Morphological distribution mapping: Utilisation of modelling to integrate particle size and shape distributions.

The aim of this work was to develop approaches to utilize whole particle distributions for both particle size and particle shape parameters to map the full range of particle properties in a curated dataset. It is hoped that such an approach may enable a more complete understanding of the particle landscape as a step towards improving the link between particle properties and processing behaviour. A 1-dimensional principal component analysis (PCA) approach was applied to create a 'morphological distribution landscape'. A dataset of imaged APIs, intermediates and excipients encompassing particle size, particle shape (elongation, length and width) and distribution shape was curated between 2008 and 2022. The curated dataset encompassed over 200 different materials, which included over 150 different APIs, and approximately 3500 unique samples. For the purposes of the current work, only API samples were included. The morphological landscape enables differentiation of materials of equivalent size but varying shape and vice versa. It is hoped that this type of approach can be utilised to better understand the influence of particle properties on pharmaceutical processing behaviour and thereby enable scientists to leverage historical knowledge to highlight and mitigate risks associated to materials of similar morphological nature.

Particle Property Characterization and Data Curation for Effective Powder Property Modeling in the Pharmaceutical Industry.

Computational modeling, machine learning, and statistical data analysis are increasingly utilized to mitigate chemistry, manufacturing, and control failures related to particle properties in solid dosage form manufacture. Advances in particle characterization techniques and computational approaches provide unprecedented opportunities to explore relationships between particle morphology and drug product manufacturability. Achieving this, however, has numerous challenges such as producing and appropriately curating robust particle size and shape data. Addressing these challenges requires a harmonized strategy from material sampling practices, characterization technique selection, and data curation to provide data sets which are informative on material properties. Herein, common sources of error in particle characterization and data compression are reviewed, and a proposal for providing robust particle morphology (size and shape) data to support modeling efforts, approaches for data curation, and the outlook for modeling particle properties are discussed.

Preparation, Characterization and Study of the Dissociation of Naproxen from Its Chitosan Salt.

Salts of naproxen (NAP) with chitosan (CTS) and reticulated chitosan (CEP) were prepared under optimized conditions to maximize the yield of reaction. The objective was to evaluate the dissociation in water, which can guide studies of release of the drug from biopolymeric salts in pharmaceutical applications. Higher salification was found after 24 h of reaction at 60 °C in a molar ratio 1:1.05 (CTS:NAP, mol/mol), resulting in a degree of substitution (DS) of 17% according to 13C NMR, after neutralization of the -NH2 group of the biopolymer by the carboxylic group of the drug. The presence of NAP salt is evidenced by FTIR bands related to the -NH3+ group at 856 cm-1, a decrease in crystallinity index in XRD diffractograms as well as changes in mass loss ratios (TG/DTG/DTA) and increased thermal stability of the salt regarding CTS itself. The CEPN crosslinked salt presented a DS = 3.6%, probably due to the shielding of the -NH2 groups. Dissociation studies revealed that at pH 2.00, dissociation occurred faster when compared to at pH 7.00 in the non-reticulated salt, while the opposite was observed for the reticulated one.

Neoadjuvant Selicrelumab, an Agonist CD40 Antibody, Induces Changes in the Tumor Microenvironment in Patients with Resectable Pancreatic Cancer.

PURPOSE: CD40 activation is a novel clinical opportunity for cancer immunotherapy. Despite numerous active clinical trials with agonistic CD40 monoclonal antibodies (mAb), biological effects and treatment-related modulation of the tumor microenvironment (TME) remain poorly understood. PATIENTS AND METHODS: Here, we performed a neoadjuvant clinical trial of agonistic CD40 mAb (selicrelumab) administered intravenously with or without chemotherapy to 16 patients with resectable pancreatic ductal adenocarcinoma (PDAC) before surgery followed by adjuvant chemotherapy and CD40 mAb. RESULTS: The toxicity profile was acceptable, and overall survival was 23.4 months (95% confidence interval, 18.0-28.8 months). Based on a novel multiplexed immunohistochemistry platform, we report evidence that neoadjuvant selicrelumab leads to major differences in the TME compared with resection specimens from treatment-naïve PDAC patients or patients given neoadjuvant chemotherapy/chemoradiotherapy only. For selicrelumab-treated tumors, 82% were T-cell enriched, compared with 37% of untreated tumors (P = 0.004) and 23% of chemotherapy/chemoradiation-treated tumors (P = 0.012). T cells in both the TME and circulation were more active and proliferative after selicrelumab. Tumor fibrosis was reduced, M2-like tumor-associated macrophages were fewer, and intratumoral dendritic cells were more mature. Inflammatory cytokines/sec CXCL10 and CCL22 increased systemically after selicrelumab. CONCLUSIONS: This unparalleled examination of CD40 mAb therapeutic mechanisms in patients provides insights for design of subsequent clinical trials targeting CD40 in cancer.

