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Wang C, Fang X, Hua Y, Liu Y, Zhang Z, Gu X, Wu X, Tang Z, Guan S, Liu H, Liu B, Guo X, Ji X. Lipoprotein-Associated Phospholipase A2 and Risk of Carotid Atherosclerosis and Cardiovascular Events in Community-Based Older Adults in China. Angiology 2017; 69:49-58. [PMID: 28429599 DOI: 10.1177/0003319717704554] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We explored the associations between lipoprotein-associated phospholipase A2 (Lp-PLA2) level and carotid atherosclerosis with all phenotypes and cardiovascular disease (CVD) events in Chinese older adults. A total of 1257 adults aged ≥55 years who were free of CVD were enrolled in this cohort study. Lipoprotein-associated phospholipase A2 level was evaluated in 3 categories: Lp-PLA2 < 175, 175≤ Lp-PLA2 < 223, and Lp-PLA2 ≥ 223 ng/mL. The highest level of Lp-PLA2 was independently associated with common carotid artery intima-media thickening (≥1.0 mm; odds ratio [OR]: 1.60, 95% confidence interval [CI]: 1.14-2.26) and carotid plaque (OR: 1.42, 95% CI: 1.01-1.99) in individuals without carotid artery stenosis. At the end of the 5-year follow-up, after adjustment for CVD risk factors and carotid atherosclerosis status, Lp-PLA2 had remained an independent predictor for myocardial infarction (MI; hazard ratio [HR]: 1.90, 95% CI: 1.02-3.55) and CVD death (HR: 1.78, 95% CI: 1.02-3.13). However, no association was found with stroke. Therefore, elevated Lp-PLA2 level in the older adults studied was associated with an increased risk of carotid atherosclerosis and MI and CVD mortality. Lipoprotein-associated phospholipase A2 assessment might be used for MI and CVD death risk prediction.
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Affiliation(s)
- Chunxiu Wang
- 1 Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xianghua Fang
- 1 Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- 2 Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yutong Liu
- 3 Department of Applied Mathematics, School of Mathematics and System Science, Beihang University, Beijing, China
| | - Zhongying Zhang
- 4 Department of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiang Gu
- 5 Department of Geriatrics, Youyi Hospital, Capital Medical University, Beijing, China
| | - Xiaoguang Wu
- 1 Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhe Tang
- 1 Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shaochen Guan
- 1 Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongjun Liu
- 1 Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Beibei Liu
- 2 Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiuhai Guo
- 6 Department of Neurological, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- 7 Department of Neurological Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Younus A, Humayun C, Ahmad R, Ogunmoroti O, Kandimalla Y, Aziz M, Malik R, Saand AR, Valdes C, Badlani R, Younus MA, Ali SS, Chen Y, Nasir K. Lipoprotein-associated phospholipase A2 and its relationship with markers of subclinical cardiovascular disease: A systematic review. J Clin Lipidol 2017; 11:328-337. [DOI: 10.1016/j.jacl.2017.02.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 02/02/2017] [Accepted: 02/14/2017] [Indexed: 11/26/2022]
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Tsouli SG, Kiortsis DN, Xydis V, Argyropoulou MI, Elisaf M, Tselepis AD. Antibodies Against Various Forms of Mildly Oxidized Low-Density Lipoprotein Are Not Associated With Carotid Intima-Media Thickness in Patients With Primary Hyperlipidemia. Angiology 2016; 57:615-22. [PMID: 17067985 DOI: 10.1177/0003319706293142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The carotid intima-media thickness (IMT) can reflect early atherosclerosis. Oxidative modification of low-density lipoprotein (LDL) leads to the formation of several immunogenic epitopes and different forms of antibodies against oxidized LDL (oxLDL). We investigated the possible relationship between autoantibody titers against various forms of mildly oxLDL and carotid IMT in patients (n=100) with primary hyperlipidemia. Three different types of mildly oxidized LDL—oxLDLL, oxLDLP, and oxLDLD—were prepared at the end of lag, propagation, and decomposition phases of oxidation, respectively. Similar types of oxLDL were also prepared from the same LDL preparations after inactivation of the LDL-associated platelet-activating factor acetylhydrolase (PAF-AH). These types were denoted as oxLDL(-)L, oxLDL(-)P, and oxLDL(-)D. OxLDL types are primarily enriched in lysophosphatidylcholine (lyso-PC) due to hydrolysis of oxidized phospholipids (oxPL) by PAF-AH. OxLDL(-) types are mainly enriched in intact oxPL due to the inactivation of the LDL-associated PAF-AH before oxidation. IgG autoantibodies against all types of oxLDL were determined and IMT was evaluated ultrasonographically. IMT values were significantly associated with age, systolic blood pressure and serum triglyceride levels, whereas no correlation was found between IMT values and antibody titers against all types of either oxLDL or oxLDL(-). We suggest that autoantibodies against various types of mildly oxidized LDL enriched either in lyso-PC or in oxPL are not associated with the extent of carotid atherosclerosis. This supports the concept that extensively oxidized LDL enriched in aldehydes rather than mildly oxidized LDL may play a prominent role in the early stage of atherosclerosis.
