Controlling the Size of Hydrotalcite Particles and Its Impact on the Thermal Insulation Capabilities of Coatings.

This study focuses on the development of high-performance insulation materials to address the critical issue of reducing building energy consumption. Magnesium-aluminum layered double hydroxides (LDHs), known for their distinctive layered structure featuring positively charged brucite-like layers and an interlayer space, have been identified as promising candidates for insulation applications. Building upon previous research, which demonstrated the enhanced thermal insulation properties of methyl trimethoxysilane (MTS) functionalized LDHs synthesized through a one-step in situ hydrothermal method, this work delves into the systematic exploration of particle size regulation and its consequential effects on the thermal insulation performance of coatings. Our findings indicate a direct correlation between the dosage of MTS and the particle size of LDHs, with an optimal dosage of 4 wt% MTS yielding LDHs that exhibit a tightly interconnected hydrotalcite lamellar structure. This specific modification resulted in the most significant improvement in thermal insulation, achieving a temperature difference of approximately 25.5 °C. Furthermore, to gain a deeper understanding of the thermal insulation mechanism of MTS-modified LDHs, we conducted a thorough characterization of their UV-visible diffuse reflectance and thermal conductivity. This research contributes to the advancement of LDH-based materials for use in thermal insulation applications, offering a sustainable solution to energy conservation in the built environment.

Responsiveness to Tocilizumab in Anti-Acetylcholine Receptor-Positive Generalized Myasthenia Gravis.

Tocilizumab, a humanized IL-6R monoclonal antibody, has been used in autoimmune diseases closely related to humoral immunity. This report aims to evaluate the efficacy and safety in patients with anti-acetylcholine receptor-positive (AChR+) generalized myasthenia gravis (gMG). We performed a prospective, open-label, single-arm study in patients with gMG in a 48-week follow-up. All patients were AChR+ and were given tocilizumab by intravenous infusion at a dose of 8 mg/kg at intervals of 4 weeks. The primary endpoint was mean change from baseline in quantitative MG (QMG) score at week 12. The secondary endpoints were mean changes from baseline in MG activities of daily living (MG-ADL) score, AChR-ab titers, and the dosage of oral prednisone at week 12. At week 48, QMG, MG-ADL, and the use of prednisone were also evaluated. Fourteen gMG patients were enrolled and all of them completed the study. Tocilizumab treatment started 8 (4-192) months after the onset of gMG. During tocilizumab treatment, the QMG score was significantly decreased from 15.5 (interqualile range, 9-26) at baseline to 4 (0-9) at week 12 (p < 0.001). The change of ADL was decreased from 14.5(11-19) at baseline to 4 (0-19) at week 12 (p < 0.001) and the change of AChR-ab titers from 15 (7.5-19) at baseline to 6.8 (11.6-4.3) at week 12 (p < 0.001). The dosage of prednisone decreased from baseline 60 (20-65) mg/d to 30 (30-50) mg/d at week 12 (p < 0.001). By the end of the study, the QMG score was 2 (0-7) and MG-ADL score was 1.5 (0-6). 12 (85.7%) patients achieved minimal manifestations. 4 (28.6%) patients were able to discontinue prednisone. No patients experienced exacerbation at the end of the study. No serious adverse events were observed during follow-up. Tocilizumab treatment was associated with a good clinical response and safety over a 48-week observation period, as evidenced by significant improvements in QMG and MG-ADL.

Cerebrospinal fluid oligoclonal bands in Chinese patients with multiple sclerosis: the prevalence and its association with clinical features.

