熊去氧胆酸抗免疫性大鼠肝纤维化作用的研究

目的　研究熊去氧胆酸 (UDCA)对免疫性大鼠肝纤维化的影响 ,并探讨其作用机制。方法　 3 6只SD大鼠随机分为 3组。 2 4只大鼠腹腔内注射猪血清 (每周 2次 ,共 8周 )诱导建立肝纤维化模型 ;其中 12只予以UDCA[15mg/(kg·d]干预 (UDCA组 ) :余 12只为模型组。对照组 12只大鼠未予任何处理。 8周后处死动物。观察肝组织纤维化程度、胶原表达及血清透明质酸 (HA) ;羟脯氨酸 (Hyp)水平的变化 ;免疫组化染色观察α 平滑肌肌动蛋白 (α SMA)、转化生长因子 β1(TGF β1)及核因子κB(NFκBp65 )表达的情况 ;各组结果分别进行比较。结果　模型组大鼠肝内胶原面积明显高于对照组 ( 11 1± 2 0 9vs 0 73± 0 15 ,P <0 0 5 ) ,血清HA、Hyp及α SMA、TGF β1,NFκBp65在肝内的表达亦显著增高 (P <0 0 5 )。与模型组相比较 ,UDCA组肝内胶原面积无明显变化 ( 9 49±1 3 1vs 11 1± 2 0 9,P >0 0 5 ) ,其余指标在两组间均无显著性差异 (P >0 0 5 )。结论　一般剂量的UDCA对大鼠免疫性肝纤维化无显著改善作用     

安体舒通抗肝纤维化作用实验性研究

目的　研究和评估安体舒通对实验性大鼠肝纤维化的防治作用 ,探讨其抗肝纤维化作用的可能机制。结果　将雄性Wistar大鼠 80只随机分为正常对照组 (A组 ,16只 ) ,肝纤维化模型组Ⅰ (B组 ,5 4只 ) ,安体舒通治疗组Ⅰ (C组 ,10只 ) ,采用CCl4 复合因素造模 ,治疗组于造模同时予安体舒通每日 10 0mg·kg-1·mL-1灌胃 ,6周末造模成功处死C组大鼠 ,同时随机处死A组及B组大鼠各 8只 ;对B组剩下大鼠行二次随机分组 ,分为模型对照组Ⅱ (D组 ,12只 ) ,安体舒通治疗组Ⅱ (E组 ,10只 ) ,E组于第 7周开始给予安体舒通治疗 ,10周末处死大鼠。检测大鼠肝功能 ,血清透明质酸 (HA) ,层粘蛋白 (LN) ,Ⅲ型前胶原 (PCⅢ ) ,Ⅳ型胶原 (CIV) ;免疫组化法检测肝组织基质金属蛋白酶组织抑制因子 (TIMP -1)的表达。结果　C组与B组比较 ,血清ALT、AST、HA、LN、CIV、PCⅢ均显著降低 (P <0 .0 1) ,TIMP -1活性明显降低 (0 .34± 0 .0 5vs 0 .45± 0 .0 5 ,P <0 .0 1) .E组与D组相较 ,TIMP -1活性亦有明显降低(0 .31± 0 .0 7vs 0 .42± 0 .0 6,P <0 .0 1)。结论　安体舒通对肝纤维化有一定预防作用 ,并可能通过抑制TIMP -1活性表达而促进肝细胞外基质降解     

氧化苦参碱预防半乳糖胺诱导的大鼠肝纤维化的实验研究

目的　观察氧化苦参碱预防大鼠肝纤维化的疗效并探讨其作用机制。方法　采用半乳糖胺诱导的大鼠肝纤维化模型 ,观察氧化苦参碱 ( 30mg/kg、90mg/kg)干预前后肝指数、血及肝组织生化、羟脯氨酸含量、TGFβ1mRNA表达水平、电镜及病理组织学改变。结果　氧化苦参碱预防组较模型组ALT、AST下降 ,肝组织羟脯氨酸含量及TGFβ1表达水平降低 (P <0 .0 1) ;预防组肝组织内SOD、GST PX较模型组升高 ,而MDA低于模型组 ;电镜显示肝细胞损伤减轻 ,病理组织学明显改善。免疫组化显示预防组desmin及α SMA的表达明显低于模型组。结论　氧化苦参碱对半乳糖胺诱导的肝纤维化有预防作用 ,其机制为通过抗脂质过氧化而保护肝细胞、抑制肝星状细胞活化 ,从而抑制纤维生成。     

