目的 本文旨在对全流程的生物安全管理问题进行梳理,为未来出现的大规模核酸筛查提供参考。方法 我们参考技术规范及其他医疗机构的实践总结,结合自身实际经验,梳理了核酸采集场所、个人防护、标本采集转运检测流程共3个方面的生物安全管理需注意的问题及解决措施。严格要求采样队伍按标准要求执行,以达到保质保量完成筛查任务的目的。结果 新冠核酸筛查期间我院共外派采集标本361 841人次。标本零污染零丢失,未发生一例生物安全事件,圆满完成采样任务。结论 大规模新冠核酸筛查是查清疫情源头、抑制疫情蔓延的重要手段。为了保证全流程的生物安全,应做好充足准备,严格落实各项生物安全措施。

Objective This article aims to sort out the problems in the whole process of biosafety management and provide reference for large-scale nucleic acid screening in the future. Methods We refer to the technical guidelines and the practice of other medical institutions, combined with our practical experience, summarized the problems and solutions needing attention in biosafety management in three aspects: nucleic acid sampling place, personal protection and the process from sample collection to detection. The sampling team was strictly required to implement the standard requirements, so as to complete the screening task with quality and quantity. Results A total of 361 841 samples were collected during SARS-CoV-2 nucleic acid screening. No samples were contaminated or lost, and no biosafety accident occurred. The sampling task were successfully completed. Conclusion Large-scale SARS-CoV-2 nucleic acid screening is an important method to find out the source of the epidemic and curb the spread of the SARS-CoV-2 pandemic. In order to ensure the biosafety of the whole process, sufficient preparations should be made and biosafety measures should be strictly implemented.

目的 上消化道出血发作急、变化快,具有较高的危险性,本研究目的在于分析急性上消化道出血患者的临床特征及危险因素,为临床诊治提供参考。方法 将2019年1月—2021年2月年我院的242例疑似急性上消化道出血患者作为研究对象,收集患者的年龄、性别、是否有长期抽烟史、饮酒史,是否有合并症以及并发症等一般资料,运用单因素分析其临床特征,运用多因素Logistic回归分析其独立危险因素。结果 患者年龄、长期饮酒史、消化性溃疡、门脉高压、急性胃黏膜病变、服用阿司匹林(ASA药物)、Hp感染等临床特征与急性上消化道出血具有相关性,与患者的性别、长期抽烟史不具有相关性;年龄、消化性溃疡、门脉高压、服用ASA药物、Hp感染是急性上消化道出血的危险性因素。结论 急性上消化道出血病势程度较重,死亡率高,出血需及时针对性治疗;对于急性上消化道出血高危患者,严密监测病情变化,评估其风险系数。

Objective Upper gastrointestinal bleeding has a high risk because of its rapid change. The purpose of this study is to analyze the clinical characteristics and risk factors of patients with acute upper gastrointestinal bleeding, so as to provide reference for clinical diagnosis and treatment. Methods A total of 242 patients with suspected acute upper gastrointestinal bleeding in our hospital from January 2019 to February 2021 were selected as the research objects. The general data such as patients' age, gender, whether they had a long-term history of smoking or drinking, whether they had complications and data of complications were collected. The clinical characteristics were analyzed by univariate analysis, and the independent risk factors were analyzed by multivariate Logistic regression analysis. Results Age, long-term drinking history, peptic ulcer, portal hypertension, acute gastric mucosal lesions, taking aspirin (ASA drugs), Hp infection and other clinical characteristics were correlated with acute upper gastrointestinal bleeding, but gender and long-term smoking history were not. Age, peptic ulcer, portal hypertension, taking ASA drugs and Hp infection were the risk factors of acute upper gastrointestinal bleeding. Conclusion The acute upper gastrointestinal bleeding is a serious disease, with high mortality, and the bleeding needs timely targeted treatment. For patients with high-risk acute upper gastrointestinal bleeding, closely monitor the changes of the disease and evaluate the risk coefficient are needed.

