Lemon Peel Water Extract: A Novel Material for Retinal Health, Protecting Retinal Pigment Epithelial Cells against Dynamin-Related Protein 1-Mediated Mitochondrial Fission by Blocking ROS-Stimulated Mitogen-Activated Protein Kinase/Extracellular Signal-Regulated Kinase Pathway

Previous studies showed that NaIO3 can induce oxidative stress-mediated retinal pigment epithelium (RPE) damage to simulate age-related macular degeneration (AMD). Lemon peel is rich in antioxidants and components that can penetrate the blood-retinal barrier, but their role in retinal oxidative damage remains unexplored. Here, we explore the protection of lemon peel ultrasonic-assisted water extract (LUWE), containing large amounts of flavonoids and polyphenols, against NaIO3-induced retinal degeneration. We initially demonstrated that LUWE, orally administered, prevented retinal distortion and thinning on the inner and outer nuclei layers, downregulating cleaved caspase-3 protein expression in RPE cells in NaIO3-induced mice. The effect of LUWE was achieved through the suppression of apoptosis and the associated proteins, such as cleaved PARP and cleaved caspase-3, as suggested by NaIO3-induced ARPE-19 cell models. This is because LUWE reduced reactive oxygen species-mediated mitochondrial fission via regulating p-Drp-1 and Fis1 expression. We further confirmed that LUWE suppresses the expression of p-MEK-1/2 and p-ERK-1/2 in NaIO3-induced ARPE-19 cells, thereby providing the protection described above, which was confirmed using PD98059 and U0126. These results indicated that LUWE prevents mitochondrial oxidative stress-mediated RPE damage via the MEK/ERK pathway. Elucidation of the molecular mechanism may provide a new protective strategy against retinal degeneration.

Pb(NO3 )2 induces cell apoptosis through triggering of reactive oxygen species accumulation and disruption of mitochondrial function via SIRT3/SOD2 pathways

Lead (Pb) is nonbiodegradable and toxic to the lungs. To investigate the potential mechanisms of Pb-induced reactive oxygen species (ROS) accumulation and cell death in the lungs, human non-small lung carcinoma H460 cells were stimulated with Pb(NO3 )2 in this study. The results showed that Pb(NO3 )2 stimulation increased cell death by inducing cell apoptosis which showed a reduced Bcl-2 expression and an enhanced caspase 3 activation. Pb(NO3 )2 also caused the production of H2 O2 in H460 cells that triggering the buildup of ROS and mitochondrial membrane potential loss. We found that Pb(NO3 )2 modulates oxidoreductive activity through reduced the glutathione-disulfide reductase and glutathione levels in Pb(NO3 )2 -exposed H460 cells. Furthermore, the superoxide dismutase (SOD) upstream molecule sirtuin 3 (SIRT3) was increased with Pb(NO3 )2 dose. Collectively, these results demonstrate that Pb(NO3 )2 promotes lung cell death through SIRT3/SOD-mediated ROS accumulation and mitochondrial dysfunction.

Association of physical functional activity impairment with severity of sarcopenic obesity: findings from National Health and Nutrition Examination Survey

We aim to clarify the relationship between low skeletal muscle mass and varying levels of adiposity and to identify the types of physical function impairments associated with sarcopenic obesity (SO). This study examined cross-sectional data from the National Health and Nutrition Examination Survey with whole-body dual-energy X-ray absorptiometry (DXA) scans. The data included age, gender, DXA-assessed body composition, and physical functional activity with performing daily tasks by questionnaire. We subdivided the data by body composition into a non-SO group and a SO group (ASMI 0-49.99% and FMI of 50-100%), after which the SO data were subdivided into three classes. A higher class indicated higher adiposity and lower muscle mass. The physical function impairment of the two groups was compared. Our study examined 7161 individuals, of which 4907 did not have SO and 2254 had SO, and their data were further divided into three classes (i.e., class I, 826 individuals; class II, 1300 individuals; and class III, 128 individuals). Significant differences in demographics and DXA parameters were identified between the non-SO and SO groups (P < 0.001); the individuals with SO were older, included more women, and exhibited high adiposity and less lean muscle mass. The individuals with class III SO exhibited greater differences and reported more difficulty in performing daily activities. The individuals with class III SO exhibited the most severe physical function impairment. Our study highlights the considerable difficulties encountered by individuals with SO in performing daily activities. Given this finding, customized rehabilitation strategies should be implemented to improve the quality of life of individuals with SO.

The protective effects of beta-mangostin against sodium iodate-induced retinal ROS-mediated apoptosis through MEK/ERK and p53 signaling pathways

Previous studies have indicated that NaIO3 induces intracellular reactive oxygen species (ROS) production and has been used as a model for age-related macular degeneration (AMD) due to the selective retinal pigment epithelium (RPE) cell damage it induces. Beta-mangostin (BM) is a xanthone-type natural compound isolated from Cratoxylum arborescens. The influence of BM on NaIO3-induced oxidative stress damage in ARPE-19 cells has not yet been elucidated. In this study, we investigated how BM protects ARPE-19 cells from NaIO3-induced ROS-mediated apoptosis. Our results revealed that BM notably improved cell viability and prevented ARPE-19 cell mitochondrial dysfunction mediated-apoptosis induced by NaIO3; it was mediated by significantly reduced NaIO3-upregulated ROS, cellular H2O2 production and improved downregulated glutathione and catalase activities. Furthermore, we found that BM could suppress the expression of Bax, cleaved PARP, and cleaved caspase-3 by decreasing phosphorylation of MEK/ERK and p53 expression in NaIO3-induced ARPE-19 cells. At the same time, we also used MEK inhibitors (PD98059) to confirm the above phenomenon. Moreover, our animal experiments revealed that BM prevented NaIO3 from causing retinal deformation; it led to thicker outer and inner nuclear layers and downregulated cleaved caspase-3 expression compared to the group receiving NaIO3 only. Collectively, these results suggest that BM can protect the RPE and retina from NaIO3-induced apoptosis through ROS-mediated mitochondrial dysfunction involving the MEK/ERK and p53 signaling pathways.

Assessing the Practical Differences in LDL-C Estimates Calculated by Friedewald, Martin/Hopkins, or NIH Equation 2: An Observation Cross-Sectional Study

Objective

Low-density lipoprotein-cholesterol (LDL-C) remains a clinically important cholesterol target in primary prevention of atherosclerotic cardiovascular disease. The present study aimed to assess the practical differences among three equations utilized for the estimation of LDL-C: the Friedewald, the Martin/Hopkins, and the NIH equation 2.

Methods

Blood lipid measurements from 4,556 noninstitutionalized participants, aged 12 to 80, were obtained from the 2017-2020 National Health and Nutrition Examination Survey study. We 1) assessed the differences between three calculated LDL-C estimates, 2) examined the correlations between LDL-C estimates using correlation coefficients and regression, and 3) investigated the degree of agreement in classifying individuals into the LDL-C category using weighted Kappa and percentage of agreement.

Results

The differences in LDL-C estimates between equations varied by sex and triglyceride levels (p<0.001). Overall, the mean of absolute differences between Friedewald and Martin/Hopkins was 3.17 mg/dL (median=2.0, 95% confidence interval [CI] [3.07-3.27]). The mean of absolute differences between Friedewald and NIH Equation 2 was 2.08 mg/dL (median=2.0, 95% CI [2.03-2.14]). Friedewald correlated highly with Martin/Hopkins (r=0.991, rho=0.989) and NIH Equation 2 (r=0.998, rho=0.997). Cohen's weighted Kappa=0.92 between Friedewald and Martin/Hopkins, and 0.95 between Friedewald and NIH equation 2. The percentage of agreement in classifying individuals into the same LDL-C category was 93.0% between Friedewald and Martin/Hopkins, and 95.4% between Friedewald and NIH equation 2.

Conclusion

Understanding the practical differences in LDL-C calculations can be helpful in facilitating decision-making during a paradigm shift.

Current and Potential Applications of Atmospheric Cold Plasma in the Food Industry

The cost-effectiveness and high efficiency of atmospheric cold plasma (ACP) incentivise researchers to explore its potentials within the food industry. Presently, the destructive nature of this nonthermal technology can be utilised to inactivate foodborne pathogens, enzymatic ripening, food allergens, and pesticides. However, by adjusting its parameters, ACP can also be employed in other novel applications including food modification, drying pre-treatment, nutrient extraction, active packaging, and food waste processing. Relevant studies were conducted to investigate the impacts of ACP and posit that reactive oxygen and nitrogen species (RONS) play the principal roles in achieving the set objectives. In this review article, operations of ACP to achieve desired results are discussed. Moreover, the recent progress of ACP in food processing and safety within the past decade is summarised while current challenges as well as its future outlook are proposed.

