Endoreduplication of the mouse genome in the absence of ORC1.

The largest subunit of the origin recognition complex (ORC1) is essential for assembly of the prereplicative complex, firing of DNA replication origins, and faithful duplication of the genome. Here, we generated knock-in mice with LoxP sites flanking exons encoding the critical ATPase domain of ORC1. Global or tissue-specific ablation of ORC1 function in mouse embryo fibroblasts and fetal and adult diploid tissues blocked DNA replication, cell lineage expansion, and organ development. Remarkably, ORC1 ablation in extraembryonic trophoblasts and hepatocytes, two polyploid cell types in mice, failed to impede genome endoreduplication and organ development and function. Thus, ORC1 in mice is essential for mitotic cell divisions but dispensable for endoreduplication. We propose that DNA replication of mammalian polyploid genomes uses a distinct ORC1-independent mechanism.

Enhancing productivity and sustainability of ravine lands through horti-silviculture and soil moisture conservation: A pathway to land degradation neutrality.

Ravine lands are the worst type of land degradation affecting soil quality and biodiversity. Crop production in such lands is impossible without adopting proper conservation measures. In-situ moisture conservation techniques could play an instrumental role in restoring ravine lands by improving soil moisture. We hypothesized that restoring ravine land through a combination of tree planting, fruit crop cultivation, and in-situ moisture conservation practice would result in significant improvements in productivity, profitability, and soil fertility. An experiment was conducted involving the combination of Malabar Neem (Melia dubia) and Dragon fruit (Hylocereus undatus) in conjunction with in-situ soil moisture conservation measures specifically involving half-moon structures (HM). The experiment was conducted under randomized block design (RBD) comprising eight treatments. These treatments include sole Melia cultivation (MD 3m × 3m), sole cultivation of dragon fruit (DF 3m × 3m), silviculture system (MDF-3m × 3m), horti-silviculture system with larger spacing (MDF-4m × 4m), sole Melia cultivation with in-situ moisture conservation (MDH-3m × 3m), sole Dragon fruit cultivation with in-situ moisture conservation (DFH-3m × 3m), horti-silviculture system of Melia and Dragon fruit with in-situ moisture conservation (MDFH-3m × 3m), and horti-silviculture system with larger spacing and in-situ moisture conservation (MDFH-4m × 4m). Each treatment was replicated thrice to evaluate their impact on productivity, profitability, soil fertility, and carbon sequestration for 8 years (2016-2023). The results revealed that the horti-silviculture system (MDFH-3 × 3 m) exhibited the highest total tree biomass and total carbon sequestration with an increase of 183.2% and 82.8% respectively, compared to sole Melia cultivation without HM and sole Melia with HM. Furthermore, sole Melia with HM augmented soil nutrients (N, P, K, and SOC) by 74.4%, 66.4%, 35.2%, and 78.3%, respectively, compared to control (no planting), with performance at par with MDFH-3 × 3 m. Similarly, sole Melia with HM enhanced SOC stock and SOC sequestration rate by 79.2% and 248% over control. However, it was found at par with MDFH-3 × 3 m. The horti-silviculture system (MDFH-3 × 3 m) consistently produced the highest fruit yield throughout the years surpassing other treatments. This treatment increased the average dragon fruit yield by 115.3% compared to sole dragon fruit without HM. Hence, the adoption of the horti-silviculture system (MDFH-3 × 3 m) could be a promising strategy for achieving enhanced environmental and economic benefits in ravine lands. Therefore, dragon fruit based horti-silviculture system (MDFH-3 × 3 m) could be recommended for restoration of ravine lands, improving land productivity, and mitigating impact of soil erosion particularly in Western India or similar agro-climatic regions of the world.

Single-cell RNA-seq reveals developmental plasticity with coexisting oncogenic states and immune evasion programs in ETP-ALL.

