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This option should be limited to otherwise healthy children who have a caregiver who will reliably be able to observe the child pain treatment center llc buy trihexyphenidyl 2 mg with amex, recognize symptoms of worsening illness, and have access to prompt medical care and follow-up if improvement does not occur. Analgesics Patients should undergo routine pain assessment, and appropriate pain-reducing treatments should be provided when needed. Various analgesics may be considered, including acetaminophen, ibuprofen, topical agents, and narcotics for severe pain. As no one agent has proven benefit over another, the product selected should incorporate patient/caregiver preference. Antibiotics Antibiotic treatment is recommended for infants under 6 months of age, all children with moderate to severe symptoms, and children who worsen or fail to improve over an initial observation period. For most children, amoxicillin at a dose of 80 to 90 mg/kg per day is recommended (see Table 38-3). Amoxicillin is the first-line agent because of its safety record, low cost, tolerable taste, limited antibacterial spectrum of activity, and effectiveness against susceptible and moderately resistant pneumococci. For patients with moderate to severe pain, or fever 39 C, initiate therapy with amoxicillin­clavulanate. If the patient does not improve over this time frame, reassess the patient to confirm the diagnosis, and consider changing the antibacterial agent. Strong evidence supports the use of the following medications as secondline agents (see Table 38-3): amoxicillin­clavulanate, cefuroxime, ceftriaxone, cefprozil, loracarbef, cefdinir, cefixime, and cefpodoxime. If a patient gives a history of penicillin allergy, consider an allergy consultation, as penicillin allergy is evanescent, and proper identification of allergic individuals can increase antibiotic choice in this population. Use of nasal decongestants and corticosteroids is not supported by the literature. Controllable prevention measures include breastfeeding, feeding the child upright if bottle-fed, avoiding passive smoke exposure, limiting exposure to other children, encouraging correct hand-washing techniques, decreasing pacifier use after 6 months of age, and keeping immunizations up-to-date. Patients should be retested after resolution of the effusion to document improvement. A short course of antibiotics with or without steroids may result in quicker improvement. However, the long term benefits and the risk/benefit ratio have not been demonstrated, and therefore these medications are not recommended. With appropriate care and aggressive monitoring, up to 70% of patients have spontaneous resolution of their symptoms without antibiotics. In observational studies conducted in different countries, the rates of mastoiditis did not differ in places where clinicians typically treat with antibiotics earlier as compared with areas where supportive care and monitoring are used preferentially. Most infants should have follow-up within a few days of onset of infection to detect treatment response and complications. For this reason, repeat antibiotics should only be used if patients appear to have continued infection and inflammation. Referral Patients may benefit from an otolaryngology referral if they develop mastoiditis or labyrinthitis, or if fever, agitation, or irritability persists after 48 hours despite therapy. In most patients, effusion will spontaneously resolve within 3 months, thereby decreasing the need for significant medical therapy. Children who are generally healthy can tolerate the brief periods associated with tinnitus, decreased hearing acuity, and possible vertigo. Thus, after 3 months, the decision to intervene will be based on a risk/benefit analysis utilizing clinical judgment, parental preference, impact on patient health, and available medical facilities. In patients with no evidence for hearing loss or secondary structural abnormalities of the middle ear, regular observation is suggested until the effusion resolves. If evidence for structural abnormalities is seen, then patients should be referred to otolaryngology for tympanostomy tube insertion. The term rhinosinusitis is increasing in popularity as sinusitis is usually, if not always, accompanied by rhinitis. Also, anatomic abnormalities, cystic fibrosis, ciliary motility disorders and immune deficiencies contributing to rhinosinusitis require unique approaches that are beyond the scope of this book. It is responsible for thousands of lost workdays, school days, and decreased productivity. It significantly affects quality of life, and has well known associated comorbid conditions, such as asthma and chronic cough, that also contribute to its overall cost. During an upper respiratory tract infection, nasal fluid may be forced into the sinuses, especially when a person blows their nose. This enables viral particles, cellular debris, and bacteria to be transported into the sinuses to produce a possible infection and an inflammatory response. These materials are either too thick or they become increasingly mucinous so that the normal ciliary mechanisms cannot clear them. Their persistence in sinus cavities may trigger a more exuberant inflammatory response thereby causing increased swelling, inflammation, and mucus production locally. The natural history of viral rhinosinusitis ranges from 1 to 33 days, with most patients showing improvement within 7 to 10 days, and 25% of patients having continued symptoms after 14 days. Determining whether the cause is infectious or noninfectious is usually as simple as taking a very thorough history and physical examination. Briefly, the hallmark of allergic disease is itching and sneezing, as compared to viral illnesses which often lack a significant pruritic component. Differentiating between the various causes of sinus inflammation is critical to determine appropriate treatment. Acute bacterial rhinosinusitis is defined as a cold that is worse or no better after 10 to 14 days. Common symptoms include nasal congestion and anterior and/or posterior nasal drainage. Additional symptoms may include cough, sore throat, headache, facial pain or pressure, periorbital edema, earache, halitosis, tooth pain, and hyposmia.

