The Relationship between Serum Zinc Level and Heart Failure: A Meta-Analysis

Association between biomarkers of zinc and copper status and heart failure: a meta-analysis

AIMS

Previous studies have investigated the relationship between heart failure (HF) and levels of zinc and copper, but conflicting results have been reported. This meta-analysis aims to clarify the role of zinc and copper in HF progression by examining the associations between HF and concentrations of these minerals.

METHODS AND RESULTS

We utilized STATA 12.0 software to calculate the standard mean difference (SMD) and 95% confidence interval (CI) for serum zinc and copper levels in patients with HF compared with healthy controls (HCs). The meta-analysis indicated a lower serum zinc level in patients with HF compared with HCs, using a random effects model (SMD = -0.77; 95% CI: -1.01, -0.54; I2 = 61.9%, the P-value for Q test = 0.002). Additionally, the meta-analysis showed an increased serum copper level in patients with HF compared with HCs, using a random effects model (SMD = 0.66; 95% CI: 0.09, 1.23; I2 = 93.8%, the P-value for Q test < 0.001). Meta-regression analysis indicated that publication year, age, and gender were not responsible for heterogeneity across studies.

CONCLUSIONS

This meta-analysis demonstrates that patients with HF have lower serum zinc and higher copper concentrations compared with healthy subjects. However, the potential of zinc supplementation as a therapy for HF should be approached with caution. The heterogeneity among the included studies was found to be high. It is recommended that further well-designed large sample studies be conducted to validate these findings.

Association between the serum zinc level and nutritional status represented by the geriatric nutritional Rrisk index

BACKGROUND

Although it is widely known that patients with chronic kidney disease (CKD) can develop zinc deficiency, in our previous analysis, the estimated glomerular filtration rate (eGFR) was not independently associated with the serum zinc level. Thus, a post hoc analysis was conducted to investigate the involvement of nutritional status.

METHODS

A total of 655 subjects not on dialysis (402 males; mean age, 57 ± 18 years) who underwent serum zinc level measurements at Jikei University Hospital between April 2018 and March 2019 were selected using the Standardized Structured Medical Information eXchange2 (SS-MIX2) system. In addition, anthropometric data and the Geriatric Nutritional Risk Index (GNRI) representing nutritional status were obtained, and the relationship between the serum zinc level and nutritional status was investigated by multiple regression analysis.

RESULTS

The serum albumin level and the GNRI were lower in the zinc-deficiency group, and both were positively associated with the serum zinc level (rho = 0.44, P < 0.01 and rho = 0.44, P < 0.01, respectively). On multiple regression analysis, the GNRI (t = 3.09, P < 0.01) and serum albumin level (t = 4.75, P < 0.01) were independently associated with the serum zinc level. Although a higher eGFR was associated with a higher serum zinc level, this association disappeared on multivariate analysis.

CONCLUSION

In this post hoc analysis, the GNRI, as well as the serum albumin level, were correlated with the serum zinc level, indicating that nutritional status is an important determinant of the zinc level. Further investigations are needed to clarify the effects of nutritional status and kidney function on zinc deficiency.

Serum zinc concentration in patients with myocardial infarction: a retrospective study

BACKGROUND

Zinc regulates the oxidative stress and inflammatory signaling cascade and affects the development and deterioration of cardiovascular disease. We investigated the prognosis of developing heart failure in patients with myocardial infarction.

METHODS

Patients with myocardial infarction (n = 243) were divided using the median value of zinc concentration on admission into low (< 66 µg/dL at admission, n = 111) and high zinc group (≥ 66 µg/dL at admission, n = 132). During follow-up (mean ± SD: 734 ± 597 days; median 691 days), admission due to heart failure was observed in 12 patients: 10 and 2 cases in the low and high zinc groups, respectively.

RESULTS

The risk of admission due to heart failure was significantly higher in the low zinc than in the high zinc group (P = 0.0043). Relative to the high zinc group, the hazard ratio for admission due to heart failure was 15.7 (95% confidence interval 1.11-221, P = 0.042) via adjusted Cox proportional hazards analysis. Even after propensity score matching, the risk of admission due to heart failure was significantly higher in the low zinc than in the high zinc group (P = 0.048).

