2019 EULAR recommendations for the generic core competences of health professionals in rheumatology
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* Lisa Edelaar
* Elena Nikiphorou
* George E Fragoulis
* Annamaria Iagnocco
* Catherine Haines
* Margot Bakkers
* Lurdes Barbosa
* Nada Cikes
* Mwidimi Ndosi
* Jette Primdahl
* Yeliz Prior
* Polina Pchelnikova
* Valentin Ritschl
* Valentin Sebastian Schäfer
* Hana Smucrova
* Inger Storrønning
* Marco Testa
* Dieter Wiek
* Theodora P M Vliet Vlieland

## Abstract

**Background/objectives** To maintain and optimise the quality of care provided by health professionals in rheumatology (HPRs), adequate educational offerings are needed. This task force (TF) aimed to develop evidence-based recommendations for the generic core competences of HPRs, with specific reference to nurses, physical therapists (PTs) and occupational therapists (OTs) to serve as a basis for their postgraduate education.

**Methods** The EULAR standardised operating procedures for the development of recommendations were followed. A TF including rheumatologists, nurses, PTs, OTs, patient-representatives, an educationalist, methodologists and researchers from 12 countries met twice. In the first TF meeting, 13 research questions were defined to support a systematic literature review (SLR). In the second meeting, the SLR evidence was discussed and recommendations formulated. Subsequently, level of evidence and strength of recommendation were assigned and level of agreement (LoA) determined (0–10 rating scale).

**Results** Three overarching principles were identified and 10 recommendations were developed for the generic core competences of HPRs. The SLR included 79 full-text papers, 20 of which addressed the competences, knowledge, skills, attitudes and/or educational needs of HPRs from multiple professions. The average LoA for each recommendation ranged from 9.42 to 9.79. Consensus was reached both on a research and educational agenda.

**Conclusion** Evidence and expert opinion informed a set of recommendations providing guidance on the generic core competences of HPRs. Implementation of these recommendations in the postgraduate education of HPRs at the international and national level is advised, considering variation in healthcare systems and professional roles.

*   competences
*   educational needs
*   recommendations
*   health professionals
*   rheumatology

## Introduction

Health professionals in rheumatology (HPRs) play an important role in the care of people with rheumatic and musculoskeletal diseases (RMDs). Up-to-date knowledge and relevant skills are essential to provide safe and effective patient care. Although multiple educational offerings have been developed for HPRs at postgraduate level, their availability and content vary largely among countries as well as by profession.1 It is imperative that the definition or development of a curriculum for HPRs, that is harmonised across countries, has international consensus on the core competences needed for the management of people with RMDs.

A set of desirable competences already exists at European level for rheumatologists.2 For HPRs, relevant work has been done only at national level. In the UK, a Delphi-based study identified the core competences that non-specialist community-based nurses and allied HPRs should have.3 Also, the Health Education England, NHS England and Skills for Health recently published the musculoskeletal core capabilities framework for a range of practitioners in rheumatology who act as first point reference.4 Currently, no such sets of generic competences HPRs of multiple professions have in common exist at European level.

To address this unmet need, a EULAR task force (TF) was set up to develop EULAR-endorsed recommendations for generic core competences of HPRs of multiple professions at the postgraduate level. These would need to constitute the common base of competences every HPR working with people with RMDs should have. On top of that, HPRs may need additional competences, depending on their specific profession. Although it was considered that HPRs represent a broad range of professions, the project focused on nurses, physical therapists (PTs) and occupational therapists (OTs). These professionals were, apart from physicians, considered to be most frequently involved in the care of people with RMDs. The EULAR recommendations for the generic core competences of HPRs are intended for all HPRs and other healthcare providers in the field of RMDs and are relevant to key stakeholders that is, patients, as well as their (inter)national organisations; institutions and clinical educators providing education for HPRs. Furthermore, these recommendations could serve as a framework for all relevant stakeholders other than just service providers, including health insurers and policy makers as well as a reference document for generic competences of health professionals in other specialties.

