Association between physical activity and allostatic load among pregnant women.

Allostatic load (AL) in pregnant women is associated with maternal and infant health outcomes. Whether physical activity (PA) is a modifiable factor associated with AL during pregnancy is unknown. In this cross-sectional study, including 725 pregnant women in 3 different trimesters, 8 biomarkers were included, and the high-risk quartile approach based on sample distribution was used to construct AL index (ALI). ALI <2 was defined as a low level and ≥2 as a high level. Student's t-test or Mann-Whitney U test and chi-squared test or Fisher exact test were used to compare differences in AL with different demographic characteristics among pregnant women. The relationship between PA and AL in pregnant women was analyzed using a binary logistic regression model. The results show that the detection rate of high-risk AL during pregnancy was 47.3%. In the adjusted model, sufficient PA was related to a lower AL than insufficient PA (OR = .693, 95%CI:.494,.971; p = .033). Compared with low- and high-intensity PAs, moderate-intensity PA was associated with lower AL (OR = .645, 95%CI:.447,.930; p = .019). The results suggest that PA is a modifiable factor related to AL, and intervention is recommended to be carried out in the first trimester to prevent the increased likelihood of high AL as pregnancy progresses. In addition, health care personnel should encourage pregnant women to participate in PA, especially moderate-intensity PA, in order to obtain lower AL and promote maternal and child health.

Factors influencing self-regulatory fatigue in patients undergoing chemotherapy for gynecologic cancer: a cross-sectional study.

Objective: To understand the current status of self-regulatory fatigue among gynecologic cancer chemotherapy patients and explore influencing factors. Methods: Using convenient sampling, a total of 232 gynecological cancer chemotherapy patients from two tertiary hospitals in Zhengzhou, Henan, China, were selected as study subjects from February 2023 to April 2023. General information questionnaire, Self-Regulatory Fatigue Scale (SRF-S), Strategies Used by People to Promote Health (SUPPH) Scale, Connor-Davidson resilience scale (CD-RISC) and Perceived Social Support Scale (PSSS) were employed for data collection. The data were analyzed using SPSS 26.0 software. Chi-square test and binary logistic regression were executed to explore the correlates of self-regulatory fatigue, the significance level (α) was set at 0.05. Results: The self-regulatory fatigue score of the 232 patients was 44 (36, 56). Binary logistic regression analyses revealed significant associations, demonstrating that residing in urban areas (OR=0.241, P=0.015), having no comorbidities (OR=0.158, P=0.015), increased perceived social support (OR=0.937, P=0.001), strong self-efficacy (OR=0.959, P=0.021), and heightened psychological resilience (OR=0.895, P<0.001) acted as protective factors against self-regulatory fatigue (P < 0.05). Conclusion: Patients residing in rural areas, having more than two comorbidities, lower self-efficacy and psychological resilience levels, and lower perceived social support are indicative of higher levels of self-regulatory fatigue. Identifying these influencing factors can provide references and support for developing individualized support and intervention measures to improve patients' physical and mental well-being.

Immobilization-free and label-free electrochemical DNA biosensing based on target-stimulated release of redox reporter and its catalytic redox recycling.

Herein, we demonstrate a simple, homogenous and label-free electrochemical biosensing system for sensitive nucleic acid detection based on target-responsive porous materials and nuclease-triggered target recycling amplification. The Fe(CN)63- reporter was firstly sealed into the pores of Fe3O4 nanoparticles by probe DNA. Target DNA recognition triggered the controllable release of Fe(CN)63- for the redox reaction with the electron mediator of methylene blue enriched in the dodecanethiol assembled electrode and thereby generating electrochemical signal. The exonuclease III (Exo III)-assisted target recycling and the catalytic redox recycling between Fe(CN)63- and methylene blue contributed for the enhanced signal response toward target recognition. The low detection limit toward target was obtained as 478 fM and 1.6 pM, respectively, by square wave voltammetry and cyclic voltammetry methods. It also possessed a well-discrimination ability toward mismatched strands and high tolerance to complex sample matrix. The coupling of bio-gated porous nanoparticles, nuclease-assisted target amplification and catalytic redox recycling afforded the sensing system with well-controllable signal responses, sensitive and selective DNA detection, and good stability, reusability and reproducibility. It thus opens a new avenue toward the development of simple but sensitive electrochemical biosensing platform.

