BMI is associated with larger index tumors and worse outcome after radical prostatectomy.

BACKGROUND: To investigate the impact of body mass index (BMI) on tumor characteristics and biochemical recurrence (BCR) after radical prostatectomy (RP) for prostate cancer (PCa) in Japanese men. METHODS: We evaluated data from consecutive patients who had undergone RP. Data analyzed included age, preoperative serum PSA, prostatic volume, BMI (continuous or categorized (≤ 25 kg/m(2)) values), clinical and pathological findings including index tumor volume (ITV), and current status in areas such as smoker or nonsmoker and presence or absence of diabetes. We analyzed association between BMI and BCR, especially based on ITV using univariate and multivariate analysis. RESULTS: We analyzed data from a total of 703 patients. The median follow-up time was 38.4 months. BCR was diagnosed in 154 patients (21.9%) at a median of 9.7 months postoperatively. Multivariate linear regression analysis adjusted for preoperative variables showed a significant positive association between BMI and ITV (continuous BMI: P=0.002; categorical BMI: P<0.001, respectively), especially for higher-grade tumors (Gleason score ≥ 7). Cox proportional hazards analysis showed a significant association between continuous BMI and BCR after surgery (preoperative variables, hazard ratio (HR) 1.09, 95% confidence interval (CI) 1.02-1.16, P=0.008), independent of clinical and pathological findings. In patients with high-risk cancer, the positive association between BMI and BCR was strengthened (preoperative variables, continuous BMI, HR 1.16, 95% CI 1.07-1.26, P<0.001; categorical BMI, HR 2.11, 95% CI 1.29-3.45, P=0.003, respectively). CONCLUSIONS: Greater BMI significantly correlates with higher rates of BCR after surgery; BMI is a preoperative variable associated with high-grade ITV. Our results suggest that the biological environment created by greater BMI may contribute to increasing tumor aggressiveness.

Transient ligation of umbilical vessels elevates placental tissue oxygen index (TOI) values measured by near-infrared spectroscopy (NIRS) in clawn miniature pig animal model.

We recently found a significant elevation in placental tissue oxygen index (TOI) values in cases of fetal growth restriction using near-infrared spectroscopy (NIRS), indicating high oxygenation in the placental tissue. We hypothesized that insufficient fetoumbilical blood flow is causatively associated with high oxygenation levels in placental tissue. We transiently (for 15 sec) ligated the whole umbilicus, umbilical arteries, or veins of pregnant Clawn miniature pigs (102-113 days of gestation) and assessed the changes in TOI values of the placenta and fetus. The ligation significantly increased placental TOI values (p<0.01, respectively), but concomitantly decreased fetal TOI values (p<0.01, respectively), suggesting a decline in oxygen inflow from the maternal to fetal circulation in the placental tissue to be causative of the elevated placental TOI values. These observations suggest the promising clinical use of placental TOI values measured noninvasively by the transabdominal application of NIRS to assess the fetoplacental circulation.

Successful treatment of monomorphic primary central nervous system post-transplantation lymphoproliferative disorder 5 years after kidney transplantation.

A 31-year-old man underwent living-related kidney transplantation in 2004 as a consequence of primary focal segmental glomerulosclerosis (FSGS). Four years after the transplantation, we confirmed nephrotic syndrome caused by recurrent FSGS. We performed plasmapheresis and low-density lipoprotein adsorption. We also combined steroid therapy with a reduction in the dose of tacrolimus and an increased dose of mycophenolate mofetil. The nephrotic syndrome improved dramatically with this combined therapeutic approach. However, 10 months after these treatments, he revisited our hospital because of altered consciousness. We detected multiple tumor masses in his brain that were ring enhanced on contrast magnetic resonance imaging. Consequently, we suspected primary central nervous system post-transplantation lymphoproliferative disorder (CNS-PTLD). We performed a craniotomy to biopsy the brain tumors. The biopsy specimen showed Epstein-Barr virus-associated diffuse large B-cell lymphoma. There is no definitive treatment for CNS-PTLD. Therefore, we treated the primary CNS-PTLD successfully with whole-brain radiation and discontinuation of immunosuppression therapy.

Correlation of circulating dehydroepiandrosterone with activated protein C generation and carotid intima-media thickness in male patients with type 2 diabetes.

