Advances in Endoscopic Diagnosis and Treatment of Gastric Neuroendocrine Neoplasms.

Gastric neuroendocrine neoplasms refer to a group of diseases that are relatively rare. They can be classified into three subtypes based on their clinical and histopathological features, and there are significant differences in diagnosis, treatment, and prognosis among the different subtypes. The incidence of gastric neuroendocrine neoplasms has been increasing globally in recent years with the localized disease being particularly evident. Gastrointestinal endoscopy is of irreplaceable importance for the diagnosis and management of g-NENs. Endoscopy with biopsy is the gold standard for the diagnosis of g-NENs. Ultrasound endoscopy can assess the depth of tumor invasion and the presence of lymphatic metastases, which is important for the development of treatment strategies. Meanwhile, for some small and low-risk lesions, endoscopic surveillance or endoscopic resection has satisfactory therapeutic results and prognosis. This means that even though the incidence has increased, advances in endoscopic techniques have allowed more patients to adopt a relatively conservative treatment strategy. However, the criteria for patients suitable for endoscopic surveillance or endoscopic resection remain controversial.

Esophagogastroscopic Abnormalities Potentially Guided Patients Younger than 50 Years Old to Undergo Colonoscopy Earlier: A Retrospective Cross-Sectional Study.

BACKGROUND: The incidence of early-onset colorectal cancer (CRC) is continuously increasing worldwide. Current guidelines in China recommend average-risk individuals starting CRC screening at age 50. AIMS: To investigate the relationship between the gastric histopathology and colorectal neoplasms to identify CRC risk factors which potentially guide earlier colonoscopy in individuals aged < 50 years. METHODS: A retrospective cross-sectional study was conducted on 8819 patients younger than age 50 who underwent gastroscopy and colonoscopy simultaneously between November 7, 2020 and November 14, 2022. Multivariate logistic regression was used to evaluate whether various gastric histopathology are risk factors for different types of colorectal polyps, reporting odds ratios (ORs) with corresponding 95% confidence intervals (CIs). RESULTS: A total of 3390 cases (38.44%) under 50 years old were diagnosed as colorectal polyps. Advanced age (OR 1.66, 95%CI 1.57-1.76), male sex (OR 2.67, 95%CI 2.33-3.08), Helicobacter pylori (H. pylori) infection (OR 1.43, 95%CI 1.24-1.65), gastric polyps (OR 1.29, 95%CI 1.10-1.52), and low-grade intraepithelial neoplasia (LGIN) (OR 2.52, 95%CI 1.39-4.57) were independent risk factors for colorectal adenomas. For non-adenomatous polyps, reflux esophagitis (OR 1.38, 95%CI 1.11-1.71) was also an independent risk factor. Besides, older age (OR 1.90, 95%CI 1.66-2.18), male sex (OR 2.15, 95%CI 1.60-2.87), and H. pylori infection (OR 1.67, 95%CI 1.24-2.24) were associated with a higher risk of advanced neoplasms (advanced adenoma and CRC). CONCLUSIONS: Earlier colonoscopy for identification and screening may need to be considered for individuals younger than 50 years old with H. pylori infection, LGIN, gastric polyps, and reflux esophagitis. Risk-adapted CRC screening initiation age allows a personalized and precise screening.

Protective Effect of Mesenchymal Stem Cell Active Factor Combined with Alhagi maurorum Extract on Ulcerative Colitis and the Underlying Mechanism.

Ulcerative colitis (UC) is a relapsing and reoccurring inflammatory bowel disease. The treatment effect of Alhagi maurorum and stem cell extracts on UC remains unclear. The aim of the present study was to investigate the protective role of Alhagi maurorum combined with stem cell extract on the intestinal mucosal barrier in an intestinal inflammation mouse model. Sixty mice were randomly divided into a control group, model group, Alhagi group, MSC group, and MSC/Alhagi group. MSC and Alhagi extract were found to reduce the disease activity index (DAI) scores in mice with colitis, alleviate weight loss, improve intestinal inflammation in mice (p < 0.05), preserve the integrity of the ileal wall and increase the number of goblet cells and mucin in colon tissues. Little inflammatory cell infiltration was observed in the Alhagi, MSC, or MSC/Alhagi groups, and the degree of inflammation was significantly alleviated compared with that in the model group. The distribution of PCNA and TNF-alpha in the colonic tissues of the model group was more disperse than that in the normal group (p < 0.05), and the fluorescence intensity was lower. After MSC/Alhagi intervention, PCNA and TNF-alpha were distributed along the cellular membrane in the MSC/Alhagi group (p < 0.05). Compared with that in the normal control group, the intensity was slightly reduced, but it was still stronger than that in the model group. In conclusion, MSC/Alhagi can alleviate inflammatory reactions in mouse colonic tissue, possibly by strengthening the protective effect of the intestinal mucosal barrier.

