The main parameters and characteristics of the APS process [15].
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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Psoriasis is a common skin disease characterized by inflammation and a chronic course with exacerbation and remission episodes. The worldwide prevalence is approximately 1–2% [1]. The most common involvement of the nail is encountered in psoriasis among all skin diseases. The nail changes may be accompanied by the skin lesions, but in some patients they occur alone. Regarding the literature, the prevalence of the nail involvement is between 10 and 83% [2]. Isolated nail involvement is observed only in 1–5% of all psoriatic patients [2, 3]. There is no difference between the genders considering the prevalence of the nail involvement. The incidence of the nail involvement in children is between 7 and 17%. The cutaneous psoriasis has usually a more severe course in patients with the nail involvement [1]. The changes affecting the nails are encountered in 90% of the psoriatic patients during their lifetime. The prevalence of the nail psoriasis is higher in patients with psoriatic arthritis. The nail involvement is between 75 and 86% in patients with arthropathic psoriasis [4]. It was reported that nail psoriasis is more common in hands compared to the feet. The nail involvement in psoriasis is concomitant with insertion points of tendons and ligament inflammation. Several studies focused on the co-occurrence of nail involvement, and psoriatic arthritis confirmed the anatomical connection between the nail matrix and the enthesis of the distal interphalangeal (DIP) joint extensor. In the light of these observations, it is believed that the nail lesions are caused by a reaction, which is developing as a reaction to the abnormal tissue stress and inflammation in the nail-joint region, and not as an autoimmune response [5]. Gupta et al. investigated the toenails of 561 psoriatic patients and determined nail disorders in 47% of them [6]. Larsen et al. determined nail changes in 82.3% of 79 psoriatic patients and Salmon et al. in 78.3% of 106 psoriatic patients [7, 2]. The nail lesions emerge usually 10 years later than the skin lesions. This explains why nail psoriasis is less common in children.
The pathophysiology of nail psoriasis was first described by Nardo Zaias in 1969 [1]. The etiology of psoriasis is not fully elucidated yet. The genetic susceptibility may play a role, but also environmental factors, drugs, infections, trauma, and psychogenic factors may trigger the disease.
The role of genetic factors has been a matter of research in the past decades. In his study, Lomholt demonstrated the presence of psoriasis at least in one of the first- and second-degree relatives of 91% of the psoriatic patients [4].
Genome-wide association studies have identified nine chromosomal loci (PSORS1 through PSORS9) that can be linked to psoriasis. Human leukocyte antigen (HLA)-Cw6, involved in antigen presentation, seems to be a susceptible allele located on PSORS1. HLA-CW6 allele is directly associated with the genetic base of the disease, and it is a major region leading the immunopathogenetic model. The HLA-CW 602 allele, which is localized in this locus, has a significant co-occurrence pattern with psoriasis. Other candidate genes, which may be related to psoriasis, are HLA-C, corneodesmosin, and HCR. Studies showed a co-occurrence with PSORS1 gene on the chromosome 6p12. However, HLA-C seems to be a gene marker rather than an etiological factor. In cases, in which there is a co-occurrence with HLA antigens, the rates of the nail involvement and arthritis are higher than the other types [8].
The tissue reaction seen in psoriasis involves a complex immunological reaction, which ends up with epidermal hyperproliferation along with severe inflammation and abnormal keratinocyte differentiation. The activation of the keratinocytes and dendritic cells follows particularly the activation of the T cells, which migrate to the skin. Certain functional T-cell subpopulations like Th1 and Th17 emerge under the influence of some cytokines like interleukin (IL)-12 and IL-23. These mediators stimulate the secretion of pro-inflammatory cytokines like the tumor necrosis factor-alpha (TNF-α), IL-17, IL-20, and IL-22. The secretion of the adhesion molecules and other mediators aggravates the inflammatory process in psoriasis. As a result of this cascade, neutrophil migration emerges, which ends up with the development of the epidermal microabscess. The increase of the proliferative activity and the abnormal maturation of the keratinocytes lead to hyperparakeratosis, which is characteristic for psoriasis. Studies showed that TNF-α, nuclear factor kappa B, IL-6, and IL-8 were increased in the affected nail tissue [8, 9].
It is believed that certain fungal infections like
The factors affecting the onset and the exacerbations of the disease vary from person to person. Trauma is among the factors, which trigger psoriasis. These factors are radiation (UV, X-ray), dermabrasion, burns, tattoos, vaccines, and inflammatory skin diseases [11]. It is well-known for a long time that infections may trigger and exacerbate psoriasis. Particularly, group A beta-hemolytic streptococci,
Drugs currently known for affecting psoriasis are the following: beta-adrenergic receptor blockers, non-steroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, tetracyclines, lithium, and interferons. Certain topical antipsoriatic agents like tar and anthralin may sometimes cause exacerbations in patients, who are in the active stage of the disease [16]. The relationship between the climatic features and psoriasis is well-known. In some patients, the lesions may be aggravated by the sunlight [17, 18]. The relationship between psoriasis and obesity was first reported by Lindegard [19]. Several studies showed that obesity is a risk factor for psoriasis. The demonstration of the pro-inflammatory character of obesity and the action of the adipose tissue like an endocrine and immune organ explained its role in psoriasis. Weight loss and diet restriction decrease TNF-α and IL-6 concentrations and consequently decrease the oxidative stress. It was reported that high-calorie diets and some foods that contain PUFA, such as nuts and fish, increase the severity and incidence of psoriasis. Therefore, it is believed that low-calorie diets may contribute to the remission of the disease [19]. Some studies reported that particularly smoking and alcohol had a correlation with psoriasis [12].
The nail folds are soft tissue structures that protect the lateral and proximal edges of the nail plate. The nail originates from the matrix and is attached to the nail bed and ends up with a free margin at the distal side. The term “nail units” comprises all nail structures and involves nail fold, eponychium, paronychium, hyponychium, nail bed, and nail plate with proximal and lateral nail folds and soft tissue structures [20, 21, 22, 23].
