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Phase 2
Harriet Ribbons and Caroline Hoernig
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Aims:
• Understand the different types of arthritis:
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Osteoarthritis
Rheumatoid Arthritis
Seronegative spondyloarthropathies
Crystal arthropathies
• Understand Systemic Lupus Erythematousus
(SLE)
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Arthritis Introduction:
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Common joint condition
Causes pain and inflammation in a joint
10,000 people per year seek help for arthritis
Symptoms include:
o Joint pain
o Restricted movement
o Joint tenderness
around the joints
o Joint stiffness
o Warm, red skin over
o Inflammation around
the joints
the joints
o Muscle weakness
o Muscle wasting
The Peer Teaching Society is not liable for false or misleading information…
The Peer Teaching Society is not liable for false or misleading information…
JOINT PAIN
INFLAMMATORY
Autoimmune
Crystal arthritis
NON-INFLAMMATORY
Infection
Degenerative
Non-Degenerative
Sports medicine
Seronegative Spondylarthropathy
Vasculitis
Rheumatoid arthritis
Connective tissue disease
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Inflammatory
Degeneratve
• Pain eases with use, worst
at rest
• Morning stiffness
>60mins
• Swelling usually due to
joint effusions
• Joints hot and red
• Affects younger people
• Hands and feet
• Responds to NSAIDS
• Pain increases with use
• Morning stiffness
<30mins
• Bony swelling
• Not clinically inflamed
• Affects older patients,
prior occupation/sport
• Knees, hips, CMCP
• Less convincing response
to NSAIDS
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INFLAMMATORY
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Rheumatoid Arthritis (RA)
• Affects synovial joints
• Joints affected:
– (DIP sparing)
– PIP
– MCP
– Wrists
– Feet
• Bony erosions on XRay
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Hypertrophy synovium -> New capillary formation -> Inflammtion ->
Synovial villi form and grow into bone -> PANNUS -> Cytokines released
RA risk factors:
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Increasing age (may occur at any age).
Female sex
Premenopausal
Smoking
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RA symptoms:
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Pain
Morning stiffness
Myalgia
Fatigue
Weight loss
Joint pain
Synovitis of small joints
Mono/ bilateral arthropathy of the shoulder/ wrist
Tenosynovitis or bursitis
“Swan neck deformity” late on
“Boutonniere” deformity late on
Finger drop
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RA diagnosis:
 4 of the following symptoms:
1. Morning stiffness >1 hour >6 weeks
2. Arthritis >3 joints
3. Arthritis in hand joints
4. Symmetrical arthritis
5. Rheumatoid nodules
6. Positive RF
7. Radiological changes
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Z-Shaped thumb
Hypertrophy synovium -> New capillary formation -> Inflammtion ->
Synovial villi form and grow into bone -> PANNUS -> Cytokines released
RA Xray changes:
1.Soft tissue swelling
2.Juxta articular osteopenia
3.Loss of joint space
4.Bony erosions
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Extra-articular involvement
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RA investigations:
• Bloods:
– FBC
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Anaemia
– ESR
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High
– RF
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Positive in 80%
– Anti CCP
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Positive in 80%
– ANA
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<50% positive
– ALL TESTS NEGATIVE IN 20%
• Xray
– Erosions seen
– Periarticular osteopenia
– (Joint space narrowing)
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RA treatment:
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NSAIDs
– Pain relief
Glucocorticoids
– Intramuscular injections
Disease Modifying Anti Rheumatic Drugs (DMARDs):
– Azathioprine, ciclosporin, penicillamine, leflunomide, methotrexate and
sulfasalazine.
– Can be used with steroids
– Reduced damage to joints
– METHOTREXATE side effects lung fibrosis, liver effects.
