Neural crest stem cells protect spinal cord neurons from excitotoxic damage and inhibit glial activation by secretion of brain-derived neurotrophic factor.

The acute phase of spinal cord injury is characterized by excitotoxic and inflammatory events that mediate extensive neuronal loss in the gray matter. Neural crest stem cells (NCSCs) can exert neuroprotective and anti-inflammatory effects that may be mediated by soluble factors. We therefore hypothesize that transplantation of NCSCs to acutely injured spinal cord slice cultures (SCSCs) can prevent neuronal loss after excitotoxic injury. NCSCs were applied onto SCSCs previously subjected to N-methyl-D-aspartate (NMDA)-induced injury. Immunohistochemistry and TUNEL staining were used to quantitatively study cell populations and apoptosis. Concentrations of neurotrophic factors were measured by ELISA. Migration and differentiation properties of NCSCs on SCSCs, laminin, or hyaluronic acid hydrogel were separately studied. NCSCs counteracted the loss of NeuN-positive neurons that was otherwise observed after NMDA-induced excitotoxicity, partly by inhibiting neuronal apoptosis. They also reduced activation of both microglial cells and astrocytes. The concentration of brain-derived neurotrophic factor (BDNF) was increased in supernatants from SCSCs cultured with NCSCs compared to SCSCs alone and BDNF alone mimicked the effects of NCSC application on SCSCs. NCSCs migrated superficially across the surface of SCSCs and showed no signs of neuronal or glial differentiation but preserved their expression of SOX2 and Krox20. In conclusion, NCSCs exert neuroprotective, anti-apoptotic and glia-inhibitory effects on excitotoxically injured spinal cord tissue, some of these effects mediated by secretion of BDNF. However, the investigated NCSCs seem not to undergo neuronal or glial differentiation in the short term since markers indicative of an undifferentiated state were expressed during the entire observation period.

[Endovideosurgery (minimally invasive surgery) in treatment for malignant tumors of female genital organs: a 5-year experience of the clinic of the N.N.Petrov Research Institute of Oncology].

During the period of 2010-2015 laparoscopic surgery was performed in 1263 patients: 1113 with endometrial cancer (588 hysterectomies, 509 hysterectomies with pelvic lymphadenectomy, among them 16 with sentinel lymph node (SLN) mapping with Indocyanine green (ICG)); 86 with cervical cancer (80 nerve-sparing radical hysterectomies (NSRH), among them 15 with SLN mapping, 6 radical vaginal trachelectomies with endovideoassisted lymphadenectomy); 64 with ovarian malignancies. The average operating time in the group of hysterectomies was 101 minutes, in the group of hysterectomies with pelvic lymphadenectomy - 184 minutes, in the group of NSRH - 230 minutes. Average blood loss was less than 50 ml. No intraoperative complications were registered. Asymptomatic lymph cysts were observed in 122 cases. Symptomatic lymph cysts requiring surgical treatment were registered in 9 cases. Inconsistencies of vaginal sutures after radical hysterectomy were in two cases, ureterovaginal fistulas - in two cases. During a 3-year follow-up period twelve recurrences were observed in endometrial cancer patients (12/443; 2,7%), four patients (0,9%) died from disease. After NSRH two local recurrences (2,5%) were registered in patients with cervical cancer, after radical trachelectomy -two local recurrences (33%). One patient became pregnant in the group of vaginal trachelectomies. Therefore laparoscopic approach in treatment of female genital malignacies allows performing an adequate volume of surgery with minimal risk of intra- and postoperative complications, favorable course of the rehabilitation period, and oncological safety.

Differentiating neural crest stem cells induce proliferation of cultured rodent islet beta cells.