The main findings of the nail psoriasis are pitting, onycholysis, thickening of the nail plate, oil-drop discoloration on the nail bed, transverse ridges, Beau’s lines, splinter hemorrhages, subungual hyperkeratosis, and psoriatic paronychia [24].
The histopathological features of the nail psoriasis are neutrophilic inflammation, psoriasiform hyperplasia, and dilated and inflamed capillaries. The granular layer of the hyponychium disappears in the psoriatic nail, and a granular layer emerges in the nail matrix and nail bed. The hyperkeratosis is usually mild or moderate. Spongiosis is common. Parakeratosis foci may emerge on the dorsal, medial, or ventral segments of the nail plate and may cause pitting, leukonychia, and onycholysis. Before the histopathological diagnosis of the nail psoriasis, a differential diagnosis regarding onychomycosis with the help of the Periodic acid Schiff stain is recommended [25].
In the finger nail psoriasis, the findings by order of frequency are pitting, red-oily spots, onycholysis, subungual hyperkeratosis, and splinter hemorrhage. In the toenail psoriasis, the common findings are subungual hyperkeratosis and diffuse yellow-brown discoloration in the nail plate, onycholysis, and splinter hemorrhage [26, 27].
Splinter hemorrhages develop as a result of the erythrocyte extravasation from the dermal ridges located between the epidermis and the nail plate. This finding is similar to the Auspitz phenomenon in the skin. The “Auspitz sign” refers to the bleeding that can occur when the surface of a scaling rash has been removed. Onycholysis is defined as the detachment of the nail plate from the nail bed. The detachment area has a whitish appearance due to the air accumulation. The onycholytic area can be distinguished from the normal nail with its erythematous appearance. Onycholysis and subungual hyperkeratosis are predictors of the hyponychium psoriasis [26]. Pustular psoriasis in the nail bed and nail folds, nail loss (anonychia), onychomadesis, and absence of the nail growth are other findings in the psoriatic nail [20].
Psoriasis in the proximal nail fold: The cuticle is damaged, and there is a typical appearance of the chronic paronychia along with the erythema, squam, and edema in the proximal nail fold. Hyponychium involvement causes subungual hyperkeratosis and onycholysis [29].
Several numeric scales were developed to determine the numeric equivalent of the response to the treatment of psoriasis. These numeric scales enable an easier follow-up of the disease and of the response to the treatment. The Nail Psoriasis Severity Index (NAPSI) is a scoring system developed by Riche and Scher in 2003 [30]. According to this system, the nail matrix findings (pitting, leukonychia, red spots in lunula, increased friability of the nail plate) and the nail bed findings (onycholysis, splinter hemorrhage, oil drop, and nail bed hyperkeratosis) are scored as follows: If any of these signs is present in all four quadrants, a score of 4 is given. A score of 0 represents no signs in any quadrant. Each nail is evaluated for a matrix and a nail bed score of 0–4. They are combined to yield a maximal score of 0–8 for each nail. [26] After the scoring is completed, the sum of the scores is recorded as the NAPSI score. The NAPSI scores calculated for each nail are summed up to find the total NAPSI score. The single nail score can be between 0 and 8 and the total score between 0 and 160. Regarding the Cannavo’s scoring system, the nail findings are scored between 0 and 3, and the scoring is done according to the presence or absence of the findings [31].
The modified NAPSI, which is described by Parrish et al., is based on the scoring of the common findings [32]. The scoring is done between 0 and 3 according to the number of pitting. The modified NAPSI score for 1 finger can be between 0 and 14 and for 10 fingers between 0 and 140 [33].
As the nail involvement pursues skin psoriasis, its diagnosis is rather easy. However, 5% of the cases are isolated nail psoriasis, and the diagnosis may become difficult. Like in the skin, biopsy has a diagnostic value. Biopsy sampling should be taken from the proximal segment, and it should enclose partly the subungual soft tissue to detect the matrix involvement [34].
Except for biopsy, dermoscopy, and videodermoscopy may support the clinical findings and thus the diagnosis. Videodermoscopy provides a 1000x higher magnification compared to the dermoscopy, and the images can be examined on a monitor. It is beneficial particularly for the observation of the capillaries in the hyponychium. The capillaroscopy is used to determine the dilated capillaries in the proximal nail fold. The vascular structures may be better visualized with the confocal microscopy. High-frequency ultrasonography (USG) can be useful only if performed by experienced hands. The increase in the blood flow and the thickening of the nail bed can be determined with the Doppler USG. The optical coherence tomography is a noninvasive imaging method and has a relatively higher resolution and thus is effective in the detection of the changes in the nail plate and vessels [35].
The nail psoriasis is usually diagnosed with the help of the clinical findings. The differential diagnosis between nail psoriasis and other diseases, which causes nail dystrophy (e.g., onychomycosis), can be done with biopsy and histopathological examination. Klaassen et al. reported that the prevalence of onychomycosis is higher in psoriatic patients compared to the patients without psoriasis [36].
Several diseases affecting nails can be confused with the psoriatic nail. Following conditions should be considered during the differential diagnosis: trauma, onychomycosis, pityriasis rubra pilaris, palmoplantar keratoderma, chronic venous stasis, many drugs, alopecia areata, eczema, lichen planus, Darier disease, pachyonychia congenita, and Hailey-Hailey disease [37].
Besides, toenail dystrophy is particularly more common in elderly people. Peripheral artery disease, chronic venous stasis, peripheral neuropathy, and certain drugs (beta-blockers, lithium, interferon-α) should also be considered during the differential diagnosis [38].
Pitting, which can be encountered in alopecia areata, lichen planus, and eczema, is one of the most common nail findings in psoriasis, and it is relatively more deep-seated in psoriasis compared to other diseases. The dorsal pterygium and longitudinal fissures are rather typical findings in lichen planus [38].
Onycholysis, which is another typical finding in the nail psoriasis, emerges first in the distal segment of the nail and extends in time to the proximal segment. This finding can be encountered also in nail traumas, fungal infections, and thyroid disorders [39].
Beau’s lines characterized by the transverse lines on the nail can emerge in Raynaud’s disease as a result of the exposure to the cold [40].
