Wernicke-Korsakoff Syndrome

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Wernicke-Korsakoff Syndrome (WKS) classically, but not always, presents with the clinical triad of confusion, ataxia, and nystagmus. It is best conceptualized as 2 distinct syndromes, with one being characterized by an acute/subacute confusional state and often reversible findings of Wernicke encephalopathy (a type of delirium) and the other by persistent and irreversible findings of Korsakoff dementia. (See Clinical and Workup.)

In 1881, Carl Wernicke first described an illness that consisted of paralysis of eye movements, ataxia, and mental confusion, in 3 patients. The patients, 2 males with alcoholism and a female with persistent vomiting following sulfuric acid ingestion, exhibited these findings, developed coma, and eventually died. On autopsy, Wernicke detected punctate hemorrhages affecting the gray matter around the third and fourth ventricles and aqueduct of Sylvius. He felt these to be inflammatory and therefore named the disease polioencephalitis hemorrhagica superioris.

Sergei Korsakoff, a Russian psychiatrist, described the disturbance of memory in the course of long-term alcoholism in a series of articles from 1887-1891. He termed this syndrome psychosis polyneuritica, believing that these typical memory deficits, in conjunction with polyneuropathy, represented different facets of the same disease. In 1897, Murawieff first postulated that a single etiology was responsible for both syndromes.

Wernicke-Korsakoff Syndrome (WKS) classically, but not always, presents with the clinical triad of confusion, ataxia, and nystagmus. It is best conceptualized as 2 distinct syndromes, with one being characterized by an acute/subacute confusional state and often reversible findings of Wernicke encephalopathy (a type of delirium) and the other by persistent and irreversible findings of Korsakoff dementia. (See Clinical and Workup.)

In 1881, Carl Wernicke first described an illness that consisted of paralysis of eye movements, ataxia, and mental confusion, in 3 patients. The patients, 2 males with alcoholism and a female with persistent vomiting following sulfuric acid ingestion, exhibited these findings, developed coma, and eventually died. On autopsy, Wernicke detected punctate hemorrhages affecting the gray matter around the third and fourth ventricles and aqueduct of Sylvius. He felt these to be inflammatory and therefore named the disease polioencephalitis hemorrhagica superioris.

Sergei Korsakoff, a Russian psychiatrist, described the disturbance of memory in the course of long-term alcoholism in a series of articles from 1887-1891. He termed this syndrome psychosis polyneuritica, believing that these typical memory deficits, in conjunction with polyneuropathy, represented different facets of the same disease. In 1897, Murawieff first postulated that a single etiology was responsible for both syndromes.

Etiology

A deficiency of thiamine (vitamin B-1) is responsible for the symptom complex manifested in Wernicke-Korsakoff syndrome, and any condition resulting in a poor nutritional state places patients at risk. The structural lesions associated with Wernicke-Korsakoff syndrome are more likely to manifest in patients with malnutrition. However, it is crucial to recognize that Wernicke-Korsakoff syndrome also appears in patients without exposure to alcohol. The occurrence of WKS in patients without alcohol use disorders is well described in the literature and cited in the section below.

The following are associated with Wernicke-Korsakoff syndrome:

  • Chronic alcoholism – There may be a synergistically destructive effect of alcohol and thiamine deficiency that contributes to the Wernicke-Korsakoff syndrome. Alcohol interferes with active gastrointestinal transport, and chronic liver disease leads to decreased activation of thiamine pyrophosphate from thiamine, as well as decreased capacity of the liver to store thiamine.
  • Bariatric surgery – Wernicke encephalopathy can present as early as 2 weeks after surgery; recovery typically occurs within 3-6 months of initiation of therapy but may be incomplete if this syndrome is not recognized promptly and treated (the highest risk is in young women with vomiting)
  • Nutritional deficiency and certain diets
  • Starvation – Persons with anorexia nervosa,schizophrenia, or terminal cancer; prisoners of war
  • Thiamine-deficient formula
  • Hyperemesis gravidarum – In a study of 49 cases of Wernicke encephalopathy in pregnancy, pregnancy loss attributable to Wernicke encephalopathy was nearly 48% [12]
  • Gastric malignancy, inflammatory bowel disease
  • Intestinal obstruction, including abdominal abscess
  • Plastic surgery – Panniculectomy
  • Systemic diseases – Malignancy, disseminated tuberculosis, acquired immunodeficiency syndrome (AIDS),  uremia, stem cell transplantation
  • Iatrogenic – Intravenous hyperalimentation (without thiamine supplementation), refeeding after starvation, chronic hemodialysis
  • Encephalitic infections or infarctions affecting the mammillary bodies or hippocampus Rare reports – Rare reports
  • Infants breastfed by mothers with inadequate intake of thiamine
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The Dangers of Korsakoff Syndrome

