{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\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_at_symbol.js?nzowg1\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_article_reference_popup.js?nzowg1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\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\\\/24\\\/36\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/24\\\/36\u0022}],\u0022ac\u0022:{\u0022spmdc;14\\\/24\\\/36\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;14\\\/24\\\/36\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\/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\u003EStroke is a serious condition that can result in substantial morbidity and mortality. It is the number one cause of disability and the second-most common cause of death in the world [World Health Organization.\u003Cem\u003EThe Atlas of Heart Disease and Stroke\u003C\/em\u003E 2004]. A major underlying cause of stroke in many patients is atrial fibrillation (AF). This article discusses the role of AF in cryptogenic stroke.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EStroke is a serious condition that can result in substantial morbidity and mortality. It is the number one cause of disability and the second-most common cause of death in the world [World Health Organization. \u003Cem\u003EThe Atlas of Heart Disease and Stroke\u003C\/em\u003E 2004]. A major underlying cause of stroke in many patients is atrial fibrillation (AF). Hakop Hrachian-Haftevani, MD, Baptist Health International, Miami, Florida, USA, discussed the role of AF in cryptogenic stroke.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThere are multiple potential causes of cardioembolic stroke, including AF, low ejection fraction, and cardiac thrombus, as well as rarer events, such as cardiac tumor, vegetation on cardiac valves, mobile aortic arch atheroma, endocarditis, and patent foramen ovale with an embolism from a venous source. However, if the workup is negative for the preceding etiologies and there is no history of AF, then the stroke is deemed cryptogenic, and the patient is considered to be at a high risk of stroke recurrence, disability, and death.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EAF increases the risk of stroke 5-fold, with similar risk among patients with paroxysmal or permanent AF [Hart RG et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2000]. However, up to 90% of paroxysmal AF is asymptomatic, and even a few minutes a month of AF episodes is sufficient to cause stroke [Israel CW et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2004]. In addition, 25% of AF-related strokes occur in patients with no history of AF. Therefore, identifying AF is important and can change the treatment of cryptogenic stroke\u2014namely, by treating patients with oral anticoagulants (OACs) instead of antiplatelet agents [Camm AJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EIn determining whether AF is present, it is important to not rely on patients\u0027 symptoms, because there is a poor association between their perceptions of symptoms and actual AF events [Strickberger SA et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2005]. However, short-term or intermittent monitoring may not be adequate to record AF-related events. In a study showing a subgroup analysis of the TRENDS trial [Glotzer TV et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E 2009], 60% of patients with stroke had newly detected AF identified \u2265 30 days after the stroke, which was recorded by a continuous monitoring via a pacemaker or implantable cardioverter defibrillator [Ziegler PD et al. \u003Cem\u003EStroke\u003C\/em\u003E 2010]. Importantly, there is a 4-fold higher risk of stroke recurrence in patients with newly detected AF compared with patients with known AF or no AF [Kamel H et al. \u003Cem\u003EJ Stroke Cerebrovasc Dis\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EIn a retrospective analysis of 574 patients with pacemakers who were known to have AF, monitoring that was performed on randomly selected days to simulate intermittent monitoring proved to be inaccurate in identifying AF [Ziegler PD et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2006]. In contrast, the SURPRISE study [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01498146\u0026amp;atom=%2Fspmdc%2F14%2F24%2F36.atom\u0022\u003ENCT01498146\u003C\/a\u003E] monitored 84 patients with cryptogenic stroke or transient ischemic attack (TIA) with no known AF, with an implanted Reveal XT for up to 3 years [Christensen LM et al. ISC 2013 (abstr 209)]. The results indicated AF in 15.5% of the patients, with a median time of 106 days from stroke onset to the first recorded AF-related event.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EIn a study that used an implantable loop recorder, AF was identified in 25.5% of patients with cryptogenic stroke [Cotter PE et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2013]. The median time to AF detection was 48 days following the implant, with the first detected episode lasting a median of 6 minutes (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\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\/24\/36\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Detection of Atrial Fibrillation With an Implantable Loop Recordera             \u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1503782238\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Detection of Atrial Fibrillation With an Implantable Loop Recorder\u0026amp;lt;sup\u0026amp;gt;a\u0026amp;lt;\/sup\u0026amp;gt;             \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\/14\/24\/36\/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\/24\/36\/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\/24\/36\/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\/14818\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-8\u0022 class=\u0022first-child\u0022\u003EDetection of Atrial Fibrillation With an Implantable Loop Recorder\u003Csup\u003Ea\u003C\/sup\u003E\n            \u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003E\n            \u003Csup\u003Ea\u003C\/sup\u003E Dashed lines represent median and interquartile ranges. Case 3 had a delay of 0 days (AF on postimplantation device check).