Commutability evaluation of candidate reference materials and ERM-DA470k/IFCC for immunoglobulin M using two international approaches.

BACKGROUND: This study aimed to assess the commutability of frozen pooled human serum (PHS), high concentration of Immunoglobulin M (IgM) pure diluted materials (HPDM), commercialized pure materials (CPM), and dilutions of ERM-DA470k/IFCC in IgM detection using the CLSI and IFCC approaches, to support standardization or harmonization of IgM measurement. METHODS: Twenty-four serum samples, relevant reference materials (PHS, HPDM, CPM), and different ERM-DA470k/IFCC dilutions were analyzed in triplicate using six routine methods. The commutability of the relevant reference materials was carried out following CLSI EP30-A and IFCC bias analysis. RESULTS: According to the CLSI approach, low, medium, and high concentrations of PHS, HPDM, and CPM were commutable on 10, 13, 15, 13, and 8 of 15 assay combinations, respectively. Using the IFCC approach, low, medium, and high concentrations of PHS, HPDM, and CPM were commutable on 10, 11, 9, 15, and 10 of 15 assay combinations, respectively. The ERM-DA470k/IFCC dilutions with D-PBS and RPMI-1640 Medium were commutable on 13 of 15 assay combinations according to CLSI and were commutable on all 15 assay combinations using IFCC approach. CONCLUSIONS: High concentration of PHS were commutable on all six detection systems using the CLSI approach. Low and medium concentration of PHS showed unsatisfied commutability. HPDM, not CPM have good commutability, has the potential to become reference materials. ERM-DA470k/IFCC diluted with different medium showed different commutability.

Effects of Ferroptosis on Male Reproduction.

Ferroptosis is a relatively novel form of regulated cell death that was discovered in 2012. With the increasing research related to the mechanisms of ferroptosis, previous studies have demonstrated that the inactive of the intracellular antioxidant system and iron overload can result in the accumulation of reactive oxygen species (ROS), which can ultimately cause lipid peroxidation in the various cell types of the body. ROS accumulation can cause sperm damage by attacking the plasma membrane and damaging DNA. Acute ferroptosis causes oxidative damage to sperm DNA and testicular oxidative stress, thereby causing male reproductive dysfunction. This review aims to discuss the metabolic network of ferroptosis, summarize and analyze the relationship between male reproductive diseases caused by iron overload as well as lipid peroxidation, and provide a novel direction for the research and prevention of various male reproductive diseases.

Derepression of specific miRNA-target genes in rice using CRISPR/Cas9.

MicroRNAs (miRNAs) target specific mRNA molecules based on sequence complementarity for their degradation or repression of translation, thereby regulating various developmental and physiological processes in eukaryotic organisms. Expressing the target mimicry (MIM) and short tandem target mimicry (STTM) can block endogenous activity of mature miRNAs and eliminate the inhibition of their target genes, resulting in phenotypic changes due to higher expression of the target genes. Here, we report a strategy to achieve derepression of interested miRNA-target genes through CRISPR/Cas9-based generation of in-frame mutants within the miRNA-complementary sequence of the target gene. We show that two rice genes, OsGRF4 (GROWTH REGULATING FACTOR 4) and OsGRF8 carrying in-frame mutants with disruption of the miR396 recognition sites, escape from miR396-mediated post-transcriptional silencing, resulting in enlarged grain size and increase in brown planthopper (BPH) resistance, in their respective transgenic rice lines. These results demonstrate that CRISPR/Cas9-mediated disruption of miRNA target sites can be effectively employed to precisely derepress particular target genes of functional importance for trait improvement in plants.

Cytoskeleton protein 4.1R suppresses murine keratinocyte cell hyperproliferation via activating the Akt/ERK pathway in an EGFR-dependent manner.

