Zinc and vitamin A deficiency in a cohort of children with autism spectrum disorder.

BACKGROUND AND OBJECTIVES: Studies suggest that trace element and vitamin deficiencies are common in children with autism spectrum disorder (ASD). Data describing the rates of vitamin and trace element deficiencies in the ASD population of the northwest of Ireland is lacking. We wished to determine the prevalence of zinc and vitamin A deficiency in the ASD population compared with controls within this geographical area. METHODS: Parents of children aged 2-18 years with ASD were invited to participate in the study. The control group consisted of well children attending the paediatric department for routine blood sampling. Children on vitamin supplements were excluded from both ASD and control groups. Informed written consent was obtained prior to recruitment. Samples were analysed for zinc and vitamin A levels according to standardized laboratory procedures. RESULTS: Seventy-four of the 150 children with ASD who were invited and 72 controls underwent blood sampling. Mean zinc and vitamin A levels were normal in both groups. There were significantly more males in the ASD group (88% versus 56%, p value < 0.001). The mean (SD) zinc level was not different between the groups (ASD 11.7 [1.7] versus control 11.6 [2.1] µmol/L, p value = 0.86). The mean (standard deviation) vitamin A level was higher in the ASD group (ASD 350.6 [82.6] versus 319.2 [82.8] µg/L, p value = 0.03), but this was likely confounded by age. CONCLUSION: Children with ASD in the northwest of Ireland have mean zinc and vitamin A levels within the normal range. It is important that these findings are relayed to health professionals and to parents of children with ASD so that informed decisions on vitamin supplementation can be made.

The Challenges of Identifying and Classifying Child Sexual Abuse Material.

The aim of the present study was to (a) assess the reliability with which indecent images of children (IIOC) are classified as being of an indecent versus nonindecent nature, and (b) examine in detail the decision-making process engaged in by law enforcement personnel who undertake the difficult task of identifying and classifying IIOC as per the current legislative offense categories. One experienced researcher and four employees from a police force in the United Kingdom coded an extensive amount of IIOC (n = 1,212-2,233) to determine if they (a) were deemed to be of an indecent nature, and (b) depicted a child. Interrater reliability analyses revealed both considerable agreement and disagreement across coders, which were followed up with two focus groups involving the four employees. The first entailed a general discussion of the aspects that made such material more or less difficult to identify; the second focused around images where there had been either agreement (n = 20) or disagreement (n = 36) across coders that the images were of an indecent nature. Using thematic analysis, a number of factors apparent within IIOC were revealed to make the determination of youthfulness and indecency significantly more challenging for coders, with most relating to the developmental stage of the victim and the ambiguity of the context of an image. Findings are discussed in light of their implications for the identification of victims of ongoing sexual exploitation/abuse, the assessment and treatment of individuals in possession of IIOC, as well as the practice of policing and sentencing this type of offending behavior.

Neutrophil and monocyte toll-like receptor 4, CD11b and reactive oxygen intermediates, and neuroimaging outcomes in preterm infants.

BACKGROUND: Activated leukocytes and infection are implicated in neonatal brain injury. Leukocyte surface receptors are increased in stroke models and may be targets for future adjunctive therapies. METHODS: Serial blood samples were analyzed from preterm infants (n = 51; <32 wk gestation) on days 0, 1, 2, and 7 of life. Monocyte and neutrophil activation were evaluated via flow cytometry at baseline and following endotoxin stimulation ex vivo by measuring CD11b (activation), toll-like receptor 4 (TLR-4; endotoxin recognition) expression, and intracellular reactive oxygen intermediate (ROI) production (function). RESULTS: Control preterm infants with normal neuroimaging had elevated baseline CD11b and TLR-4 expression and ROI production compared with adults as well as a robust immune response following endotoxin stimulation. Preterm infants with abnormal neuroimaging had increased neutrophil TLR-4 and ROI compared with all controls. CONCLUSION: Preterm infants have a robust immune response compared with adults. Increased TLR-4 expression in preterm infants with abnormal neuroimaging is similar to findings in adult stroke. In addition, ROI production may cause tissue injury. The modulation of these responses may be beneficial in preterm inflammatory disorders.

Comparison of diagnostic techniques for the detection of Cryptosporidium oocysts in animal samples.

