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Biomedical subjects

G Tredici

Publications and source records attributed to G Tredici.

At least 37 records · Page 2Linked to original sources

Epidermal growth factor as a local mediator of the neurotrophic action of vitamin B(12) (cobalamin) in the rat central nervous system.

We have recently demonstrated that the myelinolytic lesions in the spinal cord (SC) of rats made deficient in vitamin B(12) (cobalamin) (Cbl) through total gastrectomy (TG) are tumor necrosis factor-alpha (TNF-alpha)-mediated. We investigate whether or not permanent Cbl deficiency, induced in the rat either through TG or by chronic feeding of a Cbl-deficient diet, might modify the levels of three physiological neurotrophic factors-epidermal growth factor (EGF), vasoactive intestinal peptide (VIP), and somatostatin (SS)-in the cerebrospinal fluid (CSF) of these rats. We also investigated the ability of the central nervous system (CNS) in these Cbl-deficient rats to synthesize EGF mRNA and of the SC to take up labeled Cbl in vivo. Cbl-deficient rats, however the vitamin deficiency is induced, show a selective decrease in EGF CSF levels and an absence of EGF mRNA in neurons and glia in various CNS areas. In contrast, radiolabeled Cbl is almost exclusively taken up by the SC white matter, but to a much higher degree in totally gastrectomized (TGX) rats. Chronic administration of Cbl to TGX rats restores to normal both the EGF CSF level and EGF mRNA expression in the various CNS areas examined. This in vivo study presents the first evidence that the neurotrophic action of Cbl in the CNS of TGX rats is mediated by stimulation of the EGF synthesis in the CNS itself. It thus appears that Cbl inversely regulates the expression of EGF and TNF-alpha genes in the CNS of TGX rats.

Animals↗

Myelinolytic lesions in spinal cord of cobalamin-deficient rats are TNF-alpha-mediated.

Repeated intracerebroventricular (i.c.v.)microinjection of tumor necrosis factor-alpha (TNF-alpha) into normal rats causes intramyelin and interstitial edema in the white matter of the spinal cord (SC). This response is identical to that observed in the SC white matter of rats made cobalamin (Cbl) deficient by total gastrectomy (TG). Immunoblot analysis showed that: 1) the level of the biologically active form of the TNF-alpha protein (17 kDa) is higher in the SC of totally gastrectomized (TGX) rats 2 months after TG, i.e., at the postoperative time when edema is observed; 2) SC levels of TNF-alpha protein (17 kDa) in 2-mo-TGX-, Cbl-treated rats are reduced to control. Repeated i.c.v. microinjections of anti-TNF-alpha antibodies, transforming growth factor-beta1 (TGF-beta1) or interleukin-6 (IL-6) into TGX rats, begun shortly after TG, substantially reduced both intramyelin and interstitial edema in the SC white matter. This study provides the first evidence that the hallmark myelin damage of Cbl-deficient central neuropathy, which is a pure myelinolytic disease, is not caused directly by the withdrawal of the vitamin itself, but reflects enhanced production of the biologically active form of TNF-alpha by SC cells. This study thus supports the view that TGF-beta1 and IL-6 may act as neuroprotective agents in Cbl deficiency central neuropathy.

Animals↗

Chronic axonal sensory and autonomic polyneuropathy without motor involvement: a new 'chronic inflammatory neuropathy?'.

We report the case of a woman with axonal sensory and autonomic neuropathy lasting several months who improved in association with steroid administration. During the course of her disease and in the follow-up, the patient underwent repeated cerebrospinal fluid (CSF) examinations, neurophysiological somatic, autonomic nervous system studies and sural nerve biopsy. Clinical and laboratory assessments demonstrated the occurrence of a monophasic, chronic sensory and autonomic neuropathy. A sural nerve biopsy suggested an axonopathy. After a progressive worsening of symptoms lasting about 6 months, steroid treatment was started and within 6 months a complete recovery, with normalization of the CSF findings, was observed. Although the 'chronic inflammatory neuropathies' are still debated entities, the features of this chronic, exclusively sensory and autonomic neuropathy are new, and the occurrence of a high protein level in the CSF, together with the favorable outcome associated with steroid treatment, suggests that our case might be another variant in this debated area.

Autonomic Nervous System Diseases↗

Resveratrol, map kinases and neuronal cells: might wine be a neuroprotectant?

