Efficient delivery of C/EBP beta gene into human mesenchymal stem cells via polyethylenimine-coated gold nanoparticles enhances adipogenic differentiation

Cysteamine functionalized gold nanoparticles exhibit high efficiency delivery of genetic materials in embryonic stem cells majorly via clathrin mediated endocytosis

Efficient and safe gene delivery is vital for genetic manipulation of stem cells for regenerative medicine. Gold nanoparticles have been used for various biomedical applications in the past, and are currently being researched as transfection agents. In this study, we report a simple one-pot synthesis of positively charged gold nanoparticles functionalized with cysteamine. The nanoparticles exhibit no cytotoxicity and can bind to both plasmid DNA (pDNA) as well as small interference RNA (siRNA). We observed that a five fold lower concentration of pDNA was sufficient for achieving comparable overexpression as that of a commercial transfection agent. We also observed that about 70 % transient silencing of the target gene was achieved with only 25 nM siRNA delivered by our nano-vehicle. To better understand the fate of the nanoparticle, we attempted to identify its uptake mechanism. The results indicate that while all the mechanisms contribute to the uptake, the clathrin-dependent pathway plays a major role. This is the first study on understanding the mechanism of uptake of CA-AuNPs conjugated to pDNA by embryonic stem cells. This is also the first study, where a successful transfection using gold based nanoparticles has been achieved in ESCs at a concentration as low as 0.5 µg/ml for pDNA and 25ƞM siRNA.

Inorganic nanoparticle-integrated mesenchymal stem cells: A potential biological agent for multifaceted applications

Mesenchymal stem cell (MSC)-based therapies are flourishing. MSCs could be used as potential therapeutic agents for regenerative medicine due to their own repair function. Meanwhile, the natural predisposition toward inflammation or injury sites makes them promising carriers for targeted drug delivery. Inorganic nanoparticles (INPs) are greatly favored for their unique properties and potential applications in biomedical fields. Current research has integrated INPs with MSCs to enhance their regenerative or antitumor functions. This model also allows the in vivo fate tracking of MSCs in multiple imaging modalities, as many INPs are also excellent contrast agents. Thus, INP-integrated MSCs would be a multifunctional biologic agent with great potential. In this review, the current roles performed by the integration of INPs with MSCs, including (i) enhancing their repair and regeneration capacity via the improvement of migration, survival, paracrine, or differentiation properties, (ii) empowering tumor-killing ability through agent loaded or hyperthermia, and (iii) conferring traceability are summarized. An introduction of INP-integrated MSCs for simultaneous treatment and tracking is also included. The promising applications of INP-integrated MSCs in future treatments are emphasized and the challenges to their clinical translation are discussed.

Size-tunable lipid vectors for controlled local delivery of siRNA from gene activated matrix

Tissue engineering aims to restore or replace different types of biological tissues through the association of cells, biologic factors and biomaterials. Currently, stem cells arise as a major cell source for many therapeutic indications, and their association with 3D scaffolds allow increasing regenerative medicine efficiency. In this context, the use of RNA interference to enhance or control stem cell differentiation into the desired phenotype appears as a promising strategy. However, achieving high transfection efficiency of cells in a 3D structure requires the use of a vector allowing for the spatiotemporally controlled release of the genetic material from these scaffolds. In this study, we report a new siRNA nanovector, called solvent exchange lipoplexe formulation (SELF), which has a tunable size, is stable over time in cell culture conditions and possess a high efficiency to transfect primary human mesenchymal stromal cells (hMSC). We associated SELFs with porous 3D collagen microspheres and demonstrated that the loading capacity and release kinetics were different depending on the size of the associated SELF. Interestingly, these different release profiles resulted in differences in the transfection kinetics of hMSCs. This original and unique type of gene activated matrix, with adaptable release kinetics, could be of interest for long-term and/or sequential transfection profiles of stem cells in 3D culture. STATEMENT OF SIGNIFICANCE: This work combines the use of human mesenchymal stromal cell (hMSC) and gene therapy for tissue engineering. Here, a gene-activated matrix was elaborated with collagen microspheres supporting hMSCs and acting as a reservoir for transfection vectors. This injectable GAM allows for the local and sustained delivery of nucleic acids, hence long-lasting transfection of the supported cells. With the original synthesis protocol presented herein, the size of the nanocarriers can be easily adapted, resulting in different siRNA release profiles from the microspheres. Most interestingly, different siRNA release profiles gave rise to different cell transfection profiles as assessed by the downregulation of a target gene. This highlights the versatility of the system and its suitability for various pathophysiological needs in regenerative medicine.

