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Alcantara M, Mannan S, de la Cruz J, Bril V. Value of multi-modality small fiber assessments in a genotypically diverse cohort of transthyretin-related amyloidosis in the early stages of disease. Med Clin (Barc) 2024; 162:e64-e69. [PMID: 38616431 DOI: 10.1016/j.medcli.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/10/2024] [Accepted: 02/17/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Transthyretin-related amyloidosis (ATTRv) is a progressive multisystem disorder, predominantly involving the peripheral nerve system (PNS) and heart. Quantification of small fiber damage may help guide treatment decisions, as amyloid deposits frequently affect those fibers early in disease course. Corneal confocal microscopy (CCM) is a promising method to monitor patients with ATTRv, due to similarities between corneal nerves and PNS, as the cornea is innervated by Aδ and C fibers. METHODS We compared CCM measures from ATTRv patients to a group of healthy individuals, matched by age and gender. We then investigated the correlations between small fiber tests (SFT): CCM, LDI-Flare and CDT, COMPASS-31 and disability scales (RODS and ONLS) in patients. RESULTS Of 20 patients (6 with V30M), mean age 50.3±15.3Y, 7 female (35%), six (30%) had polyneuropathy and 10 (50%) carpal tunnel syndrome. CDT was abnormal in 9 and LDI-flare in 6 patients. CCM was abnormal in 19 tested patients and significantly reduced when compared to controls (CNFL: 6.31±0.31 vs. 15.21±1.02mm/mm2, p<0.001). Mean COMPASS-31-scores were 22.27±22.84; RODS and ONLS were 38.15±12.33 and 2.05±2.3, with no significant differences between sub-group scores. Disease duration was significantly correlated with ONLS (0.43, p=0.05) and RODS (0.46, p=0.03). There were no significant correlations between measures of disability and SFT. CONCLUSIONS In a diverse cohort of ATTRv patients, CCM was the most frequent abnormal measurement. CCM can be a useful test to triage patients in the early disease stages and with few or equivocal symptoms.
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Affiliation(s)
- Monica Alcantara
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Shabber Mannan
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - James de la Cruz
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
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Nabar S, Fernandez J, Prakash V, Safder S. Gastrointestinal manifestations seen in pediatric patients diagnosed with small fiber neuropathy. J Pediatr Gastroenterol Nutr 2024; 78:583-591. [PMID: 38504414 DOI: 10.1002/jpn3.12099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/22/2023] [Accepted: 09/23/2023] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Small fiber neuropathy (SFN) affects the fibers involved in cutaneous and visceral pain and temperature sensation and are a crucial part of the autonomic nervous system. Autonomic dysfunction secondary to SFN and autoimmune receptor antibodies is being increasingly recognized, and gastrointestinal (GI) manifestations include constipation, early satiety, nausea, vomiting, and diarrhea. Enteric nervous system involvement may be a possible explanation of abnormal GI motility patterns seen in these patients. METHODS Children suspected to have SFN based on symptoms underwent skin biopsy at the Child Neurology clinic at Arnold Palmer Hospital for Children, which was processed at Therapath™ Neuropathology. SFN was diagnosed using epidermal nerve fiber density values that were below 5th percentile from the left distal leg (calf) as reported per Therapath™ laboratory. RESULTS Twenty-six patients were diagnosed with SFN. Retrospective chart review was performed, including demographic data, clinical characteristics, and evaluation. A majority of patients were white adolescent females. Autonomic dysfunction, including orthostasis and temperature dysregulation were seen in 61.5% of patients (p = 0.124). Somatosensory symptoms, including pain or numbness were seen in 85% of patients (p < 0.001). GI symptoms were present in 85% of patients (p < 0.001) with constipation being the most common symptom seen in 50% of patients. This correlated with the motility testing results. CONCLUSIONS Pediatric patients with SFN commonly have GI symptoms, which may be the main presenting symptom. It is important to recognize and look for symptoms of small fiber neuropathy in children with refractory GI symptoms that may explain multisystemic complaints often seen in these patients.
