What are the common causes of finger and toe clubbing. How is clubbing diagnosed and what symptoms accompany it. When should you seek medical attention for clubbed digits.

Understanding Clubbing: A Sign of Underlying Health Issues

Clubbing is a medical condition characterized by changes in the areas under and around the toenails and fingernails. This phenomenon is often associated with various disorders and can manifest as noticeable alterations in nail appearance and surrounding tissue. To fully comprehend this condition, it’s essential to delve into its causes, symptoms, and implications for overall health.

What exactly is clubbing?

Clubbing occurs when the tips of the fingers or toes enlarge and the nails become extremely curved from front to back. This process can happen relatively quickly, sometimes within weeks, and is often indicative of an underlying health issue. The good news is that clubbing can also recede rapidly once the root cause is addressed and treated effectively.

Common Symptoms and Characteristics of Clubbing

Recognizing the signs of clubbing is crucial for early detection and prompt medical intervention. Here are the primary symptoms to watch out for:

• Softening of the nail beds
• Nails appearing to “float” rather than being firmly attached
• A sharper angle formed between the nails and cuticles
• Enlargement or bulging of the fingertips or toe tips
• Warmth and redness in the affected areas
• Downward curving of nails, resembling an upside-down spoon

How does clubbing progress?

Clubbing typically develops over time, but the process can be surprisingly swift in some cases. The changes may become noticeable within weeks, highlighting the importance of regular self-examination and awareness of one’s body. It’s worth noting that the reversal of clubbing can be equally rapid once appropriate treatment for the underlying cause begins.

The Root Causes of Clubbing: Beyond Cosmetic Concerns

Clubbing is not merely a cosmetic issue but often a symptom of more serious health conditions. Understanding the potential causes can help in early diagnosis and treatment of underlying diseases.

Which conditions commonly lead to clubbing?

Several health issues can trigger clubbing, with lung cancer being the most prevalent cause. However, numerous other conditions can also result in this symptom:

1. Chronic low blood-oxygen levels
2. Congenital heart defects
3. Chronic lung infections (e.g., bronchiectasis, cystic fibrosis, lung abscess)
4. Infectious endocarditis
5. Interstitial lung disease
6. Celiac disease
7. Liver cirrhosis and other liver diseases
8. Dysentery
9. Graves’ disease
10. Overactive thyroid
11. Various types of cancer (liver, gastrointestinal, Hodgkin lymphoma)

The Connection Between Clubbing and Oxygen Levels

One of the primary mechanisms behind clubbing is chronic low blood-oxygen levels. This connection explains why many respiratory and cardiovascular conditions are associated with this symptom.

How do low oxygen levels contribute to clubbing?

When the body experiences prolonged periods of reduced oxygen in the blood, it triggers a series of physiological responses. These responses can include changes in blood flow to the extremities and alterations in tissue growth patterns. Over time, these adaptations can manifest as the characteristic enlargement and curvature seen in clubbed digits.

Diagnosing Clubbing: From Observation to Medical Evaluation

While the visual signs of clubbing can be apparent, proper diagnosis requires a comprehensive medical evaluation. This process typically involves a combination of physical examination, patient history, and diagnostic tests.

What steps are involved in diagnosing clubbing?

The diagnostic process for clubbing often includes:

• Thorough physical examination
• Evaluation of family and medical history
• Assessment of accompanying symptoms
• Specific questions about breathing difficulties, skin color changes, and symptom progression
• Diagnostic tests such as arterial blood gas analysis, chest CT scans, chest x-rays, echocardiograms, electrocardiograms (ECG), and pulmonary function tests

These comprehensive evaluations aim not only to confirm the presence of clubbing but also to identify its underlying cause, enabling appropriate treatment strategies.

When to Seek Medical Attention for Clubbing

Given that clubbing can be indicative of serious health issues, it’s crucial to know when to consult a healthcare professional.

At what point should you contact a doctor about clubbing?

If you notice any signs of clubbing in your fingers or toes, it’s advisable to call your healthcare provider promptly. Early detection and diagnosis can be crucial in addressing the underlying condition effectively. Don’t hesitate to seek medical attention if you observe changes in the shape, size, or appearance of your digit tips or nails.

