Face-to-Face or Telematic Cognitive Stimulation in Patients with Multiple Sclerosis and Cognitive Impairment: Why Not Both?

INTRODUCTION: Cognitive impairment (CI) affects 40-65% of patients with multiple sclerosis (MS). Few studies address telematic cognitive stimulation (TCS) in MS. The objective of this study is to evaluate the efficacy and impact of telestimulation or distance cognitive stimulation (TCS), with and without the support of face-to-face cognitive stimulation (FCS) in cognitive impairment in MS. METHODS: Multicentre, prospective, randomised, controlled study. We will include 98 MS patients with EDSS ≤ 6, symbol digit modality test (SDMT) ≤ Pc 25, and Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNQ) > 26 points. Patients will be randomised into 3 groups, a TCS group, a mixed TCS/FCS group, and a control group. CS is performed 3 days a week for 3 months. Processing speed, memory, attention, and executive functions will be rehabilitated. FCS will include ecological exercises and strategies. EDSS and a cognitive evaluation (SDMT, CTMT, PASAT, and TAVEC), MSNQ, psychological impact scales (MSIS), and depression (BDI) will be carried out, baseline, postrehabilitation, and also 6 and 12 months later, to evaluate the effect of CS in the longer term. CONCLUSION: This study could help to establish the usefulness of TCS or, in its absence, TCS with face-to-face help for CI in MS. The interest lies in the clear benefits of remote rehabilitation in the daily life of patients.

Afectación visuoespacial/visuoconstrucción en pacientes con esclerosis múltiple. Relación con el volumen lesional regional y la atrofia subcortical / Impairment of visuospatial/visuoconstructional skills in multiple sclerosis patients: the correlation with regional lesion load and subcortical atrophy

Introducción: Solo el 20-26% de los pacientes con esclerosis múltiple presenta déficits en habilidades visuoespaciales-visuoconstructivas (VE-VC) pese a la frecuente afectación témporo-parieto-occipital en resonancia magnética. No hay estudios que analicen la relación entre estas funciones y el volumen lesional (VL) de estas áreas cerebrales. Objetivo: Evaluar la relación del VL parieto-occipito-temporal y la atrofia subcortical con el rendimiento en funciones VE-VC en esclerosis múltiple. Metodología: De 100 pacientes de esclerosis múltiple con evaluación neuropsicológica rutinaria se seleccionan 21 por afectación en habilidades VE-VC, medidas por Figuras incompletas, Cubos (WAIS-III) y Figura compleja de Rey-Osterrieth, y 13 sin déficit cognitivo (grupo control). El VL regional se cuantifica por un método semiautomático en secuencias FLAIR y T1, y la atrofia subcortical por el ratio bicaudado y la anchura del iii ventrículo (AIIIV). Se utilizan correlaciones parciales (controlando con edad y escolarización) y regresión lineal para analizar la relación entre los parámetros de resonancia magnética y el rendimiento cognitivo. Resultados: Todas las medidas de VL y de atrofia cerebral son significativamente mayores en pacientes con deterioro cognitivo. El VL regional en FLAIR, ratio bicaudado y AIIIV muestran significativa correlación inversa con el rendimiento cognitivo, mayor entre la AIIIV y VC (Cubos: p = 0,001; Figura compleja de Rey-Osterrieth: p < 0,000). En el análisis multivariante, la AIIIV influye significativamente en tareas de VC (Cubos: p = 0,000; Figura compleja de Rey-Osterrieth: p = 0,000) y el VL regional en FLAIR en tareas VE (Figuras incompletas; p = 0,002). Conclusiones: Las medidas de atrofia subcortical se relacionan con tareas de visuoconstrucción y el VL regional con tareas VE

