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2.
Chirurgia (Bucur) ; 115(1): 69-79, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32155401

RESUMO

Background: Basal cell carcinoma (BCC) and Squamous cell carcinoma (SCC) are the most frequent skin cancers with a continuous increasing incidence and a cause of economic impact. Mohs micrographic surgery (MMS) is known as the gold-standard of treatment of non-melanoma skin cancer. Methods: The files of the patients treated with MMS were analysed during a 6 year period (2014-2019) and demographic information was extracted in addition to the information on tumor histology, localization of tumors, number of stages required for a complete removal of the tumors, and the evolution of the patients. We also analysed the information regarding the number and type of reconstructions performed. Results: Over the course of 6 years, 1,356 cutaneous tumors were treated in our clinic by means of MMS. BCC represented 80.5%, SCC 17.6%, and other tumors such as melanoma in situ, DFSP, Extramammary Paget's Disease - being 1.9% of the number of other treated tumors. During the period under review, only 4 cases of post-Mohs Micrographic Surgery recurrence have been recorded, with a cure rate of over 99.7%. Conclusions: Mohs micrographic surgery is an efficient treatment method in removing cutaneous carcinoma as well as tumors with special indications with a low recurrence rate therefore reducing the need of successive surgical interventions.


Assuntos
Cirurgia de Mohs , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Instituições de Assistência Ambulatorial , Humanos , Cirurgia de Mohs/métodos , Romênia , Resultado do Tratamento
3.
Dermatol Online J ; 26(1)2020 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-32155034

RESUMO

Sox10 immunostaining is used for the diagnosis and margin evaluation of melanocytic lesions. Sox10 was initially thought not to stain fibrohistiocytic processes. Consequently, it was believed to reliably distinguish desmoplastic melanoma from scar. However, recent data from formalin sections suggest Sox10 is less specific than previously thought. In this report, we demonstrate that Sox10-stained Mohs sections commonly show strong, fractional staining of scar. When using Sox10 with frozen section immunohistochemistry, Mohs practitioners should recognize the potential of this marker to stain scar to avoid overdiagnosis of desmoplastic melanoma.


Assuntos
Cicatriz/patologia , Corantes/efeitos adversos , Melanoma/diagnóstico , Neoplasias Cutâneas/diagnóstico , Secções Congeladas , Humanos , Imuno-Histoquímica , Melanoma/cirurgia , Cirurgia de Mohs , Neoplasias Cutâneas/cirurgia , Coloração e Rotulagem
4.
Plast Reconstr Surg ; 145(3): 606e-607e, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32097328

RESUMO

Reconstruction of substantial-sized upper lip defects may require an Abbe flap reconstruction to avoid excessive tightness and deformity. The design of the Abbe or lip switch flap harvested from the lower lip is important for a satisfactory aesthetic and functional result. Harvest of the flap is performed to enable a definitive inset into the defect. The video that accompanies this article depicts rotation of an Abbe flap into a philtral defect created by basal cell carcinoma excision.


Assuntos
Carcinoma Basocelular/cirurgia , Neoplasias Labiais/cirurgia , Lábio/cirurgia , Cirurgia de Mohs/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Carcinoma Basocelular/patologia , Feminino , Humanos , Lábio/patologia , Neoplasias Labiais/patologia , Pessoa de Meia-Idade , Retalhos Cirúrgicos/transplante , Resultado do Tratamento
5.
Plast Reconstr Surg ; 145(2): 533-542, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985654

RESUMO

BACKGROUND: The lips provide key functional and aesthetic features of the face. From social interactions and speech to swallowing and oral competence, a functional dynamic structure is required. This interaction with surrounding landmarks presents a challenge for reconstruction. There are a myriad of ways reported to reconstruct these defects; however, as the authors' practice has evolved, a more refined approach was developed to optimize results and minimize the complexity of each patient's surgery. METHODS: A retrospective review from 2004 to 2018 was performed of consecutive patients who underwent lip reconstruction following Mohs cancer resection performed by a single surgeon. Each case was evaluated for key patient characteristics, defect location, defect size, defect composition, reconstructive modality, and complications. In addition, the evolution of treatment types over those 14 years was evaluated. RESULTS: Six hundred fifteen patients underwent lip reconstruction. Defects most commonly involved the upper lateral lip, and 247 (40 percent) involved both the skin and vermillion. A significant majority of the patient's defects were repaired using either linear closure or V-wedge excision and closure. A complication rate of 10.2 percent (n = 63) was found, ranging from oral incompetence to cancer recurrence. There was no significant difference in complication rates in patients older than 75 years, in smokers, or in patients who were on anticoagulation. CONCLUSIONS: The authors' techniques have evolved from more invasive advancement and rotation flaps to a more reliable linear closure method over the past 14 years. This study shows that lip reconstruction is safe in elderly patients, smokers, and patients who are on anticoagulation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Neoplasias Labiais/cirurgia , Lábio/cirurgia , Cirurgia de Mohs/métodos , Retalhos Cirúrgicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Curativos Biológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Transplante de Pele/métodos , Resultado do Tratamento , Adulto Jovem
7.
J Am Acad Dermatol ; 82(1): 139-148, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31279037