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Affiliation(s)
- Shruti Nabar
- Center for Digestive Health and Nutrition, Orlando Health Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Jenelle Fernandez
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Vikram Prakash
- Orlando Health Arnold Palmer Hospital for Children Neurology, Orlando, Florida, USA
| | - Shaista Safder
- Center for Digestive Health and Nutrition, Orlando Health Arnold Palmer Hospital for Children, Orlando, Florida, USA
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Idiaquez JF, Martinez R, Barnett-Tapia C, Perkins BA, Bril V. Reliability of confocal corneal microscopy for measurement of dendritic cell density in suspected small fiber neuropathy. Muscle Nerve 2023; 68:460-463. [PMID: 37534704 DOI: 10.1002/mus.27948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION/AIMS Dendritic cells (DCs) and their contacts with corneal nerves are described in animal models of nerve damage. Dendritic cell density (DCD) is a potential marker of immune activity in suspected small-fiber neuropathy (SFN). Here, we aim to evaluate the intra- and inter-rater reliability of DCD measurements in suspected SFN. METHODS This retrospective study collected DCD from confocal microscopy images from the corneal sub-basal epithelium of the eye from 48 patients (mean age 49.6 ± 12.1 y, 61% female). Two examiners, each blinded to the other's examinations and measurements, assessed DCD to evaluate inter-rater reliability. For intra-rater reliability, the first examiner performed a second measurement after 14 days. DCs were classified into two cell morphological subtypes: mature and immature. RESULTS Test-retest reliability for total DCD showed excellent agreement, with an intraclass correlation coefficient of 0.96 and inter-rater reliability intraclass correlation coefficient of 0.77. The immature cell subtype showed excellent intra-rater reliability but lower inter-rater reliability. DISCUSSION We found that DCD measurements in the corneal sub-basal epithelium are sufficiently reliable for consideration in clinical studies of patients with suspected SFN.
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Affiliation(s)
- Juan Francisco Idiaquez
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo Martinez
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett-Tapia
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, University of Toronto, and the Leadership Sinai Centre for Diabetes, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Corneal Sub-Basal Nerve Plexus in Non-Diabetic Small Fiber Polyneuropathies and the Diagnostic Role of In Vivo Corneal Confocal Microscopy. J Clin Med 2023; 12:jcm12020664. [PMID: 36675593 PMCID: PMC9862881 DOI: 10.3390/jcm12020664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/24/2022] [Accepted: 01/07/2023] [Indexed: 01/18/2023] Open
Abstract
In vivo corneal confocal microscopy (IVCM) allows the immediate analysis of the corneal nerve quantity and morphology. This method became, an indispensable tool for the tropism examination, as it evaluates the small fiber plexus in the cornea. The IVCM provides us with direct information on the health of the sub-basal nerve plexus and indirectly on the peripheral nerve status. It is an important tool used to investigate peripheral polyneuropathies. Small-fiber neuropathy (SFN) is a group of neurological disorders characterized by neuropathic pain symptoms and autonomic complaints due to the selective involvement of thinly myelinated Aδ-fibers and unmyelinated C-fibers. Accurate diagnosis of SFN is important as it provides a basis for etiological work-up and treatment decisions. The diagnosis of SFN is sometimes challenging as the clinical picture can be difficult to interpret and standard electromyography is normal. In cases of suspected SFN, measurement of intraepidermal nerve fiber density through a skin biopsy and/or analysis of quantitative sensory testing can enable diagnosis. The purpose of the present review is to summarize the current knowledge about corneal nerves in different SFN. Specifically, we explore the correlation between nerve density and morphology and type of SFN, disease duration, and follow-up. We will discuss the relationship between cataracts and refractive surgery and iatrogenic dry eye disease. Furthermore, these new paradigms in SFN present an opportunity for neurologists and clinical specialists in the diagnosis and monitoring the peripheral small fiber polyneuropathies.
