Muscle activity during running in water and on dry land: matched physiology.

We investigated muscle activity during deep water running (DWR) and treadmill running on dry land (TMR) at similar physiological responses. 9 subjects (30.7±10.4 years) participated in this study. The baseline conditions consisted of TMR at 3 ratings of perceived exertion (RPE) level (RPE 11, 13, and 15) with heart rate (HR) recorded during each condition. The target HR for each level of DWR condition was determined by the HR recorded during the TMR. Muscle activity from the rectus femoris (RF), biceps femoris (BF), tibialis anterior (TA), and gastrocnemius (GA) were measured. As originally planned, HR was not different between modes (P>0.05) and was different between exercise intensities (P<0.001). Only TA muscle activity was influenced by the interaction of mode and intensity (P<0.05). Muscle activity from the GA during DWR was significantly lower than that of TMR (a 34-48% decrease; P<0.05), although muscle activity from the remaining tested muscles were not influenced by modes of exercise (P>0.05). These observations suggest that matching HR can be recommended to produce similar magnitude of lower extremity muscle activity during DWR to that of TMR, with the exception of the GA.

Re-evaluation of stomach position as a simple prognostic factor in fetal left congenital diaphragmatic hernia: a multicenter survey in Japan.

OBJECTIVES: To document outcome and to explore prognostic factors in fetal left congenital diaphragmatic hernia (CDH). METHODS: This was a multicenter retrospective study of 109 patients with prenatally diagnosed isolated left CDH born between 2002 and 2007. The primary outcome was intact discharge, defined as discharge from hospital without major morbidities, such as a need for respiratory support including oxygen supplementation, tube feeding, parenteral nutrition or vasodilators. All patients were managed at perinatal centers with immediate resuscitation, gentle ventilation (mostly with high-frequency oscillatory ventilation) and surgery after stabilization. Prenatal data collected included liver and stomach position, lung-to-head ratio, gestational age at diagnosis and presence or absence of polyhydramnios. Stomach position was classified into four grades: Grade 0, abdominal; Grade 1, left thoracic; Grade 2, less than half of the stomach herniated into the right chest; and Grade 3, more than half of the stomach herniated into the right chest. RESULTS: Overall intact discharge and 90-day survival rates were 65.1% and 79.8%, respectively. Stomach herniation was classified as Grade 0 in 19.3% of cases, Grade 1 in 45.9%, Grade 2 in 13.8% and Grade 3 in 21.1%. Multivariate analysis revealed that liver position was the strongest prognostic variable for intact discharge, followed by stomach position. Based on our results, we divided patients into three groups according to liver (up vs. down) and stomach (Grade 0-2 vs. Grade 3) position. Intact discharge rates declined significantly from liver-down (Group I), to liver-up with stomach Grade 0-2 (Group II), to liver-up with stomach Grade 3 (Group III) (87.0%, 47.4% and 9.5% of cases, respectively). CONCLUSION: Current status and outcomes of prenatally diagnosed left CDH in Japan were surveyed. Stomach herniation into the right chest was not uncommon and its grade correlated with outcome. The combination of liver and stomach positions was useful to stratify patients into three groups (Group I-III) with different prognoses.

Determination of muscle activity during running at reduced body weight.

The aim of this study was to investigate how lower extremity muscles are influenced by body weight support during running at different speeds. Nine participants (age 24 ± 2 years, height 1.75 ± 0.12 m, mass 73.5 ± 15.7 kg) ran at 100%, 115%, and 125% of preferred speed at 100%, 90%, 80%, 70%, and 60% of body weight on a treadmill that provided body weight support. Preferred speed was self-selected by each participant and represented a speed that he or she could sustain if going for a 30 min run. Electromyography (EMG) data were recorded (1000 Hz, 1 min) from the bicep femoris, rectus femoris, tibialis anterior, and gastrocnemius for each condition together with knee angle (electrogoniometer). Average and root mean square EMG were calculated across 30 s. Muscle patterns were determined by smoothing (low-pass filter, 4 Hz) and extracting patterns for 49 cycles defined by consecutive maximum knee flexion angles. Repeated-measures analyses of variance were used to compare average and root mean square across body weight and speeds. Correlations were computed between the 100% speed/100% body weight condition and all other conditions per muscle. There was no interaction between body weight and speed (P > 0.05). Average and root mean square decreased as body weight decreased for all muscles (P < 0.05) and increased across speeds for all muscles (P < 0.05). Correlations for all muscles between conditions were high (range: 0.921-0.999). Although a percent reduction in body weight did not lead to the same reduction in muscle activity, it was clear that reducing body weight leads to a reduction in muscle activity with no changes in muscle activity patterns.

