Enhanced Cholesterol-Lowering and Antioxidant Activities of Soymilk by Fermentation with Lactiplantibacillus plantarum KML06

This study aimed to evaluate the cholesterol-lowering and antioxidant activities of soymilk fermented with probiotic Lactobacillaceae strains and to investigate the production of related bioactive compounds. Lactiplantibacillus plantarum KML06 (KML06) was selected for the fermentation of soymilk because it has the highest antioxidant, cholesterol-lowering, and β-glucosidase activities among the 10 Lactobacillaceae strains isolated from kimchi. The genomic information of strain KML06 was analyzed. Moreover, soymilk fermented with KML06 was evaluated for growth kinetics, metabolism, and functional characteristics during the fermentation period. The number of viable cells, which was similar to the results of radical scavenging activities and cholesterol assimilation, as well as the amount of soy isoflavone aglycones, daidzein, and genistein, was the highest at 12 h of fermentation. These results indicate that soymilk fermented with KML06 can prevent oxidative stress and cholesterol-related problems through the production of soy isoflavone aglycones.

Deep Learning-Based Software Improves Clinicians' Detection Sensitivity of Aneurysms on Brain TOF-MRA

BACKGROUND AND PURPOSE

The detection of cerebral aneurysms on MRA is a challenging task. Recent studies have used deep learning-based software for automated detection of aneurysms on MRA and have reported high performance. The purpose of this study was to evaluate the incremental value of using deep learning-based software for the detection of aneurysms on MRA by 2 radiologists, a neurosurgeon, and a neurologist.

MATERIALS AND METHODS

TOF-MRA examinations of intracranial aneurysms were retrospectively extracted. Four physicians interpreted the MRA blindly. After a washout period, they interpreted MRA again using the software. Sensitivity and specificity per patient, sensitivity per lesion, and the number of false-positives per case were measured. Diagnostic performances, including subgroup analysis of lesions, were compared. Logistic regression with a generalized estimating equation was used.

RESULTS

A total of 332 patients were evaluated; 135 patients had positive findings with 169 lesions. With software assistance, patient-based sensitivity was statistically improved after the washout period (73.5% versus 86.5%, P < .001). The neurosurgeon and neurologist showed a significant increase in patient-based sensitivity with software assistance (74.8% versus 85.2%, P = .03, and 56.3% versus 84.4%, P < .001, respectively), while the number of false-positive cases did not increase significantly (23 versus 30, P = .20, and 22 versus 24, P = .75, respectively).

CONCLUSIONS

Software-aided reading showed significant incremental value in the sensitivity of clinicians in the detection of aneurysms on MRA without a significant increase in false-positive findings, especially for the neurosurgeon and neurologist. Software-aided reading showed equivocal value for the radiologist.

P–153 Comparison outcome of vitrified human embryos stored in vapor phase liquid nitrogen (LN2) and direct LN2

Study question

Is vapor cryopreserved LN2 storage beneficial for clinical outcomes of vitrified human embryos that are frozen compared to vitrified human embryos having direct contact with LN2.

Summary answer

There are no significant differences compared to clinical outcomes of human embryos stored in LN2 vapor and direct store in LN2.

What is known already

There has been concerned about potential cross-contamination and biohazard issues of embryos for long term storage using direct LN2. This study aimed to compare clinical outcomes of human embryos transfer between vapor phase and liquid LN2.

Study design, size, duration

The embryo has undergone vitrification for long term storage with vapor or direct contact in LN2. After the thawing of the embryo, we checked on the survival rates. We transferred only one or two embryos per patient and kept analyzing the implantation and pregnancy rates

Participants/materials, setting, methods

This retrospective study was carried out from January 2018 to December 2019 with 3272cycles 4713embryos; vitrified for long term storage in vapor phase or direct contact with LN2. We compared the clinical outcomes of frozen embryo transfer cycles using vitrified for long term storage in vapor phase and direct contact with LN2. Clinical outcomes monitored were embryo survival, subsequent implantation and pregnancy after single or double embryo transfer

Main results and the role of chance

A total of 4713 fertilized human embryos are vitrified and then stored in LN2 vapor (n = 2520 cycles) or direct contact LN2 (n = 752 cycles). The study showed that the blastocyst stored in vapor able to retain full development. Survival was 97.8% (vapor) and 97.6% (direct contact LN2), and the vapor storage of human embryos had no significant difference in survival rates after a long term storage. For single blastocyst transfer, pregnancy and implantation rates were 51.5%, 52.4% in vapor, 54.6%, 54.9% in direct LN2; respectively (p=NS). In double blastocyst transfer, the pregnancy and implantation rates were 61.8%, 42.0% in vapor and 64.7%, 44.5% in direct LN2; respectively (p=NS). There were also no significant differences between two groups.

Limitations, reasons for caution

The study showed that the blastocyst stored in vapor can retain full development. A vapor storage system thus is safe and effective for long term vapor storage of vitrified human embryos.Within the limits of this study, there was no detection of an adverse effect of vapor storage.

Wider implications of the findings: Vapor storage systems thus represent a useful alternative for safe and effective long-term storage of vitrified human embryos that can avoid cross contamination chances from having direct contact with LN2.

Trial registration number

Not applicable

P–370 RPL-protease A as a potential biomarker for predicting recurrent pregnancy loss

Study question

Could the reduction of RPL-protease A be involved in the dysfunctional trophoblast for resulting in recurrent pregnancy loss (RPL).

Summary answer

Low expression of RPL-protease A may result in RPL and low serum RPL-protease A level may be a potential biomarker for predicting RPL.

What is known already

The RPL-protease A is expressed and secreted by placenta. The RPL-protease A is involved in the pathogenesis of pre-eclampsia, and the serum RPL-protease A level is higher in the patients with pre-eclampsia than that of normal groups. In our previous study, we identified that the RPL-protease A mRNA level was lower in the villi of patients with RPL than that of normal groups.

Study design, size, duration

Using the CRISPR/Cas9 system, the RPL-protease A gene knockout BeWo cell (BeWo KO) line was established, and the wild type (BeWo WT) and BeWo KO cells were applied to investigate the roles of RPL-protease A in trophoblasts. The human serum RPL-protease A levels were investigated by Western blot analysis and ELISA kit.

Participants/materials, setting, methods

The cell-cell fusion, cell counting analysis, invasion and scratch wound assays, cell cycle analysis, and immunocytochemical analysis were used to investigate cellular functions of RPL-protease A in trophoblast. The sera were obtained from 32 normal pregnant women and 60 women with RPL. The Western blot analysis and ELISA were used for detection of serum RPL-protease A levels.

Main results and the role of chance

The β-hCG was detected in fused BeWo WT cells, while the BeWo KO cells cannot fuse and did not express the β-hCG. The ability of invasion was decreased, but the capacity of migration and proliferation was higher in BeWo KO cells than BeWo WT cells. Cell fusion related factor (β-hCG), and cell invasion related factors (MMP–2 and MMP–9) were highly expressed in BeWo WT cells, and cell related factor (FAK), and cell proliferation related factors (ERK, p38, JNK, MKK3, MKK6, Raf, and Ras) were highly expressed in BeWo KO cells. The Western blot analysis and ELISA indicate that the serum RPL-protease A level was decreased in patients with RPL compared to that of normal groups.

Limitations, reasons for caution

The results of this study have the limitation of RPL-protease A functions in vitro.

Wider implications of the findings: The cellular functions of RPL-protease A in trophoblasts were investigated to explain the pathogenesis of RPL, and low serum RPL-protease A level can be used for a potential biomarker predicting RPL.

Trial registration number

Not applicable

Molecular insights into the development of hepatic metastases in colorectal cancer: a metastasis prediction study

OBJECTIVE

Colorectal cancer is presently the third most commonly diagnosed cancer in the United States. In this study, we identified molecular differences between hepatic and non-hepatic metastases in colorectal cancer and evaluated their prognostic significance.

MATERIALS AND METHODS

We downloaded primary data from the NCBI Gene Expression Omnibus (GSE6988, GSE62321, GSE50760, and GSE28722). To identify the molecular differences, we used the Significance Analysis of Microarray method. We selected nine prognostic genes (SYTL2, PTPLAD1, CDS1, RNF138, PIGR, WDR78, MYO7B, TSPAN3, and ATP5F1) with hepatic metastasis prediction score in colorectal cancer (hereafter referred to as LASSO Score). We confirmed the prognostic significance of the LASSO Score by using Kaplan-Meier survival analysis, multivariate analysis, the time-dependent area under the curve (AUC) of Uno's C-index, and the AUC of the receiver operating characteristic curve at 1-5 years.

RESULTS

Survival analysis revealed that a high LASSO Score is associated with a poor prognosis in colorectal cancer patients with hepatic metastases (p = 0). Analysis of C-indices and AUC values from the receiver operating characteristic curve further supported this prediction by the LASSO Score. Multivariate analysis confirmed the prognostic significance of the LASSO Score (p = 1.13e-06).

CONCLUSIONS

This study reveals the biological mechanisms underlying hepatic metastases in colorectal cancer and will help in developing targeted therapies for colorectal cancer.

