Psoriatic Arthritis–Related Dactylitis

Psoriatic arthritis–related dactylitis, often called “sausage digit,” is a hallmark feature of psoriatic arthritis (PsA) characterized by diffuse swelling of an entire finger or toe. This swelling results from a combination of synovitis (inflammation of the joint lining), tenosynovitis (inflammation of the tendon sheath), and enthesitis (inflammation where tendons or ligaments attach to bone), leading to a uniformly enlarged, tender digit. Approximately 16–49% of individuals with PsA develop dactylitis at some point in their disease course, and its presence correlates with more aggressive joint damage and poorer functional outcomes National Psoriasis FoundationPMC.

Psoriatic arthritis–related dactylitis, often called “sausage digit,” is the diffuse swelling of an entire finger or toe due to inflammation of the flexor tendon sheath, adjacent soft tissues, and joint capsule. It is a hallmark of psoriatic arthritis (PsA) and signals active disease that can lead to long-term joint damage if untreated. Patients typically experience a swollen digit that is tender to touch, warm, and may limit function, often accompanied by skin changes such as nail pitting or plaque psoriasis American College of RheumatologyMayo Clinic.

Types of Psoriatic Dactylitis

In clinical practice, psoriatic dactylitis can be broadly categorized based on predominant tissue involvement and symptomatology:

• Tender (“hot”) dactylitis is marked by pain, warmth, and redness over the affected digit, reflecting active inflammation of the joint lining and tendon sheaths ScienceDirectPMC.

• Non-tender (“cold”) dactylitis presents as painless swelling without significant erythema or increased temperature, often indicating chronic changes and fibrotic tissue without active inflammation ScienceDirectPMC.

• Synovitis-predominant dactylitis features prominent joint lining inflammation detectable on ultrasound or MRI, leading to joint capsule distension and pain with motion PMCResearchGate.

• Tenosynovitis-predominant dactylitis arises mainly from inflammation of the flexor tendon sheaths, causing tenderness along the tendon path and characteristic fusiform swelling PMCPMC.

• Enthesitis-predominant dactylitis involves inflammation at the entheses around the digit, often accompanied by adjacent bone marrow edema on MRI PMCResearchGate.

Types of Psoriatic Dactylitis

1. Tender (“hot”) dactylitis: Characterized by pain, warmth, and redness over the affected digit due to active inflammation of joints and tendons ScienceDirectPMC.

2. Non-tender (“cold”) dactylitis: Presents as painless swelling without erythema, suggesting chronic changes and fibrotic tissue rather than active inflammation ScienceDirectPMC.

3. Synovitis-predominant dactylitis: Features primary joint lining inflammation, leading to pain on motion and swelling detectable via ultrasound or MRI PMCResearchGate.

4. Tenosynovitis-predominant dactylitis: Results from predominant inflammation of the flexor tendon sheaths, causing tenderness along tendon paths and fusiform swelling PMCPMC.

5. Enthesitis-predominant dactylitis: Involves primary inflammation at tendon/ligament insertions, often with adjacent bone marrow edema on MRI PMCResearchGate.

 Causes

1. Genetic Predisposition
   Individuals with PsA often carry HLA-B27 and other genetic markers that increase susceptibility to enthesitis and digital inflammation, laying the groundwork for dactylitis WikipediaMedlinePlus.

2. Autoimmune Inflammation
   An overactive immune system mistakenly attacks joint and tendon structures, releasing inflammatory cytokines like TNF-α and IL-17, which drive dactylitic swelling WikipediaPMC.

3. Enthesitis
   Inflammation at the entheses around the digit causes local bone marrow edema and soft tissue swelling that can manifest as diffuse digit enlargement PMCResearchGate.

4. Tenosynovitis
   Persistent inflammation of flexor tendon sheaths leads to fluid accumulation and fusiform swelling along the digit’s length PMCPMC.

5. Synovitis
   Inflamed joint linings in the metacarpophalangeal or interphalangeal joints contribute directly to sausage-digit swelling PMCScienceDirect.

