Preoperative Pain Catastrophizing Is Associated with Early Postoperative Pain and Suboptimal Early Weight Loss after Sleeve Gastrectomy

Abstract

Objective:

To evaluate whether preoperative Pain Catastrophizing Scale (PCS) scores predict postoperative pain, opioid use, and suboptimal early weight loss after sleeve gastrectomy.

Methods:

In this prospective single-center cohort, 80 adults undergoing laparoscopic sleeve gastrectomy completed PCS, Beck Depression, and Beck Anxiety inventories preoperatively. Pain was recorded using the Numeric Rating Scale (NRS) at several time points in the first 24 h; opioid consumption was converted to morphine equivalents. Weight loss was assessed at 6 months as percent excess weight loss (%EWL). Receiver-operating characteristic (ROC) analysis was performed to determine the optimal PCS threshold for identifying patients at risk of suboptimal early weight loss (%EWL < 60) at 6 months. Multivariable logistic regression analysis was performed adjusting for age, sex, body mass index (BMI), depression, and anxiety.

Results:

Higher PCS scores strongly correlated with NRS pain at all time points (Spearman correlation coefficient [r] ≥ 0.70 at 2 h and 8 h; p < 0.001) and greater opioid use. ROC analysis identified PCS of ≥26 as the optimal cut-off for predicting %EWL of <60 (p = 0.048). Patients with PCS of ≥26 achieved lower mean %EWL (69.7 ± 19.5%) than those with PCS < 26 (77.7 ± 15.0%). In multivariable logistic regression analysis, PCS of ≥26 was associated with increased odds of suboptimal early weight loss (OR = 3.27, 95% CI: 0.51–21.10); however, this association did not reach statistical significance after adjustment.

Conclusion:

High PCS scores identify patients at risk for severe early pain and suboptimal early weight loss trajectory. Routine PCS screening may guide targeted perioperative pain management and behavioral interventions to improve bariatric outcomes.

Keywords

bariatric surgery catastrophizing sleeve gastrectomy pain management weight loss psychosocial factors

Introduction

Obesity is a global public health problem defined by the World Health Organization as a body–mass index (BMI) of ≥30 kg/m² and is strongly associated with higher cardiometabolic morbidity and mortality.¹ Recent data indicate that more than 650 million adults worldwide are obese, and this figure has risen by roughly 30% each decade.² Metabolic bariatric surgery (MBS) has become the gold-standard treatment for obesity, enabling patients to lose 25%–35% of their total body weight and achieve remission of comorbidities such as type 2 diabetes.³ Nevertheless, 10%–30% of cases fail to attain the target weight loss or experience weight regain in the long term.⁴ The variability in these failure rates has highlighted the importance of psychosocial factors in addition to technical aspects.

Numerous studies have shown that depression, anxiety, and eating disorders adversely affect postoperative weight loss, and, therefore, preoperative psychological assessment is now routine practice in many centers.^5,6 However, pain catastrophizing a cognitive emotional tendency to perceive pain in an exaggerated, catastrophic manner has been relatively overlooked in the bariatric population. In obese surgical patients, high levels of catastrophizing are linked to more severe acute pain, increased opioid requirements, and prolonged functional limitations.⁷

In this study, we investigated whether preoperative PCS scores in adult candidates for MBS could predict a less favorable early postoperative weight loss trajectory at 6 months after surgery. As a secondary aim, we examined the relationship between catastrophizing and both early postoperative pain intensity and opioid consumption.

Materials and Methods

Study design and ethical approval

This single-center, prospective, observational study was conducted in the Department of General Surgery of Tokat Gaziosmanpaşa University, Faculty of Medicine, between 30 July and 30 November 2018. The protocol was approved by the local ethics committee, and written informed consent was obtained from all participants in accordance with the Declaration of Helsinki.

Participants

Patients scheduled for elective sleeve gastrectomy, aged 18–65 years, classified as American Society of Anesthesiologists (ASA) physical statuses I–III, and meeting either a body mass index (BMI) of ≥40 kg/m² or a BMI of 35–40 kg/m² with at least one obesity related comorbidity were eligible. Exclusion criteria were psychotic disorders, cognitive impairment precluding cooperation, suspected secondary obesity, and refusal to participate. Of 90 patients screened, 10 were excluded, leaving 80 patients (female/male = 62/18) in the final cohort. All analyses were conducted on the 80 patients who completed the full 6 month follow up. Complete case analysis was performed; all included patients had complete data for postoperative pain scores (0–24 h NRS) and 6-month weight loss outcomes. Therefore, no missing-data imputation was required (Fig. 1).

