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A book for future publishers and authors order diclofenac gel 20 gm with visa, for doctors and students Free – for all those who would like to know how medical textbooks are produced today 20 gm diclofenac gel fast delivery. Medical Bernd Sebastian Kamps (BSK) is the director of the international Amedeo Literature Project (www buy 20gm diclofenac gel free shipping. Yanowitz, MD Professor of Medicine University of Utah School of Medicine Medical Director, Intermountain Healthcare ECG Services LDS Hospital & Intermountain Medical Center Salt Lake City, Utah frank. Lindsay, MD (1923-1987) master teacher of electrocardiography, friend, mentor, and colleague. Many of the excellent ECG tracings illustrated in this learning program are from Dr. The materials presented in the “Introduction to ECG Interpretation” Booklet are for your information only. You accept all risk of use of, and reliance on, the materials contained in the Booklet. This document and the ECG website offer an introduction to clinical electrocardiography. ECG terminology and diagnostic criteria often vary from book to book and from one teacher to another. In this document an attempt has been made to conform to standardized terminology and criteria, although new diagnostic concepts derived from the recent ECG literature have been included in some of the sections. The sections in this booklet are organized in the same order as the recommended step- wise approach to ECG interpretation outlined in Section 2 (p7). Beginning students should first go through the sections in the order in which they are presented. Others may choose to explore topics of interest in any order they wish. It is hoped that all students will be left with some of the love of electrocardiography shared by Dr. This list (updated in 2016) is provided on the following page and is also found on http://ecg. Students of electrocardiography are encouraged to study this list and become familiar with the ECG recognition of these diagnoses. Most of the diagnoses are illustrated in this document. This section describes the basic components of the ECG and the standard lead system used to record the ECG tracings. The diagram illustrates ECG waves and intervals as well as standard time and voltage measures on the ECG recordings. 0 It is important to recognize that lead I (and to a lesser extent aVL) are right -to- left in direction. Also, lead aVF (and to a lesser extent leads II and III) are superior -to- inferior in direction. The diagrams on the next page further illustrate the frontal plane and chest lead hookup. Precordial lead placement V1: 4th intercostal space (IS) adjacent to right sternal border V2: 4th IS adjacent to left sternal border V3: Halfway between V2 and V4 V4: 5th IS, midclavicular line V5: horizontal to V4; anterior axillary line V6: horizontal to V4-5; midaxillary line (Note: in women with large breasts, V4-6 leads should be placed under the breast surface as close to the 5th IS as possible) 6 2. Like the approach to a physical exam, it is important to follow a standardized sequence of steps in order to avoid missing subtle abnormalities in the ECG tracing, some of which may have clinical importance. The 6 major sections in the "method" should be considered in the following order: 1. MEASUREMENTS (usually made in the frontal plane leads):  Heart rate (state both atrial and ventricular rates, if different)  PR interval (from beginning of P to beginning of QRS complex)  QRS duration (width of most representative QRS)  QT interval (from beginning of QRS to end of T)  QRS axis in frontal plane (see "How to Measure QRS Axis" on p 8) 2. CONDUCTION ANALYSIS:  "Normal" conduction implies normal sino-atrial (SA), atrio-ventricular (AV), and intraventricular (IV) conduction. WAVEFORM DESCRIPTION:  Carefully analyze each of the12-leads for abnormalities of the waveforms in the order in which they appear: P-waves, QRS complexes, ST segments, T waves, and…. FINAL ECG INTERPRETATION:  This is the conclusion of the above analyses. Occasionally the term "borderline" is used if unsure about the significance of certain findings or for minor changes. Examples of "abnormal" statements are:  Inferior MI, probably acute  Old anteroseptal MI 7  Left anterior fascicular block (LAFB)  Left ventricular hypertrophy (LVH)  Right atrial enlargement (RAE)  Nonspecific ST-T wave abnormalities  Specific rhythm abnormalities such as atrial fibrillation Example of a 12-lead ECG interpretation using the “Method”: Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A= 67 V=67 Normal sinus Normal SA, rS in II, III, aVF; Abnormal ECG: PR=180 ms rhythm