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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\\\/1\\\/32\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;13\\\/1\\\/32\u0022}],\u0022ac\u0022:{\u0022spmdc;13\\\/1\\\/32\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;13\\\/1\\\/32\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\u003E\u201cWake-up\u201d strokes occur when an individual wakes up with neurological deficits from a stroke. The most frequent time of onset for all subgroups of ischemic stroke is between 6 am and 12 pm [Marsh EE et al. \u003Cem\u003EArch Neurol\u003C\/em\u003E 1990]. Retrospective studies have shown that wake-up stroke is common, with a prevalence of approximately 14% to 28%. Although tissue plasminogen activator (tPA) significantly improves outcomes [Hacke W et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008], patients with wake-up stroke are often not eligible for this therapy because the medication must be given within 4.5 hours of when the patient was last known to be normal. This article discusses the epidemiology, clinical features, and available data for the effectiveness of thrombolytic treatment in patients with wake-up stroke.\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\u003EIschemia\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ENeurology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EIschemia\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003E\u201cWake-up\u201d strokes occur when an individual wakes up with neurological deficits from a stroke. The most frequent time of onset for all subgroups of ischemic stroke is between 6 am and 12 pm [Marsh EE et al. \u003Cem\u003EArch Neurol\u003C\/em\u003E 1990]. Retrospective studies have shown that wake-up stroke is common, with a prevalence of approximately 14% to 28%. Although tissue plasminogen activator (tPA) significantly improves outcomes [Hacke W et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008], patients with wake-up stroke are often not eligible for this therapy because the medication must be given within 4.5 hours of when the patient was last known to be normal. Epidemiology, clinical features, and available data for the effectiveness of thrombolytic treatment in patients with wake-up stroke were described in this session.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EJason Mackey, MD, Indiana University, Indianapolis, Indiana, USA, addressed the epidemiology of wake-up strokes. The Greater Cincinnati\/Northern Kentucky Stroke Study [GCNKSS] was a large population-based investigation that compared patients with wake-up stroke with those who were awake at the time of symptom onset [Mackey J et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2011]. Of 1854 patients presenting to an emergency department with ischemic stroke, 14.3% had a wake-up stroke (adjusted wake-up stroke event rate, 26.0\/100,000; 95% CI, 22.9 to 29.1). Extrapolated to the nation as a whole, the authors estimated that 58,000 patients presented to an emergency department with a wake-up stroke in 2005. The authors also estimated that at \u226535.9% of the wake-up stroke patients would have been eligible for thrombolysis if arrival time were not a factor.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EWhether there are differences between wake-up strokes and other strokes is unclear. In GCNKSS, wake-up stroke patients were more likely to be older. Other studies have suggested that obesity [Jim\u00e9nez-Conde J et al. \u003Cem\u003EJ Neurol\u003C\/em\u003E 2007] and smoking [Nadeau JO et al. \u003Cem\u003ECan J Neurol Sci\u003C\/em\u003E 2005] might increase the risk for wake-up stroke.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EIt is also unclear whether there is a difference in severity between wake-up and awake stroke. Some studies have shown wake-up stroke to be more severe [Huisa BN et al. \u003Cem\u003EJ Stroke Cerebrovasc Dis\u003C\/em\u003E 2010; Jim\u00e9nez-Conde J et al. \u003Cem\u003EJ Neurol\u003C\/em\u003E 2007; Kim BJ et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011; Mackey J et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2011], but at least one study has shown awake stroke to be more severe [Fink JN et al. \u003Cem\u003EStroke\u003C\/em\u003E 2002] and another found no difference [Serena J et al. \u003Cem\u003ECerebrovasc Dis\u003C\/em\u003E 2003]. Outcomes have also been mixed. There was no significant difference in 90-day mortality (approximately 16% in both groups) in GCNKSS, but 1 recent small study showed that wake-up stroke patients fared better, although this benefit was not statistically significant [Huisa BN et al. \u003Cem\u003EJ Stroke Cerebrovasc Dis\u003C\/em\u003E 2010]. Other studies have shown that wake-up stroke patients do worse, with patients being less likely to return home [Nadeau JO et al. \u003Cem\u003ECan J Neurol Sci\u003C\/em\u003E 2005] and having worse functional outcomes at 3 months [Jim\u00e9nez-Conde J et al. \u003Cem\u003EJ Neurol\u003C\/em\u003E 2007].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EVictor C. Urrutia, MD, The Johns Hopkins Hospital Stroke Center, Baltimore, Maryland, USA, discussed the circadian variation in stroke, and several studies that assessed early ischemic changes detected on computed tomography (CT) and magnetic resonance imaging (MRI) in patients with wake-up and awake stroke.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EA circadian variation for stroke occurrence appears well established with relative risk for early morning stroke being 49% compared with the number expected if strokes were distributed evenly throughout the day (95% CI, 44 to 55; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Elliott WJ. \u003Cem\u003EStroke\u003C\/em\u003E 1998]. Potential causes for the circadian rhythm include coagulability [Jafri SM et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 1992]; fibrinolysis [Jovicic A, Mandic S. \u003Cem\u003EThrombosis Res\u003C\/em\u003E 1991]; platelet aggregation [Andrews NP et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 1996]; elevated epinephrine, norepinephrine, and cortisol levels; and higher blood pressure in the morning [Panza JA et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 1991; Stergiou GS et al. \u003Cem\u003EStroke\u003C\/em\u003E 2002].