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Purposeassessment of patients with impaired level of consciousness.

The FOUR Score is a clinical grading scale designed for use by medical professionals in the assessment of patients with impaired level of consciousness. It was developed by Dr. Eelco F.M. Wijdicks and colleagues in Neurocritical care at the Mayo Clinic in Rochester, Minnesota. "FOUR" in this context is an acronym for "Full Outline of UnResponsiveness".

The FOUR Score is a 17-point scale (with potential scores ranging from 0 - 16). Decreasing FOUR Score is associated with worsening level of consciousness. The FOUR Score assesses four domains of neurological function: eye responses, motor responses, brainstem reflexes, and breathing pattern.

The rationale for the development of the FOUR Score constituted creation of a clinical grading scale for the assessment of patients with impaired level of consciousness that can be used in patients with or without endotracheal intubation. The main clinical grading scale in use for patients with impaired level of consciousness has historically been the Glasgow Coma Scale (GCS), which cannot be administered to patients with an endotracheal tube (one component of the GCS is the assessment of verbal responses, which are not possible in the presence of an endotracheal tube).[1]

The FOUR score has been validated with reference to the Glasgow Coma Scale in several clinical contexts, including assessment by physicians in the Neurocritical Care Unit,[2] assessment by intensive care nurses,[3] assessment of patients in the medical intensive care unit (ICU),[4] and assessment of patients in the Emergency Department.[5] Comparison of the inter-observer reliability of the FOUR Score and the GCS suggests that the FOUR Score may have a modest but significant advantage in this particular measure of test function.[6]

Overall, FOUR score has better biostatistical properties than Glasgow Coma Scale in terms of sensitivity, specificity, accuracy and positive predictive value.[7]

A 2024 systematic review found that the FOUR score was significantly more accurate than the Glasgow Coma Scale in predicting ICU mortality, based on higher area under the Receiver operating characteristic (AUROC) values.[8] The review also found the FOUR score to be more responsive in detecting clinically meaningful changes in patients with low levels of consciousness, as most patients with the lowest GCS score (GCS 3) had FOUR scores between 1 and 8 due to intact brainstem functions.

FOUR - Full Outline of UnResponsiveness[2]
Points Eye response Motor response Brainstem reflexes Respiration
4 Eyelids open or opened, tracking, or blinking to command Thumbs-up, fist, or peace sign Pupil and corneal reflexes present Not intubated, regular breathing pattern
3 Eyelids open but not tracking Localizing to pain One pupil wide and fixed Not intubated, Cheyne–Stokes breathing pattern
2 Eyelids closed but open to loud voice Flexion response to pain Pupil or corneal reflexes absent Not intubated, irregular breathing
1 Eyelids closed but open to pain Extension response to pain Pupil and corneal reflexes absent Breathes above ventilator rate
0 Eyelids remain closed with pain No response to pain or generalized myoclonus status Absent pupil, corneal, and cough reflex Breathes at ventilator rate or apnea

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FOUR score

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The FOUR score, formally known as the Full Outline of UnResponsiveness score, is a standardized clinical tool designed to assess the level of consciousness in patients with impaired responsiveness, such as those in coma within intensive care settings. It evaluates four key components—eye response, motor response, brainstem reflexes, and respiration—each graded on a scale from 0 (worst) to 4 (best), resulting in a total score ranging from 0 to 16, where higher scores indicate better neurological function. Developed in 2005 by Eelco F. M. Wijdicks and colleagues at the Mayo Clinic as an alternative to the Glasgow Coma Scale (GCS), the FOUR score addresses limitations of the GCS, including the inability to score verbal responses in intubated patients and the lack of assessment for brainstem function or respiratory patterns. Unlike the GCS, which totals 3 to 15 and relies on eye, verbal, and motor components, the FOUR score offers greater neurological detail, enabling detection of conditions like locked-in syndrome, vegetative states, and brain herniation stages.[1] Initial validation involved prospective evaluation in 120 intensive care unit (ICU) patients, demonstrating excellent interrater reliability comparable to the GCS (weighted kappa of 0.82 for both scales). Subsequent studies have confirmed the FOUR score's reliability and validity across diverse populations, including medical ICU patients, with interrater agreement consistently high (kappa values exceeding 0.6 in most analyses) and strong correlation to GCS outcomes (r > 0.8).[2] It shows superior predictive power for mortality and poor functional outcomes in neurocritical care, outperforming the GCS in intubated cases and at the lowest score levels (e.g., 89% in-hospital mortality at FOUR score 0 versus 71% at GCS 3).[2] A 2020 systematic review of 42 studies involving over 4,500 patients highlighted its advantages in brainstem and respiration evaluation, supporting its widespread use in critical care for serial monitoring and prognostication.[1]

