Nkx2-5 and Sarcospan genetically interact in the development of the muscular ventricular septum of the heart.

The muscular ventricular septum separates the flow of oxygenated and de-oxygenated blood in air-breathing vertebrates. Defects within it, termed muscular ventricular septal defects (VSDs), are common, yet less is known about how they arise than rarer heart defects. Mutations of the cardiac transcription factor NKX2-5 cause cardiac malformations, including muscular VSDs. We describe here a genetic interaction between Nkx2-5 and Sarcospan (Sspn) that affects the risk of muscular VSD in mice. Sspn encodes a protein in the dystrophin-glycoprotein complex. Sspn knockout (SspnKO) mice do not have heart defects, but Nkx2-5+/-/SspnKO mutants have a higher incidence of muscular VSD than Nkx2-5+/- mice. Myofibers in the ventricular septum follow a stereotypical pattern that is disrupted around a muscular VSD. Subendocardial myofibers normally run in parallel along the left ventricular outflow tract, but in the Nkx2-5+/-/SspnKO mutant they commonly deviate into the septum even in the absence of a muscular VSD. Thus, Nkx2-5 and Sspn act in a pathway that affects the alignment of myofibers during the development of the ventricular septum. The malalignment may be a consequence of a defect in the coalescence of trabeculae into the developing ventricular septum, which has been hypothesized to be the mechanistic basis of muscular VSDs.

Adaptive working memory strategy training in early Alzheimer's disease: randomised controlled trial.

BACKGROUND: Interventions that improve cognitive function in Alzheimer's disease are urgently required. AIMS: To assess whether a novel cognitive training paradigm based on 'chunking' improves working memory and general cognitive function, and is associated with reorganisation of functional activity in prefrontal and parietal cortices (trial registration: ISRCTN43007027). METHOD: Thirty patients with mild Alzheimer's disease were randomly allocated to receive 18 sessions of 30 min of either adaptive chunking training or an active control intervention over approximately 8 weeks. Pre- and post-intervention functional magnetic resonance imaging (fMRI) scans were also conducted. RESULTS: Adaptive chunking training led to significant improvements in verbal working memory and untrained clinical measures of general cognitive function. Further, fMRI revealed a bilateral reduction in task-related lateral prefrontal and parietal cortex activation in the training group compared with controls. CONCLUSIONS: Chunking-based cognitive training is a simple and potentially scalable intervention to improve cognitive function in early Alzheimer's disease.

Association of genes with physiological functions by comparative analysis of pooled expression microarray data.

The physiological functions of a tissue in the body are carried out by its complement of expressed genes. Genes that execute a particular function should be more specifically expressed in tissues that perform the function. Given this premise, we mined public microarray expression data to build a database of genes ranked by their specificity of expression in multiple organs. The database permitted the accurate identification of genes and functions known to be specific to individual organs. Next, we used the database to predict transcriptional regulators of brown adipose tissue (BAT) and validated two candidate genes. Based upon hypotheses regarding pathways shared between combinations of BAT or white adipose tissue (WAT) and other organs, we identified genes that met threshold criteria for specific or counterspecific expression in each tissue. By contrasting WAT to the heart and BAT, the two most mitochondria-rich tissues in the body, we discovered a novel function for the transcription factor ESRRG in the induction of BAT genes in white adipocytes. Because the heart and other estrogen-related receptor gamma (ESRRG)-rich tissues do not express BAT markers, we hypothesized that an adipocyte co-regulator acts with ESRRG. By comparing WAT and BAT to the heart, brain, kidney and skeletal muscle, we discovered that an isoform of the transcription factor sterol regulatory element binding transcription factor 1 (SREBF1) induces BAT markers in C2C12 myocytes in the presence of ESRRG. The results demonstrate a straightforward bioinformatic strategy to associate genes with functions. The database upon which the strategy is based is provided so that investigators can perform their own screens.

Complex trait analysis of ventricular septal defects caused by Nkx2-5 mutation.