FIG. 1.

Patient enrollment flowchart.

Preoperative assessment and PCS

All patients underwent detailed history and physical examination; height, weight, BMI, comorbidities, and medications were recorded. Laboratory work-up included a complete blood count, routine biochemistry, HbA₁c, C-peptide, thyroid function tests, lipid profile, and a 1 mg dexamethasone suppression test. Chest radiography and electrocardiogram (ECG) were performed, and the patients were evaluated by endocrinology, cardiology, pulmonology, psychiatry, and anesthesiology. Upper gastrointestinal endoscopy was completed, and Helicobacter pylori eradication was provided when necessary. For thromboembolism prophylaxis, 0.6 IU subcutaneous enoxaparin was administered 12 h before surgery.

PCS, a 13-item instrument originally developed by Sullivan et al., was administered to assess patients’ preoperative, pain-related negative cognitions. Items are rated from 0 (“not at all”) to 4 (“all the time”), yielding a total score between 0 and 52, with higher scores indicating greater catastrophizing. Scores for the three subscales, Rumination (RPCS), Magnification (MPCS), and Helplessness (HPCS), were recorded separately and analyzed alongside the global score.⁸ Psychosocial evaluation was carried out 1 day before surgery in the ward under supervision of an experienced resident, using the PCS, Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). During the same session, patients were instructed on the Numeric Rating Scale (NRS, 0–10) for postoperative pain assessments.

Anesthesia and surgical approach

General anesthesia was induced with propofol (2 mg kg⁻¹), fentanyl (1 µg kg⁻¹), and rocuronium (0.6 mg kg⁻¹); maintenance consisted of desflurane (5%–6%) and target-controlled remifentanil infusion. As part of multimodal analgesia, 1 g paracetamol and 50 mg dexketoprofen were given intravenously. Laparoscopic sleeve gastrectomy was performed with a five-trocar standard technique by the same senior surgeon(s). The greater curvature was mobilized from the pylorus to the angle of His; starting at the antrum, the stomach was transected over a 36 Fr orogastric bougie using stapler cartridges. The staple line was oversewn with 2-0 polyprolene for reinforcement, and bleeding points were sutured with 3/0 polypropylene. A leak test with methylene blue was performed, and a silicone drain was placed in the left subdiaphragmatic space.

Postoperative pain management and early care

Pain was assessed using NRS on ward admission and at 0, 2, 6, 8, 18, and 24 h postoperatively. Patients with a pain score ≥3 received a 0.2 mg intravenous (IV) morphine bolus. The routine analgesia protocol comprised 100 mg IV tramadol and 1 g IV paracetamol every 8 h. Patients were mobilized within the first 6–8 h; oral intake was initiated with 10 mL/h water at 24 h and increased by 10 mL every 24 h. On postoperative day 4, the diet was advanced to clear liquids and strained soup.

Discharge and long-term follow-up

Patients were discharged on postoperative day 4. They were prescribed enoxaparin for 7 days, a proton pump inhibitor for 3 months, and continuous multivitamin supplementation. Follow-up visits were scheduled on day 10 after discharge, at months 1 and 3, and every 3 months thereafter. At each visit, height and weight were measured. The primary outcome was %EWL at 6 months. For the purposes of early risk stratification in this cohort, suboptimal early weight loss was defined as %EWL of <60. Because 6-month weight loss may reflect an early postoperative trajectory rather than definitive long-term success or failure, %EWL of ≥60 threshold was treated as an exploratory benchmark for a satisfactory early response. Receiver-operating characteristic (ROC) analysis was, therefore, used to determine the optimal PCS cut-off for identifying patients at risk of suboptimal early weight loss.

