Internal iliac artery ligation as a damage control method in hemodynamically unstable pelvic fractures: A systematic review of the literature.

PURPOSE: Internal iliac artery ligation (IIAL) has been used as a damage control procedure to treat hemodynamically unstable pelvic fracture for many years. However, there is ongoing debate regarding the effectiveness and safety of this hemostatic method. Therefore, we performed a systematic literature review to assess the efficacy and safety of IIAL for pelvic fracture hemostasis. METHODS: Three major databases, PubMed, Embase, and Google Scholar, were searched to screen eligible original studies published in English journals. Two reviewers independently read the titles, abstracts, and full texts of all literature. Articles were included if they reported the use and effects of IIAL. RESULTS: A total of 171 articles were initially identified, with 22 fully meeting the inclusion criteria. Among the analyzed cases, up to 66.7% of patients had associated abdominal and pelvic organ injuries, with the urethra being the most frequently injured organ, followed by the bowel. The outcomes of IIAL for achieving hemostasis in pelvic fractures were found to be satisfactory, with an effective rate of 80%. Hemorrhagic shock was the leading cause of death, followed by craniocerebral injury. Notably, no reports of ischemic complications involving the pelvic organs due to IIAL were found. CONCLUSION: IIAL has a good effect in treating hemodynamically unstable pelvic fracture without the risk of pelvic organ ischemia. This procedure should be considered a priority for hemodynamically unstable pelvic fracture patients with abdominal organ injuries.

A randomized controlled trial investigating the impact of a single flash cupping session on patients with chronic lower back pain using multichannel surface electromyographic assessment.

BACKGROUND: Chronic lower back pain (CLBP) is one of the most common disorders worldwide. Flash cupping has the ability to relieve CLBP; nevertheless, its impact on CLBP and the likely mechanism of action have not been studied. OBJECTIVE: The goal of this study was to assess the impact of a single, brief cupping session on CLBP and low back muscle activity using multichannel surface electromyography (sEMG). METHODS: In this randomized controlled trial, 24 patients with CLBP were enrolled and randomly assigned to the control group (treated by acupuncture) and cupping group (treated by acupuncture and flash cupping). Acupuncture was applied on the shen shu (BL23), dachang shu (BL25), and wei zhong (BL40) acupoints in both the groups. A brief cupping treatment was applied to the shen shu (BL23), qihai shu (BL24), dachang shu (BL25), guanyuan shu (BL26), and xiaochang shu (BL27) acupoints on both sides of the lower back in the cupping group. The numeric rating scale (NRS) was used to assess therapy efficacy for lower back pain (LBP) before and after treatment. Surface EMG data collected during symmetrical trunk flexion-extension movements were utilized to measure lower back muscle activity and the effectiveness of LBP therapy. RESULTS: There was no statistically significant difference (P= 0.63) in pain intensity between the two groups before and after treatment. There was a statistically significant difference (P= 0.04) between the control group and the cupping group in the sEMG topographic map parameter CoGx-To-Midline. CONCLUSION: This study established a connection between the action mechanism of flash cupping and enhanced horizontal synchronization of lower back muscular activity.

Cross-species investigation into the requirement of XPA for nucleotide excision repair.

After reconstitution of nucleotide excision repair (excision repair) with XPA, RPA, XPC, TFIIH, XPF-ERCC1 and XPG, it was concluded that these six factors are the minimal essential components of the excision repair machinery. All six factors are highly conserved across diverse organisms spanning yeast to humans, yet no identifiable homolog of the XPA gene exists in many eukaryotes including green plants. Nevertheless, excision repair is reported to be robust in the XPA-lacking organism, Arabidopsis thaliana, which raises a fundamental question of whether excision repair could occur without XPA in other organisms. Here, we performed a phylogenetic analysis of XPA across all species with annotated genomes and then quantitatively measured excision repair in the absence of XPA using the sensitive whole-genome qXR-Seq method in human cell lines and two model organisms, Caenorhabditis elegans and Drosophila melanogaster. We find that although the absence of XPA results in inefficient excision repair and UV-sensitivity in humans, flies, and worms, excision repair of UV-induced DNA damage is detectable over background. These studies have yielded a significant discovery regarding the evolution of XPA protein and its mechanistic role in nucleotide excision repair.

