Prognostic Value of Transthoracic Echocardiography in Hemodynamically Stable Patients With Acute Symptomatic Pulmonary Embolism. 7 Other findings included atrial . D-Dimer: Normal D-Dimer level makes acute PE/DVT less likely but elevated D-Dimer cannot confirm PE due to its low positive predictive value. A D-dimer's value is in its positive predictive value. PEs - the classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III ("S1Q3T3"). Assessment of cardiac stress from massive pulmonary embolism with 12-lead ECG. T wave inversion in V2-V3 6. RBBB 5. Right-sided S3 Parasternal lift P.E. When compared with manual chart review, NLP interrogation of CUS, CTPA, CT angiography of the chest, and V/Q scan yielded a sensitivity = 93.3%, specificity = 99.6%, positive predictive value = 97 . If the D-dimer is positive consider chest CTA. Posted by Steve Smith at 9:28 AM Email ThisBlogThis!Share to TwitterShare to FacebookShare to Pinterest The ECG changes associated with acute pulmonary embolism may be seen in any condition that causes acute pulmonary hypertension, including hypoxia causing pulmonary hypoxic vasoconstriction. Conclusion: Inpatient CTPAs appear to be over-requested and can potentially be rationalised based on a combination of clinical predictors and Wells' criteria and/or PERC rule. . . Sensitivity = 60%. Kosuge M et al AJJ 99:15 March 2007;pp817-821 Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T waves. . Patients with PTE had a significantly longer mean QTc in V1 (454.6 ± 44.3 vs 417.5 ± 31.3 ms, P < .001) and larger QTc difference (V1 - V6) (34.8 ± 30.5 vs -12.5 ± 16.6 ms, P < .001) than non-PTE controls. do not have leg symptoms at time of diagnosis Patients with leg symptoms may have asymptomatic P.E. Frequently, its diagnosis is delayed or frankly missed and often it is only discovered during autopsy. In one study, for patients with suspected PE and with normal PaO. surgery within the past 4 weeks or immobilization for the past 3 days + 1.5. previously diagnosed PE or DVT + 1.5. hemoptysis +1. A prospective study comparing angiographic clot burden score and ECG score in 105 patients with PE found no correlation between the two, and neither predictor correlated with 12-month mortality. 1. (ABG) ABG: Hypoxemia Hypocapnia . Pulmonary embolism (PE) is a disease entity with a high mortality rate, ranging from 2.5-33%. T wave inversion in V2-V3 6. the threshold for a positive test is 600 ng/mL in a 60 year old, 700 ng/mL in a 70 year old, etc. low risk. The ECG in pulmonary embolism: predictive value of negative T waves in precordial leads: 80 case reports. Sreeram and colleagues 5 reviewed the value of the 12 lead ECG at hospital admission in the diagnosis of PE. The most specific test was ECG showing S1Q3T3 (SPE - 100%, P = 0.421), followed by Wells score > 6 (SPE - 91%, P = 0.211). However, its reported incidence in acute PE is quite variable from 10-50% and in some studies has been found to be equally likely in patients without PE [1,7]. We calculated risk ratios (RR) with a 95% confidence interval (CI) for each variable in the model. Statistical analysis was with SPSS 12.0. They found that NEGATIVE T waves in III and V1 had a 97% positive predictive value for PE. The ECG showing S1Q3T3 had highest specificity but again was poorly sensitive (SNS 14%, SPE 100%; P = 0.421). There was no test with sensitivity and specificity more than 90% Positive and negative predictive values of scoring system 57.1 and 81.7 respectively. Compare this to the left ventricular strain pattern, where ST/T-wave changes are present in the left ventricular leads (I, aVL, V5-6). 1.3% incidence of PE. Crossref Medline Google Scholar; 10 Daniel KR, Courtney DM, Kline JA. Ventilation-Perfusion Scans Useful if Normal (negative predictive value of 97%) Also useful if High probability (positive predictive value of 85 to 90%) Unfortunately, only diagnostic in 30 to 50% of patients 17. Results . 2. Atrial arrhythmias not previously diagnosed showed a high negative predictive value for death from PE at 15 days (97%), but the positive predictive value was low (Table 4). . S1Q3T3, inverted T waves in leads V1-V4 . Acute ECG features were analysed in 49 patients with proven PE and . In most patients the threshold for a positive d-dimer test is 500 ng/mL. PULMONARY EMBOLISM DIAGNOSIS Dr.Tinku Joseph DM Resident Dept. The prevalence of PE is high in their study, and the positive predictive value may be lower than expected despite the very high positive LR of 16 in our patient population, which is likely to have a lower rate of positive PE studies (closer to the 6% prevalence rate from Marchick's study). Table 4 cTnI results of PE (+) and PE (-) patients. 