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Plant tissues are plentiful, diverse, and due to convergent evolution are structurally similar to many animal tissues. Decellularized plant tissues feature microtopographies that resemble cancellous bone (porous parenchyma) and skeletal muscle (fibrous vascular bundles). However, the use of plant tissues as an inexpensive and abundant biomaterial for controlling stem cell behavior has not been widely explored.Celery plant tissues were cut cross-sectionally (porous parenchyma) or longitudinally (fibrous vascular bundles) and decellularized. Human mesenchymal stem cells (MSCs) were then cultured atop plant tissues and confocal imaging of single cells was used to evaluate the early effects of microtopography on MSC adhesion, morphology, cytoskeletal alignment, Yes-associated protein (YAP) signaling, and downstream lineage commitment to osteogenic or myogenic phenotypes.Microtopography was conserved post plant tissue decellularization and MSCs attached and proliferated on plant tissues. MSCs cultured on porous parenchyma spread isotropically along the periphery of plant tissue pores. In contrast, MSCs cultured on vascular bundles spread anisotropically and aligned in the direction of fibrous vascular bundles. Differences in microtopography also influenced MSC nuclear YAP localization and actin anisotropy, with higher values observed on fibrous tissues. When exposed to osteogenic or myogenic culture medium, MSCs on porous parenchyma had a higher percentage of cells stain positive for bone biomarker alkaline phosphatase, whereas myoblast determination protein 1 (MyoD) was significantly upregulated for MSCs on fibrous vascular bundles.Together, these results show that plant tissues are an abundant biomaterial with defined microarchitecture that can reproducibly regulate MSC morphology, mechanosensing, and differentiation.The online version of this article contains supplementary material available 10.1007/s12195-022-00737-9.

The meniscus plays a central load bearing role in the knee joint. Unfortunately, meniscus injury is common and can lead to joint degeneration and osteoarthritis. In small animal models, progressive degenerative changes occur with unloading of the meniscus via destabilization of the medial meniscus (DMM). However, few large animal models of DMM exist and the joint-wide initiation of disease has not yet been defined in these models. Thus, the goal of this study was to develop and validate a large-animal model of surgically-induced destabilization of the medial meniscus and to use multi-modal (mechanical, histological, and MRI) and multi-scale (joint to tissue level) quantitative measures to evaluate degeneration in both the meniscus and cartilage. DMM was achieved using an arthroscopic approach in thirteen Yucatan minipigs. One month after DMM, joint contact area decreased and peak pressure increased, indicating altered load transmission as a result of meniscus destabilization. By three months, the joint had adapted to the injury and load transmission patterns were restored to baseline, likely due to the formation and maturation of a fibrovascular scar at the anterior aspect of the meniscus. Despite this, we found a decrease in the indentation modulus of the tibial cartilage and an increase in cartilage histopathology scores at one month compared to Sham operated animals; these deleterious changes persisted through three months. Over this same time course, meniscus remodeling was evident through decreased proteoglycan staining in DMM compared to Sham menisci at both one and three months. These findings support that arthroscopic DMM results in joint degeneration in the Yucatan minipig and provides a new large animal test bed in which to evaluate therapeutics and interventions to treat post-traumatic osteoarthritis (PTOA) that originates from meniscal injury.