The correct functioning of epidermal growth factor receptor (EGFR), a receptor tyrosine kinase, is required for normal skin development and homeostasis. Cellular hyperproliferation induced by dysregulation of EGFR is tightly associated with structural and functional defects of hair follicles, skin lesions, and tumorigenesis. However, a number of questions still remain regarding the mechanism of EGFR activation and signaling. Here, we report that 4.1R, a member of the membrane-cytoskeleton linker FERM family proteins, plays critical roles in EGFR activation and signaling in keratinocytes. We demonstrated that knockout of 4.1R augments the excessive proliferation potential of keratinocytes by immunohistochemical analysis using murine skin samples. 4.1R-/- keratinocytes display enhanced EGFR-mediated Akt/ERK signaling by upregulating EGFR expression and phosphorylation, which can be reversed by either EGFR or MEK phosphorylation inhibitors. Mechanistically, coimmunoprecipitation and immunofluorescent staining results confirmed that 4.1R can impair the activation of EGFR through direct binding to EGFR and reduce the downstream signaling. Taken together, a deficiency of 4.1R would therefore serve to sustain aberrant EGFR-mediated cellular signaling, leading to hyperproliferation. Our findings highlight the role of 4.1R in the regulation of EGFR signaling in keratinocytes and suggest that 4.1R acts as a novel regulator for EGFR activation.

Prevalence of Clonorchis sinensis infection in fish in South-East Asia: A systematic review and meta-analysis.

Clonorchis sinensis, an important fish-borne zoonotic trematode, is widely distributed in South-East Asia, especially in China. Infections from human and animal reservoir hosts occur due to the consumption of raw or undercooked fish with C. sinensis metacercariae. This study aimed to evaluate the prevalence of C. sinensis metacercariae in fish in South-East Asia via systematic review and meta-analysis. We searched PubMed, ScienceDirect, China National Knowledge Infrastructure, Wanfang and Chongqing VIP databases for studies published between 1976 and 2020 that are related to the prevalence of C. sinensis metacercariae in fish. Studies were screened with keywords based on inclusion and exclusion criteria. Seventy-one eligible articles were identified, covering three countries: China, Korea and Vietnam. The pooled prevalence of C. sinensis metacercariae in fish from South-East Asia was 30.5%, with 35.1% in China, 29.7% in Korea and 8.4% in Vietnam. In subgroup analyses of climate, season, water source and publication date, the highest prevalence was identified in the Dwb climate type (43.3%), summer (70.2%), river (34.5%) and pre-2001 publications (38.9%), respectively. In comparison, the lowest prevalence was found in the Dfa climate type (14.5%), winter (19.5%), lake (8.0%) and post-2001 publications (23.8%). Meta-regression results indicated that country (p = .009), the published time (p = .035) and water source subgroups (p = .003) may be the source of heterogeneity. Overall, our study indicates that a high prevalence of C. sinensis infections occurs in fish in China, Korea and Vietnam, illuminating a significant public health concern in these countries.

A sensitive method to determine dopamine in the presence of uric acid based on In2O3 nanosheet arrays grown on 3D graphene.

A nonenzymatic voltammetric assay for dopamine (DA) was developed based on the combination of three-dimensional graphene (3D Gr) and indium oxide nanosheet arrays (In2O3 NSAs). 3D Gr was prepared by chemical vapor deposition (CVD), and In2O3 NSAs were grown on its surface by hydrothermal synthesis. The results show that 3D Gr maintains a good porous structure (200 µm), and the pore size of In2O3 NSAs is 0.50 µm. Differential pulse voltammetry (DPV) is mainly used to determine the electrochemical properties of In2O3 NSAs/3D Gr. It possesses a sensitivity of 2.69 µA·µM-1·cm-2 towards DA (5-60 µM) at 0.14 V, and the detection limit (LOD) is 0.10 µM (S/N = 3). The recoveries obtained for spiked samples in the real sample detection is 105 (± 8)%. Graphical abstractSchematic representation of DA sensitive detection by growing In2O3 nanosheets arrays on three-dimentional graphene modified ITO.

Generation of a PPM1A-deficient human induced pluripotent stem cell line using CRISPR-Cas9 technology.

