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Sun J, Zhou X, Xia W, Wu H, Liu S, Wang H, Liu Y. Unusual Presentation and Surgical Treatment of a Phosphaturic Mesenchymal Tumor in a Knee. Front Surg 2022; 9:746623. [PMID: 35693311 PMCID: PMC9174667 DOI: 10.3389/fsurg.2022.746623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
A 30-year-old woman presented to our hospital with an 11-year history of gradually enlarging masses around the left knee and 2-year history of progressively worsening bone pain. Tumor-induced osteomalacia (TIO), a rare paraneoplastic syndrome caused by phosphaturic mesenchymal tumors (PMTs) was suspected, but the postoperative pathology of her two operations was both reported as tenosynovial giant cell tumor (TGCT), making its diagnosis confusing. The possibility of hypophosphatemia, insufficient blood supply, innervation of the left lower limbs, as well as the unclear pathology, make it unreasonable to perform tumor-type knee prosthesis replacement directly. Finally, we placed static polymethylmethacrylate (PMMA) spacer at first, then when the concentration of blood phosphorus level rose to the normal range, the pathology was confirmed to be TIO, the blood supply and innervation was satisfying, tumor-type knee prosthesis replacement was performed. She was discharged post operative day 15 after the prothesis implantation without incident. One and a half years after her surgery, the concentration of blood phosphorus was still in the normal range, the symptom of systemic bone pain had improved significantly, the prosthesis was still in a good position and no recurrence was caught.
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Affiliation(s)
- Juan Sun
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi Zhou
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huanwen Wu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuzhong Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huizhen Wang
- Department of Operating Room, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Correspondence: Yong Liu
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Zanchetta MB, Jerkovich F, Nuñez S, Mocarbel Y, Pignatta A, Elías N, Díaz AG, Roganovich JM, Vigovich C, Balonga MC, Cohen AC, Mumbach G, Gonzalez S, Plantalech L, Fradinger E, Zanchetta JR. Impaired bone microarchitecture and strength in patients with tumor-induced osteomalacia. J Bone Miner Res 2021; 36:1502-1509. [PMID: 33950560 DOI: 10.1002/jbmr.4325] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/15/2021] [Accepted: 04/25/2021] [Indexed: 12/29/2022]
Abstract
Some studies based on bone biopsy have demonstrated that in patients with tumor-induced osteomalacia (TIO) the mineralization process of the bone matrix is profoundly disturbed. However, the interrelationship between clinical and biochemical features and bone microarchitecture in this disease needs further analysis. With this purpose in mind, we set out three objectives: (i) to determine bone microarchitecture and estimated bone strength in a group of patients with tumor-induced osteomalacia using high-resolution peripheral quantitative computed tomography (HR-pQCT) and finite element analysis (FEA), (ii) to investigate correlations between duration of disease, biochemical features, bone density, HR-pQCT and FEA parameters, and (iii) to compare HR-pQCT and FEA parameters with a healthy control group. Ten patients with TIO were included. All patients had non-resolved disease. At the distal radius, all bone microarchitecture parameters were significantly affected in patients with TIO in comparison with healthy controls. At the distal tibia, all parameters were significantly impaired, except for trabecular thickness. All the parameters were more affected in the distal tibia than in the distal radius. Women with TIO (n = 7) had significantly lower bone strength parameters than healthy controls. In men (n = 3), bone strength parameters were significantly lower than in the control group at the distal tibia. Alkaline phosphatase levels exhibited a negative correlation with microarchitecture parameters, failure load, and stiffness. Higher levels of parathyroid hormone correlated with poorer microarchitecture parameters. We believe that in TIO, hormonal disturbances and the lack of mechanical stimulus specially converge to generate an extremely harmful combination for bone health. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- María Belén Zanchetta
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
| | - Fernando Jerkovich
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina.,División Endocrinología, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Selva Nuñez
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
| | - Yamile Mocarbel
- División Endocrinología, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Analía Pignatta
- Servicio de Endocrinología, Hospital Interzonal San Juan Bautista, San Fernando del Valle de Catamarca, Argentina
| | - Natalia Elías
- Servicio de Endocrinología, Metabolismo, Nutrición y Diabetes, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Adriana Graciela Díaz
- División Endocrinología, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | | | - María Celeste Balonga
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
| | | | | | | | - Luisa Plantalech
- Servicio de Endocrinología y Medicina Nuclear, Sector Osteopatías, Hospital Italiano, Buenos Aires, Buenos Aires, Argentina
| | - Erich Fradinger
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
| | - José Rubén Zanchetta
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
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3
