Tumor-related Processes Research Articles

Role of alternative splicing events in endometrial cancer prognosis.

Alternative splicing (AS), as a potent and pervasive mechanism of transcriptional regulation, can expand the genome's coding capacity. Growing evidence suggests that the AS events may be associated with various types of cancer. This study aims to explore the prognostic value of AS in endometrial cancer (EC). Differently expressed AS (DEAS) events were screened by pairing the percent spliced in (PSI) value of tumor and paracancerous tissues in The Cancer Genome Atlas (TCGA) database, and gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were performed on their parental gene analysis of organisms. Subsequently, univariate Cox analysis was used to identify the prognostic AS events and a stepwise multi-factor Cox regression analysis was performed to further construct prognostic models. Furthermore, the diagnostic value of the prognostic model was evaluated by receiver operating characteristic (ROC) curve and Kaplan-Meier analysis. Finally, the regulatory network of AS events and splicing factory in the model was also constructed. A total of 28 281 AS events were detected in EC. Of them, 42 DEAS were identified, and their parental genes were involved in tumor-related processes such as meiotic nuclear division, alpha-amino acid biosynthetic process, nuclear division, and so on. Univariate Cox analysis identified 2 289 prognostic-related AS events and constructed Cox prognostic models based on 7 different types and all types of AS events, in which the area under the curve of ROC of all types was as high as 0.882 and was better than that of 7 different splicing types. Finally, 12 splicing factors and AS events showed an obvious regulatory relationship. We use the whole genome analysis of AS events to establish a scientific prognostic prediction model for EC patients, which provides a reliable theoretical basis for the evaluation of EC clinical prognosis.

MicroRNAs as Epigenetic Determinants of Treatment Response and Potential Therapeutic Targets in Prostate Cancer.

Simple SummaryProstate cancer is one of the most common and lethal tumors in men worldwide. Due to the high heterogeneity of the disease, the optimal treatment choice for individual patients is very challenging, thus leading to treatment failure caused by poor responsiveness and/or tumor recurrence. Therefore, the identification of novel actionable targets involved in determining tumor treatment response is essential for developing patient-tailored therapeutic strategies. In this scenario, microRNAs, small endogenous RNA molecules able to epigenetically regulate cellular processes that are widely deregulated in cancer, have been proposed as potential treatment response modulators in many tumor types, including prostate cancer. In this review, we provide an overview on the main microRNAs involved in prostate cancer response to radiation and drug therapy, describing the mechanisms by which they concur to determine disease response, and illustrate whether they can be considered novel therapeutic targets/tools for improving treatment response in prostate cancer patients.Prostate cancer (PCa) is the second most common tumor in men worldwide, and the fifth leading cause of male cancer-related deaths in western countries. PC is a very heterogeneous disease, meaning that optimal clinical management of individual patients is challenging. Depending on disease grade and stage, patients can be followed in active surveillance protocols or undergo surgery, radiotherapy, hormonal therapy, and chemotherapy. Although therapeutic advancements exist in both radiatiotherapy and chemotherapy, in a considerable proportion of patients, the treatment remains unsuccessful, mainly due to tumor poor responsiveness and/or recurrence and metastasis. microRNAs (miRNAs), small noncoding RNAs that epigenetically regulate gene expression, are essential actors in multiple tumor-related processes, including apoptosis, cell growth and proliferation, autophagy, epithelial-to-mesenchymal transition, invasion, and metastasis. Given that these processes are deeply involved in cell response to anti-cancer treatments, miRNAs have been considered as key determinants of tumor treatment response. In this review, we provide an overview on main PCa-related miRNAs and describe the biological mechanisms by which specific miRNAs concur to determine PCa response to radiation and drug therapy. Additionally, we illustrate whether miRNAs can be considered novel therapeutic targets or tools on the basis of the consequences of their expression modulation in PCa experimental models.

Roles of the tumor suppressor inhibitor of growth family member 4 (ING4) in cancer.

