Higher diversity of sulfur-oxidizing bacteria based on soxB gene sequencing in surface water than in spring in Wudalianchi volcanic group, NE China.

INTRODUCTION: Sulfur-oxidizing bacteria (SOB) play a key role in the biogeochemical cycling of sulfur. OBJECTIVES: To explore SOB diversity, distribution, and physicochemical drivers in five volcanic lakes and two springs in the Wudalianchi volcanic field, China. METHODS: This study analyzed microbial communities in samples via high-throughput sequencing of the soxB gene. Physical-chemical parameters were measured, and QIIME 2 (v2019.4), R, Vsearch, MEGA7, and Mothur processed the data. Alpha diversity indices and UPGMA clustering assessed community differences, while heat maps visualized intra-sample variations. Canoco 5.0 analyzed community-environment correlations, and NMDS, Adonis, and PcoA explored sample dissimilarities and environmental factor correlations. SPSS v.18.0 tested for statistical significance. RESULTS: The diversity of SOB in surface water was higher than in springs (more than 7.27 times). We detected SOB affiliated to ß-proteobacteria (72.3 %), α-proteobacteria (22.8 %), and γ-proteobacteria (4.2 %) distributed widely in these lakes and springs. Rhodoferax and Cupriavidus were most frequent in all water samples, while Rhodoferax and Bradyrhizobium are dominant in surface waters but rare in springs. SOB genera in both habitats were positively correlated. Co-occurrence analysis identified Bradyrhizobium, Blastochloris, Methylibium, and Metyhlobacterium as potential keystone taxa. Redundancy analysis (RDA) revealed positive correlations between SOB diversity and total carbon (TC), Fe2+, and total nitrogen (TN) in all water samples. CONCLUSION: The diversity and community structure of SOB in volcanic lakes and springs in the Wudalianchi volcanic group were clarified. Moreover, the diversity and abundance of SOB decreased with the variation of water openness, from open lakes to semi-enclosed lakes and enclosed lakes.

Exploring the pharmacological mechanism of Glycyrrhiza uralensis against KOA through integrating network pharmacology and experimental assessment.

Knee osteoarthritis (KOA), a major health and economic problem facing older adults worldwide, is a degenerative joint disease. Glycyrrhiza uralensis Fisch. (GC) plays an integral role in many classic Chinese medicine prescriptions for treating knee osteoarthritis. Still, the role of GC in treating KOA is unclear. To explore the pharmacological mechanism of GC against KOA, UPLC-Q-TOF/MS was conducted to detect the main compounds in GC. The therapeutic effect of GC on DMM-induced osteoarthritic mice was assessed by histomorphology, µCT, behavioural tests, and immunohistochemical staining. Network pharmacology and molecular docking were used to predict the potential targets of GC against KOA. The predicted results were verified by immunohistochemical staining Animal experiments showed that GC had a protective effect on DMM-induced KOA, mainly in the improvement of movement disorders, subchondral bone sclerosis and cartilage damage. A variety of flavonoids and triterpenoids were detected in GC via UPLC-Q-TOF/MS, such as Naringenin. Seven core targets (JUN, MAPK3, MAPK1, AKT1, TP53, RELA and STAT3) and three main pathways (IL-17, NF-κB and TNF signalling pathways) were discovered through network pharmacology analysis that closely related to inflammatory response. Interestingly, molecular docking results showed that the active ingredient Naringenin had a good binding effect on anti-inflammatory-related proteins. In the verification experiment, after the intervention of GC, the expression levels of pp65 and F4/80 inflammatory indicators in the knee joint of KOA model mice were significantly downregulated. GC could improve the inflammatory environment in DMM-induced osteoarthritic mice thus alleviating the physiological structure and dysfunction of the knee joint. GC might play an important role in the treatment of knee osteoarthritis.

A novel selenium nanocomposite modified by AANL inhibits tumor growth by upregulating CLK2 in lung cancer.