Assessment of Tyrosine Kinase Inhibitors and Survival and Cardiovascular Outcomes of Patients With Non-Small Cell Lung Cancer in Taiwan

Importance

Tyrosine kinase inhibitors (TKIs) have been recognized as the standard treatment for patients with non-small cell lung cancers (NSCLCs) and epidermal growth factor receptor (EGFR) sequence variation. Although TKIs have been reported to cause cardiotoxicity, they are widely administered owing to the high prevalence of EGFR sequence variation in Taiwan.

Objective

To compare the outcomes of death and major adverse cardiac and cerebrovascular events among patients with NSCLC who use and do not use TKIs in a national cohort.

Design, Setting, and Participants

Using data from the Taiwanese National Health Insurance Research Database and National Cancer Registry, patients treated for NSCLC from 2011 to 2018 were identified, and their outcomes were analyzed, including death and major adverse cardiac and cerebrovascular events (MACCEs; such as heart failure, acute myocardial infarction, and ischemic stroke) after adjusting for age, sex, cancer stage, comorbidities, anticancer therapies, and cardiovascular drugs. The median follow-up duration was 1.45 years. The analyses were performed from September 2022 to March 2023.

Exposures

TKIs.

Main Outcomes and Measures

Cox proportional hazards models were used to estimate death and MACCEs in patients treated with and without TKIs. Given that death may reduce the incidence of cardiovascular events, the competing risk method was used to calculate the MACCE risk after adjustment for all potential confounders.

Results

Overall, 24 129 patients treated with TKIs were matched with 24 129 patients who did not receive TKIs (24 215 [50.18%] were female; and the mean [SD] age was 66.93 [12.37] years). Compared with those not receiving TKIs, the TKI group presented with a significantly lower hazard ratio (HR) of all-cause death (adjusted HR, 0.76; 95% CI, 0.75-0.78; P < .001), and the reason for death was primarily cancer. In contrast, the HR of MACCEs significantly increased (subdistribution HR, 1.22; 95% CI, 1.16-1.29; P < .001) in the TKI group. Furthermore, afatinib use was associated with a significantly reduced risk of death among patients receiving various TKIs (adjusted HR, 0.90; 95% CI, 0.85-0.94; P < .001) compared with those receiving erlotinib and gefitinib, although the outcomes of MACCEs were similar between the 2 groups.

Conclusions and Relevance

In this cohort study of patients with NSCLC, TKI use was associated with reduced HRs of cancer-related death but increased HRs of MACCEs. These findings suggest the importance of close monitoring of cardiovascular problems in individuals receiving TKIs.

Impact of infection-related admission in patients with heart failure: a 10 years national cohort study

Infection is a common cause of hospitalization in patients with heart failure (HF). The impact of infection on long term cardiovascular outcome in HF is not well studied. The aim of this study was to compare the long term risk of major adverse cardiovascular events (MACE) in HF patients with or without prior hospitalization for infection. From 2009 to 2015, 310,485 patients with their first HF admissions were enrolled from the Taiwan National Health Insurance Research Database. Among the patients, those with readmission due to infection within one year after HF discharge were defined as infection group and those without any infection admission were controls. The propensity score matching method was used to balance covariates between the two groups. Patients were followed until the occurrence of any component of the MACE or the end date of the study, December 31, 2019. In a mean follow-up time of 4.29 ± 2.92 years, 86.19% of patients in the infection group and 63.63% of patients in the control group had MACE. Multivariate Cox proportional hazards analysis showed the infection group had a higher risk of MACE (HR 1.760, 95% CI 1.714-1.807), including all-cause mortality (HR 1.587, 95% CI 1.540-1.636), myocardial infarction (HR 1.332, 95% CI 1.224-1.450), stroke (HR 1.769, 95% CI 1.664-1.882) and hospitalization for HF (HR 1.993, 95% CI 1.922-2.066). In conclusion, many HF patients discharged from the hospital experienced acute infection that required readmission. The patients had worse cardiovascular outcome after readmission for infectious disease compared to those without any infection.

The association between tyrosine kinase inhibitors and fatal arrhythmia in patients with non-small cell lung cancer in Taiwan

Objective

As a standard therapy, tyrosine kinase inhibitors (TKIs) improved survival in patients with non-small cell lung cancer (NSCLC) and epidermal growth factor receptor (EGFR) mutation. However, treatment-related cardiotoxicity, particularly arrhythmia, cannot be ignored. With the prevalence of EGFR mutations in Asian populations, the risk of arrhythmia among patients with NSCLC remains unclear.

Methods

Using data from the Taiwanese National Health Insurance Research Database and National Cancer Registry, we identified patients with NSCLC from 2001 to 2014. Using Cox proportional hazards models, we analyzed outcomes of death and arrhythmia, including ventricular arrhythmia (VA), sudden cardiac death (SCD), and atrial fibrillation (AF). The follow-up duration was three years.

Results

In total, 3876 patients with NSCLC treated with TKIs were matched to 3876 patients treated with platinum analogues. After adjusting for age, sex, comorbidities, and anticancer and cardiovascular therapies, patients receiving TKIs had a significantly lower risk of death (adjusted HR: 0.767; CI: 0.729-0.807, p < 0.001) than those receiving platinum analogues. Given that approximately 80% of the studied population reached the endpoint of mortality, we also adjusted for mortality as a competing risk. Notably, we observed significantly increased risks of both VA (adjusted sHR: 2.328; CI: 1.592-3.404, p < 0.001) and SCD (adjusted sHR: 1.316; CI: 1.041-1.663, p = 0.022) among TKI users compared with platinum analogue users. Conversely, the risk of AF was similar between the two groups. In the subgroup analysis, the increasing risk of VA/SCD persisted regardless of sex and most cardiovascular comorbidities.

Conclusions

Collectively, we highlighted a higher risk of VA/SCD in TKI users than in patients receiving platinum analogues. Further research is needed to validate these findings.

Association of Statin Use With Cancer- and Noncancer-Associated Survival Among Patients With Breast Cancer in Asia

Importance

In addition to protective effects on the cardiovascular system, statins may reduce the risk of breast cancer recurrence owing to potential anti-inflammatory benefits. Given that patients with breast cancer in Asia are relatively younger at diagnosis and most are free from traditional cardiovascular risk factors, it is uncertain whether the use of statins can improve survival.

Objective

To investigate the association of statin use with cancer- and noncancer-associated survival in patients with breast cancer.

Design, Setting and Participants

This cohort study used the Taiwanese National Health Insurance Research Database and National Cancer Registry to identify patients diagnosed with breast cancer from January 2012 to December 2017. Age, cancer stage, anticancer therapies, comorbidities, socioeconomic status, and cardiovascular drugs were matched by propensity score method. Statistical analyses, including Cox proportional hazards models, were performed from June 2022 to February 2023. The mean (SD) follow-up duration was 4.10 (2.96) years.

Interventions

Patients receiving statins within 6 months before the diagnosis of breast cancer were compared with those not receiving statins.

Main Outcomes and Measures

Outcomes included death, heart failure, and arterial and venous events.

Results

Overall, 7451 patients (mean [SD] age, 64.3 [9.4] years) treated with statins were matched with 7451 nonusers (mean [SD] age, 65.8 [10.8] years). Compared with nonusers, statin users had a significantly lower risk of all-cause death (adjusted hazard ratio [HR], 0.83; 95% CI, 0.77-0.91; P < .001). Notably, the risk reduction was mainly attributed to cancer-related death (adjusted HR, 0.83; 95% CI, 0.75-0.92; P < .001). Only a small number of patients died of cardiovascular causes, and the ratios were similar between statin users and nonusers. No significant differences were observed in cardiovascular outcomes, including heart failure and arterial and venous events, between statin users and nonusers. Using a time-dependent analysis, statin users also presented a significantly lower risk of cancer-related death (adjusted HR, 0.28; 95% CI, 0.24-0.32; P < .001) than nonusers, and notably, the risk was even lower in high-dose statin (HDS) users compared with non-HDS users (HDS users: adjusted HR, 0.84; 95% CI, 0.73-0.98; P = .002; non-HDS users: adjusted HR, 0.79; 95% CI, 0.68-0.91; P = 001).

Conclusions and Relevance

In this cohort study of Asian patients with breast cancer, statin use was associated with a reduced risk of cancer-associated death rather than cardiovascular death. Our findings provide evidence to support the use of statins in patients with breast cancer; however, randomized studies are necessary.