6. Nail Psoriasis
   Psoriatic changes in the nail matrix and bed create a local inflammatory environment that predisposes nearby joints and tendons to dactylitis WikipediaMedlinePlus.

7. Mechanical Stress
   Repeated microtrauma from daily activities can exacerbate enthesis and tendon sheath inflammation, triggering dactylitic episodes PMCScienceDirect.

8. Obesity
   Excess body weight increases mechanical load on joints and entheses, amplifying inflammatory responses that lead to dactylitis WikipediaMedical News Today.

9. Smoking
   Tobacco exposure alters immune regulation and vascular health, exacerbating inflammation in digits Medical News TodayScienceDirect.

10. Infection Triggers
    Prior streptococcal or bacterial infections can precipitate reactive-like dactylitis in genetically susceptible individuals DermNet®PMC.

11. Cold Weather
    Lower temperatures may induce vascular constriction and altered immune activity, worsening digit swelling Medical News TodayNational Psoriasis Foundation.

12. Metabolic Syndrome
    Components like insulin resistance and dyslipidemia promote systemic inflammation, raising the risk of dactylitis WikipediaMedical News Today.

13. Age-Related Changes
    PsA most commonly presents between ages 30 and 50, with age-related immune shifts contributing to digital inflammation WikipediaNational Psoriasis Foundation.

14. Psychological Stress
    Chronic stress can dysregulate cytokine production, heightening susceptibility to inflammatory flares including dactylitis Medical News TodayPMC.

15. Delayed Psoriasis Treatment
    Inadequate control of skin disease allows persistent systemic inflammation, paving the way for joint and tendon involvement manifesting as dactylitis WikipediaJRheum.

Symptoms

1. Diffuse Swelling
   Entire fingers or toes appear uniformly enlarged, giving a “sausage” appearance that distinguishes dactylitis from joint-only swelling National Psoriasis FoundationPMC.

2. Pain and Tenderness
   Affected digits are often painful to touch and movement, reflecting active inflammation of multiple tissues Medical News TodayPMC.

3. Warmth and Redness
   Inflamed digits may feel warm and look red, especially in tender dactylitis, indicating increased blood flow to the area PMCNational Psoriasis Foundation.

4. Stiffness
   Patients commonly report difficulty bending or straightening the digit, particularly after periods of inactivity ScienceDirectWikipedia.

5. Reduced Range of Motion
   Chronic swelling and pain limit flexion and extension, impairing fine motor tasks and gait when toes are involved PMCScienceDirect.

6. Nail Changes
   Psoriatic nail features—pitting, onycholysis, oil-spot discoloration—often accompany or precede dactylitis in the same digit MedlinePlusNational Psoriasis Foundation.

7. Joint Deformity
   Long-standing dactylitis can lead to joint erosions and deformities visible on imaging and during physical exam WikipediaPMC.

8. Functional Impairment
   Swollen, painful digits compromise grip strength and dexterity, or balance and walking if toes are involved JRheumScienceDirect.

9. Morning Stiffness
   Stiffness lasting more than 30 minutes upon awakening is common, improving with movement throughout the day PMCWikipedia.

10. Systemic Symptoms
    Low-grade fever, fatigue, and malaise may occur during severe inflammatory flares, reflecting systemic immune activation WikipediaMedical News Today.

Diagnostic Tests

Physical Exam

1. Visual Inspection
   The clinician observes uniform digit swelling, erythema, and deviations in digit alignment PMCNational Psoriasis Foundation.

2. Palpation
   Gentle pressure along the flexor tendon sheaths and joints assesses tenderness and warmth, distinguishing tender from cold dactylitis PMCNational Psoriasis Foundation.

3. Range of Motion Testing
   Active and passive flexion/extension measurements quantify functional loss in the affected digit ScienceDirectPMC.

4. Circumferential Measurement
   Caliper or tape measurements of digit circumference track swelling progression or response to therapy PMCResearchGate.

Manual Tests

5. Tenderness Mapping
   Systematic palpation along joints and tendon paths localizes pain points, guiding further imaging or lab evaluation PMCJRheum.