As the splinter hemorrhages, which progress with linear spotlike bleedings, can also emerge in vasculitis, bacterial endocarditis, and traumas. Therefore, they should be considered during the differential diagnosis [1].
Regarding the treatment of nail psoriasis, the protection of the nail from the external physical and chemical factors is critical. Manicure and pedicure should be avoided due to the risk of the Köbner reaction.
As nail is a slow-growing cutaneous appendage, a long-term treatment should be considered in the nail psoriasis. The outcome of any treatment cannot be evaluated before 3–6 months, and the achievement of a maximum therapeutic success can be evaluated only after 1 year or longer [42]. There are various alternatives for the treatment. The decision on a treatment method depends on several factors such as the severity of the nail involvement and its effects on the quality of life, presence of other skin lesions, presence of psoriatic arthritis, comorbidities, occupation, age, patient’s preferences, potential risks, and cost.
Although the nail psoriasis is usually resistant to the topical treatments, it should be the first choice if the skin is also involved. As the applied drug can hardly penetrate into the matrix in the presence of subungual hyperkeratosis and pitting, resistance to the treatment is the rule. Nevertheless, at least a 3-month application is needed to observe the effect of the topical antipsoriatic agent [43].
The most common treatment agents in the nail psoriasis are the topical corticosteroids. If the matrix and nail bed are involved, high-potency topical steroids are applied once or twice a day to the nail plate and proximal nail fold. All high-potency steroids may cause atrophy and hyperpigmentation if they come into contact with the skin during the treatment [44]. In the recent years, studies showed that topical opaque nail polish formulations, which contain 8% clobetasol propionate, were more effective than the steroids. It was reported that this product, which was safe, effective, and easily applicable due to the cosmetic formulation, did not cause periungual skin atrophy like topical cream forms [45, 46].
Topical calcipotriol is used in the treatment of the chronic plaque psoriasis. It is effective on the thickening of the nail plate and subungual hyperkeratosis. Main side effects are local skin irritations. Vitamin D3 and its analogs are well established in the therapy of psoriasis vulgaris [47].
One study conducted on subject groups showed that topical 5-FU solutions with 20% urea were effective on pitting, subungual hyperkeratosis, and oil-drop appearance [48].
It is a calcineurin inhibitor, and cyclosporine is good effect on psoriasis. Although topical use of cyclosporine in nail psoriasis has been discussed, only limited success could be achieved with 10% oily preparations [49].
Anthralin is an effective treatment of skin lesions in psoriasis. In one uncontrolled study, anthralin in a Vaseline-containing ointment was applied to 20 psoriasis patients with nail involvement. Therapy was applied to the affected nail bed once daily, and 60% of the patients showed good improvement of onycholysis. The most important complication of this treatment is pigmentation [50].
Tazarotene is a synthetic retinoid with anti-inflammatory and antiproliferative actions on keratinocytes. Gel formulations of 0.1% tazarotene were used in the topical treatment of the nail psoriasis, and varying results were achieved. It may cause certain side effects like erythema and burning sensation in the periungual region [51].
The perilesional injections constitute another form of the local treatment (Figure 1). During this treatment, a maximum efficacy is obtained with a minimum dose of the drug, which is applied into the lesion. Intralesional injections of corticosteroids are the most common method. As injections into the matrix and under the nail bed are painful, local anesthesia is necessary. A proximal finger block or hand and wrist block can be preferred. Cold application to the proximal nail fold before the injection may reduce the pain. The injection is usually done with a 30G needle. 0.05–0.1 triamcinolone acetonide suspension is injected into both sides of the proximal nail fold monthly for 6 months. This treatment is most effective on salmon spots and subungual hyperkeratosis [52]. Possible complications of this treatment are subungual hematoma, transient nail dystrophy, atrophy of the terminal phalanx bone, extensor tendon rupture, and epidermoid inclusion cysts [53].
(a) Subungual hyperkeratosis with pitting in fingernails before the MTX intramatricial injection. (b) Improvement of nail dystrophy was observed after 6 months of follow-up.
In nail psoriasis, methotrexate (MTX) and cyclosporine may be applied to the proximal fold with an intralesional injection technique. In patients with nail psoriasis, who had pitting and subungual hyperkeratosis on a single nail, Sarıcaoğlu et al. applied 2.5 mg MTX to two lateral points of the proximal fold once weekly for 6 weeks and observed no recurrence during the 2-year follow-up period [54]. Mittal et al. conducted a study on 20 patients with nail psoriasis and compared the efficacy of intramatricial triamcinolone acetonide, methotrexate, and cyclosporine injections and found out that methotrexate and corticosteroid had comparable efficacies. They also reported that the side effects of MTX were less frequently and cyclosporine was less effective and caused pain, which lasted a couple of days [55].
The combination of oral psoralen and UVA, which is also called PUVA is a photochemotherapy method. It was reported that it provided successful results in patients with nail bed involvement, which ended up with onycholysis and salmon patches. However, it was also stated that it was not effective on pitting, which is an indicator of matrix involvement. Marx and Scher conducted a study on ten patients and showed that PUVA improved all nail lesions except pitting in 95% of the patients [56]. Except for oral psoralen, local PUVA treatment with the topical 1% 8-methoxypsoralen is an alternative for the treatment of the psoriatic nail [57]. As the penetration of the narrow band UVB is rather superficial, it is not an effective option for the palmoplantar psoriasis lesions and nail involvement [58].
Superficial radiotherapy is the application of the electromagnetic radiation on the skin surface. It is rarely used in the treatment of psoriatic nail. It was reported in one study that it decreased the nail thickness in the patients with subungual hyperkeratosis [59]. Grenz rays and electron beam therapy are low-voltage radiation treatments, which do not penetrate the subdermal structures. In patients older than 30 years, Grenz rays [maximum 10Gy (1000 rad)] to each area can be applied. If it is applied to healthy areas and surrounding skin, it may cause hyperpigmentation and malignant skin tumors in the late stage [60].
