Quality assurance of human functional magnetic resonance imaging: a literature review

Functional magnetic resonance imaging (fMRI) has been a popular approach in brain research over the past 20 years. It offers a noninvasive method to probe the brain and uses blood oxygenation level dependent (BOLD) signal changes to access brain function. However, the BOLD signal only represents a small fraction of the total MR signal. System instability and various noise have a strong impact on the BOLD signal. Additionally, fMRI applies fast imaging technique to record brain cognitive process over time, requiring high temporal stability of MR scanners. Furthermore, data acquisition, image quality, processing, and statistical analysis methods also have a great effect on the results of fMRI studies. Quality assurance (QA) programs for fMRI can test the stability of MR scanners, evaluate the quality of fMRI and help to find errors during fMRI scanning, thereby greatly enhancing the success rate of fMRI. In this review, we focus on previous studies which developed QA programs and methods in SCI/SCIE citation peer-reviewed publications over the last 20 years, including topics on existing fMRI QA programs, QA phantoms, image QA metrics, quality evaluation of existing preprocessing pipelines and fMRI statistical analysis methods. The summarized studies were classified into four categories: QA of fMRI systems, QA of fMRI data, quality evaluation of data processing pipelines and statistical methods and QA of task-related fMRI. Summary tables and figures of QA programs and metrics have been developed based on the comprehensive review of the literature.

Primary Acute Angle-Closure Glaucoma: Three-Dimensional Reconstruction Imaging of Optic Nerve Heard Structure in Based on Optical Coherence Tomography (OCT)

Background

In glaucoma, the cup to plate ratio enlargement is a recognized pathological phenomenon. At present, the research on optic nerve in China and abroad mainly focuses on 2-dimensional research, and the measurement of 3-dimensional volume data is less well studied. Therefore, the recognition of 3-dimensional morphological changes is conducive to timely clinical intervention to prevent or slow down progressive vision loss.

Material/Methods

In this paper, optical coherence tomography (OCT) volume imaging technology was used to analyze and compare the morphological changes of primary acute angle-closure glaucoma in three-dimensional morphology, reconstruct the volume data of three-dimensional optic nerve head (ONH), and make morphological measurements.

Results

The rim width of the glaucoma group was significantly lower than that of the control group, and the average volume and intraocular pressure of the optic cup were significantly increased (P<0.05), while the rim width and intraocular pressure of the other group were not significantly changed (P>0.05).

Conclusions

We used three-dimensional reconstruction to identify OCT images between glaucoma patients and the control group with significant differences.

Functional MRI reveals effects of high intraocular pressure on central nervous system in high-tension glaucoma patients

PURPOSE

To evaluate the effects of high intraocular pressure (IOP) on central nervous system in patients with high-tension glaucoma (HTG) by using resting-state functional magnetic resonance imaging (rs-fMRI).

METHODS

Thirty-six patients with HTG and twenty age- and gender-matched healthy controls (HCs) were recruited and underwent IOP measurement and rs-fMRI scan. The whole brain regional homogeneity (ReHo) value was calculated among the enrolled subjects. Two-sample t tests with permutation test and threshold-free cluster enhancement was performed between HTG group and HCs. Correlation analyses between IOP and ReHo values were conducted.

RESULTS

Compared with HCs, HTG group showed increased ReHo values in the left lobule 8 of cerebellar hemisphere, left lobule 4 and 5 of cerebellar hemisphere and left fusiform gyrus (FG) (p < 0.05). HTG group showed decreased ReHo value in the left middle frontal gyrus (MFG) (p < 0.05). Intraocular pressure of the left eye in HTG group experienced a significant positive correlation with ReHo value of the left FG (r = 0.370, p = 0.026), IOP of the right eye in HTG group showed a significant negative correlation with ReHo value in the left MFG (r = -0.421, p = 0.011).

CONCLUSION

Resting-state fMRI ReHo analyses associated elevated IOP with abnormal regional activity in several brain regions related to higher visual function and visual memory consolidation. High-tension glaucoma patients also showed diminished integration of visual information and cerebellar function. These results may provide imaging support for pathophysiological research of HTG and may reveal new targets for the accurate treatment of HTG.

