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BACKGROUND: The role of circRNAs in hepatocellular carcinoma (HCC) progression remains unclear. CircPIAS1 (circBase ID: hsa_circ_0007088) was identified as overexpressed in HCC cases through bioinformatics analysis. This study aimed to investigate the oncogenic properties and mechanisms of circPIAS1 in HCC development. METHODS: Functional analyses were conducted to assess circPIAS1's impact on HCC cell proliferation, migration, and ferroptosis. Xenograft mouse models were employed to evaluate circPIAS1's effects on tumor growth and pulmonary metastasis in vivo. Bioinformatics analysis, RNA immunoprecipitation, and luciferase reporter assays were utilized to elucidate the molecular pathways influenced by circPIAS1. Additional techniques, including RNA pulldown, fluorescence in situ hybridization (FISH), chromatin immunoprecipitation (ChIP), qPCR, and western blotting, were used to further explore the underlying mechanisms. RESULTS: CircPIAS1 expression was elevated in HCC tissues and cells. Silencing circPIAS1 suppressed HCC cell proliferation and migration both in vitro and in vivo. Mechanically, circPIAS1 overexpression inhibited ferroptosis by competitively binding to miR-455-3p, leading to upregulation of Nuclear Protein 1 (NUPR1). Furthermore, NUPR1 promoted FTH1 transcription, enhancing iron storage in HCC cells and conferring resistance to ferroptosis. Treatment with ZZW-115, an NUPR1 inhibitor, reversed the tumor-promoting effects of circPIAS1 and sensitized HCC cells to lenvatinib. CONCLUSION: This study highlights the critical role of circPIAS1 in HCC progression through modulation of ferroptosis. Targeting the circPIAS1/miR-455-3p/NUPR1/FTH1 regulatory axis may represent a promising therapeutic strategy for HCC.
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Factores de Transcripción con Motivo Hélice-Asa-Hélice Básico , Carcinoma Hepatocelular , Proliferación Celular , Ferroptosis , Regulación Neoplásica de la Expresión Génica , Neoplasias Hepáticas , MicroARNs , Proteínas de Neoplasias , ARN Circular , Animales , Femenino , Humanos , Masculino , Ratones , Factores de Transcripción con Motivo Hélice-Asa-Hélice Básico/metabolismo , Factores de Transcripción con Motivo Hélice-Asa-Hélice Básico/genética , Carcinoma Hepatocelular/genética , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/metabolismo , Línea Celular Tumoral , Movimiento Celular/genética , Progresión de la Enfermedad , Ferroptosis/genética , Neoplasias Hepáticas/genética , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/metabolismo , MicroARNs/genética , Proteínas de Neoplasias/genética , Proteínas de Neoplasias/metabolismo , ARN Circular/genética , Ensayos Antitumor por Modelo de XenoinjertoRESUMEN
BACKGROUND: Although ROX index is frequently used to assess the efficacy of high-flow nasal cannula treatment in acute hypoxemic respiratory failure (AHRF) patients, the relationship between the ROX index and the mortality remains unclear. Therefore, a retrospective cohort study was conducted to evaluate the ability of the ROX index to predict mortality risk in patients with AHRF. METHOD: Patients diagnosed with AHRF were extracted from the MIMIC-IV database and divided into four groups based on the ROX index quartiles. The primary outcome was 28-day mortality, while in-hospital mortality and follow-up mortality were secondary outcomes. To investigate the association between ROX index and mortality in AHRF patients, restricted cubic spline curve and COX proportional risk regression were utilized. RESULT: A non-linear association (L-shaped) has been observed between the ROX index and mortality rate. When the ROX index is below 8.28, there is a notable decline in the 28-day mortality risk of patients as the ROX index increases (HR per SD, 0.858 [95%CI 0.794-0.928] P < 0.001). When the ROX index is above 8.28, no significant association was found between the ROX index and 28-day mortality. In contrast to the Q1 group, the mortality rates in the Q2, Q3, and Q4 groups had a substantial reduction (Q1 vs. Q2: HR, 0.749 [0.590-0.950] P = 0.017; Q3: HR, 0.711 [0.558-0.906] P = 0.006; Q4: HR, 0.641 [0.495-0.830] P < 0.001). CONCLUSION: The ROX index serves as a valuable predictor of mortality risk in adult patients with AHRF, and that a lower ROX index is substantially associated with an increase in mortality.
