Through experiments performed in vivo, using a water-soluble, less toxic hsp90-specific inhibitor, 17-DMAG, we show that hsp90 inhibition decreases proinflammatory cytokine production and alleviates LPS-induced liver injury. Previous limitations for in vivo use of geldanamycin and its derivatives have been their dose-limiting toxicity, leading to weight loss, hematologic, hepatic, and renal toxicity, and cell death.38, 39 Pharmacodynamic studies showed that the medium tolerated dose of 17-DMAG in vivo is 75 mg/kg with minimal toxicity.40, 41 Here, we used a single dose of 17-DMAG, ranging from 2.5 mg/kg to 30

mg/kg, with less concern Bafilomycin A1 research buy for nonspecific or toxic effects. Our data here suggest hsp90 as an attractive therapeutic target in liver diseases. Although

inhibitors of hsp90 were primarily identified for their therapeutic importance in cancer, their role in inflammatory diseases,42 such as rheumatoid arthritis,28 endotoxin-mediated uveitis,18 sepsis,43 and atherosclerosis,44, 45 is emerging. Because LPS-mediated this website inflammatory responses are crucial to the development of liver diseases, strategies that prevent this response in the liver could have a beneficial effect. The inhibitory function of hsp90 inhibitors on liver inflammatory responses could be a dual mechanism: either loss of client proteins resulting (-)-p-Bromotetramisole Oxalate from loss of chaperone function19, 21 or induction of anti-inflammatory transcription factor HSF1 and hsp70 expression.46 Here, we report that inhibition of hsp90 in the liver induces HSF1 and inhibits LPS-induced NFκB activation and proinflammatory cytokine production, thereby alleviating liver injury (Fig. 8). The chaperone function of

hsp90 on LPS-signaling intermediates explains its effect on the expression of down-stream proinflammatory cytokines. In this context, 17-DMAG could affect the transcription of cytokine genes and their production. We observed that the proinflammatory cytokines, TNFα and IL-6, were significantly inhibited, both at the mRNA and protein level, in whole livers treated with 17-DMAG and LPS. Concomitant reduction of serum TNFα and IL-6 paralleled the liver cytokine profile. We predict that hsp90 inhibition in the liver alters LPS-signaling events proximal to proinflammatory cytokine gene transcription. The transcription factor, NFκB, is a key downstream signaling intermediate of the LPS receptors, CD14 and TLR4. Earlier studies showed that 17-DMAG reduces NFκB activity in respiratory epithelial cells,47 either directly or through inhibition of upstream the LPS receptors, CD14 and TLR4.14 Hsp90 associates with the LPS receptor complex,14 and its inhibition decreases CD14 expression.48 Our results showed significant down-regulation in CD14 mRNA without changes in TLR4 mRNA in the liver.

Such varices are less effective in lowering the portal pressure, compared with esophageal and gastric varices. The serosal and submucosal location of DV, limits visualization during endoscopy. Their clinical significance is not apparent until the varix expands into the submucosal space where Selleckchem Ixazomib it can hemorrhage into the gastrointestinal lumen. Because of the infrequency of DV hemorrhage, treatment modalities have not been prospectively validated. These include surgical intervention (variceal ligation, duodenal resection, and extra-hepatic portosystemic shunt creation), interventional radiological procedures (tranjugular intrahepatic portosystemic shunt, percutaneous transhepatic obliteration, trans-ileocolic vein obliteration,

balloon occluded retrograde transvenous obliteration),

and endoscopic techniques (band ligation, sclerotherapy and clipping). Contributed by “
“The migration of foreign bodies into the biliary system has been well-described in the medical literature. One example is the migration of sutures or clips that are placed on the cystic duct stump at the time of cholecystectomy. It seems likely that these buy Roscovitine often pass spontaneously into the duodenum. However, if they remain within the bile duct, they can act as a nidus for further stone formation. Other reports have documented the migration of sutures or clips into the bile duct after various forms of hepatic surgery. In this report, we describe the migration of hepatic coils Thymidine kinase into the bile duct that were used to treat a pseudoaneurysm