CONCLUSION

Low serum zinc concentration may be a risk factor for admission due to heart failure after myocardial infarction.

Contaminant Metals and Cardiovascular Health

A growing body of research has begun to link exposure to environmental contaminants, such as heavy metals, with a variety of negative health outcomes. In this paper, we sought to review the current research describing the impact of certain common contaminant metals on cardiovascular (CV) health. We reviewed ten metals: lead, barium, nickel, chromium, cadmium, arsenic, mercury, selenium, zinc, and copper. After a literature review, we briefly summarized the routes of environmental exposure, pathophysiological mechanisms, CV health impacts, and exposure prevention and/or mitigation strategies for each metal. The resulting article discloses a broad spectrum of pathological significance, from relatively benign substances with little to no described effects on CV health, such as chromium and selenium, to substances with a wide-ranging and relatively severe spectrum of CV pathologies, such as arsenic, cadmium, and lead. It is our hope that this article will provide clinicians with a practical overview of the impact of these common environmental contaminants on CV health as well as highlight areas that require further investigation to better understand how these metals impact the incidence and progression of CV diseases.

Four-week administration of an energy and protein dense oral nutritional supplement improves micronutrient concentrations but does not completely correct deficiencies in institutionalized malnourished older adults

Introduction

Poor food intake is common among elderly living in nursing homes, leading to micronutrient deficiency (MD). There are no recommendations for the management of MD in malnourished older adults.

Methods

We conducted a single arm, open-label, multicenter interventional study in institutionalized malnourished older adults to describe the effect of a 4-week daily energy and protein dense oral nutritional supplementation (ONS, 600 kcal, 30 g protein per unit) containing 50% of the recommended daily micronutrient intake on micronutrient status. Plasma concentrations of vitamins (A, B9, B12, C, E), magnesium (Mg), selenium (Se) and zinc (Zn), and erythrocyte vitamin B9 were measured at baseline and after 4 weeks.

Results

Forty-six participants completed the study (age 87.4 ± 6.6). At baseline, the most frequent MD were Se (48%), Zn (35%), Mg (24%) and vitamin C (24%). Plasma concentrations of vitamins B9, B12, C and E, Mg, Se and Zn significantly increased and the proportion of subjects with at least one MD decreased (p = 0.006). However, after 4 weeks, 40% of subjects still had at least one MD.

Discussion

ONS consumption improved micronutrient status but did not correct MD in all participants. Our data suggest that the prescription of vitamin, mineral and trace element supplementation should be considered in institutionalized malnourished older adults in addition to high energy and high protein ONS.

Cardiovascular Diseases and Zinc

Zinc is structurally and functionally essential for more than 300 enzymes and 2000 transcription factors in human body. Intracellular labile zinc is the metabolically effective zinc and tiny changes in its concentrations significantly affect the intracellular signaling and enzymatic responses. Zinc is crucial for the embrionic and fetal development of heart. Therefore, it is shown to be related with a variety of congenital heart defects. It is involved in epithelial-to-mesenchymal transformation including endocardial cushion development, which is necessary for atrioventricular septation as well as the morphogenesis of heart valves. In atherosclerosis, monocyte endothelial adhesion, and diapedesis, activation and transformation into macrophages and forming foam cells by the ingestion of oxidized LDL are monocyte related steps which need zinc. Intracellular zinc increases intracellular calcium through a variety of pathways and furthermore, zinc itself can work as a second messenger as calcium. These demonstrate the significance of intracellular zinc in heart failure and arterial hypertension. However, extracellular zinc has an opposite effect by blocking calcium channels, explaining decreased serum zinc levels, contrary to the increased cardiomyocyte and erythrocyte zinc levels in hypertensive subjects. These and other data in the literature demonstrate that zinc has important roles in healthy and diseased cardiovascular system but zinc-cardiovascular system relationship is so complex that, it has not been explained in all means. In this article, we try to review some of the available knowledge about this complex relationship.

Effect of E-OJ-01 on Left Ventricular Ejection Fraction and Myocardial Oxygen Consumption: A Randomized, Double-Blind, Placebo-Controlled Study

Purpose

E-OJ-01 (Oxyjun^TM), a proprietary, standardized aqueous extract of Terminalia arjuna (TA) bark, has previously shown promising cardiovascular health benefits in healthy young athletic adults and is now being tested to determine its ability to support left ventricular ejection fraction and associated parameters in a diverse population.

