COVID Associated Mucormycosis: A Study on the Spectrum of Clinical, Biochemical and Radiological Findings in A Series of Ten Patients.

BACKGROUND: There is more than twofold rise in prevalence of mucormycosis cases in India during the COVID-19 pandemic which needs to be evaluated. AIMS: The study aimed to document the spectrum of cases of mucormycosis seen at our Institute during COVID-19 times. METHODS: The study is a retrospective observational study carried out at our Institute from May 2021 to mid-June 2021. All patients with biopsy-proven mucormycosis were enrolled in the study. The patients were subjected to complete history taking, ophthalmological examination, and imaging studies. The patients were treated with a multidisciplinary approach with antifungal therapy as well as surgical intervention when needed. RESULTS: Ten patients (n=10) were seen, with a mean age of 50.3 years. The major risk factors included recent use of steroids, uncontrolled diabetes, and CKD. The most common presentation was swelling of unilateral eye and ptosis, followed by loss of vision. Inflammatory marker (CRP) and d-dimer were raised at presentation in all cases. Imaging showed the spread of infection from paranasal sinus to orbit and brain via cavernous sinus, which was a poor prognostic factor. Intravenous Amphotericin-B was given to all patients for at least 4 weeks. Two patients were discharged after completion of treatment and mortality was seen in three patients. CONCLUSION: We present an array of COVID-associated-mucormycosis (CAM) cases from Eastern India. CAM is presenting with rhino-orbito-cerebral involvement. There is poor outcome with cerebral involvement and high incidence of adverse effects with deoxycholate formulation of amphotericin-B. The causal association of COVID-19 with mucormycosis needs to be unearthed but possible preventive role of anticoagulation should be evaluated.

Clinicopathological Study of Primary Pediatric Gastrointestinal Lymphomas.

BACKGROUND: Primary gastrointestinal lymphomas (PGIL) are uncommon in children and account for <5% of all pediatric malignancies. The objective of our study was to analyze the prognostic factors of pediatric PGILs with reference to its histological subtypes, stage, and outcomes using immunohistochemistry. MATERIALS AND METHODS: Twenty cases were studied over 11 years. Clinicopathological profiles, histological details, and immunohistochemical (IHC) profiles were analyzed. RESULTS: The mean age at the presentation was 6 years. Using IHC stains (CD CD10, CD19, CD20, CD3, terminal deoxynucleotidyl transferase, BCL 2 and 6, PAX 5, and MUM1), diffuse large B-cell lymphoma (DLBCL) was most prevalent (45%), followed by Burkitt lymphoma (35%) and lymphoblastic lymphoma (20%). DLBCLs (9) were classified using the Han's algorithm. Six were activated B-cell and 3 were germinal center B-cell subtypes. The cases of lymphoblastic lymphoma and those in Stage I disease had the best prognosis. CONCLUSION: Pediatric PGILs have variable presentation, outcomes, and diverse treatment modalities depending on the histological subtypes. A panel of IHC stains can be a useful adjunct for the categorization and prognosis of pediatric PGILs.

Laparoscopy in the Evaluation of Impalpable Testes and Its Short-term Outcomes: A 7 Years' Experience.

AIMS: The aim of this study is to report and analyze results of laparoscopy in impalpable testes performed between 2009 and 2016 and its short-term outcomes. MATERIALS AND METHODS: Demographic data, laterality, laparoscopic findings, operative time, procedure, hospital stay, complications, and follow-up data of 76 patients with 79 impalpable testes from 2009 to 2016 were retrospectively collected and analyzed. Successful outcome was defined as maintenance of intrascrotal position with no atrophy at a follow-up of at least 6 months. RESULTS: Impalpable testes constituted 24% of undescended testes in our series. Mean age was 3.9 years. Forty-two patients had left-sided, 31 right-sided, and three bilateral impalpable testes. Of the 79 clinically impalpable testes, on laparoscopy, 3 were vanishing testes, 52 were intra-abdominal (6 high-lying and 46 low-lying), 18 canalicular and 6 nubbin testes. Ultimately, 52 underwent laparoscopic orchiopexy: 46 single-staged orchiopexy and 6 two-staged Fowler-Stephens procedure. Mean operating time was 77 min. Complications were few and mostly minor. Eleven patients were lost in follow-up. On a mean follow-up of 23 months, one testis that underwent single-staged laparoscopic orchiopexy atrophied whereas good size and intrascrotal position were maintained in the rest. CONCLUSIONS: Laparoscopy in impalpable testes was safe, feasible, and effective. Overall outcome was good which was obtained by minimal use of electrocautery, dissection with wide strip of peritoneum and extensive retroperitoneal dissection for mobilization. There is a need for wide reporting of cases from high-volume pediatric surgery centers in India.