Sequential culture with aroma-producing yeast strains to improve the quality of Kyoho wine

Despite many non-Saccharomyces yeasts being considered spoilage microorganisms, they can increase aroma and flavor diversity in alcoholic beverages. The purpose of this study was to investigate nontraditional inoculation strategies using aroma-producing yeast strains for Kyoho wine fermentation, followed by an instrumental analysis and sensory evaluation. The winemaking process was carried out using Saccharomyces cerevisiae Gr112, Hanseniaspora uvarum Pi235, and Pichia kluyveri Pe114. Multiple inoculation strategies were explored. In instrumental analysis results, mixed culture could promote the formation of esters (5.9-folds) and glycerol (1.3-folds) and reduce the content of ethanol (-0.5% [v/v]) in wine. The sensory analysis results suggested that the three yeast strains sequential inoculation treatment was associated with the aroma attributes "floral," "red fruity," and "tropical fruity." Co-cultivation contributed to an increase in complexity and aromatic intensity, with the three-strain inoculation treatment presenting a more distinctive appearance. PRACTICAL APPLICATION: The inoculation of S. cerevisiae improved the accumulation of volatile acids and esters by inhibiting the growth of non-Saccharomyces yeast strains. Inoculation of H. uvarum and P. kluyveri would effectively solve the defect of excessive content of higher alcohols in wines produced by S. cerevisiae. The suitable inoculation strategy between non-Saccharomyces yeasts could improve the overall quality of Kyoho wine whose starter might be widely used in fermentation industry.

Dunaliella salina Alga Protects against Myocardial Ischemia/Reperfusion Injury by Attenuating TLR4 Signaling

Myocardial ischemia/reperfusion (I/R) injury is marked by rapid increase in inflammation and not only results in myocardial apoptosis but also compromises the myocardial function. Dunaliella salina (D. salina), a halophilic unicellular microalga, has been used as a provitamin A carotenoid supplement and color additive. Several studies have reported that D. salina extract could attenuate lipopolysaccharides-induced inflammatory effects and regulate the virus-induced inflammatory response in macrophages. However, the effects of D. salina on myocardial I/R injury remain unknown. Therefore, we aimed to investigate the cardioprotection of D. salina extract in rats subjected to myocardial I/R injury that was induced by occlusion of the left anterior descending coronary artery for 1 h followed by 3 h of reperfusion. Compared with the vehicle group, the myocardial infarct size significantly decreased in rats that were pre-treated with D. salina. D. salina significantly attenuated the expressions of TLR4, COX-2 and the activity of STAT1, JAK2, IκB, NF-κB. Furthermore, D. salina significantly inhibited the activation of caspase-3 and the levels of Beclin-1, p62, LC3-I/II. This study is the first to report that the cardioprotective effects of D. salina may mediate anti-inflammatory and anti-apoptotic activities and decrease autophagy through the TLR4-mediated signaling pathway to antagonize myocardial I/R injury.

Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs and the Risk of Vascular Dementia in Patients with Spondyloarthritis: A Database Cohort Study

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease that mainly affects the axial bones, and dementia is characterized by a decline in cognitive function, leading to dependence in everyday activity. Although the association between dementia and ankylosing spondylitis has been investigated, the influence of axSpA medication on dementia risk is unclear. The aim of this study was to investigate the risk of dementia among axSpA patients and if the conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) can reduce the risk of dementia. Patients with axSpA whose data were recorded during 2004-2008 and who were followed up until the end of 2010 were recruited. A control cohort was matched by age and sex. A Cox multivariate proportional hazards model was applied to analyze the risk factors for dementia. The hazard ratio (HR) and adjusted HR (aHR) were estimated between the study and control cohorts. The effects of csDMARDs and steroid use on the risk of different types of dementia were also analyzed. In total, 2341 and 11,705 patients constituted the axSpA and control cohort, respectively. The axSpA cohort had a greater risk of vascular dementia (aHR = 2.09 (1.36-3.20). The risk of dementia (aHR = 1.01 (0.55-1.85) did not significantly differ between patients with axSpA who received csDMARDs. In conclusion, patients with axSpA are at a risk of vascular dementia, which could be reduced by csDMARDs.

[Impact of capsular tension ring implantation in cataract patients with high myopia]

The capsular tension ring (CTR) can stabilize the capsule, support the lax zonules, and inhibit the proliferation and migration of lens epithelial cells. Clinically, CTR is mostly used in patients with zonular weakness, which can improve the stability of intraocular lens (IOL) and reduce the incidence of posterior capsular opacity (PCO). The relatively large capsular bag volume, zonular weakness in cataract patients with high myopia may increase the instability of IOL and PCO. Therefore, many clinicians have implanted CTR in cataract patients with high myopia. In this review, we summarized the application of CTR in cataract patients with high myopia.

Cumulative risk assessment and exposure characteristics of parabens in the general Taiwanese using multiple hazard indices approaches

Parabens, a group of endocrine disrupting chemicals (EDCs), are well known preservatives in pharmaceuticals and personal care products (PPCPs). However, studies on parabens exposure and their cumulative effects in Asian population are limited. This study aimed to identify the exposure characteristics and estimate the cumulative risk of four parabens in the general Taiwanese. We have collected urine samples including 271 adults (18-97 yrs old) and 95 minors (7-17 yrs old), from Taiwan Environmental Survey for Toxicants 2013, and analyzed for four urinary parabens including methyl (MeP)-, ethyl (EtP)-, propyl (PrP)-, and butylparaben (BuP) by using ultraperformance liquid chromatography-tandem mass spectrometry. The health-based guidance value (HBGV) and the antiandrogenic properties of parabens were used to calculate the hazard index (HI) for cumulative risk. MeP and PrP were most abundant compounds and startlingly higher than those in other countries. Adults had a higher geometric mean level of four parabens than minors (adults: MeP, 381.7; PrP, 108.6; EtP, 39.6 and BuP 6.3 ng/mL; minors: MeP, 65.7; PrP, 7.9, EtP, 2.6 and BuP 2.2 ng/mL). Participants who used a higher number of personal care products had a significantly higher risk with higher concentrations of PrP (above 75th %tile) [adjusted odds ratio (aOR): 1.79, 95 % CI: 1.01-3.15] and BuP [aOR: 1.78, 95 % CI: 1.03-3.07]. The median and 95th %tile HI (the sum of the HQs of each paraben) was as 1.10 and 4.39-fold higher than acceptable cumulative threshold (HI <1) and PrP accounted for 90 % of the HI. Our results indicate omnipresent exposure to parabens among the Taiwanese population, which might cause certain level of concerns. These significant increasing trends of HI with age dependence were observed, which mainly driven by PPCPS used. Routine survey of parabens in PPCPs and continued biomonitoring needs to be urgently addressed.

Legacy effects of infection in patients with heart failure: a national cohort study of 31,318 patients in Taiwan

Background

Although infection is a common cause of hospitalization in patients (pts) with heart failure (HF), the long-term cardiovascular (CV) prognosis in HF after infection is not well studied.

Methods and results

From 2009 to 2015, 310,485 pts with their first HF admissions and survival to discharge were identified from the National Health Insurance Research Database. Among the pts, 103,505 (33.3%) were readmitted within 1 year after HF discharge for infection, including pneumonia (44.2%), urinary tract infection (UTI) (37.9%), skin and soft tissue infections (9.7%), and others (8.1%). Those without admission for any infection were controls. We compared the primary composite endpoint, including all-cause death, acute myocardial infarction (AMI), stroke, and hospitalization for HF (HHF) between the 2 groups after the infection episode. After propensity score matching, the clinical characteristics (age 71.7±13.9 years, male 52.0%) and treatment were similar between the groups (n=15,659 in each group). In a mean follow-up time of 4.3±2.9 years, 86.2% pts with a history of infection admission and 63.6% pts in the control group met the primary endpoint. Multivariate Cox proportional hazards analysis showed the infection group had a higher risk of the primary composite endpoint (HR 1.760, 95% CI 1.714–1.807), including all-cause death (HR 1.587, 95% CI: 1.540–1.636), HHF (HR 1.993, 95% CI 1.922–2.066), AMI (HR 1.332, 95% CI 1.224–1.450), and stroke (HR 1.769, 95% CI 1.664–1.882). In infection group, HHF was the earliest outcome event with a mean time of 17.5 months and mortality is the second early event with a mean time of 23 months after discharge from the infection episode. Pneumonia carried a higher risk than UTI for the primary composite endpoint (HR 1.140, 95% CI 1.104–1.178).

Conclusions

One-third of HF pts discharged from the hospital experienced acute infection that required readmission. The pts had worse CV prognosis after readmission for infectious disease compared to those without infection

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): This study is supported by National Cheng Kung University Hospital and Tainan Hospital, Ministry of Health and Welfare, Taiwan.

