Longitudinal change of energy expenditure, body composition and dietary habits in Progressive Supranuclear Palsy patients

INTRODUCTION

Alterations in metabolic status, body composition, and food intake are present in all neurodegenerative diseases. Aim of this study was to detect the progression of these changes in Progressive Supranuclear Palsy (PSP).

METHODS

We conducted a longitudinal study of 15 patients with PSP. The assessments were performed at baseline (T0) and after 7(IQR = 5) months of follow-up (T1). We collected anthropometric measures including body weight, height, body mass index and waist circumference, metabolic parameters through indirect calorimeters, body composition using bioimpedance analysis, and dietary habits with a validated questionnaire. PSP-rating scale (PSP-rs) was used to evaluate disease severity and dysphagia.

RESULTS

The majority of patients (66.66%) presented PSP-Richardson Syndrome and 33.33% the other variant syndromes of the disease. At T1 there was a decrease in intake of total daily calories (p < 0.001), proteins (p < 0.001), fibers (p = 0.001), calcium (p = 0.008), iron (p < 0.001), zinc (0.034), vitamin E (p = 0.006) and folates (p = 0.038) compared to T0. No other changes were found. As for T1 data, no significant differences were shown according to disease phenotypes or the presence of clinically significant dysphagia for solids.

CONCLUSIONS

Within a mid-term follow up, PSP patients presented reduced caloric and proteins intake regardless the presence of dysphagia. The PSP-rs is likely not adequate to assess dysphagia, which should be investigated by specific clinical scales or instrumental examinations. With the goal of maintaining adequate nutritional status, the administration of protein and vitamin supplements should be considered even in the absence of dysphagia evidenced by the rating scales.

Direct Current Stimulation of Prefrontal Cortex Is Not Effective in Progressive Supranuclear Palsy: A Randomized Trial

BACKGROUND

Progressive supranuclear palsy (PSP) is a rare 4R-tauopathy. Transcranial direct current stimulation (tDCS) may improve specific symptoms.

OBJECTIVES

This randomized, double-blinded, sham-controlled trial aimed at verifying the short-, mid-, and long-term effect of multiple sessions of anodal tDCS over the left dorsolateral prefrontal cortex (DLPFC) cortex in PSP.

METHODS

Twenty-five patients were randomly assigned to active or sham stimulation (2 mA for 20 minute) for 5 days/week for 2 weeks. Participants underwent assessments at baseline, after the 2-week stimulation protocol, then after 45 days and 3 months from baseline. Primary outcomes were verbal and semantic fluency. The efficacy was verified with analysis of covariance.

RESULTS

We failed to detect a significant effect of active stimulation on primary outcomes. Stimulation was associated to worsening of specific behavioral complaints.

CONCLUSIONS

A 2-week protocol of anodal left DLPFC tDCS is not effective in PSP. Specific challenges in running symptomatic clinical trials with classic design are highlighted. © 2024 International Parkinson and Movement Disorder Society.

Bariatric surgery and dimethyl fumarate-induced lymphopenia in patients with multiple sclerosis

INTRODUCTION

Lymphopenia is a known side effect of dimethyl fumarate (DMF), a disease-modifying therapy (DMT) for patients with multiple sclerosis (pwMS). A body mass index ≥ 30 kg/m2 has been identified as a protective factor; however, no data are available on lymphopenia in pwMS undergoing to weight loss due to bariatric surgery.

METHODS

We described two pwMS with history of bariatric surgery who started DMF as DMT.

RESULTS

The two pwMS experienced persistent lymphopenia during DMF-treatment, which was resolved after its discontinuation.

CONCLUSIONS

Several mechanisms might modify DMF pharmacokinetic profiles after bariatric surgery and its bioavailability. Absolute lymphocyte count should be monitored in pwMS treated with DMF and history of bariatric surgery and weight loss.

Is there a role for adjuvant therapy in radiation-induced angiosarcoma of the breast? A case report and review of the literature

BACKGROUND

Angiosarcoma (AS) of the breast is very rare, accounting for 1% of all soft tissue breast tumors. AS may present as primary tumors of the breast or as secondary lesions usually associated with previous radiotherapy. Commonly, secondary AS affects older women (median age 67-71 years) with a clinical history of breast cancer. The preferred site of onset of RIAS is the edge of radiation fields, where radiation doses and tumor necrosis may be heterogeneous, resulting in a DNA damage and instability. Radical surgery is the treatment of choice, but no clear consensus exists on surgical management of breast AS.

