MiR-204 suppresses cell proliferation and promotes apoptosis in ovarian granulosa cells via targeting TPT1 in polycystic ovary syndrome

Multi-omics insights and therapeutic implications in polycystic ovary syndrome: a review

Polycystic ovary syndrome (PCOS) is a common gynecological disease that causes adverse effects in women in their reproductive phase. Nonetheless, the molecular mechanisms remain unclear. Over the last decade, sequencing and omics approaches have advanced at an increased pace. Omics initiatives have come to the forefront of biomedical research by presenting the significance of biological functions and processes. Thus, multi-omics profiling has yielded important insights into understanding the biology of PCOS by identifying potential biomarkers and therapeutic targets. Multi-omics platforms provide high-throughput data to leverage the molecular mechanisms and pathways involving genetic alteration, epigenetic regulation, transcriptional regulation, protein interaction, and metabolic alterations in PCOS. The purpose of this review is to outline the prospects of multi-omics technologies in PCOS research by revealing novel biomarkers and therapeutic targets. Finally, we address the knowledge gaps and emerging treatment strategies for the management of PCOS. Future PCOS research in multi-omics at the single-cell level may enhance diagnostic and treatment options.

IL23 suppresses proliferation and promotes apoptosis of human granulosa-like tumor cell line KGN by targeting the androgen receptor signal pathway

Background: Polycystic ovary syndrome (PCOS) is associated with chronic low-grade inflammation. IL23 is a classic pro-inflammatory factor, which has been found that serum levels of IL23 were higher in patients with PCOS. However, the exact function of IL23 in regulating the pathogenesis of PCOS has not been elucidated. This study aimed to investigate the role of IL23 in the pathogenesis of PCOS and uncover the possible molecular mechanism. Methods: We investigated the role of IL23 in the proliferation, cell cycle progression and apoptosis of granulosa cells (GCs) using the human granulosa-like tumor cell line KGN. Results: IL23 suppressed the proliferation, arrested cell cycle progression, and increased apoptosis of KGN cells. We also found that IL23 decreases proliferation and promotes apoptosis in KGN cells is mediated by androgen receptor (AR) signaling. Conclusions: Our results demonstrated that IL23 suppressed cell proliferation and promoted apoptosis of KGN cells, which might provide new evidence for abnormal proliferation and apoptosis of GCs in PCOS.

Identification and expression analysis of sex biased miRNAs in chinese hook snout carp Opsariichthys bidens

As an economically important fish, Opsariichthys bidens has obvious sexual dimorphism and strong reproductive capacity, but no epigenetics study can well explain its phenotypic variations. In recent years, many microRNAs involved in the regulation of reproductive development have been explored. In this study, the small RNA libraries of O. bidens on the testis and ovary were constructed and sequenced. A total of 295 known miRNAs were obtained and 100 novel miRNAs were predicted. By comparing testis and ovary libraries, 115 differentially expressed (DE) miRNAs were selected, of which 53 were up-regulated and 62 were down-regulated. A total of 64 GO items (padj < 0.01) and 206 KEGG pathways (padj < 0.01) were enriched in the target gene of miRNA. After that, the expression levels of nine DE miRNAs, including let-7a, miR-146b, miR-18c, miR-202-5p, miR-135c, miR-9-5p, miR-34c-3p, miR-460-5p and miR-338 were verified by qRT-PCR. Furthermore, bidirectional prediction of DE miRNAs and sex-related genes was carried out and the targeting correlation between miR-9-5p and nanos1 was verified by Dual-Luciferase reporter assay. Our findings identified the differentially expressed miRNA and paved the way to new possibilities for the follow-up study on the mechanism of miRNA-mRNA interaction in the gonads of O. bidens.

Dysregulation of miR-204-5p/APLN axis affects malignant progression and cell stemness of esophageal cancer

OBJECTIVE

This study attempted to investigate the mechanism of miR-204-5p and its downstream gene in regulating bio-functions of esophageal cancer (EC).

METHODS

Bioinformatics analysis was performed to select the mature miRNAs, mRNAs, and clinical data of EC. The miRNA-mRNA regulatory axis was predicted through bioinformatics and used Dual-luciferase analysis to verify the interaction between miR-204-5p and APLN. qRT-PCR was applied to analyze expression of miR-204-5p and APLN mRNA. Western blot was utilized to detect APLN protein expression. Functional assays like CCK-8, wound healing, Transwell, and stem cell sphere formation assays were launched to confirm proliferative, migratory, invasive and stemness of cells in different treatment groups.

