Genome-wide profiling of the expression of serum derived exosomal circRNAs in patients with hepatic alveolar echinococcosis.

The patients with hepatic alveolar echinococcosis is poorly detected due to invasive and slow growth. Thus, early diagnosis of hepatic alveolar echinococcosis is so important for patients. Circular RNAs are crucial types of the non-coding RNA. Recent studies have provided serum-derived exosomal circRNAs as potential biomarkers for detection of various diseases. The clinical importance of exosomal circRNAs in hepatic alveolar echinococcosis have never been explored before. Here, we investigated the serum-derived exosomal circRNAs in the diagnosis of hepatic alveolar echinococcosis. Firstly, High-throughput Sequencing was performed using 9 hepatic alveolar echinococcosis and 9 control samples to detect hepatic alveolar echinococcosis related circRNAs. Afterwards, bioinformatic analyzes were performed to identify differentially expressed circRNAs and pathway analyzes were performed. Finally, validation of the determined circRNAs was performed using RT-PCR. The sequencing data indicated that 59 differentially expressed circRNAs; 31 up-regulated and 28 down-regulated circRNA in hepatic alveolar echinococcosis patients. The top 5 up-regulated and down-regulated circRNAs were selected for validation by RT-qPCR assay. As a result of the verification, circRNAs that were significantly up- and down-regulated showed an expression profile consistent with the results obtained. Importantly, our findings suggested that identified exosomal circRNAs could be a potential biomarker for the detection of hepatic alveolar echinococcosis serum and may help to understand the pathogenesis of hepatic alveolar echinococcosis.

Serology for the diagnosis of human hepatic cystic echinococcosis and its relation with cyst staging: A systematic review of the literature with meta-analysis.

BACKGROUND: The diagnosis of cystic echinococcosis (CE) is primarily based on imaging, while serology should be applied when imaging is inconclusive. CE cyst stage has been reported among the most important factors influencing the outcome of serodiagnosis. We performed a systematic review and meta-analysis of the relation between cyst stage of hepatic CE and diagnostic sensitivity of serological tests, to evaluate whether their relation is a consistent finding and provide guidance for the interpretation of results of serological tests. METHODOLOGY/PRINCIPAL FINDINGS: MEDLINE, EMBASE, CENTRAL, and Lilacs databases were searched on December 1st 2019. Original studies published after 2003 (year of publication of the CE cyst classification), reporting sensitivity of serological tests applied to the diagnosis of human hepatic CE, as diagnosed and staged by imaging, were included. The quality of studies was assessed using the Newcastle-Ottawa Scale. Data from 14 studies were included in the meta-analysis. Summary estimates of sensitivities and 95% confidence intervals were obtained using random effects meta-analysis. Overall, test sensitivity was highest in the presence of CE2 and CE3 (CE3a and/or CE3b), and lowest in the presence of CE5 and CE4 cysts. ELISA, ICT and WB showed the highest sensitivities, while IHA performed worst. CONCLUSIONS/SIGNIFICANCE: The results of our study confirm the presence of a clear and consistent relation between cyst stage and serological tests results. Limitations of evidence included the heterogeneity of the antigenic preparations used, which prevented to determine whether the relation between cyst stage and sensitivity was influenced by the type of antigenic preparation, the paucity of studies testing the same panel of sera with different assays, and the lack of studies assessing the performance of the same assay in both field and hospital-based settings. Our results indicate the absolute need to consider cyst staging when evaluating serological results of patients with hepatic CE.

Diagnostic Performances of Commercial ELISA, Indirect Hemagglutination, and Western Blot in Differentiation of Hepatic Echinococcal and Non-Echinococcal Lesions: A Retrospective Analysis of Data from a Single Referral Centre.

