Calmodulinopathy is a common cause of critical cardiac phenotypes in fetus and infancy

Background

Cardiac calmodulinopathy is a life-threatening arrhythmia syndrome which presents several phenotypes of inherited primary arrhythmia syndrome (IPAS), and caused by mutations in calmodulin-encoded genes (CALM1–3). We aimed clarify the frequency and their clinical characteristics of calmodulinopathy in our IPAS cohort.

Methods

By using next generation sequencing, we screened arrhythmia related genes including calmodulin-encoding genes in 322 unrelated symptomatic children (0–12 years) who were suspected as IPAS; they included 40 cases with lethal arrhythmic attacks (LAE) under 6-year-old. After gene screening, we investigated their physiological and clinical characteristics about mutation carriers.

Results

Among 322 children, we identified 6 mutations of calmodulin-encoded genes in 9 probands (2.8%); one CALM1 in 2 probands (N98S), and 5 CALM2 in 7 probands (E46K, D96V, D96G, N98S, E141K). Their clinical diagnoses were long QT syndrome (LQTS, n=4), catecholaminergic polymorphic ventricular tachycardia (CPVT, n=3) and both (n=2). Their age of diagnosis ranges at 0–9 with the median of 5 years. There were three major clinical phenotypes; 1) CALM2-D96V, and E141K: two infants with advanced atrio-ventricular block, significant QTc prolongation, severe heart failure from their fetal period – both of them deceased within 1.5-year-old. Their clinical phenotypes resembled classical Timothy syndrome caused by CACNA1C mutations. 2) CALM1-N98S (n=2), CALM2-N98S (n=2), and CALM2-D96G: four preschoolers with LAEs and one syncope: all of them were 3–5 years old. In addition, a T wave morphology of CALM2-D96G carrier was very similar to LQT1. 3) CALM2-E46K (n=2): two were first diagnosed with neurological and developmental disorders, and showed phenotype of CPVT: their cardiac phenotypes were milder compared with that of 1) or 2). Overall, these phenotypes seemed to be mutation specific (indicated in figure). Their cardiac features were severer, and the onset of LAEs was earlier compared with other genotypes of LQTS/CPVT. As the treatment, β-blocker was effective for control of LAEs.

Conclusion

Cardiac calmodulinopathy presented serious and potentially lethal phenotypes in fetus or infancy. To prevent cardiac death in them, we must correctly diagnose and start the treatment as earlier as possible.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): MEXT KAKENHI from the Ministry of Education, Culture, Sports, Science, and Technology of Japan

P4764Relationship of the duration of pulmonary vein isolation-refractory non-paroxysmal atrial fibrillation to the middle- to long-term outcome of the ExTRa Mapping-guided ablation

Introduction

It is reported that for patients with non-paroxysmal (persistent or long-standing persistent) atrial fibrillation (Non-PAF), extended ablation to atrial walls in addition to pulmonary vein isolation (PVI) did not improve the long-term outcome. On the other hand, modulation of Non-PAF drivers (or perpetuators) has been proposed as one of the alternative effective ablation strategies for Non-PAF.

Purpose

To clarify whether the rotor ablation under online real-time high-density phase mapping system is effective for PVI-refractory Non-PAF ablation.

Methods

Under such circumstances, our academic group had recently developed the online real-time high-density phase mapping system (ExTRa Mapping™) by industrial alliance. The phase map moving images were based on 41 intra-atrial bipolar signals recorded by a 20-pole spiral-shaped catheter (2.5 cm in diameter) and on in silicorapid prediction of spatio-temporal atrial excitations (artificial intelligence system). Then we applied the ExTRa Mapping to clinical practice in order to directly visualize rotors in patients with Non-PAF, and investigated the middle- to long-term outcome of the ExTRa Mapping-guided rotor ablation (ExTRa-ABL).

Results

Thirty-eight patients (63±8 y/o, 30 males) with Non-PAF demonstrating refractoriness to PVI were enrolled in this study. Ablation for cavo-tricuspid isthmus and/or superior vena cava isolation was additionally performed at physicians' discretion. After these procedures, the ExTRa-ABL was performed in order to modify Non-PAF substrates, causing rotor control. The modification of the rotors was evaluated by re-mapping with the use of the ExTRa Mapping at the end of each ablation session. Patients were followed at 1, 3, 6 months and every year after the procedure. All of them were followed for 21±8 months. During the follow-up period, Non-PAF was recurred in only 8 of 38 (21%). Furthermore, we found if PVI-refractory Non-PAF duration was shorter than 6 years, the non-recurrence rate remained ≥80% (see Figure), which was markedly better outcome comparing with previous reports with regard to Non-PAF ablation.

Figure 1

Conclusion

Comparing with conventional Non-PAF ablation strategies, our novel approach with the use of the online real-time high-density phase mapping system might improve medium- to long-term outcome of PVI-refractory Non-PAF treatment.

Body odour aldehyde reduction by acetic acid bacterial extract including enzymes: alcohol dehydrogenase and aldehyde dehydrogenase

OBJECTIVE

The major causes of unpleasant human body odour are aldehydes produced by axillary-resident bacteria. There are many methods of body odour prevention; however, they all carry risks of destroying indigenous dermal bacteria that are necessary for the maintenance of the normal physical function of the skin. Furthermore, some methods cannot directly reduce the concentrations of substances that cause body odour. Therefore, a novel method of reducing body odour more safely and effectively is required. We focused on acetic acid bacterial enzymes, which can convert aldehydes into carboxylic acids, and investigated their effect on aldehydes and body odour.

METHODS

Subjects with strong body odour were recruited using screening questionnaires. Acetic acid bacterial extract including enzymes was applied to subjects' skin, and their effects were evaluated by trained panellists and by quantitative aldehyde analysis using thermal detector gas chromatography/mass spectrometry.

RESULTS

Acetic acid bacterial extract including enzymes decreased the ratio of dilution to threshold and the concentration of body odour-producing aldehydes dropped by up to 98.7%.

CONCLUSION

These results indicate that simply applying acetic acid bacterial enzymes on the skin can reduce the concentration of aldehydes that cause unpleasant body odour by directly converting them into carboxylic acids. Therefore, acetic acid bacterial enzymes can potentially be developed into new products that do not destroy indigenous bacteria and yet can effectively reduce unpleasant body odour.

