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BACKGROUND AND AIMS: Gastric emptying scintigraphy (GES) is the criterion standard for the diagnosis of gastroparesis. However, data are lacking regarding the prognostic value of preoperative intragastric meal distribution during GES in patients undergoing gastric peroral endoscopic myotomy (G-POEM) for gastroparesis. This study investigated the association of GES morphologic parameters and the long-term clinical success of G-POEM. METHODS: This retrospective study included patients who underwent G-POEM for refractory gastroparesis in a tertiary center with preoperative GES data. Intragastric meal distribution was measured using the proximal to distal count ratio (PDCR) at 0, 1, 2 and 4 hours, and the retention index was calculated. Clinical success was defined as a decrease of at least 50% in the Gastroparesis Cardinal Symptom Index total score after G-POEM. RESULTS: In total, 77 patients were included with a mean follow-up of 40.14 months. Clinical success was observed in 54.55% of patients. The retention index was not associated with clinical success. Only PDCR at 0 hours (PDCR0) was associated with clinical success. In univariate analysis, the median PDCR0 was 6.0 (interquartile range, 5.59) in patients with clinical success and 4.29 (interquartile range, 4.51) in patients with clinical failure (P = .019). In multivariate analysis, PDCR0 >5.25 was associated with clinical success (odds ratio, 4.36; 95% confidence interval, 1.55-12.26; P = .00524). CONCLUSIONS: This study suggests that in patients with gastroparesis, a high PDCR0 value (suggestive for a preferential fundic meal distribution) during preoperative GES is associated with long-term clinical response to G-POEM.
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Axicabtagene ciloleucel (axi-cel) demonstrated superior efficacy compared to standard of care as second-line therapy in patients with high-risk relapsed/refractory (R/R) large B cell lymphoma (LBCL) considered eligible for autologous stem cell transplantation (ASCT); however, in clinical practice, roughly half of patients with R/R LBCL are deemed unsuitable candidates for ASCT. The efficacy of axi-cel remains to be ascertained in transplant-ineligible patients. ALYCANTE, an open-label, phase 2 study, evaluated axi-cel as a second-line therapy in 62 patients with R/R LBCL who were considered ineligible for ASCT. The primary end point was investigator-assessed complete metabolic response at 3 months from the axi-cel infusion. Key secondary end points included progression-free survival, overall survival and safety. The study met its primary end point with a complete metabolic response of 71.0% (95% confidence interval, 58.1-81.8%) at 3 months. With a median follow-up of 12.0 months (range, 2.1-17.9), median progression-free survival was 11.8 months (95% confidence interval, 8.4-not reached) and overall survival was not reached. There was no unexpected toxicity. Grade 3-4 cytokine release syndrome and neurologic events occurred in 8.1% and 14.5% of patients, respectively. These results support axi-cel as second-line therapy in patients with R/R LBCL ineligible for ASCT. ClinicalTrials.gov Identifier: NCT04531046 .
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Produtos Biológicos , Transplante de Células-Tronco Hematopoéticas , Linfoma Difuso de Grandes Células B , Humanos , Transplante Autólogo , Linfoma Difuso de Grandes Células B/terapia , Produtos Biológicos/uso terapêutico , Síndrome da Liberação de Citocina , Imunoterapia Adotiva/efeitos adversos , Antígenos CD19RESUMO
18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) is an essential part of the management of patients with lymphoma at staging and response evaluation. Efforts to standardize PET acquisition and reporting, including the 5-point Deauville scale, have enabled PET to become a surrogate for treatment success or failure in common lymphoma subtypes. This review summarizes the key clinical-trial evidence that supports PET-directed personalized approaches in lymphoma but also points out the potential place of innovative PET/CT metrics or new radiopharmaceuticals in the future.
