Evidence-based assessment/Process phase

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Process, Progress, and Outcome Phase

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Overview

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Measuring process, progress, and outcome helps make adjustments over the course of therapy, often improving outcomes. Process refers to ways of looking at treatment mediators, and also measures of engagement, adherence, and fidelity. Progress refers to tracking change on target measures, typically measured with more brief and frequently repeated tools than used at other assessment stages. Outcome measures can include tools with predefined benchmarks or a priori definitions of reliable improvement or worsening. All of these are described in more detail below.

Rationale

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The primary goal at this phase of assessment is to improve patient outcomes.

Process Measures

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Progress Measures

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Outcome Measures

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Outcome measures are tools to document progress towards major goals in treatment. In clinical trials, these are often symptom severity measures based on interviews, and the average scores are compared for groups receiving different treatments (e.g., cognitive-behavioral therapy versus antidepressant, or dialectical behavioral-therapy versus treatment as usual), or comparing the average at the end of treatment to the average at baseline.

These tests are looking at the average outcome. There usually is a wide range of individual scenarios, though. Some people get much better than typical outcomes, some do less well, and some cases may actually get worse over the course of treatment. Clinical significance is a way of looking at an individual's outcome, and deciding whether treatment produced meaningful benefit. All of the different techniques within the "clinical significance" set focus on each individual case, rather than the group average.


Here's a link to a tool that shows the reliable change index and the A, B, C benchmarks for several widely used measures with youths. It includes some interactive graphics that may help visualize the comparisons with the clinical and nonclinical groups to see where the individual case falls.

Steps to put into practice

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Ways of evaluating change

Visualization Methods

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There are many ways of charting or visualizing change over time to get a sense of progress. These include line charts, dot plots, Brinley plots, and others.

Annotated bibliography

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Tables and figures

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Commonly Used Outcome and Process Measures
Adult Behavior Checklist (ABCL) Child Behavior Checklist (CBCL) PROMIS Pediatric Symptom Checklist (PSC)
Anorexia Nervosa
Attention Deficit Hyperactivity Disorder
Autism Spectrum Disorder
Bipolar (adults)
Bipolar (child)
Conduct disorder
Depression (youth)
Generalized anxiety disorder
Non-suicidal self injury
Obsessive-compulsive disorder
Oppositional defiant disorder
Posttraumatic stress disorder
Schizophrenia
Simple phobia
Social anxiety disorder
Substance use disorder
Traumatic brain injury

Clinically significant change benchmarks for widely-used outcome measures

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Benchmarks Based on Published Norms
Measure Subscale Cut-off scores Critical Change

(unstandardized scores)

MID (d 0.5)
A B C 95% 90% SEdifference
Beck Depression Inventory[1] BDI Mixed Depression 4 22 15 9 8 4.8 3.4
CBCL T-scores

(2001 Norms)

Total 49 70 58 5 4 2.4 -
Externalizing 49 70 58 7 6 3.4 -
Internalizing n/a 70 56 9 7 4.5 -
Attention Problems n/a 66 58 8 7 4.2 -
CBCL T-scores

Age 1 1/2 - 5

(2001 Norms)

Total 42.9 71.2 56.3 4.8 4.1 2.5 4.1
Externalizing 41.5 70.8 56.5 5.7 4.8 2.9 4.8
Internalizing 40.1 70.9 54.4 9.1 7.6 4.6 7.6
Attention Problems 40.0 67.3 57.1 7.6 6.4 3.9 6.4
CBCL T-scores

Age 6 - 11 (Male/Female)

(2001 Norms)

Male Total 49.1 69.3 59.2 4.5 3.8 2.3 4.7
Female Total 43.3 68.6 57.1 4.6 3.9 2.4 4.9
Male Externalizing 49.1 68.9 59.3 6.4 5.4 3.3 4.7
Female Externalizing 42.5 68.0 57.4 6.6 5.6 3.4 5.0
Male Internalizing 42.6 69.3 56.4 8.7 7.3 4.4 5.0
Female Internalizing 36.2 69.0 54.6 9.4 7.9 4.8 5.5
Male Attention Problems 45.4 65.2 58.7 7.8 6.6 4.0 6.6
Female Attention Problems 41.8 66.1 58.5 8.1 6.8 4.1 6.8
CBCL T-scores

