Differential expression of the angiogenesis growth factors in psoriasis vulgaris

Vascularized 3D Human Skin Models in the Forefront of Dermatological Research

In vitro engineered skin models are emerging as an alternative platform to reduce and replace animal testing in dermatological research. Despite the progress made in recent years, considerable challenges still exist for the inclusion of diverse cell types within skin models. Blood vessels, in particular, are essential in maintaining tissue homeostasis and are one of many primary contributors to skin disease inception and progression. Substantial efforts in the past have allowed the successful fabrication of vascularized skin models that are currently utilized for disease modeling and drugs/cosmetics testing. This review first discusses the need for vascularization within tissue-engineered skin models, highlighting their role in skin grafting and disease pathophysiology. Second, the review spotlights the milestones and recent progress in the fabrication and utilization of vascularized skin models. Additionally, advances including the use of bioreactors, organ-on-a-chip devices, and organoid systems are briefly explored. Finally, the challenges and future outlook for vascularized skin models are addressed.

Evaluation of serum vascular endothelial growth factor level and findings of nailfold capillaroscopy by dermatoscope in the differential diagnosis of palmoplantar psoriasis and palmoplantar eczema

OBJECT

This study aimed to evaluate VEGF level, capillaroscopic findings, and these features for differential diagnosis of palmoplantar psoriasis and eczema patients.

METHODS

This comparative cross-sectional study included 40 patients clinical and histopathologically diagnosed with eczema or psoriasis (20 psoriasis and 20 eczema) and 30 patients of similar age and gender without inflammatory disease in the control group. Serum samples of patients were collected and analyzed for VEGF by enzyme-linked immunosorbent assay (ELISA) and at the same time, we applied capillaroscopy with computerized dermatoscopy qualitatively and semiquantitatively.

RESULTS

In the qualitative evaluation, a decrease in capillary density and a significant increase of the avascular area was in palmoplantar plaque psoriasis (PPP) and palmoplantar eczema (PPE) patients compared to the control group. In the semiquantitative evaluation, the mean score decreased capillary density was significantly higher in PPE than in the PPP and control groups (p < 0.001). Minor morphological change (tortuous, crossed and enlarged capillary) scores were significantly higher in patients with PPE compared to PPP and control groups (p = 0.011). Major morphological change (mega, meandering, branching, bushy, bizarre, and disorganized polymorphic capillary) score was significantly higher in patients with PPP than PPE and the control group (p < 0.001). Major morphological change and m-PPPASI scores were correlated in PPP patients (p < 0.05). Disorganized capillaries in PPP patients were significantly higher than in the PPE and control groups (p < 0.001). There was no significant correlation between serum VEGF value and clinical severity and capillaroscopy findings of the patients.

CONCLUSION

Significant morphological changes were detected between PPP, PPE, and control groups in the qualitative and semi-quantitative evaluation of capillaroscopic findings. In the differential diagnosis of PPP and PPE, major morphological change, especially the presence of disorganized polymorphic capillaries, was considered an important finding in the capillaroscopic evaluation. These capillaroscopic findings may be helpful to discriminate eczema and psoriasis. However, there was no significant relationship between serum VEGF level and the patients' capillaroscopic findings and clinical severity.

Integrated bioinformatic analysis of gene expression profiling data to identify combinatorial biomarkers in inflammatory skin disease

Selection of appropriate biomarker to identify inflammatory skin diseases is complicated by the involvement of thousands of differentially expressed genes (DEGs) across multiple cell types and organs. This study aimed to identify combinatorial biomarkers in inflammatory skin diseases. From one gene expression microarray profiling dataset, we performed bioinformatic analyses on dataset from lesional skin biopsies of patients with inflammatory skin diseases (atopic dermatitis [AD], contact eczema [KE], lichen planus [Li], psoriasis vulgaris [Pso]) and healthy controls to identify the involved pathways, predict upstream regulators, and potential measurable extracellular biomarkers. Overall, 434, 629, 581, and 738 DEGs were mapped in AD, KE, Li, and Pso, respectively; 238 identified DEGs were shared among four different inflammatory skin diseases. Bioinformatic analysis on four inflammatory skin diseases showed significant activation of pathways with known pathogenic relevance. Common upstream regulators, with upregulated predicted activity, identified were CNR1 and BMP4. We found the following common serum biomarkers: ACR, APOE, ASIP, CRISP1, DKK1, IL12B, IL9, MANF, MDK, NRTN, PCSK5, and VEGFC. Considerable differences of gene expression changes, involved pathways, upstream regulators, and biomarkers were found in different inflammatory skin diseases. Integrated bioinformatic analysis identified 12 potential common biomarkers of inflammatory skin diseases requiring further evaluation.

