competition for two years on the first offense. In 1988, Canadian sprinter Ben Johnson was stripp... more competition for two years on the first offense. In 1988, Canadian sprinter Ben Johnson was stripped of a gold medal and was later banned from track-and-field competition for life after he tested positive for steroids. At the 2000 Summer Olympic Games in Sydney, Australia, Romanian gymnast Andrea Raducan had her gold medal taken away when she tested positive for pseudoephedrine, a stimulant. American shot-putter C.J. Hunter withdrew from competition after it was revealed that he had tested positive four times for the steroid nandrolone. Scores of other athletes were also expelled from the Sydney Games after flunking drug tests. More recently, at the 2002 Winter Olympic Games in Salt Lake City, Utah, British skier Alain Baxter was stripped of his bronze medal after testing positive for methamphetamine, although an appeal is pending. Detection efforts notwithstanding, seeking an edge over one's opponents has long made the use of performance-enhancing drugs a part of athletic competition. A review of sports history reveals that drugs and sports have gone hand-in-hand for centuries, and surprisingly, drugs have only been banned from the Olympic Games since 1968. Explains Ivan Waddington in his book Sport, Health, and Drugs, "Performanceenhancing drugs have been used by people involved in sport and sportlike activities for some 2,000 years, but it is only very recently (specifically, since the introduction of anti-doping regulations and doping controls from the 1960s) that this practice has been regarded as unacceptable. In other words, for all but the last three or four decades, those involved in sports have used performance-enhancing drugs without infringing any rules and without the practice giving rise to highly emotive condemnation and stigmatization." This shift from tolerating doping in sports to testing athletes and ostracizing drug cheats has been driven by several factors. Perhaps most important, technological advances in performance-enhancing drugs, beginning in the 1950s, have bolstered the contention that drug use threatens the integrity of sports. Another motivation behind the shift has been to deter athletes from using illicit substances with unknown health effects. Consider, for example, the evolution of performance-enhancing drugs. Athletes in the late-nineteenth and early-twentieth centuries looking for chemical enhancement were stuck with the limited efficacy of stimulants and painkillers. In the mid-1950s, anabolic steroids, synthetic versions of the male sex hormone testosterone, were introduced. Anabolic steroids build muscle and bone mass by stimulating the muscle and bone cells to make new protein. Coaches and athletes saw these drugs as a major breakthrough because they enabled athletes to transcend the limits of natural ability and reach new levels of competitiveness. The first indication that athletes were using steroids came during the 1956 World Games in Moscow, Russia. According to Robert Voy in his book Drugs, Sport, and Politics, an American doctor, John B. Ziegler, observed Soviet athletes using urinary catheters, because steroids had enlarged their prostates to the point where urination was difficult. Ziegler returned to the United States and helped develop Dianobol, a steroid that was quickly embraced by American athletes, who hoped it would level the playing field with the Soviets. As a result, steroid use became widespread among elite athletes. Concerns that doped athletes were exercising an unfair advantage
Background: In spite of the widespread performance of intra-articular zygapophyseal joint (IAZJ) ... more Background: In spite of the widespread performance of intra-articular zygapophyseal joint (IAZJ) injections, we know of no systematic analysis to date that examines the risks and types of adverse events when IAZJ injections are performed. Objective: To describe the type, incidence, and factors contributing to adverse events associated with fluoroscopically guided IAZJ injections. Study design: A retrospective, cohort study of English-speaking adults aged 18 - 90 years who underwent fluoroscopically guided IAZJ injections between March 8, 2004, and April 19, 2007. Following IAZJ injections, 3 senior researchers recorded the presence and type of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with Fisher's exact or Wilcoxon rank sum 2-sided tests. Frequency of immediate (during or immediately after the procedure) or delayed (within 24 - 72 hours following the procedure) adverse events. Setting: Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic. Results: One hundred ninety-one patients (111 men) underwent 239 procedures. The mean and standard deviation (SD) of subject age was 56.4 (16.6) years ranging from 20 to 89. The mean and SD of pre-procedure 11-point Visual Analog Pain Scale was 5.5 (2.2) ranging from 0 to 10, and for post-procedure was 2.6 (2.6) ranging from 0 to 10. Trainees were involved in 52.3% of procedures. Reported immediate adverse events were vasovagal reaction (3.8%, n = 9) and steroid clogged needle (0.4%, n = 1). Follow-up data were available for 185/239 procedures (77.4%). There were 35 adverse events reported at mean follow-up interval of 1.8 days, of which the most frequent were injection site soreness (6.0%, n = 11), pain exacerbation (4.3%, n = 8), sleeplessness (2.2%, n = 4), and transient headache (1.6%, n = 3). Patient gender, age, trainee involvement, pre-procedural pain score, systolic or diastolic blood pressure, pulse, hemoglobin saturation as measured by pulse oximetry, volume of corticosteroid injected, and duration of fluoroscopy were not found to have a significant effect on immediate or delayed adverse events. Limitations: This study is limited by a 24- to 72-hour follow-up window, which may have also been too small to capture more delayed complications, and a sample size too small to accurately define the incidence of rare complications. Conclusion: Fluoroscopically guided IAZJ injections have minimal adverse effects. The most common immediate adverse event was vasovagal reaction and most common delayed adverse event was injection site soreness.
