Clinical Analysis and Treatment of Esophageal Perforation / 대한흉부외과학회지

BACKGROUND: Perforation of the esophagus is a deadly injury that requires expert management for survival. The mediastinal contamination with microorganisms, gastric acid, and digestive enzymes results in a mediastinitis that is often fatal if untreated. MATERIAL AND METHOD: Between January 1990 and June 2004, 38 patients with esophageal perforation were treated in our hospital. Retrospective review of these cases has been performed. RESULT: There were 28 males and 10 females. The mean age was 43.84+/-18.89 years (range 1~73 years). Spontaneous rupture was found in 34% of perforations, iatrogenic perforation in 32% and traumatic perforation in 34%. Perforation occurred in the cervical esophagus in 8 cases, thoracic esophagus in 29 and abdominal esophagus in 1. In the cervical esophageal perforation, managements were primary closure in 8 and drainage in 2. In the thoracic esophageal perforation, managements were primary closure in 14, resection in 3 and conservative management in 12. The mortality rate was 25% in cervical esophageal perforation and 34.5% in thoracic esophageal perforation. We revealed risk factor of esophageal perforation to be peropertaive septic condition (p=0.005). CONCLUSION: Most important risk factor of esophageal perforation was preoperative septic condition. Preoperative prompt and aggressive preoperative treatment may improve the survival rate of esophageal perforation.

Comparison of Myocardial Protective Effect between the Cold Blood Cardioplegia and Histidine-Tryptophan-Ketoglutarate Solution / 대한흉부외과학회지

Background: Blood cardioplegia is known as an established cardioplegic solution during open heart surgery. Recently, the Histidine-Tryptophan-Ketoglutarate (HTK) solution has been introduced as a cardioplegia in Korea. This study was designed to compare the myocardial protective effect between the cold blood cardioplegia (CBC) and HTK solution. Material and Method: Forty patients who underwent valve surgery or coronary artery bypass surgery were randomly divided into CBC group (n=20) and HTK group (n=20). The perioperative hemodynamic and clinical data were analyzed. The concentration of CK-MB, Troponin I and Lactate from coronary sinus and radial arterial blood were compared for the evaluation of the myocardial damage. The postoperative serial CK-MB levels were measured. Result: The characteristics of preoperative patients were similar in two groups. The hemodynamic parameters and postoperative clinical data were also similar between the two groups. There were no statistical significances between the CBC and HTK group in the difference of biochemical markers: delta CK-MB (15.3+/-26.0 vs 19.3+/-14.3), delta Tro-I (2.4+/-4.9 vs 2.0+/-2.20), delta Lac (1.6+/-1.0 vs 1.9+/-2.5). The serial CK-MB levels were not significantly different between the two groups. Conclusion: These results suggested that the myocardial protective effect of HTK solution was similar to cold blood cardioplegia during open heart surgery.

Clinical Characteristics of Pleomorphic Carcinoma / 대한흉부외과학회지

BACKGROUND: The research sought to identify the clinical features of pleomorphic carcinoma of the lung generally known as a rare subtype in accordance with the lung cancer classification done in 1999 by WHO. MATERIAL AND METHOD: 256 cases of surgically resected lung cancers were collected in this hospital from January 1992 to December 2001. This study included 42 cases of pleomorphic carcinoma diagnosed through light microscope and immunohistochemistry. RESULT: Out of 42 cases, males represented 31, and females 11, the age ranged from 26 to 77. Main clinical symptoms included coughing, hemoptysis, sputum. Diagnoses disclosed the stage as stage Ia in 3 cases (7%), Ib in 16 (38%), IIa in 1 (2%), IIb in 8 (19%), IIIa in 15 (35%), and IIIb in 1 (2%). Out of these, no lymph node metastasis was represented in 23 cases (54%), while N1 and N2 involving lymph node metastasis was shown 19 cases (46%). A total of 19 patients developed metastasis, comprising the brain in 5 cases (26%), bone in 4 (21%), muscle in 4 (21%), Lymph node in 2 (10%), and 1 liver, ovary, contralateral lung, and adrenal gland, respectively. The size of the tumor ranged from 1 cm to 11 cm, averaging 5.85 cm. Out of the 42 patients, the total two-year and five-year survival rates in accordance with the Kaplan-Meier method represented 26% and 13%, respectively, These figures compared to the corresponding 44% and 34% in cases other than pleomorphic carcinoma from the survey target of 256 cases, proved to be significantly low (p <0.002). No significant difference was found in the survival rates compared between age and tumor size, between stage I and above stage II, and between N0 and above N1. Patients who developed postoperative metastasis all died, and showed significantly low survival rates (p <0.002) compared to those patients without metastasis. CONCLUSION: With the new diagnosis method of 1999 WHO's lung cancer classification applied, pleomorphic carcinoma showed a higher prevalence rate than under previous classifications, their postoperative survival rate was significantly low compared to histologic type of non small cell lung carcinomas.

