KE EP AU S TIN WELL YOUR GUIDE TO LIVING WELL EVERY DAY
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Keep Austin Well contents KEEP AU S TIN WE LL
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89 TRIO: The Trifecta Approach To Healthy Living 90 Eat Right With Color: Tips For Busy Families 92 Why Do Our Faces Age? And What Can We Do About It? 94 Innovative Scoliosis Correction Surgery
Specializing in the care of anorexia, bulimia, and binge eating disorder
95 You Will Be Assimilated: The Fate of the Independent Physician under Health Care Reform
Experienced Multidisciplinary Treatment Team Assessments and consultations 10 and 6 hour partial hospitalization programs, 7 days a week Intensive outpatient program, 3 days a week Outpatient services and aftercare Comprehensive treatment for male and Comprehens female adults and adolescents
Ted Weltzin, MD, Executive Medical Director Brad Kennington, LMFT, LPC, Executive Director Samantha Symons, MD, Staff Psychiatrist Lea Gebhardt, MS, RD, LD, Nutrition Coordinator 4613 Bee Caves Road, Suite 104 Austin, Texas 78746 Toll free: 877.755.2244 Phone: 512.732.2400 Fax: 512.732.2404
www.cedarspringsaustin.com ww Austin Eating Disorders Partners, LLC
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CONTRIBUTING WRITERS Roxanne Wilson, Tarie Beldin, Anand D. Patel, MD, Jerri Lynn Ward ART DIRECTOR Daniel Ramirez ADVERTISING & CONTACT Kristen Donner, kristen@austinlifestylemagazine.com
TRIO
The Trifecta Approach to Healthy Living KEEP AU S TIN WE LL
BY ROXANNE WILSON
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he key to a complete workout is cardio, strength training and stretching. It’s something long standing exercise programs have mastered. In this day and age, when time is of the essence, it is nice to find a fitness center that gives that complete workout in an interesting package. Trio Life Fitness, established in November 2010 by Mardee Calkins, does exactly that. Trio Life incorporates three fitness favorites: Spinning, Pilates and Yoga, generating the ultimate cardio, strength training and stretching combination. Although Trio Life offers classes dedicated to each element, as well as Cardiolates (Pilates on trampolines), it is known for its signature class: Trio Fit - an hour or an hour and fifteen minute class incorporating all three fitness programs. I had to give it a try! Part one: 20-25 minutes of Spinning. Although I am an Austinite, bikes aren’t really “my thing.” I’ve taken less than a handful of spinning classes. I was a little timid, but the instructor assisted me in setting up the Spinner bike and my fellow classmates were warm and welcoming. For the next twenty-five minutes we cycled up and down hills in time with the music as we managed our own resistance accordingly. Jennifer, the instructor, prepared the class for what was coming up in the routine, how long the “hill” was and how much resistance to add or take away. Once I got into the groove of spinning, the music took over and I could feel the hills naturally and soon found that I could adjust my Spinner bike gauge to the proper resistance on my own. Part two: 20-25 minutes of Stick Pilates. Stick? This was a first! Stick Pilates is a combination of strength training moves for the abdominals, upper and lower torso with a stick attached by bungees to the wall. As I stood and leaned at least five feet away from the wall for extra resistance and began bicep and tricep exercises, I couldn’t help but engage my abdominals to keep my balance. We moved to the floor for inner and outer thigh repetitions as well as glute moves. The Stick required extreme muscle control even as you felt the burn. Whew! And just when the class as a whole couldn’t go for any more, we moved to… Part three: Yoga. The trio culminated with yoga to open up the muscles used during Spinning and Stick Pilates. It was a perfect way to calm and cool the spirit and ease out of the workout. I can’t stress how unintimidating the entire experience was. The students were helpful and inviting, the staff was first-rate and the facilities were attractive and clean (including the bathrooms)—definitely setting Trio Life Fitness apart from other fitness center experiences. If you enjoy variety while you are working out, Trio Life Fitness will provide you an interesting full body workout in one pretty package. RoxanneWilson.com | Twitter @RoxanneWilson To see Roxanne’s workout in action, go to austinlifestyle.com.