The diagnosis of cystic echinococcosis (CE) is based on imaging. Serology supports imaging in suspected cases, but no consensus exists on the algorithm to apply when imaging is inconclusive. We performed a retrospective analysis of serology results of patients with untreated hepatic CE and non-CE lesions, seen from 2005 to 2017, to evaluate their accuracy in the differential diagnosis of hepatic CE. Serology results of three seroassays for echinococcosis (ELISA RIDASCREEN, indirect hemagglutination (IHA) Cellognost, and Western blot LDBIO) and clinical characteristics of eligible patients were retrieved. Patients were grouped as having active or inactive CE and liquid or solid non-CE lesions. Sensitivity, specificity, and diagnostic accuracy were compared between scenarios encompassing different test combinations. Eligible patients included 104 patients with CE and 257 with non-CE lesions. Sensitivity and diagnostic accuracy of Western blot (WB) were significantly higher than those of the following: 1) IHA or ELISA alone, 2) IHA+ELISA interpreted as positive if both or either tests positive, and 3) IHA+ELISA confirmed by WB if discordant. The best performances were obtained when WB was applied on discordant or concordant negative IHA+ELISA. Analyses performed within "active CE (n = 52) versus liquid non-CE (n = 245)" and "inactive CE (n = 52) versus solid non-CE (n = 12)" groups showed similar results. Specificity was high for all tests (0.99-1.00) and did not differ between test combination scenarios. WB may be the best test to apply in a one-test approach. Two first-level tests confirmed by WB seem to provide the best diagnostic accuracy. Further studies should be performed in different settings, especially where lower test specificity is likely.

Deciphering the metabolic perturbation in hepatic alveolar echinococcosis: a 1H NMR-based metabolomics study.

BACKGROUND: Hepatic alveolar echinococcosis (HAE) is caused by the growth of Echinococcus multilocularis larvae in the liver. It is a chronic and potentially lethal parasitic disease. Early stage diagnosis for this disease is currently not available due to its long asymptomatic incubation period. In this study, a proton nuclear magnetic resonance (1H NMR)-based metabolomics approach was applied in conjunction with multivariate statistical analysis to investigate the altered metabolic profiles in blood serum and urine samples obtained from HAE patients. The aim of the study was to identify the metabolic signatures associated with HAE. RESULTS: A total of 21 distinct metabolic differences between HAE patients and healthy individuals were identified, and they are associated with perturbations in amino acid metabolism, energy metabolism, glyoxylate and dicarboxylate metabolism. Furthermore, the present results showed that the Fischer ratio, which is the molar ratio of branched-chain amino acids to aromatic amino acids, was significantly lower (P < 0.001) in the blood serum obtained from the HAE patients than it was in the healthy patient group. CONCLUSIONS: The altered Fischer ratio, together with perturbations in metabolic pathways identified in the present study, may provide new insights into the mechanistic understanding of HAE pathogenesis and potential therapeutic interventions.

[Value of magnetic resonance imaging in assessment of iron deposition among patients with hepatic alveolar echinococcosis: a preliminary evaluation].

OBJECTIVE: To assess the value of MRI combined with serum ferritin analysis in measurement of hepatic iron deposition among patients with hepatic alveolar echinococcosis. METHODS: A total of 96 patients with definitive diagnosis of hepatic alveolar echinococcosis and 30 healthy volunteers were enrolled and underwent routine 1.5T MR scanning, and all laboratory examination data were captured. The liver-to-muscle signal intensity ratio, serum ferritin level and liver functions were analyzed. RESULTS: The liver-to-muscle signal intensity ratio was (1.95 ± 0.57) in patients with hepatic alveolar echinococcosis and (2.22 ± 0.28) in healthy volunteers (t = 2.022, P < 0.05), and the liver-to-muscle signal intensity ratio was negatively associated the serum ferritin level in patients with hepatic alveolar echinococcosis (rs = -0.446, P < 0.01). CONCLUSIONS: Abnormal iron deposition is detected in the liver of patients with hepatic alveolar echinococcosis, and serum ferritin level may be helpful for the identification of abnormal iron deposition in the liver of patients with hepatic alveolar echinococcosis. The liver-to-muscle signal intensity ratio measured by MRI may be a non-invasive approached used to assess the hepatic iron deposition in patients with hepatic alveolar echinococcosis.

