Evaluation of gastroprotectant administration in hospitalized cats in a tertiary referral hospital.

OBJECTIVES: The primary objective of this study was to evaluate the prescription patterns and appropriateness of the use of gastroprotectant medication in cats. METHODS: Pharmacy dispensation logs from an academic tertiary referral center were reviewed between 1 January 2018 and 31 December 2018. Cats that were administered proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, misoprostol, antacids or a combination were included. Data regarding medication, dosage, formulation, duration of administration, completeness of discharge instructions and clinical rationales for administration were obtained from medical records. The appropriateness of gastroprotectant use was assessed according to the American College of Veterinary Internal Medicine consensus statement guidelines. RESULTS: Of the 110 cases, 67 (60.9%) were prescribed a gastroprotectant medication without an appropriate indication. The most common reason for prescription was acute kidney injury in 26/67 (38.8%). PPIs were the most common gastroprotectant medication administered in 95/110 (86.3%) cats, followed by sucralfate in 18/110 (16.4%) and H2RAs in 11/110 (10%). Of the 35 cases in which gastroprotectant therapy was indicated, the medication chosen or dosage administered was considered suboptimal in 16 (45.7%). Instructions regarding the duration of administration, potential adverse effects and timing of administration in relation to meals or other medications were inconsistently provided in discharge instructions to pet owners. Of the 29 cases discharged with omeprazole, only 13 (44.8%) instructions included a duration of administration, while 6 (20.7%) recommended continuing gastroprotectants indefinitely until further notice, 16 (55.2%) discussed the timing of the administration in relation to a meal and six (20.7%) mentioned potential adverse effects; none advised tapering of omeprazole before discontinuation. CONCLUSIONS AND RELEVANCE: When prescribed, gastroprotectant medications were frequently prescribed injudiciously to cats in this referral population over a 12-month period. Discharge instructions to pet owners also often lacked information and recommendations regarding optimal administration, potential adverse effects, and tapering or discontinuation of the medications.

Prevalence and gender disparities of type 2 diabetes mellitus and obesity in Esmeraldas, Ecuador: a population-based survey in a hard-to-reach setting.

BACKGROUND: Type 2 Diabetes (T2DM) prevalence is increasing in low- and middle-income countries along with high levels of obesity which vary according to socioeconomic and contextual characteristics. We aim to estimate the prevalence of T2DM and obesity in men and women in a hard-to-reach rural area in northern Ecuador considering socio-demographic characteristics. METHODS: Cross-sectional descriptive study based on a population-based survey in the Eloy Alfaro health district of Esmeraldas between October 2020 and January 2022. We collected sociodemographic information and risk factors for non-communicable diseases with an adapted version of the STEPS survey, performed oral glucose tolerance tests, biochemistry and took physical measurements. We estimated the prevalence of T2DM, obesity, and calculated Odds Ratios (OR) with confidence intervals by logistic regression in Stata v.15. RESULTS: The overall prevalence of T2DM was 6.8% (CI95%: 4.9-8.7), markedly higher among women compared to men (10.4%, CI95% 7.3-13.4%, compared 2.0%, CI95% 0.4-3.7% respectively). The risk of having T2DM in women was 5 times higher than in men adjusting for age, ethnicity, employment, household earnings and obesity (OR: 5.03; 95%CI: 1.68-15.01). Regarding age, the risk of T2DM increased by 6% per year (adjusted OR: 1.06; 95%CI: 1.03-1.08). Obesity prevalence was 30.8% (CI95%: 27.3-34.3), in women was nearly three times higher than in men (43.2% CI95%: 38.2-48.2, compared to 14.7% prevalence, CI95%: 10.6-18.8). Indigenous women had a lower prevalence of obesity compared with the Afro-Ecuadorian women (OR: 0.05; 95%CI: 0.02-0.18) after adjusting for age, employment status, household earnings and setting. CONCLUSION: We found alarming differences between the prevalence of T2DM and obesity in women and men that may be explained by gender roles, exacerbated in the rural context. Health promotion measures with a gender perspective should be adapted according to the characteristics of isolated rural contexts.

Comparison of capillary blood and plasma samples for the evaluation of seroprevalence to SARS-CoV-2 antibodies by lateral flow immunoassay in a university population in Medellín, Colombia, 2020.

