Professional Documents
Culture Documents
ICD-9 710.0
OMIM 152700
DiseasesDB 12782
MedlinePlus 000435
eMedicine med/2228
emerg/564
MeSH D008180
Contents
[hide]
• 1 Classification
• 2 Signs and symptoms
o 2.1 Common symptoms explained
• 3 Causes
• 4 Pathophysiology
o 4.1 Abnormalities in apoptosis
• 5 Diagnosis
o 5.1 Diagnostic criteria
5.1.1 Alternative criteria
• 6 Treatment
o 6.1 Drug therapy
o 6.2 Lifestyle changes
• 7 Prevention
o 7.1 Complications during pregnancy
o 7.2 Prognosis
• 8 Epidemiology
• 9 History
o 9.1 Origins of "lupus erythematosus"
• 10 Notable patients
• 11 See also
• 12 References
• 13 External links
[edit] Classification
Lupus is a chronic autoimmune disease. It can affect multiple organ systems, including
the heart, skin, joints, kidneys, and nervous system. There are several types of lupus; in
general, when the word lupus alone is used, reference is to systemic lupus
erythematosus or SLE, as discussed in this article. Other types include:
Dermatological manifestations
As many as 30% of patients present with some dermatological symptoms (and
65% suffer such symptoms at some point), with 30% to 50% suffering from the
classic malar rash (or butterfly rash) associated with the disease. Patients may
present with discoid lupus (thick, red scaly patches on the skin). Alopecia; mouth,
nasal, and vaginal ulcers; and lesions on the skin are also possible manifestations.
Musculoskeletal manifestations
Patients most often seek medical attention for joint pain, with the small joints of
the hand and wrist usually affected, although all joints are at risk. The Lupus
Foundation of America estimates that more than 90 percent will experience joint
and/or muscle pain at some time during the course of their illness.[7] Unlike
rheumatoid arthritis, lupus arthritis is less disabling and usually does not cause
severe destruction of the joints. Fewer than ten percent of people with lupus
arthritis will develop deformities of the hands and feet.[7]
Hematological manifestations
Anemia and iron deficiency may develop in as many as half of patients. Low
platelet and white blood cell counts may be due to the disease or a side-effect of
pharmacological treatment. Patients may have an association with
antiphospholipid antibody syndrome (a thrombotic disorder), wherein
autoantibodies to phospholipids are present in the patient's serum. Abnormalities
associated with antiphospholipid antibody syndrome include a paradoxical
prolonged PTT (which usually occurs in hemorrhagic disorders) and a positive
test for antiphospholipid antibodies; the combination of such findings have earned
the term lupus anticoagulant-positive. Another autoantibody finding in lupus is
the anticardiolipin antibody, which can cause a false positive test for syphilis.
Cardiac manifestations
Patients may present with inflammation of various parts of the heart, such as
pericarditis, myocarditis, and endocarditis. The endocarditis of SLE is
characteristically noninfective (Libman-Sacks endocarditis) and involves either
the mitral valve or the tricuspid valve. Atherosclerosis also tends to occur more
often and advances more rapidly in SLE patients than in the general
population.[8][9][10]
Pulmonary manifestations
Lung and pleura inflammation can cause pleuritis, pleural effusion, lupus
pneumonitis, chronic diffuse interstitial lung disease, pulmonary hypertension,
pulmonary emboli, pulmonary hemorrhage, and shrinking lung syndrome.
Hepatic involvement
See autoimmune hepatitis.
Renal involvement
Painless hematuria or proteinuria may often be the only presenting renal
symptom. Acute or chronic renal impairment may develop with lupus nephritis,
leading to acute or end-stage renal failure. Because of early recognition and
management of SLE, end-stage renal failure occurs in less than 5% of patients.
A histological hallmark of SLE is membranous glomerulonephritis with "wire
loop" abnormalities.[11] This finding is due to immune complex deposition along
the glomerular basement membrane, leading to a typical granular appearance in
immunofluorescence testing.
Neurological manifestations
About 10% of patients may present with seizures or psychosis. One-third may test
positive for abnormalities in the cerebrospinal fluid.
T-cell abnormalities
Abnormalities in T cell-signaling are associated with SLE, including a deficiency
in CD45 phosphatase and increased expression of CD40 ligand.
