Hsa-miR-134-5p predicts cardiovascular risk in circulating mononuclear cells and improves angiogenic action of senescent endothelial progenitor cells.

This research explores the role of microRNA in senescence of human endothelial progenitor cells (EPCs) induced by replication. Hsa-miR-134-5p was found up-regulated in senescent EPCs where overexpression improved angiogenic activity. Hsa-miR-134-5p, which targeted transforming growth factor ß-activated kinase 1-binding protein 1 (TAB1) gene, down-regulated TAB1 protein, and inhibited phosphorylation of p38 mitogen-activated protein kinase (p38) in hsa-miR-134-5p-overexpressed senescent EPCs. Treatment with siRNA specific to TAB1 (TAB1si) down-regulated TAB1 protein and subsequently inhibited p38 activation in senescent EPCs. Treatment with TAB1si and p38 inhibitor, respectively, showed angiogenic improvement. In parallel, transforming growth factor Beta 1 (TGF-ß1) was down-regulated in hsa-miR-134-5p-overexpressed senescent EPCs and addition of TGF-ß1 suppressed the angiogenic improvement. Analysis of peripheral blood mononuclear cells (PBMCs) disclosed expression levels of hsa-miR-134-5p altered in adult life, reaching a peak before 65 years, and then falling in advanced age. Calculation of the Framingham risk score showed the score inversely correlates with the hsa-miR-134-5p expression level. In summary, hsa-miR-134-5p is involved in the regulation of senescence-related change of angiogenic activity via TAB1-p38 signalling and via TGF-ß1 reduction. Hsa-miR-134-5p has a potential cellular rejuvenation effect in human senescent EPCs. Detection of human PBMC-derived hsa-miR-134-5p predicts cardiovascular risk.

NT-proBNP point-of-care testing for predicting mortality in end-stage renal disease: A survival analysis.

This study examines the predictive value of elevated N-terminal-pro brain natriuretic peptide (NT-pro BNP) levels for mortality among patients with end-stage renal disease (ESRD). Data from 768 ESRD patients, excluding those with cancer or lost follow-up, were analyzed using Kaplan-Meier curves and Cox proportional hazards models over three years. Results indicated that patients with very high NT-pro BNP levels had shorter average survival times and a significantly higher risk of mortality (hazard ratio 1.43). Advanced age, ICU admission, and comorbidities like cerebrovascular diseases and chronic obstructive pulmonary disease also contributed to increased mortality risks. Thus, elevated NT-pro BNP is an independent risk factor for mortality in ESRD patients.

Serum Albumin was Associated with a Long Term Cardiovascular Mortality among Elderly Patients with Stable Coronary Artery Disease.

Background: Serum albumin (SA), a multifunction protein, contributes to maintaining a variety of physiological functions. Studies have linked SA to atherosclerosis with possible mechanisms including a response to inflammation. The contribution of albumin to cardiovascular (CV) mortality in elderly patients with stable coronary artery disease (CAD) remains unclear. Methods: We investigated 321 elderly patients with stable CAD undergoing coronary angiography between 2003 and 2006. CV mortality data were obtained from the National Registry of Deaths in Taiwan. CV mortality included deaths attributable to ischemic heart disease, congestive heart disease, and stroke. The association between baseline SA and CV mortality was assessed using a Cox model and Fine-Gray model when non-CV mortality was considered a competing event. Results: During a median follow-up of 97 months, 39 (12.1%) participants died from CV disease and 76 (23.7%) died from non-CV diseases. After adjusting for covariates, patients in the SA ≥ 3.75 g/dL group had a lower frequency of CV mortality compared with those in the SA < 3.75 g/dL group [hazard ratio (HR): 0.20; 95% confidence interval (CI): 0.08-0.49; p < 0.001]. Similarly, compared to the participants with non-CV mortality, the SA ≥ 3.75 g/dL group had a lower frequency of CV mortality compared with the SA < 3.75 g/dL group (subdistribution HR: 0.27; 95% CI: 0.11-0.65; p < 0.001) in adjusted competing risk models. Conclusions: A SA level ≥ 3.75 g/dL at admission was associated with decreased long-term CV mortality and may be useful for risk prediction in elderly patients with stable CAD.

Hsa-miR-409-3p regulates endothelial progenitor senescence via PP2A-P38 and is a potential ageing marker in humans.