RESUMO

BACKGROUND: Outcomes for patients with cutaneous squamous cell carcinoma (CSCC) treated with Mohs micrographic surgery (MS) in the United States have never been prospectively defined. Risk factors as they relate to outcomes are primarily derived from single-institution, retrospective data without regard for treatment modality. The American Joint Committee on Cancer Staging Manual, Eighth Edition, and the Brigham and Women's Hospital T staging systems have not been prospectively validated. OBJECTIVE: To prospectively quantify outcomes by T stage and verify historically high-risk features as they pertain to outcomes in MS-treated CSCC. METHODS: A 5-year, prospective, multicenter analysis of patients undergoing MS for invasive CSCC was conducted. RESULTS: The study enrolled 647 patients with 745 tumors. The 5-year local recurrence (LR)-free survival, nodal metastasis (NM)-free survival, and disease-specific survival were 99.3%, 99.2%, and 99.4%, respectively. Both staging systems were predictive of NM, disease-specific death, and all-cause death; neither was predictive of LR. Although Breslow depth was statistically associated with LR, NM, and disease-specific death, incidental perineural invasion was not. LIMITATIONS: The Brigham and Women's Hospital and the American Joint Committee on Cancer Staging Manual, Eighth Edition T staging systems were published after study enrollment, therefore T stages were retrospectively applied using the prospectively collected data. CONCLUSION: MS is a highly effective treatment for CSCC and may mitigate factors typically considered high risk. Uniform reporting of Breslow depth should be considered in CSCC. The American Joint Committee on Cancer Staging Manual, Eighth Edition, and the Brigham and Women's Hospital staging system are useful prognosticators but are not predictive of LR after MS.


Assuntos
Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Cirurgia de Mohs , Recidiva Local de Neoplasia/patologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo
8.
J Am Acad Dermatol ; 82(1): 149-155, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31473297

RESUMO

BACKGROUND: Optimal surgical management for melanoma of the head and neck remains controversial. OBJECTIVE: Assess outcomes for melanomas of the head and neck treated with Mohs micrographic surgery (MMS) versus wide local excision (WLE) from the National Cancer Database. METHODS: Head and neck melanoma data from the National Cancer Database from years 2004-2015 were analyzed. RESULTS: In total, 50,397 cases of head and neck melanoma were reviewed; 3510 (7%) were treated with MMS and 46,887 (93%) with WLE. After controlling for potential confounding variables, patients treated with MMS were more likely than patients treated with WLE to survive after 5 years (hazard ratio [HR] 1.181, 95% confidence interval [CI] 1.083-1.288; P < .001). Factors associated with a statistically significant survival disadvantage included male sex (HR 1.287, 95% CI 1.242-1.357; P = 0), tumor ulceration (HR 1.687, 95% CI 1.616-1.760; P = 0), and positive surgical margins (HR 1.395, 95% CI 1.306-1.490; P = 0). Patient survival was inversely proportional to tumor Breslow depth. LIMITATIONS: Database study, limited number of MMS treated melanomas. CONCLUSION: MMS is a valid treatment option for melanoma of the head and neck; National Cancer Database data suggests that MMS might confer a survival benefit over WLE.


Assuntos
Neoplasias de Cabeça e Pescoço/cirurgia , Melanoma/cirurgia , Cirurgia de Mohs , Neoplasias Cutâneas/cirurgia , Idoso , Bases de Dados Factuais , Feminino , Neoplasias de Cabeça e Pescoço/complicações , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Masculino , Margens de Excisão , Melanoma/complicações , Melanoma/mortalidade , Melanoma/patologia , Neoplasia Residual , Fatores Sexuais , Neoplasias Cutâneas/complicações , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/patologia , Úlcera Cutânea/etiologia , Taxa de Sobrevida , Estados Unidos/epidemiologia
12.
Dermatol Surg ; 46(1): 26-30, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30829774

