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ID PMID Title PublicationDate abstract
11490512 Immunopathology of Sjögren's syndrome. 1998 Feb Sjögren's syndrome is a chronic autoimmune disorder characterized by mononuclear cell infiltration around epithelial cells of exocrine glands. In recent years, several studies have tried to elucidate the components of the immunopathologic interaction in Sjögren's syndrome as well as the function of these components. The majority of the mononuclear infiltrating cells are CD4 positive T lymphocytes (60-70%) whereas B cells constitute one fourth of the infiltrating cells. Macrophages and natural killer cells are poorly represented in the lesion. Epithelial cells of minor salivary glands of patients with Sjögren's syndrome express several cytokines (IL-1 beta, IL-6, NO), protooncogenes (c-myc), autoantigens (Ro, La, Fodrin) and costimulatory molecules (B71, B72). The characteristic destruction of epithelial cells of Sjögren's syndrome patients is probably due to activation of several apoptotic pathways since epithelial cells express different apoptosis related molecules such as Fas, FasL, Bax, while mononuclear cells express Perforin and Granzymes. Finally epithelial cells seem to exert a regenerative effort since they express trefoil proteins (pS2). The above mentioned properties give epithelial cells the leading role in the pathophysiology of the syndrome but the exact causative agent which drives the immune system towards an autoimmune reaction still remains obscure.
11488418 Reproducibility of biopsy grade in Sjögren's syndrome. 2001 Aug The purpose of this study was to examine the reproducibility of biopsy grades at various tissue depths in Sjögren's syndrome. The biopsy grades of 38 minor salivary gland biopsies were examined at 6 microm, 50 microm, 100 microm, 150 microm, 200 microm, and 250 microm tissue depths. Tissue sections were stained with routine hematoxylin and eosin, graded I-IV, and compared with the initial "baseline" biopsy grade. The majority of the biopsies showed a wide range of grade variability at all depths. No tissue depth was consistently reproducible for any grade (P> or =0.41, 0.64, 0.91, and 0.20, respectively). The difference between baseline grades and grades of deeper sections was sufficient to impact the diagnosis of Sjögren's syndrome in approximately 60% of the biopsies (P<0.001). The overall result of this study suggests that examination of multiple sections of minor salivary gland biopsies is advisable to improve the reliability of the grade when evaluating Sjögren's syndrome.
11126667 [Primary Sjögren's syndrome presenting as unconsciousness associated with IgA-lambda M-pr 1999 Jun We describe the case of a 43-year-old woman who presented with primary Sjögren's syndrome (SS) which manifestated as unconsciousness due to M protein. A diagnosis of SS was made based on a ten-year history of dryness, a Shirmer test, and the histological findings of labial biopsy. A rouleaux formation was observed and serum protein electrophoresis revealed a monoclonal spike of 4.0 gm/dl in the gamma-region, which was characterized as IgA-lambda. Biopsy of the minor salivary glands showed marked polyclonal lymphoproliferation with lymphoid follicles, including both T cells and B cells as revealed by immunohistological staining. Therefore, the patient had a lymphoproliferative lesion of the minor salivary glands, which is also known as pseudolymphoma. We conclude that fainting associated with marked M protein may be manifestation of SS. Such cases should be followed carefully since the subsequent neoplastic transformation of pseudolymphomas have been previously reported.
10609070 Sialic acid residues in the labial salivary glands from Sjögren's syndrome patients. 1999 Nov OBJECTIVE: To investigate the composition and expression of sialic acid in the labial salivary glands (LSG) in Sjögren's syndrome (SS). METHODS: LSG of 19 patients with primary SS (n = 11) or secondary SS (n = 8) were studied. Specimens from 7 healthy women served as controls. Computer-assisted microscopy was employed to quantitatively determine the percentage of positive structures, the staining intensity and the heterogeneity for the 4 biotinylated plant lectins Tritricum vulgaris L. (WGA), Maackia amurensis (MAA), Sambucus nigra (SNA) and Canavalia ensiformis L. (Con A). RESULTS: In the acini there was a significant decrease in the staining heterogeneity of WGA in SS compared to controls; the same was observed with respect to MAA staining in the connective tissue and extralobular ducts. In the intralobular ducts, primary SS differed from normal and secondary SS mainly in terms of a decrease in the percentage of positively labeled MAA tissue. In addition, Con A stained acinar cells were significantly more numerous in secondary SS compared with primary SS. CONCLUSION: Differences in the degree of glycoconjugate sialylation were found in SS labial salivary glands, and may play a role in the disease process.
