Effects of endoscopic variceal sclerotherapy on azygos vein blood flow and systemic haemodynamics

The present study was designed to determine the systemic haemodynamic effects of obliterating oesophageal varices by endoscopic sclerotherapy. We evaluated systemic and splanchnic haemodynamics before and after the first course of sclerotherapy in cirrhotic patients. The baseline cardiac index was significantly correlated with baseline azygos vein blood flow (r = 0.64; P < 0.01) and the azygos vein blood flow and cardiac index significantly decreased (-33% and -16%, respectively; P < 0.01) following sclerotherapy. The systemic vascular resistance index was also increased significantly (+ 20%; P < 0.01) in these patients. Moreover, the per cent change in azygos vein blood flow was directly correlated with that of the cardiac index (r = 0.51; P < 0.03). We conclude from these findings that the obliteration of portosystemic collaterals by sclerotherapy significantly reverses hyperdynamic circulation in such patients via a decrease in cardiac preload. The blood flow of the portosystemic shunt per se is a leading contributor to the hyperdynamic circulation observed in patients with well-developed portal systemic collateral vessels.

Histological and biochemical evaluation of osteogenic response in porous hydroxyapatite coated alumina ceramics

We compared the osteogenic response in porous alumni (Al) and hydroxyapatite coated porous alumni ceramic (HA/Al) by grafting rat bone marrow cells with these implants subcutaneously in the back of syngeneic rats. The ceramics did not show any bone formation without marrow, but did when combined with marrow cells. The osteogenesis in HA/Al began directly on the ceramic surface, but in Al began away from the ceramic surface, and fibrous tissue interposition was seen between the de novo bone and its surface. Alkaline phosphatase activity and bone specific bone gla protein content in HA/Al with marrow were both about three times higher than in Al with marrow. These results indicate that HA/Al has excellent osteoconductive properties and that a composite of marrow and HA/Al is clinically applicable osteogenic biomaterial.

Hemorrhage from abdominal non-Hodgkin's lymphoma treated successfully by emergency transcatheter arterial embolization

A 49-year-old Japanese woman with follicular lymphoma who presented with severe abdominal and back pain is reported. She was known to have malignant lymphoma and had been previously treated with combination chemotherapy. An abdominal tumor occurring at the root of the mesentery and involving the superior mesenteric artery (SMA) had been diagnosed by computed tomography (CT), magnetic resonance imaging, and abdominal angiography. Emergent ultrasonography and CT findings showed intraperitoneal bleeding from the abdominal tumor. Selective SMA angiography revealed extravasation from a small branch originating from the dorsal pancreatic artery, which was embolized through a catheter by using platinum coils. It should be noted that a large tumor of malignant lymphoma, involving large vessels, may bleed, and in such a case selective transcatheter arterial embolization may be one of the effective modalities for hemostasis.

