Shoulder Muscle Dosimetry and Post-Treatment Rehabilitation Utilization for Early-Stage Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

Rehabilitation services for recovery of impaired physical function following breast cancer treatments are largely underutilized. We previously found that breast cancer survivors treated with radiation who received higher radiation doses to the pectoralis major are more likely to self-report shoulder pain and disability. This study aims to address whether radiation dose delivered to the pectoralis major (Pmaj) and pectoralis minor (Pmin) are correlated with referrals for rehabilitation services post-treatment.

MATERIALS/METHODS

A retrospective 1:1 matched case-control study was conducted for breast cancer patients who were and were not referred for breast or shoulder rehabilitation services between 2014-2019 at a single academic institution. Patients were included if they had a lumpectomy and adjuvant radiation without regional nodal irradiation. Cohorts were matched based on age, axillary surgery (none vs. sentinel lymph node biopsy (SLNB)), and use of radiation boost. We used non-parametric Mann-Whitney U tests to determine whether Pmaj or Pmin doses (mean, V50Gy, V45Gy, V40Gy, V35Gy, V30Gy, V20Gy) were different between the two groups. Muscle doses were converted to EQD2 assuming an α/β ratio of 2.5.

RESULTS

In our study of 30 patients of a median age 57 years (IQR 12.75), 20 (66.67%) patients underwent SLNB in addition to lumpectomy. Median tumor size was 1.1cm (range 0.16 - 7.30cm). Stage was 0 for 11 patients (36.67%), I for 14 patients (46.67%), and II for 5 patients (16.67%). 3D conformal radiation was delivered to the whole breast with a moderately hypofractionated (n = 17) or conventionally fractionated regimen (n = 13). The most common rehabilitation diagnoses were lymphedema (n = 8), scar management (n = 7) and shoulder pain (n = 5). Mean dose to both the Pmaj (20.8Gy vs. 18.6Gy; p = 0.02) and Pmin (30.6Gy vs. 24.6Gy; p = 0.01) were significantly higher in patients who received post-treatment rehabilitation compared to those without. The V40Gy, V35Gy, V30Gy and V20Gy (all p<0.02) for the Pmin and V35Gy, V30Gy and V20Gy for the Pmaj (all p<0.04) were also significantly higher in those who underwent rehabilitation.

CONCLUSION

In this cohort of patients with early-stage breast cancer, increased mean doses to the pectoralis muscles were correlated with increased use of rehabilitation services after radiation. Physicians might consider using these dosimetric data to complement clinical symptoms in the decision-making process for referrals for rehabilitation services. This may help facilitate earlier referral to rehabilitation interventions, which is important since early intervention is correlated with improved shoulder morbidity.

Comparison of predictive value of risk scores for gastrointestinal bleeding in antiplatelet therapy

Gastrointestinal bleeding (GIB) is the most common serious bleeding complication of antiplatelet therapy. The bleeding risk score (BRS) of GIB may help to determine the risk of bleeding, and provides a reference for the formulation of antiplatelet therapy regimen in clinical practice, but we found that no specific risk scores are available in East Asian patients. This study analyzed patients who were administered antiplatelet therapy from May 2015 to December 2018 in two medical centers. Patient's baseline data were obtained. We assessed four BRSs (New Score, RIETE Score, Cuschieri Score, de Groot Score) and compared them using the area under the receiver operating characteristic curve (AUC). The 4,052 patients enrolled in this study had an average age of 69.6 ± 10.8 years, and 65.9% of them were male. Among the 4,052 patients included, 171 patients experienced GIB within 6 months of follow-up. In the study population, the AUCs for the New, RIETE, Cuschieri, and de Groot scores were 0.673 (95% confidence interval (CI) 0.616-0.729, P < .001), 0.742 (95% CI 0.690-0.794, P < .001), 0.598 (95% CI 0.537-0.659, P = .002), and 0.875 (95% CI 0.839-0.912, P < .001), respectively. After validation, the de Groot Score has better performance. Among the four scores, the de Groot Score might be more suitable for helping Chinese clinicians to predict the risk of GIB in patients taking antiplatelet drugs, and reduce GIB events.

[Efficacy and safety of Kangbingdu granules in the treatment of influenza: a randomized, double-blind, double-dummy, positive-drug parallel control multicenter clinical trial]

Objective: To observe the efficacy and safety of Kangbingdu granules (KBD) in the treatment of influenza. Methods: A multicenter, randomized, double-blind, double-dummy, and positive-drug parallel control trial was conducted in 27 Grade ⅢA hospitals in China and the subjects were randomly assigned to the KBD test group or the oseltamivir phosphate capsule control group at a ratio of 1∶1. 200 subjects were planned to be enrolled in each group. The experimental group was given KBD (18g each time, 3 times a day) and oseltamivir phosphate simulator orally, while the control group was given oseltamivir phosphate capsule (75 mg each time, twice a day) and KBD simulator orally for 5 days. The primary efficacy indicators included the remission time of major clinical symptoms and the time of complete defervescence. The secondary efficacy indicators included dosage of acetaminophen, the change of traditional Chinese medicine (TCM) syndrome score and the remission time of other important clinical symptoms. The efficacy of KBD in the test group and Oseltamivir phosphate control group were compared. Adverse events or adverse reactions were observed at the same time to evaluate the safety of KBD Granules. Results: A total of 393 subjects from 27 Grade ⅢA hospitals in China were enrolled. The experimental group included 195 subjects and 191 subjects (97.95%) completed the trial, While the control group included 198 subjects and 195 subjects (98.48%) completed the trial. There was no significant difference in the shedding rate and rejection rate between the two groups (P>0.05). In the Full Analysis Set (FAS), the mean age of the experimental group was (34.9±14.4) years old, with 83 males (42.78%). The mean age of the control group was (33.3±13.5) years old, with 78 males (39.59%). There were no statistically significant differences between the two groups in demographic data, physical examination, viral pathogen detection, total score of TCM syndromes and scores of each symptom at baseline (P>0.05). In the FAS, the remission time M (Q₁, Q₃) of major clinical symptoms was 3.0 (3.0, 4.0) days in the experimental group and 3.0 (3.0, 4.0) days in the control group, and the difference was not statistically significant (P>0.05). The time M (Q₁, Q₃) of complete defervescence was 34.0 (20.3, 49.0) hours in the experimental group and 36.5 (19.6, 48.8) hours in the control group, and the difference was not statistically significant (P>0.05). KBD granules had the same effect as Oseltamivir phosphate capsule (P>0.05) in terms of acetaminophen dosage, TCM syndrome effect and disappearance rate of most important clinical symptoms. Meanwhile, the disappearance rate of dizziness and chest distress on day 3 in the KBD granules group was better than that of oseltamivir phosphate capsule (P<0.05). Conclusion: KBD granules have the same efficacy as Oseltamivir Phosphate capsule in the treatment of influenza and the drug safety is good.