Participants and Methods

Healthy adults aged 30-70 years (n=72) were included in the study to investigate the effect of 400 mg/day of E-OJ-01 when administered for 8 weeks on myocardial pumping capacity, primarily left ventricular ejection fraction (LVEF). The secondary endpoints were improvement in diastolic filling (E/A) ratio, rate pressure product (RPP), and fatigue severity scale (FSS) score. The effect of the intervention on blood lipids and gamma-glutamyltransferase (GGT) levels was also explored. The safety of the intervention was evaluated by monitoring adverse events, vitals (heart rate (HR), blood pressure (BP), and body temperature (BT)), and liver (serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT)) and kidney function (serum creatinine).

Results

E-OJ-01 increased the LVEF by 6.28% (percentage change) from the baseline compared with 0.24% (percentage change) in the placebo group (p<0.05). It reduced fatigue (22.52%), RPP (1.54%), and GGT levels (5.90%) from the baseline. No adverse events related to the intervention were observed during the study.

Conclusion

The study showed that E-OJ-01 could improve cardiac pumping capacity by significantly increasing LVEF and reducing fatigue in a diverse, healthy population.

The Beneficial Impact of Zinc Supplementation on the Vascular Tissue of the Abdominal Aorta under Repeated Intoxication with Cadmium: A Study in an In Vivo Experimental Model

In an in vivo rat model of human exposure to cadmium (Cd; 5 and 50 mg/L, 6 months), whether the supplementation with zinc (Zn; 30 and 60 mg/L, increasing its daily intake by 79% and 151%, respectively) protects against the unfavourable impact of this xenobiotic on the vascular tissue of the abdominal aorta was investigated. The treatment with Cd led to oxidative stress and increased the concentrations of pro-inflammatory interleukin 1β (IL-1β), total cholesterol (TC), triglycerides (TG), and endothelial nitric oxide synthase (eNOS) and decreased the concentration of anti-inflammatory interleukin 10 (IL-10) in the vascular tissue. Cd decreased the expression of intercellular adhesion molecule-1 (ICAM-1), platelet endothelial cell adhesion molecule-1 (PECAM-1), and L-selectin on the endothelial cells. The administration of Zn prevented most of the Cd-induced alterations or at least weakened them (except for the expression of adhesive molecules). In conclusion, Zn supplementation may protect from the toxic impact of Cd on the blood vessels and thus exert a beneficial influence on the cardiovascular system. The increase in the intake of Zn by 79% may be sufficient to provide this protection and the effect is related to the antioxidative, anti-inflammatory, and antiatherogenic properties of this essential element.

Interplay between Zn2+ Homeostasis and Mitochondrial Functions in Cardiovascular Diseases and Heart Ageing

Zinc plays an important role in cardiomyocytes, where it exists in bound and histochemically reactive labile Zn²⁺ forms. Although Zn²⁺ concentration is under tight control through several Zn²⁺-transporters, its concentration and intracellular distribution may vary during normal cardiac function and pathological conditions, when the protein levels and efficacy of Zn²⁺ transporters can lead to zinc re-distribution among organelles in cardiomyocytes. Such dysregulation of cellular Zn²⁺ homeostasis leads to mitochondrial and ER stresses, and interrupts normal ER/mitochondria cross-talk and mitophagy, which subsequently, result in increased ROS production and dysregulated metabolic function. Besides cardiac structural and functional defects, insufficient Zn²⁺ supply was associated with heart development abnormalities, induction and progression of cardiovascular diseases, resulting in accelerated cardiac ageing. In the present review, we summarize the recently identified connections between cellular and mitochondrial Zn²⁺ homeostasis, ER stress and mitophagy in heart development, excitation–contraction coupling, heart failure and ischemia/reperfusion injury. Additionally, we discuss the role of Zn²⁺ in accelerated heart ageing and ageing-associated rise of mitochondrial ROS and cardiomyocyte dysfunction.

