Comparison of the Efficacy of Low Dose Tadalafil with Tamsulosin against Lower Urinary Tract Symptoms and Sexual Dysfunction after Low Dose Rate Prostate Brachytherapy

PURPOSE/OBJECTIVE(S)

Patients with clinically localized prostate cancer (PCa) can be curatively treated with different modalities, including low dose rate (LDR) prostate brachytherapy (PB). LDR-PB allows the patient a relatively short recovery time compared with other treatment modalities such as prostatectomy. However, PB might exert distinct impact on quality of life, lower urinary tract symptoms (LUTS) and sexual dysfunction (SD) are two major concerns. The aim of present study was to assess prospectively the efficacy of low dose tadalafil treatment on both SD and LUTS compared with tamsulosin treatment in patients treated PB for localized PCa.

MATERIALS/METHODS

Patients scheduled for PB with I-125 seeds for low or intermediate-risk localized PCa at our institution were eligible for this study. The prescribed dose was set at 160 gray. Participants were randomized into two groups; those started treating with a daily use of 0.2 mg of tamsulosin hydrochloride or 5 mg of tadalafil just after PB. The duration of the study was 12 months and the patients were assessed for urinary and sexual function status at baseline, and 1, 3, 6, and 12 months after PB. The primary study endpoints were both changes from baseline in urinary and sexual function status.

RESULTS

Between July 2015 and August 2020, 120 participants were enrolled in this study. The median age was 68 years with the median PSA of 6.5 ng/ml. A total 15 patients were excluded within 6 months after randomization. All subjective LUTS findings, including International Prostate Symptom Score (IPSS), and Over Active Bladder Symptom Score (OABSS), were significantly deteriorated at 1, 3, and 6 months after PB compared with baseline in both groups, respectively (p<0.05). Among objective LUTS findings, a significant decrease in maximum urinary flow rate (Qmax) was found at 1, 3, 6, and 12 months after PB compared with baseline in both groups, respectively (p<0.05). A significant increase in post void residual urine (PVR) was found at 1, 3, and 6 months after PB compared to baseline in tadalafil group, whereas no significant increase was seen in tamsulosin group. There were no statistically significant differences between the 2 groups in scores of the total International Index of Erectile Function (IIEF)-15 and Erection Hardness Score (EHS) before and at 1 month post PB. The EHS was significantly higher in tadalafil group compared with tamsulosin group at 3, 6 and 12 months (p = 0.001, p = 0.004, and p = 0.019, respectively). The EHS after PB in tadalafil group was not significantly decreased from baseline.

CONCLUSION

After LDR-PB, tamsulosin treatment significantly decreased PVR compared with tadalafil. On the other hand, tadalafil contributed to maintain erection hardness compared with tamsulosin.

In vitro analysis of factors affecting the continuous hemodiafiltration clearance of teicoplanin

BACKGROUND

In the treatment of sepsis, continuous hemodiafiltration (CHDF) and the administration of antibiotics such as teicoplanin (TEIC) are frequently performed in parallel. We aimed to clarify the factors influencing the CHDF clearance (CL_CHDF ) of TEIC using a polymethylmethacrylate (PMMA) membrane or a polyacrylonitrile and sodium methallyl sulfonate copolymer membrane coated with polyethylenimine (AN69ST). We also investigated whether the adsorption of TEIC onto the hemofilters inhibits the adsorption of interleukin (IL)-6 onto the membranes.

METHODS

TEIC, human serum albumin (HSA), and IL-6 were incubated with pieces of hemofilter membranes and adsorption rates were calculated. The CL_CHDF , diafiltration rate, and adsorption rate of TEIC were calculated using an in vitro CHDF circuit model.

RESULTS

The adsorption rates of TEIC onto the pieces of PMMA and AN69ST membranes ranged from 15.0% to 100% and from -10% to 5%, respectively. The adsorption rate of IL-6 was similar with or without TEIC. The CL_CHDF and adsorption rate of TEIC under PMMA-CHDF depended on HSA, but not on effluent flow rate (Qe). The CL_CHDF under AN69ST-CHDF depended on HSA and Qe. The observed CL_CHDF under AN69ST-CHDF was similar to the predicted value (the product of Qe and the plasma unbound fraction). The observed CL_CHDF under PMMA-CHDF was 2.0-7.8 times greater than the predicted value.