6. Tenosynovitis Provocation
   Passive stretching of flexor tendons reproduces pain, indicating sheath involvement PMCPMC.

7. Nail-fold Capillaroscopy
   Examination of periungual capillaries may reveal microvascular changes supporting PsA diagnosis MedlinePlusNational Psoriasis Foundation.

8. Joint Line Tenderness
   Palpation along joint lines differentiates synovitis from pure soft tissue swelling ScienceDirectPMC.

Laboratory and Pathological Tests

9. Erythrocyte Sedimentation Rate (ESR)
   Elevated ESR indicates systemic inflammation but is nonspecific WikipediaPMC.

10. C-Reactive Protein (CRP)
    High CRP levels correlate with active disease and may parallel dactylitis severity PMCWikipedia.

11. Rheumatoid Factor and Anti-CCP Antibodies
    Negative RF/anti-CCP help exclude rheumatoid arthritis in dactylitic presentations WikipediaScienceDirect.

12. HLA-B27 Typing
    Presence of HLA-B27 supports a spondyloarthropathy diagnosis, though not specific to dactylitis WikipediaMedlinePlus.

Electrodiagnostic Tests

13. Nerve Conduction Studies
    Rule out compressive neuropathies when digit numbness accompanies swelling ScienceDirectPMC.

14. Electromyography (EMG)
    Assesses muscle involvement if digit weakness coexists with dactylitis ScienceDirectPMC.

Imaging Tests

15. Plain Radiography (X-ray)
    Identifies joint erosions, bone proliferation, and soft tissue swelling patterns characteristic of chronic dactylitis ResearchGatePMC.

16. Musculoskeletal Ultrasound
    Visualizes synovitis, tenosynovitis, enthesitis, and power-Doppler signals indicating active inflammation PMCPMC.

17. Magnetic Resonance Imaging (MRI)
    Detects bone marrow edema, synovial enhancement, and tendon sheath fluid with high sensitivity PMCResearchGate.

18. Computed Tomography (CT) Scan
    Provides detailed bone architecture assessment, particularly useful in advanced erosive disease WikipediaWikipedia.

19. Bone Scintigraphy
    Highlights increased osteoblastic activity at inflamed sites, aiding in early detection of enthesitis-related dactylitis PMCResearchGate.

20. Dual-Energy CT Iodine Mapping
    Differentiates PsA from rheumatoid arthritis by visualizing periarticular inflammation distribution ResearchGate.

Non-Pharmacological Treatments

Below are evidence-based non-drug approaches, each described in simple English with its purpose and mechanism.

Physiotherapy & Electrotherapy

1. Transcutaneous Electrical Nerve Stimulation (TENS)

   • Description: Small electrodes on the skin deliver mild electrical pulses.

   • Purpose: Reduce pain by interrupting pain signals to the brain.

   • Mechanism: Stimulates large nerve fibers that inhibit transmission of pain signals in the spinal cord Physiopedia.

2. Therapeutic Ultrasound

   • Description: A probe emits sound waves deep into tissues.

   • Purpose: Promote tissue healing and reduce inflammation.

   • Mechanism: Mechanical vibrations increase blood flow and cell activity in inflamed areas Physiopedia.

3. Low-Level Laser Therapy

   • Description: Low-intensity lasers target inflamed joints.

   • Purpose: Alleviate pain and speed tissue repair.

   • Mechanism: Photobiomodulation stimulates cellular mitochondria to boost healing ╴no direct citation available╴.

4. Hydrotherapy

   • Description: Exercises performed in warm water.

   • Purpose: Improve mobility and reduce joint load.

   • Mechanism: Buoyancy decreases stress on joints, while warmth relaxes muscles Physiopedia.

5. Cryotherapy

   • Description: Application of cold packs to swollen digits.

   • Purpose: Decrease swelling and numb pain.

   • Mechanism: Vasoconstriction reduces fluid leakage and slows nerve conduction Physiopedia.

6. Thermotherapy (Heat)

   • Description: Warm packs or paraffin wax baths.

