Myxozoans as biological tags for stock identification of the Argentine hake, Merluccius hubbsi (Gadiformes: Merlucciidae).

Myxozoans have been successfully used as tags for fish stock identification around the world. However, few studies using myxozoan tags have been carried out in the Southern Atlantic, a region with complex oceanography that constitutes a potentially suitable scenario for testing the utility of myxozoans as indicators. Its usefulness was tested using six samples of Merluccius hubbsi in two different regions of the Argentine Sea. Generalized linear models were performed to assess the effects of fish size and sex, and year and region of capture and selected using the Information Theoretic approach. Three myxozoan species were recorded: Kudoa rosenbuschi, Myxoproteus meridionalis and Fabespora sp. Results of modelling species individually showed differential capabilities for detecting geographical population structure at different spatial scales, with K. rosenbuschi and Fabespora sp. allowing the discrimination of northern and southern stocks, but Fabespora sp. also as a promissory indicator of intrapopulation sub-structure due to different migratory routes during non-reproductive periods. This work confirms that myxozoans offer a set of suitable markers at different spatial scales, which can be selected individually or in any combination, depending on the geographical extent of the study, constituting tools adaptable to the objectives of further research on fish population structure.

Molecular characterization of Sphaerospora molnari (Myxozoa), the agent of gill sphaerosporosis in common carp Cyprinus carpio carpio.

Sphaerospora molnari Lom, Dyková, Pavlásková and Grupcheva, 1983 often causes severe infections in the gills and skin of common carp fingerlings Cyprinus carpio carpio in Central Europe. Although most Sphaerospora spp. are coelozoic and affect the excretory system of fish, S. molnari develops mature spores in the epithelia of gill filaments, making it a rare representative of histozoic freshwater species within the genus. On the basis of a partial 18S rDNA sequence assigned as belonging to S. molnari, previous phylogenetic studies located the species within the Myxobolus clade. In the present study, S. molnari isolates from Hungary and the Czech Republic were characterized based on morphology, DNA sequence analysis and phylogenetic comparison. The obtained 3714 bp final consensus 18S rDNA sequence of the parasite showed several, sometimes extremely long inserts in the variable regions of the gene and differed considerably from the one published in GenBank in 2002. In situ hybridization confirmed the validity of the obtained DNA sequence and detected pre-sporogonic blood stages in the interstitium and blood vessels of the kidney. Phylogenetic analysis showed that S. molnari clusters within the Sphaerospora sensu stricto clade with a high support, revealing it as the first known histozoic member of the Sphaerospora subclade comprising parasites of freshwater fish.

[Applications of numerical simulation in musculoskeletal research and its impact on orthopedic surgery]. / Einsatzgebiete der numerischen Simulation in der muskuloskelettalen Forschung und ihre Bedeutung für die Orthopädische Chirurgie.

Finite element analyses (FEA) as well as multibody system dynamics (MSD) are the main tools used for numerical simulation in the field of musculoskeletal research. While FEA is utilized for field problems, such as calculation of stress and strain distribution, MSD is applied for solving kinematic analyses, such as calculation of muscle and joint forces. Depending on the focus of investigation, modelling of biological tissue may vary from simple homogeneous behavior to modelling biochemical processes on the microscale and nanoscale. An important milestone in biomechanical research was the analysis of stress shielding, which led to further research on bone remodelling. Various models of implant-bone fixation used for the prediction of micromotion have been published. New possibilities for biomechanical analyses are achieved by consideration of complex muscle forces which are generated by MSD simulation and imported into FEA models as limiting conditions. A numerical model always requires experimental validation. If the results are confirmed experimentally, various advantages of numerical simulation apply and problems can be analysed isolated from many influencing factors. Therefore, straightforward parameter variation is possible, enabling studies which would be impossible in an experimental or clinical setup.

[Results of hearing screenings in 14- to 15-year old adolescents]. / Ergebnisse eines Hörscreenings bei 14- bis 15-jährigen Jugendlichen.