Treatment Approaches for Clubbing

While clubbing itself doesn’t have a direct treatment, addressing the underlying cause is paramount in managing this condition.

Can clubbing be treated directly?

There is no specific treatment for clubbing as a standalone symptom. Instead, medical professionals focus on diagnosing and treating the underlying condition causing the clubbing. Once the root cause is effectively managed, clubbing often resolves on its own. This underscores the importance of a thorough diagnostic process to identify and address the primary health issue.

Living with Clubbing: Monitoring and Management

For individuals diagnosed with clubbing, ongoing monitoring and management are essential components of care.

How can patients effectively manage and monitor their condition?

Living with clubbing involves:

• Regular check-ups with healthcare providers
• Adherence to treatment plans for underlying conditions
• Self-monitoring for changes in clubbing severity or new symptoms
• Maintaining overall health through proper nutrition and lifestyle choices
• Staying informed about the underlying condition and its management

By actively participating in their care and maintaining open communication with medical professionals, patients can effectively manage clubbing and its associated health issues.

Understanding clubbing of the fingers and toes goes beyond recognizing physical changes. It requires awareness of potential underlying health issues, prompt medical attention, and ongoing management. By staying informed and vigilant, individuals can ensure timely diagnosis and treatment of conditions associated with this distinctive symptom, potentially improving long-term health outcomes.

Clubbing of the fingers or toes Information | Mount Sinai

Clubbing

Clubbing is changes in the areas under and around the toenails and fingernails that occur with some disorders. The nails also show changes.

Clubbing may result from chronic low blood-oxygen levels. This can be seen with cystic fibrosis, congenital cyanotic heart disease, and several other diseases. The tips of the fingers enlarge and the nails become extremely curved from front to back.

Clubbed fingers is a symptom of disease, often of the heart or lungs which cause chronically low blood levels of oxygen. Diseases which cause malabsorption, such as cystic fibrosis or celiac disease can also cause clubbing.

Considerations

Common symptoms of clubbing:

• The nail beds soften. The nails may seem to “float” instead of being firmly attached.
• The nails form a sharper angle with the cuticle.
• The last part of the finger may appear large or bulging. It may also be warm and red.
• The nail curves downward so it looks like the round part of an upside-down spoon.

Clubbing can develop quickly, often within weeks. It also can go away quickly when its cause is treated.

Causes

Lung cancer is the most common cause of clubbing. Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood. These may include:

• Heart defects that are present at birth (congenital)
• Chronic lung infections that occur in people with bronchiectasis, cystic fibrosis, or lung abscess
• Infection of the lining of the heart chambers and heart valves (infectious endocarditis). This can be caused by bacteria, fungi, or other infectious substances
• Lung disorders in which the deep lung tissues become swollen and then scarred (interstitial lung disease)

Other causes of clubbing:

• Celiac disease
• Cirrhosis of the liver and other liver diseases
• Dysentery
• Graves disease
• Overactive thyroid gland
• Other types of cancer, including liver, gastrointestinal, Hodgkin lymphoma

When to Contact a Medical Professional

If you notice clubbing, call your health care provider.

What to Expect at Your Office Visit

A person with clubbing often has symptoms of another condition. Diagnosing that condition is based on:

• Family history
• Medical history
• Physical exam that looks at the lungs and chest

The provider may ask questions such as:

• Do you have any trouble breathing?
• Do you have clubbing of the fingers, toes, or both?
• When did you first notice this? Do you think it is getting worse?
• Does the skin ever have a blue color?
• What other symptoms do you have?

The following tests may be done:

• Arterial blood gas
• Chest CT scan
• Chest x-ray
• Echocardiogram
• Electrocardiogram (ECG)
• Pulmonary function tests

There is no treatment for the clubbing itself. The cause of clubbing can be treated, however.

Drake WM, Chowdhury TA. General patient examination and differential diagnosis. In: Glynn M, Drake WM, eds. Hutchison’s Clinical Methods. 24th ed. Philadelphia, PA: Elsevier; 2018:chap 2.

