1.Correlation of serum metabolites and clinical features in patients with peripheral T-cell lymphoma
Yishuo DUAN ; Jun RAO ; Jing XIA ; Naya MA ; Shijia LIN ; Fu LI ; Shuhan TANG ; Sha ZHOU ; Yunjing ZENG ; Xinlei LI ; Dezhi HUANG ; Qiong LI ; Bangdong LIU ; Xianlan ZHAO ; Jin WEI ; Xi ZHANG
Journal of Army Medical University 2024;46(4):352-358
Objective To explore the changes in serum energy metabolites in patients with peripheral T-cell lymphoma,and investigate serum biomarkers for monitoring peripheral T-cell lymphoma from the perspective of energy metabolism.Methods Multiple/selected reaction monitoring(MRM/SRM)was used to detect the energy-related metabolites in the sera of 16 patients with newly diagnosed peripheral T-cell lymphoma admitted in the Hematology Medical Center of the Second Affiliated Hospital of Army Medical University from November 2020 to December 2021,as well as 10 recruited healthy volunteers.The corresponding clinical data including medical history,laboratory results and image data were collected and retrospectively analyzed.Results Significant differences were seen in the contents and expression profiles of serum energy metabolism-related products between the patients and the healthy volunteers.The patients had significantly reduced serum contents of cyclic AMP,succinate,citrate and cis-aconitate(P<0.05),and elevated D-glucose 6-phosphate content(P<0.05).The serum contents of citrate and succinate were negatively correlated with the risk stratification(low-,moderate-and high-risk)and clinical stage of the disease(P<0.05).Meanwhile,there was a negative correlation between the contents of L-malic acid and citrate and the mid-term efficacy evaluation results,such as complete/partial response(CR/PR)or stable disease(SD)(P<0.05).For patients with extranodal NK/T cell lymphoma(n=10),there were also significant reductions in the contents of cyclic AMP,succinate,citrate,isocitrate and cis-aconitate in the sera of patients compared with healthy volunteers(P<0.05),and the contents of citrate and succinate were negatively correlated with the clinical stage(P<0.05)and were rather correlated with mid-term efficacy evaluation results(CR/PR or SD)(P<0.05).For patients with angioimmunoblastic T-cell lymphoma(n=6),the serum contents of cyclic AMP,citrate and succinate were significantly lower,while the content of D-glucose 6-phosphate was higher when compared with the healthy volunteers(P<0.05),and the content of succinate was negatively correlated with both clinical stage and risk grade of the patients(P<0.05).Conclusion There are 5 serum differential metabolites identified between patients with peripheral T-cell lymphoma and healthy controls,and succinate and citrate are expected to be serum biomarkers of peripheral T-cell lymphoma.
2.Historical Evolution and Textual Research on Classic Prescription Danggui Buxuetang
Xinlei LI ; Xueyan ZHANG ; Han ZHAO ; Boran DU ; Jingxia ZHAO ; Wei WANG ; Leilei GONG ; Xin FENG
Chinese Journal of Experimental Traditional Medical Formulae 2023;29(12):38-45
Danggui Buxuetang, derived from Clarifying Doubts about Damage from Internal and External Causes (Volume 2): Treatise on Heat Injury to Stomach Qi(《内外伤辨惑论卷中·暑伤胃气论》) by LI Dongyuan in the Jin and Yuan dynasties, is a classic and famous formula for tonifying qi and generating blood that has been inherited and promoted by successive generations of medical practitioners and has been included in the "Catalogue of Ancient Classical Prescriptions (First Batch)" published by the National Administration of Traditional Chinese Medicine in 2018. The paper analyzed the historical origin, composition, dosage, processing, preparation, decocting, and taking methods, efficacy, and application of the classic formula Danggui Buxuetang by consulting ancient and modern literature and combining the key information examination principles of ancient classic prescriptions. A total of 604 pieces of information on relevant ancient literature were collected, including 186 ancient Chinese medical books, of which 40 (five in the Jin and Yuan dynasties, 19 in the Ming Dynasty, and 16 in the Qing Dynasty) had detailed records of composition, processing, and dosage. Danggui Buxuetang is mainly comprised of Astragali Radix and Angelicae Sinensis Radix. According to the ancient and modern dose conversion, there are 37.3-38.1 g of Astragali Radix and 7.5-7.6 g of Angelicae Sinensis Radix in the formula. Astragali Radix is preferably fried with honey and Angelicae Sinensis Radix with wine. Astragali Radix and Angelicae Sinensis Radix are decocted with 600 mL of water to 300 mL, and taken warm before meals. The main effect of this formula are described in ancient books as blood deficiency and fever, with symptoms of muscle fever, dryness and heat, irritability and thirst, red eyes and face, sleeplessness in daytime and night, and surging and feeble pulse which is weak under hard pressing, and it is a famous formula for replenishing qi and generating blood. Modern research shows that Danggui Buxuetang is commonly used in the treatment of various kinds of anemia, diabetic nephropathy, tumors, and cardiovascular and cerebrovascular diseases. The above research results can provide a reference for the subsequent development and research on the classic formula Danggui Buxuetang.
