ObjectiveTo provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.DesignA consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.MethodsThe authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations.ResultsKey recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao2/Fio2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao2/Fio2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C).ConclusionsStrong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Colin Stephan Daniele Elena Emanuele Antonio L Andreas E Baigent Windecker Andreini Arbelo Barbato Bartorel, C. Baigent, S. Windecker
et al.
Abstract Aims Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular (CV) disease in association with COVID-19. Methods and results A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, which was reported previously, focused on the epidemiology, pathophysiology, and diagnosis of CV conditions that may be manifest in patients with COVID-19. This second part addresses the topics of: care pathways and triage systems and management and treatment pathways, both of the most commonly encountered CV conditions and of COVID-19; and information that may be considered useful to help patients with CV disease (CVD) to avoid exposure to COVID-19. Conclusion This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.
Mohammad K. El Badrawy, Afaf Abd El-Hafez, Mostafa Elmansy
et al.
Abstract Background Pulmonary embolism (PE) means occlusion of the pulmonary artery with thrombi, tumor tissue, air, or fat. Blood clots may be located in the main pulmonary artery or in its branches. Aim To assess the frequency of hemoptysis among cases with pulmonary embolism at Mansoura Emergency Hospital and its relation to other symptoms, laboratory data, radiological findings, and the outcome of the affected patients. Methodology This prospective cross-sectional observational investigation has been performed on 73 cases admitted at Mansoura University Emergency Department, Mansoura, Egypt, over 1 year between May 2022 and May 2023. Patients were diagnosed with PE according to the clinical presentation, laboratory findings, and computed tomography pulmonary angiography (CTPA). They were divided into 2 groups, either with or without hemoptysis. Results Mortality was higher in patients with hemoptysis (37.5% vs 7.7%, OR = 6.9, 95% CI 1.4–33.2, p = 0.011). The need for mechanical ventilation and prolonged hospital stay (> 7 days) was also higher in patients with hemoptysis. Median hospital stay is as follows: 15 (10–29) days vs 9 (6–20), p < 0.001. Conclusion Hemoptysis is an uncommon presentation in cases with pulmonary embolism, as it was present in 11% of cases. Hemoptysis is highly associated with pulmonary infarction and must direct the attention to the severity of pulmonary embolism as well as the worse outcome.
Diseases of the respiratory system, Medical emergencies. Critical care. Intensive care. First aid
Masataka Kuwana, Aiko Saito, Sue Farrington
et al.
Summary What is this summary about? Systemic sclerosis (SSc) is a condition that affects the immune system (the body’s natural defence system) and causes the skin to harden and thicken in large patches. Research shows that 30% to 90% of people with SSc also have interstitial lung disease (ILD), a condition that causes inflammation and scarring of the lungs. When people have SSc and ILD, it is known as SSc-associated ILD or SSc-ILD. The authors of this plain language summary of publication (PLS-P) reviewed different articles to find out what the key issues were in the way doctors and patients with SSc-ILD communicate with each other. What were the results? The key messages from the studies were: Most patients felt uneasy when they were diagnosed with SSc-ILD Good communication between doctors and patients at the first visit is crucial as it sets the tone for future relationships Both doctors and patients avoid talking about how SSc-ILD symptoms may get worse (prognosis) or the subject of death. Patients should be encouraged to ask questions to address important and personal topics that would not be talked about otherwise Patients may feel intimidated by a doctor, which could interfere with communication Doctors must be able to listen and show empathy to build a relationship with patients and be aware that different communication styles may suit a patient during different stages in their journey Doctors should avoid using a lot of technical terms. Patients felt metaphors helped them understand their condition better Patients have different awareness, thoughts, and feelings about SSc-ILD than doctors. If doctors understand this, it may improve the communication between doctors and patients Ways to close the gap between the way doctors and patients communicate include patients having the opportunity to access: Self-learning and patient organizations Peer-mentoring (patients mentoring other patients) Information technology Shared decision-making, where the doctor and patient work together to come to a decision about treatment and care What do the results mean? The best way to improve the feelings patients have when they are diagnosed with SSc, including SSc-ILD, is to improve the quality of the communication between doctors and patients. The quality of the first meeting between a doctor and patient sets the tone for future checkups, especially if the doctor can listen, show empathy, and allow the patient to ask questions. Improving the patient’s knowledge about SSc-ILD, for example by using websites, reading printed materials, or taking part in peer-mentoring schemes, may also contribute to a better conversation.