Fajardo E, Davis JL. History and physical examination. In: Broaddus VC, Ernst JD, King TE, Lazarus SC, Sarmiento KF, Schnapp LM, Stapleton RD, eds. Murray and Nadel’s Textbook of Respiratory Medicine. 7th ed. Philadelphia, PA: Elsevier; 2022:chap 18.

Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM. Cyanotic congenital heart lesions: lesions associated with decreased pulmonary blood flow. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 457.

Last reviewed on: 5/24/2021

Reviewed by: Neil K. Kaneshiro, MD, MHA, Clinical Professor of Pediatrics, University of Washington School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Lichen planus Information | Mount Sinai

Lichen planus is a condition that forms a very itchy rash on the skin or in the mouth.

Lichen planus is an intensely itchy (pruritic) inflammatory lesion of the skin. The lesions are generally violaceous (red-purple), slightly raised bumps (papules) with fine scales. The papules may run together (coalesce) to form a larger raised surface (plaque). This is a condition usually seen in adults, although it can occur in children.

Lichen nitidus consists of tiny flesh colored to pink raised lesions (papules). The papules are asymptomatic but persist for long periods of time. They generally occur only on the abdomen, flexor surfaces of the elbows and palms, and on the male genitalia.

The cause of lichen planus is unknown. It appears as raised, many-sided purple bumps (violaceous polygonal papules) with overlying white lines (Wickham’s striae). It commonly involves the wrists (flexor surface), lower back (lumbar region), shins, and ankles. The lesions often itch. Females are more frequently affected than males and the age range is approximately 30 to 60 years of age.

The cause of lichen planus is unknown. It appears as raised, many-sided purple bumps (violaceous polygonal papules) with overlying white lines (Wickham’s striae). It commonly involves the wrists (flexor surface), lower back (lumbar region), shins, and ankles. The lesions often itch. Females are more frequently affected than males and the age range is approximately 30 to 60 years of age. This is a less common variant, shown here with scales.

Oral lichen planus occurs in about half of the people who have lichen planus on their skin. It consists of painless, whitish streaks on the mucous membranes. This may also produce ulcers, which are usually painful.

Lichen striatus begins similarly to lichen planus, with small bumps (papules), but over a period of days expands to form a long streak or band of affected skin. The condition clears spontaneously (without medication) over a period of months. This condition is seen frequently in children less than 16 years old, but may also occur in adults.

Lichen striatus begins similarly to lichen planus, with small bumps (papules), but over a period of days expands to form a long streak or band of affected skin. It clears over a period of months without needing treatment. This condition is seen frequently in children less than 16 years old but, also occurs in adults.

Lichen striatus begins similarly to lichen planus, with small bumps (papules), but over a period of days expands to form a long streak or band of affected skin. The condition clears spontaneously over a period of months. This condition is seen frequently in children less than 16 years old, but also occurs in adults.

Causes

The exact cause of lichen planus is unknown. It may be related to an allergic or immune reaction.

Risks for the condition include:

• Exposure to certain medicines, dyes, and other chemicals (including gold, antibiotics, arsenic, iodides, chloroquine, quinacrine, quinine, phenothiazines, and diuretics)
• Diseases such as hepatitis C

Lichen planus mostly affects middle-aged adults. It is less common in children.

Symptoms

Mouth sores are one symptom of lichen planus. They:

• May be tender or painful (mild cases may not cause pain)
• Are located on the sides of the tongue, inside of the cheek, or on the gums
• Look like bluish-white spots or pimples
• Form lines in a lacy network
• Gradually increase in size
• Sometimes form painful ulcers

Skin sores are another symptom of lichen planus. They:

• Usually appear on the inner wrist, legs, torso, or genitals
• Are extremely itchy
• Have even sides (symmetrical) and sharp borders
• Occur alone or in clusters, often at the site of a skin injury
• May be covered with thin white streaks or scratch marks
• Are shiny or scaly looking
• Have a dark, violet color
• May develop blisters or ulcers

Other symptoms of lichen planus are:

• Dry mouth
• Hair loss
• Metallic taste in the mouth
• Ridges in the nails

Exams and Tests

Your health care provider may make the diagnosis based on the appearance of your skin or mouth lesions.

