Topic:Tumor

The Impact of Excision Interval on Equine Melanoma Progression: Time Matters?
Animals : an open access journal from MDPI    April 22, 2024   Volume 14, Issue 8 1244 doi: 10.3390/ani14081244
Pimenta J, Prada J, Pires I, Cotovio M.Equine melanomas are a common neoplasm in gray horses. However, scientific knowledge about their progression over time is quite scarce. Some owners and veterinarians still believe that early intervention is not necessary, stating that tumors evolve very slowly and intervention could worsen the animal's condition. This work aims to identify clinical and histological differences that may exist between equine melanomas with different excision intervals (time between tumor detection and surgical excision). A total of 42 tumors (13 benign and 29 malignant) from 34 horses were included in this study...
Intrahepatic mucinous cholangiocarcinoma with recurrent colic in a horse: case report and literature review of cholangiocarcinoma in horses. Barrantes Murillo DF, Cattley RC, Cullen JM, Withers C, Towns J, Pfeifle R, Wooldridge A, Neto RLALT.A 17-y-old Arabian mare was presented to the Auburn Large Animal Veterinary Teaching Hospital with a long-term history of intermittent mild recurrent colic that responded to medical treatment. CBC revealed mild lymphopenia; serum biochemistry findings were of increased gamma-glutamyl transferase and creatine kinase activities, hyperferremia, hyperglycemia, hypomagnesemia, and hypokalemia. Abdominocentesis was compatible with low-protein transudate. Due to the progression and duration of clinical signs, the owner elected euthanasia. Postmortem examination and histopathology confirmed a cholangi...
Impact of Equine Ocular Surface Squamous Neoplasia on Interactions between Ocular Transcriptome and Microbiome.
Veterinary sciences    April 7, 2024   Volume 11, Issue 4 167 doi: 10.3390/vetsci11040167
Chow L, Flaherty E, Pezzanite L, Williams M, Dow S, Wotman K.Ocular surface squamous neoplasia (OSSN) represents the most common conjunctival tumor in horses and frequently results in vision loss and surgical removal of the affected globe. Multiple etiologic factors have been identified as contributing to OSSN progression, including solar radiation exposure, genetic mutations, and a lack of periocular pigmentation. Response to conventional treatments has been highly variable, though our recent work indicates that these tumors are highly responsive to local immunotherapy. In the present study, we extended our investigation of OSSN in horses to better und...
Hemadsorption extracorporeal therapy removes cytokines ex vivo in horses.
American journal of veterinary research    March 18, 2024   1-8 doi: 10.2460/ajvr.24.01.0022
Hobbs KJ, Davis JL, Cooper BL, Ueda Y, Burke MJ, Sheats MK.Plasma cytokine adsorption has shown benefit as an adjunctive therapy in human sepsis but has yet to be investigated in horses. We hypothesized that ex vivo filtration of equine plasma with a novel cytokine adsorption device would significantly reduce concentrations of lipopolysaccharide-stimulated cytokines. We also hypothesized that the device would adsorb medications commonly used to treat sepsis. Methods: 8 horses owned by North Carolina State University. Methods: Four liters of heparinized whole blood was collected from healthy adult horses (n = 8) and stimulated with lipopolysaccharide (...
Metastatic cutaneous myxosarcoma in an adult horse.
Veterinary clinical pathology    March 3, 2024   Volume 53, Issue 1 116-121 doi: 10.1111/vcp.13329
Rabelo AA, Maranhu00e3o RPA, de Miranda ALS, Ocarino NM, Amaral CI, Paes PRO, Monteiro NCC, Fantini P.A 25-year-old mixed-breed equine with separate nodular cutaneous lesions in the right thoracic limb (RTL) and right ventral abdominal region was admitted to a Veterinary Hospital in Belo Horizonte, Minas Gerais. Fine-needle aspiration cytology was performed on the RTL lesion and superficial cervical lymph node, and the results were suggestive of a malignant neoplasm known as myxosarcoma. Due to the unfavorable prognosis, the animal was euthanized. Based on the macroscopic and microscopic findings, the diagnosis of metastatic cutaneous myxosarcoma was confirmed. Although rare, this tumor should...
Intralesional interferon alpha-2b as a novel treatment for periocular squamous cell carcinoma in horses.