Background: Cerebrospinal fluid oligoclonal band (CSF-OCB) is an established biomarker in diagnosing multiple sclerosis (MS), however, there are no nationwide data on CSF-OCB prevalence and its diagnostic performance in Chinese MS patients, especially in the virtue of common standard operation procedure (SOP). Methods: With a consensus SOP and the same isoelectric focusing system, we conducted a nationwide multi-center study on OCB status in consecutively, and recruited 483 MS patients and 880 non-MS patients, including neuro-inflammatory diseases (NID, n = 595) and non-inflammatory neurological diseases (NIND, n=285). Using a standardized case report form (CRF) to collect the clinical, radiological, immunological, and CSF data, we explored the association of CSF-OCB positivity with patient characters and the diagnostic performance of CSF-OCB in Chinese MS patients. Prospective source data collection, and retrospective data acquisition and statistical data analysis were used. Findings: 369 (76.4%) MS patients were OCB-positive, while 109 NID patients (18.3%) and 6 NIND patients (2.1%) were OCB-positive, respectively. Time from symptom onset to diagnosis was significantly shorter in OCB-positive than that in OCB-negative MS patients (13.2 vs 23.7 months, P=0.020). The prevalence of CSF-OCB in Chinese MS patients was significantly higher in high-latitude regions (41°-50°N)(P=0.016), and at high altitudes (>1000m)(P=0.025). The diagnostic performance of CSF-OCB differentiating MS from non-MS patients yielded a sensitivity of 76%, a specificity of 87%. Interpretation: The nationwide prevalence of CSF-OCB was 76.4% in Chinese MS patients, and demonstrated a good diagnostic performance in differentiating MS from other CNS diseases. The CSF-OCB prevalence showed a correlation with high latitude and altitude in Chinese MS patients.

A multicentre, prospective, double-blind study comparing the accuracy of autoantibody diagnostic assays in myasthenia gravis: the SCREAM study.

Background: Laboratory determination of autoantibodies against acetylcholine receptor (AChR), muscle-specific kinase (MuSK) and other autoantigens have been integrated into the diagnosis of myasthenia gravis (MG). However, evidence supporting the selection of methodologies is lacking. Methods: In this prospective, multicentre cohort study, we recruited patients with suspected MG to evaluate the diagnostic accuracy of cell-based assay (CBA), radioimmunoprecipitation assay (RIPA) and enzyme-linked immunosorbent assay (ELISA) in detecting AChR and MuSK autoantibodies. This study is registered with www.clinicaltrials.gov, number NCT05219097. Findings: 2272 eligible participants were recruited, including 2043 MG, 229 non-MG subjects. AChR antibodies were detected in 1478, 1310, and 1280 out of a total of 2043 MG patients by CBA, RIPA, and ELISA, respectively; sensitivity, 72.3% (95% CI, 70.3-74.3), 64.1% (95% CI, 62.0-66.2), 62.7% (95% CI, 60.5-64.8); specificity, 97.8% (95% CI, 95.0-99.3), 97.8% (95% CI, 95.0-99.3), 94.8% (95% CI, 91.9-97.7). MuSK antibodies were found in 59, 50, and 54 from 2043 MG patients by CBA, RIPA and ELISA, respectively; sensitivity, 2.9% (95% CI, 2.2-3.7), 2.4% (95% CI, 1.8-3.2), 2.6% (95% CI, 2.0-3.4); specificity, 100% (95% CI, 98.4-100), 100% (95% CI, 98.4-100), and 99.1% (95% CI, 96.9-99.9). The area under the curve of AChR antibodies tested by CBA was 0.858, and there were statistical differences with RIPA (0.843; p = 0.03) and ELISA (0.809; p < 0.0001). Interpretation: CBA has a higher diagnostic accuracy compared to RIPA or ELISA in detecting AChR and MuSK autoantibodies for MG diagnosis. Funding: New Terrain Biotechnology, Inc., Tianjin, China.

Rituximab induces a transient fluctuation of peripheral and follicular helper T cells in neuromyelitis optica spectrum disorder.

Autoreactive CD4+ helper T cells are implicated in the pathogenesis of neuromyelitis optica spectrum disorder (NMOSD). Both PD-1+CXCR5+CD4+ T follicular helper (Tfh) cells and PD-1+CXCR5-CD4+ T peripheral helper (Tph) cells can contribute to B-cell immune responses and the production of antibodies. Here we show the effect of B-cell depletion with rituximab on the homeostasis of Tfh cells, Tph cells and their subsets in patients with NMOSD. After rituximab treatment, total Tph cells, total Tfh cells, Tph17 cells, Tph17.1 cells, Tph1 cells, and Tfh1 cells tended to decrease at month 1, but gradually increased at month 6 and restored at month 12. Besides, Tph17.1 cells and Tfh17.1 cells were correlated with the proportion of CD19- antibody-secreting cells. Our data suggest that rituximab induced a fluctuation of proinflammatory Tph and Tfh subsets within one year after initiation of the treatment.

[Effect of neuroelectrophysiological changes on the clinical manifestations and surgical outcomes of lumbar degenerative diseases].

