• Title/Summary/Keyword: pH shock

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Changing Proteins in Granulosa Cells during Follicular Development in Pig (돼지 난포 발달 시 과립막 세포에서 발현되는 단백질의 변화)

  • Chae, In-Soon;Jang, Dong-Min;Cheong, Hee-Tae;Yang, Boo-Keun;Park, Choon-Keun
    • Reproductive and Developmental Biology
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    • v.33 no.3
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    • pp.183-187
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    • 2009
  • This study analyzed change of proteins in granulosa cells during the porcine follicuar development by proteomics techniques. Granulosa cells of the follicles, of which the diameter is $2{\sim}4\;mm$ and $6{\sim}10\;mm$, were collected from ovary of slaughtered pig that each follicle of diameter $1{\sim}4\;mm$ and $6{\sim}10\;mm$. We extracted glanulosa cell proteins by M-PER Mammalian Protein Extraction Reagent. Proteins were refined by clean-up kit and quantified by Bradford method until total protein was $200{\mu}l$. Immobilized pH gradient(IPG) strip used 18 cm, $3{\sim}10\;NL$. SDS-PAGE used 10% acrylamide gel. After silver staining, Melanie 7 and naked eye test were used for spot analyzation. Increasing proteins in glanulosa cell of $6{\sim}10\;mm$ follicle were 7 spots. This spots were analyzed by MALDI-TOF MS and searched on NCBInr. In results, 7 spots were similar to zinc/ling finger protein 3 precursor (RING finger protein 203), angiomotin, heat shock 60 kDa protein 1 (chaperonin) isoform 1 (HSP60), similar to transducin-like enhancer protein 1 (TLE 1), SH3 and PX domains 2A (SH3PXD2A). Those proteins were related with transfer between cells. Increase of proteins has an effect on follicular development.

Effect of the Extracorporeal Circulation on Renal Function in Adult Open Heart Patients (개심술시 체외순환이 신장기능에 미치는 영향)

  • Lee, Jae-Won;Seo, Gyeong-Pil
    • Journal of Chest Surgery
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    • v.18 no.4
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    • pp.718-731
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    • 1985
  • Renal dysfunction is a common complication of open-heart surgery: a form of controlled hemorrhagic shock, and successful perioperative management of renal dysfunction depends on recognition of the risk factors and optimal management of factors influencing renal function, including cardiopulmonary bypass, and early detection of renal failure. Changes in renal functional parameters including Ccr, Cosm, CH2O, FENa, and RFI were observed prospectively in forty five patients operated on at Dept. of Thoracic and Cardiovascular Surgery, S.N.U.H., from April to June, 1985. They were 23 males and 22 females with 35 acquired and 10 congenital heart diseases and the mean age and body surface area of them were 38.010.3 years [22-63] and 1.5518 M2[1.151.92] respectively. Followings are the conclusion. 1. The Ccr, representative of renal function, is significantly improved from 90.231.3 ml/min/M2 preoperatively to 101.536.4 ml/min/M2 postoperative and day [P<0.05], and all patients were classified as postoperative renal functional class I of Abel, which representing adequate renal protection during our cardiopulmonary bypass. 2. The Cosm is significantly elevated at immediate postperfusion time and remained high at postoperative one day representing osmotic diuresis at that time, but CH2O shows no significant changes at immediate postperfusion period and is decreased significantly at postoperative one day, representing recovery of renal concentrating ability at that time with decreasing urine flow. 3. The absolute value and changing tendency in FENa and RFI during perioperative period shows no diagnostic reliability on these parameters, but those of CH2O appear to reveal future renal function more accurately than Ccr 4. The depth of hypothermia may be protective upon renal function against the ill effects of prolonged nonpulsatile cardiopulmonary bypass. 5. The depth of the hypothermia, pump time of more than 150 minutes, poor cardiac function, and intraoperative events such as embolism appear to be related with immediate postperfusion renal function. 6. Hemoglobinuria and hemolysis, poor preoperative renal function, history of cardiac surgery, and massive transfusion associated with bleeding appear not to be related with renal dysfunction.