Surgical Treatment of Complete Atrioventricular Septal Defect with Tetralogy of Fallot: Report of one case / 대한흉부외과학회지

We experienced primary repair of complete atrioventricular septal defect with Teralogy of Fallot.The diagnosis was established preoperatively by echocardiography,cardiac catheterization and cardioangiography.Repair was accomplished using cardiopulmonary bypass.Two patch techinque were performed using Dacron patch for ventricular septal defect and pericardial patch for atrial septal defect.Infundibullectomy and right ventricular outflow tract reconstruction with the transannular pericardial patch were performed.The postoperative echocardiography showed mild mitral and tricuspid regurgitation,but there were no hemodynamic abnormalities.

The Tendency of Compensatory Hyperhidrosis after Sympathicotomy in Essential Hyperhidrosis / 대한흉부외과학회지

BACKGROUND: Thoracoscopic sympathicotomy is an effective treatment in essential hyperhidrosis. However,many patients suffer from compensatory hyperhidrosis. Compensatory hyperhidrosis is avery uncomfortable problem,but the mechanisms underlying compensatory hyperhidrosis are not completely understood. MATERIAL AND METHOD: From May 1999 to June 2001,25 cases of thoracoscopic sympathicotomy at the 2nd rib for facial hyperhidrosis and 116 cases of thoracoscopic sympathicotomy at the 3rd rib for palmar hyperhidrosis were performed in 141 patients.All of the patients were divided into noncompensatory sweating(NCS)and compensatory sweating(CS)group.Each group was investigated according to age,sex,body surface area(BSA), level of sympathicotomy and occupation. RESULT: The global rate of compensatory hyperhidorsis were 64.5%(91/141).There was no difference between the two groups for BSA,level of sympathicotomy and occupation.Mean age showed 23.2 years old in NCS group and 26.4 years old in CS group(p=0.09).In CS group,46 cases were male(50.5%)and 45 cases were female(49.5%)and in NCS group,19 cases were male(38.0%)and 31 cases were female(62.0%) (p=0.16). CONCLUSION: There were no available statistical data,but there was the fact that old age and male patients had the tendency for compensatory hyperhidrosis.If we have more patient group and consider the patient's family history or psychiatric pr obl ems ,we will have mor evaluable data for compensatory hyperhidrosis.

Transhiatal versus Transthoracic Esophagectomy for Esophageal Cancer / 대한흉부외과학회지

BACKGROUND: The classic approach for esophagectomy is via the combined thoracic and abdominal approach. Controversy exists whether patients with esophageal carcinoma are best managed with Ivor-Lewis esophagectomy(ILO) as combined thoracic and abdominal approach or transhiatal esophagectomy(THO). The THO approach is known to be superior with respect to operative time, severity of leak, morbidity/mortality, and length of stay, but may represent an inferior cancer operation as a result of survival disadvantage due to inadequate mediastinal clearance compared with ILO. Accordingly, we reviewed the results of our esophageal resections to compare these outcome parameters for each operative approach. MATERIAL AND METHOD: From January 1993 to July 2001, We performed a retrospective review of all esophagectomies performed at Keimyung University Dongsan Medical Center; 27 underwent THO, and 45 underwent ILO RESULT: The two groups were comparable in terms of age, sex, and stage of the disease. Mean tumor length and mean operative time were 3.81cm and 354 minutes for THO versus 5.31cm and 453 minutes for ILO, respectively (p < 0.01 and p < 0.001). Respiratory complications were 11.1% for THO versus 35.6% for ILO(p < 0.05). Hospital mortality was 11.1% for THO versus 22.2% for ILO. There were no significant differences between THO and ILO with respect to other types of complications, amount of blood transfusion, leak and stricture rates, and hospital stay. Overall long-term survival at 5 years was 37%, respectively. CONCLUSION: There was no significant difference in long-term survival of patients of both operative approach. ILO had significantdifference in respiratory complications associated with hospital mortality. Hence, THO is a valid alternative to ILO for well selected patients. And either approach appears to be acceptable depending on the surgeons, preferences and experiences.