Overview

Definition and Purpose

The FOUR (Full Outline of UnResponsiveness) score is a standardized clinical tool designed to assess the level of consciousness in patients with severe neurological impairment, particularly those in coma or unable to communicate verbally.[3] It provides an objective evaluation of coma depth by examining key neurological functions, enabling healthcare providers to monitor disease progression, guide treatment decisions, and predict outcomes in critical care settings.[2] The primary purpose of the FOUR score is to offer a reliable measure of neurological status in patients with brain injuries, acute neurological conditions, or respiratory failure, where traditional verbal-based assessments may be infeasible. Unlike earlier scales, it avoids reliance on verbal responses, making it particularly valuable for intubated or sedated individuals in intensive care units (ICUs), emergency departments, and neurocritical care environments.[4] This focus ensures applicability across diverse patient populations with impaired consciousness, including non-traumatic etiologies like stroke or metabolic disorders.[5] Key features of the FOUR score include its 16-point scale, ranging from 0 (indicating the deepest level of coma) to 16 (full responsiveness), derived from four distinct domains: eye response, motor response, brainstem reflexes, and respiration. Each domain is scored from 0 to 4, allowing for a granular yet straightforward assessment that captures subtle changes in brainstem function and respiratory patterns often overlooked in other tools.[3] Developed to address limitations in existing coma scales, such as the Glasgow Coma Scale (GCS), the FOUR score enhances accuracy in detecting conditions like locked-in syndrome and brain herniation without requiring patient cooperation.[2]

Development and History

The FOUR score was developed by Dr. Eelco F. M. Wijdicks and colleagues at the Mayo Clinic in Rochester, Minnesota, as a novel tool for assessing consciousness in comatose patients.[6] First described in 2005 in a validation study published in the Annals of Neurology, the scale was designed to address key limitations of the Glasgow Coma Scale (GCS), including its inability to evaluate verbal responses in intubated or sedated patients and its omission of brainstem reflexes and respiratory patterns.[6] The developers aimed to create a simple yet comprehensive system that could be applied reliably across various clinical scenarios, particularly in neurocritical care settings involving mechanically ventilated individuals.[6] Initial testing occurred prospectively in the neurocritical care unit at Mayo Clinic, involving 120 intensive care unit patients with acute neurological conditions.[6] Assessments were performed by neuroscience nurses, neurology residents, and neurointensivists, demonstrating excellent inter-rater reliability for the total FOUR score (weighted kappa = 0.82), comparable to that of the GCS.[6] The study confirmed the scale's ability to provide detailed neurological information, such as identifying locked-in syndrome and stages of brainstem herniation, while correlating well with in-hospital mortality outcomes.[6] Following its introduction, the FOUR score underwent rapid evolution through targeted adaptations and validations in diverse contexts. In 2008, researchers at Mayo Clinic validated its use in the emergency department by non-neurology staff, highlighting its feasibility and equivalence to the GCS in predicting outcomes among patients with altered mental status. Pediatric adaptations emerged shortly thereafter, with a 2009 study confirming the scale's inter-rater reliability and predictive validity in children, allowing for age-appropriate assessments in comatose pediatric populations. By 2010, international validations had begun, including a 2009 study in Thailand that demonstrated the FOUR score's reliability and prognostic utility in emergency settings outside the United States.[7] Subsequent research, including a 2020 systematic review of 42 studies involving over 4,500 patients, has affirmed the FOUR score's reliability, validity, and advantages in brainstem and respiration evaluation across global settings.[1]

