Medical Perspective Antiphospholipid Antibodies,Thrombosis and Atherosclerosis in Systemic Lupus Erythematosus: a Unifying 'Membrane Stress Syndrome' Hypothesis

Isenberg DA , Horsfall AC Systemic lupus erythematosus. In: Oxford Textbook of Rheumatology . Maddison PJ , Isenberg DA , Woo P , Glass DN (eds). Oxford: Oxford Medical Publications, 1993; 733-55.

Kong TQ , Kellum RE , Haserick JR Clinical diagnosis of cardiac involvement in systemic lupus erythematosus. A correlation of clinical and autopsy findings in thirty patients. Circulation 1962; 26: 7-11.

Haider YS , Roberts WC Coronary arterial disease in systemic lupus erythematosus. Quantification of degrees of narrowing in 22 necroscopy patients (21 women) aged 16 to 37 years. Am J Med 1981; 70: 775-81.

Meller J. , Conde CA , Deppisch LM , Donoso E. , Dack S. Myocardial infarction due to coronary atherosclerosis in three young adults with systemic lupus erythematosus. Am J Cardiol 1975; 35: 309-14.

Tsakraklides VG , Blieden IC , Edwards JE Coronary atherosclerosis and myocardial infarction associated with systemic lupus erythematosus. Am Heart J 1974; 87: 637-41.

Bulkley BH , Roberts WC The heart in systemic lupus erythematosus and the changes induced in it by corticosteroid therapy. Am J Med 1978; 58: 243-64.

Fukumoto S. , Tsumagari T. , Kinjo M. , Tanaka K. Coronary atherosclerosis in patients with systemic lupus erythematosus at autopsy. Acta Pathol Jpn 1987; 37: 1-9.

Parrillo JE , Fauci AS , Necrotizing vasculitis, coronary angiitis and the cardiologist. Am Heart J 1980; 99: 547-554.

Hamsten A. , Norberg R. , Bjorkholm M. , de-Faire U. , Holm G. Antibodies to cardiolipin in young survivors of myocardial infarction: an association with recurrent cardiovascular events. Lancet 1986; 18: 113-16.

Klemp P. , Cooper RC , Strauss PJ , Jordaans ER , Przybojewski JZ , Nel N. Anticardiolipin antibodies in ischaemic heart disease. Clin Exp Immunol 1988; 74: 254-7.

De Caterina R. , d'Ascanio A. , Mazzone A. et al. Prevalence of anticardiolipin antibodies in coronary artery disease. Am J Cardiol 1990 ; 65: 922-4.

Eber B. , Kronberger-Schaffer E. , Brussee H. , Klima J. , Obemosterer A. Anticardiolipin antibodies are no marker for survived myocardial infarction . Klin Wochenschr 1990; 68: 594-6.

Asherson RA , Khamashta MA , Baguely E. , Oakley CM , Rowell NR , Hughes Grv. Myocardial infarction and antiphospholipid antibodies in SLE and related disorders. Q J Med 1989; 73: 1103-15.

Morton KE , Gavaghan TP , Krilis SA et al. Coronary artery bypass graft failure: an autoimmune phenomenon ? Lancet 1986; ii: 1353-7.

McDonald K. , Rector T. , Braunlin E. , Olivari MT Cytomegalovirus infection in cardiac transplant recipients predicts the incidence of allograft atherosclerosis. J Am Coll Cardiol 1989 (Suppl. 1) 213 (abstract).

Misra R. , Venables Pjw , Watkins Rpf , Maini RN Autoimmunity to cardiolipin in infectious mononucleosis. Lancet 1987; 2: 629.

Galve E. , Ordi J. , Barquinero J. , Evangelista A. , Vilardell M. , Soler-Soler J. Valvular heart disease in the primary antiphospholipid syndrome. Ann Intern Med 1992; 116: 293-8.

Nihoyannopoulos P. , Gomez PM , Joshi J. , Loizu S. , Walport MJ , Oakley CM Cardiac abnormalities in systemic lupus erythematosus . Circulation 1990; 82: 369-75.

Ford PM , Ford SE , Lillicrap DP Association of lupus anticoagulant with severe valvular heart disease in systemic lupus erythematosus. J Rheumatol 1988 ; 15: 597-600.

