Discovery of sulfonamide resistance genes in deep groundwater below Patna, India.

Global usage of pharmaceuticals has led to the proliferation of bacteria that are resistant to antimicrobial treatments, creating a substantial public health challenge. Here, we investigate the emergence of sulfonamide resistance genes in groundwater and surface water in Patna, a rapidly developing city in Bihar, India. We report the first quantification of three sulfonamide resistance genes (sulI, sulII and sulIII) in groundwater (12-107 m in depth) in India. The mean relative abundance of gene copies was found to be sulI (2.4 × 10-2 copies/16S rRNA gene) > sulII (5.4 × 10-3 copies/16S rRNA gene) > sulIII (2.4 × 10-3 copies/16S rRNA gene) in groundwater (n = 15) and surface water (n = 3). A comparison between antimicrobial resistance (AMR) genes and wastewater indicators, particularly tryptophan:fulvic-like fluorescence, suggests that wastewater was associated with AMR gene prevalence. Urban drainage channels, containing hospital and domestic wastes, are likely a substantial source of antimicrobial resistance in groundwater and surface water, including the Ganges (Ganga) River. This study is a reference point for decision-makers in the fight against antimicrobial resistance because it quantifies and determines potential sources of AMR genes in Indian groundwater.

Surface-derived groundwater contamination in Gulu District, Uganda: Chemical and microbial tracers.

Groundwater is consumed by over 2 billion people globally, though it can be impacted by microbial and chemical contamination in both rural and (peri-)urban areas. This issue is particularly pertinent in regions like East Africa, where rapid urbanisation has strained local infrastructure, including water and sanitation systems. We use selected tracers of human and animal waste to assess the quality of community drinking sources with regards to surface-derived groundwater inputs and to compare urban versus rural water quality, under the rapidly developing urban area of Gulu, Northern Uganda. Specifically, we examine bulk and fluorescent dissolved organic matter (DOM), microorganisms (total coliforms, E. coli) and inorganic tracers of anthropogenic waste (NO3-, SO42-, Cl/Br) from various sources: boreholes (12-76 m depth; n = 90), protected springs (n = 11) and municipal taps (n = 4). Our results show that NO3- and SO42- were elevated in groundwater sources in the Gulu city urban area and the Cl/Br ratio was elevated in springs, compared to concentrations in the more rural Aswa and Omoro County area (p < 0.05). Interestingly, human and animal waste indicators E. coli and Tryp:FA (the ratio of tryptophan-like to fulvic-like fluorescence) displayed no significant difference between rural and urban settings (p > 0.05), though total coliforms were significantly higher in rural boreholes (p < 0.05). The presence of a pollution source, pollution carrier and a breakdown of a sanitary barrier at the borehole, as spot-checked by a visual sanitary risk assessment, was significantly associated with groundwater E. coli abundances. Evidence suggests monitoring and mitigation should be improved for all water types in Gulu District to meet WHO and Uganda Standard guidelines for potable water. This study offers valuable insights for water management planning and risk assessment of community water sources particularly in the context of East Africa and similar settings.

Spatial and seasonal controls on dissolved organic matter composition in shallow aquifers under the rapidly developing city of Patna, India.

The distribution and composition of dissolved organic matter (DOM) affects numerous (bio)geochemical processes in environmental matrices including groundwater. This study reports the spatial and seasonal controls on the distribution of groundwater DOM under the rapidly developing city of Patna, Bihar (India). Major DOM constituents were determined from river and groundwater samples taken in both pre- and post-monsoon seasons in 2019, using excitation-emission matrix (EEM) fluorescence spectroscopy. We compared aqueous fluorescent DOM (fDOM) composition to satellite-derived land use data across the field area, testing the hypothesis that the composition of groundwater DOM, and particularly the components associated with surface-derived ingress, may be controlled, in part, by land use. In the pre-monsoon season, the prominence of tryptophan-like components likely generated from recent biological activity overwhelmed the humic-like and tyrosine-like fluorescence signals. Evidence from fluorescence data suggest groundwater in the post-monsoon season is composed of predominantly i) plant-derived matter and ii) anthropogenically influenced DOM (e.g. tryptophan-like components). Organic tracers, as well as Eh and Cl-, suggest monsoonal events mobilise surface-derived material from the unsaturated zone, causing dissolved organic carbon (DOC) of more microbial nature to infiltrate to >100 m depth. A correlation between higher protein:humic-like fluorescence and lower vegetation index (NDVI), determined from satellite-based land use data, in the post-monsoon season, indicates the ingression of wastewater-derived OM in groundwater under the urban area. Attenuated protein:humic-like fluorescence in groundwater close to the river points towards the mixing of groundwater and river water. This ingress of surface-derived OM is plausibly exacerbated by intensive groundwater pumping under these areas. Our approach to link the composition of aqueous organics with land use could easily be adapted for similar hydrogeochemical settings to determine the factors controlling groundwater DOM composition in various contexts.