Screening of Spinal Muscular Atrophy Carriers and Prenatal Diagnosis in Pregnant Women in Yancheng, China.

Spinal muscular atrophy (SMA) is a neuromuscular disorder with an autosomal recessive inheritance pattern. Patients with severe symptoms may suffer respiratory failure, leading to death. The homozygous deletion of exon 7 in the SMN1 gene accounts for nearly 95% of all cases. Population carrier screening for SMA and prenatal diagnosis by amniocentesis for high-risk couples can assist in identifying the risk of fetal disease. We provided the SMA carrier screening process to 55,447 pregnant women in Yancheng from October 2020 to December 2022. Among them, 8185 participated in this process, with a participation rate of around 14.76% (95% CI 14.47-15.06%). Quantitative real-time polymerase chain reaction (qPCR) was used to detect deletions of SMN1 exons 7 and 8 (E7, E8) in screened pregnant women. 127 were identified as carriers (111 cases of E7 and E8 heterozygous deletions, 15 cases of E7 heterozygous deletions, and 1 case of E7 heterozygous deletions and E8 homozygous deletions), resulting in a carrying rate of around 1.55% (95% CI 1.30-1.84%). After genetic counseling, 114 spouses of pregnant women who tested positive underwent SMA carrier screening; three of them were screened as SMA carriers. Multiplexed ligation-dependent probe amplification (MLPA) was used for the prenatal diagnosis of the fetuses of high-risk couples. Two of them exhibited two copies of SMN1 exon 7 (normal), and the pregnancy was continued; one exhibited no copies of SMN1 exon 7 and exon 8 (SMA patient), and the pregnancy was terminated. Analyzing SMN1 mutations in Yancheng and provide clinical evidence for SMA genetic counseling and birth defect prevention. Interventional prenatal diagnosis for high-risk families can promote informed reproductive selection and prepare for the fetus's early treatment.

UFObow: A single-wavelength excitable Brainbow for simultaneous multicolor ex-vivo and in-vivo imaging of mammalian cells.

Brainbow is a genetic cell-labeling technique that allows random colorization of multiple cells and real-time visualization of cell fate within a tissue, providing valuable insights into understanding complex biological processes. However, fluorescent proteins (FPs) in Brainbow have distinct excitation spectra with peak difference greater than 35 nm, which requires sequential imaging under multiple excitations and thus leads to long acquisition times. In addition, they are not easily used together with other fluorophores due to severe spectral bleed-through. Here, we report the development of a single-wavelength excitable Brainbow, UFObow, incorporating three newly developed blue-excitable FPs. We have demonstrated that UFObow enables not only tracking the growth dynamics of tumor cells in vivo but also mapping spatial distribution of immune cells within a sub-cubic centimeter tissue, revealing cell heterogeneity. This provides a powerful means to explore complex biology in a simultaneous imaging manner at a single-cell resolution in organs or in vivo.

The experiences of family resilience in patients with permanent colostomy and their spouses: A dyadic qualitative study.

PURPOSE: With the prolonged survival time of patients with permanent colostomy for colorectal cancer, they and their spouses face tremendous pressure and development dilemmas that can easily lead to family adaptation crises. This qualitative study amid to explore the dyadic experiences of family resilience among Chinese patients with permanent colostomy and their spouses. METHODS: A phenomenological research method was adopted. Semi-structured, in-depth, face-to-face interviews with 10 dyads of patients with permanent colostomy and their spouses were recruited through purposive sampling from a public tertiary hospital in China from March 2023 to July 2023.The Dyadic interview analysis and Colaizzi methods were used to analyze the interview data. RESULTS: Three themes and nine subthemes were developed. (1) family crisis and dichotomous coping with stress-family crisis and coping pressure caused by enterostomy; (2) Adjustment and adaptation within the family-Joint adjustment and adaptation within the couple's family; and (3) integration and utilization of multi-dimensional social external resources (micro-level, meso-level, and macro-level). CONCLUSIONS: Couples living with permanent colostomy often undergo a complex emotional journey, experiencing varied levels of individual stress as they navigate social interactions and daily activities, which can contribute to a decline in family adaptation. With the help of the perspective of family advantage, health practitioners should pay attention to the evaluation of individual factors and family environmental resources, to fully mobilize advantage resources and give effective interventions to improve the family and social adaptation level of patients and their spouses.

