Transcriptomic Analysis of Retinal Gene in Experimental Retinal Detachment Rats and Exploration of S100A9 and TLR4 in Human Vitreous

PURPOSE

To screen for the differentially expressed genes in experimental retinal detachment rats, and to explore the expression of S100 calcium-binding protein A9 and Toll-like receptor 4 in the vitreous of rhegmatogenous retinal detachment patients.

METHODS

Three rats of experimental retinal detachment and three normal rats were enrolled in the study. Transcriptomics (RNAseq) sequencing technology was used to screen differentially expressed genes in the retinas of the experimental retinal detachment group and the normal group. The selected differentially expressed genes for gene ontology and Kyoto Encyclopedia of Genes and Genomes functional enrichment analysis were performed. In addition, the vitreous of 15 patients with rhegmatogenous retinal detachment and six patients with the control group were collected. The expressions of S100 calcium-binding protein A9 and Toll-like receptor 4 were detected by Elisa, and the differences in expression levels were analyzed statistically.

RESULTS

A total of 198 differentially expressed genes were screened by RNAseq sequencing, including 118 upregulated genes and 80 downregulated genes. Kyoto Encyclopedia of Genes and Genomes analysis confirmed that the most enriched pathway was the mitogen-activated protein kinase signaling pathway. Compared to the normal group, the expressions of suppressor of cytokine signaling-3, Storkhead box-2, S100 calcium-binding protein A9, Spi-1 proto-oncogene, phosphodiesterase 1B, and kinesin-light chain 1 mRNA in the retinas of the experimental retinal detachment rats were up-regulated, and the expressions of Max interacting protein 1 and the voltage-gated sodium 1 were down-regulated. Compared to the control group, the expressions of S100 calcium-binding protein A9 and Toll-like receptor 4 were upregulated by Elisa in the vitreous humor of rhegmatogenous retinal detachment patients with a statistically significant difference (p all <.05).

CONCLUSION

The differentially expressed genes of experimental retinal detachment rats were suppressor of cytokine signaling-3, Storkhead box-2, S100 calcium-binding protein A9, Spi-1 proto-oncogene, phosphodiesterase 1B, kinesin-light chain 1, Max interacting protein 1, voltage-gated sodium 1, etc. The differences of S100 calcium-binding protein A9 and Toll-like receptor 4 expressions between the rhegmatogenous retinal detachment patients and the control group were statistically significant, indicating that they may play a potential role in the inflammatory process of rhegmatogenous retinal detachment.

Circ-MKLN1/miR-377-3p/CTGF Axis Regulates the TGF-β2-induced Posterior Capsular Opacification in SRA01/04 Cells

OBJECTIVE

Posterior capsular opacification (PCO) is a common postoperative ocular complication after cataract surgery. Little research focused on the regulation of circular RNAs (circRNAs) in PCO. This study was designed to investigate the function of circRNA-muskelin (circ-MKLN1) in PCO.

METHODS

SRA01/04 cells were treated with transforming growth factor (TGF)-β2. Cell viability was analyzed by Cell Counting Kit-8 (CCK-8) assay. Transwell assay was used for cell migration and invasion detection. Cell migration was also measured by wound healing assay. Epithelial-mesenchymal transition (EMT)-related proteins and connective tissue growth factor (CTGF) were quantified using western blot.

RESULTS

Cell viability, migration, invasion and EMT process in SRA01/04 cells were facilitated by TGF-β2. Circ-MKLN1 expression was enhanced in 17 PCO lens samples relative to 19 normal lens samples and TGF-β2-treated SRA01/04 cells contrasted to control cells. Downregulation of circ-MKLN1 inhibited the effects of TGF-β2 on SRA01/04 cells. Circ-MKLN1 targeted miR-377-3p and the regulation of si-circ-MKLN1 for the TGF-β2-induced influences was related to the upregulation of miR-377-3p. CTGF was the target gene for miR-377-3p. CTGF knockdown also abolished the TGF-β2-mediated cell growth, migration and invasion of SRA01/04 cells. The function of miR-377-3p was achieved by reducing the CTGF level. TGF-β2-induced CTGF expression promotion was alleviated by si-circ-MKLN1 through upregulating the expression of miR-377-3p.

