Effect of Inoue balloon mitral valvotomy on severe pulmonary arterial hypertension in 315 patients with rheumatic mitral stenosis: immediate and long-term results

BACKGROUND AND AIMS OF THE STUDY

Despite advances in surgical techniques, mitral valve surgery in patients with severe pulmonary arterial hypertension (PAH) causes considerable mortality and morbidity. Balloon mitral valvotomy (BMV) is an established alternative to treat high-risk surgical patients with mitral stenosis (MS). The study aims were to evaluate immediate and long-term efficacy of BMV in patients with MS and severe PAH, compared to those with mild/moderate PAH.

METHODS

Among 1,125 patients who underwent Inoue BMV, 315 had severe PAH (mean pulmonary artery (PA) pressure > or = 50 mmHg (group I; 79 of these patients had suprasystemic PAH). Results from this group were compared with those of patients with mild/moderate PAH (group II).

RESULTS

Group I patients were younger and more symptomatic (mean PA pressure 62 +/- 10.6 mmHg versus 32.6 +/- 8.2 mmHg in group II). Before BMV, mean transmitral gradient (17.8 +/- 6.5 versus 14.4 +/- 5.4 mmHg) and pulmonary capillary wedge pressure (PCWP) (31.6 +/- 6.1 versus 22.8 +/- 6.2 mmHg) were significantly higher, while mitral valve area (MVA) (0.66 +/- 0.2 versus 0.85 +/- 0.2 cm2) was significantly lower in group I. After BMV, PA mean pressure was significantly reduced (34.8 +/- 11.2 and 21.1 +/- 8.4 mmHg), transmitral gradient (8.0 +/- 3.9 and 6.9 +/- 3.2 mmHg) and mean PCWP (12.8 +/- 5.8 and 11.0 +/- 5.1 mmHg) in groups I and II, respectively, with a comparable increase in MVA (1.77 +/- 0.4 and 1.84 +/- 0.5 cm2). Group I patients had worse baseline hemodynamic parameters than group II, but the former had a higher absolute gain in hemodynamic parameters. Residual severe PAH after BMV was seen in 9.8% of patients, with PA pressures normalized in 9.5%. Among 79 patients with suprasystemic PA pressure (mean PA systolic pressure 116.6 +/- 28.2 mmHg), 16.5% normalized their PA pressures and 25.3% had residual severe PAH. At mean follow up of 33 months, 80.4% were in NYHA class I. Mean PA systolic pressure in 161 patients was 39.0 +/- 14.2 mmHg compared with a post-BMV value of 55.0 +/- 16.9 mmHg; thus, a sustained fall in pressure was demonstrated at follow up.

CONCLUSION

Inoue BMV is safe and effective in patients with MS and severe PAH. Although these patients have worse clinical and hemodynamic parameters before BMV, they achieve a greater absolute gain in terms of improvement in all hemodynamic parameters.

Extracting weak phase information from B-->V1V2 decays

We describe a new method for extracting weak, CP-violating &Dmacr;phase information, with no hadronic uncertainties, from an angular analysis of B-->V1V2 decays, where V1 and V2 are vector mesons. The quantity sin (2)(2beta+gamma) can be cleanly obtained from the study of decays such as B(0)(d)(t)-->D*+/-rho(-/+), D(*+/-)a(-/+)(1), D(;) *0K(;) (*0), etc. Similarly, one can use B(0)(s)(t)-->D(*+/-)(s)K*-/+ to extract sin (2)gamma. There are no penguin contributions to these decays. It is possible that sin (2)(2beta+gamma) will be the second function of CP phases, after sin2beta, to be measured at B factories.

Is axillary temperature an appropriate surrogate for core temperature?

The ideal technique for measuring temperature should be rapid, painless, reproducible and accurately reflect the core temperature. While axillary temperature is commonly used because of convenience and safety, there are conflicting reports about its accuracy. To determine whether axillary temperature can act as a surrogate for oral/rectal temperatures, a prospective comparative study was conducted. The axillary and rectal temperatures (Group 1: infants < 1 year age) and axillary and oral temperatures (Group 2: children 6-14 years age) were compared using mercury-in-glass thermometers. Various tests of agreement were applied to the data obtained. Rectal and axillary temperatures for infants agreed well; the mean difference (95% limits of agreement) between the two being 0.6 degree C (-0.3 degree C, 1.4 degrees C). Similarly, the mean difference (95% limits of agreement) between oral and axillary measurements for children aged 6-14 years was observed to be 0.6 degree C (-0.4 degree C, 1.4 degrees C). Axillary temperature appears to be an acceptable alternative to rectal/oral temperature measurements in children.