Prokr2-deficient mice display vascular dysmorphology of the fetal testes: potential implications for Kallmann syndrome aetiology.

Kallmann syndrome is a form of hypogonadotropic hypogonadism also associated with the loss of smell. It is a phenotypically and genetically heterogeneous disorder, with mutations in several known causative genes now accounting for approximately 30% of cases. The prevalence for the disease is also much higher in males than in females, a phenomenon that remains to be fully explained. Here, we show that loss of Prokr2, which is linked to autosomal recessive Kallmann syndrome type 3 (KAL3; OMIM 244200), affects fetal testis differentiation in mice. We find that Prokr2 is specifically expressed in the XY gonads during sex determination and fetal sexual differentiation, and knockout mice display a variable degree of compromised vasculature in the fetal testes. This phenotype offers potential insight into the clinical heterogeneity observed within familial cases, and may contribute to the gender bias in Kallmann syndrome patients.

Impact of deletion of envelope-related genes of recombinant Sendai viruses on immune responses following pulmonary gene transfer of neonatal mice.

We demonstrated previously that the additive-type recombinant Sendai virus (rSeV) is highly efficient for use in pulmonary gene transfer; however, rSeV exhibits inflammatory responses. To overcome this problem, we tested newly developed non-transmissible constructs, namely, temperature-sensitive F-deleted vector, rSeV/dF (ts-rSeV/dF) and a rSeV with all the envelope-related genes deleted (rSeV/dFdMdHN), for pulmonary gene transfer in neonatal mice, by assessing their toxicity and immune responses. The gene expression in the lungs of neonatal ICR mice peaked on day 2, then gradually decreased until almost disappearing at 14 days after infection in all constructs. Loss of body weight and mortality rate, however, were dramatically improved in mice treated with SeV/dFdMdHN (mortality=0%, n=41) and ts-rSeV/dF (24.2%, n=33) compared with additive rSeV (70.7%, n=58). Although the deletion of envelope-related genes of SeV had a small impact on the production of antibody and cytotoxic T-lymphocyte activity in both adults and neonates, a dramatic reduction was found in the events related to innate responses, including the production of proinflammatory cytokines, particularly in the case of neonates. These results indicate that pulmonary gene transfer using SeV/dFdMdHN warrants further investigation for its possible use in developing safer therapeutics for neonatal lung diseases, including cystic fibrosis.

Spontaneous rupture of sacrococcygeal teratoma associated with acute fetal anemia.

Sacrococcygeal teratoma (SCT) is the most common congenital tumor, with affected fetuses having a high risk of perinatal complications and death. We report a case of a fetus with an SCT that developed acute anemia due to spontaneous rupture of the tumor in utero. The fetus was referred at 25 weeks' gestation for evaluation of a large solid and cystic mass in the sacral region. There were no signs of hydrops or placentomegaly. At 33 weeks' gestation, loss of variability in the fetal heart rate pattern was recorded. Doppler ultrasonography showed increased middle cerebral artery peak systolic velocity, suggesting fetal anemia. Markedly bloody amniotic fluid, with 82% hemoglobin F, was observed on amniocentesis, suggesting rupture of the SCT with active fetal bleeding. An emergency Cesarean section was performed. At delivery, the tumor was bleeding actively and the neonatal hemoglobin concentration was 3.1 g/dL. There were no findings of hemorrhage or necrosis within the tumor. The neonate received a blood transfusion, and surgical resection of the tumor was carried out on the first day after delivery. Postoperatively, the baby did well. We suggest that fetal SCTs run the risk of inducing acute fetal anemia due to intrauterine hemorrhage of the tumor, a finding which could lead to an earlier and more appropriate management of this condition.

The effect of a valine-rich diet on intestinal adaptation to massive small bowel resection in the rat.