BACKGROUND: A hearing screening among 14- to 15-year-old pupils was performed to estimate the number of hearing-impaired individuals in the adolescent population. MATERIALS AND METHODS: A total of 1,298 pupils from 30 schools in Tyrol (Austria) participated in the screening. Hearing tests were performed in a silent room at the school. Sinus tones at frequencies 0.5/1/2/4/6 kHz and at levels of 25/20/20/20/20 dB HL, respectively, were delivered via headphones to either ear. Failure of screening was defined as not hearing one or more frequencies in one or both ears. RESULTS: The screening was failed by 16.3% of the pupils. There was a small but not significant difference between males and females (17.0 vs. 15.2%). Most of the pupils failed at only one frequency (9.6%). Failing at two or more frequencies in the same ear occurred in 3.9% of the pupils, thereof in 1.1% bilaterally. CONCLUSION: As the specificity of our screening is limited, false-positive results may result. Thus, the rate of hearing deficits in our sample is probably a bit lower than indicated by the figures above. Most of the adolescents who failed the screen failed at only one frequency. These subjects have a small elevation of their hearing threshold, not a hearing loss in the sense of a raised averaged threshold. A hearing loss in the latter sense is supposed to be present in only very few percent of adolescents, a bilateral hearing loss in perhaps less than 1%.

In vitro treatments for the theront stage of the ciliate protozoan Cryptocaryon irritans.

The ciliate protozoan Cryptocaryon irritans Brown, 1951, the 'marine white spot', causes one of the most important parasitic fish diseases, with extensive losses every year in mariculture and in the ornamental fish industry. In the present study, we explore the in vitro use of 8 different compounds against the theront (infective) stage of C. irritans; these compounds include extracts of natural products (epigallocatechin gallate (EGCG), L-DOPA, papain), peracetic acid-based compounds (Proxitane 5:23 and 15% peracetic acid, PAA), quinine-based compounds (quinacrine hydrochloride and chloroquine diphosphate) and hydrogen peroxide. All of these compounds had an effect on theront survival; however, only EGCG caused significant theront mortality when applied in doses > or =50 mg l(-1) and over a period of 3 h; papain caused a maximum theront mortality of <50%. We discuss the type of application and potential utility of the compounds tested as part of a management control strategy for C. irritans infections in marine aquaculture and the ornamental fish industry.

Infection dynamics of two renal myxozoans in hatchery reared fry and juvenile Atlantic cod Gadus morhua L.

In order to study the infection dynamics of 2 renal myxozoans, Zschokkella hildae Auerbach, 1910 and Gadimyxa atlantica Køie, Karlsbakk and Nylund, 2007 in cultured Atlantic cod, Gadus morhua L. aged 3-19 months, a specific single-round PCR assay and a double-label in situ hybridization protocol were developed. The results demonstrated that the 2 myxozoans show spatial separation of their development with regard to spore formation inside the renal tubules versus the collecting ducts and ureters, as well as temporal separation with Z. hildae proliferating and developing spores only once the G. atlantica infection decreases, despite the presence of both myxozoans in the smallest fry studied. These results strongly suggest within-host competition of the 2 myxozoans with potential suppression of Z. hildae by G. atlantica until G. morhua acquires immunity against G. atlantica. The quantification of the G. atlantica infection inside the renal tubules before and after a 29-day experimental growth performance study using fry from hatcheries with differing filtration systems showed that the intensity of infection with G. atlantica seems to be controlled if prolonged exposure to the myxozoan transmission stages takes place from hatching onwards. Surprisingly, growth rates in the trial were inversely affected suggesting that G. atlantica does not negatively influence cod fry growth performance.

Morphological and molecular redescription of the myxozoan Unicapsula pflugfelderi Schubert, Sprague & Reinboth 1975 from two teleost hosts in the Mediterranean. A review of the genus Unicapsula Davis 1924.

Elongate plasmodia with myxosporean spores belonging to the genus Unicapsula, Davis, 1924 were found in the skeletal muscle of the striped seabream, Lithognathus mormyrus (L.), a candidate for the mediterranean aquaculture. The only species of Unicapsula described from the Mediterranean is Unicapsula pflugfelderi Schubert et al. 1975, which occurs in the picarel, Spicara smaris (L.). For morphological and molecular comparison of U. pflugfelderi from S. smaris with Unicapsula sp. from L. mormyrus measurements of plasmodia and spores, ultrastructural details and 18S and 28S rDNA sequences were analysed. Whereas plasmodia were 2-3 times larger in S. smaris than in L. mormyrus (length 2.47-0.81 mm; width 0.22-0.09 mm; P = 0.000), spore morphology showed minor differences and both 18S and 28S rDNA sequences were 100% identical identifying the myxozoan as U. pflugfelderi. Scanning electron microscopy of the spores revealed a different shell valve distribution than the one used for the diagnosis of the genus Unicapsula. This resulted in a review of the genus Unicapsula dividing it into two morphological groups of different spore valve arrangement. TEM revealed the presence of a yet undescribed crystalline structure in the sporoplasm of the spores.

