Combination of a solid phase extraction and a two-dimensional LC-UV method for the analysis of vitamin D3 and its isomers in olive oil.

The current HPLC methods for the quantification of vitamin D3 (VitD3) and its two isomers previtamin D3 (PreVitD3) and trans-vitamin D3 (trans-VitD3) in olive oil preparations present some limitations mainly due to peak overlapping of the oily matrix components with the compounds of interest. The use of two-dimensional liquid chromatography (2D-LC) with different retention mechanism can reach higher resolving power thus allowing the analysis of complex samples. The present paper proposes a new alternative method including a solid phase extraction sample preparation step and a two-dimensional liquid chromatographic analysis using routine instrumentation, fitting the needs of quality assurance and quality control laboratories of pharmaceutical companies. The extraction protocol was demonstrated to provide a clean-up of the sample and a quantitative recovery of the species of interest. The 2D method proved its suitability in the isolation of vitamins from oil components in the first dimension and the separation and quantification of the analytes in the second dimension thanks to the orthogonal selectivities of phenyl and porous graphitic carbon (PGC) stationary phases. The method was validated following ICH guidelines and possesses an adequate sensitivity to quantify the impurity trans-VitD3 in pharmaceuticals considering the limits imposed by regulatory agencies. The applicability of the phenyl x PGC 2D-LC-UV method to quality control of medicinal products based on VitD3 in olive oil was confirmed by the successful quantification of vitamins in olive oil formulations.

Quantification of 10 B vitamins in mouse colon by LC-MS/MS: Application on breast cancer mice treated with doxorubicin.

B vitamins play important roles in various physiological processes, including cell metabolism and DNA synthesis. The intestine is critical for the absorption and utilization of B vitamins, but few analytical methods for detecting intestinal B vitamins are currently available. In this study, we developed a novel liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the simultaneous quantification of 10 B vitamins in mouse colon tissue, including thiamin (B1), riboflavin (B2), nicotinic acid (B3), niacinamide (B3-AM), pantothenic acid (B5), pyridoxine (B6), pyridoxal 5'-phosphate (B6-5P), biotin (B7), folic acid (B9), and cyanocobalamin (B12). The method was thoroughly validated following the U.S. Food and Drug Administration (FDA) guidelines and yielded good results in terms of linearity (r2 > 0.9928), lower limit of quantification (40-600 ng/g), accuracy (88.9-119.80 %) and precision (relative standard deviation ≤ 19.71 %), recovery (87.95-113.79 %), matrix effect (91.26-113.78 %), and stability (85.65-114.05 %). Furthermore, we applied our method to profile B vitamins in the colons of mice with breast cancer after doxorubicin chemotherapy treatment, which revealed that the doxorubicin treatment led to significant colon damage and accumulation of several B vitamins including B1, B2 and B5. We also confirmed the capability of this method for quantifying B vitamins in other intestinal tissues like the ileum, jejunum, and duodenum. The newly developed method is simple, specific, and useful for targeted profiling of B vitamins in mouse colon, with a potential for future studies on the role of these micronutrients in healthy and diseased states.

Recovery of Polyphenolic Compounds and Vitamins from the Stinging Nettle Leaves: Thermal and Behavior and Biological Activity of Obtained Extracts.

Stinging nettle (SN) is an extraordinary plant from the Urticaceae botanical family. It is well-known and widely used in food and folk medicine to treat different disorders and diseases. This article aimed to study the chemical composition of SN leaves extracts, i.e., polyphenolic compounds and vitamins B and C, because many studies ascribed high biological potency to these compounds and their significance in the human diet. Besides the chemical profile, the thermal properties of the extracts were studied. The results confirmed presence of many polyphenolic compounds and vitamins B and C. It also showed that the chemical profile closely correlated with the applied extraction technique. The thermal analysis showed that analyzed samples were thermally stable up to about 160 °C. Thermal degradation of samples UAE, MAE, and MAC took place in four steps, and sample SE in three steps. Altogether, results confirmed the presence of health-beneficial compounds in stinging nettle leaves and indicated the possible application of its extract in pharmaceutical and food industries as both a medicinal and food additive.

Vitamin K intake and breast cancer incidence and death: results from a prospective cohort study.