CONCLUSIONS

Adsorption mainly contributes to the CL_CHDF of TEIC using PMMA membranes, whereas diafiltration mainly contributes to the CL_CHDF of TEIC using AN69ST membranes. TEIC adsorption might not affect the adsorption of IL-6 onto PMMA membrane.

Contribution of diafiltration and adsorption to vancomycin clearance in a continuous hemodiafiltration circuit model in vitro

BACKGROUND

Vancomycin (VCM) is eliminated mainly by diafiltration under continuous hemodiafiltration (CHDF), but the contribution of adsorption to CHDF clearance (CL_CHDF ) of VCM using a polyacrylonitrile and sodium methallyl sulfonate copolymer membrane coated with polyethylenimine (AN69ST) or a polymethylmethacrylate (PMMA) membrane is unknown. This study sought to investigate the contribution of diafiltration and adsorption to the CL_CHDF of VCM using AN69ST and PMMA membranes in vitro.

METHODS

An in vitro CHDF circuit model was developed. The initial concentration of VCM was 50 μg/mL and human serum albumin (HSA) was prepared at a concentration of 0, 2.5, or 5.0 g/dL. The effluent flow rate (Qe) was set at 800, 1500, or 3000 mL/h. The CL_CHDF , diafiltration rate, and adsorption rate of VCM were calculated.

RESULTS

Total CL_CHDF of VCM using the AN69ST membrane increased and decreased with increasing Qe and HSA concentration, respectively. Diafiltration and adsorption rates were 82.1 ± 9.8% and 12.1 ± 6.1% under all conditions, respectively. Total CL_CHDF using the PMMA membrane increased with increasing Qe. Diafiltration and adsorption rates were 89.2 ± 20.4% and 4.6 ± 17.0% under all conditions, respectively. The observed CL_CHDF values significantly correlated with the predicted CL_CHDF , calculated according to a previous study as the product of Qe and the plasma unbound fraction.

CONCLUSIONS

Diafiltration predominantly contributed to CL_CHDF of VCM using AN69ST and PMMA membranes. When diafiltration rather than adsorption mainly contributes to the CL_CHDF of VCM, the CL_CHDF could be predicted from the Qe and HSA concentration, at least in vitro.

The temporal evolution of income polarization in Canada's largest CMAs

Income polarization is a pressing issue which is increasingly discussed by academics and policymakers. The present research examines income polarization in Canada’s eight largest Census Metropolitan Areas (CMAs) using data at the census-tract (CT) level between 1971 and 2016. Generally, there are significant decreasing trends in the middle-income population with simultaneously increasing trends in low-income groups. The high-income groups have been relatively stable with fewer significant increasing population trends. Using conventional mapping and cartograms, patterns of the spatial evolution of income inequality are illustrated. Every CMA examined contains an increasing trend of spatial fragmentation at the patch level within each CMA’s landscape mosaic. The results of a spatial autocorrelation analysis at the sub-patch, CT level, exhibit significant spatial clustering of high-income CTs as one process that dominates the increasingly fragmented landscape mosaic.

Association between socioeconomic indicators and geographic distribution of vestibular schwannomas in West Scotland: a 15-year review

OBJECTIVE

Socioeconomic risk factors may contribute to geographic variation in diseases, but studies are limited due to lack of large available cohorts.

METHOD

A geographic analysis was performed of the association between socioeconomic risk factors and the distribution of vestibular schwannomas in adults diagnosed with sporadic vestibular schwannomas through the National Health Services in the West of Scotland from 2000 to 2015.

RESULTS

A total of 511 sporadic vestibular schwannomas were identified in a population of over 3.1 million. Prevalence of vestibular schwannomas were lowest in cases with good health (-0.64, 95 per cent confidence interval: -0.93,-0.38; p = 0.002) and level 1 qualifications (-0.562, 95 per cent confidence interval: -0.882 to -0.26; p = 0.01). However, these risk factors did not demonstrate consistent linearity of correlations. Prevalence was lower in people originating from European Union accession countries from April 2001 to March 2011 (-0.63, 95 per cent confidence interval: -0.84 to -0.43; p = 0.002). No correlation between distribution of vestibular schwannomas and socioeconomic risk factors met our threshold criteria (± 0.7).

