These interviews were conducted

These interviews were conducted Vismodegib by e-mail, telephone conference calls, and personal contacts. Vaccine development is a long, complex, expensive and risky process. It follows a standard set of stages to demonstrate that a vaccine is safe, immunogenic and protective before it is licensed and marketed (Fig. 1). This requires significant and diverse resources and expertise, and results from the contribution of

several public and private actors. Basic research regarding pathogens and immune responses is supported by a cross-section of academic and government organizations and industry, whereas development-related and clinical research programs are funded primarily by industry. Large vaccine companies are involved in significant amounts of targeted research, but their preponderant role is in clinical and process development. Small biotechnology companies are playing an increasingly important role in the vaccine industry. They are often

started by university scientists, supported by venture capitalists, and apply novel click here technology to translate basic research into vaccine candidates in the early stages of clinical development (phase I and II/proof of concept in humans). If research results are favorable, major vaccine producers will enter into pro-active partnerships to ensure capacity in process development, phase III clinical trials, registration and manufacturing [2], [3], [4], [5], [6] and [7]. While large vaccine companies increasingly externalize research in order to access new areas of science and share the risk of development with partners [8], only they have the necessary expertise and know-how in project management and the various disciplines necessary to achieve vaccine development, Rutecarpine navigate regulatory pathways and manufacture vaccines to international standards. It

usually takes 12–15 years to develop a new vaccine (ranging from 7 years to >20 years). Estimates of the total cost for vaccine development varies, depending on what is measured. If one includes R&D costs on products that fail, post-licensure clinical studies, and improvements in manufacturing processes, these costs can climb to over $1 billion. For vaccine companies, each successful product has to recover not only the costs of its design and development, but also the costs of the unsuccessful candidates [2], [9] and [10]. Vaccine development follows a graduated funnel that involves several stages: basic and applied research, preclinical testing, clinical testing, regulatory approval, production and distribution [2], [3], [4], [5], [6] and [7]. At each of the different stages, even the most promising candidates can fail to perform as anticipated and can be either abandoned or modified and re-tested. Only relatively few vaccines make the jump from the laboratory to clinical trials. The cumulative probability from pre-clinical to launch for a vaccine is 0.22 (0.39 from Phase I to launch; 0.64 from Phase II to launch; 0.

These lesions often have an exophytic growth and are indistinguis

These lesions often have an exophytic growth and are indistinguishable from renal cell carcinoma

on computed tomography scan. The management of EAML is surgical resection given its malignant potential, which can only be ascertained by a thorough pathologic examination. There is no clearly identified role for neoadjuvant, adjuvant, or primary chemotherapy or targeted therapies. Nephron-sparing surgery should be attempted as these patients are at increased risk for both benign and malignant Caspase inhibitor pathologies, which may require procedures that exacerbate renal function. Because the natural course of this rare neoplasm is not predictable, these patients should undergo surveillance for recurrence or development of new lesions. Of the 33 patients with follow-up data reported by Nese et al,5 5 patients recurred with a mean time to recurrence of 32 months (range, 8-72 months). There are no guidelines on the imaging modality or frequency for surveillance. EAML is a rare variant of AML that can mimic renal cell carcinoma in its radiographic appearance. Histologically, EAML can be diagnosed by Human Melanoma Black-45 staining and the presence of dysmorphic vasculature, epithelioid smooth muscle, and adipocytic tissue. Treatment is often

surgical excision as current literature suggests the potential for malignancy. “

kidney is an extremely rare abnormality, and to our knowledge there is only 1 case reporting it along with a horseshoe see more kidney.1 The true incidence of this anomaly cannot be calculated because of its infrequent occurrence. We report a case of supernumerary kidney consisting of 4 renal moieties and including a horseshoe kidney. A 40-year-old CYTH4 woman presented with intermittent vague abdominal pain and heaviness. She could not remember the exact time of onset of her symptoms but explained that she had visited physicians a few times for this problem over the last few years. Her genitourinary history was also significant for a spontaneous stone passage that had occurred 3 years ago. Her physical examination did not reveal any significant finding. Hematologic and biochemical investigations were within normal limits. Ultrasonography of the urinary tract revealed 2 kidneys on the left side and horseshoe kidneys located distal to them. The right horseshoe kidney was small in size. She underwent further imaging evaluation with computed tomography and excretory urography, which showed the following findings: on the left, there are 3 kidneys. The inferior pole of the most rostral kidney (110 mm × 44 mm) is fused to the upper pole of another moiety (80 mm × 44 mm; Figure 1 and Figure 2).