\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAF=atrial fibrillation.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced from Cotter PE et al. Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke. \u003Cem\u003ENeurology\u003C\/em\u003E. 2013;80(17):1546\u20131550. With permission from Lippincott Williams and Wilkins\/Wolters Kluwer Health.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003EAnother study demonstrated that an implantable cardiac monitor (ICM) identified AF in 17% of patients with cryptogenic stroke compared with 1.7% identified by a 7-day Holter monitor (p = .0077) [Ritter MA et al. \u003Cem\u003EStroke\u003C\/em\u003E 2013]. The mean time to detection of AF was 64 days following ICM implantation.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EThe prospective randomized CRYSTAL-AF study [Sanna T et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2014] evaluated ICM versus the standard of care in the detection of AF in patients with cryptogenic stroke with no known AF. The primary end point of AF at 6 months was detected in 8.9% of the ICM arm and 1.4% of the control arm (HR, 6.4; 95% CI, 1.9 to 21.7; p \u0026lt; .001. At 36 months, AF was detected in 30% and 3% of the ICM and control arms, respectively (HR, 8.8; 95% CI, 3.5 to 22.2; log-rank p \u0026lt; .0001). These data suggest that long-term continuous monitoring is needed to better identify AF in patients with cryptogenic stroke.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EOne type of ICM is the Reveal XT, which can be implanted in 20 minutes under local anesthesia and explanted in 10 minutes, if required. There are no wires or leads; it is compatible with magnetic resonance imaging; and it does not restrict activity or movement. Reveal XT can be accessed by CareLink, and it is able to detect AF at heart rates \u0026gt; 100 beats per minute. Similarly, the Reveal LINQ is substantially smaller and thinner than the Reveal XT and is implanted with a special needle-like tool. Both devices have been approved by the US Food and Drug Administration for use in patients with clinical syndromes or situations that increase their risk of cardiac arrhythmias and for patients who experience symptoms that suggest cardiac arrhythmia.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EPatients with AF who experience stroke have an higher risk of morbidity and mortality compared with patients without AF who experience stroke, likely due to the severity of the event or comorbidities [Dulli DA et al. \u003Cem\u003ENeuroepidemiology\u003C\/em\u003E 2003]. Therefore, early identification of AF is important, as well as the prevention of stroke in this population. Theodore Wein, MD, Montreal General Hospital, Montreal, Canada, discussed the effects of AF-related stroke and the role of OACs.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EWarfarin is an OAC that has been in clinical use for \u0026gt; 60 years, and it reduces the risk of AF-associated stroke by about two-thirds [Hart RG et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2007; Connolly S et al. \u003Cem\u003ELancet\u003C\/em\u003E 2006]; however, warfarin also increases the risk of hemorrhage, including intracranial hemorrhage [Gomes T et al. \u003Cem\u003ECMAJ\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EDespite the data favoring warfarin use to prevent stroke in patients with AF, one study found that only 10% of high-risk patients with AF and 18% of high-risk patients with AF and a history of stroke or TIA received therapeutic warfarin [Gladstone DJ et al. \u003Cem\u003EStroke\u003C\/em\u003E 2009]. More recently, dabigatran, rivaroxaban, and apixaban were approved for the prevention of stroke in patients with nonvalvular AF, all of which were at least equivalent to warfarin in terms of stroke prevention and bleeding risk [Granger CB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011; Patel MR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011; Connolly SJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010]. Prof. Wein stated that, in his opinion, based on indirect comparison, dabigatran (150 mg, twice per day [bid]) is best for stroke prophylaxis, followed by apixaban (5 mg, bid), dabigatran (110 mg, bid), then rivaroxaban (20 mg), and that the agent with the lowest risk of bleeding is apixaban, followed by dabigatran (110 mg, bid), dabigatran (150 mg, bid), then rivaroxaban (20 mg).\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EProf. Wein concluded by pointing out that a major reason why the novel OACs provide a greater benefit than warfarin for many patients is due to the reduced risk of intracerebral hemorrhage, which in turn means that patient populations who may not have been considered for OAC may now benefit from therapy with a novel OAC.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EIn conclusion, cryptogenic stroke is frequently a result of undetected AF, and prolonged or intensive monitoring may be necessary to detect AF. It is important that AF be detected early to prevent stroke recurrence, which is best done with a long-term continuous monitor such as an ICM. If AF is detected, many patients will benefit from stroke prophylaxis with an OAC. The novel OACs should be considered over warfarin because of the reduced risk of intracerebral hemorrhage and at least equivalent risk of stroke, if not lower.\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\/24\/36.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?nzowg1\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?nzowg1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}