Age 12 - 18 (Male/Female)

(2001 Norms)

Male Total 46.8 69.3 58.2 4.4 3.7 2.2 4.6
Female Total 47.0 69.3 58.3 4.5 3.8 2.3 4.7
Male Externalizing 45.8 69.4 58.1 6.4 5.4 3.3 4.8
Female Externalizing 44.0 69.0 57.4 6.5 5.5 3.3 4.8
Male Internalizing 42.2 69.6 56.6 8.4 7.1 4.3 4.8
Female Internalizing 43.9 69.2 57.3 8.5 7.1 4.3 4.9
Male Attention Problems 43.9 66.0 58.3 7.8 6.5 4.0 6.5
Female Attention Problems 43.6 65.2 58.0 7.9 6.6 4.0 6.6
TRF T-scores

(2001 Norms)

Total n/a 70 57 5 4 2.3 -
Externalizing n/a 70 56 6 5 3.0 -
Internalizing n/a 70 55 9 7 4.4 -
Attention Problems n/a 66 57 5 4 4.8 -
C-TRF T-scores

Age 1 1/2 - 5

(2001 Norms)

Total 42.9 71.2 56.3 4.8 4.1 2.5 -
Externalizing 41.5 70.8 56.5 5.7 4.8 2.9 -
Internalizing 40.1 70.9 54.4 9.1 7.6 4.6 -
TRF T-scores

Age 6 - 11 (Male/Female)

(2001 Norms)

Male Total 43.7 70.2 56.6 4.7 3.9 2.4 3.9
Female Total 42.1 69.8 55.8 4.7 3.9 2.4 3.9
Male Externalizing 43.4 67.9 56.9 5.1 4.3 2.6 4.3
Female Externalizing 37.8 67.7 54.5 5.9 5.0 3.0 5.0
Male Internalizing 36.8 69.9 54.5 8.9 7.5 4.6 7.5
Female Internalizing 36.8 70.1 53.9 8.7 7.3 4.4 7.3
Male Attention Problems 44.3 66.2 57.1 4.4 3.7 2.3 3.7
Female Attention Problems 43.2 65.8 57.3 4.6 3.9 2.4 3.9
TRF T-scores

Age 12 - 18 (Male/Female)

(2001 Norms)

Male Total 46.1 70.4 57.2 4.4 3.7 2.3 3.7
Female Total 47.5 70.3 58.0 4.5 3.7 2.3 3.7
Male Externalizing 45.3 68.5 57.9 5.2 4.3 2.6 4.3
Female Externalizing 41.7 68.1 56.2 5.9 4.9 3.0 4.9
Male Internalizing 41.6 69.4 55.5 8.2 6.9 4.2 6.9
Female Internalizing 41.8 69.0 55.8 8.2 6.9 4.2 6.9
Male Attention Problems 43.2 67.6 57.1 4.7 4.0 2.4 4.0
Female Attention Problems 45.5 66.8 58.1 4.6 3.9 2.4 3.9
YSR T-scores

(2001 Norms)

Total n/a 70 54 7 6 3.3 -
Externalizing n/a 70 54 9 8 4.6 -
Internalizing n/a 70 54 9 8 4.8 -
YSR T-scores

Age 11 - 18

(2001 Norms)

Male Total 35.3 69.8 54.0 6.7 5.6 3.4 5.6
Female Total 36.8 69.8 54.1 6.4 5.4 3.3 5.4
Male Externalizing 38.3 69.3 54.6 8.9 7.5 4.6 7.5
Female Externalizing 35.7 70.2 53.8 9.2 7.8 4.7 7.8
Male Internalizing 32.7 69.9 53.2 9.6 8.1 4.9 8.1
Female Internalizing 35.6 70.2 53.8 9.3 7.8 4.8 7.8
Male Attention Problems 38.6 67.1 56.6 10.5 8.8 5.3 8.8
Female Attention Problems 39.8 65.8 56.2 9.5 8.0 4.8 8.0
Benchmarks Based on Published Norms (Raw Scores)
Benchmarks Based on Published Norms
Measures Subscale Age Cut-off scores Critical Change

