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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\\\/4\\\/8\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;13\\\/4\\\/8\u0022}],\u0022ac\u0022:{\u0022spmdc;13\\\/4\\\/8\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;13\\\/4\\\/8\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\u003ENocturnal noninvasive ventilation (nNIV) is used for treatment of multiple pathologies such as neuromuscular disorders, sleep apneas, restrictive thoracic disorders, chronic obstructive pulmonary disease, and obesity-hypoventilation syndrome with the goals of increasing gas exchange, decreasing respiratory muscle fatigue, decreasing stress, and increasing comfort and sleep. This article discusses the basics of nNIV and highlighted areas of emerging research and new challenges in the field, the use of nNIV in patients with heart failure that have sleep-disordered breathing, the efficacy of different modes of bilevel nNIV in patients with obesity hypoventilation syndrome, and the use of nNIV in patients with neuromuscular disorders.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ELower Respiratory Infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EObesity\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESleep Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EChronic Obstructive Pulmonary Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ELower Respiratory Infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EObesity\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESleep Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EChronic Obstructive Pulmonary Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary \u0026amp; Critical Care\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003ENocturnal noninvasive ventilation (nNIV) is used for treatment of multiple pathologies such as neuromuscular disorders, sleep apneas, restrictive thoracic disorders, chronic obstructive pulmonary disease (COPD), and obesity-hypoventilation syndrome with the goals of increasing gas exchange, decreasing respiratory muscle fatigue, decreasing stress, and increasing comfort and sleep. Sairam Parthasarthy, MD, University of Arizona, Tucson, Arizona, USA, presented on the basics of nNIV and highlighted areas of emerging research and new challenges in the field.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EPositive airway pressure (PAP) results in greater thoracic and lung volume, which leads to increased cardiac output, reduced venous return, and reducing afterload [Antonescu-Turcu A, Parthasarthy S. \u003Cem\u003ERespir Care\u003C\/em\u003E 2010]. Despite such favorable physiological effects, continuous PAP (CPAP) therapy resulted in a similar rate of transplantation-free survival, as compared with a control group [Bradley TD et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2005]. Dr. Parthasarthy said that such a finding may be due to residual central sleep apnea despite CPAP therapy and that a different method of respiratory support, called adaptive servo-ventilation (ASV) can significantly reduce central sleep apnea when compared with control populations in patients with heart failure [Teschler H et al. \u003Cem\u003EAm J Resp Crit Care Med\u003C\/em\u003E 2001; Morgenthaler TI et al. \u003Cem\u003ESleep\u003C\/em\u003E 2007; Arzt M et al. \u003Cem\u003EChest\u003C\/em\u003E 2008; Javaheri S et al. \u003Cem\u003ESleep\u003C\/em\u003E 2011]. Such amelioration of central sleep apnea was observed across various manufacturers of these devices and across a variety settings.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EDr. Parthasarthy also addressed the question of how to determine the target tidal volume in patients with nocturnal hypoventilation and challenges that may prevent achieving the target. For example, an air leak tracing during polysomnography can indicate the degree of air-leak present during NIV titration, and that such an air-leak can reduce patient adherence due to diminished performance of the system [Valentin A et al. \u003Cem\u003ESleep\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EStefano Nava, MD, Bologna University Hospital Authority St. Orsola-Malpighi Polyclinic, Bologna, Italy, discussed the controversial issue of nNIV use in patients with COPD and overlap syndrome (COPD and sleep apnea). Prof. Nava pointed out that, at the present time, the long-term use of nNIV is not recommended in COPD patients for the treatment of chronic respiratory failure due to several evidence-based factors. A recent study demonstrated that chronic nNIV did not improve mortality in patients with COPD [Shi JX et al. \u003Cem\u003EChin Med J (Engl)\u003C\/em\u003E 2013] and another study demonstrated a significant trend in decreased mortality with nNIV treatment [McEvoy RD et al. \u003Cem\u003EThorax\u003C\/em\u003E 2009]. In addition, Prof. Nava highlighted a meta-analysis that analyzed other parameters such as sleep efficiency, CO\u003Csub\u003E2\u003C\/sub\u003E partial pressure, forced expiratory volume and forced vital capacity (FVC) reported no significant difference in mortality with nNIV treatment, as compared with long-term oxygen therapy [Wijkstra PJ et al. \u003Cem\u003EChest\u003C\/em\u003E 2003].