Cardicola aurata sp. n. (Digenea: Sanguinicolidae) from Mediterranean Sparus aurata L. (Teleostei: Sparidae) and its unexpected phylogenetic relationship with Paradeontacylix McIntosh, 1934.

A new sanguinicolid trematode, Cardicola aurata sp. n., is described from gilthead seabream Sparus aurata L., from off the Spanish Mediterranean coast. The morphology of C. aurata sp. n. generally agrees with the diagnosis of the genus, however, in contrast to all other reported Cardicola spp. the male pore is located sub-medially at the posterior end of the body instead of sinistrally before the posterior end of the body. Based on a comparison of the morphology as well as partial 28S and ITS2 rDNA sequence data from the present species with that from closely related species, it was decided to emend the diagnosis of Cardicola rather than create a new genus, as the aberrant position of the male pore is likely to be an autapomorphy. The phylogenetic analyses revealed a close relationship between Cardicola and Paradeontacylix, two genera with considerable morphological differences; C. aurata sp. n. occupies a position intermediate to these genera. Thus, a morphological comparison of Cardicola, Paradeontacylix and Braya, a genus which is morphologically similar to Cardicola but clusters basal to the Cardicola/Paradeontacylix clade, was conducted. The results of this comparison showed that despite large differences with regard to body shape, the organisation of the internal organs is very similar in species of Cardicola and Paradeontacylix. The synopsis of morphological data and molecular phylogeny allows for interpretations regarding the importance of different morphological features for the phylogenetic inference of the Sanguinicolidae.

CTLA4Ig inhibits T cell-dependent B-cell maturation in murine systemic lupus erythematosus.

Long-term administration of CTLA4Ig prevents the onset of disease in systemic lupus erythematosus-prone (SLE-prone) NZB/NZW F1 mice. To determine the mechanism of this effect, we engineered an adenovirus that expresses murine CTLA4Ig. Administration of a single high dose of this virus results in long-term expression of CTLA4Ig in the serum and absence of an immune response to the adenoviral vector. We administered Ad-CTLA4Ig to 19- to 22-week-old NZB/NZW F1 mice and evaluated the effect on anti-DNA antibody-producing B cells. We show that CTLA4Ig has a beneficial effect on murine SLE for as long as it is present in the serum. This effect is associated with decreased expansion of both the IgM and IgG autoreactive B-cell population, inhibition of immunoglobulin class switching, decreased frequency and altered pattern of somatic mutation, and a marked decrease in the numbers of activated CD4-positive T cells. In contrast, intrinsic B-cell hyperreactivity and the survival of plasma cells in the bone marrow, both of which are less dependent on T-cell help, appear to be unaffected by CTLA4Ig. High-dose CTLA4Ig did not induce permanent tolerance in this autoimmune disease model. Furthermore, although the mice survived in a conventional housing facility, treatment with Ad-CTLA4Ig was immunosuppressive.

Laparoscopic versus open myomectomy: a double-blind study to evaluate postoperative pain.

The advantages of laparoscopic over open surgery have been documented in nonblinded settings. Our prospective, double-blind setting evaluated pain scores 72 h after surgery by comparing patients who underwent laparoscopic myomectomy or with laparotomy. Forty women referred for conservative myomectomy were included in the study. After stratification (myoma size, number of myomas, and surgeon), patients were randomized to either laparoscopy (n = 19) or laparotomy (n = 21) and received a standardized anesthesia and patient-controlled analgesia for 24 h after surgery. Identical wound dressings were applied to blind the patient and the observer to the surgical approach. The postoperative pain scores were documented on a visual analog scale (VAS; 0 = no and 10 = unbearable pain) at 24, 48, and 72 h after surgery. As the primary outcome variable, we calculated the mean overall VAS-score at these time points. P < 0.05 (t-test and analysis of covariance) was considered statistically significant. There were no differences in patient characteristics among the groups. The mean overall VAS score at 24, 48, and 72 h was statistically significantly lower in the laparoscopic group compared with the laparotomy group (2.28 +/- 1.38 versus 4.03 +/- 1.63; P < 0.01). Our data demonstrate, for the first time in a double-blind setting, that laparoscopic myomectomy reduces postoperative pain for 72 h after surgery compared with laparotomy.