AIMS: Dehydroepiandrosterone exerts a protective effect against cardiovascular diseases. However, the relationship of dehydroepiandrosterone with the anticoagulant factor activated protein C, generated by the thrombin-thrombomodulin complex on vascular endothelial cells, remains unknown. This study aimed at studying the relationship between dehydroepiandrosterone and activated protein C generation in patients with Type 2 diabetes. METHODS: Sixty-two male patients with Type 2 diabetes were enrolled in this study. Data obtained from 40 healthy male subjects were used as controls. The plasma levels of dehydroepiandrosterone, the activated protein C-protein C inhibitor complex, high-sensitivity C-reactive protein and monocyte chemoattractant protein-1 were measured by enzyme immunoassays. Carotid intima-media thickness was measured by ultrasonography. RESULTS: The plasma levels of dehydroepiandrosterone (5.15 ± 2.81 vs. 3.76 ± 2.16 ng/ml; P < 0.005) and the activated protein C-protein C inhibitor complex (1.90 ± 1.07 vs. 1.02 ± 0.51 ng/ml; P < 0.001) were significantly lower in patients with diabetes than in normal subjects. Univariate analysis showed a significant correlation of the plasma level of dehydroepiandrosterone with that of the activated protein C-protein C inhibitor complex (r = 0.48, P < 0.001), high-sensitivity C-reactive protein (r = -0.30, P < 0.05) and with the mean intima-media thickness (r = -0.28, P < 0.05) in patients with diabetes. Stepwise multiple regression analysis showed that the plasma level of dehydroepiandrosterone is significantly correlated with the plasma levels of the activated protein C-protein C inhibitor complex (F = 18.06) and high-sensitivity C-reactive protein (F = 4.94). There was no correlation between the plasma levels of dehydroepiandrosterone and monocyte chemoattractant protein-1. CONCLUSIONS: These results suggest that lower circulating levels of dehydroepiandrosterone are associated with decreased activated protein C generation and higher intima-media thickness in patients with Type 2 diabetes.

Immunohistochemical detection of meconium in the fetal membrane, placenta and umbilical cord.

OBJECTIVE: To develop the immunohistochemistry specific for meconium in the placenta, fetal membrane and umbilical cord. STUDY DESIGN: We previously reported the specific presence of zinc coproporphyrin I (ZnCP-I) in human meconium and demonstrated the possible diagnostic use of an elevation in maternal plasma ZnCP-I levels in cases of amniotic fluid embolism. In this study, we developed a new specific monoclonal antibody for ZnCP-I and applied it to the immunostaining of meconium in the placenta, fetal membrane, and umbilical cord. RESULTS: Immunoreactivity of ZnCP-I clearly and specifically identified meconium in the placenta, fetal membrane, and umbilical cord. It was especially useful in cases of severe chorioamnionitis to detect meconium in the macrophages surrounded by numerous neutrophils. In more than half of the cases, meconium was detected in clear amniotic fluid at delivery, suggesting previous exposure. CONCLUSIONS: Immunohistochemical detection of ZnCP-I is a highly sensitive histological diagnosis of meconium.

Postoperative skeletal stability and accuracy of a new combined Le Fort I and horseshoe osteotomy for superior repositioning of the maxilla.

Postoperative skeletal stability and accuracy were evaluated in a combination of Le Fort I and horseshoe osteotomies for superior repositioning of maxilla in bi-maxillary surgeries in 19 consecutive patients. 9 underwent Le Fort I osteotomy alone (preoperative planned superior movement <3.5 mm). 10 underwent Le Fort I and horseshoe osteotomy (combination group) (preoperative planned superior movement >3.5 mm). The maxilla was osteotomized and fixed with 4 titanium Le Fort plates followed by bilateral sagittal split ramus osteotomy of the mandible, fixed with 2 semi-rigid titanium miniplates. Maxillomandibular fixation was performed for 1 week. Lateral cephalograms were obtained preoperatively, 1 week postoperatively, 3, 6, 12 months later. The changes in point A, point of maxillary tuberosity, and upper molar mesial cusp tip were examined. Discrepancy between the planned and measured superior movement of the maxilla in the Le Fort I and combination groups was 0.30 and 0.23 mm, respectively. The maxillae in both groups were repositioned close to their planned positions during surgery. 1 year later, both groups showed skeletal stability with no significant postoperative changes. When high superior repositioning of the maxilla is indicated, horseshoe osteotomy combined with Le Fort I is reliable and useful for accuracy and postoperative stability.