BACKGROUND: The occurrence of a congenital heart defect has long been thought to have a multifactorial basis, but the evidence is indirect. Complex trait analysis could provide a more nuanced understanding of congenital heart disease. METHODS AND RESULTS: We assessed the role of genetic and environmental factors on the incidence of ventricular septal defects (VSDs) caused by a heterozygous Nkx2-5 knockout mutation. We phenotyped >3100 hearts from a second-generation intercross of the inbred mouse strains C57BL/6 and FVB/N. Genetic linkage analysis mapped loci with lod scores of 5 to 7 on chromosomes 6, 8, and 10 that influence the susceptibility to membranous VSDs in Nkx2-5(+/-) animals. The chromosome 6 locus overlaps one for muscular VSD susceptibility. Multiple logistic regression analysis for environmental variables revealed that maternal age is correlated with the risk of membranous and muscular VSD in Nkx2-5(+/-) but not wild-type animals. The maternal age effect is unrelated to aneuploidy or a genetic polymorphism in the affected individuals. The risk of a VSD is not only complex but dynamic. Whereas the effect of genetic modifiers on risk remains constant, the effect of maternal aging increases over time. CONCLUSIONS: Enumerable factors contribute to the presentation of a congenital heart defect. The factors that modify rather than cause congenital heart disease substantially affect risk in predisposed individuals. Their characterization in a mouse model offers the potential to narrow the search space in human studies and to develop alternative strategies for prevention.

Correction methodology for the spectral interfering γ-rays overlapping to the analytical peaks used in the analysis of 232Th.

In the γ-ray spectrometric analysis of the radionuclides, a correction factor is generally required for the spectral interfering γ-rays in determining the net areas of the analytical peaks because some interfering γ-rays often might contribute to the analytical peaks of interest. In present study, a correction methodology for the spectral interfering γ-rays (CSI) is described. In particular, in the analysis of (232)Th contained in samples, the interfering γ-rays due to (226)Ra, (235)U, (238)U and their decay products often overlap to the peaks of interest from (232)Th decay products, and vise versa. For the validation of the proposed CSI method, several certified reference materials (CRM) containing U and Th were measured by using a 76.5% efficient n-type Ge detector. The required correction factors were quantified for spectral interference, self-absorption and true coincidence summing (TCS) effects for the relevant γ-rays. The measured results indicate that if one ignores the contributions of the interfering γ-rays to the analytical peaks at 583.2 keV of (208)Tl and 727.3 keV of (212)Bi, this leads to a significantly systematic influence on the resulted activities of (232)Th. The correction factors required for spectral interference and TCS effects are estimated to be ∼13.6% and ∼15.4% for 583.2 keV peak. For the 727.3 keV peak, the correction factor is estimated to be ∼15% for spectral interference, and ∼5% for the TCS effects at the presently used detection geometry. On the other hand, the measured results also indicate that ignoring the contribution of the interfering γ-rays to the areas of the analytical peaks at 860.6 keV of (208)Tl, 338.3 and 911.2 keV of (228)Ac does not lead to any significant systematic influence on the (232)Th analysis. Because these factors are remained generally less than ∼5%, i.e., within overall uncertainty limits. The present study also showed that in view of both the spectral interference and TCS effects, the "cleaner" analytical peaks are seen at 338.3 keV (11.25%) and 911.2 keV (26.13%) of (228)Ac when high resolution γ-rays spectrometry was used in the (232)Th activity measurements. Therefore, they can be adopted as the "reference" peaks in the (232)Th analysis.

True coincidence-summing corrections for the coincident gamma-rays measured with coplanar grid CdZnTe detectors.

In this study, true coincidence-summing (TCS) correction factors have been measured for the sources (22)Na, (60)Co, (133)Ba and (152)Eu by use of three large volume coplanar grid CdZnTe (acronym: CZT) detectors. In case of a close-in detection geometry, two different TCS calculation algorithms were used to compute the required TCS correction factors. Both of the algorithms are based on the measured total-to-peak (TTP) ratio and full-energy peak (FEP) efficiency values that were obtained using almost "single" energy and coincidence-free nuclides. The results for TCS correction factors obtained by two different algorithms were agreeable to each other. The obtained TCS factors were ranged from about 7% to 30.5% in a 2250 mm(3) CZT detector when a close counting geometry was used. For other two detectors with a volume of 1000 and 1687.5mm(3), the resulted TCS correction factors were relatively smaller and varied between about 0.1% and 20% at the close counting geometry condition. Therefore, the results indicate that there is a need for the estimation of TCS corrections in CZT detectors, especially when their crystal volumes are greater than 1cm(3) and these detectors are used in the case of a close-in detection geometry.