Effect of lead on Sertoli-germ cell coculture of rat

Mixed cultures of Sertoli and germ cells were prepared from rat testes and their response to lead (Pb) was studied. Cultures consisted of a monolayer of Sertoli cells to which clusters of germ cells were attached. The effect of Pb added as lead acetate was tested at 0.0, 0.4, 4.0 and 40.0 microM for 24 and 48 h intervals. Addition of Pb to the culture medium caused germ cells to progressively detach from the Sertoli cell monolayer into the medium in a concentration and duration dependent manner Viability of the detached cells as judged by trypan blue exclusion test showed a decrease with increase in time and concentration of Pb. Significant leakage of lactate dehydrogenase (LDH) was recorded in the culture media only at the higher concentrations of 4.0 and 40.0 microM. Thus Pb at the doses tested induced cytotoxicity in rat Sertoli-germ cell coculture.

Primary congenital anomalies of the coronary arteries: a coronary: arteriographic study

Geographic variations in the incidence of different congenital coronary anomalies are well known, but infrequently studied in the Indian population. Among 4,100 adult patients who underwent diagnostic coronary arteriography, 39 (0.95%) patients (34 males, 5 females) had one or more anomalous coronary arteries. Their mean age was 46.4 +/- 8.2 years (range, 26-68 years). Thirty-five (89.74%) had anomalies of origin and distribution, while the remaining four (10.25%) had coronary artery fistulae. Right coronary artery was the commonest anomalous vessel, involved in 19 (48.74%) patients. It was originating from the left sinus of Valsalva in 15 and from the non-facing aortic sinus in four patients. Anomalous left circumflex artery was the second commonest anomaly, seen in 14 (35.89%) patients. Anomalous left anterior descending artery and anomalous left coronary artery from pulmonary artery were seen in one patient each. Among patients with coronary fistulae, two had fistulae between the left anterior descending artery and the main pulmonary artery, one between the conal artery and the right atrium, while the fourth patient had fistulae from the right coronary as well as from the left anterior descending artery to the left atrium. Atherosclerotic plaques in the anomalous arteries were seen in only 13 (33.33%) patients, much less than the overall incidence of coronary artery disease in patients with congenital coronary anomalies in this series (66.66%). In four (10.25%) patients, only the anomalous vessels were involved in coronary artery disease. Thus, in a small subgroup there does not appear to be an increased risk for development of atherosclerotic coronary artery disease in anomalous coronary arteries. Recognition of coronary anomalies is important in patients undergoing coronary arteriography, coronary interventions and cardiac surgery. Variations in the frequency of primary congenital coronary anomalies may possibly have a genetic background.

Intermittent electromechanical dissociation due to mechanical prosthetic valve dysfunction

We describe a patient who developed the rare hemodynamic phenomenon of intermittent electromechanical dissociation during normal sinus rhythm at about four months after mitral valve replacement with a Medtronic Hall prosthesis, along with resuspension of the papillary muscles using Gore-Tex sutures. Echocardiographic examination confirmed the presence of a filamentous structure that could be either suture material, tissue tag or thrombus, and was entangling intermittently in the prosthesis. The patient recovered spontaneously after a three-week symptomatic period, with no subsequent evidence of either electromechanical dissociation or the filamentous structure; normal prosthetic valve function was restored. During a subsequent three-month follow up period, the patient was asymptomatic, with normal prosthetic valve function. The diagnostic and hemodynamic aspects of this case are discussed.

