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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.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\u003EThe two forms of large-vessel (LV) vasculitis\u2014giant cell arteritis and Takayasu arteritis\u2014pose a clinical challenge because they are relatively uncommon, complex to diagnose, and have few treatment options. This article reviews the epidemiology and management of patients with LV vasculitis and highlighted unmet needs with respect to diagnosis and treatment choices.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EVasculitis\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ERheumatology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EVasculitis\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe two forms of large-vessel (LV) vasculitis\u2014giant cell arteritis (GCA) and Takayasu arteritis (TAK)\u2014pose a clinical challenge because they are relatively uncommon, complex to diagnose, and have few treatment options. This session reviewed the epidemiology and management of patients with LV vasculitis and highlighted unmet needs with respect to diagnosis and treatment choices.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EGIANT CELL ARTERITIS: BEYOND STEROID THERAPY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EBhaskar Dasgupta, MD, MRCP, Southend University Hospital, Essex, United Kingdom, discussed the management of patients with GCA. Temporal artery biopsy is the gold standard for diagnosis and should be performed on all patients with suspected cranial GCA, Prof. Dasgupta said. Histology is not only diagnostic but can also be prognostic, since the degree of intimal hyperplasia predicts subsequent ischemic complications [Makkuni D et al. \u003Cem\u003ERheumatology (Oxford)\u003C\/em\u003E 2008]. Temporal artery ultrasound is also valuable for diagnosis, with or without ultrasonography of the axillary artery. The presence of the \u201chalo sign\u201d has high diagnostic accuracy [Karassa FB et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2005]; also, unlike biopsy, ultrasound allows the entire artery to be assessed. The Temporal Artery Biopsy Versus Ultrasound in Diagnosis of GCA [TABUL; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00974883\u0026amp;atom=%2Fspmdc%2F13%2F18%2F28.atom\u0022\u003ENCT00974883\u003C\/a\u003E] study is now underway to compare biopsy and ultrasound with regard to diagnostic accuracy and cost-effectiveness. Results are expected in 2014.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EA major manifestation of cranial GCA is visual loss, and Prof. Dasgupta suggested that GCA should be managed using a \u201cfast-track pathway\u201d (FTP) analogous to that used in patients with myocardial infarction or stroke. GCA is a critically ischemic disease, he said, yet the average time from symptom onset to diagnosis is 35 days [Ezeonyegi AN et al. \u003Cem\u003EClin Rheumatol\u003C\/em\u003E 2011]. To expedite treatment, Southend University Hospital has implemented an FTP (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) in which patients with suspected GCA are immediately started on high-dose steroids and undergo temporal artery ultrasound and biopsy within 7 days. This protocol has reduced the average time to diagnosis and dramatically improve visual outcomes [Patil P et al. ACR 2013 (abstr 1928)]. Furthermore, the pathway is cost-effective and offers an incremental gain in quality-adjusted life years [Achilleos K et al. ACR 2013 (abstr 2667)].\u003C\/p\u003E\n         \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\/18\/28\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Fast-Track Pathway for Suspected GCA\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-618173286\u0022 data-figure-caption=\u0022Fast-Track Pathway for Suspected GCA\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\/18\/28\/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\/18\/28\/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\/18\/28\/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\/13775\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-5\u0022 class=\u0022first-child\u0022\u003EFast-Track Pathway for Suspected GCA\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EA\u0026amp;E=accident and emergency; FTP=fast-track pathway; GCA=giant cell arteritis;\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EIV=intravenous.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EAdapted from Patil P et al. ACR 2013 (Abst 1928).