氧化苦参碱预防肝纤维化的实验研究

目的　观察氧化苦参碱预防大鼠肝纤维化的疗效并探讨其作用机制。方法　建立半乳糖胺和二甲基亚硝胺大鼠肝纤维化模型 ,观察氧化苦参碱 (3 0mg/kg、90mg/kg)预防前后肝指数、血及肝组织生化、羟脯氨酸含量、TGFβ1mRNA表达、电镜及病理组织学改变。结果　氧化苦参碱预防组较模型组肝功能改善、肝组织羟脯氨酸含量及TGFβ1表达水平降低 (P <0 .0 1) ;预防组肝组织内SOD、GST PX较模型组升高 ,而MDA低于模型组 ;电镜显示肝细胞损伤减轻 ,病理组织学明显改善。结论　氧化苦参碱对半乳糖胺及二甲基亚硝胺诱导的肝纤维化均有预防作用 ,其主要机制为抗脂质过氧化、保护肝细胞和抑制肝星状细胞活化 ,从而抑制纤维生成等     

氧化苦参碱防治二甲基亚硝胺诱导的大鼠肝纤维化的实验研究

目的　观察氧化苦参碱预防及治疗大鼠肝纤维化的疗效并探讨其作用机制。方法　采用二甲基亚硝胺诱导的大鼠肝纤维化模型 ,观察氧化苦参碱 (30mg/kg、90mg/kg)干预前后肝指数、血及肝组织生化、羟脯氨酸含量、肿瘤坏死因子 (TGF) β1mRNA表达水平、电镜及病理组织学改变。结果　氧化苦参碱干预组较模型组丙氨酸转氨酶、天冬氨酸转氨酶下降 ,肝组织羟脯氨酸含量及TGF β1mR NA表达水平降低 (P <0 .0 1) ;干预组肝组织内超氧化物歧化酶、谷胱甘肽过氧化物酶较模型组升高 ,而丙二醛低于模型组 ;电镜显示肝细胞损伤减轻 ,病理组织学改善。结论　氧化苦参碱对二甲基亚硝胺诱导的肝纤维化有预防及治疗作用 ,其部分机制为通过抗脂质过氧化而保护肝细胞、抑制纤维生成等     

雌二醇对肝纤维化大鼠Ⅰ,Ⅲ型胶原及TGFβ1表达的影响

目的:观察雌二醇对肝纤维化大鼠肝脏胶原沉积和转化生长因子β_1(TGF β_1)表达的影响,研究雌激素对肝纤维化形成的抑制作用,并探讨其可能的机制。方法:设立模型组、治疗对照组、雌二醇组和正常对照组,以四氯化碳复合因素诱导大鼠肝纤维化动物模型,雌二醇组在四氯化碳应用的同时皮下注射苯甲酸雌二醇1mg/kg,2次/wk,共8wk。大鼠肝脏HE染色与Masson染色,分级观察肝组织的炎性坏死与胶原纤维沉积变化,并观察对大鼠肝纤维化形成过程中肝脏表达Ⅰ,Ⅲ型胶原蛋白及对TGF β_1的影响。结果:与正常对照组比较,四氯化碳模型大鼠出现典型的肝纤维化表现,肝脏胶原纤维间隔广泛形成,肝小叶与肝窦内胶原增生沉积明显,Ⅰ,Ⅲ型胶原(0.58±0.26vs 6.34±2.24,1.07±0.49 vs 5.28±1.28,P值均<0.001)及TGF β_1基因表达明显增多;雌二醇应用可以明显减轻肝脏内胶原纤维增生沉积P<0.05),抑制肝脏Ⅰ、Ⅲ型胶原蛋白(2.47±0.76 vs 6.34±2.24,3.02±1.20 vs5.28±1.28,P值均<0.05)及TGF β_1的合成表达。结论:雌二醇可抑制肝纤维化大鼠肝脏Ⅰ,Ⅲ型胶原蛋白及TGF β_1的合成表达,发挥对肝纤维化的抑制作用。     

