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QuickDASH Validity and Realiabity

QuickDASH Validity and Realiabity - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related


ral
ss
BioMed Cent
BMC Musculoskeletal Disorders
Open Acce
Research article
The shortened disabilities of the arm, shoulder and hand
questionnaire (QuickDASH): validity and reliability based on
responses within the full-length DASH
Christina Gummesson*
1,2
, Michael M Ward
1
and Isam Atroshi
3
Address:
1
National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland 20892, USA,
2
Department of Health
Sciences, Division of Physiotherapy, Lund University, Lund, SE 22185, Sweden and
3
Department of Orthopedics Hässleholm-Kristianstad,
Hässleholm Hospital, Hässleholm SE 28125, Sweden
Email: Christina Gummesson* - christina.gummesson@med.lu.se; Michael M Ward - wardm1@mail.nih.gov;
Isam Atroshi - Isam.Atroshi@skane.se
* Corresponding author
Abstract
Background: The 30-item disabilities of the arm, shoulder and hand (DASH) questionnaire is increasingly
used in clinical research involving upper extremity musculoskeletal disorders. From the original DASH a
shorter version, the 11-item QuickDASH, has been developed. Little is known about the discriminant
ability of score changes for the QuickDASH compared to the DASH. The aim of this study was to assess
the performance of the QuickDASH and its cross-sectional and longitudinal validity and reliability.
Methods: The study was based on extracting QuickDASH item responses from the responses to the full-
length DASH questionnaire completed by 105 patients with a variety of upper extremity disorders before
surgery and at follow-up 6 to 21 months after surgery. The DASH and QuickDASH scores were compared
for the whole population and for different diagnostic groups. For longitudinal construct validity the effect
size and standardized response mean were calculated. Analyses with ROC curves were performed to
compare the ability of the DASH and QuickDASH to discriminate among patients classified according to
the magnitude of self-rated improvement. Cross-sectional and test-retest reliability was assessed.
Results: The mean DASH score was 34 (SD 22) and the mean QuickDASH score was 39 (SD 24) at
baseline. For the different diagnostic groups the mean and median QuickDASH scores were higher than
the corresponding DASH scores. For the whole population, the mean difference between the QuickDASH
and DASH baseline scores was 4.2 (95% CI 3.2–5.3), follow-up scores was 2.6 (1.7–3.4), and change scores
was 1.7 (0.6–2.8).
The overall effect size and standardized response mean measured with the DASH and the QuickDASH
were similar. In the ROC analysis of change scores among patients who rated their arm status as somewhat
or much better and those who rated it as unchanged the difference in the area under the ROC curve for
the DASH and QuickDASH was 0.01 (95% CI -0.05–0.07) indicating similar discriminant ability.
Cross-sectional and test-retest reliability of the DASH and QuickDASH were similar.
Conclusion: The results indicate that the QuickDASH can be used instead of the DASH with similar
precision in upper extremity disorders.
Published: 18 May 2006
BMC Musculoskeletal Disorders 2006, 7:44 doi:10.1186/1471-2474-7-44
Received: 04 November 2005
Accepted: 18 May 2006
This article is available from: http://www.biomedcentral.com/1471-2474/7/44
© 2006 Gummesson et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Page 1 of 7
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BMC Musculoskeletal Disorders 2006, 7:44 http://www.biomedcentral.com/1471-2474/7/44
Background
Patient-reported outcome measures have become an
important part of the assessments used in clinical studies.
One of the outcome measures intended for upper extrem-
ity disorders is the 30-item disabilities of the arm, shoul-
der and hand (DASH) questionnaire, which has been
assessed regarding reliability, cross-sectional validity and
longitudinal validity in a variety of arm disorders [1-3].
The use of the DASH has been growing rapidly in clinical
trials and other studies of upper extremity disorders and it
is now available in several languages [4].
From the original DASH questionnaire a shorter version,
named the QuickDASH, has been developed using what
was called a "concept-retention" approach [5]. The Quick-
DASH consists of 11 items from the original 30-item
DASH. The QuickDASH may be more appealing to use
than the DASH because a shorter questionnaire is associ-
ated with less burden on the responder as well as less
administrative burden. To date, data regarding the devel-
opment process and various aspects of reliability and
validity have been published only for the English version
of the QuickDASH [5]. It is important that translated ver-
sions of shortened questionnaires also are subjected to an
appropriate validation process. Furthermore, little is
known about how the QuickDASH scores can be inter-
preted in comparison to the DASH scores or which ver-
sion is more favorable with respect to precision of the
scoring.
To determine whether a shortened questionnaire may be
used to replace an existing full-length questionnaire, sev-
eral assessments can be performed to show that the short
version should be measuring what the original version is
measuring. Different aspects of cross-sectional validity
can be compared [6]. Further, longitudinal construct
validity, which concerns the measure's ability to detect a
true change in health status and its precision in detecting
changes of different magnitudes (also referred to as
responsiveness or sensitivity to change) needs to be
addressed to determine the clinical usefulness of the short
version [7-9].
The purpose of this study was to evaluate the performance
of the 11-item QuickDASH in comparison to the full-
length 30-item DASH regarding different aspects of valid-
ity and reliability. The data for the QuickDASH were
extracted from the full-length DASH.
Methods
Design
This study was designed as a reanalysis of collected data
for the 30-item DASH questionnaire, from which scores
gitudinal construct validity of the DASH has been
described previously [10]. The study was conducted in
agreement with the local ethical guidelines for clinical
studies and informed consent was obtained from the par-
ticipants.
Questionnaire
The DASH questionnaire mainly consists of a 30-item dis-
ability/symptom scale. The two optional scales of the
DASH (sport/music and work) were not part of the study.
Each item in the disability/symptom scale has 5 response
options. If at least 27 of the 30 items are completed a scale
score, ranging from 0 (no disability) to 100 (most severe
disability), can be calculated.
From the full-length DASH the 11 items that constitute
the QuickDASH were extracted. To calculate a QuickDASH
score at least 10 of the 11 items must be completed. Sim-
ilar to the DASH, each item has 5 response options and,
from the item scores, scale scores are calculated, ranging
from 0 (no disability) to 100 (most severe disability).
The follow-up questionnaire included an item inquiring
about change in the status of the arm as compared to its
status before surgery. The item had 5 response options;
much better, somewhat better, unchanged, somewhat
worse, much worse. This item was accidentally missing in
the initially mailed questionnaires and was therefore only
completed by the last 83 participants, 82 of whom had
QuickDASH scores and could be included in the present
analysis.
Setting and participants
From an orthopedic department 109 of 118 consecutive
patients with upper extremity disorders who fulfilled the
eligibility criteria (scheduled for elective surgery, 18 years
or older, symptom duration of at least 2 months, able to
answer questionnaires) responded to the Swedish version
of the DASH before surgery and at the follow-up evalua-
tion. The follow-up was done at 6 to 21 (mean 12)
months after surgery.
Of the 109 responders, 105 had responded to at least 10
of the 11 items used in the QuickDASH and were included
in the analysis. The mean age of the 105 participants was
52 (range 18–83) years; 60 (57%) were women and 45
were men.
Analysis
The baseline, follow-up and change scores for the DASH
and the QuickDASH were calculated for the whole popu-
lation and for specific diagnostic groups.
Page 2 of 7
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for both the DASH and the QuickDASH were calculated.
The data collection process for the assessment of the lon-
To study the longitudinal construct validity the effect size
(mean change score divided by the standard deviation of

