mRNA incorporation of C(5)-halogenated pyrimidine ribonucleotides and induced high expression of corresponding protein for the development of mRNA vaccine.

In this report, we present our studies on mRNA, which was modified by introducing various halogen substituents at the C(5) position of the pyrimidine base. Specifically, we synthesized C(5)-halogenated (F, Cl, Br, I) pyrimidine ribonucleoside triphosphates and incorporated them into mRNA during in-vitro transcription. The efficiency of the in-vitro transcription reaction of halogenated pyrimidine was observed to decrease as the size of the halogen substituent increased and the electronegativity thereof decreased (F > Cl > Br) except for iodine. Interestingly, we found that, among the C(5)-halogenated pyrimidine ribonucleotides, mRNA incorporating C(5)-halogenated cytidine (5-F rCTP and 5-Cl rCTP) exhibited more prominent protein expression than mRNA modified with C(5)-halogenated uridine and unmodified mRNA. In particular, in the case of mRNA to which fluorine (5-F rCTP) and chlorine (5-Cl rCTP) were introduced, the protein was dramatically expressed about 4 to 5 times more efficiently than the unmodified mRNA, which was similar to pseudouridine (ψ). More interestingly, when pseudouridine(ψ) and fluorocytidine nucleotides (5-F rCTP), were simultaneously introduced into mRNA for dual incorporation, the protein expression efficiency dramatically increased as much as tenfold. The efficiency of cap-dependent protein expression is much higher than the IRES-dependent (internal ribosome entry site) expression with mRNA incorporating C(5)-halogenated pyrimidine ribonucleotide. We expect these results to contribute meaningfully to the development of therapeutics based on modified mRNA.

Vascularized Ulnar Transposition and Ulno-scapholunate Fusion for Reconstructing Campanacci Grade 3 Giant Cell Tumor of Distal Radius: Technique and a Series of 5 Cases.

Campanacci grade 3 distal radius giant cell tumors are difficult to treat and just doing a curettage and bone grafting is insufficient. These lesions are associated with a high chance of recurrence. We are presenting our technique and series of 5 patients who underwent enbloc excision and ulna transposition with ulno-scapholunate fusion. Between 2014 and 2017 5 patients underwent en bloc excision of Campanacci grade 3 giant cell tumor of the distal radius, ulna transposition and ulno carpal fusion. These patients were regularly followed for evidence of union, range of motion, grip strength, and to look for recurrence of tumor. All 5 patients were Campanacci grade 3 tumors. The average duration of symptoms was 5 months (1 to 9 mo). The average duration of follow-up was 33 months (24 to 48 mo). The average time for ulno-scapholuante fusion was 8 weeks (6 to 10 wk) and the average time to radio ulnar fusion was 14.5 weeks (12 to 16 wk). The average arc of wrist flexion and extension was 34 degrees. The average grip strength was 58.2% of the contralateral side (48% to 69%). In conclusion vascularized ulnar transposition with partial wrist fusion for a Camapanacci grade 3 giant cell tumor is an alternate procedure in the management of these difficult tumors.

Poly(methylene blue)-Based Electrochemical Platform for Label-Free Sensing of Acrylamide.

The present work reports the electrochemical sensing of acrylamide (AM) using a poly(methylene blue)-modified glassy carbon electrode (PMB/GCE) where PMB functions as an electrochemical reporter. PMB was prepared by electrochemical polymerization of methylene blue. Electrochemical sensing of AM was facilitated by the interaction between AM and PMB. Further the interaction between AM and PMB was investigated using ultraviolet-visible (UV-vis) spectroscopy and Raman analysis. The surface morphology was confirmed by atomic force microscopy (AFM) and field emission scanning electron microscopy (FESEM) analyses. PMB/GCE was further characterized by X-ray photoelectron spectroscopy (XPS), and the electrochemical performance was assessed using cyclic voltammetry and differential pulse voltammetry. Cyclic voltammetry analysis showed a decrease in current at the redox center of PMB upon addition of AM. The association constant and binding number of AM with PMB/GCE were calculated using differential pulse voltammetry and found to be 8.9 × 106 M-1 and 0.64 (∼1), respectively. The results indicated a strong interaction of AM on the PMB/GCE surface. Further, chronocoulometry analysis of PMB/GCE in the presence of AM showed a decrease in charge due to the interaction of AM with PMB. Under optimized conditions, PMB/GCE exhibited a decrease in current proportional to the concentration of AM in the range of 0.025-16 µM with sensitivity and detection limit 0.252 µA nM-1 and 0.13 nM, respectively. Real sample analysis was carried out by the standard addition method using the solution extracted from potato chips.