OBJECTIVE: To evaluate the effects of electromyography on the clinical manifestations and prognosis after posterior lumbar interbody fusion(PLIF) of degenerative lumbar diseases. METHODS: A retrospective analysis was performed on 68 patients with degenerative lumbar diseases, including 29 males and 39 females, aged 21 to 84 years old, who underwent electromyogram (EMG) from January 2018 to October 2019. The patients were divided into negative and positive groups according to whether theresults of EMG was normal or abnormal, PLIF surgery was performed in both groups. The preoperative duration of illness, postoperative recovery time, operative time, intraoperative blood loss, postoperative ambulation time and length of postoperative hospital stay were recorded. The clinical efficacy was evaluated by visual analogue scale(VAS) of low back and lower limb, the Japanese Orthopedic Association(JOA) score before and after operation. RESULTS: All patients were follow-up from 26 to 39 months. The subjective symptoms, clinical signs, daily activities and JOA total scores after operation in two groups were significantly higher than those before preoperation(P<0.05);the clinical signs score and total JOA score in the negative group at 3 months after operation were higher than those in the positive group(P<0.05). The VAS score of leg pain in the negative group after 1 and 3 months was less than that in the positive group(P<0.05). Patients 's illness time, postoperative recovery time, hospitalization time and implantation time in the negative group were shorter than those in the positive group(P<0.05). At other time points, there was no significant difference in low pain VAS, leg pain VAS, JOA scores in the two groups(P>0.05). There was no significant difference in the operation time and intraoperative bleeding volume between the two groups(P>0.05). CONCLUSION: Patients with normal electromyography had shorter disease duration than ones with abnormal electromyography in lumbar degenerative disease;after PLIF, patients with normal electromyography recovered faster than ones with abnormal electromyography, but the results of electromyography had no effect on the final prognosis of PLIF surgery.

Methyl-Trimethoxy-Siloxane-Modified Mg-Al-Layered Hydroxide Filler for Thermal-Insulation Coatings.

The development of high-performance insulation materials that facilitate the reduction in building energy consumption is of paramount significance. In this study, magnesium-aluminum-layered hydroxide (LDH) was prepared by the classical hydrothermal reaction. By implementing methyl trimethoxy siloxane (MTS), two different MTS-functionalized LDHs were prepared via a one-step in situ hydrothermal synthesis method and a two-step method. Furthermore, using techniques, such as X-ray diffraction, infrared spectroscopy, particle size analysis, and scanning electron microscopy, we evaluated and analyzed the composition, structure, and morphology of the various LDH samples. These LDHs were then employed as inorganic fillers in waterborne coatings, and their thermal-insulation capabilities were tested and compared. It was found that MTS-modified LDH via a one-step in situ hydrothermal synthesis method (M-LDH-2) exhibited the best thermal insulating properties by displaying a thermal-insulation-temperature difference (ΔT) of 25 °C compared with the blank panel. In contrast, the panels coated with unmodified LDH and the MTS-modified LDH via the two-step method exhibited thermal-insulation-temperature difference values of 13.5 °C and 9.5 °C, respectively. Our investigation involved a comprehensive characterization of LDH materials and coating films, unveiling the underlying mechanism of thermal insulation and establishing the correlation between LDH structure and the corresponding insulation performance of the coating. Our findings reveal that the particle size and distribution of LDHs are critical factors in dictating their thermal-insulation capabilities in the coatings. Specifically, we observed that the MTS-modified LDH, prepared via a one-step in situ hydrothermal approach, possessed a larger particle size and wider particle size distribution, resulting in superior thermal-insulation effectiveness. In contrast, the MTS-modified LDH via the two-step method exhibited a smaller particle size and narrow particle size distribution, causing a moderate thermal-insulation effect. This study has significant implications for opening up the potential for LDH-based thermal-insulation coatings. We believe the findings can promote the development of new products and help upgrade industries, while contributing to local economic growth.

Quantitative trait locus mapping and improved resistance to sclerotinia stem rot in a backbone parent of rapeseed (Brassica napus L.).

