CN115274053A - Nutritional follow-up management method and system for disabled elderly based on ICF nutritional management - Google Patents
Nutritional follow-up management method and system for disabled elderly based on ICF nutritional management Download PDFInfo
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Abstract
The invention discloses a nutrition follow-up management method and system for disabled old people based on ICF nutrition management. On one hand, the nutrition follow-up management method for the disabled old people based on ICF nutrition management comprises the following steps: s1, establishing a nutrition management file for disabled old people based on an ICF nutrition management category, wherein the nutrition management file comprises an evaluation index, a nutrition management target, a nutrition management plan and an effect evaluation; s2, inputting the disabled old people nutrition management file into a preset evaluation model to evaluate the nutrition state of a patient to obtain a nutrition problem; and S3, remotely conducting health intervention guidance on the disabled old people or caregivers according to nutrition problems and based on a preset nutrition guidance model. On the other hand, the invention also provides a system adopting the nutrition follow-up management method for the disabled elderly based on ICF nutrition management. The invention can effectively analyze the nutrition problem of the disabled old, provide effective nutrition decision and intervention, promote the nutrition state and realize good follow-up effect.
Description
Technical Field
The invention relates to the field of medical systems, in particular to a nutrition follow-up management method and system for disabled old people based on ICF nutrition management.
Background
Unbalanced diet is a prominent problem of incapacitated people, as the body function declines, the digestive and absorptive capacity of the human body declines, malnutrition often results, and the malnutrition is also one of the important factors causing the incapacitance, and the two factors affect each other. Therefore, nutritional therapy is a key link for disability recovery.
Nutrition management is a systematic project, different medical resources need to be integrated, a scientific evaluation, efficient standardized management mode and an effective quality monitoring and quality improvement system need to be established. Therefore, there is a need for a standardized nutritional nomenclature to uniformly assess the results of nutritional management, thereby enabling uniform comparison and evaluation of nutritional treatments across different medical staff, across different disciplines, across different medical areas, across different countries.
At present, the terms used for nutrition management in communities, civil administration systems, medical systems, endowment institutions and the like are different, standards are also different, national standards, local standards and self-made indexes exist at present, and management standards even do not exist in institutions in some regions. And among the standards that have been developed: the nutrition assessment tools are not uniform, the nutrition risk grading basis is not uniform, the grading assessment program is not clear, the uniformity is lacked, and the like, so that the nutrition condition of the old cannot be truly and objectively reflected, and the development of nutrition management of the disabled old in China is hindered to a certain extent. Therefore, it is necessary to form a scientific, reasonable and normative nutrition management follow-up system for disabled elderly people.
International Classification of function, disability and health (ICF) provides a unified language and framework for describing health and wellness related conditions, suitable for team work in multidisciplinary collaboration. The application area of ICF is very wide, as a term system, classification system and coding system. The system can be used as a statistical tool to collect data, and can also be used as an evaluation tool to measure the level of functions and disabilities, environmental factor influence, quality of life and the like. ICF has over 1400 categories, however its widespread availability reduces its accuracy in different industries. To facilitate the clinical practical application of ICF, ICF nutrition has increased by about 900 nutritionally relevant categories to achieve acceptable accuracy of nutritional and nutrition management.
According to the content, in order to solve the problems that the existing standards are not unified, different assessment terms are used by different assessment personnel, and assessment results are not comparable, a nutrition follow-up management method and system for disabled elderly people based on ICF nutrition management is necessary to be provided.
Disclosure of Invention
The invention aims to provide a nutrition follow-up management method for disabled old people based on ICF nutrition management, so as to overcome the defects in the prior art and realize a very good follow-up effect.
The second purpose of the invention is to provide a system adopting the nutrition follow-up management method for the disabled elderly based on ICF nutrition management.
In order to achieve the purpose, the technical scheme adopted by the invention is as follows:
on one hand, the nutrition follow-up management method for the disabled old based on ICF nutrition management comprises the following steps:
s1, establishing a nutrition management file for disabled old people based on an ICF (intensive care function) nutrition management category, wherein the nutrition management file comprises evaluation indexes, nutrition management targets, a nutrition management plan and effect evaluation;
s2, inputting the disabled old people nutrition management file into a preset evaluation model to evaluate the nutrition state of a patient to obtain a nutrition problem;
and S3, remotely guiding the health intervention of the disabled old people or the caregivers according to the nutrition problems and based on a preset nutrition guidance model.