 April 1, 2016 by Tim Powers 

The-Dangers-of-Korsakoff-Syndrome-2

Alcohol is a dangerous drug–a very dangerous drug.

While the use of alcohol has become part of the common fabric of many social gatherings and it widely available for purchase on literally every street corner, alcohol misuse and abuse continues to be widespread throughout the United States and remains a major health and societal issue. Consider the following statistics:

  • Nearly 90,000 fatalities annually are attributed to the over-consumption of alcohol
  • Alcoholism is the 3rd cause of preventable, lifestyle based deaths in the United States
  • Alcohol abuse can potentially shorten an addict’s lifespan up to 30 years
  • Over 40 percent of all U.S. hospital f syndrome is a chronic memory disorder that is usually associated with heavy drinking over a long period of time, but can also occur as a result of chronic infections, AIDS and poor nutrition. People who are afflicted with this disorder experience loss of short term memory. This syndrome is diagnosed in about one in eight people with alcoholism and is present in about 2% in the population, which is about 1 in 1,000 worldwide.  The cause for development of this syndrome is a lack of thiamine (vitamin B1) which affects the brain and nervous system.  People who are excessive in their consumption of alcohol tend to be deficient in thiamine.

What is Thiamine?

Thiamine is an essential nutrient that all of the tissues in the body, including the brain, need in order for correct functioning. When thiamine enters an organ, it uses the nutrient to create a molecule called adenosine triphosphate (ATP) that transports energy within cells. When there are deficiencies in thiamine as a result of high alcohol consumption or other issue, it can seriously impact the nervous system, the heart and can severly impact brain function.

Causes of Korsakoff Syndrome

The root of this deficiency in thiamine is because many heavy drinkers have poor dietary habits and what they are consuming does not contain the essential nutrients.  Alcohol can block the absorption of thiamine and therefore the conversion of the vitamin to its active form does not occur. Also, alcohol can cause inflammation in the stomach lining and as a result frequent vomiting can occur. As a result, key vitamins essential for proper nutrition are not absorbed and it makes it harder for the liver to store these vitamins.

Development of Korsakoff Syndrome

Korsakoff syndrome is a part of a larger condition known as Wernicke-Korsakoff’ syndrome which consists of two separate stages.  The first stage of the disorder is known as Wernicke’s encephalopathy, which is followed by Korsakoff’s syndrome. Wernicke’s encephalopathy usually develops suddenly and in some cases there may be no obvious symptoms which can make it difficult to diagnose. When combined, both disorders produce the following list of symptoms:

  • Confusion
  • Dramatic changes to vision
  • Loss of muscle coordination
  • Speech impediments
  • Hallucinations
  • Hard time swallowing
  • Memory loss
  • Confabulation (when an individual makes up stories to fill the gaps of memory loss and claiming they actually occurred)
  • Inability to make sense when they speak

If Wernicke’s encephalopathy is suspected, immediate treatment is essential. If treatment is carried out in time (within a few days of diagnosis) most of the symptoms can be reversed. However, if left untreated, Korsakoff syndrome usually follows. Korsakoff syndrome, unlike Wernicke’s, develops gradually. Damage associated with the syndrome is usually concentrated in the part of the brain responsible for short-term memory. Despite the impact on short-term memory, working memory among other abilities remain intact.

The main symptom in Korsakoff syndrome is memory loss, along with difficult is acquiring new information and learning skill set along with changes in personality (with can in extremes between apathy and repetitive behavior). Also, an individual may not have insight into their condition even when large gaps in memory are noticed by that individual.