of a branch of the right hepatic artery. A woman, aged 77, was admitted to hospital with cholangitis caused by stones in the bile duct. The initial management was that of percutaneous transhepatic biliary drainage. Three weeks after placement of the drain, she developed hemobilia with bleeding into the duodenum and out through the transhepatic drain. Hepatic arteriography showed a large pseudoaneurysm that was located in a branch of the right hepatic artery close to the transhepatic drain (Figure 1, arrows). This was treated by the placement of six coils within the pseudoaneurysm and five microcoils within the hepatic artery branch supplying the aneurysm. Thereafter, bleeding ceased and the patient was subsequently treated by open cholecystectomy, exploration of the bile duct and choledochoduodenostomy. Three years after surgery, she was readmitted with a 2-month history of intermittent biliary-type pain. A plain abdominal x-ray (Figure 2, left) showed air within the bile duct as a result of the choledochoduodenostomy. The microcoils were still in place (white arrow) but only one stainless steel coil remained and it had “unravelled” within the bile duct (black arrow). This compares with the radiological appearance at the completion of hepatic angiography where microcoils are shown with the white arrow and six stainless steel coils are highlighted with the black arrow (Figure 2, right).

Therefore, it can be hypothesized that treatment strategies aimed at reducing daytime sleepiness may also lead to an improvement in night sleep architecture in these patients. The two case reports confirmed that HE is associated with prominent, reversible changes of both wake and nap EEG structure. Interestingly, in these two cases the HE-related sleep EEG changes were particularly prominent within the sleep spindle range, an area of the spectrum that was only moderately affected by the AAC. Similar findings have been

reported once before in a group of patients with overt HE.10 Clearly, differences are to be expected between the electrophysiological profile of full-blown, spontaneous or TIPS-related overt HE and AAC-related hyperammonemia because Compound Library the latter is only a model of the former, it is not meant to induce severe neuropsychiatric dysfunction and it is not necessarily accompanied by the degree of hepatic failure and/or

the precipitants which are associated with spontaneous Selleck Pembrolizumab HE. In conclusion, profound changes were observed in response to the AAC in clinical (subjective sleepiness), wake and nap EEG indices, suggesting that such techniques are exquisitely sensitive to ammonia levels, which have limited neuropsychiatric/neuropsychological correlates. These findings have important clinical implications: (1) subjective sleepiness may be a useful surrogate marker of HE; (2) correction of excessive daytime sleepiness, either by pharmacological or chronotherapeutic see more strategies, may also result in improved night sleep. We thank all study participants

for their patient and cheerful cooperation. We thank Professor Carlo Merkel, University of Padua, for helpful discussions on the article and constant support. “
“HCC, hepatocellular carcinoma; HCV, hepatitis C virus; PBMC, peripheral blood mononuclear cell; SVR, sustained virologic response. About 10% to 45% of persons who develop acute hepatitis C recover spontaneously, signaled by improved symptoms, normalized liver-related chemistries, loss of hepatitis C virus (HCV) RNA from serum, and the development of hepatitis C antibody.1 If spontaneous recovery should happen, it is always within 6 months of the acute infection and almost never beyond that time, when the disease is now regarded as chronic hepatitis C. At this point, viral loss occurs only if treatment is successful. Currently being debated is whether spontaneous and treatment-induced conversion from detectable to nondetectable serum HCV RNA establishes cure of the infection and the resulting liver disease.

After 7 d, the secreted mucilage became entangled, forming adhesive strands that crisscrossed the substratum surface. In the initial secreted Tyrosine Kinase Inhibitor Library manufacturer mucilage atomic force microscopy identified a high proportion of adhesive molecules without regular retraction curves and some modular-like adhesive molecules, in the 7 d old biofilm, the adhesive molecules were longer with fewer adhesive events but greater adhesive strength. Chemical characterization was carried out

on extracted proteins and polysaccharides. Differences in protein composition, monosaccharide composition, and linkage analysis are discussed in relation to the composition of the frustule and secreted adhesive mucilage. Polysaccharide analysis showed a broad range of monosaccharides and linkages across all fractions with idiosyncratic enrichment of particular monosaccharides and linkages in each fraction. 3-linked Mannan was highly enriched in the cell frustule fractions

indicating a major structural role, while Rhamnose and Fucose derivatives selleck inhibitor were enriched in the secreted fractions of the ovoid morphotype suggesting involvement in cell adhesion. Comparison of SDS-PAGE of extracellular proteins showed two major bands for the ovoid morphotype and four for the fusiform morphotype of which only one appeared to be common to both morphotypes. “
“Measuring qualitative traits of plant tissue is important to understand how plants respond to environmental change and biotic interactions. Near infrared reflectance spectrometry (NIRS) is a cost-, time-, and sample-effective method of measuring