Folding and binding cascades: dynamic landscapes and population shifts

Whereas previously we have successfully utilized the folding funnels concept to rationalize binding mechanisms (Ma B, Kumar S, Tsai CJ, Nussinov R, 1999, Protein Eng 12:713-720) and to describe binding (Tsai CJ, Kumar S, Ma B, Nussinov R, 1999, Protein Sci 8:1181-1190), here we further extend the concept of folding funnels, illustrating its utility in explaining enzyme pathways, multimolecular associations, and allostery. This extension is based on the recognition that funnels are not stationary; rather, they are dynamic, depending on the physical or binding conditions (Tsai CJ, Ma B, Nussinov R, 1999, Proc Natl Acad Sci USA 96:9970-9972). Different binding states change the surrounding environment of proteins. The changed environment is in turn expressed in shifted energy landscapes, with different shapes and distributions of populations of conformers. Hence, the function of a protein and its properties are not only decided by the static folded three-dimensional structure; they are determined by the distribution of its conformational substates, and in particular, by the redistributions of the populations under different environments. That is, protein function derives from its dynamic energy landscape, caused by changes in its surroundings.

Recurrent acute coronary events in a patient with primary antiphospholipid syndrome: successful management with intracoronary stenting

Patients with Antiphospholipid syndrome usually present with recurrent deep vein thrombosis, pulmonary thromboembolism and thromboembolic stroke. Recurrent coronary events, though reported, are rare. We describe an unusual case of Antiphospholipid syndrome who presented with recurrent acute ischaemic events in two different coronary territories, who was managed successfully with intracoronary stenting.

Captopril for prevention of contrast-induced nephropathy in diabetic patients: a randomised study

Contrast-induced nephrotoxicity is an important cause of hospital-acquired acute renal insufficiency. Different modalities have been used to prevent contrast induced-nephrotoxicity namely saline infusion, mannitol, furosemide, calcium channel blockers, atrial natriuretic factor and dopamine infusion with variable success. The possible role of medullary ischaemia mediated by renin angiotensin system in genesis of contrast-induced nephrotoxicity prompted us to investigate the role of captopril (a sulfhydryl group containing angiotensin-converting enzyme inhibitor) in its prevention. Seventy-one patients of diabetes mellitus undergoing coronary angiography were included in the study. Patients randomised to receive captopril, received the drug in a dose of 25 mg thrice a day for three days, starting one hour prior to angiography while the patients in the control group underwent angiography in a routine manner without receiving captopril. Following angiography, patients in the control group developed a significant increase in serum creatinine and blood urea nitrogen levels, as compared to those who received captopril. Contrast-induced nephrotoxicity (i.e. a rise of 0.5 mg/dL in serum creatinine) developed in 29 percent of the control group. Administration of captopril reduced the risk of development of contrast-induced nephrotoxicity by 79 percent. Glomerular filtration rate as measured by Tc DTPA renal scanning prior to and 24-72 hours following angiography demonstrated a mean fall of 9.6 ml/min in the control group while those in the captopril group had a mean increase of 13 ml/min in glomerular filtration rate. We conclude that abnormalities of renal perfusion possibly mediated by renin angiotensin system are responsible for development of contrast-induced nephrotoxicity. Administration of the angiotensin-converting enzyme inhibitor, captopril, offers protection against development of contrast-induced nephrotoxicity.

Cytotoxic effect of endosulfan on rat Sertoli-germ cell coculture

Endosulfan induced testicular impairment has been reported in vivo in rats. The present study was conducted to evaluate the cytotoxic effects of endosulfan in vitro employing rat testicular cells in culture, that is Sertoli-germ cell coculture. Cytotoxic changes induced by endosulfan (0, 2, 20, 40, and 80 microM) in mixed cultures of Sertoli and germ cells were seen after 24 and 48 h of treatment. Endosulfan led to an increase in germ cell detachment from the Sertoli cell monolayer in a dose dependent manner. A loss in the viability of detached cells was observed in all treated groups. Substantial leakage of the cytosolic enzyme lactate dehydrogenase was observed in the medium after 24 and 48 h endosulfan treatment at concentrations of 20 to 80 microM. The extent of toxicity was greater after 48 h of treatment.

Phylogenetic relationships and evolution of the KNOTTED class of plant homeodomain proteins

Knotted-like (KNOX) proteins constitute a group of homeodomain proteins involved in pattern formation in developing tissues of angiosperms and other green plants. We conducted phylogenetic analyses of nucleotide and amino acid sequences of all known KNOX proteins in order to examine their evolution. Our analyses reveal two groups of KNOX proteins, classes I and II. Dicot and monocot sequences occur in both classes, indicating that the protein classes arose prior to the origin of the monocots. A conifer (Picea) sequence is nested within class I, suggesting that there are likely to be other copies of KNOX genes in this and other conifers. The orthology of several grass genes (including Zea Kn1, ZMKN1) is strongly supported by phylogenetic and synteny analyses. However, no compelling evidence supports the hypothesis of orthology previously proposed for several dicot genes and ZMKN1. Analysis of expression patterns suggests that the ancestral KNOX gene was expressed in all plant parts and that the propensity to be downregulated in roots and leaves evolved in the class I genes.

