Amongst them, IL-5 is responsible

for the selective diffe

Amongst them, IL-5 is responsible

for the selective differentiation of eosinophils [7]. IL-5 also stimulates release of eosinophils from the bone marrow into the peripheral circulation and promotes their migration to the lung upon allergen challenge; a key step in the development of lung inflammation [8] and [9]. In accord with these important roles for IL-5, antibodies that Screening Library in vitro neutralize IL-5 inhibit both allergen-induced blood eosinophilia and the recruitment of eosinophils to the lung in murine models of asthma [10] and [11]. In addition to IL-5, cytokines from the eotaxin family also stimulate eosinophils to migrate from blood into tissues [12]. There are two variants of murine eotaxin, namely eotaxin 1 (eotaxin) and eotaxin 2 which both belong to the family of CC type chemokines [13] and [14]. Murine eotaxin has marked synergism with IL-5. Anti-eotaxin and anti-IL-5 antibodies alone and in combination have been shown click here to reduce OVA-induced airway eosinophilia but failed to inhibit AHR [15]. Importantly, blocking eosinophil-activity in mice prevents allergen induced airway eosinophilia and AHR and results in reduced lung-fibrosis, a severe consequence of asthma [16] and [17]. For humans, therapeutic intervention strategies aimed at blocking the action of eosinophils have been investigated in various asthma settings and eosinophilic disorders. Blockade of IL-5

with the humanized monoclonal antibody Mepolizumab has reduced circulating and

sputum eosinophils and shown evidence for an effect on airway remodelling [17] but, has failed to achieve discernable effects on AHR or the late asthmatic response. Recent clinical testing of Mepolizumab in refractory eosinophilic asthma and prednisone dependent asthma has shown decreases in blood and sputum eosinophils and statistically significant decreases in the number of asthma exacerbations Bay 11-7085 [18] and [19]. Thus, anti-eosinophil strategies may be a promising therapy in asthma subgroups with heavy eosinophilic loads in which conventional anti-inflammatory therapy is only partially effective. Monoclonal antibodies (mAbs) are highly active molecules that are currently used in a numerous disease indications, including cancer and inflammation. However, due to the high amounts of antibodies required and their generally short half-life, therapies involving monoclonal antibodies are costly. In addition, long-term treatment with mAbs may result in the development of neutralizing anti-antibodies, which may reduce their efficacy or induce adverse effects [20]. Active immunization against self-antigens typically results in relatively long-lived antibody responses and has been viewed as a potential alternative to mAb therapies. It has previously been shown that highly repetitive antigens displayed on viral surfaces are able to efficiently overcome B cell unresponsiveness [21].

Although the effects were small, the intervention is quick to app

Although the effects were small, the intervention is quick to apply, is maintained in situ for one week, and does not require ongoing commitment of time and effort, as do some other physiotherapy interventions (eg, exercises). Therefore, some patients may consider that the costs and inconvenience involved are small and that a combination of small reductions in pain and disability may make taping worthwhile overall. The borderline effect on lumbar flexion range of motion

is interesting. Kinesio Taping on the lower trunk increased active lower trunk flexion range of motion in healthy subjects (Yoshida and Kahanov 2007). Although various mechanisms

see more were postulated to explain this, some of which could apply in our participants, we must also consider that the mild reduction in pain could explain the greater range in our participants. The mild analgesic effect may also explain the greater performance of the trunk muscles on the McQuade test. Unfortunately, we did not record whether pain or fatigue was the limiting factor for participants during this test. Another possibility is that the presence of the taping led to greater awareness and, in turn, greater muscular activation around the area during the intervention period. This may have introduced a mild endurance training effect on the trunk musculature. The precise mechanisms underlying the effect of Kinesio

Taping on musculoskeletal pain are not yet clear. Some authors have BMN 673 mouse hypothesised that pain is relieved by Kinesio Taping because sensory modalities operate within interconnecting, intermodal and cross-modal networks (McGlone and Reilly 2010). Others have suggested that keratinocytes Histone demethylase may be non-neural primary transducers of mechanical stimuli, probably via a signal transduction cascade mechanism (eg, intracellular Ca2+ fluxes) to evoke a response on adjacent C-fibres (Lumpkin and Caterina 2007). Another hypothesis is that the cutaneous stretch stimulation provided by Kinesio Taping may interfere with the transmission of mechanical and painful stimuli, delivering afferent stimuli that facilitate pain inhibitory mechanisms (gate control theory) and pain reduction (DeLeo 2006, Paolini et al 2011). A further possible mechanism by which Kinesio Taping induced these changes may be related to the neural feedback received by the participants, which may improve their ability to reduce the mechanical irritation of soft tissues when moving the lumbar spine (Kase et al 2003). Furthermore, Kase and colleagues (1996) proposed a theoretical framework to explain the decrease in lumbar pain-associated disability observed immediately after Kinesio Taping.

