Using support vector regression coupled with the genetic algorithm for predicting acute toxicity to the fathead minnow

The potential toxicity of chemicals may present adverse effects to the environment and human health. The quantitative structure-activity relationship (QSAR) provides a useful method for hazard assessment. In this study, we constructed a QSAR model based on a highly heterogeneous data set of 571 compounds from the US Environmental Protection Agency, for predicting acute toxicity to the fathead minnow (Pimephales promelas). An approach coupling support vector regression (SVR) with the genetic algorithm (GA) was developed to build the model. The generated QSAR model showed excellent data fitting and prediction abilities: the squared correlation coefficients (r(2)) for the training set and the test set were 0.826 and 0.802, respectively. Only eight critical descriptors, most of which are closely related to the toxicity mechanism, were chosen by GA-SVR, making the derived model readily interpretable. In summary, the successful case reported here highlights that our GA-SVR approach can be used as a general machine learning method for toxicity prediction.

A systematic comparison between collagen-induced arthritis and pristane-induced arthritis in Dark Agouti rats

OBJECTIVES

Both collagen-induced arthritis (CIA) and pristane-induced arthritis (PIA) are commonly used rat models of rheumatoid arthritis (RA). The aim of this study was systematically to compare the differences between CIA and PIA in Dark Agouti (DA) rats.

METHODS

The CIA was induced by immunising DA rats intradermally with collagen type (C) and PIA was induced by injecting subcutaneously with pristane. The arthritis was evaluated macroscopically and microscopically. Nitric oxide (NO) level of plasma was determined by Griess reaction method. Plasma autoimmune antibodies, including C specific IgG antibody (anti-C IgG), cyclic citrullinated peptide specific IgG antibody (anti-CCP IgG), IgM and IgG rheumatoid factors (IgM RF and IgG RF), were detected by the enzyme-linked immunosorbent assay.

RESULTS

The onset of PIA rats was earlier than that of CIA rats. The involved sites of PIA rats were mostly wrist/ankle and metacarpophalangeal/metatarsophalangeal (MCP/MTP) joints while those of CIA rats were primarily distal interphalangeal (DIP) joints. NO level of plasma was increased in PIA rats, as anti-C IgG, anti-CCP IgG, IgM RF and IgG RF levels of plasma were increased in CIA rats. The kidney hyaline casts were more frequent in CIA rats than in control rats, with 9/12 in PIA group, 8/8 in CIA, and 4/8 in control, respectively.

CONCLUSIONS

PIA mainly affected wrist/ankle joints and MCP/MTP joints, had more severe inflammation and hardly involved other organs; while CIA mostly influenced DIP joints, had more autoimmune antibodies in plasma, and always showed hyaline casts in kidney. These findings will be useful to select the animal model of RA.

Establishment and evaluation of a model of a community health service in an underdeveloped area of China

OBJECTIVES

To develop and evaluate an applicable model for a community health service (CHS) in an underdeveloped area of China that ensures efficient, convenient and affordable primary healthcare access for all residents.

STUDY DESIGN

The current study was carried out in Puyang, a typical medium-sized city in central-eastern China. Based on the healthcare requirements of the residents in Puyang, a CHS network was set up and its operation was evaluated from 1999 to 2006. The system is characterized by its focus on community health education (CHE).

METHODS

Firstly, 8231 residents, selected at random, were surveyed to investigate the healthcare requirements of the local residents. Meanwhile, the operation of the pre-existing healthcare resources was investigated in Puyang. Based on the information gained, a network-based CHS system was proposed and established, with CHE as the major focus. This study compared CHS operation prior to and after establishment of the network. Finally, an analytic hierarchy process based evaluation model was applied to evaluate the operation of the CHS network.

RESULTS

There was a high prevalence (86.98 per thousand) of chronic diseases among the residents who participated in this investigation. The majority (84.39%) of the residents who had healthcare requirements resorted to professional health care; the other residents did not have access to health services. Among those residents who sought professional treatment, 71.3% visited primary healthcare institutions. This information reflects the enormous requirement for a CHS in primary health care but the lack of accessibility among the residents; this motivated the authors to establish a system to solve the problem. The improvement in CHS operation after the network was established suggests the importance of a network for optimizing the primary healthcare system. The improvement was indicated by better understanding of the residents regarding the CHS, and enhanced capability of self-monitoring for chronic diseases such as hypertension after the network was established. Moreover, the residents' knowledge of health care was significantly increased and, accordingly, the incidence of health risk behaviour was reduced after the network was established. Furthermore, the CHE index between 1999 and 2006 showed good correlation (r=0.988, p<0.005) with the CHS index, suggesting the important role of CHE in CHS development.