Production of Siamenoside I and Mogroside IV from Siraitia grosvenorii Using Immobilized β-Glucosidase

Siraitia grosvenorii is a type of fruit used in traditional Chinese medicine. Previous studies have shown that the conversion of saponins was often carried out by chemical hydrolysis, which can be problematic because of the environmental hazards it may cause and the low yield it produces. Therefore, the purpose of this study is to establish a continuous bioreactor with immobilized enzymes to produce siamenoside I and mogroside IV. The results show that the immobilization process of β-glucosidase exhibited the best relative activity with a glutaraldehyde (GA) concentration of 1.5%, carrier activation time of 1 h and binding enzyme time of 12 h. After the immobilization through GA linkage, the highest relative activity of β-glucosidase was recorded through the reaction with the substrate at 60 °C and pH 5. Subsequently, the glass microspheres with immobilized β-glucosidase were filled into the reactor to maintain the optimal active environment, and the aqueous solution of Siraitia grosvenorii extract was introduced by controlling the flow rate. The highest concentration of siamenoside I and mogroside IV were obtained at a flow rate of 0.3 and 0.2 mL/min, respectively. By developing this immobilized enzyme system, siamenoside I and mogroside IV can be prepared in large quantities for industrial applications.

Particulate matter 2.5 exposure induces epithelial-mesenchymal transition via PI3K/AKT/mTOR pathway in human retinal pigment epithelial ARPE-19 cells

Exposure to particulate matter 2.5 (PM2.5) has been linked to ocular surface diseases, yet knowledge of the molecular mechanism impacted on retina pathogenesis is limited. Therefore, the purpose of this study was to explore the effects and involved factors of PM2.5 exposure in human retinal pigment epithelial APRE-19 cells. Our data revealed a decreased cell viability and an increased migratory ability in APRE-19 cells after PM2.5 stimulation. The MMP-2 and MMP-9 protein levels were markedly increased while the MMPs regulators TIMP-1 and TIMP-2 were significantly reduced in PM2.5-exposed APRE-19 cells. PM2.5 also increased pro-MMP-2 expression in the cell culture supernatants. Additionally, PM2.5 promoted the EMT markers through the activation of PI3K/AKT/mTOR pathway. Moreover, the ICAM-1 production was also remarkably increased by PM2.5 but reduced by PI3K/AKT inhibitor LY294002 in APRE-19 cells. Taken together, these results suggest that PM2.5 promotes EMT in a PI3K/AKT/mTOR-dependent manner in the retinal pigment epithelium.

Impact of the Dual Antiplatelet Therapy Score on Clinical Outcomes in Acute Coronary Syndrome Patients Receiving P2Y12 Inhibitor Monotherapy

Background

Dual antiplatelet therapy (DAPT) score is used to stratify ischemic and bleeding risk for antiplatelet therapy after percutaneous coronary intervention (PCI). This study assessed the association between the DAPT score and clinical outcomes in acute coronary syndrome (ACS) patients who were treated with P2Y12 inhibitor monotherapy.

Methods

A total of 498 ACS patients, with early aspirin discontinuation for various reasons and who received P2Y12 inhibitor monotherapy after PCI, were enrolled during the period from January 1, 2014 to December 31, 2018. The efficacy and safety between those with low (<2) and high (≥2) DAPT scores were compared during a 12-month follow-up after PCI. Inverse probability of treatment weighting was used to balance the covariates between the two groups. The primary endpoint was a composite outcome of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months. The safety endpoint was major bleeding, defined as Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding.

Results

The primary composite endpoint occurred in 11.56 and 14.38% of the low and high DAPT score groups, respectively. Although there was no significant difference in the primary composite endpoint between the two groups in the multivariate Cox proportional hazards models, the risk of recurrent ACS or unplanned revascularization was significantly higher in the high DAPT score group (adjusted hazard ratio [HR]: 1.900, 95% confidence interval [CI]: 1.095-3.295). The safety outcome for BARC 3 or 5 bleeding was similar between the two groups.

Conclusions

Our results indicate that ACS patients receiving P2Y12 monotherapy with high DAPT score had an increased risk of recurrent ACS or unplanned revascularization.

Osteoporosis increases the risk of rotator cuff tears: a population-based cohort study

INTRODUCTION

Osteoporosis has been demonstrated to be a risk factor for rotator cuff retears after surgery; however, no studies have directly investigated the association between osteoporosis and the development of rotator cuff tears. To investigate whether osteoporosis is associated with an increased risk of rotator cuff tears.

MATERIALS AND METHODS

We conducted a population-based, matched-cohort study with a 7-year follow-uTwo matched cohorts (n = 3511 with osteoporosis and 17,555 without osteoporosis) were recruited from Taiwan's Longitudinal Health Insurance Dataset. Person-year data and incidence rates were evaluated. A multivariable Cox model was used to derive an adjusted hazard ratio (aHR) after controlling for age, sex, and various prespecified comorbidities. Age and sex were added in the model to test for interaction with osteoporosis.

RESULTS

Women constituted 88.5% of the cohorts. During follow-up of 17,067 and 100,501 person-years for the osteoporosis and nonosteoporosis cohorts, 166 and 89 rotator cuff tears occurred, respectively. The cumulative incidence of rotator cuff tears was significantly higher in the osteoporosis cohort than in the nonosteoporosis cohort (p < 0.001, log-rank). The Cox model revealed a 1.79-fold increase in rotator cuff tears in the osteoporosis cohort, with an aHR of 1.79 (95% confidence interval, 1.55-2.05). Effect modification of sex and age on rotator cuff tears was not found in patients with osteoporosis.

CONCLUSION

This population-based study supports the hypothesis that compared with individuals without osteoporosis, those with osteoporosis have a higher risk of developing rotator cuff tears.

Association and Risk of Axial Spondyloarthritis of Scoliosis Patients: A Database Study

STUDY DESIGN

Retrospective longitudinal cohort study.

OBJECTIVE

To investigate the incidence and risk of axial spondyloarthritis (axSpA) in patients with scoliosis in Taiwan.

SUMMARY OF BACKGROUND DATA

Scoliosis and axSpA causes back pain which reduces quality of life in many patients. Both scoliosis and axSpA had attracted numerous research attention, but the association between the two was hardly known.

METHODS

In this retrospective study, the data of 25,566 patients were obtained from Taiwan's National Health Insurance Research Database. We identified patients diagnosed with scoliosis and included them in the study cohort. We included age- and sex-matched patients without scoliosis in the control cohort. The total follow-up period was 7 years. Cox proportional hazards models were used to analyze the retrieved data. Hazard ratios (HRs) and adjusted HRs were calculated.

RESULTS

The study and control cohorts included 4261 and 21,305 patients, respectively. The incidences of axSpA were 141 and 46 per 100,000 person-years in the study and control cohorts, respectively. The crude HRs and adjusted HRs for patients with scoliosis were 2.98 (95% confidence interval, 1.87-4.73; P < 0.001) and 2.78 (95% confidence interval, 1.74-4.43; P < 0.001), respectively. The prevalence of comorbidities such as chronic obstructive pulmonary disease, osteoporosis, depression, autoimmune diseases (rheumatoid arthritis and systemic lupus erythematosus), and thyroid disease was significantly higher in the study cohort.

CONCLUSION

Our findings indicate an association between scoliosis and axSpA. Additional studies should be performed to explain this phenomenon.Level of Evidence: 3.

Risks of Aromatase Inhibitor-Related Cardiotoxicity in Patients with Breast Cancer in Asia

Simple Summary

In Asian breast cancer patients, whether the risks of major adverse cardio- and cerebrovascular events (MACCEs) are different between users of aromatase inhibitors (AIs) and selective estrogen receptor modulators (SERMs) remains uncertain. In this nationwide cohort study, the risks of MACCEs were significantly higher in users of SERMs compared with users of AIs in those who were at an old age (above 50 years old) or with advanced cancer stage (stage 3–4). Although the choice of hormone therapies is primarily based on the effectiveness regarding cancer survival, AI treatment should be considered for patients for whom the benefits outweigh the risks.