Lineage plasticity and stemness have been invoked as causes of therapy resistance in cancer, because these flexible states allow cancer cells to dedifferentiate and alter their dependencies. We investigated such resistance mechanisms in relapsed/refractory early T-cell progenitor acute lymphoblastic leukemia (ETP-ALL) carrying activating NOTCH1 mutations via full-length single-cell RNA sequencing (scRNA-seq) of malignant and microenvironmental cells. We identified 2 highly distinct stem-like states that critically differed with regard to cell cycle and oncogenic signaling. Fast-cycling stem-like leukemia cells demonstrated Notch activation and were effectively eliminated in patients by Notch inhibition, whereas slow-cycling stem-like cells were Notch independent and rather relied on PI3K signaling, likely explaining the poor efficacy of Notch inhibition in this disease. Remarkably, we found that both stem-like states could differentiate into a more mature leukemia state with prominent immunomodulatory functions, including high expression of the LGALS9 checkpoint molecule. These cells promoted an immunosuppressive leukemia ecosystem with clonal accumulation of dysfunctional CD8+ T cells that expressed HAVCR2, the cognate receptor for LGALS9. Our study identified complex interactions between signaling programs, cellular plasticity, and immune programs that characterize ETP-ALL, illustrating the multidimensionality of tumor heterogeneity. In this scenario, combination therapies targeting diverse oncogenic states and the immune ecosystem seem most promising to successfully eliminate tumor cells that escape treatment through coexisting transcriptional programs.

STAT5B mutations in myeloid neoplasms differ by disease subtypes but characterize a subset of chronic myeloid neoplasms with eosinophilia and/or basophilia.

STAT5B has been reported as a recurrent mutation in myeloid neoplasms (MNs) with eosinophilia, but the overall frequency and importance across a spectrum of MNs are largely unknown. We conducted a multicenter study on a series of 82 MNs with STAT5B mutations detected by next-generation sequencing. The estimated frequency of STAT5B mutation in MNs was low.

Angioimmunoblastic T-cell lymphoma presenting with severe plasmacytosis mimicking plasma cell leukemia.

Peripheral blood smear (A) demonstrates increased numbers of plasma cells (representative cells indicated by arrows), (B) demonstrates polytypic nature of plasma cells.

Primary Effusion Lymphoma in an HIV-Negative Patient with Chronic Myeloid Leukemia Treated with Dasatinib.

INTRODUCTION: Primary effusion lymphoma (PEL) is a malignant lymphomatous effusion, which by definition is Kaposi sarcoma herpesvirus/human herpesvirus 8-positive. PEL typically occurs in HIV-infected patients but can also occur in HIV-negative individuals, including in organ transplant recipients. Tyrosine kinase inhibitors (TKIs) are currently the standard of care for patients with chronic myeloid leukemia (CML), BCR::ABL1-positive. Although TKIs are extremely effective in treating CML, they alter T-cell function by inhibiting peripheral T-cell migration and altering T-cell trafficking and have been associated with the development of pleural effusions. CASE PRESENTATION: We report a case of PEL in a young, relatively immunocompetent patient with no history of organ transplant receiving dasatinib for CML, BCR::ABL1-positive. DISCUSSION: We hypothesize that the loss of T-cell function secondary to TKI therapy (dasatinib) may have resulted in the unchecked cellular proliferation of Kaposi sarcoma herpesvirus (KSHV)-infected cells, leading to the emergence of a PEL. We recommend cytologic investigation and KSHV testing in patients being treated with dasatinib for CML who present with persistent or recurrent effusions.

Now you see me, now you don't: Isolated central nervous system recurrence of CD19-negative diffuse large B-cell lymphoma following CD19-directed CAR T-cell treatment.

The authors discuss a case of CD19-negative diffuse large B-cell lymphoma with central nervous system relapse following CD19-directed CAR T-cell treatment. Absence of CD19 expression by the tumour cells presented a challenge for flow cytometry evaluation.

Genomic alterations in patients with somatic loss of the Y chromosome as the sole cytogenetic finding in bone marrow cells.

