Bone morphogenetic proteins inhibit adipocyte differentiation by bone marrow stromal cells

Adipogenic differentiation of human mesenchymal stromal cells is down-regulated by microRNA-369-5p and up-regulated by microRNA-371

Long-term culture of human mesenchymal stromal cells (MSC) has implications on their proliferation and differentiation potential and we have demonstrated that this is associated with up-regulation of the five microRNAs miR-29c, miR-369-5p, miR-371, miR-499, and let-7f. In this study, we examined the role of these senescence-associated microRNAs for cellular aging and differentiation of MSC. Proliferation was reduced upon transfection with miR-369-5p, miR-371, and miR-499. Adipogenic differentiation was impaired by miR-369-5p whereas it was highly increased by miR-371. This was accompanied by respective gene expression changes of some adipogenic key molecules (adiponectin and fatty acid-binding protein 4 [FABP4]). Furthermore luciferase reporter assay indicated that FABP4 is a direct target of miR-369-5p. Microarray analysis upon adipogenic or osteogenic differentiation revealed down-regulation of several microRNAs albeit miR-369-5p and miR-371 were not affected. Expression of the de novo DNA methyltransferases DNMT3A and DNMT3B was up-regulated by transfection of miR-371 whereas expression of DNMT3A was down-regulated by miR-369-5p. In summary, we identified miR-369-5p and miR-371 as antagonistic up-stream regulators of adipogenic differentiation and this might be indirectly mediated by epigenetic modifications.

Differentiation of human mesenchymal stem cells: the potential mechanism for estrogen-induced preferential osteoblast versus adipocyte differentiation

INTRODUCTION

Bone marrow-derived mesenchymal stem cells (MSCs) are capable of differentiating into osteoblasts and adipocytes. This critical balance between osteoblast and adipocyte differentiation plays a significant role in maintaining normal bone homeostasis. In osteoporosis, a metabolic bone disease seen mainly in postmenopausal women because of estrogen deficiency, the concomitant occurrence of increased bone marrow adipocyte production with diminished production of osteoblasts, points to the potential role of estrogen in shifting the balance of MSC differentiation.

METHODS

We established an in vitro differentiation model of isolated human MSCs (hMSCs) and examined the role of distinct estrogen signaling pathways in regulating the differentiation of hMSCs.

RESULTS

Estrogen promoted the differentiation of hMSCs to osteoblasts in contrast to adipocytes, the former of which was mediated through the PI3K/SSH1L but not the mitogen-activated protein kinase pathway.

CONCLUSION

This study provides a novel mechanistic understanding of estrogen-related osteoporosis and identifies potential targets for antiosteoporosis therapies.

Identification of multipotent stem/progenitor cells in murine sclera

PURPOSE

The sclera forms the fibrous outer coat of the eyeball and acts as a supportive framework. The purpose of this study was to examine whether the sclera contains mesenchymal stem/progenitor cells.

METHOD

Scleral tissue from C57BL6/J mice was separated from the retina and choroid and subsequently enzyme digested to release single cells. Proliferation capacity, self-renewal capacity, and ability for multipotent differentiation were analyzed by BrdU labeling, flow cytometry, reverse transcriptase-polymerase chain reaction, immunocytochemistry, and in vivo transplantation.

RESULTS

The scleral stem/progenitor cells (SSPCs) possessed clonogenic and high doubling capacities. These cells were positive for the mesenchymal markers Sca-1, CD90.2, CD44, CD105, and CD73 and negative for the hematopoietic markers CD45, CD11b, Flk1, CD34, and CD117. In addition to expressing stem cell genes ABCG2, Six2, Notch1, and Pax6, SSPCs were able to differentiate to adipogenic, chondrogenic, and neurogenic lineages.

CONCLUSIONS

This study indicates that the sclera contains multipotent mesenchymal stem cells. Further study of SSPCs may help elucidate the cellular and molecular mechanism of scleral diseases such as scleritis and myopia.

Nuttall M, M. Gimble J. Fine-Tuning Reception in the Bone: PPARgamma and Company

PPARgamma plays a central role in the formation of fat. Regulation of PPARgamma activity depends on numerous factors ranging from dietary ligands to nuclear hormone coactivators and corepressors to oxygen-sensing mechanisms. In addition, the interplay of PPARgamma with other nuclear hormone receptors has implications for the balance between adipogenesis and osteogenesis in mesenchymal stem cells of the bone marrow stroma. This review will explore a range of factors influencing PPARgamma activity and how these interactions may affect osteogenesis.

Nasal septum-derived multipotent progenitors: a potent source for stem cell-based regenerative medicine

Thus far, autologous adult stem cells have attracted great attention for clinical purposes. In this study, we aimed at identifying and comprehensively characterizing a subpopulation of multipotent cells within human nasal septal cartilage. We also conducted a comparative investigation with other well-established stem cells such as bone marrow-mesenchymal stem cells, adipose tissue-mesenchymal stem cells, and unrestricted somatic stem cells. The isolated clonal population was characterized using immunofluorescence, flow cytometry, reverse transcriptase, and real-time polymerase chain reaction. Nasal septal progenitors (NSP) expressed critical pluripotency and mesoectodermal stem cell markers. They also shared many characteristics with MSC in expression of CD90, CD105, CD106, CD166, and HLA-ABC and lack of expression of CD34, CD45, and HLA-DR. NSP distinctly presented CD133 (Prominin-1). These cells could proliferate rapidly in vitro with a higher clonogenic potential and showed a longer lifespan than other studied cells. This population bears some other multipotent properties in showing a high capacity to be differentiated into other lineages including chondrocytes, osteocytes, and neural-like cell types. Another strong/positive feature of this population was their ability to be safely expanded ex vivo with no susceptibility to chromosomal abnormality or tumorigenicity both in vitro and in vivo. In conclusion, NSP could be considered as an alternative autologous cell source that can bring them to the top of therapeutic applications.