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FT-transgenic spray-type Chrysanthemum (Dendranthema grandiflorum Kitamura) showing early-flowering (FT 유전자 형질전환 스프레이 국화 (Dendranthema grandiflorum (Ramat.) Kitamura)의 조기개화성)

  • Lee, Su-Young;Han, Bong-Hee;Hur, Eun-Joo;Shin, Hak-Kee;Lee, Il-Ha;Lee, Eun-Kyung;Kim, Seung-Tae;Kim, Won-Hee;Kwon, O-Hyeon
    • Journal of Plant Biotechnology
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    • v.39 no.3
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    • pp.140-145
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    • 2012
  • The flowering locus T (FT) gene, of which expression will be controlled at high temperature by heat shock promoter (it printed as to HSproFT), was introduced into spray-type chrysanthemum (Dendranthema grandiflorum (Ramat.) Kitamura) 2 cultivars ('Pink PangPang' and 'Pink Pride' by co-cultivation with Agrobacterium tumefaciens strain C58C1 harboring pCAMBIA2300 containing the HSproFT gene. After leaf segments of the 2 cultivars were infected with the A. tumafaciens with C58C1 as explants, shoots were regenerated from the explants cultured on the $1^{st}$ selection medium (MS basal salts + 1.0 mg/L BA, 0.5 mg/L IAA + 10 mg/L kanamycin + 0.7% plant agar, pH 5.8). The shoots were transferred into the $2^{nd}$ selection medium (MS basal salts + 1.0 mg/L BA, 0.5 mg/L IAA + 20 mg/L kanamycin + 0.7% plant agar, pH 5.8). One hundred seventeen plantlets from 'Pink PangPang' and 5 ones from 'Pink Pride' were confirmed as transformants by PCR analysis. Twenty six of the transformants and non-transformants were acclimatized and established well in a green house. Eights of 26 transgenic lines showed flower bud 1.7~10 days earlier than nontransgenic plants, and 24 of them flowered 1~6 days earlier than non- transgenic plants. The shape and color of flower of all HSproFT-transgenic lines were not different with those of non- transgenic plants.

Anti-oxidative and Anti-inflammatory Effects of Genistein in BALB/c Mice Injected with LPS (LPS 주사한 BALB/c 마우스에서 Genistein의 산화적 스트레스 억제효과 및 항염증 효과)

  • Cho, Hye-Yeon;Noh, Kyung-Hee;Cho, Mi-Kyung;Jang, Ji-Hyun;Lee, Mi-Ok;Kim, So-Hee;Song, Young-Sun
    • Journal of the Korean Society of Food Science and Nutrition
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    • v.37 no.9
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    • pp.1126-1135
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    • 2008
  • This study was carried out to investigate the anti-oxidative and anti-inflammatory actions of genistein in BALB/c mice injected with lopopolysaccharide (LPS), called endotoxin. Mice (10 weeks of age) weighing approximately 20 g were divided into 4 groups. Endotoxin shock was induced by intraperitoneal injection of LPS (100 mg/kg BW). LPS and genistein+LPS groups were injected with LPS 30 min after phosphate buffered saline (PBS) solution and genistein (200 mg/kg BW) injections, respectively. Genistein group was injected with genistein, followed by PBS, while PBS group received two injections of PBS. Superoxide anion generation of peritoneal macrophage cells was significantly (p<0.05) lower in the genistein+LPS group than in the LPS injection group at 8 h after intraperitoneal injection, while SOD activity was significantly higher in genistien+LPS group than LPS group. Tumor necrosis factor-$\alpha$ levels of plasma were significant lower (p<0.05) in the genistein+LPS injection group than LPS group at 8 h after intraperitoneal injection. Plasma TBARS was lower in genistein+LPS group than LPS group, while hepatic TBARS were not different among groups. Hepatic glutathione concentrations and antioxidant enzyme activities were ignificantly higher in the genistein+LPS group than in the LPS group at 1 h and 8 h after intraperitoneal injection. Nuclear factor-kappa B (NF-${\kappa}B$) transactivation was significantly (p<0.05) inhibited in LPS group. These results demonstrate genistein may ameliorate inflammatory diseases through inhibition of NF-${\kappa}B$ transactivation and oxidative stress, which may be mediated partially by anti-oxidative effect of genistein.

