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Biomedical subjects

K Inoue

Publications and source records attributed to K Inoue.

At least 271 records · Page 15Linked to original sources

[Small cell carcinoma of the urinary bladder with synchronous esophageal cancer and incidental lung cancer: a case report].

We present a case of triple primary cancers occurring synchronously in the urinary bladder, esophagus, and incidentally in the lung. A 65-year-old man with a chief complaint of gross hematuria was admitted to our hospital. Cystoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a non-papillary broad-based bladder tumor. Histological diagnosis was transitional cell carcinoma of the urinary bladder and he underwent one course of neoadjuvant chemotherapy (M-VAC) with the preoperative diagnosis of T3bN0M0. After one course of chemotherapy, chest CT, lymph node biopsy and esophagoscopy revealed squamous cell carcinoma of the esophagus. He first underwent radiochemotherapy (total 70 Gy, CDDP 5 mg x 41, 5-FU 250 mg x 24) for esophageal cancer and achieved complete remission. Then, he underwent radiotherapy for a total of 60 Gy for bladder cancer. However, his general condition gradually became worse and he died from metastatic cancer. The autopsy proved that he died from multiple metastases of small cell carcinoma of the urinary bladder and incidentally squamous cell carcinoma of the lung was identified.

Aged↗

[Enucleation of renal tumor using a microwave tissue coagulator].

We report our clinical findings on 7 tumors in 5 patients who underwent successful enucleation of renal tumor with a microwave tissue coagulator. All patients presented with incidentally-found renal tumor on ultrasonography or computed tomography. One patient had bilateral renal tumors. The mean size of the renal tumor was 2.5 cm (Range 1.0-5.2 cm). One patient had a tumor larger than 5 cm, and was found to have renal insufficiency preoperatively. Four cases were clinically diagnosed as T1aN0M0. In all patients, the renal tumor was enucleated with a microwave tissue coagulator successfully without renal pedicle clamping. The mean operative time and blood loss were 241 minutes and 788 ml, respectively. The pathological diagnosis was renal cell carcinoma in all cases. Although 2 patients had preoperative renal insufficiency, there were no serious postoperative complications and no evidence of loss of renal function as a result of this operation. Our findings suggest that renal tumors can be enucleated with a microwave tissue coagulator safely and successfully without damaging renal function.

Adenocarcinoma↗

[A case of traumatic rupture of the testis: usefulness of magnetic resonance imaging].

Traumatic rupture of the testis is rare because of the protection afforded by surrounding structures. Moreover, it is difficult to accurately diagnose preoperatively. A 17-year-old man was referred to our department with the complaint of painful swelling of the left testis after being hit by a basketball. Although ultrasonography and computed tomography did not reveal the rupture of the tunica albuginea, we preoperatively diagnosed the rupture of the left testis by magnetic resonance imaging (MRI). We repaired the tunica albuginea and preserved the left testis. In this report, the advantages of MRI for preoperative diagnosis of traumatic rupture of the testis are discussed. In addition, previous cases with traumatic rupture of the testis in the Japanese literature are also reviewed.

Adolescent↗

Adenoviral gene transfer of glial cell line-derived neurotrophic factor to injured adult motoneurons.

Glial cell line-derived neurotrophic factor (GDNF) strongly supports the survival of injured neonatal motoneurons, suggesting its potential uses in the treatment of motoneuron injury and motor neuron diseases. We examined neuroprotective effects of an adenoviral vector encoding GDNF (AxCAhGDNF) on the survival of lesioned adult rat facial and spinal motoneurons. The facial nerve or the seventh cervical segment (C7) ventral and dorsal roots of 3 month-old Fischer 344 male rats were avulsed and removed from the stylomastoid or vertebral foramen, respectively, and AxCALacZ (adenovirus containing beta-galactosidase gene), AxCAhGDNF, or PBS was inoculated in the lesioned foramen. One week after the avulsion and treatment with AxCALacZ, the animal showed expression of beta-galactosidase activity in lesioned facial and spinal motoneurons. Animals avulsed and treated with AxCAhGDNF showed intense immunolabeling for GDNF in lesioned facial and spinal motoneurons and expression of virus-induced human GDNF mRNA transcripts in the lesioned brain stem and spinal cord tissues. The treatment with AxCAhGDNF after avulsion significantly prevented the loss of lesioned facial and C7 spinal motoneurons, ameliorated choline acetyltransferase immunoreactivity, and suppressed the activity of nitric oxide synthase in these neurons. These results indicate that the adenovirus-mediated gene transfer of GDNF may prevent the degeneration of motoneurons in adult humans with motoneuron injury and motor neuron diseases.

