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Associations between Serum Levels of Cholesterol and Survival to Age 90 in Postmenopausal Women


OBJECTIVES

Although elevated lipid levels predict increased risk of coronary heart disease and death in middle‐aged women and men, evidence is mixed if lipid levels measured in later life predict survival to very old ages. We examined lipid levels and survival to age 90 with or without intact mobility in a large cohort of older women.

DESIGN

Prospective cohort.

SETTING

Laboratory collection at a Women’s Health Initiative (WHI) center and longitudinal follow‐up via mail.

PARTICIPANTS

Women aged 68 to 81 years at baseline.

MEASUREMENTS

Serum high‐density lipoprotein (HDL) and low‐density lipoprotein (LDL) cholesterol were collected at baseline. Participant survival status and self‐reported mobility was compared across lipid levels.

RESULTS

HDL and LDL levels were not associated with survival to age 90 after adjustment for cardiovascular risk factors (HDL: quartile (Q) 2: odds ratio [OR] = 1.14 [95% confidence interval [CI] = .94‐1.38]; Q3 OR = 1.08 [95% CI = .88‐1.33]; Q4 OR = 1.09 [95% CI = .88‐1.35]; LDL: Q2 OR = 1.07 [95% CI = .88‐1.31]; Q3 OR = 1.27 [95% CI = 1.04‐1.55]; Q4 OR = 1.07 [95% CI = .88‐1.31]). Similarly, no associations were observed between HDL and LDL levels and survival to age 90 with mobility disability. High HDL was not associated with survival to age 90 with intact mobility after adjustment for other cardiovascular risk factors. Compared with the lowest LDL quartile, the three upper LDL quartiles were associated with greater odds of survival to age 90 with intact mobility (LDL: Q2 OR = 1.31 [95% CI = .99‐1.74]; Q3 OR = 1.43 [95% CI = 1.07‐1.92]; Q4 OR = 1.35 [95% CI = 1.01‐1.80]; P = .05).

CONCLUSION

Neither higher HDL nor lower LDL levels predicted survival to age 90, but higher LDL predicted healthy survival. These findings suggest the need for reevaluation of healthy LDL levels in older women.

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Taking care of yourself? That can be messy for millennials

Published on Thursday, January 9, 2020

By: Ruth Cummins, [email protected]

When mom tells her millennial “Take care of yourself,” eating a healthy diet and getting enough sleep and exercise might seem like it’s enough.

But for true self-care, young adults in the millennial age group of about 23-38 must also take care of their mental and emotional health. That can be a tall order for a population that’s big on technology, but perhaps not so big on routine preventive care and consistently good decision-making on health issues.

Portrait of Dr. Danny Burgess
Burgess

“A lot of times, millennials will talk to me and say that when they’re overwhelmed or stressed, they will watch Netflix for two or three hours, or thumb through Facebook on their phones,” said Dr. Danny Burgess, associate professor of psychiatry and director of University of Mississippi Medical Center’s Center for Integrative Health.

“There’s nothing wrong with disengaging, but it’s a passive coping behavior. With self-care, you need to recognize what your body needs, and you need to be intentional about it.”

Taking good care of your body at any age is a key to good health, but in young adults, getting into a mindset of self-care might be necessary in order to achieve health goals.

“Self-care has to do with your physical body, your emotions, and your spiritual, social and leisure time needs,” Burgess said. “I want my patients to think of care in all of those areas, and then ask themselves: ‘What is it that works for me, and how can I intentionally incorporate that into my life?’

“For some people, it might be going to yoga, or going for a run. For some, it might be journaling. It’s not just going home and crashing on the couch,” Burgess said. “You deliberately engage in activities that are good for you.”

Third-year internal medicine resident Dr. Meredith Sloan is preparing to go into study mode for her boards. She finishes her residency in May, but is continuing for another year as chief resident.

“It’s definitely not something that I’ve given up on,” she said of practicing self-care as a millennial, and at one of the busiest times in her life. “I’m about six months out from finishing, so self-care is taking a back burner.”