Antiphospholipid Antibody Stroke Study Group. Clinical and laboratory findings in patients with antiphospholipid antibodies and cerebral ischemia. Stroke 1990 ; 21: 1268-73.

Montalban J. , Codina A. , Ordi J. , Vilardell M. , Khamashta MA , Hughes Grv Antiphospholipid antibodies in cerebral ischemia . Stroke 1991 ; 22: 750-3.

Kitagawa Y. , Gotoh F. , Koto A. , Okayasu H. Stroke in systemic lupus erythematosus. Stroke 1990; 21: 1533-9.

Asherson RA , Kharnashta MA , Gil A. et al. Cerebrovascular disease and antiphospholipid antibodies in systemic lupus erythematosus, lupus-like disease and the primary antiphospholipid syndrome. Am J Med 1989; 86: 391-9.

Pope JM , Canny CL , Bell DA Cerebral ischemic events associated with endocarditis, retinal vascular disease and lupus anticoagulant. Am J Med 1991; 90: 299-309.

Levine SR , Welch KM The spectrum of necrologic disease associated with antiphospholipid antibodies, lupus anticoagulants and anticardiolipin antibodies. Arch Neurol 1987; 44: 876-83.

Ginsburg KS , Liang M. , Newcomer L. et al. Anticardiolipin antibodies and the risk for ischemic stroke and venous thrombosis. Ann Intern Med 1992 ; 117: 997-1002.

Sletnes KE , Smith P. , Abdelnoor M. , Arnesen H. , Wisloff F. Antiphospholipid antibodies after myocardial infarction and their relation to mortality, reinfarction and non-haemorrhagic stroke. Lancet 1992; 339: 451-3.

Alarcon-Segovia D. , Cardiel MH , Reyes E. Antiphospholipid arterial vasculopathy. J Rheumatol 1989; 16: 762-7.

Rossi E. , Sani C. , Zini M. et al. Anticardiolipin antibodies and renovascular hypertension. Ann Rheum Dis 1992; 51: 1180-1.

Mandreoli M. , Zuccalà A. , Zucchelli P. Fibromuscular dysplasia of the renal arteries associated with antiphospholipid antibodies: two case reports. Am J Kidney Dis 1992; 20: 500-3.

Mandreoli M. , Zucchelli P. Renal vascular disease in patients with primary antiphospholipid antibodies. Nephrol Dial Transplant 1993; 8: 1277-80.

Ip JH , Fuster V. , Taubma M. , Badimon J. , Chesebro JH Syndromes of accelerated atherosclerosis. Role of vascular injury and smooth muscle cell proliferation. J Am Coll Cordiol 1990; 15: 1667-87.

Ilowite NT , Samuel P. , Ginzler E. , Jacobson MS Dyslipoproteinemia in pediatric systemic lupus erythematosus. Arthritis Rheum 1988; 31: 859-63.

Rossner S. Further studies on serum lipoproteins in connective tissue diseases . Atherosclerosis 1978; 31: 93-9.

Ettinger WH , Hazzard WR Elevated apolipoprotein-B levels in corticosteroid-treated patients with systemic lupus erythematosus. J Clin Endocrinol Metab 1988; 67: 425-8.

MacGregor AJ , Dhillon VB , Binder et al. Fasting lipids and anticardiolipin antibodies as risk factors for vascular disease in systemic lupus erythematosus. Ann Rheum Dis 1992; 51: 152-5.

Lahita RG , Rivkin E. , Cavanagh I. , Romano P. Low levels of total cholesterol, high density lipoprotein and apolipoprotein Al in association with anticardiolipin antibodies in patients with systemic lupus erythematosus. Arthritis Rheum 1993; 36: 1566-74.

Halliwell B. , Chirico S. Lipid peroxidation: its mechanism, measurement and significance. Am J Clin Nutr 1993; 57 (Suppl.) 715S-725S.

Berliner JA , Territo MC , Sevanian A. et al. Minimally modified low-density lipoprotein stimulates monocyte endothelial interactions. J Clin Invest 1990; 85: 1260-6.

Lehr HA , Krober M. , Hubner C. et al. Stimulation of leukocyte/ endothelial interaction by oxidized low-density lipoprotein in hairless mice. Involvement of CD11/CD18 adhesion receptor complex. Lab Invest 1993; 68: 388-95.

