Coleman v. Social Security Administration, Commissioner
MEMORANDUM OF DECISION. Signed by Judge R David Proctor on 8/1/2016. (AVC)
2016 Aug-01 PM 04:29
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
CAROLYN W. COLVIN,
Acting Commissioner, Social Security
Case No.: 4:15-CV-01137-RDP
MEMORANDUM OF DECISION
Plaintiff Brenda Coleman brings this action pursuant to Sections 205(g) and 1631(c)(3) of
the Social Security Act (the “Act”), seeking review of the decision of the Commissioner of
Social Security (“Commissioner”) denying her claims for a period of disability, disability
insurance benefits (“DIB”), and Supplemental Security Income (“SSI”). See also, 42 U.S.C. §§
405(g) and 1383(c). Based on the court’s review of the record and the briefs submitted by the
parties, the court finds that the decision of the Commissioner is due to be affirmed.
On September 20, 2012, Plaintiff filed her application for a period of disability and DIB
with a concurrent application for SSI. (Tr. 16). Both applications alleged that her disability began
February 1, 2012. (Id.). Plaintiff’s claims were initially denied by the Social Security
Administration on January 2, 2013. (Id.). After Plaintiff requested a hearing before an
Administrative Law Judge (“ALJ”), a hearing was conducted on April 28, 2014. Plaintiff’s
applications were denied on September 22, 2014. (Tr. 16, 43, 37). The ALJ determined that,
contrary to her claims, Plaintiff had not been under a disability as defined in the Act since
February 1, 2012, the alleged onset date. (Tr. 37). After the Appeals Council denied Plaintiff’s
request for review of the ALJ’s decision, that decision became the final decision of the
Commissioner, and therefore a proper subject of this court’s appellate review. (Tr. 1). 42 U.S.C.
§§ 405(g) and 1383(c).
At the time of the hearing, Plaintiff was fifty-three years old. (Tr. 301). She had
completed high school and had additional training qualifications including registration as an
apartment manager, a real estate license, and telecommunicator/911 training. (Tr. 49; Gov. Mem.
2). Plaintiff stopped working in December 2011, and alleged in her hearing that she has been
unable to engage in substantial gainful activity (“SGA”) since February 1, 2012 due to
impairments. (Tr. 49).1 Plaintiff reported that she was limited in her working ability due to
diabetes, hypertension, arthritis, temperomandibular joint dysfunction (“TMJ”) and depression.
operator/telecommunicator, a billing and loan clerk, and a gaming manager. (Tr. 36).
Plaintiff has a history of hypertension, poorly controlled diabetes mellitus—type II, and
obesity. (Tr. 310-311, 369). She complains of tingling and sometimes numbness in her feet, and
osteoarthritis that affects her ankles, knees, hands, and shoulders.2 Plaintiff claims that the pain in
her jaw, hands, legs, and most joints is constant, and prevents her from lifting, squatting, using
her hands, and walking more than half a block without rest. (Tr. 19). She has no difficulty with
“bathing, shaving, feeding herself or using the toilet.” (Id.). While her daughters help her with
However, Plaintiff gave a non-impairment related reason for leaving work in the Disability Report: She didn’t have
anyone to stay with her youngest daughter during work hours. (Tr. 19).
Plaintiff claims that she has to keep her feet elevated, though no physician record suggested elevation. (Tr. 21).
most household chores, Plaintiff sometimes cooks, helps with the laundry, and drives to shop for
groceries. (Id.). She also has a pet she cares for. (Id.).
Dr. Konstantins Kociasvili treated the Plaintiff from April 5, 2011 to August 24, 2011.
On April 5, 2011, Plaintiff was admitted to Stringfellow Memorial Hospital with complaints of
“general weakness, not feeling well, uncontrolled diabetes mellitus—type II, and severe
abdominal pain” (Tr. 28, 303). Her hospital stay was uneventful, and Plaintiff was discharged on
April 7, 2011, with diagnoses including “poorly controlled diabetes mellitus, hyperglycemia,
urinary tract infection, obesity, and hypertension.” (Tr. 29, 303).3 On August 12, 2011, Plaintiff
arrived at the emergency room complaining of abdominal pain. She underwent a laparoscopic
cholecystectomy, and was discharged on August 16, 2011. (Tr. 29, 309).