Investigation of the Applicability of a Rapid Diagnosis Test in the Diagnosis of Cystic Echinococcosis

OBJECTIVE: Echinococcus granulosus, the etiological agent of cystic echinococcosis (CE) in humans and livestock, is a widely distributed zoonotic pathogen tapeworm. The infection is transmitted to humans by the ingestion of E. granulosus eggs released in the feces of definitive hosts such as dogs. The larval stage of the parasite develops a slowly enlarging cyst in the visceral organs, particularly in the liver and/or lung. The aim of the present study was to evaluate the diagnostic value of an immunochromatographic test (ICT) for CE. METHODS: A total of 50 sera from surgically and/or pathologically confirmed patients with CE were included in the study as the study group; the control group comprised patients who tested negative for enzyme-linked immunosorbent assay (ELISA). Sera were selected from the collection at Adnan Menderes University, Faculty of Medicine, Parasitology Laboratory, by simple random sampling. The collection included sera obtained between 2010 and 2014; antibody titers of each serum sample were determined using in-house ELISA, before storage at -20°C. The presence of E. granulosus antibody in the sera was determined using a commercially available ICT (VIRAPID® HYDATIDOSIS) kit method. RESULTS: In the study group (E. granulosus-confirmed cases), two (4%) of the 50 sera were negative and 48 (96%) were positive with ICT. In the control group (ELISA-negative), all were negative with ICT. CONCLUSION: The rapid diagnostic test has been evaluated as a practical, easy-to-use method for detecting CE, and it can be used as a screening test in routine diagnosis and research.

Plasma IL-23 and IL-5 as surrogate markers of lesion metabolic activity in patients with hepatic alveolar echinococcosis.

Fluorodeoxyglucose (FDG) uptake by alveolar echinococcosis (AE) liver lesions is a signal of their metabolic activity and of disease progression. In order to find a surrogate marker for this status, we investigated whether parameters of the peripheral and/or periparasitic immune responses were associated with metabolic activity in a prospective case-control study of 30 AE patients and 22 healthy controls. Levels of 18 cytokines and chemokines, representative of innate and adaptive immune responses, were assessed in plasma and peripheral cells of two groups of patients with (MAAE) and without (MIAE) metabolically active lesions, and in the liver of MAAE patients. Mixed cytokine profile was observed in the peripheral blood of AE patients, with a predominance of Th2, Th17 and Treg responses. Among the detected markers only plasma IL-5 and IL-23, more elevated in MAAE patients, were found discriminant. Discrimination between MAAE and MIAE patients obtained by using IL-23 was improved when IL-5 was used in combination. The combination of elevated levels of IL-5 and IL-23 is significantly associated with FDG uptake at PET scan. It offers a new tool for the follow-up of AE patients which could substitute to FDG-PET whenever non-available to assess disease progression.

Risk factors and a simple model for predicting bile leakage after radical hepatectomy in patients with hepatic alveolar echinococcosis.

Postoperative bile leakage (BL) is a major complication of hepatic alveolar echinococcosis (HAE). The purpose of this study was to identify the risk factors for BL and to establish a simple scoring system for predicting BL.A total of 152 patients with HAE were included in the study between May 2004 and December 2016. The patient's baseline data, laboratory blood tests, imaging features, and surgical management were collected. Univariate and multivariate analyses were used to screen for factors to predict BL. The cutoff values for those factors and predictive value of a model were determined by receiver operative characteristic curve (ROC) analysis.BL was detected in 22 of the 152 patients. Univariate analyses showed significant differences in the lesion diameter, levels of lactate dehydrogenase (LDH), alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase and direct bilirubin (DBIL), inferior vena cava invasion, surface area of hepatectomy, blood loss and history of percutaneous transhepatic cholangial drainage between patients with and without BL. On multivariate analyses, DBIL > 7.1 µmol/L, LDH > 194 U/L, lesion diameter > 12 cm and a larger surface area of hepatectomy were independent predictors of BL. The resulting area under the ROC of the scoring model was 0.724 (95% CI, 0.646-0.793).The lesion diameter, DBIL, larger surface area of hepatectomy, and elevated LDH were the important factors affecting the occurrence of BL after surgery. The risk score model will help the clinician to assess BL before surgery. More studies are needed to confirm the scoring model and risk factors.

Efficacy and safety of ultrasound-guided percutaneous microwave ablation for the treatment of hepatic alveolar echinococcosis: A preliminary study.

