Abnormal eye movements increase as motor disabilities and cognitive impairments become more evident in Multiple Sclerosis: A novel eye-tracking study.

Background: Eye movements can reflect brain alterations and inform on the presence of motor disabilities and cognitive impairments in people with multiple sclerosis (pwMS). Objective: The aim of the study was to determine the correlation between motor and cognitive measurements and eye movement parameters when performing the n-back task (NBKT). Methods: This was a cross-sectional study carried out at Ramos Mejía Hospital, a center specialized in demyelinating diseases in Buenos Aires, Argentina. The study population consisted of 66 patients with relapsing-remitting multiple sclerosis (RRMS) and 5 patients with secondary progressive multiple sclerosis (SPMS). pwMS performed the n-back test while using a device head mounted display (HMD) with eyetracking capabilities in order to capture eye movement. Clinical motor and cognitive measures were assessed with Expanded Disability Status Scale (EDSS), Nine Hole Peg Test (NHPT), Timed 25-Foot Walk (T25FW), and Symbol Digit Modalities Test (SDMT). Results: pwMS showed strong and statistically significant correlations between gaze duration; number of fixations, saccade amplitude and motor disabilities and cognitive impairments as measured by EDSS, NHPT, T25FW, and SDMT. Conclusion: This study found significant correlations between eye movement behavior and motor and cognitive disability in pwMS. These findings suggest that eye movements have the potential to be used as a surrogate biomarker in MS progression.

Integration of Total Worker Health ® Training for Occupational Health and Safety Professionals With Efforts to Promote Worker Health, Safety, and Well-being in Mexico.

OBJECTIVE: We sought to test whether a 2-week Total Worker Health (TWH) training mapped to TWH education competencies could be administered to a Mexican audience of occupational safety and health professionals and could lead to positive changes to knowledge and behaviors. METHODS: This study used robust program evaluation methods collected before and after each of the nine training days and at the end of the course. RESULTS: Overall course quality received a mean score of 4.6 (SD = 0.6) and 98.8% of participants agreed that their TWH knowledge increased. All participants intended to make at least one change to their professional practice, most frequently helping companies assess their organizational culture to support health, safety, and well-being. CONCLUSIONS: This TWH training was well received and led to positive self-reported increase in knowledge and abilities to influence workers' health, safety, and well-being.

Apuntes para la historia de la alergología en Matanzas. 1961-2022

Introducción: La especialidad de alergología compite entre las más caras de la práctica médica en los países desarrollados, donde se promueve el criterio de que la alergia es una enfermedad de ricos y que los pobres no la padecen, cuando en realidad se trata de un problema de posibilidades de acceso a ese servicio. En Cuba, la alergología tiene una organización social diferente, comparada con otros países. Objetivo: Desarrollar un bosquejo histórico de la especialidad de alergología en la provincia de Matanzas. Materiales y métodos: Fueron utilizados los métodos teóricos histórico-lógico y analítico-sintético, y los empíricos entrevista y análisis documental. Resultados: Se describe el comienzo de la especialidad de alergología en Matanzas en 1961, enfatizando en la figura del Dr. Gonzalo Álvarez Rodríguez como el primer alergólogo de la provincia. Se evidencia el desarrollo y salto cualitativo del servicio, y se recogen apuntes relacionados con su origen, formación de especialistas, progreso científico, condiciones de trabajo y ampliación de la cobertura a la población en estos años. Conclusiones: Con este trabajo se inició un recuento del origen y desarrollo de la alergología en Matanzas, que enriqueció la historia de la especialidad, como parte de los servicios de salud en la provincia.

Introduction: The specialty of Allergology competes among the most expensive in medical practice in developed countries, where the criterion is promoted that allergy is a disease of the rich and that the poor do not suffer from it, when in fact it is a problem of access possibilities to that service. In Cuba, the allergy specialty has a different social organization compared with other countries. Objective: To elaborate a historical outline of allergology in the province of Matanzas. Materials and methods: Historical-logical and analytical-synthetic theoretical methods were used, as well as interview and documentary analysis empirical ones. Results: The beginning of the specialty of Allergology is described, emphasizing the role of Dr. Gonzalo Álvarez Rodríguez as the first allergist in the province. The development and qualitative leap of the service was evidenced, and notes are collected related to its origin, training of specialists, scientific progress, working conditions and expansion of coverage to the population in these years. Conclusions: With this work, an account of the origin and development of allergology in Matanzas began, which enriched the history of the specialty as part of the health services in the province.