Deficiency of glucose-6-phosphate dehydrogenase is prevalent in certain parts of the world and is a frequent cause of hemolytic anemia (see above) pain treatment center mallory lane franklin tn buy cheap trihexyphenidyl 2mg line. Parasitic infections (eg, the plasmodia causing malaria) are also important causes of hemolytic anemias in certain geographic areas. In HbM, mutation changes the amino acid residue to which heme is attached, thus altering its affinity for oxygen and favoring its oxidation. Ingestion of certain drugs (eg, sulfonamides) or chemicals (eg, aniline) can cause acquired methemoglobinemia. Cyanosis (bluish discoloration of the skin and mucous membranes due to increased amounts of deoxygenated hemoglobin in arterial blood, or in this case due to increased amounts of methemoglobin) is usually the presenting sign in both types and is evident when over 10% of hemoglobin is in the "met" form. Diagnosis is made by spectroscopic analysis of blood, which reveals the characteristic absorption spectrum of methemoglobin. Additionally, a sample of blood containing methemoglobin cannot be fully reoxygenated by flushing oxygen through it, whereas normal deoxygenated blood can. Ingestion of methylene blue or ascorbic acid (both reducing agents) is used to treat mild methemoglobinemia due to enzyme deficiency. Acute massive methemoglobinemia (due to ingestion of chemicals) should be treated by intravenous injection of methylene blue. Laboratory investigations that aid in the diagnosis of hemolytic anemia are listed in Table 52­6. Methemoglobin Is Useless in Transporting Oxygen the ferrous iron of hemoglobin is susceptible to oxidation by superoxide and other oxidizing agents, forming methemoglobin, which cannot transport oxygen. Morphologic (eg, electron microscopy, freeze-fracture electron microscopy) and other techniques (eg, use of antibodies to specific components) have also been widely used. When red blood cells are lysed under specific conditions, their membranes will reseal in their original orientation to form ghosts (right-side-out ghosts). By altering the conditions, ghosts can also be made to reseal with their cytosolic aspect exposed on the exterior (inside-out ghosts). Both types of ghosts have been useful in analyzing the disposition of specific proteins and lipids in the membrane. All in all, more is known about the membrane of the red blood cell than about any other membrane of human cells (Table 52­7). The inherited form is usually due to deficient activity of cytochrome b5 reductase, but mutations can also affect the activity of cytochrome b5. All these major proteins have been isolated, most of them have been identified, and considerable insight has been obtained about their functions (Table 52­8). In addition, it has been determined which are integral or peripheral membrane proteins, which are situated on the external surface, which are on the cytosolic surface, and which span the membrane (Figure 52­5). Many minor components can also be detected in the red cell membrane by use of sensitive staining methods or two-dimensional gel electrophoresis. It is an example of a multipass membrane protein, extending across the bilayer approximately fourteen times. It probably exists as a dimer in the membrane, in which it forms a tunnel, permitting the exchange of chloride for bicarbonate. Carbon dioxide, formed in the tissues, enters the red cell as bicarbonate, which is exchanged for chloride in the lungs, where carbon dioxide is exhaled. Purified band 3 has been added to lipid vesicles in vitro and has been shown to perform its transport functions in this reconstituted system. Glycophorins A, B, and C are also transmembrane glycoproteins but of the single-pass type, extending across the membrane only once. A is the major glycophorin, is made up of 131 amino acids, and is heavily glycosylated (about 60% of its mass). Its amino terminal end, which contains 16 oligosaccharide chains (15 of which are O-glycans), extrudes out from the surface of the red blood cell. Approximately 90% of the sialic acid of the red cell membrane is located in this protein. Glycophorin A contains binding sites for influenza virus and for Plasmodium falciparum, the cause of one form of malaria. Intriguingly, the function of red blood cells of individuals who lack glycophorin A does not appear to be affected. Attached to the inner aspect of the membrane of the red blood cell are a number of peripheral cytoskeletal proteins (Table 52­8) that play important roles in respect to preserving shape and flexibility; these