Leydig Cell Tumor of Testis in a Child: An Uncommon Presentation.

Leydig cell tumors (LCTs) are rare testicular tumors. Incidence is 1%-3% of all testicular neoplasms, bilateral in 10%. They are frequently hormonally active, leading to feminizing or virilizing syndromes. LCTs can be either pure or mixed with germ cell tumors or other sex cord-stromal tumors. Here, we are reporting a benign pure LCT in a 6-year-old boy presented with pseudopuberty.

Uncommon renal tumors in children: A single center experience.

AIMS: Scrutiny over the clinical behaviors, management, and the final outcome of some rare renal neoplasm in order to find out some hidden facts about these tumors which are playing an important role in the disease course and its management. MATERIALS AND METHODS: Retrospective evaluation of uncommon (non-Wilms') renal neoplasm in the pediatric population in a tertiary care center. Fifteen cases of uncommon renal tumors were treated in our institution over the last 5 years (January 2008 to December 2012). The cases were tabulated in the form of age, sex, mode of presentation, preoperative investigations, intraoperative grading, pathological type, postoperative management and the final outcome. The patients were followed up for 2 years (clinically every 3 months and ultrasonography abdomen in every 6 months for first 2 years) in order to see any evidence of recurrence and complications related to postoperative chemotherapy. RESULTS: Out of 15 cases, four cases were clear cell sarcoma (CCS) (26.6%), three cases were rhabdoid tumor (20%), three cases were congenital mesoblastic nephroma (20%), two cases were multilocular cystic nephroma (13.3%), two cases were renal teratoma (13.3%), and one case of teratoid Wilms' tumor (6.6%). There were two deaths (one CCS and one rhabdoid tumor) due to chemotherapy-related toxicity but no recurrence. Three patients were lost during postoperative follow-up; ten patients are doing well and getting a regular visit in the follow-up clinic. CONCLUSION: The clinical presentations of these uncommon renal tumors are similar to that of Wilms' tumor. Thus, preoperative diagnosis is difficult even with modern imaging techniques. Some of these tumors (CCS, rhabdoid tumor) are rapidly progressing and have a poor outcome. Hence, early intervention in the form of complete surgical resection of the tumor (whenever possible) and postoperative chemo/radiotherapy are imperative for fruitful outcome.

Colonic atresia associated with annular pancreas: An extremely rare and previously unreported association.

Colonic atresia is the rarest entity among the all intestinal atresias and may be associated with anterior abdominal wall defect, small intestinal atresia, Hirschsprung's disease, and other anomalies. Here, we are reporting a case of colonic atresia associated with annular pancreas, which has not been reported previously to the best of our knowledge.

Adrenal myelolipoma: An incidental and rare benign tumor in children.

Myelolipoma is a rare benign tumor of adrenal gland and rarer in children. Myelolipoma contains adipose tissue and myeloid precursor producing white blood cells (WBC), red blood cells (RBC) and megakaryocytes. Asymptomatic tumor does not require treatment whereas symptomatic tumor needs operation. We are reporting a rare adrenal myelolipoma in a child with review of literature.

Impact of image guided fine needle aspiration cytology in diagnosis of pediatric hepatic mass and cytohistologic concordance.