Other rarer manifestations
Lupus gastroenteritis, lupus pancreatitis, lupus cystitis, autoimmune inner ear
disease, parasympathetic dysfunction, retinal vasculitis, and systemic vasculitis.
[edit] Causes
Transmission
In SLE, the body's immune system produces antibodies against itself, particularly against
proteins in the cell nucleus. SLE is triggered by environmental factors that are unknown
(but probably include viruses) in people with certain combinations of genes in their
immune system.
"All the key components of the immune system are involved in the underlying
mechanisms" of SLE, according to Rahman, and SLE is the prototypical autoimmune
disease. The immune system must have a balance (homeostasis) between being sensitive
enough to protect against infection, and being too sensitive and attacking the body's own
proteins (autoimmunity). From an evolutionary perspective, according to Crow, the
population must have enough genetic diversity to protect itself against a wide range of
possible infection; some genetic combinations result in autoimmunity. The likely
environmental triggers include ultraviolet light, drugs, and viruses. These stimuli cause
the destruction of cells and expose their DNA, histones, and other proteins, particularly
parts of the cell nucleus. Because of genetic variations in different components of the
immune system, in some people the immune system attacks these nuclear-related proteins
and produces antibodies against them. In the end, these antibody complexes damage
blood vessels in critical areas of the body, such as the glomeruli of the kidney; these
antibody attacks are the cause of SLE. Researchers are now identifying the individual
genes, the proteins they produce, and their role in the immune system. Each protein is a
link on the autoimmune chain, and researchers are trying to find drugs to break each of
those links. [12][13][14]
Genetics
The first mechanism may arise genetically. Research indicates that SLE may have
a genetic link. Lupus does run in families, but no single "lupus gene" has yet been
identified. Instead, multiple genes appear to influence a person's chance of
developing lupus when triggered by environmental factors. The most important
genes are located on chromosome 6, where mutations may occur randomly (de
novo) or may be inherited. In addition, people with SLE have an altered RUNX-1
binding site, which may be either cause or contributor (or both) to the condition.
Altered binding sites for RUNX-1 have also been found in people with psoriasis
and rheumatoid arthritis.
Environmental triggers
The second mechanism may be due to environmental factors. These factors may
not only exacerbate existing lupus conditions but also trigger the initial onset.
They include certain medications (such as some antidepressants and antibiotics),
extreme stress, exposure to sunlight, hormones, and infections. Some researchers
have sought to find a connection between certain infectious agents (viruses and
bacteria), but no pathogen can be consistently linked to the disease. UV radiation
has been shown to trigger the photosensitive lupus rash, but some evidence also
suggests that UV light is capable of altering the structure of the DNA, leading to
the creation of autoantibodies. Some researchers have found that women with
silicone gel-filled breast implants have produced antibodies to their own collagen,
but it is not known how often these antibodies occur in the general population,
and there is no data that show that these antibodies cause connective tissue
diseases such as lupus.
Drug reactions
Drug-induced lupus erythematosus is a reversible condition that usually occurs in
patients being treated for a long-term illness. Drug-induced lupus mimics
systemic lupus. However, symptoms of drug-induced lupus, in general, disappear
once a patient is taken off the medication that triggered the episode. There are
about 400 medications currently in use that can cause this condition, the most
common of which are procainamide, hydralazine, quinidine, and Phenytoin.
Non-SLE forms of lupus
Discoid (cutaneous) lupus is limited to skin symptoms and is diagnosed by biopsy
of skin rash on the face, neck, or scalp. Often an antinuclear antibody (ANA) test
for discoid patients is negative or a low-titer positive. About 1–5% of discoid
lupus patients eventually develop SLE.
Clearance deficiency
Clearance deficiency.
The exact mechanisms for the development of systemic lupus erythematosus (SLE) are
still unclear, since the pathogenesis is a multifactorial event. Beside discussed causations,
impaired clearance of dying cells is a potential pathway for the development of this
systemic autoimmune disease. This includes deficient phagocytic activity and scant
serum components in addition to increased apoptosis.
