Recombinant Russell’s viper venom-factor X activator (RVV-X)-specific antibody: neutralization and crossreactivity with Cryptelytrops albolabris and Calloselasma rhodostoma venoms.

Background: Russell’s viper venom-factor X activator (RVV-X) is a major procoagulant in Russell’s viper venom, and is composed of a heavy chain (RVV-XH) and two light chains (RVV-XL). It directly activates factor X in the final common coagulation pathway, which leads to rapid formation of blood clots. Objective: Produce rabbit anti-recombinant protein antibodies and identify their cross-reactivity with two viperine snake venoms. Methods: cDNA clones encoding RVV-XH and one of the light chains (RVV-XL; LC1) were recombinantly expressed in E. coli BL21 and used as antigens for rabbit immunization. The cross-reactivity of these anti-recombinant protein antibodies with two viperine snake venoms was determined using Western blot analysis. Results: rRVV-XH was more immunogenic than rRVV-XL. Rabbit anti-rRVV-XH and rRVV-XL IgG antibodies bind specifically to RVV-X, but they do not neutralize purified RVV-X. In addition, rabbit anti-rRVV-XH IgG antibody also bind to an 18-kDa protein in C. rhodostoma venom, and many proteins in C. albolabris venom. Rabbit antirRVV- XL IgG antibody recognized protein bands of crude venoms of C. rhodostoma and C. albolabris at about 25-kDa and 23-kDa, respectively. Conclusion: Rabbit anti-rRVV-XH and rRVV-XL IgG antibodies cross-reacted with molecules in other viperine venoms, which could have molecules with similar antigenic determinants. These antibodies could be useful to purify snake venom molecules by affinity chromatography as the first step in purification of factor X activator and other cross reacting molecules.

Transcutaneous bilirubin in the pre-term infants.

OBJECTIVE: 1) To evaluate the accuracy of transcutaneous bilirubin (T(C)B) measurement compared to total serum bilirubin level (TSB) in the pre-term infants and 2) To establish cut-off values of T(C)B that indicated need for TSB. MATERIAL AND METHOD: Premature infants whose birth weight was more than 1,000 grams and gestational age less than 36 weeks had paired T(C)B-TSB assessment when jaundice was observed. T(C)B was done using JM 103 (Minolta AirShields Jaundice Meter) on the forehead. T(C)B, which corresponded to TSB level that required phototherapy, was chosen as the cut-off point that indicated blood sampling for TSB. RESULTS: Two hundred and forty-nine paired T(CB)-TSB measurements from 196 premature neonates were obtained. Birth weight was 1,887 +/- 344.4 grams. TSB ranged from 4.5-17.6 mg/dL (mean 9.4, SD 2.2 mg/dL), T(C)B 4.1-17.7 mg/dL (mean 9.7, SD 2.4 mg/dL). The correlation coefficient between T(C)B and TSB was significant (r 0.79, p < 0.0001). T(C)B had a tendency to overestimate TSB with the mean difference of TSB- T(C)B = -0.3 +/- 1.5 mg/dL and 95% confidence interval of the mean -0.1 to -0.5 mg/dL. Of all the variables of birth weight, gestational age, and postnatal age, only postnatal age significantly influenced the correlation of T(C)B-TSB. In the early postnatal age of 1-4 days, the number of T(C)B reading overestimated TSB more than underestimated. However, at > or = 5 days of age, the number of underestimation was more than those of overestimation. The cut-off points of T(C)B that indicated the need for blood sampling for TSB were chosen as the same level of TSB of 6, 8, 10, 11, and 12 mg/dL when phototherapy was recommended. Screening with T(C)B would eliminate painful procedure of blood taking by 40%. CONCLUSION: Noninvasive T(C)B assessment demonstrated significant accuracy when compared to TSB. T(C)B can be adopted as a screening test to identify the need for blood sampling of serum bilirubin in premature infants.

Diffuse Neonatal Hemangiomatosis: report of 5 cases.

Diffuse Neonatal Hemangiomatosis (DNH) is a rare, life-threatening condition associated with a few to hundreds of small, cutaneous and visceral hemangiomas. The authors reported 5 cases of DNH in which hepatic hemangioma were the most common visceral involvement. Response to prednisolone in these cases was not good, one died and four required second line therapy. Of these four cases, one case with embolisation; one with interferon and two with vinblastine. Response to vinblastine was good, but long-term follow-up of the side effects are needed.

