Cytological characteristics of premalignant cervical epithelial lesions in postmenopausal women based on endocrine indices and parakeratosis

OBJECTIVE

To identify useful cytological findings for detecting premalignant lesions in postmenopausal women, cervicovaginal smear samples were analyzed and compared between women with or without premalignant lesions based on endocrine indices and presence of parakeratosis (PK).

METHODS

The cervicovaginal smear samples of postmenopausal women with premalignant lesions (n = 94) and those who were without (n = 344), who were diagnosed between 2012 and 2014 were retrieved and analyzed. Women cytologically diagnosed with malignancy or those with suspicion of malignancy were excluded from this study. Cytological endocrine indices, such as the maturation index (MI) and eosinophilic index (EI) and the prevalence of PK were compared between the groups and analyzed using the 2 × 2 χ2 test. The association of endocrine indices combined with the presence of PK and histological findings was also evaluated.

RESULTS

Postmenopausal women with premalignant lesions had higher endocrine indices (EI of ≥11%; 65% vs. 43%, P < 0.01, f = 0.18) and a higher prevalence of PK positivity (PK ≥ 1; 46% vs. 7%, P < 0.01, f = 0.44) than those without lesions. Further analysis indicated that the combination of high EI and the presence of PK in postmenopausal women with cytological premalignant cases was highly associated with histological squamous intraepithelial lesions (SIL) (86% in women with premalignant lesions vs. 53% in those without; P = 0.01, f = 0.34).

CONCLUSION

Our research demonstrated that high EI and PK positivity were correlated with SIL in postmenopausal women. These cytological findings could provide potential diagnostic clues for detecting dysplasia.

Co-expression of low-risk HPV E6/E7 and EBV LMP-1 leads to precancerous lesions by DNA damage

Background

Low-risk human papillomavirus (HPV), such as types 6 and 11, is considered non-oncogenic, but these types have been detected in oral cancer tissue samples, suggesting their possible involvement in oral carcinogenesis. Because double infection of high-risk HPV and Epstein-Barr virus (EBV) is known to be involved in oral carcinogenesis, we hypothesized that low-risk HPV and EBV co-infection can transform the oral cells. To verify our hypothesis, we evaluated the transformation activity of cell lines expressing both low-risk HPV E6/E7 and EBV LMP-1.

Methods

We transduced HPV6, 11 and 16 E6/E7 genes and EBV LMP-1 gene into primary mouse embryonic fibroblasts. The cell lines were examined for indices of transformation activity such as proliferation, induction of DNA damage, resistance to apoptosis, anchorage-independent growth, and tumor formation in nude mice. To evaluate the signaling pathways involved in transformation, NF-κB and p53 activities were analyzed. We also assessed adhesion signaling molecules associated with anchorage-independent growth such as MMP-2, paxillin and Cat-1.

Results

Co-expression of low-risk HPV6 E6 and EBV LMP-1 showed increased cell proliferation, elevated NF-κB activity and reduced p53 induction. Moreover, co-expression of low-risk HPV6 E6 and EBV LMP-1 induced DNA damage, escaped from apoptosis under genotoxic condition and suppression of DNA damage response (DDR). Co-expression of low-risk HPV11 E6/E7 and EBV LMP-1 demonstrated similar results. However, it led to no malignant characteristics such as anchorage-independent growth, invasiveness and tumor formation in nude mice. Compared with the cells co-expressing high-risk HPV16 E6 and EBV LMP-1 that induce transformation, co-expression of low-risk HPV6 E6 and EBV LMP-1 was associated with low MMP-2, paxillin and Cat-1 expression.

Conclusions

The co-expression of low-risk HPV E6/E7 and EBV LMP-1 does not induce malignant transformation, but it allows accumulation of somatic mutations secondary to increased DNA damage and suppression of DDR. Thus, double infection of low-risk HPV and EBV could lead to precancerous lesions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08397-0.

Effect of PM2.5 for hospitalization of cardiovascular diseases and medical expenses by age group: a nationwide study from the Japanese Registry Of All cardiac and vascular Diseases (JROAD)

Introduction

Although particulate matter with an aerodynamic diameter less than or equal to 2.5 μm (PM2.5) exposure influences cardiovascular events, there is limited knowledge how PM2.5 exposure is associated with cardiovascular hospitalization in Japan.

