RESUMEN
Breast cancer has now replaced lung cancer as the most prevalent malignant tumor worldwide, posing a serious health risk to women. We have recently designed a promising option strategy for the treatment of breast cancer. In this work, cyclodextrin metal-organic frameworks with high drug-carrying properties were endo-crosslinked by 3,3'dithiodipropionyl chloride to form cubic phase gel nanoparticles, which were drug-loaded and then coated by MCF-7 cell membranes. After intravenous injection, this multifunctional nanomedicine achieved dramatically homologous targeting co-delivery of honokiol and indocyanine green to the breast tumor. Further, the disulfide bonds in the nanostructures achieved glutathione-responsive drug release, induced tumor cells to produce reactive oxygen species and promoted apoptosis, resulting in tumor necrosis, and at the same time, inhibited Ki67 protein expression, which enhanced photochemotherapy, and resulted in a 94.08 % in vivo tumor suppression rate in transplanted tumor-bearing mice. Thereby, this nanomimetic co-delivery system may have a place in breast cancer therapy due to its simple fabrication process, excellent biocompatibility, efficient targeted delivery of insoluble drugs, and enhanced photochemotherapy.
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Compuestos de Bifenilo , Neoplasias de la Mama , Liberación de Fármacos , Glutatión , Verde de Indocianina , Lignanos , Estructuras Metalorgánicas , Fotoquimioterapia , Verde de Indocianina/administración & dosificación , Verde de Indocianina/química , Animales , Femenino , Humanos , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/patología , Células MCF-7 , Fotoquimioterapia/métodos , Compuestos de Bifenilo/administración & dosificación , Compuestos de Bifenilo/química , Estructuras Metalorgánicas/química , Glutatión/metabolismo , Lignanos/administración & dosificación , Lignanos/química , Lignanos/farmacología , Ratones Endogámicos BALB C , Ciclodextrinas/química , Ratones , Apoptosis/efectos de los fármacos , Nanopartículas/química , Nanopartículas/administración & dosificación , Sistemas de Liberación de Medicamentos/métodos , Especies Reactivas de Oxígeno/metabolismo , Ratones Desnudos , Portadores de Fármacos/química , Compuestos Alílicos , FenolesRESUMEN
Global warming and unpredictable nature possess a negative impact on fisheries and the daily activities of other habitats. GIS and remote sensing approach is an effective tool to determine the morphological characteristics of the lake. The present study addresses the interactive effect of climate and landuse changes hit on fish catch in lake fisheries. We used a combination of the landscape disturbance index, vulnerability index, and loss index to construct a complete ecological risk assessment framework based on the landscape structure of regional ecosystems. The results indicate an increase from around 45%-76% in the percentage of land susceptible to moderate to ecological severe risk in the landscape from 2004 to 2023. Since 1950, temperature changes have increased by 0.4%, precipitation has decreased by 6%, and water levels have decreased by 4.2%, based on the results. The results indicate that landuse, water temperature, precipitation, and water depth significantly impact the aquaculture system. The findings strongly suggest integrating possible consequences of environmental change on fish yield for governance modeling techniques to minimize their effects.
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Cambio Climático , Explotaciones Pesqueras , Peces , Lagos , Animales , Medición de Riesgo , TemperaturaRESUMEN
Conventional transnasal brain-targeted drug delivery strategies are limited by nasal cilia clearance and the nasal mucosal barrier. To address this challenge, we designed dissolving microneedles combined with nanocarriers for enhanced nose-to-brain drug delivery. To facilitate transnasal administration, a toothbrush-like microneedle patch was fabricated with hyaluronic acid-formed microneedles and tannic acid-crosslinked gelatin as the base, which completely dissolved in the nasal mucosa within seconds leaving only the base, thereby releasing the loaded cyclodextrin-based metal-organic frameworks (CD-MOFs) without affecting the nasal cilia and nasal microbial communities. As nanocarriers for high loading of huperzine A, these potassium-structured CD-MOFs, reinforced with stigmasterol and functionalized with lactoferrin, possessed improved physical stability and excellent biocompatibility, enabling efficient brain-targeted drug delivery. This delivery system substantially attenuated H2O2- and scopolamine-induced neurocyte damage. The efficacy of huperzine A on scopolamine- and D-galactose & AlCl3-induced memory deficits in rats was significantly improved, as evidenced by inhibiting acetylcholinesterase activity, alleviating oxidative stress damage in the brain, and improving learning function, meanwhile activating extracellular regulated protein kinases-cyclic AMP responsive element binding protein-brain derived neurotrophic factor pathway. Moreover, postsynaptic density protein PSD-95, which interacts with two important therapeutic targets Tau and ß-amyloid in Alzheimer's disease, was upregulated. This fruitful treatment was further shown to significantly ameliorate Tau hyperphosphorylation and decrease ß-amyloid by ways including modulating beta-site amyloid precursor protein cleaving enzyme 1 and a disintegrin and metalloproteinase 10. Collectively, such a newly developed strategy breaks the impasse for efficient drug delivery to the brain, and the potential therapeutic role of huperzine A for Alzheimer's disease is further illustrated.