CONCLUSION

This study demonstrated that there is little variation in distribution of vestibular schwannomas by socioeconomic risk factors.

Robotic Radical Trachelectomy Using the Double Bipolar Method- Aiming for a Bloodless Operative Field

Study Objective

To report the application of the double bipolar technique in a patient with 1b1 cervical cancer who wished to preserve her fertility potential.

Design

After experiencing 105 cases of laparoscopic and robotic radical trachelectomy with a 5 year survival rate of 98% and the birth of 29 babies from 51 of these patients who attempted pregnancy, we introduced the double bipolar method to overcome technical difficulties of the procedure due to the necessity for precise dissection and reconstruction in the deep pelvis. We will show our operative techniques, such as nerve sparing radical trachelectomy and retroperitoneal lymphadenectomy for early invasive cervical cancer in a bloodless operative field.

Setting

Urban general hospital.

Patients or Participants

Robotic radical trachelectomy using the double bipolar method was performed in three patients with 1b1 cervical cancer.

Interventions

After Robotic radical trachelectomy using monopolar scissors in 30 cases of stage Ib1 cervical cancer, we considered techniques for a more bloodless operative field. The double bipolar method (DBM) was originated by a robotic gastrointestinal surgeon, Prof Ichiro Uyama. Using robotic Maryland forceps as a cutting device allows for pinpoint accuracy that cannot be found in other instruments. It is important for bladder and ureteral dissection and exposure of vessels. Cuts are made at a very limited point by a lightning strike mechanism, meaning there is minimal thermal spread to adjacent organs.

Measurements and Main Results

Blood loss was 250ml in the cases presented. In surgeries not using the DBM(n=34), the blood loss ranged from 350ml(100-1200ml). While there is no supporting data, the dissection of the ureter was very smooth.

Conclusion

A bloodless operative field allows for accurate dissection and can prevent intraoperative injuries. The double bipolar method is able to provide precision cutting and limit thermal spread to adjacent tissue, reducing injury and allowing for a clear operative field.

Roles of Re-entrant cluster glass state and spin-lattice coupling in magneto-dielectric behavior of giant dielectric double perovskite La1.8Pr0.2CoFeO6

La based Co-Fe combined double perovskite (La1.8Pr0.2CoFeO6) was synthesized and the dielectric (zero-field and in-field), magnetic, x-ray absorption and Raman spectroscopy measurements have been investigated for La1.8Pr0.2CoFeO6double perovskite. The existence of re-entrant cluster glass state is observed. The magneto-dielectric (MD) is found in two temperature regions (25-80 K and 125-275 K). It has been demonstrated that the observed MD at low and high temperatures are respectively due to the spin freezing and the spin-lattice coupling. Furthermore, the very large dielectric constant and the low loss suggest that La1.8Pr0.2CoFeO6is very important from the application point of view.

AB0619 PROGNOSTIC FACTORS OF PATIENTS WITH ANTI-MDA5 ANTIBODY-POSITIVE DERMATOMYOSITIS COMPLICATED WITH INTERSTITIAL PNEUMONIA -A JAPANESE SINGLE CENTER STUDY-

Background:

Anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive dermatomyositis (DM) is frequently associated with rapidly progressive interstitial pneumonia (RPIP), whose prognosis is assumed to be poor[1]. Although outcome of DM-RPIP has been reported to be improved by early immunosuppressive therapy, we still experience the cases with severe outcome. Only several reports mentioned the prognostic factors and they have not been fully elucidated.

Objectives:

To identify the predictors of prognosis in patients with anti-MDA5 Ab-positive DM associated with interstitial pneumonia (DM-IP).

Methods:

Anti-MDA5 Ab-positive DM-IP patients admitted to Fujita Health University Hospital between January 2010 and October 2019 were consecutively included and stratified into 2 groups, the survived and the deceased groups. DM was diagnosed according to the criteria proposed by Bohan and Peter[2]. Clinically amyopathic DM was diagnosed according to the criteria proposed by Sontheimer [3]. Diagnosis of IP was based on findings of high resolution CT scan (HRCT). The definition of RPIP was rapid exacerbation of hypoxemia or HRCT findings in a period of days to one month after the onset. Clinical features and prognosis of the patients were collected retrospectively and compared between groups. Candidates of predictors are extracted by the univariable analysis using Fisher’s exact test for dichotic parameters and Wilcoxon signed-rank test for continuous parameters and multivariable analysis using logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was examined to obtain the cut-off level. Survival was examined using Kaplan-Meier method and Log-rank test.

