Impact of clonal haematopoiesis on atherosclerotic cardiovascular disease according to low-density lipoprotein cholesterol levels in general population.

AIMS: Clonal haematopoiesis of indeterminate potential (CHIP), defined as a clonal expansion of age-related recurrent somatic mutations, has recently emerged as a novel cardiovascular risk factor. However, the precise role of CHIP in the development of atherosclerotic cardiovascular disease (ASCVD) remains unclear. METHODS: Among 4,300 asymptomatic Korean participants aged 40-79 years, we investigated the risk of ASCVD by CHIP and the interplay between CHIP and conventional risk factors in ASCVD development. Additionally, we assessed changes in coronary arteries based on the presence of CHIP using coronary computed tomography angiography (CCTA). RESULTS: CHIP was present in 363 participants (8.4%), and its prevalence increased with age. Commonly mutated genes were DNMT3A, TET2 and ASXL1, in order. During follow-up (median, 4.7 years), 18 ASCVD cases (5.0%) were observed in CHIP carriers vs. 62 (1.6%) in non-carriers (p < 0.001), indicating an elevated risk of ASCVD associated with CHIP (adjusted HR 2.49, 95% CI 1.45-4.29, p < 0.001). Notably, with high levels of low-density lipoprotein (LDL) cholesterol, CHIP enhanced the risk of ASCVD (adjusted HR 6.20, 95% CI 3.14-12.23, p < 0.001), demonstrating synergism between CHIP and LDL cholesterol levels (S-index, 4.94; 95% CI 1.08-22.53, p = 0.039). Serial CCTAs confirmed that CHIP, in conjunction with high LDL cholesterol levels, had significant early impact on coronary arteries, revealing new measurable coronary atherosclerosis, mainly with unstable plaque, in proximal lesions. CONCLUSIONS: The presence of CHIP was significantly associated with the risk of ASCVD, promoting the early stage of atherosclerosis through synergy with high LDL cholesterol in the general population.

In this cohort study of 4,300 asymptomatic community-dwelling Korean adults, we demonstrated a detailed interplay between clonal haematopoiesis of indeterminate potential (CHIP) and conventional risk factors in the development of atherosclerotic cardiovascular disease (ASCVD).The presence of CHIP significantly increased the risk of ASCVD in the general population, displaying a notable synergistic effect with high levels of low-density lipoprotein (LDL) cholesterol.Analyses of serial coronary computed tomography angiography scans revealed that CHIP, in conjunction with high LDL cholesterol levels, may contribute to the promotion of "early" stage in coronary atherosclerosis, providing new insights into CHIP-associated atherosclerosis in the primary prevention.

Correlation of extended Martin/Hopkins equation with a direct homogeneous assay in assessing low-density lipoprotein cholesterol in patients with hypertriglyceridemia.

BACKGROUND: The Friedewald or Martin/Hopkins equation is widely used to estimate low-density lipoprotein cholesterol (LDL-C) at triglyceride (TG) levels <400 mg/dL. In this study, we aimed to validate the recently developed Sampson and extended Martin/Hopkins equations intended for use in patients with TG levels up to 800 mg/dL by comparing them to a direct homogenous assay. METHODS: In total, 8676 participants with serum TG levels <800 mg/dL were enrolled in this study. LDL-C was directly measured using Abbott homogeneous assay (DLDL) and estimated using the Friedewald (FLDL), Martin/Hopkins (MLDL), extended Martin/Hopkins (EMLDL), and Sampson equations (SLDL). The overall concordance between the DLDL and LDL-C estimates was calculated. The performance of the four equations was also compared using Bland-Altman plots and mean absolute difference (MAD). RESULTS: The EMLDL was more accurate than other LDL-C equations particularly for patients with TG≥400 mg/dL (MAD = 10.43; vs. FLDL: MAD = 21.1; vs. SLDL: MAD 11.62). The overall concordance of FLDL, MLDL, EMLDL, and SLDL with DLDL in TG values ranging from 200 to 799 mg/dL were 52.2, 70.5, 71.6, and 65.7%, respectively (p < 0.001), demonstrating the EMLDL as the most optimal estimation method, particularly for high TG levels (≥200 mg/dL). CONCLUSION: Both the original and extended Martin/Hopkins method are optimal in estimating LDL-C levels in clinical laboratories using the Abbott analyzer in patients with TG levels of 200-399 and 400-799 mg/dL, respectively. Meanwhile, caution is need that considerable underestimation of Friedewald and Sampson equation could lead to undertreatment in hypertriglyceridemia.

