Efficacy and safety of ligelizumab in adults and adolescents with chronic spontaneous urticaria: results of two phase 3 randomised controlled trials

BACKGROUND

Many patients with chronic spontaneous urticaria (CSU) do not achieve complete control of their symptoms with current available treatments. In a dose-finding phase 2b study, ligelizumab improved urticaria symptoms in patients with H1-antihistamine (H1-AH) refractory CSU. Here, we report the efficacy and safety outcomes from two ligelizumab phase 3 studies.

METHODS

PEARL-1 and PEARL-2 were identically designed randomised, double-blind, active-controlled and placebo-controlled parallel-group studies. Patients aged 12 years or older with moderate-to-severe H1-AH refractory CSU were recruited from 347 sites in 46 countries and randomly allocated in a 3:3:3:1 ratio via Interactive Response Technology to 72 mg ligelizumab, 120 mg ligelizumab, 300 mg omalizumab, or placebo, dosed every 4 weeks, for 52 weeks. Patients allocated to placebo received 120 mg ligelizumab from week 24. The primary endpoint was change-from-baseline (CFB) in weekly Urticaria Activity Score (UAS7) at week 12, and was analysed in all eligible adult patients according to the treatment assigned at random allocation. Safety was assessed throughout the study in all patients who received at least one dose of the study drug. The studies were registered with ClinicalTrials.gov, NCT03580369 (PEARL-1) and NCT03580356 (PEARL-2). Both trials are now complete.

FINDINGS

Between Oct 17, 2018, and Oct 26, 2021, 2057 adult patients were randomly allocated across both studies (72 mg ligelizumab n=614; 120 mg ligelizumab n=616; 300 mg omalizumab n=618, and placebo n=209). A total of 1480 (72%) of 2057 were female, and 577 (28%) of 2057 were male. Mean UAS7 at baseline across study groups ranged from 29·37 to 31·10. At week 12, estimated treatment differences in mean CFB-UAS7 were as follows: for 72 mg ligelizumab versus placebo, -8·0 (95% CI -10·6 to -5·4; PEARL-1), -10·0 (-12·6 to -7·4; PEARL-2); 72 mg ligelizumab versus omalizumab 0·7 (-1·2 to 2·5; PEARL-1), 0·4 (-1·4 to 2·2; PEARL-2); 120 mg ligelizumab versus placebo -8·0 (-10·5 to -5·4; PEARL-1), -11·1 (-13·7 to -8·5; PEARL-2); 120 mg ligelizumab versus omalizumab 0·7 (-1·1 to 2·5; PEARL-1), -0·7 (-2·5 to 1·1; PEARL-2). Both doses of ligelizumab were superior to placebo (p<0·0001), but not to omalizumab, in both studies. No new safety signals were identified for ligelizumab or omalizumab.

INTERPRETATION

In the phase 3 PEARL studies, ligelizumab demonstrated superior efficacy versus placebo but not versus omalizumab. The safety profile of ligelizumab was consistent with previous studies.

FUNDING

Novartis Pharma.

Expression map of entry receptors and infectivity factors for pan-coronaviruses in preimplantation and implantation stage human embryos

PURPOSE

To predict if developing human embryos are permissive to multiple coronaviruses.

METHOD

We analyzed publicly available single-cell RNA-seq datasets of human embryos for the known canonical and non-canonical receptors and spike protein cleavage enzymes for multiple coronaviruses like SARS-CoV, SARS-CoV-2, MERS-CoV, hCoV-229E, and hCoV-NL63. We also analyzed the expression of host genes involved in viral replication, host proteins involved in viral endosomal sorting complexes required for transport (ESCRT), genes of host proteins that physically interact with proteins of SARS-CoV-2, and the host genes essential for coronavirus infectivity.

