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Molto A, López-Medina C, Van den Bosch FE, Boonen A, Webers C, Dernis E, van Gaalen FA, Soubrier M, Claudepierre P, Baillet A, Starmans-Kool M, Spoorenberg A, Jacques P, Carron P, Joos R, Lenaerts J, Gossec L, Pouplin S, Ruyssen-Witrand A, Sparsa L, van Tubergen A, van der Heijde D, Dougados M. Efficacy of a tight-control and treat-to-target strategy in axial spondyloarthritis: results of the open-label, pragmatic, cluster-randomised TICOSPA trial. Ann Rheum Dis 2021; 80:1436-1444. [PMID: 33958325 PMCID: PMC8522451 DOI: 10.1136/annrheumdis-2020-219585] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/16/2021] [Accepted: 04/18/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To compare the benefits of a tight-control/treat-to-target strategy (TC/T2T) in axial spondyloarthritis (axSpA) with those of usual care (UC). METHODS Pragmatic, prospective, cluster-randomised, controlled, open, 1-year trial (NCT03043846). 18 centres were randomised (1:1). Patients met Axial Spondylo Arthritis International Society (ASAS) criteria for axSpA, had an Ankylosing Spondylitis Disease Activity Score (ASDAS) ≥2.1, received non-optimal treatment by non-steroidal anti-inflammatory drugs and were biologic-naive. INTERVENTIONS (1) TC/T2T: visits every 4 weeks and prespecified strategy based on treatment intensification until achieving target (ie, ASDAS <2.1); (2) UC: visits every 12 weeks and treatment at the rheumatologist's discretion. MAIN OUTCOME Percentage of patients with a ≥30% improvement on the ASAS-Health Index (ASAS-HI). Other efficacy outcomes and adverse events were recorded. A health economic evaluation was performed. STATISTICAL ANALYSIS Two-level mixed models were used to estimate efficacy outcomes. Cost-effectiveness was assessed by the incremental cost per quality-adjusted life-year (QALY) gained for TC/T2T versus UC. RESULTS 160 patients were included (80/group). Mean (SD) age was 37.9 (11.0) years and disease duration was 3.7 (6.2) years; 51.2% were men. ASDAS at inclusion was 3.0 (0.7), and ASAS-HI was 8.6 (3.7). ASAS-HI improved by ≥30% in 47.3% of the TC/T2T arm and in 36.1% of those receiving UC (non-significant). All secondary efficacy outcomes were more frequent in the TC/T2T arm, although not all statistically significant. Safety was similar in both arms. From a societal perspective, TC/T2T resulted in an additional 0.04 QALY, and saved €472 compared with UC. CONCLUSION TC/T2T was not significantly superior to UC for the primary outcome, while many secondary efficacy outcomes favoured it, had a similar safety profile and was favourable from a societal health economic perspective. TRIAL REGISTRATION NUMBER NCT03043846.
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Affiliation(s)
- Anna Molto
- Rheumatology Department, Hospital Cochin, Paris, France
- ECAMO team, INSERM U1153, Paris, France
| | - Clementina López-Medina
- ECAMO team, INSERM U1153, Paris, France
- Rheumatology Department, Reina Sofia University Hospital, Cordoba, Andalucía, Spain
| | | | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Casper Webers
- Department of Internal Medicine, Division of Rheumatology, Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | | | | | | | - Pascal Claudepierre
- Rheumatology, Henri Mondor Hospital Rheumatology Service, Creteil, France
- EpiDermE, Université Paris Est Créteil, Créteil, France
| | - Athan Baillet
- Rheumatology, Hopital Sud, Echirolles, France
- GREPI EA7408, Universite Grenoble Alpes, Saint-Martin-d'Heres, France
| | | | - Anneke Spoorenberg
- Rheumatology & Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Peggy Jacques
- Rheumatology Department, University Hospital Ghent, Gent, Oost-Vlaanderen, Belgium
- Rheumatology, VIB-UGent Center for Inflammation Research, Zwijnaarde, Belgium
| | - Philippe Carron
- Rheumatology, VIB-UGent Center for Inflammation Research, Zwijnaarde, Belgium
- Rheumatology, University Hospital Ghent, Gent, Belgium
| | - Rik Joos
- Rheumatology, ZNA UKJA, Antwerpen, Belgium
| | - Jan Lenaerts
- Rheumatology, Reumainstituut Hasselt, Hasselt, Belgium
| | - Laure Gossec
- Rheumatology Department, University Hospital Pitié Salpêtrière, Paris, France
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | | | - Adeline Ruyssen-Witrand
- Rheumatology, University Hospital Centre Toulouse, Toulouse, France
- Paul Sabatier University, Toulouse, France
| | - Laetitia Sparsa
- Rheumatology department, Hospital Centre Mulhouse, Mulhouse, France
| | - Astrid van Tubergen
- Department of Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Maxime Dougados
- Rheumatology Department, Hospital Cochin, Paris, France
- ECAMO team, INSERM U1153, Paris, France