Exploring the role of copper and selenium in the maintenance of normal thyroid function among healthy Koreans.

BACKGROUND: Selenium and iodine are trace elements well known to have important roles in the synthesis and metabolism of thyroid hormones. However, the effects of other trace elements on thyroid hormones are still inconclusive. We investigated the association between several trace elements and thyroid hormones. METHODS: The data of 448 subjects who were measured for both, trace elements and TSH/free T4, at the Heath Checkup Center were retrospectively reviewed. The presence of thyroiditis (from thyroid echogenicity) and thyroid nodules were reviewed in the subjects who underwent thyroid ultrasonography. RESULTS: Blood concentrations of manganese, copper, selenium, and molybdenum were associated with TSH or free T4. After adjusting for age, sex, BMI, smoking, and alcohol consumption, blood copper levels were positively associated with free T4 in both sexes and selenium levels were positively associated with free T4 in women. There was no association between trace elements and thyroiditis. Blood copper concentration had a weak non-linear association with the presence of thyroid nodules. CONCLUSIONS: This study demonstrated that blood concentrations of copper and selenium were significantly associated with free T4 in healthy Korean subjects with sufficient iodine intake suggesting their role in maintaining normal thyroid function.

Association of Plasma Oligomerized Beta Amyloid with Neurocognitive Battery Using Korean Version of Consortium to Establish a Registry for Alzheimer's Disease in Health Screening Population.

The increasing prevalence of Alzheimer's disease (AD) has become a global phenomenon presenting serious social and health challenges. For detecting early molecular changes in the disease, several techniques to measure varied species of amyloid beta in the peripheral blood have been recently developed, but the efforts to associate them with cognitive assessments have yet to produce sufficient data. We prospectively collected participants from the consecutive population who visited our center for brain health screening. In total, 97 participants (F:M = 58:39) aged 69.4 ± 7.52 were assessed. Participants performed the Korean version of the Consortium to Establish a Registry for Alzheimer's disease (CERAD-K), the clinical dementia rating (CDR), plasma oligomeric amyloid-ß (OAß) level tests, routine blood tests, ApoE genotype, and brain MRI. Among total population, 55.7% had a CDR of 0, and 40.2% had a CDR of 0.5. The results showed that word memory and word recall, and the total scores of the CERAD-K were negatively correlated with the plasma OAß level. With a cut-off value of 0.78 ng/mL for the OAß level and a -1.5 standard deviation of age/sex/education adjusted norms for the CERAD-K; naming, word memory, word recall, word recognition, and total score were significantly correlated with the OAß level. No correlation between the OAß level and mini-mental status examination was found. Our results demonstrate that the level of plasma OAß was well correlated with the measure of cognitive function through the CERAD-K in the field data collected from consecutive populations. Studies on longitudinal comparisons with large cohorts will further validate the diagnostic value of plasma OAß as a useful biomarker for screening AD and predicting progression.

GWAS identifying HLA-DPB1 gene variants associated with responsiveness to hepatitis B virus vaccination in Koreans: Independent association of HLA-DPB1*04:02 possessing rs1042169 G - rs9277355 C - rs9277356 A.

