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A new asymmetric synthetic route to (+)- and (-)-limaspermidine was devised, starting with chirally resolved enantiomerically pure 2-pyrone Diels-Alder cycloadducts. This route utilizes intramolecular Pd-catalyzed aromatic C-H amidation and imino-Diels-Alder reactions to construct the key indoline and indolizidine subunits onto the central cyclohexane core, allowing the straightforward formal total syntheses of both (+)- and (-)-limaspermidine.
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Intranasal infection is commonly used to establish a SARS-CoV-2 mouse model due to its non-invasive procedures and a minimal effect from the operation itself. However, mice intranasally infected with SARS-CoV-2 have a high mortality rate, which limits the utility of this model for exploring therapeutic strategies and the sequelae of non-fatal COVID-19 cases. To resolve these limitations, an aerosolised viral administration method has been suggested. However, an in-depth pathological analysis comparing the two models is lacking. Here, we show that inhalation and intranasal SARS-CoV-2 (106 PFU) infection models established in K18-hACE2 mice develop unique pathological features in both the respiratory and central nervous systems, which could be directly attributed to the infection method. While the inhalation-infection model exhibited relatively milder pathological parameters, it closely mimicked the prevalent chest CT pattern observed in COVID-19 patients with focal, peripheral lesions and fibrotic scarring in the recuperating lung. We also found the evidence of direct neuron-invasion from the olfactory receptor neurons to the olfactory bulb in the intranasal model and showed the trigeminal nerve as an alternative route of transmission to the brain in inhalation infected mice. Even after viral clearance confirmed at 14 days post-infection, mild lesions were still found in the brain of inhalation-infected mice. These findings suggest that the inhalation-infection model has advantages over the intranasal-infection model in closely mimicking the pathological features of non-fatal symptoms of COVID-19, demonstrating its potential to study the sequelae and possible interventions for long COVID.
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COVID-19 , Modelos Animales de Enfermedad , Pulmón , SARS-CoV-2 , Animales , COVID-19/patología , COVID-19/virología , Ratones , Pulmón/patología , Pulmón/virología , Enzima Convertidora de Angiotensina 2/metabolismo , Enzima Convertidora de Angiotensina 2/genética , Bulbo Olfatorio/patología , Bulbo Olfatorio/virología , Humanos , Administración Intranasal , Femenino , Neuronas Receptoras Olfatorias/virología , Neuronas Receptoras Olfatorias/metabolismoRESUMEN
Viral load and the duration of viral shedding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are important determinants of the transmission of coronavirus disease 2019. In this study, we examined the effects of viral doses on the lung and spleen of K18-hACE2 transgenic mice by temporal histological and transcriptional analyses. Approximately, 1×105 plaque-forming units (PFU) of SARS-CoV-2 induced strong host responses in the lungs from 2 days post inoculation (dpi) which did not recover until the mice died, whereas responses to the virus were obvious at 5 days, recovering to the basal state by 14 dpi at 1×102 PFU. Further, flow cytometry showed that number of CD8+ T cells continuously increased in 1×102 PFU-virus-infected lungs from 2 dpi, but not in 1×105 PFU-virus-infected lungs. In spleens, responses to the virus were prominent from 2 dpi, and number of B cells was significantly decreased at 1×105 PFU; however, 1×102 PFU of virus induced very weak responses from 2 dpi which recovered by 10 dpi. Although the defense responses returned to normal and the mice survived, lung histology showed evidence of fibrosis, suggesting sequelae of SARS-CoV-2 infection. Our findings indicate that specific effectors of the immune response in the lung and spleen were either increased or depleted in response to doses of SARS-CoV-2. This study demonstrated that the response of local and systemic immune effectors to a viral infection varies with viral dose, which either exacerbates the severity of the infection or accelerates its elimination.