Statistical analysis

Data were analyzed with SPSS v22.0. Normality of continuous variables was assessed with the Kolmogorov–Smirnov and Shapiro–Wilk tests. Normally distributed data are presented as mean ± standard deviation; nonnormal data are presented as median (minimum–maximum). Categorical variables are reported as counts and percentages. Specifically, the distribution of %EWL within each PCS group was assessed using the Shapiro–Wilk test. As %EWL values were normally distributed in both groups (p > 0.05), comparisons between PCS groups were performed using an independent samples Student’s t-test. Student’s t-test was used for parametric comparisons and the Mann–Whitney U test for nonparametric data. Multiple-group comparisons employed the Kruskal–Wallis test with Bonferroni-corrected pairwise analyses. Relationships between %EWL and PCS, BDI, and BAI were examined using Spearman correlation. A two-sided p value of <0.05 was considered statistically significant. No missing-data imputation was performed. Based on the sample size analysis, with a statistical power of 80% and a significance level of 0.05 (95% confidence interval), and according to Cohen’s criteria indicating an effect size of 0.64, a total of 80 patients were determined to be required in the sample to detect a statistically significant difference in %EWL values between the two independent groups formed according to PCS score levels.

Results

A total of 80 consecutive adults who underwent laparoscopic sleeve gastrectomy between July and November 2018 were included in the final analysis. Women comprised two-thirds of the cohort (n = 53, 66.3%), while men accounted for 27 patients (33.8%). Age ranged from 18 to 63 years, with a mean ± SD of 35.55 ± 10.85 years; 44 patients (55%) were ≤35 years and 36 (45%) were >35 years. Descriptive statistics for all continuous variables, including anthropometrics and psychometric scores, are presented in Table 1.

Table 1.

Descriptive Statistics of Quantitative Variables

Variable	Mean	SD	Median	Min	Max
Age	35.55	10.85	34.5	18.0	63.0
Weight (kg)	128.8	24.09	123.5	90.0	196.0
Height (cm)	167.46	10.21	165.5	146.0	200.0
BMI(kg/m²)	45.73	5.93	44.49	36.46	64.74
Chronic pain NRS	2.55	0.89	2.5	1.0	4.0
RPCS (Items 8, 9, 10, and 11)	5.45	3.91	4	0.0	16.0
MPCS (Items 6, 7, and 13)	4.5	3.36	4	0.0	11.0
HPCS (Items 1, 2, 3, 4, 5, and 12)	9.23	6.25	8	0.0	24.0
%TWL	41.3	10.91	42	15.0	80.0
Beck depression	7.54	9.39	4	0.0	42.0
Beck anxiety	19.48	15.9	13	0.0	59.0

A minimum value of 0 represents a valid response, not missing data.

BMI, body mass index; HPCS, Helplessness Pain Catastrophizing Subscale; Max, maximum; Min, minimum; MPCS, Magnification Pain Catastrophizing Subscale; NRS, Numerical Rating Scale; RPCS, Rumination Pain Catastrophizing Subscale; SD, standard deviation; %TWL, percentage of total weight loss.

All three PCS subscales—RPCS, MPCS, and HPCS—as well as the total PCS score were positively correlated with NRS pain scores at every measured time point postsurgery (p < 0.001 for all). The most pronounced associations occurred during the first 8 h: MPCS versus NRS: r = 0.726 at 2 h and r = 0.709 at 8 h. HPCS versus NRS: r = 0.700 at 2 h. Total PCS versus NRS: r = 0.732 at 2 h and r = 0.662 at 8 h. Correlations at 18 and 24 h remained statistically significant but declined to moderate strength (r ≈ 0.40–0.55; Table 2).

Table 2.

Spearman Correlation Coefficients Between Rumination Pain Catastrophizing Subscale, Magnification Pain Catastrophizing Subscale, Helplessness Pain Catastrophizing Subscale, Total Pain Catastrophizing Scale, Beck Depression, and Beck Anxiety Scores and Postoperative Numerical Rating Scale Levels