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Alcaloides , Enfermedad de Alzheimer , Ciclodextrinas , Polifenoles , Sesquiterpenos , Animales , Ratas , Enfermedad de Alzheimer/tratamiento farmacológico , Acetilcolinesterasa , Peróxido de Hidrógeno , Encéfalo , Mucosa Nasal , Péptidos beta-Amiloides , EscopolaminaRESUMEN
Although the introduction of glycerosomes has enriched strategies for efficient transdermal drug delivery, the inclusion of cholesterol as a membrane stabilizer has limited their clinical application. The current study describes the development and optimization of a new type of glycerosome (S-glycerosome) that is formed in glycerol solution with ß-sitosterol as the stabilizer. Moreover, the transdermal permeation properties of lappaconitine (LA)-loaded S-glycerosomes and peppermint oil (PO)-mediated S-glycerosomes (PO-S-glycerosomes) are evaluated, and the lipid alterations in the stratum corneum are analyzed via lipidomics. The LA-loaded S-glycerosomes prepared by the preferred formulation from the uniform design have a mean size of 145.3 ± 7.81 nm and an encapsulation efficiency of 73.14 ± 0.35%. Moreover, the addition of PO positively impacts transdermal flux, peaking at 0.4% (w/v) PO. Tracing of the fluorescent probe P4 further revealed that PO-S-glycerosomes penetrate deeper into the skin than S-glycerosomes and conventional liposomes. Additionally, treatment with PO-S-glycerosomes alters the isoform type, number, and composition of sphingolipids, glycerophospholipids, glycerolipids, and fatty acids in the stratum corneum, with the most notable effect observed for ceramides, the main component of sphingolipids. Furthermore, the transdermal administration of LA-loaded PO-S-glycerosomes improved the treatment efficacy of xylene-induced inflammation in mice without skin irritation. Collectively, these findings demonstrate the feasibility of ß-sitosterol as a stabilizer in glycerosomes. Additionally, the inclusion of PO improves the transdermal permeation of S-glycerosomes, potentially by altering the stratum corneum lipids.
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Fitosteroles , Absorción Cutánea , Ratones , Animales , Administración Cutánea , Fitosteroles/metabolismo , Fitosteroles/farmacología , Piel/metabolismo , Liposomas , Esfingolípidos/metabolismo , Esfingolípidos/farmacologíaRESUMEN
We designed cholesterol- and phospholipid-free multilamellar niosomes (MLNs) structured by glyceryl monooleate (GMO) and poloxamer 407 (F127), and evaluated their capacity for transdermal drug delivery. The optimized MLNs had a mean size of 97.88 ± 63.25 nm and an encapsulation efficiency of 82.68% ± 2.14%. The MLNs exhibited a remarkable sustained cargo release, and improved the permeation of the stratum corneum. Compared with the tincture, lower transdermal flux but higher skin deposition of aconitine in vitro were achieved in the MLN group (p < 0.05). Additionally, both water-soluble rhodamine B- and liposoluble coumarin 6-labeled MLNs were found to penetrate deeply into the skin through the hair follicles and could be internalized by fibroblasts Notably, the MLNs possessed greater wettability, and the study focused on delivery to deeper hair follicles and up to the outer hair sheath, which showed advantages for treating diseases of hair follicles, and was potentially superior to the hydrophobic PLGA nanoparticles (diameter: 637.87 ± 22.77 nm) which mainly accumulated in superficial hair follicles. Hair follicles were therefore demonstrated to be an important way to enhance skin permeability, and MLNs are a promising alternative for topical and transdermal drug delivery.