CONCLUSION

These results showed that circ-MKLN1 contributed to the progression of PCO in vitro by increasing the CTGF expression via sponging miR-377-3p. Circ-MKLN1 might be important for improving the molecular target therapy in PCO.

AI-Model for Identifying Pathologic Myopia Based on Deep Learning Algorithms of Myopic Maculopathy Classification and "Plus" Lesion Detection in Fundus Images

Background: Pathologic myopia (PM) associated with myopic maculopathy (MM) and “Plus” lesions is a major cause of irreversible visual impairment worldwide. Therefore, we aimed to develop a series of deep learning algorithms and artificial intelligence (AI)–models for automatic PM identification, MM classification, and “Plus” lesion detection based on retinal fundus images.

Materials and Methods: Consecutive 37,659 retinal fundus images from 32,419 patients were collected. After excluding 5,649 ungradable images, a total dataset of 32,010 color retinal fundus images was manually graded for training and cross-validation according to the META-PM classification. We also retrospectively recruited 1,000 images from 732 patients from the three other hospitals in Zhejiang Province, serving as the external validation dataset. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, accuracy, and quadratic-weighted kappa score were calculated to evaluate the classification algorithms. The precision, recall, and F1-score were calculated to evaluate the object detection algorithms. The performance of all the algorithms was compared with the experts’ performance. To better understand the algorithms and clarify the direction of optimization, misclassification and visualization heatmap analyses were performed.

Results: In five-fold cross-validation, algorithm I achieved robust performance, with accuracy = 97.36% (95% CI: 0.9697, 0.9775), AUC = 0.995 (95% CI: 0.9933, 0.9967), sensitivity = 93.92% (95% CI: 0.9333, 0.9451), and specificity = 98.19% (95% CI: 0.9787, 0.9852). The macro-AUC, accuracy, and quadratic-weighted kappa were 0.979, 96.74% (95% CI: 0.963, 0.9718), and 0.988 (95% CI: 0.986, 0.990) for algorithm II. Algorithm III achieved an accuracy of 0.9703 to 0.9941 for classifying the “Plus” lesions and an F1-score of 0.6855 to 0.8890 for detecting and localizing lesions. The performance metrics in external validation dataset were comparable to those of the experts and were slightly inferior to those of cross-validation.

Conclusion: Our algorithms and AI-models were confirmed to achieve robust performance in real-world conditions. The application of our algorithms and AI-models has promise for facilitating clinical diagnosis and healthcare screening for PM on a large scale.

Dehaze of Cataractous Retinal Images Using an Unpaired Generative Adversarial Network

Cataracts are the leading cause of visual impairment worldwide. Examination of the retina through cataracts using a fundus camera is challenging and error-prone due to degraded image quality. We sought to develop an algorithm to dehaze such images to support diagnosis by either ophthalmologists or computer-aided diagnosis systems. Based on the generative adversarial network (GAN) concept, we designed two neural networks: CataractSimGAN and CataractDehazeNet. CataractSimGAN was intended for the synthesis of cataract-like images through unpaired clear retinal images and cataract images. CataractDehazeNet was trained using pairs of synthesized cataract-like images and the corresponding clear images through supervised learning. With two networks trained independently, the number of hyper-parameters was reduced, leading to better performance. We collected 400 retinal images without cataracts and 400 hazy images from cataract patients as the training dataset. Fifty cataract images and the corresponding clear images from the same patients after surgery comprised the test dataset. The clear images after surgery were used for reference to evaluate the performance of our method. CataractDehazeNet was able to enhance the degraded image from cataract patients substantially and to visualize blood vessels and the optic disc, while actively suppressing the artifacts common in application of similar methods. Thus, we developed an algorithm to improve the quality of the retinal images acquired from cataract patients. We achieved high structure similarity and fidelity between processed images and images from the same patients after cataract surgery.

Retinal break associated with traumatic lens dislocation or subluxation requiring vitrectomy

BACKGROUND

Both ectopia lentis and retinal injury are common results of blunt ocular trauma. Here, we investigated the incidence and characteristics of retinal breaks associated with ectopia lentis caused by blunt ocular trauma.

METHODS

Patients who underwent pars plana vitrectomy to treat traumatic lens subluxation and dislocation were retrospectively reviewed. The incidence, characteristics, and outcomes of retinal breaks were analyzed.

