Disappearance of the 'no-reflow' phenomenon after adjunctive intracoronary administration of nicorandil in a patient with acute myocardial infarction

Adjunctive intracoronary administration of nicorandil, an ATP-sensitive potassium channel opener, after successful coronary revascularization was performed in a 54-year-old patient with acute myocardial infarction. The 'no-reflow' phenomenon disappeared after nicorandil administration and significant functional recovery of the infarcted myocardium was achieved. This suggests that nicorandil could eliminate the 'no-reflow' phenomenon after successful coronary revascularization.

The RY sequence is necessary but not sufficient for the transcription activation of a winged bean chymotrypsin inhibitor gene in developing seeds

A winged bean Kunitz-type chymotrypsin inhibitor (WCI) is expressed in seeds and tuberous roots. In seeds, the expression of WCI is restricted to the period between the mid- and late-maturation stage. To understand the mechanisms that regulate the expression of WCI genes, we analyzed the promoter activity of the upstream region of the WCI-3b gene, which encodes a major WCI protein, in transgenic tobacco plants. By using a series of constructs with 5' deletions in the upstream sequences, the region between -882 and -623, relative to the transcription start site, was shown to contain multiple sequences which are responsible for high level expression in mid-maturation stage seeds. However, when this region was fused to the cauliflower mosaic virus 35S core promoter in both orientations, the chimeric promoters showed only a weak transcription activity in transgenic tobacco plants. Further analyses using internal deletion constructs revealed that the region between -882 and -174 is required for the transcription activation. Disruption of the RY sequence at -517, which is conserved in many seed protein genes, resulted in a drastic reduction of the transcription activity in seeds. These results suggest that sequences necessary for high level induction of the WCI-3b gene transcription in developing seeds are dispersed in the region between -882 and -174, and that the RY sequence is one of these sequences.

Angiotensin converting enzyme inhibitors suppress production of tumor necrosis factor-alpha in vitro and in vivo

It has been reported that angiotensin converting enzyme (ACE) inhibitors have beneficial effects on insulin resistance and congestive heart failure, in which elevations of serum tumor necrosis factor-alpha (TNF-alpha) level have been indicated. Therefore, in this study, we examined effect of ACE inhibitors on TNF-alpha production both in vitro and in vivo by using human blood mononuclear cells and mice, respectively. LPS (20 micrograms/ml)-induced in vitro TNF-alpha production, measured by bioassay and enzyme-linked immunosorbent assay, was significantly inhibited with captopril, delapril and cilazapril in a concentration of 10(-3) mol/l. A single, oral administration of captopril, delapril and cilazapril at more than 10-fold doses of common clinical use in man significantly inhibited LPS (2 mg/kg)-induced serum TNF-alpha activity in Balb/c mice. These results indicate that ACE inhibitors such as captopril, delapril and cilazapril have an inhibitory effect on TNF-alpha production not only in vitro as previously reported, but also in vivo, although relatively high concentrations and large doses were required in this study.

The effect of YNK-01 (an oral prodrug of cytarabine) on hepatocellular carcinoma

Thirty-two patients with hepatocellular carcinoma (HCC) were treated with YNK-01, a prodrug of cytarabine for oral administration. A dose of 200 mg/d of YNK-01 was administered to 17 cases and 300 mg/d to 15 cases. One course was 2 weeks in duration, and this was repeated every 4 weeks for as long as the patients were able to tolerate it. There were five partial responses (15%) and 13 patients with no change (41%). A higher partial response rate was observed in the 300 mg/d group (27%) compared with the 200 mg/d group (6%). The average durations of partial response and no change were approximately 4 and 3 months, respectively. The main side effects of YNK-01 were anemia, leukopenia, thrombocytopenia, and symptoms of the alimentary tract (nausea, anorexia, diarrhea, etc). These results suggest that YNK-01 is a potentially useful oral agent for chemotherapy of hepatocellular carcinoma.