BMC Musculoskeletal Disorders 2006, 7:44 http://www.biomedcentral.com/1471-2474/7/44
the baseline scores) and the standardized response mean
(mean change score divided by the standard deviation of
the change scores) for the DASH and QuickDASH were
calculated.
To compare the performance of the DASH and the Quick-
DASH in discriminating among patients who differed in
the degree of arm-related disability, receiver operating
characteristic (ROC) curves were constructed using
change scores (baseline to follow-up) as the test variable
and patients' responses to the global item concerning per-
ceived change in arm status after surgery as the dichot-
omized classifying variable; the difference in the areas
under the ROC curves for the two questionnaire versions
was calculated [11,12]. In the first ROC analysis the DASH
and QuickDASH were compared with regard to their abil-
ity to discriminate the patients who rated their arm status
as "much better" or "somewhat better" (combined into
one group) from those who rated it as "unchanged". In
the second analysis the ability to discriminate the "much
better" group from the "somewhat better" group was com-
pared. The difference in the areas under the ROC curves
indicates the magnitude of the difference in the discrimi-
nant ability of the two measures. The number of patients
who had reported worsening was too small to perform an
analysis comparing the ability of the 2 measures to detect
deterioration.
To assess reliability the Cronbach alpha coefficient was
calculated for the baseline and follow-up item responses.
Agreement between the QuickDASH and the full-length
DASH was assessed with the intraclass correlation coeffi-
cient (ICC) using the 2-way mixed and absolute agree-
ment model [13]. The difference between the DASH
scores and the QuickDASH scores was assessed with the
paired-samples t-test. Because the QuickDASH responses
were extracted from the full-length DASH some degree of
correlation between part of the questionnaire and the
whole is expected. To explore the possible effect of this
factor we created two hypothetical 11-item short-forms by
computer-generated random selection from the 30 items
of the full-length DASH. These random 11-item short-
forms were analyzed with regard to reliability in a similar
fashion as done with the QuickDASH.
Test-retest reliability was studied in a subgroup of 30
patients (14 women) with a mean age of 54 (range 27–
79) years, who had completed the full-length DASH on
two occasions prior to surgery with a median interval of 5
(range 5–17) days [14]. The scores for the DASH, Quick-
DASH and the random short-forms from both response
times were calculated. The ICC (2-way mixed, absolute
agreement) and the paired-samples t-test were used for
this analysis.
Results
Cross-sectional validity
The baseline mean DASH score was 34 (SD 22) and the
mean QuickDASH score was 39 (SD 24) (Table 1). A best
possible score of zero (ceiling) at baseline was recorded
for the QuickDASH in 3 patients (2.9%) and for the DASH
in 1 patient (1%) and a score of less than 10 was found in
19 patients (18%) and 20 patients (19%), respectively
(Figure 1). At follow-up, 12 patients (14%) had a best
possible QuickDASH and 10 (9.5%) a best possible DASH
score. No patient had a score exceeding 90 at any evalua-
tion except for 1 patient who had a QuickDASH score of
93 at follow-up.
The mean difference between the QuickDASH and the
DASH scores at baseline was 4.2 (SD 5.4) and the mean
difference at follow-up was 2.6 (SD 4.6). The mean differ-
ence between the QuickDASH and DASH change scores
was 1.7 (SD 5.8; 95% CI 0.6–2.8).
For the different diagnostic groups the mean and median
QuickDASH scores were higher than the corresponding
DASH scores by up to 5 points in most groups (Table 2).
Among patients with shoulder disorders the mean DASH
score was 44 (SD 15) and the mean QuickDASH score was
49 (SD 18); the difference among patients with CTS was
even larger.
Table 1: The DASH and QuickDASH scores at baseline and follow-up for the 105 responders.
Baseline Follow-up Difference
Mean (SD) Median (IQR) Mean (SD) Median (IQR) Mean (SD) Median (IQR) Effect Size Standardized
Response
Mean
DASH 35
(22)
33
(15–50)
24
(23)
16
(4–42)
10
(17)
8
(1–21)
0.46 0.61
QuickDASH 39
(24)
39
17–59)
27
(25)
18
(5–47)
12
(19)
9
(0–27)
0.50 0.63
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The scores for both scales range from 0 (no disability) to 100 (most severe disability).
IQR, interquartile range