Objectives: The aim of this study was to estimate the seroprevalence of anti-SARS-CoV-2 antibodies using the SARS-CoV-2 antibody test in a university population. Capillary blood and plasma samples were compared and correlated with symptomatology to establish rapid treatment processes and develop a public health strategy within the community. Study design: Descriptive study of seroprevalence of anti-SARS-CoV-2 antibodies in a university population. Methods: Standardised and validated laboratory serological tests were used to assess the immune response detected in capillary blood and plasma samples. In this study, 280 participants from the University Colegio Mayor de Antioquia in the Municipality of Medellín, Colombia, were tested for SARS-CoV-2 antibodies in capillary blood and plasma samples between November 2020 and January 2021. Results: In total, 29 (11.2%) individuals had positive results for anti-SARS-CoV-2 antibodies (IgG/IgM); 28 (96.6%) had positive results in plasma samples and 11 (37.9%) in capillary blood samples. The two tests were compared, and the overall sensitivity and specificity of capillary vs plasma samples was 36.7% and 99.6%, respectively. Conclusions: Anti-SARS-CoV-2 antibodies (IgG/IgM) can be used to estimate the seroprevalence in populations, including immunity by vaccination; however, capillary blood samples should not be used to detect previous infection as they provide low sensitivity compared to plasma samples.

[68Ga]Ga-iPSMA-Lys3-Bombesin: Biokinetics, dosimetry and first patient PET/CT imaging.

BACKGROUND: The prostate-specific membrane antigen (PSMA) and the gastrin-releasing peptide receptor (GRPR) are overexpressed in prostate cancer (PCa). In preclinical studies, the iPSMA-Lys3-Bombesin (iPSMA-BN) heterodimeric ligand has shown a suitable affinity for PSMA and GRPR. This research aimed to assess the biokinetics and radiation dosimetry of [68Ga]Ga-iPSMA-BN in four healthy volunteers based on biodistribution data obtained from whole-body PET/CT studies, as well as to visualize the [68Ga]Ga-iPSMA-BN tumor uptake in a patient with PCa. METHODS: PET/CT images acquired at 5 min, 0.5, 1, and 2 h after radiotracer administration (124.5 ± 2.1 MBq) were corrected for attenuation, scattering, dead-time, and decay. The activity in the segmented volumes of interest (VOIs) in each source organ at different times was adjusted to mono- and bi-exponential biokinetic models (A(t)VOI), from which the total disintegrations (N) were calculated to assess the internal radiation doses by using the OLINDA V1.1 code. RESULTS: Images from the patient showed an evident uptake by the metastasis (SUVmax of 4.7) and by the organs expressing GRPR (pancreas) and PSMA (salivary glands). The average effective dose was 2.70 ± 0.05 mSv, which was like those known for most of the 68Ga studies, making [68Ga]Ga-iPSMA-BN a promising dual-target PET imaging radiotracer for PCa. CONCLUSIONS: [68Ga]Ga-iPSMA-BN, capable of detecting both PSMA and GRPR with suitable biokinetics and dosimetric patterns, could be a potential complementary diagnostic tool for the improvement of prostate cancer PET imaging.

Contextualizing Evidence for Action on Diabetes in Low-Resource Settings-Project CEAD Part-II, Strengthening the Health System: A Mixed-Methods Study Protocol.

Diabetes is a major public health problem, increasingly affecting low- and middle-income countries. The project CEAD (Contextualizing Evidence for Action in Diabetes in low-resource settings) aims to evaluate the implementation of comprehensive diabetes care in two low-resource settings in Ecuador and to stimulate context-led health systems innovations to improve diabetes care and reduce inequity. The mixed-methods approach includes a 24-month retrospective study to assess the current level of implementation of comprehensive diabetes care and participants will be followed up prospectively for two years to assess changes in healthcare and clinical outcomes from the outset of the research. We will include individuals diagnosed with type-2 diabetes aged over 18 years, who are accessing diabetes care in health facilities in the study districts. Varied stakeholders (patients and family members, community members, healthcare workers and decision-makers) will interpret the underlying causes of the observed weaknesses and propose solutions to strengthen diabetes-related healthcare in focus group discussions (FG). A second set of FG will analyze perceived improvements in healthcare based on prospective cohort findings and consider the success/failure of any context-led innovations occurring throughout the research. Our study will demonstrate how evidence can be contextualized to stimulate local innovations and overcome weaknesses of diabetes-related healthcare in low resource settings.