Effect of long-term treatment with complete Freund's adjuvant on KK-Ay mouse, a model of non-insulin-dependent diabetes mellitus

Nonspecific stimulation with immunoadjuvants significantly improves glucose tolerance in animal models for non-insulin-dependent diabetes mellitus (NIDDM). In this study, we observed the effect of long-term treatment with complete Freund's adjuvant (CFA) on serum factors and histology of various organs in KK-Ay mice with NIDDM. The mice were injected with CFA weekly or every 2 weeks for 12 weeks. Glucose tolerance was significantly improved in the CFA-treated mice throughout the experiment. At the end of the experiment, hypertriglyceridemia was significantly reduced, but serum total protein, glutamic pyruvic transaminase, creatinine, and nonfasting insulin levels were not changed by the treatment. Fatty change of the liver and index of glomerular lesions of the kidney were significantly inhibited in the CFA-treated mice, whereas the pancreatic islet morphology remained unchanged. No toxic effect was observed by the CFA treatment. These results imply that the novel treatment with CFA could control NIDDM and inhibit the development of diabetic glomerular lesions in KK-Ay mice.

Prospective and randomized trial of lipiodol-transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma: a comparison of epirubicin and doxorubicin (second cooperative study). The Cooperative Study Group for Liver Cancer Treatment of Japan

A randomized, controlled clinical trial was conducted to compare the use of epirubicin (EPI) and doxorubicin (DOX) in Lipiodol (Laboratoire Guerbet, Roissy-Charles-de-Gaulle Cedex, France)-transcatheter arterial chemoembolization as a treatment of hepatocellular carcinoma. One hundred ninety-two hospitals participated, and 415 patients were enrolled in the study during the period between October 1989 and December 1990. The patients were randomly allocated to group A (EPI) or group B (DOX) by a centralized telephone registration. The actual doses of EPI and DOX were 72 mg/body and 48 mg/body, respectively. The 1-, 2-, and 3-year survival rates were, respectively, 69%, 44%, and 33% for group A and 73%, 54%, and 37% for group B. There were no statistically significant differences (P = .2296, log-rank test). When each group of patients was classified retrospectively into high-risk and low-risk subgroups based on the severity index calculated by the Cox regression model from the significant prognostic factors (the pretreatment tumor size, the pretreatment serum alpha-fetoprotein level, tumor encroachment, and Child's classification), the survival curve of the low-risk DOX subgroup was significantly superior to that of the low-risk EPI subgroup (P = .0182). However, there was no significant difference between the high-risk subgroups (P = .4606). The change in the serum alpha-fetoprotein level, the extent of Lipiodol accumulation in the tumor, and the extent of tumor reduction after the treatment did not show any significant differences between the groups. The white blood cell count in group B showed a tendency to decrease slightly more than in group A at 3 weeks after Lipiodol-transcatheter arterial chemoembolization. In conclusion, there was no statistically significant difference between the survival curves of the EPI and DOX groups in Lipiodol-transcatheter arterial embolization treatment of hepatocellular carcinoma.

Fibroblasts spread on immobilized fibrin monomer by mobilizing a beta1-class integrin, together with a vitronectin receptor alphavbeta3 on their surface

Human and murine fibroblasts were found to spread far more avidly on fibrin monomer monolayers than on immobilized fibrinogen, indicating that removal of fibrinopeptides by thrombin is a prerequisite for the fibrin-mediated augmentation of cell spreading. In fact, cell spreading was not efficiently augmented on monolayers of a thrombin-treated dysfibrinogen lacking the release of fibrinopeptide A due to an Aalpha Arg-16 --> Cys substitution. Since a synthetic Arg-Gly-Asp (RGD)-containing peptide inhibited the fibrin-mediated cell spreading, subsequent dissociation of the carboxyl-terminal globular domain of the Aalpha-chains appears to render the RGD segments accessible to the cell-surface integrins. In support of this, fibrin-augmented cell spreading was inhibited by an antibody recognizing a 12-kDa peptide segment with gamma Met-89 at its amino terminus, which is located in close association with the RGD segment at Aalpha 95-97 in the helical coiled-coil interdomainal connector. The fibrin-mediated augmentation of cell spreading was inhibited not only by an antibody against human vitronectin receptor (LM 609) but also by an antibody against the beta1 subunit of integrin (mAb13), suggesting that the beta1-class integrin together with a vitronectin receptor, alphavbeta3, is mobilized onto the surface of fibroblasts upon contact with the fibrin monomer monolayer.