As angiogenesis is considered as a pathogenetic factor for psoriasis, pulsed-dye laser (PDL) was used in several studies to treat nail psoriasis. The target of the laser therapy is the matrix and the dilated capillaries in the nail bed. A PDL laser at wavelength 595 nm and with a spot size of 7 mm was usually preferred. It was observed that the pain increased along with the pulse duration [61].
Several systemic agents are used for the treatment of the nail psoriasis. The most commonly used drugs are MTX, retinoids, and cyclosporine. However, they are usually preferred in patients with severe dermal and articular involvement. They are not the first choice for psoriasis, which affects only nails.
Acitretin is effective on the thickening of the nail plate, subungual hyperkeratosis, Hallopeau acrodermatitis, and the nail involvement in pustular psoriasis. Its usual dose is 0.5–1 mg/kg/day. Although etretinate decreases significantly the thickening of the nails, it was reported that it increased pitting and onycholysis [43, 62].
Methotrexate (MTX), which is an antimetabolite agent, slows down the nail growth and therefore delays the healing process in the nail lesions. Intralesional MTX injections are preferred to the oral administration due to the side effects like hepatotoxicity and pancytopenia, and studies reported improvement in the affected nail with intralesional injections [54, 55]. MTX is used in the Hallopeau acrodermatitis and the affected nails in pustular psoriasis, which is resistant to the topical treatments [49].
The calcineurin inhibitor cyclosporine A is another systemic antipsoriatic agent and has powerful immunosuppressive activity. Its positive effect on cutaneous psoriasis and nail psoriasis was clearly demonstrated in both uncontrolled and comparative studies [63]. Its recommended dose is 3–5 mg/kg. Cyclosporine A treatment is limited to 6–12 months due to the potential of serious side effects such as kidney function disorder and arterial hypertension.
Fumaric acid esters can also be used in the treatment of psoriasis. Its efficacy on the affected nails was demonstrated in a case report [64].
Leflunomide is an antirheumatic agent effective in psoriatic arthritis. It was also reported that it is effective in nail psoriasis [65].
Apremilast is an oral phosphodiesterase-4 inhibitor, which decreases the expression of various pro-inflammatory mediators. Its mechanism of action is related rather to anti-inflammatory activity than the immunosuppressive activity. It has a preferable side effect profile [66]. Studies reported that it provided improvement in the skin and nail psoriasis after a 32-month treatment [67].
Tofacitinib is an oral Janus kinase inhibitor, which exhibits its effects through the JAK–STAT pathway. It was demonstrated that it was effective on the nail lesions of psoriasis and alopecia areata [68].
As there are only a limited number of studies focused on the use of biologic agents in the nail psoriasis, experience about their efficacy is limited. The number of the studies focused on the use of the biologic agents in the treatment of psoriatic nails will increase depending on their increasing use in psoriasis and psoriatic arthritis. In the studies, which compared the biologic agents with the conventional systemic drugs, it was shown that the efficacy of the biologic agents was lower and the improvement in the NAPSI score started approximately after 47 months [69]. Their high cost is another factor, which limits their usage.
Infliximab is a mouse-derived chimeric monoclonal antibody, which antagonizes membrane-bound and soluble TNF-α, and it is the most fast-acting TNF-α inhibitor. The recommended dose is 5 mg/kg IV at 0, 2, and 6 weeks and thereafter once every 8 weeks. In a study conducted on 38 patients, who had nail psoriasis, an almost complete improvement was achieved after 38 weeks [70].
Adalimumab is a human monoclonal IgG1 antibody against TNF-α. It has a similar mechanism of action to infliximab, but it does not increase the incidence of onychomycosis like infliximab. Van den Bosch et al. reported a 20% improvement in the NAPSI score with a dose of 40 mg/week after 20 weeks [71].
Etanercept blocks TNF-α depending on the fusion between the Fc portion of the IgG1 antibody and TNF receptor. In a randomized study, 564 patients with moderate psoriasis and nail involvement were treated with etanercept, and the NAPSI score decreased about 51% after 54 weeks [72].
The new-generation biologic agents inhibit interleukins, which affect the psoriatic process. However, their immunosuppressive efficacy is weaker than the TNF- α inhibitors. The IL-17 inhibitors secukinumab, ixekizumab, and brodalumab were recently introduced in the therapy. Ustekinumab is a monoclonal antibody targeting the p40 subunit of IL-12/23. Patsatsi et al. administered 45 mg ustekinumab at the baseline, in the fourth week and afterwards in every 12 weeks, and reported that the NAPSI scored was declined from 73 to 0 after 40 weeks [73].
Biologic agents and interleukin inhibitors are not the first choices in the treatment of the nail psoriasis due to their side effect potential. The treatment should be started with topical agents. The conventional systemic antipsoriatic agents should be administered if there is no improvement after 4–6 months with topical agents. The biologic agents should remain as the last choice.
The nail psoriasis is considered as the precursor of severe inflammatory joint disorders, and it has a positive correlation with the joint involvement [30]. The presence of the joint and nail symptoms may indicate the severity of psoriasis and affect the management of the disease. Therefore, in order to prevent the progressive joint damage, the nail findings should be considered as the early symptoms of psoriatic arthritis especially in patients with skin psoriasis.
Psoriasis vulgaris is an inflammatory skin disease involving the skin, nails, and joints. Nail changes are frequent in psoriasis and being found in up to 60% of patients. Patients with nail psoriasis can develop a wide variety of nail changes, such as pitting, onycholysis, subungual hyperkeratosis, and splinter hemorrhages. Nail psoriasis is also strongly associated with psoriatic arthritis. Nail psoriasis results from psoriatic inflammation involving the nail matrix or nail bed. As the nail involvement pursues skin psoriasis, its diagnosis is rather easy. However, 5% of the cases are isolated nail psoriasis, and the diagnosis may become difficult. Onychomycosis should be distinguished from nail psoriasis in the differential diagnosis. The decision on a treatment method depends on several factors and the severity of nail psoriasis.