Trio Life Fitness 12101 Bee Cave Road Suite 5E Austin, Texas 78738 512.263.9600 triolifefitness.net
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Eat Right With Color Tips for Busy Families
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arch is National Nutrition Month, which means dietitians help shift the focus of dietary education to focus on the basics of healthy eating. This year’s theme, “Eat Right With Color,” encourages Americans to include a colorful variety of fruits, vegetables, whole grains, lean proteins and dairy on their plates every day (even after March!). A rainbow of color on your plate creates a palette of nutrients, and there are plenty of colorful foods to choose from. Healthy eating involves more than just calorie counting. In fact, most children do not get all of the essential nutrients they need for growth and development. I’m often asked by busy, working parents, who have a household of picky eaters, “How can I make sure my family has enough color in their diet?” Below are some of the colors that you can include in meals to get more nutrients in your family’s diet: Green Produce in shades of green contains antioxidants, which may help reduce cancer and promote healthy vision. Fruits include avocados, grapes, honeydew and kiwi. Vegetables include artichokes, asparagus, broccoli, green beans, green peppers and leafy greens, such as spinach. Orange or Deep Yellow Produce in shades of orange or deep yellow contains nutrients to protect the immune system and vision and reduce the risk of cancer. Fruits include apricots, mangos, cantaloupes, peaches and pineapple. Vegetables include carrots, orange or yellow peppers, corn and sweet potatoes. Purple or Blue Produce in shades of purple or blue have antioxidant and anti-aging benefits, which may help with memory, urinary tract health and reduce the risk of cancer. Fruits include blueberries, blackberries, plums and raisins. Vegetables include eggplant and purple cabbage.
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BY TARIE BELDIN
Red Produce in shades of red can help maintain a healthy heart and immune system and reduce cancer risk. Fruits include cherries, cranberries, pomegranates, red or pink grapefruits and watermelon. Vegetables include beets, red peppers and tomatoes. White, Tan, or Brown Produce in shades of white, tan or brown contains nutrients that may promote heart health and reduce cancer risk. Fruits include bananas, pears, dates and white peaches. Vegetables include cauliflower, mushrooms, onions, parsnips, turnips and potatoes. The goal is to include at least three different colors on your plate at each meal. For example, rather than having a dinner of grilled chicken with a baked potato, top the chicken with salsa and add mashed sweet potatoes and a spinach salad with strawberry slices. The more colorful your plate, the more visually appealing it is. It should also increase the natural flavor and will contain more nutrients. Have your children help plan meals that contain at least three colors and allow them to help prepare part of the meal. The more involved children are with the meal planning and preparation, the more likely they will be to eat—or at least taste—the different colors and foods. Remember, it can take up to 20 times for a child to try a food until they actually enjoy it! Don’t give up. Continue offering healthy options with foods they are familiar with. We are the greatest role models for our children. When they see mom or dad eating healthy and being physically active, they are more likely to follow in our footsteps. Tarie Beldin is a registered and licensed dietitian with the Fit 4 Life Weight Management program at St. David’s Round Rock Medical Center.
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Why Do Our Faces Age?
And What We Can Do About It! BY ANAND D. PATEL, MD
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etting older would be much more enjoyable if we didn’t have to look older as well. Many of us feel younger on the inside than we look on the outside, and that can be tough to deal with. To make matters worse, our society tends to associate beauty and youth with value and success. This is especially true when it comes to our faces. So, it’s no surprise that many of us are constantly looking out for the miracle product or service that will turn back the clock. But why does it happen? How does aging cause wrinkles, deep lines of expression, droopy skin and a sunken look? A simple approach to understanding facial aging is to think of the effects as either qualitative or quantitative. The qualitative changes involve the character of the skin, which includes dryness and texture, coarse and fine wrinkling, age spots, prominent blood vessels and the appearance of benign or precancerous lesions. Over time, the effect of facial muscles pulling on the overlying skin leads to deep wrinkles that worsen with facial expression. The quantitative changes include skin laxity and volume loss in the face. Bone loss is seen in the central face and the jawbone. The fatty pads of the face that give us fullness in the cheeks and lips tend to thin, while other areas, such as under the chin, tend to build up fat. Altogether, this leads to the telltale signs of facial aging. With aged skin, collagen and elastin production begins to breakdown. This leads to loss of volume and strength and more laxity.
