Comparing Cortical Bone Trajectory and Traditional Pedicle Screws in Transforaminal Lumbar Interbody Fusion: A Retrospective Cohort Study of One-Year Outcomes.

INTRODUCTION: This is a retrospective study of consecutive patients undergoing transforaminal lumbar interbody fusion (TLIF) at a single institution. The objective of this study was to compare the long-term results associated with cortical bone trajectory (CBT) and traditional pedicle screw (TPS) via posterolateral approach in TLIF. METHODS: Consecutive patients treated from November 2014 to March 2019 were included in the CBT TLIF group, while consecutive patients treated from October 2010 to August 2017 were included in the TPS TLIF group. Inclusion criteria comprised single-level or two-level TLIF for degenerative spondylolisthesis with stenosis and at least one year of clinical and radiographic follow-up. Variables of interest included pertinent preoperative, perioperative, and postoperative data. Non-parametric evaluation was performed using the Wilcoxon test. Fisher's exact test was used to assess group differences for nominal data. RESULTS: Overall, 140 patients met the inclusion criteria; 69 patients had CBT instrumentation (mean follow-up 526 days) and 71 patients underwent instrumentation placement via TPS (mean follow-up 825 days). Examination of perioperative and postoperative outcomes demonstrate comparable results between the groups with perioperative complications, length of stay, discharge destination, surgical revision rate, and fusion rates all being similar between groups (p = 0.1; p = 0.53; p = 0.091; p = 0.61; p = 0.665, respectively). CONCLUSIONS: CBT in the setting of TLIF offer equivalent outcomes to TPS with TLIF at both short- and long-term intervals of care.

Identifying the Sources of Racial Disparity in the Treatment of Parkinson's Disease With Deep Brain Stimulation.

BACKGROUND: Deep brain stimulation (DBS) is a highly efficacious treatment for appropriately selected patients with advanced, medically refractory Parkinson's disease (PD). It is severely underutilized in Black patients-constituting a major treatment gap. The source of this disparity is unknown, but its identification and correction are necessary to provide equitable care. OBJECTIVE: To identify sources of racial disparity in DBS for PD. METHODS: We predicted the demographics of potential DBS candidates by synthesizing published data on PD and race. We retrospectively examined the clinical course of a cohort including all patients with PD evaluated for DBS at our center from 2016 to 2020, testing whether the rate of DBS use and time from evaluation to surgery differed by race. We also tested whether the geographic distribution of patient catchment was biased relative to racial demographics. RESULTS: Far fewer Black patients were evaluated for DBS than would be expected, given regional demographics. There was no significant difference in the rate at which Black patients evaluated in our clinic were treated with DBS, compared with White patients. Fewer patients were recruited from portions of the surrounding area with larger Black populations. CONCLUSION: The known underuse of DBS in Black patients with PD was replicated in this sample from a center in a racially diverse metropolitan area, but was not attributable to the presurgical workup. Future work should examine the transition from medical management to surgical evaluation where drivers of disparity are potentially situated. Surgical practices should increase outreach to physicians managing PD in underserved areas.

The laterodorsal tegmentum and seizure regulation: Revisiting the evidence.

Electrical deep brain stimulation (DBS) is now a routine treatment option for patients suffering from medically refractory epilepsy. DBS of the anterior nucleus of the thalamus (ANT) has proven to be effective but, despite its success, few patients experience complete cessation of seizure activity. However, improving the therapy is challenging because the mechanism underlying its action remains largely unknown. One angle on improving the effectiveness of ANT stimulation is to better understand the various anatomic regions that send projections to and through this area. Here, the authors utilized a connectomic atlas of the mouse brain to better understand the regions projecting to the ANT and were particularly interested by the presence of robust cholinergic projections from the laterodorsal tegmentum (LDT). A subsequent review of the literature resulted in limited studies, which presented convincing evidence supporting this region's role in seizure control present in acute rodent models of epilepsy. It is thus the purpose of this paper to encourage further research into the role of the LDT on seizure mitigation, with mechanistic effects likely stemming from its cholinergic projections to the ANT. While previous studies have laid a firm foundation supporting the role of this region in modulation of seizure activity, modern scientific methodology has yet to be applied to further elucidate the mechanisms and potential benefits associated with LDT stimulation in the epileptic population.