While a large number of laboratory methods for the detection of Cryptosporidium oocysts in faecal samples are now available, their efficacy for identifying asymptomatic cases of cryptosporidiosis is poorly understood. This study was carried out to determine a reliable screening test for epidemiological studies in livestock. In addition, three molecular tests were compared to identify Cryptosporidium species responsible for the infection in cattle, sheep and horses. A variety of diagnostic tests including microscopic (Kinyoun's staining), immunological (Direct Fluorescence Antibody tests or DFAT), enzyme-linked immunosorbent assay (ELISA), and molecular methods (nested PCR) were compared to assess their ability to detect Cryptosporidium in cattle, horse and sheep faecal samples. The results indicate that the sensitivity and specificity of each test is highly dependent on the input samples; while Kinyoun's and DFAT proved to be reliable screening tools for cattle samples, DFAT and PCR analysis (targeted at the 18S rRNA gene fragment) were more sensitive for screening sheep and horse samples. Finally different PCR primer sets targetedat the same region resulted in the preferential amplification of certain Cryptosporidium species when multiple species were present in the sample. Therefore, for identification of Cryptosporidium spp. in the event of asymptomatic cryptosporidiosis, the combination of different 18S rRNA nested PCR primer sets is recommended for further epidemiological applications and also tracking the sources of infection.

Classification of pathologic response to neoadjuvant therapy in esophageal and junctional cancer: assessment of existing measures and proposal of a novel 3-point standard.

OBJECTIVE: To assess existing measures of pathologic response to neoadjuvant therapy in esophageal and junctional cancer, and to recommend an optimum classification. BACKGROUND: Multimodal therapy is increasingly the standard of care for locally advanced esophageal cancer. Numerous measures of pathologic response have been studied; however, no international standardization exists and no measure is incorporated into the current American Joint Committee on Cancer staging system. METHODS: A total of 393 consecutive patients completing multimodal therapy were studied, all with prospectively recorded Mandard tumor regression grades (TRG). Seven other published methods of response were compared, and a novel 3-point TRG [TRG 1 (complete); TRG 2/3 (partial); TRG 4/5 (none/minimal)] was tested. Clinical and pathologic evidence of nodal regression was assessed in a consecutive subset of 200 comprehensively staged patients. RESULTS: All models had similar discriminatory and stratification power, and they predicted survival (P < 0.0001) on univariate analysis. Conversely, only the 3-point TRG (P = 0.042) along with ypN (P < 0.001) and ypT stage (P < 0.001) independently predicted survival. The median survival for TRG 1 was 71 months compared with 30 and 17 months for TRG 2/3 and TRG 4/5, respectively (P < 0.0001). Apparent complete nodal response (cN1 to ypN0) was seen in 64% of the TRG 1 group, 30% of the TRG 2/3 group, and 5% of the TRG 4/5 group (P < 0.0001). CONCLUSIONS: No existing response measure independently predicts outcome. A complete response (TRG 1) defines a unique cohort after neoadjuvant therapy, associated closely with nodal response, and overall survival. This classification merits consideration for standardization of treatment response, and for inclusion in staging nomenclature.

Carotid plaque inflammation on 18F-fluorodeoxyglucose positron emission tomography predicts early stroke recurrence.

OBJECTIVE: Symptomatic carotid stenosis is associated with a 3-fold risk of early stroke recurrence compared to other stroke subtypes. Current carotid imaging techniques rely on estimating plaque-related lumen narrowing but do not evaluate intraplaque inflammation, a key mediator of plaque rupture and thromboembolism. Using combined (18) F-fluorodeoxyglucose positron-emission tomography (FDG-PET)/computed tomography, we investigated the relation between inflammation-related FDG uptake and stroke recurrence. METHODS: Consecutive patients with a recent (median, 6.5 days; interquartile range, 4-8) stroke, transient ischemic attack (TIA), or retinal embolism and ipsilateral carotid stenosis (≥50%) were included. FDG uptake was quantified as mean standardized uptake values (SUVs, g/ml). Patients were followed prospectively for stroke recurrence. RESULTS: Sixty patients were included (25 stroke, 29 TIA, 6 retinal embolism). Twenty-two percent (13 of 60) had stroke recurrence within 90 days. FDG uptake in ipsilateral carotid plaque was greater in patients with early recurrent stroke (mean SUV, 1.85 g/ml; standard deviation [SD], 0.44 vs 1.58 g/ml; SD, 0.32, p = 0.02). On life-table analysis, 90-day recurrence rates with mean SUV greater than a 2.14 g/ml threshold were 80% (95% confidence interval [CI], 41.8-99.2) versus 22.9% (95% CI, 12.3-40.3) with SUV ≤2.14 g/ml (log-rank, p < 0.0001). In a Cox regression model including age and degree of stenosis (50-69% or ≥70%), mean plaque FDG uptake was the only independent predictor of stroke recurrence (adjusted hazard ratio, 6.1; 95% CI, 1.3-28.8; p = 0.02). INTERPRETATION: In recently symptomatic carotid stenosis, inflammation-related FDG uptake was associated with early stroke recurrence, independent of the degree of stenosis. Plaque FDG-PET may identify patients at highest risk for stroke recurrence, who may be selected for immediate revascularization or intensive medical treatment.