IL-10对实验性肝纤维化大鼠转化生长因子β1表达的影响

目的探讨TGFβ1在实验性肝纤维化过程中的表达状况及IL-10对肝纤维化大鼠转化生长因子β1(TGFβ1)表达的影响.方法建立大鼠肝纤维化模型并行IL-10干预实验.从正常对照组(C组)和CCl4诱导肝纤维化模型组(M组)及IL-10干预肝纤维化组(T组)中取肝脏组织,采用S-P免疫组织化学方法检测分析不同组大鼠在肝纤维化进程的不同阶段肝组织中TGFβ1表达的情况.结果成功建立大鼠肝纤维化模型;随着肝纤维化程度的加重,TGFβ1在肝组织中阳性表达明显增强;经Ridit分析,C组与M组间TGFβ1阳性表达水平有显著性差异(P＜0.01);T组TGFβ1阳性表达较M组明显减弱,经Ridit分析,组间差异有显著性(P＜0.01).结论TGFβ1的阳性表达随着肝纤维化程度的进展升高,外源性IL-10对CCl4诱导的肝纤维化中TGFβ1的表达具有明显拮抗作用.     

肝力克对肝纤维化大鼠肝组织转化生长因子β1 mRNA表达的影响

[目的 ]探讨中药复方肝力克对肝纤维化大鼠肝组织转化生长因子 β1(TGF β1)mRNA表达的影响。 [方法 ]用 4 0 ?l4皮下注射建立SD大鼠肝纤维化模型。造模结束后 ,给予不同剂量的肝力克和秋水仙碱灌胃治疗 9周。采用原位杂交法观察大鼠肝组织中TGF β1mRNA的表达情况。 [结果 ]肝纤维化模型组大鼠肝组织TGF β1mRNA阳性表达较正常对照组明显升高 (P <0 .0 1) ;应用肝力克大、中、小剂量和秋水仙碱治疗后 ,大鼠肝组织TGF β1mRNA阳性表达均较肝纤维化模型组明显降低 (P <0 .0 1,<0 .0 5 )。肝纤维化模型组大鼠肝组织纤维化计分与TGF β1表达程度呈明显正相关 (r =0 .80 1,P <0 .0 1)。 [结论 ]肝纤维化大鼠肝组织TGF β1mRNA表达程度与肝纤维化的发生发展有密切关系 ;中药肝力克降低肝纤维化大鼠肝组织TGF β1mRNA的表达可能是其抗肝纤维化的作用途径之一。     

大鼠肝纤维化模型肝细胞凋亡及肝细胞坏死的动态分析

目的　观察肝细胞凋亡和肝细胞坏死在肝纤维化形成过程中的变化 ,探讨其在肝纤维化发病机制中的作用。方法　雄性Wistar大鼠 32只 ( 85～ 95克 )随机分为 4组。A ,B ,C为实验组 ,采用腹腔注射CCl4 的方法造模 ;D为对照组 ,代之以生理盐水。于 2 ,4,6周末分别处死A ,B ,C三组大鼠 ,D组同期处理。取肝脏石蜡包埋 ,连续切片做病理学检查、细胞凋亡原位检测。测定血清ALT。结果　病理学检查A ,B ,C ,D四组分别符合肝纤维化的S1,S3 ,S4 ,S0 期。各实验组 (A ,B ,C)的肝细胞坏死记分值均高于对照组 (D) ( 1 6 7± 0 82 ) ,( 2 83± 0 75 ) ,( 2 5 0± 1 0 5 )vs( 0 16± 0 4 1) ,(P <0 0 1) ,肝细胞凋亡级数也均高于对照组 (D) ( 2 5 0± 0 5 5 ) ,( 2 83± 0 4 1) ,( 2 0 0± 0 6 3)vs( 0 33± 0 5 2 ) ,(P <0 0 1)。各实验组 (A ,B ,C)的ALT均高于对照组 (D) ( 76 83± 2 1 87) ,( 117 0 0±15 94) ,( 10 3 6 7± 36 6 8)vs( 39 16± 2 32 ) ,(P <0 0 5 )。结论　肝细胞凋亡和肝细胞坏死在肝纤维化发生过程中存在动态变化 ,二者在其不同时期发挥的作用不同。     

实验性肝纤维化大鼠细胞因子及超微结构的变化和意义

目的:研究四氯化碳(CCl4)诱导肝纤维化大鼠肝脏转化生长因子β1(TGFβ1)和结缔组织生长因子(CTGF)的表达及定位,血清IL-6、IL-10和IL-18的变化,以及肝组织超微结构的改变.方法:将28只大鼠随机分为正常对照组与模型组,模型组大鼠予以40?l4皮下注射8周后处死.免疫组化技术检测TGFβ1和CTGF在肝脏的表达及细胞内的定位;ELISA检测血清IL-6、IL-10和IL-18;电镜检测肝组织超微变化.结果:与正常组大鼠比较,模型组大鼠肝内TGFβ1和CTGF表达增加,免疫阳性反应信号的主要位于纤维间隔中的细胞浆;模型组大鼠血清IL-6和IL-18升高,而IL-10较正常组降低(P＜0.05 or P＜0.01);超微结构符合肝纤维化改变.结论:TGFβ1、CTGF、IL-6、IL-10和IL-18与肝纤维化的形成发展有关,可作为抗肝纤维化的新途径.     