Biological drugs:
– Rituximab (Anti CD20), etanercept (TNF inhibitor) and abatacept (T cell
stimulator modulator)
– Inhibits the immune system
Surgery
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DEGENERATIVE
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Osteoarthritis
• Most common condition affecting synovial joints
• All joint tissues involved, esp. articular cartilage
• Risk factors;
– Age
– Sex
– Genetics
– Obesity
– Trauma/occupation
– ?protective effect of cigarette smoking
• Knees (esp. medial compartment), hips and hands most
commonly affected
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Radiological changes in OA
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Clinical features of OA
• Symptoms;
- PAIN
- POOR MOBILITY
- FUNCTIONAL IMPAIRMENT
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Signs:
ALTERED GAIT
JOINT SWELLING/TENDERNESS
CREPITUS
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Treatment of OA
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Education and lifestyle advice eg. lose weight!
Analgesia (topical, oral, transdermal)
Steroid injections
Surgery
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Uncontrolled pain
Significant limitation of function
NB. Aim is to relieve pain not increase movement
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SERONEGATIVE
SPONDYLARTHOPATHY
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SERONEGATIVE SPONDYLARTHOPATHY
– High rate of HLA-B27
– Rheumatoid factor NEGATIVE.
– Types
• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis
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SERONEGATIVE SPONDYLARTHOPATHY
– Ankylosing spondylitis
– Psoriatic arthritis
– Reactive arthritis
– Enteropathic arthritis
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Ankylosing Spondylitis (AS):
• Sacroilitis
– Inflammation of one of both of the sacroiliac
joints
• Inflammatory back pain
• Enthesitis
– Inflammation of the enthesis (where the tendons/
ligaments enter the bone)
• (Anterior uveitis)
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AS risk factors:
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20- 30 years
HLA-B27 linked
Caucasian
Men
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AS symptoms:
• Back pain in the morning
• Morning stiffness
– Ossification of ligament/ tendon
– Longer than 30 minutes
• Pain improves with movement
• Enthesitis
– Ossification of capsule insertions
• Synovitis
– Common at the large peripheral joints
• Stooped posture
• “Bamboo spine” at a late stage
• Micro-fractures
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6 A’s of AS:
- A Atlantic axial instability
- A Atypical lung fibrosis
- A Anterior uveitis
- A Amyloidosis
- A Autoimmune bowel disease and UC
- A Aortic incompetance
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AS extra-articular symptoms:
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Aortic incompetence
Cardiomegaly
Amyloidosis
Fractures
Fatigue
Weight loss
Low grade fever
Anaemia
Upper lobe pulmonary fibrosis
Iritis
Pleuritis
Osteoporosis
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AS investigations:
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Bloods:
– ESR
• High
– RF:
• Negative
Xray
– Sacroiliac changes
– Ascending spread of disease
– Facet joint involvement
– Squaring of vertebrae
– Syndesmophyte (bony growth in the ligament)
– Ossification
– Osteitis pubis (inflammation of pubis synthesis)
MRI (*Gold standard)
– Joint erosions
– Fluid
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AS treatment:
• Exercise
• Physiotherapy
• NSAIDs
– Pain relief
• Disease Modifying Anti Rheumatic Drugs (DMARDs):
– Azathioprine,
ciclosporin,
penicillamine,
leflunomide,
methotrexate and sulfasalazine.
• Biological drugs:
– Rituximab (Anti CD20), etanercept (TNF inhibitor) and abatacept
(T cell stimulator modulator)
– Inhibits the immune system
• Local steroid injections
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SERONEGATIVE SPONDYLARTHOPATHY
– Ankylosing spondylitis
– Psoriatic arthritis
– Reactive arthritis
– Enteropathic arthritis
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Psoriatic arthritis:
• Joints affected:
– DIP
– Spine
– Nail involvement
– Sacroiliac joints
• In people with psoriasis or family history of
psoriasis
• Less severe than RA
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Psoriatic arthritis types:
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Distal interpharyngeal arthritis (DIPJs)
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Most typical form
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Nail dystrophy
Seronegative symettrical polyarthritis
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Similar to RA eg knees, wrists, DIPs (not MCPs)
Arthritis mutilans
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5% affected.