We report comparator characteristics of the Zone population as we

We report comparator characteristics of the Zone population as weighted averages, weighting each Zone LSOA by its total population of residents living in that LSOA plus non-residents commuting to that LSOA. We used linear regression

to examine correlates of ‘mean number of trips’ (primary outcome), and logistic regression to examine correlates of ‘ever use’ (secondary outcome). We hypothesised that the association between socio-demographic explanatory variables and outcome variables might be affected by the geographical positioning of the scheme in relation to users, and by users’ decisions regarding HA-1077 when and how to register for the scheme. We therefore adjusted for these variables using a hierarchical modelling approach. Model one includes the socio-demographic variables (gender,;

place of residence,; and area-level income-deprivation, ethnicity and commuter behaviour); model two also adjusts for distance and density of BCH stations from the registered address; and model three further adjusts for month of registration and access type. We accounted for spatial autocorrelation using maximum likelihood estimation to fit three-level linear and logistic random intercept models, of individuals nested within LSOAs nested within boroughs (further details in supplementary material). STATA 11 was used for all statistical analyses and ARC GIS 9.2 was used Birinapant to create a map. Ethical

approval was granted by the London School of Hygiene and Tropical Medicine’s ethics committee. Between 30th July 2010 and 23rd February 2011, 100,801 individuals registered to use the BCH scheme. Data was complete for 99,615 individuals (98.8%). A total of 2,497,919 trips were made between 30th July 2010 and 17th March 2011, below however one quarter (25.4%) of registered users made no trips in the recorded period. The mean total number of trips per registered user was 24.8, (standard deviation 47.9; 95%CI 24.5–25.1), with a mean of 4.15 (standard deviation 7.9; 95%CI 4.10–4.20) trips per user per month of registration. Among those whose gender was known, less than one fifth (18.4%) of the total number of trips were made by females. Over two-thirds (69.6%) of registered users were male, and approximately three-quarters (77.5%) had London postcodes. One-third (34.3%) lived within 500 m of a BCH docking station, and one-quarter (27.3%) had one or more BCH docking stations within a 250-metre radius of their address. Half (50.5%) registered within the first two months of the scheme, with registrations declining over time, perhaps partly due to the transition to winter. 58.7% of users registered for 1-day access and 37.1% registered for annual access. Males were more likely than females to be non-London residents (25.7% versus 13.9%) and to choose annual access (39.5% versus 30.6%).

The ICD 10 (G00-05) search according to the methods described abo

The ICD 10 (G00-05) search according to the methods described above yielded a total of 73 cases (ICD-10 database). Electronic search of discharge summaries for the terms “meningitis”, “encephalitis”, “enzephalitis”, “myelitis”, “encephalomyelitis”, and “enzephalomyelitis” yielded a total of 902 cases (clinical database). The clinical database and the ICD-10 database were merged and duplicate entries and multiple hospitalizations were again deleted. Fig. 1 provides an overview of the merging process. The diagnostic labels according

to the diagnoses listed in the discharge summary yielded PI3K targets the following distribution of unique and overlapping diagnoses (Fig. 2) Applying the Brighton Collaboration algorithms yielded a distribution, which was considerably less complex ( Fig. 3). A total number of 108 cases were ruled out entirely. Diagnostic labels and BC levels of diagnostic

certainty were compared. Overall rates of agreement (ORA), positive percent agreement (PPA) and negative percent agreement (NPA) were calculated for each level of diagnostic certainty. Table 1 demonstrates Epigenetic Reader Domain inhibitor that ORA ranged from of 77 to 98% for ENC, MYE, and ADEM. Again, as expected for a confirmatory test, levels of positive percent agreement (PPA) were lower than values for negative percent agreement (NPA). The comparison of ASM showed 67% ORA in Level 1, but a significantly lower value at Level 2 (38%), reflecting the overlap with cases of bacterial meningitis (see Section 3.5.2). Point estimates