Lung cancer is a malignant tumor with high mortality and drug resistance. Therefore, it is urgent to explore natural and nontoxic drugs to treat lung cancer. In this study, the natural active ingredient AANL extracted from Agrocybe aegirita was used to modify nanoselenium by an oxidation-reduction method. Transmission electron microscope detection and infrared spectroscopy showed that a novel selenium nanocomposite named AANL-SeNPs was successfully prepared. The results of nanoscale characterization showed that AANL-SeNPs had good stability and uniform dispersion in aqueous solution by zeta potential and spectrum analysis. At the cellular level, we found that AANL-SeNPs significantly inhibited the cell viability of lung cancer cells, and the cell inhibition rate of 60 nM AANL-SeNPs was 39 % in H157 cells, 67 % in H147 cells, and 62 % in A549 cells. The IC50 value of AANL-SeNPs was 51.85 nM in A549 cells and 81.57 nM in H157 cells. Moreover, AANL-SeNPs could inhibit the cell proliferation and migration, and enhance the sensitivity of lung cancer cells to osimertinib and has no toxic to normal cells. In vivo, AANL-SeNPs significantly slowed tumor growth in tumor-bearing mice by establishing a subcutaneous transplantation tumor model for lung cancer, and the tumor size was smaller and was reduced about 79 % in 2 mg/kg AANL-SeNPs group compared with PBS group. Mechanistically, a total of 38 differentially expressed proteins were identified by data-independent acquisition mass spectrometry. A significantly upregulated protein, CDC-like kinase 2 (CLK2), was screened and validated for further analysis, which showed that the expression levels of CLK2 were increased in H157 and H1437 cells after AANL-SeNPs treatment. The results obtained in this study suggest that a novel selenium nanocomposite AANL-SeNPs, which inhibits lung cancer by upregulating the expression of CLK2.

Boosting Efficiency in Piezo-Photocatalysis Process Using Poled Ba0.7Sr0.3TiO3 Nanorod Arrays for Pollutant Degradation and Hydrogen Production.

Recently, the combination of the piezoelectric effect in the photocatalytic process, referred to as piezo-photocatalysis, has gained considerable attention as a promising approach for enhancing the degradation of organic pollutants. In this investigation, we studied the piezo-photocatalysis by fabricating arrays of barium strontium titanate (Ba0.7Sr0.3TiO3) nanorods (BST NRs) on a glass substrate as recoverable catalysts. We found that the degradation rate constant k of the rhodamine B solution achieved 0.0447 min-1 using poled BST NRs in the piezo-photocatalytic process, indicating a 2-fold increase in efficiency compared to the photocatalytic process (0.00183 min-1) utilizing the same material. This is mainly ascribed to the generation of the piezopotential in the poled BST NRs under ultrasonic vibration. Moreover, the BST NR array demonstrated a hydrogen (H2) production rate of 411.5 µmol g-1 h-1. In the photoelectrochemical process, the photocurrent density of poled BST NRs achieved 1.97 mA cm-2 at an applied potential of 1.23 V (ERHE (reversible hydrogen electrode)) under ultrasonic vibrations, representing a 1.7-fold increase compared with the poled BST NRs without ultrasonic vibrations. The measurement results from the liquid chromatograph mass spectrometer (LC-MS) demonstrated the formulation of a degradation pathway for rhodamine B molecules. Moreover, ab initio molecular dynamics (AIMD) simulation results demonstrate the dominance of hydroxyl radicals (•OH) rather than superoxide radicals (•O2-) in the degradation process. This study not only benefits the understanding of the principle of the piezo-photocatalytic process but also provides a new perspective for improving the catalytic efficiency for organic pollutants degradation.

Synergistic analysis of lignin degrading bacterial consortium and its application in rice straw fiber film.

Fiber film have received widespread attention due to its green friendliness. We can use microorganisms to degrade lignin in straw to obtain cellulose and make fiber films. Herein, a group of high-temperature (50 °C) lignin degrading bacterial consortium (LDH) was enriched and culture conditions for lignin degradation were optimized. Combined with high-throughput sequencing technology, the synergistic effect of LDH-composited bacteria was analyzed. Then LDH was used to treat rice straw for the bio-pulping experiment. The results showed that the lignin of rice straw was degraded 32.4 % by LDH at 50 °C for 10 d, and after the optimization of culture conditions, lignin degradation rate increased by 9.05 % (P < 0.001). The bacteria that compose in LDH can synergistically degrade lignin. Paenibacillus can encode all lignin-degrading enzymes present in the LDH. Preliminary tests of LDH in the pulping industry have been completed. This study is the first to use high temperature lignin degrading bacteria to fabricate fiber film.