Purpose

We tested the hypothesis that PM2.5 exposure was related to the number of cardiovascular hospitalizations, hospitalization period, and medical expenses.

Methods

We included 835,405 subjects who were admitted to acute care hospitals in Japan. We classified PM2.5 exposure concentration into quintile groups (from low to high in the order of “PM-1” to “PM-5” group). Multilevel mixed-effects Poisson and linear regression analysis were used to estimate the association of PM2.5 exposure concentration with the cardiovascular hospitalization events, duration and medical expenses. We also analyzed those factors classified by age.

Results

PM-2, 3, 4, 5 group were positively related to the number of cardiovascular hospitalization events compared with PM-1 group (Table 1). PM-3, 4, 5 group were positively associated with a 0.018, 0.029, and 0.029 (all p&lt;0.001) of the difference of log cardiovascular hospitalization period compared with PM-1 group (p for trend &lt;0.001). These groups were also positively associated with a 0.016, 0.023, and 0.021 (all p&lt;0.001) of the difference of log medical expenses compared with PM-1 group (p for trend &lt;0.001). Analyzed by age group, hospitalization duration was longer (p&lt;0.05) and medical expenses was lower (p&lt;0.05) significantly in super-aging group (over 90 years old) than the group under 64 years old (Figure 1).

Conclusions

PM2.5 exposure concentration has harmful effect on not only cardiovascular events but cardiovascular hospitalization period and medical expenses due to big-data in Japan. Medical costs were kept low in comparison with their hospitalization period in subjects over 90 years old.

Figure 1

Funding Acknowledgement

Type of funding source: None

K1 gene transformation activities in AIDS-related and classic type Kaposi's sarcoma: Correlation with clinical presentation

Kaposi's sarcoma-associated herpesvirus (KSHV) causes both AIDS-related Kaposi's sarcoma (KS) and classic KS, but their clinical presentations are different, and respective mechanisms remain to be elucidated. The KSHV K1 gene is reportedly involved in tumorigenesis through the immunoreceptor tyrosine-based activation motif (ITAM). Since we found the sequence variations in the K1 gene of KSHV isolated from AIDS-related KS and classic KS, we hypothesized that the transformation activity of the K1 gene contributes to the different clinical presentations. To evaluate our hypothesis, we compared the transformation activities of the K1 gene between AIDS-related KS and classic KS. We also analyzed ITAM activities and the downstream AKT and NF-κB. We found that the transformation activity of AIDS-related K1 was greater than that of classic K1, and that AIDS-related K1 induced higher ITAM activity than classic K1, causing more potent Akt and NF-κB activities. K1 downregulation by siRNA in AIDS-related K1 expressing cells induced a loss of transformation properties and decreased both Akt and NF-κB activities, suggesting a correlation between the transformation activity of K1 and ITAM signaling. Our study indicates that the increased transformation activity of AIDS-related K1 is associated with its clinical aggressiveness, whereas the weak transformation activity of classic type K1 is associated with a mild clinical presentation and spontaneous regression. The mechanism of spontaneous regression of classic KS may provide new therapeutic strategy to cancer.

Esophageal Xanthoma: Presence of M2 Macrophages Suggests Association with Late Inflammatory and Reparative Processes

Esophageal xanthoma is a rare lesion which is an asymptomatic small yellowish polyp, and most of the reported cases were solitary lesion. Histologically, aggregations of foam cells are found under the papillary hypertrophic squamous epithelium and the foam cells express CD68. The etiology of esophageal xanthoma is unknown. The focal irritation of the esophageal mucosa and infiltrated inflammatory cells are presumed to contribute to its pathogenesis. Although the pathogenesis may be associated with inflammation, the type and nature of the macrophages remain unclear. Here we report a 46-year-old male with esophageal xanthoma, which was incidentally found by endoscopy. Histologically, acute inflammation was not noted, and immunohistochemistry revealed that the foam cells seen in this case of esophageal xanthoma expressed increased levels of M2 macrophage markers. These findings suggest that esophageal xanthoma is associated with late inflammatory and reparative processes long after the initial inflammation of esophageal squamous epithelium.

