Biochemically recurrent prostate cancer: rationalisation of the approach to imaging

AIM

To assess the utility of magnetic resonance imaging (MRI) in addition to the additive benefit of the conventional imaging techniques, computed tomography (CT) and nuclear medicine (NM) bone scintigraphy, for investigation of biochemical recurrence (BCR) post-prostatectomy where access to prostate specific membrane antigen (PSMA) positron-emission tomography (PET)-CT is challenging.

MATERIALS AND METHODS

Relevant imaging over a 5-year period was reviewed. Ethical approval was granted by the internal review board. All patients with suspected BCR, defined as a PSA ≥0.2 ng/ml on two separate occasions, underwent a retrospective imaging review. This was performed on PACS archive search database in a single centre using search terms "PSA" and "prostatectomy" in the three imaging methods; MRI, CT, and NM bone scintigraphy. All PSMA PET CT performed were recorded.

RESULTS

One hundred and eighty-five patients were identified. Patients with an MRI pelvis that demonstrated distant metastases (i.e., pelvic bone metastases or lymph node involvement more cranial to the bifurcation of the common iliac arteries) were more likely to have a positive CT and/or NM bone scintigraphy. The Pearson correlation coefficient between the findings of M1 disease at MRI pelvis and the presence of distant metastases at CT thorax, abdomen, pelvis and NM bone scintigraphy was calculated at 0.81 (p<0.01) and 0.91 (p<0.01) respectively.

CONCLUSION

An imaging strategy based on risk stratification and technique-specific selection criteria leads to more appropriate use of resources, and in turn, increases the yield of conventional imaging methods. MRI prostate findings can be used to predict the additive value of CT/NM bone scintigraphy allowing a more streamlined approach to their use.

First Evidence of Axial Shape Asymmetry and Configuration Coexistence in ^{74}Zn: Suggestion for a Northern Extension of the N=40 Island of Inversion

The excited states of N=44 ^{74}Zn were investigated via γ-ray spectroscopy following ^{74}Cu β decay. By exploiting γ-γ angular correlation analysis, the 2_{2}^{+}, 3_{1}^{+}, 0_{2}^{+}, and 2_{3}^{+} states in ^{74}Zn were firmly established. The γ-ray branching and E2/M1 mixing ratios for transitions deexciting the 2_{2}^{+}, 3_{1}^{+}, and 2_{3}^{+} states were measured, allowing for the extraction of relative B(E2) values. In particular, the 2_{3}^{+}→0_{2}^{+} and 2_{3}^{+}→4_{1}^{+} transitions were observed for the first time. The results show excellent agreement with new microscopic large-scale shell-model calculations, and are discussed in terms of underlying shapes, as well as the role of neutron excitations across the N=40 gap. Enhanced axial shape asymmetry (triaxiality) is suggested to characterize ^{74}Zn in its ground state. Furthermore, an excited K=0 band with a significantly larger softness in its shape is identified. A shore of the N=40 "island of inversion" appears to manifest above Z=26, previously thought as its northern limit in the chart of the nuclides.

Rapid, application-based survey to characterise the impacts of COVID-19 on LGBTQ+ communities around the world: an observational study

INTRODUCTION

Emerging evidence indicates that the COVID-19 pandemic, and the responses it has generated, have had disproportionate impacts on lesbian, gay, bisexual, transgender and queer (LGBTQ+) communities. This study seeks to build on existing information and provide regional insight.

METHODS

In response, a cross-sectional survey was administered to a global sample of LGBTQ+ individuals (n=13 358) between 16 April and 20 May 2020 via the social networking application Hornet. The survey contained questions that characterise the impact of COVID-19 and associated mitigation strategies on economics, employment, mental health and access to healthcare.

RESULTS

5191 (43.9%) individuals indicated they were somewhat, slightly or unable to meet basic needs with their current income, while 2827 (24.1%) and 4710 (40.1%) felt physically or emotionally unsafe in their living environment, respectively. 2202 individuals (24.7%) stated they are at risk for losing health insurance coverage. 2685 (22.7%) persons reported having skipped or cut meals as there was not enough money.

CONCLUSION

Many LGBTQ+persons who responded reported adverse consequences to mental health, economics, interruptions to care and lack of support from their government. This data is part of ongoing analyses but accentuates the unique needs of LGBTQ+ communities that will require targeted, ameliorative approaches.

