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Sahoo S, Mishra E, Premkumar M. Antidepressants in People With Chronic Liver Disease and Depression: When Are They Warranted and How to Choose the Suitable One? J Clin Exp Hepatol 2024; 14:101390. [PMID: 38515504 PMCID: PMC10950710 DOI: 10.1016/j.jceh.2024.101390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/26/2024] [Indexed: 03/23/2024] Open
Abstract
Most chronic medical illnesses are associated with significant psychiatric comorbidity, especially in the form of depression, anxiety, and suicidality. Chronic liver disease (CLD) is no exception to this and rather is placed uniquely as compared to other diseases because of its intersection with alcohol use disorder and other substance use, which in itself is a mental illness. Patients with CLD may have comorbid psychiatric illnesses; the pharmacokinetic concerns arising out of hepatic dysfunction which affects pharmacotherapy for depression and vice versa. The high prevalence of medical comorbidities with CLD may further complicate the course and outcome of depression in such patients, and diagnostic and management issues arise from special situations like transplant evaluation, alcohol use disorder, and hepatic encephalopathy or multifactorial encephalopathy seen in a disoriented or agitated patient with CLD. For this narrative review, we carried out a literature search in PubMed/PubMed Central and in Google Scholar (1980-2023) with the keywords "depression in cirrhosis", "antidepressants in liver disease", "anxiety in liver disease", "depression in liver transplantation", and "drug interactions with antidepressants". This review presents a comprehensive view of the available research on the use of antidepressants in patients with CLD, including deciding to use them, choosing the right antidepressant, risks, drug interactions, and adverse reactions to expect, and managing the same. In addition, liver transplant fitness and the overlap of hepatic encephalopathy with neuropsychiatric illness will be discussed.
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Affiliation(s)
- Swapnajeet Sahoo
- Department of Psychiatry, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Eepsita Mishra
- Department of Psychiatry, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
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Berkowitz E, Trevick S. Non-Psychiatric Treatment Refusal in Patients with Depression: How Should Surrogate Decision-Makers Represent the Patient's Authentic Wishes? HEC Forum 2024:10.1007/s10730-024-09522-9. [PMID: 38280180 DOI: 10.1007/s10730-024-09522-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2024] [Indexed: 01/29/2024]
Abstract
Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or "authentic" self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, when that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a "restorative representation" model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their "truest self" would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient's treatment refusal and previously undiagnosed depression led to difficulty determining the patient's authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions.
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Affiliation(s)
- Esther Berkowitz
- Ascension Holy Family, 100 North River Rd, Des Plaines, IL, 60016, USA.
| | - Stephen Trevick
- Northwest Neurology, Ltd., 22285 North Pepper Rd #401, Barrington, IL, 60010, USA
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Kelly T, Kelly K, Borghesani P. Introduction of a Novel Ethics Curriculum to the Third-Year Psychiatry Clerkship Experience. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2023; 47:646-652. [PMID: 37415064 DOI: 10.1007/s40596-023-01810-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE The purpose of this study was to determine if a brief ethics curriculum embedded in a third-year required clerkship differentially impacted students' self-rated confidence versus competence (determined by a written examination) regarding ethical principles related to psychiatry. METHODS Using a naturalistic design, 270 medical students at the University of Washington were assigned to one of three groups during their third-year psychiatry clerkship: a control group with no additional ethics content, a group with access to a pre-recorded video ethics curriculum, or a group with live didactic sessions in addition to the video curriculum. All students took a pre- and post-test that assessed their confidence and competence in ethical theory and behavioral health ethics. RESULTS Confidence and competence were not statistically different across the three groups prior to completing the curriculum (p > 0.1). Post-test scores on confidence in behavioral health ethics were not significantly different between the three groups (p > 0.05). Post-test scores on confidence in ethical theory were significantly higher in the video-only and video + discussion group as compared to the control group (3.74 ± 0.55 and 4.00 ± 0.44 vs. 3.19 ± 0.59 respectively; p < 0.0001). Both the video-only and video + discussion group showed greater improvement in competence in ethical theory and application than the control group (0.68 ± 0.30 and 0.76 ± 0.23 vs. 0.31 ± 0.33, respectively; p < 0.0001) and behavioral health ethics (0.79 ± 0.14 and 0.85 ± 0.14 vs. 0.59 ± 0.15, respectively; p < 0.002). CONCLUSIONS With the addition of this ethics curriculum, students showed both increased confidence and competence in their ability to analyze ethical situations as well as increased competence regarding behavioral health ethics.