Molecular Signature of Tumors with Monoallelic 13q14 Deletion: a Case Series of Spindle Cell Lipoma and Genetically-Related Tumors Demonstrating a Link Between FOXO1 Status and p38 MAPK Pathway

Spindle cell/pleomorphic lipomas (SCLs), cellular angiofibromas (CAFs) and mammary-type myofibroblastomas (MFBs) are rare benign mesenchymal tumors with monoallelic 13q14 deletion. They are predicted to have a common pathogenic mechanism due to shared similar histological and immunohistochemical features; however, pathological consequences of monoallelic 13q14 deletion remain unknown. We previously reported a CAF case with monoallelic 13q14 deletion in which the tumor expressed decreased levels of FOXO1 and RB1, both of which were encoded in 13q14, and increased reactive oxygen species (ROS) levels. We further demonstrated the activation of p38 mitogen-activated protein kinase (p38 MAPK) pathway induced by oxidative stress. We hypothesized that SCLs, CAFs and MFBs would share common molecular signatures involving FOXO1, ROS and p38 MAPK and that their expression patterns were different from those tumors without monoallelic 13q14 deletion such as solitary fibrous tumors (SFTs). We compared the expression levels of FOXO1, RB1, ROS markers and several signal transduction factors between SCLs and SFTs. SCLs expressed decreased levels of FOXO1 and RB1, whereas SFTs showed no change. Both tumor types exhibited increased markers of ROS; however, nuclear localization of phosphorylated p38 was significantly more frequent in SCLs than that in SFTs, suggesting p38 MAPK activation by oxidative stress. SFTs showed lower p38 MAPK activity and higher β-catenin expression, implying that oxidative stress was caused by increased cellular proliferation stress. Finally, CAFs and MFBs showed changes similar to those observed in SCLs. Overall, tumors with monoallelic 13q14 deletion showed shared molecular signatures that might be associated with pathogenesis.

Endotracheal Expandable Metallic Stent Placement in Dogs

Various types of Gianturco zig-zag wire stent were implanted into the tracheas of 4 dogs to define the suitable characteristics of the endotracheal wire stent in these animals. The stents were constructed of 0.45, 0.40, and 0.33 mm stainless steel wire. The diameter of the fully expanded stents was 3 cm and their lengths were 2, 3, and 4 cm. The 2 cm stent constructed of 0.33 mm wire showed minimum pathologic changes of the trachea of the dog compared to the other stents, and at the same time had a complete covering of ciliated columnar epithelium over the stent surface.

Treatment of Tuberculous Bronchial Stenosis with Expandable Metallic Stents

Gianturco expandable metallic stents were placed in 5 patients with dyspnea on exercise due to tuberculous bronchial stenosis. The stents were placed after dilatation with a 10-mm diameter high pressure balloon catheter. In all 5 patients, obstructive changes disappeared following the procedure, and dyspnea on exercise improved markedly. No complications related to the procedure were encountered. At follow-up during a period of up to 38 months, 2 patients showed bronchial restenosis at 11 and 17 months, respectively, after stent placement. Restenosis by granulomatous tissue was successfully treated by laser ablation. One patient showed slight one-day hemoptysis 26 months after stent placement.

Abstract P5-12-11: Duration of ovarian function suppression for premenopausal women with hormone receptor-positive breast cancer: Retrospective study

Background: Although tamoxifen (TAM) plus ovarian function suppression (OFS) is one of standard adjuvant treatments in premenopausal women with hormone receptor-positive breast cancer, the optimal duration of OFS has not been clearly established.

Patients and Methods: We retrospectively reviewed data of premenopausal patients with breast cancer, who received TAM and OFS (goserelin or leuprorelin) as adjuvant therapy between February 2004 and April 2015. The primary analysis was to compare disease-free survival (DFS) between patients who received OFS shorter than 3 years and those who received OFS longer than 3 years. The analyses were performed with Cox proportional hazards models and propensity score matching models.

