Additional Material

Pain Scales I

NRS: Numerical Rating Scale

Numeric Pain Scale
Numeric Pain Scale


Wong-Baker FACES Pain Rating Scale
Wong-Baker FACES Pain Rating Scale

Find out more about the Wong-Baker FACES Pain Rating Scale at

© 1983 Wong-Baker FACES® Foundation. Used with permission

Pain Scales II: Behavioral


FLACC is a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain. Pain is assessed through observation of 5 categories including face, legs, activity, cry, and consolability.

Learn more at


Voepel-Lewis T et al. Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care. 2010 Jan;19(1):55-61

Numerical Rating Scale Works Well in Many Settings

Numeric Pain Rating Scale ease of use
Numeric Pain Rating Scale ease of use

Data from: The measurement of pain in intensive care unit: Comparison of 5 self-report intensity scalesPAIN Volume 151, Issue 3, December 2010, pp 711-721.

Which Scale is Right?

Choosing between pain rating scales
Choosing between pain rating scales


Voepel-Lewis T et al. Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care. 2010 Jan;19(1):55-61

NRS and Literacy

Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. J Rheumatol. 1990 Aug;17(8):1022-4. Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P, Goldsmith CH.

“The assessment of a measure of chronic pain, should be reliable, valid and sensitive to change. Our study evaluated the reliability of 3 pain scales, visual analogue scale (VAS), numerical rating scale (NRS) and verbal rating scale (VRS) in literate and illiterate patients with rheumatoid arthritis (RA). Patients with RA attending an outpatient rheumatology clinic were interviewed and asked to score their pain levels on the 3 pain scales. The scales were presented in random order, twice, before and just after a regular medical consultation. Ninety-one patients were studied (25 illiterate and 66 literate). The Pearson product moment correlation between first and second assessment was 0.937 for VAS, 0.963 for NRS and 0.901 for VRS in the literate patient group and 0.712 for VAS, 0.947 for NRS and 0.820 for VRS in the illiterate patient group. These results indicate that the NRS has the higher reliability in both groups of patients.”

Beyond Intensity Multi-Dimensional Assessment

  • Quality
  • Region
  • Severity (aka Intensity)
  • Timing
  • Usually associated with… e.g., rash, nausea
  • Very much better with… e.g., rest, ice
  • Worse with… e.g., activity, pressure

Impact: function, roles, mood, enjoyment

Words for Pain: (Quality)

  • Temporal quality, e.g.,
    • Flickering
    • Pounding
  • Thermal quality, e.g.,
    • Burning
    • Freezing
  • Sensory quality, e.g.,
    • Pricking
    • Stabbing
  • Affective quality, e.g.,
    • Punishing

Learn more about the MPQ Pain Rating scale at

Pain Assessment: Verbal Older Adults, Cognitively Intact

  • Older adults may not use the term “pain”
  • Open ended questions: “Tell me about your pain, aches, soreness or discomfort”
  • Ask for descriptions: Burning, aching, dull, throbbing, stabbing, crushing…
  • Location(s): Localized vs. flare
  • What is the meaning of this pain to you?
  • Can use NRS (0-10 scale), use pain anchors.

Pain Assessment Non-Verbal Older Adults

Look for the following:

  • Facial grimacing
  • Wincing
  • Bruxism/teeth grinding
  • Sweating
  • Restlessness
  • Agitation
  • Social isolation
  • Tachycardia, tachypnea, hypertension (blunted in AD)


American Geriatrics Society, 2002; Fine & Portenoy, 2004; Herr & Decker, 2004 

Pain Assessment in Persons with Alzheimer’s

    • Observational means of assessing pain in persons with advanced cognitive impairment
  • 5 assessment areas
    • Breathing
    • Vocalization
    • Facial expression
    • Body language
    • Consolability

Caution: behaviors may indicate something other than pain – know your older adult

Special Considerations for Older Adults

  • Most older adults have undertreated pain
  • May have numerous comorbid conditions
    • Greater risk for conditions associated with pain
    • Greater risk for drug-drug, drug-disease interactions
  • Have decreased ability to metabolize and excrete drugs (hepatic system, renal system)
  • Chronic pain a risk factor for falls in older adults


Fine, 2004; Fine & Portenoy, 2004

Questions for the Study of NSAIDs and Acetaminophen in the Treatment of Pain

The five brand name products include:

  1. Aleve 
  2. Bayer Regular Strength
  3. Regular Strength Tylenol 
  4. Advil
  5. Excedrin Extra Strength

Question 1

Which of the following products can be used as both a pain reliever and fever reducer?