目的 统计分析Ⅲ型食管闭锁与食管气管瘘(esophageal atresia and tracheoesophageal fistula,EA-TEF)术后气管食管瘘复发(recurrent tracheoesophageal fistula,RTEF)的高危因素,并计算高危因素预测RTEF的能力。方法 回顾分析2015年9月—2021年1 月我院EA-TEF患儿的临床资料,并根据术后是否气管食管瘘复发分成复发组(recurrent组,R组)及无复发组(not recurrent组,NR组),比较两组患儿的基本情况、开放手术或胸腔镜手术、手术时间、气管食管瘘结扎方式等术中情况,统计分析RTEF的高危因素,分析其预测RTEF的能力。结果 研究期间共纳入Ⅲ型食管闭锁患儿154例,男98例,女56 例,R组11例,NR组143例,单因素对比分析R组与NR组患儿除吻合口瘘外其余均无统计学差异,其中R组吻合口瘘6人,占该组54.55%;NR组13人,占该组9.10%,P<0.001;Logistic回归模型调整后可见有吻合口瘘相对于无吻合口瘘发生RTEF的风险增加12倍(OR=12.000,95%CI:3.216~44.771)。结论 RTEF与患儿基本情况、术中情况无关,与吻合口瘘显著相关,且有吻合口瘘的患儿出现RTEF风险是无吻合口瘘患儿的12倍。

Objective To statistical analyze the high-risk factors of recurrent tracheoesophageal fistula (RTEF) after the repair of type Ⅲ esophageal atresia and tracheoesophageal fistula (EA-TEF),and evaluate the ability of these high-risk factors predicting RTEF. Methods Retrospectively analyzed the clinical data of children with type Ⅲ EA-TEF in our hospital from September 2015 to January 2021. Patients were divided into two groups (recurrent and non-recurrent group,R and NR group) according to whether there was RTEF. The general situation of those patients, situation during surgery like open or thoracoscopic surgery,operation time,method of tracheoesophageal fistula ligation were compared. Those factors of two groups were analyzed, the high-risk factors of RTEF were summarized, and Logistic regression analysis on the high-risk factors was performed to analyze the ability of predicting RTEF. Results A total of 154 infants with type Ⅲ EA-TEF were included in the study, 98 males, 56 females. There were 11 cases in R group, 143 cases in NR group. Univariate comparative analysis was carried out on R group and NR group, and no statistical differences were found except in anastomotic fistula. There were 6 patients in R group with anastomotic fistula, accounting for 54.55%, and 13 patients in NR group, accounting for 9.10%,P< 0.001. After adjusting the Logistic regression model with the high-risk factors, there was 12-fold increase in the risk of RTEF with anastomotic fistula (OR=12.000, 95%CI: 3.216~44.771) compared with no anastomotic fistula. Conclusion RTEF was not related to patients' general situation or surgery situation, but significantly related to anastomotic fistula. Patients who with anastomotic fistula had a 12-fold increase in the risk of RTEF compared with no anastomotic fistula.

目的 比较冷冻前和复苏后脐带血样本的造血功能,探讨冷冻袋附属小管是否可用于脐带血质量控制及移植供体发放前复核。方法 选取2009年3月—2021年2月在广州脐血库冻存的53份脐带血为研究对象,常规复温后,从冷冻袋和附属小管抽取样本,分为冷冻前、小管复苏和大袋复苏组。评价各组的总有核细胞(total nucleated cells,TNCs)数、细胞活率、CD34阳性细胞数量、粒-巨噬细胞集落(colony-forming units-granulocyte/macrophages, CFU-GMs)数量、祖细胞集落(colony-forming units, CFUs)数量等质量参数。结果 小管复苏后TNCs数量、细胞活率、CFU-GMs数量及CFUs数量较冷冻前均显著减少,差异有统计学意义(P＜0.05),而二者的CD34阳性细胞数量差异无统计学意义(P＞ 0.05);大袋复苏后TNCs数量、细胞活率及CFUs数量较冷冻前各相应值比较,差异有统计学意义(P＜0.05),而二者的CD34阳性细胞数量及CFU-GMs数量差异无统计学意义(P＞ 0.05);小管复苏后的TNCs数量、细胞活率、CD34阳性细胞活率、CFU-GMs数量及CFUs数量较大袋复苏后的相应值均减少,差异有统计学意义(P＜0.05),而二者的CD34阳性细胞数量差异无统计学意义(P＞ 0.05)。小管复苏与大袋复苏后的各项参数存在高度相关性。结论 附属小管在一定程度上可作为脐血库质量控制和产品发放前复核的取材。