Adenoviridae↗

[IFN combined cyclosporin A therapy].

Current therapy of chronic hepatitis C with a 6 months course of alpha interferon shows limited effectiveness for patients with chronic hepatitis C. In particular more effective therapy is needed to treat patients who have high serum level of group 1-HCV RNA. We previously reported that a combination of interferon and cyclosporin A was more effective than interferon monotherapy. We also examined whether CsA has an antiviral effect on HCV using cultured human hepatocyte cell line. Propagation of HCV seems to be inhibited by CsA in a dose dependent manner. Further study is needed to clarify the action of cyclosporin A.

Clinical Trials as Topic↗

[Factors allowing continuous working of female nurses in the People's Republic of China--survey of 15 hospitals in 5 areas].

PURPOSE: Few investigations have been conducted on working, childcare and home education among female nurses (nurses) in the People's Republic of China (P.R. of China). The purpose of this study was to clarify the factors allowing continued working of female nurses. METHODS: The subjects were nurses from 15 hospitals in 3 provinces and 2 autonomous areas. They were surveyed by questionnaire regarding their childcare and home education. In was distributed by the Ministry of Health in the P.R. of China and the data were collected between February and April in 1996. RESULTS: A total of 4,284 (80.0%) questionnaires were collected. 1. About 60% of the nurses began working when they were 15 to 19 years old. The average length of service was 13.9 years. 2. Their professional position correlated directly with their years of service. 3. 4.3% of them had not continued working. 4. The nurses entrust their children to day-care institutions (61.2%) or grandparents (22.3%) during the daytime, and to the father (66.3%) or the grandparents (19.5%) during the night. 5. 17.6% of them have experienced being away from home for more than one month due to their job. 6. 66.8% of the nurses have experienced more than one month official trip, and had children under 14 years old at the time. They entrusted their children to day-care institutions (34.1%), to the father (29.2%) and grandparents (25.3%) during the official trip. CONCLUSIONS: In summary, most nurses are employed when they are young and go on working as nurses. It is possible for them to continue their work after marriage, childbirth, and while they are bringing up their children. The high rate of working woman, sufficient nursery schools and family cooperation in housework can be pointed out as main factors that enable them to continue their work.

Adolescent↗

[Childcare and home education in families of female nurses in the People's Republic of China--survey of 15 hospitals in 5 areas].

PURPOSE: The purpose of this study was to investigate the actual conditions of childcare and home education among families of female nurses in the P. R. of China. METHODS: The subjects were nurses from 15 hospitals in 3 provinces and 2 autonomous areas. They were surveyed by questionnaire regarding their childcare and home education. It was distributed by the Ministry of Health in the P. R. of China and data were collected between February and April in 1996. RESULTS: A total of 4284 (80.0%) questionnaires were collected. 1. The age of the subjects was between 18 and 62 years old with a mean of 32.9 +/- 9.0 (SD) years 71.4% of them had husbands, whose ages were between 23 and 71 years old, the mean age being 38.3 +/- 8.4 (SD) years. The family types were 63.2% nuclear family and 33.7% extended family, with 3.1% being single. 65.1% of the subjects had children, whose mean number was 1.1 +/- 0.4 (SD). Firstborn children were 49.9% girls and 50.1% boys. 2. The most popular method of infant nutrition was breast-feeding, utilized by 60.1%. The highest rate (67.8%) was in the age group of 25 to 29 years old (P < 0.01). 3. The practice of "swaddling" (wrapping the child so as not to allow movement) was more common in the over 40 year old age group than the under 40 year old group (P < 0.01). Swaddling-practice showed significant differences by area. 4. The rates for children who helped with housework were 50.3% for girls and 46.7% for boys. 5. A number of children between 7 and 18 years old were studying English privately. 6. The greatest expectation of the subjects, for their children aged between 7 and 18 years old, was to study. CONCLUSIONS: 1. Infant nutrition showed significant differences between generations, and swaddling-practice differed with the generation and the area. 2. Although girls help their parents more than boys in Japan, boys and girls equally helped their parents in the P. R. of China. 3. Concerning the topics of private learning and parents expectations, the results were similar to those in Japan.