General pharmacology of recombinant human basic fibroblast growth factor

General pharmacological effects of recombinant human basic fibroblast growth factor (bFGF) were investigated. 1. Central nervous system: Basic FGF produced almost no effect on the general symptoms and behaviors of mice. Basic FGF did not influence the spontaneous motor activity, hexobarbital-induced anesthesia, electroshock seizure threshold, pentylenetetrazole-induced seizure in mice and normal body temperature and spinal reflex in rats up to a dose of 1 mg/kg (s.c., i.v.). As regards pain sensation, it inhibited the acetic acid-induced writhing at 1 mg/kg (s.c.). No abnormal waves were observed in spontaneous EEG of the rabbit up to 1 mg/kg (i.v.) of bFGF, but at 0.1 mg/kg it had a slight effect on the ratio of EEG levels and at 1 mg/kg induced an increase in rest period, disappearance in the period of fast wave sleep and a decrease in the period of deep sleep. 2. Somatic nervous system: Basic FGF did not influence the corneal reflex, twitch response of the skin and diaphragm-phrenic nerve preparations. 3. Autonomic nervous system and smooth muscle: Basic FGF showed little effects on the spontaneous movement of the isolated ileum, contraction induced by various agonists in isolated ileum, resting tension and noradrenaline(NA)-induced contraction of the aorta, resting tension and histamine-induced contraction of isolated trachea, spontaneous movement and 5-HT-induced contraction of isolated strips of stomach fundus, NA-induced contraction of isolated vas deferens of the rat up to the concentration of 10(-4) g/ml. Basic FGF augmented the tone of the isolated non-pregnant uterus at the concentrations of 10(-5) g/ml and above and inhibited or tended to inhibit the contractile tension of non-pregnant or pregnant uterus at 10(-4) g/ml, but it did not influence the spontaneous movement of the uterus, either the non-pregnant or pregnant, under in situ conditions even at a dose of 1 mg/kg (i.v.). Basic FGF did not influence the pupil size. 4. Respiratory and circulatory systems: Basic FGF had no effect on the isolated heart. The influence was not exerted on the heart rate for the isolated atria but slight inhibition of contractile force was observed at 10(-4) g/ml. In anesthetized dogs a decrease in blood pressure, a slight increase in heart rate and respiratory rate and a decrease in femoral blood flow were observed at 0.01 and 0.1 mg/kg (i.v.) of bFGF Similarly, a slight increase in heart rate and a slight decrease of blood pressure were observed at 1 mg/kg (s.c.) in conscious rats. 5. Digestive system: Administration of bFGF at 1 mg/kg did not result in changes in the transport capacity within the gastrointestinal tract (s.c., i.v.) and the secretion of the gastric juice (s.c.). 6. Urine output and electrolyte metabolism: Basic FGF produced a decrease in urinary Na+ excretion at 1 mg/kg (s.c.), and showed a tendency to increase in urinary volume at 0.01 and 0.1 mg/kg (i.v.). At 1 mg/kg (i.v.) urinary excretion of Na+ and Cl- was decreased significantly. It had no effect on the ability of rats to excrete PSP (phenol red) up to 1 mg/kg (s.c.). 7. Blood system: Basic FGF did not influence the coagulation time of the whole blood, prothrombin time and activated partial thromboplastin time of rats up to 1 mg/kg (s.c., i.v.). It did not influence the aggregation of rabbit platelets induced by collagen and ADP up to 10(-4) g/ml. Basic FGF at concentration of 10(-4) g/ml exhibited no hemolytic action. 8. Local action: Plantar subcutaneous injection of bFGF at above 0.005 mg/site induced edema by itself on and after the next day, and also reinforced carrageenin-induced edema from 1 day after injection. The results show that bFGF did not produce any acute effects on the somatic nervous system, autonomic nervous system, smooth muscle and blood system. In contrast, bFGF produced slight effects on the circulatory system, central nervous system and kidney function when injected systemically. Subcutaneous administration may produce edema at the s

Apoptosis observed in peripheral T lymphocytes from patients with chronic hepatitis B

BACKGROUND & AIMS

Activation-induced cell death is involved in regulating peripheral T-cell function. Understanding the kinetics of these T cells is important to elucidate the pathogenesis of chronic hepatitis B, which is mediated by cellular immune mechanisms.

METHODS

Subtle apoptotic cells in CD3+ cells were discriminated by flow-cytometric assay using freshly obtained and in vitro recombinant hepatitis B core antigen-stimulated peripheral lymphocytes from patients with chronic hepatitis.

RESULTS

The ratio of apoptotic cells in freshly obtained CD3+ cells was significantly higher during the decreasing phase than increasing phase of serum alanine aminotransferase activity in each patient, and apoptosis of CD3+ cells was induced by stimulation with recombinant hepatitis B core antigen.

CONCLUSIONS

Activation-induced cell death in peripheral T cells was found in chronic hepatitis B virus infection, similar to some other viral infections. The apoptosis in T cells during the decreasing phase of serum alanine aminotransferase activity results in a vast amount of T-cell deletion that may weaken T-cell function of cytotoxicity over hepatitis B virus-infected hepatocytes. Thus, activation-induced cell death is considered an important modulator in down-regulating the "burst" of responding T cells in patients with chronic hepatitis B.