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Cánula , Insuficiencia Respiratoria , Adulto , Humanos , Estudios Retrospectivos , Mortalidad Hospitalaria , Administración Intranasal , Bases de Datos Factuales , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/terapia , Terapia por Inhalación de OxígenoRESUMEN
BACKGROUND: Gastric cancer (GC) is the fifth most commonly diagnosed malignancy worldwide, with over 1 million new cases per year, and the third leading cause of cancer-related death. AIM: To determine the optimal perioperative treatment regimen for patients with locally resectable GC. METHODS: A comprehensive literature search was conducted, focusing on phase II/III randomized controlled trials (RCTs) assessing perioperative chemotherapy and chemoradiotherapy in treating locally resectable GC. The R0 resection rate, overall survival (OS), disease-free survival (DFS), and incidence of grade 3 or higher nonsurgical severe adverse events (SAEs) associated with various perioperative regimens were analyzed. A Bayesian network meta-analysis was performed to compare treatment regimens and rank their efficacy. RESULTS: Thirty RCTs involving 8346 patients were included in this study. Neoadjuvant XELOX plus neoadjuvant radiotherapy and neoadjuvant CF were found to significantly improve the R0 resection rate compared with surgery alone, and the former had the highest probability of being the most effective option in this context. Neoadjuvant plus adjuvant FLOT was associated with the highest probability of being the best regimen for improving OS. Owing to limited data, no definitive ranking could be determined for DFS. Considering nonsurgical SAEs, FLO has emerged as the safest treatment regimen. CONCLUSION: This study provides valuable insights for clinicians when selecting perioperative treatment regimens for patients with locally resectable GC. Further studies are required to validate these findings.
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Five undescribed eremophilane-type sesquiterpenes, remophilanetriols E-I (1-5), along with seven known compounds (6-12) were isolated from the fresh roots of Rehmannia glutinosa. Their structures were characterized by extensive spectroscopic data analysis and their absolute configurations were determined by comparing their calculated electronic circular dichroism (ECD) spectra and experimental ECD spectra. The anti-pulmonary fibrosis activities of all compounds were evaluated in vitro by MTT methods, and compounds 2, 8, 10, and 12 exhibited excellent anti-pulmonary fibrosis activities. In addition, compound 2 can reduce the levels of ROS and apoptosis in TGF-ß1-induced BEAS-2B cells.
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Fitoquímicos , Raíces de Plantas , Rehmannia , Raíces de Plantas/química , Estructura Molecular , Rehmannia/química , Humanos , Fitoquímicos/farmacología , Fitoquímicos/aislamiento & purificación , Sesquiterpenos/farmacología , Sesquiterpenos/aislamiento & purificación , Sesquiterpenos/química , Apoptosis/efectos de los fármacos , Línea Celular , Especies Reactivas de Oxígeno/metabolismo , China , Sesquiterpenos Policíclicos/farmacología , Sesquiterpenos Policíclicos/aislamiento & purificación , Sesquiterpenos Policíclicos/químicaRESUMEN
Augmented CD4+ T cell response in autoimmunity is characterized by extensive metabolic reprogramming. However, the epigenetic molecule that drives the metabolic adaptation of CD4+ T cells remains largely unknown. Here, we show that lysine acetyltransferase 6A (KAT6A), an epigenetic modulator that is clinically associated with autoimmunity, orchestrates the metabolic reprogramming of glucose in CD4+ T cells. KAT6A is required for the proliferation and differentiation of proinflammatory CD4+ T cell subsets in vitro, and mice with KAT6A-deficient CD4+ T cells are less susceptible to experimental autoimmune encephalomyelitis and colitis. Mechanistically, KAT6A orchestrates the abundance of histone acetylation at the chromatin where several glycolytic genes are located, thus affecting glucose metabolic reprogramming and subsequent CD4+ T cell responses. Treatment with KAT6A small-molecule inhibitors in mouse models shows high therapeutic value for targeting KAT6A in autoimmunity. Our study provides novel insights into the epigenetic programming of immunometabolism and suggests potential therapeutic targets for patients with autoimmunity.
