Tag Archives: medicine

Using Twitter and Social Media to Predict Disease: Identifying Risk and Impacting Change

Social media can be an exceptionally useful tool in Medicine.  Many platforms are  ideal for educating colleagues, patients and the community at large about chronic medical conditions as well as spreading the news of new medical innovations and treatments.  Social media platforms such as twitter, YouTube and Facebook (among others) can allow communication between people from different backgrounds and can connect those separated by oceans and thousands of miles all across the world.  While the medical establishment remains skeptical of social media and is often slow to adopt its routine use, it is emerging as an important part of many practices.

Twitter–both in and outside of its use in medicine–certainly has been shown to stir media controversies, influence politics and significantly impact careers (both positively and negatively) due to its ease of use and potential for immediate widespread dissemination.  Beyond the more traditional uses of social media platforms in medicine, a new study has recently been released that shows that one particular platform may actually be useful in predicting disease.  Researchers at the University of Pennsylvania published a study in the January issue of Psychological Science in which they carefully examined the relationship between the “type” of language posted on twitter and an individual’s risk for cardiovascular disease.  Stress, anger and other hostile emotions have long been associated with increased levels of cortisol, catecholamines (stress hormones) and increased inflammation.  These biologic byproducts of anger and hostile emotion have been associated with an increased risk for cardiovascular events.  Based on this information, researchers set out to identify whether or not the type of language utilized in tweets by a defined population could predict those at greater risk of cardiac events such as heart attack and stroke.  In the study, researchers analysed tweets between 2009 and 1010 using a previously validated emotional dictionary and classified them as to whether they represented anger, stress or other types of emotions.  They found that negative emotion laden tweets–particularly those that expressed anger or hate–were significantly correlated with a higher rate of cardiovascular disease and death.  Conversely, those whose tweets were more positive and optimistic seemed to confer a much lower risk for heart disease and cardiovascular related death.

While this is certainly not a randomized controlled clinical trial–and while we must interpret these results in the context of the study design–it does illustrate an new utility for social media.  As we continue to reach out and engage with patients on social media, our interactions may actually provide more than just communication of ideas–these interactions may produce important clinical data that may provide clues to assist us in the treatment of our patients in the future.  This particular study allowed researchers to predict risk for entire communities based on an analysis of random tweets from those residing in that geographical area.  For primary care physicians, using clues provided from social media interaction may provide insight into both an entire community’s health risk as well as an individual patient’s demeanor and allow for more aggressive screening and treatment for a wide variety of diseases from depression to cardiovascular disease.

Social media use will continue to grow among medical professionals.  I believe that when healthcare providers use all available tools and data in the care of their patients, outcomes will improve.  We must continue to explore the use of social media platforms such as twitter in clinical care and we must continue to examine ways in which the social media behavior of patient populations can predict disease.  I commend the researchers from the University of Pennsylvania for their creativity and vision–we need more creative minds who are willing to use pioneering strategies to improve care for our patients.  We can no longer shy away from social media in medicine–we must embrace it and begin to learn how to use it as a tool to effect change.

 

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An Apple A Day—Changing Medicine Through Technology and Engagement

The practice of medicine and healthcare in general has become an electronic and increasingly mobile interaction. Patients are better informed, more engaged, more connected and have a much greater virtual presence. In fact, according to Pew Research data, the fastest growing demographic on Twitter are those who are in the 45-65 age bracket.   Nearly 50% of all seniors engage online on a daily basis through at least one social media platform and many of these interactions and online engagements occur via mobile devices. Almost 75% of all adults go online within hours of attending a visit with their physician in order to gather more information about their particular medical problem. For healthcare providers—and for patients—the internet and mobile technology presents us all with wonderful opportunities to interact, engage, support and ultimately improve outcomes.