Dr. Muzamil Babiker treated the Plaintiff from August 14, 2012 to July 29, 2013. (Tr.
29). Plaintiff visited Dr. Babiker on August 14, 2012 complaining of jaw pain, bruising on her
left foot, and numbness and tingling in her hands. (Tr. 338). Dr. Babiker diagnosed her with
diabetes mellitus, hypertension, obesity, depression, and left side TMJ. (Tr. 339). Plaintiff
returned to Dr. Babiker’s office again on August 27 and September 6, 2012 for follow-up
appointments, but no significant changes were made to her care plan. (Tr. 337).
Plaintiff saw Dr. Babiker at Cleburne Medical Clinic on October 22, 2012, reporting
symptoms of multiple joint pain. (Tr. 347, 389). Under the musculoskeletal portion of the record,
Dr. Babiker noted that Plaintiff exhibited “no clubbing, cyanosis, or edema. Grossly normal
motor and strength.” (Id.). Regarding the subject “neurological” he recorded, “No focal deficit.”
(Id.). After this visit, he added unspecified multiple site osteoarthritis to her diagnoses.
Dr. Kociasvili includes diabetic neuropathy in Plaintiff’s past medical history, but there doesn’t seem to be any
clinical evidence supporting this diagnosis. (Tr. 305).
Plaintiff returned on November 8, 2012 with “recurrent pain, swelling and cramping in
her hands.” (Tr. 350, 361, 385). Next to “musculoskeletal,” Dr. Babiker wrote, “Patient denies
muscle weakness, joint pain or back pain. Patient complains of swelling and cramping in both
her hands.” (Tr. 351, 362, 386). He again confirmed his assessment of unspecified multiple site
On November 27, 2012, Plaintiff saw Dr. Babiker for increased pain in her jaw, hip, and
hands. (Tr. 364, 381). Again, Dr. Babiker found “no clubbing, cyanosis, or edema. Grossly
normal motor and strength.” (Tr. 365, 382). However, he did not diagnose Plaintiff with
unspecified multiple site osteoarthritis after this visit. (Tr. 366, 383). Rather, his neurologic
assessment of Plaintiff was normal. (Tr. 365, 382).
On March 18, 2013, Plaintiff complained of pain in her left wrist. (Tr. 378). Dr. Babiker
noted tenderness in her wrist, but no swelling. (Tr. 379). He took an X-ray of her wrist and found
only a sprain. (Tr. 380, 419). He again diagnosed her with unspecified multiple site
Plaintiff was admitted to Northeast Alabama Regional Medical Center on May 10, 2013
with an elevated blood pressure, because she didn’t refill her blood pressure medication. (Tr.
398-399). The admitting physician wrote, “Rest of examination is unremarkable including
neurological examination.” (Tr. 402). The physicians placed her on her regular blood pressure
medication, and she was released four days later. (Tr. 399).
Plaintiff’s last recorded visit with Dr. Babiker occurred on July 29, 2013. (Tr. 416).
Plaintiff had pain in her right knee and hand, but denied “muscle weakness, joint pain or back
pain.” (Id.). Dr. Babiker nevertheless confirmed his diagnosis of unspecified multiple site
osteoarthritis. (Tr. 417).
On July 28, 2013, Dr. Babiker completed a medical statement in which he opined that
“plaintiff had Type II diabetes and neuropathy, which caused her to be able to work no hours per
day, stand for only 15 minutes at a time, sit for 60 minutes at a time, and occasionally balance.”
(Gov.’s Mem. 8; Tr. 31, 403). He asserted that Plaintiff could stand/walk and sit for 0-2 hours
out of every 8-hour workday, could not lift any weight, and could not “use her hands for
repetitive fine manipulation or her feet for repetitive operation of foot controls.” (Gov.’s Mem. 8;
Tr. 31, 405). He further opined that Plaintiff could not work in any capacity and would never be
able to return to work. (Gov.’s Mem. 8; Tr. 31, 404-406).
