Bifico Ameliorates Neurological Deficits After Ischemic Stroke in Mice: Transcriptome Profiling.

BACKGROUND/AIM: Evidence suggests that gut microbiota can affect various neurological diseases, including stroke. Stroke patients have an increase in harmful gut bacteria and a decrease in beneficial bacteria. This increases intestinal permeability, increases the risk of infection, and even affects many inflammatory factors. While probiotics may affect stroke prognosis by improving the gut environment. This study aimed to investigate the effect of probiotic Bifico on the neural function in mice after focal cerebral ischemia and explore its mechanisms of action. MATERIALS AND METHODS: A focal cerebral ischemia model was established in mice. Four weeks before modeling, animals were divided into three groups: Stroke plus Vehicle group, Stroke plus Pre-Bifico group and Bifico group. The infarct volume and neurobehaviors were evaluated. Whole-gene expression profiling was performed at different days after treatment (D1, D7, D14, D28) by RNA-seq. Differentially expressed genes (DEGs) were the processed for Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG). Some inflammation and immune related genes were screened and their expression was analyzed. RESULTS: Compared to the Stroke plus Vehicle group and Bifico group, the infarct volume and neurological score were significantly reduced in the Pre-Bifico group. There were 2 DEGs at D1, 193 DEGs at D7, 70 DEGs at D28 between Stroke plus Pre-Bifico group and Stroke plus Vehicle group. For GO analysis, there were 139 significant terms at D7 and 195 at D28. For KEGG, there were 2 significant pathways at D7 and 9 at D28. Among 87 genes related to inflammation and immunity, 6 DEGs were identified. The expression of CCL9 was significantly elevated at most time points after stroke compared to the Stroke plus Vehicle group, while that of CCL6, CXCL10, CD48, CD72 and CLEC7A was highly expressed only in the recovery stage of stroke. CONCLUSION: Oral pre-treatment with Bifico for 28 days can reduce cerebral infarction and promote recovery of neurological function in stroke mice, which may be ascribed to the regulation of immunity and inflammation in the brain.

Comparison of fluorescence biosensors and whole-cell patch clamp recording in detecting ACh, NE, and 5-HT.

The communication between neurons and, in some cases, between neurons and non-neuronal cells, through neurotransmission plays a crucial role in various physiological and pathological processes. Despite its importance, the neuromodulatory transmission in most tissues and organs remains poorly understood due to the limitations of current tools for direct measurement of neuromodulatory transmitters. In order to study the functional roles of neuromodulatory transmitters in animal behaviors and brain disorders, new fluorescent sensors based on bacterial periplasmic binding proteins (PBPs) and G-protein coupled receptors have been developed, but their results have not been compared to or multiplexed with traditional methods such as electrophysiological recordings. In this study, a multiplexed method was developed to measure acetylcholine (ACh), norepinephrine (NE), and serotonin (5-HT) in cultured rat hippocampal slices using simultaneous whole-cell patch clamp recordings and genetically encoded fluorescence sensor imaging. The strengths and weaknesses of each technique were compared, and the results showed that both techniques did not interfere with each other. In general, genetically encoded sensors GRABNE and GRAB5HT1.0 showed better stability compared to electrophysiological recordings in detecting NE and 5-HT, while electrophysiological recordings had faster temporal kinetics in reporting ACh. Moreover, genetically encoded sensors mainly report the presynaptic neurotransmitter release while electrophysiological recordings provide more information of the activation of downstream receptors. In sum, this study demonstrates the use of combined techniques to measure neurotransmitter dynamics and highlights the potential for future multianalyte monitoring.

Selenium Improves Bone Microenvironment-Related Hematopoiesis and Immunity in T-2 Toxin-Exposed Mice.

The T-2 toxin is one of the most frequent contaminants in the environment and agricultural production globally. It exerts a wide range of toxic effects. Selenium (Se), as an antioxidant, has the potential to be widely used to antagonize mycotoxin toxicity. To investigate the protective effects of Se on bone microenvironment (BM)-related hematopoiesis and immunity after T-2 toxin exposure, 36 male mice were treated with the T-2 toxin (1 mg/kg) and/or Se (0.2 mg/kg) by intragastric administration for 28 days. The results showed that Se alleviated T-2 toxin-induced cytopenia and splenic extramedullary hematopoiesis. Se also significantly relieved T-2 toxin-induced immunosuppression, as assessed by immune factors and lymphocytes. Furthermore, Se also attenuated oxidative stress and apoptosis and improved the BM in T-2 toxin-exposed mice. Therefore, Se improves BM-related hematopoiesis and immunity after T-2 toxin exposure. This study provides references for identifying the toxic mechanism and screening potential therapeutic drugs of the T-2 toxin.

