Antimalarials and macrolides: a review of off-label pharmacotherapies during the first wave of the SARS-CoV-2 pandemic

Abstract We critically analyzed clinical trials performed with chloroquine (CQ) and hydroxychloroquine (HCQ) with or without macrolides during the first wave of COVID-19 and discussed the design and limitations of peer-reviewed studies from January to July 2020. Seventeen studies were eligible for the discussion. CQ and HCQ did not demonstrate clinical advantages that justified their inclusion in therapeutic regimens of free prescription for treatment or prophylactic purposes, as suggested by health authorities, including in Brazil, during the first wave. Around August 2020, robust data had already indicated that pharmacological effects of CQ, HCQ and macrolides as anti-SARS-CoV-2 molecules were limited to in vitro conditions and largely based on retrospective trials with low quality and weak internal validity, which made evidence superficial for decision-making. Up to that point, most randomized and nonrandomized clinical trials did not reveal beneficial effects of CQ or HCQ with or without macrolides to reduce lethality, rate of intubation, days of hospitalization, respiratory support/mechanical ventilation requirements, duration, type and number of symptoms, and death and were unsuccessful in increasing virus elimination and/or days alive in hospitalized or ambulatory patients with COVID-19. In addition, many studies have demonstrated that side effects are more common in CQ-or HCQ-treated patients.

Experiencia en cirugía de condilomas anales en mayores de 15 años / Experience in anal condyloma surgery in patients older than 15 years

Resumen Objetivo: Describir la experiencia en cirugía electiva de condilomas anales en pacientes mayores de 15 años en un hospital terciario de la Región Metropolitana. Material y Método: Estudio observacional retrospectivo y descriptivo, en el cual se analizan las intervenciones quirúrgicas electivas realizadas entre 2008 a 2021. Resultados: Dentro del período analizado se obtuvo 165 cirugías de condilomas anales, lo que corresponde a 137 pacientes en total. El 85% de los pacientes son de sexo masculino, el 68% de los pacientes son VIH positivo, un 87% de los pacientes MSM (hombres que tienen sexo con otros hombres) son VIH positivo, el 34% de los pacientes tiene antecedente de ETS, el 46% de los pacientes recibió terapia tópica como tratamiento preoperatorio o posoperatorio. Un 25% de los pacientes presenta recidiva en su historia personal, un 21% de los pacientes presenta lesiones anales intraepiteliales de alto grado, un 6% presenta carcinoma escamoso infiltrante. No hubo mortalidad descrita. Discusión: El presente estudio, describe la experiencia en cirugía de condilomas de un hospital terciario de la Región Metropolitana de Chile, cuya población corresponde a un estrato socioeconómico medio y bajo. Se logra describir a la población que es intervenida de condilomas acuminados, además de sus resultados quirúrgicos precoces y a largo plazo. Conclusión: El presente estudio, presenta una población de 137 pacientes operados de condilomas anales, a partir de los hallazgos de la cirugía. Se cumple el objetivo del estudio de caracterizar en un período de 12 años los resultados quirúrgicos de dicha serie, algo no reportado previamente en la literatura chilena.

Objective: To describe the experience in elective surgery for anal condylomas in patients over 15 years of age in a tertiary hospital in the Metropolitan Region. Materials and Method: Retrospective and descriptive observational study about elective surgical interventions performed between 2008 to 2021. Results: Within the analyzed period, 165 anal warts surgeries were obtained, corresponding to 137 patients. 85% of the patients are male, 68% are HIV positive, 87% of the MSM patients are HIV positive, 34% of the patients have a history of STDs, 46% of the patients received topical therapy as preoperative or postoperative treatment. 25% present recurrence in their personal history, 21% present high-grade anal intraepithelial lesions, 6% present infiltrating squamous carcinoma. There was no reported mortality. Discussion: The present study describes the experience in condyloma surgery in a tertiary hospital in the Metropolitan Region of Chile, whose population corresponds to a medium and low socioeconomic stratum. It is possible to describe the population that undergoes surgery for this reason, in addition to its early and long-term surgical results. Conclusion: The present study presents a population of 137 patients operated on for anal condylomas, based on the findings of the surgery. The objective of the study to characterize the surgical results of this series over a 12-year period is fulfilled, something not previously reported in the Chilean literature.