Alcohol is noxious to the brain and peripheral nervous system. However, wine contains substances that may have positive biological and pharmacological effects. Resveratrol is the most studied and probably the most active of these substances. This naturally occurring compound, which is present in wine and grapes, reduces oxidative stress in neuronal-like cell cultures. We have shown that resveratrol induces phosphorylation of the mitogen-activated protein (MAP) kinase family members, extracellular regulated kinase 1 (ERK1) and ERK2, in the human neuroblastoma SH-SY5Y cells in vitro at much lower concentrations than those found in the plasma of rats after oral wine administration. MAP kinases are involved in numerous different aspects of signal transduction in the cells. In particular, phosphorylation of ERK2 has been related to the synaptic changes at the basis of memory and learning processes. These findings, together with our own, on resveratrol-induced activation of MAP kinases in human neuronal-like cells, and previously published epidemiological studies which have demonstrated an inverse relationship between moderate wine intake and dementia, suggest that wine (not alcohol) may have a positive effect on nervous cells.

Animals↗

Cisplatin-induced DNA-platination in experimental dorsal root ganglia neuronopathy.

The mechanism(s) and site(s) of the neurotoxic effect of cisplatin (CDDP) are still not entirely elucidated. A more detailed knowledge of these aspects of CDDP treatment might be useful to obtain a better understanding of the pathogenesis of its peripheral neurotoxicity, which is the dose-limiting side effect of CDDP. In the present study, the occurrence of CDDP-induced DNA-platination in dorsal root ganglia (DRG) of rats was evaluated in relation to DRG neuron pathological changes and CDDP-induced neuronopathy. Eight adult Wistar rats were treated with 2 mg/kg i.p. CDDP twice weekly for 9 times to induce sensory peripheral neuropathy. DNA-platination in specimens of DRG and kidney was measured immunohistochemically, with a polyclonal antibody (GPt) detecting CDDP-induced Pt-DNA adducts. Results were compared with those of untreated rats. Chronic CDDP-induced neurotoxicity, in a well described experimental model of chronic CDDP neurotoxicity in the Wistar rat, was confirmed by sensory DRG neuronopathy with secondary neuropathy, and demonstrated by reduced pain detection, decreased nerve conduction velocity in the tail nerve as well as morphological and morphometric changes in DRG neurons. Nuclear immunostaining for Pt-DNA adducts was observed in tubular cells of the kidney in 75% of the evaluated CDDP-treated rats, while in DRG cells CDDP-induced Pt-DNA adducts formation was found in 43% of the evaluated CDDP-treated rats. CDDP-induced DNA-platination was demonstrated in rat DRG neurons using a schedule of chronic CDDP administration which induced the onset of a sensory neuronopathy with secondary peripheral neuropathy. This finding further supports the hypothesis that CDDP is neurotoxic because it directly damages the DRG neurons.

Animals↗

Expression of Fos immunoreactivity in the rat supraspinal regions following noxious visceral stimulation.

We used immunohistochemical detection of the Fos protein to study the neuronal activation in the brain of methoxyfluorane-anesthetized rats after noxious deep somatic or visceral stimulation. The anesthesia was effective in triggering gene induction in many brain regions. Nevertheless, Fos appeared de novo in several brain nuclei following noxious stimulation in anesthetized animals. This could be of clinical relevance, as it suggests that the gas anesthetic does not suppress noxious stimulus-evoked reactivity in brain neurons. Two types of visceronociceptive stimuli were used to compare the effects of a diffuse visceral inflammation (peritoneal inflammation) with those of a more restricted inflammation (urinary bladder inflammation). In the same supraspinal areas, there were very few immunostained neurons in unstimulated controls, whereas Fos-positive cells were slightly more numerous in anesthetized controls and significantly more numerous after noxious stimulation. The peritoneal inflammation induced more Fos-labeled neurons than the restricted visceral stimulation. Labeled cells were found in these cases mainly in the ventrolateral medulla, parabrachial complex, dorsal raphe nucleus, periaqueductal gray, several hypothalamic and thalamic nuclei, amygdaloid complex, and cortex. Altogether these findings indicated that somatic and visceral inputs generally activate the same neuronal groups. However, a separation between the activation of somatic and visceral pathways was found in some brain nuclei, such as the parabrachial complex, hypothalamic, and thalamic nuclei.