Treatment of Relapsing Ph+ Acute Lymphoblastic Leukemia with Donor Leukocyte Infusion Followed by Quantitative Monitoring of Residual Disease

The case of a 34-year-old man with relapsing Ph+ acute lymphoblastic leukemia (ALL), which occurred five months after allogeneic bone marrow transplantation, is described. He was originally treated with aggressive chemotherapy, which put him in hematological remission, and he subsequently received donor leukocyte infusion (DLI) form the original donor. To assess the efficacy of this adoptive immunotherapy, we monitored minor-BCR/ABL (m-BCR/ABL) mRNA levels using the recently established real-time quantitative RT-PCR (RQ-PCR) assay. The results were compared with those obtained using conventional qualitative RT-PCR assays run in parallel. RQ-PCR, but not RT-PCR-based, minimum residual disease (MRD) detection showed a good correlation with the rapid changes documented during the post-DLI clinical course. Currently, six months after DLI, the patient continues to be in remission, which is consistent with the undetectable levels of m-BCR/ABL mRNA in the leukemic clone using RQ-PCR found in this study. Thus, monitoring of m-bcr/abl transcripts using RQ-PCR provides more useful information on a clinical assessment of MRD.

Parallel chemical switches underlying pollinator isolation in Asian Mitella

Floral scents are among the key signals used by pollinators to navigate to specific flowers. Thus, evolutionary changes in scents should have strong impacts on plant diversification, although scent-mediated plant speciation through pollinator shifts has rarely been demonstrated, despite being likely. To examine whether and how scent-mediated plant speciation may have occurred, we investigated the Asimitellaria plant lineage using multidisciplinary approaches including pollinator observations, chemical analyses of the floral scents, electroantennographic analyses and behavioural bioassays with the pollinators. We also performed phylogenetically independent contrast analyses of the pollinator/floral scent associations. First, we confirmed that the pairs of the sympatric, cross-fertile Asimitellaria species in three study sites consistently attract different pollinators, namely long-tongued and short-tongued fungus gnats. We also found that a stereoisomeric set of floral volatiles, the lilac aldehydes, could be responsible for the pollinator specificity. This is because the compounds consistently elicited responses in the antennae of the long-tongued fungus gnats and had contrasting effects on the two pollinators, that is triggering the nectaring behaviour of long-tongued fungus gnats while repelling short-tongued fungus gnats in a laboratory experiment. Moreover, we discovered that volatile composition repeatedly switched in Asimitellaria between species adapted to long-tongued and short-tongued fungus gnats. Collectively, our results support the idea that recurrent scent-mediated speciation has taken place in the Asimitellaria–fungus gnat system.

A retrospective observational study to assess adverse transfusion reactions of patients with and without prior transfusion history

BACKGROUND AND OBJECTIVES

This study compares the frequency of adverse transfusion reactions (ATRs) after first transfusions with the frequency of ATRs for subsequent (non-first) transfusions.

MATERIALS AND METHODS

Five hospitals agreed to systematically collect and share 2 years of data. This was a retrospective observational analysis of data including the number of transfusion episodes and ATRs for red blood cells (RBCs), fresh frozen plasma (FFP) and platelet concentrates (PCs) given to first-time transfusion recipients and to those previously transfused.

RESULTS

First transfusion ATRs to RBCs, FFP and PCs were 1.08%, 2.84% and 3.34%, respectively. These are higher than ATR incidences to RBCs (0.69%), FFP (1.91%) and PCs (2.75%) on subsequent transfusions. Specifically, first transfusion incidences of febrile non-haemolytic transfusion reactions (FNHTRs) to RBCs (0.43%) and allergic reactions to FFP (2.51%) were higher than on subsequent transfusions (RBCs: 0.23%, FFP: 1.65%).

CONCLUSION

There are risks of ATRs on the first transfusion as well as transfusions of patients with transfusion history.

Plasma protein adsorption to nanofabricated fluorinated polyimide surface

In this article, a series of fluorinated polyimides rubbed at different pressures was prepared, and the plasma protein adsorption on the rubbed polyimide films was evaluated using a micro-bicinchoninic acid protein assay. Interestingly, the amount of plasma protein adsorbed on the polyimide surface strongly depended on the rubbing pressure. The amounts of BSA and Fbg adsorbed on the rubbed polyimide film significantly decreased with an increase in the rubbing pressure. In contrast, the amounts of IgG adsorbed on the rubbed film dramatically increased with an increase in the rubbing pressure. In particular, it is interesting to note that a specific adsorption surface for IgG is formed by the rubbing process. We proposed that the nano-ordered hydrophilic and hydrophobic patternings formed on the top and bottom surfaces on the rubbed fluorinated polyimide film might have a significant influence on the plasma protein adsorption.

Separation of EEG and ECG components based on wavelet shrinkage and variable cosine window

During ambulatory monitoring, it is sometimes required to record an electroencephalogram (EEG) and an electrocardiogram (ECG) simultaneously. It would be ideal if both EEG and ECG could be obtained with one measurement. Here, we introduce an algorithm that combines the wavelet shrinkage and variable cosine window operation to separate the EEG and ECG components from an EEG signal recorded with a noncephalic reference (NCR). Evaluation using simulated data and actual measured data showed that accurate frequency analysis of EEG and an R-R detection-based heart rate analysis were feasible with our proposed algorithm, which improved the signal-averaging based algorithm so that ECG components containing ectopic beats can be applied.

Multicenter phase II study of FOLFOX for metastatic colorectal cancer (mCRC) in Japan; SWIFT-1 and 2 study

BACKGROUND/AIMS

This study assessed the efficacy and toxicity of the FOLFOX4 (SWIFT1) and mFOLFOX6 (SWIFT2) regimens in Japanese patients with metastatic colorectal cancer (mCRC).

METHODOLOGY

Patients with mCRC were required to have ECOG performance status of 0 to 1, and to have adequate organ function. Two multicenter Phase II studies (SWIFT1/SWIFT2) were conducted in chemotherapy naive patients with mCRC.