Recently, HLA class II loci, including HLA-DPB1, have been reported to be associated with interindividual variance in the hepatitis B (HB) vaccine response. In this study, we investigated significant single nucleotide polymorphisms (SNPs) for anti-HBs antibody levels in 6867 healthy Koreans using a genome-wide association study (GWAS). In GWAS, the top 20 SNPs that showed significant association with anti-HBs levels (P < 1.0 × 10-29 ) all resided in HLA-DPB1. Utilizing PCR sequencing, we verified the relationship of the top 3 most significant SNPs (rs1042169, rs9277355 and rs9277356) from the GWAS and genotypes of HLA-DPB1 with the HB vaccine response in Korean infants who received a scheduled vaccination. The DPB1*04:02 allele has G, C and A nucleotides for the 3SNP sites, and was significantly more frequent in responders than in nonresponders (10.9% vs 1.0%, Pc  = 0.018). DPB1*05:01 was significantly more frequent in nonresponders than in responders (49.0% vs 31.1%, Pc  = 0.018). In multivariate logistic regression, DPB1*04:02 showed a significant association with both vaccine response (P = 0.037, OR = 8.465) and high-titre response (P = 0.027, OR = 9.860). The haplotypes rs1042169 G - rs9277355 C - rs9277356 A showed a significant association with a high-titre response only (P = 0.002, OR = 2.941). In conclusion, DPB1*04:02 possessing rs1042169 G - rs9277355 C - rs9277356 A is an independent predictor of the HB vaccine response in Koreans.

Update on low-density lipoprotein cholesterol quantification.

PURPOSE OF REVIEW: ß-Quantification is considered the reference measurement procedure for low-density lipoprotein cholesterol (LDL-C). However, this technique is time-consuming and thus is inappropriate for routine clinical practice. Therefore, the Friedewald equation or homogeneous assays have been widely utilized. As several pitfalls exist with these two methods, a novel method for estimating LDL-C was developed by Martin et al. RECENT FINDINGS: Martin's method uses a strata-specific median for the triglycerides/very low-density lipoprotein cholesterol (VLDL-C) ratio on the basis of triglycerides and non-HDL-C concentrations. Recent studies show that Martin's method better correlates with ß-quantification or homogeneous assays compared with the Friedewald equation, especially with values of triglycerides at least 150 mg/dl and/or LDL-CD less than 70 mg/dl. Such findings have also been demonstrated in other ethnic groups (Japanese and Korean) and disease populations, including diabetes and cardiovascular disease, in which the triglycerides/VLDL-C ratio can be affected. SUMMARY: For the current therapeutic goal of LDL-C values below 70 mg/dl in high-risk patients, accurate assessment of LDL-C levels at very low levels is required. Martin's method could overcome pitfalls such as underestimation of the Friedewald equation at this level. Further evaluation of the triglycerides/VLDL-C ratio in participants with diverse ethnic backgrounds or clinical conditions would expand the implementation of this novel method.

HbA1c showed a positive association with carcinoembryonic antigen (CEA) level in only diabetes, not prediabetic or normal individuals.

BACKGROUND: This study was conducted to investigate the association of carcinoembryonic antigen (CEA) and glycated hemoglobin (HbA1c) in normal, prediabetic, and diabetic subjects. METHODS: A total of 2,911 participants who underwent general health checkups were enrolled and categorized into the normal, prediabetes, and diabetes groups. Demographic, anthropological, and clinical variables were investigated, and correlations with CEA were analyzed. For 28 diabetic subjects with CEA levels above the upper limit, the follow-up CEA and HbA1c data were analyzed. RESULTS: Carcinoembryonic antigen levels were significantly different among the normal, prediabetes, and diabetes groups (1.7 ± 1.1 vs 2.0 ± 1.1 vs 2.5 ± 1.5; P < 0.001), and men had higher CEA levels than women in all three groups. Correlation analysis identified a significant positive correlation between serum CEA and HbA1c in the diabetes group using unadjusted and adjusted models (r = 0.189, P < 0.001 and r = 0.218, P < 0.001), and multiple linear regression analysis also revealed that HbA1c was independently and positively correlated with CEA in the diabetes group (ß = 0.275, P < 0.001). However, these relationships were inconsistent in the normal and prediabetes groups. The changes in CEA and HbA1c from baseline to follow-up (delta CEA and delta HbA1c) showed a significant positive correlation (P = 0.021). CONCLUSIONS: In diabetes, the CEA level was independently and positively correlated with glycemic control status. Additionally, the change in CEA level (delta CEA) showed a positive correlation with the change in HbA1c level (delta HbA1c) in the follow-up data analysis.

Usefulness of the Martin Method for Estimation of Low-Density Lipoprotein Cholesterol in Coronary Atherosclerosis.