CONCLUSIONS

A network-characterized CHS system was established in Puyang, and improved the primary healthcare situation. This study provides a feasible model for the development of a CHS in medium and small cities in underdeveloped parts of China.

Isoflurane preconditioning neuroprotection in experimental focal stroke is androgen-dependent in male mice

Isoflurane preconditioning neuroprotection in experimental stroke is male-specific. The role of androgens in the ischemic sensitivity of isoflurane preconditioned male brain and whether androgen effects are androgen receptor dependent were assessed. Male C57BL/6 mice were implanted with flutamide (androgen receptor antagonist), or castrated and implanted with testosterone, dihydrotestosterone, flutamide, letrozole (aromatase inhibitor), or vehicle 7-13 days before preconditioning. P450 estrogen aromatase wild-type and knockout mice were also evaluated. All mice were preconditioned for 4 h with 0% (sham preconditioning) or 1% isoflurane (isoflurane preconditioning) and recovered for 24 h. Mice then underwent 2 h of middle cerebral artery occlusion and were evaluated 22 h later for infarct volume. For neurobehavioral outcomes, sham and isoflurane preconditioned castrated male+/-dihydrotestosterone groups underwent 1 h of middle cerebral artery occlusion followed by 9 days of reperfusion. Isoflurane preconditioning neuroprotection relative to infarct volume outcomes were testosterone and dihydrotestosterone dose-specific and androgen receptor-dependent. Relative to long-term neurobehavioral outcomes, front paw sensorimotor function improved in isoflurane preconditioned mice regardless of androgen status while androgen replacement independently improved sensorimotor function. In contrast, isoflurane preconditioning improved cognitive function in castrates lacking endogenous androgens, but this improvement was absent in androgen replaced mice. Our findings suggest that androgen availability during isoflurane preconditioning may influence infarct volume and neurobehavioral outcomes in male mice following experimental stroke.

Age-related changes of human conjunctiva on in vivo confocal microscopy

AIMS

To analyse age-related changes of human conjunctiva by in vivo laser scanning confocal microscopy (LSCM).

METHODS

80 healthy subjects were enrolled and divided into four groups according to age: A (0-19 years), B (20-39 years), C (40-59 years) and D (over 60 years). In vivo LSCM was performed on the subjects' bulbar conjunctivas, and the images were recorded. The morphology and densities of conjunctival epithelial cells, goblet cells (GCs), dendritic cells (DCs) and the positive rate of conjunctival microcysts were analysed. The diameters of subepithelial fibres in each group were measured as well.

RESULTS

The morphology and the densities of both conjunctival epithelial cells and GCs showed no significant age-related differences. The positive rates of conjunctival microcysts were 30% (6/20), 50% (10/20), 60% (12/20) and 75% (15/20) in each group, showing a substantial increase with age (p = 0.035). The densities of DCs decreased significantly with ageing (p = 0.033). The diameters of subepithelial fibres reduced with age significantly also (p = 0.000).

CONCLUSIONS

The age-related changes of conjunctivas included decreasing densities of DCs as well as the degeneration of subepithelial structures. Even though no significant changes in GCs densities could be seen in the different age groups, the increasing rates of conjunctival microcysts indicated that the cellular function of GCs declined while ageing.

On energy consumption for size-reduction and yields from subsequent enzymatic saccharification of pretreated lodgepole pine