AV, and IV SIII > SII ; Left Anterior Fascicular Block QRS=90 ms conduction Small q in I, aVL; QT=400 ms Poor R progression Axis= -50 V1-4 6. These changes may have important implications for clinical management decisions. How to Measure the Frontal Plane QRS AXIS: INTRODUCTION: The frontal plane QRS axis represents the average direction of all ventricular depolarization forces in the frontal plane leads. As such this measure can inform the ECG reader of changes in the sequence of ventricular activation (e. In the next diagram the normal range is shaded grey (-30° to +90°). In the adult left axis deviation (see: superior, leftward blue arrow) is defined from -30° to -90°, and right axis deviation (see: inferior, rightward blue arrow) is defined from +90° to +180°. From -90° to ±180° is very unusual and is often due to lead placement error. This is often the lead with the smallest QRS complex. Isoelectric More likely axis Less likely axis Lead I +90 -90 II -30 +150 III +30 -150 aVR -60 +120 aVL +60 -120 aVF 0 +/-180  If there is no isoelectric lead, there are usually two leads that are nearly isoelectric, and these are always 30° apart on the diagram. Find the perpendiculars for each lead and chose an approximate QRS axis within the 30° range. An axis cannot be determined and is called indeterminate. Lead aVF is the isoelectric lead (note: equal forces positive and negative). Therefore, of the two choices, the axis has to be 0°. Lead aVR is closest to being isoelectric (but slightly more positive than negative) 2. Note that Lead I is mostly negative; lead III is mostly positive. Because aVR is slightly more positive, the axis is slightly beyond +120° (i. The following "normal" ECG characteristics, therefore, are not absolute. It takes considerable ECG reading experience to discover all the 11 normal variants. The normal 12-lead ECG illustrated below is an example of the usual 4- channel continuous 10 second recording including the V1 rhythm strip. Mearurements: Rhythm (s): Conduction: Waveform: Interpretation: A=55 V=55 Normal Sinus Normal SA, Normal P, QRS, ST, Normal ECG PR=140 Rhythm AV, and IV and U QRS=106 conduction QT=440 uncorrected Axis= +80 I. For example, normal QT is: QT  380 ms @ 80 bpm QT  420 ms @ 60 bpm  Frontal Plane QRS Axis: +90° to -30° (in the adult) II. Normal CONDUCTION: Normal Sino-Atrial (SA), Atrio-Ventricular (AV), and Intraventricular (IV) conduction IV. Normal WAVEFORM DESCRIPTION: 12 P Wave: It is important to remember that the P wave represents the sequential activation of the right and left atria, and it is common to see notched (lead II) or biphasic P waves (Lead V1) of right and left atrial activation. Two determinates of QRS voltages are:  Size of the ventricular chambers (i. This gives rise to asymmetrical T waves in most leads (see below). The ST segment occurs during Phase 2 (the plateau) of the myocardial cell action potentials. In some normal individuals, particularly women, T waves can be more symmetrical with a distinct horizontal ST segment.

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Thus far cheap diclofenac gel 20 gm on-line, specific obsessions and compulsions have not predicted outcome in the vast majority of follow- examined level of functioning in OCD generic 20gm diclofenac gel, pretreatment func- up studies buy diclofenac gel 20 gm without prescription. In a preliminary analysis of 544 patients from tioning did not predict follow-up outcome (73). Duration a multicenter trial of acute clomipramine, the authors failed of symptoms was not predictive in any study (78,79,81, to find any significant correlation between symptom sub- 82), although it is possible that chronicity accompanied by type, identified by the Y-BOC Symptom Checklist, and comorbidity may worsen prognosis. However, STABILITY OVER TIME few systematic clinical psychopathologic studies had been completed before 1985. Earlier studies were retrospective The beginning clinician is often struck by the diversity of and failed to utilize standardized diagnostic criteria or relia- the clinical presentations of OCD. During the last 15 years, we have character- ters on whether a psychopathologic continuum exists for ized the phenomenologic and clinical features of more than the two disorders. Some investigators have suggested that 1,000 patients with OCD. The basic types and frequencies obsessions are a preliminary sign of schizophrenia, whereas of obsessive-compulsive symptoms have been found to be others have claimed that obsessional thoughts are a neurotic consistent across cultures and time (84). Why particular defense against psychotic decompensation. Most current re- symptom patterns