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Archives of Clinical Neuropsychology 23 (2008) 139147

Cancellation task in very low educated people

Sonia Maria Dozzi Brucki a,b, , Ricardo Nitrini a
a University of Sao Paulo, Brazil
b Mamirau a Institute, Brazil
Accepted 23 November 2007

Cancellation tasks have been largely used to evaluate visuospatial function and attention. Cognitive evaluation of low literacy
subjects remains a challenge in developing countries, when it becomes necessary to distinguish between what is pathological and
what is biased by low education. Performance of river bank dwellers of the Amazon region was studied, in a structured nonverbal
cancellation task, verifying their searching strategies (randomized/organized), time of completion, number of correct cancelled
targets and number of false-positive targets. A difference was observed in performance and searching strategies between illiterates
and literates with only a few years of schooling (mean = 0.8, S.D. = 1.6 years of education) across all measures. There was a
significant difference between literate groups in the searching strategy, as well as between illiterates who had never attended school
and those who had, showing that a minimal contact with graphic presentations and organization of writing was able to modify this
cognitive function.
2007 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.

Keywords: Cancellation task; Attention-illiteracy; Education; Cognitive evaluation; Visuospatial task

Cancellation tests have long been used in the neurological assessment of visuospatial function and selective attention,
mainly in stroke patients, where they are utilized to assess spatial inattention or neglect. Cognitive domains involved
in the cancellation task include sustained and selective attention, psychomotor speed, visual searching and motor
Cancellation tests can be characterized by type of stimulus (letters, geometric figures, numbers), by size of matrix
(number of rows and columns) and configuration of matrix (random or organized arrays). The number of correct
or incorrect target stimuli identified, together with the time to complete the task is used to evaluate the subjects
performance. Reports have affirmed that healthy individuals scanned the page in an organized fashion, following rows or
columns even when target arrays were disorganized (Gauthier, Dehaut, & Joanette, 1989; Weintraub & Mesulam, 1988).
Mesulams symbol cancellation test provides a measure of attention, organization and neglect (Mesulam, 1985). It
is composed by four test forms, consisting of random and structured arrays of verbal and nonverbal stimuli. Each sheet
of paper contains 60 targets, with 15 targets in each quadrant. In subjects over 50 years of age, the expected omission
is one target from each quadrant, while over the age of 80; as many as four targets may go undetected in each visual
field. Normal adults under the age of 65 can complete the test within 2 min, and older individuals can be allowed up
to 3 min (Mesulam, 1985, 2000).

Corresponding author at: Rua Humberto Primo 740, 123 Sao Paulo 04018-032, SP, Brazil. Tel.: +55 11 55797104; fax: +55 11 55797104.
E-mail address: sbrucki@uol.com.br (S.M.D. Brucki).

0887-6177/$ see front matter 2007 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.
140 S.M.D. Brucki, R. Nitrini / Archives of Clinical Neuropsychology 23 (2008) 139147