Oxidative stress does not influence weight loss induced by aerobic training in adults: randomized clinical trials.

BACKGROUND: High levels of oxidative stress promote degradation of the cell membrane impairing cellular function in fat oxidation. However, the influence of oxidative stress on exercise-induced weight-loss has not yet been investigated. Therefore, the aim of this study was to verify the influence of a lipidic peroxidation marker (malondialdehyde, MDA) and antioxidant status (total antioxidant capacity marker, TAC) on the magnitude of weight-loss by aerobic-induced exercise in previously sedentary overweight or obese individuals. METHODS: Seventy-five physically inactive adults were randomized into experimental (N.=58) and control (N.=17) groups, who engaged in a 12-week program of aerobic training walking and/or running (3 to 5 days/week) or stretching (1 day/week), respectively. Body composition (DXA), aerobic capacity (ergospirometric) and blood collections for oxidative stress analysis (MDA and TAC) were determined before and after the experimental protocol. Two-way ANOVA for repeated measures or Friedman's test were used to evaluate differences in time/group interaction. Pearson correlation was used to verify the relationship between the variables of oxidative stress and of body composition. RESULTS: Significant reduction was found in fat body mass of experimental when compared to control group (-1.3±1.9 kg versus -0.3±1.3, P=0.04). Experimental group also altered significantly the total body mass (-1.2±4.7 kg; effect size 0.44), body mass index - BMI (-0.3±1.1 effect size 0.37), fat percentage (1.3±1.6%; effect size 0.50) and lean body mass (0.6±1.5 kg; effect size 0.32).There was increase in MDA of 2.3 µmol/L to 2.7 µmol/L (P=0.00), without changes to TAC (25.6±13.9% to 28.0±10.4%). No correlation was found between these variations in body composition with either the initial values of MDA and TAC or delta variation of these indicators of oxidative stress in response to the training program. CONCLUSIONS: Indicators of oxidative stress (MDA and TAC) does not influence the magnitude of weight-loss induced by aerobic training.

Preparation, Characterization and In Vivo Biocompatibility Studies of Cotton Cellulose Nanofibers.

Cellulose nanofibers have mechanical properties that make them very attractive in a myriad of fields such as biomedicine, tissue engineering, biosensors, cosmetics and food packet products. To evaluate the potential health risks of airborne cellulose nanofibers, the cellulose nanofiber was prepared and characterized and then its pulmonary potential toxicity to a mouse model was studied. Cellulose nanofiber has been prepared by acid hydrolysis of cotton cellulose and characterized by transmission electron microscopy, zeta potential and X-ray diffraction analysis. Then, using a short-term inhalation test, the pulmonary biocompatibility of cotton cellulose nanofibers at different concentrations (0.5 mg/mL, 1 mg/mL and 2 mg/mL) were evaluated. Transmission electron images showed needle-shaped particle with a diameter of about 6-18 nm and a length of 85-225 µm. Zeta potential was -25.3±7.80 mV and the X-ray diffraction patterns indicate that cotton cellulose nanofiber has pure structural characteristics. The In Vivo results revealed that the exposure to cotton cellulose nanofiber did not alter the number of inflammatory cells or cytokine secretion by lung cells (p > 0.05). The results demonstrate that the cotton cellulose nanofiber is biocompatible and it is an environment-friendly nanomaterial with promise in various industrial sectors.

A new look towards the thermal decomposition of chitins and chitosans with different degrees of deacetylation by coupled TG-FTIR.