develop in given persons remains un- searchers feel that the two disorders are different entities known. The most common obsessions include contamina- without any true relationship. If OCDwas closely related to tion, pathologic doubt, aggressive and sexual thoughts, so- schizophrenia, one would expect that schizophrenia would matic concerns, and the need for symmetry and precision. How- The most common rituals are checking, cleaning, and ever, follow-up studies have shown that the incidence of counting. Rosen (85), in a retrospective terms of variation in overall intensity of symptoms, finer chart review of 850 inpatients with schizophrenia, found analyses of variations in symptom focus or symptom mix that approximately 10% exhibited prominent obsessive- have not been attempted. Nevertheless, in their study of compulsive symptoms. This finding was replicated by childhood OCD, Swedo and Leonard (22) reported that Fenton and McGlashan (86), who found that 10% of 90% of patients experienced some change in symptom pat- schizophrenics in a Chestnut Lodge (Rockville, Maryland) tern over time, often starting with a solitary ritual without follow-up study exhibited prominent obsessive-compulsive associated obsessive thoughts (notably uncommon in symptoms. These obsessive-compulsive schizophrenic pa- adults), then later adding new symptoms that sometimes tients tended to have a more chronic course and a greater became predominant over earlier ones. More work is needed frequency of social or occupational impairment in compari- to delineate the frequency and magnitude of the cyclic varia- son with a matched sample of schizophrenics without obses- tions in intensity and focus of obsessive-compulsive symp- sive-compulsive features. The average Y-BOCS score for those meeting the criteria COMORBIDITY for OCDwas 22. The relationship between obsessions, compulsions, and Biological markers and neuropharmacologic challenge stud- depression was the subject of several early studies. These ies depend on the selection of homogeneous clinical popula- were primarily retrospective and failed to use diagnostic cri- tions that reduce the variance. In studying a disorder like teria or structured interviewing. Thus, many aspects of the OCD, the presence of other axis I disorders is a serious association between depression and OCDremain unclear. The majority (57%) of OCDpatients present- tive episodes in OCDare primary or secondary. Dividing ing to our clinic have at least one other DSM-III-R diagno- depressed obsessional patients into these two categories (i. To complicate matters further, OCDis a chronic illness, primary and secondary) was originally advocated by Lewis and an even higher percentage of our patients have a lifetime (24). No systematic study of the frequency of obsessions history of another axis I disorder. Distinguishing primary and compulsions in a sample of depressed patients existed from secondary diagnoses can often be difficult, if not im- until recently. Although a great deal of interest has been possible. The coexistence of other anxiety states, depression, It has been noted that obsessive-compulsive features are and psychotic symptoms with obsessive-compulsive symp- rarely, if ever, seen in mania. We reported a case of OCD Chapter 111: Obsessive-Compulsive Disorder 1603 in a patient with bipolar disorder whose obsessions and childhood. Videbach (92) observed the same in 52 (50%) compulsions worsened in direct proportion to the severity of his 104 depressed, ruminative patients. Similarly, Ingram of his depression and totally disappeared when he became (26) reported that 22 (25%) of 89 OCDpatients had had manic (89). Although preliminary evidence suggests that significant phobias in childhood. During the last 5 years, OCDis rarely seen in mania, no systematic data on the several studies have examined the association of OCDwith frequency of obsessive-compulsive symptoms in a bipolar other anxiety disorders. In a study of 60 patients with panic population were available until recently. Subsequent studies by Mellman and found that 21% of patients with bipolar disorder, 12. Insel (88) pointed with other disorders had OCDin the National Epidemiol- out the importance of the distinction between primary and ogy Catchment Area Survey sample. For example, it is often difficult that 35% of patients with both bipolar and unipolar depres- to distinguish a primary social phobia with obsessive features sion had an obsessive-compulsive syndrome. Many of these from primary OCDthat is centered on obsessing about depressed patients suffer from obsessions, which are at times having to complete a ritual in public. The finding of a