Loss of the Y chromosome (LOY) is one of the most common somatic genomic alterations in hematopoietic cells in men. However, due to the high prevalence of LOY as the sole cytogenetic finding in the healthy older population, differentiating isolated LOY associated with clonal hematologic processes from aging-associated mosaicism can be difficult in the absence of definitive morphological features of disease. In the past, various investigators have proposed that a high percentage of metaphases with LOY is more likely to represent expansion of a clonal myeloid disease-associated population. It is unknown whether the proportion of metaphases with LOY is associated with the incidence of myeloid neoplasia-associated genomic alterations. To address this question, we identified marrow samples with LOY as isolated cytogenetic finding and used targeted next generation sequencing-based molecular analysis to identify common myeloid neoplasia-associated somatic mutations. Among 73 patients with median age of 75 years (range 29-90), the percentage of metaphases with LOY was <25% in 23 patients, 25-49% in 10, 50-74% in 8 and ≥75% in 32. A threshold of ≥75% LOY was significantly associated with morphologic diagnosis of myeloid neoplasm (p = 0.004). Further, ≥75% LOY was associated with a higher lifetime incidence of diagnosis of myelodysplastic syndromes (MDS; p < 0.0001), and in multivariate analysis ≥75% LOY was a statistically significant independent predictor of myeloid neoplasia [OR 6.17; 95% CI = 2.15-17.68; p = 0.0007]. Higher LOY percentage (≥75%) was associated with greater likelihood of having somatic mutations (p = 0.0009) and a higher number of these mutations (p = 0.0002). Our findings indicate that ≥75% LOY in marrow is associated with increased likelihood of molecular alterations in genes commonly seen in myeloid neoplasia and with morphologic features of MDS. These observations suggest that ≥75% LOY in bone marrow should be considered an MDS-associated cytogenetic aberration.

EGCG, a Green Tea Catechin, as a Potential Therapeutic Agent for Symptomatic and Asymptomatic SARS-CoV-2 Infection.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has emerged to be the greatest threat to humanity in the modern world and has claimed nearly 2.2 million lives worldwide. The United States alone accounts for more than one fourth of 100 million COVID-19 cases across the globe. Although vaccination against SARS-CoV-2 has begun, its efficacy in preventing a new or repeat COVID-19 infection in immunized individuals is yet to be determined. Calls for repurposing of existing, approved, drugs that target the inflammatory condition in COVID-19 are growing. Our initial gene ontology analysis predicts a similarity between SARS-CoV-2 induced inflammatory and immune dysregulation and the pathophysiology of rheumatoid arthritis. Interestingly, many of the drugs related to rheumatoid arthritis have been found to be lifesaving and contribute to lower COVID-19 morbidity. We also performed in silico investigation of binding of epigallocatechin gallate (EGCG), a well-known catechin, and other catechins on viral proteins and identified papain-like protease protein (PLPro) as a binding partner. Catechins bind to the S1 ubiquitin-binding site of PLPro, which might inhibit its protease function and abrogate SARS-CoV-2 inhibitory function on ubiquitin proteasome system and interferon stimulated gene system. In the realms of addressing inflammation and how to effectively target SARS-CoV-2 mediated respiratory distress syndrome, we review in this article the available knowledge on the strategic placement of EGCG in curbing inflammatory signals and how it may serve as a broad spectrum therapeutic in asymptomatic and symptomatic COVID-19 patients.

Land use and land cover dynamics with special emphasis on shifting cultivation in Eastern Ghats Highlands of India using remote sensing data and GIS.

Continual, historical, and accurate information about the land use/land cover (LULC) changes of the earth's surface is extremely important for sustainable management of natural resources. In this study, historical topographic sheets, IRS P6 LISS-III, and LANDSAT TM images were used to provide recent and historical LULC conditions of the Eastern Ghats Highlands of east India. The supervised classification results were further improved by employing image enhancement and visual interpretation. Ratio Vegetation Index with fuzzy-based possibilistic c-means classification approach has improved the classification accuracy of the shifting cultivated area. Post-classification comparisons of the classified images indicated that the major change consisted of barren land and forestland changing into agricultural land and scrubland. Between 1931 and 2008, forest cover was decreased from 52.7% to 29.6% of total area. There was an increase in the scrub area from 874 (10.4%) to 1269 km2 (15.2%), and agricultural land from 978 (11.7%) to 2864 km2 (34.2%) during the same period. The rate of deforestation was found to be 0.65 km2 per year for reserve forest and 24.50 km2 per year for mixed forest. The shifting cultivated area in the district was 308.7 km2 during 2004, and that has been reduced since then and now is stabilized to 186.4 km2 area. Among this 186.4 km2 area, nearly half is covered by abandoned shifting cultivation. The decadal rate of decrease of shifting cultivated area is 0.15% per year. The shifting cultivated areas were mainly distributed at elevations 580-810 and 810-907 m and slopes 20-30 and 30-40%. Southeast and south facing slopes were preferred for shifting cultivation. Based on the identified causes of the change in shifting cultivation, policy recommendations for their better management were made.