The Impact of COVID-19 on Anxiety and Worries for Families of Individuals with Special Education Needs and Disabilities in the UK

COVID-19 has affected people across the world. The current study examined anxiety and worries during the first UK national lockdown in March 2020. Parents (n = 402) reported on their own anxiety and worries as well as that of their son/daughter with Special Education Needs and Disabilities (SEND) and typically developing (TD) child (n = 186) at three time points. Although both groups showed increased anxiety across the three time points, levels of anxiety in the SEND group, but not the TD siblings, were predicted by awareness about COVID-19. In addition, worries differed between the groups showing that COVID-19 impacts the wellbeing of those with SEND differently to that of their TD siblings.

What is community engagement and how can it drive malaria elimination? Case studies and stakeholder interviews

Background

In light of increasing complexity of identifying and treating malaria cases in low transmission settings, operational solutions are needed to increase effective delivery of interventions. Community engagement (CE) is at the forefront of this conversation given the shift toward creating local and site-specific solutions. Malaria programmes often confuse CE with providing information to the community or implementing community-based interventions. This study seeks to expand on CE approaches for malaria by looking to a variety of health and development programmes for lessons that can be applied to malaria elimination.

Methods

Qualitative data was collected from key informant interviews and community-based focus group discussions. Manual analysis was conducted with a focus on key principles, programme successes and challenges, the operational framework, and any applicable results.

Results

Ten programmes were included in the analysis: Ebola, HIV/Hepatitis C, Guinea worm, malaria, nutrition, and water, sanitation and hygiene. Seven focus group discussions (FGDs) with 69 participants, 49 key informant (KI) interviews with programme staff, and 7 KI interviews with thought leaders were conducted between October–April 2018. Participants discussed the critical role that village leaders and community health workers play in CE. Many programmes stated understanding community priorities is key for CE and that CE should be proactive and iterative. A major theme was prioritizing bi-directional interpersonal communication led by local community health workers. Programmes reported that measuring CE is difficult, particularly since CE is ongoing and fluid.

Conclusions

Results overwhelmingly suggest that CE must be an iterative process that relies on early involvement, frequent feedback and active community participation to be successful. Empowering districts and communities in planning and executing community-based interventions is necessary. Communities affected by the disease will ultimately achieve malaria elimination. For this to happen, the community itself must define, believe in, and commit to strategies to interrupt transmission.

Electronic supplementary material

The online version of this article (10.1186/s12936-019-2878-8) contains supplementary material, which is available to authorized users.

Stranger danger awareness in Williams syndrome

BACKGROUND

The developmental disorder Williams syndrome (WS) is characterised by a distinctive cognitive profile and an intriguing social phenotype. Individuals with the disorder are often highly social engaging with familiar and unfamiliar people and once in an interaction they often show subtle abnormalities of social behaviour. Atypically increased approach to unfamiliar people is widely reported in the existing literature for both children and adults. Parents frequently report interactions with unfamiliar people as a major concern.

METHODS

In this study we aimed to evaluate 'stranger danger' awareness using a video vignette task with individuals who had WS. When linked to other components of the WS phenotype (e.g. reduced intellectual ability, increased social approach) an awareness of stranger danger is particularly important.

RESULTS

Qualitative and quantitative data showed that young people with WS have difficulties making judgements about whether or not to trust and engage in conversation with unfamiliar people. Qualitative data showed that individuals with WS often suggested that they would engage in an interaction with an unfamiliar person.

CONCLUSIONS

The findings have substantial implications for the safety of young people with the disorder and emphasise the need for intervention regarding this behaviour.

Ramsey county day treatment services:

Ramsey County Extended Day Treatment is designed for persons with a serious and persistent mental illness such as major depression, schizophrenia, bipolar disorder or personality disorder. The uniqueness of the model is the combination of an intake and referral group with six levels of group psychotherapy. Additionally, single issue groups provide a concentrated focus on employment or community contribution, anger management, and peer relationships. The result is a well-structured, non-residential program where a client can work in a treatment environment based on one's ability to participate. This article describes the intake and referral group, outlines the six separate programs, and describes the use of occupational therapy and cognitive behavioral therapy throughout the model.

