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Lin SY, Huang HY, Chang LL, Wang YL, Chen TC, Chang K, Tu HP, Lu PL. The impact of the fluconazole trailing effect on the persistence of Candida albicans bloodstream infection when treated with fluconazole. Clin Microbiol Infect 2024; 30:945-950. [PMID: 38527614 DOI: 10.1016/j.cmi.2024.03.023] [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: 08/25/2023] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVES The trailing effect of Candida species is a phenomenon characterized by reduced but persistent growth at antifungal concentrations above the MIC. We assessed the impact of trailing growth on the persistence of Candida albicans candidemia in patients receiving fluconazole (FLC) therapy. METHODS We retrospectively investigated candidemia isolates at three hospitals in southern Taiwan between 2013 and 2020. Patients treated with FLC for FLC-susceptible C. albicans candidemia were enrolled. The degree of trailing was determined as the average growth above the MIC divided by the measured growth at the lowest drug concentration using the EUCAST method and classified into four categories: residual (0.1-5%), slight (6-10%), moderate (11-15%), and heavy trailers (>15%). RESULTS Among isolates from 190 patients, the proportions of heavy trailers at 24 hours, 48 hours, and 72 hours were 63.7% (121/190), 63.2% (120/190), and 74.7% (142/190), respectively. Persistent candidemia was observed in 17 (8.9 %) patients. The proportion of persistent C. albicans candidemia in heavy trailing isolates at 48 hours was higher than in isolates without heavy trailing (13.3% [16/120] vs. 1.4% [1/70], p = 0.007). A multivariate analysis showed that immunosuppression (OR = 7.92; 95% CI: 2.38-26.39, p = 0.001), hospitalization days after the index date of C. albicans identification (OR = 1.03; 95% CI: 1.01-1.05, p = 0.011), and heavy trailing isolates at 48 hours (OR = 10.04; 95% CI: 1.27-79.88, p = 0.029) were independent factors for persistent candidemia. DISCUSSION The current study revealed that heavy trailing in C. albicans isolates is associated with persistent candidemia in patients receiving FLC treatment.
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Affiliation(s)
- Shang-Yi Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ho-Yin Huang
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Lin-Li Chang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Microbiology and Immunology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ya-Ling Wang
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tun-Chieh Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ko Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Pin Tu
- Department of Public Health and Environmental Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Liang Lu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Levinson T, Dahan A, Novikov A, Paran Y, Berman J, Ben-Ami R. Impact of tolerance to fluconazole on treatment response in Candida albicans bloodstream infection. Mycoses 2020; 64:78-85. [PMID: 33000505 DOI: 10.1111/myc.13191] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/04/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Treatment of Candida albicans bloodstream infection with fluconazole is associated with significant mortality despite in vitro susceptibility to the drug. OBJECTIVES We sought to determine whether tolerance to fluconazole is predictive of treatment failure. METHODS We reviewed patients with monomicrobial C albicans bloodstream infection who received primary monotherapy with fluconazole. Tolerance to fluconazole, defined as the fraction of growth above the MIC, was quantified using the disc diffusion assay and digital image analyses. Survival analyses were performed with host and treatment factors as predictive variables. RESULTS Among 44 patients included in the study, all-cause mortality was 29.5% at 30 days and 43.1% at 12 weeks. Forty-one isolates (93%) were susceptible to fluconazole (MIC50, 0.5 mg/L). Fluconazole tolerance was strongly associated with death for patients treated with fluconazole within 24 h of candidemia onset (33.3% vs 0%; p = .007), but not among patients whose treatment was started later. MIC did not correlate with survival, regardless of treatment delay. A Cox regression model including time to treatment, tolerance to fluconazole, fluconazole exposure and Pitt bacteraemia score provided good prediction of treatment outcome (area under the receiver-operator curve, 0.82). CONCLUSIONS In patients with C albicans bloodstream infection, tolerance testing was predictive of fluconazole efficacy if the drug was started early. Further study is required to validate the utility of this metric to guide treatment choices.