Synthesis and biological evaluation of novel quaternary ammonium antibody drug conjugates based on camptothecin derivatives.

Antibody drug conjugates (ADCs) have emerged as a highly promising class of cancer therapeutics, comprising antibodies, effector molecules, and linkers. Among them, DS-8201a with DXd as the effector molecule, has shown remarkable anti-tumor efficacy against solid tumors, sparking a surge of interest in ADCs with camptothecin derivatives as ADC effector molecules. In this study, we introduced and successfully constructed quaternary ammonium ADCs utilizing camptothecin derivatives WL-14 and CPTS-1 for the first time. All four ADCs displayed excellent stability under physiological conditions and in plasma, facilitating their prolonged circulation in vivo. Moreover, the four ADCs, employing Val-Cit or Val-Ala dipeptide linkers effectively achieved complete release of the effector molecules via cathepsin B. Although, the in vitro antitumor activity of these ADCs was comparatively limited, the development of quaternary ammonium ADCs based on novel camptothecin derivatives as effector molecules is still a viable and promising strategy. Significantly, our study provides valuable insights into the crucial role of linker optimization in ADCs design.

In vitro DNA repair genomics using XR-seq with Escherichia coli and mammalian cell-free extracts.

The XR-seq (eXcision Repair-sequencing) method has been extensively used to map nucleotide excision repair genome-wide in organisms ranging from Escherichia coli to yeast, Drosophila, Arabidopsis, mice, and humans. The basic feature of the method is to capture the excised oligomers carrying DNA damage, sequence them, and align their sequences to the genome. We wished to perform XR-seq in vitro with cell-free extract supplemented with a damaged DNA substrate so as to have greater flexibility in investigating factors that affect nucleotide excision repair in the cellular context [M. J. Smerdon, J. J. Wyrick, S. Delaney, J. Biol. Chem. 299, 105118 (2023)]. We report here the successful use of ultraviolet light-irradiated plasmids as substrates for repair in vitro and in vivo by E. coli and E. coli cell-free extracts and by mammalian cell-free extract. XR-seq analyses demonstrated common excision product length and sequence characteristics in vitro and in vivo for both the bacterial and mammalian systems. This approach is expected to help understand the effects of epigenetics and other cellular factors and conditions on DNA repair.

Increasing positive rate of IgG against hepatitis E virus with steady IgM positivity and clinical incidence: A retrospective seroprevalence time series analysis of HEV from 2012 to 2021 in Chongqing, China.

China is an epidemic area of hepatitis E, and the serum prevalence data is very important for formulating prevention and control strategies. However, almost all related research in the past decade are cross-sectional studies. In this study, we analyzed the serological data from 2012 to 2021 in Chongqing for 10 consecutive years. We found that the positive rate of hepatitis E IgG antibody increased gradually, from 1.61% in January 2012 to 50.63% in December 2021. The autoregressive integrated moving average model was used to predict the trend, and it was found that it will continue to show an upward trend in the recent future. In contrast, the positive rate of IgM and clinical incidence of hepatitis E showed a relatively stable trend. Although the positive rate of antibodies gradually increased with age, there was no significant difference in the age distribution of the subjects each year. Therefore, these results suggest that the accumulated infection of hepatitis E in Chongqing may be gradually increasing, but the clinical incidence rate remains unchanged, which provides a new concern for formulating prevention and control strategies.

Acalculous cholecystitis is a common extrahepatic manifestation of hepatitis E and suggests a more serious condition.

BACKGROUND: This study aimed to understand the incidence and clinical significance of acalculous cholecystitis in patients with acute hepatitis E (HE). PATIENTS AND METHODS: A single center enrolled 114 patients with acute HE. All patients underwent imaging of the gallbladder, and patients with gallstones and cholecystectomy were excluded. RESULTS: Acalculous cholecystitis was found in 66 patients (57.89%) with acute HE. The incidence in males was 63.95%, which was significantly higher than in females (39.29%) (P = 0.022). The mean length of hospital stay and the incidence of spontaneous peritonitis in patients with cholecystitis (20.12 ± 9.43 days and 9.09%, respectively) were significantly higher than those in patients without cholecystitis (12.98 ± 7.26 days and 0%, respectively) (P < 0.001 and P = 0.032). Albumin, total bile acid, bilirubin, cholinesterase, and prothrombin activity in patients with cholecystitis were significantly inferior to those in patients without cholecystitis (P < 0.001, P < 0.001, P < 0.001, P < 0.001 and P = 0.003, respectively). After correction by multivariate analysis, albumin and total bile acid were found to be closely related to acalculous cholecystitis in HE. CONCLUSION: Acalculous cholecystitis is very common in patients with acute HE, and may serve as a predictor of increased peritonitis, synthetic decompensation, and longer hospital stay.