Animals↗

Dendritic arborization and spines of the neurons of the cat and human periaqueductal gray: a light, confocal laser scanning, and electron microscope study.

Neurons of the periaqueductal gray (PAG) have an extensive dendritic tree which plays an important role in the neuronal circuits supporting the functional activities of this region. The complexity of the local circuits is increased by the occurrence of dendritic spines. We have compared the dendritic and spine organization in the cat with that of man in order to verify whether an inverse relationship exists between dendritic tree extension and spine density and complexity. Sections of cat and human PAG prepared according to the Golgi-Cox method were studied with the conventional light microscope (LM) and the confocal laser scanning microscope (CLSM). The cat PAG was also studied at the electron microscopic level. The light microscopic study provided the morphoquantitative characteristics of the dendritic arborization and spines of the multipolar and fusiform neurons of the human and cat PAG. The CLSM methodology, thanks to the three-dimensional reconstruction of the neurons and the rotation of the reconstructed images, brought into view dendritic branches and spines that could not have been observed at the LM, thereby showing a wider dendritic tree and more numerous spines. The data combined from LM and CLSM demonstrate that in both species most spiny neurons are multipolar and probably projection neurons. In man, the multipolar neurons show a more extensive dendritic tree due to a wider secondary ramification, which would seem to be balanced by more numerous spines in cat. At the electron microscopic level, axo-dendritic synapses are numerous and show symmetrical and asymmetrical junctions in equal proportions; furthermore, the great majority of the spines are in contact with synaptic boutons which contain round vesicles and make predominantly asymmetrical contacts features which indicate excitatory activity. The combined use of different techniques gave a complete picture of the dendritic tree and spines of the neurons of human and cat PAG and showed a wider dendritic surface available for the receipt of the synaptic contacts than had been reported previously. Furthermore, our findings demonstrate that the PAG dendritic spines are important and specific structures in the synaptic complex of the neuropil, suggesting that they might create a local device to modulate and integrate the afferent inputs, probably in an excitatory way. The differences observed in the two species suggest that afferent information might be handled in different ways in human and cat PAG.

Adult↗

Polyneuropathy due to cobalamin deficiency in the rat.

In the present study, we investigated the peripheral nervous system (PNS) (both in terms of its ultrastructure and in terms of its function) of rats made cobalamin (Cbl)-deficient either through total gastrectomy or through prolonged feeding on a Cbl-deficient diet. In both these types of Cbl-deficient neuropathies we found: (a) ultrastructurally, intramyelin and endoneural edema, with no or minimal axonal damage in the PNS, in dorsal root ganglia, and the ventral and dorsal rootlets of the spinal cord; (b) electrophysiologically, a significant reduction in the nerve conduction velocity, consistent with that reported in (a); (c) morphometrically, a significant reduction in the density of myelinated fibers both in the sciatic nerve and in the peroneal nerve. All these pathological changes were reversed by chronic postoperative administration of Cbl into totally gastrectomized (TGX)-rats, hinting at the specificity of the damage itself in relation to the permanent Cbl-deficient status of the TGX-rats. No signs of segmental demyelination or remyelination were found. We also observed a turning of type I fibers into type II fibers in the soleus muscle of all our Cbl-deficient rats, however the Cbl deficiency had been induced. This muscular change was still present in TGX- and Cbl-treated rats, and it cannot be related to a malnutrition status, since it has been observed also in rats fed a Cbl-deficient diet. All these results demonstrate that Cbl deficiency strongly affects rat PNS within different parameters.

Animals↗

Experimental cisplatin neuronopathy in rats and the effect of retinoic acid administration.

Peripheral nervous system alterations were induced in adult rats by administration of cisplatin (CDDP) 2 mg/kg twice weekly for 4.5 weeks. Dorsal root ganglion neurons showed pathological changes. Morphometric determinations demonstrated a reduction in size of the somatic, nuclear and nucleolar area. The nucleoli were the most involved subcellular structures. Nerve conduction velocity and the tail-flick test for pain were both significantly altered in CDDP treated rats, whereas the rota-rod test for coordination revealed no changes in either treated or control rats. Analytical determinations demonstrated platinum accumulation in the DRG of CDDP treated rats. Spontaneous recovery, demonstrated by morphometric, electrophysiological, functional and analytical determinations, occurred after treatment discontinuation within about 7 weeks. A pilot study of the possible neuroprotective action of retinoic acid (RA) was also performed with this model of cisplatin neuronopathy. The rationale for using RA was based on its assumed antioxidant and neurotrophic effect. However, RA failed to prevent morphometric, electrophysiological, functional and analytical alterations induced by CDDP on DRG neurons. RA induced only a mild generalized protective effect.