Results: We analyzed 206 premenopausal patients with hormone receptor-positive breast cancer. Median follow-up time was 56 months. Median age was 42 years (range, 24-52 years). Twenty six per cent of the patients had positive axillary nodes and 30% had received neo-adjuvant or adjuvant chemotherapy. Median duration of OFS was 26 months. Duration of OFS was shorter than three years (OFS &lt; 3y) in 74% patients, and longer than three years (OFS &gt; 3y) in 26% patients. Patients with node-positive disease were more in OFS &gt; 3y group than in OFS &lt; 3y group, and more patients received chemotherapy in OFS &gt; 3y group than in OFS &lt; 3y group. 5-year disease-free survival (DFS) was 96.1%. DFS in patients aged ≤ 40 years and aged &gt; 40 years were 91.8% and 99.0%, respectively (p=0.0223). Propensity score matching model showed that DFS was not significantly different between patients in OFS &lt; 3y group and those in OFS &gt; 3y group (97.4%, 91.6%; p=0.2406). In patients aged ≤ 40 years and/or those who received chemotherapy, 5-year DFS was 96.7% in OFS &lt; 3y group, 90.1% in OFS &gt; 3y group (p=0.3011).

Conclusions: Our data suggest that OFS &lt; 3y is not inferior to OFS &gt; 3y for premenopausal women with hormone receptor-positive breast cancer as adjuvant endocrine therapy. A randomized trial is needed to establish the optimal OFS duration for these patients.

Citation Format: Ozaki Y, Tamura N, Utiyama M, Masuda J, Koganemaru S, Miura Y, Tanabe Y, Ogura T, Kadowaki M, Miura D, Kawabata H, Takano T. Duration of ovarian function suppression for premenopausal women with hormone receptor-positive breast cancer: Retrospective study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-12-11.

CD10 expression in the neuroendocrine carcinoma component of endometrial mixed carcinoma: association with long survival

Backgound

Endometrial mixed carcinoma with the neuroendocrine carcinoma (NEC) component is rare and is believed to have a poor prognosis. CD10 expression is reported to be a favorable prognostic marker for some tumors such as B-lymphoblastic leukemia/lymphoma, but unfavorable for others. Here, we report the case of a 33-year-old woman diagnosed with endometrial mixed carcinoma with the NEC component expressing CD10 who showed a favorable outcome.

Case presentation

The patient presented with lumbago and brownish discharge from the genitals. Imaging modalities revealed a large exophytic mass in the uterine corpus, and a small one in the uterine cervix. Radical hysterectomy with bilateral salpingo-oophorectomy was performed. Microscopic examination of the endometrial and cervical masses revealed that the NEC component accounted for the maximum area in both masses. However, small areas in both lesions showed well differentiated endometrioid adenocarcinoma (WDEA) components, and histological transition between the two components was also observed. In addition to CD56 and synaptophysin expression, the NEC component was positive for CD10 but negative for estrogen receptor (ER), progesterone receptor (PgR), and carcinoembryonic antigen (CEA). In contrast, the WDEA component expressed both ER and PgR, but neither CD10 nor neuroendocrine markers were demonstrated. The CD10 and neuroendocrine markers clearly distinguished between the NEC and WDEA components. Furthermore, retained expression of phosphatase and tensin homolog (PTEN) and weak phosphorylated Akt expression were found, which were assumed to suppress the aggressive behavior of the tumor. The patient received postoperative chemotherapy and has survived without recurrence for 6 years after the operation.

Conclusion

This is the first case of endometrial mixed carcinoma with the NEC component expressing CD10 that showed a long survival.

Reconstruction of band structure induced by electronic nematicity in an FeSe superconductor

We have performed high-resolution angle-resolved photoemission spectroscopy on an FeSe superconductor (T_{c}∼8  K), which exhibits a tetragonal-to-orthorhombic structural transition at T_{s}∼90  K. At low temperature, we found splitting of the energy bands as large as 50 meV at the M point in the Brillouin zone, likely caused by the formation of electronically driven nematic states. This band splitting persists up to T∼110  K, slightly above T_{s}, suggesting that the structural transition is triggered by the electronic nematicity. We have also revealed that at low temperature the band splitting gives rise to a van Hove singularity within 5 meV of the Fermi energy. The present result strongly suggests that this unusual electronic state is responsible for the unconventional superconductivity in FeSe.