chemical components in organic samples commonly used in the agricultural and pharmaceutical industries. To assess the applicability of NIRS to measure the ecologically important tissue traits of carbon, nitrogen, and phlorotannins (secondary metabolites) in brown algae, we developed NIRS calibration models for these constituents in dried Sargassum flavicans (F. K. Mertens) C. Agardh tissue. 5-FU concentration We then tested if the developed NIRS models could detect changes in the tissue composition of S. flavicans induced by experimental manipulation of temperature and nutrient availability. To develop the NIRS models, we used partial least squares regression to determine the statistical relationship between trait values determined in laboratory assays and the NIRS spectral data of S. flavicans calibration samples. Models with high predictive power were developed for all three constituents that successfully detected changes in carbon, nitrogen, and phlorotannin content in the experimentally manipulated S. flavicans tissue. Phlorotannin content in S.

A total of 198 patients with dyspeptic symptoms were included in the study. A gastric biopsy was collected for histopathology and rapid urease testing. Stool specimens for HpSA testing were also collected. Patients were considered H. pylori positive if two invasive tests (histological and rapid urease tests) were positive. The sensitivity see more and specificity were 92.2% and 94.4%, respectively, for the Premier Platinum HpSA Plus test; 48.9% and 88.9%, respectively, for the HP Ag test; 86.7% and 88.9, respectively, for the

One Step HpSA test; 68.9% and 92.6%, respectively, for the ImmunoCard STAT! HpSA test; and 78.9% and 87%, respectively, for the H. Pylori fecal antigen test. The Premier Platinum HpSA Plus EIA test was determined to be the most accurate stool test for diagnosing H. pylori infections in adult dyspeptic patients. The currently available ICA-based tests are fast and easy to use but provide less reliable results. “
“The heterogeneity of hepatitis C virus (HCV) infection cannot always be explained by HCV genotypes or

host genetic factors, raising the issue of possible cofactors. A new form of hepatitis leading to liver cancer was discovered in 1992 in mice, owing to an infection by Helicobacter hepaticus. Moreover, several studies showed an association between the presence of HCV and Helicobacter in the liver of patients with severe liver diseases suggesting a possible synergism between https://www.selleckchem.com/products/azd9291.html the two pathogens. In an HCV transgenic mouse model with a B6C3F1 background, C-X-C chemokine receptor type 7 (CXCR-7) the combination of H. hepaticus infection and the HCV transgene resulted in a significantly greater incidence and multiplicity of preneoplastic and neoplastic liver foci in males. Because the mouse genetic background is a major determinant in the development of liver disease,

our aim was to test the synergism between HCV and H. hepaticus infection using transgenic mice with a more sensitive genetic background to H. hepaticus infection. For this purpose, four groups of mice were followed up to 14 months, the presence of H. hepaticus was monitored by PCR and hepatic lesions were looked for. We found that H. hepaticus, but not the HCV transgene, increased the number of hepatic lesions. The presence of carcinoma was more likely to occur on a background of hepatitis, and the overall lesions were more frequent in the presence of steatosis. The effect of the mouse genetic background was greater than the effect of the HCV transgene and was sufficient to promote lesions particularly via its sensitivity to H. hepaticus infection. Genetic susceptibility may be a more important factor than expected. Indeed, the synergism between HCV and H. hepaticus infection involved in liver disease may be highly host dependent. “
“Background:  Although gastric cancer (GC) and duodenal ulcer (DU) are both strongly associated with Helicobacter pylori infection, a DU is negatively associated with the risk of GC.

