Lipid metabolism in crocodilians: A field with promising applications in the field of ecotoxicology.

In the last years, lipid physiology has become an important research target for systems biology applied to the field of ecotoxicology. Lipids are not only essential components of biological membranes, but also participate in extra and intracellular signaling processes and as signal transducers and amplifiers of regulatory cascades. Particularly in sauropsids, lipids are the main source of energy for reproduction, growth, and embryonic development. In nature, organisms are exposed to different stressors, such as parasites, diseases and environmental contaminants, which interact with lipid signaling and metabolic pathways, disrupting lipid homeostasis. The system biology approach applied to ecotoxicological studies is crucial to evaluate metabolic regulation under environmental stress produced by xenobiotics. In this review, we cover information of molecular mechanisms that contribute to lipid metabolism homeostasis in sauropsids, specifically in crocodilian species. We focus on the role of lipid metabolism as a powerful source of energy and its importance during oocyte maturation, which has been increasingly recognized in many species, but information is still scarce in crocodiles. Finally, we highlight priorities for future research on the influence of environmental stressors on lipid metabolism, their potential effect on the reproductive system and thus on the offspring, and their implications on crocodilians conservation.

Protocol for assessing mortality reduction with the early use of noninvasive ventilation in prehospital emergency services: A multicentre, observational cohort study in Madrid, Spain.

BACKGROUND: Acute respiratory failure (ARF) has become one of the most prevalent serious pathologies encountered in the emergency medical service (EMS). In hospital settings, noninvasive ventilation (NIV) therapy prevents complications from more aggressive treatments for that condition. However, the scarce evidence on the benefits of NIV in prehospital EMS (i.e., during transport to the hospital) is inconclusive. OBJECTIVES: To determine whether the administration of NIV during prehospital EMS in cases of ARF reduces in-hospital mortality compared with starting NIV on arrival to in-patient EMS. METHODS: This is a multicentre, observational, prospective cohort study. We recruited a total of 317 patients from the Madrid region (Spain) who were prescribed NIV for their ARF using a nonprobabilistic consecutive sampling method. Analyses of the main outcome (in-hospital mortality) and secondary outcomes (length of hospital stay, readmissions, percentage of intensive care unit admissions, and cost-effectiveness) will include descriptive analyses of patients' characteristics, as well as bivariate and multivariate analyses and cost-effectiveness analysis. DISCUSSION: This study will provide data on NIV management in prehospital and in-patient EMS in patients with ARF. Results will contribute to the existing evidence on the benefits of NIV in the context of prehospital EMS while underlining the importance of a standardized formal training for physicians and nurses working in prehospital and in-patient EMSs. CONCLUSION: The VentilaMadrid study will provide valuable data on the clinical factors of patients receiving NIV in prehospital EMS. Further, were our hypothesis to be confirmed, our results would strongly suggest that the administration of NIV in prehospital EMS by medical and nursing profesionals formally trained in the technique reduces mortality and improves prognoses.

Chitosan-triclosan particles modulate inflammatory signaling in gingival fibroblasts.

BACKGROUND AND OBJECTIVES: An important goal of periodontal therapy is the modulation of the inflammatory response. To this end, several pharmacological agents have been evaluated. Triclosan corresponds to an antibacterial and anti-inflammatory agent currently used in periodontal therapy. Chitosan is a natural polymer that may act as a drug delivery agent and exerts antibacterial and anti-inflammatory activities. Therefore, an association between both molecules might be useful to prevent inflammation and tissue destruction in periodontal tissues. MATERIAL AND METHODS: In the present study, we have generated chitosan-triclosan particles and evaluated their morphology, charge, biocompatibility and gene expression analysis in human gingival fibroblasts. RESULTS: The chitosan-triclosan particles size and Z potential were 129 ± 47 nm and 51 ± 17 mV respectively. Human gingival fibroblast viability was not affected by chitosan-triclosan. A total of 1533 genes were upregulated by interleukin (IL)-1ß. On the other hand, 943 were downregulated in fibroblasts stimulated with IL-1ß plus chitosan-triclosan particles. Fifty-one genes were identified as molecular targets upregulated by IL-1 ß and downregulated by the chitosan-triclosan particles. The gene ontology analysis revealed that these genes were enriched in categories related to biological processes, molecular function and cellular components. Furthermore, using real-time reverse transcription-polymerase chain reaction beta-actin, fibronectin, interleukin-6 and IL-1b genes were confirmed as targets upregulated by IL-1ß and downregulated by chitosan-triclosan particles. CONCLUSION: Our results show that chitosan-triclosan particles are able to modulate the inflammatory response in gingival fibroblasts. This effect might be useful in the prevention and/or treatment of inflammation in periodontal diseases.