Rosai-Dorfman disease and juvenile xanthogranuloma in a Thai boy: report of a case.

A 3-year-old Thai boy suffered from two histiocytoses, Rosai-Dorfman disease (RDD) and juvenile xanthogranuloma (JXG). The patient first presented with massive cervical lymphadenopathy at the age of one year. Biopsy revealed typical RDD; abnormally large CD68- and S-100 protein-positive histiocytes with occasional emperipolesis filled up the sinuses. Two years later, he developed polyuria and polydypsia. Skull film demonstrated osteolytic lesions at the occiput and left parietal region. Enlargement of the pituitary stalk was found on the magnetic resonance imaging. Despite the clinical impression of Langerhans cell histiocytosis, biopsy of the occipital lesion disclosed numerous large histiocytes with foamy cytoplasm. Several Touton giant cells with wreath-like arrangement of the nuclei were also observed. The abnormal cells expressed CD68 and factor XIIIa, but were non-reactive with S-100 protein and CD1a. Biopsy of the pituitary stalk was not performed According to the authors' literature search, this represents the first report of RDD and JXG affecting the same person.

Comparison of two transcutaneous bilirubinometers--Minolta AirShields Jaundice Meter JM103 and Spectrx Bilicheck--in Thai neonates.

Transcutaneous bilirubin (TcB) has been reported to have a high correlation with serum bilirubin. The objectives of this study were: (1) to compare the accuracy of two transcutaneous bilirubinometer (Minolto AirShields Jaundice Meter, JM103 (JM) and SpectRx, Bilicheck (BC) in estimating total serum bilirubin (TSB) levels; and (2) to assess the predictive ability of transcutaneous bilirubin in relation to specific selected TSB levels. A total of 154 measurements of TcB, using JM and BC, and TSB were recruited from 134 term and near-term infants. Postnatal ages ranged from 19 to 160 hours (x = 64.7, SD = 25.6). TSB levels ranged from 4.5 to 17.5 mg/dl (x = 10.4, SD = 2.5). The correlation coefficients between TcB (JM and BC) and TSB measurements were significant and similar (r 0.80 and 0.82, respectively). The errors of distribution were, for TSB and TcB-JM, the mean difference of 0.7 mg/dl (SD 1.6 mg/dl and 95% confidence interval of the mean (CI) 0.4 and 1.0]; and, for TSB and TcB-BC, the mean difference of -0.6 mg/dl (SD 1.5 mg/dl and 95% CI -0.4 and -0.8). TcB-JM had a tendency to underestimate TSB levels, and TcB-BC had a tendency to overestimate TSB levels. The sensitivity of BC was higher, but specificity was lower, than JM in corresponding to different TSB levels, except at a TSB level of 15 mg/dl when both instruments yielded 100% sensitivity. The accuracy of JM in predicting TSB was higher than BC at all TSB levels. Operating the JM was simple and uncomplicated. It would be suitable for clinical use when a number of personnel perform the measurement.

Resolution of eosinophilia after treatment of cutaneous gnathostomiasis.

The present study was to investigate the dynamics of eosinophil in peripheral blood of patients with cutaneous gnathostomiasis before and after worm removal. The total of 28 proven cases of cutaneous gnathostomiasis treated by albendazole were included in the present study. The absolute eosinophil count (AEC) was higher than 500/ul during infestation in almost all the patients, the positive rate was 89%, and significantly decreased to normal level after receiving albendazole and worm removal within 3 months in 96%. In conclusion, an increas of AEC is another important hallmarks of cutaneous gnathostomiasis and this parameter could be the earlier indicator for responsiveness to treatment.

Computer-assisted instruction in parasitology: a cross-over design.