Further, the evaluation indexes in step S1 include physical function, physical structure, activity and participation, environmental factors and personal factors, wherein the physical function, physical structure, activity and participation, environmental factors and personal factors all include a plurality of ICF categories, each ICF category is used for representing a certain function needing improvement, maintenance or compensation in nutrition of the disabled elderly, and each ICF category is graded and evaluated by an ICF limit value;
and setting the nutrition management target and the nutrition management plan according to the ICF category of the patient and based on a target management model, and evaluating the effect through the nutrition management target and the nutrition management plan.
Further, the goal management model includes each ICF category, a corresponding ICF restriction level, and a nutritional deficiency corresponding to each ICF restriction level; the steps of setting the nutritional management goals, the nutritional management plan, according to the patient's ICF category and based on a goal management model specifically comprise:
identifying an ICF category of all ICF categories of the patient for which the ICF restriction level is below a predetermined value;
acquiring the nutrient deficiency of the ICF category lower than the preset value and carrying out unique marking;
counting the number of the uniquely marked nutritional deficiencies, and setting a nutritional management goal and a nutritional management plan according to all nutritional deficiencies.
Further, the evaluation model in the step S2 includes a nutrition dynamic simulation model, an effect evaluation modification model, and a nutrition problem model;
the nutrition dynamic simulation model is used for inputting a nutrition management plan and a nutrition management target in a preset disabled elderly model, applying nutrition to the disabled elderly model according to the nutrition management plan, comparing a result with the nutrition management target and outputting an effect evaluation correction coefficient, and the effect evaluation correction model corrects the effect evaluation according to the effect evaluation correction coefficient; and the nutrition problem model is used for really obtaining nutrition problems according to the corrected effect evaluation and nutrition corresponding to the grade of the ICF limiting value.
Further, the specific step of comparing the result with the nutrition management target and outputting the effect evaluation correction coefficient comprises:
and if the comparison result is smaller than the preset value, outputting the effect evaluation correction coefficient as 1, and if the comparison result is larger than the preset value, reducing the corresponding multiple according to the multiple of the comparison result and the base number of the evaluation correction coefficient as 1.
Further, the step S2 of inputting the nutrition management file of the disabled elderly into a preset evaluation model to evaluate the nutrition state of the patient, and the specific steps of obtaining the nutrition problem are as follows:
comparing a nutrition management target and a nutrition management plan in the nutrition management file of the disabled old through a nutrition dynamic simulation model to obtain an effect evaluation correction coefficient;
correcting the effect evaluation of the nutrition management file of the disabled elderly according to the effect evaluation correction coefficient;
and judging the corrected effect evaluation, if the corrected effect evaluation can meet the preset effect requirement, defining the nutrition missing combination corresponding to the ICF limit value grade as a nutrition problem, otherwise discarding a plurality of ICF categories with the grades lower than the set value until the corrected effect evaluation reaches the preset effect, and defining the latest nutrition missing combination corresponding to the ICF limit value grade as the nutrition problem.
Further, the nutrition guidance model in step S3 comprises nutrition questions and corresponding health intervention guidance content, wherein the health intervention guidance content comprises knowledge guidance, skill guidance and belief and attitude guidance; the step of remotely conducting health intervention guidance on the disabled old people or caregivers according to nutrition problems and based on a preset nutrition guidance model specifically comprises the following steps:
inputting the nutrition problems into the nutrition guidance model to obtain results of knowledge guidance, skill guidance and belief and attitude guidance;
and the results of the knowledge guidance, the skill guidance and the belief and attitude guidance are remotely used for conducting health intervention guidance on the disabled old people or caregivers in a video mode.
Further, step S3 is preceded by: and judging the department where the health intervention guidance is located, performing special referral according to the department, and performing health intervention guidance according to the referred special department.
Further, after step S3, the method further includes:
and S4, storing and recording each disabled elderly nutrition management file and the corresponding health intervention guidance to form a similar case prediction model, and inputting the disabled elderly nutrition management file into the similar case prediction model for searching in advance when nutrition management is performed on disabled elderly every time.