Implementation of an evidence based guideline reduces blood tests and length of stay for the limping child in a paediatric emergency department.

INTRODUCTION: Acute non-traumatic limp is a common reason for children to present to the emergency department (ED). There is a wide differential diagnosis for these patients, and there are certain serious conditions which cannot be missed. An evidence based guideline for the 'limping child' was designed and the impact of guideline implementation on a number of specific, predefined quantitative outcomes was assessed. METHODS: An initial retrospective chart review over 3 months was carried out for all patients presenting with acute non-traumatic limp. Following guideline introduction and implementation, information was gathered prospectively for a further 3 month period. Data outcomes between the two patient groups were then compared. RESULTS: 110 patients met the criteria for inclusion: 56 pre-guideline and 54 post-guideline implementation. Baseline characteristics and diagnosis breakdown were similar in both groups. The rate of laboratory investigations was significantly reduced following guideline implementation (68% of patients pre-guideline, vs 48% post-guideline; (χ(2)), p=0.03). The number of x-rays carried out was similar in each group (74 pre- vs 67 post-guideline, mean 1.32 vs 1.28; (χ(2)), p=0.53). Length of time spent in the ED was significantly reduced following guideline implementation (median time 150 min pre- vs 82.5 min post-guideline; (χ(2)), p=0.04). No cases of serious pathology were missed using the guideline. CONCLUSION: Implementation of an evidence based clinical practice guideline for the limping child in a paediatric ED reduced the overall time patients spent in the ED, reduced the need for unnecessary laboratory investigations and ensured that appropriate investigations were carried out on an individual patient basis.

Using wastewater and high-rate algal ponds for nutrient removal and the production of bioenergy and biofuels.

This paper projects a positive outcome for large-scale algal biofuel and energy production when wastewater treatment is the primary goal. Such a view arises partly from a recent change in emphasis in wastewater treatment technology, from simply oxidising the organic matter in the waste (i.e. removing the biological oxygen demand) to removing the nutrients - specifically nitrogen and phosphorus - which are the root cause of eutrophication of inland waterways and coastal zones. A growing need for nutrient removal greatly improves the prospects for using new algal ponds in wastewater treatment, since microalgae are particularly efficient in capturing and removing such nutrients. Using a spreadsheet model, four scenarios combining algae biomass production with the making of biodiesel, biogas and other products were assessed for two of Australia's largest wastewater treatment plants. The results showed that super critical water reactors and anaerobic digesters could be attractive pathway options, the latter providing significant savings in greenhouse gas emissions. Combining anaerobic digestion with oil extraction and the internal economies derived from cheap land and recycling of water and nutrients on-site could allow algal oil to be produced for less than US$1 per litre.

Emissions Reduction Strategies for the Orange and Cherry Industries in New South Wales.

The orange and cherry industries in New South Wales, Australia, are major horticulture industries with a high export value. Climate change has resulted in the carbon footprint of products being used by consumers to guide purchases meaning that products with a relatively high carbon footprint risk losing market access. The carbon footprint of cherry and orange production is unknown and there is no assessment of the success of climate change mitigation strategies to reduce the carbon footprint of their production and move production towards being carbon neutral. This study assesses the climate change mitigation potential of five management changes to on-farm cherry and orange production (revegetation, the use of nitrification inhibitors, renewable energy, green N fertilisers, and pyrolysis of orchard residues) over a 25-year period. for example, orchards in relevant growing regions. The results show that the carbon footprint of production can be reduced by 73 and 83% for cherries and oranges, respectively, when strategies that avoid emissions are included in their production. When strategies that sequester C from the atmosphere are also included, cherry and orange production becomes C negative in the first few years of the scenario. The economics of implementing these strategies are unfavourable, at present; however, our results indicate that the NSW cherry and orange industries can be confident in achieving emissions reductions in on-farm production to assure market access for their products.