Emerging roles for the transforming growth factor-{beta} superfamily in regulating adiposity and energy expenditure

Members of the TGF-β superfamily regulate many aspects of development, including adipogenesis. Studies in cells and animal models have characterized the effects of superfamily signaling on adipocyte development, adiposity, and energy expenditure. Although bone morphogenetic protein (BMP) 4 is generally considered a protein that promotes the differentiation of white adipocytes, BMP7 has emerged as a selective regulator of brown adipogenesis. Conversely, TGF-β and activin A inhibit adipocyte development, a process augmented in TGF-β-treated cells by Smads 6 and 7, negative regulators of canonical TGF-β signaling. Other superfamily members have mixed effects on adipogenesis depending on cell culture conditions, the timing of expression, and the cell type, and many of these effects occur by altering the expression or activities of proteins that control the adipogenic cascade, including members of the CCAAT/enhancer binding protein family and peroxisome proliferator-activated receptor-γ. BMP7, growth differentiation factor (GDF) 8, and GDF3 are versatile in their mechanisms of action, and altering their normal expression characteristics has significant effects on adiposity in vivo. In addition to their roles in adipogenesis, activins and BMP7 regulate energy expenditure by affecting the expression of genes that contribute to mitochondrial biogenesis and function. GDF8 signals through its own receptors during adipogenesis while antagonizing BMP7, an example of a ligand from one major branch of the superfamily regulating the other. With such intricate relationships that ultimately affect adiposity, TGF-β superfamily signaling holds considerable promise as a target for treating human obesity and its comorbidities.

HIV type 1 alters mesenchymal stem cell differentiation potential and cell phenotype ex vivo

An increased incidence of bone and lipid toxicities is associated with HIV-1 infection and its treatment. Mesenchymal stem cells (MSCs) are multipotent cells that can differentiate into both osteoblasts (OB) and adipocytes (AC). We hypothesize that the interaction of MSC and HIV-1 underlie these toxicities. Serum was collected from uninfected control and HIV-infected, antiviral-naive patients. Sera were divided into three groups: HIV-negative sera (n = 5), HIV-positive low viral load (LVL) (VL range 120; 4000, n = 5) or high viral load (HVL) (VL range 100,000; 500,000, n = 5). MSCs were exposed to these sera (5%) in an adipogenic/osteogenic condition and in nondifferentiating conditions in acute and chronic exposure models. Markers of adipogenesis/osteogenesis were examined in both MSCs induced to differentiated and nondifferentiating cells. Sera from HVL HIV-1-infected individuals induced a clear proadipogenic phenotype, as evidenced by an increase in adipocyte formation and the induction of increased expression of adipogenic markers including LPL and PPARγ. Both CD4 receptor blockade and treatment with the antiretroviral AZT attenuated these proadipogenic effects, suggesting that an infection event may underlie the observed phenomena. Finally, inhibition of COUP TF-1 by HIV-1 TAT was identified as a potential molecular mechanism for these effects. These results suggest that HIV-1 directly interacts with and may infect MSCs resulting in alterations of their differentiation potential, findings that significantly enhance our understanding of HIV-1-associated bone and fat toxicities.

Wnt signalling mediates the cross-talk between bone marrow derived pre-adipocytic and pre-osteoblastic cell populations

The mechanisms underlying the inverse relationship between osteogenic and adipogenic differentiation of bone marrow stromal cells (MSC) are not known in detail. We have previously established two cell lines from mouse bone marrow that are committed to either osteogenic (osteoblasts and chondrocytes) (mMSC(Bone)) or adipogenic (mMSC(Adipo)) lineage. To identify the molecular mechanism determining the lineage commitment, we compared the basal gene expression profile of mMSC(Bone) versus mMSC(Adipo) using Affymetrix GeneChip® MG430A 2.0 Array. Gene annotation analysis based on biological function revealed an over-representation of skeletal development genes in mMSC(Bone) while genes related to lipid metabolism and immune response were highly expressed in mMSC(Adipo). In addition, there was a significant up-regulation of canonical Wnt signalling genes in mMSC(Bone) compared to mMSC(Adipo) (p<0.006). Dual-luciferase assay and expression analysis of genes related to Wnt signalling demonstrated significant activation of Wnt signalling pathway in mMSC(Bone) compared to mMSC(Adipo). Reduced Wnt activity in mMSC(Adipo) was associated with increased expression of the Wnt inhibitor, secreted frizzled-related protein 1 (sFRP-1) at both mRNA and protein levels in mMSC(Adipo). Interestingly, conditioned medium (CM) collected from mMSC(Adipo) (mMSC-CM(Adipo)) inhibited osteoblast differentiation of mMSC, while depletion of sFRP-1 protein from mMSC-CM(Adipo) abolished its inhibitory effect on osteoblast differentiation. Furthermore, treatment of mMSC with recombinant sFRP-1 resulted in a dose-dependent inhibition of osteoblast and stimulation of adipocyte differentiation. In conclusion, cross-talk exists between different populations of MSC in the bone marrow, and Wnt signalling functions as a molecular switch that determines the balance between osteoblastogenesis and adipogenesis.

Low doses of bone morphogenetic protein 4 increase the survival of human adipose-derived stem cells maintaining their stemness and multipotency

Mesenchymal stem cells (MSCs) have emerged as important tools for cell therapy; therefore, identification of factors capable of governing their ex vivo expansion become essential. In this study we demonstrate that human adipose-derived stem cells (ASCs) express all components of the bone morphogenetic protein (BMP)/BMP receptor signaling pathway and respond to BMP4 inducing upregulated expression of its specific target genes Id1-Id4. Moreover, ASCs grown in a medium reduced in serum produce endogenous BMP4 that could affect autocrinely ASC growth. On the contrary, dorsomorphin, an inhibitor of BMP signaling pathway, decreases cell numbers yielded from ASC cultures in correlation with increased apoptosis and decreased cycling cells. Therefore, BMP4 emerges as a possible factor for ex vivo expanding human ASCs. Our results demonstrate that, as other morphogens, BMP4 effects on human MSCs are dose dependent. High doses significantly increased apoptosis and drastically reduced cell proliferation, whereas low doses of BMP4 (0.01-0.1 ng/mL) significantly increase culture cell content, reduce the number of apoptotic cells, and increase that of cycling cells. Further, treatment of human ASCs with low doses of BMP4 does not modify expression of Nanog and Oct4, two transcription factors involved in self-renewal and pluripotency of stem cells or avoid their osteogenic or osteoblastic differentiation capacities when cultured in adequate inducing media, as shown by the induction of specific gene expression (CEBP, PPARγ, and RUNX2). Our results therefore support BMP4 as a promising factor for expanding human adipose tissue-derived MSCs maintaining their properties of stemness and multipotency.

