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Maddox v. Commissioner of Social Security

United States District Court, N.D. Ohio, Eastern Division

May 29, 2018

NUKEYDA MADDOX, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          DAN AARON POLSTER JUDGE.

          REPORT & RECOMMENDATION

          THOMAS M. PARKER MAGISTRATE JUDGE.

         I. Introduction

         Plaintiff, Nukeyda Jean Maddox (“Maddox”), seeks judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act (“Act”). This matter is before the court pursuant to 42 U.S.C. §405(g), 42 U.S.C. §1383(c)(3) and Local Rule 72.2(b).

         Because the ALJ (i) properly applied the treating source rule to Dr. Ranjan's opinion, (ii) failed to properly apply the treating source rule to Dr. Haddad's opinion, and (iii) the RFC determination is not supported by substantial evidence, I recommend that the final decision of the Commissioner be VACATED and this matter be REMANDED, pursuant to sentence four of 42 U.S.C. §405(g).

         II. Procedural History

         Maddox applied for SSI and DIB on June 21, 2013 (Tr.18), alleging a disability onset date of January 26, 2010. (Tr. 18, 41) Maddox alleged disability based predominantly on back/neck pain, headaches, right hand carpal tunnel symptoms, and depression. (Tr. 23) Maddox's application was denied initially and on reconsideration. (Tr. 18) Thereafter, Maddox filed a written request for rehearing. (Tr. 7) Administrative Law Judge Peter Beekman (“ALJ”) heard the case on November 19, 2015. (Tr. 40-66) The ALJ denied Maddox's claim on March 11, 2016. (Tr. 15) The Appeals Council denied further review on April 13, 2017, rendering the ALJ's March 11, 2016, decision the final decision of the Commissioner. (Tr. 1-3)

         Maddox had previously applied for SSI and DIB on April 6, 2010, alleging a disability onset date of January 26, 2010. (Tr. 18, 263, 265) Maddox's earlier application alleged disability based on depression, anxiety, chronic disc osteophyte, carpal tunnel syndrome, cervical, thoracic, and lumbosacral neuritis or radiculitis, vitamin D deficiency, asthma, fibromyalgia, chronic migraine, and restless legs. (Tr. 303) On February 22, 2012, an ALJ found Maddox was not disabled from the alleged onset date through February 22, 2012, the date of her prior administrative hearing. (Id.) The Appeals Council notified Maddox it was denying her request to review that hearing decision on June 13, 2013. (Id.) The prior hearing decision issued on February 22, 2012 is administratively final under the doctrine of res judicata and the ALJ's March 11, 2016 decision only considered whether Maddox had been disabled since February 23, 2012. (Id.)

         III. Evidence

         A. Personal, Educational and Vocational Evidence

         Maddox was 30 years old on her alleged onset date, February 23, 2012, and had turned 34 by the time of the hearing. (Tr. 28, 43) Maddox attended school through the ninth or tenth grade, attained a GED in 2009, and “got some credits in online college.” (Tr. 43, 536) Maddox has worked as a cashier, fast food manager, customer service supervisor, and child care monitor. (Tr. 58-59)

         B. Relevant Medical Records

         1. Treatment Records Regarding Maddox's Physical Impairments

         On December 21, 2011, Dhruv Shah, M.D., evaluated Maddox regarding her complaint of generalized body ache and pain in her neck and lower back. (Tr. 408) Maddox rated her pain as an eight out of ten and stated that the pain increased with almost all activities. (Id.) Dr. Shah found generalized tenderness all over her body, including diffuse tenderness in Maddox's lower lumbar region, paraspinal lumbar region, mid and lower cervical region, and both trapezii. (Id.) She had fourteen tender spots out of eighteen on a fibromyalgia check-up. (Id.) Dr. Shah noted that a previous x-ray of Maddox's lumbar spine showed mild degenerative changes, a MRI of her cervical spine showed very minimal disc bulge, and a MRI of her lumbar spine was within normal limits. (Id.) Dr. Shah prescribed Lyrica, step aerobic exercise for fibromyalgia, and physical therapy. (Id.)