BMC Musculoskeletal Disorders 2006, 7:44 http://www.biomedcentral.com/1471-2474/7/44
Longitudinal construct validity
When assessing the magnitude of change from baseline to
follow-up the overall effect size and standardized
response mean measured with the DASH and the Quick-
DASH were similar (Table 1). Among the 24 patients with
shoulder disorders treated with arthroscopic acromio-
plasty, the effect size measured with the DASH and Quick-
DASH was 0.79 and 0.74, and the standardized response
mean was 0.45 and 0.46, respectively. Among the 19
patients with carpal tunnel syndrome, the effect size of
open carpal tunnel release surgery measured with the
DASH and QuickDASH was 0.66 and 0.89 and the stand-
ardized response mean was 0.98 and 1.05, respectively.
In the ROC analysis of the change scores for the patients
who rated their arm status after surgery as better (includ-
ing "much better" and "somewhat better") and those who
rated it as "unchanged", the difference in the area under
the ROC curves for the DASH and QuickDASH was 0.01
(95% CI -0.05–0.07), indicating no difference in their
ability to discriminate between the 2 groups (Table 3). In
the ROC analysis comparing the ability to discriminate
the DASH and the QuickDASH was 0.03 (95% CI -0.03–
0.09).
Reliability
QuickDASH
In the assessment of cross-sectional reliability among the
105 responders, the alpha coefficient for the scores
exceeded 0.90 and the corrected item-total correlations
(ITC) exceeded 0.62, except for 1 item with ITC of 0.42 at
baseline (Table 4). The ICC values for the agreement
between the QuickDASH and the DASH scores were high,
exceeding 0.90 at baseline and follow-up.
In the analysis of test-retest reliability, the ICC for the
QuickDASH scores on the 2 response times was high and
the mean difference between the QuickDASH scores on
the first and second response time was almost zero and
the 95% confidence interval was within 4 points in each
direction.
Random 11-item forms
The first short-form included 11 randomly selected items
Table 2: The DASH and QuickDASH scores for different diagnostic groups among the 105 responders.
Baseline Follow-up
Mean (SD) Median Mean (SD) Median
Shoulder disorder (n
= 27)
DASH 44 (15) 48 33 (24) 33
QuickDASH 49 (18) 50 37 (25) 34
Carpal tunnel
syndrome (n = 19)
DASH 41 (20) 40 28 (26) 15
QuickDASH 49 (20) 46 31 (29) 23
Dupuytren's disease
(n = 13)
DASH 19 (23) 8 15 (23) 5
QuickDASH 22 (27) 9 17 (23) 7
Ganglion (n = 7) DASH 15 (23) 8 11 (15) 5
QuickDASH 16 (22) 14 12 (14) 9
Trapeziometacarpal
arthritis (n = 6)
DASH 48 (17) 48 24 (22) 25
QuickDASH 51 (15) 52 27 (24) 30
Tenosynovitis (n = 9) DASH 35 (17) 30 20 (19) 8
QuickDASH 39 (17) 34 23 (22) 9
Other (n = 24) DASH 29 (24) 24 21 (23) 15
QuickDASH 32 (26) 33 23 (23) 16
The scores for both scales range from 0 (no disability) to 100 (most severe disability)
Page 4 of 7
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the "much better" group from the "somewhat better"
group, the difference in the area under the ROC curves for
from the full-length DASH (items 1, 3, 5, 8, 10, 11, 12, 19,
20, 24, 27). The mean score was 38 (SD 24) at baseline