BACKGROUND & AIMS: Vitamin K prevents growth and metastasis of certain cancers, but there is little evidence regarding the association between dietary vitamin K and breast cancer incidence and death. We sought to examine whether intakes of total vitamin K, phylloquinone (vitamin K1) and menaquinones (MKs) (vitamin K2) may influence risks of breast cancer incidence and death in the US population. METHODS: Herein, 2286 breast cancer cases and 207 breast cancer deaths were identified during 702,748 person-years of follow-up. Cox regression and competing risk regression were used to estimate multivariable-adjusted hazards ratios (HRs) and 95% confidence intervals (95% CIs) by dietary vitamin K intake quintile (Q) for risk of breast cancer incidence and mortality. RESULTS: After adjustment for confounders, the total MK intake was associated with an increased risk of breast cancer (HR Q5 vs Q1, 1.26; 95% CI, 1.05 to 1.52; Ptrend, 0.01) and death from breast cancer (HR Q5 vs Q1, 1.71; 95% CI, 0.97 to 3.01; Ptrend, 0.04). Non-linear positive dose-response associations with risks of breast cancer incidence and death were found for total MKs intake (Pnon-linearity<0.05). No statistically significant associations were observed between the intake of total vitamin K and phylloquinone and breast cancer. CONCLUSIONS: The present study suggests that total MK intake was associated with an altered risk of the occurrence and death of breast cancer in the general US population. If our findings are replicated in other epidemiological studies, reducing dietary intake of menaquinones may offer a novel strategy for breast cancer prevention.

The evaluation of vitamin K status in children with febrile seizure.

BACKGROUND: Febrile seizure is the most common neurological disorder in childhood. The exact pathophysiology of febrile seizures is unknown. Recent studies showed the role of vitamin K in nonhematological and inflammatory disorders. This study aimed to investigate the serum vitamin K levels in children with febrile seizures. AIMS: To evaluate vitamin K levels in children with febrile seizures. STUDY DESIGN: Prospective case-control study. METHODS: This multicenter study examined representative populations in 8 different cities in Turkey between April 1, 2018 and April 1, 2019. Blood samples were taken from all children at presentation. Vitamin K1, vitamin K2, tumor necrosis factor-alpha, interleukin 1 beta, and interleukin 6 levels were determined by enzyme-linked immunosorbent assay. RESULTS: A total of 155 children were included in the study-84 children with febrile seizures and 71 children in febrile control group. Serum vitamin K1 and vitamin K2 levels were also higher in children with febrile seizures than in the controls. The results of statistical analysis showed that vitamin K1 and vitamin K2 levels were correlated with tumor necrosis factor-alpha, interleukin 1 beta, and interleukin 6 levels. The median vitamin K1 and vitamin K2 levels of children experiencing their first febrile seizure were higher than those in children with recurrent febrile seizures. Type of febrile seizure has no effect on serum vitamin K1 and vitamin K2 levels. CONCLUSION: In children with febrile seizures, vitamin K levels are higher than those in the control group. These new findings may contribute to elucidating the etiopathogenesis of febrile seizures.

Development, Optimization, and Comparison of Different Sample Pre-Treatments for Simultaneous Determination of Vitamin E and Vitamin K in Vegetables.

The absence of vitamin E from the diet can lead to cardiovascular disease, cancer, cataracts, and premature aging. Vitamin K deficiency can lead to bleeding disorders. These fat-soluble vitamins are important nutritional factors that can be determined in different methods in vegetables. In this work, the simultaneous determination of α-tocopherol, α-tocopheryl acetate, phylloquinone, and menaquinone-4 by gas chromatography-mass spectrometry (GC-MS) has been optimized using both direct injection and solid phase microextraction (SPME). Three different sample pre-treatment approaches based on: (A) solid-liquid-liquid-liquid extraction (SLE-LLE), (B) SLE, and (C) SPME were then applied to extract the target analytes from vegetables samples using menaquinone as internal standard. All the procedures allowed the determination of the target analytes in onion, carrot, celery, and curly kale samples. Similar results were obtained with the three different approaches, even if the one based on SPME offers the best performance, together with a reduced use of solvent, time consumption, and experimental complexity, which makes it the preferable option for industrial applications.

Changes in International Normalized Ratios After Plasma Transfusion of Varying Doses in Unique Clinical Environments.

