Affinity labeling, molecular cloning, and comparative amino acid sequence analyses of sex steroid-binding protein of plasma. A multidisciplinary approach for understanding steroid-protein interaction and its physiological role

Arginine-140 and isoleucine-141 determine the 17beta-estradiol-binding specificity of the sex-steroid-binding protein (SBP, or SHBG) of human plasma

Arginine-140 and isoleucine-141 were identified as key determinants of 17beta-estradiol (E(2)) binding affinity of the sex-steroid-binding protein (SBP, or SHBG) of human plasma. Amino acid residues that differ between human and rabbit SBP sequences were replaced in the human protein and the products tested for lowered E(2)binding activity as are seen in the rabbit protein. Only mutants containing either R140K or I141L replacements display an E(2) equilibrium dissociation constant (Kd) higher than the wild type, reaching a value of 30 nM when both were present. The 5alpha-dihydrotestosterone (DHT) equilibrium dissociation constant of these mutants was unaffected. The quadruple mutant M107I/I138V/R140K/I141L yielded an E(2) Kd of 65 nM, significantly closer to the 80 nM rabbit SBP E(2) Kd value. Although mutants containing the M107I and I138V replacements in the absence of R140K and I141L had normal E(2) Kds, the presence of the M107I replacement in the quadruple mutant was necessary to obtain an accurate E(2) Kd value by competitive Scatchard analysis. Molecular modeling using coordinates for the recently determined N-terminal domain of human SBP revealed a significant shift of the F56 phenyl ring away from ring A of E(2) in mutant models containing the R140K and I141L replacements. We conclude that R140 and I141 are required for sustaining the right proximity of the phenyl ring of F56 to ring A of 17beta-estradiol, thus optimizing the E(2)-binding affinity of human SBP.

Rabbit sex hormone-binding globulin: expression in the liver and testis during postnatal development and structural characterization by truncated proteins

Although sex hormone binding globulin (SHBG) is found in the blood plasma of adult humans and rabbits and the gene is expressed in their livers, it is not detected in the plasma of adult rodents nor is it expressed in adult rodent livers. Thus the rabbit represents a good model to study the metabolism and function of SHBG in the blood. We have used a cloned rabbit SHBG cDNA to detect mRNA expression in rabbits during the postnatal period, and to construct truncated SHBG proteins for structure/function analysis. The SHBG mRNA appeared in the testis as early as 3 days after birth. The level increased gradually in abundance throughout postnatal development, and attained a maximum at 12 weeks of age when the gonads were fully matured. In contrast, SHBG mRNA in the livers of male and female animals increased to a maximum by 4 weeks of age, and were maintained at this level until 12 weeks before subsiding to the initial levels. The increase and decrease in SHBG mRNA levels in the liver were accompanied by similar changes in serum SHBG. This suggests that SHBG in the blood circulation comes from the liver and this might also provide a source of SHBG for the male reproductive tract before formation of the blood-testis barrier. To elucidate the minimal sequence of rabbit SHBG responsible for steroid-binding, a panel of 13 truncated SHBG proteins was constructed, expressed in Escherichia coli, and biochemically purified for study. It was shown that the complete protein sequence of rabbit SHBG was important for maintaining a stable steroid-protein complex. Unlike human SHBG for which a truncated protein of the first 206 residues of the 373 amino acid protein can still bind steroid, removal of 43 or more residues from the C-terminus of rabbit SHBG completely abolished steroid-binding.

Sex hormone binding globulin mRNA in human breast cancer: detection in cell lines and tumor samples