We explored the roles of hsa-microRNA (miR)-409-3p in senescence and signalling mechanism of human endothelial progenitor cells (EPCs). Hsa-miR-409-3p was found upregulated in senescent EPCs. Overexpression of miRNA mimics in young EPCs inhibited angiogenesis. In senescent EPCs, compared to young EPCs, protein phosphatase 2A (PP2A) was downregulated, with activation of p38/JNK by phosphorylation. Young EPCs treated with siPP2A caused inhibited angiogenesis with activation of p38/JNK, similar to findings in senescent EPCs. Time series analysis showed, in young EPCs treated with hsa-miR-409-3p mimics, PP2A was steadily downregulated for 72 h, while p38/JNK was activated with a peak at 48 hours. The inhibited angiogenesis of young EPCs after miRNA-409-3p mimics treatment was reversed by the p38 inhibitor. The effect of hsa-miR-409-3p on PP2A signalling was attenuated by exogenous VEGF. Analysis of human peripheral blood mononuclear cells (PBMCs) obtained from healthy people revealed hsa-miR-409-3p expression was higher in those older than 65 years, compared to those younger than 30 years, regardless of gender. In summary, hsa-miR-409-3p was upregulated in senescent EPCs and acted as a negative modulator of angiogenesis via targeting protein phosphatase 2 catalytic subunit alpha (PPP2CA) gene and regulating PP2A/p38 signalling. Data from human PBMCs suggested hsa-miR-409-3p a potential biomarker for human ageing.

The association of pericardial fat and peri-aortic fat with severity of nonalcoholic fatty liver disease.

Visceral adipose tissue (VAT) is associated with central obesity, insulin resistance and metabolic syndrome. However, the association of body-site specific adiposity and non-alcoholic fatty liver disease (NAFLD) has not been well characterized. We studies 704 consecutive subjects who underwent annual health survey in Taiwan. All subjects have been divided into three groups including normal (341), mild (227) and moderate and severe (136) NAFLD according to ultrasound finding. Pericardial (PCF) and thoracic peri-aortic adipose tissue (TAT) burden was assessed using a non-contrast 16-slice multi-detector computed tomography (MDCT) dataset with off-line measurement (Aquarius 3DWorkstation, TeraRecon, SanMateo, CA, USA). We explored the relationship between PCF/TAT, NAFLD and cardiometabolic risk profiles. Patients with moderate and mild NAFLD have greater volume of PCF (100.7 ± 26.3vs. 77.1 ± 21.3 vs. 61.7 ± 21.6 ml, P < 0.001) and TAT (11.2 ± 4.1 vs. 7.6 ± 2.6 vs. 5.5 ± 2.6 ml, P < 0.001) when compared to the normal groups. Both PCF and TAT remained independently associated with NAFLD after counting for age, sex, triglyceride, cholesterol and other cardiometabolic risk factors. In addition, both PCF and TAT provided incremental prediction value for NAFLD diagnosis. (AUROC: 0.85 and 0.87, 95%, confidence interval: 0.82-0.89 and 0.84-0.90). Both visceral adipose tissues strongly correlated with the severity of NAFLD. Compared to PCF, TAT is more tightly associated with NAFLD diagnosis in a large Asian population.

Highly Correlated Recurrence Prognosis in Patients with Metastatic Colorectal Cancer by Synergistic Consideration of Circulating Tumor Cells/Microemboli and Tumor Markers CEA/CA19-9.

Circulation tumor cells (CTCs) play an important role in metastasis and highly correlate with cancer progression; thus, CTCs could be considered as a powerful diagnosis tool. Our previous studies showed that the number of CTCs could be utilized for recurrence prediction in colorectal cancer (CRC); however, the odds ratio was still lower than five. To improve prognosis in CRC patients, we analyzed CTC clusters/microemboli, CTC numbers, and carcinoembryonic antigen (CEA)/carbohydrate antigen 19-9 (CA19-9) levels using a self-assembled cell array (SACA) chip system for recurrence prediction. In CRC patients, the presence of CTC clusters/microemboli may have higher correlation in metastasis when compared to the high number of CTCs. Additionally, when both the number of CTCs and serum CEA levels are high, very high odds ratios of 24.4 and 17.1 are observed in patients at all stages and stage III of CRC, respectively. The high number of CTCs and CTC clusters/microemboli simultaneously suggests the high chance of relapse (odds ratio 8.4). Overall, the characteristic of CTC clusters/microemboli, CEA level, and CTC number have a clinical potential to enhance CRC prognosis.