PloS one    February 21, 2024   Volume 19, Issue 2 e0297366 doi: 10.1371/journal.pone.0297366
Martabano BB, Dow S, Chow L, Williams MMV, Mack MK, Bellone R, Wotman KL.To determine the safety and efficacy of perilesional human recombinant interferon alpha-2b (IFNα2b) for treatment of periocular squamous cell carcinoma (PSCC) in horses. Methods: Eleven horses (12 eyes) with PSCC were enrolled in this prospective clinical study with owner consent. Methods: Systemically healthy horses were included in the study following confirmation of PSCC via biopsy. Every two weeks for a maximum of six treatments, horses were sedated and perilesional injection of IFNα2b (10 million IU) was performed. Tumors were measured prior to each injection and at one, three, and 12 m...
Single-dose nonsteroidal anti-inflammatory drugs in horses have no impact on concentrations of cytokines or growth factors in autologous protein solution and platelet-rich plasma.
American journal of veterinary research    February 15, 2024   1-9 doi: 10.2460/ajvr.23.11.0258
Brown KA, Gregorio EN, Barot D, Usimaki A, Linardi RL, Missanelli JR, You Y, Robinson MA, Ortved KF.To determine the effects of a single dose of the NSAIDs phenylbutazone, firocoxib, flunixin meglumine, and ketoprofen on concentrations of growth factors and cytokines in autologous protein solution (APS) and platelet-rich plasma (PRP). Methods: 6 adult university-owned horses. Methods: For the first phase, 6 horses were randomized to receive ketoprofen (1,000 mg) or flunixin meglumine (500 mg) IV. Blood was obtained and processed for APS (Pro-Stride) and PRP (Restigen) before and 6 hours after administration of NSAIDs. Horses underwent a 2-week washout period, after which the protocol was rep...
Cross-Species Comparison of the Pan-RAF Inhibitor LY3009120’s Anti-Tumor Effects in Equine, Canine, and Human Malignant Melanoma Cell Lines.
Genes    February 3, 2024   Volume 15, Issue 2 202 doi: 10.3390/genes15020202
Gao Y, Packeiser EM, Wendt S, Sekora A, Cavalleri JV, Pratscher B, Alammar M, Hu00fchns M, Brenig B, Junghanss C, Nolte I, Murua Escobar H.Malignant melanomas (MMs) are the abnormal proliferation of melanocytes and are one of the lethal skin cancers in humans, equines, and canines. Accordingly, MMs in companion animals can serve as naturally occurring animal models, completing conventional cancer models. The common constitutive activation of the MAPK and PI3K pathways in MMs has been described in all three species. Targeting the related pathways is considered a potential option in comparative oncologic approaches. Herein, we present a cross-species comparative analysis exposing a set of ten melanoma cell lines (one human, three e...
Investigation of integrated time nanosecond pulse irreversible electroporation against spontaneous equine melanoma.
Frontiers in veterinary science    January 30, 2024   Volume 11 1232650 doi: 10.3389/fvets.2024.1232650
Fesmire CC, Peal B, Ruff J, Moyer E, McParland TJ, Derks K, O'Neil E, Emke C, Johnson B, Ghosh S, Petrella RA, DeWitt MR, Prange T, Fogle C, Sano MB.Integrated time nanosecond pulse irreversible electroporation (INSPIRE) is a novel tumor ablation modality that employs high voltage, alternating polarity waveforms to induce cell death in a well-defined volume while sparing the underlying tissue. This study aimed to demonstrate the efficacy of INSPIRE against spontaneous melanoma in standing, awake horses. Unassigned: A custom applicator and a pulse generation system were utilized in a pilot study to treat horses presenting with spontaneous melanoma. INSPIRE treatments were administered to 32 tumors across 6 horses and an additional 13 tumor...
Vulvo-vaginal epithelial tumors in mares: A preliminary investigation on epithelial-mesenchymal transition and tumor-immune microenvironment.