Sex hormone binding globulin (SHBG) is a high affinity binding protein for estrogens and androgens. SHBG has been found in breast tissue and cell lines through immunostaining. The goal of this series of experiments was to determine whether mRNA for SHBG is expressed in breast cancer cell lines and tumor tissue. Reverse transcriptase-polymerase chain reaction (RT-PCR) was used to detect SHBG and beta-2 microglobulin (control for tissue extractions). Three breast cancer cell lines, ZR-75-1, MCF-7, and MDA-MB-231 and 56 breast tissue samples were collected and analysed for SHBG mRNA expression. mRNA was successfully extracted from 30 of these breast tissue samples. SHBG mRNA was detected in ZR-75-1, MCF-7 and MDA-MB-231 cells, and in 11 of the breast tissue samples. Two PCR products were routinely amplified from the breast cancer cell line RNA, one at approximately 500 bp and another at approximately 300 bp. The DNA sequence of the 300 bp PCR produce was consistent with alternate splicing of the SHBG mRNA, where exon 7 is deleted, and is accompanied by a point deletion at the beginning of exon 8. SHBG protein production from the three breast cancer cell lines was detected by immunoprecipitation using an affinity purified SHBG antibody. SHBG mRNA was found in 11 of 30 samples of breast tissue. Some samples expressed only the 500 bp or the 300 bp PCR product, whereas others expressed both PCR products. The presence of SHBG mRNA in these samples was not associated with either the presence or absence of steroid receptors. SHBG mRNA is thus expressed in breast cancer cell lines, and in some breast tissue samples.

Endocytosis of androgen-binding protein (ABP) by spermatogenic cells

To test whether Sertoli cell-secreted ABP could serve as steroid carrier to the germ cell (GC) lineage, radiolabeled ABP and SHBG and gold SHBG were used for binding studies and for internalization studies based on transmission electron microscope analyses and autoradiography of the radiolabeled samples. The data clearly showed that: (1) rat and human germ cells possess a single class of binding sites for rat ABP and human SHBG respectively (Kd of 0.78 and 0.56 nM); (2) 1.7 x 10(10) and 2.7 x 10(10) sites/mg protein was found in the corresponding plasma membrane preparations; (3) the receptor peak was eluted in the same position as dextran blue: 2000 kDa (M(r) = 2 x 106) for labeled rat ABP; (4) in the whole GC lineage, the labeled ligand was internalized through an endocytic pathway involving clathrin coated structures and the distribution was similar throughout the maturation step, however striking differences in the internalization rate were revealed with regard to the maturation step; and (5) this internalization occurred even in ligated seminiferous tubules, via the Sertoli cells cytoplasm. When isolated rat GC were incubated in the presence of ABP, a dose dependent increase in labeled secreted protein was observed for spermatocytes (50-250%) whereas ABP had no effect on spermatids. Addition of steroids and ABP caused a 200 and 50% increase in labeled secreted proteins for spermatocytes and spermatids respectively. 2-D SDS-PAGE analysis revealed that ABP alone increased the secretion of specific spermatocyte proteins whereas steroids in the presence of ABP resulted in the synthesis of new spermatocyte secreted proteins. Taken together these results strongly suggest that ABP may be required for spermatogenesis either as a steroid transmembrane carrier or on its own.

Sex hormone-binding globulin/androgen-binding protein: steroid-binding and dimerization domains

Plasma sex hormone-binding globulin (SHBG) and testicular androgen-binding protein (ABP) are homodimeric glycoproteins that share the same primary structure, and differ only with respect to the types of oligosaccharides associated with them. The biological significance of these differences is not understood, but enzymatically deglycosylated SHBG and a non-glycosylated SHBG mutant both bind steroids normally. Various affinity-labelling experiments, and studies of recombinant SHBG mutants have indicated that a region encompassing and including Met-139 in human SHBG represents an important component of its steroid-binding site. Analyses of chimeric proteins comprising various portions of human SHBG and rat ABP have also indicated that residues important for the much higher affinity of human SHBG for steroid ligands are probably located within the N-terminal portion of these molecules. Recent studies of SHBG mutants have confirmed this, and a deletion mutant containing only the first 205 N-terminal residues of human SHBG has been produced which dimerizes and binds steroids appropriately. The introduction of amino-acid substitutions between Lys-134 and Phe-148 of SHBG has also indicated that residues including and immediately N-terminal of Met-139 may influence steroid-binding specificity, while those immediately C-terminal of Met-139 represent at least a part of the dimerization domain. These studies have also demonstrated that dimerization is induced by the presence of steroid ligand in the binding site, and that divalent cations play an important role in this process. Together, these data have led us to conclude that SHBG is a modular protein, which comprises an N-terminal steroid-binding and dimerization domain, and a C-terminal domain containing a highly-conserved consensus sequence for glycosylation that may be required for other biological activities, such as cell-surface recognition.

