|Year : 2018 | Volume
| Issue : 4 | Page : 163-167
Role of adenosine deaminase in pleural fluid in tubercular pleural effusion
Suchita Dilip Modi1, Anil Kalyandas Agrawal1, Arvind S Bhake1, Vikas R Agrawal2
1 Department of Pathology, JNMC, Wardha, Maharashtra, India
2 Department of Surgery, JNMC, Wardha, Maharashtra, India
|Date of Web Publication||16-Apr-2019|
Dr. Suchita Dilip Modi
Department of Pathology, JNMC, Sawangi (Meghe), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Each year approximately 1 million patients develop the pleural effusion. Tuberculosis (TB), the single most frequent infectious cause of death worldwide, also is one of the leading causes of pleural effusion. Despite the advent of novel improvements in the diagnosis and treatment of pulmonary TB, a definite diagnosis of TB in a significant number of patients is problematic. Measurement of the level of adenosine deaminase (ADA) enzyme in body fluids is a helpful diagnostic tool. The level of ADA elevates as the lymphocyte (T-cell) activity increases. The present study was carried out to evaluate the ADA activity in pleural fluid for early diagnosis and management of tubercular pleural effusion (TPE). Objectives: The main objective is to determine the tubercular pleural fluid ADA level and its sensitivity and specificity. Materials and Methods: The prospective analytical study was conducted at Acharya Vinobha Bhave Rural Hospital, Sawangi (Meghe), in 105 patients of suspected case of TPE. A structured proforma was used for documenting the history, symptoms, side of effusion, hemogram and erythrocyte sedimentation rate (ESR), pleural fluid findings which included pH, glucose, proteins, lactate dehydrogenase (LDH), total leukocyte count (TLC) and differential leukocyte counts and serum ADA level was also calculated. Results: ADA sensitivity, specificity, positive predictive value, and negative predictive value (NPV) are 89.47%, 48.28%, 81.93%, and 63.65%, respectively, for TB. Pleural fluid ADA activity has been shown to be a valuable biochemical marker that has a high sensitivity for TB diagnosis. Conclusion: Pleural fluid ADA is markedly raised in tubercular effusions. ADA estimation is a simple, reliable, cost-efficient, and diagnostically useful investigation.
Keywords: Adenosine deaminase, pleural effusion, tuberculosis
|How to cite this article:|
Modi SD, Agrawal AK, Bhake AS, Agrawal VR. Role of adenosine deaminase in pleural fluid in tubercular pleural effusion. J Datta Meghe Inst Med Sci Univ 2018;13:163-7
|How to cite this URL:|
Modi SD, Agrawal AK, Bhake AS, Agrawal VR. Role of adenosine deaminase in pleural fluid in tubercular pleural effusion. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2019 May 21];13:163-7. Available from: http://www.journaldmims.com/text.asp?2018/13/4/163/256215
| Introduction|| |
Pleural effusion is defined as an excessive accumulation of fluid in the pleural space, it indicates an imbalance between pleural fluid formation and absorption. The normal pleural space contains a relatively minimal fluid quantity, approximately 0.1–0.2 ml/kg of body weight on each side. Pleural effusion can be of two types: transudative and exudative. Transudative pleural effusions are caused by fluid leaking into the pleural space and increased hydrostatic pressure or decreased oncotic pressure. Exudative effusions due to increased capillary permeability which is caused by blocked blood vessels, inflammation, lung injury, or drug reactions.
Each year approximately 1 million patients develop pleural effusion. Pleural effusions are associated with many infective conditions or as a complication of the pulmonary disease and it may also complicate in malignant diseases, heart diseases, liver diseases, gastrointestinal diseases, kidney diseases, or in collagen vascular disease. Tuberculosis (TB), the single most frequent infectious cause of death worldwide, also is one of the leading cause of pleural effusion.
Mycobacterium tuberculosis (MTB) is a pathogenic bacterial species in the family Mycobacteriaceae and the causative agent of most cases of TB. Despite being isolated by Robert Koch in 1882, as well as the availability of effective treatment and the use of a live attenuated vaccine in many parts of the world, TB remains one of the deadliest communicable diseases. In 2013, an estimated 90 lakh people developed active TB, with 15 lakh deaths attributed to the disease.