BACKGROUND: Plasma transfusion is commonly performed for the correction of abnormal coagulation screening tests. The goal of this investigation was to assess the relationship between the dose of plasma administered and changes in coagulation test results in a large and diverse cohort of patients with varying levels of coagulation abnormalities and comorbid disease and in a variety of clinical settings. METHODS: In this single-center historical cohort study, all plasma transfusion episodes in adult patients with abnormal coagulation screening tests were extracted between 2011 and 2015. The primary outcome was the proportion of patients attaining normal posttransfusion international normalized ratio (INR ≤ 1.1) with secondary outcomes including the proportion of patients attaining partial normalization of INR (INR ≤ 1.5) or at least 50% normalization in pretransfusion values with respect to an INR of 1.1. RESULTS: In total, 6779 unique patients received plasma with a median (quartiles) pretransfusion INR of 1.9 (1.6-2.5) and a median transfusion volume of 2 (2-3) units. The majority (85%) of transfusions occurred perioperatively, with 20% of transfusions administered prophylactically before a procedure. The median decrease in INR was 0.4 (0.2-0.8). Complete INR normalization was obtained in 12%. Reductions in INR were modest with pretransfusion INR values <3. Patients receiving ≥3 units of plasma were more likely to achieve at least 50% normalization in INR than those receiving ≤2 units (68% vs 60%; P < .001). CONCLUSIONS: Changes in INR after plasma transfusion were modest at typically used clinical doses, particularly in those with less severely deranged baseline coagulation screening tests. Further studies are necessary to assess the relationships between plasma-mediated changes in INR and clinical outcomes.

Dispelling myths about intravenous fish oil-based lipid emulsions: a clinical perspective.

PURPOSE OF REVIEW: Intravenous lipid emulsions (IVLEs) are an essential component of parenteral nutrition. With the recent incorporation of new lipid emulsions into the Canadian and American market, the clinician responsible for prescribing these lipids should be educated regarding the different fatty acid (FA) profiles of these lipids, as well as their metabolic and functional effects. RECENT FINDINGS: New IVLEs contain a mix of soybean oil and olive oil, or a mix of soybean oil, coconut oil, olive oil and fish oil. These new lipid emulsions provide less essential fatty acids (FAs) (linoleic and alpha linolenic acids) than in pure soybean oil, yet incorporation of fish oil into an IVLE may decrease the amount of essential FAs required. Fish oil is a treatment for hypertriglyceridemia, and therefore, IVLEs that include fish oil may decrease serum triglycerides. Historical perspective is that fish oil can be associated with increased bleeding time. Evidence suggests that there is no association between fish oil and increased bleeding in patients, even those who are using anticoagulants. New IVLEs provide less vitamin K than soybean oil alone. Patients, or the parenteral nutrition solutions that include these new IVLEs should be supplemented with vitamin K. SUMMARY: Canadian and American Guidelines for IVLEs were based on soybean oil. Current practice should be tailored to which IVLE is being prescribed.

Vitamin K: content in food consumed in São Paulo, Brazil

ABSTRACT Recent research on Vitamin K has shown its importance in maintaining vascular and bone health. Brazilian food composition tables do not show phylloquinone content in national foods. These data are needed to obtain more reliable results in nutritional status assessment studies of individuals in relation to this vitamin as studies have shown a geographical influence in food phylloquinone content. This study aims to determine phylloquinone (Vitamin K1) levels in its most important source: dark green leaved vegetables. Several varieties of vegetables were purchased directly from CEAGESP (General Warehouse Company of São Paulo) at different times. Phylloquinone was extracted using organic solvents and quantified by High Performance Liquid Chromatography - HPLC. Results show the concentrations of phylloquinone in commonly consumed foodstuffs. In general, results showed variations with data from literature on the amount of Vitamin K in the plants analysed.

Exogenous and endogenous determinants of vitamin K status in cystic fibrosis.