Comparison of Repair and Replacement for Mitral / 대한흉부외과학회지

BACKGROUND: Mitral valve repair has been suggested to provide better postoperative outcome than valve replacement for mitral regurgita tion. MATERIAL AND METHOD: From Janu ary 1996 to May 2000, 87 patients had mitral valve repair(59 patients) or replac ement(28 patients) for mitral regurgitation. RESULT: The two groups were si milar in age, sex, and functional class. The cause of mitral regurgitation in th e repair group was degenerative in 45 patients, rheumatic in 12 patients, endoca rditis in 1, and ischemic in 1, and in the replacement group was degenerative in 12 patients, rheumatic in 11 patients, endocarditis in 4 and traumatic in 1 pat ient. A Carpentier ring was used in 51 patients and the most common size was 30 mm. The aortic cross-clamp time was 88.3+/-24.7 minutes in the repair group and 7 0.3+/-23.8 minutes in the replacement group(p<0.05), and total pump time was 13 9.6+/-30.5 minutes and 110.4+/-34.3 minutes(p<0.05) respectively. There was no hos pital death in both groups. Four-year actuarial survival was 97.9% for the repai r group and 100% for the replacement group(p = not significant). Postoperative c ardiothoracic ratio and ejection fraction decreased, and postoperative functiona l class improved in both groups(p = not significant). CONCLUSION: Mitral valve repai r for patients with mitral regurgitation can be performed with the satisfactory results as valve replacement.

Clinical Analysis for Thymic Carcinoma / 대한흉부외과학회지

BACKGROUND: Thymic carcinoma is a very rare disease and treatment modality is not standardized. So, we report our experience of management of thymic carcinoma. MATERIAL AND METHOD: Between 1984 and 1998, eight patients with thymic carcinoma were treated at Keimyung University Dongsan Medical center. RESULT: The median age was 46 years with a range of 23 to 67 years. Chief complaint was a anterior chest pain. Histologic subtypes included two lymphoepithelioma-like carcinoma, two squamous cell carcinoma, one basaloid carcinoma, and three mixed type. Clinical staging was classified to stage I in 2, stage II in 4, stage III in 1, and stage IVA in 1 according to the modified Masaoka staging system. Four patients underwent complete resection and three patients were found to have incomplete resection by histologic evaluation. One patient underwent only biopsy due to pericardial dissemination and invasion of adjacent organ. All patients had adjuvant chemotherapy, radiation therapy was administered to five patients for positive resection margin and above stage III. The median follow up period was 55.3+/-64.6 months, three patiants died and four patients are alive without recurrence. One patient in recurrence had two times re-operations and adjuvant chemoradiotherapy. He is still alive. CONCLUSION: We concluded that completely surgical resection and adequate adjuvant chemoradiotherapy after early diagnosis are useful to management of thymic carcinoma.

Simultaneous Repair of Pectus Excavatum and Secundum Atrial Septal Defect / 대한흉부외과학회지

We at Keimyung University Dongsan Medical Center experienced simultaneous repair of pectus excavatum and secundum atrial septal defect. We used resection deformed perichondrium, raising sternum at right angle to secure good operative field for open heart surgery. Mechanical ventilation was applied which could be weaned on postoperative 2 hours. The hospital course was uneventful without any other sequale. The patient was discharged on postoperative day 6.

Treatment of Esophageal Stenosis by Idiopathic Mediastinal Fibrosis: A case Report / 대한흉부외과학회지

Mediastinal fibrosis is uncommon but may result in entrapment and erosion of vital mediastinal structures by fibrous tissues. Idiopathic mediastinal fibrosis involved esophagus is very rare, and only a few cases have ever been reported. Such idiopathic mediastinal fibrosis involved esophagus is an enigmatic inflammatory fibrous tissue proliferation, but the treatment has not yet been clearly defined. We had successfully treated in such a case with partial esophagolysis and esophagomyotomy.