RESULTS

112 patients were enrolled in these studies (SWIFT1: 54 patients / SWIFT2: 58 patients). The disease sites for each study were the colon in 27 patients and 28 patients, and the rectum in 27 patients and 30 patients, respectively. All patients received a median of 8 courses. After a median follow-up period of 35 months, 54 patients and 58 patients were evaluable in the respective studies, and the overall response rate was 50.0% (CR:31 PR:53). The response rate according to the sites of metastasis were as follows: liver, 54.1% (46/85); lung, 17.4% (4/23); and lymph node, 23.3% (7/30). Grade 3/4 neutropenia occurred in 14 patients (12.5%), while Grade 3/4 non-hematological toxicities were observed in 16 patients (31.0%) and Grade 3 neurotoxicity was observed in 6patients (5.4%) and 5 patients (4.5%), respectively.

CONCLUSIONS

FOLFOX4 (SWIFT1) and mFOLFOX6 (SWIFT2) regimens complying with the international standard dosage and schedule can also be administered safely and effectively in Japan.

Use of genotype subset selections of multi-UGT1As polymorphisms to predict severe neutropenia and tumor responses of metastatic CRC patients received FOLFIRI regimen

e15038

Introduction: The pharmacogenetics of irinotecan indicate that a common polymorphism in the uridine diphosphate glucuronosyltransferase 1As (UGT1As) gene predict severe toxicity. However the tumor response to irinotecan is variable and unpredictable. Methods: Two multi-center phase II studies of FOLFIRI (FLIGHT-1 and FLIGHT-2 study) were conducted for patients with metastatic colorectal cancer (CRC) in Japan. FLIGHT-1 study was first-line chemotherapy, and FLIGHT-2 study was FOLFOX-refractory second-line chemotherapy. 103 patients have been enrolled in these studies (53 patients in FLIGHT-1 and 50 patients in FLIGHT-2) from 20 institutions by April 2007 from November 2005. Seventy one patients were analyzed UGT1As polymorphisms, UGT1A1*28 (TA6>TA7), UGT1A1*6 (G>A), UGT1A1*60 (T>C), UGT1A7 (N129K; T>G), UGT1A7 (-57 T>G), UGT1A9*22 (T10>T9). Results: Out of 71 patients, 34 had G3/4 neutropenia or leukopenia, and 23 had tumor responses (CR +PR). G3/4 neutropenia was more frequent in patients with *6, N129K(G), -57(G), *22 allele than patients without these allele (p<0.05). Other polymorphism was not the predictive factor for toxicity and tumor response, independently. On the other hand, genotype subset selection of multi-UGT1As polymorphisms was useful to predict severe toxicities and tumor responses. Only 7 patients of 22 patients with TA6/TA6 and T10/T10, or TA6/TA7 and -57(T/T), or *6(G/G) and *60(T/T) had grade3/4 toxicity. Similarly, high risk group of toxicity or high and low tumor responses groups was also predicted by genotype subset selections. Conclusions: Genotype subset selections of multi-UGT1As polymorphisms were the excellent predictor for severe toxicities and tumor responses of metastatic CRC patients received FOLFIRI regimen.

No significant financial relationships to disclose.

Bone response to titanium implants coated with thin sputtered HA film subject to hydrothermal treatment and implanted in the canine mandible

Hydroxyapatite (HA) was coated onto titanium implants using radio frequency magnetron sputtering. The HA films were crystallized in an autoclave tube using low temperature hydrothermal treatment. The average film thickness on the implant was 1.1 microm. HA-coated and pure-titanium implants were inserted into canine mandibles for up to 24 weeks. Forty-eight implants were placed in eight beagles. After 2, 4, 12 and 24 weeks, implants were retrieved and prepared for histological observation, and the HA film thickness was determined using energy-dispersive X-ray spectroscopy. Light microscopy revealed that, after two weeks, the bone response to the HA-coated implants was much better than to the pure titanium implants, and osteoblasts were observed at the bone-implant interface. After four weeks, the screw threads of the HA-coated implants were almost completely covered with bone. The HA film thickness rapidly decreased up to four weeks of implantation, then gently decreased, reaching 0.40+/-0.03 microm at the upper region of the implant after 12 weeks. That indicates that about 80% of the HA film had dissolved after 12 weeks of implantation. The rate of decrease in the HA film thickness was greater with increasing implant depth.

Serial changes in plasma brain natriuretic peptide concentration at the infarct and non-infarct sites in patients with left ventricular remodelling after myocardial infarction

OBJECTIVES

To clarify the role of infarct and non-infarct sites on left ventricular (LV) remodelling after myocardial infarction by measuring brain natriuretic peptide (BNP) from each site.

METHODS AND RESULTS

BNP from the aorta and the anterior interventricular vein (AIV) was measured in 45 patients with first anterior myocardial infarction at one, six, and 18 months. The LV was significantly dilated (> 10 ml/m(2) of end diastolic volume from one to 18 months) in 20 patients (remodelling (R) group) but not in 25 others (non-remodelling (NR) group). Patient characteristics and LV functions did not differ significantly at one month but plasma BNP concentration was higher in group R than in group NR (336 (288) v 116 (106) pg/ml, p < 0.01), predicting the degree of LV dilatation. The difference in BNP concentration between the aortic root and AIV (DeltaBNP), reflecting BNP secreted from the infarct site, did not differ at one month. In both groups BNP and DeltaBNP significantly decreased from one to six months (p < 0.05) and decreased from six months to 18 months, but the change was not significant. BNP and DeltaBNP were significantly higher in group R than in group NR after six months, when LV dilatation was not evident in both groups.

CONCLUSION

Enhanced BNP secretion at one month in the non-infarct and infarct ventricular sites predicts subsequent LV dilatation (that is, remodelling). The slower process of LV remodelling decreased BNP secretion at both sites. Thus, BNP concentration should be useful for monitoring ventricular remodelling after infarction.

Clinical features and treatment of hematopoietic stem cell transplantation-associated gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) may occur after hematopoietic stem cell transplantation (HSCT) and cause severe and prolonged gastric bleeding. The underlying pathology of transplant-associated GAVE (HSCT-GAVE) is poorly understood and an effective therapeutic strategy has not been established yet. We retrospectively reviewed the medical records of 230 consecutive allogeneic transplant recipients in our institution between January 1997 and June 2002. We identified five patients who developed HSCT-GAVE (2.2%). Four patients had bleeding from HSCT-GAVE and one patient had HSCT-GAVE discovered incidentally. The clinical features of these patients were similar in that they all received conditioning treatment with busulfan and had history of thrombotic microangiopathy. Furthermore, treatment with a beta-blocker apparently improved the outcome of HSCT-GAVE in three patients.