This study investigated the effects of chemical pretreatment and disk-milling conditions on energy consumption for size-reduction and the efficiency of enzymatic cellulose saccharification of a softwood. Lodgepole pine wood chips produced from thinnings of a 100-year-old unmanaged forest were pretreated by hot-water, dilute-acid, and two SPORL processes (Sulfite Pretreatment to Overcome Recalcitrance of Lignocellulose) at acid charge on oven dry (od) wood of 0% and 2.21%. The pretreated wood chips were then milled using a laboratory disk mill under various solids-loadings and disk-plate gaps to produce substrates for enzymatic hydrolysis. We found that post-chemical-pretreatment size-reduction of forest biomass can decrease size-reduction energy consumption by 20-80% depending on the pretreatment applied under 20% solids-loading and a disk-plate gap of 0.76 mm in milling. SPORL with a sodium bisulfite charge of 8% and sulfuric acid charge of 2.21% on wood was the most effective in decreasing size-reduction energy consumption. Solids-loading had the most significant effect on disk-milling energy. When solids-loading was reduced from 30% to 3%, disk-milling energy could be decreased by more than a factor of 10 for wood chips pretreated by both SPORL and dilute-acid at an acid charge of 2.21%. The enzymatic hydrolysis glucose yields (EHGY) from the substrates produced by all pretreatments were independent of the solids-loading in milling, indicating that these energy savings in size-reduction can be realized without affecting EHGY. When wood chips were pretreated by SPORL with 2.21% acid charge, size-reduction energy consumption was decreased to less than 50 Wh/kg od wood at a practical solids-loading of approximately 10-20%, equivalent to that used in size-reduction of agriculture biomass, with excellent EHGY of about 370 g per kg od wood. Similar effects on size-reduction energy savings and excellent EHGY were also achieved when large disk-plate gaps (up to 1.52 mm studied) were applied in disk-milling of wood chips pretreated by SPORL with acid.

Expression of steroidogenic factor 1 (SF-1) and steroidogenic acute regulatory protein (StAR) in endometriosis is associated with endometriosis severity

This study was designed to investigate the levels of expression of steroidogenic factor 1 (SF-1) and steroidogenic acute regulatory protein (StAR) in endometriosis, and to explore the association between these two factors and the menstrual cycle and the severity of endometriosis. Levels of SF-1 and StAR protein were evaluated using immunohistochemistry in 38 cases of endometriosis with ectopic endometria and in 25 normal endometria (controls). The SF-1 and StAR protein levels were significantly higher in ectopic endometria than in normal endometria. There was a significant correlation between the level of SF-1 and StAR in ectopic endometriotic tissues. It is concluded that protein levels of SF-1 and StAR are upregulated in ectopic endometria and are significantly correlated with the severity of endometriosis.

Growth inhibition of Microcystis aeruginosa by white-rot fungus Lopharia spadicea

Harmful cyanobacterial blooms cause water deterioration and threaten human health. It is necessary to remove harmful cyanobacteria with useful methods. A bio-treatment may be one of the best ways to do this. A strain of specific white-rot fungus, Lopharia spadicea, with algicidal ability was isolated. Its algicidal ability on algae under various conditions was determined using three main influence factors: initial chlorophyll-a content, initial pH, and algal cell mixture. The result showed that the chlorophyll-a content of Microcystis aeruginosa FACHB-912, Oocystis borgei FACHB-1108, and Microcystis flos-aquae FACHB-1028 decreased from 798+/-13, 756+/-40, and 773+/-24 microg/L to 0 within 39 h. L. spadicea could also remove more than 95% chlorophyll-a when initial chlorophyll-a content increased from 397+/-13 to 2,132+/-4 microg/L. Moreover, the strain has great removal ability under a broad initial pH range of 5.5 to 9.5. The chlorophyll-a content of the three algal strain mixtures decreased from about 672+/-23 microg/L to 0 within 45 h. After superoxide dismutase (SOD) and malondialdehyde (MAD) were assessed in a co-culture of L. spadicea, it was observed that an increase in MAD content was correlated with the decrease in chlorophyll-a content of M. aeruginosa FACHB-912. This result suggested that the algae was not only greatly inhibited but also severely damaged by the fungus.

In vivo confocal microscopy of conjunctival goblet cells in patients with Sjogren's syndrome dry eye

BACKGROUND

To study the morphology and the density of conjunctival goblet cells (GC) in patients with Sjögren's syndrome dry eye with in vivo laser scanning confocal microscopy (LSCM), and to explore its correlation with the GC density detected by impression cytology.

METHODS

A total of 43 Sjögren's syndrome dry eye patients were recruited. All were required to fill in the Ocular Surface Disease Index Questionnaires. The tear break-up time was measured, followed by corneal fluorescein staining examination and Schirmer I test. The images of conjunctiva were taken by the Heidelberg retina tomography (HRT-II)/Rostock cornea module. Finally, the specimens for impression cytology were obtained. SPSS V.13.0 software was used to analyse the data.