Veterinary pathology    November 1, 2023   3009858231207025 doi: 10.1177/03009858231207025
Armando F, Porcellato I, de Paolis L, Mecocci S, Passeri B, Ciurkiewicz M, Mechelli L, Grazia De Ciucis C, Pezzolato M, Fruscione F, Brachelente C....Vulvo-vaginal epithelial tumors are uncommon in mares, and data on the epithelial-to-mesenchymal transition (EMT) and the tumor-immune microenvironment (TIME) are still lacking. This is a study investigating the equus caballus papillomavirus type 2 (EcPV2) infection state as well as the EMT process and the tumor microenvironment in vulvo-vaginal preneoplastic/ benign (8/22) or malignant (14/22) epithelial lesions in mares. To do this, histopathological, immunohistochemical, transcriptomic, hybridization, and correlation analyses were carried out. Immunohistochemistry quantification showed tha...
[Ocular and non-ocular squamous cell carcinomas in the Haflinger: Eight cases at the Institut Suisse de Médecine Equine (2015-2022)].
Schweizer Archiv fur Tierheilkunde    October 12, 2023   Volume 165, Issue 10 644-655 doi: 10.17236/sat00406
Schu00e4fer J, Graubner C, Gerber V, Dru00f6gemu00fcller C, Underberg J, Gurtner C, Unger L.This case series describes the clinical course of ocular and non-ocular squamous cell carinoma (SCC) in the Haflinger horse and is intended to raise awareness of the high recurrence rate and tendency to metastasize. Eight Haflingers with histologically confirmed SCC were included, five ocular and three non-ocular, who were presented at the Institut Suisse de Médecine Équine (ISME) Bern between July 2015 and January 2022. The ocular SCC cases were all presented because of an apparent mass, which in most cases was post-treatment recurrence. The occurrence of recurrences was observed between 3 ...
Review of local extravascular delivery systems for chemotherapeutic agents in small animals and horses.
The Canadian veterinary journal = La revue veterinaire canadienne    October 2, 2023   Volume 64, Issue 10 957-967 doi: 10.1111/vsu.13506
Risselada M, Worth DB.Tumors of various sizes and locations can create a treatment dilemma in achieving adequate surgical margins when sufficient free tissue is not available for closure. Extravascular local adjunctive chemotherapy has been investigated clinically to aid in achieving local tumor control in animals with naturally occurring neoplastic disease. Local chemotherapy can be an alternative primary or a local adjunctive treatment. This is a summary of relevant findings of and studies on local chemotherapeutic delivery through carrier media, together with a summary of outcomes of clinical use of local deli...
Successful intra-abdominal resection of a 24 kg ovarian granulosa cell tumor in a Warmblood mare.
Open veterinary journal    September 30, 2023   Volume 13, Issue 9 1212-1218 doi: 10.5455/OVJ.2023.v13.i9.17
Tommasa SD, Roth SP, Triebe T, Brehm W, Lohmann KL, Stu00f6ckle SD.Granulosa cell tumors (GCTs) are the most common ovarian tumors in mares. The classical presentation of a GCT is a unilaterally enlarged ovary appearing as a multicystic honeycomb mass. In rare cases, GCTs cause hemoperitoneum as a result of the rapid growth of the tumor. The clinical diagnosis of GCT is usually based on history, rectal examination, ultrasonographic examination, and serum hormone analysis, and surgical removal of the affected ovary is the treatment of choice. The different surgical approaches are based on the dimension of the GCT. A 7-year-old mare was referred to the departme...
Association of the severity of colic in horses with oxidative stress biomarkers, acute-phase proteins, and certain trace elements.
Journal of equine science    September 8, 2023   Volume 34, Issue 3 73-81 doi: 10.1294/jes.34.73
Hajimohammadi A, Ghane M, Ghari Tehrani M, Paravar B, Mirzaei A, Razavi S, Nikzad M.Sixty-one horses were enrolled in this study and divided into 3 different groups according to their severity of colic (heart rate, oral mucous membrane color, and abdominal distention): a strangulating colic (SC) group (n=21), non-strangulating colic (NC) group (n=20), and control group (n=20) consisting of randomly selected normal horses without signs of colic. The serum concentrations of haptoglobin, tumor necrosis factor-α (TNFα), nitric oxide (NO), malondialdehyde (MDA), zinc, iron, and copper were evaluated in all horses. The average concentration of TNFα in the SC group was higher tha...
Perivascular wall tumour presenting as pastern mass in a Standardbred gelding.