[A prospective multi-center clinical investigation of HIV-negative pulmonary cryptococcosis in China]

Objective: To investigate the current status of the diagnosis and treatment of pulmonary cryptococcosis in respiratory medicine and improve the understanding of the clinical characteristics of HIV-negative pulmonary cryptococcosis in China. Methods: A prospective multi-center open cohort study was designed to screen for pulmonary cryptococcosis in the general wards and intensive care units of the Department of Respiratory Diseases in 22 hospitals. The HIV-negative patients with positive cryptococcal etiological diagnosis based on smear culture, antigen detection and histopathology were enrolled in the study. The clinical data of enrolled patients were collected and analyzed. Results: A total of 457 cases of pulmonary cryptococcosis were enrolled, among which 3.28% (15/457) were disseminated infections. The case fatality rate was 0.88% (4/457). The majority of the cases were diagnosed by histopathological examinations (74.40%, 340/457) and cryptococcus antigen detection (37.64%, 172/457). Patients with pulmonary cryptococcosis accounted for 2.04‰ (457/223 748) of the total hospitalized patients in the Department of Respiratory Diseases during the same period, and the ratio was the highest in south and east China. Meanwhile, 70.24% (321/457) of the patients had no underlying diseases, while 87.75% (401/457) were found to have immunocompetent status. Cough and expectoration were the most common clinical symptoms in patients with pulmonary cryptococcosis. However, 25.16% (115/457) of the patients had no clinical symptom or physical signs. In terms of imaging features on pulmonary CT, multiple pulmonary lesions were more common than isolated lesions, and there were more subpleural lesions than perihilar or medial lesions. Morphologically, most of the lesions were middle-sized nodules (1-5 cm) or small-sized nodules (3 mm to 1 cm). The sensitivity of serum cryptococcus antigen test was 71.99% (203/282). Moreover, antigen-positive patients differed from antigen-negative patients in terms of basic immune status, clinical symptoms, imaging features and infection types. Meanwhile, immunocompromised patients differed from immunocompetent patients in terms of clinical symptoms, physical signs, infection-related inflammation indicator levels, imaging features, serum cryptococcus antigen positive rate and prognosis. Conclusions: The majority of cases of HIV-negative pulmonary cryptococcosis in China had no underlying disease or immunocompromised status, and the overrall prognosis was favorable. However, early diagnosis of HIV-negative pulmonary cryptococcosis remains challenging due to the complicated manifestations of the disease.

[Clinical analysis of Langerhans cell histiocytosis originating in the base of nasal skull]

Objective:To summarize the clinical features, diagnosis and treatment of Langerhans histiocytosis（LCH） which first appeared in the nasal skull base. Method:Ten cases of LCH with nasal and skull base symptoms were analyzed retrospectively. The clinical characteristics of LCH with nasal and skull base symptoms were summarized. The correlation of other systems involved in LCH was analyzed. Result:Among the 10 patients, the youngest was 1 year and 5 months, and the oldest was 8 years, the average age was 3 years. The main imaging manifestations were osteolytic changes and soft tissue invasion. Seven patients were monofocal and three patients were multifocal. For localized lesions, radical resection and follow-up chemotherapy were performed, and conservative treatment was performed for patients with multiple system involvement and obvious systemic symptoms. Eight patients survived, 2 died. Conclusion:LCH occurs frequently in children and has certain clinical characteristics. Single system and single lesion surgery have a better therapeutic effect, and can achieve a greater survival rate with follow-up chemotherapy.

[The role of HuR in mediating snail expression in human small airway epithelium induced by cigarette smoke extract]

Objective: To investigate the abundance of human antigen R (HuR) in small airway epithelial cells stimulated by cigarette smoke extract (CSE) as well as the role of HuR in mediating snail which is recognized as a key transcription factor in regulating epithelial-mesenchymal transition (EMT). Methods: Human small airway epithelial cells (HSAEpiC) cultured in vitro were exposed to cigarette smoke extract (CSE) to model COPD status. Real-time PCR and western blotting analysis were used in detecting HuR protein and mRNA expression in cells with CSE which were divided into 5 groups: a control group, a 1%-24 h group, a 3%-24 h group, a 1%-48 h group and a 3%-48 h group. Small interfering RNA (siRNA) transfection was used to decrease HuR abundance. HuR expression at both mRNA and protein levels was detected using Real-time PCR and Western blotting analysis respectively, and the experiment was divided into 3 groups: a control group, a transfection control group and a transfection group. Snail, E-cadherin and vimentin levels were determined using Western blotting test in cells with both CSE exposure and HuR siRNA transfection which were divided into three groups: control group, CSE group and CSE + transfection group. Results: After CSE stimulation, HuR expression was increased at both mRNA and protein levels [mRNA 1%-24 h group (1.12±0.04), 3%-24 h group (1.41±0.06), 1%-48 h group (1.26±0.05), 3%-48 h group (1.49±0.06), protein 3%-24 h group (1.35±0.08), 1%-48 h group (1.17±0.06), 3%-48h group (1.42±0.06) all P<0.05]. Compared with the control siRNA, after HuR siRNA transfection, HuR mRNA and protein levels were significantly reduced [mRNA level (0.33±0.06) vs (1.02±0.10), protein level (0.46±0.07) vs (0.97±0.06), all P<0.01]. Control siRNA transfection had no effect on HuR expression [mRNA level (1.02±0.10), protein level (0.97±0.06), all P>0.05]. After 48 h stimulation with 3% CSE, the expression of HuR (1.47±0.11), snail (1.46±0.05) and vimentin (1.56±0.05) increased and the expression of E-cadherin (0.49±0.05) decreased. After transfection and CSE stimulation, the expression of HuR (0.84±0.06), snail (1.22±0.06) and vimentin (1.11±0.09) decreased and the expression of E-cadherin (0.73±0.06) increased. (All P>0.05). Conclusions: CSE promoted the expression of HuR in human small airway epithelial cells. HuR participated in the regulation process of EMT key transcription factor snail and might regulate EMT process by this action.