On the other hand, the invention also provides a system adopting the nutrition follow-up management method for the disabled elderly based on ICF nutrition management, which comprises the following steps: the system comprises a filing module, a data processing module and a data processing module, wherein the filing module is used for establishing a disabled old people nutrition management file based on an ICF nutrition management category, and the nutrition management file comprises an evaluation index, a nutrition management target, a nutrition management plan and an effect evaluation; the evaluation module is used for inputting the nutrition management file of the disabled old into a preset evaluation model to evaluate the nutrition state of the patient to obtain a nutrition problem; the health intervention guidance module is used for remotely guiding the health intervention of the disabled old people or caregivers according to nutrition problems and based on a preset nutrition guidance model; the filing module is connected with the health intervention guiding module after passing through the evaluation module.
Compared with the prior art, the invention has the advantages that:
the nutrition follow-up management method and system for the disabled elderly based on ICF nutrition management can effectively analyze the nutrition problem of the disabled elderly by using the standard terms based on ICF nutrition management categories, can enable multi-disciplinary medical care personnel and other department level workers to have unified standards, provide effective nutrition decision and intervention, improve the nutrition state, realize the health intervention guidance for the disabled elderly or caregivers, and have good follow-up effect.
Drawings
In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings used in the embodiments or the technical solutions in the prior art will be briefly described below, it is obvious that the drawings in the following description are only some embodiments of the present invention, and for those skilled in the art, other drawings can be obtained according to the drawings without creative efforts.
FIG. 1 is a flow chart of a method of the present invention;
FIG. 2 is a flow chart of step S1 in the method of the present invention;
FIG. 3 is a flow chart of step S2 in the method of the present invention;
FIG. 4 is a flow chart of step S3 in the method of the present invention; and (c) a second step of,
fig. 5 is a block diagram of the system of the present invention.
Detailed Description
The preferred embodiments of the present invention will be described in detail below with reference to the accompanying drawings so that the advantages and features of the present invention can be more easily understood by those skilled in the art, and the scope of the present invention will be more clearly and clearly defined.
Referring to fig. 1 to 4, the invention discloses a nutrition follow-up management method for disabled elderly based on ICF nutrition management, which comprises the following steps:
s1, establishing a nutrition management file for disabled old people based on the ICF nutrition management category, wherein the nutrition management file comprises evaluation indexes, nutrition management targets, a nutrition management plan and effect evaluation.
The evaluation index comprises physical function, physical structure, activity and participation, environmental factors and personal factors, wherein the physical function, the physical structure, the activity and the participation, the environmental factors and the personal factors all comprise a plurality of ICF categories, each ICF category is used for representing a certain function needing improvement, maintenance or compensation in the aspect of nutrition of the disabled elderly, and each ICF category is subjected to graded evaluation by adopting an ICF limit value.
And setting the nutrition management target and the nutrition management plan according to the ICF category of the patient and based on a target management model, and evaluating the effect through the nutrition management target and the nutrition management plan.
In the invention, the evaluation of the three parts of physical function, physical structure, activity and participation adopts 5 levels, and 0, 1, 2, 3 and 4 respectively represent no problem, mild problem, moderate problem, severe problem and complete problem; the environmental factor and personal factor part has 9 rating levels, respectively, of-1, -2, -3, -4, 0, 1, 2, 3, 4, respectively, representing the mild, moderate, severe and complete influence of the hindering factor, 0, and 1, 2, 3, 4, respectively, representing the mild, moderate, severe and complete influence of the favorable factor; short-term and long-term nutritional management goals can be set based on the patient's performance in a particular ICF category, a nutritional management plan can be developed, and the nutritional management efficacy can be evaluated.
In the present invention, nutritional function assessments are provided for at least 7 time nodes, week 1, week 2, week 3, week 4, week 6, week 8 and week 12 after discharge. Nutritional issues were determined for the patients after each assessment, forming follow-up intervention plans, goals and embodiments.
Specifically, the target management model comprises each ICF category, a corresponding ICF limiting value grade and nutrient deficiency corresponding to each ICF limiting value grade; the steps of setting the nutritional management goals, the nutritional management plan, according to the patient's ICF category and based on a goal management model specifically comprise:
s11, identifying the ICF categories of which the ICF limiting value levels are lower than a preset value in all the ICF categories of the patient;
s12, acquiring the nutritional deficiency of the ICF category lower than the preset value and carrying out unique marking;
and S13, counting the number of the nutrition losses of the unique marks, and setting a nutrition management target and a nutrition management plan according to all the nutrition losses.
