Cyst infection in hospital-admitted autosomal dominant polycystic kidney disease patients is predominantly multifocal and associated with kidney and liver volume

Positron-emission tomography/computed tomography (PET/CT) has improved cyst infection (CI) management in autosomal dominant polycystic kidney disease (ADPKD). The determinants of kidney and/or liver involvement, however, remain uncertain. In this study, we evaluated clinical and imaging factors associated with CI in kidney (KCI) and liver (LCI) in ADPKD. A retrospective cohort study was performed in hospital-admitted ADPKD patients with suspected CI. Clinical, imaging and surgical data were analyzed. Features of infected cysts were evaluated by PET/CT. Total kidney (TKV) and liver (TLV) volumes were measured by CT-derived multiplanar reconstruction. CI was detected in 18 patients who experienced 24 episodes during an interval of 30 months (LCI in 12, KCI in 10 and concomitant infection in 2). Sensitivities of CT, magnetic resonance imaging and PET/CT were 25.0, 71.4, and 95.0%. Dysuria (P<0.05), positive urine culture (P<0.01), and previous hematuria (P<0.05) were associated with KCI. Weight loss (P<0.01) and increased C-reactive protein levels (P<0.05) were associated with LCI. PET/CT revealed that three or more infected cysts were present in 70% of the episodes. TKV was higher in kidney-affected than in LCI patients (AUC=0.91, P<0.05), with a cut-off of 2502 mL (72.7% sensitivity, 100.0% specificity). TLV was higher in liver-affected than in KCI patients (AUC=0.89, P<0.01) with a cut-off of 2815 mL (80.0% sensitivity, 87.5% specificity). A greater need for invasive procedures was observed in LCI (P<0.01), and the overall mortality was 20.8%. This study supports PET/CT as the most sensitive imaging method for diagnosis of cyst infection, confirms the multifocal nature of most hospital-admitted episodes, and reveals an association of kidney and liver volumes with this complication.

Cyst infection in hospital-admitted autosomal dominant polycystic kidney disease patients is predominantly multifocal and associated with kidney and liver volume.

Positron-emission tomography/computed tomography (PET/CT) has improved cyst infection (CI) management in autosomal dominant polycystic kidney disease (ADPKD). The determinants of kidney and/or liver involvement, however, remain uncertain. In this study, we evaluated clinical and imaging factors associated with CI in kidney (KCI) and liver (LCI) in ADPKD. A retrospective cohort study was performed in hospital-admitted ADPKD patients with suspected CI. Clinical, imaging and surgical data were analyzed. Features of infected cysts were evaluated by PET/CT. Total kidney (TKV) and liver (TLV) volumes were measured by CT-derived multiplanar reconstruction. CI was detected in 18 patients who experienced 24 episodes during an interval of 30 months (LCI in 12, KCI in 10 and concomitant infection in 2). Sensitivities of CT, magnetic resonance imaging and PET/CT were 25.0, 71.4, and 95.0%. Dysuria (P<0.05), positive urine culture (P<0.01), and previous hematuria (P<0.05) were associated with KCI. Weight loss (P<0.01) and increased C-reactive protein levels (P<0.05) were associated with LCI. PET/CT revealed that three or more infected cysts were present in 70% of the episodes. TKV was higher in kidney-affected than in LCI patients (AUC=0.91, P<0.05), with a cut-off of 2502 mL (72.7% sensitivity, 100.0% specificity). TLV was higher in liver-affected than in KCI patients (AUC=0.89, P<0.01) with a cut-off of 2815 mL (80.0% sensitivity, 87.5% specificity). A greater need for invasive procedures was observed in LCI (P<0.01), and the overall mortality was 20.8%. This study supports PET/CT as the most sensitive imaging method for diagnosis of cyst infection, confirms the multifocal nature of most hospital-admitted episodes, and reveals an association of kidney and liver volumes with this complication.

Clinical relevance of positron emission tomography/computed tomography-positive inguinal nodes in rectal cancer after neoadjuvant chemoradiation.