Interaction between fibroblast cells and fluorinated polyimide with nano-modified surface

In this study, we investigated the effect of surface nano-modification of aromatic fluorinated polyimide (6FDA-6FAP) derived from 2,2'-bis (3,4-dicarboxyphenyl) hexafluoropropane dianhydride (6FDA) and 2,2'-bis (4-aminophenyl) hexafluoropropane (6FAP) on the interaction with proteins and cells. The surface of 6FDA-6FAP was modified by surface-rubbing showed nano-ordered stripes along the rubbing direction. The rat fibroblast FR cells formed multicellular spheroids with high cell density on the rubbed surface then expressed excellent collagen production similarly in vivo, while on the non-modified surface the cells formed two-dimensional monolayers and the collagen production was negligible. The modulation of cell function by the surface nano-modification along with surface micro-modification may be one of the most important considerations during the design and manufacture of novel biochips or tissue engineering materials.

Isolation of an Acinetobacter sp. ST-550 which produces a high level of indigo in a water-organic solvent two-phase system containing high levels of indole

Acinetobacter sp. strain ST-550 was isolated from fumus soil as an efficient indigo producer in the presence of organic solvent. The minimum inhibitory concentration of indole was 0.4 mg/ml for ST-550. ST-550 produced only a small amount of indigo (less than 0.01 microg/ml) when grown in the presence of indole at concentrations of 0.05 to 0.3 mg/ml without any organic solvent. However. ST-550 produced indigo effectively when grown in the presence of a large volume of diphenylmethane and a high level of indole: optimized conditions were 3 ml of a medium containing 0.3 ml diphenylmethane and 2.7 mg indole. Under these conditions, ST-550 produced 0.88 mg indigo (292 microg/mI medium).

A human case of protothecosis successfully treated with itraconazole

Cutaneous protothecosis developed in a 63-year-old Japanese female. The patient had a long history of steroid use for bronchial asthma. A tender, swollen, erythematous plaque with white papules covered the dorsal aspect of the patients right hand. Histopathological examination showed typical protothecosis with numerous mulberry-like sporangia positive for periodic acid-Schiff stain. The pathogen was identified as Prototheca wickerhamii. After a 6-week course of 150-200 mg/day itraconazole (ITCZ) therapy, the patients culture was negative for P. wickerhamii. No recurrence was seen after 12 weeks of ITCZ therapy. This case of protothecosis and those of 16 patients are summarized. All the patients had lived in mid- to southern Japan. Only 12 cases of protothecosis treated with ITCZ have been reported in the literature; 8 of these cases were cured with ITCZ therapy alone. In cases treated with ITCZ at no more than 100 mg/day, medication was typically needed for 2 months; most of the cases treated with ITCZ at 200 mg/day were successfully cured within 2 months. A 2-month course of ITCZ at 200 mg/day appears to be adequate treatment for human protothecosis.

Optical mapping of ventricular defibrillation in isolated swine right ventricles: demonstration of a postshock isoelectric window after near-threshold defibrillation shocks

BACKGROUND

Investigators who studied ventricular defibrillation by use of optical mapping techniques failed to observe an initial defibrillation event (isoelectric window or quiescent period) shown by electrode mapping studies. This discrepancy has important implications for the mechanisms of defibrillation. The purpose of the present study was to demonstrate an optical equivalent of an isoelectric window after a near-threshold defibrillation shock. Methods and Results-- We studied 10 isolated, perfused swine right ventricles. Upper limit of vulnerability was determined by shocks on T waves. A 50% probability of successful defibrillation (DFT50) was determined with an up-down algorithm. Immediately after unsuccessful defibrillation shock, new wavefronts were generated. When the shock strength was low, immediate reinitiation of reentry and ventricular fibrillation might occur without a postshock isoelectric window. However, if the shock strength was within 50 V of DFT50 (near-threshold), a synchronized activation occurred, followed by organized repolarization that ended 64+/-18 ms after shock. After a period of quiescence (18+/-24 ms), activation recurred 83+/-33 ms after shock and reinitiated ventricular fibrillation. Similar patterns of activation, including a quiescent period, were observed after shock was applied on the T wave of the paced beat that induced ventricular fibrillation. Upper limit of vulnerability correlated well with DFT50.

CONCLUSIONS

In isolated swine right ventricles, an optical equivalent of an isoelectric window exists after near-threshold defibrillation shocks. These findings support the idea that a near-threshold defibrillation shock terminates all activation wavefronts but fails to halt ventricular fibrillation because the same shock reinitiates ventricular fibrillation after an isoelectric window.

Effects of diacetyl monoxime and cytochalasin D on ventricular fibrillation in swine right ventricles

Whether or not the excitation-contraction (E-C) uncoupler diacetyl monoxime (DAM) and cytochalacin D (Cyto D) alter the ventricular fibrillation (VF) activation patterns is unclear. We recorded single cell action potentials and performed optical mapping in isolated perfused swine right ventricles (RV) at different concentrations of DAM and Cyto D. Increasing the concentration of DAM results in progressively shortened action potential duration (APD) measured to 90% repolarization, reduced the slope of the APD restitition curve, decreased Kolmogorov-Sinai entropy, and reduced the number of VF wave fronts. In all RVs, 15-20 mmol/l DAM converted VF to ventricular tachycardia (VT). The VF could be reinduced after the DAM was washed out. In comparison, Cyto D (10-40 micromol/l) has no effects on APD restitution curve or the dynamics of VF. The effects of DAM on VF are associated with a reduced number of wave fronts and dynamic complexities in VF. These results are compatible with the restitution hypothesis of VF and suggest that DAM may be unsuitable as an E-C uncoupler for optical mapping studies of VF in the swine RVs.

Second allogeneic peripheral blood stem cell transplantation with fludarabine-based low-intensity conditioning regimen for relapsed myelodysplastic syndrome after allogeneic bone marrow transplantation

We describe the case of a 51-year-old patient with relapsed myelodysplastic syndrome after allogeneic bone marrow transplantation (BMT), who underwent allogeneic peripheral blood stem cell transplantation (PBSCT) after conditioning with a novel regimen consisting of fludarabine, busulfan, and antithymocyte globulin. The second PBSCT was performed early, at 3 months after the initial allogeneic BMT, but it was well tolerated and complete hematologic remission was documented. The patient did not experience any early transplantation-related organ toxicity but died from opportunistic infection 6 months after the second transplantation. Our experience suggests that this novel regimen may induce remission and could be offered to patients relapsing after the first transplantation; however, the fludarabine-containing regimen might be accompanied by profound immunosuppression.