According to the World Health Organization global TB report (2016), in 2015, there were an estimated 1.04 crore new (incident) TB cases diagnosed worldwide, of which 59 lakh (56%) were among men, 35 lakh (34%) among women, and 10 lakh (10%) among children. The number of TB deaths fells from 1.8 million in 2000 to 1.4 million in 2015 globally.
Although TB affects the lungs in the majority of patients, extrapulmonary TB serves as an initial presentation in about 25% of adults and primarily involves the lymph nodes and pleura. Adenosine deaminase (ADA) has been proposed to be a significant surrogate marker for TB diagnosis as it can be detected in the pleural fluid, pericardial fluid, cerebrospinal fluid, and peritoneal fluid, and elevated ADA levels have been reported in these cases.
For the diagnosis of extrapulmonary TB estimation of ADA level,,,,,,, sensitivity and specificity is reported more than 90%. ADA predicts disease probability by 99% in countries with high prevalence of TB, but there are some studies which did not show such correlation.,, ADA activity in pleural fluid is a practical and useful approach to take therapeutic decisions in patients with suspected tubercular pleural effusion (TPE). The beginning of empirical treatment when a patient has a high ADA value in tubercular fluid seems to be a right approach while waiting for the results of mycobacterial cultures and biopsies.
ADA is essentially T-lymphocyte enzyme which catalyzes the conversion reaction of adenosine and deoxyadenosine nucleoside to inosine and deoxyinosine, respectively. Many studies have investigated the importance of ADA in pleural fluid for the early diagnosis of TPE and confirmed that the determination of ADA levels is an easy and inexpensive method for diagnosing TPE. ADA levels also elevated in human immunodeficiency virus-infected TB patients in pleural fluid even with deficient CD4+ T-cells.,
Despite the advent of novel improvements in the diagnosis and treatment of pulmonary TB, a definite diagnosis of TB in significant number of patients is problematic.
Measurement of ADA enzyme level in body fluids is a helpful diagnostic tool. The level of ADA elevates, as the lymphocyte (T-cell) activity increases.
Neutrophil-rich exudative effusions are due to acute inflammatory processes, example pneumonia or acute pulmonary embolism, whereas lymphocytic effusions have a much longer list of differential diagnosis. However, in areas with higher incidence of TB; pulmonary TB and malignancy are the most likely cause for lymphocytic pleural effusion., Elevated ADA levels are observed in patients with tuberculous pleurisy.
The sensitivity of Ziehl–Neelsen staining and culture are 10%–40% and 8%–49%, respectively, for the diagnosis of TB infection. Definitive diagnosis of TB requires culture of the suspected organism. M. tuberculosis grows very slowly, it can take up to 6 weeks to isolate it in culture. Determination of drug susceptibility can add another 3–6 weeks to the process. Meanwhile, the disease may progress and be transmitted to others when appropriate treatment is delayed. There is a need for simple, rapid, and reliable test which can be easily carried out in the clinical laboratory. The present study was carried out to evaluate the ADA activity in pleural fluid for early diagnosis and management of TPE. The aim of this study is to determine ADA level in pleural fluid in patients of TB and its interpretation and its diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).
| Materials and Methods|| |
The prospective analytical study was conducted in the Department of Pathology at Acharya Vinobha Bhave Rural Hospital, Sawangi (Meghe) in indoor patients of suspected case of TPE. The study included 105 patients who were admitted (inpatient department) in AVBRH.
A structured standard pro forma was prepared and used for recording the history, symptoms, side of effusion, hemogram and erythrocyte sedimentation rate (ESR), pleural fluid findings which included pH, sugar, proteins, lactate dehydrogenase (LDH), total leukocyte count (TLC) and differential leukocyte counts and serum ADA level was also calculated.
A cutoff of 40 II/L for ADA was taken as a cutoff value for diagnosing tubercular effusion.,,
On cytology, pleural fluid labeled as TB when abundant lymphocytes in the smear seen and the nuclei of the lymphocytes show characteristic morphologic features.
An effusion was diagnosed as malignant only when confirmed by positive cytology in pleural effusion. Parapneumonic effusions were diagnosed based on clinical and radiographic features that were consistent with an acute pulmonary infection and exclusion of other causes of pleural effusion.
