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American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP Internal Medicine 2011 News for 4-9-11

Internal Medicine 2011 News reports breaking news and events live each day from Internal Medicine 2011 and the American College of Physicians.

Highlights

  • Evaluating knee injuries in the ‘weekend warrior’
  • Ethics committee brings medical dilemmas to life
  • Systematic approach makes diagnosis, follow-up of depression manageable
  • Health care workers should get vaccinated alongside their patients

Breaking news

  • Reformed Medicaid program must put coordinated care at forefront of efforts
  • ACP honors outstanding chapter activities with John Tooker Evergreen Awards

For attendees

  • Two sessions canceled
  • Take Internal Medicine 2011 back to your practice
  • ACP Annual Business Meeting to be held Saturday in Room 17

Highlights

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Evaluating knee injuries in the ‘weekend warrior’

At a session on “Evaluation of the Weekend Warrior” Friday morning, C. David Geier Jr., MD, assistant professor of orthopedic surgery at the Medical University of South Carolina, had a message for his audience of internists. “What I do isn’t rocket science,” he said. “The surgeries are very technical, but as far as workup, it’s not that hard.”

Knee injuries are the most common type of sports-related injury, Dr. Geier said. In young adults, knee injuries are typically ligament tears and patellofemoral pain syndrome, while older adults more often have degenerative meniscal tears and osteoarthritis.

Along with patient age, the way an injury occurred can give physicians a clue as to its type. Patients with a knee injury due to collision or contact sports generally have fractures or ligament injuries. Jumping sports most often lead to tendinitis, while repetitive sports, like running, cause overuse syndromes. It’s also important to determine what activities or motions reproduce the symptoms, such as twisting motions, ascending or descending stairs, or sitting for a long time.

Dr. Geier recommended internists ask four important questions any time they see patients with knee pain:

  1. Is the knee swollen? If swelling is visible, that’s never normal and requires a thorough workup.
  2. Does the knee buckle or give way? If so, that may indicate a torn anterior cruciate ligament (ACL) or quadriceps weakness.
  3. Does the knee lock or catch? A knee that gets stuck in a certain position can indicate a meniscal tear.
  4. Does it hurt to go up or down stairs? That indicates a patellofemoral source for the pain.

ACL injuries might be commonly associated with pro football players, but Dr. Geier said they’re actually two to eight times more common in female athletes. They generally result from a twisting injury when the foot is planted, and the injured person usually feels or hears a popping sound. The knee swells immediately, can’t easily bear weight, and gives way with turning or cutting maneuvers, and the person is unable to keep playing.

The treatment for ACL tears is almost always surgical, Dr. Geier said. But injuries to the medial collateral ligament, which often result from contact, almost always heal on their own with the use of a brace or immobilizer. Patellofemoral pain and iliotibial band syndrome, the latter of which is common in runners, also respond to nonsurgical treatment, such as physical therapy, home exercises and stretching.

Acute meniscal tears, which are due to a twisting injury and present with localized pain and locking or catching, generally don’t heal well without surgery. “Nonoperative treatment is unfortunately somewhat abysmal,” Dr. Geier said, because the injury doesn’t heal and the symptoms don’t improve. However, for a degenerative meniscal tear associated with arthritis, surgery isn’t usually a viable option if the arthritis is the actual source of the pain.

This is one reason why Dr. Geier cautions against proceeding directly to an MRI for knee injuries. MRIs can show the meniscal tear but not the associated arthritis, so patients who get just an MRI will expect surgery to cure them when it won’t. But while an X-ray should never be skipped for knee injury, Dr. Geier stressed, “a non-weight-bearing AP lateral X-ray—which, sorry, all of you guys do—is not terribly helpful either.”

It’s important to get weight-bearing views that involve flexion, he noted, and to X-ray both knees so you can tell the difference side-to-side.

Dr. Geier’s routine X-ray sequence for a right knee includes a standing AP, a lateral right knee, a standing bilateral AP in 45-degree flexion on one cassette, and bilateral Merchant views on one cassette.

