumford

resection for a subcromial impingement of the right shoulder, acromioclavicuar joint

degeneration, inferior synovitis of the rotator cuff, and labral degeneration (TR 197-202).

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Following surgery, Dr. Conklin referred Plaintiff to Dr. Bodell for her continued pain. Plaintiff

complained of pain in her right shoulder and Dr. Bodell noted that there were signs of

impingement and assessed Plaintiff as having tendinitis. On August 18, 1999, Dr. Bodell

recommended proceeding with surgery on the right carpal tunnel, and indicated that Plaintiff

"remains on a no-work status referable to persistent pain, the continuing problem of the

untreated carpal tunnel, and the residual problems following surgery of her right shoulder" (TR

405).

On September 10, 1999, Dr. Bodell determined that it was appropriate to proceed with

right carpal tunnel decompression (TR 402). On November 18, 1999, Dr. Gottlieb performed

the surgery, noting that her symptoms had lasted for a year without improvement using

conservative treatment (TR 225). On November 30, 1999, Dr. Bodell examined Plaintiff 12

days post carpal tunnel release and reported a concern for her finger extension and the pain that

it caused (TR 401). On December 20, 1999, Plaintiff was seen by Dr. Bodell regarding her left

wrist and hand. He noted her wrist motion had decreased and she continued to have radiating

pain. He suspected carpal tunnel in the left hand; however, despite her great pain, he

recommended that the right hand heal before taking any action on the left (TR 400). 

On January 17, 2000, Dr. Bodell examined Plaintiff and made recommendations with

respect to her work description as a hairdresser. Ultimately, Dr. Bodell said she could work as

long as the work “falls under the sedentary to light, non-repetitive type job descriptions as

described by U.S. Department of Labor” (TR 397). On March 6, 2000, Dr. Bodell noted that

"if the carpal tunnel were the only issue she could probably return to a modified work status"

(TR 396). He concluded that "[t]he real issue that is preventing her from returning to work

seems to be the shoulder" (Id.). On April 11, 2000, Dr. Bodell sought authorization for an EMG

for Plaintiff's left shoulder (TR 395). On November 30, 2000, Dr. Bodell filled out a form from

the SSA regarding her ability to work, indicating that Plaintiff could never do work overhead

or above shoulder level, and could only do occasional non-power or non-repetitive handling or

holding with the right and left hand, and could only use the left or right hand occasionally. He

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noted that she was also capable of picking or pinching occasionally - for 1/3 of a normal 8 hour

workday (TR 391-392).

Dr. Phillips first treated Plaintiff in May, 2000. At that time, he noted that she was

capable of light duty, "with essentially no forceful use of the right upper extremity. She may

do no hair cutting, no reaching, lifting, pushing or pulling with the right upper extremity" (TR

483). On August 22, 2000, Dr. Phillips performed arthroscopic right shoulder surgery with

capsulotomy, and acromioplasty revision for adhesive capsulitis of the right shoulder (TR 247-

249). A week later, on August 28, 2000, in a post-operative examination, Dr. Phillips noted

Plaintiff's trouble getting motion back and advised that she may use the arm for daily activities

but not for lifting anything heavy (TR 460). 

On October 12, 2000, Dr. Phillips diagnosed Plaintiff with acromioclavicular

degenerative disease in her left shoulder. Plaintiff was also assessed with a work-related rotator

cuff tendinopathy with a possible tear. The MRI showed impingement of the supraspinatus and

spurring consistent with subcromial bursitis. There were also symptoms of carpal tunnel in her

left wrist (TR 455). He recommended left median nerve decompression for her left shoulder;

Plaintiff decided against surgery because of the limited success of her right shoulder surgery

(TR 452). On November 21, 2000, Dr. Phillips filled out a form regarding Plaintiff's ability to

work. He indicated that for 1/3 of an 8 hour work day Plaintiff could work below the shoulder

level, extend her wrist and use fingering. However, Dr. Phillips indicated that other than those

identified, all other activities could never be performed (TR 453-454).

