Neutral Cholesterol Esterase Activity Research Articles

Effect of sex, ovariectomy and female sex hormones on neutral cholesterol ester hydrolase in rat liver.

The effects of sex, ovariectomy and female sex hormones on neutral cholesterol ester hydrolase activity were investigated in rat liver cytoplasm. Hydrolase activity was determined at pH 7.45 with an acetone dispersed cholesterol oleate substrate preparation. Neutral cholesterol esterase activity was higher in male than in female rats and the ovariectomy decreased the enzyme activity. The administration of only estradiol or combined with progesterone to ovariectomized rats for three consecutive days resulted in an increase in esterase activity to the level observed in intact animals. By contrast, the only progesterone resulted in no significant changes of activity. In intact female rats, the short-term treatments of gonadal hormones did not produce any alteration on cholesterol esterase. Examination of the effects of a single dose of estradiol and progesterone for intervals between 1 and 24 h showed that both hormones promoted early and opposite effects on neutral ester hydrolase. Activity was decreased in 3-4 h by the estradiol and was markedly increased throughout 3-4-6 h by the progesterone injection. In vitro, the two female sex hormones behaved as potent inhibitors of the enzyme, competing with the substrate for the active centre of the hydrolase.

Effect of Pitavastatin on Macrophage Cholesterol Metabolism

Pitavastatin is the first totally synthetic HMG-Co A reductase inhibitor in Japan that significantly reduces LDL cholesterol while raising HDL cholesterol. Clinical trial showed that pitavastatin has potent effects for LDL cholesterol lowering and is expected effectively to prevent atherosclerosis. To clarify the mechanism of reduction of atherosclerosis by pitavastatin, we examined the effect of pitavastatin on foam cell formation of RAW264.7 macrophages. Macrophages were cultured with pitavastatin for 24 h and exposed to oxidized LDL with pitavastatin for 3 days. Pitavastatin decreased the cellular cholesteryl ester content in a dose-dependent manner, and this effect was not via inhibition of HMG-CoA reductase because the 3-30 nM pitavastatin did not inhibit [14C]cholesterol synthesis from [14C]acetic acid and the effect was not influenced by addition of mevalonic acid. Pitavastatin increased neutral cholesterol esterase (NCEase) activity and did not affect ACAT activity, and decreased the expression of CD36 and ABCA1 mRNA. The mechanism of the increase of NCEase activity was that pitavastatin directly modified the substrate state, which was cholesterol oleate emulsified with lecithin. Clinical blood concentrations of pitavastatin prevent foam cell formation of RAW macrophages by oxidized LDL, and this was not via inhibition of HMG-CoA reductase, and modify substrate condition.

Th-P15:13 A C-terminal peptide derived from human SAA does not increase macrophage neutral cholesterol esterase activity by enhancing its transcription

Th-P15:13 A C-terminal peptide derived from human SAA does not increase macrophage neutral cholesterol esterase activity by enhancing its transcription

Hormone-sensitive Lipase Is a Cholesterol Esterase of the Intestinal Mucosa

The identity of the enzymes responsible for lipase and cholesterol esterase activities in the small intestinal mucosa is not known. Because hormone-sensitive lipase (HSL) catalyzes the hydrolysis of acylglycerols and cholesteryl esters, we sought to determine whether HSL could be involved. HSL mRNA and protein were detected in all segments of the small intestine by Northern and Western blot analyses, respectively. Immunocytochemistry experiments revealed that HSL was expressed in the differentiated enterocytes of the villi and was absent in the undifferentiated cells of the crypt. Diacylglycerol lipase and cholesterol esterase activities were found in the different segments. Analysis of gut from HSL-null mice showed that diacylglycerol lipase activity was unchanged in the duodenum and reduced in jejunum. Neutral cholesterol esterase activity was totally abolished in duodenum, jejunum, and ileum of HSL-null mice. Analysis of HSL mRNA structure showed two types of transcripts expressed in equal amounts with alternative 5'-ends transcribed from two exons. This work demonstrates that HSL is expressed in the mucosa of the small intestine. The results also reveal that the enzyme participates in acylglycerol hydrolysis in jejunal enterocytes and cholesteryl ester hydrolysis throughout the small intestine.