3.Reverse effect of Semaphorin-3F on rituximab resistance in diffuse large B-cell lymphoma via the Hippo pathway.
Qiong LI ; Naya MA ; Xinlei LI ; Chao YANG ; Wei ZHANG ; Jingkang XIONG ; Lidan ZHU ; Jiali LI ; Qin WEN ; Lei GAO ; Cheng YANG ; Lingyi RAO ; Li GAO ; Xi ZHANG ; Jun RAO
Chinese Medical Journal 2023;136(12):1448-1458
BACKGROUND:
Exploring the underlying mechanism of rituximab resistance is critical to improve the outcomes of patients with diffuse large B-cell lymphoma (DLBCL). Here, we tried to identify the effects of the axon guidance factor semaphorin-3F (SEMA3F) on rituximab resistance as well as its therapeutic value in DLBCL.
METHODS:
The effects of SEMA3F on the treatment response to rituximab were investigated by gain- or loss-of-function experiments. The role of the Hippo pathway in SEMA3F-mediated activity was explored. A xenograft mouse model generated by SEMA3F knockdown in cells was used to evaluate rituximab sensitivity and combined therapeutic effects. The prognostic value of SEMA3F and TAZ (WW domain-containing transcription regulator protein 1) was examined in the Gene Expression Omnibus (GEO) database and human DLBCL specimens.
RESULTS:
We found that loss of SEMA3F was related to a poor prognosis in patients who received rituximab-based immunochemotherapy instead of chemotherapy regimen. Knockdown of SEMA3F significantly repressed the expression of CD20 and reduced the proapoptotic activity and complement-dependent cytotoxicity (CDC) activity induced by rituximab. We further demonstrated that the Hippo pathway was involved in the SEMA3F-mediated regulation of CD20. Knockdown of SEMA3F expression induced the nuclear accumulation of TAZ and inhibited CD20 transcriptional levels via direct binding of the transcription factor TEAD2 and the CD20 promoter. Moreover, in patients with DLBCL, SEMA3F expression was negatively correlated with TAZ, and patients with SEMA3F low TAZ high had a limited benefit from a rituximab-based strategy. Specifically, treatment of DLBCL cells with rituximab and a YAP/TAZ inhibitor showed promising therapeutic effects in vitro and in vivo .
CONCLUSION
Our study thus defined a previously unknown mechanism of SEMA3F-mediated rituximab resistance through TAZ activation in DLBCL and identified potential therapeutic targets in patients.