Clinical Efficacy of Neuroendoscopy Combined with Intracranial Pressure Monitoring for the Treatment of Hypertensive Intracerebral Hemorrhage.

OBJECTIVE: To compare the differences in postoperative complications and prognosis between patients treated with neuroendoscopy versus conventional craniotomy surgery for hypertensive intracerebral hemorrhage (HICH). METHODS: In this retrospective study, a total of 107 patients with HICH were included. Among them, 58 underwent neuroendoscopy (Group A), while 49 underwent conventional craniotomy under microscopic guidance (Group B). Intracranial pressure monitoring was applied in both groups. The clinical data, incidence of postoperative complications, preoperative and postoperative intracranial pressure values, and rate of favorable prognosis were compared between the 2 groups. RESULTS: No significant difference in baseline clinical data upon admission was observed between the 2 groups (P > 0.05). The preoperative intracranial pressure did not differ between the 2 groups (P > 0.05), but the postoperative intracranial pressure in Group A was significantly lower than that in Group B (P < 0.05). After intervention with the different surgical approaches, Group A showed a significantly lower incidence of postoperative cerebral infarction and a significantly higher rate of favorable prognosis compared with Group B (P < 0.05). CONCLUSIONS: Neuroendoscopy combined with Intracranial pressure monitoring is a safe and reliable approach for the treatment of HICH that reduces the incidence of postoperative cerebral infarction and improves the recovery of neurological function after surgery.

Recent advances in IgG4-related autoimmune pancreatitis.

The incidence of IgG4-related autoimmune pancreatitis (IgG4-AIP) is high in Asia and other countries, and unnecessary treatment is often undertaken due to both missed diagnosis and misdiagnosis in clinical practice. Although IgG4-AIP has attracted increasing attention, the details of IgG4-AIP pathogenesis and systemic immune response, including its relationship to tumor pathogenesis, are still unclear. In recent years, research on serum immunological detection, pathological features, clinical manifestations, diagnosis and treatment measures for IgG4-AIP has gradually increased. It is of great importance to summarize and discuss the latest progress regarding IgG4-AIP disease.

Mechanosensing by Piezo1 and its implications in the kidney.

Piezo1 is an essential mechanosensitive transduction ion channel in mammals. Its unique structure makes it capable of converting mechanical cues into electrical and biological signals, modulating biological and (patho)physiological processes in a wide variety of cells. There is increasing evidence demonstrating that the piezo1 channel plays a vital role in renal physiology and disease conditions. This review summarizes the current evidence on the structure and properties of Piezo1, gating modulation, and pharmacological characteristics, with special focus on the distribution and (patho)physiological significance of Piezo1 in the kidney, which may provide insights into potential treatment targets for renal diseases involving this ion channel.

Isolation, purification, and biological activities of polysaccharides from Amorpha fruticosa flowers.

The extraction, isolation, structural characterisation and biological activities of polysaccharides from Amorpha fruticosa flowers were investigated. First, the crude polysaccharide AFP was extracted, and two major purified polysaccharide fractions AFP-2 and AFP-3 were isolated. The molecular weight and monosaccharide compositions of AFP-2 and AFP-3 were determined. Then the antioxidant activities of AFP, AFP-2 and AFP-3 were assessed by DPPH radical, ß-Carotene bleaching and hydroxyl radical assays. All three tested polysaccharides showed good antioxidant activity while AFP was the strongest one. The study also showed that AFP, AFP-2 and AFP-3 have good tyrosinase inhibition, moisture absorption and retention activities. The results will provide a helpful reference for the application of polysaccharide from Amorpha fruticosa flowers as a natural cosmetic ingredient.

YTHDC1 promotes the malignant progression of gastric cancer by promoting ROD1 translocation to the nucleus.

RNA-binding proteins (RBPs) make vital impacts on tumor progression and are important potential targets for tumor treatment. Previous studies have shown that RBP regulator of differentiation 1 (ROD1), enriched in the nucleus, is abnormally expressed and functions as a splicing factor in tumors; however, the mechanism underlying its involvement in gastric cancer (GC) is unknown. In this study, ROD1 is found to stimulate GC cell proliferation and metastasis and is related to poor patient prognosis. In vitro experiments showed that ROD1 influences GC proliferation and metastasis through modulating the imbalance of the level of the oncogenic gene OIP5 and the tumor suppressor gene GPD1L. Further studies showed that the N6-methyladenosine (m6A) "reader" protein YTHDC1 can interact with ROD1 and regulate the balance of the expression of the downstream molecules OIP5/GPD1L by promoting the nuclear enrichment of ROD1. Therefore, YTHDC1 stimulates GC development and progression through modulating nuclear enrichment of the splicing factor ROD1.