and 95% confidence intervals were constructed, using GBA3 the total sample size for which comparative assessments were available (n = 255) for all calculations. Table 2 shows the results for ASM, BM, ENC, MYE, and ADEM for any level of diagnostic certainty. In most instances, NPA was higher than PPA, which is consistent with a confirmatory test rather than a screening tool, as reported previously in the evaluation of BC definitions [35] and [36]. As mentioned previously, cases of BM were included as negative controls and tested against the BC definition for ASM. As expected, we found significantly lower levels of agreement between a clinical case of BM and the BC category of ASM. Of the 140 cases with an exclusive clinical diagnosis of aseptic meningitis, 96 (68.6%) fulfilled the BC definition for ASM, 44 cases did not fulfill the definition for ASM. In 39 of these discordant cases, no documented gram stain report was available upon chart review. A negative gram stain is a major criterion and required for any level of diagnostic certainty in the Brighton Collaboration definition of ASM.

In summary, in this study of more than 40,000 LAIV recipients 5–1

In summary, in this study of more than 40,000 LAIV recipients 5–17 years of age, rates of MAEs and SAEs were compared between LAIV-vaccinated individuals and multiple nonrandomized controls. SAEs and hospitalizations after vaccination with LAIV were uncommon, and no pattern of MAEs was found to occur at higher rates than control groups. The results of this study are consistent with preapproval click here studies [3], [13] and [14] and with reports to the Vaccine Adverse Events Reporting System in the years after the initial approval of

LAIV [12], which demonstrated no significant adverse outcomes after receipt of LAIV by eligible individuals 5–17 years of age. A similar study is currently underway in children 2–4 years of age. Contributors: Study concept and design: Drs. Baxter, Toback, Sifakis, and Ambrose, Mr. Hansen, Ms. Bartlett, Ms. Aukes, and Mr. Lewis. Acquisition of data: Dr. Baxter, Mr. Hansen, Ms. Bartlett, Ms. Aukes, and Mr. Lewis. Analysis and interpretation of data: all authors. AZD9291 mouse Drafting of the manuscript:

all authors. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: Ms. Bartlett and Dr. Wu. All authors have seen and approved the final manuscript for submission. Financial disclosures: Drs. Toback, Sifakis, Wu, and Ambrose are employees of MedImmune, LLC, Gaithersburg, MD. Dr Baxter receives grants from Merck, GSK, Novartis, and Sanofi Pasteur. Funding/support: This research was funded by MedImmune. Role of the sponsor: Employees of MedImmune worked collaboratively with the investigators in the design of the study, in analysis L-NAME HCl and interpretation

of the data, and reviewed and approved the manuscript. Additional contributions: Editorial assistance in formatting the manuscript for submission was provided by Susan E. Myers, MSc, and Gerard P. Johnson, PhD, of Complete Healthcare Communications, Inc. (Chadds Ford, PA) and funded by MedImmune. “
“T cells are important mediators of the adaptive immune response against infections caused by intracellular microorganisms, including the digenetic intracellular protozoan parasite Trypanosoma cruzi, the causative agent of Chagas disease (American trypanosomiasis). Genetic deficiency or specific treatments leading to the depletion of CD4+ or CD8+ T cells critically impairs the acquired immunity observed during experimental mouse infection [1], [2], [3] and [4]. Although, the anti-parasitic effect exerted by the T cells is largely mediated by IFN-γ, other mediators may also participate in the efficient elimination of parasites from the host [1], [2], [3] and [4]. In inbred mouse strains or humans, MHC class II-restricted CD4+ T cells recognize multiple antigens from T. cruzi [5], [6], [7], [8] and [9], whereas MHC class Ia-restricted CD8+ T cells are primarily specific for immunodominant epitopes that are expressed by surface antigens members of a large family of T.