AIMS/HYPOTHESIS: Efficient stimulation of cycling activity in cultured beta cells would allow the design of new strategies for cell therapy in diabetes. Neural crest stem cells (NCSCs) play a role in beta cell development and maturation and increase the beta cell number in co-transplants. The mechanism behind NCSC-induced beta cell proliferation and the functional capacity of the new beta cells is not known. METHODS: We developed a new in vitro co-culture system that enables the dissection of the elements that control the cellular interactions that lead to NCSC-dependent increase in islet beta cells. RESULTS: Mouse NCSCs were cultured in vitro, first in medium that stimulated their proliferation, then under conditions that supported their differentiation. When mouse islet cells were cultured together with the NCSCs, more than 35% of the beta cells showed cycle activity. This labelling index is more than tenfold higher than control islets cultured without NCSCs. Beta cells that proliferated under these culture conditions were fully glucose responsive in terms of insulin secretion. NCSCs also induced beta cell proliferation in islets isolated from 1-year-old mice, but not in dissociated islet cells isolated from human donor pancreas tissue. To stimulate beta cell proliferation, NCSCs need to be in intimate contact with the beta cells. CONCLUSIONS/INTERPRETATION: Culture of islet cells in contact with NCSCs induces highly efficient beta cell proliferation. The reported culture system is an excellent platform for further dissection of the minimal set of factors needed to drive this process and explore its potential for translation to diabetes therapy.

Neural crest stem cells increase beta cell proliferation and improve islet function in co-transplanted murine pancreatic islets.

AIMS/HYPOTHESIS: Long-term graft survival after islet transplantation to patients with type 1 diabetes is insufficient, necessitating the development of new strategies to enhance transplant viability. Here we investigated whether co-transplantation of neural crest stem cells (NCSCs) with islets improves islet survival and function in normoglycaemic and diabetic mice. METHODS: Islets alone or together with NCSCs were transplanted under the kidney capsule to normoglycaemic or alloxan-induced diabetic mice. Grafts were analysed for size, proliferation, apoptosis and insulin release. In diabetic recipients blood glucose levels were examined before and after graft removal. RESULTS: In mixed transplants NCSCs actively migrated and extensively associated with co-transplanted pancreatic islets. Proliferation of beta cells was markedly increased and transplants displayed improved insulin release in normoglycaemic mice compared with those receiving islet-alone transplants. Mixed grafts survived successfully and partially restored normoglycaemia in alloxan-induced diabetic mice. CONCLUSIONS/INTERPRETATION: Co-grafting of NCSCs with pancreatic islets improved insulin release in mixed transplants and enhanced beta cell proliferation, resulting in increased beta cell mass. This co-transplantation model offers an opportunity to restore neural-islet interactions and improve islet functions after transplantation.

[Strategies to repair lost sensory connections to the spinal cord].

Failure of injured axons to regenerate in the central nervous system (CNS) is the main obstacle for repair of stroke and traumatic injuries to the spinal cord and sensory roots. This regeneration failure is highlighted at the dorsal root transitional zone (DRTZ), the boundary between the peripheral (PNS) and central nervous system where sensory axons enter the spinal cord. Injured sensory axons regenerate in the PNS compartment of the dorsal root but are halted as soon as they reach the DRTZ. The failure of regenerating dorsal root axons to re-enter the mature spinal cord is a reflection of the generally non-permissive nature of the CNS environment, in contrast to the regeneration supportive properties of the PNS. The dorsal root injury paradigm is therefore an attractive model for studying mechanisms underlying CNS regeneration failure in general and how to overcome the hostile CNS environment Here we review the main lines which have been pursued to achieve growth of injured dorsal root axons into the spinal cord: 1) modifying the inhibitory nature of the DRTZ by breaking down or blocking the effect of growth repelling molecules, 2), stimulate elongation of injured dorsal root axons by a prior conditioning lesion or administration of specific growth factors, 3) implantation of olfactory ensheathing cells to provide a growth supportive cellular terrain at the DRTZ and 4) replacing the regeneration deficient adult dorsal root ganglion neurons with embryonic neurons or neural stem cells.

The impact of neurotrophin-3 on the dorsal root transitional zone following injury.