Initial experience with a rapid access blackouts triage clinic

Transient loss of consciousness (T-LOC), or blackout, is common in acute medicine. Clinical skills are not done well, with at least 74,000 patients misdiagnosed and mistreated for epilepsy in England alone. The aim of this study was to provide a rapid, structured assessment and an electrocardiogram (ECG) for patients with blackouts, aiming to identify high risk, reduce misdiagnoses, reduce hospital admission rates for low-risk patients, diagnose and treat where appropriate, and also provide onward specialist referral. The majority of patients had syncope, and very few had epilepsy. A high proportion had an abnormal ECG. A specialist-nurse-led rapid access blackouts triage clinic (RABTC) provided rapid effective triage for risk, a comprehensive assessment format, direct treatment for many patients, and otherwise a prompt appropriate onward referral. Rapid assessment through a RABTC reduced re-admissions with blackouts. Widespread use of the web-based blackouts tool could provide the NHS with a performance map. The U.K. has low rates of pacing compared to Western Europe, which RABTCs might help correct. The RABTC sits between first responders and specialist referral, providing clinical assessment and ECG in all cases, and referral where appropriate.

Davalintide (AC2307), a novel amylin-mimetic peptide: enhanced pharmacological properties over native amylin to reduce food intake and body weight

OBJECTIVE

The current set of studies describe the in vivo metabolic actions of the novel amylin-mimetic peptide davalintide (AC2307) in rodents and compares these effects with those of the native peptide.

RESEARCH DESIGN AND METHODS

The anti-obesity effects of davalintide were examined after intraperitoneal injection or sustained peripheral infusion through subcutaneously implanted osmotic pumps. The effect of davalintide on food intake after lesioning of the area postrema (AP) and neuronal activation as measured by c-Fos, were also investigated.

RESULTS

Similar to amylin, davalintide bound with high affinity to amylin, calcitonin and calcitonin gene-related peptide receptors. Acutely, davalintide displayed greater suppression of dark-cycle feeding and an extended duration of action compared with amylin (23 versus 6 h). Davalintide had no effect on locomotor activity or kaolin consumption at doses that decreased food intake. Davalintide-induced weight loss through infusion was dose dependent, durable up to 8 weeks, fat-specific and lean-sparing, and was associated with a shift in food preference away from high-fat (palatable) chow. Metabolic rate was maintained during active weight loss. Both davalintide and amylin failed to suppress food intake after lesioning of the AP and activated similar brain nuclei, with davalintide displaying an extended duration of c-Fos expression compared with amylin (8 versus 2 h).

CONCLUSION

Davalintide displayed enhanced in vivo metabolic activity over amylin while retaining the beneficial properties possessed by the native molecule. In vitro receptor binding, c-Fos expression and AP lesion studies suggest that the metabolic actions of davalintide and amylin occur through activation of similar neuronal pathways.

Comparing the Accuracy of Digital Subtraction Angiography, CT Angiographyand MR Angiography at Estimating the Volume of Cerebral Aneurysms

SUMMARY

While there are many studies that compare imaging modalities in the detection of cerebralaneurysms there are no existing studies that compare two dimensional digital subtraction angiography (DSA), CT angiography (CTA) and MR angiography (MRA) in calculating the volume of cerebral aneurysms. This study will compare these imaging modalities on seven in vitro models of known volume. Seven silicone models of cerebral aneurysms were chosen representing slight variations in geometric shape and size. The volume of each model was measured by weighing the amount of water required to fill the aneurysm to the parentartery. Contrast enhanced images of the modelswere taken with DSA, CTA and MRA. The images were interpreted by four independent readers and the volumes were calculated. The measured volumes from the water weight analysis were compared to the volumes calculated from the interpreter's measurements. The accuracy of DSA, CTA and MRA were compared using the percent of absolute and true variance from the measured volume. The average percent absolute variance for DSA was 14.3%, CTA was 16.8% and MRA was 18.6%. While these differences were minimal, comparing the percent of true variance demonstrated an average variance of -1.9% for DSA, 16.1% for CTA and -15.9% for MRA. Calculating the volume of cerebral aneurysms, while increasingly important, is difficult and error prone. It is important to understand the limitations and inherent errors before relyingon calculated volumes in clinical decision making. Regardless of imaging modality, one should consider error rates of 14-19% for calculatingvolume while keeping in mind the tendencyfor CTA to overestimate volume, MRA to underestimate volume and DSA to both under and overestimate equally.