Case of large lentigo maligna melanoma of the scalp treated with 5% and 3. 75% Imiquimod

Abstract The paper presents a case of lentigo maligna melanoma of the scalp in an elderly patient treated for the nodular part with surgery and the residual melanoma in situ with 5% Imiquimod and subsequently with 3.75% Imiquimod (each concentration for 4 months, 5 times per week), with complete regression of the lesion. 3.75% Imiquimod, which is already used for the treatment of actinic keratosis, could be a useful weapon with the same effectiveness and fewer side effects compared to 5% Imiquimod.

Dermatoscopy-guided therapy of pigmented basal cell carcinoma with imiquimod

Abstract BACKGROUND: Dermatoscopy is a non-invasive diagnostic tool used to examine skin lesions with an optical magnification. It has been suggested as a useful tool for monitoring therapeutic response in lentigo maligna patients treated with imiquimod. OBJECTIVE: To examine the accuracy of dermatoscopy as a tool to monitor the therapeutic response of pigmented basal cell carcinoma treated with imiquimod. METHOD: The authors designed a prospective study. Patients with pigmented basal cell carcinoma were included and data regarding the dermatoscopy features were collected following the Menzies criteria, prior to initiating the imiquimod treatment. Subsequent dermatoscopic evaluations were performed at weeks 4 and 8, following imiquimod discontinuation. RESULTS: Twenty lesions were included. The most common pigmented dermatoscopy features were large blue-grey ovoid nests (80%), followed by blue-grey globules (50%) and leaf-like areas (30%). No spoke wheel areas were observed. In 17 out of 20 patients, a response was noted during the first evaluation at 4 weeks, while the clearance was noted at the second check-up after 8 weeks. In two patients, the clearance was found at the initial evaluation at 4 weeks, while in one patient, the response remained unchanged. Blue-grey globules were the fastest to exhibit clearance (50% at week 4), followed by leaf-like areas (15%) and large blue-grey ovoid nests (6.25%). CONCLUSION: According to our results, dermatoscopic evaluation enhances the accuracy in the assessment of the clinical response to imiquimod in pigmented basal cell carcinoma.

The TLR7 agonist Imiquimod promote the immunogenicity of msenchymal stem cells

BACKGROUND: Mesenchymal stem cells (MSCs) are considered the best candidate in stem cells therapy due to their multipotent differentiation ability, low expression of co-stimulatory molecules (CD80, CD86, CD34 and HLA-II) and immunosuppression effects on in vivo immune responses. MSCs were now widely used in clinical trials but received no encourage results. The major problem was the fate of engrafted MSCs in vivo could not be defined. Some studies indicated that MSCs could induce immune response and result in the damage and rejection of MSCs. As toll like receptors (TLRs) are important in inducing of immune responses, in this study we study the role of TLR7 in mediating the immune status of MSCs isolated from umbilical cord. RESULTS: Our results indicated that TLR7 agonist Imiquimod could increase the proliferation of PBMC isolated from healthy human volunteers and release of lactate dehydrogenase (LDH) in supernatant from PBMC-UCMSCs co-culture system. Flow cytometry and quantitative PCR also confirmed the regulated expression of surface co-stimulatory molecules and pro-inflammatory genes (IL-6, IL-8, IL-12, TGF-β and TNF-α). And the down-regulation expression of stem cell markers also confirmed the loss of stemness of UCMSCs. We also found that the osteo-differentiation ability of UCMSCs was enhanced in the presence of Imiquimod. CONCLUSION: To our knowledge, this is the first report that activation of TLR7 pathway increases the immunogenicity of UCMSCs. Extensive researches have now been conducted to study whether the change of immune status will be help in tumor rejection based on the tumor-tropism of MSCs.

Vulvar vitiligo-like depigmentation and multiple halos of hypomelanosis at the trunk following treatment with imiquimod 5% cream for vulvar condylomata: casual or related events?

A 25-year-old Caucasian female with multiple genital warts involving the vulvar area was treated with imiquimod 5% cream. During follow-up the patient developed areas of hypopigmentation at the site of application of imiquimod cream and areas of hypomelanosis around multiple preexisting nevi of the trunk. At 18 months follow-up genital depigmentation persisted and halo nevi of the trunk were still present. Different mechanisms of imiquimod-induced depigmentation have been reported. Halo nevi are considered expression of an autoimmune response. In the case presented here, it might be conceivable that both vitiligo-like depigmentation at the site of application and halo of hypomelanosis around melanocytic nevi have been induced by the same immunologic mechanism elicited by topical application of imiquimod.

