Inhibition of cysteine protease disturbs the topological relationship between bone resorption and formation in vitro.

INTRODUCTION: Osteoporosis is a global health issue. Bisphosphonates that are commonly used to treat osteoporosis suppress both bone resorption and subsequent bone formation. Inhibition of cathepsin K, a cysteine proteinase secreted by osteoclasts, was reported to suppress bone resorption while preserving or increasing bone formation. Analyses of the different effects of antiresorptive reagents such as bisphosphonates and cysteine proteinase inhibitors will contribute to the understanding of the mechanisms underlying bone remodeling. MATERIALS AND METHODS: Our team has developed an in vitro system in which bone remodeling can be temporally observed at the cellular level by 2-photon microscopy. We used this system in the present study to examine the effects of the cysteine proteinase inhibitor E-64 and those of zoledronic acid on bone remodeling. RESULTS: In the control group, the amount of the reduction and the increase in the matrix were correlated in each region of interest, indicating the topological and quantitative coordination of bone resorption and formation. Parameters for osteoblasts, osteoclasts, and matrix resorption/formation were also correlated. E-64 disrupted the correlation between resorption and formation by potentially inhibiting the emergence of spherical osteoblasts, which are speculated to be reversal cells in the resorption sites. CONCLUSION: These new findings help clarify coupling mechanisms and will contribute to the development of new drugs for osteoporosis.

Neuroprotection and axon regeneration by novel low-molecular-weight compounds through the modification of DOCK3 conformation.

Dedicator of cytokinesis 3 (DOCK3) is an atypical member of the guanine nucleotide exchange factors (GEFs) and plays important roles in neurite outgrowth. DOCK3 forms a complex with Engulfment and cell motility protein 1 (Elmo1) and effectively activates Rac1 and actin dynamics. In this study, we screened 462,169 low-molecular-weight compounds and identified the hit compounds that stimulate the interaction between DOCK3 and Elmo1, and neurite outgrowth in vitro. Some of the derivatives from the hit compound stimulated neuroprotection and axon regeneration in a mouse model of optic nerve injury. Our findings suggest that the low-molecular-weight DOCK3 activators could be a potential therapeutic candidate for treating axonal injury and neurodegenerative diseases including glaucoma.

Longitudinal Evaluation Using Preclinical 7T-Magnetic Resonance Imaging/Spectroscopy on Prenatally Dose-Dependent Alcohol-Exposed Rats.

Prenatal alcohol exposure causes many detrimental alcohol-induced defects in children, collectively known as fetal alcohol spectrum disorders (FASD). This study aimed to evaluate a rat model of FASD, in which alcohol was administered at progressively increasing doses during late pregnancy, using preclinical magnetic resonance (MR) imaging (MRI) and MR spectroscopy (MRS). Wistar rats were orally administered 2.5 mL/day of ethanol (25% concentration) on gestational day 15, and postnatal fetuses were used as FASD models. Four groups were used: a control group (non-treatment group) and three groups of FASD model rats that received one, two, or four doses of ethanol, respectively, during the embryonic period. Body weight was measured every other week until eight weeks of age. MRI and MRS were performed at 4 and 8 weeks of age. The volume of each brain region was measured using acquired T2-weighted images. At 4 weeks of age, body weight and cortex volume were significantly lower in the three FASD model groups (2.5 × 1: 304 ± 6 mm3, p < 0.05; 2.5 × 2: 302 ± 8 mm3, p < 0.01; 2.5 × 4: 305 ± 6 mm3, p < 0.05) than they were in the non-treatment group (non-treatment: 313 ± 6 mm3). The FASD model group that received four doses of alcohol (2.5 × 4: 0.72 ± 0.09, p < 0.05) had lower Taurine/Cr values than the non-treatment group did (non-treatment: 0.91 ± 0.15), an effect that continued at 8 weeks of age (non-treatment: 0.63 ± 0.09; 2.5 × 4: 0.52 ± 0.09, p < 0.05). This study is the first to assess brain metabolites and volume over time using MRI and MRS. Decreases in brain volume and taurine levels were observed at 4 and 8 weeks of age, suggesting that the effects of alcohol persisted beyond adulthood.

Spatiotemporal Analysis of Osteoblast Morphology and Wnt Signal-Induced Osteoblast Reactivation during Bone Modeling in Vitro.