Cancellation tests may be affected by educational level. Normal literate adults who read occidental languages
conduct a systematic search beginning on the left and proceeding to the right in horizontal or vertical rows even in the
random arrays (Mesulam, 1985, 2000).
Cognitive evaluation in low educated populations represents a challenge for all researchers. Low educational levels
are not homogeneous, with often significant differences in performance being evident in individuals with between 0
and 3 years of education (Ostrosky-Solis, Ardila, Rosselli, Lopez-Arango, & Uriel-Mendoza, 1998). Non-educated
subjects have difficulties in visual discrimination, evident in superimposed figures (Ardila & Moreno, 2001; Ardila,
Rosselli, & Rosas, 1989), in naming two-dimensional objects (Reis, Petersson, Castro-Caldas, & Ingvar, 2001), and
in differences in naming black and white objects from drawings and photos (Reis, Fasca, Ingvar, & Petersson, 2006).
Moreover, in tasks involving motor speed, educational level showed a significant effect, evident in time spent on the line
cancellation task (Rosselli, Ardila, & Rosas, 1990). Literacy raises performance on coding, encoding, and generating
2D representations, by having developed visual and visuo-motor skills through reading and writing.
Some authors have reported that, on visual search tasks with targets and distractors with similar perceptual char-
acteristics, processing time increases in proportion to the number of stimuli to be considered as potential targets
(Geldmacher, 1998; Lezak, 1995; Schneider & Schiffrin, 1977) as well as to stimulus number and target-to-distractor
ratio (Geldmacher, 1996; Geldmacher & Hills, 1997). It is conceivable that non-literate persons and subjects with
low educational level take more time to perform visual search tasks and commit more errors such as false-positives,
or achieve a lesser number of correct cancelled targets. An important source of variance among results of different
studies in cancellation tests is the use of different, culturally influenced cognitive strategies to complete the task. For
example, different strategies or right-to-left reading patterns could influence the error pattern for letter cancellation
task in Arabic readers (Geldmacher & Alhaj, 1999).
Our aims were to verify the performance of very low educated subjects on the cancellation task of random and
nonverbal shapes, and to analyze which strategy they employed to carry out the test. Furthermore, we sought to analyze
how illiteracy influenced cognitive strategies to complete the test. Furthermore, we sought to analyze how illiteracy
influenced cognitive strategies employed to complete the test, and whether minimal exposure to graphemephoneme
mappings and organizing into lines, although not resulting in literacy, was able to change target scanning approaches.
Given less developed countries have a higher percentage of non-literate persons; how to cope with difficulties
experienced by such individuals with no formal education, together with their cognitive strategies, is of relevance to
many researchers. Furthermore, knowledge about how cultural variables affect the performance on a particular task
and how to cope with these subjects is very important (Ostrosky-Sols & Oberg, 2006).

1. Methods

1.1. Participant characteristics

This study was conducted in small rural communities, in the Amazonian region of Brazil as a part of a comprehensive
clinical and neuropsychological study of this population. Briefly, these populations live in small communities along
the river banks, each village comprising 13 domestic households on average, where these are typically linked by
kinship ties which characterize the communities as being nuclei of a small group of related people. It is essentially a
subsistence-based economy, with very low incomes (annual family incomes of about US$ 900). Activities are divided
among fishing, growing manioc for flour and in some communities, hunting. The houses are timber-built, being elevated
from the ground because of high water levels. Activities extend throughout the lifetimes of most subjects. Only in the
elderly do physical activities decrease. Women tend to work making flour, housekeeping and taking care of children.
Almost all communities have schools, providing education for up to 4 years. The communities have limited access
to radio, TV, where electricity is produced by diesel generator (when available), and to newspapers, daily use of
telephone, and bank accounts. The distance of communities from nearest towns varies between 9 and 18 h by boat.
The evaluations were conducted in 1-day visits. A nurse born in this region accompanied us to introduce us to each
All individuals had almost identical genetic, educational and cultural backgrounds while facing the same demands
from the environment, and the subsistence economy.
All were submitted to a thorough clinical and neurological evaluation, to verify possible concomitant diseases,
where no financial compensation was given for participation.
S.M.D. Brucki, R. Nitrini / Archives of Clinical Neuropsychology 23 (2008) 139147 141

Ninety-four participants were examined, 82 of which fulfilled inclusion criteria. The adult group (n = 55) had a
mean age of 55.8 (4.2) years and 1.1 (2.0) years of schooling. Elderly participants (n = 27) had a mean age of 70.8 (5.5)
years and 0.3 (0.9) years of education. Analysis by literate group revealed a mean age of 62.9 (8.5) years for illiterates
and 58.5 (8.7) years for literates.

1.2. Inclusion/exclusion criteria

All potential participants were aged 50 or older and Portuguese native speakers. Persons were classified as illiterates
when they reported never to have attended school (or had attended school for less than 1 year) and were unable to read
the phrase close your eyes from the Mini Mental State Examination (MMSE). Only illiterates with 16 points or more
on the MMSE were included (inferior quartile for illiteratesP25) whilst literates (1 year of education) were included
if they had MMSE scores of 22 or more (inferior quartile for this educational levelP25) according to normative data
for the Brazilian population (Brucki, Nitrini, Caramelli, Bertolucci, & Okamoto, 2003) and Portuguese version of the
MMSE (Bertolucci, Brucki, Campacci, & Juliano, 1994). Other inclusion criteria were: absence of physical, functional,
or neurological evidence of dementia; and no visual deficit that compromised target identification. All subjects selected
were free of cognitive impairment (evaluated by MMSE and no compromise of daily activities) and independent for
their daily activities including personal, social, familial, and were capable of self-care. A combination of cognitive
screening tests with functional activities ruled out dementia.
The samples have been divided by:

- age group: 5064 years old (adult group) and 65 or more years old (elder group);
- literacy status: illiterates and literates;
- schooling status: illiterates who went to school (G1), and those who had never attended to school (G0).