Diagnosis and Treatment

Korsakoff syndrome cannot be diagnosed until a person has stopped drinking for a period of several weeks. The administration of a physical exam, along with performing lab tests and taking a medical history are important steps. In addition, psychological testing of memory and other abilities will be performed. The individual will be observed to see if their condition improves or worsens without alcohol. If an individual’s condition worsens, another form of dementia such as Alzheimer’s disease may be diagnosed.

If caught early on, Korsakoff syndrome is treatable through thiamine injections. These injections can improve brain function and improve the condition of an individual’s tissues and organs. Additionally, those early in recovery who were diagnosed with Wernicke-Korsakoff’s syndrome may also benefit from medications that are used for the treatment of Alzheimer’s disease.

Most who find their way towards recovery can benefit from regaining all of what was lost, including vision and memory. In addition to thiamine treatments, those who are in recovery must abstain completely from alcohol and adopt a healthy and balanced diet. Improvement is usually gradual with the average time occurring within a period of two years. However, if an individual is not diagnosed with Korsakoff syndrome until its’ later stages, their brain functioning will most likely suffer some degree of permanent impairment.

National Institute on drug abuse for teens

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For more on this and other topics click: HERE
The NIDA Blog Team

Many people think drug addiction, dependence, and tolerance are pretty much the same thing. But in fact, each term means something very different about how drugs affect a person’s body and brain. Learning the difference is important.

Tolerance

Tolerance happens when a person no longer responds to a drug in the way they did at first. So it takes a higher dose of the drug to achieve the same effect as when the person first used it. This is why people with substance use disorders use more and more of a drug to get the “high” they seek.

Dependence

Dependence means that when a person stops using a drug, their body goes through “withdrawal”: a group of physical and mental symptoms that can range from mild (if the drug is caffeine) to life-threatening (such as alcohol or opioids, including heroin and prescription pain relievers). Many people who take a prescription medicine every day over a long period of time can become dependent; when they go off the drug, they need to do it gradually, to avoid withdrawal discomfort. But people who are dependent on a drug or medicine aren’t necessarily addicted.

Addiction

Unlike tolerance and dependence, addiction is a disease but like tolerance and dependence, addiction can result from taking drugs or alcohol repeatedly. If a person keeps using a drug and can’t stop, despite negative consequences from using the drug, they have an addiction (also called a severe substance use disorder). But again, a person can be dependent on a drug, or have a high tolerance to it, without being addicted to it.

Addiction throws brain’s impulse, self-control systems out of balance

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BY FELICE J. FREYER

Journal Medical Writer

 

Why don’t they just stop? Seeing all the harm to themselves and those they love, why do addicts keep taking drugs?

To those who aren’t afflicted, that’s the central mystery of addiction. But research has shown that for addicts, “just stopping” is not an option: the drugs have commandeered the brain, causing a complete loss of control.

“Drugs of abuse change the structure of the brain,” says Dr. Robert Swift, professor of psychiatry and human behavior at Brown University. “It’s a brain disease, not a weakness of character.”

Dr. John Femino, an addiction medicine specialist and medical director of Meadow’s Edge Recovery Center, in North Kingstown, puts it this way: “I’ve never met an addict that planned on being one. Their brain gets co-opted.”

People take drugs because it makes them feel good or relieves pain and distress, including underlying disorders such as depression, anxiety and posttraumatic stress.

The drugs’ positive effects can lead people to keep taking them, and that repeated drug use distorts two brain systems. The first, the limbic system, bestows pleasure: it makes things such as eating and sex enjoyable to ensure survival of the species. Counterbalancing this system is the frontal cortex, the cop in charge of judgment and decision-making.

There is a constant give-and-take between these two systems, between impulse and self-control. Your limbic system makes sure you don’t starve; your frontal cortex dissuades you from that second piece of cake.

Drug use primes the limbic system and saps the frontal cortex. That means the urge for drugs strengthens just as one’s ability to control that urge becomes impaired, or as Femino puts it, drugs are “turbocharging your engine and weakening your brakes.”

Eventually, the urge to consume drugs becomes so powerful that “a person will give up everything that’s important to them as a human being –– their relationships, their job, their health –– because it changes your brain and it alters your thinking,” Swift says. “You literally do lose yourself.”