Correction: Lung epithelial cell-derived extracellular vesicles activate macrophage-mediated inflammatory responses via ROCK1 pathway

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Effect of dietary melamine concentrations on growth performance, excreta characteristics, plasma measurements, and melamine residue in the tissue of male and female broiler chickens

The objectives of the current experiment were to investigate the effect of dietary melamine concentrations on growth performance, excreta characteristics, plasma measurements, and melamine residue in the tissue of male and female broiler chickens. Finally, the safe levels of melamine in broiler diets were determined based on BW gain (BWG) and melamine residue in the breast meat. A total of 1,008 1-d-old Ross 308 male and female broiler chickens were allotted to 1 of 7 dietary treatments within each sex in a completely randomized design. There were 6 replicates per treatment and each replicate consisted of 12 birds. Dietary melamine concentrations were set to 0; 250; 500; 750; 1,000; 5,000; or 10,000 mg/kg by adding a purified form of melamine. Diets were provided to birds on ad libitum basis for 35 d. Results indicated that no significant interaction between sex and dietary melamine concentrations was observed for all measurements. The BW, BWG, and feed intake for birds fed diets containing 10,000 mg/kg melamine were less (P < 0.05) than for those fed other diets. Melamine residues in the kidney and breast for birds fed diets containing 10,000 mg/kg melamine were greater (P < 0.05) than for birds fed other diets. The toxic level of dietary melamine based on BWG was determined by the one-slope broken-line analysis. The resulting equation was Y = 1,851 - 0.0404 × (X - 4,292), which indicated that a greater than 4,292 mg/kg melamine in diets was toxic to broiler chickens. The safe level of dietary melamine to limit melamine residue in the broiler breast was analyzed using the linear regression, which indicated that the safe level of melamine in broiler diets was 814 mg/kg. In conclusion, less than 814 mg/kg melamine in broiler diets should be maintained to satisfy human food safety regulations for melamine residue in the breast meat of broiler chickens.

Image Quality of Low-Dose Cerebral Angiography and Effectiveness of Clinical Implementation on Diagnostic and Neurointerventional Procedures for Intracranial Aneurysms

BACKGROUND AND PURPOSE

Awareness of the potential for exposure to high doses of radiation from interventional radiologic procedures has increased. The purpose of this study was to evaluate image quality and dose reduction of low-dose cerebral angiography during diagnostic and therapeutic procedures for intracranial aneurysms.

MATERIALS AND METHODS

A retrospective review of 1137 prospectively collected patients between January 2012 and June 2014 was performed. Beginning in April 2013, a dose-reduction strategy was implemented. Subjective image-quality assessment of 506 standard and 540 low-dose cerebral angiography images was performed by 2 neuroradiologists using a 5-point scale and was tested using noninferiority statistics. Radiation dose-area product and air kerma of 1046 diagnostic and 317 therapeutic procedures for intracranial aneurysms were analyzed and compared between groups before (group 1) and after (group 2) clinical implementation of a dose-reduction strategy.

RESULTS

The image quality of the low-dose cerebral angiography was not inferior on the basis of results from the 2 readers. For diagnostic cerebral angiography, the mean dose-area product and air kerma were 140.8 Gy×cm² and 1.0 Gy, respectively, in group 1 and 82.0 Gy×cm² and 0.6 Gy in group 2 (P < .001, P < .001). For the neurointerventional procedure, the mean dose-area product and air kerma were 246.0 Gy×cm² and 3.7 Gy, respectively, in group 1 and 169.8 Gy×cm² and 3.3 Gy in group 2 (P < .001, P = .291).

CONCLUSIONS

With low-dose cerebral angiography, image quality was maintained, and implementation of dose-reduction strategies reduced radiation doses in patients undergoing diagnostic and neurointerventional procedures for intracranial aneurysms.

Effect of stocking density and sex on growth performance, meat quality, and intestinal barrier function in broiler chickens

The objective of the current experiment was to investigate the effect of stocking density and sex on growth performance, meat quality, and intestinal barrier function in broiler chickens. The experiment was conducted in a completely randomized design with a 2 × 4 factorial arrangement consisting of sex and four different stocking densities in battery cages. A total of 540 1-d-old Ross 308 broiler chickens were allotted to one of eight treatments with five replicates. Within each sex, birds were raised at four different stocking densities of 15.2, 20.2, 25.3, or 30.4 birds/m2 from 1 to 28 d of age. Different stocking densities were achieved by raising a different number of birds per battery cage with identical floor size (0.76 m × 0.78 m). At the end of the experiment, two birds per replicate were euthanized by CO2 asphyxiation to collect tissue samples for further analyses. Results indicated that no interactions between sex and stocking density were observed for all measurements except for serum lipopolysaccharide (LPS) concentrations. Increasing stocking density decreased (linear, P < 0.01) body weight gain and feed intake, but had no negative effects on meat quality. Trans-epithelial electrical resistance values, a measure of intestinal permeability, were decreased (linear, P < 0.01) with increasing stocking density, regardless of sex. Accordingly, serum LPS concentrations were increased (linear, P < 0.01) with increasing stocking density. However, increasing stocking density increased serum LPS concentrations in male broiler chickens, but had no effects on female broiler chickens, showing an interaction (P < 0.01). The expression of zonula occludens-1 (ZO-1) and junctional adhesion molecule B (JAM-2) was decreased (linear, P < 0.05) with increasing stocking density. In conclusion, increasing stocking density decreases broiler performance regardless of sex and this negative effect is likely associated with decreased intestinal barrier function.

Systemic lupus erythematosus is a risk factor for cancer: a nationwide population-based study in Korea

OBJECTIVE

Specific differences in cancer risk have been observed between systemic lupus erythematosus patients and the general population. Although meta-analyses have estimated cancer incidence in systemic lupus erythematosus patients, results have been inconclusive. Hence, we aimed to assess malignancy risk in systemic lupus erythematosus patients, compared to the risk in the general population.

METHODS

Systemic lupus erythematosus patients ( n = 21,016; mean age 41.67 ± 13.14 years; female 90.22%) were selected from the Korean National Health Insurance Service database between 2008 and 2014. Age- and sex-matched controls were randomly sampled in a 5:1 ratio ( n = 105,080).

RESULTS

During the 7 years of follow up, malignancy was detected in 763 (3.63%) systemic lupus erythematosus patients and 2667 (2.54%) controls. Systemic lupus erythematosus patients had a higher risk of malignancy than controls (odds ratio 1.44; 95% confidence interval 1.327-1.559), after multivariate adjustment. Systemic lupus erythematosus patients had a higher odds ratio for developing cervical, thyroid, ovarian, and oral cancer, as well as lymphoma, leukemia, and multiple myeloma than controls. Based on subgroup analysis, male systemic lupus erythematosus patients and patients younger than 40 years showed the highest lymphoma risk.

CONCLUSIONS

Systemic lupus erythematosus might be an independent risk factor for cancer. Therefore, the importance of cancer screening programs should be emphasized in systemic lupus erythematosus patients. Our study is the first large nationwide cohort study for evaluating the risk of cancer in systemic lupus erythematosus patients.

Systemic lupus erythematosus is a risk factor for cardiovascular disease: a nationwide, population-based study in Korea

OBJECTIVE

To investigate the incidence and clinical significance of cardiovascular disease in systemic lupus erythematosus patients.

METHODS

We included systemic lupus erythematosus patients ( n = 18,575) without previous cardiovascular disease and age- and sex-matched individuals without systemic lupus erythematosus (controls; n = 92,875) from the Korean National Health Insurance Service database (2008-2014). Both cohorts were followed up for incident cardiovascular disease and death until 2015.

RESULTS

During follow up, myocardial infarction occurred in 203 systemic lupus erythematosus patients and 325 controls (incidence rate: 1.76 and 0.56 per 1000 person-years, respectively), stroke occurred in 289 patients and 403 controls (incidence rate: 2.51 and 0.70 per 1000 person-years, respectively), heart failure occurred in 358 patients and 354 controls (incidence rate 3.11 and 0.61 per 1000 person-years, respectively), and death occurred in 744 patients and 948 controls (incidence rate 6.54 and 1.64 per 1000 person-years, respectively). Patients with systemic lupus erythematosus had higher risks for myocardial infarction (hazard ratio: 2.74, 95% confidence interval: 2.28-3.37), stroke (hazard ratio: 3.31, 95% confidence interval: 2.84-3.86), heart failure (hazard ratio: 4.60, 95% confidence interval: 3.96-5.35), and cardiac death (hazard ratio: 3.98, 95% confidence interval: 3.61-4.39).

CONCLUSIONS

Here, systemic lupus erythematosus was an independent risk factor for cardiovascular disease, thus cardiac assessment and management are critical in systemic lupus erythematosus patients.

Implications of CaCl2 application to plants in LID facilities

Low impact development (LID) technologies mimic the natural water cycle through the physico-chemical and biological interactions of plants, filter media and soil, and microorganisms, thereby reducing the release of pollutants. In LID facilities, plants carry out photosynthesis, facilitate microbial growth, and uptake pollutants contained in stormwater runoff. However, de-icers (CaCl₂) used to melt snow during winter slow the growth of plants and even increase plant mortality. In addition, de-icers change the soil structure, causing changes in soil content and affecting the growth of plants and microorganisms. Therefore, this study examined the effects of CaCl₂ on the resistance of plants, the removal efficiency of non-point source pollutants, and water circulation. The mortality rate of the tree and shrubs caused by CaCl₂ was found to be in the order of Rhododendron indicum > Spiraea prunifolia var. simpliciflora > Metasequoia glyptostroboides. For herbaceous plants, mortality rate was in the order of Pratia pedunculata > Aquilegia japonica > Tagetes erecta > Sedum makinoi aurea > Hosta longipes > Dianthus chinensis > Acorus gramineus > Liriope platyphylla. In addition, it was found that the amount of chlorophyll decreases with high concentrations of CaCl₂. The findings of this research will be useful for plant selection considering CaCl₂ concentrations applied to paved areas during the winter.