Cystic fibrosis (CF) patients are at high risk for vitamin K deficiency. The effects of vitamin K supplementation are very ambiguous. Therefore, we aimed to define the determinants of vitamin K deficiency in a large cohort of supplemented - 146 (86.9%) and non-supplemented - 22 (13.1%) CF patients. Vitamin K status was assessed using prothrombin inducted by vitamin K absence (PIVKA-II) and undercarboxylated osteocalcin (u-OC). The pathological PIVKA-II concentration (≥ 2 ng/ml) and abnormal percentage of osteocalcin (≥ 20%) were found in 72 (42.8%) and 60 (35.7%) subjects, respectively. We found that liver involvement, diabetes, and glucocorticoid therapy were potential risk factors for vitamin K deficiency. Pathological concentrations of PIVKA-II occurred more frequently in patients with pancreatic insufficiency and those who have two severe mutations in both alleles of the CFTR gene. Pathological percentage of u-OC was found more frequently in adult CF patients and those not receiving vitamin K. However, it seems that there are no good predictive factors of vitamin K deficiency in CF patients in everyday clinical care. Early vitamin K supplementation in CF patients seems to be warranted. It is impossible to clearly determine the supplementation dose. Therefore, constant monitoring of vitamin K status seems to be justified.

Mediastinal Yolk Sac Tumor Producing Protein Induced by Vitamin K Absence or Antagonist-II.

Extragonadal yolk sac tumors (YSTs) are rare. We herein report the case of a 66-year-old man with mediastinal, lung and liver tumors. The largest mass was located in the liver and contained a high concentration of protein induced by vitamin K absence or antagonist-II (PIVKA-II) and alpha-fetoprotein. Therefore, the lesion was difficult to distinguish from hepatocellular carcinoma. Finally, YST was diagnosed based on the results of a liver biopsy. Although chemotherapy was effective, the patient died of respiratory failure. The autopsy revealed primary mediastinal YST. In the current report, we describe this case of PIVKA-II-producing YST and review previous cases of PIVKA-II-producing tumors other than hepatoma.

Teores de vitamina K em hortaliças consumidas na cidade de São Paulo / Levels of vitamin K in vegetables consumed in the city of São Paulo

Estudos sobre a vitamina K têm evidenciado seu papel na manutenção da saúde óssea e vascular. A atuação desta vitamina em tecidos extra-hepáticos não é considerada na recomendação dietética da DRI de 2001, sendo reconhecidas necessidades maiores para função óssea em pessoas acima dos 60 anos e em indivíduos que fazem uso de medicamentos antivitamina K. Visando colaborar com pesquisas futuras, onde o conhecimento do teor de vitamina K1 é relevante, além de contribuir com dados para Tabela Brasileira de Composição de Alimentos - TBCA-USP, o presente trabalho foi conduzido para determinação do teor de filoquinona (vitamina K1) de hortaliças consumidas na cidade de São Paulo. As hortaliças analisadas foram escolhidas após a conclusão de um inquérito alimentar realizado, com adultos e idosos, num projeto de pesquisa desenvolvido junto ao Departamento de Alimentos e Nutrição Experimental da FCF/USP visando a análise da ingestão diária de vitamina K. Desta forma, foram analisadas as hortaliças mais consumidas por esses grupos, submetidas ou não ao processo de cocção. Estas amostras foram adquiridas diretamente na CEAGESP - Companhia de Entrepostos e Armazéns Gerais de São Paulo. As metodologias empregadas na determinação da filoquinona (vitamina K1) foram extração e purificação pelo método líquido-líquido utilizando solventes orgânicos e quantificação através da Cromatografia Líquida de Alta Eficiência (CLAE). Os resultados mostraram que as amostras de hortaliças de colorações verdes mais escuras apresentaram os maiores teores da vitamina como: salsa 491,05 µg/100g; espinafre 375,01 µg/100g, quando comparados com as amostras de colorações verdes mais claras as quais como é o caso da alface americana 113,42 µg/100g e a couve-flor 32,55 µg/100g. A maioria das hortaliças analisadas apresentaram variações entre as diferentes épocas do ano e quando comparadas com dados da literatura