Question 2

Which of the following products does not contain a nonsteroidal anti-inflammatory drug as an active ingredient?


Question 3

Which of the following products contains a warning against consuming 3 or more alcoholic beverages while using the product?

Correct. Tylenol contains warning or possible liver damage when using excessive alcohol; NSAIDS give warning of excessive stomach bleeding promoted by alcohol use.

Question 4

Each of these products may be used in children 12 years or older for pain relief. However, which of the following should not be used to treat pediatric patients over the age of 12 with the chicken pox or experiencing flu-like symptoms?

Correct. Bayer product information warns that aspirin should not be used in pediatric patients with chicken pox or experiencing flu-like symptoms due to possibility of Reye’s syndrome, a rare but serious illness associated with aspirin in these patients.

Question 5

Which of the products does not contain an allergy alert?

Correct. Aspirin can produce a severe allergic reaction and the alert is prominently featured; NSAIDs also contain the alert since an allergic reaction to aspirin or another pain reliever potentially predisposes to a similar reaction to other NSAIDs.

Question 6

Which product is not contraindicated for use in the third trimester of pregnancy?

Correct. All NSAIDs contain warning against use in third trimester, while Tylenol states that patient should consult health care professional before use

Question 7

What is the maximum recommended daily dose of acetaminophen according to the Tylenol product literature?

Correct. Insert states do not exceed 3900 mg, however, the FDA has recommended a maximum daily dose of 3000 mg.

Question 8

What is the maximum recommended daily dose of ibuprofen according to the Advil product literature?

Correct. Insert states do not exceed 6 tablets daily, 6 x 200 mg = 1200 mg

Question 9

What are the major concerns for a patient using Excedrin Extra Strength for chronic tension headaches?

Correct. Since Excedrin contains both acetaminophen and aspirin, cautions that apply to either active ingredient apply to the use of this product.

Questions for Discussion if Time Permits

What do you think the grade reading level is for the product information for a patient with English as their primary language? If English was the second language for the patient, do you think the instructions and warnings are less understandable?

The FDA has reported that most Americans read at an 8th or 9th grade level. Literacy levels are lower in some ethnic groups. It is recommended that patients receive both written and oral instruction in medications, sentences should be short: 10-12 words and words of more than 3 syllables avoided.

Is the type size on the product cartons readable for a geriatric patient?

  • No.

Case 1 – Painful Swollen Ankle

Ms. P., a 21-year old female college student, presents to an emergent care clinic after injuring her right ankle during a basketball game on Saturday afternoon. She reports that her right ankle rolled in after landing from a jump. The ankle appears inflamed and bruised. Ms. P. can bear weight on her right ankle for more than four steps, indicating it is not fractured. She reports her pain intensity as 4 out of 10 when not bearing weight on her right ankle. Her pain increases to an intensity of 7 out of 10 when she bears weight on the ankle. Ms. P. reported directly to the clinic and has not used OTC medications for her pain or ice on her ankle yet.

Upon examination there is no bony tenderness; the pain is localized to the anterior talofibular ligament (AFTL). There is significant swelling of the anterior ankle and the top of the foot. There is not significant translation of the AFTL during the anterior drawer test suggesting no ATFL disruption. The injured ankle is diagnosed as a grade 1 ankle sprain.

The only medical history of note is that Ms. P. suffers from occasional migraines. During her early teen years, Ms. P.’s migraines occurred once a month in conjunction with her menstrual cycle. For the past three years, the frequency of her migraine attacks has decreased to 3-4 per year, always in conjunction with her menstrual cycle. Ms. P. states that she filled a new prescription for Imitrex (sumatriptan) last year which she is still using. She reports that this new prescription works better for her migraine than the previous one but cannot say what the difference between the prescriptions is.

Ms. P. appears to be in an excellent state of overall health. She claims that she does not smoke cigarettes, does not use OTC medicines, does not use alcohol and does not use any illicit drugs.