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Affiliation(s)
- Tim Kelly
- University of Washington, Seattle, WA, USA.
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Swirsky ES, Boyd AD, Gu C, Burke LA, Doorenbos AZ, Ezenwa MO, Knisely MR, Leigh JW, Li H, Mandernach MW, Molokie RE, Patil CL, Steffen AD, Shah N, deMartelly VA, Staman KL, Schlaeger JM. Monitoring and responding to signals of suicidal ideation in pragmatic clinical trials: Lessons from the GRACE trial for Chronic Sickle Cell Disease Pain. Contemp Clin Trials Commun 2023; 36:101218. [PMID: 37842321 PMCID: PMC10569945 DOI: 10.1016/j.conctc.2023.101218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/11/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023] Open
Abstract
Sickle cell disease (SCD) is a hemoglobin disorder and the most common genetic disorder that affects 100,000 Americans and millions worldwide. Adults living with SCD have pain so severe that it often requires opioids to keep it in control. Depression is a major global public health concern associated with an increased risk in chronic medical disorders, including in adults living with sickle cell disease (SCD). A strong relationship exists between suicidal ideation, suicide attempts, and depression. Researchers enrolling adults living with SCD in pragmatic clinical trials are obligated to design their methods to deliberately monitor and respond to symptoms related to depression and suicidal ideation. This will offer increased protection for their participants and help clinical investigators meet their fiduciary duties. This article presents a review of this sociotechnical milieu that highlights, analyzes, and offers recommendations to address ethical considerations in the development of protocols, procedures, and monitoring activities related to suicidality in depressed patients in a pragmatic clinical trial.
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Affiliation(s)
| | | | - Carol Gu
- University of Illinois Chicago, Chicago, IL, USA
| | | | | | | | | | | | - Hongjin Li
- University of Illinois Chicago, Chicago, IL, USA
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Serdenes R, Arana F, Karasin J, Kontos N, Musselman M. Approaching differential diagnosis and decisional capacity assessment in the context of COVID-19 conspiracy beliefs: A narrative review and clinical discussion. Gen Hosp Psychiatry 2023; 83:75-80. [PMID: 37119781 PMCID: PMC10121076 DOI: 10.1016/j.genhosppsych.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/20/2023] [Accepted: 04/17/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE COVID-19 conspiracy theories have become widespread since the onset of the pandemic and compound the existing challenges of decisional capacity assessment. This paper aims to review the literature pertaining to decisional capacity assessment in the context of COVID-19 conspiracy beliefs and synthesize a practical approach with an emphasis on differential diagnosis and clinical pearls for the practicing physician. METHODS We reviewed papers on decisional capacity assessment and differential diagnosis in the context of COVID-19 conspiracy beliefs. A literature search was conducted using the US National Library of Medicine's PubMed.gov resource and Google Scholar. RESULTS The resulting article content was utilized to synthesize a practical approach to decisional capacity assessment in the context of COVID-19 conspiracy beliefs. Specifically, aspects related to the history, taxonomy, evaluation, and management are reviewed. CONCLUSIONS Appreciating the nuanced differences between delusions, overvalued ideas, and obsessions while with integrating the non-cognitive domains of capacity into the assessment are crucial to navigating the wide differential diagnosis of COVID-19 conspiracy beliefs. It is important to attempt to clarify and optimize patient decision-making abilities by addressing circumstances, attitudes, and cognitive styles specific to patients with seemingly irrational beliefs about COVID-19.
