CD40 is essential in the upregulation of TRAF proteins and NF-kappaB-dependent proinflammatory gene expression after arterial injury

Despite extensive investigations, restenosis, which is characterized primarily by neointima formation, remains an unsolved clinical problem after vascular interventions. A recent study has shown that CD40 signaling through TNF receptor associated factor 6 (TRAF6) plays a key role in neointima formation after carotid artery injury; however, underlying mechanisms are not clearly elucidated. Because neointima formation may vary significantly depending on the type of injury, we first assessed the effect of CD40 deficiency on neointima formation in 2 injury models, carotid artery ligation and femoral artery denudation injury. Compared with wild-type mice, CD40 deficiency significantly reduced neointima formation and lumen stenosis in two different models. Further, we investigated the mechanism by which CD40 signaling affects neointima formation after arterial injury. In wild-type mice, the expression levels of CD40, several TRAF proteins, including TRAF1, TRAF2, TRAF3, TRAF5, and TRAF6, as well as total NF-kB p65 and phospho-NF-kB p65, in the carotid artery were markedly upregulated within 3-7 days after carotid ligation. Deficiency of CD40 abolished the injury-induced upregulation of TRAFs including TRAF6 and NF-kB-p65 in the injured vessel wall. Further, CD40(-/-) mice showed a significant decrease in the recruitment of neutrophils (at 3, 7d) and macrophages (at 7, 21d) into injured artery; this effect was most likely attributed to inhibition of NF-kB activation and marked downregulation of NF-kB-related gene expression, including cytokines (TNFα, IL-1β, IL-6), chemokines (MCP-1), and adhesion molecules (ICAM-1, VCAM-1). Moreover, neutrophil recruitment in a model of thioglycollate-induced peritonitis is impaired in CD40-deficient mice. In vitro data revealed that CD40 deficiency blocked CD40L-induced NF-kB p65 nuclear translocation in leukocytes. Altogether, our data identified for the first time that CD40 is essential in the upregulation of TRAF6, NF-kB activation, and NF-kB-dependent proinflammatory genes in vivo. Our findings firmly established the role for CD40 in neointima formation in 2 distinct injury models.     

Roles of chymase in stenosis occurring after polytetrafluoroethylene graft implantations

Chymase is an important enzyme for the generation of angiotensin (Ang) II and in the activation of transforming growth factor (TGF)-beta1. Therefore, chymase may be involved in the hemodialysis access dysfunction, which is caused by intimal hyperplasia that occurs after polytetrafluoroethylene (PTFE) graft implantations. Bilateral U-shaped PTFE grafts were placed between the femoral vein and artery in dogs. Chymase inhibitor (NK3201, 1 mg/kg per day, p.o.) treatments were initiated 3 days before the operation. After the implantation, the stenosis by neointima proliferation was most frequently observed in the venous side of the PTFE grafts. In the hyperplastic neointima, myofibroblasts were the main cellular components. On the other hand, fibroblasts only occupied cellular components in a much smaller proportion in the neointima. However, these cells seem to be rich in the properties of proliferation and migration. After PTFE graft implantations, extensive accumulations of chymase-positive mast cells were found mainly in the tissue surrounding the grafts. The Ang II- and TGF-beta-positive cells were found in an adjacent section that was in close proximity to the chymase-positive cells. In contrast, the AT(1) receptors, as well as TGF-beta type II receptors, were expressed either in the neointima or in the outside adventitia of the PTFE grafts. Chymase inhibitor treatment resulted in a reduction of chymase, Ang II and TGF-beta1 expression, leading to a significant inhibition of neointimal formation. These findings indicating that an increase of chymase via promoting Ang II and TGF-beta1 generation plays a pivotal role in the neointimal formation after the implantation of PTFE grafts and also suggesting that chymase inhibition may be a new strategy that can be used to prevent PTFE graft dysfunctions in clinical settings.     