Strong familial association of bone mineral density between parents and offspring: KNHANES 2008-2011

Bone mineral density (BMD) of offspring was significantly associated with their parents' BMD. Parental BMD Z-score ≤-1 was a significant predictor for BMD Z-score ≤-1 in their offspring. Peak bone mass acquisition during early adulthood is more substantially influenced by genetic factors rather than lifestyle or environmental factors.

INTRODUCTION

A person's BMD is affected by both genetic and environmental factors. Family history of osteoporosis or fragility fracture is a well-known risk factor for low bone mass or fracture. The purpose of the present study was to investigate the familial association of BMD between parents and offspring in Korean population.

METHODS

This is a cross-sectional study based on the data from the Korea National Health and Nutrition Examination Surveys (KNHANES) conducted from 2008 to 2011. A total of 5947 subjects (3135 parents and 2812 offspring) were included.

RESULTS

In age-adjusted partial correlation analyses, all BMD values acquired from the lumbar spine, femur neck, total hip, and whole body showed significant associations between parents and offspring. Among these associations, whole-body BMD showed the strongest relationship between offspring and parents. The narrow-sense heritability of BMD ranged from 0.203 to 0.542 in male offspring and from 0.396 to 0.689 in female offspring. Multiple linear regression analyses showed that offspring's BMD was independently associated with BMD of both parents after adjusting for covariates. Lifestyle or environmental factors including dietary calcium intake, serum 25-hydroxyvitamin D level, regular exercise, current smoking, and alcohol intake showed only moderate or no associations with BMD. In multiple logistic regression analyses in offspring aged 19-25 years, the son's risk of having BMD Z-score ≤-1 was associated with both parents' BMD Z-score ≤-1, while the daughter's risk was only associated with maternal BMD Z-score ≤-1.

CONCLUSIONS

Our findings confirm the strong familial association of BMD between parents and offspring in Korean population and suggest that peak bone mass acquisition during early adulthood is more substantially influenced by genetic factors rather than lifestyle or environmental factors.

A prospective study on symptom generation according to spicy food intake and TRPV1 genotypes in functional dyspepsia patients

BACKGROUND

Capsaicin is an ingredient of red peppers that binds to transient receptor potential vanilloid subtype 1 (TRPV1), and Koreans eat more capsaicin-rich food than do Japanese. This study aimed to compare symptom generation according to TRPV1 genotypes and the intake of spicy foods.

METHODS

Consecutive functional dyspepsia (FD) patients who were evaluated at Konkuk University Medical Centre (Korea) and Keio University Hospital (Japan) were included. Questionnaires on spicy food intake, patient assessment of gastrointestinal symptoms (PAGI-SYM), patient assessment of quality of life, and hospital anxiety and depression scale were provided. Blood was sampled for the detection of TRPV1 polymorphisms, and upper gastrointestinal endoscopy was performed with biopsies.

KEY RESULTS

Of 121 included subjects, 35 and 28 carried the TRPV1 CC and GG genotypes, respectively, with the prevalence rates not differing between Japan and Korea. The prevalence of FD subtypes did not differ with the spicy food intake, TRPV1 genotypes, or Helicobacter pylori infection. Neither TRPV1 polymorphisms nor H. pylori infections were related to scores on the PAGI-SYM questionnaires, but spicy food intake was positively correlated with the scores for stomach fullness (p = 0.001) and retching (p = 0.001). Using the linear regression analysis, stomach fullness was associated with spicy food intake (p = 0.007), whereas retching was related to younger age (p < 0.001) and female gender (p = 0.014).

CONCLUSIONS & INFERENCES

Upper gastrointestinal symptoms are more common in subjects with a higher consumption of spicy foods, younger age and female gender, regardless of TRPV1 genotypes and the H. pylori infection status. Capsaicin-rich foods may induce stomach fullness.

Role of peripheral sigma-1 receptors in ischaemic pain: Potential interactions with ASIC and P2X receptors

BACKGROUND

The role of peripheral sigma-1 receptors (Sig-1Rs) in normal nociception and in pathologically induced pain conditions has not been thoroughly investigated. Since there is mounting evidence that Sig-1Rs modulate ischaemia-induced pathological conditions, we investigated the role of Sig-1Rs in ischaemia-induced mechanical allodynia (MA) and addressed their possible interaction with acid-sensing ion channels (ASICs) and P2X receptors at the ischaemic site.

METHODS

We used a rodent model of hindlimb thrombus-induced ischaemic pain (TIIP) to investigate their role. Western blot was performed to observe changes in Sig-1R expression in peripheral nervous tissues. MA was measured after intraplantar (i.pl.) injections of antagonists for the Sig-1, ASIC and P2X receptors in TIIP rats or agonists of each receptor in naïve rats.

RESULTS

Sig-1R expression significantly increased in skin, sciatic nerve and dorsal root ganglia at 3 days post-TIIP surgery. I.pl. injections of the Sig-1R antagonist, BD-1047 on post-operative days 0-3 significantly attenuated the development of MA during the induction phase, but had no effect on MA when given during the maintenance phase (days 3-6 post-surgery). BD-1047 synergistically increased amiloride (an ASICs blocker)- and TNP-ATP (a P2X antagonist)-induced analgesic effects in TIIP rats. In naïve rats, i.pl. injection of Sig-1R agonist PRE-084 alone did not produce MA; but it did induce MA when co-administered with either an acidic pH solution or a sub-effective dose of αβmeATP.

CONCLUSION

Peripheral Sig-1Rs contribute to the induction of ischaemia-induced MA via facilitation of ASICs and P2X receptors. Thus, peripheral Sig-1Rs represent a novel therapeutic target for the treatment of ischaemic pain.

The CONTIN algorithm and its application to determine the size distribution of microgel suspensions

We review a powerful regularization method, known as CONTIN, for obtaining the size distribution of colloidal suspensions from dynamic light scattering data. We show that together with the so-called L-curve criterion for selecting the optimal regularization parameter, the method correctly describes the average size and size distribution of microgel suspensions independently characterized using small-angle neutron scattering. In contrast, we find that when using the default regularization process, where the regularizer is selected via the "probability to reject" method, the results are not as satisfactory.

Association of heart rate with albuminuria in a general adult population: the 2011 Korea National Health and Nutrition Examination Survey

BACKGROUND

Albuminuria is associated with increased risk of multiple adverse health outcomes, such as progressive renal failure, cardiovascular disease and death. However, in the general population, it is uncertain whether albuminuria is associated with elevated heart rate, which is an independent and powerful risk factor for cardiovascular disease.

AIM

To investigate whether an elevated heart rate is an independent factor associated with albuminuria in the general adult population of Korea.

METHODS

A cross-sectional analysis was carried out on 5198 Korean adults aged 19 years or older who participated in the fifth (2011) Korea National Health and Nutrition Examination Survey (KNHANES V-2).

RESULTS

The prevalence of albuminuria showed an increasing trend throughout the whole range of heart rate, even after adjusting for confounders (P = 0.002). The increment was most profound at the heart rate of 70-75 and >76 beats per minute (b.p.m.; P = 0.011). In multiple logistic regression analysis, age (P < 0.001), hypertension (P < 0.001), diabetes (P < 0.001), hypertriglyceridaemia (P = 0.025), estimated glomerular filtration rate (P = 0.028) and heart rate (P = 0.023) were independently associated with the presence of albuminuria in Korean adults. Compared with participants with heart rate ≤ 64 b.p.m., the odds ratio (95% CI) for albuminuria was 1.50 (1.15-1.96) for those with heart rate ≥ 76 b.p.m.

CONCLUSIONS

The prevalence of albuminuria is independently associated with heart rate in the general adult population of Korea.

Artefacts at a glance: differentiating features of artefactual stenosis from true stenosis at the genu of the petrous internal carotid artery on TOF MRA

AIM

To investigate the distinguishing features of artefactual stenosis from true stenosis at the genu of the petrous internal carotid artery (ICA) on time of flight (TOF) magnetic resonance angiography (MRA).

MATERIALS AND METHODS

Both TOF MRA and digital subtraction angiography (DSA) were performed in 65 patients with 74 vessels who demonstrated artefactual stenosis in 43 patients with 50 vessels and true stenosis in 22 patients with 24 vessels. The following findings of the signal loss were compared between the two groups: (1) margin, (2) darkness, (3) the presence of bilaterality, (4) the presence of tandem arterial stenosis, (5) the location of the epicentre, and (6) length.

RESULTS

In five out of the six evaluated items, statistically significant differences were present between the two groups (p<0.00 in all five items). Artefactual stenosis more frequently showed signal loss with ill-defined margins (47/50), less darkness compared to the background darkness (46/50), the absence of tandem arterial stenosis (35/50), epicentre at the genu (34/50), and shorter length (2.57 ± 0.68 mm). No significant difference was noted in the presence of bilaterality of signal loss between the two groups (p=0.706).

CONCLUSION

Several MRA features can be useful for suggesting artefactual stenosis rather than true stenosis at the genu of the petrous ICA on TOF MRA.