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Affiliation(s)
- Sofia G Tsouli
- Department of Internal Medicine, University of Ioannina, Ioannina, Greece
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Efe TH, Ertem AG, Altunoglu A, Koseoglu C, Erayman A, Bilgin M, Kurmuş Ö, Aslan T, Bilge M. Serum Paraoxonase Levels are Correlated with Impaired Aortic Functions in Patients with Chronic Kidney Disease. ACTA CARDIOLOGICA SINICA 2016; 32:75-80. [PMID: 27122934 DOI: 10.6515/acs20150429a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The correlation between aortic functions and paraoxonase levels has been previously demonstrated by several earlier studies. In this study, we aimed to investigate the correlation between serum paraoxonase levels and aortic functions among patients with chronic kidney disease. METHODS Our study enrolled 46 chronic kidney disease patients and 45 healthy controls. From these patients, serum cholesterol, creatinine, hemoglobin, and paraoxonase-1 levels were analyzed. RESULTS Paraoxonase-1 levels were significantly lower in patients with chronic kidney disease compared to the controls (p < 0.001). Additionally, the extent of aortic stiffness index (%) was significantly higher in chronic kidney disease patients, but aortic strain and aortic distensibility were significantly higher in healthy controls (p < 0.001, p < 0.001, and p < 0.001, respectively). We further found that paraoxonase-1 levels were correlated with aortic stiffness index, aortic strain, and aortic distensibility (p < 0.001, p < 0.001, and p < 0.001, respectively). CONCLUSIONS Our study demonstrated that serum paraoxonase-1 levels were significantly correlated with impaired aortic functions. The results of this study highlight the impact of serum paraoxonase-1 activity on atherosclerosis and cardiovascular adverse events. KEY WORDS Aortic functions; Atherosclerosis; Chronic kidney disease; Echocardiography; Paraoxonase.
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Affiliation(s)
- Tolga H Efe
- Department of Cardiology, Diskapi Yildirim Beyazit Education and Research Hospital
| | - Ahmet G Ertem
- Department of Cardiology, Ankara Penal Institution Campus State Hostital
| | | | - Cemal Koseoglu
- Department of Cardiology, Ankara Ataturk Training and Research Hospital, Ankara
| | - Ali Erayman
- Department of Cardiology, Pazarcik State Hospital, Kahramanmaras, Turkey
| | - Murat Bilgin
- Department of Cardiology, Diskapi Yildirim Beyazit Education and Research Hospital
| | - Özge Kurmuş
- Department of Cardiology, Ankara Ataturk Training and Research Hospital, Ankara
| | - Turgay Aslan
- Department of Cardiology, Ankara Ataturk Training and Research Hospital, Ankara
| | - Mehmet Bilge
- Department of Cardiology, Ankara Ataturk Training and Research Hospital, Ankara
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Is Lipoprotein-Associated Phospholipase A2 a Link between Inflammation and Subclinical Atherosclerosis in Rheumatoid Arthritis? BIOMED RESEARCH INTERNATIONAL 2015; 2015:673018. [PMID: 26504820 PMCID: PMC4609366 DOI: 10.1155/2015/673018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 04/23/2015] [Indexed: 12/23/2022]
Abstract
Objective. Lipoprotein-associated phospholipase A2 (Lp-PLA2), a marker of vascular inflammation, is associated with cardiovascular disease. This prospective study of an inception cohort aimed to investigate whether the level of Lp-PLA2 is associated with subclinical atherosclerosis in patients with rheumatoid arthritis (RA). Methods. Patients from northern Sweden diagnosed with early RA were consecutively recruited into an ongoing prospective study. From these, all patients ≤60 years (n = 71) were included for measurements of subclinical atherosclerosis at inclusion (T0) and five years later (T5). Forty age- and sex-matched controls were included. The patients were clinically assessed, SCORE, Reynolds Risk Score, and Larsen score were calculated, and blood samples were drawn from all individuals at T0 and T5. Results. There was no significant difference in the level of Lp-PLA2 between patients with RA and controls (p > 0.05). In simple linear regression models among patients with RA, Lp-PLA2 at T0 was significantly associated with intima media thickness (IMT) at T0 and T5, flow mediated dilation (FMD) at T0 and T5, ever smoking, male sex, HDL-cholesterol (inversely), non-HDL-cholesterol, SCORE, Reynolds Risk Score, and Larsen score (p < 0.05). Conclusion. In this cohort of patients with early RA, the concentration of Lp-PLA2 was associated with both subclinical atherosclerosis and disease severity.