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EProf. Nava suggested that one reason that few COPD patients respond to nNIV may be setting related. The three largest trials reported in the literature that demonstrated no benefit with nNIV treatment used an inspiratory PAP (IPAP) and expiratory PAP (EPAP) of 12 cm H\u003Csub\u003E2\u003C\/sub\u003EO and 4 cm H\u003Csub\u003E2\u003C\/sub\u003EO [Casanova C et al. \u003Cem\u003EChest\u003C\/em\u003E 2000], and 14 cm H\u003Csub\u003E2\u003C\/sub\u003EO and 2 cm H\u003Csub\u003E2\u003C\/sub\u003EO [Clini E et al. \u003Cem\u003EEur Respir J\u003C\/em\u003E 2002]; whereas a study that demonstrated nNIV benefit used an IPAP and EPAP of 13 cm H\u003Csub\u003E2\u003C\/sub\u003EO and 5 cm H\u003Csub\u003E2\u003C\/sub\u003EO [Mc Evoy RD et al. \u003Cem\u003EThorax\u003C\/em\u003E 2009]. Prof. Nava highlighted a study that used more aggressive pressures with an IPAP of 31 mm Hg that resulted in a significantly lower partial pressure of CO\u003Csub\u003E2\u003C\/sub\u003E during spontaneous breathing after the discontinuation of nNIV (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Windisch W et al. \u003Cem\u003ERespir Physiol Neurobiol\u003C\/em\u003E 2006]. This approach however may harm the cardiovascular system, since when compared with lower levels of IPAP, the \u201cGerman approach\u201d resulted in a significant reduction in cardiac output [Luk\u00e1csovits J et al. \u003Cem\u003EEur Respir J\u003C\/em\u003E 2012].\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\/4\/8\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Aggressive IPAP in nNIV Decreases CO2 Partial Pressure in Patients With COPD\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1314487677\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Aggressive IPAP in nNIV Decreases CO\u0026amp;lt;sub\u0026amp;gt;2\u0026amp;lt;\/sub\u0026amp;gt; Partial Pressure in Patients With COPD\u0026amp;lt;\/div\u0026amp;gt;\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\/4\/8\/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\/4\/8\/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\/4\/8\/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\/13135\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-7\u0022 class=\u0022first-child\u0022\u003EAggressive IPAP in nNIV Decreases CO\u003Csub\u003E2\u003C\/sub\u003E Partial Pressure in Patients With COPD\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EnNIV=nocturnal noninvasive ventilation; IPAP=inspiratory positive airway pressure.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Windisch W et al. Nocturnal non-invasive positive pressure ventilation: Physiological effects on spontaneous breathing. \u003Cem\u003ERespir Physiol Neurobiol\u003C\/em\u003E 2006;150(2\u20133):251\u2013260. 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-8\u0022\u003EFinally, Prof. Nava pointed out that patients with overlap syndrome appear to respond well to nNIV. Several studies demonstrated a significant increase in survival rates in patients with overlap syndrome that were treated with CPAP, as compared with overlap syndrome patients not treated with CPAP and COPD patients [Kouns A, Philips B. \u003Cem\u003ECurr Treat Options Neurol\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003ES. Javaheri, MD, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA, discussed the use of nNIV in patients with heart failure that have sleep-disordered breathing. The benefits of ASV devices include their ability to automatically vary the inspiratory support, automatic CPAP to prevent obstructive events from occurring, and automatic back-up rate to prevent apnea.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EASV devices can automatically increase inspiratory support during hypopneas and decrease support during hyperpnea. Dr. Javaheri pointed out that this feature is important in patients with heart failure as the mechanisms that underlie periodic breathing and central sleep apnea in these patients is oscillations in ventilatory drive. ASV devices decrease these oscillations. In addition, ASV devices also initiate a mandatory breath on a timed basis, aborting the course of an impending apnea. Finally, the expiratory pressure prevents upper airway closure and eliminates obstructive events. In the new generation of auto ASV devices, the expiratory pressure varies automatically in a similar fashion to auto CPAP devices. These three features of ASV devices, autoinspiratory pressure support, auto CPAP and auto back-up rate make ASV devices most appropriate for mixed\/hybrid sleep-disordered breathing consisting both of central sleep apnea, obstructive sleep apnea and hypopneas, provided that these events were not all eliminated by the use of CPAP.