RESULTS

Of the known receptors of SARS viruses, ACE2, BSG, GOLGA7, and ZDHHC5 were expressed in different proportions in the zygote, 4-cell, 8-cell, morula, and blastocysts including the trophectoderm. The MERS-CoV receptor, DPP4, and hCoV-229E receptor, ANPEP, were expressed mainly from the compact morula to the blastocyst stages. Transcripts of the MERS-CoV alternate receptor LGALS1 were detected in most cells at all stages of development. TMPRSS2 transcripts were detected in the epiblast, primitive endoderm, and trophectoderm, while transcripts of the endosomal proteases CTSL, CTSB, and FURIN were expressed in most cells at all stages of development. ACE2 and TMPRSS2 were co-expressed in a proportion of epiblast and trophectoderm cells. The embryonic cells expressed genes involved in ESCRT, viral replication, SARS-CoV-2 interactions, and coronavirus infectivity. The ACE2 and TMPRSS2 co-expressing cells were enriched in genes associated with lipid metabolism, lysosome, peroxisome, and oxidative phosphorylation pathways.

CONCLUSION

Preimplantation and implantation stage human embryos could be permissive to multiple hCoVs.

Cutaneous paraneoplastic syndrome associated with anal squamous cell carcinoma: a rare presentation of an uncommon cancer

Paraneoplastic syndromes associated with anal squamous cell carcinoma (scc) are rare. Erythema gyratum repens (egr) is a cutaneous paraneoplastic syndrome with distinctive characteristics. Here, we report the rare case of a 73-year-old woman with a chronic erythematous rash for 11 months associated with intense pruritus. She was treated with prednisone and antihistamines by dermatologists, but did not respond. The patient was subsequently seen in our clinic for unintentional weight loss and anorexia with intermittent nausea and vomiting. During further evaluation with imaging studies, upper endoscopy, and colonoscopy with biopsy, poorly differentiated anal scc was identified. Biopsies of the skin rash were characteristic of egr. She was treated using concurrent chemotherapy with 5-fluorouracil and mitomycin C and pelvic radiation (50.4 Gy in 28 fractions) for anal scc. She tolerated the treatment, and her rash faded, with resolution of the pruritus.

The 2019 PGDIS position statement on transfer of mosaic embryos within a context of new information on PGT-A

BACKGROUND

A recently published Position Statement (PS) by the Preimplantation Genetics Diagnosis International Society (PGDIS) regarding utilization of preimplantation genetic testing for aneuploidy (PGT-A) in association with in vitro fertilization (IVF) contained inaccuracies and misrepresentations. Because opinions issued by the PGDIS have since 2016 determined worldwide IVF practice, corrections appear of importance.

METHODS

The International Do No Harm Group in IVF (IDNHG-IVF) is a spontaneously coalesced body of international investigators, concerned with increasing utilization of add-ons to IVF. It is responsible for the presented consensus statement, which as a final document was reached after review of the pertinent literature and again revised after the recent publication of the STAR trial and related commentaries.

RESULTS

In contrast to the PGDIA-PS, we recommend restrictions to the increasing, and by IVF centers now often even mandated, utilization of PGT-A in IVF cycles. While PGT-A has been proposed as a tool for achieving enhanced singleton livebirth outcomes through embryo selection, continued false-positive rates and increasing evidence for embryonic self-correction downstream from the testing stage, has led IDNHG-IVF to conclude that currently available data are insufficient to impose overreaching recommendations for PGT-A utilization.

DISCUSSION

Here presented consensus offers an alternative to the 2019 PGDIS position statement regarding utilization of preimplantation genetic testing for aneuploidy (PGT-A) in association with in vitro fertilization (IVF). Mindful of what appears to offer best outcomes for patients, and in full consideration of patient autonomy, here presented opinion is based on best available evidence, with the goal of improving safety and efficacy of IVF and minimizing wastage of embryos with potential for healthy births.

CONCLUSIONS

As the PGDIS never suggested restrictions on clinical utilization of PGT-A in IVF, here presented rebuttal represents an act of self-regulation by parts of the IVF community in attempts to control increasing utilization of different unproven recent add-ons to IVF.

Latent genital tuberculosis adversely affects the ovarian reserve in infertile women

STUDY QUESTION

What is the effect of latent genital tuberculosis (GTB) on ovarian reserve in infertile women?

SUMMARY ANSWER

Women with latent GTB have lower ovarian reserves and yield lower numbers of oocytes in IVF.

WHAT IS KNOWN ALREADY

Limited evidence suggests that women with GTB may have a low ovarian reserve. Infertile women have a high incidence of latent GTB and treatment improves fertility outcomes.