Drug use doesn’t do this to most people, only those with a certain type of brain anatomy.

The vulnerability to addiction is caused by a variety of factors: genes, social circumstances and traumatic experiences, such as childhood abuse or military combat.

European studies of twins raised by separate families found a powerful genetic effect: the children of addicts were at much higher risk for addiction. “About 95 percent of the people that get treated have a family history of alcohol or drug problems,” Femino says.

Another sign of danger is having an atypical response to drugs, such as feeling energized after taking a painkiller (most people get sleepy) or being able to drink large amounts of alcohol without getting a hangover.

Among those prone to addiction, the next step is exposure, usually repeated exposure, to addictive drugs. It typically takes weeks to months of drug-taking to develop an addiction, Swift says.

Adolescents are especially vulnerable, in two ways: the parts of the brain controlling judgment are not fully developed until the mid-20s, leading to risk-taking. And those who become addicted in adolescence will have a much harder time recovering.

Once you’ve become addicted, your brain is forever changed. That’s why those who undergo treatment frequently relapse.

“People who are struggling with addiction work harder than anyone I know,” says Swift. “They have to fight the urges and compulsion to use the drug.”

To recover, people learn to develop support systems and mental tricks to keep the urges at bay. Especially in the beginning, they need to avoid the places and circumstances that can trigger the compulsion to use again. One drink, one pill, can destroy months of carefully nurtured self-control.

In other words, addiction needs to be vigilantly managed like any chronic illness, such as diabetes and asthma, which have similar rates of relapse.

This doesn’t mean that people should avoid painkillers or treatments for mental illness for fear of addiction, both doctors say. But they should be mindful of the risks.

If you have a family history of addiction or have had an atypical response to an addictive substance, watch yourself. If you are prescribed a painkiller, take only the amount prescribed and then stop; switch to a non-narcotic painkiller or other treatments if your pain doesn’t abate. If you drink, stick within the recommended parameters (no more than one drink a day for women, two for men). Use your frontal cortex to follow the rules, lest you lose the ability to do so.

Spirituality Improves Outcomes for Teens in Rehab

Emerging research finds that spirituality helps teens in treatment for substance abuse.

Researchers from The University of Akron, Case Western Reserve University and Baylor University determined increased spiritual experiences were associated with greater likelihood of abstinence (as measured by toxicology screens), increased positive social behaviors and reduced narcissism.

The study combined two ongoing studies of adolescent addiction and explored changes in daily spiritual experiences of 195 substance-dependent adolescents, ages 14-18.

Researchers studied the rehabilitative approach used at an adolescent residential treatment facility in Northeast Ohio.

The facility, called New Directions, provides a range of evidence-based therapies, including cognitive-behavioral therapy, motivational enhancement therapy, group therapies, and relapse prevention and aftercare.

New Directions uses the 12-step recovery program of Alcoholics Anonymous , which does not require participants to hold any particular religious beliefs.

For the study, researchers measured “daily spiritual experiences” independently of “religious beliefs and behaviors.”

Daily spiritual experiences are not bound to any particular religious tradition and include reported feelings of a divine presence, inner peace or harmony, and selflessness and benevolence toward others.

The researchers found that, on the “religious beliefs and behaviors” scale, adolescents reported a range of belief orientations at intake, including atheist, agnostic, unsure, non-denominational spiritual or denominational religious.

The researchers also found that most of the adolescents, regardless of their religious background or denomination, reported having more daily spiritual experiences by the end of the two-month treatment period.

The study is the first to include detailed measures of both spirituality and religiosity as independent variables at baseline and over the course of treatment, while controlling for background characteristics and clinical severity, said co-investigator Matthew T. Lee, Ph.D.

Participants, most of whom were marijuana dependent (92 percent) with comorbid alcohol dependence (60 percent), were interviewed within the first 10 days of treatment and two months later at treatment discharge.

Outcomes assessed included urine toxicology screens, alcohol/drug craving symptoms, clinical characteristics, global psychosocial functioning, spiritual experiences and religious behaviors.

Co-investigator Byron R. Johnson, Ph.D., said that “although about a third of the teens self-identified as agnostic or atheist at intake, two-thirds of whom claimed a spiritual identity at discharge, a most remarkable shift.”