New cell motility model observed in parasitic cnidarian Sphaerospora molnari (Myxozoa:Myxosporea) blood stages in fish.

Cellular motility is essential for microscopic parasites, it is used to reach the host, migrate through tissues, or evade host immune reactions. Many cells employ an evolutionary conserved motor protein- actin, to crawl or glide along a substrate. We describe the peculiar movement of Sphaerospora molnari, a myxozoan parasite with proliferating blood stages in its host, common carp. Myxozoa are highly adapted parasitic cnidarians alternately infecting vertebrates and invertebrates. S. molnari blood stages (SMBS) have developed a unique "dancing" behaviour, using the external membrane as a motility effector to rotate and move the cell. SMBS movement is exceptionally fast compared to other myxozoans, non-directional and constant. The movement is based on two cytoplasmic actins that are highly divergent from those of other metazoans. We produced a specific polyclonal actin antibody for the staining and immunolabelling of S. molnari's microfilaments since we found that neither commercial antibodies nor phalloidin recognised the protein or microfilaments. We show the in situ localization of this actin in the parasite and discuss the importance of this motility for evasion from the cellular host immune response in vitro. This new type of motility holds key insights into the evolution of cellular motility and associated proteins.

The predictive value of behavioural risk factors for sudden infant death.

In order to examine the predictive value of risk factors for the Sudden Infant Death Syndrome (SIDS), we have interviewed the parents of 80 SIDS victims and 80 parents of a healthy control group. From these interviews a list of 24 clinical and behavioural symptoms was assembled which appeared to be associated with the risk for SIDS. Out of this list of 24 symptoms the average number of symptoms reported to be observable in SIDS victims was twice as large as the average number of symptoms reported for healthy controls. The following symptoms appeared markedly more often in SIDS victims than in the controls: difficulties in awakening the baby, shrill crying, apathy, few movements during sleep, and cyanosis. We have attempted to consider a possible bias in the report of the parents of deceased infants by the introduction of an "exaggeration factor". By application of Bayes' theorem the highest predictive probability, 2.7%, was found for difficulties in awakening the baby. This is approximately nine times the assumed a priori probability of SIDS of 0.3%. We conclude that behavioural risk factors have a low but still remarkable predictive probability. A behavioural pattern of apathy and sleepiness indicates risk with a high probability.

Gram staining and lectin binding properties of Myxosporea and Sporozoea.

The staining method developed by Christian Gram was introduced as a simple and highly selective tool for demonstrating myxosporean and coccidian sporogonic stages. When using standard blood staining procedures for those enigmatic parasites it is sometimes difficult to distinguish them from fish host tissue. They clearly exhibit a partial gram-positive reaction in histological sections, but staining is variable in air dried fish organ imprints. To visualize the gram-negative background of different host tissue components in histological sections, the conventional safranin counterstain of the gram protocol may be modified as follows: after application of 2% crystal violet (basic violet 3) and Lugol's solution, sections are stained with 0.1% nuclear fast red-5% aluminum sulfate and 0.35% aniline blue (acid blue 22) dissolved in saturated aqueous picric acid. Replacement of the gram-specific dye crystal violet with 2% malachite green gave similar results in organ imprints containing myxospores or coccidia, but only in sections containing myxosporea. Staining for 1 min with an aqueous solution of 0.5% malachite green and followed 1 min washing was sufficient for rapidly demonstrating the parasite spores in organ imprints of both myxosores and oocysts. With regard to the role of acid mucopolysaccharides and other carbohydrates in the gram reaction of spores, alcian blue 8GX staining was compared to the binding of FITC-labeled WGA, GS I and GS II. Each lectin was applied at 20 microl/ml PBS, HEPES for 1 hr. Whereas WGA yielded a nonspecific pattern like the alcian blue staining, GS II resulted in a pattern similar to the gram staining results. This binding was weak in untreated specimens, but was significantly enhanced when digested first within trypsin overnight in a humid chamber at 37 degrees C. The binding of GS II to both myxosporidian and coccidian spores suggests that they are both composed of polymers containing N-acetyl-D-glucosamine residues. Furthermore, the results suggest that this hexosamine plays a key role in the gram reaction.