Technique for Retraction of the Fourth Compartment Tendons in Approach to the Wrist Joint.

Most procedures that require exposure of the wrist joint requires us to go through the third and fourth compartment. This is followed by dividing the septum between the 3rd and 4th compartments and retracting the EDC tendons ulnarwards. This can be done by various techniques. Using a form of self-retaining retractor is cumbersome and has to be repeatedly repositioned as the tendons keep slipping out. We describe a novel method to maintain this retraction throughout any wrist procedure.

Adipose derived mesenchymal stem cells along with Alpinia oxyphylla extract alleviate mitochondria-mediated cardiac apoptosis in aging models and cardiac function in aging rats.

ETHNOPHARMACOLOGICAL RELEVANCE: The Fructus (Alpinia oxyphylla MIQ) known as Yi Zhi Ren in Chinese medicine has been used as a food and herbal medicinal substance in China for centuries; in the year 2015 Chinese Pharmacopoeia Commission reported water extracts of Alpinia oxyphyllae Fructus (AoF) as a popular medication for aging-related diseases in the form of tonic, aphrodisiac, and health-care food in south China. AIM OF THE STUDY: Adipose mesenchymal stem cells are physiologically and therapeutically associated with healthy vascular function and cardiac health. However aging conditions hinder stem cell function and increases the vulnerability to cardiovascular diseases. In this study, the effect of the anti-aging herbal medicine AoF to enhance the cardiac restorative function of adipose-derived mesenchymal stem cells (ADMSCs) in aging condition was investigated. MATERIALS AND METHODS: Low dose (0.1 µM) Doxorubicin and D-galactose (150 mg/kg/day for 8 weeks) were used to respectively induce aging in vitro and in vivo. For In vivo studies, 20 week old WKY rats were divided into Control, Aging induced (AI), AI + AoF, AI + ADMSC, AI + AoF Oral + ADMSC, and AI + AoF treated ADMSC groups. AoF (100 mg/kg/day) was administered orally and ADMSCs (1 × 106 cells) were injected (IV). RESULTS: AoF preconditioned ADMSC showed reduction in low dose Dox induced mitochondrial apoptosis and improved DNA replication in H9c2 cardiomyoblasts. In vivo experiments confirmed that both a combined treatment with AoF-ADMSCs and with AoF preconditioned ADMSCs reduced aging associated cardiac damages which was correlated with reduction in apoptosis and expression of senescence markers (P21 and ß-gal). Survival and longevity markers were upregulated up on combined administration of AoF and ADMSCs. The cardiac performance of the aging-induced rats was improved significantly in the treatment groups. AoF along with ADMSCs might activate paracrine factors to restore the performance of an aging heart. CONCLUSION: Hence, we propose that ADMSCs combined with AoF have promising therapeutic properties in the treatment of healthy aging heart.

Functional Outcome of Surgically Managed Perilunate Injuries.

BACKGROUND: Perilunate injuries are rare and quite often missed. We present our experience and outcomes, surgically managing these difficult injuries. METHODS: We analysed data from 14 patients who underwent open reduction and internal fixation of perilunate injuries. All patients underwent open reduction and fixation through the dorsal approach. Fractures were fixed with either K-wires or Headless compression screws. At regular intervals radiographs, range of motion, grip strength, modified Mayo score, Quick DASH score and Lyon wrist scores were collected. RESULTS: The average age of our patients was 29.2. Average time to surgical intervention was 11.3 days. The mean follow-up period was 42.3 months. modified Mayo wrist score, QuickDASH score and Lyon wrist scores were 77.86, 1.62 and 80.86, respectively. Wrist flexion/extension arc was 101.43. Wrist radial/ulnar deviation was 50.0. Mean grip strength was 69.93% of the opposite side. Radiological evidence of wrist arthritis and lunate avascular necrosis was seen in 8 (57.14%) and 4 (28.6%) cases, respectively. CONCLUSION: Early open reduction of perilunate injuries gives reliable results, in spite of radiological evidence of wrist arthritis in a majority of the cases.

