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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;13\\\/15\\\/30\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;13\\\/15\\\/30\u0022}],\u0022ac\u0022:{\u0022spmdc;13\\\/15\\\/30\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;13\\\/15\\\/30\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink 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\u003ERenal denervation (RDN) is a promising emerging treatment option for resistant hypertension, as well as other diseases that appear to be associated with sympathetic activation. This article discusses guideline recommendations for the diagnosis and conventional treatment of resistant hypertension; data of RDN efficacy and safety; investigational indications for RDN therapy; as well as the reasons behind the popularity and success of RDN.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Radiology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHypertensive Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERenal Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHypertension \u0026amp; Kidney Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Radiology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHypertensive Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERenal Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHypertension \u0026amp; Kidney Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003ERenal denervation (RDN) is a promising emerging treatment option for resistant hypertension, as well as other diseases that appear to be associated with sympathetic activation. Alexandra O. Konradi, MD, PhD, Almazov Federal Center for Heart, Blood and Endocrinology, St. Petersburg, Russia, presented guideline recommendations for the diagnosis and conventional treatment of resistant hypertension.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EProf. Konradi highlighted an algorithm adapted from the 2008 American Heart Association guidelines for resistant hypertension [Calhoun DA et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2008] that addresses many important underlying issues in the diagnosis and management of resistant hypertension (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). According to the 2013 European Society of Hypertension\/European Society of Cardiology guidelines, resistant hypertension can be caused by lifestyle factors such as obesity, excessive alcohol or sodium intake, chronic use of vasopressor or sodium-retaining agents, obstructive sleep apnea (OSA), secondary forms of hypertension, or advanced or irreversible organ damage [Mancia G et al. \u003Cem\u003EJ Hypertens\u003C\/em\u003E 2013]. Therefore, physicians should screen patients for OSA and agents that can increase blood pressure (BP), including nonsteroidal anti-inflammatory drugs, diet pills, and oral contraceptives among others. In addition, treatment adherence is highly important and should be assessed routinely [Mancia G et al. \u003Cem\u003EJ Hypertens\u003C\/em\u003E 2013]. In addition, physicians should exclude secondary causes of hypertension when appropriate and continually work to optimize antihypertensive regimens.\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\/13\/15\/30\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Algorithm to Validate Resistant Hypertension in Presenting Patients\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1001037324\u0022 data-figure-caption=\u0022Algorithm to Validate Resistant Hypertension in Presenting Patients\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\/13\/15\/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\/13\/15\/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\/13\/15\/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\/13591\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-4\u0022 class=\u0022first-child\u0022\u003EAlgorithm to Validate Resistant Hypertension in Presenting Patients\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EABPM=ambulatory blood pressure monitoring; Aldo=aldosteronism; BP=blood pressure; HBPM=home blood pressure measurement; OSA=obstructive sleep apnea; Pheo=pheochromocytoma.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAdapted from Calhoun DA et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2008.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-5\u0022\u003EMarkus Schlaich, MD, PhD, Neurovascular Hypertension \u0026amp; Kidney Disease Laboratory, Melbourne, Australia, discussed the principles underlying RDN as a treatment of resistant hypertension. When the sympathetic nervous system is overactive, norepinephrine acts to stimulate the kidneys, heart, veins, and arterioles. Sympathetic stimulation of the kidneys results in sodium retention, renin release, and vasoconstriction. Stimulation of the heart increases heart rate and stroke volume, with chronic activation by norepinephrine leading to arrhythmias and left ventricular hypertrophy. In addition, norepinephrine affects the metabolism by stimulating lipolysis in adipocytes, gluconeogenesis in the liver, altering insulin release by the pancreas and rarefaction of the skeletal arterioles.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EProf. Schlaich highlighted multiple factors that can cause chronic activation of the sympathetic nervous system. For example, obesity may be associated with chronic sympathetic activation and it has been observed that individuals who lose \u223c8% to 9% of their body weight through diet or diet plus exercise demonstrate a significant decrease in sympathetic nerve activity [Straznicky NE et al. \u003Cem\u003EDiabetes\u003C\/em\u003E 2010]. Moreover, \u223c70% to 80% of patients with resistant hypertension also have OSA, and OSA is associated with high sympathetic nervous activation.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EHenry Krum, MBBS, PhD, Centre of Cardiovascular Research \u0026amp; Education in Therapeutics, Monash University, Melbourne, Australia, presented data of RDN efficacy and safety. The Symplicity HTN Program included three trials that evaluated RDN in refractory hypertension. In Symplicity HTN-1, 153 patients with \u2265160 mm Hg systolic BP (SBP) despite treatment with \u22653 antihypertensive agents and an estimated glomerular filtration rate (eGFR) of \u226545 mL\/min\/1.73 m\u003Csup\u003E2\u003C\/sup\u003E received RDN [Symplicity HTN-1 Investigators. \u003Cem\u003EHypertension\u003C\/em\u003E 2011; Krum H et al. \u003Cem\u003ELancet\u003C\/em\u003E 2009]. Patients undergoing RDN had reductions in office BP with a mean change from baseline of \u221227 mm Hg in SBP and \u221217 mm Hg in diastolic BP (DBP) at 12 months (p\u0026lt;0.001) and \u221232 and \u221214 mm Hg in SBP and DBP, respectively, at 36 months (in those patients for which follow up was available 88 patients, 58%).