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Aronowitz DI, Geoffrion TR, Piel S, Morton SR, Starr J, Melchior RW, Gaudio HA, Degani R, Widmann NJ, Weeks MK, Ranieri NR, Benson E, Ko TS, Licht DJ, Hefti M, Gaynor JW, Kilbaugh TJ, Mavroudis CD. Normoxic Management during Cardiopulmonary Bypass Does Not Reduce Cerebral Mitochondrial Dysfunction in Neonatal Swine. Int J Mol Sci 2024; 25:5466. [PMID: 38791504 PMCID: PMC11122014 DOI: 10.3390/ijms25105466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/05/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Optimal oxygen management during pediatric cardiopulmonary bypass (CPB) is unknown. We previously demonstrated an increase in cortical mitochondrial reactive oxygen species and decreased mitochondrial function after CPB using hyperoxic oxygen management. This study investigates whether controlled oxygenation (normoxia) during CPB reduces cortical mitochondrial dysfunction and oxidative injury. Ten neonatal swine underwent three hours of continuous CPB at 34 °C (flow > 100 mL/kg/min) via cervical cannulation targeting a partial pressure of arterial oxygen (PaO2) goal < 150 mmHg (normoxia, n = 5) or >300 mmHg (hyperoxia, n = 5). The animals underwent continuous hemodynamic monitoring and serial arterial blood sampling. Cortical microdialysate was serially sampled to quantify the glycerol concentration (represents neuronal injury) and lactate-to-pyruvate ratio (represents bioenergetic dysfunction). The cortical tissue was analyzed via high-resolution respirometry to quantify mitochondrial oxygen consumption and reactive oxygen species generation, and cortical oxidized protein carbonyl concentrations were quantified to assess for oxidative damage. Serum PaO2 was higher in hyperoxia animals throughout CPB (p < 0.001). There were no differences in cortical glycerol concentration between groups (p > 0.2). The cortical lactate-to-pyruvate ratio was modestly elevated in hyperoxia animals (p < 0.03) but the values were not clinically significant (<30). There were no differences in cortical mitochondrial respiration (p = 0.48), protein carbonyls (p = 0.74), or reactive oxygen species generation (p = 0.93) between groups. Controlled oxygenation during CPB does not significantly affect cortical mitochondrial function or oxidative injury in the acute setting. Further evaluation of the short and long-term effects of oxygen level titration during pediatric CPB on cortical tissue and other at-risk brain regions are needed, especially in the presence of cyanosis.
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Affiliation(s)
- Danielle I. Aronowitz
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.)
| | - Tracy R. Geoffrion
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.)
| | - Sarah Piel
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Sarah R. Morton
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jonathan Starr
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Richard W. Melchior
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.)
| | - Hunter A. Gaudio
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Rinat Degani
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Nicholas J. Widmann
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - M. Katie Weeks
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Nicolina R. Ranieri
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Emilie Benson
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Physics & Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tiffany S. Ko
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Physics & Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel J. Licht
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Marco Hefti
- Department of Pathology, University of Iowa Health Care, Iowa City, IA 52242, USA
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.)
| | - Todd J. Kilbaugh
- Resuscitation Science Center of Emphasis, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Constantine D. Mavroudis
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.)
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Brohan O, Chenouard A, Gaultier A, Tonna JE, Rycus P, Pezzato S, Moscatelli A, Liet JM, Bourgoin P, Rozé JC, Léger PL, Rambaud J, Joram N. Pao2 and Mortality in Neonatal Extracorporeal Membrane Oxygenation: Retrospective Analysis of the Extracorporeal Life Support Organization Registry, 2015-2020. Pediatr Crit Care Med 2024:00130478-990000000-00326. [PMID: 38511990 DOI: 10.1097/pcc.0000000000003508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
OBJECTIVES Extracorporeal life support can lead to rapid reversal of hypoxemia but the benefits and harms of different oxygenation targets in severely ill patients are unclear. Our primary objective was to investigate the association between the Pao2 after extracorporeal membrane oxygenation (ECMO) initiation and mortality in neonates treated for respiratory failure. DESIGN Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry data, 2015-2020. PATIENTS Newborns supported by ECMO for respiratory indication were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pao2 24 hours after ECMO initiation (H24 Pao2) was reported. The primary outcome was 28-day mortality. We identified 3533 newborns (median age 1 d [interquartile range (IQR), 1-3]; median weight 3.2 kg [IQR, 2.8-3.6]) from 198 ELSO centers, who were placed on ECMO. By 28 days of life, 731 (20.7%) had died. The median H24 Pao2 was 85 mm Hg (IQR, 60-142). We found that both hypoxia (Pao2 < 60 mm Hg) and moderate hyperoxia (Pao2 201-300 mm Hg) were associated with greater adjusted odds ratio (aOR [95% CI]) of 28-day mortality, respectively: aOR 1.44 (95% CI, 1.08-1.93), p = 0.016, and aOR 1.49 (95% CI, 1.01-2.19), p value equals to 0.045. CONCLUSIONS Early hypoxia or moderate hyperoxia after ECMO initiation are each associated with greater odds of 28-day mortality among neonates requiring ECMO for respiratory failure.