Evolution of a multigene family that encodes the Kunitz chymotrypsin inhibitor in winged bean: a possible intermediate in the generation of a new gene with a distinct pattern of expression

Winged bean Kunitz chymotrypsin inhibitor (WCI) accumulates in an organ-specific and temporally regulated manner. The protein is encoded by a multigene family that includes at least four putative inhibitor-coding genes and three pseudogenes. The structure of the WCI genes indicates that an insertion at a 5' proximal site occurred after duplication of the ancestral WCI gene and that several gene conversion events subsequently contributed to the evolution of this gene family. Analysis of the promoter activity of the 5' regions of the WCI genes in transgenic tobacco showed that only the 5' regions of the WCI-3a and WCI-3b genes, which encode the major WCI protein in winged bean, promoted the organ-specific and temporally regulated expression of a reporter gene. The 5' region of a pseudogene, the WCI-P1 gene which contains frameshift mutations, exhibited constitutive promoter activity in tobacco, an indication that the 5' region of the WCI-P1 gene might spontaneously have acquired new regulatory sequences during evolution. Since gene conversion is a relatively frequent event and since the homology between the WCI-P1 and WCI-3a/b genes is disrupted at a 5' proximal site by remnants of an inserted sequence, the WCI-P1 gene appears to be a possible intermediate that could be converted into a new functional gene with a distinct pattern of expression by a single gene-conversion event.

Monocytes modulate the fibrinolytic balance of endothelial cells

Cultured endothelial cells (ECs) produced a constitutive plasminogen activator inhibitor-I (PAI-1), whereas primary culture of monocytes from blood did not produce a detectable amount of PAI-1. Addition of monocytes to ECs caused the accumulation of a large amount of PAI-1 in the supernatant in a dose- and time-dependent manner. Having almost no effect on the production of tissue-type plasminogen activator (t-PA), monocytes decreased the potential fibrinolytic activity of ECs. The 6 hours conditioned medium obtained from the coculture system between monocytes and either ECs or paraformaldehyde-fixed ECs had almost the same effect on the other ECs to produce PAI-1 and t-PA as monocytes that were direct contact with ECs. In addition, this effect was specifically inhibited by using two antibodies against interleukin-1 beta and tumor necrosis factor-alpha. These results indicate that interleukin-1 beta and tumor necrosis factor-alpha induced by the coculture are mostly responsible for decreasing the fibrinolytic activity of ECs.

[Clinical study on azithromycin in 10% fine granules and 100mg capsules in the field of pediatrics]

Azithromycin (AZM), a new oral macrolide antibiotic, in 10% fine granules or 100 mg capsules was given to pediatric patients to treat various infections. The following results were obtained in our studies of AZM for its antibacterial activities against clinical isolates, its pharmacokinetics, its efficacy, and its safety. 1. MICs of AZM, erythromycin (EM) and clarithromycin (CAM) were determined against a total of 57 strains all at 10(6) cfu/ml. Among Gram-positive cocci, MICs of AZM ranged from 0.78 to > 100 micrograms/ml against Staphylococcus aureus (20 strains), from 0.05 to 0.1 microgram/ml against Streptococcus pyogenes (11 strains), and from 0.0125 to 3.13 micrograms/ml against Streptococcus pneumoniae (10 strains). These MICs were similar to those of the other macrolides. Among Gram-negative bacilli, MICs of AZM were 0.05 micrograms/ml against Moraxella subgenus Branhamella catarrhalis (1 strain), from 0.78 to 3.13 micrograms/ml against Haemophilus influenzae (9 strains), 0.78 micrograms/ml against Haemophilus parainfluenzae (1 strain) and 6.25 micrograms/ml against salmonella sp. (1 strain). These values were similar to or lower than those of the other macrolides. Against Mycoplasma pneumoniae, MICs of AZM were < or = 0.0008 micrograms/ml in three strains. One strain of M. pneumoniae showed tolerance to AZM at MIC 25 micrograms/ml. The other agents exhibited higher MIC than AZM against this organism. 2. Plasma samples were collected from five patients receiving fine granules and four patients receiving capsules for drug level determination. The patients received AZM at 10.0 approximately 16.3 mg/kg body weight once daily for 3 days. Drug concentrations in plasma at two hours after Day 3 dosing were in a range between 0.02 and 0.19 micrograms/ml for fine granules and were in a range between 0.11 and 0.42 micrograms/ml for capsules. 3. Urine samples were collected from four patients receiving fine granules and four patients receiving capsules. Drug levels were determined to be 3 micrograms/ml at post-treatment 48 hours for fine granules and post-treatment 72 hours for capsules. Urinary excretion rates of AZM in three patients on capsules lied in a range between 4.69 and 10.17%. 4. Effectiveness of AZM in fine granules was evaluated in 128 patients having a total of 19 different infections. AZM was rated "excellent" in 51 patients, "good" in 63, "fair" in 8, "poor" in 6, resulting in an efficacy rate of 89.1%. Effectiveness of AZM in capsular form was evaluated in 23 patients with five different infections. AZM was found "excellent" in 13 patients and "good" in 10, resulting in an efficacy rate of 100%. 5. AZM in fine granules eradicated 45 strains of 54 in 8 different bacteria. AZM in capsules eradicated 9 strains of 10 strains in 6 different bacteria. 6. As for adverse reactions, one patient complained of eruption, one vomiting, one loose stool, five diarrhea, when administered with fine granular form of AZM. One patient on AZM capsules experienced urticaria and vomiting. 7. As for abnormal laboratory changes, three patients were found with decreased WBC, seven with increased eosinophil, two with increased GOT and GPT, one with increased GPT. They were all on fine granular form of AZM. As far as abnormalities found in patients administered with AZM in capsular form, two showed decreased WBC, one decreased WBC along with increased eosinophil, and three increased eosinophil.

