An Adaptation and Validation of Cocaine Craving Questionnaire for Malaysians Who Use Amphetamine-Type Stimulants.

Introduction: Cases of amphetamine-type stimulants (ATS) use have been increasing over the past decade. Cravings are considered a causal factor for recurrent relapses in ATS use cases. The absence of questionnaires measuring cravings for ATS in the local population necessitates the creation of one, especially considering the rising number of cases. Objective: This study aimed to adapt and validate the Cocaine Cravings Questionnaire into a questionnaire suitable for measuring cravings for ATS in the local population. Methodology: The original questionnaire was adapted by substituting "cocaine" with "ATS". The process involved a back-to-back translation, followed by a round of face and content validation. The participants included people who use drugs (PWUD) with a history of ATS use recruited from rehabilitation centers in Malaysia. A set of questionnaires consisting of demographic items and the adapted ATS Cravings Questionnaire (ATS-CQ) were given. Results: This cross-sectional study recruited a total of 205 PWUD, mostly single men, with a mean age of 33.32 (s.d.=13.14). The mean age of ATS initiation was 22.89 (s.d.=9.39), with a median duration of ATS use of 60 months (IQR=24.00, 120.00). The adapted questionnaire received a good score for content validation. Unlike the original, this adapted version was found to have only three factors showing good internal consistency, ranging from 0.707 to 0.918 for all three factors. Test-retest reliability also showed good results, with an interclass correlation coefficient of 0.875 (95% CI=0.835, 0.905). Conclusion: The translated ATS-CQ has been finalized and deemed valid and reliable for use among Malaysian substance users to measure ATS cravings.

Enhanced MAPK signaling induced by CSF3R mutants confers dependence to DUSP1 for leukemic transformation.

ABSTRACT: Elevated MAPK and the JAK-STAT signaling play pivotal roles in the pathogenesis of chronic neutrophilic leukemia and atypical chronic myeloid leukemia. Although inhibitors targeting these pathways effectively suppress the diseases, they fall short in providing enduring remission, largely attributed to the cytostatic nature of these drugs. Even combinations of these drugs are ineffective in achieving sustained remission. Enhanced MAPK signaling besides promoting proliferation and survival triggers a proapoptotic response. Consequently, malignancies reliant on elevated MAPK signaling use MAPK feedback regulators to intricately modulate the signaling output, prioritizing proliferation and survival while dampening the apoptotic stimuli. Herein, we demonstrate that enhanced MAPK signaling in granulocyte colony-stimulating factor 3 receptor (CSF3R)-driven leukemia upregulates the expression of dual specificity phosphatase 1 (DUSP1) to suppress the apoptotic stimuli crucial for leukemogenesis. Consequently, genetic deletion of Dusp1 in mice conferred synthetic lethality to CSF3R-induced leukemia. Mechanistically, DUSP1 depletion in leukemic context causes activation of JNK1/2 that results in induced expression of BIM and P53 while suppressing the expression of BCL2 that selectively triggers apoptotic response in leukemic cells. Pharmacological inhibition of DUSP1 by BCI (a DUSP1 inhibitor) alone lacked antileukemic activity due to ERK1/2 rebound caused by off-target inhibition of DUSP6. Consequently, a combination of BCI with a MEK inhibitor successfully cured CSF3R-induced leukemia in a preclinical mouse model. Our findings underscore the pivotal role of DUSP1 in leukemic transformation driven by enhanced MAPK signaling and advocate for the development of a selective DUSP1 inhibitor for curative treatment outcomes.

MAPK-negative feedback regulation confers dependence to JAK2V617F signaling.