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Lisina Acetiltransferasas , Linfocitos T , Animales , Humanos , Ratones , Autoinmunidad/genética , Linfocitos T CD4-Positivos/metabolismo , Epigénesis Genética , Glucosa/metabolismo , Histona Acetiltransferasas/genética , Histona Acetiltransferasas/metabolismo , Lisina Acetiltransferasas/genética , Lisina Acetiltransferasas/metabolismo , Linfocitos T/metabolismoRESUMEN
Nowadays, great uncertainty still exists on the urban- and regional-scale anthropogenic CO2 emission estimation based on emission inventories. In order to achieve the carbon peaking and neutrality targets for China, it is urgent to accurately estimate anthropogenic CO2 emissions at regional scales, especially in large urban agglomerations. Using two inventories (EDGAR v6.0 inventory and a modified inventory combining EDGAR v6.0 with GCG v1.0) as prior anthropogenic CO2 emission datasets andtaking themas input data respectively, this study utilized the WRF-STILT atmospheric transport model to simulate atmospheric CO2 concentration in the Yangtze River Delta region from December 2017 to February 2018. The simulated atmospheric CO2 concentrations were further improved by referencing atmospheric CO2 concentration observation at a tall tower in Quanjiao County of Anhui Province and using the scaling factors obtained from the Bayesian inversion method. An estimation of anthropogenic CO2 emission flux in the Yangtze River Delta regionwas finally accomplished. The results indicated that:â in winter, in comparison to the atmospheric CO2 concentration simulated based on EDGAR v6.0, the atmospheric CO2 concentration simulated based on the modified inventory was more consistent with observed values. â¡The simulated atmospheric CO2 concentration was higher than observation at night and lower than observation during the daytime. The CO2 emission data of emission inventories could not fully reflect the diurnal variation in anthropogenic emissions, andtheoverestimation, caused by the simulated low-atmospheric boundary layer height at night, of the contribution from point sources with higher emission height near the observation station were the main reasons. â¢The simulation performance on atmospheric CO2 concentration was greatly affected by the emission bias of the EDGAR grid points that significantly contributed to concentrations of the observation station, and this indicated that the uncertainty in the spatial distribution in EDGAR emission was the main factor influencing the simulation accuracy. â£The posterior anthropogenic CO2 emission flux in the Yangtze River Delta from December 2017 to February 2018 was around (0.184±0.006) mg·(m2·s)-1and (0.183±0.007) mg·(m2·s)-1 based on EDGAR and the modified inventory, respectively. It is suggested that the inventories with higher temporal and spatial resolutions and more accurate spatial emission distribution should be selected as the prior emissions to obtain a more accurate estimation of the regional anthropogenic CO2 emissions.
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Manganese dioxide nanoparticles (MnO2-NPs) have a wide range of applications in biomedicine. Given this widespread usage, it is worth noting that MnO2-NPs are definitely toxic, especially to the brain. However, the damage caused by MnO2-NPs to the choroid plexus (CP) and to the brain after crossing CP epithelial cells has not been elucidated. Therefore, this study aims to investigate these effects and elucidate potential underlying mechanisms through transcriptomics analysis. To achieve this objective, eighteen SD rats were randomly divided into three groups: the control group (control), low-dose exposure group (low-dose) and high-dose exposure group (high-dose). Animals in the two treated groups were administered with two concentrations of MnO2-NPs (200 mg kg-1 BW and 400 mg kg-1 BW) using a noninvasive intratracheal injection method once a week for three months. Finally, the neural behavior of all the animals was tested using a hot plate tester, open-field test and Y-type electric maze. The morphological characteristics of the CP and hippocampus were observed by H&E stain, and the transcriptome of CP tissues was analysed by transcriptome sequencing. The representative differentially expressed genes were quantified by qRT-PCR. We found that treatment with MnO2-NPs could induce learning capacity and memory faculty decline and destroy the structure of hippocampal and CP cells in rats. High doses of MnO2-NPs had a more obvious destructive capacity. For transcriptomic analysis, we found that there were significant differences in the numbers and types of differential genes in CP between the low- and high-dose groups compared to the control. Through GO terms and KEGG analysis, high-dose MnO2-NPs significantly affected the expression of transporters, ion channel proteins, and ribosomal proteins. There were 17 common differentially expressed genes. Most of them were transporter and binding genes on the cell membrane, and some of them had kinase activity. Three genes, Brinp, Synpr and Crmp1, were selected for qRT-PCR to confirm their expression differences among the three groups. In conclusion, high-dose MnO2-NPs exposure induced abnormal neurobehaviour, impaired memory function, destroyed the structure of the CP and changed its transcriptome in rats. The most significant DEGs in the CP were within the transport system.