   • Purpose: Ease stiffness and promote circulation.

   • Mechanism: Heat dilates blood vessels, improving nutrient delivery and muscle relaxation Physiopedia.

7. Manual Joint Mobilization

   • Description: Gentle, skilled movements by a therapist.

   • Purpose: Restore joint alignment and range of motion.

   • Mechanism: Stretching joint capsule and surrounding tissues reduces stiffness ╴no direct citation available╴.

8. Extracorporeal Shockwave Therapy

   • Description: High-energy pulses target entheses.

   • Purpose: Reduce chronic pain and promote repair.

   • Mechanism: Mechanical stress induces tissue regeneration and modulates inflammation ╴no direct citation available╴.

9. Infrared Therapy

   • Description: Infrared lamps deliver deep heat.

   • Purpose: Penetrate tissues to decrease pain.

   • Mechanism: Infrared energy increases local circulation and metabolic activity ╴no direct citation available╴.

10. Splinting & Assistive Devices

    • Description: Custom splints or braces support digits.

    • Purpose: Immobilize inflamed joints to allow healing.

    • Mechanism: Reduces mechanical stress and prevents deformity Physiopedia.

Exercise Therapies

11. Aerobic Exercise

    • Improves cardiovascular health and helps control weight, reducing joint stress.

    • Mechanism: Increases anti-inflammatory cytokines and endorphins PsOPsA Hub.

12. Strength Training

    • Builds muscle around affected joints to improve stability.

    • Mechanism: Muscle hypertrophy offloads joints and enhances proprioception PsOPsA Hub.

13. Range-of-Motion Exercises

    • Gentle movements through full joint arcs.

    • Mechanism: Maintains cartilage nutrition via synovial fluid movement PsOPsA Hub.

14. Flexibility/Stretching

    • Prevents contractures and maintains soft-tissue elasticity.

    • Mechanism: Lengthens muscle-tendon units, reducing stiffness PsOPsA Hub.

15. Balance Training

    • Improves coordination to prevent falls and joint injuries.

    • Mechanism: Enhances neuromuscular control and proprioception PsOPsA Hub.

 Mind-Body Therapies

16. Yoga

    • Combines stretching and relaxation to reduce pain and stress.

    • Mechanism: Lowers systemic inflammation via vagal activation PsOPsA Hub.

17. Tai Chi

    • Slow, flowing movements that enhance joint mobility.

    • Mechanism: Improves balance and decreases inflammatory markers PsOPsA Hub.

18. Mindfulness Meditation

    • Teaches present-moment awareness to reduce pain perception.

    • Mechanism: Modulates brain pain networks and stress response ╴no direct citation available╴.

Educational Self-Management

19. Patient Education Programs

    • Workshops on disease process, treatment options, and lifestyle.

    • Mechanism: Empowers patients to adhere to therapies and adopt healthy behaviors PsOPsA Hub.

20. Self-Management Workshops

    • Interactive sessions on goal-setting, pacing, and pain coping.

    • Mechanism: Builds self-efficacy and reduces healthcare utilization PsOPsA Hub.

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Key Drugs for Dactylitis

Each paragraph covers dosage, class, schedule, and side effects.

1. Naproxen (NSAID)

   • Dose: 250–500 mg orally twice daily.

   • Schedule: Morning and evening with food.

   • Side Effects: Stomach irritation, heartburn, GI bleeding, renal impact Drugs.comMayo Clinic.

2. Prednisone (Oral Corticosteroid)

   • Dose: 5–60 mg daily, tapered as inflammation subsides.

   • Schedule: Once daily, preferably in the morning.

   • Side Effects: Weight gain, mood swings, osteoporosis, glucose intolerance Medical News TodayDrugs.com.

3. Methotrexate (csDMARD)

   • Dose: 7.5–25 mg once weekly, plus folic acid.

   • Schedule: Same day each week.

   • Side Effects: Nausea, liver enzyme elevation, cytopenias GoodRxPMC.

4. Sulfasalazine (csDMARD)

   • Dose: Start 500 mg/day and titrate to 2–3 g/day.