Psychometric evaluation of a brief geriatric depression screen

This article is a psychometric evaluation of the experimental Geriatric and Extended Careline Depression Screen (GEDS) for geriatric nursing care residents. The GEDS is a five-item depression screen based on an abbreviated version of the Center for Epidemiological Studies Depression Scale (CES-D). A total sample of 91 male residents over the age of 60 were recruited from a Veterans Administration Nursing Home Care Unit. The Geriatric Depression Scale-Short Form (GDS-SF) was used as a gold standard test to examine the convergent validity of the GEDS. The Discriminant Trait Inventory was used to assess divergent validity and the confounding effects of method variance in this research design. Test-retest reliability, redundance and omission in item content validity were systematically evaluated. A receiver operating characteristics (ROC) curve was used to identify the most effective cut-off score for clinical selection. Reliability was significant, but moderate. Convergent validity with the Geriatric Depression Scale was high. No items were identified as redundant. A review of literature suggested that irritability is an important factor of geriatric depression that had not been included in the original screen. The inclusion of an experimental item to assess irritability, however, did not improve the psychometric properties of the GEDS.

Safe exposure times for slit-lamp fundus biomicroscopy with high plus lenses

PURPOSE

The purpose of this study was to calculate the retinal irradiance and maximum permissible exposure time (MPE) using high plus fundus biomicroscopy lenses.

METHODS

Four Volk handheld condensing lenses (+78 D, +90 D, Superfield NC, and Super 66) were tested with biomicroscopes from three manufacturers (Nikon, Topcon, and Zeiss) on both high and medium illumination. Using the conservation of radiance theorem, the retinal irradiance was calculated and. with guidelines from the American National Standard Institute (ANSI). the maximum permissible exposure time was determined.

RESULTS

The range of MPE time across all lenses and biomicroscopes was from 23 seconds to 74 seconds on high illumination setting. The average MPE times were: for the +78 D, 36 seconds; the Superfield NC, 57 seconds; the Super 66, 32 seconds; and the +90 D, 52 seconds.

CONCLUSION

Retinal irradiances and safe exposure times are useful guidelines in both the clinical and academic setting. Fundus biomicroscopy with non-contact high plus condensing lenses produced calculated retinal irradiances and MPE times similar to those of other commonly used ophthalmic equipment. Awareness of the maximum permissible exposure time increases the safety of this valuable technique.

Cutting edge: identification of a novel chemokine receptor that binds dendritic cell- and T cell-active chemokines including ELC, SLC, and TECK

Searching for new receptors of dendritic cell- and T cell-active chemokines, we used a combination of techniques to interrogate orphan chemokine receptors. We report here on human CCX CKR, previously represented only by noncontiguous expressed sequence tags homologous to bovine PPR1, a putative gustatory receptor. We employed a two-tiered process of ligand assignment, where immobilized chemokines constructed on stalks (stalkokines) were used as bait for adhesion of cells expressing CCX CKR. These cells adhered to stalkokines representing ELC, a chemokine previously thought to bind only CCR7. Adhesion was abolished in the presence of soluble ELC, SLC (CCR7 ligands), and TECK (a CCR9 ligand). Complete ligand profiles were further determined by radiolabeled ligand binding and competition with >80 chemokines. ELC, SLC, and TECK comprised high affinity ligands (IC50 <15 nM); lower affinity ligands include BLC and vMIP-II (IC50 <150 nM). With its high affinity for CC chemokines and homology to CC receptors, we provisionally designate this new receptor CCR10.

Socioeconomic status, social environment, depression and postdischarge adjustment of the cardiac patient

In this study, we assess the adjustment achieved by patients following discharge from coronary care and the role of socioeconomic status (SES), social environment (SE), and depression in achieving that adjustment. Two hundred eighty-seven patients were enrolled. The SE into which the patients were to be discharged was rated significantly poorer for patients of lower SES, who also scored higher on depression. At 1, 6, and 12 months postdischarge, lower SES patients recorded significantly poorer levels of adjustment across a range of functioning. Predischarge depression, together with measures of SE and SES, determined 10% to 28% of the variance in 12-month postdischarge adjustment. These data suggest the importance of identifying patients at greater risk for less than optimal outcome (those lower in SES and higher in depression), and the need to address the nature of the SE in which the patient has to effect his/her recovery.