Methods for spectral interference corrections for direct measurements of 234U and 230Th in materials by gamma-ray spectrometry.

When the high-resolution gamma-ray spectrometry was used in the analysis of (234)U and (230)Th in samples, there is a much more need to correct for the measured activity results of (234)U and (230)Th mainly due to self-absorption effects and the interfering lines from (226)Ra, (235)U, (238)U and their decay products that often might be present in the samples. Therefore, in the present study, the methods for the spectral interference corrections for the analytical peaks of (234)U and (230)Th are suggested to take into account the contributions of the overlapping gamma rays to these peaks. For the method validation, direct gamma-ray spectrometric measurements were carried out using certified reference materials (CRM) by use of a 76.5 % n-type Ge detector. The activities measured for the CRM samples were corrected for spectral interferences, self-absorption and true coincidence-summing (TCS) effects. The obtained results indicate that ignoring of the contribution of the interference gamma rays to the main analytical peak at 53.2 keV of (234)U leads to a lager systematic error of 87.3-90.4 % for the measured activities of (234)U, and similarly if one ignores the contributions of the interference gamma rays to the main analytical peak at 67.7 keV of (230)Th, this leads to a much smaller systematic error of 2.1-2.7 % for the activities of (230)Th. Therefore, the required correction factors for spectral interferences to the analytical peaks of (234)U and (230)Th are not negligible and thus they should also be considered besides necessary self-absorption factors to determine more accurate activities in the samples. On the other hand, it is estimated that although the TCS effects on the main analytical peaks of both (234)U and (230)Th are negligibly small, those TCS correction factors for their interference gamma rays to these peaks should be taken into account when direct measurements are performed in a close-counting geometry condition. Otherwise, the resulted activities can have serious erroneous results for both (234)U and (230)Th while using gamma-ray spectrometry, thereby leading to inaccuracies in their derived quantities, for instance, the corresponding age determinations of the samples.

Assessment of radiation doses to cardiologists during interventional examinations.

The accuracy of two on line dosimetric techniques was investigated for the estimation of cardiologist doses. The first technique involves the establishment of a database relating the cardiologist extremity doses to patient DAP values. Doses of nine cardiologists were measured together with patient doses during the interventional cardiac examinations of 166 patients for this purpose. Data were collected from five cardiology departments. The mean of the eye, thyroid, waist, right-left wrist, and right-left leg doses per procedure were measured as 72.4 (31.6-107.1), 68.5 (13.3-174.6), 11.2 (0.9-28.4), 67.8 (21.9-120.3) to 216 (52.7-425.4), and 137 (51.4-386.2) to 384 (135-1168.3) microGy/procedure. The effective doses were calculated according to the use of protection tools and a mean value of 12.14 (1.2-30.2) microSv/procedure was found. The ratios of staff dose to patient DAP were found to be within the range of 0.14-3.75 for each procedure. In the second method, cardiologist doses were calculated and compared with the measured values. Scatter doses were measured at the positions of cardiologists from Rando phantom exposures using similar conditions with patient procedures for this purpose. The parameters obtained from these exposures and patient examinations were used to calculate the doses to cardiologists.

Patient and staff doses for some complex x-ray examinations.

The aim of this study was to measure patient and staff doses simultaneously for some complex x-ray examinations. Measurements of dose-area product (DAP) and entrance skin dose (ESD) were carried out in a sample of 107 adult patients who underwent different x-ray examinations such as double contrast barium enema (DCBE), single contrast barium enema (SCBE), barium swallow, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC), and various orthopaedic surgical procedures. Dose measurements were made separately for each projection, and DAP, thermoluminescent dosimetry (TLD), film dosimetry and tube output measurement techniques were used. Staff doses were measured simultaneously with patient doses for these examinations, with the exception of barium procedures. The measured mean DAP values were found to be 8.33, 90.24, 79.96 Gy cm(2) for barium swallow, SCBE and DCBE procedures with the fluoroscopy times of 3.1, 4.43 and 5.86 min, respectively. The calculated mean DAP was 26.33 Gy cm(2) for diagnostic and 89.76 Gy cm(2) therapeutic ERCP examinations with the average fluoroscopy times of 1.9 and 5.06 min respectively. Similarly, the calculated mean DAP was 97.53 Gy cm(2) with a corresponding fluoroscopy time of 6.1 min for PTC studies. The calculated mean entrance skin dose (ESD) was 172 mGy for the orthopaedic surgical studies. Maximum skin doses were measured as 324, 891, 1218, 750, 819 and 1397 mGy for barium swallow, SCBE, DCBE, ERCP, PTC and orthopaedic surgical procedures, respectively. The high number of radiographs taken during barium enema examinations, and the high x-ray outputs of the fluoroscopic units used in ERCP, were the main reasons for high doses, and some corrective actions were immediately taken.