Inhibitor of growth family member 4 (ING4) is best known as a tumor suppressor that is frequently downregulated, deleted, or mutated in many cancers. ING4 regulates a broad array of tumor-related processes including proliferation, apoptosis, migration, autophagy, invasion, angiogenesis, DNA repair and chromatin remodeling. ING4 alters local chromatin structure by functioning as an epigenetic reader of H3K4 trimethylation histone marks (H3K4Me3) and regulating gene transcription through directing histone acetyltransferase (HAT) and histone deacetylase (HDAC) protein complexes. ING4 may serve as a useful prognostic biomarker for many cancer types and help guide treatment decisions. This review provides an overview of ING4's central functions in gene expression and summarizes current literature on the role of ING4 in cancer and its possible use in therapy.

Aquaporins: A Multidisciplinary Perspective on The Water Channel Proteins

Aquaporins are unique water channel proteins located at cell membranes that possess high water permeability and high solute rejection. Their primary function is to maintain the osmotic balance of the cells via regulating the water transport. However, their discovery had also provided the scientists to understand the pathophysiology of some diseases. In fact, aquaporins are shown to be strongly related to cancer by taking part in several tumor-related processes such as cell migration, cell proliferation and cell adhesion. Other than their functions in human body, recently, aquaporins have started to be used in engineering biomimetic membranes, for different applications such as desalination. This review investigates the properties and functions of the aquaporins in a multidisciplinary point of view and demonstrates the recent developments in aquaporin-based research.

PLAC1 is essential for FGF7/FGFRIIIb-induced Akt-mediated cancer cell proliferation.

PLAC1 (placenta enriched 1) is a mammalian trophoblast-specific protein. Aberrant expression of PLAC1 is observed in various human cancers, where it is involved in the motility, migration, and invasion of tumor cells, which are associated with the phosphoinositide 3-kinase (PI3K)/AKT pathway. We previously demonstrated that AKT activation mediates the downstream effects of PLAC1; however, the molecular mechanisms of PLAC1-induced AKT-mediated tumor-related processes are unclear. We studied human choriocarcinoma and breast cancer cell lines to explore the localization and receptor-ligand interactions, as well as the downstream effects of PLAC1. We show secretion and adherence of PLAC1 to the extracellular matrix, where it forms a trimeric complex with fibroblast growth factor 7 (FGF7) and its receptor, FGF receptor 2 IIIb (FGFR2IIIb). We further show that PLAC1 signaling via FGFR2IIIb activates AKT phosphorylation in cancer cell lines. As the FGF pathway is of major interest in anticancer therapeutic strategies, these data further promote PLAC1 as a promising anticancer drug target.

Regulation of the Ras-Related Signaling Pathway by Small Molecules Containing an Indole Core Scaffold: A Potential Antitumor Therapy.

The Ras-Related signaling pathway plays an important role in cell development and differentiation. A growing body of evidence collected in recent years has shown that the aberrant activation of Ras is associated with tumor-related processes. Several studies have indicated that indole and its derivatives can target regulatory factors and interfere with or even block the aberrant Ras-Related pathway to treat or improve malignant tumors. In this review, we summarize the roles of indole and its derivatives in the isoprenylcysteine carboxyl methyltransferase-participant Ras membrane localization signaling pathway and Ras-GTP/Raf/MAPK signaling pathway through their regulatory mechanisms. Moreover, we briefly discuss the current treatment strategies that target these pathways. Our review will help guide the further study of the application of Ras-Related signaling pathway inhibitors.

Effective Treatments for Bladder Cancer Affecting CXCL9/CXCL10/CXCL11/CXCR3 Axis: A Review.

Bladder cancer (BC) originates mainly from the epithelial compartment of the bladder, which is defined as transitional cell carcinoma or urothelial cell carcinoma. About 70% of patients with BC will survive five years from diagnosis. Previous studies revealed that the immune system and its mediators, particularly chemokines, play a crucial role in modulating responses against BC. Chemokines, which serve as chemoattractants for leukocytes, are small proteins that can initiate inflammatory and anti-inflammatory immune responses and also are associated with many aspects of both regulation and progression of mentioned responses. Additionally, these immune mediators can interfere with the other tumor-related processes, including tumor proliferation, neovascularization, and metastases. Among these chemokines, CXC chemokines, including CXCL9, CXCL10, and CXCL11, are recognized as the main ligands of C-X-C motif chemokine receptor 3 (CXCR3) and contribute to related immune responses after therapeutic strategies for BC. Evidence suggests that the production of these chemokines can have two important implications. First, these mediators can trigger the accumulation of CD8+ T cells that can contribute to the elimination of the tumor. Secondly, the production of these chemokines by tumor tissue may trigger the migration and activation of immune cells including myeloid-derived suppressor cells and regulatory T cells, which act in favor of the tumor and its progress. Therefore, in this review, we describe the latest therapeutic approaches based on targeting this axis’s components and subsequent immune phenomenon.