Six-Year Follow-up of Slaughterhouse Surveillance (2008-2013): The Catalan Slaughterhouse Support Network (SESC).

Meat inspection has the ultimate objective of declaring the meat and offal obtained from carcasses of slaughtered animals fit or unfit for human consumption. This safeguards the health of consumers by ensuring that the food coming from these establishments poses no risk to public health. Concomitantly, it contributes to animal disease surveillance. The Catalan Public Health Protection Agency (Generalitat de Catalunya) identified the need to provide its meat inspectors with a support structure to improve diagnostic capacity: the Slaughterhouse Support Network (SESC). The main goal of the SESC was to offer continuing education to meat inspectors to improve the diagnostic capacity for lesions observed in slaughterhouses. With this aim, a web-based application was designed that allowed meat inspectors to submit their inquiries, images of the lesions, and samples for laboratory analysis. This commentary reviews the cases from the first 6 years of SESC operation (2008-2013). The program not only provides continuing education to inspectors but also contributes to the collection of useful information on animal health and welfare. Therefore, SESC complements animal disease surveillance programs, such as those for tuberculosis, bovine cysticercosis, and porcine trichinellosis, and is a powerful tool for early detection of emerging animal diseases and zoonoses.

Tuning the Magnetic Anisotropy at a Molecule-Metal Interface.

We demonstrate that a C(60) overlayer enhances the perpendicular magnetic anisotropy of a Co thin film, inducing an inverse spin reorientation transition from in plane to out of plane. The driving force is the (60)/Co interfacial magnetic anisotropy that we have measured quantitatively in situ as a function of the (60) coverage. Comparison with state-of-the-art ab initio calculations show that this interfacial anisotropy mainly arises from the local hybridization between (60) p(z) and Co d(z(2)) orbitals. By generalizing these arguments, we also demonstrate that the hybridization of (60) with a Fe(110) surface decreases the perpendicular magnetic anisotropy. These results open the way to tailor the interfacial magnetic anisotropy in organic-material-ferromagnet systems.

"Ethnic disparities in the prevalence of Molar-Incisor-Hypomineralisation (MIH) and caries among 6-12-year-old children in Catalonia, Spain".

AIM: To study the prevalence of MIH and caries in 6- and 12-year-old schoolchildren and their association with ethnic disparities and other relevant factors. BACKGROUND: In recent years, there has been uneven improvement in school children's oral health, highlighting inequalities in access to dental care and health outcomes, particularly among ethnic minorities. The most prevalent oral disease in childhood, caries, is preventable, as its risk factors are well known. However, MIH, a common condition affecting the enamel of permanent incisors and/or molars, has no established aetiology or preventive measures. METHODS: A cross-sectional study among schoolchildren was conducted in 725 children from Masnou (Barcelona, 2013) and in 577 children from Sant Andreu de Llavaneres (Barcelona, 2018-2020). Data collection was carried out by means of clinical examination and a selfreferenced questionnaire. Oral health outcomes included: presence of dental caries, presence of MIH, hypomineralised second primary molars (HSPM). All variables were analysed according to ethnic disparities and other variables such as socioeconomics, diet, hygiene habits, plaque and access to dental services. We performed multivariate Poisson regression models with robust variance to examine ethnic disparities in MIH and caries. CONCLUSION: This cross-sectional study based in Catalonia, Spain showed that there are ethnic disparities in caries as observed with other child's diseases; however, they do not seem to follow the same pattern for MIH. More studies are needed (i) to explore how MIH behaves among populations in terms of inequality; (ii) to study the aetiological factors of MIH; and (iii) to identify potential factors associated with MIH and caries that have not been studied and that may contribute to the observed ethnic disparities.

Blood mRNA biomarkers for detection of treatment response in acute pulmonary exacerbations of cystic fibrosis.