No Association of Hair Zinc Concentration with Coronary Artery Disease Severity and No Relation with Acute Coronary Syndromes

Cardiovascular diseases (CVDs) are the leading cause of death worldwide. Although zinc (Zn) was reported to have antioxidant, anti-inflammatory and protective properties in CVDs, its association with coronary artery disease (CAD) is still unclear. As methods commonly used to assess Zn levels in blood and urine do not show the full picture of the microelement supply, in this study, the nutritional status of Zn in patients with angiographically confirmed CAD was assessed using inductively coupled plasma optical emission spectrometry. We found no association between Zn and the severity of CAD evaluated with the Coronary Artery Surgery Study Score (p = 0.67). There were no statistically significant differences in Zn levels between patients with acute coronary syndrome and those with stable CAD (p = 0.937). A statically significant negative correlation was observed between Zn content and serum triglyceride concentration (p < 0.05). Patients with type 2 diabetes mellitus were found to have a significantly lower hair Zn content compared to non-diabetic individuals (p < 0.01). The role of Zn in the pathogenesis of CAD and its complications need further well-designed research as the moderation and supplementation of Zn dietary intake could be a simple intervention to reduce the CVDs risk.

Comparison of zinc levels in the various biosubstrates of patients with unstable atherosclerotic plaque

The article describes the content and comparative characteristics of zinc level in the hair, biopsies of carotid atherosclerotic plaques (AP) and serum in patients with carotid atherosclerosis. The highest concentration of zinc is found in hair compared to the AP and serum. Zinc levels is higher in AP than in the serum. It is noteworthy that the level of zinc in biopsies of unstable AP was lower compared to the level of zinc in hair.

Slc39a2-Mediated Zinc Homeostasis Modulates Innate Immune Signaling in Phenylephrine-Induced Cardiomyocyte Hypertrophy

Zinc dyshomeostasis has been involved in the pathogenesis of cardiac hypertrophy; however, the dynamic regulation of intracellular zinc and its downstream signaling in cardiac hypertrophy remain largely unknown. Using Zincpyr1 staining, we found a significant decrease of intracellular Zinc concentration in phenylephrine (PE)-induced hypertrophy of neonatal rat ventricular myocytes (NRVMs). We then screened SLC39 family members responsible for zinc uptake and identified Slc39a2 as the only one altered by PE treatment. Slc39a2 knockdown in NRVMs reduced the intracellular Zinc level, and exacerbated the hypertrophic responses to PE treatment. In contrast, adenovirus-mediated Slc39a2 overexpression enhanced zinc uptake and suppressed PE-induced Nppb expression. RNA sequencing analysis showed a pro-hypertrophic transcriptome reprogramming after Slc39a2 knockdown. Interestingly, the innate immune signaling pathways, including NOD signaling, TOLL-like receptor, NFκB, and IRFs, were remarkably enriched in the Slc39a2-regulated genes. Slc39a2 deficiency enhanced the phosphorylation of P65 NFκB and STAT3, and reduced the expression of IκBα. Finally, the expression of IRF7 was significantly increased by Slc39a2 knockdown, which was in turn suppressed by IRF7 knockdown. Our data demonstrate that zinc homeostasis mediated by a Slc39a2/IRF7 regulatory circuit contributes to the alteration of innate immune signaling in cardiomyocyte hypertrophy.

Concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in adults with chronic heart failure

Background

The study investigated the relationship between the concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in the blood serum of patients with heart failure (HF) and the potential influence on the development and progression of HF.

Material & methods

The study included 214 patients (155 men and 59 women), aged 40–87 years, presenting symptoms or signs typical of HF (according to the NYHA functional classification). Serum concentrations were determined for Mg, Ca, Fe, Cu, Zn, P, C-reactive protein (CRP), creatinine, urea, triglyceride levels (TG), total cholesterol (CH), high density protein (HDL), low density protein (LDL). The levels of macro-and microminerals were analysed using inductively coupled serum optical emission spectrometry (ICP-OES).