Impact of Chemotherapy on Extracellular Vesicles: Understanding the Chemo-EVs.

Chemotherapy is the standard go-to treatment for cancer besides surgery and radiation. It has recently come to light that the interaction between chemotherapy and the immune system is important in maintaining tumor immunity as well as influencing the efficacy of the therapy. However, ample preclinical studies have shown that in addition to direct cytotoxic effects on cancer cells, a fraction of chemotherapeutic agents may promote immunogenic cell death, and alter the inflammatory milieu of the tumor microenvironment. Extracellular vesicles (EV) have been shown to interact with the tumor microenvironment by delivering alterative signals to the surrounding cells; as a result, this results in interference with each cell's capability to eradicate tumors or gives advantages to cancer cells so as to survive therapy. Chemotherapy-induced extracellular vesicles (chemo-EVs) have been theorized to be carrying different cargo loads than non-chemotherapy-induced EVs. Aside from chemoresistance, there is growing evidence to suggest that chemo-EVs could dictate tumor behavior, especially in terms of metastasis, immune response, and cancer stemness. This mini-review attempts to summarize and evaluate recent developments on the role of chemo-EVs in other aspects of tumor-related processes.

Deconvolution of transcriptomes and miRNomes by independent component analysis provides insights into biological processes and clinical outcomes of melanoma patients

BackgroundThe amount of publicly available cancer-related “omics” data is constantly growing and can potentially be used to gain insights into the tumour biology of new cancer patients, their diagnosis and suitable treatment options. However, the integration of different datasets is not straightforward and requires specialized approaches to deal with heterogeneity at technical and biological levels.MethodsHere we present a method that can overcome technical biases, predict clinically relevant outcomes and identify tumour-related biological processes in patients using previously collected large discovery datasets. The approach is based on independent component analysis (ICA) – an unsupervised method of signal deconvolution. We developed parallel consensus ICA that robustly decomposes transcriptomics datasets into expression profiles with minimal mutual dependency.ResultsBy applying the method to a small cohort of primary melanoma and control samples combined with a large discovery melanoma dataset, we demonstrate that our method distinguishes cell-type specific signals from technical biases and allows to predict clinically relevant patient characteristics. We showed the potential of the method to predict cancer subtypes and estimate the activity of key tumour-related processes such as immune response, angiogenesis and cell proliferation. ICA-based risk score was proposed and its connection to patient survival was validated with an independent cohort of patients. Additionally, through integration of components identified for mRNA and miRNA data, the proposed method helped deducing biological functions of miRNAs, which would otherwise not be possible.ConclusionsWe present a method that can be used to map new transcriptomic data from cancer patient samples onto large discovery datasets. The method corrects technical biases, helps characterizing activity of biological processes or cell types in the new samples and provides the prognosis of patient survival.

Novel Associations Within the Tumor Microenvironment: Fibulins Meet ADAMTSs.

The maintenance of tissue homeostasis in any organism is a very complex and delicate process in which numerous factors intervene. Cellular homeostasis not only depends on intrinsic factors but also relies on external factors that compose the microenvironment or cellular niche. Thus, extracellular matrix (ECM) components play a very important role in maintaining cell survival and behavior, and alterations in the ECM composition can lead to different pathologies. Fibulins and ADAMTS metalloproteases play crucial roles in the upkeep and function of the ECM in different tissues. In fact, members of both of these families of secreted multidomain proteins can interact with numerous other ECM components and thus shape or regulate the molecular environment. Individual members of both families have been implicated in tumor-related processes by exhibiting either pro- or antitumor properties. Recent studies have shown both an important relation among members of both families and their participation in several pathologies, including cardiogenesis or cancer. In this review, we summarize the associations among fibulins and ADAMTSs and the effects elicited by those interactions on cellular behavior.

Anti-Cancer Effects of Pristimerin and the Mechanisms: A Critical Review.