Lung epithelial cell-derived extracellular vesicles activate macrophage-mediated inflammatory responses via ROCK1 pathway

Despite decades of research, the pathogenesis of acute respiratory distress syndrome (ARDS) remains poorly understood, thus impeding the development of effective treatment. Diffuse alveolar damage (DAD) and lung epithelial cell death are prominent features of ARDS. Lung epithelial cells are the first line of defense after inhaled stimuli, such as in the case of hyperoxia. We hypothesized that lung epithelial cells release 'messenger' or signaling molecules to adjacent or distant macrophages, thereby initiating or propagating inflammatory responses after noxious insult. We found that, after hyperoxia, a large amount of extracellular vesicles (EVs) were generated and released into bronchoalveolar lavage fluid (BALF). These hyperoxia-induced EVs were mainly derived from live lung epithelial cells as the result of hyperoxia-associated endoplasmic reticulum (ER) stress. These EVs were remarkably different from epithelial 'apoptotic bodies', as reflected by the significantly smaller size and differentially expressed protein markers. These EVs fall mainly in the size range of the exosomes and smaller microvesicles (MVs) (50-120 nm). The commonly featured protein markers of apoptotic bodies were not found in these EVs. Treating alveolar macrophages with hyperoxia-induced, epithelial cell-derived EVs led to an increased secretion of pro-inflammatory cytokines and macrophage inflammatory protein 2 (MIP-2). Robustly increased macrophage and neutrophil influx was found in the lung tissue of the mice intranasally treated with hyperoxia-induced EVs. It was determined that EV-encapsulated caspase-3 was largely responsible for the alveolar macrophage activation via the ROCK1 pathway. Caspase-3-deficient EVs induced less cytokine/MIP-2 release, reduced cell counts in BALF, less neutrophil infiltration and less inflammation in lung parenchyma, both in vitro and in vivo. Furthermore, the serum circulating EVs were increased and mainly derived from lung epithelial cells after hyperoxia exposure. These circulating EVs also activated systemic macrophages other than the alveolar ones. Collectively, the results show that hyperoxia-induced, lung epithelial cell-derived and caspase-3 enriched EVs activate macrophages and mediate the inflammatory lung responses involved in lung injury.

Dipeptidyl peptidase 4 promotes epithelial cell transformation and breast tumourigenesis via induction of PIN1 gene expression

BACKGROUND AND PURPOSE

Dipeptidyl peptidase 4 (DPP4) is an aminopeptidase that is widely expressed in different cell types. Recent studies suggested that DPP4 plays an important role in tumour progression in several human malignancies. Here we have examined the mechanisms by which up-regulation of DPP4 expression causes epithelial transformation and mammary tumourigenesis.

EXPERIMENTAL APPROACH

Expression of DPP4 and the peptidylprolyl cis/trans isomerase, NIMA-interacting 1 (PIN1), and the cytotoxic effects of combined treatment with sitagliptin and juglone were investigated by immunohistochemistry, immunoblotting, real-time PCR, TUNEL and soft agar assays, using MCF7 cells. The effects of sitagliptin on tumour development in vivo were studied in the syngeneic 4T1 metastatic breast cancer model.

KEY RESULTS

Activity of the transcription factor E2F1 induced by EGF was enhanced by DPP4, thus increasing PIN1 expression. Furthermore, DPP4 enhanced MEK/ERK and JNK/c-Jun signalling induced by EGF, inducing AP-1 activity and epithelial cell transformation. In contrast, DPP4 silencing or DPP4 inhibition in MCF7 cells inhibited PIN1 expression via E2F1 activity induced by EGF, decreasing colony formation and inducing DNA fragmentation. In the syngeneic 4T1 metastatic breast cancer model, DPP4 overexpression increased tumour development, whereas treatment with sitagliptin and/or juglone suppressed it. Consistent with these observations, DPP4 levels were positively correlated with PIN1 expression in human breast cancer.

CONCLUSIONS AND IMPLICATIONS

DPP4 promoted EGF-induced epithelial cell transformation and mammary tumourigenesis via induction of PIN1 expression, suggesting that sitagliptin targeting of DPP4 could be a treatment strategy in patients with breast cancer.

Interleukin-33/ST2 axis promotes epithelial cell transformation and breast tumorigenesis via upregulation of COT activity

Cytokines of the interleukin-1 (IL-1) family, such as IL-1α/β and IL-18, have pleiotropic activities in innate and adaptive immune responses in host defense and diseases. Insight into their biological functions helped develop novel therapeutic approaches to treat human inflammatory diseases. IL-33 is an important member of the IL-1 family of cytokines and is a ligand of the ST2 receptor, a member of the IL-1 receptor family. However, the role of the IL-33/ST2 axis in tumor growth and metastasis of breast cancer remains unclear. Here, we demonstrate that IL-33 is a critical tumor promoter during epithelial cell proliferation and tumorigenesis in the breast. IL-33 dose- and time-dependently increased Cancer Osaka Thyroid (COT) phosphorylation via ST2-COT interaction in normal epithelial and breast cancer cells. The IL-33/ST2/COT cascade induced the activation of the MEK-ERK (MEK-extracellular signal-regulated kinase), JNK-cJun (cJun N-terminal kinase-cJun) and STAT3 (signal transducer and activator of transcription 3) signaling pathways, followed by increased AP-1 and stat3 transcriptional activity. When small interfering RNAs of ST2 and COT were introduced into cells, IL-33-induced AP-1 and stat3 activity were significantly decreased, unlike that in the control cells. The inhibition of COT activity resulted in decreased IL-33-induced epithelial cell transformation, and knockdown of IL-33, ST2 and COT in breast cancer cells attenuated tumorigenicity of breast cancer cells. Consistent with these observations, ST2 levels were positively correlated with COT expression in human breast cancer. These findings provide a novel perspective on the role of the IL-33/ST2/COT signaling pathway in supporting cancer-associated inflammation in the tumor microenvironment. Therapeutic approaches that target this pathway may, therefore, effectively inhibit carcinogenesis in the breast.

Interleukin-33/ST2 axis promotes epithelial cell transformation and breast tumorigenesis via upregulation of COT activity

Cytokines of the interleukin-1 (IL-1) family, such as IL-1α/β and IL-18, have pleiotropic activities in innate and adaptive immune responses in host defense and diseases. Insight into their biological functions helped develop novel therapeutic approaches to treat human inflammatory diseases. IL-33 is an important member of the IL-1 family of cytokines and is a ligand of the ST2 receptor, a member of the IL-1 receptor family. However, the role of the IL-33/ST2 axis in tumor growth and metastasis of breast cancer remains unclear. Here, we demonstrate that IL-33 is a critical tumor promoter during epithelial cell proliferation and tumorigenesis in the breast. IL-33 dose- and time-dependently increased Cancer Osaka Thyroid (COT) phosphorylation via ST2-COT interaction in normal epithelial and breast cancer cells. The IL-33/ST2/COT cascade induced the activation of the MEK-ERK (MEK-extracellular signal-regulated kinase), JNK-cJun (cJun N-terminal kinase-cJun) and STAT3 (signal transducer and activator of transcription 3) signaling pathways, followed by increased AP-1 and stat3 transcriptional activity. When small interfering RNAs of ST2 and COT were introduced into cells, IL-33-induced AP-1 and stat3 activity were significantly decreased, unlike that in the control cells. The inhibition of COT activity resulted in decreased IL-33-induced epithelial cell transformation, and knockdown of IL-33, ST2 and COT in breast cancer cells attenuated tumorigenicity of breast cancer cells. Consistent with these observations, ST2 levels were positively correlated with COT expression in human breast cancer. These findings provide a novel perspective on the role of the IL-33/ST2/COT signaling pathway in supporting cancer-associated inflammation in the tumor microenvironment. Therapeutic approaches that target this pathway may, therefore, effectively inhibit carcinogenesis in the breast.

Dipeptidyl peptidase 4 promotes epithelial cell transformation and breast tumourigenesis via induction of PIN1 gene expression

BACKGROUND AND PURPOSE

Dipeptidyl peptidase 4 (DPP4) is an aminopeptidase that is widely expressed in different cell types. Recent studies suggested that DPP4 plays an important role in tumour progression in several human malignancies. Here we have examined the mechanisms by which up-regulation of DPP4 expression causes epithelial transformation and mammary tumourigenesis.

EXPERIMENTAL APPROACH

Expression of DPP4 and the peptidylprolyl cis/trans isomerase, NIMA-interacting 1 (PIN1), and the cytotoxic effects of combined treatment with sitagliptin and juglone were investigated by immunohistochemistry, immunoblotting, real-time PCR, TUNEL and soft agar assays, using MCF7 cells. The effects of sitagliptin on tumour development in vivo were studied in the syngeneic 4T1 metastatic breast cancer model.

KEY RESULTS

Activity of the transcription factor E2F1 induced by EGF was enhanced by DPP4, thus increasing PIN1 expression. Furthermore, DPP4 enhanced MEK/ERK and JNK/c-Jun signalling induced by EGF, inducing AP-1 activity and epithelial cell transformation. In contrast, DPP4 silencing or DPP4 inhibition in MCF7 cells inhibited PIN1 expression via E2F1 activity induced by EGF, decreasing colony formation and inducing DNA fragmentation. In the syngeneic 4T1 metastatic breast cancer model, DPP4 overexpression increased tumour development, whereas treatment with sitagliptin and/or juglone suppressed it. Consistent with these observations, DPP4 levels were positively correlated with PIN1 expression in human breast cancer.

CONCLUSIONS AND IMPLICATIONS

DPP4 promoted EGF-induced epithelial cell transformation and mammary tumourigenesis via induction of PIN1 expression, suggesting that sitagliptin targeting of DPP4 could be a treatment strategy in patients with breast cancer.