RESULTS

Forty-five eyes from 45 patients were included in the study. Seventeen eyes (37.7%) were complicated by retinal breaks or detachment, but only four (8.9%) were identified pre-operation. Our study revealed that retinal breaks were more frequently located at the superior (72.7%) and peripheral (81.8%) retina. All patients achieved anatomic recovery post-surgery. The eyes with and without retinal breaks did not differ significantly with respect to initial or final visual acuity. The final visual outcomes were independently and significantly associated with visual acuity at presentation (P = 0.001).

CONCLUSIONS

Retinal breaks occurred in approximately one-third of patients with traumatic ectopia lentis and were difficult to observe pre-operation. Complete ophthalmic evaluation and timely intervention may help achieve favorable outcomes.

Altered Expression Profile of Circular RNAs in the Serum of Patients with Diabetic Retinopathy Revealed by Microarray

PURPOSE

Diabetic retinopathy (DR) is the leading cause of blindness among working age adults. Circular RNAs (circRNAs) are a kind of noncoding RNAs that are involved in the development of some diseases. Here, we aimed to determine the possible role of circRNAs in the pathogenesis of DR by determining the expression profile of circRNAs in the serum of DR patients.

METHODS

Nineteen subjects with type 2 diabetes mellitus with proliferative DR (T2DR), 15 subjects with type 2 diabetes mellitus without DR (T2DM), and 21 age-matched nondiabetic control subjects were included in the study. Expression profiles in the serum samples from 5 subjects of each group were studied by circular microarray and validated by quantitative real-time polymerase chain re- action (qRT-PCR) in another 40 subjects. Bioinformatic software was used to predict the microRNA response elements.

RESULTS

Thirty circRNAs were significantly upregulated in the serum of T2DR patients compared with the serum from both T2DM and control patients. Further, the altered expression of 7 circRNAs (hsa_circRNA_063981, hsa_circRNA_ 404457, hsa_circRNA_100750, hsa_circRNA_406918, hsa_ circRNA_104387, hsa_circRNA_103410, and hsa_circRNA_ 100192) were verified by qRT-PCR.

CONCLUSION

This study suggested a potential role of circRNAs in the pathogenesis of DR and provides novel molecular targets for clinical therapy.

Silencing Matrix Metalloproteinases 9 and 2 Inhibits Human Retinal Microvascular Endothelial Cell Invasion and Migration

PURPOSE

Proliferative retinal angiogenesis may severely impair the retina. Previous studies have indicated that matrix metalloproteinase (MMP)-2 and MMP-9 play important roles in the process of retinal angiogenesis. In this study, we suppressed MMP-2 and MMP-9 expression with RNA interference (RNAi) and then observed the inhibitory effects on the invasion and migration of human retinal microvascular endothelial cells (HRMECs).

METHODS

Small interfering RNAs against MMP-2 mRNA and MMP-9 mRNA were synthesized. After transfection, the MMP-2 and MMP-9 expression in HRMECs was examined by real-time polymerase chain reaction and Western blot analysis. Cell migration and invasion were measured with a migration assay and a scratch wound assay, respectively.

RESULTS

RNAi against MMP-2 and MMP-9 successfully inhibited the mRNA and protein expression of MMP-2 and MMP-9 in HRMECs. MMP-2 and MMP-9 knockdown could inhibit the invasion and migration of HRMECs.

CONCLUSIONS

These findings suggest that the RNAi approach towards MMP-2 and MMP-9 may be a potentially effective therapeutic method for the treatment of proliferative retinal angiogenesis.

MiR-181a confers resistance of cervical cancer to radiation therapy through targeting the pro-apoptotic PRKCD gene