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Nanopartículas , Óxidos , Ratas , Animales , Óxidos/toxicidad , Óxidos/química , Compuestos de Manganeso/química , Plexo Coroideo , Transcriptoma , Ratas Sprague-Dawley , Nanopartículas/toxicidadRESUMEN
Three pairs of undescribed diarylpentanoid enantiomers (1-3) and five undescribed phenylpropanoids (4-8), along with seven known compounds, were isolated from the roots of Anthriscus sylvestris. The structures of compounds (1-8) were determined by analysis of their 1D and 2D NMR spectra, HRESIMS, and electronic circular dichroism. In addition, the inhibitory activities against hypoxia-stimulated pulmonary arterial smooth muscle cells abnormal proliferation were evaluated by MTT assay. The mRNA expression levels of Bcl-2, BAX, Caspase3, and IL-6 were detected by quantitative real-time PCR. The results showed that compounds (-)-1, (+)-1, (-)-2, (+)-3, 4, 8-10, 14, and 15 inhibited the abnormal proliferation of PASMCs by regulating the levels of apoptosis and inflammatory factors.
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Apiaceae , Extractos Vegetales , Extractos Vegetales/química , Arteria Pulmonar , Proliferación CelularRESUMEN
To explore the characteristics and sources of PM2.5 pollution in winter of Handan City in the past five years, PM2.5 samples were collected in winter of 2016 to 2020, and eight types of water-soluble inorganic ions were analyzed. The principal component analysis(PCA) model was used to analyze the types of pollution sources, and the backward trajectory and potential source contribution factor(PSCF) were used to simulate the transport trajectory and pollution sources. The results showed that the PM2.5 concentration in winter of 2018 was the highest, increasing by 60.44%, 25.46%, 91.43%, and 21.53% compared with that in 2016, 2017, 2019, and 2020, respectively. In the winter of 2020, the concentration of water-soluble inorganic ions(WSIIs) decreased by 18.86% compared with that in 2016, and WSIIs/PM2.5 decreased to 26.69%. The PM2.5 concentration(110.20-209.65 µg·m-3) at night was higher than that in the daytime(95.21-193.00 µg·m-3). The concentration of NO3- and NH4+ increased more at night. On the contrary, the concentration and proportion of Cl-decreased annually. In the winter of 2020, the daytime concentrations of K+, Ca2+, Na+, and Mg2+ decreased by 69.72%, 97.10%, 90.91%, and 74.51% compared with that of 2018, and the night concentrations decreased by 66.67%, 95.38%, 91.67%, and 77.78%, respectively. In 2020, the concentrations of NO3-, SO42-, and NH4+ on polluted days were 4.90, 5.80, and 5.20 times those on non-polluted days, with the largest increase in five years. PCA results showed that the main sources of pollution were secondary sources, coal sources, biomass combustion sources, and road and building dust. The backward trajectory and PSCF analysis results showed that pollution transport continued to exist between south-central Mongolia and central Inner Mongolia in winter and was influenced by the transport between northern Henan and Handan and central Hebei and Handan in winter of 2016 and 2017, whereas the latter had a greater impact in winter of 2018-2020.