And S2, inputting the nutrition management file of the disabled old into a preset evaluation model to evaluate the nutrition state of the patient to obtain the nutrition problem.
Specifically, the evaluation model comprises a nutrition dynamic simulation model, an effect evaluation correction model and a nutrition problem model; the nutrition dynamic simulation model is used for inputting a nutrition management plan and a nutrition management target in a preset disabled elderly model, applying nutrition to the disabled elderly model according to the nutrition management plan, comparing a result with the nutrition management target and outputting an effect evaluation correction coefficient, and the effect evaluation correction model corrects the effect evaluation according to the effect evaluation correction coefficient; and the nutrition problem model is used for really obtaining nutrition problems according to the corrected effect evaluation and nutrition corresponding to the grade of the ICF limiting value.
The specific steps of comparing the result with the nutrition management target and outputting the effect evaluation correction coefficient comprise: and if the comparison result is smaller than the preset value, outputting the effect evaluation correction coefficient to be 1, and if the comparison result is larger than the preset value, reducing the corresponding multiple according to the multiple of the comparison result and the base number of the evaluation correction coefficient which is 1.
Wherein, step S2 specifically includes the steps of:
and S21, comparing the nutrition management target and the nutrition management plan in the nutrition management file of the disabled old through a nutrition dynamic simulation model to obtain an effect evaluation correction coefficient.
And S22, correcting the effect evaluation of the disabled elderly nutrition management file according to the effect evaluation correction coefficient.
And S23, judging the corrected effect evaluation, defining the nutrition lack combination corresponding to the grade of the ICF limit value as a nutrition problem if the corrected effect evaluation can meet the preset effect requirement, otherwise discarding a plurality of ICF categories with the grade lower than a set value until the corrected effect evaluation reaches the preset effect, and defining the latest nutrition lack combination corresponding to the grade of the ICF limit value as the nutrition problem.
And S3, remotely conducting health intervention guidance on the disabled old people or caregivers according to nutrition problems and based on a preset nutrition guidance model.
Specifically, the nutrition guidance model comprises nutrition problems and corresponding health intervention guidance contents, wherein the health intervention guidance contents comprise knowledge guidance, skill guidance, belief and attitude guidance; wherein, the knowledge part is used for knowing the nutrition management knowledge level (including energy intake, fat intake, protein intake, carbohydrate, dietary fiber, water and the like) according to the feedback of the old or the care person, and providing correction and guidance for the part with poor grasp; a skill part, which evaluates the skill condition of nutrition management of the old people or the caregivers thereof (comprising cooking methods, diet requirements corresponding to diseases and the like), reviews the process of the nutrition management skill with the old people or the caregivers thereof, answers the places in question, and corrects and guides the places which are not correct; the belief and attitude part encourages the patients to actively participate in nutrition management and timely feed back to medical care personnel by communicating and knowing nutrition knowledge, life attitude, information, acceptance degree and the like of the old and the care givers.
In the invention, the step of remotely guiding the health intervention of the disabled old people or caregivers according to the nutrition problems and based on a preset nutrition guidance model specifically comprises the following steps:
s31, inputting the nutrition problems into the nutrition guidance model to obtain results of knowledge guidance, skill guidance, belief and attitude guidance;
and S32, remotely conducting health intervention guidance on disabled old people or caregivers in a video mode according to the results of the knowledge guidance, the skill guidance and the belief and attitude guidance.
Most preferably, the method further comprises the steps of judging the department where the health intervention guide is located between the step S3, performing specialized referral according to the department, and performing the health intervention guide according to the specialized referral.
That is, when a problem which is not solved by the subject is encountered, such as dyslipidemia, abnormal blood glucose, and ulcer, the nurse sends a referral short message to other health professionals (physicians, dieticians) in the team through the system, and the intervention personnel can make a video call and provide consultation and guidance within 24 hours of receiving the short message.