Accurate diagnosis of Mendelian diseases is crucial for precision therapy and assistance in preimplantation genetic diagnosis. However, existing methods often fall short of clinical standards or depend on extensive datasets to build pretrained machine learning models. To address this, we introduce an innovative LLM-Driven multi-agent debate system (MD2GPS) with natural language explanations of the diagnostic results. It utilizes a language model to transform results from data-driven and knowledge-driven agents into natural language, then fostering a debate between these two specialized agents. This system has been tested on 1,185 samples across four independent datasets, enhancing the TOP1 accuracy from 42.9% to 66% on average. Additionally, in a challenging cohort of 72 cases, MD2GPS identified potential pathogenic genes in 12 patients, reducing the diagnostic time by 90%. The methods within each module of this multi-agent debate system are also replaceable, facilitating its adaptation for diagnosing and researching other complex diseases.
In temperate regions, respiratory virus epidemics recur on a yearly basis, primarily during the winter season. This is believed to be induced by seasonal forcing, where the rate at which the virus can be transmitted varies cyclically across the course of each year. Seasonal epidemics can place substantial burden upon the healthcare system, with large numbers of infections and hospitalisations occurring across a short time period. However, the interactions between seasonal forcing and the factors necessary for epidemic resurgence - such as waning immunity, antigenic variation or demography - remain poorly understood. In this manuscript, we examine how the dynamics of antibody waning and antigenic variation can shape the seasonal recurrence of epidemics. We develop a novel susceptible-infectious-susceptible (SIS) immuno-epidemiological model of respiratory virus spread, where the susceptible population is stratified by their antibody level against the currently circulating strain of the virus, with this decaying as both antibody waning and antigenic drift occur. In the absence of seasonal forcing, we demonstrate the existence of two Hopf bifurcations over the effective antibody decay rate, with associated periodic model solutions. When seasonal forcing is introduced, we identify complex interactions between the strength of forcing and the effective antibody decay rate, yielding myriad dynamics including multi-year periodicity, quasiperiodicity and chaos. The timing and magnitude of seasonal epidemics is highly sensitive to this interaction, with the distribution of infection timing (by time of year) varying substantially across the parameter space. Finally, we show that seasonal forcing can produce resonant damping resulting in a cumulative infection incidence that is less than would otherwise be observed.
Jose R. Palacio, Katherine B. Ensor, Sallie A. Keller
et al.
Wastewater-based epidemiology (WBE) is an effective tool for tracking community circulation of respiratory viruses. We address estimating the effective reproduction number ($R_t$) and the relative number of infections from wastewater viral load. Using weekly Houston data on respiratory syncytial virus (RSV), we implement a parsimonious Bayesian renewal model that links latent infections to measured viral load through biologically motivated generation and shedding kernels. The framework yields estimates of $R_t$ and relative infections, enabling a coherent interpretation of transmission timing and phase. We compare two input strategies-(i) raw viral-load measurements with a log-scale standard deviation, and (ii) state-space-filtered load estimates with time-varying variances-and find no practically meaningful differences in inferred trajectories or peak timing. Given this equivalence, we report the filtered input as a pragmatic default because it embeds week-specific variances while leaving epidemiological conclusions unchanged.
Rare diseases affect over 300 million individuals worldwide, yet timely and accurate diagnosis remains an urgent challenge. Patients often endure a prolonged diagnostic odyssey exceeding five years, marked by repeated referrals, misdiagnoses, and unnecessary interventions, leading to delayed treatment and substantial emotional and economic burdens. Here we present DeepRare, a multi-agent system for rare disease differential diagnosis decision support powered by large language models, integrating over 40 specialized tools and up-to-date knowledge sources. DeepRare processes heterogeneous clinical inputs, including free-text descriptions, structured Human Phenotype Ontology terms, and genetic testing results, to generate ranked diagnostic hypotheses with transparent reasoning linked to verifiable medical evidence. Evaluated across nine datasets from literature, case reports and clinical centres across Asia, North America and Europe spanning 14 medical specialties, DeepRare demonstrates exceptional performance on 3,134 diseases. In human-phenotype-ontology-based tasks, it achieves an average Recall@1 of 57.18%, outperforming the next-best method by 23.79%; in multi-modal tests, it reaches 69.1% compared with Exomiser's 55.9% on 168 cases. Expert review achieved 95.4% agreement on its reasoning chains, confirming their validity and traceability. Our work not only advances rare disease diagnosis but also demonstrates how the latest powerful large-language-model-driven agentic systems can reshape current clinical workflows.
Abstract Extracellular traps (ETs) are a specialized form of innate immune defense in which leukocytes release ETs composed of chromatin and active proteins to eliminate pathogenic microorganisms. In addition to the anti-infection effect of ETs, researchers have also discovered their involvement in the pathogenesis of inflammatory disease, tumors, autoimmune disease, and allergic disease. Asthma is a chronic airway inflammatory disease involving multiple immune cells. The increased level of ETs in asthma patients suggests that ETs play an important role in the pathogenesis of asthma. Here we review the research work on the formation mechanism, roles, and therapeutic strategies of ETs released by neutrophils, eosinophils, and macrophages in asthma.