The hemostatic performance and mechanism of palygorskite with structural regulate by oxalic acid gradient leaching.

Palygorskite (Pal) is a naturally available one-dimensional clay mineral, featuring rod-shaped morphology, nanoporous structure, permanent negative charges as well as abundant surface hydroxyl groups, exhibiting promising potential as a natural hemostatic material. In this study, the hemostatic performance and mechanisms of Pal were systematically investigated based on the structural regulate induced by oxalic acid (OA) gradient leaching from perspectives of structure, surface attributes and ion release.In vitroandin vivohemostasis evaluation showed that Pal with OA leaching for 1 h exhibited a superior blood procoagulant effect compared with the raw Pal as well as the others leached for prolonging time. This phenomenon might be ascribed to the synergistic effect of the intact nanorod-like morphology, the increase in the surface negative charge, the release of metal ions (Fe3+and Mg2+), and the improved blood affinity, which promoted the intrinsic coagulation pathway, the fibrinogenesis and the adhesion of blood cells, thereby accelerating the formation of robust blood clots. This work is expected to provide experimental and theoretical basis for the construction of hemostatic biomaterials based on clay minerals.

Epigenetic Alteration in Colorectal Cancer: Potential Diagnostic and Prognostic Implications.

Colorectal cancer (CRC), a prevalent malignant tumor of the digestive system, ranks as the third and second in global incidence and mortality, respectively, in 2020, with 1.93 million new cases (≈10% of all cancers). There are 940,000 deaths (≈9.4% of all cancers), and the incidence of CRC in younger patients (under 50 years of age) has become a new trend. The pathogenesis of CRC is primarily attributed to a series of genetic and epigenetic abnormalities within normal colonic epithelial cells, coupled with the reshaping of the tumor microenvironment in the surrounding stroma. This process leads to the transformation of colorectal adenomas into invasive adenocarcinomas. Although genetic changes are known to be the primary driving force in the occurrence and progression of CRC, recent research indicates that epigenetic regulation serves as a crucial molecular marker in cancer, playing a significant role in the pathological and physiological control of interactions between genetics and the environment. This review discusses the current global epidemiology of CRC, its risk factors, and preventive treatment strategies. The current study explores the latest advancements in the epigenetic regulation of CRC, including DNA methylation, histone modifications, and non-coding RNAs (ncRNAs). These developments hold potential as screening tools, prognostic biomarkers, and therapeutic targets for CRC.

Synthesis, antibacterial activity, and 3D-QASR studies of matrine-indole derivatives as potential antibiotics.

Matrine and indole have antibacterial, anticancer, and other biological activities, in order to develop new antibiotics to solve the problem of multi-drug resistant bacteria. In this paper, we synthesized a series of 29 novel matrine derivatives as potential drug candidates by combining indole analogs and matrine. The antibacterial activity of these compounds was evaluated through minimum inhibitory concentration (MIC) assays against five bacterial strains (S. aureus, C. albicans, P. acnes, P. aeruginosa, and E. coli). The obtained results demonstrated promising antibacterial efficacy, particularly for compounds A20 and A18, which exhibited MICs.au values of 0.021 and 0.031 mg/ml, respectively, against S. aureus. Moreover, compounds A20 and A27 displayed remarkable MICc.al values of 2.806 and 4.519 mg/ml, respectively, against C. albicans, surpassing the performance of the clinical antibiotic penicillin G sodium (0.0368 mg/ml) and fluconazole (4.849 mg/ml). These findings underscore the significant bacteriostatic activity of the matrine derivatives. Furthermore, to gain a deeper understanding 3D-QSAR modeling was employed, revealing the critical influence of steric structure, charge distribution, hydrophobic interactions, and hydrogen bonding within the molecular structure on the bacteriostatic activity of the compounds. Additionally, molecular docking simulations shed light on the interaction between compound A20 and bacterial proteins, highlighting the involvement of hydrogen bonding, hydrophobic interactions, and π-π conjugation in the formation of stable complexes that inhibit the normal functioning of the proteins. This comprehensive analysis provided valuable insights into the antibacterial mechanism of the novel matrine derivatives, offering theoretical support for their potential application as antibiotics.