The purpose of this study was to define the roles of miR-181a in determining sensitivity of cervical cancer to radiation therapy, to explore the underlying mechanism and to evaluate the potential of miR-181a as a biomarker for predicting radio-sensitivity. Tumor specimens from 18 patients with a histological diagnosis of squamous cervical carcinoma (stage IIIB) were used in the micro-RNA profiling and comparison. These patients never received any chemotherapy before radiation therapy. Human cervical cancer cell lines, SiHa and Me180, were used in vitro (cell culture) and in vivo (animal) studies. Transfection of tumor cells with the mimic or inhibitor of miR-181a, and reporter gene assay, were performed to investigate the role of miR-181a in determining radio-sensitivity and the target gene. Higher expression of miR-181a was observed in human cervical cancer specimens and cell lines that were insensitive to radiation therapy, as compared with sensitive cancer specimens and the cell lines. We also found that miR-181a negatively regulated the expression of PRKCD, a pro-apoptotic protein kinase, via targeting its 3'-untranslated region (UTR), thereby inhibiting irradiation-induced apoptosis and decreasing G2/M block. The role of miR-181a in conferring cellular resistance to radiation treatment was validated both in cell culture models and in mouse tumor xenograft models. The effect of miR-181a on radio-resistance was mediated through targeting the 3'-UTR of PRKCD gene. Thus, the expression level of miR-181a in cervical cancer may serve as a biomarker for sensitivity to radiation therapy, and targeting miR-181a may represent a new approach to sensitizing cervical cancer to radiation treatment.

Protective effect of perindopril on diabetic retinopathy is associated with decreased vascular endothelial growth factor-to-pigment epithelium-derived factor ratio: involvement of a mitochondria-reactive oxygen species pathway

OBJECTIVE

This study aimed to verify whether the decreased vascular endothelial growth factor (VEGF)-to-pigment epithelium-derived factor (PEDF) ratio can serve as an indicator for the protective effect of angiotensin-converting enzyme inhibitors (ACEIs) on diabetic retinopathy (DR) and to investigate the role of mitochondrial reactive oxygen species (ROS) in the downregulated VEGF-to-PEDF ratio.

RESEARCH DESIGN AND METHODS

Diabetic rats and control animals were randomly assigned to receive perindopril or vehicle for 24 weeks, and bovine retinal capillary endothelial cells (BRECs) were incubated with normal or high glucose with or without perindopril. VEGF, PEDF, PPARgamma, and uncoupling protein-2 (UCP-2) in the rat retinas or BREC extracts were examined by Western blotting and real-time RT-PCR. The levels of VEGF and PEDF in cell culture media were examined by ELISA. Mitochondrial membrane potential (Deltapsim) and ROS production were assayed using JC-1 or CM-H2DCFDA.

RESULTS

The VEGF-to-PEDF ratio was increased in the retina of diabetic rats; perindopril lowered the increased VEGF-to-PEDF ratio in diabetic rats and ameliorated the retinal damage. In BRECs, perindopril lowered the hyperglycemia-induced elevation of VEGF-to-PEDF ratio by reducing mitochondrial ROS. We found the decreased ROS production was a result of perindopril-induced upregulation of PPARgamma and UCP-2 expression and the subsequent decrease of Deltapsim.

CONCLUSIONS

It is concluded that the protective effect of ACEI on DR is associated with a decreased VEGF-to-PEDF ratio, which involves the mitochondria-ROS pathway through PPARgamma-mediated changes of UCP-2. This study paves a way for future application of ACEI in treatment of DR.

[Transantral orbit decompression to malignant ophthalmopathy]

OBJECTIVE

To recognize the indication and the value of transantral orbit decompression to malignant ophthalmopathy.

METHOD

9 eyes of 5 cases undergone transantral orbital decompression from November 1986 to October 1998 were reviewed.

RESULT

After 3 months-2 years of follow-up. We found this approach successfully improved visual function of all 5 cases. Average proptosis reduction was 5 mm. The eye lids could be closed in 4 of the 5 cases and the palpebral fissures was decreased 1-2 mm in 1 of the 5 cases. Preoperative exposure keratitis resolved in both of the 2 cases. Diplopia was cured in both of the 2 cases. Secondary glucorna also recovered in both the 2 cases. Disturbance of ocular motility in both of the 2 cases improved postoperatively and preoperative visual acurity worsen also improved in both of the 2 cases.

CONCLUSION

It has been suggested that the transantral decompression of the orbit provided a safe, effective therapeutic modality for patients with vision-threatening or major cosmetic problem.