AIM: Inguinal nodes may be a possible route for lymphatic spread in patients with distal rectal cancer. The outcome was examined for patients with distal rectal cancer undergoing neoadjuvant chemoradiation (CRT) and having 2-fluorine-18-fluoro-2-deoxy-d-glucose (FDG)-avid inguinal nodes using positron emission tomography/computed tomography (PET/CT) imaging. METHOD: Ninety-nine consecutive patients with cT2-4N0-2M0 distal rectal adenocarcinoma were enrolled in a clinical trial (NCT00254683) and underwent baseline PET/CT followed by 54 Gy and 5-fluorouracil-based CRT. After CRT, patients underwent 6- and 12-week PET/CT. Patients with positive inguinal node uptake were compared with patients with negative uptake. The inguinal region was not included in the field of radiation therapy. RESULTS: Seventeen (17%) patients had baseline positive inguinal node FDG uptake. They were more likely to have the tumour closer to the anal verge (2.0 vs 4.2 cm; P = 0.001). Of these, eight (47%) demonstrated a positive inguinal uptake at PET/CT after 12 weeks from CRT. Patients with inguinal node FDG uptake after CRT (positive PET at baseline and 12 weeks) had a significantly worse 3-year overall and disease-free survival (P = 0.02 and P = 0.03). After a median follow-up period of 22 months, none of these patients had developed inguinal recurrence. CONCLUSION: Uptake of inguinal nodes at PET/CT may be present in up to 17% of patients with distal rectal cancer, particularly with ultra-low tumours. Nearly half of these nodes no longer show uptake after CRT despite the groin area not being included in the radiation field. Persistence of inguinal node uptake 12 weeks after CRT completion may be a marker for worse oncological outcome.

Cognitive impairment and magnetic resonance imaging correlations in Wilson's disease.

OBJECTIVES: To evaluate the cognitive performance of a group of patients with Wilson's disease (WD) and to correlate the cognitive findings with changes in magnetic resonance imaging (MRI). METHODS: All patients with WD consecutively attended in a Movement Disorders Clinic between September 2006 and October 2007 were invited to participate in the study, together with a group of matched healthy controls. Patients and controls were submitted to comprehensive neuropsychological assessment. MRI was performed in all patients, and abnormalities (high-intensity signal, low-intensity signal and atrophy) were semi-quantitatively rated. Performance of patients and controls in each cognitive test was compared, and correlations between cognitive scores and MRI changes were investigated within the patients' group. RESULTS: Twenty patients with WD (11 men) and 20 controls (nine men) were evaluated. Mean age in the WD and control groups was 30.05 ± 7.25 and 32.15 ± 5.37 years, respectively. Mean schooling years were 11.15 ± 3.73 among WD cases and 10.08 ± 2.62 among controls. Patients with WD performed significantly worse than controls in the Mini-Mental State Examination, Dementia Rating Scale, phonemic verbal fluency (FAS), verb generation, digit span forward, Stroop test, Frontal Assessment Battery and in the Brief Cognitive Screening Battery. A significant correlation emerged between global cognitive impairment and MRI scale (r = 0.535), being higher for high-intensity signal plus atrophy (r = 0.718). CONCLUSION: Patients with WD presented cognitive impairment, especially in executive functions, with good correlation between cognitive abnormalities and MRI changes.

A simple technique for repair of distal limb prolapse of a loop colostomy.

Several procedures have been proposed for the prolapse of a loop colostomy. However, most are associated with a high recurrence rate or are rather expensive. We have newly developed a simple, safe, and inexpensive method, which is a modification of Thiersch's method, for repair of distal limb prolapse of a loop colostomy.

Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study.

BACKGROUND AND PURPOSE: Tinnitus is a frequent disorder which is very difficult to treat and there is compelling evidence that tinnitus is associated with functional alterations in the central nervous system. Targeted modulation of tinnitus-related cortical activity has been proposed as a promising new treatment approach. We aimed to investigate both immediate and long-term effects of low frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) in patients with tinnitus and normal hearing. METHODS: Using a parallel design, 20 patients were randomized to receive either active or placebo stimulation over the left temporoparietal cortex for five consecutive days. Treatment results were assessed by using the Tinnitus Handicap Inventory. Ethyl cysteinate dimmer-single photon emission computed tomography (SPECT) imaging was performed before and 14 days after rTMS. RESULTS: After active rTMS there was significant improvement of the tinnitus score as compared to sham rTMS for up to 6 months after stimulation. SPECT measurements demonstrated a reduction of metabolic activity in the inferior left temporal lobe after active rTMS. CONCLUSION: These results support the potential of rTMS as a new therapeutic tool for the treatment of chronic tinnitus, by demonstrating a significant reduction of tinnitus complaints over a period of at least 6 months and significant reduction of neural activity in the inferior temporal cortex, despite the stimulation applied on the superior temporal cortex.