RESULTS

Tear film function test showed that all patients had moderate to severe dry eye. The GC in LSCM images was characterised as a large hyper-reflective oval-shape cell with relatively homogeneous brightness. Though GC density assessed by LSCM (332 ± 137) cells/mm² was higher than that measured by impression cytology (200 ± 141) cells/mm², they showed a significant positive correlation, ρ = 0.908 (p < 0.05). Conclusion Conjunctival GC could be easily discriminated under the LSCM. LSCM may be a valuable tool in monitoring the progress and the follow-up of patients with Sjögren's syndrome dry eye.

Detection of hepatitis B virus markers using a biosensor based on imaging ellipsometry

A biosensor based on imaging ellipsometry (BIE) has been developed and validated in 169 patients for detecting five markers of hepatitis B virus (HBV) infection. The methodology has been established to pave the way for clinical diagnosis, including ligand screening, determination of the sensitivity, set-up of cut-off values (CoVs) and comparison with other clinical methods. A matrix assay method was established for ligand screening. The CoVs of HBV markers were derived with the help of receiver operating characteristic curves. Enzyme-linked immunosorbent assay (ELISA) was the reference method. Ligands with high bioactivity were selected and sensitivities of 1 ng/mL and 1 IU/mL for hepatitis B surface antigen (HBsAg) and surface antibody (anti-HBs) were obtained respectively. The CoVs of HBsAg, anti-HBs, hepatitis B e antigen, hepatitis B e antibody and core antibody were as follows: 15%, 18%, 15%, 20% and 15%, respectively, which were the percentages over the values of corresponding ligand controls. BIE can simultaneously detect up to five markers within 1 h with results in acceptable agreement with ELISA, and thus shows a potential for diagnosing hepatitis B with high throughput.

The association between intensive glycemic control and vascular complications in type 2 diabetes mellitus: a meta-analysis

BACKGROUND AND AIM

In patients with type 2 diabetes mellitus, the relationship between lowering glycated hemoglobin (HbA(1c)) and macrovascular complications is not clear and therefore lowering the level of HbA(1c) is controversial.

METHODS AND RESULTS

We searched for all randomized controlled trials comparing the effects of intensive and standard glycemic control on vascular events in patients with type 2 diabetes mellitus. The primary endpoint was combined macrovascular complications, including cardiac events, stroke and peripheral vascular disease. Fixed and random effect models were used to analyze the results. Eight studies were included according to selection criteria. The results showed no benefits of intensive glycemic control on macrovascular and microvascular complications (P>0.1), but a higher rate of severe hypoglycemia (P<0.00001) in the intensive control group when the target HbA(1c) level was <7.0%. When the target HbA(1c) level was lowered to 7.0-7.9%, intensive glycemic control showed benefits on the reduction of microvascular events (P<0.05) without increasing the risk of severe hypoglycemia (P=0.74), but no influence on macrovascular complications (P>0.1).

CONCLUSION

The results of this analysis suggest that a target HbA(1c) level of 7.0-7.9% may be a better glycemic control target than that of <7.0% in patients with established type 2 diabetes mellitus.

Species differences for stereoselective metabolism of ethofumesate and its enantiomers in vitro

1. The stereoselective metabolism of ethofumesate (ETO) and its enantiomers in rabbit and rat liver microsomes have been studied by chiral high-performance liquid chromatography (HPLC) method. Two metabolites were detected in both liver microsomes in the presence of beta-nicotinamide adenine dinucleotide phosphate (NADPH). 2. The T(1/2) of (+)-ETO and (-)-ETO in rabbit liver microsomes were 12.2 and 4.7 min of rac-ETO and 25.9 and 6.7 of ETO enantiomers. However, the T(1/2) of (+)-ETO and (-)-ETO in rat liver microsomes were 5.3 and 5.9 min of rac-ETO and 7.8 and 10.6 of ETO enantiomers. The stereoselective selectivity is similar to the in vivo study. 3. After incubation of ETO enantiomers, stereoselectivity was present in the formation of ETO-OH enantiomer in rabbit liver microsomes, but stereoselectivity was not evident in rat liver microsomes. 4. There was no chiral inversion from the (+)-ETO to (-)-ETO or inversion from (-)-ETO to (+)-ETO in both rabbit and rat liver microsomes.