Associations between serum 25-hydroxyvitamin D and bone mineral density and proximal femur geometry in Koreans: the Korean National Health and Nutrition Examination Survey (KNHANES) 2008-2009

The association between 25-hydroxyvitamin D (25(OH)D) levels and bone mineral density (BMD) and proximal femur bone geometry was examined in the Korean population. A positive relationship between skeletal health and 25(OH)D levels was observed. However, there were no significant differences in skeletal health between the groups with 25(OH)D level of 50-75 nmol/L and greater than 75 nmol/L.

INTRODUCTION

Vitamin D plays an important role in calcium and phosphate homeostasis and normal mineralization of bone. However, the optimal level of vitamin D for skeletal health has not been clearly established. We analyzed the associations between serum 25(OH)D and BMD and proximal femur bone geometry and determined the optimal 25(OH)D level.

METHODS

This was a cross-sectional study of 10,062 participants (20-95 years, 4,455 men, 5,607 women) in the Fourth Korea National Health and Nutrition Examination Surveys (KNHANES IV) conducted from 2008 to 2009. Participants were divided into groups according to 25(OH)D level (<25, 25-50, 50-75, and ≥75 nmol/L). BMD and proximal femur geometric indices were measured.

RESULTS

The group with 25(OH)D levels of 50-75 nmol/L had greater bone density values, with the exception of the lumbar spine, and also had greater femur neck cortical thickness, cross-sectional area, and cross-sectional moment of inertia, as well as a lesser buckling ratio than the groups with 25(OH)D level of 25-50 nmol/L and less than 25 nmol/L. However, there were no significant differences in BMD and proximal femur geometry properties between the groups with 50-75 nmol/L and greater than 75 nmol/L of 25(OH)D.

CONCLUSION

The skeletal outcomes, including BMD and proximal femur geometric indices observed in this study, suggest that serum 25(OH)D levels of 50 to <75 nmol/L are optimal for skeletal health.

σ1 receptors activate astrocytes via p38 MAPK phosphorylation leading to the development of mechanical allodynia in a mouse model of neuropathic pain

BACKGROUND AND PURPOSE

Spinal astrocytes have emerged as important mechanistic contributors to the genesis of mechanical allodynia (MA) in neuropathic pain. We recently demonstrated that the spinal sigma non-opioid intracellular receptor 1 (σ1 receptor) modulates p38 MAPK phosphorylation (p-p38), which plays a critical role in the induction of MA in neuropathic rats. However, the histological and physiological relationships among σ1, p-p38 and astrocyte activation is unclear.

EXPERIMENTAL APPROACH

We investigated: (i) the precise location of σ1 receptors and p-p38 in spinal dorsal horn; (ii) whether the inhibition of σ1 receptors or p38 modulates chronic constriction injury (CCI)-induced astrocyte activation; and (iii) whether this modulation of astrocyte activity is associated with MA development in CCI mice.

KEY RESULTS

The expression of σ1 receptors was significantly increased in astrocytes on day 3 following CCI surgery. Sustained intrathecal treatment with the σ1 antagonist, BD-1047, attenuated CCI-induced increase in GFAP-immunoreactive astrocytes, and the treatment combined with fluorocitrate, an astrocyte metabolic inhibitor, synergistically reduced the development of MA, but not thermal hyperalgesia. The number of p-p38-ir astrocytes and neurons, but not microglia was significantly increased. Interestingly, intrathecal BD-1047 attenuated the expression of p-p38 selectively in astrocytes but not in neurons. Moreover, intrathecal treatment with a p38 inhibitor attenuated the GFAP expression, and this treatment combined with fluorocitrate synergistically blocked the induction of MA.

CONCLUSIONS AND IMPLICATIONS

Spinal σ1 receptors are localized in astrocytes and blockade of σ1 receptors inhibits the pathological activation of astrocytes via modulation of p-p38, which ultimately prevents the development of MA in neuropathic mice.

Effects of agmatine on blood-brain barrier stabilization assessed by permeability MRI in a rat model of transient cerebral ischemia

BACKGROUND AND PURPOSE

BBB disruption after acute ischemic stroke and subsequent permeability increase may be enhanced by reperfusion. Agmatine has been reported to attenuate BBB disruption. Our aim was to evaluate the effects of agmatine on BBB stabilization in a rat model of transient cerebral ischemia by using permeability dynamic contrast-enhanced MR imaging at early stages and subsequently to demonstrate the feasibility of dynamic contrast-enhanced MR imaging for the investigation of new therapies.

MATERIALS AND METHODS

Thirty-four male Sprague-Dawley rats were subjected to transient MCA occlusion for 90 minutes. Immediately after reperfusion, agmatine (100 mg/kg) or normal saline was injected intraperitoneally into the agmatine-treated group (n = 17) or the control group, respectively. MR imaging was performed after reperfusion. For quantitative analysis, regions of interest were defined within the infarct area, and values for volume transfer constant, rate transfer coefficient, volume fraction of extravascular extracellular space, and volume fraction of blood plasma were obtained. Infarct volume, infarct growth, quantitative imaging parameters, and numbers of factor VIII-positive cells after immunohistochemical staining were compared between control and agmatine-treated groups.

RESULTS

Among the permeability parameters, volume transfer constant and volume fraction of extravascular extracellular space were significantly lower in the agmatine-treated group compared with the control group (0.05 ± 0.02 minutes(-1) versus 0.08 ± 0.03 minute(-1), P = .012, for volume transfer constant and 0.12 ± 0.06 versus 0.22 ± 0.15, P = .02 for volume fraction of extravascular extracellular space). Other permeability parameters were not significantly different between the groups. The number of factor VIII-positive cells was less in the agmatine-treated group than in the control group (3-fold versus 4-fold, P = .037).

CONCLUSIONS

In ischemic stroke, agmatine protects the BBB, which can be monitored in vivo by quantification of permeability by using dynamic contrast-enhanced MR imaging. Therefore, dynamic contrast-enhanced MR imaging may serve as a potential imaging biomarker for assessing the BBB stabilization properties of pharmacologic agents.

Helminth infection reactivates latent γ-herpesvirus via cytokine competition at a viral promoter

Mammals are coinfected by multiple pathogens that interact through unknown mechanisms. We found that helminth infection, characterized by the induction of the cytokine interleukin-4 (IL-4) and the activation of the transcription factor Stat6, reactivated murine γ-herpesvirus infection in vivo. IL-4 promoted viral replication and blocked the antiviral effects of interferon-γ (IFNγ) by inducing Stat6 binding to the promoter for an important viral transcriptional transactivator. IL-4 also reactivated human Kaposi's sarcoma-associated herpesvirus from latency in cultured cells. Exogenous IL-4 plus blockade of IFNγ reactivated latent murine γ-herpesvirus infection in vivo, suggesting a "two-signal" model for viral reactivation. Thus, chronic herpesvirus infection, a component of the mammalian virome, is regulated by the counterpoised actions of multiple cytokines on viral promoters that have evolved to sense host immune status.

Volatile Flavor Components of Ripe and Overripe Ki-mikans (Citrus flaviculpus Hort. ex Tanaka) in Comparison with Hyuganatsu (Citrus tamurana Hort. ex Tanaka)

The volatile flavor components of ripe and overripe ki-mikan (Citrus flaviculpus Hort. ex Tanaka) peel oil samples, which had been isolated by cold-pressing, were investigated by capillary GC and GC-MS, and compared with the Hyuganatsu (Citrus tamurana Hort. ex Tanaka) flavor. Limonene (ripe fruit, 82.44%; overripe fruit, 73.10%) was the most abundant compound in the ki-mikan oil, this being followed by gamma-terpinene (8.83% and 13.74%), trans-beta-farnesene (1.76% and 3.12%) and myrcene (1.54% and 1.13%). The composition of overripe ki-mikan oil was characterized by higher amounts of aliphatic and sesquiterpene hydrocarbons, monoterpene and sesquiterpene alcohols, ketones and esters than that of ripe ki-mikan oil. Monoterpene hydrocarbons, especially limonene (84.78%), were predominant in Hyuganatsu oil. The CPO composition of ki-mikan was qualitatively similar to that of Hyuganatsu, but differed quantitatively. The content of sesquiterpene hydrocarbons was higher in the ki-mikan oil samples than in Hyuganatsu oil, while ketones showed the opposite predominance. These differences were more evident in the trans-beta-farnesene and l-carvone contents. The ratio of both these compounds could be used to distinguish ki-mikan oil from Hyuganatsu oil.

DCE and DSC MR perfusion imaging in the differentiation of recurrent tumour from treatment-related changes in patients with glioma

AIM

To retrospectively compare the utility of perfusion magnetic resonance imaging (MRI) in distinguishing treatment-related changes from recurrent disease in glioma patients.

MATERIALS AND METHODS

Thirty-one patients with histologically diagnosed gliomas and increased enhancement after or during concurrent (chemo-) radiation therapy were enrolled. They underwent dynamic contrast-enhanced (DCE) permeability MRI followed by dynamic susceptibility contrast (DSC) perfusion MRI. The vascular transfer constant (rK(trans)) and initial areas under the concentration curve (riAUC) were obtained from DCE MRI, and cerebral blood volume (rCBV) was obtained from DSC MRI. Patients were classified as having treatment-related changes or recurrent tumours based on clinicoradiological results or pathological results from surgery.