10200720 Candida albicans levels in patients with Sjögren's syndrome before and after long-term us 1998 Nov OBJECTIVE: The purpose of this study was to compare the quantities of oral Candida albicans in patients with primary and secondary Sjögren's syndrome before and after the use of orally administered pilocarpine hydrochloride for 1 year. METHOD AND MATERIALS: Twelve female subjects with primary (n = 4) and secondary (n = 8) Sjögren's syndrome (mean age +/- SEM = 56.7 +/- 5.7 years) were enrolled in the study, after meeting rigid enrollment criteria. Oropharyngeal collection of samples and culturing was performed on each subject. Cultures specific for Candida albicans were plated into a culture media tube using the Oricult kit and also by serial dilutions and plating by a streptomycin-vancomycin technique. Cultures were incubated for 48 hours at 37 degrees C. The subjects used 5 mg of pilocarpine hydrochloride, administered orally three times daily, for 1 year, after which both of the Candida cultures were repeated. None of the subjects used antifungal medications, none smoked, and all were dentate. RESULTS: There was a significant difference in the prevalence of Candida after the use of pilocarpine hydrochloride for both groups. At the start of the study, 75% of all subjects were positive for Candida. Following the use of pilocarpine, 25% had positive cultures. There was also a decrease in the prevalence of clinical manifestations of infection from 75% of subjects to 25%. There was a significant decrease in the numbers of Candida cultured following the use of pilocarpine. CONCLUSION: Long-term administration of pilocarpine hydrochloride resulted in a significant reduction in Candida albicans colonization in patients with primary or secondary Sjögren's syndrome.
9263150 Quantitative analysis of apoptosis and bcl-2 in Sjögren's syndrome. 1997 Aug OBJECTIVE: To determine whether apoptosis plays a significant role in tissue damage of Sjögren's syndrome (SS). METHODS: We performed a quantitative analysis of programmed cell death on salivary glands of 11 patients. Ten age matched women with sicca syndrome served as controls. Morphometric measurement of the fractional volume of acini and ducts showing DNA strand breaks was performed in sections stained by deoxynucleotidyl transferase assay. The extent of bcl-2 expression was determined in sections labeled with monoclonal antibody. The different cell populations infiltrating the glands were examined in tissues stained with anti-leukocyte common antigen and OPD4 monoclonal antibodies. RESULTS: In patients with SS, 68% of the ductal epithelium was occupied by apoptotic structures, whereas only 12% of acini showed DNA strand breaks. Corresponding values in control salivary glands were 3 and 0.13%. bcl-2 labeling was higher in ducts than in acini of both control and pathologic glands. However, in SS a 43% (p < 0.001) and 75% (p < 0.001) reduction in bcl-2 expression was observed in ductal and acinar epithelium, respectively. In comparison with controls, the numerical density of CD4+ cells and plasma cells scattered throughout the interstitium was 323% and 203% higher (p < 0.001) in SS. Moreover, T helper/inducer lymphocytes represented 52% of the inflammatory foci. CONCLUSION: Apoptosis occurs in minor salivary glands of patients with SS with a prevailing localization on the ductal epithelium in association with downregulation of bcl-2 and a large number of infiltrating CD4+ lymphocytes. Thus, the destruction of glandular tissue and the loss of secretory function in SS is dependent on the activation of the suicide program of epithelial cells.
11571548 Evaluation of pulse sequences used for magnetic resonance sialography. 2001 Sep OBJECTIVES: To determine the most appropriate sequences for the visualization of small parotid ducts in MR sialography. METHODS: MR images of a phantom consisting of distilled water in polyethylene tubes were obtained with turbo-spin echo (TSE), single-shot turbo-spin echo (SSTSE), half-fourier acquisition, single-shot turbo-spin echo (HASTE) and turbo gradient-spin echo (TGSE) pulse sequences and compared visually and quantitatively. MR sialograms obtained from healthy volunteers and patients with Sjögren's syndrome (SS) were obtained using the same four sequences. RESULTS: In the phantom, TSE images were best and the contrast-noise ratio (CNR) highest. In the volunteers, the main ducts were especially clearly visualized with TSE and in SSTSE; however, the majority of secondary and/or tertiary parotid ducts were not depicted by any of the sequences used. In SS patients, images of small main ducts and small pseudocysts were clearer using TSE. However, TSE could not depict the narrow main ducts or peripheral ducts or very small pseudocysts. CONCLUSIONS: TSE is considered the most suitable MR sequence for assessing small parotid gland ducts. However, further improvement is needed since it does not always visualize them sufficiently.