Humans
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Animals
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Mice
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Rituximab/therapeutic use*
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Hippo Signaling Pathway
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Lymphoma, Large B-Cell, Diffuse/pathology*
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Prognosis
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Semaphorins/therapeutic use*
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Antineoplastic Combined Chemotherapy Protocols/therapeutic use*
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Membrane Proteins/genetics*
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Nerve Tissue Proteins/genetics*
4.Life History Recorded in the Vagino-cervical Microbiome Along with Multi-omes
Jie ZHUYE ; Chen CHEN ; Hao LILAN ; Li FEI ; Song LIJU ; Zhang XIAOWEI ; Zhu JIE ; Tian LIU ; Tong XIN ; Cai KAIYE ; Zhang ZHE ; Ju YANMEI ; Yu XINLEI ; Li YING ; Zhou HONGCHENG ; Lu HAORONG ; Qiu XUEMEI ; Li QIANG ; Liao YUNLI ; Zhou DONGSHENG ; Lian HENG ; Zuo YONG ; Chen XIAOMIN ; Rao WEIQIAO ; Ren YAN ; Wang YUAN ; Zi JIN ; Wang RONG ; Liu NA ; Wu JINGHUA ; Zhang WEI ; Liu XIAO ; Zong YANG ; Liu WEIBIN ; Xiao LIANG ; Hou YONG ; Xu XUN ; Yang HUANMING ; Wang JIAN ; Kristiansen KARSTEN ; Jia HUIJUE
Genomics, Proteomics & Bioinformatics 2022;20(2):304-321
The vagina contains at least a billion microbial cells,dominated by lactobacilli.Here we perform metagenomic shotgun sequencing on cervical and fecal samples from a cohort of 516 Chinese women of reproductive age,as well as cervical,fecal,and salivary samples from a second cohort of 632 women.Factors such as pregnancy history,delivery history,cesarean section,and breastfeeding were all more important than menstrual cycle in shaping the microbiome,and such information would be necessary before trying to interpret differences between vagino-cervical micro-biome data.Greater proportion of Bifidobacterium breve was seen with older age at sexual debut.The relative abundance of lactobacilli especially Lactobacillus crispatus was negatively associated with pregnancy history.Potential markers for lack of menstrual regularity,heavy flow,dysmenor-rhea,and contraceptives were also identified.Lactobacilli were rare during breastfeeding or post-menopause.Other features such as mood fluctuations and facial speckles could potentially be predicted from the vagino-cervical microbiome.Gut and salivary microbiomes,plasma vitamins,metals,amino acids,and hormones showed associations with the vagino-cervical microbiome.Our results offer an unprecedented glimpse into the microbiota of the female reproductive tract and call for international collaborations to better understand its long-term health impact other than in the settings of infection or pre-term birth.
5.Simultaneous Determination of 7 Effective Components in Yao Medicine Yueli Yaomi Spray by QAMS
Jingzhi ZHANG ; Danqing ZHAO ; Zhengrong WANG ; Jinyan JIA ; Lin YANG ; Shengsheng ZHANG ; Xinlei LIU ; Qing WU ; Wei PAN
China Pharmacy 2020;31(9):1044-1049
OBJECTIVE:To establish QAMS method for simultaneou s determination of 7 effective components in Yao medicine Yueli yaomi spray ,such as α-cyperone,α-pinene,β-pinene,limonene,β-elemene,caryophyllene oxide and ligustilide , so as to provide method reference for the quality control of the preparation. METHODS :GC method was adopted. The determination was performed on DB- 1701P capillary column ,using nitrogen as carrier gas. The temperature of the hydrogen flame ion detector was 240 ℃. The temperature was programmed ,the inlet temperature was 240 ℃,the injection volume was 1 μL and the split ratio was 20 ∶ 1. Using limonene as internal reference ,the relative correction factors of other 6 components were calculated,the contents of them were calculated with relative correction factors ,and then compared with the results of internal standard method (using naphthalene as internal standard ). RESULTS :The mass concentration linear range of α-cyperone, α-pinene,β-pinene,limonene,β-elemene,caryophyllene oxide and ligustilide were 0.008 9-1.110 0,0.028 3-3.540 0,0.020 5- 2.560 0,0.023 0-2.880 0,0.016 3-2.035 0,0.013 1-1.640 0,0.008 3-1.040 0 mg/mL(all r>0.999 0);the limits of quantification were 0.005 6,0.013 1,0.011 4,0.018 6,0.010 8,0.008 9,0.004 5 mg/mL;the detection limits were 0.001 9,0.004 1,0.003 7, 0.006 2,0.003 5,0.002 9,0.001 5 mg/mL;RSDs for precision ,stability(24 h),and repeatability tests were all less than 2% (n=5 or n=6); the average recoveries were 98.48% , 014) 101.37%,97.96%,99.80%,102.79%,97.77%,102.14%, and RSDs were all lower than 2%(n=9),respectively. The average relative correction factors of α-cyperone,α-pinene, β-pinene,β-elemene,caryophyllene oxide and ligustilide were 1.045 8,0.621 0,0.488 5,0.382 9,0.708 9,0.956 9 respectively,and the RSDs were all lower than 2%(n=6). There wa s no statistical significance in contents of 7 components between QAMS method and internal standard method (P>0.05). CONCLUSIONS :The established QAMS method is simple , accurate,stable and reproducible ,and can be used for simultaneous determination for 7 components in Yueli yaomi spray.