(unstandardized scores)

A B C 95% 90% SEdifference
CBCL (Raw Scores) Total Male 6-11 3.8 57.1 39 11.1 9.3 5.7
Male 12-17 1.7 63 40 11.6 9.8 5.9
Female 6-11 - 55.1 35 10.7 9 5.5
Female 12-17 - 58.2 37 11.6 9.7 5.9
TRF (Raw Scores) Total Male 6-11 - 70.1 38 13 11 6.6
Male 12-17 - 75.4 40 14 11.8 7.2
Female 6-11 - 55.1 27 11.7 9.9 6
Female 12-17 - 54.6 29 12 10.1 6.1
YSR (Raw Scores) Total Male 11-18 - 113 54 18.3 15.4 9.3
Female 11-18 1 117 59 18 15.2 9.2
Beck Depression Inventory   Mixed Depression 13-80 4 22 15 9 8 4.8
PGBI-10M Total 5-18 1 9 6 6 5 3.2
CMRS 10 Total 5-18 -- 6 4 5 4 2.3
PGBI-10Da Total 5-18 -- 7 4 6 5 3.0
PGBI-10Db Total 5-18 -- 7 4 6 5 2.9
AGBI-10M Total 11-90 -- 14 7 6 5 3.1
AGBI-10Da Total 11-90 -- 18 7 6 5 3.2
AGBI-10Db Total 11-90 -- 16 7 6 5 2.9
7 Up Total 11-90 -- 8 4 4 4 2.2
7 Down Total 11-90 -- 12 5 5 4 2.3
KMRS Total 5-18 19 19 19 3 3 1.6
KDRS Total 5-18 12 19 18 5 4 2.4
CDRS-R Total Total 5-18+ -- 24 22 6 5 2.9
YMRS Total Total 5-90 4 3 3 3 3 1.8
Measure Symptom Domain Subscale Cut-off scores Critical Change (Unstandardized scores) MID (d .5)
Acronym Full Name A B C 95% 90% SE Difference
7PS 7-Item Psychosis Screener Psychosis Distress
Total
A-ASWS Abbreviated Adolescent Sleep Wake Scale Sleep Falling Asleep and Reinitiating Sleep 3.88 4.74
Returning to Wakefulness 2.44 3.28
Going to bed 3.93 3.66
AAQ-II Acceptance and Action Questionnaire-II Anxiety Total 8.5 32.61 22.59 9.27 7.81 4.73 4.30
ADHD-RS-IV ADHD Rating Scale-IV ADHD Inattention (Parent) 9.54 15.34 12.44 4.85 4.08 2.47 2.34
Hyperactivity/Impulsivity (Parent) 4.62 17.68 11.76 5.42 4.56 2.76 2.85
Inattention (Teacher) 7.25 0.36
Hyperactivity/Impulsivity (Teacher) 7.17 0.45
AIMS Abnormal Involuntary Movement Scale Total 1.50 3.00 2.60 5.52 4.64 2.81 1.24
AQ-10 Autism Spectrum Quotient Autism Child 5.78 4.95 5.38 1.31 1.11 0.67 0.75
Adolescent 5.02 5.38 5.19 1.60 1.35 0.82 0.87
Adult 4.97 6.77 5.40 2.11 1.78 1.08 0.98
ASQ Ask Suicide-Screening Questions Self Injury Total
ASRS Adult ADHD Self-Report Scale (ASRS) ADHD Total -4.4 1.13
BCMRS Brief Child Mania Rating Scale Bipolar/Mania Total 4.57 10.74 7.86 5.55 4.67 2.83 2.37
BFCSI Bush-Francis Catatonia Screening Instrument Schizophrenia Total -9.71 1.73
BFCRS Bush-Francis Catatonia Rating Scale Scizophrenia Total -18.92 3.50
BIS-11 Barratt Impulsiveness Scale Risk/Impulsiveness Attentional 24.9 1.45
Motor 30 1.41
Nonplanning 33.4 1.73
Overall 46.15 82.9 66.38 13.02 10.96 6.65 5.76
CAS Clinical Anger Scale Conduct Problems Male 31.01 3.61
Female 25.52 2.86
Total 27.11 3.08
CAST Childhood Autism Spectrum Test Autism Total 10.06 11.87 11.16 12.29 10.39 6.27 2.32
CHRT Concise Health Risk Tracking Scale Self Injury Propensity 0.60 3.68
Risk/suicidal thoughts -3.00 0.78