Improvement of compactin (ML-236B) production by genetic engineering in compactin high-producing Penicillium citrinum.

An increase in compactin (ML-236B) production was achieved by introducing a whole compactin biosynthetic gene cluster or the regulatory gene mlcR into compactin high-producing Penicillium citrinum. In the previous report, we introduced mlcR encoding the positive regulator of compactin biosynthetic genes into compactin high-producing strain no. 41520, and most of the transformants produced higher amounts of compactin. Here, we characterize one of the resulting high producers (strain TIR-35, which produced 50% more compactin) and reveal that TIR-35 contained five copies of mlcR and that early, enhanced expression of mlcR caused compactin overproduction. Similarly, the introduction of mlcR into strain T48.19, which was created previously from strain no. 41520 by introducing a partial compactin biosynthetic gene cluster, enhanced compactin production further. Our results indicated that genetic engineering is an effective tool to improve compactin production, even in compactin high producers.

Targeted disruption of the genes, mlcR and ariB, which encode GAL4-type proteins in Penicillium citrinum.

The role of two genes, mlcR and ariB, was investigated by gene disruption experiments. The mlcR gene in the ML-236B biosynthetic gene cluster of Penicillium citrinum encodes a putative 50.2-kDa protein with a Zn (II) 2Cys6 DNA-binding domain, and has similarity to most of the GAL4-type regulatory proteins. The mlcR disruptant did not produce ML-236B or its intermediates, suggesting that mlcR is involved in ML-236B biosynthesis. Transcriptional analysis of the mlcR disruptant by Northern hybridization and RT-PCR indicated that MlcR activates the transcription of mlcA, B, C,D, F, G and H in a pathway-specific manner. On the other hand, MlcR did not affect the transcription of mlcE and the genes outside the ML-236B cluster. The ariB gene, next to mlcR, encodes another GAL4-type protein. Transcriptional analysis of the ariB disruptant indicated that it is a transcriptional activator of the genes outside the ML-236B cluster, and is not related to ML-236B biosynthesis.

Effects of antidepressant treatment with rTMS and fluoxetine on brain perfusion in PD.

BACKGROUND: Although depression is highly prevalent in Parkinson disease (PD), little is known about the neural correlates associated with depression and antidepressant treatment in PD. OBJECTIVE: To examine the effects of fluoxetine and repetitive transcranial magnetic stimulation (rTMS) on regional cerebral blood flow (rCBF) using SPECT in patients with PD and depression. METHODS: Twenty-six patients were enrolled into two groups: One received active rTMS and placebo medication and the other sham rTMS and fluoxetine 20 mg/day. Brain SPECT was performed at baseline and after 2 and 8 weeks. Changes in rCBF were compared across timepoints and correlated with clinical scores. In addition, baseline rCBF of these patients was compared with that of 29 healthy, age-matched subjects. RESULTS: At baseline, patients with PD and depression showed significantly lower rCBF in the left prefrontal cortex, posterior cingulate gyrus, left insula, and right parietal cortex when compared with healthy controls. Both treatments induced significant clinical improvement and increases in rCBF in the posterior cingulate gyrus and decreases in rCBF in the right medial frontal gyrus. These changes were significantly correlated to the clinical outcome. Furthermore, the comparison between these two treatments revealed that whereas rTMS treatment was associated with an increased perfusion in the right and left prefrontal cortex, fluoxetine treatment was associated with a relative rCBF increase in the occipital lobe. CONCLUSION: Depression in patients with Parkinson disease is correlated with a dysfunction of the frontal-limbic network that can be modulated by two different antidepressant therapies.

Diffusion tensor imaging of cerebral white matter in patients with myotonic dystrophy.