Chitins and Chitosans with different degrees of deacetylation (DD¯) were analyzed for the first time by thermogravimetry coupled to infrared spectroscopy TG-FTIR in order to evaluate the effect of DD¯ on the thermal decomposition process. DD¯ values of chitins and chitosans were determined by 1H-NMR and structural difference were investigated by FTIR, SEM and XRD. Thermal stability of chitosan with 98, 87, 71% DD¯, chitins with 47 and 27% DD¯ and commercial α-chitin were evaluated. Thermal decomposition of chitosans occurs in two steps, while for chitins occurs predominantly in first stage under air atmosphere. Commercial chitin thermally decomposed at lower temperatures than highly deacetylated chitosan. A faster thermal degradation process was found for chitins, except for commercial sample. TG-FTIR of evolved gas evidenced a complex gaseous mixture mainly composed by ammonia, acetic acid, acetamide, water, monoxide and carbon dioxide in proportions that are deeply dependent on the DD¯.

Accuracy of Motion Palpation Flexion-Extension Test in Identifying the Seventh Cervical Spinal Process.

OBJECTIVE: The aim of this study was to evaluate the accuracy of a motion palpation procedure, the flexion-extension test, in localizing the spinous process of the seventh cervical vertebra (C7). METHODS: We analyzed 101 adult participants with metal markers that permitted the identification of the C7 spinous process. This analysis occurred during a flexion-extension test and was confirmed by radiography. Data sample characteristics were analyzed by descriptive statistics, and the relationship between independent variables (weight, height, sex, age, and body mass index [BMI]) and dependent variables (coincidence between the most prominent vertebra and the stationary vertebra, as determined by the flexion-extension test) was determined via logistic regression. RESULTS: The sample population was 48.5% male with a mean age of 56.8 years (standard deviation, ±14.9) and a mean BMI of 25.54 kg/m2 (standard deviation, ±5.5). In 54.5% of cases, the C7 spinous process was correctly identified by the flexion-extension test. The agreement between the flexion-extension test and radiography in accuracy of localization of the C7 spinous process was significant (P = .021), as was the correct localization of C7 (P = .05). CONCLUSION: The localization of the C7 spinous process was more accurate in individuals with a BMI <25 kg/m2 and whose most prominent vertebra coincided with the stationary vertebra as determined by the flexion-extension test.

Use of similarity scoring in the development of oral solid dosage forms.

In the oral solid dosage form space, material physical properties have a strong impact on the behaviour of the formulation during processing. The ability to identify materials with similar characteristics (and thus expected to exhibit similar behaviour) within the company's portfolio can help accelerate drug development by enabling early assessment and prediction of potential challenges associated with the powder properties of a new active pharmaceutical ingredient. Such developments will aid the production of robust dosage forms, in an efficient manner. Similarity scoring metrics are widely used in a number of scientific fields. This study proposes a practical implementation of this methodology within pharmaceutical development. The developed similarity metrics is based on the Mahalanobis distance. Scanning electron microscopy was used to confirm morphological similarity between the reference material and the closest matches identified by the metrics proposed. The results show that the metrics proposed are able to successfully identify material with similar physical properties.

The Impact of Previous Physical Training on Redox Signaling after Traumatic Brain Injury in Rats: A Behavioral and Neurochemical Approach.

Throughout the world, traumatic brain injury (TBI) is one of the major causes of disability, which can include deficits in motor function and memory, as well as acquired epilepsy. Although some studies have shown the beneficial effects of physical exercise after TBI, the prophylactic effects are poorly understood. In the current study, we demonstrated that TBI induced by fluid percussion injury (FPI) in adult male Wistar rats caused early motor impairment (24 h), learning deficit (15 days), spontaneous epileptiform events (SEE), and hilar cell loss in the hippocampus (35 days) after TBI. The hippocampal alterations in the redox status, which were characterized by dichlorofluorescein diacetate oxidation and superoxide dismutase (SOD) activity inhibition, led to the impairment of protein function (Na(+), K(+)-adenosine triphosphatase [ATPase] activity inhibition) and glutamate uptake inhibition 24 h after neuronal injury. The molecular adaptations elicited by previous swim training protected against the glutamate uptake inhibition, oxidative stress, and inhibition of selected targets for free radicals (e.g., Na(+), K(+)-ATPase) 24 h after neuronal injury. Our data indicate that this protocol of exercise protected against FPI-induced motor impairment, learning deficits, and SEE. In addition, the enhancement of the hippocampal phosphorylated nuclear factor erythroid 2-related factor (P-Nrf2)/Nrf2, heat shock protein 70, and brain-derived neurotrophic factor immune content in the trained injured rats suggests that protein expression modulation associated with an antioxidant defense elicited by previous physical exercise can prevent toxicity induced by TBI, which is characterized by cell loss in the dentate gyrus hilus at 35 days after TBI. Therefore, this report suggests that previous physical exercise can decrease lesion progression in this model of brain damage.