Detrimental effects of cerium oxide nanoparticles on testis, sperm parameters quality, and in vitro fertilization in mice: An experimental study

Background

Cerium oxide nanoparticles (CeO2 NPs) as an important nanomaterial have a wide range of applications in many fields and human beings' exposure to this nanomaterial is unavoidable. The effects of CeO2 NPs on the male reproductive system are controversial.

Objective

To determine the effects of the administration of CeO2 NPs on the testis tissue, sperm parameters, and in vitro fertilization (IVF) in mice.

Materials and Methods

Twenty-four male mice were divided into three groups (n = 8/each): one control and two experimental groups receiving CeO2 NPs at doses of 50 and 100 mg/kg body weight, respectively, for 35 days. At the end of the experiment, the diameter of seminiferous tubules (SNTs), epithelial height of SNTs, spermiogenesis index in testes, sperm parameters (count, motility, viability, and morphology), sperm chromatin condensation, DNA integrity, and IVF assays were analyzed.

Results

Histological results showed that the tubular diameter, the epithelial height of the SNTs, and the spermiogenesis index were significantly decreased in the experimental groups receiving CeO2 NPs. All sperm parameters in the experimental groups were significantly reduced and, additionally, the percentages of immature sperms and sperms with DNA damage were significantly increased in groups treated with CeO2 NPs compared to the control. Furthermore, the rates of IVF and in vitro embryo development were decreased.

Conclusion

Collectively, the current study showed that oral administration of CeO2 NPs in mice had detrimental effects on the male reproductive system through inducing testicular tissue alterations, decreasing sperm parameters quality, and also diminishing the IVF rate and in vitro embryonic development.

Genetically Modified Mesenchymal Stromal/Stem Cells: Application in Critical Illness

Critical illnesses including sepsis, acute respiratory distress syndromes, ischemic cardiovascular disorders and acute organ injuries are associated with high mortality, morbidity as well as significant health care system expenses. While these diverse conditions require different specific therapeutic approaches, mesenchymal stem/stromal cell (MSCs) are multipotent cells capable of self-renewal, tri-lineage differentiation with a broad range regenerative and immunomodulatory activities, making them attractive for the treatment of critical illness. The therapeutic effects of MSCs have been extensively investigated in several pre-clinical models of critical illness as well as in phase I and II clinical cell therapy trials with mixed results. Whilst these studies have demonstrated the therapeutic potential for MSC therapy in critical illness, optimization for clinical use is an ongoing challenge. MSCs can be readily genetically modified by application of different techniques and tools leading to overexpress or inhibit genes related to their immunomodulatory or regenerative functions. Here we will review recent approaches designed to enhance the therapeutic potential of MSCs with an emphasis on the technology used to generate genetically modified cells, target genes, target diseases and the implication of genetically modified MSCs in cell therapy for critical illness.

Green Sources Derived Carbon Dots for Multifaceted Applications

For the past decade, the Carbon dots (CDs) a tiny sized carbon nanomaterial are typically much attentive due to their outstanding properties. Nature is a fortune of exciting starting materials that provides many inexpensive and renewable resources which have received the topmost attention of researchers because of non-hazardous and eco-friendly nature that can be used to prepare green CDs by top-down and bottom-up synthesis including hydrothermal carbonization, microwave synthesis, and pyrolysis due to its simple synthetic process, speedy reactions and clear-cut end steps. Compared to chemically derived CDs, green CDs are varied by their properties such as less toxicity, high water dispersibility, superior biocompatibility, good photostability, bright fluorescence, and ease of modification. These nanomaterials are a promising material for sensor and biological fields, especially in electrochemical sensing of toxic and trace elements in ecosystems, metal sensing, diagnosis of diseases through bio-sensing, and detection of cancerous cells by in-vitro and in-vivo bio-imaging applications. In this review, the various synthetic routes, fluorescent mechanisms, and applications of CDs from discovery to the present are briefly discussed. Herein, the latest developments on the synthesis of CDs derived from green carbon materials and their promising applications in sensing, catalysis and bio-imaging were summarized. Moreover, some challenging problems, as well as upcoming perspectives of this powerful and tremendous material, are also discussed.