OBJECTIVE: This study was conducted to validate the Martin method in coronary atherosclerosis in comparison with the Friedewald equation. SUBJECTS AND METHODS: A total of 299 participants with a coronary artery calcium score (CACS) ≥300 and a serum triglyceride (TG) level <400 mg/dL at Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea, were enrolled in this study. Low-density lipoprotein cholesterol (LDL-C) was directly measured with a homogeneous assay (DLDL) and estimated by both the Friedewald equation (FLDL) and Martin method (MLDL). Overall concordances between DLDL and LDL-C estimates were calculated as the percent agreement. The McNemar test was used to compare the rate of reclassification of participants with FLDL and MLDL, and to determine which differed significantly from each other. RESULTS: Overall concordance between DLDL and MLDL was slightly higher than that between DLDL and FLDL (73.2 vs. 70.9%, p < 0.001). The FLDL showed poor performance when the TG level was ≥200 mg/dL, mostly by underestimation, which represented a 64.7% discordance with DLDL. The reclassification rate by MLDL, however, did not exceed 35.3% in all of the TG groups. CONCLUSIONS: The Martin method to estimate LDL-C using the strata-specific TG:VLDL ratio showed a 2-fold better concordance with LDL-C measured with a direct homogeneous assay in coronary atherosclerosis compared to the Friedewald equation when the TG level was ≥200 mg/dL. This finding suggests that MLDL could be a better alternative for estimating LDL-C compared to FLDL when the TG level is ≥200 mg/dL in coronary atherosclerosis.

Proposal of standardized guidelines for the production and quality control of autologous serum eye drops in Korea: based on a nationwide survey.

BACKGROUND: Autologous serum eye drops (ASEDs) have been used to treat many eye diseases. However, there are no standardized guidelines for the production and quality control (QC) of ASEDs in Korea. Our aim was to propose standardized guidelines for the production and QC of ASEDs. STUDY DESIGN AND METHODS: We conducted a nationwide survey consisting of questions regarding the methods used in each hospital for the production and QC of ASEDs. The survey was sent by e-mail to 89 doctors responsible for the blood banks at different hospitals. RESULTS: Thirty-two hospitals replied, and 13 hospitals reported using the ASEDs in the treatment of patients with eye diseases. The screening test for patients, amount of blood sampling, type of bottle used for blood collection, details about the production of the eye drops, and storage methods and shelf life of unopened and opened bottles of eye drops varied between hospitals. CONCLUSION: Based on an analysis of the survey results and a review of the standard operating procedures and protocols for ASEDs used in Japan, Germany, England and Wales, and the United States, we proposed standardized guidelines for the production and QC of ASEDs in Korea. ASEDs are not cell therapy products in the strictest sense. However, because eye drops are composed of serum isolated from blood and are used in patients, we consider ASEDs to be the basis for cell therapy products. Therefore, ASEDs should be produced and stored according to standardized guidelines based on the Good Manufacturing Practice guidelines.

Serum des-R prothrombin activation peptide fragment 2: a novel prognostic marker for disseminated intravascular coagulation.

INTRODUCTION: Disseminated intravascular coagulation (DIC) is diagnosed based on the combination of predisposing underlying conditions and laboratory tests for plasma coagulation markers. Because the collection of blood plasma samples is a fastidious procedure, the serum sample method may be preferred for measurement of coagulation markers when feasible. MATERIALS AND METHODS: The novel serum marker des-R prothrombin activation peptide fragment 2 (des-R F2) was measured using a sandwich enzyme-linked immunosorbent assay in 181 patients suspected of having DIC. Thrombin generation potential was estimated with a calibrated automated thrombogram. RESULTS: Serum des-R F2 was generated with an in vitro clotting process within a serum separation tube after blood collection. Carboxypeptidase inhibitor inhibited the formation of des-R F2 during in vitro clotting. Low levels of prothrombin and thrombin generation potential resulted in low serum des-R F2 levels. Serum des-R F2 was significantly decreased in overt DIC. Levels of des-R F2 correlated with DIC severity and other coagulation markers. Of note, the decrease in serum des-R F2 levels was a significant marker for predicting mortality. CONCLUSIONS: The serum marker, des-R F2, can be used for the investigation of DIC severity and prognosis. It should be considered a useful marker, especially when only serum samples are available.