Results:

Twenty-one patients were involved. Eight were deceased and 13 were survived. The deceased group had a higher ratio of male (75% versus 25%, p= 0.018). All deceased cases were with RPIP and 67 % in the survived cases. Levels of serum ferritin (4490 versus 646 ng/mL, p = 0.0026), CRP (2.1 versus 0.9 mg/dL, p = 0.0490), CK (1150 versus 290 U/L, p = 0.017), AST (194 versus 108 U/L, p = 0.025) and LDH (674 versus 368 U/L, p = 0.011) were higher in the deceased group. Interestingly, skin ulcers were tended to be more frequent (12.5% versus 87.5%, p= 0.0587), and anti-SS-A antibody was also more frequently detected (14.3% versus 85.7%, p=0.0072) in the survived group. Using ROC analysis cut-off values were 963 ng/mL for serum ferritin level (sensitivity 100%, specificity 83%), 0.7 mg/dL for CRP (sensitivity 75%, specificity 69%), 308 U/L for CK (sensitivity 88%, specificity 77%), 62 U/L for ALT (sensitivity 100%, specificity 62%), and 454 U/L for LDH (sensitivity 88%, specificity 77%). Patients were divided into two groups based on these cut-offs or based on dichotic parameters and survival was examined between 2 groups. Except CRP and anti-SS-A antibody, survival was significantly worse in parameter-positive or higher groups. Interestingly, anti-SS-A antibody-positive group had better outcome compared with those without.

Conclusion:

In our analysis, novel candidates such as serum CK, AST, and LDH levels were newly extracted and parameters previously reported was also included and those were also associated with the clinical outcome. In addition, anti-SS-A antibody was identified as a novel protective factor associated with a good outcome.

References:

[1]Nakashima R, Hosono Y, Mimori T. Clinical significance and new detection system of autoantibodies in myositis with interstitial lung disease. Lupus 2016;25:925-33.

[2]Bohan A, Peter JB. Polymyositis and dermatomyositis. N Eng J Med 1975;292:344-7.

[3]Sontheimer RD. Dermatomyositis: an overview of recent progress with emphasis on dermatologic aspects. Dermatol Clin 2000;20:387-408.

Disclosure of Interests:

None declared

Investigation of multi-mode spin-phonon coupling and local B-site disorder in Pr2CoFeO6 by Raman spectroscopy and correlation with its electronic structure by XPS and XAS studies

Electronic structure of Pr₂CoFeO₆ (at 300 K) was investigated by x-ray photoemission spectroscopy (XPS) and x-ray absorption spectroscopy techniques. All three cations, i.e. Pr, Co and Fe were found to be trivalent in nature. XPS valance band analysis suggested the system to be insulating in nature. The analysis suggested that Co³⁺ ions exist in low spin state in the system. Moreover, Raman spectroscopy study indicated the random distribution of the B-site ions (Co/Fe) triggered by same charge states. In temperature-dependent Raman study, the relative heights of the two observed phonon modes exhibited anomalous behaviour near magnetic transition temperature T _N ~ 270 K, thus indicating towards interplay between spin and phonon degrees of freedom in the system. Furthermore, clear anomalous softening was observed below T _N which confirmed the existence of strong spin-phonon coupling occurring for at least two phonon modes of the system. The line width analysis of the phonon modes essentially ruled out the role of magnetostriction effect in the observed phonon anomaly. The investigation of the lattice parameter variation across T _N (obtained from the temperature-dependent neutron diffraction measurements) further confirmed the existence of the spin-phonon coupling.