Bone nodule formation by differentiating osteoblasts is considered an in vitro model that mimics bone modeling. However, the details of osteoblast behavior and matrix production during bone nodule formation are poorly understood. Here, we present a spatiotemporal analysis system for evaluating osteoblast morphology and matrix production during bone modeling in vitro via two-photon microscopy. Using this system, a change in osteoblast morphology from cuboidal to flat was observed during the formation of mineralized nodules, and this change was quantified. Areas with high bone formation were densely populated with cuboidal osteoblasts, which were characterized by blebs, protruding structures on their cell membranes. Cuboidal osteoblasts with blebs were highly mobile, and osteoblast blebs exhibited a polar distribution. Furthermore, mimicking romosozumab treatment, when differentiated flattened osteoblasts were stimulated with BIO, a GSK3ß inhibitor, they were reactivated to acquire a cuboidal morphology with blebs on their membranes and produced more matrix than nonstimulated cells. Our analysis system is a powerful tool for evaluating the cell morphology and function of osteoblasts during bone modeling. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Effect of baricitinib in patients with coronavirus disease 2019 and respiratory failure: A propensity score-matched retrospective cohort study.

In this retrospective cohort study, we evaluated the efficacy of baricitinib in the treatment of coronavirus disease 2019 (COVID-19). Among 404 adult patients with COVID-19 who were admitted to our hospital between October 23, 2020, and July 31, 2021, 229 patients with respiratory failure were included. Among these, 41 patients in the baricitinib group and 41 patients in the control group were selected by propensity score matching to adjust for background factors. We compared the survival rates of the two groups at 30 and 60 days after admission. The 30-day survival rate was significantly higher in the baricitinib group than in the control group. However, there was no significant difference in 60-day survival in the two groups. Baricitinib may improve the early prognosis of patients with respiratory failure associated with COVID-19. However, efforts should be made to improve the long-term prognosis.

Successful Treatment of Acute Chest Syndrome with Manual Exchange Transfusion in a Patient with Sickle Beta+-thalassemia.

Acute chest syndrome (ACS), characterized by fever, respiratory symptoms, and new pulmonary infiltration, is a serious complication of sickle cell disease (SCD). Regardless of the etiology, the conventional treatment options for ACS include empirical antibiotic therapy, the administration of analgesics, and red cell transfusion. The indications and methods of red cell transfusion are critical. We herein report the case of a 26-year-old African-American man with SCD who developed ACS and who was successfully treated with manual exchange transfusion. Despite increasing globalization, SCD remains extremely rare in Japan. Manual exchange transfusion can be performed easily anywhere and should be considered for treating SCD patients presenting with ACS.

Different developmental histories of beta-cells generate functional and proliferative heterogeneity during islet growth.

The proliferative and functional heterogeneity among seemingly uniform cells is a universal phenomenon. Identifying the underlying factors requires single-cell analysis of function and proliferation. Here we show that the pancreatic beta-cells in zebrafish exhibit different growth-promoting and functional properties, which in part reflect differences in the time elapsed since birth of the cells. Calcium imaging shows that the beta-cells in the embryonic islet become functional during early zebrafish development. At later stages, younger beta-cells join the islet following differentiation from post-embryonic progenitors. Notably, the older and younger beta-cells occupy different regions within the islet, which generates topological asymmetries in glucose responsiveness and proliferation. Specifically, the older beta-cells exhibit robust glucose responsiveness, whereas younger beta-cells are more proliferative but less functional. As the islet approaches its mature state, heterogeneity diminishes and beta-cells synchronize function and proliferation. Our work illustrates a dynamic model of heterogeneity based on evolving proliferative and functional beta-cell states.Βeta-cells have recently been shown to be heterogeneous with regard to morphology and function. Here, the authors show that ß-cells in zebrafish switch from proliferative to functional states with increasing time since ß-cell birth, leading to functional and proliferative heterogeneity.

Whole organism high content screening identifies stimulators of pancreatic beta-cell proliferation.