The effect of the interaction of these two antimicrobial agents a

The effect of the interaction of these two antimicrobial agents and their fractional inhibitory concentration (FIC) on the chosen strains was studied using checkerboard method.13 The layout of the checkerboard study for one plate is shown in Fig. 1. FIC was calculated by using following formula and FIC index is the sum of FIC of each of the drug present in the plate: FIC=MICofAincombination/MICofAalone+MICofBincombination/MICofBalone FICindex=FICA+FICBwhere A is the concentration of drug A, FICA is the fractional inhibitory concentration of drug A. Similarly, B is the concentration

of drug B, FICB is the fractional inhibitory concentration of drug B. Using above method, the combination is considered synergistic A-1210477 cell line when Cabozantinib mouse the FIC index is ≤0.5, additive when the FIC index is >0.5 to <2, and antagonistic when the FIC index is ≥2. We also estimated FICImin and FICImax. The MIC was determined by agar dilution method following

the method of the CLSI guidelines.14 AST was determined by the cup-plate agar diffusion method as described earlier.15 30 μl of the drug preparation CVA1020 (vancomycin with l-arginine + ceftriaxone (30:30 μg), vancomycin (30 μg) and ceftriaxone (30 μg)) was placed into the wells and allowed the plates to incubate at 37 °C for 18 h. After incubation the zone of inhibition around the wells was measured in mm (millimeter), averaged and the mean values were recorded. TKC study was performed according to CLSI guidelines.14 Twice the MIC of vancomycin with

l-arginine and ceftriaxone (CVA1020), ceftriaxone and vancomycin alone was used for this study. The samples were removed at 0, 2, 4, 6, 8, 10 and 12 h and were diluted and plated on MHA. Suplatast tosilate Synergism was defined as a 3 log decrease in cfu/ml.16 A fixed amount of l-arginine was added into the combination as without l-arginine, ceftriaxone and vancomycin get precipitated. Fig. 2 summarizes the results of the FIC index analysis of the various ratios of vancomycin with l-arginine and ceftriaxone tested against clinical isolates of S. aureus, S. epidermidis, S. pneumoniae, E. faecalis, MRSA and hGISA. The results revealed that equal ratio of vancomycin with l-arginine and ceftriaxone was the most synergistic. Further increasing the concentration of ceftriaxone synergistic activity was lost. FIC index study conducted in all selected clinical isolates as well as positive controls and similar findings were obtained. FIC index were 0.375 ± 0.032, 0.285 ± 0.023, 0.238 ± 0.022 0.267 ± 0.021 for positive controls, S. aureus, S. epidermidis, S. pneumoniae and E. faecalis, respectively. From the FIC index data of clinical isolates, FICImin and FICImax were determined and presented in Fig. 3. The FICImin and FICImax were significantly lower equal to less than 0.

Low-risk women were identified as the patients having no underlyi

Low-risk women were identified as the patients having no underlying medical problems (diabetes, hypertension, cardiac disease, coagulopathy, etc.), preeclampsia, BI 2536 manufacturer placenta previa, abruptio placenta, chorioamnionitis, previous myomectomy/septum resection, myoma uteri.6 Hemorrhage was defined as a decrease in hemoglobin concentration of 30% or greater which estimated blood loss greater than 1500 ml.7 The patients with antenatal or any history of severe bleeding and preoperative Hb levels below 10 g/dl

and women who had elective or eventful cesarean sections were excluded. Detailed chart review was conducted to collect demographic data, assess intraoperative factors and analyze postoperative courses. A total of 87 women during April to KU-57788 concentration August 2011 underwent unplanned and uneventful

cesarean section in our clinic. The mean age of subjects was 28.2 ± 5.2 year in range of 17–42 years. General anesthesia was used for all cases. Routine Hb and Hct measurement and blood-type sampling and screening test were performed just prior to surgery and Hb measurement was repeated 12 h after the surgery. None of the patients showed any subjective symptoms of anemia, pulse rate above 95 beats/min and blood pressure under 95/65 mmHg. The mean preoperative hemoglobin was 12.4 ± 0.95 g/dl, whereas it was 11.8 ± 1.08 g/dl, postoperatively and the mean preoperative hematocrit was 37.5 ± 2.5%, whereas it was 35.8 ± 2.8% postoperatively (P < 0.001). Demographic and laboratory data are shown in Tables 1 and 2. None of cases had Hb dropped more than 30%. About 75% of the patients who experienced a decline, the hemoglobin levels dropped less than 10%