Radiation doses of patients and urologists during percutaneous nephrolithotomy.

Renal stones can be treated either by extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL). Increasing use of fluoroscopic exposure for access and to detect stone location during PCNL make the measurement of patient and staff doses important. The main objective of this work was to assess patient and urologist doses for the PCNL examination. We used the tube output technique for determination of patient doses (n = 20) and lithium fluoride thermoluminescent dosimeter (TLD) chips for urologist dose measurements. The TLD technique was also used for some patient dose measurements (n = 7) for comparison with the tube output technique. Mean entrance skin doses of 191 and 117 mGy were measured by the tube output technique for anterior-posterior (AP) and right anterior oblique (RAO) 30 degrees /left anterior oblique (LAO) 30 degrees projections, respectively. The mean urologist doses for eye, finger and collar were measured as 26, 33.5 and 48 microGy per procedure, respectively. The mean effective dose per procedure for the urologist was 12.7 microSv. None of the individual skin dose results approach deterministic levels.

Spectral interference corrections for the measurement of (238)U in materials rich in thorium by a high resolution gamma-ray spectrometry.

In this study, the spectral interferences are investigated for the analytical peaks at 63.3 keV of (234)Th and 1001.0 keV of (234m)Pa, which are often used in the measurement of (238)U activity by the gamma-ray spectrometry. The correction methods are suggested to estimate the net peak areas of the gamma-rays overlapping the analytical peaks, due to the contribution of (232)Th that may not be negligible in materials rich in natural thorium. The activity results for the certified reference materials (CRMs) containing U and Th were measured with a well type Ge detector. The self-absorption and true coincidence-summing (TCS) effects were also taken into account in the measurements. It is found that ignoring the contributions of the interference gamma-rays of (232)Th and (235)U to the mixed peak at 63.3 keV of (234)Th ((238)U) leads to the remarkably large systematic influence of 0.8-122% in the measured (238)U activity, but in case of ignoring the contribution of (232)Th via the interference gamma-ray at 1000.7 keV of (228)Ac to the mixed peak at 1001 keV of (234m)Pa ((238)U) results in relatively smaller systematic influence of 0.05-3%, depending on thorium contents in the samples. The present results showed that the necessary correction for the spectral interferences besides self-absorption and TCS effects is also very important to obtain more accurate (238)U activity results. Additionally, if one ignores the contribution of (232)Th to both (238)U and (40)K activities in materials, the maximum systematic influence on the effective radiation dose is estimated to be ~6% and ~1% via the analytical peaks at 63.3 and 1001 keV for measurement of the (238)U activity, respectively.

Reference levels at European level for cardiac interventional procedures.

In interventional cardiology, a wide variation in patient dose for the same type of procedure has been recognised by different studies. Variation is almost due to procedure complexity, equipment performance, procedure protocol and operator skill. The SENTINEL consortium has performed a survey in nine european centres collecting information on near 2000 procedures, and a new set of reference levels (RLs) for coronary angiography and angioplasty and diagnostic electrophysiology has been assessed for air kerma-area product: 45, 85 and 35 Gy cm2, effective dose: 8, 15 and 6 mSv, cumulative dose at interventional reference point: 650 and 1500 mGy, fluoroscopy time: 6.5, 15.5 and 21 min and cine frames: 700 and 1000 images, respectively. Because equipment performance and set-up are the factors contributing to patient dose variability, entrance surface air kerma for fluoroscopy, 13 mGy min(-1), and image acquisition, 0.10 mGy per frame, have also been proposed in the set of RLs.

When thoughts become action: an fMRI paradigm to study volitional brain activity in non-communicative brain injured patients.