胰岛素瘤的解剖分布特点分析

目的胰岛素瘤是最常见的胰腺神经内分泌肿瘤，因其临床表现多样，导致诊断困难。影像学诊断尤其是超声内镜(EUS)在胰岛素瘤的诊断中起着重要作用，拥有较高的敏感性和特异性。本研究拟通过明确胰岛素瘤的解剖分布特点，以期有助于提高影像学的诊断准确率和降低漏诊率，尤其是在教育和培训实践中对于EUS的学习者更具有指导价值。 方法回顾性分析解放军总医院第一医学中心病案资料数据库1993年1月至2019年11月经外科手术、病理确诊为胰岛素瘤的患者的临床资料，检索方法采取搜索术后病理诊断为"胰岛素瘤"的病例，通过查阅病例的方法，提取出胰岛素瘤的大小和解剖分布等数据，进一步分析其特点。 结果共检索到确诊为胰岛素瘤的患者116例，其中，男45例、女71例，年龄13～76岁，平均年龄(44.4±14.85)岁。胰岛素瘤单发110例(94.8%)、多发6例(5.2%)。位置分布：头颈部46例(39.7%)，单发45例、多发1例；体尾部68例(58.6%)，单发65例、多发3例；全胰腺多发2例(1.7%)。病变大小特点：最大径0.4～3.4 cm，平均大小(1.53±0.58)cm。≤1 cm 29例、>1 cm而≤1.5 cm41例、>1.5 cm而≤2.0 cm28例，≤3 cm 15例，>3 cm 3例。年龄与肿瘤的大小相关，≤44岁患者肿瘤平均大小为(1.36±0.51)cm、>44岁患者肿瘤平均大小为(1.70±0.60)cm，P<0.05。头颈部的肿瘤大于体尾部的肿瘤，头颈部肿瘤平均大小(1.66±0.63)cm，体尾部(1.42±0.52)cm，P<0.05。 结论胰岛素瘤在胰腺体尾部较头颈部更好发；绝大多数单发，但可以全胰腺多发；多数小于1.5 cm，肿瘤的大小与患者年龄和肿瘤的解剖分布相关。     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease

BACKGROUND AND AIM: Both the clinical presentation and the degree of mucosal damage in coeliac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease. PATIENTS AND METHODS: We correlated mode of presentation (classical, diarrhoea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time. RESULTS: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy (p=0.052). There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy, though the majority still had total villous atrophy. CONCLUSIONS: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhoea in coeliac disease.     

Demonstration of the mechanism of action of biguanides

Summary Palmitic acid oxidation in rat diaphragm homogenate is depressed by biguanide concentrations that are still incapable of inhibiting oxidative phosphorylation. Glucose oxidation is not directly effected by the same biguanide concentrations: however, the inhibitory effect of palmitic acid on glucose oxidation is partly removed by biguanides. Inhibition of fatty acid oxidation, which accounts for most of the metabolic effects caused by these drugs, can be regarded as the fundamental mechanism of action of biguanides. There is some evidence suggesting that these drugs might interact with carnitine, thus preventing long-chain fatty acids from being transported across the mitochondrial membrane to the site of oxidation. Traduzione a cura degli AA.     

血吸虫童虫生长发育及其机制的研究进展

血吸虫童虫是宿主免疫系统攻击的重要靶标,包括皮肤型、肺型和肝门型童虫。宿主分子对童虫生长发育具有重要作用。童虫生长发育机制包括免疫调节、信号转导、性别发育及凋亡等。肌动蛋白、组织蛋白酶、烯醇化酶和葡萄糖基转移酶等分子为血吸虫童虫生长发育的重要分子。本文对血吸虫童虫生长发育及其机制的研究进展做一综述。     