of the preoperative value and in 15%, Hb level decrease was between 10 and 20% and just in two cases were more than 20% that one Non-specific serine/threonine protein kinase of them had 42 years and five parity and the other was 35 years and had two parity and history of two abortion. Also 7.5% had no change in their Hb concentration. Maternal age, number of gestation, previous delivery, abortion and type of blood groups showed no statistically significant difference (P > 0.05). There was no blood transfusion among the 87 subjects. Reduction of unnecessary and unneeded laboratory tests could result decreasing the costs of health-care without affecting the quality of it. Combs et al reported that women undergoing cesarean delivery experienced only a mean drop of 4.0–4.2% in Hct whereas 17% had no decline.4 Another study by Kaplan et al on usefulness of preoperative laboratory screening found that blood types and screen testing are unnecessary and suggested to be eliminated since they did not contribute to treatment8 and in the similar study published by Larsen et al, the result revealed that frequency of blood transfusion related to unplanned and uneventful cesarean section was 0%.

The sample is a representation of the NP microbiome, which contai

The sample is a representation of the NP microbiome, which contains numerous bacterial species [67] and may include close relatives of pneumococci such as

S. pseudopneumoniae, Streptococcus mitis and other streptococcal species that also inhabit this niche [68]. The ideal method for non-culture identification in NP swabs should unequivocally detect the pneumococcus with high sensitivity and specificity; it should also be rapid, easy to perform, inexpensive, and deployable on a large scale. In the last decade, several non-culture methods aiming to detect pneumococci in biological samples have been developed including PCR-based strategies targeting specific DNA markers such as rpoA [69], sodA [70], tuf [71], recA [72], selleck piaA [73], Spn9802 [74], ply [75], a 181-bp pneumococcal-specific fragment [76], 16S-rDNA [77], LY2109761 ic50 psaA [78], and lytA [79], [80] and [81]. For many of these methods specificity problems have been detected [64], [65], [82] and [83]. For others, there has been insufficient validation against diverse collections of close relatives of pneumococci. In addition, there is an increasing body of more sophisticated

methods that, although promising, may not be easily applied in routine analysis of NP samples [84], [85], [86] and [87]. While there is currently no gold standard method for non-culture identification of pneumococci from NP swabs [63], [88] and [89], the lytA real-time PCR assay described by Carvalho et al. [81] is widely used and appears to be species-specific. However, given the capacity of pneumococci to exchange genes with other oral streptococci [88] and [90] a multilocus approach such as used in multilocus sequence typing (MLST), microarray or whole genome-sequencing may prove valuable [64], [91] and [92].

Culture should remain the gold standard for detection of pneumococci in NP swab samples. Investigators may wish to complement culture detection with a non-culture technique; the method we currently recommend is lytA real-time PCR [81]. A systematic laboratory validation of non-culture methods against large collections of nasopharyngeal and non-classical isolates is needed to guide future recommendations. Studies that are designed to determine the clinical over relevance of pneumococcal culture-negative but DNA-positive samples are needed. The current standard method for serotyping of pneumococcal isolates is the capsular reaction/swelling test (Quellung reaction or Neufeld test) [1]. The traditional method described by Lund [93], Austrian [94] and the Statens Serum Institut [95] using ×100 magnification with oil immersion, is still widely used in Europe and North America. In Australia and Papua New Guinea, the ‘dry’ method using ×40 magnification without oil [96] has been in use since at least the 1970s (M. Gratten, personal communication).