Recent Update on Immunopathogenesis of Psoriasis

Psoriasis is a chronic disabling complex inflammatory disorder prevalent worldwide with environmental and genetic components that involve predominantly skin in addition to nails and joints associated with various systemic comorbidities having periods of exacerbations and remissions. Psoriasis is characterized by hyper-proliferation as well as abnormal differentiation of epidermal keratinocytes and lymphocyte infiltration (mainly T cells) with resultant inflammatory cytokines and chemokines. Immunological and genetic studies over the last decade have identified genetic susceptibility risk alleles, molecular, cellular and immunological mechanisms involved in immunopathogenesis of psoriasis. The current disease model emphasizes the role of aberrant Th1 and Th17 responses regulated by a complex network of different cytokines, including TNF-α, IL-17 and IL-23; signal transduction pathways downstream to the cytokine receptors; and various activated transcription factors, including NF-κB, interferon regulatory factors and signal transducer and activator of transcriptions. Cytokines targeting biologics (IL-17, IL-23 and TNFα) therapies have revolutionized the management of severe skin disease having beneficial effects on joints and systemic inflammation of psoriasis as well. Further better understanding of immunopathogenesis of psoriasis will pave way for precision medicine based on specific immunopathogenic targets in a given phenotype of disease. Complex interplay of psoriasis with associated comorbidities is also a future area of research for overall better patient management and to improve their quality of life.

Morphometric study of lymphangiogenesis in different lesions of psoriasis vulgaris with correlation to disease activity

BACKGROUND AND OBJECTIVES

In the last decades, attention to the role of lymphangiogenesis in psoriasis has been paid. Our study was conducted to evaluate podoplanin-stained lymphatic vessels and the level of lymphangiogenesis in papular psoriatic lesions and psoriatic plaques and ascertain if podoplanin provides any additional prognostic information.

MATERIALS AND METHODS

Number of lymphatic vessels and total lymphatic vessel area were morphometrically analyzed in podoplanin-stained sections, using anti-D2-40, together with the immunohistochemical study of epidermal Ki-67 in psoriasis vulgaris (n = 20) (papules = 7 and plaques = 13) and control skin specimens (n = 20).

RESULTS

The number of lymphatic vessels and total lymphatic vessel area were higher in psoriasis cases compared with normal skin (p = 0.01, p = 0.01 respectively). In psoriatic plaques, the number of lymphatic vessels, total lymphatic vessel area, and epidermal Ki-67 immunoreactivity were higher than in papular lesions (p = 0.002, p = 0.008, and p = 0.01, respectively).

CONCLUSIONS

Psoriasis vulgaris is found to be a lymphangiogenesis-dependent disease, and the lymphatic vascular network is in remodeling and expanding process. Podoplanin may be implicated in the pathogenesis of psoriasis and could be used as a prognostic biomarker for disease severity and progression.

Study of serum level and immunohistochemical expression of von Willebrand factor in psoriasis

Von Willebrand factor (vWF) is angiogenic, hypercoagulable, and inflammatory marker that increases inflammation and vasculitis and reflects endothelial cells dysfunction. vWF could play a role in psoriasis pathogenesis and prognosis. To assess the serum and immunohistochemical expression of vWF in psoriasis to evaluate its possible role in disease pathogenesis and prognosis. This case-control study included 30 cases of psoriasis vulgaris with different degrees of severity and 30 age- and sex-matched healthy controls. Serum level of vWF was measured by ELISA. Immunohistochemical staining of skin biopsies for von Willebrand factor (vVF) antibody was done. Significantly higher vWF serum level in cases (24.3 ± 14.0) vs (15.7 ± 6.85) for controls (p = .002) and significantly higher epidermal expression intensity in patients than in controls (P value = .001). There was also significant difference between cases and control regarding the dermal expression of vWF in inflammatory cells, adenexa, and endothelial cell (P value = .001, 0.065, 0.004, respectively,). Von Willebrand factor could be used as an indicator of the hypercoaguable state which may develop in patients with psoriasis and may serve as a new therapeutic target in psoriasis treatment protocols. Patients with psoriasis especially those with high PASI score are more prone to develop vascular complication. Serum vWF could be used as a better marker for psoriasis severity than PASI which is considered the gold-standard noninvasive assessment but it only measures skin involvement, while psoriasis is considered a systemic disease.