1.3. Cancellation task

We placed an 11-in. 14-in. sheet of paper directly in front of the subject showing random arrays of nonverbal
stimuli, containing 60 targets, with 15 targets in each quadrant of the sheet (Fig. 1). Participants were not allowed to
change the position of the page and were asked to mark every open circle crossed by a single slanted line. Subjects
were asked to strike corresponding targets as quickly and accurately as possible (Mesulam, 1985). After 300 s the
task was interrupted. We recorded the completion time (in seconds), number of correct and incorrect signaled tar-
gets, and searching strategy (randomized or organized searching: horizontal scanning, for example, from left to the
right, or vertical scanning). Analysis by quadrant was performed considering: first quadrant (left upper cornerQ1);
second quadrant (right upper cornerQ2); third quadrant (left lower cornerQ3) and fourth quadrant (right lower
cornerQ4). In addition, we divided these into upper quadrants (Q1 and Q2) and lower quadrants (Q3 and Q4)
We calculated quality of performance using the index developed by Geldmacher (1998). Higher scores reflect more
efficient performance: performance = (correct responses/total targets) (correct responses/total time).

1.4. Statistical analysis

For statistical analyses, comparisons involving the cancellation test were carried out using a MannWhitney non-
parametric analysis. The Chi-square analysis was used to compare the proportion of randomized and non-randomized
search strategies between groups. The value of significance accepted was 0.05, but Bonferroni correction has been
made, then significance was p < 0.0125. The software Statistica 4.3 (Statsoft, Inc., 1993) was used in analyses.
The study was approved by the Ethics Committees of the Hospital das Clnicas of the Sao Paulo University School
of Medicine and of the Mamiraua Institute. All subjects had given written consent for their participation in the study,
or relatives had given written consent on behalf of those subjects unable to sign.

2. Results

There was no difference by age between gender, but a difference was present by education years (p = 0.039), with
a greater schooling level among males, as well as in the adult group versus the elder group (p = 0.003).
142 S.M.D. Brucki, R. Nitrini / Archives of Clinical Neuropsychology 23 (2008) 139147

Fig. 1. Cancellation task.

Among illiterates, 78.5% had never attended school (G0) and 21.5% had attended school for less than 1 year, but
were unable to read and write (G1).
There was no difference between age groups, while there were differences across all measures between literacy
groups, except on cancellation time (Table 1). Comparing age groups by literacy status (illiterates versus literates)
yielded a difference between adults on correct targets (p = 0.008), and on number of false-positives (p = 0.006), with
illiterates demonstrating poorest performance. There was no difference in these measures between illiterates and
literates in the elder group.
Analysis by performance index (higher scores reflect more efficient performance) among groups can be seen in
Table 1, where no differences were observed between age groups (adults versus elder) and illiterates compared to
literates. Comparing results in each age group by literacy we observed a significant difference between adult illiterates
and literates (MannWhitney U-test, p = 0.002) which was not present between elders (illiterates and non-illiterates),
p = 0.125.
For comparison among results by quadrant in the total sample, the Wilcoxon Matched pairs test was used, with
significance among Q1 and Q3 (Z = 3.01, p = 0.003); Q2 and Q3 (Z = 2.65, p = 0.008); Q3 and Q4 (Z = 2.81, p = 0.005).
Difference was also noted among upper quadrants and lower quadrants (Z = 2.72, p = 0.007). These results showed that
in this population the greatest number of correct targets was in Q3 (lower left quadrant) and in lower quadrants. When
we compared within each literacy group we identified that among illiterates there was no difference between quadrants
as well as among literates. Notably, within each educational group there were more corrected targets in Q3 (left lower
quadrant), and in lower quadrants among illiterates. As shown by Table 2, the number of correct targets signaled was
greater in lower quadrants among almost all groups.
Our analysis by search organization (randomized or organized) revealed a difference only between illiterates that
never attended school (G0) and those that had some schooling (G1). Search strategy was random in 90.4% of our
sample and in 93.8% of illiterates, but unexpectedly, this same kind of strategy was also performed by 80% of non-
illiterate participants (Table 3). There was a difference between subjects who had never attended school (G0) and
illiterates that had contact with some two dimensions representations, such as letters and symbols, presented in formal
S.M.D. Brucki, R. Nitrini / Archives of Clinical Neuropsychology 23 (2008) 139147 143