Effects of Phosphatidylcholine/Phosphatidylethanolamine Composition in Cholesteryl Ester–Micellar Substrates on Neutral Cholesterol Esterase Activity

The effect of phospholipid composition in cholesteryl ester (CE)–micellar substrates on neutral cholesterol esterase (N-CEase) activity was examined. N-CEase preparation was incubated with micelles composed of cholesteryl-[1-14C]-oleate, sodium taurocholate, and phosphatidylcholine (PC)/phosphatidylethanolamine (PE) at varying ratios (%PE:0 = PC only, 17, 33, 50, 66, 83). The activity increased dependently with the increase in PE content; the activity with the micelles containing the highest ratio of PE was 2.5-fold compared with the micelles consisting of PC only.Vmaxwith the micelles of 83, 66, and 50% PE was 3.1-, 2.7-, and 1.9-fold, respectively, compared with the micelles of PC only. Each micellar preparation was chromatographed through a Superose 6 column by the FPLC system. In 66 and 83% PE-containing micelles, PC, PE, CE, and part of sodium taurocholate eluted completely together in a single peak, whereas in micelles with 33 and 50% PE they eluted loosely together. The micelles with PC only or 17% PE formed PC–micelles without including CE and PE. It is concluded that PE plays a critical role in the formation of CE micelles with PC, and in the interaction with N-CEase. The CE–micelles with 66–83% PE serve as substrates for sensitive and reproducible N-CEase assay.

Cholesterol-mediated changes of neutral cholesterol esterase activity in macrophages. Mechanism for mobilization of cholesteryl esters in lipid droplets by HDL.

Cholesteryl esters (CE) in lipid droplets undergo a continual cycle of hydrolysis and reesterification by neutral cholesterol esterase (N-CEase) and acyl CoA:cholesterol acyltransferase (ACAT), respectively. The mechanism by which HDL mobilizes CE from lipid droplets in J774 A.1 cells was investigated, focusing on N-CEase activity. We asked whether HDL enhances the activity and, if so, what signals induce the change of the activity. An incubation of cells with HDL enhanced the decline of cholesteryl-[l-14C]-oleate in foam cells and increased N-CEase activity in the supernatant of cell homogenate in a concentration-dependent manner, whereas incubation with LDL decreased the activity. In addition, N-CEase activity was fivefold higher when cells were cultured in 10% lipoprotein-deficient serum (LPDS) medium (2 micrograms cholesterol/mL) than when cultured in 10% fetal calf serum medium (31 micrograms cholesterol/mL), suggesting that changes in N-CEase activity are mediated by cholesterol. An addition of cholesterol (0 to 30 micrograms/mL) in LPDS medium markedly inhibited N-CEase activity with a concomitant increase in cellular cholesterol concentration. This inhibitory effect of cholesterol was also observed in mouse peritoneal macrophages. In vitro addition of cholesterol did not affect N-CEase activity. Treatment of cells with HMG-CoA reductase inhibitors enhanced N-CEase activity, whereas ACAT inhibitor decreased the activity. Northern blot analysis of N-CEase mRNA showed that the expression was not altered by the presence of cholesterol in LPDS medium. These results suggest that cholesterol downregulates N-CEase activity, probably through cholesterol-dependent appearance of some factors.

1.P.69 Down regulation of neutral cholesterol esterase activity by cholesterol

1.P.69 Down regulation of neutral cholesterol esterase activity by cholesterol

Regulation of neutral cholesterol esterase activity by cholesterol in J774 A.1 macrophages.

Regulation of neutral cholesterol esterase activity by cholesterol in J774 A.1 macrophages.