Components of the FOUR Score

Eye Response

The eye response component of the FOUR score assesses a patient's oculomotor function and level of arousal by evaluating eyelid opening and visual tracking in response to stimuli, contributing 0 to 4 points to the total score.[8] This subscale provides a nuanced evaluation of cortical and brainstem integrity, particularly in patients with impaired consciousness.[9] The scoring criteria are as follows:
  • 4 points: Eyelids open or opened, tracking, or blinking to command (recognizes locked-in syndrome with vertical eye movements).[8]
  • 3 points: Eyelids open but not tracking.[8]
  • 2 points: Eyelids closed but open to loud voice.[8]
  • 1 point: Eyelids closed but open to pain.[8]
  • 0 points: Eyelids remain closed with pain.[8]
Clinically, this component is valuable for distinguishing subtle states of awareness, such as a vegetative state (score of 3, with spontaneous opening but no tracking) from locked-in syndrome (score of 4, with command-following).[9] It enables detection of incremental improvements in responsiveness, even in intubated or aphasic patients where verbal assessments are infeasible, and demonstrates excellent interrater reliability (weighted κ = 0.96).[9]

Motor Response

The motor response component of the FOUR score evaluates the best motor response in the upper extremities of comatose patients, using verbal commands or painful stimuli such as temporomandibular joint or supraorbital pressure, to assess the integrity of motor pathways. This component is scored on a 0-to-4 scale, where higher scores indicate more intact motor function and lower scores reflect greater impairment. The detailed scoring criteria for motor response are as follows:
ScoreCriteria
4Thumbs-up, fist, or peace sign (purposeful response to command)
3Localizing to pain (patient touches the examiner's hand or site of stimulus)
2Flexion response to pain (withdrawal or decorticate posturing)
1Extension response to pain (decerebrate posturing)
0No response to pain or generalized myoclonus status epilepticus
These criteria are derived from observations in intensive care settings and emphasize reproducible testing methods. Clinically, the motor response measures the function of the motor cortex and descending corticospinal pathways, distinguishing purposeful movements (scores 3–4) from reflexive or abnormal ones (scores 0–2), which helps localize lesions to cortical, subcortical, or brainstem levels. A score of 2 identifies decorticate posturing, characterized by upper extremity flexion and lower extremity extension due to disruption above the red nucleus, while a score of 1 denotes decerebrate posturing, involving rigid extension of all extremities from midbrain or lower dysfunction, both indicating severe neurological injury. The presence of generalized myoclonus at score 0 is a poor prognostic indicator, particularly in post-cardiac arrest scenarios.[10]

Brainstem Reflexes

The brainstem reflexes component of the FOUR score evaluates the integrity of the brainstem through assessment of pupillary light response, corneal reflex, and cough reflex, targeting functions in the mesencephalon, pons, and medulla oblongata.[8] This component is scored on a scale from 0 to 4 points, with higher scores indicating preserved reflex activity and lower scores reflecting progressive brainstem dysfunction.[8] The specific scoring criteria are as follows:
  • 4 points: Both pupils and corneal reflexes are present, demonstrating intact midbrain and pontine pathways.
  • 3 points: One pupil is dilated and fixed, often signaling ipsilateral oculomotor nerve compression due to transtentorial herniation.
  • 2 points: Either pupillary or corneal reflexes are absent, indicating partial brainstem impairment.
  • 1 point: Both pupillary and corneal reflexes are absent, suggesting more advanced dysfunction.
  • 0 points: Pupillary, corneal, and cough reflexes are all absent, with the cough reflex tested via tracheal suctioning only if the other reflexes are already lost; this level points to severe medullary involvement.[8]
Clinically, this component provides critical insight into brainstem viability, which is essential for coma assessment as it detects early signs of herniation syndromes—such as fixed and dilated pupils indicating a high risk of irreversible damage—and helps differentiate conditions like brain death from locked-in syndrome.[8] By incorporating these reflexes, the FOUR score offers a more nuanced evaluation of lower brainstem function compared to scales that omit such testing.[8]