RESULTS

MiR-204-5p was lowly expressed while its target gene APLN was highly expressed in tumor tissues. Besides, miR-204-5p overexpression hindered proliferation, invasion, migration, and stemness of EC cells. Additionally, dual-luciferase assay verified the interaction of miR-204-5p and APLN. MiR-204-5p could downregulate APLN level and its overexpression reduced the effect of APLN on EC cell functions.

CONCLUSION

Dysregulation of miR-204-5p/APLN axis was linked with malignant progression of EC. MiR-204-5p/APLN may be an underlying candidate for the design of anticarcinogens.

CircRNA circ_0043533 facilitates cell growth in polycystic ovary syndrome by targeting miR-1179

Increasing evidence indicates that circular RNAs (CircRNAs) have an important role in human diseases, including polycystic ovary syndrome (PCOS). Recently, circ_0043533, a novel circRNA, was proposed to be involved in the progression of PCOS. However, its role in PCOS has not been explored. In this study, the expression levels of circ_0043533 and miR-1179 in ovarian granulosa cells (OGCs) were examined by qRT-PCR analysis. Moreover, knockdown of circ_0043533 in OGC lines COV434 and KGN, respectively, the cell viability, proliferation, apoptosis, and cycle-related markers of insulin-triggered OGCs were examined by CCK-8, EdU staining, flow cytometry, and western blot assays, respectively. The interaction between circ_0043533 and miR-1179 was examined by bioinformatics, dual-luciferase assay, and RNA immunoprecipitation. Besides, effects of the miR-1179 inhibitor on cell viability and apoptosis in OGC lines with circ_0043533 knockdown were also evaluated. OGCs and insulin-treated OGCs exhibited higher circ_0043533 levels in comparison to the IOSE80 cells. Additionally, knockdown of circ_0043533 remarkably inhibited the cell viability and proliferation and promoted the apoptosis of insulin-treated COV434 and KGN cells, respectively. Meanwhile, circ_0043533 knockdown could down-regulate the Bcl-2, CDK2, and Cyclin D1 expressions, and up-regulate the Bax levels. Furthermore, we demonstrated that circ_0043533 acted as a sponge to absorb miR-1179. Interestingly, miR-1179 inhibition remarkably attenuated the effect of circ_0043533 silence on cell proliferation and apoptosis in insulin-treated COV434 and KGN cells. Taken together, this study revealed that circ_0043533 knockdown restrained the malignant progression of PCOS via targeting miR-1179. Our data suggested that circ_0043533 would serve as a novel therapeutic target for PCOS.

mir-204-5p Acts as a Tumor Suppressor by Targeting DNM2 in Osteosarcoma Cells

Osteosarcoma is a malignant bone tumor composed of interstitial cells. We aim to seek the function of mir-204-5p/DNM2 in osteosarcoma cells. From April 2017 to August 2019, 58 cases of cancer tissues and paracancer tissues were obtained from patients with osteosarcoma in our hospital. qPCR was used to detect mir-204-5p in excisional cancer tissues and paracarcinoma tissues of osteosarcoma patients. The overexpression vector of mir-204-5p was established and transfected into osteosarcoma cells, and the propagation, invasiveness, migration, and apoptosis of osteosarcoma cells were observed. StarBase was employed to forecast the binding site of mir-204-5p and DNM2. The targeting connection of mir-204-5p with DNM2 was detected via double luciferase reporter gene. mir-204-5p was lessened in osteosarcoma (p < 0.05). mir-204-5p overexpression suppressed propagation and accelerated apoptosis of osteosarcoma cells (p < 0.05). The results of double luciferase reporter gene revealed that the fluorescence activity of mir-204-5p was obviously declined when binding to DNM2 (p < 0.05). mir-204-5p functions as a tumor inhibitor by targeting DNM2 in osteosarcoma cells. Our research is helpful to provide new ideas for clinical treatment.

miR-23b-3p inhibits chicken granulosa cell proliferation and steroid hormone synthesis via targeting GDF9