will now be described. These chains, measuring approximately 100 nm in length, are aligned in an antiparallel manner and are loosely intertwined, forming a dimer. Both chains are made up of segments of 106 amino acids that appear to fold into triple-stranded -helical coils joined by nonhelical segments. The overall shape confers flexibility on the protein and in turn on the membrane of the red blood cell. At least four binding sites can be defined in spectrin: (1) for self-association, (2) for ankyrin (bands 2. In turn, ankyrin binds tightly to band 3, securing attachment of spectrin to the membrane. Actin (band 5) exists in red blood cells as short, doublehelical filaments of F-actin. Abnormalities in the Amount or Structure of Spectrin Cause Hereditary Spherocytosis & Elliptocytosis Hereditary spherocytosis is a genetic disease, transmitted as an autosomal dominant, that affects about 1:5000 North Americans. It is characterized by the presence of spherocytes (spherical red blood cells, with a low surface-to-volume ratio) in the peripheral blood, by a hemolytic anemia (see Figure 52­3), and by splenomegaly. The spherocytes are not as deformable as are normal red blood cells, and they are subject to destruction in the spleen, thus greatly shortening their life in the circulation. Hereditary spherocytosis is curable by splenectomy because the spherocytes can persist in the circulation if the spleen is absent.

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The augmented pulmonary blood flow returns through the left atrium to the left ventricle pain solutions treatment center hiram cheap trihexyphenidyl 2 mg otc. To accommodate the increased pulmonary venous return, the left ventricle dilates (Figure 4. As dilation occurs, the radius and circumference of the left ventricle increase and the myocardial fibers lengthen. Therefore, as the left ventricle dilates and increases its radius, it must develop increased wall tension to maintain ventricular pressure. If the left ventricle becomes greatly dilated, the myocardium cannot develop sufficient tension to maintain the pressure­volume relationship, causing congestive cardiac failure. The pressure (P) in both the wide and narrow portions of the balloon is the same, but the wall tension (T) is greater where the radius (r) is greater. The signs and symptoms of a large ventricular septal defect vary with the relative vascular resistances and the volume of pulmonary blood flow. History In many patients with a large ventricular septal defect, the murmur may not be heard until the first postnatal visit. By that age, the pulmonary vascular resistance has fallen sufficiently that enough blood flows through the defect to generate the murmur. Patients with a large defect develop congestive cardiac failure by 2­3 months of age. By this time, the pulmonary arterioles have matured sufficiently to permit a large volume of pulmonary blood flow. As a consequence, left ventricular dilation develops and results in cardiac failure and its symptoms of tachypnea, slow weight gain, and poor feeding. The classic auscultatory finding is a loud pansystolic murmur heard best in the third and fourth left intercostal spaces. The murmur begins with the first heart sound and includes the isovolumetric contraction period of the cardiac cycle. The loudness of the murmur does not directly relate to the size of the defect; loudness depends on other factors, such as volume of blood flow through the defect. In patients with a large ventricular septal defect and a large volume of pulmonary blood flow, the volume of pulmonary venous blood crossing the mitral valve from the left atrium into the left ventricle during diastole is greatly increased. When the volume of blood flow across the mitral valve exceeds twice normal, a mid-diastolic inflow murmur may be heard, often following the third heart sound. Patients with a large ventricular septal defect have pulmonary hypertension related to various combinations of pulmonary blood flow and increased pulmonary vascular resistance. Regardless of etiology, pulmonary hypertension is indicated by an increased loudness of the pulmonary component of the second heart sound. The louder the pulmonary component, the higher is the pulmonary arterial pressure. In the presence of an apical diastolic murmur, the loud pulmonic valve closure primarily relates to increased pulmonary flow. The absence of a mitral diastolic murmur indicates that the pulmonary hypertension is secondary to increased pulmonary vascular resistance. Cardiomegaly is found in patients with