Increased systemic immune-inflammation index predicts hemorrhagic transformation in anterior circulation acute ischemic stroke due to large-artery atherosclerotic.

BACKGROUND AND PURPOSE: Inflammation and immune response play an important role in hemorrhage transformation after acute ischemic stroke. According to previous studies, systemic immune-inflammation index is associated with severity of stroke. We aimed to evaluate the association between systemic immune-inflammation index and hemorrhage transformation in anterior circulation acute ischemic stroke due to large-artery atherosclerosis. METHODS: This was a retrospective analysis of patients with anterior circulation acute ischemic stroke due to large-artery atherosclerosis. The laboratory data were collected within 24 h after admission. Hemorrhage transformation was defined on follow-up magnetic resonance imaging or Computed Tomography. The univariate analysis and multivariate logistic regression were performed to assess the association of systemic immune-inflammation index with hemorrhage transformation. Then the relationship between systemic immune-inflammation index and hemorrhage transformation in different stroke subtypes was further studied. RESULTS: We included 310 Chinese anterior circulation acute ischemic stroke patients due to large-artery atherosclerosis (mean age 65 ± 11.4 years; 72.6% male). Hemorrhage transformation occurred in 41 patients (13.2%). After multivariate regression analyses, systemic immune-inflammation index (odds ratio [OR] 1.109, 95% Confidence Interval [CI] 1.054-1.167, p＜0.001) was independently associated with hemorrhage transformation. Systemic immune-inflammation index was found to be significantly related to hemorrhagic transformation in artery-to-artery embolization (OR 1.111, 95% CI 1.029-1.210, p＜0.001) and in-situ thrombosis (OR 1.059, 95% CI 1.011-1.194, p = 0.045). CONCLUSIONS: Higher systemic immune-inflammation index is associated with greater risk of hemorrhagic transformation in patients with anterior circulation acute ischemic stroke due to large-artery atherosclerosis, especially in artery-to-artery embolization and in-situ thrombosis.

Coexistence of Primary Sjögren's Syndrome and Autoimmune Gastritis With Pernicious Anemia and Subacute Combined Degeneration of the Spinal Cord: Case Report and Literature Review.

Background: Autoimmune gastritis (AIG) and Primary Sjögren's syndrome (pSS) are both autoimmune diseases with low prevalence in China. Subacute combined degeneration (SCD) of the spinal cord is the most common neurological manifestation of vitamin B12 deficiency. Until now, a patient with pSS and complications of AIG including SCD has not been reported. Case Presentation: A 69-year-old woman presented with palpitations and symmetrical and progressive numbness in her hands and feet. The patient had a sense of stepping on cotton and could not write or walk without help. We reviewed the patient's history and analyzed her blood tests, imaging, gastroscopic findings, and pathological results. The patient fulfilled the criteria of AIG, pSS, spinal cord SCD and early pernicious anemia (PA) simultaneously. Although pSS can lead to reduction of vitamin B12, this is the first overlapping case of pSS with spinal cord SCD. After symptomatic treatment, the patient returned to a normal life. Conclusions: This first report about the coexistence of pSS and complications of AIG including SCD and PA will promote a better understanding of the relationship between these diseases.

GJA1 reverses arsenic-induced EMT via modulating MAPK/ERK signaling pathway.