RESULTS

Nineteen patients were diagnosed as having recurrences and 12 patients as having treatment-related changes. The rK(trans), riAUC, and rCBV values in the recurrent group were significantly higher than the values in the group with treatment-related changes (p < 0.05). For all 31 patients, there was no significant difference between DSC MRI and DCE MRI for the differentiating power between recurrence and treatment-related changes (p = 0.7227). However, when including only the 24 patients with concordant values of rK(trans) and riAUC, DCE MRI showed a significant AUC value of 0.786 in the receiver operating characteristic (ROC) curve analysis (p = 0.003), whereas DSC MRI did not (AUC = 0.643, p = 0.229).

CONCLUSION

MRI perfusion images appear to show promise in distinguishing treatment-related changes from recurrent tumours. When both rK(trans) and riAUC show concordant values, DCE MRI seems to be more powerful than DSC MRI in the differentiation of recurrence from treatment-related changes.

A simple novel endoscopic successive suture device: a validation study for closure strength and reproducibility

BACKGROUND AND STUDY AIMS

Endoscopic surgical technology has been developing rapidly. Although several successful endoscopic closure devices have already been introduced, only a few of them have demonstrated improvements in closure strength and reproducibility over conventional endoscopic clip closures or hand sutures. The objective of this study was to test the feasibility of a novel successive suturing device (SSD) by measuring closure strength and reproducibility.

MATERIAL AND METHODS

Porcine stomach models were used in this study. Endoclips, full-thickness hand sutures, and the novel SSD sutures were used to close a perforation in the stomach wall, with 10 stomachs being tested for each closure method. Endoclips and SSD sutures were performed using a two-channel endoscope, and the hand sutures were performed from outside of the stomach wall. Air leakage pressure was measured to determine the closure strength and reproducibility of each method.

RESULTS

The mean air leakage pressure of the SSD closure was 62.7 ± 8.2 mmHg. SSD-treated stomachs exhibited significantly greater air leakage pressure than Endoclip-treated stomachs. The standard deviation of bursting pressure in SSD stomachs was found to be significantly smaller than that of hand-sewn stomachs but was not different from that of Endoclip stomachs.

CONCLUSIONS

The consistent closure strength of SSD stomachs demonstrated the reliability and reproducibility of this new closure method. These promising results in closure strength and reproducibility suggest the feasibility of the proposed device for clinical applications.

Molecular characterization and an infectious clone construction of sweet potato leaf curl virus (SPLCV) isolated from Korea

Sweet potato leaf curl disease (SPLCD) was primarily identified in sweet potato fields in Korea in 2003, and the complete genomic sequence of sweet potato leaf curl virus (SPLCV) has been cloned. The genome of the Korean SPLCV isolate (SPLCV-KR) comprises 2,828 nucleotides with six open reading frames in DNA-A, similar to a monopartite begomovirus. Additionally, neither the genome B genomic component nor the DNA beta sequence was detected. The results of phylogenetic analysis using the maximum parsimony method showed that SPLCV-KR is more closely related to SPLCV-US (US) than SPLCV-CN (China) and SPLCV-JP (Japan). A tandem repeat dimer of SPLCV-KR was cloned and found to be infectious in sweet potatoes (Ipomoea batatas) via biolistic inoculation. The SPLCV-infected sweet potatoes exhibited mild leaf curl symptoms of SPLCD, and the newly-replicated viral DNA was detected via Southern blot analysis. Results of biotic, molecular, and phylogenetic characterization suggest that SPLCV-KR is a new strain of SPLCV and is importantly placed in the evolutionary progression from curtoviruses to begomoviruses.

KEYWORDS

sweet potato leaf curl virus; sweet potato leaf curl disease; phylogenetic analysis; infectious clone; biolistic infection.

High anxiety, young age and long waits increase the need for preoperative sedatives in children

OBJECTIVE

This prospective, observational study aimed to identify children likely to require sedation preoperatively by measuring anxiety levels using the modified Yale Preoperative Anxiety Scale (mYPAS). Other possible predictive factors for preoperative sedation were also investigated.

METHODS

A total of 455 patients aged 2-12 years scheduled for surgery requiring general anaesthesia were enrolled in the study. Patients' anxiety levels were measured using the mYPAS in a preoperative holding area just before patients were separated from their parents or guardians and entered the operating theatre. Anaesthetists blindedto the mYPAS assessments judged whether the child could be separated and enter the operating theatre without a sedative. The ability of the mYPAS to predict the need for preoperative sedation was analysed by receiver operating characteristic (ROC) curve analysis.

RESULTS

The optimum mYPAS cut-off for requiring sedatives was 41.7 according to ROC curve analysis. Multivariate logistic regression analysis showed that age, mYPAS>40 and waiting time were independent predictors of the requirement for sedative administration.

CONCLUSIONS

High anxiety levels, young age and long waits contributed to the need for preoperative sedation in children.

Proyl isomerase Pin1 facilitates ubiquitin-mediated degradation of cyclin-dependent kinase 10 to induce tamoxifen resistance in breast cancer cells

Endocrine therapies that inhibit estrogen receptor (ER)-α signaling are the most common and effective treatment for ER-α-positive breast cancer. However, the use of these agents is limited by the frequent development of resistance. The aim of this study was to elucidate the mechanisms by which downregulation of CDK10 expression confers resistance to tamoxifen in breast cancer. Here, we show that peptidyl-prolyl isomerase Pin1 downregulates CDK10 protein as a result of its interaction with and ubiquitination of CDK10, thereby affecting CDK10-dependent Raf-1 phosphorylation (S338). Pin1(-/-) mouse embryonic fibroblasts (MEFs) show higher CDK10 expression than Pin1(+/+) MEFs, whereas CDK10 protein was downregulated in the rescued Pin1(-/-) MEFs after reexpression of Pin1. Pin1 silencing in SKBR-3 and MCF7 cells increased the CDK10 expression. In human tamoxifen-resistant breast cancer and tamoxifen-resistant MCF7 cells, immunohistochemical staining and immunoblotting analysis shows an inverse correlation between the expression of CDK10 and the degree of tamoxifen resistance. There was also a positive correlation between the high level of P-Raf-1 (Ser338) and Pin1 in human tamoxifen-resistant breast cancer and tamoxifen-resistant MCF7 (TAMR-MCF7) cells. Importantly, 4-OH tamoxifen (4-OHT), when used in combination with overexpressed CDK10 or Raf-1 inhibitor, increased cleaved PARP and DNA fragmentation to inhibit cologenic growth of MCF7 cells and Tamoxifen-resistant MCF7 cells, respectively. On the basis of these findings, we suggest that the Pin1-mediated CDK10 ubiquitination is a major regulator of tamoxifen-resistant breast cancer cell growth and survival.

Predictors for lymph node metastasis in T1 colorectal cancer

BACKGROUND AND STUDY AIMS

It is critical that the risk of lymph node metastasis (LNM) is evaluated for determining the suitability of endoscopic resection for T1 colorectal cancer (CRC). Reported risk factors for LNM in completely resected T1 CRC are deep submucosal invasion, grade 3, angiolymphatic invasion, and budding. The aim of the present study was to identify the histopathologic factors associated with LNM in T1 CRC.

PATIENTS AND METHODS

The study involved 435 patients with T1 CRC treated by endoscopic or surgical resection between January 2001 and April 2010 at the National Cancer Center, Korea. The 435 patients were classified into two groups - those undergoing surgical resection (n = 324) and those undergoing endoscopic resection (n = 111). In the surgically resected group, details regarding depth of submucosal invasion, angiolymphatic invasion, tumor grade, budding, and background adenoma (BGA) were evaluated with respect to presence or absence of LNM. In the endoscopically resected group, the results of follow-ups and additional salvage surgeries were studied.

RESULTS

In the surgically resected group, LNM was detected in 42 patients (13.0 %). Grade 3, angiolymphatic invasion, budding, and the absence of BGA were identified as factors associated with LNM in univariate and multivariate analyses (P < 0.05). Among the 50 patients in the endoscopically resected group with high risk, three were diagnosed as being LNM-positive during the follow-up period. There was no LNM in the endoscopically resected group with low risk.

CONCLUSIONS

Grade 3, angiolymphatic invasion, budding, and the absence of BGA are the risk factors that predict LNM in patients with T1 CRC. In cases where endoscopically resected T1 CRC has no risk factor, cautious follow-up could be recommended. However, if the tumor has any risk factor, additional surgical resection should be considered.

Carbohydrate but not fat is associated with elevated aminotransferases

BACKGROUND

Recently, many studies reported that high carbohydrate and simple sugar intake increase a risk of obesity and metabolic syndrome significantly.

AIM

To investigate the effect of carbohydrate on aminotransferase levels in Korea, where the proportion of carbohydrate in meals is extremely high but fat is low.

METHODS

We used the data of Korean National Health and Nutrition Examination Surveys (KNHANES). A total of 19 749 people were included. Amounts and types of consumed foods were examined by the 24 h recall method.

RESULTS

Mean carbohydrate and fat proportions in total energy intake were 67.7% and 17.4%, respectively. Aminotransferase activity increased according to the rise of the proportion of carbohydrate in the energy intake. A high carbohydrate intake (>70% of energy) was associated with abnormal aminotransferase activity and metabolic syndrome. After adjusting for covariates, such as age, energy intake and body mass index, abnormal aminotransferase activity was significantly associated with carbohydrate proportion. There was a negative correlation between fat proportion in the total energy intake and aminotransferase activity (P < 0.01). The relation between aminotransferase activity and carbohydrate composition showed a J-shaped curve. The lowest point (the J point) was located at 50-60% carbohydrate.