Abstract

Background: Despite a preferred endocrine therapy for women with estrogen and progesterone receptor-positive breast cancer, aromatase inhibitors (AIs) have been reported to increase risks of cardiovascular events. Given that breast cancer patients in Asia are younger at diagnosis, it is urgent to investigate this safety concern. Methods: Through the Taiwanese National Cohort, we identified breast cancer patients initiating selective estrogen receptor modulators (SERMs) or AIs from 2010 to 2016. Outcomes includes major adverse cardio- and cerebrovascular events (MACCEs). The average follow-up duration was five years. Results: We identified 16,730 breast cancer patients treated with SERMs and 11,728 receiving AIs. The population was older and had more comorbidities in the AI group than in the SERM group. After adjusting for age, cancer stage, cancer therapies, cardiovascular drugs and comorbidities, despite similar risks of MACCEs between AI and SERM users, the risk of HF was significantly higher in patients treated with SERMs after adjusted mortality as a competing risk. When divided by the age of 50 years, despite a similar MACCEs in the younger population, MACCEs remained significantly higher in the older population who received SERMs. Conclusions: In this Asian cohort, we found that among patients of old age or with advanced cancer stage, the use of SERMs was associated with a higher risk of cardiovascular events than the use of AIs.

Glucose Sensing in Human Whole Blood Based on Near-Infrared Phosphors and Outlier Treatment with the Programming Language "R"

A near-infrared paper-based analytical device (NIR-PAD) for glucose detection in whole blood was based on iridium(III) metal complexes embedded in a three-dimensional (3D) enzyme gel. These complexes emit NIR luminescence, can avoid interference from the color of blood, and increase the sensitivity of sensing glucose. The glucose reaction behaviors of another two different iridium(III) and platinum(II) complexes were also tested. When the glucose solution was added to the device, the oxidation of glucose by glucose oxidase caused oxygen consumption and increased the intensity of the phosphorescence emission. To the best of our knowledge, this is the first time that data have been treated with the programming language "R", which uses Tukey's test to identify the outliers in the data and calculate a median for establishing a calibration curve, in order to improve the accuracy of NIR-PADs for sensing glucose. Compared with other published devices, NIR-PADs exhibit a wider linear range (1-30 mM, [relative emission intensity] = 0.0250[glucose] + 0.0451, and R 2 = 0.9984), a low detection limit (0.7 mM), a short response time (<2 s), and a small sample volume (2 μL). Finally, blood specimens were obtained from 19 patients enrolled in Taipei Veterans General Hospital under an approved IRB protocol (Taiwan; 2017-12-002CC). The sensors exhibited remarkable characteristics for glucose detection in comparison with other methods, including the clinical method in hospitals as well as those without blood sample pretreatment or a dilution factor. The above results confirm that NIR-PAD sensors can be put to practical use for glucose detection.

Luteolin Reduces Aqueous Extract PM2.5-induced Metastatic Activity in H460 Lung Cancer Cells

Fine particulate matter (PM2.5) is the critical cause of lung cancer and can further promote tumor cell migration and invasion. This study investigated the effects of luteolin, an antiangiogenic flavonoid agent, on blocking aqueous extract PM2.5-prompted cancer progression. We observed that luteolin reduced cell migration and the expression of pro-metastatic factors pro-matrix metalloproteinase (MMP)-2 and intercellular adhesion molecule (ICAM)-1 in PM2.5-exposed H460 lung cancer cells. Luteolin treatment also reduced the transduction of PM2.5-induced epidermal growth factor receptor (EGFR)-phosphatidylinositol 3-kinase (PI3K)-protein kinase B (AKT) cascade signaling. Furthermore, the reduction of MMP-2 expression and ICAM-1 production by luteolin in PM2.5-stimulated H460 cells is EGFR-PI3K-AKT pathway dependent. These results suggest that luteolin exhibits antitumor progression by inhibiting EGFR-PI3K-AKT pathway.

Cervical Spine Pathology Increases the Risk of Rotator Cuff Tear: A Population-Based Cohort Study

Background:

Patients with cervical radiculopathy typically present with shoulder pain and weakness; these symptoms are similar to those of rotator cuff disease. Studies investigating cervical spine pathology (CSP) as an independent risk factor for rotator cuff tear (RCT) are lacking in the literature.

Purpose:

To investigate the risk of RCT among patients with CSP who have undergone cervical diskectomy (CD) and to determine whether CD reduces this risk.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors queried the Taiwan National Health Insurance Research Database for patients diagnosed with CSP between 2004 and 2008 and followed up until the end of 2010. A control cohort comprised patients without CSP who were age- and sex-matched in a 4-to-1 ratio with patients with CSP through propensity score matching. A Cox multivariate proportional hazards model was applied to analyze the risk factors for RCT. After adjustment for confounders, the authors calculated the hazard ratio (HR) and adjusted HR (aHR) between the study and control cohorts. The effects of CD on the risk of RCT were also analyzed.

Results:

The study included 3245 patients and 12,980 matched controls. A higher RCT incidence rate was found in the CSP cohort, with an aHR of 1.52 (95% CI, 1.22-1.89; P < .001). Patients with CSP who underwent CD had a risk of RCT similar to that of the controls, with an aHR of 1.65 (95% CI, 0.90-3.03; P > .05).

Conclusion:

Patients with CSP had a 1.52-fold higher risk of RCT than healthy controls. Patients with CSP with CD did not have a high risk of RCT, possibly indicating a protective effect of diskectomy against RCT.

The Protective Effects of α-Mangostin Attenuate Sodium Iodate-Induced Cytotoxicity and Oxidative Injury via Mediating SIRT-3 Inactivation via the PI3K/AKT/PGC-1α Pathway

It is well known that age-related macular degeneration (AMD) is an irreversible neurodegenerative disease that can cause blindness in the elderly. Oxidative stress-induced retinal pigment epithelial (RPE) cell damage is a part of the pathogenesis of AMD. In this study, we evaluated the protective effect and mechanisms of alpha-mangostin (α-mangostin, α-MG) against NaIO₃-induced reactive oxygen species (ROS)-dependent toxicity, which activates apoptosis in vivo and in vitro. MTT assay and flow cytometry demonstrated that the pretreatment of ARPE-19 cells with α-MG (0, 3.75, 7.5, and 15 μM) significantly increased cell viability and reduced apoptosis from NaIO₃-induced oxidative stress in a concentration-dependent manner, which was achieved by the inhibition of Bax, cleaved PARP-1, cleaved caspase-3 protein expression, and enhancement of Bcl-2 protein. Furthermore, pre-incubation of ARPE-19 cells with α-MG markedly inhibited the intracellular ROS and extracellular H₂O₂ generation via blocking of the abnormal enzyme activities of superoxide dismutase (SOD), the downregulated levels of catalase (CAT), and the endogenous antioxidant, glutathione (GSH), which were regulated by decreasing PI3K-AKT-PGC-1α-STRT-3 signaling in ARPE-19 cells. In addition, our in vivo results indicated that α-MG improved retinal deformation and increased the thickness of both the outer nuclear layer and inner nuclear layer by inhibiting the expression of cleaved caspase-3 protein. Taken together, our results suggest that α-MG effectively protects human ARPE-19 cells from NaIO₃-induced oxidative damage via antiapoptotic and antioxidant effects.

Ganoderma formosanum Exopolysaccharides Inhibit Tumor Growth via Immunomodulation

Ganoderma formosanum (GF) is a medicinal mushroom endemic to Taiwan. Previous research established the optimal culture conditions to produce exopolysaccharide rich in β-glucan (GF-EPS) from submerged fermentation of GF. The present study investigated the antitumor effects of GF-EPS in a Lewis lung carcinoma cell (LLC1) tumor-bearing mice model. In the preventive model, GF-EPS was orally administered to mice before LLC1 injection. In the therapeutic model, GF-EPS oral administration was initiated five days after tumor cell injection. The tumor size and body weight of the mice were recorded. After sacrifice, the lymphocyte subpopulation was analyzed using flow cytometry. Spleen tissues were used to analyze cytokine mRNA expression. The results showed that GF-EPS (80 mg/kg) effectively suppressed LLC1 tumor growth in both the preventive and therapeutic models. GF-EPS administration increased the proportion of natural killer cells in the spleen and activated gene expression of several cytokines. Our results provide evidence that GF-EPS promotes tumor inhibition through immunomodulation in tumor-bearing mice.

Real-World Analyses of the Safety Outcome among a General Population Treated with Statins: An Asian Population-Based Study

Aim: The safety concern of statins is still a major issue for Asians. The aim of this study is to compare the risk of statin-associated adverse events among potent statins.

Methods: We included patients from the Taiwan National Health Insurance Research Database who had been treated with atorvastatin, rosuvastatin, or pitavastatin and were without diabetes at baseline. They were classified into three groups: usual-dose statin (atorvastatin 10 mg/d or rosuvastatin 5–10 mg/d), high-dose statin (atorvastatin 20–40 mg/d and rosuvastatin 20 mg/d), and pitavastatin (2–4 mg/d). The primary endpoint is a composite of safety events, including hepatitis, myopathy, and new-onset diabetes mellitus (NODM). We matched age, sex, and year of recruitment among the three groups (n=50,935 in each group) and then used the multivariate Cox proportional hazards model to evaluate the relation between the safety endpoint and different statin groups.