Corrigendum: Zilucoplan, a macrocyclic peptide inhibitor of human complement component 5, uses a dual mode of action to prevent terminal complement pathway activation.

[This corrects the article DOI: 10.3389/fimmu.2023.1213920.].

Zilucoplan, a macrocyclic peptide inhibitor of human complement component 5, uses a dual mode of action to prevent terminal complement pathway activation.

Introduction: The complement system is a key component of the innate immune system, and its aberrant activation underlies the pathophysiology of various diseases. Zilucoplan is a macrocyclic peptide that binds and inhibits the cleavage/activation of human complement component 5 (C5). We present in vitro and ex vivo data on the mechanism of action of zilucoplan for the inhibition of C5 activation, including two clinically relevant C5 polymorphisms at R885. Methods: The interaction of zilucoplan with C5, including for clinical C5 R885 variants, was investigated using surface plasmon resonance (SPR), hemolysis assays, and ELISA. The interference of C5b6 formation by zilucoplan was investigated by native gel analysis and hemolysis assay. The permeability of zilucoplan in a reconstituted basement membrane was assessed by the partition of zilucoplan on Matrigel-coated transwell chambers. Results: Zilucoplan specifically bound human complement C5 with high affinity, competitively inhibited the binding of C5 to C3b, and blocked C5 cleavage by C5 convertases and the assembly of the cytolytic membrane attack complex (MAC, or C5b9). Zilucoplan fully prevented the in vitro activation of C5 clinical variants at R885 that have been previously reported to respond poorly to eculizumab treatment. Zilucoplan was further demonstrated to interfere with the formation of C5b6 and inhibit red blood cell (RBC) hemolysis induced by plasmin-mediated non-canonical C5 activation. Zilucoplan demonstrated greater permeability than a monoclonal C5 antibody in a reconstituted basement membrane model, providing a rationale for the rapid onset of action of zilucoplan observed in clinical studies. Conclusion: Our findings demonstrate that zilucoplan uses a dual mode of action to potently inhibit the activation of C5 and terminal complement pathway including wild-type and clinical R885 variants that do not respond to eculizumab treatment. These data may be relevant to the clinically demonstrated benefits of zilucoplan.

Coat Color in Local Goats: Influence on Environmental Adaptation and Productivity, and Use as a Selection Criterion.

This paper aims to review, systematically synthesize, and analyze fragmented information about the importance of coat color in local goats and its relationship with productivity and other important traits. Topics on current research on color expression are addressed, the relationship that has as a mechanism of environmental adaptation, its relationship with the production of meat, milk, and derivates, and the economic value of this characteristic. The use of this attribute as a tool to establish selection criteria in breeding programs based on results reported in the scientific literature is significant, particularly for low-income production systems, where the implementation of classic genetic improvement schemes is limited due to the lack of productive information, which is distinctive of extensive marginal or low scaled production systems around the world.

EspEn Graph for the Spatial Analysis of Entropy in Images.

The quantification of entropy in images is a topic of interest that has had different applications in the field of agronomy, product generation and medicine. Some algorithms have been proposed for the quantification of the irregularity present in an image; however, the challenges to overcome in the computational cost involved in large images and the reliable measurements in small images are still topics of discussion. In this research we propose an algorithm, EspEn Graph, which allows the quantification and graphic representation of the irregularity present in an image, revealing the location of the places where there are more or less irregular textures in the image. EspEn is used to calculate entropy because it presents reliable and stable measurements for small size images. This allows an image to be subdivided into small sections to calculate the entropy in each section and subsequently perform the conversion of values to graphically show the regularity present in an image. In conclusion, the EspEn Graph returns information on the spatial regularity that an image with different textures has and the average of these entropy values allows a reliable measure of the general entropy of the image.

Human Neutrophils Respond to Complement Activation and Inhibition in Microfluidic Devices.