11337569 Salivary and lacrimal gland dysfunction (sicca syndrome) after radioiodine therapy. 2001 May Salivary gland dysfunction has been described in patients undergoing radioiodine therapy but associated lacrimal gland dysfunction (sicca syndrome) has never been reported. We conducted a prospective cohort study with follow-up for up to 3 y in a tertiary care university center to determine the prevalence of sicca syndrome in patients after high-dose radioiodine treatment. METHODS: From January 1990 to December 1995, all patients undergoing radioiodine therapy (n = 79) with a standard dose of 925 MBq to 18.5 GBq (25-500 mCi) were interviewed using a standardized questionnaire to determine subjective ocular and oral dryness and were examined for objective lacrimal and salivary gland dysfunction. RESULTS: After radioiodine treatment, 32.9% of the patients reported subjective xerostomia and 25.3% reported subjective xerophthalmia in the first year of follow-up. Xerostomia persisted to the second year of follow-up in 20.3% of cases and was still present >3 y after the last dose of radioiodine in 15.2% of cases. Xerophthalmia persisted to the second year of follow-up in 17.7% of cases and was still present in the third year of follow-up in 13.9% of cases. Severe xerostomia occurred in 4 patients. Reduced salivary and lacrimal gland function was documented in 40 (50.6%) and 14 (17.7%) of the 79 cases, respectively, in the first year of follow-up. Objective xerostomia persisted in 13.9% of cases to the second year of follow-up and was still present in all patients >3 y after the last radioiodine application. Keratoconjunctivitis sicca persisted in 11 patients (13.9%) to the second year of follow-up but was only present in 6 patients (7.6%) >3 y after the last radioiodine application. Additionally, 28/79 patients (35.4%) who had a normal salivary gland scintigraphy previously showed reduced salivary gland function in the third year of follow-up. No significant dependence on cumulative treatment was found for objective xerostomia or xerophthalmia, but doses >11.1 GBq (300 mCi) were related to stage 3 dysfunction on salivary gland scintigraphy. CONCLUSION: Salivary and lacrimal gland dysfunction (sicca syndrome) is relatively frequent after radioiodine therapy. In most cases this is a transient side effect, but in some patients it may persist for a long period or appear late.
11326475 Manometric assessment of impaired esophageal motor function in primary Sjögren's syndrome 2001 Mar OBJECTIVE: To evaluate by manometry the esophageal motility changes in patients with primary Sjögren's syndrome (SS). METHODS: Esophageal manometry was carried out in 25 (F/M: 22/3) primary SS patients with systemic manifestations and in 42 control subjects. The primary SS patients also completed a dysphagia scoring questionnaire and underwent whole salivary flow measurements. RESULTS: As compared with the controls the primary SS patients exhibited a decreased lower esophageal sphincter (LES) pressure (P < 0.01) and a prolongation of LES relaxations (P < 0.02). In the esophageal body (EB) a decreased peristaltic velocity (p < 0.01), an increased duration of contractions (p < 0.01) and a higher occurrence of simultaneous waves (p < 0.01) were detected. Since decreased peristaltic velocity was the most frequent motor abnormality (11/25 cases), two groups of patients were formed for further analysis: patients with a decreased (group I, n = 11) and patients with a normal (group II, n = 14) peristaltic velocity. The SS patients with a decreased EB propagation velocity (< or = 2.7 cm/s, group I) displayed more significantly decreased pressures (p < 0.01) and more prolonged relaxation times (p < 0.05) in the LES, with higher rates of simultaneous contractions on dry swallows (p = 0.05) in the EB, as compared with those who had a normal peristaltic velocity (group II). Of the clinical parameters, the decreased EB peristaltic velocity was associated with a smaller whole saliva production both in the basal state and after stimulation. Furthermore, this group of patients had a significantly higher liquid requirement for swallowing than those who had normal peristaltic velocities (p = 0.05). CONCLUSIONS: Primary SS patients with systemic manifestations exhibit several esophageal motility abnormalities. In this study, a decreased EB peristaltic velocity was the most common manometric change, and showed an association with impaired saliva production and higher liquid requirement for swallowing, but not with the laboratory parameters or with the systemic manifestations of the disease.