Finite element analysis of the ovine hip: development, results and comparison with the human hip.

OBJECTIVES: The ovine hip is often used as an experimental research model to simulate the human hip. However, little is known about the contact pressures on the femoral and acetabular cartilage in the ovine hip, and if those are representative for the human hip. METHODS: A model of the ovine hip, including the pelvis, femur, acetabular cartilage, femoral cartilage and ligamentum transversum, was built using computed tomography and micro-computed tomography. Using the finite element method, the peak forces were analysed during simulated walking. RESULTS: The evaluation revealed that the contact pressure distribution on the femoral cartilage is horseshoe-shaped and reaches a maximum value of approximately 6 MPa. The maximum contact pressure is located on the dorsal acetabular side and is predominantly aligned in the cranial-to-caudal direction. The surface stresses acting on the pelvic bone reach an average value of approximately 2 MPa. CONCLUSIONS: The contact pressure distribution, magnitude, and the mean surface stress in the ovine hip are similar to those described in the current literature for the human hip. This suggests that in terms of load distribution, the ovine hip is well suited for the preclinical testing of medical devices designed for the human hip.

Host-parasite relationship of Ceratomyxa puntazzi n. sp. (Myxozoa: Myxosporea) and sharpsnout seabream Diplodus puntazzo (Walbaum, 1792) from the Mediterranean with first data on ceratomyxid host specificity in sparids.

Sparidae are economically important fishes to both, fisheries and aquaculture in the Mediterranean. Species diversification is an important strategy for the development of Mediterranean aquaculture. One of the species recently introduced is the sharpsnout seabream Diplodus puntazzo (Walbaum, 1792). During a parasitological study of fish from the Gulf of Valencia and the Mar Menor (Spain), myxozoan spores belonging to the genus Ceratomyxa were found in the gall bladder of D. puntazzo. A morphological description of the spores, which includes histology and transmission electron microscopy (TEM) as well as molecular (SSU ribosomal DNA) data resulted in the erection of a new species, Ceratomyxa puntazzi n. sp. A histopathological study of C. puntazzi n. sp. infection in D. puntazzo showed that the parasite causes necrosis and loss of epithelial cells in the gall bladder, and provokes a pericholangitis in the liver tissue surrounding the bile ducts. Furthermore, molecular data obtained from C. puntazzi n. sp. and three other ceratomyxids from the closely related fish species Diplodus annularis L. and Sparus aurata L. which share the same habitat suggest that the genus Ceratomyxa is host-specific in sparids, which agrees with data previously obtained from Serranidae, Labridae and Pomacentridae, and that ceratomyxid species from sparids in the Mediterranean originated from a common ancestor.

Auricular acupuncture for postoperative pain after gynecological surgery: a randomized controlled trail.

BACKGROUND: Acupuncture for postoperative pain remains controversial. Potential sources of bias are failures in patient-blinding and therapist-patient interactions. Our study investigates the effects of electrical auricular acupuncture (AA) on postoperative pain in patients undergoing laparoscopy with an emphasis on patient-blinding and the exclusion of therapist-patient interactions. METHODS: With institutional review board approval and written informed consent, we included 40 female patients undergoing laparoscopy. Patients were randomly assigned to receive AA (shen men, thalamus and one segmental organ-specific point) or electrodes only and an electrical stimulation device. All patients received this intervention under general anesthesia guaranteeing patient blinding and excluding therapist-patient interactions. Needles and devices were removed 72 hours postoperatively. Postoperatively, patients received 1,000 mg paracetamol every 6 hours. Additional piritramide was given on demand. A blinded observer obtained the VAS scores at 0, 2, 24, 48, and 72 hours as well as the postoperatively administered doses of piritramide. RESULTS: There was no difference in VAS scores or the consumption of piritramide during the first 72 hours postoperatively between groups (acupuncture versus placebo: 2.32 [1.40-3.25] versus 2.62 [1.89-3.36] average pain on VAS 0-10; 15.3 [12.0-18.6] mg versus 13.9 [10.5-17.3] mg piritramide). Values are expressed as mean [CI]. CONCLUSION: Our study shows no reduction in postoperative pain or an opioid sparing effect of auricular acupuncture in women undergoing laparoscopic procedures. Because we emphasized blinding of the patients and the exclusion of therapist-patient interactions, our study suggests that electrical auricular acupuncture has no effect on postoperative pain.