Evidence supporting deep brain stimulation of the medial septum in the treatment of temporal lobe epilepsy.

Electrical brain stimulation has become an essential treatment option for more than one third of epilepsy patients who are resistant to pharmacological therapy and are not candidates for surgical resection. However, currently approved stimulation paradigms achieve only moderate success, on average providing approximately 75% reduction in seizure frequency and extended periods of seizure freedom in nearly 20% of patients. Outcomes from electrical stimulation may be improved through the identification of novel anatomical targets, particularly those with significant anatomical and functional connectivity to the epileptogenic zone. Multiple studies have investigated the medial septal nucleus (i.e., medial septum) as such a target for the treatment of mesial temporal lobe epilepsy. The medial septum is a small midline nucleus that provides a critical functional role in modulating the hippocampal theta rhythm, a 4-7-Hz electrophysiological oscillation mechanistically associated with memory and higher order cognition in both rodents and humans. Elevated theta oscillations are thought to represent a seizure-resistant network activity state, suggesting that electrical neuromodulation of the medial septum and restoration of theta-rhythmic physiology may not only reduce seizure frequency, but also restore cognitive comorbidities associated with mesial temporal lobe epilepsy. Here, we review the anatomical and physiological function of the septohippocampal network, evidence for seizure-resistant effects of the theta rhythm, and the results of stimulation experiments across both rodent and human studies, to argue that deep brain stimulation of the medial septum holds potential to provide an effective neuromodulation treatment for mesial temporal lobe epilepsy. We conclude by discussing the considerations necessary for further evaluating this treatment paradigm with a clinical trial.

Loss of efferent projections of the hippocampal formation in the mouse intrahippocampal kainic acid model.

Unilateral intrahippocampal injection of kainic acid is used as a model of medial temporal lobe epilepsy and provides a platform to study the mechanisms of epilepsy. Here, we used an AAV-9 EYFP-tagged viral vector as an anterograde tracer, injected into the dorsal and ventral hippocampus after kainic acid injection, to map out the efferent hippocampal projections after the development of spontaneous seizures in this model. The purpose of the study was to identify the extent of changes in hippocampal efferent system in several brain regions that receive significant inputs from the hippocampus. Loss of efferent hippocampal fibers was greatest in the retrosplenial cortex where neuronal loss was also observed. Loss of fibers was also observed in the fornix without any specific effect in the lateral mammillary nuclei. Although expected, these observations provide further evidence of the broader network effects as a result of hippocampal cell loss.

Biomorphic Ceramics: Synthesis and Characterization of Preceramic Polymer-Modified Melanin.

Recent efforts have demonstrated that the morphology of ceramics can be manipulated to control both their deformation mechanism and mechanical performance. However, precise control of the ceramic nanostructure is still difficult to achieve. Biotemplating, leading to biomorphic materials, provides a facile route to manipulate the nanostructure of the resulting materials, and the use of melanin as a coating provides a new route to biotemplated materials. Melanin is underutilized for structural materials partly due to the cost of procuring it from natural sources and the inability to control the shape and sizes of melanin particles. Taking a combined synthetic biology and chemical synthesis approach, we report the melanization of Escherichia coli and its subsequent silanization and functionalization with preceramic polymers to make novel biomorphic silicon-based ceramic materials. Graft-to and graft-from reactions were used to append preceramic polymers to the melanin, followed by pyrolysis under argon. Samples were analyzed by FTIR, XRD, XPS, and TEM and found to retain the shape and size of the original cells with high fidelity. The homogeneity of coverage and yield of the resulting ceramic materials depended on the type of grafting reaction. This work provides a promising proof-of-concept that bacterial-templated ceramics can be readily made and opens a host of possibilities for further studies and applications.

Transient acoustic vaporization signatures unique to low boiling point phase change contrast agents enable super-resolution ultrasound imaging without spatiotemporal filtering.