As a quinonemethide triterpenoid extracted from species of the Celastraceae and Hippocrateaceae, pristimerin has been shown potent anti-cancer effects. Specifically, it was found that pristimerin can affect many tumor-related processes, such as apoptosis, autophagy, migration and invasion, vasculogenesis, and drug resistance. Various molecular targets or signaling pathways are also involved, such as cyclins, reactive oxygen species (ROS), microRNA, nuclear factor kappa B (NF-κB), mitogen-activated protein kinase (MAPK), and PI3K/AKT/mammalian target of rapamycin (mTOR) pathways. In this review, we will focus on the research about pristimerin-induced anti-cancer activities to achieve a deeper understanding of the targets and mechanisms, which offer evidences suggesting that pristimerin can be a potent anti-cancer drug.

Sortilin inhibition limits secretion-induced progranulin-dependent breast cancer progression and cancer stem cell expansion

BackgroundCancer progression is influenced by genetic aberrations in the cancer cell population as well as by other factors including the microenvironment present within a tumour. Direct interactions between various cell types as well as cellular signalling via secreted cytokines can drive key tumourigenic properties associated with disease progression and treatment resistance. Also, cancer stem cell functions are influenced by the microenvironment. This challenging subset of cells has been linked to malignant properties. Within a screen, using in vivo like growth conditions, we identified progranulin as a highly secreted cytokine affecting cancer stem cells in breast cancer. This cytokine is known to play a role in numerous biological and tumour-related processes including therapy resistance in a range of cancer types.MethodsDifferent in vitro and in vivo relevant conditions were used to validate breast cancer stem cell expansion mediated by progranulin and its receptor sortilin. Small interfering ribonucleic acid (siRNA) and pharmacological inhibition of sortilin were used to elucidate the role of sortilin as a functional receptor during progranulin-induced breast cancer stem cell propagation, both in vitro and in vivo, using breast cancer xenograft models. In addition, single-cell gene expression profiling as well as a Sox2 reporter breast cancer cell line were used to validate the role of dedifferentiation mediated by progranulin.ResultsIn various in vivo-like screening assays, progranulin was identified as a potent cancer stem cell activator, highly secreted in ERα-negative breast cancer as well as in ERα-positive breast cancer under hypoxic adaptation. Progranulin exposure caused dedifferentiation as well as increased proliferation of the cancer stem cell pool, a process that was shown to be dependent on its receptor sortilin. Subcutaneous injections of progranulin or its active domain (GRN A) induced lung metastases in breast cancer xenograft models, supporting a major role for progranulin in cancer progression. Importantly, an orally bioavailable small molecule (AF38469) targeting sortilin, blocked GRN A-induced lung metastases and prevented cancer cell infiltration of the skin.ConclusionThe collective results suggest that sortilin targeting represents a potential novel breast cancer therapy approach inhibiting tumour progression driven by secretion and microenvironmental influences.

Advances in the research of the relationship between miRNA-29c and cancer

miRNAs are a class of endogenous non coding, single stranded small RNAs, which regulate the expression of tumor suppressor genes and oncogenes and involve in almost all of the tumor-related processes. miRNA-29c, acting as a tumor suppressor of miRNA, has low expression in many solid malignancies such as nasopharyngeal carcinoma, glioma, gastric cancer, hepatocellular carcinoma, bladder cancer, esophageal cancer, breast cancer, colon cancer and so on. It relates with cancerous proliferation, apoptosis, invasion and metastasis. miRNA-29c directly inhibits the transcription of the target gene encoding protein and down regulates the expression of the target gene. miRNA-29c inhibits tumor cells infinite proliferation and promotes apoptosis by regulating the signal pathways, oncogene, and cell cycle. miRNA-29c can inhibit the invasion and metastasis of tumor cells by regulating different target genes, signal pathways and mediating epithelial-mesenchymal transition. In tumor tissues, the lower expression of miRNA-29c, the higher clinical stage,and the poorer prognosis, so it can be used as an indicator of early diagnosis and prognosis. miRNA-29c is also closely related to head and neck cancer. Therefore, enhancement of the expression of miRNA-29c in tumor cells is expected to be a potential therapeutic strategy for cancer. Selective COX2 inhibitors and demethylated drugs can significantly increase the expression of miRNA-29c. miRNA-29c can be a new tumor biomarker and drug or gene therapeutic target.