Experimental autoimmune encephalomyelitis-induced upregulation of tumor necrosis factor-alpha in the dorsal root ganglia

Background: Multiple sclerosis (MS) is a chronic, neurological disease characterized by targeted destruction of central nervous system (CNS) myelin. The autoimmune theory is the most widely accepted explanation of disease pathology. Circulating Th1 cells become activated by exposure to CNS-specific antigens such as myelin basic protein. The activated Th1 cells secrete inflammatory cytokines, which are pivotal for inflammatory responses. We hypothesize that enhanced production of inflammatory cytokines triggers cellular events within the dorsal root ganglia (DRG) and/or spinal cord, facilitating the development of neuropathic pain (NPP) in MS. NPP, the second worst disease-induced symptom suffered by patients with MS, is normally regulated by DRG and/or spinal cord.

Objective: To determine gene and protein expression levels of tumor necrosis factor-alpha (TNFα) within DRG and/or spinal cord in an animal model of MS.

Methods: Experimental autoimmune encephalomyelitis (EAE) was induced in adolescent female Lewis rats. Animals were sacrificed every 3 days post-disease induction. DRG and spinal cords were harvested for protein and gene expression analysis.

Results: We show significant increases in TNFα expression in the DRG and of EAE animals at peak disease stage, as assessed by clinical symptoms.

Conclusion: Antigen-induced production of inflammatory cytokines such as TNFα within the DRG identifies a potential novel mechanism for MS-induced NPP.

Equilibrium and kinetic studies of copper(II) removal by three species of dead fungal biomasses

The batch experiments were conducted to study the copper(II) removal by formaldehyde inactivated Cladosporium cladosporioides, Gliomastix murorum and Bjerkandera sp., at conditions of agitation speed of 150 rpm, temperature of 25 degrees C, biosorbent dose of 2 g l(-1) and contact time of 12h. It was found that, for each biomass, the optimum pH was 6.0 and the equilibrium establishing time was about 2h. Without acid or alkali treatment for improving adsorption properties, the experimental maximum copper(II) biosorptions were relatively high: 7.74 mg g(-1) for C. cladosporioides, 9.01 mg g(-1) for G. murorum, and 12.08 mg g(-1) for Bjerkandera sp.. The biosorption data of all the dead fungal biomasses were quite fitted to Langmuir isotherm model and pseudo second-order kinetic model; first-order Lagergren kinetic model gave good adjustment to the data of Bjerkandera sp. but did not fit the data of C. cladosporioides and G. murorum very well. These fungal biomasses exhibited relatively high capacity for the removal of copper(II) from aqueous solutions.

Identification of a novel mutation in a Chinese family with X-linked ocular albinism

PURPOSE

The purpose of the study was to evaluate the GPR143 gene (G-protein coupled receptor 143) in a Chinese three-generation family with OA1, including four carriers and a proband with clinical features of X-linked ocular albinism.

METHODS

The proband underwent a detailed ophthalmologic evaluation. Blood samples of family members were obtained and genomic DNA isolated. Mutational analysis by SSCP and direct sequencing of the GPR143 gene was used to screen all nine exons including the intron/exon junctions. The novel mutation c.943G>T (p.G315X) found in the study was confirmed by DHPLC to exclude the possibility of polymorphism.

RESULTS

Ophthalmic features of the proband were characteristic of X-linked ocular albinism. The authors identified a novel nonsense mutation p.G315X on exon 8 that was not found in 100 non-albinism subjects by DHPLC. This novel mutation in the GPR143 gene is predicted to subject to nonsense mediated decay.

CONCLUSIONS

The novel mutation p.G315X in the OA1 gene was identified in a Chinese family with ocular albinism, which is predicted to generate a premature stop codon. These findings extend the mutational spectrum of GPR143 gene and will be useful for gene diagnosis and genetic counseling in Chinese OA1 patients.