Comparison of modified multiple-locus variable-number tandem-repeat fingerprinting with pulsed-field gel electrophoresis for typing clinical isolates of Staphylococcus aureus.

BACKGROUND: Multiple-locus variable-number tandem-repeat fingerprinting (MLVF) is based on multiplex PCR, utilizing variable number tandem repeat. Our goal was to compare the performance of MLVF in distinguishing clinical Staphylococcus aureus isolates with that of pulsed-field gel electrophoresis (PFGE), which has traditionally been the gold standard. METHODS: Sixty-three clinically significant S. aureus isolates were tested using both PFGE and MLVF. Multiplex PCR for MLVF was performed using PCR primers for clfA, clfB, sdrCDE, sspA, and spa. PFGE was performed with genomic DNA fragments generated by SmaI endonuclease digestion. Banding patterns of MLVF or PFGE were analyzed using InfoQuestFP software. RESULTS: The hands-on time of our modified method was about 3 h, on average, for each of 18 isolates. PFGE (80% cutoff) or MLVF (75% cutoff) separated all of the 63 isolates into 13 and 12 types, respectively. Three types generated by PFGE were identical to those generated by MLVF. PFGE and MLVF yielded similar Simpson's diversity indices, indicating similar discriminatory power. The overall concordance between PFGE and MLVF was low, as represented by adjusted Rand indices (0.266-0.278). PFGE predicted MLVF type better than MLVF predicted PFGE type, as reflected by Wallace coefficients (PFGE cutoff 80% vs. MLVF cutoff 75%, 0.389 vs. 0.233). Analysis of the relationship between a pair of isolates showed 91.0% concordance between the PFGE (80% cutoff) and MLVF (75% cutoff). CONCLUSIONS: Our simple, low-cost, modified MLVF protocol can effectively discriminate between S. aureus clinical isolates. MLVF can replace PFGE for the hospital infection control of S. aureus.

Quantity of clonal cells detected by conventional cytogenetic analysis correlates with bone marrow blasts and survival in myelodysplastic syndromes.

We performed quantitative and qualitative analyses of conventional cytogenetic analysis and interphase FISH results in 87 MDS patients. The quantity of clonal cells for each chromosome of CCA did not correlate with the result of iFISH (r, range 0.0761-1.0577). The clonal cell percentage in CCA was higher in patients with >5% bone marrow blasts than those with <5% (44.7% vs. 23.1%, p=0.017). Multivariate analysis showed that a high quantity of clonal cells in CCA analysis is an independent prognostic factor for overall survival in MDS (p=0.012).

A case of brain abscess caused by Propionibacterium acnes 13 months after neurosurgery and confirmed by 16S rRNA gene sequencing.

Propionibacterium acnes is a gram-positive anaerobic bacillus and a normal inhabitant of the skin. Although it is often considered a contaminant of blood cultures, it can occasionally cause serious infections, including postoperative central nervous system infections. Here, we report the case of a 70-yr-old man who developed a large cerebral abscess caused by P. acnes 13 months after neurosurgery. Immediate gram staining of the pus from his brain revealed the presence of gram-positive coccobacilli. However, colony growth was observed only after 5 days of culture. Therefore, we performed 16S rRNA gene sequencing of the pus specimen. The isolate was identified as P. acnes. The colonies developed 9 days after the initial culture. The API Rapid ID 32A test (bioMérieux, France) was performed using a colony, but an unacceptable profile was obtained. Then, the pus was transferred into the enrichment broths of the BACTEC FX (Becton Dickinson, USA) and BacT/Alert 3D (bioMérieux, Organon Teknika, USA) systems, but only the BACTEC FX system could detect growth after 5 days. We performed 16S rRNA gene sequencing and API Rapid 32A profiling with a colony recovered from Brucella agar, which was inoculated with the microbial growth in the enrichment broth from the BACTEC FX system. The organism was identified as P. acnes by both methods. This case suggests that 16S rRNA gene sequencing may be a useful alternative for identifying slowly growing P. acnes from specimens that do not show growth after 5 days of culture.

Neutrophil and monocyte activation markers have prognostic impact in disseminated intravascular coagulation: in vitro effect of thrombin on monocyte CD163 shedding.