What else would you like to know from the patient?

Has she had any problems taking NSAIDs, does she have any allergies to medicines, does she have problems with her stomach (heartburn, indigestion), does she have any bleeding problems. Does she have far to walk each day?  Does she have exams coming up (will it be difficult for her to keep up if she has a day or two of pain and limited mobility)?

What other exam findings will you be looking for?

Bruising, wear patterns on her shoes to suggest orthopedic issues 

What diagnostic testing would you like to perform?

It is reasonable to consider an xray. A grade 1 ankle sprain means that there is only a stretch injury to the ligament and no substantive injury to the articular surfaces. An MRI is not needed. It is estimated that 25,000 ankle sprains occur daily in the U.S.!

What do you want to know about her daily life?

It is important to assess alcohol use patterns as the treatment of this sprain is acetaminophen or NSAIDs has important implications for the use of alcohol. It is prudent to avoid alcohol with these medicines but if this patient has a pattern of binge drinking or heavy drinking, she needs to be instructed not to mix alcohol with these medicines and certainly more than one drink a day while receiving these treatments is not advisable. It is important to make sure that she know not to take other peoples pain relievers, the number of deaths from prescription drug overdoses exceeds 10000 per year in the U.S., most of these deaths are among young people.

What are the management options you’d like to implement?

  • RICE-M
  • Rest, you should provide this patient with a note for school so that she can have 2-3 days to spend icing the ankle (20 minutes every 3 hours) and resting the ankle
  • Ice – as above
  • Compression – a splint is not required for this grade ankle sprain but a gentle compression wrap or ankle brace may improve comfort, and will reduce swelling.
  • Elevation – the patient should take rest breaks for the first couple days and make sure to elevate the foot.
  • Medication – acetaminophen or ibuprofen may be used. Make sure the patient is no allergic or having a history of adverse events with these medications. 

Case 2 – Low Back Pain

Mr. R. is a 50 year-old roofing crew chief currently receiving care for both hypertension and right knee osteoarthritis. Both Mr. R. and his wife communicate primarily in Spanish in their everyday lives. You have replaced his primary care physician and meet Mr. R. and his wife for the first time today. Mr. R.’s history is significant for cessation of smoking at the age of 45, with a 30 pack year history. According to his records, Mr. R. consumes up to 0-2 alcoholic beverages per day. He has a maternal history of stroke, affecting both his mother and uncle and a paternal history of myocardial infarction affecting his father and his siblings before the age of 60.

Mr. R. has been prescribed an ACE-inhibitor, benazepril, to control his hypertension. Mr. R. and his wife check his blood pressure each month at the pharmacy when they fill his prescription. Three days ago, Mr. R.’s BP was elevated, at 140/85, and the pharmacist recommended he see his doctor.

According to Mr. R.’s medical record, his hypertension has been well-controlled for over two years using 10 mg benazepril, twice a day, and 81 mg acetyl salicylic acid once a day for cardiovascular prophylaxis. You realize that the mostly likely reason for an increase in blood pressure is lack of compliance with his anithypertension medication. The documentation also states that Mr. R. takes 2 650 mg acetaminophen extended-release geltabs twice a day for knee pain.

Mr. R. has a friendly manner and claims he is feeling well, without any discomfort or pain. His wife, Mrs. R., appears anxious and wants to stay in the room for history taking. Upon questioning, Mr. R. claims to be compliant with his cardiac medication. His wife confirms that she is present when he takes the 10 mg benazepril at breakfast and at dinner. Mr. R. takes controlled-release acetaminophen for knee pain at the same time as the benazepril. Mr. R.’s wife does all of the cooking and packs his lunch, adhering to the same reduced-sodium diet she instituted 5 years ago. Mr. R. denies taking up smoking again and his wife claims that she would know by the odor since she washes his clothes. Mrs. R. claims that the only unusual incident in the past month is that Mr. R. missed two days of work due to back pain. Mrs. R. claims that Mr. R. was reluctant to take the day off of work to come in for the present appointment.