The unique activation signal of phase-change contrast agents (PCCAs or droplets) can be separated from the tissue signal and localized to generate super-resolution (SR) ultrasound (US) images. Lipid-shelled, perfluorocarbon PCCAs can be stochastically vaporized (activated) by a plane wave US transmission thereby enabling them to be used as separable targets for ultrasound localization microscopy. The unique signature of droplet vaporization imaging and the transient inherent nature of this signature increases signal contrast and therefore localization confidence, while the poor resolution of the low-frequency vaporization signal is overcome by the super-resolution result. Furthermore, our proposed PCCA SR technique does not require the use of user-dependent and flow-dependent spatio-temporal filtering via singular-value decomposition. Rather, matched filters selected by Fourier-domain analysis are able to identify and localize PCCA activations. Droplet SR was demonstrated in a crossed-microtube water phantom by localizing the activation signals of octafluoropropane nanodroplets (OFP, C3F8, -37 °C boiling point) to resolve 100 µm diameter fluorinated ethylene propylene tubes, which are ordinarily 35% smaller than the native diffraction-limited resolution of the imaging system utilized.

Surface-Induced Ordering Depresses Through-Film Ionic Conductivity in Lamellar Block Copolymer Electrolytes.

Lamellar block copolymers based on polymeric ionic liquids (PILs) show promise as electrolytes in electrochemical devices. However, these systems often display structural anisotropy that depresses the through-film ionic conductivity. This work hypothesizes that structural anisotropy is a consequence of surface-induced ordering, where preferential adsorption of one block at the electrode drives a short-range stacking of the lamellae. This point was examined with lamellar diblock copolymers of polystyrene (PS) and poly(1-(2-acryloyloxyethyl)-3-butylimidazolium bis(trifluoromethanesulfonyl)imide) (PIL). The bulk PS-PIL structure was comprised of randomly oriented lamellar grains. However, in thin PS-PIL films (100-400 nm), the lamellae were stacked normal to the plane of the film, and islands/holes were observed when the as-prepared film thickness was incommensurate with the natural lamellar periodicity. Both of these attributes are well-known consequences of preferential wetting at surfaces. The ionic conductivity of thick PS-PIL films (50-100 µm) was approximately 20× higher in the in-plane direction than in the through-plane direction, consistent with a mixed structure comprised of randomly oriented lamellae throughout the interior of the film and highly oriented lamellae at the electrode surface. Therefore, to fully optimize the performance of a block copolymer electrolyte, it is important to consider the effects of surface interactions on the ordering of domains.

Variability in circulating gas emboli after a same scuba diving exposure.

PURPOSE: A reduction in ambient pressure or decompression from scuba diving can result in ultrasound-detectable venous gas emboli (VGE). These environmental exposures carry a risk of decompression sickness (DCS) which is mitigated by adherence to decompression schedules; however, bubbles are routinely observed for dives well within these limits and significant inter-personal variability in DCS risk exists. Here, we assess the variability and evolution of VGE for 2 h post-dive using echocardiography, following a standardized pool dive in calm warm conditions. METHODS: 14 divers performed either one or two (with a 24 h interval) standardized scuba dives to 33 mfw (400 kPa) for 20 min of immersion time at NEMO 33 in Brussels, Belgium. Measurements were performed at 21, 56, 91 and 126 min post-dive: bubbles were counted for all 68 echocardiography recordings and the average over ten consecutive cardiac cycles taken as the bubble score. RESULTS: Significant inter-personal variability was demonstrated despite all divers following the same protocol in controlled pool conditions: in the detection or not of VGE, in the peak VGE score, as well as time to VGE peak. In addition, intra-personal differences in 2/3 of the consecutive day dives were seen (lower VGE counts or faster clearance). CONCLUSIONS: Since VGE evolution post-dive varies between people, more work is clearly needed to isolate contributing factors. In this respect, going toward a more continuous evaluation, or developing new means to detect decompression stress markers, may offer the ability to better assess dynamic correlations to other physiological parameters.

Tailoring Surface Properties through in Situ Functionality Gradients in Reactively Modified Poly(2-vinyl-4,4-dimethyl azlactone) Thin Films.