BMC Musculoskeletal Disorders 2006, 7:44 http://www.biomedcentral.com/1471-2474/7/44
and 28 (SD 26) at follow-up. For the second short-form
(items 3, 7, 11, 12, 13, 15, 22, 25, 26, 27, 28), the mean
score was 36 (SD 23) at baseline and 25 (SD 24) at follow-
up. The reliability coefficients and agreement with the
DASH were high and similar to those for the QuickDASH
(Table 4).
Discussion
The aim of this study was to compare the performance of
the 11-item QuickDASH with that of the 30-item DASH,
with the QuickDASH scores extracted from the responses
to the full-length DASH. The results indicate that the
DASH can be replaced by the shorter QuickDASH. The
magnitude of the differences between the DASH and the
QuickDASH scores found in this study implies that the
same questionnaire should be used in longitudinal stud-
ies because the score differences between the question-
naires may inflate small random differences and make
them reach the level of an important change.
In all analyses the QuickDASH scores were slightly higher
than the corresponding DASH scores, which may be an
advantage for the QuickDASH as this allows for larger
improvement to occur, provided that the scores consid-
ered as "normal" are equal. Among the different diagnos-
tic groups the QuickDASH mean scores were higher; in fact
this difference was more pronounced among patients
with greater disability, such as those with shoulder disor-
der, than patients with little disability, such as those with
wrist ganglion (Table 2). This suggested that the Quick-
DASH potentially had better precision in detecting differ-
ent degrees of disability. To further assess possible
differences in the two measures' ability to detect improve-
ment, ROC curves were studied. In all analyses, the confi-
dence intervals for the difference contained null,
indicating that no differences were found between the
DASH and the QuickDASH in their ability to discriminate
among groups that differed in the degree of self-rated
improvement in arm status after surgery.
Table 4: Reliability
Scale Test-retest reliability Cross-sectional reliability Agreement with
DASH
Baseline Baseline Follow-
up
Baseline Follow-
up
Agreement Difference
*
Agreement Difference Agreement Difference
ICC (95%
CI)