PPM1A is a member of the serine/threonine protein phosphatase family. It can bind to a variety of proteins to dephosphorylate them, and extensively regulates many life activities such as cell growth, cell stress, immune response, and tumor formation. Here we constructed a human induced pluripotent stem cell (hiPSC) line with knockout of PPM1A using CRISPR/Cas9-mediated gene targeting. This cell line exhibits normal karyotype, pluripotency, and trilineage differentiation potential, which could provide a useful cellular resource for exploring the mechanism of PPM1A in regulating downstream signaling pathways and explore the application of PPM1A in anti-tumor and anti-infection.

Improved Proton Conductivity of Chitosan-Based Composite Proton Exchange Membrane Reinforced by Modified GO Inorganic Nanofillers.

Non-fluorinated chitosan-based proton exchange membranes (PEMs) have been attracting considerable interest due to their environmental friendliness and relatively low cost. However, low proton conductivity and poor physicochemical properties have limited their application in fuel cells. In this work, a reinforced nanofiller (sulfonated CS/GO, S-CS/GO) is accomplished, for the first time, via a facile amidation and sulfonation reaction. Novel chitosan-based composite PEMs are successfully constructed by the incorporation of the nanofiller into the chitosan matrix. Additionally, the effects of the type and amount of the nanofillers on physicochemical and electrochemical properties are further investigated. It is demonstrated that the chitosan-based composite PEMs incorporating an appropriate amount of the nanofillers (9 wt.%) exhibit good membrane-forming ability, physicochemical properties, improved proton conductivity, and low methanol permeability even under a high temperature and low humidity environment. When the incorporated amounts of S-CS/GO are 9 wt.%, the proton conductivity of the composite PEMs was up to 0.032 S/cm but methanol permeability was decreased to 1.42 × 10-7 cm2/s. Compared to a pristine CS membrane, the tensile strength of the composite membrane is improved by 98% and the methanol permeability is reduced by 51%.

MnFe2O4/MoS2 catalyst used for ozonation: optimization and mechanism analysis of phenolic wastewater treatment.

The performance of catalytic ability of MFe2O4/MoS2 in the ozonation process was investigated in this work. The synthesized MnFe2O4/MoS2 was optimize prepared and then characterized by scanning electron microscopy, transmission electron microscopy, X-ray diffraction, X-ray photo-electron spectroscopy, and magnetic saturation strength. The results showed that when Cphenol = 200 mg/L, initial pH = 9.0, Q = 0.10 L/min, and CMnFe2O4/MoS2 = 0.10 g/L, MnFe2O4/MoS2 addition improved the degradation efficiency of phenol by 20.0%. The effects of pH, catalyst dosage, and inorganic ions on the phenol removal by the MnFe2O4/MoS2 catalytic ozonation were investigated. Five cycle experiments proved that MnFe2O4/MoS2 had good recyclability and stability. MnFe2O4/MoS2 also showed good catalytic performance in the treatment of coal chemical wastewater pesticide wastewater. The MnFe2O4 doped with MoS2 could provide abundant surface active sites for ozone and promote the stable cycle of Mn2+/Mn3+and Fe2+/Fe3+, thus generating large amounts of •OH and improving the degradation of phenol by ozonation. The MnFe2O4/MoS2/ozonation treatment system provides a technical reference and theoretical basis for industrial wastewater treatment.

Responses of lettuce (Lactuca sativa L.) growth and soil properties to conventional non-biodegradable and new biodegradable microplastics.

Residual plastic films in soils are posing a potential threat to agricultural ecosystem. However, little is known about the impacts of microplastics (MPs) derived from biodegradable and non-biodegradable plastic films on plant-soil systems. Here, we carried out a pot experiment using soil-cultivated lettuce treated by two types of MPs, degradable poly(butylene adipate-co-terephthalate) (PBAT-MPs) and non-biodegradable polyethylene (PE-MPs). MPs resulted in different degrees of reduction in shoot biomass, chlorophyll content, photosynthetic parameters, and leaf contents of nitrogen (N), phosphorus (P), and potassium (K), accelerated accumulation of hydrogen peroxide and superoxide, and increased malondialdehyde content in lettuce leaves. Moreover, MPs obviously decreased contents of total N, nitrate, ammonium, and available K in soils, and increased available P, thus altering soil nutrient availability. MPs also significantly decreased proportions of macroaggregates, and decreased soil electrical conductivity and microbial activity. PBAT-MPs had significantly greater impacts on oxidative damage, photosynthetic rate, soil aggregation, microbial activity, and soil ammonium than those of PE-MPs. Our results suggested that MPs caused oxidative damages, nutrient uptake inhibition, soil properties alteration, ultimately leading to growth reduction, and PBAT-MPs exhibited stronger impacts. Therefore, it is urgent to further study the ecological effects of MPs, especially biodegradable MPs, on soil-plant systems.