A skin lesion biopsy or biopsy of a mouth lesion can confirm the diagnosis.

Treatment

The goal of treatment is to reduce symptoms and speed healing. If your symptoms are mild, you may not need treatment.

Treatments may include:

• Antihistamines
• Medicines that calm down the immune system (in severe cases)
• Lidocaine mouthwashes to numb the area and make eating more comfortable (for mouth sores)
• Topical corticosteroids or oral corticosteroids to reduce swelling and lower immune responses
• Corticosteroid shots into a sore
• Vitamin A as a cream or taken by mouth
• Other medicines that are applied to the skin
• Dressings placed over your skin with medicines to keep you from scratching
• Ultraviolet light therapy

Outlook (Prognosis)

Lichen planus is usually not harmful. Most often, it gets better with treatment. The condition often clears up within 18 months, but may come and go for years.

If lichen planus is caused by a medicine you are taking, the rash should go away once you stop the medicine.

Possible Complications

Mouth ulcers that are present for a long time may develop into oral cancer.

When to Contact a Medical Professional

Contact your provider if:

• Your skin or mouth lesions change in appearance
• The condition continues or gets worse, even with treatment
• Your dentist recommends changing your medicines or treating conditions that trigger the disorder

James WD, Elston DM, Treat JR, Rosenbach MA, Neuhaus IM. Lichen planus and related conditions. In: James WD, Elston DM, Treat JR, Rosenbach MA, Neuhaus IM, eds. Andrews’ Diseases of the Skin: Clinical Dermatology. 13th ed. Philadelphia, PA: Elsevier; 2020:chap 12.

Patterson JW. An approach to the interpretation of skin biopsies. In: Patterson JW, ed. Weedon’s Skin Pathology. 5th ed. Philadelphia, PA: Elsevier; 2021:chap 2.

Last reviewed on: 11/18/2022

Reviewed by: Elika Hoss, MD, Assistant Professor of Dermatology, Mayo Clinic, Scottsdale, AZ. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Nail cancer – symptoms, treatments, prevention and diagnosis

Nail melanoma is a malignant tumor characterized by rapid growth and multiplication. The appearance of nail cancer is similar to a post-traumatic bruise. In this case, the thumb is considered the most common place of occurrence.

Development of nail melanoma

Primary nail melanoma is almost invisible. Outwardly, it is difficult to identify a malignant tumor, while the nail plate acquires a dark brown and dark blue color. Melanoma under the nail is also colorless due to a small amount of melanin. Nail cancer destroys the nail slowly. Melanoma of the nail does not leave the opportunity to recover. Timely detected melanoma under the nail makes it possible to prescribe treatment with greater efficiency. Melanoma of the big toe nail appears more often due to the presence of a weak point. Melanoma of the nail of the hand is accompanied by a change in the appearance of the fingers.

Causes

Melanoma under the nail is more common in the elderly. The true causes of nail cancer have not yet been identified. Factors affecting the appearance of nail melanoma:

• the presence of moles and warts;
• skin defects of fingers from birth;
• development of tumors in other organs and tissues;
• treated fungus or viral infection;
• regular injury to the site of nail melanoma;
• late treatment of injuries with antiseptics;
• UV burns;
• lack of melanin;
• heredity.

Among the likely causes of nail cancer is a violation of the principle of a healthy lifestyle – lack of sleep, lack of physical activity, malnutrition. All this contributes to a decrease in immunity, which allows the development of melanoma of the nail.

Types of nail melanoma

In the selection of adequate therapy for cancer under the nail is the definition of its type. According to the forms of nail cancer, the following types are distinguished:

• superficial – develops in a horizontal position;
• nodal – characterized by deep penetration and rapid spread;
• lentigo – differs from horizontal uneven staining;
• achromatic – characterized by a dark shade of nail melanoma;
• acrolentiginous – initially appears on the surface and gradually penetrates deep into, affecting, including lips, palms and fingers. There are three types depending on the location: nail matrix, plate, epidermis.