There are three main challenges to improving sclerotinia stem rot (SSR) resistance in rapeseed (Brassica napus L.). First, breeding materials such as the backbone parents have not been extensively investigated, making the findings of previous studies difficult to directly implement. Second, SSR resistance and flowering time (FT) loci are typically linked; thus, use of these loci requires sacrifice of the rapeseed growth period. Third, the SSR resistance loci in susceptible materials are often neglected, thereby reducing the richness of resistant resources. This study was conducted to investigate the stem resistance, disease index, and FT of a doubled haploid population consisting of 151 lines constructed from the backbone parent 19514A and conventional rapeseed cultivar ZY50 within multiple environments. Quantitative trait locus (QTL) mapping revealed 13 stem resistance QTLs, 9 disease index QTLs, and 20 FT QTLs. QTL meta-analysis showed that uqA04, uqC03.1, and uqC03.2 were repeatable SSR resistance QTLs derived from different parents but not affected by the FT. Based on these three QTLs, we proposed a strategy for improving the SSR resistance of 19514A and ZY50. This study improves the understanding of the resistance to rapeseed SSR and genetic basis of FT and demonstrates that SSR resistance QTLs can be mined from parents with a minimal resistance level difference, thereby supporting the application of backbone parents in related research and resistance improvement.

Deep-E Enhanced Photoacoustic Tomography Using Three-Dimensional Reconstruction for High-Quality Vascular Imaging.

Linear-array-based photoacoustic computed tomography (PACT) has been widely used in vascular imaging due to its low cost and high compatibility with current ultrasound systems. However, linear-array transducers have inherent limitations for three-dimensional imaging due to the poor elevation resolution. In this study, we introduced a deep learning-assisted data process algorithm to enhance the image quality in linear-array-based PACT. Compared to our earlier study where training was performed on 2D reconstructed data, here, we utilized 2D and 3D reconstructed data to train the two networks separately. We then fused the image data from both 2D and 3D training to get features from both algorithms. The numerical and in vivo validations indicate that our approach can improve elevation resolution, recover the true size of the object, and enhance deep vessels. Our deep learning-assisted approach can be applied to translational imaging applications that require detailed visualization of vascular features.

An explainable COVID-19 detection system based on human sounds.

Acoustic signals generated by the human body have often been used as biomarkers to diagnose and monitor diseases. As the pathogenesis of COVID-19 indicates impairments in the respiratory system, digital acoustic biomarkers of COVID-19 are under investigation. In this paper, we explore an accurate and explainable COVID-19 diagnosis approach based on human speech, cough, and breath data using the power of machine learning. We first analyze our design space considerations from the data aspect and model aspect. Then, we perform data augmentation, Mel-spectrogram transformation, and develop a deep residual architecture-based model for prediction. Experimental results show that our system outperforms the baseline, with the ROC-AUC result increased by 5.47%. Finally, we perform an interpretation analysis based on the visualization of the activation map to further validate the model.

Associations of parenting daily hassles with parents' mental health during the COVID-19 school closure.

RATIONALE: Parenting is a demanding task associated with parents' mental health, which is likely exacerbated by the COVID-19 pandemic lockdown. The present study investigated daily parenting hassles and their effects on parents' mental health during this period. METHODS: A total of 7314 parents with children aged 3-14 years old completed a sociodemographic questionnaire and reported on their perceived daily parenting hassles, mental health, family support, and co-parenting during the COVID-19 school closure. RESULTS: Most parents (73.4%) showed different degrees of daily hassles, and a relatively higher prevalence of depression (18.7%), anxiety (22.4%), and stress (12.1%) were found. Motherhood, parents' younger ages, lower education parents, job loss, and having younger children, boys, and multiple children were associated with elevated daily parenting hassles and mental health issues. Importantly, daily parenting hassles were uniquely associated with mental health problems after controlling for various sociodemographic characteristics, family support, and co-parenting. Furthermore, family support and co-parenting can attenuate daily parenting hassles, which, in turn, protect parents' mental health. CONCLUSIONS: The findings of the present study underscore the critical need to consider daily parenting hassles and their effects on the mental health of parents during the COVID-19 lockdown. The present study also outlines potential factors (family support and co-parenting) that attenuate parents' daily parenting hassles and protect their mental health during the COVID-19 lockdown.

A fitness training optimization system based on heart rate prediction under different activities.

