Search

Plasma endothelin-1, the nitric oxide (NO) mediator intraplatelet cyclic guanosine monophosphate (cGMP), the prostacyclin mediator cyclic adenosine monophosphate (cAMP) and the macrophage derived inflammatory mediator plasma neopterin were measured in men with Type 2 diabetes mellitus (n = 91), impaired glucose tolerance (IGT; n = 51), previously abnormal glucose tolerance (PAGT; n = 20), and 34 healthy control men. Plasma endothelin-1 was higher in men with Type 2 diabetes mellitus than in controls [4.1 (1.0-14.3) vs. 2.1 (0.2-8.7) ng/l; P < 0.001). Intraplatelet cGMP was higher in men with PAGT [0.84 (0.57-2.76) pmol/109 platelets; P < 0.05], IGT [0.85 (0.48-3.53); P < 0.001] and Type 2 diabetes mellitus [0.90 (0.47-3.86); P < 0.001] than in controls [0.70 (0.42-1.70]. No differences existed between groups concerning intraplatelet cAMP or plasma neopterin. Plasma endothelin-1 correlated with fasting plasma glucose (r = 0.33; P < 0.001) and HbA1(c) (r = 0.29; P < 0.001). In conclusion, elevated plasma endothelin-1 in Type 2 diabetes mellitus and its relationship to glucose and HbA1(c) suggest a putative role for endothelin-1 in diabetic endothelial cell damage. Increased cGMP indicating enhanced production/activity of NO suggests that factors other than reduced NO activity contribute to enhanced platelet aggregation in diabetes. (C) 2000 Elsevier Science Ireland Ltd. (Less)

Objectives. To evaluate beneficial effects of postmenopausal hormone replacement therapy (HRT) on endothelial function, measured as intraplatelet cyclic guanosine monophosphate (cGMP, mediator of nitric oxide), cyclic adenosine monophosphate (cAMP, mediator of prostacyclin) and plasma endothelin-1 (ET-1), and on monocyte activation, measured as plasma neopterin. Design. Part 1: double-blind randomized trial for 3 months; part 2: open study for 9 months. Setting. The study was performed at the Department of Endocrinology, University Hospital, Malmo, Sweden. Subjects. Fifty-one postmenopausal women participated in part 1 and 46 in part 2. Inclusion criteria included a history of amenorrhoea for at least 6 months before the study and body mass index ≥ 24 kg m-2 Intervention. Randomization for either placebo (n = 24) or HRT (n = 27). HRT was given as 2 mg oestradiol valerate for the first 3 months with the addition of 10 mg medroxyprogesterone for 10 days every third month thereafter. Measurements. Performed at baseline and after 3 and 12 months of the study. Results. In the HRT group, intraplatelet cGMP increased from 0.56 (0.35-0.94) to 0.61 (0.423.40) and 0.65 (0.43-1.08) pmol (109 platelets)-1 after 3 and 12 months, respectively (P = 0.01), whereas plasma ET-1 decreased from 3.2 (1.1.-6.8) to 2.0 (0.8-5.1) and 1.8 (0.4-15.4) pg mL-1 (P < 0.001). Intraplatelet cAMP and plasma neopterin were unchanged. When smokers (n = 15) and non-smokers (n = 12) in the HRT group were analysed separately, significant effects were seen only amongst smokers. The control group showed unchanged levels of cGMP, cAMP, ET-1 and neopterin. Conclusions. These data suggest beneficial effects of HRT on endothelial function which may account for anti-atherogenic effects of HRT in postmenopausal women, especially in smokers. No effects of HRT were seen upon monocyte activation.

Leukocyte-derived inflammatory mediators and endothelial production of vasoconstrictive factors, such as endothelin-1, and vasodilatory and platelet anti-aggregatory factors, such as nitric oxide (NO) and prostacyclin (PGI2), may have a role in the pathogenesis of atherosclerosis. In this study we evaluated whether insulin affects the monocyte-derived inflammatory mediator neopterin and endothelin- in plasma (p), and NO and PGI2 mediators cyclic 3'-5' guanosine monophosphate (cGMP) and cyclic 3'-5' adenosine monophosphate (cAMP) in platelets. P-neopterin was measured by enzyme linked immunosorbent assay (ELISA), and p-endothelin-1, intraplatelet cAMP and cGMP were measured by radioimmunoassay (RIA) before and after euglycaemic hyperinsulinaemic clamping in 51 healthy postmenopausal women aged 53-54 years. "Placebo clamping" with NaCl infusion was performed in a subgroup of 5/51 women. During euglycaemic hyperinsulinaemic clamping, p-endothelin-1 decreased (from 3.3+/-0.2 pg/ml to 2.4+/-0.2 pg/ml; p