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Garg PK, McClelland RL, Jenny NS, Criqui MH, Greenland P, Rosenson RS, Siscovick DS, Jorgensen N, Cushman M. Lipoprotein-associated phospholipase A2 and risk of incident cardiovascular disease in a multi-ethnic cohort: The multi ethnic study of atherosclerosis. Atherosclerosis 2015; 241:176-82. [PMID: 26004387 PMCID: PMC4504012 DOI: 10.1016/j.atherosclerosis.2015.05.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 04/10/2015] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Prospective studies reporting a positive association of lipoprotein-associated phospholipase A2 (Lp-PLA2) mass and activity with incident cardiovascular disease (CVD) have included primarily white individuals. We evaluated associations of Lp-PLA2 and first-time cardiovascular events in a healthy multi-ethnic cohort characterized by presence or absence of baseline subclinical atherosclerosis. METHODS Lp-PLA2 mass and activity were measured at baseline in 5456 participants in the Multi-Ethnic Study of Atherosclerosis. Individuals were characterized for presence of baseline subclinical disease (coronary artery calcium score > 0 or carotid intima-media thickness value > 80th percentile) and followed prospectively for development of CVD events (coronary heart disease, ischemic stroke, and cardiovascular death). RESULTS 516 incident CVD events occurred over median follow-up of 10.2 years. In adjusted Cox proportional hazards models, each higher standard deviation of both Lp-PLA2 activity and mass was associated with an increased risk of cardiovascular events; hazard ratios (HR; 95% confidence intervals (CI)) 1.12 (1.01-1.26) for Lp-PLA2 activity and 1.10 (1.01-1.21) for mass. Associations did not differ by subclinical disease status (p-value for interaction 0.99 for Lp-PLA2 activity and 0.32 for Lp-PLA2 mass) and there was no confounding by subclinical atherosclerosis measures. Associations of Lp-PLA2 activity but not mass were weaker in Chinese participants but there were relatively few events among Chinese in race-stratified analysis. CONCLUSION In this multi-ethnic cohort, Lp-PLA2 was positively associated with CVD risk, regardless of the presence of coronary artery calcium or a thickened carotid-intimal media.
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Affiliation(s)
- Parveen K Garg
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Nancy S Jenny
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| | - Michael H Criqui
- Department of Family & Preventive Medicine, University of California in San Diego, La Jolla, CA, USA
| | - Philip Greenland
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robert S Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Neal Jorgensen
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Mary Cushman
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Burlington, VT, USA; Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA.
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Pokharel Y, Nambi V, Martin SS, Hoogeveen RC, Nasir K, Khera A, Wong ND, Jones PH, Boone J, Roberts AJ, Ballantyne CM, Virani SS. Association between lipoprotein associated phospholipase A2 mass and subclinical coronary and carotid atherosclerosis in Retired National Football League players. Atherosclerosis 2014; 236:251-6. [DOI: 10.1016/j.atherosclerosis.2014.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/06/2014] [Accepted: 07/13/2014] [Indexed: 11/17/2022]
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Fratta Pasini A, Stranieri C, Pasini A, Vallerio P, Mozzini C, Solani E, Cominacini M, Cominacini L, Garbin U. Lysophosphatidylcholine and carotid intima-media thickness in young smokers: a role for oxidized LDL-induced expression of PBMC lipoprotein-associated phospholipase A2? PLoS One 2013; 8:e83092. [PMID: 24358251 PMCID: PMC3866188 DOI: 10.1371/journal.pone.0083092] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 11/08/2013] [Indexed: 12/13/2022] Open
Abstract
Background Although cigarette smoking has been associated with carotid intima-media thickness (CIMT) the mechanisms are yet not completely known. Lysophosphatidylcholine (lysoPC), a main product of lipoprotein-associated phospholipase A2 (Lp-PLA2) activity, appears to be a major determinant of the pro-atherogenic properties of oxidized LDL (oxLDL) and to induce proteoglycan synthesis, a main player in intimal thickening. In this study we assessed whether cigarette smoking-induced oxidative stress may influence plasma Lp-PLA2 and lysoPC and Lp-PLA2 expression in peripheral blood mononuclear cells (PBMC), as well as the relationship between lysoPC and CIMT. Methods/Results 45 healthy smokers and 45 age and sex-matched subjects participated in this study. Smokers, compared to non-smokers, showed increased plasma concentrations of oxLDL, Lp-PLA2 and lysoPC together with up-regulation of Lp-PLA2 (mRNA and protein) expression in PBMC (P<0.001). Plasma Lp-PLA2 positively correlated with both lysoPC (r=0.639, P<0.001) and PBMC mRNA Lp-PLA2 (r=0.484, P<0.001) in all subjects. Moreover CIMT that was higher in smokers (P<0.001), positively correlated with lysoPC (r=0.55, P<0.001). Then in invitro study we demonstrated that both oxLDL (at concentrations similar to those found in smoker’s serum) and oxidized phospholipids contained in oxLDL, were able to up-regulate mRNA Lp-PLA2 in PBMC. This effect was likely due, at least in part, to the enrichment in oxidized phospholipids found in PBMC after exposure to oxLDL. Our results also showed that in human aortic smooth muscle cells lysoPC, at concentrations similar to those found in smokers, increased the expression of biglycan and versican, two main proteoglycans. Conclusions In smokers a further effect of raised oxidative stress is the up-regulation of Lp-PLA2 expression in PBMC with subsequent increase of plasma Lp-PLA2 and lysoPC. Moreover the correlation between lysoPC and CIMT together with the finding that lysoPC up-regulates proteoglycan synthesis suggests that lysoPC may be a link between smoking and intimal thickening.