The present study aims to assess the efficacy and safety of ultrasound-guided percutaneous microwave ablation (MWA) for hepatic alveolar echinococcosis (HAE) preliminarily.Seventeen patients diagnosed to HAE and treated with MWA (80 watts, 4 min) were retrospectively analyzed. The upper abdominal computed tomography (CT) was performed at 1, 6, 12 months after the MWA treatment. The complications were evaluated to assess the safety.The diameters of the lesions in the HAE patients ranged from 1.9 to 4.7 cm. The patients included 10 males and 7 females, aged 26 to 70 (45.82 ±â€Š13.36) years, 5 patients infecting with chronic hepatitis viral B and 8 patients with positive hydatid antibody (IgG). The lesions observed in the postoperative CT (1, 6, 12 months) were calcified compared with those observed in the preoperative CT and without relapse. No serious treatment-related complications occurred after treatment.MWA is a novel and effective therapeutic method for HAE with a single lesion (diameter≤=5 cm). Further studies based on prospective random control trials to confirm our findings are necessary.

Preoperative albumin level is a marker of alveolar echinococcosis recurrence after hepatectomy.

AIM: To identify a preoperative blood marker predictive of alveolar echinococcosis (AE) recurrence after hepatectomy. METHODS: All consecutive patients who underwent operation for liver AE at the Lausanne University Hospital (CHUV) between January 1992 and December 2015 were included in this retrospective study. Preoperative laboratory values of leukocytes, mean corpuscular volume (MCV), red blood cell distribution width (RDW), thrombocytes, C-reactive protein (CRP) and albumin were collected and analyzed. Univariate and multivariate Cox regression analyses were performed to determine the risk factors for AE recurrence after liver resection. A receiver operating characteristic (ROC) curve was used to define the best discrimination threshold of the blood marker. Moreover, recurrence-free survival curves were calculated using the Kaplan-Meier method. RESULTS: The cohort included 68 adult patients (37 females) with median age of 61 years [interquartile range (IQR): 46-71]. Eight of the patients (12%) presented a recurrence over a median follow-up time of 76 mo (IQR: 34-128). Median time to recurrence was 10 mo (IQR: 6-11). Median preoperative leukocyte, MCV, RDW, thrombocyte and CRP levels were similar between recurrent and non-recurrent cases. Median preoperative albumin level was 43 g/L (IQR: 41-45) for non-recurrent cases and 36 g/L (IQR: 33-42) for recurrent cases (P = 0.005). The area under the ROC curve for preoperative albumin level to predict recurrence was 0.840 (95%CI: 0.642-1, P = 0.002). The cut-off albumin level value was 37.5 g/L for sensitivity of 94.5% and specificity of 75%. In multivariate analysis, preoperative albumin and surgical resection margins were independent predictors of AE recurrence (HR = 0.099, P = 0.007 and HR = 0.182, P = 0.045 respectively). CONCLUSION: Low preoperative albumin level was associated with AE recurrence in the present cohort. Thus, preoperative albumin may be a useful biomarker to guide follow-up.

Cystobiliary communication in hepatic hydatid cyst: predictors and outcome.

BACKGROUND/AIMS: Cystobiliary communication (CBF) with hepatic hydatid disease is responsible for postoperative bile leakage after surgical management. This study aims to detect various predictors of CBF and its outcome after surgical management. MATERIALS AND METHODS: This is a retrospective, cohort study of all patients who underwent surgical management for hydatid disease of the liver. Patient data were recorded on an internal web-based registry system supplemented by paper records. Patients were classified into two groups according to the presence of CBF: group (A) patients with CBF and group (B) patients without CBF. RESULTS: There were 123 patients with a hepatic hydatid cyst with a mean age of 39.92±14.59 years. Patients were classified into group (A), 26 patients (21.1%) with CBF, and group (B), 97 patients (78.9%) without CBF. The age group (p=0.04), presence of jaundice (p=0.001), serum glutamic-pyruvic transaminase (SGPT) (p=0.001), cyst size (p=0.0001), and cyst size group (>10 cm) (p=0.0001) were associated with CBF. That cyst size was the only independent predictor of the occurrence of CBF. Intraoperative suturing and the T tube led to complete healing of CBF, and postoperative endoscopic retrograde cholangio-pancreatography (ERCP) and tubal drainage led to a rapid reduction in the bile output and the healing of the fistulas after 9±2.6 days. CONCLUSION: That cyst size was the only independent predictor for the occurrence of CBF. Management is related to the size of the fistula, the site of the cyst, and the experience of the hepatobiliary surgeon. ERCP is an important option for the management of CBF.

Serological validation of an alveolar echinococcosis rat model with a single hepatic lesion.