Release of inflammatory mediators from leukocytes and endothelial release of vasoactive factors are both important in the pathogenesis of atherosclerosis. To evaluate the concen trations of a specific marker for macrophage activation, neopterin, and the potent endothelial derived vasoconstrictive peptide endothelin-1 (ET-1), during the acute and chronic stages of cerebral ischemia, plasma concentrations of neopterin and ET-1 were measured in 59 patients with acute cerebral infarction or transient ischemic attack (median age 73 years, range 43-93, 27 men) and after a 1-year follow-up in 57/59 (97%) of patients. Plasma neopterin was higher at follow-up (6.3 nmol/L [3.7-21.6] vs 5.6 nmol/L [3.5-17.2]; p < 0.05) than at the acute stage, whereas the plasma ET-1 concen tration was unchanged. Plasma concentrations of both neopterin and ET-1 correlated directly with age both in the acute stage ( r = 0.42 and r = 0.35, respectively; p < 0.01) and after follow-up ( r = 0.34; p < 0.05 and r = 0.27; p = 0.05, respectively). In conclusion, plasma neopterin increased after acute cerebral ischemia, indicating chronic inflammatory activity and continuous macrophage activation in ischemic cerebrovascular diseases.

To clarify relationships between the (endothelial vasodilatory and vasoconstrictive function) and leukocyte inflammatory mediators in subjects with asymptomatic athero sclerosis, we measured (intraplatelet cyclic 3-5 ¢ guanosine monophosphate [cGMP] and cyclic 3-5 ¢ adenosine monophosphate [cAMP]), plasma endothelin (ET-1), and plasma neopterin in 197 subjects with asymptomatic atherosclerosis (median age 63 years, range 49-69 years). We measured neutrophil protease 4 (NP 4), tumor necrosis factor (TNFμ), soluble tumor necrosis factor receptor-1 (sTNFR-1), and neutrophil gelatinase associ ated lipocalin (NGAL) in 152 of the 197 subjects. Intraplatelet cGMP correlated inversely with plasma ET-1 (r=-0.22; p=0.01), which confirms earlier in vitro data of the inhibitory effect of ET-1 on NO production and/or the cGMP mediated inhibitory effect of NO on ET-1 production. Plasma neopterin as well as NP4 correlated directly with intraplatelet cGMP (r=0.24; p

Inflammatory mediators secreted by activated leukocytes play a role in the pathogenesis of atherosclerosis. They may also affect the production of vasodilatory and platelet antiaggregatory factors such as nitric oxide (NO) and prostacyclin (PGI2) from the vascular endothelium. Production of NO and PGI2, the effecs of which are mediated by cyclic 3′,5′-guanosine monophosphate (cGMP) and cyclic 3′,5′-adenosine monophosphate (cAMP), respectively, is disturbed in atherosclerosis, whereas increased NO levels have been found in acute cerebral ischemia. To investigate leukocyte activation and its possible influence upon endothelial function in cerebral ischemia we measured plasma neutrophil gelatinase-associated lipocalin (NGAL) and soluble tumor necrosis factor receptor protein-1 (sTNFR-1) by ELISA, and intraplatelet cAMP and cGMP by radioimmunoassay in 59 patients with acute ischemic stroke or transient ischemic attack (mean age 71 years, 27 males) and after a 1-year follow-up in 57/59 (97%) patients. NGAL (152 ± 58 vs. 126 ± 48 µg/l), sTNFR-1 (3.50 ± 2.2 vs. 2.59 ± 1.31 µg/l), and cAMP (5.12 ± 1.71 vs. 4.06 ± 0.92 pmol/109 platelets) were higher (p < 0.001) after follow-up than in acute cerebral ischemia. At follow-up sTNFR-1 and cGMP partially correlated (r = 0.31; p < 0.05), controlling for age and platelet count. In conclusion, plasma NGAL and sTNFR-1 and intraplatelet AMP increase after acute cerebral ischemia, indicating chronic inflammatory activity and endothelial activation. Plasma sTNFR-1 levels are related to intraplatelet cGMP levels.