We report here the results of the study using CAI compared to the hard copy for study of lessons in parasitology. We evaluated the CAI compared to hard copy lessons in 60 students, attending the third-year parasitology course at Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. The students were randomly divided into two groups (30 each). The lessons tested were Ascaris lumbricoides and Enterobius vermicularis, which were prepared as CAI and hard copy form. Using a cross-over design, the first group was provided CAI form on the topic of A. lumbricoides, then switched to hard copy form on the topic of E. vermicularis. The second group was provided hard copy form on the topic of A. lumbricoides, then switched to CAI form on the topic of E. vermicularis. After 30 minute reading, the 10-multiple choice question test was provided for each topic. There was no significant difference of the scores between 2 groups. The most students (91.67%) had more satisfaction when using CAI compared to hard copy in terms of easy to use, convenient to use, less time consuming, more understandable, more attractive to read, and less stress for study. There were 32.8% students complaining that reading hard copy was boring. Other comments were stress when reading (2%), more difficult (17.2%) and more time needed to search specific information (17.2%), and wasting papers (17.2%). However 58.6% still complained problems when using CAL. About 25% had physical discomfort (e.g. Headache, eye pain), and 25% had difficulty to access to use CAI (e.g. no computers available, problems with computer or network error). We suggested that instructors should create and improve CAI lessons in biomedical sciences both in quantity and quality (e.g. content with details, pictures, narrations).

Nomogram for prediction of the risk of neonatal hyperbilirubinemia, using transcutaneous bilirubin.

Assessing the risk of developing severe hyperbilirubinemia, based on a nomogram has been recommended by the American Academy of Pediatrics. The objectives of this study were: 1) To develop an hour-specific nomogram, using transcutaneous bilirubin level (TCB, Bilicheck, SpecRx, Inc, Norcross, GA, USA), in Thai newborn infants and 2) To determine the risk zones that will predict the development of severe hyperbilirubinemia. Three hundred and ninety two (392) healthy neonates, born by C-section, were recruited from November 2003 to May 2004. One hundred and eight (108) infants were excluded from the nomogram development due to hemolytic diseases (ABO incompatibility 51, G6PD deficiency 34, combined ABO incompatibility and G6PD deficiency 3) and requirement of phototherapy (20). Nomogram, using daily hour-specific TcB for 4 days, of 284 neonates was constructed Plotting all 392 infants, TcB on the nomogram, the risk zones in relation to the requirement of phototherapy was determined. The 90th percentile (P90) was designated as high risk track with the sensitivity of 96.9%, specificity 78.8%, positive and negative predictive values 29.1% and 99% respectively, and LR 4.6. P10 was labeled as very low risk track, area between P10-P25 as low risk zone, P25-P90 as intermediate zone with P25-P50 as low intermediate and P50-P90 as high intermediate. In conclusion, an hour-specific TcB nomogram, can be used to identify the risk of subsequent development of severe hyperbilirubinemia. Recognizing the infants risk enables awareness of the problem and prompt intervention which should reduce severe hyperbilirubinemia and chance to develop bilirubin encephalopathy.

Mucocutaneous findings in febrile neutropenic children with acute leukemias.

Febrile neutropenia is common in children with leukemia. Mucous membrane and skin are most common portals of entry for microorganisms in these patients. The aim of the present study was to find the prevalence of mucocutaneous findings infebrile neutropenic leukemic children. The authors prospectively examined children with fever with neutropenia in acute leukemia, aged 1-15 years, who were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital, between September 2000 and August 2001. During the study period, 46 children had 116 admissions, 51 of which were due to febrile neutropenia. Their cancer diagnoses were ALL (76%) and ANLL (24%). The prevalence of mucocutaneous findings was 86% (61% were from infections, 22% from mucositis and 4% from chemical phlebitis). Other detected sites of infection were lower respiratory tract (36%), urinary tract (32%), upper respiratory tract (11%), septicemia (11%) and unidentified (35%). Thirty-four percent of the patients had more than one site of infection. Gram-negative septicemia was the most common infection (15cases/71%) followed by gram positive (4cases/19%) and candida (2cases/10%). The prevalence of infection was found in severe neutropenia (absolute neutrophil count, ANC less than 500 cell/cu mm), moderate neutropenia (ANC, 500-1000 cell/cu mm) and mild neutropenia (ANC, 1001-1500 cell/cu mm) was 72%, 9% and 5%, respectively. Infection in patients in the severe neutropenia group was significantly more common than in moderate mild neutropenia groups (p < 0.01). Seven patients (15%) died, all of them had severe and prolonged neutropenia, for more than 7 days. Daily physical examination of skin and mucous membrane are suggested for proper and prompt diagnosis and treatment of febrile neutropenic children with acute leukemia to reduce mortality and morbidity in these patients. A Guideline for the use of antimicrobial agents in neutropenic patients with acute leukemia is proposed In conclusion, infection was commonly found in severe neutropenia. Mucocutaneous infection was the most common site of infection infebrile neutropenia in children with leukemia.