Selenium nanoparticles produce a beneficial effect in psoriasis by reducing epidermal hyperproliferation and inflammation

Background

Psoriasis is a chronic autoimmune skin disease characterized by hyperproliferation of keratinocytes. Wide treatment options used to treat psoriasis is associated with various adverse effects. To overcome this nanoformulation is prepared. Selenium is an essential trace element and plays major role in oxidation reduction system. Toxicity and stability limits the applications of selenium. Toxicity can be reduced and stabilized upon preparation into nanoparticles.

Results

Selenium nanoparticles (SeNPs) exhibit potent apoptosis through the generation of reactive oxygen species (ROS) with cell cycle arrest. SeNPs topical gel application produced significant attenuation of psoriatic severity with the abrogation of acanthosis and splenomegaly. SeNPs reduced the phosphorylation and expressions of MAPKs, STAT3, GSK-3β, Akt along with PCNA, Ki67, and cyclin-D1.

Conclusion

SeNPs inhibit various inflammation and proliferation mediated pathways and could be an ideal candidate for psoriasis therapy.

Materials and methods

SeNPs were characterized and various techniques were used to determine apoptosis and other molecular mechanisms. In vivo studies were performed by inducing psoriasis with imiquimod (IMQ). SeNPs were administered via topical route.

Graphic Abstract

Increased number of endothelial progenitor cells in the blood of patients with psoriasis vulgaris

Introduction

Psoriasis vulgaris (PsV) is a common dermatosis characterized by excessive activation of neovascularization. Latest research has shown that endothelial progenitor cells (EPCs) are a crucial factor involved in the repair of endothelial injury and formation of new blood vessels, in a process termed postnatal vasculogenesis. However, the exact mechanism of creating psoriatic skin patches and the involvement of EPCs in this process remains unknown.

Aim

To evaluate the number of EPCs in the blood of patients with PsV, characterized by the expression of specific cell surface markers, including CD45-, CD31+, CD34+ and CD133+.

Material and methods

A total of 49 patients suffering from PsV and 40 healthy volunteers were enrolled in the study. The number of EPCs in each of the volunteers' whole blood samples was measured with a FACSCalibur flow cytometer using monoclonal antibodies directed against antigens specific for EPCs.

Results

The number of EPCs was significantly higher in patients with psoriasis compared with the controls (p = 0.0007) and inversely correlated with disease severity assessed by PASI score (R = -0.2935, p = 0.0407). Statistical analysis did not show significant relations between the count of EPCs and age, body mass index, gender, disease duration, blood pressure, extent of itching, severity and frequency of pruritus, presence of bruises, vitamin D supplementation and smoking habit.

Conclusions

The results of our studies indicate that patients with psoriasis showed an increased mobilization of EPCs compared with healthy individuals which correlated negatively with disease severity.

Role of neuroimmune circuits and pruritus in psoriasis

Psoriasis is a chronic inflammatory skin disease presenting with an array of clinical phenotypes, often associated with pruritus. Environmental and psychological stressors can exacerbate psoriasis symptoms and provoke flares. Recent studies suggest a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis in some patients with psoriasis that can result in immune dysregulation. The immune system, in turn, can communicate with the nervous system to induce, maintain or aggravate psoriasis. In the skin, peripheral sensory as well as autonomic nerves control release of inflammatory mediators from dendritic cells, mast cells, T cells or keratinocytes, thereby modulating inflammatory responses and, in case of sensory nerves, pruritus. In response to the environment or stress, cytokines, chemokines, proteases, and neuropeptides fluctuate in psoriasis and influence immune responses as well as nerve activity. Furthermore, immune cells communicate with sensory nerves which control release of cytokines, such as IL-23, that are ultimately involved in psoriasis pathogenesis. Nerves also communicate with keratinocytes to induce epidermal proliferation. Notably, in contrast to recent years the debilitating problem of pruritus in psoriasis has been increasingly appreciated. Thus, investigating neuroimmune communication in psoriasis will not only expand our knowledge about the impact of sensory nerves in inflammation and pruritus and give new insights into the impact of environmental factors activating neuroimmune circuits or of stress in psoriasis, but may also lead to novel therapies. This review summarizes the relevant literature on the role of neuroimmune circuits, stress and how the central HPA axis and its peripheral equivalent in the skin, impact psoriasis.