Complement activation is key to anti-microbial defenses by directly acting on microbes and indirectly by triggering cellular immune responses. Complement activation may also contribute to the pathogenesis of numerous inflammatory and immunological diseases. Consequently, intense research focuses on developing therapeutics that block pathology-causing complement activation while preserving anti-microbial complement activities. However, the pace of research is slowed down significantly by the limitations of current tools for evaluating complement-targeting therapeutics. Moreover, the effects of potential therapeutic agents on innate immune cells, like neutrophils, are not fully understood. Here, we employ microfluidic assays and measure chemotaxis, phagocytosis, and swarming changes in human neutrophils ex vivo in response to various complement-targeting agents. We show that whereas complement factor 5 (C5) cleavage inhibitor eculizumab blocks all neutrophil anti-microbial functions, newer compounds like the C5 cleavage inhibitor RA101295 and C5a receptor antagonist avacopan inhibit chemotaxis and swarming while preserving neutrophil phagocytosis. These results highlight the utility of microfluidic neutrophil assays in evaluating potential complement-targeting therapeutics.

Comparison of the systemic action of electroacupuncture and laserpuncture in experimental injuries on the back skin of Wistar rats (Rattus novergicus).

OBJECTIVE: To evaluate the systemic action of electroacupuncture and laserpuncture in the repair of excisional cutaneous injuries on the back of adult female Wistar rats. METHODS: Ninety animals were divided into three experimental groups: C-control; E-treated with electroacupuncture [acupoints: Feishu (BL13), Geshu (BL17), Zusanli (ST36)]; L-treated with laserpuncture (same acupoints) and euthanized on the 7th, 14th and 21st days for tissue removal and preparation for histomorphometric and biochemical (dosages, zymography and Western blotting) analysis. RESULTS: The number of fibroblasts in the E and L groups presented higher values than the C on the 14th and 21st days. The number of granulocytes was lower than C on the 21st day in groups E and L. The total number of newly formed vessels increased on the 21st day and was higher in both treatments when compared to C. The birefringent collagen fibers detected on the 21st day was lower in groups E and L than group C. The glycosaminoglycans and hydroxyproline amount was similar among groups throughout the experimental period. The active isoform of matrixmetallo proteinase (MMP)-2 and the latent isoform of MMP-9 did not show any differences among all groups and experimental periods. The amount of collagen Ⅰ presented higher values in the L group on the 14th day and in the E and L groups on the 21st day. For type III collagen, groups E and L presented values lower than C in all experimental periods. The amount of transforming growth factor-ß1 in the E and L groups showed higher amounts than C on the 7th day and lower on the 14th and 21st days. For vascular endothelial growth factor, E and L groups presented similar and lower values than C on the 7th and 14th days, respectively, and similar on the 21st day. CONCLUSION: The therapies evaluated in this article stimulated fibroblast proliferation, neoangiogenesis and altered the reorganization of collagen fibers in the repair of excisional injuries in female adult rats.

Complement C5 inhibition protects against hemolytic anemia and acute kidney injury in anthrax peptidoglycan-induced sepsis in baboons.

Late-stage anthrax infections are characterized by dysregulated immune responses and hematogenous spread of Bacillus anthracis, leading to extreme bacteremia, sepsis, multiple organ failure, and, ultimately, death. Despite the bacterium being nonhemolytic, some fulminant anthrax patients develop a secondary atypical hemolytic uremic syndrome (aHUS) through unknown mechanisms. We recapitulated the pathology in baboons challenged with cell wall peptidoglycan (PGN), a polymeric, pathogen-associated molecular pattern responsible for the hemostatic dysregulation in anthrax sepsis. Similar to aHUS anthrax patients, PGN induces an initial hematocrit elevation followed by progressive hemolytic anemia and associated renal failure. Etiologically, PGN induces erythrolysis through direct excessive activation of all three complement pathways. Blunting terminal complement activation with a C5 neutralizing peptide prevented the progressive deposition of membrane attack complexes on red blood cells (RBC) and subsequent intravascular hemolysis, heme cytotoxicity, and acute kidney injury. Importantly, C5 neutralization did not prevent immune recognition of PGN and shifted the systemic inflammatory responses, consistent with improved survival in sepsis. Whereas PGN-induced hemostatic dysregulation was unchanged, C5 inhibition augmented fibrinolysis and improved the thromboischemic resolution. Overall, our study identifies PGN-driven complement activation as the pathologic mechanism underlying hemolytic anemia in anthrax and likely other gram-positive infections in which PGN is abundantly represented. Neutralization of terminal complement reactions reduces the hemolytic uremic pathology induced by PGN and could alleviate heme cytotoxicity and its associated kidney failure in gram-positive infections.