Serology is important for the diagnosis and follow-up of human alveolar echinococcosis (AE). However, patient conditions are highly variable among those with AE, and antibody responses in serological follow-up have not been well-defined. We recently described a new AE rat model established by implantation of small AE tissue into a single arbitrary location in the liver; no metastasis and dissemination were observed. In the present study, we examined the serological characteristics in our rat model before and after surgical treatment. The results showed that antibody responses against crude antigens were increased at one month after transplantation and similar to those of other model animals. For the antigen Em18, antibody responses were slower in our rat model than in other animal models. After surgical resection, changes in antibody responses against Em18 were similar to those observed in human patients with AE. Because of the slow growth of lesions, establishment of a single hepatic lesion and patterns of antibody responses, our rat model may be useful for clarifying follow-up serodiagnoses in human AE and determining the mechanisms of multi-organ involvement by primary infection with oncospheres rather than metastasis.

Synthesis and Antigenicity against Human Sera of a Biotin-Labeled Oligosaccharide Portion of a Glycosphingolipid from the Parasite Echinococcus multilocularis.

Synthesis of a biotinylated analog of the carbohydrate portion of a glycosphingolipid from the parasite Echinococcus multilocularis has been achieved. We synthesized ß-D-Galp-(1→6)-ß-D-Galp-(1→6)-[α-L-Fucp-(1→3)]-ß-D-Galp-(1→R: biotin probe) (1) and compared the antigenicity by an enzyme linked immunosorbent assay (ELISA) with biotinylated trisaccharide α-D-Galp-(1→4)-ß-D-Galp-(1→3)-α-D-Galp-(1→R: biotin probe) (F), which has been shown to have significant antigenicity. Both of the oligosaccharides reacted with sera of alveolar echinococcosis (AE) patients, but showed different reactivity. Among the 60 sera of AE patients, more sera reacted with the linear sequence Galα1→4Galß1→3GalNAcα1→R of oligosaccharide (F) than for branched compound 1. Some sera showed high specificity to one of the compound, indicating that the antibodies in the sera of AE patients differ in their specificity to recognize carbohydrate sequences of glycosphingolipids. Our results demonstrate that both of the biotinylated oligosaccharides 1 and F have good serodiagnostic potential and are complementary to detect infections caused by the parasite Echinococcus multilocularis.

Comparison of the Diagnostic Accuracy of Three Rapid Tests for the Serodiagnosis of Hepatic Cystic Echinococcosis in Humans.

BACKGROUND: The diagnosis of cystic echinococcosis (CE) is based primarily on imaging, in particular with ultrasound for abdominal CE, complemented by serology when imaging results are unclear. In rural endemic areas, where expertise in ultrasound may be scant and conventional serology techniques are unavailable due to lack of laboratory equipment, Rapid Diagnostic Tests (RDTs) are appealing. METHODOLOGY/PRINCIPAL FINDINGS: We evaluated the diagnostic accuracy of 3 commercial RDTs for the diagnosis of hepatic CE. Sera from 59 patients with single hepatic CE cysts in well-defined ultrasound stages (gold standard) and 25 patients with non-parasitic cysts were analyzed by RDTs VIRapid HYDATIDOSIS (Vircell, Spain), Echinococcus DIGFA (Unibiotest, China), ADAMU-CE (ICST, Japan), and by RIDASCREEN Echinococcus IgG ELISA (R-Biopharm, Germany). Sensitivity, specificity and ROC curves were compared with McNemar and t-test. For VIRapid and DIGFA, correlation between semiquantitative results and ELISA OD values were evaluated by Spearman's coefficient. Reproducibility was assessed on 16 randomly selected sera with Cohen's Kappa coefficient. Sensitivity and Specificity of VIRapid (74%, 96%) and ADAMU-CE (57%, 100%) did not differ from ELISA (69%, 96%) while DIGFA (72%, 72%) did (p = 0.045). ADAMU-CE was significantly less sensitive in the diagnosis of active cysts (p = 0.019) while DIGFA was significantly less specific (p = 0.014) compared to ELISA. All tests were poorly sensitive in diagnosing inactive cysts (33.3% ELISA and ADAMU-CE, 42.8% DIGFA, 47.6% VIRapid). The reproducibility of all RDTs was good-very good. Band intensity of VIRapid and DIGFA correlated with ELISA OD values (r = 0.76 and r = 0.79 respectively, p<0.001). CONCLUSIONS/SIGNIFICANCE: RDTs may be useful in resource-poor settings to complement ultrasound diagnosis of CE in uncertain cases. VIRapid test appears to perform best among the examined kits, but all tests are poorly sensitive in the presence of inactive cysts, which may pose problems with accurate diagnosis.

