Crown Scaffold Pty Ltd v King

Case

[2024] NSWPICMP 847

10 December 2024


DETERMINATION OF APPEAL PANEL
CITATION: Crown Scaffold Pty Ltd v King [2024] NSWPICMP 847
APPELLANT: Crown Scaffold Pty Ltd
RESPONDENT: Jordan King
APPEAL PANEL
MEMBER: Marshal Douglas
MEDICAL ASSESSOR: Mark Burns
MEDICAL ASSESSOR: John Brian Stephenson
DATE OF DECISION: 10 December 2024
CATCHWORDS: 

WORKERS COMPENSATION - Whether Medical Assessor (MA) erred by failing to explain his assessment of respondent’s impairment due to injury to long thoracic nerve; whether MA erred by combining respondent’s impairment due to restricted range of motion of left shoulder and respondent’s impairment due to injury to long thoracic nerve; whether MA erred by failing to grade the respondent’s impairment due to long thoracic nerve; Appeal Panel held MA erred by failing to grade the respondent’s impairment due to long thoracic nerve, but did not err with respect to the other matters appellant raised; respondent re-examined; Held – Medical Assessment Certificate revoked.

BACKGROUND TO THE APPLICATION TO APPEAL

  1. On 22 July 2024 Crown Scaffold Pty Ltd, the appellant, lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Rob Kuru, a Medical Assessor, who issued a Medical Assessment Certificate (MAC) on
    25 June 2024.

  2. The appellant relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act):

    ·        the assessment was made on the basis of incorrect criteria, and

    ·        the MAC contains a demonstrable error.

  3. The delegate is satisfied that, on the face of the application, at least one ground of appeal has been made out. The Appeal Panel has conducted a review of the original medical assessment but limited to the ground(s) of appeal on which the appeal is made.

  4. Rule 128 of the Personal Injury Commission Rules 2021 (PIC Rules) and Procedural Direction PIC7 - Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.

  5. The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed
    1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).

RELEVANT FACTUAL BACKGROUND

  1. The appellant employed Jordan King, the respondent, as a scaffolder.  On 6 July 2018 the respondent, while working for the appellant, fell 3.5m injuring his neck, left shoulder, back and both knees.

  2. The respondent had surgery on his left shoulder on 2 November 2018 when an arthroscopy, anterior stabilisation, capsular plication and labral reconstruction were done.  On
    29 August 2019 he had further surgery on his shoulder when further decompression and a repair of a SLAP lesion was done.  He also had surgery on his left knee and two surgeries on his right knee. 

  3. At the request of his solicitors, Dr Roger Pillemer, an orthopaedic surgeon, examined the respondent on 17 October 2022. In a report dated 21 October 2022 Dr Pillemer advised the respondent’s solicitors that he assessed the respondent had 27% whole person impairment (WPI) from his injury, being a combination of 7% WPI relating to his left upper extremity, 5% WPI relating to his lumbar spine, 6% WPI relating to his right lower extremity, and 1% WPI relating to his left lower extremity. Relying on that report, the respondent’s solicitors advised the appellant’s solicitors by letter dated 14 July 2023 that the respondent claimed compensation from it under s 66 of the Workers Compensation Act 1987 (the 1987 Act) for 27% WPI. 

  4. In order to respond to that claim, the appellant’s solicitors arranged for the respondent to be examined by orthopaedic surgeon Dr Peter Sharwood on 11 October 2023.  In a report dated 17 October 2023 Dr Sharwood advised the appellant’s solicitors he assessed the respondent had 8% WPI from his injury, being a combination of 0% WPI relating to the respondent’s cervical spine, 0% WPI relating to the respondent’s lumbar spine, 6% WPI relating to the respondent’s left upper extremity, 1% WPI relating to the respondent’s right lower extremity and 1% WPI relating to the respondent’s left lower extremity.  On 8 December 2023 the appellant’s insurer issued a dispute notice to the respondent pursuant to s 78 of the 1998 Act, advising him that it denied liability to pay compensation to him for permanent impairment from his injury.  It advised him that its reason for denying liability was that it considered
    Dr Sharwood’s assessment of his permanent impairment was “a more accurate assessment of your current impairment than the assessment Dr Pillemer had made”, which meant that his impairment did not exceed the threshold imposed by s 66(1) of the 1978 Act of greater than 10% to entitle him to compensation for permanent impairment.