   • Schedule: Divided into 2–3 daily doses with meals.

   • Side Effects: GI upset, headache, rash Medical News TodayMayo Clinic.

5. Leflunomide (csDMARD)

   • Dose: 20 mg once daily (loading 100 mg for 3 days optional).

   • Schedule: Daily with food.

   • Side Effects: Diarrhea, hypertension, hepatotoxicity PMC.

6. Adalimumab (TNF-α inhibitor)

   • Dose: 40 mg subcutaneously every other week.

   • Schedule: Inject at the same time of day.

   • Side Effects: Injection site reactions, infection risk humira.comDrugs.com.

7. Etanercept (TNF-α inhibitor)

   • Dose: 50 mg subcutaneously once weekly.

   • Schedule: Same day each week.

   • Side Effects: Infection, injection site pain Drugs.com.

8. Secukinumab (IL-17A inhibitor)

   • Dose: 150 mg subcutaneously at Weeks 0–4 then every 4 weeks (up to 300 mg if needed).

   • Schedule: Monthly maintenance after loading.

   • Side Effects: Candidiasis, diarrhea cosentyx.comMayo Clinic.

9. Apremilast (PDE4 inhibitor)

   • Dose: Titrate to 30 mg twice daily by Day 6.

   • Schedule: Morning and evening, with or without food.

   • Side Effects: Diarrhea, headache, weight loss Drugs.comMayo Clinic.

10. Tofacitinib (JAK inhibitor)

    • Dose: 5 mg orally twice daily.

    • Schedule: Morning and evening.

    • Side Effects: Infection, lipid changes Nature.

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Dietary Molecular Supplements

Each supports joint health or modulates inflammation.

1. Omega-3 Fatty Acids (Fish Oil)

   • Dose: 2–3 g EPA/DHA daily.

   • Function: Anti-inflammatory.

   • Mechanism: Competes with arachidonic acid to reduce pro-inflammatory eicosanoids.

2. Vitamin D

   • Dose: 1,000–2,000 IU daily.

   • Function: Immune regulation.

   • Mechanism: Modulates T-cell responses and cytokine production.

3. Gamma-Linolenic Acid (Evening Primrose Oil)

   • Dose: 1,000 mg twice daily.

   • Function: Anti-inflammatory.

   • Mechanism: Converted to dihomo-γ-linolenic acid, reducing inflammation.

4. Curcumin

   • Dose: 500 mg thrice daily (standardized 95% extract).

   • Function: Cytokine modulation.

   • Mechanism: Inhibits NF-κB and COX-2 pathways.

5. Boswellia Serrata Extract

   • Dose: 300 mg three times daily.

   • Function: Joint comfort.

   • Mechanism: Inhibits 5-lipoxygenase to reduce leukotriene synthesis.

6. Ginger

   • Dose: 1 g daily (extract).

   • Function: Analgesic, anti-inflammatory.

   • Mechanism: Inhibits prostaglandin synthesis and COX enzymes.

7. Vitamin E

   • Dose: 400 IU daily.

   • Function: Antioxidant.

   • Mechanism: Scavenges free radicals in inflamed tissues.

8. Probiotics

   • Dose: ≥10^9 CFU daily.

   • Function: Gut-joint axis support.

   • Mechanism: Modulates systemic immune responses via gut microbiota.

9. S-Adenosylmethionine (SAMe)

   • Dose: 400–800 mg daily.

   • Function: Joint health.

   • Mechanism: Supports cartilage matrix synthesis and has analgesic effects.

10. Vitamin C

    • Dose: 500 mg twice daily.

    • Function: Collagen formation.

    • Mechanism: Cofactor for proline and lysine hydroxylation in collagen.

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Advanced/Regenerative Therapies

Emerging treatments with limited but growing evidence.

1. Alendronate (Bisphosphonate)

   • Dose: 70 mg weekly.

   • Function: Bone remodeling.

   • Mechanism: Inhibits osteoclasts to reduce bone erosion.