[Rapidly progressive pulmonary malignant perivascular epithelioid cell tumor: a case report and literature review]

Objective: To analyze the pathogenesis, clinical features, diagnosis and differential diagnosis of primary perivascular epithelioid cell tumor(PEComa). Methods: The clinical features, auxiliary examinations and diagnosis of a case with rapidly progressive pulmonary malignant PEComa were reported and the related literatures were reviewed.The literature review was carried out respectively in Wanfang Data, CNKI and PubMed from Jan. 1975 to Jul. 2015 with "pulmonary malignant perivascular epithelioid cell tumor" and "PEComa" being the search terms. Results: A 50 year-old female patient was admitted to the hospital on September 4, 2014 because of cough and dyspnea for 60 days, hemoptysis for 40 days and fever for 7 days.Chest CT scan showed diffuse small nodules with infiltrative border and multiple pure and mixed ground-glass opacity. Transbronchial lung biopsy (TBLB) was performed and the pathological study confirmed the diagnosis of primary pulmonary malignant PEComa. The patient declined further specific therapy, but followed by rapidly progressive respiratory failure, and died two weeks after the diagnosis. A total of 8 literatures were retrieved from Wanfang Data, CNKI and PubMed and all of them were case reports.There were 3 male and 5 female patients, aging from 50 to 79 years.Radiographically, the previously reported cases presented as round and well-circumscribed masses with or without multiple nodules in both lungs. The symptoms had no specificity. Conclusions: Pulmonary malignant PEComa is a rare disease.It is easily misdiagnosed because of non-specific clinical and imaging manifestations.The final diagnosis depends on pathological biopsy.TBLB is an effective diagnostic method.

A fluorescence-Raman dual-imaging platform based on complexes of conjugated polymers and carbon nanotubes

The present study describes a flexible nanoplatform based on electrostatic assembly of conjugated polyelectrolytes (CPEs) and carboxylated multi-walled carbon nanotubes (cMWNTs). It is demonstrated that the obtained nanocomposites inherit intrinsic optical properties of CPEs and characteristic Raman vibration modes of MWNTs, providing a fluorescence-Raman dual-imaging method for intracellular tracking and locating of MWNTs. We suggest that the cellular internalization of the CPE-cMWNT nanocomposites is a surface charge-dependent process. The strengths of this nanoplatform include satisfying biocompatibility, enhanced protein-repellent property, and ease of implementation, making it available for both in vitro and in vivo applications.

Novel mutations of ABCB6 associated with autosomal dominant dyschromatosis universalis hereditaria

Objective

Dyschromatosis universalis hereditaria (DUH) is a rare heterogeneous pigmentary genodermatosis, which was first described in 1933. The genetic cause has recently been discovered by the discovery of mutations in ABCB6. Here we investigated a Chinese family with typical features of autosomal dominant DUH and 3 unrelated patients with sporadic DUH.

Methods

Skin tissues were obtained from the proband, of this family and the 3 sporadic patients. Histopathological examination and immunohistochemical analysis of ABCB6 were performed. Peripheral blood DNA samples were obtained from 21 affected, 14 unaffected, 11 spouses in the family and the 3 sporadic patients. A genome-wide linkage scan for the family was carried out to localize the causative gene. Exome sequencing was performed from 3 affected and 1 unaffected in the family. Sanger sequencing of ABCB6 was further used to identify the causative gene for all samples obtained from available family members, the 3 sporadic patients and a panel of 455 ethnically-matched normal Chinese individuals.

Results

Histopathological analysis showed melanocytes in normal control’s skin tissue and the hyperpigmented area contained more melanized, mature melanosomes than those within the hypopigmented areas. Empty immature melanosomes were found in the hypopigmented melanocytes. Parametric multipoint linkage analysis produced a HLOD score of 4.68, with markers on chromosome 2q35-q37.2. A missense mutation (c.1663 C>A, p.Gln555Lys) in ABCB6 was identified in this family by exome and Sanger sequencing. The mutation perfectly cosegregated with the skin phenotype. An additional mutation (g.776 delC, c.459 delC) in ABCB6 was found in an unrelated sporadic patient. No mutation in ABCB6 was discovered in the other two sporadic patients. Neither of the two mutations was present in the 455 controls. Melanocytes showed positive immunoreactivity to ABCB6.

Conclusion

Our data add new variants to the repertoire of ABCB6 mutations with DUH.

[The effect of prostatectomy on nocturia in patients with benign prostatic hyperplasia]

OBJECTIVE

To explore the effect of prostatectomy on nocturia in patients with benign prostatic hyperplasia (BPH).

METHODS

The data of patients who had received prostatectomy for BPH between June 2006 and December 2007 were collected. Nocturia severity was assessed preoperatively and 3 to 6 months after prostatectomy by the number of nocturia events, the time from falling sleep to the first awakening to void (hours of undisturbed sleep, HUS), the score of the nocturia quality of life (N-QOL) questionnaire, the International Prostatic Symptom Score (IPSS) and the quality of life (QOL) score.

RESULTS

One hundred and twenty five cases were included. Of them, 73 patients finished the follow-up completely. There were 62 patients whose number of nocturia events before the operation was equal or more than 2. The data from these 62 patients were analyzed. Of them, 56 patients underwent transurethral resection of prostate, the remaining 11 patients suprapubic prostatectomy. Significant improvement (P < 0.01) was noted in all the following parameters after treatment: the number of nocturia events decreased from 4.2 ± 2.4 to 2.2 ± 1.0, HUS increased from (1.8 ± 0.7) h to (3.0 ± 1.4) h, N-QOL score raised from 30 ± 10 to 40 ± 7, IPSS decreased from 23 ± 5 to 8 ± 5, and QOL score fell down from 4.4 ± 0.7 to 1.5 ± 1.0.

CONCLUSION

The prostatectomy can markedly improve the symptoms of nocturia, sleep and life quality in the BPH patients who accompanied with nocturia.