BACKGROUND/PURPOSE: Recently, valine, which is one of the branched chain amino acids, has been reported to enhance liver regeneration after hepatectomy in the rat. The aim of this study was to investigate the effect of enteral valine supplementation on intestinal adaptation. MATERIALS/METHODS: Seven-week-old male Lewis rats underwent a 90% small bowel resection. The rats were randomly divided into two groups: group V (valine-rich diet) and group S (standard rat chow), according to the diet. The rats were sacrificed at the operation day and on postoperative days (POD) 7, 14, 30, and 60. The metrics were body weight (BW), blood amino acids, urine organic acids, and morphology of the residual small intestine. RESULTS: The BW and the intestinal wet weight, jejunal crypt depth, and proliferating cell nuclear antigen-positive cells in group V at POD 7 were significantly higher than those values in group S, while those in group V at POD 30 and 60 were smaller than those in group S. The urine methylmalonic acid (MMA) level in group V at POD 30 and 60 was much higher than in group S. CONCLUSION: Valine enhanced intestinal adaptation after massive small bowel resection in the acute phase. However, the long-term supplementation disturbed intestinal adaptation, which might be due to the high production of MMA.

The distribution of matrix metalloproteinases and tissue inhibitors of metalloproteinases in the lungs of congenital diaphragmatic hernia patients and age-matched controls.

AIMS: In congenital diaphragmatic hernia (CDH), the pathogenesis of abnormal pulmonary morphology is still incompletely understood. Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) are known to play an important role in the turnover of the extracellular matrix (ECM) during development and in remodelling of tissue. The aim of this study was to investigate differences in the expression of MMPs and TIMPs between CDH lungs and controls, against the background of the abnormal pulmonary vasculature in CDH. METHODS: We studied 12 lungs of term CDH patients who died < 24 h after birth and 11 normal age-matched control lungs, by immunohistochemistry with antibodies against human MMP-1, -2, -9, TIMP-1 and -2. RESULTS: There was a clear increase in the number of MMP-1-reactive capillaries and fibroblasts in CDH lungs compared with controls. In contrast, TIMP-2 reactivity in these structures was decreased in CDH lungs. The arterial endothelium and medial smooth muscle expressed MMP-2, -9 and TIMP-2 in both CDH and control lungs. In small arteries (< 100 microm in diameter), the positive surface area of MMP-2, -9 and TIMP-2 was significantly larger in CDH lungs than in controls. There was no difference in the distribution and expression of TIMP-1 between CDH lungs and normal controls. CONCLUSION: The differences in staining pattern of MMPs and TIMPs between normal and CDH lungs suggest that these enzymes might play a role in the abnormal remodelling of the interstitium and the pulmonary arteries in CDH lungs. This could contribute to our understanding of the abnormal lung morphology and the occurrence of pulmonary hypertension, which forms one of the major obstacles to the successful treatment of these patients.

Expression of matrix metalloproteinases and tissue inhibitors of metalloproteinases during normal human pulmonary development.

AIMS: Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) are thought to be involved in lung development because they play an important role in the turnover of the extracellular matrix. Although limited data on MMP and TIMP expression are available from animal studies during prenatal pulmonary development, little is known about their expression during human fetal lung development. The aim of this study was to investigate the expression of MMP-1, -2, -9, TIMP-1, -2 and -3 in human fetal lungs from 9 to 42 weeks of gestation. METHODS AND RESULTS: Forty-five normal human fetal lung samples were analysed by immunohistochemistry. MMP-1, -9, TIMP-1, -2 and -3, but not MMP-2, were expressed in the epithelium at all gestational ages. The endothelium of all vessels and the arterial smooth muscle cells expressed MMP-1, -2, -9, TIMP-2 and -3, but not TIMP-1, at all developmental stages. CONCLUSION: The extensive distribution of MMPs and TIMPs throughout all stages of human lung development suggests that they play a significant role in the remodelling that occurs in the interstitium and epithelial basement membrane during lung development and in pulmonary vascular development. These data will serve as a base line for comparison with neonatal lung pathology, including pulmonary hypertension.

An abnormal distribution of C-kit positive cells in the normoganglionic segment can predict a poor clinical outcome in patients with Hirschsprung's disease.