8 A D-dimer assay is not indicated if your patient has an intermediate or high risk of having a PE. 2, PaCO. Around 66% of deaths occur during the first hour of presentation and 75% of deaths during the initial hospitalization. 1) A. Predictive value of high-sensitivity troponin-I for future adverse cardiovascular outcome in stable patients with type 2 diabetes mellitus. Answers. Very few studies define S1Q3T3. We calculated risk ratios (RR) with a 95% confidence interval (CI) for each variable in the model. 30% c. 50% d.80%. CONCLUSIONS: 21-ECG score is a simple and cheap method which can be used to predict RVD and serious complications in patients with APE. It was calculated that high cTnI level had 50.7% sensitivity and 88.3% specificity, positive predictive value (PPV) was 86.4% and negative predictive value (NPV) was 55.8%. Both PERC and Wells criteria had poor positive predictive value (27% and 12% respectively), but the negative predictive value for PERC was 100% and 95.8% for Wells. For massive PE anterior T wave inversions had a sensitivity of 85%, a specificity of 81%, a positive predictive value of 93%, and a negative predictive value of 65%. Normal d-dimer values increase with age, so 100 ng/mL may be added per decade of life over the age of 50: E.g. The sensitivity (SEN), specificity (SPE), positive predictive value (PPV), and negative predictive value (NPV) were calculated for each test. Sonographic features characteristic, albeit nonspecific, of hemothoraces include 12; homogenously echogenic effusion 1100 consecutive patients referred for investigation for PE. 24 of the positive MRSA cultures were from blood, 7 from urine and 9 from sputum. ECG: Common ECG findings are Tachycardia, non-specific ST-segment, and T-wave changes with S1Q3T3 pattern, right ventricular strain, Right Bundle Branch Block. Around 66% of deaths occur during the first hour of presentation and 75% of deaths during the initial hospitalization. pooled from reproduced data - sensitivity = 36-90% depending on the case series. The most frequently cited abnormality, in addition to sinus tachycardia, is the S1Q3T3 sign (McGinn-White sign): an S wave in lead I, a Q wave in lead III, . S1Q3T3 (3.7%), P pulmonale (0.5%) and right axis deviation (4.2%) were infrequent findings. The classic EKG findings of S1Q3T3, right ventricular strain, and new incomplete right bundle branch block are seen in patients with massive acute PE and cor pulmonale.15-17 Findings associated with poor prognosis include:15 . 1,2 The ECG findings have been assessed in relation to the PE size, pulmonary artery mean pressure, and partial pressure of oxygen in arterial blood. Table 2 Electrocardiographic characteristics of patients with or without pulmonary thromboembolism. The model established in this study had a superior AUC (0.8741) compared with the other scoring systems investigated. Precordial T-wave inversion, along with a negative T-wave in lead III, should alert you to the strong possibility of pulmonary embolism. RBBB 5. In contrast, a positive D-dimer yields a poor positive predictive value with poor specificity. ST Elevation in aVR . ; D-dimer testing — in people with a Wells score of 4 points or less when PE is thought to be unlikely. The S1Q3T3 pattern describes the presence of an S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III. In the Marchik article, (assuming they defined it the same way, and the methods do not specify this), among patients with suspicion for PE, S1Q3T3 was found in 8.5% of patients with PE and 3.3% of patients without PE. . A metanalysis demonstrated that a positive NP test (BNP >100 pg/mL; NT-proBNP >600 ng/L) was associated with an increased risk of between 6 to 16 for all-cause in-hospital or short-term mortality in patients with acute PE . The hypothesis was that 12‐lead electrocardiography (ECG) can aid in this determination . In this study which had a prevalence of detection was 32%, the positive predictive value of 67.0% and negative predictive value of 85.2%. c. Changes found in fewer than 10% of cases of PE. • Angiography: Pulmonary angiography is . Right bundle branch . They have a specificity of 99% and a positive predictive value of 97% for a PE Am J Cardiol, March 2007. CT Angiography 18. An arterial blood gas (ABG) analysis should be obtained to assess for oxygenation and to determine the possible need for advanced ventilation techniques. 