Heart rate can be considered as an indicator of the exercise intensity in people's daily physical activities. Five heart rate zone theory is commonly adopted by individuals and professional athletes during their exercises and training. These heart rate zones are based upon percentages of people's maximal heart rate, which indicate different exercise intensities. The aim of paper is to propose an optimization training system based on dynamic heart rate prediction, which can predict people's heart rate under three different types of exercises: walking, running and rope jumping. The system can help people optimize their exercise by advising them to adjust the speed or workload to reach their predetermined training intensity under different activities. Four Long Short-Term Memory (LSTM) neural networks are deployed, one for human activity recognition (HAR) and three for heart rate prediction.

Stress prediction using micro-EMA and machine learning during COVID-19 social isolation.

Accurately predicting users' perceived stress is beneficial to aid early intervention and prevent both mental illness and physical disease during the COVID-19 pandemic. However, the existing perceived stress predicting system needs to collect a large amount of previous data for training but has a limited prediction range (i.e., next 1-2 days). Therefore, we propose a perceived stress prediction system based on the history data of micro-EMA for identifying risks 7 days earlier. Specifically, we first select and deliver an optimal set of micro-EMA questions to users every Monday, Wednesday, and Friday for reducing the burden. Then, we extract time-series features from the past micro-EMA responses and apply an Elastic net regularization model to discard redundant features. After that, selected features are fed to an ensemble prediction model for forecasting fine-grained perceived stress in the next 7 days. Experiment results show that our proposed prediction system can achieve around 4.26 (10.65% of the scale) mean absolute error for predicting the next 7 day's PSS scores, and higher than 81% accuracy for predicting the next 7 day's stress labels.

Metal-ion-binding properties of ulvan extracted from Ulva clathrata and structural characterization of its complexes.

The acidic polysaccharide ulvan extracted from the cell wall of the green algae Ulva is a good ligand for metal ions. Therefore, the adsorption properties of the U. clathrata derived ulvan toward Ca(II), Zn(II), Co(II), Cu(II), and Cr(III) were investigated in this study. The results demonstrate that ulvan exhibited good metal ion adsorption capacity at pH 7 and 50 °C. These adsorption processes can largely be explained by the Freundlich isotherm model and the pseudo-second-order kinetic model. The order of the adsorption capacity and affinity is as follows: Cr(III) > Cu(II) > Zn(II) ≈ Co(II) > Ca(II) and Cr(III) > Zn(II) > Co(II) ≈ Cu(II) > Ca(II). Furthermore, structural characterization revealed that the hydroxyl and carboxyl groups were the main functional groups involved in metal ion binding. Unlike the divalent metal ions, Cr(III) can trigger crosslinking of the ulvan chains, and its adsorption capacity was approximately 4.0 mmol/g.

Synthesis and antitumor activity evaluation of oleanolic acid saponins bearing an acetylated l-arabinose moiety.

A series of oleanolic acid derivatives bearing acetyl-substituted l-arabinose moiety has been synthesized and screened in vitro for cytotoxicity against ten cancer cell lines and four normal cell lines. The antiproliferative evaluation indicated that synthetic derivatives showed excellent selectivity, as they were toxic against only A431 cell line. Among them, the compound 6 possesses the best inhibitory activity. A series of pharmacology experiments showed that compound 6 significantly induced A431 cells apoptosis and cell cycle arrest, which could serve as a promising lead candidate for further study.

Low-dose rituximab treatment for new-onset generalized myasthenia gravis.

The aim of this retrospective case series study was to evaluate the response and durability of rituximab in patients with new-onset acetylcholine receptor positive (AChR +) generalized myasthenia gravis (MG). Patients were initiated with low-dose rituximab treatment within 3.5 months of onset without concomitant oral immunosuppressants. Seventeen patients (89%) remained relapse-free with a mean follow-up of 51.3 months. Clinical improvement was observed in parallel with the maintenance of low-dose corticosteroids or the complete discontinuation of corticosteroids. Long-term depletion of B cells with low-dose rituximab treatment has shown favorable efficacy and tolerance in reducing disease activity for AChR+ generalized MG.

Improved Antiglioblastoma Activity and BBB Permeability by Conjugation of Paclitaxel to a Cell-Penetrative MMP-2-Cleavable Peptide.