Articular cartilage is integral to the mechanical function of many joints in the body. When injured, cartilage lacks the capacity to self-heal, and thus, therapies and replacements have been developed in recent decades to treat damaged cartilage. Given that the primary function of articular cartilage is mechanical in nature, rigorous physical evaluation of cartilage tissues undergoing treatment and cartilage constructs intended for replacement is an absolute necessity. With the large number of groups developing cartilage tissue engineering strategies, however, a variety of mechanical testing protocols have been reported in the literature. This lack of consensus in testing methods makes comparison between studies difficult at times, and can lead to misinterpretation of data relative to native tissue. Therefore, the purpose of this study was to systematically review mechanical testing of articular cartilage and cartilage repair constructs over the past 10 years (January 2009–December 2018), to highlight the most common testing configurations, and to identify key testing parameters. For the most common tests, key parameters identified in this systematic review were validated by characterizing both cartilage tissue and hydrogels commonly used in cartilage tissue engineering. Our findings show that compression testing was the most common test performed (80.2%; 158/197), followed by evaluation of frictional properties (18.8%; 37/197). Upon further review of those studies performing compression testing, the various modes (ramp, stress relaxation, creep, dynamic) and testing configurations (unconfined, confined, in situ) are described and systematically reviewed for parameters, including strain rate, equilibrium time, and maximum strain. This systematic analysis revealed considerable variability in testing methods. Our validation testing studies showed that such variations in testing criteria could have large implications on reported outcome parameters (e.g., modulus) and the interpretation of findings from these studies. This analysis is carried out for all common testing methods, followed by a discussion of less common trends and directions in the mechanical evaluation of cartilage tissues and constructs. Overall, this work may serve as a guide for cartilage tissue engineers seeking to rigorously evaluate the physical properties of their novel treatment strategies. IMPACT STATEMENT: Articular cartilage tissue engineering has made significant strides with regard to treatments and replacements for injured tissue. The evaluation of these approaches typically involves mechanical testing, yet the plethora of testing techniques makes comparisons between studies difficult, and often leads to misinterpretation of data compared with native tissue. This study serves as a guide for the mechanical testing of cartilage tissues and constructs, highlighting recent trends in test conditions and validating these common procedures. Cartilage tissue engineers, especially those unfamiliar with mechanical testing protocols, will benefit from this study in their quest to physically evaluate novel treatment and regeneration approaches.

Articular cartilage is a remarkable tissue whose sophisticated composition and architecture allow it to withstand complex stresses within the joint. Once injured, cartilage lacks the capacity to self-repair, and injuries often progress to joint wide osteoarthritis (OA) resulting in debilitating pain and loss of mobility. Current palliative and surgical management provides short-term symptom relief, but almost always progresses to further deterioration in the long term. A number of bioactive factors, including drugs, corticosteroids, and growth factors, have been utilized in the clinic, in clinical trials, or in emerging research studies to alleviate the inflamed joint environment or to promote new cartilage tissue formation. However, these therapies remain limited in their duration and effectiveness. For this reason, current efforts are focused on improving the localization, retention, and activity of these bioactive factors. The purpose of this review is to highlight recent advances in drug delivery for the treatment of damaged or degenerated cartilage. First, we summarize material and modification techniques to improve the delivery of these factors to damaged tissue and enhance their retention and action within the joint environment. Second, we discuss recent studies using novel methods to promote new cartilage formation via biofactor delivery, that have potential for improving future long-term clinical outcomes. Lastly, we review the emerging field of orthobiologics, using delivered and endogenous cells as drug-delivering "factories" to preserve and restore joint health. Enhancing drug delivery systems can improve both restorative and regenerative treatments for damaged cartilage. STATEMENT OF SIGNIFICANCE: Articular cartilage is a remarkable and sophisticated tissue that tolerates complex stresses within the joint. When injured, cartilage cannot self-repair, and these injuries often progress to joint-wide osteoarthritis, causing patients debilitating pain and loss of mobility. Current palliative and surgical treatments only provide short-term symptomatic relief and are limited with regards to efficiency and efficacy. Bioactive factors, such as drugs and growth factors, can improve outcomes to either stabilize the degenerated environment or regenerate replacement tissue. This review highlights recent advances and novel techniques to enhance the delivery, localization, retention, and activity of these factors, providing an overview of the cartilage drug delivery field that can guide future research in restorative and regenerative treatments for damaged cartilage.