Despite significant advances in developing selective JAK2 inhibitors, JAK2 kinase inhibitor (TKI) therapy is ineffective in suppressing the disease. Reactivation of compensatory MEK-ERK and PI3K survival pathways sustained by inflammatory cytokine signaling causes treatment failure. Concomitant inhibition of MAPK pathway and JAK2 signaling showed improved in vivo efficacy compared to JAK2 inhibition alone but lacked clonal selectivity. We hypothesized that cytokine signaling in JAK2V617F induced MPNs increases the apoptotic threshold that causes TKI persistence or refractoriness. Here, we show that JAK2V617F and cytokine signaling converge to induce MAPK negative regulator, DUSP1. Enhanced DUSP1 expression blocks p38 mediated p53 stabilization. Deletion of Dusp1 increases p53 levels in the context of JAK2V617F signaling that causes synthetic lethality to Jak2V617F expressing cells. However, inhibition of Dusp1 by a small molecule inhibitor (BCI) failed to impart Jak2V617F clonal selectivity due to pErk1/2 rebound caused by off-target inhibition of Dusp6. Ectopic expression of Dusp6 and BCI treatment restored clonal selectively and eradicated the Jak2V617F cells. Our study shows that inflammatory cytokines and JAK2V617F signaling converge to induce DUSP1, which downregulates p53 and establishes a higher apoptotic threshold. These data suggest that selectively targeting DUSP1 may provide a curative response in JAK2V617F-driven MPN.

Cardiac Children Hospital Early Warning ScoreVersus the Inadequate Oxygen Delivery Index for the Detection of Early Warning Signs of Deterioration.

To assess the utility of the Cardiac Children's Hospital Early Warning Score (C-CHEWS) in the early detection of deterioration. DESIGN: Single-center longitudinal pilot study. SETTING: Pediatric cardiac ICU (PCICU), Aga Khan University. INTERVENTIONS: C-CHEWS and Inadequate Oxygen Delivery (IDO2) Index calculation every 2 hours. PATIENTS: A total of 60 children (0 d to 18 yr old). MEASUREMENTS AND MAIN RESULTS: A single-center longitudinal pilot study was conducted at PCICU. All postoperative extubated patients were assessed and scored between 0 and 11, and these scores were then correlated with the IDO2 index data available from the T3 platform. Adverse events were defined as a need for cardiopulmonary resuscitation, or reintubation, and death. A total of 920 C-CHEWS and IDO2 scores were analyzed on 60 patients during the study period. There were 36 males and 24 females, and the median age of the study population was 34 months (interquartile range, 9.0-72.0 mo). Fourteen patients (23.3%) developed adverse events; these included 9 reintubations and 5 cardiopulmonary arrests, resulting in 2 deaths. The area under the curve (AUC) for C-CHEWS scores fell in an acceptable range of 0.956 (95% CI, 0.869-0.992), suggesting an optimal accuracy for identifying early warning signs of cardiopulmonary arrest. Whereas, IDO2 showed no discriminatory power to detect the adverse events with an AUC of 0.522 (95% CI, 0.389-0.652). CONCLUSIONS: The C-CHEWS tool provides a standardized assessment and approach to deteriorating congenital cardiac surgery patients in recognizing early postoperative deterioration.

Rational polypharmacological targeting of FLT3, JAK2, ABL, and ERK1 suppresses the adaptive resistance to FLT3 inhibitors in AML.

Despite significant advancements in developing selective FMS-like tyrosine kinase 3 (FLT3) inhibitors, resistance to treatment is common even on continued therapy. Acquisition of on-target mutations or adaptation to MAPK, JAK2, and ABL signaling pathways drive treatment failure and disease relapse. Although combinatorial targeting of all escape routes in preclinical models demonstrated its efficacy, the clinical application is challenging owing to drug-drug interaction and differing pharmacokinetics of the inhibitors. We reasoned that selective polypharmacological targeting could lead to a durable response with reduced toxicity. A cell-based screening was carried out to identify inhibitors targeting FLT3, RAS-MAPK, BCR-ABL, and JAK2 to target the adaptive resistance observed with FLT3 inhibitors. Here, we show that pluripotin is an equipotent inhibitor of FLT3, BCR-ABL, and JAK2 in addition to inhibiting Ras-GAP and extracellular signal-regulated kinase 1 (ERK1). Structural modeling studies revealed that pluripotin is a type II kinase inhibitor that selectively binds with inactive conformations of FLT3, ABL, and JAK2. Pluripotin showed potent inhibitory activity on both mouse and human cells expressing FLT3ITD, including clinically challenging resistant mutations of the gatekeeper residue, F691L. Likewise, pluripotin suppressed the adaptive resistance conferred by the activation of RAS-MAPK pathways, BCR-ABL, and JAK2 signaling. Treatment with pluripotin curbed the progression of acute myeloid leukemia (AML) in multiple in vivo models including patient-derived primary AML cells in mouse xenotransplants. As a proof of concept, we demonstrate that targeted polypharmacological inhibition of key signaling nodes driving adaptive resistance can provide a durable response.