Relationship of Porphyromonas gingivalis with glycemic level in patients with type 2 diabetes following periodontal treatment.

INTRODUCTION: The aim of this study was to assess the relationship between serum glycemic levels and subgingival microbial profile alteration following periodontal treatment in patients with type 2 diabetes mellitus. METHODS: We studied 30 periodontitis patients with type 2 diabetes mellitus who received full-mouth subgingival debridement by analyzing their subgingival microbial profiles using a polymerase chain reaction method at baseline and various time-points for 12 months following treatment. Concurrently, probing pocket depth, bleeding on probing, and metabolic parameters, including glycated hemoglobin A1c (HbA1c), blood sugar level, C-reactive proteins, total cholesterol, triglyceride, and high-density and low-density lipoprotein cholesterol, were recorded. RESULTS: Periodontal conditions were significantly improved after treatment, and the occurrence rates of periodontal bacterial species, including Porphyromonas gingivalis, Tannerella forsythensis, Treponema denticola, and Prevotella intermedia, were also reduced. Interestingly, P. gingivalis was detected more frequently in subjects with increased HbA1c values after periodontal treatment than in those patients with decreased HbA1c values. Furthermore, P. gingivalis with type II fimbriae was detected only in HbA1c-increased subjects, while improvements in HbA1c values were observed only in subjects without type II clones. CONCLUSIONS: These results suggest that glycemic level in diabetes is affected by the persistence of P. gingivalis, especially clones with type II fimbriae, in periodontal pockets.

The BMP signaling and its Smads in mandibular distraction osteogenesis.

AIM: The aim of the present study was to clarify the mechanism of signal transduction of bone morphogenetic proteins (BMPs) through their specific down signaling molecules Smads inducing bone formation in response to mechanical stimulus during distraction osteogenesis (DO) in the rat mandible. MATERIALS AND METHODS: Osteotomy of the left mandible was performed in 45 rats. Thirty rats underwent mandibular distraction (protocol; 5 days latency, 8 days distraction, and 2 weeks consolidation) while 15 rats served as non-distracted (fracture healing) group. The expression of BMPs-2,-4 and Smads 1, 5, and 8 were evaluated in the new regenerate area using immunohistochemistry. RESULTS: Expressions of BMPs-2,-4 and Smads 1, 5, and 8 were moderate during latency, significantly increased during distraction and decreased towards consolidation period. CONCLUSIONS: The enhanced expression of BMPs and its Smads during distraction compared to the non-distracted group suggests the possible role of BMP signaling pathway in translation of mechanical forces into biological results during DO.

Morphological features of cartilage observed during mandibular distraction in rabbits.

Ossification during distraction osteogenesis can be classified as intramembranous or endochondral. It is not known whether cartilage in the distraction gap is transformed into new bone. The aim of this study was to investigate the morphological features of ossification in the transition of cartilage to bone during mandibular distraction osteogenesis in a rabbit model. A cortical osteotomy was performed and custom-made devices were applied. Immediately after surgery, the devices were lengthened by 0.25 mm every 12h for up 10 days, during which time four rabbits were killed at 0, 5 and 10 days and examined using histological staining and immunohistochemical methods. Apoptotic cells were identified by an in-situ detection assay for nuclear DNA fragmentation using a modified TUNEL procedure, with several sections analyzed using software for histomorphometric analysis. The results showed that the amount of cartilage in the distraction gap was significantly decreased. The cartilage had ossified in two ways, termed endochondral ossification and transchondroid bone formation.

A simple method for bone positioning of mandibular segments.

A simple bone-positioning technique is reported, using a combination of bone plates and a flexible tube filled with acrylic polymer. The flexible tube is solidified by injection of acrylic monomer. This technique is applicable for bone positioning after mandibular resection as well as positioning of the proximal segment after sagittal split ramus osteotomy. This technique has the advantages of greater simplicity and flexibility compared to previously reported methods of bone positioning.

Peripheral primitive neuroectodermal tumor of the vulva: report of a case with imprint cytology.