Meniscal lesions represent one of the most common orthopedic injuries, and the standard of care, partial meniscectomy, often leads to long-term joint deterioration. The current meniscal replacement devices fail to recreate the native meniscus biomechanics that may explain the uncertainty of their clinical efficacy. A biomechanically functional, collagen-hyaluronan infused, three-dimensional printed polymeric scaffold was implanted into 18 sheep for up to 24 weeks to assess the scaffold's fixation, cellular response, tissue generation, integration to the host tissue, and effect on the surrounding articular cartilage. The scaffolds were assessed via gross inspection, histology, immunofluorescence, and biochemical analysis and the articular cartilage was assessed via gross inspection and histology. Scaffolds were ingrown with cells that generated a dense fibrocartilage-like tissue with significant collagen and glycosaminoglycan deposition. The stability of the surgical fixation was variable, however, with three partially displaced and five completely displaced implants at 12 weeks and three anatomic, four partially displaced, and two completely displaced implants at 24 weeks. Those implants remaining in the anatomic position displayed markedly improved outcomes. There was no significant degeneration observed in the surrounding articular cartilage for any condition. This study demonstrated the scaffold induces fibrochondrocytic tissue ingrowth, integrates robustly, and continues to mature as late as 24 weeks, and the articular cartilage is not adversely changed. The surgical model and fixation method must be improved and longer time points need to be investigated to further determine the scaffold's efficacy and chondroprotective abilities. IMPACT STATEMENT: The only FDA-approved partial meniscus scaffold, the Collagen Meniscus Implant (CMI), is not approved for reimbursement by government and only reimbursable by certain private insurers. Scaffolds with improved mechanical properties and greater efficacy are needed. A previous study (Ghodbane, et al. DOI: 10.1002/jbm.b.34331) demonstrated the ability of our novel acellular, off-the shelf scaffold to restore knee biomechanics following partial meniscectomy, which could potentially decrease the risk of osteoarthritis following partial meniscectomy, providing the motivation for this study. This article presents a first-in-animal feasibility study.

The menisci transmit load by increasing the contact area and decreasing peak contact stresses on the articular surfaces. Meniscal lesions are among the most common orthopedic injuries, and resulting meniscectomies are associated with adverse polycaprolactone contact mechanics changes and, ultimately, an increased likelihood of osteoarthritis. Meniscus scaffolds were fabricated by 3D-printing a network of circumferential and radial filaments of resorbable polymer (poly(desaminotyrosyl-tyrosine dodecyl ester dodecanoate)) and infused with collagen-hyaluronan. The scaffold demonstrated an instantaneous compressive modulus (1.66 ± 0.44 MPa) comparable to native meniscus (1.52 ± 0.59 MPa). The scaffold aggregate modulus (1.33 ± 0.51 MPa) was within 2% of the native value (1.31 ± 0.36 MPa). In tension, the scaffold displayed a comparable stiffness to native tissue (127.6-97.1 N/mm) and an ultimate load of 33% of the native value. Suture pull-out load of scaffolds (83.1 ± 10.0 N) was within 10% of native values (91.5 ± 15.4 N). Contact stress analysis demonstrated the scaffold reduced peak contact stress by 60-67% and increased contact area by 38%, relative to partial meniscectomy. This is the first meniscal scaffold to match both the axial compressive properties and the circumferential tensile stiffness of the native meniscus. The improvement of joint contact mechanics, relative to partial meniscectomy alone, motivates further investigation using a large animal model. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B:2457-2465, 2019.

Background:Meniscal lesions represent one of the most common intra-articular knee injuries. Meniscus replacement devices are needed to restore load distribution and knee stability after meniscectomy. Fixation of these devices is crucial to the generation of hoop stresses and the distribution of loads in the joint.Purpose:To evaluate 2 different fixation techniques (suture endobutton and interference screw) for implantation of a novel meniscus device.Study Design:Controlled laboratory study.Methods:In 7 human cadaveric knees (aged 17-61 years), 1 anterior and 2 potential posterior tunnel locations were investigated, and both fixation techniques were tested in each tunnel. The native meniscus roots, devices fixed with a suture endobutton, and devices fixed with an interference screw were gripped with cryoclamps, and tibias were drilled and loaded into a custom jig. Samples were preloaded, preconditioned, loaded for 500 cycles (50-150 N), and tested in tension until failure.Results:For all 3 tunnels, suture fixation resulted in greater elongation (54.1%-150.7% greater; P < .05) during cyclic loading than interference screw fixation, which approximated the native roots. Both fixation techniques displayed ultimate tensile loads in the same range as native roots. However, stiffness of the suture fixation groups (36.5-41.6 N/mm) was only 28% to 37% of that of the interference screw fixation groups (98.7-131.6 N/mm), which had values approaching those of the native roots (anterior: 175.4 ± 24.2 N/mm; posterior: 157.6 ± 22.9 N/mm).Conclusion:Interference screw fixation was found to be superior to suture fixation with regard to elongation and stiffness, a finding that should be considered in the design and implantation of novel meniscus replacement devices.Clinical Relevance:With the emergence of various devices for total meniscus replacement, the establishment of fixation strategies is crucial for the generation of tensile hoop stresses and the efficacy of these approaches.