BACKGROUND: Acute pulmonary exacerbations accelerate pulmonary decline in cystic fibrosis (CF). There is a critical need for better predictors of treatment response. OBJECTIVE: To test whether expression of a panel of leucocyte genes directly measured from whole blood predicts reductions in sputum bacterial density. METHODS: A previously validated 10-gene peripheral blood mononuclear cell (PBMC) signature was prospectively tested in PBMC and whole blood leucocyte RNA isolated from adult subjects with CF at the beginning and end of treatment for an acute pulmonary exacerbation. Gene expression was simultaneously quantified from PBMCs and whole blood RNA using real-time PCR amplification. Test characteristics including sensitivity, specificity, positive and negative predictive values were calculated and receiver operating characteristic curves determined the best cut-off to diagnose a microbiological response. The findings were then validated in a smaller independent sample. RESULTS: Whole blood transcript measurements are more accurate than forced expiratory volume in 1 s (FEV(1)) or C reactive protein (CRP) alone in identifying reduction of airway infection. When added to FEV(1), the whole blood gene panel improved diagnostic accuracy from 64% to 82%. The specificity of the test to detect reduced infection was 88% and the positive predictive value for the presence of persistent infection was 86%. The area under the curve for detecting treatment response was 0.81. Six genes were the most significant predictors for identifying reduction in airway bacterial load beyond FEV(1) or CRP alone. The high specificity of the test was replicated in the validation cohort. CONCLUSIONS: The addition of blood leucocyte gene expression to FEV(1) and CRP enhances specificity in predicting reduced pulmonary infection and may bolster the assessment of CF treatment outcomes.

Long-range ordered nanodomains of grafted electroactive molecules.

We demonstrate the capability to build zero and one-dimensional electroactive molecular nanostructures ordered over a macroscopic scale and stable under ambient conditions. To realize these arrays, we use the selective grafting of functionalized thiols (juglon and terthiophene based) on a self-organized metallic template. The nanoscale patterning of the molecular conductance is demonstrated and analyzed by scanning tunneling spectroscopy. Finally, the influence of the nanostructuring on electro-chemical properties is measured, paving the way to an all-bottom-up fabrication of nanostructured templates for nanosciences.

Large magnetoresistance through a single molecule due to a spin-split hybridized orbital.

Using organic materials in spintronic devices raises a lot of expectation for future applications due to their flexibility, low cost, long spin lifetime, and easy functionalization. However, the interfacial hybridization and spin polarization between the organic layer and the ferromagnetic electrodes still has to be understood at the molecular scale. Coupling state-of-the-art spin-polarized scanning tunneling spectroscopy and spin-resolved ab initio calculations, we give the first experimental evidence of the spin splitting of a molecular orbital on a single non magnetic C(60) molecule in contact with a magnetic material, namely, the Cr(001) surface. This hybridized molecular state is responsible for an inversion of sign of the tunneling magnetoresistance depending on energy. This result opens the way to spin filtering through molecular orbitals.

Directed growth of mixed self-assembled monolayers on a nanostructured template: a step toward the patterning of functional molecular domains.

We report on the elaboration of networks of SAM domains. More precisely, we show the feasibility in making arrays of functionalized alkylthiol nanodomains bordered with an alkylthiol matrix. The several step process relies on the replication of a self-organized cobalt array grown on Au(111). The SAM process takes place in solution. The chemical affinity of thiol for gold leads to the selective grafting of molecules on the surface. After having removed the inorganic array, alkylthiol functionalized with a terthiophene unit is grafted in free gold areas. The efficiency of the replication of the initial template depends on the stability of the first SAM. We also investigate electronic tunnel transport through oligothiophene islands with the STM. The variation of the molecular contrast with bias voltage between the two molecular species indicates a potential resonant tunneling mechanism through the orbitals of the aromatic compound.

Many-body effects in electronic bandgaps of carbon nanotubes measured by scanning tunnelling spectroscopy.

Single-walled carbon nanotubes provide an ideal system for studying the properties of one-dimensional (1D) materials, where strong electron-electron interactions are expected. Optical measurements have recently reported the existence of excitons in semiconducting nanotubes, revealing the importance of many-body effects. Surprisingly, pioneering electronic structure calculations and scanning tunnelling spectroscopy (STS) experiments report the same gap values as optical experiments. Here, an experimental STS study of the bandgap of single-walled semiconducting nanotubes, demonstrates a continuous transition from the gap reduced by the screening resulting from the metal substrate to the intrinsic gap dominated by many-body interactions. These results provide a deeper knowledge of many-body interactions in these 1D systems and a better understanding of their electronic properties, which is a prerequisite for any application of nanotubes in the ultimate device miniaturization for molecular electronics, or spintronics.