Arsenic is known as a well-established human carcinogen. Gap Junction Protein Alpha 1 (GJA1) is a multifunction protein that forms gap junction channels and is important for intercellular communication. Recently, its aberrant expression has been shown to associate with cancer recurrence and metastatic spread. However, whether GJA1 plays a role in arsenic carcinogenesis remains unknown. Here, we demonstrated that chronic exposure of human bronchial epithelial BEAS-2B cells to sodium arsenite promoted epithelial-mesenchymal transition (EMT) via increasing the expression of EMT inducer S100A4 and activation of MAPK/ERK signaling. In vitro and in vivo experiments showed that chronic exposure to sodium arsenite reduced GJA1 expression. Forced expression of GJA1 inhibited sodium arsenite-induced EMT via suppressing MAPK/ERK signaling whereas GJA1 knockdown produced an opposite effect. Intriguingly, chronic exposure to sodium arsenite increased autophagy flux. Inhibition of autophagy by pharmacological intervention or genetic deletion of autophagy core gene Beclin-1 upregulated GJA1 expression. These results suggested that GJA1 restrained the carcinogenic effect of sodium arsenite by limiting MAPK/ERK signaling, and GJA1 expression was decreased by arsenic-activated autophagy. In addition, interventions directed at enhancing the level or functional activity of GJA1 could be of preventive and therapeutic interest.

MrgprF acts as a tumor suppressor in cutaneous melanoma by restraining PI3K/Akt signaling.

The incidence of cutaneous melanoma (CM) has been increasing annually worldwide. In this study, we identify that MrgprF, a MAS related GPR family member, is decreased in cutaneous melanoma tissues and cell lines due to hypermethylation of its promoter region, and show that patients with CM expressing high levels of MrgprF exhibit an improved clinical outcome. We demonstrate that MrgprF forced expression inhibits tumor cell proliferation, migration, xenograft tumor growth, and metastasis. On the contrary, MrgprF knockdown promotes tumor cell proliferation and transformation of immortalized human keratinocyte-HaCaT cells, supporting the inhibitory role of MrgprF during tumor progression. Mechanistic studies reveal that MrgprF reduces the phosphoinositol­3­kinase (PI3K) complex formation between p101 and p110γ subunits, the critical step for phosphatidylinositol-(3, 4)-P2 (PIP2) conversion to phosphatidylinositol-(3, 4, 5)-P3 (PIP3), and then reduces the activation of PI3K/Akt signaling. This effect can be reversed by Akt specific agonist SC79. In addition, AMG 706, a previously documented inhibitor for endothelial cell proliferation, is identified as a potential agonist for MrgprF, and can impede tumor growth both in vitro and in vivo. Taken together, our findings suggest that MrgprF, a novel tumor suppressor in cutaneous melanoma, may be useful as a therapeutic target in the future.

Clinical Symptoms, Etiology and Prognosis of Acute Bilateral Posterior Circulation Cerebral Infarction.

Background: Acute BPCCI was previously presented only as a case report. The prognosis of acute BPCCI is related to many factors, such as gender, age, NIHSS, Hypertension and so on. We first systematically analyzed the clinical symptoms, imaging, etiology and prognosis of acute BPCCI and identified a statistically significant factor. Methods: A total of 72 acute BPCCI patients admitted to the Department of Neurology, Beijing Friendship hospital, Capital Medical University were included. The demographics, risk factors, clinical manifestations, National Institute of Health stroke scale (NIHSS) on admission, imaging findings, and the modified Rankin Scale (mRS) at the third month after onset were collected. The mRS score greater than 3 indicated poor prognosis. The factors affecting their prognosis were analyzed. Results: We included 72 Chinese patients with acute BPCCI (82% male). The most common symptoms and signs of the patients were dizziness and unilateral limb weakness. Patients with acute BPCCI involving cerebellum accounted for 85% of the patients. The number of patients with large-artery atherosclerosis was 46 (64%), the number of patients with cardiogenic embolism was 12 (17%), and the number of patients with other causes and unknown causes was 14 (19%). After multivariate regression analyses, NIHSS score (odds ratio 0.725, 95% confidence interval 0.586-0.896, P = 0.003) was closely related with the prognosis of acute BPCCI. Conclusion: Our study found that the symptoms and signs of acute BPCCI were nonspecific and mainly depended on imaging diagnosis. Acute BPCCI involving cerebellum was the most common case of acute BPCCI. The main cause of acute BPCCI was large-artery atherosclerosis. NIHSS score is identified as a statistically significant factor. The higher NIHSS score on admission showed the worse prognosis. Therefore, an acute BPCCI patient with a high NIHSS score should be paid more attention at the time of diagnosis.

A tumor-specific pro-IL-12 activates preexisting cytotoxic T cells to control established tumors.