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BACKGROUND: The global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to approximately 500 million cases and 6 million deaths worldwide. Previous investigations into the pathophysiology of SARS-CoV-2 primarily focused on peripheral blood mononuclear cells from patients, lacking detailed mechanistic insights into the virus's impact on inflamed tissue. Existing animal models, such as hamster and ferret, do not faithfully replicate the severe SARS-CoV-2 infection seen in patients, underscoring the need for more relevant animal system-based research. METHODS: In this study, we employed single-cell RNA sequencing (scRNA-seq) with lung tissues from K18-hACE2 transgenic (TG) mice during SARS-CoV-2 infection. This approach allowed for a comprehensive examination of the molecular and cellular responses to the virus in lung tissue. FINDINGS: Upon SARS-CoV-2 infection, K18-hACE2 TG mice exhibited severe lung pathologies, including acute pneumonia, alveolar collapse, and immune cell infiltration. Through scRNA-seq, we identified 36 different types of cells dynamically orchestrating SARS-CoV-2-induced pathologies. Notably, SPP1+ macrophages in the myeloid compartment emerged as key drivers of severe lung inflammation and fibrosis in K18-hACE2 TG mice. Dynamic receptor-ligand interactions, involving various cell types such as immunological and bronchial cells, defined an enhanced TGFß signaling pathway linked to delayed tissue regeneration, severe lung injury, and fibrotic processes. INTERPRETATION: Our study provides a comprehensive understanding of SARS-CoV-2 pathogenesis in lung tissue, surpassing previous limitations in investigating inflamed tissues. The identified SPP1+ macrophages and the dysregulated TGFß signaling pathway offer potential targets for therapeutic intervention. Insights from this research may contribute to the development of innovative diagnostics and therapies for COVID-19. FUNDING: This research was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (2020M3A9I2109027, 2021R1A2C2004501).
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COVID-19 , Melfalán , gammaglobulinas , Animales , Cricetinae , Ratones , Humanos , SARS-CoV-2 , Leucocitos Mononucleares , Hurones , Bronquios , Factor de Crecimiento Transformador beta , Ratones Transgénicos , Modelos Animales de Enfermedad , PulmónRESUMEN
The integration of artificial intelligence (AI) into drug discovery has markedly advanced the search for effective therapeutics. In our study, we employed a comprehensive computational-experimental approach to identify potential anti-SARS-CoV-2 compounds. We developed a predictive model to assess the activities of compounds based on their structural features. This model screened a library of approximately 700,000 compounds, culminating in the selection of the top 100 candidates for experimental validation. In vitro assays on human intestinal epithelial cells (Caco-2) revealed that 19 of these compounds exhibited inhibitory activity. Notably, eight compounds demonstrated dose-dependent activity in Vero cell lines, with half-maximal effective concentration (EC50) values ranging from 1 µM to 7 µM. Furthermore, we utilized a clustering approach to pinpoint potential nucleoside analog inhibitors, leading to the discovery of two promising candidates: azathioprine and its metabolite, thioinosinic acid. Both compounds showed in vitro activity against SARS-CoV-2, with thioinosinic acid also significantly reducing viral loads in mouse lungs. These findings underscore the utility of AI in accelerating drug discovery processes.
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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection induces excessive pro-inflammatory cytokine release and cell death, leading to organ damage and mortality. High-mobility group box 1 (HMGB1) is one of the damage-associated molecular patterns that can be secreted by pro-inflammatory stimuli, including viral infections, and its excessive secretion levels are related to a variety of inflammatory diseases. Here, the aim of the study was to show that SARS-CoV-2 infection induced HMGB1 secretion via active and passive release. Active HMGB1 secretion was mediated by post-translational modifications, such as acetylation, phosphorylation, and oxidation in HEK293E/ACE2-C-GFP and Calu-3 cells during SARS-CoV-2 infection. Passive release of HMGB1 has been linked to various types of cell death; however, we demonstrated for the first time that PANoptosis, which integrates other cell death pathways, including pyroptosis, apoptosis, and necroptosis, is related to passive HMGB1 release during SARS-CoV-2 infection. In addition, cytoplasmic translocation and extracellular secretion or release of HMGB1 were confirmed via immunohistochemistry and immunofluorescence in the lung tissues of humans and angiotensin-converting enzyme 2-overexpressing mice infected with SARS-CoV-2.