Primary Repair of Traumatic Aortic Transection with Clamp and Sew Technique: Report of 2 cases / 대한흉부외과학회지

Traumatic aortic transection after blunt chest injury is highly lethal and has high operative mortality. Recently, the diagnostic and therapeutic method of this injury is advanced, especially in spinal cord protection during aortic cross-clamping. We have experienced two cases of traumatic aortic transection with left hemothorax after blunt chest injury, which was diagnosed in operative field. The transected aorta was primarily repaired with clamp and sew method and postoperative paraplegia had not occured. The patients were dischraged without any significant complications. We report these cases with a review of literature.

The Effects of Glucose , Insulin and Angiotensin II on Plasminogen Activator Inhibitor-1 Expression and Growth of Aortic Vascular Smooth Muscle Cell in Rats / 대한흉부외과학회지

BACKGROUND: Plasminogen activator inhibitor-1(PAI-1) is known as the primary physiological inhibitor of tissue-type plasminogen activator(t-PA) in the plasma, and is present within the atherosclerotic vessels. Increased plasma levels of PAI-1 are one of the major disturbances of the hemostatic system in patients with diabetes and/or hypertension, and may have multiple interrelations with the important risk factors in the development of atherosclerosis. This study was performed to determine whether altered gene expression of PAI-1 occurs within the arterial wall, and thereby potentially contributing to the increase of cardiovascular risks associated with diabetes and/or hypertension. MATERIAL AND METHOD: The aortic vascular smooth muscle cells of the rat were exposed to 22 mM glucose, angiotensin II, and insulin increased PAI-1 mRNA expression with the use of Northern blotting were examined. Also examined were the effects of 22 mM glucose, angiotensin II and insulin on the growth of the rat's aortic smooth muscle cells by using MTT assay. RESULT: Twenty-two mM glucose treatment increased the PAI-1 mRNA expression in a time- and dose-dependent manner. Aniotensin II treatment synergistically increased the glucose-induced PAI-1 mRNA expression. In contrast, addition of insulin attenuated the increase of 22 mM glucose and angiotensin II induced PAI-1 mRNA expression. Furthermore, treatment of 22 mM glucose, angiotensin II and insulin resulted in a significant increase in cell numbers. This study demonstrated that 22 mM glucose and angiotensin II have a synergistic effect in stimulating the PAI-1 mRNA expression and in the cell growth of the rat's aortic smooth muscle cells. CONCLUSION: Elevation of glucose and angiotensin II may be important risk factors in impairing fibrinolysis and developing atherosclerosis in diabetic patients.

Valve Replacement in Children / 대한흉부외과학회지

BACKGROUND: Thirty children ranging from 3 to 15 years of age underwent cardiac valve replacement at Dongsan Medical Center from 1982 to 1997. MATERIAL AND METHOD: There were 16 boys and 14 girls. The mean age was 12.1. The underlying pathological cause for valve replacement was congenital heart disease in 17 children and acquired heart disease in 13. The valve replaced was mitral in 15 children, aortic in 11, tricuspid in 3, and combined aortic and mitral in 1. Twenty-one mechanical and 10 tissue valves were placed: primary mechanical valve have been utilized since 1985. Eight of ten patients with tissue valves have had successful second valve replacements 4 to 11 years after the initial operation. RESULT: The operative mortality was 6.7%, but mortality was higher among patients less than 5 years of age and patients who had previous cardiac operations. Of the 28 operative survivors, 4 patients were lost to follow-up: the remaining patients were observed for a total of 2091 patient/months(mean 74.7 months, maximum 187 months). There was one late death from dilated cardiomyopathy after mitral valve replacement in 7 year-old patient with atrioventricular septal defect. After the operation, all patients with mechanical valves were placed on a strict anticoagulant regimen with Coumadin. The actuarial survival rate was 96% at the end of the follow-up. No instance of thromboembolism or major bleeding were observed in the survivors. CONCLUSION: These results indicate that valve replacement can be performed with low mortality in children, and with satisfactory long-term survival.

Supra-Arterial Myotomy without Cardiopulmonary Bypass for Myocardial Bridging: One case report / 대한흉부외과학회지

Systolic coronary arterial narrowing, secondary to myocardial bridging which is capable of producing chest pain, myocardial infarction and ventricular fibrillation is a known but an uncommon entity. A supra-arterial myotomy in a case of myocardial bridge causing medication-refractory angina is described. Under the partial sternotomy incision, we performed a supra-arterial myotomy in the left anterior descending coronary artery without cardiopulmonary bypass. The postoperative course was uneventful.