11197978 Study of quantitative oral radioactivity in salivary gland scintigraphy and determination 2001 Jan In this study, the oral radioactivity seen in salivary gland scintigraphy, which was established entirely on the basis of radioactive saliva secreted by the parotid and submandibular glands, was evaluated quantitatively in healthy volunteers and in patients with Sjögren's syndrome. METHODS: Salivary gland scintigraphy and labial biopsy were performed on 70 patients with Sjögren's syndrome. After intravenous administration of 99mTc-sodium pertechnetate, dynamic scintigraphy was performed and time-activity curves for the oral cavity and four major salivary glands were generated. Lemon juice stimulation was delivered at 40 min. The prestimulatory oral activity index, poststimulatory oral activity index, and time interval between the vascular perfusion peak and the prestimulated maximum oral activity point were calculated to quantify the oral activity. Other glandular functional parameters-namely, maximum accumulation (MA), maximum secretion, secretion velocity, time at maximum count, time interval from stimulation to minimum count, and uptake ratio (UR) of the parotid and submandibular glands-were also calculated. Salivary gland scintigraphy was also performed on 21 healthy subjects with no evidence of salivary gland malfunction. RESULTS: Histopathologic grade 1 or 2 was found in 29 patients and grade 3 or 4 was found in 41 patients, and they were regarded as being in the early and advanced stages of Sjögren's syndrome, respectively. After overall analysis, all of the oral activity indices and the MA and UR of the submandibular gland clearly decreased as clinical severity progressed, and statistically significant differences were observed. CONCLUSION: New oral activity indices correlated with the stage of Sjögren's syndrome, and these quantitative oral indices together with certain glandular parameters (mainly MA and UR of the submandibular gland) were found to be sensitive enough to distinguish the disease severity of Sjögren's syndrome.
10803698 Clinical constellation of annular erythema associated with anti-Ro/La autoantibodies. 2000 Apr Annular erythema (AE) associated with anti-Ro (SSA) and/or La (SSB) autoantibody in patients with Sjögren syndrome (SS) or with SS/systemic lupus erythematosus overlap syndrome (SS/SLE), has recently been described in Orientals, and it may be a counterpart of annular skin lesion of the subacute cutaneous LE seen mostly in Caucasians. The author examined five Korean AE patients in respect to dinical diversity. In this small-sample study, subtle differences appeared between individual cases regarding the serologic features and the diagnoses of the disease. Among the five cases, four had circulating anti-Ro and anti-La antibodies, and one had only anti-La. Regarding the diagnosis, one was SS/SLE, two were primary SS, and the remaining two were only "AE associated with anti-Ro/La antibody". There seem to be a wide clinical spectrum in the disease expression of AE associated with anti-Ro/La autoantibody than previously thought.
10354376 Haematopathology of 'Sjögren-mice': histopathological changes in spleens after semialloge 1999 Jun Haematopoietic transplantation chimeras may be readily produced in adult mice, using F1-hybrids of selected inbred strains as recipients and mice from one of the parental strains as donors. We transplanted spleen cells from BALB/c donors into nonirradiateded F1-hybrids of BALB/c and CBA/H-T6. Both female and male recipients developed a primary Sjögren's syndrome-like exocrinopathy without signs of kidney disease. At long-term follow-up, 7(1/2) months after cell transfer, lymph nodes were enlarged, and spleens were diminished and irregular in shape. In general, changes in haematopoietic organs were more prominent in males. The results verify that although hybrid mice of either sex develop glandular manifestations comparable with primary Sjögren's syndrome, when the immune system is stimulated by semiallogeneic immunocytes, the evoked reactions in haematopoietic tissues show gender difference.