Results: After a mean follow-up of 3.08±0.83 years, the safety events occurred in 9.84% in the pitavastatin group, 10.88% in the usual-dose statin group, and 10.49% in high-dose statin group. The multivariate Cox proportional hazards model indicated that usual-dose statin and high-dose statin were associated with a higher risk of the composite safety events compared with pitavastatin (adjusted hazard ratio [aHR]: 1.12, 95% confidence interval [CI]: 1.08–1.17 for usual-dose statin and aHR: 1.06, 95% CI: 1.02–1.10 for high-dose statin). The risks of hepatitis requiring hospitalization and NODM were especially lower in pitavastatin group.

Conclusions: Compared with atorvastatin and rosuvastatin, pitavastatin might be associated with a lower risk of safety events in Asians.

Risks of trastuzumab-related cardiotoxicity in breast cancer patients in Taiwan

Aims

In contrast to Western patients with breast cancer, Asian patients are relatively younger at diagnosis, and most are free from traditional cardiovascular risk factors. Despite trastuzumab‐related major adverse cardiac and cerebrovascular event (MACCE) being reported, its incidence and predictors remain unknown in Taiwan.

Methods and results

Through a three‐hospital retrospective cohort study, we analysed the incidence of MACCE in 386 breast cancer patients' exposure to trastuzumab from 2010 to 2018. To further reconfirm our findings, in a nationwide study using the Taiwanese National Health Insurance Research Database and National Cancer Registry, we identified 13 502 women diagnosed with breast cancer who received chemotherapy from 2010 to 2015 and found 6751 women who received initial treatment with trastuzumab. After 1:1 propensity score matching with trastuzumab non‐users, the incidence of MACCE was measured with a median follow‐up of 36 months. In the hospital‐based study, among 386 patients receiving trastuzumab, the 5‐year incidences of MACCE and heart failure (HF) were 5.4 and 2.8%, respectively. In the national cohort, the crude incidences of MACCEs and HF were 4.67 and 3.21%, respectively. After adjustment for age and comorbidities, the hazard ratio of MACCE was 1.485 (95% CI 1.246–1.769). Notably, among the endpoints, only the hazard ratio of HF was significantly higher in patients receiving trastuzumab than in nonusers. In the subgroup analysis, except for patients also using taxanes, those receiving trastuzumab had a higher risk of MACCE than non‐users.

Conclusions

From clinical observations in a nationwide cohort, we found an increased risk of MACCE, especially HF, in patients receiving trastuzumab. Given that its cardiotoxicity is independent of traditional cardiovascular risks, our findings highlight critical concerns regarding the cardiac safety of trastuzumab use.

Effect of aspirin treatment duration on clinical outcomes in acute coronary syndrome patients with early aspirin discontinuation and received P2Y12 inhibitor monotherapy

Recent clinical trials showed that short aspirin duration (1 or 3 months) in dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor monotherapy reduced the risk of bleeding and did not increase the ischemic risk compared to 12-month DAPT in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). However, it is unclear about the optimal duration of aspirin in P2Y12 inhibitor monotherapy. The purpose of this study was to evaluate the influence of aspirin treatment duration on clinical outcomes in a cohort of ACS patients with early aspirin interruption and received P2Y12 inhibitor monotherapy. From January 1, 2014 to December 31, 2018, we included 498 ACS patients (age 70.18 ± 12.84 years, 71.3% men) with aspirin stopped for various reasons before 6 months after PCI and received P2Y12 inhibitor monotherapy. The clinical outcomes between those with aspirin treatment ≤ 1 month and > 1 month were compared in 12-month follow up after PCI. Inverse probability of treatment weighting was used to balance the covariates between groups. The mean duration of aspirin treatment was 7.52 ± 8.10 days vs. 98.05 ± 56.70 days in the 2 groups (p<0.001). The primary composite endpoint of all-cause mortality, recurrent ACS or unplanned revascularization and stroke occurred in 12.6% and 14.4% in the 2 groups (adjusted HR 1.19, 95% CI 0.85-1.68). The safety outcome of BARC 3 or 5 bleeding was also similar (adjusted HR 0.69, 95% CI 0.34-1.40) between the 2 groups. In conclusion, patients with ≤ 1 month aspirin treatment had similar clinical outcomes to those with treatment > 1 month. Our results indicated that ≤ 1-month aspirin may be enough in P2Y12 inhibitor monotherapy strategy for ACS patients undergoing PCI.

Enhanced antioxidant activity of Chenopodium formosanum Koidz. by lactic acid bacteria: Optimization of fermentation conditions

In this study, different probiotics commonly used to produce fermented dairy products were inoculated independently for Chenopodium formosanum Koidz. fermentation. The strain with the highest level of antioxidant activity was selected and the fermentation process was further optimized via response surface methodology (RSM). Lactobacillus plantarum BCRC 11697 was chosen because, compared to other lactic acid bacteria, it exhibits increased free radical scavenging ability and can produce more phenolic compounds, DPPH (from 72.6% to 93.2%), and ABTS (from 64.2% to 76.9%). Using RSM, we further optimize the fermentation protocol of BCRC 11697 by adjusting the initial fermentation pH, agitation speed, and temperature to reach the highest level of antioxidant activity (73.5% of DPPH and 93.8% of ABTS). The optimal protocol (pH 5.55, 104 rpm, and 24.4°C) resulted in a significant increase in the amount of phenolic compounds as well as the DPPH and ABTS free radical scavenging ability of BCRC 11697 products. The IC50 of the DPPH and ABTS free radical scavenging ability were 0.33 and 2.35 mg/mL, respectively, and both protease and tannase activity increased after RSM. An increase in lower molecular weight (<24 kDa) protein hydrolysates was also observed. Results indicated that djulis fermented by L. plantarum can be a powerful source of natural antioxidants for preventing free radical-initiated diseases.

Hyperlipidemia Is a Risk Factor of Adhesive Capsulitis: Real-World Evidence Using the Taiwanese National Health Insurance Research Database

Background:

Patients with adhesive capsulitis are evaluated for pain and progressive contracture of the glenohumeral joint. Whether endocrine, immune, or inflammatory processes are involved in its definite pathogenesis is still under debate. Some cross-sectional studies with a small sample size have noted that hyperlipidemia is a possible risk factor for frozen shoulders.

Purpose/Hypothesis:

The purpose was to conduct a longitudinal population-based study to investigate the risk of adhesive capsulitis among patients with hyperlipidemia. It was hypothesized that patients with hyperlipidemia would have a higher risk of adhesive capsulitis and that the use of statin drugs could reduce the rate.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using data from the National Health Insurance Research Database (NHIRD) of Taiwan, the authors obtained the records of patients with hyperlipidemia who received a diagnosis between 2004 and 2005 and were followed up until the end of 2010. The control cohort comprised age- and sex-matched patients without hyperlipidemia. Propensity score matching was performed for the other comorbidities. A Cox multivariate proportional hazards model was applied to analyze the risk factors of adhesive capsulitis. The hazard ratio (HR) and adjusted HR were estimated between the study and control cohorts after adjustment for confounders. The effects of statin use on adhesive capsulitis risk were also analyzed.

Results:

The NHIRD records of 28,748 patients and 114,992 propensity score–matched controls were evaluated. A higher incidence rate of adhesive capsulitis was revealed in the hyperlipidemia cohort, with a crude HR of 1.70 (95% CI, 1.61-1.79; P < .001) and adjusted HR of 1.50 (95% CI, 1.41-1.59; P < .001). Patients with hyperlipidemia who used a statin still had higher crude and adjusted HRs compared with controls. Statin use did not exert protective effects on patients with hyperlipidemia.

Conclusion:

Patients with hyperlipidemia had a 1.5-fold higher risk of adhesive capsulitis than did healthy controls. Statin use did not provide protection against adhesive capsulitis in patients with hyperlipidemia.