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Liposomas , Nanopartículas , Administración Cutánea , Animales , Colesterol/metabolismo , Portadores de Fármacos/química , Sistemas de Liberación de Medicamentos , Folículo Piloso , Liposomas/química , Nanopartículas/química , Fosfolípidos/química , Ratas , Ratas Sprague-Dawley , Piel/metabolismo , Absorción CutáneaRESUMEN
Triptolide exerts strong anti-inflammatory and immunomodulatory effects; however, its oral administration might be associated with side effects. Transdermal administration can improve the safety of triptolide. In this study, glycerosomes were prepared as the transdermal vehicle to enhance the transdermal delivery of triptolide. With entrapment efficiency and drug loading as dependent variables, the glycerosome formulation was optimized using an orthogonal experimental design. Phospholipid-to-cholesterol and phospholipid-to-triptolide mass ratios of 30:1 and 5:1, respectively and a glycerol concentration of 20 % (V/V) were used in the optimization. The glycerosomes prepared with the optimized formulation showed good stability, with an average particle size of 153.10 ± 2.69 nm, a zeta potential of -45.73 ± 0.60 mV and an entrapment greater than 75 %. Glycerosomes significantly increased the transdermal delivery of triptolide compared to conventional liposomes. As efficient carriers for the transdermal delivery of drugs, glycerosomes can potentially be used as an alternative to oral triptolide administration.
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Portadores de Fármacos , Absorción Cutánea , Administración Cutánea , Proyectos de Investigación , Liposomas/metabolismo , Liposomas/farmacología , Fosfolípidos/metabolismo , Fosfolípidos/farmacología , Tamaño de la Partícula , Sistemas de Liberación de Medicamentos , PielRESUMEN
In this work, paclitaxel (Ptx) combined with tanshinone IIA (TanIIA) was found to show synergistic effect on inducing apoptosis of human acute promyelocytic leukemia (APL) cell line NB4, and the anti-tumor effect was strongest when its molar ratio was 1:1. To enhance the efficacy and reduce side effects, an active targeting drug delivery system with mesoporous silica nanoparticles (MSNs) coated with folic acid (FA) modified PEGylated lipid-bilayer (LB) membrane (FA-LB-MSNs) was established for co-loading drugs. The drug loadings of Ptx and TanIIA in FA-LB-MSNs were 5.5% and 1.8%, respectively. Compared with the uncoated MSNs, the FA-LB-MSNs showed a sustained drug release, and Ptx and TanIIA released synchronously from the carriers. By means of biological adhesion between FA and its receptors, the uptake of FA-LB-MSNs by NB4 cells was significantly higher than that of uncoated preparations, and Ptx combined with TanIIA had strong synergistic effect to enhance the apoptosis and differentiation of NB4 cells. The results of pharmacodynamics in vivo showed that the FA-LB-MSNs targeted tumor in nude mice more effectively than the compared formulations without FA modification. The Ptx and TanIIA-loaded FA-LB-MSNs group showed significantly better effects on inducing apoptosis and inhibiting tumor growth than the reference groups, which agreed with the results of anti-tumor experiments in vitro. Furthermore, no toxicity was observed to the heart, liver, spleen, lung and kidney of the tumor-bearing animals, indicating good biocompatibility of the prepared novel nanocarriers. This study confirmed the synergistic therapeutic effect of Ptx and TanIIA on APL, and the superior of FA-LB-MSNs as co-loaded nanocarriers for active targeted therapy of tumors.