More important, these changes strongly predicted toxicology, narcissism and positive social behavior, Lee said.

“The key message is that changes in spiritual experiences are associated with better outcomes, including lower toxicology, reduced self-centeredness, and higher levels of helping others,” Lee said.

first step

The study, one of the few involving teens participating in Alcoholics Anonymous , “supports the AA theory of addiction — which views self-centeneros as a root cause — and suggests that this approach would be helpful in designing treatment options for adolescents,” Johnson said.

The adolescents’ capacity to become more spiritual, and overcome self-centeredness, evidences the malleability of personality and belief orientation, Lee says.

“Contrary to the conventional wisdom,” he said, “personality is not relatively fixed by late adolescence, and Axis II disorders such as narcissistic personality disorder can improve. What this means is that belief orientation, like personality more generally, is malleable.

“Just because an adolescent is not spiritual prior to participating in the treatment project, does not mean that they are incapable of becoming spiritual. Our results demonstrate that if they do become spiritual, they will tend to have much better outcomes.”

Principal investigator Maria Pagano, Ph.D., associate professor of psychiatry at CWRU’s School of Medicine, suggested that “changes in spirituality during treatment may serve as the ‘switch’ that moves youth off of the track of substance dependency and onto the track of recovery and enhanced well-being, thereby countering harmful social trends like youth unemployment and decreased volunteering that have worked against addiction recovery.”

“In other words,” she said, “change is possible and spiritual experience may be the key. Hopefully our results will encourage other researchers to further explore this thesis.”

Source: University of Akron

Addiction is a Mental Illness. Treat it That Way.

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by Scott Kellogg and Andrew Tatarsky

 

Many addicts have mental health problems, and all have complex reasons for using substances. In order to effectively address both the addiction and what drives it, providers require training and skills in psychotherapy.

The recent suicide of country singer Mindy McCready brings the death toll of patients who were treated on Celebrity Rehab to five. On Monday, Fix columnist Maia Szalavitz questioned the effectiveness and ethics of Dr. Drew’s specific approach. But McCready’s death also calls for us to reflect more generally on the nature of addiction and its treatment. In addition, the loss of these five entertainers and public figures speaks to how devastating both addiction and mental illness remain as well as how our society conceives of addiction.

The DSM-IV-TR and the upcoming revision, DSM-V, due out in May, define addictions to alcohol and drugs as psychiatric disorders. Nora Volkow, MD, the director of the National Institute on Drug Abuse, agrees, saying, “We need to first recognize that drug addiction is a mental illness.” This focus on mental health also conforms to research increasingly revealing the many ways that addiction is a brain disease.

By contrast, Alcoholics Anonymous has been centred on a model of alcoholism established before the development of thiskind of disease paradigm, and it has not espoused clinically complex models of psychological motivation. As AA cofounder Dr. Bob told attendees at a 1950 AA convention: “There are two or three things that flashed into my mind on which it would be fitting to lay a little emphasis; one is the simplicity of our program. Let’s not louse it up with Freudian complexes and things that are interesting to the scientific mind, but have very little to do with our actual AA work.”

Our own approach to addiction, which we call Integrative Addiction Psychotherapy, is based on the following assumptions:

• Addictions are psychiatric/mental health disorders.

• Many, if not most, addicts also have additional psychiatric issues such as PTSD, depression, anxiety disorders, psychosis, ADHD, and various personality disorders.

• With or without a diagnosable condition, people use substances for reasons that need to be respected and addressed.

• The treatment of addictions require professionals trained in mental health, skilled in psychotherapy, knowledgeable about the full range of psychological treatments, and fluent in the use of both addiction and psychiatric medications. Passion and dedication are important, but they do not make up for deep skill and knowledge.

What does an Integrative Addiction Psychotherapy based on these assumptions look like? Building on themes that were addressed in a previous Fix article and a related article on addiction treatment reform, we believe there are seven essential components:

1. Individual Psychotherapy: Each patient is unique and treatment must be individualized to address their specific needs, history, biology, pain, dreams and desires. While group experiences may be very powerful, even life changing, the integrity and depth of the individual psychotherapy session remains a uniquely curative experience — and the cornerstone of this approach.