Effect of Sex Hormones on Brain Connectivity Related to Sexual Function in Perimenopausal Women: A Resting-State fMRI Functional Connectivity Study

BACKGROUND

Perimenopause is associated with increased risk of depression, vasomotor symptoms, and sexual dysfunction.

AIMS

To explore the effect of sex hormones on the functional connectivity (FC) of different brain regions related to sexual function in perimenopausal women.

METHODS

32 premenopausal women (mean age, 47.75 ± 1.55 years) and 25 perimenopausal women (mean age, 51.60 ± 1.63 years) underwent sex hormone level measurements and resting-state fMRI.

MAIN OUTCOME MEASURES

Serum levels of sex hormones, including prolactin (PRL), follicle-stimulating hormone (FSH), luteotropic hormone (LH), estradiol (E2), free testosterone (free-T), and progesterone (P), were measured. 10 brain regions related to sexual function were selected according to a meta-analysis, and FCs of the selected regions of interest were calculated as Pearson's correlation coefficient.

RESULTS

Compared with premenopausal women, perimenopausal women showed increased FC between the right area 13 (A13_r) and the right medial superior frontal gyrus (mSFG), between the left dorsal granular insula (dIg_L) and the right superior frontal gyrus (SFG) (Gaussian random field-corrected at the voxel level, P < .001, and cluster level, P < .025). Furthermore, the PRL level was negatively correlated with the FC of A13_R with the right mSFG and the FC of dIg_L with the right SFG.

CLINICAL TRANSLATION

These findings may be applicable to assessing brain dysfunction with FC changes in women approaching menopause.

STRENGTHS & LIMITATIONS

This study is the first to evaluate a direct relationship between sex hormone levels and brain FC changes in women approaching menopause. Sexual function was not assessed, which may weaken the conclusions related to sexual function.

CONCLUSIONS

The results show that women approaching menopause suffered from aberrant intrinsic FC in regions related to sexual function, and reveal a direct relationship between serum sex hormone levels and FC changes related to sexual function. Lu W, Guo W, Cui D, et al. Effect of Sex Hormones on Brain Connectivity Related to Sexual Function in Perimenopausal Women: A Resting-State fMRI Functional Connectivity Study. J Sex Med 2019;16:711-720.

Abstract P2-01-20: LAP2alpha, a novel tumor marker candidate is related to metastasis of breast cancer

Background: To date, there is no suitable serum marker for diagnosis and prognosis of breast cancer. In our early research, a new tumor marker candidate of breast cancer whose molecular weight was 5.6 kDa was screened from serum using mass spectrometry technology. It was decoded to be a fragment of isoform alpha of lamina-associated polypeptide 2 (LAP2α). The survival analysis revealed that LAP2α was over-expressed in breast cancer patients and indicated poor prognosis.

Materials and Methods: Immunohistochemistry (IHC) was utilized to evaluate LAP2α expression in paired primary breast tumor, metastasis of axillary lymph node and ipsilateral normal breast tissue of 29 breast cancer patients. An inhibition plasmid vector of LAP2α-small hairpin RNA (LAP2α-shRNA) was constructed and transfected into MCF-7 cells. The abilities of cell proliferation and metastasis were assessed both in vitro and in vivo. The association of LAP2α with epithelial-to-mesenchymal transition (EMT) was determined by western blot.

Results: LAP2α expression of paired tissue descended in order of metastasis of axillary lymph node (21/29, 72.4%), primary breast tumor (11/29, 37.9%) and ipsilateral normal breast tissue (4/29, 13.8%) (P&lt;0.05 in comparisons between each two groups). CCK-8 experiments on transfected and control cells showed that inhibition of LAP2α could not influence cell proliferation. Transwell and matrigel-transwell assays indicated that inhibition of LAP2α could significantly reduce cell migration and invasion abilities. In vivo experiments utilizing subcutaneous xenograft model and tail vein-injection mouse model revealed that the down-regulation of LAP2α might suppress tumorigenesis and metastasis of breast cancer. Western blot suggested that down regulation of LAP2α increased the E-cadherin expression level but repressed N-cadherin and vimentin expression levels.