How the disease develops

Development stage nail melanoma has the following:

• initial stage nail melanoma is almost impossible to diagnose due to the absence of any manifestations and discomfort;
• Stage 2 is characterized by the appearance of nodules and penetration into the depths, as well as a change in color;
• Stage 3 occurs with damage to the lymph nodes and destruction of the nail;
• Stage 4 occurs with damage to other vital internal organs and severe pain.

Each stage of nail melanoma has its own signs and characteristics.

Symptoms

Symptoms of melanoma:

• separation of the nail plate and the appearance of a thickening in the form of a tubercle;
• discoloration of the nail plate for no apparent reason;
• the appearance of a longitudinal strip in the center of the nail;
• purulent discharge in advanced disease;
• throbbing pain in the affected area, first on pressure, then constant;
• detachment of the nail.

If there are several symptoms, the specialist correctly diagnoses melanoma of the toenail or handnail.

Diagnostics

Melanoma of the toenail or handnail does not allow to determine the disease by external signs. In the process of diagnosis, an anamnesis is collected and dermatoscopy is performed. Examination of melanoma of the nail on the leg or hand occurs with a magnifying glass or other magnifying device. Examining melanoma under the thumbnail is a difficult task. For an accurate diagnosis of toenail or handnail cancer, a biopsy is necessary, as well as blood sampling for tumor markers. With melanoma of the big toe on the leg or arm, the diagnosis is carried out by the following methods – urine and venous blood analysis, MRI, ultrasound of internal organs. The examination is carried out under the supervision of a dermatologist and an oncologist.

Contacting a specialist

In the oncological center “Sofia”, located in the center of Moscow, patients will be provided with the necessary medical care by dermatologists and oncologists trained in leading foreign clinics, as well as psychologists aimed at the correct perception of the diagnosis and the patient’s aspirations to a cure.

Here we are ready to offer you the most modern diagnostic methods that allow you to make an accurate diagnosis and start an adequate treatment. To diagnose melanoma of the toenail or hand, the following procedures are used – MRI, CT, SPECT, PET, radiography, fluoroscopy, ultrasound, laboratory tests.

Treatment

Thumbnail melanoma is the most common form of this disease. The only effective way to treat melanoma of the nail on the thumb and all other places is surgery to remove it.

There are several types of operations:

• a simple operation – the neoplasm itself is removed;
• cryotherapy is exposure to liquid nitrogen, effective in the initial stages;
• laser removal – carried out only in the initial stages of the disease.

Before surgery, it is necessary to undergo a course of chemotherapy, to stop the reproduction of malignant cells. And after surgery, a course of radiation therapy is needed to suppress the remaining atypical cells.

How to make an appointment with a doctor? Melanoma of the toenail or hand has more promising prospects due to the fact that the high qualifications and extensive experience of specialists make it possible to accurately diagnose and choose the best method of therapy.

Subungual melanoma – diagnosis, treatment at the international clinic Medica24

There are cells in the skin that are responsible for its color – melanocytes. They produce the pigment melanin. The degeneration of these cells causes the formation of a malignant tumor – melanoma, which can occur in an open area or under the nail.

Our expert in this area:

Sergeev Petr Sergeevich

Deputy chief physician for medical work. Oncologist, surgeon, chemotherapist, Ph.D.

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Subungual melanoma is a relatively rare, but formidable and insidious oncological disease. At an early stage, these neoplasms are quite successfully treated with the help of modern conservative methods and minimally invasive interventions used in the international clinic Medica24. But with the transition to the later stages, treatment becomes more complicated.

The danger of subungual melanoma is active metastasis to the liver, lungs, bones, despite the fact that it is not always possible to recognize it at an early stage. A person may not pay attention to a dark line or speck under the nail until it causes pain.

And only when the nail plate, soft tissues, bones are involved in the process, pressing on the nail becomes painful, the person goes to the doctor. As a rule, this means that the disease has reached the third or fourth stage, and a major operation is required.

Symptoms

The exact cause of nail melanoma has not been established. Contributing factors can be frostbite, burns, injuries, work with chemical toxins. Most often, the neoplasm affects the big toe or toe.