Tendon-derived stem/progenitor cell aging: defective self-renewal and altered fate

Aging is a major risk factor for tendon injury and impaired tendon healing, but the basis for these relationships remains poorly understood. Here we show that rat tendon- derived stem ⁄ progenitor cells (TSPCs) differ in both self-renewal and differentiation capability with age. The frequency of TSPCs in tendon tissues of aged animals is markedly reduced based on colony formation assays. Proliferation rate is decreased, cell cycle progression is delayed and cell fate patterns are also altered in aged TSPCs. In particular, expression of tendon lineage marker genes is reduced while adipocytic differentiation increased. Cited2, a multi-stimuli responsive transactivator involved in cell growth and senescence, is also downregulated in aged TSPCs while CD44, a matrix assembling and organizing protein implicated in tendon healing, is upregulated, suggesting that these genes participate in the control of TSPC function.

Differential gene expression in adipose stem cells cultured in allogeneic human serum versus fetal bovine serum

In preclinical studies, human adipose stem cells (ASCs) have been shown to have therapeutic applicability, but standard expansion methods for clinical applications remain yet to be established. ASCs are typically expanded in the medium containing fetal bovine serum (FBS). However, sera and other animal-derived culture reagents stage safety issues in clinical therapy, including possible infections and severe immune reactions. By expanding ASCs in the medium containing human serum (HS), the problem can be eliminated. To define how allogeneic HS (alloHS) performs in ASC expansion compared to FBS, a comparative in vitro study in both serum supplements was performed. The choice of serum had a significant effect on ASCs. First, to reach cell proliferation levels comparable with 10% FBS, at least 15% alloHS was required. Second, while genes of the cell cycle pathway were overexpressed in alloHS, genes of the bone morphogenetic protein receptor-mediated signaling on the transforming growth factor beta signaling pathway regulating, for example, osteoblast differentiation, were overexpressed in FBS. The result was further supported by differentiation analysis, where early osteogenic differentiation was significantly enhanced in FBS. The data presented here underscore the importance of thorough investigation of ASCs for utilization in cell therapies. This study is a step forward in the understanding of these potential cells.

Altered metabolism and lipodystrophy in the early B-cell factor 1-deficient mouse

We previously reported that mice deficient for the transcription factor early B-cell factor (Ebf1) exhibit markedly increased numbers of osteoblasts, bone formation rate, and serum osteocalcin, but the bone marrow of Ebf1(-/-) mice is also striking in its increased marrow adiposity. The purpose of this work was to analyze the metabolic phenotype that accompanies the altered bone morphology of Ebf1(-/-) mice. Whereas marrow adiposity was increased, deposition of white adipose tissue in other regions of the body was severely reduced (sc 40-50%, abdominally 80-85%). Brown adipose exhibited decreased lipid deposition. Subcutaneous and perigonadal white adipose tissue showed a decrease in mRNA transcripts for peroxisomal proliferator-activated receptor-gamma2 and CCAAT/enhancer-binding protein-beta in Ebf1(-/-) tissue compared with wild type. Circulating levels of leptin were decreased in Ebf1(-/-) animals compared with their littermate controls (down 65-95%), whereas adiponectin remained comparable after 2 wk of age. Serum analysis also found the Ebf1(-/-) animals were hypoglycemic and hypotriglyceridemic. After ip injection of insulin, the serum glucose levels in Ebf1(-/-) mice took longer to recover, and after a glucose challenge the Ebf1(-/-) animals reached serum glucose levels almost twice that of their wild-type counterparts. Measurement of circulating pancreatic hormones revealed normal or reduced insulin levels in the Ebf1(-/-) mice, whereas glucagon was significantly increased (up 1.7- to 8.5-fold). Metabolically the Ebf1(-/-) mice had increased O(2) consumption, CO(2) production, food and water intake, and activity. Markers for gluconeogenesis, however, were decreased in the Ebf1(-/-) mice compared with controls. In conclusion, the Ebf1-deficient animals exhibit defects in adipose tissue deposition with increased marrow adiposity and impaired glucose mobilization.

Spontaneously beating cardiomyocytes derived from white mature adipocytes

AIMS

Adipose stromal cells and dissociated brown adipose tissue have been shown to generate cardiomyocyte-like cells. However, it is not clear whether white mature adipocytes have the same potential, even though a close relationship has been found between adipocytes and vascular endothelial cells, another cardiovascular cell type. The objective of this study was to examine if white adipocytes would be able to supply cardiomyocytes.

METHODS AND RESULTS

We prepared a highly purified population of lipid-filled adipocytes from mice, 6-7 weeks of age. When allowed to lose lipids, the adipocytes assumed a fibroblast-like morphology, so-called dedifferentiated fat (DFAT) cells. Subsequently, 10-15% of the DFAT cells spontaneously differentiated into cardiomyocyte-like cells, in which the cardiomyocyte phenotype was identified by morphological observations, expression of cardiomyocyte-specific markers, and immunocytochemical staining. In addition, electrophysiological studies revealed pacemaker activity in these cells, and functional studies showed that a beta-adrenergic agonist stimulated the beating rate, whereas a beta-antagonist reduced it. In vitro treatment of newly isolated adipocytes or DFAT cells with inhibitors of bone morphogenetic proteins (BMP) and Wnt signalling promoted the development of the cardiomyocyte phenotype as determined by the number or beating colonies of cardiomyocyte-like cells and expression of troponin I, a cardiomyocyte-specific marker. Inhibition of BMP was most effective in promoting the cardiomyocyte phenotype in adipocytes, whereas Wnt-inhibition was most effective in DFAT cells.

CONCLUSION

White mature adipocytes can differentiate into cardiomyocyte-like cells, suggesting a link between adipocyte and cardiomyocyte differentiation.

Emerging role of bone morphogenetic proteins in adipogenesis and energy metabolism

Bone morphogenetic proteins (BMPs) regulate many processes in embryonic development as well as in the maintenance of normal tissue function later in adult life. However, the role of this family of proteins in formation of adipose tissue has been underappreciated in the field of developmental biology. With the growing epidemic of obesity, improved knowledge of adipocyte development and function is urgently needed. Recently, there have been significant advances in understanding the role of different members of the BMP superfamily in control of adipocyte differentiation and systemic energy homeostasis. This review summarizes recent progress in understanding how BMPs specify adipose cell fate in stem/progenitor cells and their potential role in energy metabolism. We propose that BMPs provide instructive signals for adipose cell fate determination and regulate adipocyte function. These findings have opened up exciting opportunities for developing new therapeutic approaches for the treatment of obesity and its many associated metabolic disorders.