Combined sequestration, bronchogenic cyst, and dysgenetic lung simulating congenital lobar emphysema

We report the case of a newborn with bronchopulmonary sequestration, bronchogenic cyst, and dysgenetic lung that radiographically simulated congenital lobar emphysema. We discuss congenital malformations of the lungs and the concept of a continuum in the development of pulmonary anomalies.

The efficacy of individual computer heart rate indices in detecting acidemia at birth in growth-restricted fetuses

OBJECTIVE

To determine the efficacy of individual fetal heart rate (FHR) indices, as determined by computer analysis of the FHR tracing, in detecting fetal acidemia at birth in growth-restricted fetuses.

METHODS

The study population consisted of 38 growth-restricted fetuses at 26-37 weeks' gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. The 1-hour FHR tracing was analyzed by computer within 4 hours of cesarean birth before the onset of labor. Umbilical artery cord blood was collected at birth, and pH was determined within 5 minutes of collection.

RESULTS

On linear regression, the duration of episodes of low variation in minutes (r = -0.77, r2 = 0.59) and short-term (r = 0.72, r2 = 0.52) and long-term (r = 0.69, r2 = 0.47) variation in milliseconds were significantly related to umbilical artery pH at birth, and more so than the number of accelerations of ten (r = 0.57, r2 = 0.32) and 15 (r = 0.38, r2 = 0.14) beats per minute. There were significant differences in computer measurements of FHR accelerations and variation between the umbilical artery pH categories of acidemia (pH less than 7.20), preacidemia (7.20-7.25), and nonacidemia (greater than 7.25). Stepwise regression revealed that episodes of low variation best described the model for predicting umbilical artery pH at birth (P < .001), with no improvement provided by the addition of other computer-analyzed FHR characteristics.

CONCLUSION

In this population of growth-restricted fetuses delivered by elective cesarean, the computer indices of duration of episodes of low variation and short-term and long-term variation were significantly associated with umbilical artery pH and predicted umbilical artery acidemia at birth.

Sonography in the evaluation of the cervix during pregnancy

Sonographic techniques have been developed to study the biometry and behavior of the cervix during pregnancy which have led to a better understanding of the pathogenesis of pregnancy loss and preterm birth. Nomograms have been developed for singleton and twin gestations, and associations between cervical sonographic characteristics and various adverse pregnancy outcomes have been observed. The new concept of 'relative' cervical incompetence suggests that the cervix may be an independent contributor to preterm birth. The incorporation of cervical sonography in management schemes for the prevention of pregnancy loss or preterm delivery has the potential to impact favorably on perinatal outcome.

Kikuchi-Fujimoto disease: a report of two cases and an overview

Kikuchi-Fujimoto disease (KFD) has been widely reported from Japan and sporadically from many parts of the world including Saudi Arabia, since its original description in 1972 but the disease remains poorly known by clinicians. In this paper we report two Saudi patients seen in Tabuk, Saudi Arabia. One was a 36-year-old Saudi man and the other a 16-year-old Saudi girl. Both presented with cervical lymphadenopathy and pyrexia. Histological examination of biopsy material from both showed classical features of KFD. Other laboratory findings were unremarkable except for leucopenia. Following excision biopsy both patients recovered without sequelae. KFD is a self-limiting process of uncertain aetiology that predominantly affects young women aged 20-30 years. We review the pathology, clinical featuers and possible aetiology of this interesting disease, which may well be underdiagnosed. Increased awareness of KFD will minimize the risk of confusing this entity with malignant lymphoma or other serious conditions.

Hyperprolactinemia in acute myeloid leukemia and indication of ectopic expression of human prolactin in blast cells of a patient of subtype M4

The sera of 28 patients with acute myeloid leukemia AML--subtypes M1 to M6 were screened for human prolactin (h-PRL). Serum TSH (thyroid stimulating hormone), LH (luteinizing hormone), FSH (follicle stimulating hormone), beta-estradiol, free T4 (tetra-iodotyronine) and testosterone were also determined. It was found that in 16 of the 28 patients h-PRL was significantly elevated while all other endocrine values were normal. In a patient subtype M4 with elevated serum h-PRL we demonstrate by immunoblotting that the hormone and its dimer are present in the blast cells. This may reflect ectopic synthesis due to altered expression of homeobox genes and a requirement of h-PRL as a growth stimulant of the leukemic myeloblast.