Presence of first or more than one of the following criteria was adopted to label a case as TB:,
- Bacteriological confirmation of the presence of M. tuberculosis (direct smear or culture or histological finding)
- Histopathology finding of caseating granulomas
- Radiological findings consistent with TB
- Clinical presentation consistent with TB with positive tuberculin test (>20 mm induration) with exclusion of other clinical considerations
- Definite clinical and radiological improvement in 2 months of administration of exclusive anti-tubercular treatment.
Patients with a history of typhoid fever, infectious mononucleosis, liver disease, leukemia, Brucellosis More Details, rheumatoid arthritis, and active cirrhosis will be excluded because they also show increase ADA level due to cellular system stimulation.,,
Adenosine deaminase estimation
Two milliliter of pleural fluid was collected in a sterile container. ADA levels were estimated in the sample by using Proton ADA-MTB/kinetic kit which work on the principle of Giusti and Galanti et al.
Data were tabulated and analyzed using Statistical Package for Social Sciences version 21.0 software (Armonk, NY: IBM Corp). Data have been represented using bar and other diagrams. All the variables assessed separately. Mean and standard deviation of the variables calculated and compared. In the statistical analysis, accuracy, sensitivity, specificity, PPV, and NPV were also calculated.,
| Results|| |
In this study, 73.33% were male and 26.67% were female [Table 1], hence showing a male predominance. Majority of patients in this study were from age 26 to 45 years. The mean age was 43.19 ± 17 [Table 2]. Of the 105 cases of pleural effusion, 83 (79.04%) were tubercular, 17 (16.19%) malignant, and 5 (4.76%) were parapneumonic. In tubercular effusion, 50.60% of patients sputum AFB were positive, 26.51% show Mantoux test positivity, and only 2.41% of patients show pleural fluid culture positivity.
In TPE, the most common complaints are chest pain (75.90%) and fever (68.67%). In malignant pleural effusion (MPE), chest pain was 82% and 80% in parapneumonic pleural effusion. There was no difference in hemoglobin percentage and blood total leukocyte count in all the groups, and ESR and platelet show statistically significant relationship with a P < 0.05.
Pleural fluid investigations such as pH, glucose, protein, and LDH showed no major difference in all groups, and their relation was statistically not significant. Pleural fluid TLC and polymorphs showed a raised value in parapneumonic group. Pleural fluid TLC mean in this study was 1188.40 ± 1373.47 in PPE, 888.44 ± 1240.20 in TPE, and 142.41 ± 149.31 in MPE. In TPE, lymphocytes percentage was high, that is, 67.87%. In this study, majority of the patients almost 56.2% had right-sided effusion, and left-sided effusion was present in 36.2%, bilateral effusion was seen in 7.62% cases. In the present study [Table 3], the mean ADA was 85.09 ± 30.20, 51.20 ± 14.80, and 24.47 ± 12.44 in TPE, PPE, and MPE, respectively. 81.93% participants in TPE [Table 4] have ADA cutoff ≥40 IU/L. In MPE (23.53%), 4 out of 17 and in PPE (80%) 4 out of 5 participants are having ADA ≥40 IU/L. More than 80.72% cases of confirmed TB [Table 5] were diagnosed by cytology, whereas 100% clinical cases of MPE and PPE were confirmed by cytology. At a cutoff of 40 IU/L ADA sensitivity, specificity, PPV, and NPV, are 89.47%, 48.28%, 81.93%, and 63.65%, respectively, for TB.
|Table 3: Distribution of patients according to mean adenosine deaminase level|
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Pleural fluid ADA activity has been shown to be a valuable biochemical marker that has a high sensitivity for TB diagnosis.
| Discussion|| |
Gender-wise distribution of the study participants in the present study was approximately 3:1 with male and female percentage of 73.33% and 26.67%, respectively. This distribution is in accordance with Sharma et al., Gupta et al., Kelam et al., Tay and Tee, and Mehta et al.