Salonen JT , Y1a-Herttuala S. , Yamamoto R. et al. Autoantibody against oxidised LDL and progression of carotid atherosclerosis. Lancet 1992; 339: 883-7.

Vaarala O. , Alfthan G. , Jauhiainen M. , Leirisala-Repo M. , Aho K. , Palosuo T. Crossreaction between antibodies to oxidised low-density lipoprotein and to cardiolipin in systemic lupus erythematosus. Lancet 1993; 341: 923-5.

Borba EF , Santos RD , Bonfa E. et al. Lipoprotein (α) levels in systemic lupus erythematosus. J Rheumatol 1994; 21: 220-3.

McLean JW , Tomlinson JE , Kuang WJ et al. DNA sequence of human apolipoprotein (α) is homologous to plasminogen. Nature 1987; 330: 132-7.

Loscalzo J. , Weinfeld M. , Fless G. , Scanu AM Lipoprotein (α), fibrin binding and plasminogen activation. Arteriosclerosis 1990; 10: 240-8.

Ezratty AM , Simon DI , Fless GM , Scanu AM , Loscalzo J. Lipoprotein (α) inhibits fibrinogen uptake and degradation by mononuclear cells. Clin Res 1993; 41: 183 (abstract).

Ettingen OR , Hajjar DP , Hajjar KA , Harpel PC , Nachman RL Lipoprotein (α) regulates plasminogen activator inhibitor expression in endothelial cells. A potential mechanism for thrombosis. J Biol Chem 1991; 226: 2459-68.

Grainger DJ , Kirschenolhr HL , Metcalf JC , Weissberg PL , Wade DP , Lawn RM Proliferation of human smooth muscle cell promoted by lipoprotein (α). Science 1993 ; 260: 1655-60.

Murai A. , Miyahara T. , Fujimoto N. , Matsuda M. , Kameyama M. Lipoprotein (α) as a risk factor for coronary heart disease and cerebral infarction. Atherosclerosis 1986; 59: 199-204.

Tsakiris DA , Marbet GA , Makris PE , Settas L. , Duckert F. Impaired fibrinolysis as an essential contribution to thrombosis in patients with lupus anticoagulant . Thromb Haemost 1989; 61: 175-7.

Violi F. , Ferro D. , Qiuntarelli C. , Saliola M. , Grandilli MA , Balsano F. Tissue plasminogen activator in patients with systemic lupus erythematosus and thrombosis. Br Med J 1990; 300: 1099-102.

Keeling DM , Campbell SJ , Mackie J. , Machin SJ , Isenberg DA The fibrinolytic response to venous occlusion and the natural anticoagulants in patients with antiphospholipid antibodies both with and without systemic lupus erythematosus. Br J Haematol 1991; 77: 354-9.

Jurado M. , Paramo JA , Gutierrez-Pimentel M, Rocha. Fibrinolytic potential and antiphospholipid antibodies in systemic lupus erythematosus and other connective tissue disorders. Thromb Haemost 1992; 68: 516-20.

Awada H. , Barlowatz-Meimon G. , Dougadous M. , Maisonneuve P. , Sultan Y. , Amor B. Fibrinolysis abnormalities in systemic lupus erythematosus and their relation to vasculitis. J Clin Lab Med 1988; 111:229-36.

Grimaudo V. , Bachman F. , Hauert J. , Christe MA , Kruithof Eko. Hypofibrinolysis in patients with a history of idiopathic deep vein thrombosis and/or pulmonary embolism. Thromb Haemost 1992; 67: 397-401.

Juhan-Vague I. , Alessi MC Plasminogen activator inhibitor 1 and atherothrombosis . Thromb Haemost 1993 ; 70: 138-43.

Cariou R. , Tobelem G. , Belluci S. et al. Effect of lupus anticoagulant on antithrombogenic properties of endothelial cells: inhibition of thrombodulin-dependent protein C activation . Thromb Haemost 1988; 60: 54-8.

Malia RG , Kitchen S. , Greaves M. , Preston F. Inhibition of activated protein C and its cofactor protein S by antiphospholipid antibodies. Br J Haematol 1990; 76: 101-7.

Keeling DM , Campbell SJ , Mackie IM , Machin SJ , Isenberg DA Total and free protein S in systemic lupus erythematosus. Thromb Res 1990; 60: 237-40.