, Swiftwater, PA, USA) [74] Safety and immune response non-infer

, Swiftwater, PA, USA) [74]. Safety and immune response non-inferiority has been demonstrated for co-administration of Cervarix® and Boostrix®-IPV (diphtheria, tetanus, acellular pertusis, inactivated polio; GlaxoSmithKline Biologicals, Rixensart, Belgium) [75]. These encouraging results might eventually lead to co-formulation of HPV and

other vaccines, particularly with hepatitis B where vaccination schedules and adjuvants appear most compatible. Several second-generation HPV prophylactic vaccines are under development with the goal of addressing PD0332991 order some of the inherent limitations of the current vaccines. The approach that is by far the most advanced is to simply increase the valency of an L1 VLP vaccine to address the issue of type-restricted protection. Merck appears to be well advanced in a Phase III efficacy trial of a nonavalent vaccine, which, in addition to the four types in Gardasil®, contains L1 VLPs of types 31, 33, 45, 52 and 58 [76]. Even if the vaccine is entirely type-specific, Selleckchem Trametinib it would have the potential

to prevent approximately 85% of cervical cancer-associated HPV infections [6]. Vaccines based on L1-pentameric subunits produced in E. coli have been generated to address the cost of production in eukaryotic cells [77]. These capsomere-based vaccines have demonstrated protection from experimental challenge in animal models [78]. Phase I clinical trials of a capsomere-based vaccine are anticipated in the near future [76]. Alternatives for lowering the cost of manufacturing being investigated include the generation of the L1 VLPs in alternative yeast production systems, such as Pichia pastoris [79], or in plants [80]. Live recombinant viral and bacterial vectors, such a measles [81], adeno-associated virus [82] and Salmonella typhi [83], expressing L1 have also generated promising results in preclinical of studies. Vaccines based on the minor virion protein, L2, have generated increasing interest in recent years (reviewed

in [84]). L2 contains some remarkably broad cross-type neutralizing epitopes. These epitopes are able to induce antibodies that prevent infection by genital and cutaneous HPV types both in cultured cells and animal models. Simple L2 polypeptides generated in E. coli or synthetically can elicit these broadly cross-neutralizing antibodies, raising the possibility of an inexpensive monovalent vaccine with the potential to be broadly protective. However, neutralizing antibody titers to L2-based immunogens are invariably lower than homologous type neutralizing titers elicited by VLP-based immunogens. There have been a number of strategies employed to increase L2-induced neutralizing titers, including virus-like display approaches and fusion to immunogenic peptides. Whether the responses will be sufficient to induce long-term type specific and cross-type protection remains to be determined.


“The East Indian sandalwood tree, Santalum album L (a San


“The East Indian sandalwood tree, Santalum album L. (a Santalaceae member) is MK-2206 chemical structure a woody, tropical tree acclaimed for costliest heartwood and the essential oil obtained from it. Upon steam-distillation the heartwood yields precious sandalwood oil that has over 90% santalols (α- and β-santalols and their sesquiterpenoid isomers). 1 The sesquiterpenoid rich sandalwood essential oil is accumulated beyond

15 years of growth of the tree. The yield ranges from 2.5 to 6% depending on the age of the tree, the color of the heartwood, individual tree understudy, sampling site within the tree and the environment of growth. 2 Reported sandalwood essential oil constituents are sesquiterpenoids, 3 triterpenoids and phenylpropanoids. 4 The major essential oil components are ‘santalane-backbone bearing’ sesquiterpenoids as santalenes and santalols. 1, 3, 5 and 6 However, in sandalwood oil α-santalol is more abundant (46%) than β-santalol (20%) 7, 8 and 9 although both differ in their stereochemistry and biological activity. However, reported literature on total volatile constituents of this tropical essential oil-yielding tree is scanty. Besides, it is highly likely that the non-sesquiterpenoid constituents, other than santalols could play critical roles in several ethnopharmacological and therapeutic properties. The GC–MS profiles of commercially available sandalwood oil obtained by the process of steam-distillation constitute one of the first reports

in this direction. 1 Previously conducted investigations Enzalutamide on heartwood volatiles of sandalwood tree focused mostly on santalol biosynthetic pathway intermediates. 6 In lieu of the available limited information on the wood volatiles, in this study, we investigated the solvent extractable volatiles from the matured heartwood by GC–MS. The heartwood of a 15-year-old tree grown in the Department of Biotechnology, Indian Institute of Technology Kharagpur campus, was bored at 100 cm height from the ground and