Objectives. To assess the effect on the fibrinogen concentration of sleep disturbance and mental stress, taking into account the effect of 21 other variables related to the risk of cardiovascular disease. Design. A cross-sectional study on men threatened by redundancy, and controls. Setting. A health screening programme in Malmo, Sweden. Subjects. Four hundred and eighty five workers in a shipbuilding yard, scheduled for closure, and 190 age-matched men. The subjects were randomly selected from a larger group of shipyard workers and controls invited to a health screening programme. Mean age was 51.6 years (range 38–62 years). Main outcome measures. Plasma fibrinogen concentration, serum Cortisol concentration, body composition, blood pressure, heart rate, blood lipids, platelet number and size, white blood cell count, haemoglobin concentration, vital capacity, liver enzymes, blood glucose concentration fasting and after an oral glucose tolerance test. Questionnaire designed to evaluate muscle tension, sleep disturbance, anxiety, depression, job stress, alcohol and smoking habits and perceived health. Results. In stepwise regression analysis fibrinogen concentration was found to be correlated to white blood cell count, muscle tension, heart rate, body mass index, age and serum cholesterol concentration in non-smokers, which together explained 14.9% of the variation in fibrinogen concentration. In smokers, platelet count, heart rate, serum triglyceride concentration, age and fasting glucose explained 22.5% of the variation in fibrinogen concentration. The fibrinogen concentration was inversely correlated to the psychological variables, but unrelated to the serum Cortisol concentration or to factors connected with the job situation, and it was decreased in moderate alcohol consumers. Conclusions. Our interpretation of the findings is that an increase in the plasma fibrinogen concentration reflects the presence of a low-grade inflammatory process, and poor physical fitness.

This retrospective study evaluated long-term effects of percutaneous transluminal renal angioplasty (PTRA) in atherosclerotic renal artery stenosis (ARAS), and predictors of benefit on blood pressure (BP).During 1997-2003, 234 patients (age 69+/-11 years, 138 [59%] males) underwent PTRA for ARAS at Malmö Vascular Centre. Cure was defined as diastolic (D)BP90 mmHg and systolic (S)BP140 mmHg off antihypertensive medication. Improvement was defined as DBP90 mmHg and/or SBP140 mmHg on the same or reduced number of medications, or reduction in DBP ofor=15 mmHg with the same or reduced number of medications. Benefit was defined as cure or improvement.After PTRA, SBP and DBP decreased (P0.001), and remained lower (P0.001) until last follow-up after 4.1+/-3.3 years. Antihypertensive medication decreased (P0.001), and remained lower at one month (P0.001), one year (P0.01), and last follow-up (P0.05). Renal function was unchanged until last follow-up, when it deteriorated (P0.001). Patients showing benefit of PTRA on BP at last follow-up (N.=150 [64%]) used more antihypertensive drugs before PTRA (P=0.012), especially angiotensin converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) (P=0.010), and diuretics (P=0.015). In logistic regression, use of ACEi or ARBs failed to reach significancy (P=0.054). Patients dying during follow up (N.=100 [43%]) showed higher age (P0.0001) and s-creatinine (P0.0001), lower glomerular filtration rate (P0.0001), and higher frequency of diabetes mellitus (P0.005). In logistic regression only age (P=0.009) and diabetes mellitus (P=0.014) predicted mortality.We confirmed beneficial effects on BP with PTRA in ARAS. ACEi, ARB and diuretic treatment before PTRA predict favourable long-term BP-response in univariate analysis.

The relationships between abdominal and pelvic fat compartments and glucose and lipid metabolism were investigated in early postmenopausal women. Fifty-five healthy, postmenopausal women aged 52-53 yr participated in the study. Fat distribution (intra-abdominal and sc abdominal fat, and intrapelvic and sc pelvic fat) was estimated by computed tomography. Insulin sensitivity was assessed by euglycemic hyperinsulinemic clamp. In a multiple regression analysis, the size of the intra-abdominal fat compartment was the only significant predictor of insulin sensitivity (r(2) = 24%; P = 0.0002). Plasma triglycerides were closely related to the size of the intra-abdominal fat compartment (r(2) = 26%; P0.0001), whereas plasma free fatty acid concentrations only correlated to the size of the sc abdominal fat compartment (r(2) = 18.5%, P = 0.001). In early postmenopausal women the amount of the intra-abdominal fat strongly influences insulin sensitivity and plasma triglyceride levels, whereas plasma free fatty acids are closely related to the amount of the sc abdominal fat. Accordingly, from a metabolic standpoint it seems most essential to reduce intra-abdominal fat in postmenopausal women.