Modelling drug degradation in a spray dried polymer dispersion using a modified Arrhenius equation.

The Pharmaceutical industry is increasingly utilizing amorphous technologies to overcome solubility challenges. A common approach is the use of drug in polymer dispersions to prevent recrystallization of the amorphous drug. Understanding the factors affecting chemical and physical degradation of the drug within these complex systems, e.g., temperature and relative humidity, is an important step in the selection of a lead formulation, and development of appropriate packaging/storage control strategies. The Arrhenius equation has been used as the basis of a number of models to predict the chemical stability of formulated product. In this work, we investigate the increase in chemical degradation seen for one particular spray dried dispersion formulation using hydroxypropyl methylcellulose acetate succinate (HPMC-AS). Samples, prepared using polymers with different substitution levels, were placed on storage for 6 months under a range of different temperature and relative humidity conditions and the degradant level monitored using high-performance liquid chromatography (HPLC). While the data clearly illustrates the impact of temperature and relative humidity on the degradant levels detected, it also highlighted that these terms do not account for all the variability in the data. An extension of the Arrhenius equation to include a term for the polymer chemistry, specifically the degree of succinoyl substitution on the polymer backbone, was shown to improve the fit of the model to the data.

Multivariate analysis in the pharmaceutical industry: enabling process understanding and improvement in the PAT and QbD era.

In the pharmaceutical industry, chemometrics is rapidly establishing itself as a tool that can be used at every step of product development and beyond: from early development to commercialization. This set of multivariate analysis methods allows the extraction of information contained in large, complex data sets thus contributing to increase product and process understanding which is at the core of the Food and Drug Administration's Process Analytical Tools (PAT) Guidance for Industry and the International Conference on Harmonisation's Pharmaceutical Development guideline (Q8). This review is aimed at providing pharmaceutical industry professionals an introduction to multivariate analysis and how it is being adopted and implemented by companies in the transition from "quality-by-testing" to "quality-by-design". It starts with an introduction to multivariate analysis and the two methods most commonly used: principal component analysis and partial least squares regression, their advantages, common pitfalls and requirements for their effective use. That is followed with an overview of the diverse areas of application of multivariate analysis in the pharmaceutical industry: from the development of real-time analytical methods to definition of the design space and control strategy, from formulation optimization during development to the application of quality-by-design principles to improve manufacture of existing commercial products.

Application of imaging based tools for the characterisation of hollow spray dried amorphous dispersion particles.

The aim of this study was to investigate novel approaches to determine spray dried dispersion (SDD) specific particle characteristics through the use of imaging based technologies. The work demonstrates approaches that can be applied in order to access quantitative approximations for powder characteristics for hollow particles, such as SDD. Cryo-SEM has been used to measure the solid volume fraction and/or particle density of SDD particles. Application of this data to understand the impact of spray drying process conditions on SDD powder properties, and their impact on processability and final dosage form quality were investigated. The use of data from a Morphologi G3 image based particle characterisation system was also examined in order to explain both the propensity and extent of attrition within a series of SDD samples, and also demonstrate the use of light transmission data to assess the relative wall thickness of SDD particles. Such approaches demonstrate a means to access potentially useful information that can be linked to important particle characteristics for SDD materials which, in addition to the standard bulk powder measurements such as bulk density, may enable a better understanding of such materials and their impact on downstream processability and final dosage form acceptability.

Selegiline reverses aß25₋35-induced cognitive deficit in male mice.