BACKGROUND: Pediatric hepatic mass is a heterogeneous group of benign and malignant lesions. Percutaneous fine needle aspiration cytology (FNAC) can be utilized as a diagnostic modality to assess the nature of radiologically demonstrated hepatic lesions and thus facilitate individualized treatment. AIMS AND OBJECTIVE: The objective of the present study was to determine the diagnostic accuracy of percutaneous FNAC of pediatric liver masses, a procedure that is less invasive than open biopsy. MATERIALS AND METHODS: A prospective, observational study was carried out in the Department of Pathology in collaboration with Department of Pediatric surgery and Radio-diagnosis including 31 pediatric patients presenting over last two years (June 2011 to May 2013) with focal hepatic lesion on ultrasound and computed tomography (CT) scan. FNAC was carried out under image guidance and cytodiagnosis was reached after appropriate staining. By comparing with histopathology reports, diagnostic accuracy of cytology was evaluated. RESULT: Among 31 cases included in the study, 51.6% cases were cytologically benign and hemangioma was the most common benign lesion. Hepatoblastoma was the most accounted malignant tumour (12.9%). FNAC provided 94% sensitivity and 92% specificity in diagnosing benign and malignant tumours. Overall diagnostic accuracy was 93.10%. No significant complication was noted. CONCLUSION: Percutaneous FNAC under image guidance is an effective diagnostic tool for diagnosis of primary and metastatic tumours of liver in pediatric patients.

Insights into biomimetic system-ligand interaction of substituted isophthalic acid: A functionality induced photophysical study.

The present article attempts to interpret the modulation of photophysical properties of isophthalic acid (IPA) through its amino [5-amino isophthalic acid (5-amino IPA)] and azido [5-azido isophthalic acid (5-azido IPA)] substituted derivatives which are chemically potent organic ligands. The ground state structure-reactivity correlation of 5-amino IPA and 5-azido IPA has been deciphered through computational studies. The computed energetics show significant interaction feasibility of the substituted ligand systems with the biomimetic systems which is further validated experimentally. The binding interaction of the probes with oppositely polarized functionalization is studied to be significant with cetyltrimethylammonium bromide (CTAB) and bovine serum albumin (BSA) with the amino functionalized derivative having a comparatively stronger binding constant value. The steady-state absorption and fluorescence study establish significant modification of polarity of the heteronuclear probes. The micro polarity study in water-dioxane mixtures enables determination of polarity of 5-amino IPA in CTAB and BSA unlike 5-azido IPA. Presence of an overlapping region between the emission spectrum of BSA and the absorption spectrum of the probes as probable donor-acceptor pair are also scrutinized via the steady-state fluorescence studies. The photophysical behavior of 5-amino IPA is observed to be somewhat dissimilar to that of 5-azido IPA.

Gallbladder polyp: A rare lesion in pediatric population.

An 11-years-old girl with a polyp in the gallbladder is reported. Laparoscopic cholecystectomy was curative.

Ovarian cysts and tumors in infancy and childhood.

AIM: Review of the clinical presentation, types (histology), and stages of presentation and overall outcome of ovarian tumors. MATERIALS AND METHODS: This is a retrospective study. Forty nine girls from 3 days to 12 years were included in the study. RESULTS: Fourteen girls had benign and thirty three had malignant ovarian tumors. One girl had bilateral ovarian non-Hodgkin lymphoma. Dysgerminoma (40%) was the commonest malignant tumor followed by malignant teratoma (16.6%). CONCLUSION: Pain and abdominal lump are the most common modes of presentation. Prognosis depends on the size of the tumor, stage and histology of the tumor. Conservative surgery should be the aim. Multidisciplinary management gives good prognosis.

Advancing Electrode Properties through Functionalization for Solid Oxide Cells Application: A Review.

Hydrogen energy has emerged as the only renewable which is capable of sustaining the prevalent energy crisis in conjunction with other intermittent sources. In this connection, solid oxide cell (SOC) is the most sustainable solid-state devices capable of recycling and reproducing green hydrogen fuel. It is operable in reversible modes viz, fuel cell (FC) and electrolysis cell (EC). SOC is capable of engaging multiple fuels thereby promoting carbon neutral planet. The all-solid design further augments the optimization of cost, efficiency, durability and endurance at higher temperature. Electrodes are therefore, an important component which is responsible for electrocatalytic processing of fuel and oxidant for higher recyclability of cell/stack. The present review article embarks a detailed overview on the past and present status of electrode composition, heterointerface engineering applicable for SOC's. Recent trends in electrode engineering and the possibilities for advancement in SOC is also reviewed with respect to both experimental and computational aspects.

Methyl mercury in fish--a case study on various samples collected from Ganges river at West Bengal.