10. The various radiological studies for diagnosis of PTE (CT pulmonary angiography, V/Q scan, and echocardiogram) sometimes divert the clinicians to use ECG as a diagnostic tool. Lab Findings in P.E. The positive LR of S1Q3T3 is 3.7. Discussion. 1. The sensitivity (SEN), specificity (SPE), positive predictive value (PPV), and negative predictive value (NPV) were calculated for each test. with a 92-96% positive and negative predictive values (when interpreted appropriately). RESULTS 2001; 120: 474-481. pulmonary embolism (PE) is the most likely diagnosis +3. atrial arrhythmias, most frequently atrial . Risk factors include immobility, inherited hypercoagulability disorders, pregnancy, puerperium . ST depression and T wave inversion in leads corresponding to the right ventricle: Inferior leads II, III, aVF, often most pronounced in lead III as this is the most rightward facing lead. Background Pulmonary embolism (PE) is a disease entity with a high mortality rate, ranging from 2.5-33%. The electrocardiographic (ECG) findings in patients with pulmonary embolism (PE) and no previous cardiopulmonary disease are well documented. ABG BNP Cardiac Enzymes: Troponin D-dimer EKG CXR Ultrasound V/Q Scan Angiography Lab Findings in P.E. Conversely, the positive predictive value of a positive CT result was high (92-96%) in patients with an intermediate or high clinical . have good sensitivity and negative predictive value, but poor specificity and positive predictive value. The ECG score assigned varying weights to several measures related to right ventricular strain, such as right bundle branch block, precordial T wave inversion, and the S1Q3T3 pattern. Objectives Treatment guidelines for acute pulmonary embolism (PE) recommend risk stratifying patients to assess PE severity, as those at higher risk should be considered for therapy in addition to standard anticoagulation to prevent right ventricular (RV) failure, which can cause hemodynamic collapse. Prognostic Value of Transthoracic Echocardiography in Hemodynamically Stable Patients With Acute Symptomatic Pulmonary Embolism. In a second retrospective study of 33 consecutive patients with massive PE by conventional clinical criteria, there was also no correlation between findings on CT angiography and mortality. Both PERC and Wells criteria had poor positive predictive value (27% and 12% respectively), but the negative predictive value for PERC was 100% and 95.8% for Wells. T wave inversion in V1-V4. Ventilation:perfusion scanning of the lungs (and explain why Dr. Elliott is a much . 14 Pro-BNP also falls in line with this trend, with negative and positive predictive values for adverse outcomes of 97% and 45% . Positive predictive value of CT pulmonary angiography (CTA) in the PIOPED II study; Location of embolism Number of patients with true positive CTA . Lab & Radiologic Findings in P.E. Evidence is . 2, 38% were We also compared the performance of the combination of tests like 2D ECHO and d -dimer in patients with intermediate to high probability of PE (Wells score ≥ 3, Wells score > 6) ( Table 4 ). Dr Yarusi: The constellation of an elevated cardiac troponin I, signs of right ventricular strain on ECG, and dyspnea associated with syncope is highly suspicious for life-threatening PE. The classic S1Q3T3, right axis-deviation, and new incomplete RBBB are less common. Kosuge M et al AJJ 99:15 March 2007;pp817-821 Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T waves. "False . . This pattern was first described by McGinn and White in 1935, and is fairly well known as an indication of acute pulmonary embolism. A clinical decision rule, including the presence of oral contraceptive use, tachycardia, and oxygen saturation <95%, demonstrated a sensitivity and specificity of 90 and 56%, respectively, a positive and negative likelihood ratio of 2.0 and 0.2, and a positive and negative predictive value of 0.12 and 0.99, respectively . D-dimer: D-dimer tests have a strong negative predictive value for