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Xray shows periarticular osteolysis and bone shortening
Unilateral or bilateral sacroilitis
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15% affected.
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Affects the cervical spine
Assymetrical arthritis
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Warm red tender joints
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Dactylitis in hands and feet
Juvenille onset
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20% childhood arthritis
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Psoriatic arthritis symptoms:
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Stiffness and pain
Joint involvement:
– DIP joint
– Asymmetrical oligoarticular
arthritis
– Symmetrical polyarthritis
– Arthritis mutilans
(degeneration of joint)
– Sacroilitis
Psoriasis (some cases):
– Scalp
– Perineum
– Umbilicus
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Nail lesions
– Pitting
– Onchyolysis
– Splinter haemorrhages
Skin lesions:
– Erythematous lesions
– Pus
– Erythroderma
Enthesitis
Dactylitis (sausage digits)
Synovitis
Subcutaneous nodules
Conjunctivitis and uveitis
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Psoriatic arthritis investigations:
• Bloods:
– ESR
• High
– FBC:
• Anaemia
• Xray
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Psoriatic arthritis treatment:
• Exercise
• NSAIDs
– Pain relief
• Disease Modifying Anti Rheumatic Drugs (DMARDs):
– Azathioprine, ciclosporin, penicillamine, leflunomide,
methotrexate and sulfasalazine.
• Biological drugs:
– Rituximab (Anti CD20), etanercept (TNF inhibitor) and
abatacept (T cell stimulator modulator)
– Inhibits the immune system
The Peer Teaching Society is not liable for false or misleading information…
SERONEGATIVE SPONDYLARTHOPATHY
– Ankylosing spondylitis
– Psoriatic arthritis
– Reactive arthritis
– Enteropathic arthritis
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Reactive arthritis (Reiter’s):
• Triad of symptoms:
– Can’t see (Conjunctivitis)
– Can’t pee (Urethritis)
– Can’t climb a tree (Arthritis)
• Common in 18-30
• Commoner in lower extremities
• 30% chronic.
• Majority resolve within 3-24
months
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Reactive arthritis Causes:
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Shigella
Chlamydia
Salmonella
HIV
Enterocolli.
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Reactive arthritis investigations:
• Bloods:
– ESR
• High
• ECG
• Xray
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Reactive arthritis treatment:
• NSAIDs
– Pain relief
• Steroids
– Used in flare ups
• Antibiotics
– Treat the underlying cause
• (DMARDs)
The Peer Teaching Society is not liable for false or misleading information…
SERONEGATIVE SPONDYLARTHOPATHY
– Ankylosing spondylitis
– Psoriatic arthritis
– Reactive arthritis
– Enteropathic arthritis
The Peer Teaching Society is not liable for false or misleading information…
Enteropathic arthritis:
• Occurs in 10-15% of all IBD cases (Ulcerative
colitis and Crohns)
• HLA B27 linked in 50% of cases
• Asymetrical arthritis
• Mainly affects the lower limbs
• Remission of IBD leads to improvement in
symptoms
• TREAT IBD TO TREAT ARTHRITIS
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CONNECTIVE TISSUE DISEASE
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Systemic lupus erythematosus
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Inflammatory, multisystem autoimmune disorder ->
autoantibodies which form immune complexes/bind to
tissues
90% occurs in females
Peak onset 20-40yrs
Predisposing factors
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Heredity
Genetics
Sex hormone status (pre-menopausal)
Drugs (hydralazine, isoniazid, penicillamine)
UV light
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Clinical features of SLE
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Most suffer from…
FATIGUE
ARTHRALGA (>90%) -> symmetrical, small joints,
deformity and erosions rare
SKIN PROBLEMS (85%) -> butterfly rash, vasculitic
lesions, photosensitivity, raynauds
But can affect any organ…
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Lungs, heart, nervous system, eyes, GI system
• DIAGNOSIS -> based on ACR criteria, must have >4/11
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Other manifestations in SLE
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Investigation of SLE
• FBC
– Often pancytopenia (low WBC, anaemia,
thrombycytopenia)
– Raised ESR
• U + E’s
– Urea and creatinine elevated in advanced disease
• Autoantibodies
– ANA (but 10% of normal population +ve!)