Streptococcus pneumoniae - An Uncommon but Noteworthy Cause of Intrauterine Fetal Demise and Acute Necrotizing Funisitis.

Background: Streptococcus pneumoniae (S. pneumoniae) is an uncommon cause of amniotic fluid infection and intrauterine fetal demise. Case report: A 39-year-old G8P2052 presented with preterm premature rupture of membrane at 22 weeks gestation and had a spontaneous vaginal delivery of a neonate who soon expired. Placental examination revealed retroplacental hematoma, acute necrotizing chorioamnionitis, acute three-vessel vasculitis and necrotizing funisitis of the umbilical cord. Postmortem examination demonstrated features of amniotic fluid infection syndrome with blood culture growing S. pneumoniae. Antenatal screening does not typically quantify S. pneumoniae infection, but small series have found vaginal colonization in fewer than 1% of women. Intrauterine or peritoneal infection derives primarily from ascending infection although other routes are hypothetically possible. Intra-amniotic and neonatal infections by S. pneumoniae are associated with high morbidity and mortality. Conclusion: S. pneumoniae should be considered in perinatal death of immature fetus with severe amniotic fluid infection syndrome and acute necrotizing funisitis.

Autophagy is induced upon platelet activation and is essential for hemostasis and thrombosis.

Autophagy is important for maintaining cellular homeostasis, and thus its deficiency is implicated in a broad spectrum of human diseases. Its role in platelet function has only recently been examined. Our biochemical and imaging studies demonstrate that the core autophagy machinery exists in platelets, and that autophagy is constitutively active in resting platelets. Moreover, autophagy is induced upon platelet activation, as indicated by agonist-induced loss of the autophagy marker LC3II. Additional experiments, using inhibitors of platelet activation, proteases, and lysosomal acidification, as well as platelets from knockout mouse strains, show that agonist-induced LC3II loss is a consequence of platelet signaling cascades and requires proteases, acidic compartments, and membrane fusion. To assess the physiological role of platelet autophagy, we generated a mouse strain with a megakaryocyte- and platelet-specific deletion of Atg7, an enzyme required for LC3II production. Ex vivo analysis of platelets from these mice shows modest defects in aggregation and granule cargo packaging. Although these mice have normal platelet numbers and size distributions, they exhibit a robust bleeding diathesis in the tail-bleeding assay and a prolonged occlusion time in the FeCl3-induced carotid injury model. Our results demonstrate that autophagy occurs in platelets and is important for hemostasis and thrombosis.

Performance evaluation of different empirical models for reference evapotranspiration estimation over Udhagamandalm, The Nilgiris, India.

Evapotranspiration (ETo) is an important component of the hydrological cycle and reliable estimates of ETo are essential for assessing crop water requirements and irrigation management. Direct measurement of evapotranspiration is both costly and involves complex and intricate procedures. Hence, empirical models are commonly utilized to estimate ETo using accessible meteorological data. Given that empirical methods operate on various assumptions, it is essential to assess their performance to pinpoint the most suitable methods for ETo calculation based on the availability of input data and the specific climatic conditions of a region. This study aims to evaluate different empirical methods of ETo in the tropical highland Udhagamandalam region of Tamil Nadu, India, utilizing sixty years of meteorological data from 1960-2020. In this study, 8 temperature-based and 10 radiation-based empirical models are evaluated against ETo estimates derived from pan evaporation observation and the FAO Penman-Monteith method (FAO-PM), respectively. Statistical error metrics indicate that both temperature and radiation-based models perform better for the Udhagamandalam region. However, radiation-based models performed better than the temperature based models. This is possibly due to the high humidity of the study region throughout the year. The results suggest that simple temperature and radiation-based models using minimum meteorological information are adequate to estimate ETo and thus find potential application in agricultural water practices, hydrological processes, and irrigation management.

Implementation of flow cytometry testing on rare matrix samples: Special considerations and best practices when the sample is unique or difficult to obtain.