Mitral Valve Repair for Mitral Regurgitation / 대한흉부외과학회지

From February 1996 to May 1997, 18 patients underwent mitral valve repair for mitral regurgitation. There were 9 male and 9 female patients aged from 19 to 68 years (mean, 53). Thirteen patients were in New York Heart Association (NYHA) class III and IV. The cause of mitral regurgitation was degenerative in 12 patients, rheumatic in 5 patients and infective in 1 patient. Fifteen patients were in Carpentier's functional classification II, 2 patients in Carpentier's class III and 1 patient in Carpentier's class I. Surgical procedures included prosthetic ring annuloplasty (16 cases), rectangular resection of posterior leaflet (15 cases), chordal shortening (5 cases), triangular resection of anterior leaflet (2 cases), commissurotomy (2 cases), partial transposition of posterior leaflet (1 case). These procedures were combined in most patients. There was no operative death. These patients have been followed from 1 to 15 months, mean of 6.7 months. There was one late death resulted from low cardiac output following mitral valve replacement. The function of the repaired valve in other 17 patients has remained satisfactory during the observed interval. We consider that mitral valve repair is highly satisfactory in patients with mitral regurgitation.

Reoperations on Heart Valve Prostheses / 대한흉부외과학회지

BACKGROUND: All currently available mechanical and bioprosthetic valves are associated with various types of deterioration leading to dysfunction and/or valvular complications. Reoperation on prosthetic heart valves is increasingly under consideration for both clinical and prophylactic indications. This review was conducted to determine the factors affecting the risk of reoperation for prosthetic valve replacement. MATERIAL AND METHOD: From January 1985 to July 1996, 124 patients underwent reoperation on prosthetic heart valves, and 3 patients had a second valve reoperation. The causes of reoperation were prosthetic valve failure (96 cases, 77.4%), prosthetic valve thrombosis (16 cases, 12.9%), prosthetic valve endocarditis (7 cases, 5.6%) and paravalvular leak (5 cases, 4.1%). This article is based on the analysis of the experience with particular emphasis on the preoperative risks affecting the outcome of the reoperation. RESULT: Overall hospital mortality rate was 8.9% (11/124). Low cardiac output was the most common cause of death (70.6%). Left ventricular systolic dimension (p=0.001), New York Heart Association functional class IV (p=0.003) and serum creatinine level (p=0.007) were the independent risk factors, but age, sex and cardiothoracic ratio did not have any influence on the operative mortality. Follow-up period was ranged from 3 to 141 months (mean, 50.6 months). A late mortality rate was 1.8%. CONCLUSION: The surgical risk of reoperation on heart valve prostheses in the advanced NYHA class patients is higher, therefore reoperation is recommended before the hemodynamic impairment become severe.

Surgical Treatment of Pectus Excavatum / 대한흉부외과학회지

The pectus excavatum is the most common deformity of chest wall. The most common cause of surgical correction is cosmetic problem. From January 1981 to July 1996, 24 patients had undergone surgery for pectus excavatum and they were corrected by Ravitch operation (n=4) or modified Wada operation (n=20) respectively. We analyzed each surgical cases according to age, sex, chief complaint, degree of deformity, EKG findings, complications and satisfaction degree of patient. In some cases, we measured Welch index preoperatively and postoperatively. The postoperative complications were wound infection in two, pneumothorax in two and reccurrence in one. The average value of Welch index was significantly improved from 5.86+/-0.51 preoperatively to 4.10+/-0.51 postoperatively (p<0.05). The results by Humphreys' criteria were satisfiable in 88% (excellent 71%, good 17%). The findings of this study suggest that surgical correction of pectus excavatum with modified Wada rocedure and submammary s in incision is effective method in physical and psychiatric aspect.