Regulation of hormone-sensitive lipase in streptozotocin-induced diabetic rats

Insulin deficiency as seen in insulin-dependent diabetes mellitus causes an activation of lipolysis in adipose tissue that results in hydrolysis of stored triglycerides and release of large amounts of fatty acids into the plasma, leading to diabetic ketoacidosis (DKA). Hormone-sensitive lipase (HSL) is thought to be the rate-limiting enzyme of lipolysis in adipose tissue. This study was designed to examine the effects of insulin deficiency on the regulation of HSL in isolated adipocytes. Insulin deficiency was induced by a single dose of streptozotocin. After 8 days, some animals were treated with insulin, and all animals were killed 10 days after induction of insulin deficiency. Compared with levels in control rats, 10 days of insulin deficiency increased HSL activity twofold ( P < .05), as assayed for neutral cholesterol esterase activity, and insulin treatment returned HSL activity to normal. HSL protein was increased twofold ( P < .05) in streptozotocin-induced diabetic rats, as estimated by immunoblotting, but remained elevated after insulin treatment. Levels of HSL mRNA assessed by Northern blot analysis also increased twofold ( P < .01) in adipose cells isolated from streptozotocin-induced diabetic rats, and remained elevated after insulin treatment. In conclusion, our studies suggest that 10 days of insulin deficiency increases HSL expression via pretranslational mechanisms and short-term insulin treatment returns HSL activity to normal via posttranslational mechanisms in adipose tissue.

Regulation of neutral cholesterol esterase activity by phospholipids containing negative charges in substrate liposome

The effect of phospholipids on cholesteryl ester hydrolysis by neutral cholesterol esterase in alveolar macrophages was studied. Among the phospholipids used as emulsifiers, those with a negative charge, such as phosphatidylserine, phosphatidic acid, phosphatidylinositol, and cardiolipin, gave a higher level of hydrolysis by neutral cholesterol esterase than other less negatively charged phospholipids, such as phosphatidylcholine, lysophosphatidylcholine, phosphatidylethanolamine, and sphingomyelin. Phospholipase D treatment of liposomes emulsified with phosphatidylcholine produced phosphatidic acid and enhanced cholesteryl ester hydrolysis. Phospholipase A2 treatment produced lysophosphatidylcholine and decreased the hydrolysis. The hydrolysis of cholesteryl ester in lipid droplets obtained from cholesterol-laden macrophages elicited by thioglycollate in the rat peritoneal cavity was low compared to artificial liposomes emulsified with phosphatidylcholine. The reason for this was speculated to be that lipid droplets were low in total phospholipids and poor in phospholipids with strong negative charges but rich in phosphatidylethanolamine and sphingomyelin. These results suggest that the polar heads of phospholipids may play an important role in cholesteryl ester hydrolysis by neutral cholesterolesterase.

Genetic differences of lipid metabolism in macrophages from C57BL/6J and C3H/HeN mice.

Cholesterol metabolism in macrophages from atherosclerosis-prone C57BL/6J mice was compared with that in macrophages from atherosclerosis-resistant C3H/HeN mice. Plasma total cholesterol levels of both types of mice were significantly increased, but HDL cholesterol level was increased only in C3H/HeN mice when a high-cholesterol diet (1% cholesterol) was fed for 5 weeks. After incubation of macrophages from male and female mice on the high-cholesterol diet with beta-VLDL for 24 hours, cholesterol content in macrophages from C57BL/6J was approximately 1.5- to 2.0-fold higher than in those from C3H/HeN mice. [3H]Cholesterol oleate-beta-VLDL incorporation into macrophages from C57BL/6J mice on the high-cholesterol diet was greater than incorporation into those from C3H/HeN mice. The release of [3H]cholesterol from macrophages from C57BL/6J mice on the high-cholesterol diet was one seventh that from macrophages from C57BL/6J mice on the basal diet or that from macrophages from C3H/HeN mice on the basal or high-cholesterol diet. Acid cholesterol esterase activity was almost the same in macrophages from any group. Acyl CoA:cholesterol acyltransferase activity in macrophages from C57BL/6J mice on the high-cholesterol diet increased compared with that from macrophages from C57BL/6J mice on the normal diet. Neutral cholesterol esterase activity in macrophages from C57BL/6J mice was about half of that in macrophages from C3H/HeN mice independent of the type of diet. There were no sex differences in these metabolisms. Considered with our previous data, these results suggested that a high-cholesterol diet may cause metabolic changes to accumulate cholesterol ester in macrophages from C57BL/6J mice in accordance with genetic abnormalities.