Fluoride and children's intelligence: a meta-analysis

This paper presents a systematic review of the literature concerning fluoride that was carried out to investigate whether fluoride exposure increases the risk of low intelligence quotient (IQ) in China over the past 20 years. MEDLINE, SCI, and CNKI search were organized for all documents published, in English and Chinese, between 1988 and 2008 using the following keywords: fluorosis, fluoride, intelligence, and IQ. Further search was undertaken in the website www.fluorideresearch.org because this is a professional website concerning research on fluoride. Sixteen case-control studies that assessed the development of low IQ in children who had been exposed to fluoride earlier in their life were included in this review. A qualitative review of the studies found a consistent and strong association between the exposure to fluoride and low IQ. The meta-analyses of the case-control studies estimated that the odds ratio of IQ in endemic fluoride areas compared with nonfluoride areas or slight fluoride areas. The summarized weighted mean difference is -4.97 (95%confidence interval [CI] = -5.58 to -4.36; p < 0.01) using a fixed-effect model and -5.03 (95%CI = -6.51 to 3.55; p < 0.01) using a random-effect model, which means that children who live in a fluorosis area have five times higher odds of developing low IQ than those who live in a nonfluorosis area or a slight fluorosis area.

PROTECTIVE EFFECTS OF BENDAZAC LYSINE ON DIABETIC PERIPHERAL NEUROPATHY IN STREPTOZOTOCIN-INDUCED DIABETIC RATS

1. Diabetic neuropathy is a many faceted complication of both type I and II diabetes. The aim of the present study was to investigate the effects of bendazac lysine (BDL), an anticataract drug, on experimental diabetic peripheral neuropathy (DPN) in rats. 2. Diabetes was induced in rats by intraperitoneal injection of 75 mg/kg streptozotocin (STZ) dissolved in 0.1 mol/L citrate buffer (pH 4.4). Bendazac lysine was administered to rats at doses of 50, 100 and 200 mg/kg twice a day for 12 weeks. 3. Diabetic rats without treatment showed hypopraxia, polydipsia, polyuria, slow weight gain, cataract, increased tail-flick threshold temperature, decreased motor nerve conduction velocity (nd induced pathological morphological changes of myelinated nerve fibres. All these symptoms were ameliorated in diabetic rats treated with BDL. Bendazac lysine ameliorated the blood glucose concentration, glycosylated haemoglobin levels and insulin levels in the plasma of diabetic rats, reduced aldose reductase activity in erythrocytes and advanced glycation end-products in both nerves and serum and increase the activity of glutathione peroxidase in the nerves and Na(+)/K(+)-ATPase in the nerves and erythrocytes. 4. Bendazac lysine exerts its protective effects against the progression of diabetic peripheral neuropathy in STZ-diabetic rats through multiple mechanisms and is a potential drug for the prevention of deterioration in DPN.

Effectiveness of transient immunosuppression using cyclosporine for xenomyoblast transplantation for cardiac repair

We studied the survival of human myoblast for cellular myocardial reconstruction in a porcine model of chronic myocardial ischemia with immune tolerance using transient immunosuppression. A porcine model of chronic cardiac ischemia was created in 10 pigs (DMEM medium-injected n = 4; myoblast transplanted n = 6) by clamping ameroid ring around left circumflex coronary artery. Three weeks later, 3 x 10(8) human myoblasts carrying lac-z reporter gene were transplanted in multiple sites (0.25 mL each) into the left ventricular wall. Immunosuppression was achieved with 5 mg/kg cyclosporine for 6 weeks after cell transplantation. After animals were euthanized between 6 and 30 weeks after cell transplantation; the heart was removed for histological studies. Discontinuation of immunosuppression after 6 weeks of cell transplantation did not result in donor cell rejection. The lac-z-positive donor cells were detected in porcine host cardiac tissue for up to 30 weeks posttransplantation, expressing human skeletal myosin heavy chain. The results highlight the effectiveness of transient immunosuppression for myoblast transplantation for cardiac repair.

Generating multiply charged protein ions by ultrasonic nebulization/multiple channel-electrospray ionization mass spectrometry

An ultrasonic nebulization/multiple channel electrospray ionization (USN/MC-ES) source, which generates multiply charged peptides and proteins ions, was developed. The source is an ultrasonic nebulizer that is connected to a multiple channel electrospray ionization source. Aerosols were formed by ultrasonically nebulizing the sample solution. The aerosols were then purged into the central channel of a seven-channel ES source via nitrogen gas. A methanol solution that contained 1% trifluroacetic acid was electrosprayed through the outlying six electrosprayers. Detection of multiply charged peptide and protein ions indicated that electrospray was generated from the charged droplet containing analyte. The sample aerosol appeared to fuse with the charged methanol droplet in the air. Then electrospray ionization of the analyte occurred from the newly formed droplet. The peptide and protein prepared in deionized water were detected by this USN/MC-ES-MS. By varying the electrospray solvents, the signals of certain components in the mixture were selectively suppressed.

Functional and structural changes of the epidermal barrier induced by various types of insults in hairless mice

Acute barrier disruption, regardless of the method of induction, depletes the stratum corneum intercellular lipids and this stimulates a series of lipid/ DNA synthesis activities which lead to barrier recovery. After barrier disruption by tape stripping, occlusion with a water vapor-impermeable membrane inhibits barrier repair. In this study, we investigated the changes in the murine epidermis after barrier perturbation by tape stripping and three different types of surfactants (Emalex NP-12, ENP-12; sodium dodecyl sulfate, SDS; benzalkonium chloride, BKC). To examine the effect of an artificial barrier, we covered the animals with a water vapor-impermeable membrane for 3 days following barrier disruption and then exposed them to the air for 2 days. The histological findings after occlusion or air exposure were similar. However, after air exposure for 2 days, the thickness of the epidermis including the stratum corneum and the stratum granulosum layers decreased to about half that of the epidermis after occlusion. Ultrastructural examination revealed obvious distortion of the lamellar bilayers within the stratum corneum interstices immediately after barrier disruption. After 3 days of occlusion, extensive disorganization was evident in the intercellular domain of the stratum corneum, whereas 2 days after removal of the occlusion, the normal basic unit structure of the lamellar bilayers had partially reappeared. Our findings provide evidence that the kinetic pattern of barrier repair and the morphological changes are similar after occlusion following barrier disruption regardless of the mechanism of disruption.

