Question 1

An otherwise healthy 44-year-old man with no prior medical history has had increasing back pain and right hip pain for the past decade. The pain is worse at the end of the day. On physical examination he has bony enlargement of the distal interphalangeal joints. A radiograph of the spine reveals the presence of prominent osteophytes involving the vertebral bodies. There is sclerosis with narrowing of the joint space at the right acetabulum seen on a radiograph of the pelvis. Which of the following diseases is he most likely to have?

A Gout

B Rheumatoid arthritis

C Osteoarthritis

D Osteomyelitis

E Lyme disease

F Pseudogout

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Question 2

An 80-year-old woman has had no major medical problems, but she has never been physically active for most of her life. One day she falls out of bed and immediately notes a sharp pain in her left hip. She is subsequently unable to ambulate without severe pain. Radiographs show not only a fracture of the left femoral head, but also a compressed fracture of T10. Which of the following conditions is she most likely to have?

A Vitamin D deficiency

B Acute osteomyelitis

C Osteogenesis imperfecta

D Osteoporosis

E Polyostotic fibrous dysplasia

F Metastatic breast carcinoma

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Question 3

A 51-year-old man has noted constant, dull right hip pain for the past 3 months. On physical examination he has diminished range of motion of the right hip. A radiograph reveals a 10 x 13 cm mass involving the right ischium of the pelvis. The mass has irregular borders and there are extensive areas of bony destruction along with some scattered calcifications. The lesion is resected, and grossly the mass has a bluish-white cut surface. Which of the following is the most likely diagnosis?

A Osteosarcoma

B Enchondroma

C Osteoblastoma

D Chondrosarcoma

E Paget sarcoma

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Question 4

A 62-year-old man has had back pain for 4 months. No abnormal findings are noted on physical examination. Laboratory findings include WBC count of 3700/microliter, hemoglobin 10.3 g/dL, hematocrit 31.1%, MCV 85 fL, and platelet count 110,000/microliter. His total serum protein is 9.5 gm/dl with an albumin of 4.1 gm/dl. A chest radiograph shows no abnormalities of heart or lung fields, but there are several lucencies noted in the vertebral bodies. A sternal bone marrow aspirate is performed and yields a dark red jelly-like material in the syringe. Which of the following cell types is most likely to be numerous on microscopic examination of this aspirate?

A Giant cells

B Fibroblasts

C Osteoblasts

D Metastatic renal carcinoma cells

E Plasma cells

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Question 5

A 58-year-old man has the sudden onset of severe pain in his left great toe. There is no history of trauma. On examination there is edema with erythema and pain on movement of the left 1st metatarsophalangeal joint, but there is no overlying skin ulceration. A joint aspirate is performed and on microscopic examination reveals numerous neutrophils and needle-shaped crystals. Over the next 3 weeks, he has two more similar episodes. On physical examination between these attacks, there is minimal loss of joint mobility. Which of the following laboratory test findings is most characteristic for his underlying disease process?

A Hyperglycemia

B Positive antinuclear antibody

C Hyperuricemia

D Hypercalcemia

E High rheumatoid factor titer

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Question 6

An 11-year-old boy has pain in his left leg that has persisted for 3 weeks. On physical examination his temperature is 37.9°C. A radiograph of the leg reveals a mass in the diaphyseal region of the left femur with overlying cortical erosion and soft tissue extension. A bone biopsy is performed and the lesion on microscopic examination shows numerous small round blue cells. Karyotypic analysis of these cells shows t(11;22). Which of the following neoplasms is he most likely to have?

A Ewing sarcoma

B Medulloblastoma

C Neuroblastoma

D Chondroblastoma

E Osteoblastoma

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Question 7

A 14-year-old West African man has a history of multiple episodes of sudden onset of severe abdominal pain and back pain lasting for hours. Each time this happens, his peripheral blood smear demonstrates numerous sickled erythrocytes. A hemoglobin electrophoresis shows 94% Hgb S, 5% Hgb F, and 1% Hgb A2. He now has a painful right hip that is tender to palpation. A radiograph reveals irregular bony destruction of the femoral head. Which of the following infectious agents is most likely responsible for his findings?