is a 44-year-old woman with a 2-year history of numbness and tingling in her dominant right hand.... more is a 44-year-old woman with a 2-year history of numbness and tingling in her dominant right hand. She reports that the symptoms are primarily in her third digit but also into her thumb and index finger. She works as a secretary and notes that she occasionally drops things, although she is not sure if this is because of true weakness or difficulty feeling things in her hand. She was diagnosed by her primary care physician with carpal tunnel syndrome and had a course of hand therapy with some improvement, but she still has persistent symptoms. She wears a custom splint made by her therapist, which does help with night pain, but she is frustrated with her symptoms at work. She has had electrodiagnostic testing, which demonstrated moderate median mononeuropathy at the wrist, with prolonged distal latency of both the motor and sensory studies but no evidence of axonal involvement. She would like to avoid surgery if possible and asked her primary care physician to refer her to someone with expertise in carpal tunnel injections. She presents to your office today, with the goal of having a carpal tunnel injection. She did some research on carpal tunnel injections, and although she is already committed to having the injection, she is unsure whether she would like this performed with ultrasound guidance. She is soliciting your advice: should the injection be performed with ultrasound guidance? Arguing for the position that yes, the injection should be performed with ultrasound guidance, is Gary Goldberg, MD. Dr Goldberg is a professor of physical medicine and rehabilitation at Virginia Commonwealth University, with expertise in brain injury, electrodiagnostic medicine, and therapeutic use of diagnostic ultrasound and ultrasound-guided procedures. Arguing for the position that, no, the injection does not need to performed with ultrasound guidance is Ronit Wollstein, MD. Dr Wollstein is an associate professor of orthopedic surgery and plastic surgery at the University of Pittsburgh, with special expertise in hand surgery.
Bill Dexter, 2. Early touch down weight-bearing with crutches. Subsequent progression of rehabili... more Bill Dexter, 2. Early touch down weight-bearing with crutches. Subsequent progression of rehabilitation focusing on range of motion, quadriceps strengthening (closed chain), and hamstring flexibility. 3. Five months later, the right knee was doing very well but patient was having persistent anterior left knee pain. Underwent local steroid and lidocaine injection over the patella avoiding the tendon. 4. One week later, MRI of left knee revealed persistent patellar tendinopathy. 5. Continued physical therapy with complete resolution of pain after two more months. Subsequently cleared for full activity. 6. Two months later suffered left patellar tendon rupture while performing standing long jumps (eccentric load) during training. Subsequently underwent patellar tendon repair.