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PURPOSE: Plasmablastic lymphoma (PBL) is a rare variant of diffuse large B cell lymphomas (DLBCL) clinically characterized by a poorer prognostic. Few clinical and imaging data are available and derived from pooled case reports and small series. The aim of the study was to evaluate the FDG avidity at baseline and the utility of 18-Fluorodeoxyglucose (FDG) positron-emission-tomography/computed-tomography (PET/CT) for staging and response assessment. METHODS: Patients with newly diagnosed PBL seen at Lymphoma Study Association centers during the period 2005-2015 were included if they underwent a PET/CT at staging and at the end of treatment (eotPET) and had received an anthracycline-based first line therapy. EotPET scans were analyzed using the 5-point-scale visual analysis in accordance with Lugano criteria. Patients were classified in complete metabolic response (CMR) or no-CMR including partial metabolic response (PMR), stable disease (SD) and progression disease (PD). EotPET results were assessed for the ability to predict event free survival (EFS) and overall survival (OS). RESULTS: Thirty-five PBL patients fulfilled the inclusion criteria. The median follow-up was 34 months (2.8-120 months). FDG avidity was found in all patients at diagnosis. Most patients (80%) achieved CMR, and 20% were no-CMR including 9% PMR, 6% SD, and 6% PD. A CMR after first line chemotherapy predicted higher EFS (p < 0.0001) and OS (p = 0.0006). CONCLUSIONS: This study confirmed the FDG avidity of PBL subtype and the usefulness of PET/CT scanning in restaging an aggressive lymphoma at the completion of chemotherapy. EotPET can predict outcomes following treatment in patients with PBL.
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Linfoma Plasmablástico/diagnóstico por imagem , Linfoma Plasmablástico/terapia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fluordesoxiglucose F18 , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: The aim of the study was to evaluate dynamic contrast-enhanced magnetic resonance (MR) imaging in the characterization of parotid gland tumors. METHODS: Fifty-five parotid lesions in 55 patients were retrospectively included. Two observers interpreted 2 reading protocols derived from all MR imaging in 2 distinct sessions, independently and blinded. Benign versus malignant distinction was carried out for protocol 1 (without contrast administration) and protocol 2 (with dynamic contrast-enhanced sequence). Histopathological results after surgical resection were used as the criterion standard. Diagnostic accuracy was compared between protocols using McNemar test. A P values of less than 0.05 indicated significant difference. RESULTS: There was no intraobserver statistical discordance between protocols for both observers (P = 0.27 and P = 1). Interobserver reliability showed moderate agreement for protocol 1 (κ = 0.591; 95% confidence interval [CI], 0.376-0.806) and 2 (κ = 0.463, 95% CI, 0.226-0.701). Intraobserver reliability showed moderate agreement for observer 1 (κ = 0.507; 95% CI, 0.279-0.736) and 2 (κ = 0.477; 95% CI, 0.241-0.712). CONCLUSIONS: Magnetic resonance imaging protocol including dynamic sequence for the characterization of parotid gland lesion yielded nonsignificant increases in sensitivity, specificity, or positive predictive values, and negative predictive values over noninjected protocol.
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Meios de Contraste , Aumento da Imagem/métodos , Processamento de Imagem Assistida por Computador/métodos , Imageamento por Ressonância Magnética/métodos , Neoplasias Parotídeas/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Glândula Parótida/diagnóstico por imagem , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