A novel Microproteomic Approach Using Laser Capture Microdissection to Study Cellular Protrusions.

Cell⁻cell communication is vital to multicellular organisms, and distinct types of cellular protrusions play critical roles during development, cell signaling, and the spreading of pathogens and cancer. The differences in the structure and protein composition of these different types of protrusions and their specific functions have not been elucidated due to the lack of a method for their specific isolation and analysis. In this paper, we described, for the first time, a method to specifically isolate distinct protrusion subtypes, based on their morphological structures or fluorescent markers, using laser capture microdissection (LCM). Combined with a unique fixation and protein extraction protocol, we pushed the limits of microproteomics and demonstrate that proteins from LCM-isolated protrusions can successfully and reproducibly be identified by mass spectrometry using ultra-high field Orbitrap technologies. Our method confirmed that different types of protrusions have distinct proteomes and it promises to advance the characterization and the understanding of these unique structures to shed light on their possible role in health and disease.

Reweighting anthropometric data using a nearest neighbour approach.

When designing products and environments, detailed data on body size and shape are seldom available for the specific user population. One way to mitigate this issue is to reweight available data such that they provide an accurate estimate of the target population of interest. This is done by assigning a statistical weight to each individual in the reference data, increasing or decreasing their influence on statistical models of the whole. This paper presents a new approach to reweighting these data. Instead of stratified sampling, the proposed method uses a clustering algorithm to identify relationships between the detailed and reference populations using their height, mass, and body mass index (BMI). The newly weighted data are shown to provide more accurate estimates than traditional approaches. The improved accuracy that accompanies this method provides designers with an alternative to data synthesis techniques as they seek appropriate data to guide their design practice.Practitioner Summary: Design practice is best guided by data on body size and shape that accurately represents the target user population. This research presents an alternative to data synthesis (e.g. regression or proportionality constants) for adapting data from one population for use in modelling another.

Analysis of shoulder abduction by dynamic shoulder radiograph following suprascapular nerve repair in brachial plexus injury.

BACKGROUND: Suprascapular nerve repair is a widely-prioritized procedure for shoulder reconstruction following brachial plexus injury. Although this procedure only reconstructs glenohumeral joint motion, the standard clinical assessment of shoulder function also includes the scapulothoracic joint contribution. The purpose of this preliminary study was to develop an objective method to accurately analyze shoulder abduction following suprascapular nerve repair in brachial plexus injury patients. METHODS: We introduced an objective method to accurately analyze independent shoulder abduction performed by supraspinatus muscle with the help of dynamic shoulder radiography. Antero-posterior radiographs of both shoulders in adduction and maximal active abduction were obtained. Five parameters were measured. They included global abduction, abduction in glenohumeral, scapulothoracic and clavicular joints along with lateral flexion of thoracic spine. Data were analyzed to distinguish glenohumeral joint contribution from that of scapulothoracic motion. The detailed biomechanics of glenohumeral motion were also analyzed in relation to scapulothoracic motion to separately define the contribution of each in global shoulder abduction. RESULTS: The test-retest, intra-examiner and inter-examiner reliabilities of the measurements were assessed. Intra-class correlation coefficient, Bland-Altman plots and repeatability coefficients showed excellent reliability for each parameter. The range of glenohumeral abduction showed high correlation to subtraction of the range of scapulothoracic from the range of global abduction. However, not all negative ranges of glenohumeral abduction meant non-recovery after nerve repair, because scapulothoracic motion contributed in parallel but not uniformly to global shoulder motion. CONCLUSION: The conventional measurement of shoulder global abduction with goniometer is not an appropriate method to analyze the results of suprascapular nerve repair in brachial plexus palsy patients. We recommend examination of glenohumeral and scapulothoracic motions separately with dynamic shoulder radiographic analysis. With scapulothoracic contribution to the global shoulder motion, the glenohumeral motion can be wrongly assessed.

Arthroplasty for fifth carpometacarpal joint arthritis.