CASE REPORT

We describe an atypical case of relapsed RIAS after radical mastectomy, treated with new surgery and, considering the higher risk of recurrence, subsequent adjuvant chemotherapy with weekly paclitaxel.

CONCLUSIONS

The frequency of radiation-induced angiosarcomas (RIAS) after breast-conserving surgery and radiotherapy has been increased to 0.14-0.5% among long survivors. Nevertheless, even if RIAS continues to be prognostically an extremely unfavorable cancer due to a high rate of recurrence, distant spread, and median overall survival (OS) of about 60 months, the benefits of loco-regional breast radiotherapy are clearly higher than the risk in developing angiosarcoma.

A Phospholipid Profile at 4 Months Predicts the Onset of Celiac Disease in at-Risk Infants

Celiac disease (CeD) is a multifactorial disease influenced by both genetic and environmental risk factors. CeD genetic components are mainly due to HLA class II genes, which account for approximately 40% of the disease heritability. The environmental factor is linked to gliadin ingestion. Despite genetic and epigenetic studies, the pathological molecular mechanism remains unclarified. The strong genetic component does not explain more than half of the hereditability; we identified several epigenetic features that contribute to the understanding of the missing hereditability. The lipid profile of infants has been proposed as a potential biomarker of CeD metabolism that can be measured before they exhibit developmental disorders and clinical symptoms. We suggest that the state of the host is a main factor for the abnormal immune response to gluten. Long before any exposure to the offending agent or any production of specific antibodies, several molecular mechanisms are differentially expressed in infants who will develop CeD compared to their peers matched for the same genetic profile. The present study explored the serum phospholipid profile of a group of infants at risk for celiac disease, followed up to 8 years to monitor the onset of CeD. We compared 30 patients who developed the disease with 20 age- and sex-matched peers with similar genetic profiles who did not develop the disease within 8 years. Serum phospholipids were analysed at 4 months, before exposure to gluten, and at 12 months of age, when none showed any marker of disease. In the 30 CeD patients, we also analysed the serum at the time of diagnosis (>24 months). The serum phospholipid profile was fairly constant across 4 and 12 months of age and, in CeD, up to 24–36 months. The phospholipid signature was dramatically different in infants who developed CeD when compared to that of control NY-CeD (Not Yet developing Celiac Disease) peers. We identified a specific serum phospholipid signature that predicts the onset of celiac disease in HLA at-risk infants years before the appearance of antibodies specific for CeD in the serum and before any clinical symptoms, even before gluten introduction into the diet at 4 months. Specifically, lysophosphatidylcholine, phosphatidylcholine, alkylacyl-phosphatidylcholine, phosphoethanolamines, phosphatidylserines, phosphatidylglycerol and phosphatidylinositol were found to be differentially represented in CeD versus NY-CeD. A set constituted by a limited number of alkylacyl-phosphatidylcholine and lyso-phosphatidylcholine, together with the duration of breast-feeding, allows the discrimination of infants who develop celiac disease before 8 years of age from those at a similar genetic risk who do not develop the disease. In addition to recent discovery, our paper unveiled a specifc phopholipid profile, able to discriminate infants who eventually develop celiac disease years before antibodies or clinical symptoms ensue.

[Solid pseudo papillary tumor of the pancreas: case report and literature review]

Solid pseudopapillary neoplasm (SPT) of the pancreas is a rare exocrine tumor, for the first time described from Frantz et al. in 1959. Despite the increasing recognition of the tumor in this last year, its pathogenesis remain unclear. It occurs predominantly in young woman and behave in an indolent fashion, even when distant metastasis are present. The Authors report the case of a 24 years-old woman with an abdominal mass localized in retro-peritoneum, removed with body-tail of the pancreas and spleen, diagnosed as pancreatic SPT after histological examination.