UNLABELLED: The purpose of this study was to compare a routine bone SPECT/CT protocol using CT reconstructed with filtered backprojection (FBP) with an optimized protocol using low-dose CT images reconstructed with adaptive statistical iterative reconstruction (ASiR). METHODS: In this prospective study, enrolled patients underwent bone SPECT/CT, with 1 SPECT acquisition followed by 2 randomized CT acquisitions: FBP CT (FBP; noise index, 25) and ASiR CT (70% ASiR; noise index, 40). The image quality of both attenuation-corrected SPECT and CT images was visually (5-point Likert scale, 2 interpreters) and quantitatively (contrast ratio [CR] and signal-to-noise ratio [SNR]) estimated. The CT dose index volume, dose-length product, and effective dose were compared. RESULTS: Seventy-five patients were enrolled in the study. Quantitative attenuation-corrected SPECT evaluation showed no inferiority for contrast ratio and SNR issued from FBP CT or ASiR CT (respectively, 13.41 ± 7.83 vs. 13.45 ± 7.99 and 2.33 ± 0.83 vs. 2.32 ± 0.84). Qualitative image analysis showed no difference between attenuation-corrected SPECT images issued from FBP CT or ASiR CT for both interpreters (respectively, 3.5 ± 0.6 vs. 3.5 ± 0.6 and 3.6 ± 0.5 vs. 3.6 ± 0.5). Quantitative CT evaluation showed no inferiority for SNR between FBP and ASiR CT images (respectively, 0.93 ± 0.16 and 1.07 ± 0.17). Qualitative image analysis showed no quality difference between FBP and ASiR CT images for both interpreters (respectively, 3.8 ± 0.5 vs. 3.6 ± 0.5 and 4.0 ± 0.1 vs. 4.0 ± 0.2). Mean CT dose index volume, dose-length product, and effective dose for ASiR CT (3.0 ± 2.0 mGy, 148 ± 85 mGyâ cm, and 2.2 ± 1.3 mSv) were significantly lower than for FBP CT (8.5 ± 3.7 mGy, 365 ± 160 mGyâ cm, and 5.5 ± 2.4 mSv). CONCLUSION: The use of 70% ASiR blending in bone SPECT/CT can reduce the CT radiation dose by 60%, with no sacrifice in attenuation-corrected SPECT and CT image quality, compared with the conventional protocol using FBP CT reconstruction technique.
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Osso e Ossos/diagnóstico por imagem , Doses de Radiação , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Tomografia Computadorizada de Emissão/métodos , Idoso , Idoso de 80 Anos ou mais , Artefatos , Relação Dose-Resposta à Radiação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Razão Sinal-Ruído , Tomografia Computadorizada com Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
BACKGROUND: Acute infectious mononucleosis (AIM) is generally associated with a large EBV B cell reservoir cells and an intense B-cell polyclonal activation whereas the number of quiescent EBV-infected memory B cells in chronically EBV-infected healthy controls is very low. OBJECTIVES: To evaluate the extent and functionality of ex vivo B-cell polyclonal activation, quantify the EBV DNA integrated in B cells, enumerate the functional EBV DNA reservoir in B cells and circulating B cells spontaneously secreting EBV antigens in AIM. STUDY DESIGN: Circulating B cells and B cells differentiating into plamablasts and plasma cells, early (BZLF1)- and late viral antigen (gp350)-secreting-cells (SCs) were enumerated in six AIM patients and seven healthy EBV carriers. RESULTS: In vitro B-cell polyclonal activation induced 8000-24,000 BZLF1- and 1000-3000gp350-SCs/10(6) B cells, respectively. These data suggest that only 11.1-19.5% of cells expressing BZLF1 synthesized gp350 and so completed the EBV-lytic cycle. Furthermore, circulating spontaneous BZLF1- and gp350-SCs that reflect ongoing viral replication were rare (20-120 and 10-30/10(6) B cells, respectively), and their low numbers contrasted with the high levels of circulating plasma cells (1.1-10.2% of CD19(+) B cells). CONCLUSION: The in vivo terminal-B-cell differentiation into plasma cells could unmask EBV B-cell reservoir to specific cytotoxic T-cell response and combined with a predominant abortive functional-EBV-reservoir, strongly contribute to rapid decay of cellular EBV reservoir in AIM.