Dr. Geier also reviewed a list of physical exam techniques that can help pinpoint the cause of a knee injury. Presence of an effusion can be determined by appearance, the milking maneuver, or the ballotable patella sign. There’s usually no effusion with arthritis, Dr. Geier said.

Range of motion should also be assessed, keeping in mind what’s normal for the patient. Lack of full extension or pain with full flexion indicates a problem. To test for joint line tenderness, flex the knee to 90 degrees and assess it medially and laterally for pain. “You will hit the spot and be right on it if it’s a meniscal tear,” Dr. Geier said.

Lachman’s test, the pivot shift maneuver and the anterior drawer test are used to test for injury to the ACL, while the posterior drawer test is the best test for injury to the posterior cruciate ligament. The varus/valgus stress test evaluates the integrity of the collateral ligaments. The McMurray test is used to look for meniscal tears, and with patellofemoral pain it’s important to assess crepitus, tracking and apprehension.

Dr. Geier acknowledged that this list of tests might seem daunting to a general internist. “It’s like me doing a heart exam,” he said. “But the flip side of that is, it doesn’t take that much practice. You do it for a couple weeks, and I promise, you’ll get to where you can diagnose this stuff about 80% to 90% of the time.”

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Ethics committee brings medical dilemmas to life

A passerby wandering into Room 8 on Thursday afternoon might have been shocked by the ethics being displayed by physicians on the stage.

Kathy Faber-Langendoen, FACP, described how she prescribed opiates for her own mother, and accused physicians of having left her grandmother to die. And Steven Levy, FACP, was flouting his ego. “You mentioned that I’m the best. That’s true,” he said, to laughter from the audience.

There were moments of both laughter and sadness during the ACP Ethics Committee’s session on “Ethical Challenges in Physician Relationships with Patients and Family Caregivers,” led by Drs. Faber-Langendoen and Levy along with Kesavan Kutty, MACP. The session primarily consisted of two case studies, in which the physicians role-played ethical dilemmas, in some instances deliberately demonstrating unethical behavior.

The first case involved an internist talking to two siblings who disagreed about whether to continue aggressive care for their incapacitated mother. After Dr. Levy, who was playing the internist, failed to bring the family to an agreement, a member of the audience was brought up to give it a try.

The physician from the audience made numerous improvements on the Dr. Levy’s “what not to do” role playing—introducing herself, asking about the patient’s lifestyle, and clearly explaining the potential futility of continuing care.

But even she was unable to overcome the obstinacy of Dr. Faber-Langendoen’s character, who maintained her unwillingness to consider a lower level of care for her mother to the end of the role play, making arguments such as, “If she dies after we do everything, then it’s not my fault.”

At the conclusion of the role play, other audience members offered their advice on the proper handling of such difficult conversations. One attendee suggested clarifying the distinction between immediate care decisions (whether to treat the mother’s pneumonia with antibiotics) and longer-term choices (whether to start CPR or ventilation if needed). Another suggested talking more about the likelihood that medical interventions would cause discomfort to the patient.

Once freed of their fictional roles, the session leaders also offered some advice. Dr. Levy suggested having a series of conversations with the family. “We try to resolve these complicated issues in a 10-minute discussion,” he said. “It’s typical of us to want to get things done quickly, but it’s a mistake in a case like this.”

As difficult as it is, physicians also need to include the word “death” in these conversations, added Dr. Faber-Langendoen. “Something like, ‘Your mother, I’m afraid, is dying.’ You’ll have your own script.” But that script must include the “d-word,” she said. “It’s not ‘Your mother is doing badly.’”

Assessing the family’s understanding of a prognosis was not an issue in the session’s second case study, in which Dr. Levy played an oncologist and Dr. Faber-Langendoen played an internist whose mother had recently been diagnosed with gastric cancer. Dr. Faber-Langendoen was trying to convince Dr. Levy to take her mother on as a patient, but in the process she made clear her plan to be involved in the case in ethically questionable ways.