\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-6\u0022\u003ELong-term steroids are the mainstay of therapy for GCA and, while effective in most patients, they are associated with adverse events such as diabetes and fractures. Better treatments are therefore urgently needed. Disease-modifying agents such as methotrexate have limited efficacy in GCA; leflunomide is effective and well-tolerated but has not been evaluated in a randomized controlled trial (RCT); and biologics to date have been disappointing. Interleukin-6 is a key player in the pathogenesis of GCA and tocilizumab has shown impressive efficacy in refractory patients. An RCT, the Giant Cell Arteritis Clinical Research Study [GiACTA; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01791153\u0026amp;atom=%2Fspmdc%2F13%2F18%2F28.atom\u0022\u003ENCT01791153\u003C\/a\u003E], is now underway comparing tocilizumab with prednisolone.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ELARGE VESSEL VASCULITIS IN GIANT CELL ARTERITIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EKenneth Warrington, MD, Mayo Clinic College of Medicine, Rochester, Minnesota, USA, reviewed LV vasculitis in patients with GCA. GCA is an extensive vasculopathy that can involve arteries of the upper and lower extremities as well as the aorta, he noted.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe prevalence of upper extremity LV disease among patient with GCA is \u223c80% and usually involves the subclavian arteries [Blockmans D et al. \u003Cem\u003EArthritis Rheum\u003C\/em\u003E 2006]. Lower extremity LV disease is less prevalent, at \u223c37%, and usually involves the superficial femoral and popliteal arteries. In both scenarios, bilateral disease is common and symptoms are rare. Claudication of the arm and leg is reported by 4% to 6% and 1% to 20% of those with upper and lower extremity disease, respectively [Schmidt WA et al. \u003Cem\u003ERheumatology (Oxford)\u003C\/em\u003E 2008; Nuenninghoff DM et al. \u003Cem\u003EArthritis Rheum\u003C\/em\u003E 2003; Czihal M et al. \u003Cem\u003EJ Rheumatol\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003ECompared with cranial artery GCA, LV-GCA patients tend to be younger, do not experience vision loss, are less likely to have cranial symptoms, and are more likely to have vascular findings [Schmidt WA et al. \u003Cem\u003ERheumatology (Oxford)\u003C\/em\u003E 2008]. The diagnosis of LV-GCA is challenging and typically takes 3 to 7 months from symptom onset. Diagnosis is based on careful clinical examination, with assessment of pulses and blood pressure in all four extremities, together with vascular imaging\u2014either catheter-directed, magnetic resonance (MR), or computed tomography (CT) angiography [Grayson PC et al. \u003Cem\u003EJ Rheumatol\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EPatients with LV-GCA tend to have more refractory disease than those with cranial symptoms, with more relapses and a greater reliance on steroids [Muratore F et al. \u003Cem\u003EArthritis Rheum\u003C\/em\u003E 2012 (abstr 2358)]. In upper extremity disease, ischemic complications are rare and most patients improve slowly without needing revascularization [Muratore F et al. \u003Cem\u003EArthritis Rheum\u003C\/em\u003E 2012 (abstr 2358); Schmidt WA et al. \u003Cem\u003ERheumatology (Oxford)\u003C\/em\u003E 2008]. By contrast, about one quarter of patients with lower extremity involvement develop critical leg ischemia [Czihal M et al. \u003Cem\u003EJ Rheumatol\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe aorta is involved in more than half of patients with GCA [Blockman D. \u003Cem\u003ERheumatology (Oxford)\u003C\/em\u003E 2008]. This is clinically significant because aortitis at the onset of GCA may predict subsequent aortic dilatation. Patients with GCA face a significantly increased risk of aortic aneurysm and the risk increases progressively over time. It is therefore important to monitor patients for aortic disease, even if they are asymptomatic, because aortic dissection or aneurysm in GCA patients significantly increases mortality (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Kermani TA et al. \u003Cem\u003EAnn Rheum Dis\u003C\/em\u003E 2013]. There are limited data to support screening; however, Prof. Warrington stated that CT or MR angiography at baseline and repeated every 3 years seems \u201creasonable.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ETAKAYASU ARTERITIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EEamonn Molloy, MD, MS, FRCPI, St. Vincent\u0027s University Hospital, Dublin, Ireland, reviewed the management of patients with TAK. This is a primary idiopathic LV vasculitis that typically affects patients under the age of 50 and is more common in women than in men [Kerr GS et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 1994].