Emerging organic contaminants in the River Ganga and key tributaries in the middle Gangetic Plain, India: Characterization, distribution & controls.

The presence and distribution of emerging organic contaminants (EOCs) in freshwater environments is a key issue in India and globally, particularly due to ecotoxicological and potential antimicrobial resistance concerns. Here we have investigated the composition and spatial distribution of EOCs in surface water along a ∼500 km segment of the iconic River Ganges (Ganga) and key tributaries in the middle Gangetic Plain of Northern India. Using a broad screening approach, in 11 surface water samples, we identified 51 EOCs, comprising of pharmaceuticals, agrochemicals, lifestyle and industrial chemicals. Whilst the majority of EOCs detected were a mixture of pharmaceuticals and agrochemicals, lifestyle chemicals (and particularly sucralose) occurred at the highest concentrations. Ten of the EOCs detected are priority compounds (e.g. sulfamethoxazole, diuron, atrazine, chlorpyrifos, perfluorooctane sulfonate (PFOS), perfluorobutane sulfonate, thiamethoxam, imidacloprid, clothianidin and diclofenac). In almost 50% of water samples, sulfamethoxazole concentrations exceeded predicted no-effect concentrations (PNECs) for ecological toxicity. A significant downstream reduction in EOCs was observed along the River Ganga between Varanasi (Uttar Pradesh) and Begusarai (Bihar), likely reflecting dilution effects associated with three major tributaries, all with considerably lower EOC concentrations than the main Ganga channel. Sorption and/or redox controls were observed for some compounds (e.g. clopidol), as well as a relatively high degree of mixing of EOCs within the river. We discuss the environmental relevance of the persistence of several parent compounds (notably atrazine, carbamazepine, metribuzin and fipronil) and associated transformation products. Associations between EOCs and other hydrochemical parameters including excitation emission matrix (EEM) fluorescence indicated positive, significant, and compound-specific correlations between EOCs and tryptophan-, fulvic- and humic-like fluorescence. This study expands the baseline characterization of EOCs in Indian surface water and contributes to an improved understanding of the potential sources and controls on EOC distribution in the River Ganga and other large river systems.

The complete plastome of Hyacinthoides non-scripta (L.) Chouard ex Rothm. (Asparagaceae).

The whole plastome sequence of Hyacinthoides non-scripta, was assembled and annotated in this study. This is the first complete plastid genome for the genus Hyacinthoides. The plastome is 155,035 bp long and consists of a large single-copy (LSC) region spanning 83,947 bp, a small single-copy (SSC) region spanning 18,496 bp, and two inverted repeat (IR) regions, each of which is 26,296 bp in length. There are 132 genes annotated in the plastome, of which the protein-coding gene infA has pseudogenized.

Targeting the progression of Parkinson's disease.

By the time a patient first presents with symptoms of Parkinson's disease at the clinic, a significant proportion (50-70%) of the cells in the substantia nigra (SN) has already been destroyed. This degeneration progresses until, within a few years, most of the cells have died. Except for rare cases of familial PD, the initial trigger for cell loss is unknown. However, we do have some clues as to why the damage, once initiated, progresses unabated. It would represent a major advance in therapy to arrest cell loss at the stage when the patient first presents at the clinic. Current therapies for Parkinson's disease focus on relieving the motor symptoms of the disease, these unfortunately lose their effectiveness as the neurodegeneration and symptoms progress. Many experimental approaches are currently being investigated attempting to alter the progression of the disease. These range from replacement of the lost neurons to neuroprotective therapies; each of these will be briefly discussed in this review. The main thrust of this review is to explore the interactions between dopamine, alpha synuclein and redox-active metals. There is abundant evidence suggesting that destruction of SN cells occurs as a result of a self-propagating series of reactions involving dopamine, alpha synuclein and redox-active metals. A potent reducing agent, the neurotransmitter dopamine has a central role in this scheme, acting through redox metallo-chemistry to catalyze the formation of toxic oligomers of alpha-synuclein and neurotoxic metabolites including 6-hydroxydopamine. It has been hypothesized that these feed the cycle of neurodegeneration by generating further oxidative stress. The goal of dissecting and understanding the observed pathological changes is to identify therapeutic targets to mitigate the progression of this debilitating disease.