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Throughout the recent COVID-19 pandemic, South Korea led national efforts to develop vaccines and therapeutics for SARS-CoV-2. The project proceeded as follows: 1) evaluation system setup (including Animal Biosafety Level 3 (ABSL3) facility alliance, standardized nonclinical evaluation protocol, and laboratory information management system), 2) application (including committee review and selection), and 3) evaluation (including expert judgment and reporting). After receiving 101 applications, the selection committee reviewed pharmacokinetics, toxicity, and efficacy data and selected 32 final candidates. In the nonclinical efficacy test, we used golden Syrian hamsters and human angiotensin-converting enzyme 2 transgenic mice under a cytokeratin 18 promoter to evaluate mortality, clinical signs, body weight, viral titer, neutralizing antibody presence, and histopathology. These data indicated eight new drugs and one repositioned drug having significant efficacy for COVID-19. Three vaccine and four antiviral drugs exerted significant protective activities against SARS-CoV-2 pathogenesis. Additionally, two anti-inflammatory drugs showed therapeutic effects on lung lesions and weight loss through their mechanism of action but did not affect viral replication. Along with systematic verification of COVID-19 animal models through large-scale studies, our findings suggest that ABSL3 multicenter alliance and nonclinical evaluation protocol standardization can promote reliable efficacy testing against COVID-19, thus expediting medical product development.
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COVID-19 , Animales , Cricetinae , Ratones , Humanos , SARS-CoV-2 , Pandemias , Anticuerpos Neutralizantes , Mesocricetus , Modelos Animales de EnfermedadRESUMEN
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) has been a global health concern since 2019. The viral spike protein infects the host by binding to angiotensin-converting enzyme 2 (ACE2) expressed on the cell surface, which is then processed by type II transmembrane serine protease. However, ACE2 does not react to SARS-CoV-2 in inbred wild-type mice, which poses a challenge for preclinical research with animal models, necessitating a human ACE2 (hACE2)-expressing transgenic mouse model. Cytokeratin 18 (K18) promoter-derived hACE2 transgenic mice [B6.Cg-Tg(K18-ACE2)2Prlmn/J] are widely used for research on SARS-CoV-1, MERS-CoV, and SARS-CoV-2. However, SARS-CoV-2 infection is lethal at ≥105 PFU and SARS-CoV-2 target cells are limited to type-1 alveolar pneumocytes in K18-hACE2 mice, making this model incompatible with infections in the human lung. Hence, we developed lung-specific SARS-CoV-2 infection mouse models with surfactant protein B (SFTPB) and secretoglobin family 1a member 1 (Scgb1a1) promoters. After inoculation of 105 PFU of SARS-CoV-2 to the K18-hACE2, SFTPB-hACE2, and SCGB1A1-hACE2 models, the peak viral titer was detected at 2 days post-infection and then gradually decreased. In K18-hACE2 mice, the body temperature decreased by approximately 10°C, body weight decreased by over 20%, and the survival rate was reduced. However, SFTPB-hACE2 and SCGB1A1-hACE2 mice showed minimal clinical signs after infection. The virus targeted type I pneumocytes in K18-hACE2 mice; type II pneumocytes in SFTPB-hACE2 mice; and club, goblet, and ciliated cells in SCGB1A1-hACE2 mice. A time-dependent increase in severe lung lesions was detected in K18-hACE2 mice, whereas mild lesions developed in SFTPB-hACE2 and SCGB1A1-hACE2 mice. Spleen, small intestine, and brain lesions developed in K18-hACE2 mice but not in SFTPB-hACE2 and SCGB1A1-hACE2 mice. These newly developed SFTPB-hACE2 and SCGB1A1-hACE2 mice should prove useful to expand research on hACE2-mediated respiratory viruses.
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Enzima Convertidora de Angiotensina 2 , COVID-19 , Animales , Humanos , Ratones , Células Epiteliales Alveolares/virología , Enzima Convertidora de Angiotensina 2/genética , Modelos Animales de Enfermedad , Ratones Transgénicos , SARS-CoV-2RESUMEN
[This corrects the article DOI: 10.3389/fimmu.2022.1055811.].