Kudoa unicapsula n. sp. (Myxosporea: Kudoidae) a parasite of the Mediterranean mullets Liza ramada and L. aurata (Teleostei: Mugilidae).

A new multivalvulid myxozoan parasite, Kudoa unicapsula n. sp., is described from the intestinal mesentery, intestine and pyloric caeca of the thin-lipped grey mullet Liza ramada (Risso 1826) and the golden grey mullet L. aurata (Risso, 1810) from the Mediterranean coastal waters of Spain. It is characterized by the presence of elongated, rice corn-like white cysts of 0.47-0.56 x 0.18-0.38 mm, filled with tetracapsulate, slightly asymmetric spores, rectangular in apical view and tear-shaped in lateral view with four polar capsules of considerably different size and slightly unequal spore valves with rounded edges, overlapping each other on the apex of the spore. One large polar capsule includes a polar filament coiled in two to three turns, and the other three polar capsules, which are very small, posses only a rudimental filament. Both light and electron microscopy data showed that this species differs from all previously described Kudoa spp. with unequal polar capsules. The molecular analysis based on 18S and 28S ribosomal deoxyribonucleic acid DNA sequence data of K. unicapsula n. sp. indicates a close relationship and thus phylogenetic clustering together with K. trifolia, a myxozoan from the same host and the same geographical location.

Molecular studies on the seasonal occurrence and development of five myxozoans in farmed Salmo trutta L.

Five myxozoan species, Tetracapsuloides bryosalmonae, Sphaerospora truttae, Chloromyxum schurovi, Chloromyxum truttae and a Myxobolus species were detected in farmed brown trout, Salmo trutta L. from Central Scotland. Using PCR and in situ hybridization, this study investigated the seasonal occurrence and tissue location of these species in young of the year brown trout. C. schurovi, C. truttae and Myxobolus sp. were first detected in brown trout in April, 2 months before T. bryosalmonae and S. truttae. T. bryosalmonae and S. truttae showed proliferation in the blood with intravascular stages of T. bryosalmonae accumulating in the heart. In contrast, only small amounts of PCR products of C. schurovi and C. truttae were obtained from the blood, suggesting that these species use the vascular system for transport but proliferate only in their target tissues from which large amounts of PCR product were obtained and where parasites were visible in histological sections. Large amounts of PCR product were obtained for T. bryosalmonae, S. truttae and both Chloromyxum species from the gills of brown trout, suggesting the gills as entry locus for these species. The neurotropic Myxobolus species formed plasmodia predominantly in the peripheral nerves, possibly indicating an entry route through the skin. Presporogonic stages of all other species had disappeared by September and mature spores were present from August onwards.

Kudoa trifolia sp. n. - molecular phylogeny suggests a new spore morphology and unusual tissue location for a well-known genus.

A new species of myxozoan, Kudoa trifolia sp. n., was found in various organs of the golden grey mullet, Liza aurata (Risso), and the thinlip mullet, L. ramada (Risso), from the western Mediterranean. Spores developed in subspherical plasmodia of 0.28-1 mm diameter within connective tissue, predominantly in the spleen, the outer wall of the gall bladder and the gut, the mesenteries and occasionally also in the gills. The spores of K. trifolia differ from the commonly known shape of Kudoa by considerable enlargement of one of the four valve cells, thus forming a 'spore body', which contains the major part of the binucleate sporoplasm. Scanning electron microscopy of the spores revealed the presence of grape-like appendages, which occur in bundles terminally on the valve cells. Phylogenetic analysis based on the 18S rDNA sequence of K. trifolia showed that this species is deeply embedded in the genus Kudoa despite its aberrant morphology and host tissue location. This suggests important amendments to the morphological diagnosis of the genus Kudoa.

[Aphasia--characteristics and therapeutic measures]. / Aphasien--Merkmale und Massnahmen.

The Otorhinolaryngologist may need information about patients with central language disorders. Some behavioural features and intervention strategies are discussed for evaluating aphasic syndromes.