A Yersinia pestis

B Clostridium perfringens

C Salmonella enterica

D Group B Streptococcus

E Candida albicans

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Question 8

A 69-year-old man has noted increasing back and leg pain for 3 years. He has greater difficulty hearing on the left. On physical examination he has decreased range of motion at the hips. Radiographs reveal bony sclerosis of the sacroiliac, lower vertebral, and upper tibial regions. His hats don't even fit him anymore. He now has orthopnea and pedal edema. Laboratory studies show a serum alkaline phosphatase of 264 U/L. Which of the following conditions is he most likely to have?

A Metastatic adenocarcinoma

B Paget disease of bone

C Renal failure with renal osteodystrophy

D Osteoporosis

E Vitamin D deficiency

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Question 9

An 18-year-old woman has noted pain and swelling of her right distal thigh associated with activity for the past year. She has no history of any trauma. On examination after performing physical exercise, there is tenderness on palpation above the right knee. Radiographs show an expansile, eccentric, lytic lesion located in the metaphysis of the distal femur that is surrounded by a rim of reactive new bone as a host response. Which of the following bone diseases is she most likely to have?

A Fibrous dysplasia

B Ewing sarcoma

C Chondrosarcoma

D Osteoid osteoma

E Aneurysmal bone cyst

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Question 10

A 77-year-old man has experienced persistent dull back pain for 4 months, unrelated to physical activity. He has noted a 6 kg weight loss during this time. On physical examination there are no remarkable findings. A CT scan of the spine reveals scattered 0.4 to 1.2 cm bright lesions in the vertebral bodies. Laboratory findings include a WBC count of 6700/microliter with differential of 70 segs, 8 bands, 2 metamyelocytes, 15 lymphs, 5 monos, and 2 nucleated RBCs/100 WBCs, Hgb 11.2 g/dL, Hct 33.3%, MCV 88 fL, and platelet count 89,000/microliter. Serum chemistries include urea nitrogen 35 mg/dL, creatinine 3.8 mg/dL, and glucose 78 mg/dL. Which of the following additional laboratory test findings is he most likely to have?

A Blood culture positive for Neisseria gonorrheae

B Parathyroid hormone, intact, of 100 pg/mL

C Serum prostate specific antigen of 35 ng/mL

D Serum calcium of 5.5 mg/dL

E Positive serology for Borrelia burgdorferi

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Question 11

A 16-year-old boy has noted pain in his left knee after each hockey practice session for the past month. On examination there is tenderness to palpation of his left knee, with reduced range of motion. A plain film radiograph of the left leg reveals a mass of the proximal tibial metaphysis that erodes bone cortex, lifting up the periosteum where reactive new bone is apparent. The mass does not extend into the epiphyseal region. A bone biopsy is performed and microscopic examination shows atypical, elongated cells with hyperchromatic nuclei in an osteoid stroma. Which of the following neoplasms is he most likely to have?

A Ewing sarcoma

B Osteosarcoma

C Chondrosarcoma

D Multiple myeloma

E Metastatic seminoma

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Question 12

A 53-year-old man has noted a slowly enlarging "bump" on his left elbow for the past 2 years. On physical examination there is a 2 cm firm, non-tender mass over the left olecranon process. An aspirate from this mass examined microscopically shows elongated, needle-shaped crystals that under polarized light are negatively birefringent. The mass is excised and on sectioning has a chalky white consistency. Microscopically there is a granulomatous inflammatory infiltrate. Which of the following disorders is most likely to potentiate his findings?

A Chronic renal failure

B Hepatic cirrhosis

C Peptic ulcer disease

D Chronic obstructive pulmonary disease

E Inflammatory bowel disease

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Question 13

A 5-year-old boy measures at the 5th percentile in height for age. On physical examination most of his decreased height is due to very short legs. However, his trunk and head appear normally proportioned for age. He is of above average intelligence and becomes an orthopedic surgeon. His parents and relatives are not affected by this disorder. Which of the following is the most likely diagnosis?

A Fibrous dysplasia

B Osteogenesis imperfecta

C Ollier disease

D Alport syndrome

E Achondroplasia

F Thanatophoric dysplasia

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Question 14

A 38-year-old woman has severe systemic lupus erythematosus with renal complications. She is treated with long-term corticosteroid therapy. Which of the following bone diseases is she most likely to develop?

A Paget disease of bone

B Rickets

C Osteochondritis

D Osteoporosis

E Osteomalacia

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Question 15

A 15-year-old girl is noted to be developing odd, twisted appearance to her back for the past 3 years. On exam she is tall and thin. A radiograph reveals an abnormal lateral bowing of the spine, with 20 degrees of lateral curvature in the mid-thoracic region. Which of the following is most likely to produce these findings?