In vitro cytotoxic and genotoxic effect of the crude and ethanolic extract from the rhizome of Curcuma longa L. / Efecto citotóxico y genotóxico in vitro del extracto crudo y etanólico del rizoma de Curcuma longa L.

OBJECTIVES: To determine the in vitro cytotoxic and genotoxic effect of the crude and ethanolic extract from the Curcuma longa L. rhizome. MATERIALS AND METHODS: The cytotoxic effect was evaluated using DU-145, HT-29, 3T3 BALB/c cell lines. The growth percentages in 48 hours; and the half maximal inhibitory concentration (IC50) were determined. The genotoxic effect on human genomic DNA was determined using the Tomasevich method. RESULTS: Crude extract produced an IC50 of 12.98 ± 0.21 µg/mL for the HT-29 tumor cell line, which is lower than the value obtained for DU-145, with an IC50 of 36.77 ± 9.12 µg/mL. The ethanolic extract presented an IC50 of 13.24 ± 0.77 and 20.54 ± 2.58 µg/mL for both cell lines, respectively; the curcumin standard compound presented an IC50 of 3.96 ± 0.60 and 13.94 ± 2.79 µg/mL, respectively. Crude extract concentrations of 50 and 100 mg/mL fragmented between 40% to 95% of human genomic DNA; while at 200 mg/mL, fragmentation was greater than 95%. The ethanolic extract at all concentrations did not fragment the DNA. Curcumin at 200 mg/mL fragmented less than 5% of human genomic DNA. CONCLUSIONS: The crude and ethanolic extracts of Curcuma longa L. demonstrate different in vitro cytotoxic effects for the human tumor cell lines DU-145 and HT-29; similar to the standard curcumin compound. The crude extract of Curcuma longa L. shows a potent genotoxic in vitro activity against human genomic DNA; this type of effect is not produced by the ethanolic extract.

OBJETIVOS: Determinar el efecto citotóxico y genotóxico in vitro del extracto crudo y etanólico del rizoma de Curcuma longa L. MATERIALES Y MÉTODOS: El efecto citotóxico fue evaluado utilizando líneas celulares DU-145, HT-29, 3T3 BALB/c. Se hallaron los porcentajes de crecimiento en 48 horas y se determinó la concentración inhibitoria 50 (CI50). El efecto genotóxico en el ADN genómico humano se determinó mediante el método Tomasevich. RESULTADOS: El extracto crudo produjo una CI50 de 12,98 ± 0,21 µg/mL para la línea celular tumoral HT-29, que es inferior a DU-145 con una CI50 de 36,77 ± 9,12 µg/mL; el extracto etanólico presentó una CI50 de 13,24 ± 0,77 y 20,54 ± 2,58 µg/mL para ambas líneas celulares, respectivamente; el compuesto estándar curcumina presentó una CI50 de 3,96 ± 0,60 y 13,94 ± 2,79 µg/mL, respectivamente. El extracto crudo a concentraciones de 50 y 100 mg/mL fragmentó entre el 40% a 95% de ADN genómico humano; mientras que, a 200 mg/mL, la fragmentación fue mayor al 95%. El extracto etanólico a todas las concentraciones no fragmentó el ADN. La curcumina a 200 mg/mL fragmentó menos del 5% de ADN genómico humano. CONCLUSIONES: Los extractos crudo y etanólico de Curcuma longa L. demuestran efecto citotóxico in vitro diferencial para la línea celular tumoral humana DU-145 y HT29 semejante al compuesto estándar curcumina. El extracto crudo de Curcuma longa L. presenta una potente actividad genotóxica in vitro frente al ADN genómico humano, esta actividad está ausente en el extracto etanólico.