Specifically, the nutrition knowledge, skills and attitudes after intervention are compared before and after the health intervention guidance, and besides, other ending indexes are set for effect evaluation: nutritional risk scoring: evaluating by using an NRS2002 scale; feeding intolerance: evaluating indexes such as constipation, abdominal distension, diarrhea and the like; BMI value: calculation was performed by measuring body weight. Laboratory indexes: evaluation was performed using albumin, preproprotein, hemoglobin, and the like.
After step S3, further comprising:
and S4, storing and recording each disabled elderly nutrition management file and the corresponding health intervention guidance to form a similar case prediction model, and inputting the disabled elderly nutrition management file into the similar case prediction model for searching in advance when disabled elderly nutrition management is performed each time.
The system also can comprise a task reminding function, can automatically remind medical staff of different institutions, can check the follow-up visit condition and the illness state progress condition of the old after discharge of the old in time, and can also have a countdown reminding function.
Referring to fig. 5, the present invention further provides a system for implementing the above-mentioned nutrition follow-up management method for disabled elderly based on ICF nutrition management, including: the system comprises a filing module 1, a data processing module and a data processing module, wherein the filing module is used for establishing a nutrition management file of disabled old people based on an ICF nutrition management category, and the nutrition management file comprises evaluation indexes, nutrition management targets, a nutrition management plan and effect evaluation; the evaluation module 2 is used for inputting the nutrition management file of the disabled old into a preset evaluation model to evaluate the nutrition state of the patient and obtain a nutrition problem; the health intervention guidance module 3 is used for remotely guiding the health intervention of the disabled old people or caregivers according to nutrition problems and based on a preset nutrition guidance model; the profiling module 1 is connected with the health intervention guidance module 3 after passing through the evaluation module 2.
Preferably, the present invention may further comprise: and the similar case prediction module 4 is used for storing and recording each disabled elderly nutrition management file and the corresponding health intervention guidance to form a similar case prediction model, inputting the disabled elderly nutrition management file into the similar case prediction model in advance for searching when disabled elderly nutrition management is performed each time, and the similar case prediction module 4 is connected with the health intervention guidance module 3.
The invention can effectively analyze the nutrition problem of the disabled old, provide effective nutrition decision and intervention and improve the nutrition state.
Although the embodiments of the present invention have been described with reference to the accompanying drawings, various changes or modifications can be made by the owner within the scope of the appended claims, and the scope of the present invention should be covered by the owner as long as the protection scope of the present invention is not exceeded by the claims.
Claims (10)
1. A nutrition follow-up management method for disabled elderly based on ICF nutrition management is characterized by comprising the following steps:
s1, establishing a disabled elderly nutrition management file based on ICF nutrition management categories, wherein the nutrition management file comprises evaluation indexes, nutrition management targets, nutrition management plans and effect evaluation;
s2, inputting the nutrition management file of the disabled old into a preset evaluation model to evaluate the nutrition state of the patient to obtain a nutrition problem;
and S3, remotely conducting health intervention guidance on the disabled old people or caregivers according to nutrition problems and based on a preset nutrition guidance model.
2. The nutrition follow-up management method for disabled elderly based on ICF nutrition management as claimed in claim 1, wherein the evaluation index in step S1 includes physical function, physical structure, activity and participation, environmental factors and personal factors, the physical function, physical structure, activity and participation, environmental factors and personal factors each include several ICF categories, each ICF category is used for representing a certain function in nutrition aspect of disabled elderly needing improvement, maintenance or compensation, each ICF category is graded and evaluated by ICF limit value;
and setting the nutrition management target and the nutrition management plan according to the ICF category of the patient and based on a target management model, and evaluating the effect through the nutrition management target and the nutrition management plan.
3. The ICF nutrition management based nutritional follow-up management method for disabled elderly people according to claim 2, wherein the objective management model comprises each ICF category, corresponding ICF restriction level, and nutritional loss corresponding to each ICF restriction level; the steps of setting the nutritional management goals, the nutritional management plan, according to the patient's ICF category and based on a goal management model specifically comprise:
identifying an ICF category of all ICF categories of the patient for which the ICF restriction level is below a predetermined value;
acquiring the nutrient deficiency of the ICF category lower than the preset value and carrying out unique marking;
counting the number of the nutritional deficiencies uniquely marked and setting nutritional management goals and nutritional management plans based on all nutritional deficiencies.