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Affiliation(s)
- Orlane Brohan
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France
| | - Aurélie Gaultier
- Nantes Université, CHU Nantes, Direction de la Recherche et de l'innovation, Plateforme de méthodologie et biostatistique, Nantes, France
| | - Joseph E Tonna
- Extracorporeal Life Support Organization (ELSO), Ann Arbor, MI
| | - Peter Rycus
- Extracorporeal Life Support Organization (ELSO), Ann Arbor, MI
| | - Stefano Pezzato
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France
| | - Jean-Christophe Rozé
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France
- Clinical Investigation Center (CIC) 1413, INSERM, Public Health, Clinic of the Data, University Hospital of Nantes, Nantes, France
| | - Pierre-Louis Léger
- Pediatric Intensive Care Unit, Trousseau University Hospital, Paris, France
- INSERM U955-ENVA, University Paris 12, Paris, France
| | - Jérôme Rambaud
- Pediatric Intensive Care Unit, Trousseau University Hospital, Paris, France
- INSERM U955-ENVA, University Paris 12, Paris, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France
- INSERM U955-ENVA, University Paris 12, Paris, France
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Sznycer-Taub NR, Lowery R, Yu S, Owens G, Charpie JR. Reducing Hyperoxia Exposure in Infants Requiring Veno-Arterial Extracorporeal Membrane Oxygenation after Cardiac Surgery. Pediatr Cardiol 2024; 45:143-149. [PMID: 37698698 DOI: 10.1007/s00246-023-03277-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/12/2023] [Indexed: 09/13/2023]
Abstract
Recent studies have suggested worse outcomes in patients exposed to hyperoxia while supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, there are no data regarding the effect of reducing hyperoxia exposure in this population by adjusting the fraction of inspired oxygen (FiO2) of the sweep gas of the ECMO circuit. A retrospective review of 143 patients less than 1 year of age requiring VA-ECMO following cardiac surgery from 2007 to 2018 was completed. 64 patients had a FiO2 of the sweep gas < 100% with an average PaO2 of 210 mm Hg in the first 48 h of support [vs 405 mm Hg in the group with a FiO2 = 100% (p < 0.0001)]. There was no difference in mortality at 30 days after surgery or other markers of end-organ injury with respect to whether the FiO2 was adjusted. At least one PaO2 value < 200 mm Hg in the first 24 h on ECMO in patients with a FiO2 < 100% trended toward a significant association (OR = 0.45, 95% CI = 0.21-1.01) with decreased risk of 30-day mortality when compared to those patients with a FiO2 = 100% and all PaO2 values > 200 mm Hg. Only 47% of patients with a FiO2 < 100% had an average PaO2 less than 200 mm Hg which indicates that the intervention of reducing the FiO2 of the sweep gas was not entirely effective at reducing hyperoxia exposure. Future research is needed for developing clinical protocols to avoid hyperoxia and to identify mechanisms for hyperoxia-induced injury on VA-ECMO.
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Affiliation(s)
- Nathaniel R Sznycer-Taub
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA.
| | - Ray Lowery
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - Gabe Owens
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - John R Charpie
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
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Abstract
The September 2023 issue and this year has already proven to be important for improving our understanding of pediatric acute respiratory distress syndrome (PARDS); Pediatric Critical Care Medicine (PCCM) has published 16 articles so far. Therefore, my three Editor's Choice articles this month highlight yet more PCCM material about PARDS by covering the use of noninvasive ventilation (NIV), the trajectory in cytokine profile during illness, and a new look at lung mechanics. The PCCM Connections for Readers give us the opportunity to focus on some clinical biomarkers of severity and mortality risk during critical illness.
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Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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Neutrophil Count as Atrioventricular Block (AVB) Predictor following Pediatric Heart Surgery. Int J Mol Sci 2022; 23:ijms232012409. [PMID: 36293263 PMCID: PMC9604473 DOI: 10.3390/ijms232012409] [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] [Received: 08/29/2022] [Revised: 10/07/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022] Open
Abstract
Neutrophils play a significant role in immune and inflammatory reactions. The preoperative inflammatory activation may have a detrimental effect on postoperative outcomes. The aim of the study was to investigate the relation between preoperative hematological indices on postoperative complications’ risk in pediatric cardiac congenital surgery. The retrospective single center analysis included 93 pediatric patients (48 (65%) males and 45 (35%) females), mean age of 7 (3−30) months referred for cardiac surgery in cardiopulmonary bypass due to functional single ventricle disease (26 procedures), shunts lesions (40 procedures) and cyanotic disease (27 procedures). Among simple hematological indices, the receiver-operating-characteristic curve showed that a neutrophil count below 2.59 K/uL was found as an optimal cut-off point for predicting postoperative atrioventricular block following pediatric cardiac surgery (AUC = 0.845, p < 0.0001) yielding a sensitivity of 100% and a specificity of 65.62%. Preoperative values of neutrophil count below 2.59 K/uL in whole blood analysis can be regarded as a predictive factor (AUC = 0.845, p < 0.0001) for postoperative atrioventricular block in pediatric cardiac surgery.