Generating physical or chemical gradients in thin-film scaffolds is an efficient approach for screening and optimizing an interfacial structure or chemical functionality to create tailored surfaces that are useful because of their wetting, antifouling, or barrier properties. The relationship between the structure of poly(2-vinyl-4,4-dimethyl azlactone) (PVDMA) brushes created by the preferential assembly of poly(glycidyl methacrylate)- block-PVDMA diblock copolymers and the ability to chemically modify the PVDMA chains in situ to create a gradient in functionality are examined to investigate how the extent of functionalization affects the interfacial and surface properties. The introduction of a chemical gradient by controlled immersion allows reactive modification to generate position-dependent properties that are assessed by ellipsometry, attenuated total reflectance-Fourier transform infrared spectroscopy, contact angle measurements, and atomic force microscopy imaging. After functionalization of the azlactone rings with n-alkyl amines, ellipsometry confirms an increase in thickness and contact angle measurements support an increase in hydrophobicity along the substrate. These results are used to establish relationships between layer thickness, reaction time, position, and the extent of functionalization and demonstrate that gradual immersion into the functionalizing solution results in a linear change in chemical functionality along the surface. These findings broadly support efforts to produce tailored surfaces by in situ chemical modification, having application as tailored membranes, protein resistant surfaces, or sensors.

Impact of Protein Palmitoylation on the Virulence Potential of Cryptococcus neoformans.

The localization and specialized function of Ras-like proteins are largely determined by posttranslational processing events. In a highly regulated process, palmitoyl groups may be added to C-terminal cysteine residues, targeting these proteins to specific membranes. In the human fungal pathogen Cryptococcus neoformans, Ras1 protein palmitoylation is essential for growth at high temperature but is dispensable for sexual differentiation. Ras1 palmitoylation is also required for localization of this protein on the plasma membrane. Together, these results support a model in which specific Ras functions are mediated from different subcellular locations. We therefore hypothesize that proteins that activate Ras1 or mediate Ras1 localization to the plasma membrane will be important for C. neoformans pathogenesis. To further characterize the Ras1 signaling cascade mediating high-temperature growth, we have identified a family of protein S-acyltransferases (PATs), enzymes that mediate palmitoylation, in the C. neoformans genome database. Deletion strains for each candidate gene were generated by homogenous recombination, and each mutant strain was assessed for Ras1-mediated phenotypes, including high-temperature growth, morphogenesis, and sexual development. We found that full Ras1 palmitoylation and function required one particular PAT, Pfa4, and deletion of the PFA4 gene in C. neoformans resulted in altered Ras1 localization to membranes, impaired growth at 37°C, and reduced virulence.

Pulse sequences for uniform perfluorocarbon droplet vaporization and ultrasound imaging.

Phase-change contrast agents (PCCAs) consist of liquid perfluorocarbon droplets that can be vaporized into gas-filled microbubbles by pulsed ultrasound waves at diagnostic pressures and frequencies. These activatable contrast agents provide benefits of longer circulating times and smaller sizes relative to conventional microbubble contrast agents. However, optimizing ultrasound-induced activation of these agents requires coordinated pulse sequences not found on current clinical systems, in order to both initiate droplet vaporization and image the resulting microbubble population. Specifically, the activation process must provide a spatially uniform distribution of microbubbles and needs to occur quickly enough to image the vaporized agents before they migrate out of the imaging field of view. The development and evaluation of protocols for PCCA-enhanced ultrasound imaging using a commercial array transducer are described. The developed pulse sequences consist of three states: (1) initial imaging at sub-activation pressures, (2) activating droplets within a selected region of interest, and (3) imaging the resulting microbubbles. Bubble clouds produced by the vaporization of decafluorobutane and octafluoropropane droplets were characterized as a function of focused pulse parameters and acoustic field location. Pulse sequences were designed to manipulate the geometries of discrete microbubble clouds using electronic steering, and cloud spacing was tailored to build a uniform vaporization field. The complete pulse sequence was demonstrated in the water bath and then in vivo in a rodent kidney. The resulting contrast provided a significant increase (>15 dB) in signal intensity.

A comparative evaluation of ultrasound molecular imaging, perfusion imaging, and volume measurements in evaluating response to therapy in patient-derived xenografts.