New connected devices and medical applications for mobile devices are on growing exponentially.   The world responded favorably to the latest release of the iPhone 6 and the iOS8 operating system recently released by Apple. The new device has many interesting features but one in particular caught my eye early on. Apple has created a standard package for all iOS 8 devices that is called the Health Kit. This particular application allows a user to track calories, steps taken (similar to a pedometer), flights of stairs climbed and other customizable health related data points. These data can be organized into graphs and charts that allow users to track progress and adjust activity levels to achieve particular goals. More impressively, the device will allow other health related applications to organize data in the Health Kit as well. One of the biggest problems with medial applications in the past is that there has never been an easy place to organize, store, collect and view all of the data together. Moreover, this data is not easily shared with healthcare providers. The Health Kit and Apple may revolutionize this entire process of data collection, retrieval and sharing—Apple has partnered with a major electronic medical record service known as EPIC. Work is underway to allow the Health Kit data and applications to easily interact with the EPIC medical record. This would allow for easy downloads of health data during a face-to-face encounter with healthcare providers. Currently, most major hospitals and healthcare systems are moving to the EPIC platform. The data collected and downloaded at one location would subsequently be available to all providers in the system—portability of data allows for better care and less duplication of effort.

Much has been written about patient engagement and improved outcomes in the medical literature. I can think of no better way to improve engagement than through the use of real time health applications –these allow patients to receive real time feedback—both good and bad—and respond quickly in order to improve their overall health status. I think that this type of technology will only continue to grow. Apple plans to release the Apple Watch in early 2015. I expect that this will also be integrated with Health Kit and allow for the measurement of respiratory rate, heart rate, body temperature and other biologic measurements. As these tools continue to develop and applications grow, healthcare providers as well as patients must be receptive to their use. These technologies have the potential to allow clinicians to better assess patients between office visits and provide more directed and timely changes in therapy. Ultimately I believe these technologies will transform healthcare. As we continue to struggle with healthcare cost containment in the era of healthcare reform, the ability to shift care and routine interaction to mobile platforms may very well prove to be a critical piece of the puzzle.

This is an exciting time in medicine as well as in healthcare technology. Moving forward, I look to a day where biologic sensors collect data, relay data to mobile devices and then transmit information seamlessly to healthcare systems. The healthcare providers are alerted to any abnormalities and electronic responses are generated—those patients requiring timely in person visits can be identified and scheduled, while those that can be handled virtually can be managed quickly and effectively as well. Ultimately, our goal is to better manage disease and improve outcomes. I think that technologies such as the Health Kit and the Apple Watch are giant leaps forward and are just the beginning of a new age of virtual healthcare.

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Personalized Technology in Medicine & Building Steve Austin: Better, Stronger, Faster

As a child, I often watched science fiction movies and television shows wondering how much would become reality in my lifetime.  From space travel in Buck Rogers and Star Trek to time travel in Back to the Future, I often imagined growing up in a world where the impossible became probable.  Bionics and the repair of human tissues was captivating and the Six Million Dollar Man (and its spin-offs)  became a hit series.  (we never missed an episode on Friday nights in my house!) Now, much of what was thought to be science fiction is becoming a reality in today’s world.  No other discipline has seen science fiction become reality and produce human impact as readily as the medicine and the treatment of human disease.

Medicine is becoming increasingly “electronic” and patients of all ages are more consistently “wired” through the use of the internet, mobile devices and mobile applications for health.  Patients are able to track health status, blood pressure, blood glucose and other indicators via their smartphones.  This ability to track and transmit data is important to streamlining care and improving the efficiency of the doctor patient interaction.  Hospitalizations are prevented through early intervention when physicians and patients have access to data while the patient is still an outpatient.  For example, many implantable cardioverter defibrillators (ICDs) and pacemakers have diagnostic sensors that can transmit important information to clinicians and allow for the outpatient adjustments of medication before the patient reaches the point where hospitalization is necessary for congestive heart failure and other cardiovascular diseases.

Now, researchers are beginning to develop small, unobtrusive diagnostic tools that have the potential to not only transmit health status but also deliver therapy.  In Monday’s Wall Street Journal, author Robert Lee Holtz reports on implants that are as thin as tattoos that are able to collect, process and respond to health data.  Even more impressive is the fact that in early clinical trials, some of these sensors are able to deliver medications and therapies in response to the collected biologic information. The biophysics of personalized medicine is upon us–experiments are being conducted in laboratories all over the country in order to design miniature, accurate, responsive sensors that can easily integrate with the body and dissolve when no longer needed.  In fact, as reported in the Journal, current experiments include using digital technology sensors on eyes for glaucoma, wrapping around hearts in need of a pacemaker and implants that control pain after surgery.  These types of technologies, while potentially years away from routine human use, represent a major shift in the way in which doctors are able to care for patients.  We are becoming increasingly web savvy–at all ages and in all demographics.  As a society, we must accept more individual accountability and responsibility for our own healthcare in order to help contain costs.  New developments such as implantable sensors and drug delivery systems may help doctors treat more diseases remotely and avoid costly hospitalizations.  For patients, increased education, increased self awareness and the ability to receive real time feedback from therapies may improve their ability to make lifestyle adjustments and improve their own health status.