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Balcarcel DR, Coates BM, Chong G, Sanchez-Pinto LN. Excessive Oxygen Supplementation in the First Day of Mechanical Ventilation Is Associated With Multiple Organ Dysfunction and Death in Critically Ill Children. Pediatr Crit Care Med 2022; 23:89-98. [PMID: 35119429 PMCID: PMC8820279 DOI: 10.1097/pcc.0000000000002861] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine if greater cumulative exposure to oxygen despite adequate oxygenation over the first 24 hours of mechanical ventilation is associated with multiple organ dysfunction syndrome at 7 days and inhospital mortality in critically ill children. DESIGN Retrospective, observational cohort study. SETTING Two urban, academic PICUs. PATIENTS Patients less than 18 years old who required mechanical ventilation within 3 days of admission between 2010 and 2018 (Lurie Children's Hospital) or 2010 and 2016 (Comer Children's Hospital). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 5,406 mechanically ventilated patients, of which 960 (17.8%) had multiple organ dysfunction syndrome on day 7 of admission and 319 died (5.9%) during their hospitalization. Cumulative exposure to greater amounts of supplemental oxygen, while peripheral oxygen saturation was 95% or more during the first 24 hours of mechanical ventilation was independently associated with an increased risk of both multiple organ dysfunction syndrome on day 7 and inhospital mortality after adjusting for confounders. Patients in the highest quartile of cumulative oxygen exposure had an increased odds of multiple organ dysfunction syndrome on day 7 (adjusted odds ratio, 3.9; 95% CI, 2.7-5.9) and inhospital mortality (adjusted odds ratio, 1.7; 95% CI, 1.1-2.9), when compared with those in the lowest quartile of cumulative oxygen exposure after adjusting for age, presence of multiple organ dysfunction syndrome on day 1 of mechanical ventilation, immunocompromised state, and study site. CONCLUSIONS Greater cumulative exposure to excess supplemental oxygen in the first 24 hours of mechanical ventilation is independently associated with an increased risk of multiple organ dysfunction syndrome on day 7 of admission and inhospital mortality in critically ill children.
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Affiliation(s)
- Daniel R. Balcarcel
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bria M. Coates
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Critical Care, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Grace Chong
- Section of Critical Care, The University of Chicago Comer Children’s Hospital, Chicago, IL
| | - L. Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Critical Care, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Section of Critical Care, The University of Chicago Comer Children’s Hospital, Chicago, IL
- Department of Preventive Medicine (Health and Biomedical Informatics), Northwestern University Feinberg School of Medicine, Chicago, IL
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Affiliation(s)
- Gareth A L Jones
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Mark J Peters
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, United Kingdom
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Barreto JA, Weiss NS, Nielsen KR, Farris R, Roberts JS. Hyperoxia after pediatric cardiac arrest: Association with survival and neurological outcomes. Resuscitation 2021; 171:8-14. [PMID: 34906621 DOI: 10.1016/j.resuscitation.2021.12.003] [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: 10/07/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the association between hyperoxia in the first 24 hours after in-hospital pediatric cardiac arrest and mortality and poor neurological outcome. METHODS This is a retrospective cohort study of inpatients in a freestanding children's hospital. We included all patients younger than 18 years of age with in-hospital cardiac arrest between December 2012 and December 2019, who achieved return of circulation (ROC) for longer than 20 minutes, survived at least 24 hours after cardiac arrest, and had documented PaO2 or SpO2 during the first 24 hours after ROC. Hyperoxia was defined as having at least one level of PaO2 above 200 mmHg in the first 24 hours after cardiac arrest. RESULTS There were 187 patients who met eligibility criteria, of whom 48% had hyperoxia during the first 24 hours after cardiac arrest. In-hospital mortality was 41%, with similar mortality between oxygenation groups (hyperoxia 45% vs no hyperoxia 38%). We did not observe an association between hyperoxia and in-hospital mortality or poor neurological outcome after adjusting for confounders (odds ratio 1.2, 95% confidence interval 0.5-2.8). On sensitivity analysis using two additional cutoffs of PaO2 (>150 mmHg and > 300 mmHg), there was also no association with in-hospital mortality or poor neurological outcome after adjusting for confounders. Similarly, on multivariable logistic regression using SpO2 > 99% as the exposure, there was no difference in the frequency of death or poor neurological outcome at hospital discharge. CONCLUSION Hyperoxia after pediatric cardiac arrest was common and was not associated with worse in-hospital outcomes.
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Affiliation(s)
- Jessica A Barreto
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, United States.
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, WA, United States.
| | - Katie R Nielsen
- Department of Pediatrics, Division of Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.
| | - Reid Farris
- Department of Pediatrics, Division of Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.
| | - Joan S Roberts
- Department of Pediatrics, Division of Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.
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Tasker RC. Editor's Choice Articles for May. Pediatr Crit Care Med 2021; 22:443-444. [PMID: 37611931 DOI: 10.1097/pcc.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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