increased pulmonary blood flow; it is indicated by a laterally and inferiorly displaced cardiac apex and/or a precordial bulge. Tachypnea, tachycardia, and dyspnea (especially with poor feeding and diaphoresis increasing during feeding in infants) suggest congestive cardiac failure. Peripheral edema and abnormal lung sounds are not typical signs of congestive heart failure in infants. Electrocardiogram the electrocardiogram reflects the types of hemodynamic load placed upon the ventricles: left ventricular volume overload related to increased pulmonary blood flow and right ventricular pressure overload related to pulmonary hypertension. Deep Q wave and tall R wave in lead V6 indicate volume overload of left ventricle. Right ventricular hypertrophy indicates elevated right ventricular systolic pressure paralleling the pulmonary arterial pressure level. Biventricular enlargement/hypertrophy exists in patients with a large volume of pulmonary blood flow and pulmonary hypertension due to a large defect. Isolated right ventricular hypertrophy and right-axis deviation occur in patients with pulmonary hypertension related to increased pulmonary vascular resistance of any cause. The increased pulmonary vascular resistance limits pulmonary blood flow, and therefore a pattern of left ventricular hypertrophy is absent. The radiographic appearance of the heart varies according to the magnitude of the shunt and the level of pulmonary arterial pressure. Ranging from normal to markedly enlarged, the size varies directly with the magnitude of the shunt. The cardiac enlargement results from enlargement of both the left atrium and the left ventricle from the increased flow. The left atrium is a particularly valuable indicator of pulmonary blood flow because this chamber is easily assessed on a lateral projection. By itself the right ventricular hypertrophy does not contribute to cardiac enlargement. The lateral view shows left atrial enlargement, outlined by barium within the esophagus. Summary of clinical findings the primary finding of ventricular septal defect is a pansystolic murmur along the left sternal border. The secondary features of ventricular septal defect reflect the components of the equation P = R Ч Q. The pulmonary arterial pressure (P) is indicated by the loudness of the pulmonary component of the second heart sound and by the degree of right ventricular hypertrophy on the electrocardiogram. Pulmonary blood flow (Q) is indicated by a history of congestive cardiac failure, an apical diastolic murmur, left ventricular hypertrophy on the electrocardiogram, cardiomegaly, and left atrial enlargement on chest X-ray.

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Second pain medication for dogs tramadol dosage buy cheap trihexyphenidyl 2mg line, focusing on the post-movement period, we compare error-related -power modulation for reaches in which movement-execution error is induced by an unexpected visual perturbation with trials in which the sensory-prediction error is expected and dissociated for the goal achievement. Third, in the light of previous studies examining -oscillatory correlates of feedback processing in the context of reward-learning tasks, we examine -band response to positive reinforcement. Existing research typically uses mappings that are well-learned at the outset such as using a computer mouse to control the movement of a cursor on a screen. Here, we study acquisition of novel sensorimotor maps by having participants learn center-out arm movements to auditory targets. The sounds were not physically localised in space but consisted of oscillators whose frequencies depended in a non- trivial fashion on the end position of the movement. We previously showed that this mapping can be learned, but the neurochemical bases of this learning are unclear. In order to assess learning performance, testing blocks were administered before and after learning where participants made reaching movements without receiving auditory feedback to a fixed set of targets, each of which repeated two times in random order. They then showed a marked reduction in reaching error over the course of training indicating that they learned the novel sensorimotor mapping. Interestingly, the change in aspartate concentration was significantly correlated with the amount of learning on a subject-level basis, suggesting a possible role of aspartate metabolism in sensorimotor learning. We also assessed changes in functional connectivity at rest between primary motor cortex and other motor and sensory structures that are correlated