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The mechanism of this process is still being worked out, but various enzymes, proteins and free oxygen radicals are thought to contribute. Both genetic and environmental factors are to blame. It seems that our cells are genetically programmed to stop replicating after a time. Protective mechanisms, such as DNA and tissue repair systems, enzymatic inhibitors and even antioxidants are produced by the body to combat aging, but they also decline over time. Why some people age faster than others is likely due to both behavioral and genetic reasons. Skin pigmentation, likely the most important genetic factor, is protective against the most pervasive environmental factor, ultraviolet radiation (UV). There are two types of UV that contribute to aging, UVA and UVB, albeit by different mechanisms. The UV radiation results in photoaging, a chronic inflammation of the skin which not only accelerates normal aging, but also causes a hardened, leathery quality to the skin. Other environmental factors that affect aging include an unhealthy diet, alcohol use, smoking and nicotine, pollution and poor overall health. Scientific studies leave little doubt that smoking and nicotine markedly trigger premature wrinkling. The key is prevention, and you’re never too young or too old to start. Those with healthy lifestyles also tend to look healthier. It seems the adage “garbage in, garbage out” also applies to aging. That means good nutrition, regular exercise, proper skin care, and staying away
poly-L-lactic acid components. The fillers differ in the area or depth they are injected and how long they last, and some can stimulate more production of your own collagen. Most fillers can last anywhere from six to fifteen months. Generally, they fade faster in areas that move a lot (e.g. around the mouth). For fine, etched lines that do not go away with stretching of the skin or after Botulinum treatment, a skin resurfacing procedure can give an amazing result. Skin resurfacing removes the top layers of skin, allowing new baby skin to take its place. The deeper the resurfacing treatment, the better the result, but the longer the downtime. Skin resurfacing can also be helpful for age spots and even precancerous lesions. Generally, there are three types of resurfacing: dermabrasion, chemical peels and laser. Laser resurfacing has revolutionized the field by providing a more precise and accurate treatment. The effects of aging on the face can be disheartening, but we are lucky to live in an exciting time when we can actually alter our
one can get a “relaxed” look without full paralysis. It takes days to weeks before the injections take effect and they last about three months. Most importantly, in the relatively small doses used for cosmetic purposes, Botulinum has proved to be safe over time. Soft tissue fillers are injected substances that are used to plump up areas under the skin that lack volume. Fillers have been used in many parts of the face, but the most common are the smile lines, marionette lines and lips. These days, the most common types include collagen, hyaluronic acid, calcium hydroxyapatite and
appearances. The gold standard for patients with significant skin laxity or volume loss is still aesthetic surgery, which aims to restore one’s previous appearance. There is a multitude of new treatments – many of which are noninvasive – that can help restore a more refreshed, youthful appearance. Unfortunately, we have not figured out a way to stop the aging process altogether – at least, not yet Anand D. Patel, MD is a Facial Plastic and Reconstructive Surgeon with Devenir Aesthetics.