However, this does not appear to provide a solid explanation for

However, this does not appear to provide a solid explanation for the lack of physiotherapy-led presentations

at national conferences identified in recent years. It find more also fails to explain the imbalance between representation of physiotherapists and other health professionals in this arena. Physiotherapy organisations, academic institutions, and therapists could develop strategies to increase the engagement of physiotherapists in cardiology research. Some simple strategies could include the implementation of a mentoring system designed to link physiotherapists with established research backgrounds and clinicians working in the management or prevention of cardiac disease. Greater mentorship of postgraduate physiotherapy research on cardiac topics is also needed in physiotherapy schools. The establishment of more frequent communication between clinical and research physiotherapists, via bodies such as Cardiorespiratory Physiotherapy Australia, CSANZ, and ACRA may also inspire clinicians to consider research in this area. Funding and academic opportunities in the area of cardiovascular disease management are JNK inhibitor extensive. Exploration of these opportunities by physiotherapists would be fruitful for individual physiotherapists, the profession and, ultimately and most importantly, for patients. Research opportunities are widely available and physiotherapists

are ideally positioned to take a leadership role in the future evolution of cardiac management. In summary,

cardiac disease is a leading international health problem. Despite physiotherapists being ideally trained with relevant clinical experience there appears to be a general lack of engagement with cardiology research. The problem manifests across a range of domains including professional membership, active participation in national conferences, and publication of research in the area of cardiovascular disease. The expertise and capacity of physiotherapists coupled with extensive career opportunities in the area of cardiology research presents a range of opportunities for physiotherapists to explore. “
“Mechanical ventilation temporarily replaces or supports spontaneous breathing in critically ill patients in intensive care units. Weaning is the withdrawal of mechanical ventilation Astemizole to re-establish spontaneous breathing. Patients are considered to have successfully weaned from ventilatory support when they can breathe on their own for at least 48 hours (Sprague and Hopkins, 2003). Weaning typically comprises 40–50% of the total duration of mechanical ventilation, with almost 70% of patients in intensive care weaning without difficulty on the first attempt (Boles et al 2007). Other patients have a more difficult or prolonged period of weaning, which is associated with a poorer prognosis (Vallverdu et al 1998, Esteban et al 1999).

Few analytical methods have been reported for the verification of

Few analytical methods have been reported for the verification of steroidal hormone drugs, especially for those with similar selleck screening library chemical properties. In this paper, our aim was to develop a set of simple High-performance liquid chromatographic (HPLC) with evaporative light scattering detection12, 13, 14 and 15 (ELSD) and with dual

ESI ionization mass spectrometry (LCMS) methods are presented to distinguish and qualitatively analyze used to identify of Dexamethasone, Testosterone and Estrone (E1) in the combination form. Pure standards of Dexamethasone, Testosterone and Estrone (E1) were obtained from the Sigma–Aldrich, India. Organic solvents for chromatography were purchased in LCMS grade, ACS grade Acetonitrile was purchased from Honeywell-Burdick & Jackson (USA), water was obtained from ultra-purified from Elix Advantage 5 system equipped with Milli-Q Biocel (Millipore), all the chemicals used were of analytical reagent grade, and the solvents were of ACS. The purity of each reference standard was determined by HPLC PDA, ELSD detectors and dual ESI (LCMS). All solvents and samples were filtered through MILLEX FG (Millipore),

13 mm, 0.2 μM, fluoropore, non-sterile membrane sample filter paper before injecting into system. The analyses were performed using an Agilent 1200 Series HPLC system, equipped with a binary pump, an auto-sampler, a column oven, PDA detector and a mass hunter software version B.02.01 (B2116.20) over (Agilent Technologies, USA). Agilent 1260 Infinity Evaporative Light Scattering Detector (ELSD) instrument, operated by the Agilent 35900E multichannel interface which converts analog signal to digital (A/D) (Agilent Technologies, USA), was connected to the liquid chromatography for detection of steroids. The separation was carried out on a reverse phase Shodex C18, 3 μm, 4.6 × 100 mm at ambient temperature. The isocratic elution mode with a mobile phases

Acetonitrile and 0.1% formic acid in water and eluted by the following program at the flow 1 mL/min, runtime 6 min. The drift tube temperature for ELSD was set at 50 °C and the nitrogen flow rate was 53 psi. Agilent 6520 Quadrupole time-of-flight (Q-TOF) mass spectrometer. Coupled to an Agilent 1200 series HPLC system (Agilent Technologies, USA) is equipped with binary pump, auto sampler, thermostatted column compartment, variable wavelength detector, auto sampler thermostatted (G 1330B). The Agilent Q-TOF (6520) mass spectrometer is equipped with dual electrospray ionization (ESI) ion source, and the HPLC conditions were identical to those used for HPLC–ELSD analyses mentioned above. Mass spectra were acquired in positive mode with scan range from m/z 100 to 500 Da. The conditions of dual ESI source were as followed: drying gas (N2) flow rate, 30.