         Dr. Nemr saw Maddox several times between March and October 2012 regarding her complaints of chronic and constant back pain, primarily in the cervical or lumbar spine (Tr. 359, 362, 371, 374, 377), and for migraines. (Tr. 368, 380) Maddox reported that sitting too long or walking aggravated her back pain. (Tr. 359, 377) Her musculoskeletal examination findings were normal. (Tr. 359, 364, 367, 369, 373, 376, 379, 381, 384) Maddox's migraine pain improved with treatment. (Tr. 368, 382) Dr. Nemr referred Maddox for pain management (Tr. 361, 364, 376), prescribed Percocet (Tr. 361, 364, 367, 373, 376, 379) and Gabapentin (Tr. 379), and provided her with patient education handouts regarding acute low back pain. (Tr. 373) Maddox was prescribed Effexor, Wellbutrin, and Trazadone for her depression and anxiety. (Tr. 376, 382) Dr. Nemr noted that an MRI of Maddox's spine showed evidence of disc disease. (Tr. 379)

         On October 31, 2012, Haitham M. Azem, M.D. saw Maddox and found multiple tender points bilaterally and a painful range of motion. (Tr. 478)

         On December 21, 2012, a MRI of Maddox's cervical spine showed mostly normal and unremarkable findings. (Tr. 413) The MRI showed degenerative changes which were most severe at the C4-C5 and C5-C6, including minimal flattening of the ventral aspect of the cord by disc osteophyte complex formation at the C4-C5 and mild flattening of the ventral cord and minimal neural foraminal narrowing at the C5-C6. (Id.)

         On May 1, 2013, orthopedist Robert Anderson, M.D. saw Maddox regarding numbness and tingling in her right hand and to a lesser extent in her left hand. (Tr. 454) Dr. Anderson found Maddox had full finger, wrist, forearm, and elbow motion and good cervical range of motion. (Id.) Dr. Anderson found positive carpal tunnel syndrome much greater in her right hand than in her left. (Id.) Dr. Anderson found conservative measures had largely failed and recommended surgical carpal tunnel release. (Id.) On June 24, 2013, Dr. Anderson performed carpal tunnel release on Maddox's right hand. (Tr. 419-20) On August 7, 2013, Maddox returned to Dr. Anderson and reported that the tingling in her fingers that had been constant began to come and go. (Tr. 457) Dr. Anderson found that Maddox had improved movement in her fingers. (Id.) He recommended Maddox continue with physical therapy. (Id.)

         Maddox participated in physical and occupational therapy from July 25, 2013 through August 14, 2013 (Tr. 494-500), but still reported pain and limited use of her hand and had a positive Tinel's sign at the wrist. (Tr. 494)

         On August 26, 2013, Dr. Anderson saw Maddox regarding her complaints of worsening and burning pain in the area of the incision from her surgery that radiated up her forearm. (Tr. 508) Dr. Anderson found allodynia reproducing her burning pain and was concerned Maddox might have an early RSD variant, and recommended that Maddox work on her range of motion, take Vitamin C, and go to pain management. (Id.)

         On February 3, 2014, Dr. Anderson saw Maddox in follow up to the right carpal tunnel release surgery he had performed seven months earlier. (Tr. 693) Maddox reported continued burning pain at the area of her incision that radiated up her forearm. (Id.) Maddox reported that her occupational therapy did not help. (Id.) Despite Dr. Anderson's advice, Maddox did not go to pain management regarding her early RSD[1] variant, take vitamin C, or do the desensitization exercises that Dr. Anderson had directed her to do. (Id.) Dr. Anderson found Maddox's incision was well healed, but there was mild allodynia near the incision. (Tr. 697) Maddox's fingers had full range of motion. (Id.) Dr. Anderson noted mild discomfort at Maddox's incision site with wrist motion, but no instability. (Id.) He again directed Maddox to seek pain management treatment. (Id.)