Mr. R. is overweight at a height of 5’6”, weight of 170 pounds and BMI of 27.4 kg/m2. His current BP is 140/85 and his HR is 70 beats per minute. At his last office visit 6 months ago, his BP was 130/75 and his heart rate was identical at 70 beats per minute. Cardiac examination and electrocardiogram are unchanged compared to Mr. R.’s record. Examination of Mr. R.’s right knee reveals no evidence of joint swelling, slight bony deformity and crepitus, consistent with his medical record.

You are aware that NSAIDs, in combination with antihypertensive agents, may result in increases of BP, usually less than 10 mm, in the range of Mr. R.’s elevation. You ask Mr. R. whether he is taking any additional pain relievers. He admits to using a drugstore medication which his coworkers recommended to him, naproxen. He didn’t want to worry his wife about the amount of pain and discomfort he had been feeling and there is no one to do his job if he doesn’t go to work. Mr. R. explains that his job is active, requiring him to climb ladders in order to supervise the roofing work, but it pays well. He hurt his back helping his crew move equipment 3 ½ weeks ago. He rated his pain when he initially hurt his back as 9 out of 10. Now, he rates his discomfort as 0 or 1 out of 10 when he uses naproxen. When he doesn’t use the naproxen, he rates his pain as 4 out of 10. He hasn’t used any other treatments for his back pain other than the OTC pain relievers. Examination of his back is consistent with a diagnosis of healing nonspecific low back pain.

What else would you like to know from the patient?

Has there been any change in alcohol consumption? If so, what is the pattern of drinking lately? Does the patient wear a brace or has he been to physical therapy or back school? Has he taken any other medications for the pain? Has he ever tried prescription pain relievers? What has he done that has helped the back pain? How is his sleep at night? What is his usual sleeping position and how old is his bed? When he injured his back, did the pain radiate down the leg? Has he had any weakness in one leg of the other since then? Has there been any change in bowel, bladder or sexual function?

What other exam findings will you be looking for?

You will examine the back to see if there is any bony deformity, e.g. scoliosis, kyphosis, lordosis. It is reasonable to palpate the back to determine if there is any focal tenderness, to test the strength of selected leg muscles, check reflexes in the lower extremities and perform a straight leg raise (SLR) test to check for signs of nerve root tension.

What diagnostic testing would you like to perform?

For a resolving episode of low back pain without radiation or ‘red flags’ (incontinence, weight loss, (constitutional signs), radiation of pain, or focal weakness), it is not necessary to perform imaging. For pain that remains severe, is associated with focal weakness, lost reflexes, other neurological changes or red flags, an additional work up is needed.

What do you want to know about his daily life?

How much sitting, walking, lifting and climbing does his work involve. Does he exercise do anything to increase core strength? Does he take any dietary supplements?

What are the management options you’d like to implement?

NSAIDs can increase blood pressure. It is important to increase the use of non-pharmacological therapies in this patient: ice after the back is stressed (daily), core muscle strengthening, ergonomics training, optimization of sleep habits and improved exercise routines are all recommended.

Optional Material for Instructors

Small Group Activities

Day 1: Small group activity A

Case – Radicular low back pain

This case introduces the Pain Assessment Alphabet as a guide to comprehensive assessment.
Mrs. D. is a 52 year old woman who first developed some mild lower back pain beginning 2 months ago.
Three days prior to being seen, the pain suddenly became much worse and she had to stop working.
Today she notes that the pain is constant at a level of 5, but that if she moves the pain becomes severe,
at its worst it is 9/10 in severity. She describes the pain as mostly deep and dull but at times it is sharp.
The pain is worst across the lower back but radiates down the right leg. When severe, the pain seems to
involve the left leg as well. She feels that her legs may be somewhat weak and the pain has limited her
ability to walk. She has not been able to find anything to make the pain better other than lying in bed.
The resident who examined her is not sure there’s anything wrong. The patient refuses to accept this
and wants better pain control.

Pain assessment includes 7 characteristics

Q – quality
R – region
S – severity (intensity)
T – timing
U – usually associated with
V – very much better with
W – worse with

Questions to Ask
  • What else would you like to know from the patient?
  • What exam findings will you be looking for?
  • What diagnostic testing would you like to perform?
  • What do you want to know about her daily life?
  • What are the management options you’d like to implement?