On February 1, 2001, Dr. Phillips increased her pain medication and referred her to a

pain management specialist (TR 451). On November 29, 2001, Dr. Phillips noted that Plaintiff

could be developing full blown regional pain syndrome of the upper left extremity similar to the

right side (TR 475). Finally, a month later, on December 28, 2001, Dr. Phillips reported that

the Plaintiff could not lift, reach, push, or pull with her left arm (TR 476).

On February 10, 2000, Dr. Guidera examined Plaintiff after she had been sent to him by

a Senior Claims Representative for her employer’s insurance company, Gallager Basset

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Services, for an Independent Medical Evaluation. Upon examination, Dr. Guidera diagnosed

her with mild left carpal tunnel syndrome, resolved right carpal tunnel and with adhesive

capsulitis of the right shoulder (TR 447). He found she had a normal range of motion on her

left and limited shoulder motion on her right (TR 445).

On March 30, 2000, Dr. Guidera filled out a form regarding her ability to work, based

on his treatment of her carpal tunnel syndrome. He indicated that she was limited to typing

fifteen minutes per hour for a maximum of two hours per day (TR 438-440). On June 12, 2000,

Dr. Guidera found that there were no signs of atrophy and Plaintiff had resolved numbness and

paresthesis in her right hand; however, she continued to have it in the left hand. He suggested

a corticosteroid injection for the left hand, foregoing operative intervention because of the mild

nature of her symptoms. He also put Plaintiff on protective, non-repetitive work status (TR

432). He again suggested she receive a corticosteroid injection on her July 17, 2000 visit (TR

433).

A month later, on August 14, 2000, Dr. Guidera noted that the left shoulder pain would

benefit from nerve decompression and that Plaintiff's left hand was symptomatic again (TR

428). On September 25, 2000, Dr. Guidera’s examination indicated that Plaintiff was still

symptomatic with respect to her left carpal tunnel syndrome (TR 428). On October 24, 2000,

Dr. Guidera recommended proceeding with left median nerve decompression at the wrist (TR

425). On December 5, 2000, he reported that Plaintiff was concerned with proceeding with a

carpal tunnel release on her left hand because she could not reach behind her with her right hand

because of her shoulder stiffness and thus would be unable to perform activities of daily living

(TR 425). On January 15, 2001, Dr. Guidera performed a follow up examination, and reported

Plaintiff’s biggest problems were her shoulders, and that her hand was a source of discomfort.

 He indicated that it would be appropriate to wait until her right upper extremity motion is better

before proceeding on the left (TR 424).

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Administrative Hearing

At the administrative hearing, Plaintiff testified, as did Sandra Richter, the Vocational

Expert. Plaintiff testified that she can do light dishwashing; is able to help a little with

housework, by watering plants; and her worst medical problem is both of her shoulders (TR

498, 503). She testified that on a good day (about 10-15 days a month ) she can walk a block

without having to rest; can stand and/or sit for one hour; she can't lift above her shoulders, and

can lift three pounds (TR 500, 503). Walking causes her right shoulder to swell; standing

causes her pain; when she sits, the right arm starts to go numb, and the left causes her pain (TR

511-512). She testified that she had trouble with grip strength, manipulation, and that cold

weather bothered her (TR 501). She attempted to return to work part-time, cleaning and

answering phones at the salon; she tried to resume work as a hairdresser without success (TR

506). Before the second shoulder surgery, her pain level was 7-10, on a scale of 1-10 (TR 510).

She testified that her daughter helps her dress, and combs her hair (TR 513).

Following Plaintiff's testimony, the ALJ asked the VE several questions. The VE

testified that Plaintiff could not perform her past work. The ALJ then asked her to assume the

restrictions set forth in Dr. Guidera's Physical Capacities Evaluation (which the ALJ

acknowledged was related solely to Plaintiff's hand problems, because he was not treating her

shoulders), there were "possible assembly positions that she might be able to do" (TR 519). The

ALJ found in his decision that Plaintiff "retains the residual functional capacity to perform a

significant range of sedentary work," based upon Dr. Guidera's opinion (TR 38).