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Affiliation(s)
- Ryan Serdenes
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America.
| | - Francesca Arana
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Jamie Karasin
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Nicholas Kontos
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Meghan Musselman
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
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Ethical Framework to Guide Decisions of Treatment Over Objection. J Am Coll Surg 2021; 233:508-516.e1. [PMID: 34325018 DOI: 10.1016/j.jamcollsurg.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/15/2021] [Accepted: 07/02/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Whether to proceed with a medical intervention over the objection of a patient who lacks capacity is a common problem facing practitioners. Despite this, there is a notable gap in the literature describing how to proceed in such situations in an ethically rigorous and consistent fashion. We elaborate on the practical application of the 2018 Rubin/Prager seven-question algorithm for ethics consultations regarding treatment over objection and we describe the impact of each of the seven questions. STUDY DESIGN We retrospectively review a series of consultations at Columbia University Irving Medical Center for treatment over objection in adult patients determined to lack capacity between April 2017 and May 2020. Outcomes regarding the final ethics recommendation and the assessment of each of the seven questions are reported. The statistical analysis was designed to determine which of the seven questions in the algorithm were most predictive of the final ethics recommendation. RESULTS In our series, there was an ethics recommendation to proceed over the objection of a patient in 63% of consultations. While all seven questions were considered to be important to the ethical analysis of a patient's situation, the presence of logistical barriers to treatment and the imminence of harm to a patient without treatment emerged as the most significant drivers of the recommendation of whether to proceed over objection or not. CONCLUSIONS Cases of treatment over objection in a patient lacking capacity are frequently encountered problems that requires a careful balance of patient autonomy and a physician's duty of beneficence. The application of the Rubin/Prager seven-question algorithm reliably guides a care team through such a complex ethical dilemma.
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O'Cionnaith C, Wand APF, Peisah C. Navigating the Minefield: Managing Refusal of Medical Care in Older Adults with Chronic Symptoms of Mental Illness. Clin Interv Aging 2021; 16:1315-1325. [PMID: 34285476 PMCID: PMC8285123 DOI: 10.2147/cia.s311773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this case series is to illustrate the complexity of considerations across health (physical and mental), ethical, human rights and practical domains when an older adult with chronic symptoms of mental illness refuses treatment for a serious medical comorbidity. A broad understanding of these considerations may assist health care professionals in navigating this challenging but common aspect of clinical practice. Case Presentation Three detailed case reports are described. Participants were older adults with an acute presentation of a chronic mental illness, admitted to a specialized older persons mental health inpatient unit (OPMHU) in an Australian metropolitan hospital. Significant comorbid medical issues were detected or arose during the admission and the patient refused the recommended medical intervention. Data extracted from patients' medical records were analyzed and synthesized into detailed case reports using descriptive techniques. Each patient was assessed as lacking capacity for healthcare and treatment consent and did not have relatives or friends to assist with supported decision-making. Multifaceted aspects of decision-making and management are highlighted. Conclusion There are multiple complex issues to consider when an older adult with chronic symptoms of mental illness refuses treatment for serious comorbid medical conditions. In addition to optimizing management of the underlying mental illness (which may be impairing capacity to make healthcare decisions), clinicians should adopt a role of advocacy for their patients in considering the potential impact of ageism and stigma on management plans and inequities in physical healthcare. Consultation with specialist medical teams should incorporate multifaceted considerations such as potentially inappropriate treatment and optimum setting of care. Equally important is reflective practice; considering whether treatment decisions may infringe upon human rights or cause trauma.