STUDY DESIGN: Morphological and Stereological assessment of the dorsal root transitional zone (DRTZ) following complete crush injury, using light microscopy (LM) and transmission electron microscopy (TEM). OBJECTIVES: To assess the effect of exogenous neurotrophin-3 (NT-3) on the response of glial cells and axons to dorsal root damage. SETTING: Department of Anatomy, University College Cork, Ireland and Department of Physiology, UMDS, University of London, UK. METHODS: Cervical roots (C6-8) from rats which had undergone dorsal root crush axotomy 1 week earlier, in the presence (n=3) and absence (n=3) of NT-3, were processed for LM and TEM. RESULTS: Unmyelinated axon number and size was greater in the DRTZ proximal (Central Nervous System; CNS) and distal (Peripheral Nervous System; PNS) compartments of NT-3-treated tissue. NT-3 was associated with a reduced astrocytic response, an increase in the proportion of oligodendrocytic tissue and a possible inhibition or delay of microglial activation. Disrupted-myelin volume in the DRTZ PNS and CNS compartments of treated tissue was lower, than in control tissue. In the PNS compartment, NT-3 treatment increased phagocyte and blood vessel numbers. It decreased myelinating activity, as sheath thickness was significantly lower and may also account for the noted lower Schwann cell and organelle volume in the test group. CONCLUSIONS: Our observations suggest that NT-3 interacts with non-neuronal tissue to facilitate the regenerative effort of damaged axons. This may be as a consequence of a direct action or indirectly mediated by modulation of non-neuronal responses to injury.

Intracellular calcium-binding protein S100A4 influences injury-induced migration of white matter astrocytes.

Astrocytes play a crucial role in central nervous system (CNS) pathophysiology. White and gray matter astrocytes are regionally specialized, and likely to respond differently to CNS injury and in CNS disease. We previously showed that the calcium-binding protein S100A4 is exclusively expressed in white matter astrocytes and markedly up-regulated after injury. Furthermore, down-regulation of S100A4 in vitro significantly increases the migration capacity of white matter astrocytes, a property, which might influence their function in CNS tissue repair. Here, we performed a localized injury (scratch) in confluent cultures of white matter astrocytes, which strongly express S100A4, and in cultures of white matter astrocytes, in which S100A4 was down-regulated by transfection with short interference (si) S100A4 RNA. We found that S100A4-silenced astrocytes rapidly migrated into the injury gap, whereas S100A4-expressing astrocytes extended hypertrophied processes toward the gap, but without closing it. To explore the involvement of S100A4 in migration of astrocytes in vivo, we induced focal demyelination and transient glial cell elimination in the spinal cord white matter by ethidium bromide injection in S100A4 (-/-) and (+/+) mice. The results show that astrocyte migration into the demyelinated area is promoted in S100A4 (-/-) compared to (+/+) mice, in which a pronounced glial scar was formed. These data indicate that S100A4 reduces the migratory capacity of reactive white matter astrocytes in the injured CNS and is involved in glial scar formation after injury.

Sensory neurite outgrowth on white matter astrocytes is influenced by intracellular and extracellular S100A4 protein.

The central nervous system (CNS) is considered a nonpermissive environment for axonal regeneration because of the presence of myelin and associated repulsive molecules. However, neural cells transplanted to the CNS preferably migrate and extend their fibers in white matter areas. We previously showed that white matter astrocytes in vivo express the calcium-binding protein S100A4, which is strongly up-regulated in areas of white matter degeneration. To investigate the role of white matter astrocytes and their specific protein S100A4 in axonal regeneration, we developed white matter astrocyte cultures with strong S100A4 expression and grew dissociated adult dorsal root ganglion (DRG) cells on top of astrocytes for 24 hr. By using small interfering S100A4 RNA, we were able to eliminate S100A4 expression and compare growth of DRG cell neurites on S100A4-silenced and S100A4-expressing astrocytes. In addition, we studied whether extracellular S100A4 has an effect on neurite growth from adult DRG cells cultured on S100A4-expressing white matter astrocytes. Our data show that white matter astrocytes are permissive for neurite growth, although high levels of S100A4 in white matter astrocytes have a negative effect on this growth. Extracellular application of S100A4 induced extensive growth of DRG cell neurites on white matter astrocytes. These findings suggest that white matter astrocytes are able to support axonal regeneration and, furthermore, that administration of extracellular S100A4 provides strong additional support for axonal regeneration.

Functional connections are established in the deafferented rat spinal cord by peripherally transplanted human embryonic sensory neurons.