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Petropoulos IN, Bitirgen G, Ferdousi M, Kalteniece A, Azmi S, D'Onofrio L, Lim SH, Ponirakis G, Khan A, Gad H, Mohammed I, Mohammadi YE, Malik A, Gosal D, Kobylecki C, Silverdale M, Soran H, Alam U, Malik RA. Corneal Confocal Microscopy to Image Small Nerve Fiber Degeneration: Ophthalmology Meets Neurology. FRONTIERS IN PAIN RESEARCH 2022; 2:725363. [PMID: 35295436 PMCID: PMC8915697 DOI: 10.3389/fpain.2021.725363] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022] Open
Abstract
Neuropathic pain has multiple etiologies, but a major feature is small fiber dysfunction or damage. Corneal confocal microscopy (CCM) is a rapid non-invasive ophthalmic imaging technique that can image small nerve fibers in the cornea and has been utilized to show small nerve fiber loss in patients with diabetic and other neuropathies. CCM has comparable diagnostic utility to intraepidermal nerve fiber density for diabetic neuropathy, fibromyalgia and amyloid neuropathy and predicts the development of diabetic neuropathy. Moreover, in clinical intervention trials of patients with diabetic and sarcoid neuropathy, corneal nerve regeneration occurs early and precedes an improvement in symptoms and neurophysiology. Corneal nerve fiber loss also occurs and is associated with disease progression in multiple sclerosis, Parkinson's disease and dementia. We conclude that corneal confocal microscopy has good diagnostic and prognostic capability and fulfills the FDA criteria as a surrogate end point for clinical trials in peripheral and central neurodegenerative diseases.
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Affiliation(s)
| | - Gulfidan Bitirgen
- Department of Ophthalmology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Alise Kalteniece
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Shazli Azmi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Luca D'Onofrio
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Sze Hway Lim
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | | | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ibrahim Mohammed
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Ayesha Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - David Gosal
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Christopher Kobylecki
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Monty Silverdale
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Handrean Soran
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Clinical Sciences Centre, Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool University Hospital National Health System (NHS) Foundation Trust, Liverpool, United Kingdom
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.,Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Malik RA, Efron N. Corneal Confocal Microscopy and the Nervous System: Introduction to the Special Issue. J Clin Med 2022; 11:jcm11061475. [PMID: 35329801 PMCID: PMC8953792 DOI: 10.3390/jcm11061475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/05/2022] [Indexed: 12/07/2022] Open
Affiliation(s)
- Rayaz A. Malik
- Weill Cornell Medicine-Qatar, Research Division, Qatar Foundation, Education City, Doha 24144, Qatar;
| | - Nathan Efron
- School of Optometry and Vision Science, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
- Correspondence:
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Verdugo RJ, Matamala JM, Inui K, Kakigi R, Valls-Solé J, Hansson P, Bernhard Nilsen K, Lombardi R, Lauria G, Petropoulos IN, Malik RA, Treede RD, Baumgärtner U, Jara PA, Campero M. Review of techniques useful for the assessment of sensory small fiber neuropathies: Report from an IFCN expert group. Clin Neurophysiol 2022; 136:13-38. [DOI: 10.1016/j.clinph.2022.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 02/09/2023]
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Florou C, Aissopou E, Chalkiadaki E, Andreanos K, Koutsandrea C, Papaconstantinou D, Georgalas I. Corneal endothelial cells and central corneal thickness in patients with neurofibromatosis type 1. Indian J Ophthalmol 2021; 69:1522-1526. [PMID: 34011734 PMCID: PMC8302278 DOI: 10.4103/ijo.ijo_1967_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose: The aim of this study was to evaluate the morphological properties of corneal endothelial cells and central corneal thickness (CCT) in patients with neurofibromatosis type 1 (NF1) and to compare them with age-matched healthy controls. Methods: Nineteen NF1 patients and 38 healthy individuals were recruited. All participants underwent complete ophthalmological examination as well as noncontact specular microscopy to measure endothelial cell density (ECD), average cell area (AVG), coefficient of variation of cell area (CV), the percentage of hexagonal cells, and CCT. Eyes with previous ocular trauma, inflammation or surgery, and preexisting corneal and ocular surface diseases were excluded. Results: NF1 patients had higher ECD compared to healthy controls of the same age (2764.2 ± 270.4 versus 2570.4 ± 449.2 cells/mm, respectively), although at a borderline level (P = 0.051). Patients with NF1 presented significantly lower CV and AVG when compared to controls (32.9 ± 4.6 versus 37.8 ± 9.5%, P = 0.011 and 364.9 ± 34.4 versus 406.0 ± 107.4 µm, P = 0.038, respectively). The NF1 group had significantly higher hexagonality in comparison with controls (55.7 ± 6.5 versus 50.5 ± 9.9%, P = 0.025). CCT was similar between the two groups (P = 0.955). Conclusion: Our results show that corneal endothelium has more favorable morphological characteristics in NF1 patients compared to healthy individuals of the same age.