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Affiliation(s)
- Anna Fratta Pasini
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
- * E-mail:
| | - Chiara Stranieri
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
| | - Andrea Pasini
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
| | - Paola Vallerio
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
| | - Chiara Mozzini
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
| | - Erika Solani
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
| | - Mattia Cominacini
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
| | - Luciano Cominacini
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
| | - Ulisse Garbin
- Section of Internal Medicine D, Department of Medicine, University of Verona, Verona, Italy
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Abstract
Although an atherogenic lipoprotein phenotype has been well recognized as an important predictor of cardiovascular disease, recent studies have demonstrated a number of additional lipid-related markers as emerging biomarkers to identify patients at risk for future coronary heart disease. Among them, lipoprotein-associated phospholipase A(2) (Lp-PLA(2)), seems to be a promising candidate that might be added to the clinical armamentarium for improved prediction of cardiovascular disease in the future. Of particular note, Lp-PLA(2) is the only enzyme that cleaves oxidized low-density lipoprotein (oxLDL) in the subendothelial space, with further generation of proinflammatory mediators such as lysophosphatidylcholine (LysoPC) and oxidized fatty acid (oxFA), thereby probably linking two important features of atherogenesis, namely oxidation of LDL and local inflammatory processes within the atherosclerotic plaque. This overview aims to summarize our current knowledge based on observations from recent experimental and clinical studies. Emphasis has been put on potential pathophysiological mechanisms of action and on the clinical relevance of Lp-PLA(2) in a wide variety of clinical settings, including apparently healthy individuals, patients with stable angina or acute coronary syndromes, after myocardial infarction, and with subclinical disease. Although a growing body of evidence from epidemiological and clinical studies suggests that Lp-PLA(2) may represent an independent and clinically relevant long-term risk marker for coronary heart disease and, probably, also for stroke, the role of this enzyme in the setting of the acute coronary syndrome remains to be established.
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Affiliation(s)
- Natalie Khuseyinova
- Department of Internal Medicine II - Cardiology, University of Ulm Medical Center, Ulm, Germany
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Al-Zoairy R, Melmer A, Ress C, Laimer M, Kaser S, Ebenbichler C. Lipid profile changes after pronounced weight loss induced by bariatric surgery. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/clp.12.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Constantinides A, van Pelt LJ, van Leeuwen JJJ, de Vries R, Tio RA, van der Horst ICC, Sluiter WJ, Dullaart RPF. Carotid intima media thickness is associated with plasma lipoprotein-associated phospholipase A2 mass in nondiabetic subjects but not in patients with type 2 diabetes. Eur J Clin Invest 2011; 41:820-7. [PMID: 21281278 DOI: 10.1111/j.1365-2362.2011.02471.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND A recent meta-analysis showed that both plasma lipoprotein-associated phospholipase A(2) (Lp-PLA(2) ) mass and activity independently predict cardiovascular events. Notably, Lp-PLA(2) activity but not mass was found to be a determinant of cardiovascular outcome in type 2 diabetes mellitus. We questioned whether relationships of carotid intima media thickness (IMT), a measure of subclinical atherosclerosis, with Lp-PLA(2) mass differ between diabetic and nondiabetic subjects. MATERIALS AND METHODS Relationships of IMT with plasma Lp-PLA(2) mass (turbidimetric immunoassay) were compared in 74 patients with type 2 diabetes and in 64 nondiabetic subjects. RESULTS IMT was increased (P=0·016), but plasma Lp-PLA(2) mass was decreased in patients with diabetes compared to nondiabetic subjects (277±66 vs. 327±62μgL(-1) , P<0·001). In nondiabetic subjects, IMT was correlated positively with Lp-PLA(2) (r=0·325, P<0·009); multiple linear regression analysis confirmed an independent association of IMT with Lp-PLA(2) (ß=0·192, P=0·048). In contrast, IMT was unrelated to Lp-PLA(2) in patients with diabetes (r=0·021, P=0·86), and the relationship of IMT with Lp-PLA(2) was different in diabetic and control subjects (P<0·001). The relationship of Lp-PLA(2) with the total cholesterol/high-density lipoprotein (HDL) cholesterol ratio also differed between diabetic and nondiabetic subjects (P<0·001). CONCLUSIONS Plasma Lp-PLA(2) may relate to early stages of atherosclerosis development. In diabetes mellitus, in contrast, the association of IMT with plasma Lp-PLA(2) mass is abolished, which could be partly ascribed to redistribution of Lp-PLA(2) mass from apolipoprotein B-containing lipoproteins towards HDL. These findings raise questions about the usefulness of plasma Lp-PLA(2) mass measurement as a marker of subclinical atherosclerosis in type 2 diabetes mellitus.