Anti-inflammatory effects of Flos Lonicerae Japonicae Water Extract are regulated by the STAT/NF-κB pathway and HO-1 expression in Virus-infected RAW264.7 cells

This study examined the effect of the Flos Lonicerae Japonicae water extract (FLJWE), chlorogenic acid, and luteolin on pseudorabies virus (PRV)-induced inflammation in RAW264.7 cells and elucidated related molecular mechanisms. The results revealed that FLJWE and luteolin, but not chlorogenic acid, inhibited the production of inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2), and inflammatory cytokines in PRV-infected RAW 264.7 cells. We found that the FLJWE and luteolin suppressed nuclear factor (NF)-κB activation by inhibiting the phosphorylation of signal transducer and activator of transcription 1 and 3 (STAT1 and STAT3, respectively). Moreover, the FLJWE significantly upregulated the expression of pNrf2 and its downstream target gene heme oxygenase-1 (HO-1). Our data indicated that FLJWE and luteolin reduced the expression of proinflammatory mediators and inflammatory cytokines, such as COX-2 and iNOS, through the suppression of the JAK/STAT1/3-dependent NF-κB pathway and the induction of HO-1 expression in PRV-infected RAW264.7 cells. The findings indicate that the FLJWE can be used as a potential antiviral agent.

Indium Uptake and Accumulation by Rice and Wheat and Health Risk Associated with Their Consumption

The increasing use of indium in high-tech industries has inevitably caused its release into the environment. However, knowledge of its environmental fate has been very limited so far. This study investigates the indium uptake and accumulation by two staple crops, rice (Oryza sativa L.) and wheat (Triticum aestivum L.), and evaluates potential risks associated with their consumption. Rice and wheat were grown on three kinds of soil, including acidic soils spiked with a high indium concentration (1.0 mmol kg^-1), which is considered the worst-case scenario, because high soil acidity promotes indium bioavailability. The results revealed that a large portion of soil indium was associated with iron hydroxides, even in acidic soils. Indium precipitates in soils resulted in relatively low availability at the plant root site. Most absorbed indium accumulated at the roots, with only a tiny portion reaching the grains. The corresponding Hazard Quotient indicated no adverse effects on human health. Due to the low translocation of indium from soil to grain, the consumption of rice and wheat grains harvested from indium-contaminated soils may pose an insignificant risk to human health. Further field studies are necessary to better elucidate the risks associated with consuming crops grown in indium-contaminated soils.

P2Y12 Inhibitor Monotherapy with Clopidogrel Versus Ticagrelor in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Background: P2Y12 inhibitor monotherapy is an alternative antiplatelet strategy in patients undergoing percutaneous coronary intervention (PCI). However, the ideal P2Y12 inhibitor for monotherapy is unclear. Methods and Results: We performed a multicenter, retrospective, observational study to compare the efficacy and safety of monotherapy with clopidogrel versus ticagrelor in patients with acute coronary syndrome (ACS) undergoing PCI. From 1 January 2014 to 31 December 2018, 610 patients with ACS who received P2Y12 monotherapy with either clopidogrel (n = 369) or ticagrelor (n = 241) after aspirin was discontinued prematurely were included. Inverse probability of treatment weighting was used to balance covariates between the groups. The primary endpoint was the composite of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months after discharge. Overall, 84 patients reached the primary endpoint, with 57 (15.5%) in the clopidogrel group and 27 (11.2%) in the ticagrelor group. Multivariate adjustment in Cox proportional-hazards models revealed a lower risk of the primary endpoint with ticagrelor than with clopidogrel (adjusted hazard ratio (aHR): 0.67, 95% confidence interval (CI): 0.49–0.93). Ticagrelor significantly reduced the risk of recurrent ACS or unplanned revascularization (aHR: 0.46, 95% CI: 0.28–0.75). No significant difference in all-cause mortality and major bleeding events was observed between the 2 groups. Conclusions: Among patients with ACS undergoing PCI who cannot complete course of dual antiplatelet therapy, a significantly lower risk of cardiovascular events was associated with ticagrelor monotherapy than with clopidogrel monotherapy. The major bleeding risk was similar in both the groups.

Patients with Axial Spondyloarthritis Are at Risk of Developing Adhesive Capsulitis: Real-World Evidence Database Study in Taiwan

Patients with axial spondyloarthritis (ax-SpA) present with inflammation invading the axial skeleton. Symptoms of ax-SpA interfere with patients' quality of life, and peripheral symptoms are also noted. Human leukocyte antigen B27 was associated with adhesive capsulitis. However, epidemiological studies investigating the associated incidence and risk factors for patients with ax-SpA with adhesive capsulitis are limited. The data of patients with ax-SpA were recorded during the 2004-2008 period and followed to the end of 2010. The control cohort comprised age- and sex-matched non-ax-SpA subjects. A Cox multivariate proportional hazards model was applied to analyze the risk factors for adhesive capsulitis. The hazard ratio (HR) and adjusted hazard ratio (aHR) were estimated between the study and control cohorts after confounders were adjusted for. Effects of sulfasalazine (SSZ), methotrexate (MTX), and hydroxychloroquine (HCQ) use on adhesive capsulitis risk were also analyzed. We enrolled 2859 patients with ax-SpA in the study cohort and 11,436 control subjects. A higher incidence of adhesive capsulitis was revealed in the ax-SpA cohort: The crude HR was 1.63 (95% CI, 1.24-2.13; p < 0.001), and the aHR was 1.54 (95% CI, 1.16-2.05; p = 0.002). For patients with ax-SpA using SSZ or HCQ, no difference in aHR was noted compared with control participants, but patients with ax-SpA treated with MTX had higher HR and aHR than controls. Patients with ax-SpA are at risk for adhesive capsulitis. When these patients receive SSZ or HCQ, the risk of adhesive capsulitis can be lowered compared with that of the control cohort.

Changing Treatment Patterns in Patients With Venous Thromboembolism in Taiwan

BACKGROUND

In Asia, little information is available about contemporary real-world treatment patterns for venous thromboembolism (VTE).Methods and Results:Consecutive patients (n=11,414) from the Taiwan National Health Insurance Research Database with initial VTE and taking oral anticoagulants between May 1, 2014 and June 30, 2016 were included. The temporal trends of using oral anticoagulants and pharmacomechanical therapy during the study period were evaluated. The efficacy and safety of nonvitamin K antagonist oral anticoagulants (NOACs) vs. warfarin were compared. Propensity score analysis (NOACs n=3,647 vs. warfarin n=3,647) was used to balance covariates between groups, and Cox proportional hazards models with adjustment were used to estimate the risks of clinical outcomes. The use of NOACs increased from 0.3% to 60.2% for VTE treatment during the study period. Pharmacomechanical therapy was used in 9.60%, 8.22%, and 5.63% from 2014 through 2016. NOACs were associated with a 16% risk reduction (adjusted hazard ratio [aHR] 0.84, 95% confidence interval [CI] 0.77-0.93) in all-cause mortality and a 21% risk reduction (aHR 0.79, 95% CI 0.65-0.96) in recurrent VTE vs. warfarin. Overall, NOACs were associated with a lower risk of major bleeding compared with warfarin (aHR 0.804, 95% CI 0.648-0.998).

CONCLUSIONS

In real-world practice, NOACs have become the major anticoagulant used for Asians with VTE. Although NOACs had a lower risk of recurrent VTE and major bleeding compared with warfarin in Taiwan, we still need a large-scale randomized controlled trial to confirm the findings.

Full-scale investigation of in-situ iron and alkalinity generation for efficient sulfide control

Hydrogen sulfide induced corrosion of concrete sewer pipes is a major issue for wastewater utilities globally. One of the most commonly used methods to combat hydrogen sulfide is the addition of ferric chloride. While a reliable and effective method, ferric chloride is acidic causing OH&S concerns as well as alkalinity consumption in sewage. This study investigates, under full-scale field conditions, an alternative method for sulfide control by in-situ electrochemical generation of iron ions using sacrificial iron electrodes. This method concomitantly produces alkalinity through cathodic OH^- generation, rather than consumption. The gaseous hydrogen sulfide concentrations at the discharge wet well of a real-life rising main (length: ∼1 km in, diameter: 150 mm) decreased from 173 ppm to 43 ppm (90 percentile of peak values), when a current of 0.86 A/m³ of sewage was applied. The 90 percentile peak H₂S value was further reduced to 6.6 ppm when the applied current was increased to 1.14 A/m³ sewage. Moreover, methane generation was almost completely inhibited from 25.3 ± 1.46 mg COD/L to 0.06 ± 0.04 mg COD/L. The overall cell voltage remained constant throughout the experimental period clearly showing the stability of the process. Detailed characterization of the down-stream sewer pipe biofilm revealed the complexity of the iron chemistry as the in-situ produced iron ions undergo transformation into a variety of iron species. Overall, this study demonstrates that in-situ generation of iron and alkalinity is an effective alternative method for hydrogen sulfide control in sewers.