Thai medical graduates in the United States residency training programs: 1988-2003.

In the past 2 decades, international medical graduates (IMG) were needed to fill graduate medical education (GME) positions in the United States (U.S.). The author built a database of Thai medical graduates in accredited U.S. residency systems between 1988-2003, and analyzed the trend and opportunity for Thai IMG. During the 16-year study period, there were 281 Thai medical graduates who successfully entered residency in the U.S., with a rising trend that reached a peak between 1993-1994, and subsequently declined to about 10-15 per year Thai physicians entered U.S. residency program 4.2 +/- 3.3 years after medical school graduation. Thai IMGs were mostly in internal medicine (N=153, 54.4%) and pediatric residency programs (N=76, 27.1%), with much fewer in psychiatry (N=10), surgery (N=9), neurology (N=8), anesthesiology (N=7), and other specialties (N=18). Thai medical graduates tended to be clustered in a few residency programs. Half of the Thai graduates in the U.S. internal medicine residency were accepted in 9 programs; the largest were Texas Tech (Lubbock, N=18), Albert Einstein University (Philadelphia, N=14), and University of Hawaii (Honolulu, N=13). For pediatric residency, about half of the Thai graduates (56.6%) were in 6 programs; the largest were Christ Hospital (Oaklawn, N=11), University of Illinois at Chicago (N=11), and Jersey City Medical Center (N=9). After residency training, most Thais (94.5%) chose to do subspecialty training. The most popular medical subspecialties were cardiology, nephrology, and hematology-oncology. The most popular pediatric subspecialties were allergy-immunology, endocrinology, and cardiology. In conclusion, there are too few Thais in the U.S. residency system. This information may be helpful for Thai medical graduates who seek residency abroad.

Noninvasive transcutaneous bilirubin as a screening test to identify the need for serum bilirubin assessment.

Hyperbilirubinemia is a common problem in the newborn infant. It can progress to develop kernicterus unless intervention is initiated. Severity and decision for management are usually based on serum bilirubin (TsB) which needs blood sampling. Transcutaneous bilirubin measurement is a noninvasive technique and the result correlates closely with TsB. A new transcutaneous bilirubinometer, Minolta AirShields Jaundice Meter, JM103, has been introduced The objectives of this study were: 1) To evaluate the accuracy of transcutaneous bilirubin (TcB) measured by JM 103, when compared to TsB, used clinically in a hospital setting (Leica Unistat Bilirubinometer) and 2) To develop a cut-off point of TcB level which indicated the need for serum bilirubin assessment. Three hundred and eighty eight term and near-term newborn infants with 460 paired TcB-TsB specimens were studied from August to November 2003. Birth weight was 3117.57 +/- 424.82 grams. TsB ranged from 4 to 19.6 mg/dL (x 10.5, SD 2.46). The correlation coefficient between TcB and TsB was significant (r 0.8, p < 0.001). TcB showed a tendency to underestimate TsB, with mean difference of 0.7 mg/dL, SD 1.6 mg/dL, and 95% confidence interval 0.85 and 0.55 mg/dL. TcB values of 8, 9, 10, 12 mg/dL were chosen as cut-off points that indicated the need for blood sampling for TsB (corresponded to hour-specific levels of 10, 12, 13 and 15 mg/dL, respectively when phototherapy should be initiated). In conclusion, noninvasive TcB assessment demonstrates significant accuracy, compared to TsB. It can be used as a screening test to identify the need for blood sampling for serum bilirubin level.

Pneumocystis pneumonia: an update.