“We’ve worked together on other patients. Can we work together?” she asked him. “I wrote some Vicodin for her, just to hold her until she gets in to see you. We can be partners. Mostly [I’ll] be the eyes and ears.”

Dr. Levy, in character, responded forcefully. “I want you to be my eyes and ears, but I’m the brains of the operation.” At that point, Dr. Kutty put the situation out for debate by the audience: “Where do we go from here? And what lines were crossed?”

Several audience members shared personal dilemmas involving medical care for family members.

“I’ve been fighting this battle since medical school, when my family was so excited to have a doctor in the family,” said one internist. Her family saw her caring for them as an act of love, she explained, not understanding the potential perils. “I think we tend to minimize the complaints [of family members],” the doctor said, noting that she had dismissed as normal effects of aging symptoms reported by her mother which turned out to be a serious disease.

Another physician described how he had called in a prescription for opiates for a friend when the patient’s hospice physician was unavailable. Audience members were divided on the ethics of that action, and whether there was a distinction between prescribing antibiotics and narcotics for family members.

There is definitely a legal distinction, said Dr. Levy. Although physicians are not supposed to prescribe for anyone who isn’t their patient, the government takes a particular interest in narcotic prescriptions. “The DA and the DEA get involved in those kind of things. Worse case scenario, you end up wearing orange for a while,” he said.

Another audience member offered a rule for evaluating this kind of ethical dilemma. “Think about what you could do if you did not have an MD degree. If you could do that, that’s probably acceptable,” he said. For example, under that rule, it’s acceptable to evaluate the treatment decisions of a family member’s physician based on the evidence (because a lay person could use the Internet to gather the necessary information), but it’s not OK to write a prescription.

Further advice on these dilemmas will be provided by the 6th edition of the ACP ethics manual, which the committee is working on now, Dr. Faber-Langendoen said.

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Systematic approach makes diagnosis, follow-up of depression manageable

If you think it’s not worth your time to address depression in your primary care patients, think again.

“Once I started [addressing depression], I saw improvements in A1C and blood pressure in patients who had been making no progress with their diabetes and hypertension. If patients are depressed, they often won’t follow through on medication adherence or diet changes that affect these other conditions,” said Damara N. Gutnick, ACP Member, an assistant professor of medicine and psychiatry at New York University’s Langone Medical Center who sees patients at Bellevue Hospital Center.

In a Friday session on managing depression in primary care, Dr. Gutnick and co-speaker Kristin Remus, ACP Member, clinical instructor of medicine at Beth Israel Deaconess Medical Center in Boston, outlined a systematic, manageable approach to diagnosing and treating depressed patients.

It begins with having patients fill out a two-item screening questionnaire for depression, the Patient Health Questionnaire (PHQ-2), in the waiting room. If a patient answers yes to either question on the screener, the patient should then be directed to complete the PHQ-9, a screener that was developed for use in primary care and has been validated for diagnostic assessment and follow-up of outcomes in racial and ethnically diverse populations. The PHQ-9, as well as instructions on scoring and other material, is available from the MacArthur Initiative on Primary Care and Depression at www.depression-primarycare.org/clinicians/.

The PHQ-9 is quick, easy to score and available in several languages, noted Dr. Gutnick. A numerical value of 0 through 3 is assigned to each question based on how often a patient reports having experienced the symptoms described in the nine questions (such as feeling tired or having a poor appetite) in the past two weeks.

“We use a cutoff of 10 [points], because below that you will detect dysthymic patients, but not necessarily those who are having most of the symptoms of major depressive disorder,” Dr. Remus said.

A patient who scores a 20 to 27 is severely depressed, and referral to a psychiatrist for treatment should be considered, particularly if the patient has psychotic or manic symptoms, active suicidal ideation or attempts, substance abuse or dependence, severe psychosocial problems, severe personality disorder, or poor response to antidepressants after titration.

Patients who score between 10 and 14 on the PHQ-9 are moderately depressed; for them, consider prescribing medication and/or counseling, and discuss self-management support like exercise. Patients who score between 15 and 19 are considered to have moderately severe depression, and “are more likely to be started on medication right away….You can also start them on therapy,” Dr. Remus said.