Stabilization of the i-motif by intramolecular adenine-adenine-thymine base triple in the structure of d(ACCCT)

The crystal structure of d(ACCCT), solved by molecular replacement, shows a four-stranded i-motif conformation, where two parallel duplexes intercalate with one another in opposite orientations. Each duplex is stabilized by hemi-protonated C-C+ base pairing between parallel strands, and a string of water molecules bridge the cytosine N4 atoms to phosphate O atoms. This structure of d(ACCCT) shows examples of reversed Hoogsteen and Watson-Crick base pairing in both intermolecular and intramolecular manners to stabilize the tetraplex. Noticeably, the four-stranded complex is further stabilized at one end by a three-base hydrogen-bonding network, in which two adenines and a thymine form four hydrogen bonds via a reverse Hoogsteen and an asymmetric adenine-adenine base pairing. The structure of d(ACCCT) shows a similar local structure to that found in the d(TAA) part of the crystal structure of d(TAACCC) and provides further structural evidence that these base arrangements are essential for stabilizing these novel DNA super-secondary structures.

Genetic, molecular, and morphological analysis of compound leaf development

Leaves, the plant organs responsible for capturing and converting most of the 170 billion metric tons of carbon fixed globally each year, can be broadly grouped into two morphological categories: simple and compound. Although simple-leaved species such as corn and Arabidopsis have traditionally been favored model systems for studying leaf development, recent years have seen an increase in genetic and molecular studies of compound leaf development. Two compound-leaved species in particular have emerged as model systems: tomato and pea. A variety of mutations which alter leaf morphology in these species have been described, and analyses of these mutations have allowed the construction of testable models of leaf development. Also, the knotted-like homeobox (KNOX) genes, which were originally discovered as regulators of meristem function, now appear to have a role in compound leaf development. In addition to the recent genetic and molecular analyses of tomato and pea, insight into the nature of compound leaf development may be gained through the study of (a) heteroblasty and heterophylly, phenomena in which a range of leaf forms can be produced by a single shoot, and (b) the evolutionary origins of compound leaves.

Influence of sub valvular pathology on immediate results and follow up events of Inoue balloon mitral valvotomy

We evaluated the influence of sub valvular pathology (SVP) on the immediate results and follow up events of Inoue Balloon Mitral Valvotomy (IBMY) in 206 patients with severe SVP (Group I) and compared their outcome with 206 age and sex matched patients selected from the rest of 619 patients having mild/moderate SVP (Group II). Pre-procedure echocardiographic recordings were reviewed and mitral valve morphology was evaluated using U.S. California Score. The severe SVP group had lower mitral valve areas (MVA) (0.7 cm2 vs. 0.8 cm2) and higher mean pulmonary artery pressure (MPAP) (46.3+/-16.9 mmHg vs. 40.7+/-16.25 mmHg) and mean pulmonary capillary wedge pressure (PCWP) (27.5+/-7.3 mmHg vs. 25.7+/-8.0 mmHg) (p<0.001). IBMV was done using standard technique. The procedure was technically successful in 192/206 patients (93.2%) in group I and 187/206 (91%) in group II (p=ns). The mean transmitral gradient decreased from 24.8+/-7.6 mmHg to 7.46+/-3.4 mmHg while mean PCWP fell from 27.5+/-7.3 mmHg to 12.2+/-5.6 mmHg and MPAP fell from 46.3+/-16.9 mmHg to 23.6+/-12.2 mmHg (p=<0.001). MVA increased from 0.7+/-0.2 cm2 to 1.7+/-0.4 cm2 (p=<0.001). Severe mitral regurgitation (MR) occurred in 2 patients out of which one patient, who had associated coronary artery disease, died post operatively, and moderate MR occurred in 8 patients. The results achieved in patients with severe SVP were not statistically different from those with mild/moderate SVP. The benefits achieved immediate post IBMV were sustained in 184 patients with severe SVP who were available for follow up at a mean duration of 15.2 months (range 3 months to 51 months). Thus IBMV is safe and effective in patients with severe SVP. This group of patients with severe SVP are more hemodynamically deranged pre-BMV and also achieve better hemodynamic benefit compared to those with mild/moderate SVP. Severe SVP does not have any adverse effect either on immediate results (success/occurrence of MR) or on intermediate term follow up.