A battery of monoclonal antibodies that induce unique conformations to evolve cryptic but constitutive functions of plasminogen

Two groups of anti-plasminogen monoclonal antibodies, whose epitope was either in the kringle 1 + 2 + 3 domain (F3P2, F11P5, F11P6, and F12P18) or the kringle 5 domain (F1P6 and F12P16), were isolated and their effects on the conformation of plasminogen were explored. All antibodies except F1P6 had 3- to 10-fold higher affinity toward Lys-plasminogen than Glu-plasminogen. F1P6 exhibited a comparable affinity to Glu- and Lys-plasminogen. Among these, only F11P5 binding was inhibited by epsilon-amino-nu-caproic acid (EACA) in a concentration-dependent manner, with half maximal inhibition at 3 mM. From a competition assay, we concluded that the epitopes of F11P5, F11P6, and F12P18 should be very close, and located at or near the low affinity lysine binding site on the kringle 2 + 3. These three antibodies dramatically enhanced the binding of Glu-plasminogen to the other antibodies, except to F1P6. Interestingly, F3P2, whose non-overlapping epitope was in the kringle 2 + 3 domain, also augmented the binding of Glu-plasminogen to the other antibodies. In contrast, we did not observe enhanced binding of Lys-plasminogen to one antibody in the presence of the other antibodies, and the binding of Glu-plasminogen to these antibodies did not increase in the presence of 10 mM EACA. In the presence of these antibodies, including F1P6, Glu-plasminogen bound more efficiently to immobilized degraded fibrin, with a binding profile similar to Lys-plasminogen. All antibodies except F1P6 enhanced the conversion rate of plasminogen to plasmin remarkably. Taken together, we propose that these two groups of monoclonal antibodies can dissociate the intramolecular interactions of Glu-plasminogen and induce the conformational transition of Glu-plasminogen to Lys-plasminogen. In addition, the kringle 2 + 3 and kringle 5 structures of Glu-plasminogen liganded with EACA are distinct from the Lys-plasminogen structure.

A gene encoding a major Kunitz proteinase inhibitor of storage organs of winged bean is also expressed in the phloem of stems

Winged bean Kunitz chymotrypsin inhibitor (WCI) accumulates abundantly in seeds and tuberous roots, and small amounts of the WCI protein and mRNA can also be detected in stems. In this study, we analyzed the localization of the WCI protein in stems of winged bean. The results demonstrated that the WCI protein was localized in sieve tubes. Furthermore, we showed that the 5' region of the WCI-3b gene, which exhibited strong transcriptional activity in developing seeds, also promoted transcription of a reporter gene in the phloem of stems of transgenic tobacco.