Objective To compare the hematopoietic function of cord blood before and after cryopreservation, and to explore whether sampling from the attached segment can be used for quality control of cord blood units and confirmatory testing before transplantation. Methods A total of 53 cryopreserved cord blood units from March 2009 to February 2021 in Guangzhou Cord Blood Bank were enrolled in this study. After routine thawing, samples were taken from main bag and its attached segment. They were divided into pre-freezing, post-thawing segment and post-thawing main bag groups. Total nucleated cells (TNCs), cell viability, CD34 positive cells, colony-forming units-granulocyte/macrophages(CFU-GMs)and colony-forming units (CFUs) were examined. Results The number of TNCs [(1.12±0.38)×10⁹], cell viability [(79.11±7.71)%], the number of CFU-GMs [(5.55±4.58)×10⁵] and the number of CFUs [(15.11±9.68)×10⁵] were significantly decreased in samples from post-thawing attached segments compared with those pre-freezing(P＜0.05), but there was no significant difference in the number of CD34 positive cells between two groups (P＞0.05). The number of TNCs [(1.25±0.40)×10⁹], cell viability [(84.75±5.89)%] and CFUs [(18.61±6.42)×10⁵] in samples from post-thawing main bags were significantly different from those pre-freezing (P＜0.05), but there were no significant differences in the number of CD34 positive cells and CFU-GMs between them (P＞0.05). The number of TNCs, cell viability, CD34 positive cell viability, the numbers of CFU-GMs and CFUs were significantly decreased in post-thawing segments compared with those in main bags after thawing (P＜0.05), but there was no significant difference in the number of CD34 positive cells between the two groups (P＞0.05). Spearman correlation analysis showed that the parameters of samples from main bag and its attached segment were highly correlated after thawing. Conclusion Cord blood from attached segment could be quality control sample for cord blood bank and confirmatory testing before product release in some degree.

目的 本研究对广州地区5家教学医院的鲍曼不动杆菌进行分子流行病学分析。方法 5家教学医院共采集138株鲍曼不动杆菌,利用多位点序列分型(multilocus sequence typing,MLST)及eBURST算法评价菌株之间的遗传关系。结果 MLST将138株鲍曼不动杆菌分为8个已有序列类型(STs),分别为ST195、ST208、ST457、ST136、ST254、ST548、ST445和ST53,还发现17个新STs。其中ST195的数量最多,占所有分离株的35.5%(49/138),其次为ST208,占所有分离株的21.0%(29/138)。eBURST算法分析显示以ST195为预测祖先型的克隆复合体(clonal complex, CC) 195在医院环境中广泛传播。结论 鲍曼不动杆菌CC195是广州地区的流行克隆,各家医疗机构应根据其自身实际制定感染防控策略。

Objective We analyzed the molecular epidemiology of A.baumannii isolated from 5 teaching hospitals in Guangzhou to identify the epidemic clone in this area. Methods A total of 138 strains of A.baumannii were collected from 5 teaching hospitals, and the genetic relationship was evaluated by multilocus sequence typing (MLST) and eBURST algorithm. Results MLST divided 138 strains of A.baumannii into 8 existing sequence types (STs), namely ST195, ST208, ST457, ST136, ST254, ST548, ST445 and ST53, and 17 new STs. Among them, ST195 had the largest number, accounting for 35.5% (49/138) of all isolates, followed by ST208, accounting for 21.0% (29/138) of all isolates. eBURST algorithm showed that the clonal complex (CC) 195, the predicted founder ST195, was widely spread in the hospital environment. Conclusion A.baumannii CC195 was an epidemic clone in Guangzhou area. Medical institution should develop infection prevention and control strategies according to its own actual conditions.