Neoplasia vaginal intraepitelial / Vaginal intraepithelial neoplasia

Objetivo: actualizar los conocimientos disponibles sobre la neoplasia vaginal intraepitelial (VAIN) especialmente en el diagnóstico y tratamiento. Métodos: revisión de la literatura en Pubmed de los últimos 20 años, especialmente de los publicados desde 2005 hasta la actualidad y considerando sobre todo los ensayos clínicos aleatorizados. Resultados: su prevalencia real es desconocida, aunque es una patología rara generalmente en mujeres posmenopaúsicas. Su fisiopatología es similar a la neoplasia cervical intraepitelial, con el HPV como principal factor de riesgo, sobre todo el serotipo 16, pero su progresión a cáncer es menor. Un grupo importante es el de VAIN tras histerectomía, que supone el 48-70 por ciento del total de las VAIN. La colposcopia para el diagnóstico no es sencilla y se aconseja preparación con estrógenos en las pacientes menopáusicas y utilización de ácido acético y lugol para identificar las zonas sospechosas. Las tres opciones terapéuticas son la cirugía (excisional, láser, ultrasonidos), braquiterapia y tratamiento médico (imiquimod, 5-fluorouracilo, ácido tricloroacético). Se expone la técnica y las ventajas e inconvenientes de cada uno de ellos. Conclusión: aunque la VAIN es una entidad rara, es preciso tenerla en cuenta ante un diagnóstico de lesión citológica. Su diagnóstico a veces no es sencillo y el tratamiento dependerá del grado, la localización y el tamaño de la lesión y las circunstancias personales de la paciente. Se necesitan más ensayos aleatorizados que comparen la eficacia entre las distintas opciones terapéuticas y su repercusión en la calidad de vida de las pacientes.

Aims: update the knowledge about vaginal intraepithelial neoplasia (VAIN) with special emphasis on diagnosis and therapeutic management. Method: electronic search of Pubmed of all kinds of articles about the VAIN, for the last 20 years with special attention to those published from 2005 to the present and considering especially randomized clinical trials. Results: its prevalence is unknown, although it is a rare condition that usually occurs in postmenopausal women. The physiopathology is similar to cervical intraepithelial neoplasia, being HPV the main risk factor, particularly serotype 16, but its progression to cancer is lower. An important group is VAIN after hysterectomy, 48-70 percent of total VaIN. Colposcopy for the diagnosis is not easy and in patients with postmenopausal the preparation with local estrogen is necessary and use both of acetic acid and lugol to identify suspicious areas. The three treatment options are surgery (excisional, laser, ultrasound), brachytherapy and medical management (imiquimod, 5-fluorouracil, tricholoroacetic acid). The technique and the advantages and disadvantages of each are explained. Conclusion: although VAIN is rare, it must take it into account before a cytological diagnosis of dysplasia. Its diagnosis is sometimes not easy and the treatment depends on the extent, location and size of the lesion and the individual preferences of the patient. We need more randomized trials comparing different treatment options and also their impact on quality of life of patients.

Aberraciones cromosomales en bulbos de cebolla Allium cepa inducidas pormoléculas híbridas 4-aminoquinolínicas / Chromosomal aberrations in Allium cepa onion bulbs induced by 4-aminoquinoline hybrid molecules