Spin-polarized scanning tunneling microscopy and spectroscopy study of chromium on a Cr(001) surface.

Several tens of chromium layers were deposited at 250 °C on a Cr(001) surface and investigated by spin-polarized scanning tunneling microscopy (SP-STM), Auger electron spectroscopy (AES) and scanning tunneling spectroscopy (STS). Chromium is found to grow with a mound-like morphology resulting from the stacking of several monolayers which do not uniformly cover the whole surface of the substrate. The terminal plane consists of an irregular array of Cr islands with lateral sizes smaller than 20 × 20 nm(2). Combined AES and STS measurements reveal the presence of a significant amount of segregants prior to and after deposition. A detailed investigation of the surface shows that it consists of two types of patches. Thanks to STS measurements, the two types of area have been identified as being either chromium pure or segregant rich. SP-STM experiments have evidenced that the antiferromagnetic layer coupling remains in the chromium mounds after deposition and is not significantly affected by the presence of the segregants.

Prioritization criteria of patients on scheduled waiting lists for abdominal wall hernia surgery: a cross-sectional study.

PURPOSE: Long delays in waiting lists have a negative impact on the principles of equity and providing timely access to care. This study aimed to assess waiting lists for abdominal wall hernia repair (incisional ventral vs. inguinal hernia) to define explicit prioritization criteria. METHODS: A cross-sectional single-center study was designed. Patients in the waiting list for incisional/ventral hernia (n = 42) and inguinal hernia (n = 50) repair were interviewed by phone and completed health-related quality of life (HRQoL) questionnaires (EQ-5D, COMI-hernia, HerQLes) as a measure of severity. Priority was measured as hernia complexity, patient frailty using the modified frailty index (mFI-11), and the consumption of analgesics for hernia. RESULTS: The mean (SD) time on the waiting list was 5.5 (3.2) months (range 1-14). Complex hernia was present in 34.8% of the patients. HRQoL was moderately poor in patients with incisional/ventral hernia (mean HerQL score 66.1), whereas it was moderately good in patients with inguinal hernia (mean COMI-hernia score 3.40). The use of analgesics was higher in patients with incisional/ventral hernia as compared with those with inguinal hernia (1.48 [0.54] vs. 1.31 [0.51], P = 0.021). Worst values of mFI were associated with inguinal hernia as compared with incisional/ventral hernia (0.21 [0.14] vs. 0.12 [0.11]; P = 0.010). CONCLUSION: Explicit criteria for prioritization in the waiting lists may be the consumption of analgesics for patients with incisional/ventral hernia and frailty for patients with inguinal hernia. A reasonable approach seems to establish separate waiting lists for incisional/ventral hernia and inguinal hernia repair.

Ordered surface alloy of bulk-immiscible components stabilized by magnetism.

Using scanning tunneling microscopy and a diffraction experiment, we have discovered a new ordered surface alloy made out of two bulk-immiscible components, Fe and Au, deposited on a Ru(0001) substrate. In such a system, substrate-mediated strain interactions are believed to provide the main driving force for mixing. However, spin-polarized ab initio calculations show that the most stable structures are always the ones with the highest magnetic moment per Fe atom and not the ones minimizing the surface stress, in remarkable agreement with the observations. This opens up novel possibilities for creating materials with unique properties of relevance to device applications.

Spin-wave-assisted thermal reversal of epitaxial perpendicular magnetic nanodots.

The magnetic susceptibility of self-organized two-dimensional Co nanodots on Au(111) has been measured as a function of their size in the 2-7 nm diameter range. We show that the activation energy for the thermal reversal displays a power law behavior with the dot volume. Atomic scale simulations based on the Heisenberg Hamiltonian show that this behavior is due to a deviation from the macrospin model for dot size as small as 3 nm in diameter. This discrepancy is attributed to finite temperature effects through the thermal excitation of spin-wave modes inside the particles.