\u003C\/p\u003E\n         \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\/18\/28\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Survival of Patients With GCA or Aortic Aneurysm\/Dissection Who Develop Large-Artery Stenosis\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-618173286\u0022 data-figure-caption=\u0022Survival of Patients With GCA or Aortic Aneurysm\/Dissection Who Develop Large-Artery Stenosis\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\/18\/28\/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\/18\/28\/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\/18\/28\/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\/13776\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\u003ESurvival of Patients With GCA or Aortic Aneurysm\/Dissection Who Develop Large-Artery Stenosis\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced from Kermani TA et al. Large-vessel involvement in giant cell arteritis: a population-based cohort study of the incidence-trends and prognosis. \u003Cem\u003EAnn Rheum Dis\u003C\/em\u003E 2013;72(12):1989\u201394.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-5\u0022\u003EWith permission from BMJ Publishing Group.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EAssessment of disease activity is challenging in patients with TAK. Patients with TAK may be asymptomatic; symptoms, when present, may be systemic or related to arterial inflammation or arterial compromise [Maksimowicz-McKinnon K et al. \u003Cem\u003EArthritis Rheum\u003C\/em\u003E 2007]. There is no single diagnostic test; instead, diagnostic assessment requires consideration of the history, physical examination, laboratory tests, and imaging. Particularly early in the course of disease, physical exam may be normal and there is no established biomarker for TAK. New clinical features that develop during the course of follow-up may also relate to vascular damage, secondary atherosclerosis, medication side effects, intercurrent infection or other comorbidities rather than active TAK. Catheter-directed angiography was the historic gold standard for visualizing vascular lesions; it has now largley been supplanted by noninvasive modalities such as MR or CT angiography and positron emission tomography (PET) scanning [Grayson PC et al. \u003Cem\u003EJ Rheumatol\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EIn patients with established TAK, vascular imaging should be performed at least annually, even in the absence of symptoms. The detection of a new vascular lesion should prompt a thorough evaluation of the aorta and first-order branches as well as other vessels based on the patient\u0027s symptoms and history. Hypertension is a frequent complication of TAK and can go undetected because of peripheral arterial stenosis and present with end-organ damage. In some cases, catheter-directed angiography may be required to measure central aortic pressure.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003ESteroids are the mainstay of treatment of TAK, with prednisolone being started at 40 to 60 mg\/day and gradually tapered. This brings about remission in \u223c60% of patients, although relapses tend to occur during taper [Keser G et al. \u003Cem\u003ERheumatology (Oxford)\u003C\/em\u003E 2013]. Patients often need other drugs to counter the adverse effects of prednisolone [Maksimowicz-McKinnon K et al. \u003Cem\u003EArthritis Rheum\u003C\/em\u003E 2007]. Furthermore, most patients require other immunosuppressants to achieve disease control. Several drugs have shown efficacy in this setting, including methotrexate, azathioprine, and mycophenolate mofetil, but none have been evaluated in an RCT. Cyclophosphamide is reserved for use in immediately life-threatening disease [Maksimowicz-McKinnon K et al. \u003Cem\u003EArthritis Rheum\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThe use of biologic therapies in TAK has been reported including anti-tumor necrosis factor drugs, tocilizumab and rituximab, with the greatest experience to date being with infliximab. However, to date, none of these has been evaluated in a RCT. The RCT Abatacept for Treating Adults with Giant Cell Arteritis and Takayasu\u0027s Arteritis [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00556439\u0026amp;atom=%2Fspmdc%2F13%2F18%2F28.atom\u0022\u003ENCT00556439\u003C\/a\u003E] evaluating the efficacy and safety of abatacept in TAK is currently recruiting; results will not likely be available before 2015.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESUMMARY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EThe information presented at the session reinforced the notion that managing LV vasculitis requires a highly skilled specialist and that much of current practice is unsupported by robust data. Furthermore, steroids are the mainstay of therapy and are hampered by poor tolerability, highlighting the urgent need to develop new treatment options.\u003C\/p\u003E\n      \u003C\/div\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\/18\/28.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?nzo6r1\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?nzo6r1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}