BACKGROUND: Peripheral primitive neuroectodermal tumor (PNET) of the vulva is an extremely rare disease, and, to our knowledge, only two cases have been previously reported. CASE: A 45-year-old woman presented with a mass in the right labium major. Three years after removal of the tumor, she noticed a new lesion in the same place and underwent a partial vulvectomy. The imprint cytology of the recurrent tumor showed a monomorphic appearance, composed of small round cells with scant cytoplasm against a hemorrhagic background. These tumor cells were loosely connective, but rosettelike structures were observed focally. On pathologic examination, the neoplasm was composed of small round tumor cells showing sinusoidal, diffuse or micropapillary growth. Immunohistochemically, the neoplastic cells stained positively for neuron-specific enolase, vimentin and HBA 71 and negatively for cytokeratin, HBA 45 and muscle-specific actin. The morphologic characteristics of the disease were well expressed in the imprint cytology, and this influenced the selection of immunohistochemical studies. CONCLUSION: Cytologic examination for vulvar tumors, even imprint cytology, can be a useful tool in obtaining an accurate pathologic diagnosis of a rare disease, such as peripheral PNET.

Application of high-surface-area ZrO2 in preconcentration and determination of 18 elements by on-line flow injection with inductively coupled plasma atomic emission spectrometry.

A flow-injection analysis (FIA) system incorporating a micro-column of ZrO2 has been used for the development of an on-line multi-element method for the simultaneous preconcentration and determination of Al, Bi, Cd, Co, Cr, Cu, Fe, Ga, In, Mn, Mo, Ni, Pb, Tl, V, Sb, Sn, and Zn by inductively coupled plasma atomic emission spectrometry (ICP-AES). The conditions for quantitative and reproducible preconcentration, elution, and subsequent on-line ICP-AES determination were established. A sample (pH 8) is pumped through the column at 3 mL min(-1) and sequentially eluted directly into the ICP-AES with 3 mol L(-1) HNO3. With a sample volume of 100 mL and an elution volume of 1 mL signal enhancement 100 times better than for conventional continuous aspirating systems was obtained for the elements studied. The reproducibility (RSD %) of the method at the 10 ng mL(-1) level in the eluate is acceptable - less than 8% for five replicates. Recoveries between 95.4% and 99.9% were obtained for the elements analysed. ZrO2, with a specific surface area of 57 m2 g(-1) and a capacity of approximately 5 mg g(-1) for the elements studied, was synthesized by hydrolysis of ZrCl4. The preconcentration system was evaluated for several simple synthetic matrices, standard water samples and synthetic seawater. The effect of foreign ions on the efficiency of preconcentration of the elements studied was investigated. The application of a micro-column filled with high-surface-area ZrO2 and flow injection inductively coupled plasma atomic emission spectrometry enables preconcentration and simultaneous determination of 18 elements at low concentrations (ng L(-1)) in different water samples.

Initial experience of percutaneous renal cryosurgery under the guidance of a horizontal open MRI system.

OBJECTIVE: The aim of this study was to obtain preliminary results of cryoablation of renal tumors by using a percutaneous approach guided by a horizontal open MRI system, and to assess the safety and efficacy of this procedure. MATERIALS AND METHODS: Four patients with renal tumors underwent percutaneous cryosurgery with local anesthesia using a horizontal open MRI system (AIRIS II, Hitachi Medical Corp., Tokyo, Japan). The size of the mass was radiographically documented as 4 cm or less in diameter. A 2- or 3-mm cryoprobe was advanced into the renal mass under real-time MR monitoring. Growth of the iceball during cryoablation was monitored by two-dimensional MR images. Follow-up dynamic CT and physical examination were done after two weeks and six weeks. RESULT: MR imaging demonstrated the iceballs as sharply marginated regions of signal loss that expanded and engulfed the renal mass with clear contrast between the iceball and surrounding tissue. Cryoablated tumors resolved, and there were no serious complications and no clinically significant changes during the procedures and follow-up study. CONCLUSION: In this limited clinical trial of percutaneous renal tumor surgery, cryoablation demonstrated its feasibility with minimal morbidity. Intraprocedual MR-guided cryosurgery can be used as a safe modality, although further studies are necessary to determine the long-term efficacy of this procedure.

[Pulmonary infarction caused by the spontaneous migration of the vena caval tumor thrombus of right renal cell carcinoma: a case report].