Determination of lead in fish samples by slurry sampling electrothermal atomic absorption spectrometry

Ultrasonic slurry sampling electrothermal atomic absorption spectrometry (USS-ETAAS) was been applied to the determination of lead in several fish samples. The influences of instrument operating conditions and slurry preparation on the signal were examined. Palladium and ammonium nitrate were used as the modifier to improve the signal. Since the sensitivity to lead in various fish slurries and aqueous solutions was different, the standard additions method was used for the determination of lead in these fish samples. The method was applied to the determination of lead in dogfish muscle reference material (DORM-2) and a swordfish muscle sample purchased from the local market. The analysis results agreed with the reference value. The accuracy was better than 6%. The precision between sample replicates was better than 16% with the USS-ETAAS method. The detection limit of lead estimated from standard additions curve was about 0.053-0.058 microgram g-1 in different samples.

Structural and functional effects of oleic acid and iontophoresis on hairless mouse stratum corneum

The aim of this study was to assess the effects of chemical and electrical modes of percutaneous penetration enhancement on the intercellular lipid lamellae of the stratum corneum. Hairless mice were treated with either oleic acid/propylene glycol and iontophoresis separately or together. Permeability barrier function was evaluated by measuring transepidermal water loss and correlated with the structure of stratum corneum intercellular lamellae, as evaluated by electron microscopy, using ruthenium tetroxide postfixation. Transepidermal water loss levels did not change following 1 h iontophoresis alone. In contrast, topical applications of 0.3 M oleic acid in propylene glycol for 1 h increased transepidermal water loss significantly. Moreover, the combined use of iontophoresis plus 0.3 M oleic acid for 1 h further increased transepidermal water loss at equivalent time points. Ultrastructural observations demonstrated both marked disorganization of the intercellular lipid lamellae, as well as the presence of distended lacunae within the stratum corneum in oleic acid/propylene glycol plus or minus iontophoresis-treated stratum corneum. This study provides direct evidence that the oleic acid/propylene glycol system can disrupt the stratum corneum lipid lamellar structures, and that coapplications of oleic acid with iontophoresis further enhance the effects of oleic acid. The synergy between chemical and physical enhancement may afford a new approach to promote transdermal drug delivery.

Persistent infection of bovine herpesvirus type 4 in bovine endothelial cell cultures

Herpesviruses can establish a persistent infection in the cells and tissues of their natural hosts and thus may produce diseases due to cytolytic infections. We have isolated a herpesvirus from a bovine vascular endothelial cell culture after continuous subculturing. Typical cytopathic changes were observed in bovine endothelial cell cultures 2 days after inoculation of the virus. The virus had an icosahedral nucleocapsid of 100-150 nm in diameter and an envelope. The sequences of some DNA fragments of the virus were highly homologous to those of the bovine herpesvirus type 4 (BHV-4) strains. The DNA restriction maps of the virus and the reference strains of BHV-4, DN 599 and Movar 33/63 were very similar but not identical. Therefore, the newly isolated virus has been designated Taiwan strain. The presence of BHV-4 DNA in apparently normal bovine endothelial cell cultures was shown by Southern blot hybridization with the BamHI fragment of the newly isolated BHV-4 and was further confirmed by digestion of the DNA with BamHI plus AccI. In conclusion, we have demonstrated that BHV-4 persisted in the bovine endothelial cell cultures and continuous subcultures could lead to the production of infectious viral particles.

The changes of epidermal calcium gradient and transitional cells after prolonged occlusion following tape stripping in the murine epidermis

Disruption of the epidermal permeability barrier causes an immediate loss of the calcium gradient, and barrier recovery is parallel with the restoration of the calcium gradient in the epidermis. Artificial restoration of the barrier function by occlusion with a water vapor-impermeable membrane abrogate the expected increase in lipid synthesis and retard the barrier recovery, as well as block the normalization of the epidermal calcium gradient. To clarify the long-term effects of occlusion after acute barrier perturbation, we studied the calcium distribution and epidermal keratinocytes response after occlusion with a water vapor-impermeable membrane immediately following tape stripping in the murine epidermis. Acute barrier disruption caused an immediate depletion of most calcium ions in the upper epidermis, obliterating the normal calcium gradient. When the skin barrier function was artificially corrected by occlusion, the return of calcium ions to the epidermis was blocked. After 2 h of air exposure or occlusion, the density of epidermal calcium precipitates remained negligible. The transitional cell layers appeared with occlusion, but not or negligibly with air exposure. By 6 h though, calcium precipitates could be seen, the density of the calcium precipitates with occlusion was more sparse than with air exposure. With the air exposure, the thickness of the stratum corneum had normalized and the calcium gradient nearly recovered to normal after 24 h. The longer the occlusion period, the greater was the increase of transitional cells. By 60 h of occlusion, the thickness of the stratum corneum had increased and the transitional cell layers had disappeared, in parallel with the calcium gradient which was almost normalized. These results show that prolonged occlusion of tape-stripped epidermis induced transitional cells and delayed the restoration of the epidermal calcium gradient, the stratum corneum was then restored, transitional cells having disappeared, in parallel with normalization of the epidermal calcium gradient.

Kinetics of germanium dioxide in rats

The kinetics of germanium dioxide (GeO2) in single dose and repeated exposures were investigated in male Wistar rats. In the single dose GeO2 (100 mg/kg BW, p.o.) exposure study, values of several kinetic parameters were shown as follows, a maximum concentration in serum of 15.5+/-0.7 microg/ml (mean +/- S.E.M.), an absorption half-life of 0.7+/-0.1 h (mean +/- S.E.M.), an elimination half-life of 2.3+/-0.5 h (mean +/- S.E.M.), a distribution of the central compartment Vp (3.1+/-0.3 1, mean +/- S.E.M.), and the apparent volume of distribution of the tissue compartment Vt (8.5+/-2.9 1, mean +/- S.E.M.). In the repeated exposure study, 730+/-92 mg GeO2 in 1 1 double-distilled H2O ( = 100 mg/kg/day) was given daily to rats for 4 weeks (p.o.). After sacrificing the rats, the analysis of tissue distribution showed that GeO2 was accumulated in some important organs or tissues in the body, especially the peripheral nerves and kidney. These results indicate that GeO2 could be absorbed rapidly but had a longer elimination half-life in rats. In addition, GeO2 was accumulated especially in the nerves and kidney following long-term exposure.