A Asymmetric cartilage growth of vertebral body end plates

B Multiple osteochondromas of the vertebral bodies

C Vitamin D deficiency with rickets

D Disorder of procollagen synthesis with multiple compressed fractures

E Repeated episodes of blunt force trauma to the torso

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Question 16

A 23-year-old man notes some minor discomfort over the lateral aspect of his right knee after a day working in a cramped cubicle (because IT put the 'desktop' workstation on the floor). On physical examination he has a palpable "bump" in this region. A radiograph of the knee reveals a lateral bony projection from the lower femoral metaphysis. There is no adjacent soft tissue swelling. The lesion is excised and is composed of a 3 cm stalk of bony cortex capped by cartilage. Which of the following is the most likely diagnosis?

A Osteochondroma

B Giant cell tumor

C Aneurysmal bone cyst

D Osteoid osteoma

E Enchondroma

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Question 17

A 75-year-old man has complained of lower back pain for 8 years. As part of a workup for a persistently elevated lymphocytosis, he has a right posterior iliac crest marrow biopsy performed. On microscopic examination hematopoiesis is normal, but the bone spicules are thickened with irregular cement lines forming a mosaic appearance with both increased osteoblastic and osteoclastic activity. Which of the following conditions is most likely to occur in conjunction with his underlying bone disease process?

A Dementia

B Myelofibrosis

C Hepatic cirrhosis

D Chronic renal failure

E Congestive heart failure

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Question 18

Bone densitometry performed on a 42-year-old woman shows her bone mass decreased more than 2 standard deviations below the young adult mean in her left femoral head, wrist, and lumbar vertebral region. Six months later, the amount of bone loss is seen to be 2.5 SDs below young adult mean by repeat densitometry examination. These findings are most likely to be associated with which of the following serum laboratory test abnormalities:

A Parathormone of 5 pg/mL

B Cortisol of 75 microgm/dL

C Total immunoglobulin of 3.5 g/dL

D Uric acid of 15.7 mg/dL

E Total cholesterol of 514 mg/dL

F Alkaline phosphatase of 238 U/L

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Question 19

A 30-year-old healthy man has experienced headaches for the past month. On physical examination there are no abnormal findings. Laboratory studies show a serum calcium of 12.3 mg/dL with phosphorus of 2.2 mg/dL and albumin of 4.3 g/dL. Which of the following bone lesions is most frequently associated with these findings?

A Osteochondroma

B Giant cell tumor

C Paget disease of bone

D Osteitis fibrosa cystica

E Fibrous dysplasia

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Question 20

A 22-year-old man has persistent lower back pain and stiffness that diminishes with activity. Over the next 10 years he develops hip and shoulder pain with decreased range of motion. On physical examination at age 42 he has diminished lumbar lordosis with decreased lumbar spine mobility. He has no other major medical problems. Which of the following is the most likely diagnosis?

A Rheumatoid arthritis

B Ankylosing spondylitis

C Osteoarthritis

D Lyme disease

E Calcium pyrophosphate dihydrate deposition disease

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Question 21

A clinical study is performed with subjects who have been diagnosed with a primary bone lesion. The demographic data for these subjects is analyzed. Which of the following bone diseases is most likely to be found to have a female predominance?

A Aneurysmal bone cyst

B Osteosarcoma

C Chondrosarcoma

D Ewing sarcoma

E Osteochondroma

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Question 22

A 21-year-old college student has noted increasing pain and soreness in his left shoulder after a summer bucking bales of hay (heavy lifting and turning motions) while at a ranch. On physical examination he can hardly adduct his left arm to the level of his shoulder. An aspiration of the subacromial region is performed and clear fluid is obtained. Which of the following is the most likely diagnosis?

A Tenosynovitis

B Costochondritis

C Bursitis

D Ganglion cyst

E Pseudogout

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Question 23

Over the past 4 days, an 18-year-old man has developed marked pain and swelling in his right hip that makes movement difficult. He has no history of major medical problems. On physical examination there is pain on movement with diminished range of motion of the hip. A joint aspirate from the hip reveals cloudy fluid that on microscopic examination shows numerous neutrophils but no crystals. Which of the following conditions is most likely to have preceded development of his hip problem?