In order to solve the problems of receptor promiscuity and poor blood-brain barrier (BBB) penetration in the treatment of glioblastomas (GBM), a novel dual-functional nanocomplex drug delivery system is developed based on the strategy of peptide-drug conjugates. In this study, SynB3-PVGLIG-PTX is designed and screened out by matrix metalloproteinase-2 (MMP-2), to which it exhibits the best affinity. The MMP-2-sensitive peptide (PVGLIG) and a cell-penetration peptide (SynB3) are combined to form a dual-functional peptide. Moreover, as a drug-peptide nanocomplex, SynB3-PVGLIG-PTX exhibited a high potential to form an aggregation with good solubility that can release paclitaxel (PTX) through the cleavage of MMP-2. From a functional perspective, it is found that SynB3-PVGLIG-PTX can specifically inhibit the proliferation, migration, and invasion of GBM cells in vitro in the presence of MMP-2, in contrast to that observed in MMP-2 siRNA transfected cells. Further investigation in vivo shows that SynB3-PVGLIG-PTX easily enters the brain of U87MG xenograft nude mice and can generate a better suppressive effect on GBM through a controlled release of PTX from SynB3-PVGLIG-PTX compared with PTX and temozolomide. Thus, it is proposed that SynB3-PVGLIG-PTX can be used as a novel drug-loading delivery system to treat GBM due to its specificity and BBB permeability.

A novel synergistic confinement strategy for controlled synthesis of high-entropy alloy electrocatalysts.

We report a synergistic confinement strategy for the synthesis of high-entropy alloy nanoparticles (HEA-NPs). The carbon nitride substrate and polydopamine coating layer synergistically confine the growth of NPs and contribute to the formation of homogeneous HEA-NPs. The HEA-NPs exhibit superior electrocatalytic performance for oxygen reduction and evolution reactions. This work demonstrates the great potential of HEA-NPs for electrocatalysis.

Boosting oxygen evolution through phase and electronic modulation of highly dispersed tungsten carbide with nickel doping.

Exploring efficient, stable, and earth-abundant electrocatalysts for oxygen evolution reaction (OER) is of great significance for clean and renewable energy conversion technologies. In this work, in situ uniform Ni-doped tungsten carbide (Ni/WCX) nanoparticles (~3 nm) on carbon nanofibers (Ni/WCX-CNFs) that were to function as efficient OER catalysts were developed. Both the composition and electronic state of tungsten carbide (WCX: W-WC-W2C) could be regulated through varied Ni coupling. Owing to the synergistic effect between Ni and WCX, the reaction kinetics were facilitated, resulting in improved OER activity with low overpotentials of η10 = 350 mV (modified glassy carbon electrode) and η10 = 335 mV (self-supporting electrode). This work opens a facile territory for the development of cost-effective and highly promising OER electrocatalysts for use in real life applications.

Cortical Thinning and Ventricle Enlargement in Neuromyelitis Optica Spectrum Disorders.

Background: In neuromyelitis optica spectrum disorders (NMOSDs), inflammation is not the sole driver of accumulation of disability; neurodegeneration is another important pathological process. We aim to explore different patterns of cortical atrophy and ventricular enlargement in NMOSD. Methods: We retrospectively analyzed a cohort of 230 subjects, comprising 55 healthy controls (HCs), 85 multiple sclerosis (MS), and 90 NMOSD patients from Tianjin Medical University General Hospital and Beijing Tiantan Hospital. Different compartments of the brain (total gray, cortex, subcortex gray, and ventricle volume) were evaluated with the FreeSurfer. Multiple linear regressions were adopted to explore associations between cortex volume and predict factors. Results: Compared with HCs, NMOSD, and MS displayed an enlarged lateral and third ventricle (p < 0.001), whereas expansion of the fourth ventricle was observed in MS rather than NMOSD (p = 0.321). MS and NMOSD patients exhibited cortical thinning in comparison with HCs. However, pronounced cortical atrophy were only significant in pre-cuneus, parahippocampal, and lateral occipital lobe between MS and NMOSD. Patients with NMOSD had decreased local gyrification index in orbitofrontal and pre-cuneus lobe, and reduced pial surface area. Linear regression analysis revealed cortex volume were predicated by advanced age (standardized ß = -0.404, p = 0.001) as well as prolonged disease history (standardized ß = -0.311, p = 0.006). Conclusion: NMOSD exhibited global cortex atrophy with enlarged lateral and third ventricles. Moreover, cortex volume is associated with age and disease duration.