In1-ghrelin splicing variant is associated with reduced disease-free survival of breast cancer patients and increases malignancy of breast cancer cells lines.

Ghrelin gene generates several variants that regulate multiple pathophysiological functions, including tumor-related processes. In1-ghrelin is a splicing variant that was previously shown to be overexpressed in breast cancer (BCa), where it correlated with proliferation markers; however, its possible association with clinical outcome of BCa patients and underlying mechanisms are still unknown. To address this issue, expression levels and clinical associations of In1-ghrelin were analyzed in a cohort of 117 BCa samples. Additionally, a battery of cellular and molecular assays was implemented using two BCa cell lines (MCF-7 and MDA-MB-231), wherein the role of In1-ghrelin on proliferation, migration, dedifferentiation and signaling pathways was explored. The results generated revealed that high expression of In1-ghrelin in BCa samples was associated with lymph node metastasis and reduced disease-free survival. Indeed, In1-ghrelin overexpression stimulated proliferation and migration in MCF-7 and MDA-MB-231 cells. Similar results were found by treating MDA-MB-231 and MCF-7 with In1-ghrelin-derived peptides. Conversely, In1-ghrelin silencing decreased proliferation and migration capacities of MDA-MB-231. Furthermore, In1-ghrelin (but not ghrelin) overexpression increased the capacity to form mammospheres in both cell lines. These effects could be associated with activation of MAPK-ERK, Jag1/Notch, Wnt/β-catenin and/or TGF-β1 pathways. Altogether, our data indicate that In1-ghrelin could play relevant functional roles in the regulation of BCa development and progression and may provide insights to identify novel biomarkers and new therapeutic approaches for this pathology.

Knockdown of LRP/LR induces apoptosis in pancreatic cancer and neuroblastoma cells through activation of caspases

The 37kDa/67kDa laminin receptor (LRP/LR) serves various physiological and pathological roles such as enhancing tumour-related processes including metastasis, angiogenesis, cellular viability and telomerase activation in cancerous cell lines. The present study investigates the effect of siRNA mediated downregulation of LRP/LR on pancreatic cancer (AsPC-1) and neuroblastoma (IMR-32) cells. MTT and BrdU assays revealed that siRNA mediated downregulation of LRP resulted in a significant reduction in cell viability and cell proliferation. In addition, knock-down of LRP resulted in phosphatidylserine externalization, diminished nuclear integrity and significantly enhanced caspase-3 activity, which is indicative of apoptosis. LRP downregulation resulted in a significant increase in caspase-8 activity in IMR-32 cells and enhanced caspase-8 and 9 activity in AsPC-1 cells. These data recommend siRNA mediated knock-down of LRP as a potential therapeutic avenue for the treatment of pancreatic cancer and neuroblastoma.

Protein content and functional characteristics of serum-purified exosomes from patients with colorectal cancer revealed by quantitative proteomics.

Tumor cells of colorectal cancer (CRC) release exosomes into the circulation. These exosomes can mediate communication between cells and affect various tumor-related processes in their target cells. We present a quantitative proteomics analysis of the exosomes purified from serum of patients with CRC and normal volunteers; data are available via ProteomeXchange with identifier PXD003875. We identified 918 proteins with an overlap of 725 Gene IDs in the Exocarta proteins list. Compared with the serum-purified exosomes (SPEs) of normal volunteers, we found 36 proteins upregulated and 22 proteins downregulated in the SPEs of CRC patients. Bioinformatics analysis revealed that upregulated proteins are involved in processes that modulate the pretumorigenic microenvironment for metastasis. In contrast, differentially expressed proteins (DEPs) that play critical roles in tumor growth and cell survival were principally downregulated. Our study demonstrates that SPEs of CRC patients play a pivotal role in promoting the tumor invasiveness, but have minimal influence on putative alterations in tumor survival or proliferation. According to bioinformatics analysis, we speculate that the protein contents of exosomes might be associated with whether they are involved in premetastatic niche establishment or growth and survival of metastatic tumor cells. This information will be helpful in elucidating the pathophysiological functions of tumor-derived exosomes, and aid in the development of CRC diagnostics and therapeutics.

Computational Approaches for Translational Oncology: Concepts and Patents.