Partial purification and MALDI-TOF MS analysis of UN1, a tumor antigen membrane glycoprotein

UN1 is a membrane glycoprotein that is expressed in immature human thymocytes, a subpopulation of peripheral T lymphocytes, the HPB acute lymphoblastic leukemia (ALL) T-cell line and fetal thymus. We previously reported the isolation of a monoclonal antibody (UN1 mAb) recognizing the UN1 protein that was classified as "unclustered" at the 5th and 6th International Workshop and Conference on Human Leukocyte Differentiation Antigens. UN1 was highly expressed in breast cancer tissues and was undetected in non-proliferative lesions and in normal breast tissues, indicating a role for UN1 in the development of a tumorigenic phenotype of breast cancer cells. In this study, we report a partial purification of the UN1 protein from HPB-ALL T cells by anion-exchange chromatography followed by immunoprecipitation with the UN1 mAb and MALDI-TOF MS analysis. This analysis should assist in identifying the amino acid sequence of UN1.

Evaluation of hepatic metastases from colorectal carcinoma with MR-superparamagnetic iron oxide

The purpose of this study was to compare the results obtained with superparamagnetic iron oxide-enhanced and unenhanced Magnetic Resonance at 1.5 T with that of spiral-computed tomography (CT) in order to select those patients suitable for liver resection; the intraoperative US (IOUS) comprised the gold standard. Thirty five candidates for liver resection with known colorectal neoplasm were studied; 26 patients underwent surgery, one patient underwent RF ablation and 8 of them were submitted to follow-up. MR examination was performed using a 1.5 T superconductive instrument, CT examination was performed on a Somatom-Plus (Siemens) scanner. Dimensions and number of the lesions were defined in all patients as well as the sensitivity of spiral CT and MR imaging, using either the plain technique or after Ferumoxides c.m.. In those patients submitted to surgery, results have been correlated to those of IOUS. From 26 patients, a total of 48 lesions were removed surgically. With CT, 34 lesions with 3 false positive cases were detected; 32 with plain MR imaging, while MR imaging with Ferumoxides detected 41 lesions. In the patients not submitted to surgery, MR iron-oxide imaging identified 15 lesions, while both plain MR imaging and CT showed 8 lesions. The smallest lesion was 6 mm. as shown by MR imaging with Ferumoxides. In the cases submitted to surgery, the CT sensitivity was 71%, plain MR imaging 66% and MR imaging with Ferumoxides 85%. In our experience, Ferumoxides-enhanced MR imaging of the liver shows increased sensitivity compared to plain and spiral-CT in the evaluation of hepatic metastases. We think that MR superparamagnetic iron oxide should be used in all patients selected for liver resection.

Bladder cancer within a direct inguinal hernia: CT demonstration

We present a case of a urothelial neoplasm arising within a direct bladder hernia in the inguinal canal. Bladder hernias are rarely found preoperatively and are exceptional sites of neoplasm. Spiral computed tomography with gaseous insufflation of the bladder demonstrated the bladder hernia and the extension of the neoplasm in the inguinal canal more accurately than other computed tomographic techniques with nonopacified and iodinated urine.

Primary cancer of the urinary bladder: CT evaluation of the T parameter with different techniques

The evaluation of mural invasion (T) in primary urinary bladder carcinoma is important in the planning of an appropriate surgical or radiochemotherapeutic strategy. Previous investigators using computed tomography (CT) have evaluated the bladder filled with urine, urine opacified with iodinated contrast material, or air insufflation. The purpose of this trial was to establish which of these three techniques was the most accurate by comparing data obtained in postoperative staging (pT). Sixty-five patients with primary bladder cancer were enrolled, all of whom were studied by spiral CT with these three techniques. Patients were assigned to four stage groups: Ta-T1, T2-T3a, T3b, and T4. The results demonstrated total accuracies of 95% for the air-insufflated bladder, 90.5% for opacified urine, and 87% for noncontrast studies. In conclusion, the air-insufflated bladder is the more accurate technique in the evaluation of the T parameter in primary bladder cancer, especially in the first and third stage groups.