Microplastics inhibit the growth of endosymbiotic Symbiodinium tridacnidorum by altering photosynthesis and bacterial community.

Microplastics, ubiquitous anthropogenic marine pollutants, represent potential threats to coral-Symbiodiniaceae relationships in global reef ecosystems. However, the mechanism underlying the impacts of polystyrene microplastics (PS-MPs) on Symbiodiniaceae remains poorly understood. In this study, the cytological, physiological, and microbial responses of Symbiodinium tridacnidorum, a representative Symbiodiniaceae species, to varying concentrations of PS-MPs (0, 5, 50, 100, and 200 mg L-1) were investigated. The results revealed that microplastic exposure inhibited cell division, resulting in reduced cell density compared to control group. Furthermore, algal photosynthetic activity, as indicated by chlorophyll content, Fv/Fm, and net photosynthetic rate, declined with increasing microplastic concentration up to 50 mg L-1. Notably, elevated levels of microplastics (100 and 200 mg L-1) prompted a significant increase in cell size in S. tridacnidorum. Transmission electron microscopy and fluorescence microscopy indicated that hetero-aggregation was formed between high levels of PS-MPs and algal cells, ultimately causing damage to S. tridacnidorum. Moreover, the impact of PS-MPs exposure on the bacterial community associated with S. tridacnidorum was investigated. The results showed a reduction in alpha diversity of the bacterial community in groups exposed to 50, 100, and 200 mg L-1 of microplastics compared to those treated with 0 and 5 mg L-1. Additionally, the relative abundance of Marinobacter, Marivita, and Filomicrobium significantly increased, while Algiphilus and norank Nannocystaceae declined after microplastic exposure. These findings suggest that MPs can inhibit the growth of S. tridacnidorum and alter the associated bacterial community, posing a potential serious threat to coral symbiosis involving S. tridacnidorum.

2-Aminopurine-based quencher-free DNA tweezers with fluorescence properties well tuned by surrounding bases.

Reversible structural changes in DNA nanomachines have great potential in the field of bioanalysis. Here, we demonstrate an assembly strategy for quencher-free and tunable DNA tweezers based on 2-aminopurine (2-AP), avoiding the tedious fluorescence labelling step. The conformational state of the tweezers could be controlled by specific oligonucleotides (fuel or anti-fuel). Taking advantage of the local environmental sensitivity of 2-AP, the structural changes of the tweezers were easily tracked, and multiple cyclic switching of the tweezers between the open and closed states was achieved. In addition, the influence of oligonucleotide structure on the fluorescence properties of 2-AP was deeply explored. We figured out that the fluorescence of 2-AP was highly quenched by the base-stacking of natural bases in DNA oligonucleotides. Moreover, by comprehensively regulating the type of bases surrounding the inserted 2-AP site, a sensitive fluorescence response towards dynamic change can be obtained. This principle of quencher-free nanodevices based on 2-AP provides a convenient method for monitoring the structural changes of DNA nanomachines.

Letermovir Effectively Prevents Cytomegalovirus Infection in Patients with Aplastic Anemia After Hematopoietic Stem Cell Transplantation: A Real-World Retrospective Cohort Study.

INTRODUCTION: In this single-center retrospective cohort study, we investigated the efficacy of letermovir in preventing Cytomegalovirus (CMV) infection in patients with aplastic anemia (AA) who have undergone allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS: Based on whether or not letermovir was used for preventing CMV infection, the patients were categorized into two groups: letermovir and control groups. The overall survival (OS) rate and cumulative incidence of CMV infection during the first 100 days after allo-HSCT were evaluated. The study included 21 matched pairs of patients, identified through propensity score matching analysis, to compare CMV infection rates, treatment efficacy, and regression. RESULTS: The incidence of CMV infection within 100 days after transplantation was significantly lower in the letermovir group than in the control group (26.5 vs. 77.4%, respectively; P < 0.001), among a total of 87 patients who underwent the transplant. In the matched cohort of 21 patients with AA, the letermovir group also showed a significantly reduced cumulative incidence of CMV infection (14.3 vs. 90.5% in the control group; P < 0.001). Compared to the control group, patients with CMV infection in the letermovir group had lower CMV-DNA load and a shorter clearance time. However, there was no significant difference in OS between both groups (P = 0.34). CONCLUSIONS: Letermovir effectively prevents CMV infection in allo-HSCT recipients with AA and demonstrates a high safety profile.