A Gonococcal urethritis

B Sickle cell anemia

C Rheumatoid arthritis

D Systemic lupus erythematosus

E Erythema chronicum migrans

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Question 24

A social worker refers a 2-year-old child to the physician because of suspected child abuse with multiple bone fractures. On physical examination, the child has blue sclerae, diminished hearing in both ears, and misshapen teeth. There are no external contusions or lacerations of the skin. Radiographs of the child's extremities show recent and healing long bone fractures. Which of the following is the most likely diagnosis?

A Trauma ("shaken child syndrome")

B Osteogenesis imperfecta

C Achondroplasia

D Rickets

E Osteopetrosis

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Question 25

A 23-year-old G2 P1 woman has noted minimal fetal movement at 18 weeks gestation. An ultrasound scan shows that the fetal limbs are shortened. At 30 weeks gestation a stillborn fetus is delivered. A postmortem radiograph reveals extensive long bone, rib, and pelvic fractures. Autopsy reveals a normal appearance to internal organs. A mutation involving a gene encoding for which of the following proteins is most likely to produce these findings?

A Fibrillin

B Fibroblast growth factor receptor 3

C Retinoblastoma prtoein (pRB)

D Neurofibromin

E Type I collagen

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Question 26

A 41-year-old previously healthy man has had backache with muscle spasms, weakness, and pain felt in the right hip radiating all the way to his toes for the past 8 months. He does not have headaches or other neurologic problems. Physical examination reveals that the circumference of his right leg is smaller than the left, and he has paresthesias in an L5 distribution in the right leg. Which of the following conditions is he most likely to have?

A Spondylolisthesis

B Spina bifida occulta

C Herniated disk

D Osteoporosis

E Paget disease of bone

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Question 27

A 6-year-old child has complained of pain on the left side of his head for 3 weeks. There are no abnormal findings on physical examination. A skull radiograph reveals a solitary destructive bony lesion of the left mastoid region. A biopsy is performed and microscopic examination shows that this lesion is composed of a mixed inflammatory cell infiltrate. Which of the following is the most likely diagnosis?

A Osteoid osteoma

B Letterer-Siwe syndrome

C Eosinophilic granuloma

D Osteitis fibrosa cystica

E Tuberculosis

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Question 28

A 49-year-old man has complained of episodes of joint pain for over 10 years. This pain has occurred mostly in his hands and feet, and in a remitting and relapsing pattern. On physical examination there are deformities of his hands involving the fingers, with swan-neck deformities and ulnar deviation. His condition improves following methotrexate therapy. Which of the following serologic tests is most likely to be positive in this man?

A Rapid plasma reagin

B HLA-B27

C Anti-double stranded DNA

D Cyclic citrullinated peptide

E Borrelia burgdorferi antibody

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Question 29

An 11-year-old boy has complained of pain in the region of the right upper thigh for 2 weeks. This pain is worse at night and is relieved by aspirin. On physical examination no abnormal findings are noted. A radiograph of his right leg reveals a small lucent area in the proximal femoral cortex surrounded by sclerotic bone. Which of the following is the most likely diagnosis?

A Enchondroma

B Multiple myeloma

C Eosinophilic granuloma

D Osteoid osteoma

E Osteochondroma

F Ewing sarcoma

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Question 30

A 70-year-old man has had a 6 kg weight loss during the past 3 months without dieting. He is a smoker. During the past 3 weeks he has had extensive bone pain in his back and extremities. On physical examination the range of motion of his extremities is normal. His stool is negative for occult blood. A radiograph of the spine shows focal vertebral lytic lesions. A nuclear medicine scan reveals focal areas of increased uptake ("hot spots") in the pelvis, vertebrae, and ribs. Laboratory studies show a serum alkaline phosphatase of 281 U/L. A urinalysis shows microscopic hematuria. Which of the following neoplasms is he most likely to have?

A Chondrosarcoma of bone

B Small cell carcinoma of lung

C Infiltrating ductal carcinoma of breast

D Renal cell carcinoma

E Adenocarcinoma of prostate

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Question 31

A 49-year-old woman has noted increasing difficulty with movement of her left hand for the past 2 years. On examination she cannot completely extend the left middle finger. In the palm of her hand at the base of this finger there is an ill-defined mass that is very firm to palpation. What will microscopic examination of this excised mass most likely show?