ruling out PE when clinical suspicion is low (see below). Admission ECG showed sinus tachycardia with a rightward axis, S1Q3T3 pattern, and additional T-wave inversions in leads V 1 and V 2. In summary, this ECG increases my suspicion for a pulmonary embolism. These LR data suggest that six ECG findings can significantly alter prognosis of patients with PE (heart rate > 100 beats/min, S1Q3T3, complete RBBB, inverted T waves in V1-V4, ST elevation in aVR, and atrial fibrillation), assuming that ECG findings with both a negative LR (LR-) value with upper limit 95% CI below unity and a positive LR . Its sensitivity and positive predictive value for identifying PTE were 17.8% and 61.5%, respectively. 1 Localized tenderness along the distribution of the deep venous system 1 Entire leg swollen 1 Calf swelling at least 3 cm larger than that on the asymptomatic side (measured 10 cm below tibial tuberosity) 1 Pitting edema confined to the symptomatic leg 1 Previously documented deep-vein thrombosis 1 < 2 points. S1Q3T3 (3.7%), P pulmonale (0.5%) and right axis deviation (4.2%) were infrequent findings. This may help identify patients with a lower risk and better prognosis. S1Q3T3 pattern. The results of cTnI of both groups were presented in Table 4. . Diagnostic utility of ECG scoring system (previously derived in patients diagnosed as PE positive) assessed for validation. In the validation cohort, the Daniel-ECG score, Wells score, and Geneva score exhibited favorable specificity and a positive predictive value and exhibited poor sensitivity and a negative predictive value. (D-dimer) • D-dimer: • Degredation product of fibrin • >500 is abnormal • Sensitivity: High, 95% of PE pts will be positive • Specificity: Low • Negative Predictive Value: Excellent. In fact, the patient had a CTPA and had bilateral large emboli! Within each category, findings are listed in approximate order of positive predictive value (expert opinion). Crossref Medline Google Scholar Of Pulmonary Medicine AIMS, Kochi. The following ECG variables were tak- tality incidence with sensitivities of 58% and 59%, en as abnormal: complete RBBB, atrial arrhythmias, specificities of 60% and 58%, positive predictive ST segment depression in leads V4-V6, and ST seg- values of 16% and 10%, and negative predictive ment elevation in lead I, aVL and V4-V6, Q waves . In this particular case series, it was not the most prevalent ECG finding; rather, T wave inversion was. We present sensibility, specificity, positive and negative predictive values, and positive and negative likelihood ratios for prognostic electrocardiographic findings. Nighttime vital signs can disrupt sleep and adversely affect patient satisfaction and contribute to delirium. Unfortunately it is not seen in all patients affected by PE. Statistical analysis was with SPSS 12.0. What percentage of ambulatory patients who present with PE have no identifiable clinical risk factors? S1Q3T3 4. May have a very high sensitivity (92%), specificity (100%) positive predictive values (100%) and negative predictive values (98%) for the detection of a hemothorax in the context of preceding trauma 2. The most common ECG abnormality in patients with PE was sinus tachycardia (28%). Conversely the positive predictive value of a positive CTPA was high (92% to 96%) in patients with an intermediate or high probability pre-test Wells Score but only 58% in those with a low probability pre-test score. . Whereas a negative D . Secondary care investigations for pulmonary embolism (PE) may include one or more of the following: Computed tomographic pulmonary angiography — the investigation of choice for most people with high clinical probability of PE, or non-high clinical probability and a positive D-dimer test. The sensitivity (SEN), specificity (SPE), positive predictive value (PPV), and negative predictive value (NPV) were calculated for each test. Predictive value of high-sensitivity troponin-I for future adverse cardiovascular outcome in stable patients with type 2 diabetes mellitus. I don't think there's really an S1Q3T3 pattern, as there's a small r in front of the 'Q' wave . PE-SCORE resulted in a score of zero (low-risk) with a negative predictive value of 97.9% and 2% had the primary outcome, and a score >5 to define high-risk patients who all had the primary outcome. S1Q3T3, a traditional ECG marker, had no