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Reproduced by Sabinet Gateway under licence granted by the Publisher ( dated 2012)
©MimfeiD ff^wfew
Nail changes-local disorder
or systemic disease?
NORMAN LEVINE, MD
Disorders of the nails offer the medical
pracuuoner some rather challenging
diagnostic and therapeutic problems—-because many such conditions
have similar clinical signs, and some
disorders respond poorly to treatment.
Moreover, nail changes also accompany some systemic diseases and thus
can be useful diagnostically.
In this article, I shall discuss the
differential diagnosis of a number of
the more common local nail disorders,
as well as their treatment, and also describe some of the cutaneous nail findings associated with systemic disease.
K e y points of this presentation are
summarised in tables i and 2.
Local nail disorders
Psoriasis is one of the most common
causes of fingernail deformity. A frequent diagnostic clue to nail psoriatic
dystrophy is evidence of psoriasis
elsewhere, such as on the scalp, knees,
or trunk. Psoriatic nails have three
typical characteristics:
1. Nail pits are pinhead-sized depressions in the nail plate, which may
assume either an irregular or a gridlike
pattern (figure 1).
2. Onycholysis, the separation of
the nail plate from the underlying nail
bed, appears as a well-demarcated
white area on the distal nail plate.
3. Yellow-brown
discolouration
and thickening occur on the nail plate
(figure 2).
Other, less common psoriatic nail
changes are caused by superimposed
infections, such as Candida infections
that appear a? paronychia, and
Modern Medicine /March 1980
Abstract: Numerous cutaneous disorders
affect the mils of the fingers and toes,
among them psoriasis, fungal infections,
paronychia, and benign and malignant
tumours. Most can be diagnosed by physical examination and simple laboratory
tests, such as potassium hydroxide wet
mount and bacterial culture. Biopsy may
be required to identify some diseases that
cause nail dystrophy, such as pyogenic
granuloma or melanoma.
Moreover,
nails may show changes characteristic of
systemic diseases, including connective
tissue disease, pulmonary disease, hypochromic anaemia, and impaired circulation. Thus, identification of changes in
the nails may be helpful in solving a
larger diagnostic problem.
Pseudomonas superinfection that imparts a greenish colour to the nail
plate. 1 Dermatophyte (or tinea) infections are very rarely associated with
psoriatic nails. 2
Local treatment of nail psoriasis is
not very helpful. Topical or intralesional corticosteroids do not work
well. Topical fluorouracil solution(i%)
applied around the nail may result in
partial reconstitution of the normal
nail plate, but the agent itself may be
irritating and produce onycholysis. 3
Patients
using
methotrexate
for
generalised psoriasis often show improvement of the nails, but this treatment is never indicated for psoriatic
nails alone.
Onychomycosis, or fungal nail infections, particularly those involving the
toenails, are quite common in adults
(figure 3). Early in the course, thickening and yellow-brown discolouration
of the nail plate begin at the lateral nail
fold and gradually spread over the remainder of the nail, but the surrounding paronychium is spared. Although
onycholysis commonly occurs, nail
pitting is not as prominent as it is in
psoriasis. Such patients often have
evidence of fungal infection elsewhere
on the feet and hands.
Definitive diagnosis may be made
by either a 1 0 % potassium hydroxide
( K O H ) wet mount of the involved nail
or by culture of the material on
Sabouraud's agar, which can be incubated at room temperature in the office.
Treatment of nail fungal infections
requires several months of oral
griseofulvin therapy; up to 6 months is
indicated for fingernail infections,
perhaps as long as 18 months for
toenails. N e w e r , ultramicronised preparations (Fulvicin P/G) can be given
daily as a single 2 5 0 mg dose. Treatment should continue until a totally
healthy nail plate has grown out. Unfortunately, recurrences are common,
even
after
apparently
adequate
therapy, so one might consider discouraging therapy if the nail involvement is not a great cosmetic or
psychological burden to the patient.
Topically applied antifungal agents are
Dr Levine is an assistant professor in the de- rarely helpful.
partment of internal medicine (dermatology) at
Paronychia is an acute or chronic
the University of Arizona College of Medicine
inflammatory reaction of the periunin Tucson.