Hyperhomocysteinemia is an independent risk factor for vascular disease. In order to evaluate relations between hyperhomocysteinemia and endothelial and leukocyte function, the investigators related homocysteine to indices of endothelial function (plasma endothelin-1 [p-ET-1] and intraplatelet levels of the nitric oxide [NO] and prostacyclin mediators 3'-5' guanosine monophosphate [cGMP] and cyclic 3'-5' adenosine monophosphate [cAMP]) and the monocyte-derived inflammatory mediator neopterin in 168 men (mean age 69, range 49-72 years) with disturbed glucose metabolism and a reference group of 52 male subjects (mean age 70, range 61-79 years). Among the 168 patients with disturbed glucose metabolism plasma (p)-homocysteine correlated signifi cantly with age (r=0.20; p < 0.01), glycosylated hemoglobin (HbA1c) (r=0.17; p < 0.05), triglycerides (r=0.20; p

Lipid-lowering statin treatment reduces cardiovascular morbidity and mortality and improves endothelial function in patients with hypercholesterolemia. The aim of the present study was to evaluate plasma levels of fibrinogen, factor VII, and the macrophage-derived inflammatory mediator neopterin during lipid lowering. In addition, the endothelial production of platelet antiaggregatory and vasodilatory factors such as nitric oxide and prostacyclin, and vasoconstrictive factors such as endothelin-1, was assessed. Plasma fibrinogen, factor VII, endothelin-1, and the neopterin and intraplatelet nitric oxide and prostacyclin mediators cyclic 3'-5'guanosine monophosphate (cGMP) and cyclic 3'-5'adenosine monophosphate (cAMP) were measured before and 6 months after the institution of treatment with fluvastatin in 17 patients (eight men and nine women, median age 60 years) with vascular disease and previously untreated hypercholesterolemia. After 6 months, a decrease of 1.62 mmol/l [1.26-2.18 (19%); P < 0.01] was noted in levels of total cholesterol, and a decrease of 1.70 mmol/l [1.52-2.30 (28%); P < 0.01] in levels of low-density lipoprotein cholesterol. Plasma levels of fibrinogen had increased [from 4.81 g/l (4.26- 5.27) to 5.17 g/l (4.81-5.67); P < 0.05], whereas no significant changes had occurred in intraplatelet levels of cGMP [decrease by 0.05 pmol/109 platelets (-0.17 to 0.24); NS], cAMP [decrease by 0.13 pmol/109 platelets (- 0.37 to 0.86); NS], plasma endothelin-1 [decrease by 0.05 pg/ml (-0.60 to 0.70); NS], plasma factor VII [from 1.14 IE/ml (0.58-1.38) to 1.22 IE/ml (0.96-1.46); NS], or plasma neopterin [from 8.6 nmol/l (7.1-11.5) to 8.7 nmol/l (7.9-11.3); NS]. In conclusion, during cholesterol-lowering treatment with fluvastatin, plasma levels of fibrinogen increased whereas intraplatelet cyclic nucleotide levels and plasma endothelin-1, factor VII and neopterin levels were unchanged. (Less)