Conclusions: A novel tumor marker candidate, LAP2α is related to metastasis of breast cancer both in clinical samples and tissue culture experiments. Inhibition of LAP2α could suppress aggressiveness and metastasis of breast cancer probably via EMT suppression.

Funding: The Natural Science Foundation of Zhejiang Province of China (No. LY14H160030 and LY13H160011), the National Program on Key Basic Research Project of China (973 Program; No. 2014CB542003), the National Natural Science Foundation of China (No. 30801341) and Zheng Shu Elite Scholarship for Clinical Medicine.

Citation Format: Hu Y, Qiu J, Zhou M, Li X, Huang Y. LAP2alpha, a novel tumor marker candidate is related to metastasis of breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-01-20.

Abstract P3-03-20: Which biopsy is preferred to stage the axilla under ultrasound guidance in early breast cancer patients: Fine-needle aspiration cytology or core needle biopsy?

Background:

Preoperative axillary ultrasound (AUS) offers the potential to identify clinically axillary negative patients with axillary lymph node (ALN) metastasis directly to axillary lymph node dissection (ALND) with avoid of unnecessary sentinel lymph node biopsy (SLNB) except Z0011 candidates. Which biopsy should be preferred is pendent with lack of enough prospective studies. The purpose of our study was to compare the accuracy of ultrasound guided fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB) for the designated ALN prospectively.

Methods:

Consecutive patients with histologically confirmed breast cancer from April, 2010 to December, 2014 were preliminary screened for our study. All the candidate patients were prospectively assessed by ipsilateral AUS before initial treatment regardless of clinical ALN status.Abnormal lymph nodes were characterized by round shape with uniform or eccentric thickening, focal bulging or irregularity of the cortex displacement, obliteration of the hilum; or total loss of recognizable lymph node architecture. If suspicious ALN was identified, both ultrasound-guided FNAC and CNB were performed for the same designated ALN.The diameter in longitudinal section, transverse section and maximum cortical thickness of the target node was recorded. When more than one abnormal lymph node was present, the most abnormal-appearing node was sampled. The target tissue for biopsy was hypoechoic thickened cortex. Patients with a positive FNAC/CNB underwent ALND, and those with a negative FNAC and CNB biopsy or without suspicious ALN by AUS underwent SLNB. The paired parameters of FNAC and CNB were compared using McNemar's exact test.

Results:

705 consecutive patients were screened and 558 patients (561 axillae) underwent AUS evaluation with confirmed ALN pathological results.145 patients (146 axillae) with both FNAC and CNB were finally enrolled. Final histopathological results showed that 83.6% (122/146) were node positive (5 micro-metastases were considered negative). Sensitivity of FNAC and CNB was 67.2% (82/122) and 91.8% (112/122). Overall accuracy of FNAC and CNB was 72.6% (106/146) and 93.2% (136/146). Negative predictive value (NPV) of FNAC and CNB was 37.5% (24/64) and 70.6% (24/34). There was significant difference in sensitivity, overall accuracy and NPV between FNAC and CNB (p&lt;0.001). 80.6% (29/36) FNAC negative and CNB positive patients have ALN cortical thickness of 3.3-7.2 mm.

Conclusion:

CNB is more sensitive and accurate than FNAC to stage the axilla under ultrasound guidance in operable breast cancer patients, especially in patients with ALN cortical thickness of 3.3-7.2 mm.

Citation Format: Zhou M, Qiu J, Chen J, Hu Y, Deng Y, Zheng S. Which biopsy is preferred to stage the axilla under ultrasound guidance in early breast cancer patients: Fine-needle aspiration cytology or core needle biopsy? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-20.

Validation of a predictive method for sunscreen formula evaluation using gene expression analysis in a Chinese reconstructed full-thickness skin model

OBJECTIVE

This study aimed to establish a predictive in vitro method for assessing the photoprotective properties of sunscreens using a reconstructed full-thickness skin model.

MATERIALS AND METHODS

A full-thickness skin model reconstructed with human fibroblasts and keratinocytes isolated from Chinese skin was exposed to daily UV radiation (DUVR). We examined the transcriptomic response, identifying genes for which expression was modulated by DUVR in a dose-dependent manner. We then validated the methodology for efficacy evaluation of different sunscreens formulas.