15
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16
Figure I .Pitting of the nails ia psoriasis is seen here In a
typical grid)ike partem.
Figure. 2. Psoriatic nails mar hecomc markedly dystrophic, with thickening and gross discoloration of the
nail plates,
Figure 3. Fungal infection* of the na/is usually affect the
toenails in adults and produce ihickenmg and yellow
discoloration, bur usually spare the pamnyi^.hial area.
Figure 4. Acute paronychia appears
a md, edematous, and tender posterior nail fold, (Photo courtesy of
C. Nelson.)
Figure 5. Dermatitis involving the distal digit typically
causes uail plate dystrophy and destroys the cuticle,
Figure 6. Periungual warts usually arise as verrucous
papules that may surround the nail.
Modem Medicine I March 1980
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dltofesill
Treating dermatitis of
the fingers with topical
corticosteroids will
allow affected nails
to grow normally
gual tissue. Fingernails are involved
more often than toenails, and persons
whose hands are frequently in water,
such as cooks, bartenders, or dishwashers, are particularly susceptible.
Diabetes also may predispose to
chronic paronychia.
Acute paronychia presents as a painful, warm, red, tender, and oedematous posterior nail fold, which, on incision, may exude purulent material (figure 4). Patients with the acute form
may have a history of trauma, and a
mixed infection with Candida species
and bacteria is often found. Foreign
debris also may contribute to the inflammatory reaction.4
Chronic paronychia appears as an
oedematous, erythematous area of
either the posterior or lateral nail fold,
with scaling and separation of the nail
fold from the underlying nail plate.
Over several months a dystrophic, discoloured nail plate may develop. An
infectious cause may be demonstrated
by Gram staining for bacteria and
doing a K O H wet mount of the purulent material and looking for Candida
species.
Carefully avoiding moisture and
trauma to the affected area is the most
important element of treatment. This
alone will often clear any paronychia!
infections.
Topical
anti-infective
agents, such as nystatin cream, clotrimazole (Lotrimin) solution, 4 %
thymol in chloroform, or 1% alcoholic solution of gentian violet,
should also be used. The nails will
grow out normally in 4 to 6 months if
the inflammatory process in the
paronychial area has been eliminated.
Dermatitis of the fingers, such as
atopic dermatitis or dyshidrosis, may
occur on the distal digits, involving the
proximal nail fold and causing dystrophic changes in the nail plate (figure
5). It becomes roughened with cross
ridges and coarse nail pits, while the
nail cuticle is destroyed.
Modern Medicine /March 1980
The diagnosis is easily made by
eliciting a history of previous dermatitis and observing eczematous
changes—vesiculation, scaling, and
erythema—of the distal digits. Treatment of the dermatitis alone with topical corticosteroids will allow the nails
to re-grow normally.
Benign tumours of the nails sometimes develop on the paronychial areas
and nail beds. The most common
growths are warts that arise as isolated
or confluent papules. With extensive
growth, the nail may be completely
surrounded (figure 6). Therapy is difficult, particularly if the wart extends
under the nail plate.
Destructive treatment approaches,
such as liquid nitrogen or curettage
and electrocautery, are useful, but care
must be taken to avoid destroying the
nail matrix that underlies the proximal
nail fold. Judicious use of topical peeling agents, such as salicylic acid-lactic
acid solution (Duofilm) is sometimes
effective if used over several weeks.
Even so, partial avulsion of the nail
plate may be necessary to eradicate
subungual wart tissue.
Pyogenic granulomas may occur adjacent to the lateral nail fold, usually
after trauma such as an ingrown
toenail. They appear as bright red
papules with an irregular surface that
bleeds easily. It is important to differentiate this tumour from malignant
melanoma, which may have similar
characteristics.
Curettage and electrocautery make
an effective treatment method for
pyogenic granuloma, and a specimen
of the tumour should be submitted for
pathological examination to rule out
melanoma. Pyogenic granuloma may
occur if destruction of the original
tumour is incomplete.
