Category: The Soap Box

Empathy and the End of Life

Empathy and the End of Life

Sometimes in our line of work, our patients do not get better.  Sometimes, despite our best efforts, they get worse.  And sometimes they die.  This month  has been a difficult one, as the majority of my hospital caseload has included patients at the end of life.  I have also had a graduate student working with me. Needless to say, we have experienced many “teachable moments” together this month and my twitter feed has been surprisingly supportive (see posts/retweets @CCCSLPNET).

What  I have learned/tried to teach is:

The  importance of  understanding the patient’s goals and perspective.

The importance of withholding  my personal feelings/judgements while providing the most accurate information I can to explain the patient’s deficits.

The importance of alternatives, knowing that if ‘Plan A’ does not meet the patient’s goals, there needs to be a ‘Plan B’, and possibly a ‘Plan C’.

The importance of teamwork

I am fortunate to work with a wonderful team of physicians, nurses, dietitians, case managers and a great Palliative Nurse Practitioner.  Through these collaborations I have learned that the Palliative Care conversation, that “first conversation” can happen early, before the end of life, to help clarify the patient’s goals for care in  order to mitigate unnecessary care and  avoid unwanted returns  to the hospital. I have learned to avoid blaming the patient for their informed choices by endeavoring to eliminate the  term “non-compliant” from my documentation.  If after education, the patient decides not to follow my recommendations, that is their choice.  They are not non-compliant.  They are choosing a different course of care based on their goals/values.  I need to respect that.

My biggest contribution to my team has been in providing education regarding what alternative nutrition (G tubes) can and cannot do for chronically ill patients at the end of life. Knowing that G tubes are contraindicated in patients over 75, with advanced dementia, advanced/chronic illness, low BMI, previous aspiration and UTI and that there is no evidence that tube feeding in patients with advanced dementia prolongs survival, prevents aspiration pneumonia, reduces the risk of pressures sores or infections, improves function or provides comfort has helped our team in its quest for compassionate care.

It is always an on-going process.  Each patient is different and it is never easy, but we strive. I remind myself that it is an honor and a privilege to  assist in the care of these patients at this stage of their life…. That helps.

For more information regarding Palliative Care and PEG tubes see:
Plonk Jr., WM. To PEG or Not to PEG. Practical Gastroenterology. July, 2005.  pp 18-31.  Great summary with multiple additional references.

About the Author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.
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What are you thankful for?

What are you thankful for?

Please join me on the Soapbox on this Thanksgiving Day to share what you are grateful for.

I am thankful for so many things:

My family  because they possess unconditional love

My son because he is my greatest joy

My friends because they are such greats listeners

My patients who get better because they make me proud

My patients who don’t get better because they teach me humility

People who are pleasant because they make me smile

People who are not pleasant because they teach me patience

The good things which make me happy

The bad things which make me stronger

Chocolate when I am happy

Chocolate when I’m sad

Fleece sheets and a toasty fire on a cold winter night

A cool a breeze and an icy beverage on a warm night

Household appliances which work most of the time

A short commute

And…..

All of the support we have gotten for this website

Thank you so much

Happy Thanksgiving to All!

*****post what you are thankful for below*****…

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How Do You Count Success?

How Do You Count Success?

by Lisa Yauch-Cadden, MS CCC-SLP

Here at ASHA 2013, I am not standing on my soapbox, I am standing on a mountain peak. The journey to get here started when 2 friends began chatting about work, needing an ear to listen, a shoulder to cry on. That conversation grew into a website, a Facebook page and a Twitter feed. Now we have 1000 friends who can share ideas, frustrations, successes and be an ear to listen and a shoulder to cry on.

The climb up this mountain was not easy, but we persevered. We have much more to do, but the view is awesome and we can’t wait to see what awaits us. We invite all of our colleagues to join us in a conversation about our favorite subject: Communication disorders. Nothing is off limits, because there are no limits when we work together. Welcome to cccslp.net. Join us as we continue our climb.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.…

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Productivity Schmroductivity

Productivity Schmroductivity

by Lisa Yauch-Cadden, MS CCC-SLP

“You need to get your productivity up”.
“Your productivity is way down”.
“Speech Efficiency needs to improve”.
“We need to fill these gaps in your schedule”.
“You’re spending too much time with your patients”.
“We have to do more with less.”

And the list goes on….

I know there is not one clinician out there who has not heard these words and been totally frustrated by them. Within all of these quotes is the assumption that we are doing something wrong; that we do not know how to do our jobs and that we are wasting time and money. In all my years as an SLP, providing direct care and supervising others, from new grads to seasoned clinicians, I would say that this is rarely the case. Most of the time, nay nearly all of the time, we are working in the service of our patients, and if you, like me are the only clinician at your site, I would say that except for lunch and bathroom breaks (and sometimes not even those) you are spending all of your your time in the service of your patients.