Small aortic annulus: a functional definition

BACKGROUND & OBJECTIVE

Small aortic annulus is conventionally associated with poor outcome after aortic valve replacement (AVR). Contrarily, several patients have excellent follow-up results after AVR with 19, 20 or 21 size Medtronic Hall (MH) or Sorin Carbocast (SC) prostheses. This disparity prompted a relook at the semantics of a small aortic annulus.

METHODS

Available survivors of isolated AVR with #19, #20 or #21 prostheses - 13 with 19 SC or 20 MH valves (Group A) and 29 with 21 SC or MH valves (Group B) were studied. Disparity between actually implanted prostheses versus predicted prosthetic size (tissue annulus diameter) was analysed according to nomograms of Rowlatt et al, NIH Plehn, Kishimoto formula and Sievers composite criteria. Preoperative and follow-up echocardiographic assessments were used for hemodynamic and prosthetic function indices.

RESULTS

Both groups were similar in age, height, weight, BSA, BMI, mean NYHA class, CTR, preoperative peak gradient (PG) (92. 0 +/- 29.55 vs 102.88 +/- 33.65), mean gradient (MG) (56.8 +/- 24.6 vs 61.55 +/- 16.56), LVEDD (50.75 +/- 10.92 vs 56.0 +/- 13.5), LVESD (34.37 +/- 13.32 vs 38.52 +/- 13.85) and LVEF (67.5 +/- 12.5 vs 63.9 +/- 14.3). By developmental indices of Rowlatt et al. and NIH, no valve annulus could be designated as narrow. By Sievers composite nomogram all implanted valves were undersized by echocardiographic parameters, in normal range by angiographic criteria and oversized by anatomic autopsy data. Implanted valves in both groups were bigger than Plehn-predicted size (18.16 +/- 1.48 in GrA, 19.46 +/- 1. 10 in GrB). Valve size indices (VSI) (GrA 16.16 +/- 2.85 GrB 14.24 +/- 1.64) and geometric orifice area indices (VAI: valve area index) (GrA 1.50 +/- 0.28 vs 1.41 +/- 0.19) and postoperative rest PG (GrA 47.2 +/- 18.6 GrB 33.8 +/- 9.9) and MG (GrA 27.2 +/- 12.9 vs 19.0 +/- 9.9) were acceptable. LVEDD and LVESD regressed in both groups. LV mass indices regressed from 218.56 +/- 100.85 to 128.17 +/- 27.7 in GrA and 238.94 +/- 102.5 to 134.22 +/- 34.72 in GrB. Performance indices of implanted valves and postoperative aortic valve resistances were correlative.

CONCLUSIONS

The size of the implanted prostheses per se does not denote narrowness. Patient-prosthesis mismatch may be considered if predicted prosthesis has VSI <12 mm/m2, VAI <1.31 cm2/m2 or prosthesis orifice diameter <19 mm which may indicate annular enlargement.

Probing RegA/RNA interactions using electrospray ionization-fourier transform ion cyclotron resonance-mass spectrometry

The interactions of bacteriophage T4 regA protein, a unique translational regulator, with RNAs of various size and sequence were studied using electrospray ionization-Fourier transform ion cyclotron resonance-mass spectrometry. Using very gentle interface conditions, regA/RNA complexes with a 1:1 binding stoichiometry were observed for all four target RNAs studied, consistent with solution binding studies. Competitive binding of target RNAs and their degradation products with regA demonstrated that the loss of a single nucleotide resulted in a dramatic change in binding affinity in some cases. Competitive binding of regA with four target RNAs revealed similar relative binding affinity order to that suggested by previous in vitro repression experiments. The use of sustained off-resonance irradiation for collisionally induced dissociation of a regA/RNA complex suggested the potential for directly obtaining information regarding the regA binding domain.