diagnostic value for acute PTE. In one other series, it was 90% prevalent (equivalent to TWI), and in PMID 123074, it is the most prevalent at 69% while TWI is only 42%. Results . d. Cannot use normal ABGs to exclude PE. QTc difference (V1 - V6) was negative in all patients without PTE. Pulmonary embolism is the obstruction of one or more pulmonary arteries by solid, liquid, or gaseous masses.In most cases, the embolism is caused by blood thrombi, which arise from the deep vein system in the legs or pelvis (deep vein thrombosis) and embolize to the lungs via the inferior vena cava. Showed S1Q3T3 pattern with a concern for pulmonary thromboemboli sm (PE) which prompt obtaining chest CT scan with IV contrast didn't rev eal pulmonary thromboembolism but showed a right -sided. Like cardiac troponin, BNP has a high negative predictive value for adverse outcomes in pulmonary embolism but a low positive predictive value (97% and 48%, respectively, in a study using a cutoff value of 50 pg/mL). The prevalence of the S1Q3T3 pattern was 17.8% in the PTE group, which was not significantly different from that (11.4%) in the non-PTE group. Purpose: We developed a predictive . Archivos De Bronconeumologia, 2007. . S1Q3T3 (poor sensitivity & specificity) Results 20%-25% of patients with PE, including those with large clot load, had normal ECGs. It was described way back in 1935 and both S1 and Q3 were defined as 1.5 mm (0.15 mV). ST segment migration in V1 through V4. RESULTS 4. 20,000 Days On Earth, Wizards Of Waverly Place Alex Vs Alex Full Episode, Drink With Me, Hacker 2019 Sub Indo, Cours Infirmier 1ère Année, Battle Of Wagram, Young Doctors In Love, Winter Storm Quebec, S1q3t3 Positive Predictive Value, Love Is Strange Imdb, Reformation Hollyhock Dress, Conclusion Inpatient CTPAs appear to be over-requested and can potentially be rationalised based on a combination of clinical predictors and Wells' criteria and/or PERC rule. Most common finding is normal chest x-ray. 1997; 111: 537-543. ECG: sinus tachycardia, normal sinus rhythm, and nonspecific ST-segment and T-wave changes are the most common findings. We present sensibility, specificity, positive and negative predictive values, and positive and negative likelihood ratios for prognostic electrocardiographic findings. 2, and P(A-a)O. S1Q3T3 4. 2. Always consider these. The overall positive predictive value (PPV) of MRSA swabs in predicting future MRSA cultures was 8.1% and negative predictive value (NPV) was 99.1% (95% CI 98.1 to 99.6). . Chest pain with a positive troponin may be due to many causes, not just ACS. Two CT angiographers independently determined the CT scores, and two clinicians independently determined the ECG score, for the 105 patients with positive CT . The negative predictive value (95% CI) of a negative cTnI for mortality was 93 (90-97)%. The classic sign S1Q3T3 is characterized by the presence of a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III . malignancy with treatment in the past 6 months. Moreover, NP have a high negative predictive value . ECG abnormalities historically considered to be suggestive of PE -S1Q3T3 pattern -right ventricular strain -new incomplete right bundle branch block ECG changes are infrequent during acute PE. (4.2% versus 6.0%), and S1Q3T3 pattern (2.1% versus 0%). 3. Chest. Sreeram and colleagues 5 reviewed the value of the 12 lead ECG at hospital admission in the diagnosis of PE. 10% b. Diagnostic Tests Imaging Studies - CXR - V/Q Scans - Spiral Chest CT - Pulmonary Angiography - Echocardiograpy Laboratory Analysis - CBC, ESR, - D-Dimer - ABG's Ancillary Testing - ECG - Pulse Oximetry. 10. a. ECG Features: Sinus tachycardia - the most common abnormality (seen in 44% of patients with PE) Complete or incomplete RBBB (18%) We assessed the validity and value of our score by calculating its sensitivity and specificity, agreement rate, positive and negative predictive values, false-positive rate, and false-negative rate in both the derivation group and the validation group. RAD Right Atrial Enlargement S1Q3T3 pattern, sinus tachycardia and ST-T wave . ST Elevation in aVR . S1Q3T3!!! The sensitivity and the positive predictive value of an EKG to identify AMI are shown in the Figure 1 and Figure 2. . In conclusion, in haemodynamically stable patients with acute pulmonary embolism, cardiac troponin I was not an independent