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van Boheemen L, Turk S, Beers-Tas MV, Bos W, Marsman D, Griep EN, Starmans-Kool M, Popa CD, van Sijl A, Boers M, Nurmohamed MT, van Schaardenburg D. Atorvastatin is unlikely to prevent rheumatoid arthritis in high risk individuals: results from the prematurely stopped STAtins to Prevent Rheumatoid Arthritis (STAPRA) trial. RMD Open 2021; 7:e001591. [PMID: 33685928 PMCID: PMC7942258 DOI: 10.1136/rmdopen-2021-001591] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Persons at high risk of rheumatoid arthritis (RA) might benefit from a low-risk pharmacological intervention aimed at primary prevention. Previous studies demonstrated disease-modifying effects of statins in patients with RA as well as an association between statin use and a decreased risk of RA development. A randomised, double-blind, placebo-controlled trial investigated whether atorvastatin could prevent arthritis development in high-risk individuals. METHODS Arthralgia patients with anticitrullinated protein antibody (ACPA) >3 xULN or ACPA and rheumatoid factor, without (a history of) arthritis, were randomised to receive atorvastatin 40 mg daily or placebo for 3 years. The calculated sample size was 220 participants. The primary endpoint was clinical arthritis. Cox regression analysis was used to determine the effect of atorvastatin on arthritis development. RESULTS Due to a low inclusion rate, mainly because of an unwillingness to participate, the trial was prematurely stopped. Data of the 62 randomised individuals were analysed. Median follow-up was 14 (inner quartiles 6-35) months. Fifteen individuals (24%) developed arthritis: 9/31 (29%) in the atorvastatin group; 6/31 (19%) in the placebo group: HR 1.40, 95% CI 0.50 to 3.95. CONCLUSIONS In this small set of randomised high-risk individuals, we did not demonstrate a protective effect of atorvastatin on arthritis development. The main reason for the low inclusion was unwillingness to participate; this may also impede other RA prevention trials. Further research to investigate and solve barriers for prevention trial participation is needed.
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Affiliation(s)
- Laurette van Boheemen
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, Noord-Holland, The Netherlands
| | - Samina Turk
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, Noord-Holland, The Netherlands
| | - Marian van Beers-Tas
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, Noord-Holland, The Netherlands
| | - Wouter Bos
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, Noord-Holland, The Netherlands
| | - Diane Marsman
- Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Ed N Griep
- Rheumatology, Antonius Hospital Sneek, Sneek, The Netherlands
| | | | - Calin D Popa
- Rheumatology, Bernhoven Hospital Location Uden, Uden, The Netherlands
- Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Alper van Sijl
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, Noord-Holland, The Netherlands
| | - Maarten Boers
- Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC Locatie VUmc, Amsterdam, Noord-Holland, The Netherlands
- Rheumatology and immunology, AI&I, Amsterdam UMC Locatie VUmc, Amsterdam, Noord-Holland, The Netherlands
| | - Michael T Nurmohamed
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, Noord-Holland, The Netherlands
- Rheumatology and immunology, AI&I, Amsterdam UMC Locatie VUmc, Amsterdam, Noord-Holland, The Netherlands
| | - Dirkjan van Schaardenburg
- Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, Noord-Holland, The Netherlands
- Rheumatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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Moltó A, López-Medina C, Van den Bosch F, Boonen A, Webers C, Dernis E, Van Gaalen FA, Soubrier M, Claudepierre P, Baillet A, Starmans-Kool M, Van der Heijde D, Dougados M. THU0370 CLUSTER-RANDOMIZED PRAGMATIC CLINICAL TRIAL EVALUATING THE POTENTIAL BENEFIT OF A TIGHT-CONTROL AND TREAT-TO-TARGET STRATEGY IN AXIAL SPONDYLOARTHRITIS: THE RESULTS OF THE TICOSPA TRIAL. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.1543] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Current recommendations for axial spondyloarthritis (axSpA) management include tight control and treat-to-target (TC) strategies, but no study has evaluated its potential benefitObjectives:To evaluate the benefit of TC strategies in comparison to usual care (UC) in patients with axSpA.Methods:Study design:Pragmatic, prospective, cluster-randomized controlled (2 arms), one-year trial (NCT03043846).Centers: 18 axSpA expert centers randomly allocated (1:1) to the treatment arm: TC vs. UC.Patients: axSpA diagnosis and ASAS criteria, non-optimally treated with NSAIDs, bDMARD-naïve, and ASDAS > 2.1 at inclusion.Study treatment:a) TC arm: the strategy was pre-specified by the scientific committee based on current axSpA recommendations and aiming at a target (ASDAS <2.1); visits every 4w;b) UC arm:treatment