Overexpression of a homeobox gene, LeT6, reveals indeterminate features in the tomato compound leaf

The cultivated tomato (Lycopersicon esculentum) has a unipinnate compound leaf. In the developing leaf primordium, major leaflet initiation is basipetal, and lobe formation and early vascular differentiation are acropetal. We show that engineered alterations in the expression of a tomato homeobox gene, LeT6, can cause dramatic changes in leaf morphology. The morphological states are variable and unstable and the phenotypes produced indicate that the tomato leaf has an inherent level of indeterminacy. This is manifested by the production of multiple orders of compounding in the leaf, by numerous shoot, inflorescence, and floral meristems on leaves, and by the conversion of rachis-petiolule junctions into "axillary" positions where floral buds can arise. Overexpression of a heterologous homeobox transgene, kn1, does not produce such phenotypic variability. This indicates that LeT6 may differ from the heterologous kn1 gene in the effects manifested on overexpression, and that 35S-LeT6 plants may be subject to alterations in expression of both the introduced and endogenous LeT6 genes. The expression patterns of LeT6 argue in favor of a fundamental role for LeT6 in morphogenesis of leaves in tomato and also suggest that variability in homeobox gene expression may account for some of the diversity in leaf form seen in nature.

An Escherichia coli ccm (cytochrome c maturation) deletion strain substantially expresses Hydrogenobacter thermophilus cytochrome c552 in the cytoplasm: availability of haem influences cytochrome c552 maturation

The maturation of Hydrogenobacter thermophilus cytochrome c552 in the cytoplasm of Escherichia coli is unique among bacterial c-type cytochromes. It is now shown to be matured in a strain lacking the whole set of ccm (cytochrome c maturation) genes that are normally required for c-type cytochrome biogenesis in E. coli. As this cytochrome is thermostable we propose that the apocytochrome c552 has sufficient tertiary structure to allow the haem to slot into its binding pocket, which in turn triggers the spontaneous covalent attachment between apocytochrome c552 and haem. The ccm deletion strain of E. coli, derived from a strain that synthesizes elevated levels of endogenous c-type cytochromes, also produces larger amounts of cytoplasmic H. thermophilus cytochrome c552 than a reference strain. This implies that elevated production of c-type cytochromes is not a consequence of high activity of ccm genes but rather an enhanced ability to supply haem, a view that is supported by the increase in thermophilic cytochrome c552 biogenesis that occurs in a reference strain following supplementation of growth media with delta-aminolevulinic acid.

Pressure zone used and the occurrence of mitral regurgitation in Inoue balloon mitral commissurotomy

Mitral regurgitation (MR) is a known complication of Inoue balloon mitral commissurotomy (BMC) and has been variously ascribed to the presence of severe subvalvular pathology (SVP), preexisting MR, calcification, or oversizing. The pressure zone used--with the low pressure zone (LPZ) the lower half of the spectrum of sizes available out of a single balloon, and the high pressure zone (HPZ) the upper two levels, i.e., within 2 mm of its maximum size--could have a bearing on the occurrence of MR, but has not been studied before. We analysed 251 consecutive patients (mean age 28.6 + 9.7 years), undergoing BMC from October 1993 onwards, with pliable, non-calcific, splittable (bilateral dark zones present) valves with not more than trivial MR (1 + in grades of 1-4). Balloon sizing was done with standard formula using height with stepwise dilatation starting 2 mm below the reference size. Thirty-two patients additionally had severe SVP. Patients were divided into two groups, HPZ-BMC and LPZ-BMC, depending upon the final balloon size needed for a successful result. Incidence of MR (2+ or more) was significantly lower in the LPZ BMC (18%) vs. HPZ BMC (32.2%) (P < 0.05). Moderate to severe MR (3+/4+) was also less in LPZ BMC (2.8%) vs. HPZ BMC (8.2%) (P < 0.05). Amongst patients with severe SVP, 3/15 (20%) developed MR in the LPZ-BMC group (all mild only) as against 8/17 (42%) (P < 0.05) in the HPZ-BMC group with half of them having moderate to severe MR. In 54 patients where the reference size had to be exceeded, no patient (0/8) developed MR as long as the higher size was in the LPZ of the particular balloon used as compared to 17/46 (36.9%) who developed MR when the size used fell in the HPZ. We conclude that the pressure zone used has a strong bearing on the occurrence of MR in Inoue BMC and that a low-pressure strategy could avoid MR.