Detection of Mycobacterium bovis lymphocyte stimulating antigens in culture filtrates of a recombinant Mycobacterium smegmatis cosmid library

Culture filtrates derived from a Mycobacterium bovis cosmid library in Mycobacterium smegmatis were screened for bovine lymphocyte stimulatory antigens using peripheral blood mononuclear cells (PBMC) from cattle vaccinated with a low dose of Mycobacterium bovis BCG. Lymphocyte proliferation and interferon-gamma (IFN-gamma) production were used as cellular response markers for antigen recognition. In the primary screen, approximately 28% of all culture filtrates (CF) stimulated responses by PBMC from at least two out of four vaccinated cattle. In one of these CF, the M. bovis Ag85-B antigen was detected by Western-blot analysis. Despite heterogeneous lymphocyte responses of the animals, twenty-four of the culture filtrates stimulated lymphocyte proliferation and IFN-gamma production from at least six out of eight vaccinated animals in a secondary screen. Analysis of the cosmid DNA associated with these positive CF demonstrated that several contained homologous DNA sequences. It appears that the lymphocyte screening has detected M. bovis antigens that are immuno-dominant in cattle vaccinated with M. bovis BCG.

[Long-term results of surgical treatment of intractable Menière's disease for control of vertigo]

OBJECTIVE

To acquire the long-term (an average of over 10 years follow-up) results of surgical treatment of patients with Meniere's disease for control of vertigo.

METHOD

Endolymphatic sac surgery was done in 6 cases (1 case of endolymphatic sac decompression and 5 cases of sac-mastoid shunting) and translabyrinth vestibular neurotomy was operated on 6 cases.

RESULT

Complete relief from symptoms of vertigo occurred in the 6 cases through vestibular neurotomy and there were no recurrence in 11-13 years follow-up. Three of 6 cases with endolymphatic sac surgery had complete control of vertigo and were cured clinically. Symptoms of vertigo of the rest 3 cases were effectively controlled.

CONCLUSION

Endolymphatic sac surgery and translabyrinth vestibular neurotomy are effective way for control of vertigo of patients with intractable Meniere's disease. Translabyrinth vestibular neurotomy are more effective for control of vertigo for appropriately selected patients.

Leishmania mexicana: extracellular proton concentration is a key regulator of cysteine proteinase CPb expression

The purpose of this work was to determine which parameters trigger expression of proteins that are potentially important for the differentiation of Leishmania mexicana from the promastigote to the amastigote stage. To this effect, a protein-free axenic incubation system was used that supported the differentiation of L. mexicana promastigotes into amastigotes at 33 degreesC and at acidic pH. The predominant modification detected in SDS-PAGE patterns of extracted soluble proteins was the appearance in parasites cultured for 4 days of a strong 28-kDa protein band that displayed the same position and intensity as seen in amastigotes extracted from a mouse lesion. These molecules exhibited in gelatin gels the typical lytic pattern of cysteine proteinases (CPs) and were shown to belong to the CPb family, as further demonstrated by N-terminal amino acid sequencing. The expression of these enzymes was quantified by their lytic activity on the fluorogenic Z-F-R-AMC CP substrate. When the parasites were incubated at 33 degreesC for 3 days at various initial pHs, CPb started to be induced when the pH dropped below 5. When comparing cultures maintained at 26 or 33 degreesC for 3 days, it was seen that a rise in extracellular proton concentration (to pH 4.2-4.6) resulted in production of CPb at both temperatures (around 20-fold over the concentration measured in promastigotes cultured at 26 degreesC, pH >6). These results demonstrate that extracellular proton concentration is a key regulator of cysteine proteinase CPb synthesis and that an increase in temperature is neither necessary nor sufficient for the expression of this enzyme.

Apoptosis in the rat mammary gland and ventral prostate: detection of cell death-associated genes using a coincident-expression cloning approach