Monocytes isolated from whole blood of SLE patients show reduced expression of CD44
surface molecules involved in the uptake of apoptotic cells. Most of the monocytes and
tingible body macrophages (TBM), which are found in the germinal centres of lymph
nodes, even show a definitely different morphology in patients with SLE; they are
smaller or scarce and die earlier. Serum components like complement factors, CRP, and
some glycoproteins are, furthermore, decisively important for an efficiently operating
phagocytosis. In patients, these components are often missing, diminished, or inefficient.
Germinal centres.
[edit] Pathophysiology
One manifestation of lupus is abnormalities in apoptosis, a type of programmed cell death
in which aging or damaged cells are neatly disposed of as a part of normal growth or
functioning.
[edit] Abnormalities in apoptosis
Tingible body macrophages (TBMs) are large phagocytic cells in the germinal centers of
secondary lymph nodes; they express CD68 protein. These cells normally engulf B cells
that have undergone apoptosis after somatic hypermutation. In some patients with SLE,
significantly fewer TBMs can be found, and these cells rarely contain material from
apoptotic B cells. Also, uningested apoptotic nuclei can be found outside of TBMs. This
material may present a threat to the tolerization of B cells and T cells. Dendritic cells in
the germinal center may endocytose such antigenic material and present it to T cells,
activating them. Also, apoptotic chromatin and nuclei may attach to the surfaces of
follicular dendritic cells and make this material available for activating other B cells that
may have randomly acquired self-specificity through somatic hypermutation.[17]
[edit] Diagnosis
Some physicians make a diagnosis on the basis of the ACR classification criteria (see
below). The criteria, however, were established mainly for use in scientific research (i.e.,
inclusion in randomized controlled trials), and patients may have lupus but never meet
the full criteria.
Antinuclear antibody testing and anti-extractable nuclear antigen (anti-ENA) form the
mainstay of serologic testing for lupus. Antiphospholipid antibodies occur more often in
SLE and can predispose for thrombosis. More specific are the anti-Smith and anti-dsDNA
antibodies. Other tests routinely performed in suspected SLE are complement system
levels (low levels suggest consumption by the immune system), electrolytes and renal
function (disturbed if the kidney is involved), liver enzymes, and a complete blood count.
Previously, the lupus erythematosus (LE) cell test was not commonly used for diagnosis
because those LE cells are only found in 50–75% of SLE patients, and are also found in
some patients with rheumatoid arthritis, scleroderma, and drug sensitivities. Because of
this, the LE cell test is now performed only rarely and is mostly of historical
significance.[18]
A useful mnemonic for these 11 criteria is SOAP BRAIN MD: Serositis (8), Oral ulcers
(4), Arthritis (5), Photosensitivity (3), Blood Changes (9), Renal involvement
(proteinuria or casts) (6), ANA (10), Immunological changes (11), Neurological signs
(seizures, frank psychosis) (7), Malar Rash (1), Discoid Rash (2).
Another popular mnemonic is DOPAMIN RASH: Discoid rash (2), Oral ulcers (4),
Photosensitivity (3), Arthritis (5), Malar Rash (1), Immunological changes (11),
Neurological signs (seizures, frank psychosis) (7), Renal involvement (proteinuria or
casts) (6), ANA (10), Serositis (8), Hematological Changes (5).
Some patients, especially those with antiphospholipid syndrome, may have SLE without
four criteria, and SLE is associated with manifestations other than those listed in the
criteria.[23][24][25]
Recursive partitioning has been used to identify more parsimonious criteria.[21] This
analysis presented two diagnostic classification trees:
• sensitivity = 92%
• specificity = 92%
• sensitivity = 97%
• specificity = 95%
[edit] Treatment
As lupus erythematosus is a chronic disease with no known cure, treatment is restricted to
dealing with the symptoms. In essence, this involves preventing flares and reducing their
severity and duration when they occur. There are several means of preventing and dealing
with flares, including drugs, alternative medicine, and lifestyle changes.
Due to the variety of symptoms and organ system involvement with lupus patients, the
severity of the SLE in a particular patient must be assessed in order to successfully treat
SLE. Mild or remittent disease can sometimes be safely left untreated. If required,
nonsteroidal anti-inflammatory drugs and antimalarials may be used.
Disease-modifying antirheumatic drugs (DMARDs) are used preventively to reduce the
incidence of flares, the process of the disease, and lower the need for steroid use; when
flares occur, they are treated with corticosteroids. DMARDs commonly in use are
antimalarials and immunosuppressants (e.g., methotrexate and azathioprine).