Atmospheric plasma spray (APS) appeared after Second World War as a surface finishing technology. It is now widely used to deposit thick coatings (from hundreds of micrometers up to a few millimeters) in a substrate to protect in aggressive environments or to improve its function. APS is commonly used in many industrial sectors, including aeronautics, energy, automotive, mining, biomedical, and electronics [1]. The synthesis of coatings by APS technique occurs by stacking the lamellae resulting from the impact, flattening, and solidification by the colliding molten particles [2]. The material precursor of the coating may be in the form of powders, wires, melt materials, solutions, or suspensions [3]. APS can be applied to a wide variety of materials, including metallic and refractory materials. In this technique, a carrier gas conducts the material particles by injecting them at high velocity through the plasma, where they are molten or partially molten, taking the form of droplets that settle and solidify on the surface being coated. The material to be deposited is carried in the form of a solution or powder to a torch with sufficient enthalpy to generate a plasma jet to melt the particles [4, 5]. The parameters of the plasma spraying process, as well as the characteristics of the precursor (solids or liquids) used for coating, influence the properties of the deposited materials [6, 7]. Characteristics of the coatings such as porosity, atomic structure, roughness, cohesion, and adhesion are fundamentally related to the interaction of the precursor with the plasma jet [8, 9].
\nThe main driving force for the manufacture of thick coatings by APS is their high deposition rate; a few kilograms per hour of raw material can be processed with torches, with a power level of a few tens of kilowatts at a relatively low operating cost. Plasma spray is probably the most versatile of all thermal spray processes because there are few limitations of materials that can be sprayed or on the material, size, and shape of the substrate [4]. The coatings are characterized by a highly anisotropic lamellar structure. In addition, stacking of the particles generates specific interlamellar characteristics throughout the structure, especially voids, which may connect or not through the particles encountering the coating thereafter.
\nConventional plasma spray processes (CPS) use powders with a particle size ranging from 10 to 100 μm. Typically, these result in coatings formed by lamellae of micrometer thickness and diameter of a few tens to hundreds of micrometers. The interest in developing and studying plasma spray coatings that have nanometric and non-micrometric characteristics has been the focus of the last 30 years. This interest stems from improved nanometric coating properties compared to micron size [10]. Reducing the structure to the nanoscale improves hardness, elasticity modulus, and thermal conductivity of the coating as well as reduces defects (voids). One of the main drawbacks in the processing of nanometric particles by APS is the difficulty in injecting them into the high enthalpy jet core. In this case, it is necessary to adjust the injection angle and the transport gas flow of the material in such a way that it is not so intense that it crosses the plasma jet or so smooth that it cannot reach the center of the jet [11]. For this reason, new plasma torches have been developed using axial injection, which is a method by which the material is injected directly into the plasma torch, ensuring that all material is processed. This feature assists in the processing of materials with nanometric magnitude, which can mainly be dispersed in liquid medium to facilitate loading and processing [12].
\nCoatings are applied to substrates (metallic, ceramic, polymeric, or composite) to incorporate to their surface one or more characteristics or qualities that they do not originally possess, to maximize the useful life of a material/equipment, by increasing its resistance to corrosion, wear, oxidation, thermal protection, or gaining efficiency, depending on its application [13].
\nThe improved performance of a given component means, in addition to a providing greater longevity, reduces costs related to the project and subsequent maintenance. In this context, the choice of material is as important as the design of the final product. New materials have been developed for the most diverse applications, which are subjected to extreme conditions, such as in high temperatures, abrasive wear, oxidizing and corrosive atmospheres, or even in a combination of these conditions. However, it is impossible for a single material to meet all these requirements, even for special alloys. This fact contributes to increased demand for the applied coatings, which can be deposited in substrates of most materials and with properties adjusted to specific necessities [14].
\nCoatings can be divided into thin and thick films. The thin films have thicknesses up to 20 μm and are typically synthesized by chemical vapor deposition (CVD) or physical vapor deposition (PVD). However, most thin film deposition processes require reactors that work at low pressures, increasing process costs and limiting the dimensions and geometry of the substrate to be coated. Another category of coatings are thick films, which have thicknesses greater than 20 μm, or even a few millimeters. These are applied when the performance of the protection depends directly of the thickness of the coating, for example, coatings applied in aerospace devices, which are subjected to severe erosion, corrosion, and oxidation environments. The deposition methods of thick films include chemical/electrochemical plating, brazing, solder overlays, and plasma spray that are performed at atmospheric pressure [15].
\nThe evolution of these coatings is often the limiting factor in the development of a technology. For example, the input temperature of the first gas turbine (1933) was 400°C. In 2011, the Japanese company Mitsubishi Hitachi Power Systems developed an advanced gas turbine with input temperature of 1600°C, and efforts are under way to raise this temperature to 1700°C [16]. Initially this evolution occurred through the development of super leagues and the consolidation of these by directional solidification and monocrystals. The construction projects also promoted advances, mainly in the cooling through internal channels of the parts in the hot section of the turbine, where cold air is injected. However, the greatest advance in the temperature operation of these thermal machines occurred with the application of thermal barrier coatings (TBC), which are applied with APS process [17]. The TBCs (Figure 1) are composed of three layers: the first layer is a metallic layer (bond coat), which provides resistance to oxidation and corrosion, and has an intermediate coefficient of thermal expansion between the substrate and the ceramic layer. The second is a layer of oxide (thermal grown oxide (TGO)) that appears, along the thermal cycles, in the interface between the metallic layer and ceramic, due to the oxidation of the metallic layer. The third layer is a ceramic (top coating), which is responsible for the durability of TBC as a whole, as it promotes thermal insulation and protects the metallic layer and substrate from exposure to hot and oxidizing gases from combustion.
\nThermal barrier coatings applied on turbine blade.
Atmospheric plasma spray belongs to a family of processes called thermal spray. Thus, the thermal spray process encompasses a set of processes where sprayed materials (powder on the order of μm or solutions in the form of suspensions, solutions, sol-gel or colloids) are heated (to be melted or semi-melted or partially evaporated) and accelerated against a substrate to form a coating, which may be lamellar or columnar. The thermal source may be by combustion of hydrocarbons or electric arc. The plasma spray process consists of forming the plasma jet, which interact the particles with the plasma. The plasma jet provides thermal and kinetic energy to the material to be deposited by directing it to a substrate to produce coating [18].