PURPOSE: The loss or decrease of interstitial cells of Cajal (ICCs) has been implicated in several disorders of human intestinal motility. We have encountered a few cases suffering from severe constipation or enterocolitis resulting in patient death after a definitive operation for HD, even though the normoganglionic intestine had been successfully pulled through. We investigated the distribution of ICCs using c-kit immunostaining in the normoganglionic segment and compared these findings with the clinical outcome after a definitive operation in each case. PATIENTS AND METHODS: The distributions of ICCs were investigated by using c-kit immunostaining in the normoganglionic segment in the resected bowel in 15 cases with HD. The distributions of protein gene product 9.5 (PGP 9.5) as a general neuronal marker and those of NADPH-diaphorase (NADPH-d) as a marker of nitric-oxide neurons were also examined. The numbers of ICCs and neurons were evaluated quantitatively. The histopathological results were compared with the clinical outcome after definitive operation in each case. RESULTS: C-kit immunoreactive cells showed a normal distribution in the normoganglionic segment in 13 cases, while they were markedly (less than 50% compared with the other cases) decreased in 2 cases. The distributions of PGP 9.5 and NADPH-d were almost the same in all cases. The bowel movements of 13 cases showing normal c-kit distribution were satisfactory. In contrast, the bowel movements were impaired in 2 cases with a decreased number of c-kit positive cells. One infant suffered from severe persistent constipation and thus had to undergo a resection of a dilated colon. The other infant died of sepsis due to postoperative enterocolitis and showed a markedly dilated colon. CONCLUSION: A decreased number of c-kit positive cells in the normoganglionic segment can thus allow us to predict a poor clinical outcome after definitive surgery, probably due to poor intestinal motility. Therefore examining the c-kit distribution in a resected bowel specimen in patients with HD should be mandatory in order to select the optimal postoperative treatment regimen for each case.

Arrangement of high-energy neutron irradiation field and shielding experiment using 4 m concrete at KENS.

An irradiation field of high-energy neutrons produced in the forward direction from a thick tungsten target bombarded by 500 MeV protons was arranged at the KENS spallation neutron source facility. In this facility, shielding experiment was performed with an ordinary concrete shield of 4 m thickness assembled in the irradiation room, 2.5 m downstream from the target centre. Activation detectors of bismuth, aluminium, indium and gold were inserted into eight slots inside the shield and attenuations of neutron reaction rates were obtained by measurements of gamma-rays from the activation detectors. A MARS14 Monte Carlo simulation was also performed down to thermal energy, and comparisons between the calculations and measurements show agreements within a factor of 3. This neutron field is useful for studies of shielding, activation and radiation damage of materials for high-energy neutrons, and experimental data are useful to check the accuracies of the transmission and activation calculation codes.

Real-time monitoring for detecting rejection using strain gauge force transducers in porcine small bowel transplantation.

PURPOSE: The clinical results of small bowel transplantation (SBT) have not been satisfactory mainly because of the immunological barrier. It is important to detect the presence of and to perform adequate treatment of rejection as early as possible to improve graft survival. Therefore, we have established a pig model to monitor graft motility as a means to detect rejection in real time. METHODS: Orthotropic SBT was performed in 25 pigs using FK-506 (0.05 to 0.1 mg/kg/d) immunosuppression. The interdigestive motor patterns were evaluated using strain gauge force transducers (SG). Seven pigs without SBT were treated as controls (C). Animals that displayed migrating motor complex (MMC) activity as evidenced by duration, amplitude, and interval in the graft were alive more than 10 days with adequate oral feeding: the functional graft (FG) group. In contrast the rejection (R) group did not show these activities on data recorded within 10 days before death due to rejection. RESULTS: The FG group showed MMC propagated throughout the graft with all parameters almost the same as the control group except for the duration. In contrast, all parameters in the group R were significantly lower than those in group FG, suggesting that group R motility was obviously impaired by rejection. CONCLUSIONS: The SG method may afford real-time monitoring of transplanted bowel motility that could be useful to detect rejection after SBT.

Tissue distribution of a new photosensitizer ATX-S10Na(II) and effect of a diode laser (670 nm) in photodynamic therapy.