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BACKGROUND: This study addresses the association of matrix metalloproteinase-1 (MMP-1) and vascular endothelial growth factor-C (VEGF-C) expression in esophageal squamous cell carcinoma (SCC) with clinicopathologic characteristics in the patients. MATERIAL AND METHODS: We profiled the expression of MMP-1 and VEGF-C by cDNA microarray in 4 cases and by reverse transcription-polymerase chain reaction (RT-PCR) in 14 cases of esophageal SCC. Another 90 cases were reviewed by immunohistochemical examination of paraffin-embedded sections. RESULTS: Expression of MMP-1 and VEGF-C mRNA in normal esophageal tissue and tumor tissue was compared. Data were fully consistent with the results of RT-PCR. Immunohistochemistry showed that compared to the normal mucosa MMP-1 and VEGF-C protein expression was upregulated in both esophageal atypical hyperplasia (n = 16) and esophageal SCC. Depth of tumor invasion, lymph node metastasis, and clinical stage were directly associated with prognosis in all cases. Furthermore, median overall survival and disease-free survival were significantly shorter in patients with a higher expression of MMP-1 and VEGF-C than in patients with lower expression levels. CONCLUSION: We demonstrated that the expression of both MMP-1 and VEGF-C mRNA and protein was upregulated in esophageal SCC tissues. Protein expression was associated with progressive tumor stage and poor prognosis in patients with esophageal SCC.
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Biomarcadores de Tumor/análisis , Carcinoma de Células Escamosas/metabolismo , Carcinoma de Células Escamosas/mortalidad , Neoplasias Esofágicas/metabolismo , Neoplasias Esofágicas/mortalidad , Metaloproteinasa 1 de la Matriz/análisis , Factor C de Crecimiento Endotelial Vascular/análisis , Carcinoma de Células Escamosas/diagnóstico , China/epidemiología , Neoplasias Esofágicas/diagnóstico , Femenino , Humanos , Incidencia , Masculino , Pronóstico , Medición de Riesgo , Análisis de Supervivencia , Tasa de Supervivencia , Regulación hacia ArribaRESUMEN
BACKGROUND: Distal ischemic necrosisis a common complication of orthopedic random skin flaps surgery. Paeoniflorin, a natural compound extracted from Paeonia lactiflora, can enhances angiogenesis and alleviates excessive inflammatory response. We investigated the changes of ischemic extra-long flaps with paeoniflorin and its possible mechanism. METHODS: We raised dorsal McFarlane flaps in 54 Sprague-Dawley rats. We designed three groups of rats: high-paeoniflorin group (HP, 50 mg/kg/d), low-paeoniflorin group (LP, 20 mg/kg/d), and control group. The flap survival rate was calculated, seven days after flap construction.Blood perfusion was detected by laser Doppler flow imaging, and angiogenesis wasdetected by Lead oxide/gelatin angiography.Oxidative stress levels of flaps were determined by detecting superoxide dismutase (SOD) and malondialdehyde (MDA). The histopathological status of flap was evaluated by hematoxylin and eosin (H&E) staining.Immunohistochemistry was used to determine the expression of high mobility group protein B1 (HMGB1), nuclear factor-kappa B (NF-κB), Toll-like receptor 4 (TLR4), tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-1ß, IL-18, vascular endothelial growth factor (VEGF), cysteine protease-1 (caspase-1) and NLPR3. RESULTS: The flap survival rates and SOD activity in the experimental groups were significantly higher, while MDA activity was lower. Experimental groups showed significantly improved microcirculatory blood flow to the flap and increased angiogenesis. Immunohistochemistry revealed that paeoniflorin was associated with significantly increased VEGF expression, and decreased level of HMGB1, TLR4, TNF-α, NF-κB, IL-6, IL-1ß, caspase-1, NLPR3, and IL-18. CONCLUSIONS: Paeoniflorin effectively enhanced the survival of rat random skin flaps by promoting vascular hyperplasia, inhibiting pyroptosis, and down-regulating inflammation.
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Neovascularización Fisiológica , Factor A de Crecimiento Endotelial Vascular , Animales , Glucósidos , Supervivencia de Injerto , Microcirculación , Monoterpenos , Ratas , Ratas Sprague-Dawley , Factor A de Crecimiento Endotelial Vascular/metabolismoRESUMEN
Nine undescribed compounds, together with 21 known components, were isolated from the fresh roots of Rehmannia glutinosa. Their structures were elucidated based on spectroscopic data analysis, and the absolute configurations of undescribed compounds were determined by comparison of their calculated and experimental electronic circular dichroic (ECD) spectra and interpretation of their optical rotation data. The α-glucosidase inhibitory effects of the isolated compounds were investigated and all of them exhibited slightly inhibitory activities.