Vitamin K-dependent protein S in Leydig cells of human testis

Protein S is an anticoagulant plasma protein, functioning as a cofactor to activated protein C in the regulation of blood coagulation. In addition, protein S forms a complex with the complement regulatory protein, C4b-binding protein. Protein S is unique among the vitamin K-dependent proteins in being structurally similar to androgen binding proteins. Protein S immunoreactivity was demonstrated in Leydig cells of human testis. In Northern blotting experiments, the presence of protein S mRNA in human testis tissue could be shown. In situ hybridization experiments localized protein S mRNA to the Leydig cells, demonstrating transcription of the protein S gene in these cells. Five protein S clones were isolated from a human testis cDNA library, partially sequenced and characterized by restriction enzyme mapping. Three unique clones contained information for the entire coding sequence and approximately two-thirds of the 5' and 3' non-coding sequences. The results indicate the nucleotide sequences of testis and liver protein S mRNA to be identical. No binding of androgens to protein S could be demonstrated. In conclusion, we demonstrate the presence of protein S immunoreactivity as well as protein S mRNA in the Leydig cells of human testis. These results suggest local synthesis of protein S in Leydig cells of human testis which may be functionally important for local anticoagulation.

Structure, function, and regulation of androgen-binding protein/sex hormone-binding globulin

Despite over 20 years of research, the functions of ABP and SHBG remain elusive. The major reason for this lack of knowledge has been the unavailability of natural mutants with clinical defects for study. There is strong evidence that these binding proteins do act to modulate the gene regulatory actions of nuclear sex steroid receptors by controlling the availability of androgens and estrogens. In plasma, SHBG controls the metabolic clearance rate of sex steroids. In addition there is strong evidence that they have a much broader function. The identification of plasma membrane receptors in target tissues and the finding of homologous domains in several developmental proteins support other functions. Moreover, other experiments suggest the proteins may actually be hormones or growth factors. These findings are not compatible with a model that has the proteins only regulating free steroid hormone levels. Obviously, much more experimentation will be necessary to reveal the functions of ABP and SHBG. The recent discoveries have offered several clues to their functions and open new routes for study. These experiments, coupled with newly developed techniques, such as gene knockout by homologous recombination, make one optimistic that the functions of these unique proteins will be deciphered in the near future.

Evidence for soluble and nuclear site I binding of estrogens in human aorta

The purpose of this study was to establish the estrogen receptor (ER) expression and content in human aorta fragments removed at the time of by-pass surgery. To this end, we adopted a radioligand binding assay to evaluate either soluble (S) or nuclear (N) ER using dextran-coated charcoal (DCC) and filtration methods, respectively. To better define the intratissular distribution and content of ER, we also measured the presence of a 27 kDa heat shock protein (HSP27), a well established ER-associated protein, using D5 monoclonal antibody. Finally, we analysed the different molecular isoforms of both S and N ER using size exclusion-high performance liquid chromatography (SE-HPLC). High affinity (type I) sites of estrogen binding were detected in 17 out of 19 samples in either S or N fraction, although only 9 out of 19 cases displayed site 1 ER in both cell compartments. ER levels in aortic tissues, detected by radioligand method, compare well with those we have found in other hormone-sensitive human cancer tissues and cells. SE-HPLC analysis revealed two main receptor isoforms in the soluble fraction, having 65 kDa and 18 kDa molecular mass, while a minor component of 29 kDa was also found; the nuclear fraction displayed again two major components of 38 and 23 kDa. Using the HSP27 immunohistochemistry we observed a major staining occurring in smooth muscle cells (SMC), with an increasing intensity towards the lumen. All samples, including the ER negative ones, exhibited some degree of histochemical staining. Using an arbitrary cut-off value, 7 out of 12 samples displayed a highly positive staining, 6 of which showed nuclear ER. Furthermore, SE-HPLC separation indicated the presence of a 64.9 kDa component in the soluble fraction, according to the well known relative molecular mass of ER. Following HSP27 immunohistochemistry, the overall staining intensity in aortic SMC approaches that seen in endometrial and breast epithelia, whilst the muscle ER content is generally lower. Although our data are compatible with a direct role of estrogens in arterial function, the extent of the link with arterial disease remains to be established.