Walker TS , Triplett DA , Javed N. , Musgrave. Evaluation of lupus anticoagulants: antiphospholipid antibodies, endothelium associated immunoglobulin, endothelial prostacyclin secretion and antigenic protein S levels. Thromb Res 1988; 51: 267-81.

Ruiz-Arguelles A. , Vazquez-Prado JV , Deleze M. et al. Presence of serum antibodies to coagulation protein C in patients with systemic lupus erythematosus is not associated with antigenic or functional protein C deficiencies. Am J Hematol 1993; 44: 58-9.

Boey ML , Loizu S. , Colaco B. , Matkin JA , Hughes Grv. Antithrombin III in systemic lupus erythematosus. Clin Exp Rheumatol 1984; 2: 51-6.

Carreras LO , Vermylen J. Antiphospholipid antibodies and impairment of prostacyclin synthesis in the endothelium. In: Phospholipid binding antibodies. Harris EN , Exner T , Hughes GRV , Asherson R (eds). New York, CRC, 1991.

Watson KV , Schorer AG Lupus anticoagulant inhibition of in vitro prostacyclin release is associated with a thrombosis-prone subset of patients. Am J Med 1991; 90: 47-54.

Lindsey NJ , Henderson FI , Malia R. , Milford-Ward MA , Greaves M. , Hughes P. Inhibition of prostacyclin release by endothelial binding anticardiolipin antibodies in thrombosis-prone patients with systemic lupus erythematosus and the antiphospholipid syndrome. Br J Rheumatol 1994; 33: 20-6.

Rustin Mha , Bull HA , Dowd PM , Isenberg DA , Snaith MD , Machin SJ Presence of the lupus anticoagulant in patients with systemic lupus erythematosus does not cause inhibition of prostacyclin production. Thromb Haemost 1987; 58: 390 (abstract).

Hasselaar P, Derksen RHWM, Blokzijl L, de Groot PG. Thrombosis associated with antiphospholipid antibodies cannot be explained by the effects on endothelial and platelet prostanoid synthesis. Thromb Haemost 1988; 59: 80-5.

Schorer AE , Wickham Nwr , Watson KV Lupus anticoagulant induces a selective defect in thrombin-mediated endothelial cell prostacyclin release and platelet aggregation. Br J Haematol 1989; 71: 399-407.

Arfors L. , Vesterqvist O. , Johnsson H. , Green K. Increased thromboxane formation in patients with antiphospholipid syndrome . Eur J Clin Invest 1990; 20: 607-12.

Lellouche P. , Martinuzzo M. , Said P. , Maclouf J. , Carreras LO Imbalance of thromboxane/prostacyclin biosynthesis in patients with lupus anticoagulant. Blood 1991; 78: 2894-9.

Love PE , Santoro SE Antiphospholipid antibodies: anticardiolipin and the lupus anticoagulant in systemic lupus erythematosus (SLE) and in non-SLE disorders. Ann Intern Med 1990; 112: 682-98.

Ginsburg JS , Demers C. , Brill-Edwards P. et al. Increased thrombin generation and activity in patients with systemic lupus erythematosus and anticardiolipin antibodies: evidence for a prothrombotic sate. Blood 1993 ; 81: 2958-63.

Angles-Cano E. , Sultan Y. , Clauvel JP Predisposing factors to thrombosis in systemic lupus erythematosus. J Clin Lab Med 1979; 94: 312-23.

Nilsson TK , Lofvenberg E. Decreased fibrinolytic capacity and increased von Willebrand factor levels as indicators of endothelial cell disfunction in patients with lupus anticoagulant . Clin Rheum 1989; 8: 58-63.

Matsuda J. , Kawasugi K. , Gohchi K. et al. Clinical significance of the venous occlusion test on patients with systemic lupus erythematosus: a focus on changes in blood levels of tissue plasminogen activator, von Willebrand factor antigen and thrombomodulin. Acta Haematol 1992; 88: 22-6.

Ames Prj , Brancaccio V. , Iannaccone L. et al. Hemostatic variables, antiphospholipid antibodies and thrombosis. A survey on 133 patients. Thromb Haemost 1993 ; 69 (Suppl. 6): 2412 (abstract).

