Changes in renal function in primary hypothyroidism

Renal function impairment and electrolyte disorders in hypothyroidism are frequently subtle and rarely observed in clinical practice. To assess the extent of these defects, serum concentration of electrolytes and glomerular filtration rate were estimated before and after thyroid replacement therapy in 41 patients with primary hypothyroidism. All patients had decreased glomerular filtration rates and 22 patients had increased serum creatinine levels. Although a relationship between creatinine clearance and serum thyrothropin-stimulating hormone was not found, a weak correlation between age and serum creatinine concentration was observed. Hyponatremia was documented in 45% of 22 patients with elevated serum creatinine but in only 21% of 19 patients with normal creatinine. All these defects were corrected by treatment with thyroid hormone. We conclude that creatinine clearance was slightly decreased in all patients with hypothyroidism, this decrease being more noticeable in elderly patients. The greater the impairment in renal function, the more common was the occurrence of hyponatremia.

[Antiaggregant treatment for cerebral ischemia: ticlopidine versus aspirin]

INTRODUCTION

There at present exists marked controversy as to the possible greater efficacy of ticlopidine as opposed to aspirin in brain ischaemia secondary prophylaxis. In our study we compare the efficacy and safety of antiaggregant treatment with ticlopidine as opposed to aspirin in a group of 310 patients admitted to the 'Hospital Mutua de Terrassa' between the years 1990 and 1994.

RESULTS

In the group of patients treated with ticlopidine we found a larger number of new cerebrovascular incidents (p = 0.02) and peripheral vascular incidents (p = 0.01). New cerebrovascular incidents were more frequent in males (p = 0.03), in those patients with substantiated infarct (p = 0.02) and in patients with ischaemia in the carotidal region (p = 0.04). On the other hand, the group of patients treated with ticlopidine presented more secondary effects than the group treated with aspirin at the digestive (p < 0.001) and haematologic (p < 0.001) levels. The most frequent digestive secondary effects were diarrhoea (p < 0.001) and hepatopathy (p = 0.02); abnormalities in the leucocyte count were more frequent in patients treated with ticlopidine (p < 0.001), neutropenia being found in 0.8% of cases.

CONCLUSION

In the patients we studied ticlopidine was less efficacious than aspirin in the secondary prophylaxis of new vascular incidents (both cerebrovascular and peripheral vascular) and also presented a greater incidence of secondary (digestive and haematological) effects.

[Antimicrobial resistance in Haemophilus influenzae in the city of Havana, Cuba]

Fifty five Haemophilus influenzae strains were studied to determine their resistance to different antimicrobial drugs. They were isolated in Habana City, Cuba, during June 1992 to May 1993, from invasive and non invasive infections. An agar dilution method, according to NCCLS guidelines, was employed. We observed that 49%, 47.3% and 27.3% were resistant to ampicillin, tetracycline and chloramphenicol, respectively. beta-lactamase production was demonstrated in 22 strains (40%). There was neither resistance to ceftriaxone, cefotaxime nor rifampicin. 36.4% of the strains were multiresistant, being described 7 different resistance patterns. The rate of resistance to the drugs was substantially higher among serotype b than among non type b strains.

Ethanol intake, plasma catecholamine levels, and ST-segment changes without myocardial injury in rats with short-term ethanol consumption

The authors studied the effect of short-term ethanol consumption on the ST-segment and the association between ST-segment changes and the amount of daily ethanol intake and levels of plasma catecholamines. The study used 63 rats (control group n = 20, study group n = 43). The rats in the study group were exposed for 6 days to progressively larger doses of ethanol followed by 15 days of continuous exposure to ethanol. At baseline an electrocardiogram (ECG) was recorded, and on day 25 the ECG was repeated and plasma catecholamine levels were measured. The animals' hearts were removed and processed for histologic study. Repolarization abnormalities were observed in 68% of the ethanol-consuming rats. Two factors differentiated the subgroup of ethanol-consuming rats with ST-segment changes from the subgroup without ST-segment changes: amount of daily ethanol intake (0.0077 +/- 0.02 mL/g/d vs 0.0058 +/- 0.019 mL/g/d) and plasma epinephrine levels (3,881 +/- 733 pg/mL vs 1,478 +/- 406 pg/mL). No myocardial damage was detected. Our results suggest that in ethanol-consuming rats, high-volume daily ethanol intake and increased plasma catecholamines may mediate changes in the ST-segment.