Factors Influencing the Serological Response in Hepatic Echinococcus granulosus Infection.

Knowledge of variables influencing serology is crucial to evaluate serology results for the diagnosis and clinical management of cystic echinococcosis (CE). We analyzed retrospectively a cohort of patients with hepatic CE followed in our clinic in 2000-2012 to evaluate the influence of several variables on the results of commercial enzyme-linked immunosorbent assay (ELISA) and indirect hemagglutination (IHA) tests. Sera from 171 patients with ≥ 1 hepatic CE cyst, and 90 patients with nonparasitic cysts were analyzed. CE cysts were staged according to the WHO-IWGE classification and grouped by activity. A significant difference in ELISA optical density (OD) values and percentage of positivity was found among CE activity groups and with controls (P < 0.001). The serological response was also influenced by age (P < 0.001) and cyst number (P = 0.003). OD values and cyst size were positively correlated in active cysts (P = 0.001). IHA test showed comparable results. When we analyzed the results of 151 patients followed over time, we found that serology results were significantly influenced by cyst activity, size, number, and treatment ≤ 12 months before serum collection. In conclusion, serological responses as assessed by commercial tests depend on CE cyst activity, size and number, and time from treatment. Clinical studies and clinicians in their practice should take this into account.

Clinical and serological outcomes with different surgical approaches for human hepatic hydatidosis.

INTRODUCTION: Hydatidosis is the result of infection with the larval stages of some species of the genus Echinococcus. Treatment approaches for hydatid cysts include the use of albendazole, surgery, and/or medico-surgical procedures. The choice of the therapeutic surgical approach depends on the cyst number and localization, surgeon expertise, and presence of complications. The present study aimed to compare the outcomes of the following therapeutic approaches for the treatment of hepatic hydatid cysts: pericystectomy; the puncture, aspiration, injection, and reaspiration (PAIR) technique; and the PAIR technique followed by deroofing, evacuation of cysts, and omentoplasty. METHODS: The 54 patients were divided into 3 groups: Group I (14 patients) who underwent pericystectomy, Group II (23 patients) who underwent the PAIR technique, and Group III (17 patients) who underwent the PAIR technique followed by deroofing and omentoplasty. The diagnosis of hydatid cysts was based on serological testing using enzyme-linked immunosorbent assay, abdominal ultrasound, and parasitological examination of the cyst contents. Morbidity, mortality, length of hospital stay, recurrence, and postoperative complications were evaluated. RESULTS: Postoperative bleeding, infection, and recurrence were reported in Groups I and II; Group III did not experience postoperative infection and had shorter hospital stays. Recurrence and postoperative complications did not occur in Group III. CONCLUSIONS: The partial surgical procedure with deroofing, evacuation of the cysts, and omentoplasty, as performed in the present study, is recommended as a safe and effective method for elimination of the entire parasite with minimal possibility for intra-peritoneal spillage.

Analysis on Serum Trace Element Levels of Echinococciasis Patients in Garze Tibetan Autonomous Prefecture in Sichuan, China, 2011.

In Garze Tibetan autonomous prefecture in Sichuan province, China, 41 echinococciasis patients who had received surgical treatment were recruited in the study, and 82 health persons who had lived in Garze for at least 10 years were selected as controls. The serum levels of Zn, Se and Cu of the cases and controls were detected. The results showed that most echinococciasis cases were distributed in Shiqu county (17.1%, 7/41), and only 1 case was distributed in Yajiang county (2.4%). The male to female ratio of the cases was 1:1.56. The echinococciasis patients were mainly aged 30-39 years (36.59%, 15/41). And, the cases aged 20-49 years accounted for 68.29% (28/41). Compared with health controls, the serum levels of Zn and Se of the cases significantly declined. However, the serum level of Cu of the cases had no significantly change. It was confirmed that the serum levels of Zn and Se were interrelated with the prevalence of echinococciasis.