6.In vitro multi-enzyme molecular machines - a review.
Chinese Journal of Biotechnology 2019;35(10):1870-1888
In vitro multi-enzyme molecular machines that follow the designed multi-enzyme pathways, require the rational optimization and adaptation of several purified or partially purified enzyme components, in order to convert certain substrates into target compounds in vitro in an efficient manner. This type of molecular machine is component-based and modularized, so that its design, assembly, and regulation processes are highly flexible. Recently, the advantages of in vitro multi-enzyme molecular machines on the precise control of reaction process and the enhancement of product yield have suggested their great application potential in biomanufacturing. Studies on in vitro multi-enzyme molecular machines have become an important branch of synthetic biology, and are gaining increasing attentions. This article systematically reviews the enzyme component-/module-based construction strategy of in vitro multi-enzyme molecular machines, as well as the research progress on the improvement of compatibility among enzyme components/modules. The current challenges and future prospects of in vitro multi-enzyme molecular machines are also discussed.
Biotechnology
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Enzymes
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chemistry
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metabolism
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Multienzyme Complexes
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chemistry
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metabolism
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Synthetic Biology
7.Multifunctional polymeric micelle-based chemo-immunotherapy with immune checkpoint blockade for efficient treatment of orthotopic and metastatic breast cancer.
Jiaojie WEI ; Yang LONG ; Rong GUO ; Xinlei LIU ; Xian TANG ; Jingdong RAO ; Sheng YIN ; Zhirong ZHANG ; Man LI ; Qin HE
Acta Pharmaceutica Sinica B 2019;9(4):819-831
Immunotherapy has become a highly promising paradigm for cancer treatment. Herein, a chemo-immunotherapy was developed by encapsulating chemotherapeutic drug doxorubicin (DOX) and Toll-like receptor 7 agonist imiquimod (IMQ) in low molecular weight heparin (LMWH)-d--tocopheryl succinate (TOS) micelles (LT). In this process, LMWH and TOS were conjugated by ester bond and they were not only served as the hydrophilic and hydrophobic segments of the carrier, but also exhibited strong anti-metastasis effect. The direct killing of tumor cells mediated by DOX-loaded micelles (LT-DOX) generated tumor-associated antigens, initiating tumor-specific immune responses in combination with IMQ-loaded micelles (LT-IMQ). Furthermore, the blockade of immune checkpoint with programmed cell death ligand 1 (PD-L1) antibody further elevated the immune responses by up-regulating the maturation of DCs as well as the ratios of CD8 CTLs/T and CD4 T/T. Therefore, such a multifunctional strategy exhibited great potential for inhibiting the growth of orthotopic and metastatic breast cancer.
8.The Huashan diagnostic criteria and clinical classification of Hirayama disease
Hongli WANG ; Chaojun ZHENG ; Xiang JIN ; Feizhou LYU ; Xiaosheng MA ; Xinlei XIA ; Wei ZHU ; Jianyuan JIANG
Chinese Journal of Orthopaedics 2019;39(8):458-465
Objective To establish Huashan diagnostic criteria and clinical classification system for Hirayama disease.Methods Retrospective analysis 359 cases of puberty onset,upper extremity muscle atrophy as main clinical manifestations,and complete clinical data from September 2007 to August 2018.There were 348 males and 11 females(31.6:1 male and female)in this group.The average age of onset was 16.7±2.2 years,the average age of visits was 19.2±4.5 years,and the average duration of treatment was 29.3±45.4 months.Descriptive study of the clinical manifestations,radiologic and neurophysiological findings of this group of patients,the Huashan clinical diagnostic criteria of Hirayama disease were established by including 100% of the clinical manifestations,imaging and neurophysiological findings.According to the following parameters,the clinical classification system of Hirayama disease was proposed.The parameters specifically included:the muscle atrophy involves the upper limbs,whether the quadriplegia was active or hyperactive,the Babinski sign positive and other pyramidal tract damage,whether it was accompanied by sensory dysfunction such as upper limb numbness,muscle atrophy location,and the progress of clinical symptoms or electrophysiological examination within 6 months.Thirty