Analysis of mammalian circadian clock protein complexes over a circadian cycle.

Circadian rhythmicity is maintained by a set of core clock proteins including the transcriptional activators CLOCK and BMAL1, and the repressors PER (PER1, PER2, and PER3), CRY (CRY1 and CRY2), and CK1δ. In mice, peak expression of the repressors in the early morning reduces CLOCK- and BMAL1-mediated transcription/translation of the repressors themselves. By late afternoon the repressors are largely depleted by degradation, and thereby their expression is reactivated in a cycle repeated every 24 h. Studies have characterized a variety of possible protein interactions and complexes associated with the function of this transcription-translation feedback loop. Our prior investigation suggested there were two circadian complexes responsible for rhythmicity, one containing CLOCK-BMAL and the other containing PER2, CRY1, and CK1δ. In this investigation, we acquired data from glycerol gradient centrifugation and gel filtration chromatography of mouse liver extracts obtained at different circadian times to further characterize circadian complexes. In addition, anti-PER2 and anti-CRY1 immunoprecipitates obtained from the same extracts were analyzed by liquid chromatography-tandem mass spectrometry to identify components of circadian complexes. Our results confirm the presence of discrete CLOCK-BMAL1 and PER-CRY-CK1δ complexes at the different circadian time points, provide masses of 255 and 707 kDa, respectively, for these complexes, and indicate that these complexes are composed principally of the core circadian proteins.

Systematic Evaluation of the Efficacy of Acupuncture Associated with Physical and Mental Intervention when Treating Idiopathic Tinnitus and the Improvement of Tinnitus Symptoms.

Objective: To systematically evaluate the efficacy of acupuncture associated with physical and mental intervention when treating idiopathic tinnitus and the improvement of tinnitus symptoms, so as to supply evidence-based medicine for its popularization and adoption. Methods: PubMed, EMBASE, ScienceDirect, Cochrane Library, China knowledge Network Database (CNKI), China VIP Database, Wanfang Database, and China Biomedical Literature Database (CBM) online database were searched for the controlled trial of acupuncture associated with physical and mental intervention when treating idiopathic tinnitus. The retrieval time limit is from January 2010 to March 2022. Separately, two researchers extracted the data, and according to the Cochrane Handbook 5.3, the bias risk of each piece of literature was assessed. The collected data were measured using RevMan5.3 statistical software. Results: Finally, 5 CT articles were included in this study, with a total sample size of 282. Meta-analysis showed that the effective rate of the study group was significantly higher than that of the control group (P < 0.05). The scores of tinnitus disorder scale (THI) after treatment were analyzed by Meta. The THI scores of the study group after treatment were significantly lower than those before treatment. Meta-analysis of the severity of tinnitus after treatment showed that the severity of tinnitus in the observation group after treatment was significantly lower than that before treatment. There is a certain publication deviation in the literature, which may be related to the heterogeneity of the research and the small number of literatures. Conclusion: On the basis of acupuncture treatment, associated with physical and mental intervention is helpful to the recovery of patients with idiopathic tinnitus, can effectively improve their clinical symptoms, and is suitable for clinical application. A popularization of this concept in clinical practice is worth considering, but further research and follow-up with a higher methodological quality and longer intervention time are needed to confirm its efficacy.

Nucleotide excision repair removes thymidine analog 5-ethynyl-2'-deoxyuridine from the mammalian genome.