Variable	Postop 0 h NRS	Postop 2 h NRS	Postop 6 h NRS	Postop 8 h NRS	Postop 24 h NRS
RPCS (r)	0.577 (0.41–0.71)^a	0.602 (0.44–0.73)^a	0.577 (0.41–0.71)^a	0.615 (0.46–0.74)^a	0.501 (0.32–0.65)^a
MPCS (r)	0.606 (0.45–0.73)^a	0.726 (0.60–0.82)^a	0.661 (0.52–0.77)^a	0.709 (0.58–0.80)^a,*	0.684 (0.55–0.79)^a
HPCS (r)	0.583 (0.42–0.71)^a	0.700 (0.57–0.80)^a	0.649 (0.50–0.76)^a	0.668 (0.53–0.77)^a	0.684 (0.55–0.79)^a
PCS total (r)	0.643 (0.49–0.76)^a	0.732 (0.61–0.82)^a	0.665 (0.52–0.77)^a	0.703 (0.57–0.80)^a	0.662 (0.52–0.77)^a
Beck depression (r)	0.464 (0.27–0.62)^a	0.471 (0.28–0.63)^a	0.506 (0.32–0.65)^a	0.426 (0.23–0.59)^a	0.402 (0.20–0.57)^a
Beck anxiety (r)	0.411 (0.21–0.58)^a	0.617 (0.46–0.74)^a	0.554 (0.38–0.69)^a	0.532 (0.35–0.67)^a	0.538 (0.36–0.68)^a

^aSpearman correlation coefficient.

All correlations are statistically significant at p < 0.001.

PCS, Pain Catastrophizing Scale; r, correlation coefficient.

These data indicate that patients who entered surgery with stronger catastrophic pain cognitions consistently reported higher acute pain levels, particularly in the hyper-acute ≤8 h) phase. Parallel to the pain findings, cumulative morphine-equivalent opioid consumption showed significant positive correlations with RPCS, MPCS, HPCS, and total PCS at every assessment (p < 0.001). Peak correlations were seen at 6 and 8 h. Even at 24 h, catastrophizing remained a moderate predictor of analgesic demand. Collectively, these findings suggest that higher preoperative catastrophizing translated into both greater perceived pain and a higher pharmacological burden during the first postoperative day.

Correlation analysis (Table 3) demonstrated weak but statistically significant inverse relationships between postoperative weight loss and both BDI and BAI scores (r ≈ −0.24 to −0.30; p < 0.05).

Table 3.

Spearman Correlation Coefficients Between Weight Loss and Beck Depression and Beck Anxiety Scores

Variable	Beck depression	Beck anxiety
Weight loss (r)^a	−0.278 (95% CI, −0.47– −0.06)	−0.312 (95% CI, −0.5– −0.1)
Weight loss (p)	0.012	0.005

^aSpearman correlation coefficient.

CI, confidence interval; p, p value; r, Spearman correlation coefficient.

The mean total weight loss (%TWL) was 41.3 ± 10.91, whereas the median excess weight loss (%EWL) was 74.9% at 6 months. The primary endpoint of the study was %EWL at 6 months. Suboptimal early weight loss was defined as %EWL of <60. ROC analysis identified a PCS score of 26 points as the optimal threshold for discriminating patients at risk of suboptimal early weight loss. Patients with PCS of ≥26 had a significantly lower mean %EWL at 6 months than those with PCS of <26 (69.74 ± 19.53 vs. 77.68 ± 14.97, p = 0.048), corresponding to an absolute between-group difference of 7.9 percentage points.

The intergroup difference of 7.9 percentage points was statistically significant (p = 0.048; Table 4), and the distribution is visualized in Figure 2. Thus, preoperative catastrophizing above 26 points identified patients at increased risk of suboptimal early weight loss 6 months after metabolic surgery.

Table 4.

Comparison of Excess Weight Loss Values According to Pain Catastrophizing Scale Groups

Variable	PCS group	n	Mean %EWL	SD	Min	Max	Mean difference (95% CI)	p
%EWL (6 months)^a	PCS < 26	54	77.68	14.97	51.18	118.27
	PCS ≥ 26	26	69.74	19.53	20.78	94.22	7.94 (0.08 to 15.80)	0.048^a

^aIndependent samples t-test (Student’s t-test).

PCS, Pain Catastrophizing Scale; %EWL, percent excess weight loss.

FIG. 2.

Comparison of %EWL between low and high PCS groups at 6 months. %EWL, percent excess weight loss; PCS, Pain Catastrophizing Scale.

Chi-square and t-tests showed no significant differences between low- and high-PCS groups in:

ASA status (χ² = 0.015; p = 0.902).

Sex distribution (38.9% vs. 23.1% male; χ² = 1.962; p = 0.161).

Mean age (36.81 ± 11.32 vs. 32.92 ± 9.47 years; p = 0.134).