PURPOSE: To determine whether myotonic dystrophy (MyD) patients have diffusion tensor abnormalities suggestive of microstructural changes in normal-appearing white matter (NAWM). MATERIAL AND METHODS: Conventional and diffusion tensor magnetic resonance images of the brain were obtained in 19 MyD patients and 19 age-matched normal control subjects. Fractional anisotropy (FA) and mean diffusivity (MD) values were calculated in white matter lesions (WMLs) and NAWM in MyD patients and in the white matter of normal control subjects. Differences between WML and NAWM values and between MyD patient and control subject values were analyzed statistically. RESULTS: Significantly lower FA and higher MD values were found in all regions of interest in the NAWM of MyD patients than in the white matter of control subjects (P<0.01), as well as significantly lower FA and higher MD values in WMLs than in NAWM of MyD patients (P < 0.05). There was no significant correlation of mean FA or MD values in NAWM with patient age, age at onset, or duration of illness (P>0.1). CONCLUSION: Diffusion tensor imaging analysis suggests the presence of diffuse microstructural changes in NAWM of MyD patients that may play an important role in the development of disability.

Functional analysis of mlcR, a regulatory gene for ML-236B (compactin) biosynthesis in Penicillium citrinum.

The mlcR gene encodes a putative 50.2-kDa protein with a Zn(II)(2)Cys(6) DNA-binding domain, which may be involved in the regulation of ML-236B biosynthesis in Penicillium citrinum. The induction of ML-236B production appears to correlate with the expression of mlcR, and the ML-236B biosynthetic genes mlcA- mlcH, and occurs mostly during the stationary phase. The present study was designed to examine the effects of alterations in mlcR expression on ML-236B biosynthesis. We first set out to increase the mlcR copy number in the chromosome of P. citrinum. Transformants with additional copies of native mlcR showed increased transcription of mlcR and produced larger amounts of ML-236B than the parent strain. Altered mlcR expression was also achieved by introducing a construct, designated pgkA(P)::mlcR, that contained the mlcR coding region fused to the (constitutively active) promoter and terminator sequences of the Aspergillus nidulans 3-phospho-glycerate kinase (pgkA) gene. Transformants carrying the pgkA(P)::mlcR construct expressed mlcR constitutively, and produced ML-236B during the exponential growth phase, suggesting that the pgkA(P)::mlcR construct does affect the regulation of ML-236B biosynthesis. Comparative expression analysis by RT-PCR showed that altering the expression profile of mlcR influenced the expression of some of the ML-236B biosynthetic genes. The evidence suggests that mlcR may indeed be involved in the transcriptional activation of some of the pathway-specific genes required for ML-236B biosynthesis.

Effect of increased dosage of the ML-236B (compactin) biosynthetic gene cluster on ML-236B production in Penicillium citrinum.

The gene cluster responsible for ML-236B (compactin) biosynthesis has recently been characterized from P. citrinum No. 41520. Here, we describe how the ML-236B-producing strain was improved using a cosmid-mediated recombination technique. The introduction of the cosmid pML48, which contains seven of the nine ML-236B biosynthetic genes, into P. citrinum No. 41520 resulted in transformants which produced increased amounts of ML-236B. Southern analysis showed that pML48 had been incorporated by a homologous recombination event, and all high producers possessed two copies of each of the seven genes, mlcA- mlcF and mlcR, suggesting that increased dosage of the biosynthetic gene cluster was responsible for the enhanced production of ML-236B. On the other hand, various kinds of mutants with decreased titers of ML-236B were also obtained. Characterization of one such mutant, designated as T48.28, which was more sensitive to ML-236B than the parental strain, suggested that one of the ML-236B biosynthetic genes, mlcD, which encodes a putative HMG-CoA reductase, was involved in conferring resistance to ML-236B.

Molecular cloning and characterization of an ML-236B (compactin) biosynthetic gene cluster in Penicillium citrinum.