In vitro melanin binding of NS-49, a phenethylamine class alpha 1A-adrenoceptor agonist

Characteristics of the in vitro binding of NS-49 ((R)-(-)-3'-(2-amino-1-hydroxyethyl)-4'-fluoromethanesulfonanilide hydrochloride, CAS 137431-04-0) to synthetic melanin were determined and compared with those of other drugs. At all the drug concentrations tested (12.5-200 mumol/l), chloroquine (CAS 54-05-7) had the highest melanin binding (%), followed by ofloxacin (CAS 82419-36-1), NS-49, norephedrine (CAS 154-41-6) and diazepam (CAS 439-14-5). Binding constants (Kb), calculated with the Langmuir adsorption isotherm were, in the order (largest to smallest) chloroquine, ofloxacin, NS-49, norephedrine, the Kb value for NS-49 being one-thirteenth that for chloroquine, one-seventh that for ofloxacin and ten times higher than that for norephedrine. 53% of NS-49 that was bound to synthetic melanin dissociated during 24 h of incubation after the binding experiment. The percent of dissociation for NS-49 was higher than the values for chloroquine (5%) and ofloxacin (39%). After 1 day incubation in the dissociation experiment, the amount of NS-49 bound per mg of melanin was 23 nmol, being less than the amounts of chloroquine (210 nmol) and ofloxacin (78 nmol). These findings indicate that NS-49 has a lower affinity for synthetic melanin than chloroquine and ofloxacin, which have high affinities and therefore accumulate in melanin containing ocular tissues.

Effect of sesame seeds rich in sesamin and sesamolin on fatty acid oxidation in rat liver

Activities of enzymes involved in hepatic fatty acid oxidation and synthesis among rats fed sesame (Sesamum indicum L.) differing in lignan content (sesamin and sesamolin) were compared. Sesame seeds rich in lignans from two lines, 0730 and 0732, lines established in this laborary, and those from a conventional cultivar (Masekin) were employed. Seeds from the 0730 and 0732 lines contained sesamin and sesamolin at amounts twice those from Masekin. Sesame seeds were added at levels of 200 g/kg to the experimental diets. Sesame increased both the hepatic mitochondrial and the peroxisomal fatty acid oxidation rate. Increases were greater with sesame rich in lignans than with Maskin. Noticeably, peroxisomal activity levels were >3 times higher in rats fed diets containing sesame seeds from the 0730 and 0732 lines than in those fed a control diet without sesame. The diet containing Masekin seed caused only a 50% increase in the value, however. Diets containing seeds from the 0730 and 0732 lines, compared to the control and Masekin diets, also significantly increased the activity of hepatic fatty acid oxidation enzymes including acyl-CoA oxidase, carnitine palmitoyltranferase, 3-hydroxyacyl-CoA dehydrogenase, and 3-ketoacyl-CoA thiolase. In contrast, diets containing sesame lowered the activity of enzymes involved in fatty acid synthesis including fatty acid synthase, glucose-6-phosphate dehydrogenase, ATP-citrate lyase, and pyruvate kinase. No significant differences in enzyme activities were, however, seen among diets containing sesame from Masekin cultivar and lines 0730 and 0732. Serum triacylglycerol concentrations were lower in rats fed diets containing sesame from lines 0730 and 0732 than in those fed the control or Masekin diet. It is apparent that sesame rich in lignans more profoundly affects hepatic fatty acid oxidation and serum triacylglycerol levels. Therefore, consumption of sesame rich in lignans results in physiological activity to alter lipid metabolism in a potentially beneficial manner.

Effect of leucocyte reduction on the potential alloimmunogenicity of leucocytes in fresh-frozen plasma products

BACKGROUND AND OBJECTIVES

Adverse effects mediated by leucocytes in cellular blood products are widely recognized. There are few studies, however, concerning the effects of residual leucocytes in fresh-frozen plasma (FFP). We examined the quantities and characteristics of leucocytes in FFP in order to investigate the potential leucocyte-associated adverse effects of FFP transfusion, focusing on the risk of alloimmunization.

MATERIALS AND METHODS

The quantity of leucocytes in FFP was estimated by using the Nageotte method and flow cytometry (FCM) analysis. The viability and subsets of leucocytes were determined by FCM using propidium iodide (PI) and fluorescein-conjugated antibodies. To investigate alloimmunogenicity caused by the leucocytes in FFP, mixed lymphocyte cultures (MLC) were performed using fresh, allogeneic peripheral blood mononuclear cells (PBMCs) as responder cells and cell-concentrated thawed FFP as a stimulator. We also studied the performance of leucocyte-reduction filters with FFP products.

RESULTS

The average number of leucocytes in a single unit of FFP, derived from 200 ml of whole blood, was 2.98 x 10(6) (range 0.99-8.38 x 10(6)). The majority of these cells were PI-positive dead cells; however, a small but consistent population of PI-negative cells was present in these products. Both dead and live cells expressed human leucocyte antigen (HLA) class I antigens, and approximately 38% of these cells expressed HLA class II antigens. The average number of viable CD3+ T cells in one unit of FFP was 2.36 x 10(4). Growth of the allogeneic PBMCs increased following stimulation with highly concentrated FFP. Use of leucocyte-reduction filters significantly reduced the concentrations of both PI-positive (dead) and PI-negative (live) cells. The growth of allogeneic lymphocytes after stimulation with FFP was also completely suppressed by leucocyte filtration of FFP.

CONCLUSION

Transfusion of FFP is potentially alloimmunogenic owing to its residual leucocyte content. Leucocyte-reduction filters appear to be effective in suppressing the alloimmunogenicity of FFP.