[Sentinel lymph node biopsy for lymphophilic conjunctival and eyelid tumors: report of 8 cases]. / Biopsie du ganglion sentinelle dans les tumeurs lymphophiles conjonctivales et palpébrales: à propos de 8 cas.

OBJECTIVE: To report our experience in sentinel lymph node biopsy for lymphophilic conjunctival and eyelid tumours. METHODS AND RESULTS: Preliminary study (2005-2007) on 8 patients with conjunctival and or eyelid tumours (melanomas, epidermoid carcinoma, Merkel cell carcinoma). All patients underwent preoperative lymphoscintigraphy 18 FdG pet CT Surgery was performed with complete neck dissection. Sentinel nodes and other nodes harvested were processed separately for histopathologic study; the sentinel were confirmed as histologicaly positive for five patients. Additional positive nodes were found in two out of those five patients. No positive lymph node was found in patients with negative lymphoscintigraphy. After a follow up ranging from 12 to 43 months: two patients died, and 6 are free of disease. CONCLUSIONS: These results demonstrate a very hight level of invaded NO lymph node and confirm the interest of sentinel node technique for optimisation of the therapeutic strategy in lymphophilic conjunctival and eyelid tumours.

Mid-term rhinosinusal consequences of bony orbital decompression in Graves' disease: a retrospective study.

OBJECTIVES: The aim of this work was to detect and study mid-term rhinosinusal complications arising after bony orbital decompression via the inferior palpebral approach in patients with Graves' ophthalmopathy. MATERIALS AND METHODS: This retrospective study considered 48 patients treated for proptosis from 1999 to 2001 who underwent bony orbital decompression via the inferior palpebral approach. Nineteen (19) of these patients agreed to participate further by consenting to follow-up examinations performed specifically for the purpose of this study, which consisted of ophthalmologic (visual acuity, proptosis) and ENT (nasal dysfunction, rhinoscopy) examinations. RESULTS: Mean mid-term postoperative follow-up of the 19 patients was 43.5 months (+/-12 months). Predominant rhinosinusal signs (rhinorrhea, altered sense of smell, nasal obstruction) were observed in 20% of this group (4 patients) without any unfavorable effect on daily life. Fiber-optic rhinoscopy disclosed mucosal secretions and edema in 5% (one patient). CONCLUSION: Mid-term complications of bony orbital decompression via an inferomedial approach are relatively rare. Late postoperative sinusitis has not been reported. Signs of minor nasal dysfunction may occur but would have little impact on quality of life.

[Surgical treatment of benign intracranial hypertension: optic nerve sheath fenestration]. / Traitement chirurgical de l'hypertension intracrânienne bénigne: fenestration des gaines du nerf optique.

Optic nerve sheath fenestration (ONSF) is rarely used in France. The aim of surgery is to release pressure around the optic nerve. Although debated, ONSF can be used in selected cases of benign intracranial hypertension. The authors describe the approach of the anterior part of the optic nerve and the technique itself. The indications, results and potential complications of this technique are developed in this paper.

[Surgery of lacrimal secretion]. / Chirurgie de la sécrétion lacrymale.

Surgical treatment of lacrimal secretion consists in reducing the product of tears in the lacrimal gland. Denervation of the lacrimal gland was described long ago by Whitwell and remains in current use. Recently, injection of botulinum toxin into the lacrimal gland was successfully carried out. In our department, we have been developing lacrimal duct orifice cauterization for several years. We discuss these three methods and develop the latter in greater detail.

GSK-3ß dysregulation contributes to parkinson's-like pathophysiology with associated region-specific phosphorylation and accumulation of tau and α-synuclein.