Sulforaphane decreases oxidative stress and inhibits NLRP3 inflammasome activation in a mouse model of ulcerative colitis.

Excessive oxidative stress and NLRP3 inflammasome activation are considered the main drivers of inflammatory bowel disease (IBD), and inhibition of inflammasomes ameliorates clinical symptoms and morphological manifestations of IBD. Herein, we examined the roles of NLRP3 activation in IBD and modulation of NLRP3 by sulforaphane (SFN), a compound with multiple pharmacological activities that is extracted from cruciferous plants. To simulate human IBD, we established a mouse colitis model by administering dextran sodium sulfate in the drinking water. SFN (25, 50 mg·kg-1·d-1, ig) or the positive control sulfasalazine (500 mg/kg, ig) was administered to colitis-affected mice for 7 days. Model mice displayed pathological alterations in colon tissue as well as classic symptoms of colitis beyond substantial tissue inflammation. Expression of NLRP3, ASC, and caspase-1 was significantly elevated in the colonic epithelium. The expression of NLRP3 inflammasomes led to activation of downstream proteins and increases in the cytokines IL-18 and IL-1ß. SFN administration either fully or partially reversed these changes, thus restoring IL-18 and IL-1ß, substantially inhibiting NLRP3 activation, and decreasing inflammation. SFN alleviated the inflammation induced by LPS and NLRP3 agonists in RAW264.7 cells by decreasing the levels of reactive oxygen species. In summary, our results revealed the pathological roles of oxidative stress and NLRP3 in colitis, and indicated that SFN might serve as a natural NLRP3 inhibitor, thereby providing a new strategy for alternative colitis treatment.

Large-scale generation of IL-12 secreting macrophages from human pluripotent stem cells for cancer therapy.

Genetically engineered macrophages (GEMs) have emerged as an appealing strategy to treat cancers, but they are largely impeded by the cell availability and technical challenges in gene transfer. Here, we develop an efficient approach to generate large-scale macrophages from human induced pluripotent stem cells (hiPSCs). Starting with 1 T150 dish of 106 hiPSCs, more than 109 mature macrophages (iMacs) could be generated within 1 month. The generated iMacs exhibit typical macrophage properties such as phagocytosis and polarization. We then generate hiPSCs integrated with an IL-12 expression cassette in the AAVS1 locus to produce iMacs secreting IL-12, a strong proimmunity cytokine. hiPSC-derived iMacs_IL-12 prevent cytotoxic T cell exhaustion and activate T cells to kill different cancer cells. Furthermore, iMacs_IL-12 display strong antitumor effects in a T cell-dependent manner in subcutaneously or systemically xenografted mice of human lung cancer. Therefore, we provide an off-the-shelf strategy to produce large-scale GEMs for cancer therapy.

Autophagy is essential for human myelopoiesis.

Emergency myelopoiesis (EM) is essential in immune defense against pathogens for rapid replenishing of mature myeloid cells. During the EM process, a rapid cell-cycle switch from the quiescent hematopoietic stem cells (HSCs) to highly proliferative myeloid progenitors (MPs) is critical. How the rapid proliferation of MPs during EM is regulated remains poorly understood. Here, we reveal that ATG7, a critical autophagy factor, is essential for the rapid proliferation of MPs during human myelopoiesis. Peripheral blood (PB)-mobilized hematopoietic stem/progenitor cells (HSPCs) with ATG7 knockdown or HSPCs derived from ATG7-/- human embryonic stem cells (hESCs) exhibit severe defect in proliferation during fate transition from HSPCs to MPs. Mechanistically, we show that ATG7 deficiency reduces p53 localization in lysosome for a potential autophagy-mediated degradation. Together, we reveal a previously unrecognized role of autophagy to regulate p53 for a rapid proliferation of MPs in human myelopoiesis.