RESUMO

BACKGROUND: Recently, the safety of lidocaine plus epinephrine use in outpatient surgery has come under scrutiny despite its long history of use in outpatient dermatologic procedures and surgeries. OBJECTIVE: To assess the frequency of crash cart and other emergency interventions during Mohs micrographic surgery when lidocaine plus epinephrine is used as a local anesthetic and evaluate patient comorbidities associated with these events. MATERIALS AND METHODS: A retrospective chart review was conducted in an outpatient Mohs micrographic surgery clinic. RESULTS: One thousand one hundred twenty-seven Mohs cases were reviewed from the period of March 2015 to June 2016 with 864 meeting the inclusion criteria of patient weight, medical history, and amount of lidocaine administered recorded. No adverse events requiring emergency intervention with a crash cart or transfer to the emergency department occurred despite a patient population with advanced age and a wide range of comorbidities. CONCLUSION: No serious adverse events requiring emergency intervention were associated with lidocaine with epinephrine doses administered below the Food and Drug Administration recommended maximum. The authors did not find evidence from this study or after a literature search to support the requirement for a crash cart and other emergency equipment to be present during procedures.


Assuntos
Anestésicos Locais/efeitos adversos , Epinefrina/efeitos adversos , Lidocaína/efeitos adversos , Cirurgia de Mohs/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Simpatomiméticos/efeitos adversos , Idoso , Anestésicos Locais/administração & dosagem , Epinefrina/administração & dosagem , Feminino , Humanos , Injeções Intradérmicas , Injeções Subcutâneas , Lidocaína/administração & dosagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Simpatomiméticos/administração & dosagem
13.
Dermatol Surg ; 46(1): 1-6, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31188146

RESUMO

BACKGROUND: Dermatologists overall perform a large number of procedures billed to Medicare, though the proportion of surgical procedures attributable to general dermatologists who do not perform Mohs micrographic dermatologic surgery (MDS) is unknown. OBJECTIVE: To determine the surgical volume of dermatologists who do not perform MDS and compare it to the surgical volume of MDS-performing dermatologists and all non-dermatologists. METHODS: A cross-sectional analytical study was performed using the Medicare public use file for 2014. Data were divided by physician specialty (dermatologists vs all non-dermatologists), and dermatologists were then dichotomized by MDS performance. RESULTS: Non-MDS dermatologists performed 42.19% of the benign excisions, 57.18% of the malignant excisions, and 46.00% of the intermediate repairs billed to Medicare in 2014. Micrographic dermatologic surgery-performing dermatologists were responsible for most of the complex repairs (67.56%), flaps (52.85%), and grafts (59.65%) billed to Medicare. CONCLUSION: Dermatologists who do not perform MDS represent the single largest group billing Medicare for benign excisions, malignant excisions, and intermediate repairs. They also bill for more complex repairs than all non-dermatologists combined. Micrographic dermatologic surgery-performing dermatologists performed most of the complex repairs, flaps, and grafts billed to Medicare.


Assuntos
Dermatologia , Medicare , Cirurgia de Mohs/estatística & dados numéricos , Padrões de Prática Médica , Neoplasias Cutâneas/cirurgia , Estudos Transversais , Humanos , Neoplasias Cutâneas/patologia , Retalhos Cirúrgicos , Estados Unidos
15.
An Bras Dermatol ; 94(6): 671-676, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31789269

RESUMO

BACKGROUND: Mohs micrographic surgery is a surgical technique for the treatment of nonmelanoma skin cancer. Surgery begins by removing the visible tumor before excision of the tissue specimens for evaluation of the tumor margins. OBJECTIVES: To present a new way to evaluate the material obtained from debulking, by horizontal histological analysis of the fragment. METHODS: Descriptive retrospective cross-sectional study based on the medical records and histological lamellae of patients with primary basal cell carcinomas smaller than 1.5cm submitted to Mohs micrographic surgery and who had the visible tumor analyzed by horizontal histological sections. RESULTS: The sample evaluated included 16 patients with lesions located on the face. Comparing the histopathological examinations of incisional biopsy in vertical sections and debulking in horizontal sections, there was agreement in seven cases. The histological analysis performed in horizontal sections allowed identification of the tumor site in 13 cases, and the relation between tumor and margin showed that in 11 cases, the lateral margin was compromised. STUDY LIMITATIONS: The technique was better-applied in lesions smaller than 2cm. CONCLUSION: Horizontal histological analysis of debulking has advantages for Mohs surgery, since it allows visualization of almost all tumor extension in the same view plane of the dermatoscopy, allowing better definition of the histological subtype, tumor site, and tumor/margin of lesions less than 1.5cm.