Lung Injury Indices Depending on Tumor Necrosis Factor-$\alpha$ Level and Novel 35 kDa Protein Synthesis in Lipopolysaccharide-Treated Rat (내독소처치 흰쥐에서 Tumor Necrosis Factor-$\alpha$치 상승에 따른 폐손상 악화 및 35 kDa 단백질 합성)

  • Choi, Young-Mee;Kim, Young-Kyoon;Kwon, Soon-Seog;Kim, Kwan-Hyoung;Moon, Hwa-Sik;Song, Jeong-Sup;Park, Sung-Hak
    • Tuberculosis and Respiratory Diseases
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    • v.45 no.6
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    • pp.1236-1251
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    • 1998
  • Background : TNF-$\alpha$ appears to be a central mediator of the host response to sepsis. While TNF-$\alpha$ is mainly considered a proinflammatory cytokine, it can also act as a direct cytotoxic cytokine. However, there are not so many studies about the relationship bet ween TNF-$\alpha$ level and lung injury severity in ALI, particularly regarding the case of ALI caused by direct lung injury such as diffuse pulmonary infection. Recently, a natural defense mechanism, known as the stress response or the heat shock response, has been reported in cellular or tissue injury reaction. There are a number of reports examining the protective role of pre-induced heat stress proteins on subsequent LPS-induced TNF-$\alpha$ release from monocyte or macrophage and also on subsequent LPS-induced ALI in animals. However it is not well established whether the stress protein synthesis such as HSP can be induced from rat alveolar macrophages by in vitro or in vivo LPS stimulation. Methods : We measured the level of TNF-$\alpha$, the percentage of inflammatory cells in bronchoalveolar lavage fluid, protein synthesis in alveolar macrophages isolated from rats at 1, 2, 3, 4, 6, 12, and 24 hours after intratracheal LPS instillation. We performed histologic examination and also obtained histologic lung injury index score in lungs from other rats at 1, 2, 3, 4, 6, 12, 24 h after intratracheal LPS instillation. Isolated non-stimulated macrophages were incubated for 2 h with different concentration of LPS (0, 1, 10, 100 ng/ml, 1, or 10 ${\mu}g/ml$). Other non-stimulated macrophages were exposed at $43^{\circ}C$ for 15 min, then returned to at $37^{\circ}C$ in 5% CO2-95% for 1 hour, and then incubated for 2 h with LPS (0, 1, 10, 100ng/ml, 1, or 10 ${\mu}g/ml$). Results : TNF-$\alpha$ levels began to increase significantly at 1 h, reached a peak at 3 h (P<0.0001), began to decrease at 6 h, and returned to control level at 12 h after LPS instillation. The percentage of inflammatory cells (neutrophils and alveolar macrophages) began to change significantly at 2 h, reached a peak at 6 h, began to recover but still showed significant change at 12 h, and showed insignificant change at 24 h after LPS instillation compared with the normal control. After LPS instillation, the score of histologic lung injury index reached a maximum value at 6 h and remained steady for 24 hours. 35 kDa protein band was newly synthesized in alveolar macrophage from 1 hour on for 24 hours after LPS instillation. Inducible heat stress protein 72 was not found in any alveolar macrophages obtained from rats after LPS instillation. TNF-$\alpha$ levels in supernatants of LPS-stimulated macro phages were significantly higher than those of non-stimulated macrophages(p<0.05). Following LPS stimulation, TNF-$\alpha$ levels in supernatants were significantly lower after heat treatment than in those without heat treatment (p<0.05). The inducible heat stress protein 72 was not found at any concentrations of LPS stimulation. Whereas the 35 kDa protein band was exclusively found at dose of LPS of 10 ${\mu}g/ml$. Conclusion : TNF-$\alpha$ has a direct or indirect close relationship with lung injury severity in acute lung injury or acute respiratory distress syndrome. In vivo and in vitro LPS stimulation dose not induce heat stress protein 72 in alveolar macrophages. It is likely that 35 kDa protein, synthesized by alveolar macrophage after LPS instillation, does not have a defense role in acute lung injury.