  5. The respondent then instituted proceedings in the Personal Injury Commission (Commission) by filing an Application to Resolve a Dispute dated 19 December 2023. By that he sought the Commission determine his claim for compensation.  A delegate of the President of the Commission referred the medical dispute between the parties relating to the degree of the respondent’s permanent impairment from his injury to the Medical Assessor to assess.  The Medical Assessor examined the respondent on 10 May 2024 to do that and, as said, issued the MAC on 25 June 2024.  In that he certified the degree of the respondent’s permanent impairment from his injury is 20% WPI, being a combination of 18% WPI for the respondent’s left upper extremity (shoulder), 1% WPI for the respondent’s left lower extremity, 1% WPI for the respondent’s right lower extremity and 0% WPI for the respondent’s lumbar spine. 

  6. The appellant’s appeal against the Medical Assessor’s assessment of the medical dispute relates only to the Medical Assessor’s assessment of the respondent’s permanent impairment relating to his left upper extremity.

  7. The findings the Medical Assessor recorded in the MAC from his examination of the range of movement of the respondent’s shoulders were:

MOVEMENT

RIGHT

LEFT

Flexion

90°

180°

Extension

10°

50°

Abduction

80°

180°

Adduction

10°

40°

Internal rotation

40°

80°

External rotation

40°

80°

  1. The Medical Assessor also recorded that he found the respondent’s left upper limb to be distally neurovascularly intact and that he found no objective sensory deficit.  The Medical Assessor recorded that the respondent “demonstrated winging of his left scapula leaning against a wall”.

  2. The Medical Assessor calculated the respondent’s impairment with respect to his left shoulder is 18% WPI. That was by reference to the following criteria:

    “The shoulders are assessed according to AMA 5 page 476 16.40, 477 16.43 and 479 16.46. On the basis of restricted range of motion in the shoulder, 18% upper extremity impairment is assessed. According to AMA 5 page 492, Table 16.5, 15% upper extremity impairment is assessed for injury to the long thoracic nerve. 18% UEI combined with 15% UEI gives 30% UEI. According to AMA 5 page 439 16.3, this converts to 18% whole person impairment.”

  3. The Appeal Panel notes that the Medical Assessor’s reference to “Table 16.5” seems to be a typographical error and that the actual table by reference to which he assessed the respondent’s impairment relating to the long thoracic nerve was Table 16.15. 

  4. The Medical Assessor referred to the assessment that Dr Sharwood had made of the respondent’s impairment.  The Medical Assessor, with respect to Dr Sharwood’s assessment of the respondent’s impairment of the upper extremity, made the following comment:

    “I am in agreement, but I was unable to detect evidence of peripheral nerve injury. I did, however, find a greater restriction in range of motion and have assessed greater impairment for it. I did detect winging of the left scapula, consistent with injury to the thoracic nerve and have assessed impairment for this.”

  5. The Medical Assessor also referred to Dr Pillemer’s assessment of the respondent’s permanent impairment detailed in Dr Pillemer’s report of 20 October 2022. With respect to that he said he had found the respondent had greater restrictions in the movement of his left shoulder than Dr Pillemer did and that he did not find the respondent had shoulder instability whereas Dr Pillemer did.  The Medical Assessor also noted that he assessed the respondent had impairment for injury to the long thoracic nerve, which Dr Pillemer did not.

PRELIMINARY REVIEW

  1. The Appeal Panel conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the Procedural Direction PIC7.

  2. As a result of that preliminary review, the Appeal Panel determined that the respondent should undergo a further medical examination.  This is because, for reasons explained below, the Appeal Panel found the MAC contained a demonstrable error and to correct that error the Appeal Panel needed further clinical data which it could only obtain by further examination of the respondent.  The Appeal Panel appointed one of its members, namely Medical Assessor Mark Burns, to conduct that examination. Medical Assessor Burns did so on 20 November 2024.  His report to the Appeal Panel is copied below in “Findings and Reasons”.