Respiration

The respiration component of the FOUR score assesses breathing patterns and respiratory drive to evaluate brainstem function in comatose patients, with scores ranging from 0 to 4 points. A score of 4 indicates the patient is not intubated and exhibits a regular breathing pattern, reflecting intact respiratory control. A score of 3 applies to non-intubated patients showing Cheyne-Stokes respiration, characterized by cycles of increasing then decreasing depth of breathing followed by apnea. A score of 2 is assigned to non-intubated patients with irregular, apneustic, or asymmetrical breathing patterns, suggesting disrupted rhythm generation. For intubated patients, a score of 1 denotes breathing above the set ventilator rate, indicating preserved spontaneous respiratory effort, while a score of 0 signifies breathing at the ventilator rate or complete apnea, implying absent or minimal respiratory drive.[11] This component primarily evaluates the function of the medullary respiratory centers in the lower brainstem, which generate the basic respiratory rhythm, and detects abnormalities signaling higher-level dysfunction. Abnormal patterns such as Cheyne-Stokes respiration often indicate diencephalic or bihemispheric involvement, where impaired integration of sensory inputs disrupts ventilatory control. In intubated patients, scoring ventilation dependency provides critical insight into respiratory autonomy, aiding differentiation from ventilator synchrony and supporting assessments in sedated or mechanically ventilated individuals without the limitations seen in other scales.[12][2]

Scoring and Interpretation

Calculation of the Total Score

The FOUR score is calculated by summing the individual scores from its four components: eye response, motor response, brainstem reflexes, and respiration, each of which is scored on a scale from 0 to 4. This straightforward addition yields a total score ranging from 0, representing the absence of all assessed functions, to 16, indicating intact neurological function and full alertness. The equation for the total score is as follows:
Total FOUR Score=Eye Score (0-4)+Motor Score (0-4)+Brainstem Score (0-4)+Respiration Score (0-4) \text{Total FOUR Score} = \text{Eye Score (0-4)} + \text{Motor Score (0-4)} + \text{Brainstem Score (0-4)} + \text{Respiration Score (0-4)}
No weighting, subtraction, or other adjustments are applied to the component scores during calculation. Assessment of the FOUR score is conducted by trained clinicians, such as neurointensivists, neurology residents, or neuroscience nurses, and typically takes only a few minutes to complete. Each component is evaluated independently based on the patient's best response to standardized stimuli, with serial assessments recommended to track changes in neurological status over time. A total score of 0 signifies deep coma with no elicitable responses, while a score of 16 reflects normal consciousness.

Clinical Interpretation and Prognosis

The total FOUR score, ranging from 0 to 16, provides a graded assessment of coma severity, with higher scores indicating better neurological function. These ranges are approximate and often equated to Glasgow Coma Scale (GCS) severity levels: scores of 14 to 16 are associated with mild impairment (equivalent to GCS 13–15), where patients exhibit near-normal responsiveness; 11 to 13 reflect moderate impairment (GCS 9–12) with noticeable deficits in arousal or motor function; and 0 to 10 denote severe impairment (GCS 3–8), often involving significant unresponsiveness.[13][4] The prognostic value of the FOUR score is well-established, particularly in intensive care settings. Scores below 4 are linked to high mortality rates, reaching up to 89% in medical ICU patients overall and 100% in post-cardiac arrest patients for scores ≤4 on days 3–5.[14][4] Improvements in the total score over time, such as an increase of 2 or more points, correlate with enhanced recovery prospects and survival, especially in response to interventions like sedation reduction. Specific patterns, including a low brainstem reflexes subscore (0-1), predict poor brainstem function and adverse outcomes independent of the total score.[15] In validation studies, the FOUR score demonstrates strong correlations with patient outcomes, outperforming the Glasgow Coma Scale in predicting ICU mortality with an area under the receiver operating characteristic curve (AUROC) of 0.88 compared to 0.87 for the GCS on admission, and showing superior performance at later assessments (e.g., 0.96 vs. 0.91 at 6 hours).[16][17] This predictive accuracy supports its use in clinical triage to prioritize care and in end-of-life decision-making, where persistently low scores inform discussions on withholding or withdrawing support. Serial FOUR scoring enhances prognostic precision, with day-3 assessments yielding AUROC values exceeding 0.90 for in-hospital mortality in some studies.[16][17]