Cloning of genes encoding polyketide synthases (PKSs) has allowed us to identify a gene cluster for ML-236B biosynthesis in Penicillium citrinum. Like lovastatin, which is produced by Aspergillus terreus, ML-236B (compactin) inhibits the enzyme 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. Genomic sequencing and Northern analysis showed that nine predicted genes for ML-236B biosynthesis were located within a 38-kb region and were transcribed when ML-236B was produced. The predicted amino acid sequences encoded by these nine genes, designated mlcA- mlcH and mlcR, were similar to those encoded by the genes for lovastatin synthesis, and were therefore assumed to be involved either directly or indirectly in ML-236B biosynthesis. Targeted disruption experiments provided evidence that two PKS genes in the cluster, mlcA and mlcB, are required for the biosynthesis of the nonaketide and the diketide moieties, respectively, of ML-236B, suggesting that the gene cluster as a whole is responsible for ML-236B biosynthesis in P. citrinum. Bioconversion of some of the predicted intermediates by an mlcA-disrupted mutant was also investigated in order to analyze the ML-236B biosynthetic pathway. The molecular organization of the gene cluster and proposed functions for the ML-236B biosynthetic genes in P. citrinum are described.

Three-dimensional portography using multislice helical CT is clinically useful for management of gastric fundic varices.

OBJECTIVE: This study seeks to evaluate three-dimensional (3D) helical CT portography as a tool for examining patients with gastric fundic varices. SUBJECTS AND METHODS: We compared 3D helical CT portography and conventional angiographic portography in 30 consecutive patients with gastric fundic varices. We assessed whether 3D helical CT portography is useful in selecting patients and in evaluating the results of balloon-occluded retrograde transvenous obliteration. RESULTS: Three-dimensional helical CT portography simultaneously depicted second or third branches of the intrahepatic portal vein and provided images of entire portosystemic collaterals. On 3D helical CT portography, gastric fundic varices were seen in 30 patients (100%), left gastric veins in 19 (63%), posterior gastric veins or short gastric veins in 28 (93%), gastrorenal shunts in 27 (90%), paraumbilical veins in three (10%), and inferior phrenic veins in two patients (7%). Findings of 3D helical CT portography and conventional angiographic portography were in close agreement. However, in four patients, posterior gastric veins or short gastric veins were not seen on conventional angiographic portography images of the spleen, but they were clearly revealed on 3D helical CT portography. Treatment was successful in all patients except one. Three-dimensional helical CT portography could easily evaluate therapeutic results. CONCLUSION: Three-dimensional helical CT portography proved so effective that it can be considered a less invasive alternative than conventional angiographic portography in assessing portosystemic collaterals. CT portography is useful in selecting candidates from patients with gastric fundic varices for retrograde transvenous obliteration and also in evaluating therapeutic results.

[Appearance of the hepatic artery in Multidetector-row CT using a test bolus injection].

To separate the hepatic artery from the portal vein for the clear appearance of the hepatic artery, we used a test bolus injection in Multidetector-row CT. We examined 25 patients using the following method: 75 ml Iopamidol (370 mgI/ml), at a rate of 5 ml/sec, with scanning commencing 5 sec after the contrast medium reached the upper abdominal aorta. Successful separation could be obtained in almost all of the patients (88%). Separating the hepatic artery from the portal vein enabled us to evaluate the anatomy of the hepatic artery and the abnormality of blood flow in the liver.

High-level secretory production of phospholipase A1 by Saccharomyces cerevisiae and Aspergillus oryzae.

Phospholipase A1 (PLA1) is a hydrolytic enzyme that catalyzes the removal of the acyl group from position 1 of lecithin to form lysolecithin. The PLA1 gene, which had been cloned from Aspergillus oryzae, was expressed in Saccharomyces cerevisiae and A. oryzae. Through the modification of the medium composition and the feeding conditions of substrate, the production level of PLA1 by S. cerevisiae was increased to a level fivefold higher than that indicated in a previous report. In the case of A. oryzae, introduction of multicopies of PLA1 expression units, and the morphological change from the pellet form to the filamentous form were effective for the enhancement of PLA1 production. We succeeded in producing 3,500 U/ml of PLA1 using an industrial-scale fermentor.

Depressive behavior and alterations in receptors for dopamine and 5-hydroxytryptamine in the brain of the senescence accelerated mouse (SAM)-P10.