Mechanisms of bone repair and regeneration

Bone problems can have a highly deleterious impact on life and society, therefore understanding the mechanisms of bone repair is important. In vivo studies show that bone repair processes in adults resemble normal development of the skeleton during embryogenesis, which can thus be used as a model. In addition, recent studies of skeletal stem cell biology have underlined several crucial molecular and cellular processes in bone formation. Hedgehog, parathyroid hormone-related protein, Wnt, bone morphogenetic proteins and mitogen-activated protein kinases are the main molecular players, and osteoclasts and mesenchymal stem cells are the main cells involved in these processes. However, questions remain regarding the precise mechanisms of bone formation, how the different molecular processes interact, and the real identity of regenerative cells. Here, we review recent studies of bone regeneration and repair. A better understanding of the underlying mechanisms is expected to facilitate the development of new strategies for improving bone repair.

A comprehensive analysis of the dual roles of BMPs in regulating adipogenic and osteogenic differentiation of mesenchymal progenitor cells

Pluripotent mesenchymal stem cells (MSCs) are bone marrow stromal progenitor cells that can differentiate into osteogenic, chondrogenic, adipogenic, and myogenic lineages. Several signaling pathways have been shown to regulate the lineage commitment and terminal differentiation of MSCs. Here, we conducted a comprehensive analysis of the 14 types of bone morphogenetic protein (BMPs) for their abilities to regulate multilineage specific differentiation of MSCs. We found that most BMPs exhibited distinct abilities to regulate the expression of Runx2, Sox9, MyoD, and PPARgamma2. Further analysis indicated that BMP-2, BMP-4, BMP-6, BMP-7, and BMP-9 effectively induced both adipogenic and osteogenic differentiation in vitro and in vivo. BMP-induced commitment to osteogenic or adipogenic lineage was shown to be mutually exclusive. Overexpression of Runx2 enhanced BMP-induced osteogenic differentiation, whereas knockdown of Runx2 expression diminished BMP-induced bone formation with a decrease in adipocyte accumulation in vivo. Interestingly, overexpression of PPARgamma2 not only promoted adipogenic differentiation, but also enhanced osteogenic differentiation upon BMP-2, BMP-6, and BMP-9 stimulation. Conversely, MSCs with PPARgamma2 knockdown or mouse embryonic fibroblasts derived from PPARgamma2(-/-) mice exhibited a marked decrease in adipogenic differentiation, coupled with reduced osteogenic differentiation and diminished mineralization upon BMP-9 stimulation, suggesting that PPARgamma2 may play a role in BMP-induced osteogenic and adipogenic differentiation. Thus, it is important to understand the molecular mechanism behind BMP-regulated lineage divergence during MSC differentiation, as this knowledge could help us to understand the pathogenesis of skeletal diseases and may lead to the development of strategies for regenerative medicine.

Effect of bone morphogenetic protein-2 (BMP-2) or troglitazone, as an inducer of osteogenic cells or adipocytes, on differentiation of a bone marrow mesenchymal progenitor cell line established from temperature-sensitive (ts) simian virus (SV) 40 T-antigen gene transgenic mice

TBR31-2 is one of the bone marrow stromal cell lines. Differentiation toward osteogenic cells and calcification was observed when TBR31-2 cells were cultured for 4 weeks. Bone morphogenetic protein-2 (BMP-2) stimulated alkaline phosphatase (ALP) activity in a dose- and time-dependent manner. On the other hand, troglitazone increased oil droplet accumulation in a dose-dependent manner. In the presence of BMP-2, an increase of expression in osteogenic cell differentiation marker genes and a decrease of expression in adipocyte differentiation marker genes were observed with the exception of the induced expression of peroxisome proliferator-activated receptor gamma (PPARgamma), however, troglitazone, a ligand of PPARgamma treatment exhibited the opposite tendency. Interestingly, treatment with both BMP-2 and troglitazone resulted in a decrease of ALP activity and an increase of oil droplet accumulation. Reverse tanscription-polymerase chain reaction (RT-PCR) analysis also indicated that osteogenic differentiation markers decreased and that adipocyte differentiation markers increased. Thus, when the cells were cultured with BMP-2, osteogenic differentiation was enhanced while the expression of PPARgamma was maintained, and the addition of troglitazone caused a significant number of differentiated cells into adipocytes. These findings indicate that BMP-2 enhanced osteogenic differentiation and the expression of adipogenic transcription factor (PPARgamma) followed by osteogenic differentiation without activation of PPARgamma by its ligand.

Is PPARγ a prospective player in HIV-1-associated bone disease?

Currently infection with the human immunodeficiency virus-1 (HIV-1) is in most instances a chronic disease that can be controlled by effective antiretroviral therapy (ART). However, chronic use of ART has been associated with a number of toxicities; including significant reductions in bone mineral density (BMD) and disorders of the fat metabolism. The peroxisome proliferator-activated receptor γ (PPARγ) transcription factor is vital for the development and maintenance of mature and developing adipocytes. Alterations in PPARγ expression have been implicated as a factor in the mechanism of HIV-1-associated lipodystrophy. Both reduced BMD and lipodystrophy have been well described as complications of HIV-1 infection and treatment, and a question remains as to their interdependence. Interestingly, both adipocytes and osteoblasts are derived from a common precursor cell type; the mesenchymal stem cell. The possibility that dysregulation of PPARγ (and the subsequent effect on both osteoblastogenesis and adipogenesis) is a contributory factor in the lipid- and bone-abnormalities observed in HIV-1 infection and treatment has also been investigated. This review deals with the hypothesis that dysregulation of PPARγ may underpin the bone abnormalities associated with HIV-1 infection, and treats the current knowledge and prospective developments, in our understanding of PPARγ involvement in HIV-1-associated bone disease.