2. Zoledronic Acid (Bisphosphonate)

   • Dose: 5 mg IV annually.

   • Function: Preserve bone density.

   • Mechanism: Suppresses osteoclast activity.

3. Platelet-Rich Plasma (PRP) (Regenerative)

   • Dose: 3–5 mL PRP per injection.

   • Function: Promote healing.

   • Mechanism: Concentrated growth factors stimulate tissue repair.

4. Autologous Conditioned Serum (Regenerative)

   • Dose: 1–2 mL per injection weekly for 4 weeks.

   • Function: Anti-inflammatory.

   • Mechanism: High IL-1Ra levels inhibit IL-1β.

5. Hyaluronic Acid Viscosupplementation

   • Dose: 20 mg per injection, 1 injection weekly for 3–5 weeks.

   • Function: Joint lubrication.

   • Mechanism: Restores synovial fluid viscosity to cushion joints.

6. Mesenchymal Stem Cell Therapy

   • Dose: 10–50 million cells intra-articularly.

   • Function: Tissue regeneration.

   • Mechanism: MSCs secrete anti-inflammatory factors and differentiate into chondrocytes.

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Surgical Options

Procedures reserved for advanced damage.

1. Tenosynovectomy

   • Procedure: Removal of inflamed tendon sheath.

   • Benefits: Reduces pain and prevents tendon rupture.

2. Synovectomy

   • Procedure: Excision of inflamed synovium.

   • Benefits: Improves joint function and halts destructive changes.

3. Joint Debridement

   • Procedure: Arthroscopic removal of loose bodies and pannus.

   • Benefits: Alleviates mechanical symptoms.

4. Joint Fusion (Arthrodesis)

   • Procedure: Fuses adjacent bones.

   • Benefits: Provides pain relief in non-ambulatory digits.

5. Joint Replacement (Arthroplasty)

   • Procedure: Replaces damaged joint surfaces with prosthesis.

   • Benefits: Restores mobility and relieves pain in severely damaged joints.

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Prevention Strategies

1. Maintain healthy weight

2. Quit smoking

3. Balance rest and activity

4. Protect digits with ergonomic tools

5. Manage comorbidities (diabetes, hypertension)

6. Regular low-impact exercise

7. Balanced anti-inflammatory diet

8. Vitamin D sufficiency

9. Stress management

10. Early rheumatology referral

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When to See a Doctor

• New or worsening sausage-digit swelling

• Persistent joint pain unrelieved by NSAIDs

• Signs of infection (fever, redness)

• Functional impairment of hands or feet

• Progressive joint deformity

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“Do’s and Don’ts”

Do:

1. Follow prescribed exercise regimen

2. Take medications as directed

3. Use splints for flare-ups

4. Eat anti-inflammatory foods

5. Practice good skin care

Don’t:
6. Overuse inflamed digits
7. Skip physical therapy sessions
8. Ignore new symptoms
9. Smoke or consume excessive alcohol
10. Delay medical review during flares

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Frequently Asked Questions

1. What causes dactylitis? Autoimmune inflammation of tendon sheaths and synovium.

2. Is dactylitis reversible? Often yes, with early treatment.

3. Can diet help? Anti-inflammatory diets may reduce flares.

4. Are supplements safe? Generally yes, but discuss with your doctor.

5. How long do flare-ups last? Days to weeks, variable by treatment.

6. Is surgery common? Reserved for severe, refractory cases.

7. Can exercise worsen dactylitis? High-impact exercise can; low-impact is encouraged.

8. Are biologics effective? Yes, especially TNF and IL inhibitors.

9. Do I need blood tests? Yes, for DMARD safety monitoring.

10. Can children get PsA? Juvenile forms exist but dactylitis is less common.

11. Is dactylitis painful? Often very painful and tender.

12. Will my digit deform permanently? Early treatment minimizes risk.

13. Are injections helpful? Steroid injections can give rapid relief.

14. Do I need imaging? Ultrasound/MRI can assess tendon inflammation.

15. Where can I find support? Patient groups like the National Psoriasis Foundation.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: July 11, 2025.

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