Eight software applications are compared for their performance in estimating the octanol-water partition coefficient (Kow), melting point, vapor pressure and water solubility for a dataset of polychlorinated biphenyls, polybrominated diphenyl ethers, polychlorinated dibenzodioxins, and polycyclic aromatic hydrocarbons. The predicted property values are compared against a curated dataset of measured property values compiled from the scientific literature with careful consideration given to the analytical methods used for property measurements of these hydrophobic chemicals. The variability in the predicted values from different calculators generally increases for higher values of Kow and melting point and for lower values of water solubility and vapor pressure. For each property, no individual calculator outperforms the others for all four of the chemical classes included in the analysis. Because calculator performance varies based on chemical class and property value, the geometric mean and the median of the calculated values from multiple calculators that use different estimation algorithms are recommended as more reliable estimates of the property value than the value from any single calculator.

Cartilage injuries and subsequent tissue deterioration impact millions of patients. Since the regeneration of functional hyaline cartilage remains elusive, methods to stabilize the remaining tissue, and prevent further deterioration, would be of significant clinical utility and prolong joint function. Finite element modeling shows that fortification of the degenerate cartilage (Reinforcement) and reestablishment of a superficial zone (Sealing) are both required to restore fluid pressurization within the tissue and restrict fluid flow and matrix loss from the defect surface. Here, a hyaluronic acid (HA) hydrogel system is designed to both interdigitate with and promote the sealing of the degenerated cartilage. Interdigitating fortification restores both bulk and local pericellular tissue mechanics, reestablishing the homeostatic mechanotransduction of endogenous chondrocytes within the tissue. This HA therapy is further functionalized to present chemo mechanical cues that improve the attachment and direct the response of mesenchymal stem/stromal cells at the defect site, guiding localized extracellular matrix deposition to "seal" the defect. Together, these results support the therapeutic potential, across cell and tissue length scales, of an innovative hydrogel therapy for the treatment of damaged cartilage.

Atypical food intake is a primary cause of obesity and other eating and metabolic disorders. Insight into the neural control of feeding has previously focused mainly on signalling mechanisms associated with the hypothalamus1-5, the major centre in the brain that regulates body weight homeostasis6,7. However, roles of non-canonical central nervous system signalling mechanisms in regulating feeding behaviour have been largely uncharacterized. Acetylcholine has long been proposed to influence feeding8-10 owing in part to the functional similarity between acetylcholine and nicotine, a known appetite suppressant. Nicotine is an exogenous agonist for acetylcholine receptors, suggesting that endogenous cholinergic signalling may play a part in normal physiological regulation of feeding. However, it remains unclear how cholinergic neurons in the brain regulate food intake. Here we report that cholinergic neurons of the mouse basal forebrain potently influence food intake and body weight. Impairment of cholinergic signalling increases food intake and results in severe obesity, whereas enhanced cholinergic signalling decreases food consumption. We found that cholinergic circuits modulate appetite suppression on downstream targets in the hypothalamus. Together our data reveal the cholinergic basal forebrain as a major modulatory centre underlying feeding behaviour.

Background:Meniscus injuries in the United States result in an estimated 850,000 surgical procedures each year. Although meniscectomies are the most commonly performed orthopaedic surgery, little advancement has been made in meniscus replacement and regeneration, and there is currently no total meniscus replacement device approved by the Food and Drug Administration.Hypothesis:A novel fiber-reinforced meniscus scaffold can be used as a functional total meniscus replacement.Study Design:Controlled laboratory study.Methods:A tyrosine-derived, polymer fiber–reinforced collagen sponge meniscus scaffold was evaluated mechanically (tensile and compressive testing) and histologically after 16 and 32 weeks of implantation in an ovine total meniscectomy model (N = 20; 16 implants plus 4 meniscectomies, divided equally over the 2 time periods). The extent of cartilage damage was also measured on tibial plateaus by use of toluidine blue surface staining and on femoral condyles by use of Mankin scores on histological slides.Results:Scaffolds induced formation of neomeniscus tissue that remained intact and functional, with breaking loads approximating 250 N at both 16 and 32 weeks compared with 552 N for native menisci. Tensile stiffness values (99 and 74 N/mm at 16 and 32 weeks, respectively) were also comparable with those of the native meniscus (147 N/mm). The compressive modulus of the neomeniscus tissue (0.33 MPa at both 16 and 32 weeks) was significantly increased compared with unimplanted (time 0) scaffolds (0.15 MPa). There was histological evidence of extensive tissue ingrowth and extracellular matrix deposition, with immunohistochemical evidence of types I and II collagen. Based on significantly decreased surface damage scores as well as Mankin scores, the scaffold implants provided greater protection of articular cartilage compared with the untreated total meniscectomy.Conclusion:This novel fiber-reinforced meniscus scaffold can act as a functional meniscus replacement, with mechanical properties similar to those of the native meniscus, while protecting the articular cartilage of the knee from the extensive damage after a total meniscectomy.Clinical Relevance:This meniscus replacement scaffold has the potential to improve surgical treatment and provide better long-term outcomes for those suffering from severe meniscus damage.