Nucleotide excision repair is the principal mechanism for removing bulky DNA adducts from the mammalian genome, including those induced by environmental carcinogens such as UV radiation, and anticancer drugs such as cisplatin. Surprisingly, we found that the widely used thymidine analog EdU is a substrate for excision repair when incorporated into the DNA of replicating cells. A number of thymidine analogs were tested, and only EdU was a substrate for excision repair. EdU excision was absent in repair-deficient cells, and in vitro, DNA duplexes bearing EdU were also substrates for excision by mammalian cell-free extracts. We used the excision repair sequencing (XR-seq) method to map EdU repair in the human genome at single-nucleotide resolution and observed that EdU was excised throughout the genome and was subject to transcription-coupled repair as evidenced by higher repair rates in the transcribed strand (TS) relative to the nontranscribed strand (NTS) in transcriptionally active genes. These properties of EdU, combined with its cellular toxicity and ability to cross the blood-brain barrier, make it a potential candidate for treating cancers of the brain, a tissue that typically demonstrates limited replication in adults.

CSB-independent, XPC-dependent transcription-coupled repair in Drosophila.

Drosophila melanogaster has been extensively used as a model system to study ionizing radiation and chemical-induced mutagenesis, double-strand break repair, and recombination. However, there are only limited studies on nucleotide excision repair in this important model organism. An early study reported that Drosophila lacks the transcription-coupled repair (TCR) form of nucleotide excision repair. This conclusion was seemingly supported by the Drosophila genome sequencing project, which revealed that Drosophila lacks a homolog to CSB, which is known to be required for TCR in mammals and yeasts. However, by using excision repair sequencing (XR-seq) genome-wide repair mapping technology, we recently found that the Drosophila S2 cell line performs TCR comparable to human cells. Here, we have extended this work to Drosophila at all its developmental stages. We find TCR takes place throughout the life cycle of the organism. Moreover, we find that in contrast to humans and other multicellular organisms previously studied, the XPC repair factor is required for both global and transcription-coupled repair in Drosophila.

Quantification of Ceramsite Granules in Lightweight Concrete Panels through an Image Analysis Technique.

Ceramsite particles are an important component of lightweight ceramsite concrete wall panels, and the density of the aggregate is much lower than the density of the slurry. It is generally accepted that there are inhomogeneities in the distribution of ceramsite particles in wall panels. Ceramsite concrete wallboard material is a research hotspot in the field of fabricated building materials at home and abroad; however, there is no effective way to quantify their inhomogeneity. Based on the application of image recognition technology in concrete homogeneity, a method to quantitatively evaluate the distribution of light aggregates in wall panels was developed. Three commercial lightweight vitrified concrete wall panels were cut into 324 cubes. The four cut surfaces of each specimen were photographed to analyze the proportion of ceramsite particle area, while the density, ultrasonic pulse velocity, and compressive strength of the specimens were tested. The results demonstrated that the image analysis method could effectively describe the homogeneity of the panels. The proportion of particle area of aggregate in the section of the cube had a strong correlation with the compressive strength, ultrasonic pulse velocity, and density, and there was an obvious linear relationship with the height of the plate where the cube was located. Based on this, the correlation equations of the proportion of particle area of aggregate, density, ultrasonic pulse velocity, compressive strength, and the height where the specimen was located were proposed. The quantitative parameters of the relevant properties of the wall panels were also obtained: the maximum difference between the proportion of particle area of the aggregate was 24%, the maximum difference between the density at the top and bottom of the wall panels was 115 kg/m3, and the maximum difference in the strength reached 5 MPa.

The Durability of Recycled Fine Aggregate Concrete: A Review.

With the rapid development of urbanization, many new buildings are erected, and old ones are demolished and/or recycled. Thus, the reuse of building materials and improvements in reuse efficiency have become hot research topics. In recent years, scholars around the world have worked on improving recycle aggregates in concrete and broadening the scope of applications of recycled concrete. This paper reviews the findings of research on the effects of recycled fine aggregates (RFAs) on the permeability, drying shrinkage, carbonation, chloride ion penetration, acid resistance, and freeze-thaw resistance of concrete. The results show that the content of old mortar and the quality of recycled concrete are closely related to the durability of prepared RFA concrete. For example, the drying shrinkage value with a 100% RFA replacement rate is twice that of normal concrete, and the depth of carbonation increases by approximately 110%. Moreover, the durability of RFA concrete decreases as the RFA replacement rate and the water-cement ratio improve. Fortunately, the use of zeolite materials such as fly ash, silica fume, and meta kaolin as surface coatings for RFAs or as external admixtures for RFA concrete had a positive effect on durability. Furthermore, the proper mixing methods and/or recycled aggregates with optimized moisture content can further improve the durability of RFA concrete.