目的 探讨广州地区儿童2019新型冠状病毒(2019 novel coronavirus, 2019-nCoV)感染筛查/疑似病例的流行病学特点、发病特点、可能的原因及防控建议。方法 回顾性分析2020年1月20日—2020年2月29日广州市唯一一家儿童2019-nCoV感染隔离定点医疗单位隔离病房收治住院的符合儿童2019-nCoV感染筛查/疑似病例129例,对其流行病学、发病特点、临床特征、实验室检查及转归、随访等进行总结分析。 结果 男 79例,女 50例,最小1个月,最大13岁,中位数2岁,51例(39.5%)有武汉疫区旅游或居住史,20例(15.5%)有与来自疫区有呼吸道症状人员接触史,17例(13.1%)周边或社区有确诊病例,3例(2.3%)有确诊病人接触史(其中2例为家庭确诊病例密切接触史),38例(29.5%)为临床符合或聚集性发病;临床症状:发热121例(93.8%),咳嗽92例(71.3%),流涕50例(38.8%),32例伴有腹泻、呕吐/腹痛(24.8%),102例(79.0%)白细胞降低或正常,C反应蛋白(C-reactive protein,CRP)＜20 mg/L有103例(79.8%),57例(44.2%)胸片或CT示肺部斑片状影或实变;病原学检查:2019-nCoV实时荧光定量反转录PCR检测结果:所有患儿及陪同家属都有行咽拭子检查,只有21例患儿(16.3%)有行肛拭子检查,仅有1例(0.78%)家庭确诊病例密切接触者肛拭子阳性,但连续多次咽拭子结果阴性,余患者肛拭子和咽拭子及陪同家属咽拭子结果均阴性。其他病原学检查结果61例(47.3%),包括14例RSV阳性,9例流感病毒A,8例人偏肺病毒,6例肠道病毒,6例流感病毒B,6例肺炎支原体,4例副流感病毒1型,1例副流感病毒3型,2例人博卡病毒,3例腺病毒,1例肺炎克雷伯菌,1例人型葡萄球菌,其中1例合并副流感病毒1型及人博卡病毒。跟踪唯一1例确诊患者咽拭子多次检查均阴性,肛拭子持续19天后才转阴,一直无任何症状。其余患者好转出院后第3天、7天及14天进行随访,无异常发现。结论 儿童2019-nCoV感染筛查/疑似病例临床多表现为呼吸道或消化道症状,确诊主要依靠核酸检测,新冠病毒感染确诊率极低,而其将近50%病例能找到除新冠病毒外的其它相关病原体;高危患者为密切接触者,但存在漏诊的可能,肛拭子阳性率或高于咽拭子。

Objective To explore the epidemiological characteristics, onset characteristics, pathogenic mechanism of 2019-nCoV infection in children, and its control and prevention in Guangzhou. Methods From January 20, 2020 to February 29, 2020, a retrospective analysis was carried out on 129 suspected cases of 2019-nCoV infection admitted to the isolation ward of the only medical unit designated for children in Guangzhou. The epidemiology, disease characteristics, clinical characteristics, laboratory examination, outcome and follow-up were summarized and analyzed. Results There were 79 males and 50 females, with a minimum age of 1 month and a maximum age of 13 years. Anong them, 51 cases (39.5%) had a history of tourism or residence in the epidemic area of Wuhan, 20 cases (15.5%) had a history of contact with people with respiratory symptoms from the epidemic area, 17 cases (13.1%) with a confirmed case in the surrounding area or community, 3 cases (2.3%) had a history of contact with a confirmed patient (2 of them were family clustering cases), 38 cases (29.5%) were clinically suspected cases. Clinical symptoms: 121 cases with fever (93.8%), 92 cases with coughing (71.3%), 50 cases with runny nose (38.8%), 32 cases with diarrhea, vomiting or abdominal pain (24.8%). In 102 cases (79.0%), white blood cells were decreased or normal, 103 cases (79.8%) with CRP＜20 mg/L, and 57 cases (44.2%) showed focal infection on chest X-ray or CT scan. Etiological examination: only one case (0.78%) of the family confirmed cases had positive anal swab result, but the throat swab results were negative all the time. The anal swab and throat swab results of other patients and the throat swab results of their accompanying family members were negative. Other pathogens were detected in 61 cases (47.3%), including 14 RSV positive cases, 9 influenza A positive cases, 8 human metapneumovirus positive cases, 6 enterovirus positive cases, 6 influenza B positive cases, 6 Mycoplasma pneumoniae positive cases, 4 parainfluenza virus type 1 positive cases, 1 parainfluenza virus type 3 positive cases, 2 human bocavirus positive cases, 3 adenovirus positive cases, 1 Klebsiella pneumoniae positive cases, 1 Human Staphylococcus positive case, and 1 case with parainfluenza virus type 1 and human bocavirus. The only confirmed patient was followed up while multiple pharyngeal swab results were negative, and the positive anal swab results lasted for 19 days before turning negative and remained asymptomatic. Other patients were followed up on the 3rd, 7th and 14th day after discharge, and no abnormal findings were found. Conclusion Screening/suspected cases of 2019-nCoV infection in children were mostly clinically manifested as respiratory or gastrointestinal symptoms. The diagnosis rate of nucleic acids was extremely low, and there was a possibility of missed diagnosis. Nearly 50% of cases could find other relevant pathogens excluding the 2019-nCoV. The positive rate of anal swab results was higher than that of pharyngeal swab.