Animals↗

Carboplatin toxic effects on the peripheral nervous system of the rat.

BACKGROUND: The most striking of carboplatin's advantages (CBDCA) over cisplatin (CDDP) is its markedly reduced rate of neurotoxic effects. However, the use of CBDCA higher-intensity schedules and the association with other neurotoxic drugs in polychemotherapy may cause some concern about its safety with respect to peripheral nervous system damage. MATERIALS AND METHODS: Two different schedules of CBDCA administration (10 mg/kg and 15 mg/kg i.p. twice a week for nine times) were evaluated in Wistar rats. Neurotoxicity was assessed for behavioral (tail-flick test), neurophysiological (nerve conduction velocity in the tail nerve), morphological, morphometrical and analytical effects. RESULTS: CBDCA administration induced dose-dependent peripheral neurotoxicity. Pain perception and nerve conduction velocity in the tail were significantly impaired, particularly after the high-dose treatment. The dorsal root ganglia sensory neurons and, to a lesser extent, satellite cells showed the same changes as those induced by CDDP, mainly affecting the nucleus and nucleolus of ganglionic sensory neurons. Moreover, significant amounts of platinum were detected in the dorsal root ganglia and kidney after CBDCA treatment. CONCLUSIONS: CBDCA is neurotoxic in our model, and the type of pathological changes it induces are so closely similar to those caused by CDDP that it is probable that neurotoxicity is induced in the two drugs by the same mechanism. This model can be used alone or in combination with other drugs to explore the effect of CBDCA on the peripheral nervous system.

Animals↗

Supraspinal connections and termination patterns of the parabrachial complex determined by the biocytin anterograde tract-tracing technique in the rat.

We have re-evaluated, using the anterograde tracer biocytin, supraspinal efferent projections from the parabrachial complex (PBN) to gain new information about the nature of its connections and nerve terminal patterns. We selectively injected biocytin into the 3 main regions of the nucleus (lateral PBN, medial PBN and Kölliker-Fuse nucleus). We observed distinct groups of ascending and descending fibres of different calibre from the PBN running throughout the brain and reaching many brain areas involved in the regulation of autonomic function. Here we detected labelled bouton-like terminals and fibres with en-passage varicosities. The ascending efferents from the lateral PBN mainly reached the reticular, raphe and thalamic nuclei, the zona incerta (ZI), central nucleus of the amygdala (CeA) and lateral area of the periaqueductal grey (PAG). Thin descending efferents reached the ventral region of the solitary tract nucleus (STN). The ascending efferents from the medial PBN were seen in the raphe nuclei, reticular nuclei, ventral and lateral areas of the PAG, thalamic nuclei, and in the medial and lateral nuclei of the amygdala. Descending efferents were seen in the STN and in some reticular nuclei. The ascending projections from the Kölliker-Fuse targeted the ventral area of PAG, CeA, ZI, lateral hypothalamic area, ventromedial thalamic nucleus and, with only a few terminals, the ipsi and contralateral reticular area. A large number of descending efferents reached STN, caudal and paragigantocellular reticular nuclei. The higher sensitivity of biocytin compared with other types of markers allowed us to determine more effectively the distribution, nature and extent of the supraspinal PBN connections. This suggested that in several nerve circuits the PBN probably plays a more important role than previously thought.

Animals↗

Abolition of the neocortically monitored theta rhythm after ibotenic acid lesion of the parafascicular nucleus in behaving rats.

Seven adult Sprague-Dawley rats, chronically implanted with standard electrodes to monitor frontoparietal electroencephalographic (EEG) and nuchal electromyographic (EMG) activity, received, under deep anesthesia, unilateral or bilateral microinjections of ibotenic acid in the lateral part of the parafascicular nucleus of the thalamus. Four days after the injections (corresponding to the period of neuronal destruction), obliteration of the oscillatory activity in the theta range was found on the side ipsilateral to the injection, while on the intact hemisphere the rhythm was well developed. The asymmetry between the two hemispheres was particularly evident during REM sleep but was also seen during attentive but immobile alertness. In bilaterally injected rats, the neocortical theta rhythm was abolished on both hemispheres. These results suggest that in freely-moving rats the lateral parafasciculus neurons are part of the network on which the emergence of the theta rhythm relies.