Role of gender and anatomical region on induction of osteogenic differentiation of human adipose-derived stem cells

Adipose-derived stem cells (ASCs) display multilineage plasticity and, under appropriate conditions, can mineralize their extracellular matrix and undergo osteogenesis. The aims of this study are to examine in vitro osteogenic differentiation properties of ASCs to assess the role of gender, fat depot, and optimal duration as variables for differentiation. Human ASCs were isolated from superficial and deep adipose layers of the abdominoplasty specimens obtained from patients undergoing elective surgeries. ASCs were cultured in osteogenic media (OM). After 1, 2, and 4 weeks of differentiation, cultures were assessed for markers of osteogenesis. Alkaline phosphatase (AP), alizarin red (AR) and Masson trichrome (MT) stainings for osteoblastic transformation, matrix mineralization, and collagen production; enzyme-linked immunosorbent assay (ELISA) for Gla-osteocalcin; and Western blot analysis for osteonectin protein expression were performed. Osteogenic differentiation began as early as 1 week. Cells exhibited a vertical growth pattern, lacunae formed in the cultures, matrix volume increased, and mineralization was observed. Differences in AP staining were most evident during the first week. AR activity progressively increased over 4 weeks, and collagen was secreted only by differentiated ASCs. There was no significant difference in the degree of osteogenic differentiation between the ASCs from both depots in the female. In the male, the superficial depot ASCs differentiated faster and more efficiently than those of the deep depot. Male ASCs from both depots differentiated more effectively than female ASCs from both depots. We describe a hierarchy of osteogenic differentiation potential based on gender and anatomic harvest site by layering adipose tissues of the abdominal wall. ASCs derived from male superficial layer were most efficient in achieving osteogenesis. In future clinical applications using stem cells for osseous healing, these gender and depot differences will guide our clinical methods.

Establishment of a preadipocyte cell line derived from mature adipocytes of GFP transgenic mice and formation of adipose tissue

We established a preadipocyte cell line from mature adipocytes obtained from subcutaneous fat tissue of green fluorescent protein (GFP) transgenic mice. The floating top layer, containing mature adipocytes, was isolated from subcutaneous fat tissue by collagenase digestion and filtration. Fluorescence-activated cell sorting and microscopic analysis revealed that the floating cell fraction comprised a highly homogeneous adipocyte population with no adipose stromal-vascular cells. Isolated mature adipocytes dedifferentiated into fibroblast-like cells and actively proliferated in ceiling culture. In vitro studies showed that the cells could redifferentiate into mature adipocytes in an identical way to 3T3-L1 preadipocytes. No changes in the differentiation pattern were observed during the propagation of our cells. They were successfully maintained and differentiated for at least 22 passages. We named these cells dedifferentiated fat (DFAT-GFP) cells. When DFAT-GFP cells were implanted subcutaneously into C57BL/6N mice, they developed highly vascularized fat pads that morphologically resembled normal subcutaneous adipose tissue and consisted of GFP-positive cells; however, implanted 3T3-L1 cells did not have such an effect on the mice. We conclude that DFAT-GFP cells provide a model that should enable us to study the mechanisms of adipocyte differentiation and adipose tissue formation in vivo and in vitro.

On the transplantation, regeneration and induction of bone: the path to bone morphogenetic proteins and other skeletal growth factors

The clinical and experimental transplantation of bone dates back to the seventeenth century and human allogeneic (homogeneic) bone has been successfully used as an alternative to autogenous bone since 1878, when Sir William Macewen reconstructed the right humerus of William Connell. This review describes how subsequent studies of bone transplantation led to the eventual discovery of a new family of secreted signalling molecules--the bone morphogenetic proteins (BMPs), and the realisation of the important role of polypeptide growth factors in mediating the growth, remodelling and regeneration of the skeleton. The development of suitable alternatives to both autogenous and allogeneic bone has been a goal of bone and biomaterials research for more than 30 years. The first requirement is a biocompatible, bioresorbable, osteoconductive framework supporting the ingrowth of host cells from the recipient bed. Many materials including collagen, calcium phosphate ceramics and synthetic polymers have been widely tested experimentally with varying success. The discovery of osteoinductive BMPs and their availability in recombinant human forms has given considerable impetus to the field. However, progress to date in engineering significant quantities of functional bone tissue in vivo has been disappointing; finding suitable carriers for BMPs has proven to be a greater challenge than expected. The dilemma for the clinician and the biotechnology industry, at present, is that, while recombinant human growth factors are readily available for clinical use, the lack of delivery systems that can adequately mimic both the physical properties and release kinetics of bone matrix remains a major handicap.

Identification of tendon stem/progenitor cells and the role of the extracellular matrix in their niche

The repair of injured tendons remains a great challenge, largely owing to a lack of in-depth characterization of tendon cells and their precursors. We show that human and mouse tendons harbor a unique cell population, termed tendon stem/progenitor cells (TSPCs), that has universal stem cell characteristics such as clonogenicity, multipotency and self-renewal capacity. The isolated TSPCs could regenerate tendon-like tissues after extended expansion in vitro and transplantation in vivo. Moreover, we show that TSPCs reside within a unique niche predominantly comprised of an extracellular matrix, and we identify biglycan (Bgn) and fibromodulin (Fmod) as two critical components that organize this niche. Depletion of Bgn and Fmod affects the differentiation of TSPCs by modulating bone morphogenetic protein signaling and impairs tendon formation in vivo. Our results, while offering new insights into the biology of tendon cells, may assist in future strategies to treat tendon diseases.

Hyperglycemia enhances adipogenic induction of lipid accumulation: involvement of extracellular signal-regulated protein kinase 1/2, phosphoinositide 3-kinase/Akt, and peroxisome proliferator-activated receptor gamma signaling

The molecular events of hyperglycemia-triggered increase in adipogenic induction of lipid accumulation remain unclear. We examined the effects of hyperglycemia on adipogenic induction of lipid accumulation and its involved signaling molecules, such as phosphoinositide 3-kinase (PI3K), ERKs, and peroxisome proliferator-activated receptor gamma (PPAR gamma). Bone marrow-derived mesenchymal stem cells (MSCs) isolated from FVB/N mice were capable of differentiating into adipocytes in adipogenic medium. The effects of high glucose (HG) (25.5 mm) were assessed in vitro by RT-PCR, ELISA, flow cytometry, immunostaining, and immunoblotting. The in vivo effect of hyperglycemia was further studied in streptozotocin (STZ)-induced diabetic FVB/N mice. Exposure of MSCs to HG enhanced adipogenic induction of lipid accumulation as compared with 5.5 mm glucose. HG increased PPAR gamma expression and PI3K activity and its downstream effector Akt phosphorylation during adipogenesis. Inhibition of PI3K/Akt activity with PI3K inhibitor LY294002 or by expressing the dominant negative p85 or Akt prevented the HG-enhanced PPAR gamma-dependent adipogenic induction of lipid accumulation. Moreover, HG increased the phosphorylation of ERK1/2 during adipogenesis. MAPK/ERK inhibitor PD98059 inhibited the PI3K activity, Akt phosphorylation, and lipid accumulation triggered by HG. PI3K inhibitor LY294002 did not affect the HG-increased ERK1/2 phosphorylation during adipogenesis. We next observed that adipogenic induction of lipid accumulation of MSCs isolated from STZ-induced diabetic mice is enhanced. Moreover, triglyceride, PPAR gamma expression, phosphorylated Akt and ERK1/2, and marrow fat in bones of STZ-diabetic mice were also increased. These results suggest that hyperglycemia enhances the adipogenic induction of lipid accumulation through an ERK1/2-activated PI3K/Akt-regulated PPAR gamma pathway.