[A patient with dysphagia treated successfully and discharged without nutritional support]

One of the main targets of medical care provided in our ward, which specializes in the cooperative practice of hospital- and home-doctors, is to maintain the quality of patients' lives after they are discharged from our hospital through home medical care by home-doctors. Intravenous hyperalimentation and tube-feeding at home are suitable solutions for some patients with dysphagia after cerebral infarction. However, the difficulties faced in their management are the burden on the families, which tends to be an obstacle for at-home-practice. We describe herein a case of severe dysphagia treated successfully through our rehabilitation program and discharged without nutritional supports. An 82-year-old man was admitted to our hospital suffering from pyrexia and dysbasia. The man, who lives with his wife and his son's family, was diagnosed with aspiration pneumonia and multiple cerebral infarctions. The test for swallowing reflex revealed an impaired first phase reflex and intravenous hyperalimentation was performed for his nutritional support. He was still suffering from dysphagia but had the desire to eat orally after his dysbasia and aspiration pneumonia were cured. A rehabilitation program was scheduled with the aims of 1) recovery of ingestion and 2) sufficient expectoration, with an ongoing teaching program for the management of intravenous hyperalimentation. After one month of rehabilitation (ice-massaging, muscle rehabilitation of the tongue and neck and expectoration training in a prone position and after gorging), his ability to swallow was gradually recovered. With the frequent confirmation of absence of aspiration, special forms of diets were served and upgraded from jelly, paste-like-food to soft-cooked steamed rice. The patient is now at home without any nutritional support. Nutritional management without intravenous hyperalimentation or tube-feeding is important or even essential for some families providing home-care for patients. The problem of aging requires us to reduce the burden that families (who may be also getting older) should carry. We try to support patients and families for better home-care through cooperation with society and home-doctors.

Mutation and association analysis of the 5' region of the dopamine D3 receptor gene in schizophrenia patients: identification of the Ala38Thr polymorphism and suggested association between DRD3 haplotypes and schizophrenia

Although the association between the Ser9Gly polymorphism of the dopamine D3 receptor gene (DRD3) and schizophrenia has been investigated by many research groups, it is not known whether the Ser9Gly polymorphism alone or a variation in linkage disequilibrium may effect susceptibility to schizophrenia. We searched the 5' region of the DRD3 gene and found three novel polymorphisms: -712G/C, -205A/G, and Ala38Thr. The Ala38Thr polymorphism is located in the first transmembrane region and is conserved in the monkey, mouse, and rat. Case-control comparisons in 153 Japanese schizophrenia patients and 122 Japanese controls did not suggest an association between Ala38Thr and schizophrenia. However, there was a marginally significant association between the Ser9 allele of the Ser9Gly polymorphisms and schizophrenia (P = 0.02). Furthermore, there was a highly significant association between haplotypes of the -712G/C, -205A/G, and Ser9Gly polymorphisms and schizophrenia (P = 0.0007, corrected P = 0.007). These positive findings were replicated in an additional 99 Japanese schizophrenia patients and 132 controls (P = 0.04 and 0.0004, respectively). The most allelic differences of the Ser9Gly polymorphism between patient and control groups arose from the chromosome carrying specific alleles of the other three polymorphisms. This study indicates unknown variant(s) in linkage disequilibrium with the DRD3 haplotypes associated with schizophrenia.

Identification of a polymorphism in the promoter region of DRD4 associated with the human novelty seeking personality trait

Polymorphism in the human dopamine D4 receptor gene (DRD4) exon III has been associated in some but not all studies of the human personality trait of Novelty Seeking. We searched for polymorphisms in the 5' region of DRD4 and identified six polymorphisms as follows: -1217G Ins/Del, -809G/A, -616C/G, -603T Ins/Del, -602(G)8-9, and -521C/T. Associations between these polymorphisms and personality traits measured by the Temperament and Character Inventory (TCI) were investigated in 86 healthy Japanese volunteers. The -521C/T polymorphism was significantly associated with Novelty Seeking (P = 0.0001). Subjects with the C/C genotype exhibited the highest Novelty Seeking scores and those with the T/T genotype exhibited the lowest. A transient expression method revealed that the T variant of the C-521T polymorphism reduces transcriptional efficiency. The present study suggests a contribution of dopamine D4 receptor availability to individual differences in Novelty Seeking behavior. Molecular Psychiatry (2000) 5, 64-69.

[Varicella-zoster virus infection after hematopoietic stem cell transplantation]

Of 264 patients aged 15 years or more who underwent hematopoietic stem cell transplantation between 1989 and September 1998 at the Tokyo Metropolitan Komagome Hospital, 47 were infected by the varicella-zoster virus (VZV). In 2 patients, visceral disease preceded cutaneous dissemination. One of these patients exhibited gastrointestinal symptoms followed by disseminated skin rash 6 days later. In the other patient, epigastralgia developed and was followed by seizures secondary to meningitis; the appearance of a skin rash 5 days after these initial symptoms yielded the diagnosis. Early diagnosis and treatment of VZV infection are important, especially for patients who present with visceral symptoms suspected to be due to VZV.

A patient with rectal cancer associated with ulcerative colitis in whom endoscopic ultrasonography was useful for diagnosis

Endoscopic ultrasonography (EUS) was helpful for the diagnosis of rectal cancer associated with ulcerative colitis. The patient was a 38-year-old Japanese man with a 19-year history of relapsing-remitting type ulcerative colitis involving the entire colon. Routine colonoscopy revealed multiple polypoid prominences in the upper portion of the rectum. EUS revealed a hypoechoic mass in the submucosa beneath and around the polypoid lesion on the most oral side. Signet ring cells were found in a biopsy specimen from this lesion. Subtotal colectomy was performed. A depressed lesion was observed around the prominence on the most oral side; histologically, this lesion was poorly differentiated mucinous and signet ring cell carcinoma extending into the subserosa. The polypoid lesion on the most anal side was well differentiated adenocarcinoma, which was limited to the mucosa. Our findings suggest that EUS is helpful for detecting invasive cancer associated with ulcerative colitis.

Molecular remission in adult T cell leukemia after autologous CD34+ peripheral blood stem cell transplantation

This report describes a patient with acute-type adult T cell leukemia/lymphoma (ATLL) successfully treated by autologous CD34+ peripheral blood stem cell transplantation after fractionated total body irradiation and high-dose cytarabine and cyclophosphamide. A newly established inverse polymerase chain reaction method was used to demonstrate the disappearance of ATLL clonal cells. The patient achieved a sustained molecular remission after transplantation, but died from opportunistic infection 4 months after transplantation. Thus, autologous CD34+ peripheral blood stem cell transplantation is promising for this type of malignancy. However, a prudent clinical attitude toward immunological fragility after transplantation is needed for better outcome.