A pigmented nevus (mole) occasionally occurs in the nail matrix, giving rise to a dense, longitudinal pigmented band in the outgrowing nail
plate. This phenomenon is particularly common in blacks and Asians.
No therapy is indicated for the lesion,
but if the band of pigment enlarges,
widens, or becomes irregular, a nail
matrix biopsy must be performed to
rule out melanoma. Special attention
m w f m w
should be given to any recently acquired pigmented band in a white person, since benign nail-matrix nevi
rarely occur in Caucasians.6
Subungual melanomas typically
arise as brown to blue-black discolourations of the nail bed, with streaks of
pigment in the nail plate. Varying degrees of nail dystrophy and destruction
may follow, as well as ulceration and
bleeding of the nail bed.7
A characteristic diagnostic clue is a
motded, macular, brown to black discolouration in the area adjacent to the
tumour (figure 7). Some tumours,
however, lack pigment entirely and
appear as red, irregular, often friable
subungual plaques or papules. A
biopsy of the lesion will establish the
diagnosis of melanoma, and such patients should then be referred for definitive surgery.
Other malignancies involving the
nail bed and surrounding tissue are
quite rare, but early recognition can
change the prognosis markedly.
Squamous cell and basal cell carcinomas may appear as slow-growing,
subungual papules that become painful and lift the overlying nail plate. A
biopsy of the tumour will confirm the
diagnosis. If underlying bone is
spared, local excision or curettage and
electrodessication are curative.8
Brittle, breakable nails are probably
the most common complaints of patients with nail disorders. Most of
these cases have no apparent cause,
although sometimes excessive exposure to solvents or cleaners is responsible. On the other hand, deficiencies of
calcium or zinc are almost never the
cause, because these metals are present
in only trace amounts in normal nails.
Severe protein deficiency might account for brittie nails, but such patients should also show thin, brittie
hair and generalised body wasting.
Likewise, vitamin deficiencies do not
cause britde nails.
The problem of britde, easily broken nails can be minimised by having
the patient clip the nails as short as
possible. Some persons use nail hardeners, but these agents contain a potential skin sensitiser—formaldehyde.
Some nail polishes contain nylon fibres
17
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Total laevo-rotatory alkaloids o l belladonna 0,25 mg, Phenobarbitone 50 mg. Reg. No.
B E L L A D E N A L / B E L L A D E N A L RETARD
[si]
Metixene hydrochloride 1 mg, Dlmethylpolysiloxane 40 mg, Cellulase 600 CUW, Pepsin Ph.H.V. 200 mg, Glutamic acid h y d r o c h l o r i d e 100 mg,
Pancreatin Ph.H.V. 200 mg. Sodium dehydrocholate 20 mg. Reg. No.
SPASMO CANULASE BITABS
Belladenal Retard, Belladenal and
Spasmo Canulase Bitabs
Irregular eating habits, poor nutrition, sedentary living or stress can make a digestive system
argue with his owner and disturb the peace.
Belladenal and Spasmo Canulase can restore the peace.
Belladenal and Belladenal Retard uncoil both
acute and reoccurring Gl spasms.
Belladenal Retard is a long acting antispasmodic with sedating properties.
Spasmo
irritable
Spasmo
multiple
Canulase calms all aspects of the
bowel syndrome.
Canulase eliminates the need for
medication.
Dosages
Belladenal Retard: 2 daily; 1 in the morning
and 1 at night.
Belladenal: 2-3 tablets daily (delivered in
fractional doses).
Spasmo Canulase: 1-2 bitabs just before or
with meals.
Keep digestive systems in harmony.
WANDER
P.O. Box 371 Randburg 2125
5941
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©Mimfegill
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Table 1. Local nail disorders, diagnosis and treatment
Problem
Diagnostic clues
Treatment
Psoriasis
Psoriasis elsewhere
Nail pitting
Onycholysis
Yellow-brown discolouration
Nail thickening
No beneficial topical therapy available
Onychomycosis
(fungal infections)
Nail thickening
Yellow-brown discolouration
Onycholysis
Posilive KOH wet mount
Positive fungal culture
Fulvicin P/G, 250 mg per day
tor 6 to 18 months
Paronychia
History of nail trauma, hands in
water
Painful, warm, tender, oedematous
proximal nail fold
Dystrophic nai! plate in chronic
infections
Positive KOH wet mount (or Monilia
or culture of bacteria
Avoid moisture and trauma
Topical clotrimazole lotion.