Dynamic monitoring of an enzymatically driven dissipative toehold-mediated strand displacement reaction.

A general strategy to program self-resettable and dissipative toehold-mediated strand displacement reactions was proposed, using DNA strands as the fuel and lambda exonuclease as the fuel-consuming unit. This non-equilibrium system is reversible and temporally controllable. Furthermore, it can be well integrated into a DNA network to temporally control its cascade reaction or dynamic behaviour.

Tuning Chemoenzymatic Pd/Laccase Conformation Toward Optimized Heterogeneous Aerobic Oxidation.

Heterogeneous chemoenzymatic catalysts differing in their spatial organization and relative orientation of their enzymatic laccase and Pd units confined into macrocellular silica foams were tested on veratryl alcohol oxidation. When operating under continuous flow, we show that the catalytic efficiency of hybrids is significantly enhanced when the Pd(II) complex is combined with a laccase exhibiting a surface located lysine next to the T1 oxidation site of the enzyme.

Analysis of the status and factors influencing physical activity in patients undergoing ovarian cancer chemotherapy.

Background: Ovarian cancer is a common gynecological malignancy, leading to approximately 200,000 deaths globally in 2020. Research has shown that regular physical activity can reduce the toxic side effects of cancer treatment, reduce morbidity and mortality, extend survival time, and improve quality of life. We aimed to evaluate physical activity regimens in patients undergoing chemotherapy for ovarian cancer and analyze the factors influencing physical activity levels. Methods: To facilitate the selection of patients with ovarian cancer hospitalized for chemotherapy in the Third Affiliated Hospital of Zhengzhou University and the First Affiliated Hospital of Zhengzhou University from August 2022 to February 2023, questionnaire surveys were conducted using the General Information Questionnaire, International Physical Activity Questionnaire, Hospital Anxiety and Depression Scale, and Revised Piper Fatigue Scale. Results: Data were collected from 167 patients with ovarian cancer. Overall, 96 (57.5%) patients had low physical activity levels, 53 (31.7%) had moderate physical activity levels, and 18 (10.8%) had high physical activity levels. Logistic regression analysis revealed that sleep status, social support, anxiety, depression, and cancer-related fatigue were the main factors influencing physical activity in patients undergoing chemotherapy for ovarian cancer. Conclusions: Physical activity levels of patients undergoing ovarian cancer chemotherapy were generally low. Therefore, healthcare professionals should pay greater attention to the physical activity in these patients. Targeted and individualized health guidance is recommended, and activity interventions should be implemented according to the influencing factors to promote disease understanding and increase physical activity levels.

Complete mitochondrial genome and phylogenetic analysis of the marine microalga Symbiochlorum hainanensis (Ulvophyceae, Chlorophyta).

Symbiochlorum hainanensis Gong et al. (2018). is a unicellular green alga belonging to Ulvophyceae, Chlorophyta, and considered as an important species in coral-algae symbiont areas. In this study, we revealed firstly the mitochondrial genome sequence of the S. hainanensis. This mitochondrial genome was a circular DNA molecule of 59,508 bp, including 24 transfer RNA genes, 3 ribosomal RNA genes, and 31 protein-coding genes. The GC content of the genome was 35.4%. The phylogenetic tree suggested that S. hainandiae was a sister to the OUU clade within the class Ulvophyceae. The mitochondrial genome structure and gene content of S. hainanensis supported that S. hainanensis was a new unidentified green alga in Ulvophyceae.

Pluronic F-127 Hydrogel Loaded with Human Adipose-Derived Stem Cell-Derived Exosomes Improve Fat Graft Survival via HIF-1α-Mediated Enhancement of Angiogenesis.