Table 1
Analysis of cancellation test
Cancellation time Correct targets False-positive targets Index performance
(mean/S.D.) (mean/S.D.) (mean/S.D.) (mean/S.D.)

Elder group (n = 27) 253.5/60.8 33.4/17.1 5.1/7.1 0.11/0.09

Adult group (n = 55) 240.7/68.6 42.0/18.2 5.8/10.3 0.16/0.11
p value* 0.439 0.015 0.725 0.029
Females (n = 39) 254.0/64.7 38.1/17.1 6.2/9.3 0.12/0.09
Males (n = 43) 237.4/67.1 40.4/19.1 5.8/9.6 0.16/0.12
p value* 0.147 0.190 0.416 0.164
Illiterates (n = 65) 254.5/60.6 35.0/18.9 6.2/8.8 0.11/0.09
Literates (n = 17) 223.0/73.8 49.1/12.0 4.2/10.8 0.21/0.11
p value* 0.017 0.002# 0.008# 0.0002#
G1 (n = 14)a 251.4/75.7 36.8/22.0 3.0/4.1 0.13/0.12
G0 (n = 51)b 256.4/56.3 35.3/18.6 7.24/4.11 0.11/0.09
p value* 0.675 0.720 0.300 0.759
All participants 244.7/66.2 39.4/18.2 5.6/9.4 0.14/0.11

G1: Illiterates who went to school; G0: illiterates who had never attended to school.
a Elders (n = 7) and adults (n = 10).
b Elders (n = 20) and adults (n = 31).
* MannWhitney U-test.
# p < 0.0125.

Table 2
Correct targets in cancellation test by quadrants
Quadrant 1, Quadrant 2, Upper quadrant, Quadrant 3, Quadrant 4, Lower quadrant,
mean/S.D. mean/S.D. mean/S.D. mean/S.D. mean/S.D. mean/S.D.
(median) (median) (median) (median) (median) (median)

All subjects 9.7/4.4 (11) 9.4/4.9 (11) 19.2/8.9 (22) 10.2/5.1 (12) 9.5/5.7 (12) 19.8/10.3 (24)
Elder group 7.8/4.4 (8) 8.5/4.6 (9) 16.2/8.4 (17) 8.5/5.3 (8) 8.6/5.8 (11) 17.3/10.4 (18)
Adult group 10.6/4.2 (13) 9.9/5.1 (12) 20.5/8.9 (25) 11.0/4.8 (14) 9.9/5.6 (13) 21.0/10.2 (25)
p value* 0.003# 0.159 0.021 0.017 0.258 0.056
Females 9.7/4.0 (11) 8.4/4.8 (9) 18.1/8.3 (18) 9.9/5.2 (12) 8.7/5.6 (11) 18.7/10.4 (24)
Males 9.7/4.8 (12) 10.4/4.9 (13) 20.1/9.4 (25) 10.5/5.1 (13) 10.2/5.7 (13) 20.7/10.2 (25)
p value* 0.489 0.019 0.085 0.635 0.058 0.204
Illiterates 8.8/4.7 (10) 8.2/5.0 (8) 17.0/9.2 (17) 9.2/5.4 (10) 8.4/6.0 (10) 17.7/7.4 (18)
Literates 11.7/3.0 (14) 12.1/3.6 (13) 23.8/6.2 (26) 12.4/3.7 (14) 11.9/4.1 (14) 24.3/7.4 (27)
p value* 0.003# 0.001# 0.001# 0.007# 0.014 0.007#
G1 9.5/4.9 (12) 8.3/6.0 (9) 17.8/10.5 (21) 10.3/5.8 (14) 8.6/6.9 (12) 18.9/12.1 (26)
G0 8.6/4.7 (9) 8.2/4.8 (7) 16.8/9.0 (17) 9.0/5.3 (9) 8.4/5.8 (10) 17.4/10.6 (18)
p value* 0.474 0.734 0.594 0.539 0.707 0.741
* MannWhitney U-test.
# p < 0.0125.