RESULTS

The reconstructed skin model was histologically consistent with human skin, and upon DUVR exposure, the constituent fibroblasts and keratinocytes exhibited transcriptomic alterations in pathways associated with oxidative stress, inflammation and extracellular matrix remodelling. When used to evaluate sunscreen protection on the model, the observed level of protection from UV-induced gene expression was consistent with the corresponding protection factors determined clinically and allowed for statistical ranking of sunscreen efficacy.

CONCLUSIONS

Within this study we show that quantification of gene modulation within the reconstructed skin model is a biologically relevant approach with sensitivity and predictability to evaluate photoprotection products.

3D-printed breast phantom for multi-purpose and multi-modality imaging

Background

Breast imaging technology plays an important role in breast cancer planning and treatment. Recently, three-dimensional (3D) printing technology has become a trending issue in phantom constructions for medical applications, with its advantages of being customizable and cost-efficient. However, there is no current practice in the field of multi-purpose breast phantom for quality control (QC) in multi-modalities imaging. The purpose of this study was to fabricate a multi-purpose breast phantom with tissue-equivalent materials via a 3D printing technique for QC in multi-modalities imaging.

Methods

We used polyvinyl chloride (PVC) based materials and a 3D printing technique to construct a breast phantom. The phantom incorporates structures imaged in the female breast such as microcalcifications, fiber lesions, and tumors with different sizes. Moreover, the phantom was used to assess the sensitivity of lesion detection, depth resolution, and detectability thresholds with different imaging modalities. Phantom tissue equivalent properties were determined using computed tomography (CT) attenuation [Hounsfield unit (HU)] and magnetic resonance imaging (MRI) relaxation times.

Results

The 3D-printed breast phantom had an average background value of 36.2 HU, which is close to that of glandular breast tissue (40 HU). T1 and T2 relaxation times had an average relaxation time of 206.81±17.50 and 20.22±5.74 ms, respectively. Mammographic imaging had improved detection of microcalcification compared with ultrasound and MRI with multiple sequences [T1WI, T2WI and short inversion time inversion recovery (STIR)]. Soft-tissue lesion detection and cylindrical tumor contrast were superior with mammography and MRI compared to ultrasound. Hemispherical tumor detection was similar regardless of the imaging modality used.

Conclusions

We developed a multi-purpose breast phantom using a 3D printing technique and determined its value for multi-modal breast imaging studies.

Design and fabrication of a personalized anthropomorphic phantom using 3D printing and tissue equivalent materials

To fabricate an individualized anthropomorphic lung phantom with tissue-equivalent radiation attenuation properties using a cost-effective three-dimensional (3D) printing technique. Based on anonymized human chest CT images, the phantom contained a 3D-printed skin shell, filled with tissue equivalent materials with similar radiation attenuation characteristics. The filling materials were a mixture of CaCO₃, MgO, agarose, NaCl, pearl powder and silica gel. The dose calculation accuracy of different treatment planning system (TPS) algorithms was validated and compared with the ion chamber measurements in the phantom, including tumor and surrounding normal tissues. The chest phantom was shown to represent a human's chest in terms of radiation attenuation property and human anatomy. The Hounsfield unit ranges were -60 to -100, 20 to 60, and 120 to 300 for fat, muscle, and bone, respectively. The actual measured values of the ionization chamber were 213.7 cGy for the tumor, 53.85 cGy for normal lung tissue, and 4.1 cGy for the spinal cord, compared to 214.1, 55.2, and 4.5 cGy, respectively, with use of the Monte Carlo algorithm in TPS. The application of 3D printing in anthropomorphic phantoms can improve personalized medical need and efficiency with reduce costs thus, can be used for radiation dose verification.