Introduction: About 20% to 26% of patients with multiple sclerosis (MS) show alterations in visuospatial/visuoconstructive (VS-VC) skills even though temporo-parieto-occipital impairment is a frequent finding in magnetic resonance imaging. No studies have specifically analysed the relationship between these functions and lesion volume (LV) in these specific brain areas. Objective: To evaluate the relationship between VS-VC impairment and magnetic resonance imaging temporo-parieto-occipital LV with subcortical atrophy in patients with MS. Methodology: Of 100 MS patients undergoing a routine neuropsychological evaluation, 21 were selected because they displayed VS-VC impairments in the following tests: Incomplete picture, Block design (WAIS-III), and Rey-Osterrieth complex figure test. We also selected 13 MS patients without cognitive impairment (control group). Regional LV was measured in FLAIR and T1-weighted images using a semiautomated method; subcortical atrophy was measured by bicaudate ratio and third ventricle width. Partial correlations (controlling for age and years of school) and linear regression analysis were employed to analyse correlations between magnetic resonance imaging parameters and cognitive performance. Results: All measures of LV and brain atrophy were significantly higher in patients with cognitive impairment. Regional LV, bicaudate ratio, and third ventricle width are significantly and inversely correlated with cognitive performance; the strongest correlation was between third ventricle width and VC performance (Block design: P = .001; Rey-Osterrieth complex figure: P < .000). In the multivariate analysis, third ventricle width only had a significant effect on performance of VC tasks (Block design: P = .000; Rey-Osterrieth complex figure: P = .000), and regional FLAIR VL was linked to the VS task (Incomplete picture; P = .002). Conclusions: Measures of subcortical atrophy explain the variations in performance on visuocostructive tasks, and regional FLAIR VL measures are linked to VS task

Impairment of visuospatial/visuoconstructional skills in multiple sclerosis patients: the correlation with regional lesion load and subcortical atrophy.

INTRODUCTION: About 20% to 26% of patients with multiple sclerosis (MS) show alterations in visuospatial/visuoconstructive (VS-VC) skills even though temporo-parieto-occipital impairment is a frequent finding in magnetic resonance imaging. No studies have specifically analysed the relationship between these functions and lesion volume (LV) in these specific brain areas. OBJECTIVE: To evaluate the relationship between VS-VC impairment and magnetic resonance imaging temporo-parieto-occipital LV with subcortical atrophy in patients with MS. METHODOLOGY: Of 100 MS patients undergoing a routine neuropsychological evaluation, 21 were selected because they displayed VS-VC impairments in the following tests: Incomplete picture, Block design (WAIS-III), and Rey-Osterrieth complex figure test. We also selected 13 MS patients without cognitive impairment (control group). Regional LV was measured in FLAIR and T1-weighted images using a semiautomated method; subcortical atrophy was measured by bicaudate ratio and third ventricle width. Partial correlations (controlling for age and years of school) and linear regression analysis were employed to analyse correlations between magnetic resonance imaging parameters and cognitive performance. RESULTS: All measures of LV and brain atrophy were significantly higher in patients with cognitive impairment. Regional LV, bicaudate ratio, and third ventricle width are significantly and inversely correlated with cognitive performance; the strongest correlation was between third ventricle width and VC performance (Block design: P=.001; Rey-Osterrieth complex figure: P<.000). In the multivariate analysis, third ventricle width only had a significant effect on performance of VC tasks (Block design: P=.000; Rey-Osterrieth complex figure: P=.000), and regional FLAIR VL was linked to the VS task (Incomplete picture; P=.002). CONCLUSIONS: Measures of subcortical atrophy explain the variations in performance on visuocostructive tasks, and regional FLAIR VL measures are linked to VS tasks.

Species identification of staphylococci by amplification and sequencing of the tuf gene compared to the gap gene and by matrix-assisted laser desorption ionization time-of-flight mass spectrometry.

Staphylococcal species, notably, coagulase-negative staphylococci (CoNS), are frequently misidentified using phenotypic methods. The partial nucleotide sequences of the tuf and gap genes were determined in 47 reference strains to assess their suitability, practicability, and discriminatory power as target molecules for staphylococcal identification. The partial tuf gene sequence was selected and further assessed with a collection of 186 strains, including 35 species and subspecies. Then, to evaluate the efficacy of this genotyping method versus the technology of matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF-MS), the 186 strains were identified using MALDI-TOF-MS (Axima® Shimadzu) coupled to the SARAMIS® database (AnagnosTec). The French National Reference Center for Staphylococci identification method was used as a reference. One hundred and eighty-four strains (98.9%) were correctly identified by tuf gene sequencing. Only one strain was misidentified and one was unidentified. MALDI-TOF-MS identified correctly 138 isolates (74.2%). Four strains were misidentified, 39 were unidentified, five were identified at the group (hominis/warneri) level, and one strain was identified at the genus level. These results confirm the value of MALDI-TOF-MS identification for common species in clinical laboratory practice and the value of the partial tuf gene sequence for the identification of all staphylococcal species as required in a reference laboratory.