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The National Survey of Acute Respiratory Distress Syndrome in Korea (급성호흡곤란증후군의 전국 실태조사 보고)

  • Scientific Subcommittee for National Survey of Acute Respiratory Distress Syndrome in Korean Academy of Tuberculosis and Respiratory Disease
    • Tuberculosis and Respiratory Diseases
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    • v.44 no.1
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    • pp.25-43
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    • 1997
  • Introduction : The outcome and incidence of acute respiratory distress syndrome (ARDS) could be variable related to the varied definitions used for ARDS by researchers. The purpose of the national survey was to define the risk factors of ARDS and investigate the prognostic indicies related to mortality of ARDS in Korea according to the definition of ARDS determined by the American-European Concensus Conference on 1992 year. Methods : A Multicenter registry of 48 University or University-affliated hospital and 18 general hospital s equipped with more than 400 patient's beds conducted over 13 months of patients with acute respiratory distress syndrome using the same registry protocol. Results : 1. In the 12 months of the registry, 167 patients were enrolled at the 24 hospitals. 2. The mean age was 56.5 years (${\pm}17.2$ years) and there was a 1.9:1 ratio of males to females. 3. Sepsis was the most common risk factors (78.1%), followed by aspiration (16.6%), trauma (11.6%), and shock (8.5%). 4 The overall mortality rate was 71.9%. The mean duration was 11 days (${\pm}13.1$ days) from the diagnosis of ARDS to the death. Respiratory insufficiency appeared to be a major cause in 43.7% of the deaths followed by sepsis (36.1%), heart failure (7.6%) and hepatic failure (6.7%). 5. There were no significant differences in mortality based on sex or age. No significant difference in mortality in infectious versus noninfectious causes of ARDS was found. 6. There were significant differences in the pulse rate, platelet numbers, serum albumin and glucose levels, the amounts of 24 hour urine, arterial pH, $Pa0_2$, $PaCO_2$, $Sa0_2$, alveolar-arterial oxygen differences, $PaO_2/FIO_2$, and PEEP/$FI0_2$ between the survivors and the deaths on study days 1 through 6 of the first week after enrollment. 7. The survivors had significantly less organ failure and lower APACHE III scores at the time of diagnosis of ARDS (P<0.05). 8. The numbers of organ failure (odd ratio 1.95, 95% confidence intervals:1.05-3.61, P=0.03) and the score of APACHE III (odd ratio 1.59, 95% confidence interval:1.01-2.50, P=0.04) appeared to be independent risk factors of the mortality in the patients with ARDS. Conclusions : The mortality was 71.9% of total 167 patients in this investigation using the definition of American-European Consensus Conference on 1992 year, and the respiratory insufficiency was the leading cause of the death. In addition, the numbers of organ failure and the score of APACHE III at the time of diagnosis of ARDS appeared to be independent risk factors of the mortality in the patients with ARDS.

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A Study On Structural Stability Of Blast Door by Blast Pressure (폭압에 의한 방폭문의 구조적 안정성에 대한 연구)

  • Kim, Nam Hyuk;Park, Kwan Jin;Lee, Keun-Oh
    • Journal of the Korean Society of Safety
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    • v.31 no.3
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    • pp.8-15
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    • 2016
  • The purpose of this study is to design a model with the structural stability so as not to lose the operational function due to structural plastic or fail of a sliding blast door by blast pressure to this aim, a numerical simulation was performed using full-size experiments and M&S (Modeling & Simulation) of the sliding blast door. The sliding blast door ($W3,000{\times}H2,500mm$) under the blast load is in the form of a sliding type 2-way metal grill, which was applied by a design blast pressure (reflected pressure $P_r$) of 17 bar. According to the experimental results of a real sliding blast door under blast load, the blast pressure reached the sliding blast door approximately 4.3 ms after the explosion and lasted about 4.0 ms thereafter. The maximum blast pressure($P_r$) was 347.7 psi (2,397.3 kPa), it is similar to the UFC 3-340-02 of Parameter(91 %). In addition, operation inspection that was conducted for the sliding blast door after real test showed a problem of losing the door opening function, which was because of the fail of the Reversal Bolt that was installed to prevent the shock due to rebound of the blast door from the blast pressure. According to the reproduction of the experiment through M&S by applying the blast pressure measurement value of the full-size experiments, the sliding blast door showed a similar result to the full-size experiment in that the reversal bolt part failed to lose the function. In addition, as the pressure is concentrated on the failed reversal bolt, the Principal Tensile Failure Stress was exceeded in only 1.25 ms after the explosion, and the reversal bolt completely failed after 5.4 ms. Based on the result of the failed reversal bolt through the full-size experiment and M&S, the shape and size of the bolts were changed to re-design the M&S and re-analyze the sliding blast door. According to the M&S re-analysis result when the reversal bolt was designed in a square of 25 mm ($625mm^2$), the maximum pressure that the reversal bolt receives showed 81% of the principal tensile failure stress of the material, in plastic stage before fail.