Purpose: Autologous fat grafting is playing an increasingly important role in plastic surgery. However, high absorption and low survival of autologous fat grafts limit their clinical application. This study aimed to investigate whether human adipose-derived stem cell-derived exosomes (hASC-Exos) encapsulated in a PF-127 hydrogel can improve the survival of autologous fat grafts and to elucidate the underlying mechanisms. Patients and Methods: Exosomes were isolated from hASCs and identified using transmission electron microscopy, nanoparticle tracking analysis and Western blotting. We performed functional assays in vitro to assess the effect of hASC-Exos on proliferation, migration, and tube formation as well as their regulatory role in the HIF-1α/VEGF signaling pathway. hASC-Exos encapsulated in the PF-127 hydrogel were used as an in vivo autologous fat graft model. The effects of the PF-127 hydrogel/hASC-Exos and the role of the HIF-1α/VEGF signaling pathway in promoting angiogenesis in an autologous fat grafting model were assessed. Results: hASC-Exos were taken up by human umbilical vein endothelial cells and enhanced their proliferation, migration, and tubule formation in vitro. The effects of hASC-Exos on promoting angiogenesis were mediated by the HIF-1α/VEGF signaling pathway. Moreover, we fabricated a PF-127 hydrogel for the sustained release of hASC-Exos, and in vivo results showed that hASC-Exos encapsulated in PF-127 hydrogel improved the survival of autologous fat grafts. Conclusion: Our findings indicated that hASC-Exos encapsulated in PF-127 hydrogel serve as a key regulator of angiogenesis by activating the HIF-1α/VEGF signaling pathway and provide a promising strategy for autologous fat grafting treatment.

A study of the purchase intention of insect protein food as alternative foods for fitness proteins.

The purpose of this study is to investigate the influencing factors for fitness enthusiasts' willingness to purchase insect protein foods as fitness protein replacements. Using structural equation modeling, a model was developed to understand the factors influencing the purchase intention of insect alternative foods. We conducted an online survey of 968 fitness enthusiasts in China. In accordance with the data processing results, perceived value appears to be one of the most significant factors that contribute to consumers' purchase intention, attitude, and satisfaction with their purchase decisions. Furthermore, satisfaction has the potential to improve user attitudes and increase user purchase intentions. As a whole, this study extends research on insect protein alternatives as a potential alternative product for bodybuilding supplements. Moreover, make some recommendations to producers, designers, and promoters.

Progress and future prospects of hemostatic materials based on nanostructured clay minerals.

The occurrence of uncontrolled hemorrhage is a significant threat to human life and health. Although hemostatic materials have made remarkable advances in the biomaterials field, it remains a challenge to develop safe and effective hemostatic materials for global medical use. Natural clay minerals (CMs) have long been used as traditional inorganic hemostatic agents due to their good hemostatic capability, biocompatibility and easy availability. With the advancement of science, technology and ideology, CM-based hemostatic materials have undergone continuous innovations by integrating new inspirations with conventional concepts. This review systematically summarizes the hemostatic mechanisms of different natural CMs based on their nanostructures. Moreover, it also comprehensively reviews the latest research progress for CM-based hemostatic hybrid and nanocomposite materials, and discusses the challenges and developments in this field.

Neuron-secreted NLGN3 ameliorates ischemic brain injury via activating Gαi1/3-Akt signaling.

We here tested the potential activity and the underlying mechanisms of neuroligin-3 (NLGN3) against ischemia-reperfusion-induced neuronal cell injury. In SH-SY5Y neuronal cells and primary murine cortical neurons, NLGN3 activated Akt-mTOR and Erk signalings, and inhibited oxygen and glucose deprivation (OGD)/re-oxygenation (OGD/R)-induced cytotoxicity. Akt activation was required for NLGN3-induced neuroprotection. Gαi1/3 mediated NLGN3-induced downstream signaling activation. NLGN3-induced Akt-S6K1 activation was largely inhibited by Gαi1/3 silencing or knockout. Significantly, NLGN3-induced neuroprotection against OGD/R was almost abolished by Gαi1/3 silencing or knockout. In vivo, the middle cerebral artery occlusion (MCAO) procedure induced NLGN3 cleavage and secretion, and increased its expression and Akt activation in mouse brain tissues. ADAM10 (A Disintegrin and Metalloproteinase 10) inhibition blocked MCAO-induced NLGN3 cleavage and secretion, exacerbating ischemic brain injury in mice. Neuronal silencing of NLGN3 or Gαi1/3 in mice also inhibited Akt activation and intensified MCAO-induced ischemic brain injury. Conversely, neuronal overexpression of NLGN3 increased Akt activation and alleviated MCAO-induced ischemic brain injury. Together, NLGN3 activates Gαi1/3-Akt signaling to protect neuronal cells from ischemia-reperfusion injury.