Refining the localization of the PKD2 locus on chromosome 4q by linkage analysis in Spanish families with autosomal dominant polycystic kidney disease type 2

Autosomal dominant polycystic kidney disease (ADPKD) is a genetically heterogeneous disorder. At least two distinct forms of ADPKD are now well defined. In approximately 86% of affected European families, a gene defect localized to 16p13.3 was responsible for ADPKD, while a second locus has been recently localized to 4q13-q23 as candidate for the disease in the remaining families. We present confirmation of linkage to microsatellite markers on chromosome 4q in eight Spanish families with ADPKD, in which the disease was not linked to 16p13.3. By linkage analysis with marker D4S423, a maximum lod score of 9.03 at a recombination fraction of .00 was obtained. Multipoint linkage analysis, as well as a study of recombinant haplotypes, placed the PKD2 locus between D4S1542 and D4S1563, thereby defining a genetic interval of approximately 1 cM. The refined map will serve as a genetic framework for additional genetic and physical mapping of the region and will improve the accuracy of presymptomatic diagnosis of PKD2.

Homozygous tandem duplication within the gene encoding the beta-subunit of rod phosphodiesterase as a cause for autosomal recessive retinitis pigmentosa

Autosomal recessive retinitis pigmentosa (ARRP) is a degenerative disease of photoreceptors in which defects in the rhodopsin and phosphodiesterase beta-subunit (PDEB) loci have been reported. To assess the involvement of PDEB in ARRP families from Spain, we screened a panel of 19 families for linkage to markers within or close to the PDEB gene. Homozygosity was also tested in cases of consanguinity. This combined approach ruled out PDEB as the cause of the disease in all but one of the families. Molecular characterization of the gene in that family (a consanguineous pedigree) revealed a homozygous 71-bp tandem duplication in exon 1 of the affected member, the parents being heterozygous. This defect causes a frameshift mutation which leads to a premature stop codon, suggesting that this mutant allele is the underlying cause of ARRP in this patient. According to the data presented here, the PDEB gene is not the main gene responsible for ARRP, but accounts for about 5% of the cases.

[Variations of angiotensin converting enzyme in chronic obstructive pulmonary disease and chronic respiratory insufficiency]

Maintained hypoxia has been reported to induce inactivation of the Angiotensin Converting Enzyme (ACE). Variations have also been observed in patients with chronic obstructive pulmonary disease (COPD) who have chronic hypoxemia and loss of the vascular endothelium.

OBJECTIVES

1) to determine serum ACE activity in patients with COPD treated with and without continuous ambulatory oxygen therapy (CAOT); 2) to verify whether there is a correlation between ACE and any hematological, spirometric or gasometric parameter.

METHODS

fifty-eight patients fulfilling clinical and spirometric parameters of COPD were studied. Patients were assigned to two groups of therapy: A) Group A, without Continuous Ambulatory Oxygen Therapy (CAOT): 31 males and 1 female (mean age: 64.8 +/- 6.52). B) Group B (with CAOT): 23 males and 3 females (mean age years: 63.76 +/- 8 years). The following procedures were performed: spirometry, gasometry, blood chemistry, and serum ACE measurements by means of a radioenzymatic assay. The Student "t" test with the Bonferroni correction and Pearson regression analysis were used for the statistical analysis.

RESULTS

significant differences were observed for ACE values between Group A and Group B: 42.81 +/- 11.30 vs. 33.40 +/- 9.43 mumol/min/l, with a p value of 0.001, and also between Group B and reference values: 33.40 +/- 9.43 vs. 39.70 +/- 9.65 mumol/min/l, with a p value of 0.002. No differences were observed between Group A and reference values. No correlations wer found between ACE and any of the variables studied.

CONCLUSIONS

ACE was not decreased in all patients with COPD. ACE was decreased only in patients with COPD and respiratory insufficiency requiring CAOT and with advanced disease. This results can be correlated with changes in vascular endothelium, pulmonary parenchyma and metabolism. It could be a marker of poor prognosis or advanced disease.