The assessment of voluntary behavior in non-communicative brain injured patients is often challenging due to the existence of profound motor impairment. In the absence of a full understanding of the neural correlates of consciousness, even a normal activation in response to passive sensory stimulation cannot be considered as proof of the presence of awareness in these patients. In contrast, predicted activation in response to the instruction to perform a mental imagery task would provide evidence of voluntary task-dependent brain activity, and hence of consciousness, in non-communicative patients. However, no data yet exist to indicate which imagery instructions would yield reliable single subject activation. The aim of the present study was to establish such a paradigm in healthy volunteers. Two exploratory experiments evaluated the reproducibility of individual brain activation elicited by four distinct mental imagery tasks. The two most robust mental imagery tasks were found to be spatial navigation and motor imagery. In a third experiment, where these two tasks were directly compared, differentiation of each task from one another and from rest periods was assessed blindly using a priori criteria and was correct for every volunteer. The spatial navigation and motor imagery tasks described here permit the identification of volitional brain activation at the single subject level, without a motor response. Volunteer as well as patient data [Owen, A.M., Coleman, M.R., Boly, M., Davis, M.H., Laureys, S., Pickard J.D., 2006. Detecting awareness in the vegetative state. Science 313, 1402] strongly suggest that this paradigm may provide a method for assessing the presence of volitional brain activity, and thus of consciousness, in non-communicative brain-injured patients.

Simultaneous determination of equivalent dose to organs and tissues of the patient and of the physician in interventional radiology using the Monte Carlo method.

This study presents the results of computations of organ equivalent doses and effective doses for the patient and the primary physician during an interventional cardiological examination. The simulations were carried out for seven x-ray spectra (between 60 kVp and 120 kVp) using the Monte Carlo code MCNP. The voxel-based whole-body model VIP-Man was employed to represent both the patient and the physician, the former lying on the operation table while the latter standing 15 cm from the patient at about waist level behind a lead apron. The x-rays, which were generated by a point source positioned around the table and were directed with a conical distribution, irradiated the patient's heart under five major projections used in a coronary angiography examination. The mean effective doses under LAO45, PA, RAO30, LAO45/CAUD30 and LLAT irradiation conditions were calculated as 0.092, 0.163, 0.161, 0.133 and 0.118 mSv/(Gy cm2) for the patient and 1.153, 0.159, 0.145, 0.164 and 0.027 microSv/(Gy cm2) for the shielded physician. The effective doses for the patient determined in this study were usually lower than the literature data obtained through measurements and/or calculations and the discrepancies could be attributed to the fact that this study computes the effective doses specific to the VIP-Man body model, which lacks an ovarian contribution to the gonadal equivalent dose. The effective doses for the physician agreed reasonably well with the literature data.

Patient and staff doses in interventional neuroradiology.

Radiation doses for interventional examinations are generally high and therefore necessitate dose monitoring for patients and staff. Relating the staff dose to a patient dose index, such as dose-area product (DAP), could be quite useful for dose comparisons. In this study, DAP and skin doses of 57 patients, who underwent neurointerventional examinations, were measured simultaneously with staff doses. Although skin doses were comparable with the literature data, higher DAP values of 215 and 188.6 Gy cm2 were measured for the therapeutical cerebral and carotid examinations, respectively, owing to the use of biplane system and complexity of the procedure. Mean staff doses for eye, finger and thyroid were measured as 80.6, 77.6 and 28.8 microGy per procedure. The mean effective dose per procedure for the radiologists was 32 microSv. In order to allow better comparisons to be made, DAP normalised doses were also presented.

Comparison of effective doses obtained from dose-area product and air kerma measurements in interventional radiology.

In this study, measurements of dose-area product (DAP) and entrance dose were carried out simultaneously in a sample of 162 adult patients who underwent different interventional examinations. Effective doses for each measurement technique were estimated using the conversion factors that have been determined for specific X-ray views in a mathematical phantom. Exposure conditions used in clinical practice never match these theoretical models exactly, and deviations from the assumed standard conditions cause uncertainties in effective dose estimations. Higher effective dose values are found if the air kerma results are used rather than DAP readings, both for patient and Rando phantom studies. Comparison of DAP, fluoroscopy times and skin doses were made with published data. DAP measurement for the effective dose calculation and thermoluminescent dosimeter for the skin dose estimates are found to be the most reliable methods for patient dosimetry.