It is a challenge to effectively reactivate preexisting tumor-infiltrating lymphocytes (TILs) without causing severe toxicity. Interleukin-12 (IL-12) can potently activate lymphocytes, but its clinical use is limited by its short half-life and dose-related toxicity. In this study, we developed a tumor-conditional IL-12 (pro-IL-12), which masked IL-12 with selective extracellular receptor­binding domains of the IL-12 receptor while preferentially and persistently activating TILs after being unmasked by matrix metalloproteinases expressed by tumors. Systemic delivery of pro-IL-12 demonstrated reduced toxicity but better control of established tumors compared with IL-12-Fc. Mechanistically, antitumor responses induced by pro-IL-12 were dependent on TILs and IFNγ. Furthermore, direct binding of IL-12 to IL-12R on CD8+, not CD4+, T cells was essential for maximal effectiveness. Pro-IL-12 improved the efficacy of both immune checkpoint blockade and targeted therapy when used in combination. Therefore, our study demonstrated that pro-IL-12 could rejuvenate TILs, which then combined with current treatment modalities while limiting adverse effects for treating established tumors.

The Protective Effect of Selenium on T-2-Induced Nephrotoxicity Is Related to the Inhibition of ROS-Mediated Apoptosis in Mice Kidney.

T-2 toxin is produced by the Fusarium genus. Ingestion of food or feed contaminated by T-2 toxin will cause damage to kidney. Selenium (Se), an essential trace element, showed the significant protective effects against kidney and renal cell damage induced by toxic substances. To explore the protective effects and mechanisms of Se against T-2-induced renal lesions, forty-eight male Kunming mice were exposed to T-2 toxin (1.0 mg/kg) and/or Se (0.2 mg/kg) for 28 days. In this study, we found that Se alleviated T-2-induced nephrotoxicity, presenting as increasing the body weight and kidney coefficient, relieving the renal structure injury, decreasing the contents of renal function-related biomarkers, decreasing the levels of reactive oxygen species (ROS), and increasing the mitochondrial membrane potential in T-2 toxin-treated mice. In addition, inhibition of renal cell apoptosis by Se was associated with blocking the mitochondrial pathway in T-2 toxin-treated mice, presenting as decreasing the protein expression of cytochrome-c, activities of caspase-3/9, as well as regulating the protein and mRNA expressions of Bax and Bcl-2. These results documented that the alleviating effect of Se on T-2-induced nephrotoxicity is related to the inhibition of ROS-mediated renal apoptosis.

NG2 glia-derived GABA release tunes inhibitory synapses and contributes to stress-induced anxiety.

NG2 glia, also known as oligodendrocyte precursor cells (OPCs), play an important role in proliferation and give rise to myelinating oligodendrocytes during early brain development. In contrast to other glial cell types, the most intriguing aspect of NG2 glia is their ability to directly sense synaptic inputs from neurons. However, whether this synaptic interaction is bidirectional or unidirectional, or its physiological relevance has not yet been clarified. Here, we report that NG2 glia form synaptic complexes with hippocampal interneurons and that selective photostimulation of NG2 glia (expressing channelrhodopsin-2) functionally drives GABA release and enhances inhibitory synaptic transmission onto proximal interneurons in a microcircuit. The mechanism involves GAD67 biosynthesis and VAMP-2 containing vesicular exocytosis. Further, behavioral assays demonstrate that NG2 glia photoactivation triggers anxiety-like behavior in vivo and contributes to chronic social defeat stress.

ROS-mediated mitophagy and apoptosis are involved in aluminum-induced femoral impairment in mice.

The problem of excessive aluminum (Al) content in food is widespread. After Al enters the body, it can cause mineral metabolism imbalance and reactive oxygen species (ROS) overproduction, which ultimately leads to bone impairment. ROS is mainly produced in mitochondria and acts on mitochondria. Mitochondrial damage is closely related to mitophagy and apoptosis. In order to clarify whether ROS-mediated mitophagy and apoptosis are involved in Al-induced femoral impairment, forty-eight male C57BL/6 N mice were exposed to AlCl3 (179.3 mg/kg) and/or NAC (100 mg/kg) for 90 days. Our results showed that NAC inhibited the mitophagy and apoptosis, and alleviated growth inhibition, mineral metabolism imbalance, structural damage, decreased bone mineral density and decreased bone formation factor expressions in the femora of Al-treated mice. These results suggest that ROS-mediated mitophagy and apoptosis are involved in Al-induced femoral impairment in mice, exogenous ROS clearance is a potential strategy for the treatment of Al-induced bone impairment.