Cholesterol metabolism in monocyte-derived macrophages from macrophage colony-stimulating factor administered rabbits

The metabolism of ß-very-low-density lipoproteins (ß-VLDL) in macrophages from the blood monocytes of rabbits, which had been administered macrophage colony-stimulating factor (M-CSF) in vivo, was investigated in order to clarify the mechanism of the suppressive effect of M-CSF on cholesterol accumulation in macrophages. Cholesterol ester content after incubation with ß-VLDL, and [ 3H]cholesterol oleate-ß-VLDL incorporation remarkably increased in cultured macrophages from blood monocytes in the high cholesterol diet control group compared to those in the normal diet control group. Those in macrophages from M-CSF-treated groups, both normal diet and high cholesterol diet, were the same as in the normal diet control group. The ratio of released [ 3H]cholesterol to incorporated [ 3H]cholesterol oleate-ß-VLDL in macrophages from control was smaller than that from the M-CSF group. The acyl-coenzyme A:cholesterol acyltranseferase (ACAT) activity was enhanced in the high cholesterol diet groups, and the activity in M-CSF-treated groups decreased. The neutral cholesterol esterase activity was enhanced in the M-CSF-treated groups compared with that in the non-treated control groups. These results suggest that high cholesterol diet induced further cholesterol esterification and that M-CSF treatment enhanced cholesterol clearance in macrophages.

Impact of monocyte colony-stimulating factor upon β-very low density lipoprotein (β-VLDL) cholesterol metabolism in tetradecanoyl phorbol acetate-derived THP-1 cells

The effect of monocyte colony stimulating factor (M-CSF) on the β-very low density lipoprotein (β-VLDL) metabolism in THP-1 cells (human leukemia cell line) was studied. THP-1 cells treated with M-CSF decreased Latex Bead phagocytosis, but the cells incubated with 12-tetradecanoyl-phorbol-13-acetate (TPA) enhanced phagocytosis 2.5-fold. Binding activity of 125I-M-CSF to THP-1 cells was higher than that in THP-1 cells elicited with TPA. THP-1 cells incubated with M-CSF before TPA treatment were designated MT macrophages, and those incubated with M-CSF after TPA treatment were called TM macrophages. When these cells were incubated with β-VLDL, the cholesterol ester content in MT macrophages was less than in TM macrophages. The uptake of [ 3H]cholesterol oleate-β-VLDL in MT macrophages was the same as in TM macrophages. The released radioactivity from [ 3H]cholesterol oleate-β-VLDL loaded MT macrophages was higher than that from TM macrophages. Acid cholesterol esterase activity and ACAT activity were the same in both types of macrophages. Neutral cholesterol esterase activity was higher in MT than in TM macrophages. These results suggested that β-VLDL-induced cholesterol ester deposition in THP-1 cells-derived macrophages was suppressed by M-CSF, when M-CSF acted at the stage of monocytes (THP-1 cells), and that the reduction of cholesterol ester might be due to enhanced release of cholesterol from the cells with high neutral cholesterol esterase activity.

The multifunctional role of hormone-sensitive lipase in lipid metabolism

Hormone sensitive lipase (HSL) is an enzyme of relatively broad specificity, having the ability to hydrolyze tri-, di- and mono-acylglycerols as well as cholesterol esters and small water-soluble substrates. This broad specificity allows HSL to perform a variety of functions in several tissues. A key feature of HSL is its ability to be activated via phosphorylation by cyclic AMP-dependent protein kinase. In addition it is phosphorylated at a second site by several kinases, notably AMP-activated protein kinase. Phosphorylation of this site apparently plays a role in rendering the enzyme hormone-insensitive, in that prior phosphorylation at site 2 prevents phosphorylation and activation at site 1 by cyclic AMP-dependent protein kinase. Investigation of the protein phosphatases responsible for dephosphorylation of these sites has indicated that phosphatase 2A plays a predominant role but also that protein phosphatase 2C is a significant phosphatase targeted against both phosphorylation sites. Evidence indicates that HSL has at least three functional domains which contain (a) the phosphorylation sites which control activity, (b) the active site responsible for the catalytic activity and (c) a lipid binding site responsible for anchoring the lipase at the water-lipid interface. Using limited proteolytic studies we have found that it is possible to cleave HSL into several fragments including a stable domain of M r approximately 17.6 kDa which contains the active site serine residue. Digestion under similar conditions also generates a stable domain of M r approximately 11.5 kDa containing both phosphorylation sites. Furthermore, under appropriate conditions it is possible to digest HSL and retain activity against water-soluble substrates but with the concomitant loss of activity against triacylglycerol, implying that a lipid binding domain is lost during this procedure. HSL is responsible for the neutral cholesterol esterase activity in macrophages and it may play a role in the accumulation of cholesterol esters which occur during the development of foam cells. HSL activity is reduced in macrophage foam cells, at least partly due to increased activity of a cytosolic HSL inhibitor protein. A finding unexplained for many years has been that, although lipolysis can be stimulated 50–100-fold in adipocytes by lipolytic hormones, HSL can apparently only be activated 2–3-fold via phosphorylation in vitro by cyclic AMP-dependent protein kinase. One possibility to explain this discrepancy is that an additional anchoring protein is missing from the in vitro system and indirect evidence is now accumulating for such a protein.