[Visiting nurse support for patients wishing to die at home]

Thirty-two (1994) and 55 (1995) patients in the terminal stage of many kinds of cancer were cared for satisfactorily at home by a visiting team of nurses from Niigata Cancer Center Hospital. A prostate cancer patient with multiple bone metastasis was suffering from morphine-resistant intractable pain, and highly dependent on medical care. We continued to take care of him by frequent visitation and psychological assist until he eventually died at home according to his wishes. It is important to create a suitable support team for the continual difficult home care of each terminal patient.

Comparison of two fetal growth curves in screening for high-risk neonates

The International Statistical Classification of Diseases and Related Health Problems (ICD-10) defines the 10th percentiles on the fetal growth curve as the cutoff point for light- and small-for-gestational-age infants, instead of the mean bodyweight -1.5 standard deviation (SD) on the fetal growth curve, which has been used in Japan since 1983. Data on a 5260 sample of term neonates who were born during the 30-month period between January 1993 and June 1995 were obtained. The clinical usefulness of the 10th percentiles and mean bodyweight -1.5 SD cutoff on the fetal growth curve as screening criteria for high-risk neonates of light- and small-for-gestational-age infants was evaluated. There was a statistically significant higher morbidity rate among the neonates whose birthweight was below mean bodyweight -1.5 SD than for those whose birthweight was below the 10th percentile cut off. But there was no significant difference between the morbidity rate of neonates whose birthweight was between mean bodyweight -1.5 SD and the 10th percentile cutoff and the morbidity rate of neonates whose birthweight was above the 10th percentile cutoff. Therefore, mean bodyweight -1.5 SD on the fetal growth curve is a more effective means of screening for high-risk light- and small-for-gestational-age infants than the 10th percentile cutoff on the fetal growth curve.

Dexamethasone and bacterial meningitis in Pakistan

The objective of this study was to assess, in a developing country setting, the effect of dexamethasone therapy on bacterial meningitis outcomes. A prospective double blind placebo controlled trial was conducted in 89 children aged from 2 months to 12 years suffering from bacterial meningitis. Neurological, developmental, and hearing assessments were conducted at one, four, and 12 months after discharge. Forty eight patients received dexamethasone and 41 placebo. Initial antimicrobial drugs used were ampicillin and chloramphenicol. For all patients at the time of admission the mean duration of illness was 5.7 days; 47% had had seizures and 56% had impaired consciousness. Seventeen of 89 (19%) patients died. The mortality for the dexamethasone group was 25% as compared with 12% in the group receiving placebo. Presentation to the hospital after four days of symptoms and with impaired conscious state were independent predictors of death. Of the dexamethasone group survivors, 26.5% had neurological sequelae and 42.3% had hearing impairment, whereas in the placebo group it was 24% and 30% respectively. Altered state of consciousness was a predictor of neurological sequelae. The presence of neurological sequelae and high cerebrospinal fluid protein independently predicted hearing loss. No beneficial effect of dexamethasone was observed on morbidity or mortality of this group of patients with bacterial meningitis. Dexamethasone is therefore not useful in developing countries as adjunctive treatment in patients seriously ill with bacterial meningitis, who present late for treatment and have been partially treated.

Hodgkin disease occurring in a patient with extremely high serum antibody titers to Epstein-Barr virus--associated antigens without chronic illness

PURPOSE

We described for the first time a patient with long-lasting, extremely high serum antibody titer against Epstein-Barr virus (EBV) viral capsid antigen and early antigen without clinical symptoms suggestive of active EBV infection; the patient finally developed Hodgkin disease (HD) after 7 years of follow-up.

PATIENT AND METHODS

High serum EBV antibody titers were noted at 2 years of age. Immunological evaluation was performed at the age of 7 years. EBV-specific cytotoxic T-lymphocyte activity was normal. None of the other results showed any significant abnormalities except for the abnormal antibody titers against EBV-associated antigens.

RESULTS

The patient developed HD at the age of 9 years. In addition, EBV genomes were found in the nuclei of Hodgkin and Reed-Sternberg cells in the lymph node.

CONCLUSIONS

This case suggests that (a) a patient with extremely high serum antibody titers against EBV-associated antigens may develop HD after a prolonged period, even though no clinical symptom suggestive of active EBV infection is observed; (b) EBV may play an important role in the occurrence of HD.