In TPE, majority of the patients (29%) belongs to 26–35 years age group. Majority of patients in MPE (30%) and PPE (40%) are from 56 to 65 years age group. Bhavsar Kaushal and Pujara Krupal, Biswas et al., and Kumari et al. showed age group affected in TPE were young and MPE were elder which is similar to this study
In the present study, chest pain was more common presenting complain in tubercular effusion (76%), MPE (82%), and PPE (80%). The second most common complaint was fever 68% in TPE, whereas dyspnea next common in malignant (76%) and parapneumonic pleural effusion (80%). As per the studies by Bhavsar Kaushal and Pujara Krupal, Kate et al., and Yadav et al., these findings are equivocal.
Right-sided TPE was 1.7 times more commonly affected then left and 6.86 times than bilateral involvement. Right-sided MPE is 1.26 and 9 times more common than the left and bilateral involvement, respectively, whereas in PPE, the left side is 1.5 times more commonly involved than the right. and no bilateral involvement is seen. Ibrahim et al., Valdés et al., and Duggal et al. also showed that the right side was more commonly involved than left and bilateral for TPE.
In the present study, the diagnostic criteria for TB were maximum (50%) by sputum AFB and least (<3%) by pleural fluid culture. 26% of cases were diagnosed by the Mantoux test. Valdés et al. showed Mantoux test positive in 73.3% cases and Gupta et al. showed AFB positive in 10%–25% and culture in <25% cases. Bhavsar Kaushal and Pujara Krupal showed 76.4% cases diagnosed by tuberculin and by AFB was only 1%.
Sensitivity and specificity of ADA was determined in patients of TPE using a cutoff of 40 IU/L. Sensitivity, specificity, PPV, and NPV are 89.47%, 48.28%, 81.93%, and 63.65%, respectively.
Sensitivity index is consistent with Gupta et al., Kapisyzi et al., Garcia-Zamalloa et al., Kelam et al., Mehta et al., Kate et al., and Pande et al. using cutoff of 40 IU/L.
Specificity Index are consistent with Kelam et al., whereas it is high (>50%) in Gupta et al., Garcia-Zamalloa et al., Mehta et al., Kate et al., and Pande et al.
More than 75% PPV was observed in Gupta et al., Kelam et al., Mehta et al., Kate et al., and Pande et al., which is inconsistent with this study, whereas Kapisyzi et al., Garcia-Zamalloa et al. have <70% PPV.
NPV is <70% in our study which is in concordance with Garcia-Zamalloa et al., whereas Gupta et al., Kapisyzi et al., Mehta et al., Kate et al., and Pande et al. have NPV >70%.
| Conclusion|| |
Pleural effusion is a common disease in medical practice and in developing countries like India, TB is the most common cause of pleural effusion ADA level estimation is a simple, reliable, cost-efficient, and diagnostically useful investigation, particularly in region where TB is prevalent and where other studies as microbiological or biochemical test fail in early detection and accurate determination of cause for exudation.
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| References|| |
Sahn SA. State of the art. The pleura. Am Rev Respir Dis 1988;138:184-234.
Light RW. Pleural Diseases. 6th
ed. Philadelphia: Lippincott Williams and Wilkins; 1983. p. ix.
Smith I. Mycobacterium tuberculosis
pathogenesis and molecular determinants of virulence. Clin Microbiol Rev 2003;16:463-96.
Vorster MJ, Allwood BW, Diacon AH, Koegelenberg CF. Tuberculous pleural effusions: Advances and controversies. J Thorac Dis 2015;7:981-91.
World Health Organization. Global Tuberculosis Report. Geneva, Switzerland: World Health Organization; 2016.
Porcel JM. Tuberculous pleural effusion. Lung 2009;187:263-70.
Dinnes J, Deeks J, Kunst H, Gibson A, Cummins E, Waugh N, et al.
Asystematic review of rapid diagnostic tests for the detection of tuberculosis infection. Health Technol Assess 2007;11:1-96.
Ocaña I, Martinez-Vazquez JM, Ribera E, Segura RM, Pascual C. Adenosine deaminase activity in the diagnosis of lymphocytic pleural effusions of tuberculous, neoplastic and lymphomatous origin. Tubercle 1986;67:141-5.
Bañales JL, Pineda PR, Fitzgerald JM, Rubio H, Selman M, Salazar-Lezama M, et al.
Adenosine deaminase in the diagnosis of tuberculous pleural effusions. A report of 218 patients and review of the literature. Chest 1991;99:355-7.
