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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\u003EThe 2014 American College of Chest Physicians (CHEST) guidelines for cough, pulmonary arterial hypertension, acute exacerbations of chronic obstructive pulmonary disease, and mass critical care are discussed in this article.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EChronic Obstructive Pulmonary Disease Thromboembolic Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary Guidelines\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EChronic Obstructive Pulmonary Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary \u0026amp; Respiratory Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThromboembolic Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary Guidelines\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EDaniel Ouellette, MD, Henry Ford Hospital, Detroit, Michigan, USA, discussed the development of the 2014 American College of Chest Physicians (CHEST) guidelines, which were presented for cough, pulmonary arterial hypertension (PAH), acute exacerbations of chronic obstructive pulmonary disease (COPD [AECOPD]), and mass critical care. The 2014 CHEST guidelines follow other evidence-based guidelines concerning antithrombotic therapy, lung cancer diagnosis\/management, pulmonary hypertension therapy, and COPD. The guidelines relied on the Institute of Medicine (IOM) standards that govern the formulation of clinical practice guidelines.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EOne standard is funding transparency. While prior CHEST guidelines were industry-funded, the current version was funded by CHEST. Evidence was evaluated considering the target population, intervention, comparative data, and outcomes. Other key IOM standards included rating strengths, systematic review, external review (typically part of the publication submission process), updating, and communication of recommendations to concerned clinicians and others.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe process of guideline development from establishment of the panel to the submission of the recommendations for publication takes about 14 months. At any time, a host of guidelines addressing specific areas can be in different phases of development. Each guideline development group should be a balance of topic experts, methodology experts, clinicians, and selected and unbiased consumer representatives and should have patient\/public involvement. An ongoing part of any guideline development panel is the disclosure of any existing\/new pertinent conflict of interest and if necessary, exclusion of the conflicted panelist.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EIn instances where formulation of clinical practice guidelines necessitates a systematic review of the literature, attention should be paid to the use of existing reviews judged to be acceptable and in-house reviews. Each recommendation involves \u2265 2 panelists, \u2265 1 of whom has no pertinent conflict of interest; that person writes the recommendation\/suggestion. Rating the strength of the evidence involves a description of the benefits and harms, ratings of the level of confidence and strength of each recommendation, and a description of any differences of opinion during recommendation formulation. The result is a rating scale from 1A to 2C (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\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\/15510\/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\/15510\/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\/15510\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-6\u0022 class=\u0022first-child\u0022\u003EStrength of Evidence of the CHEST Recommendations\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-8\u0022\u003EOf the adopted recommendations, which are voted on anonymously, strongly rated recommendations should be worded in a way that allows compliance to be monitored.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECOUGH GUIDELINES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003ERichard Irwin, MD, University of Massachusetts, Worcester, Massachusetts, USA, described an interim report of the CHEST cough guideline. The latest version continues the evidence-based format that extends back to 1998. Then as now, cough is the most common reason for ambulatory medical care in Americans. By 2006, the year of the last CHEST cough guideline, \u0026gt; 12 countries had formulated and published cough guidelines.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe goals of the 2014 CHEST cough guideline were to review new developments in the intervening years, update information according to the IOM guidelines, and identify topics of clinical\/research importance. The latter includes acute cough (acute bronchitis and allergic rhinitis), subacute postinfection cough, and chronic cough due to a variety of causes; cough in special patient groups; and symptomatic treatment using cough suppressants and pharmacologic therapy. The guideline provides an overview of cough management and associated methods, cough anatomy\/neurophysiology, assessing outcomes of studies of chronic cough, and classification of cough. Over a dozen other topics are nearing publication or are in various stages of development.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMANAGEMENT OF PULMONARY ARTERIAL HYPERTENSION IN ADULTS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EDarren Taichman, MD, PhD, University of Pennsylvania, Philadelphia, Pennsylvania, USA, discussed an updated pharmacological therapy guideline for adult PAH [Taichman DB et al. \u003Cem\u003EChest\u003C\/em\u003E. 2014]. Treatment must be preceded by an accurate diagnosis involving echocardiogram, blood work, assessed lung function, imaging, and cardiac catheterization; Dr Taichman stressed that since treatment for PAH is not the same as for other forms of pulmonary hypertension, treatment before accurate diagnosis is irresponsible.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EAs guideline standards have changed, the 2014 guideline differs from the previous, 2007 version. Recommendations now need to be based on \u2265 2 randomized controlled trials, using pooled data that is consistent in both the interventions and the outcomes. As well, evidence is evaluated and downgraded if it is judged to be indirect, inconsistent, or imprecise.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EThe result can be a less-than-optimal evidence base, but clinicians still require guidance. Thus, the 2014 document is a hybrid, with evidence-based recommendations as warranted, as well as consensus-based (CB) statements. The guideline approach is based on World Health Organization (WHO) functional classes (FC) (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\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\/15511\/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\/15511\/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\/15511\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 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EWHO Functional Classification\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EThe available evidence does not provide a clear, simple treatment algorithm. Rather, the severity of PAH should be evaluated on a case-by-case, systematic, and consistent basis using a combination of the WHO FC, patient capacity for exercise, possible benefits and adverse effects of the available drugs, clinician judgment, and data from assessments including echocardiograms. Assessments should involve a center with expertise in the diagnosis of PAH.