         Dr. Haddad evaluated and treated Maddox multiple times between October 31, 2012 and September 2015, regarding, in relevant part, her back pain (Tr. 431, 437, 442, 651, 662, 658, 664, 668, 703, 721, 727, 783, 786, 1050, 1101), neck pain (Tr. 431, 437, 442, 651, 703, 721, 1050, 1101), depression (Tr. 431), migraines (Tr. 437, 651, 658), carpal tunnel and pain in her right hand (Tr. 431, 592), numbness in her hands (Tr. 437, 464, 592, 658, 662, 703, 781, 1034, 1050) and feet (Tr. 442, 464, 658, 1050), tremors (Tr. 582, 585, 615), and blackouts (Tr. 1101). At times, Maddox reported that medications decreased the chronic pain in her cervical spine and rated her pain as 3/10 (Tr. 431, 442, 464, 587, 709, 1027, 1034, 1101, 1145), 3-4/10 (Tr. 651, 721), or 4/10 (Tr. 592, 703, 1050). Maddox reported that weather changes and activity aggravated her cervical and lumbar spine pain. (Tr. 664, 703, 1027, 1034) Maddox also reported that her migraines were well-controlled by her medications (Tr. 431, 442, 1034). Dr. Haddad noted that Maddox was able to focus and had no social phobias when she was compliant with her medications for her depression. (Tr. 703) At times, Maddox's depression would improve. (Tr. 721, 1145) Maddox reported her generalized tremors improved. (Tr. 709) Dr. Haddad noted that Maddox could - at various times - lift, push, and pull a few pounds (Tr. 464), 5-10 pounds (Tr. 1145), up to 10 pounds (Tr. 442, 715), up to 15 pounds repetitively (Tr. 592, 1101), up to 15-20 pounds repetitively (Tr. 703), or up to 20 pounds repetitively (Tr. 721). Dr. Haddad noted Maddox was independent with activities of daily life within her limitations, although she required some help for activities like vacuuming. (Tr. 464, 592, 715, 721) Maddox also discussed her social security claim and associated paperwork with Dr. Haddad. (Tr. 464)

         Dr. Haddad often observed normal musculoskeletal (Tr. 431, 434, 437, 443, 445, 468, 593, 704, 710) and psychiatric findings. (Tr. 431, 435, 438, 443, 468, 593, 596, 710, 713, 722, 725, 1028, 1035, 1051, 1055, 1105) Dr. Haddad also observed cervical spine spasm and tenderness (Tr. 435, 440, 445, 468, 596, 655, 658, 664, 668, 704, 708, 714, 719, 731, 783, 1031, 1039, 1105), decreased range of motion in Maddox's cervical and/or lumbar spine (Tr. 440, 655, 658, 708, 714, 731, 1031, 1039, 1105), lumbar spine bilateral tenderness (Tr. 708, 714), severe pain in Maddox's right hand after her carpal tunnel release surgery (Tr. 468), and back pain, limb pain, and muscle weakness. (Tr. 1027, 1035, 1051) Dr. Haddad found tremors in Maddox's upper and lower extremities bilaterally. (Tr. 585) In relevant part, Dr. Haddad diagnosed Maddox with depression (Tr. 1032), carpal tunnel syndrome (Tr. 655, 662), common migraine (Tr. 655, 1032), cervical disc degeneration (Tr. 596, 655), median nerve neuritis (Tr. 596), low back pain (Tr. 1032), and cervical disc herniation C4-5, C5-6. (Tr. 1042, 1055) Dr. Haddad prescribed treatments for Maddox's back pain including Oxycodone-Acetaminophen (Tr. 435, 446, 468, 596, 655, 1033, 1055, 1106), Gabapentin (Tr. 446, 596), Percocet (Tr. 557, 658, 664), and pain management (Tr. 662, 781, 783, 1033).

         On December 21, 2012, an MRI of Maddox's cervical spine showed degenerative changes that were most severe at ¶ 4-C5 and C5-C6. (Tr. 414) At ¶ 4-C5 there was minimal flattening of the ventral aspect of the cord by disc osteophyte complex formation. (Tr. 413) At the C5-C6 there was disc osteophyte complex, facet, and uncinated joint hypertrophy that resulted in mild flattening of the ventral cord and minimal neural foraminal narrowing. (Tr. 413)

         On October 21, 2013, Dr. Haddad referred Maddox for a neurological evaluation and ordered an MRI of Maddox's brain after finding Maddox had tremors in her upper and lower extremities bilaterally. (Tr. 585)

         On February 17, 2015, an MRI of Maddox's cervical spine showed minimal degenerative changes in the mid to lower cervical spine, including small broad-based central disc herniation at the C4-5 and C5-6. (Tr. 1161) There was no significant canal or foraminal stenosis at any level. (Id.)