124例耐多药结核分枝杆菌基因突变特征分析

目的对临床分离的耐多药结核分枝杆菌相关基因的突变特征进行分析。方法对124例耐多药结核分枝杆菌以及50株敏感株的耐药相关基因(包括异烟肼inh A、kat G、oxyR-ahp C间隔区以及利福平rpo B)进行序列测定,分析其基因突变情况。结果异烟肼耐药inh A基因突变率为14.5%;kat G基因突变率为70.2%(87/124),主要位于315位;oxyR-ahp C间隔区突变率为15.3%;inh A、kat G两种基因同时突变率75.0%,三种基因同时突变率为89.5%。利福平rpo B基因突变的检出率高达95.2%,突变主要发生在531、526、516位点。结论我省耐多药菌异烟肼耐药相关基因最常见突变为kat G 315、inh A C-T(-15)、axyR-ahp C间隔区(-10)C-T,利福平为rpo B531、526、516。结合MDR-TB耐药相关基因的特征分析,可以建立一种快速、准确、特异的适合于我省的检测结核菌耐多药性的新方法。     

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low. Received: 26 September 2001 / Accepted: 8 February 2002     

Numerical Simulation of the Effect of Rate of Change of Glucose on Measurement Error of Continuous Glucose Monitors

Background

A 5-day in-patient study designed to assess the accuracy of the FreeStyle Navigator® Continuous Glucose Monitoring System revealed that the level of accuracy of the continuous sensor measurements was dependent on the rate of glucose change. When the absolute rate of change was less than 1 mg•dl⁻¹•min⁻¹ (75% of the time), the median absolute relative difference (ARD) was 8.5%, with 85% of all points falling within the A zone of the Clarke error grid. When the absolute rate of change was greater than 2 mg•dl⁻¹•min⁻¹ (8% of the time), the median ARD was 17.5%, with 59% of all points falling within the Clarke A zone.

Method

Numerical simulations were performed to investigate effects of the rate of change of glucose on sensor measurement error. This approach enabled physiologically relevant distributions of glucose values to be reordered to explore the effect of different glucose rate-of-change distributions on apparent sensor accuracy.

Results

The physiological lag between blood and interstitial fluid glucose levels is sufficient to account for the observed difference in sensor accuracy between periods of stable glucose and periods of rapidly changing glucose.

Conclusions

The role of physiological lag on the apparent decrease in sensor accuracy at high glucose rates of change has implications for clinical study design, regulatory review of continuous glucose sensors, and development of performance standards for this new technology. This work demonstrates the difficulty in comparing accuracy measures between different clinical studies and highlights the need for studies to include both relevant glucose distributions and relevant glucose rate-of-change distributions.     

氯硝柳胺悬浮剂的毒性评价

目的评价氯硝柳胺悬浮剂的毒性，为现场大规模应用灭螺提供依据。方法按照中华人民共和国国家标准GB 15670-1995《农药登记毒理学试验方法》和鱼类毒性试验方法进行。结果经口、经皮肤的LDso雌、雄性大鼠均>5 000 mg/kg，经呼吸道的LCso雌、雄性大鼠均>5 000mg/m3，该药经口、经皮肤、经呼吸道毒性均属微毒类药物；兔眼用药后，观察期内无不良反应，对眼无刺激性；皮肤用药后对皮肤无刺激性。与氯硝柳胺原药、氯硝柳胺乙醇胺盐原药和氯硝柳胺乙醇胺盐可湿性粉剂相比，氯硝柳胺悬浮剂对鱼急性毒性最低。结论氯硝柳胺悬浮剂属微毒类药物，对鱼的毒性低于其乙醇胺盐可湿性粉剂，适合于现场应用。     

Study of constancy of hydrogen-consuming flora of human colon

The constancy of the hydrogen consuming flora of the human colon was studied in 15 healthy subjects via two measurements obtained 18 to 36 months apart. Hydrogen disappearance rate and the major products of H₂-consuming bacteria, methane and sulfide, were measured during incubation of fecal homogenates with excess hydrogen and sulfate. In 11/15, the hydrogen consumption rate and the predominant hydrogen-consuming pathway (methanogenesis, sulfate reduction, or neither) remained constant. However, major shifts in these pathways were observed in four subjects, with two losing and two gaining the ability to produce methane. Methanogenesis was associated with the highest hydrogen consumption rate. This study demonstrates that clinically unrecognizable, major alterations of the colonic flora occur in healthy subjects. Understanding of the factors responsible for these alterations might allow for therapeutic manipulation of the colonic flora.Supported in part by the Department of Veterans Affairs and NIDDKD RO1 DK 13309-25.