As I have said many times in my blogs, engaged patients enjoy improved outcomes.  New technologies such as tiny implantable sensors and drug delivery systems will allow patients to connect like never before.  I look forward to a future where devices are individualized and personalized for each patient’s particular disease process and needs.  I believe that it will not only be important for physicians to be able to interact with the biologic data BUT also for patients to receive and interpret this information via a smartphone, computer, tablet or other mobile device in order to make adjustments and prevent complications or exacerbations of disease.  Although we don’t have Steve Austin or the Six Million Dollar Man with us, we do have the technology to make all of us Better, Stronger and Healthier.  The Age of Digital Medicine is here–we must embrace these new technologies and promote their development and deployment in the marketplace in order to improve the lives of our patients TODAY.

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The Doctor Shortage of Tomorrow: Fact or Fiction?

This week in the New York Times, Drs Scott Gottlieb and Ezekiel Emanuel make the case in an Op Ed piece that there will NOT be a physician shortage as a result of the Affordable Care Act (ACA). Both have extensive experience in policy and have held respected positions in government.  Based on a projected need of nearly 90,000 more physicians by 2020, I have difficulty seeing how a shortage will not occur.  The Affordable Care Act has already demonstrated the ineptness of government to manage healthcare–the laughable website rollout, newly discovered “backend” issues with signups, inaccurate quotes and information and questionable security (and this is all since October).  Now, as the mandates loom, consumers are beginning to wonder where exactly they will be able to get care and who may be providing it…

How can there NOT be a physician shortage?

Using the Massachusetts healthcare plan as an example, Drs Gottlieb and Emmanuel argue that the shortage predictions are flawed.  However, Massachusetts is not at all representative of the entirely of the US–one cannot extrapolate the response in Massachusetts to the rural Midwest, or the Deep South or Sunny California.  Moreover, the provisions and funding of the legislation in Massachusetts are very different from those in the ACA.  (its like comparing apples to oranges).  They argue that the biggest driver of increased physician manpower needs is more related to an aging population rather than the impacts of Obamacare and the flood of new patients that are insured by either medicaid or the ACA Exchanges that are able to set reimbursement levels at new all time lows.  They state that the solution to shortage issues will come in the form of technology driven “remote medicine” and the use of non Physician extenders such as Advanced practice nurses and Physician assistants. Moreover, they go on to argue that the solution is NOT producing more doctors–rather it is getting those of us in current practice to become “more efficient”

Really?  We are already doing more every day with much much less than we have had in the past….

As doctors often do in clinical practice,  I respectfully disagree with their assessment.  Obamacare will soon flood the system with millions of newly insured patients.  As evidenced by the current climate in California, many physicians will choose NOT to participate in the exchanges due to very poor reimbursement rates.  Recent surveys in that state found that nearly 75% of doctors would not take the Exchange insurance or Medicaid due to the fact that the Exchange payments were far below the standard CMS Medicare rates.  Many practices are unable to maintain autonomy as payments continue to decrease–many are being integrated into hospital systems.  Overhead continues to increase in order to meet Federal requirements for electronic documentation and records as well as maintaining coding experts to keep up with the ever changing systems such as the newly minted ICD-10 to be implemented in 2014.   The concept of a completely free standing private practice will no longer exist within the next 3 years.  Whether in academic or private settings, all physician groups will be employees of health conglomerates.

What is ultimately going to drive the physician shortage and what are the potential solutions?