Studies on vitamin K have shown its role in maintaining bone and vascular health. The role of this vitamin in extrahepatic tissues is not considered in the dietary recommendation of DRI 2001. Increased need for vitamin K intake is recognized for the bone function in people over age 60 and individuals who use anti-vitamin K drugs. Aiming at supporting future research, where knowledge of vitamin K1 is relevant, and contribute data to the Brazilian Table of Food Composition - TBCA-USP, this study was conducted to determine the level of phylloquinone (vitamin K1) of vegetables consumed in the city of São Paulo. The vegetables studied were chosen after completion of a nutrition survey carried out with adults and elderly people, a research project developed by the Department of Food and Experimental Nutrition FCF / USP aimed at analyzing the daily intake of vitamin K. Therefore, we analyzed the most consumed vegetables by these groups submitted or not to the cooking process. These samples were acquired directly at CEAGESP - General Warehouses Company of São Paulo. The methodologies employed in the determination of phylloquinone (vitamin K1) were extraction and purification method using liquid-liquid organic solvents followed by High Performance Liquid Chromatography (HPLC). The results showed that the samples of darker green vegetables showed the highest levels of vitamin such as parsley (491.05 µg/100g) and spinach (375.01 µg/100g), when compared with samples of lighter coloration (e.g. 113.42 µg/100g lettuce, and 32.55 µg/100g cauliflower). Most vegetables analyzed showed variation in results when compared to the different seasons and the literature data

Fast-food and full-service restaurant consumption in relation to daily energy and nutrient intakes among US adult cancer survivors, 2003-2012.

BACKGROUND: Healthy diet is an essential component in cancer survivorship care planning. Cancer survivors should be particularly prudent regarding their daily food choices, with an aim of ensuring safe consumption, reducing risk of recurrence or other comorbidity, and improving quality of life. OBJECTIVE: We aimed to examine the impacts of fast-food and full-service restaurant consumption on daily energy and nutrient intakes among US adult cancer survivors. METHODS: Nationally representative data of 1308 adult cancer survivors came from the National Health and Nutrition Examination Survey 2003-2012 waves. First-difference estimator was adopted to address confounding bias from time-invariant unobservables like personal food/beverage preferences by using within-individual variations in diet and restaurant consumption status between two non-consecutive 24-hour dietary recalls. RESULTS: Fast-food and full-service restaurant consumption, respectively, was associated with an increase in daily total energy intake by 125.97 and 152.26 kcal and sodium intake by 312.47 and 373.75 mg. Fast-food consumption was significantly associated with a decrease in daily vitamin A intake by 119.88 µg and vitamin K intake by 30.48 µg, whereas full-service restaurant consumption was associated with an increase in daily fat intake by 8.99 g and omega-6 fatty acid intake by 3.85 g, and a decrease in vitamin D intake by 0.93 µg. Compared with fast-food and full-service restaurant consumption at home, consumption away from home led to further reduced diet quality. CONCLUSIONS: Individualized nutrition counseling and food assistance programs should address cancer survivors' overall dining-out behavior rather than fast-food consumption alone.

[Thromboelastography/-metry and external quality control. Results of a pilot study]. / Evaluation von Ringversuchsproben zur externen Qualitätssicherung viskoelastischer Messungen - Eine Pilotstudie.

Thromboelastography/thromboelastometry (TEG/ROTEM) is widely used in near-patient setting, especially in perioperative and intensive care medicine for the management of acute bleeding. Until now a comprehensive quality management especially an external quality control of TEG/ROTEM results is not established. Here we report about our results of a pilot survey performed in 2008 and 2009 integrated in the External Quality Assessment Schemes (EQAS) performed by INSTAND. According to this first EQAS data ROTEM results can be controlled in external quality schemes using lyophilized plasma samples. The clot firmness (A20) and clot formation kinetics characterized by the alpha-angle showed very good reproducibility both between the participants and between different surveys. Variations for CT and CFT were considerably higher especially in the plasma sample with reduced fibrinogen level. Regular participation in an external quality assurance will help to confirm this beneficial technology in emergency settings.

Using median regression to obtain adjusted estimates of central tendency for skewed laboratory and epidemiologic data.

BACKGROUND: Laboratory studies often involve analyses of highly skewed data for which means are not an adequate measure of central tendency because they are sensitive to outliers. Attempts to transform skewed data to symmetry are not always successful, and medians are better measures of central tendency for such skewed distributions. When medians are compared across groups, confounding can be an issue, so there is a need for adjusted medians. METHODS: We illustrate the use of quantile regression to obtain adjusted medians. The method is illustrated by use of skewed nutrient data obtained from black and white men attending a prostate cancer screening. For 3 nutrients, saturated fats, caffeine, and vitamin K, we obtained medians adjusted by age, body mass index, and calories for men in each race group. RESULTS: Quantile regression, linear regression, and log-normal regression produced substantially different adjusted estimates of central tendency for saturated fats, caffeine, and vitamin K. CONCLUSIONS: Our method was useful for analysis of skewed and other nonnormally distributed continuous outcome data and for calculation of adjusted medians.