The publication of Clinical and Laboratory Standards Institute's guideline H62 has provided the flow cytometry community with much-needed guidance on development and validation of flow cytometric assays (CLSI, 2021). It has also paved the way for additional exploration of certain topics requiring additional guidance. Flow cytometric analysis of rare matrices, or unique and/or less frequently encountered specimen types, is one such topic and is the focus of this manuscript. This document is the result of a collaboration subject matter experts from a diverse range of backgrounds and seeks to provide best practice consensus guidance regarding these types of specimens. Herein, we define rare matrix samples in the setting of flow cytometric analysis, address validation implications and challenges with these samples, and describe important considerations of using these samples in both clinical and research settings.

A Single Trophoblast Layer Acts as the Gatekeeper at the Endothelial-Hematopoietic Crossroad in the Placenta.

During embryonic development the placental vasculature acts as a major hematopoietic niche, where endothelial to hematopoietic transition ensures emergence of hematopoietic stem cells (HSCs). However, the molecular mechanisms that regulate the placental hematoendothelial niche are poorly understood. Using a parietal trophoblast giant cell (TGC)-specific knockout mouse model and single-cell RNA-sequencing, we show that the paracrine factors secreted by the TGCs are critical in the development of this niche. Disruptions in the TGC-specific paracrine signaling leads to the loss of HSC population and the concomitant expansion of a KDR+/DLL4+/PROM1+ hematoendothelial cell-population in the placenta. Combining single-cell transcriptomics and receptor-ligand pair analyses, we also define the parietal TGC-dependent paracrine signaling network and identify Integrin signaling as a fundamental regulator of this process. Our study elucidates novel mechanisms by which non-autonomous signaling from the primary parietal TGCs maintain the delicate placental hematopoietic-angiogenic balance and ensures embryonic and extraembryonic development.

The evolution of metastatic upper tract urothelial carcinoma through genomic-transcriptomic and single-cell protein markers analysis.

The molecular characteristics of metastatic upper tract urothelial carcinoma (UTUC) are not well understood, and there is a lack of knowledge regarding the genomic and transcriptomic differences between primary and metastatic UTUC. To address these gaps, we integrate whole-exome sequencing, RNA sequencing, and Imaging Mass Cytometry using lanthanide metal-conjugated antibodies of 44 tumor samples from 28 patients with high-grade primary and metastatic UTUC. We perform a spatially-resolved single-cell analysis of cancer, immune, and stromal cells to understand the evolution of primary to metastatic UTUC. We discover that actionable genomic alterations are frequently discordant between primary and metastatic UTUC tumors in the same patient. In contrast, molecular subtype membership and immune depletion signature are stable across primary and matched metastatic UTUC. Molecular and immune subtypes are consistent between bulk RNA-sequencing and mass cytometry of protein markers from 340,798 single cells. Molecular subtypes at the single-cell level are highly conserved between primary and metastatic UTUC tumors within the same patient.

Use of pre-operative hemoglobin a1c to predict early post-operative renal failure and infection risks in patients who are not diabetics and undergoing elective off pump coronary artery bypass graft surgery.

Background: Recent studies have indicated that patients, both with and without diabetes with an increased HbA1c, have a higher rate of adverse outcomes following cardiac surgeries. Our study is focused on to evaluate the prognostic impact of admission value of HbA1c in non-diabetic patients for postoperative renal failure and infections. Materials and Methods: Plasma HbA1c levels were collected from 200 consecutive nondiabetic patients who got admitted for elective off pump coronary artery bypass graft (CABG) procedure over a 2-year period under two groups, Group A whose HbA1c was < 6% at admission and Group B whose HbA1c was ≥6% and ≤6.4% at admission. After surgery, patients were followed up to see if they have got infection or renal failure as postoperative complication. Student's unpaired t test was used to test the significance of difference between the quantitative variables, Yate's and Fisher's chi square tests were used for qualitative variables. Results: We found early postoperative renal failure in 14 (3/96 in Group A and 11/104 in Group B) out of 200 patients (7%) and infection in 21 (8/96 in Group A and 13/104 in Group B) out of 200 patients (10.5%). After data analysis, it was noted that there is a positive correlation between HbA1c and postoperative renal failure (P = 0.0213) whereas no association was found between HbA1c and postoperative infections (P = 0.175) in patients undergoing off-pump CABG surgery. Conclusion: In patients without diabetes, a plasma HbA1c ≥6% was a significant independent predictor for early postoperative renal failure.