4% thymol in chloroform Topical
gentian violet 1% solution
Dermatitis
History of dermatitis of fingers
Eczema involving fingers, proximal
nail fold
Roughened, ridged, coarse nail
plates
Treat underlying dermatitis
Periungual warts
Verrucous papules without
underlying inflammation
Excision
Electrocautery
Topical keratolyses {Duofilm)
Liquid nitrogen
Pyogenic granuloma
Earlier trauma or ingrown toenail
Bright red papule that bleeds easily
Curettage and electrocautery
Melanoma
Amputation of affected digit
Brown-black discolouration
Mottled brown colour in area adjacent
to tumour
Pigmented streaks in nail plate
that may strengthen nails, but if polish
is used it should not be removed frequendy because the nails can be
weakened by the strong solvent used in
the polish remover.
The nails may be deformed by even
minor trauma, such as nail biting, a
habit that is difficult to break and leads
to severe dystrophy.
Subungual
haematomas are common; blood is incorporated into the nail plate and
moves forward with growth. The pain
of subungual haematomas may be relieved by heating a paper clip and
gendy boring the wire end into the nail
plate to evacuate the sequestered
blood. There is no effective topical
therapy.
Modern Medicine /March 1980
Minor trauma to the nails also may
lead to separation of the nail plate from
the nail bed (onycholysis). Typists, for
example, whose nails are continually
being abused, are commonly afflicted
with this problem. Such patients
should be advised to clip the nails as
short as possible to avoid additional
injury. A normal nail will eventually
grow out.
diseases.)
Ingrown toenails are caused by lateral compression of the toes (principally the big toe), often by ill-fitting
shoes (figure 9). These patients frequendy have excessively curved nails:
The lateral fold is penetrated by the
edge of the nail plate, causing pain,
infection, and from time to time
pyogenic granulomas.
Several weeks after an injury to the
area of the proximal nail fold, a horizontal, depressed ridge often grows
out on the nail plate (figure 8). Called a
Beau's line, it represents temporary
nail matrix dysfunction induced at the
time of trauma. (See "Beau's lines" in
section on nail disorders and systemic
The patient should be told to wear
shoes wide enough to decrease the lateral pressure on the foot. 9 Toenails
should be clipped straight across instead of in a semicircle, and the nail
should be clipped only when the edges
have grown beyond the end of the toe.
Early infection can be managed with
19
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JB2170
be remembered)
Dosage: One 100 mg tablet once doily
there's more to it because there's less to take
fisgtSaW
IiEKtaiTiarh
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©HflimS.mil mBwfmw
Figure 7 Melanoma should be suspected if brown-black
pigmentation appears adjacent to the nail, {Photo courtesy of R Gallego.)
Figure 8. A typical Beau's line is a depressed horizontal
nail plate ridge that appears after trauma or systemic
Illness. (Photo courtesy of C. Nelson.)
Figure V, The ingrown toenail Is usually caused by lat- Figure 10. Thickened, rough, irregular cuticles are
eral compression, often from ill-fitting shoes, and can characteristic of dermatomyositis.
lead to Infection nod swelling, shown here in characteristic involvement of the great toe.
Figure 11. Transverse white hands in the nail bed that Figure 12. The "half-and-half nail"-the proximal nail is
do not grow out with the plate may appear in patients white and the distal nail is reddish-bmwn-occurs in
with hypoalbuminemia.
< Photo courtesy of R. ,4. patients with severe renal disease. (Photo courtesy of C.
Nelson.)
Schwartz.)
Modern Medicine /March 1980
21
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Systemic disease may
be associated with an
increase in melanin
production that leads
to darkened nails
warm water soaks and insertion of cotton pledgets under the nail plate to lift
it gradually away from the lateral nail
fold. 9 Severe infection can be treated
with systemic antibiotics. Surgical avulsion of the whole nail plate should be
done only after all other measures have
failed.