Overcoming resistance to chronomodulated 5-fluorouracil and folinic acid by the addition of chronomodulated oxaliplatin in advanced colorectal cancer patients

The addition of oxaliplatin (L-OHP) to a 5-fluorouracil (5-FU)/ leucovorin (FA) regimen was retrospectively evaluated in 35 consecutive advanced colorectal cancer patients after progression of disease. L-OHP, 25 mg/m2/day, was infused from 10.00-22.00 with a peak flow at 16.00 while 5-FU, 700 mg/m2/day and FA, 150 mg/m2/day of the I-form or 300 mg/m2/day of the racemic form, from 22.00 to 10.00 with a nocturnal peak at 4.00, for 5 days every 3 weeks in 24 patients and for 4 days every 2 weeks in the other 11. Diarrhea and sensitive neuropathy were the most relevant types of toxicity (17% of patients). An objective response was achieved in 8/35 patients (23%) [95% CL 9-37], stabilization in 15 patients (43%) which included five minor responses, and progression in 12. There was no relevant difference in quality of life assessed with the EORTC QLQ C30+3 questionnaire before and after treatment. Median duration of response and median progression-free survival were 6 months; median overall survival was 11 months. This retrospective study showed that it is possible to reverse resistance to chronomodulated 5-FU by adding chronomodulated L-OHP to the previous regimen; comparison with different schedules of this combination should be performed in order to identify the best tolerated and active regimen as second-line treatment of advanced colorectal cancer.

Ciliary motility at light microscopy: a screening technique for ciliary defects

To verify whether or not ciliary motility can be reliably assessed by light microscopy alone, we examined the nasal brushings of 53 patients with suspected ciliary dyskinesia and 10 healthy controls. The results of light microscopy were compared with cilia ultrastructure assessed with electron microscopy. Ciliary motility was significantly related with cilia ultrastructure. However, eight cases of lung disease due to bronchiectasis of unknown origin had immotile cilia on light microscopy, but normal ciliary ultrastructure on electron microscopy. Instances of normal and abnormal ultrastructure were detected in one case with motile cilia. There was an 83% agreement between electron microscopy and light microscopy. Sensitivity and specificity of light microscopy were 92% and 80%, respectively. In conclusion, light microscopy evaluation of ciliary motility does not appear to be a reliable screening test for ciliary dyskinesia because it does not quantify ciliary beat activity, which is a criterion for deranged ciliary motion. A complete evaluation of ciliary ultrastructure together with in vivo, if applicable, or in vitro function test (namely, the analysis of ciliary beat frequencies and/or waveform) is required for a definite diagnosis of ciliary dyskinesia.

Cranioplasty performed with a new osteoconductive osteoinducing hydroxyapatite-derived material

OBJECT

Cranioplasty is required to protect underlying brain, correct major aesthetic deformities, or both. The ideal material for this purpose is autogenous bone. When this is not available, alloplastic or artificial materials may be used. These materials should be malleable, strong, lightweight, inert, noncarcinogenic, nonferromagnetic, and, if possible, inexpensive. The authors reviewed their surgical experience with a new bone substitute and discuss outcomes in patients in whom it was used.

METHODS

The 11 patients presented in this series had bone defects resulting from bone-involving tumor (eight cases), trauma (two cases), or aesthetic deformity due to repeated craniotomies (one case). The defects were repaired using Osprogel, a bone substitute that consists of calcium hydroxyapatite combined with synthetic, human bone-derived gelatin, glycerol, and water. Osprogel is not only a bioinert material but also an osteoconductive and osteoinducing substrate; when it is placed in contact with healthy cancellous bone, it induces osteogenesis and angiogenesis, thus permitting the regrowth of nearly normal bone. The sheet of Osprogel was modeled onto the cranial defect intraoperatively and was kept in place either by using a titanium micronet secured to surrounding bone with microscrews (first two cases) or by using a single- or double-layer titanium mesh secured with stitches. No complications due to the procedure were observed. The results, evaluated at least 6 months after surgery by using three-dimensional (3-D) reconstructed computerized tomography scans, were excellent in seven patients, good in three, and fair in one. In the patient with a fair result, the repair was unsatisfactory because there was lack of experience in using the material. In part of the area to be repaired, the Osprogel was used as filler; here it was washed out and resorbed. The cases deemed as having a good result had good bone replacement; however, the curvature was faulty.

CONCLUSIONS

In the near future, this technique may be refined to achieve good or excellent results either without the use of supporting material or with the use of individual, computer-designed 3-D prostheses.

Cystic fibrosis: when should high-resolution computed tomography of the chest Be obtained?

OBJECTIVE

To provide indications for high-resolution computed tomography (HRCT) of the chest in patients with cystic fibrosis (CF).

DESIGN

We compared the HRCT and conventional chest radiography (CCR) scores and assessed their correlation with clinical scores and pulmonary function tests.