The infiltrative, diffuse pattern of recurrence in patients with malignant gliomas treated with bevacizumab

2057

Background: There is no standard of care for recurrent gliomas; however, bevacizumab is often used as a salvage chemotherapy regimen. A diffuse, infiltrative pattern of recurrence, as evidenced by MR imaging, was seen manifesting as multifocal disease or presumed CSF dissemination with subependymal spread. Methods: We conducted a retrospective analysis of 40 recurrent glioma patients followed at Moffitt Cancer Center from September 2006 through December 2008 treated with bevacizumab alone or in combination with irinotecan. Histologies included glioblastoma (GB), anaplastic astrocytomas (AA), anaplastic oligodendrogliomas (AO), anaplastic oligoastrocytomas (AOA), and low-grade astrocytomas. Rate of diffuse, infiltrative recurrence, progression free survival (PFS) and overall survival (OS) were analyzed and correlated with respect to specific prognostic variables. Results: 38% (15) of the patients were female and 63% (25) were male. The median (range) age was 51 (20–72) years. The median (range) KPS was 80 (50–100). Twenty-six (65%) patients had GB, 8 (20%) AA, 2 (5%) AO, and 3 (8%) AOA and 1 (3%) had LGA. Five (13%) patients had a gross total resection (GTR), 23 (58%) a subtotal resection (STR) and 12 (30%) had biopsy only. The median (range) number of prior therapies was 2 (1–7). At time of analysis 28 (70%) patients had died. Incidence of diffuse, infiltrative recurrence was seen in 8 (20%) of patients (95% CI: [9%, 36%]). This recurrence seems to be negatively associated with age: rate for age<=50: 6/18 (33%); (95% CI: [13%, 59%]) while rate for age>50: 2/22 (9%); (95% CI: [1%, 29%]), with an odds ratio (OR) of 5.0. Conclusions: There appears to be an increase in a diffuse, infiltrative pattern of recurrence among recurrent glioma patients treated with bevacizumab as a salvage regimen. In our experience, this appears most prevalent in patients less than 50 years of age. It is unclear why the disparity among this subset of patients occurs, however, we hypothesize that this may once again highlight the distinct tumor biology among young glioma patients. The impact of this observation on clinical decision making on whether to utilize bevacizumab in young recurrent glioma patients warrants further investigation.

[Table: see text]

Outcomes following induction chemotherapy in patients with AML arising from MDS: Analysis of prognostic factors

7088

Background: Secondary acute myeloid leukemia (sAML) arising from myelodysplasia (MDS) or a myeloproliferative neoplasm (MPN) has a poor prognosis. To date, there is limited knowledge about risk factors that determine how sAML will respond to treatment. This analysis evaluated possible prognostic factors in patients with sAML that were treated with anthracycline-based induction therapy. Methods: Retrospective chart review of patients with untreated AML from MDS/MPN treated with standard induction therapy from January 2004 to September 2008. Age, IPSS, ECOG PS, cytogenetics, duration of MDS, and prior MDS treatment were evaluated for their impact on obtaining complete remission (CR) or CR with low platelets (CRp) and overall survival (OS). Results: Sixty-one patients with sAML who received induction therapy were evaluated: median age (range) = 66 (36–82) years; M = 67%, ECOG PS 0 or 1 = 86%; poor-risk (PR) cytogenetics = 33%; IPSS > 1 = 43%; prior therapy for MDS with decitabine or azacitidine (DM) or lenalidomide (L) = 41% (25 pts). Of the entire group, 59% (36 pts) achieved CR/CRp (95% CI: 46%-71%) and the median OS was 6.5 (95% CI: 3.9–8.1) mo. Multivariable analysis indicated that the same three factors were significantly negatively associated with CR/CRp as well as OS: PR cytogenetics, prior treatment with DM/L, and long transformation to AML on log scale. Only 32% of the group that received prior treatment with a DM/L achieved CR/CRp compared to 78% in non DM/L-treated patients (OR = 0.13, 95% CI: 0.04–0.42). The CR/CRp rate for those with intermediate risk (IR) cytogenetics was 70% compared to only 35% for those with PR cytogenetics (OR = 4.33, 95% CI: 1.38–13.6). Those with PR cytogenetics had a median OS of 2.8 mo compared to 7.5 mo for IR (p = 0.01). The median OS for those treated with a DM/L was 3.7 mo compared to 10.5 mo for non DM/L-treated patients (p < 0.0001). Conclusions: Prior MDS treatment with a DM/L, PR cytogenetics and long transformation to AML are independent negative prognostic factors for response and OS in patients with sAML following induction therapy, suggesting that such patients may be better served by novel approaches, and that stratification for these risk factors should be considered in future clinical trials. Larger-scale confirmation of these data is ongoing.

No significant financial relationships to disclose.