EVIDENCE

  1. The Appeal Panel has before it all the documents that were sent to the Medical Assessor for the original medical assessment and has taken them into account in making this determination. 

SUBMISSIONS

  1. Both parties made written submissions. They are not repeated in full, but have been considered by the Appeal Panel.

  2. In summary, the appellant submitted that the Medical Assessor did not properly explain why he found the respondent had injured his long thoracic nerve.  The appellant referred to s 16.5b of AMA5 which instructs that a careful examination should be done by an examiner who has sufficient knowledge of anatomy and function of the part. The appellant highlighted that within that section a recommendation is made to use of electromyographic studies if there is doubt about the presence of a nerve injury in order to confirm the diagnosis.  The appellant noted that within the materials there was a neurophysiology and electromyography report dated 24 January 2019 to which the Medical Assessor did not refer. 

  3. The appellant also highlighted that the Medical Assessor, when comparing his assessment of the respondent’s left upper extremity with Dr Sharwood’s assessment, the Medical Assessor noted that he “was unable to detect evidence of peripheral nerve injury” which the appellant submitted contradicts the Medical Assessor’s finding of a long thoracic nerve injury. 

  4. The appellant submitted that the Medical Assessor erred by not addressing whether the respondent’s impairment with respect to the left upper extremity resulted solely from a peripheral nerve injury, which if it did it would mean that the Medical Assessor erred by assessing impairment for both a peripheral nerve injury and restricted range of motion of the shoulder.  The appellant submitted that was contrary to the requirement of paragraph 2.9 of the Guidelines.

  5. The appellant also submitted that the Medical Assessor did not correctly apply paragraph 2.10 of the Guidelines and Table 16-15 of AMA5, in that the Medical Assessor did not grade the severity of the respondent’s impairment relating to the long thoracic nerve.

  6. In reply, the respondent submitted that the Medical Assessor based his finding of an injury to the long thoracic nerve by reference to his physical examination and the material provided to him, and consequently not solely on winging alone.  The respondent also highlighted that the Medical Assessor did not say that his impairment of the left upper extremity was due solely to the long thoracic nerve injury. 

  7. The respondent further submitted that the Medical Assessor made his assessment of the impairment of the left upper extremity in accordance with “Table 16-3” of AMA 5.

  8. The respondent submitted that it is apparent from the MAC that the Medical Assessor considered that his impairment did not result solely from the injury to the long thoracic nerve. 

  9. The respondent submitted that “it can fairly be assumed” that the Medical Assessor complied with Table 16-11 with respect to grading the severity of his impairment due to the long thoracic nerve.

FINDINGS AND REASONS

  1. The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made.

  2. In Campbelltown City Council v Vegan [2006] NSWCA 284 the Court of Appeal held that the Appeal Panel is obliged to give reasons.

  3. A Medical Assessor is required in accordance with s 325(2) of the 1998 Act to set out his or her reasons for the assessment made and to set out the facts upon which the assessment is based. That obligation requires a Medical Assessor to reveal the reasons by which he or she arrived at the assessment in sufficient detail such that it can be ascertained whether there is any error in their reasoning. The reasons must be sufficient such that the unsuccessful party knows why he, she or it has failed.[1]

    [1] Wingfoot Australia Partners Ltd v Kocak [2013] HCA 43 at [55]; Vitaz v Westform (NSW) Pty Ltd [2011] NSWCA 254 (Vitaz) at [34].

  4. The task of ascertaining the Medical Assessor’s reasons requires the MAC to be read as whole, and not with an eye fine-tuned for error.[2] The reasons do not necessarily need to be comprehensible to a person with no medical expertise. In a circumstance where an assessment or conclusion of a Medical Assessor would be self-evident to a medical practitioner and there is no medical contest regarding it, a Medical Assessor can shortly state his or her reasons. If, however, a conclusion is medically contestable or controversial a more extensive explanation will be required.[3]

    [2] Broadspectrum (Aust) Pty Ltd v Fiona Louise Wills [2018] NSWSC 1320 (Wills) at [73].