Results

Our study confirmed the role of known risk factors in the development of heart failure, including: overweight, diabetes, hypertension, high triglycerides (TG), high total cholesterol (CH), high levels of low density protein (LDL) and reduced levels of high density protein (HDL), high CRP, high creatinine. Moreover, deficient serum concentrations of Mg (47% of the studied men and 54% of the women) and Cu (in 44% of men and more than 30% of women) were observed, as well as subnormal serum Fe (2% of women) and Zn (1% of men). Elevated serum Ca was found in 50% of men and 49% of women. In 44% of the studied men and 52% of the studied women, P levels in serum were also above-average. The study revealed a significant positive correlation between serum levels of Ca and Mg, and also Ca and Cu in women. In men, serum Cu was positively correlated with Mg and Ca concentrations. In patients from group 1 (NYHA I–II), Mg content was positively correlated with Ca and Cu. In this patient group, Ca was also positively associated with Cu content in serum. In group 2 (NYHA III-IV), serum Mg concentration was significantly positively correlated with that of Cu and Ca.

Conclusions

Changes in the serum concentrations of macro-and microminerals may significantly affect the severity of HF in Polish patients.

Zinc as a Biomarker of Cardiovascular Health

The importance of zinc (Zn) for cardiovascular health continuously gains recognition. As shown earlier, compromised Zn homeostasis and prolonged inflammation are common features in various cardiovascular diseases (CVDs). Similarly, Zn biochemistry alters several vascular processes, and Zn status is an important feature of cardiovascular health. Zn deficiency contributes to the development of CVDs; thus, Zn manipulations, including Zn supplementation, are beneficial for preventing and treating numerous cardiovascular (CV) disorders. Finally, additional long-term, well-designed studies, performed in various population groups, should be pursued to further clarify significant relationships between Zn and CVDs.

Association between Reduced Serum Zinc and Diastolic Dysfunction in Maintenance Hemodialysis Patients

Diastolic dysfunction is an emerging challenge among hemodialysis (HD) patients, and the associations between serum zinc with echocardiographic parameters and diastolic function remain uncertain. A total of 185 maintenance HD patients were stratified by the tertiles of serum zinc level to compare their clinical characteristics and echocardiography. Correlations of serum zinc levels with echocardiographic parameters were examined using Pearson’s analysis. Univariate and multivariate logistic regression analyses were performed to investigate the determinants of E/e’ ratio >15 and left atrial volume index (LAVI) > 34 mL/m², both indicators of diastolic dysfunction. Patients belonging to the first tertile of serum zinc level had a significantly higher E/e’ ratio and LAVI. Serum zinc levels were negatively correlated with E (r = −0.204, p = 0.005), E/e’ ratio (r = −0.217, p = 0.003), and LAVI (r = −0.197, p = 0.007). In a multivariate analysis, older age, diabetes, coronary artery disease, and lower serum zinc levels (OR = 0.974, 95% CI = 0.950–0.999, p = 0.039) were significantly associated with E/e’ ratio >15. Furthermore, diabetes and lower serum zinc levels (OR = 0.978, 95% CI = 0.958–0.999, p = 0.041) were significantly associated with LAVI >34 mL/m². Reduced serum zinc level was significantly associated with diastolic dysfunction among HD patients. Further prospective studies are warranted to investigate whether zinc supplementation can attenuate cardiac dysfunction in maintenance HD patients.

Concurrent Heavy Metal Exposures and Idiopathic Dilated Cardiomyopathy: A Case-Control Study from the Katanga Mining Area of the Democratic Republic of Congo

Blood and/or urine levels of 27 heavy metals were determined by ICPMS in 41 patients with dilated cardiomyopathy (DCM) and 29 presumably healthy subjects from the Katanga Copperbelt (KC), in the Democratic Republic of Congo (DRC). After adjusting for age, gender, education level, and renal function, DCM probability was almost maximal for blood concentrations above 0.75 and 150 µg/dL for arsenic and copper, respectively. Urinary concentrations above 1 for chromium, 20 for copper, 600 for zinc, 30 for selenium, 2 for cadmium, 0.2 for antimony, 0.5 for thallium, and 0.05 for uranium, all in μg/g of creatinine, were also associated with increased DCM probability. Concurrent and multiple exposures to heavy metals, well beyond permissible levels, are associated with increased probability for DCM. Study findings warrant screening for metal toxicity in case of DCM and prompt public health measures to reduce exposures in the KC, DRC.