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Affiliation(s)
- Tal Levinson
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Dahan
- The George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Anna Novikov
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Paran
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Judith Berman
- The George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hauzer M, Cohen MJ, Polacheck I, Moses A, Korem M. The prevalence and clinical significance of microcolonies when tested according to contemporary interpretive breakpoints for fluconazole against Candida species using E-test. Med Mycol 2020; 57:718-723. [PMID: 30576514 DOI: 10.1093/mmy/myy130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/28/2018] [Accepted: 11/06/2018] [Indexed: 12/21/2022] Open
Abstract
Changes in the interpretive-breakpoints for antifungals against various Candida species have raised the need to examine the significance of the phenomenon of the growth of microcolonies in agar diffusion inhibition zones, which has generally been considered negligible. The objective was to determine the incidence of cases in which microcolonies demonstrate fluconazole resistance according to current interpretive-breakpoints and whether their growth is associated with therapeutic failure. The fluconazole minimum inhibitory concentrations (MICs) of 100 blood culture isolates of Candida were performed by E-test on Roswell Park Memorial Institute (RPMI) agar and examined for the appearance of microcolonies. Fluconazole MICs of microcolonies were then determined over three generations. The significance of the phenomenon of microcolonies was determined according to clinical data retrieved from electronic files. Microcolonies were a common phenomenon among Candida isolates following incubation on RPMI agar, with a higher frequency among C. albicans isolates as compared to non-albicans Candida across generations (57-93% vs 31-93%, respectively) and a similar fluconazole susceptibility rate over three generations. The rate of microcolonies was similar in both patients with successful and unsuccessful outcome (41% vs 42%, respectively). Microcolonies are a common phenomenon. No increase in MIC was demonstrated throughout three generations of microcolony inoculation on RPMI, and no difference in clinical outcome was observed.
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Affiliation(s)
- Michael Hauzer
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Itzhack Polacheck
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Allon Moses
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Maya Korem
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Berzaghi R, Agócs A, Curto MA, Gulyás-Fekete G, Kocsis B, Ribas JC, Lóránd T. Novel Cell Wall Antifungals Reveal a Special Synergistic Activity in pbr1 Mutants Resistant to the Glucan Synthesis Antifungals Papulacandins and Echinocandins. Front Microbiol 2019; 10:1692. [PMID: 31428061 PMCID: PMC6689975 DOI: 10.3389/fmicb.2019.01692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 07/09/2019] [Indexed: 01/22/2023] Open
Abstract
A series of 4-(arylmethylene)-3-isochromanones have been prepared with base-catalyzed Knoevenagel condensation starting from 3-isochromanone and aromatic aldehydes. The outcome of the reaction- the isomeric composition of the products depends on the aromatic aldehyde applied. These reactions afforded mostly the more stable E-diastereoisomer, but some condensations resulted in the Z-diastereoisomer or mixture of the stereoisomers (1-16). The products showed antifungal effect against some pathogenic fungi. We wanted to extend this study and to synthesize a new generation of 4-(arylmethylene)-3-isochromanones. These condensations led mostly to E-diastereoisomers (17-30). The structure verifications were performed by FT IR, 1H and13C NMR methods. Both the 1-16 and the novel 17-30 compounds have been screened against the three yeast models, fission yeast Schizosaccharomyces pombe (wild-type, and pbr1-6 and pbr1-8 mutants resistant to specific cell wall synthesis inhibitors), budding yeast Saccharomyces cerevisiae (wild-type and pbr1-1) and pathogenic yeast Candida albicans (wild-type, ATCC 26555, 90028 and SC5314). Osmotic protection with sorbitol attenuated the in vivo inhibition in living cells suggesting a cell wall-specific antifungal effect. Moreover, the S. pombe wild-type and mutant strains were tested for their resistant or sensitive in vitro β(1,3)-glucan synthase (GS) activity. We found both in vivo in living cells and in vitro in the enzymatic GS assay a synergistic effect of higher sensitivity of the pbr1 mutants resistant to the specific GS inhibitors papulacandins and echinocandins. These results may provide new insights into new strategies of combined antifungal therapy of GS inhibitors directed against spontaneous mutants resistant to echinocandins.