Genetic structure and temporal environmental niche dynamics of sideoats grama [Bouteloua curtipendula (Michx.) Torr.] populations in Mexico.

In the past years, several plant breeding programs have been done to select outstanding genotypes of sideoats grama (Bouteloua curtipendula) for restoration purposes. Such programs have been focused mainly on agronomic traits; however, little attention has been paid to the genetic structure and environmental adaptation of the selected genotypes. Thus, in this study we evaluated the genetic structure of 85 sideoats grama populations in Mexico. In addition, we modeled the past, present and future environmental niche of the genetic clusters of this species. Ninety sideoats grama populations were genetically analyzed through AFLP (Amplified Fragment Length Polymorphisms) markers. The environmental niche of the population clusters was modeled by using the maximum entropy method. The genetic analysis separated the populations into two genetically different clusters (p = 0.0003). The differentiation of these lineages can be partially explained by the paleoclimatic events experienced during the last interglacial and glacial maximums. Consequently, the genetic clusters have different environmental niche at the present time. Suitability areas for the distribution of Cluster I are mainly located in the central part of the country while the environmental niche of Cluster II is located in the semiarid region, close to the mountain range of the Sierra Madre Occidental. Thus, selection and restoration programs with sideoats grama must be carried out using local germplasm from each environmental niche. Given the environmental niche of both genetic clusters will suffer changes in the near and mid-century future, climate change must be considered for genotypes selection and restoration programs.

Associations of DMT therapies with COVID-19 severity in multiple sclerosis

Background: People with multiple sclerosis (MS) are a vulnerable group for severe COVID-19, particularly those taking immunosuppressive disease-modifying therapies (DMTs). We examined the characteristics of COVID-19 severity in an international sample of people with MS. Methods: Data from 12 data-sources in 28 countries were aggregated. Demographic and clinical covariates were queried, alongside COVID-19 clinical severity outcomes, hospitalisation, admission to ICU, requiring artificial ventilation, and death. Characteristics of outcomes were assessed in patients with suspected/confirmed COVID-19 using multilevel mixed-effects logistic regression. Results: 657 (28.1%) with suspected and 1,683 (61.9%) with confirmed COVID-19 were analysed. Older age, progressive MS-phenotype, and higher disability were associated with worse COVID-19 outcomes. Compared to dimethyl fumarate, ocrelizumab and rituximab were associated with hospitalisation (aOR=1.56,95%CI=1.01-2.41; aOR=2.43,95%CI=1.48-4.02) and ICU admission (aOR=2.30,95%CI=0.98-5.39; aOR=3.93,95%CI=1.56-9.89), though only rituximab was associated with higher risk of artificial ventilation (aOR=4.00,95%CI=1.54-10.39). Compared to pooled other DMTs, ocrelizumab and rituximab were associated with hospitalisation (aOR=1.75,95%CI=1.29-2.38; aOR=2.76,95%CI=1.87-4.07) and ICU admission (aOR=2.55,95%CI=1.49-4.36; aOR=4.32,95%CI=2.27-8.23) but only rituximab with artificial ventilation (aOR=6.15,95%CI=3.09-12.27). Compared to natalizumab, ocrelizumab and rituximab were associated with hospitalisation (aOR=1.86,95%CI=1.13-3.07; aOR=2.88,95%CI=1.68-4.92) and ICU admission (aOR=2.13,95%CI=0.85-5.35; aOR=3.23,95%CI=1.17-8.91), but only rituximab with ventilation (aOR=5.52,95%CI=1.71-17.84). Importantly, associations persisted on restriction to confirmed COVID-19 cases. No associations were observed between DMTs and death. Conclusions: Using the largest cohort of people with MS and COVID-19 available, we demonstrated consistent associations of rituximab with increased risk of hospitalisation, ICU admission, and requiring artificial ventilation, and ocrelizumab with hospitalisation and ICU admission, suggesting their use may be a risk factor for more severe COVID-19.

Series of Novel and Highly Potent Cyclic Peptide PCSK9 Inhibitors Derived from an mRNA Display Screen and Optimized via Structure-Based Design.