Wnt signaling plays an essential role in developmental and regenerative myelination of the CNS, therefore it is critical to understand how the factors associated with the various regulatory layers of this complex pathway contribute to these processes. Recently, Apcdd1 was identified as a negative regulator of proximal Wnt signaling, however its role in oligodendrocyte (OL) differentiation and reymelination in the CNS remain undefined. Analysis of Apcdd1 expression revealed dynamic expression during OL development, where its expression is upregulated during differentiation. Functional studies using ex vivo and in vitro OL systems revealed that Apcdd1 promotes OL differentiation, suppresses Wnt signaling, and associates with β-catenin. Application of these findings to white matter injury (WMI) models revealed that Apcdd1 similarly promotes OL differentiation after gliotoxic injury in vivo and acute hypoxia ex vivo. Examination of Apcdd1 expression in white matter lesions from neonatal WMI and adult multiple sclerosis revealed its expression in subsets of oligodendrocyte (OL) precursors. These studies describe, for the first time, the role of Apcdd1 in OLs after WMI and reveal that negative regulators of the proximal Wnt pathway can influence regenerative myelination, suggesting a new therapeutic strategy for modulating Wnt signaling and stimulating repair after WMI.

Controlled racemization of enantiopure alcohols is a key step in dynamic kinetic resolution. We recently reported the racemization of enantiopure phenyl-ring-containing alcohols using W110A Thermoanaerobacter ethanolicus secondary alcohol dehydrogenase (W110A TeSADH), which relies on selectivity mistakes. Trp-110 lines the large pocket of the active site of TeSADH, which allows W110A TeSADH mutant to accommodate phenyl-ring-containing substrates in Prelog mode, albeit with selectivity mistakes. Here, we report the racemization of enantiopure phenyl-ring-containing alcohols using several Trp-110 mutants of TeSADH in the presence of the oxidized and reduced forms of nicotinamide–adenine dinucleotide. We observed a noticeable enhancement in racemization efficiency when W110G TeSADH was used compared with W110Q, W110M, W110L, W110I, and W110V. This observation was anticipated because the W110G mutation is expected to open the large pocket of the active site to a greater extent compared to other mutants of TeSADH at W110. Both enantiomers of 1-phenyl-2-propanol and 4-phenyl-2-butanol were fully racemized by W110G TeSADH. We also constructed a triple mutant of TeSADH, W110A/I86A/C295A, by site-directed mutagenesis with the aim of opening the two pockets of the active site of TeSADH. The W110A/I86A/C295A mutant was employed to racemize enantiopure phenyl-ring-containing alcohols. The current study demonstrates that W110G and W110A/I86A/C295A TeSADH are more efficient catalysts for the racemization of enantiopure secondary alcohols than the previously reported mutant W110A TeSADH [6] .

Alcohol dehydrogenases (ADHs) are enzymes that catalyze the reversible reduction of carbonyl compounds to their corresponding alcohols. We have been studying a thermostable, nicotinamide-adenine dinucleotide phosphate (NADP+)-dependent, secondary ADH from Thermoanaerobacter ethanolicus (TeSADH). In the current work, we expanded our library of TeSADH and adopted the site-saturation mutagenesis approach in creating a comprehensive mutant library at W110. We used phenylacetone as a model substrate to study the effectiveness of our library because this substrate showed low enantioselectivity in our previous work when reduced using W110A TeSADH. Five of the newly designed W110 mutants reduced phenylacetone at >99.9% ee, and two of these mutants exhibit an enantiomeric ratio (E-value) of over 100. These five mutants also reduced 1-phenyl-2-butanone and 4-phenyl-2-butanone to their corresponding (S)-configured alcohols in >99.9% ee. These new mutants of TeSADH will likely have synthetic utility for reduction of aromatic ketones in the future.