A 70-year-old male with right renal mass incidentally found by annual check-up using ultrasound, was referred to Department of Urology, Jikei University Affiliated Kashiwa Hospital. He was diagnosed as having right renal cell carcinoma with vena caval tumor thrombus extending above the diaphragm (T3c) preoperatively. The day before the scheduled day of operation, right pulmonary infarction caused by spontaneous migration of vena caval tumor thrombus of right renal cell carcinoma developed. Although arterial blood gas findings were poor, he only had low grade chest pain without shock. Therefore, we successfully performed right radical nephrectomy and thrombectomy of right pulmonary artery the next day. He was discharged 42 days postoperatively, but, he died from acute heart failure 9 months after the operation.

[A case of patent urachus in an adult male].

A 31-year-old man was referred to our hospital for evaluation of urachal rest. The history of his present illness dated back to birth, when the umbilicus was projected and urinary discharge was noted. At that time, the symptom of discharge had spontaneously subsided. At the age of 22, however, the patient again experienced discharge from the umbilicus. Although he did not seek treatment, after six years this symptom disappeared. Around this time, however, pyuria was revealed during medical examination, and abdominal ultrasonography (US) suggested the presence of urachal rest. At the time of hospitalization, physical examination revealed that the patient's right testis was not palpable. He was diagnosed with patent urachus with hemilateral aplasia and monorchism by US, computed tomography, magnetic resonance imaging and cystoscopy. The patient subsequently underwent radical operation. Patent urachus in adults is very rare, and only a few cases have been reported. To our knowledge, only one previously reported case involved a recurrence after spontaneous healing. Further, this is the first report of a patient with patent urachus with hemilateral aplasia and monorchism. Radical operation is generally recommended, based on the fact that very few cases heal conservatively.

[Clinical statistics on patients and operations during a 20-year period (1978-1997) at Department of Urology, Jikei University School of Medicine].

A statistical analysis was made of diseases, patients, and operations at our department in the four affiliated hospitals of Jikei University School of Medicine from 1978 through 1997. Our findings were as follows. Newly diagnosed urogenital malignancies, except testicular tumors, have been increasing in the last two decades among both outpatients and inpatients. Urogenital infections, including tuberculosis, have gradually been decreasing in the last two decades. The treatment of urinary stone diseases was markedly altered by the induction of extracorponeal shock wave lithotripsy.

[A case of Sipple syndrome whose bilateral pheochromocytomas were resected separately after a 3-year interval].

A 23-year-old woman who had undergone total thyroidectomy and parabronchial lymphadenectomy at the Department of Otolaryngology in our hospital was suspected to have a thyroid carcinoma. Histological examination revealed a medullary carcinoma of the thyroid and normal parathyroid glands. Because a computed tomographic scan after surgery revealed a tumor of the left adrenal gland, the patient was examined at our department two months after the thyroidectomy, 1994. Endocrinic examinations and 123I-MIBG scintigraphy revealed a left adrenal pheochromocytoma of Sipple syndrome. She then underwent left adrenalectomy. Histological diagnosis was pheochromocytoma of the left adrenal gland. Three years after the surgery, a right adrenal tumor was detected by computed tomography. Although results of endocrine examinations were normal, 131I-MIBG scintigraphy showed a hot spot in the right adrenal gland. Right adrenal pheochromocytoma was diagnosed 3 years after surgery for a contralateral adrenal pheochromocytoma. Although surgery was recommended, the patient consented to right adrenalectomy, 1 year later after marriage and before becoming pregnant. Histological examination of the resected specimen revealed pheochromocytoma of the right adrenal gland.

Speciation of selenium compounds with ion-pair reversed-phase liquid chromatography using inductively coupled plasma mass spectrometry as element-specific detection.