Cancer is a heterogeneous disease, which is based on an intricate network of processes at different spatiotemporal scales, from the genome to the tissue level. Hence the necessity for the biomedical and pharmaceutical research to work in a multiscale fashion. In this respect, a significant help derives from the collaboration with theoretical sciences. Mathematical models can in fact provide insights into tumor-related processes and support clinical oncologists in the design of treatment regime, dosage, schedule and toxicity. The main objective of this article is to review the recent computational-based patents which tackle some relevant aspects of tumor treatment. We first analyze a series of patents concerning the purposing the purposing or repurposing of anti-tumor compounds. These approaches rely on pharmacokinetics and pharmacodynamics modules, that incorporate data obtained in the different phases of clinical trials. Similar methods are also at the basis of other patents included in this paper, which deal with treatment optimization, in terms of maximizing therapy efficacy while minimizing side effects on the host. A group of patents predicting drug response and tumor evolution by the use of kinetics graphs are commented as well. We finally focus on patents that implement informatics tools to map and screen biological, medical, and pharmaceutical knowledge. Despite promising aspects (and an increasing amount of the relative literature), we found few computational-based patents: there is still a significant effort to do for allowing modelling approaches to become an integral component of the pharmaceutical research.

The emerging role of chemokine receptor CXCR2 in cancer progression

Chemokines and their receptors form a complex network controlling leukocyte migration, particularly during infection and inflammation. Besides their critical contributions to the immune system, they are being increasingly implicated in tumour development and metastasis. Chemokines also mediate other tumour-related processes, including angiogenesis and even chemoresistance. There are four subgroups of chemokines based on the position of the first two N-terminal cysteine residues: CXC, CC, CX3C and C. The CXC subgroup is further divided into ELR+ and ELR− chemokines. Chemokines with the ELR motif have angiogenic properties and bind mainly to CXC chemokine receptor 2 (CXCR2). CXCR2 and its ligands are intimately involved in tumour regulation and growth, and its functional inhibition shows promising results in several cancer types. This review discusses the contribution of CXCR2 to the progression of the most frequently occurring cancers including lung, prostate, breast and colorectal cancer, in addition to recent relevant data on ovarian and pancreatic cancer. Pharmacological intervention against CXCR2 and its potential therapeutic benefits are also addressed.

The emerging role of chemokine receptor CXCR2 in cancer progression

: Chemokines and their receptors form a complex network controlling leukocyte migration, particularly during infection and inflammation. Besides their critical contributions to the immune system, they are being increasingly implicated in tumour development and metastasis. Chemokines also mediate other tumour-related processes, including angiogenesis and even chemoresistance. There are four subgroups of chemokines based on the position of the first two N-terminal cysteine residues: CXC, CC, CX3C and C. The CXC subgroup is further divided into ELR+ and ELR− chemokines. Chemokines with the ELR motif have angiogenic properties and bind mainly to CXC chemokine receptor 2 (CXCR2). CXCR2 and its ligands are intimately involved in tumour regulation and growth, and its functional inhibition shows promising results in several cancer types. This review discusses the contribution of CXCR2 to the progression of the most frequently occurring cancers including lung, prostate, breast and colorectal cancer, in addition to recent relevant data on ovarian and pancreatic cancer. Pharmacological intervention against CXCR2 and its potential therapeutic benefits are also addressed.

Síndrome febril de origen desconocido. Indicaciones de la PET/TC con 18F-FDG en los procesos inflamatorios e infecciosos

Fever of unknown origin is defined as a body temperature greater than 38.3°C lasting more than three weeks for which the cause could not be found within one week of hospital admission. More than 200 causes have been reported, and these can be classified into four categories: infections, inflammatory diseases, oncologic processes, and miscellaneous conditions.Noninvasive diagnostic techniques are used in 69.2% of cases and invasive techniques in 30.8%. Structural imaging techniques show the morphological changes from infectious, inflammatory, and tumor-related processes, but they do not allow the detection of the early changes brought about by these processes. The metabolic information provided by 18F-FDG PET/CT has a promising role in these patients. 18F-FDG uptake is based on the cells’ use of glucose as a source of energy, so it can be observed in infectious, inflammatory, and tumor-related processes. The established non-oncologic indications for 18F-FDG PET/CT are sarcoidosis, osteomyelitis, spondylodiscitis, fever of unknown origin, and vasculitis, which together account for more than 85% of studies.