Ribera E, Martinez-Vazquez JM, Ocaña I, Segura RM, Pascual C. Activity of adenosine deaminase in cerebrospinal fluid for the diagnosis and follow-up of tuberculous meningitis in adults. J Infect Dis 1987;155:603-7.
Pettersson T, Klockars M, Weber TH, Somer H. Diagnostic value of cerebrospinal fluid adenosine deaminase determination. Scand J Infect Dis 1991;23:97-100.
Voigt MD, Kalvaria I, Trey C, Berman P, Lombard C, Kirsch RE. Diagnostic value of ascites adenosine deaminase in tuberculous peritonitis. Lancet 1989;1:751-4.
Dwivedi M, Misra SP, Misra V, Kumar R. Value of adenosine deaminase estimation in the diagnosis of tuberculous ascites. Am J Gastroenterol 1990;85:1123-5.
Bhargava DK, Gupta M, Nijhawan S, Dasarathy S, Kushwaha AK. Adenosine deaminase (ADA) in peritoneal tuberculosis: Diagnostic value in ascitic fluid and serum. Tubercle 1990;71:121-6.
Greco S, Girardi E, Masciangelo R, Capoccetta GB, Saltini C. Adenosine deaminase and interferon gamma measurements for the diagnosis of tuberculous pleurisy: A meta-analysis. Int J Tuberc Lung Dis 2003;7:777-86.
Kaur A, Basha A, Ranjan M, Oommen A. Poor diagnostic value of adenosine deaminase in pleural, peritoneal and cerebrospinal fluids in tuberculosis. Indian J Med Res 1992;95:270-7.
Malan C, Donald PR, Golden M, Taljaard JJ. Adenosine deaminase levels in cerebrospinal fluid in the diagnosis of tuberculous meningitis. J Trop Med Hyg. 1984;87:33-40.
Maartens G, Bateman ED. Tuberculous pleural effusions: Increased culture yield with bedside inoculation of pleural fluid and poor diagnostic value of adenosine deaminase. Thorax 1991;46:96-9.
Baba K, Hoosen AA, Langeland N, Dyrhol-Riise AM. Adenosine deaminase activity is a sensitive marker for the diagnosis of tuberculous pleuritis in patients with very low CD4 counts. PLoS One 2008;3:e2788.
Zhai K, Lu Y, Shi HZ. Tuberculous pleural effusion. J Thorac Dis 2016;8:E486-94.
Light RW. Pleural Diseases. 5th
ed. Philadelphia: Lippincott Williams and Wilkins; 2007. p. 79-80.
Sahn SA. Getting the most from pleural fluid analysis. Respirology 2012;17:270-7.
Valdés L, Alvarez D, Valle JM, Pose A, San José E. The etiology of pleural effusions in an area with high incidence of tuberculosis. Chest 1996;109:158-62.
Liam CK, Lim KH, Wong CM. Causes of pleural exudates in a region with a high incidence of tuberculosis. Respirology 2000;5:33-8.
Neves DD, Dias RM, da Cunha AJ, Preza PC. What is the probability of a patient presenting a pleural effusion due to tuberculosis? Braz J Infect Dis 2004;8:311-8.
Jay SJ. Diagnostic procedures for pleural disease. Clin Chest Med 1985;6:33-48.
Lamsal M, Gautam N, Bhatta N, Majhi S, Baral N, Bhattacharya SK, et al.
Diagnostic utility of adenosine deaminase (ADA) activity in pleural fluid and serum of tuberculous and non-tuberculous respiratory disease patients. Southeast Asian J Trop Med Public Health 2007;38:363-9.
Mehta AA, Gupta AS, Ahmed S, Rajesh V. Diagnostic utility of adenosine deaminase in exudative pleural effusions. Lung India 2014;31:142-4.
] [Full text]
Liang QL, Shi HZ, Wang K, Qin SM, Qin XJ. Diagnostic accuracy of adenosine deaminase in tuberculous pleurisy: A meta-analysis. Respir Med 2008;102:744-54.
Spieler P. The cytologic diagnosis of tuberculosis in pleural effusions. Acta Cytol 1979;23:374-9.