Binding of sex-hormone-binding globulin (SHBG) to testicular membranes and solubilized receptors

Sex-hormone-binding globulin (SHBG) binds to a specific protein on the surface of prostate, epididymis, and a human breast cancer cell line (MCF-7), and is internalized by these cells. The present study demonstrated specific binding of SHBG to receptor on membranes prepared from rat testes. The binding was saturable, specific, and time and temperature dependent. Scatchard analysis of these binding studies suggested that SHBG binds to a single class of sites on testicular membranes with a Kd at 37 degrees C of 5 x 10(-8) M and a binding capacity of 30 +/- 0.6 pmol/mg protein. These binding characteristics are similar to the SHBG receptor on human prostate and MCF-7 cells. Solubilization of the receptor resulted in a 5-fold increase in its binding capacity (158 +/- 0.3 pmol/mg protein) and a 10-fold decrease in binding affinity (Kd at 37 degrees C = 6.5 x 10(-7) M). The apparent molecular weight of the testicular SHBG receptor, as estimated by gel filtration, was M(r) = 174,000.

CONCLUSION

a specific binding site for SHBG was identified on testicular membranes. This binding site has been tentatively identified as a SHBG receptor based on its physical properties in testicular membrane preparations and following solubilization.

Evidence for the presence of androgen receptors in the synovial tissue of rheumatoid arthritis patients and healthy controls

OBJECTIVE

To study the presence of androgen receptors in the synovial tissue of male and female patients with rheumatoid arthritis (RA) and matched healthy controls.

METHODS

Both site I (high affinity, low binding capacity) and site II (reduced affinity, higher binding capacity) androgen receptors were investigated in soluble and nuclear fractions of homogenized synovial samples, using the dextran-coated charcoal method. The finding of pure, high-affinity site I receptors in both fractions was considered indicative of androgen receptor positivity. In order to determine what type of synovial cell was positive for androgen receptors, cryosections of synovial tissues were immunostained with a specific monoclonal anti-androgen receptor antibody (MAb), using both immunofluorescence and immunoperoxidase techniques. Double immunostaining with this MAb and specific MAb directed toward different macrophage/granulocyte antigens was also performed.

RESULTS

Remarkable differences were found between male and female controls: Most males were positive for androgen receptors, and most females were negative. The fetomolar content of androgen receptor in the nuclear fraction was fairly constant, but the soluble fraction showed a higher femtomolar concentration in female RA patients than in controls of either sex, as well as in male RA patients compared with female RA patients. The androgen receptor-positive cells in both RA and control synovial cryosections were found by immunostaining to be macrophage-like synoviocytes, and were also found to be HLA-DR positive.

CONCLUSIONS

The immunosuppressive action exerted by androgens might, at least in part, be mediated through their interaction with macrophage-like synoviocytes functioning as antigen-processing and antigen-presenting cells in rheumatoid synovia.

Characterization of Met-139 as the photolabeled amino acid residue in the steroid binding site of sex hormone binding globulin using delta 6 derivatives of either testosterone or estradiol as unsubstituted photoaffinity labeling reagents

Immunopurified human sex hormone binding globulin (SHBG) was photoinactivated and photolabeled by radioinert and radioactive photoaffinity labeling steroids delta 6-testosterone (delta 6-T) and delta 6-estradiol (delta 6-E2). The maximal levels of specific incorporation of these two reagents were 0.50 and 0.33 mol of label/mol of SHBG, respectively. Covalently labeled SHBG fractions were citraconylated, reduced, carboxymethylated, and cleaved by trypsin. Separation of tryptic digests by reverse-phase liquid chromatography gave single radioactive peaks at the same retention times with both steroid reagents. However, the two labeled peptidic fractions could be distinguished by capillary electrophoresis and immunodetection with anti-steroid antibodies, whereas the covalent attachment of radioactivity was confirmed by thin-layer chromatography on silica gel. Edman degradation of the two labeled peptides showed a single sequence His-Pro-Ile-([3H]X)-Arg corresponding to the pentapeptide His-Pro-Ile-Met-Arg 136-140 of SHBG sequence. The coincidence, in both cases, of the absence of an identifiable amino acid residue and of the elution of the most intense peak of radioactivity at the fourth cycle of Edman degradation suggests that the same Met-139 residue was labeled by delta 6-[1,2-3H2]T or by delta 6-[17 alpha-3H]E2. Liquid secondary ion mass spectrometry of the two peptides showed [M+H]+ ions at m/z 939.8 or 923.8, corresponding respectively to the addition of delta 6-T or delta 6-E2 to the pentapeptide. The presence of the steroid molecule in the delta 6-[3H]T-pentapeptide conjugate was confirmed by the difference of 2 mass units with the [M+H]+ peak of the delta 6-[4-14C]T-pentapeptide conjugate.