## Methods

The updated EULAR standardised operating procedures (SOPs) for the development of the recommendations were followed5 after approval of the TF by the EULAR Executive Committee. The multidisciplinary TF comprised of a selection of nine experts in HPRs’ education (three nurses, two PTs, three OTs, one rheumatologist), two EMEUNET members (VS, GF), three patient representatives and a steering group managing the process (convenors TVV and AI, methodologists EN and TVV, educationalist CH, fellows LE and GF). There was broad country representation in the TF from across 12 countries (Netherlands, Italy, UK, Portugal, Denmark, Norway, Czech Republic, Austria, Croatia, Germany, Russia, Greece).

During the first TF meeting, definitions of competences and a clear definition of HPRs were agreed. Clinically relevant questions on HPRs’ education, skills and practice were discussed, and research questions were defined by consensus to form the basis for the subsequent systematic literature review (SLR). The literature on the competences, roles, knowledge, attitudes, skills or educational needs of HPRs in general, or specifically for nurses, PTs or OTs and at postgraduate level was systematically identified using a structured search strategy in multiple electronic databases (PubMed/Medline, Embase, Cochrane library, CENTRAL, Emcare, PsycINFO, Academic Search Premier, Web of Science, Google Scholar and the educational databases ERIC and National Science Digital Library). National presidents or liaison persons of HPRs’ organisations were also contacted to supplement the information retrieved from the SLR. Details of the search strategy, including study selection, data extraction and data synthesis are provided in a separate manuscript (under submission). Studies addressing competences of multiple HPRs (including nurses and/or PTs and/or OTs) were considered as the most appropriate to answer the research questions. Methodological quality of each of the studies addressing competences of HPRs of multiple professions was scored (LE, GF, EN) using appropriate tools6–8 (see details in online supplementary table S1). Studies describing competences of a single profession (nurse, PT or OT) were only used to confirm the generic core competences as derived from the literature addressing generic competences of HPRs of multiple professions. If more specific information and relevant details in support of generic competences was provided in the literature addressing a single profession, that information was extracted. Competences that unambiguously can or should only be applied or performed by one profession were not taken into account, with the distinction being based on professional profiles and one of the studies providing a detailed description of desired competences per discipline.9 

### Supplementary data

[[annrheumdis-2019-215803supp001.pdf]](pending:yes) 

The findings of the SLR were presented by the fellows at the second TF meeting and formed the basis of a detailed discussion by the TF that informed the wording of overarching principles (OAPs) and recommendations. The OAPs/recommendations were voted on informally by the TF and if at least 75% approved each OAP and recommendation, these were accepted. If not, discussion was resumed with changes proposed followed by further rounds and was completed if the vote indicated the majority approved the OAP/recommendations. At the second TF meeting, a brief discussion on the educational and research agenda was also commenced, subsequently completed by email communication with all TF members.

After the second meeting, the level of evidence (LoE) and strength of the recommendation (SoR) were determined by the steering group. The LoE was determined separately for qualitative and quantitative studies using appropriate tools, both rated on a scale from 1 to 4. For the categorisation of the LoE from quantitative papers, the Oxford levels of evidence was used, as described in the EULAR SOP.10 The LoE for qualitative papers was categorised using a modified version of the hierarchy of evidence-for-practice in qualitative research by Daly *et al*,11 with subcategories (a and b) added at each level to allow for more accurate reflection of grading of the evidence based on studies falling between two levels due to their type and employed methodology. In brief, the hierarchy of evidence in qualitative research-study types suggested by Daly *et al* 11 proposes a four-level hierarchy of the quality of evidence for practice. The highest level (level I) refers to generalisable studies, level II to conceptual studies, level III to descriptive studies and level IV to single case studies. To assign a specific LoE, the number of studies available for each category was taken into account, similar to the Oxford levels of evidence.10 The SoRs was determined based on discussions within the TF including a comprehensive process of weighting the LoE in the context of the impact of the paper, evidence for practice, its quality, applicability and validity, as well as the type of study and its determined hierarchical LoE.11 

The final recommendations including the LoE and SoR were then circulated by e-mail to all TF members to provide the level of agreement (LoA) independently and anonymously on a 0–10 numeric rating scale (0=completely disagree, 10=completely agree). The mean, SD, median and range of the LoA per recommendation, were presented. Moreover, TF members were independently asked for any further input on the research and educational agenda by e-mail. Draft research and educational agendas were circulated based on suggestions from the second TF meeting and revised by the steering group based on the e-mail responses.