[Biological effects of vitamin K and concentration of vitamin K in Norwegian food]. / Biologiske effekter av vitamin K og forekomst i norsk kosthold.

BACKGROUND: Vitamin K has several biological effects and dietary intake seems to be more important than previously believed because of low bioavailability of the vitamins from the colon. MATERIALS AND METHODS: Data from the literature were identified on PubMed, and data from NORKOST II (a dietary study from 1997 based on a nation-wide sample of respondents) were used to calculate dietary intake of vitamin K. RESULTS: The dietary intake of vitamin K in Norway seems to be < 50% of what is recommended. The stores of vitamin K are small and T/2 in the body is approximately 1-1.5 day. Vitamin K executes its effects by carboxylation of proteins and as ligand (vitamin K2) for a nuclear transcription factor. Biological effects beyond coagulation include bone formation, neural functioning and blood vessel calcification. Anticoagulation with warfarin inhibits vitamin K-dependent reactions and may have detrimental effects on bone formation. INTERPRETATION: It is possible that the high incidence of osteoporosis in Norway may be due to the low dietary intake of vitamin K, hence it is suggested that the intake of vitamin K should be increased and vitamin K antagonists be replaced with specific thrombin inhibitors. New technology allows measurements of plasma concentration of vitamin K in relation to malabsorption, insufficient diet, and osteoporosis.

Ureibacillus gen. nov., a new genus to accommodate Bacillus thermosphaericus (Andersson et al. 1995), emendation of Ureibacillus thermosphaericus and description of Ureibacillus terrenus sp. nov.

A polyphasic taxonomic study was performed on the type strain of Bacillus thermosphaericus DSM 10633T and three related soil isolates. On the basis of phenotypic characteristics, chemotaxonomic profiles and phylogenetic data a new genus, Ureibacillus gen. nov., is proposed for the strains in the Bacillus thermosphaericus cluster. Strains of this cluster fall into two DNA-DNA similarity groups: while one group contains the type strain of Ureibacillus thermosphaericus comb. nov. and a single soil isolate, the other contains two soil isolates. The two groups differed in the composition of isoprenoid quinones and some phenotypic properties. These data support the description of a novel species of Ureibacillus for which the name Ureibacillus terrenus is proposed. The type strain of this new species is TH9AT (= DSM 12654T = LMG 19470T).

A comprehensive review of vitamin K and vitamin K antagonists.

For more than 60 years, vitamin K-dependent proteins have been known to play an important role in regulating blood coagulation. During recent years it has become clear, however, that vitamin K is also involved in other physiologic processes, including bone metabolism and vascular biology. Because the vitamin K requirement of bone and vessel wall is higher than that of the liver (where the clotting factors are produced) recommended daily allowance (RDA) values for K vitamins must be redefined. According to the new definition, a substantial part of the population is mildly deficient in vitamin K, and at later ages this deficiency may contribute to increased bone fracture risk, arterial calcification, and cardiovascular disease.

Vitamin K contents in liver tissue of hepatocellular carcinoma patients.

Serum protein induced in vitamin K absence-II (PIVKA-II) is used as a tumor marker because it increases at a notably higher rate in patients with hepatocellular carcinoma. To clarify the mechanism causing the elevation of serum PIVKA-II, we measured the contents of vitamins K1 (phylloquinone, PK) and K2 (menaquinone, MK) (MK-4, MK-5, MK-6, MK-7, MK-8, MK-9, MK-10) in liver tissue resected from 21 hepatic cancer patients (12 patients with hepatocellular carcinoma and 9 patients with metastatic hepatic cancer), using HPLC combined with coulometric reduction and fluorometric detection. In the cancerous tissue of hepatocellular carcinoma patients, PK, MK-7, MK-8, and MK-10 were significantly lower than that found in the noncancerous tissue. Furthermore, MK-6, MK-7, MK-8, and MK-10 in the cancerous tissue of hepatocellular carcinoma patients were significantly lower than that in the cancerous tissue of metastatic hepatic cancer patients. These data suggested that one of the mechanisms of the elevation of serum PIVKA-II levels in hepatocellular carcinoma patients is a vitamin K deficiency in the local cancerous tissue.