A characteristic external sign is a dark brown or dark blue stripe that divides the nail bed lengthwise into two equal or unequal parts. This is the so-called longitudinal melanoma or melanonychia.

Melanoma may start as a tiny spot less than 1 mm in diameter. Gradually it grows, increasing in size.

The first two stages of the disease differ in the size of the neoplasm – from 1 mm to 4 mm. In the third stage, subungual melanoma metastasizes to regional lymph nodes, and in the fourth – to distant organs.

In about a third of cases, the pigmentation of the neoplasm is absent, and melanoma is not visible externally, which makes it difficult to detect.

As the tumor develops, a dark line or spot may extend beyond the nail plate. The pain syndrome gradually arises and intensifies, at first only when pressed, then without it.

The nail separates from the bed, exfoliates, becomes thinner, becomes loose, brittle and darkens, acquiring a dark blue, brown or black color, tubercles form on its surface. In this case, we are talking, as a rule, about acral lentiginous melanoma. Pus oozes from under the nail plate, when it is destroyed, the skin is exposed, covered with manifestations, nodules.

Melanoma can arise and grow from 1) the nail matrix, 2) the area of ​​the nail bed, or 3) from the area that is adjacent to the nail plate. Periungual melanoma can metastasize to the nail matrix.

In the development of subungual melanoma, two stages are distinguished – horizontal and vertical. The first means growth in the surface layer under the nail, the second – the germination of the tumor deep into, the involvement of subcutaneous, muscle tissues, bones.

Cancer cells from the primary focus spread in the body, causing metastases, most often in the lungs, liver. Malignancy of secondary foci often exceeds the primary tumor.

Local symptoms are joined by general ones – loss of appetite, weight loss, weakness, fatigue, subfebrile temperature.

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Diagnosis

Not every dark spot under the nail is melanoma. It can easily be mistaken for a hematoma, nevus, hemangioma. You can understand the nature of the neoplasm using dermatoscopy – a visual examination with a strong increase.

Often this is not enough. If necessary, clarifying data is carried out by a cytological examination of the smear, a biopsy with a histological examination of the tissue.

Examination of tissue cells under a microscope provides a basis for a confident diagnosis. In this case, additional studies are prescribed – blood tests, urine tests, MRI, ultrasound, CT to study the condition of the internal organs, lymph nodes.

Treatment

The goal of treatment is to completely remove the tumor and minimize the risk of its recurrence. In the case of nail melanoma, this risk is unfortunately high, even after radical surgery.

The main treatment for subungual melanoma is surgery. In the international clinic Medica24, preference is given to organ-preserving surgeries by default. This means that we will do our best to achieve the goal of treatment, using the minimum possible amount of intervention.

Early stage melanoma can be destroyed with cryotherapy (liquid nitrogen) or laser.

Minimal surgery means removal of the tumor, a small amount of soft tissue and part of the nail (phalanx exarticulation).

Further, if necessary, 1) the phalanx, 2) part of the finger up to the middle of the middle phalanx, or 3) the entire finger can be amputated. In the most severe cases, amputation of the entire hand or foot is performed.

Before surgery, a course of neoadjuvant chemotherapy is performed, and after it – radiation therapy, adjuvant chemotherapy.

This is a classic, traditional treatment for subungual melanoma. In the international clinic Medica24, we actively apply progressive methods using immunotherapy, targeted therapy. In many cases they give very good results.

In particular, immunotherapy is used to strengthen the immune system, stimulate it and mobilize it to fight the neoplasm. On the other hand, immunostimulating drugs are used after chemotherapy, for which our clinic uses only the most effective, including the latest drugs.

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For a long time it was considered that in the case of melanoma of the nail, it is better to remove the entire finger. However, recent data show that the recurrence rate, metastasis and survival are very little or statistically independent of the volume of excision, if it is performed within the boundaries of healthy tissues.

This means that instead of amputating the entire finger, the same result can be achieved by removing only one phalanx or the distal part of the finger at the level of the middle of the second phalanx.

The material was prepared by the Deputy Chief Physician for Medical Work of the Medica24 International Clinic, Candidate of Medical Sciences Petr Sergeev.

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