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Affiliation(s)
- Alexander Constantinides
- Department of Endocrinology Department of Cardiology Laboratory Center, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands
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Gong HP, Du YM, Zhong LN, Dong ZQ, Wang X, Mao YJ, Lu QH. Plasma lipoprotein-associated phospholipase A2 in patients with metabolic syndrome and carotid atherosclerosis. Lipids Health Dis 2011; 10:13. [PMID: 21247435 PMCID: PMC3031256 DOI: 10.1186/1476-511x-10-13] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2010] [Accepted: 01/19/2011] [Indexed: 11/18/2022] Open
Abstract
Background Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a recently identified and potentially useful plasma biomarker for cardiovascular and atherosclerotic diseases. However, the correlation between the Lp-PLA2 activity and carotid atherosclerosis remains poorly investigated in patients with metabolic syndrome (MetS). The present study aimed to evaluate the potential role of Lp-PLA2 as a comprehensive marker of metabolic syndrome in individuals with and without carotid atherosclerosis. Methods We documented 118 consecutive patients with MetS and 70 age- and sex-matched healthy subjects served as controls. The patients were further divided into two groups: 39 with carotid plaques and 79 without carotid plaques to elucidate the influence of Lp-PLA2 on carotid atherosclerosis. The plasma Lp-PLA2 activity was measured by using ELISA method and carotid intimal-media thickness (IMT) was performed by ultrasound in all participants. Results Lp-PLA2 activity was significantly increased in MetS subgroups when compared with controls, and was higher in patients with carotid plaques than those without plaques (P < 0.05). Furthermore, we found that significant difference in Lp-PLA2 was obtained between patients with three and four disorders of metabolic syndrome (P < 0.01). Age (β = 0.183, P = 0.029), LDL-cholesterol (β = 0.401, P = 0.000) and waist-hip ratio (β = 0.410, P = 0.000) emerged as significant and independent determinants of Lp-PLA2 activity. Multiple stepwise regression analysis revealed that LDL-cholesterol (β = 0.309, P = 0.000), systolic blood pressure (β = 0.322, P = 0.002) and age (β = 0.235, P = 0.007) significantly correlated with max IMT, and Lp-PLA2 was not an independent predictor for carotid IMT. Conclusions Lp-PLA2 may be a modulating factor for carotid IMT via age and LDL-cholesterol, not independent predictor in the pathophysiological process of carotid atherosclerosis in patients with MetS.
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Affiliation(s)
- Hui-Ping Gong
- Department of Cardiology, the Second hospital of Shandong University, Jinan, Shandong 250033, China
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13
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Eroglu S, Sade LE, Polat E, Bozbas H, Ulus T, Muderrisoglu H. Association Between Serum Gamma-Glutamyltransferase Activity and Carotid Intima-Media Thickness. Angiology 2011; 62:107-10. [DOI: 10.1177/0003319710386471] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Serum gamma-glutamyltransferase (GGT) activity is a marker of oxidative stress and activity is associated with cardiovascular disease. Carotid intima-media thickness (IMT) is a noninvasive predictor of atherosclerosis. We investigated the association between serum GGT activity and carotid IMT. Fifty-five persons who had normal liver function tests were consecutively enrolled. Carotid IMT was evaluated in the right and left common carotid arteries. The averaged values of carotid IMT and serum GGT activity were compared. Serum GGT activity correlated with carotid IMT (r = .396, P = .003). Serum GGT activities were increased in patients with carotid intimal hyperplasia compared with those without intimal hyperplasia (20.3 ± 11.2 vs 34.3 ± 16.1 U/L; P = .001). Serum GGT activity is associated with carotid IMT. This finding supports the concept that elevated serum GGT activity is a marker of atherosclerosis.
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Affiliation(s)
- Serpil Eroglu
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey,
| | - Leyla Elif Sade
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Ezgi Polat
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Huseyin Bozbas
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Taner Ulus
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Haldun Muderrisoglu
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey
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Ryu SK, Hutten BA, Vissers MN, Wiegman A, Kastelein JJ, Tsimikas S. Lipoprotein-associated phospholipase A2 mass and activity in children with heterozygous familial hypercholesterolemia and unaffected siblings: Effect of pravastatin. J Clin Lipidol 2011; 5:50-6. [DOI: 10.1016/j.jacl.2010.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 10/26/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022]
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Abstract
Lipoprotein-associated phospholipase A2 (Lp-PLA₂) is at the crossroads of lipid metabolism and the inflammatory response. It is produced by inflammatory cells, bound to LDL and other lipoproteins, and once in the arterial wall facilitates hydrolysis of phospholipids. Elevated serum levels of Lp-PLA₂ have been associated with increased cardiovascular risk in healthy populations and in patients with known vascular disease. Here, we review the role of Lp-PLA₂ in the development of atherosclerosis and progression to unstable disease, the utility of Lp-PLA₂ as a risk predictor for coronary and carotid events and the potential clinical benefit of pharmacologic inhibition of Lp-PLA₂.
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Affiliation(s)
- K C Epps
- Cardiovascular Division, Hospital of the University of Pennsylvania and Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA
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Duysen EG, Parikh K, Aleti V, Manne V, Lockridge O, Chilukuri N. Adenovirus-mediated human paraoxonase1 gene transfer to provide protection against the toxicity of the organophosphorus pesticide toxicant diazoxon. Gene Ther 2010; 18:250-7. [PMID: 20981111 DOI: 10.1038/gt.2010.136] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Human paraoxonase1 (hPON1) is a potential therapeutic against the toxicity of organophosphorus (OP) pesticides and chemical warfare nerve agents. We tested whether PON1 gene transfer using adenovirus provides protection against the toxicity of the OP diazoxon. Using an adenovirus construct containing hPON1 gene, we showed elevated levels of recombinant hPON1 in vitro in 293A cells and in vivo in mice. The recombinant enzyme was secreted by 293A cells into culture medium and into the systemic circulation of mice. Western blotting revealed that the virally expressed hPON1 had the expected molecular weight of 45 kDa. Recombinant hPON1 in mice was in complex with mouse high-density lipoprotein (HDL) and migrated more slowly than endogenous hPON1 in the human HDL complex. Mice injected with adenovirus expressed PON1 at 600-3480 U ml(-1) on day 5 post-treatment, which is 8-50-fold above endogenous. Six mice expressing hPON1 survived 2LD(50) doses of diazoxon. Four of the six mice survived a second dose of diazoxon (for a total of 4LD(50)) administered 24 h later. In contrast, none of the three mice in the control group survived one 2LD(50) dose. These results show that hPON1 in mice functions as a prophylactic and offers significant protection against lethal doses of diazoxon.