Efecto citotóxico y genotóxico in vitro del extracto crudo y etanólico del rizoma de Curcuma longa L / In vitro cytotoxic and genotoxic effect of the crude and ethanolic extract from the rhizome of Curcuma longa L

RESUMEN Objetivos: Determinar el efecto citotóxico y genotóxico in vitro del extracto crudo y etanólico del rizoma de Curcuma longa L. Materiales y métodos: El efecto citotóxico fue evaluado utilizando líneas celulares DU-145, HT-29, 3T3 BALB/c. Se hallaron los porcentajes de crecimiento en 48 horas y se determinó la concentración inhibitoria 50 (CI50). El efecto genotóxico en el ADN genómico humano se determinó mediante el método Tomasevich. Resultados: El extracto crudo produjo una CI50 de 12,98 ± 0,21 μg/mL para la línea celular tumoral HT-29, que es inferior a DU-145 con una CI50 de 36,77 ± 9,12 μg/mL; el extracto etanólico presentó una CI50 de 13,24 ± 0,77 y 20,54 ± 2,58 µg/mL para ambas líneas celulares, respectivamente; el compuesto estándar curcumina presentó una CI50 de 3,96 ± 0,60 y 13,94 ± 2,79 μg/mL, respectivamente. El extracto crudo a concentraciones de 50 y 100 mg/mL fragmentó entre el 40% a 95% de ADN genómico humano; mientras que, a 200 mg/mL, la fragmentación fue mayor al 95%. El extracto etanólico a todas las concentraciones no fragmentó el ADN. La curcumina a 200 mg/mL fragmentó menos del 5% de ADN genómico humano. Conclusiones: Los extractos crudo y etanólico de Curcuma longa L. demuestran efecto citotóxico in vitro diferencial para la línea celular tumoral humana DU-145 y HT29 semejante al compuesto estándar curcumina. El extracto crudo de Curcuma longa L. presenta una potente actividad genotóxica in vitro frente al ADN genómico humano, esta actividad está ausente en el extracto etanólico.

ABSTRACT Objectives: To determine the in vitro cytotoxic and genotoxic effect of the crude and ethanolic extract from the Curcuma longa L. rhizome. Materials and methods: The cytotoxic effect was evaluated using DU-145, HT-29, 3T3 BALB/c cell lines. The growth percentages in 48 hours; and the half maximal inhibitory concentration (IC50) were determined. The genotoxic effect on human genomic DNA was determined using the Tomasevich method. Results: Crude extract produced an IC50 of 12.98 ± 0.21 μg/mL for the HT-29 tumor cell line, which is lower than the value obtained for DU-145, with an IC50 of 36.77 ± 9.12 μg/mL. The ethanolic extract presented an IC50 of 13.24 ± 0.77 and 20.54 ± 2.58 μg/mL for both cell lines, respectively; the curcumin standard compound presented an IC50 of 3.96 ± 0.60 and 13.94 ± 2.79 μg/mL, respectively. Crude extract concentrations of 50 and 100 mg/mL fragmented between 40% to 95% of human genomic DNA; while at 200 mg/mL, fragmentation was greater than 95%. The ethanolic extract at all concentrations did not fragment the DNA. Curcumin at 200 mg/mL fragmented less than 5% of human genomic DNA. Conclusions: The crude and ethanolic extracts of Curcuma longa L. demonstrate different in vitro cytotoxic effects for the human tumor cell lines DU-145 and HT-29; similar to the standard curcumin compound. The crude extract of Curcuma longa L. shows a potent genotoxic in vitro activity against human genomic DNA; this type of effect is not produced by the ethanolic extract.

Contextualizing Evidence for Action on Diabetes in Low-Resource Settings-Project CEAD Part I: A Mixed-Methods Study Protocol.

Challenges remain for policy adoption and implementation to tackle the unprecedented and relentless increase in obesity, diabetes and other non-communicable diseases (NCDs), especially in low- and middle-income countries. The aim of this mixed-methods study is to analyse the contextual relevance and applicability to low-resource settings of a sample of evidence-based healthy public policies, using local knowledge, perceptions and pertinent epidemiological data. Firstly, we will identify and prioritise policies that have the potential to reduce the burden of diabetes in low-resource settings with a scoping review and modified Delphi method. In parallel, we will undertake two cross-sectional population surveys on diabetes risk and morbidity in two low-resource settings in Ecuador. Patients, community members, health workers and policy makers will analyse the contextual relevance and applicability of the policy actions and discuss their potential for the reduction in inequities in diabetes risk and morbidity in their population. This study tackles one of the greatest challenges in global health today: how to drive the implementation of population-wide preventative measures to fight NCDs in low resource settings. The findings will demonstrate how local knowledge, perceptions and pertinent epidemiological data can be used to analyse the contextual relevance and applicability of potential policy actions.