Background Fifth-carpometacarpal (CMC)-joint fractures and dislocations can produce carpometacarpal joint arthritis. The purpose of this study was to evaluate the radiographic and clinical outcomes of arthroplasty for fifth carpometacarpal joint arthritis. Material and Methods A series of six patients who had symptomatic advanced fifth-CMC arthritis and had failed to respond to conservative treatment. All patients underwent Dupert's technique of fifth-CMC arthroplasty with a mean follow-up of 17.6 months. Results were reviewed clinically and radiographically. Results Union between the fourth and fifth metacarpals was observed at an average of 6.2 weeks after surgery. Grip strength improved. Range of motion (ROM) of the fifth metacarpophalangeal (MCP) joint and the fifth metacarpal height remained unchanged. Visual analog scale (VAS) results improved significantly. Conclusion Despite the medium-term follow-up and small number of patients, our results suggest fifth-CMC arthroplasty with arthrodesis of the fourth and fifth metacarpal bases may be a reliable procedure for fifth-CMC arthritis.

Anatomical study of anterior supramalleolar artery and its potential application to design a bi-foliate fasciocutaneous flap.

PURPOSE: A further understanding of the anterior supramalleolar artery (ASMA) and its potential applications in reconstructive surgery. MATERIALS AND METHODS: A total of 24 fresh lower limbs from fresh cadavers were injected with red latex for dissection. The type of origin, course, diameter of the pedicle, and the distance between the origin of the ASMA from the anterior tibial artery to the extensor retinaculum (O-R) were recorded. Bi-foliate fasciocutaneous flaps were harvested using the branches of the ASMA. RESULTS: We found four types of origin of the ASMA, and we have accordingly classified them into four types. 10 of them were type A, 7 were type B, 6 were type C and 1 was type D. The mean O-R (origin of ASMA to retinaculum) distance was 2.0 ± 0.8 cm. The diameter of the medial branch (D1), the diameter of the lateral branch (D2), and the diameter of artery stem (D3) (only in type A) were 1.0 ± 0.2 mm, 0.8 ± 0.3 mm, 1.1 ± 0.2 mm, respectively. The mean pedicle length of the lateral flap (L1) and medial flap (L2) were 5.1 ± 1.0 cm and 3.7 ± 0.6 cm, respectively. CONCLUSIONS: The ASMA exists constantly with four different types of origin. Its sizable diameter and lengthy pedicle make it suitable for bi-foliate fasciocutaneous flap transfer.

Pedicled vascularised fibular grafting in a flow-through manner for reconstruction of infected non-union of the tibia with preservation of the peroneal artery: a case report.

We report on an 82-year-old man with an infected non-union of the right tibia in which the peroneal artery was the sole artery supplying the lower leg, owing to peripheral arterial disease. He underwent tibial reconstruction using the pedicled vascularised fibular graft in a flow-through manner (without ligation of either the proximal or distal ends of the peroneal artery) and achieved successful bony union.

The use of compound muscle action potentials (CMAP) for postoperative monitoring of free functioning gracilis muscle transfer: A preliminary report.

BACKGROUND AND PURPOSES: The use of skin flap as a monitoring tool cannot sensitively reflect the vascularity of a functioning free muscle transfer (FFMT), and it may result in delayed detection of vascular compromise. We report the use of compound muscle action potentials (CMAPs) as a supplemental method in the monitoring of free gracilis transfers. SUBJECTS AND METHODS: In 46 successful free gracilis transfers in 23 patients following total brachial plexus injury (BPI), CMAPs were measured every hour for 75 h postoperatively. We analyzed the amplitude, latency, and duration to understand the Wallerian degeneration effect and thresholds to warn vascular compromise clinically. After the primary study, we applied CMAP monitoring for 23 clinical cases. MAIN FINDINGS: Three basic wave patterns of the CMAPs with or without dispersion were recognized. Forty-two CMAPs were successfully traced and 27 CMAPs with one constant wave pattern showed two types of amplitude and latency changes; positive and negative Wallerian degeneration. The mean 1-h maximal decreases of amplitudes and elongation of latency were 36% and 77%, respectively; however, they returned to the original pattern within 1 h. There were no significant differences of reinnervation time and final strength of elbow flexion between these 46 muscle transfers. In the clinical series, we experienced two cases of vascular compromise that showed CMAP critical alterations without skin flap changes. CONCLUSIONS: Our preliminary results show that the measurement of CMAPs has great potential for the sensitive and reliable monitoring of muscle circulation after FFMT. The clinical critical values of CMAP amplitude changes for vascular compromise are >40% sudden decrease, and they continued to decrease further. This technique is most useful for postoperative vascular monitoring of a buried muscle flap, and it is proven to be of clinical significance in current vascular compromised cases. LEVEL OF EVIDENCE: Level Ⅳ, Case Series.