high difficult to differentiate from ruminations. The high prevalence of anxiety states in these pa- (72). The majority admitted to feelings of inadequacy and tients may be a consequence of common developmental/ hopelessness, and only one patient gave a history of eu- temperamental traits whose phenotypic expression is sec- phoria. During the course of their illness, most reported ondary to shared genotypic and psychosocial factors. Of that depression developed after the obsessive-compulsive particular interest in this regard is the high lifetime preva- symptoms; therefore, the patients were classified as having lence (12%) of separation anxiety in this group of patients secondary depression. A minority (8%) of patients had a (97), a finding that has also been well documented in panic simultaneous onset of obsessive-compulsive symptoms and disorder (20). Two-thirds of sional patients in his series had phobic symptoms. Among obsessive-compulsive patients have a lifetime history of a the 104 depressed obsessional patients of Videbach (92), 42 major depression, and one-third have a major depression at (40%) described phobic symptoms. In contrast, Welner et the time of first evaluation. Additional evidence supporting to have a concurrent unipolar recurrent depression. A signif- a shared vulnerability to OCDand other anxiety disorders icant overlap is also seen with the other axis I anxiety disor- is the high incidence of childhood phobias reported by ob- ders, including panic disorder, panic disorder with agora- sessional patients. Lo (28) reported that 21 (35%) of his phobia, social phobia, generalized anxiety disorder, and 59 obsessional patients had had significant phobias during separation anxiety disorder. COEXISTING AXIS I DIAGNOSES IN PRIMARY OBSESSIVE- COMPULSIVE DISORDER Current Lifetime Semistructured Semistructured From SADS Diagnosis (n = 100) (%) (n = 100) (%) (n = 60) (%) Major depressive disorder 31 67 78 Simple phobia 7 22 28 Separation anxiety disorder — 2 17 Social phobia 11 18 26 Eating disorder 8 17 8 Alcohol abuse (dependence) 8 14 16 Panic disorder 6 12 15 Tourette syndrome 5 7 6 SADS, Schedule for Affective Disorders and Schizophrenia. The patients with sexual or ag- eating disorders, Tourette syndrome, and schizophrenia. What if I do pick up the Comorbid axis I conditions can influence the course of ill- knife? On the opposite side of the spectrum are the patients Special attention has been focused recently on patients with OCDwho experience little or no anxiety that some- with tics and OCD. Approximately 20% of patients with thing terrible will happen. Janet observed that many patients OCDhave a lifetime history of multiple tics, and 5% to with OCDare tormented by an inner sense of imperfection. Their actions are never completely achieved to their satisfac- The age at onset in this subgroup is earlier, and they have tion.

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Functionally discount diclofenac gel 20 gm otc, the United 4 States is divided into UN O S regions as detailed on this m ap buy cheap diclofenac gel 20 gm line. Additional geographic divisions (ie diclofenac gel 20gm on-line, local designation) defined by the individual organ procurem ent organizations and the transplan- tation centers they service com prise the working system for cadav- eric renal allocation. UNITED NETW ORK FOR ORGAN SHARING: NUM BER OF PATIENT REGISTRATIONS ON THE NATIONAL TRANSPLANT W AITING LIST AS OF OCTOBER 31, 1997 Kidney number Kidney number Kidney number Kidney number by Kidney number by blood type (%) by race (%) by gender (%) transplantation center region (%) by age (%) Type O: 19,654(52. The UN O S patient waiting list is a com puterized list of recipients whose size or ABO type is incom patible with that patients waiting to be m atched with specific donor organs in the of a donor and then ranks those rem aining potential recipients hope of receiving a transplantation. Patients on the waiting list according to a UN O S board-approved system. As indicated are registered on the UN O S com puter by UN O S m em ber trans- here, nearly 40,000 patients are awaiting kidney transplantation plantation centers, program s, or organ procurem ent organiza- in the United States. The UN O S M atch System is an algorithm used to prioritize O rgan Sharing). Kidneys that cannot be allocated to a hum an leuko- cyte antigen (H LA)–m atched patient are Time of waiting distributed locally to candidates who are The “time of waiting” begins when a patient is listed and meets the minimum established criteria on the United ranked according to waiting tim e, with Network for Organ Sharing Patient W aiting