The senescence accelerated mouse (SAM) is known as a murine model of aging. SAM consists of senescence accelerated-prone mouse (SAMP) and senescence accelerated-resistant mouse (SAMR). Previous studies reported that SAMP10 exhibits age-related learning impairments and behavioral depression in a tail suspension test after 7 months. We investigated the changes in emotional behavior in a forced swimming test and in receptors for dopamine and 5-hydroxytryptamine (5-HT) in SAMP10. SAMP10 at 8 months showed an increase of immobility in the test compared with SAMR1. Treatment with desipramine (25 mg/kg, i.p., 3 days) in SAMP10 caused a decrease in immobility. In the cortex from SAMP10, [3H]quinpirole binding to D2/D3 dopamine receptors increased significantly compared with control SAMR1. In the hippocampus from SAMP10, [3H]8-hydroxy DPAT binding to 5-HT1A receptor increased. In midbrains from SAMP10, bindings of [3H]quinpirole and [3H]8-hydroxy DPAT increased. [3H]SCH23390 binding to D1/D5 receptors and [3H]ketanserin binding to 5-HT2 receptor in brain regions examined in SAMP10 were similar to those in SAMR1. The present findings represent the first neurochemical evidence of an increase of D2/D3 and 5-HT1A receptors in SAMP10. SAMP10 may be a useful model of aging associated depressive behavior.

Prolonged afebrile nonproductive cough illnesses in American soldiers in Korea: a serological search for causation.

A serological study was undertaken to investigate infections in active-duty United States soldiers with illnesses characterized by prolonged, afebrile, nonproductive coughs. Fifty-four soldiers were enrolled with such illness of >/=2 weeks' duration (case patients) along with 55 well soldiers (control subjects). Serum samples were tested for IgG and IgA antibody to 3 Bordetella pertussis antigens, pertussis agglutinins, IgM antibodies to Mycoplasma pneumoniae, IgM and IgG antibodies to Chlamydia pneumoniae, and IgM antibody to adenoviruses. Forty-six case patients (85%) had evidence of recent infection with Bordetella species, M. pneumoniae, or C. pneumoniae, and many had evidence of mixed infections; there were 27 Bordetella species, 20 C. pneumoniae, and 33 M. pneumoniae recent infections. Fifteen case patients had high titers of IgG or IgA to B. pertussis filamentous hemagglutinin without high titers of antibodies to other B. pertussis antigens, which suggested the presence of cross-reacting antibodies to M. pneumoniae and perhaps C. pneumoniae or unidentified infectious agent or agents. Since illnesses due to Bordetella species, M. pneumoniae, and C. pneumoniae can all be treated with macrolide antibiotics and B. pertussis illness can be prevented by immunization, and since military readiness was affected in 63% of the cases, it seems important to conduct further studies in military populations.

Effect of ethanol on the production of carboxypeptidase Y using the GAL10 promoter in a Saccharomyces cerevisiae gal80 mutant.

In the course of studying carboxypeptidase Y (CPY) production, we found that the expression level of the gene, which is under the control of the GAL10 promoter, increased in a Saccharomyces cerevisiae gal80 mutant grown in a medium containing ethanol as the sole carbon source. In the cultivation of the gal80 mutant KS58-2D/pCY303 carrying a multicopy plasmid, which contains the PRC1 gene fused to the GAL10 promoter, CPY production continued after the consumption of galactose. In this phase, the cells utilized ethanol as the carbon source. To increase the CPY production level, we examined the effect of carbon source feeding in a fed-batch culture. The production level in the fed-batch culture using ethanol was 1.3-fold higher than that in a batch culture and 1.6-fold higher than that in a fed-batch culture using galactose. By 5'-deletion analysis of the GAL10 promoter, the region between -256 and -232 was found to be important for the promoter activity in the gal80 mutant growing in the presence of ethanol.

[Developmental changes of awareness during passive and active attentions: evaluation of serial event-related potentials (N130, N180, P250)].

Serial event-related potentials (ERPs), especially the negative components before P300, were recorded to evaluate the developmental changes of awareness, or intentional attention. In this study, 36 healthy children (5-16 years of age) and eight healthy adults (19-37 years) were told to perform two attentive paradigms: passive and active. Each test condition consisted of 16 electrical stimuli. Four trials were averaged in sequence and then evaluated as serial four blocks. With repetition in both passive and active attentive paradigms the amplitude of N130 was not attenuated until six years old. During active attention, N180 remained undiminished in adolescents and adults. The amplitude of P250 decreased with repetition during passive attention in children over seven years old, but was not attenuated during active attention in adults. These results suggest that N130 reflects the orienting reflex, and that N180 is associated with the process to maintain awareness.