Plaintiff also underwent a medical exam requested by the Disability Determination
Service and performed by Dr. Sathyan Iyer. (Tr. 369). Dr. Iyer wrote that Plaintiff could stand
without assistance, walk on her heels and tiptoes, and squat partially. (Tr. 370). She also had full
range of motion of the shoulders, elbows, hips, ankles, knees and wrists (Tr. 370-371). Dr. Iyer
did, however, note that there was slight tenderness over the right hand and knees. (Tr. 371). His
overall impression was that Plaintiff did not “appear to have any significant physical limitation.
However, depending on the activity state of the fibromyalgia problem, she could have
impairment of functions.” (Tr. 372).
Disability under the Act is determined under a five-step test. 20 C.F.R. § 404.1520.
First, the ALJ must determine whether the claimant is engaging in substantial gainful activity.
20 C.F.R. § 404.1520(a)(4)(i). “Substantial work activity” is work activity that involves doing
significant physical or mental activities. 20 C.F.R. § 404.1572(a). “Gainful work activity” is
work that is done for pay or profit. 20 C.F.R. § 404.1572(b). If the ALJ finds that the claimant
engages in substantial gainful activity, then the claimant cannot claim disability. 20 C.F.R. §
Second, the ALJ must determine whether the claimant has a medically determinable
impairment or a combination of medical impairments that significantly limits the claimant’s
ability to perform basic work activities.
20 C.F.R. § 404.1520(a)(4)(ii).
impairment, the claimant may not claim disability. Id.
Under the third step of this analysis, the ALJ must determine whether the claimant’s
impairment meets or medically equals the criteria of an impairment listed in 20 C.F.R. § 404,
Subpart P, Appendix 1. See 20 C.F.R. §§ 404.1520(d), 404.1525, and 404.1526. If such criteria
are met, the claimant is declared disabled. 20 C.F.R. § 404.1520(a)(4)(iii).
If the claimant does not fulfill the requirements necessary to be declared disabled under
the third step, the ALJ may still find disability under the next two steps of the analysis. The ALJ
must first determine the claimant’s residual functional capacity (“RFC”), which refers to the
claimant’s ability to work despite her impairments. 20 C.F.R. § 404.1520(e).
In the fourth step, the ALJ then determines whether the claimant has the RFC to perform
past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant is determined to be capable
of performing past relevant work, then the claimant is deemed not disabled. Id. If the ALJ finds
the claimant unable to perform past relevant work, then the analysis proceeds to the fifth and
final step. 20 C.F.R. § 404.1520(a)(4)(v).
In the final portion of the analysis, the ALJ must determine whether the claimant is able
to perform any other work commensurate with her RFC, age, education, and work experience.
20 C.F.R. § 404.1520(g). Here, the burden of proof shifts from the claimant to the ALJ to prove
the existence, in significant numbers, of jobs in the national economy that the claimant can do
given her RFC, age, education, and work experience. 20 C.F.R. §§ 404.1520(g), 404.1560(c).
Here, the ALJ determined that Plaintiff has not engaged in substantial gainful activity
since February 1, 2012, the alleged onset date. (Tr. 18). While the ALJ disagreed with Dr.
Babiker with respect to his finding of diabetes-related neuropathy and arthritis, she found that
Plaintiff suffers from the following severe impairments: obesity, hypertension, diabetes
mellitus—Type II, fibromyalgia, and mood disorder. (Tr. 18, 27; Gov.’s Mem. 12). However,
after taking into account the objective medical evidence and Plaintiff’s subjective
symptomology, the ALJ determined that Plaintiff “does not have an impairment or combination
of impairments that meets or medically equals the severity of one of the listed impairments in 20
CFR Part 404, Subpart P, Appendix 1.” (Tr. 24).
Considering the testimony of the Vocational Expert (“VE”), the ALJ found that although
Plaintiff is unable to perform past relevant work, she nevertheless retains the residual functional
capacity (RFC) to perform light work with limitations. (Tr. 26).4 Plaintiff must work at a job that
“allows for a sit/stand at will option, with the employer allowing changing positions every 45
minutes.” (Id.). She must elevate her feet 6-12 inches. (Id.). She can frequently use her hands for
reaching and fingering, but she can never kneel, crouch, crawl, climb, work with hazardous
machinery or work in extreme temperatures. (Id.). Furthermore, Plaintiff will not “require more
than 2 unplanned absences a month.” (Id.).5
The ALJ gave “little to no weight to Dr. Babiker’s opinion” in coming to its RFC finding. (Tr. 27).