For starters…I certainly do not have all the answers….While I do agree that the aging population certainly presents a manpower challenge, I do not concede that this alone will be the driving force behind any potential physician shortage.  Medicine is becoming less attractive for young bright students considering a career in healthcare.  Training physicians is expensive–medical schools are pricey for potential students and post-graduate training (Internship, Residency and Fellowship) are costly for the academic centers where they learn.  Financially, students may no longer be able to incur the significant debt (in the hundreds of thousands of dollars) that continues to accrue when attending medical school when the job prospects promise declining financial rewards.  Once in practice, newly minted MDs will find that their hours are longer and the time that they spend with each patient will be more limited–increasing documentation requirements will result in more screen time and less time listening and bonding.

Physicians are essential to the delivery of care.  However, I also recognize the vital role that physician extenders play in healthcare today (and will in the future).  Nurse practitioners, Physician Assistants and Pharmacists are critical in ensuring that patient care is optimized.  These providers must work in concert with physicians–approaching the whole patient in a team care model will ultimately improve outcomes.  But, utilizing these allied health professionals in more independent and unsupervised roles as Drs Gottlieb and Emmanuel suggest is reckless.  Although well trained and expert in their scope of practice, these allied health professionals are not physicians–they have not completed the academic rigors of a four year medical school nor gained the experience of a 3-8 year Residency and Fellowship.  Replacing doctors with other provider types will NOT eliminate the need for physicians and will NOT forestall the expected physician shortage as we move into 2014 and beyond.  We must continue to work with physician extenders and other allied health professionals in order to meet the increasing demands of a busy medical practice–I do not advocate for the independent practice that is currently being considered in many states.

Remote medicine, telemedicine and remote monitoring are certainly complementary and extremely valuable in providing care.  In fact, as Drs Gottlieb and Emanuel suggest, these modalities may reduce the number of doctor visits and may play a major role in prevention.  While I am a real advocate for utilizing technology to engage patients and facilitate care, face to face interactions between doctor and patient must still be a part of the process.  We cannot rely on computers and other electronic devices in isolation–they can, however, enhance the delivery of care when carefully included in a comprehensive treatment plan.

Are We Simply Losing Our Way As Medicine Remains in crisis….

Ultimately, time will certainly determine the state of physician supply.  If we remain on our current course and continue to fund and implement (albeit haphazardly) the provisions of the Affordable Care Act, we will ultimately see the fallout of a significant physician shortage.  Long lines, significant wait times and scarcity of both newly trained primary care and specialty doctors will become reality.  Medicine in our country is at a crossroads. We must continue to advocate for our patients and protect our right to practice our noble profession in a way that provides the best possible outcomes for our patients today and in the future.

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Connectivity, Email and Stress: Finding the Proper Balance for Success

Well, here I am.  Again.  On vacation and connected to the internet.  I must admit, I am addicted.  Twitter, blogging, and email.  I cannot seem to just let it go–not even for a week.  Email, in particular, seems to have taken a dominating role in all of our lives.  Constant hip checks for email downloads to our iphones have become an obsession.  As we speak, I am on a beautiful 4 hour train ride from Edinburgh to London (the same route that Harry Potter and his friends take from Hogwarts, no less).

This week on the website Inc.com, I came across an interesting article that explores the ways in which email is ruining our health.  A group of UK researchers decided to examine the effect of email on a group of workers.  Objective measures such as blood pressure, heart rate and cortisol levels were measured and the workers also kept a log of their work activities during the study period.  Results of the study indicated that a single email was no more stressful than taking a single phone call–however, an inbox full of a large amount of email produced a powerful stress reaction with elevations in cortisol, heart rate and blood pressure.  Interestingly, the study did find that the type of email received had a significant effect on stress.  Email that was received about current activities and contained time relevant information as well as emails that congratulated a “job well done” were not at all stressful.  in contrast, emails that were completely irrelevant and interrupted tasks were incredibly stressful and levels of cortisol, blood pressure and heart rate all spiked.  The lead researcher, Dr Tom Jackson, concluded that the email itself is not the issue–it is how the email is used that causes the problems with increased stress.  We are managing email in the  midst of phone calls, family time, and other in person meetings.  Often, responding to and filtering through email can be a distractor and take us away from more important tasks. Hence–email is stressing us all out.