Patient satisfaction with dabigatrean and warfarin for stroke prevention in atrial fibrillation: Taiwan PASSION study.

BACKGROUND: Patient satisfaction with oral anticoagulant (OAC) therapy is an important metric of care quality and has been associated with higher medication persistence. Among OACs, dabigatran has been shown to be non-inferior to vitamin K antagonists (VKAs) with increased ease of use for stroke prevention in patients with atrial fibrillation (AF). In this study, we sought to evaluate the expectations, convenience, and satisfaction of Taiwanese AF patients on dabigatran and VKA therapies as well as associated clinical outcomes. METHODS: Patients with AF (paroxysmal, persistent, or permanent) receiving OAC medication from outpatient facilities were enrolled in 24 hospitals across Taiwan. Cohort A consisted of 139 patients switched from VKA to dabigatran, while cohort B was comprised of 1113 patients on newly initiated OAC therapy (VKA, 54). The Perception of Anticoagulant Treatment Questionnaire was distributed, and responses on a five-point Likert scale were aggregated and analyzed across demographic groups. RESULTS: In cohort A, convenience and satisfaction scores continued to increase at follow-up and significantly higher, compared to baseline, but both treatments scored similarly in cohort B. In cohort B, the two highest expectation scores were that the OAC would be "easy to take" and could be "taken independently." On the other hand, the patients were relatively less concerned about the side effects and cost of therapy before taking the OAC. For dabigatran-receiving patients, there were 1.1 stroke-related events per 100 patient-years and 3.0 bleeding-related events per 100 patient-years. CONCLUSION: In Taiwanese patients with AF and initially treated with VKA, switched to dabigatran resulted in higher convenience and treatment satisfaction. For those patients on newly initiated OAC treatment, VKA and dabigatran convenience and satisfaction scores were similar.

The medications and health care utilization of patients newly diagnosed with type 2 diabetes mellitus: A nationwide population-based cohort study.

BACKGROUND/PURPOSE: The prevalence of young-onset diabetes (YOD) is increasing in Asia, but little is known about the metabolic control, associated complications, or medical behavior in this population. Our aim was to assess the prevalence of young-onset and late-onset type 2 diabetes mellitus (T2DM) and their associated risk factors and medical behaviors in Taiwan. METHODS: Data were collected from the National Health Insurance Research Database of Taiwan on 11,244 patients from 2008 to 2013. We classified patients with young-onset diabetes if they were diagnosed before 40 years of age and late-onset diabetes (LOD) if diagnosed at 40 years of age or older. We analyzed the prevalence, medication, and medical behaviors between these groups. RESULTS: We enrolled 2556 newly diagnosed T2DM patients in 2012. Demographics and comorbidities were recorded from YOD (n = 311) and LOD (n = 2245) patients. Most newly diagnosed patients started with monotherapy and almost half of them with sulfonylurea. The prevalence of YOD in Taiwan is up to 12%. In terms of treatment, 42% of T2DM patients are treated in clinics, 58% in hospital, and 25.2% by an endocrinologist. CONCLUSION: Our study highlights the rising trend of YOD in Taiwan. National endeavors are urgently needed for early diagnosis, effective management, and primary prevention of diabetes.

Sulfonated Polyaniline as Zwitterionic and Conductive Interfaces for Anti-Biofouling on Open Electrode Surfaces in Electrodynamic Systems.