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EIn a recent study that assessed ischemic changes detected on CT, Huisa and colleagues [\u003Cem\u003EJ Stroke Cerebrovasc Dis\u003C\/em\u003E 2010] found no difference in Alberta Stroke Program Early CT Score (ASPECTS) between patients whom they named \u201cAWOKE\u201d (patients likely to have wake-up strokes defined as having a last seen normal time \u0026gt;4 hours but \u0026lt;15 hours, and presenting to the Emergency department between 4 am and 10 am) and a control group of patients with awake stroke of known onset time.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EIn the study, 89.3% of patients in the wake-up stroke group versus 95.6% of control group patients had an ASPECTS of 8 to 10 (p=0.353). Although more patients in the AWOKE group had a modified Rankin Scale (mRS) score of 0 to 1 at 90 days compared with control, the difference was not significant (73% vs 45%; p=0.079) [Huisa BN et al. \u003Cem\u003EJ Stroke Cerebrovasc Dis\u003C\/em\u003E 2010]. Diffusion-weighted- (DWI) and perfusion-weighted imaging (PWI) lesion volumes as well as DWI-PWI mismatch were similar between the 2 groups [Fink JN et al. \u003Cem\u003EStroke\u003C\/em\u003E 2002]. Additionally, it has recently been shown that fluid-attenuated inversion recovery (FLAIR) data can be used to identify patients with time from symptom onset \u22644.5 hours with high specificity; however, sensitivity is low [Cheng B et al. \u003Cem\u003EJ Cereb Blood Flow Metab\u003C\/em\u003E 2013; Thomalla G et al. \u003Cem\u003ELancet Neurol\u003C\/em\u003E 2011].\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\/1\/32\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Circadian Patterns of Onset of Stroke Symptoms\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1265903110\u0022 data-figure-caption=\u0022Circadian Patterns of Onset of Stroke Symptoms\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\/1\/32\/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\/1\/32\/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\/1\/32\/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\/12852\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-10\u0022 class=\u0022first-child\u0022\u003ECircadian Patterns of Onset of Stroke Symptoms\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ETIA=transient ischemic attack.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Elliott WJ et al. Circadian Variation in the Timing of Stroke Onset: A Meta-analysis. \u003Cem\u003EStroke\u003C\/em\u003E 1998;29(5):992\u2013996. With permission from Lipincott Williams and Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-11\u0022\u003EAccording to Dr. Urrutia, the circadian data and the FLAIR, CT, and MRI studies support the hypothesis that wake-up stokes have their onset upon awakening, suggesting that these patients could benefit from tPA therapy if they arrive to the hospital within the 4.5-hour time window. Studies are needed to confirm this hypothesis.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EDulka Manawadu, MD, King\u0027s College Hospital, London, United Kingdom, believes it is feasible and safe to thrombolyze wake-up stroke patients with clinical and imaging features comparable to patients with a known time of stroke onset. In a compassionate use with consent study, wake-up stroke patients who received thrombolysis had higher rates of excellent (mRS score 0 to 1; 14% vs 6%; p=0.06) and favorable (mRS score 0 to 2; 28% vs 13%; p=0.006) outcomes but higher mortality (15% vs 0%) compared with nontreated wake-up stroke patients (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Barreto AD et al. \u003Cem\u003EStroke\u003C\/em\u003E 2009].\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\/1\/32\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Interventional Wake-Up Stroke Studies\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1265903110\u0022 data-figure-caption=\u0022Interventional Wake-Up Stroke Studies\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\/1\/32\/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\/1\/32\/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\/1\/32\/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\/12932\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\u003EInterventional Wake-Up Stroke Studies\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EControlled for baseline NIHSS.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EER=emergency room; IAT=intra-arterial therapy; LSN=last-seen-normal; NIHSS=National Institute of Health Stroke Scale; sICH=symptomatic intracerebral hemorrhage; Thromb=thrombolysis; Tx=thrombolytics; WUS=wake-up stroke.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-5\u0022\u003EReproduced from Barreto AD et al. Thrombolytic Therapy for Patients Who Wake-Up With Stroke. \u003Cem\u003EStroke\u003C\/em\u003E 2009;40(3):827\u2013832. With permission from Lipincott Williams and Wilkins.\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\u003EDr. Manawadu and colleagues conducted a similar study that compared baseline characteristics and clinical outcomes at 90 days between thrombolyzed wake-up stroke patients (n=68), nonthrombolyzed wake-up stroke patients (n=54) [Manawadu D et al. \u003Cem\u003EStroke\u003C\/em\u003E 2013], and patients who received thrombolysis at 0 to 4.5 hours of stroke onset (n=326). Median changes in National Institute of Health Stroke Scale (NIHSS) at 24 hours, 90-day mRS scores, and 90-day mortality were similar between the 3 groups. Although symptomatic intracerebral hemorrhage (ICH) was not different, ICH was significantly lower (p=0.004) in nonthrombolyzed (3.7%) versus thrombolyzed wake-up stroke patients (22%), and the non-wake-up thrombolyzed group (20%). The authors concluded that thrombolysis in wake-up stoke patients is possible and may improve outcomes in these patients.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EAndrew D. Barreto, MD, University of Texas Health Science Center at Houston, Houston, Texas, USA, reported on 10 mostly prospective, ongoing studies of wake-up stroke and thrombolytics (thrombolysis for wake-up stroke). The studies have variable patient selection and neuroimaging protocols, as well as different inclusion criteria. Dr. Barreto feels that reproducibility in the community setting will prove challenging and investigators should consider collaboration to combine efforts. Despite the pro-thrombolysis leanings of the presenters for wake-up stroke patients, he pointed out that it is too early to give the go-ahead for the use of tPA in this group of patients.\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\/1\/32.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?nzo3qp\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?nzo3qp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}