Evolutionary pattern of human respiratory syncytial virus (subgroup A): cocirculating lineages and correlation of genetic and antigenic changes in the G glycoprotein

The genetic and antigenic variability of the G glycoproteins from 76 human respiratory syncytial (RS) viruses (subgroup A) isolated during six consecutive epidemics in either Montevideo, Uruguay, or Madrid, Spain, have been analyzed. Genetic diversity was evaluated for all viruses by the RNase A mismatch cleavage method and for selected strains by dideoxy sequencing. The sequences reported here were added to those published for six isolates from Birmingham, United Kingdom, and for two reference strains (A2 and Long), to derive a phylogenetic tree of subgroup A viruses that contained two main branches and several subbranches. During the same epidemic, viruses from different branches were isolated. In addition, closely related viruses were isolated in distant places and in different years. These results illustrate the capacity of the virus to spread worldwide, influencing its mode of evolution. The antigenic analysis of all isolates was carried out with a panel of anti-G monoclonal antibodies that recognized strain-specific (or variable) epitopes. A close correlation between genetic relatedness and antigenic relatedness in the G protein was observed. These results, together with an accumulation of amino acid changes in a major antigenic area of the G glycoprotein, suggest that immune selection may be a factor influencing the generation of RS virus diversity. The pattern of RS virus evolution is thus similar to that described for influenza type B viruses, expect that the level of genetic divergence among the G glycoproteins of RS virus isolates is the highest reported for an RNA virus gene product.

Genetic fine localization of the arrestin (S-antigen) gene 4 cM distal from D2S172

Arrestin is a component of the light transduction cascade that takes place in the outer segment of retinal rods. In situ hybridization and linkage analysis have localized the arrestin gene to a region of 50 cM between CRYG alpha and D2S23/D2S55 on chromosome 2q24-37. We have performed pairwise and multipoint linkage analysis between arrestin and four highly polymorphic markers from this region. The results indicate tight linkage between the gene and the microsatellite D2S172 (Zmax = 9.25 at theta = 0.038). This fine localization of the gene should provide a useful tool for cosegregation analyses involving the arrestin gene.

[Risk factors in cerebrovascular disease. Do transient ischemic attacks lead to changes in lifestyle?]

A minor stroke does not cause sufficient alarm in patients to change their lifestyles. 46 patients who suffered strokes in the previous 2 years were contacted by telephone, recording rehabilitation programs, medical therapy and modification of dietary habits. It was discovered that only 50% of those requiring motor rehabilitation actually received such treatment; and only one of twenty carried on speech exercises. Subsequent ischemic events were reported by 22 patients: 12 of whom had strokes, 8 ischemic myocardial attacks and two patients suffered both conditions. The majority of patients followed the prescribed medical treatment and advice badly. Of the 46 patients reviewed, 31 were hypertensive and only 16 follow recommended diets. Out of 15 smokers only, 6 gave up, and from 21 with dislypemia only 10 modified their diets. Of all patients only the most severely affected complied satisfactorily to medical treatments; a possible explanation for this would be that the contact between patients and physician (neurologist and family doctors) was discontinued immediately after the patients discharge from hospital. It is recommended therefore that steps be taken to insure better communication between neurologist, general practitioner and patient; thereby improving prognosis.

[Self-induced Cushing's syndrome due to dexamethasone abuse in nasal spray: clinical and biochemical study]

We studied a 55-year-old woman with remarkable cushingoid features, which presented biochemical evidence of suppression of the hypothalamus-hypophysis-adrenal axis. In the detailed anamnesis, we discovered that the patient had used during more than two years a nasal spray containing dexamethasone. In the initial assessment of the suprarenal function, in addition to suppressed concentrations of cortisol and ACTH, we observed the absence of response to acute stimulus (insulinic hypoglycemia and short ACTH test), as well as a normal response to sustained ACTH stimulus. After discontinuing the intranasal administration of dexamethasone, the patient remained asymptomatic; the basal concentrations of ACTH and cortisol, as well as the levels of urinary free cortisol, were normal at 3 months and the responses of cortisol and ACTH to their stimulus were restored to normal levels at 6 months. We conclude that in the cases of Cushing's syndrome with suppression of the hypothalamus-hypophysis-adrenal axis, it is necessary to conduct a detailed investigation on the consumption of glucocorticoids through unusual ways. The presence of a normal response to the sustained stimulus with ACTH may be a quick recovery index of the suprarenal function.