Notably, a Beijing-based JE-MB vaccine is not available for inter

Notably, a Beijing-based JE-MB vaccine is not available for international travelers and was thus not included in the present study. The study population consisted of JE vaccinees whose early immune responses were reported in the two former studies. In this follow-up we included subjects who had received (1) a JE-VC primary

series (group VC), (2) a JE-MB primary series followed by a single booster dose of JE-VC (group MB-VC), and (3) a JE-MB primary learn more series followed by a single booster dose of JE-MB (group MB-MB). In the booster groups, the median intervals between primary and booster vaccinations were 5.2 (range 1.1–20.5) years (group MB-VC) and 3.7 (range 1.0–12.2) years (group MB-MB). Eligibility criteria for the participants have been described previously [5] and [16]. Briefly, the subjects were adult volunteers who received JE primary or booster vaccination as part of their pre-travel consultation at two travel clinics in Finland and Sweden. The following exclusion criteria JQ1 were used: age <18 years, acute disease at the time of enrollment, pregnancy or lactation, clinically significant immunosuppression, known history of JE, alcohol or drug abuse, or suspected hypersensitivity to any

of the vaccine components. The initial study comprised 31 volunteers in group VC, 42 in MB-VC and 32 in MB-MB [5]. For this research project, we collected follow-up serum samples from all volunteers available around two years after their last vaccine dose: 15/31 participants (48%) in group VC, 19/42 (45%) in group MB-VC, and 14/32 (44%) in group MB-MB. The samples were evaluated for persistence and cross-reactivity of the JEV neutralizing antibodies. Of the subjects in the JE-VC primary vaccination group (group VC), only those were included in the analyses who showed no antibodies against the JEV strains prior to administering the vaccine series. The these study (EudraCT: 2010-023300-27) was approved by the appropriate ethics

committees and registered in the databases required. All volunteers provided informed consent. Titers of neutralizing antibodies were determined by the plaque-reduction neutralization test (PRNT), which is currently regarded the method of choice for assessment of seroprotection elicited by JE vaccines [17]. The neutralization tests were performed as described previously [5] and [18]. All serum samples were tested against seven different JEV strains representing genotypes I–IV: SM-1 (GI; isolated in Thailand 2002), 1991 (GI; Korea 1991), B 1034/8 (GII; Thailand 1983), Nakayama (GIII; Japan 1935, strain in JE-MB), SA14-14-2 (attenuated GIII strain, strain in JE-VC; parental strain China 1954), Beijing-3 (GIII, China 1949), and 9092 (GIV; Indonesia 1981). The analyses were performed in a blinded manner.

Cold-chain storage cost per dose was estimated using the 2012 WHO

Cold-chain storage cost per dose was estimated using the 2012 WHO vaccine volume calculator [18]. This estimates that the cold chain costs for a 10-dose vial

is $0.03 per dose and 5-dose vials costs $0.05 per dose. The model specified in Eqs. (4) and (5) was used to depict two policy options: (1) offering IPV in 10-dose vials and (2) offering IPV in 5-dose vials. For each country and each policy option the model ran 1000 replications drawing independently from the statistical GSK1349572 clinical trial distributions of session size for all of the various types of clinics in the country as specified in Eqs. (4) and (5). The baseline cost per dose of the vaccine was assumed to be $2.48 per dose in 10-dose vials, using the mean of the price range released by UNICEF [19], and $2.98 per dose in 5-dose vials, which is a procurement price gap of $0.50. As no price information is available for IPV 5-dose vials, we carried out a univariate sensitivity

analysis to vary the price gap from zero to a $1.00 per dose between 10- and 5-dose vials. Our study found that session size varied significantly within and across all four countries included in the analysis. Table 3 lists SB203580 datasheet the median session size and 25th to 75th percentile for different types of healthcare centers in Bangladesh, India (Uttar Pradesh), Mozambique, and Uganda. Depending on whether the clinic setting was urban, rural, outreach or fixed, the median session size varied between 3 and 15 children. To predict session size in different clinical settings, session size field data were used for statistical distribution fitting. Fig. 1 shows the Akaike Information Criteria (AICs) score associated with the best fitting parameters medroxyprogesterone within each statistical distribution family—the lower the AIC, the better the fit. The negative binomial family offered the greatest number of best-fit results compared to the other three families, though as seen in Fig. 1, the AIC score of the second best-fit did not