Adolescent↗

Metabolic activation of polycyclic aromatic hydrocarbons and other procarcinogens by cytochromes P450 1A1 and P450 1B1 allelic variants and other human cytochromes P450 in Salmonella typhimurium NM2009.

A variety of polycyclic aromatic hydrocarbons and their dihydrodiol derivatives, arylamines, heterocyclic amines, and nitroarenes, were incubated with cDNA-based recombinant (Escherichia coli or Trichoplusia ni) systems expressing different forms of human cytochrome P450 (P450 or CYP) and NADPH-P450 reductase using Salmonella typhimurium tester strain NM2009, and the resultant DNA damage caused by the reactive metabolites was detected by measuring expression of umu gene in the cells. Recombinant (bacterial) CYP1A1 was slightly more active than any of four CYP1B1 allelic variants, CYP1B1*1, CYP1B1*2, CYP1B1*3, and CYP1B1*6, in catalyzing activation of chrysene-1,2-diol, benz[a]anthracene-trans-1,2-, 3,4-, 5,6-, and 8,9-diol, fluoranthene-2,3-diol, dibenzo[a,l]pyrene, benzo[c]phenanthrene, and dibenz[a,h]anthracene and several arylamines and heterocyclic amines, whereas CYP1A1 and CYP1B1 enzymes had essentially similar catalytic specificities toward other procarcinogens, such as (+)-, (-)-, and (+/-)-benzo[a]pyrene-7,8-diol, 5-methylchrysene-1,2-diol, 7,12-dimethylbenz[a]anthracene-3,4-diol, dibenzo[a,l]pyrene-11,12-diol, benzo[b]fluoranthene-9,10-diol, benzo[c]chrysene, 5,6-dimethylchrysene-1,2-diol, benzo[c]phenanthrene-3,4-diol, 7,12-dimethylbenz[a]anthracene, benzo[a]pyrene, 5-methylchrysene, and benz[a]anthracene. We also determined activation of these procarcinogens by recombinant (T. ni) human P450 enzymes in S. typhimurium NM2009. There were good correlations between activities of procarcinogen activation by CYP1A1 preparations expressed in E. coli and T. ni cells, although basal activities with three lots of CYP1B1 in T. ni cells were very high without substrates and NADPH in our assay system. Using 14 forms of human P450s (but not CYP1B1) (in T. ni cells), we found that CYP1A2, 2C9, 3A4, and 2C19 catalyzed activation of several of polycyclic aromatic hydrocarbons at much slower rates than those catalyzed by CYP1A1 and that other enzymes, including CYP2A6, 2B6, 2C8, 2C18, 2D6, 2E1, 3A5, 3A7, and 4A11, were almost inactive in the activation of polycyclic aromatic hydrocarbons examined here.

Alleles↗

Angiotensin-converting enzyme inhibitors and probucol suppress the time-dependent increase in urinary Type IV collagen excretion of Type II diabetes mellitus patients with early diabetic nephropathy.

BACKGROUND: A multicenter prospective clinical trial was carried out in 9 National Hospitals in Japan to elucidate the time-dependent change in urinary Type IV collagen excretion rate of Type II diabetes mellitus (DM) patients, and to investigate whether an angiotensin-converting enzyme inhibitor (ACE-I) or probucol is effective in preventing progression of renal involvement of diabetics by evaluating urinary Type IV collagen excretion. METHODS: Normo- and microalbuminuric patients with Type II DM were recruited. Patients were assigned to either the control (n = 88), ACE-I (n = 43) or probucol (n = 37) group and treated for 24 months. Besides albumin excretion rate (AER), urinary Type IV collagen excretion rate was also measured. RESULTS: Although, AER, urinary N-acetyl-beta-D-glucosaminidase and beta2-microglobulin excretion rates in the control group did not vary over 24 months, urinary Type IV collagen excretion rate in the control group increased time-dependently (p < 0.01 vs baseline at 18 months and p < 0.005 vs baseline at 24 months). In the ACE-I and probucol groups, time-dependent increases in urinary Type IV collagen excretion rates were not observed. In the ACE-I group, the urinary Type IV collagen excretion rate was significantly lower than that in the control group at 24 months (p < 0.05). In the probucol group, the urinary Type IV collagen excretion rate was significantly lower than that in the control group at 6 months (p < 0.05). In the ACE-I group, AER decreased significantly compared with baseline at 18 months (p < 0.05) and at 24 months (p < 0.005). CONCLUSIONS: ACE-I has a beneficial effect and probucol may have a beneficial effect in preventing the progression of early diabetic nephropathy. Measurement of the urinary Type IV collagen excretion rate in combination with AER would be useful for the management of early renal involvement in Type II DM.