MicroRNAs (miRNAs) are ∼22 nt RNAs that direct post-transcriptional repression of mRNA targets in diverse eukaryotic lineages. Granulosa cells (GCs) are the earliest differentiated follicular somatic cells. From the initiation of primordial follicles, their differentiation and growth are closely related to the development of follicles. The research on follicular development mostly focused on the granular layer, as well as the hormone synthesis induced by granulosa cell differentiation before and after follicular selection. In this study, we evaluated the effects of miR-23b-3p on chicken granulosa cells, including granulosa cell proliferation and steroid hormone synthesis. Elevated expression of miR-23b-3p significantly inhibited granulosa cell proliferation and steroid hormone synthesis, but did not affect apoptosis. Furthermore, it was observed that the forecast growth differentiation factor 9 (GDF9) is a target gene of miR-23b-3p and miR-23b-3p can down-regulate expression of GDF9. Overall, this study demonstrated that miR-23b-3p can regulate the proliferation and steroid hormone synthesis of chicken granulosa cells by inhibiting the expression of GDF9.

Circ_0043532 regulates miR-182/SGK3 axis to promote granulosa cell progression in polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine and metabolic disease in women at childbearing age. Several circular RNAs (circRNAs) have been demonstrated to be involved in PCOS. In this study, we aimed to explore the function and mechanism of circ_0043532 in PCOS.

METHODS

Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to determine the expression of circ_0043532, miR-182 and serum/glucocorticoid regulated kinase family member 3 (SGK3). Cell proliferation was assessed by 5-ethynyl-2'-deoxyuridine (EdU) assay and 3-(4, 5-dimethyl-2-thiazolyl)-2, 5-diphenyl-2-H-tetrazolium bromide (MTT) assay. Flow cytometry analysis was employed to evaluate cell cycle and cell apoptosis. Dual-luciferase reporter assay and RNA immunoprecipitation (RIP) assay were conducted to verify the association between miR-182 and SGK3. Western blot assay was carried out to determine the protein level of SGK3.

RESULTS

Circ_0043532 was markedly elevated in PCOS granulosa cells (GCs) and KGN cells. Silencing of circ_0043532 suppressed cell proliferation and cell cycle process and promoted cell apoptosis in PCOS GCs and KGN cells. For mechanistic analysis, circ_0043532 was identified as a sponge of miR-182 and SGK3 was confirmed to be a target gene of miR-182. Inhibition of miR-182 rescued the impacts of circ_0043532 interference on PCOS GCs and KGN cell progression. Moreover, miR-182 overexpression suppressed cell proliferation and cell cycle process and promoted cell apoptosis in PCOS GCs and KGN cells by targeting SGK3.

CONCLUSION

Deficiency of circ_0043532 suppressed cell proliferation and induced cell cycle arrest and cell apoptosis in PCOS by modulation of miR-182/SGK3 axis.

microRNAs in female infertility: An overview

Infertility impacts a considerable number of women worldwide, and it affects different aspects of family life and society. Although female infertility is known as a multifactorial disorder, there are strong genetic and epigenetic bases. Studies revealed that miRNAs play critical roles in initiation and development of female infertility related disorders. Early diagnosis and control of these diseases is an essential key for improving disease prognosis and reducing the possibility of infertility and other side effects. Investigating the possible use of miRNAs as biomarkers and therapeutic options is valuable, and it merits attention. Thus, in this article, we reviewed research associated with female diseases and highlighted microRNAs that are related to the polycystic ovary syndrome (up to 30 miRNAs), premature ovarian failure (10 miRNAs), endometriosis (up to 15 miRNAs), uterine fibroids (up to 15 miRNAs), endometrial polyp (3 miRNAs), and pelvic inflammatory (6 miRNAs), which are involved in one or more ovarian or uterine disease-causing processes.

Identifying Lung Cancer Cell Markers with Machine Learning Methods and Single-Cell RNA-Seq Data

Non-small cell lung cancer is a major lethal subtype of epithelial lung cancer, with high morbidity and mortality. The single-cell sequencing technique plays a key role in exploring the pathogenesis of non-small cell lung cancer. We proposed a computational method for distinguishing cell subtypes from the different pathological regions of non-small cell lung cancer on the basis of transcriptomic profiles, including a group of qualitative classification criteria (biomarkers) and various rules. The random forest classifier reached a Matthew’s correlation coefficient (MCC) of 0.922 by using 720 features, and the decision tree reached an MCC of 0.786 by using 1880 features. The obtained biomarkers and rules were analyzed in the end of this study.