[27] This may explain the proangiogenesis potential by SIRPα-KD Mψ in tumor-bearing models. Moreover, it is reported that SIRPα is required in T- and NK-cells homeostasis in vivo, indicating an important role of SIRPα in immunomodulation.[28, 29] Nevertheless, further investigation is required to determine the role of SIRPα in Mψ crosstalking with other immune cells in the tumor microenvironment. The mechanisms contributing to the reduction of SIRPα on monocytes/Mψ in response to tumor are not yet well elucidated. Although soluble factors in the tumor microenvironment, such as TNFα, could decrease SIRPα expression GDC-941 on Mψ, specific anti-TNFα neutralization antibody only

partially reversed Hepa1-6-induced reduction of SIRPα with a concentration of antibody that effectively neutralized TNFα in the coculture system (Supporting Fig. 6A). To determine whether tumor PLX4032 cell-induced SIRPα reduction was attributable to an increased

rate of protein degradation, we examined the effects of inhibitors of protein degradation by lysosomes or the proteasome. MG132, a reagent that blocks proteasome activity, had no marked effect on the ability of tumor cells to suppress SIRPα expression. In contrast, preincubation of macrophages with dexamethasone, chloroquine, or NH4Cl, all of which inhibit lysosomal function, markedly attenuated the effect of tumor cell-induced SIRPα reduction Rucaparib manufacturer (Supporting Fig. 6B). Confocal assay showed that, in response to Hepa1-6 stimulation, SIRPα proteins translocated from cell membrane to the cytosolic fraction and mainly localized on lysosomes (Supporting Fig. 6C). Taken together, these data suggest that, in addition to transcriptional repression of SIRPα expression (Supporting Fig. 2A), tumor cells

also induce SIRPα protein degradation mainly by lysosome, which contributes to the loss of SIRPα proteins in macrophages after tumor cells stimulation. SIRPα-CD47 interactions serve as a “don’t eat me” and “self-recognized” signaling.[30] Many reports have demonstrated that the SIRPα-CD47 signaling pathway could be a therapeutic target for human tumors.[18, 30, 31] This may due to enhanced phagocytic capability of Mψ against tumor cells when treated with anti-CD47 antibodies. One problem with these series researches is that CD47-IgG antibody may not only disrupt SIRPα-CD47 interaction but also target the tumor cells by antibody-dependent cellular cytotoxicity (ADCC) or antibody-dependent phagocytosis.[32] Another problem is that most of the experiments were performed on a xenograft tumor model, which may not exactly meet the role of SIRPα in syngeneic models. It was demonstrated that additional activating signals, such as Fcγ or complement-receptor ligation, are required for Mψ-mediated phagocytosis of target cells in the absence of SIRPα-dependent inhibition.

We next verified by IF whether CD41H MKPs from FL expressed the hepatocyte nuclear factors (HNFs), HNF-1, HNF-3β, and HNF-4α, which are essential for the expression of most hepatocyte genes. In preparations Roxadustat cost from unpurified E11.5 FL cells, and from purified c-KitDCD45−

and CD49fHCD41H cells, there was only a weak punctuate nuclear HNF-4α and HNF-1 signal in CD41H cells (Fig. 5A and Supporting Fig. 5), and no staining for HNF-3β was observed (not shown). By contrast, brighter homogeneous signals were detected in the nuclei of CD49fDCD41− cells. In addition, no surface expression of hepatic glucose transporter type 2 (GLUT2) was detected in CD49fHCD41H MKPs (Fig. 5B). Therefore, the ALB protein detected in CD49fHCD41H MKPs from the E11.5 FL is most probably

accumulated by endocytosis. To further clarify the relationship between FL MKPs and HeP, the Dlk/CD13 markers used to define liver stem/progenitor cells17 were analyzed on electronically gated CD49fHCD41H and CD49fD cells from FL (Fig. 5C,D). We found that CD49fD cells contained most Dlk+CD13+ cells (1,291 ± 389 cells/FL), whereas CD49fHCD41H MKPs contained only 62.5 ± 9.8 cells/FL (n = 10) of Dlk+ cells. Taken together, BMS-907351 ic50 these results reinforce the idea that FL CD49fHCD41H MKPs are distinct to HeP, even though they share some characteristics of hepatoepithelial and endothelial cells. The c-KitDCD45− population contained HeP that can establish hepatoepithelial layers in vitro.10 Because the subpopulation of CD49fH CD41H cells present in the c-KitDCD45− HeP appear to belong to the MK lineage, and the remaining CD49fD cells express hepatoepithelial transcripts and contain Dlk+CD13+ cells, we reasoned that these CD49fD cells may represent