COIS-R Child Obsessive-Compulsive Impact Scale - Revised OCD Parent Version - School -4.5 1.73
Parent Version - Family/Activities -4.7 1.87
Parent Version - Social -7.7 3.08
Parent Version - Daily Living Skills -2.7 1.59
Child Report - Activities -6.5 3.04
Child Report - School -5.9 2.33
Child Report - Social -3.8 1.17
COWS Clinical Opiate Withdrawal Scale Substance Use Peak score (occurred about 30 min following injection) 7.6
CPSS-5 Child PTSD Symptom Scale for DSM-5 PTSD Intrusion - Interview -3.24 1.47
Avoidance - Interview -1.89 0.85
Changes in cognition and mood - Interview -6.01 2.36
Increased arousal and hyperactivity - Interview -4.55 1.81
Intrusion - Self report -2.59 0.92
Avoidance - Self-report -0.76 0.93
Changes in cognition and mood - Self-report -4.82 2.68
Arousal and hyperactivity -2.03 2.16
CRAFFT + N Car, Relax, Alone, Forget, Friends, Trouble Risk/Impulse Total -2.50 0.81
CSHQ Children's Sleep Habits Questionnaire Sleep Bedtime resistance 2.45 10.84 7.89 2.94 2.47 1.50 1.40
Sleep onset delay 0.04 2.31 1.46 1.89 1.59 0.97 0.36
Sleep duration 0.98 5.17 3.90 1.68 1.42 0.86 0.77
Sleep anxiety 2.21 7.79 5.71 2.95 2.48 1.50 1.00
Night wakings 2.49 5.29 4.29 2.48 2.08 1.26 0.65
Parasomnias 6.16 10.61 9.14 3.27 2.75 1.67 1.00
Sleep-disordered breathing -0.37 4.50 3.53 0.93 0.78 0.47 0.93
Daytime sleepiness 5.21 15.24 10.70 4.68 3.94 2.39 1.55
CSQ-8 Client Satisfaction Questionnaire - 8 Evidence-Based Assessment/Clinical Practice Total 16.86 1.61
DASA-YV Dynamic Appraisal of Situational Aggression - Youth Version Aggression Total -2.55 0.57
DES Dissociative Experiences Scale Dissociation Total 5 39.11 26.85 8.72 7.34 4.45 8.51
Amneia -19 28.6 15.46 12.23 10.30 6.23 10.22
Depersonalization -4 30.07 19.34 18.80 15.83 9.59 9.73
Absorption -2 45.12 28.69 18.40 15.49 9.39 8.82
EBPAS Evidence-Based Practice Attitude Scale Evidence-Based Assessment/Clinical Practice Appeal 1.56 0.24
Requirements 0.71 0.31
Openness 0.99 0.27
Divergence 0.24
ECBI Eyeberg Child Behavior Inventory Intensity 66.2 155.4 116.39 22.57 19.00 11.51 8.49
Problem -2 19.7 10.84 5.64 4.75 2.88 4.30
EDE-Q Eating Disorder Examination Questionnaire Eating Disorders Restraint -0.5 3.83 1.84 1.53 1.29 0.78 0.69
Eating concerns 0.6 2.27 1.64 1.41 1.19 0.72 0.58
Weight concerns 1.9 4.26 2.98 1.10 0.93 0.56 0.60
Shape concern 2.6 5.04 3.66 0.92 0.78 0.47 0.64
EDS Everyday Discrimination Scale (Short Version) Life Events/Health Discrimination frequency 1.60 0.23
Attributed to race/ethnicity 1.24 0.19
ERC Emotion Regulation Checklist PTSD Emotional Regulation - Preschool 26.96 0.84
Liability/Negativity - Preschool 37.52 1.47
Emotional Regulation - Elementary 27.72 0.91
Liability/Negativity - Elementary 10.28 1.36
FAD Family Assessment Device Family Functioning Problem solving 1.47 2.72 2.19 0.59 0.50 0.30 0.22