Functional exercise after total hip replacement (FEATHER): a randomised control trial.

BACKGROUND: Prolonged physical impairments in range of movement, postural stability and walking speed are commonly reported following total hip replacement (THR). It is unclear from the current body of evidence what kind of exercises should be performed to maximize patient function and quality of life. METHODS/DESIGN: This will be a single blind multi centre randomized control trial with two arms. Seventy subjects post primary total hip arthroplasty will be randomized into either an experimental group (n=35), or to a control group (n=35). The experimental group will attend a functional exercise class twice weekly for a six week period from week 12 to week 18 post surgery. The functional exercise group will follow a circuit based functional exercise class supervised by a chartered Physiotherapist. The control group will receive usual care. The principal investigator (BM) will perform blinded outcome assessments on all patients using validated measures for pain, stiffness, and function using the Western Ontario and Mc Master Universities Osteoarthritis index (WOMAC). This is the primary outcome measurement tool. Secondary outcome measurements include Quality of life (SF-36), 6 min walk test, Visual Analogue Scale, and the Berg Balance score. The WOMAC score will be collated on day five post surgery and repeated at week twelve and week eighteen. All other measurements will be taken at week 12 and repeated at week eighteen. In addition a blinded radiologist will measure gluteus medius cross sectional area using real time ultrasound for all subjects at week 12 and at week 18 to determine if the functional exercise programme has any effect on muscle size. DISCUSSION: This randomised controlled trial will add to the body of evidence on the relationship between muscle size, functional ability, balance, quality of life and time post surgery in patients following total hip arthroplasty. The CONSORT guidelines will be followed to throughout. Ethical approval has been gained from the Ethics committee Health Services Executive Dublin North East.

Soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in neonatal sepsis.

BACKGROUND: Efficient and accurate diagnosis of neonatal sepsis is challenging. The potential impact for a reduction in morbidity and mortality as well as antibiotic usage has stimulated the ongoing search for biomarkers of early sepsis. The objective of this pilot study was to quantify the levels of sTREM-1 and correlate with blood cultures and inflammatory markers in neonates evaluated for sepsis. METHODS: Neonates with suspected sepsis were enrolled (n = 83; Preterm n = 35; Term n = 48). Routine bloods for sepsis evaluation were included and plasma sTREM-1 levels were quantified by ELISA. RESULTS: Term and preterm neonates (n = 83; Preterm n = 35; Term n = 48) were enrolled and 16 neonates had positive blood cultures (preterm n = 15; term n = 1). sTREM-1 levels were not significantly different in infants with culture-positive or culture-negative sepsis (356 ± 218 pg/mL and 385 ± 254 pg/mL respectively). The immature-to-total granulocyte (I/T) ratio showed a significant positive correlation with sTREM-1 in the preterm group with positive blood cultures. Additionally, sTREM-1 showed a positive correlation with CRP in the preterm group with negative blood cultures. CONCLUSIONS: sTREM-1 was associated with traditional markers of inflammation (I/T ratio and CRP). However, in this cohort sTREM-1 did not improve the early detection of neonatal culture-positive sepsis.

Association between acute statin therapy, survival, and improved functional outcome after ischemic stroke: the North Dublin Population Stroke Study.