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EIn a study of patients with complex sleep apnea and some with Hunter-Cheyne-Stokes breathing with central sleep apnea, Dr. Javaheri pointed out that patients experienced the greatest benefit with auto ASV and auto ASV advanced, as compared with CPAP [Javaheri S et al. \u003Cem\u003ESleep\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EMeanwhile multiple studies have been performed in patients with heart failure with various ASV devices. In their meta-analysis, Sharma and associates [\u003Cem\u003EChest\u003C\/em\u003E 2012] included studies of \u22651 week duration comparing ASV to a control condition (which was subtherapeutic ASV, CPAP, bilevel positive airway pressure, oxygen therapy, or no treatment) in adult heart failure patients with sleep apnea. Comparing ASV to control conditions, the weighted mean difference in apnea hyponea index (AHI; \u221215 events\/hour; 95% CI, \u221221.03 to \u22128.25) significantly favored ASV. Importantly, when the crossover studies were compared, AHI decreased from baseline of about 50 events per hour to 6 per hour with ASV compared with 21 per hour in control conditions.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EThese data provide a compelling rationale for large-scale randomized controlled trials to assess the clinical impact of ASV on mortality in heart failure patients. Currently two trials are ongoing.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EAmanda Piper, PhD, Royal Prince Alfred Hospital, Camperdown, Australia, discussed the efficacy of different modes of bilevel nNIV in patients with obesity hypoventilation syndrome (OHS). In a study of 36 OHS patients with moderate to severe upper airway obstruction randomized to CPAP or bilevel support in spontaneous mode for 3 months, similar clinical outcomes were achieved delete period [Piper AJ et al. \u003Cem\u003EThorax\u003C\/em\u003E 2008].\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EA more recent study compared bilevel support in spontaneous versus spontaneous timed (S\/T) mode [Contal O et al. \u003Cem\u003EChest\u003C\/em\u003E 2013]. In this study, 10 patients with OHS were randomized to spontaneous mode, S\/T mode with a low back-up respiratory rate (BURR), or S\/T mode with a high BURR over 3 nights. A greater number of respiratory events occurred in patients treated with spontaneous mode, compared with either of the S\/T mode, raising the issue of whether the spontaneous mode should be used in this population. However, Prof. Piper pointed out that the study included only a small number of patients na\u00efve to nNIV therapy with settings not titrated to the mode used. Nevertheless, data from other studies suggests more passive ventilation in this population may yield greater clinical benefits. Prof. Piper also discussed the use of volume targeted pressure support in OHS, with a recent large study finding no additional clinical benefit of this mode over standard bilevel therapy in routine practice [Murphy PB et al. \u003Cem\u003EThorax\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EProf. Piper also highlighted the importance of titrating inspiratory support to achieve an adequate tidal volume. For patients with OHS, 8 to 10 mL\/kg of ideal body weight appears to be a good nocturnal tidal volume target [Murphy PB et al. \u003Cem\u003EThorax\u003C\/em\u003E 2012; Budwesier S et al. \u003Cem\u003EJ Intern Med\u003C\/em\u003E 2007].\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EAmy Atkeson, MD, Columbia University College of Physicians \u0026amp; Surgeons, New York, New York, USA, discussed the use of nNIV in patients with neuromuscular disorders. The rationale for treating patients with neuromuscular disorders with nNIV is that it may help rest overtaxed respiratory muscles, improvement of muscle strength and contractility, improvement in respiratory mechanics, and recruitment of atelectatic and partially atelectatic alveoli.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EEarly initiation of nNIV therapy in patients with neuromuscular disorders, such as ALS, may confer a survival advantage. Dr. Atkeson highlighted several studies that demonstrated a reduced decline in FVC [Kleopa KA et al. \u003Cem\u003EJ Neurol Sci\u003C\/em\u003E 1999] and cost-effectiveness [Gruis KL et al. \u003Cem\u003EHealth Serv Res\u003C\/em\u003E 2005]. However, Dr. Atkeson pointed out that although the evidence is generally positive, it is weak and more research is required to determine the optimal use of nNIV in patients with neuromuscular disorders.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EAlthough additional research is required in many cases to determine the benefit and\/or optimal use of nNIV in conditions that cause sleep disorder, nNIV appears to offer the promise of improved outcomes in patients with sleep disorders.\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\/4\/8.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?nznwsq\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?nznwsq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}