Systemic hemodynamics and serum nitrate levels in patients undergoing endoscopic variceal ligation

The effects of endoscopic variceal ligation (EVL) on systemic hemodynamics are unknown. This study was conducted to determine whether the obliteration of portal-systemic collaterals by EVL affects systemic hemodynamics and serum nitrate concentrations in patients with compensated cirrhosis. We measured systemic and hepatic hemodynamics, azygos vein blood flow (AzBF), and serum nitrate concentrations before and immediately following EVL. A prompt decrease in left ventricular end-diastolic volume (LVEDV), stroke volume, cardiac index (CI), and an increase in systemic vascular resistance index (SVRI) were observed following variceal ligation. The reduction in LVEDV was associated with a decline in CI with a rise in SVRI. There was also a prompt reduction in serum nitrate concentration following variceal ligation. AzBF also significantly decreased following variceal ligation. These findings indicate that EVL decreased cardiac output via a reduction in cardiac preload (central venous return). Blood flow through portal-systemic collaterals has an important role in the enhanced cardiac preload of cirrhotic patients. The sudden decrease in serum nitrate concentrations suggests that endogenous nitric oxide may be involved in the regulation of systemic hemodynamics in patients with compensated cirrhosis.

Effect of basic fibroblast growth factor on wound healing in healing-impaired animal models

The effect of basic fibroblast growth factor (bFGF) on wound healing was studied in healing-impaired animal models such as metabolic diseases (obesity and diabetes), infection, steroid treatment, malnutrition and chronic liver failure. bFGF treatment resulted in an acceleration of wound healing in an almost same dose range regardless of impairment causes or animal species used. The beneficial effects of bFGF on wound healing were suggested to be due to its potent angiogenesis and granulation tissue formation activities, leading to a rapid reepitherialization of the wound. In addition, the findings that bFGF promoted healing in infection wound and burn wound of diabetic mice, and burn wound of dietary-restricted rats indicated its ability to accelerate wound contraction, another important process of wound closure.

High prevalence of T cell receptor D delta 2(D delta)J delta rearrangement in CD7-positive early T cell acute lymphoblastic leukemia

We have studied the molecular characteristics of the T cell receptor (TcR) genes in 16 patients with CD7+ early T cell acute lymphoblastic leukemia (T-ALL), defined as being positive for CD7 but negative for CD3/4/8, myeloperoxidase (MPO), and CD19/20. Using gene analysis, rearrangement was demonstrated in one patient for immunoglobulin heavy chain (IgH) gene, five for TcR-beta gene, and four for TcR-gamma gene. Fifteen patients (94%) had rearranged band(s) involving the joining region of the TcR-delta chain gene. In nine cases these were the only rearrangements, whereas in six cases TcR-beta and/or TcR-gamma gene rearrangements were found as well. The D delta 2(D delta)J delta 1 rearrangement was demonstrated in 87.5% (14/16) of cases. D delta 2(D delta)J delta 3 was recognized in one patient, D delta 2D delta 3 was found in three, and V(D)DJ using only V delta 2 and V delta 3 was recognized in two patients. We found no V2D delta 3, V3D delta 3, or V1(D)DJ delta rearrangement patterns. Five of nine cases with DDJ delta were positive for cytoplasmic CD3 epsilon(CyCD3 epsilon). Our data suggest that DDJ delta joining occurs at an early stage during T cell differentiation, followed by rearrangements of V delta to the DDJ delta complex. Furthermore, our findings suggest that DDJ delta recombination occurs earlier than expression of CyCD3 epsilon protein products. DDJ delta rearrangements have never been observed in non-T cell malignancies, such as precursor-B-ALL or acute myeloid leukemia. Therefore, detection of DDJ delta rearrangement in the TcR-delta locus is a useful tool to establish lineage and clonality of leukemic cells in the most immature stages of T cell development.

Acceleration of wound healing in diabetic mice by basic fibroblast growth factor

We studied the effect of recombinant human basic fibroblast growth factor (bFGF) on wound healing in genetically diabetic mice. Wound closure after full-thickness excision of skin was markedly delayed in diabetic mice compared to normoglycemic mice. A single application of bFGF caused a marked acceleration of wound healing in a dose-dependent manner. There were no hypertrophic scars or unlimited granulation tissue formation in regenerated tissues treated with any doses of bFGF under histological examination. The repeated application of bFGF for 7 d showed a bell-shaped dose-response in the rate of wound closure, and the optimal dose was as small as 0.2-2 mu g per wound. Reduced angiogenesis and granulation tissue formation were observed in diabetic mice compared to normal mice, and bFGF treatment restored both responses to significant levels. The beneficial effect of bFGF on wound healing would be largely explained by enhanced angiogenesis and granulation tissue formation.