Although the ALJ’s findings regarding Plaintiff’s depression are not directly relevant to the issues raised on
appeal, the ALJ found that Plaintiff can perform simple, routine tasks and concentration; occasionally interact with
coworkers; and concentrate and maintain persistence or pace for 2 hours at a time over an eight-hour workday. (Tr.
Plaintiff’s Argument for Reversal
Plaintiff raises three issues on appeal: (1) the ALJ did not accord proper weight to Dr.
Muzamil Babiker’s opinion and failed to state specific reasons for rejecting that opinion (Pl.’s
Mem. 11); (2) the ALJ’s finding that Plaintiff retains the RFC to perform light work with
limitations is not supported by substantial evidence (Pl.’s Mem. 16); and (3) the ALJ failed to
apply Grid Rule 201.14 (Pl.’s Mem. 20).
Standard of Review
The only issues before this court are whether the record reveals substantial evidence to
sustain the ALJ’s decision, see 42 U.S.C. § 405(g); Walden v. Schweiker, 672 F.2d 835, 838
(11th Cir. 1982), and whether the correct legal standards were applied. See Lamb v. Bowen, 847
F.2d 698, 701 (11th Cir. 1988); Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). Title 42
U.S.C. § 405(g) mandates that the Commissioner’s findings are conclusive if supported by
“substantial evidence.” Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). The district
court may not reconsider the facts, reevaluate the evidence, or substitute its judgment for that of
the Commissioner; instead, it must review the final decision as a whole and determine if the
decision is reasonable and supported by substantial evidence. See Id. (citing Bloodsworth v.
Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)).
Substantial evidence falls somewhere between a scintilla and a preponderance of
evidence; “[i]t is such relevant evidence as a reasonable person would accept as adequate to
support a conclusion.” Martin, 894 F.2d at 1529 (quoting Bloodsworth, 703 F.2d at 1239) (other
citations omitted). If supported by substantial evidence, the Commissioner’s factual findings
must be affirmed even if the evidence preponderates against the Commissioner’s findings. See
Martin, 894 F.2d at 1529. While the court acknowledges that judicial review of the ALJ’s
findings is limited in scope, the court also notes that review “does not yield automatic
affirmance.” Lamb, 847 F.2d at 701.
The ALJ Properly Considered the Opinion of Muzamil Babiker, M.D.
It is well established in the Eleventh Circuit that “the testimony of a treating physician
must be given substantial or considerable weight unless ‘good cause’ is shown to the contrary.”
Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1159 (11th Cir. 2004) (quoting Lewis v.
Callahan, 125 F.3d 1436, at 1140 (11th Cir. 1997), Edwards v. Sullivan, 937 F.2d 580, 583-84
(11th Cir. 1991). Good cause to discount a treating physician’s opinion exists when the: “(1)
treating physician’s opinion was not bolstered by the evidence; (2) evidence supported a contrary
finding; or (3) treating physician’s opinion was conclusory or inconsistent with the doctor’s own
medical records.” Phillips v. Barnhart, 357 F.3d 1232, at 1241 (11th Cir. 2004).
The ALJ rejected Dr. Babiker’s opinion because it was “not well supported by his
treating notes.” (Tr. 21). Specifically, his opinion was lacking in clinical evidence of hand or
joint difficulties and neuropathy. (Id.) During Plaintiff’s visits to Dr. Babiker from 2012 to 2013,
she complained mostly of hip, knee, and hand pain. Despite these complaints, his treating notes
consistently showed that the clinical examinations of the musculoskeletal and neurological
systems were normal and that Plaintiff denied the presence of joint pain. (Tr. 22, 347, 351, 362,
365, 382, 386, 389).
The ALJ concluded that there is nothing in Dr. Babiker’s clinical observations that would
support an arthritis diagnosis, let alone arthritis affecting unspecified sites. (Tr. 22) As the ALJ
stated, “It is of course difficult to find a medically determinable impairment is present, much less
objective evidence to support it, if the doctor is unable to specify the location of the condition.”