         On June 15, 2015, Dr. Haddad requested an EMG and nerve conduction study for Maddox's cervical disc disease, cervical disc herniation, and median nerve neuritis. (Tr. 1055)

         2. Treatment Records Regarding Maddox's Mental Impairments

         On June 7, 2012, Maddox started mental health treatment at Charak Center for Health and Wellness for her complaints of depression, anxiety, and panic attacks. (Tr. 528) Maddox reported that she suffered from asthma, fibromyalgia, tubal ligation, and chronic migraines. (Id.) She reported that she was taking Effexor XR and Wellbutrin XL for depression. (Id.) She reported seven to ten crying spells a day, mood swings, moderate anxiety, worries, several panic attacks a month, fear of crowds, irritability, racing thoughts, and difficulty sleeping. (Tr. 531, 892) She reported impaired concentration, paranoia, impulse control problems, fibromyalgia, and asthma. (Id.) The evaluating nurse found Maddox was well groomed, agitated, and withdrawn, and that her thought process was logical and her intelligence was average. (Tr. 532, 893) The nurse found Maddox was depressed and irritable, with a flat effect, impaired judgment, impulse control, memory, and concentration, and poor insight. (Id.) The nurse diagnosed Maddox with a mood disorder and a GAF score of 55 and prescribed Trileptal and Valium for her mood disorder and anxiety. (Tr. 533, 894)

         On June 19, 2012, Maddox reported that she was still feeling depressed and there had been no change since her last visit. (Tr. 885) Maddox was cooperative with a logical thought process, depressed mood, full affect, impaired attention and concentration, average intelligence, impaired memory, average insight, fair judgment, and normal impulse control. (Tr. 886-87) Maddox was prescribed Effexor, Wellbutrin, continued Trileptal, and an increased dosage of Valium. (Tr. 887)

         On August 23, 2012, Maddox reported that she did not like Prozac because it made her more depressed and she cried more often. (Tr. 881) Maddox reported that she had moderate depressive symptoms, irritability, and racing thoughts, but no anxiety, insomnia, or panic attacks. (Id.) Maddox was well groomed, cooperative, made average eye contact, and had a depressed mood, full affect, poor insight, fair judgment, normal impulse control and memory, and impaired attention and concentration. (Tr. 883) Maddox was prescribed continued Valium, Trileptal, and Effexor, and increased Prozac. (Tr. 883)

         On October 29, 2012, Maddox reported to Dr. Adityanjee of the Charak Center that her depression was worsening, that she was having crying spells and irritability, and that she wanted Xanax instead of Prozac. (Tr. 877) Maddox reported moderate depressive symptoms and irritability, mild mood swings, anxiety, and insomnia, but no panic attacks or racing thoughts. (Id.) Maddox's eye contact was avoidant, her mood was depressed and irritable, and her affect was full. (Tr. 878) Dr. Adityanjee noted that Maddox wanted to be on SSDI and refused to take antidepressants. (Tr. 879) Dr. Adityanjee prescribed Valium, Effexor, and Trileptal; Prozac was discontinued, and Celexa was added. (Id.)

         On November 14, 2012, Maddox reported worsened depression, increased anxiety, anger outbursts, continued crying spells and irritability. (Tr. 1005) Maddox was prescribed continued Valium, Effexor, and Trileptal, discontinued Celexa, and added Vistaril. (Tr. 1007)

         On December 12, 2012, Dr. Adityanjee noted that Maddox was not fully compliant with her medications and would have her primary care provider prescribe psychotropic drugs if she did not get what she liked. (Tr. 869) Dr. Adityanjee noted that Maddox's primary care provider had told her that she is unable to work and Maddox wanted a written statement of disability from her psychologist. (Tr. 869, 871) Maddox complained of drowsiness, memory impairment, and declining interactions. (Tr. 869) Maddox's eye contact was avoidant, her motor activity was slowed, she displayed poor concentration, and her demeanor was hostile, preoccupied, disinterested, and demanding. (Tr. 870) Maddox's mood was angry and irritable and her affect was constricted. (Tr. 870-71) Dr. Adityanjee prescribed continued Wellbutrin, Effexor, Trileptal, and Valium. (Tr. 871)