Communication 1.52 2.81 2.20 0.56 0.47 0.29 0.20
Roles 1.52 2.9 2.26 0.53 0.45 0.27 0.18
Affective responsiveness 1.14 2.91 2.12 0.60 0.50 0.30 0.26
Affective involvement 1.33 2.86 2.11 0.56 0.47 0.29 0.22
Behavior control 1.13 2.25 1.77 0.51 0.43 0.26 0.18
General functioning 1.33 2.62 2.02 0.36 0.30 0.18 0.23
FASA Family Accommodation Scale - Anxiety Anxiety Total -3.34 3.15
Participation -1.22 1.86
Modification -4.6 1.73
Distress -1.1 0.50
Consequences -2.36 1.39
FIRM Family Index of Risk for Mood Bipolar/Mania, Depression Nonbipolar -3.00 1.13
Bipolar -2.40 1.34
Total -2.90 1.17
FOCI Florida Obsessive-Compulsive Inventory OCD Total 5.72 10.52 8.19 3.55 2.99 1.81 1.71
C-FOCI Children's Florida Obsessive-Compulsive Inventory OCD Symptom Checklist -0.86 4.55 4.55 1.25
Severity Scale 3.08 5.3 4.59 3.55 2.99 1.81 1.59
GAD-7 Generalized Anxiety Disorder-7 Anxiety Total 5.00 14.5 9.70 3.72 3.13 1.90 2.38
GIDYQ-AA Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults Gender Dysphoria Heterosexual 5.18 0.06
Nonheterosexual 5.37 0.15
Gender Identity Patients 1.51 0.17
HHS Healthy Habits Survey Life Events/Health Total
HSQ Home Situations Questionnaire Life Events/Health Problem Situations* (Not technically a subscale) 9.68 1.14
Mean Severity* (Not technically a subscale) 4.62 0.52
HSQ-ASD Home Situations Questionnaire - Autism Spectrum Disorder Autism Socially Inflexible 9.18 7.21
Demand Specific -2.13 7.39
Total 16.22 12.98
ISI Insomnia Severity Index Sleep Total 11.5 1.45
ISQ Insomnia Symptom Questionnaire Sleep Total
LDQ Leeds Dependence Questionnaire Substance Use Total 1.57 2.91
MDQ Mood Disorder Questionnaire Bipolar/Mania, Depression Bipolar I* (Not technically a subscale) 5.71 0.95
Bipolar II* (Not technically a subscale) 4.34 1.02
Unipolar -1.64 1.00
MOAS Modified Overt Aggression Scale Conduct Problems Verbal Aggression -7.51 2.41
Verbal Aggression* (Repeat?) -2.37 0.66
Property Aggression -2.72 0.89
Autoaggression -2.27 0.55
Physical Aggression Against Others -2.79 0.79
MSI-BPD McLean Screening Instrument for Borderline Personality Disorder Borderline Personality Disorder Total -0.35 10.34 4.49 4.14 3.48 2.11 1.48
NAS Novaco Anger Scale Conduct Problems Cognitive 20.2 33.8 28.36 5.19 4.36 2.65 2.29
Arousal 19.6 34.3 28.25 5.39 4.54 2.75 2.59
Behavioral 13.5 30.9 24.66 4.67 3.93 2.38 2.75
Anger Regulation -7.7 33.9 27.5 10.50 8.84 5.36 5.93
OCI-R Obsessive Compulsive Inventory - Revised OCD Washing -4.27 7.41 3.12 3.15 2.65 1.61 1.76
Checking -2.89 8.03 3.68 3.59 3.02 1.83 1.64
Ordering -3.24 10.46 4.56 3.05 2.57 1.56 1.77
Obsessing -0.45 8.3 4.67 3.10 2.61 1.58 1.66
Hoarding -4.07 9.75 4.12 2.82 2.37 1.44 1.66
Neutralizing -4.44 6.22 2.32 3.31 2.79 1.69 1.56