Apoptosis plays a striking role in the hormone-dependent involution of the mammary gland, but it has proved difficult to distinguish between the 'cell death' associated genes and the 'tissue remodelling' genes which are expressed concurrently. To identify cell death-associated genes, we have established a 'coincidence analysis' based on the previously described 'RNA differential display' method of Liang and Pardee (1992). Coincidence analysis allows the detection of genes expressed during related processes in different organs and was employed here to identify transcripts in which expression patterns are seen to be associated with apoptosis during involution of both rat mammary- and the ventral prostate glands. That the coincidence analysis is a promising approach can be seen from the fact that while widely accepted apoptosis markers such as transglutaminase (Fesus et al, 1987; Strange et al, 1992) and sulfated glycoprotein-2 (Buttyan et al, 1989; Strange et al, 1992; Guenette et al 1994) exhibited similar expression in both regressing tissues, transcription of tissue remodelling enzymes was minimal in the involuting prostate. We describe here the characteristics of five clones isolated which show coincident expression during programmed cell death in mammary and prostate tissues. Partial sequence analysis revealed for three clones high homologies with previously described genes; the putative rat homolog of the growth arrest gene gas-1 (Schneider et al, 1988; Del Sal et al, 1992), an homolog of the mouse 'Integrin Associated Protein' (IAP) (Brown et al, 1990; Lindberg et al, 1993) and the sequence encoding for the 'Allograft Inflammatory Factor' AIF-1 (Autieri et al, 1995; Utans et al, 1995). One clone displayed homology with an expressed human sequence tag and one clone unrelated to any known DNA sequence was isolated. The expression of these genes in involuting rat mammary and ventral prostate, was correlated with that in other organs and in situ hybridization was applied to establish that the secretory epithelial cells which undergo programmed cell death are the site of elevated expression during the course of involution. Furthermore, we conclude that the coincidence analysis approach described here could be easily applied to facilitate the characterization of gene expression i.e. for the detection and comparison of hormonally regulated genes in different organs.

DDC-4, an apoptosis-associated gene, is a secreted frizzled relative

The differential display method has been used in our laboratory as a coincidence analysis to isolate genes expressed in common in each of three different rat tissues undergoing physiological apoptosis: mammary gland, ovarian corpus luteum and ventral prostate. The most interesting of these isolates, DDC-4, shows a clear association with apoptosis, its expression being confined to these three organs, and only during their involution. Using DDC-4 as probe, we screened a rat ovarian cDNA library to obtain full-length isolates. One isolate, Y81 clone 40, gives rise to a protein of approximately 40 kDa with coupled in vitro transcription/translation. Sequencing of this clone indicates an open reading frame of 1044 nucleotides encoding a protein of 39.7 kDa with a putative signal sequence. This clone exhibits a high homology with the cysteine-rich domain, i.e. the ligand-binding domain, of the fizzled gene family originally defined as tissue polarity genes in Drosophila. The homology of Y81 clone 40 is most extensive with the newly described secreted frizzled relatives, the frzb subfamily.

Isolation of cell death-associated cDNAs from involuting mouse mammary epithelium

Although apoptosis is important in determining cell fate and maintaining tissue homeostasis, the initiation and control of apoptotic cell death in epithelium is not well understood. Post-lactationai involution of the mammary gland provides both an important developmental process and a normal physiological setting for studying apoptosis of epithelium. We used a differential screening strategy, based on previous studies correlating morphology with gene expression and nucleic acid integrity during mammary gland involution, to isolate genes involved in the regulation and execution of apoptotic cell death in regressing mammary epithelium. This screening strategy yielded a large number of genes the expression of which is significantly altered during mammary gland involution. These include genes associated with cell death processes, tissue remodelling and mesenchymal differentiation. In addition, a number of novel genes have been isolated. We have used Northern analysis and in situ hybridisation to study the expression of a selection of these putative death-associated genes during post-lactational mouse mammary gland involution.

Protein kinase A and AP-1 (c-Fos/JunD) are induced during apoptosis of mouse mammary epithelial cells

At weaning the mammary gland undergoes a reductive remodelling process (involution) which is associated with the cessation of milk protein gene expression and programmed cell death of milk-producing epithelial cells. Elevated nuclear protein kinase A (PKA) activity was observed from one day post-lactation, paralleled by increased c-fos, junB, junD and to a lesser extent c-jun mRNA levels. AP-1 DNA binding activity was transiently induced and the AP-1 complex was shown to consist principally of cFos/JunD. Oct-1 DNA binding activity and Oct-1 protein were gradually lost from the gland over the first 4 days of involution, whereas Oct-1 mRNA levels remained unchanged. Comparing nuclear extracts from normal mammary glands with nuclear extracts from glands which had been cleared of all epithelial cells 3 weeks after birth, revealed that PKA activation, AP-1 induction and Oct-1 inactivation all are dependent on the presence of the epithelial compartment. The increased Fos/Jun expression and the inactivation of Oct-1 may be consequences of the increased PKA activity. A similar induction of AP-1 (cFos/JunD) was also observed in the involuting rat ventral prostate pointing to a possible role for AP-1 in programmed cell death.