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Lignanos , Rehmannia , Lignanos/química , Norisoprenoides/química , Raíces de Plantas/química , Rehmannia/química , alfa-GlucosidasasRESUMEN
BACKGROUND: Random skin flaps are often used for plastic repair because they are convenient and flexible. However, necrosis of flaps is a common complication that may lead to disastrous consequences. Exenatide, a glucagon-like peptide 1 receptor agonist, can enhance angiogenesis and ameliorate ischemia/reperfusion injury. Our experiments explored random skin flap outcomes after its use. METHODS: We established modified dorsal McFarlane flaps on 54 Sprague-Dawley rats and divided the rats into three groups (control, Exe-I, and Exe-II). We intraperitoneally injected either 4 or 8 µg/kg/day exenatide into the rats of the Exe-I and Exe-II groups, respectively. On the seventh day after the operation, we measured the levels of superoxide dismutase (SOD) and malondialdehyde (MDA). Tissue sections were obtained for histopathological and immunohistochemical analyses, and we evaluated the expression of vascular endothelial growth factor (VEGF), interleukin (IL) 6, IL-1ß, nuclear factor kappa beta (NF-κB), Toll-like receptor 4 (TLR4), and tumor necrosis factor α (TNF-α). We measured blood flow reconstruction and angiogenesis using laser Doppler blood flowmetry and lead oxide/gelatin angiography, respectively. RESULTS: Exenatide increased the average survival area of the flap and improved microvascular density and blood flow intensity in a dose-dependent manner. Meanwhile, the SOD level was up-regulated and the MDA level down-regulated. Exenatide also enhanced the expression of VEGF and reduced the expression of inflammatory cytokines (IL-6, IL-1ß, NF-κB, TLR4, and TNF-α), thereby promoting angiogenesis and inhibiting inflammation. CONCLUSIONS: Exenatide potentially inhibits necrosis in our rat random skin flap model.
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Inductores de la Angiogénesis/farmacología , Exenatida/farmacología , Neovascularización Fisiológica/efectos de los fármacos , Daño por Reperfusión/prevención & control , Piel/irrigación sanguínea , Colgajos Quirúrgicos/irrigación sanguínea , Animales , Antiinflamatorios/farmacología , Antioxidantes/farmacología , Citocinas/metabolismo , Modelos Animales de Enfermedad , Masculino , FN-kappa B/metabolismo , Necrosis , Estrés Oxidativo/efectos de los fármacos , Ratas Sprague-Dawley , Flujo Sanguíneo Regional , Daño por Reperfusión/metabolismo , Daño por Reperfusión/patología , Daño por Reperfusión/fisiopatología , Transducción de Señal , Piel/metabolismo , Piel/patología , Colgajos Quirúrgicos/patología , Colgajos Quirúrgicos/cirugía , Receptor Toll-Like 4/metabolismo , Factor A de Crecimiento Endotelial Vascular/metabolismoRESUMEN
Random skin flaps are widely used to repair tissue defects. However, the distal flap regions are prone to ischemic necrosis, limiting clinical applications. Azadirachtin A, a fruit extract from the neem, improves tissue blood supply and metabolism, reduces cell swelling, promotes tissue healing, and prevents venous thrombosis. We explored whether it enhances random skin flap survival. Fifty-four Sprague-Dawley rats were divided into control, low-dose, and high-dose Azadirachtin A-treated groups using a random number table. We used an improved version of the McFarlane technique to create flaps. On day 2, superoxide dismutase and malondialdehyde levels were measured. Tissue slices prepared on day 7 were stained with hematoxylin and eosin. The expression levels of vascular endothelial growth factor (VEGF), toll-like receptor 4 (TLR4), nuclear factor kappa-B (NF-kB), interleukin-1ß (IL-1ß), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) were immunohistochemically assayed. Microcirculatory blood flow was measured via laser Doppler blood flowmetry. Flap angiography was performed using the lead-oxide gelatin injection technique. And the azadirachtin A groups exhibited a greater mean flap survival area, an improved mean blood vessel density, a greater blood flow, and higher superoxide dismutase and VEGF levels, especially at the high dose. Azadirachtin A markedly reduced the levels of TNF-α, IL-6, IL-1ß, TLR4, and NF-kB. These findings suggest that azadirachtin A promotes random skin flap survival by improving the blood supply, reducing tissue inflammation, and inhibiting flap ischemia reperfusion injury.