## Results

At the first TF meeting, competences of HPRs were in general defined as “A set of knowledge, skills and attitudes that concern the consistent and appropriate use of communication, knowledge, skills, clinical reasoning, emotions, values and reflection on practice, for the benefit of people with RMDs and the community”. For HPRs a definition used by EULAR was employed: “A professional involved in the care of people with RMDs, who is not a registered medical practitioner and is eligible to be a member of the organization through which a country has become a EULAR HP member”. Furthermore, agreement on 13 main themes, translated into research questions (see online supplementary table S2) was achieved and subsequently formed the basis of the SLR (see separate manuscript). In total, 79 papers were included; 20 addressed the competences HPRs of multiple professions have in common,1 3 4 9 12–27 43 the competences of nurses,28–70 12 of PTs71–82 and four of OTs.83–86 From the 20 papers addressing the competences HPRs of multiple professions have in common, 75% (n=15) had a qualitative design.1 3 4 9 12 13 15 16 18–20 23 25–27 The rest consisted of two systematic reviews,11 21 one quantitative study,14 one mixed design study9 and one opinion paper.19 Quality scoring of each of these papers revealed half of them (n=10) to be of high quality, five of medium/moderate quality, three of low quality, one of critically low quality. One paper was not scored (opinion paper).

### Supplementary data

[[annrheumdis-2019-215803supp002.pdf]](pending:yes) 

Overall, the evidence for the OAPs and recommendations was derived from the papers addressing the competences of HPR of multiple professions.1 3 4 9 12–27 The evidence was supported by studies describing the desired competences of specific professions.28–86 

At the second TF meeting three OAPs and 10 recommendations were formulated. For all three OAPs and the recommendations a high LoE was determined (level I or II).11 Regarding the SoR, five recommendations were graded as strength level A, four as strength B and one as strength B/C. The average LoA for each recommendation ranged from 9.42 to 9.79. Table 1 summarises the OAPs and recommendations with their associated LoE, SoR and LoA.

View this table:
[Table 1](http://ard.bmj.com/content/79/1/53/T1)

Table 1 
Overarching principles and recommendations for the generic core competences of health professionals in rheumatology (HPRs)

### Overarching principles

Table 2 presents the OAP along with the supporting literature.

#### Recommendation 1: HPRs should have knowledge of the aetiology, pathophysiology, epidemiology, clinical features and diagnostic procedures of common RMDs, including their impact on all aspects of life

View this table:
[Table 2](http://ard.bmj.com/content/79/1/53/T2)

Table 2 
Overarching principles of the EULAR recommendations for the generic core competences of health professionals in rheumatology (HPRs)

HPRs should have updated knowledge of the normal structure and function and the pathophysiology of the musculoskeletal system; common pathophysiological processes to support diagnosis and management of RMDs; and the epidemiology, clinical features and diagnostic procedures of common RMDs.1 3 4 9 23 This knowledge should include the prognosis and progression of RMDs.23 It is stressed in particular that HPRs should be able to understand and distinguish between inflammatory arthritis (IA) and osteoarthritis (OA).16 Finally, evidence supports that HPRs should have knowledge on the impact of RMDs on all aspects of life, that is, all components of the International Classification of Functioning, Disability and Health (ICF).9 23 

#### Recommendation 2: Using a structured assessment, HPRs should identify aspects that may influence individuals with RMDs and their families, including: (a) clinical characteristics, risks, red flags and comorbidities, (b) limits to their activity and participation and (c) personal and environmental factors

There is substantial evidence on HPRs’ competences regarding the performance of a structured and comprehensive assessment.1 3 4 9 14 16 17 20–23 25 Such a structured, comprehensive assessment is needed to understand the impact of the RMD on the individual; not only on his or her physical or mental health but also on relationships with family and friends, and on societal participation.3 4 9 16 For that purpose, the assessment should be based on a biopsychosocial model.3 4 13 16 20 21 Two studies reported that a basic understanding of the ICF could serve this purpose16 21 (see Overarching Principle 1). The structured assessment includes an exploration of the individuals’ perceptions, concerns, ideas or beliefs about their symptoms and condition, as these may act as a driver or form a barrier to recovery or a return to usual activity or work.4 20 Apart from history taking, the assessment may consist of physical examination and interpretation of findings from additional examinations. Based on the results of the assessment, HPRs should use their clinical reasoning skills to interpret findings, develop working and differential diagnoses, formulate, communicate, implement and evaluate management plans.4 