Determination of cadmium and lead in urine by electrothermal vaporization isotope dilution inductively coupled plasma mass spectrometry

Electrothermal vaporization isotope dilution inductively coupled plasma mass spectrometry (ETV-ID-ICP-MS) was applied to the determination of Cd and Pb in urine samples. The isotope ratios for each element in each analytical run were calculated from the peak areas of each isotope. A relatively low vaporization temperature was used, which separated the analyte from the major matrix components and improved the ion signals of Cd and Pb significantly. Various chemical modifiers were tested to obtain the best signal of Cd and Pb. After preliminary studies, 1% HNO3 was added to the samples as the chemical modifier. The ETV-ID-ICP-MS method was applied to the determination of Cd and Pb in freeze-dried urine reference material NIST SRM 2670 and several fresh urine samples. The results for NIST SRM 2670 agreed satisfactorily with the certified values. The results for other samples obtained by isotope dilution and the method of standard additions agreed satisfactorily. The detection limits were 0.02 and 0.005 ng ml-1 for Cd and Pb, respectively. The precision between sample replicates was better than 11% for all determinations.

Relationship of plasma folic acid and status of DNA methylation in human gastric cancer

To evaluate the anti-cancer effects of folic acid at the molecular level, we determined plasma folic acid concentration by radioimmuno-assay and the degree of total genomic DNA methylation by incubating DNA with 3H-S-adenosylmethionine (3H-SAM) in the presence of a methylase, and analyzed the methylation status of the c-myc and c-Ha-ras oncogenes by Southern blotting in 21 patients with advanced gastric cancer. The degree of total genomic DNA methylation of cancerous tissues was significantly lower than that of paracancerous and non-cancerous tissues; c-myc and c-Ha-ras oncogenes from cancerous (10/21, 5/10) and paracancerous (13/21, 4/10) tissues were hypomethylated. The plasma folic acid concentration in patients who showed hypomethylation was lower than that patients showing normal methylation. These findings suggest that a decrease in folic acid, and the subsequent DNA hypomethylation, may be involved in human gastric carcinogenesis.

Studies on the hypomethylation of c-myc, c-Ha-ras oncogenes and histopathological changes in human gastric carcinoma

In order to study the status of DNA methylation of specific oncogenes and the relationship between them and the pathological changes in gastric carcinoma, we analysed the methylated status of c-myc, c-Ha-ras oncogenes by Southern blot hybridization. Genomic DNA from cancerous, paracancerous and non-cancerous areas of surgically resected specimens were examined in 22 cases of advanced human gastric carcinoma. Specimens were digested by the restriction endonucleases MspI/HpaII, which are able to cleave between methylated and non-methylated cytosine at their nucleotide recognition site the DNA 5'-CCGG sequence, and were hybridized with c-myc, c-Ha-ras oncogene probes. Moreover, the corresponding pathological changes in gastric carcinoma were observed. The results showed that c-myc, c-Ha-ras oncogenes from cancerous (10/22, 5/10) and paracancerous areas (13/22, 4/10) were hypomethylated and that there was no significant relationship between them and the histopathological changes.

Seroprevalence of Helicobacter pylori infection in medical staff in Shanghai

BACKGROUND

The epidemiology of Helicobacter pylori is still under investigation. It is postulated that the human stomach is the natural reservoir and that spread occurs by oral-oral or fecal-oral transmission. The aim of this study was to determine whether medical staff, especially endoscopy unit personnel, are at an increased risk of acquiring H. pylori infection.

METHODS

An enzyme-linked immunosorbent assay technique was used to detect circulating H. pylori IgG antibodies in 1050 medical staff from 16 hospitals in Shanghai, including 125 GI endoscopists, 45 endoscopy unit nurses, 71 gastroenterologists not doing endoscopy, 105 nurses working in gastroenterology wards, 417 internists, and 287 general nurses. This group was compared with an age-matched population obtained from the same urban area of the city.

RESULTS

The overall prevalence of H. pylori infection in total medical staff was 70.0%, compared to 44.6% in general population (P < 0.0001). Age-adjusted comparisons between subgroups of medical staff were made. The prevalence of H. pylori in GI endoscopists was 82.4%, which is significantly higher than 66.4% in internists and 65.8% in general nurses (all, P < 0.01) but not significantly different from 77.7% in endoscopy unit nurses or from 74.2% in nurses working in gastroenterology wards (all, P > 0.05). Further analysis did not show any significant difference in the prevalence of H. pylori between other subgroups. The prevalence of H. pylori infection in GI endoscopists increased with the number of years of practice.

CONCLUSIONS

Medical staff, especially endoscopy unit personnel, are at increased risk of infection with H. pylori. These findings strongly suggest the medical practice and endoscopy procedures are risk factors for H. pylori infection and support person-to-person transmission in this setting, probably from patients to medical staff.

Enzyme-linked immunosorbent assay for detection of immunoglobulin G antibody against Helicobacter pylori

Eight strains of sonicated Helicobacter pylori (H. pylori) were pooled as group antigen to detect the serum IgG antibody to H. pylori in patients with various gastroduodenal diseases and subjects at health check-up. The enzyme-linked immunosorbent assay method used had a sensitivity of 94%, a specificity of 87%, and a positive predictive value of 96%. The prevalence of serum IgG antibody to H. pylori was 19.0% in patients with Type A gastritis, 76.0% in patients with Type B gastritis, 91.5% in duodenal ulcer, and 92.9% in gastric ulcer. Moreover, the prevalence of serum IgG antibody to H. Pylori in newborns was 53% (probably acquired from mother), in children below 10 years old was 25%. The detection rate gradually rose to 70% with the increase of age, but decreased to 40% in those over 70 years of age.

Evaluation of HemoQuant test and enteroclysis in estimating the sites of obscure gastrointestinal bleeding

The HemoQuant test includes the measurement of total fecal hemoglobin (Hb) or porphyrin derived from heme, and of intestinal converted fraction (ICF) which is the performed porphyrin probably by bacteria during enterocolic transit. The mean +/- SD of HemoQuant in 31 healthy subjects was 0.57 +/- 0.49 mg Hb/g stool, values above 2 mg Hb/g stool are considered to be positive. In patients with upper GI bleeding (n = 44), small bowel bleeding (n = 11) and large bowel bleeding (n = 16), the ICF ranged 0.03-23%, 0.09-20.20% and 0.35-11.0%, respectively. There was major overlap in individual ICF due to some influencing factors such as the quantity of fecal blood and the enterocolic transit. We conclude that HemoQuant is a sensitive assay for detection of fecal occult blood, but ICF is not helpful in estimating the anatomic site of bleeding. Seventy-one patients with GI bleeding of obscure origin underwent enteroclysis. The results showed 77.5% had definite lesions in the small bowel, but 22.5% still were undefined. It is suggested that enteroclysis should be performed without delay if upper and lower GI endoscopic studies are negative.