         On April 3, 2013, Maddox was very irritable and angry because she felt she had to wait too long for her appointment. (Tr. 864) Maddox reported moderate mood swings, anxiety, irritability, and insomnia, moderate to severe depressive symptoms, and no anxiety attacks or racing thoughts. (Id.) Maddox was well groomed and cooperative, she made average eye contact, her thought process was logical, mood was irritable, angry, and anxious, and her affect was constricted. (Tr. 865-66) Her medications were unchanged. (Tr. 864)

         On July 5, 2013, Rakesh Ranjan, M.D. saw Maddox regarding her mood swings. (Tr. 522) Dr. Ranjan found Maddox had moderate depressive symptoms, mood swings, racing thoughts, and insomnia, mild anxiety, no panic attacks, severely impaired concentration, decreased appetite, and severely decreased energy. (Tr. 522) Maddox's mood was depressed, irritable, and anxious and her affect was labile. (Tr. 524) Dr. Ranjan prescribed continued Valium, Effexor, and Wellbutrin and added Latuda. (Tr. 525)

         On August 5, 2013, Maddox reported to Dr. Ranjan that she stopped taking Latuda because it did not help her, her mood swings got worse, and she gained weight. (Tr. 516) Dr. Ranjan noted that Maddox did not want to take any new medications. (Tr. 516) Maddox reported severe depressive symptoms, mood swings, anxiety, irritability, and racing thoughts, moderate insomnia, and decreased energy, interests, and appetite. (Tr. 516) Maddox reported hearing voices and having suicidal and intrusive thoughts and flashbacks. (Id.) Maddox was cooperative with a full affect and anxious and angry mood. (Tr. 518) Dr. Ranjan prescribed continued Wellbutrin, Effexor, and Valium, added Keppra, and discontinued Latuda. (Tr. 519)

         On September 9, 2013, Dr. Ranjan saw Maddox regarding her complaints of agitation and panic attacks. (Tr. 510) Maddox reported panic attacks, insomnia, impaired concentration, decreased energy and interests, and flashbacks. (Id.) Dr. Ranjan noted that Maddox was stressing about her SSI paperwork not being completed. (Tr. 511) Dr. Ranjan generally noted normal findings in the mental status exam, but found that Maddox was agitated, depressed, and irritable. (Tr. 511-512). He increased Maddox's Keppra prescription. (Tr. 513) Dr. Ranjan assessed Maddox's condition as deteriorating. (Tr. 514)

         On February 7, 2014, Maddox reported that five months had elapsed since her last appointment because she missed her follow-up appointment, had insurance issues, and was getting her medications from her primary care physician. (Tr. 842) Maddox reported that her symptoms were all still severe and she was only getting four hours of sleep per day. (Id.) She reported that Valium helped her to sleep. (Id.) Maddox reported that her health issues were keeping her from working, and it made her angry and depressed that she could not work. (Id.) Maddox avoided eye-contact and displayed cooperative demeanor, rapid speech, a depressed, anxious, irritable, and angry mood, impaired attention and concentration, and reported auditory hallucinations and compulsions for checking, arranging, and cleaning. (Tr. 843-44) Dr. Ranjan found that Maddox's condition was deteriorating and prescribed continued Wellbutrin, discontinued Effexor, and added Valium and Keppra. (Tr. 845)

         On March 14, 2014, Maddox reported to Dr. Ranjan that she noticed tremors and numbness in her hands and more frequent headache, nausea, and fainting spells after the increase in her dosage of Keppra. (Tr. 837) She reported high anxiety, problems sleeping, and worsening depression due to her health issues. (Id.) Maddox reported severe depressive symptoms, mood swings, anxiety, irritability, racing thoughts, and sleep disturbance; moderate insomnia; decreased appetite, energy, and interests; compulsions; flashbacks; and daily panic attacks. (Tr. 837) Dr. Ranjan indicated that Maddox's condition was deteriorating. (Tr. 840) Maddox reported that she was more stable when taking Valium, Keppra, Wellbutrin, and Effexor. (Tr. 837)