Electrodynamic systems for bioanalytical applications constantly suffer from biofouling due to electrical field-induced nonspecific bioadsorption on electrode surfaces. To minimize this issue, surface modification using anti-biofouling and conductive materials is necessary to not only protect the electrode surface from nonspecific bioadsorption but also maintain desired electrodynamic properties for electrode operation. In this study, we designed and prepared a conductive, zwitterionic, and self-doped sulfonated polyaniline (SPANI) coating on Au electrode surfaces for anti-biofouling applications. The zwitterionic coating was fabricated by electrochemical polymerization of aniline on the Au electrode surface functionalized with cysteamine (HS-CH2CH2-NH2) and then a post-polymerization treatment with fuming sulfuric acid. We found that the SPANI-coated electrodes exhibited an excellent anti-biofouling ability in dielectrophoresis (DEP) capturing-and-releasing processes, with a very low average residual mass rate of 1.44% for the SPANI-5s electrode, whereas electrodes modified with poly(ethylene glycol) (PEG) gave an average residual mass rate of 14.30%. Even under continuous operation for more than 1 h, the SPANI-5s electrode still showed stable anti-biofouling ability for an 11-cycle E. coli capturing-and-releasing DEP process, with the residual mass rate for all 11 cycles being kept at or below 2.18% to give an average residual mass rate of 1.62% with a standard deviation of 0.40%. This study demonstrates that electrodynamic systems with zwitterionic SPANI coated on open electrode surfaces can excellently function with decent conductance and anti-biofouling performance.

High-Throughput White Blood Cell (Leukocyte) Enrichment from Whole Blood Using Hydrodynamic and Inertial Forces.

A microfluidic chip, which can separate and enrich leukocytes from whole blood, is proposed. The chip has 10 switchback curve channels, which are connected by straight channels. The straight channels are designed to permit the inertial migration effect and to concentrate the blood cells, while the curve channels allow the Dean flow to further classify the blood cells based on the cell sizes. Hydrodynamic suction is also utilized to remove smaller blood cells (e.g., red blood cell (RBC)) in the curve channels for higher separation purity. By employing the inertial migration, Dean flow force, and hydrodynamic suction in a continuous flow system, our chip successfully separates large white blood cells (WBCs) from the whole blood with the processing rates as high as 1 × 108 cells/sec at a high recovery rate at 93.2% and very few RBCs (~0.1%).

Effects of Clopidogrel and Proton Pump Inhibitors on Cardiovascular Events in Patients with Type 2 Diabetes Mellitus after Bare Metal Stent Implantation: A Nationwide Cohort Study.

BACKGROUND: To investigate whether there is an increased risk of cardiovascular (CV) events in patients with diabetes associated with adding proton pump inhibitors (PPIs) to clopidogrel (CLO) therapy after bare-metal stent (BMS) deployment. METHODS: We used the National Health Insurance Research Database to conduct this retrospective cohort study. We enrolled 6,757 patients with diabetes who underwent BMS deployment and received CLO with/without PPIs for 90 days (6,243 in the CLO subgroup and 514 in the CLO plus PPI subgroup). The endpoints were acute coronary syndrome and re-admission for revascularization (PCI or coronary artery bypass graft surgery) after 3, 6, and 12 months. RESULTS: The patients who received CLO with PPIs had no significant increase in adverse CV events compared to those without PPIs within 1 year after BMS deployment [3-month hazard ratio (HR) = 0.87, 95% confidence interval (CI), 0.65-1.15; 6 months, HR = 0.95, 95% CI, 0.78-1.15; 1 year, HR = 0.60, 95% CI, 0.81-1.12]. CONCLUSIONS: In patients with diabetes undergoing BMS deployment, there was no evidence of an increased risk of CV events among concomitant users of CLO and PPIs. Our results indicate that the use of PPIs may not modify the protective effect of CLO after BMS implantation.

Ultra-sensitive electrochemical detection of bacteremia enabled by redox-active gold nanoparticles (raGNPs) in a nano-sieving microfluidic system (NS-MFS).

Early diagnosis of bacterial infections is crucial to improving survival rates by enabling treatment with appropriate antibiotics within the first few hours of infection. This paper presents a highly sensitive amperometric biosensor for the detection of several pathogenic bacterial cells in blood plasma around 30 min. The proposed device is based on an electropolymerized self-assembled layer on gold nanoparticles operated in a portable nano-sieving microfluidic system (NS-MFS). The redox-active gold nanoparticles (raGNPs) enhanced the electrical conductivity and provided a greater number of electrochemically active molecules for sensing, while improving resistance to the fouling of sensors by oxidation products in blood plasma. The detection limit of the device has been shown to reach 10 CFU/mL for Pseudomonas aeruginosa and Staphylococcus aureus spiked in plasma. The dynamic range of the sensing system falls between 10 and 105 CFU/mL in a buffer solution by cyclic voltammetry (CV) measurements. The results demonstrated that the raGNPs/NS-MFS can successful detect P. aeruginosa and S. aureus in human plasma, and is very useful for the diagnosis of bacteremia from clinical samples.