– Anti – dsDNA (useful prognostic indicator)
– Anti-Ro, Anti-La, Antiphospholipid Ab
• Complement -> C3 and C4 often decreased in active disease
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Management
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Avoid sunlight exposure
Decrease cardiovascular risk factors
NSAIDS -> for arthritis, fever
Antimalarials -> chloroquine, hydroxychloroquine
Corticosteroids -> for severe flares, IMI, higher doses in
renal/cerebral disease
Cyclophosphamide, Mycophenoate, Azathioprine, MTX
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Severe flares, not controlled by steroids
• Biologics -> RITUXIMAB (Anti-CD20)
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Course and prognosis of SLE
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Usually episodic with exacerbations and remissions
Can be chronic and persistent
Early deaths are due to renal/cerebral disease
Deaths later on are due to CAD and stroke
Recurrent miscarriages can occur
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CRYSTAL ARTHROPATHY
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Crystal arthropathies
GOUT
-> hyperuricaemia
-> intra-articular sodium urate crystals
PSEUDOGOUT
-> calcium pyrophosphate crystals
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GOUT
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Increased prevalence in developed countries; diet
important!
M:F = 10:1
Prevalence in older female is increased by diuretic use
Pathology;
Hypoxanthine ===> Xanthine ===> Uric acid
Xanthine Oxidase
*Uric acid levels depend on the balance beween purine synthesis and
ingestion and elimination of urate by the kidney/gut*
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Serum uric acid levels increase with: age, obesity, western
diet, DM, IHD, HTN, FHx
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Acute gout
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Ingestion of sodium urate crystals by polymorphs causing
release of cytokines and complement activation in a joint
Typically in middle-aged men
Sudden onset of pain, swelling and redness of a joint,
typically the 1st MTPJ
Triggers: too much food/alcohol, dehydration, starting a
diuretic
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Investigating gout
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Clinical picture often diagnostic; gout should always be on
your list of differentials for a red, hot, swollen joint (along
with septic arthritis!)
Joint fluid microscopy
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Gout; negatively birefringent sodium urate crystals
• Serum uric acid
– Usually >600umol/L
• Serum urea/creatinine/eGFR
– Monitored for renal impairment
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Treating acute gout
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High dose NSAIDS or COXIBS
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eg. Naproxen, Diclofenac, Indomethacin
In renal impairment;
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Colchicine or corticosteroids
• Dietary advice
– Reduce alcohol esp. beer and reduce calories/cholesterol and avoid
shellfish
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Reduce serum uric acid levels to <360um/L
*ALLOPURINOL*
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Blocks xanthine oxidase
Given for frequent attacks despite change in diet/if patient can’t
tolerate NSAIDS/if renal impairment present/tophi
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Chronic tophaceous gout
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Occurs if uric acid levels very high
Sodium urate forms tophi in skin around joints and on ears,
fingers.
• Punched-out bone cysts on Xray
• Superimposed acute attacks can occur
• Often associated with renal impairment
+/- diuretic use
• Treatment;
– Stop diuretics or swap
– Allopurinol
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Pseudogout
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Calcium pyrophosphate deposits in hyaline or fibrocartilage
Similar to acute gout but…more common in elderly women,
usually affects knee and wrists
• DIAGNOSIS;
- Appearance of chondrocalcinosis on XRay
- Joint aspirate -> rhomboidal, weakly positive birefringent
crystals
• Treatment
- Joint aspiration
- NSAIDS or COLCHICINE
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GOOD LUCK!