Host finding by Uscana lariophaga (Hymenoptera: Trichogrammatidae) in stored cowpea: the effect of distance, time interval, host patch size and spatial orientation

Host finding and parasitization by Uscana lariophaga Steffan, a potential biocontrol agent of the storage pest Callosobruchus maculatus (Fabricius), were investigated in stored cowpea. Host finding was shown to be a function of distance, time, host patch size and the spatial position of U. lariophaga relative to the host patch. Uscana lariophaga females were able to find hosts up to 75 cm horizontal distance from the host patch, which was the largest distance tested. The probability that a host patch was found when an individual U. lariophaga female was released at 2.5 cm horizontal distance from the host patch ranged from 0.6 after 2 h foraging time to 0.9 after 8 h foraging time. At 10 cm from the host patch, host finding probability ranged from 0.2 to 0.45 at these respective foraging times. Finding probabilities doubled compared to horizontal distances when U. lariophaga was released below the host patch, and halved when it was released above the host patch. The negative geotaxic response was shown not to be an artefact of the release method. The median net displacement rate in the direction of the host patch was two beans per hour (1.4 cm h(-1)). The results suggest that U. lariophaga females start searching for hosts regardless of the quality of the olfactory information they receive. Additional observations indicated that U. lariophaga is adapted to a host with a patchy distribution, which implies that host finding over larger distances is relevant for U. lariophaga.     

An S-type bypass can improve the hemodynamics in the bypassed arteries and suppress intimal hyperplasia along the host artery floor

The development of distal end-to-side anastomotic intimal hyperplasia (IH) has been attributed to the flow disturbance and abnormal wall shear stress (WSS) distribution there. The geometry of the bypass has a strong influence on the flow pattern and WSS distribution. Using a canine model of end-to-side anastomosis, a 45 degrees S-type bypass was compared with 60 degrees , 45 degrees and 30 degrees conventional bypasses in the term of IH along the host artery floor. Numerical blood flow simulations were also carried out to characterize the flow patterns at the distal parts of the bypassed arteries for the 4 models. The results showed that the averaged intima thicknesses of the host artery floors for the 4 bypass models were 119.50+/-10.30 microm (60 degrees ), 65.56+/-6.53 microm (45 degrees ), 45.26+/-5.99 microm (30 degrees ) and 47.64+/-4.85 microm (S-type), respectively, vs. 9.81+/-1.88 microm in the control group (without bypass surgery). Compared with the control group, neointima thickness in all 4 bypass models was significantly increased, but the neointima thickness of the 45 degrees S-type bypass was apparently much better than its 45 degrees conventional counterpart, and was as good as the 30 degrees conventional bypass. The numerical simulation revealed an apparent swirling flow pattern in the S-type bypass, which was very different than the flow patterns in the 3 conventional bypass models. This swirling flow altered the overall flow pattern in the distal part of the bypassed artery and eliminated the low WSS zone along the host artery floor. The improvement in the term of IH for the S-type bypass is most likely due to the alteration of the overall flow pattern and WSS distribution by the geometrical configuration of the S-type bypass.     

Flexible Use of Patch-Leaving Mechanisms in a Parasitoid Wasp

Classical optimal-foraging theory predicts that a parasitoid is less likely to leave a patch after a host encounter when the host distribution is aggregated, whereas a parasitoid is more likely to leave after a host encounter when the host distribution is regular. Field data on host distributions in the area of origin of the whitefly parasitoid Encarsia formosa showed that whiteflies aggregate at several spatial scales. However, infested leaves most likely contained a single host. This suggests that a host encounter is not enough to decide when to leave. We therefore tested the effect of host distribution and parasitoid experience on patch-leaving behavior. Each parasitoid was observed for several consecutive days in a three-dimensional arena with leaflets containing on average one host per leaflet in an either regular or aggregated host distribution. A proportional hazards model showed that a host encounter decreased the leaving tendency on a leaflet with one host when the time since the latest host encounter was short, but increased the leaving tendency when the time since the latest host encounter was long, independent of host distribution. We conclude that a parasitoid can switch from decreasing to increasing its tendency to leave a patch after a host encounter. We propose two hypotheses that may explain the evolution of such a switching mechanism.     