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Affiliation(s)
- Cathal O'Cionnaith
- Older Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Anne P F Wand
- Older Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, NSW, Australia.,Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Discipline of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Carmelle Peisah
- Discipline of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Capacity Australia, Crows Nest, NSW, Australia
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Marks J, Predescu I, Dunn LB. Ethical Issues in Caring for Older Adults. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:325-329. [PMID: 34690601 PMCID: PMC8475933 DOI: 10.1176/appi.focus.20210011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Jarrod Marks
- Department of Psychiatry, SUNY Upstate Medical University, Syracuse (Marks); University of Pittsburgh Medical Center Altoona, Altoona, Pennsylvania (Predescu); Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Dunn)
| | - Iuliana Predescu
- Department of Psychiatry, SUNY Upstate Medical University, Syracuse (Marks); University of Pittsburgh Medical Center Altoona, Altoona, Pennsylvania (Predescu); Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Dunn)
| | - Laura B Dunn
- Department of Psychiatry, SUNY Upstate Medical University, Syracuse (Marks); University of Pittsburgh Medical Center Altoona, Altoona, Pennsylvania (Predescu); Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Dunn)
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9
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Hwang H, Kim CJ. Nurse roles in the advance directive system in Korea. Int Nurs Rev 2021; 69:159-166. [PMID: 34115378 DOI: 10.1111/inr.12683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 03/06/2021] [Accepted: 04/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In 2016, the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care was implemented in Korea, providing a broad framework for end-of-life decision-making for the first time and making advance directives legally recognized documents. This Act can correct long-standing under-recognition of patients as valid decision makers for their own treatment choices. However, limited recognition of patient self-determination, rigid legal forms for documenting patient wishes, and the roles of family under the Act may pose challenges both to patients and nurses. AIM This paper critiques whether this newly introduced system of advance directives can truly guarantee protection of the patient's interests and respect for patient autonomy in real life, and discusses ethical and legal issues regarding the Act. SOURCE OF EVIDENCE We reviewed the current system of advance directives by raising three questions: (1) Do advance directives reflect a competent person's voluntary and informed choice?, (2) Are advance directives applicable in diverse clinical situations?, and (3) Does the Korean advance directive system ensure that such directives are honored in reality? CONCLUSION Although the Act is an important first step in respecting patient autonomy in end-of-life decision-making, it remains inadequate as it fails to provide thorough guidance in terms of the quality of writing process, applicability, and the guaranteed effects of advance directives. IMPLICATIONS FOR NURSING AND HEALTH POLICY As nurses are best situated for addressing these limitations due to their roles and competencies in clinical practice, expanding the roles of nurses in every stage of advance directive practice could help achieve the original purpose of advance directives. This calls for a policy that promotes an expanded role of nurses to improve the quality of advance directive practice.
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Affiliation(s)
- Hyeyoung Hwang
- Pediatric and Adolescent Center, Samsung Medical Center, Seoul, Korea
| | - Claire Junga Kim
- Department of Medical Humanities, Dong-A University College of Medicine, Busan, Korea
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Ehrman SE, Norton KP, Karol DE, Weaver MS, Lockwood B, Latimer A, Scott E, Jones CA, Macauley R. Top Ten Tips Palliative Care Clinicians Should Know About Medical Decision-Making Capacity Assessment. J Palliat Med 2021; 24:599-604. [PMID: 33595361 DOI: 10.1089/jpm.2021.0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Palliative care (PC) clinicians treat seriously ill patients who are at increased risk for compromised decision-making capacity (DMC). These patients face profound and complex questions about which treatments to accept and which to decline. PC clinicians, therefore, have the especially difficult task of performing thorough, fair, and accurate DMC assessments in the face of the complex effects of terminal illness, which may be complicated by fluctuating acute medical conditions, mental illness, or cognitive dysfunction. This study, written by a team of clinicians with expertise in PC, ethics, psychiatry, pediatrics, and geriatrics, aims to provide expert guidance to PC clinicians on best practice for complex DMC assessment.
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Affiliation(s)
- Sarah E Ehrman
- Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Kavitha P Norton
- Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA
| | - David E Karol
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA.,Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Meaghann S Weaver
- Division of Pediatric Palliative Care, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Bethany Lockwood
- Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Abigail Latimer
- University of Kentucky College of Social Work, Lexington, Kentucky, USA
| | - Erin Scott
- Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Christopher A Jones
- Department of Medicine and Palliative Care Program, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert Macauley
- Division of Pediatric Palliative Care, Oregon Health and Science University, Portland, Oregon, USA
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Abstract
This article focuses on confidentiality and capacity issues affecting patients receiving care in the emergency department. The patient-physician relationship begins with presumed confidentiality. The article also clarifies instances where a physician may be required to break confidentiality for the safety of patients or others. This article then discusses risk management issues relevant to determining a patient's capacity to accept or decline medical care in the emergency department setting. Situations pertaining to refusal of care and discharges against medical advice are examined in detail, and best practices for mitigating risk in informed consent and barriers to consent are reviewed.
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Affiliation(s)
- Joseph H Kahn
- Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA.
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