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Affiliation(s)
- Rodrigo Berzaghi
- Instituto de Biología Funcional y Genómica, Consejo Superior de Investigaciones Científicas, Universidad de Salamanca, Salamanca, Spain
| | - Attila Agócs
- Department of Biochemistry and Medical Chemistry, University of Pécs Medical School, Pécs, Hungary
| | - María A. Curto
- Instituto de Biología Funcional y Genómica, Consejo Superior de Investigaciones Científicas, Universidad de Salamanca, Salamanca, Spain
| | - Gergely Gulyás-Fekete
- Department of Biochemistry and Medical Chemistry, University of Pécs Medical School, Pécs, Hungary
| | - Béla Kocsis
- Department of Medical Microbiology and Immunology, University of Pécs Medical School, Pécs, Hungary
| | - Juan C. Ribas
- Instituto de Biología Funcional y Genómica, Consejo Superior de Investigaciones Científicas, Universidad de Salamanca, Salamanca, Spain
| | - Tamás Lóránd
- Department of Biochemistry and Medical Chemistry, University of Pécs Medical School, Pécs, Hungary
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The Etest Performed Directly on Blood Culture Bottles Is a Reliable Tool for Detection of Fluconazole-Resistant Candida albicans Isolates. Antimicrob Agents Chemother 2017; 61:AAC.00400-17. [PMID: 28483951 DOI: 10.1128/aac.00400-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/28/2017] [Indexed: 11/20/2022] Open
Abstract
We assessed the ability of the Etest performed directly on positive blood cultures (ETDIR) to detect fluconazole susceptibility in 6 fluconazole-resistant and 12 fluconazole-susceptible Candida albicans isolates, according to CLSI M27-A3 and EUCAST EDef 7.2 procedures. Categorical agreement between ETDIR and broth microdilution was 100% when the trays were incubated at 25°C and trailing effect was ruled out. ETDIR is a reliable procedure when screening for the presence of fluconazole resistance in C. albicans.
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Cretella D, Barber KE, King ST, Stover KR. Comparison of susceptibility patterns using commercially available susceptibility testing methods performed on prevalent Candida spp. J Med Microbiol 2016; 65:1445-1451. [PMID: 27902377 DOI: 10.1099/jmm.0.000383] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The rising rates of invasive fungal infections caused by non-albicans Candida and the increasing emergence of antifungal resistance complicate the management of invasive candidiasis. Accurate and timely antifungal susceptibility testing is critical to targeting antifungal therapy. The purpose of this study was to compare commercially available susceptibility testing methods using prospectively collected Candida isolates. Susceptibility testing was performed on 74 Candida isolates collected from July 2014 to March 2015 using broth microdilution according to the Clinical and Laboratory Standards Institute method, Etest, Vitek 2 (YS-05) and Sensititre. Essential agreement and categorical agreement (CA) were assessed using the reference method. Of the 34 total blood isolates collected, Candida albicans comprised only 38 % (13) of the Candida spp. with Candidaglabrata being nearly as prevalent (29 %, 10). CA using Etest was 86 % for fluconazole, 72 % for caspofungin, 98 % for micafungin and 97 % for anidulafungin. Vitek 2 CA was 90 % for fluconazole and 98 % for caspofungin. Sensititre CA was 93 % for fluconazole, 98 % for caspofungin, 98 % for micafungin and 100 % for anidulafungin. Although our study tested a small population of Candida isolates, our results were variable by method. When implementing antifungal susceptibility testing, clinicians should be aware of the strengths and limitations of each testing method.