Effect of the eradication of Helicobacter pylori on duodenal ulcer healing and ulcer relapse: randomized controlled study in Japan

To investigate the effect of the eradication of Helicobacter pylori on the healing and relapse of duodenal ulcers. 50 patients with active duodenal ulcer and H. pylori infection were randomly allocated to two treatment groups. One group (cimetidine group) received cimetidine 400 mg twice daily for 6 weeks and the other group (double-therapy group) received 300 mg amoxicillin granules and 250 mg metronidazole thrice daily for 2 weeks, in addition to the same regimen of cimetidine as the cimetidine group. Forty-two patients completed the study. After confirmation of ulcer scar, all patients were followed up for 6 months while receiving treatment with teprenone, an agent that does not affect acid secretion or the eradication of H. pylori. The healing rates at 6 weeks were 90% in the cimetidine group and 95.5% in the double-therapy group. H. pylori eradication occurred in 0% of the cimetidine group and in 73.7% of the double-therapy group (P = 0.004). The cumulative relapse rates in the two groups at 6 months were 64.3% and 11.1%, respectively (P = 0.0007). In the double-therapy group, the cumulative relapse rate at 6 months in the patients in whom H. pylori persisted was 50% (2/4); the rate was 0% (0/14) in the patients in whom H. pylori had been eradicated (P = 0.005). Histological gastritis significantly improved compared with the baseline in the double-therapy group, but no such improvement was seen in the cimetidine group. White scarring was found in 7.1% of the cimetidine group and in 83.3% of the double-therapy group after 6 months (P < 0.0001). The eradication of H. pylori markedly decreased the relapse rate in duodenal ulcer patients, and it significantly improved both the grade of gastritis and the quality of the ulcer scar.

[Clinical efficacy of fluconazole against fungal infections in hematological diseases]

Clinical efficacy of fluconazole was evaluated against fungal infections complicated with hematological diseases. Fluconazole 200 approximately 400 mg was administered intravenously to 20 suspected fungal infections occurring in patients with hematological diseases (acute leukemia 6, malignant lymphoma 11, adult T cell leukemia 2, chronic myelogenous leukemia blastic crisis 1). These mycoses included 8 cases of suspected pulmonary fungal infection, 10 cases suspected fungemia, and two cases of suspected hepatic fungal abscess. The clinical response rate was 60.0%. Side effects were observed in two cases, one with transient liver function test abnormality and the other with nausea. Fluconazole is considered to be a potent, safe antifungal agent for the treatment of suspected fungal infections associated with hematological diseases.

Activated eosinophils stimulate phosphatidylcholine secretion in primary culture of rat type II pneumocytes

Activated eosinophils in airway epithelium are involved in the pathogenesis of many airway diseases. We examined whether activated eosinophils influence the secretion of phosphatidylcholine (PC), the predominant component of pulmonary surfactant, in primary culture of rat type II pneumocytes. The eosinophils (10(5) cells/ml) activated by opsonized zymosan (100 micrograms/ml) increased PC secretion from the type II pneumocytes. The increased PC secretion reduced in the presence of both superoxide dismutase (2 units/ml) and catalase (1000 units/ml). These results suggest that activated eosinophils stimulate the secretion of pulmonary surfactant partly through superoxide anions.

Yearly variation of spontaneous somatic mutation frequency in the stamen hairs of Tradescantia clone KU 9 grown outdoors, which showed a significant increase after the Chernobyl accident

Scoring of spontaneous somatic pink mutation frequency in the stamen hairs of Tradescantia clone KU 9, a heterozygote for flower color (blue/pink; the blue color being dominant), was carried out for 11 years on plants grown outdoors, during the period of May 11-31 (for 3 weeks) in every year from 1982 to 1992. Weekly and yearly variations of the spontaneous mutation frequency were observed, and such variations could mostly be correlated to the difference in temperature. That is, the mutation frequency was generally higher in the weeks and years when the temperature was relatively low, showing the strongest negative correlation with the average minimum temperature. The variations were also correlated to the diurnal temperature difference, the mutation frequency being higher with larger diurnal temperature difference in general. However, the mutation frequency observed in 1986 was exceptionally higher than that expected from the temperature for this year, and was very significantly higher than for other years. The scoring of mutation frequency was thus continued in 1986 for an additional 4 weeks (June 1-28), and it was confirmed that such higher mutation frequencies lasted for 6 weeks in total. The exceptionally high mutation frequency seemed to be related to the radioactive fallout which occurred in early to mid May of 1986, even in Japan, after the serious nuclear reactor accident at Chernobyl, and also to the biological concentrations of radioactive nuclides which subsequently occurred, although it was difficult to conclude this definitely. The mutation frequency in 1987 was second highest, and was also significantly higher than the lowest mutation frequency observed in 1990.