Asked to assume Dr. Phillips' restrictions, the VE stated "[i]t's a little bit contradictory,

because he says light duty she could do, but she could do no hair cutting, no reaching, no lifting,

pushing or pulling with the right upper extremity...if she can't use her right upper extremity for

any lifting" (TR 520). She went on to conclude that she did "not know of a job that would fit

into the category of work that she could do, that would not require some lifting" (Id.). Even if

she assumed that the lifting would have to be done with the left hand, "that would be a problem"

(TR 520).

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Plaintiff's counsel then asked the VE to assume the restrictions outlined by Dr. Bodell.

The VE testified that assuming such restrictions, it would preclude the assembly positions

because Dr. Bodell's opinion "says non-power, non-repetitive and she can only use the left or

right hand occasionally. Which would be a problem because those jobs would require frequent"

[sic] (TR 521). In addition, the VE testified that assuming the restrictions outlined by Dr.

Phillips, and how that would impact the earlier hypothetical considering the limitations set forth

by Dr. Guidera, the VE opined that "these physical limitations seem to say that she can only

work below shoulder level occasionally, and then he is limiting her grasping and holding with

the right hand to nothing. So based upon those limitations, there would not be jobs that she

could do" (TR 521). Then, adding the limitations regarding the left arm in the later report by

Dr. Phillips to the ones that related to her wrists, the VE was asked whether that would preclude

the assembly position. She responded: "It says no lifting, reaching, pushing or pulling with the

left arm. So that would eliminate the left arm. And she could not do the job without using the

left arm" (TR 522).

STANDARD OF REVIEW

The ALJ findings will be affirmed if they are supported by substantial evidence and are

free from reversible error. Marcia v. Sullivan, 900 F.2d 172, 174 (9th Cir. 1990). Substantial

evidence is more than a scintilla, but less than a preponderance; it is “such relevant evidence

as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales,

402 U.S. 389, 401 (1971). In determining whether substantial evidence supports the ALJ’s

decision, the court considers the record as a whole, weighing both the evidence that supports

and that which detracts from the ALJ’s conclusions. Reddick v. Charter, 157 F.3d 715,720 (9th

Cir. 1988). The ALJ is responsible for resolving conflicts, ambiguity, and determining

credibility. Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). If there is sufficient

evidence to support the ALJ’s determination, the Court cannot substitute its own determination.

Young v. Sullivan, 911 F.2d 180, 184 (9th Cir. 1990).

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The court must affirm the ALJ’S decision where the evidence considered in its entirety

substantially supports it and the decision is free from reversible error. 42 U.S.C. § 405(g);

Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 1989). Where the evidence is susceptible to

more than one rational interpretation, the ALJ’s decision must be upheld. Andrews at 1039-40.

DISCUSSION

Treating Physicians' Opinions

An examining physician’s uncontradicted opinion may be rejected only for clear and

convincing reasons supported by substantial evidence in the record. Lester v. Chater, 81 F.3d

821, 830-31 (9th Cir. 1995). Even if the examining physician’s opinion is contradicted by

another physician, the ALJ may not reject an examining physician’s opinion without setting

forth “specific and legitimate reasons” supported by substantial evidence in the record. Id.

“Specific and legitimate reasons” must be set out by the ALJ in a detailed and through

factual summary of the conflicting clinical evidence and presented in the interpretation of the

evidence as supported by an explanation of why the ALJ’s interpretation, rather than the

doctor’s, is correct. Reddick, 157 F.3d at 722. An ALJ is not free to accept one portion of a

treating physician's report and disregard others. Eduland v. Massanari, 253 F.3d 1152, 1159

(9th Cir. 2001). When the ALJ does not provide adequate reasons for rejecting an examining

physician’s opinion, that opinion is credited “as a matter of law.” Lester v. Chater, 81 F.3d 821,

834 (9th Cir. 1995) (quoting Hammock v. Bowen, 879 F.2d 498 (5th Cir.1989)). 