Synergistic effect of two bacterial strains promoting anaerobic digestion of rice straw to produce methane.

A large amount of agricultural waste causes global environmental pollution. Biogas production by microbial pretreatment is an important way to utilize agricultural waste resources. In this study, Sporocytophaga CG-1 (A, cellulolytic strain) was co-cultured with Bacillus clausii HP-1 (B, non-cellulolytic strain) to analyze the effect of pretreatment of rice straw on methanogenic capacity of anaerobic digestion (AD). The results showed that weight loss rate of filter paper of co-culture combination is 53.38%, which is 29.37% higher than that of A. The synergistic effect of B on A can promote its degradation of cellulose. The cumulative methane production rate of the co-culture combination was the highest (93.04 mL/g VS substrate), which was significantly higher than that of A, B and the control group (82.38, 67.28 and 67.70 mL/g VS substrate). Auxiliary bacteria can improve cellulose degradation rate by promoting secondary product metabolism. These results provide data support for the application of co-culture strategies in the field of anaerobic digestion practices.

Long noncoding RNAs underlie multiple domestication traits and leafhopper resistance in soybean.

The origin and functionality of long noncoding RNA (lncRNA) remain poorly understood. Here, we show that multiple quantitative trait loci modulating distinct domestication traits in soybeans are pleiotropic effects of a locus composed of two tandem lncRNA genes. These lncRNA genes, each containing two inverted repeats, originating from coding sequences of the MYB genes, function in wild soybeans by generating clusters of small RNA (sRNA) species that inhibit the expression of their MYB gene relatives through post-transcriptional regulation. By contrast, the expression of lncRNA genes in cultivated soybeans is severely repressed, and, consequently, the corresponding MYB genes are highly expressed, shaping multiple distinct domestication traits as well as leafhopper resistance. The inverted repeats were formed before the divergence of the Glycine genus from the Phaseolus-Vigna lineage and exhibit strong structure-function constraints. This study exemplifies a type of target for selection during plant domestication and identifies mechanisms of lncRNA formation and action.

[Snoring noise removal method for bowel sound signal during sleep].

Monitoring of bowel sounds is an important method to assess bowel motility during sleep, but it is seriously affected by snoring noise. In this paper, the complete ensemble empirical mode decomposition with adaptive noise (CEEMDAN) method was applied to remove snoring noise from bowel sounds during sleep. Specifically, the noisy bowel sounds were first band-pass filtered, then decomposed by the CEEMDAN method, and finally the appropriate components were selected to reconstruct the pure bowel sounds. The results of semi-simulated and real data showed that the CEEMDAN method was better than empirical mode decomposition and wavelet denoising method. The CEEMDAN method is used to remove snoring noise from bowel sounds during sleep, which lays an important foundation for using bowel sounds to assess the intestinal motility during sleep.

Ensemble Extreme Learning Machine Method for Hemoglobin Estimation Based on PhotoPlethysmoGraphic Signals.

Non-invasive detection of hemoglobin (Hb) concentration is of great clinical value for health screening and intraoperative blood transfusion. However, the accuracy and stability of non-invasive detection still need to be improved to meet clinical requirement. This paper proposes a non-invasive Hb detection method using ensemble extreme learning machine (EELM) regression based on eight-wavelength PhotoPlethysmoGraphic (PPG) signals. Firstly, a mathematical model for non-invasive Hb detection based on the Beer-Lambert law is established. Secondly, the captured eight-channel PPG signals are denoised and fifty-six feature values are extracted according to the derived mathematical model. Thirdly, a recursive feature elimination (RFE) algorithm is used to select the features that contribute most to the Hb prediction. Finally, a regression model is built by integrating several independent ELM models to improve prediction stability and accuracy. Experiments conducted on 249 clinical data points (199 cases as the training dataset and 50 cases as the test dataset) evaluate the proposed method, achieving a root mean square error (RMSE) of 1.72 g/dL and a Pearson correlation coefficient (PCC) of 0.76 (p < 0.01) between predicted and reference values. The results demonstrate that the proposed non-invasive Hb detection method exhibits a strong correlation with traditional invasive methods, suggesting its potential for non-invasive detection of Hb concentration.