As I mentioned, I am currently on “holiday” in the United Kingdom with my family.  I have tried very hard not to use email but I have failed miserably.  For me, the act of checking email twice a day has lowered my levels of anxiety about work.  However, when I stumbled upon certain email messages my levels of stress began to spike.  These were often emails that I could  do nothing about until I return to the states.  (As with most folks, feelings of loss of control and the inability to respond also create elevated levels of stress).  Luckily, I have my family with me on our tour through the UK to set me straight–instead of fretting over the emails and how to handle them, I was “convinced” to take a walk to Edinburgh castle and enjoyed a nice day in the sun (It may have been the only sunny day in Scotland this year).  My family and I had a wonderful day together in the castle.

I think that, in reality, one must find a balance between connectivity and relaxation.  For each person this balance is going to be different and based on individual personality traits.  I enjoy blogging and it is a very relaxing, stress reducing activity for me.  As I have mentioned in a previous blog, writing allows me to process my thoughts and share my feelings.  (Hence this blog is being written over the course of a four hour train ride).  For others, a completely disconnected holiday is the best course.  Whatever it may be, find your own balance.  Understand that email is an important tool for productivity and that it can be abused.  For me, I am learning what types of emails tend to elevate my own cortisol levels and will attempt to avoid these emails on future vacations.  Life work balance is essential to success and longevity–finding your own balance with email and connectivity is a critical component to this process.  With that, I am going to sign off and stare out the window at the beautiful Scottish wind blown sheep.

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How Can We Fix the $2.7 Trillion Dollar Medical Bill????

It is clear that healthcare in the US is more costly than in any other place in the world.  We spend 18% of the gross domestic product on healthcare and our outcomes are no different than those of other industrialized nations who spend less than half that amount.  How did we get here and what are we to do about it?

Recently, an article appeared in the New York Times that explored the increased costs of particular procedures in the US today.  In the Times piece, Elisabeth Rosenthal provides insight into possible reasons for the elevated cost and the ballooning trillion dollar healthcare deficit.  Certainly, insurers, hospital systems, industry and physicians all play a role in the high cost of care in the US.  In general, US healthcare systems tend to test more (and the tests are much more expensive here) and provide heroic care in the late stages of life (and this care may not have a real impact on longevity or quality of life).  Ms Rosenthal uses the colon cancer screening procedure known as colonoscopy as an example of a test that has widely variable cost.  Depending on where you get your test the price tag can vary by thousands of dollars–but in other countries it can cost as little as a few hundred dollars.

How does this happen?  

Ms Rosenthal certainly makes many good points in her article and gives us all pause–industry, hospitals, insurers and physicians all share some responsibility.  However, one important group that she does not mention as a contributor to the  escalating healthcare costs are the trial lawyers and the American Association for Justice (previously known as the  Association of Trial Lawyers of America)–you may can guess why the name change.

First and foremost, I believe the lack of tort reform and the highly litigenous environment that has been allowed to thrive in medicine in the US is a major contributor to escalating cost.  Physicians must often order more tests than necessary in order to avoid frivolous lawsuits and utlimately find themselves practicing “defensive medicine”.  Unfortunately for US citizens, most politicians are attorneys by profession and they tend to “look after their own.”  There has been little activity on tort reform–the trial lawyers are an incredibly powerful lobby.  Medical lawsuits have been allowed to continue unchecked and settlement amounts continue to rise to astronomical levels.  Many lawyers have made fortunes by “chasing ambulances”

Secondly, as physicians begin to see revenue fall and medicare/insurance reimbursement are cut, many turn to free standing surgical centers to increase revenue.  By owning the “facility” and treating the patient there instead of the hospital, the physician group is able to recoup a “facility fee “ that is normally collected by the hospital.  In addition, medicare billing (which often makes no sense whatsoever) will pay higher fees if the procedure is considered “outpatient” or is performed in an ambulatory surgical center.  In addition, academic institutions often are reimbursed at higher rates in order to offset the cost associated with training young doctors.  A more standardized approach to determining payments and reimbursements for procedures and tests must be put in place.  Medicare and CMS reform is essential to this process.  Currently the application of common sense appears to be quite absent from the government regulation and medicare payment determinations.  The system is full of waste and redundancy.  Although an entirely new “coding” system for medicare is due to be launched soon–I am certain that this new process will solve none of our current problems.