Functionally useful repair of the mature spinal cord following injury requires axon growth and the re-establishment of specific synaptic connections. We have shown previously that axons from peripherally grafted human embryonic dorsal root ganglion cells grow for long distances in adult host rat dorsal roots, traverse the interface between the peripheral and central nervous system, and enter the spinal cord to arborize in the dorsal horn. Here we show that these transplants mediate synaptic activity in the host spinal cord. Dorsal root ganglia from human embryonic donors were transplanted in place of native adult rat ganglia. Two to three months after transplantation the recipient rats were examined anatomically and physiologically. Human fibres labelled with a human-specific axon marker were distributed in superficial as well as deep laminae of the recipient rat spinal cord. About 36% of the grafted neurons were double labelled following injections of the fluorescent tracers MiniRuby into the sciatic and Fluoro-Gold into the lower lumbar spinal cord, indicating that some of the grafted neurons had grown processes into the spinal cord as well as towards the denervated peripheral targets. Electrophysiological recordings demonstrated that the transplanted human dorsal roots conducted impulses that evoked postsynaptic activity in dorsal horn neurons and polysynaptic reflexes in ipsilateral ventral roots. The time course of the synaptic activation indicated that the human fibres were non-myelinated or thinly myelinated. Our findings show that growing human sensory nerve fibres which enter the adult deafferentated rat spinal cord become anatomically and physiologically integrated into functional spinal circuits.

Metastasis-associated mts1 (S100A4) protein in the developing and adult central nervous system.

We have found recently that white matter astrocytes in the spinal cord constitutively express immunoreactivity for Mts1 (S100A4) protein and that this expression is up-regulated ipsilaterally after sciatic nerve or dorsal root injury. Here, we have studied the expression pattern of Mts1 throughout the rat central nervous system (CNS). We found Mts1 immunoreactivity in myelinated tracts such as the olfactory tract, optic nerve, corpus callosum, internal capsule, fimbria, and spinal cord funiculi but not in cerebellar white matter. Mts1-immunoreactive (IR) cells were consistently astrocytic (glial fibrillary acidic protein positive). In addition to myelinated tracts, Mts1 immunoreactivity was also present in a few nonmyelinated or poorly myelinated areas, such as pituitary gland, olfactory bulb, and around the lateral ventricle. Based on location, three Mts1-IR astrocyte groups were distinguished: 1) astrocytes at the surfaces of the CNS, i.e., adjacent to the cerebrospinal fluid, organized perpendicularly to the bundles of axonal tracts; 2) astrocytes located in parallel to, and inserted between, axonal bundles; and 3) clusters of astrocytes around the lateral ventricle and in the olfactory bulb. We further analyzed the relationship between Mts1 immunoreactivity and the development of CNS fiber tracts by combining staining for Mts1 and myelin basic protein (MBP). Mts1 immunoreactivity appeared postnatally in recently myelinated areas. During the development of corpus callosum and the optic tract, Mts1 immunoreactivity was concentrated at the frontier of myelination. The developmental expression pattern suggests a role of Mts1-IR astrocytes in the maturation of myelinated fiber tracts. The preferential localization of Mts1 to the subpial region in the mature CNS suggests that Mts1 participates in astrocyte-mediated CNS-cerebrospinal fluid exchange.

Effects of dorsal root transection on morphology and chemical composition of degenerating nerve fibers and reactive astrocytes in the dorsal funiculus.

The morphology and chemical (elemental) composition of the dorsal funiculus of the rat spinal cord were examined 1 and 7 days after unilateral transection (rhizotomy) of the L4 and L5 dorsal roots, using light and electron microscopy as well as X-ray microanalysis. Changes were observed only in the dorsal funiculus on the side of injury and included disintegration of the axonal cytoskeleton, enlargement of axonal mitochondria, and widening of the myelin lamellae of the injured axons. X-ray microanalysis demonstrated a significant increase in intraaxonal sodium at 1 day after injury. This increase was abolished at 7 days, but at this stage there was a significant lowering of potassium in axons and myelin sheaths and of phosphorus in myelin as well as a marked increase in calcium in the axoplasm of the degenerating axons. The nonneuronal cell compartment, largely composed of astrocytes, showed elevated sodium, chlorine, and calcium and lowered potassium levels. The changes in chemical composition paralleled an increase in immunoreactivity for the calcium-binding Mts1 (S100A4) protein, which is exclusively expressed by white matter astrocytes. The influx of calcium is likely to play a crucial role in the loss of axonal integrity after rhizotomy, while the alterations in potassium, and perhaps also phosphorus, may contribute to activation of the nonneuronal cells, including the up-regulation of Mts1 expression in astrocytes.

Glial cell proliferation in the spinal cord after dorsal rhizotomy or sciatic nerve transection in the adult rat.