Tsuyoshi Sasada, Ryo Tachikawa, Shigeo Hara
et al.
Key message A 78‐year‐old woman presented with multiple pulmonary nodules, mixed with solid and ground‐glass nodules. We pathologically confirmed that the multiple pulmonary nodules were a combination of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and multiple pulmonary meningothelial‐like nodules (MPMNs). This is the first case report of concurrent DIPNECH and MPMNs.
Abstract Objective This study aimed to explore the role and regulatory mechanism of lncRNA ZEB1‐AS1 in lung cancer. Methods The expression of ZEB1‐AS1 and miR‐320b was determined by qRT‐PCR. Cell viability, proliferation migration, and invasion were assessed using the CCK‐8, colony‐forming, and Transwell assay. EMT markers were quantified using western blot. The growth of subcutaneous tumor growth and metastatic bone tumors was evaluated in mouse model of lung cancer. Additionally, metastatic bone tumors were examined using H&E staining. Results ZEB1‐AS1 expression was upregulated, while miR‐320b levels were downregulated in lung cancer. Knockdown of ZEB1‐AS1 resulted in a significant suppression of cell viability, proliferation, migration, invasion, and EMT in A549 cells. Furthermore, we confirmed the targeting relationship between ZEB1‐AS1 and miR‐320b, as well as between miR‐320b and BMPR1A. Our findings suggested that ZEB1‐AS1 regulated cell viability, proliferation, migration, and invasion, as well as EMT, in lung cancer cells by targeting the miR‐320b/BMPR1A axis. Moreover, our in vivo experiments confirmed that ZEB1‐AS1 mediated bone metastasis through targeting miR‐320b/BMPR1A axis in mice with lung cancer. Conclusion ZEB1‐AS1 mediated bone metastasis through targeting miR‐320b/BMPR1A axis in lung cancer.
The use of Electronic Health Records (EHRs) has increased dramatically in the past 15 years, as, it is considered an important source of managing data od patients. The EHRs are primary sources of disease diagnosis and demographic data of patients worldwide. Therefore, the data can be utilized for secondary tasks such as research. This paper aims to make such data usable for research activities such as monitoring disease statistics for a specific population. As a result, the researchers can detect the disease causes for the behavior and lifestyle of the target group. One of the limitations of EHRs systems is that the data is not available in the standard format but in various forms. Therefore, it is required to first convert the names of the diseases and demographics data into one standardized form to make it usable for research activities. There is a large amount of EHRs available, and solving the standardizing issues requires some optimized techniques. We used a first-hand EHR dataset extracted from EHR systems. Our application uploads the dataset from the EHRs and converts it to the ICD-10 coding system to solve the standardization problem. So, we first apply the steps of pre-processing, annotation, and transforming the data to convert it into the standard form. The data pre-processing is applied to normalize demographic formats. In the annotation step, a machine learning model is used to recognize the diseases from the text. Furthermore, the transforming step converts the disease name to the ICD-10 coding format. The model was evaluated manually by comparing its performance in terms of disease recognition with an available dictionary-based system (MetaMap). The accuracy of the proposed machine learning model is 81%, that outperformed MetaMap accuracy of 67%. This paper contributed to system modelling for EHR data extraction to support research activities.
Bardia Baraeinejad, Maryam Forouzesh, Saba Babaei
et al.
In the last few decades, several wearable devices have been designed to monitor respiration rate in an effort to capture pulmonary signals with higher accuracy and reduce patients' discomfort during use. In this article, we present the design and implementation of a device for real-time monitoring of respiratory system movements. When breathing, the circumference of the abdomen and thorax changes; therefore, we used a Force Sensing Resistor (FSR) attached to the Printed Circuit Board (PCB) to measure this variation as the patient inhales and exhales. The mechanical strain this causes changes the FSR electrical resistance accordingly. Also, for streaming this variable resistance on an Internet of Things (IoT) platform, Bluetooth Low Energy (BLE) 5 is utilized due to the adequate throughput, high accessibility, and possibility of power consumption reduction. Furthermore, this device presents features such as low power consumption (0.4 mW), high precision, and ease of use.
Masoud Elhamiasl, Frederic Jolivet, Ahmadreza Rezaei
et al.