Plaintiff contends that the ALJ selectively reviewed the medical record, using earlier

assessments rather than later more restrictive findings, when the most recent are the most

probative. Specifically, Plaintiff contends that the ALJ ignored some of Dr. Phillips' limitations

in his later opinions, including the December, 2001 opinion, even though, according to the VE,

these limitations would preclude a hypothetical claimant from work. Instead, the ALJ used the

May, 2000 report that Plaintiff "could perform light work with no forceful use of her right upper

extremity" ignoring the next sentence where Dr. Phillips stated that she "cannot reach, lift, push

or pull with the right upper extremity." In addition, Plaintiff asserts that the ALJ provided no

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reasons for rejecting the treating physicians' opinions, particularly in light of the VE's testimony

that when all of Dr. Phillips' limitations are considered, including those listed in his November,

2000 and December, 2001 notes, in addition to Dr. Guidera's hand limitations, that a

hypothetical claimant with those limitations could not work. In addition, the VE testified that

with Dr. Bodell's November, 2000 limitations, in addition to Dr. Guidera's hand limitations, a

hypothetical claimant could not work.

The ALJ's adoption of Dr. Phillips' older assessment was less probative of Plaintiff's

condition. Young v. Heckler, 803 F.2d 968 (9th Cir. 2001). It was also improper to selectively

adopt one sentence in the opinion, while ignoring the next sentence. Eduland v. Massanari.

The ALJ give no explanation for rejecting the majority of Dr. Phillips' and Dr. Bodell's

opinions, which necessarily means that he did not give the “specific and legitimate reasons”

supported by substantial evidence in the record. Lester v. Chater. This is particularly important

because of the VE's conclusion, based upon their limitations, in addition to those listed by Dr.

Guidera, that Plaintiff would be precluded from work. The Court finds that in light of the ALJ's

failure to give any reasons for rejecting these opinions, they will be accepted as true as a matter

of law. Id.

Credibility Findings

The ALJ is responsible for determining credibility, resolving conflicts in medical

testimony, and resolving ambiguities. Andrews, 53 F.3d at 1039. The ALJ’s finding must be

supported by specific, cogent reasons. Reddick, 157 F.3d at 722. Once the claimant produces

medical evidence of an underlying impairment, the ALJ may not discredit the claimant’s

testimony as to the severity of her symptoms merely because they are unsupported by objective

medical evidence. Id. The ALJ can discredit claimant’s allegations based on inconsistencies

in testimony, but cannot discredit solely because the degree of pain alleged by the claimant is

not supported by objective medical evidence. Bunnell v. Sullivan, 947 F.2d 341, 346 (9th Cir.

1991). Unless there is affirmative evidence showing that a claimant is malingering, the ALJ’s

reasons for rejecting the claimant’s testimony must be “clear and convincing.” Lester v. Chater.

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“General findings are insufficient, rather the ALJ must identify what testimony is not credible

and what evidence undermines the claimant’s complaints.” Id. Where the ALJ fails to properly

refute a claimant’s testimony regarding her symptoms, that testimony is accepted as true as a

matter of law. Rodriguez v. Bowen, 876 F.2d 759, 661 n.6 (9th Cir. 1989). Finally, an ALJ may

not selectively rely on treatment notes in rejecting a claimant's credibility. Holohan v.

Massanari, 246 F.3d 1195, 1208 (9th Cir. 2001).

The Court finds that the ALJ committed reversible error in evaluating Padilla's

credibility. He found that "[w]hile there is objective support for claimant's allegations of pain,

the undersigned finds the claimant's pain is not as limiting as she alleges." SSR 96-7p requires

detailed instructions regarding the analysis of credibility as it relates to pain. The ALJ may

discount subjective complaints only if there are inconsistencies in the record as a whole,

supported by substantial evidence. Regennitter v. Comm'r of Soc. Sec. Admin., 169 F.3d 595,

599 (9th Cir. 1999). The level of activity must be inconsistent with claimed limitations. 

The ALJ listed daily activities "including the ability to wash dishes, water plants, shop

for groceries with assistance, and prepare meals," but did not explain how those activities were

inconsistent with claimed limitations in walking, sitting and standing. The ALJ cannot rely on

a claimant’s limited activities of daily living to demonstrate the ability to perform substantial

gainful activity because many home activities are not transferable to the workplace where it may

be impossible to periodically rest or take medication. Vertigan v. Halter, 966 F.3d 1044, 1049-

50 (9th Cir. 2001); Fair v. Bowen, 885 F.2d 597, 603 (9th Cir. 1989). In addition, disability

claimants should not be penalized for attempting to lead normal lives in the face of their

limitations. Reddick, 157 F.3d at 722.