Baseline BMI (46.28 ± 5.80 vs. 44.56 ± 6.03 kg m⁻²; p = 0.226).

Accordingly, the observed impact of catastrophizing on weight loss may not be fully explained by confounding factors such as age, sex, ASA risk, or initial adiposity. Positive correlations were observed between total PCS (and each subscale) and both BDI and BAI (r ≈ 0.40–0.55; p < 0.001), highlighting the clustering of catastrophic thinking with affective distress. However, while catastrophizing remained independently associated with postoperative pain, its association with weight loss did not persist after adjustment for mood scores and other confounders in multivariable models (Table 5).

Table 5.

Multivariable Logistic Regression Analysis for Predictors of Suboptimal Early Weight Loss (%EWL < 60)

Variable	Odds ratio (OR)	95% CI	p
PCS ≥ 26	3.27	0.51–21.10	0.213
Age	0.96	0.89–1.03	0.276
Sex (female)	0.23	0.04–1.15	0.074
BMI	0.89	0.78–1.00	0.058
BDI score	0.94	0.85–1.03	0.173
BAI score	1.02	0.95–1.08	0.652

Discussion

To our knowledge, this prospective, single-center cohort is the largest study to evaluate the bidirectional impact of preoperative pain catastrophizing on both immediate analgesic needs and early weight-loss success after SG. The data reinforce the concept that psychological determinants exert parallel influence on two key domains of bariatric outcomes: (1) peri-operative pain control and (2) the sustainability of weight reduction.

Adequate control of early postoperative pain is a recognized quality-of-care metric, as poorly managed pain delays mobilization, exaggerates postoperative nausea and vomiting, predisposes to pulmonary complications, and is a driver of chronic postsurgical pain.^9,10 The literature is divided on whether general anxiety and depressive symptoms are reliable predictors of acute pain: Several investigations have reported significant correlations, whereas others have failed to detect an association.^11,12 In our cohort, BDI and BAI scores were consistently and positively related to both NRS pain scores and opioid consumption across all time points, supporting the view that psychological distress amplifies analgesic requirements.

Pain catastrophizing, the tendency to interpret pain as unbearable, uncontrollable, and threatening, shares neurobiological pathways with anxiety and depression (e.g., increased amygdala reactivity, diminished prefrontal modulation).¹³ Multiple surgical studies have identified high PCS as a robust predictor of severe early pain and elevated opioid needs.^14,15 Our findings extend this concept to a bariatric population: Rumination, magnification, helplessness, and overall PCS scores displayed moderate-to-strong correlations with pain intensity, peaking at 2 and 8 h postincision. Opioid requirements followed the same gradient, with PCS correlations surpassing 0.75 at 8 h. Notably, these correlations exceeded mean effect sizes reported in meta-analytic estimates, suggesting that the SG cohort may be particularly sensitive to catastrophizing cognitions, possibly because of heightened pre-existing pain expectations linked to obesity-associated joint or musculoskeletal complaints. Although the multimodal analgesia protocol was standardized, patient-triggered morphine boluses (NRS ≥ 3) may reflect subjective pain thresholds. Therefore, part of the higher opioid use among high-PCS individuals may reflect altered pain perception rather than increased nociceptive input.

Although %EWL of <50 has traditionally been used to define inadequate weight loss, we used %EWL <60 at 6 months as an early risk stratification marker. This approach is supported by previous findings, including a sleeve gastrectomy study identifying a 6-month %EWL threshold of 58.57% for long-term outcome prediction.¹⁶Chahal-Kummen et al. reported no association between preoperative PCS and %TWL at 24 months. In contrast, our ROC analysis identified a PCS threshold of 26 points that most accurately discriminated patients who failed to achieve ≥60% EWL. Patients below this cut-off achieved, on average, nearly 8 percentage points more %EWL than those with higher PCS scores, a clinically meaningful gap that corresponds to roughly 8–10 kg of additional EWL in a typical sleeve gastrectomy patient.

