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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EAcute coronary syndrome (ACS), which encompasses ST elevation myocardial infarction, non-ST elevation myocardial infarction, and unstable angina, is a dynamic event whose pathophysiology should dictate therapy. This article discusses approaches to treatment of ACS.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAcute coronary syndrome (ACS), which encompasses ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA), is a dynamic event whose pathophysiology should dictate therapy. Victor Elliott, MD, University Hospital of the West Indies, Kingston, Jamaica, discussed approaches to treatment of ACS.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EACS is almost always associated with rupture of an atherosclerotic plaque and partial\/complete thrombosis of the infarct-related artery. The identification and definition of the concept of the \u003Cem\u003Evulnerable plaque\u003C\/em\u003E in 2003 contributed to the development of a risk stratification scheme for ACS, in which plaque stability is related to its histological composition (ie, pathological intimal thickening [PIT], thin-capped fibroatheroma [TCFA], thick-capped fibroatheroma [ThCFA], fibrotic plaque, or fibrocalcific plaque) [Naghavi M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2003]. The dynamic character of plaque was confirmed in a recent study in which virtual histology intravascular ultrasound was used to monitor changes in plaque over a 1-year period. In that study, \u223c10% of plaque that was classified as PIT progressed to TCFA compared with 19% to ThCFA, and while 25% of TCFA plaque remained TCFA, \u223c60% progressed to ThCFA. Of particular interest was that \u223c6% of ThCFA plaque became TCFA [Kubo T et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003ETherapies for unstable ischemic heart disease include medication (eg, antiplatelet agents, anticoagulants, fibrinolytics, and statins) and coronary revascularization with percutaneous coronary intervention (PCI) or coronary bypass surgery (CABG).\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EPlatelets play an important role in atherothrombosis, and platelet activation is implicated in the genesis of ACS. While aspirin has been in clinical use as an antithrombotic for almost a half-century, more potent antiplatelet agents, like clopidogrel, prasugrel, and ticagrelor, which function by interrupting specific sites in the sequence of platelet activation, have become part of routine care for patients with ACS, in addition to aspirin. The TRITON TIMI 38 study showed that prasugrel was superior to clopidogrel in terms of reducing recurrent cardiovascular events in patients with ACS who were undergoing PCI. In an analysis of patients with STEMI in this trial, the primary study endpoint (cardiovascular death, MI, and stroke at 15 months) was reduced from 12.4% for clopidogrel to 10.0% with prasugrel (RRR=21%; p=0.02) [Montalescot et al. ESC 2008]. Similarly, prasugrel was more efficacious than clopidogrel in patients with non-STE ACS (RRR=19%; p\u0026lt;00.001) [Wiviott SD et al. \u003Cem\u003ENEJM\u003C\/em\u003E 2007].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EGlycoprotein IIb\/IIIA inhibitors interrupt the final step of platelet aggregation. These intravenous agents (abciximab, eptifibatide, and tirofiban) are fast-acting and reversible and are indicated for use in the acute setting, particularly at the time of PCI. They improve vessel patency, reduce reinfarction rates, and decrease mortality. In the PRISM trial, tirofiban significantly reduced the 30-day event rate in medically managed (p=0.004) and revascularized patients (p=0.02) with NSTEMI ACS who had evidence of myocardial necrosis [Heeschen C. et al. \u003Cem\u003ELancet\u003C\/em\u003E 1999].\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EStatins also play an important role in the management of ACS because of their anti-inflammatory effect. The key is to start statins early and use high doses. The REVERSAL study showed that atorvastatin significantly halted atherosclerosis. The ASTEROID study showed that in statin-na\u00efve patients with coronary artery disease, regression of coronary atherosclerosis can be achieved with intensive statin therapy with 40 mg rosuvastatin. In that study, rosuvastatin significantly reduced low-density lipoprotein cholesterol by 53% (p\u0026lt;0.001) and significantly raised high-density lipoprotein cholesterol by 14.7% (p\u0026lt;0.001) [Nissen S et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2006; Ballantyne C et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008]. Importantly, PROVE IT \u2013 TIMI 22 and MIRACL have shown that starting these lipid-lowering drugs immediately after an ACS is associated with a significant reduction in cardiovascular events. Statin therapy after coronary artery stenting is associated with an unadjusted odds ratio (OR) of 0.46 (95% CI, 0.33 to 0.65), indicating a 54% reduction in the risk of death at 1 year (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Schomig A et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2002].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/30\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Cumulative One-Year Mortality Curves for Patients with and without Statins.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-256547796\u0022 data-figure-caption=\u0022Cumulative One-Year Mortality Curves for Patients with and without Statins.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/30\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/30\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/30\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12575\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003ECumulative One-Year Mortality Curves for Patients with and without Statins.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from the American College of Cardiology. Sch\u00f6mig A et al. Statin treatment following coronary artery stenting and one-year survival. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E Jan 1, 2002;40(5):854\u2013861.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003EDr. Elliot stressed the need to begin therapy by initially stabilizing the plaque before it ruptures and following the recommended treatment guidelines.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EMyocardial revascularization is a key component in the management of patients with ACS. Outcomes can be optimized by early treatment and risk stratification and by using an adequate antithrombotic regimen before revascularization. Restoring coronary flow, limiting infarct area, preserving left ventricular function, reducing ischemic effects, and limiting thrombus burden are all important goals in treating patients with ACS; however, according to Jo\u00e3o Morais, MD, Servi\u00e7o de Cardiologia Hospital de Santo Andr\u00e9, EPE Leiria, Portugal, the primary goal should be improving survival. This is best achieved in the acute setting with the use of antithrombotic drugs, followed by PCI (including coronary stenting) or CABG.