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Affiliation(s)
- David Cretella
- Pharmacy Services, University of Mississippi Medical Center, Jackson, MS, USA
| | - Katie E Barber
- Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - S Travis King
- Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA.,Medicine-Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kayla R Stover
- Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA.,Medicine-Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA
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Evaluation of the possible influence of trailing and paradoxical effects on the clinical outcome of patients with candidemia. Clin Microbiol Infect 2016; 23:49.e1-49.e8. [PMID: 27677697 DOI: 10.1016/j.cmi.2016.09.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 08/05/2016] [Accepted: 09/20/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Paradoxical growth (PG) and trailing effect (TE) are frequently observed during antifungal susceptibility testing (AFST). These two phenomena interfere with the determination of the minimal inhibitory concentration (MIC). The aim of this study was to assess the clinical impact of TE and PG. METHODS We analysed the frequency of TE and PG of 690 Candida isolates collected from a population-based study performed in Spain (CANDIPOP) and correlated the results with clinical outcome of the patients. RESULTS Around 70% (484/690) of the isolates exhibited TE to azoles. Candida tropicalis showed the highest presence of TE (39/53 isolates exhibited residual growth >25% of control). No TE was seen in most of the isolates from the psilosis complex. PG was mainly associated with echinocandins. In patients treated with fluconazole within the first 48 hours after blood sampling (n = 221), the presence of TE to azoles tended to be associated with lower 30-day mortality (odds ratio (OR) 0.55, 95% confidence interval (CI) 0.25-1.00) but not with clinical failure (OR 0.85, 95% CI 0.45-1.54). In the subgroup of 117 patients treated with echinocandins, the presence of PG was not associated with patient's response to antifungal treatment (OR for 30-day mortality 1.63, 95% CI 0.76-4.03; OR for clinical failure 1.17, 95% CI 0.53-2.70). CONCLUSIONS TE or PG are widely expressed among Candida spp., although they do not seem to influence clinical outcome.
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Kolecka A, Chorvát D, Bujdáková H. The impact of growth conditions on biofilm formation and the cell surface hydrophobicity in fluconazole susceptible and tolerant Candida albicans. Folia Microbiol (Praha) 2014; 60:45-51. [DOI: 10.1007/s12223-014-0338-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
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Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical. Braz J Infect Dis 2013; 17:283-312. [PMID: 23693017 PMCID: PMC9427385 DOI: 10.1016/j.bjid.2013.02.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 02/16/2013] [Indexed: 01/07/2023] Open
Abstract
Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.
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Brazilian guidelines for the management of candidiasis: a joint meeting report of three medical societies – Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia, Sociedade Brasileira de Medicina Tropical. Braz J Infect Dis 2012. [DOI: 10.1016/s1413-8670(12)70336-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Borecká S, Pinjon E, Sullivan DJ, Kuchler K, Blaško J, Kulková N, Bujdáková H. Cdr2p contributes to fluconazole resistance in Candida dubliniensis clinical isolates. Can J Microbiol 2011; 57:416-26. [PMID: 21542785 DOI: 10.1139/w11-025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
The development of resistance to azole antifungals used in the treatment of fungal infections can be a serious medical problem. Here, we investigate the molecular mechanisms associated with reduced susceptibility to fluconazole in clinical isolates of Candida dubliniensis , showing evidence of the trailing growth phenomenon. The changes in membrane sterol composition were studied in the presence of subinhibitory fluconazole concentrations. Despite lanosterol and eburicol accumulating as the most prevalent sterols after fluconazole treatment, these ergosterol precursors still support growth of Candida isolates. The overexpression of ABC transporters was demonstrated by immunoblotting employing specific antibodies against Cdr1p and Cdr2p. The presence of a full-length 170 kDa protein Cdr1p was detected in two isolates, while a truncated form of Cdr1p with the molecular mass of 85 kDa was observed in isolate 966/3(2). Notably, Cdr2p was detected in this isolate, and the expression of this transporter was modulated by subinhibitory concentrations of fluconazole. These results suggest that C. dubliniensis can display the trailing growth phenomenon, and such isolates express similar molecular mechanisms like that of fluconazole-resistant isolates and can therefore be associated with recurrent infections.
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Affiliation(s)
- Silvia Borecká
- Comenius University in Bratislava, Department of Microbiology and Virology, Mlynská dolina, Bratislava, Slovak Republic
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