Acetylglucosaminidase↗

Development of a cryopreservation procedure employing a freezer bag for pancreatic islets using a newly developed cryoprotectant.

One of the most important requirements for success in clinical islet transplantation is the use of a large number of viable donor islets. To achieve this, the ability to cryopreserve islets and to establish an islet bank are critical. Previously, we developed a two-step cryopreservation procedure with freezing tubes utilizing low and high concentrations of dimethyl sulfoxide (DMSO) and using a fully automated cryomachine for human pancreatic islets and porcine islet-like cell clusters (ICCs). Based on these experiments, we developed a simple and efficient cryopreservation procedure of a freezer bag for isolated islets using a fully automated computer-controlled cryomachine with a newly developed cryoprotectant consisting of ethylene glycol (EG) instead of DMSO for decreasing injury of the islets by freezing. A 250 ml Cryocyte blood freezer bag and our newly developed cryoprotectant containing ethylene glycol (EG) were used in the freezing procedure. The islets were frozen by a fully automated computer-controlled cryomachine (GE 9,000) with our original program of slow cooling. Nucleation occurred at -8 degrees C, and the frozen islets were stored at -196 degrees C in a liquid nitrogen tank. The frozen-stored islets were subsequently rapidly thawed in a 37 degrees C water bath and cultured before viability testing. In vitro function, the stimulation index of insulin release during the static incubation test for rat islets cryopreserved in a freezer bag vs. nonfrozen islets as control, was 2.13 +/- 0.42 and 2.02 +/- 0.38 (94.8% compared with control), respectively (n = 5, p = NS). The islet recovery compared with the nonfrozen control group was 85% (n = 5) in insulin content. When 1000 rat islets cryopreserved in a freezer bag were transplanted into the renal capsule of diabetic athymic mice, all the mice became normoglycemic within 7 days from transplantation. Before nephrectomy, the intravenous glucose torelance test (IVGTT) was performed. The fractional decay constant of the glucose level (K value) of the frozen-thawed group was 0.42 +/- 0.06%/min. A histological study of renal subcapsular grafts demonstrated the morphological integrity of the islets. These results demonstrate the utility of our cryopreservation procedure of a freezer bag for isolated islets using a fully automated computer-controlled cryomachine with a newly developed cryoprotectant for the maintenance of viability and function of frozen-stored islets both in culture and after transplantation. Cryopreservation using freezer bags with the new cryoprotectant is an effective and simple method for making an islet bank for clinical trials of islet transplantation.

Animals↗

Functional comparison of the single-layer agarose microbeads and the developed three-layer agarose microbeads as the bioartificial pancreas: an in vitro study.

In this study, the insulin secretory characteristics of the microencapsulated hamster islets were studied during long-term culture. The hamster islets were encapsulated as single-layer agarose microbeads or three-layer agarose microbeads with agarose and agarose containing poly(styrene sulfonic acid) (PSSa), respectively. The influence of PSSa on the function of the rat islets microencapsulted in three-layer microbeads was primarily monitored. The aim of this study was to examine the influence of the PSSa on the in vitro function of the islets encapsulated in the agarose/PSSa microbeads compared with single-layer agarose microbeads during long-term culture. The microbeads were cultured for 30 days in medium of Eagle's MEM at 37 degrees C in 5% CO2 and 95% air. The basal insulin secretion into the culture medium was measured daily during the first 12 days and two times per week until 30 days. The microbeads were subjected to static incubation test on the 10th, 20th, and 30th day during culture. The basal insulin secretion level of the agarose/PSSa microbeads was significantly higher than that of single-layer agarose microbeads. The static incubation tests revealed a similar pattern of insulin secretion from both microbeads when they were exposed to high glucose challenge. In the static incubation test, both could significantly increase insulin release to more than 6.61 times (stimulation index) in response to high glucose stimulation and could significantly decrease when glucose concentration returned from high glucose to low glucose on the 10th, 20th, and 30th day of culture. This study demonstrated that the hamster islets enclosed in agarose/PSSa hydrogel not only continuously secreted basal amounts of insulin, but also maintained their response to high glucose stimulation similar to the agarose microbeads. The above results together with those of our previous in vivo study suggest that the three-layer microbeads (agarose/PSSa) are well suitable for xenotransplantation of islets for the clinical application.