Zinc oxide nanoparticles: A comprehensive review on its synthesis, anticancer and drug delivery applications as well as health risks

In recent years, zinc oxide nanoparticles (ZnONPs) emerged as an excellent candidate in the field of optical, electrical, food packaging and particularly in biomedical research. ZnONPs show cancer cell specific toxicity via the pH-dependent (low pH) dissolution into Zn²⁺ ions, which generate reactive oxygen species and induce cytotoxicity in cancer cells. Further, ZnONPs have also been used as an effective carrier for the targeted delivery of several anticancer drugs into tumor cells. The increasing focus on ZnONPs resulted in the development of various synthesis approaches including chemical, pHysical, and green or biological for the manufacturing of ZnONPs. In this article, at first we have discussed the various synthesis methods of ZnONPs and secondly its biomedical applications. We have extensively reviewed the anticancer mechanism of ZnONPs on different types of cancers considering its size, shape and surface charge dependent cytotoxicity. Photoirradiation with UV light or NIR laser further increase its anticancer activity via synergistic chemo-photodynamic effect. The drug delivery applications of ZnONPs with special emphasis on drug loading mechanism, stimuli-responsive controlled release and therapeutic effects have also been discussed in this review. Finally, its side effects to vital body organs with mechanism via different exposure routes, the future direction of the ZnONPs research and application are also discussed.

Non-viral Gene Delivery Methods for Bone and Joints

Viral carrier transport efficiency of gene delivery is high, depending on the type of vector. However, viral delivery poses significant safety concerns such as inefficient/unpredictable reprogramming outcomes, genomic integration, as well as unwarranted immune responses and toxicity. Thus, non-viral gene delivery methods are more feasible for translation as these allow safer delivery of genes and can modulate gene expression transiently both in vivo, ex vivo, and in vitro. Based on current studies, the efficiency of these technologies appears to be more limited, but they are appealing for clinical translation. This review presents a summary of recent advancements in orthopedics, where primarily bone and joints from the musculoskeletal apparatus were targeted. In connective tissues, which are known to have a poor healing capacity, and have a relatively low cell-density, i.e., articular cartilage, bone, and the intervertebral disk (IVD) several approaches have recently been undertaken. We provide a brief overview of the existing technologies, using nano-spheres/engineered vesicles, lipofection, and in vivo electroporation. Here, delivery for microRNA (miRNA), and silencing RNA (siRNA) and DNA plasmids will be discussed. Recent studies will be summarized that aimed to improve regeneration of these tissues, involving the delivery of bone morphogenic proteins (BMPs), such as BMP2 for improvement of bone healing. For articular cartilage/osteochondral junction, non-viral methods concentrate on targeted delivery to chondrocytes or MSCs for tissue engineering-based approaches. For the IVD, growth factors such as GDF5 or GDF6 or developmental transcription factors such as Brachyury or FOXF1 seem to be of high clinical interest. However, the most efficient method of gene transfer is still elusive, as several preclinical studies have reported many different non-viral methods and clinical translation of these techniques still needs to be validated. Here we discuss the non-viral methods applied for bone and joint and propose methods that can be promising in clinical use.

Role of Liposomes-Based Stem Cell for Multimodal Cancer Therapy

The utilization of stem cells as novel carriers to target tissues or organs of interest is a challenging task in delivery system. The composite cellular delivery with diverse signalling molecules as therapeutics increases stem cell capability and possesses the promising potential to augment, modify or commence localized or systemic restoration for vital applications in regenerative medicine. The inherent potential of stem cells to immigrate and reside at wounded site facilitates transportation of genes, polypeptides or nanosized molecules. Liposomes are micro- to nano-lipidic vesicles formed in aqueous solutions to encapsulate complex hydrophilic and lipophilic chemical substances. Moreover, these novel nanocarriers provide safer and efficient delivery of bioactives together with their potential applications in vaccine production, cosmeceuticals, imaging and diagnostic purpose. Tissue engineering promotes rejuvenation process and involves the synchronized utilization of cells with 3D bio-material scaffolds to fabricate living structures. This strategy requires regulated stimulus of cultured cells through combined mechanical signals and bioactive agents. This review highlights and summarizes the mechanism involved in stem cell migration, strategies to enhance homing, safety and efficacy studies of stem cells in various disease models and discusses the potential role of liposomes in prolonged and localized delivery of bioactives for regenerative medicines and tissue engineering techniques. Graphical Abstract Role of PEGylated liposomes in cancer stem cell therapy.