Hsp90 Inhibitor Induces Cell Cycle Arrest and Apoptosis of Early Embryos and Primary Cells in Pigs

  • Son, Myeong-Ju;Park, Jin-Mo;Min, Sung-Hun;Hong, Joo-Hee;Park, Hum-Dai;Koo, Deog-Bon
    • Reproductive and Developmental Biology
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    • v.35 no.1
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    • pp.33-45
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    • 2011
  • Heat shock protein 90 (Hsp90) is ATPase-directed molecular chaperon and affects survival of cancer cell. Inhibitory effect of Hsp90 by inducing cell cycle arrest and apoptosis in the cancer cell was reported. However, its role during oocyte maturation and early embryo development is very insufficient. In this study, we traced the effects of Hsp90 inhibitor, 17-allylamino-17-demethoxygeldanamycin (17-AAG), on meiotic maturation and early embryonic development in pigs. We also investigated several indicators of developmental potential, including structural integrity, gene expression (Hsp90-, cell cycle-, and apoptosis-related genes), and apoptosis, which are affected by 17-AAG. Then, we examined the roles of Hsp90 inhibitor on viability of primary cells in pigs. Porcine oocytes were cultured in the NCSU-23 medium with or without 17-AAG for 44 h. The proportion of GV arrested oocytes was significantly different between the 17-AAG treated and untreated group (78.2 vs 34.8%, p<0.05). After completion of meiotic maturation, the proportion of MII oocytes was lower in the 17-AAG treated group than in the control group (27.9 vs 71.0%, p<0.05). After IVF, the percentage of penetrated oocytes was significantly lower in the 17-AAG treated group (25.2%), resulting in lower normal pronucleus formation (2PN of 14.6%). Therefore, the inhibition of meiotic progression by Hsp90 inhibitor played a critical role in fertilization status. Porcine embryo were cultured in the PZM-3 medium with or without 17-AAG for 6 days. In result, significant differences in developmental potential were detected between the embryos that were cultured with or without 17-AAG. Terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) showed that the number of containing fragmented DNA at the blastocyst stage increased in the 17-AAG treated group compared with control (7.5 vs 4.4, respectively). Blastocysts that developed in the 17-AAG treated group had low structural integrity and high apoptotic nuclei than those of the untreated control, resulting in decrease the embryonic qualities of preimplantation porcine blastocysts. The mRNA expressions of cell cycle-related genes were down-regulated in the 17-AAG treated group compared with control. Also, the expression of the pro-apoptotic gene Bax increased in 17-AAG treated group, whereas expression of the anti-apoptotic gene Bel-XL decreased. However, the expression of ER stress-related genes did not changed by 17-AAG. Cultured pESF cells were treated with or without 17-AAG and used for MIT assay. The results showed that viability of pESF cells were decreased by treatment of 17-AAG ($2{\mu}M$) for 24 hr. These results indicated that 17-AAG decreased cell proliferation and increased cell death. Expression patterns Hsp90 complex genes (Hsp70 and p23), cell cycle-related genes (cdc2 and cdc25c) and apoptosis-related genes (Bax and Bcl-XL) were significantly changed by using RT-PCR analysis. The spliced form of pXbp-1 product (pXbp-1s) was detected in the tunicamycin (TM) treated cells, but it is not detected in 17-AAG treated cells. In conclusion, Hsp90 appears to play a direct role in porcine early embryo developmental competence including structural integrity of blastocysts. Also, these results indicate that Hsp90 is closely associated with cell cycle- and apoptosis-related genes expression in developing porcine embryos.