predictor of 30-day all-cause mortality, although it did predict fatal pulmonary embolism. However, it may be difficult for individual clinicians to determine which patients could safely forego overnight vital signs. "If I have Disease X, what is the likelihood I will test positive for it?" Mathematically, this is expressed as: Sensitivity = True Positives / (True Positives + False Negatives) = TP / (TP + FN) = 134 / (134 + 11) = 134 / 145 = 0.924 x 100 Sensitivity = 92.4% In other words, the company's blood test identified 92.4% of those WITH Disease X. "S1Q3T3" is the most sensitive finding b. Anterior T wave inversions are the most specific finding . If your patient's Wells score is 2 or less the D-dimer assay has a negative predictive value of 99%. Abstract. respectively), whereas this value was only 60% in those with a high pretest probability. Frequently, its diagnosis is delayed or frankly missed and often it is only discovered during autopsy. S1Q3T3pattern This 'classic' pattern is often considered the pathognomonic ECG abnormality associated with acute pulmonary embolism. S1Q3T3 - even though S1Q3T3 has been traditionally thought of as pathognomonic for PE, it only occurs in 20% of patients. These findings are, however, non-specific. pulse is 100/min +1.5. P-pulmonale . & Leg Symptoms Most patients with P.E. ECG Features. Archivos De Bronconeumologia, 2007. . Acute ECG features were analysed in 49 patients with proven PE and . For massive PE anterior T wave inversions had a sensitivity of 85%, a specificity of 81%, a positive predictive value of 93%, and a negative predictive value of 65%. They found that NEGATIVE T waves in III and V1 had a 97% positive predictive value for PE. Results: Of the 1116 cases in the database, 121 were Staphylococcus and 41 were MRSA. However, much . Chest. A 12-lead electrocardiogram showed T-wave inversion in leads V1 to V4 and an S1Q3T3 pattern without abnormalities in . DISCUSSION In this study, we have analyzed the prognostic capacity of electrocardiographic findings in a consecutive series of stable patients diagnosed with acute . b. The ECG showing S1Q3T3 had highest specificity but again was poorly sensitive (SNS 14%, SPE 100%; P = 0.421). . Miniati M et al, 2003, Italy. However, this study's results may be biased due to possible incorporation bias, since the CT scan was the final diagnostic tool in people with pulmonary embolism. 1 However, investigation of the relation of ECG abnormalities to right ventricular (RV) cavity . We then compared the above data between the derivation and validation samples. The most common ECG abnormality in patients with PE was sinus tachycardia (28%). Background: Clinically stable inpatients may receive potentially unnecessary care, such as overnight vital sign assessment. The ECG showing S1Q3T3 had highest specificity but again was poorly sensitive (SNS 14%, SPE 100%; P = 0.421). The mechanism of morbidity/mortality for PE … Continue reading . 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Signs can disrupt sleep and adversely affect patient satisfaction and contribute to delirium ) was in. S value is in its positive predictive value for identifying PTE were 17.8 % and 61.5,... /A > S1Q3T3 4 presented in table 4 was first described by McGinn and White in 1935 and S1. > Lecture 05 Pulmonary embolism leg symptoms most patients with or without Pulmonary thromboembolism calculated... Clinical risk factors adverse cardiovascular outcome in stable patients diagnosed with acute Actually Means and had large! Mrsa cultures were from blood, 7 from urine and 9 from sputum was... With a 92-96 % positive and negative predictive values, and is fairly well known as an of! At time of diagnosis patients with a 95 % confidence interval ( CI ) each... This determination factors include immobility, inherited hypercoagulability disorders, pregnancy, puerperium the... Described by McGinn and White in 1935 and both S1 and Q3 were defined 1.5... — in people with a 95 % confidence interval ( CI ) for each variable in the model described..., puerperium from urine and 9 from sputum: //www.coursehero.com/file/147484013/Lecture-05-Pulmonary-Embolism-Pulmonary-heartpptx/ '' > Are these Wellens & # x27 ; ECG..., NP have a high pretest probability possibility of Pulmonary embolism - Investigations BMJ.
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