Evolution of thermochromism during oxidation of evaporated vanadium films

Thin vanadium oxide films were made by vacuum evaporation followed by the annealing posttreatment in the presence of air. The thickness increased by a factor as large as approximately 2.3 on oxidation. Electron diffractograms indicated a bcc ? monoclinic transformation during the annealing, and electron micrographs showed pronounced grain growth. Temperature-dependent electrical conductivity as well as spectral transmittance was measured vs annealing time. At an initial thickness of 0.12 microm, it took a few hours to establish VO(2) films with a well defined semiconductor-metal transition and concomitant thermochromic switching at approximately 57 degrees C.

Cytophotometric DNA analysis on canine stomach carcinogenesis induced by ENNG

DNA content and nuclear area were measured by microspectrophotometry in gastric carcinogenesis of three adult wolfdogs induced by N-ethyl-N'-nitro-N-nitrosoguanidine (ENNG). The mean values and standard deviations of DNA content and nuclear area in normal gastric mucosa were 10.03 +/- 2.30 AU and 28.76 +/- 5.85/microns2; those in atrophic gastritis were 12.04 +/- 3.34 AU and 28.69 +/- 8.02/microns2; in mild dysplasia 13.52 +/- 3.73 AU and 28.23 +/- 8.12/microns2; in moderate dysplasia 20.88 +/- 4.57 AU and 47.58 +/- 10.74/microns2; in severe dysplasia 24.01 +/- 4.48 AU and 56.64 +/- 12.53/microns2; in well-differentiated adenocarcinoma 33.07 +/- 9.38 AU and 72.99 +/- 15.57/microns. These figures were different (P less than 0.01). The nuclear area of gastric carcinoma increased with DNA content (r = 0.73, P less than 0.01). The distribution patterns of DNA content in the histogram showed that diploidy was decreased and polyploidy increased in cancer cells. These findings indicate that DNA ploidy patterns and nuclear area can be useful indices for differentiating carcinoma from precancerous lesions.

The efficacy of furazolidone and metronidazole in the treatment of chronic gastritis associated with Helicobacter (Campylobacter) pylori--a randomized double-blind placebo-controlled clinical trial

Seventy-two patients with Helicobacter pylori-associated chronic gastritis were randomized to a 3-week oral treatment with furazolidone 0.1g t.i.d. or metronidazole 0.2g t.i.d. or placebo. Endoscopy was performed before and after treatment, and biopsy specimens were taken from the antrum of the stomach for histological examination and culture of Helicobacter pylori. Disappearance rates of Helicobacter pylori in furazolidone, metronidazole and the control groups were 74% (20/27) if considering completion of therapy, the 20/25 or 80%, 33.3% (8/24) and 14.3% (3/21) respectively. There was a significant difference in the disappearance rate of Helicobacter pylori between furazolidone and metronidazole, and between furazolidone and the placebo group (p less than 0.01), but there was no such difference between metronidazole and the placebo group (p greater than 0.05). In the patients receiving furazolidone, the eradication of Helicobacter pylori was accompanied by marked improvement in both inflammatory infiltration in the gastric mucosa and symptoms. These results reasonably suggest that Helicobacter pylori may play an etiological role in the pathogenesis of chronic gastritis, and that furazolidone is effective in the treatment of Helicobacter pylori-associated chronic gastritis.

[Humoral factors in the modulation of sustained discharges of polymodal nociceptors]

By using a model of sustained discharges of polymodal nociceptors (PMN) due to injection of a compound algogenic substance into the skin in anesthetized rats, it was found that stimulation of the sciatic nerve inhibited or facilitated at first and then inhibited the PMN sustained discharges markedly. In a crossperfused preparation, stimulation of the sciatic nerve of donor rat caused the similar effects on sustained discharges of PMN of the recipient rat. Injection of the animal serum after stimulation of the sciatic nerve affected PMN activity obviously. The inhibitory course of most units could not be reversed by naloxone. In the animal tolerance to morphine, the effects of stimulation of the sciatic nerve could still be obtained. Preadministration of reserpine almost completely abolished the facilitatory effect. The results indicate that sustained activity of PMN could be modulated by some humoral factors due to somatic afferents. The inhibitory substances in the humoral factor seem to be both opioid and nonopioid in nature. The facilitatory substance seem to be a catecholamine.

[Pre-, post-operation and before death of blood stasis syndrome in patients with gastric malignant tumor]

In the past three years, the authors observed substance of tongue and 5 indexes of blood coagulation (AT-III, Fn, Fa, VIII R:Ag and beta TG) for a long time in 140 patients of gastric malignant tumor pre-operation, one month post-operation and 3 months before death. All patients were verified as gastric carcinoma by pathological section. The results showed that the positive rate of substance of tongue in patients pre-operation was as high as 58% (51/88), 5 indexes of blood coagulation in patients had obvious difference (P less than 0.001) comparing to that of healthy persons. This implied it existed relationship between gastric malignant tumor and blood stasis in TCM and accorded with diagnosis of blood stasis syndrome. With the resection of tumor focus, the states of blood stasis in patients had been improved to a certain extent. But the positive rate of substance of tongue post-operation was still as high as 51.1% (45/88) comparing to that pre-operation (P greater than 0.05), 5 indexes of blood coagulation in patients post-operation had no obvious improvement comparing to those pre-operation. This showed that the simple resection did not basically improve blood stasis in patients. The another important result was that the substance of tongue and 5 indexes of blood coagulation of 23 patients in last 3 months before death had more obvious blood stasis comparing to those post-operation even those pre-operation. This explained that blood stasis is one of the main characters of gastric malignant tumor before death. In conclusion, the extent of blood stasis syndrome can be used as an objective index to judge seriousness and prognosis of gastric malignant tumor patients' condition.

Pernicious anemia and type A atrophic gastritis in the Chinese

Pernicious anemia has been considered a rare disease among the Chinese. But in recent years, by wide-spread use of gastroscopy, more cases of Type A atrophic gastritis associated with pernicious anemia have been discovered. Among 28 patients with Type A atrophic gastritis, we had identified 20 cases of pernicious anemia, 18 in frank form and 2 in latent form. This paper presented the results of our studies on clinical, endoscopic, and laboratory examinations of these patients. The findings suggest that pernicious anemia was not so rare among the Chinese. If we keep an alertness on this disease, more such cases could be diagnosed.