Alzheimer's disease (AD) is biochemically characterized by the occurrence of extracellular deposits of amyloid beta peptide (Aß) and intracellular deposits of the hyperphosphorylated tau protein, which are causally related to the pathological hallmarks senile plaques and neurofibrillary tangles. Monoamine oxidase B (MAO-B) activity, involved in the oxidation of biogenic monoamines, is particularly high around the senile plaques and increased in AD patients in middle to late clinical stages of the disease. Selegiline is a selective and irreversible MAO-B inhibitor and, although clinical trials already shown the beneficial effect of selegiline on cognition of AD patients, its mechanism of action remains to be elucidated. Therefore, we first investigated whether selegiline reverses the impairment of object recognition memory induced by Aß25-35 in mice, an established model of AD. In addition, we investigated whether selegiline alters MAO-B and MAO-A activities in the hippocampus, perirhinal and remaining cerebral cortices of Aß25-35-injected male mice. Acute (1 and 10 mg/kg, p.o., immediately post-training) and subchronic (10 mg/kg, p.o., seven days after Aß25-35 injection and immediately post-training) administration of selegiline reversed the cognitive impairment induced by Aß25-35 (3 nmol, i.c.v.). Acute administration of selegiline (1 mg/kg, p.o.) in combination with Aß25-35 (3 nmol) decreased MAO-B activity in the perirhinal and remaining cerebral cortices. Acute administration of selegiline (10 mg/kg, p.o.) decreased MAO-B activity in hippocampus, perirhinal and remaining cerebral cortices, regardless of Aß25-35 or Aß35-25 treatment. MAO-A activity was not altered by selegiline or Aß25-35. In summary, the current findings further support a role for cortical monoaminergic transmission in the cognitive deficits observed in AD.

Synthesis of 1,4-anthracene-9,10-dione derivatives and their regulation of nitric oxide, IL-1ß and TNF-α in activated RAW264.7 cells.

Mitoxantrone is an anthracenedione antineoplastic and immunosuppressive agent approved for multiple sclerosis treatment. Novel mono- and disubstituted anthraquinone derivatives, analogues of mitoxantrone, were synthesized through the addition of lipophilic amino alcohols and evaluated for their effect on IL-1ß, TNF-α and nitric oxide production by LPS/IFN-γ-stimulated RAW264.7 cells. The disubstituted 1,4-anthracene-9,10-dione 10 showed significant inhibition of nitric oxide, TNF-α and IL-1ß production at the concentration of 5 µg/mL, with a much lower cytotoxicity than mitoxantrone. The monosubstituted 3, 4, 11, 12 and 13 also displayed a moderate to good inhibitory capacity on IL-1ß production. However, the methylated compounds 11, 12 and 13 failed to inhibit the TNF-α production, and compound 13 was the only one to decrease the production of nitric oxide. None of these derivatives was toxic at the tested concentrations. Compounds 10 and 13 had better inhibitory capacity of the inflammatory mediators analyzed, with reliable viability of the cells.

Low-level laser reduces the production of TNF-α, IFN-γ, and IL-10 induced by OVA.

Delayed, or type IV, hypersensitivity reactions are a useful model to study the effects of new substances on the immune system. In this study, the experimental model of the delayed type hypersensitivity (DTH) reaction to ovalbumin (OVA) was used to evaluate the immunomodulating effects of low-level laser therapy (LLLT), which is used as an adjuvant therapy in medicine, dentistry, and physical therapy because of its potential anti-inflammatory and analgesic effects observed in several studies. The effects of LLLT (λ 780 nm, 0.06 W/cm(2) of radiation, and fluency of 3.8 J/cm(2)) in reaction to ovalbumin in Balb/C mice were examined after the induction phase of the hypersensitivity reaction. The animals treated with azathioprine (AZA), the animals that received a vehicle instead of ovalbumin, and those not immunized served as controls (n = 6 for each group). Footpad thickness measurements and hematoxylin-eosin histopathological exams were performed. Proliferation tests were also performed (spontaneous, in the presence of concanavalin A and ovalbumin) to determine the production in mononuclear cells cultures of tumor necrosis factor-alpha (TNF-α), INF-γ, and IL-10. In the group of animals irradiated with lasers and in the group treated with AZA, footpad thickness measurements were significantly reduced in comparison to the control group (p < 0.05). This reduction was accompanied by a very significant reduction in the density of the inflammatory infiltrate and by a significant reduction in the levels of TNF-α, INF-γ, and IL-10. LLLT radiation was shown to have an immunomodulating effect on DTH to OVA in Balb/C mice.

Preparation of amino alcohols condensed with carbohydrates: Evaluation of cytotoxicity and inhibitory effect on NO production.