A human forebrain organoid model of fragile X syndrome exhibits altered neurogenesis and highlights new treatment strategies.

Fragile X syndrome (FXS) is caused by the loss of fragile X mental retardation protein (FMRP), an RNA-binding protein that can regulate the translation of specific mRNAs. In this study, we developed an FXS human forebrain organoid model and observed that the loss of FMRP led to dysregulated neurogenesis, neuronal maturation and neuronal excitability. Bulk and single-cell gene expression analyses of FXS forebrain organoids revealed that the loss of FMRP altered gene expression in a cell-type-specific manner. The developmental deficits in FXS forebrain organoids could be rescued by inhibiting the phosphoinositide 3-kinase pathway but not the metabotropic glutamate pathway disrupted in the FXS mouse model. We identified a large number of human-specific mRNAs bound by FMRP. One of these human-specific FMRP targets, CHD2, contributed to the altered gene expression in FXS organoids. Collectively, our study revealed molecular, cellular and electrophysiological abnormalities associated with the loss of FMRP during human brain development.

Parkin-mediated mitochondrial quality control protects against aluminum-induced liver damage in mice.

Aluminum (Al) is known to be hepatotoxic. Oxidative stress is the main mechanism of liver injury caused by Al, and can also lead to mitochondrial damage. Mitochondrial damage is a prerequisite for mitochondrial quality control (MQC) dysregulation. Parkin can activate MQC and maintain mitochondrial homeostasis. However, the role of Parkin-mediated MQC in Al-induced liver damage has not been elucidated. In this study, forty male wild type (WT) C57BL/6N mice were treated with 0, 44.825, 89.65 or 179.3 mg/kg body weight AlCl3 in drinking water for 90 days, respectively. We found that Al induced mitophagy and disrupted mitochondrial dynamics and mitochondrial biogenesis. Then, twenty male WT C57BL/6N mice and twenty male Parkin knockout (Parkin-/-) C57BL/6N mice were divided into four groups and treated with 0, 89.65, 0, 89.65 mg/kg body weight AlCl3 in drinking water for 90 days, respectively. We found that Parkin-/- inhibited mitophagy and further disrupted mitochondrial dynamics and mitochondrial biogenesis. These results indicated that Parkin-mediated MQC could be disrupted by Al and protected against Al-induced liver damage.

H2S exposure induces cell death in the broiler thymus via the ROS-initiated JNK/MST1/FOXO1 pathway.

Hydrogen sulfide (H2S) is a common toxic gas in chicken houses that endangers the health of poultry. Harbin has a cold climate in winter, and the conflict between heat preservation and ventilation in poultry houses is obvious. In this study, we investigated the H2S content in chicken houses during winter in Harbin and found that the H2S concentration exceeded the national standard in individual chicken houses. Then, a model of H2S exposure was established in an environmental simulation chamber. We also developed a NaHS exposure model of chicken peripheral blood lymphocytes in vitro. Proteomics analysis was used to reveal the toxicology of thymus injury in broilers, the FOXO signaling pathway was determined to be significantly enriched, ROS bursts and JNK/MST1/FOXO1 pathway activation induced by H2S exposure were detected, and ROS played an important switch role in the JNK/MST1/FOXO1 pathway. In addition, H2S exposure-induced thymus cell death involved immune dysregulation. Overall, the present study adds data for H2S contents in chicken houses, provides new findings for the mechanism of H2S poisoning and reveals a new regulatory pathway in immune injury.

PINK1/Parkin-Mediated Mitophagy Plays a Protective Role in the Bone Impairment Caused by Aluminum Exposure.