Long-Term Outcomes of a Cohort of Hypertensive Subjects in Rural Ecuador.

BACKGROUND: In contrast with the abundance of global epidemiological descriptive data on cardiovascular diseases and their risk factors, information on the outcomes of real populations prospectively followed up in their life and care settings is much rarer, especially in low-income countries. OBJECTIVES: This study sought to evaluate the feasibility and the overall results of a hypertension control program, based mainly on a network of community nonprofessional health promoters, in the poor rural region of Borbon (Ecuador). METHODS: This is a prospective cohort study describing the results of a program of hypertension diagnosis, treatment and follow-up from 2004 to 2015 in the area, carried out mainly by the health promoters. RESULTS: The number of hypertensive patients identified and followed over the years increased from 1,024 in 2004 to 1,733 in 2015. The percentage of patients with no visits during a year was reduced to <10%, whereas the proportion of hypertensive subjects attending all 4 scheduled annual checks approached and, in some years, exceeded 50%. From 2004 to 2015, the proportion of patients at high or very high cardiovascular risk progressively decreased from 26.6% in 2004 to 17.5% in 2015 (p for trend <0.01), whereas the proportion of hypertensive patients at low or very low risk increased from 30.4% in 2004 to 45.0% in 2015 (p for trend <0.01). CONCLUSIONS: In a poor, disadvantaged area, a strategy of control mainly based on the involvement and responsibility of community health promoters (with health professionals as supporters more than direct actors) can achieve adequate follow-up of the population of hypertensive patients and improve their global cardiovascular risk level.

Caracterización físico-química y capacidad antioxidante de extractos del rizoma de Curcuma longa L / Physical-chemical characterization and antioxidant activity the Curcuma longa L. rhizome

Objetivo. Determinar los parámetros físico-químicos y la capacidad antioxidante in vitro del extracto crudo y etanólico de Curcuma longa L. Materiales y métodos. Se obtuvieron dos extractos vegetales: crudo y en 96% de etanol. Se determinaron las características físico-químicas y la presencia de principales grupos de metabolitos mediante screening fitoquímico, asociados con actividad biológica. El contenido de polifenoles totales se determinó mediante el ensayo de Folin-Ciocalteu y la actividad antioxidante de los extractos se evaluó in vitro mediante el ensayo 2,2-difenil-1-picrilhidrazilo (DPPH) y 2,2-azinobis-[3 etilbenzotiazolin-6-sulfónico] (ABTS). Resultados. Los extractos crudo y etanólico de Curcuma longa L. presentaron una densidad relativa 0,8144 y 1,0536g/mL, respectivamente. Respecto al screening fitoquímico, se logró identificar algunos metabolitos en ambos extractos, destacando compuestos fenólicos, flavonoides, alcaloides y heterósidos. El contenido de fenoles totales fueron 252,05 y 296,43 (µg EAG/mg es) para los extractos crudo y etanólico. La capacidad antioxidante con el método DPPH tuvieron IC50 64,26 y 17,01 µg/mL y con el método de ABTS IC50 57,67 y 15,12 µg/mL para los extractos crudo y etanólico. La capacidad antioxidante equivalente a trolox (TEAC-DPPH) fueron 52,95 y 202,855 (µg trolox/mg es) para los extractos crudo y etanólico, la capacidad antioxidante equivalente a trolox (TEAC-ABTS) fueron 49,796 y 182,773 (µg trolox/mg es) para los extractos crudo y etanólico. Conclusiones. El extracto crudo, así como el extracto etanólico del rizoma de la Curcuma longa L. exhiben capacidad antioxidante que guardan correlación con el contenido de compuestos fenólicos.