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Abietanos/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Leucemia Promielocítica Aguda/tratamiento farmacológico , Paclitaxel/administración & dosificación , Abietanos/farmacología , Animales , Protocolos de Quimioterapia Combinada Antineoplásica/farmacología , Línea Celular Tumoral , Preparaciones de Acción Retardada , Portadores de Fármacos/química , Sistemas de Liberación de Medicamentos , Liberación de Fármacos , Femenino , Ácido Fólico/química , Humanos , Leucemia Promielocítica Aguda/patología , Membrana Dobles de Lípidos , Ratones , Ratones Endogámicos BALB C , Ratones Desnudos , Nanopartículas , Paclitaxel/farmacología , Dióxido de Silicio/química , Ensayos Antitumor por Modelo de XenoinjertoRESUMEN
BACKGROUND: Lipid-based nanosystems have great potential for transdermal drug delivery. In this study, nanostructured lipid carriers (NLCs) for short-acting alkaloids lappacontine (LA) and ranaconitine (RAN) isolated from Aconitum sinomontanum (AAS) at 69.47 and 9.16% (w/w) yields, respectively, were prepared to enhance percutaneous permeation. Optimized NLC formulations were evaluated using uniform design experiments. Microstructure and in vitro/in vivo transdermal delivery characteristics of AAS-loaded NLCs and solid lipid nanoparticles (SLNs) were compared. Cellular uptake of fluorescence-labeled nanoparticles was probed using laser scanning confocal microscopy and fluorescence-activated cell sorting. Nanoparticle integrity during transdermal delivery and effects on the skin surface were also investigated. RESULTS: NLC formulations were less cytotoxic than the AAS solution in HaCaT and CCC-ESF cells. Moreover, coumarin-6-labeled NLCs showed biocompatibility with HaCaT and CCC-ESF cells, and their cellular uptake was strongly affected by cholesterol and lipid rafts. Significantly greater cumulative amounts of NLC-associated LA and RAN than SLN-associated alkaloids penetrated the rat skin in vitro. In vivo microdialysis showed higher area under the concentration-time curve (AUC)0-t for AAS-NLC-associated LA and RAN than for AAS-SLN-associated alkaloids. CONCLUSIONS: NLC formulations could be good transdermal systems for increasing biocompatibility and decreasing cytotoxicity of AAS. AAS-NLCs showed higher percutaneous permeation than the other preparations. These findings suggest that NLCs could be promising transdermal delivery vehicles for AAS.
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Aconitina/análogos & derivados , Aconitum/química , Portadores de Fármacos/química , Lípidos/química , Nanoestructuras/química , Aconitina/administración & dosificación , Aconitina/farmacocinética , Administración Cutánea , Animales , Línea Celular , Humanos , Masculino , Ratas , Ratas Sprague-Dawley , Piel/metabolismo , Absorción CutáneaRESUMEN
This study investigated the transdermal permeability of baicalin, a hydrophobic and readily hydrolyzed drug, delivered by glyceryl monooleate (GMO)-based cubic phase gel (CPG) mediated with Transcotol(®) P (TP, diethylene glycol monoethyl ether). A range of CPGs was produced by varying GMO, water, and TP levels. Examination of their physicochemical properties revealed that the optically isotropic CPG showed higher viscosity than lamellar phase gels (LPG), and the baicalin cargo increased CPG viscosity. The GMO:TP ratio and water content also altered viscosity. CPG-mediated delivery increased baicalin's skin permeation, with 76.65- to 200.24-fold higher (p<0.05) transdermal flux than that of a Carbopol(®)-based hydrogel (HDG), and 6.72- to 17.55-fold (p<0.05) higher than that of LPG, with the same water content. Rat in vivo microdialysis showed that CPG produced sustained baicalin release, with superior pharmacokinetic parameters to those of HDG. Furthermore, cutaneous drug absorption was more efficient on rat abdominal skin, compared to that in the chest or scapular region. Effective fusion between the CPG lipid matrix and the stratum corneum may explain this enhancement of transdermal permeation. CPG containing TP therefore, achieved excellent transdermal drug delivery and good baicalin stability, indicating that this system represents a promising transdermal delivery vehicle.