Animals↗

Subacute combined degeneration in totally gastrectomized rats: an ultrastructural study.

Severe permanent cobalamin (Cbl) deficiency was induced in rats either by total gastrectomy (TG) or through prolonged dietary Cbl deprivation. This paper deals with an ultrastructural investigation of different parts of the central nervous system (CNS) of rats made Cbl-deficient through one of these of two procedures. In both totally gastrectomized (TGX) rats and in rats chronically fed a Cbl-deficient diet, we observed intramyelin edema, with splitting of the lamellae, and interstitial edema affecting the white matter, mainly in the spinal cord (SC). These lesions were also present in the subcortical white matter, although to a lesser degree. In both TGX-rats and in rats chronically fed a Cbl-deficient diet the pyramidal tract and the optic nerve were completely spared. Vascular lesions were never observed. Intramyelin edema and interstitial edema of the white matter account for the patchy myelopathic spongy vacuolation, which is the histological hallmark of human subacute combined degeneration and has been previously seen in SC white matter of TGX-rats. Macro- and micro-glial cells in the white matter were activated, at least as seen ultrastructurally. Interestingly enough, there were activated glial cells even in the gray matter, in which neurons showed absolutely no alterations. Chronic subcutaneous Cbl administration of TGX-rats partially repaired the CNS damage. However, the amelioration produced by this treatment was greater when Cbl was given shortly after TG than when given three and four months after TG, i.e. when the lesions have already been formed.

Animals↗

Enhanced levels of biochemical markers for cobalamin deficiency in totally gastrectomized rats: uncoupling of the enhancement from the severity of spongy vacuolation in spinal cord.

The totally gastrectomized (TGX) rat is a new experimental model for studying the pathogenesis of cobalamin (Cbl)-deficient myelopathy, i.e., subacute combined degeneration, total gastrectomy (TG) serving as a surgical paradigm of human pernicious anemia. We determined the serum levels of some biochemical indicators of Cbl deficiency in TGX rats at 2 to 10 months after TG. Methylmalonic acid (MMA) rose within 2 months and progressively increased thereafter until the end of the investigation period. 2-Methylcitric acid (MCA) rose significantly by 6 months and showed a further increment 4 months later. Homocysteine was only clearly elevated much later than the serum MMA, i.e., 10 months after the operation. The concentrations of MMA, MCA, and cystathionine were increased in kidney, liver, and spinal cord (SC) of TGX rats at 10 months. Chronic treatment of TGX rats with Cbl greatly decreased the serum levels of all the metabolic indicators of Cbl deficiency. Chronic peroral administration of the antibiotic lincomycin to TGX rats in an attempt to suppress the enteric flora markedly decreased serum MMA levels. Only Cbl, however, given either for the first 2 months after TG or for the third and fourth postoperative months (i.e., after SC abnormalities had already appeared) significantly decreased the severity of spongy vacuolation in SC white matter, although not completely preventing or repairing the neuropathological damage. Therefore, neither the early impairment in TGX rats of the Cbl-dependent methylmalonyl-coenzyme A mutase reaction nor the more delayed impairment of the Cbl-dependent methionine synthase step, as reflected by changes in serum metabolite levels, seems to be causally related to the TG-induced spongy vacuolation in SC white matter.

5-Methyltetrahydrofolate-Homocysteine S-Methyltran↗

Neurotoxicity and ototoxicity of cisplatin plus paclitaxel in comparison to cisplatin plus cyclophosphamide in patients with epithelial ovarian cancer.