Inducing beta-cell mass expansion in diabetic patients with the aim to restore glucose homeostasis is a promising therapeutic strategy. Although several in vitro studies have been carried out to identify modulators of beta-cell mass expansion, restoring endogenous beta-cell mass in vivo has yet to be achieved. To identify potential stimulators of beta-cell replication in vivo, we established transgenic zebrafish lines that monitor and allow the quantification of cell proliferation by using the fluorescent ubiquitylation-based cell cycle indicator (FUCCI) technology. Using these new reagents, we performed an unbiased chemical screen, and identified 20 small molecules that markedly increased beta-cell proliferation in vivo. Importantly, these structurally distinct molecules, which include clinically-approved drugs, modulate three specific signaling pathways: serotonin, retinoic acid and glucocorticoids, showing the high sensitivity and robustness of our screen. Notably, two drug classes, retinoic acid and glucocorticoids, also promoted beta-cell regeneration after beta-cell ablation. Thus, this study establishes a proof of principle for a high-throughput small molecule-screen for beta-cell proliferation in vivo, and identified compounds that stimulate beta-cell proliferation and regeneration.

Development of surface-engineered yeast cells displaying phytochelatin synthase and their application to cadmium biosensors by the combined use of pyrene-excimer fluorescence.

The development of simple, portable, inexpensive, and rapid analytical methods for detecting and monitoring toxic heavy metals are important for the safety and security of humans and their environment. Herein, we describe the application of phytochelatin (PC) synthase, which plays a critical role in heavy metal responses in higher plants and green algae, in a novel fluorescent sensing platform for cadmium (Cd). We first created surface-engineered yeast cells on which the PC synthase from Arabidopsis (AtPCS1) was displayed with retention of enzymatic activity. The general concept for the sensor is based on the Cd level-dependent synthesis of PC2 from glutathiones by AtPCS1-displaying yeast cells, followed by simple discriminative detection of PC2 via sensing of excimer fluorescence of thiol-labeling pyrene probes. The intensity of excimer fluorescence increased in the presence of Cd up to 1.0 µM in an approximately dose-dependent manner. This novel biosensor achieved a detection limit of as low as 0.2 µM (22.5 µg/L) for Cd. Although its use may be limited by the fact that Cu and Pb can induce cross-reaction, the proposed simple biosensor holds promise as a method useful for cost-effective screening of Cd contamination in environmental and food samples. The AtPCS1-displaying yeast cells also might be attractive tools for dissection of the catalytic mechanisms of PCS.

Reconstructing a 3-dimensional image of the results of antinuclear antibody testing by indirect immunofluorescence.

Indirect immunofluorescence anti-nuclear antibody testing (IIF-ANAT) is an essential screening tool in the diagnosis of various autoimmune disorders. ANA titer quantification and interpretation of immunofluorescence patterns are determined subjectively, which is problematic. First, we determined the examination conditions under which IIF-ANAT fluorescence intensities are quantified. Next, IIF-ANAT was performed using homogeneous, discrete speckled, and mixed serum samples. Images were obtained using Bio Zero BZ-8000, and 3-dimensional images were reconstructed using the BZ analyzer software. In the 2-dimensional analysis, homogeneous ANAs hid the discrete speckled pattern, resulting in a diagnosis of homogeneous immunofluorescence. However, 3-dimensional analysis of the same sample showed discrete speckled-type ANA in the homogeneous background. This study strengthened the current IIF-ANAT method by providing a new approach to quantify the fluorescence intensity and enhance the resolution of IIF-ANAT fluorescence patterns. Reconstructed 3-dimensional imaging of IIF-ANAT can be a powerful tool for routine laboratory examination.

Comparison of antithrombotic and haemorrhagic effects of edoxaban, an oral direct factor Xa inhibitor, with warfarin and enoxaparin in rats.

