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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;14\\\/41\\\/24\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/41\\\/24\u0022}],\u0022ac\u0022:{\u0022spmdc;14\\\/41\\\/24\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;14\\\/41\\\/24\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\u003EA flail chest injury occurs when a segment of the thoracic cage is separated from the rest of the chest wall. Such injuries are associated with severe pulmonary restriction; they generally require intubation and mechanical ventilation; and they are associated with high rates of morbidity and mortality. This article discusses flail chest injury data from the National Trauma Databank of North America, the use of open reduction and internal fixation, indications for chest wall repair, as well as the current need for additional trial data.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedic Procedures\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETrauma\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedics\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedic Procedures\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETrauma\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EA flail chest injury occurs when a segment of the thoracic cage is separated from the rest of the chest wall. Such injuries are associated with severe pulmonary restriction; they generally require intubation and mechanical ventilation; and they are associated with high rates of morbidity and mortality.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ENiloofar Dehghan, MD, St Michael\u0027s Hospital, Toronto, Ontario, Canada, presented the results of a retrospective analysis of data from the National Trauma Databank of North America that examined outcomes in 3467 patients admitted to a trauma center with a flail chest injury from 2007 to 2009 [Dehghan N et al. \u003Cem\u003EJ Trauma Acute Care Surg.\u003C\/em\u003E 2014]. Outcomes included days on mechanical ventilation, time in the intensive care unit (ICU), length of hospital stay, and rates of pneumonia, sepsis, tracheostomy, chest tube placement, and death. Treatment approach was also an area of interest.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EMost patients (82%) were admitted to the ICU (mean stay 11.7 days), and 59% required mechanical ventilation (mean 12.1 days; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Patients remained in hospital for a mean of 16.6 days.\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\/14\/41\/24\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Outcomes: Total Population\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-99564743\u0022 data-figure-caption=\u0022Outcomes: Total Population\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\/41\/24\/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\/41\/24\/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\/41\/24\/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\/15126\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\u003EOutcomes: Total Population\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EARDS, adult respiratory distress syndrome; ICU, intensive care unit.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAdapted from Dehghan N et al. Flail chest injuries: A review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76:462\u2013468. With permission from Lippincott Williams \u0026amp; Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EPatients with concurrent severe head injury (15%) had significantly worse outcomes (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .05) in every category when compared with those with no head injury. Patients with pulmonary contusions (54%) had a higher need for mechanical ventilation and ICU admission, as well as higher rates of pneumonia and chest tubes.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EOnly 8% of patients received an epidural catheter for pain control, and very few (0.7%) were treated with open reduction and internal fixation (ORIF). Given the mortality and morbidity in patients with flail chest injuries, alternate methods of treatment need to be investigated, including increased use of epidural catheters for pain and possibly expanded use of surgical fixation.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EInterest in surgical fixation for flail chest injuries has been increasing in recent years as a result of new rib-specific implants and recognition of poor outcomes with the current approaches. After conducting a thorough search of the literature, Gerard Slobogean, MD, MPH, University of British Columbia, Vancouver, British Columbia, Canada, believes that there remains insufficient trial evidence to recommend this approach. He noted that only 3 small randomized controlled trials (RCTs) have compared rib fixation with nonsurgical management of flail chest injuries [Marasco SF et al. \u003Cem\u003EJ Am Coll Surg.\u003C\/em\u003E 2013; Granetzny A et al. \u003Cem\u003EInteract Cardiovasc Thorac Surg.\u003C\/em\u003E 2005; Tanaka H et al. \u003Cem\u003EJ Trauma.\u003C\/em\u003E 2002] and that the remainder of the literature consists of heterogeneous, poorly controlled studies.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003ETwo recent meta-analyses indicate significant benefits with surgical fixation when compared with nonoperative management, in terms of reductions in the duration of mechanical ventilation and ICU stay and decreased mortality, pneumonia, chest deformity, septicemia, and tracheostomy management [Leinicke JA et al. \u003Cem\u003EAnn Surg.\u003C\/em\u003E 2013; Slobogean GP et al. \u003Cem\u003EJ Am Coll Surg.