Nail disorders and
systemic disease
Pathological changes in the nail may
be valuable diagnostic clues to underlying systemic diseases (table 2). For
this reason, a complete physical
examination should always include inspection of the fingernails and
toenails. Some of the diseases and
specific nail manifestations include:
• Connective tissue disease. Both
dermatomyositis and systemic lupus
erythematosus may have periungal
erythema or telangiectasia or both.
Thickening, roughness, and irregularity of the cuticle have been reported
with dermatomyositis (figure 10). 10
• Impaired peripheral circulation. Patients with Raynaud's phenomenon
may have brittle, thin, and ridged
nails, with subsequent nail plate flattening. In elderly patients with
atherosclerosis, the nails may be thickened, with associated dystrophy and
onycholysis. 9
• Clubbed fingers. These may appear
as an enlargement of the distal digits
with a loss of the normal angle between
the posterior nail fold and the nail
plate. They occur in cyanotic heart
disease and chronic lung disease, including carcinoma of the lung. Clubbing also is associated with thyroid
disease, hepatic cirrhosis, ulcerative
colitis, and sprue. One autosomal dominant hereditary variant occurs
around puberty. 11
• Koilonychia (spoon nails). In this
deformity, the nail plate becomes flattened or even spoon shaped and may
22
Table 2. Nail disorders in systemic disease
Disease
Nail changes
Dermatomyositis
Periungual erythema
Periungual telangiectasia
Roughened, irregular cuticles
Systemic lupus erythematosus
Periungual erythema
Periungual telangiectasia
Raynaud's phenomenon
Brittle, thin nail plates
Chronic lung disease
Finger clubbing
Cyanotic heart disease
Finger clubbing
Hypochromic anaemia
Flattened or spoon-shaped
nail plates
Septic embolic disease
(subacute bacterial
endocarditis, etc)
Subungual splinter haemorrhage
Vitamin Bt: deficiency
Darkened nails
Hypoalbuminaemia
Parallel white bands in nail bed
Renal disease
Whiteness ot proximal nail
Red discolouration of distal nail
Cirrhosis
Whiteness of nail
also be thinned. It is associated with
hypochromic anaemia, the treatment
of which may reverse the anomaly.
There is also a heriditary form that
affects children but is not associated
with anaemia. 12
•Beauts lines. As with trauma to the
nail matrix, severe systemic illness
may cause temporary dysfunction of
the matrix and produce a thinner nail
plate. As the area regrows, transverse
grooves are noted in all nails (figure 8).
• Splinter haemorrhage. Since the
blood vessels of the nail fold sit in longitudinal ridges, bleeding from these
vessels often gives rise to a splinterlike
appearance. This occurs most commonly after minor local trauma,
psoriasis, and fungal nail infections. 9 It
can also occur in severe systemic illness
as
evidence
of
embolic
phenomena, such as in subacute bacterial endocarditis. Trichinosis may also
cause splinter haemorrhages. However, nail haemorrhage is rarely the
sole or presenting sign of these diseases.
•Abnormal pigmentation of the nails.
A number of systemic diseases, includ-
ing
Peutz-Jeghers
syndrome, 13
14
pinta, and vitamin B12 deficiency 15
are associated with an increase in
melanin production in the nail bed and
a consequent darkening of the nails.
Wilson's disease may cause a bluebrown discolouration of the lunula
(the half-moon under the nail plate).
Paired, narrow white bands that fail to
grow out with the nail plate are seen in
patients with hypoalbuminaemia (figure II). The "half-and-half nail" occurs in severe renal disease; the proximal portion of the nail is white, while
the distal part is reddish-brown (figure
12). 16 In some patients with cirrhosis,
all but the distal margin of the nail bed
may appear white.
The so-called yellow-nail syndrome
is a rare entity in patients with lymphedema of the face and extremities,
respiratory disorders, and fingernails
that are thickened, opaque, yellow,
and slow growing. The nail changes
may precede the pathologic findings
by many years. Lymphangiograms
may show abnormalities of the lymphatic vessels.