The problem of course is defining what is “productive time”? Most often, it is considered “direct” time with the patient, which according to Medicare is the face to face time we spend with the patient. This of course would be a fine tracker of productivity, if Medicare (and everyone else) didn’t require that we document our time with the patient, according to their guidelines (of course), so that they will not look back retrospectively and deny our servicies. It would also be a fine indicator of productivity if we didn’t have to deal with pesky things like doctors and doctor’s orders and families and referring clinicians and other team members, and patients who get sick and can’t/won’t participate. If we worked in a vacuuum with patients that came to us on a conveyor belt, we could just go from patient to patient and be 100% productive. That would be grand….And it would be wrong.

That is because patients are people and they deserve respect. They deserve our time and our thought and our planning and our follow through. As we all know, a treatment session isn’t just our time with the patient. It is the chart review and the materials preparation and the face to face time and the documentation and the billing and the call to the family, physician or fellow clinician. It should involve collaboration and teamwork. All of that is skilled service. If we don’t do it and do it well, then, while we may have been very efficient, we haven’t been very effective.

And that is why I say productivity schromuctivity. Because it all counts! It’s all important. You can put any productivity standard out there that you want, but if all those things don’t happen, you won’t get paid anyway. The patient won’t make progress and we will find ourselves further marginalized in healthcare, as payors decide that treatment doesn’t benefit the patient.

So, what to do? Well, first things first, determine who is appropriate for services and treat the patient to the best of your ability. Do the right thing. Document appropriately. And at all times advocate for your patients and yourself. Most often, when “efficiency” is down, it is because someone decided to stop counting something that needs to be done or decided that it should take less time to do something than it actually does. Most often the people that decide these things are not clinicians. People often quote the “7 minute” rule to demonstrate built in “down-time” or “indirect time” with Medicare patients. Well this would be fine if built in down-time was recognized across all payors and if notes (daily, weekly, monthly,etc.), team communication, etc., only took seven minutes and if you could always wrap up or extend your sessions to capitalize on those 7 minutes. In my experience, this is rarely the case.

Furthermore, the least expensive care for the patient is at the bedside. We should be advocating for more therapy hours not less to improve levels of function and patient independence, in order to decrease burdens of care and chronic hospitalizations. Our patients at every level, need more, appropriate, state of the art therapy, not less. If we cease to advocate for ourselves and our patients, we will find that we will have no problem being efficient, because there will be no one left for us to treat.

Your thoughts?

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.…

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Celebrating Differences

Celebrating Differences

In a status update on our Facebook page, I posted a quote form Arthur Helps (which I discovered through our Twitter feed– thank you disability.gov!):  “Wise sayings often fall on barren ground, but a kind word is never thrown away”.

I was going to use this as a stepping stone to get up on my soap box to remind one and all that it is often not our expertise, evidence based practice or academic platitudes that make the most difference to our patients, but our kindness and our understanding that has the biggest impact.

Then I went in search of Arthur Helps and discovered that Sir Arthur was educated at Eton and Cambridge, and served as Dean to the Privy Council during the reign of Queen Victoria. Then I discovered some more of his writings and had even more to think about.  In this political season and as many of us return to work after a summer break, these thoughts seem rather timely……

“In the first place, if people are to live happily together, they must not fancy, because they are thrown together now, that all their lives have been exactly similar up to the present time, that they started exactly alike, and that they are to be for the future of the same mind. A thorough conviction of the difference of men is the great thing to be assured of in social knowledge: it is to life what Newton’s law is to astronomy. Sometimes men have a knowledge of it with regard to the world in general: they do not expect the outer world to agree with them in all points, but are vexed at not being able to drive their own tastes and opinions into those they live with. Diversities distress them. They will not see that there are many forms of virtue and wisdom. Yet we might as well say, “Why all these stars; why this difference; why not all one star?”

“Many of the rules for people living together in peace, follow from the above. For instance, not to interfere unreasonably with others, not to ridicule their tastes, not to question and re-question their resolves, not to indulge in perpetual comment on their proceedings, and to delight in their having other pursuits than ours, are all based upon a thorough perception of the simple fact, that they are not we” (The Art of Living with Others, 1848).

They are not we.  I love that.  As people and professionals, we should embrace that.  All people have value.  All people are different.  We should celebrate those differences, seek common ground and work toward real solutions and optimal outcomes.  Forget platitiudes, name calling and blaming.  Of course, we must work from a sound knowledge base and within the scope of reality.  It would not be wise to embrace foolishness or danger, without recognizing and voicing the risks, but when we work diligently and cooperatively we can do great things.  Our actions and our kindness are what matters.  The rest is just “blah blah blah”.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.…

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Thank you!