Proliferation of glial cells is one of the hallmarks of CNS responses to neural injury. These responses are likely to play important roles in neuronal survival and functional recovery after central or peripheral injury. The boundary between the peripheral nervous system (PNS) and CNS in the dorsal roots, the dorsal root transitional zone (DRTZ), marks a distinct barrier for growth by injured dorsal root axons. Regeneration occurs successfully in the PNS environment, but ceases at the PNS-CNS junction. In order to understand the role of different glial cells in this process, we analysed the proliferation pattern of glial cells in central (CNS) and peripheral (PNS) parts of the dorsal root and the segmental white and grey spinal cord matter after dorsal rhizotomy or sciatic nerve transection in adult rats 1-7 days after injury. Monoclonal antibody MIB-5 or antibodies to bromodeoxyuridine were used to identify proliferating cells. Polyclonal antibodies to laminin were used to distinguish the PNS and CNS compartments of the dorsal root. Dorsal root lesion induced glial cell proliferation in the CNS as well as PNS beginning at 1 day, with peaks from 2 to 4 days postoperatively. After sciatic nerve injury, cell proliferation occurred only in the CNS, was minimal at 1 day, and peaked from 2 to 4 days postoperatively. Double immunostaining with specific glial cell markers showed that after dorsal root transection 60% of the proliferating cells throughout the postoperative period examined were microglia, 30% astrocytes and 10% unidentified in the CNS, while in the PNS 40% were Schwann cells, 40% macrophages and 20% unidentified. After sciatic nerve injury virtually all proliferating cells were microglia. These findings indicate that non-neuronal cells in the CNS and PNS are extremely sensitive to the initial changes which occur in the degenerating dorsal root axons, and that extensive axonal degeneration is a prerequisite for astroglial and Schwann cell, but not microglial cell, proliferation.

Metastasis-associated mts1 (S100A4) protein is selectively expressed in white matter astrocytes and is up-regulated after peripheral nerve or dorsal root injury.

The S100 family of calcium binding proteins has been shown to be involved in a variety of physiological functions, such as regulation of enzyme function, cell motility, modification of extracellular matrix, and cell proliferation. Several members of the S100 family are expressed in the nervous system, but their functional roles are still largely obscure. The Mts1 gene codes for the S100A4 protein, which has been implicated in the control of cell proliferation and metastasis activity of tumor cells. We have used immunohistochemistry to examine the expression pattern of the Mts1 protein in the adult rat spinal cord and how this expression is influenced by peripheral nerve or dorsal root injury. Mts1 immunoreactivity (IR) was present only in white matter astrocytes in the intact spinal cord. Sciatic nerve as well as dorsal root injury induced a marked and prolonged up-regulation of Mts1-IR in astrocytes in the region of the dorsal funiculus containing the central processes of the injured primary sensory neurons. These findings suggest that Mts1 plays a unique physiological role in white matter astrocytes as well as in the response of astrocytes to degeneration of myelinated axons.

Central neuron-glial and glial-glial interactions following axon injury.

Axon injury rapidly activates microglial and astroglial cells close to the axotomized neurons. Following motor axon injury, astrocytes upregulate within hour(s) the gap junction protein connexin-43, and within one day glial fibrillary acidic protein (GFAP). Concomitantly, microglial cells proliferate and migrate towards the axotomized neuron perikarya. Analogous responses occur in central termination territories of peripherally injured sensory ganglion cells. The activated microglia express a number of inflammatory and immune mediators. When neuron degeneration occurs, microglia act as phagocytes. This is uncommon after peripheral nerve injury in the adult mammal, however, and the functional implications of the glial cell responses in this situation are unclear. When central axons are injured, the glial cell responses around the affected neuron perikarya appears to be minimal or absent, unless neuron degeneration occurs. Microglia proliferate, and astrocytes upregulate GFAP along central axons undergoing anterograde, Wallerian, degeneration. Although microglia develop into phagocytes, they eliminate the disintegrating myelin very slowly, presumably because they fail to release molecules which facilitate phagocytosis. During later stages of Wallerian degeneration, oligodendrocytes express clusterin, a glycoprotein implicated in several conditions of cell degeneration. A hypothetical scheme for glial cell activation following axon injury is discussed, implying the injured neurons initially interact with adjacent astrocytes. Subsequently, neighbouring resting microglia are activated. These glial reactions are amplified by paracrine and autocrine mechanisms, in which cytokines appear to be important mediators. The specific functional properties of the activated glial cells will determine their influence on neuronal survival, axon regeneration, and synaptic plasticity. The control of the induction and progression of these responses are therefore likely to be critical for the outcome of, for example, neurotrauma, brain ischemia and chronic neurodegenerative diseases.