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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and potentially fatal virus. So far, most comprehensive analyses encompassing clinical and transcriptional manifestation have concentrated on the lungs. Here, we confirmed evident signs of viral infection in the lungs and spleen of SARS-CoV-2-infected K18-hACE2 mice, which replicate the phenotype and infection symptoms in hospitalized humans. Seven days post viral detection in organs, infected mice showed decreased vital signs, leading to death. Bronchopneumonia due to infiltration of leukocytes in the lungs and reduction in the spleen lymphocyte region were observed. Transcriptome profiling implicated the meticulous regulation of distress and recovery from cytokine-mediated immunity by distinct immune cell types in a time-dependent manner. In lungs, the chemokine-driven response to viral invasion was highly elevated at 2 days post infection (dpi). In late infection, diseased lungs, post the innate immune process, showed recovery signs. The spleen established an even more immediate line of defense than the lungs, and the cytokine expression profile dropped at 7 dpi. At 5 dpi, spleen samples diverged into two distinct groups with different transcriptome profile and pathophysiology. Inhibition of consecutive host cell viral entry and massive immunoglobulin production and proteolysis inhibition seemed that one group endeavored to survive, while the other group struggled with developmental regeneration against consistent viral intrusion through the replication cycle. Our results may contribute to improved understanding of the longitudinal response to viral infection and development of potential therapeutics for hospitalized patients affected by SARS-CoV-2.
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COVID-19 , Virosis , Animales , Humanos , Ratones , Enzima Convertidora de Angiotensina 2/genética , COVID-19/genética , Citocinas , Modelos Animales de Enfermedad , Perfilación de la Expresión Génica , Pulmón , Ratones Transgénicos , SARS-CoV-2 , Bazo/metabolismo , TranscriptomaRESUMEN
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological agent of COVID-19, causes life-threatening disease. This novel coronavirus enters host cells via the respiratory tract, promoting the formation of severe pulmonary lesions and systemic disease. Few animal models can simulate the clinical signs and pathology of COVID-19 patients. Diverse preclinical studies using K18-hACE2 mice and Syrian golden hamsters, which are highly permissive to SARS-CoV-2 in the respiratory tract, are emerging; however, the systemic pathogenesis and cellular tropism of these models remain obscure. We intranasally infected K18-hACE2 mice and Syrian golden hamsters with SARS-CoV-2, and compared the clinical features, pathogenesis, cellular tropism and infiltrated immune-cell subsets. In K18-hACE2 mice, SARS-CoV-2 persistently replicated in alveolar cells and caused pulmonary and extrapulmonary disease, resulting in fatal outcomes. Conversely, in Syrian golden hamsters, transient SARS-CoV-2 infection in bronchial cells caused reversible pulmonary disease, without mortality. Our findings provide comprehensive insights into the pathogenic spectrum of COVID-19 using preclinical models.
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COVID-19 , Cricetinae , Ratones , Animales , Mesocricetus , SARS-CoV-2 , Modelos Animales de Enfermedad , Pulmón/patología , Ratones TransgénicosRESUMEN
BACKGROUND: As the number of large-scale studies involving multiple organizations producing data has steadily increased, an integrated system for a common interoperable format is needed. In response to the coronavirus disease 2019 (COVID-19) pandemic, a number of global efforts are underway to develop vaccines and therapeutics. We are therefore observing an explosion in the proliferation of COVID-19 data, and interoperability is highly requested in multiple institutions participating simultaneously in COVID-19 pandemic research. RESULTS: In this study, a laboratory information management system (LIMS) approach has been adopted to systemically manage various COVID-19 non-clinical trial data, including mortality, clinical signs, body weight, body temperature, organ weights, viral titer (viral replication and viral RNA), and multiorgan histopathology, from multiple institutions based on a web interface. The main aim of the implemented system is to integrate, standardize, and organize data collected from laboratories in multiple institutes for COVID-19 non-clinical efficacy testings. Six animal biosafety level 3 institutions proved the feasibility of our system. Substantial benefits were shown by maximizing collaborative high-quality non-clinical research. CONCLUSIONS: This LIMS platform can be used for future outbreaks, leading to accelerated medical product development through the systematic management of extensive data from non-clinical animal studies.