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Linfócitos B/imunologia , Infecções por Vírus Epstein-Barr/imunologia , Herpesvirus Humano 4/imunologia , Mononucleose Infecciosa/imunologia , Ativação Linfocitária/imunologia , Doença Aguda , Antígenos Virais/imunologia , Linfócitos B/metabolismo , Infecções por Vírus Epstein-Barr/virologia , Antígenos Nucleares do Vírus Epstein-Barr/imunologia , Herpesvirus Humano 4/metabolismo , Humanos , Mononucleose Infecciosa/diagnóstico , Mononucleose Infecciosa/patologia , Linfócitos T Citotóxicos/imunologia , Transativadores/análise , Transativadores/biossíntese , Transativadores/metabolismo , Proteínas Virais/análise , Proteínas Virais/biossíntese , Proteínas Virais/metabolismo , alfa-Macroglobulinas/imunologiaRESUMO
BACKGROUND: Transmission of human immunodeficiency virus type 1 (HIV-1) through breast-feeding may involve both cell-free and cell-associated virus. This latter viral reservoir remains, however, to be fully explored. CD4+ T cell-associated virus production in breast milk was therefore investigated. METHODS: The ex vivo spontaneous production of HIV-1 antigen and HIV-1 RNA by CD4+ T cells was measured in paired blood and breast milk samples from 15 HIV-1 infected women treated or not with antiretroviral drugs. Spontaneous antigen secreting cells (HIV-1-AgSCs) from breast milk and blood were enumerated by an ELISpot assay, and cell-associated HIV-1 RNA was quantified by real-time PCR in supernatants of CD4+ T cells cultured for 18 hours without addition of polyclonal activators. RESULTS: Among the CD4+ T cells present in breast milk, memory cells expressing high levels of cell-surface activation markers were predominant. Spontaneous HIV-1-AgSCs were detected and enumerated in the breast milk of all 15 women, with a median number of 13.0 and 9.5 HIV-1- AgSCs/106 CD4+ T cells in aviremic (n = 7) and viremic (n = 8) women, respectively. Cell- associated HIV-1 RNA was detected in cell-free supernatants from 4/7 aviremic and 5/8 viremic individuals at median levels of 190 and 245 copies/ml, respectively. CONCLUSIONS: Activated CD4+ T cells producing HIV-1 are detected in the breast milk of untreated individuals as well as those receiving highly active antiretroviral therapy. This finding strongly suggests that HIV-1 replication occurs in latently infected CD4+ T cells that, upon spontaneous activation, revert to productively infected cells. These cells might be responsible for a residual breast milk transmission despite maternal highly active antiretroviral therapy.
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Linfócitos T CD4-Positivos/virologia , Infecções por HIV/transmissão , Infecções por HIV/virologia , HIV-1/fisiologia , Leite Humano/citologia , Leite Humano/virologia , Fármacos Anti-HIV/uso terapêutico , ELISPOT , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/imunologia , HIV-1/crescimento & desenvolvimento , HIV-1/isolamento & purificação , Humanos , Técnicas In Vitro , Gravidez , RNA Viral/biossíntese , RNA Viral/genética , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Proteínas Virais/biossíntese , Proteínas Virais/imunologia , Ativação ViralRESUMO
While secretory Abs have been extensively explored in human breast milk, the existence, features, and functions of B lymphocytes remain largely unexplored in this compartment. We analyzed breast milk and blood lymphocytes from 21 lactating women, including 12 HIV-1-infected mothers. Breast milk B cells displayed a phenotype of class-switched memory B cells, with few IgD(+) memory and naive B cells. We observed that breast milk B lymphocytes bore a unique profile of adhesion molecules (CD44(+), CD62L(-), alpha(4)beta(7)(+/-), alpha(4)beta(1)(+)). Higher percentages of activated B cells (CD38(+)), large-sized B cells, plasmablasts, and plasma cells (CD19(+), CD20(low/-), CD27(high), CD138(+)) were found as compared with blood. This indicates that a significant proportion of breast milk B cells underwent terminal plasma cell differentiation. We also observed a higher frequency of cells secreting Ig spontaneously in breast milk. Among these cells, IgG-secreting cells predominated over IgA-secreting cells as measured by Ig ELISPOT assays. Specific Ab-secreting cells were investigated following polyclonal activation using the CD40L ligation. Finally, the detection of anti-HIV-1-secreting cells demonstrates the existence of B cells specific to HIV-1 Ag in breast milk from HIV-1-infected women. Breast milk B cells display a phenotype strikingly different from blood, are primed to secrete Abs, and have a mucosal homing profile similar to B cells located in gut-associated lymphoid tissue.