Antibody response to OspC-I synthetic peptide derived from outer surface protein C of Borrelia burgdorferi in sera from Japanese forestry workers

The prevalence of antibodies against Lyme disease spirochaetes in serum samples from 80 forestry workers at high occupational risk of Lyme disease was surveyed by enzyme-linked immunosorbent assay (ELISA) with the OspC-I synthetic peptide. The peptide is part of the outer surface protein C (OspC) amino acid sequence located in the region conserved among Borrelia burgdorferi sensu stricto or sensu lato. Positivity for antibodies against OspC-I was observed in 25 (313%) of the forestry workers. Of these positive cases, 12 (15.0%) and 19 (23.8%) were positive for immunoglobulin M (IgM) and IgG antibody, respectively. Among 62 workers who were negative for IgG antibody against B. garinii or B. japonica in our previous study, 9 (14.5%) and 4 (6.5%) were positive for IgM and IgG antibody, respectively, in OspC-I ELISA. These results demonstrate for the first time that Lyme disease in forestry workers can be revealed using OspC-I ELISA. We conclude that forestry workers who show positive results for antibodies against OspC-I have very likely been exposed to Lyme disease spirochaetes, and that those who show positivity for IgM antibody against OspC-I may be in the early stage of Lyme disease.

A genetic polymorphism in the promoter region of DRD4 associated with expression and schizophrenia

The human dopamine D4 receptor gene (DRD4) is an important candidate gene for schizophrenia. We identified a novel -521C>T polymorphism in the 5'-promoter region of DRD4. A transient expression method revealed that the T allele of this polymorphism reduces the transcriptional efficiency by 40% compared with the C allele. This polymorphism is of interest because of reported elevation of D4-like sites and DRD4 mRNA in the postmortem schizophrenic brain. The C allele frequency was significantly higher in 252 Japanese schizophrenics (0.48) than in 269 Japanese controls (0.41) (p = 0. 02) [odds ratio = 1.35 (95% confidence interval 1.05 - 1.72)]. Although the association is weak and should be considered tentative until other studies replicate it, this polymorphism provides a tool with the potential to examine whether DRD4 is related to susceptibility to and neuroleptic response in schizophrenia.

Successful closure of coronary-bronchial artery fistula with vein graft-coated stent

A coronary-bronchial fistula and aneurysmal dilatation of the proximal part of the fistula was successfully closed using an autologous vein graft-coated stent (Palmaz-Schatz stent). This is the first report that demonstrates the feasibility of the vein-coated stent for the treatment of congenital disease.

A comparative study of a new, fully automated procedure and the standard mononuclear cell program using the Cobe Spectra for peripheral blood stem cell collection

Recently, a completely automated procedure, the AutoPBSC program for the COBE Spectra cell separator, has been developed for peripheral blood stem cell harvest (PBSCH). We compared the performance of the AutoPBSC program with the standard mononuclear cell (MNC) program in the same patients and in a donor. Peripheral blood stem cells (PBSC) were collected from 3 patients or a donor alternately using the MNC program and the AutoPBSC program in a course of PBSC mobilization. Equal blood volume was processed from each patient (200 ml/kg) and a donor (150 ml/kg). We used a harvest volume of 3 ml and a chase volume of 7 ml in all AutoPBSC procedures. The procedure duration was almost equivalent for both programs. The volume of products was significantly lower in the AutoPBSC program (71 +/- 13 ml) than in the MNC program (183 +/- 30 ml). MNC yields were fewer, and total nucleated cell (TNC) and MNC collection efficiency was less for the AutoPBSC program compared to the MNC program. The CD34+ cell collection efficiency was less for the AutoPBSC program (26.5 +/- 13.7%, compared with 77.7 +/- 60.6%; p > 0.05). The contamination of platelets and red cells was significantly less in the AutoPBSC program than in the MNC program. In conclusion, we consider that the collection efficiency in the new program should be improved by modification of parameters because there exist great advantages to automated procedures.

The effects of nucleotides and potassium channel openers on the SUR2A/Kir6.2 complex K+ channel expressed in a mammalian cell line, HEK293T cells

The effects of potassium channel opening drugs and intracellular nucleotides on the ATP-sensitive K+ (KATP) channel composed of SUR2A and Kir6.2 in HEK293T cells were examined using the patch-clamp technique. The SUR2A/Kir6.2 channel was activated effectively by pinacidil, marginally by nicorandil but not by diazoxide. The pinacidil-activated channel currents were inhibited by glibenclamide with a Ki value of 160 nM. Upon formation of inside-out (I-O) patches, spontaneous openings of the channels appeared, which were inhibited by intracellular ATP (ATPi) equipotently in the presence and in the absence of intracellular Mg2+ (Mg2+i). The channel activity ran-down gradually in I-O patches. The run-down channels could be reactivated by ATPi only in the presence of Mg2+i. Uridine 5'-diphosphate (UDP) antagonized the ATPi-mediated inhibition of the channel activity before run-down. After run-down, UDP activated the channel without antagonizing ATPi-mediated channel inhibition. Thus, the SUR2A/Kir6.2 reproduced the major properties of the native cardiac KATP channel well in terms of nucleotide regulation and pharmacology, and therefore can be a useful tool with which to elucidate the molecular mechanisms characterizing the KATP channel.

Paraoxonase has a major role in the hydrolysis of prulifloxacin (NM441), a prodrug of a new antibacterial agent

NM441 is a prodrug of the new quinolone carboxylic acid antibacterial agent NM394. A rat serum enzyme (NM441-hydrolase) that catalyzes the hydrolysis of NM441 to NM394 was purified by ultracentrifugation, heparin-Sepharose column chromatography, and HPLC with a Mono Q anion exchange column. The enzyme showed a single protein band after sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Its molecular mass was estimated as 46 kDa. The amino-terminal sequence and two internal amino acid sequences of the NM441-hydrolase resemble those of mouse, rabbit, and human serum paraoxonases. Moreover, its enzymatic characteristics (optimum pH, calcium requirement, and molecular mass) were similar to those of the paraoxonases. These findings identify the NM441-hydrolase as rat serum paraoxonase. To determine whether the paraoxonase catalyzes the hydrolysis of NM441 to NM394 in human serum, we investigated whether the paraoxonase and NM441-hydrolase activities were correlated. There was a positive correlation (r = 0.653, p < 0.005) found in the sera of 67 healthy volunteers, indicating that paraoxonase is responsible for the conversion of NM441 to NM394 in humans. Human paraoxonase shows polymorphism. There was a 9-fold variation in paraoxonase activity but only a 2-fold variation in NM441-hydrolase activity. These findings show that paraoxonase polymorphism does not cause marked interindividual variation in NM441-hydrolase activity and is substrate dependent.