Pathogenetic analysis of polycystic ovary syndrome from the perspective of omics

Polycystic ovary syndrome (PCOS) is the most common gynecological endocrine disease, involving multiple genes, multiple pathways, and complex hormone secretion processes. Hence, the pathogenesis of PCOS cannot be explained by a single factor. Omics analysis includes genomics, transcriptomics, and proteomics, which are fast and effective methods for studying the pathogenesis of diseases. PCOS is primarily characterized by androgen excess, and reproductive and metabolic dysfunctions. The application of omics analysis in the body fluids, blood, cells or tissues of women with PCOS offers the potential for unexpected molecular advantages in explaining new mechanisms of PCOS etiology and pathophysiology, and provides new perspectives for identifying potential biomarkers and developing new therapeutic targets. At present, several omics analyses have been applied to produce complex datasets. In this manuscript, the recent advances in omics research on PCOS are summarized, aiming at an important and parallel review of the newly published research.

miR-130b-3p is high-expressed in polycystic ovarian syndrome and promotes granulosa cell proliferation by targeting SMAD4

BACKGROUND

Being one of the most prevalent metabolic and endocrine disorders, Polycystic Ovary Syndrome (PCOS) has been proven to be associated with microRNA-130b-3p (miR-130b-3p). However, the exact role played by miR-130b-3p in the pathogenesis and progression of PCOS remains unknown. Thus, this article is focused on elucidating the function of miR-130b-3p in the pathogenesis of PCOS.

METHODS

The expression levels of miR-130b-3p and SMAD4 in tissues and cells responsible for the development of PCOS were determined by RT-qPCR and western blot. A miR-130b-3p mimic/inhibitor or si-SMAD4 were transfected into KGN cells. The cell viability was detected by CCK-8 and EDU methods. The activity of caspase-3 was measured by caspase-3 analysis. Subsequently, apoptosis and the cell cycle were measured via flow cytometry. The correlation between SMAD4 and miR-130b-3p was confirmed using an RNA pull-down assay and a dual luciferase reporter system assay.

RESULTS

MiR-130b-3p was upregulated in the KGN cells and ovarian granulosa cells (GCs) of PCOS patients. It was found that miR-130b-3p overexpression or SMAD4 silencing can promote KGN cell proliferation and positive EDU rates, induce S phase arrest, inhibit apoptosis and caspase-3 activity. On the other hand, miR-130b-3p inhibitors reduce KGN cell proliferation, inhibit apoptosis and reverse the effect of si-SMAD4.

CONCLUSION

MiR-130b-3p directly interacts with SMAD4 to induce KGN cell proliferation, inhibit apoptosis, suggesting that miR-130b-3p expression is positively correlated with the development of PCOS. This may serve as new evidence for the abnormal proliferation of GCs in PCOS.

MicroRNA-451a plays a role in polycystic ovary syndrome by regulating ovarian granulosa cell proliferation and apoptosis

The present study aimed to investigate whether microRNA (miR)-451a plays a role in polycystic ovary syndrome by regulating the biological function of ovarian granulosa cells and investigate the underlying molecular mechanism. In the present study, reverse transcription-quantitative PCR (RT-qPCR) analysis detected markedly low expression of miR-451a in KGN cells. TargetScan predicted that cyclic AMP-dependent transcription factor ATF-2 (ATF2) was a potential target gene of miR-451a, which was confirmed by a Dual-Luciferase reporter gene assay. Moreover, western blotting and RT-qPCR experiments indicated that ATF2 was significantly overexpressed in KGN cells. In addition, western blotting and RT-qPCR experiments were utilized to assess cell transfection efficiency, and it was found that miR-451a mimic significantly increased miR-451a expression in KGN cells. Subsequently, MTT assay was performed to detect cell proliferation and flow cytometry was utilized to detect cell apoptosis. Western blot and RT-qPCR assays were utilized to assess the protein and mRNA expression of ATF2 and cyclin D1. The results confirmed that miR-451a mimic significantly decreased ATF2 protein and mRNA expression in KGN cells, and this decrease was reversed by ATF2-plasmid co-transfection. Moreover, miR-451a mimic inhibited cell proliferation, enhanced cell apoptosis, reduced cyclin D1 expression, increased caspase-3 activity and cleaved caspase-3 protein levels, while it reduced pro-caspase 3 protein levels in KGN cells, and these effects were significantly reversed by ATF2-plasmid. The present preliminary results demonstrated that miR-451a regulated the proliferation and apoptosis of ovarian granulosa cells by targeting ATF2. Thus, the miR-451a/ATF2 axis may be a new potential target for the treatment of polycystic ovary syndrome.