The aims of the present study were to analyse the quantitative tissue distribution of ATX-S10Na(II) and to investigate the maximal effect of a diode laser and the irradiation conditions required to obtain this effect in photodynamic therapy (PDT) with ATX-S10Na(II). Spectrofluorometry was used to obtain quantitative tissue distribution of ATX-S10Na(II) in Colon 26 carcinoma-bearing mice as a function of time following administration. Next, transplanted tumours of mice with or without ATX-S10Na(II) were treated with the diode laser under conditions in which power density and irradiation time were varied. Tumour tissue concentrations of ATX-S10Na(II) were higher than in all tissues at all intervals following administration. The uptake of ATX-S10Na(II) by most tissues was rapid, with maximal concentrations occurring 1 h after i.v. injection, and ATX-S10Na(II) was almost excreted within 24 h after administration. The maximal depth of necrosis induced by PDT in the treated tumour was 7.9 mm under conditions in which power density was 160 mW/cm2 and total dose was above 100 J/cm2. PDT with ATX-S10Na(II) and the diode laser is useful for the treatment of superficial cancers.

A novel polymorphism of the human APRIL gene is associated with systemic lupus erythematosus.

OBJECTIVE: We investigated the association of gene polymorphisms in APRIL, a new member of the TNF family, with systemic lupus erythematosus. METHODS: To detect polymorphisms of the human APRIL gene by exon-specific polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) analysis, we first determined the structure of the human APRIL gene. We designed exon-specific oligonucleotide primers according to the genomic DNA sequence of APRIL. All of the coding regions in exons of the APRIL gene were analysed by exon-specific PCR-SSCP in 148 SLE patients and 146 unaffected controls, then the nucleotide sequences of exons that displayed aberrant bands were determined. RESULTS: The human APRIL gene comprised at least six exons with five introns, spanning approximately 2.8 kilobases of the genomic DNA. By exon-specific PCR-SSCP, we identified two novel polymorphisms at codons 67 and 96. Both had amino acid substitutions: G67R and N96S respectively. Only the 67G allele was associated with SLE in 148 Japanese SLE patients, with allele frequency 0.662 compared with 0.575 for 146 unaffected controls (P=0.0302). The frequency of the individuals who possessed at least one 67G allele in SLE patients (91.9%) was significantly higher than that in the unaffected controls (80.1%) (P=0.0036). CONCLUSION: The 67G allele of APRIL may be a contributing factor in the pathogenesis of SLE.

Universal distribution of c-kit-positive cells in different types of Hirschsprung's disease.

Interstitial cells of Cajal (ICCs) have been reported to play the role of a pacemaker in regulating bowel motility. The relationship between neurons and ICCs, however, remains unclear. Hirschsprung's disease (HD) is an ideal model for investigating this relationship. The operated specimens obtained from 6 short and 3 long segment aganglionosis patients and 3 controls were used as the subject materials in this study. ICCs were immunohistochemically identified using a specific antiserum c-kit, a tyrosine kinase receptor expressing ICCs. Nitrergic nerves were demonstrated by NADPH-diaphorase (NADPH-d) histochemistry. C-kit immunohistochemistry was also combined with protein gene product 9.5 (PGP 9.5; as a general neuronal marker). In the normoganglionic segment of HD, numerous c-kit-positive cells and NADPH-d positive neurons were found in the proper muscle layer, including Auerbach's plexus. In the oligoganglionic segment, the number of c-kit-positive cells and NADPH-d neurons slightly decreased. In the inner border of the circular muscle layer (IBCM), the c-kit-positive cell networks and NADPH-d activities remained in short segment cases, while both of them were absent in the long segment cases. In the aganglionic segment, c-kit positive cells were present universally but the number of them was slightly decreased in the proper muscle layer. The c-kit-positive cell networks of IBCM were seen where extrinsic neurons were present, while they were almost completely absent where extrinsic neurons were absent in the proximal zone of the long segment cases. C-kit positive cells were present universally in the oligoganglionic as well as aganglionic segments of HD. The distribution and properties of c-kit positive cells were related to the presence of extrinsic neurons in aganglionic segment. Based on these findings, aperistalsis is considered not to relate with c-kit positive cells, and c-kit positive cells are not supposed to have a neurogenic origin and can develop without neurons, however the lack of enteric neurons may influence the full differentiation of ICCs.

Thermostability of doubly glycosylated recombinant lysozyme.