Hydroxychloroquine (trade name Plaquenil) is an FDA-approved antimalarial used for
constitutional, cutaneous, and articular manifestations, whereas cyclophosphamide (trade
names Cytoxan and Neosar) is used for severe glomerulonephritis or other organ-
damaging complications. In 2005, mycophenolic acid (trade name CellCept) became
accepted for treatment of lupus nephritis.
In more severe cases, medications that modulate the immune system (primarily
corticosteroids and immunosuppressants) are used to control the disease and prevent
recurrence of symptoms (known as flares). Depending on the dosage, patients that require
steroids may develop side-effects such as central obesity, puffy round face, diabetes
mellitus, large appetite, difficulty sleeping and osteoporosis. Those side-effects can
subside if and when the large initial dosage is reduced, but long-term use of even low
doses can cause elevated blood pressure and cataracts.
Since a large percentage of lupus patients suffer from varying amounts of chronic pain,
stronger prescription analgesics may be used if over-the-counter drugs (mainly
nonsteroidal anti-inflammatory drugs) do not provide effective relief. Moderate pain in
lupus patients is typically treated with mild prescription opiates such as
dextropropoxyphene (trade name Darvocet) and co-codamol (trade name Tylenol #3).
Moderate to severe chronic pain is treated with stronger opioids, such as hydrocodone
(trade names Lorcet, Lortab, Norco, Vicodin, Vicoprofen) or longer-acting continuous-
release opioids, such as oxycodone (trade name OxyContin), MS Contin, or Methadone.
The Fentanyl Duragesic Transdermal patch is also a widely-used treatment option for the
chronic pain of lupus complications because of its long-acting timed release and ease of
use. When opioids are used for prolonged periods, drug tolerance, chemical dependency,
and (rarely) addiction may occur. Opiate addiction is not typically a concern for lupus
patients, since the condition is not likely to ever completely disappear. Thus, lifelong
treatment with opioids is fairly common in lupus patients that exhibit chronic pain
symptoms, accompanied by periodic titration that is typical of any long-term opioid
regimen.
[edit] Prevention
Lupus is not understood well enough to be prevented, but, when the disease develops,
quality of life can be improved through flare prevention. The warning signs of an
impending flare include increased fatigue, pain, rash, fever, abdominal discomfort,
headache, and dizziness. Early recognition of warning signs and good communication
with a doctor can help individuals with lupus remain active, experience less pain, and
reduce medical visits.[4]
While most infants born to mothers with lupus are healthy, pregnant mothers with SLE
should remain under a doctor's care until delivery. Neonatal lupus is rare, but
identification of mothers at highest risk for complications allows for prompt treatment
before or after birth. In addition, SLE can flare during pregnancy, and proper treatment
can maintain the health of the mother longer. Women pregnant and known to have the
antibodies for anti-Ro (SSA) or anti-La (SSB) should have echocardiograms during the
16th and 30th weeks of pregnancy to monitor the health of the heart and surrounding
vasculature.[4]
[edit] Prognosis
In the 1950s, most patients diagnosed with SLE lived fewer than five years. Advances in
diagnosis and treatment have improved survival to the point where over 90% of patients
now survive for more than ten years, and many can live relatively asymptomatically. The
most common cause of death is infection due to immunosuppression as a result of
medications used to manage the disease. Prognosis is normally worse for men and
children than for women; however, if symptoms are present after age 60, the disease
tends to run a more benign course. The ANA is the most sensitive screening test, wheres
anti-Sm (anti-Smith) is the most specific. The ds-DNA (double-stranded DNA) antibody
is also fairly specific and often fluctuates with disease activity; the ds-DNA titer is
therefore sometimes useful to diagnose or monitor acute flares or response to
treatment.[27]
[edit] Epidemiology
Previously believed to be a rare disease, lupus has seen an increase in awareness and
education since the 1960s. This has helped many more patients get an accurate diagnosis,
making it possible to estimate the number of people with lupus with some certainty. In
the United States alone, it is estimated that between 270,000 and 1.5 million people have
lupus, making it more common than cystic fibrosis or cerebral palsy. The disease affects
both females and males, though young women are diagnosed nine times more often than
men. SLE occurs with much greater severity among African-American women, who
suffer more severe symptoms as well as a higher mortality rate.[28] Worldwide, a
conservative estimate states that over 5 million people have lupus.