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Glicoles de Etileno/administración & dosificación , Flavonoides/administración & dosificación , Glicéridos/administración & dosificación , Absorción Cutánea , Administración Cutánea , Animales , Estabilidad de Medicamentos , Glicoles de Etileno/química , Glicoles de Etileno/farmacología , Flavonoides/química , Flavonoides/farmacocinética , Geles , Glicéridos/química , Glicéridos/farmacología , Técnicas In Vitro , Masculino , Ratones Desnudos , Microdiálisis , Ratas Sprague-Dawley , Piel/metabolismoRESUMEN
Span 40-based niosomes were employed as nanocarriers to improve cutaneous absorption of salidroside. The niosomal formulation with a molar proportion of Span 40 to cholesterol of 4:3 showed the highest transdermal flux and skin deposition of salidroside. The transdermal flux of the 4:3 niosomal formulation was significantly greater than that of the aqueous solution. Salidroside-loaded niosomes showed good biocompatibility with skin tissue, human epidermal immortal keratinocytes (HaCaT), and human embryonic skin fibroblasts (CCC-ESF). The fluorescence intensity of HaCaT cells after uptake of coumarin 6-labeled niosomes was similar to that observed after uptake of the aqueous suspension. The fluorescence intensity of CCC-ESF cells was greater than that of the aqueous suspension after incubation for 10 min, but was not significantly different after 60 min. Further investigation revealed that internalization of niosomes by HaCaT cells may be achieved through pinocytotic vesicles and macropinocytosis, which consumes energy, rather than via lysosomes. In CCC-ESF cells, pinocytotic vesicles and lysosomes were both important mediators of endocytosis. The niosome formulations reported here could improve the dermal and transdermal salidroside delivery, and the in vitro cell uptake evaluation results serve as a basis for further research into the mechanisms through which niosomes enhance drug permeability.
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Glucósidos/administración & dosificación , Fenoles/administración & dosificación , Administración Cutánea , Animales , Transporte Biológico/efectos de los fármacos , Línea Celular , Colesterol/química , Glucósidos/química , Glucósidos/farmacocinética , Glucósidos/farmacología , Hexosas/química , Humanos , Técnicas In Vitro , Liposomas , Masculino , Ratones Desnudos , Fenoles/química , Fenoles/farmacocinética , Fenoles/farmacología , Ratas Sprague-Dawley , Piel/efectos de los fármacos , Piel/metabolismo , Dodecil Sulfato de Sodio/químicaRESUMEN
OBJECTIVE: To investigate the effects of total saponins from rhizomes and flowers of Panax notoginseng on tumor cell induced platelet aggregation (TCIPA). METHODS: MDA-MB-231 breast carcinoma was applied as inductor and the platelet aggregation were investigated by Born's method in vitro and in vivo. RESULTS: Saponins from the flowers of Panax notoginseng inhibited TCIPA at the dose of 120, 240, 480 mg/L respectively in vitro and in vivo. Saponins from rhizomes of Panax notoginseng inhibited TCIPA only at its high dose in vivo. CONCLUSION: The saponins from Panax notoginseng has a dose-dependent inhibition of TCIPA. It may be a new class of antimetastatic agent.
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Neoplasias de la Mama/patología , Panax notoginseng/química , Agregación Plaquetaria/efectos de los fármacos , Saponinas/farmacología , Animales , Antineoplásicos/farmacología , Neoplasias de la Mama/sangre , Neoplasias de la Mama/tratamiento farmacológico , Línea Celular Tumoral , Movimiento Celular , Relación Dosis-Respuesta a Droga , Femenino , Flores/química , Humanos , Ratones , Ratones Desnudos , Metástasis de la Neoplasia , Inhibidores de Agregación Plaquetaria/farmacología , Distribución Aleatoria , Rizoma/química , Saponinas/administración & dosificaciónRESUMEN
BACKGROUND: The chronic pathological changes in vascular walls of hypertension may exert destructive effects on multiple organ systems. Accumulating evidence indicates that inflammatory reactions are involved in the pathological changes of hypertension. Three peroxisome proliferator-activated receptors (PPARs) have been identified: PPARalpha, PPARbeta/delta, and PPARgamma, all of which have multiple biological effects, especially the inhibition of inflammation. The aim of this study was to evaluate PPAR isoforms expression profile in important organs of spontaneously hypertensive rats (SHR) and to understand the modulation of endogenous PPAR isoforms under inflammatory condition. METHODS: Tissues (kidney, liver, heart, and brain) were dissected from SHR and age-matched control Wistar-Kyoto rats (WKY) to investigate the abundance of PPAR isoforms and PPAR-responsive genes (acyl-CoA oxidase and CD36). The expression of CCAAT/enhancer-binding protein delta (C/EBPdelta), which can trans-activate PPARgamma expression, was also observed. The inflammatory response was analyzed by the expression of inflammatory mediators inducible nitric oxide synthase (iNOS), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), E-selectin, interleukin-1 beta (IL-1beta), and tumor necrosis factor alpha (TNFalpha), and formation of carbonyl and nitrated proteins. RESULTS: The expressions of 3 PPAR isoforms and PPAR-responsive genes were markedly upregulated in SHR compared with those of WKY. Specifically, the expression of PPARalpha protein in the kidney, liver, heart and brain increased by 130.76%, 91.48%, 306.24%, and 90.70%; PPARbeta/delta upregulated by 109.34%, 161.98%, 137.04%, and 131.66%; PPARgamma increased by 393.76%, 193.17%, 559.29%, and 591.18%. In consistent with the changes in PPARgamma, the expression of C/EBPdelta was also dramatically elevated in SHR. Inflammatory mediators expressions were significantly increased in the most organs of SHR than WKY. As a consequence, increased formation of carbonyl and nitrated proteins were also observed in the most organs of SHR. CONCLUSIONS: These findings suggest an enhanced inflammatory response in the organs of SHR, which might play a key role in pathogenesis of hypertension and secondary organ complications. Changes (increases) in PPARs expression may reflect a compensatory mechanism to the inflammatory status of hypertensive rats.