[Unilateral acute endophthalmitis due to Staphylococcus epidermidis after simultaneous bilateral intravitreal injection using the same ranibizumab vial: a case report]. / Endophtalmie aiguë unilatérale àStaphylococcus epidermidis après injection intra-vitréenne bilatérale et concomitante de ranibizumab à partir d'un même flacon: à propos d'un cas.

PURPOSE: To report a case of unilateral acute endophthalmitis due to Staphylococcus epidermidis after simultaneous bilateral intravitreal injection using the same ranibizumab vial. CASE REPORT: A 68-year-old phakic man had uneventful bilateral sequential ranibizumab intravitreal injection for bilateral neovascular age-related macular degeneration using the same vial. All of the vial contents (0.3 mL) were withdrawn through the filter needle attached to a 1-cc tuberculin syringe. Using the same syringe but separate injection needles, 0.05 mL was administrated to the right eye before 0.05 mL was injected into the left eye. Sterile gloves, drape, and eyelid speculum were used for each eye. Early Staphylococcus epidermidis postoperative endophthalmitis developed 3 days later in the right eye (injected first) with intense vitreous inflammation, limiting visual acuity to light perception. Management included intravitreal antibiotic agents and pars plana vitrectomy. The patient achieved an excellent visual outcome. DISCUSSION: This case report demonstrates that bacterial endophthalmitis is a rare but potential complication of intravitreal anti-VEGF injection, that infection generally results from self-contamination of the patient from his or her own bacterial flora, and that simultaneous bilateral intravitreal injection should be avoided.

Cytokine IL-1 beta but not IL-1 alpha promoter polymorphism is associated with Alzheimer disease in a population from the Canary Islands, Spain.

AIMS: Previous studies have reported the presence of low-grade inflammation in Alzheimer disease (AD). Based on these data, our work attempts to investigate the effects of some promoter polymorphisms of pro-inflammatory cytokines [interleukin (IL)-1 alpha and IL-1 beta] on AD. PATIENTS AND METHODS: A PCR-RFLP technique was used to analyze the promoter polymorphisms of both IL-1 alpha (-889 C/T) and IL-1 beta (-511 C/T) and the APOE genotype from the DNA samples of 282 patients (according to NINCDS-ADRDA criteria) and 312 control subjects. RESULTS: (i) The risk of developing AD in our population was associated with the IL-1 beta (-511 C/T) promoter polymorphism; (ii) such risk was independent of the risk factor allele in the APOE gene (APOE4); and (iii) the IL-1 alpha promoter polymorphism (-889 C/T) was not associated with the disease. CONCLUSION: In our population, IL-1 beta promoter polymorphism (-511 C/T) is an independent risk factor for AD.

[Tropheryma whipplei and Whipple disease: false positive PCR detections of Tropheryma whipplei in diagnostic samples are rare]. / Tropheryma whipplei et maladie de Whipple: résultats de la recherche par polymerase chain reaction (PCR) dans les échantillons à visée diagnostique.

BACKGROUND: PCR can be used to detect T. whipplei (Tw) in samples from variable tissue types and body fluids. We report clinical, evolutive characteristics and final diagnosis in patients with positive Tw PCR assay. METHODS: Retrospective study of Tw PCR realized since 10years in a microbiology laboratory. RESULTS: Twenty-five Tw PCR assays were positive among 200 realized. Diagnosis was not confirmed in six cases. One patient was missing for follow up. Eighteen patients presented with Whipple's disease. Among these 18 patients, 14 had a classic Whipple's disease, three patients presented an endocarditis and one patient isolated neurological manifestations. Ten patients presented fever, seven a weight loss and 12 joint involvement. Four patients presented cutaneous manifestations, only six had gastrointestinal symptoms. Neurological involvement was reported in five cases, pulmonary symptoms in four cases, cardiac involvement in six cases and ocular signs in two cases. Anemia was reported in four patients and elevated levels of acute-phase reactants in 14 cases. Positive predictive value of Tw PCR for Whipple's disease diagnosis was 75%. Thirteen patients had a good evolution with antibiotics. Three patients presented recurrence and two cases with cardiovascular involvement died. CONCLUSION: Whipple's disease is rare but often mentioned in internist experience. The diagnosis should be every time confirmed. Tw PCR assay is an important diagnostic tool but is not sufficient to establish the diagnosis and must be interpreted with histopathology and immunohistochemical testing results.