Optimized induction of mitochondrial apoptosis for chemotherapy-free treatment of BCR-ABL+acute lymphoblastic leukemia.

BCR-ABL+acute lymphoblastic leukemia (ALL) in adults has a poor prognosis with allogeneic stem cell transplantation (SCT) considered the best curative option for suitable patients. We here characterize the curative potential of BH3-mimetics differentially targeting mitochondrial BCL2-family members using a combination therapy approach with dexamethasone and tyrosine kinase inhibitors targeting BCR-ABL. In BCR-ABL + ALL BH3-mimetics act by redistribution of mitochondrial activator BIM, which is strongly required for cytotoxicity of the BCL2-specific BH3-mimetic ABT-199, tyrosine kinase inhibitors (TKIs) and dexamethasone. BIM expression is enhanced by dexamethasone and TKIs and both synergize with ABT-199 in BCR-ABL + ALL. Triple combinations with ABT-199, dexamethasone and TKIs efficiently attenuate leukemia progression both in tissue culture and in primary cell xenotransplantation models. Notably, the dasatinib-containing combination led to treatment- and leukemia-free long-term survival in a BCR-ABL + mouse model. Finally, response to BH3-mimetics can be predicted for individual patients in a clinically relevant setting. These data demonstrate curative targeted and chemotherapy-free pharmacotherapy for BCR-ABL + ALL in a preclinical model. Clinical evaluation, in particular for patients not suitable for allogeneic SCT, is warranted.

miR-125b regulates chemotaxis and survival of bone marrow derived granulocytes in vitro and in vivo.

The evolutionary conserved miR-125b is highly expressed in hematopoietic stem cells (HSC) enhancing self-renewal and survival. Accordingly, over-expression of miR-125b in HSC may induce myeloproliferative neoplasms and leukemia with long latency. During hematopoietic cell maturation miR-125b expression decreases, and the function of miR-125b in mature granulocytes is not yet known. We here use transplantation of miR-125b over-expressing HSC into syngeneic hosts to generate and analyse miR-125b over-expressing granulocytes. Under steady state conditions, miR-125b over-expression inhibits granulocytic chemotaxis and LPS- but not PMA- and TNFα- induced cell death. Inflammatory signals modulate the effects of miR-125b over-expression as demonstrated in a sterile peritonitis and a polymicrobial sepsis model. In particular, survival of mice with miR-125b over-expressing granulocytes is significantly reduced as compared to controls in the polymicrobial sepsis model. These data demonstrate inflammation dependent effects of miR-125b in granulocytes and may point to therapeutic intervention strategies in the future.

Surface enhanced Raman scattering (SERS) based biomicrofluidics systems for trace protein analysis.

In recent years, Surface Enhanced Raman Scattering (SERS) has been widely applied to many different areas, including chemical analysis, biomolecule detection, bioagent diagnostics, DNA sequence, and environmental monitor, due to its capabilities of unlabeled fingerprint identification, high sensitivity, and rapid detection. In biomicrofluidic systems, it is also very powerful to integrate SERS based devices with specified micro-fluid flow fields to further focusing/enhancing/multiplexing SERS signals through molecule registration, concentration/accumulation, and allocation. In this review, after a brief introduction of the mechanism of SERS detection on proteins, we will first focus on the effectiveness of different nanostructures for SERS enhancement and light-to-heat conversion in trace protein analysis. Various protein molecule accumulation schemes by either (bio-)chemical or physical ways, such as immuno, electrochemical, Tip-enhanced Raman spectroscopy, and magnetic, will then be reviewed for further SERS signal amplification. The analytical and repeatability/stability issues of SERS detection on proteins will also be brought up for possible solutions. Then, the comparison about various ways employing microfluidic systems to register, concentrate, and enhance the signals of SERS and reduce the background noise by active or passive means to manipulate SERS nanostructures and protein molecules will be elaborated. Finally, we will carry on the discussion on the challenges and opportunities by introducing SERS into biomicrofluidic systems and their potential solutions.

Real-World Experience with Idarucizumab to Reverse Anticoagulant Effect in Dabigatran-Treated Patients: Report of 11 Cases from Taiwan.