miR-221-3p regulates apoptosis of ovarian granulosa cells via targeting FOXO1 in older women with diminished ovarian reserve (DOR)

In our earlier study, we showed that the expression of microRNA‐221‐3p (miR‐221‐3p) was significantly lower in women of advanced age with diminished ovarian reserve (DOR) compared with young women with normal ovarian reserve (NOR). Therefore, in this study, we aimed to explore how miR‐221‐3p regulates apoptosis of granulosa cells and the pathogenesis of DOR. Bioinformatics prediction and dual‐luciferase reporter assay were conducted to identify the target gene of miR‐221‐3p. miR‐221‐3p expression was manipulated by transfecting KGN cells with miR‐221‐3p mimics, inhibitor, and negative control. Following transfection, apoptosis of granulosa cells was determined by flow cytometry, and the expression of the target gene was measured by quantitative real‐time polymerase chain reaction (qRT‐PCR) and western blot analysis (WB). In addition, the expression of the target gene in granulosa cells of DOR patients and NOR patients was measured. miR‐221‐3p were found to directly bind the 3ʹ untranslated region of Forkhead box O1 (FOXO1). Transfection with miR‐221‐3p mimics significantly decreased the apoptosis rate of KGN cells compared with transfection with miR‐221‐3p inhibitors. The expression level of miR‐221‐3p was negatively correlated with the messenger RNA and protein levels of the FOXO1 gene. Besides, FOXO1 expression was upregulated in DOR patients. In conclusion, these results provide evidence that downregulation of miR‐221‐3p expression promotes apoptosis of granulosa cells by upregulating FOXO1 expression, thus serving an important role in DOR pathogenesis.

MicroRNA-489-3p plays a significant role in congenital hypothyroidism through regulating neuronal cell apoptosis via targeting translationally controlled tumor protein 1

Accumulating reports have indicated that congenital hypothyroidism (CH) is an endocrine disorder caused by underdeveloped thyroid gland or thyroid dyshormonogenesis. It has been also reported that certain microRNAs (miRNAs) may exert protective effects against the development of CH. However, whether miR-489-3p regulates CH progression remains unclear. The aim of the present study was to investigate the effects of miR-489-3p on CH and elucidate the underlying mechanisms. Therefore, Sprague Dawley rats were injected with propylthiouracil (50 mg/day) to establish a CH model. Reverse transcription-quantitative PCR (RT-qPCR) assay demonstrated that miR-489-3p was upregulated in the hippocampal tissues of CH rats. Furthermore, the TargetScan software was employed to predict the target gene of miR-489-3p, and a dual luciferase reporter assay revealed that translationally controlled tumor protein 1 (TPT1) was directly targeted by miR-489-3p. Additionally, RT-qPCR and western blot assays suggested that TPT1 was markedly downregulated in the hippocampal tissues of CH rats compared with control rats. In addition, inhibitor control, miR-489-3p inhibitor, control-shRNA or TPT1-shRNA were injected into CH rats. The results of the open-field and forced swimming tests revealed that miR-489-3p inhibitor notably improved the behavior of CH rats. Flow cytometry was applied to explore the effects of miR-489-3p inhibitor on neuronal cell apoptosis, and the findings indicated that miR-489-3p inhibitor attenuated CH-induced neuronal cell apoptosis, whereas these effects were reversed by treatment with miR-489-3p inhibitor and TPT1-shRNA. Finally, the function of miR-489-3p in neuronal cells was investigated in vitro. Neuronal cell viability, apoptosis and the expression of apoptosis-related proteins were determined using MTT assay, flow cytometry and western blot analysis, respectively. The results demonstrated that miR-489-3p inhibitor enhanced cell viability, suppressed apoptosis and upregulated Pim-3, phosphorylated (p)-Bad (Ser112) and Bcl-xL expression. Rescue experiments indicated that these effects were reversed following silencing of TPT1. Taken together, the findings of the present study demonstrated that miR-489-3p inhibitor could relieve CH-induced neurological damage through regulating TPT1 expression.