INTRODUCTION: Factor Xa (FXa) is a key serine protease in the coagulation cascade and a promising target for a new antithrombotic agent. Edoxaban is an oral, selective and direct FXa inhibitor. The objective of this study was to compare the antithrombotic and haemorrhagic effects of edoxaban with clinically available anticoagulants, warfarin and enoxaparin, in rat models of thrombosis and haemorrhage. METHODS: Rats were treated with single oral administration of edoxaban, repeated oral dosing of warfarin for 4 days and single subcutaneous administration of enoxaparin before thrombosis or haemorrhage induction. Thrombosis was induced by the insertion of a platinum wire into the inferior vena cava for 60 min. Tail template bleeding time was measured after making an incision on the tail. RESULTS: Edoxaban at 0.3, 1 and 3mg/kg exerted dose-dependent and significant inhibition of venous thrombus formation. The 50% thrombus inhibition dose (ED(50)) was 1.9 mg/kg. At supra-therapeutic doses (10 and 20mg/kg), edoxaban significantly but moderately (less than 2-fold) prolonged bleeding time. Warfarin and enoxaparin also dose-dependently inhibited venous thrombosis and prolonged bleeding time. The ED(50) values of warfarin and enoxaparin were 0.12 mg/kg and 500 IU/kg, and the 2-fold bleeding time prolongation doses (BT2) were 0.16 mg/kg and 1700 IU/kg, respectively. The safety margin (ratio of BT2 to ED(50)) of edoxaban (>10.5) was greater than those of warfarin (1.3) and enoxaparin (3.4). CONCLUSIONS: Edoxaban inhibited venous thrombosis comparably to warfarin and enoxaparin, and the attendant bleeding risk of edoxaban was lower than that of warfarin and enoxaparin in rats.

Melagatran, a direct thrombin inhibitor, but not edoxaban, a direct factor Xa inhibitor, nor heparin aggravates tissue factor-induced hypercoagulation in rats.

There are concerns that some anticoagulants can paradoxically increase thrombogenesis under certain circumstances. We have shown that low-dose administration of a direct thrombin inhibitor, melagatran, significantly worsens the coagulation status induced by tissue factor injection in rats. We compared the effect of inhibition of thrombin and factor Xa for their potential to aggravate tissue factor-induced coagulation in rats. Hypercoagulation was induced by the injection of 2.8 U/kg tissue factor after administration of melagatran, heparin and edoxaban in rats. Blood samples were collected 10min after tissue factor injection. Platelet numbers, thrombin-antithrombin complex concentrations and plasma compound concentrations were measured. Though a high dose of melagatran (1mg/kg, i.v.) suppressed platelet consumption and thrombin-antithrombin complex generation induced by tissue factor, lower doses of melagatran (0.01, 0.03 and 0.1mg/kg, i.v.) significantly enhanced platelet consumption and thrombin-antithrombin complex generation. In addition, although melagatran (3mg/kg, i.v.) improved coagulation status when tissue factor was given 5min after the drug administration, and 2, 4 and 8h after melagatran dosing, it deteriorated coagulation status. These results were well explained by the plasma melagatran concentration. Low concentrations (15-234ng/ml) of melagatran aggravated coagulation status whereas it was mended by high concentrations (1190ng/ml or more) of the compound. In contrast, edoxaban and heparin did not show any exacerbation under these examination conditions. These results show that subtherapeutic concentrations of melagatran are associated with coagulation pathway activation, whereas factor Xa inhibition with edoxaban has a low risk of paradoxical hypercoagulation.

[Two cases of Nocardia farcinica brain abscess].

Brain abscess caused by Nocardia is a relatively rare disease, but its prognosis is poor, with the fatality being 3 times as high as that of other types of brain abscess. Nocardiosis caused by N. farcinica has higher fatality rates than nocardiosis caused by the other bacteria of the genus Nocardia. We report two cases of brain abscess caused by N. farcinica. Case 1: 72-year-old immunocompetent man. In this case, the disease healed in response to burr hole drainage and treatment with antibiotics (pazufloxacin, ciprofloxacin). Case 2: A 78-year-old woman with a history of liver cirrhosis. This patient received burr hole drainage and treatment with multiple antibiotics (sulfamethoxazole/trimethoprim, pazufloxacin, meropenem, amikacin, minocycline, and linezolid). Her brain abscess tended to alleviate but her general condition worsened, leading to death. N. farcinica is often resistant to multiple antibiotics. For treatment of brain abscess caused by this bacterium, it is essential to perform pathogen identification and a drug sensitivity test immediately, and to select optimum antibiotics, taking into account the general condition of individual patients.

Comparison of antithrombotic efficacy between edoxaban, a direct factor Xa inhibitor, and fondaparinux, an indirect factor Xa inhibitor under low and high shear rates.