Compression of spinal cord caused by spinal deformation in a cat

An 8-month-old cat with bilateral hindlimb paresis was admitted. Radiography revealed a curvature of the thoracic spine and a partial deformation of thoracolumbar vertebrae (dorsal extrusion of the cranial and caudal edges). Compression of the spinal cord (T9-L1 and L6-7) was found by myelography. Medicinal treatment did not yield the desired result. Hemilaminectomy and laminectomy were done to relieve pressure on the spinal cord leading to improved gait. It is, however, not clear whether this syndrome was primarily caused by metabolic or genetic factors.

A case of dermatofibrosarcoma protuberans on the right first toe

Reports of dermatofibrosarcoma protuberans on a toe are extremely rare. It frequently occurs on the trunk and extremities. A Japanese woman presented with a dark-brownish hyperkeratotic plaque on the dorsal skin of her first toe. The initial clinical diagnosis of verruca vulgaris prompted treatment with cryotherapy. After that a glossy milky-white tumor appeared. Only the results of the histopathologic examination resulted in a diagnosis of dermatofibrosarcoma protuberans. The unusual macroscopic finding was considered to be due to repetitive stimulation by foot movement.

Elevation of serum creatine phosphokinase during growth hormone treatment in patients with multiple pituitary hormone deficiency

Serum creatinine phosphokinase (s-CPK) increased to more than 500 U/l in 5 out of 21 patients with growth hormone (GH) deficiency during the 2 years of treatment with biosynthetic GH. In three of these five patients, s-CPK had elevated gradually after the start of GH treatment and remained high in one patient except in the period when GH injection was interrupted, and gradually decreased in the other two patients during treatment. These three patients had complete GH deficiency associated with multiple pituitary hormone deficiency due to pituitary stalk transection. One of the remaining two patients had Noonan syndrome and his s-CPK levels before therapy were relatively high. The fifth patient was a baseball athlete and the elevation of s-CPK seemed to be attributable to the strenuous exercise. Conclusion. s-CPK increases significantly in a certain group of patients with GH deficiency during GH replacement therapy. Measurement of s-CPK is to be included in the follow up laboratory tests at least in the 1st treatment year to evaluate the potential hazardous effects of GH on muscle.

Sandwich enzyme-linked immunosorbent assay for quantitative measurement of serum amyloid A protein in horses

To measure the concentration of serum amyloid A (sAA) protein in horses, a sensitive and highly reproducible sandwich (ELISA) was established, using affinity purified SAA antibody. Results of the ELISA were found to have a high correlation (r = 0.95) with those of the single radial immunodiffusion test. Equine SAA concentration was measured by use of this ELISA. In clinically normal horses, the concentration of SAA was high immediately after birth to 2 weeks of age. After that, SAA concentration had periodic fluctuations in the range of approximately 1.0 to 30 micrograms/ml. Mean (+/- SD)) concentrations of SAA in foals (< or = 12 months old) and adult horses (> or = 18 months old) were 21.23 +/- 12.20 and 14.93 +/- 9.07 micrograms/ml, respectively. In mares during the perinatal period, SAA concentration remained stable within the reference range before parturition. It increased quickly after delivery, and reached a peak value of 101.29 +/- 98.82 micrograms/ml on postpartum day 3, then began to decrease, at postpartum week 2, to the reference range by the end of postpartum month 1. In horses with experimentally induced inflammation, SAA concentration increased quickly and reached approximately four- to 40-fold increase over the pretreatment value on day 1 and remained high on days 2 to 6 after treatment. It then returned to the baseline value by 2 to 4 weeks in association with disappearance of local signs of inflammation. The SAA concentration was high in most horses with clinical signs of inflammation. It was concluded from these data that this ELISA is sensitive and reliable for measuring SAA in horses.