Changes in acid-base balance and calcium metabolism after urinary diversion through ileal segments. II. Treatment with nicotinic acid

Investigations in animals have shown that nicotinic acid, an intestinal cyclic-AMP inhibitor, partially corrects the metabolic changes associated with urinary diversion through intestinal segments. Blood and serum chemistry were studied in patients before and 3 to 5 months after undergoing urinary diversion through ileal segments, both with and without nicotinic acid treatment. It was found that diverted patients had metabolic acidosis, an increased anion gap and increased levels of serum alkaline phosphatase; there were no significant changes in serum PTH and vitamin D levels, calcaemia and phosphoraemia. There was a tendency towards dehydration, hypernatraemia, hyperchloraemia and secondary hyperaldosteronism produced by ileal secretion of a hypotonic fluid. Nicotinic acid 3 g/day significantly reduced the chloraemia but did not correct the metabolic acidosis, although it reduced its severity, since blood pH decreased when treatment was suspended. Nicotinic acid cannot be recommended for routine use in the management of metabolic acidosis after urinary diversion, and patients with a marginal renal reserve should not be considered for trans-intestinal urinary diversion.

[Pancoast's syndrome: difficulties in its diagnosis]

We present four patients with pancoast tumor diagnosed between 6 to 13 months after the appearance of symptoms. In three of the patients, the presence of old pulmonary apical fibrous lesions complicated diagnosis by simple radiology. Clinical suspicion of the tumor provided the basis for further complementary explorations which confirmed the apical lesion: TC in two patients and RM in the third. Three patients histological diagnosis was obtained by aspirative transthoracic punction. The late diagnosis resulted in the treatment being purely palliative in three cases. It should be stressed that when presented with persistent shoulder pain, clinicoradiological assessment need to be exhaustive in order to make an early diagnosis.

[Elevated negative predictive value of angiotensin converting enzyme in the diagnosis of active sarcoidosis]

OBJECTIVE

To evaluate the usefulness of angiotensin converting enzyme (ACE) in the differential diagnosis of active sarcoidosis in action with other interstitial and granulomatous processes.

METHODS

The study involved 30 patients with a histological diagnosis of sarcoidosis, 38 subjects with anatomopathologically and/or microbiologically confirmed pleuropulmonary tuberculosis, and 12 subjects with idiopathic pulmonary fibrosis confirmed by histological studies. Following the technique developed by Rohatgi and Ryan, a radioenzymatic system was used to determine the activity of serum ACE. In patients with sarcoidosis, levels of ACE were measured in active cases as well as those in remission. Our laboratory reference values for those over 20 years of age are 39.84 +/- 9.19 mumol/min/l.

RESULTS

Levels of ACE were significantly higher (p < 0.001) in active sarcoidosis (67.71 +/- 17.73 mumol/min/l) than during inactivity (41.18 +/- 16.00 mumol/min/l), tuberculosis (46.99 +/- 13.65 mumol/min/l), or fibrosis (35.87 +/- 11.36 mumol/mol/l). A cut-off point of 59 mumol/min/l shows a significant association with the diagnosis of active sarcoidosis (p < 0.001) and reaches a negative predictive value of 90.90%.

CONCLUSION

The usefulness of serum ACE in the differential diagnosis of sarcoidosis should be reconsidered.

Three new human skulls from the Sima de los Huesos Middle Pleistocene site in Sierra de Atapuerca, Spain

Three important fossil hominids were found in July 1992 in the Middle Pleistocene cave site called Sima de los Huesos (Sierra de Atapuerca, Burgos, Northern Spain). One is a complete calvaria (cranium 4), the second a virtually complete cranium (cranium 5), the third represents a more fragmentary cranium of an immature individual (cranium 6). There is a large difference in size between the two adult specimens (for example endocranial volume 1,125 cm3 versus 1,390 cm3). The Atapuerca human remains are dated to > 300,000 years. The Atapuerca cranial sample fits within the 'archaic Homo sapiens' group, but is well differentiated from the Asian Homo erectus group. The extensive Atapuerca human collection is the most complete sample of Middle Pleistocene humans yet discovered from one site, and appears to document an early stage in Neanderthal evolution.