We prepared a lysozyme mutant (Q41S/R61S) introducing Asn-type glycosylation signal sites by yeast expression system. On purification by cation exchange column at pH 7, three fractions were obtained. Peptide mapping and mass-spectrometry showed the fractions were the derivatives glycosylated at both Asn39 and Asn59, at only Asn39, and not glycosylated. It was revealed that the processing of Asn-linked oligosaccharide at Asn39 and Asn59 occurred independently in yeast cells. The denaturation temperatures of these derivatives by differential scanning calorimetry were 76.0, 68.8, and 67.5 degrees C at pH 3, respectively. The stabilization of glycosylated lysozyme depends on the degree of glycosylation. We concluded that stabilized proteins can be constructed by glycosylation at proper sites. Thermodynamic stabilization by the artificial double glycosylations on a protein has not yet been reported.

Funnel chest: treatment strategy and follow-up.

Although funnel chest is the most frequently seen deformity of the anterior chest wall in children, there is still considerable controversy regarding three major aspects, namely, the frequency of such deformities, their physiological importance, and the methods available for treatment. We retrospectively analyzed our experience with the 154 patients managed in our department. In 81 of these an operation was performed (OP), and the clinical findings for this group were compared with the 73 patients in whom an operation was not performed (NOP). Evaluation included subjective findings, especially the views of the patients' parents, and objective findings, including chest radiographs, computed tomography (CT), spirogram, electrocardiography, and echocardiography. In all patients the assessment included postoperative respiratory symptoms, appearance of the chest, and psychological aspects related to the deformity. Post-operatively, respiratory symptoms almost invariably subsided. The cosmetic result could initially be regarded as satisfactory or fair during the first 10 years following surgery, but over time there was frequently increasing concern regarding the scar. The NOP patients showed significantly less severity of the funnel index compared with OP patients. However, there was no spontaneous improvement in the deformity in older patients; most of the NOP patients continued to show a cosmetic deformity and 26.7% had psychological problems. This retrospective study confirms that our treatment strategy of objective criteria for operation (functional compression index > 0.2, % vital capacity <80, and CT index less than 0.25) and timing of operation (between 4 and 6 years of age) provides good results. Based on the analysis of long-term follow-up, surgery is considered indicated in patients with severe deformity. However, in the interest of psychological development, the indications for surgery may be extended.

Cornelia de Lange syndrome associated with cecal volvulus: report of a case.

UNLABELLED: Cornelia de Lange syndrome is known to be occasionally associated with gastrointestinal malformation. However, the occurrence of cecal volvulus in such anomalies is very rare. We report a 15-y-old Japanese boy with Cornelia de Lange syndrome associated with a cecal volvulus secondary to non-fixation of the cecum and ascending colon. The patient was admitted to our hospital because of abdominal pain and bilious vomiting. At emergent laparotomy, cecal volvulus with non-fixation of the ascending colon and cecum was diagnosed. Release of the cecal volvulus and the fixation of the cecum and ascending colon to the right retroperitonium were performed. The postoperative course was uneventful, except for sepsis caused by aspiration pneumonia soon after the operation. CONCLUSION: Clinicians treating patients with this syndrome should be aware that such patients may be at risk for developing severe gastrointestinal anomalies, including cecal volvulus.

Interstitial photodynamic therapy with rotating and reciprocating optical fibers.

BACKGROUND: Photodynamic therapy (PDT) is an effective treatment modality that allows selective destruction of malignant tumor cells. However, because of the difficulty in exposing deeper areas of tumors, the modality has strictly limited indications. In this study, the authors introduce a new method for delivering laser light to a three-dimensional, wide area with the purpose of improving the therapeutic value of PDT. METHODS: Three patients with squamous cell carcinoma of the tongue were treated with the present course. After administering porfimer sodium, laser-proof tubes were inserted through the tumor, and optical fibers were passed through the tubes. Pulse laser was emitted from the obliquely prepared fiber tip and distributed toward the target area while rotating and reciprocating the optical fiber. RESULTS: Two patients achieved a complete response without any complications or functional disabilities. The third patient, however, had a partial response and required surgery. CONCLUSIONS: The results indicate the capability of distributing laser light to an entire area of solid tumor. However, the ideal dose of laser light for the treatment of tumors remains unknown. Interstitial PDT will be more efficacious and reliable after the dosimetry is established.