High myosin binding protein H expression predicts poor prognosis in glioma patients.

Glioma is the most common and fatal primary brain tumor in humans. Myosin binding protein H (MYBPH), which was first identified as an important myofibrillar constituent of vertebrate skeletal and cardiac muscles, reduces cell motility and metastasis. However, its role in gliomas remains unclear. We evaluated the expression of MYBPH in glioma using Gene Expression Profiling Interactive Analysis ( http://gepia.cancer-pku.cn/ ) and Chinese Glioma Genome Atlas ( https://www.cgga.org.cn/ ). The results showed that MYBPH was highly expressed in glioma tissues. Moreover, MYBPH expression was significantly associated with high tumor aggressiveness and poor outcomes in glioma patients. Mechanistically, the results suggested that MYBPH might promote tumor progression by improving tumor invasion and migration. Our results establish MYBPH as an important prognostic biomarker that could be considered a potential epigenetic and immunotherapeutic target for treatment. We showed that MYBPH is a novel biomarker that is variably expressed in glioblastoma (GBM). The association of high MYBPH expression with poor prognosis in newly diagnosed GBM patients and increased expression in recurrent GBM is indicative of its role in tumor aggressiveness.

Seeking transnational social protection during a global pandemic: The case of Chinese immigrants in the United States.

Drawing on in-depth interviews with Chinese immigrants in the U.S. during the COVID-19 pandemic, this article examines the construction of immigrants' transnational social safety net and its gaps as the pandemic struck their home and host societies successively. Building upon the scholarship on transnational migration and transnational social protection, we argue that understanding how immigrants manage moments of crisis requires a cross-border optic. As we show, transnational connections can be translated into valuable material and immaterial resources. However, such protections are contingent upon the reception of their local receiving communities. The perceived hierarchy between the sending and receiving society, coupled with the U.S.' lack of experience with infectious disease outbreaks, limits the extent to which immigrants could put their transnational knowledge and resources to use. Our analyses shed new light upon the circumstances that empower and constrain immigrants as the global pandemic unsettles their daily routines.

Circadian clock, carcinogenesis, chronochemotherapy connections.

The circadian clock controls the expression of nearly 50% of protein coding genes in mice and most likely in humans as well. Therefore, disruption of the circadian clock is presumed to have serious pathological effects including cancer. However, epidemiological studies on individuals with circadian disruption because of night shift or rotating shift work have produced contradictory data not conducive to scientific consensus as to whether circadian disruption increases the incidence of breast, ovarian, prostate, or colorectal cancers. Similarly, genetically engineered mice with clock disruption do not exhibit spontaneous or radiation-induced cancers at higher incidence than wild-type controls. Because many cellular functions including the cell cycle and cell division are, at least in part, controlled by the molecular clock components (CLOCK, BMAL1, CRYs, PERs), it has also been expected that appropriate timing of chemotherapy may increase the efficacy of chemotherapeutic drugs and ameliorate their side effect. However, empirical attempts at chronochemotherapy have not produced beneficial outcomes. Using mice without and with human tumor xenografts, sites of DNA damage and repair following treatment with the anticancer drug cisplatin have been mapped genome-wide at single nucleotide resolution and as a function of circadian time. The data indicate that mechanism-based studies such as these may provide information necessary for devising rational chronochemotherapy regimens.

Electroacupuncture and Transcutaneous Electrical Nerve Stimulation Induced Sensations in Bell's Palsy Patients: A Quantitative Current Intensity Analysis.