List. One point will be assigned to the patient waiting for the longest additional points for degrees of H LA m is- period, with fractions of points being assigned proportionately to all other patients according to their relative m atch and antibody sensitization. Panel reactive antibody Patients will be assigned 4 points if they have a panel reactive antibody level of 80% or more. Medical urgency No points will be assigned to patients based on medical urgency for regional or national allocation of kidneys. W hen there is more than one local renal transplantation center, a cooperative medical decision is required before assignment of points for medical urgency. Pediatric kidney transplantation candidates 4 points if the patient is under 11 years of age. FIGURE 8-14 CROSSM ATCH M ETHODS Crossm atch m ethods. Early reports correlating a positive crossm atch between recipient serum and donor lym phocytes with hyperacute rejection of transplanted kidneys led to establishing tests of recipient sera as the standard of practice in transplantation. H owever, Lymphocytotoxicity: controversy rem ains regarding 1) the level of sensitivity needed for crossm atch testing; Auto–crossmatch vs allo–crossmatch 2) the relevance of B-cell crossm atches, a surrogate for class II incom patibilities; 3) the T or B cell relevance of immunoglobulin class and subclass of donor-reactive antibodies; 4) the significance of historical antibodies, ie, antibodies present previously but not at the time of transplantation; Short/long/wash/AHG methods 5) the techniques and type of analyses to be perform ed for serum screening; and 6) the IgG vs IgM appropriate frequency and timing of serum screening. Despite a number of variables, when Flow cytometry the data from reported studies are considered collectively, several observations can be Enzyme-linked immunosorbent assay m ade. H um an leukocyte antigen–donor-specific antibodies present in the recipient at the tim e of transplantation are a serious risk factor that significantly dim inishes graft function and graft survival. Antibodies specific for human leukocyte antigen class II antigens (HLA-DR and -DQ) are as detrimental as are those specific for class I antigens (HLA-A, -B, and -C). The degree of risk resulting from H LA-specific antibodies varies am ong im m unoglobulin classes, with im m unoglobulin G antibodies representing the m ost serious risk. Two of the m ost sensitive tech- niques are the antiglobulin-augm ented lym - 200 200 R2 phocytotoxicity (AH G) and flow cytom et- ric crossm atching. A, The use of flow 150 150 cytom etry to define the lym phocyte popu- lation by light scatter param eters, followed 100 100 by a specific m arker for T lym phocytes, R1 ie, CD3 (B) allows this technique to be 50 50 highly specific for hum an leukocyte antigen (H LA) class I–positive cells. The donor 0 0 lym phocytes have been preincubated with 0 50 100 150 200 250 0 50 100 150 200 250 recipient serum , washed, and subsequently A FSC B FSC stained with AH G-Fluorescsin isothio- cyanate (FITC), a fluorochrom e-labeled antihum an globulin. C, Results of flow 100 cytom etric cross-m atching are evaluated as 200 shifts in the fluorescence from negative sera T cell 90 Neg (n= 508) and are interpreted as positive or negative 160 80 Neg (n= 75) based on independently defined cutoffs 120 above the negative. D, M ultiple studies in 70 Pos (n= 106) renal transplantation have shown correla- 80 60 tions between positive AH G or flow cyto- M 1 Pos (n= 43) m etric cross-m atches and decreased graft 50 40 survival at 1 year or m ore. The largest 40 differences are seen when patients are 0 First Regraft grouped as prim ary grafts versus repeat 30 0 50 100 150 200 250 0 6 12 0 6 12 grafts. In som e instances the effect of using C ∝ Human IgG-Fc-FITC D M onths after transplantation a m ore sensitive cross-m atch technique only can be seen in patients having repeat grafts or those with a higher im m unologic FIGURE 8-15 risk. CD3 PE— m onoclonal antibody to Techniques of crossm atch testing. Early crossm atch testing provided a m eans to prevent CD3 fluorescent labelled with phycoery- m ost but not all hyperacute rejections. These early tests were perform ed with a technique thrin; FC— constant fragm ent of IgG m ole- of rather low sensitivity. Subsequently, m ore sensitive techniques were em ployed in an cule; FITC— fluorescent labelled with fluo- attem pt to not only prevent all hyperacute rejections but also im prove graft survival rescein isothiocynate; FSC— forward scat- rates. Techniques that have been used include variations of the lym phocytotoxicity test ter; R1— region 1; R2— region 2; SSC— side that