凝血酶调节蛋白基因防治血管内膜增生狭窄的实验研究

目的:观察凝血酶调节蛋白(Thrombomodulin,TM)基因转染兔髂动脉损伤模型后,对动脉血管内膜增生狭窄的防治作用。方法:用注射式加压转染的方式对兔动脉壁转染pcDNA3.1/hTM质粒,再制造动脉损伤-阻滞模型,于术后3天、7天、14天、28天用免疫组化的方法观察TM蛋白在各组血管腔内的表达,术后14天、28天用彩色多普勒观察活体吻合口内径和血流流速;再做病理切片Verhoeff染色,观察血管内膜增生的程度、部位,计算血管内膜面积、中膜面积和血管狭窄率。结果:术后3天、7天、14天、28天hTM质粒转染组中hTM表达一直保持在高水平,7天达到高峰,14天、28天虽有所下降但是表达强度仍然高于载体质粒转染组合空白对照组。在术后14天、28天彩色多普勒观察测量吻合口内径:hTM质粒转染组分别为1.93mm±0.34mm,1.89mm±0.28mm;载体质粒转染组为1.59mm±0.43mm,1.38mm±0.28mm;空白对照组1.46mm±0.25mm,1.44mm±0.32mm。在这两个时间点,hTM质粒转染组血管狭窄率为32±23%,37±14%;载体质粒转染组为58±21%,63±17%;空白对照组为58±19%,61±23%。结论:hTM基因在转染动脉壁后能减少动脉损伤-阻滞模型在后期的血管内膜增生,改善血管的狭窄状况。     

To mark the host or the patch: Decisions of a parasitoid searching for concealed host larvae

We found evidence for patch marking in the parasitic wasp Halticoptera laevigata (Hymenoptera: Pteromalidae) foraging for concealed hosts. Wasps attack larvae of the fruit fly Myoleja lucida (Diptera: Tephritidae) in fruits of honeysuckle. A special feature of this host-parasitoid system is the limited food supply of a patch (i.e. a fruit of honeysuckle), which allows the successful development of only a single host fly larva. Females of the parasitoid H. laevigata were found to mark the host patch with a pheromone and to abandon the patch following oviposition into a single host larva. Field data revealed that eggs of the parasitoid were spread out evenly among infested patches, with several larvae of the host fly left unparasitized in those patches that contained more than one host. Since many parasitic insects mark the parasitized host after oviposition, we assumed host marking to be the ancestral character state and studied the patch-marking behaviour of H. laevigata as a derived character state as an alternative foraging strategy. We used stochastic dynamic modelling to investigate under what conditions mutant (patch) markers would be able to invade a population of normal (larval) markers. The models suggested that, under a variety of conditions, wasps marking the patch obtained higher fitness than wasps only marking the larva. Consequently, the results from our model predict the evolution of the patch-marking behaviour found in the empirical investigation. Finally, we discuss alternative pathways to the evolution of patch marking and point out under what circumstances the evolution of a patch-marking behaviour can generally be expected.     

Arrestment responses of the parasitoid, Nemeritis canescens, to a contact chemical produced by its host, Plodia interpunctella

ABSTRACT. The locomotory response of walking parasitoids to a contact chemical from their host is reviewed, and in particular the response of the ichneumonid, Nemeritis canescens Grav., to the mandibular gland secretion of its host, Plodia interpunctella Hubn., is investigated. In response to the presentation of the host chemical on a surface, a walking Nemeritis exhibits a complex ortho-kinetic response involving stopping, walking at a reduced speed and probing with the ovipositor. In response to the removal of the chemical following presentation, as would occur when the insect left the edge of the chemical patch, the wasp exhibits a klinotactic response which directs it back to the patch at an average angle of 157° relative to the orientation at the moment of stimulation. This turning-back response at the patch edge greatly increases the time spent on a patch of contact chemical. The waning of this response determines when a host patch is abandoned. This waning is retarded by increasing the concentration of contact chemical on the patch and by opposition while on the patch.     

兔血管外膜对血管重构及收缩功能影响的初步观察

本文研究血管外膜在血管重塑及功能调控中的作用。实验采用在体去除兔颈动脉外膜的方法,于术后即刻、1周及2周取出动脉作组织学、免疫组织化学染色及血管反应性测定。结果显示：(1)去除颈动脉局部外膜对内皮及中层平滑肌无明显损伤;(2)去除外膜后血管平滑肌细胞增殖,并有新生内膜形成;(3)与对照例比较,去外膜侧血管对去甲肾上腺素的收缩反应在术后即刻及1周时减弱(P＜0．05)。上述研究结果提示：去除动脉外膜可导致血管内膜增殖及血管平滑肌收缩功能的改变,表明外膜可能参与血管重塑及对血管功能的调控。     