Isolation and characterization of postnatal stem cells from human dental tissues

It was reported that postnatal stem cells are present in adult tissues such as bone marrow, liver, muscle, dental pulp, and periodontal ligament. We isolated postnatal stem cells from human dental tissues such as dental pulp (DPSC), periodontal ligament (PDLSC), periapical follicle (PAFSC), and the surrounding mandibular bone marrow (MBMSC) to ascertain their properties. Immunocytochemistry proved the existence of stem cells in these cell populations using STRO-1 as a stem cell marker. These cells also expressed the mesenchymal stem cell (MSC) markers CD29 and CD44. The isolated cells showed self-renewal capabilities and colony-forming efficiency. Almost all of the dental stem cells showed optimal growth when they were cultured in alpha modification of Eagle's medium (alpha-MEM) supplemented with 10% fetal calf serum (FCS) and 100 microM ascorbic acid. Only the PAFSC showed increased proliferation in 20% FCS and 50 microM ascorbic acid. All of the dental stem cells were capable of differentiating into adipocytes and mineral nodule forming cells. MBMSC, in particular, showed much better mineralization compared to the others. These results indicate that MSCs exist in various tissues of the teeth and can differentiate into osteoblasts, adipocytes, and other kinds of cells with varying efficiency.

BMP7 promotes adipogenic but not osteo-/chondrogenic differentiation of adult human bone marrow-derived stem cells in high-density micro-mass culture

The objective of our study was to elucidate the potential of bone morphogenetic protein-7 (BMP7) to initiate distinct mesenchymal lineage development of human adult mesenchymal stem cells (MSC) in three-dimensional micro-mass culture. Expanded MSC were cultured in high-density micro-masses under serum-free conditions that favor chondrogenic differentiation and were stimulated with 50-200 ng/ml BMP7 or 10 ng/ml transforming growth factor-beta3 (TGFbeta3) as control. Histological staining of proteoglycan with alcian blue, mineralized matrix according to von Kossa, and lipids with Oil Red O, immunostaining of type II collagen as well as real-time gene expression analysis of typical chondrogenic, adipogenic, and osteogenic marker genes showed that BMP7 promoted adipogenic differentiation of MSC. Micro-masses stimulated with BMP7 developed adipocytic cells filled with lipid droplets and showed an enhanced expression of the adipocyte marker genes fatty acid binding protein 4 (FABP4) and the adipose most abundant transcript 1 (apM1). Development along the chondrogenic lineage or stimulation of osteogenic differentiation were not evident upon stimulation with BMP7 in different concentrations. In contrast, TGFbeta3 directed MSC to form a cartilaginous matrix that is rich in proteoglycan and type II collagen. Gene expression analysis of typical chondrocyte marker genes like cartilage oligomeric matrix protein (COMP), link protein, aggrecan, and types IIalpha1 and IXalpha3 collagen confirmed chondrogenic differentiation of MSC treated with TGFbeta3. These results suggest that BMP7 promotes the adipogenic and not the osteogenic or chondrogenic lineage development of human stem cells when assembled three-dimensionally in micro-masses.

A comprehensive and critical review of dental implant placement in diabetic animals and patients

OBJECTIVES

A thorough and exhaustive analysis of the available studies concerning placement of endosseous dental implants in diabetic subjects has not been previously published. The aim of the present study was to perform a comprehensive and critical review of experimental and clinical studies published in the international peer-reviewed literature in the English language regarding endosseous implant installation in diabetic subjects and to draw evidence-based conclusions on the effectiveness and predictability of dental implant therapy in diabetic patients.

MATERIAL AND METHODS

Literature search for articles published up to and including March 2005 in the English language was performed with a personal computer (PC) using The National Library Of Medicine (http://www.ncbi.nlm.nih.gov/PubMed) and Cochrane Oral Health Group databases. Search strategy included a specific series of terms and key words. The reference lists of identified publications, relevant texts and previous workshops were also scanned. Data sources also included several hand-searched journals and contact with experts, when it was considered appropriate. Search was conducted independently by the three reviewers (S. K., I. K. K., I. F.). At the first phase of selection the titles and abstracts and at the second phase full papers were screened independently by the three reviewers. Disagreement regarding inclusion of full papers was resolved by discussion among the reviewers.

RESULTS

The search provided 227 potentially relevant titles and abstracts. At the first phase of evaluation, 199 publications were rejected based on title and abstract. At the second phase, the full text of the remaining 28 publications was retrieved for more detailed evaluation. These publications included 11 experimental studies and 16 clinical studies (one clinical study corresponded to two publications). Finally, 11 experimental and eight clinical studies were accepted. Clinical studies included four prospective and four retrospective studies. Because of the limited number of available studies and their heterogeneity, focusing on a specific predefined question to be answered by a systematic review was not feasible and therefore no meta-analysis was planned.

CONCLUSION

Within the limits of the existing investigations, experimental studies seem to reveal an impaired bone healing response to implant placement in diabetic animals compared with non-diabetic controls, both quantitatively and qualitatively. The majority of clinical studies tend to indicate that diabetes is no contraindication for implant placement, on condition that it remains under metabolic control. However, definitive guidelines with objective criteria, such as type and duration of diabetes and glucosylated hemoglobin levels, need to be established in the future.