Deep mapping gentrification in a large Canadian city using deep learning and Google Street View

Gentrification is multidimensional and complex, but there is general agreement that visible changes to neighbourhoods are a clear manifestation of the process. Recent advances in computer vision and deep learning provide a unique opportunity to support automated mapping or ‘deep mapping’ of perceptual environmental attributes. We present a Siamese convolutional neural network (SCNN) that automatically detects gentrification-like visual changes in temporal sequences of Google Street View (GSV) images. Our SCNN achieves 95.6% test accuracy and is subsequently applied to GSV sequences at 86110 individual properties over a 9-year period in Ottawa, Canada. We use Kernel Density Estimation (KDE) to produce maps that illustrate where the spatial concentration of visual property improvements was highest within the study area at different times from 2007–2016. We find strong concordance between the mapped SCNN results and the spatial distribution of building permits in the City of Ottawa from 2011 to 2016. Our mapped results confirm those urban areas that are known to be undergoing gentrification as well as revealing areas undergoing gentrification that were previously unknown. Our approach differs from previous works because we examine the atomic unit of gentrification, namely, the individual property, for visual property improvements over time and we rely on KDE to describe regions of high spatial intensity that are indicative of gentrification processes.

A direct observation method for auditing large urban centers using stratified sampling, mobile GIS technology and virtual environments

BACKGROUND

With the expansion and growth of research on neighbourhood characteristics, there is an increased need for direct observational field audits. Herein, we introduce a novel direct observational audit method and systematic social observation instrument (SSOI) for efficiently assessing neighbourhood aesthetics over large urban areas.

METHODS

Our audit method uses spatial random sampling stratified by residential zoning and incorporates both mobile geographic information systems technology and virtual environments. The reliability of our method was tested in two ways: first, in 15 Ottawa neighbourhoods, we compared results at audited locations over two subsequent years, and second; we audited every residential block (167 blocks) in one neighbourhood and compared the distribution of SSOI aesthetics index scores with results from the randomly audited locations. Finally, we present interrater reliability and consistency results on all observed items.

RESULTS

The observed neighbourhood average aesthetics index score estimated from four or five stratified random audit locations is sufficient to characterize the average neighbourhood aesthetics. The SSOI was internally consistent and demonstrated good to excellent interrater reliability. At the neighbourhood level, aesthetics is positively related to SES and physical activity and negatively correlated with BMI.

CONCLUSION

The proposed approach to direct neighbourhood auditing performs sufficiently and has the advantage of financial and temporal efficiency when auditing a large city.

Calibration of the microcalorimeter spectrometer on-board the Hitomi (Astro-H) observatory (invited)

The Hitomi Soft X-ray Spectrometer (SXS) was a pioneering non-dispersive imaging x-ray spectrometer with 5 eV FWHM energy resolution, consisting of an array of 36 silicon-thermistor microcalorimeters at the focus of a high-throughput soft x-ray telescope. The instrument enabled astrophysical plasma diagnostics in the 0.3-12 keV band. We introduce the SXS calibration strategy and corresponding ground calibration measurements that took place from 2012-2015, including both the characterization of the microcalorimeter array and measurements of the x-ray transmission of optical blocking filters.

Inositol 1,4,5-Triphosphate Receptor Protein Immunohistochemistry of Cerebellar Purkinje Cells in Two Dogs with Hypoglycemia

Immunohistochemical study was performed on cerebellar Purkinje cells of two dogs with hypoglycemia using an antibody against the inositol 1,4,5-triphosphate receptor that is identical to the cerebellar Purkinje cell glycoprotein P400 (P400/InsP3R). In the cerebellar neocortex of an acute case of hypoglycemia, the P400/InsP3R staining of hypoglycemic Purkinje cells was heterogeneous: some peripheral dendrites, including spiny branchlets, were negative and others were stained with various intensities, although Purkinje cells were morphologically intact by hematoxylin and eosin (HE) stain. In a chronic case of hypoglycemia, almost all the dendrites of Purkinje cells of both the neo- and archicortex of the cerebellum were not stained with the P400/InsP3R antibody. This is in contrast to the normal dog where Purkinje cell bodies, axons, and dendrites, including spiny branchlets, are intensely stained by the P400/InsP3R antibody. These results suggest that P400/InsP3R immunolabeling of Purkinje cells decreased, despite their morphology being preserved by HE stain, and that the function of P400/InsP3R, especially in spiny branchlets that receive inputs originating from axon terminals of parallel fibers, may be impaired in hypoglycemia.