miR-206 serves an important role in polycystic ovary syndrome through modulating ovarian granulosa cell proliferation and apoptosis

An increasing number of studies have reported that microRNAs (miRNAs) have an important role in polycystic ovary syndrome (PCOS). Downregulation of miR-206 in patients with PCOS has been found, however, its specific role remains unclear. The present study aimed to investigate the roles of miR-206 in (PCOS) and to determine the underlying molecular mechanisms. Reverse transcription-quantitative PCR (RT-qPCR) was performed to analyze the expression levels of miR-206 in normal ovarian surface epithelial IOSE80 cells and human ovarian granulosa cell-like KGN cells. TargetScan was used to predict the target gene of miR-206, which was subsequently verified using a dual-luciferase reporter gene assay. The mRNA expression levels of cyclin D2 (CCND2) and the transfection efficiencies of the miR-206 mimic and CCDN2 overexpression plasmid were determined using RT-qPCR analysis. The protein expression levels of CCND2, cleaved-caspase-3 and pro-caspase-3 were analyzed using western blotting, and an MTT assay and flow cytometric analysis were used to evaluate the cell viability and levels of apoptosis, respectively, in the cells following transfection. Finally, the activity of caspase-3 was analyzed using a caspase-3 activity assay kit. The results of the present study revealed that the expression levels of miR-206 were downregulated in KGN cells compared with IOSE80 cells. CCND2 was predicted and verified to be a direct target gene of miR-206, and the mRNA and protein expression levels of CCND2 were discovered to be upregulated in KGN cells compared with IOSE80 cells. The miR-206 mimic and CCND2 overexpression plasmid significantly upregulated the expression levels of miR-206 and CCND2, respectively, in KGN cells. The miR-206 mimic also downregulated the expression levels of CCND2 in KGN cells, while this effect was reversed following the transfection with the CCND2 overexpression plasmid. Compared with the mimic control group, the miR-206 mimic significantly decreased the cell viability, induced the levels of apoptosis, increased the activity of caspase-3, upregulated cleaved-caspase-3 protein expression levels and downregulated pro-caspase-3 protein expression levels in KGN cells following transfection; these effects were reversed following the overexpression of CCND2. In conclusion, the findings of the present study suggested that miR-206 may serve an important role in PCOS through modulating ovarian granulosa cell viability and apoptosis.

CircASPH promotes KGN cells proliferation through miR-375/MAP2K6 axis in Polycystic Ovary Syndrome

Polycystic Ovary Syndrome (PCOS) is a kind of endocrine disorder which is prevalent in adult women, so exploring more biomarkers for PCOS is imperative. Recently, circular RNA and microRNA are confirmed to be related with PCOS development. Whether circular RNA ASPH (circASPH) is involved in PCOS need to be studied further. We utilized RT‐qPCR to measure the expression levels of circASPH, miR‐375 and MAP2K6 in PCOS patients and normal group. The effects of circASPH and miR‐375 on KGN cells proliferation and apoptosis were observed by CCK‐8 assay, EdU incorporation assay and apoptosis assay, separately. Then Dual‐luciferase reporter assay was carried out to verify the circASPH/miR375 axis and miR375/MAP2K6 axis. The interaction between circASPH and MAP2K6 were detected with the support of RT‐qPCR and Western blot. We found circASPH and MAP2K6 were both over‐expressed in PCOS patients, while miR‐375 was in the opposite direction. Moreover, miR‐375 was negatively regulated by circASPH, while MAP2K6 was positively regulated by circASPH. In addition, circASPH directly targeted miR‐375, which targeted MAP2K6. More than that, the knockdown of circASPH repressed KGN cells proliferation and enhanced apoptosis, while the silence of miR‐375 reversed the above effects. In conclusion, circASPH promotes KGN cells proliferation through miR‐375/MAP2K6 axis in PCOS, and they are thought‐provoking biomarkers for PCOS diagnosis and therapy.