Our healthcare system is sick.  Until Washington stops playing politics and calls all parties to the table for talks of compromise, reform and action nothing will change.  The system cannot be fixed by only dealing with one component.  We must strive for tort reform so that physicians can do what is in the best interest of the patient rather than what must be done “in case” they are sued one day.  Politicians must stand up for the American people and stop being swayed by the trial lawyer lobby.  Standardized, equitable and sensible payment systems must be put in place so that the system is not abused by moving procedures from one location to another in order to receive higher payments.  This is a big job.  There is no easy fix.  But we must commit to finding a solution so that the US can continue to claim to have the best healthcare in the world.

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The Blogging Patient and Cyberspace: Unlimited Possibilities for Improving Health and Battling Disease

Social media has opened a whole new world for patients.  Now, information about disease is readily accessible and available to everyone.  Certainly, there are issues with reliability and accuracy of internet sources and this can create uneasiness and misunderstanding for both physician and patient.  However, the internet can also provide many new therapeutic possibilities.  In particular, online support groups, twitter chats and blogging can provide a positive outlet for patients suffering with disease.  Today, I want to focus on one of these internet opportunities–the patient blog.  Recently, a online article on iHealth Beat explored this concept  of patient blogging and its benefits.

Just as commonly experienced in the climax and resolution phase of Greek tragedy, writing a blog about one’s experience as a patient can be cathartic.  Patients with chronic illnesses or with a new diagnosis are often confused, frightened and angry.  Numerous studies in the psychiatry literature have demonstrated that journaling or writing about one’s feelings and experiences can have a very positive effect on emotional health.  Journaling has been shown to have several other unexpected benefits as well.  In the age of the internet and social media, journaling is now called blogging.  Blogging can be a private posting (where only you  or those you approve can see) or can be made public for anyone to see.

Blogging can have many benefits that are very similar to journaling.   From a pure neuro-biological standpoint, while you are occupied with writing, the analytical left brain is engaged in the writing process.  This allows the right brain to be free to feel, emote and create.  In this setting, you are able to better understand yourself and the world around you.  Specifically, there are four distinct benefits that patients can receive from blogging that I believe are worth mentioning:

1. Blogging helps to clarify thoughts and feelings:  Often writing down our feelings provides a way for us to better organize our thoughts.  Blogging can help patients with terminal illnesses better understand their disease and how they are reacting or adjusting to the challenges of the diagnosis and/or therapy.

2. Blogging helps you to get to know yourself better:  Writing routinely will help you better understand what makes you happy and content.  Conversely, writing will also help you better understand what people and situations upset you.  This can be incredibly important when battling chronic disease.  It is important that you are able to spend more time doing the things that make you happy and are able to identify and avoid things that are upsetting.

3. Blogging helps you to reduce stress:  Patients who receive a diagnosis of a major illness or who suffer daily with the challenges of chronic disease often have a great deal of anger and resentment.  It is human nature to ask questions such as “why me?”.  Blogging about angry feelings can be a positive and therapeutic release of emotion.  It allows for the writer to return from the blog more centered and better equipped to deal with negative emotion

4. Blogging helps unlock your creativity:  Often we approach problem solving from a purely left brain analytical perspective.  This is how we are taught throughout our education to attack problems in math and science in school.  However, some problems are only solved through creativity and through the use of a more right brain approach.  Writing allows the right brain to creatively attack problems while the analytical side of the brain is occupied with the mechanics of the writing process.

I believe that blogging can be just as important as medication compliance in patients with chronic disease.  The diagnosis of a chronic disease can produce a great deal of stress and emotional angst.  Patients who are able to deal with negative feelings and emotions in a more positive way are better suited to tackling their health problems.  As mentioned above, blogging has many benefits on our emotional health.  By dealing with negative emotions and unlocking creativity, we are better able to deal with the realities of chronic disease and more effectively interact with friends and loved ones.  I encourage everyone–patient, physician, family member or friend–to begin to blog.  I expect that the health benefits of writing will be well worth the time in front of the computer screen and the insights that you may discover about yourself may be be life changing.


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