Cells Undergo Major Changes in the Quantity of Cytoplasmic Organelles after Uptake of Gold Nanoparticles with Biologically Relevant Surface Coatings

Here, we use cryo soft X-ray tomography (cryo-SXT), which delivers 3D ultrastructural volumes of intact cells without chemical fixation or staining, to gain insight about nanoparticle uptake for nanomedicine. We initially used dendritic polyglycerol sulfate (dPGS) with potential diagnostic and therapeutic applications in inflammation. Although dPGS-coated gold nanoparticle (dPGS-AuNP) uptake followed a conventional endocytic/degradative pathway in human lung epithelial cell lines (A549), with cryo-SXT, we detected ∼5% of dPGS-AuNPs in the cytoplasm, a level undetectable by confocal light microscopy. We also observed ∼5% of dPGS-AuNPs in a rarely identified subcellular site, namely, lipid droplets, which are important for cellular energy metabolism. Finally, we also found substantial changes in the quantity of cytoplasmic organelles upon dPGS-AuNP uptake over the 1-6 h incubation period; the number of small vesicles and mitochondria significantly increased, and the number of multivesicular bodies and the number and volume of lipid droplets significantly decreased. Although nearly all organelle numbers at 6 h were still significantly different from controls, most appeared to be returning to normal levels. To test for generality, we also examined cells after uptake of gold nanoparticles coated with a different agent, polyethylenimine (PEI), used for nucleic acid delivery. PEI nanoparticles did not enter lipid droplets, but they induced similar, albeit less pronounced, changes in the quantity of cytoplasmic organelles. We confirmed these changes in organelle quantities for both nanoparticle coatings by confocal fluorescence microscopy. We suggest this cytoplasmic remodeling could reflect a more common cellular response to coated gold nanoparticle uptake.

Bioactive nanocomposite coatings under visible light illumination promoted surface-mediated gene delivery

Bioactive coatings with photothermal conversion ability were used to spatially and temporally control surface-mediated gene delivery under visible light illumination.

Targeted delivery of quercetin via pH-responsive zinc oxide nanoparticles for breast cancer therapy

Naturally occurring bioactive compounds are gaining much importance as anti-tumor agents in recent times due to their high therapeutic potential and less systemic toxicity. However, different preclinical and clinical studies have noted significant shortcomings, such as nonspecific tumor targeting and low bioavailability which limit their usage in therapeutics. Therefore, a safe and compatible nanoparticle mediated controlled drug delivery system is in high demand to enable effective transport of the drug candidates in the tumor tissue. Herein, we have synthesized phenylboronic acid (PBA) conjugated Zinc oxide nanoparticles (PBA-ZnO), loaded with quercetin (a bioflavonoid widely found in plants), with zeta potential around -10.2 mV and diameter below 40 nm. Presence of PBA moieties over the nanoparticle surface facilitates targeted delivery of quercetin to the sialic acid over-expressed cancer cells. Moreover, Quercetin loaded PBA-ZnO nanoparticles (denoted as PBA-ZnO-Q) showed pH responsive drug release behavior. Results suggested that PBA-ZnO-Q induced apoptotic cell death in human breast cancer cells (MCF-7) via enhanced oxidative stress and mitochondrial damage. In line with the in vitro results, PBA-ZnO-Q was found to be effective in reducing tumor growth in EAC tumor bearing mice. Most interestingly, PBA-ZnO-Q is found to reduce tumor associated toxicity in liver, kidney and spleen. The cytotoxic potential of the nanohybrid is attributed to the combinatorial cytotoxic effects of quercetin and ZnO in the cancer cells. Overall, the presented data highlighted the chemotherapeutic potential of the novel nanohybrid, PBA-ZnO-Q which can be considered for clinical cancer treatment.