Momelotinib is a highly potent inhibitor of FLT3-mutant AML.

Despite the introduction of more selective FLT3 inhibitors to treat FLT3-mutated acute myeloid leukemia (AML), remissions are short lived, and patients show progressive disease after an initial response. Acquisition of resistance-conferring genetic mutations and growth factor signaling are 2 principal mechanisms that drive relapse. FLT3 inhibitors targeting both escape mechanisms could lead to a more profound and lasting clinical response. Here, we show that the JAK2 inhibitor momelotinib is an equipotent type 1 FLT3 inhibitor. Momelotinib showed potent inhibition of FLT3-internal tandem duplication in mouse and human primary cells and effectively suppressed its clinically relevant resistant variants within the activation loop at residues D835, D839, and Y842. Additionally, momelotinib efficiently suppressed the resistance mediated by growth factors and hematopoietic cytokine-activated JAK2 signaling. Consequently, concomitant inhibition of FLT3 and suppression of growth factor signaling by momelotinib treatment showed better efficacy in suppressing leukemia in a preclinical murine model of AML. Altogether, these data provide evidence that momelotinib is an effective type 1 dual JAK2/FLT3 inhibitor and may offer an alternative to gilteritinib. Its ability to impede the resistance conferred by growth factor signaling and activation loop mutants suggests that momelotinib treatment could provide a deeper and durable response and, thus, warrants its clinical evaluation.

Design and optimisation of magnetically-tunable hybrid piezoelectric-triboelectric energy harvester.

The demand for energy harvesting technologies has been increasing over the years that can be attributed to its significance to low power applications. One of the key problems associated with the available vibration-based harvester is the maximum peak power can only be achieved when the device frequency matches the source frequency to generate low usable power. Therefore, in this study, a magnetically-tunable hybrid piezoelectric-triboelectric energy harvester (MT-HPTEH) was designed and optimised. Four key design factors: mass placement, triboelectric surface area, extension length and magnetic stiffness were investigated and optimised. The voltage generation from piezoelectric and triboelectric mechanisms was determined individually to understand the effect of each design factor on the mechanisms. An output power of 659 µW at 180 kΩ at 44 Hz was obtained from the optimised MT-HPTEH with a theoretical-experimental discrepancy of less than 10%. The added magnetically-tunable feature enabled the harvester to work at the desired frequency range with an open circuit voltage between 7.800 and 20.314 V and a frequency range from 38 to 54 Hz. This MT-HPTEH can power at least six wireless sensor networks and can be used for low power applications such as RFID tags. Future work may include designing of energy-saving and sustainable harvester.

Implementation of the International Academy of Cytology Yokohama standardized reporting for breast cytopathology: An 8-year retrospective study.

BACKGROUND: The International Academy of Cytology (IAC) Yokohama reporting system was recently proposed to serve as a standardized diagnostic platform for the cytological interpretation of breast fine needle aspiration biopsy (FNAB). Five cytological categories were suggested, linked to a certain risk of malignancy (ROM). The aim of this study was to assess the potency of this newly proposed reporting guideline, with a review of literatures. METHODS: This is a retrospective study over 8-year duration in which all the breast FNABs performed in our institution were recategorized in accordance to the IAC Yokohama reporting system. Kappa coefficient was used to evaluate the agreement between the proposed cytological category and corresponding histological diagnosis, with the level of significance set at 5%. Cyto-histopathological correlation and its diagnostic performance were also assessed. RESULTS: A total of 1136 breast FNABs were analyzed, including 31 repeat FNABs. Of these, 521 (47.1%) cases had matched histopathological results. Respective ROM for each category was: "insufficient" 13.6%, "benign" 0.4%, "atypical" 25.0%, "suspicious" 85.7%, and "malignant" 100%. There was substantial agreement (κ=0.757) between cytology and histopathological results. Our data revealed a high-diagnostic specificity, sensitivity, positive and negative predictive value of 99.3% (95% CI: 97.6%-99.9%), 94.2% (95% CI: 87.9%-97.9%), 98.0% (95% CI: 92.5%-99.5%), 98.0% (95% CI: 96.1%-99.1%) respectively when both the "suspicious" and "malignant" cases were considered as positive tests, with area under the curve of 0.993. CONCLUSIONS: The IAC Yokohama system is a reliable, evidence-based, and standardized reporting system that helps to facilitate communication among cytopathologists, radiologists, and surgeons toward individualized patient management.