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EThe last 30 years has seen a continuous evolution regarding the treatment of STEMI and NSTEMI, beginning with the use of lytic therapy, to mechanical reperfusion and then PCI. With time and experience, the invasive approach to treating NSTEMI has proved to be more efficacious for most patients. Long-term data (out to 5 years) from the FRISC II (Fragmin and Fast Revascularization during Instability in Coronary Artery Disease) study noted that 19.9% of patients who received invasive therapy experienced death or MI compared with 24.5% who received noninvasive therapy (RR, 0.81; 95% CI, 0.69 to 0.95; p=0.009) [Lagerqvist B et al. \u003Cem\u003ELancet\u003C\/em\u003E 2006]. The TACTICS-TIMI 18 trial results support the use of an early invasive strategy in NSTEMI, high-risk (TIMI risk score 3 to 7) patients with UA and MI who have been previously treated with aspirin, heparin, and the glycoprotein IIb\/IIIa inhibitor tirofiban. A more recently published overview of three crucial trials [FRISC-2; ICTUS; RITA-3] confirmed the benefit of early revascularization in higher-risk patients with NSTEMI.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EAchieving sufficient platelet inhibition in order to minimize thrombotic complications in patients who are undergoing PCI is a significant part of ACS treatment strategy. The level of platelet inhibition that is achieved has been independently associated with the risk of major adverse coronary events (composite of death, MI, and urgent target vessel revascularization) after PCI (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Steinhubl S et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2001]. The efficacy of the antiplatelet agent clopidogrel (300 mg followed by 75 mg daily), given in addition to aspirin in NSTE-ACS patients through 12 months from their index event, was assessed in the CURE trial. The primary outcome of cardiovascular death, MI, or stroke occurred in 9.3% of the patients in the clopidogrel group and 11.4% of the patients in the placebo group (RR, 0.80; 95% CI, 0.72 to 0.90; p\u0026lt;0.001) [Yusuf S et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2001]. Newer antiplatelet agents, like prasugrel and ticagrelor, are more potent and have a faster onset of action compared with clopidogrel. These agents have been tested against clopidogrel in the TRITON TIMI 38 trial (prasugrel) and the PLATO trial (ticagrelor), with both studies demonstrating superiority in the reduction of recurrent cardiovascular events with the newer-generation ADP receptor blockers.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/30\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Relationship of Platelet Level Inhibition and MACE.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-256547796\u0022 data-figure-caption=\u0022Relationship of Platelet Level Inhibition and MACE.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/30\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/30\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/30\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12576\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003ERelationship of Platelet Level Inhibition and MACE.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from J. Morais, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-14\u0022\u003EThough the best time for intervention is still a matter of debate, in the Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial, slight differences were noted for early intervention (coronary angiography \u226424 hours after randomization) versus delayed intervention (coronary angiography \u226536 hours after randomization). At 6 months, the primary outcome occurred in 9.6% of patients in the early intervention group, as compared with 11.3% in the delayed intervention group (HR, 0.85; 95% CI, 0.68 to 1.06; p=0.15). As previously noted, subgroup analyses showed that early intervention improved the primary outcome in the third of patients who were at highest risk (GRACE score \u2265140) but not in the two-thirds at low-to-intermediate risk [Mehta SR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009]. Thus, international guidelines recommend an early invasive strategy for NSTEMI patients with high-risk ACS.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003ECardiac disease rates in the Caribbean are similar to those in the United States and Europe (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E), but there is a two-tiered system of cardiac care (public and private), which impacts treatment availability. Richard Ishmael, MD, Queen Elizabeth Hospital, St. Michael, Barbados, discussed the possibility of meeting the European Society of Cardiology (ESC) guidelines for ACS in the Caribbean, while urging the Caribbean Cardiac Society to compile its own guidelines.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12577\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12577\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12577\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-16\u0022 class=\u0022first-child\u0022\u003ELeading Causes of Death.\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-17\u0022\u003EGuideline-based treatment of ACS patients with STEMI by primary PCI is possible in the Caribbean but only in private hospitals, and the management is directly related to the individual facility, the cost, and patients\u0027 ability to pay. STEMI treatment by fibrinolysis is generally available in most public hospitals in the Caribbean; however, follow-up coronary angiography regarding the need for PCI or CABG is not readily available. Fibrinolytics are widely available in the region, although streptokinase is more commonly used than t-PA, due to a marked difference in cost. Management is limited by the ability to monitor patients adequately due to lack of beds and trained nurses. Dr. Ishmael believes that the best way to treat patients in public hospitals with state-of-the-art care for ACS (STEMI) is to first begin fibrinolysis, followed by transfer to a private facility for coronary angiography and consideration for PCI.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EFor patients with NSTE-ACS, treatment that is based on the ESC guidelines is attainable both in public and private hospitals. However, in public hospitals in some regions of the Caribbean, blood biomarkers may not be always available for early diagnosis. The resource challenges that are noted above in patients with STEMI also apply to patients with NSTE-ACS, and in addition, follow-up cardiac testing (ie, nuclear stress testing, CT angiography, and coronary angiography) is often not available in public hospitals.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EOverall, in the Caribbean, management of ACS is hampered by a critical shortage of cardiac cath lab facilities and skilled cardiologists and nurses. In addition, patients often present late after onset of chest pain, reducing the opportunity for early intervention. \u201cGovernments in the region are urged to partner with private institutions to provide the best possible cardiac care for their citizens,\u201d said Dr. Ishmael.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/9\/30.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzn05p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn05p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzn05p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}