This study investigated the presence of total mercury (Hg) and organic mercury levels in the muscle of 19 common fresh water fish species captured from river Ganges, West Bengal, India. The total mercury level found in our study may not cause any toxic effect, but the methyl mercury (MeHg) level in some freshwater fish species was surprisingly very high and toxically unacceptable. The results of mercury analysis in various specimens indicated that some fish muscles tended to accumulate high levels of Hg, and approximately 50-84% of Hg was organic mercury. A strong positive correlation between mercury levels in muscle with food habit and fish length (age) was found. Wallago attu possessed the highest amount of organic mercury in their muscle tissues, and it was 0.93 ± 0.61 µg Hg/g of wet weight. Whereas in small-sized fishes Eutropiichthys murius, Puntius sarana, Cirrhinus mrigala, Mystus vittatus or Mystus gulio, and Tilapia mossambicus, it was below the detection limit. Contamination in Catla catla (0.32 ± 0.11), Anguilla bengalensis bengalensis (0.26 ± 0.07 µg Hg/g), Chitala chitala (0.25 ± 0.18), Rita rita (0.34 ± 0.14), and Ompok pabda (0.26 ± 0.04) was also above the 0.25 µg Hg/g of wet weight, the limit set by the PFA for the maximum level for consumption of fish exposed to MeHg. Though in Labeo rohita (0.12 ± 0.03), Mastacembelus armatus (0.17 ± 0.02), Pangasius pangasius (0.12 ± 0.16), Bagarius bagarius (0.12 ± 0.01), and Clupisoma garua (0.1 ± 0.01), concentration was below the recommended level, in Lates calcarifer (0.23 ± 0.0) and Mystus aor (0.23 ± 0.1), it was threatening. Interestingly, a low concentration of Hg was found in post-monsoon samples.

Spectrum of pediatric kidney tumours with special references to WT1 immunostain at a tertiary care hospital.

Context or Background: Pediatric renal tumours are the second most common solid tumours in children. The most common in this group is Wilms tumour with mesoblastic nephroma being the 2nd most common tumour in children, younger than 3 months. Aims and Objectives: The present study was conducted to study the epidemiological occurrence of pediatric renal tumours at a tertiary care hospital and to study the diagnostic efficacy of WT1 immunostaining in distinguishing Wilms tumour from other types of renal tumours. Materials and Methods: It was a single institution-based prospective and observational study conducted for 2 years (from October 2013 to September 2015) in the department of pathology in our hospital. A total of 50 cases were enrolled in this study all were below 15 years of age. Results: Nephroblastoma or Wilms tumour was found to be the most common type, occurring in 66% cases. Fourteen out of 33 cases of Wilms tumour showed triphasic components (blastemal, epithelial, and stromal) with Blastemal type Wilms being the second most common (11 cases). WT1 immunostaining was positive in 93.9% cases of nephroblastoma. The highest amount of nuclear positivity noted in blastemal cells followed by epithelial cells. Rhabdomyoblastic differentiation and regressive variant showed nonspecific cytoplasmic staining. Cystic partially differentiated nephroblastoma and diffuse anaplasia type Wilms tumour showed nuclear staining in blastemal cells. Conclusion: The expression of WT1 immunostain was found to be diagnostically significant in differentiating Wilms tumour from other renal tumours.

Supramolecular Arrangement and DFT analysis of Zinc(II) Schiff Bases: An Insight towards the Influence of Compartmental Ligands on Binding Interaction with Protein.

We report, for the first time, a detailed crystallographic study of the supramolecular arrangement for a set of zinc(II) Schiff base complexes containing the ligand 2,6-bis((E)-((2-(dimethylamino)ethyl)imino)methyl)-4-R-phenol], where R=methyl/tert-butyl/chloro. The supramolecular study acts as a pre-screening tool for selecting the compartmental ligand R of the Schiff base for effective binding with a targeted protein, bovine serum albumin (BSA). The most stable hexagonal arrangement of the complex [Zn-Me] (R=Me) stabilises the ligand with the highest FMO energy gap (ΔE=4.22 eV) and lowest number of conformations during binding with BSA. In contrast, formation of unstable 3D columnar vertebra for [Zn-Cl] (R=Cl) tend to activate the system with lowest FMO gap (3.75 eV) with highest spontaneity factor in molecular docking. Molecular docking analyses reported in terms of 2D LigPlot+ identified site A, a cleft of domains IB, IIIA and IIIB, as the most probable protein binding site of BSA. Arg144, Glu424, Ser428, Ile455 and Lys114 form the most probable interactions irrespective of the type of compartmental ligands R of the Schiff base whereas Arg185, Glu519, His145, Ile522 act as the differentiating residues with ΔG=-7.3 kcal mol-1 .