Ligament reconstruction with tendon interposition arthroplasty for first carpometacarpal joint osteoarthritis.

BACKGROUND: Ligament reconstruction tendon interposition (LRTI) is the most commonly performed surgical procedure for first carpometacarpal joint osteoarthritis. The purpose of this study was to examine the radiographic and clinical outcomes of LRTI arthroplasty and document the clinical results based on metacarpal subsidence. METHODS: From January 2008 to January 2011, 19 patients (21 thumbs) underwent surgery for thumb carpometacarpal arthritis using ligament reconstruction tendon interposition arthroplasty with flexor carpi radialis (FCR) in Kleinert Kutz Hand Care Center of Louisville University, USA. The follow-up period was an average of 13.9 months. Pain, grip strength, tip pinch strength, range of motion, and radiographic measurements were recorded. Based on first metacarpal subsidence, the cases were classified in to mild, moderate, and severe. Clinical outcomes of the groups were evaluated and compared. RESULTS: Grip strength improved from 18.6 kg to 20.5 kg, and tip pinch strength increased from 4.4 kg to 4.5 kg after the surgery. Radial abduction and palmar abduction improved after surgery. Radial abduction increased from 55.7° to 60.6° and palmar abduction improved from 56.7° to 63.5° after the procedure. Visual analogue scores (VAS) were significantly reduced, from 6.6 to 0.5. Compared with the preoperative radiographs the first metacarpal had subsided about 54.6% of the arthroplasty space. The height of arthroplasty space and index of the arthroplasty space significantly decreased from 12.4 mm to 5.6 mm and from 0.27 to 0.12 respectively. Between the various groups (mild, moderate and severe metacarpal subsidence), there was no difference in grip strength, tip pinch strength, thumb range of motion, and VAS. CONCLUSIONS: Ligament reconstruction tendon interposition arthroplasty resulted in excellent relief of pain and increase in range of motion. However, LRTI cannot maintain the arthroplasty space. Compared with the preoperative radiographs, the metacarpal subsided more than 50%. The amount of first metacarpal subsidence has no bearing on the results.

Camitz tendon transfer using flexor retinaculum as a pulley in advanced carpal tunnel syndrome.

PURPOSE: To report the outcomes of modified Camitz abductor plasty using the released flexor retinaculum as a pulley in patients with advanced carpal tunnel syndrome. METHODS: A retrospective review of 46 hands in 43 patients who underwent modified Camitz abductor plasty was performed. Active palmar abduction of thumb and pulp pinch strength were assessed. Patient-reported outcome measures were assessed using the Disabilities of the Arm, Shoulder, and Hand and Carpal Tunnel Syndrome instrument. As an electrophysiological assessment, compound muscle action potential (CMAP) from abductor pollicis brevis (APB) was investigated. RESULTS: At 3 months, active palmar abduction of thumb and pulp pinch strength significantly improved. Although pulp pinch strength further improved, active abduction of thumb did not improve at the final follow-up. Both the patient-reported outcome measures improved at 3 months and further improved at final follow-up. Approximately 75% of improved scores were obtained at the first 3 months after surgery and the balance of improved scores (25%) was obtained by the time of final follow-up. Useful recovery of postoperative APB-CMAP (amplitude > 1.8 mV) was obtained in 3 hands (7%) at 3 months after surgery and in 23 hands (50%) at final follow-up. There was no statistical significance of the postoperative results including active palmar abduction of thumb and improvement of patient-reported outcome measures at final follow-up between the hands with useful recovery of postoperative APB-CMAP and the hands without it. CONCLUSIONS: Modified Camitz abductor plasty benefitted the early improvement of activity of daily living in patients with advanced carpal tunnel syndrome. It acted not only as an internal orthosis in patients who eventually recovered thenar muscle function but also as the sole palmar abductor of the thumb in patients who failed to recover useful thenar muscle function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reconstruction of shoulder and elbow function using multiple muscle transfers for cervical spondylotic amyotrophy.