mean (95%
CI)
alpha ITC range alpha ITC range ICC (95%
CI)

mean (95%
CI)

ICC (95%
CI)

mean (95%
CI)

DASH 0.93 (0.86–
0.97)
0.9 (- 2.3–
4.0)
a
0.970.41–0.860.980.57–0.901010
QuickDA
SH
0.93 (0.87–
0.97)
-0.2(-3.6–
3.1)
b
0.92 0.42–0.83 0.95 0.63–0.88 0.96 (0.84–
0.98)
4.2 (3.2–
5.3)
0.97 (0.92–
0.99)
2.6 (1.7–
3.4)
Random-
11 1
0.92 (0.84–
0.96)
-2.1(-5.7–
1.5)
c
0.93 0.55–0.82 0.95 0.55–0.88 0.96 (0.92–
0.98)
3.1 (2.0–
4.2)
0.97 (0.91–
0.98)
3.4 (2.4–
4.5)
Random-
11 2
0.93 (0.85–
0.96)
-0.3(-3.7–
3.1)
b
0.91 0.42–0.81 0.95 0.62–0.87 0.97 (0.96–
0.98)
1.7 (0.7–
2.7)
0.99 (0.98–
0.99)
0.7 (0–1.4)
*calculated as the score at time 1 minus the score at time 2.

All ICC values were statistically significant (p < 0.001).
Table 3: The area under the receiver operating characteristic (ROC) curve for the DASH and the QuickDASH, constructed using the
change scores for patients classified, according to their response to the global item about self-rated improvement in arm status after
surgery, into "much better", "somewhat better" or "unchanged"; item administered to 82 participants.
Area under ROC curve (95% CI)
"better" vs "unchanged" "much better" vs "somewhat better"
(n = 65)* (n = 9) (n = 47) (n = 18)
DASH 0.81 (0.70–0.89) 0.71 (0.59–0.82)
QuickDASH 0.82 (0.71–0.90) 0.68 (0.56–0.79)
difference between DASH
and QuickDASH
0.01 (0.05–0.07), p = 0.8 0.03 (-0.03–0.09), p = 0.3
*combining patients responding "much better" and those responding "somewhat better" to the global item.
The remaining responders to the global item were 6 with "much worse" and 2 "somewhat worse" responses.
Page 5 of 7
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All differences between the DASH and the other 3 forms were significant (p ≤ 0.001) except for random-11 form 2 at follow-up (p = 0.053)
a
p = 0.6,
b
p = 0.9,
c
p = 0.2.
ICC, intraclass correlation coefficient; alpha, Cronbach alpha coefficient; ITC, item-total correlation