Objectives. To determine the physic-chemical parameters and in vitro antioxidant capacity of the crude and ethanolic extract of Curcuma longa L. Materials and methods. It was two vegetable extracts: crude and in 96% ethanol. It was determined Physic-chemical characteristics, presence of main groups of metabolites by phytochemical screening, associated with Biological activity. The content of total polyphenols was determined through the Folin-Ciocalteu test and the antioxidant activity of the extracts was evaluated in vitro by the assay 2,2-diphenyl-1-picrylhydrazyl (DPPH) and 2,2-azinobis- [3-ethylbenzothiazolin] -6-sulfonic] (ABTS). Results. The crude and ethanolic extracts of Curcuma longa L., showed a relative density of 0,8144 and 1,0536 g/mL respectively. Regarding phytochemical screening, some metabolites were identified in both extracts, highlighting phenolic compounds, flavonoids, alkaloids and heterosides. The content of total phenols was 252, 05 y 296,43 µg EAG/mg for the crude and ethanolic extracts. The antioxidant capacity with the DPPH method was IC50 64, 26 and 17,01 µg / mL and with the ABTS method IC50 57,67 y 15,12 µg/mL for the crude and ethanolic extracts. The antioxidant capacity equivalent to trolox (TEAC-DPPH) was 52,95 y 202,855 (µg trolox/mg es) for the crude and ethanolic extracts; and the antioxidant capacity equivalent to trolox (TEAC-ABTS) was 49,796 y 182,773 (µg trolox/mg es) for the crude and ethanolic extracts. Conclusions. The crude extract as well as the ethanolic extracts of Curcuma longa L. rhizome exhibit the antioxidant capacity that correlate with the content of phenolic compounds.

Influence of transitional states on the microbial ecology of anaerobic digesters treating solid wastes.

A better understanding of the microbial ecology of anaerobic processes during transitional states is important to achieve a long-term efficient reactor operation. Five wastes (pig manure, biodiesel residues, ethanol stillage, molasses residues, and fish canning waste) were treated in five anaerobic reactors under the same operational conditions. The influence of the type of substrate and the effect of modifying feeding composition on the microbial community structure was evaluated. The highest biomethanation efficiency was observed in reactors fed with fish canning waste, which also presented the highest active archaeal population and the most diverse microbial communities. Only two Bacteria populations could be directly related to a particular substrate: Ilyobacter with biodiesel residues and Trichococcus with molasses residues. Results showed that the time to achieve steady-state performance after these transitional states was not dependent on the substrate treated. But reactors needed more time to handle the stress conditions derived from the start-up compared to the adaptation to a new feeding. Cluster analyses showed that the type of substrate had a clear influence on the microbiology of the reactors, and that segregation was related to the reactors performance. Finally, we conclude that the previous inoculum history treating solid waste and higher values of active Archaea population are important factors to face a successful change in substrate not entailing stability failure.

Relationship between microbial activity and microbial community structure in six full-scale anaerobic digesters.

High activity levels and balanced anaerobic microbial communities are necessary to attain proper anaerobic digestion performance. Therefore, this work was focused on the kinetic performance and the microbial community structure of six full-scale anaerobic digesters and one lab-scale co-digester. Hydrolytic (0.6-3.5 g COD g(-1) VSS d(-1)) and methanogenic (0.01-0.84 g COD g(-1) VSS d(-1)) activities depended on the type of biomass, whereas no significant differences were observed among the acidogenic activities (1.5-2.2 g COD g(-1) VSS d(-1)). In most cases, the higher the hydrolytic and the methanogenic activity, the higher the Bacteroidetes and Archaea percentages, respectively, in the biomasses. Hydrogenotrophic methanogenic activity was always higher than acetoclastic methanogenic activity, and the highest values were achieved in those biomasses with lower percentages of Methanosaeta. In sum, the combination of molecular tools with activity tests seems to be essential for a better characterization of anaerobic biomasses.

Applications of Anammox based processes to treat anaerobic digester supernatant at room temperature.

The supernatant of an anaerobic digester was treated at 20 degrees C in two systems. The first one is a two units configuration, conformed by two sequencing batch reactors (SBR), carrying out partial nitrification and Anammox processes, respectively. Partial nitrification was achieved by granular biomass with a mean diameter of 3 mm, operating at a dissolved oxygen concentration of 2.7 mg/L. The combined system allowed the removal of nitrogen loading rates around 0.08 g N/(Ld). Afterwards, Anammox biomass was spontaneously developed in the inner core of the nitrifying granules of the SBR and therefore, partial nitrification and Anammox process were carried out in a single unit. Once the stable CANON process was established, a mean nitrogen removal rate of 0.8 g N/(Ld) was registered. The settling velocities of the granules ranged from 70 to 150 m/h with sludge volumetric index values lower than 50 mL/g VSS during the whole operation.