She has several favorite ways to de-stress. “Sometimes, it’s just taking the evening off and watching Netflix,” said Sloan, who lives in Ridgeland. “I enjoy running whenever there’s a nice day, and to just get out of the hospital and enjoy the outdoors.”

Portrait of Dr. Daniel Williams
Williams

Millennials would do well to practice boundaries between work and their personal life, said Dr. Daniel Williams, division chief in the Department of Psychiatry and Human Behavior. Williams also is associate director of UMMC’s Office of Well-being. 

“This balance may be slightly different for different people and different jobs, but having a way to separate yourself from work is important,” Williams said. “Consider some boundaries such as not answering the phone or texts during dinner, or not checking work emails after hours unless it’s a true emergency”

The biggest hurdle to millennials practicing self-care, Burgess believes, is the guilt they might feel. However, “self-care is not selfish,” he said. “Taking time for yourself isn’t a selfish thing to do. That might be treating yourself to a nice dinner, or taking a bubble bath, or just cocooning in your bed. You’re not doing something at the expense of someone else, but instead, taking care of yourself so that you can be productive in life and in relationships.”

Sloan understands the guilt thing. “I call it study guilt,” she said.

“It starts in med school, when any time you’re not studying, you feel like you should be. You have to forgive yourself for not getting everything on your to-do list done in a day,” she said.

It can be hard to achieve a guilt-free balance, Sloan said. “It’s something you have to learn, and some people come by it more naturally than others.”

Even small, quick actions can contribute to self-care, Williams said. “Learn fast-acting ways to relax. Practicing mindfulness, deep breathing or meditation can be done in several-minute blocks and can significantly improve how you feel,” he said.

“Taking a few minutes between meetings, at lunch or when you get home from work to center your thoughts and bodily responses can make a surprising difference.”

And if running or a yoga class seem impossible in your schedule, you can still move toward fitness – at the office, Williams suggests. “A good first step is to take a few minutes at work to get up, out of your chair, and move your body in a gentle way,” he said. “Stretch your muscles to let your body get out of your usual computer posture. Walk down the hall and get a drink from the water fountain. Maybe even take the stairs to your next meeting.”

Self-care in millennials, Burgess said, “is not always well-modeled for us. It’s always, ‘How are you helping other people?’ or ‘Are you working as hard as you can?’ There’s not enough emphasis on the balance. You need to pause and be deliberate about your self-care and not feel guilty.”

Burgess advises planning self-care into your schedule, just like a doctor’s appointment. “You need to say that on Wednesday at a certain time, I’m going to read a book. That’s you planning and being deliberate about your self-care, and making it as much of a priority as going to a doctor’s appointment. Treat it as if it’s just as important.”

Reschedule your self-care if you have to delay it. “If your bath time gets interrupted, reschedule your bubble bath to tomorrow. Make sure you keep your self-care behaviors as a priority, and not something easily canceled or dismissed,” Burgess said.

“You want to feel good about those behaviors, and feel good about yourself and taking care of yourself.”

“It’s natural for our time and attention to focus on our problems, worries and concerns,” Williams said. “Sometimes, this means that we don’t take time to savor our accomplishments, appreciate our successes, and be grateful for good things in our lives.

“Write down a few things you are grateful for, tell a friend or family member why you appreciate them, and take stock of progress you have made recently. You may be surprised at what you find when you intentionally appreciate positive things in your life.”
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First Person: A Perfect Life with a Stubborn Heart

Wolters Kluwer Health

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Mortality and Cholesterol Metabolism in Subjects Aged 75 Years and Older: The Helsinki Businessmen Study


BACKGROUND/OBJECTIVES

In many studies, low serum cholesterol is paradoxically associated with a higher mortality risk among older adults. Therefore, we studied whole‐body cholesterol metabolism and its role in all‐cause mortality of older men in two subcohorts of different ages.

DESIGN

Prospective long‐term cohort.

SETTING

Home‐dwelling men of the Helsinki Businessmen Study.

PARTICIPANTS

Two partly overlapping subcohorts were recruited, in 2003 (n = 660; mean age = 76 years) and in 2011 (n = 398; mean age = 83 years). The younger subcohort was followed up after 3 and 11 years, and the older subcohort was followed up after 3 years.