Se estudiaron las propiedades toxicológicas de los trescompuestos híbridos quinolin-tiazolidinona (FR-72 y FR-121), y acridinepoxiisoindolindiona(FR-154) aplicándolos en el test de las raíces debulbos de cebolla Allium cepa. Las moléculas FR-72, FR-121 y FR-154 fueron sintetizadas de novo según protocolos experimentalesdescritos. Los bulbos de Allium cepa (2n = 16) limpios y sanos,previamente sumergidos en el agua destilada, se secaron con papeltoalla y se colocaron directamente en los tubos de ensayo llenos conla sustancia a evaluar. Los experimentos se realizaron a temperaturaambiente 20 ± 2°C y se mantuvieron en oscuridad. El periodo deexposición de los bulbos fue de 120 horas y las raíces que se utilizaronpara el montaje de genotoxicidad eran en promedio de 2 a 2.5 cmde longitud. La evaluación del comportamiento de las tres moléculasquinolínicas sobre la inhibición del crecimiento promedio de las raícesde bulbos de cebolla Allium cepa se realizó con los tres parámetrosde bioactividad (CE50, IM, ACs) en diferentes concentraciones. Lassustancias evaluadas pueden considerarse aneugénicas, ya que actúana nivel de estructuras celulares y moleculares e impiden la fijación delas fibras del huso acromático, por ende ocasionan el desplazamientode cromosomas en anafase o pérdidas de cromosomas, llegandoincluso a ser inductoras de la apoptosis al sobrepasar la capacidadhomeostática de la célula. El análisis preliminar indicó que la moléculaFR-121 a concentración 10-6 M y la molécula FR-154 a concentración10-3 M resultaron ser potentes agentes fitotóxicos provocando diversasaberraciones claustogénicas y aneugénicas...

The toxicological properties of three hybridcompounds, quinoline-thiazolidinone (FR-72 and FR-121)and acridin-epoxyisoindolindione (FR-154) were studiedby applying named compounds to the test of the rootsof Allium cepa onion bulbs. Molecules FR-72, FR-121 andFR-154 were synthesized de novo according to describedsynthetic protocols. Clean and healthy bulbs of Alliumcepa (2n = 16), previously immersed in distilled water,were dried with paper towels and placed directly into testtubes filled with the test substance. The experiments werecarried out at room temperature 20 ± 2°C and were keptin darkness. The period of exposure of bulbs was 120hours; the roots used for the genotoxicity evaluation wereon average of 2 to 2.5 cm in length. The evaluation of theeffect of the three quinolinic molecules on the growthof onion roots of Allium cepa bulbs was achieved usingdifferent concentrations of the three growth parameters(EC50, IM, ACs) The evaluated substances performedaneugenic actions, operating at cellular and molecularstructure level and preventing the fixing of mitoticspindle fibers, causing the movement of chromosomesin the anaphase or loss of chromosomes, even inducingapoptosis by exceeding the homeostatic capacity of thecell. The preliminary analysis indicated that molecule FR-121 at 10-6 M concentration and molecule FR-154 at 10-3M concentration, proved to be potent phytotoxic agentscausing various claustogenic and aneugenic aberrations...

Foram estudadas as propriedades toxicológicas dos trêscompostos híbridos, quinolina-tiazolidinona (FR-72 e FR-121)e hidroacridin-epoxiisoindolindiona (FR-154) aplicando-os noteste das raízes de bulbos de cebola Allium cepa. As moléculas FR-72, FR-121 e FR-154 foram sintetizadas de novo de acordo com osprotocolos experimentais já descritos. Os bulbos de Allium cepa (2n= 16) limpos e sádios, previamente imersos em água destilada, foramsecos com papel toalha e colocados diretamente em tubos de ensaio,cheios com a substância de teste. Os experimentos foram realizadosà temperatura ambiente 20 ± 2°C e mantiveram-se na escuridão. Operíodo de exposição dos bulbos foi de 120 horas e as raízes usadaspara a montagem de genotoxicidade tinham, em média, de 2 a 2,5 cmde comprimento. A avaliação do comportamento das três moléculasquinolínicas sobre a inibição do crescimento médio das raízes debulbos de cebola Allium cepa foi realizada com os três parâmetrosde bioatividade (EC50, IM, ACs) em diferentes concentrações. Assubstâncias avaliadas podem se considerar aneugénicas, já queatuam ao nível de estruturas celulares e moleculares, e impedem oestabelecimento de fibras do fuso acromático, provocando assim odeslocamento dos cromossomos na anáfase ou perda de cromossomos,chegando, inclusive, a serem indutoras da apoptose ao ultrapassar acapacidade homeostática da célula. A análise preliminar indicou que amolécula FR-121 em concentração de 10-6 M e a molécula de FR-154em concentração de 10-3 M resultaram ser potentes agentes fitotóxicosprovocando várias aberrações claustogénicas e aneugénicas...