3. Discussion

The orderly array task was chosen because there was a possibility to analyze specific scan paths by participants due
to literacy or formal contact with graphic elements of reading and writing, even among illiterates. As observed in other
studies, influence of education is not homogeneous among low levels, whereby zero schooling is different from 3 years
144 S.M.D. Brucki, R. Nitrini / Archives of Clinical Neuropsychology 23 (2008) 139147

Table 3
Search organization among groups
Randomized strategy (%) 2 p value

Elder group 86.6 0.37 0.545

Adult group 90.7
Females 93 0.62 0.432
Males 86.5

Illiterates 93.8 0.054*
Non illiterates 80

G0 98.1 0.006#,*
G1 75
* Fisher Exact test.
# p < 0.0125.

of education. Our results indicated this same pattern, namely a difference among non-formal educated persons and
those with very little schooling (Ardila, Ostrosky-Solis, Rosselli, & Gomez, 2000; Grossi et al., 1993; Ostrosky-Solis
et al., 1998; Puente & Ardila, 2000).
Our sample was very homogeneous, considering that all subjects had lived in a rural area all their lives and at a low
socioeconomic level. By the same token, educational level was also homogeneous due to the same rural background,
and cultural environment, where all had received a public education, thus rendering our analyses less susceptible to
these types of influence. This enabled us to evaluate the influence of a small amount of schooling on the cancellation
One limitation concerns the study scanning mechanisms in the cancellation task as we only used structured shapes
to verify the type of search strategies. Weintraub and Mesulam (1988) affirmed that erratic search strategy tends
to be present when the stimuli are in an unstructured array, while a structured array prompted a more systematic
search. Participants performed searching in a random way, mainly among illiterates. These results allowed us to infer
that formal education had a great influence on type of scanning, and that illiterates with minimal school attendance
displayed a difference in random versus non random scanning compared to illiterates that never attended school, leading
us to conclude that minimal contact with graphic elements of writing and writing-reading in lines, modified visual
Comparing age groups, we observed greater time to complete the task among elders, similar to results shown in other
studies (Geldmacher & Riedel, 1999; Lowery, Ragland, Gur, Gur, & Moberg, 2004; Mesulam, 2000; Rosselli et al.,
1990; Scuteri, Palmieri, lo Noce, & Giampaoli, 2005; Uttl & Pilkenton-Taylor, 2001), as well as an interaction between
age and education (Ardila et al., 2000; Ostrosky-Solis et al., 1998). Age differences among four educational groups
were found in the visual detection task of NEUROPSI (Ardila et al., 2000). Aging does not seem to have influenced
number of errors in various studies (Geldmacher & Riedel, 1999; Lowery et al., 2004; Mesulam, 1985, 2000; Uttl &
Pilkenton-Taylor, 2001), and our results remain in accordance with previous findings, and no difference by aging in
number of false-positives. This latter result was in contrast to results from a survey by Byrd, Jacobs, Hilton, Stern, and
Manly (2005) which observed that elders with lower reading levels committed more errors on items that differed in
geometric properties.
Among our participants there was extensive disorganization in searching, revealed by a greater number of signaled
targets in lower quadrants, with random scanning being responsible for this finding, and proximity of this region of
the page to the person. Our low educated subjects performed a random scan in searching for targets and did not use an
occidental pattern of reading (horizontal and left to the right). In contrast to work by Le Carret et al. (2003), our subjects
did not demonstrate failure in the lower half of the matrix, but performed best on lower quadrants. They also found
that the upper left quadrant was better scanned whereas subjects with high educational level gave more recognition
responses on the bottom quadrant (whether wrong or right) in relation to low education subjects in the Benton Visual
Retention Test, suggesting they may explore these two bottom quadrants more frequently before making their choice.
In line with our findings, they observed better performance in more educated individuals. They concluded that effect
of education may be mediated either by better encoding strategy or by better recognition strategy, as a measure of
working memory.
S.M.D. Brucki, R. Nitrini / Archives of Clinical Neuropsychology 23 (2008) 139147 145