Structure/function analyses of human sex hormone-binding globulin by site-directed mutagenesis

Human sex hormone-binding globulin (hSHBG) and rat androgen-binding protein (rABP) exhibit distinct affinities for sex-steroids. We therefore constructed and expressed a hSHBG/rABP hybrid cDNA encoding the N-terminal portion of hSHBG (205 residues) and the C-terminal portion of rABP (168 residues). The resulting chimera displayed similar steroid-binding characteristics as hSHBG and was recognised by a monoclonal antibody (S1B5) for hSHBG. We then created substitutions at Ser-133, His-136 and Met-139. The Asp-133 and Gln-136 mutants bound steroids in the same way as normal hSHBG while the steroid-binding affinity of Trp-139 was reduced. All three mutants cross-reacted similarly in a hSHBG radioimmunoassay, but Gln-136 was recognised poorly by the S1B5 antibody. These data imply that residues involved in steroid-binding are located within the N-terminal half of hSHBG and include Met-139, and that the S1B5 epitope is located in this region.

Soluble and nuclear type I and II androgen-binding sites in benign hyperplasia and cancer of the human prostate

This paper presents an approach for the assessment of the androgen receptor (AR) status in benign prostatic hyperplasia (BPH) and prostate cancer (PCa) tissues. Evaluation of AR was carried out in both soluble and nuclear fractions by a standard competition method, using tritiated mibolerone as radioligand. Based on our experience with breast and endometrial cancer, this approach focused on both type I (high affinity, low capacity) and type II (reduced affinity, higher capacity) binding sites, aiming mainly at establishing a putative "functional" receptor mechanism, i.e., the presence of type I AR in both cytosol and nucleus. Ancillary studies were carried out to exclude a potential overestimation of the AR content by interference with other steroid receptors, namely, progesterone (PgR) or glucocorticoid (GcR) receptors. Results showed that the interaction by PgR or GcR upon AR measurement was not relevant. The distribution of AR, namely the percent of positivity either in a single or in both cell compartments, was not significantly different in BPH (N = 32) or PCa (N = 24) tissues. For type I binding, the percent of positivity in both soluble and nuclear fractions (i.e., the "functional" AR status) was very close to that observed for other endocrine-related tumors, like breast cancer. Concentrations of type I AR appeared significantly higher in PCa than in BPH tissues; this was true for both soluble and nuclear fractions. In contrast, no significant difference was found in type II AR concentrations in either cell fraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Androgen receptor assays in specimens of prostatic tissue obtained by transurethral resection and transvesical adenomectomy

The main goal of this study was to ascertain whether routine transurethral resection (TUR) of prostate may provide useful material for the evaluation of androgen receptor (AR) status. At the same time, either intracellular distribution of binding affinity and capacity of receptor molecules were particularly taken into account. Based on our previous findings in breast and endometrial cancer, we suggest that a "functional" receptor status may correspond to the presence of type I (high affinity, low capacity) AR in both soluble and nuclear fractions. However, the precise significance of type II (lower affinity, higher capacity) binding sites remains to be clarified. Ten samples of large prostatic adenomas, obtained by transvesical adenomectomy (TVA), were compared with ten parallel specimens obtained by an in vitro TUR, whereby a pure cutting current was used. The AR assay was carried out with a standard competition method using tritiated mibolerone as the radioligand and Scatchard analysis for data processing. No significant difference between the TUR and TVA groups emerged concerning type I AR content of soluble, nuclear or soluble together with nuclear fractions; this was also true when the results were expressed either as fmol/ml homogenate or as fmol/mg DNA. Similarly, concentrations of type II AR in TVA and TUR samples did not differ significantly in either cell compartment, although they were widely scattered, especially in the soluble fraction. In the light of our findings, it is suggested that TUR specimens represent suitable material for receptor studies, provided that only cutting current is employed and that the use of coagulation current, to control bleeding from the prostatic bed, is confined to the final step of the TUR procedure.