decisions were at the rheumatologist’s discretion with visits every 12w.Outcomes:the % of patients with a significant (>30%) improvement in the ASAS-HI score over one-year follow-up was the main outcome. Other outcomes (disease activity, quality of life, treatment, …) over follow-up were evaluated (Table 1). The number/type of adverse events were collected.Statistical analysis: this was an intention-to-treat analysis. To take into account the cluster-randomization design, for all outcomes, two models were performed: first a two-level mixed model with 2 random effects was used to estimate the % of responders/the change of the outcome over follow-up (i.e. mod1); in a second step, the imbalanced variables observed at baseline were included in the model (i.e.mod2). Cost-effectiveness was assessed by estimating the (baseline- and cluster-adjusted) incremental cost per quality-adjusted life-year (QALY) gained for TC vs. UC.Estimated outcomes at week 48Cluster-adjusted (mod1)Cluster and imbalance-adjusted (mod2)TCUCASDAS LDA*76.5%59.5%<0.010.03ASDAS ID25.9%18.7%--ASDAS CII61.2%46.0%<0.010.02ASDAS MI16.5%14.9%--ASAS4052.3%34.7%<0.010.01ASAS2094.9%85.9%<0.010.03BASDAI 5079.0%43.8%0.010.03Physician Global (0-10)2.0 (0.2)1.8 (0.2)--CRP (mg/L)3.9(1.4)3.5 (1.5)--BASG (0-10)2.6 (0.5)3.4 (0.5)0.09-BASFI (0-10)1.7(0.5)2.4 (0.5)--ASAS HI SMD47.3%36.1%--EQ5D0.7(0.1)0.8(0.1)0.02-ASAS-NSAID score1.5(2.2)- 4.9 (2.9)--Results:160 patients were included (80 in TC and 80 in UC). Mean age was 37.9(11.0) years with a disease duration of 3.7(6.2) years, 51.2% were males. A radiographic damage of the SI-joints, a (ever) positive MRI sacroiliitis and HLA-B27+ were seen in 46.9%, 81.9% and 75.0% patients respectively. Mean ASDAS at inclusion was 3.0 (0.7) and mean ASASHI was 8.6 (3.7). 72 patients per group attended the one-year visit. Although 47.3% vs. 36.1% patients in the TC and UC arms achieved a significant improvement in ASASHI at the one-year visit, the difference was not statistically significant, with either model. Across all other outcomes a trend was observed in favor of the TC arm (Table 1). The number of bDMARDs was significantly higher in TC arm (56.2% vs. 27.2%). The number of infections was comparable in both groups (15 vs. 16 in the TC and UC, respectively), with only 2 severe infections occurring in the UC arm. From a societal perspective, TC resulted in an additional 0.04 QALY and saved €265 when compared to UC and a 67% probability of being cost-effective at a cost-effectiveness threshold of €20,000 per QALY.Conclusion:In this setting of SpA expert centers, UC resulted in a good outcome in a substantial number of patients but the TC was not superior for the primary outcome despite a greater number of bDMARDs prescription. Nevertheless, a general trend in favor of the tight control was observed, with a comparable safety profile and was found to be favorable from a societal health economic perspective.Acknowledgments:this trial has been conducted thanks to an unrestricted grant from UCBDisclosure of Interests:Anna Moltó Grant/research support from: Pfizer, UCB, Consultant of: Abbvie, BMS, MSD, Novartis, Pfizer, UCB, Clementina López-Medina: None declared, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Annelies Boonen Grant/research support from: AbbVie, Consultant of: Galapagos, Lilly (all paid to the department), Casper Webers: None declared, Emmanuelle Dernis Speakers bureau: Lilly, Novartis, Floris A. van Gaalen: None declared, Martin SOUBRIER: None declared, Pascal Claudepierre Speakers bureau: Janssen, Novartis, Lilly, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review, Mirian Starmans-Kool: None declared, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Maxime Dougados Grant/research support from: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Speakers bureau: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma
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Ghiti Moghadam M, Vonkeman HE, Ten Klooster PM, Tekstra J, van Schaardenburg D, Starmans-Kool M, Brouwer E, Bos R, Lems WF, Colin EM, Allaart CF, Meek IL, Landewé R, Bernelot Moens HJ, van Riel PLCM, van de Laar MAFJ, Jansen TL. Stopping Tumor Necrosis Factor Inhibitor Treatment in Patients With Established Rheumatoid Arthritis in Remission or With Stable Low Disease Activity: A Pragmatic Multicenter, Open-Label Randomized Controlled Trial. Arthritis Rheumatol 2017; 68:1810-7. [PMID: 26866428 DOI: 10.1002/art.39626] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 02/02/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Tumor necrosis factor inhibitor (TNFi) biologic agents are an effective treatment for rheumatoid arthritis (RA). It is unclear whether patients whose disease is in remission or who have stable low disease activity need to continue use of TNFi or can stop this treatment. This study was undertaken