MEASUREMENTS

Cholesterol metabolism was assessed via serum noncholesterol sterol‐cholesterol ratios, and quantification was performed by gas‐liquid chromatography with flame ionization detection. All statistical analyses were performed with age and statin treatment as covariates.

RESULTS

At the end of the 3‐year follow‐up, 10% of the younger and 13% of the older subcohort had died; and at the end of the 11‐year follow‐up, 40% of the younger subcohort had died. Serum total and low‐density lipoprotein (LDL) cholesterol and cholesterol precursors reflecting cholesterol synthesis were lower in the older than in the younger subcohort (P < .001 for all). In the older subcohort, low serum campesterol and sitosterol, reflecting decreased cholesterol absorption efficiency, predicted all‐cause mortality (P < .05). This was supported by a trend toward low serum campesterol and sitosterol predicting mortality (P = .088 and P = .079, respectively) in the younger subcohort after 11 years. Cholesterol synthesis did not predict mortality, but in the older subcohort, decreased cholesterol absorption was less efficiently compensated for by decreased cholesterol synthesis.

CONCLUSIONS

Low cholesterol absorption efficiency predicted all‐cause mortality, especially in men aged 83 years on average, and cholesterol synthesis was lowered. These metabolic changes could contribute to the lowering of serum total and LDL‐cholesterol in older men.

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New Ph.D. in research program resonates with radiologists

Published on Monday, January 13, 2020

By: Gary Pettus, [email protected]

When he was a medical student deciding where to train as a specialist, Dr. Elliot Varney had his eye on Texas, but his heart in Mississippi.

A 2019 graduate of the School of Medicine at the University of Mississippi Medical Center, Varney was determined to do his residency in radiology, but hoped, at the same time, to earn his Ph.D. in radiology research, an option not available at UMMC then.

“I wanted to stay at UMMC,” said Varney, who grew up in the Gluckstadt/Madison area near Jackson, “because of my relationships here – the personal ones, but also the ones with the faculty and the ones I had throughout medical school.

“But I had interviewed at the University of Texas at San Antonio, which had the only radiology residency/Ph.D. program in the country.”

In mid-December, that changed, and Varney is now the first-ever trainee in a new program at UMMC: the Biomedical Imaging/Bioengineering Ph.D. track.

“When we started the program, I thought he was the perfect inaugural candidate for it,” said Dr. Candace Howard-Claudio, associate professor of radiology, vice chair of research in radiology and director of the new program.

McCowan,-Timothy_100715-Web.jpg
McCowan

Varney is a “known entity in the department,” said Dr. Timothy McCowan, professor and chair of radiology. “He was one of our top choices for our residency program. This is a great fit for him and for us.”

Varney is now fusing his training in radiology – the use of radiation, including X-rays and ultrasound, to diagnose and treat disease – with research: He is exploring the applications of biomedical imaging/engineering in the cause of helping doctors, therapists and others develop ways and equipment to better serve their patients.

“As an undergraduate, I fell in love with the research surrounding nanotechnology,” said Varney, who attended Mississippi State University before graduating from Millsaps College. In particular, radiology lit him up once he discovered how the field had started using microparticles and nanotechnology to treat and diagnose cancer.

Radiology is also wielded to treat and/or uncover liver and kidney problems, heart disease, back pain and more.

“A big reason I wanted to do the Ph.D. is that I have a fascination with the possibility of changing the status quo,” Varney said. “That’s where my love of research is. Instead of reading someone else’s work about patient care, why not be a part of that work, no matter how big or small your contribution may be?

“At one time, I had thought I would do surgery, but I became interested in radiology and imaging,” he said, meaning such technologies as MRI and CT. “So this program was a no-brainer choice.”

The choice had existed before, but not officially, or at least formally, said Dr. Richard Summers, associate vice chancellor for research and Billy S. Guyton Professor of Emergency Medicine.

summers,-richard-web.jpg
Summers

“The concept for the program started a few years ago with Dr. Andrew Smith,” said Summers, referring to the former UMMC associate professor radiology and director of radiology research who is now at the University of Alabama at Birmingham.