Kumatakenin inhibited iron-ferroptosis in epithelial cells from colitis mice by regulating the Eno3-IRP1-axis.

Inhibition of epithelial ferroptosis in colonic tissues relieved clinical symptoms and improved endoscopic presentations in inflammatory bowel disease (IBD). Kumatakenin, the main ingredient of traditional Chinese medicinal cloves and Alpinia purpurata, is reported to possess therapeutic benefits. However, whether kumatakenin could inhibit ferroptosis and further alleviate colitis remains unclear. Here, we measured the effects of kumatakenin on ferroptosis of colonic epithelial cells from colitis mice. The colitis model was induced in mice by oral intake of 2.5% dextran sulfate sodium in drinking water. RNA sequencing was performed to investigate the mechanism underlying kumatakenin-mediated effects on colitis. The results showed that different doses of kumatakenin significantly alleviated symptoms and suppressed intestinal inflammation in the colitis mouse model. Kumatakenin supplementation decreased cellular iron levels and suppressed ferroptosis in epithelial cells from colitis mice. RNA sequencing, qPCR, and pharmacological inhibition assays showed that kumatakenin reduced cellular iron levels and suppressed ferroptosis in epithelial cells from colitis mice at least partially by upregulating expression of enolase (Eno-3). Furthermore, kumatakenin decreased iron levels in epithelial cells by modulating the Eno3-iron regulatory protein (IRP1) axis. Molecular docking results revealed that kumatakenin could bind Eno3 via hydrogen bonding with the amino acid residues Thr208, Val206, and Pro203. This work will provide a scientific basis for the clinical use of kumatakenin in the treatment of colitis.

Adverse effects of sulfamethoxazole on locomotor behavior and lipid metabolism by inhibiting acetylcholinesterase and lipase in Daphnia magna.

Sulfamethoxazole (SMZ), a kind of sulfonamide antibiotic, is widely used in both human and veterinary medicine. Frequent detection of SMZ in natural aquatic environments has prompted growing attention and posed ecological risks to the ecosystem and human health. In this study, we investigated the ecotoxicological properties of SMZ upon Daphnia magna, and the mechanisms of the deleterious effects of SMZ were attempted to be elucidated by investigating a chain of parameters, including survival, reproduction, growth, locomotor behavior, metabolism, as well as levels of related enzyme activity and gene expression. After a 14-d sub-chronic exposure to SMZ at environmentally relevant concentrations, we observed virtually no lethal effect, weak growth inhibition, significant reproductive damage, evident ingestion rate decline, obvious change in locomotor behavior, and remarkable metabolic disorder. Notably, we identified SMZ as an inhibitor against acetylcholinesterase (AChE)/lipase in D. magna both in vivo and in vitro, which explained the adverse effects of SMZ on locomotor ability and lipid metabolism at the molecular levels. Furthermore, the direct interactions between SMZ and AChE/lipase were confirmed by using fluorescence spectrum and molecular docking. Together, our findings provide a new insight to advance the understanding of the environmental effects of SMZ on freshwater organisms.

Remodeling of Gut Microbiota by Probiotics Alleviated Heat Stroke-Induced Necroptosis in Male Germ Cells.

SCOPE: Systemic heat stress (or heatstroke; HS) induces germ cell death and spermatogenesis disorders in men and male mammals. Also, it affects the immune environment of the circulatory system promoting gut inflammation and intestinal permeability, leading to pathogenic infection. In this study, the crosstalk between the gut and testis (gut-testis axis) under HS is explored, by examining the effects of intestinal immune status on the health of the male reproductive system in mice. METHODS AND RESULTS: A mouse model of systemic heat stress is established to investigate the effect of probiotics on testis health. The results reveal that pro-inflammatory factor receptor activation pathway and pathogen infection response pathway are significantly upregulated in HS testes, leading to necroptosis, while pro-inflammatory factor and endotoxin are detected locally in the intestine and then entered the blood. The study then uses probiotics to intervene in gut microbiota, which results in milder gut microbial changes, lower inflammatory responses in the HS gut, and less necroptosis in the HS testes. CONCLUSION: Probiotics-based remodeling of gut microbiota (GM) reduces the proliferation of abnormal bacteria and decreases the spread of gut-derived inflammatory mediators into the blood circulation under long-term systemic heat stress, which relieves inflammation on germ cells.