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from smoking, nicotine and other environmental toxins. It’s not possible to totally avoid the sun, so the appropriate sunscreen with a high enough potency (SPF 30) becomes critical. Make sure that your sunscreen protects against both UVA and UVB, because some do not. In a world where the effectiveness of many products is ill-supported by hard data, Tretinoin, a form of topical Vitamin A, is one with good evidence of its efficacy in reversing photoaging. Ask your dermatologist if you are a good candidate. For those of us beyond the point of prevention, there are good treatments to turn back time. Botulinum toxin was originally used in high doses to treat muscles spasms, but has gained widespread success in much smaller doses to relax facial muscles and soften deep facial lines. It is particularly good for forehead lines, the glabellar “elevens” between the eyes and the crow’s feet on the sides of the eyes. Botulinum works by disrupting communication between the motor nerves from the brain and the facial muscles. There is an art to these injections and
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Innovative Scoliosis Correction
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any women embrace their curves, but not if they suffer from scoliosis, a spinal condition causing a curvature of the spine. Scoliosis is often diagnosed during adolescence and, if left untreated, can slowly progress and cause serious complications like breathing problems and pain. Stephanie Griffin is an active Central Texas 15-year-old who enjoys dancing and hanging out with her friends. Like most teens, the idea of slowing down because of a spinal deformity like scoliosis was not appealing. Neither was the fact that her spinal curve was worsening. Stephanie was first diagnosed with scoliosis at age 14. Initially, she tried a brace, but her curvature worsened to 50 degrees, causing painful back symptoms. Like many others with scoliosis, her spinal curvature also began to take an emotional toll. Her mother scoured the internet for the latest scoliosis correction procedures and treatment options. Their search ended with a local spine surgeon, Dr. Matthew Geck, from the Seton Spine and Scoliosis Center. He presented Stephanie and her mother with an innovative treatment option: a new, minimally invasive scoliosis procedure that corrects the spinal curve through three small incisions instead of a long incision and scar. During traditional scoliosis surgery, surgeons must make a large incision from the top of the scoliosis to the bottom and peel muscles off the spine to attach instruments to straighten the spine’s curve. This translates to significant post-surgery pain and longer recovery times. “It has taken years to bring minimally-invasive surgery techniques to scoliosis surgery,” explains Dr. Geck, who is one of only three surgeons in the country – and the first in Texas – to perform minimally invasive scoliosis surgery. “This isn’t just a new procedure but a new approach to correct scoliosis,” says Dr. Geck. “It’s a great way to take care of patients and have them go through less surgery with fewer complications.” With the newer procedure, screws are percutaneously placed through two or three tiny incisions, typically three to seven centimeters in length. It spares muscle surrounding the spine, resulting in a faster recovery and less post-operative pain. Dr. Geck corrected Stephanie’s 50 degree curvature to 12 degrees with a few small incisions and the standard rods and screws to complete the correction. Just four days after surgery, Stephanie slowly started back with her daily activities. After a few short weeks, she was back at dance practice and is now able to perform her high stepping moves and splits with her high school dance team. “I was shocked at how fast the recovery was and am so happy I had the procedure. I would do it all over again if I had to,” explains Stephanie. Dr. Geck has taken his skills with the new minimally-invasive scoliosis surgery abroad to Cali, Colombia with the global outreach program, SpineHope. This biannual mission trip involves teaching a group of neurosurgeons and orthopedic surgeons how to perform minimally-invasive and complex scoliosis surgeries. Dr. Geck says the future of minimally-invasive scoliosis surgery is exciting and includes a combination of imaging guidance surgery and robotics.