Evaluation of primary prophylaxis with granulocyte colony-stimulating factor for epithelial ovarian cancer

PURPOSE

Primary prophylaxis with G-CSF has been used to minimize myelosuppression caused by anticancer agents and to avoid severe neutropenia. The authors retrospectively examined the value of primary prophylaxis using granulocyte colony-stimulating factor (G-CSF) for epithelial ovarian cancer.

MATERIALS AND METHODS

From 2001 to 2010, 105 patients with ovarian cancer receiving chemotherapy in the present hospital were divided into two groups: one received primary prophylaxis with G-CSF and the other did not receive it in compliance with the guidelines for G-CSF usage. The incidence of febrile neutropenia (FN), degree of neutropenia, frequency of G-CSF administration, number of days of hospitalization, progression-free survival (PFS), and overall survival (OS) were evaluated.

RESULTS

Neutrophils decreased almost equally and the length of hospitalization was not significantly lower between the groups. Five-year PFS or OS showed no significant difference either.

CONCLUSIONS

Primary prophylaxis with G-CSF in chemotherapy for epithelial ovarian cancer could be of low significance.

Outcome of fertility-sparing treatment with medroxyprogesterone acetate for atypical hyperplasia and endometrial carcinoma in young Japanese women

PURPOSE

To review the outcome in patients with atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) who received MPA treatment in the present hospital.

MATERIALS AND METHODS

Patients with AEH or EC were administered MPA for 12 weeks followed by endometrial curettage. The rates of effect, recurrence, pregnancy, and complications were evaluated. The changes in progesterone receptors and FOXO-1, known as a target of MPA treatment, were examined by immunostaining.

RESULTS

Four of seven patients with endometrial cancer and three of three patients with AH had complete response. Four of seven patients had recurred within one year after the treatment and had to undergo hysterectomy. None of the patients showed changes in progesterone receptors. Although six of seven patients were negative for FOXO-1 before and after treatment, all the patients showed increased developments of FOXO-1 during MPA treatment.

CONCLUSION

Progestin as a fertility-preserving treatment is expected to be effective for endometrial cancer, but judicious use might be required because it shows high rate of recurrence. Further studies regarding the mechanism may be necessary to achieve high efficacy.

Kairomone from dandelion,Taraxacum officinale, attractant for scarab beetleAnomala octiescostata

The attraction of the scarab beetleAnomala octiescostata to dandelion,Taraxacum officinale, was demonstrated to be chemically mediated by a mixture ofcis-3-hexenyl acetate, benzaldehyde, phenylacetaldehyde, benzyl alcohol, phenethyl alcohol, phenylacetonitrile, and benzyl benzoate, in the ratio 4:8:14:3:5:19:11. Combination of the synthetic kairomone and sex pheromone (buibuilactone + japonilure, 8:2), significantly increased the total catches ofA. octiescostata. Catches of male (but not female) beetles were significantly higher with the kairomone-pheromone blend than with kairomone alone. The synergistic effect of the kairomone from dandelion on the attractiveness did not significantly differ from that of a food-type lure, anethol, geraniol, and phenethyl propionate (9:0.5:0.5). The latter combined with the synthetic sex pheromone resulted in better attraction of female (but not male)A. octiescostata than the sex pheromone alone.

Identification and field evaluation ofAnomala octiescostata (Coleoptera: Scarabaeidae) sex pheromone

Using GC-EAD, the sex pheromone of the scarab beetleAnomala octiescostata was identified to be a 8:2 binary mixture of (R,Z)-5-(-)-(oct-1-enyl)oxacyclopentan-2-one and (R,Z)-5-(-)-(dec-1-enyl)oxacyclopentan-2-one. These semiochemicals have been also reported as sex pheromone constituents of otherAnomala species, either geographically or seasonally isolated fromA. octiescostata. Synthetic sex pheromone was highly attractive in the field; 0.1 mg captured significantly more males than two virgin females. Buried traps were significantly more attractive than those positioned at 30, 90, and 150 cm above the ground. In a dose-response test (0.1-100 mg), no saturation due to overdose of pheromone was observed, but in most cases, two dosages differing by 10-fold were not significantly different. Response of males to traps baited with different ratios of the two components was tested in two experiments with randomized blocks and Latin-square designs. Deviation from the natural ratio (8:2) of sex pheromone did not significantly diminish the response of males. Peak flight activity of beetle was recorded at 9:00-10:00 AM JST on sunny days in the end of April 1993.