(Id.). Dr. Babiker never took an X-ray of Plaintiff’s hands, ankles, or knees that would reveal the
cause of her alleged joint pain. (Id.).6 Without medically determinable evidence of Plaintiff’s
alleged knee and hand pain, it was reasonable for the ALJ to conclude that Dr. Babiker’s arthritis
diagnosis was not supported.
Similarly, there was no objective evidence to support the presence of neuropathy (which
Dr. Babiker found so limiting to the Plaintiff in his medical source statement). (Gov.’s Mem. 9;
Tr. 21, 403). The word “neuropathy” is not mentioned in Dr. Babiker’s treating notes. (Tr. 22).7
While Plaintiff may have complained of pain, the record repeatedly denies “neurological
compromise.” (Tr. 22; Gov.’s Mem. 10). During her 2012 and 2013 visits, Dr. Babiker
consistently reported normal neurological functioning. (Tr. 347, 389, 402). In 2013, he planned
to perform a nerve conduction study, which would have effectively confirmed or denied a
neuropathy diagnosis, but the record shows no evidence that the study was ever completed. (Tr.
22, 417). Because Dr. Babiker never diagnosed Plaintiff with neuropathy in his treating record,
the ALJ’s decision to reject his opinion was reasonable.
Dr. Babiker’s opinion is also inconsistent with other record evidence, including the
consultative exam performed by Dr. Iyer and Plaintiff’s day-to-day activities. While Dr. Babiker
opined that Plaintiff would never be able to return to work due to the severity of her
impairments, Dr. Iyer reported that she did not “appear to have any significant physical
limitation.” (Tr. 372). The ALJ gave some weight to this opinion by adjusting her determination
Both the ALJ and the Government assert that Plaintiff’s hand X-ray was negative for arthritis, but the record
reflects the X-ray was actually of the wrist. (Tr. 419). Regardless, Dr. Babiker took no X-rays that would have
provided clinical evidence of his arthritis diagnosis.
In fact, the only neuropathy diagnosis prior to Dr. Babiker’s in his medical source statement appears in the medical
record from Plaintiff’s admission into Stringfellow Memorial Hospital in 2011. (Tr. 305). However, there does not
appear to be any clinical evidence to support this diagnosis.
to accommodate the probable existence of fibromyalgia. (Tr. 20, 24). Plaintiff’s lack of any
“significant physical limitation” is reflected in her daily activities as well. (Tr. 19, 62-63). This
evidence contradicts Dr. Babiker’s opinion, and the ALJ had good cause to discount his opinion.
Furthermore, Dr. Babiker’s opinion on issues relating to Plaintiff’s ability to work is not
entitled to weight. This is because it is not a medical opinion, but rather an opinion “reserved to
the Commissioner because they are administrative findings that are dispositive of a case; i.e., that
would direct the determination or decision of disability.” 20 C.F.R. §§ 404.1527(d), 416.927(d);
see SSR 96-5p; Denomme v. Comm’r, Soc. Sec. Admin., 518 F. App’x 875, 877-78 (11th Cir.
2013); Bell v. Bowen, 796 F.2d 1350, 1353-54 (11th Cir. 1986). Opinions that are reserved to the
Commissioner, even if offered by a treating physician, are not “entitled to controlling weight or
special significance.” See SSR 96-5p. (Gov.’s Mem. 7).
Substantial Evidence Supports the ALJ’s RFC Determination that Plaintiff
Has the Capacity to Perform Light Work.
Plaintiff argues in her brief that the RFC assessment was conclusory in that the ALJ
found that Plaintiff was able to perform light work, but incapable of performing her past relevant
work, which was sedentary. (Pl.’s Mem. 16-17). This assertion ignores the fact that an RFC
determination encompasses more than the “exertional level” of a particular job. (Gov.’s Mem.
13). In deciding that Plaintiff retained the RFC to perform light work, the ALJ factored in
additional limitations, including those that would have prevented Plaintiff from performing her
past relevant work. (Gov.’s Mem. 13; Tr. 26-27, 36).
Plaintiff argues the ALJ should have accorded greater weight to her complaints of hand
pain and numbness before making the RFC determination. (Pl.’s Mem. 17). The court disagrees.