Assuntos
Carcinoma Basocelular/patologia , Carcinoma Basocelular/cirurgia , Cirurgia de Mohs/métodos , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Idoso , Idoso de 80 Anos ou mais , Biópsia , Estudos Transversais , Dermoscopia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Carga Tumoral
16.
Pan Afr Med J ; 33: 245, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31692779

RESUMO

Mohs micrographic surgery (MMS) is a technique allowing for intraoperative histologic assessment of surgical margin of malignant tumors. This study aims to highlight the role of MMS in the achievement of radical healing of basal cell carcinoma (BCC) in our patients. We conducted a study of 29 patients with basal cell carcinoma of the face over a period of 5 years. The median age of patients was 45.8 years (12-80). The sex-ratio M/F was 1.23. One-stage surgical procedure was sufficient to obtain complete resection in 51% of cases. Three-stage surgical procedure was needed in 14% of the cases. The mean duration of one-stage surgical procedure was 1 hour. No complications were reported in the postoperative period and sequelae were simple. The aesthetic and functional result was satisfactory. No recurrence was noted. BCC accounts for approximately 80% of all skin cancers. The decision to use MMS to treat BCC is based on three variables: the seat and the size of the tumor, its histological appearance with the identification of resection margin and its recurrent nature. MMS is currently the most effective method in the treatment of BCC and allows maximum healthy tissue preservation. It is a safe and repeatable surgical procedure based on team work and adapted to the treatment of patients with BCC who are at high risk of recidivism. The aesthetic and functional results are satisfactory. Recurrence rate at 5 years is 10 times lower than with the other methods.


Assuntos
Carcinoma Basocelular/cirurgia , Neoplasias Faciais/cirurgia , Cirurgia de Mohs/métodos , Neoplasias Cutâneas/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Basocelular/patologia , Criança , Neoplasias Faciais/patologia , Feminino , Hospitais Universitários , Humanos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Marrocos , Estudos Prospectivos , Neoplasias Cutâneas/patologia , Resultado do Tratamento , Adulto Jovem
17.
Pan Afr Med J ; 33: 297, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31692830

RESUMO

Usually most patients with dermatofibrosarcoma protuberans (DFSP) may present rather late when the tumor is in protuberant phase due to its rarity and indolent onset. It has a high propensity for local recurrence and destructive nature. Management of DFSP requires a biopsychosocial and Multidisplinary approach regardless of the clinical or immunohistochemical variant. Surgery is the Gold standard management of localized disease. DFSP rarely exhibits any lymphatic or hematogenous dissemination. It is because of its high recurrence rate associated with Wide Local Excision (WLE), the introduction of Mohs micrographic surgery (MMS) has really helped in reducing the rates of recurrence of DFSP. Thus, the aim of this meta-analysis and systemic review is to advocate for MMS over WLE for DFSP and other cutaneous malignancies using DFSP as a prototype. The objective of this study were to conduct a meta-analysis on comparative surgical methods used in the cure of DFSP with regards to WLE verses MMS, to evaluate the cure rates with relation to recurrence rates, offer a recommendation on the various treatment modalities based on the location of lesion, and use of adjuvant therapy in different clinical-medical setups. A comprehensive retrospective analysis search in EMBASE, Google Scholar and Medline (PubMed) for studies published from 2008 to 2018 containing the surgical management of DFSP with WLE verses MMS were reviewed. Five studies of moderate-quality evidence (level B) with a pooled patient load of 684 was analyzed and found for recurrence of DFSP after WLE and MMS to be 9.10% and 2.72% respectively after an average follow-up time for both groups of 5.32 years with a female predominance of 1.58. The trunk is the commonest site for the DFSP lesion which was at 52.80% then the upper and lower extremities zones and the head and neck zones at 31.75% and 15.45% respectively. The pooled adjusted odds ratio (OR) analysis indicated that there was a direct relationship with regards the reduced recurrence rate of DFSP in the MMS group compared to the WLE group (OR:0.31;95%; CI :0.17-0.56). Furthermore, there was significant association between the reduced recurrence rate with the MMS in DFSP patients with a statistical P-value of 0.0001 at 95% CI. The expected increased recurrence rate by zones was in WLE head and neck zone at 38.19% then trunk and extremities zone at 13.34%. In the MMS group it was at of 23.4% as compared to 16.0% in the head and neck zone. Mohs Micrographic Surgery (MMS) is more efficacious in the cure rate and recurrence reduction of DFSP and should be advocated for as first line therapy especially in high recurrence prone zones.