Expression of Vascular Endothelial Growth Factor and Microvessel Density in Psoriatic Skin Lesions

Background:

Psoriasis is a common chronic and immune-mediated skin disorder having a significant impact on the patient's quality of life. An analysis of the role of angiogenic vascular endothelial growth factor (VEGF) expression and microvessel density in psoriatic skin lesions may help in better understanding of the disease pathogenesis. The aim of this study was to examine the expression of vascular endothelial growth factor (VEGF) and microvessel density using CD34 antibodies in psoriatic skin lesions by immunohistochemical examination using normal skin of healthy individuals as controls.

Materials and Methods:

Patients with clinical diagnosis of plaque type of psoriasis (e.g., chronic plaque) (n = 49) were included in the study. 5-mm punch biopsies were taken from the psoriatic skin lesions in these patients. A total of 20 punch biopsies were taken from the control group comprising of 20 healthy volunteers. The biopsies were subjected to histopathological examination for confirmation of diagnosis and grading. Immunohistochemical evaluation was done for the expression of VEGF, and microvessel density was assessed using CD34 and compared with the controls.

Results:

An increased VEGF expression by keratinocytes (49.80% ± 21.16%) and microvessel density in the papillary dermis (15.302% ± 3.8061%) was observed in patients with psoriasis, which was significantly higher as compared to controls (P < 0.0001). A significant positive correlation was observed between VEGF expression by keratinocytes and the microvessel density in the dermis (r = 0.664, P = 0.01). No significant correlation was observedbetween the histopathological grade of psoriasis and microvessel density, or with the VEGF expression.

Conclusion:

VEGF expression ascertained to be a significant factor in the pathogenesis of psoriasis.

Lymphangiogenesis: fuel, smoke, or extinguisher of inflammation's fire?

Lymphangiogenesis is a recognized hallmark of inflammatory processes in tissues and organs as diverse as the skin, heart, bowel, and airways. In clinical and animal models wherein the signaling processes of lymphangiogenesis are manipulated, most studies demonstrate that an expanded lymphatic vasculature is necessary for the resolution of inflammation. The fundamental roles that lymphatics play in fluid clearance and immune cell trafficking from the periphery make these results seemingly obvious as a mechanism of alleviating locally inflamed environments: the lymphatics are simply providing a drain. Depending on the tissue site, lymphangiogenic mechanism, or induction timeframe, however, evidence shows that inflammation-associated lymphangiogenesis (IAL) may worsen the pathology. Recent studies have identified lymphatic endothelial cells themselves to be local regulators of immune cell activity and its consequential phenotypes - a more active role in inflammation regulation than previously thought. Indeed, results focusing on the immunocentric roles of peripheral lymphatic function have revealed that the basic drainage task of lymphatic vessels is a complex balance of locally processed and transported antigens as well as interstitial cytokine and immune cell signaling: an interplay that likely defines the function of IAL. This review will summarize the latest findings on how IAL impacts a series of disease states in various tissues in both preclinical models and clinical studies. This discussion will serve to highlight some emerging areas of lymphatic research in an attempt to answer the question relevant to an array of scientists and clinicians of whether IAL helps to fuel or extinguish inflammation. Impact statement Inflammatory progression is present in acute and chronic tissue pathologies throughout the body. Lymphatic vessels play physiological roles relevant to all medical fields as important regulators of fluid balance, immune cell trafficking, and immune identity. Lymphangiogenesis is often concurrent with inflammation and can potentially aide or worsen disease progression. How new lymphatic vessels impact inflammation and by which mechanism is an important consideration in current and future clinical therapies targeting inflammation and/or vasculogenesis. This review identifies, across a range of tissue-specific pathologies, the current understanding of inflammation-associated lymphangiogenesis in the progression or resolution of inflammation.