A number of drugs also can cause
Modem Medicine I March 1980
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nail colour changes. Antimalarial
agents may give the nails a bluish hue,
while silver salts impart a striking,
slate-gray colour to the lunula. Acute
arsenic intoxication may lead to transverse white bands in the nail, and Adriamycin and other cancer chemotherapeutic agents may cause pigmented bands that migrate outward
with the nail plate. 17
Highlights of this material on diagnosis, treatment, and significance of
nail disorders can be found in the
tables.
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A n d C o d i s is h i g h l y s o l u b l e for rapid a b s o r p t i o n
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References
1. Z a i a s N :
Psoriasis of the nail.
Arch
Dermatol
99:567-579» 1969
,
.
2 . W h i t e C J , L a r p p l y T C : Histopathology of nail
diseases. J Invest Dermatol 1 9 : 1 2 1 - 1 2 4 , 1 9 5 2
3 . Fredrikkson T : Topically applied fluorouracil in
the treatment of psoriatic naiJs. A r c h Dermatol
1 1 0 : 7 3 5 - 7 3 6 , 1974
4 . Stone O J , Mullins J F : Experimental studies on
chronic paronychia. A r c h Dermatol 8 9 : 4 5 5 - 4 6 0 , 1 9 6 4
5 . A r n d t K A : M a n u a l of Dermatologic Therapeutics.
Boston, Little B r o w n & C o m p a n y , 1 9 7 4
6. A l l y n B K o p f A W , K a h n M et al: Incidence of
pigmented nevi. J A M A 1 8 6 : 8 9 0 - 8 9 3 , 1 9 6 3
7 . K o p f A W , B a n R S , Rodriquez-Sains R S : M a l i g nant melanoma: A review. J Dermatol S u r g Oncol
3:75-77, 1977
8. Zaias N : Malignant tumors of nails. In D e m i s D J ,
Dobson R L , M c G u i r e J (Editors): Clinical Dermatology. Hagerstown, M D , Harper & R o w , 1 9 7 7
9. S a m m a n P D : T h e nails. In R o o k A , Wilkinson D S ,
Ebling F J G (Editors): T e x t b o o k of Dermatology.
L o n d o n , Blackwell, 1 9 7 2
10.
Samitz
MH:
Cuticular
changes
in
dermatomyositis. A r c h Dermatol 1 1 0 : 8 6 6 - 8 6 7 , >974
1 1 . Fischer D S , Singer D H , F e l d m a n S M : Clubbing:
A review with emphasis on hereditary acropathy.
M e d i c i n e (Baltimore) 4 3 : 4 5 9 - 4 7 4 , 1 9 6 3
1 2 . Burgeron J R , Stone O J : Koilonychia. A r c h D e r matol 9 5 : 3 5 i - 3 5 3 » 1 9 6 7
1 3 . Valero A , S h e r f K : Pigmented nails m PeutzJeghers syndrome. A m J Gastroenterol 4 3 : 5 6 - 5 8 , 1 9 6 5
14. Z a i a s N : A b n o r m a l pigmentation of nails. In
D e m i s D J , Dobson R L , M c G u i r e J (Editors): Clinical
Dermatology. Hagerstown, M D , H a r p e r & R o w ,
1977
1 5 . Baker S S , Ignatius M , Johnson S et al: H y p e r p i g mentation of skin. B r M e d J 2 : 1 7 1 3 - 1 7 1 5 , 1 9 6 3
16. L i n d s a y P G : T h e half-and-half nail. A r c h Intern
Med 119:583-587, 1967
1 7 . Rothberg H , Place H , Shteir O : A d r i a m y c i n
( N S C - 1 2 3 1 2 7 ) toxicity: Unusual melanotic reaction.
Cancer Chemother R e p 5 8 : 7 4 9 - 7 5 1 , 1 9 7 4
TO OUR READERS
When you have a different
point of view, or an
addendum comes to mind,
please let us know, so that
it may be brought to the
attention of other readers.
Write to — The Editor
Modern Medicine
of South Africa
Box 335 Cape Town 8000
HC8135
Modern Medicine /March 1980
23
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