The influence of renal failure on the kinetics of intravenous midazolam: an "in vitro" and "in vivo" study

The effect of renal failure upon the "in vitro" binding of midazolam, a new water-soluble short-acting benzodiazepine, has been studied in man. An increase of its free fraction (ranging from 2.52 to 5.17%) in serum from uremic patients was observed. A similar situation was originated in rabbits by administering uranyl nitrate (2 mg/Kg i.v.) and posterior hypnosis with midazolam. Uremic rabbits showed a marked increase in the free concentration of midazolam in serum (ranging from 8.9 to 13.7 micrograms/ml) and in midazolam brain levels (156.2 micrograms/g in cortex vs 84.5 micrograms/g in control animals). A positive correlation between brain and serum free concentration of midazolam was also observed. It is concluded that in renal patients more unbound drug is available to produce central nervous system effects, and a decrease in intravenous dose of midazolam could be recommended in this clinical situation.

Skeletal malformations in hatchery reared Rana perezi tadpoles

Skeletal malformations at metamorphosis in Rana perezi tadpoles reared in culture have been studied. Tadpoles were fed ten artificially compounded and fresh diets and kept at two different temperatures. Animals were maintained in fiberglass tanks. Bone damages are related to the nourishment with compound diets. Tadpoles fed such diets showed variable percentages of scoliosis, kyphosis, luxations, and subluxations in the hind limbs, aplasia in phalanges, and wide failures of ossification. The data suggest the origin of the lesions is a deficiency in some compounded diets that could alter collagen metabolism during skeletal adjustments at metamorphosis.

Beta 2 microglobulin in CAPD

The peritoneal clearance (Kp) and renal clearance (Kr) of beta 2 microglobulin (beta 2 m) were studied prospectively on 50 ESRD patients treated with CAPD, in order to determine the effect of the number of daily exchanges on Kp and to investigate the factors which influence the serum levels of beta 2m. Kr and Kp of beta 2m and creatinine (Cr) were calculated using standard formulae at the initiation of study and again at 6, 12, 18 and 24 months by collecting 24 hour urinary output and dialysate effluent. Kp of beta 2m of patients on 3 exchanges/day was .94 +/- .08 ml/min at the initiation of study and 1.1 +/- .08 at the end. For patients on 4 exchanges/day it was .99 +/- .14 ml/min and 1.1 +/- .12 respectively. There was no significant difference. Serum levels of beta 2m were lower on patients with significant residual renal function (RRF) (17 +/- .9 mg/L) than on patients without RRF (38 +/- 2 mg/L. p = .001). Serum levels of beta 2m correlated inversely with Kr of Cr and beta 2m at the initiation of study and at the end (r = .67 and .77 respectively, p = .0001). We conclude that serum levels of beta 2m correlate inversely with Kr of Cr and are expected to rise as RRF decreases. The combined peritoneal and renal excretion of beta 2m is less than its daily production. The number of dialysis exchanges does not influence Kp of beta 2m.

[Cancer incidence by municipalities in Puerto Rico]

This study consist of the trends of those malignant tumours in Puerto Rico diagnosed 1960 to 1988 that we considered more related with some environmental factors. For this purpose 160,288 cancer cases analyzed included 16,286 of squamous and basal cell carcinomas of the skin diagnosed from 1950 up to 1975 only. We have darkened in the map and mentioned below in this summary those municipalities with incidence greater than Puerto Rico's average.

[School children poisoning by ornamental trees]

Eleven cases of poisoning of children who had chewed threads from the barks of trees subsequently identified as Robinia pseudo-acacia were detected in Sanlúcar La Mayor (Sevilla). A retrospective study was carried out of all children who had chewed barks of these trees on the days 28, 29 and 30 of January. The data were collected from the daily record of emergencies. From the twenty fulfilled epidemiological questionnaires it was found out that the predominant symptoms were abdominal pain, nausea, "biliary" vomits and some degree of weakness. This fact points to the need to identify and to control the risk factors in a given milieu so as to prevent these occurrences.

[Surgical treatment of tumors of the carotid body with reconstruction of the internal carotid artery]

The experience about treatment in infiltrating tumors of Carotid Corpus, III Degree (Shamblin), is presented. Different methods of carotid reconstruction, and biologic and evolutive characteristics are emphasized, discussing preoperatory study and surgical technics.