However, this association should not be interpreted as causal. Pain catastrophizing may not directly impair biological weight loss mechanisms; rather, it may reflect a behavioral risk phenotype associated with poorer adherence to postoperative recommendations and early weight loss outcomes. From a clinical perspective, identifying high-PCS patients preoperatively may allow for targeted psychological interventions, such as cognitive behavioral therapy, to improve postoperative outcomes. Higher PCS may correlate with other postoperative factors, including persistent pain, adherence to recommendations, physical activity levels, nutritional compliance, and engagement in follow-up that itself influences weight-loss trajectories. We did not directly measure these behavioral and recovery-related variables, so residual confounding and mediation are plausible. Prospective studies incorporating longitudinal behavioral follow-up are needed to determine whether catastrophizing exerts an independent effect on weight-loss outcomes or whether it primarily operates through these modifiable behaviors.

Notably, existing qualitative work suggests that individuals with high catastrophizing tend to adopt more passive coping styles and exhibit lower self-efficacy, which could translate into weaker adherence to physical activity regimens, protein-focused dietary prescriptions, and scheduled follow-up visits once the initial rapid weight-loss phase subsides. This raises the possibility that catastrophizing may not biologically limit weight loss per se but may signal a behavioral risk phenotype that is potentially targetable. Although weak but significant inverse correlations were observed between depression/anxiety and weight loss, the association between catastrophizing and weight loss did not persist after adjustment for BDI and BAI in the multivariable model. This supports the notion that PCS captures a distinct cognitive affective dimension centered on pain-related helplessness and rumination beyond generic negative affect. Taken together with prior evidence that catastrophizing is associated with more difficult postoperative recovery and higher analgesic needs, our data suggest that a comprehensive psychological work-up should include both mood screening and catastrophizing assessment to avoid missing high-risk phenotypes.^17,18

Cognitive behavioral therapy, mindfulness-based stress reduction, and acceptance and commitment therapy have proven efficacy in lowering PCS scores.¹⁹ Embedding such modules into bariatric preparation programs may help reduce postoperative analgesic burden and foster better long-term weight control. Recognizing high catastrophizers preoperatively allows anesthesiologists to escalate nonopioid multimodal strategies (e.g., regional blocks, α-2 agonists, and NMDA antagonists) and arrange enhanced pain-service follow-up. Because catastrophizing may erode motivation during the vulnerable 6–18-month window after SG, integrating behavioral coaching or digital self-monitoring tools could counteract weight-regain tendencies.

Because this was a single-center study involving a relatively homogeneous cultural and socioeconomic cohort, the generalizability of the PCS threshold (≥26) is limited. Multicenter validation in diverse populations is warranted. We acknowledge that a 6-month outcome may not reflect long-term weight-loss trajectories or regain patterns, which often emerge after 18–24 months. Future research, including longer follow-up durations, may be warranted to confirm the persistence of these associations. The data were collected between July and November 2018. However, the surgical technique, anesthetic management, and Enhanced Recovery After Surgery (ERAS) protocols used remain consistent with current (2025) clinical practice. Objective measures of dietary adherence, physical activity, and follow-up compliance were not assessed, limiting our ability to evaluate their potential mediating effects on weight-loss outcomes. Finally, cultural factors may influence catastrophizing expression; thus, multicenter, cross-cultural replication is warranted.

Conclusions

High preoperative pain catastrophizing (PCS ≥ 26) was associated with an increased risk of suboptimal early weight loss (%EWL < 60) at 6 months sleeve gastrectomy. Systematic screening for catastrophizing alongside depression and anxiety offers a practical lever to personalize peri-operative pain strategies and to implement focused psychosocial interventions that may ultimately enhance bariatric surgery outcomes. Future studies should incorporate adherence-related variables, including dietary adherence, physical activity, and follow-up compliance, to better elucidate the relationship between pain catastrophizing and weight-loss outcomes.

Authors’ Contributions

All authors made substantial contributions to the study. Y.S.A. and Z.Ö. conceptualized and designed the study. E.D. and M.F.D. contributed to data collection and analysis. M.Y. and M.S. interpreted the results. İ.O., E.B., and M.Ş. contributed to the drafting and critical revision of the article. All authors read and approved the final version.

Ethical Approval Statement

This study was approved by the Ethics Committee of Tokat Gaziosmanpaşa University on April 25, 2018, with approval number 2018/104.

Data Availability Statement

The data that support the findings of this study are not publicly available due to privacy or ethical restrictions.

Footnotes

Author Disclosure Statement

The authors declare no conflicts of interest related to this study.

Funding Information

No external funding was received for this study.

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