with the amount of learning. We relate these changes in functional connectivity with metabolic changes obtained using spectroscopy. The present works is a first step towards uncovering the neurochemical basis of changes in brain connectivity in the context of learning novel sensorimotor maps. However, the neural bases that allow us to learn these skills have been little investigated. Furthermore, studies on the neural basis of motor learning typically focus on either online task performance or on the changes in brain function observable at rest, once learning is complete, but it remains unclear how these two facets of brain plasticity relate to each other. Functional scans were collected during motor learning as well as at rest, immediately before and after learning. We show that in the active phase of learning, motor skill acquisition is accompanied by cerebellar, primary motor as well as prefrontal brain activity and connectivity. Immediately following the task we observed learning-related changes in the spontaneous activity of the brain, involving the connections between the cerebellum, premotor areas and sensory areas, both visual and somatosensory. Our findings provide an account of the changes in brain function throughout the early stages of acquiring a motor skill, suggesting that the cerebellum functions as a hub tying together motor performance, motor learning and early consolidation. Although the relationship between neuronal oscillations in the beta frequency range (15-30 Hz) and motor behaviour is well established, the functional relevance of resting and movement-related betaband activity for motor learning and retention in humans is incompletely understood. Here, we investigated the neurophysiological mechanisms underlying inter-individual variability in short-term motor learning behaviour. Since alterations in beta oscillations have been seen with ageing (Rossiter et al. Twenty young (18-30 years) and twenty elderly (62-77 years) healthy adults were trained on a motor sequence tracking task and subsequently tested for early (45-60 min) and late (24 hours) retention. Crucially, we found that pre-training levels of resting beta power from contralateral sensorimotor cortex were correlated with early motor sequence retention (r = -0. These findings contribute to our understanding of the neurophysiological mechanisms underlying motor learning, and suggest that beta oscillations as potential markers of the net inhibitory and excitatory mechanisms in human sensorimotor cortex are linked to individual differences in the capacity to retain learned motor skills. In the context of disease, beta oscillations may offer novel targets for therapeutic interventions designed to promote rehabilitative outcomes after brain injury. An issue of increasing concern is the effects of concussion history on skilled performance and motor learning, particularly in asymptomatic young athletes competing at or hoping to compete at elite levels. As expected there was a main effect of group on improvement in slalom course movement time (p<0. These data show that there are subtle differences in the ability to learn complex skills in young elite athletes with a concussion history, despite being deemed recovered by current standards. Most stroke survivors access neurorehabilitation to improve sensory and motor function. However, little is known about how stroke influences basic mechanisms of sensorimotor learning, and understanding these mechanisms may help improve rehabilitation outcomes. Here we examine motor learning patterns in a task that required stroke survivors and healthy adults to adapt their reaching movements to a novel visuomotor rotation. Subjects (5 stroke survivors; 21 healthy adults) interacted with a virtual reality system through the movement of their arms. The position of their fingertip was displayed in real time using a white cursor (0. We asked subjects to reach back-and-forth between two circular targets (2cm diameter) positioned 10-cm apart. We then introduced a 30counter-clockwise rotation onto the hand feedback cursor to examine how subjects adapted their movements. Subjects then performed another 25 movements with true hand feedback to examine how they de-adapted their movements. Preliminary analysis revealed marked differences in the learning patterns of stroke subjects and healthy adults. Although the overall extent of learning was similar across groups, stroke subjects required more trials to adapt (>90 trials) their movements to the same visuomotor rotation as healthy adults (<40 trials).