[The characteristics of Trypanosoma cruzi strains isolated from patients who have undergone a heart transplant]

Three strains of Trypanosoma cruzi were isolated from Chagas' disease patients transplanted for heart failure, after cardiac transplantation, and were studied in an experimental model of Chagas' disease, in mice, with evaluation of parasitic load, mortality and extension of inflammatory infiltrates in the heart. These parameters were compared with the standard strain Y. The strains had differences in the studied parameters, but there was no clear relationship between those and post-transplant evolution of the patients. Probably the clinical response is multifactorial and derives only in part from biological characteristics of the infecting T. cruzi strain, as measured in our model.

Heat-insoluble cryoglobulin in a patient with essential type I cryoglobulinemia and massive cryoglobulin-occlusive glomerulonephritis

We report a case of type I essential cryoglobulinemia with massive cryoglobulin-occlusive glomerulonephritis, in which the clinical course and the physical characteristics of the cryoglobulin were unusual. Nine years before appearance of cryoglobulin, this 54-year-old man noted edema and purpura of the lower extremities. Renal biopsy performed 2 years later showed large amounts of amorphous, weakly eosinophilic, weakly periodic acid-Schiff (PAS)-positive materials occluding the glomerular capillaries. Immunostaining showed the material to be weakly immunoglobulin (Ig) G positive, and electron microscopy showed homogeneous, electron-dense deposits. Nephrotic syndrome and azotemia did not respond to steroid treatment, and dialysis was begun 5 years after the biopsy. A small amount of cryoglobulin was first detected 2 years later, 9 years after the onset of disease. The cryoglobulin had a white gelatinous appearance, was resistant to resuspension, and did not redissolve when rewarmed to 37 degrees C. Immunoelectrophoresis of the cryoglobulin, which partially dissolved at 54 degrees C, showed it to be composed of monoclonal IgG-kappa and a small amount of albumin. We consider that the unusual physical characteristics of the cryoglobulin in this case precipitated a massive cryoglobulin-occlusive glomerulonephritis, which progressed to end-stage renal failure in the absence of significant cryoglobulinemia during the initial onset of disease.

Quantitative measurement of canine renal arterial blood flow using Doppler ultrasonography

The aim of this study was to estimate the accuracy of the quantitative measurement of renal blood flow using the non-invasive method, Doppler ultrasonography. First, we determined a method of approach to the renal artery in order to detect the rate and pattern of flow, using 8 adult beagles under general anesthesia. Secondly, we examined the renal arterial blood flow using the Doppler method and electromagnetic flowmeter using 7 mongrel dogs. A significant correlation (r = 0.879; p < 0.01) was found between two methods, though the Doppler system tended to indicate high values than the electromagnetic flowmeter. Our study suggests that the Doppler method is a useful non-invasive technique of measuring renal blood flow in the dog.

Attenuation of adrenomedullin-induced renal vasodilatation by NG-nitro L-arginine but not glibenclamide

1. The present study was conducted in order to elucidate the in vivo contribution of nitric oxide (NO) and the glibenclamide-sensitive potassium channel in the renal action of adrenomedullin in anaesthetized dogs. 2. Intrarenal arterial infusion of adrenomedullin (20 ng kg-1 min-1) elicited a pronounced increase in renal blood flow with no changes in systemic blood pressure. The renal vasodilator action of adrenomedullin was markedly attenuated by pretreatment with NG-nitro L-arginine (L-NOARG), but this was reversed by continuous infusion of L-arginine. 3. Pretreatment with glibenclamide almost completely blocked the renal vasodilatation induced by lemakalim, but had no effect on the renal vasodilator and diuretic action of adrenomedullin. 4. Intrarenal arterial infusion of adrenomedullin induced diuresis and natriuresis. Diuretic and natriuretic action of adrenomedullin was also attenuated by L-NOARG. L-Arginine partly reversed the effect of L-NOARG and adrenomedullin-induced diuresis and natriuresis. 5. These data indicate that the in vivo renal vasodilator action of adrenomedullin is mediated by the release of NO. The glibenclamide-sensitive potassium channel is not involved in the renal action of adrenomedullin, at least, not in anaesthetized dogs. Since the inhibition of L-NOARG of adrenomedullin-induced diuresis occurred concomitantly with the attenuation of the renal vasodilator action of adrenomedullin, direct involvement of NO in adrenomedullin-induced diuresis remains to be established.