Whole-body PET imaging is often hindered by respiratory motion during acquisition, causing significant degradation in the quality of reconstructed activity images. An additional challenge in PET/CT imaging arises from the respiratory phase mismatch between CT-based attenuation correction and PET acquisition, leading to attenuation artifacts. To address these issues, we propose two new, purely data-driven methods for the joint estimation of activity, attenuation, and motion in respiratory self-gated TOF PET. These methods enable the reconstruction of a single activity image free from motion and attenuation artifacts. The proposed methods were evaluated using data from the anthropomorphic Wilhelm phantom acquired on a Siemens mCT PET/CT system, as well as 3 clinical FDG PET/CT datasets acquired on a GE DMI PET/CT system. Image quality was assessed visually to identify motion and attenuation artifacts. Lesion uptake values were quantitatively compared across reconstructions without motion modeling, with motion modeling but static attenuation correction, and with our proposed methods. For the Wilhelm phantom, the proposed methods delivered image quality closely matching the reference reconstruction from a static acquisition. The lesion-to-background contrast for a liver dome lesion improved from 2.0 (no motion correction) to 5.2 (proposed methods), matching the contrast from the static acquisition (5.2). In contrast, motion modeling with static attenuation correction yielded a lower contrast of 3.5. In patient datasets, the proposed methods successfully reduced motion artifacts in lung and liver lesions and mitigated attenuation artifacts, demonstrating superior lesion to background separation. Our proposed methods enable the reconstruction of a single, high-quality activity image that is motion-corrected and free from attenuation artifacts, without the need for external hardware.
Aim The aim of this article is to present the method and results of the data quality control system and audit within the Netherlands Heart Registration (NHR) using data of patients treated with percutaneous coronary intervention (PCI) in the Netherlands as an example. Methods The NHR is a Dutch nationwide registry of all cardiac interventions, comprising data from all 71 hospitals, of which 30 are cardiac intervention or heart centres. Each year, within the NHR, data validation and verification is performed by standard quality controls and monitoring visits (audits). For the audit in 2019, a sample of 50–100 medical records of patients treated with PCI in 2016 and 2017 were reviewed in each hospital by an independent auditor. The data received by the NHR were compared with the information in the hospitals’ medical records. In total 12 patient characteristics, 5 intervention variables and 3 outcome variables were screened. The value of a variable was considered discrepant if more than 10% of the medical records reviewed regarding this variable were not consistent with the reported data received by the NHR. Results For all variables together, the consistency was high, 97.6%. All variables, except multivessel disease (9.3% discrepancy in the 2622 medical records reviewed), had an accuracy above 95%. Conclusion The results of the audit of the PCI medical records show that the overall quality of the data is high. For variables such as multivessel disease it is important to improve knowledge of the definitions and to train all those involved in the registration process.
Rachel Z. Blumhagen, Jonathan S. Kurche, Carlyne D. Cool
et al.
Abstract Background Idiopathic pulmonary fibrosis (IPF) is a heterogeneous disease that is pathologically characterized by areas of normal-appearing lung parenchyma, active fibrosis (transition zones including fibroblastic foci) and dense fibrosis. Defining transcriptional differences between these pathologically heterogeneous regions of the IPF lung is critical to understanding the distribution and extent of fibrotic lung disease and identifying potential therapeutic targets. Application of a spatial transcriptomics platform would provide more detailed spatial resolution of transcriptional signals compared to previous single cell or bulk RNA-Seq studies. Methods We performed spatial transcriptomics using GeoMx Nanostring Digital Spatial Profiling on formalin-fixed paraffin-embedded (FFPE) tissue from 32 IPF and 12 control subjects and identified 231 regions of interest (ROIs). We compared normal-appearing lung parenchyma and airways between IPF and controls with histologically normal lung tissue, as well as histologically distinct regions within IPF (normal-appearing lung parenchyma, transition zones containing fibroblastic foci, areas of dense fibrosis, and honeycomb epithelium metaplasia). Results We identified 254 differentially expressed genes (DEGs) between IPF and controls in histologically normal-appearing regions of lung parenchyma; pathway analysis identified disease processes such as EIF2 signaling (important for cap-dependent mRNA translation), epithelial adherens junction signaling, HIF1α signaling, and integrin signaling. Within IPF, we identified 173 DEGs between transition and normal-appearing lung parenchyma and 198 DEGs between dense fibrosis and normal lung parenchyma; pathways dysregulated in both transition and dense fibrotic areas include EIF2 signaling pathway activation (upstream of endoplasmic reticulum (ER) stress proteins ATF4 and CHOP) and wound healing signaling pathway deactivation. Through cell deconvolution of transcriptome data and immunofluorescence staining, we confirmed loss of alveolar parenchymal signals (AGER, SFTPB, SFTPC), gain of secretory cell markers (SCGB3A2, MUC5B) as well as dysregulation of the upstream regulator ATF4, in histologically normal-appearing tissue in IPF. Conclusions Our findings demonstrate that histologically normal-appearing regions from the IPF lung are transcriptionally distinct when compared to similar lung tissue from controls with histologically normal lung tissue, and that transition zones and areas of dense fibrosis within the IPF lung demonstrate activation of ER stress and deactivation of wound healing pathways.