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Exosomes are nanosized vesicles commonly found in biological fluids as a result of a secretion process involving endosomes and multivesicular bodies. The isolation and analysis of exosomes can be useful for noninvasive clinical diagnosis of a variety of human diseases. We investigated the utility of analyzing exosomal proteins, using matrix-assisted laser desorption/ionization combined with Fourier-transform ion cyclotron resonance mass spectrometry (MALDI-FTICR-MS), as a means of determining the presence of exosomes. MALDI-FTICR-MS analyses of exosomes enriched from human serum via centrifugation in a mass range of m/z 1000-20â¯000 yielded a distinctive protein around m/z 7766. The high mass accuracy and resolution of MALDI-FTICR-MS allowed for reliable comparisons against a protein database, through which the protein was identified as platelet factor 4 (PLF4), whose singly charged protein peak has an elemental composition of C341H577N96O101S4+, with a theoretical most abundant isotopic peak at m/z 7765.194 and a theoretical average peak at m/z 7766. The MALDI-TOF MS analysis of exosomes from the serum of 27 patients with different states of liver diseases provided the most abundant PLF4 peak for each mass spectrum, along with several additional minor peaks. In conclusion, MALDI-MS is suitable as an alternative exosome detection method, serving as a valuable confirmation tool, greatly decreasing the time and workload associated with exosome identification.
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Exosomas/química , Factor Plaquetario 4/sangre , Biomarcadores/sangre , Humanos , Hepatopatías/sangre , Espectrometría de Masa por Láser de Matriz Asistida de Ionización DesorciónRESUMEN
Direct-acting antiviral treatment for hepatitis C virus (HCV) infection is costly and does not protect from re-infection. For human and chimpanzees, recovery from acute HCV infection correlates with host CD4+ and CD8+ T cell responses. DNA plasmids targeting the HCV non-structural antigens NS3, NS4, and NS5, were previously reported to induce robust and sustained T cell responses in mice and primates. These plasmids were combined with a plasmid encoding cytokine IL-28B, together named as VGX-6150. The dose-dependent T cell response and safety of VGX-6150 administered intramuscularly and followed by electroporation was assessed in mice. Immune responses plateaued at 20 µg/dose with IL-28B demonstrating significant immunoadjuvant activity. Mice administered VGX-6150 at 40, 400, and 800 µg given either as a single injection or as 14 injections given bi-weekly over 26 weeks showed no vaccine related changes in any clinical parameter compared to placebo recipients. There was no evidence of VGX-6150 accumulation at the injection site or in any organ 1 month following the 14th vaccination. Based on these studies, the approximate lethal dose (ALD) exceeds 800 µg/dose and the NOAEL was 800 µg/dose in mouse. In conclusion, VGX-6150 appears safe and a promising preventive vaccine candidate for HCV infection.
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Hepacivirus/genética , Hepacivirus/inmunología , Antígenos de la Hepatitis C/inmunología , Hepatitis C/inmunología , Hepatitis C/prevención & control , Vacunas de ADN/inmunología , Vacunas contra Hepatitis Viral/inmunología , Animales , Citocinas/biosíntesis , Modelos Animales de Enfermedad , Relación Dosis-Respuesta Inmunológica , Femenino , Antígenos de la Hepatitis C/genética , Humanos , Inmunidad Celular , Inmunización , Esquemas de Inmunización , Masculino , Ratones , Ratones Endogámicos C57BL , Linfocitos T/inmunología , Linfocitos T/metabolismo , Factores de Tiempo , Distribución Tisular , Vacunas de ADN/administración & dosificación , Vacunas de ADN/efectos adversos , Vacunas contra Hepatitis Viral/administración & dosificación , Vacunas contra Hepatitis Viral/efectos adversos , Vacunas contra Hepatitis Viral/genéticaRESUMEN
Ultrasonic treatment for sludge reduction in wastewater treatment plants (WWTPs) can substantially affect the fate of trace pollutants. However, their fates in the different phases of sludge and mass balances have rarely been reported. In this study, wastewater sludge samples were ultrasonicated at 600W for 0-30min. Then, the leaching of the 16 priority polycyclic aromatic hydrocarbons (PAHs) from the sludge solids (sediment) to the liquid phase (supernatant) was investigated. The total concentration of PAHs (∑16 PAHs) in the sludge sediment (2.10µg/g) was comparable with those of previous worldwide studies. Among the 16 PAHs, naphthalene and acenaphthylene were dominant. The total concentrations of PAHs in the supernatant generally increased with sonication time, indicating that PAHs associated with sludge materials, such as microorganisms, were released into the supernatant. Lighter and more water soluble PAHs were released preferentially into the supernatant in dissolved form, whereas heavier and more hydrophobic PAHs were strongly bound to particles. According to mass balance calculations, 21% of the PAHs in the sludge sediment moved to the supernatant without discernible sonodegradation. An additional experiment for degradation of PAHs supported this interpretation, and several reasons for the no significant sonodegradation were discussed. This result suggests that leaching trace pollutants may significantly contaminate the sludge filtrate after ultrasonic treatment, and therefore their fates should be investigated.