         On March 28, 2014, Maddox reported to Dr. Ranjan that she had not improved much since her appointment in February, despite the changes in medication. (Tr. 832) She reported that she continued to have fading spells, could not focus, and was still depressed and anxious. (Id.) Maddox couldn't sit still and was constantly tapping her fingers and trembling her knees during the appointment. (Id.) Maddox stated that her workers compensation had ended and she was trying to get social security disability. (Tr. 832) Maddox avoided eye contact and displayed average motor activity, cooperative demeanor, rapid speech, depressed, anxious, angry, and irritable mood, constricted affect, and her thought process was a flight of ideas. (Tr. 834) Dr. Ranjan prescribed continued Wellbutrin and added Valium, Keppra, and Brintellix. (Tr. 835)

         Dr. Ranjan saw Maddox on April 25, 2014. (Tr. 827) Maddox was well groomed, avoided eye contact, and displayed average motor activity, cooperative demeanor, rapid speech, depressed mood, flat affect, impaired concentration, attention, and memory, and her thought process was a flight of ideas. (Tr. 829) Dr. Ranjan prescribed continued Wellbutrin, Valium, Keppra, and Brintellix. (Tr. 830)

         On July 16, 2014, Dr. Ranjan saw Maddox regarding her severe depression, moderate mood swings, and severe anxiety. (Tr. 822) Maddox reported severe depression, severe anxiety, mood swings, crying, anger and screaming, decreased appetite, and low energy. (Id.) On September 22, 2014, Maddox reported that her medication adjustment from the previous month was not working and requested to be prescribed Wellbutrin and Brintellix. (Tr. 943) Dr. Ranjan prescribed Wellbutrin, Valium, Keppra, and Brintellix. (Tr. 946) He indicated that Maddox's condition was deteriorating and assigned her a GAF score of 60. (Id.).

         On August 14, 2014, Maddox reported to Parvath Nanjundiah M.D. that she continued to have problems sleeping, to feel depressed and anxious, and to have panic attacks. (Tr. 948) Maddox was well groomed and displayed average eye contact, slowed motor activity, cooperative demeanor, logical thought process, depressed, anxious, irritable mood, constricted affect, and no obsessions. (Tr. 949-950) Dr. Nanjundiah prescribed continued Valium, Keppra, and Brintellix, but stopped Wellbutrin. (Tr. 951)

         On September 22, 2014, Maddox reported to Dr. Ranjan that the medication adjustments were not working and reported having flashbacks and that everything was a challenge for her. (Tr. 943) Maddox was well groomed, displayed average eye contact, slowed motor activity, cooperative demeanor, a logical thought process, depressed, irritable, and anxious mood, constricted affect, and compulsions for checking, arranging, and cleaning. (Tr. 945) Dr. Ranjan prescribed continued Wellbutrin, Valium, Keppra, and Brintellix. (Tr. 946)

         On July 17, 2015, Dr. Ranjan saw Maddox regarding her stress and anxiety. (Tr. 938) Maddox reported that she experienced panic attacks that were not being controlled by the Valium she was taking. (Id.) She reported getting three hours of sleep at night and a low appetite. (Id.)

         On November 13, 2015, Dr. Ranjan saw Maddox regarding refilling her medications. (Tr. 1170) Maddox was very quiet and stated that she thought her medication was working okay. (Id.) Maddox was well groomed, displayed average eye contact, average motor activity, cooperative demeanor, logical thought process, euthymic mood, full affect, and her cognition was not impaired. (Tr. 1169) Dr. Ranjan found that Maddox's condition was improving. (Tr. 1172) Dr. Ranjan prescribed continued Valium, Keppra, Brintellix, and Wellbutrin. (Id.)

         On January 8, 2016, Dr. Ranjan saw Maddox regarding her mental condition. (Tr. 1175) Maddox reported that she was very stressed and had attended her SSI hearing. (Id.) Dr. Ranjan found that Maddox was well groomed and displayed average eye contact, build, motor activity, cooperative demeanor, circumstantial thought process, anxious mood, full affect, and unimpaired cognition. (Tr. 1176-77) Dr. Ranjan prescribed continued Valium, Keppra, Brintellix, and Wellbutrin. (Tr. 1178)

         C. Opinion Evidence

         1. Mitchell Wax, Ph.D. - Consultative ...


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