\nIn the deposition process of plasma spray, the substrate is usually prepared to receive the coating by performing cleaning procedures (removing oils and greases), inducing surface roughness, preheating, and controlling movement. The adhesion of the particles to the substrate and between the lamellae strongly depends on the preparation of the substrate, preheating temperature, and morphology and composition of the material. Preheating, generally performed with the plasma jet itself, is a key point and has to be controlled according to the size and thickness of the part to be coated. Substrate and coating temperatures, either for preheating or during deposition, are linked to the residual voltage distribution, which is a controlled parameter [19].
\nAnother important step in the deposition process is the material injection, which is mainly influenced by the injection method, feed system type, and the characteristics of the material. The injection method may be radial or axial (Figure 2).
\nRadial and axial material injection.
In the radial injection method, the parameters to be optimized primarily include the flow of the loading gas and the position and geometry of the injector. The point is to ensure that the momentum density of the particles (product of the specific mass by velocity) is equal to the momentum of the plasma jet at the point of injection. The radial injection method has restrictions and some negative aspects, such as the heterogeneity of the heating and the acceleration of the particles, according to their granulometric distribution; and the difficulty of processing precursors with high particle velocity, because of the low plasma-particle heat transfer efficiency. The APS process should attempt to maximize the residence time of the particles in the plasma jet. To overcome the residence time problem, small amounts of hydrogen are added to the working gas to increase the enthalpy of the plasma jet; however, this also increases the electric arc oscillation [20].
\nAnother method is axial injection, which is used in flame spray, high velocity oxygen fuel (HVOF), induction (RF) plasma torches, and some plasma torches from a direct current source (DC). In axial injection the distribution of particles are keeping more concentrated, and the interaction time between plasma-particle is greater, which ensures a better processing of the material. With higher heat transfer efficiency between plasma/particle, there is a lower incidence of unmelted particles that may weaken the coating. The problems are the clogging of the nozzle and the operational stability of the plasma torch. Thus, there is a need to develop new plasma torches that operate better with this injection method.
\nCaliari et al. [21] presented a plasma torch with axial material injection, which can produce high velocity plasma jet (>1200 m/s). The materials are injected into the back of the plasma torch (Figure 3), ensuring that all material passes through hot area near of the electric arc, which is the hottest part of the torch, thereby obtaining a lower rate of unmelted particles. The process called “High Velocity Plasma Spray” has a stable torch that operates with low currents between 50~150 A and voltage of 240~360 V, unlike conventional torches, which operate at low voltages and up to five times higher current values. This differential guarantees lower erosion of the electrodes, and its geometry provides better use of the energy with close to 80% efficiency of electric to thermal energy conversion. This high efficiency enables the processing of metallic and ceramic materials, both solids or liquids precursors (suspensions or solutions) [12].
\nHigh velocity plasma spray with axial injection presented by Caliari et al. [
The principal components of the plasma spray systems are (see Figure 4): plasma torch, process control, power supply, gas supply, material feeder (powder or liquid), and dynamic sample holder. The main element of a plasma spray system is the plasma torch, which is responsible for converting electric energy into thermal energy, necessary for material processing. A process control console allows adjustment of the operating parameters, i.e., the control of arc current, arc ignition, plasma gas flow rates, material and carrier gas flow rates. The additional systems necessary for operation are the plasma gas supply system, the power supply system (including the high-frequency starter unit), the high-pressure cooling water system, and the material (powder or solutions) feed system. The systems also have mechanical equipment (sample holder) to control relative motion between the plasma torch and the substrate.
\nPlasma spray system: (1) gas supply, (2) material supply, (3) control panel, (4) DC power supply, (5) plasma torch, (6) sample holder, and (7) cooling system.
Plasma torches are devices used to stabilize an electric discharge with gas flow and to convert electric energy into thermal energy. In a thermal plasma torch, operating from an electric discharge, the high enthalpy plasma results from the interaction of the gas with the electric arc. The study of electric discharges in gases and plasma jet formation involves the phenomena of gas dynamics, mass and heat transfer, and electrophysical and aero-thermodynamic processes [22].
\nPlasma torches can be classified according to the source of electrical energy (electric arcs generated from a direct current, DC, or alternating current, AC source) or by the type of discharge used (transferred or non-transferred arc). Transferred arc torches have one of the electrodes external to the torch body, through which the arc extends from the inner electrode. Due to the electric current transport in the generated plasma jet, this configuration forms higher enthalpy plasma jets than non-transferred arc torches. For non-transferred arc torches, both electrodes are positioned inside the torch. Thus, the electric arc remains confined in the discharge channel and the generated plasma jet does not carry electric current [23].
\nIn the design of a thermal plasma torch, one should consider the type of electric power source, the enthalpy and temperature of the plasma jet suitable for the application, the choice of appropriate materials, the implementation of arc stabilization, and control system for the length of the electric arc (if any). In the case of non-transferred arc torches, the stabilization of the electric arc can be done with a gas vortex (that forms the plasma), discharge chamber wall, magnetic field and its combinations. In most cases the arc self-fixation method, based on shunting effect, is used. In addition, to fix the arc length, a magnetic field generated by one or more solenoids may be used. In this case, the radial part of the electric arc moves axially to the place where the axial component of the magnetic field is greater. Moreover, the interaction between the magnetic field and the electric arc current produces the driving force that displaces the arc tangentially, which avoids the positioning of the arc spot at a fixed point, thus reducing erosion of the electrode [24].
\nThe materials applied in plasma torches, especially those exposed to the electric arc, are submitted to a high thermal load in the place of fixation of the electric arc, that destroyed the electrode. Properties such as specific heat, melt temperature, coefficient of thermal expansion, thermal conductivity, work function, and electrical resistivity should be considered in the choice of these materials.