is a 37-year-old man who works loading crates at a hardware store; he developed a right foot slap... more is a 37-year-old man who works loading crates at a hardware store; he developed a right foot slap and lateral lower leg pain after a long day of work. He was referred by his occupational health physician, who suspected lumbar radiculopathy. Initially, the patient worked with a physical therapist, who was able to centralize some of the patient's symptoms from the patient's lower leg into the buttock but never was able to fully centralize the symptoms. His foot slap is improving, but he still notices some increased fatigue of his tibialis anterior at long days of work. Because of the persistence of symptoms despite 6 weeks of physical therapy, the patient was referred to you for further assessment, and a magnetic resonance imaging of the lumbar spine was ordered. On examination, you note focal weakness of 4/5 strength in the tibialis anterior and the extensor hallicus longus, and with side-lying hip abduction. You also note a decreased medial hamstring reflex on the affected right side. The slump sit test did provoke symptoms on the right side that is improved with cervical extension. The remainder of the examination is normal. The magnetic resonance imaging reveals a neuroforaminal L5-S1 disk protrusion abutting the right L5 nerve root in the neuroforamen. The patient is interested in having an epidural steroid injection and is inquiring whether he should also have an electrodiagnostic study performed. Arguing that, yes, the patient should also have electrodiagnostic studies performed is Thiru Annaswamy, MD, MA. Arguing that, no, electrodiagnostic studies are not necessary is Robert W. Irwin, MD.
dence of HO in a large nonmilitary amputee population and describe its characteristics. Design: R... more dence of HO in a large nonmilitary amputee population and describe its characteristics. Design: Retrospective chart analysis. Setting: Amputee clinic at a large university-based tertiary care medical center. Participants: Adult lower extremity amputees. Interventions: Non applicable. Main Outcome Measures: Presence of HO, demographic characteristics. Results: In this cohort, 261 subjects were evaluated with average age at amputation of 50 years, and 69.3% men. With regard to etiology, 45.6% were traumatic, 29.9% were vascular and 23.0% were from infection. Most patients had transtibial amputation (67%) while 29.5% had transfemoral amputation. Residual limb pain was noted in 44.1% of the subjects while 55.9% reported phantom pain. Common medical comorbidities included hypertension (53.6%), diabetes mellitus (37.5%) and coronary heart disease (25.7%). Using plain radiographs of the residual limb, 37 (14.2%) had HO diagnosed. In the HO group, 8 (21.6%) had a vascular etiology, 23 (62.2%) were traumatic and 6 (16.2%) had an infectious etiology. Logistic regression was performed using HO as the dependent variable. The only variable significantly associated with HO diagnosis was the presence of diabetes mellitus. Conclusions: This is the largest study to date to characterize the incidence of HO in a civilian amputee population. We report the incidence of HO as 14.2% but this condition is not exclusive to individuals with traumatic amputation. Diabetes mellitus was the only independent variable associated with HO.
Review and reinterpretation of existing literature. Objective: This review article summarizes the... more Review and reinterpretation of existing literature. Objective: This review article summarizes the anatomy and pathogenesis of disease processes that contribute to low back pain, and discusses key issues in existing therapies for chronic low back pain. The article also explains the scientific rationale for investigational pharmacology and highlights emerging compounds in late development. Results/conclusion: While the diverse and complex nature of chronic low back pain continues to challenge clinicians, a growing understanding of chronic low back pain on a cellular level has refined our approach to managing chronic low back pain with pharmacology. Many emerging therapies with improved safety profiles are currently in the research pipeline and will contribute to a multimodal therapeutic algorithm in the near future. With the heterogeneity of the patient population suffering from chronic low back pain, the clinical challenge will be accurately stratifying the optimal pharmacologic approach for each patient.
David J. Kennedy, MD Department of Orthopaedics, Stanford J.F. is a 38-year-old physiatrist who h... more David J. Kennedy, MD Department of Orthopaedics, Stanford J.F. is a 38-year-old physiatrist who has been in a small group practice since she completed her fellowship 6 years ago. Her practice is a general physiatric practice. She does rounds daily on an inpatient service of 9 patients and has a mixed outpatient clinic that consists of follow-ups from her inpatient service, electromyograms, and amputee care. Her group was recently acquired by a larger medical institution in the area, and she became an employee of the hospital system. In recognition that medicine is changing and outcomes may be tied to future reimbursement, her new hospital business administrator implemented the random utilization of Press Ganey patient satisfaction surveys (Press Ganey Associated Inc, South Bend, IN). She was told that high patient satisfaction is imperative and that her bonus salary will be correlated with the results of these satisfaction surveys. Brian F. White, DO, and Gary Chimes, MD, PhD, will argue that satisfaction surveys do not enhance medical care. Peter Esselman, MD, will argue that satisfaction surveys are an integral part of a modern medical practice and facilitate better patient care.