Aberrant posttranslational modifications (PTMs) of proteins, namely phosphorylation, induce abnormalities in the biological properties of recipient proteins, underlying neurological diseases including Parkinson's disease (PD). Genome-wide studies link genes encoding α-synuclein (α-Syn) and Tau as two of the most important in the genesis of PD. Although several kinases are known to phosphorylate α-Syn and Tau, we focused our analysis on GSK-3ß because of its accepted role in phosphorylating Tau and to increasing evidence supporting a strong biophysical relationship between α-Syn and Tau in PD. Therefore, we investigated transgenic mice, which express a point mutant (S9A) of human GSK-3ß. GSK-3ß-S9A is capable of activation through endogenous natural signaling events, yet is unable to become inactivated through phosphorylation at serine-9. We used behavioral, biochemical, and in vitro analysis to assess the contributions of GSK-3ß to both α-Syn and Tau phosphorylation. Behavioral studies revealed progressive age-dependent impairment of motor function, accompanied by loss of tyrosine hydroxylase-positive (TH+ DA-neurons) neurons and dopamine production in the oldest age group. Magnetic resonance imaging revealed deterioration of the substantia nigra in aged mice, a characteristic feature of PD patients. At the molecular level, kinase-active p-GSK-3ß-Y216 was seen at all ages throughout the brain, yet elevated levels of p-α-Syn-S129 and p-Tau (S396/404) were found to increase with age exclusively in TH+ DA-neurons of the midbrain. p-GSK-3ß-Y216 colocalized with p-Tau and p-α-Syn-S129. In vitro kinase assays showed that recombinant human GSK-3ß directly phosphorylated α-Syn at a single site, Ser129, in addition to its known ability to phosphorylate Tau. Moreover, α-Syn and Tau together cooperated with one another to increase the magnitude or rate of phosphorylation of the other by GSK-3ß. Together, these data establish a novel upstream role for GSK-3ß as one of several kinases associated with PTMs of key proteins known to be causal in PD.

Place of radiotherapy in the treatment of Graves' orbitopathy.

PURPOSE: The aim of this study is to evaluate the response of Graves' orbitopathy to irradiation, and to specify the prognostic factors allowing one to better define the indications of orbital radiotherapy. METHODS AND MATERIALS: From 1977 to 1996, 199 patients received bilateral orbital irradiation delivering 20 Gy in 10 fractions and 2 weeks for a progressive Graves' orbitopathy. 195 patients were seen between 1 and 6 months after radiotherapy. The different symptoms were studied and their response to radiation was analyzed. Factors such as age, sex, evolution of thyroid disease, history of symptoms, and previous or combined treatments were analyzed. RESULTS: The results revealed that 50 patients (26%) had a good or excellent response, 98 (50%) had a partial response, 37 (19%) were stable, 10 (5%) had a progression of disease. The signs that best responded to radiotherapy were the infiltration of soft tissues and the corneal involvement. Responses of proptosis or oculomotor disorders were more complete when these signs were not advanced at the time of treatment. Irradiation seemed to have the same efficacy when applied as first-line treatment or after failure of corticosteroids. Neither modality of treatment of hyperthyroidism nor thyroid status at the time of orbital irradiation modified the results. The best results were recorded for early or moderately advanced presentation (p = 0.05). Patients treated within a delay of 7 months after the beginning of the ophthalmopathy had better responses than patients treated later (p = 0.10). CONCLUSION: Radiation therapy was successful in Graves' orbitopathy by stopping the progression of disease in almost all cases, by improving the comfort of patients, by obtaining objective responses, and by avoiding surgical treatments particularly when signs were moderate.

Severity of diabetic retinopathy is linked to lipoprotein (a) in type 1 diabetic patients.