Proprotein convertase subtilisin-like/kexin type 9 (PCSK9) is a key regulator of plasma LDL-cholesterol (LDL-C) and a clinically validated target for the treatment of hypercholesterolemia and coronary artery disease. In this paper, we describe a series of novel cyclic peptides derived from an mRNA display screen which inhibit the protein-protein interaction between PCSK9 and LDLR. Using a structure-based drug design approach, we were able to modify our original screening lead 2 to optimize the potency and metabolic stability and minimize the molecular weight to provide novel bicyclic next-generation PCSK9 inhibitor peptides such as 78. These next-generation peptides serve as a critical foundation for continued exploration of potential oral, once-a-day PCSK9 therapeutics for the treatment of cardiovascular disease.

Correction to: Clinical and demographic characteristics of primary progressive multiple sclerosis in Argentina: Argentinean registry cohort study (RelevarEM).

The above article was published online with incorrect figure 1.

Decision-making on management of ms and nmosd patients during the COVID-19 pandemic: A latin american survey.

BACKGROUND: The emergence of COVID-19 and its vertiginous spreading speed represents a unique challenge to neurologists managing multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). The need for data on the impact of the virus on these patients grows rapidly. There is an urgent necessity of sharing information to enable evidence-based decision making on the clinical management. There are no data on what physicians are doing on clinical practice in Latin American countries. AIM: to investigate current management opinion of Latin American MS and/or NMOSD expert neurologists based on their experience and recommendations. METHODS: we developed a voluntary web-based survey based on hypothetical situations that these patients may encounter, while taking into account the potential risk of developing severe COVID-19 infection. RESULTS: 60% of the experts had the possibility of monitoring their patients by telemedicine. Most neurologists postpone magnetic resonance. Laboratory blood tests delay is associated with the type of treatment. Platform therapies, dimethyl-fumarate and natalizumab are considered safe options to initiate in naive patients. CONCLUSION: decision-making about MS and NMOSD patients has become even more complex in order to adapt to the COVID-19 pandemic. Risks and benefits should be taken into consideration throughout the patient follow-up.

Template-Directed Nonenzymatic Primer Extension Using 2-Methylimidazole-Activated Morpholino Derivatives of Guanosine and Cytidine.

Efforts to develop self-replicating nucleic acids have led to insights into the origin of life and have also suggested potential pathways to the design of artificial life forms based on non-natural nucleic acids. The template-directed nonenzymatic polymerization of activated ribonucleotide monomers is generally slow because of the relatively weak nucleophilicity of the primer 3'-hydroxyl. To circumvent this problem, several nucleic acids based on amino-sugar nucleotides have been studied, and as expected, the more-nucleophilic amine generally results in faster primer extension. Extending this logic, we have chosen to study morpholino nucleic acid (MoNA), because the secondary amine of the morpholino-nucleotides is expected to be highly nucleophilic. We describe the synthesis of 2-methylimidazole-activated MoNA monomers from their corresponding ribonucleoside 5'-monophosphates and the synthesis of an RNA primer with a terminal MoNA nucleotide. We show that the activated G and C MoNA monomers enable rapid and efficient extension of the morpholino-terminated primer on homopolymeric and mixed-sequenced RNA templates. Our results show that MoNA is a non-natural informational polymer that is worthy of further study as a candidate self-replicating material.

Aspectos de interés sobre dermatitis atópica, su diagnóstico y tratamiento / Interest aspects about Atopic Dermatitis, its diagnosis and treatment

RESUMEN La evolución favorable de los pacientes afectados con dermatitis atópica está muy relacionada con un diagnóstico y orientación precoz en la atención primaria, para un seguimiento más especializado en las consultas de dermatología y alergología, por ser una entidad que ofrece dificultades en su identificación. Es necesario incrementar el nivel de información en los médicos de las áreas de salud, por ser estos escenarios donde ocurre el primer contacto con el paciente. El objetivo es ofrecer una visión actualizada sobre el diagnóstico y tratamiento de la dermatitis atópica que contribuya a la formación de los médicos en la atención primaria. Se realiza una revisión bibliográfica de los últimos 5 años, principalmente en las bases de datos PubMed y Scielo sobre el tema. Se abordan aspectos de interés relacionados con las manifestaciones clínicas, criterios diagnósticos y tratamiento. Los resultados que se ofrecen en este trabajo contribuirán a la formación profesional para una mejor promoción, prevención, diagnóstico precoz y tratamiento de esta enfermedad, cuya prevalencia es mayor en la infancia.