Animals↗

The influence of the anticomplement synthetic sulfonic polymers on the function of pancreatic islets: an in vitro study.

In a previous experiment, we demonstrated the anticomplementary efficacy of poly(stryrene sulfonic acid) (PSSa) and poly(2-acrylamido-2-methyl propane sulfonic acid) (PAMPS). The aim of this study was to examine their influence on the function of pancreatic islets in vitro. In this study, after culturing the rat islets with RPMI-1640 culture medium containing different concentrations of soluble PSSa or PAMPS for 24 h at 37 degrees C, we performed morphological and functional examination of the rat islets. We found that the islets maintained their normal morphology regardless of whether they were in the PSSa or PAMPS groups when the concentrations of soluble PSSa or PAMPS in the media were below 1 g/dl. In the static incubation study, the islets cultured in the PAMPS groups showed significantly high insulin secretory response to glucose challenge but those in the PSSa groups lost the response when the concentrations of soluble PSSa or PAMPS in the media were below 1 g/dl. The PAMPS not only had strong anticomplementry effect, but also maintained the good insulin secretory capacity of the islets. These results indicated that PAMPS is a promising bioartificial material for future clinical application of biohybrid artificial pancreas preparation. It is well suitable for xenotransplantation experiments.

Animals↗

Evaluation of insulin secretion of isolated rat islets cultured in extracellular matrix.

Islet isolation involves enzymatic digestion of the interstitial matrix and mechanical disruption of the tissue. It is possible that a fundamental change of islet biology resulting from the loss of critical factors required for islet function or survival will occur. Extracellular matrix (ECM) is one of the most important components of the islet microenvironment. Reconstruction of the cell-matrix relationship seems to be effective for improving the loss of differentiated islet structure and function. The purpose of this study was to characterize and compare the effects of collagen gel mixture or Matrigel on beta-cell function and islet cell survival. After isolation by the collagenase digestion technique, rat islets were divided and cultured with various types of collagen gel mixture. They were assessed for their glucose-stimulated insulin secretion and cell viability. Glucose-induced insulin secretion of islets cultured with collagen type I gel or a mixture of collagen type I and IV was improved after 11 days in culture. In conclusion, a type of gel composed of collagen type I and/or type IV as an islet microenvironment is sufficient to maintain glucose responsiveness and may be useful for islet transplantation.

Animals↗

Development of a new method to induce angiogenesis at subcutaneous site of streptozotocin-induced diabetic rats for islet transplantation.

The subcutaneous space is a potential site for clinical islet transplantation. Even though there are several advantages, poor blood supply at this site mainly causes failure of islet survival. In this study, angiogenesis was induced in advance at the diabetic rats subcutis for islet transplantation by implanting a polyethylene terephthalate (PET) mesh bag containing gelatin microspheres incorporating basic fibroblast growth factor (bFGF) (MS/bFGF) and a collagen sponge. The bFGF was incorporated into gelatin microspheres for controlled release of bFGF. As controls, a PET mesh bag with or without either collagen sponges or MS/bFGF was implanted at the subcutaneous site of diabetic rats. Macroscopic and microscopic examinations revealed the formation of capillary network in and around the PET mesh bag containing MS/bFGF and collagen sponges 7 days after implantation when compare with other control groups. When tissue hemoglobin level was also measured, a significantly high level of hemoglobin amount was observed compared with that of control groups. When allogeneic islets mixed with 5% agarose were transplanted into the prevascularized rat subcutis, normoglycemia was maintained for more than 40 days, while other control groups were ineffective. This study demonstrated that combination of gelatin microspheres incorporating bFGF and collagen sponges enabled the mesh to induce neovascularization even at the subcutaneous site of streptozotocin-induced diabetic rats, resulting in improved function of islet transplantation.