competition for two years on the first offense. In 1988, Canadian sprinter Ben Johnson was stripp... more competition for two years on the first offense. In 1988, Canadian sprinter Ben Johnson was stripped of a gold medal and was later banned from track-and-field competition for life after he tested positive for steroids. At the 2000 Summer Olympic Games in Sydney, Australia, Romanian gymnast Andrea Raducan had her gold medal taken away when she tested positive for pseudoephedrine, a stimulant. American shot-putter C.J. Hunter withdrew from competition after it was revealed that he had tested positive four times for the steroid nandrolone. Scores of other athletes were also expelled from the Sydney Games after flunking drug tests. More recently, at the 2002 Winter Olympic Games in Salt Lake City, Utah, British skier Alain Baxter was stripped of his bronze medal after testing positive for methamphetamine, although an appeal is pending. Detection efforts notwithstanding, seeking an edge over one's opponents has long made the use of performance-enhancing drugs a part of athletic competition. A review of sports history reveals that drugs and sports have gone hand-in-hand for centuries, and surprisingly, drugs have only been banned from the Olympic Games since 1968. Explains Ivan Waddington in his book Sport, Health, and Drugs, "Performanceenhancing drugs have been used by people involved in sport and sportlike activities for some 2,000 years, but it is only very recently (specifically, since the introduction of anti-doping regulations and doping controls from the 1960s) that this practice has been regarded as unacceptable. In other words, for all but the last three or four decades, those involved in sports have used performance-enhancing drugs without infringing any rules and without the practice giving rise to highly emotive condemnation and stigmatization." This shift from tolerating doping in sports to testing athletes and ostracizing drug cheats has been driven by several factors. Perhaps most important, technological advances in performance-enhancing drugs, beginning in the 1950s, have bolstered the contention that drug use threatens the integrity of sports. Another motivation behind the shift has been to deter athletes from using illicit substances with unknown health effects. Consider, for example, the evolution of performance-enhancing drugs. Athletes in the late-nineteenth and early-twentieth centuries looking for chemical enhancement were stuck with the limited efficacy of stimulants and painkillers. In the mid-1950s, anabolic steroids, synthetic versions of the male sex hormone testosterone, were introduced. Anabolic steroids build muscle and bone mass by stimulating the muscle and bone cells to make new protein. Coaches and athletes saw these drugs as a major breakthrough because they enabled athletes to transcend the limits of natural ability and reach new levels of competitiveness. The first indication that athletes were using steroids came during the 1956 World Games in Moscow, Russia. According to Robert Voy in his book Drugs, Sport, and Politics, an American doctor, John B. Ziegler, observed Soviet athletes using urinary catheters, because steroids had enlarged their prostates to the point where urination was difficult. Ziegler returned to the United States and helped develop Dianobol, a steroid that was quickly embraced by American athletes, who hoped it would level the playing field with the Soviets. As a result, steroid use became widespread among elite athletes. Concerns that doped athletes were exercising an unfair advantage
Background: In spite of the widespread performance of intra-articular zygapophyseal joint (IAZJ) ... more Background: In spite of the widespread performance of intra-articular zygapophyseal joint (IAZJ) injections, we know of no systematic analysis to date that examines the risks and types of adverse events when IAZJ injections are performed. Objective: To describe the type, incidence, and factors contributing to adverse events associated with fluoroscopically guided IAZJ injections. Study design: A retrospective, cohort study of English-speaking adults aged 18 - 90 years who underwent fluoroscopically guided IAZJ injections between March 8, 2004, and April 19, 2007. Following IAZJ injections, 3 senior researchers recorded the presence and type of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with Fisher's exact or Wilcoxon rank sum 2-sided tests. Frequency of immediate (during or immediately after the procedure) or delayed (within 24 - 72 hours following the procedure) adverse events. Setting: Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic. Results: One hundred ninety-one patients (111 men) underwent 239 procedures. The mean and standard deviation (SD) of subject age was 56.4 (16.6) years ranging from 20 to 89. The mean and SD of pre-procedure 11-point Visual Analog Pain Scale was 5.5 (2.2) ranging from 0 to 10, and for post-procedure was 2.6 (2.6) ranging from 0 to 10. Trainees were involved in 52.3% of procedures. Reported immediate adverse events were vasovagal reaction (3.8%, n = 9) and steroid clogged needle (0.4%, n = 1). Follow-up data were available for 185/239 procedures (77.4%). There were 35 adverse events reported at mean follow-up interval of 1.8 days, of which the most frequent were injection site soreness (6.0%, n = 11), pain exacerbation (4.3%, n = 8), sleeplessness (2.2%, n = 4), and transient headache (1.6%, n = 3). Patient gender, age, trainee involvement, pre-procedural pain score, systolic or diastolic blood pressure, pulse, hemoglobin saturation as measured by pulse oximetry, volume of corticosteroid injected, and duration of fluoroscopy were not found to have a significant effect on immediate or delayed adverse events. Limitations: This study is limited by a 24- to 72-hour follow-up window, which may have also been too small to capture more delayed complications, and a sample size too small to accurately define the incidence of rare complications. Conclusion: Fluoroscopically guided IAZJ injections have minimal adverse effects. The most common immediate adverse event was vasovagal reaction and most common delayed adverse event was injection site soreness.