ABSTRACT The favorable evolution of the patients affected with Atopic Dermatitis is quite related with a diagnosis and precocious orientation in the primary attention, for a more specialized follow up in the dermatology and alergology consultations, as it is an entity that offers difficulties in its identification. It is necessary to increase the level of knowledge of doctors in these medical areas as these are the scenarios where it occurs the first contact patient doctor. Offering an updated vision about Atopic Dermatitis that contributes to the continuous formation of the professionals of the health sector in the primary attention. A revision of articles in the PubMed and Scielo database is carried out principally during the last 5 years. Aspects of interest related with the clinical manifestations, diagnoses criteria and treatment are considered. The results that are offered in this work will contribute to the professional formation for a better promotion, prevention, precocious diagnosis and treatment of this illness that is more likely to be found in the childhood.

Aspectos de interés sobre dermatitis atópica, su diagnóstico y tratamiento / Interest aspects about Atopic Dermatitis, its diagnosis and treatment

RESUMEN La evolución favorable de los pacientes afectados con dermatitis atópica está muy relacionada con un diagnóstico y orientación precoz en la atención primaria, para un seguimiento más especializado en las consultas de dermatología y alergología, por ser una entidad que ofrece dificultades en su identificación. Es necesario incrementar el nivel de información en los médicos de las áreas de salud, por ser estos escenarios donde ocurre el primer contacto con el paciente. El objetivo es ofrecer una visión actualizada sobre el diagnóstico y tratamiento de la dermatitis atópica que contribuya a la formación de los médicos en la atención primaria. Se realiza una revisión bibliográfica de los últimos 5 años, principalmente en las bases de datos PubMed y Scielo sobre el tema. Se abordan aspectos de interés relacionados con las manifestaciones clínicas, criterios diagnósticos y tratamiento. Los resultados que se ofrecen en este trabajo contribuirán a la formación profesional para una mejor promoción, prevención, diagnóstico precoz y tratamiento de esta enfermedad, cuya prevalencia es mayor en la infancia (AU).

ABSTRACT The favorable evolution of the patients affected with Atopic Dermatitis is quite related with a diagnosis and precocious orientation in the primary attention, for a more specialized follow up in the dermatology and alergology consultations, as it is an entity that offers difficulties in its identification. It is necessary to increase the level of knowledge of doctors in these medical areas as these are the scenarios where it occurs the first contact patient doctor. Offering an updated vision about Atopic Dermatitis that contributes to the continuous formation of the professionals of the health sector in the primary attention. A revision of articles in the PubMed and Scielo database is carried out principally during the last 5 years. Aspects of interest related with the clinical manifestations, diagnoses criteria and treatment are considered. The results that are offered in this work will contribute to the professional formation for a better promotion, prevention, precocious diagnosis and treatment of this illness that is more likely to be found in the childhood (AU).

Incidence and treatment of malignant tumors of the genitourinary tract in renal transplant recipients

ABSTRACT Purpose: To provide data of the incidence and management of common urological malignancies in renal transplant recipients. Materials and Methods: We conducted a retrospective analysis of a prospective database from August 1967 to August 2015. A descriptive analysis of the sample was performed. Results: Among 1256 consecutive RTR a total of 88 patients developed malignancies (7%). There were 18 genitourinary tumors in the 16 patients (20.45 % of all malignant neoplasms), incidence of 1.27%. The most common neoplasm encounter was renal cancer (38.8%), followed by urothelial carcinoma (33.3%). Median follow-up of transplantation was 197 months (R, 36-336). Mean time from RT to cancer diagnosis 89±70 months (R, 12-276). CsA and AZA was the most common immunosuppression regimen in 68.75%. Mean follow-up after diagnosis was 103±72 months (R 10-215). Recurrence free survival rate of 100%. Overall survival of 89.5% of the sample; there were two non-related cancer deaths during follow-up. Conclusions: The incidence of neoplasms in RTR was lower than in other series, with favorable functional and oncologic results after treatment. This suggests that actions to reduce the risk of these malignancies as well as a strict follow-up are mandatory for an early detection and treatment.