Follow-up should be completed within one to three weeks after an initial depression diagnosis to assess adherence to treatment (whether counseling, medication or self-management) and side effects of medication, if relevant, Dr. Remus said. This can be done by support staff like a care manager, she said. Suicide risk should also be assessed at this time, as this “risk sometimes increases as patients respond to treatment and become more energetic,” Dr. Remus said.

A recently developed algorithm for assessing suicidality is the P4 screener, Dr. Remus said. The four Ps in the P4 are Present (i.e., how active are a patient’s thoughts of self-harm), a Plan for self-harm, Past history of suicide attempts, and Probability of following through. The last “P” can be partially discerned by whether the patient has the protective factors afforded by the four “Fs”: a Family that would be affected by the suicide, hope for the Future, religious Faith, and Fear of failing at the suicide attempt.

The PHQ-9 should be repeated four to eight weeks after starting treatment, since “this is when we would expect the maximum response to treatment to occur,” Dr. Remus noted. At this time, a drop of more than five points on the PHQ-9, or an overall score less than 5, is considered an “adequate response,” and no change in treatment is needed. These patients should be followed monthly until remission—defined as a PHQ-9 of less than five maintained for more than two months—then every six months after that, she said.

Patients who see a drop of two to four points at follow-up have had a “possibly inadequate response” to treatment, and it may be appropriate to increase or change medication, increase the intensity of psychotherapy, and/or increase self-management support measures. For those with a drop of one point, or no change, in their score, consider the same measures as those with a possibly inadequate response, in addition to consultation or referral to a specialist. In all patients in whom treatment is adjusted, repeat the PHQ-9 again in four to eight weeks, Dr. Remus recommended.

Bellevue, an inner-city facility, uses a collaborative care model to manage depression, Dr. Gutnick said. A medical assistant administers the PHQ-2s and PHQ-9s. If the latter is positive, the assistant circles the score to draw the attention of the primary care physician, who uses the score and the patient visit to determine a depression diagnosis and possible treatment. A depression care team is then activated for follow-up—including a psychiatric nurse practitioner who can titrate or change medications if needed. The team members provide regular feedback to the physicians about patients. “It’s an active collaborative process between [physicians] and care managers; I can offer suggestions for treatment, or step in if a problem becomes more acute,” Dr. Gutnick said.

Collaborative care for depression has been shown to improve patient outcomes compared to usual care, Dr. Remus noted, although “it will be one to two years before you see cost savings from collaborative care.”

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Health care workers should get vaccinated alongside their patients

Many health care workers refuse annual flu vaccines, but not Margaret C. Fisher, MD. Dr. Fisher, a pediatric disease subspecialist and the medical director of The Children’s Hospital at Monmouth Medical Center, in Long Branch, N.J., is a proponent of vaccination, to say the least.

Speaking Friday morning, she suggested employer mandates as a way to drive health care worker vaccination rates. Despite recommendations from the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society and the American Academy of Pediatrics, health care worker vaccination compliance stands at 35% nationwide. “That is a dismal rate,” she said.

The only way to achieve compliance is an employer mandate: If you want to work in this office/hospital, get immunized, Dr. Fisher said.

Her session, titled “Vaccines: Not Just for Kids,” discussed how health care worker vaccination is one way to maintain past successes in wiping out the world’s most debilitating diseases, and a method to combat those that are rare but not yet eradicated.

While Dr. Fisher herself hasn’t seen a case of Haemophilus influenzae type B in 10 years, “which is truly miraculous,” there were six cases in Minnesota in 2009, five among children not immunized by parental choice and a sixth in a child who had been immunized but who didn’t respond to it.

“The decision not to vaccinate is one that can be regrettable,” Dr. Fisher said.

Failure to vaccinate is an issue with measles as well. The U.S. sees “imported” measles all the time, Dr. Fisher said. Recent news reports highlighted her point. Women who’d flown to the U.S. from France and England led to public health officials having to track down people who were on the same airplanes and at the same airports and may have been exposed.