PAM Physical Activity Monitoring Life Events/Health Total
PCQ Parental Competence Questionnaire Family Functioning Parental Efficacy 19.27 17.62
Parental Responsibility 32.6 30.43
Child Control 16.29 14.37
Fate/Chance 22.51 21.55
Parental Control 31.44 26.63
PHQ-8 Patient Health Questionnaire - 8 items Depression Total 10.47 1.36
PHQ-9 Patient Health Questionnaire - 9 items Depression, Self Injury Total -0.77 9.95 6.14 4.91 4.14 2.51 2.58
PHQ-15 Patient Health Questionnaire - 15 items Depression Total -0.29 12 7.10 5.03 4.24 2.57 2.63
PQ-B Prodromal Questionnaire - Brief Version (PQ-B) Schizophrenia Total -22.6 8.87
Symptom Frequency 13 1.48
Distress -5.47 2.68 2.53 1.79 1.51 0.91 1.64
PSC-17 Pediatric Symptom Checklist Broad Psychopathology Attention -2.00 0.99
Externalizing -2.50 1.13
Internalizing -1.80 0.99
PSOC-R The Parenting Sense of Competence Scale: Updating a Classic Family Functioning Efficacy 22.44 2.92
Satisfaction 28.25 1.77
SCARED-41 Screen for Child Anxiety Related Emotional Disorders Anxiety Total -6.8 5.45
Panic Disorder -4.37 1.75
Generalized Anxiety Disorder -2.87 1.68
Separation Anxiety Disorder -3.51 1.33
Social Anxiety Disorder -2.23 1.35
School Avoidance -1.83 0.77
SCI Sleep Condition Indicator Sleep Total 3.11 2.10
SCOFF Make Self Sick, Loss of Control, One-month Weight Loss, Believe am Fat, and Food Dominates Life Eating Disorders Total -1.52 0.49
SCORE-15 Systemic Clinical Outcome and Routine Evaluation - 15 item Family Functioning Total 22.68 54.65 40.37 7.90 6.65 4.03 6.44
Strengths and Adaptability Subscale
Overwhelmed by Difficulties Subscale
Disrupted Communication Subscale
SHI Self-Harm Inventory Self Injury Total 1.01 12.36 7.36 4.64 3.90 2.37 2.06
SMFQ Short Mood and Feelings Questionnaire Depression Total 0.10 11.00 6.91 4.46 3.76 2.28 2.47
SOCS Short Obsessive-Compulsive Disorder Screener OCD Total 1.26 11.3 6.55 3.79 3.19 1.93 1.50
UGDS-GS Utrecht Gender Dysphoria Scale - Gender Spectrum Gender Dysphoria Overall 72.81 5.00
Dysphoria 55.07 3.94
Gender Affirmation 17.57 1.03
VADPRS Vanderbilt ADHD Diagnostic Parent Rating Scale Broad Psychopathology Inattention 24.91 2.55
Hyperactivity/impulsivity 23.52 2.56
Conduct/oppositional 29.42 3.39
Anxiety/depression 15.27 1.86
VADTRS Vanderbilt ADHD Diagnostic Teacher Rating Scale Broad Psychopathology Inattention 0.82 22.61 6.69 2.45 2.06 1.25 2.85
Hyperactive/impulsive -1.72 19.45 4.99 2.88 2.42 1.47 2.71
Conduct/oppositional -3.99 12.95 2.15 2.66 2.24 1.36 2.10
Anxiety/depression -2.39 8.77 1.35 2.13 1.80 1.09 1.32
YP-CORE Young Person's Clinical Outcomes in Routine Evaluation Broad Psychopathology Total 4.00 24.00 12.14 9.17 7.72 4.68 3.70

Will be updated as RISE internship continues!

References

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