A brief review of cytotoxicity of nanoparticles on mesenchymal stem cells in regenerative medicine

Multipotent mesenchymal stem cells have shown great promise for application in regenerative medicine owing to their particular therapeutic effects, such as significant self-renewability, low immunogenicity, and ability to differentiate into a variety of specialized cells. However, there remain certain complicated and unavoidable problems that limit their further development and application. One of the challenges is to noninvasively monitor the delivery and biodistribution of transplanted stem cells during treatment without relying on behavioral endpoints or tissue histology, and it is important to explore the potential mechanisms to clarify how stem cells work in vivo. To solve these problems, various nanoparticles (NPs) and their corresponding imaging methods have been developed recently and have made great progress. In this review, we mainly discuss NPs used to label stem cells and their toxic effects on the latter, the imaging techniques to detect such NPs, and the current existing challenges in this field.

SF-1 mediates reproductive toxicity induced by Cerium oxide nanoparticles in male mice

Background

Cerium oxide nanoparticles (CeO₂ NPs) have potential application for use in biomedical and in various consumer products. However, it is largely unclear whether CeO₂ NPs have effects on male reproductive function.

Methods

In this study, male mice were examined for toxicity, if any, following chronic oral administration of CeO₂ NPs for 32 days. In each animal, epididymides were examined for sperm motility and DNA integrity. Bloods were tested for testosterone levels. Testicular tissues were collected to determine the element Ce content, the daily sperm production (DSP), marker enzymes such as ACP, G6PD, γ-GT and SDH, mRNA expression levels of steroidogenesis genes Star, P450scc, P450c17, 3β-Hsd, and 17β-Hsd, as well as steroidogenic factor-1 (SF-1) gene/protein levels.

Results

The results showed that CeO₂ NPs (20 mg/kg and 40 mg/kg) increased the element Ce content in testis, the testis histopathological patterns and sperm DNA damage whereas decreased the testis weight, DSP and sperm motility. There were also remarkable reduction in testosterone levels and marker enzymes activities, down-regulated mRNA expression levels of several steroidogenesis genes such as Star, P450scc, P450c17, 3β-Hsd, and 17β-Hsd, as well as altered gene and protein expressions of SF-1.

Conclusion

These results reveal the male reproductive toxicity of chronic exposure of CeO₂ NPs in mice, hinting that the utilization of CeO₂ NPs need to be carefully evaluated about their potential reproductive toxicity on the human health.

Electronic supplementary material

The online version of this article (10.1186/s12951-019-0474-2) contains supplementary material, which is available to authorized users.

Stable Genetic Modification of Mesenchymal Stromal Cells Using Lentiviral Vectors

Mesenchymal stromal cell (MSC) therapy has produced very promising results for multiple diseases in animal models, with over 780 clinical trials on going or completed. However, most of the human clinical trials have not been as successful as trials using preclinical models. To improve the therapeutic potential of MSCs, different research groups have used gene transfer vectors to express factors involved in migration, survival, differentiation, and immunomodulation. The ideal gene transfer vector for most applications should achieve long-term, stable (constitutive or inducible) transgene expression in MSCs and their progeny. Given their efficiency and low impact on transduced cells, lentiviral vectors (LVs) are the vectors of choice. In this chapter we will describe a detailed protocol for the generation of genetically modified MSCs using lentiviral vectors (LVs). Although this protocol has been optimized for MSC lentiviral transduction, it can be easily adapted to other stem cells by changing culture conditions while maintaining volumes and incubation times.

Synthesis and in vitro Evaluation of ADAM10 and ADAM17 Highly Selective Bioimaging Probes

A disintegrin and metalloproteinase (ADAMs) are membrane-bound metalloproteases responsible for the ectodomain shedding of various transmembrane proteins and play important roles in multiple relevant biological processes. Their altered expression is involved in several pathological conditions, and in particular ADAM10 or ADAM17 overexpression is found in various forms of cancer. To better understand how they are regulated in the cellular context, it is useful to visualize the specific ADAMs pathway by means of molecular imaging techniques. For this purpose, we synthesized bioactive fluorescent probes suitable for cell imaging and that are able to specifically target ADAM10 or ADAM17. Two previously developed ADAM17- and ADAM10-selective inhibitors were chosen for conjugation, respectively, to a Cy5.5 dye and to Cy5.5 and FITC dyes. Herein we also report the synthesis of a gold-labeled compound as an additional bioimaging probe for ADAM10. The newly synthesized ligands were found to be active in vitro on human recombinant ADAM10 and/or ADAM17, showing IC₅₀ values in the nanomolar range and a good selectivity over matrix metalloproteinases (MMPs). Finally, these newly developed probes were successfully used for ADAMs staining on different lymphoma cell lines and lymph node mesenchymal stromal cells.