9352624 Serum secretory leukoprotease inhibitor levels in chronic bronchitis and Sjögren's syndro 1997 Aug Serum secretory leukoprotease inhibitor (SLPI) is synthesized and secreted by serous cells in airway glands, and the serum level is speculated to reflect airway gland hyperplasia. To test this hypothesis, we measured the serum SLPI in 38 clinically stable patients with chronic bronchitis (3F and 35M; 58 +/- 2 years, mean +/- S.E.M.) (group CB), 24 patients with Sjögren's syndrome (24F; 52 +/- 3 years) (group SG), and compared it with 12 healthy control subjects (6F and 6M; 54 +/- 3 years) (group CN) using an enzyme-linked immunosorbent assay (ELISA). The serum SLPI from group CB (105 +/- 8 ng/ml) was significantly higher than that from group CN (60 +/- 2 ng/ml) and further, it significantly correlated with sputum volume per day. Although the mean value of serum SLPI from group SG (64 +/- 5 ng/ml) was not different from that from group CN, serum SLPI significantly correlated with the duration of respiratory symptoms (cough and/or sputum) in group SG. In conclusion, serum SPLI level reflects airway gland hyperplasia, suggesting that SLPI measurement is a possible laboratory method to estimate airway glandular hyperplasia.
9159376 Premature fat deposition in the salivary glands associated with Sjögren syndrome: MR and 1997 May PURPOSE: To investigate abnormal fat deposition in the major salivary glands associated with Sjögren syndrome. METHODS: We analyzed the fat deposition in the parotid and submandibular glands of 33 patients with Sjögren syndrome by using short-inversion-time inversion recovery (STIR) and fat-saturation MR sequences and CT values. RESULTS: All three in vivo techniques substantially confirmed premature deposition of fat in the major salivary glands in association with Sjögren syndrome. Furthermore, this change was characteristic of Sjögren syndrome, and the severity of fat deposition correlated well with the impaired rates of salivary flow in these patients. CONCLUSION: Monitoring of fat deposition might be useful for diagnosing Sjögren syndrome and assessing its progress in patients whose clinical and serologic findings are suggestive of the disease.
11803482 Lacrimal gland fluid secretion and lymphocytic infiltration in the NZB/W mouse model of Sj 2001 Sep PURPOSE: The fluid secretory impairment of lacrimal and salivary glands in Sjögren's syndrome (SS) is thought to be related to the extent of lymphocytic infiltration (LI) and subsequent loss of glandular tissue. In this study, we examine the correlation between the extent of tear flow reduction and the extent of LI of lacrimal glands in the NZB/W mouse, a model of SS. METHODS: We stimulated tear production by topical application of carbachol onto the gland while fluid was collected from the lacrimal duct. The lacrimal glands were removed after fluid collection for histology. RESULTS: Fluid secretion in response to carbachol was less in the majority of young NZB/W females compared to C57 control animals and none of the glands showed LI. Fluid secretion was also impaired in the majority of old NZB/W females, and the extent of LI was highly variable. Some of the old SW females also showed blunted fluid secretory responses and some degree of focal LI. Young SW females showed no LI and most animals exhibited normal flow responses. Analysis of paired flow and LI measurements showed no correlation between LI and flow impairment in any of the groups or in the pooled data. Carbachol-stimulated protein secretion from lacrimal gland slices in vitro were similar in young and old SW and NZB/W mice. CONCLUSIONS: These results suggest that LI alone is not sufficient to explain the secretory dysfunction in the NZB/W mouse model of Sjögren's syndrome.
11752947 Bronchus-associated lymphoid tissue (BALT) lymphoma of the lung showing mosaic pattern of 2000 Jul The authors present a case of histologically proven bronchus-associated lymphoid tissue (BALT) lymphoma of the lung in a patient with primary Sjögren's syndrome that manifested on thin-section CT scan as a mosaic pattern of inhomogeneous attenuation due to mixed small airway and infiltrative abnormalities
11212157 Genetic association between interleukin-10 promoter region polymorphisms and primary Sjög 2001 Jan OBJECTIVE: To determine whether the haplotypes formed on the basis of single-base-exchange polymorphisms at positions -1082, -819, or -592 of the interleukin-10 (IL-10) gene predispose subjects to primary Sjögren's syndrome (SS). METHODS: The frequency of IL-10 polymorphisms was analyzed in 62 patients with primary SS and in 400 healthy subjects. These data were assessed for correlations with the concentration of IL-10 in the plasma. RESULTS: The frequency of the IL-10 GCC haplotype (G at position -1082, C at position -819, and C at position -592 of the IL-10 gene) was increased (P < 0.05, odds ratio [OR] 1.90, 95% confidence interval [95% CI] 0.955-3.62) and the frequency of the ACC haplotype decreased (P < 0.05, OR 0.443, 95% CI 0.257-0.764) in primary SS patients compared with healthy controls. Moreover, the frequency of the ATA haplotype was similar in primary SS patients and healthy controls, but the incidence of the GCC/ATA genotype was elevated in the primary SS patients (P < 0.05, OR 2.19, 95% CI 1.19-4.03). The concentration of plasma IL-10 was significantly higher in patients carrying the GCC haplotype than in non-carriers of GCC. CONCLUSION: These results suggest that the presence of the GCC haplotype or the GCC/ATA genotype and the absence of the ACC haplotype of the IL-10 gene are associated with an increased susceptibility to primary SS. This effect is probably mediated by the increased capability to produce IL-10 among carriers of the GCC haplotype.