Pneumocystis pneumonia is a major cause of illness and death in immunocompromised hosts. The numbers of pneumocystis pneumonia cases in Thailand have increased each year from 1992 to 2000 and peaked in 2000 at 6,255 cases. The microbe that causes pneumocystis pneumonia in humans is called Pneumocystis jirovecii. Pneumocystis sp. was discovered nearly a century ago, but the knowledge of Pneumocystis sp. remained poorly understood, until the molecular biology techniques help scientists verify it fungus nature. In the past, Pneumocystis sp. was misclassified as protozoan due to its morphologic features. Later, it was reclassified as fungus due to DNA analysis. Cotrimaxazole, the combination of trimethoprim-sulfamethoxazole, is the drug of choice for treatment and prophylaxis of pneumocystis pneumonia. However, increasing evidence of mutations in the enzyme dihydropteroate synthase (DHPS), the target of sulfa drugs represent emergence of sulfa resistance.

Prevalence of bancroftian filariasis on the Thai-Myanmar border.

To achieve the goal of eliminating lymphatic filariasis by the year 2020, close monitoring systems and effective control strategies need to be implemented and the real disease burden needs to be assessed. Bancroftian filariasis is endemic at the Thai-Myanmar border. However, there are only limited data on the prevalence of this disease in Thailand available. We employed microscopic examination, together with ELISA kits to detect W. bancrofti-specific Og4C3 circulating antigen and specific anti-filarial IgG4 antibodies to determine the burden of bancroftian filariasis in an endemic area at the Thai-Myanmar border in Umphang District, Tak province, Thailand. A total of 433 Thai-Karen blood samples were analyzed. The microfilarial rate determined by microscope was 6% and the W. bancrofti-specific Og4C3 antigenemia rate was 22%, while the specific anti-filarial IgG4 antibody rate was 54%. There were statistically significant higher levels of W. bancrofti-specific Og4C3 antigen in the microfilaremic-antigenemic group than in the amicrofilaremic-antigenemic group (unpaired Student's t-test; p < 0.001), similar to the specific anti-filarial IgG4 antibody results (unpaired Student's t-test; p < 0.001). A statistically significant correlation of moderate degree between the presence of W. bancrofti-specific Og4C3 antigen and of specific anti-filarial IgG4 antibody was found in the amicrofilaremic group (r = 0.474, p < 0.001), but not in the microfilaremic group (r = 0.291, p > 0.05). Our study revealed a very high prevalence of bancroftian filariasis in this endemic area and thus emphasized the importance of using highly sensitive and specific diagnostic tools to evaluate the true prevalence of the disease.

Efficacy and safety of meropenem as an empirical treatment for febrile neutropenia in children with cancer.

Meropenem is a promising carbapenem antibiotic as an empirical monotherapy in patients with febrile neutropenia (FN). With the limited data of the therapy in pediatric patients, the authors conducted this study to evaluate the efficacy and safety of meropenem as empirical antibiotic therapy in 30 pediatric cancer patients with FN (mean age = 7.5 years), who were admitted to King Chulalongkorn Memorial Hospital from May 2000 to December 2001. Meropenem 60 mg/kg/day was given intravenously every 8 hours. The efficacy of meropenem was assessed as successful, inconclusive and failure on days 3 and 5 of the therapy and compared to that of other empirical antibiotics used from January 1997 to April 2000. The study showed that six blood culture specimens (20%) grew organisms, half of which were considered to be contaminants, and six urine culture specimens (20%) grew gram negative rod bacteria. On day 3 and 5 of the therapy, the success rate of meropenem was higher than that of comparatives (30.0% vs 17.6% on day 3, 50.0% vs 39.3% on day 5). The use of meropenem appeared safe, with minimal side effects. In conclusion, the present study showed that meropenem was safe and tolerable in children. The efficacy as an empirical monotherapy in pediatric cancer patients with FN was satisfactory, with a failure rate of 23.3 per cent on day 5 of treatment.

Red cell indices and therapeutic trial of iron in diagnostic work-up for anemic Thai females.