STUDY DESIGN, SIZE, DURATION

This prospective study from February 2013 to January 2016 compared 431 infertile women diagnosed with latent GTB (Group I) to 453 infertile women without latent GTB (Group II).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at Shreyas Hospital, Kolhapur, India, a tertiary referral centre for infertility. Women of both groups were 21-38 years of age. Group I consisted of infertile women with proven tubal patency but with latent GTB diagnosed by DNA PCR testing of an endometrial biopsy. Day 2-4 anti-Mullerian hormone (AMH) and antral follicle count (AFC) were assessed in both groups. All women with latent GTB took antituberculosis therapy (ATT). Gonadotropin dosages and oocyte and embryo details were noted in both groups for those who underwent IVF.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with latent GTB were younger (29.8 ± 4.4 years vs. 30.8 ± 4.5 years; P = 0.003) and, following adjustment for age, had significantly lower AMH [Median (IQR): 2 (0.9, 4.1) ng/ml vs 2.8 (1.3, 5) ng/ml; P = 0.01] and AFC [Median (IQR): 7 (5, 11) vs 8 (5, 14); P < 0.001]. Post ATT, women with latent GTB yielded fewer oocytes (9.3 ± 7.6 vs. 10.9 ± 8.1; P = 0.01), but had more grade I embryos transferred (1.1 ± 0.5 vs. 0.89 ± 1.0; P = 0.001) and a better implantation rate (26.8% vs. 17.5%; P = 0.004) in IVF compared to women in Group II. Group I had a higher pregnancy rate compared to Group II (51.6% vs. 40.5%; P = 0.001), through various treatment modalities. Considering the adequacy of the sample size and use of robust ovarian reserve markers, the role of chance is minimal.

LIMITATIONS REASONS FOR CAUTION

The study is limited to an infertile population visiting a tertiary referral centre. The mechanisms by which latent GTB infection would lead to ovarian damage are unclear.

WIDER IMPLICATIONS OF THE FINDINGS

It is believed that latent GTB is without any clinical significance. However, a low ovarian reserve in young women with latent GTB necessitates considering it as a cause of infertility, in women with prolonged infertility. These women may experience an accelerated decline in ovarian reserve with reduced success in achieving biological parenthood. Clinicians must be aware of this condition and its consequences while managing infertility.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Sushrut Assisted Conception Clinic, Shreyas Hospital, Kolhapur, India. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Identification of motility-associated progesterone-responsive differentially phosphorylated proteins

Progesterone is one of the regulators of sperm motility and hyperactivation. In human spermatozoa, the effects of progesterone are thought to be mediated by protein phosphorylation. In the present study, we identified 22 proteins that are differentially phosphorylated (12 phosphorylated and 10 dephosphorylated) by progesterone in human spermatozoa. Functionally, the differentially phosphorylated proteins are predicted to have cytoskeletal localisation and to be associated with sperm motility. 5µM of progesterone to capacitated increased the phosphorylation of tyrosine residues in the principal piece and protein tyrosine kinase activity increased by almost 3.5-fold. For the first time, we demonstrate that tyrosine phosphatases are also activated in response to progesterone and that inhibition of tyrosine phosphatases attenuates dephosphorylation of flagellar proteins. We propose that progesterone activates both kinase and phosphatase pathways, leading to changes in the phosphorylation of many proteins in sperm flagella to increase motility.

Accessing completeness of pregnancy, delivery, and death registration by Accredited Social Health Activists [ASHA] in an innovative mHealth project in the tribal areas of Gujarat: A cross-sectional study

Background:

The Innovative Mobile-phone Technology for Community Health Operation (ImTeCHO) is a mobile-phone application that helps Accredited Social Health Activists (ASHAs) in complete registration through the strategies employed during implementation that is linking ASHAs’ incentives to digital records, regular feedback, onsite data entry, and demand generation among beneficiaries.

Objective:

To determine the proportion of pregnancies, deliveries, and infant deaths (events) being registered through the ImTeCHO application against actual number of events in a random sample of villages.

Materials and Methods:

Five representative villages were randomly selected from the ImTeCHO project area in the tribal areas of Gujarat, India to obtain the required sample of 98 recently delivered women. A household survey was done in the entire villages to enumerate each family and create a line-listing of events since January 2014; the line-listing was compared with list of women registered through the ImTeCHO application. The proportion of events being registered through the ImTeCHO application was compared against the actual number of events to find sensitivity of the ImTeCHO application.