patients were randomly selected from the above 359 cases.Four orthopedic surgeons who were not involved in the classification system completed the clinical classification within the specified time.The Kappa value was used for the credibility evaluation.Results The Huashan diagnostic criteria of Hirayama disease included clinical manifestations,imaging examinations and neurophysiological examinations.The main diagnostic indicators were:1)occult onset puberty,more common in men;2)localized muscle atrophy and weakness in the upper extremities;3)compared with the cervical neutral MRI,the MRI of cervical flexion showed that spinal cord was significantly shift forward and the anterior spinal cord was narrowed or disappeared.4)MRI T2 weighting of the cervical flexion showed cyst-wall separation behind the spinal cord;5)Neurophysiological examination showed that the affected muscles were neurogenic damage.6)The affected parts are limited to the middle and lower neck segment.At the same time,it was necessary to combine imaging and neurophysiological manifestations to distinguish cervical spondylosis with upper limb muscle atrophy and motor neuron disease.According to the clinical characteristics of different patients,Hirayama disease can be divided into type I-III.Type I:72.1%,one-sided upper limb or one upper limb-based hand inner muscle and forearm muscle atrophy.According to whether progress of symptoms or electrophysiological examination was seen in the past 6 months,type I can be divided into:Ia.stable period.Regular follow-up assessment was recommended.If the disease progressed,to wear a cervical collar was suggested;surgery could be done if necessary;Ib.progression period,it was recommended to use a cervical collar,and regularly evaluate,if patients could not wear cervical collar for long,it was recommended to operate.Type II:14.2%,unilateral upper limb or one upper limb-based hand inner muscle and forearm muscle atrophy with pyramidal tract injury.Surgery was recommended.Type II:13.7%,atypical Hirayama disease,including upper limb proximal muscle atrophy,symmetrical double upper limb muscle atrophy,and sensory disturbances associated with upper limb numbness.Wear a cervical collar,and follow-up and assess closely,and choose surgical treatment if necessary.The credibility evaluation showed that the average Kappa value of the classification was 0.732(0.688-0.834),which is a basic credibility.Conclusion The Huashan diagnostic criteria of Hirayama disease was conducive to the early diagnosis.The clinical classification system of Hirayama disease has good credibility and good clinical intervention guidance value.
9.Predictive value of dynamic F-wave In surgical treatment of Hirayama disease
Chaojun ZHENG ; Cong NIE ; Xiang JIN ; Hongli WANG ; Wei ZHU ; Xinlei XIA ; Xiaosheng MA ; Feizhou LYU ; Jianyuan JIANG
Chinese Journal of Orthopaedics 2019;39(8):496-503
Objective To investigate the predictive value of dynamic F wave in the treatment of Hirayama disease(HD)after anterior cervical fusion and internal fixation.Methods From February 2014 to January 2016,thirty-six patients with HD were included in this study(age:17.9±2.6 years,height:173.1±6.2 cm,disease duration:20.1±13.1 months;male to female ratio:35:1),and all of these 36 patients underwent anterior cervical autogenous iliac fusion and internal fixation.All of these patients underwent bilateral dynamic F-wave detection(The F-wave was tested on the cervical standard position and at least 30 minutes after cervical flexion)on the median nerve before operation and 3-5 days after operation.The latency and maximum amplitude of M-wave,the persistence of F-wave,the shortest latency of F-wave,the ratio of F/M and the persistence of repeated F-wave were measured.Dynamic F-wave abnormalities were defined when repeated F-wave was only found during neck flexion or the standard-flexion difference of each measurements of F-wave was more than 2 standard deviations from the normal value(the shortest latency of F-wave:0.6±0.5 ms,persistence of F-wave:7.3%±5.7%,the ratio of F/M:1.1±1.0).Furthermore,these patients with HD accepted both bilateral grip strength and hand function score(disabilities of arm,shoulder and hand,DASH)before and 1 year after operation.According to the presence of abnormal dynamic F-wave before operation,patients were divided into abnormal dynamic F-wave group and normal dynamic F-wave group.Fisher exact test was used to compare the percentage of the patient with improved DASH score in both patient groups after operation.Both DASH score and bilateral grip strength were analyzed by paired sample t test before and after operation.Results