Thank you!

I am standing on my soap box right now and shouting out a big THANK YOU! to anyone visiting or returning to our site. We have been away a while but we have not forgotten about you or our craft. We continue to toil every day in our jobs, often alone with little to no recognition. So I am here right one to say THANK YOU to you for all that you do. For all of the endless hours you spend working with your patients, and thinking about your patients, and planning your treatments. For all of the follow-up that you do with families and physicians and teachers and payors- thank you for all that goes unnoticed and unacknowledged. You deserve a pat on the back and probably more. But right now, my words will have to suffice.

I hope this site will help you find support and be a place for your voice. And if you are in a position to thank someone for their work or their help, please do so. We don’t hear enough of that as professionals (or probably as people). My colleague just started a new job. After her first few days, she was sincerely thanked by her boss for her efforts and the contributions she had already brought to the team. She was appreciative, but also realized that the last time she had been thanked for her work was when she worked for me, and that was 10 years ago! That’s a long time to go without recognition, wouldn’t you say?

So before you start that e-mail, or note, or conversation or performance review, remember to say thank you, the person on the receiving end has probably done something worthy of recognition and might be happy and likely much more cooperative if you noticed it.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.…

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I hope you had a good day

I hope you had a good day

By Lisa Yauch-Cadden

“I hope you had a good day”

My family and I are ABC News fans. I always loved Peter Jennings. I, like many people was saddened at his passing, and I thought my news program would never be the same. I liked Peter’s sense of gravity and calm. He was always well so spoken and articulate, even in times of crisis, even when he was speaking extemporaneously – now that was a man you could trust. I now like Diane Sawyer very much, better in fact than I thought I would. But in between Peter and Diane, there was Charlie Gibson, and I loved Charlie. I thought he was great on Good Morning America, was happy when they brought him back and was really happy when he picked up the evening news. He had a fatherly, folksy way of delivering the news, was also well spoken and he had a great sign off – “I’m Charles Gibson and I hope you had a good day”. I loved that! What a great way to end a newscast. After all the bad news he’d delivered, he encouraged us take a moment to reflect on our day, and for me, that was refreshing, because I rarely had an opportunity to think about that when I was working 8, 10, 12 hours a day and always wondering what I had to do next.

I find that even now, when I am working just 30-35 hours a week, primarily in one location, with very little travel, that I can still get caught up in my day; rushing from patient to patient, worrying about productivity, always thinking: What do I have to do next? What else can I get done? What have I left undone? What’s on the schedule for tomorrow? Only recently, have I been able to slow my thought processes to reflect on my day. Was it a good day? Did I make a difference? Did I help someone? Did I contribute? Lately, I have been able to answer “Yes” to these questions, and to answer Charlie, I am having more “good days”.

So what’s changed? My caseload is about the same as it was a year ago. It goes up and down with the hospital census (and the flu season). The out-patient schedule is fairly constant. The productivity demands are the same. There has been no significant change in personnel as it relates to my position. So the difference must be me. I have changed how I look at my job. I am still cognizant of the productivity demands. I am still accountable to lots of people, but my top priority is to be of service to my patients – to do the best job I can and to provide them with as much information as possible to make decisions about their care, as it relates to my portion of the treatment plan (usually swallowing). I spend time educating patients and families, reviewing MBSs in detail, providing treatment beyond just the diagnostic kind, establishing home programs and making sure they understand what their options are. I am not successful 100% of the time, but more often than not, I feel like I am making a difference. When I reflect on my day, I can say, “Yes, it was a good day”.

I think if we can all find those small moments, those 1 or 2 patients, that if not for you, they might not be doing as well, that through your knowledge or kindness, you improved the quality of their life or their opportunity for a better outcome. If we can reflect on those things at the end of the day, we can all have a good day and look forward to a better tomorrow.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.

If you have something to say, please submit your article for consideration to lycslp@gmail.com. .…

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R-E-S-P-E-C-T

R-E-S-P-E-C-T

By Lisa Yauch-Cadden

“R-E-S-P-E-C-T”

As someone who grew up in Motown, I know a little bit about Aretha Franklin and her mantra. As a clinician who has been around awhile, I know a lot about why it is so important.

In our business, we deal with all kinds of people: patients, families, physicians, nurses, therapists, case managers, social workers, insurance representatives, students, etc. Like any business that involves personal interaction, everyone has a perspective, an agenda, a point of view. In our role as a diagnostician/therapist, we may need to bring all of these perspectives together, and if we can’t bring them all together, we certainly need to appreciate them. Every person that works with/interacts with our patient has a perspective about that patient, and those perspectives may be important to us. When I evaluate a patient, I always try to ask them what they think the nature of their problem is. I also ask their family members: “What problems do you see?” “Why do you think they are occurring?” I canvas the nurses and the CNAs. I consult with the physician. I ask the treating clinician (CFY, SLP-A) who may be working with them. All of these people invariably know the patient better than I do and their insights are important to me and to the patient. When I come to a conclusion, I let patients/families know, “Here’s what I think”. I seek confirmation, when I can, (e.g., “Does this make sense with what you see at home?”). It provides for a better recommendation, usually leading to one the patient can live with (think: modified diet/thickened liquids).