\nFigure 5 presents a generic scheme of a non-transferred arc plasma torch with the electrodes (cathode, 1, and anode, 2) arranged concentrically and between the electric arc [25]. To stabilize the arc, the gas vortex formed by the vortex camera (4) installed between the insulated electrodes (3). To fix the arc in the anode surface, a magnetic field produced by the solenoids (7) is applied. The electrodes are subjected to high heat flows, and to maintain their functionality, they are cooled by a continuous flow of water through the cooling jacket (6).
\nDiagram of a linear thermal plasma torch, (1) hot cathode, (2) anode, (3) electrical insulation, (4) vortex chamber, (5) gas inlet, (6) cooling water inlet and outlet, and (7) solenoid.
Although there is a great diversity of plasma torch designs, their principle of operation is based on the generation of plasma flow due to forced convective interaction of a gas with the electric arc, established between two electrodes [23]. The application of a high frequency and high voltage at electrodes allows transform the electrical insulator gas into conductor and form an electric conductor channel. The high temperature in the channel, caused by Joule effect reduces the electrical resistance of the gas, due to an increase in the number of charged particles, thus allowing the passage of high current by the gas, establishing the arc. The electrons, accelerated by the electric field in the region between the electrodes, transfer their kinetic energy to the heavy particles through collisions, raising the temperature of the gas, dissociating its molecules, and exciting and ionizing the atoms, which are factors that contribute to the increased degree of plasma ionization. The electric field generated near the cathode accelerates the positively charged heavy particles, which collide against the surface of the cathode. As the mobility of heavy particles is much smaller than that of the electrons, an excess of positive volume of charged particles is formed in the region near the cathode. This phenomenon increases the electric field in the vicinity of the electrode, which in turn, facilitates the emission of the electrons of the electrode (due to the tunneling and field effect) by increasing the density of electrons in the plasma [23]. The constriction of the arc in the cathode (another important phenomenon) increases the current density and, respectively, the thermal flow to the surface of the cathode, increasing its temperature and the emission of the electrons by thermionic effect.
\nThe input parameters and the operational characteristics of the plasma spray process are described in Table 1 [15]. The input parameters are controlled during the experiment and, therefore, are independent variables. However, the operational characteristics often depend on the combination of the input parameters, thus, they are dependent variables.
\nThe main parameters and characteristics of the APS process [15].
To obtain operational control of the plasma torch, it is necessary to know the operating range of the input parameters in order to stabilize the electric arc. Hence, one must know the current-voltage characteristics (SVS) (voltage—versus current for different flow rates) of the electric arc, (CVC), which usually influenced by the characteristic curve of the electric power source. According to Heimann [26], the most common gases used in plasma torches are nitrogen, argon, helium, and hydrogen. Gas flow and its chemical composition, current and outlet electrode (nozzle) design directly influence the energetic and kinetic characteristics of the plasma jet and its stability. The arc voltage, in turn, depends on the gas flow rate, plasma torch geometry and mode of arc stabilization. Thermal efficiency represents the ability to convert electrical energy into thermal one (enthalpy of the plasma jet). Part of the thermal energy is dissipated in the electrodes with cooled walls. In conventional plasma torches, the thermal efficiency is approximately 50% [15].
\nThe applications of atmospheric plasma spray technology have changed considerably since its beginning in the 1950s. The global pressures on prices have forced companies to face challenges in their manufacturing processes; they generally answer by an acceleration of production, increasing in throughput and consistency in quality of the coating. Also, plasma-sprayed coatings have to cover a greater demand of applications such as higher operation temperatures, wear and corrosion under extreme conditions, and longer life span of parts and devices. A potential response for coatings with improved properties is the deposition of coatings with finer microstructure, i.e., finer lamellae and smaller voids as well as coating with microstructure more resistant to mechanical and thermal stresses than the lamellar microstructure exhibited by conventional plasma-sprayed coatings. This requirement has led to the development of innovative plasma coating processes for producing coatings with grain size in the nanometer range while keeping the high deposition rate and flexibility of plasma spraying [27, 28]. The process uses the basic equipment of the conventional plasma spray process but the feedstock is a liquid suspension or a solution of chemical precursors instead of the conventional powder feedstock, which takes advantage of the high enthalpy content of the plasma jet to evaporate the spray material and then forms a coating by fine droplets and/or condensation of the vaporized material on the substrate [29, 30]. To form the coating with liquid precursors, these must be injected into the plasma region in smaller droplets (sprayed or atomized). Then the solvent is evaporated, forming the solid material, which is melted (or forms a shell) and accelerated towards the substrate, as shown in Figure 6. As all these steps occur almost instantaneously, the plasma generator must provide suitable energy to process the liquid precursor and form the material.
\nFormation of the material from a liquid precursor with low and high concentration of the material to be deposited.
Available since the 1990s, nanostructured materials are still considered a new concept that increase the performance of engineering components. Many studies have instigated the properties of nanostructured materials used in structural components and coatings. Ceramic materials gained attention mainly because they have greater hardness due to the smaller grain size, greater resistance to wear, and less incidence of defects [10, 31].
\nNanostructured coatings can be obtained by plasma spray processes using liquid precursors. Solid precursors (powders) with nanometric distribution have difficulty with fluidity between the feed line and the plasma torch, causing intermittent injection of the material. The fluidity problem is overcome by increasing the flow of the carrier gas; however, this causes the plasma jet axis to shift and produce a non-uniform coating on the substrate. Another factor is that the nanoparticle may not penetrate the center of the plasma jet by inhibiting fusion and acceleration processes towards the substrate to form the coating [5, 32, 33, 34, 35].
\nThe solution plasma spray technique allows the deposition of thick nanostructured coatings (Figure 7), without the need for a very sophisticated infrastructure. Expenditure on materials (liquid precursor) is much lower than on the powders. The flexibility to use different feedstock enables a variety of compositions of the liquid precursor to be exploited by adjusting its concentration according to the desired application.
\n(a) Top view of the coating, (b) nanostructure of coatings, and (c) particle measurements.