Stem cells as delivery vehicles for regenerative medicine-challenges and perspectives

The use of stem cells as carriers for therapeutic agents is an appealing modality for targeting tissues or organs of interest. Combined delivery of cells together with various information molecules as therapeutic agents has the potential to enhance, modulate or even initiate local or systemic repair processes, increasing stem cell efficiency for regenerative medicine applications. Stem-cell-mediated delivery of genes, proteins or small molecules takes advantage of the innate capability of stem cells to migrate and home to injury sites. As the native migratory properties are affected by in vitro expansion, the existent methods for enhancing stem cell targeting capabilities (modified culture methods, genetic modification, cell surface engineering) are described. The role of various nanoparticles in equipping stem cells with therapeutic small molecules is revised together with their class-specific advantages and shortcomings. Modalities to circumvent common challenges when designing a stem-cell-mediated targeted delivery system are described as well as future prospects in using this approach for regenerative medicine applications.

Stem cells as delivery vehicles for regenerative medicine-challenges and perspectives

The use of stem cells as carriers for therapeutic agents is an appealing modality for targeting tissues or organs of interest. Combined delivery of cells together with various information molecules as therapeutic agents has the potential to enhance, modulate or even initiate local or systemic repair processes, increasing stem cell efficiency for regenerative medicine applications. Stem-cell-mediated delivery of genes, proteins or small molecules takes advantage of the innate capability of stem cells to migrate and home to injury sites. As the native migratory properties are affected by in vitro expansion, the existent methods for enhancing stem cell targeting capabilities (modified culture methods, genetic modification, cell surface engineering) are described. The role of various nanoparticles in equipping stem cells with therapeutic small molecules is revised together with their class-specific advantages and shortcomings. Modalities to circumvent common challenges when designing a stem-cell-mediated targeted delivery system are described as well as future prospects in using this approach for regenerative medicine applications.

Molecular design of upconversion nanoparticles for gene delivery

Due to their large anti-Stokes shifts, sharp emission spectra and long excited-state lifetimes, upconversion nanoparticles (UCNPs) have attracted an increasing amount of research interests, and have shown great potential for enhancing the practical utility of gene therapy, whose versatility has been limited by existing gene delivery technologies that are basically mono-functional in nature. Despite this, up to now in-depth analysis of the development of UCNPs for gene delivery has been scant in the literature, even though there has been an upsurge of reviews on the chemistry of UCNPs and their applications in bioimaging and drug delivery. To fill this gap, this review aims to present the latest advances in the development and applications of UCNPs as gene carriers. Prior to describing the prominent works published in the field, a critical view on the properties, chemistry and molecular design of UCNPs for gene delivery is provided. With a synopsis of the recent advances in UCNP-mediated gene delivery, challenges and opportunities could be illuminated for clinical translation of works in this nascent field of research.

Adipose Tissue Formation Utilizing Fat Flap Distraction Technique

Co-regulation between adipocytes and supporting vasculature is considered an important process in adipose tissue generation. The objective of this study was to evaluate the mechanical and biological effects of a distraction technique on adipose tissue formation and maintenance. Based on the hypothesis that fat flaps gradually receding from each other can develop an adipose tissue construct, perforated polycarbonate syringe-shaped chambers were implanted in a rabbit model. Latency (1 week) and distraction (3 weeks) periods were followed by a consolidation period in the experimental groups (4, 8, and 12 weeks). In the distraction group, the volume of fat pad gradually increased up to 16 weeks. A transition zone was observed at 8 weeks, indicating the initiation of tissue generation. Histomorphologic analysis showed adipose and collagen connective tissue at 8 weeks. At 16 weeks, the relative composition was altered significantly. Adipose components occupied most of the tissue, and connective tissue was reduced. Blood vessels with endothelial lining were noted adjacent to adipocyte clusters, as well as in inter-adipocyte areas. The vessels had increased in number and were evenly distributed by 16 weeks. Our distraction technique produced more balanced adipose tissue generation than a non-distraction method, with co-development of adipose and vascular tissues.