BMP signaling and skeletogenesis

Bone morphogenetic proteins (BMPs) are members of the transforming growth factor (TGF)-beta superfamily of signal molecules that mediate many diverse biological processes ranging from early embryonic tissue patterning to postnatal tissue homeostasis. BMPs trigger cell responses mainly through the canonical signaling pathway where intracellular Smads play central roles in delivering the extracellular signals to the nucleus. While the same Smads are used by BMPs in all types of cells, different transcription factors account in part for the functional diversity of BMPs. These transcription factors are recruited by Smads to regulate the expression of specific subsets of target genes depending on the cell types. Among the transcription factors are Hox proteins. Experimental gain and loss-of-function studies as well as naturally occurring mutations in Hox genes demonstrate their central roles in embryonic skeletal patterning. In addition to the interactions with Smads observed for several Hox proteins, there is also evidence that the expression of a number of Hox genes is regulated by BMPs. It is suggested that Hox proteins play an important role in the BMP pathway.

Lentiviral transduction of human postnatal skeletal (stromal, mesenchymal) stem cells: in vivo transplantation and gene silencing

Systems for gene transfer and silencing in human skeletal stem cells (hSSCs, also stromal or mesenchymal stem cells) are important for addressing critical issues in basic hSSC and skeletal biology and for developing gene therapy strategies for treatment of skeletal diseases. Whereas recent studies have shown the efficacy of lentiviral transduction for gene transfer in hSSCs in vitro, no study has yet proven that lentivector-transduced hSSCs retain their distinctive organogenic potential in vivo, as probed by in vivo transplantation assays. Therefore, in addition to analyzing the in vitro growth and differentiation properties of hSSCs transduced with advanced-generation lentivectors, we ectopically transplanted LV-eGFP-transduced hSSCs (along with an osteoconductive carrier) in the subcutaneous tissue of immunocompromised mice. eGFP-transduced cells formed heterotopic ossicles, generating osteoblasts, osteocytes, and stromal cells in vivo, which still expressed GFP at 2 months after transplantation. eGFP-expressing cells could be recovered from the ossicles 8 weeks posttransplantation and reestablished in culture as viable and proliferating cells. Further, we investigated the possibility of silencing individual genes in hSSCs using lentivectors encoding short hairpin precursors of RNA interfering sequences under the control of the Pol-III-dependent H1 promoter. Significant long-term silencing of both lamin A/C and GFP (an endogenous gene and a transgene, respectively) was obtained with lentivectors encoding shRNAs. These data provide the basis for analysis of the effect of gene knockdown during the organogenesis of bone in the in vivo transplantation system and for further studies on the silencing of alleles carrying dominant, disease-causing mutations.

Schnurri-2 controls BMP-dependent adipogenesis via interaction with Smad proteins

Adipocyte differentiation is an important component of obesity, but how hormonal cues mediate adipocyte differentiation remains elusive. BMP stimulates in vitro adipocyte differentiation, but the role of BMP in adipogenesis in vivo is unknown. Drosophila Schnurri (Shn) is required for the signaling of Decapentaplegic, a Drosophila BMP homolog, via interaction with the Mad/Medea transcription factors. Vertebrates have three Shn orthologs, Shn-1, -2, and -3. Here, we report that Shn-2(-/-) mice have reduced white adipose tissue and that Shn-2(-/-) mouse embryonic fibroblasts cannot efficiently differentiate into adipocytes in vitro. Shn-2 enters the nucleus upon BMP-2 stimulation and, in cooperation with Smad1/4 and C/EBPalpha, induces the expression of PPARgamma2, a key transcription factor for adipocyte differentiation. Shn-2 directly interacts with both Smad1/4 and C/EBPalpha on the PPARgamma2 promoter. These results indicate that Shn-2-mediated BMP signaling has a critical role in adipogenesis.

Dental pulp stem cells

Postnatal stem cells have been isolated from a variety of tissues. These stem cells are thought to possess great therapeutic potential for repairing damaged and/or defective tissues. Clinically, hematopoietic stem cells have been successfully used for decades in the treatment of various diseases and disorders. However, the therapeutic potential of other postnatal stem cell populations has yet to be realized, because of the lack of detailed understanding of their stem cell characteristics at the cellular and molecular levels. Furthermore, there is limited knowledge of their therapeutic value at the preclinical level. Therefore, it is necessary to develop optimal strategies and approaches to overcome the substantial challenges currently faced by researchers examining the clinical efficacy of different postnatal stem cell populations. In this review, we introduce methodologies for isolating postnatal stem cells from human dental pulp and discuss their potential role in tissue regeneration.

Playing with bone and fat

The relationship between bone and fat formation within the bone marrow microenvironment is complex and remains an area of active investigation. Classical in vitro and in vivo studies strongly support an inverse relationship between the commitment of bone marrow-derived mesenchymal stem cells or stromal cells to the adipocyte and osteoblast lineage pathways. In this review, we focus on the recent literature exploring the mechanisms underlying these differentiation events and discuss their implications relevant to osteoporosis and regenerative medicine.

Basic fibroblast growth factor enhances PPARgamma ligand-induced adipogenesis of mesenchymal stem cells

Mesenchymal stem cells (MSCs) are capable of differentiating into a variety of lineages, including bone, cartilage, or fat, depending on the inducing stimuli and specific growth and differentiation factors. It is widely acknowledged that basic fibroblast growth factor (bFGF) modulates chondrogenic and osteogenic differentiation of MSCs, but thorough investigations of its effects on adipogenic differentiation are lacking. In this study, we demonstrate on the cellular and molecular level that supplementation of bFGF in different phases of cell culture leads to a strong enhancement of adipogenesis of MSCs, as induced by an adipogenic hormonal cocktail. In cultures receiving bFGF, mRNA expression of peroxisome proliferator-activated receptor gamma2 (PPARgamma2), a key transcription factor in adipogenesis, was upregulated even prior to adipogenic induction. In order to investigate the effects of bFGF on PPARgamma ligand-induced adipogenic differentiation, the thiazolidinedione troglitazone was administered as a single adipogenic inducer. Basic FGF was demonstrated to also strongly increase adipogenesis induced by troglitazone, that is, bFGF clearly increased the responsiveness of MSCs to a PPARgamma ligand.