Role of EGFR and HER-2/NEU Expression in Gall Bladder Carcinoma (GBC).

Background Gall bladder carcinoma (GBC) is the most common malignancy of the biliary tract. Being known for its geographical and racial variations, and compared with the global statistics, its incidence is higher in the Indian subcontinent, mainly in the northern and eastern regions, accounting for 80 to 95% of cases. Aims and Objectives This study was conducted to evaluate the clinic-pathological spectrum and expression of EGFR and HER-2/NEU in GBCs and to understand their relation to prognosis, paving the way for targeted therapies for better treatment outcomes and patient survival. Materials and Methods This is a prospective study performed in a tertiary care hospital in 30 resected specimens of GBC cases recorded in our Department of Pathology from November 2017 to November 2019. Clinical history including the radiological reports and demographic parameters were included in the study pro forma. Immunohistochemical (IHC) staining for EGFR and HER-2/NEU was performed on all the selected cases. Clinicopathologic parameters like age, sex, histologic type, perineural, and lymphovascular invasion were compared and correlated with EGFR and HER-2/NEU status. Results Expression of EGFR was found in 93.33% of cases, which showed a highly significant correlation with histological tumor type ( p = 0.000). HER-2/NEU expression was found in 56.66% of cases, which also showed a significant correlation with histological tumour type ( p = 0.021). We found most of the cases with strong EGFR immunoreactivity (3+) were poorly differentiated tumors and most of the cases showing weak immunoreactivity for EGFR (1+) were well-differentiated. Conversely, in case of HER-2/NEU immunoreactivity, strong staining (3+) was seen in well-differentiated tumors and weak staining (1+) in poorly differentiated tumors. A significant correlation was also found between EGFR and HER-2/NEU expression ( p = 0.000) and between cholelithiasis and EGFR expression ( p = 0 .033). Conclusion EGFR is expressed in most cases of GBC. Its expression is more in poorly differentiated carcinomas as compared to the well-differentiated carcinomas, whereas HER-2/NEU expression is more in well-differentiated carcinomas. Therefore, they may serve as independent prognostic factors and also as targets for molecular therapy in GBCs.

Molecular profiling and utility of cell-free DNA in nonsmall carcinoma of the lung: Study in a tertiary care hospital.

BACKGROUND: Lung carcinoma accounts to the most common cause of cancer globally. Optimal management of nonsmall cell lung carcinoma (NSCLC) requires prognostic biomarkers that help in targeted therapy and identification of tumor subsets with a distinctive molecular profile that can foretell response to therapy. Quantitative analysis of circulating cell-free DNA is considered as a possible aid for lung cancer screening. AIMS AND OBJECTIVES: The main aim of our study was detection of the clinicopathological spectrum of NSCLC, immunohistochemical (IHC) study of lung adenocarcinoma with epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and molecular expression of EGFR mutation using Formalin fixed paraffin embedded tissue (FFPE) and cell-free DNA (cfDNA) from blood samples. MATERIALS AND METHODS: It was a prospective and observational study conducted in the Department of Pathology in association with the Department of Chest Medicine in a tertiary care hospital for 18 months, done on 50 patients. Histological subtyping of lung carcinomas was done, followed by IHC analysis using P40, thyroid transcription factor (TTF1), EGFR, and ALK. Molecular analysis for EGFR mutation was done using FFPE and cfDNA from the patient's blood samples. RESULTS AND ANALYSIS: On histological subtyping, majority (66%) of the cases were found to be adenocarcinoma. All adenocarcinoma (66%) cases show TTF1 positivity and all squamous cell carcinoma (32%) cases show P40 positivity. All the ALK-positive (6%) cases were never smokers and histologically diagnosed as adenocarcinoma. About 58% of the NSCLC cases were found to be EGFR IHC positive. Formalin-fixed paraffin tissue (FFPE) showed EGFR mutation in 32% cases, of which majority were deletion (19, 28%) and rest (4%) of the cases involving mutation in exon 21. From cfDNA, mutations were noticed in 16% of the cases where majority involved deletion 19 (12%), whereas the rest of the cases were positive for missense mutation in exon 21 of the EGFR gene (2%) and compound heterozygous mutation involving deletion 19 and missense mutation for exon 21 (2%). On correlation of EGFR mutation studies from FFPE with that of cfDNA analysis, the study was statistically significant (P = 0.000). CONCLUSION: This study reports clinicopathological, immunochemical, and molecular analysis of EGFR among NSCLC cases. EGFR mutation detection from cfDNA has its advantage of being a noninvasive technique to avoid rebiopsy in cases of the progressive disease to detect resistance to a drug and emergence of a newer mutation. Mutation detection from FFPE samples still remains the gold standard for targeted therapy using EGFR tyrosine kinase inhibitors. ALK rearrangement detection using IHC serves as an adjunct to EGFR diagnosis.