#### Recommendation 3: HPRs should communicate effectively: to make contributions to other healthcare providers and stakeholders in RMD care and to collaborate with other healthcare providers, signpost or refer where appropriate to optimise the interdisciplinary care of people with RMDs

Collaboration in the multidisciplinary team is important to optimise care for people with RMDs and to make appropriate referrals according to the HPR literature.3 4 16 22 26 For this purpose, HPRs must understand, respect and draw on each other’s roles and competences.3 4 21 The literature highlights that effective communication includes explaining and advising people with RMDs about the importance of relevant healthcare professionals and organisations such as patient organisations.9 20 23 

#### Recommendation 4: HPRs should have an understanding of common pharmacological and surgical therapies in RMDs, including their anticipated benefits, side-effects and risks, and use this knowledge to advise or refer as appropriate

HPRs should have a broad knowledge and understanding on how to give advice on the use of drug treatment in RMDs1 3 4 9 16 23 and have knowledge on the most common and/or serious side effects of specific drugs. This includes simple analgesics, non-steroidal anti-inflammatory drugs, glucocorticoids; disease-modifying antirheumatic drugs (DMARDS, that is, conventional synthetic DMARDs, targeted synthetic DMARDs and biological DMARDs) and other drugs used in treating patients with IA and other RMDs and in the management of persistent pain. Responses to medication should be reviewed regularly with the patient, taking into account patients’ fears, beliefs and concerns, in order to recognise differences in the balance of risks and benefits.4 For joint injections, HPRs should understand the role of joint injections in the management of RMDs, and, how to advice on the expected benefits and limitations, and, refer as appropriate.4 Additionally, HPRs are expected to have knowledge about common surgical interventions in RMDs like OA and IA. They should be able to discuss with patients their fears and concerns regarding surgery, and able to provide advice about potential risks and benefits to support patient education.3 4 

#### Recommendation 5: HPRs should provide advice on non-pharmacological interventions, treat or refer as appropriate, based on the evidence, expected benefits, limitations and risks for people with RMDs

There is evidence suggesting that HPRs should understand the role of and provide advice on non-pharmacological interventions, treat or refer as appropriate, based on the evidence, expected benefits, limitations and risks for people with RMDs.1 3 4 9 16 23 28 Planning and implementation of non-pharmacological treatment should be done in collaboration with the patient and the multidisciplinary team (see also recommendation 3). Furthermore, HPRs should work with patients to alleviate their concerns about treatment, with an understanding that some people with RMDs (eg, patients with mental health conditions, multimorbidity, fatigue or frailty) might need additional support during rehabilitation and that their trajectory of recovery or increased independence may be slower than others.4 Addressing fitness to work in people with RMDs was also highlighted in the literature.4 

#### Recommendation 6: HPRs should assess the educational needs of people with RMDs and their carers to provide tailored education using appropriate modes of delivery, relevant resources and evaluate their effectiveness

HPRs should be able to assess the educational needs of patients and provide a tailored education based on the patient’s individual needs and characteristics.22 27 The provision of tailored education for patients with RMDs and their carers should be based on a theoretical framework24 and include the use of appropriate modes of delivery (eg, face-to-face individual or group, through websites, e-mail or social media), relevant resources and evaluation of its effectiveness.3 9 12 16 20 23 26 27 HPRs should be able to signpost to sources of education and information3 16 20 (see recommendation 3). The content of the education should be carefully checked for its evidence-base.24 Moreover, the importance of the promotion of a healthy lifestyle, in particular physical activity education, diet and nutrition, or smoking cessation, was underlined in multiple papers.4 9 13 19 

#### Recommendation 7: HPRs should take responsibility for their continuous learning and ongoing professional development to remain up-to-date with the clinical guidelines and/or recommendations on the management of RMDs

HPRs should continuously undertake professional development and remain up-to-date with the best available evidence.4 9 26 27 This can be achieved through organised and accredited educational courses, implementation of clinical guidelines, research findings and/or recommendations on the management of RMDs.4 9 26 