4. The ICF nutrition management-based nutrition follow-up management method for disabled elderly people, according to claim 2, wherein the evaluation model in step S2 comprises a nutrition dynamic simulation model, an effect evaluation modification model and a nutrition problem model;
the nutrition dynamic simulation model is used for inputting a nutrition management plan and a nutrition management target in a preset disabled elderly model, applying nutrition to the disabled elderly model according to the nutrition management plan, comparing a result with the nutrition management target and outputting an effect evaluation correction coefficient, and the effect evaluation correction model corrects the effect evaluation according to the effect evaluation correction coefficient; and the nutrition problem model is used for really obtaining nutrition problems according to the corrected effect evaluation and nutrition corresponding to the grade of the ICF limiting value.
5. The ICF nutrition management-based nutrition follow-up management method for disabled elderly people according to claim 4, wherein the specific steps of comparing the result with the nutrition management target and outputting the effect evaluation correction coefficient comprise:
and if the comparison result is smaller than the preset value, outputting the effect evaluation correction coefficient as 1, and if the comparison result is larger than the preset value, reducing the corresponding multiple according to the multiple of the comparison result and the base number of the evaluation correction coefficient as 1.
6. The nutrition follow-up management method for disabled elderly based on ICF nutrition management as claimed in claim 5, wherein the step S2 of inputting the nutrition management file of disabled elderly into the preset evaluation model to evaluate the nutrition status of the patient, and the specific steps of obtaining nutrition problem are as follows:
comparing a nutrition management target and a nutrition management plan in the disabled old man nutrition management file through a nutrition dynamic simulation model to obtain an effect evaluation correction coefficient;
correcting the effect evaluation of the disabled elderly nutrition management file according to the effect evaluation correction coefficient;
and judging the corrected effect evaluation, if the corrected effect evaluation can meet the preset effect requirement, defining the nutrition missing combination corresponding to the ICF limit value grade as a nutrition problem, otherwise discarding a plurality of ICF categories with the grades lower than the set value until the corrected effect evaluation reaches the preset effect, and defining the latest nutrition missing combination corresponding to the ICF limit value grade as the nutrition problem.
7. The ICF nutrition management based nutritional follow-up management method for disabled elderly persons according to claim 2, wherein the nutrition guidance model in step S3 comprises nutrition questions and corresponding health intervention guidance content, the health intervention guidance content comprises knowledge guidance, skill guidance and belief and attitude guidance; the step of remotely conducting health intervention guidance on the disabled old people or caregivers according to nutrition problems and based on a preset nutrition guidance model specifically comprises the following steps:
inputting the nutrition problem into the nutrition guidance model to obtain results of knowledge guidance, skill guidance and belief and attitude guidance;
and the results of the knowledge guidance, the skill guidance and the belief and attitude guidance are used for remotely carrying out health intervention guidance on disabled old people or caregivers in a video mode.
8. The follow-up management method for nutrition of disabled elderly based on ICF nutrition management as claimed in claim 1, further comprising before said step S3: and judging the department where the health intervention guidance is located, performing special referral according to the department, and performing health intervention guidance according to the post-referral special department.
9. The follow-up management method for nutrition of disabled elderly based on ICF nutrition management as claimed in claim 1, further comprising after step S3:
and S4, storing and recording each nutrition management file of the disabled elderly and the corresponding health intervention guidance to form a similar case prediction model, and inputting the nutrition management file of the disabled elderly into the similar case prediction model for searching in advance when nutrition management of the disabled elderly is performed each time.
10. A system for realizing the nutrition follow-up management method for disabled elderly based on ICF nutrition management in any one of claims 1-7, comprising:
the system comprises a filing module, a data processing module and a data processing module, wherein the filing module is used for establishing a nutrition management file for disabled old people based on an ICF nutrition management category, and the nutrition management file comprises an evaluation index, a nutrition management target, a nutrition management plan and an effect evaluation;
the assessment module is used for inputting the disabled elderly nutrition management file into a preset assessment model to assess the nutrition state of a patient to obtain a nutrition problem;
the health intervention guidance module is used for remotely guiding the health intervention of the disabled old people or caregivers according to the nutrition problems and based on a preset nutrition guidance model;
the profiling module is connected with the health intervention guidance module after passing through the evaluation module.
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