To determine the relationship between plasma Lp(a) concentration and the risk of developing diabetic retinopathy, 341 Type 1 diabetic patients underwent an annual retinal fluorescein angiography and were assigned to one of 3 groups according to the stage of their diabetic retinopathy: no retinopathy (NR), non-proliferative diabetic retinopathy (N-PDR), or proliferative diabetic retinopathy (PDR). One hundred and twenty-three Type 1 diabetic patients had no retinopathy, 188 had N-PDR and 30 had PDR. The ages of the three groups and the duration of diabetes were significantly different. Hypertension, microalbuminuria and diabetic nephropathy were more frequent in PDR than in NR or N-PDR (p < 0.0001). Plasma HbA1c was higher in PDR than in NR or N-PDR (p < 0.01). Type 1 patients who had been diabetic for at least 20 years included 30 NR, 108 N-PDR and 24 PDR. Type 1 diabetic patients with PDR had microalbuminuria and macroproteinuria more frequently than other patients (p < 0.0001 and 0.01, respectively). Type 1 diabetic patients with PDR had the highest median plasma Lp(a) and the highest frequency of Lp(a) above 30 mg/dl (p < 0.05). Multivariate analysis carried out in Type 1 diabetic patients with a duration of diabetes of at least 20 years showed that microproteinuria, HbA1c and Lp(a) accounted significantly for 21% of variance in retinal status. Lp(a) above 30 mg/dl was related to the risk of developing PDR (OR = 8.40, p < 0.05). Lipoprotein(a) appears to be associated with the severity of diabetic retinopathy in Type 1 diabetic patients, and particular attention should be paid to those with Lp(a) above 30 mg/dl and pre-proliferative retinopathy.

Angle-fixated anterior chamber phakic intraocular lens for myopia of -7 to -19 diopters.

PURPOSE: To assess the safety and efficacy of a second generation, anterior chamber phakic intraocular lens (Baikoff Model ZB5M) in patients with high myopia. METHODS: One hundred and twenty-one patients (134 eyes) with myopia of -7.00 to -18.80 D were implanted with the ZB5M lens and followed for 18 to 52 months; the number of eyes evaluated was: 6 months (104 eyes), 1 year (91 eyes), 18 months (78 eyes), 2 years (68 eyes), and 3 years (35 eyes). RESULTS: Postoperative spherical equivalent refraction averaged -1.00 D and the error in refractive correction (achieved minus intended) averaged -0.40 D during the first 2 years, increasing -to -1.30 D refraction and -0.60 D error in refractive correction at 3 years. At 2 years, approximately 40% of eyes had a spherical equivalent refraction within +/-0.50 D, and 65% within +/-1.00 D. The uncorrected distance visual acuity was 0.048 at baseline and 0.5 at 3 years; near visual acuity was 0.21 at baseline and approximately 0.7 over the 3 years of follow-up. Spectacle-corrected distance visual acuity at baseline was 0.54; it improved to 0.7. Near visual acuity was 0.65 at baseline and it improved to approximately 0.75. Endothelial cell counts in the central and peripheral cornea were reduced by an average 3.3% at 6 months, declining an additional 1% to 2% over the remaining follow-up period. Regression analyses indicated that most of the endothelial cell loss was due to surgery. Additional complications included halos/glare in 37 of 133 eyes (27.8%) and iris retraction with pupillary ovalization in 30 of 133 eyes (22.6%). The intraocular lens was exchanged in four of 133 eyes (3.0%) and removed in three of 133 eyes (2.3%), the latter because of halos (one eye) and a flat anterior chamber with severe inflammation (two eyes). CONCLUSIONS: Implantation of the Baikoff ZB5M lens in the anterior chamber of phakic eyes significantly reduced high myopia and produced a stable refractive outcome over the 3 years, accompanied by marked improvement in uncorrected distance visual acuity and minimal, non-progressive damage to the corneal endothelium. Frequent complications included pupillary ovalization and halos/glare. Improvements in accuracy of IOL power calculations are needed.

Clinical and scintigraphic comparison of silicone and polyvinylpyrrolidone coated silicone perforated plugs.

BACKGROUND/AIM: Isolated stenosis of the lacrimal punctum is a frequent cause of epiphora. Treatment relies on surgical opening or dilatation with bi- or monocanalicular prosthesis. Recently, silicone perforated punctum plugs (PPP) were proposed. The drawback with these silicone PPP was that secretions accumulate in the central orifice blocking the spontaneous flow of tears. A modification of the surface of the PPP using polyvinylpyrrolidone (PVP) was thus proposed. The aim was to compare silicone PPP with new PVP surface treated PPP. METHODS: A prospective study was conducted of 20 patients with dilatable stenosis of the lacrimal puncta who developed epiphora. Epiphora, tolerance, implantation of the PPP, and lacrimal drainage were evaluated using scintigraphy of the lacrimal ducts. RESULTS: The raw data and statistical analysis showed evidence of a superior performance of PVP surface treated PPP. CONCLUSION: Long term evaluation of the advantages or risks of PVP plugs and comparison with microsurgical punctoplasty are warranted.