A parametrical study of disinfection with hydrodynamic cavitation.

The physical and chemical conditions generated by cavitation bubbles can be used to destroy microorganisms and disinfect wastewater. The effect of different cavitation chamber designs and diverse operational parameters on the inactivation rate of Escherichia coli have been studied and used to understand the mechanisms involved in cell disruption.

A theoretical study of hydrodynamic cavitation.

The optimization of hydrodynamic cavitation as an AOP requires identifying the key parameters and studying their effects on the process. Specific simulations of hydrodynamic bubbles reveal that time scales play a major role on the process. Rarefaction/compression periods generate a number of opposing effects which have demonstrated to be quantitatively different from those found in ultrasonic cavitation. Hydrodynamic cavitation can be upscaled and offers an energy efficient way of generating cavitation. On the other hand, the large characteristic time scales hinder bubble collapse and generate a low number of cavitation cycles per unit time. By controlling the pressure pulse through a flexible cavitation chamber design these limitations can be partially compensated. The chemical processes promoted by this technique are also different from those found in ultrasonic cavitation. Properties such as volatility or hydrophobicity determine the potential applicability of HC and therefore have to be taken into account.

Acute postoperative endophthalmitis caused by Staphylococcus lugdunensis.

Acute postoperative endophthalmitis caused by Staphylococcus lugdunensis is infrequently reported in clinical studies. Five cases of acute postcataract surgery endophthalmitis caused by S. lugdunensis were taken from a multicenter prospective study conducted in four university-affiliated hospitals in France (2004 to 2005). These cases were characterized by severe ocular inflammation occurring with a mean delay of 7.6 days after cataract surgery, severe visual loss (hand motions or less in three cases), and dense infiltration of the vitreous. Each of these patients was initially treated by using a standard protocol with intravitreal (vancomycin and ceftazidime), systemic, and topical antibiotics. Given the severity of the endophthalmitis, even though bacteria were sensitive to intravitreal antibiotics, pars plana vitrectomy was needed in four cases. The final visual prognosis was complicated by severe retinal detachment in three cases. The microbiological diagnosis was reached by using conventional cultures with specific biochemical tests and eubacterial PCR amplification followed by direct sequencing.

Application of salicylic acid dosimetry to evaluate hydrodynamic cavitation as an advanced oxidation process.

The generation of OH* radicals inside hydrodynamic cavitation bubbles was monitored using a salicylic acid dosimeter. The reaction of this scavenger with OH* produces 2,5-dihydroxybenzoic acid (2,5-DHB) and, to a lesser degree, 2,3-DHB. The former, is a specific reaction product that can be determined with a very high sensitivity using HPLC-IF. This method has been applied to study the influence of the flow-rate and the solution pH for a given cavitation chamber geometry. The salicylic dosimetry has proven especially suitable for the characteristic time scales of hydrodynamic cavitation (higher than those of ultrasonic cavitation), which usually gives rise to recombination of radicals before they can reach the liquid-phase. Working at low pH the hydrophobic salicylic acid migrates to the gas-liquid interface and reacts with the OH* radicals, increasing the trapping efficiency of the dosimeter. Hydrodynamic cavitation works as a very low frequency sonochemical reactor, and therefore its potential as an Advanced Oxidation Process might be limited to reactions at the gas-liquid interface and inner bubble (i.e. with volatiles and/or hydrophobic substances).

[Microbiological and clinical diagnosis of acute endophthalmitis]. / Diagnostic microbiologique des endophtalmies aiguës.

The microbiological study identifies the bacterial spectrum after surgery, in acute, delayed-onset, or chronic endophthalmitis. DNA amplification of eubacterium-specific sequences in DNA extracted from ocular samples is a new tool for the etiological diagnosis of endophthalmitis. The most successful way to identify bacteria in endophthalmitis is the association of conventional cultures and panbacterial PCR on vitreous samples. Both techniques are complementary. The efficacy of these new molecular techniques should modify our future therapeutic strategies.