Comparison with Other Scales

Advantages over the Glasgow Coma Scale

The FOUR score addresses a key limitation of the Glasgow Coma Scale (GCS) by omitting a verbal response component, enabling complete assessment in intubated or sedated patients where the GCS is capped at a maximum of 10 (with "T" for tube substitution). This design allows for full scoring across all domains without arbitrary substitutions, providing a more accurate reflection of neurological status in critically ill individuals who cannot vocalize due to mechanical ventilation or pharmacological sedation.[2][3] In addition to eye and motor responses, the FOUR score incorporates brainstem reflexes and respiration, offering a broader neurological evaluation than the GCS, which lacks these elements and may overlook critical abnormalities such as apnea or absent pupillary responses. For instance, the brainstem component can identify locked-in syndrome—where patients appear comatose but retain consciousness—through preserved vertical eye movements or intact pupillary light reflexes, a distinction the GCS cannot make due to its focus on basic arousal and motor function. Similarly, the respiration subscale detects patterns like irregular breathing or Cheyne-Stokes respiration in non-intubated patients, highlighting potential brainstem dysfunction that the GCS ignores entirely.[2][3] The FOUR score provides higher resolution with 17 possible total values (ranging from 0 to 16) compared to the GCS's 13 (3 to 15), delivering greater granularity particularly in profound unresponsiveness where GCS scores cluster at the lower end. Each of its four components uses a straightforward 0-4 scale, which is easier to apply and remember than the GCS's uneven structure, while avoiding ambiguities in verbal scoring such as distinguishing incomprehensible sounds from no response. In the motor domain, for example, it explicitly differentiates myoclonus status epilepticus from true absence of response (both scored as 0 but noted distinctly), enhancing precision in identifying subtle pathological movements.[2][3]

Validation and Reliability Studies

The FOUR score was initially validated in a prospective study of 120 patients in a neuro-intensive care unit, demonstrating excellent inter-rater reliability with a weighted kappa of 0.82, and it outperformed the Glasgow Coma Scale (GCS) in predicting mortality.[15] In a 2010 study conducted in a general intensive care unit setting with unselected critically ill patients, the FOUR score showed substantial inter-rater agreement between nurses and physicians, surpassing the agreement of the GCS, with comparable predictive performance for in-hospital mortality.[18] Validation in the emergency department was established in a 2009 prospective observational study involving 69 comatose patients assessed by non-neurology emergency medicine staff, where the FOUR score exhibited high inter-rater reliability (weighted kappa 0.88) and performed comparably to the GCS overall, but demonstrated superiority in evaluating intubated patients by incorporating brainstem and respiratory components without relying on verbal responses.[19] A 2024 systematic review and meta-analysis of 20 studies confirmed the FOUR score's superior predictive validity for mortality compared to the GCS, with higher sensitivity and specificity across diverse etiologies including traumatic brain injury and stroke.[20] The FOUR score has been validated in pediatric populations, as shown in a 2012 study of 100 children with head trauma where it provided equivalent prognostic accuracy for mortality and outcomes to the GCS, and similar validations in other settings.[21] Cross-cultural consistency has been evidenced in various international adaptations, indicating reliable application across diverse cultural and linguistic contexts.

Clinical Applications

Use in Healthcare Settings

In neurocritical care units, the FOUR score serves as a standard tool for serial monitoring of patients with conditions such as traumatic brain injury (TBI) and subarachnoid hemorrhage, providing detailed neurological assessment to track changes in consciousness and guide interventions. It is typically performed every 1-4 hours in acute phases to detect deterioration or improvement, offering advantages over other scales by evaluating brainstem reflexes and respiration without relying on verbal responses. This frequent application helps clinicians correlate score trends with outcomes, such as early mortality prediction in TBI cases.[22] In general intensive care units (ICUs), the FOUR score is applied to patients with non-neurological causes of coma, including drug overdose and sepsis, where it facilitates comprehensive evaluation of responsiveness and respiratory patterns to inform management decisions like ventilator weaning. Its inclusion of a respiration component allows for objective assessment of breathing drive, aiding in the transition from mechanical ventilation when scores indicate sufficient brainstem function. This utility extends to diverse critically ill populations, enhancing prognostic insights in medical ICUs.[2] Emergency departments employ the FOUR score for rapid triage of patients presenting with altered mental status, enabling quick assessment by non-specialist staff such as nurses, who can complete scoring in under 2 minutes with high reliability. It supports efficient decision-making for intubation or neuroimaging, particularly in time-sensitive scenarios like trauma or stroke. Validation studies confirm its feasibility in this setting, where it provides neurologic detail comparable to or exceeding traditional scales.[23] Emerging applications in prehospital and emergency medical services (EMS) settings highlight the FOUR score's portability for field assessments of TBI or other coma etiologies, allowing paramedics to perform quick evaluations during transport without specialized equipment. Its simplicity and lack of verbal components make it suitable for intubated or aphasic patients en route to hospitals.[24] The FOUR score is often integrated with complementary diagnostics, such as CT or MRI imaging and laboratory tests, to contextualize findings in overall patient care; for instance, low scores may prompt urgent neuroimaging to rule out structural lesions. Training protocols emphasize standardized administration to ensure inter-rater consistency, with brief education sessions enabling nurses and residents to achieve reliable results across healthcare teams.[2]