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Hipertensión/metabolismo , Inflamación/metabolismo , Receptores Activados del Proliferador del Peroxisoma/metabolismo , Animales , Presión Sanguínea , Western Blotting , Selectina E/genética , Selectina E/metabolismo , Expresión Génica , Hipertensión/genética , Hipertensión/fisiopatología , Inflamación/genética , Inflamación/fisiopatología , Interleucina-1beta/genética , Interleucina-1beta/metabolismo , Masculino , PPAR alfa/genética , PPAR alfa/metabolismo , PPAR delta/genética , PPAR delta/metabolismo , PPAR gamma/genética , PPAR gamma/metabolismo , Receptores Activados del Proliferador del Peroxisoma/genética , Pletismografía/métodos , Ratas , Ratas Endogámicas SHR , Ratas Endogámicas WKY , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Factor de Necrosis Tumoral alfa/genética , Factor de Necrosis Tumoral alfa/metabolismo , Molécula 1 de Adhesión Celular Vascular/genética , Molécula 1 de Adhesión Celular Vascular/metabolismoRESUMEN
The hypertension is one of chronic vascular diseases, which often implicates multiple tissues causing stroke, cardiac hypertrophy, and renal failure. A growing body of evidence suggests that inflammatory mechanisms are important participants in the pathophysiology of hypertension. In this study, the inflammatory status of these tissues (kidney, liver, heart, and brain) in spontaneously hypertensive rats (SHR) was analyzed and its molecular mechanism was explored. The tissues were dissected from SHR and age-matched control Wistar-Kyoto (WKY) rats to investigate the abundance of inflammation-related mediators (IL-1beta, TNFalpha, ICAM-1, iNOS, C/EBPdelta and PPARgamma). mRNA levels were determined by reverse transcription-polymerase chain reaction and protein expression was evaluated by Western blot. To evaluate the oxidative stress of tissues, carbonyl protein content and total antioxidant capacity of tissues were detected by spectrophotometry and ferric reduction ability power (FRAP) method. The results suggest that: (1) Expressions of inflammation-related mediators (IL-1beta, TNFalpha, ICAM-1, iNOS, C/EBPdelta and PPARgamma) in SHR were higher compared with those in WKY rats except no evident increase of IL-1beta mRNA in liver and brain in SHR. (2) Tissues in SHR contained obviously increased carbonyl protein (nmol/mg protein) compared to that in WKY rats (8.93+/-1.08 vs 2.27+/-0.43 for kidney, 2.23+/-0.23 vs 0.17+/-0.02 for heart, 13.42+/-1.10 vs 5.72+/-1.01 for brain, respectively, P<0.05). However, no evident difference in the amount of carbonyl protein in liver was detected between SHR and WKY rats. (3) Total antioxidant capacities of kidney, liver, heart and brain were markedly lower in SHR than that in WKY rats (P<0.05). Thus, the present data reveal a higher inflammatory status in the important tissues in SHR and indicate that inflammation might play a potential role in pathogenesis of hypertension and secondary organ complications.