Capnometry levels as an indicator of renal graft evolution in uncontrolled non-heart beating donors. / Niveles de capnometría como indicador de evolución de injerto renal de donantes en asistolia no controlada.

OBJECTIVE: The capnometry values during resuscitation are an evolutive predictor of kidneys obtained from uncontrolled non-heart beating donors. DESIGN: The study comprised a retrospective onset cohort of 37 non-heart beating donors and a validation cohort of 55 trasplanted kidneys in the period 2013-2017. SCOPE: The population served by the emergency service and referred to Hospital Universitario Doce de Octubre (Madrid, Spain) as potential uncontrolled non-heart beating donors. PATIENTS: A total of 55 renal transplant patients subjected to hemodialysis and with grafts from uncontrolled non-heart beating donors. INTERVENTIONS: Capnometry and capnography measurements in potential uncontrolled non-heart beating donors. VARIABLES: Capnometry values recorded initially and at transfer in hospital for comparison with the viability of the extracted kidneys; renal failure and delayed renal function. RESULTS: A total of 55 out of 74 extracted kidneys were trasplanted (74.3%). The rest were ruled out due to poor perfusion or signs of ischemia. An association was observed (P=.016) between the capnometry values during resuscitation in the grafted kidneys (µ=22.8 mmHg) and in the kidneys discarded for transplantation (µ=17.35 mmHg). CONCLUSIONS: Capnometry during resuscitation serves as a marker to be taken into account in relation to the viability of the trasplanted organs in uncontrolled non-heart beating donors.

Diagnostic yield of magnetic resonance imaging and intraoperative frozen section in the determination of deep myometrial invasion in endometrial cancer. / Rédito diagnóstico de la resonancia magnética y el estudio por congelación intraoperatorio en la determinación de la invasión miometrial profunda en cáncer de endometrio.

BACKGROUND AND OBJECTIVES: The standard treatment for endometrial cancer is simple hysterectomy with bilateral salpingo-oophorectomy. Patients with high risk also benefit from lumbo-aortic lymphadenectomy. High risk patients include those with grades and histologic subtypes associated with poor prognosis and depth of myometrial invasion greater than 50% (M2). To determine which patients would benefit from lumbo-aortic lymphadenectomy, the depth of myometrial invasion can be assessed by intraoperative frozen section or by magnetic resonance imaging (MRI). We aimed to determine the diagnostic yield of intraoperative frozen section and MRI for detecting the presence of M2 in patients with endometrial cancer. MATERIALS AND METHODS: This cross-sectional study included women with a histologically confirmed diagnosis of endometrial cancer who underwent baseline MRI and surgical intervention in our institution between 1 January 2010 and 31 December 2017. We reviewed the MRI studies and the intraoperative frozen section reports and compared them with the information in the histopathology report. We compared the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the two tests. We also calculated the diagnostic accuracy of each method and the percentages of underestimation and overestimation. Finally, we calculated the predictive value of MRI for the presence of M2, adjusting it for the histologic variables known to be associated with poor prognosis. RESULTS: To detect M2, MRI had 63% sensitivity, 87% specificity, 73% PPV, and 81% NPV; the diagnostic accuracy was 78.8%, with 13.12% underestimation and 8.13% overestimation of M2. Intraoperative frozen section had 69% sensitivity, 86.7% specificity, 69% PPV, and 86% NPV; the diagnostic accuracy was 81.5%, with 9.24% underestimation and 9.24% overestimation of M2. The degree of concordance between the two methods was moderate (k=0.54, p < 0.00001). CONCLUSIONS: In our experience, MRI and intraoperative frozen section have adequate diagnostic yields for determining M2, though intraoperative frozen section is slightly better. The contribution of MRI in determining the presence and the site of deep myometrial invasion, as well as the factors that can confound the diagnosis, when added to the contribution of intraoperative frozen section, means that both methods help reduce the number of unnecessary lymph node dissections and the morbidity, mortality, and health costs associated with this practice.

Distribution of angiotensin-(1-7) and ACE2 in human placentas of normal and pathological pregnancies.