to assess whether patients with established RA who are in remission or have stable low disease activity can effectively and safely stop their TNFi therapy. METHODS The study was designed as a pragmatic multicenter, open-label randomized controlled trial. Inclusion criteria were a diagnosis of RA according to the American College of Rheumatology 1987 classification criteria, as well as use of a TNFi for at least 1 year along with a stable dose of disease-modifying antirheumatic drugs and a Disease Activity Score in 28 joints (DAS28) of <3.2 over the 6 months preceding trial inclusion. Patients were randomized in a 2:1 ratio to either stop or continue treatment with their current TNFi. Flare was defined as a DAS28 of ≥3.2 during the 12-month follow-up period and an increase in score of ≥0.6 compared to the baseline DAS28. RESULTS In total, 531 patients were allocated to the stop group and 286 to the TNFi continuation group. At 12 months, more patients had experienced a flare in the stop group (272 [51.2%] of 531) than in the continuation group (52 [18.2%] of 286; P < 0.001). The hazard ratio for occurrence of a flare after stopping TNFi was 3.50 (95% confidence interval [95% CI] 2.60-4.72). The mean DAS28 in the stop group was significantly higher during the follow-up period compared to that in the continuation group (P < 0.001). Of the 195 patients who restarted TNFi treatment after experiencing a flare and within 26 weeks after stopping, 165 (84.6%) had regained a DAS28 of <3.2 by 6 months later, and the median time to a regained DAS28 of <3.2 was 12 weeks (95% Cl 10.7-13.3). There were more hospitalizations in the stop group than in the continuation group (6.4% versus 2.4%). CONCLUSION Stopping TNFi treatment results in substantially more flares than does continuation of TNFi in patients with established RA in remission or with stable low disease activity.
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Affiliation(s)
- Marjan Ghiti Moghadam
- Arthritis Center Twente Medical Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Harald E Vonkeman
- Arthritis Center Twente Medical Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Peter M Ten Klooster
- Arthritis Center Twente Medical Spectrum Twente and University of Twente, Enschede, The Netherlands
| | | | | | - Mirian Starmans-Kool
- Atrium Medical Center, Heerlen, The Netherlands, and Orbis Medical Center, Sittard-Geleen, The Netherlands
| | | | - Reinhard Bos
- Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Willem F Lems
- VU University Medical Center and Reade Medical Center, Amsterdam, The Netherlands
| | - Edgar M Colin
- Hospital Group Almelo, Almelo, The Netherlands, and Hengelo Twente Hospital Group, Hengelo, The Netherlands
| | | | - Inger L Meek
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Landewé
- Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Hein J Bernelot Moens
- Hospital Group Almelo, Almelo, The Netherlands, and Hengelo Twente Hospital Group, Hengelo, The Netherlands
| | | | - Mart A F J van de Laar
- Arthritis Center Twente Medical Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Tim L Jansen
- VieCuri Medical Center, Rheumatology, Venlo, The Netherlands
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Gerlag D, Safy M, Maijer K, de Hair M, Tas S, Starmans-Kool M, van Tubergen A, Janssen M, Tak PP. OP0182 Prevention of Rheumatoid Arthritis by B Cell Directed Therapy in The Earliest Phase of The Disease: The Prairi Study. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.6042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Vercoutere W, Starmans-Kool M, Peeters RM. [Anakinra in refractory adult onset Still's disease]. Ned Tijdschr Geneeskd 2011; 155:A2966. [PMID: 21466723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Adult onset Still's disease (AOSD) is a rare--but potentially dangerous and difficult to treat--generalized auto-inflammatory disease which shares some similarities with the systemic form of juvenile idiopathic arthritis (SoJIA or Still's disease). CASE DESCRIPTION AOSD was diagnosed in 2 young adult women of 21 and 23 years old. The disease was found to be resistant to treatment in these patients. The patients were treated successively with NSAIDs, glucocorticoids, methotrexate and anti tumour necrosis factor(TNF)-α antagonists, with only partial effects or none at all. Treatment with the interleukin-1 receptor antagonist anakinra was subsequently started, which led to remission of AOSD. CONCLUSION These cases illustrate the clinical spectrum of AOSD and the possibility of an important addition to the therapeutic arsenal for treatment of refractory AOSD.
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Affiliation(s)
- Ward Vercoutere
- Atrium Medisch Centrum Parkstad, afd. Reumatologie, Heerlen, the Netherlands.
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