Intravenous tryptophan tolerance test for liver function

An intravenous tryptophan tolerance test (ITrpTT) was designed for liver function since 95% Trp is metabolized by the liver. After an intravenous loading dose of 4 mg/kg body weight, serum levels of both free (F) and total (T) Trp were determined at 45 and 60 minutes. In normal controls and nonhepatic-disease patients, F45 (60) and T45 (60) did not exceed 7 mumol/L and 80 mumol/L, respectively, and F/T ratio not greater than 0.14. These were set up as cutoffs of upper normal limits. The test was abnormal in 87.5% of chronic persistent hepatitis (CPH) characterized by elevation of T45 (60), 100% of chronic active hepatitis (CAH) by elevation of F45 (60) and/or T45 (60), and 100% of hepatic cirrhosis by increase in F45 (60) and F/T ratio but not in T45 (60). The test seems to be more sensitive than the conventional tests for liver function. However, one should be cautious in interpretation of the test as there are some factors which might influence the Trp metabolism like exercise, alcoholism, corticosteroids and enzyme-inducers. It merits as an indication of liver dysfunction only when these factors are considered and excluded.

[Measurement of anticardiolipin antibodies and its significance in systemic lupus erythematosus]

A method for detection of anticardiolipin (ACL) antibodies with enzyme-linked immunosorbent assay was developed. Microtitre plates were coated with cardiolipin at a concentration of 20 micrograms/ml by evaporation under 4 degree centigrade overnight. Non-specific binding of diluted sera was eliminated by blocking of plates with 10% fetal calf serum in phosphate buffered saline (FCS/PBS) for 2 hours at room temperature. Sera (50 microliters/well) at a dilution of 1:100 were incubated for 2 hours at room temperature. Horseradish peroxidase conjugated rabbit anti-human IgG, IgM, IgA at a dilution of 1:2000, 1:1000, 1:500 respectively was added to the wells, and incubated for one and half hours at room temperature. The results were read at 490nm after incubation with substrates at 37 degree centigrade. 85 patients with systemic lupus erythematosus (SLE), 45 with rheumatoid arthritis (RA), 25 with progressive systemic scleroderma (PSS), and 18 primary Sjogren's syndrome were tested. The frequency of ACL antibody in SLE (48%) was much higher than that in RA (11%), PSS (12), SS (5.5). Three isotypes of ACL (IgG, IgM, IgA) were detected in the study with predominance of IgG isotype. ACL antibody was significantly associated with thrombosis, cutaneous vasculopathy, thrombocytopenia, and spontaneous abortion in patients with SLE. Strong relationship between ACL antibody and lupus anticoagulant was found. There was no correlation between ACL and anti-DNA antibodies, nor was ACL and VDRL test. The level of ACL antibody could be reduced by use of corticosteroids.

Low-refractive-index indium-tin-oxyfluoride thin films made by high-rate reactive dc magnetron sputtering

Indium-tin-oxyfluoride (ITOF) films were prepared by dc magnetron sputtering of indium-tin in Ar + O(2) + CF(4). Spectrophotometric measurements in the 0.2-2.5-microm wavelength range were used to evaluate the dielectric function. Wide band gap ITOF, with a refractive index of ~1.5 in the visible and good durability, was produced at a rate of ~1.2 nms(-1). indium-tin-oxide coatings.

A comparison of changes seen on radiographs of rheumatoid arthritis patients in Australia and in China

To test the hypothesis that rheumatoid arthritis in patients in China is milder in severity than that in patients in a western country, a comparison was made of 2 series of consecutive outpatients with definite or classic rheumatoid arthritis who were attending referral centers in Melbourne, Australia and Shanghai, China. This paper reports the findings on radiographs of the wrists and hands. Making allowances for age and duration of disease, changes were more frequent and severe in the Australian patient series, particularly at the metacarpophalangeal joints.

Campylobacter-like organisms in chronic gastritis, peptic ulcer, and gastric carcinoma

Biopsy samples were taken from the gastric mucosa of 209 patients endoscoped for dyspepsia symptoms. Campylobacter-like organisms (CLOs) were cultured from 74 of 179 (41.4%) cases and seen in sections from 110 of 209 (52.6%) cases and in smears from 119 of 209 (56.9%) cases; totally, 145 of 209 cases were positive, giving a rate of 69.4%. CLOs were positive in 45 of the 57 (78.9%) patients with superficial gastritis, in 52 of the 64 (81.3%) with atrophic gastritis, in 18 of the 21 (85.7%) with gastric ulcer, in 12 of the 14 (85.7%) with duodenal ulcer, and in 8 of the 10 (80.0%) with stump gastritis, whereas only a few CLOs were found in 3 of the 15 (20.0%) histologically normal subjects and in 7 of the 28 (25.0%) patients with gastric carcinoma. The organisms seem to live more frequently in diseased mucosa and are chiefly recognized through their characteristic morphology and habitat. A significant association between the presence of CLOs and chronic gastritis or peptic ulcer disease was noted, and the positive rate and the number of CLOs correlated highly with the activity of chronic gastritis. No such correlation was observed in gastric carcinoma. These findings support the view that CLOs may be etiologically related to chronic gastritis and peptic ulceration, even though their precise role still remains to be determined.

A comparison of rheumatoid arthritis in Australia and China

A comparison was made of two series of consecutive outpatients with a presumptive diagnosis of rheumatoid arthritis (RA) attending referral centres in Melbourne and Shanghai. No significant differences were observed in disease onset, course, presence of antinuclear antibodies (ANA), or seropositivity. In the Australian series there was a higher frequency of nodules, Raynaud's phenomenon, carpal tunnel syndrome, and 'classical' in comparison with 'definite' disease, and a lower frequency of lymphadenopathy and hepatomegaly. Joint tenderness and soft tissue swelling tended to be more marked in the Chinese series, while deformity and limited range of movement were less severe. Drug therapy was similar overall but influenced by drug availability. Peptic ulceration was recorded in 28% of the Australian series but in only 6% of the Chinese; although 25% of the Chinese were receiving antacids and 6% antiulcerants. X-rays of hands and feet showed more severe disease in the Australian series. The older age group and longer duration of the disease in the Australian patients, who had more chronic and less active disease, may have influenced some of these results.