incorporate wash steps, change in incubation tim es or tem peratures, or both, or add scatter. Flow cytom etry and an array of other m ethods such as antibody- with perm ission. Because completely mismatched kidney transplantations function well over long periods, an alternative approach might begin with the hypothesis that six-antigen “mismatched” transplantations were not Associated human leukocyte Approximate completely mismatched. Interest in reevaluating the potential roles CREG* antigen gene products “epitope” frequency, % of cross-reactive groups (CREGs) in transplantation is one such 1C A1,3,9,10,11,28,29,30,31,32,33 80 approach. In the early days of serologic HLA testing, a high panel 2C A2,9,28, B17 66 reactive antibody sera was considered to be composed of many anti- 5C B5,15,17,18,35,53,70,49 59 HLA antibodies. It was later noted, however, that sera of highly sensi- 7C B7,13,22,2740,41,47,48 64 tized patients awaiting solid organ transplantation were generally com- 8C B8,14,16,18 37 posed of a small number of antibodies directed at public antigens, also 12C B12,13,21,40,41 44 called CREGs, rather than multiple antibodies, each reacting with a 4C A24,25,32,34, Bw4 85 specific conventional HLA antigen. Furthermore, the frequency of the 6C Bw6, Cw1,3,7 87 CREGs was much higher, eg, 35% to 88% , than that of even the most common HLA-A and -B antigens. By inference, therefore, matching for donor and recipient antigens included in the same CREG, ie, CREG C refers to major public epitope or cross-reactive groups (CREG). In addition, because of the inclusion of several private HLA-A and -B antigens within a single CREG, a number of relatively rare antigens can be matched more easily, offering the possibility of improved graft survival for a greater number of both white and nonwhite patients. Recent large registry analyses for that patient, and if accepted by the transplantation center, was of the role for H LA m atching in renal transplantation consistently shipped for transplantation. Based on these results the United except in the case of patients with six antigen m atches. The first tim e was in 1990 to include pheno- UN O S initially determ ined that transplantations for which all six typically m atched pairs with fewer than six antigens. The policy H LA-A, -B, and -DR antigens m atched in the donor and recipient was changed for a second tim e in 1995 to include zero-m ism atched should be performed. Each cadaveric donor type was compared by a pairs in which the donor could have fewer antigens than the recipient, computer search with the HLA types of all patients awaiting kidney provided none were m ism atched. W hen a patient with six antigen m atches was perm ission. M ost of the published Serology versus M olecular (antibody defined) (Low Intermediate High resolution) transplantation outcom e data is based on serologic testing and assignm ent of antigens. These data include algorithm m atching based on “broad” hum an leukocyte antigen (H LA) specificities such as H LA-DR6 that includes H LA-DR13 and H LA-DR14 and HLA-DR13 *1301–*1312 *1314–*1330 their m any alleles. The question has now becom e one of what level of H LA testing is useful clinically for m atching purposes in renal transplantation. Although this issue has not been resolved, recent HLA-DR6 data published from the European Registry upholds the positive effect that “correct” HLA matching has had on renal graft outcome. HLA-DR14 *1401, *1402, *1405–*1429 DR1403 DR1404 Histocompatibility Testing and Organ Sharing 8. The effect on 90 graft survival of shared human leukocyte antigen (HLA) 0mm organs when defined by sero- DNA: DR 0 mm logic typing and then confirmed by molecular typing. A strong effect of HLA matching is 80 (n= 64) seen at even 1 year on the graft survival. A, Eighty-six first cadaveric kidney transplantations 70 that were reported by serologic typing as HLA-A, -B, -DR “identical-compatible” were tested DNA: DR >0 mm by molecular methods. Sixty-four transplantations were confirmed to be HLA-DR compati- 60 (n= 22) ble; however, mismatches were found in the remaining 22 transplantations. Transplantations in which HLA compatibility was confirmed had a functional success rate of 90% at 1 year 50 compared with 68% for transplantations in which the DNA typing revealed HLA-DR mis- 40 matches (P < 0. B, An analysis of the influence of HLA-class I DNA typing on kidney 0 3 6 9 12 graft survival is shown. A total of 183 cadaveric transplantations were confirmed to be A Time, mo HLA-A and B compatible after DNA typing, whereas mismatches were found in the remain- ing 32 cases.

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