This work was designed to study the expression of the vasodilator peptide angiotensin-(1-7) [Ang-(1-7)] and its generating enzyme (ACE2) in the uteroplacental interface. Placentas were obtained from 11 early pregnancy failures (5 miscarriages and 6 ectopic pregnancies), 15 normotensive, and 10 preeclamptic gestations. In placental villi, the main sites of immunocytochemical expression of Ang-(1-7) and ACE2 were the syncytiotrophoblast, cytotrophoblast, endothelium and vascular smooth muscle of primary and secondary villi. Syncitial Ang-(1-7) expression in samples obtained from miscarriages and ectopic pregnancies was increased compared to normal term pregnancy [2.0 (2.0-2.25 for the 25 and 75% interquartile range) vs 1.3 (1.0-1.9), p<0.01]. In the maternal stroma, Ang-(1-7) and ACE2 were expressed in the invading and intravascular trophoblast and in decidual cells in all 3 groups. Ang-(1-7) and ACE2 staining was also found in arterial and venous endothelium and smooth muscle of the umbilical cord. The expression of Ang-(1-7) and ACE2 was similar in samples obtained from normal term or preeclamptic pregnancies, except for increased expression of ACE2 in umbilical arterial endothelium in preeclampsia [0.5 (0.5-0.8) vs 0.0 (0.0-0.0), p<0.01]. The uteroplacental location of Ang-(1-7) and ACE2 in pregnancy suggests an autocrine function of Ang-(1-7) in the vasoactive regulation that characterizes placentation and established pregnancy.

Glucose >200 mg/dL during Continuous Glucose Monitoring Identifies Adult Patients at Risk for Development of Cystic Fibrosis Related Diabetes.

Rationale. Cystic fibrosis related diabetes (CFRD) is the most common comorbidity in patients with CF. In spite of increased screening, diagnosis, and treatment of CFRD, the mortality rate in patients with CFRD still far exceeds the mortality rate in those without CFRD. Guidelines suggest that screening for CFRD be performed annually using the 2-hour 75-gram oral glucose tolerance test (OGTT). Adherence to recommended screening has been poor, with only approximately one-quarter of adults with CF undergoing OGTT in 2014. Use of continuous glucose monitoring (CGM) for diagnosis may become an alternative. Objectives. Our objective was to determine whether abnormal CGM predicts subsequent development of CFRD, lung function, and body mass index (BMI) decline and increased rate of CF pulmonary exacerbations in adults with CF. Methods. In a prospective single center pilot trial from September 2009 to September 2010, 21 adult patients due for routine OGTT were recruited to complete simultaneous 3-day CGM and 2-hour 75 gram OGTT. Subsequently, clinical information was reviewed from 2008 to 2015. Conclusions. There was a moderate correlation between interpreted results of 2-hour OGTT and CGM (p = 0.03); CGM indicated a greater level of glucose impairment than OGTT. Glucose >200 mg/dL by CGM predicted development of CFRD (p = 0.0002).

[Nocardia farcinica lung infection in a patient with cystic fibrosis and a lung transplant]. / Infección pulmonar por Nocardia farcinica en un paciente con fibrosis quística y trasplante pulmonar.

Patients with cystic fibrosis have a higher risk of developing chronic respiratory infectious diseases. The Nocardia farcinica lung infection is rare in this group of patients, and there are limited publications about this topic. Its diagnosis is complex, due to the clinical and the radiology signs being non-specific. Identification of the agent responsible in the sputum culture is occasionally negative. It is a slow growing organism and for this reason treatment is delayed, which can lead to an increase in complications, hospitable stays, and mortality. A case is reported on a 26 year-old woman with cystic fibrosis and chronic lung colonization by Nocardia farcinica and Aspergillus fumigatus, on long-term treatment with ciprofloxacin, trimethoprim-sulfamethoxazole, and posaconazole, who was admitted to ICU after bilateral lung transplantation. The initial post-operative progress was satisfactory. After discharge, the patient showed a gradual respiratory insufficiency with new chest X-ray showing diffuse infiltrates. Initially, the agent was not seen in the sputum culture. Prompt and aggressive measures were taken, due to the high clinical suspicion of a Nocardia farcinica lung infection. Treatment with a combination of amikacin and meropenem, and later combined with linezolid, led to the disappearance of the lung infiltrates and a clinical improvement. In our case, we confirm the rapid introduction of Nocardia farcinica in the new lungs. The complex identification and the delay in treatment increased the morbimortality. There is a special need for its eradication in patients with lung transplant, due to the strong immunosuppressive treatment.