As a faculty member, Smith gave radiology residents an opportunity to do additional years in of research in their specialty. “But there was no formal degree attached to it,” Summers said.

Dr. Kevin Zand was the first to do perform such research, which he finished recently before joining the University of California, San Francisco, in the Department of Radiology and Biomedical Engineering as a clinical fellow.

But Dr. Howard-Claudio is responsible for integrating a formal Ph.D. program into radiology, Summers said. “Through her, it’s even more substantial now; it has legs and I have great hopes for it.”

Those hopes lie in the potential of the Biomedical Imaging/Bioengineering track – the second track in Biomedical Sciences Ph.D. program, which had a pathology track in place already. In fact, Varney set out on that track in August before switching to the new one after its official approval in December.

That approval came about after Howard-Claudio discussed it with Summers and Dr. Joey Granger, Billy S. Guyton Distinguished Professor and dean of the School of Graduate Studies in the Health Sciences.

“Dr. Howard has done a fantastic job,” McCowan said. “This program goes beyond radiology because, in order for it to be successful, it will require the collaboration of other departments, such as neurology or biostatistics, depending on the trainees’ research.”

Of course, as a research program, also falls into the realm of the Office of Research and Sponsored Programs, and the School of Graduate Studies in the Health Sciences, as noted by Granger.

Granger,-Joey_jpg.jpg

Granger

“We believe it will significantly add to our growing pipeline of programs to enhance clinical investigation at UMMC,” Granger said.   

As McCowan put it: “This is good for our department and for our institution.”

Varney, too, had lobbied for a program similar to the one in Texas. “At the beginning of my fourth year of medical school, I asked if there was anything like it or the chance to start it here,” he said.

Before all this, he had considered entering UMMC’s M.D./Ph.D. program, which trains medical students to become physician-scientists. But it’s a seven-year pursuit that the learner must begin in medical school.

“Part of me regretted not doing that,” Varney said.

He had done research as a medical student and thought he could do it as a physician; but, as he realized toward the end of medical student years, with a graduate degree in research “the opportunities would be broader.”

He looked for a way to stay at UMMC because, among other reasons, “the leadership is super supportive,” he said. “I can’t say enough about them. I couldn’t go anywhere else because of that support.”

In turn, Varney and the learners who join him in pursuit of the Ph.D. will be supporting radiology, which Howard-Claudio describes as “the most technologically advanced field of medicine.” Among its high-tech trimmings are artificial intelligence and deep learning – a technique that teaches computers to learn by example, the way humans do.

“Radiologists need to be drivers of the technology, not driven by it,” Howard-Claudio said. “It’s critical that we are well-versed in research, particularly in biomedical engineering. It’s a burgeoning field. We need this program so academic radiologists can be more competitive when searching for funding opportunities.

“I want [Varney] to be the strongest candidate when he applies for funding; so, it would be a shame for him not to have that [degree] behind his name.”

The price of achieving greater competitiveness is an extra year or two tacked onto the radiology residency, which is normally five years. Candidates for the degree will set out on the Holman Research Pathway, a model that ensures the program meets certain standards, and one supported by the American Board of Radiology.

The length of the journey down that research road depends on the pace of the learner, Howard-Claudio said.

More learners are on the way. At least two have asked her about the Ph.D., and one has applied to the program. “I would love to have at least two students per year,” Howard-Claudio said.

The number will depend on the funds available to support the research portion of the program; Summers’ office is providing the funding.

“This program presents us with a good strategy for recruiting and creating physician-scientists,” Summers said. “Rather than trying to recruit them to UMMC from, say, Harvard or Duke, we’re trying to grow our own.

“These are usually native Mississippians who have family here, so we hope they stay for a long career.”
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What to D.O.: Myofascial Pain Easily Diagnosed, Simply Treated

Wolters Kluwer Health

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If obstructive sleep apnea makes rest elusive, a new device can help

Published on Thursday, January 9, 2020

By: Ruth Cummins, [email protected]

Susan Walters didn’t realize how much sleep she wasn’t getting until her University of Mississippi Medical Center specialist team gave her the therapy to get a full night of restful slumber.

Since the late 1990s, Walters said, “I was waking up several times a night, gasping for breath and snoring. I didn’t think there was anything to it, and that everybody snores.”