\u003C\/em\u003E 2013]. Although these pooled analyses of the existing data generally indicate improved outcomes with surgical fixation, Prof Slobogean cautioned against placing too much reliance on these results, because the data are based mostly on small retrospective studies.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EAlthough the absolute indications for rib fixation remain unclear, it appears that early ORIF shortens ventilator time, improves pulmonary function testing, restores chest wall continuity, and allows patients to return to work faster. Patients treated with ORIF also have less pneumonia, less need for reintubation, decreased home oxygen requirements, and decreased overall costs. In a study reported by Peter L. Althausen, MD, MBA, Reno Orthopaedic Clinic, Reno, Nevada, USA, patients treated with ORIF had better outcomes across all variables. Early operative intervention significantly shortened ICU and hospital stays, as well as days on a ventilator (\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\/15128\/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\/15128\/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\/15128\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-11\u0022 class=\u0022first-child\u0022\u003EEffects of Early Operative Intervention for Flail Chest\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-13\u0022\u003EOther indications suitable for ORIF might include extensive anterolateral flail chest and gross displacement of fractured ribs or a thoracotomy because of an associated intrathoracic injury; alternately, ORIF might be needed for reduction of pain and disability, for revision of malpositioned hardware, and for painful rib nonunion.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EJohn Mayberry, MD, Saint Alphonsus Regional Medical Center, Boise, Idaho, USA, reviewed indications for chest wall repair along with examples of each. In his opinion, indications for repair include chest wall defect herniation, flail chest (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) or equivalent, reduction of acute and chronic pain, and nonunion after 4 months. Indications of a true flail chest injury might include persistence of the flail, failure to wean the patient from the ventilator, and continuation of problems with no severe extrathoracic injury.\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\/14\/41\/24\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Diagram of Flail Chest\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-99564743\u0022 data-figure-caption=\u0022Diagram of Flail Chest\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\/14\/41\/24\/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\/14\/41\/24\/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\/14\/41\/24\/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\/15127\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-15\u0022 class=\u0022first-child\u0022\u003EDiagram of Flail Chest\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced with permission from J Mayberry, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-16\u0022\u003E\n         \u003Cem\u003EChest wall implosion\u003C\/em\u003E is a term used to describe injuries such as fixed deformities of the thoracic cage, multiple segmental rib fractures, and clavicular injury, which can be effectively managed with a posterior paramidline approach without thoracotomy [Solberg BD et al.\n\u003Cem\u003EJ Trauma.\u003C\/em\u003E 2009]. Dr Mayberry believes that these injuries are equivalent to a flail and should be fixed. Although he generally supports surgical fixation, Dr Mayberry believes that careful patient selection and timing of surgery are important for a successful outcome.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EEmil H. Schemitsch, MD, St Michael\u0027s Hospital, Toronto, Ontario, Canada, discussed the need for more evidence from rib fracture fixation RCTs, preferably prospective randomized multicenter studies with clear inclusion and exclusion criteria and standard treatment arms and outcome measures. While recognizing that such studies are difficult in orthopaedics, he concluded that they are the best evidence for clinical decision making and should thus be the goal.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EThe impact of unstable chest wall injuries on the health care system is profound (eg, cost of hospital admission and, often, ICU stay; high rates of morbidity and mortality). Prof Schemitsch discussed an ongoing multicenter prospective RCT [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01367951\u0026amp;atom=%2Fspmdc%2F14%2F41%2F24.atom\u0022\u003ENCT01367951\u003C\/a\u003E] comparing surgical treatment of carefully selected patients with acute unstable chest wall injuries with the current gold standard of nonoperative management. The primary outcome is days free from mechanical ventilation in the first 28 days following injury. The hypothesis of the study is that early surgical fixation of unstable chest wall injuries will significantly improve patient outcomes over conventional, nonsurgical treatment. Patients with flail chest or severe deformity of the chest wall are being enrolled.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EIn light of the potential for substantial improvement in outcomes with surgical treatment, a well-conceived and well-performed trial has the potential to effect global impact across the multiple health disciplines that treat unstable chest injuries and to provide evidence for substantial health care savings. The potential for a paradigm shift in management also exists.\u003C\/p\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\/41\/24.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?nzom11\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?nzom11\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?nzom11\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}