11110590 Immune cytopenias as the presenting finding in primary Sjögren's syndrome. 2000 Dec A diagnostic delay of several years in primary Sjögren's syndrome is common, even in patients who present with sicca symptoms. It is much more likely in cases with prominent symptomatic extraglandular involvement. We report on three such patients who presented as Coomb's positive haemolytic anaemia, systemic symptoms with agranulocytosis and gingival bleeding due to immune thrombocytopenia, to alert clinicians to the fact that primary Sjögren's syndrome may present as clinically significant immune-mediated cytopenia in the absence of sicca symptoms. Sjögren's syndrome, a common autoimmune disorder, should be considered in the differential diagnosis of apparently 'idiopathic' cytopenias and actively sought by directed history, Schirmer test and autoantibody screening.
11053064 Fatigue in primary Sjögren's syndrome: is there a link with the fibromyalgia syndrome? 2000 Nov OBJECTIVE: To determine whether fibromyalgia (FM) is more common in patients with primary Sjögren's syndrome (pSS) who complain of fatigue. The association and prevalence of fatigue and FM was recorded in a group of patients with pSS and a control group of lupus patients, a subset of whom had secondary Sjögren's syndrome (sSS). METHODS: 74 patients with pSS and 216 patients with lupus were assessed with a questionnaire to identify the presence of fatigue and generalised pain. From the lupus group, in a subset of 117 lupus patients (from the Bloomsbury unit) those with sSS were identified. All patients were studied for the presence of FM. RESULTS: 50 of 74 patients with pSS (68%) reported fatigue-a prevalence significantly higher than in the lupus group (108/216 (50%); p<0.0087). Fatigue was present in 7/13 (54%) patients with SLE/sSS. FM was present in 9/74 patients with pSS (12%), compared with 11/216 lupus patients (5%), and in none of the patients with SLE/sSS. None of these values corresponds with previously reported figures of the incidence of FM in pSS. CONCLUSION: The results show that fatigue in patients with pSS and sSS is not due to the coexistence of FM in most cases. A lower incidence in the United Kingdom of FM in patients with pSS was found than has been previously reported.
10662881 The place of magnetic resonance and ultrasonographic examinations of the parotid gland in 2000 Jan OBJECTIVE: The aim was to determine the place of magnetic resonance imaging (MRI) and ultrasonographic (US) examination in the diagnosis and follow-up of Sjögren's syndrome (SS). METHODS: Parotid MRI and US examinations were carried out on 44 primary SS patients and 52 controls of similar age. RESULTS: The most important structural changes in SS were different degrees of parenchymal inhomogeneity, which could be detected by both methods, and were found more frequently in the SS patients than in the controls (MRI: 95.4 vs 17. 3%; US: 88.6 vs 7.7%; P<0.001). There was good agreement between the MRI and US findings both in the SS cases (93.2%) and in the controls (86.5%). In one SS patient who developed parotid lymphoma, the US examination showed a hypoechoic 'cobblestones'-like inhomogeneous internal pattern which was coupled with an almost homogeneous MRI pattern. CONCLUSIONS: MRI appears unnecessary as a routine method in the diagnosis of SS; US examination is suitable both for the diagnosis and follow-up of SS. The above combination of the seemingly contradictory US and MRI findings is highly characteristic of lymphoma which has developed in the course of the disease.