Host Search behaviour by Rhagoletis pomonella files: inter-tree movement patterns in response to wind-borne fruit volatiles under filed conditions

Abstract. Responses of Rhagoletis pomonella (Wash) (Diptera: Tephritidae) to synthetic host fruit violates were studied in the field. Individually marked females were released in the centre of a 25 m² patch containing twenty-five host trees ( Crataegus mollis var, toba ) and followed as they moved within and between trees. Fly response to three experimental conditions was studied: (1) 'clean' air; (2) synthetic host fruit violates (apple) permeating the patch; and (3) a single point source of odour placed c 1m away from the edge of the patch. Files in a patch permeated with host odour moved faster, exhibited more straightened-out moves, and reached the edges of the patch more quickly than those exposed to clean air. Flies exposed to a point source of odour exhibited clear orientation responses, arriving consistently at the tree harbouring the source of odour. Odour exposure was intermittent and usually brief ( c . 20s^-1 exposure) with intervals between exposure periods averaging 103s. Wind speed and direction were highly variable. Flies moved during wind ranging in speed form 0.5 to 4.4 m s^-1, with their activity being greatest at winds below 2m s^-1. Strong winds (>3.5 ms^-1) either arrested movement or enhanced downwind displacement. Our observations tend to support the 'series-of-steps' hypothesis reviewed by Gibson & Brandy (1985) as a mechanism of close-range host location (1-5m from odour source). Our findings are discussed with respect to theoretical and practical implications of insect orientation mechanisms to odours, dispersal, and control strategies.     

Host frass as arrestant chemicals in locating host Mythimna separata by the tachinid fly Exorista japonica

We investigated the response of the tachinid fly, Exorista japonica (Townsend), to host frass or its extracts in order to clarify the host location mechanisms of female flies in a potential host habitat. Host searching time in a patch and the number of patch visits were analyzed by using a frass-containing patch which was excreted by host larvae, Mythimna separata (Walker) (Lepidoptera: Noctuidae), and patches to which host frass extracts were applied. E. japonica females were arrested in response to the host-frass-containing patch after contacting the frass with their front tarsi, thereby spending most of the time to search the patch and to revisit the host-frass patch. While host-searching time in the patch by the females was longest at their first visit of a patch with host frass, searching time decreased with successive visits. The female flies also exhibited area-restricted searching with methanol extracts of the host frass. Area-restricted searching activity increased with the concentration of host-frass extract, i.e., total searching time in the patch and the number of patch visits varied in a dose-dependent manner. E. japonica females likely employ chemicals in host frass as arrestants in host location.     

Dermatan sulfate and bone marrow mononuclear cells used as a new therapeutic strategy after arterial injury in mice

Background aimsPreviously, we have demonstrated that administration of dermatan sulfate (DS) suppresses neointima formation in the mouse carotid artery by activating heparin co-factor II. A similar suppressive effect was observed by increasing the number of progenitor cells in circulation. In this study, we investigated the combination of DS and bone marrow mononuclear cells (MNC), which includes potential endothelial progenitors, in neointima formation after arterial injury.MethodsArterial injury was induced by mechanical dilation of the left common carotid artery. We analyzed the extension of endothelial lesion, thrombus formation, P-selectin expression and CD45⁺ cell accumulation 1 and 3 days post-injury, and neointima formation 21 days post-injury. Animals were injected with MNC with or without DS during the first 48 h after injury.ResultsThe extension of endothelial lesion was similar in all groups 1 day after surgery; however, in injured animals treated with MNC and DS the endothelium recovery seemed to be more efficient 21 days after lesion. Treatment with DS inhibited thrombosis, decreased CD45⁺ cell accumulation and P-selectin expression at the site of injury, and reduced the neointimal area by 56%. Treatment with MNC reduced the neointimal area by 54%. The combination of DS and MNC reduced neointima formation by more than 91%. In addition, DS promoted a greater accumulation of MNC at the site of injury.ConclusionsDS inhibits the initial thrombotic and inflammatory processes after arterial injury and promotes migration of MNC to the site of the lesion, where they may assist in the recovery of the injured endothelium.     