Effect of bioaugmentation on gas production and microbial community during anaerobic digestion in a low-temperature fixed-bed reactor.

Low temperature is one of the limiting factors for anaerobic digestion in cold regions. To improve the efficiency of anaerobic digestion for methane production in stationary reactors under low-temperature conditions, and to improve the structure of the microbial community for anaerobic digestion at low temperatures. We investigated the effects of different concentrations of exogenous Methanomicrobium (10, 20, 30%) and different volumes of carbon fiber carriers (0, 10, 20%) on gas production and microbial communities to improve the performance of low-temperature anaerobic digestion systems. The results show that the addition of 30% exogenous microorganisms and a 10% volume of carbon fiber carrier led to the highest daily (128.15 mL/g VS) and cumulative (576.62 mL/g VS) methane production. This treatment effectively reduced the concentrations of COD and organic acid, in addition to stabilizing the pH of the system. High-throughput sequencing analysis revealed that the dominant bacteria under these conditions were Acidobacteria and Firmicutes and the dominant archaea were Candidatus_Udaeobacter and Methanobacterium. While the abundance of microorganisms that metabolize organic acids was reduced, the functional abundance of hydrogenophilic methanogenic microorganisms was increased. Therefore, the synergistic effect of Methanomicrobium bioaugmentation with carbon fiber carriers can significantly improve the performance and efficiency of low-temperature anaerobic fermentation systems.

High-throughput DNA synthesis for data storage.

With the explosion of digital world, the dramatically increasing data volume is expected to reach 175 ZB (1 ZB = 1012 GB) in 2025. Storing such huge global data would consume tons of resources. Fortunately, it has been found that the deoxyribonucleic acid (DNA) molecule is the most compact and durable information storage medium in the world so far. Its high coding density and long-term preservation properties make itself one of the best data storage carriers for the future. High-throughput DNA synthesis is a key technology for "DNA data storage", which encodes binary data stream (0/1) into quaternary long DNA sequences consisting of four bases (A/G/C/T). In this review, the workflow of DNA data storage and the basic methods of artificial DNA synthesis technology are outlined first. Then, the technical characteristics of different synthesis methods and the state-of-the-art of representative commercial companies, with a primary focus on silicon chip microarray-based synthesis and novel enzymatic DNA synthesis are presented. Finally, the recent status of DNA storage and new opportunities for future development in the field of high-throughput, large-scale DNA synthesis technology are summarized.

Highly Sensitive Iontronic Pressure Sensor with Side-by-Side Package Based on Alveoli and Arch Structure.

Flexible pressure sensors play a significant role in wearable devices and electronic skin. Iontronic pressure sensors with high sensitivity, wide measurement range, and high resolution can meet requirements. Based on the significant deformation characteristics of alveoli to improve compressibility, and the ability of the arch to disperse vertical pressure into horizontal thrust to increase contact area, a graded hollow ball arch (GHBA) microstructure is proposed, greatly improving sensitivity. The fabrication of GHBA ingeniously employs a double-sided structure. One side uses mold casting to create convex structures, while the other utilizes the evaporation of moisture during the curing process to form concave structures. At the same time, a novel side-by-side package structure is proposed, ensuring pressure on flexible substrate is maximally transferred to the GHBA microstructure. Within the range of 0.2 Pa-300 kPa, the iontronic pressure sensor achieves a maximum sensitivity of 10 420.8 kPa-1 , pressure resolution of 0.1% under the pressure of 100 kPa, and rapid response/recovery time of 40/35 ms. In wearable devices, it is capable of monitoring dumbbell curl exercises and wirelessly correcting sitting positions. In electronic skin, it can non-contactly detect the location of the wind source and achieve object classification prediction when combined with the CNN model.

Tumor-derived apoptotic extracellular vesicle-mediated intercellular communication promotes metastasis and stemness of lung adenocarcinoma.