is a 44-year-old woman with a 2-year history of numbness and tingling in her dominant right hand.... more is a 44-year-old woman with a 2-year history of numbness and tingling in her dominant right hand. She reports that the symptoms are primarily in her third digit but also into her thumb and index finger. She works as a secretary and notes that she occasionally drops things, although she is not sure if this is because of true weakness or difficulty feeling things in her hand. She was diagnosed by her primary care physician with carpal tunnel syndrome and had a course of hand therapy with some improvement, but she still has persistent symptoms. She wears a custom splint made by her therapist, which does help with night pain, but she is frustrated with her symptoms at work. She has had electrodiagnostic testing, which demonstrated moderate median mononeuropathy at the wrist, with prolonged distal latency of both the motor and sensory studies but no evidence of axonal involvement. She would like to avoid surgery if possible and asked her primary care physician to refer her to someone with expertise in carpal tunnel injections. She presents to your office today, with the goal of having a carpal tunnel injection. She did some research on carpal tunnel injections, and although she is already committed to having the injection, she is unsure whether she would like this performed with ultrasound guidance. She is soliciting your advice: should the injection be performed with ultrasound guidance? Arguing for the position that yes, the injection should be performed with ultrasound guidance, is Gary Goldberg, MD. Dr Goldberg is a professor of physical medicine and rehabilitation at Virginia Commonwealth University, with expertise in brain injury, electrodiagnostic medicine, and therapeutic use of diagnostic ultrasound and ultrasound-guided procedures. Arguing for the position that, no, the injection does not need to performed with ultrasound guidance is Ronit Wollstein, MD. Dr Wollstein is an associate professor of orthopedic surgery and plastic surgery at the University of Pittsburgh, with special expertise in hand surgery.
Bill Dexter, 2. Early touch down weight-bearing with crutches. Subsequent progression of rehabili... more Bill Dexter, 2. Early touch down weight-bearing with crutches. Subsequent progression of rehabilitation focusing on range of motion, quadriceps strengthening (closed chain), and hamstring flexibility. 3. Five months later, the right knee was doing very well but patient was having persistent anterior left knee pain. Underwent local steroid and lidocaine injection over the patella avoiding the tendon. 4. One week later, MRI of left knee revealed persistent patellar tendinopathy. 5. Continued physical therapy with complete resolution of pain after two more months. Subsequently cleared for full activity. 6. Two months later suffered left patellar tendon rupture while performing standing long jumps (eccentric load) during training. Subsequently underwent patellar tendon repair.