Enfermedad de Heck: a propósito de un caso / Heck’s disease: a case report

La Enfermedad de Heck (EH) o Hiperplasia Epitelial Focal (HEF) es una proliferación benigna poco frecuente de la mucosa oral, generalmente asintomática, causada por el Virus Papiloma Humano (VPH), en su mayoría VPH 13 y 32. Afecta principalmente a niños, predominantemente de sexo femenino. En general se resuelve en forma espontánea, pero en algunos casos por su sintomatología o extenso compromiso se requiere de tratamiento. Existen múltiples modalidades terapéuticas, destacando entre ellas el Imiquimod. Describimos el caso de una paciente de ocho años de edad con una EH que presentó buena respuesta al tratamiento con Imiquimod 5 por ciento.

Heck’s Disease (HD) or Focal Epithelial Hyperplasia (FEH) is a rare benign proliferation of the oral mucosa, usually asymptomatic, caused by Human Papilloma Virus (HPV), especially HPV 13 and 32. Affects mainly children, predominantly female.FEH generally resolves spontaneously, but some cases, either because of intensity or extension of symptoms may require treatment. There are several therapeutic alternatives, being Imiquimod the most successful. We report the case of a 8-year old with a HD that present good response to treatment with Imiquimod 5 percent.

Herpes hipertrófico perianal tratado eficazmente com imiquimod / Hypertrophic perianal herpes successfully treated with imiquimod

A infecção pelo vírus herpes simples tipo 2 (HSV-2) é frequente em pacientes infetados pelo vírus de imunodeficiência adquirida (VIH). Nestes casos, o herpes genital pode ter uma apresentação clínica atípica. As variantes hipertróficas e vegetantes são pouco habituais. Os autores relatam um caso de herpes hipertrófico perianal em paciente infetada pelo VIH, com resposta insatisfatória ao aciclovir e valaciclovir, tratado eficazmente com imiquimod tópico. O herpes genital hipertrófico é, frequentemente, refratário aos tratamentos antivirais. Na nossa experiência, o imiquimod é um tratamento eficaz, seguro e bem tolerado que deverá ser considerado na abordagem terapêutica destes pacientes.

Herpes simplex virus type 2 (HSV-2) infections are frequent in HIV (human immunodeficiency virus) infected patients. In those cases, genital herpes may have an atypical clinical presentation. Hypertrophic and vegetating variants are unusual. The authors describe a case of hypertrophic perianal herpes in an HIV patient with unsatisfactory response to acyclovir and valacyclovir, successfully treated with imiquimod. Hypertrophic genital herpes cases are frequently refractory to antiviral treatments. In our experience, imiquimod is an efficient, safe and well tolerated treatment that should be considered in therapeutic approach of these patients.

Associação de aciclovir oral e imiquimode no tratamento de herpes simples genital hipertrófico em paciente com sida: relato de dois casos / Association of oral acyclovir and imiquimod for the treatment of hypertrophic genital herpes simplex in HIV positive patients: report of two cases

Herpes simples crônico é doença capaz de gerar apresentações exuberantes, principalmente em pacientes com sida. O provável mecanismo da formação dessas lesões hiperplásicas consiste na invasão viral dos linfócitos T CD4 situados na epiderme. Diante das dificuldades terapêuticas e da grande taxa de insucesso do tratamento nesses pacientes, novas terapias têm sido citadas na literatura atualmente. O conhecimento da imunopatologia ratificou o mecanismo pelo qual o imiquimode poderia ser eficaz como terapia adjuvante aos antivirais. Relatamos aqui dois casos de pacientes tratados com aciclovir associado ao imiquimode tópico que obtiveram resposta clínica excepcional.

Chronic herpes simplex can present as exuberant clinical lesions, especially in HIV patients. The most probable mechanism of formation of these lesions is the invasion of the epidermal CD4 T cells by the herpes simplex virus. Due to the therapeutic difficulties and the high rates of treatment failure amongst these patients, new drugs are currently being discussed on the literature. Studies based on the immunophatology of these lesions have suggested that imiquimod might work as an adjuvant therapy to the antiviral drugs. Here we present two cases of excellent response to treatment with topical imiquimod as an adjuvant drug to acyclovir.