    [3] Vitaz at [34].

  5. In this case the Appeal Panel considers that the Medical Assessor provided adequate reasons for concluding that the respondent had an injury to his long thoracic nerve and an impairment due to that.  Those reasons are that his examination of the respondent revealed the respondent had winging of his left scapula when leaning against a wall.  That explanation complies with the standard that a Medical Assessor’s reasons must reach.  The conclusion of the Medical Assessor that the respondent had impairment relating to his long thoracic nerve was based on what he observed during his examination of the respondent.  His conclusion based on his findings is a matter that would be readily comprehensible to a person with medical expertise.  It would be self-evident to a medical practitioner that the respondent’s long thoracic nerve was damaged and impaired and there could be no medical contest regarding that, based on what the Medical Assessor found during his examination.  This is because the long thoracic nerve is the only motor nerve controlling the serratus interior muscle.  That muscle rotates and elevates the scapula.  Consequently, the winging the Medical Assessor observed of the respondent’s left scapula while the respondent was leaning against a wall could only be due to damage and impaired function of that nerve. 

  6. It is the case that the Medical Assessor’s comment within 10c of the MAC that he was unable to detect evidence of a peripheral nerve image is inconsistent with his finding the respondent had impairment for injury to the long thoracic nerve.  As just said, given the fact that the Medical Assessor found from his examination that the respondent had winging of his left scapula when leaning against a wall, the Medical Assessor was correct to conclude that the respondent had injured his long thoracic nerve.  It would seem to be the case that his comment when comparing his assessment with Dr Sharwood’s assessment is more in the nature of a “proofing error”.  In other words, the inconsistency between his comment when comparing his assessment with Dr Sharwood’s assessment and his conclusion regarding the respondent’s injuring his long thoracic nerve and having impairment seems to be the consequence of a typing or drafting error made when preparing a draft of the MAC that was not remedied when proofing it.

  7. Whatever be the case, the Appeal Panel is of the view that the MAC does not contain a demonstrable error as a consequence of the Medical Assessor concluding that the respondent injured his long thoracic nerve and has a consequent impairment.

  8. The Appeal Panel also does not accept the appellant’s submission to the effect that the Medical Assessor erred by not referring to electromyographic study in evidence.  As said repeatedly, there can be no doubt in this case that the respondent suffered injury to his long thoracic nerve, and to repeat this is because the respondent exhibited winging of his left scapula when pressing against a wall, which can only be due to damage to his long thoracic nerve given that this is the only nerve supplying the serratus interior muscle.  Consequently, in this case, there was no need for the Medical Assessor to resort to electromyographic studies to confirm the diagnosis.

  9. The Appeal Panel does not accept the appellant’s submission to the effect that the Medical Assessor did not correctly apply the instruction contained within paragraph 2.9 of the Guidelines.  This is because the respondent’s impairment relating to his left upper extremity does not result solely from the injury to his long thoracic nerve, but also results from the other adverse pathology that occurred in his shoulder in the incident of 6 July 2018 which required two surgeries to repair.  The Medical Assessor was consequently correct to rate the respondent’s impairment with respect to his left upper extremity both by reference to the restricted range of motion he had in his left shoulder and the deficit of his long thoracic nerve.

  10. The Appeal Panel accepts the appellant’s submission that the Medical Assessor failed to apply the instruction of paragraph 2.10 of the Guidelines and grade the impairment of the respondent due to the injury of his long thoracic nerve.

  11. Section 16.5b of AMA5 contains the following instruction at page 484:

    “Upper extremity impairments due to motor deficits and loss of power resulting from peripheral nerve disorders are determined according to the grade of severity of loss of function and the relative maximum upper extremity impairment value of the nerve structure involved, as shown in the classification (a) and procedural (b) steps described in Table 16-11 and the impairment determination method detailed in Section 16.5b. The examiner must use clinical judgment to estimate the appropriate percentage of motor deficits and loss of power within the range of values shown for each severity grade. It is important to ascertain that weakness is due to loss of nerve function before using these tables. Weakness may be due to many causes, including pain, and Table 16-11 is not to be used for rating weakness that is not due to a diagnosed injury of a specific nerve or nerves. A diagnosis of nerve injury can usually be made by a careful physical examination done by an examiner who has sufficient knowledge of the anatomy and function of the part. If there is doubt about the presence of a nerve injury, electromyographic studies may be necessary in order to confirm the diagnosis. Note that grade 4 covers a wide range of weakness, from minimal detectable weakness to severe weakness in which the muscles are functional through a full range with only very slight resistance. The degree of weakness should be rated from 1% to 25% depending on the degree within this grade.”