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Hidrocarburos Policíclicos Aromáticos , Ultrasonido , Aguas Residuales , Industrias , Aguas del Alcantarillado , Contaminantes Químicos del Agua , Purificación del AguaRESUMEN
At present, more than 500,000 foreigner workers, most of them from Asian countries with high parasitic infection rates, are working in Korea. Since investigation into the prevalence of parasitic infections in foreigner workers has not yet been conducted in Korea, the present study was performed to determine the parasitic infection status of foreigner workers living in Cheonan City, Chungcheongnam-do (Chungnam Province) and to plan, on that basis, effective control measures. From October to December 2013, the parasitic infection status of 231 foreigner workers employed at selected Cheonan-si small businesses was investigated by both stool examination and ELISA. A total of 60 individuals (26.0%) were found to be infected with parasites. The stool examination detected 14 positive cases (6.1%), and ELISA revealed 50 positive people (21.6%), for at least a kind of parasitic disease. The most common infection was cysticercosis (8.7%), followed by toxocariasis (7.8%) and clonorchiasis (7.4%). Since it was proved that parasitic infections were prevalent among foreigner workers living in Cheonan City, more comprehensive study is urgently needed in order to understand the nationwide status of parasitic infections in foreigner workers.
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Emigrantes e Inmigrantes/estadística & datos numéricos , Parásitos/aislamiento & purificación , Enfermedades Parasitarias/diagnóstico , Adulto , Animales , Asia , Ensayo de Inmunoadsorción Enzimática , Heces/parasitología , Femenino , Humanos , Masculino , Parásitos/clasificación , Parásitos/genética , Enfermedades Parasitarias/epidemiología , Enfermedades Parasitarias/parasitología , Prevalencia , República de Corea/epidemiología , Viaje , Adulto JovenRESUMEN
The source-receptor relationship of polycyclic aromatic hydrocarbons (PAHs) in the industrial city has been generally investigated using active air samplers (AAS), but they only provide low spatial resolution data. In this study, the spatial resolution of PAHs was improved by the use of polyurethane foam based passive air samplers (PUF-PAS). We deployed 40 passive air samplers in duplicate at 20 sites in the largest industrial city of Ulsan, South Korea during winter (January 7-February 25, 2011). Among the 16 US-EPA priority PAHs, 13 compounds excluding naphthalene, acenaphthylene, and acenaphthene were selected for the calculation of air concentrations. The level of gaseous ∑(13)PAHs in Ulsan (mean: 43 ng/m(3)) was not as high as we expected due to prevailing winds which transported large amounts of PAHs to the East Sea. The spatial distribution of PAHs, principal component analysis, and diagnostic ratios suggested the influence of PAH emissions from industrial complexes to the surrounding areas. This study demonstrated that the source-receptor relationship of PAHs in the industrial area can be more clearly understood using passive air samplers.
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Contaminantes Atmosféricos/análisis , Ciudades , Monitoreo del Ambiente/métodos , Industrias , Hidrocarburos Policíclicos Aromáticos/análisis , Monitoreo del Ambiente/instrumentación , República de Corea , Estaciones del Año , Tiempo (Meteorología)RESUMEN
Transcutaneous and transconjunctival approaches are still frequently used to repair orbital wall fractures. However, medial orbital wall fracture remains a challenging area for plastic surgeons due to technical difficulties and postoperative scars. The transcaruncular approach is described and we present our experience with this approach to access the medial orbital wall in 10 patients with blowout fracture in the medial orbital region. All patients were corrected satisfactorily without cutaneous scar. The transcaruncular approach is a useful technique to repair medial orbital wall fractures.