For selenium speciation analysis, the hyphenation of chromatographic separation with element-specific detection has proved a useful technique. A powerful separation system, which is capable of resolving several biologically and environmentally important selenium compounds in a single column, is greatly needed. However, that has been difficult to achieve. In this paper eight selenium compounds, namely, selenite [Se(IV)], selenate [Se(VI)], selenocystine (SeCys), selenourea (SeUr), selenomethionine (SeMet), selenoethionine (SeEt), selenocystamine (SeCM) and trimethylselenonium ion (TMSe+), were separated by using mixed ion-pair reagents containing 2.5 mM sodium 1-butanesulfonate and 8 mM tetramethylammonium hydroxide as a mobile phase. The separation of these anionic, cationic and neutral organic selenium compounds on a LiChrosorb RP18 reversed-phase column took only 18 min at a flow-rate of 1.0 ml/min with isocratic elution, and baseline separation among the six organic Se compounds was achieved. Inductively coupled plasma mass spectrometry (ICP-MS) was employed as element-specific detection. A comparison of ICP-MS signal intensity obtained with a Barbington-type nebulizer and with an ultrasonic nebulizer (USN) was made. Different signal enhancement factors were observed for the various selenium compounds when a USN was used. The speciation technique was successfully applied to the study on chemical forms of selenium in a selenium nutritional supplement. Selenomethionine was found to be the predominant constituent of selenium in the supplement.

[Clinical efficacy of cefpirome sulfate against Bacteroides species, Prevotella species and Porphyromonas species. Society of Anaerobic Bacterial Infections in the fields of obstetrics and gynecology in Gifu].

The injectable cephalosporin cefpirome (CPR) was launched in Japan in 1993. It has widely been used in the various infectious diseases. We therefore studied the clinical and bacteriological efficacy of CPR against infections caused by Bacteroides species, Prevotella species and Porphyromonas species frequently isolated from the obstetric and gynecologic infections. Thirteen institutions were involved in this study which ran from March 1994 to January 1999. The administration dosage of CPR was 2 to 4 gram per day administered by drip infusion or intravenous infusion. The duration of treatment was from 3 to 15 days. The evaluations were performed before and after the treatment. CPR was administered to 194 patients with obstetric and gynecologic infections, and 146 of 194 cases were acceptable for the evaluation of drug efficacy. Bacteroides species were identified in 102 patients. Clinical efficacy in 146 cases was excellent in 12 patients, good in 110, fair in 9 and poor in 15 patients. The eradication rate for Bacteroides species could be in 37 cases out of 54 evaluable cases; Prevotella species in 38 out of 49; and Porphyromonas species in 5 out of 5. The overall assessment of bacteriological efficacy was "eradicated" in 91 cases out of 133 (68.4%). Adverse reactions including abnormal findings in laboratory tests were seen in 8 patients (4.76%). Based on these results, CPR promises efficacy and safety in the treatment of obstetric and gynecologic infections due to Bacteroides species.

[Clinical studies on inverted papilloma of the urinary tract].

BACKGROUND: Inverted papilloma of the urinary tract is believed to be a benign neoplasm based on its histologic morphology and clinical behavior. In recent years, however, several investigators have warned against too optimistic an approach, emphasizing the possibility of malignant cellular transformation within the lesion, or its eventual association with other urothelial tumors such as transitional cell carcinoma or carcinoma in situ. We here report on 35 clinicopathologically diagnosed cases of inverted papilloma, and present the clinical significance attributed to these lesions in view of the current literature. PATIENTS AND METHODS: From 1976 to 1997, 35 cases of inverted papilloma of the urinary tract were treated at our hospital. This report presents the clinical features of these cases, the results of prognosis research, an investigation of the cases in which inverted papilloma and transitional cell carcinoma were found to co-exist, and a discussion of the recurrent cases of inverted papilloma found in previous literature. RESULTS: The patients ranged from 24 to 77 years of age, with a mean of 54 years, and included 4 women and 31 men. The most frequently occurring symptom was grosshematuria, and more than 90% of the 35 cases occurred in the bladder. In 2 of the 35 cases, transitional cell carcinoma coexisted with the inverted papilloma, at a different location in the bladder in one case and within the same neoplasm in the ureter in the other case. Clinical courses after treatment were followed in 29 of the 35 cases, with a follow-up period of from 8 months to 19 years (mean follow-up, 5 years and 4 months). Of these 29 cases, 2 showed recurrence, one at 16 and one at 30 months after the initial resection. Many previous reports show that the association of inverted papilloma and transitional cell carcinoma is stronger in the upper urinary tract and recurrence of inverted papilloma almost always happens with 2 years. CONCLUSION: This study suggests that some cases of urinary inverted papilloma show recurrence or malignant potential. Our results indicate that all cases of urinary inverted papilloma should be treated and followed as cases of low-grade transitional cell carcinomas. Consequently, all cases must be followed for two years or more after the initial operation.