Comparison of vitamin E levels in plasma, bronchoalveolar lavage, and lung tissues of adult pulmonary patients

Plasma, bronchoalveolar lavage fluids (BAL), and lung parenchyma were analyzed for vitamin E and polyunsaturated fatty acid (PUFA) concentrations in three groups of patients routinely receiving oxygen therapy--two with adult respiratory distress syndrome (ARDS and SARDS), a third with pneumonia (PNEU), as well as a fourth group of patients receiving little or no oxygen therapy (OTHER). Only plasma alpha- and gamma-tocopherols were significantly lower in patients receiving oxygen therapy compared to those not requiring oxygen. Among diagnosis groups, PNEU patients exhibited highest levels of alpha-tocopherol in BAL, though all groups on oxygen had greater amounts of alpha-tocopheryl quinone in BAL as compared to those of the OTHER group. No significant differences in BAL measures were observed between oxygen and non-oxygen groups, however. No statistical tests on lung measures could be performed between these groups because of insufficient sampling for the OTHER group. A highly significant relationship was observed (r = +0.73, p less than 0.004) between plasma vitamin E and lung vitamin E when expressed in terms of PUFA, whereas no significant relationship was observed if plasma vitamin E and lung vitamin E levels were compared directly. No relationship was obtained for BAL alpha-tocopherol (expressed per number of cells) and lung alpha-tocopherol. These findings support previous reports that in an appropriate setting plasma vitamin E:PUFA ratios along with smoking status may be used to evaluate lung vitamin E levels when also expressed in terms of PUFA.

Behavior of expiratory neurons in response to mechanical and chemical loading

The response of medullary expiratory neurons to added mechanical and chemical loads was studied in anesthetized cats. Alterations in burst characteristics and central timing were compared in the intact and bilaterally vagotomized cat. The following results were obtained: (1) Graded expiratory airflow resistances caused progressive increases in burst duration, spikes per burst and firing rate; similar effects were noted for end-inspiratory tracheal occlusions and continuous positive breathing; all facilitation was eliminated by vagotomy. (2) Graded inspiratory airflow resistances delayed the onset of an expiratory burst but did not change the overall burst characteristics. (3) Acute hypercapnia increased ventilation without noticeable changes in expiratory burst characteristics; acute hypoxia produced a reduction in burst duration concomitant with changes in ventilation. It is concluded that (1) expiratory neurons are responsive to vagally mediated volume information and (2) transient hypoxia and hypercapnia sufficient to increase ventilation does not increase the firing rate of expiratory neurons but exerts differential effects with respect to timing. It is suggested that expiratory duration is related to the time integral of expired volume and that the increase in FRC imposed by expiratory loads does not alter the central timing of the next inspiration.

Pseudomonas aeruginosa bacteremia in a dialysis unit. 11. Relationship to reuse of coils

Blood for culture was obtained over a six week period from 17 patients undergoing long-term hemodialysis. Bacteremia was detected during 18 of 201 dialyses. Blood drawn during fifteen of these dialyses contained pseudomonas aeruginosa. Ten of the 17 patients (59 per cent) had a Pseudomonas bacteremia some time during the study. Only one patient was symptomatic. The frequency of positive cultures was related to reuse of coils. No cultures were positive until after the fifth use, but by the tenth use, 41 per cent of the dialyses were associated with bacteremia. All coils that were used repeatedly and 32 of 48 of those used only once, grew Ps. aeruginosa when filled with media and incubated. This suggests that the coils were inoculated during dialysis and that benzalkonium chloride, the sterilizing agent, was unable to eradicate this organism. With repeated uses, the number of residual bacteria in the coil became large enough to cause detectable bacteremia during dialysis.

Induced rotational autokinesis

The independent autokinesis of the components of a complex pattern was a rather common phenomenon. The direction of such independent motion was placed under E's control by use of an induced autokinesis paradigm. A sequence of related eye-movement studies showed that, while S divided his attention between the various parts of the pattern, the apparent motion of each of the components was not related to the onset of optic nystagmus. Therefore, a possible local-sign interpretation of the effect was rejected.