SETTING

Department of Pediatrics, Federico II University, Naples, Italy.

SUBJECTS

A total of 30 patients with CF 6.75 to 24 years of age.

RESULTS

CCR scores correlated highly with HRCT (r = -0.8) and clinical (r = 0.5) scores, whereas total HRCT scores were not related to clinical scores. Of all the specific HRCT findings, only bronchiectasis appeared related significantly to the clinical score (r = 0.6). Most pulmonary function tests were related to CCR and total HRCT scores, but not to HRCT scoring of specific changes. Forced vital capacity and CCR scores appeared the best predictors of the HRCT score (multiple R = 0.58 and 0.79, respectively). In patients with mild lung disease, HRCT detected bronchiectasis and air trapping in 57% and 71% of the cases, respectively. In patients with more abnormal chest radiographs, bronchiectasis and air trapping were demonstrated on HRCT in all cases.

CONCLUSIONS

These findings suggest that HRCT of the chest is most useful in the identification of early lung abnormalities in patients with CF with mild respiratory symptoms, whereas for established disease, CCR is still the first-line imaging technique. The advantage of detecting early changes on CT imaging awaits additional confirmation, at least until early therapeutic interventions affecting significantly the final outcome of the disease are demonstrated. In patients with advanced disease, HRCT may be useful in the evaluation of specific lung changes when more aggressive treatment such as chest surgical interventions is indicated. Given the cost of the procedure and the high radiation dosage compared with CCR, a careful assessment of the cost:benefit ratios of HRCT is strongly recommended in CF.

[Images of hepatic parasitic cysts: echotomography, computed tomography and magnetic resonance compared]

Hepatic hydatic cysts are a very common finding in the endemic areas like Australia, the Middle East, New Zealand, South Africa and in some countries bordering the Mediterranean. Immigration has increased the finding of this pathology in some European and North American areas. Our purpose is to show possibilities and limits using US, TC and RM to demonstrate the presence of parasitic hepatic localizations and their evolution after therapy.

[Magnetic resonance in the evaluation of mediastinal masses]

Thirty-three patients with mediastinal masses were examined by means of MRI to obtain elements for lesion characterization, to evaluate lesion extent, and to assess the relationship of the mass to the surrounding structures, especially the great vessels (accuracy: 84.84%), mediastinal structures (accuracy: 76.78%), and lung parenchyma (accuracy 69.69%). MR data were compared to CT findings; sensitivity, specificity and accuracy were subsequently compared to surgical and histologic findings. The results have shown MRI to be a very reliable method in the evaluation of mediastinal masses.

[MR in rectal cancer recurrences]

Fourteen patients, who had undergone surgery for rectal carcinoma, were studied by MR imaging to evaluate the presence of recurrences. MR results were compared to those obtained by needle biopsy or laparotomy. MR imaging proved to be a valuable method in diagnosing tumor recurrences on the basis of tissular morphology, whereas its capabilities were poor in differentiating recurrence from fibrosis on the basis of the signal intensity on T2-weighted images.

[The role of magnetic resonance in the study of cerebrospinal malformations in childhood. An analysis of 51 clinical cases]

This study was aimed at assessing MR utility in the evaluation of cerebral-medullar malformative pathologic conditions in infants. Among 274 patients 2 months to 15 years old examined by means of MR imaging, 51 (18.6%) were affected with cerebral-medullar abnormalities. Seventeen different types of pathologic conditions were identified, some of which single and some multiple; tethered cord was the most frequent finding. 45/51 patients affected with malformative pathologic conditions required sedation. The high incidence of malformative pathologic conditions in pediatrics highlights the importance of this subject for all the radiologists dealing with MR imaging in pediatrics. MR imaging appears to be the method of choice for the evaluation of cerebral-medullar abnormalities.

[MR in the evaluation of schizencephaly]

This study was aimed at evaluating MR utility in the diagnosis of schizencephaly in patients with seizures and developmental delay. In 7 patients, 8 months to 15 years old, MR imaging detected the presence of unilateral (5 cases) and bilateral (2 cases) hemisferic clefts. Moreover, MR imaging allowed the presence of such anomalies as dysgenesis of the corpus callosum, and agenesis of the septum pellucidum to be demonstrated, together with areas of polymicrogyria and heterotopic gray matter.