Detection of hormone-sensitive lipase in various tissues. I. Expression of an HSL/bacterial fusion protein and generation of anti-HSL antibodies.

Hormone-sensitive lipase (HSL) is an intracellular neutral lipase found in a variety of tissues, but primarily in adipose and steroidogenic tissues, that hydrolyzes triglycerides and cholesteryl esters. In the present studies, a portion of rat HSL cDNA was subcloned into a pET expression system and the resulting recombinant fusion protein was over-expressed in E. coli. The approximately 26 kD HSL/fusion protein was used to generate polyclonal antibodies in rabbits that recognize intact HSL (84 kD) in rat adipose tissue, ovary, adrenal, testis, heart, and lung, as well as in human adipose tissue. In addition, there was an approximately 89 kD protein observed in all rat tissues expressing the 84 kD protein. Unique to testes, there was an immunoreactive protein of approximately 102 kD in sexually immature rats, and additional immunoreactive proteins of approximately 113 kD and approximately 127 kD in sexually mature rats. The anti-HSL/fusion protein antibodies could remove approximately 60-80% of total neutral cholesterol esterase activity from extracts of rat adipose tissue and immunoprecipitated a single 84 kD protein after labeling of adipocytes with [32P]orthophosphate. The incorporation of 32P into the 84 kD HSL protein was stimulated 4-fold by incubation of adipocytes with isoproterenol. The half life of [35S]methionine-labeled HSL was approximately 4 h in normal rat adipocytes. The production of an HSL/fusion protein and generation of antibodies that recognize native HSL should be valuable tools in exploring the mechanisms regulating the expression of HSL activity and the function and localization of its immunoreactive proteins.

Effect of dietary cholesterol on rat glomerular cholesterol esterase.

The accumulation of tissue cholesterol and cholesteryl esters is commonly seen during the development of both atherosclerosis and glomerulosclerosis. The intracellular cholesterol content is regulated, in part, by the hydrolysis of cholesteryl esters to cholesterol, a reaction catalyzed by cholesterol esterase. Decreased cholesterol esterase has been linked to cholesteryl ester accumulation in vascular cells and has been postulated to be an important factor in the progression of atherosclerosis and, possibly, glomerulosclerosis. In order to determine whether cholesterol esterase regulates glomerular cholesterol accumulation, the effect of cholesterol feeding on the cholesterol content and the activity of cholesterol esterase was examined in rat glomeruli. Cholesterol esterase was measured using a cholesteryl[1-14C]oleate-lecithin liposome substrate. Total and free glomerular cholesterol was measured spectrofluorometrically. Feeding rats 4% cholesterol for 2 months decreased total glomerular (acid plus neutral) cholesterol esterase activity when compared to glomeruli from similar rats fed a normal chow (1.8 +/- 0.1 versus 1.48 +/- 0.2 nmol/mg protein/h, p < 0.05). Total, free and esterified cholesterol concentrations were higher in glomeruli from cholesterol-fed rats than from controls, consistent with decreased cholesterol esterase activity. Thus, glomerular cholesterol accumulation appears to be regulated by cholesterol esterase. This finding is similar to that in other vascular tissues which have been investigated and which are prone to accumulate cholesterol during the development of atherosclerosis.

Beta-VLDL-induced cholesterol ester deposition in macrophages may be regulated by neutral cholesterol esterase activity.