Memory access rate is a primary performance bottleneck in high-performance networking systems. The MoSys Bandwidth Engine family of integrated circuits provides a significant improvement in effective memory performance by using high-speed serial I/O's, many banks of memory, a low-latency, highly efficient protocol, and intelligence within the device. The first member of the family can perform 2 billion 72-bit reads per second or 1 billion read-modify-write operations per second.

Trypanosoma cruzi was demonstrated in blood smears and heart tissue from a 5-year old, female, English Cocker Spaniel that had never been outside of the state of Virginia, USA. Plasma from the dog was positive in a commercially available immunochromatographic dipstick assay for T. cruzi and negative in an immunochromatographic dipstick assay for visceral Leishmania spp. The plasma from the dog had an indirect immunofluorescent antibody titer of 1:800 against epimastigotes of T. cruzi while the titer was 1:50 against promastigotes of L. infantum. The parasite was isolated from the blood in vitro from the dog (TcVT-1 isolate) and used to experimentally infect female C3H and ICR mice. The parasite was nonpathogenic for experimentally inoculated mice. DNA was isolated from parasites grown in vitro and used to determine that the genotype of T. cruzi present in the dog was genotype TcIV. This genotype is common in raccoons, Procyon lotor, in North America and suggests that raccoons may serve as reservoirs for canine infection.

Atorvastatin is a 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor, and this drug leads to decreased levels of low density lipoprotein (LDL) cholesterol. Lower LDL cholesterol has direct relationship in reducing mortality from coronary heart diseases. Lipitor® (atorvastatin calcium) was the first drug to reach the annual sales of 10 billion dollars in USA and currently is the top selling pharmaceutical product globally. Atorvastatin has a side chain containing two chiral centers as its pharmacophore and it can be synthesized either from chiral pool precursors, by using metal catalysts; or more preferably by the application of free or immobilized enzymes and whole cell biocatalysts for carrying out either asymmetric synthesis or racemic resolution. Biocatalytic synthesis methods for chiral atorvastatin intermediates employ a wide variety of biocatalysts such as alcohol dehydrogenase, 2-deoxy- d -ribose 5-phosphate aldolase, nitrilase, lipase, etc. and each of these biocatalytic processes is discussed in detail in this paper.

Summary The α-pyrone antibiotic myxopyronin (Myx) inhibits bacterial RNA polymerase (RNAP). Here, through a combination of genetic, biochemical, and structural approaches, we show that Myx interacts with the RNAP "switch region"—the hinge that mediates opening and closing of the RNAP active center cleft—to prevent interaction of RNAP with promoter DNA. We define the contacts between Myx and RNAP and the effects of Myx on RNAP conformation and propose that Myx functions by interfering with opening of the RNAP active-center cleft during transcription initiation. We further show that the structurally related α-pyrone antibiotic corallopyronin (Cor) and the structurally unrelated macrocyclic-lactone antibiotic ripostatin (Rip) function analogously to Myx. The RNAP switch region is distant from targets of previously characterized RNAP inhibitors, and, correspondingly, Myx, Cor, and Rip do not exhibit crossresistance with previously characterized RNAP inhibitors. The RNAP switch region is an attractive target for identification of new broad-spectrum antibacterial therapeutic agents.

Spinocerebellar ataxia type 1 (SCA1) is an adult-onset, dominantly inherited neurodegenerative disease caused by expansion of a glutamine repeat tract in ataxin-1 (ATXN1). Although the precise function of ATXN1 remains elusive, it seems to be involved in transcriptional repression. We find that mutant ATXN1 represses transcription of the neurotrophic and angiogenic factor vascular endothelial growth factor (VEGF). Genetic overexpression or pharmacologic infusion of recombinant VEGF mitigates SCA1 pathogenesis, suggesting a new therapeutic strategy for this disease.