CONCLUSIONS

The proportion of carbohydrate in energy intake but not fat is positively correlated with abnormal aminotransferase activity in Koreans. This finding may be useful in planning a strategy of nutrition education for NAFLD in countries where the proportion of carbohydrate in most meals is extremely high.

Metformin ameliorates IL-6-induced hepatic insulin resistance via induction of orphan nuclear receptor small heterodimer partner (SHP) in mouse models

AIMS/HYPOTHESIS

IL-6 is a proinflammatory cytokine associated with the pathogenesis of hepatic diseases. Metformin is an anti-diabetic drug used for the treatment of type 2 diabetes, and orphan nuclear receptor small heterodimer partner (SHP, also known as NR0B2), a transcriptional co-repressor, plays an important role in maintaining metabolic homeostasis. Here, we demonstrate that metformin-mediated activation of AMP-activated protein kinase (AMPK) increases SHP protein production and regulates IL-6-induced hepatic insulin resistance.

METHODS

We investigated metformin-mediated SHP production improved insulin resistance through the regulation of an IL-6-dependent pathway (involving signal transducer and activator of transcription 3 [STAT3] and suppressor of cytokine signalling 3 [SOCS3]) in both Shp knockdown and Shp null mice.

RESULTS

IL-6-induced STAT3 transactivation and SOCS3 production were significantly repressed by metformin, adenoviral constitutively active AMPK (Ad-CA-AMPK), and adenoviral SHP (Ad-SHP), but not in Shp knockdown, or with the adenoviral dominant negative form of AMPK (Ad-DN-AMPK). Chromatin immunoprecipitation (ChIP), co-immunoprecipitation (Co-IP) and protein localisation studies showed that SHP inhibits DNA binding of STAT3 on the Socs3 gene promoter via interaction and colocalisation within the nucleus. Upregulation of inflammatory genes and downregulation of hepatic insulin signalling by acute IL-6 treatment were observed in wild-type mice but not in Shp null mice. Finally, chronic IL-6 exposure caused hepatic insulin resistance, leading to impaired insulin tolerance and elevated gluconeogenesis, and these phenomena were aggravated in Shp null mice.

CONCLUSIONS/INTERPRETATION

Our results demonstrate that SHP upregulation by metformin may prevent hepatic disorders by regulating the IL-6-dependent pathway, and that this pathway can help to ameliorate the pathogenesis of cytokine-mediated metabolic dysfunction.

Paradoxical response in HIV-negative patients with pleural tuberculosis: a retrospective multicentre study

OBJECTIVE

To evaluate the incidence, clinical characteristics and predicting factors for the development of paradoxical response in human immunodeficiency virus negative patients with isolated pleural tuberculosis (TB).

DESIGN

A multicentre, retrospective cohort study including 458 patients who were diagnosed and treated with isolated pleural TB between March 2005 and February 2010.

RESULTS

Paradoxical response developed in 72 patients (16%) with isolated pleural TB. The mean time to development of paradoxical response was 8.8 ± 6.4 weeks after initiation of anti-tuberculosis treatment. The main presentation of paradoxical response was aggravation of pre-existing pleural effusion in 58 patients (81%). However, the majority of the patients who developed paradoxical response had no associated symptoms (n = 49, 68%). In multiple logistic regression analysis, development of paradoxical response was independently associated with the proportion of eosinophils (adjusted OR 1.293, 95%CI 1.077-1.553) and protein concentrations (adjusted OR 0.590, 95%CI 0.397-0.878) in the pleural fluid at the time of diagnosis.

CONCLUSION

Paradoxical response developed in 16% of the patients approximately 2 months after initiation of anti-tuberculosis treatment, presenting with aggravation of pre-existing pleural effusion. Development of paradoxical response was associated with the proportion of eosinophils and protein concentrations in the pleural fluid at the time of diagnosis.

Curcumin protects against ovariectomy-induced bone loss and decreases osteoclastogenesis

Curcumin has anti-oxidative activity. In view of the increasing evidence for a biochemical link between increased oxidative stress and reduced bone density we hypothesized that curcumin might increase bone density by elevating antioxidant activity in some target cell type. We measured bone density by Micro-CT, enzyme expression levels by quantitative PCR or enzyme activity, and osteoclast (OC) formation by tartrate-resistant acid phosphatase staining. The bone mineral density of the femurs of curcumin-administered mice was significantly higher than that of vehicle-treated mice after ovariectomy (OVX) and this was accompanied by reduced amounts of serum collagen-type I fragments, which are markers of bone resorption. Curcumin suppressed OC formation by increasing receptor activator of nuclear factor-κB ligand (RANKL)-induced glutathione peroxidase-1, and reversed the stimulatory effect of homocysteine, a known H(2) O(2) generator, on OC formation by restoring Gpx activity. Curcumin generated an aberrant RANKL signal characterized by reduced expression of nuclear factor of activated T cells 2 (NFAT2) and attenuated activation of mitogen-activated protein kinases (ERK, JNK, and p38). Curcumin thus inhibited OVX-induced bone loss, at least in part by reducing osteoclastogenesis as a result of increased antioxidant activity and impaired RANKL signaling. These findings suggest that bone loss associated with estrogen deficiency could be attenuated by curcumin administration.

Changes in integrity of normal-appearing white matter in patients with moyamoya disease: a diffusion tensor imaging study

BACKGROUND AND PURPOSE

DTI is widely used for the evaluation of white matter integrity in various neurologic diseases. The purpose of this study was to investigate changes in white matter integrity by using DTI in NAWM of patients with MMD and to evaluate the correlation between diffusion and perfusion characteristics through an interhemispheric comparison.

MATERIALS AND METHODS

We retrospectively reviewed 20 primary MMD patients with asymmetric disease stage and 20 age-matched healthy controls. FA(CS) and ADC(CS) values of bilateral centrum semiovale were measured by using region of interest analysis. Mean FA(CS) and ADC(CS) were compared between patient and control groups by unpaired t test. Interhemispheric differences in FA(CS) and ADC(CS) were assessed and compared between the H-TTP(delayed) and the H-TTP(shorter) by using paired t test. AIs also were assessed to verify interhemispheric differences.

RESULTS

The patient group showed a significantly lower mean FA(CS) and a higher mean ADC(CS) value than the control group. In the patient group, the H-TTP(delayed) had a significantly lower FA(CS) and higher ADC(CS) value than the H-TTP(shorter). Both AI(FA) and AI(ADC) were significantly higher in the patient compared with the control group.

CONCLUSIONS

DTI can describe subtle changes in white matter integrity in NAWM of patients with primary MMD that are not detected by conventional MR imaging. In addition, diffusion characteristics are well correlated with perfusion characteristics. We believe that DTI is a useful ancillary tool to evaluate patients with MMD.

Differences in femoral neck geometry associated with age and ethnicity

SUMMARY

We studied femoral geometry in relation to age and ethnicity in a cross-sectional study. Age-associated cortical thinning showed the most pronounced effect, and Koreans studied here had thicker cortices and lower buckling ratios than those reported for other races. Cortical thickness may thus be a major determinant of hip fracture risk.

INTRODUCTION

The rate of hip fracture varies by age and ethnicity. The geometric properties of the femur influence femoral strength and fragility, but differences in femoral geometry according to age and ethnicity are poorly understood. To explain the high prevalence of hip fractures in the elderly and the relatively low hip fracture rate in Asian populations, we studied age-related changes and ethnic differences in femoral geometry.

METHODS

We recruited 214 peri- or postmenopausal women aged 46 to 85 years (mean age, 60.6 years). Their proximal femoral bone mineral densities (BMD) were measured by quantitative computed tomography and further analyzed geometric properties.

RESULTS

We observed large declines in trabecular volumetric bone mineral density associated with aging (33.03% less than the reference value in the oldest group, respectively). Cortical thickness decreased remarkably with age as well, and only 53.94% of the baseline value remained in the oldest group. As a result, the cortical buckling ratio increased geometrically and reached 239.14% of the reference value in the oldest group. In comparisons with other ethnic groups, Korean subjects had thicker cortices than their American, European, and African counterparts.

CONCLUSIONS

In this cross-sectional study, cortical thickness showed a pronounced age-associated decrease, and the cortical buckling ratio showed a strong age-associated increase. This may in part explain the higher rates of hip fractures in the elderly. When compared with other races, Asians had thicker cortical bone and lower buckling ratios, which may partially explain the lower prevalence of hip fractures in Asians.

Effect of synthetic temperature on the dispersion stability of gold nanocolloid produced via electrical explosion of wire

In this study, gold nanocolloid was produced via the electrical explosion of wire in water, for the purpose of medical treatment. Thus, the use of other additives was avoided to stabilize the gold nanocolloid. The temperature of the water that was to be used for explosion was changed, and its effect on the stability of the gold nanocolloid was investigated. The synthetic temperature was varied from ice temperature to 80 degrees C. The morphology and particle size were studied using a transmission electron microscope. The UV-Vis spectra confirmed the formation of gold nanoparticles in the water. The stability of the gold nanocolloid was estimated using the zeta-potential and Turbiscan methods. The results showed that the synthetic temperature affected the stability of the gold nanocolloid. The TEM images of the gold nanoparticles prepared at low temperatures (0 and 20 degrees C) have several big particles. But, when the synthetic temperature was increased to 80 degrees C, most of the nanoparticles formed a spherical shape, without neck connection. Better stability was obtained in the gold nanocolloid sample prepared at a higher temperature. The gold nanocolloid that was synthesized at 80 degrees C was stable for more than three months, with small sedimentation.