STUDY DESIGN: This was a retrospective study of 8 patients with cervical spondylotic amyotrophy who underwent multiple muscle transfers. OBJECTIVE: The purpose of this study was to evaluate results of multiple muscle transfers about the shoulder and elbow in patients with cervical spondylotic amyotrophy. SUMMARY OF BACKGROUND DATA: Cervical spondylotic amyotrophy is characterized by severe muscle atrophy of the shoulder girdle and elbow. Even after cervical spine surgery, many patients have poor shoulder and elbow function. METHODS: Multiple muscle transfer procedures including the transfer of trapezius, pectoralis major, latissimus dorsi muscles, and the Steindler procedure for reconstruction of shoulder and elbow function were performed in 8 patients with cervical spondylotic amyotrophy. Patients were evaluated at a mean of 18.2 months (range, 5-75 mo). RESULTS: All 8 patients obtained satisfactory functional recovery with improvement of active range of motion without any systemic and local complications within 3 to 6 months postoperatively. Patients at the last follow-up had obtained a mean of 91° of shoulder abduction, 111° of shoulder flexion, 23° of external rotation and 110° of elbow flexion. Disability scores (Japanese version) of the arm, shoulder, and hand improved by a mean of 28 points. CONCLUSION: Multiple muscle transfers can improve shoulder and elbow function in cervical spondylotic amyotrophy, in cases of not only poor outcome after cervical surgery, but also in advanced paralysis. It is a useful set of procedures even in old patients, and provides definitive functional improvement of shoulder and elbow function from 3 to 6 months. LEVEL OF EVIDENCE: 4.

Intraosseous xanthoma of the distal radius - a case report.

An intraosseous xanthoma is a very rare condition. It has an aggressive appearance on radiographs mimicking primary or metastatic malignant bone tumors. We report a case of intraosseous xanthoma of the distal radius in a 51-year-old male with no history of hyperlipidaemia. To the best of our knowledge, this condition has not been reported so far in the wrist and forearm region. The lesion was successfully excised and at last follow-up, there were no signs of recurrence and patient has been symptom-free.

Isolated abductor digiti minimi palsy--an unusual case of Guyon's canal compression.

We present a case of isolated Abductor Digiti Minimi (ADM) palsy caused by an anomalous branch from the ulnar artery. Electrophysiology suggested selective involvement of the motor branch to the ADM in the Guyon's canal. Surgical exploration revealed an anomalous branch of the ulnar artery causing a pincer effect on the nerve to the ADM. Division and ligation of this branch effectively decompressed the nerve and the patient recovered satisfactorily. This report highlights the need to consider vascular aberrations as a differential diagnosis for ulnar neuropathy in Guyon's canal.

d-Phenyl-glycinium bromide.

In the crystal of the title salt, C8H10NO2 (+)·Br(-), the bromide anions and the phenylglycinium cations are -linked through N-H⋯Br, O-H⋯Br and C-H⋯O hydrogen bonds, generating sheets lying parallel to (001).

Radioscapholunate arthrodesis using low-profile dorsal pi plate.

Radioscapholunate arthrodesis is a desirable method to treat isolated radiolunate arthritis or ulnar translocation of the carpal bones. An intact midcarpal joint is a prerequisite for functional range of motion. Previously, high rates of nonunion were observed with these procedures, as rigid fixation was difficult to obtain with simple Kirschner wires and screws. A successful outcome depends on bringing the scaphoid, lunate, and the radius to an anatomic alignment, and rigid fixation of the arthrodesis. We describe a technique for the arthrodesis of the radioscapholunate joint from the dorsal side using a low-profile locking Pi plate. We observed the advantages of an easy approach, better visualization of the joint, and easier manipulation of the carpal bones. The Pi plate fits on the scaphoid, lunate, and the radius with minimal adjustment. It is not necessary to remove the Lister's tubercle. Pi plate allows for rigid fixation and compression between the scaphoid, lunate, and the radius by 1 compression and 1 locking screw in scaphoid and lunate, and by 2 eccentric compression screws in the radius. Rectangular retinacular flaps were used under and over the extensor tendons. We performed these arthrodeses in patients with lunate fossa arthritis after a distal radius fracture, and with ulnar translocation of the carpus. We have observed excellent clinical results with about 50% of wrist motion preserved and no cases of nonunion or delayed union.