Evidence for an association between increased oxidative stress and derangement of FOXO1 signaling in tumorigenesis of a cellular angiofibroma with monoallelic 13q14: a case report

Cellular angiofibroma (CAF) is a rare soft tissue tumor characterized by random arrangement of spindle tumor cells in the stroma with short collagen bundles and thick- and hyalinized small vessels. CAFs share histological characteristics with spindle cell lipomas and mammary type myofibroblastomas. Because these tumors harbor monoallelic 13q14, common genetic and molecular mechanism for tumorigenesis is presumed. In this study, we reported a case of CAF in a 69-year-old man with monoallelic 13q14. Immunohistochemical analysis revealed that FOXO1, which is located in chromosome 13q14, was not expressed in the tumor. We also detected oxidative stress markers and found p38 MAPK activation, which is often induced by cellular stressors such as reactive oxygen species (ROS). Because FOXO1 induces the expression of genes encoding enzymes that generate antioxidants, oxidative stress induced by loss of FOXO1 expression may be common among CAFs, spindle cell lipomas, and mammary type myofibroblastomas.

Dual expression of Epstein-Barr virus, latent membrane protein-1 and human papillomavirus-16 E6 transform primary mouse embryonic fibroblasts through NF-κB signaling

The prevalence of Epstein-Barr virus (EBV) and high-risk human papilloma virus (HPV) infections in patients with oral cancer in Okinawa, southwest islands of Japan, has led to the hypothesis that carcinogenesis is related to EBV and HPV co-infection. To explore the mechanisms of transformation induced by EBV and HPV co-infection, we analyzed the transformation of primary mouse embryonic fibroblasts (MEFs) expressing EBV and HPV-16 genes, alone or in combination. Expression of EBV latent membrane protein-1 (LMP-1) alone or in combination with HPV-16 E6 increased cell proliferation and decreased apoptosis, whereas single expression of EBV nuclear antigen-1 (EBNA-1), or HPV-16 E6 did not. Co-expression of LMP-1 and E6 induced anchorage-independent growth and tumor formation in nude mice, whereas expression of LMP-1 alone did not. Although the singular expression of these viral genes showed increased DNA damage and DNA damage response (DDR), co-expression of LMP-1 and E6 did not induce DDR, which is frequently seen in cancer cells. Furthermore, co-expression of LMP-1 with E6 increased NF-κB signaling, and the knockdown of LMP-1 or E6 in co-expressing cells decreased cell proliferation, anchorage independent growth, and NF-κB activation. These data suggested that expression of individual viral genes is insufficient for inducing transformation and that co-expression of LMP-1 and E6, which is associated with suppression of DDR and increased NF-κB activity, lead to transformation. Our findings demonstrate the synergistic effect by the interaction of oncogenes from different viruses on the transformation of primary MEFs.

Abstract P5-08-12: Histopathological and immunohistochemical findings for epithelial-to-mesenchymal transition were associated with clinical progressive disease of triple-negative breast cancers during neoadjuvant chemotherapy

Background: Clinical progressive disease (cPD) occurs during neoadjuvant therapy (NAC) in 3 to 5% of breast cancer patients. By gene expression profiling analyses using DNA microarray, the expression of epithelial-to-mesenchymal transition (EMT)-associated genes were shown to be correlated with chemoresistant phenotype of breast cancer cell lines. In order to reveal clinical implication of EMT-associated molecules on the acquisition of cPD property, we designed a retrospective histopathilogical and immunohistochemical case-control study. Patients and Methods: From pathology database of patients who received surgical resection, 86 patients with early triple-negative breast cancer (TNBC) were identified: 23 patients suffered cPD during NAC (PD group) and 63 control group patients did not receive NAC (C group), in whom &gt;95% of patients was estimated to be non-PD group if NAC was performed. For these 86 cases, histopathological classification was performed and negativity of hormone receptors and HER2 was confirmed. As EMT markers, we immunohistochemically examined the expressions of vimentin, Twist, Twist NB and Snail. The chi-square test was used to assess statistically significant differences between the groups.Results: Histologically, PD group comprised 12 invasive ductal carcinomas (IDCs) (52%) and 11 metaplastic carcinomas (MPCs) (48%), and they all were nuclear grade 3. In C group, 52 (83%) were IDCs and 10 (16%) were histological types other than IDC or MPC, and there was only 1 MPC (1%) (p = 4.31E-08). Nuclear grade was 1, 2, and 3 in 1, 9, and 53, respectively. Vimentin was positive in cytoplasm of 74% of PD group and the incidence was higher than that in C group (49%) (p = 0.016). Cytoplasmic twist-2 and cytoplasmic and nuclear Snail expressions were detected almost equally between PD group and C group. Cytoplasmic Twist NB expression was more frequent in PD group (26%) than in C group (1.6%) (p = 0.0002). In PD group, a total of 17 cases comprising 9 MPCs and 8 IDCs, were positive for vimentin. In these 17 vimentin-positive cases, 14 were stable disease or partial response with an anthracyclin-containing regimen while all 16 patients receiving a taxane-containing regimen became cPD during the taxane-containing regimen.