Day 1: Small group activity B

Case – Pediatric pain assessment (with language barrier)

This case introduces the use of the Pain Diagram.

An eight‐year old female child is brought to the ED by her mother. The patient and her mother have
recently come from Nigeria to the US to join the patient’s older sister who is a student, studying in the
U.S. Neither the patient nor her mother can speak fluent English hampering communication.

The limited history indicates that the patient has had recurrent unexplained pain episodes, the last one
5 days ago with arm and leg pain; she has only one living sibling and her father is deceased. The patient
has previously been given acetaminophen for pain and has never been treated with other analgesics.
Examination: The patient is a slender eight‐year old who appears dehydrated with dry mucous
membranes. Temp 40.0°C, pulse rate 85 beats per minute, blood pressure 125/85 mm Hg, respiratory
rate 14 breaths per minute, SpO2 89%.

The child has whimpering softly at times and is holding her arms around her chest, trying to avoid
coughing. Patient appeared short of breath on ambulating in the ED. She refused oral hydration.
Patient is reluctant to have pulmonary examination. Patient communicates by acting that breathing is
painful; coughing exacerbates pain. Exam shows dullness to percussion is noted. Ascultation of the chest
reveals rales.

  • Results of urine test: negative for hematuria and bacteria.
  • Bloodwork results: Hb 8.5 g/dl, Reticulocytes 8%, WBC 15 x 109 l‐1
  • CXR reveals patchy scattered lung infiltrates.
Questions to Ask
  • What else would you like to know from this patient?
  • What exam findings will you be looking for?
  • What diagnostic testing would you like to perform?
  • What do you want to know about the child’s daily life?
  • What are the management options you’d like to implement?
Multiple Choice Questions
Question 1
  1. The mother indicates that the patient's pain is 5/10. What will you use as a baseline to monitor progress of pain relief?
  2. Proceed without baseline since communication is hampered.
  3. Use parent provided assessment of 5/10 as baseline.
  4. Have mother act as interpreter to explain VAS to patient and report answer.
  5. Use FACES scale and interact with patient in order to determine baseline.
  6. Make an independent assessment of the pain based on the patient's behavior.
Question 2

What is your possible diagnosis?

  1. Pulmonary tuberculosis
  2. Bronchitis
  3. Asthma
  4. Pneumonia, possible acute chest syndrome due to underlying sickle cell disease
  5. Sacoidosis

Day 1: Small Group Activity C

Case – Knee pain

This case introduces the Memorial Pain Assessment Card

Mr. N is a 73 year old man with obesity, diabetes, GERD, hypertension, CAD and a history of DJD of the lumbar spine. Although he has been active in the past and enjoys retirement with his wife of 50 years, he is recently less active. He has progressively worsening pain in the right knee that flares up from time to time. Although at rest the pain is about 4/10, when he moves the pain flares and is at its worst is 8/10. At times the pain is sharp and stabbing but usually it feels dull and aching. It is strongest in the
knee but sometimes radiates down into the leg. The pain is generally worse after a lot of walking and sometimes the knee feels like it will give out. He says the pain is better when he takes ibuprofen, 600mg but he knows this is bad for his stomach. His doctor has prescribed celecoxib, he has questions about the safety of this medication and he doesn’t think it helps.

Questions to Ask
  • What else would you like to know from this patient?
  • What exam findings will you be looking for?
  • What diagnostic testing would you like to perform?
  • What do you want to know about his daily life?
  • What are the management options you’d like to implement?

Learn more about memorial pain assessment cards:

Questions about the Memorial Pain Assessment Card
  • What do you think are the strengths of this assessment instrument?
  • What else would you most want to know about someone's pain that is not included in this card?

Additional Material for Instructors

This material can be used by instructors to personalize a supplemental module on acute pain and its clinical correlation.

Acute Pain: Clinical Correlation

Learning Objectives

By the completion of this session, the student will be able to:

  • describe the anatomy of acute pain
  • list elements of a multimodal approach to treating acute pain
  • recognize distinguishing features of acute pain in chronic pain patients and outline principles of treatment in this setting


  • Our patient
  • Anatomy of pain
  • Pain treatment plan elements
  • Recognizing acute pain in patients with chronic pain

Our Patient

This section should include a presentation of a patient with acute pain. There should be a relevant link to the anatomy section which follows.