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Duncan the care of well infants pain tmj treatment generic 2 mg trihexyphenidyl with visa, children, and adolescents is an essential prevention effort for children and youth worldwide. The evolution of this preventive health care approach is derived from the long-standing view that the science of pediatrics is a science of health and development. Accordingly, sensory deprivation during the time when synaptic changes should be occurring has profound effects. Thus, the effects of strabismus leading to amblyopia in one eye may occur quickly during early childhood; likewise, patching an eye with good vision to reverse amblyopia in the other eye is less effective in late childhood. Early experience is particularly important because learning proceeds more efficiently along established synaptic pathways. Traumatic experiences also create enduring alterations in the neurotransmitter and endocrine systems that mediate the stress response, with effects noted later in life. Certain genetic polymorphisms may be associated with later disease onset under certain circumstances. The plasticity of the brain continues into adolescence, with further development of the prefrontal cortex, which is important in decision-making, future planning, and emotional control; neurogenesis persists in adulthood in certain areas of the brain, including the subventricular zone of the lateral ventricles and in portions of the hippocampus. Overview and Assessment of Variability Susan Feigelman the goal of pediatric care is to optimize the growth and development of each child. In addition to clinical experience and personal knowledge, effective practice requires familiarity with major theoretical perspectives and evidencebased strategies for optimizing growth and development. To target factors that increase or decrease risk, pediatricians need to understand how biologic and social forces interact within the parent-child relationship, within the family, and between the family and the larger society. Growth is an indicator of overall well-being, status of chronic disease, and interpersonal and psychologic stress. By monitoring children and families over time, pediatricians can observe the interrelationships between physical growth and cognitive, motor, and emotional development. Observation is enhanced by familiarity with developmental theory and understanding of developmental models which describe normal patterns of behavior and provide guidance for prevention of behavior problems. Effective pediatricians also recognize how they can work with families and children to bring about healthy behaviors and behavioral change. This model neglects the psychologic aspect of a person who exists in the larger realm of the family and society. This basic model can be used to understand health and both acute and chronic disease. Critical to learning and remembering (and therefore development) is neuronal plasticity, which permits the central nervous system to reorganize neuronal networks in response to environmental stimulation, both positive and negative. Overproduction of neurons, by creating a reservoir of neurons upon which to draw in the case of injury or learning, appears to be adaptive. The brain comprises 100 billion neurons at birth, with each neuron developing on average 15,000 synapses by 3 yr of age. The number of synapses stays roughly constant through the first decade of life as the number of neurons declines. Synapses in frequently used pathways are preserved, whereas less-used ones atrophy, through neuronal "pruning. Increases or decreases in synaptic activity result in persistent increases or decreases in synaptic strength. Thus, experience (environment) has a direct effect on the physical properties of the brain (genetics). Children with different talents and temperaments (already a combination of genetics and environment) further elicit different stimuli from their (differing) environments. Pr C op D ont ert o e y N nt of ot N E D ot ls is F ev tri in ie bu al r the Biologic Influences Biologic influences on development include genetics, in utero exposure to teratogens, the long-term negative effects of low birthweight (increased rates of obesity, coronary heart disease, stroke, hypertension, and type-2 diabetes), postnatal illnesses, exposure to hazardous substances, and maturation. The negative effects on development of prenatal exposure to teratogens, such as mercury and alcohol, and of postnatal insults, such as meningitis and traumatic brain injury, have been extensively studied. Any chronic illness can affect growth and development, either directly or through changes in nutrition, parenting, or peer interactions. Physical and neurologic maturation propels children forward and sets lower limits for the emergence of most abilities. The age at which children walk independently is similar around the world, despite great variability in child-rearing practices. The attainment of other skills, such as the use of complex sentences, is less tightly bound to a maturational schedule. Decrements in growth rate and sleep requirements around 2 yr of age often generate concern about poor appetite and refusal to nap. Although it is possible to accelerate many developmental milestones (toilet training a 12 mo old or teaching a 3 yr old to read), the long-term benefits of such precocious accomplishments are questionable. In addition to physical changes in size, body proportions, and strength, maturation brings about hormonal changes. Behavioral effects of testosterone may be evident even in young children and continue to be salient throughout life. Correlations between testosterone levels and such traits as aggression or novelty seeking have not been consistently demonstrated. The classic theory of Thomas and Chess proposes 9 dimensions of temperament (Table 6-1). These characteristics lead to 3 common constellations: (1) the easy, highly adaptable child, who has regular biologic cycles; (2) the difficult child, who withdraws from new stimuli and is easily frustrated; and (3) the slow-to-warm-up child, who needs extra time to adapt to new circumstances. Temperament has long been described as biologic or "inherited," largely based on parent reports (although confirmed by some independent observational studies) of twins. Monozygotic twins are consistently rated by their parents as temperamentally more similar as are dizygotic twins. Estimates of heritability suggest that genetic differences account for approximately 20-60% of the variability of temperament within a popu- Figure 6-1 Continuumandhierarchyofnaturalsystemsinthebiopsychosocialmodel. It was presumed that the remaining 80-40% of the variance is environmentally influenced because genetic influences tended to be viewed as static.

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