Result:

A total of 844 families were found during household enumeration. Out of actual line-listing of pregnancies (N = 39), deliveries (N = 102), and infant deaths (N = 5) found during household enumeration, 38 (97.43%), 101 (99.01%), and 5 (100%) were registered by ASHAs through the ImTeCHO application.

Conclusion:

The use of mobile-phone technology and strategies applied during the ImTeCHO implementation should be upscaled to supplement efforts to improve the completeness of registration.

Susceptibility of gr/gr rearrangements to azoospermia or oligozoospermia is dependent on DAZ and CDY1 gene copy deletions

PURPOSE

The purpose of this study was to determine the association of AZFc subdeletions (gr/gr, b1/b3 and b2/b3) and deletion of DAZ and CDY1 gene copies with male infertility

METHODS

Three hundred twelve controls, 172 azoospermic and 343 oligozoospermic subjects were subjected to AZFc subdeletion typing by STS PCR. Deletion of DAZ and CDY1 gene copies was done using sequence family variant analysis. Sperm concentration and motility were compared between men with and without AZFc subdeletions. Effect of the AZFc subdeletions on ICSI outcome was evaluated.

RESULTS

Amongst the three AZFc subdeletions, the frequency of gr/gr was higher in oligozoospermic (10.5 %) and azoospermic (11.6 %) men as compared to controls (5.1 %). In men with AZFc subdeltions, loss of two DAZ and one CDY1 gene copy made them highly susceptible to azoospermia and severe oligozoospermia with OR of 29.7 and 26, respectively. These subdeletions had no effect on ICSI outcome, albeit there were an increased number of poor quality embryos in AZFc subdeleted group.

CONCLUSION

AZFc subdeletions are a major risk factor for male infertility in the Indian population. In the subjects with AZFc subdeletions, the deletion of DAZ and CDY1 gene copies increases its susceptibility to azoospermia or severe oligozoospermia. Since these deletions can be vertically transmitted to the future male offspring by ICSI, it will be essential to counsel the couples for the transmission of the genetic defect in the male offspring born after assisted reproduction and the risk of perpetuating infertility in future generation.

Differential concentration and time dependent effects of progesterone on kinase activity, hyperactivation and acrosome reaction in human spermatozoa

Progesterone has been identified to be one of the physiological regulators of sperm hyperactivation and acrosome reaction. However, the high sensitivity of human spermatozoa to progesterone implies that many may undergo premature hyperactivation and acrosome reaction thereby compromising their ability to fertilize. We hypothesized that if a spermatozoon has to preclude the occurrence of these events prematurely, there should be differential dose- and time-dependent effects on motility and acrosome reaction. We observed that low concentrations of progesterone (10 and 100 nm) induce sperm motility and activate tyrosine kinase; higher concentrations (1-10 μm) are required to induce extracellular signal regulated kinases 1/2 (Erk1/2), p90 ribosomal S6 kinase (p90RSK), p38 mitogen-activated protein kinase (p38MAPK), c-Jun N-terminal kinase (JNK1) and AKT phosphorylation, hyperactivation and acrosome reaction. The induction of acrosome reaction and tyrosine phosphorylation in response to higher concentration of progesterone is not absolutely dependent on activation of T-type voltage-gated Ca(2+) channel or CatSper as Mibefradil did not completely abrogate progesterone-mediated effects. These results imply that although the spermatozoa are sensitive to low concentrations of progesterone, they only activate motility and tyrosine kinase activation; higher concentrations are required to induce hyperactivation and acrosome reaction probably by activating multiple kinase pathways including the MAPK and AKT.