Streptococcus pneumoniae thoracic empyema in children: rapid diagnosis by using the Binax NOW immunochromatographic membrane test in pleural fluids.

AIM: To evaluate an immunochromatographic membrane test for Streptococcus pneumoniae antigen (Binax NOW, Inverness medical France) applied to pleural fluid samples. METHODS: Binax NOW was applied to the pleural fluids of 69 children with thoracic empyema, in comparison with conventional culture and molecular techniques. RESULTS: Binax NOW was positive on all 15 pleural fluid samples that yielded S. pneumoniae in culture, on two samples that yielded S. oralis and S. salivarius in culture and on 34 culture-negative samples. Fifteen of these 34 culture-negative samples were retrospectively tested by PCR methods, and 14 were shown to contain S. pneumoniae DNA. Thus, S. pneumoniae was identified by culture in 22% of samples and by Binax NOW in 69% of samples. CONCLUSION: Binax NOW may thus be useful for rapid diagnosis of S. pneumoniae thoracic empyema.

Rat bite fever caused by Streptobacillus moniliformis in a child: human infection and rat carriage diagnosed by PCR.

A child owning pet rats developed an eruptive fever with blisters, polyarthritis, and spectacular desquamation of the hands. Streptobacillus moniliformis was identified after culture of the child's blister fluid and was detected in rat samples by molecular methods. Such detection in the pet of a human victim of rat bite fever has not been reported previously.

Fuerte modulación del sexo sobre el riesgo conferido por el gen de la apolipoproteína E para la enfermedad de Alzheimer en la población de las Islas Canarias, España / Gender has a strong modulating effect on the risk of Alzheimer's disease conferred by the apolipoprotein e gene in the population of the canary islands, Spain

Objetivos. En la mayoría de las poblaciones estudiadas se ha encontrado que el gen de la apolipoproteína E (ApoE) es un factor de riesgo para la enfermedad de Alzheimer (EA). El objetivo del presente trabajo es el estudio de los polimorfismos de dicho gen, tanto de las variantes exónicas como los polimorfismos de promotor, en nuestra población canaria. Sujetos y métodos. Hemos analizado, por medio de técnicas de PCR-RFLP, tanto las variantes exónicas como tres de los polimorfismos de promotor más comunes del gen de la ApoE, sobre el ADN de 131 pacientes diagnosticados clínicamente de probable EA, según criterios NINCS-ADRDA, y 85 controles sin déficit cognitivo medido por el test de CAMCOG. Resultados. Hemos encontrado que las variantes alélicas exónicas del gen de la ApoE se relacionan fuertemente con la EA, presentan un claro efecto de dosis sobre la susceptibilidad a la enfermedad, mientras que no muestran ninguna asociación con la enfermedad las variantes de promotor. En nuestra muestra analizada, el gen de la ApoE no parece influir en la edad de presentación de la enfermedad, mientras que el sexo de los pacientes confiere características de susceptibilidad distintivas. Conclusión. En nuestra población, el gen de la ApoE se relaciona con la EA, y está condicionado por una fuerte modulación del sexo de los pacientes (AU)

Objectives. Apolipoprotein E (ApoE) gen has been found to confer risk for Alzheimer disease in every population studied. We are interested in analyzed the exonic variants and the promoter polymorphisms in our Canary population. Subjects and methods. By means of PCR-RFLP analysis of DNA from patients (NINCS-ADRDA criteria) and controls (cognitive state CAMCOG test measured) we analyzed the known exonic and promoter polymorphism of ApoE gen. Results. We have found an association of Alzheimer disease risk based on exonic variants of ApoE gen, with a clear cut dose-effect on susceptibility and no risk conferred by the promoter polymorphisms. Age at onset are not affected by variants of ApoE gen, and patients gender strongly modulate the disease susceptibility. Conclusion. We have found in our Canary population an association between Alzheimer disease with exonic variants of ApoE gen with a strong modulation by the patients gender (AU)

[Guillain-Barré syndrome in the northern area of Gran Canaria and the island of Lanzarote]. / Sindrome de Guillain-Barré en el area norte de Gran Canaria e isla de Lanzarote.