Grey matter differences associated with age and sex hormone levels between premenopausal and perimenopausal women: A voxel-based morphometry study

The present study aimed to explore brain morphological alterations associated with age and sex hormone levels between premenopausal and perimenopausal women using magnetic resonance imaging (MRI) T₁ -weighted structural images. Thirty-two premenopausal women aged (mean ± SD) 47.75 ± 1.55 years and twenty-five recently perimenopausal women aged 51.60 ± 1.63 years were evaluated for sex hormone levels, including prolactin, follicle-stimulating hormone, luteinising hormone, oestradiol, free testosterone and progesterone. A 3.0-Tesla MRI scanner was utilised to acquire T₁ images. Voxel-based morphometry (VBM) was used to evaluate changes in grey matter volume between the two groups. The general linear model was applied with false discovery rate correction for between group voxel-wise statistics. Spearman partial correlation analyses were conducted between age, sex hormone levels and regions of grey matter volume showing significant differences between the two groups. The VBM analysis revealed that age and menopause per se lead to grey matter volume reduction in certain brain structures. These structural changes might be potential causes of sexual dysfunction, nervous system degeneration and depression, which need to be examined in future studies. Our findings might provide evidence and guide future research in understanding the menopausal transition.

Comparative transcriptome profiles of Lindian chicken eyelids identify melanin genes controlling eyelid pigmentation

1. During the long history of chicken domestication, eyelid colour, like skin colour and shank colour, has been one of the physical traits of Chinese indigenous chickens that influence consumer buying behaviour. In China, the Lindian chicken, which has coloured feathers, is renowned for the appetizing flavour of its meat and eggs, and its eyelid colours vary from deep (black) to light shades (light yellow). 2. To investigate genes involved in eyelid colour, the expression profiles of black and light-yellow eyelids of Lindian chickens were analysed with transcriptome sequencing. 3. A total of 13 466 genes were detected in the eyelids, among which 14 were differentially expressed. Among these differentially expressed genes (DEGs), three key genes, premelanosome protein (PMEL), dopachrome tautomerase (DCT), and tyrosinase (TYR), encoded proteins that positively regulate melanogenesis and melanin deposition. PMEL, DCT and TYR were expressed much more strongly in the black eyelids than in the light-yellow eyelids. A Kyoto Encyclopedia of Genes and Genomes pathway analysis showed that tyrosine metabolism and melanogenesis genes were significantly enriched among these DEGs (corrected P < 0.05). 4. In conclusion, melanin may be one of the main factors involved in Lindian chicken eyelid colour. Furthermore, these results provide a valuable resource for the future study of the physical traits of Lindian chicken.

The Volume of Hippocampal Subfields in Relation to Decline of Memory Recall Across the Adult Lifespan

Background: The hippocampus is an important limbic structure closely related to memory function. However, few studies have focused on the association between hippocampal subfields and age-related memory decline. We investigated the volume alterations of hippocampal subfields at different ages and assessed the correlations with Immediate and Delayed recall abilities. Materials and Methods: A total of 275 participants aged 20-89 years were classified into 4 groups: Young, 20-35 years; Middle-early, 36-50 years; Middle-late, 51-65 years; Old, 66-89 years. All data were acquired from the Dallas Lifespan Brain Study (DLBS). The volumes of hippocampal subfields were obtained using Freesurfer software. Analysis of covariance (ANCOVA) was performed to analyze alterations of subfield volumes among the 4 groups, and multiple comparisons between groups were performed using the Bonferroni method. Spearman correlation with false discovery rate correction was used to investigate the relationship between memory recall scores and hippocampal subfield volumes. Results: Apart from no significant difference in the left parasubiculum (P = 0.269) and a slight difference in the right parasubiculum (P = 0.022), the volumes of other hippocampal subfields were significantly different across the adult lifespan (P < 0.001). The hippocampal fissure volume was increased in the Old group, while volumes for other subfields decreased. In addition, Immediate recall scores were associated with volumes of the bilateral molecular layer, granule cell layer of the dentate gyrus (GC-DG), cornus ammonis (CA) 1, CA2/3, CA4, left fimbria and hippocampal amygdala transition area (HATA), and right fissure (P < 0.05). Delayed recall scores were associated with the bilateral molecular layer, GC-DG, CA2/3 and CA4; left tail, presubiculum, CA1, subiculum, fimbria and HATA (P < 0.05). Conclusion: The parasubiculum volume was not significantly different across the adult lifespan, while atrophy in dementia patients in some studies. Based on these findings, we speculate that volume changes in this region might be considered as a biomarker for dementia disorders. Additionally, several hippocampal subfield volumes were significantly associated with memory scores, further highlighting the key role of the hippocampus in age-related memory decline. These regions could be used to assess the risk of memory decline across the adult lifespan.