chips/powders were collected and air dried for 48 h. Solvent extraction was done in eluotropic series (n-pentane, n-hexane, chloroform and diethyl ether) in 500 ml volume Erlenmeyer flasks, for 12 h each, at 25 ± 5 °C, with intermittent shaking much in a 10% (w/v) ratio of plant materials to solvent. During extraction 0.01% (w/v) BHT (butylated hydroxytoluene) was added as a synthetic antioxidant to protect the phytochemicals from auto oxidation and served as an internal standard. Obtained extracts were dried over Na2SO4, pooled and were concentrated in vacuuo, in a rotary evaporator (N–N Series, Eyela, Tokyo) at 40 °C. The volatile yield was determined by gravimetric method and was expressed as percentage of starting plant material. The extracts were reconstituted in n-hexane and proceeded for GC–MS analysis. The pooled volatile fraction was analyzed by GC–MS using a Thermo Trace GC Ultra™ gas chromatograph system, equipped with a 30 m (l) × 0.25 mm (i.d.), 0.

In parallel, the National Health Security Board approved the prov

In parallel, the National Health Security Board approved the provision of free seasonal IIV to high-risk groups, including the elderly and persons with one of seven chronic diseases. This will create a regular domestic market of around 4 million doses for seasonal IIV, sufficient to maintain future industrial-scale production and serve as a reserve for future pandemic response. The rapid spread in 2009 of A (H1N1) influenza across all continents compelled the GPO to move its focus away from IIV to the development of a pandemic A (H1N1) LAIV. Indeed, the much superior yields obtained with LAIV compared to IIV make this technology

a promising approach to increase production capacity in the case of a pandemic. A sub-licence signed in April 2009 with WHO to obtain the Russian LAIV 5-Fluoracil coincided with the onset of an A (H1N1) influenza outbreak. An emergency plan was thus set up to produce a LAIV from A/17/CA/2009/38 (H1N1), cold adapted/temperature sensitive (ca/ts) reassortant pre-master seed produced from master donor virus (MDV) A/Leningrad/134/17/57 (H2N2) and wild type A/California/07/2009 (H1N1). Development of the monovalent egg-based PLAIV started in July 2009. Genetic stability of the candidate vaccine after four passages was carried out by the GPO in collaboration with the Faculty of Science, Mahidol University, Thailand. Complete nucleotide sequence of the pre-master, master

and working virus seeds, as well as of clinical lots were determined. Sequences around known mutations in the PB2 (V-478-L), PB1 (K-265-N, V-591-I) and PA (L-28-P, V-341-L) genes in the vaccine strain were compared to selleck chemicals those that play a critical role in the attenuation of the ca Len/17 vaccine donor strain [3]. Apart from a novel mutation in NS (T-191-K) found in all virus preparations analysed, and which is not located in any of the regions of the genome known to contribute to virus attenuation, the genetic sequences were found

to correspond exactly to those expected, showing the stability of the vaccine virus. The need to import 5000 specific pathogen free (SPF) eggs per week from Germany and the United States of America (USA) for the production of LAIV initially posed problems for the handling, management Adenylyl cyclase and ultimate quality of the eggs. It took some time therefore to optimize the processes to obtain high virus yields and volumes of harvested allantoic fluid. To overcome a foreseeable shortage of both SPF and clean eggs, the GPO has initiated discussions with egg suppliers in Thailand regarding investment in a poultry farm to secure sufficient quantities of quality eggs for future production of both IIV and LAIV. A single dose toxicity study carried out at the GPO in outbred ICR female mice compared four vaccine dosage levels given intraperitoneally: normal saline solution (group 1, control); 7.9 log at 50% of the egg infectious dose (EID50) of the GPO PLAIV (group 2); the GPO placebo (group 3) and 7.