BACKGROUND: This study aims to observe the effectiveness and safety of idarucizumab in dabigatran-treated patients with severe bleeding or requiring surgery in Taiwan. METHODS AND RESULTS: In Taiwan, 11 dabigatran-treated patients developed severe bleeding, fracture that needed surgery, and acute ischemic stroke requiring thrombolysis. These patients were treated with idarucizumab and obtained adequate hemostasis. Our experiences reconfirmed the efficacy and safety of idarucizumab in Asian patients. CONCLUSIONS: Idarucizumab improves safety in dabigatran-treated patients. Continued education about the availability and appropriate use of idarucizumab is necessary in Asia.

Insulin supplementation attenuates cancer-induced cardiomyopathy and slows tumor disease progression.

Advanced cancer induces fundamental changes in metabolism and promotes cardiac atrophy and heart failure. We discovered systemic insulin deficiency in cachectic cancer patients. Similarly, mice with advanced B16F10 melanoma (B16F10-TM) or colon 26 carcinoma (C26-TM) displayed decreased systemic insulin associated with marked cardiac atrophy, metabolic impairment, and function. B16F10 and C26 tumors decrease systemic insulin via high glucose consumption, lowering pancreatic insulin production and producing insulin-degrading enzyme. As tumor cells consume glucose in an insulin-independent manner, they shift glucose away from cardiomyocytes. Since cardiomyocytes in both tumor models remained insulin responsive, low-dose insulin supplementation by subcutaneous implantation of insulin-releasing pellets improved cardiac glucose uptake, atrophy, and function, with no adverse side effects. In addition, by redirecting glucose to the heart in addition to other organs, the systemic insulin treatment lowered glucose usage by the tumor and thereby decreased tumor growth and volume. Insulin corrected the cancer-induced reduction in cardiac Akt activation and the subsequent overactivation of the proteasome and autophagy. Thus, cancer-induced systemic insulin depletion contributes to cardiac wasting and failure and may promote tumor growth. Low-dose insulin supplementation attenuates these processes and may be supportive in cardio-oncologic treatment concepts.

miR-181a Expression in Donor T Cells Modulates Graft-versus-Host Disease after Allogeneic Bone Marrow Transplantation.

Because miR-181a has been described to alter T cell activation, we hypothesized that manipulation of miR-181a expression in donor T cells may alter acute graft-versus-host disease (aGvHD) after allogeneic bone marrow transplantation (BMT). We therefore analyzed the impact of enhanced and reduced miR-181a expression in donor T cells on aGvHD induction by lentiviral gene transfer into primary T cells and using miR-181a/b-1(-/-) T cells, respectively. BMT-recipient mice receiving donor T cells with enhanced miR-181a expression showed no signs of aGvHD and survived for the time of follow-up, whereas T cells lacking miR-181a/b-1 accelerated aGvHD. In line with these data, analysis of donor T cells in blood, secondary lymphoid organs, and target organs of aGvHD after BMT showed significantly reduced numbers of miR-181a-transduced T cells, as compared with controls. In addition, expansion of activated T cells with enhanced miR-181a expression was reduced in vitro and in vivo. We further show that anti-apoptotic BCL-2 protein expression is reduced in murine and human T cells upon overexpression of miR-181a, suggesting that regulation of BCL-2-expression by miR-181a may contribute to altered alloreactivity of T cells in aGvHD. These data indicate that proteins regulated by miR-181a may be therapeutic targets for aGvHD prevention.

Differential Effects of Gut-Homing Molecules CC Chemokine Receptor 9 and Integrin-ß7 during Acute Graft-versus-Host Disease of the Liver.

Homing of allogeneic donor T cells to recipient tissue is imperative for the development of acute graft-versus-host disease (GVHD) after bone marrow transplantation (BMT). In this study we show that alteration of T cell homing due to integrin-ß7 deficiency on T cells or its ligand MAdCAM-1 in BMT recipients contributes to the pathophysiology of experimental GVHD. In contrast, lack of CC chemokine receptor 9 on donor T cells alters tissue homing but does not impact GVHD survival. We further demonstrate that MAdCAM-1 is aberrantly expressed in hepatic murine GVHD as well as in patients with active liver GVHD. However, infiltration of donor T cells in gut but not liver was dependent of MAdCAM-1 expression, indicating, that homing and/or retention of donor T cells rests on divergent molecular pathways depending on the GVHD target tissue.