BACKGROUND: The intensity of electrical acupoint stimulation such as electroacupuncture (EA) and transcutaneous electrical nerve stimulation (TENS) is regulated by the observation of skin shivering or the participant's comfort response. However, the specific intensity and spatial scope following EA or TENS stimulation are unclear. OBJECTIVE: This study aimed to test the stimulatory current intensities of lower and upper sensation thresholds in TENS- and EA-based treatment of Bell's palsy patients. Also, the spatial scope of the stimulation at these current intensities was simulated and measured quantitatively. METHODS: A total of 19 Bell's palsy patients were recruited. Six acupoints on the affected side of the face were stimulated by TENS and EA successively at 30-min intervals. During the stimulation, the current intensity was regulated gradually from 0 to 20 mA, and we simultaneously measured the lower (sensory) and upper (tolerability) sensations. After the treatment by TENS and EA, the modified Chinese version of the Massachusetts General Hospital Acupuncture Sensation Scales (C-MMASS) was applied to survey the de-qi sensations during stimulation. Additionally, we analyzed the correlation between current intensities and C-MMASS and comfort scores. Finite element models were established to depict the spatial distribution of electric field gradients at the lower and upper thresholds. RESULTS: The mean sensory and tolerability thresholds of TENS were 3.91-4.37 mA and 12.33-16.35 mA, respectively. The median sensory and tolerability thresholds of EA were 0.2 mA and 2.0-3.2 mA, respectively. We found a significant correlation between total C-MMASS scores and the current intensities at the tolerability threshold of TENS. The finite element model showed that the activated depths of TENS and EA at the lower threshold were 3.8 and 7 mm, respectively, whereas those at the upper threshold were both 13.8 mm. The cross-sectional diameter of the activated area during TENS was 2.5-4 times larger than that during EA. CONCLUSION: This pilot study provided a method for exploring the current intensity at which the de-qi sensations can be elicited by TENS or EA. The finite element analysis potentially revealed the spatial scope of the electrical stimulation at a specific current intensity.

Ectopic Overexpression of PPARγ2 in the Heart Determines Differences in Hypertrophic Cardiomyopathy After Treatment With Different Thiazolidinediones in a Mouse Model of Diabetes.

The clinical controversy of rosiglitazone as a hypoglycemic agent is potentially associated with heart failure, mainly due to its potent activation of peroxisome proliferator-activated receptor γ (PPARγ). PPARγ partial agonists showed superior pharmacological profiles to rosiglitazone. This study compared differences in cardiac morphology and function of the PPARγ partial agonist CMHX008 with rosiglitazone. High-fat diet (HFD) induced obese mice, ob/ob mice and cardiomyocytes overexpressing PPARγ2 were treated with CMHX008 or rosiglitazone. Heart function, myocardial morphology, and hypertrophy-related gene expression were examined. Clinical information from patients with type 2 diabetes mellitus (T2DM) who had taken rosiglitazone and undergone Doppler echocardiography was collected. HFD and ob/ob mice significantly developed cardiac contractile dysfunction, with upregulated PPARγ2 protein levels in heart tissues. Cardiomyocytes of HFD and ob/ob mice were disorderly arranged, the cell areas expanded, and collagen accumulated. In vitro cardiomyocytes overexpressing PPARγ2 displayed obvious structural abnormalities and high mRNA levels of ANP and BNP, critical cardiac hypertrophy-related genes. HFD-fed mice treated with rosiglitazone or CMHX008 had significantly improved cardiac function, but rosiglitazone induced higher expression of ANP and ßMHC and hypertrophic cardiomyopathy, while CMHX008 did not. Patients with T2DM taking rosiglitazone exhibited increased thickness of the posterior wall and the ventricular septum, suggesting cardiac hypertrophy. Our findings show that diabetic cardiomyopathy was associated with ectopic overexpression of PPARγ2. The full agonist rosiglitazone prevents cardiac dysfunction at the expense of compensatory hypertrophy, while the partial agonist CMHX008 shared a comparable protective effect without altering the structure of cardiomyocytes.

Molecular mechanism of the repressive phase of the mammalian circadian clock.

The mammalian circadian clock consists of a transcription-translation feedback loop (TTFL) composed of CLOCK-BMAL1 transcriptional activators and CRY-PER transcriptional repressors. Previous work showed that CRY inhibits CLOCK-BMAL1-activated transcription by a "blocking"-type mechanism and that CRY-PER inhibits CLOCK-BMAL1 by a "displacement"-type mechanism. While the mechanism of CRY-mediated repression was explained by both in vitro and in vivo experiments, the CRY-PER-mediated repression in vivo seemed in conflict with the in vitro data demonstrating PER removes CRY from the CLOCK-BMAL1-E-box complex. Here, we show that CRY-PER participates in the displacement-type repression by recruiting CK1δ to the nucleus and mediating an increased local concentration of CK1δ at CLOCK-BMAL1-bound promoters/enhancers and thus promoting the phosphorylation of CLOCK and dissociation of CLOCK-BMAL1 along with CRY from the E-box. Our findings bring clarity to the role of PER in the dynamic nature of the repressive phase of the TTFL.