To assess whether uncomplicated deep vein thrombosis could be treated in an out-patient setting without increasing the frequency of complications, and to determine the proportion of patients with deep vein thrombosis, traditionally treated as in-patients at the Departments of Medicine, who are eligible for such treatment.In a multicentre study, carried out at six hospitals of varying sizes and serving a population of about 600,000, consecutive patients over 18 years of age, with verified deep vein thrombosis, primarily presented as acute cases at the respective Departments of Medicine, were considered for treatment on an out-patient basis during a 1-year period.Those eligible for out-patient treatment were put on low molecular weight heparin and oral anticoagulants, and scheduled for daily attendance at the out-patient clinic of the respective Dept. of Medicine. Details of any complication were recorded according to a standard check-list. The patients underwent a full checkup at three-month follow-up.Any bleeding event or pulmonary embolism. Progress of thrombosis.Of 523 patients considered for out-patient treatment, 126 (24%) were excluded according to the defined exclusion criteria, 197 (38%) were treated entirely on an out-patient basis, and another 43 (8%) were initially treated in hospital (median two days) before being transferred to the out-patient setting. Three patients had to be hospitalized for suspected complications, but none of these turned out to be serious. No serious bleeding event or thromboembolic complication was registered.Uncomplicated acute deep vein thrombosis could be safely treated on an out-patients basis. At least 50% of the patients with this diagnosis, former treated as in-patients at the Depts. of Medicine, are eligible for such treatment.

Nitric oxide (NO) exerts its vasodilator and antiaggregatory effects through activation of soluble guanylate cyclase and the consequent increase in the concentration of cGMP in target cells. We conducted this study in order to evaluate relationships between intraplatelet cGMP levels and risk factors for atherosclerosis in middle aged subjects. Intraplatelet cGMP was determined by radioimmunoassay and related to age, BMI, blood pressure, antihypertensive treatment, total, LDL and HDL cholesterol, triglycerides, blood glucose, HbA1c, smoking habit and intimal thickness of the common carotid artery in 265 subjects participating in a health survey (age 59 +/- 6 years, range 48-68 years, 121 females, 144 males). Intraplatelet cGMP concentration was inversely correlated with total serum cholesterol (r = -0.18; p0.01) and HDL cholesterol (r = -0.14, p0.05) as well as with platelet count (r = -0.29; p0.001). When platelet count was adjusted for, only the correlation between total serum cholesterol and cGMP remained significant. No significant correlations could be demonstrated between intraplatelet cGMP levels and measurable parameters of atherosclerosis. Lower levels of the vasodilating and antiaggregating mediator cGMP in platelets are related to higher levels of serum total cholesterol. These results favour the hypothesis of a relationship between lipid levels and NO associated vasodilator and antiaggregating function in atherosclerosis.

To evaluate the effect of acute blood pressure (BP) changes on the myocardial perfusion in hypertensives, 10 patients with and 10 patients without left ventricular hypertrophy (LVH) were examined with 99TCm-Sestamibi scintigraphy at rest and after acute pharmacological BP reduction using nifedipine and captopril. Signs of LV ischaemia was quantified as the size of the hypoperfused area defined as isotope uptake below 70% of maximum LV uptake, and LVH was defined as ventricular mass (LVM)125 g/m2 BSA by use of echocardiography. Not significant relations between BP and size of the hypoperfused area was found at rest. During BP reduction patients with LVH had negative correlations (r = -0.58) between the size of the hypoperfused area and the systolic blood pressure (SBP) and the diastolic blood pressure (DBP) (r = -0.49) while patients without LVH showed positive correlations (SBP r = 0.60, DBP r = 0.48). The differences in correlation coefficients were significant (P0.01) for both. Thus, in hypertensives with LVH, ischaemia may develop at low BP providing a possible mechanism for the observed increased risk of cardiovascular events in some hypertensive patients with low achieved BP during follow-up. Until treatment goals are defined on scientific grounds, BP should not be decreased below 90 mm Hg in subjects with LVH.

To clarify a possible relationship between the level of BP and signs of myocardial ischaemia, two groups of treated hypertensive patients with (n = 12) and without (n = 18) increased left ventricular mass defined by echocardiography were investigated with 24h ambulatory BP and ECG monitoring. It was found that hypertensive patients with increased left ventricular mass had the following. (1) Higher systolic BP, heart rate (HR) and SBP x HR product during the night indicating a higher ventricular work load than hypertensives without increased LVM in this period. (2) This increased left ventricular work load during the night was concomitant with a lower DBP consistent with a lower perfusion pressure of the left ventricular myocardium. (3) Significantly depressed ST segment levels throughout the 24 hours with a significant positive correlation between BP and the level of the ST segment indicating increased ischaemic metabolic changes within the myocardium the lower the BP. (4) A higher ratio between the systolic SBP x HR product and DBP during sleep than in hypertensives without increased left ventricular mass, further corroborating that low DBP during the night might cause ischaemia through an imbalance between left ventricular work load and coronary perfusion pressure. We conclude that low BPs in hypertensive patients with increased left ventricular mass seem to induce ischaemia of the left ventricle. These findings provide a possible mechanism for the increased risk of ischaemic heart disease in hypertensive patients with low achieved BP.