Expression of Angiogenic Factors in Psoriasis Vulgaris

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease characterized by epidermal hyperproliferation, abnormal differentiation and inflammatory infiltration in the dermis. The dermal microvascular expansion associated with abnormal orientation and dilatation of capillaries in the biopsies of the psoriatic skin suggest that the disease is dependent on angiogenesis.

AIM

To analyze and compare the immunohistochemical expression of angiogenic factors - Vascular Endothelial Growth Factor (VEGF), von Willebrand Factor (vWF) and CD 34 in skin biopsies of psoriasis cases with control skin samples; and to correlate the expression of angiogenic factors with Psoriasis Area and Severity Clinical Index (PASI SCORE).

MATERIALS AND METHODS

This was a prospective case control study conducted over a period of 15 months. Thirty-two psoriasis cases and thirty control skin samples were included in the study. Skin biopsy specimen was taken from clinically diagnosed psoriasis cases who did not receive any treatment. The diagnosis of psoriasis vulgaris was confirmed after microscopic examination. Immunohistochemical expression for VEGF, vWF and CD 34 was studied.

RESULTS

VEGF expression in epidermis was significantly higher in cases when compared to control skin (p <0.01). CD 34 expression was significantly upregulated in cases when compared to controls (p<0.01). Von Willebrand factor expression was weak in both the cases and the controls. Significant correlation between the expression of VEGF and PASI score (r=0.944; p<0.01), and expression of CD 34 and PASI score was observed (r=0.942; p<0.01).

CONCLUSION

In the present study, significant overexpression of VEGF and CD 34 was noted in cases when compared to controls. The keratinocytes in the psoriatic skin lesions were recognized as a source of pro-angiogenic cytokines namely the VEGF and other growth factors which promotes angiogenesis in psoriatic plaque. Angiogenesis plays an important role in genesis and development of psoriasis vulgaris. Therefore, development of targeted anti-angiogenic therapy might be beneficial for this chronic disabling dermatological disease.

A study of dermoscopic features of nail psoriasis

Introduction

Dermoscopy is a non-invasive imaging method that enables the evaluation of pigmented and non-pigmented skin lesions. More recently, dermoscopy has been recognized as an effective tool in the diagnosis of nail diseases.

Aim

To evaluate the dermoscopic features of nail psoriasis and to assess the relationship between these features and disease severity.

Material and methods

A total of 67 patients with clinically evident nail psoriasis (14 women, 53 men) were prospectively enrolled. Following a thorough clinical examination, patients were graded according to the Nail Psoriasis Severity Index and physician’s global assessment score. A dermoscopic examination of all fingernails and toenails was performed using a videodermatoscope. Mann-Whitney U and χ² tests were used for statistical analysis, with a significance threshold of p < 0.05.

Results

The most frequently observed dermoscopic features were splinter haemorrhage (73.1%), pitting (58.2%), distal onycholysis (55.2%), dilated hyponychial capillaries (35.8%) and the pseudo-fiber sign (34.3%). The pseudo-fiber sign, dilated hyponychial capillaries, nail plate thickening and crumbling, subungual hyperkeratosis, transverse grooves, trachyonychia, pitting and salmon patches were positively associated with disease severity.

Conclusions

The pseudo-fiber sign described in this study appears to be a novel dermoscopic feature of nail psoriasis. We have demonstrated positive associations between a number of dermoscopic manifestations and disease severity. Further studies are required to support the present findings.

Angiogenesis and lymphangiogenesis in inflammatory skin disorders

Angiogenesis, the growth of new blood vessels from pre-existing vessels, occurs physiologically in wound healing, during inflammatory diseases, and in tumor growth. Lymphangiogenesis can be activated in inflammation and tumor metastasis. The family of vascular endothelial growth factors (VEGFs) and angiopoietins are essential for angiogenesis and lymphangiogenesis. The angiogenic process is tightly regulated by VEGFs, angiopoietins, and endogenous inhibitors. VEGFs and angiopoietins exert their effects by activating specific receptors present on blood and lymphatic endothelial cells. There is now compelling evidence that cells of innate and adaptive immunity (macrophages, mast cells, neutrophils, eosinophils, lymphocytes) are a major source of angiogenic and lymphangiogenic factors. Chronic inflammatory skin diseases such as psoriasis and atopic dermatitis are characterized by altered angiogenesis, lymphangiogenesis, or both. Also such acute inflammatory skin disorders as urticaria, ultraviolet B-induced damage, and angioedema are associated with changes in angiogenic factors. In systemic sclerosis there is a switch from proangiogenic to antiangiogenic factors that play a role in the defective vascular process of this disorder. As yet, there are no clinical trials showing that canonical VEGF/VEGF receptor-targeted strategies can modulate inflammatory skin diseases. Novel strategies targeting other angiogenic/lymphangiogenic pathways should also be investigated.