PURPOSE: To compare the neurotoxicity and ototoxicity of combination cisplatin plus paclitaxel versus cisplatin plus cyclophosphamide using extensive clinical and instrumental evaluation. PATIENTS AND METHODS: Forty-six of 51 consecutive patients affected by-epithelial ovarian cancer seen in our institution between October 1994 and August 1995 entered the study. After randomization, they were assigned to receive cisplatin 75 mg/m2 every 3 weeks associated with cyclophosphamide 750 mg/m2 (CC group, n = 22) or paclitaxel 175 mg/m2 over a 3-hour infusion (CP group, n = 24). Treatment was repeated six times in 43 patients and nine times in 25. Before treatment and after three, six, and nine courses of chemotherapy, patients underwent clinical and instrumental neurologic and otologic examinations. RESULTS: Mild sensory impairment was evident even after only three courses of both treatments and signs and symptoms were more severe at the end of treatment. On clinical grounds only, it was possible to demonstrate after six and nine courses a difference between CC and CP treatment, due to the involvement in some CP patients of pain and thermal sensory modalities. However, the overall severity of the neuropathy was similar. Audiometric parameters demonstrated a more negative outcome after treatment in CC compared with CP patients. However, the different severity of the involvement was closely correlated to this initial difference in audiologic performance. CONCLUSION: Up to nine courses of chemotherapy, the CC and CP schedules are similar in terms of severity of neurotoxicity and ototoxicity when patients are evaluated during and immediately after treatment. With the doses used in our study, these toxicities are not dose-limiting. Our results suggest that most of the toxic effects observed during the treatment were due to cisplatin.

Antineoplastic Combined Chemotherapy Protocols↗

Effect on the peripheral nervous system of the short-term intravenous administration of paclitaxel in the rat.

The effectiveness of paclitaxel (Taxol) in the treatment of different tumors is well-known but, on the other hand, there is little information regarding its neurotoxicity and the mechanism(s) underlying this potentially severe side effect. In this study, using behavioral, neurophysiological, morphological and morphometric methods, we evaluated the effect of intravenous administration of paclitaxel on the rat nervous system. After 2 pilot studies, 40 female Wistar rats were treated with intravenous paclitaxel via a catheter placed in the jugular vein, while 20 animals were used as controls. Paclitaxel dissolved in ethanol/Tween 80/saline (5/5/90%) was administered 5 times over a period of 10 days. At the end of the experiment half the surviving animals in each group were evaluated and sacrificed (day 11), while the rest of the rats were evaluated and sacrificed on day 25. On day 11 the treated animals had significant impairment in pain perception (tail-flick test), coordination (rota-rod test) and nerve conduction velocity in the tail nerve. At the light microscope minimal axonal damage and Schwann cell activation were observed in the sciatic nerve. At the electron microscope microtubular accumulation was present within the axon in dorsal and ventral spinal roots and in the sciatic nerve. On day 25 the behavioral tests were normal in treated rats, while the nerve conduction velocity was still moderately reduced in comparison with the controls. At the electron microscope a morphological examination evidenced that microtubular accumulation was less severe, but still evident, especially in the sciatic nerve. Morphometric determinations performed on days 11 and 25 did not evidence differences between paclitaxel-treated rats and controls. The results of this study, the first in which an extended examination of the nervous system of animals treated intravenously with paclitaxel has been carried out, suggest that short-term administration of the drug induces mainly reversible changes in the peripheral nerves and spinal roots. Microtubules seem to be the main target of paclitaxel neurotoxicity, in much the same way as has been described for its antineoplastic activity. Finally, no pathological changes were seen in the neuronal bodies of the spinal cord and dorsal root ganglia. This model may be used for further studies with combination treatments with other antineoplastic or neuroprotective agents.

Animals↗

Thalamocortical projection from the parafascicular nucleus to layer V pyramidal cells in frontal and cingulate areas of the rat.

Thalamocortical projections originating from the parafascicular nucleus were reinvestigated using biocytin or biotylinated dextran amine as anterograde tracers in the rat. After stereotaxic injection of the marker in the lateral part of the parafascicular nucleus, labelled ascending fibres were observed running ipsilaterally to the frontal motor and anterior cingulate areas. Labelled fibres gave rise in layer VI to a plexus of thin ramifications ending in layer V, where sparse boutons en passant and terminaux were seen in close apposition to pyramidal cells. Few retrogradely labelled pyramidal somata, contacted by labelled varicosities, were also observed. Electron microscopy demonstrated the synaptic nature of the labelled contacts, displaying asymmetrical junctions and a round vesicular content. The direct loop parafascicular-motor cortex-parafascicular may be of great functional significance in motor control.

Afferent Pathways↗