Progesterone activates Janus Kinase 1/2 and activators of transcription 1 (JAK1-2/STAT1) pathway in human spermatozoa

Ejaculated spermatozoa undergo capacitation and acrosome reaction by responding to extrinsic clues and activate signalling cascades to induce protein tyrosine phosphorylation. In the present study, we investigated the existence, the Janus kinase (JAK) and activator of transcription (STAT) pathway and determined its physiological relevance. JAK1 and STAT1 are localised on the equatorial region and the midpiece of their human spermatozoa, JAK2 is detected on the sperm tail. Capacitation leads to phosphorylation of JAK2 but not JAK1 and STAT1. In the uncapacitated sperm, phosphorylated JAK2 (pJAK2) is localised mainly in the tail region; in response to capacitation, the JAK2 is phosphorylated in the midpiece and the head region along with the tail. Progesterone (5 μm) leads to phosphorylation of JAK1, JAK2 and STAT1 in a time-dependent manner. In progesterone-treated spermatozoa, the JAK2 in the tail is hyperphosphorylated, the JAK2 in the head and the midpiece is dephosphorylated. We conclude that in human spermatozoa, the JAK1/2 pathway is activated upon capacitation and is further modulated by progesterone; the biological processes controlled by this pathway in sperm need to be elucidated.

Cutaneous annular sarcoidosis developing on a background of exogenous ochronosis: a report of two cases and review of the literature

Exogenous (cosmetic) ochronosis is caused by the long term use of skin-lightening creams containing hydroquinone. Three cases of systemic sarcoidosis with cutaneous sarcoidal granulomas, which developed on ochronotic skin were last described by Jacyk in 1995. Dogliotti and Leibowitz previously reported cases of granulomatous ochronosis with sarcoid-like histological changes but with no associated systemic sarcoidosis. We report two additional cases of cutaneous sarcoidal granulomas, which developed on a background of cosmetic ochronosis in patients recently diagnosed with systemic sarcoidosis.

Renal function among cancer patients with bone metastases treated with zoledronic acid in a real world setting

19540

Background: Zoledronic acid (ZA) is a bisphosphonate that reduces skeletal related events (SREs) in cancer patients (pts) with bone metastases but can impact renal function in some pts. This retrospective study examined serum creatinine (sCr) elevations and subsequent treatment changes among pts receiving ZA in community based medical practices. Methods: Data were obtained from the Varian Medical Oncology database of electronic medical records from 17 US oncology practices. Cancer pts with bone metastases and at least one ZA infusion in 2002–06 were followed; all available sCr levels were examined. SCr measurements ≤4 weeks after a ZA infusion were considered levels while on ZA. Elevated sCr was defined as an increase over baseline of ≥0.5 mg/dL or a doubling from baseline for pts with baseline levels <1.4 mg/dL (or ≥1.0 mg/dL for higher baseline levels). Pts with a sCr elevation on ZA were followed to observe changes in ZA dosing and sCr. Results: The study included 875 pts (318 with breast cancer, 131 lung, 154 prostate, 23 multiple myeloma, and 249 other or unknown cancer) with ≥1 sCr level during baseline and ≥1 (median 6) while on ZA. Median age was 66, 41% were male, and 90% had baseline sCr under 1.4 mg/dL. Pts received a median of 6 ZA infusions. SCr elevations occurred in 87 pts (10%), at a median of 19 weeks (range 0.6–126) after the start of ZA. Pts with baseline sCr over 2.0 mg/dL were more likely to experience an elevation (11 pts, 33%). Following the elevated sCr, 37 pts (43%) discontinued ZA; dose reductions and delays were infrequent. Among 49 pts who remained on ZA after elevated sCr and had further sCr while on ZA, 20 (41%) returned to within 10% of baseline, at a median of 7 weeks (range 0.3–31) after the first measured elevation. The proportion returning to normal is a conservative estimate given limited follow-up sCr data. Conclusions: The observed incidence of elevated sCr of 10% in this community based study is similar to clinical trials. Most pts either discontinued ZA or returned to baseline levels despite continued ZA treatment. Few practitioners adhered to recommendations to withhold ZA until levels return to within 10% of baseline.

No significant financial relationships to disclose.