BMC Musculoskeletal Disorders 2006, 7:44 http://www.biomedcentral.com/1471-2474/7/44
In the study assessing the English-version QuickDASH the
standardized response mean, calculated for the total pop-
ulation of 171 patients with various disorders, was 0.78
for the DASH and 0.79 for the QuickDASH [5]. In our
study the standardized response mean for the DASH and
QuickDASH also were similar, with values of 0.61 and
0.63, respectively. The mean scores for the DASH and
QuickDASH in different diagnostic groups were more sim-
ilar in the study of the English-version QuickDASH than in
our study. However, limited data was available and the
score distributions for the groups were not shown making
comparisons difficult.
In this study, as in the study that reported the develop-
ment and validation of the English version [5], the Quick-
DASH scores were computed from the full-length DASH
responses. It is not known if patients' responses to the 11
items would have differed if only the QuickDASH were
administered. In a study of the performance of three SF-36
scales (physical functioning, bodily pain and general
health perceptions) no significant differences were found
when the scales were administered independently com-
pared to when they were administered within the full 8-
scale questionnaire [15]. However, these were full scales
and not selected items as is the case with the QuickDASH.
The results of the present study, based on QuickDASH
responses extracted from the full-length DASH, are prom-
ising but further assessment of the short version adminis-
tered to different patient groups would be useful. Because
unchanged or worsened self-rated arm status the results
involving these groups may need to be interpreted with
caution.
The reliability of the QuickDASH was good. However, the
2 randomly constructed 11-item forms also had similarly
good reliability and agreement with the DASH. The 2 ran-
dom short forms showed higher scores than the DASH at
baseline and follow-up, which also was found with the
QuickDASH. Although the differences were statistically
significant, their magnitude may not be considered as
clinically important. The findings may suggest that the 30-
item full DASH may contain redundant items and that
fewer items would be sufficient for assessing disability
with the same degree of reliability and validity. It might be
argued that the random short forms may not cover all rel-
evant domains. However, the results of the DASH or
QuickDASH are usually not presented as a number of sep-
arate components or domains because they are not vali-
dated as such. Moreover, the DASH and QuickDASH are
predominantly composed of activity items that measure
physical disability leaving little impact for the non-activity
items. Because the item responses were extracted from the
responses to the full-length DASH it may not be possible
to compare with certainty the individual performance of
the QuickDASH as compared to other possible short forms
of the DASH.
In this study all participants underwent surgery, an inter-
Scatter plot of the QuickDASH and DASH scores at baseline and follow-upFigure 1
Scatter plot of the QuickDASH and DASH scores at baseline and follow-up.
Baseline
0
10
20
30
40
50
60
70
80
90
100
0 102030405060708090100
DASH
Q
u
i
c
k
D
A
S
H
Follow-up
0
10
20
30
40
50
60
70
80
90
100
0 102030405060708090100
DASH
Q
u
i
c
k
D
A
S
H
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of the small number of patients in certain diagnostic
groups as well as the small number of patients with
vention that often results in large score change. The effect
size and standardized response mean measured with

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BMC Musculoskeletal Disorders 2006, 7:44 http://www.biomedcentral.com/1471-2474/7/44
DASH and QuickDASH in populations treated with sur-
gery may be larger than those measured after other inter-
ventions. However, the overall effect size in this
population was moderate probably because the different
diagnostic groups had large variation in the degree of
baseline disability with some groups having low scores
before treatment allowing only small score improvement.
The results support the use of the QuickDASH even in the
assessment of interventions expected to have smaller
effect size.
The findings of this study are primarily related to the
validity and reliability of the Swedish version of the Quick-
DASH (available online [4]). Although many aspects also
may apply to QuickDASH versions that are derived from
other translated full-length versions with established
validity and reliability, other language versions would still
require appropriate assessment.
Conclusion
The results of this study indicate that the QuickDASH can
be used instead of the DASH to measure disability/symp-
tom severity with similar precision in a variety of arm dis-
orders.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
CG and IA participated in the design of the study, data col-
lection and analysis, and writing of this manuscript. MW
participated in the analysis and writing of this manuscript.
All authors read and approved the final manuscript.
Acknowledgements
This research was supported in part by the Intramural Research Program
of the NIH, National Institute of Arthritis and Musculoskeletal and Skin Dis-
eases, USA, and in part by the Skane County Council's research and devel-
opment foundation, Sweden, and the Division of Health Sciences, Lund
University, Sweden.
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