Regarding professional development, one of the studies concludes that HPRs should be minimally able to critically evaluate research evidence (eg, scientific papers), apply results from research into daily practice, and, identify and formulate relevant research questions.9 In addition HPRs should enable and participate (leading or contributing, as appropriate) in research to advance the development of knowledge on RMDs and practice.4 9 

#### Recommendation 8: HPRs should support people with RMDs in goal setting and shared decision making about their care (eg, identify, prioritise, address their needs and preferences and explain in lay terms)

Evidence for required HPRs’ competences to support people with RMDs in goal setting and shared decision making to facilitate the delivery of patient-centred care is noteworthy.4 9 15 20 

Regarding goal setting, the literature provides evidence that HPRs should be able to set intervention goals related to his or her own profession; the formulation of these goals should be SMART (Specific, Measurable, Attainable, Realistic, Timely).9 Support with shared decision making may consist of helping people with RMDs to identify the priorities and outcomes that are important to them, explaining in non-technical language all available options, exploring with them the risks, benefits and consequences of each available option and discussing what these mean in the context of their life and goals and supporting them to make a decision on their preferred way forward.4 

#### Recommendation 9: HPRs should support people with RMDs in self-management of their condition. This encompasses selecting and applying the appropriate behavioural approaches and techniques to optimise their health and well-being (eg, engagement in physical activity, pain and fatigue management)

There are many studies providing evidence for HPRs’ competences to support people with RMDs in self-management of their condition, including the making of lifestyle and behavioural changes.3 4 9 13 15 18–20 23–25 This support encompasses selecting and applying the appropriate cognitive and behavioural approaches and techniques to optimise their health and well-being (eg, engagement in physical activity, pain and fatigue management). The literature suggests that HPRs should be able to apply different techniques, like motivational interviewing, cognitive or behavioural approaches or other techniques.4 15 19 23 

#### Recommendation 10: HPRs should be able to select and apply outcome measures for people with RMDs, as appropriate, to evaluate the effectiveness of their interventions

HPRs should have the ability to select and apply outcome measures reflecting the objectives of their interventions for people with RMDs, to evaluate their effectiveness.3 4 9 27 

### Research and educational agendas

The TF group proposed a research agenda (box 1) reflecting potential topics for future research and an educational agenda (box 2) identifying gaps in education for HPRs.

Box 1 
### Research agenda

*   To further evaluate the patient perspective on the competences of health professionalsin rheumatology (HPRs) .

*   To refine HPRs’ competences regarding the monitoring and improvement of the quality of their practice.

*   To define the requirements for HPRs to improve and maintain their competences and explore the existence of human and financial resources to accomplish continuous education.

*   To explore the desired competences of HPRs regarding the understanding and evaluation of the economic aspects of care for people with rheumatic and musculoskeletal diseases (RMDs).

*   To define, in addition to generic core competences, discipline-specific competences, related to each of the HPRs’ unique role in the multidisciplinary team.

*   To explore the role of HPRs in communities of practice for the delivery of seamless, integrated, patient-centred care for people with RMDs across Europe.

*   To evaluate the involvement of HPRs in rheumatology research across countries and identify potential barriers and facilitators to research contribution.

Box 2 
### Educational agenda

*   To evaluate barriers and facilitators for the implementation of the generic core competences in various European countries, taking into account cultural, social and other differences.

*   To review the current learning aims and curricula of health professional in rheumatology (HPR)-specific or interprofessional education at the postgraduate level across countries and use the formulated competences to enhance or create postgraduate education for HPRs, where appropriate.

*   To confirm the validity and feasibility of the proposed set of generic competences for HPRs other than nurses, physical therapists or occupational therapists.

*   To explore, enhance and promote the recognition of HPRs’ specialist skills across countries.

*   To develop educational offerings to increase HPRs’ competences to support people with rheumatic and musculoskeletal diseases regarding self-management of pain, fatigue and the achievement or maintenance of a healthy lifestyle.

## Discussion

These are the first EULAR recommendations for the generic core competences of HPRs. Three OAP and ten recommendations were formulated and provide a basis for harmonising core competences of HPRs across countries. Ultimately, their implementation is expected to lead to improved patient care.