There was a difference in the number of false-positive errors among age groups and educational levels, but not for
gender, in the study by Byrd, Touradji, Tang, and Manly (2004). In their study the efficacy was also worse for elders.
The measure of efficiency developed by Geldmacher and Hills (1997) revealed better performance in both the adult
group and in literates, as was the case in our study.
Statistical difference in false-positive cancelled targets occurred among illiterates and literates, but did not occur
between gender, age and illiterates with or without schooling. The number of errors in our sample was higher than
previous studies, with a mean value of 5.6 (9.4) false-positive targets, possibly because of our very low educational level
(Byrd et al., 2004; Mesulam, 1985, 2000). In nonverbal forms there is no aid from verbal rehearsal that may occur in the
letter target, which can allow easier maintenance of determined targets. In contrast, visual cues are available in searching
for nonverbal targets where very subtle changes among figures may be disastrous for performance in illiterates, evident
upon comparing false-positive targets between literate groups. Illiterates seem to make a less exhaustive exploration of
the items and to examine the sheet of paper less systematically. Lack of formal education implies that these individuals
never had the opportunity to practice processing of conventional 2D representations (Reis et al., 2006). We also affirmed
that visual perception is acquired through more formal education, given that there is no difference between illiterate
groups (G0 and G1) on cancellation time, correct targets, false-positive marked targets, and performance index, or
by quadrants. In fact, it seems to us that a little formal contact with letter and figures representations could affect the
search organization, with random search in 98% of illiterates who had never attended school (G0) whereas among
those who had minimal schooling (G1) and those with low educational level (literates) there was a high percentage
of random searching, which may indicate that greater schooling is required to develop an organized search strategy.
Furthermore, our literate sample was classifiable as functional illiterates (if we considered 4 years of schooling, as
criterion), which could explain the random searching seen in majority of cases. Cancellation requires subjects to deal
with multiple occurrences of the same target across the page, but must also inhibit non-targets stimuli as well as targets
that have already been marked. This behavior can be considered an executive function. Therefore, some of the cognitive
performance impaired in illiterates, could be a reflection of some executive functions biased by schooling. Perhaps low
educational level can lead to lack of an abstract plan to guide spatial search.
Rosselli and Ardila (2003) discussed that timed non-verbal tests which score speed of performance are influenced
by the individuals culture and are unsuitable for use on people to whom time restrictions are not such important
values within their culture. However, comparison of results among members from the same cultural background allows
inferences to be made about their cognitive capacities and any cognitive peculiarities. As affirmed by Kline (1993),
the assumption of a lack of cultural bias in a test, needs to be evaluated on a context-by-context basis. Based on these
assumptions, the cancellation tasks are not indicated to evaluate illiterates or low education level subjects, they are
however important to determine possible patterns of performance in cancellation tasks in low educational populations
and in developing countries, because this test seems to predict conversion to dementia, where cognitive slowing can
be present years before definitive diagnosis of dementia (Amieva et al., 2004; Amieva, Rouch-Leroyer, Letenneur,
Dartigues, & Fabrigoule, 2004). This issue remains extremely important in that approximately 20% of the world
population is illiterate, around 780 million of the worlds adults (data from UNESCO).
Many studies have evaluated reading level and years of education and reported important findings the first of which
is the main factor of influence on neuropsychological test performance. Our sample was composed by illiterates and
functional illiterates, according to criteria of less than 4 years of formal education, outlined by the Brazilian Institute of
Geography and Statistics. As such, these subjects fall under the lowest reading level of Johnson, Flicker, and Lichtenberg
(2006), although we did not use reading level measures, only educational level, where analysis of performance and
cancellation behavior was carried out. We were also able to demonstrate some diverse findings on quality searching
in this survey among those with very low schooling and illiterates, helping to establish a more accurate analysis of
illiteracy cognition, and confirm the idea that low schooling subjects do perform non-systematic searches. Based on
these results, the presence of false-positive targets, longer time for completion of the task, and a lower performance
index should not be interpreted as pathological, since they may be caused by low schooling in healthy subjects.


The authors thank Maria Merces Bezerra, Lena V.C. Peres, Isabel S. Souza and Edila A. Moura.
Financial support for this work was provided by FAPESP, process no. 01/02921-9.
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