  1. The Appeal Panel considers that the Medical Assessor’s findings recorded in the MAC do not reveal that he did sufficient to be able to grade the respondent’s impairment of his long thoracic nerve in accordance with the criteria of Table 16-11a.  Further, there is nothing in the MAC that indicates that the Medical Assessor carried out the necessary test to enable that to be done.  If he did carry out the tests that revealed the respondent had no evidence of contractility, which would then warrant a 100% grading of motor deficit, then the Medical Assessor has erred by not explaining that he did that. 

  2. The MAC consequently contains a demonstrable error that the Appeal Panel needs to correct.  As noted earlier, the Appeal Panel required further clinical data to do that and appointed Medical Assessor Burns to conduct an examination to obtain that data.  Medical Assessor Burns’ report to the Appeal Panel is the following:

“APPEAL AGAINST MEDICAL ASSESSMENT

REPORT OF THE EXAMINATION BY MEDICAL ASSESSOR

MEMBER OF THE APPEAL PANEL

Matter Number:

M1-W9508/23

Appellant:

Crown Scaffold Pty Ltd 

Respondent:

Jordan King 

Date of Determination:

25 June 2024

Examination Conducted By:

Assessor Mark Burns

Date of Examination:

20 November 2024 


Jordon King attended with Tania Rowley, his mother in law. 

1.   The workers medical history, where it differs from previous records.

The history recorded by the Medical Assessor was discussed with Mr King.  He agreed with the history taken and the only clarification was a typographical error. In paragraph 2 and further paragraphs the Orthopaedic Surgeon he saw Dr Kuo (not Kwo).

2.   Additional history since the original Medical Assessment Certificate was performed.

Mr King reported that there had been no change in his medical history since the assessment in May 2024. I note that the Medical Appeal was only for injuries involving the left upper extremity.  Therefore, further findings will be restricted to this injury only.
Present symptoms:
Mr King reported that he has ongoing pain and discomfort in the left shoulder and occasionally that the shoulder locks and he has difficulty in movement.  There is winging in the left scapula, which has continued since his initial assessment.  I noted that he previously had reported some degree of numbness in the left middle, ring, and little fingers but this appears to have resolved. 
Current treatment:
Mr King reported that he continues to carry out a self-supervised TheraBand program, which he had commenced from the physiotherapist. He continues to do the exercises 3 times a week. When possible, he also exercises in the pool.  He was given a pulley system in order to improve range of movement in the left shoulder, but he is no longer using the pulley system.  He takes over the counter analgesia as required.  This can include Paracetamol and Nurofen. 

3.   Findings on clinical examination

Mr King was noted to walk with a normal gait and appeared in no distress at rest. His upper clothing was removed for full examination of his left and right shoulders.  At rest it was noted that there was a degree of winging in the left scapula but not the right scapula. 
Active range of movement in both shoulders was measured using a goniometer.  On the right flexion was 180°, extension 50°, abduction 180°, adduction 40°, internal rotation 80° and external rotation 80°. 
On the left flexion was 90°, extension 10°, abduction 80°, adduction 10°, internal rotation 40° and external rotation 40°. I note that this was identical with the initial assessment.
Whilst there was a degree of wasting in the serratus anterior muscle on the left side there was not complete atrophy of the muscle.  When tested pushing the left hand against the wall there was slight increase in the winging in the left scapula.  On retraction of the left shoulder, it was noted that there was a slight twitch (weak contraction) in the serratus anterior muscle, which would not have allowed the muscles to move against gravity.  Thus, whilst there was significant weakness in the serratus anterior muscle it was not complete paralysis. 