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Affiliation(s)
- Chrysoula Florou
- First Department of Ophthalmology, National and Kapodistrian University of Athens, General Hospital "G. Gennimatas", Athens, Greece
| | - Evaggelia Aissopou
- Ophthalmologist in Private Office, Papadiamantopoulou 186, Athens, Greece
| | - Evangelia Chalkiadaki
- First Department of Ophthalmology, National and Kapodistrian University of Athens, General Hospital "G. Gennimatas", Athens, Greece
| | | | - Chrysanthi Koutsandrea
- First Department of Ophthalmology, National and Kapodistrian University of Athens, General Hospital "G. Gennimatas", Athens, Greece
| | - Dimitrios Papaconstantinou
- First Department of Ophthalmology, National and Kapodistrian University of Athens, General Hospital "G. Gennimatas", Athens, Greece
| | - Ilias Georgalas
- First Department of Ophthalmology, National and Kapodistrian University of Athens, General Hospital "G. Gennimatas", Athens, Greece
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Moramarco A, Sacchetti M, Franzone F, Segatto M, Cecchetti D, Miraglia E, Roberti V, Iacovino C, Giustini S. Ocular surface involvement in patients with neurofibromatosis type 1 syndrome. Graefes Arch Clin Exp Ophthalmol 2020; 258:1757-1762. [PMID: 32388624 DOI: 10.1007/s00417-020-04717-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The aim of this study is to evaluate ocular surface morphological and functional changes in patients with neurofibromatosis type 1 (NF1). METHODS Twenty-eight patients with NF1 and 14 healthy subjects were included in this study. All participants underwent a medical history collection, a complete ophthalmological examination including slit lamp exam and assessment of best-corrected visual acuity (BCVA), corneal sensitivity, and lacrimal function (Schirmer test and fluorescein tear break-up time test). Corneal nerves' morphology and endothelial cells density were evaluated by in vivo corneal confocal microscopy (IVCM). Tear and conjunctiva epithelium samples were collected to evaluate nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) tear levels and conjunctival expression of their receptors TrkA and p75NTR. RESULTS Patients with NF1 showed a significant decrease of FTBUT when compared with healthy subjects (p < 0.001). Corneal sensitivity was ≤ 50 mm in 46% of NF1 patients. IVCM showed a significant increase of corneal nerve branching and of corneal endothelial cells density. No significant difference was observed between the two groups on NGF and BDNF tear levels and conjunctival expression of their receptors. CONCLUSION This study demonstrated the presence of ocular surface changes in NF-1 patients including decrease of tear stability and of corneal sensitivity. Patients with NF1 also showed changes of corneal endothelial cells' density.
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Affiliation(s)
- Antonietta Moramarco
- Department of Sense Organs, 'Sapienza' University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - M Sacchetti
- Department of Sense Organs, 'Sapienza' University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - F Franzone
- Department of Sense Organs, 'Sapienza' University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - M Segatto
- Department of Biosciences and Territory, University of Molise, Contrada Fonte Lappone, 86090, Pesche, Italy
| | - D Cecchetti
- Department of Sense Organs, 'Sapienza' University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - E Miraglia
- Department of Dermatology, 'Sapienza' University of Rome, Rome, Italy
| | - V Roberti
- Department of Dermatology, 'Sapienza' University of Rome, Rome, Italy
| | - C Iacovino
- Department of Dermatology, 'Sapienza' University of Rome, Rome, Italy
| | - S Giustini
- Department of Dermatology, 'Sapienza' University of Rome, Rome, Italy
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