Older adults with visual impairments are affected by age-related

Older adults with visual impairments are affected by age-related deterioration in balance to an even greater extent than the general population.18 Thus, exercise and physical training

warrant particular investigation as fall prevention strategies for people with visual impairment living in the community, as well as in residential care settings. Mobility, balance, strength and proprioception are aspects of physical function that have been identified as risk factors for falls. Thus, the impact of exercise on these factors, as well as on falls themselves, was investigated. Therefore, the research questions for this review were: 1. Does Selleckchem DAPT exercise or other physical training improve Alisertib datasheet physical function in older adults with visual impairments? A search of the literature was conducted in February 2013 of MEDLINE, Embase, CINAHL and the Cochrane Register of Controlled Trials (CENTRAL). The MEDLINE search strategy used is shown in

Appendix 1 (see eAddenda) and this was adapted for other databases. Supplementary searches of the Physiotherapy Evidence Database (PEDro), the WHO International Clinical Trials Registry and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) were also undertaken. The searches sought trials of exercise and training to improve physical function or reduce falls in older adults with untreatable visual impairments. The inclusion criteria are summarised in Box 1. Design • Randomised controlled trials or trials with factorial design Participants • Older adults ≥ 60 years of age Intervention • Exercise Outcome measures • Measures of physical function with performance tests or questionnaires Comparisons • Exercise program designed to enhance physical function compared with

control program or usual care The researchers were not blinded Cediranib (AZD2171) to any aspects of the papers. Study titles and abstracts were independently screened by two investigators (MG and LK) for inclusion in the review and any discrepancies were resolved by discussion with a third investigator (CS). Data were extracted by one investigator (MG) and checked by a second investigator (CS) and any discrepancies resolved by discussion. Data extracted included: the settings in which the trials were conducted; the characteristics of the participants (age, gender and visual status); the programs provided to the intervention and control groups; and outcome measures. The studies had already been assessed for quality using the PEDro scale,19 which includes items related to risk of bias and completeness of reporting, and reported on PEDro (http://www.pedro.org.au). Studies were not excluded on the basis of the rating. Only published, randomised trials were eligible. Language of publication was not an exclusion criterion.

The remaining Foley tubing then inadvertently obstructed the uret

The remaining Foley tubing then inadvertently obstructed the urethra, and therefore stopped all outflow of urine from the functioning left kidney. The case described here demonstrates a serendipitous method of diagnosis of ectopic ureter in an adult female. A high buy PCI-32765 level of suspicion for young girls with incontinence should raise thoughts of ectopic ureter and prompt the proper workup to prevent permanent renal damage. “
“The efficiency of chemotherapy on nonseminomatous germ cell tumors (NSGCTs) is no longer to be demonstrated.

The existence of a residual mass at the end of the treatment requires the excision of the former. That is, in fact, the only way to affirm the histologic nature conditioning the subsequent conduct of the treatment.1 The pathologic analysis of these residual masses might reveal either click here the persistence of malignant cells or the presence of a fibrosis, a necrosis, or finally, the existence of a mature teratoma.2 The latter situation has been encountered in our patient. A 19-year-old patient consulted for a swelling of the left testicular. The clinical examination found a large, firm abdominal mass, attached to the deep plane, localized at the left flank. The examination of the external genital organs found an enormous mass at the left testicular

of 15-cm long axis without associated inflammatory signs. An abdominal and pelvic computed tomography (CT) revealed a left retroperitoneal mass measuring 8 × 6 cm displacing the aorta to the right and compressing the left ureter (Fig. 1A) with bilateral hilar lymph nodes (maximum diameter 28 mm). It also showed a left testicular mass measuring 10 × 10 cm. Serum tumor markers were twice as high as the normal. Our patient

had an orchiectomy followed by 3 cycles of chemotherapy (bleomycin, cisplatin, and etoposide) for a stage IIC mixed NSGCT containing a teratomatous component and an embryonal carcinoma. Serum tumor markers were normalized after the first cycle of chemotherapy. At initial staging, hilar lymph nodes have regressed on CT data, instead the retroperitoneal mass has increased (maximum diameter 12 × 12 cm; Fig. 1B). Our patient had a second – line chemotherapy (ifosfamide plus etoposide and cisplatin). Two months later, a comparative abdominal Mephenoxalone scanner has shown that the retroperitoneal mass continued to increase (maximum diameter was 12 × 15 cm) and was responsible of a hydronephrosis. Clinically, the patient complained of an abdominal discomfort. Given the negative tumor marker and the imaging features, growing teratoma syndrome (GTS) was hypothesized. The patient underwent surgery that consisted of a complete resection of the mass. Pathologic examination of the resected lesion confirmed the diagnosis of mature teratoma in his multicystic form (Fig. 2) without viable tumor. Eighteen months later, our patient is in good health without any local or distant recurrence.