Sets of required competences HPRs of multiple professions have in common have been developed at the national level,3 4 9 with one set specifically for HPRs who act as a first point of contact.4 However, a set of core competences HPRs of multiple professions have in common was lacking at a European level, representing an unmet need. Following the European harmonisation of the competences of rheumatologists26 an international approach to HPRs’ competences is important to reduce the variation in the quality of care for people with RMDs across countries. The proposed recommendations can inform the content of an international curriculum for HPRs, but can also be used in the development and/or optimisation of national postgraduate educational offerings.

The contents of the set of recommendations is largely in line with that of recently developed sets from the UK3 4 and set from the Netherlands.9 Differences are that the UK set was specifically developed for health professionals with a role as first point of contact for adults presenting with undiagnosed musculoskeletal conditions,4 whereas the Dutch set aimed to describe discipline-specific rather than common competencies.9 Overall, the EULAR recommendations are less detailed than both the UK and Dutch sets, warranting the need for further elaboration. This should be done in close collaboration with national organisations to take into account the different roles and responsibilities of HPRs in different countries.

In general, the generic competences as described in the literature addressing HPRs of multiple professions were confirmed in the literature on competences of either nurses, PTs or OTs. Some details were stressed more in the literature on one profession than another, such as, for example, the importance of the assessment of sexual health,36 48 65 75 cardiovascular risk53 or nutritional and dietary status66 in the nurses’ literature. It should be noted in this respect that for some competences it is clear that they are applicable to HPRs of multiple professions, whereas for others the assignment to one profession or the other is ambiguous. We have used one of the papers describing generic core competences by profession9 to support the distinction between competences HPRs from multiple professions have in common and profession specific competences, but that study is from only one country. It would thus be worthwhile to take this discussion into account with the proposed evaluation of barriers and facilitators for the implementation of the generic core competences in various European countries, as formulated for one of the topics of the research agenda. The proposed educational and research agendas also include aspects of a kind of reality check regarding the proposed competences, an example being a review of how competences addressed in current and envisioned postgraduate education relate to the recommendations. Moreover, proposals on how to change current settings based on an analysis of barriers and facilitators for the implementation of the recommendations must be made.

The competent HPRs are expected to function in close collaboration with competent rheumatologists in order to provide appropriate healthcare for people with RMDs as well as participate in joint professional and educational developments. The competence-based training requirements for specialty of rheumatology, oriented towards the professional behaviour within the rheumatologist’s competences have been proposed on the European level.2 87 The main overlap between the rheumatologists’ and HPRs’ competences exists in the area of working and communicating in the multidisciplinary team (recommendation 3).

The work of this TF identified a potential challenge in formulating recommendations which are based primarily on qualitative research. Qualitative research is often underestimated, but of high relevance and importance in the study of specific topics. However, the lack of explicit frameworks or guidelines on how to best use qualitative evidence, including the formulation of recommendations, represents a challenge. As part of this work, we have identified a four-level hierarchy of evidence-for-practice in qualitative research studies,11 which along with a meticulous assessment of the quality of papers identified from the SLR, provided good ground and informed decisions on the assignment of LoE and SoR for each recommendation. Work is currently underway by the TF methodologists, to further inform the process and provide a guide on the use of appropriate tools for the assignment of LoE and SoR for recommendations stemming primarily from qualitative research. We trust that this will standardise as well as encourage the appropriate use of qualitative research to inform EULAR recommendations in the future.

In conclusion, these recommendations aim to provide a framework for the generic core competences of nurses, PTs and OTs for postgraduate education at international and national level. Efforts will be made towards their implementation through dissemination across national societies, relevant websites and presentation of this work at key international and national conferences. It is advised that variation in healthcare systems and professions across countries is considered. For this purpose, the recommendations will be shared with a larger group of HPRs, clinicians, patients and service providers, for wider consensus and external validation.

## Acknowledgments

We thank J W Schoones, Walaeus Library, Leiden University Medical Center, the Netherlands, for his assistance with the literature search in the electronic databases. We also thank Dr H Lempp, medical sociologist from King’s College London, London, UK, for her expert advice in the methodological quality assessment of qualitative research studies and considerations around hierarchical level of evidence.

## Footnotes

*   Handling editor Josef S Smolen

*   Contributors All authors have actively contributed to the work and meet the criteria for authorship.

*   Funding The task force would like to thank EULAR for financial support of this work.

*   Competing interests None declared.

*   Patient consent for publication Not required.

*   Provenance and peer review Not commissioned; externally peer reviewed.

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