Most pre-clinical therapy studies use the change in tumor volume as a measure for disease response. However, tumor size measurements alone may not reflect early changes in tumor physiology that occur as a response to treatment. Ultrasonic molecular imaging (USMI) and Dynamic Contrast Enhanced-Perfusion Imaging (DCE-PI) with ultrasound are two attractive alternatives to tumor volume measurements. Since these techniques can provide information prior to the appearance of gross phenotypic changes, it has been proposed that USMI and DCE-PI could be used to characterize response to treatment earlier than traditional methods. This study evaluated the ability of tumor volume measurements, DCE-PI, and USMI to characterize response to therapy in two different types of patient-derived xenografts (known responders and known non-responders). For both responders and non-responders, 7 animals received a dose of 30 mg/kg of MLN8237, an investigational aurora-A kinase inhibitor, for 14 days or a vehicle control. Volumetric USMI (target integrin:α av ß3) and DCE-PI were performed on day 0, day 2, day 7, and day 14 in the same animals. For USMI, day 2 was the earliest point at which there was a statistical difference between the untreated and treated populations in the responder cohort (Untreated: 1.20 ±â€…0.53 vs. Treated: 0.49 ±â€…0.40; p < 0.05). In contrast, statistically significant differences between the untreated and treated populations as detected using DCE-PI were not observed until day 14 (Untreated: 0.94 ±â€…0.23 vs. Treated: 1.31 ±â€…0.22; p < 0.05). Volume measurements alone suggested no statistical differences between treated and untreated populations at any readpoint. Monitoring volumetric changes is the "gold standard" for evaluating treatment in pre-clinical studies, however, our data suggests that volumetric USMI and DCE-PI may be used to earlier classify and robustly characterize tumor response.

WE-C-218-01: Ultrasound Contrast Agents.

Medical ultrasound has long been used in clinical applications both as a primary modality and as a supplement to other diagnostic procedures. The basis for ultrasound imaging is the transmission of high frequency (megaHertz) sound waves that propagate through tissue. These sound waves backscatter from the interfaces between tissue components with different acoustic properties and are detected by the imaging system, allowing the creation of images based on tissue characteristics and spatial location. Thus, traditional ultrasound has focused primarily on the imaging of anatomical structures and analysis of blood flow in large vessels. Unfortunately, blood is a weak scatterer, which can make vascular diagnostic applications (example: echocardiography) challenging especially with larger patients. Contrast agents help to improve on this shortcoming by enhancing the visualization of blood flow, thus improving the quality of diagnostics. The use of contrast agents for ultrasound was first reported in 1968 when Gramiak and Shah discovered that there was an increased backscatter of ultrasound caused by injected microbubbles. This is because the mismatch in acoustic impedance (a function of an object's density and compressibility) between the microbubble gas core and blood (or tissue) is several orders of magnitude, which results in substantially higher scattering from a bubble than an equivalent volume of tissue or blood. Additionally, microbubbles oscillate in response to an ultrasound field, and respond non-linearly to acoustic pulses even at low energies, unlike tissue. The non-linear property of microbubbles in an ultrasound field allows for the use of various pulsing and signal processing strategies to detect the backscattered signal from contrast agents and segment it from tissue, thus providing a high contrast-to- noise ratio. Due to these unique acoustic properties, a clinical ultrasound system can detect even single microbubble contrast agents, providing exquisite sensitivity and the ability to perform advanced diagnostic procedures. Over the last several decades, ultrasound contrast agents have been improved for enhanced stability and increased persistence times. Although preclinical studies as well as clinical use in Europe and Asia strongly suggest that the use of contrast ultrasound can substantially improve diagnostic capabilities in both cardiology and radiology applications, contrast use in the US is still very limited. Obstacles to the widespread use of microbubbles include safety concerns, the need for optimization of approaches for contrast use, and general understanding of their potential by physicians. This course covers the basic principles of contrast agents used in ultrasound imaging including their stability, shell properties and their behavior within an acoustic field. In addition, we will cover many new techniques that are being evaluated in preclinical studies including: p er fus ion-based techniques, molecular imaging, gene therapy, drug delivery, and acoustic angiography. Finally, basic safety concerns and biological effects will be reviewed. LEARNING OBJECTIVES: 1. Understand the basic principles of ultrasound contrast agents a. What are microbubble contrast agents? b. Properties of microbubbles c. Safety concerns and biological effects 2. Understand basic contrast imaging techniques a. Harmonic and suharmonic imaging techniques b. Pulse inversion techniques 3. Understand the use of contrast agents in various vascular applications a. Traditional methods (Cardiovascular, Abdominal) b. Advanced perfusion imaging techniques 4. Understand the role of contrast agents in preclinical applications a. Ultrasound molecular imaging b. Gene therapy c. Drug delivery d. Acoustic angiography.

Characterisation of polymer shelled microbubbles in wall less flow phantom using high frequency ultrasound and video microscopy.