Ontogeny and cellular localization of SRY transcripts in the human testes and its detection in spermatozoa

The sex-determining region on the Y (SRY) gene is unequivocally designated as the testis-determining factor in mammals; however, its roles beyond sex determination, if any, have been hitherto unknown. To determine whether SRY has any roles beyond sex determination, herein the expression of SRY mRNA was investigated in the midtrimester human fetal, infantile and adult testes as well as in ejaculated spermatozoa. High levels of SRY transcripts were in situ localized to the Sertoli cells of the developing testis at 9 weeks of gestation, and the expression persisted at comparable levels throughout the midtrimester (until 22 weeks) and also in the testis of an infant at 3 months of age. The germ cells and other somatic cells in the testes of fetuses and the infant were negative for SRY expression. The mRNA for SRY was detected in the spermatogenic cells, particularly the spermatogonia and the round spermatids; the expression was negligible in the meiotic stages. A single transcript of approximately 1.2 kb was detected in the adult testes and isolated spermatogonial cells. In the adult testis, in situ hybridization (ISH) studies revealed a switch in the cellular localization of SRY transcripts. SRY transcripts were also demonstrable by RT-PCR of RNA from ejaculated human spermatozoa. ISH revealed the presence of SRY transcripts in the midpiece of 50% of ejaculated sperm. These results suggest that SRY may have extensive roles in male reproductive physiology, such as maturation of fetal testis, spermatogenesis, sperm maturation and early embryonic development.

Preimplantation sex selection for family balancing in India

We describe our experience with the use of embryo biopsy and fluorescent in-situ hybridization (FISH) in order to sex embryos for the purpose of family balancing in a private IVF clinic in India from April 1999-April 2001. Embryos were biopsied and analysed on day 3, cultured in sequential media, and then transferred on day 4 or day 5 after morphological selection of the best embryos. From a total of 42 cycles started, we achieved 14 clinical pregnancies and have had nine live births so far with five ongoing pregnancies. This is the first report of the use of preimplantation sex selection for family balancing in India, where couples place a premium on having baby boys, and the social and ethical aspects of the use of this technology in this setting are discussed.

The use of preimplantation genetic diagnosis in sex selection for family balancing in India

This paper describes the use of preimplantation genetic diagnosis (PGD) in sexing embryos for family balancing in a private IVF clinic in India from April 1999 to April 2001. Embryos were biopsied and analysed on day 3, cultured in sequential media and then transferred on day 4 or day 5 after morphological selection of the best embryos. From a total of 42 cycles started, 14 clinical pregnancies and nine live births have been achieved so far, with five ongoing pregnancies. The benefits of delayed transfer 24-48 h after the embryo biopsy are that PGD centres could use the extra time available to confirm the diagnosis or introduce additional diagnostic tests for the same embryo. The selection of blastocysts for transfer should also permit the transfer of fewer embryos, thus reducing the risk of multiple gestations and increasing the pregnancy rate as a consequence of the expected higher implantation rate. This is the first report of the use of PGD in sex selection for family balancing in India, where couples place a premium on having baby boys, and the social and ethical aspects of the use of this technology in this setting are briefly discussed.

Profile of women undergoing reversal of sterilisation

Two hundred twenty women who were subjected to reversal of female sterilisation over 7 years were analysed. It was found that death of the male child was the strongest reason for seeking a reversal. This was coupled with the parity of these subjects being two or less in 70% instances at the time of primary sterilisation surgery. Nearly 85.9% reversal were sought in the higher age groups clubbed together. This has an adverse bearing on success of reversal surgery as the fertility potential of a woman declines physiologically as age advances.

Comparison of MR angiography with contrast angiography for the diagnosis of carotid artery stenosis

To assess the accuracy of MR angiography for screening vascular stenosis of the extracranial carotid arteries, 20 consecutive patients with suspected extracranial carotid atherosclerotic disease were evaluated with time-of-flight MR angiography and intra-arterial contrast angiography. Both studies were independently reviewed by three observers in a blinded manner. The internal carotid arteries were graded as either normal or mildly stenotic (0%-29%), moderately stenotic (30%-69%), severely stenotic (70%-99%) or occluded. Results of the study indicate that time-of-flight MR angiography has a high rate of agreement with contrast angiography and is an accurate screening technique of the common carotid bifurcation in patients with suspected carotid stenosis.

Skin ulceration as sole manifestation of Langerhans-cell histiocytosis

A 65-year-old black woman presented with skin ulceration of 5 years' duration which affected the left axilla, left groin, intergluteal folds and ano-perineal region. The diagnosis of Langerhans-cell histiocytosis (LCH) was confirmed by light and electron-microscopic findings and a positive S-100 stain. Extensive investigations failed to reveal any evidence of systemic involvement. A review of the literature suggests that this clinical picture as the sole manifestation of the disease is rare.