Assuntos
Dermatofibrossarcoma/cirurgia , Cirurgia de Mohs/métodos , Neoplasias Cutâneas/cirurgia , Dermatofibrossarcoma/patologia , Procedimentos Cirúrgicos Dermatológicos/métodos , Humanos , Recidiva Local de Neoplasia , Neoplasias Cutâneas/fisiopatologia , Resultado do Tratamento
18.
JAMA Facial Plast Surg ; 21(6): 518-525, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31670742

RESUMO

Importance: Objectively measuring how Mohs defect reconstruction changes casual observer attention has important implications for patients and facial plastic surgeons. Objective: To use eye-tracking technology to objectively measure the ability of Mohs facial defect reconstruction to normalize facial attention. Design, Setting, and Participants: This observational outcomes study was conducted at an academic tertiary referral center from January to June 2016. An eye-tracking system was used to record how 82 casual observers directed attention to photographs of 32 patients with Mohs facial defects of varying sizes and locations before and after reconstruction as well as 16 control faces with no facial defects. Statistical analysis was performed from November 2018 to January 2019. Main Outcomes and Measures: First, the attentional distraction caused by facial defects was quantified in milliseconds of gaze time using eye tracking. Second, the eye-tracking data were analyzed using mixed-effects linear regression to assess the association of facial defect reconstruction with normalized facial attention. Results: The 82 casual observers (63 women and 19 men; mean [SD] age, 34 [12] years) viewed control faces in a similar and consistent fashion, with most attention (65%; 95% CI, 62%-69%) directed at the central triangle, which includes the eyes, nose, and mouth. The eyes were the most visually important feature, capturing a mean of 60% (95% CI, 57%-64%) of fixation time within the central triangle and 39% (95% CI, 36%-43%) of total observer attention. The presence of Mohs defects was associated with statistically significant alterations in this pattern of normal facial attention. The larger the defect and the more centrally a defect was located, the more attentional distraction was observed, as measured by increased attention on the defect and decreased attention on the eyes, ranging from 729 (95% CI, 526-931) milliseconds for small peripheral defects to 3693 (95% CI, 3490-3896) milliseconds for large central defects. Reconstructive surgery was associated with improved gaze deviations for all faces and with normalized attention directed to the eyes for all faces except for those with large central defects. Conclusions and Relevance: Mohs defects are associated with altered facial perception, diverting attention from valuable features such as the eyes. Reconstructive surgery was associated with normalized attentional distraction for many patients with cutaneous Mohs defects. These data are important to patients who want to know how reconstructive surgery could change the way people look at their face. The data also point to the possibility of outcomes prediction based on facial defect size and location before reconstruction. Eye tracking is a valuable research tool for outcomes assessment that lays the foundation for understanding how reconstructive surgery may change perception and normalize facial deformity.


Assuntos
Movimentos Oculares , Neoplasias Faciais/cirurgia , Cirurgia de Mohs , Procedimentos Cirúrgicos Reconstrutivos , Adulto , Atenção , Feminino , Humanos , Masculino , Fotografação
19.
Dermatol Surg ; 45 Suppl 2: S47, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31764290
20.
Dermatol Surg ; 45 Suppl 2: S48-S56, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31764291

RESUMO

BACKGROUND: There is a paucity of data or publications in the literature on best practices for opening a new Mohs surgery unit. OBJECTIVE: The goal of this article is to be a "how to" guide for starting a Mohs and dermatologic surgery practice. MATERIALS AND METHODS: Two academic Mohs surgeons share their personal experiences and data from the literature. RESULTS: Topics discussed include picking a location and identifying space, equipment, staffing, regulatory practices, policies and procedures, marketing and outreach, patient experience, building culture, clinic efficiency, and vision. CONCLUSION: Although opening a new Mohs surgery unit is challenging, it can be rewarding to have the opportunity to develop best practices and systems that create a wonderful working environment and allow for exceptional care of patients.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Cirurgia de Mohs , Administração de Consultório/organização & administração , Neoplasias Cutâneas/cirurgia , Eficiência Organizacional , Humanos , Marketing de Serviços de Saúde , Edifícios de Consultórios Médicos/legislação & jurisprudência , Edifícios de Consultórios Médicos/organização & administração , Administração de Consultório/legislação & jurisprudência , Assistência Centrada no Paciente , Admissão e Escalonamento de Pessoal , Guias de Prática Clínica como Assunto
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