Identification of carriers of Streptococcus equi in a naturally infected herd.

During an outbreak of strangles in a population of research horses, 4 mares were identified as carriers of Streptococcus equi. Three of the mares had typical signs of strangles (severe regional lymphadenitis with or without rupture of abscessed lymph nodes). The 4th mare experienced episodes of serous to mucopurulent nasal discharge, but never had more than a mild degree of lymph node enlargement. Streptococcus equi was isolated from the abscessed lymph nodes and from nasopharyngeal swab specimens from the first 3 mares from 6 to 19 weeks after rupture of involved nodes. Streptococcus equi was isolated from the nasopharynx of the 4th mare on introduction into the herd and intermittently over the ensuing 6 months. During the 7th month, mare 4 was placed in isolation, where she continued to shed S equi for 4 more months. A complete physical examination during the 10th month, including radiography of the head and thorax, did not reveal any relevant abnormalities, but a pharyngeal swab specimen was culture-positive for S equi. This isolate was used to inoculate 2 yearling colts, which developed strangles and from which S equi was reisolated. Shedding of S equi by mare 4 ceased in the 11th month, and at necropsy 2 months later, S equi was not recovered from any organ or tissue. Corticosteroid administration 3 weeks prior to necropsy had induced neither shedding of the organism nor clinical signs of strangles. The study provided clinical, epidemiologic, and bacteriologic evidence to support the existence of a carrier state following natural infection with S equi.

Comparative performance of short-term diffusion barrier charcoal canisters and long-term alpha-track monitors for indoor 222Rn measurements.

The accuracy and precision of indoor 222Rn measurements obtained with the use of diffusion barrier charcoal canisters (DBCC) under actual field conditions were determined by comparing the integrated average of 26 successive 7-d exposures of DBCC in each of 16 occupied residences over a 6-mo period with simultaneous measurements using four types of commercially available alpha-track monitors (ATM) and one type of scintillation chamber continuous 222Rn monitor. The results suggest that properly calibrated DBCCs provide very good estimates of the integrated 222Rn concentrations in residential structures over the standard 1-wk exposure period despite the occurrence of large diurnal variations in the actual 222Rn concentrations. The results also suggest that a relatively small number of 1-wk DBCC measurements at selected times throughout the calendar year would provide estimates of the annual average indoor 222Rn concentrations that compare favorably with single long-term ATM measurements.

Year-to-year variations in annual average indoor 222Rn concentrations.

Annual average indoor 222Rn concentrations in 40 residences in and around Grand Junction, CO, have been measured repeatedly since 1984 using commercial alpha-track monitors (ATM) deployed for successive 12-mo time periods. Data obtained provide a quantitative measure of the year-to-year variations in the annual average Rn concentrations in these structures over this 6-y period. A mean coefficient of variation of 25% was observed for the year-to-year variability of the measurements at 25 sampling stations for which complete data were available. Individual coefficients of variation at the various stations ranged from a low of 7.7% to a high of 51%. The observed mean coefficient of variation includes contributions due to the variability in detector response as well as the true year-to-year variation in the annual average Rn concentrations. Factoring out the contributions from the measured variability in the response of the detectors used, the actual year-to-year variability of the annual average Rn concentrations was approximately 22%.

A multiyear quality control study of alpha-track radon monitors.

Quality control exposures of commercial alpha-track radon monitors have been conducted approximately weekly at the U.S. Department of Energy (DOE) Grand Junction Projects Office since early 1987 in support of DOE remedial action programs. The results of these exposures provide a historical record of the comparative performances of these radon monitors.

Recurrent orbital myositis and Crohn's disease.

Diagnosis of orbital pseudotumor remains rare in Crohn's disease; to the best of our knowledge, only six cases have been reported. In these cases, the diagnosis of Crohn's disease was made before or pending that of the orbital pseudotumor. In the present paper, we present and discuss a new case with a concomitant evolution between these two diagnoses. In our case, the diagnosis of orbital pseudotumor was made two years before that of Crohn's disease. Orbital biopsy showed a polyclonal monomorphous lymphoid infiltration and supported the hypothesis that orbital inflammation in Crohn's disease is indirect and is probably due to immune-mediated disorders.