The pollution of aluminum (Al) in agricultural production and its wide application in food processing greatly increase the chance of human and animal exposure. Al can accumulate in bone and cause bone diseases by inducing oxidative stress. Mitophagy can maintain normal cell function by degrading damaged mitochondria and scavenging reactive oxygen species. However, the role of mitophagy in the bone impairment caused by Al is unknown. In this study, we demonstrated that PTEN induced putative kinase 1 (PINK1)/ E3 ubiquitin ligase PARK2 (Parkin)-mediated mitophagy was activated in the bone impairment caused by Al in vivo. Then, the Al-induced mitophagy in Parkin-deficient mice and MC3T3-E1 cells were decreased. Meanwhile, Parkin deficiency exacerbated the bone impairment, mitochondrial damage, and oxidative stress under Al exposure, both in vivo and in vitro. In general, the results reveal that Al exposure can activate PINK1/Parkin-mediated mitophagy, and the PINK1/Parkin-mediated mitophagy plays a protective role in the bone impairment caused by Al.

The AIM2 and NLRP3 inflammasomes trigger IL-1-mediated antitumor effects during radiation.

The inflammasome promotes inflammation-associated diseases, including cancer, and contributes to the radiation-induced tissue damage. However, the role of inflammasome in radiation-induced antitumor effects is unclear. We observed that tumors transplanted in Casp1-/- mice were resistant to radiation treatment compared with tumors in wild-type (WT) mice. To map out which molecule in the inflammasome pathway contributed to this resistant, we investigated the antitumor effect of radiation in several inflammasome-deficient mice. Tumors grown in either Aim2-/- or Nlrp3-/- mice remained sensitive to radiation, like WT mice, whereas Aim2-/-Nlrp3-/- mice showed radioresistance. Mechanistically, extracellular vesicles (EVs) and EV-free supernatant derived from irradiated tumors activated both Aim2 and Nlrp3 inflammasomes in macrophages, leading to the production of interleukin-1ß (IL-1ß). IL-1ß treatment helped overcome the radioresistance of tumors growing in Casp1-/- and Aim2-/-Nlrp3-/- mice. IL-1 signaling in dendritic cells (DCs) promoted radiation-induced antitumor immunity by enhancing the cross-priming activity of DCs. Overall, we demonstrated that radiation-induced activation of the AIM2 and NLRP3 inflammasomes coordinate to induce some of the antitumor effects of radiation by triggering IL-1 signaling in DCs, leading to their activation and cross-priming.

Transcriptomic and epigenomic dynamics associated with development of human iPSC-derived GABAergic interneurons.

GABAergic interneurons (GINs) are a heterogeneous population of inhibitory neurons that collectively contribute to the maintenance of normal neuronal excitability and network activity. Identification of the genetic regulatory elements and transcription factors that contribute toward GIN function may provide new insight into the pathways underlying proper GIN activity while also indicating potential therapeutic targets for GIN-associated disorders, such as schizophrenia and epilepsy. In this study, we examined the temporal changes in gene expression and chromatin accessibility during GIN development by performing transcriptomic and epigenomic analyses on human induced pluripotent stem cell-derived neurons at 22, 50 and 78 days (D) post-differentiation. We observed 13 221 differentially accessible regions (DARs) of chromatin that associate with temporal changes in gene expression at D78 and D50, relative to D22. We also classified families of transcription factors that are increasingly enriched at DARs during differentiation, indicating regulatory networks that likely drive GIN development. Collectively, these data provide a resource for examining the molecular networks regulating GIN functionality.

Autophagy mediates bronchial cell malignant transformation induced by chronic arsenic exposure via MEK/ERK1/2 pathway.

Chronic exposure to arsenic increases the risk of developing a variety of human cancers including lung carcinomas. However, the exact molecular mechanism underlying arsenic carcinogenicity remains largely unknown. Autophagy is a conserved catabolic process for maintaining cellular protein homeostasis whose defects might result in accumulation of dysfunctional organelles and damaged proteins thus promoting tumorigenesis. In the present study, we found that chronic exposure of human bronchial epithelial BEAS-2B cells to sub-lethal dose of sodium arsenite led to autophagy activation and induced an epithelial-to-mesenchymal transition (EMT) to enhance cell migratory and invasive capability. The malignant transformation was mediated via activation of MEK/ERK1/2 signaling. Importantly, inhibition of autophagy in these arsenic-exposed cells by pharmacological intervention or genetic deletion further promoted the EMT and increased the generation of inflammasomes. Both autophagy inhibitor and genetic deletion of autophagy core gene Beclin-1 produced similar effects. These results may suggest the important role of autophagy in sodium arsenite-induced lung tumorigenesis which may serve as a potential target in prevention and treatment of arsenic-imposed lung cancer.