Edoxaban is an oral, direct factor Xa (FXa) inhibitor under late-phase clinical development. This study compared the antithrombotic efficacy of edoxaban with that of an indirect FXa inhibitor, fondaparinux, in in vivo venous and arterial thrombosis models and in ex vivo perfusion chamber thrombosis model under low and high shear rates in rats. Venous and arterial thrombi were induced by platinum wire insertion into the inferior vena cava and by application of FeCl3 to the carotid artery, respectively. The perfusion chamber thrombus was formed by blood perfusion into a collagen-coated capillary at 150 s⁻¹ (low shear rate) and 1,600 s⁻¹ (high shear rate). Effective doses of edoxaban that reduced thrombus formation by 50% (ED50) in venous and arterial thrombosis models were 0.076 and 0.093 mg/kg/h, respectively. In contrast, ED50 of fondaparinux in the arterial thrombosis model (>10 mg/kg/h) was markedly higher compared to ED50 in the venous thrombosis model (0.021 mg/kg/h). In the perfusion chamber thrombosis model, the ratio of ED50 under high shear rate (1.13 mg/kg/h) to that under low shear rate (0.63 mg/kg/h) for edoxaban was 1.9, whereas that for fondaparinux was more than 66. While the efficacy of fondaparinux markedly decreased in arterial thrombosis and in a high-shear state, edoxaban exerted consistent antithrombotic effects regardless of flow conditions. These results suggest that shear rate is a key factor in different antithrombotic effects between edoxaban and fondaparinux.

Age, viral copy number, and immunosuppressive therapy affect the duration of norovirus RNA excretion in inpatients diagnosed with norovirus infection.

Norovirus is one of the leading causes of acute gastroenteritis worldwide. Although it is becoming clear that viral excretion in the stool continues even after the clinical symptoms have disappeared, the factors that determine its duration remain unknown. Between 2007 and 2009, all inpatients and medical staff at our hospital who showed symptoms of a new onset of gastroenteritis were asked to submit a sample for norovirus testing by real-time RT-PCR. One of the 273 patients included tested positive for GI norovirus, and a further 89 were positive for GII norovirus. Of these 90 norovirus-positive individuals, 76% excreted norovirus RNA in the stool for more than 7 days. The inpatient group contained more long shedders than the medical staff group (5/32 versus 1/39, P<0.05). The median viral shedding duration was 19.3 and 15.2 days for inpatients and medical staff, respectively. Among hospitalized patients, younger individuals, those with a higher viral copy number, and individuals receiving immunosuppressive therapy tended to require a longer time to eliminate the virus. These patients should therefore be monitored and managed carefully to prevent nosocomial spread of the disease.

Sesamin induces autophagy in colon cancer cells by reducing tyrosine phosphorylation of EphA1 and EphB2.

Receptor tyrosine kinase EphB2 and autophagic machinery are known as tumor suppressors; however, the connection remains to be elucidated. Here, we show the link between EphB2 and autophagy. Sesamin, a major lignan in sesame oil, induced autophagy in the human colon cancer cell lines HT29 and LS180, as shown by electron microscopy, as well as Western blotting and immunofluorescence imaging using an anti-LC3 antibody. Receptor tyrosine kinase array analysis revealed that sesamin treatment increased the levels of unphosphorylated -EphA1 and -EphB2 in HT29 cells. Silencing of EphA1 and EphB2 blocked sesamin-induced autophagy as well as sesamin-induced loss of cell viability. These results show that EphA1 and EphB2 play a critical role in this process. The present study reveals a novel function for EphA1 and EphB2 in the induction of autophagy, suggesting a tumor suppressor role for these proteins in colorectal cancer.

(-)-Epigallocatechin-3-gallate induces apoptosis in gastric cancer cell lines by down-regulating survivin expression.

The polyphenol (-)-epigallocatechin-3-gallate (EGCG) is a green tea constituent, which has been shown to inhibit cancer cell growth in vitro, in vivo and in epidemiological studies. In this study, we investigated its effects in gastric cancer cell lines. Five gastric cancer cell lines, the MKN-1, MKN-28, MKN-45, NUGC-3 and TMK-1, were found to be sensitive to EGCG treatment. Of all the cell lines tested, NUGC-3 was the most sensitive. EGCG treatment of NUGC-3 cells induced apoptosis, which was confirmed by sub-G1 analysis, caspase-Glo assay and Western blotting against cleaved PARP and cleaved caspase-3. EGCG treatment lowered survivin and increased Bax and TRAIL expression. Furthermore, EGCG induced p73 activation in NUGC-3 cells. Small interfering RNA against p73 diminished EGCG effects on survivin expression and cell viability. These results show that EGCG induces cell death in gastric cancer cells by apoptosis via inhibition of survivin expression downstream of p73. This study provides a novel mechanism whereby EGCG potentially inhibits cancer cell growth, concluding that EGCG may be a potential candidate in anti-survivin cancer therapy.