Biomarkers of Zinc and Copper Status and Associated Factors in Outpatients with Ischemic and Non-Ischemic Heart Failure

Background: Few studies have explored the impact of ischemic and non-ischemic etiologies of heart failure and other factors associated with heart failure on zinc and copper status. This study examined zinc and copper status in 80 outpatients with ischemic (n = 36) and non-ischemic (n = 44) heart failure and associations with biodemographic, clinical, biochemical, and nutritional parameters.Materials: Biomarkers of plasma zinc and copper, copper-zinc ratio, 24-h urinary zinc excretion, ceruloplasmin, and dietary intake of zinc and copper were assessed. Plasma zinc and copper and urinary zinc were measured by inductively coupled plasma mass spectrometry (ICP-MS).Results: Patients with ischemic heart failure showed lower dietary zinc intake and higher dietary copper intake (both p = 0.02). Zinc and copper in plasma, copper-zinc ratio, ceruloplasmin, and 24-h urinary zinc excretion showed no statistical differences between the groups (all p ≥ 0.05). An inverse association was found between age (β =-0.001; p = 0.005) and the use of diuretics (β = -0.047; p = 0.013) and plasma zinc. Copper levels in plasma (β = 0.001; p < 0.001), and albumin (β = 0.090; p<0.001) were directly associated with plasma zinc. A positive association was found between ceruloplasmin (β = 0.011; p < 0.001), gamma-glutamyl transferase (β = 0.001; p < 0.001), albumin (β = 0.077; p = 0.001), and high-sensitivity c-reactive protein (β = 0.001; p = 0.024) and plasma copper.Conclusion: Zinc and copper biomarkers in clinically stable patients with heart failure did not seem to be responsive to the differences in zinc and copper intake observed in this study, regardless of heart failure etiology. The predictors of plasma zinc and copper levels related to oxidative stress and inflammation should be monitored in heart failure clinical practice.

Potential health benefits of zinc supplementation for the management of COVID-19 pandemic

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the etiological agent for the Coronavirus Disease 2019 (COVID-19). The COVID-19 pandemic has created unimaginable and unprecedented global health crisis. Since the outbreak of COVID-19, millions of dollars have been spent, hospitalization overstretched with increasing morbidity and mortality. All these have resulted in unprecedented global economic catastrophe. Several drugs and vaccines are currently being evaluated, tested, and administered in the frantic efforts to stem the dire consequences of COVID-19 with varying degrees of successes. Zinc possesses potential health benefits against COVID-19 pandemic by improving immune response, minimizing infection and inflammation, preventing lung injury, inhibiting viral replication through the interference of the viral genome transcription, protein translation, attachment, and host infectivity. However, this review focuses on the various mechanisms of action of zinc and its supplementation as adjuvant for vaccines an effective therapeutic regimen in the management of the ravaging COVID-19 pandemic. PRACTICAL APPLICATIONS: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological agent for the Coronavirus Disease 2019 (COVID-19), has brought unprecedented untold hardship to both developing and developed countries. The global race for vaccine development against COVID-19 continues with success in sight with attendant increasing hospitalization, morbidity, and mortality. Available drugs with anti-inflammatory actions have become alternative to stem the tide of COVID-19 with attendant global financial crises. However, Zinc is known to modulate several physiological functions including intracellular signaling, enzyme function, gustation, and olfaction, as well as reproductive, skeletal, neuronal, and cardiovascular systems. Hence, achieving a significant therapeutic approach against COVID-19 could imply the use of zinc as a supplement together with available drugs and vaccines waiting for emergency authorization to win the battle of COVID-19. Together, it becomes innovative and creative to supplement zinc with currently available drugs and vaccines.

Micronutrient Depletion in Heart Failure: Common, Clinically Relevant and Treatable

Heart failure (HF) is a chronic condition with many imbalances, including nutritional issues. Next to sarcopenia and cachexia which are clinically evident, micronutrient deficiency is also present in HF. It is involved in HF pathophysiology and has prognostic implications. In general, most widely known micronutrients are depleted in HF, which is associated with symptoms and adverse outcomes. Nutritional intake is important but is not the only factor reducing the micronutrient availability for bodily processes, because absorption, distribution, and patient comorbidity may play a major role. In this context, interventional studies with parenteral micronutrient supplementation provide evidence that normalization of micronutrients is associated with improvement in physical performance and quality of life. Outcome studies are underway and should be reported in the following years.