BACKGROUND AND PURPOSE: Statins improve infarct volume and neurological outcome in animal stroke models. We investigated the relationship between statin therapy and ischemic stroke outcome in the North Dublin Population Stroke Study. METHODS: A population-based prospective cohort study was performed using rigorous ascertainment methods. Prestroke and acute (≤72 hours) poststroke medications were recorded. Modified Rankin score and fatality were assessed at 7, 28, and 90 days and 1 year. RESULTS: Of 448 ischemic stroke patients, statins were prescribed before stroke onset in 30.1% (134/445) and were begun acutely (≤72 hours) in an additional 42.5% (189/445). On logistic regression analysis, adjusting for age, prestroke disability (modified Rankin scale), NIHSS score, hypertension, and aspirin, new poststroke statin therapy was independently associated with improved early and late survival (compared with statin untreated patients: OR for death, 0.12; CI, 0.03-0.54 at 7 days; OR, 0.19; CI, 0.07-0.48 at 90 days; OR, 0.26; CI, 0.12-0.55 at 1 year; P≤0.006 for all). Similar findings were observed for statin therapy before stroke onset (adjusted OR for death compared with statin-untreated-patients, 0.04; CI, 0.00-0.33; P=0.003 at 7 days; OR, 0.23; CI, 0.09-0.58; P=0.002 at 90 days; OR, 0.48; CI, 0.23-1.01; P=0.05 at 1 year). CONCLUSIONS: Statin therapy at stroke onset and newly begun statins were associated with improved early and late outcomes, supporting data from experimental studies. Randomized trials of statin therapy for treatment of acute stroke are needed.

Reply to Response to Vacuous standards - Subversion of the OSAC standards-development process.

This Letter to the Editor is a reply to Mohammed et al. (2021) https://doi.org/10.1016/j.fsisyn.2021.100145, which in turn is a response to Morrison et al. (2020) "Vacuous standards - subversion of the OSAC standards-development process" https://doi.org/10.1016/j.fsisyn.2020.06.005.

A Case Study Examining the Usefulness of Cure Modelling for the Prediction of Survival Based on Data Maturity.

INTRODUCTION: Mixture modelling is increasingly being considered where a potential cure leads to a long life. Traditional methods use relative survival models for frail populations or cure models that have improper survival functions with theoretical infinite lifespans. Additionally, much of the work uses population data with long follow-up or theoretical data for method development. OBJECTIVE: This case study uses life table data to create a proper survival function in a real-world clinical trial context. In particular, we discuss the impact of the length of trial follow-up on the accuracy of model estimation and the impact of extrapolation to capture long-term survival. METHODS: A review of recent National Institute for Health and Clinical Excellence (NICE) immuno-oncological and chimeric antigen receptor (CAR) T-cell therapy submissions was performed to assess industry uptake and NICE acceptance of survival analysis methods incorporating the potential for long-term survivorship. The case study analysed a simulated trial-based dataset investigating a curative treatment with long-term mortality based on population life tables. The analysis examined three timepoints corresponding to early trial, end-of-trial follow-up and complete follow-up. Mixture modelling approaches were considered, including both cure modelling and relative survival approaches. The curves were evaluated based on the ability to estimate cure fractions and mean life in years within the time span the models are based on and when extrapolating to capture long-term behaviour. The survival curves were fitted with Weibull distributions using non-mixture and mixture cure models. RESULTS: The performance of the cure modelling methods depended on the relative maturity of the data, indicating that care is needed when deciding when the methods should be applied. For progression-free survival, the cure fraction simulated was 15%. The cure fractions estimated using the traditional mixture cure model were 43% (95% confidence interval [CI] 30-57) at the first analysis time point (40 months), 15% (95% CI 12-20) at the end-of-study follow-up (153 months) and 0% (95% CI 0-100) at the end of follow-up. Other standard cure modelling methods produced similar results. For overall survival, we observed a similar pattern of goodness of fit, with a good fit for the end-of-study follow-up and poor fit for the other two data cuts. However, in this case, the estimate of the cure fraction was below the true value in the first analysis data. CONCLUSIONS: This case study suggests cure modelling works well with data in which the disease-specific events have had time to occur. Care is needed when extrapolating from immature data, and further information should support the estimation rather than relying on statistical estimates based on the trial alone.

Updating and Road-testing Life Cycle Inventory Data Review Criteria: Toward Global Consensus and Guidance On Data Quality Assessment.