differ greatly from the best-fit in some cases. The best-fit distributions were parameterized for each clinic type in each country and applied in the calculation of vaccine wastage. Wastage in both 10-dose vials and 5-dose vials presentations was calculated, indicating a lower wastage rate for using 5-dose vials. Table 4 shows that by switching from 10-dose vials to 5-dose vials, the wastage rate was reduced in all four countries. While using 5-dose vials produced a lower wastage rate, it also triggered an increase in the per-dose fully loaded cost, which included the procurement costs, cold-chain costs, and cost of open vial wastage. Fig. 2 shows the distributions of the present values of fully loaded per dose costs in a 10-year analytical horizon for IPV with a procurement price of $2.48 per dose in 10-dose vials and a price gap of $0.50 per dose in 5-dose vials in Bangladesh, India (Uttar Pradesh), Mozambique, and Uganda.

11 in Kinnell (2014)

11 in Kinnell (2014) Selleck PCI-32765 was incorrect. They suggested that it should be equation(12) b1(QR30EI)c1=b1(Ve30EIPe−1)c1b1QREI30c1=b1VeEI30Pe−1c1where

b1 and c1 are the empirical coefficients, QR is the runoff ratio, E is the storm kinetic energy, I30 is the maximum 30-minute intensity, Ve is the runoff amount, and Pe is the rainfall amount. While their Eq. (12) was mathematically correct, Eq. 11 in Kinnell (2014) was presented in the context of modelling soil loss in terms of runoff and sediment concentration with the expression for sediment concentration enclosed in square brackets. Consequently, Eq. 11 in Kinnell (2014) should have been written as equation(13) b1(QR30EI)c1=Ve[b1Vec1–1(30EIPe−1)c1].b1QREI30c1=Veb1Vec1–1EI30Pe−1c1. The term Vec1–1Vec1–1 was inadvertently omitted from Eq. 11 in Kinnell (2014). Eq. (13) is a mathematically correct rearrangement of Eq. (12). Eq. (13) indicates that sediment concentration varies nonlinearly with both the runoff amount and the product of the kinetic energy per unit quantity of rain (E Pe− 1) and I30. The relevance of the discussion about the effect of runoff on sediment concentration that followed Eq. 11 in Kinnell (2014) is more obvious from Eq. (13) than Eq. (12). However, the discussion in Kinnell (2014) about Ae Pe (EI30)− 1 increasing with Ve to a

power of 1.48 on 22 m long plots at Sparacia followed the observation in Bagarello et al. (2011) that nonlinear relationships between sediment concentration and the product of the kinetic energy per unit quantity of rain and BLU9931 mw I30 did not second definitely exist in experimental data obtained from runoff and soil loss plots at Masse and Sparacia when both runoff and the product of the kinetic energy per unit quantity of rain and I30 were used as independent variables in the prediction of sediment concentration. Although not stated explicitly, the discussion in Kinnell (2014) about Ae Pe (EI30)− 1 increasing with Ve to a power of 1.48 on 22 m long plots at Sparacia focussed on equation(14) b1(QR30EI)c1=Ve[b1Vec2(30EIPe−1)]b1QREI30c1=Veb1Vec2EI30Pe−1where c2 = 0.48

on 22 m long plots at Sparacia, being an alternative to Eq. (13). Given that c2 was greater than c1 − 1 at Sparacia, the conclusion by Kinnell (2014) that runoff had a significant effect on sediment concentration at Sparacia followed more from Eq. (14) than Eq. (13). “
“The authors regret that there were errors in the units for total carbon and total nitrogen in Fig. 5. The corrected version of the figure is shown below. The authors would like to apologise for any inconvenience caused. Figure options Download full-size image Download as PowerPoint slide Fig. 5. Concentrations of carbon, nitrogen, and phosphorus in the organic horizon and the upper mineral soil (0–20 cm) along the Haast dune sequence, New Zealand. Values are the mean ± standard error of three replicate plots located along the dune crest at each site.