Lindsey NJ , Dawson RA , Henderson FI , Greaves M. , Hughes P. Stimulation of von Willebrand factor release by immunoglobulin from thrombosis prone patients with systemic lupus erythematosus and the antiphospholipid syndrome. Br J Rheumatol 1993; 32: 122-6.

Wilhelmsen L. , Svardsudd E. , Korsan-Bengtsen K. , Larsson B. , Welin L. , Tibblin G. Fibrinogen as a risk factor for stroke and myocardial infarction. New Engl J Med 1984; 311: 501-5.

Jansson JH , Nilsson TK , Johnson O. Van Willebrand factor in plasma: a novel risk factor for recurrent myocardial infarction and death. Br Heart J 1991; 66: 351-5.

Minick CR , Murphy GE , Campbell WG Experimental induction of atheroarteriosclerosis by the synergy of allergic injury to arteries and lipid rich diet. I. Effect of repeated injections of horse serum in rabbit fed a dietary cholesterol supplement. J Exp Med 1966; 124: 635-51.

Stuart J. , George AJ , Davies AJ , Aukland A. , Hurlow RA Haematological stress syndrome in atherosclerosis. J Clin Pathol 1981; 34: 464-7.

Reizenstein P. The haematological stress syndrome. Br J Haematol 1979; 43: 329-34.

Allaart CF , Briet E. Familial venous thrombophilia. In Haemostasis & Thrombosis . Bloom AL , Forbes CD , Thomas DP , Tuddenham EGD (eds). 1993: 1349-60.

Stocker R. , Frei B. Endogenous antioxidant defences in human plasma. In: Oxidative Stress. Oxidants and Antioxidants. Sies H (ed.). London: Academic Press , 1991: 213-45.

Niwa Y. , Sakane T. , Shingu M. , Miyachi Y. Role of stimulated neutrophils from patients with systemic lupus erythematosus in tissue injury, with special reference to serum factors and increased active oxygen species generated by neutrophils. Inflammation 1985; 9: 163-72.

Miesel R. , Zuber M. Copper dependent antioxidase defences in inflammatory and autoimmune rheumatic diseases. Inflammation 1993; 17: 283-94.

Crawford DW , Blankenhorn DH Arterial wall oxygenation, oxy-radicals and atherosclerosis. Atherosclerosis 1991; 89: 97-108.

Natarajan V. , Scribner WM , Taher MM 4-hydroxynonenal, a metabolite of lipid peroxidation, activates phospholipase D in vascular endothelial cells. Free Rad Biol Med 1993; 15: 365-75.

Rossi M. , Garramone A. , Dianzani MU Stimulation of phospholipase C activity by 4-hydroxynonenal: influence of GTP and calcium concentration. In: J Tissue Reac 1988; 10: 321-25.

Martin TW , Wysolmerski RB , Lagnuoff D. Phosphatydilcholine metabolism in endothelial cells: evidence for phospholipase A and a novel Ca2+ independent phospholipase C. Biochim Biophys Acta 1987; 917: 296-307.

Roberts LJ , Sweetman BJ , Oates JA Metabolism of thromboxane B2 in man. Identification of twenty urinary metabolites . J Biol Chem 1981; 256: 8384-93.

Ardlie NJ , Selley ML , Simons LA Platelet activation by oxidatively modified low density lipoproteins . Atherosclerosis 1989; 76: 117-24.

Jannace PW , Lerman RH , Santos JI , Vitale JJ Effects on oral soy phosphatidylcholine on phagocytosis, arachidonate concentrations and killing by human polymorphonuclear leukocytes. Am J Clin Nutr 1992; 56: 599-603.

Yoshida LS , Miyazawa T. , Hatayama I. , Sato K. , Fujimoto K. , Kaneda T. Phosphatidylcholine peroxidation and liver cancer in mice fed a choline-deficient diet with ethionine. Free Rad Biol Med 1993 ; 14: 191-9.

Mudd SH , Skovby F. , Levh H. et al. The natural history of homozygous homocystinuria due to cystathionine beta-synthase deficiency. Am J Hum Gen 1985 ; 37: 1-31.

Olszewski AJ , McCully KS Homocysteine metabolism and the oxidative modification of proteins and lipids. Free Rad Biol Med 1993; 14: 683-93.

Di Minno G. , Davi G. , Margaglione M. et al. Abnormally high thromboxane biosynthesis in homozygous homocystinuria. Evidence for platelet involvement and probucol-sensitive mechanism. J Clin Invest 1993; 92: 1400-6.