Before operation,eleven(11/36,30.6%)patients with HD had abnormal dynamic F-wave,and there was no significant difference of age(t=-0.849,P=0.412),duration(t=1.110,P=0.282),DASH scores(t=2.002,P=0.055)and handgrips(more-symptomatic side:t=-0.673,P=0.507;symptomatic side:t=-1.729,P=0.094)between the patients with or without preoperative dynamic F-wave abnormalities.One-year follow-up demonstrated that significantly greater number of the patients presented with reduced DASH scores in the patients with preoperative dynamic F-wave abnormalities(10/11,90.9% vs 12/25,48.0%;P=0.025).Compared with the patients without preoperative dynamic F-wave abnormalities,the patients with preoperative dynamic F-wave abnormalities showed reduced DASH scores after operation(t=2.347,P=0.041).Furthermore,abnormal dynamic F-waves disappeared soon after operation in ten patients(90.9%,10/11)with preoperative dynamic F-wave abnormalities,and DASH scores reduced significantly in these ten patients after operation(4.4±3.8 vs 1.5±0.4,t=3.094,P=0.013),and the DASH score in another patient whose dynamic F wave did not disappear after operation increased significantly one year after operation(preoperative vs.postoperative:6.66 vs 9.87).Conclusion Dynamic F-wave can be used as a preoperative evaluation method for HD to predict the recovery of upper limb function after operation.At the same time,the comparison of dynamic F-wave before and after operation is an effective and immediate method to evaluate the effectiveness of surgical treatment of HD.
10.Evaluating neurological injury in Hirayama disease using threshold tracking technology
Cong NIE ; Chaojun ZHENG ; Xiaosheng MA ; Xinlei XIA ; Wei ZHU ; Xiang JIN ; Hongli WANG ; Feizhou LYU ; Jianyuan JIANG
Chinese Journal of Orthopaedics 2019;39(8):510-517
Objective To investigate the efficacy of neurological injury in patients with Hirayama disease using threshold tracking technique.Methods This study included 17 patients with Hirayama disease who visited the Department of Orthopaedics of Huashan Hospital from June 2017 to October 2017(patient group,16 males and 1 female,the average age was 18.06±0.50 years,ranging from 16 to 22 years,the average course of disease was 27.2±18.81 months,ranging from 1 to 60 months.Mean-while,a total of 20 healthy volunteers(control group,19 males and 1 female,the average age is 20.05±1.30 years,ranging from 17 to 23 years)were also enrolled in this study.In patient group,the median motor nerve conduction examination,needle EMG examination,and threshold tracking examination were performed on the severe side;while in control group,the median motor nerve conduction examination and threshold tracking examination were performed on either side.We evaluate the changes in peripheral motor nerve conduction of Hirayama disease by comparing CMAP(compound muscle action potential)and median motor nerve conduction velocity evaluate the changes in motor nerve excitability by comparing the rheobase,SDTC(Strength-duration time constant),threshold electrotonus,current-threshold I/V slope,superexcitability,and subexcitability.The upper limb function was assessed by disabilities of arm,shoulder and hand(DASH)score.The differences in threshold tracking parameters between groups were compared by independent t test,and the correlation between SDTC and DASH score was tested by Pearson correlation analysis.Results In the peripheral motor nerve conduction examination,the median nerve CMAP in patients with Hirayama disease was 4.12±1.43 mV in average,which is lower than healthy controls 8.23±1.61 mV(t=-3.8,P<0.01).There was no significant difference in the peripheral motor nerve conduction velocity(t=-0.86,P=0.39).In the threshold tracking examination,SDTC in patients with Hirayama disease was 0.48±0.09 ms,which was prolonged than healthy controls 0.39±0.06 ms(t=3.75,P<0.01).The absolute values of TEh(10-20)and TEh(20-40)decreased significantly(P<0.01),hence,the hyperpolarized part of the threshold-electrotonus curve showed "fanning-in" pattern.The slope of the current-threshold(I/V)curve had a decreasing trend.The hyper-polarized l/V slope in patients with Hirayama disease was 0.27±0.09 in average,which was lower than the healthy controls which was 0.34±0.07(t=-2.73,P=0.01).The DASH score of patients ranged from 0.86 to 19.44,with an average of 6.99±5.79.There was a correlation between SDTC and DASH score,R2=0.36,which met the F test(P=0.01).Conclusion Threshold tracking technique can be adapted in evaluating nerve injury in Hirayama disease to determine the degree of injury and potential pathogenesis.

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