We examined the role of enzyme activities involved in cholesterol ester metabolism in the accumulation of cholesterol ester in macrophages. When [3H]cholesterol linoleate-beta-very low density lipoproteins (beta-VLDLs) were incubated with rat resident peritoneal macrophages (RPMs), thioglycolate-elicited macrophages (TEMs), or alveolar macrophages (AMs), cholesterol ester accumulation was the greatest in TEMs and the least in AMs. The uptake of [3H]cholesterol linoleate-beta-VLDL into AMs was four times that into RPMs, and the uptake into TEMs was twice that into RPMs. The [3H]cholesterol released from [3H]cholesterol linoleate-beta-VLDL-loaded AMs was five times higher than from TEMs and RPMs, whereas those from RPMs and TEMs were almost the same. In studies using cell homogenates, the acid cholesterol esterase activity in AMs was 1.7 times that in TEMs and six times that in RPMs. The acyl-coenzyme A:cholesterol acyltransferase (ACAT) activities in AMs and TEMs were similar but were higher than that in RPMs. The neutral cholesterol esterase activity was seven times higher in AMs than in RPMs and TEMs. In the study using intact cells, the hydrolysis of loaded [3H]cholesterol linoleate-beta-VLDL in the presence of the ACAT inhibitor CL277,082 and the cholesterol [14C]oleate synthesis from [14C]oleate were enhanced in AMs about twofold compared with RPMs and TEMs. The reduction of de novo synthesized cholesterol [14C]oleate in the presence of CL277,082 was enhanced in AMs four times compared with TEMs or RPMs.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholesterol ester hydrolysis and hormone-sensitive lipase in lactating rat mammary tissue

Neutral cholesterol esterase activity is expressed in extracts of mammary epithelial cells. The identity of the enzyme catalyzing this hydrolysis was investigated. Anti-hormone-sensitive lipase immunoglobulin elicited the total inhibition of this activity and also immunoprecipitated a single phosphoprotein of M r 84 kDa from mammary cell extracts previously phosphorylated in vitro with [γ- 32P]ATP and cyclic AMP-dependent protein kinase. It is concluded that mammary cell cholesterol esterase activity results from the presence of hormone-sensitive lipase.

Cholestyramine treatment in early life of low-density lipoprotein receptor deficient Watanabe rabbits: decreased aortic cholesteryl ester accumulation and atherosclerosis in adult life

Effect of cholestyramine treatment in early life of Watanabe heritable hyperlipidemic rabbits (an animal model lacking low-density lipoprotein receptor activity) on subsequent (6 months recovery) occurrence of natural atherosclerotic lesion and arterial cholesterol metabolism was investigated. Initial cholestyramine treatment decreased both plasma total cholesterol and HDL-cholesterol levels which normalized within 4 weeks after treatment was discontinued. At 9 months of age (age of occurrence of spontaneous atherosclerotic lesions), the extent of aortic atherosclerosis in cholestyramine pre-treated animals was modestly lower ( P < 0.05), as compared to controls, with a significant ( P < 0.05) decrease in aortic cholesteryl ester content. Furthermore, at the end of the recovery period aortic activity of acyl-CoA: cholesterol acyltransferase and neutral cholesterol esterase activity was significantly ( P < 0.05) lower in cholestyramine-pretreated animals. These studies show that early Cholestyramine pre-treatment in a low-density lipoprotein receptor-deficient animal model causes persistent changes which might influence cholesteryl ester accumulation and atherogenesis in adult life, even after cholestyramine treatment is discontinued.

実験的家兎動脈硬化症に対するElastaseの影響

The effects of porcine pancreatic elastase on experimental atherosclerosis rabbits have been studied. Rabbits were fed 1% cholesterol for 4 months to induced experimental atherosclerosis. Two groups of atherosclerosis rabbits were kept for 5 months as follows; First group (C-group) was fed normal diets and placebo, 2nd group (E-group) was fed normal diets and orally administrated with elastase 100mg/kg/day (97units/mg). The lipids levels in plasma, in lipoprotein, and apo-protein, cholesterol esterases and Suc (ala)3 pNA hydrolytic activity in aorta were analyzed. Plasma cholesterol was rapidly decreased in E-group, and those contents in VLDL and LDL fraction were decreased in same group comparing with C-group. Also, in lipoprotein fraction, Apo E and Apo A were increased in E-group.Neutral cholesterol esterase activity and Suc (ala)3 pNA-hydrolytic activity were different from those in C-group.Pathologically, fatty streak involvement in aorta was 50% decreased in E-group. The foam cells in intima and hyperplastic intima of aorta were decreased by elastase administration. These results indicated that elastase had accelerative effect on regression of the experimental atheroscerosis.