Long-term effects on insulin sensitivity and leucocyte sodium transport were studied in 42 glucose-intolerant hypertensives on beta-blockers, randomly assigned to continuous beta-blockade (beta group) or a switch to captopril treatment (mean daily dose 69.1 mg) (ACE group). In the ACE group, despite a tendency towards improvement, glucose uptake during the euglycaemic insulin clamp procedure did not change significantly from the baseline value of 4.0(0.5-12.9) mg/kg/min, values at 6 and 12 months being 4.8(1.3-14.7) and 4.4(1.5-9.8) mg/kg/min, respectively: the corresponding values for the beta group were 4.2(1.1-15.3), 3.6(1.2-8.9) and 4.0(1.5-12.0) mg/kg/min. The 22Na efflux rate constant, both baseline and follow-up values, was similar in both groups, and unrelated to insulin sensitivity. Owing to the surprisingly great variation in peripheral glucose uptake, the subgroup with values below the median for the population as a whole (4.9 mg/kg/min) was evaluated separately: those switched to captopril treatment manifested a 60% improvement in glucose disposal at 6 months and persisting at 12 months, the respective values being 2.1(0.5-4.8) (baseline), 3.5(1.3-6.3) and 3.4(1.5-6.1) mg/kg/min, (P = 0.012). The body mass index (BMI) was not significantly affected. Values for BMI, peripheral insulin and triglycerides were higher in the subgroup with glucose disposal below the median than in the subgroup with values above the median. Correlation between BMI and glucose uptake was highly significant (r = -0.75, P = 0.0001). The present findings suggest that captopril may be a better alternative than beta-blockers for treating the highly insulin-resistant, glucose-intolerant patients, predominantly to be found among the overweight.

In a health screening programme for men aged 28-48 years, a check of serum creatinine values was included as a renal function test. Of 21,362 men screened, 114 (0.53 per cent) had two values greater than or equal to 120 mumol/l, and were further investigated vis-à-vis possible kidney disease. Of the 114 cases, renal disease including essential hypertension was present in 63, though only 29 cases had not been diagnosed previously, and in only seven cases was there no albuminuria, hypertension or history of renal disease. These findings raise doubts as to the value of analysing s-creatinine when screening for renal disease.

Smoking habits, dental status and aryl-hydrocarbonhydroxylase (AHH) inducibility were studied in a series of 52 oral leucoplakias and 20 oral cancers. There was an obvious association between leucoplakia, cancer and smoking. A significant overrepresentation of high AHH and a corresponding underrepresentation of low AHH inducibility were found among the smokers with leucoplakia and in the oral carcinoma group. In both groups, however, the dental status was largely normal.

Low sodium and potassium adenosine triphosphatase (ATPase) activity has been proposed as a mechanism behind diabetic neuropathy. In this study the platelet ATPase activity and platelet noradrenaline efflux rate were determined in 47 insulin-dependent diabetes mellitus (IDDM) patients and 20 controls. Ulnar motor conduction velocities, tested in a subgroup, were lower in patients than in controls (52.7 +/- 1.3 m s-1 vs. 61.3 +/- 1.4 m s-1; P less than 0.001). Platelet ATPase activity tended to be increased in the patients compared with the controls (29.9 +/- 1.0 x 10(-3) min-1 vs. 26.9 +/- 1.1 x 10(-3) min-1; NS). In ulnar nerve function tested subjects, ATPase activity was higher in patients than in controls (31.2 +/- 1.7 x 10(-3) min-3 vs. 25.9 +/- 1.3 x 10(-3) min-1; P less than 0.01). The platelet noradrenaline efflux rate tended to be higher in patients with lower brake indices, a sign of autonomic neuropathy, than in controls (29.0 +/- 3.0 x 10(-3) min-1 vs. 21.2 +/- 0.9 x 10(-3) min-1; P less than 0.05). The platelet ATPase activity was not decreased in IDDM patients, however, a connection between diabetic autonomic neuropathy and platelet transmittor leakage was indicated.