The role of spatial configuration in tests of working memory explored with functional neuroimaging.

While the importance of the prefrontal cortex for "higher-order" cognitive functions is largely undisputed, no consensus has been reached regarding the fractionation of functions within this region. Several recent functional neuroimaging studies have suggested that the mid-ventrolateral frontal cortex may play an important role in various aspects of human memory. Thus, similar patterns of activation have been observed in this region during analogous spatial, verbal and visual span tasks. In the present study, however, activation was observed in a more dorsolateral region of the lateral frontal cortex during a modified version of the spatial span task, which differed only in the spatial configuration of the array employed. The results of a supplementary behavioral study, designed to investigate this effect further, suggest that in spatial memory tasks certain stimulus configurations may encourage subjects to adopt mnemonic strategies, which may depend upon dorsolateral, rather than ventrolateral, regions of the frontal cortex. These findings shed further light on the functional relationship between dorsal and ventral regions of the lateral frontal cortex and, more specifically, how the "executive" processes assumed to be dependent upon these regions might contribute to aspects of human memory.

Smoking and mental illness: A population-based prevalence study.

CONTEXT: Studies of selected groups of persons with mental illness, such as those who are institutionalized or seen in mental health clinics, have reported rates of smoking to be higher than in persons without mental illness. However, recent population-based, nationally representative data are lacking. OBJECTIVE: To assess rates of smoking and tobacco cessation in adults, with and without mental illness. DESIGN, SETTING, AND PARTICIPANTS: Analysis of data on 4411 respondents aged 15 to 54 years from the National Comorbidity Survey, a nationally representative multistage probability survey conducted from 1991 to 1992. MAIN OUTCOME MEASURES: Rates of smoking and tobacco cessation according to the number and type of psychiatric diagnoses, assessed by a modified version of the Composite International Diagnostic Interview. RESULTS: Current smoking rates for respondents with no mental illness, lifetime mental illness, and past-month mental illness were 22.5%, 34.8%, and 41.0%, respectively. Lifetime smoking rates were 39.1%, 55.3%, and 59.0%, respectively (P<.001 for all comparisons). Smokers with any history of mental illness had a self-reported quit rate of 37.1% (P =.04), and smokers with past-month mental illness had a self-reported quit rate of 30. 5% (P<.001) compared with smokers without mental illness (42.5%). Odds ratios for current and lifetime smoking in respondents with mental illness in the past month vs respondents without mental illness, adjusted for age, sex, and region of the country, were 2.7 (95% confidence interval [CI], 2.3-3.1) and 2.7 (95% CI, 2.4-3.2), respectively. Persons with a mental disorder in the past month consumed approximately 44.3% of cigarettes smoked by this nationally representative sample. CONCLUSIONS: Persons with mental illness are about twice as likely to smoke as other persons but have substantial quit rates. JAMA. 2000;284:2606-2610.

Lens of the eye: radiation dose in balloon dacryocystoplasty.

PURPOSE: To evaluate the absorbed radiation dose to the lens of the eye, which is the critical organ in the primary beam during fluoroscopically guided transluminal balloon dilation of the lacrimal drainage system (balloon dacryocystoplasty) for obstructive epiphora and to evaluate the possibility of deterministic radiation effect on the lens. MATERIALS AND METHODS: The radiation dose to the lens of the eye during balloon dacryocystoplasty (which includes pre- and postintervention dacryocystography) was measured in 10 consecutive patients by using thermoluminescent dosimeters on the lids of both eyes as close as possible to the lenses. A C-arm angiographic unit coupled with a digital imaging system was used, with similar exposure and geometric parameters in all cases. RESULTS: The mean radiation dose to the lens of the treated eye was 4.6 mGy +/- 2.2 (dose range, 1.9-9.1 mGy) and to that of the untreated eye was 38.5 mGy +/- 17.5 (dose range, 14.7-67.8 mGy). CONCLUSION: The lens of the untreated eye receives a higher dose than that of the treated eye because of its closer proximity to the x-ray tube in a lateral projection. In the lens, even the highest measured radiation dose (67.8 mGy) still was well below the deterministic threshold for lens opacity and cataract formation.