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Affiliation(s)
- E G Duysen
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE, USA
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Akbas HS, Basyigit S, Suleymanlar I, Kemaloglu D, Koc S, Davran F, Demir I, Suleymanlar G. The assessment of carotid intima media thickness and serum paraoxonase-1 activity in Helicobacter pylori positive subjects. Lipids Health Dis 2010; 9:92. [PMID: 20804546 PMCID: PMC2936361 DOI: 10.1186/1476-511x-9-92] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 08/30/2010] [Indexed: 12/12/2022] Open
Abstract
Background The role of inflammation in the pathogenesis and progression of atherosclerosis has been increasingly discussed. Although the seroepidemiological studies have suggested a relationship between Helicobacter pylori (H. pylori) infection and atherosclerosis; the issue is still controversial. It is well known that abnormal lipid profil is related to atherosclerosis and the measurement of carotid-intima media thickness (CIMT) is one of the surrogate marker of atherosclerosis. The serum concentration of high-density lipoprotein (HDL-C) has been known to have an inverse correlation with the development of atherosclerosis. Paraoxonase-1 (PON1) is a major anti-atherosclerotic component of HDL-C. PON1 activity is related to lipid peroxidation and prospective cardiovascular risk. The aim of this study was to investigate CIMT and serum PON1 activities along with lipid parameters in H. pylori positive and negative subjects. Methods Thirty H. pylori positive subjects and thirty-one negative subjects were enrolled. H. pylori infection was diagnosed by the presence of positivity of stool H. pylori antigen test or Carbon 14 labeled urea breath test. Serum PON1 activity was measured spectrophotometrically. Traditional cardiovascular risk factors were investigated and laboratory analysis included measurement of serum triglycerides (TG), total cholesterol (TC), high-density lipoprotein (HDL-C) and low-density lipoprotein cholesterol (LDL-C). We assessed CIMT by high-resolution ultrasound of both common carotid arteries. Results We found that the mean and maximum values of right and overall CIMT in H. pylori positive subjects were significantly thicker than those of H. pylori negative subjects. There was no significant differences in serum HDL-C, LDL-C, TC levels and TC/HDL-C ratios between two groups. Serum TG levels of H. pylori positive subjects were significantly higher than those of H. pylori negative subjects (p = 0.014). We found that PON1 activities were significantly lower in H. pylori positive subjects compared with negative subjects. No significantly correlation was observed between PON1 and CIMT values. Conclusions There is an increase in CIMT values in patients with H. pylori positive compared to H. pylori negative subjects. PON1 activity decrease significantly in H. pylori positive subjects. However, an association between PON1 and CIMT was not found. These data indicated that H. pylori may have a role in atherosclerotic processes, however, further studies are needed to evaluate the exact mechanisms.
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Affiliation(s)
- Halide S Akbas
- Akdeniz University Faculty of Medicine, Department of Biochemistry, Antalya, Turkey.
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Association of carotid plaque Lp-PLA(2) with macrophages and Chlamydia pneumoniae infection among patients at risk for stroke. PLoS One 2010; 5:e11026. [PMID: 20543948 PMCID: PMC2882946 DOI: 10.1371/journal.pone.0011026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Accepted: 05/11/2010] [Indexed: 11/20/2022] Open
Abstract
Background We previously showed that the burden of Chlamydia pneumoniae in carotid plaques was significantly associated with plaque interleukin (IL)-6, and serum IL-6 and C-reactive protein (CRP), suggesting that infected plaques contribute to systemic inflammatory markers in patients with stroke risk. Since lipoprotein-associated phospholipase A2 (Lp-PLA2) mediates inflammation in atherosclerosis, we hypothesized that serum Lp-PLA2 mass and activity levels and plaque Lp-PLA2 may be influenced by plaque C. pneumoniae infection. Methodology/Principal Findings Forty-two patients underwent elective carotid endarterectomy. Tissue obtained at surgery was stained by immunohistochemistry for Lp-PLA2 grade, macrophages, IL-6, C. pneumoniae and CD4+ and CD8+ cells. Serum Lp-PLA2 activity and mass were measured using the colorimetric activity method (CAM™) and ELISA, respectively. Serum homocysteine levels were measured by HPLC. Eleven (26.2%) patients were symptomatic with transient ischemic attacks. There was no correlation between patient risk factors (smoking, coronary artery disease, elevated cholesterol, diabetes, obesity, hypertension and family history of genetic disorders) for atherosclerosis and serum levels or plaque grade for Lp-PLA2. Plaque Lp-PLA2 correlated with serum homocysteine levels (p = 0.013), plaque macrophages (p<0.01), and plaque C. pneumoniae (p<0.001), which predominantly infected macrophages, co-localizing with Lp-PLA2. Conclusions The significant association of plaque Lp-PLA2 with plaque macrophages and C. pneumoniae suggests an interactive role in accelerating inflammation in atherosclerosis. A possible mechanism for C. pneumoniae in the atherogenic process may involve infection of macrophages that induce Lp-PLA2 production leading to upregulation of inflammatory mediators in plaque tissue. Additional in vitro and in vivo research will be needed to advance our understanding of specific C. pneumoniae and Lp-PLA2 interactions in atherosclerosis.