4.   Results of any additional investigations since the original Medical Assessment Certificate

He reported that he has had no further investigations since the initial Medical Assessment Certificate. 

Opinion:
From my examination findings I can confirm that he has a significant injury to the long thoracic nerve on the left side.  This has led to marked weakness in the serratus anterior muscle.  This can be seen by winging in the left scapula.  I note that from Table 16-15 of AMA 5 that the long thoracic nerve has no sensory component but only a motor component.  A complete motor deficit of the long thoracic nerve would be assessed as 15% upper extremity impairment.  I note that in the Footnote below Table 16-15 that it states, “See Table 16-11a to grade motor deficits”. Turning to Table 16-11a, I note that where there is evidence of slight contractility but no significant scapula movement. Motor function in the long thoracic nerve on the left would be graded as Grade 1.  This is between 76% and 99% motor deficit. I believe that 80% would be appropriate.  This would give 12% upper extremity impairment for the motor loss in the left long thoracic nerve. 
I note that the range of movement I found in the left shoulder was the same as that found by the initial Medical Assessor.  Using Figures 16-40, 43 and 46 he would have 18% upper extremity impairment for the decrease in range of movement.  A combination of 18% for loss of range of movement and 12% for peripheral nerve injury would give 28% upper extremity impairment. This would be converted to 17% whole person impairment.
17% whole person impairment for the left upper extremity would then be combined with the Non-Appealed Assessments of the left lower extremity, right lower extremity, and lumbar spine.  There was 1% for the left lower extremity, 1% for the right lower extremity and 0% for the lumbar spine. When combined these would give 19% whole person impairment. 

DR MARK BURNS

MEDICAL ASSESSOR “

  1. The Appeal Panel is of the view that Medical Assessor Burns’ examination of the respondent was thorough and the Appeal Panel adopts the history he detailed in his report and his findings as set out therein from his examination of the respondent.[4]  The Appeal Panel also concurs with the opinion that Medical Assessor Burns expressed in his report, which is based on his findings.  Consequently, the Appeal Panel assesses the respondent has 12% upper extremity impairment for the loss of motor use in his long thoracic nerve consequent upon his injury.  The Appeal Panel also agrees that the respondent has 18% upper extremity impairment due to the restricted range of movement in his left shoulder, which when combined with the 12% upper extremity impairment due to his impairment of the long thoracic nerve produces 28% upper extremity impairment which converts to 17% WPI.  The Appeal Panel consequently assesses the degree of the respondent’s permanent impairment relating to his left upper extremity resulting from his injury is 17% WPI.

    [4] Coca-Cola Europacific Partners API Pty Ltd v Pombinho [2024] NSWCA 191 at [88].

  2. For these reasons, the Appeal Panel has determined that the MAC issued on 25 June 2024 should be revoked, and a new MAC should be issued.  The new certificate is attached to this statement of reasons.

PERSONAL INJURY COMMISSION

APPEAL PANEL

MEDICAL ASSESSMENT CERTIFICATE

Injuries received after 1 January 2002

Matter number:

W9508/23

Applicant:

Jordan King

Respondent:

Crown Scaffold Pty Ltd

This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act1998.

The Appeal Panel revokes the Medical Assessment Certificate of Medical Assessor Rob Kuru and issues this new Medical Assessment Certificate as to the matters set out in the Table below:

Table - whole person impairment (WPI)

Body Part or system

Date of Injury

Chapter,

page and paragraph number in WorkCover Guides

Chapter, page, paragraph, figure and table numbers in AMA 5 Guides

% WPI

Proportion of permanent impairment due to pre-existing injury, abnormality or condition

Sub-total/s % WPI (after any deductions in column 6)

Left upper extremity (shoulder)

06/07/2018

Chapter 2

Figures 16.40, 16.43, 16.46

Tables 16-11, 16-15

17%

-

17%

Left lower extremity

Chapter 3

Table 17-33

1%

-

1%

Right lower extremity

Chapter 3

Table 17-33

1%

-

1%

Lumbar spine

Chapter 4

Table 15-3

0%

-

0%

Total % WPI (the Combined Table values of all sub-totals)  

19%


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