COVID-19 associated rhino-orbital-cerebral mucormycosis: An observational study from Eastern India, with special emphasis on neurological spectrum.

AIMS: 1: Describe the epidemiology and determine risk factors for COVID-19 associated mucormycosis. 2: Elaborate the clinical spectrum of Rhino-Orbital-Cerebral Mucormycosis (ROCM), pattern of neuroaxis involvement and it's radiological correlates. METHODS: Observational study. Consecutive, confirmed cases of mucormycosis (N = 55) were included. A case of mucormycosis was defined as one who had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological examination (HPE). Data pertaining to epidemiology, risk factors, clinico-radiological features were analysed using percentage of total cases. RESULTS: Middle aged, diabetic males with recent COVID-19 infection were most affected. New onset upper jaw toothache was a striking observation in several cases. Among neurological manifestations headache, proptosis, vision loss, extraocular movement restriction; cavernous sinus, meningeal and parenchymal involvement were common. Stroke in ROCM followed a definitive pattern with watershed infarction. CONCLUSIONS: New onset upper jaw toothache and loosening of teeth should prompt an immediate search for mucormycosis in backdrop of diabetic patients with recent COVID-19 disease, aiding earlier diagnosis and treatment initiation. Neuroaxis involvement was characterized by a multitude of features pertaining to involvement of optic nerve, extraocular muscles, meninges, brain parenchyma and internal carotid artery.

A study on genetic polymorphism of RET proto-oncogene in Hirschsprung's disease in children.

BACKGROUND: Hirschsprung's disease (HD) is a genetic disorder with a complex pattern of inheritance. Some single-nucleotide polymorphisms (SNPs) are identified to be associated with the risk of Hirschsprung's Disease (HSCR). AIMS AND OBJECTIVES: The aim of this study is to know the association between the rearranged during transfection (RET) proto-oncogene polymorphism and HD and to characterize the SNPs of RET proto-oncogene affecting HD. MATERIALS AND METHODS: The study was conducted in the Department of Pathology in association with the Department of Pediatric Surgery. Blood samples were collected from the patients diagnosed with confirmed HD and from age- and sex-matched controls. This case-control study consisted of 53 HSCR cases and 50 controls. Genotypes of rs1800860 and rs1800861 were analysed in by polymerase chain reaction amplification and sanger sequencing. Associations with the risk of HSCR were estimated by odds ratio (OR) and their 95% confidence intervals (95% CI) using. RESULTS: We observed that in the case of rs1800860A > G genotype AG was not associated with the increasing risk of disease (OR with 95% CI = 0.568 [0.238-1.356]) while genotype GG was associated with increasing the risk of the disease (OR with 95% CI = 2.278 [0.967-5.366]). In the case of rs1800861G > T genotype GT was associated with lowering the risk of the disease (OR with 95% CI = 0.230 [0.0981-0.539]) while genotype TT was associated with increasing the risk of the disease (OR with 95% CI = 9.647 [3.830-24.302]). The difference in the genotypic distribution of GT and TT at rs1800861G > T between Short segment disease (SSD) cases and Long Segment Disease (LSD) and total colonic aganglionosis was made by Fisher's exact test and it was statistically significant (P = 0.0476 and 0.0054). CONCLUSION: The results of this study support the hypothesis that variations in RET pathway might play an important role in the development of HSCR.