Australian veterinary journal    August 13, 2023   doi: 10.1111/avj.13280
Stutsel M, Gimeno M, Young A, Bell JW, Horadagoda N.A 2-year-old Standardbred gelding was referred for a mass on the palmaromedial right front pastern which was accompanied by progressively worsening lameness. The mass was firm to palpation and covered by normal skin. Ultrasonographically, a smooth encapsulated mass was present, medial to the flexor tendons and palmar to the neurovascular bundle. Because of a poor prognosis for future athletic performance without surgical or chemotherapeutic intervention and economic constraints preventing further diagnostics and treatment, the horse was euthanised. Post-mortem magnetic resonance imaging, histo...
The serological detection of Bovine papillomavirus’s E5 oncoprotein antibodies in horses.
Veterinary immunology and immunopathology    July 26, 2023   Volume 262 doi: 10.1016/j.vetimm.2023.110633
Hoikhman R, Molinková D, Pillárová D, Linhart P, Kopecká A, Jahn P.Equine sarcoids (ES) are known globally as the most frequent skin tumour affecting horses. These tumours affect the horse's monetary value, they can affect the horse's welfare and can be difficult and expensive to treat. Bovine papillomavirus (BPV) is considered to be the aetiological agent of this tumour, as BPV 1, 2 and 13 have been detected in ES. This is the only known natural cross species infection by a papillomavirus. The BPV genome can be divided into two coding regions: The early region E which encodes the transforming proteins E5, E6 and E7 as well as the replication and transcriptio...
Behavioral Disorders in Mares with Ovarian Disorders, Outcome after Laparoscopic Ovariectomy: A Case Series.
Veterinary sciences    July 25, 2023   Volume 10, Issue 8 483 doi: 10.3390/vetsci10080483
Straticu00f2 P, Hattab J, Guerri G, Carluccio A, Bandera L, Celani G, Marruchella G, Varasano V, Petrizzi L.Owner complaints of estrus-related behavior in mares are a common cause of referral for laparoscopic ovariectomy. Granulosa cell tumors are a common neoplastic condition affecting the equine ovary, causing behavioral changes at rest and reduced performance. The reported success rate of ovariectomy in treating behavioral disorders is 64-86%. The aim of this study was to retrospectively evaluate the long-term follow-up of laparoscopic ovariectomy in mares in our case series, focusing on the owner's perspective of the behavior of the mares after surgery. In addition, the histopathological feature...
E-Cadherin Immunostaining in Equine Melanocytic Tumors.
Animals : an open access journal from MDPI    July 6, 2023   Volume 13, Issue 13 doi: 10.3390/ani13132216
Pimenta J, Pires I, Prada J, Cotovio M.Melanocytic tumors are an important neoplastic disease in human and veterinary medicine, presenting large differences regarding tumor behavior between species. In horses, these tumors present a prolonged benign behavior, with rare invasiveness and metastases. In humans and small animals, invasion and metastasis have been associated with an Epithelial-Mesenchymal Transition, where the loss of E-cadherin expression plays a key role in tumor progression. This process and the role of E-cadherin have not yet been evaluated in equine melanocytic tumors. This study aimed to assess the immunolabeling ...
Epithelial-mesenchymal transition in an EcPV2-positive vulvar squamous cell carcinoma of a mare.
Equine veterinary journal    July 3, 2023   doi: 10.1111/evj.13965
De Paolis L, Armando F, Montemurro V, Petrizzi L, Straticu00f2 P, Mecocci S, Guarnieri C, Pezzolato M, Fruscione F, Passeri B, Marruchella G....Vulvar squamous cell carcinoma (VSCC) has been recently associated with Equus caballus papillomavirus type 2 (EcPV2) infection. Still, few reports concerning this disease are present in the literature. Objective: To describe a case of naturally occurring EcPV2-induced VSCC, by investigating tumour ability in undergoing the epithelial-to-mesenchymal transition (EMT). Methods: Case report. Methods: A 13-year-old Haflinger mare was referred for a rapidly growing vulvar mass. After surgical excision, the mass was submitted to histopathology and molecular analysis. Histopathological diagnosis was c...
Immunohistochemical markers for equine granulosa cell tumors: a pilot study.