the true HeP present in the FL at E11.5. To investigate this hypothesis, we cultured purified c-KitDCD45−CD49fD (CD49fD) cells after removing c-KitDCD45−CD49fH (CD49fH) cells by FACS. In the absence of the CD49fH population, CD49fD cells could not grow in culture on any of the substrates tested (uncoated, collagen I, laminin, or fibronectin), and after 3 days in culture, most of them adopted a small, round appearance of VAV2 apoptotic cells (Supporting Fig. 6). When CD49fH cells were seeded along with CD49fD cells, the mix of the purified subpopulations formed hepatoepithelial layers, as did cultures of total purified c-KitDCD45− cells (Fig. 6A). These cultured cells expressed HNF-4α (Supporting Fig. 6). We concluded that the presence of CD49fHCD41H MKPs was required for CD49fD HeP to grow in vitro. To determine whether this process was mediated by direct cell-to-cell contacts or by soluble factors, we cultured the purified CD49fH and CD49fD populations in transwells (Fig. 6B). Again, epithelial layers developed when both subpopulations were grown together in the upper chamber of transwell plates.

For Scenario 1, SVR rates gradually increased to 90% (G1/2/4) and 80% (G3) by 2016. In the same time frame, treatment eligibility was increased to 95% for all genotypes.

Liver fibrosis stage was not considered in determining eligibility. The 2013 values for annual treated and newly diagnosed populations were held constant (Fig. 4). Scenario 2 included the same SVR and treatment eligibility increases as Scenario 1. In addition, the annual number of people treated gradually check details increased to 13 500 by 2018, and treatment was extended to individuals up to age 74 years (Fig. 4). Scenario 3 included the same events as outlined for Scenario 2. In addition, treatment restriction based on fibrosis score was considered. Restricting treatment to people with fibrosis scores of either ≥ F3 or ≥ F2 during 2013–2030 resulted in an insufficient number of eligible people to accommodate see more increases in the treated population. Instead, an approach was used where treatment was limited to people with fibrosis stages ≥ F3 beginning in 2014 and then was expanded to all patients (≥ F0) beginning in 2018 (Fig. 4).

With the base case, there were an estimated 233 490 (183 690–248 700) people with chronic HCV in 2013 (Fig. 2a); the median age was 49 years (Fig. 2b). Within this population, liver disease stage estimates were 154 700 (66%) for F0/1, 32 840 (14%) for F2, 29 770 (13%) for F3, 13 850 (6%) for compensated cirrhosis, 1430 (0.6%) for decompensated cirrhosis, and 590 for HCC (0.2%). In 2013, an estimated 530 people with chronic HCV died from HCV-related liver disease. The prevalence of chronic HCV peaks at 255 500 in 2025 and declines to 251 970 by 2030. There will be 38 130 people with compensated cirrhosis in 2030 compared with 13 850

in 2013 (Fig. 2c). In addition, there will be 2040 cases of HCC and 4170 people with Thiamet G decompensated cirrhosis by 2030 compared with 590 and 1430 in 2013. Liver-related deaths in 2030 will number 1740 compared with 530 in 2013 (Fig. 5f). In 2013, 7% of people with chronic HCV are estimated to have compensated cirrhosis or more-advanced liver disease (decompensated cirrhosis, HCC, or liver transplantation) while this proportion will increase to 18% in 2030. Costs are projected to increase from $224 million for the year 2013 to $305 million/year by 2030 (Fig. 2a). Total cumulative costs (2013–2030) are estimated at $4934 million. In 2013, 23% of costs were incurred among people with cirrhosis or advanced liver disease; the proportion is projected to increase to 50% by 2030 (Fig. 2d). The estimated lifetime cost for a male aged 30–34 years organized by disease state in 2013 is shown in Figure 3. Costs generally increased with HCV disease progression. However, lifetime cost associated with HCC was relatively low due to high mortality. With this scenario (Fig.