Her sister thought otherwise. “She was using a CPAP mask, so I got tested for one,” Walters said of continuous positive airway pressure, a ventilator therapy for sleep apnea patients that uses mild air pressure delivered through a mask to keep airways open.

The CPAP wasn’t for Walters; much newer technology offered by an implant that uses a gentle electric pulse to open up her airway was. “I thought I was sleeping, but I’d get up and feel like I hadn’t rested at all,” she said of the CPAP. “The machine cord was inconvenient when I turned over in the bed. I used a chin strap, and I had to keep my mouth closed and breathe through my nose. It was difficult.”

Walters coped with obstructive sleep apnea, a condition in which a person suffers disrupted sleep and low blood oxygen levels because their tongue is sucked against the back of their throat. That blocks their upper airway, often causing the patient to snore, be unusually sleepy during the day, and sometimes suffer cardiovascular problems, depression or loss of concentration.

Trying to better troubleshoot the problem, 77-year-old Walters underwent a sleep study conducted by Dr. Allen Richert, division chief in the UMMC Department of Psychiatry and Human Behavior and medical director of UMMC’s Sleep Center, located at Select Specialty Hospital in north Jackson.

The majority of studies involve patients spending the night at the Sleep Lab so that their breathing, snoring, movement and oxygen levels can be monitored. Some patients, though, take part in an in-home study that records air flow, oxygen levels and chest movement.

Portrait of Dr. Allen Richert
Richert

Richert said that the large majority of the sleep studies performed at UMMC are to determine if a patient has obstructive sleep apnea.  The most common treatment is CPAP or a newer version of that machine that adjusts during the night. “If the machine notes apnea, it will increase the air pressure on its own,” Richert said.

Richert suggested Walters visit Dr. Andrea Lewis, an associate professor in the Department of Otolaryngology and Communicative Sciences. Lewis determined that Walters was a candidate for a sleep therapy device that delivers mild stimulation to the hypoglossal nerve that controls movement of the tongue and some airway muscles. How much stimulation can be controlled by up and down buttons on a small, hand-held remote control.

Lewis implanted the small device in Walters’ chest as an outpatient procedure, then activated it about a month later after giving the three small incisions time to heal. Walters said she felt immediate relief.

“I was surprised the first time that it worked,” Walters said. “I felt so different when I got up in the morning. I was rested and could stay up later without being drowsy the next day. I realized what I hadn’t been getting all those years.”

The FDA-approved device, designed to provide long-term relief, has a battery life of at least 12 years. It works inside the body to address the root causes of obstructive sleep apnea, Lewis said. An electrical impulse delivered to the tongue via a coil running from the hypoglossal nerve to a battery acts much like a pacemaker, she said. A sensor placed between the muscles in the rib area detects when the patient takes a breath, activating a gentle pulse that opens the airway.

“The patient uses a remote control to turn the device on before they go to sleep, and off again after they get up,” Lewis said. “It takes about 30 minutes for it to start working,” which gives the patient time to fall asleep, she said.

The patient hears two beeps when they turn on the remote and a green light shows to indicate it’s been activated, Lewis said. “The patient feels a single pulse on their tongue when it connects,” she said. Patients turn off the device by pressing a gray button, then listening for two beeps. “A status ring on the remote will turn white,” Lewis said.

Susan Walters of Clinton uses a surgically implanted device, activated by a remote control, that works to open up her airway, allowing her to sleep soundly without interruption caused by snoring and loss of breath.
Walters uses a surgically implanted device, activated by a remote control, that works to open up her airway, allowing her to sleep soundly without interruption caused by snoring and loss of breath.

Walters is among the first patients to receive the implant surgery from Lewis, who began performing it in 2017. Lewis works with patients to find the right setting to give them the best sleep. “You can step up the setting by one level to increase the stimulation, or you can step down if it feels uncomfortable,” she said.

Most patients tend to slowly increase the stimulation during the first two months of use “until they aren’t snoring, or feel that they are sleeping better,” Lewis said. “Some people feel like they get so much benefit that they don’t turn it any higher, but when they have a follow-up sleep study, the find that they could use more.