The plasma sex steroid binding protein (SBP or SHBG). A critical review of recent developments on the structure, molecular biology and function

Significant developments have taken place within the past five years on the characterization, molecular biology and function of the plasma sex steroid-binding protein, SBP (or sex hormone binding globulin, SHBG). During the span of that time, amino acid sequences of two SBPs have been established, amino acid residues in the steroid-binding site have been identified, the structure of the human SBP gene has been deduced and evidence for the possible existence of a SBP membrane receptor has been presented. This review covers the salient aspects of these and other developments including a critical analysis of the various proposed models and interpretations with regards to the structure, evolution, molecular biology and function of SBP.

The genes for SHBG/ABP and the SHBG-like region of vitamin K-dependent protein S have evolved from a common ancestral gene

Sex hormone binding globulin (SHBG) is the most important sex steroid transport protein in human plasma. It is the product of the same single gene as the androgen binding protein (ABP) of testis. Protein S is another protein, which is an important cofactor in the anticoagulation system and, as far as is known today, functionally unrelated to SHBG/ABP. Protein S also has a role in the complement system. A comparison of the human genes for SHBG/ABP and protein S reveals a sequence similarity, which is of a low grade only, between the SHBG/ABP protein and a similar sized COOH-terminal domain of protein S. However, the intron-exon organization exhibits a striking similarity in the two genes, illustrating evolutionary events leading to the appearance of two functionally different proteins from common ancestral genetic elements.

Characterization of the human sex hormone binding globulin (SHBG) gene and demonstration of two transcripts in both liver and testis

A genomic cosmid clone for human sex hormone binding globulin (SHBG), a liver-secreted plasma glycoprotein that binds sex steroids, was isolated with a previously characterized liver cDNA as probe. Southern blot analysis of genomic DNA indicated that only one SHBG gene is present in the human haploid genome. A 3.8 Kb Xba I-fragment of the clone containing the entire coding region of SHBG was sequenced. The SHBG gene has 8 exons. The 5'-end preceding the translation start site had no TATA box or CAAT box promoter elements. Screening of a human testis cDNA library resulted in the isolation of two distinct cDNA forms. One cDNA was identical with the previously characterized liver SHBG cDNA, thus suggesting that human SHBG and the androgen binding protein (ABP) produced by Sertoli cells are coded for by the same gene. The second cDNA differed from the first by having exon I exchanged with a completely different sequence and exon VII deleted. An exon coding for the 5'-end of this cDNA was found in the cosmid clone 1.5 kb upstream of the first SHBG exon. Primer extension experiments showed the alternatively spliced transcript corresponding to the second cDNA to be present in both liver and testis. From the primary structure of this putative SHBG-gene-related protein, it may be deduced that it is a protein very different from SHBG and probably without steroid binding activity.

Half-life of plasma sex steroid-binding protein (SBP) in the primate

We have recently shown that the metabolic clearance of testosterone in plasma is directly dependent on sex steroid-binding protein (SBP or SHBG) levels [J. steroid. Biochem. 22, 739 (1986)]. In order to further understand the relationship between these two parameters, we have measured the half-life of SBP in plasma of female rhesus monkeys. SBP was purified to homogeneity from pooled Macaca nemestrina serum, and iodinated with 125I. The labeled protein ([125I]nSBP) was purified by chromatography on DEAE-agarose and fractions identified as immunologically reactive against anti-human SBP were collected. Protein purity of [125I]nSBP was established by SDS gel electrophoresis using an unlabelled Macaca nemestrina SBP as standard. The labeled protein was infused intravenously into two different adult female Macaca mulatta (rhesus) monkeys. Plasma samples were collected at short intervals during the first 24 h after infusion, and then daily for 7-9 days. The clearance profile of labeled SBP in plasma was quantitated by radioactivity measurement and immunoprecipitation. Analysis of the results indicate that the rate of SBP clearance in plasma has two components, the t1/2 (app) of the first component is 7.5 h (r = 0.94), and the t1/2 (app) of the second component is 3.95 days (r = 0.95). Over 90% of the injected 125I-nSBP was removed from plasma within 24 h at a rate corresponding to the t1/2 (app) of the first component. The data indicate that most of the SBP rapidly distributes into extravascular spaces during the first 24 h following infusion, and are consistent with the hypothesis that SBP may be directly involved in sex steroid hormone transport into tissues.