Comprehensive spatio-temporal benchmarking of surface water quality of Hindon River, a tributary of river Yamuna, India: Adopting multivariate statistical approach.

The Hindon River is the main tributary of river Yamuna and it is a significant source of surface water, which flows through the major cities of western Uttar Pradesh, India. The indiscriminate development of industries and urbanization along river basin coupled with rapid population growths contribute various amounts of pollutant in the river. Therefore, the present study was conducted to assess the spatial-temporal variability of river water quality (seventeen physicochemical parameters and eight heavy metals) during pre- and post-monsoon seasons for 5 years data at 19 sampling sites along the river stretch. Indices associated with water quality and heavy metals were computed to scale the accurate state of risk associated to its use for drinking and irrigation. During the pre- and post-monsoon seasons, only four sites were found having safe water quality index (WQI) values. The mean heavy metal concentrations are found in order of Zn > Fe > Pb > Cu > Cr > Cd > Ni > Mn. Considering the spatial and temporal distribution, the study benchmarked the water quality of Hindon River for priority attention.

A Clinical Study of Efficacy of Autologous Platelet-Rich Fibrin (PRF) in Chronic Non-Healing Ulcers.

Background: Chronic ulcers are defined as the breakdown of the epidermal and dermal tissue lasting for more than 6 weeks. There will be a lack of necessary growth factors in chronic non-healing ulcers. This study is aimed at accessing the efficacy of autologous platelet-rich fibrin in chronic non-healing ulcers. Aims and Objectives: To determine the efficacy of autologous platelet-rich fibrin in chronic non-healing ulcers and to compare the rate of healing in different ulcers based on aetiology. Methods: A hospital-based prospective study was conducted at the Department of Dermatology, Venereology, and Leprosy, at a tertiary care centre in Central Karnataka with 50 cases of chronic non-healing ulcers over 2 years. In each case baseline data including age and gender was collected and thorough general physical, local, and systemic examinations were done with the help of a predesigned proforma. PRF dressing was done weekly for 4 weeks with ulcer volume measured each time and improvement accessed. Results: In this study, the mean age of the study population was 43.56 ± 14.06 years, with 84% males. Good improvement in the volume of the ulcer was seen in 6 patients out of 50, moderate improvement was seen in 20 out of 50 patients and mild in the rest of the 24 patients. Improvement was more in the educated sector, more so in females and patients with trauma as the cause of ulcers without any comorbidities. Leprosy followed by diabetes was the main cause of chronic non-healing ulcers. Conclusions: This study shows that autologous platelet-rich fibrin therapy provides faster wound healing in chronic non-healing ulcers with no adverse events.

Evaluation of Effect of Hip/Shoulder-Width Ratio on the Sensory Level of Spinal Anesthesia - A Prospective Observational Study.

Background: Certain anthropometric measurements that are practically obtainable explain the variability in the spread of spinal anesthesia. These are useful for quick assessment of the spread of spinal anesthesia to avoid the risk of high block and also the inadequate level of block. Aims: The study aims to evaluate the effect of hip/shoulder-width ratio (HSR) on the sensory level of spinal anesthesia. Settings and Design: This prospective observational study was undertaken at a tertiary care hospital. Statistical Analysis: Pearson's correlation and multiple linear regression analyses were used to analyze the relationship between study variables with the level of sensory block. Materials and Methods: One hundred patients undergoing various surgical procedures were enrolled for the study. With a patient in a sitting position, hip-width was measured between the two iliac crests, shoulder-width was measured between two acromion processes, and vertebral column length was noted by measuring the distance from C7 vertebra to sacral hiatus. 3 mL of 0.5% hyperbaric bupivacaine was administered intrathecally at L3-L4 with 25G Quincke's needle in the lateral position. Assessment of block level was done by loss of cold sensation and loss of pinprick sensation every 5 min till 30 min. The numbers of segments blocked were noted from the S5 segment. The relationship between various factors with the level of sensory block was analyzed by the Pearson's correlation coefficient. Results: HSR and body mass index (BMI) have a significant correlation with the sensory level of spinal anaesthesia, HSR (r = 0.297, P < 0.05) and BMI (r =0.385, P < 0.05). Conclusion: HSR can help predict the cephalad spread of spinal anesthesia. We can expect a higher level of sensory blockade of spinal anesthesia in females who generally have an HSR more than one.