\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EIn the Symplicity HTN-2 Study, 106 patients with uncontrolled hypertension of \u2265160 mm Hg SBP despite \u22653 antihypertensive agents were randomized to receive RDN or control treatment [Esler MD et al. \u003Cem\u003ELancet\u003C\/em\u003E 2010]. Patients that received RDN demonstrated a 32 and 12 mm Hg reduction in SBP and DBP, respectively, compared with baseline at 6 months (p\u0026lt;0.0001), compared with a +1 mm Hg in SBP and no change in DBP in patients who received the control treatment (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). The randomized Symplicity HTN-3 trial is currently ongoing with results expected in 2016.\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\/13\/15\/30\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Effect of RDN on Office BP in Symplicity HTN-2\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1001037324\u0022 data-figure-caption=\u0022Effect of RDN on Office BP in Symplicity HTN-2\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\/13\/15\/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\/13\/15\/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\/13\/15\/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\/13593\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-9\u0022 class=\u0022first-child\u0022\u003EEffect of RDN on Office BP in Symplicity HTN-2\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003ERDN=renal denervation.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced from Symplicity HTN-2 Investigators. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. \u003Cem\u003ELancet\u003C\/em\u003E 2010;376(9756):1903\u20131909. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-10\u0022\u003ESimilar results were demonstrated in the EnLigHTN trial, which used a different catheter for the RDN procedure. In the EnLigHTN study, RDN was associated with a 26 and 10 mm Hg decrease in office-based SBP and DBP, respectively, compared with baseline [Worthley SG et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013]. Prof. Krum pointed out that multiple trials support the benefits of RDN in resistant hypertension though acknowledged that there are several case reports demonstrating no effect of RDN or even a paradoxical increase in BP [Baumbach A et al. \u003Cem\u003EInt J Cardiol\u003C\/em\u003E 2013; Persu A et al. \u003Cem\u003EJ Hypertens\u003C\/em\u003E 2013 (abstr LB01.06); Vonend O et al. \u003Cem\u003ELancet\u003C\/em\u003E 2012]. Still further, Prof. Krum noted that there needs to be more robust safety analyses and suggested that the findings of the Symplicity HTN-3 trial would be very important. There were 4 complications out of 153 patients in Symplicity HTN-1, which included renal artery dissection and access site complications [Symplicity HTN-1 Investigators. \u003Cem\u003EHypertension\u003C\/em\u003E 2011]. In addition, reports of renal artery stenosis, hypotensive episodes, hypertensive episodes, and death due to myocardial infarction, sudden cardiac death, or cardio-respiratory arrest have been published.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EImportantly, \u223c10% of the patients in Symplicity HTN-2 did not respond to RDN [Esler MD et al. \u003Cem\u003ELancet\u003C\/em\u003E 2010]. Prof. Mancia pointed out that nonresponse may be due to a variety of factors such as nonsympathetic factors or incomplete RDN. Therefore, it is important to determine which patients will benefit from RDN and the completeness of the denervation should be assessed.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EMichael B\u00f6hm, MD, PhD, Saarland University Hospital, Homburg\/Saar, Germany, presented other investigational indications for RDN therapy. These indications include atrial fibrillation (AF), ventricular arrhythmias, insulin resistance and diabetes, OSA, chronic kidney disease, and chronic heart failure.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EIn the Symplicity trials, it was observed that some patients that had received RDN experienced improved blood glucose control [B\u00f6hm M et al. \u003Cem\u003EEuroIntervention\u003C\/em\u003E 2013]. One hypothesis states that due to vasoconstriction, blood flow is directed away from insulin-sensitive organs such as the skeletal muscle, which can lead to insulin resistance. RDN is thought to restore the blood flow to insulin-sensitive organs, thus improving insulin sensitivity. In a pilot study of Symplicity data, patients with impaired fasting glucose that received RDN demonstrated a significant improvement in fasting glucose, fasting insulin, and the Homeostasis Model of Assessment-Insulin Resistance index from baseline compared with control patients at 1 and 3 months [Mahfoud F et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EIn a study of patients with moderate to severe chronic kidney disease, RDN resulted in stabilization of the disease as measured by eGFR [Hering D et al. \u003Cem\u003EJ Am Soc Nephrol\u003C\/em\u003E 2013]. In chronic heart failure, renal norepinephrine spillover is associated with significantly greater cumulative mortality (p=0.003), whereas total body spillover was not significantly associated (p=0.2) [Petersson M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2005]. In AF, RDN appears to decrease left ventricular hypertrophy beginning at 1 month following the intervention [Brandt MC et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2012]. RDN also appeared to improve OSA; in a porcine model, RDN led to a reduction in atrial effective refractory period-shortening and AF-inducibility [Linz D et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2012]. In a porcine model of ventricular arrhythmia, RDN resulted in reduced extra beats due to acute ventricular ischemia [Linz D et al. \u003Cem\u003EHearth Rhythm\u003C\/em\u003E 2013]; however, reperfusion-induced arrhythmias are not affected by RDN.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EGuiseppe Mancia, MD, PhD, University of Milano-Biccoca, Monza, Italy, discussed the reasons behind the popularity and success of RDN, which include a robust pathophysiological rationale and evidence in small studies of a durable decrease in office BP over 3 years. However, Prof. Mancia warned that the long-term efficacy and safety of RDN on BP control has not yet been demonstrated and important questions remain about fiber regeneration and the long-term safety of multiple renal artery interventions.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\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\/13\/15\/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?nznnb1\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?nznnb1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}