And if measles is not recognized in children, they can easily infect others. Dr. Fisher called the choice not to immunize one’s own children a public health issue.

“Already we’ve seen as much measles this year as we’d see in an entire year,” Dr. Fisher said. “Those immunization rates have to stay up there. Infection is just a plane ride away.”

In New York in 2010, an unimmunized child exposed a summer camp of Orthodox Jewish boys to mumps. It’s now rampant in that teen male population, since they spend so much time face-to-face. Even though many of the boys had been immunized, mumps can overpower immune memory, Dr. Fisher said.

The dwindling of immunity highlighted the point made by the title of the session—immunization is not just for children. Adults need boosters, Dr. Fisher said, citing as an example one case of diphtheria seen in a drug abuser in Washington State.

Barriers to thorough vaccination coverage include shortages, which have presented a major dilemma for physicians. Distribution is always a problem, and “It’s no fun when Walmart has the vaccine before we do,” Dr. Fisher said. The good news is that no vaccine is so scarce that physicians have to change the way that they practice.

Also good news is that vaccines are safe, but the bad news is that a minority of vocal protesters raise safety issues, including the false specter of autism. Evidence about the safety of vaccines is overwhelmed by “emotions and concerns,” she said.

The bar for vaccine safety is much higher than that of other drugs, such as chemotherapy. To say that chemo drugs have side effects is obvious. Vaccines are held to a much stricter standard.

“The safety bar for vaccines is higher than for any other product in the country,” she said.

Immunization drug safety starts during the drug development process and continues through every stage of development, including phase, I, II and II efficacy trials and during postmarket surveillance.

Postmarket surveillance continues through three programs, the Vaccine Adverse Event Reporting System (VAERS), the Vaccine Safety Datalink, and the Clinical Immunization Safety Assessment Network, all run by the Centers for Disease Control and Prevention.

VAERS was used to collect information about teens passing out during the administration of human papillomavirus vaccine. It’s true, Dr. Fisher said. Pain can induce syncope, and teens were being given the injections while standing. Those reports were used to change recommendations to encourage sitting during administration, as well as keeping patients under observation post-injection. Some of the syncopal events occurred 10 minutes after the vaccine was administered, by which time people were already out of the office.

VAERS was used to discount false reports that sudden infant death syndrome was more common after vaccination (It’s not) and that hepatitis B vaccination leads to multiple sclerosis (There’s no link).

To assuage public fears and encourage drug manufacturers to continue making vaccines, the government passed the National Childhood Vaccine Injury Act, which provides for no-fault compensation for injuries that result from vaccination. The Act that created that program also exempts the physicians from injuries that may arise.

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Breaking news

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Reformed Medicaid program must put coordinated care at forefront of efforts

A reformed Medicaid program must put coordinated primary care at the forefront of its efforts, the American College of Physicians said in a new position paper released on April 8. Medicaid and Health Care Reform highlights how primary care physicians will assume a major role in providing care to Medicaid beneficiaries.

“The Medicaid program faces significant changes in the next few years as millions of current and newly eligible people will receive Medicaid coverage” said J. Fred Ralston Jr., FACP, president of ACP. “With this challenge comes the opportunity to reform Medicaid to ensure its future sustainability and solvency.”

ACP’s paper contends that the program must do more to ensure that physicians can afford to provide care, that information can be shared across the health care infrastructure, and that administrative burdens are mitigated to allow physicians more time to care for patients. It emphasizes quality care over volume-based care and says the programs will need to provide beneficiaries with more options to meet their long-term care needs.

The 38-page paper provides brief updates on changes to the program over the last three to four years and makes a dozen recommendations on how the Medicaid program can be improved to ensure access and sustainability in the future.

Read the complete paper online.

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ACP honors outstanding chapter activities with John Tooker Evergreen Awards

At Internal Medicine 2011, ACP presented John Tooker Evergreen Awards to five chapters. The Tooker Evergreen Program provides recognition and visibility to those chapters that have successfully implemented programs that increase membership, improve communication, increase member involvement, enhance diversity, foster careers in internal medicine and improve management of the chapter.