Anemia is common among Thai females. Thalassemia and iron deficiency are highly prevalent in the Thai population. A therapeutic trial of iron has been used to differentiate between the two conditions, however, no previous study on its usefulness in a Thai population has been reported. Otherwise healthy persons who had complete blood count (CBC) as routine 'check-up' and found to be anemic (Hb < 12 g/dl) at a preventive medicine clinic were tested for hemoglobin typing, serum ferritin, serum iron, and were given oral iron sulfate (120 mg elemental iron per day for at least 2 months) and a repeat CBC on a follow-up visit. Sixty-six individuals, all females, with pre-treatment hemoglobin (Hb) level of 9.5 +/- 1.7 g/dl (mean +/- SD), had complete data for analysis. Final diagnoses were isolated iron deficiency in 23 (34.8%), iron deficient thalassemia traits in 6 (9.1%) and iron-sufficient thalassemia syndromes in 29 (43.9%) anemic subjects. After a therapeutic trial of iron, Hb rose to 12.8 +/- 1.0 g/dl (n = 16, p = 2 x 10(-8)) among the iron deficient group, but not in thalassemia. The authors have identified that the most useful red cell indices that will discriminate between iron deficiency and thalassemia is a combination of red blood cell counts (RBC) > 4.4 x 10(6)/microl and mean corpuscular volume (MCV) < 69 fl. High RBC (> 4.4 x 10(6)/microl) and very low MCV (< 69 fl) is a sensitive (92.9%) and highly specific (100%) criteria for diagnosis of mild thalassemia diseases (Hemoglobin H (HbH), Hemoglobin H-Constant Spring (HbH-CS), and homozygous Hemoglobin E (HbEE)). Conversely, a low RBC (> 4.4 x 10(6)/microl) and/or low to normal MCV (69-85 fl) is highly sensitive (91.3%) but not specific (60%) for the diagnosis of iron deficiency. The authors conclude that a therapeutic trial of iron is useful as a diagnostic test in anemic females except those with high RBC (> 4.4 x 10(6)/microl) and very low MCV (< 69 fl), a subgroup which most likely has thalassemia and are least likely to benefit from iron treatment.

Lyophilized cryoprecipitate for children with hemophilia A.

Cryoprecipitate is the most cost-effective treatment for bleeding events in hemophilia A children in Thailand. Lyophilized cryoprecipitate (LC), a freeze-dried heat-treated blood product from the National Blood Center, can be stored in a refrigerator. The objectives of this study were to assess the efficacy of LC in bleeding episodes of children with hemophilia A and to determine the pharmacokinetics of single dose LC infusion. Eight male children with congenital factor VIII deficiency, aged 1.2-13 years, with 12 active bleeding episodes were infused with reconsitituted LC (average factor VIII activity = 236 IU per bottle) at the dose of 1 bottle per 11 kg. All patients achieved clinical hemostasis by 12 hours post-infusion. The Factor VIII activity reached peak level within the first hour and declined slowly in the subsequent hours and retained in vivo Factor VIII activity at 27.3 +/- 5.6 per cent at 12 hours post-infusion. The incremental factor VIII activity was 2.37 +/- 1.05 per cent (mean +/- SD) per U infused per kilogram body weight. The half-life of infused factor VIII was 10.5 hours. The authors concluded that reconstituted LC infusion is efficacious in the treatment of bleeding episodes in children with hemophilia. Cost-effectiveness of this product and cryoprecipitate and other purified factor VIII should be evaluated.

Prevalence of parasitic infections among Thai patients at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

Parasitic diseases are still considered to be a major public health problem. Most patients with parasitic infections are asymptomatic and therefore remain undetected. Asymptomatic parasitic infections are usually discovered by routine parasite examination. To determine the result of parasite examination at the Parasitology Unit, Out Patient Department, King Chulalongkorn Memorial Hospital, Bangkok, Thailand, the authors collected the data of individuals examined for parasite infections from June to December 1997. A total of 6,231 Thais provided the data for analysis. Evidence of parasitic infections was found in 557 (8.94%) cases. The disease was most prevalent in males (57.3%), and in the age group >15-30 years old (11.13%). The population from the Northeast of Thailand was found to harbor parasites with the highest prevalence rate (17.03%), while it was 11.90 per cent in the northern group. The parasitic prevalence rates in the West, East, South and Central regions were 10.60 per cent, 8.90 per cent, 7.74 per cent, and 4.92 per cent, respectively. The parasite most commonly identified was Strongyloides stercoralis (33.39%), while giardiasis was the most common protozoan infection (14.36%). The highest infection rates of S. stercoralis, hookworms, Opisthorchis viverrini, and Gnathostoma spinigerum were found in northeasterners. People from the North of Thailand were infected mostly with G. lamblia. People of working-age from northeastern as well as northern regions harbored pathogenic parasites with high prevalence rates. To prevent parasitic infections, health education for these high risk groups should be provided.