SLE affects 1 in 4000 people in the United States, and, although SLE can occur in
anyone, at any age, it is most common in women of childbearing age. The disease
appears to be more prevalent in women of African, Asian, Hispanic, and Native American
origin, which may be due to socioeconomic factors. People with relatives that suffer from
SLE, rheumatoid arthritis, or thrombotic thrombocytopenic purpura are at a slightly
higher risk than the general population.
[edit] History
Medical historians have theorized that people with porphyria (a disease that shares many
symptoms with lupus) generated folklore stories of vampires and werewolves, due to the
photosensitivity, scarring, hair growth, and porphyrin brownish-red stained teeth in
severe recessive forms of porphyria (or combinations of the disorder, known as dual,
homozygous, or compound heterozygous porphyrias).
The history of lupus erythematosus can be divided into three periods: classical,
neoclassical, and modern. The classical period began when the disease was first
recognized in the Middle Ages and saw the description of the dermatological
manifestation of the disorder. The term lupus is attributed to 12th-century physician
Rogerius, who used it to describe the classic malar rash. The neoclassical period was
heralded by Móric Kaposi's recognition in 1872 of the systemic manifestations of the
disease. The modern period began in 1948 with the discovery of the LE cell (the lupus
erythematosus cell—a misnomer, as it occurs with other diseases as well) and is
characterised by advances in our knowledge of the pathophysiology and clinical-
laboratory features of the disease, as well as advances in treatment.
Useful medication for the disease was first found in 1894, when quinine was first
reported as an effective therapy. Four years later, the use of salicylates in conjunction
with quinine was noted to be of still greater benefit. This was the best available treatment
to patients until the middle of the twentieth century, when Hench discovered the efficacy
of corticosteroids in the treatment of SLE.
There are several explanations ventured for the term lupus erythematosus. Lupus is
Latin for wolf, and "erythro" is derived from ερυθρός, Greek for "red." All explanations
originate with the reddish, butterfly-shaped malar rash that the disease classically exhibits
across the nose and cheeks.
1. In various accounts, some doctors thought the rash resembled the pattern of fur on
a wolf's face.
2. In other accounts, doctors thought that the rash, which was often more severe in
earlier centuries, created lesions that resembled wolf bites or scratches.
3. Another account claims that the term "lupus" did not come from Latin directly,
but from the term for a French style of mask that women reportedly wore to
conceal the rash on their faces. The mask is called a "loup," French for "wolf."
4. Another common explanation for the term is that the disease's course involves
repeated attacks like those of a voracious predator, leaving behind the red
blotches.
[edit] References
1. ^ "LUPUS FOUNDATION OF AMERICA". Retrieved on 2007-07-04.
2. ^ Harrison's Internal Medicine, 17th ed. Chapter 313. Systemic Lupus
Erythematosus.
3. ^ Discoid Lupus Erythematosus
4. ^ a b c d "Handout on Health: Systemic Lupus Erythematosus". The National
Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institutes of
Health (August 2003). Retrieved on 2007-11-23.
5. ^ Lupus: The Great Imitator
6. ^ "Lupus: Symptoms - MayoClinic.com". Retrieved on 2008-07-14.
7. ^ a b Joint and Muscle Pain Lupus Foundation of America
8. ^ Yu Asanuma, M.D., Ph.D., Annette Oeser, B.S., Ayumi K. Shintani, Ph.D.,
M.P.H., Elizabeth Turner, M.D., Nancy Olsen, M.D., Sergio Fazio, M.D., Ph.D.,
MacRae F. Linton, M.D., Paolo Raggi, M.D., and C. Michael Stein, M.D. (2003).
"Premature coronary-artery atherosclerosis in systemic lupus erythematosus".
New England Journal of Medicine 349 (Dec. 18): 2407–2414.
doi:10.1056/NEJMoa035611. PMID 14681506 Abstract (full text requires
registration).
9. ^ Bevra Hannahs Hahn, M.D. (2003). "Systemic lupus erythematosus and
accelerated atherosclerosis". New England Journal of Medicine 349 (Dec. 18):
2379–2380. doi:10.1056/NEJMp038168. PMID 14681501 Extract (full text
requires registration).