Comparison of four direct homogeneous methods for the measurement of low-density lipoprotein cholesterol.

BACKGROUND: The primary lipoprotein risk factor is low-density lipoprotein cholesterol (LDL-C), and medication is targeted at lowering LDL-C values. To clarify the usefulness of direct homogeneous assays for LDL-C measurement, we compared the values obtained by various reagents to those obtained by the Friedewald equation and analyzed different reactivity to IDL/VLDL and LDL. METHODS: Serum samples were collected from 55 patients with hypercholesterolemia. The LDL-C concentrations were determined by four direct homogeneous assays using reagent A (Kyowa Medex), B (Sekisui Medical), C (Denka Seiken), and D (Sysmex), which are commercially available. RESULTS: Significant correlation was observed in LDL-C values obtained by the homogeneous assays and the Friedewald equation. However, there were two discrepancies in reagents B and C, respectively. These assays showed 40% and 55% lower LDL-C values than those calculated by the Friedewald equation, respectively. Reactivity to the IDL fraction in reagents B and C was lower than in reagents A and D. CONCLUSIONS: Direct homogeneous assays for LDL-C are suitable for routine laboratory examination. However, it was shown that attention should be given to the different reactivity to IDL and LDL among reagents in some clinical samples.

Evaluation of spa typing for the classification of clinical methicillin-resistant Staphylococcus aureus isolates.

We evaluated the utility of typing the spa gene, which encodes protein A of Staphylococcus aureus, for analyzing methicillin-resistant S. aureus (MRSA) isolates from patients with health care-associated infections by comparing the results of spa typing with those of pulsed-field gel electrophoresis (PFGE) and multiple-locus variable-number tandem repeat analysis (MLVA). We analyzed 78 clinical MRSA isolates collected at our hospital over a period of 2 months. The clinical isolates were found to have 12 different spa types, with approximately 82% (64/78) of them being typed as t002. The same clinical MRSA isolates were classified into 15 and 19 types upon MLVA and PFGE analysis, respectively, and 19 and 28 types when spa typing was used in combination with MLVA and PFGE, respectively. The discriminatory ability of spa typing alone is low, and thus indicating that this technique is insufficient for performing the initial genotyping of MRSA in short-term epidemiological studies. Therefore, spa typing should be used in combination with MLVA or PFGE for further typing of MRSA isolates.

Evaluating the utility of N1,N12-diacetylspermine and N1,N8-diacetylspermidine in urine as tumor markers for breast and colorectal cancers.

BACKGROUND: Among natural polyamines, the concentrations of the diacetylated form of spermine and spermidine increase in the urine of patients with cancer. We evaluated the utility of urinary N(1),N(12)-diacetylspermine (DiAcSpm) and N(1),N(8)-diacetylspermidine (DiAcSpd) as tumor markers for breast and colorectal cancers. METHODS: Urinary DiAcSpm and DiAcSpd concentrations were measured by an enzyme-linked immunosorbent assay. Urine and serum samples were collected from 33 and 28 patients with colorectal and breast cancers, respectively. The sensitivity of urine samples to DiAcSpm and DiAcSpd concentrations was compared with serum concentrations of carcinoembryonic antigen (CEA) and carbohydrate antigen CA 15-3 in breast cancer patients and with serum concentrations of CEA and CA 19-9 in colorectal cancer patients, respectively. RESULTS: In breast cancer patients, the sensitivity of DiAcSpm and DiAcSpd was 46.4% and 14.2%, respectively, which was higher than that of CEA and CA 15-3. In patients with colorectal cancer, the sensitivity of DiAcSpm and DiAcSpd was 69.6% and 36.3%, respectively. CEA was the second sensitive marker and CA 19-9 was the least sensitive marker in these patients. CONCLUSION: DiAcSpm is a highly sensitive tumor marker. DiAcSpm can serve as a powerful tool in settings such as initial screening for cancers in routine health examination.