The Need for Transgender Healthcare Medical Education in a Developing Country.

PURPOSE: The single most significant barrier to healthcare for people who identify as transgender is poor access to healthcare providers trained in trans-health. Despite this, trans-health education is far from being a routine component of the undergraduate medical curriculum in developing countries like Pakistan. This study aimed to assess knowledge and attitudes regarding people who identify as transgender, as well as the perceived need for trans-health in the curriculum, amongst medical students in Pakistan. MATERIALS AND METHODS: A cross-sectional study using a self-designed questionnaire was carried out amongst undergraduate medical students at the Aga Khan University. Stratified random sampling was used, whereby students were stratified based on their current year of medical education. RESULTS: A total of 249 students were included in this survey. The majority (61%) had poor overall knowledge, with a significantly higher percentage of pre-clinical students (79.6%) having poor knowledge regarding differences in transgender health needs compared to clinical students (60.3%; p = 0.001). Most students acknowledged that individuals who identified as transgender faced a lack of access to healthcare (78.3%), were poorly integrated into society (92.0%) and were treated differently in a clinical setting (58.6%). Many students were unsure of how to address (49.8%) and clinically examine (38.2%) patients identifying as transgender. However, most students demonstrated good (49.4%) or fair (45.0%) attitudes towards individuals who identified as transgender, and the majority reported a high (54.6%) or moderate (42.2%) perceived need for the inclusion of trans-health in the medical curriculum. CONCLUSION: Despite deficiencies in trans-health education in the medical school curriculum, positive attitudes and a high perceived need among students lay the foundation for developing a medical curriculum that gives due priority to trans-health. In developing countries, this can help bridge disparities in healthcare provision to people who identify as transgender.

Time reducing exposure containing 18 fluorine flourodeoxyglucose master vial dispensing in hot lab: Omega technique.

Hot lab dispensing of large doses of 18 fluorine fluorodeoxyglucose in master vials supplied from the cyclotrons requires high degrees of skill to handle high doses. Presently practiced conventional method of fractionating from the inverted tiltable vial pig mounted on a metal frame has its own limitations such as increasing isotope handling times and exposure to the technologist. Innovative technique devised markedly improves the fractionating efficiency along with speed, precision, and reduced dose exposure.

Non-surgical periodontal therapy reduces coronary heart disease risk markers: a randomized controlled trial.

AIM: Periodontal disease elevates systemic inflammatory markers strongly associated with coronary heart disease (CHD) risk. The aim of this randomized controlled trial was to investigate the effect of non-surgical periodontal therapy on systemic C-reactive protein (CRP), fibrinogen and white blood cells in CHD patients. MATERIALS AND METHODS: Angiographically proven CHD patients with periodontitis (n = 317) were randomized to intervention (n = 212) or control group (n = 105). Primary outcome was reduction in serum CRP levels; secondary outcomes were reductions in fibrinogen and white blood cells. Periodontal treatment included scaling, root planing and oral hygiene instructions. Periodontal and systemic parameters were assessed at baseline and at 2-month follow-up. Intent-to-treat (ITT) analysis was performed. RESULTS: Study was completed by 246 subjects (intervention group = 161; control group = 85). Significant improvements in periodontal and systemic parameters were observed in intervention group. The number of subjects with CRP > 3mg/L in intervention group decreased by 38% and in control group increased by 4%. ITT analysis gave a significant (χ(2) =4.381, p = 0.036) absolute risk reduction of 12.5%. CONCLUSION: In CHD patients with periodontitis, non-surgical mechanical periodontal therapy significantly reduced systemic levels of C-reactive protein, fibrinogen and white blood cells.

Lack of association between MTHFR C677T and A1298C polymorphisms and risk of childhood acute lymphoblastic leukemia in the Kurdish population from Western Iran.