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Formação de Anticorpos/imunologia , Linfócitos B/imunologia , Memória Imunológica , Leite Humano/imunologia , Anticorpos/análise , Moléculas de Adesão Celular/análise , Feminino , Anticorpos Anti-HIV/análise , Infecções por HIV , Humanos , Isotipos de Imunoglobulinas/análise , Ativação Linfocitária , Leite Humano/virologia , PlasmócitosRESUMO
BACKGROUND: Measuring lymphocyte activation provides information in addition to CD4(+) T-cell count for immune monitoring of HIV-1 infected patients. CD38 is a well-established activation marker that is generally analyzed on the whole population of CD8(+) T-cells. Focusing specifically on CD38 high expression (CD8(+)/CD38(bright)) may be an interesting surrogate gating strategy because CD38(bright) characterizes principally activated memory cells. METHODS: CD8(+)/CD38(bright) was investigated in 1,353 HIV-1 infected patients over a one-year period to establish relevant cutoff values and clarify the relationships of this marker with HIV-1 RNA viral load (VL) and CD4(+) T-cell count. RESULTS: The CD8(+)/CD38(bright) (>8,500 CD38 binding site per cells) is well correlated with HIV-1 VL (r = 0.87, P < 0.001) in this longitudinal follow-up of nonimmunodepressed patients that initiated antiviral therapy (ART). In aviremic patients on ART, the marker was highly predictive of VL rebound (sensitivity 93%, specificity 64% for a VL level of detection >200 copies/ml). While the CD8(+)/CD38(bright) moderately correlated with CD4(+) T-cell count independently of the VL (r = -0.37, P < 0.001), it increased dramatically in aviremic patient groups that exhibited profound CD4(+) T-cell depletion (median 39% for CD4(+) T-cell counts <50/mm(3)). This result indicates that other additional immunological and/or viral factors than readily detectable HIV-1 replication appears to be involved in T-cell activation of immunodepressed individuals. CONCLUSIONS: CD8(+)/CD38(bright) is an effective marker for monitoring T-cell activation, which is a central factor of HIV-1 pathogenesis. This gating strategy requires only a single additional staining in conventional four color CD4 protocols.
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ADP-Ribosil Ciclase 1/metabolismo , Linfócitos T CD4-Positivos/patologia , Linfócitos T CD8-Positivos/citologia , Infecções por HIV/imunologia , HIV-1/fisiologia , Glicoproteínas de Membrana/metabolismo , Replicação Viral/imunologia , Antirretrovirais/uso terapêutico , Biomarcadores/análise , Biomarcadores/sangue , Contagem de Linfócito CD4 , Linfócitos T CD4-Positivos/metabolismo , Linfócitos T CD8-Positivos/metabolismo , Estudos de Casos e Controles , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/patologia , Infecções por HIV/virologia , HIV-1/imunologia , Humanos , Estudos Longitudinais , Ativação Linfocitária/imunologia , Ativação Linfocitária/fisiologia , Masculino , RNA Viral/análise , RNA Viral/sangue , Sensibilidade e Especificidade , Carga ViralRESUMO
The Epstein-Barr virus (EBV) causes infectious mononucleosis, establishes latency in resting memory B lymphocytes, and is involved in oncogenesis through poorly understood mechanisms. The EBV lytic cycle is initiated during plasma cell differentiation by mRNAs transcripts encoded by BZLF1, which induce the synthesis of EBV proteins such as the immediate-early antigen ZEBRA and the late membrane antigen gp350. Therefore, we assessed the capacity of circulating EBV-infected B lymphocytes from healthy EBV-seropositive subjects to enter and complete the EBV lytic cycle. Purified B lymphocytes were polyclonally stimulated and BZLF1- or gp350-secreting cells (BZLF1-SCs or gp350-SCs) were enumerated by ELISpot assays. The number of BZLF1-SCs ranged from 50 to 480/107 lymphocytes (median, 80; 25th-75th percentiles, 70-150) and gp350-SCs from 10 to 40/107 lymphocytes (median, 17; 25th-75th percentiles, 10-20). gp350-SCs represented only 7.7% to 28.6% of BZLF1-SCs (median, 15%; 25th-75th percentiles, 10.5%-20%). This EBV functional reservoir was preferentially restricted to plasma cells derived from CD27(+) IgD(-) memory B lymphocytes. In 9 of 13 subjects, EBV DNA quantification in B-cell culture supernatants gave evidence of completion of EBV lytic cycle. These results demonstrate that EBV proteins can be secreted by EBV-infected B lymphocytes from healthy carriers, a majority generating an abortive EBV lytic cycle and a minority completing the cycle.