The ALJ found Plaintiff’s complaints to be mostly subjective and unsupported by the record. (Tr.
27 ,32, 33, 35). Dr. Iyer’s examination combined with the overall lack of objective evidence of
arthritis or neuropathy in Dr. Babiker’s records suggests that Plaintiff likely had “normal
extremities, grip strength, and muscle power.” (Tr. 27, 29, 31, 32, 35, 370).
While Plaintiff concedes that the ALJ summarized the medical evidence, she further
contends that the RFC itself is conclusory, because it does not cite any rationale or supporting
evidence. This argument is apparently based on SSR 96-8p, which requires that the RFC
assessment “include a narrative discussion describing how the evidence supports each
conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence
(e.g., daily activities, observations).” (SSR 96-8P, 1996 WL 374184; Pl.’s Mem. 17). As the
Government correctly states, “Even a cursory reading of the decision belies Plaintiff’s
argument.” (Gov.’s Mem. 15). The ALJ more than adequately described her analysis of
Plaintiff’s medical records, the weight accorded to the physicians’ opinions, and the reasoning
behind the decision. (Tr. 21-22, 28-36). Plaintiff has not demonstrated error. 8
In support of her argument, Plaintiff points to Thomason v. Barnhart, 344 F.Supp.2d
1326 (N.D. Ala. 2004) (holding that the ALJ’s RFC assessment was invalid because the record
did not contain any “formal assessment” by either examining or non-examining physicians
addressing the claimant’s ability to perform work activities) and Coleman v. Barnhart, 264
F.Supp.2d 1007 (S.D. Ala. 2003) (holding that the ALJ’s RFC assessment was invalid because
no physical capacities evaluation was conducted.). However, Plaintiff’s reliance on Thomason
and Coleman is off the mark. In this case, Plaintiff’s treating physician as well as the consultative
Moreover, even if the ALJ did not follow an SSR, remand is unnecessary unless the claimant proves that she was
prejudiced as a result of the noncompliance. In this case, Plaintiff has not shown that she was prejudiced. Carroll v.
Soc. Sec. Admin., Comm’r, 453 F. App’x 889, 892 (11th Cir. 2011) (noting “we have held that an agency’s violation
of its own government rules must result in prejudice before we will remand to the agency for compliance.”).
examiner performed a formal assessment and a PCE which addressed Plaintiff’s working
The ALJ Did Not Err in Relying upon the VE’s Testimony as Part of the
Plaintiff’s final argument faults the ALJ for relying on VE testimony instead of MedicalVocational Guideline Rule 201.14 in determining Plaintiff could perform other work. (Pl.’s
Mem. 20-21). However, the problem with Plaintiff’s argument is that the Rule applies to
claimants who are limited to sedentary work only. The ALJ found that Plaintiff was not limited
to sedentary work alone; she is instead limited to light work with additional restrictions. (Tr. 2627).
Plaintiff conflates the distinction between the grid guidelines by asserting that because
she was limited to a reduced range of light work, it follows that she would fall into the sedentary
work category. (Pl.’s Mem. 21). In cases where a Plaintiff’s exertional limitations cannot neatly
fit into one of the regulatory definitions specified in the grid, SSR 83-12 directs the ALJ to
“consult a vocational resource.” (Gov.’s Mem. 17; SSR 83-12, 1983 WL 31253). The ALJ
properly assessed the Plaintiff’s RFC by consulting a VE. After doing so, the ALJ determined
that Plaintiff was not disabled. His findings related to that determination are supported by
The court concludes that the ALJ’s determination that Plaintiff is not disabled is
supported by substantial evidence and the proper legal standards were applied in reaching this
Plaintiff’s treating physician, Dr. Babiker, performed the PCE. (Tr. 403-406). The ALJ’s decision, the
Government’s brief, and this opinion explain why weight was not given to Dr. Babiker’s examination. (Tr. 13-42;
Gov.’s Mem. 8-12).
determination. The Commissioner’s final decision is therefore due to be affirmed. A separate
order in accordance with this memorandum of decision will be entered.
DONE and ORDERED this August 1, 2016.
R. DAVID PROCTOR
UNITED STATES DISTRICT JUDGE
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