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Florenzano P, Gafni RI, Collins MT. Tumor-induced osteomalacia. Bone Rep 2017; 7:90-97. [PMID: 29021995 PMCID: PMC5633085 DOI: 10.1016/j.bonr.2017.09.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/07/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome clinically characterized by bone pain, fractures and muscle weakness. It is caused by tumoral overproduction of fibroblast growth factor 23 (FGF23) that acts primarily at the proximal renal tubule, decreasing phosphate reabsorption and 1α-hydroxylation of 25 hydroxyvitamin D, thus producing hypophosphatemia and osteomalacia. Lesions are typically small, benign mesenchymal tumors that may be found in bone or soft tissue, anywhere in the body. In up to 60% of these tumors, a fibronectin-1(FN1) and fibroblast growth factor receptor-1 (FGFR1) fusion gene has been identified that may serve as a tumoral driver. The diagnosis is established by the finding of acquired chronic hypophosphatemia due to isolated renal phosphate wasting with concomitant elevated or inappropriately normal blood levels of FGF23 and decreased or inappropriately normal 1,25-OH2-Vitamin D (1,25(OH)2D). Locating the tumor is critical, as complete removal is curative. For this purpose, a step-wise approach is recommended, starting with a thorough medical history and physical examination, followed by functional imaging. Suspicious lesions should be confirmed by anatomical imaging, and if needed, selective venous sampling with measurement of FGF23. If the tumor is not localized, or surgical resection is not possible, medical therapy with phosphate and active vitamin D is usually successful in healing the osteomalacia and reducing symptoms. However, compliance is often poor due to the frequent dosing regimen and side effects. Furthermore, careful monitoring is needed to avoid complications such us secondary/tertiary hyperparathyroidism, hypercalciuria, and nephrocalcinosis. Novel therapeutical approaches are being developed for TIO patients, such as image-guided tumor ablation and medical treatment with the anti-FGF23 monoclonal antibody KRN23 or anti FGFR medications. The case of a patient with TIO is presented to illustrate the importance of adequate and appropriate evaluation of patients with bone pain and hypophosphatemia, as well as an step-wise localization study of patients with suspected TIO.
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Key Words
- 1,25-OH2-vitamin D, 1,25(OH)2D
- CT, computerized tomography
- FDG-PET/CT, fluorodeoxyglucose positron emission tomography with computerized tomography
- FGF1, fibroblast growth factor 1
- FGF23
- FGF23, fibroblast growth factor 23
- FGFR1, fibroblast growth factor receptor-1
- FISH, fluorescence in situ hybridization
- FN1, fibronectin-1
- MAPK, mitogen-activated protein kinase
- MRI, magnetic resonance imaging
- PMT, phosphaturic mesenchymal tumor
- PTH, parathyroid hormone
- Phosphaturic mesenchymal tumors
- SPECT, single-photon emission computed tomography
- TIO, tumor-induced osteomalacia
- TRP, tubular reabsorption of phosphate
- TmP/GFR, tubular maximum reabsorption of phosphate to glomerular filtration rate
- Tumor-induced osteomalacia
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Affiliation(s)
- Pablo Florenzano
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Endocrinology Department, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rachel I Gafni
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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González G, Baudrand R, Sepúlveda MF, Vucetich N, Guarda FJ, Villanueva P, Contreras O, Villa A, Salech F, Toro L, Michea L, Florenzano P. Tumor-induced osteomalacia: experience from a South American academic center. Osteoporos Int 2017; 28:2187-2193. [PMID: 28341900 DOI: 10.1007/s00198-017-4007-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/10/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED The majority of tumor-induced osteomalacia cases have been reported in the Northern Hemisphere and Asia. In this first series of South American patients, we show that the clinical presentation and sensitivity of plasmatic fibroblast growth factor 23 and somatostatin analog-based imaging are similar to those described in other populations. INTRODUCTION Describe the experience of clinical presentation, diagnostic study, and treatment of patients with tumor-induced osteomalacia (TIO) in a South American academic center in comparison to literature. METHODS Analysis of the records of patients diagnosed with TIO. The clinical presentation, diagnostic studies, and treatment were analyzed. Fibroblast growth factor 23 (FGF23) was measured by ELISA. RESULTS Six patients were diagnosed with TIO during the studied period. The patients' median age was 53 years (range 22-64). All patients presented with weakness and pain in the extremities. Four experienced fractures during their evolution. The median time to diagnosis was 4.5 years (1-20). Biochemical studies showed hypophosphatemia, median of 1.4 mg/dL (1.2-1.6), with low maximum rates of tubular reabsorption of phosphate adjusted for glomerular filtration rate. FGF23 was elevated in 4/6 patients and inappropriately normal in the other two. In three patients, the location of the tumor was clinically evident and confirmed with anatomical imaging. In the remaining patients, two tumors were located with 68Ga DOTATATE-PET/CT and one with OctreoScan. The causal tumors were located in the lower extremities in five patients and invading the frontal sinus in one patient. In all patients, tumors were successfully removed. Within 14 days, there was normalization of phosphate and FGF23 levels and resolution of clinical symptoms in all patients. In all cases, the histopathology was compatible with a phosphaturic mesenchymal tumor. CONCLUSIONS The clinical presentation, delay time to diagnosis, FGF23 diagnostic sensitivity and histopathology in this first series of South American patients is similar to those described in other populations. The success of localization by somatostatin analog-based imaging, suggests this may the optimal imaging modality.