Yadav D, Taparia P, Mishra S, Agnihotri S. Usefulness of pleural fluid ADA level in differential diagnosis of exudative pleural effusion – A pilot study. Int J Curr Med Pharm Res 2016;2:513-9.
Tay TR, Tee A. Factors affecting pleural fluid adenosine deaminase level and the implication on the diagnosis of tuberculous pleural effusion: A retrospective cohort study. BMC Infect Dis 2013;13:546.
Light RW. Pleural Diseases. Baltimore: Lippincott Williams and Wilkins; 2001. p. 18295.
al-Shammary FJ. Adenosine deaminase activity in serum and pleural effusions of tuberculous and non-tuberculous patients. Biochem Mol Biol Int 1997;43:763-79.
Salmanzadeh S, Tavakkol H, Bavieh K, Alavi SM. Diagnostic value of serum adenosine deaminase (ADA) level for pulmonary tuberculosis. Jundishapur J Microbiol 2015;8:e21760.
Giusti G, Galanti B. Colorimetric Method. Adenosine deaminase In: Bergmeyer HU, editor. Methods of Enzymatic Analysis. 3rd
ed. Weinheim: Verlag Chemie; 1984.
Parikh R, Mathai A, Parikh S, Chandra Sekhar G, Thomas R. Understanding and using sensitivity, specificity and predictive values. Indian J Ophthalmol 2008;56:45-50.
] [Full text]
Šimundić AM. Measures of diagnostic accuracy: Basic definitions. EJIFCC 2009;19:203-11.
Sharma SK, Suresh V, Mohan A, Kaur P, Saha P, Kumar A, et al.
Aprospective study of sensitivity and specificity of adenosine deaminase estimation in the diagnosis of tuberculosis pleural effusion. Indian J Chest Dis Allied Sci 2001;43:149-55.
Gupta BK, Bharat V, Bandyopadhyay D. Role of adenosine deaminase estimation in differentiation of tuberculous and non-tuberculous exudative pleural effusions. J Clin Med Res 2010;2:79-84.
Kelam MA, Ganie FA, Shah BA, Ganie SA, Wani ML, Wani NU, et al.
The diagnostic efficacy of adenosine deaminase in tubercular effusion. Oman Med J 2013;28:417-21.
Bhavsar Kaushal M, Pujara Krupal M. Pleural effusion: A two year prospective study in Western India. Sch J App Med Sci 2015;3:2790-93.
Kumari R, Reddy B, Vipula V. Role of adenosine deaminase in diagnosis of exudative type of pleural effusion. Int J Med Sci Public Health 2017;6:1.
Kate S, Mutha B, Kulkarni G, Mahajan C, Dugad S. Study of Diagnostic importance of adenosine deaminase (ADA) level in pleural effusions. MVP J Med Sci 2015;2:104.
Ibrahim WH, Ghadban W, Khinji A, Yasin R, Soub H, Al-Khal AL, et al.
Does pleural tuberculosis disease pattern differ among developed and developing countries. Respir Med 2005;99:1038-45.
Valdés L, San José ME, Pose A, Gude F, González-Barcala FJ, Alvarez-Dobaño JM, et al.
Diagnosing tuberculous pleural effusion using clinical data and pleural fluid analysis A study of patients less than 40 years-old in an area with a high incidence of tuberculosis. Respir Med 2010;104:1211-7.
Duggal D, Yannawar A, Dharmadhikari V. Pleural fluid ada in the diagnosis of pleural effusion. J Evol Med Dent Sci 2017;6:4421-9.
Kapisyzi P, Argjiri D, Aliko A, Beli J, Vakeflliu Y, Kore R, et al
. The use of different cutoff values of ADA liquid level in diagnosis of tuberculous pleurisy in countries with different incidence of tuberculosis. Chest 2011;140:703A.
Garcia-Zamalloa A, Taboada-Gomez J. Diagnostic accuracy of adenosine deaminase and lymphocyte proportion in pleural fluid for tuberculous pleurisy in different prevalence scenarios. PLoS One 2012;7:e38729.
Pande K, Shrestha S, Shrestha A, Prasad K, Rauniyar S, Pudasaini S, et al
. Role of pleural fluid adenosine deaminase activity and lymphocytosis in the etiological diagnosis. J Pathol Nepal 2016;6:1008.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]