AIMS: Polymorphism in genes involved in folate metabolism may influence the susceptibility to acute lymphoblastic leukemia (ALL). The aim of the present study was to determine the role of the two most common polymorphisms of the 5, 10-methylenetetrahydrofolate reductase (MTHFR) gene, MTHFR C677T and A1298C, and their interaction on the susceptibility to ALL. METHODS: Seventy-two children with ALL and 109 age- and sex-matched healthy children from Western Iran were screened for MTHFR C677T and A1298C variants by using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). RESULTS: The frequencies of MTHFR 677T and 1298C alleles in patients were 29.9% and 43.1%, respectively, that were higher than those in controls (24.8% and 38.1%, respectively). Logistic regression analysis was performed and its result in the odds ratios (ORs) for possession of either MTHFR 677T or 1298C allele was found to be 1.98 [95% confidence interval (CI) 0.72-5.4, p = 0.18] and 1.48 (95% CI 0.59-3.69, p = 0.4), respectively. Also the concomitant presence of both MTHFR 677T and 1298C alleles was not associated with the risk of ALL [OR = 2.12 (95% CI 0.8-5.7, p = 0.13)]. CONCLUSION: Our results in a homogenous population with Kurdish ethnic background indicated that neither the MTHFR 677T allele nor the MTHFR 1298C allele is associated with increased risk of ALL.

Oral health status of CHD and non-CHD adults of Lahore, Pakistan.

BACKGROUND: Evidence on association of oral health and coronary heart diseases (CHD) is mounting in the literature. This study was designed to observe an association between status of oral health and cardiac diseases in Pakistani adults. MATERIALS AND METHODS: A case-control study was conducted on CHD and non-CHD adults aged >30 years. Age-gender matched individuals without CHD, fulfilling the inclusion criteria as for CHD patients were selected for comparison. Bleeding on probing (BOP), periodontal pocket depth (PPD) and tooth loss were noted as oral health parameters. RESULTS: 45 CHD patients and 35 non-CHD individuals were examined. 53.75% were males and 46.25% females, 37.5% subjects were uneducated, 65% belonged to lower income group, 58.75% subjects were ≥obese and 88.75% were non-smokers. Mean of percent sites of BOP (P =0.007), PPD (P =0.031) and tooth loss (P =0.021) were significantly higher in study group. In stepwise logistic regression analysis, BOP and tooth loss showed a significant positive association with CHD; however, association of PPD was not significant. CONCLUSION: Oral health parameters were significantly higher in CHD patients. Bleeding on probing and tooth loss was positively associated with CHD after adjusting for other socio-demographic variables.

Non-surgical periodontal therapy lowers serum inflammatory markers: a pilot study.

BACKGROUND: Evidence suggests an association between periodontal disease and coronary heart disease (CHD). C-reactive protein (CRP), fibrinogen, and white blood cell (WBC) counts are markers of inflammation, and their systemic levels have been associated with CHD risk. This pilot study investigated the effect of non-surgical periodontal therapy on systemic levels of CRP, fibrinogen, and WBC counts in subjects with CHD or no CHD (NCHD). METHODS: Twenty-seven angiographically defined patients with CHD and 18 subjects with NCHD aged >or=40 years were recruited for the study. Periodontal disease was measured through the clinical parameters bleeding on probing (BOP) and probing depth (PD). All subjects received non-surgical periodontal therapy that included oral hygiene instructions and subgingival scaling and root planing. Systemic levels of inflammatory markers (CRP, fibrinogen, and WBC counts) were measured prior to and 1 month after periodontal therapy. RESULTS: Seventeen subjects with CHD and 11 subjects with NCHD completed the study. Subjects with CHD or NCHD experienced significant reductions in BOP (59% and 34%, respectively; P <0.05) and PD (41% and 35%, respectively; P <0.05), with non-significant intergroup differences (P >0.05). In all subjects, CRP, fibrinogen, and WBC counts were reduced significantly (21% to 40%) after periodontal therapy (P <0.05). CONCLUSIONS: Periodontal treatment resulted in significant decreases in BOP and PD and lowered serum inflammatory markers in patients with CHD or NCHD. This may result in a decreased risk for CHD in the treated patients. These findings will allow pursuit of a large-scale randomized intervention trial in this population.

The evaluation of relationship between group A streptococcal infection with tic disorders in children.