A high frequency ultrasound pulse echo system and a video microscope were combined to investigate the relationship between backscatter from polymer shelled ultrasound contrast agents (UCAs) and their diameter. Individual UCAs (manufactured by Point Biomedical or Philips Research) were imaged while being sonicated with 40 MHz tone bursts. The backscatter magnitude produced by the Philips UCAs was proportional to UCA size, which is consistent with theoretically predicted behaviour of encapsulated microbubbles driven at frequencies above resonance. Despite being smaller, the Point UCAs produced a backscatter magnitude twice that of Philips UCAs, indicating that Point UCAs might behave quasi-resonantly when excited at 40 MHz.

Effects of body positioning on swallowing and esophageal transit in healthy dogs.

BACKGROUND: Contrast videofluoroscopy is the imaging technique of choice for evaluating dysphagic dogs. In people, body position alters the outcome of videofluoroscopic assessment of swallowing. HYPOTHESIS/OBJECTIVE: That esophageal transit in dogs, as measured by a barium esophagram, is not affected by body position. ANIMALS: Healthy dogs (n=15). METHODS: Interventional, experimental study. A restraint device was built to facilitate imaging of dogs in sternal recumbency. Each dog underwent videofluoroscopy during swallowing of liquid barium and barium-soaked kibble in sternal and lateral recumbency. Timing of swallowing, pharyngeal constriction ratio, esophageal transit time, and number of esophageal peristaltic waves were compared among body positions. RESULTS: Transit time in the cervical esophagus (cm/s) was significantly delayed when dogs were in lateral recumbency for both liquid (2.58+/-1.98 versus 7.23+/-3.11; P=.001) and kibble (4.44+/-2.02 versus 8.92+/-4.80; P=.002). In lateral recumbency, 52+/-22% of liquid and 73+/-23% of kibble swallows stimulated primary esophageal peristalsis. In sternal recumbency, 77+/-24% of liquid (P=.01 versus lateral) and 89+/-16% of kibble (P=.01 versus lateral) swallows stimulated primary esophageal peristalsis. Other variables were not significantly different. CONCLUSIONS AND CLINICAL IMPORTANCE: Lateral body positioning significantly increases cervical esophageal transit time and affects the type of peristaltic wave generated by a swallow.

Selective imaging of adherent targeted ultrasound contrast agents.

The goal of ultrasonic molecular imaging is the detection of targeted contrast agents bound to receptors on endothelial cells. We propose imaging methods that can distinguish adherent microbubbles from tissue and from freely circulating microbubbles, each of which would otherwise obscure signal from molecularly targeted adherent agents. The methods are based on a harmonic signal model of the returned echoes over a train of pulses. The first method utilizes an 'image-push-image' pulse sequence where adhesion of contrast agents is rapidly promoted by acoustic radiation force and the presence of adherent agents is detected by the signal change due to targeted microbubble adhesion. The second method rejects tissue echoes using a spectral high-pass filter. Free agent signal is suppressed by a pulse-to-pulse low-pass filter in both methods. An overlay of the adherent and/or flowing contrast agents on B-mode images can be readily created for anatomical reference. Contrast-to-tissue ratios from adherent microbubbles exceeding 30 dB and 20 dB were achieved for the two methods proposed, respectively. The performance of these algorithms is compared, emphasizing the significance and potential applications in ultrasonic molecular imaging.

Human alpha-1-glycoprotein and its interactions with drugs.

For about half a century, the binding of drugs to plasma albumin, the "silent receptor," has been recognized as one of the major determinants of drug action, distribution, and disposition. In the last decade, the binding of drugs, especially but not exclusively basic entities, to another plasma protein, alpha 1-acid glycoprotein (AAG), has increasingly become important in this regard. The present review points out that hundreds of drugs with diverse structures bind to this glycoprotein. Although plasma concentration of AAG is much lower than that of albumin, AAG can become the major drug binding macromolecule in plasma with significant clinical implications. Also, briefly reviewed are the physiological, pathological, and genetic factors that influence binding, the role of AAG in drug-drug interactions, especially the displacement of drugs and endogenous substances from AAG binding sites, and pharmacokinetic and clinical consequences of such interactions. It can be predicted that in the future, rapid automatic methods to measure binding to albumin and/or AAG will routinely be used in drug development and in clinical practice to predict and/or guide therapy.