This work reports the preparation of several amino alcohols condensed with d-arabinose, d-glucose, and d-galactose derivatives. These compounds were evaluated in vitro for their cytotoxicity and ability to decrease nitric oxide production in J774A.1 cells. Arabinofuranoside derivatives 5a, 5b and 5c showed a significant inhibition of nitric oxide production (>80% at 5 µg/mL), while the galactopyranoside derivative 8d showed a notable nitric oxide inhibitory activity (126% at 0.5 µg/mL).

Apoptosis of macrophages during pulmonary Mycobacterium bovis infection: correlation with intracellular bacillary load and cytokine levels.

Apoptosis of macrophages infected with pathogenic mycobacteria is an alternative host defence capable of removing the environment supporting bacterial growth. In this work the influence of virulence and bacterial load on apoptosis of alveolar macrophages during the initial phase of infection by Mycobacterium bovis was investigated. BALB/c mice were infected intratracheally with high or low doses of the virulent (ATCC19274) or attenuated (bacillus Calmette-Guérin Moreau) strains of M. bovis. The frequency of macrophage apoptosis, the growth of mycobacteria in macrophages, and the in situ levels of the cytokines tumour necrosis factor-alpha (TNF-alpha), interleukin-10 (IL-10) and IL-12 and of the anti-apoptotic protein Bcl-2 were measured at day 3 and day 7 post-infection. An increase of macrophage apoptosis was observed after infection with both strains but the virulent strain induced less apoptosis than the attenuated strain. On the 3rd day after infection with the virulent strain macrophage apoptosis was reduced in the high-dose group, while on the 7th day post-infection macrophage apoptosis was reduced in the low-dose group. Inhibition of apoptosis was correlated with increased production of IL-10, reduced production of TNF-alpha and increased production of Bcl-2. In addition, the production of IL-12 was reduced at points where the lowest levels of macrophage apoptosis were observed. Our results indicate that virulent mycobacteria are able to modulate macrophage apoptosis to an extent dependent on the intracellular bacterial burden, which benefits its intracellular growth and dissemination to adjacent cells.

Antiulcerogenic and anti-inflammatory activities of the essential oil from Pterodon emarginatus seeds.

OBJECTIVES: The objective of this work was to investigate the antiulcerogenic and anti-inflammatory activities of the essential oil from Pterodon emarginatus seeds. METHODS: The following tests were used: ulcers induced by ethanol, indometacin and HCl/ethanol, and pleurisy induced by carrageenan in Swiss albino rats. The rats were treated by the oral route with essential oil of P. emarginatus seeds. KEY FINDINGS: The essential oil at 100, 300 and 500 mg/kg exhibited significant protection against ulcers induced by ethanol, indometacin and HCl/ethanol (P < 0.001). The essential oil caused a marked reduction in the exudate volume and inhibited leucocyte and neutrophil influx (P < 0.05) in carrageenan-induced pleurisy. Moreover, the essential oil significantly decreased nitric oxide (NO) and interleukin-1 (IL-1) levels, without affecting tumour necrosis factor-alpha production. CONCLUSIONS: The results demonstrated the marked antiulcerogenic and anti-inflammatory effects of the essential oil from P. emarginatus, which are, at least in part, a consequence of NO and IL-1 modulation. P. emarginatus or its constituents might represent new therapeutic options to treat gastric ulcers and inflammatory diseases.

Cellular and humoral immune responses during intrathoracic paracoccidioidomycosis in BALB/c mice.

Paracoccidioidomycosis is a chronic infection that primarily affects the lungs. Here we investigated cellular and humoral immune responses after intrathoracic Paracoccidioidesbrasiliensis infection in BALB/c mice. P. brasiliensis-colony-forming units (CFUs), fungal DNA and granulomas in lungs increased progressively, peaking at day 90 postinfection (p.i.). IFN-gamma production was highest on day 15 p.i., declining thereafter. The kinetics of the NO production was similar to that described for IFN-gamma. In contrast, IL-10 increased from day 45 p.i. reaching a peak at day 90. Levels of serum IgG1 were higher than IgG2a between days 30 and 90 p.i. 30% of mice died by day 90 p.i. These data indicate that infection with P. brasiliensis by the intrathoracic route shows high IFN-gamma and NO production at day 15 p.i., unable to control multiplication of fungi, which appears to be associated with a progressive increase in IL-10 and in the number and complexity of granulomas.