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EPatients without right heart failure who demonstrate acute vasoreactivity can be treated using an oral calcium channel blocker (CCB); however, CCB treatment should not be given empirically, in the absence of vasodilator test results. Treatment-na\u00efve asymptomatic patients and those at increased risk of developing PAH should be monitored for symptoms that trigger treatment.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003ETreatment-na\u00efve patients with WHO FC II symptoms who are contraindicated for or have failed CCB therapy should be treated with monotherapy. Suggestions were graded on the 1A to 2C scale above or as CB, and include ambrisentan (Grade 1C), sildenafil (Grade 1C), riociguat (Grade CB), or tadalafil (Grade CB) to improve 6-minute walking distance; riociguat (Grade CB) or macitentan (Grade CB) to delay time to clinical worsening; and bosentan or riociguat to improve cardiopulmonary hemodynamics. Parenteral or inhaled prostanoids should not be chosen in this population.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003ETreatment-na\u00efve patients with WHO FC III symptoms who are contraindicated for or have failed CCB therapy should also be treated with monotherapy, with bosentan suggested to decrease hospitalization due to PAH.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003ETreatment-na\u00efve PAH patients with WHO FC III symptoms and evidence of rapid disease progression or markers of poor clinical prognosis, or FC IV patients, can be treated initially with a parenteral prostanoid: continuous intravenous epoprostenol or treprostinil, or continuous subcutaneous treprostinil.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003ECombination therapy can be considered in some cases. PAH patients who remain symptomatic when receiving stable doses of endothelin-receptor antagonist or phosphodiesterase-5 inhibitor can benefit from the addition of inhaled iloprost or treprostinil. Those who are symptomatic with stable doses of intravenous epoprostenol may benefit from additional sildenafil.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EPrudent strategies for PAH patients include maintaining current vaccinations, avoiding pregnancy, avoiding unnecessary surgery, and ensuring a supplemental supply of oxygen when flying. PAH remains incurable and disease progression is inevitable. Evidence is still sparse, which continues to make treatment challenging.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPREVENTION OF ACUTE EXACERBATIONS OF COPD\u003C\/h2\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EGerard J. Criner, MD, Temple University School of Medicine, Philadelphia, Pennsylvania, USA, described prevention of AECOPD, defined as an event requiring intervention using antibiotics and\/or systematic steroids. The focus on AECOPD is important, since the acute events can diminish both lung function and quality of life, and herald increased risks of mortality and morbidity.\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EThe goal of the 2014 evidence-based AECOPD guideline formulated by CHEST and the Canadian Thoracic Society (CTS) was to describe the current state of knowledge regarding AECOPD, with selection of the highest quality evidence [Criner GJ et al. \u003Cem\u003EChest\u003C\/em\u003E. 2014]. The process was robust and detailed (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\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\/14\/45\/14\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Evidence Review Process in the 2014 CHEST-CTS Guideline\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-402145908\u0022 data-figure-caption=\u0022Evidence Review Process in the 2014 CHEST-CTS Guideline\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\/14\/45\/14\/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\/14\/45\/14\/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\/14\/45\/14\/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\/15509\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-25\u0022 class=\u0022first-child\u0022\u003EEvidence Review Process in the 2014 CHEST-CTS Guideline\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from GJ Criner, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-26\u0022\u003EEvidence was graded with a detailed consideration of the relative value of the treatment benefits and risks\/burdens, specific to whether nonpharmacological therapy, pharmacological inhaled therapy, or pharmacological oral therapy prevented or decreased AECOPD. The quality of evidence was judged as high, moderate, or low using defined criteria.\u003C\/p\u003E\n         \u003Cp id=\u0022p-27\u0022\u003ERecommendations concerning nonpharmacological therapies included annual influenza vaccination, pulmonary rehabilitation within 4 weeks of the event, and patient education, management, and follow-up. Suggestions include pneumococcal vaccination and stopping smoking.\u003C\/p\u003E\n         \u003Cp id=\u0022p-28\u0022\u003ERecommendations for pharmacological inhaled therapy include long-acting \u03b2-agonists, long-acting muscarinic antagonists, and corticosteroids. Suggested therapy includes short-acting muscarinic antagonists in combination with short- or long-acting \u03b2-agonists.\u003C\/p\u003E\n         \u003Cp id=\u0022p-29\u0022\u003ESuggested pharmacological oral therapies include long-term macrolides, phosphodiesterase-4 inhibitors, theophylline, N-acetylcysteine, and carbocysteine. The use of systemic corticosteroids and statins is not recommended.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMASS CRITICAL-CARE EVENTS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-30\u0022\u003EMike Christian, MD, MSc, Mount Sinai Hospital, Toronto, Ontario, Canada, provided a high-level overview of the recently published CHEST Consensus Statement concerning mass critical care, specifically care of the critically ill and injured during disasters and pandemics [Christian MD et al. \u003Cem\u003EChest\u003C\/em\u003E. 2014]. The current example of mass critical care is the Ebola outbreak in western Africa, which at the time of the conference exceeded 10 000 cases.\u003C\/p\u003E\n         \u003Cp id=\u0022p-31\u0022\u003EThe CHEST supplement, comprising 18 sections, included a consensus statement on surge capacity logistics, which is the capability of providing mass critical care in times of disaster or a pandemic. Stockpiling of equipment, supplies, and pharmaceuticals is crucial for the swift implementation of mass critical care, as is a plan to utilize transportation routes. Hospitals that could be involved in mass critical care also need to be prepared for triage and potential evacuations. It is important to identify and remedy weaknesses in the supply chain. Equally important is IT support to ensure continued flow of health information during times of disruption and relocation. Finally, Dr Christian noted that although the section on infrastructure and capacity-building in resource-poor settings was initially considered as almost an afterthought, the information it contains that could aid in dealing with the next big outbreak has brought greater interest.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 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\/14\/45\/14.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?nzoik2\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?nzoik2\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?nzoik2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}