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You Will Be Assimilated KEEP AU S TIN WE LL
The Fate of the Independent Physician Under Health Care Reform BY JERRI LYNN WARD
Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctorpatient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care…is to constrain decentralized individualized decision making. –New Rules: Regulation, Markets, and the Quality of American Health Care (Jossey Bass/Aha Press Series) by Troyen A. Brennan and Donald M. Berwick MD. You Will Be Assimilated. –The Borg, Star Trek
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hose of us of a certain age have fond memories of the show, Marcus Welby, MD. The show glorified the role of physicians in independent practice. Dr. Welby even made house calls, a near impossibility after the emergence of the HMO. Since that emergence, the independence of such physicians—especially primary care physicians—has been slowly eroded by government policy and the dictates of insurers. A timely question is: How will the recent health reform impact the independent physician? A historical review is informative. Since the 1950s, physicians in independent practices began to form associations called Independent Practice Associations (“IPAs”) in order to negotiate with insurance companies. The advantage of IPAs is: “Doctors get a middleman to deal with the insurance bureaucracies, and patients get access to a wide range of health care providers at discounted prices.”1
However, the federal government has been waging a war on the independent physician and IPAs through the Federal Trade Commission (“FTC”) and the Department of Justice Antitrust Division and their prosecution of 36 IPAs since 2001.2 At least two of those prosecutions have been high-profile cases here in Texas. North Texas Specialty Physicians fought the FTC all the way to the U.S. Supreme Court (which denied cert), based on accusations that it “had engaged in illegal price-fixing when it negotiated contracts that didn’t involve risk sharing with payers on behalf of its 600 doctor members.”3 What the Fort Worth-based IPA had actually done was to poll its members “annually on the minimum rates each would accept for certain contracts.” The group then used the poll results to decide which contracts its members were likely to approve and, thus, which it would ‘messenger.’ The FTC deemed this arrangement ‘horizontal price fixing.’”4 For some context, IPAs are essentially not permitted by the FTC to actually negotiate on their behalf with insurance companies unless they are “clinically and financially integrated” (more about that later). The IPA’s designated “messengers” are allowed only to relay offers from the insurance companies to the members of the IPA, not to respond with the physician’s demands. The Fifth Circuit apparently agreed, thus squelching any efforts for IPAs to discover the positions of their members prior to “negotiating” with insurers. This is like going into a boxing match with both hands tied behind your back and your mouth taped shut.
1. Oliva, S.M. (2010, November 29). Doctors’ orders: the government’s war on medical ‘price fixing’ squelches speech without helping consumers. Hawaii Reporter, Retrieved from http:// www.hawaiireporter.com/doctors%E2%80%99-orders-the-government%E2%80%99s-war-on-medical-%E2%80%9Cprice-fixing%E2%80%9D-squelches-speech-without-helping-consumers. 2. Ibid. 3. Sorrel, A.L. (2008, June 23/30). Texas IPA’s contract talks are price-fixing, appeals court rules. American Medical News, Retrieved from http://www.ama-assn.org/amednews/2008/06/23/gvsc0623.htm. 4. Oliva, Doctor’s Orders, 2010. 5. North Texas Specialty Physicians v. Fed. Trade Comm’n, No. 06-60023 (5th Cir. May 14, 2008). http://www.ftc.gov/os/ caselist/0660023/080516opinion.pdf.
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Not only are the independent physicians who make up these IPAs constrained by the FTC in their ability to negotiate with insurance companies, the FTC purports to dictate the nature of the IPA business model. In its action against the Texas-based Southwest Physicians Association, the FTC prosecuted based on the IPA’s “refusal to continue following a commission-approved contracting model that resulted in substantial losses” to the IPA.6 What does all this have to do with health care reform and the future of the independent physician? The answer lays in the phrase, “clinically and financially integrated.” More than any other policy to date, the Patient Protection and Affordable Care Act (“PPACA”), enacted in March 2010, encourages such integration in health care by incentivizing the herding of physicians into what are called Accountable Care Organizations (“ACOs”). ACOs integrate local physicians with other members of the health care system, such as hospitals, and reward them for controlling costs and improving health care quality.