Biomaterials can be obtained with different techniques, thermal spraying shows significant advantages; in particular, the fact that the deposition and consolidation of the coating occur simultaneously without the need of a sintering treatment. Bioactive glasses are considered promising materials to be used as coatings onto implant devices, due to their high bioactivity [36, 37]. The use of solutions precursor instead of traditional thermal spraying feedstock provides unique properties, i.e., high purity materials (avoiding possible contamination from feedstock preparation steps), and nanostructured coatings with denser and more homogeneous microstructures [38].
\nSeveral efforts to use solution plasma spray process to fabricate superhydrophobic coatings have been reported [39]. Metals and metal oxides, as the most important and commonly used engineering materials, are hydrophilic for most part due to their high surface energy. There is immense interest in developing the ability to control the surface wettability of metals and metal oxides in order to improve their performance in corrosion resistance, friction reduction and efficiency in liquid transportation [40]. Xu et al. [41] presented superhydrophobic ceramic coatings with nano-sized hierarchical structure and high water contact angle, coatings were fabricated by a one-step solution precursor plasma spray process.
\nIn addition, plasma reactivity can be exploited to obtain a final coating with composition different from the original precursor. In the study presented by Miranda et al. [12], a plasma spray system with axial injection was used to deposit nanostructured coatings. Coatings with graded composition between SiO2/SiC (Figure 8) on carbon/carbon composites substrates were obtained.
\nSEM image of cross-section of sample and EDS results showing the composition of coating (A), interface (B), and substrate (C).
A relevant result, obtained during the analysis of the chemical and structural composition of the coating, was the SiC formation due to the reactions between the carbon and the liquid precursor (SiO) promoted by the plasma jet. These reactions are exemplified by means of Figure 9. The formation of SiC in the coating helps to protect the substrate because it reduces the permeability of oxygen, preventing its oxidation and, consequently, the loss of its structural characteristics. Although no coating adhesion tests were carried out, the higher SiC concentration at the substrate/coating interface indicates the occurrence of a chemical adhesion process of the coating [42]. Thus, at this stage of the deposition process, the composite is “doped” with a SiC layer and thus exposed to differentiated oxidation processes in relation to the original C/C substrate.
\nSiC formation in the deposition process [
The coatings aim at the environmental protection of carbon/carbon composite substrates of great application in the aerospace sector. The main tool of this system is the non-transferred arc plasma torch calibrated and specifically characterized by forming a high enthalpy and high velocity plasma jet, capable to processing precursors with high melt temperatures at atmospheric pressure. With these characteristics, adjusted to power systems, gas feed and liquid precursors, it is possible to obtain nanostructured coatings with low fraction of pores and inclusions.
\nIn processes using DC or RF plasma torches, typically the material is introduced into the plasma jet in the form of micrometric powders. They are accelerated due to moment transfer of the plasma jet and at the same time the process of heat transfer and mass begins. The residence time of the powder in the plasma jet, and consequently the efficiency of the process, depend on the particle’s speed and the flight distance. The process of forming nanostructured coatings relates to these factors, since particles within the plasma flame must remain a sufficient time for total evaporation of the liquid precursor and melt the particles or particle’s surface. The formation of nanostructures occurs with the rapid cooling of the vapor. It is important to point out that this process is most commonly observed in works that employ short-arc plasma torches transferred for better utilization of process energy [43, 44]. In these systems, the vapor cooling process is the main stage of nanoparticle formation. Homogeneous nucleation is facilitated by the combination of heating, evaporation, and rapid cooling, such as happens in a plasma reactor [45].
\nNanostructured materials have unique characteristics in relation to their mechanical and thermal properties, in addition to producing a lower index of defects and a lower porosity than coatings obtained in the traditional method using solid feedstock (which are limited to the size of the particle in flight). The use of atmospheric spray plasma systems is shown as an effective alternative to produce nanostructured and composite materials, which can be adjusted according to the need for application, as in the case of the use of liquid precursors. Therefore, it is necessary to advance the development of plasma torches capable of processing various types of materials to increase its range of application and consequently contribute to the technological advancement of materials processing.
\nThe authors acknowledge the financial support grant #88887.185537/2018-00 provided by the Coordination for the Improvement of Higher Education Personnel (CAPES) and the Technological Institute of Aeronautics (ITA).
\n"I work with IntechOpen for a number of reasons: their professionalism, their mission in support of Open Access publishing, and the quality of their peer-reviewed publications, but also because they believe in equality. Throughout the world, we are seeing progress in attracting, retaining, and promoting women in STEMM. IntechOpen are certainly supporting this work globally by empowering all scientists and ensuring that women are encouraged and enabled to publish and take leading roles within the scientific community." Dr. Catrin Rutland, University of Nottingham, UK
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\n\nOur platform – IntechOpen is the world’s leading publisher of OA books, built by scientists, for scientists.
\n\nOur reputation – Everything we publish goes through a two-stage peer review process. We’re proud to count Nobel laureates among our esteemed authors. We meet European Commission standards for funding, and the research we’ve published has been funded by the Bill and Melinda Gates Foundation and the Wellcome Trust, among others. IntechOpen is a member of all relevant trade associations (including the STM Association and the Association of Learned and Professional Society Publishers) and has a selection of books indexed in Web of Science's Book Citation Index.
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\n\nOur reach – Our books have more than 130 million downloads and more than 146,150 Web of Science citations. We increase citations via indexing in all the major databases, including the Book Citation Index at Web of Science and Google Scholar.
\n\nOur services – The support we offer our authors and editors is second to none. Each book in our program receives the following:
\n\nOur end-to-end publishing service frees our authors and editors to focus on what matters: research. We empower them to shape their fields and connect with the global scientific community.
\n\n"In developing countries until now, advancement in science has been very limited, because insufficient economic resources are dedicated to science and education. These limitations are more marked when the scientists are women. In order to develop science in the poorest countries and decrease the gender gap that exists in scientific fields, Open Access networks like IntechOpen are essential. Free access to scientific research could contribute to ameliorating difficult life conditions and breaking down barriers." Marquidia Pacheco, National Institute for Nuclear Research (ININ), Mexico
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