Journal of equine science    June 12, 2023   Volume 34, Issue 2 37-46 doi: 10.1294/jes.34.37
Dolin A, Schweiger P, Waselau M, Egerbacher M, Walter I.Sex cord-stromal tumors (SCSTs), generally referred to as granulosa cell tumors (GCTs) or granulosa-theca cell tumors (GTCTs) in equids, show complex compositions and variable numbers of hormone-producing cells. These tumors can be difficult to diagnose, especially in early stages. Therefore, we tested a panel of antibodies for vimentin, smooth muscle actin, laminin, Ki-67, E-cadherin, calretinin, moesin, p-ezrin, AMH, and aromatase, markers used for tumor composition and classification, progression, and prognosis in human SCSTs, on an exemplary grapefruit-size equine GCT within the left ovary...
Use of intralesional cisplatin to successfully treat distal limb haemangiosarcoma in a foal.
Australian veterinary journal    June 8, 2023   Volume 101, Issue 8 308-312 doi: 10.1111/avj.13251
Norton AM, McGilp D, Vasey JR.A 4-month old, 200 kg, grey warmblood colt presented for a firm, non painful mass on the distal medial aspect of the left third metatarsus. Excisional biopsy revealed a diagnosis of haemangiosarcoma. Equine haemangiosarcoma is uncommon and only limited reports of successful treatment are available. The prognosis for survival is therefore considered to be poor. After two separate incidences of recurrence with incomplete excision of the tumour, intralesional treatment with cisplatin without excision or debulking was performed on three separate occasions. Intralesional cisplatin injection was p...
Methylome and transcriptome data integration reveals aberrantly regulated genes in equine sarcoids.
Biochimie    May 19, 2023   Volume 213 100-113 doi: 10.1016/j.biochi.2023.05.008
Semik-Gurgul E, Szmatou0142a T, Gurgul A, Pawlina-Tyszko K, Gau0142uszka A, Pu0119dziwiatr R, Witkowski M, Zu0105bek T.DNA methylation is a key mechanism in transcription regulation, and aberrant methylation is a common and important mechanism in tumor initiation, maintenance, and progression. To find genes that are aberrantly regulated by altered methylation in horse sarcoids, we used reduced representation bisulfite sequencing (RRBS) accompanied by RNA sequencing (RNA-Seq) for methylome (whole genome DNA methylation sequencing) and transcriptome profiling, respectively. We found that the DNA methylation level was generally lower in lesion samples than in controls. In the analyzed samples, a total of 14,692 d...
Immunotherapy of Equine Sarcoids-From Early Approaches to Innovative Vaccines.
Vaccines    March 30, 2023   Volume 11, Issue 4 769 doi: 10.3390/vaccines11040769
Jindra C, Hainisch EK, Brandt S.Horses and other equid species are frequently affected by bovine papillomavirus type 1 and/or 2 (BPV1, BPV2)-induced skin tumors termed sarcoids. Although sarcoids do not metastasize, they constitute a serious health problem due to their BPV1/2-mediated resistance to treatment and propensity to recrudesce in a more severe, multiple form following accidental or iatrogenic trauma. This review provides an overview on BPV1/2 infection and associated immune escape in the equid host and presents early and recent immunotherapeutic approaches in sarcoid management.
Histological evidence of superficial inflammation is associated with lower recurrence of equine sarcoids following surgical removal: A follow-up study of 106 tumours in 64 horses.
Veterinary journal (London, England : 1997)    February 11, 2023   Volume 292 105953 doi: 10.1016/j.tvjl.2023.105953
Curnow B, Rich AF, Ireland J, Correa DC, Dunn J, Jenkins D, Carslake H, Ressel L.Although the equine sarcoid is the most common skin neoplasm in domesticated horses, histopathological characteristics have not previously been evaluated for association with recurrence. The aim of this retrospective cohort study was to investigate clinical and histopathological features of excised equine sarcoids and to evaluate their association with recurrence at the original surgical site and at new sites. Clinical records and excisional biopsies from 106 equine sarcoids from 64 horses referred to Leahurst Equine Hospital, University of Liverpool, between March 2010 and February 2015 were ...
Multiple Sex Cord-stromal Tumors in a Standardbred Stallion Testis.
Journal of equine veterinary science    February 10, 2023   Volume 123 104246 doi: 10.1016/j.jevs.2023.104246
Roxon C, Slack J, Bender S, Burns H, Turner R.A 12-year-old Standardbred stallion presented with a 5-month history of a growing mass in the left testis as well as an overall decrease in left testicular size. Palpation and ultrasonography of the left testis revealed a firm, hypoechoic, clearly delineated soft tissue mass in the craniolateral portion of the testis that measured 2.5 × 2.3 × 1.9 cm. Two smaller, hypoechoic regions also were visible ultrasonographically in the left testis, suggesting the presence of multifocal/multicentric neoplasia. The affected testis was very small (testicular volume of 40.3 cm). The right testis was ...