and/or private insurance, and that IPAs will be a relic of the past. Further, it will probably be primary care physicians who will be the most impacted, as most medical specialists are already part of “clinically and financially integrated” entities because of the expensive equipment specialists need.10 The first indication is contained in the quote preceding the title of this article taken from New Rules: Regulation, Markets, and the Quality of American Health Care (Jossey Bass/Aha Press Series) by Donald M. Berwick, M.D., Administrator of the Centers for Medicare & Medicaid Services (CMS). Dr. Berwick seems to have the view that medical ethics must evolve to fit PPCA’s view of medical care delivery. So, will physicians who resist be accused of violating newly prevailing medical ethics? The second indication lays in the earlier discussion about FTC prosecutions. Very accomplished health care lawyers are warning physicians and hospitals seeking to form ACOs that no one knows how the
A blunt, if inflammatory description of how they will work is offered by Dr. Fogoros, author of Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare, on his indispensible blog: The Covert Rationing Blog.7
FTC will treat these entities, who by their very definition will be seeking to “price-fix’ in order to lower costs so that the ACO’s can share savings with the Medicare program. This seems to be a real risk, if ACOs are structured as some sort of Supra-IPA. However, if an ACO forms in accordance with government dictates, the words of FTC Commission Chairman, John Leibowitz, in his address to the AMA are informative:
The ACOs will be run by administrators who (theoretically) will become expert at navigating the morass of rules and regulations now being conjured up under Obamacare. These administrators will interpret the rules and regulations in such a way as to determine The Way It Must Be Done, and then will pass The Way It Must Be Done down to the ACOs’ clinical chiefs (doctors who perhaps used to practice medicine, and maybe still do, a little, but who are now mainly brevet administrators), and the clinical chiefs will finally pass the restrictive rules of engagement down to the doctors who will actually take care of the patients. These doctors, struggling in the trenches, will attempt assiduously to follow those rules without exception, if they would like to keep their jobs as well as avoid a federal fraud rap. The patients, of course, will get whatever they get, but always with official assurances that whatever it is they get, it will be of the highest quality.8 How ACOs will look remains to be seen because the regulations governing them have not yet been promulgated. The debate about what those regulations should be is beginning to resemble a mud wrestling contest between insurers, hospitals and physicians.9 A provocative question is what the position of independent physicians, most of them being primary care physicians, will be once the mud settles? Will they be the Pygmies in fight against Titans? Can they maintain their independence? There are indications that the pressures to go into ACOs may be too much for independent physicians who take Medicare/Medicaid
[The health care law] establishes pilot programs for Medicare called “accountable care organizations” or ACOs as possible devices to improve quality and lower the cost of health care. Each ACO will be responsible for both the cost and the quality of care for at least 5,000 patients. ACOs will share with Medicare any savings that they generate because of their efficiency in meeting HHS performance targets. While the details of the ACO program are not yet available, so long as the government purchases the services and unilaterally sets payment levels and terms, there won’t be an antitrust issue. (bold added)11 Given all this, the future of the individual, independent practitioner appears bleak. The choices seem to be, restructure your practice to opt out or face the Borg and prepare to be assimilated.* Dr. Welby is about to become a cog in the machine. *
Attribution for this literary device goes to Richard N. Fogoros, M.D.
Co-founder of Garlo Ward, P.C., Jerri Lynn Ward provides legal representation to a broad range of health care providers and small businesses. She currently practices general civil and administrative law, and works with health care facilities and individual providers in federal and state court matters and before government regulatory agencies and boards. She has published articles on various healthcare and legal topics in several local and national publications. Find out more about Jerri Lynn at www.garloward.com.
6. Oliva, Doctor’s Orders, 2010. 7. Fogoros, R.N. (2010, December 13). Criminalizing independent physician practices [Web log message]. Retrieved from http://covertrationingblog.com/ primary-care-in-america/criminalizing-independent-physician-practices. 8. Ibid. 9. Rau, J. (2011, January 9). Insurers, health-care providers at odds on rules for ‘accountable care organizations’. Washington Post, Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2011/01/09/AR2011010903401.html. 10. Fogoros, R.N. (2010, September 3). PCPs: We are the Borg. Prepare to be assimilated [Web log message]. Retrieved from http://covertrationingblog.com/healthcare-reform/pcps-we-are-the-borg-prepare-to-be-assimilated. 11. Oliva, S.M. (2010, June 14). FTC chair denies he’s a socialist, announces greater role in healthcare [Web log message]. Retrieved from http://blog.mises.org/12964/ftc-chair-denies-hes-a-socialist-announcesgreater-role-in-healthcare/.
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