Evaluation of the vascular pattern in psoriatic plaques in children using videodermatoscopy: an open comparative study

Psoriasis is a common erythematous desquamative dermatosis. The diagnosis may sometimes be troublesome in children, especially if clinical presentation is mild or atypical. Videodermatoscopy has been suggested as a new noninvasive aid for the diagnosis of psoriasis, prognostic evaluation, and treatment monitoring. An open comparative study in children aimed at assessing the correlation between the vascular pattern evaluated using videodermatoscopy and the clinical diagnosis of psoriasis and other erythematous desquamative disorders was designed and performed. Sixty Caucasian children were enrolled and subdivided into two groups: group A, 24 patients with multiple plaque psoriasis; group B, 36 patients with other erythematous desquamative disorders. At least two lesions were examined in each patient using videodermatoscopy at 150× magnification and the superficial vascular pattern of each lesion was evaluated in three different fields. In group A, the presence of dilated capillaries with a "bushy" aspect, homogeneously distributed in all examined fields, was seen in all considered plaques. In group B, videodermatoscopic findings were not specific, showing normal-looking capillaries, slightly dilated vessels, or a few isolated "bushes." Videodermatoscopy may be considered an important adjunct diagnostic tool in clinically doubtful erythematous desquamative lesions in children, allowing a psoriatic vascular pattern to be confirmed or excluded, with some distinct advantages over skin biopsy.

Effect of FGF10 monoclonal antibody on psoriasis-like model in guinea pigs

OBJECTIVE

To investigate the therapeutical effect of topical application of FGF10 monoclonal antibody on the guinea pig model with psoriasis.

METHODS

Blank group, model group, hydrocortisone butyrate treatment group and high-dose (0.188 mg/ml), middle-dose (0.094 mg/ml) and low-dose (0.063 mg/ml) FGF10 antibody group were set, respectively. After two-week treatment, pathological changes of psoriasis-like models were observed by HE staining, and the difference in VEGF and PCNA expression levels among different groups was observed by immunohistochemical staining.

RESULTS

All the test indicators of each treatment group were lower than those of the model group, and there was a significant difference (P<0.05). The inflammatory cell count of the high-dose FGF10 antibody group was not statistically different from those of the blank group (t=0.77, P=0.443), and the counts of the rest treatment groups were significantly higher than those of the blank group and the high-dose FGF10 antibody group (P<0.05). The epidermal thickness of each FGF10 antibody treatment group was significantly higher than that of hydrocortisone butyrate treatment group (P<0.05), while no statistical difference was found in the epidermal thickness among the FGF10 antibody treatment groups (P>0.05). FGF10 monoclonal antibodies can reduce the PCNA and VEGF expression in psoriasis-like model of guinea pig's ear.

CONCLUSION

FGF10 monoclonal antibodies can affect keratinocyte proliferation and division and can also significantly inhibit the inflammatory response in the psoriasis model. Meanwhile, FGF10 monoclonal antibodies can produce a therapeutic effect on psoriatic lesions by inhibiting the abnormal epidermis cell proliferation and neovascularization of the dermis in the psoriasis model.

Psoriasis, a new challenge for laboratory medicine

Psoriasis is an immune-mediated, chronic, inflammatory disease that affects the skin and joints. Because of its high incidence and of its clinical symptoms it has a very strong social impact. In a genetically predisposed individual, the maintenance of the skin barrier integrity is strongly compromised in response to either environmental or self-antigenic insults. A persistent dysregulation of the skin immune system causes the typical evolutive skin lesions of psoriasis and recurrence of the disease. The most efficient laboratory approach consists of a well-defined evaluation of immune response in order to help diagnosis, to monitor evolution, and to evaluate the effects of individualized therapeutic treatments.