Papillomavirus-like Particles in Equine Medicine.
Viruses    January 25, 2023   Volume 15, Issue 2 345 doi: 10.3390/v15020345
Hainisch EK, Jindra C, Kirnbauer R, Brandt S.Papillomaviruses (PVs) are a family of small DNA tumor viruses that can induce benign lesions or cancer in vertebrates. The observation that animal PV capsid-proteins spontaneously self-assemble to empty, highly immunogenic virus-like particles (VLPs) has led to the establishment of vaccines that efficiently protect humans from specific PV infections and associated diseases. We provide an overview of PV-induced tumors in horses and other equids, discuss possible routes of PV transmission in equid species, and present recent developments aiming at introducing the PV VLP-based vaccine technology...
Equine Melanocytic Tumors: A Narrative Review.
Animals : an open access journal from MDPI    January 10, 2023   Volume 13, Issue 2 247 doi: 10.3390/ani13020247
Pimenta J, Prada J, Cotovio M.Adult grey horses have a high incidence of melanocytic tumors. This article narratively reviews the role of some genetic features related to melanoma formation in horses, such as STX17 mutation, ASIP or MITF alterations, and the link between the graying process and the development of these tumors. A clear system of clinical and pathological classification of melanocytic tumors in naevus, dermal melanoma, dermal melanomatosis and anaplastic malignant melanoma is provided. Clinical and laboratorial methods of diagnosing are listed, with fine needle aspiration and histopathology being the most re...
Immunogenicity analysis of BPV-1 positive equine sarcoid-derived cultured fibroblasts.
Veterinary immunology and immunopathology    January 4, 2023   Volume 256 110547 doi: 10.1016/j.vetimm.2023.110547
Gysens L, Depuydt E, Patruno M, Haspeslagh M, Spaas JH, Martens A.Sarcoids are the most common equine skin tumours Although they do not metastasize, they can be locally aggressive and cause significant clinical symptoms in affected horses. Despite being common, very little is known about the host immune response and the biological mechanisms underlying persistence and recurrence of equine sarcoids. The latter reflects the need for further research in this field. This in-vitro study used sarcoid explants from horses with naturally occurring sarcoids (n = 12) to evaluate the induction of a humoral immune response directed against equine sarcoid-derived bovin...
Markers for internal neoplasia in the horse.
Veterinary medicine and science    December 10, 2022   Volume 9, Issue 1 132-143 doi: 10.1002/vms3.1042
Drozdzewska K, Gehlen H.The diagnosis of internal neoplasia in horses is challenging. Increased production of hormones physiologic for adult animals (e.g., adrenocorticotropin, norepinephrine, and erythropoietin) or typical for the foetal phase (alpha-fetoprotein, anti-Müllerian hormone, and parathyroid-hormone-related protein) might aid in tumour diagnostics. Thymidine kinase-1 and alkaline phosphatase are examples of intracellular enzymes, whose activity in the blood may increase in some neoplasia cases. Furthermore, inappropriate production of abnormal monoclonal or autologous antibodies can accompany lymphoma an...
Expression of matrix metalloproteinases (MMPs)-2/-7/-9/-14 and tissue inhibitors of MMPs (TIMPs)-1/-2 in bovine cutaneous fibropapillomas associated with BPV-2 infection.
Frontiers in veterinary science    November 28, 2022   Volume 9 1063580 doi: 10.3389/fvets.2022.1063580
Bovine papillomaviruses -1/-2 (BPVs) are small non-enveloped double-stranded DNA viruses able to infect the skin of bovids and equids, causing development of neoplastic lesions such as bovine cutaneous fibropapillomas and equine sarcoid. Matrix metalloproteinases (MMPs) are a group of zinc-dependent endopeptidases that degrade basal membrane and extracellular matrix, whose function is essential in physiological processes such as tissue remodeling and wound healing. MMPs activity is finely regulated by a balancing with expression of tissue inhibitors of MMPs (TIMPs), a process that is impaired ...
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