Human dorsal root ganglion neurons from embryonic donors extend axons into the host rat spinal cord along laminin-rich peripheral surroundings of the dorsal root transitional zone.

Following dorsal root crush, the lesioned axons regenerate in the peripheral compartment of the dorsal root, but stop at the boundary between the peripheral and the central nervous system, the dorsal root transitional zone. We have previously shown that fibres from human fetal dorsal root ganglia grafted to adult rat hosts are able to grow into the spinal cord, but were not able to specify the route taken by the ingrowing fibres. In this study we have challenged the dorsal root transitional zone astrocyte boundary with human dorsal root ganglion transplants from 5-8-week-old embryos. By tracing immunolabelled human fibres in serial sections, we found that fibres consistently grow around the dorsal root transitional zone astrocytes in laminin-rich peripheral surroundings, and extend into the host rat spinal cord along blood vessels, either into deep or superficial laminae of the dorsal horn, or into the dorsal funiculus. Human fibres that did not have access to blood vessels grew on the spinal cord surface. These findings indicate, that in spite of a substantial growth capacity by axons from human embryonic dorsal root ganglion cells as well as their tolerance to non-permissive factors in the mature mammalian CNS, these axons are still sensitive to the repellent effects of astrocytes of the mature dorsal root transitional zone. Furthermore, this axonal ingrowth is consistently associated with laminin-expressing structures until the axons reach the host spinal cord.

Peripherally grafted human foetal dorsal root ganglion cells extend axons into the spinal cord of adult host rats by circumventing dorsal root entry zone astrocytes.

Human foetal dorsal root ganglia were grafted in place of native lumbar dorsal root ganglia in adult rat hosts. Between 4 weeks and 4 months later, the dorsal root entry zone (DREZ) in the grafted roots showed extensive peripheral outgrowth of astrocytic processes, in contrast to the normal 'smooth' interface between the peripheral and central nervous system compartments of the DREZ. Fibres originating from the grafted neurones and approaching the DREZ changed their direction of growth and entered the spinal cord through the pia by following blood vessels, grew into the grey matter and ramified there. These findings suggest that the DREZ astrocytes in vivo are non-permissive not only to mature peripheral regenerating axons, but also to growing axons from immature neurones.

Peripherally grafted human foetal dorsal root ganglion cells extend axons into the spinal cord of adult host rats by circumventing dorsal root entry zone astrocytes.

Human foetal dorsal root ganglia were grafted in place of native lumbar dorsal root ganglia in adult rat hosts. Between 4 weeks and 4 months later, the dorsal root entry zone (DREZ) in the grafted roots showed extensive peripheral outgrowth of astrocytic processes, in contrast to the normal 'smooth' interface between the peripheral and central nervous system compartments of the DREZ. Fibres originating from the grafted neurones and approaching the DREZ changed their direction of growth and entered the spinal cord through the pia by following blood vessels, grew into the grey matter and ramified there. These findings suggest that the DREZ astrocytes in vivo are non-permissive not only to mature peripheral regenerating axons, but also to growing axons from immature neurones.

[The differentiation of the nerve and glial cells of neocortical transplants placed into the brain of adult rats]. / Differentsirovka nervnykh i glial'nykh kletok neokortikal'nykh transplantatov, pomeshchennykh v mozg vzroslykh krys.

Embryonal neural tissue of 17-day-old rat embryos was transplanted into the brain of adult Wistar rats to test the differentiation of transplants with reference to the normal cerebral cortex development. The control and the experimental rats were decapitated 2, 5, 7, 10, 15, 20, 25, and 35 days after the transplantation. Differentiation of neural tissue was studied using monoclonal antibodies against neurofilaments as well as by counting the proportion of differentiated neurons. The glial differentiation was studied by immunohistochemical method using monoclonal antibodies against acid glial fibrillar protein and vimentin. The differentiation of neural cells of transplants proved to be synchronous with the normal ones while the differentiation of glial cells accelerates.