Animals↗

Isolation, culture, and characterization of endocrine cells from 6-month-old porcine pancreas.

Porcine endocrine cells were isolated from pancreas of 6-month-old pigs by two-step enzymatic digestion procedures. They were separated by the density gradient (isopycnic) centrifugation method using Histopaque-1077. Isolated cells were cultured and divided into two groups: suspension cells and adhesion cells. Suspension cells maintained their cell numbers on and after 7 days in culture. Approximately 1 x 10(7) cells were obtained from single pancreas of a 6-month-old pig. The cultured suspension cells took up dithizone (DTZ) staining 14 days after isolation in culture and indicated the presence of beta-cells. In in vitro study, the suspension cells were capable of secreting insulin into the culture medium. The suspension cells were tested for insulin and glucagon staining by Western blot analysis. These results indicated the maintenance of endocrine cell function after isolation. However, cultured adhesion cells failed to maintain their function during culture. In in vivo study, the suspension cells were transplanted into diabetes-induced nude mice. Reduction in blood glucose level was obtained after transplantation. Intraperitoneal glucose tolerance test (IPGTT) results showed a normal pattern of blood glucose clearance. After 1 week, the transplanted endocrine cells were detected with anti-insulin antibody by immunostaining and it showed the presence of viable beta-cells under the renal capsule of nude mice. Collectively, our results suggest that isolated and cultured suspension porcine endocrine cells maintained their endocrine function. These endocrine cells can be used as isolated islets for further study, including transplantation experiments.

Animals↗

Effect of basic fibroblast growth factor on insulin secretion from microencapsulated pancreatic islets: an in vitro study.

Microencapsulation of pancreatic islets represents a potentially effective method to prevent graft rejection in allotransplantation or xenotransplantation without the need of immunosuppression. Adequate insulin secretion and glucose responsiveness of microencapsulated pancreatic islets has been regarded as a prerequisite for successful transplantation. The microencapsulated pancreatic islets were respectively cultured in bFGF+ RPMI-1640 medium (bFGF+) or bFGF- RPMI-1640 medium (bFGF-) for 21 days. The functional activities of microencapsulated pancreatic islets were assessed by measuring basal insulin secretion and stimulated insulin release at different time points. The results revealed that microencapsulated pancreatic islets in the presence of bFGF demonstrated an increase in basal insulin secretion. Furthermore, microencapsulated pancreatic islets in the presence of bFGF demonstrated a marked stimulated insulin release and relative stability of stimulation indices (SI). The results in the perifusion study showed that microencapsulated pancreatic islets in the presence of bFGF maintained good glucose responsiveness over the course of culture period as well. These results indicate that bFGF has a beneficial effect on insulin secretion from microencapsulated pancreatic islets during in vitro culture. New strategies for preserving and improving function of microencapsulated pancreatic islets prior to transplantation may be developed by application of growth factors or other factors.

Animals↗

Regulation of cell proliferation using tissue engineering in MIN6 cells.

Pancreatic islet transplantation for patients with diabetes mellitus has been hindered by the problem of donor shortage, as is the case for transplantation of other organs. Among several measures to overcome this problem, cell transplantation using xenogenic cell lines has been considered. For the treatment of diabetic patients, a murine pancreatic beta-cell line MIN6 is a potential source of cell transplant. In order to restrict otherwise unlimited proliferation of transplanted MIN6 cells, cells are rendered to form spheroidal aggregates (SMIN6) on nonadherent culture dishes. SMIN6 stopped its growth around day 7 with a diameter of 220 +/- 40 microm and kept its size almost constant at least until day 28. SMIN6 cells, however, had reduced responsiveness of insulin secretion to glucose concentration compared with MIN6 cells cultured in a monolayer. On the other hand, spheroid MIN6 cells formed in the presence of extracellular matrix gel (SMIN6E) possessed the capacity for glucose-dependent insulin secretion comparable with conventional MIN6 cells. SMIN6E encapsulated in agarose beads (SMIN6E-B) was also viable for at least 1 month in vitro with a constant diameter and favorable glucose responsiveness. The development of spheroid-type MIN6 may contribute to the future clinical application of MIN6 or other beta-cell lines for treatment of diabetes mellitus.

Animals↗