Effect of Modified Ultrafiltration on Pediatric Open Heart Surgery / 대한흉부외과학회지

Total body water is increased after cardiopulmonary bypass resulting in tissue edema and organ dysfunction. Ultrafiltration has been used to reduce this accumulation of water. We have carried out a prospective randomized study in 17 children undergoing open heart surgery, comparing modified ultrafiltration (MUF) with nonfiltered controls. MUF was carried out for about 10 minutes after completion of cardiopulmonary bypass to a hematocrit 36~42%. Blood loss, blood transfused, hemodynamics, and laboratory data were recorded for 24 hours postoperatively. The results were analyzed using Mann-Whitney U test, comparing controls (n=7) to ultrafiltered (n=10). There was no death in each group. The mean filtrate volume (ml/kg) was 42 (30~68). Blood loss (ml/kg/24hr) was 14.5 mean (4.0~26.6) in controls versus 12.1 mean (6.0~21.5) in MUF (p>0.05) ; blood transfused (ml/kg/24hr) was 9.4 mean (6.0~36.3) in controls versus 3.4 mean (0~11.4) in MUF (p<0.05). There was rise in arterial blood pressure during MUF. Percent rise of systolic blood pressure was 4.2 (0~11.7) in controls versus 19.8 (7.0~36.9) in MUF (P=0.001). Percent rise of diastolic blood pressure was 10.0 (1.6~20.8) in controls versus 30.6 (5.8~73.3) in MUF (p<0.05). Platelet count, fibrinogen, and oncotic pressure rose after MUF. No complications directly attributable to the ultrafiltration were observed. Conclusively, MUF is safe, effective means of removing body water and beneficial to hemodynamics.

Effects of Autotransfusion using Cell Saver in Open Heart Surgery / 대한흉부외과학회지

Homologous blood transfusion entails substantial risks, including allergic reactions, transmission diseases such as hepatitis, acquired immunodeficiency syndrome. Autotransfusion system is a common method of reducing the need for homologous blood transfusion during cardiac operation. Between July 1993 and July 1995, a series of 40 patients undergoing open heart surgery was selected to an autotransfusion group (n=20) or a control group (n=20). The cell saver system (AT1000, Electromedics, Englewood, CO, USA) was employed for autotransfusion. With this system, shed blood in operative field during cardiopulmonary bypass (CPB) and remained blood in cardiotomy reservior after CPB was aspirated by means of a locally heparinized collecting system. After centrifuge salvaged blood, the resulting red cell concentrate reinfused subsequently. The amounts of blood loss were 766.5+/-121.3 ml in cell saver group, 770.1+/-113.6 ml in control group, and there were no significant differences between two groups (P=NS). The amounts of blood transfused were 2.91+/-1.72 units in cell saver group, 4.82+/-1.72 units in control group. Composition of processed blood by cell saver was hemoglobin 17.4 gm%, hematocrit 56.4%, RBC 5,780,000/ul, WBC 9,900/ul, and platelet 33,000/ul. There was no complication related to cell saver. Conclusively, cell saver autotransfusion system is safe, effective method for reducing the homologous blood trasfusion in cardiac surgery.

Clinical Evaluation of Esophageal Cancer / 대한흉부외과학회지

We retrospectively analyzed 54 patients with esophageal cancer treated surgically between 1992 and 1996. They composed of 51(94.4%)men, 3(5.6%)women, and the age ranged from 42 to 78, the mean was 58.7+/-8.37. Symptoms were varied with dysphagia(72.2%), epigastric discomfort(16.6%), chest pain (5.6%), and so on(5.6%). Transthoracic esophagectomy(TTE) with esophagogastrostomy was done in 36 case, TTE with esophagocologastrostomy in 4 case, and transhiatal esophagectomy(THE) with esophagogastrostomy in 14 case. The operative mortality was 12.9%(7/54); 6 underwent TTE with esophagogastrostomy, and 1 underwent TTE with esophagocologastrostomy. Postoperative complications were of anastomotic leakage in 7 case, wound infection in 10 case, anastomotic stricture in 9 case, vocal cord paralysis in 2 case, bronchial tearing in 1 case, and pneumothorax in 3 case. Locations of esophageal cancer were upper thoracic esophagus in 4 case, middle thoracic esophagus in 34 case and lower thoracic esophagus in 16 case. Histological types were adenocarcinoma in 1 case and squamous cell carcinoma in 53 case. During the follow-up period, 25 cases died. Cumulative survival rate was 52.7% in 1 year, 45.5% in 2 year, 45.5% in 3 year, 45.5% in 4 year, 45.5% in 5 year.