Monocyte and neutrophil activation occur during microvascular disturbance of disseminated intravascular coagulation (DIC). This study investigated the diagnostic and prognostic value of circulating neutrophil elastase (NE) and neutrophil volume distribution width (NDW) as neutrophil activation markers and circulating soluble CD163 (sCD163) and monocyte volume distribution width (MDW) as monocyte activation markers in 168 patients suspected of having DIC. The sCD163 provided significant diagnostic value. The prognostic value of sCD163 was comparable to that of D-dimer, but was dependent on other coagulation markers. In vitro, thrombin significantly induced sCD163 from monocytes upregulated with IL-10 or dexamethasone. NDW was an independent and powerful prognostic marker. MDW and NE did not provide diagnostic and prognostic power. Excessive thrombin during ongoing DIC induces florid secretion of CD163; sCD163 might therefore be a potential diagnostic and prognostic marker for DIC. NDW, a convenient parameter measured by an automated hematology analyzer, may be an independent prognostic parameter for DIC.

Clathrin assembly lymphoid myeloid leukemia-AF10-positive acute leukemias: a report of 2 cases with a review of the literature.

The translocation t(10;11)(p13;q14q21) has been found to be recurrent in acute lymphoblastic and myeloid leukemias, and results in the fusion of the clathrin assembly lymphoid myeloid leukemia (CALM) gene with the AF10 gene; these genes are present on chromosomes 11 and 10, respectively. Because the CALM-AF10 rearrangement is a rare chromosomal abnormality, it is not included in routine molecular tests for acute leukemia. Here, we describe the cases of 2 patients with the CALM-AF10 fusion gene. The first patient (case 1) was diagnosed with T-cell ALL, and the second patient (case 2) was diagnosed with AML. Both patient samples showed expression of the homeobox A gene cluster and the histone methyltransferase hDOT1L, which suggests that they mediate leukemic transformation in CALM-AF10-positive and mixed-lineage leukemia-AF10-positive leukemias. Both patients achieved complete remission after induction chemotherapy. The first patient (case 1) relapsed after double-unit cord blood transplantation; there was no evidence of relapse in the second patient (case 2) after allogenic peripheral blood stem cell transplantation. Since CALM-AF10- positive leukemias have been shown to have poor prognosis with conventional therapy, molecular tests for CALM-AF10 rearrangement would be necessary to detect minimal residual disease during follow-up.

Circulating hepatocyte growth factor as an independent prognostic factor of disseminated intravascular coagulation.

BACKGROUND: Hepatocyte growth factor (HGF), a pleiotropic factor regulating development and wound healing, is secreted as inactive pro-HGF and is converted into active HGF by coagulation serine proteases. HGF receptor overexpression can cause massive venous thrombi, and factor Xa is reported to release soluble HGF from granulocytes. We hypothesized that a hypercoagulable condition, such as disseminated intravascular coagulation (DIC), may increase circulating HGF through active cleavage by coagulation serine proteases. METHODS: In 172 DIC-suspected patients, plasma levels of total and active HGF, thrombin-antithrombin complex (TAT), plasmin-antiplasmin complex (PAP), and interleukin (IL)-6 were measured by ELISA. Active HGF release in granulocytes was examined in patients with and without overt-DIC. HGF-induced tissue factor expression in peripheral monocytes was measured by flow cytometry. RESULTS: Circulating levels of total and active HGF correlated well with coagulopathy severity, including DIC score, D-dimer, TAT and PAP levels. HGF positively correlated with IL-6 and absolute neutrophil count. In contrast to the cancer group, HGF levels were significantly increased in accordance with increased DIC scores in non-cancer group. Elevated circulating HGF was an independent prognostic marker in the non-cancer group, while HGF level failed to predict mortality in the cancer group. Amounts of HGF released from stimulated granulocytes were not significantly different between overt-DIC and no overt-DIC patients. HGF potentiated endotoxin-induced tissue factor expression of monocytes in vitro. CONCLUSION: These findings suggest that circulating HGF is a potential laboratory marker reflecting coagulation activity and DIC prognosis in non-cancer patients and that HGF may play a role in a vicious cycle of hypercoagulability.