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Affiliation(s)
- G González
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - R Baudrand
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - M F Sepúlveda
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - N Vucetich
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - F J Guarda
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - P Villanueva
- Departamento de Neurocirugía, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - O Contreras
- Departamento de Radiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - A Villa
- Departamento de Traumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - F Salech
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Centro de Investigacion Clinica Avanzada, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - L Toro
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Centro de Investigacion Clinica Avanzada, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - L Michea
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - P Florenzano
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile.
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Fracassi F, Malerba E, Furlanello T, Caldin M. Urinary excretion of calcium and phosphate in dogs with pituitary-dependent hypercortisolism: case control study in 499 dogs. Vet Rec 2015; 177:625. [PMID: 26626505 DOI: 10.1136/vr.103436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2015] [Indexed: 11/04/2022]
Abstract
Pituitary-dependent hypercortisolism (PDH) in dogs is frequently associated with high serum phosphate and parathormone concentrations which are in turn associated with prognosis and clinical presentation. The pathogenesis of such abnormalities remains unknown. The aim of the present study was to evaluate the serum and urinary concentrations and the urinary fractional excretion of phosphate and calcium in dogs with PDH. Medical records of newly diagnosed PDH dogs before treatment from one referral centre were retrospectively evaluated. One clinically normal and one sick dog for each dog with PDH were included as controls. One hundred and sixty-seven dogs with PDH were included. The serum phosphate concentration in PDH dogs was significantly (P<0.0001) higher compared with clinically normal control dogs (CNDs) and sick control dogs (SCDs). The serum calcium concentration in PDH dogs was significantly higher compared with SCDs but not different compared with CNDs. Urinary fractional excretion of phosphate in PDH dogs was significantly lower compared with CNDs and SCDs. Urinary fractional excretion of calcium in PDH dogs was significantly higher compared with CNDs and SCDs. In conclusion, PDH dogs have lower phosphaturia and higher calciuria compared with control dogs. These findings suggest that, at least in part, high serum phosphate concentrations are related to the renal retention of phosphate.
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Affiliation(s)
- F Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - E Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - T Furlanello
- Laboratorio Veterinario San Marco, Padova, Italy
| | - M Caldin
- Clinica Veterinaria San Marco, Padova, Italy
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Williams TL, Elliott J, Syme HM. Calcium and phosphate homeostasis in hyperthyroid cats - associations with development of azotaemia and survival time. J Small Anim Pract 2012; 53:561-71. [DOI: 10.1111/j.1748-5827.2012.01253.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- T. L. Williams
- Department of Veterinary Clinical Sciences; Royal Veterinary College; Hawkshead Lane; North Mymms; Hatfield; AL9 7TA
| | | | - H. M. Syme
- Department of Veterinary Clinical Sciences; Royal Veterinary College; Hawkshead Lane; North Mymms; Hatfield; AL9 7TA
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Pai A, Leaf EM, El-Abbadi M, Giachelli CM. Elastin degradation and vascular smooth muscle cell phenotype change precede cell loss and arterial medial calcification in a uremic mouse model of chronic kidney disease. THE AMERICAN JOURNAL OF PATHOLOGY 2011; 178:764-73. [PMID: 21281809 DOI: 10.1016/j.ajpath.2010.10.006] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 09/20/2010] [Accepted: 10/19/2010] [Indexed: 11/17/2022]
Abstract
Arterial medial calcification (AMC), a hallmark of vascular disease in uremic patients, is highly correlated with serum phosphate levels and cardiovascular mortality. To determine the mechanisms of AMC, mice were made uremic by partial right-side renal ablation (week 0), followed by left-side nephrectomy at week 2. At 3 weeks, mice were switched to a high-phosphate diet, and various parameters of disease progression were examined over time. Serum phosphate, calcium, and fibroblast growth factor 23 (FGF-23) were up-regulated as early as week 4. Whereas serum phosphate and calcium levels declined to normal by 10 weeks, FGF-23 levels remained elevated through 16 weeks, consistent with an increased phosphate load. Elastin turnover and vascular smooth muscle cell (VSMC) phenotype change were early events, detected by week 4 and before AMC. Both AMC and VSMC loss were significantly elevated by week 8. Matrix metalloprotease 2 (MMP-2) and cathepsin S were present at baseline and were significantly elevated at weeks 8 and 12. In contrast, MMP-9 was not up-regulated until week 12. These findings over time suggest that VSMC phenotype change and VSMC loss (early phosphate-dependent events) may be necessary and sufficient to promote AMC in uremic mice fed a high-phosphate diet, whereas elastin degradation might be necessary but is not sufficient to induce AMC (because elastin degradation occurred also in uremic mice on a normal-phosphate diet, but they did not develop AMC).
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Affiliation(s)
- Ashwini Pai
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
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Klonoff DC. Fibroblast growth factor: will this hormone be the hemoglobin A1c for managing phosphorus balance in chronic kidney disease? J Diabetes Sci Technol 2010; 4:770-2. [PMID: 20663436 PMCID: PMC2909504 DOI: 10.1177/193229681000400401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Wollanka H, Weidenmaier W, Giersig C. NSF after Gadovist exposure: a case report and hypothesis of NSF development. Nephrol Dial Transplant 2009; 24:3882-4. [DOI: 10.1093/ndt/gfp494] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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