目的 本文旨在研究穿心莲内酯对慢性阻塞性肺疾病急性加重期(acute exacerbation of chronic obstructive pulmonary disease,AECOPD)患者血清学中的炎症反应因子及肺部功能改变的影响。方法 从我院已出院的患者中挑选2017年6月—2018年6月期间收治的AECOPD患者共80例,其中给予哌拉西林舒巴坦抗感染和雾化吸入布地奈德及复方异丙托溴铵治疗的患者为对照组,对照组的治疗方法基础上给予喜炎平注射液的患者为观察组,各40例。对2组患者接受治疗前后血清学中的基质金属蛋白酶-9 (matrix metalloproteinase-9, MMP-9)、降钙素原 (procalcitonin, PCT)、白介素-6 (interleukin-6, IL-6) 水平和肺功能指标等方面进行比较。结果 2组治疗前血清学MMP-9、PCT、IL-6和肺功能指标第1秒用力呼气容积(forced expiratory volume in one second, FEV1)、用力肺活量(forced vital capacity, FVC)、一秒率(FEV1/FVC)无差异(P＞0.05)。观察组经过治疗后MMP-9为(1995.13±347.281)pg/mL、IL-6为(7.98±3.23)pg/mL,低于对照组的(2159.30±367.477)pg/mL、(10.03±5.45)pg/mL(P＜0.05);观察组治疗后的PCT、FEV1、FVC和FEV1/FVC与对照组相比差异无统计学意义 (P＞0.05)。结论 穿心莲内酯在AECOPD患者中可以减少血清学中炎症因子,值得在临床中推广。

Objective To investigate the effect of andrographolide on levels of serum inflammatory factors and pulmonary function in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Methods Eighty patients with AECOPD who were treated in our hospital from June 2017 to June 2018 were selected. Forty patients in the control group were given anti-infection treatment with piperacillin and sulbactam and aerosol inhalation with compound ipratropium bromide and budesonide, while other 40 patients in study group were given andrographolide additionally. The levels of serum matrix metalloproteinase-9 (MMP-9), procalcitonin (PCT), interleukin-6 (IL-6) and the pulmonary function indexes of patients in the two groups were observed and compared before and after treatment. Results There were no statistically significant differences in the serum levels of MMP-9, PCT and IL-6 and the pulmonary function indexes forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and FEV1/FVC of the two groups before treatment (P>0.05). After treatment, in the study group, the MMP-9 and IL-6 levels in serum were (1995.13±347.281)pg/mL and (7.98±3.23)pg/mL respectively, which were significantly lower than that in the control group [(2159.30±367.477) pg/mL and (10.03±5.45) pg/mL (P＜0.05)].Compared with the control group, differences in the PCT, FEV1, FVC and FEV1/FVC in the study group were not statistically significant (P>0.05). Conclusion Andrographolide had significant clinical effect on the treatment of AECOPD, which could reduce the levels of serum inflammatory factors and it is worthy of clinical application.

目的 探讨右美托咪定与咪达唑仑在儿童牙科患者术前镇静中的作用及安全性。方法 选取2020年6月—2021年1月需行择期全麻牙科治疗的60例患儿作为研究资料,将其根据数字法随机分为对照组(采取咪达唑仑)与观察组(采取右美托咪定)各30例,比较2组患儿的镇静效果。结果 2组患儿经麻醉后,观察组患儿的自主呼吸恢复时间、苏醒时间以及拔管时间低于对照组,经统计学分析有差异(P＜0.05);患儿在给药前Ramsay镇静评分中比较无差异;在给药10 min、20 min、30 min时Ramsay镇静评分均能达到2分以上,但经统计学比较无差异;血氧饱和度未发现异常,而且在给药观察期间患儿的血氧饱和度也在95%以上;但经统计学分析,患儿在给药前和给药10 min、20 min、30 min时心率、呼吸以及血氧饱和度均无差异(P＞0.05)。结论 右美托咪定与咪达唑仑均能成功用于儿童牙科患者术前镇静中,但经本文研究发现右美托咪定其效果更为显著些,而且绝大多数患儿能够配合与父母分离、配合麻醉面罩,降低患儿术后躁动发生率。