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Linfócitos B/virologia , Infecções por Vírus Epstein-Barr/virologia , Memória Imunológica , Plasmócitos/virologia , Ativação Viral/fisiologia , Adulto , Linfócitos B/metabolismo , Células Cultivadas , DNA Viral/análise , Infecções por Vírus Epstein-Barr/genética , Infecções por Vírus Epstein-Barr/imunologia , Citometria de Fluxo , Herpesvirus Humano 4/genética , Herpesvirus Humano 4/imunologia , Humanos , Plasmócitos/metabolismo , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Transativadores/metabolismo , Membro 7 da Superfamília de Receptores de Fatores de Necrose Tumoral/metabolismo , Latência Viral/fisiologiaRESUMO
BACKGROUND: The presence of HIV-1 preintegration reservoir was assessed in an in vitro experimental model of latent HIV-1 infection, and in patients treated or not with highly active antiretroviral therapy (HAART). RESULTS: In resting CD4+ T lymphocytes latently infected in vitro with HIV-1, we demonstrated that the polyclonal activation induced a HIV-1 replication, which could be prevented by the use of an HIV-1 integrase inhibitor. We also showed that this reservoir was labile since the rescuable HIV-1-antigens production from unintegrated HIV-1 genomes declined over time. These data confirm that our experimental approach allows the characterization of a functional unintegrated HIV-1 reservoir. We then explored the preintegration reservoir in HIV-1-infected patients. This reservoir was detected in 11 of 12 untreated patients, in 4 of 10 sustained responders to HAART, and in one incomplete responder. This reservoir was also inducible, labile, and anti-HIV-1 integrase drug inhibited its induction. Finally, this reservoir was associated with the presence of spontaneous HIV-1 antigens producing CD4+ T cells in blood from 3 of 3 untreated patients and 2 of 2 sustained responders to HAART harboring a preintegration reservoir. CONCLUSION: This preintegration phase of HIV-1 latency could be a consequence of the ongoing viral replication in untreated patients and of a residual viral replication in treated patients.
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Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade , Infecções por HIV/virologia , HIV-1/fisiologia , Latência Viral , Linfócitos T CD4-Positivos/virologia , DNA Viral , Infecções por HIV/tratamento farmacológico , Humanos , Ativação Viral , Integração Viral , Replicação ViralRESUMO
An HIV-1 reservoir comprised primarily of latently infected resting CD4+ T lymphocytes that can be stimulated in vivo to produce virus may play a critical role in mother-to-child postnatal transmission of HIV-1 by breastfeeding. Here, we describe an experimental protocol for the detection of resting CD4+ T cell HIV-1 reservoir from breast milk. We adapted a method for the purification of resting CD4+ T lymphocytes in blood to isolate resting CD4+ T cells in breast milk from HIV-1-infected-lactating women (n=18) and from controls (n=3). Purified resting CD4+ T cells from blood and breast milk samples of HIV-1-infected-lactating women were polyclonally stimulated to characterize and enumerate HIV-1-antigen-secreting cells (HIV-1-Ag-SCs) by an enzyme-linked immunospot (ELISpot) assay. Resting CD4+ T cells represented more than 90% of purified viable breast milk cells. CD4+ T cell polyclonal stimulation combined with the ELISpot assay led to the characterization of a breast milk T cell HIV-1 reservoir greater than the blood reservoir (median 400 and 57.14 HIV-1-Ag-SCs/10(6) resting CD4+ T cells, respectively, p<0.001). Our strategy could be adapted to other body fluids and be useful for characterizing new HIV-1 reservoirs.