“The purpose is to find the setting that gives you comfortable sleep,” Lewis said.

UMMC’s sleep team strives to find a solution for all patients, whether it’s the device implanted by Lewis; surgery ranging from removal of tonsils to the more uncommon breaking of the patient’s jaw to move it forward and stretch the face; to CPAP or the use of mouthpieces that hold the mandible forward and mouth closed.

And, weight loss is an important treatment, Richert said. “As the body mass index goes up, the incidence of sleep apnea goes up,” Richert said. “It’s becoming more common. We’re more aware of it.”

Lewis has performed 30-plus procedures, more than any other provider in the state. Lewis has served on the American Academy of Otolaryngology’s national sleep committee and holds certification in sleep medicine from the American Board of Sleep Medicine. UMMC is an ABSM-accredited sleep center.

She’s collecting data at the Medical Center as part of her committee duties. “I was on staff at the University of Pittsburg when this device was originally researched,” said Lewis, who also is a member of the American Academy of Sleep Medicine.

Walters said the device, manufactured by Inspire Sleep Apnea Innovation, has helped her both physically and mentally. The mother of three grown daughters, Walters retired to Clinton after working for 21 years at an insurance company in Ohio.

“I’d fall asleep, but I’d be back up about an hour and a half later with the CPAP,” she said. “Then I’d fall asleep in my chair. This was such a big change.

“I should have done this long ago. I mostly did it to please my sister, but once I found out what a difference it made … She was right.”


To be evaluated for the sleep therapy implant, call the Department of Otolaryngology and Communicative Sciences at (601) 815-0821.

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InFocus: Clinically Differentiating Seizure from Syncope

Wolters Kluwer Health

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The Risk of Head Injuries Associated With Antipsychotic Use Among Persons With Alzheimer’s disease


BACKGROUND/OBJECTIVES

Antipsychotic use is associated with risk of falls among older persons, but we are not aware of previous studies investigating risk of head injuries. We studied the association of antipsychotic use and risk of head injuries among community dwellers with Alzheimer’s disease (AD).

DESIGN

Nationwide register‐based cohort study.

SETTING

Medication Use and Alzheimer’s Disease (MEDALZ) cohort, Finland.

PARTICIPANTS

The MEDALZ cohort includes Finnish community dwellers who received clinically verified AD diagnosis in 2005 to 2011. Incident antipsychotic users were identified from the Prescription Register and matched with nonusers by age, sex, and time since AD diagnosis (21 795 matched pairs). Persons with prior head injury or history of schizophrenia were excluded.

MEASUREMENTS

Outcomes were incident head injuries (International Classification of Diseases, Tenth Revision [ICD‐10] codes S00‐S09) and traumatic brain injuries (TBIs; ICD‐10 codes S06.0‐S06.9) resulting in a hospital admission (Hospital Discharge Register) or death (Causes of Death Register). Inverse probability of treatment (IPT) weighted Cox proportional hazard models were used to assess relative risks.

RESULTS

Antipsychotic use was associated with an increased risk of head injuries (event rate per 100 person‐years = 1.65 [95% confidence interval {CI} = 1.50‐1.81] for users and 1.26 [95% CI = 1.16‐1.37] for nonusers; IPT‐weighted hazard ratio [HR] = 1.29 [95% CI = 1.14‐1.47]) and TBIs (event rate per 100 person‐years = 0.90 [95% CI = 0.79‐1.02] for users and 0.72 [95% CI = 0.65‐0.81] for nonusers; IPT‐weighted HR = 1.22 [95% CI = 1.03‐1.45]). Quetiapine users had higher risk of TBIs (IPT‐weighted HR = 1.60 [95% CI = 1.15‐2.22]) in comparison to risperidone users.

CONCLUSIONS

These findings imply that in addition to previously reported adverse events and effects, antipsychotic use may increase the risk of head injuries and TBIs in persons with AD. Therefore, their use should be restricted to most severe neuropsychiatric symptoms, as recommended by the AGS Beers Criteria®. Additionally, higher relative risk of TBIs in quetiapine users compared to risperidone users should be confirmed in further studies.

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