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Gasparyan AY. The use of carotid artery ultrasonography in different clinical conditions. Open Cardiovasc Med J 2009; 3:78-80. [PMID: 19606232 PMCID: PMC2710604 DOI: 10.2174/1874192400903010078] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 06/08/2009] [Accepted: 06/09/2009] [Indexed: 11/22/2022] Open
Abstract
B-mode ultrasonography of the carotid artery is a non-invasive, informative and reproducible technique used for the assessment of prevalence and course of atherosclerosis in a variety of clinical conditions. Visualization of intima-media complex, atherosclerotic plaques, rough arterial wall and calcifications of the carotid artery may be useful for the assessment of atherosclerotic burden. The latter was confirmed in a recent consensus statement of the American Society of Echocardiography. Detection of structural changes, such as Menkeber’s sclerosis of the medial layer of the carotid artery, carotid aneurysm may indicate advanced vascular pathology and prompt an appropriate treatment. Ultrasound images of patients with atherosclerotic plaque and Menkeberg’s sclerosis are presented and issues related to clinical significance of the common carotid artery intima-media thickness are discussed.
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Affiliation(s)
- Armen Yuri Gasparyan
- Department of Internal Medicine, Krankenhaus der Barmherzigen Brüder, Teaching Hospital of Medical University of Graz, Graz, Austria.
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Ali M, Madjid M. Lipoprotein-associated phospholipase A2: a cardiovascular risk predictor and a potential therapeutic target. Future Cardiol 2009; 5:159-73. [DOI: 10.2217/14796678.5.2.159] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Lipoprotein-associated phospholipase A2 (Lp-PLA2), present in the circulation and in atherosclerotic plaque, is an inflammatory marker with potential use as a predictor of cardiovascular risk and as a therapeutic target. Although Lp-PLA2 is associated with both LDL and HDL, it is important to determine whether Lp-PLA2 has a predominantly pro- or anti-atherogenic effect. Increasing evidence suggests a proatherogenic role for Lp-PLA2. ©iEpidemiologic and clinical evidence suggests Lp-PLA2 is an independent predictor of risk and may be superior to other inflammatory markers owing to its specificity and minimal biovariation. Lp-PLA2 inhibitors currently being investigated in clinical trials are promising novel anti-inflammatory agents with a specificity for the vascular bed and a potential for decreasing plaque vulnerability.
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Affiliation(s)
- Muzammil Ali
- Texas Heart Institute, 6770 Bertner Ave, MC 2-255, Houston, TX 77030, USA
| | - Mohammad Madjid
- Texas Heart Institute at St Luke’s Episcopal Hospital, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Harangi M, Seres I, Magyar MT, Csipo I, Sipka S, Valikovics A, Csiba L, Bereczki D, Paragh G. Association between Human Paraoxonase 1 Activity and Intima-Media Thickness in Subjects under 55 Years of Age with Carotid Artery Disease. Cerebrovasc Dis 2007; 25:122-8. [DOI: 10.1159/000112322] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 08/05/2007] [Indexed: 11/19/2022] Open
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Ballantyne CM. Lipoprotein-associated phospholipase A2: Risk marker or target of therapy? CURRENT CARDIOVASCULAR RISK REPORTS 2007. [DOI: 10.1007/s12170-007-0011-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Noto H, Chitkara P, Raskin P. The role of lipoprotein-associated phospholipase A(2) in the metabolic syndrome and diabetes. J Diabetes Complications 2006; 20:343-8. [PMID: 17070436 DOI: 10.1016/j.jdiacomp.2006.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 07/07/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) is a novel inflammation marker. We investigated its association with other coronary risk factors and evaluated its role as a comprehensive marker of the metabolic syndrome in individuals with type 2 diabetes. METHODS Our cross-sectional study evaluated 92 insulin-treated subjects with type 2 diabetes. Biochemical measurements of Lp-PLA(2), glycemic control, lipid profiles, and C-reactive protein were carried out. Seventy-seven subjects were diagnosed as having the metabolic syndrome, which was defined according to the American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. RESULTS Lp-PLA(2) was significantly correlated with waist-hip ratio (r=.25), triglycerides (r=.50), high-density lipoprotein cholesterol (r=-.31), and low-density lipoprotein cholesterol (LDL-C; r=.27; all P<.02). In a multiple-regression model, triglycerides and LDL-C levels were the significant predictors of Lp-PLA(2). Lp-PLA(2) was significantly higher in subjects with the metabolic syndrome than in those without it (268+/-23.4 vs. 127+/-15.8 ng/ml, P<.001). There was a linear increase in Lp-PLA(2) with an increment of the number of the metabolic syndrome criteria (P(trend)=.041). Another multiple-regression model showed that the hypertriglyceridemia component was the only predictor of Lp-PLA(2). CONCLUSIONS Our findings suggest that Lp-PLA(2) assay potentially facilitates a more comprehensive assessment of the metabolic syndrome in patients with type 2 diabetes on insulin.