Apoptosis has long been recognized as a significant mechanism for inhibiting tumor formation, and a plethora of stimuli can induce apoptosis during the progression and treatment of tumors. Moreover, tumor-derived apoptotic extracellular vesicles (apoEVs) are inevitably phagocytosed by live tumor cells, promoting tumor heterogeneity. Understanding the mechanism by which apoEVs regulate tumor cells is imperative for enhancing our knowledge of tumor metastasis and recurrence. Herein, we conducted a series of in vivo and in vitro experiments, and we report that tumor-derived apoEVs promoted lung adenocarcinoma (LUAD) metastasis, self-renewal and chemoresistance. Mechanistically, we demonstrated that apoEVs facilitated tumor metastasis and stemness by initiating the epithelial-mesenchymal transition program and upregulating the transcription of the stem cell factor SOX2. In addition, we found that ALDH1A1, which was transported by apoEVs, activated the NF-κB signaling pathway by increasing aldehyde dehydrogenase enzyme activity in recipient tumor cells. Furthermore, targeting apoEVs-ALDH1A1 significantly abrogated these effects. Collectively, our findings elucidate a novel mechanism of apoEV-dependent intercellular communication between apoptotic tumor cells and live tumor cells that promotes the formation of cancer stem cell-like populations, and these findings reveal that apoEVs-ALDH1A1 may be a potential therapeutic target and biomarker for LUAD metastasis and recurrence.

A 3D-printed microhemispherical shell resonator with electrostatic tuning for a Coriolis vibratory gyroscope.

The emergence of microhemispherical resonant gyroscopes, which integrate the advantages of exceptional stability and long lifetime with miniaturization, has afforded new possibilities for the development of whole-angle gyroscopes. However, existing methods used for manufacturing microhemispherical resonant gyroscopes based on MEMS technology face the primary drawback of intricate and costly processing. Here, we report the design, fabrication, and characterization of the first 3D-printable microhemispherical shell resonator for a Coriolis vibrating gyroscope. We remarkably achieve fabrication in just two steps bypassing the dozen or so steps required in traditional micromachining. By utilizing the intricate shaping capability and ultrahigh precision offered by projection microstereolithography, we fabricate 3D high-aspect-ratio resonant structures and controllable capacitive air gaps, both of which are extremely difficult to obtain via MEMS technology. In addition, the resonance frequency of the fabricated resonators can be tuned by electrostatic forces, and the fabricated resonators exhibit a higher quality factor in air than do typical MEMS microhemispherical resonators. This work demonstrates the feasibility of rapidly batch-manufacturing microhemispherical shell resonators, paving the way for the development of microhemispherical resonator gyroscopes for portable inertial navigation. Moreover, this particular design concept could be further applied to increase uptake of resonator tools in the MEMS community.

Comparison of survival benefit and safety between surgery following conversion therapy versus surgery alone in patients with surgically resectable hepatocellular carcinoma at CNLC IIb/IIIa stage: a propensity score matching study.

OBJECTIVE: The objective of this study is to evaluate and compare the survival benefit and safety of surgery following conversion therapy versus surgery alone in patients diagnosed with surgically resectable hepatocellular carcinoma (HCC) at China Liver Cancer Staging (CNLC) IIb/IIIa stage. METHODS: A total of 95 patients diagnosed with surgically resectable CNLC IIb/IIIa HCC were retrospectively enrolled in our study from November 2018 to December 2022. Among them, 30 patients underwent conversion therapy followed by hepatectomy, while the remaining 65 received surgery alone. The primary endpoint was recurrence-free survival (RFS). Propensity score matching was employed to minimize bias in the retrospective analysis. RESULTS: Compared to the surgery alone group, the conversion therapy group demonstrated a significantly prolonged median RFS (17.1 vs. 7.0 months; P =0.014), a reduced incidence of microvascular invasion (MVI, 23.3 vs. 81.5%; P <0.001), and a comparable rate of achieving Textbook Outcome in Liver Surgery (TOLS, 83.3 vs. 76.9%; P =0.476). Multivariate analysis indicated that conversion therapy was independently associated with improved RFS after hepatectomy (HR=0.511, P =0.027). The same conclusions were obtained after propensity score matching. CONCLUSIONS: The findings of our study offer preliminary evidence that preoperative conversion therapy significantly prolongs RFS in patients with surgically resectable HCC at CNLC IIb/IIIa stage. Furthermore, combining conversion therapy and hepatectomy represents a relatively safe treatment strategy.