Expression of T-cadherin in the rat carotid artery wall after balloon injury and in different rat organs

T-cadherin is an unusual glycosilphosphatidylinositol (GPI)-anchored member of the cadherin family of cell adhesion proteins. In contrast to classical cadherins, tissue distribution of T-cadherin so far remained unknown. We examined tissue distribution of T-cadherin in rats using Western blotting and immunohistochemical method. Our results show that T-cadherin is expressed in all types of muscles (cardiac, striated, and smooth muscles), in brain neurons, and spinal cord, in the vessel endothelium, at the apical pole of intestinal villar epithelium, in the basal layer of skin, and eosophagal epithelium. Blood-derived and lymphoid cells as well as connective tissue were T-cadherin-negative. The highest level of T-cadherin expression was revealed in the cardiovascular system. Although T-cadherin was detected in smooth muscle cells, its role in the intimal thickening and restenosis is not known. We examined T-cadherin expression within 1-28 days after balloon injury of rat left carotid arteries. T-cadherin expression was valued immunohistochemically with semiquantitative method. In uninjured arteries, T-cadherin was expressed in endothelial (vWF-positive) cells, and smooth muscle (alpha-actin-positive) cells (SMCs). After denudation of arterial wall, T-cadherin was present both in the media and neointima. We revealed dynamics of T-cadherin expression in the media of injured artery: an essential increase being registered at the stage of cell migration and proliferation in the media and neointima (1-7 days), followed by its decrease to the baseline level (10-28 days). The high upregulation of T-cadherin expression in the media and neointima during migration and proliferation of vascular cells after vessel injury enables us to suggest the involvement of T-cadherin in vessel remodeling after balloon catheter injury.     

重组人白介素-10抑制晚期糖基化终产物诱导的大鼠血管平滑肌细胞和血管新生内膜的增殖

研究观察了重组人白介素10(rhIL-l0)对晚期糖基化终产物(AGE)刺激下离体大鼠胸主动脉血管平滑肌细胞增殖及对SD大鼠血管损伤后新生内膜增殖的影响。体外培养大鼠主动脉血管平滑肌细胞,采用MTS／PES法确定血管平滑肌细胞的增殖状态;应用流式细胞术测定细胞周期;利用p44／42磷酸化抗MAPK抗体的蛋白免疫印迹法测定p44／42 MAPK磷酸化蛋白表达。利用大鼠颈动脉血管损伤模型,观察rhIL—10对新生内膜增殖的影响。结果显示：(1)AGE处理组与对照组相比,AGE对血管平滑肌细胞增殖具有明显的刺激作用(P＜0．05)。rhIL-l0单独应用对血管平滑肌细胞生长没有影响(P＞0．05)。在AGE刺激下,低至100ng／ml的rhIL-l0可抑制血管平滑肌细胞的生长(P＜0．05)。(2)流式细胞术测定的结果显示,rhIL—10可以使AGE作用下的VSMC大部分处于Go／G1期,与对照组相比有明显差异(P＜0．01)。(3)AGE对p44／p42 MAPK磷酸化蛋白表达有显著的增强作用,此作用可被rhIL—10抑制(P＜0．001)。(4)大鼠颈动脉损伤后,rhIL—10治疗组的动脉血管新生内膜/中层面积比低于对照组约45％(P＜0．01)。表明抗炎细胞因子rhIL—10可抑制AGE诱导的大鼠血管平滑肌细胞增殖和血管新生内膜的增殖。     

Urokinase stimulates whereas tissue plasminogen activator attenuates blood vessel stenosis]

Periadventitial application of the urokinase-plasminogen activator (uPA) in pluronic gel to an injured artery stimulated the neointima and neoadventitia formation as well as cell migration and proliferation in vivo. In contrast, the tissue-type plasminogen activator (tPA) reduced the number of neointimal smooth muscle cells and neointimal area and attenuated the lumen stenosis after a balloon catheter injury of the rat carotid artery. This ability to stimulate the neointima and neoadbentitia formation was found to be quite specific for the uPA. The findings suggest that this uPA property provides a specific functional target for attenuating growth of the damage.     