Data quality of life cycle inventory background databases should be ensured in order to be useful for life cycle assessment (LCA) studies. However, databases do not always have procedures to evaluate the quality of the data sets in place. The Global Guidance Principles for LCA Databases of the United Nations Environment Programme (UNEP) in collaboration with the Society of Environmental Toxicology and Chemistry (SETAC) provide, among others, recommendations to enhance data quality through improved documentation and review. Flagship 2a in Phase 3 of the UNEP/SETAC Life Cycle Initiative aimed to enable the practical implementation of these recommendations with the development of review criteria and the testing of these criteria on 3 national databases. After a pilot-testing phase, this project entered a more mature road-testing exercise, of which the results are presented in this paper. The review criteria have been updated and provide more emphasis on goal and scope documentation completeness and include a new cluster of criteria that evaluate the materiality of the data set. The updated criteria have been applied to national databases of Thailand, Australia, and Chile. All databases would benefit from additional documentation, for example, on system boundaries, the reference model, sampling procedures, and cut-off criteria. Furthermore, conducting the review was enabled by extensive documentation and data accessibility in LCA software. Communication of the criteria to the database managers enabled them to anticipate data quality requirements of the global LCA community and improve the data sets in advance. Reviewers sometimes had a different interpretation of the criteria, which suggests that there is room for additional fine-tuning of the process guidance and exemplification of review criteria. This project has demonstrated that the criteria are applicable to and provide useful feedback for databases with different levels of maturity and contribute to improving quality of life cycle inventory (LCI) data. Integr Environ Assess Manag 2020;16:517-524. © 2020 SETAC.

Structural basis for Fullerene geometry in a human endogenous retrovirus capsid.

The HML2 (HERV-K) group constitutes the most recently acquired family of human endogenous retroviruses, with many proviruses less than one million years old. Many maintain intact open reading frames and provirus expression together with HML2 particle formation are observed in early stage human embryo development and are associated with pluripotency as well as inflammatory disease, cancers and HIV-1 infection. Here, we reconstruct the core structural protein (CA) of an HML2 retrovirus, assemble particles in vitro and employ single particle cryogenic electron microscopy (cryo-EM) to determine structures of four classes of CA Fullerene shell assemblies. These icosahedral and capsular assemblies reveal at high-resolution the molecular interactions that allow CA to form both pentamers and hexamers and show how invariant pentamers and structurally plastic hexamers associate to form the unique polyhedral structures found in retroviral cores.

CryoEM structures of open dimers of gyrase A in complex with DNA illuminate mechanism of strand passage.

Gyrase is a unique type IIA topoisomerase that uses ATP hydrolysis to maintain the negatively supercoiled state of bacterial DNA. In order to perform its function, gyrase undergoes a sequence of conformational changes that consist of concerted gate openings, DNA cleavage, and DNA strand passage events. Structures where the transported DNA molecule (T-segment) is trapped by the A subunit have not been observed. Here we present the cryoEM structures of two oligomeric complexes of open gyrase A dimers and DNA. The protein subunits in these complexes were solved to 4 Å and 5.2 Å resolution. One of the complexes traps a linear DNA molecule, a putative T-segment, which interacts with the open gyrase A dimers in two states, representing steps either prior to or after passage through the DNA-gate. The structures locate the T-segment in important intermediate conformations of the catalytic cycle and provide insights into gyrase-DNA interactions and mechanism.

Pooling of bronchoalveolar lavage in children with cystic fibrosis does not adversely affect the microbiological yield or sensitivity in detecting pulmonary inflammation.

BACKGROUND: Bronchoalveolar lavage (BAL) is a potentially useful outcome measure for clinical trials in children with CF but its use is limited by variations in approach internationally. We sought to determine if pooling adversely affected the diagnostic properties of BAL. METHODS: Children undergoing bronchoscopy for clinical reasons were included. A multi-step study protocol ensured BAL was collected and analysed both separately and as a pooled fluid. RESULTS: Eighty-five children (53 CF, 32 control) were recruited. There was a high level of concordance between pooled and non-pooled samples in terms of organism identification (76%). There was good agreement (Bland Altman) between the two methods in terms of detection of inflammation independent of centre, microbiological concordance or disease status. Bi-directional variability in IL-8 levels between pooled and non-pooled samples was seen. Free neutrophil elastase (NE) was detected in 4 cases in pooled lavage when absent in non-pooled lavage. Levels of interleukin-8 (IL-8) were similar between the two groups with pooled samples showing a greater spread of values. CONCLUSIONS: Pooling of BAL in children does not negatively impact on either the detection of pulmonary infection or inflammation or the observed relationship between infection and inflammation. Intra-patient variability in BAL IL-8 levels suggests regional differences in inflammation.