Output pathway for turning behavior from the neostriatum and substantia nigra in cats

The goal of the present work was to study the output pathway of the information for turning behavior originating in the striatum and coursing through the substantia nigra pars reticulata (SNR). In 45 adult cats distributed in 3 groups, Ni-Cr electrodes were implanted in the caudate nucleus and substantia nigra pars reticulata and depending on the animal group in the superior colliculus (SC), nucleus ventralis lateralis/nucleus ventralis medialis (VL/VM) complex or nucleus tegmenti pedunculopontinus (TPP) of one cerebral hemisphere. The threshold current required to evoke turning behavior was determined in each animal for each implantation site. An electrolytic lesion of the superior colliculus, the VL/VM complex or the nucleus tegmenti pedunculopontinus was carried out in each group of cats. The effects of the lesions on behavior and on the electrical threshold currents were determined and compared with the prelesion values. Finally the extent of the lesions and electrode positions were analyzed. The results show that the substantia nigra pars reticulata is the structure with the lowest thresholds for turning and that the superior colliculus appears to be more relevant for carrying the information for turning than either the VL/VM complex or the nucleus tegmenti pedunculopontinus.

Effects of social isolation and crowding upon adrenocortical reactivity and behavior in the rat

The effects of social isolation and crowding on adrenocortical function and upon behavioral responsiveness to electric shock have been studied in male and female rats. All female experimental groups showed higher corticosterone levels and heavier adrenals than their male counterparts. The major effect of housing condition concerned the corticosterone response to stress, while basal hormone concentration was not modified. Socially housed rats showed a more intense adrenocortical response and also a greater behavioral reactivity to electric shock than the isolates.

On the preservation of avian blood cells

The functional state of erythrocytes from hen during their conservation with a preserving solution for 24 days at 4 degrees C, has been estimated by studying some biochemical and hemorheological parameters. Results show an initial phase in the preservation period (4-5 days) in which red blood cells maintain their values at levels similar to those at the beginning of the experience, except for osmotic resistance. Furthermore a progressive erythrocyte deformability loss, linked to ATP depletion (with rise in inorganic phosphate levels) as well as a gradually higher rate of hemolysis, were detected.

[Effect of various adenine derivatives on gastric acid secretion in the isolated rat stomach]

The adenine derivatives adenosine 5'-triphosphate (ATP), adenosine 5'-diphosphate (ADP), adenosine 5'-monophosphate (AMP) and adenosine (AD), in concentrations of 10(-3)M and 10(-4)M caused significant and dose-related modifications in the basal acid secretion from isolated whole rat stomach. The first three purine derivatives, ATP, ADP and AMP significantly increased the spontaneous acid secretion. On the other hand, AD caused a significant reduction in the basal acid secretion. When ATP, ADP, AMP and AD were assayed in the presence of the adrenergic and cholinergic blocking agents, ergotamine, 10(-6)M, propranolol, 5 X 10(-7)M and atropine, 10(-6)M, all these purine derivatives, including AD, caused a significant increase in the basal acid secretion.

Cancer of nasopharynx in young patients

From 1961 to 1980 17 patients with nasopharyngeal carcinoma who were less than 30 years old at time of diagnosis were treated at the two oncologic hospitals in Puerto Rico. Fourteen of the tumors were lymphoepitheliomas and the remaining three were anaplastic carcinomas. Ninety-four percent of the patients were found to have neck adenopathy at the initial examination and in 65% of them the adenopathy was bilateral. The 5-year actuarial survival was 14. The main cause of failure was the distant metastasis. Seventy-one percent of our patients developed distant metastasis sometime during the course of their disease. Carcinoma of the nasopharynx is uncommon in Puerto Rico as in other western countries. The post-adolescent age incidence peak reported from different countries is also present among Puerto Ricans.

A family with a satellited Yq chromosome

A large pedigree with a satellited Yq chromosome is described, Q, C, and NOR banding were performed. Family C proband suffers from a Klinefelter syndrome.

Cancer incidence in the United States and Puerto Rico

This study compares cancer incidence in the United States National Survey areas and Puerto Rico for the period of 1969 to 1974. There are several differences between the 2 areas. Puerto Rico has a higher incidence of cancer of the mouth, pharynx, esophagus, stomach, cervix uteri, vulva, and penis. The Survey areas have higher incidences of cancer of the colon, rectum, lung, corpus uteri, female breast, and ovary. The differences between sexes are more or less the same as in other countries.