Injury-induced expression of cytokeratins 8 and 18 by vascular smooth muscle cells requires concurrent activation of cytoskeletal and growth factor receptors

Cytokeratins are not present in the vascular smooth muscle cells (VSMCs) of normal arteries, but they are detectable in the VSMCs of atherosclerotic lesions. A correlation between cytokeratin expression and VSMC phenotype is proposed, but an examination of VSMCs after mechanical injury has yet to be performed. Immunohistochemistry was used to monitor proteins in arterial sections. Western blotting enabled quantification of protein levels. Angioplasty of porcine femoral artery in vivo and porcine coronary artery in vitro served as models of vascular injury. Cytokeratins 8 and 18 were expressed by VSMCs in porcine femoral artery lesions 14 days after balloon angioplasty. Cytokeratins were also present in the neointima of porcine coronary artery segments placed into organ culture for 4 days. Cytokeratin expression was decreased in the presence of inhibitors that affect MAP kinase, PI3 kinase, Src kinase, and G protein, but not in the presence of an AT1 receptor antagonist. Cytokeratin expression also occurred when VSMCs were plated onto collagen in the presence of serum. We conclude that mechanical injury induces expression of cytokeratin 8 and 18 both in vitro and in vivo by synthetic VSMCs that migrate into the neointima. Furthermore, cytokeratin expression requires cellular attachment to extracellular matrix proteins in conjunction with mitogenic stimulation.     

G-CSF prevents the progression of atherosclerosis and neointimal formation in rabbits

Granulocyte colony-stimulating factor (G-CSF) prevents left ventricular remodeling after myocardial infarction, but its effect on atherosclerosis is unknown. We examined two kinds of rabbit atherosclerosis models. Myocardial infarction-prone Watanabe heritable hyperlipidemic (WHHL-MI) rabbits were treated with G-CSF or saline for 7 days from 14 months old. The vascular injury models were created by inflating angioplasty balloon in the iliac artery of rabbits and were divided into G-CSF and saline group. G-CSF significantly reduced the stenosis score of coronary artery and lipid plaque area of thoracic aorta in WHHL-MI rabbits at 4 weeks after the treatment. In the vascular injury model, G-CSF significantly prevented an increase in neointima/media ratio at 4 weeks after the treatment. G-CSF accelerated the reendothelialization of denuded arteries, and the pretreatment with nitric oxide synthase inhibitor significantly inhibited it. These results suggest that G-CSF has a therapeutic potential for the progression of atherosclerosis.     

犬不同血管搭桥方法及搭桥血管内流场的计算机数值模拟

目的血管搭桥术后的内膜增生往往导致手术失败,而内膜增生与搭桥血管内的流场密切相关,为改善搭桥血管中的流场结构,作者设计了偏心搭桥手术方法,利用计算机数值模拟技术,探索偏心搭桥和传统搭桥血管中流场的变化,为血管搭桥方法提供优化设计方案。方法16只犬随机分为偏心搭桥组和传统搭桥组进行血管搭桥,测定搭桥前后血管几何数据,搭桥后近心端及远心端吻合口血流量和血压。按测定的血管几何数据,FLUENT 6.2模拟搭桥血管内的流场。结果偏心搭桥近心端和远心端吻合口不在同一平面。传统搭桥中,主体动脉远心端吻合口对应面处存在一个较低壁面剪切应力（WSS）区域及流体停滞点,离脚跟较近的一部分流体会形成涡漩,血流进入主体动脉后,还会表现出迪恩涡二次流;偏心搭桥中,主体动脉吻合口对应面上的低WSS区域和流体停滞点消失,血流接触到吻合口底面后,以切向旋转的方式改变其流动方向,不会形成涡漩,且当血流进入主体动脉后,立即发生螺旋流态且能持续很长一段。结论偏心搭桥能够产生血液旋动流,显著增加远心端血流量、提高WSS。     

Endothelin in the middle cerebral artery: a case of multiple system atrophy

In this study, we show the changes in the wall of the middle cerebral artery of a subject who suffered multiple system atrophy with autonomic failure. An electron-immunocytochemical approach was employed to reveal the presence of endothelin-1. Our results demonstrate the presence of immunoreactive endothelin-1 in the endothelial cells of the intima, vascular smooth muscle cells and macrophages of the media and neointima, and perivascular nerves/axons varicosities at the adventitial-medial border of the artery. It is concluded that endothelin-1 may, therefore, play a number of roles within diseased cerebral artery. The finding of endothelin-1-positive varicosities of autonomic innervation to this artery suggests an influence of neural endothelin on vascular smooth muscle in multiple system atrophy with autonomic failure. However, the presence of features such as neointima formation, wall irregularities and foam cells suggest the coexistence of atherosclerosis.