Patient characteristics PD group (N = 23)Control group(N = 63)Age median (range)42(25-62)55(25-77)Clinical stage:I/II/III0/11/127/44/12Diagnosi at operation:IDC/MPC or MPC containing/others12/11/052/1/10Nuclear grade:1/2/30/0/231/9/53Tumor size at diagnosis4.8(2-14)2.8(1.2-12.0)Neoadjuvant chemoterapy regimen  Anthracyclin containing:AC/CEF11/12-Taxane: paclitaxel/docetaxel20/2-

Conclusion: EMT features detected by metaplastic phenotype and cytoplasmic vimentin expression could be predictors for cPD during NAC for TNBC. The tumors of these phenotypes were likely to be resistant to a taxane-containing regimen.

Immunohistochemical profilingantibodyPD group (N = 23)Control group (N = 63)p-valueVimentin(cytoplasm)17 (74%)31 (49%)0.0411Twist-2(cytoplasm)21(91%)59 (94%)0.7849Snail-2(cytoplasm)12 (52%)38 (60%)0.5548Snail-2(nucleus)14 (61%)34 (54%)0.4677Twist NB(cyroplasm)6 (26%)1 (1.6%)0.0002

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-08-12.

Telaprevir-based triple therapy for chronic hepatitis C patients with advanced fibrosis: a prospective clinical study

BACKGROUND

Antiviral treatment is recommended for chronic hepatitis C patients with advanced fibrosis to reduce and prevent cirrhosis-related complications.

AIM

To evaluate the efficacy and safety of telaprevir (TVR)-based triple therapy for patients with advanced fibrosis in a clinical practice setting.

METHODS

This prospective, multicentre study consisted of 102 patients with advanced fibrosis (METAVIR score F3-4) who were infected with HCV genotype 1b. All received 12 weeks of TVR in combination with 24 weeks of pegylated interferon (PEG-IFN) α2b and ribavirin (RBV).

RESULTS

The sustained virological response (SVR) rate was 69.6% (71 of 102). Notably, for treatment-naïve and prior relapse patients the SVR rate was over 80%. Previous treatment response, interleukin 28B polymorphism (rs8099917) and rapid virological response (undetectable HCV RNA at week 4) were independently associated with SVR. To achieve SVR, an adequate dosage of PEG-IFNα2b (≥1.2 μg/kg/week) and RBV (≥7.5 mg/kg/day) is preferable; however, the mean weight-adjusted TVR dosage had little impact on treatment outcome. Although severe blood cytopaenia and a dermatological disorder were frequently found, the rate of discontinuation due to adverse effects was 12.7%. The inosine triphosphatase CC allele (rs1127354) was independently associated with the development of severe anaemia, and lower serum albumin level (<35 g/L) was associated with the occurrence of infection.

CONCLUSIONS

The great gain in the SVR rate by telaprevir-based triple therapy offsets the problems with adverse effects; thus, it should be considered as a potent treatment protocol for patients with advanced fibrosis, especially for those with treatment-naïve and prior relapse.

MRI findings of corticosubcortical lesions in osmotic myelinolysis: report of two cases

Reports on the MRI findings of cerebral corticosubcortical lesions in osmotic myelinolysis (OM) are rare despite several pathological descriptions of this involvement. We report two patients with subcortical lesions associated with OM that were characteristically distributed along the crowns and sides of the cerebral gyri on T(2) weighted or fluid-attenuated inversion-recovery MRI. We also discuss the MRI characteristics of corticosubcortical lesions in OM.