Vesnarinone inhibits adenosine uptake in endothelial cells, smooth muscle cells and myocytes, and mediates cytoprotection

Vesnarinone is a novel synthetic inotropic agent. Recently, it has been reported that vesnarinone inhibits adenosine uptake in the B-lymphocytoid cell line. Since extracellular adenosine is cardioprotective, we examined whether vesnarinone inhibits adenosine uptake in cells constituting the cardiovascular system. 1 microCi of -3H-adenosine was added to cells of the myocyte cell line (C2C12), human coronary smooth muscle cell line (HCASMC), human and bovine coronary endothelial cell lines (HCAEC and BCAEC), bovine arterial endothelial cell line (BAEC), and human umbilical venous endothelial cell line (HUVEC). After 10 s-5 min, cells were separated from free [3H]adenosine, and the radioactivity was measured. When 0.1-100 microM of vesnarinone was added to each cell line, the uptake of adenosine was inhibited dose-dependently {% inhibition of -3H-adenosine uptake at 10 and 30 microM of vesnarinone: 14 and 33% (C2C12), 47 and 72% (HCASMC), 37 and 58% (HCAEC), 42 and 68% (BCAEC), 19 and 68% (BAEC), 29 and 59% (HUVEC)}. The cellular viability of HCAEC exposed to 60 min of hypoxia and 60 min of reoxygenation increased from 34+/-5 to 67+/-6% (Trypan blue exclusion test) and 23+/-5 to 78+/-6% (LDH release), which was completely blunted by 8-sulfophenyltheophylline, an adenosine receptor antagonist, and was partially blunted by alpha,beta-methyleneadenosine 5'-diphosphate, an inhibitor of ecto-5'-nucleotidase. We also found that vesnarinone is cytoprotective against hypoxia and reoxygenation in C2C12 and HCASMC. We conclude that vesnarinone inhibits the uptake of adenosine in cardiovascular cells, which contributes to cytoprotection.

Role of protein kinase C-alpha in activation of ecto-5'-nucleotidase in the preconditioned canine myocardium

We have reported that activation of protein kinase C (PKC) increases ecto-5'-nucleotidase activity, which may contribute to the infarct size-limiting effect of ischemic preconditioning. Since we have reported that Ca(2+)- and phospholipid-sensitive PKC is activated due to ischemic preconditioning, we further tested 1) whether PKC-alpha or -beta is translocated to the cellular membrane of the preconditioned canine myocardium, and 2) whether activation of PKC contributes to the increase in ecto-5'-nucleotidase activity via phosphorylation-dependent mechanisms. Four times of 5 minutes coronary occlusion separated by 5 minutes of reperfusion (ischemic preconditioning) translocated PKC-alpha to the cellular membrane in the canine hearts, although PKC-beta, -delta, -epsilon, and -zeta were not translocated. The activity of Ca(2+)- and phospholipid-sensitive PKC increased, which was attenuated by the removal of either Ca2+ or phosphatidylserine. Ecto-5'-nucleotidase was also activated in the preconditioned myocardium compared with control. Inhibition of PKC due to GF109203X blunted the activation of myocardial ecto-5'-nucleotidase. Okadaic acid (an inhibitor of phosphatase) enhanced the increases in ecto-5'-nucleotidase activity due to preconditioning, and this enhancement was blunted by GF109203X. We conclude that ischemic preconditioning activates PKC-alpha, and thus ecto-5'-nucleotidase.

Butyrate activates the WAF1/Cip1 gene promoter through Sp1 sites in a p53-negative human colon cancer cell line

Butyrate is a well known colonic luminal short chain fatty acid, which arrests cell growth and induces differentiation in various cell types. We examined the effect of butyrate on the expression of WAF1/Cip1, a potent inhibitor of cyclin-dependent kinases, and its relation to growth arrest in a p53-mutated human colon cancer cell line WiDr. Five millimolar butyrate completely inhibited the growth of WiDr and caused G1-phase arrest. WAF1/Cip1 mRNA was rapidly induced within 3 h by treatment with 5.0 mM butyrate, and drastic WAF1/Cip1 protein induction was detected. Using several mutant WAF1/Cip1 promoter fragments, we found that the butyrate-responsive elements are two Sp1 sites at -82 and -69 relative to the transcription start site. We also found that a TATA element at -46 and two overlapping consensus Sp1 sites at -60 and -55 are essential for the basal promoter activity of WAF1/Cip1. These findings suggest that butyrate arrests the growth of WiDr by activating the WAF1/Cip1 promoter through specific Sp1 sites in a p53-independent fashion.

Retinoblastoma binding factor 1 site in the core promoter region of the human RB gene is activated by hGABP/E4TF1

We previously reported two oncogenic point mutations present in the RB (retinoblastoma) gene promoter region, found at consensus Sp1 and ATF sites, respectively, and in two separate hereditary RB families. However, Sp1 protein was shown not to bind to the Sp1 site; this indicated that the Sp1 consensus site mutation was blocking the action of an alternative transcription factor, which we called RBF-1 (retinoblastoma binding factor 1). Subsequent purification of RBF-1 revealed it to be hGABP/E4TF1, a transactivator from the adenovirus early-region 4 promoter. In this study, we directly examined the effects of hGABP/E4TF1 on transactivation of the RB gene promoter through the RBF-1 site. As expected, hGABP/E4TF1 enhanced the core RB promoter activity, whereas it did not stimulate a mutant RBF-1 site. We therefore conclude that the most essential transcription factor in the human RB gene is likely to be hGABP/E4TF1.

Amyotrophic lateral sclerosis with anti-acetylcholine receptor antibody

We report a case of amyotrophic lateral sclerosis (ALS) with anti-acetylcholine receptor (AChR) antibody in a 73-year-old female patient. She showed the typical course of ALS. She had no clinical findings of myasthenia gravis and had never undergone neurotoxin therapy using snake venom. Anti-AChR antibody was positive with a titer of 0.50 nmol/l on admission. We traced the titers during the progression of ALS; the titer was positive when muscle weakness worsened, and it became negative when the general condition became stable. We suppose that the occurrence of anti-AChR antibody may be partially relevant with abnormalities at the neuromuscular junction during the progression of ALS.