Prevalent vertebral fractures predict subsequent radiographic vertebral fractures in postmenopausal Korean women receiving antiresorptive agent

The relationship between prevalent vertebral fractures and new vertebral fractures in Korean women has not been previously studied. We found that prevalent vertebral fracture is a strong risk factor for subsequent radiographic vertebral fracture, independent of age and spine bone mineral density (BMD) in postmenopausal Korean women receiving antiresorptive agents.

INTRODUCTION

The presence of prevalent vertebral fractures increases the risk of subsequent vertebral fractures. This observational study examined whether prevalent vertebral fractures influenced future incident vertebral fracture in postmenopausal women receiving antiresorptive treatment.

METHODS

Using the medical records, we retrospectively assessed 1,200 postmenopausal women who had visited the osteoporosis clinic. Among them, we selected patients whose BMD was measured at least once a year for 3 years. We excluded patients whose lateral spine X-ray film at baseline or follow-up period was missing, which is the key assessment. In the end, we analyzed 666 postmenopausal women. The mean duration of follow-up period was 3.2 years.

RESULTS

The majority of patients (83%) received bisphosphonates or raloxifene during the mean duration of 3.2 years. Fifty-five of the 666 women had new incident radiographic vertebral fractures during the follow-up period. Prevalent vertebral fractures were associated with a five-fold increased risk (odd ratio 5.7, 95% CI 3.09-10.74) of incident vertebral fractures after adjusting for age. These associations remained significant after the adjustment for multiple confounding factors (odd ratio 4.4, 95% CI 1.97-9.75). The risk of incident vertebral fracture increased with the number of prevalent vertebral fractures at baseline: 3.4 (95% CI 1.54-7.70) for those with a single fracture and 7.4 (95% CI 3.10-17.54) for those with two or more after adjustment for age and spine BMD.

CONCLUSIONS

We confirmed that prevalent vertebral fracture is a strong risk factor for new vertebral fractures, independent of age and spine BMD in postmenopausal Korean women receiving antiresorptive agents.

Clinicopathological differences of laterally spreading tumors of the colorectum according to gross appearance

BACKGROUND AND STUDY AIMS

Laterally spreading tumors (LST) are classified into two subtypes, with the nongranular type harboring a higher risk of (pre)malignant changes than the granular type. Further subdifferentiation into two subgroups each has been suggested, but the clinical significance of such a subdifferentiation has not previously been studied in detail in larger numbers.

PATIENTS AND METHODS

Out of 6499 patients diagnosed with colorectal adenomas between January 2006 and November 2008, 153 patients (2.35 %) had 158 LSTs, 96 with a granular and 62 with a nongranular pattern. The former group was subdivided into homogeneous and nodular mixed, the latter group into flat elevated and pseudodepressed. Clinical and histopathological parameters were compared among the four subtypes.

RESULTS

Parameters were variably distributed between the four groups, with nodular mixed tumors being larger than the other three types ( P < 0.0001). As in other studies, malignant transformation and premalignant lesion (HGIN/CIS) were more frequent in nodular mixed than in homogeneous tumors (45.0 % vs. 5.6 %, P < 0.001), and also more common in pseudodepressed than in flat elevated tumors (41.7 % vs. 13.2 %, P = 0.011). Submucosal invasive cancer was present in 8.3 % of nodular mixed tumors, 7.9 % of flat elevated, and 12.5 % of pseudodepressed, while it was absent in homogeneous tumors. Serrated adenoma was identified in 10.8 % of all LSTs, and sessile serrated adenoma tended to be more common in flat elevated tumors.

CONCLUSIONS

Further subdifferentiation of the LST lesions to identify lesions at risk of malignant transformation makes most sense in the granular type. Among nongranular LSTs, both subtypes carry a significant risk.

Preparation and stability of gold colloid by electrical explosion of wire in various media

Gold colloids were prepared by electrical explosion of wire in various media: cold water (0 degrees C), room temperature water (25 degrees C), hot water (80 degrees C), 0.01 M polysorbate surfactant 20 (TW 20) solution, mixture of 0.01 M TW 20 and 0.01 M ascorbic acid. The size distribution of nanoparticles measured by transmission electron microscope was found to shift to a smaller size with a decrease of temperature and a presence of TW 20 surfactant. The multiple light scattering results showed that medium temperature and ambient medium of explosion process is much influence on the stability of colloid. The gold colloid prepared in cold water is unstable in comparison with one prepared in warm and hot water. The best stability of gold colloid obtained with explosion medium of TW 20 and ascorbic acid solution.

First Report of Crown Rot on Gypsophila (Gypsophila paniculata) Caused by Fusarium proliferatum in Korea

Gypsophilas commonly cultivated are Gypsophila elegans B. and G. paniculata L. In September of 2009 and 2010, a severe wilt symptom due to crown rot was observed on G. paniculata (cv. Bristol Fairy) in greenhouses in Yeosu, South Korea. The area of cultivation (~8 ha) in Yeosu covers 90% of production in the Jeonnam Province. Disease outbreak was 20 to 30% in affected greenhouses. Early symptoms included brown discoloration surrounding basal stems and slight wilting. Late symptoms included a sunken stem rot next to the roots, root rot, severe wilting, and dying plants. The causal fungus appeared to invade plants through the basal stem, causing a crown rot that prevented the plant from taking up water and nutrients. Crown rot occurred on young and mature plants. Ten fungal isolates were recovered from basal stems and roots of wilted plants. Microconidia were abundantly produced on potato dextrose agar (PDA), V8 juice agar (VA), carnation leaf agar (CLA), and oatmeal agar (OA). Microconidia were single celled, variable, oval-ellipsoid cylindrical, straight to curved, club-to-kidney shaped or spindle shaped on OA, more slender on VA. Macroconidia were not found on any media used. Microconidia on PDA were 5.9 to 15.1 (9.9) × 2.7 to 4.3 (3.5) μm. Germinated conidia (or false conidia) were often formed on CLA. Conidiophores as phialides were singly formed but often branched. Length of conidiophores was up to 31.1 μm on CLA. Small-sized chlamydospores were rarely found. Fusarium isolates (EML-GYP1, 2, and 3) were selected and identified. From extracted genomic DNA, the internal transcribed spacer (ITS) region including 5.8S rDNA was amplified using ITS1F (5'-CTTGGTCATTTAGAGGAAGT-3') and LR5F (5'-GCTATCCTGAGGGAAAC-3') primers. Sequence analyses by BLAST indicated that the isolates (GenBank HM560019, HM560020, and HM560021) were most similar to F. proliferatum (EF4534150) with sequence identity values of 99.3, 99.4, and 99.1%, respectively. The causal fungus was determined to be F. proliferatum based on morphological data and ITS rDNA sequences. Pathogenicity tests with the three isolates were performed on 10 plants of G. paniculata using the dipping method. Healthy roots and basal stems were soaked in a conidial suspension adjusted to ~1.2 × 10⁶ conidia/ml (distilled water) for 15 min. Plants were potted in sterile soil, kept in a humid chamber for 72 h, and moved to a greenhouse. The experiment was carried out in duplicate and repeated two times. Similar symptoms to those observed in the greenhouses were seen 7 days after inoculation. The causal fungus was reisolated from the artificially inoculated basal stems, fulfilling Koch's postulates. Control plants whose basal stems and roots were dipped in sterile water showed no crown rot and wilt symptoms. EML-GYP2 was determined to be the most pathogenic. Ten records of disease caused by three Fusarium species (Fusarium sp., F. oxysporum, and F. udum) have been found on gypsophilas (1), but only F. oxysporum has been reported to cause wilt on G. elgans in Korea (2). To our knowledge, this is the first report of crown rot on gypsophila caused by F. proliferatum in Korea as well as the world. References: (1) D. F. Farr and A. Y. Rossman. Fungal Databases, Systematic Mycology and Microbiology Laboratory, ARS, USDA. Retrieved from http://nt.ars-grin.gov/fungaldatabases/ , October 27, 2010, (2) W.-G. Kim and H.-M. Koo. Page 381 in: List of Plant Diseases in Korea. The Korean Society of Plant Pathology, 2009.

Clinical characteristics and outcomes of H1N1-associated pneumonia among adults in South Korea

BACKGROUND

Pneumonia has been reported to be the most life-threatening complication of influenza virus infection.

OBJECTIVE

to describe clinical characteristics and determine risk factors for death among patients with H1N1-associated pneumonia.

DESIGN

A retrospective cohort study included all adult patients diagnosed and treated with H1N1-associated pneumonia in 14 participating institutions between 1 May 2009 and 28 February 2010 in South Korea. Clinical outcomes were summarised and predictors for death evaluated through univariate and multivariate analysis.

RESULTS

A total of 269 adult patients with H1N1-associated pneumonia were diagnosed and treated. Hospital visits or admissions peaked in November 2009, coinciding with the peak in the 2009 H1N1 epidemic in South Korea. The patients' median age was 48 years; 143 were male. Most (n = 266, 98.9%) were admitted for treatment: 97 (36.1%) required intensive care and 28 (10.4%) needed mechanical ventilation. Despite the use of antiviral and antibacterial agents, 19 patients (7.1%) died. Risk factors predictive of death included presence of malignancy (aOR 12.0, 95%CI 2.8-51.5), and pneumonia severity index (PSI) score (aOR 1.03, 95%CI 1.01-1.04).

CONCLUSION

Deaths among adult patients with H1N1-associated pneumonia were not rare. Clinicians should be aware of the possibility of a poor prognosis among H1N1-associated pneumonia patients with underlying malignancy or high PSI score.