AIMS: The objective of this study is to analyse the incidence and clinical characteristics of Guillain Barre syndrome (GBS) in the Canary Islands. PATIENTS AND METHODS: We conducted a retrospective study of GBS patients (according to diagnostic criteria from the National Institute of Neurological and Communicative Disorders and Stroke) treated in the Ntra. Sra. del Pino Hospital in Gran Canaria between 1983 and 1998. Annual incidence, seasonal distribution, preceding infection, clinical and electrophysiological data, and evolution were all evaluated. Prognostic factors were studied by means of a univariate analysis. RESULTS: A total of 81 patients were selected for the study. The raw incidence was 1.04/100,000 inhab./year (CI 95%: 0.83 1.29; adjusted for age to the European population: 1.5). The rates of incidence were higher in men and increased lineally with age in both sexes. We observed an upward tendency during the winter months. 48% of the patients displayed serious motor deficits in the nadir of the disease, and 17.8% required assisted ventilation. After one year s evolution 74% were seen to experience an excellent recovery. The mortality rate was 8.2% and 37% received immunomodulatory treatment. The main variables associated with a bad prognosis at 3 and 12 months were: serious deficits in muscular balance, the need for assisted ventilation and very reduced amplitude of evoked motor potential. CONCLUSIONS: GBS incidence in the Canary Islands is similar to that found in other countries. An increase with age and an upward tendency during the winter months was observed. No differences were found in the clinical data as compared with other series.

Síndrome de Guillain-Barré en el área norte de Gran Canariae isla de Lanzarote / Guillain-Barré syndrome in the northern area of Gran Canaria and the island of Lanzarote

Objetivo. Analizar la incidencia y características clínicas del síndrome de Guillain-Barré (SGB) en Canarias. Pacientes y métodos. Estudio retrospectivo de pacientes con SGB (criterios diagnósticos del National Institute of Neurological and Communicative Disorders and Stroke) atendidos en el H. Ntra. Sra. del Pino de Gran Canaria, entre 1983 y 1998. Se evaluaron la incidencia anual, distribución estacional, infección precedente, los datos clínicos y electrofisiológicos y la evolución. Se investigaron factores pronósticos mediante un análisis univariante. Resultados. Se seleccionaron 81 pacientes. La incidencia cruda fue 1,04/100.000 hab/año (IC 95 por ciento: 0,83-1,29) (ajustada por edad a la población europea: 1,5). Las tasas de incidencia fueron más altas en el hombre y aumentaban linealmente con la edad en ambos sexos. Observamos predilección por los meses de invierno. El 48 por ciento de los pacientes alcanzaron déficit motores graves en el nadir de la enfermedad, y un 17,8 por ciento precisó ventilación asistida. Al año de evolución, el 74 por ciento tuvo una excelente recuperación. La mortalidad fue del 8,2 por ciento. El 37 por ciento recibió tratamiento inmunomodulador. Las principales variables asociadas a mal pronóstico a los tres y 12 meses fueron: déficit graves en el balance muscular, necesidad de ventilación asistida y una amplitud muy reducida de potencial motor evocado. Conclusiones. La incidencia del SGB en Canarias es similar a la que se encontró en otros países. Observamos un aumento de la incidencia con la edad y predilección por los meses de invierno. No encontramos diferencias en los datos clínicos con otras series (AU)

Probing the structure of RNAIII, the Staphylococcus aureus agr regulatory RNA, and identification of the RNA domain involved in repression of protein A expression.

RNAIII, a 514-nt RNA molecule, regulates the expression of many Staphylococcus aureus genes encoding exoproteins and cell-wall-associated proteins. We have studied the structure of RNAIII in solution, using a combination of chemical and enzymatic probes. A model of the secondary structure was derived from experimental data with the help of computer simulation of RNA folding. The model contains 14 hairpin structures connected by unpaired nucleotides. The data also point to three helices formed by distant nucleotides that close off structural domains. This model was generally compatible with the results of in vivo probing experiments with dimethylsulfate in late exponential-phase cultures. Toe-printing experiments revealed that the ribosome binding site of hld, which is encoded by RNAIII, was accessible to the Escherichia coli 30S ribosomal subunit, suggesting that the in vitro structure represented a translatable form of RNAIII. We also found that, within the 3' end of RNAIII, the conserved hairpin 13 and the terminator form an intrinsic structural domain that exerts specific regulatory activity on protein A gene expression.