I also have used this approach as a manager and find that staff generally do a better job when you treat them with respect. I know, novel concept. Having worked for managers that don’t share this philosophy, however, makes me think that this is may not be an intuitive strategy for some people. The concept, however, is simple. People have their own opinions and perspective, as do you, and like you, people think that they are right. As a manager, you need to appreciate that, and sometimes solicit that perspective, in order to come to a shared conclusion. Like you, people need to be validated. Once you let them know that their perspective has value, they are much more likely to hear your side of the story. And when that side doesn’t necessarily agree with theirs, or doesn’t give them what they want, you are less likely to have problems afterward, as long as you’ve told them the truth.

And that’s the second part of the equation: Tell the truth. Respect the person you are dealing with enough to let them know the truth. If they know you are being truthful, even if they don’t like what they are hearing, they are more likely to accept it. Isn’t that how you would like to be treated? Imagine what a world it would be if everyone acted this way.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com. .

If you have something to say, please submit your article for consideration to lycslp@gmail.com. .…

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Why we need to show up

Why we need to show up

By Lisa Yauch-Cadden

“Why we need to show up”

As we mentioned in our welcome to this website, Speech Language Pathology can be a profession of great joy, and great loneliness. Often, as sole practioners in schools, hospitals, rehab centers, medical/private offices, and home care settings, we may be the only source of speech and language services available to a child or adult in our community. I have personally worked in hospitals, with no out-patient treatment services, skilled nursing facilities with no/poor access to home care services, schools where families cannot afford additional services through out-patient clinics, and in out-patient settings, where support from the school system has been limited. I have also known clinicians who, all by themselves are the hospital based SLP, the homecare SLP, the school therapist and the out-patient provider. In these situations, we have a huge responsibility to our patients. We may be the only one to diagnose and treat a patient’s problem, or provide a family or physician with needed information. Yet, over the past several years, I have noticed more and more therapists, not taking these responsibilities so seriously.

I have known therapists to cancel appointments for convenience or to avoid a patient with behaviors, therapists that utilize the same treatment approach with multiple patients regardless of individual needs, and utilize the same treatment materials with the same patient, over and over, and then blame the patient when he/she doesn’t make progress. I have worked in facilities where staffing required multiple SLPs to service the same patient on different days, and because no single SLP felt responsibility for the patient, (they were “just covering”, after all), the patient failed to make progress. I have met with indignant therapists, astonished that a payor source would require accountability, prior to paying for services, and I have seen talented therapists leave the field, because they did not want to play by a new set of rules.

In all of these instances, I am reminded that, while as therapists, we think that Speech Language Pathology is about us – our skills, our expertise, our credentials. It is not. It is about the patient. Every client that crosses our path is referred to us, because someone who cares about that person has a question or a concern that needs to be addressed. Someone in that patient’s family, desperately wants them to get better, and often we are the only ones to whom they can turn. We cannot phone it in. We have to show up.

When Mrs. Jones sends her 3 year old autistic son to the school or the out-patient clinic, she is putting her baby in our hands, and hoping for progress. When the homecare clinician sends her patient for an MBS/FEES, she is looking for specific information on the nature of that patient’s dysphagia, as well as recommendations for intervention. When Mr. Smith, an 88 year old man enters the skilled nursing facility for rehab, he is relying on us to understand his Medicare benefit, and entrusting us get him the services he deserves. When we think it is beneath us to be told to provide 35 minutes of care or make sure that we see a patient on Thursday vs. Friday, or write a note that conveys an appropriate level of service, we only hurt the patient, and put them at risk for losing the services, to which they are entitled. And when we cover multiple facilities/multiple patients with multiple clinicians, we need to be responsible for our session, and advance the treatment plan. It is our responsibility to understand our patients’ problems and their payor source and provide skilled intervention to meet their goals.

Now, I know it is hard to bring your ‘A’ game every day, and there are lots of forces that conspire against us (family, kids, traffic, heavy caseloads, limited access to materials, uncaring bosses, budget cuts, etc.). Sometimes patients are needy and families are unrealistic, and our caseloads are unending, and on some days, we have to leave by 3:00 p.m., no questions asked, but we owe it to our patients to try our best, everyday, and honor the implied trust between us. If the situation were reversed, we would expect nothing less.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.

If you have something to say, please submit your article for consideration to lycslp@gmail.com.…

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