[CT in the evaluation of carcinoma of the pancreas]

The routine use of CT has given a great contribution both to the diagnosis and to the evaluation of the extent of pancreatic carcinomas. Forty-three patients clinically suspected of pancreatic carcinoma were examined with CT. Forty of them underwent surgical control. This study was conducted to evaluate the role of CT in the diagnosing and staging of pancreatic carcinomas. 31/43 neoplasms were identified, with a diagnostic accuracy of 90%. CT was extremely accurate in the demonstration of late metastases, while it had lower accuracy in assessing the involvement of lymph nodes and peripancreatic vessels (60-70%). CT proved to be extremely useful in diagnosing pancreatic carcinomas, for it allows the detection of masses associated with Wirsung's duct dilatation and atrophy, which are a highly pathognomonic sign of pancreatic neoplasms. Moreover, CT proved useful in the staging, by assessing the presence of lymph nodes and metastases.

[Evaluation of parietal infiltration in carcinoma of the bladder: comparison of MR imaging, CT and histology]

Twenty-two patients with bladder carcinoma were examined by MR imaging and CT to determine the degree of parietal involvement. The results were then compared with the surgical and histological findings. A classification in CT and MR stages was elaborated in order to supply corresponding models to clinical TNM staging. Three groups were thus formed, corresponding to the evolutive phases of the tumor. The first MR group included T1-T2 forms (accuracy: 75%); the second group included T3a forms (accuracy: 75%), and the third T3b-T4 forms (accuracy: 90%). Overall MR accuracy was 81.81%. The first CT group included T1 forms (acc. 71.42%), the second group T2-T3a forms (acc. 60%), and the third group included T3b-T4 forms (acc. 90%). Overall CT accuracy was 77.27%. MR imaging proved thus more accurate than CT in the staging of bladder tumors, especially thanks to its allowing deep muscular involvement to be assessed.

Computed tomographic staging of anterior mediastinal neoplasms

Sixty patients with anterior mediastinal neoplasms undergoing computed tomography before surgical exploration were entered in a prospective study to assess the value of computed tomography in the preoperative staging of anterior mediastinal tumours. Correct prediction of location, size, and tissue density was obtained in all 60 cases. Correct identification of the nature of the tumours was achieved by computed tomography in 37 of the 54 previously undiagnosed cases. Particular attention was given to the evaluation of the relation of the tumour to adjacent mediastinal structures, to predict the feasibility of radical surgical procedures. Overall sensitivity, specificity, and accuracy in identifying resectability were 46%, 85%, and 64%, with positive and negative predictive indices of 78% and 58%. Capsulated or highly invasive lesions were clearly distinguished, and the presence or absence of infiltration of mediastinal vessels, pericardium, and chest wall was correctly recognised in most cases. It is suggested that the evaluation of anterior mediastinal neoplasms should include computed tomography because of its accuracy in predicting size, location, and tissue density of the neoplasm. Computed tomography may suggest, often with good reliability, the histological type of the tumour and its relation to contiguous mediastinal structures, thus contributing to the choice of the appropriate surgical approach or route for biopsy.

Computed tomography for the evaluation of intrathoracic invasion by lung cancer

We conducted computed tomographic examinations of the chest in 171 patients with lung cancer whose disease was subsequently surgically staged; routine mediastinal exploration was undertaken in all patients undergoing thoracotomy (151), and in 20 patients only anterior mediastinotomy or mediastinoscopy was performed. We have considered three groups of patients: In Group I (including all 171 patients) mediastinal lymph nodes were evaluated for metastatic involvement; nodes were considered diseased when greater than 1 cm. Sensitivity, specificity, and accuracy were 95%, 83%, and 89%. Among these 171 patients, 34 (Group II) had a central tumor otherwise considered operable, which was shown on plain roentgenograms to be in contact with the mediastinum; infiltration of hilar and mediastinal vessels and of mediastinal tissues was investigated preoperatively with computed tomography and then ascertained at thoracotomy. Sensitivity, specificity, and accuracy were 68%, 72% and 70%. Twenty-seven patients (Group III) had a peripheral tumor abutting the pleural surface and suspected to invade the parietal pleura and chest wall; patients with evident bone infiltration were excluded. Sensitivity, specificity, and accuracy of computed tomography were 50%, 90%, and 65%.