is a 37-year-old man who works loading crates at a hardware store; he developed a right foot slap... more is a 37-year-old man who works loading crates at a hardware store; he developed a right foot slap and lateral lower leg pain after a long day of work. He was referred by his occupational health physician, who suspected lumbar radiculopathy. Initially, the patient worked with a physical therapist, who was able to centralize some of the patient's symptoms from the patient's lower leg into the buttock but never was able to fully centralize the symptoms. His foot slap is improving, but he still notices some increased fatigue of his tibialis anterior at long days of work. Because of the persistence of symptoms despite 6 weeks of physical therapy, the patient was referred to you for further assessment, and a magnetic resonance imaging of the lumbar spine was ordered. On examination, you note focal weakness of 4/5 strength in the tibialis anterior and the extensor hallicus longus, and with side-lying hip abduction. You also note a decreased medial hamstring reflex on the affected right side. The slump sit test did provoke symptoms on the right side that is improved with cervical extension. The remainder of the examination is normal. The magnetic resonance imaging reveals a neuroforaminal L5-S1 disk protrusion abutting the right L5 nerve root in the neuroforamen. The patient is interested in having an epidural steroid injection and is inquiring whether he should also have an electrodiagnostic study performed. Arguing that, yes, the patient should also have electrodiagnostic studies performed is Thiru Annaswamy, MD, MA. Arguing that, no, electrodiagnostic studies are not necessary is Robert W. Irwin, MD.
dence of HO in a large nonmilitary amputee population and describe its characteristics. Design: R... more dence of HO in a large nonmilitary amputee population and describe its characteristics. Design: Retrospective chart analysis. Setting: Amputee clinic at a large university-based tertiary care medical center. Participants: Adult lower extremity amputees. Interventions: Non applicable. Main Outcome Measures: Presence of HO, demographic characteristics. Results: In this cohort, 261 subjects were evaluated with average age at amputation of 50 years, and 69.3% men. With regard to etiology, 45.6% were traumatic, 29.9% were vascular and 23.0% were from infection. Most patients had transtibial amputation (67%) while 29.5% had transfemoral amputation. Residual limb pain was noted in 44.1% of the subjects while 55.9% reported phantom pain. Common medical comorbidities included hypertension (53.6%), diabetes mellitus (37.5%) and coronary heart disease (25.7%). Using plain radiographs of the residual limb, 37 (14.2%) had HO diagnosed. In the HO group, 8 (21.6%) had a vascular etiology, 23 (62.2%) were traumatic and 6 (16.2%) had an infectious etiology. Logistic regression was performed using HO as the dependent variable. The only variable significantly associated with HO diagnosis was the presence of diabetes mellitus. Conclusions: This is the largest study to date to characterize the incidence of HO in a civilian amputee population. We report the incidence of HO as 14.2% but this condition is not exclusive to individuals with traumatic amputation. Diabetes mellitus was the only independent variable associated with HO.
Review and reinterpretation of existing literature. Objective: This review article summarizes the... more Review and reinterpretation of existing literature. Objective: This review article summarizes the anatomy and pathogenesis of disease processes that contribute to low back pain, and discusses key issues in existing therapies for chronic low back pain. The article also explains the scientific rationale for investigational pharmacology and highlights emerging compounds in late development. Results/conclusion: While the diverse and complex nature of chronic low back pain continues to challenge clinicians, a growing understanding of chronic low back pain on a cellular level has refined our approach to managing chronic low back pain with pharmacology. Many emerging therapies with improved safety profiles are currently in the research pipeline and will contribute to a multimodal therapeutic algorithm in the near future. With the heterogeneity of the patient population suffering from chronic low back pain, the clinical challenge will be accurately stratifying the optimal pharmacologic approach for each patient.
David J. Kennedy, MD Department of Orthopaedics, Stanford J.F. is a 38-year-old physiatrist who h... more David J. Kennedy, MD Department of Orthopaedics, Stanford J.F. is a 38-year-old physiatrist who has been in a small group practice since she completed her fellowship 6 years ago. Her practice is a general physiatric practice. She does rounds daily on an inpatient service of 9 patients and has a mixed outpatient clinic that consists of follow-ups from her inpatient service, electromyograms, and amputee care. Her group was recently acquired by a larger medical institution in the area, and she became an employee of the hospital system. In recognition that medicine is changing and outcomes may be tied to future reimbursement, her new hospital business administrator implemented the random utilization of Press Ganey patient satisfaction surveys (Press Ganey Associated Inc, South Bend, IN). She was told that high patient satisfaction is imperative and that her bonus salary will be correlated with the results of these satisfaction surveys. Brian F. White, DO, and Gary Chimes, MD, PhD, will argue that satisfaction surveys do not enhance medical care. Peter Esselman, MD, will argue that satisfaction surveys are an integral part of a modern medical practice and facilitate better patient care.
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