Here is a list of the chapter winners, the titles of their programs and the categories of submission. For more information on a particular program, contact Keirston Scott at kscott@acponline.org.

Advocacy

New York for Primary Challenge: How New York Can Save Billions by Investing in Primary Care Cost Report
In collaboration with five other state-based health care organizations, the New York Chapter produced a comprehensive report to be used as a case report to convince state policy leaders to increase investment in primary care. The report was distributed to legislators and key health leaders and was reported on in daily newsletters.

Associates/Young Physicians

U.S. Navy for Resident-to-Staff Transition Symposium
Recognizing a significant gap in internal medicine training between concluding formal graduate medical education and assuming junior staff internist duties, the U.S. Navy Chapter developed a transition symposium. Over the past six years, this program has allowed the creation of a better informed, better prepared group of associate and young physician members as well as more rapid development as more complete internists.

New Jersey for Evaluating Outcomes: Training Internal Medicine Chief Residents for Future Leadership in Health Care
The New Jersey Chapter sought to enhance and cultivate leadership skills among a select group of identified leaders at the associate/young physician level. Launched in the fall of 2009, this multi-phase program included a seven-hour interactive didactic session on leadership skills and strategies, local state leadership day, and self-assessments. The chapter saw 29% of the chief residents who enrolled in the program meet criteria for certification through the College’s Leadership Enhancement and Development (LEAD) program, and plans to sponsor the program again in upcoming years.

Education/Communication

Illinois, Downstate Region for After Hours with ACP: A Webinar Series Offered by the ACP Illinois Chapter, Downstate Region
The Illinois Chapter, Downstate Region embarked on a monthly “After Hours with ACP” Webinar series in an effort to increase membership value and provide more education for chapter membership. Once a month, the chapter hosts an educational session including clinical, practice management, and advocacy topics. Recordings of each Webinar are then posted on the chapter website and provide a cost-effective way to increase member involvement.

New York for Meaningful Use Statewide Educational Summits
Working with designated Regional Extension Centers, the New York Chapter created a program to educate the state’s physicians, other providers and office staff on electronic health records. The chapter collaborated to develop a regional summit format and a meaningful curriculum while also facilitating physician feedback and post-activity evaluations

Membership Recruitment/Diversity

Pennsylvania for Recruiting Former ACP Members
The Pennsylvania Chapter launched a targeted and extensive recruitment initiative. Recognizing the unique audience available through Pri-Med Access meetings, the chapter tailored its recruitment efforts to focus on former ACP members. By identifying these individuals and reaching out to them, the chapter is also gathering valuable data on what is important to potential members.

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For attendees

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Two sessions canceled

Saturday’s sessions "Recognizing and Treating Substance Abuse" (MTP 096) and "Update in Nephrology" (UD 008) and has been canceled. The sessions were scheduled to be held from 7-8 a.m. in Room 1 and from 8:15-9:15 a.m. in Ballroom 20D, respectively.

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Take Internal Medicine 2011 back to your practice

Recordings are available for purchase on audio CD, MP3 CD, iPod Audio, and in AudioPoint format for many of the sessions at Internal Medicine 2011. Stop by one of the Meeting Recordings booths, located outside Ballrooms 6 and 20, for details and to place your order. Special discounts are available for orders placed onsite at Internal Medicine 2011.

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ACP Annual Business Meeting to be held Saturday in Room 17

All Members, Fellows, Masters, Associates and Affiliates are encouraged to attend ACP's Annual Business Meeting at Internal Medicine 2011. Incoming Officers, new Regents and Governors-Elect will be introduced.

The meeting will be held Saturday in Room 17 at the San Diego Convention Center from 12:45 p.m. to 1:45 p.m., with J. Fred Ralston Jr., FACP, ACP President, presiding. Dennis R. Schaberg, MACP, will present the Annual Report of the Treasurer. A key feature of the meeting is the presentation of ACP's priorities for 2011-2012 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.

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