Anatomy of Pain

This section should include information about the anatomical system signaling pain. Reference should be made to the case presented.

Pain perception, modulation, transmission, transduction
Pain perception, modulation, transmission, transduction


Signal transduction occurs in many different structures:

  • Skin
  • Muscle
  • Bone and bone marrow
  • Viscera
  • Discs and joints
Pain transduction
Pain transduction


Transmission is the process of delivering the encoded pain signal to the brain.

There are multiple channels that signal noxious stimuli:

  • Warm/heat
  • Pressure
  • Wide dynamic range (intensity)
  • Sharp
Pain transmission
Pain transmission


  • Somatosensory cortex: S1
  • Limbic cortex: rostral ACC
  • Basal ganglia
  • Insula
  • Cerebellum
  • SMA
Pain perception
Pain perception

Detailed Overview of Nociceptive Processing

Nociceptive processing
Nociceptive processing


  • Both suppression and facilitation occur
  • Modulation occurs at multiple levels
  • Insula
  • PAG
  • Nucleus Raphe Magnocellularis
  • Dorsal horn
Pain modulation
Pain modulation

Spinal Dorsal Horn

Spinal dorsal horn
Spinal dorsal horn

Pain Treatment Plan Elements

This section should include information about pain treatment plan elements. Reference should be made to the case presented.

Pain Treatment Plans: 4 components

  1. Goals for treatment
  2. Expectations
  3. Treatment modalities
  4. Time Course
1. Goals for treatment
S.M.A.R.T. I
  • Specific
  • Measurable
  • Attainable
  • Relevant
  • Timely
  • Specific
  • Mutually agreeable
  • Adaptable
  • Realistic
  • Time-bound

Patient + Provider = Success

2. Expectations for Treatment

Expectations for treatment vary depending on:

  • Type of Pain
  • Setting and context
  • Patient needs

Expectations should be outlined explicitly and include the patient:

  • Check for understanding
  • Ensure shared-decision making
  • Balancing pain relief and side effects
3. Treatment Modalities


  • NSAIDS and acetaminophen (OTC analgesics)
  • Neuromodulating agents
    • Anti-depressants
    • Anti-convulsants
    • Local anesthetics
    • Others
  • Opioids
  • Non-pharmacological
    • Psychological
    • Manual (PT, massage)
    • Activating (occupational)
    •  Complimentary and alternative
Mechanism-Based Classification of Pain
  • Generally straight-forward to understand and apply
  • Enhances understanding of relevant disease mechanisms
  • Guides the choice of pharmacological treatments
  • Determines the extent and type of non-pharmacological treatments
  • Anticipates the time course and degree of disability associated with pain
Mechanism-Based Classification of Pain: Management of Acute Pain
Pain management
Pain management

4. Time Course

  • Reflects realities of underlying disease:
    • Make sure to supply analgesia for the anticipated duration of acute pain: once analgesia wears off, your patient may have a sharp increase in pain!
  • Influenced by individual factors 
    • Personal history of pain, other conditions, psychological and social state
  • Includes a plan for re-assessment 
    • Don’t assume therapy is effective,  check for pain relief
  • Treatment end 
    • If opioids are prescribed for more than 3 days, make sure to structure a sound tapering plan to avoid withdrawal symptoms

Recognizing Acute Pain in Patients with Chronic Pain

This section should include information about assessment of pain. Reference should be made to the case presented.

Multi-Dimensional Assessment is Essential

Multi-dimensional assessment is essential to recognizing acute pain patients with chronic pain.

  • Quality
  • Region
  • Severity (aka Intensity)
  • Timing
  • Usually associated with… e.g., rash, nausea
  • Very much better with… e.g., rest, ice
  • Worse with… e.g., activity, pressure

Impact: function, roles, mood, enjoyment

Questions for Review

  1. What are the principle components of the ‘pain processing system’
  2. Where does pain enter the ‘central nervous system’? Is there a single place in the brain dedicated to sensing pain?
  3. How will you assess acute pain?
  4. How will you recognize when some in pain is ‘faking it? How will you know that a patient with chronic pain has a new pain problem that requires assessment? How will you go about assessing their pain?
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