(Hepatology 2014;60:158–168)

“
“Gastroesophageal variceal hemorrhage is an important complication of cirrhosis. We investigated the in-hospital mortality and its risk factors after variceal hemorrhage in a large sample population, using a nationwide Japanese database. Data on the patients with variceal hemorrhage were collected for a total of 39 months from a nationwide administrative database covering approximately 1000 hospitals in Japan. The risk factors for fatal outcome after variceal hemorrhage were analyzed with receiver–operator curves (ROC) and univariate and multivariate logistic regression. Comorbidities were assessed with the Charlson Comorbidity Index. selleck inhibitor We identified 9987 patients with variceal hemorrhage from a total of 20.3 million inpatients in the database. The median age was 63 years and 68.8% were male. The overall in-hospital mortality was 16.8% (1676 cases). In univariate analysis, Child–Pugh class was the strongest predictor; the area under the ROC of Child–Pugh score for predicting in-hospital mortality was 0.802. In multivariate analysis, increased in-hospital mortality was significantly associated with male sex (vs female: odds ratio [OR] = 1.19, P = 0.01), older age, Child–Pugh class B or C (B vs A: OR = 2.80, P < 0.001; C vs A: OR = 20.1, P < 0.001) and higher Charlson Comorbidity Decitabine supplier Index (≥6 vs ≤5; OR = 1.29, P < 0.001). In spite

of recent advances in the treatment of variceal hemorrhage, the in-hospital mortality remained as high as 16%. Poor liver function was the most important predictor, suggesting that liver failure after variceal hemorrhage might have been the cause of death. “
“Although cancer patients exhibit a generalized immunosuppressive

status, substantial evidence indicates that the inflammatory reaction at a tumor site can promote tumor growth and progression. Hepatocellular carcinoma (HCC) is usually derived from inflamed cirrhotic liver with extensive leukocyte infiltration. We recently found that proinflammatory T helper (Th)17 cells are accumulated in HCC tissue, where they promote disease progression by fostering angiogenesis. Here we show that interleukin (IL)-17-producing cells were enriched predominantly in peritumoral stroma of HCC tissues, and their levels were well correlated with monocyte/macrophage density in the same area. Most peritumoral CD68+ cells C59 exhibited an activated phenotype. Accordingly, tumor-activated monocytes were significantly superior to the suppressive tumor macrophages in inducing expansion of Th17 cells from circulating memory T cells in vitro with phenotypic features similar to those isolated from HCCs. Moreover, we found that tumor-activated monocytes secreted a set of key proinflammatory cytokines that triggered proliferation of functional Th17 cells. Inhibition of monocytes/macrophages inflammation in liver markedly reduced the level of tumor-infiltrating Th17 cells and tumor growth in vivo.

In the first of these studies, Mattsson evaluated 684 peri- and postmenopausal women between 40 and 74 years of age, with a mean age of 54 (Table 5).33 Importantly, this was the first general population study to use both ICHD criteria for the diagnosis of migraine and to estimate TBO using measured body mass indices. Neither migraine prevalence nor migraine attack frequency was associated with TBO.33 In the second study of peri- and post menopausal women, Winter et al evaluated

over 63,000 women 45 years of age or older, with a mean age of 54, (Table 5).34 The diagnosis of migraine was evaluated using self-reported information in a manner previously shown to correlate well with ICHD criteria.35 TBO was evaluated using self-reported check details Selleckchem AZD2281 height and weight. Two important findings were noted. First, although an age-adjusted increased relative risk for the prevalence of migraine was found in those with a BMI ≥ 35, adjustment for major cardiovascular risk factors and postmenopausal status completely attenuated this association. This finding supports results from Mattsson et al that there is no association between migraine prevalence and obesity in peri- and postmenopausal women. Second, the

Winter et al data support the findings from Bigal et al suggesting that the association between BMI and migraine frequency may be J-shaped. Compared with women with a BMI of 27 and 29, the relative odds of having daily migraine attacks was over 3-fold increased for women with active migraine and a BMI of ≥ 35; in addition there was an over 2-fold increase for women with active migraine and a BMI of <23.34 The third general

population study evaluating the association between migraine and TBO also evaluated older men and evaluated the prevalence of migraine and severe headaches in those older individuals with abdominal obesity.14 As in the previous studies, Peterlin et al found that TBO was not associated with migraine prevalence in older women and extended this MRIP finding to older men (Table 5). However, abdominal obesity was associated with a 26% decreased odds of migraine or severe headache in women (OR 74; CI: 0.58-0.94), a finding independent of TBO. These results may suggest that the sexual dimorphism and aging-related changes in the metabolic function of adipose tissue, such as seen with cardiovascular disease or all cause mortality or a survivorship bias may play a role in the obesity–migraine relationship.14 Further studies using ICHD criteria and measured body mass indices are needed. 1 Migraine prevalence is not associated with TBO in older women and men.