10. ^ Mary J. Roman, M.D., Beth-Ann Shanker, A.B., Adrienne Davis, A.B., Michael
D. Lockshin, M.D., Lisa Sammaritano, M.D., Ronit Simantov, M.D., Mary K.
Crow, M.D., Joseph E. Schwartz, Ph.D., Stephen A. Paget, M.D., Richard B.
Devereux, M.D., and Jane E. Salmon, M.D. (2003). "Prevalence and correlates of
accelerated atherosclerosis in systemic lupus erythematosus". New England
Journal of Medicine 349 (Dec. 18): 2399–2406. doi:10.1056/NEJMoa035471.
PMID 14681505 Abstract (full text requires registration).
11. ^ "General Pathology Images for Immunopathology". Retrieved on 2007-07-24.
12. ^ Anisur Rahman and David A. Isenberg (February 28, 2008). "Review Article:
Systemic Lupus Erythematosus". N Engl J Med 358 (9): 929–939.
doi:10.1056/NEJMra071297. PMID 18305268.
13. ^ Mary K. Crow (February 28, 2008). "Collaboration, Genetic Associations, and
Lupus Erythematosus". N Engl J Med 358 (9): 956–961.
doi:10.1056/NEJMe0800096. PMID 18204099.
14. ^ Geoffrey Hom, Robert R. Graham, Barmak Modrek, et al. (February 28, 2008).
"Association of Systemic Lupus Erythematosus with C8orf13–BLK and ITGAM–
ITGAX". N Engl J Med 358 (9): 900–909. doi:10.1056/NEJMoa0707865. PMID
18204098.
15. ^ University of South Carolina School of Medicine lecture notes, Immunology,
Hypersensitivity reactions. General discussion of hypersensitivity, not specific to
SLE.
16. ^ Gaipl US, Munoz LE, Grossmayer G, et al (2007). "Clearance deficiency and
systemic lupus erythematosus (SLE)". J. Autoimmun. 28 (2-3): 114–21.
doi:10.1016/j.jaut.2007.02.005. PMID 17368845.
17. ^ Gaipl, U S; Kuhn, A; Sheriff, A; Munoz, L E; Franz, S; Voll, R E; Kalden, J R;
Herrmann, M (2006). "Clearance of apoptotic cells in human SLE". Current
directions in autoimmunity 9: 173–87. PMID : 1639466 Abstract (full text
requires registration).
18. ^ NIM encyclopedic article on the LE cell test
19. ^ Rheumatology.org article on the classification of rheumatic diseases
20. ^ Revision of Rheumatology.org's diagnostic criteria
21. ^ a b c d e f g h i j k Edworthy SM, Zatarain E, McShane DJ, Bloch DA (1988).
"Analysis of the 1982 ARA lupus criteria data set by recursive partitioning
methodology: new insights into the relative merit of individual criteria". J.
Rheumatol. 15 (10): 1493–8. PMID 3060613.
22. ^ UpToDate Patient information article on DNA antibodies
23. ^ Asherson RA, Cervera R, de Groot PG, et al (2003). "Catastrophic
antiphospholipid syndrome: international consensus statement on classification
criteria and treatment guidelines". Lupus 12 (7): 530–4.
doi:10.1191/0961203303lu394oa. PMID 12892393.
24. ^ Sangle S, D'Cruz DP, Hughes GR (2005). "Livedo reticularis and pregnancy
morbidity in patients negative for antiphospholipid antibodies". Ann. Rheum. Dis.
64 (1): 147–8. doi:10.1136/ard.2004.020743. PMID 15608315.
25. ^ Hughes GR, Khamashta MA (2003). "Seronegative antiphospholipid
syndrome". Ann. Rheum. Dis. 62 (12): 1127. doi:10.1136/ard.2003.006163. PMID
14644846.
26. ^ Hughes GR (1998). "Is it lupus? The St. Thomas' Hospital "alternative"
criteria". Clin. Exp. Rheumatol. 16 (3): 250–2. PMID 9631744.
27. ^ [EARLY STEROIDS MAY PREVENT RELAPSES IN LUPUS, P Jarman
(Published in Journal Watch (General) July 18, 1995)
28. ^ Lupus and African-American women
Hypertrichosis (Hirsutism)
[show]
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