目的 探讨脑卒中患者应用NNN-链接延续护理模式对患者生活质量及护理结局影响。方法 将 2019年6月—2020年12月收治的60例患者按纳入研究对象,以NNN-链接为结构框架,从入院到出院后3个月实施NNN-链接延续护理模式,收集延续护理患者护理诊断、护理结局、护理措施及三者的链接,比较延续护理不同阶段脑卒中患者护理结局评分。结果 使用频率最高的护理诊断及NNN-链接分别为生活自理能力缺陷、有跌倒的危险、知识缺乏、营养失调:低于机体需要量、有误吸危险;出院后3个月,从功能健康、健康知识和行为、生理健康Ⅱ、心理社会健康、家庭健康5大领域进行护理结局评分,分值均比出院时第一个月有提高(P<0.05)。结论 NNN-链接延续护理模式能有效提高病人的健康知识与行为,提高照顾者照护能力,降低意外事件发生。

目的 探讨核结合蛋白2(NUCB2)介导的下游信号分子和通路,为阐明NUCB2在乳腺癌中的功能提供依据。方法 构建NUCB2-RNAi慢病毒载体,感染MDA-MB-231细胞株。然后将MDA-MB-231分为阴性对照病毒感染细胞组(NC组)、感染NUCB2基因shRNA病毒细胞组(KD组),用Affymetrix基因表达谱芯片对NUCB2下游基因进行筛选,并对所有数据进行独创性通路分析(IPA)分析。用qPCR测定mRNA水平。统计采用SPSS 20.0软件。结果 Path-Array研究筛选了KD组与NC组的差异基因,其中上调基因186个,下调基因356个,部分差异表达基因的检测表明,这些基因的mRNA水平与Path-Array筛选结果一致。IPA分析显示,经典途径中差异表达基因的显著富集表明胆固醇生物合成的超途径被显著抑制。上游调节因子分析显示了所有不同表达基因的上游调节因子,包括转录因子、细胞因子、小RNA、受体、激酶、化学分子和药物。疾病和功能差异表达基因的显著丰富表明,与NUCB2相关的差异表达基因与41种疾病和功能显著相关,更多与癌症、组织损伤和异常相关。结论 NUCB2的功能涉及多种基因和多种信号通路。

Objective In order to further explore the downstream signal molecules and pathways mediated by nucleobindin-2 (NUCB2), to provide a basis for elucidating the significance of NUCB2 in breast cancer. Method NUCB2-RNAi lentivirus vector was constructed and infecting MDA-MB-231 cell line.Then MDA-MB-231 cells were divived into two group, cells with negative control virus infection (NC group) and cells infected with NUCB2 gene shRNA virus (KD group). NUCB2 downstream gene screening was conducted by Affymetrix gene expression profiling Path-Array chip and all data were analyzed by ingenuity pathway analysis (IPA). The mRNA level was detected by qPCR. SPSS 20.0 software was used for statistics. Results Path-Array study screened out differential genes between KD and NC group which the number of up-regulated genes was 186, the number of down-regulated genes was 356.Detection of some differentially expressed genes showed that the mRNA levels of these genes were consistent with the results of Path-Array screening.IPA analysis revealed that significant enrichment of differentially expressed genes in the classical pathway showed superpathway of cholesterol biosynthesis was significantly inhibited.The upstream regulatory factor analysis showed the upstream regulatory factors of all the differentially expressed genes, including transcription factors, cytokine, small RNA, receptors, kinases, chemical molecules and drugs.The significant enrichment of differentially expressed genes in disease and function showed that NUCB2 associated differentially expressed genes were significantly related with 41 diseases and functions, which were more related with cancer, organismal injury and abnormities. Conclusion The function of NUCB2 involved multiple genes and multiple signaling pathways.