Fabrication of an anthropomorphic heterogeneous mouse phantom for multimodality medical imaging

This work presents a comprehensive methodology for constructing a tissue equivalent mouse phantom using image modeling and 3D printing technology. The phantom can be used in multimodality imaging and irradiation experiments, quality control, and management. Computed tomography (CT) images of a mouse were acquired and imported into 3D modeling software. A skeleton and skin shell models were segmented in the modeling software and manufactured using 3D printing technology. The bone model was constructed with VERO-WHITE printing material with additional ingredients, including a photosensitive resin, polyurethane epoxy resin, and acrylate. Acrylonitrile butadiene styrene resin material was used to construct the skin shell. The skin shell was attached to the skeleton and filled with a specially formulated gel to act as a soft tissue substitute. The gel consisted of agarose, micro-pearl powder, sodium chloride, and magnevist solution (gadopentetate dimeglumine). A micro-container filled with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) radioactive tracer was placed in the abdomen for micro and human positron emission tomography (PET)/CT imaging. The mouse phantom had tissue equivalency in dose attenuation with x-rays and relaxation times with magnetic resonance imaging (MRI). The CT Hounsfield Unit (HU) range for the gel soft tissue material was 31-36 HU. The 3D printed bone mimetic material had equivalent tissue/bone contrast compared with in vivo mouse measurements with a mean value of 130  ±  10 HU. At different magnetic field strengths, the T ₁ relaxation time of the soft tissue was 382.75-506.48 ms, and T ₂ was 51.11-70.76 ms. ¹⁸F-FDG tracer could be clearly observed in PET imaging. The 3D printed mouse phantom was successfully constructed with tissue-equivalent materials. Our model can be used for CT, MRI, and PET as a standard device for small-animal imaging and quality control.

Age-related changes in cortical and subcortical structures of healthy adult brains: A surface-based morphometry study

BACKGROUND

Cerebral structures in both cortical and subcortical regions change with aging. More specific and comprehensive studies are needed to better elucidate these changes.

PURPOSE

To investigate the relationships between age and cerebral structures regarding cortical and subcortical changes.

STUDY TYPE

Cross-cohort research.

POPULATION

54 healthy adults (28 females) aged 21-71 years.

FIELD STRENGTH/SEQUENCE

T₁ -weighted imaging was performed at 1.5T.

ASSESSMENT

The cortical thickness, local gyrification index (LGI), and the volumes of total gray matter (GM), white matter (WM), white matter hyperintensity (WMH), deep gray matter nuclei (putamen, pallidum, thalamus, caudate, amygdala, accumbens area, and hippocampus), ventricles, and hippocampal subfields were obtained using FreeSurfer software.

STATISTICAL TESTS

Regression analysis was performed to determine the relationships between age and cortical thickness, LGI, and volumes of subcortical structures. Uncorrected P values ≤ 0.001 and R²  > 0.16 were considered significant.

RESULTS

The cortical thickness and LGI decreased with age throughout almost all brain regions (R²  > 0.16; P ≤ 0.001). Except for the volumes of the WM and 4th ventricle (R²  < 0.16; P > 0.001), the volumes of the GM, WMH, lateral ventricle, inferior lateral ventricle, and 3rd ventricle showed a nonlinear correlation with aging (R²  > 0.16; P ≤ 0.001). For deep gray matter nuclei, the thalamus volume was significantly decreased with aging (R²  = 0.256; P = 0.001). Additionally, the hippocampus volume was initially increased and then decreased at age of 50, mainly in the granule cell layer of the dentate gyrus (GC-DG), cornus ammonis 2/3 (CA2/3), CA4, and fissure (R²  > 0.16; P ≤ 0.001). The volumes of the putamen, pallidum, accumbens area, amygdala and caudate showed no significance with aging (R²  < 0.16; P > 0.001).

DATA CONCLUSION

The results comprehensively show the relationships between age and cerebral structures in multiple brain regions, and these findings may help identify normal aging and other age-related neuroradiological disorders.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2019;49:152-163.