2. Therapeutic Alliance: The connection between the patient and the therapist is of vital importance as it is at the heart of treatment. Good therapists will demonstrate love for their patients and will work with authenticity, optimism, courage and determination. Research in both addiction treatment and psychotherapy show the positive benefits of patients having a good relationship with their therapists.

3. Drug Use Is Meaningful: As noted earlier, people use substances for complex and deep-seated reasons that may need to be addressed before the individual will be willing to make changes in their use. Drugs may serve as a pathway to pleasure, as a way to reduce inner pain and suffering, as a method for coping with medical problems, as a vehicle for making and affirming social connection, and as a response to social oppression and poverty.

4. Multiplicity of Self: People who use drugs often have conflicting motivational forces at work — some of which support the continued use, others that fight for change. The motivations for change might include concerns about the family, anxiety related to economic or prestige threats, existential or spiritual concerns, health issues and legal problems. This inner conflict can be usefully re-conceptualized as a community of voices, modes, selves or parts. In this way, each of these energies can be respected and given a chance to speak, and dialogues can be created among the different parts to address their needs and desires.

5. Strengthening the Inner Leader: Identifying, connecting with and empowering the Inner Leader — sometimes called the healthy adult mode or the strong and healthy ego — can work to rebalance the inner forces. The individual can then make positive connections with others and take assertive, effective and meaningful action in the world. The Inner Leader of addicted patients is often underdeveloped or severely damaged, so strengthening it will remain an ongoing concern. To be clear, the healthy mode will be distinguished by its use of existential language such as “I want,” “I am deciding to,” “I am choosing to,” “I will,” “I say yes,” and “I say no” — rather than the use of phrases like “I have to,” “I need to,” and “I should.”

6. Working on Two Dimensions: Complex models of treatment, like Integrated Harm Reduction Psychotherapy, require therapists to work on two dimensions: both the use itself and the underlying pain and desires that drive it. Sometimes one will take precedence; sometimes both need to be addressed concurrently. Given this, it can be helpful to conceive of the work as involving both Horizontal and Vertical interventions.

Horizontal Interventions are techniques and strategies specifically focused on such issues as safer use, reduced use, moderation, nonaddictive use and abstinence, including Harm Reduction/Substance Use Management, Relapse Prevention and Contingency Management. The goal is to empower the patient to be able to control their use in a way that makes sense for them. For many, if not most, this will ultimately be abstinence.

Vertical Interventions are those involved in treating the patient’s pain and underlying psychopathology. Addicts may suffer from problems connected to the past (trauma, grief and moral failure), the present (depression, anxiety disorders, lack of assertiveness and personality disorders) or the future (life decisions, identity creation, the project of recovery and the need to embark on the Hero’s Journey). The therapist will want to be able to skillfully draw upon the full range of psychotherapeutic techniques to help the patient make connections, restructure cognitions, face feared experiences, work through traumas, mitigate the impact of the inner critic, claim power, clarify values, take heroic action, and learn to meditate and self-soothe.

7. Identity Transformation: While a great deal of addiction treatment is, understandably, focused on the present and the near future, long-term recovery depends on the ability of the individual to create and maintain identities that are viable, meaningful and reinforcing. The Addict Identity, which is central during active addiction, must be replaced with identities based on some connection to family, work, recovery, spirituality or other activities that provide a self-definition that is incompatible with problematic drug use. (For example, being a father takes precedence over using cocaine.) Most stories of successful recovery and life transformation involve some sort of identity reorganization or creation.

Mindy McCready was ultimately overwhelmed and destroyed by the pain inside of her. While psychiatrists and psychologists made occasional appearances on Celebrity Rehab, none of the major protagonists were mental health providers or had extensive formal training in psychotherapy. We believe that Dr. Drew Pinsky cares deeply about his patients and is dedicated to helping them achieve healing and recovery; nonetheless, his training is in addiction medicine and, while naturally skilled, he is not a trained psychotherapist.

It is our hope that the leaders and practitioners in our field will embrace the future by working to fully integrate mental health and addiction treatment — both in the therapy we do and in the paradigms we create — so that we can understand and work with the complex interplay that exists between inner suffering and addictive behaviour. Addiction is a mental illness.

 

Today

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