Relapses or reinfections: analysis of a case of Clostridium difficile-associated colitis by two typing systems

Immunoblotting and pulsed-field gel electrophoresis of Clostridium difficile isolates were employed to differentiate reinfection by a newly acquired strain from relapse by an original strain in a 10-year-old patient with four episodes of C. difficile-associated colitis. Immunoblot typing demonstrated subserogroup K-1 of serogroup K for the first and second organisms, subserogroup A-1 of serogroup A for the third organism, and subserogroup G-4 of serogroup G for the fourth organism. PFGE analysis revealed consistent results with immunoblot analysis except that the strains from the fourth episode, whose DNA constantly degraded, were nontypable by this method. Five separate isolates of C. difficile from a specimen of each episode showed identical PFGE patterns, indicating that infections of multiple strains probably did not occur in this patient. These typing results suggested that the second episode after a 17-day course of vancomycin therapy represented a relapse by the strain causing the first episode, and that the third and fourth episodes after tapering vancomycin therapy were reinfections by other strains. Both immunoblot and PFGE typing systems are promising tools for analyzing recurrence of C. difficile infection.

Expression of plasminogen activator inhibitor 2 in the adult and embryonic mouse tissues

We have studied the expression of plasminogen activator inhibitor 2 (PAI-2) in the adult mouse and during embryonic development using immunohistochemistry and the polymerase-chain reaction. Mouse PAI-2 mRNA was mainly expressed in the skin, bone-marrow, spleen, lung, thymus, and urinary bladder. Immunohistochemical studies suggested that PAI-2 was synthesized in macrophages and epithelial cells such as skin epithelial cells, transitional cells of the urinary bladder, and mesothelial cell of peritoneum and pleura. PAI-2 mRNA and antigen expression was observed only in the skin of 15 day-old mouse embryos. These data suggest that PAI-2 may play a role in protecting the mouse embryo from the protease attack in the amniotic fluid and also in maintaining and/or protecting the structure of various surfaces in the mouse.

[Chemotherapy for pancreatic cancer]

Few antitumor agents are effective for advanced pancreatic cancer. 5-fluorouracil, doxorubicin, epirubicin, and mitomycin C were tested as single agents for their respective efficacy against pancreatic cancer. Their response rates were 15, 12, 24 and 24%, respectively. Several trials of combination chemotherapy using mitomycin C, doxorubicin and 5-FU (FAM) were performed, but their response rates did not go exceed those of single agents. Recently, the goal of chemotherapy for pancreatic cancer is thought to be quality of life. Combination of 5-FU and cisplatin or 5-FU, leucovorin and alpha interferon were effective for the prolongation of life with less toxicities. Their median survival times were 7.6 months, and 22 months in PR cases, respectively. CPT-11, gemcitabine, taxotere and BOF-A2 are promising new drugs for their effectiveness and benefits for patients with pancreatic cancer. Combination of mitomycin C, carboquone and 5-FU with angiotensin II was effective in terms of antitumor effect and prolongation of life. Generally, a large number of patients with advanced pancreatic cancer cannot receive chemotherapy because of deterioration in performance status. For them, combination of continuous venous infusion of low-dose 5-FU and low-dose cisplatin could be effective. The majority of patients with pancreatic cancer must await new agents and methodology in the future.

Postabsorptive factors are important for satiation in rats after a lipid meal

We examined satiation after intraduodenal infusion of triglyceride with or without Pluronic L-81 (L-81) in rats. L-81 suppresses lipid transport into mesenteric lymph by preventing the formation of chylomicrons. Under unrestrained conditions, a lipid emulsion was infused into 24-h fasted rats intraduodenally for 8 h. After the infusion, food intake during the first 30 min and blood samples were measured. Food intake after the 8-h lipid infusion decreased significantly (-75%) compared with that of rats infused with vehicle only, and the effect of the lipid meal was time dependent. The satiation effect of the lipid was lost as a result of L-81 treatment, but food intake was still significantly decreased (-22%). The loss of inhibition of food intake by the feeding of lipid plus L-81 was totally reversed by the cessation of L-81 infusion. In rats infused with the lipid emulsion, plasma levels of triglyceride and apolipoprotein A-IV increased significantly. This increase was abolished by the presence of L-81 in the lipid infusate. The present study indicates that postabsorptive factors are important for anorexia observed after a lipid meal in addition to preabsorptive factors. This study further supports our previous conclusion that apolipoprotein A-IV is an important postabsorptive factor for satiation after a lipid meal.