Lentigo maligno tratado com imiquimode tópico: o valor da dermatoscopia no monitoramento clínico / Lentigo maligna treated with topical imiquimod: dermatoscopy usefulness in clinical monitoring

A dermatoscopia tem seu uso consagrado na avaliação diagnóstica de lesões melanocíticas. Recentemente, entretanto, tem se revelado também como importante ferramenta no acompanhamento da resposta terapêutica em diversas dermatoses. Relatamos o caso de uma paciente idosa, com diagnóstico de lentigo maligno de difícil manejo cirúrgico, para a qual optamos pelo uso do imiquimode tópico. O acompanhamento dermatoscópico dessa alternativa terapêutica se mostrou de grande utilidade.

Dermoscopy has its usefulness well established in the diagnostic evaluation of melanocytic lesions. Recently, however, it has also shown to be an important tool in monitoring therapeutic response to various dermatoses. We report the case of an elderly patient diagnosed with lentigo maligna of difficult surgical management, which we have chosen to treat with topical imiquimod. The dermoscopic monitoring of this alternative therapy has shown to be of great usefulness.

Avanços no tratamento da leishmaniose tegumentar do novo mundo nos últimos dez anos: uma revisão sistemática da literatura / Advances in the treatment of cutaneous leishmaniasis in the new world in the last ten years: a systematic literature review

INTRODUÇÃO: O arsenal terapêutico contra a leishmaniose tegumentar é muito restrito. Os antimoniais pentavalentes permanecem como as drogas de escolha para seu tratamento há mais de 50 anos. Apesar da sua eficácia, necessita de injeções diárias, apresenta muitos efeitos colaterais e tempo de cura prolongado.

INTRODUCTION: The therapeutic arsenal against cutaneous leishmaniasis is very limited. Pentavalent antimonial compounds have been the drugs of choice for treatment of this disease for over 50 years. Despite their effectiveness, these drugs require daily injections, have many side effects and present prolonged healing time.

Resultados do tratamento das cicatrizes queloideanas com cirurgia e imiquimode 5 por cento creme: um estudo prospectivo / Results of keloids treatment with surgery and iniquimod 5 percent cream: a prospective study

INTRODUÇÃO: O tratamento do queloide representa um desáfio terapêutico, com resultados muitas vezes frustrantes. Terapias adjuvantes mais eficazes são necessárias para reduzir as altas taxas de recidivas. Essa pesquisa é baseada em uma modalidade conjunta com a aplicação de imiquimode 5 por cento creme associada à cirurgia, tendo como objetivo a avaliação do tratamento e recidiva da cicatriz queloidiana. MÉTODO: Estudo prospectivo que avaliou 14 pacientes em um total de 25 queloides, com um seguimento mínimo de 6 meses. Foi realizada excisão intralesional e iniciada a aplicação do imiquimode 5 por cento creme no dia da cirurgia e mantido por dois meses. A avaliação da cicatriz foi analisada por meio de uma Escala de Avaliação (paciente e um observador - regente de serviço de Cirurgia Plástica), sinais de recidiva e também do tamanho da cicatriz no pré e pós-operatório. RESULTADOS: Após o acompanhamento de 6 meses, houve melhora da cicatriz por parte do paciente em 72 por cento e para o observador em 88 por cento, tendo uma taxa de recidiva de 8 por cento e redução da área cicatricial (p=0,0053). CONCLUSÃO: O uso do Imiquimode 5 por cento creme no pós-operatório da cirurgia de ressecção do queloide diminuiu significativamente sua recidiva na avaliação de 6 meses.

INTRODUCTION: The treatment of keloids represents a therapeutic challenge, with results often disappointing. More effective adjuvant therapies are needed to reduce high rates of relapse. This research is based on a combined modality with application of imiquimod 5 percent cream combined with surgery, having as objective the evaluation of treatment and recurrence of keloid scar. METHODS: This prospective study evaluated 14 patients at a total of 25 keloids, with a minimum follow up of 6 months. Intralesional excision was performed and initiated the application of imiquimod 5 percent cream on the day of surgery and continued for two months. The evaluation of the scar was analyzed by an Assessment Scale (patient and an observer - ruler of service Plastic Surgery), signs of relapse and also the size of the scar in the pre-and postoperatively. RESULTS: After 6 months of follow up, patients showed an improvement of 72 percent and 88 percent in the ruler's analysis, with a recurrence rate of 8 percent and reduction of scar area (p = 0.0053). CONCLUSION: The use of Imiquimode 5 percent cream in the post surgery for resection of the keloid recurrence decreased significantly in their evaluation of 6 months.