Carew TE , Shwenke DC , Steinberg D. Antiatherogenic effect of probucol unrelated to its hypocholesterolemic effect: evidence that antioxidant in vivo can selectively inhibit LDL degradation in macrophages and slow the progression of atherosclerosis in the watanabe hyperlipidemic rabbit. Proc Natl Acad Sci USA 1987; 84: 7725-9.

Jain SK In vivo externalization of phosphatidylserine and phosphatidylethanolamine in the membrane bilayer and hypercoagulability by the lipid peroxidation of erythrocytes in rats. J Clin Invest 1985; 76: 281-6.

Branch DW , Rote NS , Dostal DA , Scott JR Association of lupus anticoagulant with antibody against phosphatidylserine . Clin Immunol Immunopathol 1987; 42: 63-75.

Karmochine M. , Berard M. , Piette JC et al. Antiphosphatidylethanolamine antibodies in systemic lupus erythematosus. Lupus 1993 ; 2: 157-60.

Ichikawa Y. , Kobayashi N. , Kawada T. et al. Reactivities of antiphospholipid antibodies to blood cells and their effects on platelet activation in vitro. Clin Exp Rheumatol 1990 ; 8: 461-8.

Mamula RJ , Lin RH , Janeway CA Jr , Hardin JA Breaking T cell tolerance with foreign and self co-immunogens. J Immunol 1992; 149 : 789-95.

Ricevuti G. , Mazzone A. , Pasotti D. , de Servi S. , Specchia G. Role of granulocytes in endothelial injury in coronary heart disease in humans. Atherosclerosis 1991 ; 91: 1-14.

Murphy EJ , Joseph L. , Stephens R. , Horrocks LA Phospholipid composition of cultured human endothelial cells. Lipids 1992; 27: 150-3.

Brody JI , Pickering NJ , Fink GB Immunocytochemical features of obstructed saphenous vein coronary artery bypass grafts. J Clin Pathol 1989; 42: 477-82.

Sironi M. , Breviario F. , Prosperio D. et al. IL-1 stimulated IL-6 production in endothelial cells. J Immunol 1989; 142: 549-53.

Gray E. , Barrowcliffe TW Inhibition of antithrombin III by lipid peroxides. Throm Res 1985;37: 241-250.

Lind SE , McDonagh JR , Smith CJ Oxidative inactivation of plasmin and other serine proteases by copper and ascorbate. Blood 1993; 82: 1522-31.

Marx G. , Chevion M. Fibrinogen coagulation without thrombin. Reaction with vitamin C and copper (II). Thromb Res 1985; 40: 11-18.

Strandberg L. , Lawrence DA , Johansson LB-A. The oxidative inactivation of plasminogen activator inhibitor type 1 results from a conformational change in the molecule and does not require the involvement of the Pl' methionine . J Biol Chem 1991; 266: 13852-8.

Weis JR , Pitas RE , Wilson BD , Rodgers GM Oxidized low-density lipoprotein increases cultured endothelial cell tissue factor activity and reduces protein C activation. FASEB J 1991; 5: 2459-65.

Hammond B. , Kontos HA , Hess ML Oxygen radicals in the adult respiratory stress syndrome, in myocardial ischemia and reperfusion injury, and in cerebral vascular damage. Can J Physiol Pharmacol 1985; 63: 173-87.

Ricevuti G. , De Servi S. , Mazzone A. , Angoli L. , Ghio S. , Specchia G. Increased neutrophil aggregability in coronary artery disease. Eur Heart J 1990; 11: 814-18.

Moake JL , Turner NA , Stathopoulos NA , Nolasco LH , Hellmus JD Shear induced platelet aggregation can be mediated by von Willebrand factor multimers, requires adenosine disphosphate and is resistant to aspirin . Blood 1988; 71: 1366-74.

Rosove MH , Petronella MC , Brewer RN Antiphosopholipid thrombosis: clinical course after the first thrombotic event in 70 patients. Ann Intern Med 1992; 117: 303-8.

Vianna JL , Khamashta M. , Ordi-Ros J. et al. Comparison of the primary and secondary antiphosopholipid syndrome: a European multicentre study of 114 patients. Am J Med 1994; 96: 3-9.