Clinical Characteristics and Prognostic Factors of Severe Community-Acquired Pneumonia (중증 지역사회획득 폐렴의 임상상 및 예후 예측인자에 관한 연구)

  • Oh, Heung-Kook;Seo, Ji-Young;Kim, Dong-Kyu;Choi, Jeong-Eun;Mo, Eun-Kyung;Park, Myung-Jae;Lee, Myung-Goo;Hyun, In-Gyu;Jung, Ki-Suck
    • Tuberculosis and Respiratory Diseases
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    • v.44 no.5
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    • pp.1072-1082
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    • 1997
  • Background : To characterize the clinical features and determine the prognostic factors of severe community-acquired pneumonia. This study is the first of its kind in Korea. Methods : Recruited were 40 patients diagnosed as severe community-acquired pneumonia in Hallym University Hospital from January 1, 1989 through July 31, 1996. Patients were analysed retrospectively for age, sex, underlying disease, respiration rate, hypoxemia, requirement of mechanical ventilation, involvement on chest radiograph, shock, and the serum concentration of BUN and albumin. All parameters were compared between survived and dead group. Results : Male to female ratio was 2.07 : 1. The mean age was $63.1{\pm}17.5$years(range 25~90years) with 65% of patients aged equal to or more than 60. The major underlying diseases were old pulmonary tuberculosis(12.5%), chronic obstructive pulmonary disease(7.5%), bronchial asthma(5%), bronchiectasis(2.5%), and diabetes mellitus(22.5%). Microbiologic diagnosis was made in 26 out of 40 patients(65%). The most common causative organism was S. pneumoniae(17.5%, 7/40) followed by S. aureus(15.0%, 6/40), K. Pneumoniae(12.5%, 5/40), M. tuberculosis(7.5%, 3/40), H. influenzae(2.5%, 1/40), coagulase negative staphylococcus(2.5%, 1/40), P. aeruginosa(2.5%. 1/40), E. cloaceae(2.5%, 1/40), and E. coli(2.5%, 1/40). M. pneumoniae was detected in no patient. The most frequent drugs administered in single or combination therapy were aminoglycosides(75%, 30/40), second- and third-generation cephalosporin(40%, 16/40 and 27.5%, 11/40), macrolides(27.5%, 11/40), and amoxicillin/clavulanic acid(22.5%, 9/40). Of the 40 patients, 14 died of severe community-acquired pneumonia(37.5%). Among them, seven patients (50%) expired within 72h of hospital arrival. According to multivariate analysis, mortality was significantly associated with requirement of mechanical ventilation, bilateral pulmonary involvement, and serum albumins$\leq$3.0g/dl. Conclusion : An understanding of the clinical characteristics and prognostic factors in severe community-acquired pneumonia identified in this study will optimize therapeutic approach in this disease and help decreasing its notorious mortality rate.

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Concise Bedside Surgical Management of Profound Reperfusion Injury after Vascular Reconstruction in Severe Trauma Patient: Case Report

  • Chung, Hoe Jeong;Kim, Seong-yup;Byun, Chun Sung;Kwon, Ki-Youn;Jung, Pil Young
    • Journal of Trauma and Injury
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    • v.29 no.4
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    • pp.204-208
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    • 2016
  • For an orthopaedic surgeon, the critical decisions to either amputate or salvage a limb with severe crushing injury with progressive ischemic change due to arterial rupture or occlusion can become a clinical dilemma at the Emergency Department (ED). And reperfusion injury is one of the fetal complications after vascular reconstruction. The authors present a case which was able to save patient's life by rapid vessel ligation at bedside to prevent severe reperfusion injury. A 43-year-old male patient with no pre-existing medical conditions was transported by helicopter to Level I trauma center from incident scene. Initial result of extended focused assessment with sonography for trauma (eFAST) was negative. The trauma series X-rays at the trauma bay of ED showed a multiple contiguous rib fractures with hemothorax and his pelvic radiograph revealed a complex pelvic trauma of an Anterior Posterior Compression (APC) Type II. Lower extremity computed tomography showed a discontinuity in common femoral artery at the fracture site and no distal run off. Surgical finding revealed a complete rupture of common femoral artery and vein around the fracture site. But due to the age aspect of the patient, the operating team decided a vascular repair rather than amputation even if the anticipated reperfusion time was 7 hours from the onset of trauma. Only two hours after the reperfusion, the patient was in a state of shock when his arterial blood gas analysis (ABGA) showed a drop of pH from 7.32 to 7.18. An imminent bedside procedure of aseptic opening the surgical site and clamping the anastomosis site was taken place rather than undergoing a surgery of amputation because of ultimately unstable vital sign. The authors would like to emphasize the importance of rapid decision making and prompt vessel ligation which supply blood flow to the ischemic limb to increase the survival rate in case of profound reperfusion injury.