The effect of heparin on osteoblast differentiation and activity in primary cultures of bovine aortic smooth muscle cells

Recent studies have suggested that aortic smooth muscle cells undergo a phenotypic transition into osteoblast-like cells and mineralize when cultured in the presence of beta-glycerophosphate. Since we had previously demonstrated that heparin could inhibit osteoblast differentiation and mineralization in primary cultures of murine calvaria cells, we were interested in determining if heparin would have a similar effect when primary aortic smooth muscle cells were cultured in the presence of beta-glycerophosphate. The effect of heparin and low molecular weight heparin (LMWH) on osteoblast differentiation and activity was therefore examined in primary cultures of bovine aortic smooth muscle cells (BASMC) over a 14-day period. Here, we report that BASMC differentiate into osteoblast-like cells when cultured in the presence of beta-glycerophosphate. Moreover, we report that heparin not only inhibits this process but that it also inhibits the ability of BASMC to mineralize as well. Importantly, these effects were found not to be dependent upon heparins' anticoagulant activity since unfractionated heparin and heparins with low anti-thrombin III affinities inhibited the mineralization process equally well. Sulfation, however, was found to be a major determinant of heparins ability to inhibit BASMC mineralization since neither dermatan sulfate nor N-desulfated heparin were able to demonstrate an effect. We conclude that BASMC cultures can undergo a phenotypic transition into mature osteoblasts and that both the differentiation process and their ability to mineralize are inhibited by heparin.

Subcutaneous adipocytes can differentiate into bone-forming cells in vitro and in vivo

Interconversion of bone marrow osteoblasts and adipocytes has been reported previously. However, the osteogenic potential of extramedullary adipocytes is not known. Thus, we incubated a pure culture of human subcutaneous adipocytes in control medium for 1-2 weeks. Afterward, the cells were incubated in either osteoblast medium (OB medium) containing various combinations of calcitriol, dexamethasone, ascorbic acid, and beta-glycerophosphate or in adipocyte medium (AD medium) containing HEPES, biotin, pantothenate, insulin, triiodothyronine, dexamethasone, and isobutylmethylxanthine for 4 weeks. Expression of osteoblastic and adipocytic phenotypes was examined by determination of lineage-specific mRNA markers and in vitro adipocyte and osteoblast formation. Cells were also implanted, mixed with hydroxyapatite-tricalcium phosphate powder, in the subcutaneous tissue of immunodeficient mice in order to assess in vivo bone formation potential. One week after incubation in control medium, cells formed fusiform elongated fibroblast-like cells. In OB medium, cells stained positive for alkaline phosphatase (AP) and expressed mRNAs encoding Cbfa1/Runx2, AP, and osteocalcin. In AD medium cells reacquired adipocyte morphology with multilocular lipid-filled cells. Also, the cells expressed adipocyte-specific mRNA markers: lipoprotein lipase and peroxisome proliferator-activated receptor gamma2. Bone was formed only in the in vivo implants of cells incubated in OB medium. In conclusion, extramedullary adipocytes can transdifferentiate to bone-forming cells. Because of their ease of isolation, adipocytes may be good candidates for tissue-engineering protocols aimed at creating bone tissue for the repair of nonunion fractures and large bone defects.

Regulation of human skeletal stem cells differentiation by Dlk1/Pref-1

Dlk-1/Pref-1 was identified as a novel regulator of human skeletal stem cell differentiation. Dlk1/Pref-1 is expressed in bone and cultured osteoblasts, and its constitutive overexpression led to inhibition of osteoblast and adipocyte differentiation of human marrow stromal cells.

INTRODUCTION

Molecular control of human mesenchymal stem cell (hMSC) differentiation into osteoblasts and adipocytes is not known. In this study, we examined the role of delta-like 1/preadipocyte factor-1 (Dlk1/Pref-1) in regulating the differentiation of hMSCs.

MATERIALS AND METHODS

As a model for hMSCs, we have stably transduced telomerase-immortalized hMSC (hMSC-TERT) with the full length of human Dlk1/Pref-1 cDNA and tested its effect on hMSC growth and differentiation into osteoblasts or adipocytes as assessed by cytochemical staining, FACS analysis, and real time PCR. Ex vivo calvaria organ cultures assay was used to confirm the in vitro effect of Dlk/Pref-1 on bone formation.

RESULTS

Dlk1/Pref-1 was found to be expressed in fetal and adult bone, hMSCs, and some osteoblastic cell lines. A retroviral vector containing the human Dlk1/Pref-1 cDNA was used to create a cell line (hMSC-dlk1) expressing high levels of Dlk1/Pref-1 protein. Overexpression of Dlk1/Pref-1 did not affect the proliferation rate of hMSC, but the ability to form mature adipocytes, mineralized matrix in vitro, and new bone formation in neonatal murine calvariae organ cultures was reduced. These effects were associated with inhibition of gene expression markers of late stages of adipocyte (adipocyte fatty acid-binding protein [aP2], peroxisome proliferator-activated receptor-gamma2 [PPARgamma2], and adiponectin [APM1]) and osteoblast differentiation (alkaline phosphatase [ALP], collagen type I [Col1], and osteocalcin [OC]). Lineage commitment markers for adipocytes (adipocyte determination and differentiation factor -1 [ADD1]) and osteoblasts (core binding factor/runt-related binding factor 2 [Cbfa1/Runx2]) were not affected.

CONCLUSION

During hMSC differentiation, Dlk1/Pref-1 maintains the size of the bipotential progenitor cell pool by inhibiting the formation of mature osteoblasts and adipocytes.

RETRACTED: A human chondrogenic cell line retains multi-potency that differentiates into osteoblasts and adipocytes

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the author, Dr. Kimihito Yagami. Dr. Yagami's collaborators Yohei Uyama, Yasumasa Yoshizawa, Saburo Kakuta, Akira Yamaguchi, Masao Nagumo were not involved in the RT-PCR experiments and figure preparation The editor, Sundeep Khosla, was notified by an independent group that specific bands in Figure 3 of the paper appear to be duplicated. This was brought to the attention of the authors. Due to the long interval from the original publication of the paper, the raw data was not available; however, the authors subsequently chose to retract the entire manuscript, and the editor agreed.

Bone and fat: old questions, new insights

Until recently, adipose tissue was considered to serve only as a triglyceride reservoir and was relegated to a passive endocrine role. With the discovery of leptin and other adipokines, adipose tissue is now recognized as an active participant in systemic metabolism. This review focuses on the complex relationship existing between adipose tissue and bone metabolism and differentiation. It explores the paradigms that have shaped the past decade's research and what these findings forecast for the future. Particular attention is given to the multipotent adult stem cell populations that reside within bone and fat. These adult stem cells have critical importance to the emerging field of tissue engineering and regenerative medicine.