The ALJ also noted that although Plaintiff testified she had difficulty walking and

standing, the "medical record did not evidence any problems that would impact her ability to

walk or stand." However, as Plaintiff points out, this ignores her obesity as a contributing

factor; in addition, she testified that walking causes shoulder pain and swelling, and sitting

causes her arms to go numb on the arm rest. The ALJ was not free to discredit this testimony

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solely because the degree of pain alleged by Plaintiff was not supported by objective medical

evidence. Bunnell v. Sullivan. Because there has been no suggestion of malingering in this

case, the ALJ was required to give clear and convincing reasons for rejecting Plaintiff's

testimony. Lester v. Chater. The ALJ's credibility assessment was legally insufficient.

Therefore, her testimony is credited as a matter of law. Id.

Hypothetical Question to Vocational Expert

Plaintiff next maintains that the ALJ did not consider the opinions of doctors regarding

Plaintiff's shoulder impairment when asking the hypothetical question, thereby violating 20 CFR

§ 1527(2)(b), which requires that he consider and evaluate every medical opinion submitted in

connection with a claim. Dr. Guidera’s own notes and his Physical Capacity Evaluation

indicate that his opinion is limited to his treatment of her carpel tunnel syndrome, because he

was not the treating physician for her shoulder problems (TR 472). The ALJ was required to

base his hypothetical on medical assumptions supported by substantial evidence in the record

that reflected not just Plaintiff's hand limitations, but her shoulder limitations as well. Light v.

Social Security Administration, 119 F.3d 789, 793 (9th Cir. 1997). This is particularly

significant in light of her testimony, and the supporting medical opinions, that her shoulders

were the main medical problem which prevented her from returning to work. Finally, as

outlined above, when the VE was posed with the hypotheticals taking into account all of

Plaintiff's impairments, she found that Plaintiff could not work. As such, her testimony

constitutes substantial evidence, supporting a disability finding.

REMAND

The decision whether to remand a case for additional evidence or simply to award

benefits is within the discretion of this Court. Swenson v. Sullivan, 876 F.2d 683, 689 (9th

Cir.1989). A remand for further proceedings is unnecessary if the record is fully developed and

it is clear from the record that the ALJ would be required to award benefits. Holohan v.

Massanari, 246 F.3d 1195, 1210 (9th Cir. 2001). This rule recognizes the importance of

expediting disability claims. Ghokassian v. Shalala, 41 F.3d 1300, 1303 (9th Cir. 1994).

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When the ALJ does not provide adequate reasons for rejecting a treating physician’s

opinion, that opinion is credited “as a matter of law.” Lester v. Chater, 81 F.3d at 834 (quoting

Hammock v. Bowen, 879 F.2d 498, 502 (9th Cir. 1989)). Here, the ALJ did not provide adequate

reasons for rejecting the majority of the treating physicians' opinions. Similarly, where the ALJ

fails to properly refute a claimant’s testimony regarding her symptoms, that testimony is

accepted as true as a matter of law. Rodriguez v. Bowen, 876 F.2d 759, 761 n.6 (9th Cir. 1989).

In this instance, the ALJ did not provide clear and convincing reasons for characterizing

Plaintiff’s testimony as not credible. Thus this Court accepts Plaintiff’s symptomatic testimony

as true as a matter of law. Finally, taking into consideration the VE's testimony responding to

counsel's hypotheticals which included the impairments from her wrists and shoulders, the VE's

testimony constitutes substantial evidence supporting a finding of disability.

IT IS HEREBY ORDERED that Plaintiff’s Motion for Summary Judgement is

GRANTED (Doc. #8-1).

IT IS FURTHER ORDERED that Defendant’s Cross Motion For Summary Judgement

is DENIED (Doc. #16). 

IT IS FURTHER ORDERED that this case be remanded to the Social Security

Administration for an award of benefits (Doc. #8-2).

DATED this 28th day of September, 2005.

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