OBJECTIVE: To evaluate the relationship between group A beta hemolytic streptococcus infection (GABHS) and tic disorders in children. METHODS: This is a case-control study that was conducted in Child and Adolescent Psychiatric Clinic, Isfahan, Iran, between May 2008 and February 2009. Thirty-six children (aged 5-15) with tic and 36 children without tic and obsessive-compulsive disorder (OCD) were investigated for clinical and laboratory signs of GABHS. The tools utilized in this research were clinical interview according to the DSM IV-TR and laboratory tests (throat culture, rapid antigen detection test [RADT], anti streptolysin O [ASO] and yale global tics severity scale [YGTSS]). The control group was of the same gender and age as the tic group who had come to the clinic for other illnesses and was in need of blood test. None of the subjects in the case and control groups had a clinical history of GABHS infection. RESULTS: The relationship between tic disorder and GABHS infection (if any of these laboratory tests takes place: throat culture, RADT, ASO > or = 250) in the tic group was 16 (44.4%) and in the control group was 9 (25%), there were significant differences (p<0.05). No significant correlation was found between ASO titer and YGTSS scores. The specificity of RADT was 100%. CONCLUSION: The result showed correlation between GABHS infection and tic disorder, but it does not mean that GABHS infection caused tic disorder.

Uncompensated tooth loss in cardiac patients of Punjab Institute of Cardiology, Lahore.

OBJECTIVE: To observe replacement of missing teeth with artificial teeth in subjects with and with out cardiac diseases and find its possible association with coronary heart diseases (CHD). METHODOLOGY: Consecutive patients aged 20 and above with coronary heart disease and accompanied healthy subjects with tooth loss were examined for oral prosthesis after having a verbal consent, over a one month period in a cross-sectional study at Punjab Institute of Cardiology, Lahore. Chi-square and T- test were applied to analyze variables in subjects with and without coronary heart disease. RESULTS: Among 1694 subjects found with tooth loss, 1473 (86.95) subjects had no oral prosthesis; 817 (87.37%) were among the 935 cardiac patients and 656 (86.42%) among 759 healthy subjects. Oral prosthesis was found in 86 (8.05%) males and 32 (5.11%) females with coronary heart diseases. Of the healthy population, 46 (4.30%) males and 57 (9.10%) females had oral prosthesis. Statistical association for prosthesis was insignificant among cardiac patients and healthy subjects. CONCLUSION: No association of uncompensated tooth loss with cardiac diseases was observed in this study. Although a large majority of cardiac patients and healthy subjects were observed with uncompensated tooth loss which was statistically insignificant.

Transcriptional recapitulation and subversion of embryonic colon development by mouse colon tumor models and human colon cancer.

BACKGROUND: The expression of carcino-embryonic antigen by colorectal cancer is an example of oncogenic activation of embryonic gene expression. Hypothesizing that oncogenesis-recapitulating-ontogenesis may represent a broad programmatic commitment, we compared gene expression patterns of human colorectal cancers (CRCs) and mouse colon tumor models to those of mouse colon development embryonic days 13.5-18.5. RESULTS: We report here that 39 colon tumors from four independent mouse models and 100 human CRCs encompassing all clinical stages shared a striking recapitulation of embryonic colon gene expression. Compared to normal adult colon, all mouse and human tumors over-expressed a large cluster of genes highly enriched for functional association to the control of cell cycle progression, proliferation, and migration, including those encoding MYC, AKT2, PLK1 and SPARC. Mouse tumors positive for nuclear beta-catenin shifted the shared embryonic pattern to that of early development. Human and mouse tumors differed from normal embryonic colon by their loss of expression modules enriched for tumor suppressors (EDNRB, HSPE, KIT and LSP1). Human CRC adenocarcinomas lost an additional suppressor module (IGFBP4, MAP4K1, PDGFRA, STAB1 and WNT4). Many human tumor samples also gained expression of a coordinately regulated module associated with advanced malignancy (ABCC1, FOXO3A, LIF, PIK3R1, PRNP, TNC, TIMP3 and VEGF). CONCLUSION: Cross-species, developmental, and multi-model gene expression patterning comparisons provide an integrated and versatile framework for definition of transcriptional programs associated with oncogenesis. This approach also provides a general method for identifying pattern-specific biomarkers and therapeutic targets. This delineation and categorization of developmental and non-developmental activator and suppressor gene modules can thus facilitate the formulation of sophisticated hypotheses to evaluate potential synergistic effects of targeting within- and between-modules for next-generation combinatorial therapeutics and improved mouse models.