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Affiliation(s)
- Hiroshi Noto
- The University Diabetes Treatment Center, Parkland Memorial Hospital, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390-8858, USA
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Nambi V, Ballantyne CM. Lipoprotein-associated phospholipase A2: Pathogenic mechanisms and clinical utility for predicting cardiovascular events. Curr Atheroscler Rep 2006; 8:374-81. [PMID: 16901407 DOI: 10.1007/s11883-006-0034-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lipoprotein-associated phospholipase A(2 )(Lp-PLA(2)), a member of the phospholipase superfamily, circulates primarily bound to low-density lipoprotein and has been associated with cardiovascular disease risk in epidemiologic studies. However, it has not been established whether Lp-PLA(2) is a risk marker or a risk factor. Identification of individuals with elevated Lp-PLA(2) may improve risk assessment, and Lp-PLA(2) may also provide an additional target of therapy. Statin therapy has been shown to reduce Lp-PLA(2), and selective inhibitors of Lp-PLA(2) are under development. Additional research is needed to further determine the role of Lp-PLA(2) in atherogenesis and atherothrombotic events.
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Affiliation(s)
- Vijay Nambi
- Section of Cardiology, Baylor College of Medicine, 6550 Fannin, SM 677, Houston, TX 77030, USA.
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Abstract
PURPOSE OF REVIEW This review discusses whether the relationship of small dense low-density lipoprotein to cardiovascular risk is direct, due to the atherogenic properties of the particle, or a reflection of concomitant abnormalities in high-density lipoprotein and plasma triglyceride. RECENT FINDINGS Recent studies have examined whether low-density lipoprotein size distribution or concentration of small low-density lipoprotein is related more strongly to risk. It appears that the latter is a better predictor in major surveys, although in smaller cohort studies particle size shows a strong association with atherosclerosis burden. While the main causes of the formation of small dense low-density lipoprotein are relatively well understood, novel metabolic factors may also play a role, and pharmacologic interventions such as glitazones may have a direct regulatory impact. SUMMARY Evidence links abnormalities in low-density lipoprotein structure to cardiovascular risk. The plasma concentration of small dense low-density lipoprotein is likely to be more informative than relative low-density lipoprotein particle size, and although methods are available for quantitation of this subfraction, there is considerable room for improvement. It is not yet clear how knowledge of the small dense low-density lipoprotein concentration may add to risk prediction.
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Affiliation(s)
- Chris J Packard
- Department of Vascular Biochemistry, University of Glasgow, Scotland, UK.
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Karabina SA, Ninio E. Plasma PAF-acetylhydrolase: an unfulfilled promise? Biochim Biophys Acta Mol Cell Biol Lipids 2006; 1761:1351-8. [PMID: 16807087 DOI: 10.1016/j.bbalip.2006.05.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 05/04/2006] [Accepted: 05/08/2006] [Indexed: 01/04/2023]
Abstract
Plasma Platelet-activating-Factor (PAF)-acetylhydrolase (PAF-AH also named lipoprotein-PLA(2) or PLA(2)G7 gene) is secreted by macrophages, it degrades PAF and oxidation products of phosphatidylcholine produced upon LDL oxidation and/or oxidative stress, and thus is considered as a potentially anti-inflammatory enzyme. Cloning of PAF-AH has sustained tremendous promises towards the use of PAF-AH recombinant protein in clinical situations. The reason for that stems from the numerous animal models of inflammation, atherosclerosis or sepsis, where raising the levels of circulating PAF-AH either through recombinant protein infusion or through the adenoviral gene transfer showed to be beneficial. Unfortunately, neither in human asthma nor in sepsis the recombinant PAF-AH showed sufficient efficacy. One of the most challenging questions nowadays is as to whether PAF-AH is pro- or anti-atherogenic in humans, as PAF-AH may possess a dual pro- and anti-inflammatory role, depending on the concentration and the availability of potential substrates. It is equally possible that the plasma level of PAF-AH is a diagnostic marker of ongoing atherosclerosis.
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Affiliation(s)
- Sonia-Athina Karabina
- INSERM U525, Université Pierre et Marie Curie-Paris6, Faculté de Médecine Pierre et Marie Curie, 91, bd de l'Hôpital 75634 Paris cedex 13, France
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Kiortsis DN, Argyropoulou MI, Xydis V, Tsouli SG, Elisaf MS. Correlation of Achilles tendon thickness evaluated by ultrasonography with carotid intima-media thickness in patients with familial hypercholesterolemia. Atherosclerosis 2006; 186:228-9. [PMID: 16516218 DOI: 10.1016/j.atherosclerosis.2006.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Accepted: 02/02/2006] [Indexed: 10/24/2022]
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