Limitations and Considerations

The FOUR score, while offering detailed neurological assessment, incorporates elements of subjectivity, particularly in evaluating motor responses to pain stimuli, where clinician interpretation of patient reactions—such as localization or flexion—can vary based on experience and technique.[25] Studies have reported interobserver variability comparable to or not significantly better than that of the Glasgow Coma Scale, underscoring the need for standardized training to enhance reliability and reduce discrepancies among raters.[25] Validation of the FOUR score remains limited in certain populations, including very young children, where a pediatric adaptation exists but has been tested primarily in older pediatric cohorts rather than neonates or infants under one year.[26] Similarly, while translations into languages such as Chinese, Italian, Greek, and Portuguese demonstrate good reliability in those settings, cultural adaptations are incomplete in many regions, potentially affecting applicability in non-Western or linguistically diverse environments without further localization.[27][28][29][30] Clinicians must avoid over-reliance on the FOUR score, as it assesses level of consciousness and brainstem function but does not substitute for a comprehensive neurological examination, potentially overlooking etiologies like aphasia or psychiatric conditions that mimic unresponsiveness without structural brainstem involvement.[15] Although administration typically requires only 1-2 minutes, consistent application demands standardized stimuli, such as central nail-bed pressure for pain assessment, to ensure reproducibility across evaluations.[2] Best practices emphasize combining the FOUR score with multimodal assessments, particularly in intubated patients where its advantages shine, to mitigate these limitations and inform prognosis accurately.[15]

References

  1. The current significance of the FOUR score: A systematic review and ...
  2. Validity of the FOUR Score Coma Scale in the Medical Intensive ...
  3. Validation of a new coma scale: The FOUR score - Wijdicks - 2005
  4. FOUR (Full Outline of UnResponsiveness) Score - MDCalc
  5. Full Outline of Unresponsiveness Score versus Glasgow Coma ...
  6. https://doi.org/10.1002/ana.20611
  7. Validation of a new coma scale: The FOUR score - Wijdicks - 2005
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719522/
  9. Decerebrate and Decorticate Posturing - StatPearls - NCBI Bookshelf
  10. Full Outline of UnResponsiveness Score - Shirley Ryan AbilityLab
  11. Level of Consciousness - Clinical Methods - NCBI Bookshelf - NIH
  12. Full Outline of Unresponsiveness Score versus Glasgow Coma...
  13. Prediction of Mortality in the Medical Intensive Care Unit with Serial ...
  14. Validation of a new coma scale: The FOUR score - PubMed
  15. Glasgow Coma Scale and FOUR Score in Predicting the Mortality of ...
  16. The Relationship of the FOUR Score to Patient Outcome
  17. Inter-rater reliability of the Full Outline of UnResponsiveness score ...
  18. The Predictive Validity of the Full Outline of UnResponsiveness ...
  19. Validation of the Full Outline of Unresponsiveness score coma scale ...
  20. The current significance of the FOUR score: A systematic review and ...
  21. Validation of a New Coma Scale, the FOUR Score, in the ...
  22. (PDF) FOUR score versus GCS in patients with traumatic brain injury ...
  23. Full Outline of UnResponsiveness score versus Glasgow Coma ...
  24. A pediatric FOUR score coma scale: interrater reliability ... - PubMed
  25. Validation of the Chinese version of the FOUR score in the ...
  26. Cross-Cultural Adaptation and Validation of the Greek Version of the ...
  27. Artificial Intelligence in Healthcare: 2024 Year in Review - medRxiv
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