A Fibromatosis

B Rhabdomyosarcoma

C Granulomatous inflammation

D Dystrophic calcification

E Giant cell tumor of tendon sheath

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Question 32

A 45-year-old woman notices that she develops tingling and numbness over the palmar surface of her thumb, index, and middle fingers after working for several hours at her computer workstation doing word processing. Pain in the same area often occurs at night as well. On physical examination she has minimal atrophy of thenar muscles of both hands. Which of the following conditions is most likely to account for her symptoms?

A Toxic neuropathy

B Rheumatoid arthritis

C Tophaceous gout

D Hypertrophic osteoarthropathy

E Diabetes mellitus

F Localized tenosynovitis

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Question 33

A 56-year-old woman has a 27 year history of poorly controlled diabetes mellitus. She develops an ulceration on the ball of her foot that does not heal for 2 months. Which of the following complications involving bone is she most likely to develop?

A Chondrocalcinosis

B Osteomyelitis

C Squamous cell carcinoma

D Osteosarcoma

E Osteopetrosis

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Question 34

A 50-year-old man has experienced pain in his right knee for the past 4 years. As he moves about during the day, the pain decreases somewhat. The pain is worse when walking for longer distances. On physical examination there is no joint swelling, warmth, or erythema, but he does have decreased range of motion. Which of the following conditions is he most likely to have?

A Osteoporosis

B Osteochondroma

C Osteomalacia

D Osteoarthritis

E Osteopetrosis

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Question 35

A 54-year-old man is bothered by slowly progressive loss of mobility of his spine at the hips since the age of 25. He has a brother who is similarly affected. On physical examination there is loss of lumbar lordosis with decreased range of motion at his hips. Which of the following pathologic abnormalities involving his sacroiliac joints is most likely to be present?

A Ankylosis

B Gummatous necrosis

C Mosaic growth pattern

D Osteonecrosis

E Pannus formation

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Question 36

A 10-year-old girl has complained of joint pain for the past 2 years. The pain is localized to her knees and ankles; it occurs either with or without movement. The arthralgias are accompanied by fever. On physical examination she has a temperature of 37.8°C. There is no deformity of her knees. She has generalized lymphadenopathy. Her antinuclear antibody test is positive. Which of the following forms of arthritis does she most likely have?

A Gonococcal arthritis

B Ankylosing spondylitis

C Juvenile idiopathic arthritis

D Tuberculous arthritis

E Chronic Lyme disease

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Question 37

A pathologic study is performed involving patients with a history of arthritis. These patients had femoral heads submitted to surgical pathology following resection and placement of hip prostheses. The pathologic findings observed by microscopic examination of these specimens are analyzed. Which of the following findings is most likely to be seen with the greatest frequency in these patients?

A Loss of articular hyaline cartilage

B Proliferative synovitis

C Underlying osteomyelitis of bone

D Bone marrow fibrosis

E Crystal deposition

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Question 38

A 48-year old previously man has developed pain in his hips that has gotten worse over the past 5 months. On physical examination there is pain on passive motion at both hips that limits range of motion. A radiograph of his pelvis shows flattening of femoral heads with collapse on the right. MR imaging shows a double line with outer low intensity reactive subchondral zone with inner high signal intensity zone on T2 weighted scans in each femoral head. Ingestion of which of the following drugs is most likely to have led to these findings?

A Acetysalicylic acid

B Prednisone

C NSAIDS

D Acetaminophen

E Opiates

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Question 39

An 83-year-old man has pain in his left knee a day after playing golf. On examination there is warmth, tendnerness, and swelling of the left knee. A radiograph of the knee shows chondrocalcinosis. Which of the following types of crystal is most likely to be identified in a joint aspirate from his left knee?

A Cholesterol

B Calcium hydroxyapatite

C Monosodium urate

D Magnesium ammonium phosphate

E Calcium pyrophosphate

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Question 40

A 30-year-old man has pain about his left knee that has been worsening "for weeks". On physical examination the left knee appears larger than the right, and there is tenderness to palpaption. A radiograph reveals a 7 cm lytic lesion involving the epiphyseal region of the distal femur with a "soap bubble" appearance. The lesion is curretted, and histologically there are numerous multinucleated cells in a stroma with plump to spindle shaped mononuclear cells. Which of the following is the most likely diagnosis?

A Osteosarcoma

B Chondrosarcoma

C Pleomorphic sarcoma

D Giant cell tumor

E Tuberculosis

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