Nickel-induced VEGF expression via regulation of Akt, ERK1/2, NFκB, and AMPK pathways in H460 cells

Prospective cohort studies have indicated that a highly nickel-polluted environment may severely affect human health, resulting in such conditions as respiratory tract cancers. Such exposure can trigger vascular endothelial growth factor (VEGF) expression. However, the signal transduction pathways leading to VEGF induction by nickel compounds are not well understood. This study revealed the occurrence of VEGF induction in human non-small-cell lung cancer H460 cells exposed to NiCl₂ . Moreover, exposing H460 cells to NiCl₂ activated extracellular signal-regulated protein kinase (ERK), nuclear factor kappa B (NFκB), and protein kinase B (Akt) as well as downregulated AMP activated protein kinase (AMPK) expression. The mitogen-activated protein kinase (MAPK) and ERK inhibitor significantly blocked NiCl₂ -induced ERK activation and VEGF production. Pretreating H460 cells with a PI3K/Akt inhibitor substantially inhibited NiCl₂ -induced VEGF expression and reduced Akt, ERK, and NFκB phosphorylation. Furthermore, 5-aminoimidazole-4-carboxamide ribonucleoside-induced AMPK activation improved VEGF expression in NiCl₂ -treated H460 cells significantly. These results indicate that NiCl₂ induces VEGF production through Akt, ERK, NFκB activation and AMPK suppression and mediates various types of pathophysiological angiogenesis.

Kaempferol suppresses cell migration through the activation of the ERK signaling pathways in ARPE-19 cells

Kaempferol is a flavonoid with anticancer and anti-metastasis activity in different cancer-cell lines. However, the underlying mechanisms by which kaempferol acts on human retinal pigment epithelial (ARPE-19) cells remain unclear. In this study, we demonstrated that kaempferol inhibited migration and invasion in ARPE-19 cells at non-toxic dosages. We discovered that kaempferol obviously reduced the enzyme activity and protein expression of matrix metalloproteinase-2 by increasing the phosphorylated levels of extracellular signal-regulated kinases 1/2 (ERK1/2) signaling pathways. Additionally, ERK1/2-specific inhibitor PD98059 significantly reversed kaempferol's inhibitory effects on migration and expression of MMP-2 in ARPE-19 cells. Overall, our results are the first to demonstrate that kaempferol is capable of inhibiting cell migration by targeting ERK1/2 signaling in human retinal pigment epithelial cells.

[Particulate matter pollution and allergic rhinitis]

Summary Outdoor air pollution has become a major environmental health problem throughout the world. In particular, exposure to particulate matter(PM) has been associated with the development and exacerbation of allergic rhinitis（AR）. Although the adverse health effects of PM have been demonstrated for many years, the underlying mechanisms have not been fully identified. In this review, we refer to recently published literature to describe the composition of PM, the epidemiological evidence of PM-induced AR, and the possible immune mechanisms of PM-induced AR.

Autoimmune Connective Tissue Diseases and the Risk of Rotator Cuff Repair Surgery: A Population-Based Retrospective Cohort Study

OBJECTIVES

Autoimmune connective tissue diseases (ACTDs) commonly involve the shoulder joint; however, clinical epidemiological studies investigating their association with tendons are scant. Rotator cuff (RC) tears can cause shoulder disability, and surgical intervention is usually required. The study investigated RC repair surgery risk in ACTD patients. The effect of anti-inflammatory medication on RC repair surgery risk was also investigated.

METHODS

We conducted a retrospective cohort study with a 7-year longitudinal follow-up period. Patients with systemic lupus erythematosus, systemic sclerosis, sicca syndrome, dermatomyositis and polymyositis diagnoses between 2004 and 2008 were enrolled. The control cohort comprised age- and sex-matched controls. The HR and adjusted HR (aHR) were estimated for the risk of RC surgery between ACTD and control cohorts after adjustment for confounders. Furthermore, the effects of steroid and non-steroidal anti-inflammatory drug (NSAID) use on the HR and aHR of RC surgery risk were analysed.

RESULTS

We enrolled 5019 ACTD patients and 25 095 controls in the ACTD and control cohorts, respectively. RC surgery incidence was 49 and 24 per 100 000 person-years in the ACTD and control cohorts, respectively. In the ACTD cohort, the crude HR for RC surgery was 2.08 (95% CI , 1.08 to 4.02, p<0.05), and the aHR was 1.97 (95% CI, 1.01 to 3.82, p<0.05). The ACTD patients who used NSAIDs had an aHR of 3.13 (95% CI, 1.21 to 8.07, p<0.05) compared with the controls, but the ACTD patients who used steroids did not have a significantly higher aHR than the controls.

CONCLUSIONS

ACTD patients had an increased risk of RC repair surgery. However, no difference was found in RC surgery risk when steroids were used compared with the control cohort. This could indicate that inflammation control may be a strategy for managing subsequent RC lesions.

The Risk of Gynecologic and Urinary Tract Cancer with Pelvic Inflammatory Disease: A Population-Based Cohort Study

Purpose: The aim of the study was to determine the association between pelvic inflammatory disease (PID) and breast, colorectal, gynecologic and urinary tract cancer.

Methods: The source of data was a longitudinal dataset compiled by the Longitudinal Health Insurance Database 2000 (LHID2000) which was collected by the National Health Insurance program. Cases of PID, at least two outpatient visits and one admission, were diagnosed from 2000 to 2013. The data for controls, age matched women who were not diagnosed with PID from 2000 to 2013, were also obtained.

Results: A total of 47,333 PID cases and 189,332 for control group were included in the study. The ectopic pregnancy incidence rate (per 10000 person months) was 1.912 and 0.595 in the PID and control group, respectively; the rate ratio was 3.211 (confidence interval, CI = 2.931-3.519). There were significantly different in gynecologic cancers and urinary tract cancers between the PID and control group; the rate ratios (95% C.I.) were 1.903 (1.672-2.166) and 1.566 (1.211-2.025), respectively.

Conclusion: Our study found that PID was associated with increased risks of gynecologic and urinary tract cancer but not colorectal or breast cancer. The information may lead to a strategy for cancer prevention and a reasonable healthcare usage through understanding PID epidemiology and controlling the inflammatory responses.

Effects of dihydromyricetin on ARPE-19 cell migration through regulating matrix metalloproteinase-2 expression

Dihydromyricetin (DHM), a flavanonol compound in Ampelopsis grossedentata, possesses several biological activities. However, the molecular mechanism underlying the effects of DHM on human proliferative vitreoretinopathy (PVR) remains unclear. We explored the effects of DHM on cell migration and the metastasis-promoting proteins in human retinal pigment epithelial (RPE) cells (ARPE-19 cells). Our results revealed that DHM attenuated ARPE-19 cell invasion and migration by reducing matrix metalloproteinase-2 (MMP-2) expression. Furthermore, a Western blot analysis revealed that DHM significantly reduced levels of phosphorylated c-Jun N-terminal kinase 1/2, but not those of extracellular signal-regulated kinase 1/2 and p38. In conclusion, our findings shown that DHM inhibits human RPE cell migration through the inhibition of MMP-2 expression; therefore, DHM may have potential therapeutic value in treating PVR as adjuvant therapy.

Bisphenol A exhibits cytotoxic or genotoxic potential via oxidative stress-associated mitochondrial apoptotic pathway in murine macrophages

Bisphenol A (BPA) is primarily used in production of polycarbonate plastics and epoxy resins including plastic containers. BPA is an endocrine disruptor and supposes to induce asthma and cancer. However, so far only a few evidences have shown the BPA-induced toxic effect and its related mechanism in macrophages. BPA demonstrated cytotoxic effect on RAW264.7 macrophages in a concentration and time-dependent manner. BPA induces necrosis, apoptosis, and genotoxicity in a concentration-dependent manner. Phosphorylation of cytochrome C (cyto C) and p53 was due to mitochondrial disruption via BCL2 and BCL-XL downregulation and BAX, BID, and BAD upregulation. Both caspase-dependent, including caspase-9, caspase-3, and PARP-1 cleavage, and caspase-independent, such as nuclear translocation of AIF, pathways were activated by BPA. Furthermore, generation of reactive oxygen species (ROS) and reduction of antioxidative enzyme activities were induced by BPA. Parallel trends were observed in the effect of BPA on cytotoxicity, apoptosis, genotoxicity, p53 phosphorylation, BCL2 family expression exchange, caspase-dependent and independent apoptotic pathways, and ROS generation in RAW264.7 macrophages. Finally, BPA-exhibited cytotoxicity, apoptosis, and genotoxicity could be inhibited by N-acetylcysteine. These results indicated that the toxic effect of BPA was functioning via oxidative stress-associated mitochondrial apoptotic pathway in macrophages.