Role of α- and ß-adrenergic signaling in phenotypic targeting: significance in benign and malignant urologic disease.

The urinary tract is highly innervated by autonomic nerves which are essential in urinary tract development, the production of growth factors, and the control of homeostasis. These neural signals may become dysregulated in several genitourinary (GU) disease states, both benign and malignant. Accordingly, the autonomic nervous system is a therapeutic target for several genitourinary pathologies including cancer, voiding dysfunction, and obstructing nephrolithiasis. Adrenergic receptors (adrenoceptors) are G-Protein coupled-receptors that are distributed throughout the body. The major function of α1-adrenoceptors is signaling smooth muscle contractions through GPCR and intracellular calcium influx. Pharmacologic intervention of α-and ß-adrenoceptors is routinely and successfully implemented in the treatment of benign urologic illnesses, through the use of α-adrenoceptor antagonists. Furthermore, cell-based evidence recently established the antitumor effect of α1-adrenoceptor antagonists in prostate, bladder and renal tumors by reducing neovascularity and impairing growth within the tumor microenvironment via regulation of the phenotypic epithelial-mesenchymal transition (EMT). There has been a significant focus on repurposing the routinely used, Food and Drug Administration-approved α1-adrenoceptor antagonists to inhibit GU tumor growth and angiogenesis in patients with advanced prostate, bladder, and renal cancer. In this review we discuss the current evidence on (a) the signaling events of the autonomic nervous system mediated by its cognate α- and ß-adrenoceptors in regulating the phenotypic landscape (EMT) of genitourinary organs; and (b) the therapeutic significance of targeting this signaling pathway in benign and malignant urologic disease. Video abstract.

Nutrient ileal digestibility evaluation of dried mealworm (Tenebrio molitor) larvae compared to three animal protein by-products in growing pigs.

OBJECTIVE: This study was to investigate the nutrient ileal digestibility of dried mealworm (Tenebrio molitor) larvae and compare with those of three animal protein by-products in growing pigs. METHODS: A total of 12 crossbred ([Landrace×Yorkshire]×Duroc) growing pigs with average body weights of 24.12±0.68 kg were surgically equipped with simple T-cannulas after being deprived of feed for 24 h according to published surgical procedures. These pigs had a recovery period of two weeks. A total of 12 pigs were assigned to individual metabolic crates and allotted to one of four treatments with 3 replicates in a fully randomized design. Dietary treatments included the following: i) Fish meal, corn-vegetable by-product basal diet+9.95% fish meal; ii) Meat meal, corn-vegetable by-product basal diet+9.95% meat meal; iii) Poultry meal, corn-vegetable by-product basal diet+9.95% poultry meal; iv) Tenebrio molitor, corn-vegetable by-product basal diet+9.95% dried Tenebrio molitor larvae. RESULTS: Results showed that the apparent ileal digestibility (AID) of Lys was higher (p<0.05) in pigs fed Tenebrio molitor diet than that in pigs fed fish meal diet. Pigs fed Tenebrio molitor diet showed increased (p<0.05) AID of His and Arg compared to pigs fed Fish meal or Meat meal diet. The AID of Cys was increased (p<0.05) in pigs fed poultry meal and Tenebrio molitor diets compared to that in pigs fish meal diet. Pigs fed meat meal, poultry meal, and Tenebrio molitor diets showed higher (p<0.05) standardized ileal digestibility (SID) of total energy compared to pigs fed fish meal diet. The SID of Arg was higher (p<0.05) in pigs fed Tenebrio molitor diet than that in pigs fed fish meal or meat meal diet. Furthermore, pigs fed poultry meal or Tenebrio molitor diets showed increased (p<0.05) SID of Cys compared to pigs fed fish meal diet. CONCLUSION: In conclusion, providing pigs with diets that contained Tenebrio molitor larvae meal improved AID and SID of nutrients as well as essential and non-essential amino acids. The digestibility of dried mealworm larvae protein and its utilization in vivo are also good. Therefore, dried mealworm larvae protein can be used as protein source at 10% level in growing pigs.

API5 confers cancer stem cell-like properties through the FGF2-NANOG axis.

Immune selection drives the evolution of tumor cells toward an immune-resistant and cancer stem cell (CSC)-like phenotype. We reported that apoptosis inhibitor-5 (API5) acts as an immune escape factor, which has a significant role in controlling immune resistance to antigen-specific T cells, but its functional association with CSC-like properties remains largely unknown. In this study, we demonstrated for the first time that API5 confers CSC-like properties, including NANOG expression, the frequency of CD44-positive cells and sphere-forming capacity. Critically, these CSC-like properties mediated by API5 are dependent on FGFR1 signaling, which is triggered by E2F1-dependent FGF2 expression. Furthermore, we uncovered the FGF2-NANOG molecular axis as a downstream component of API5 signaling that is conserved in cervical cancer patients. Finally, we found that the blockade of FGFR signaling is an effective strategy to control API5high human cancer. Thus, our findings reveal a crucial role of API5 in linking immune resistance and CSC-like properties, and provide the rationale for its therapeutic application for the treatment of API5+ refractory tumors.

Mandibular stability using sliding or conventional four-hole plates for fixation after bilateral sagittal split ramus osteotomy for mandibular setback.

Our aim was to compare the postoperative stability of the mandible when two different fixation methods had been used after bilateral sagittal split ramus osteotomy (BSSRO) for mandibular setback. The study included 23 patients who had two-jaw BSSRO mandibular setback at the Department of Oromaxillofacial Surgery, Korea University Guro Hospital, between January 2011 and June 2014. The first group (four-hole (control) group, n=13) comprised patients whose bony segments were fixed with conventional four-hole plates, and the second (sliding plate (experimental) group, n=10) included patients whose bone segments were fixed with sliding plates. Lateral cephalograms were taken and analysed at three time points: preoperatively (T1), and one week (T2), and 1year (T3) postoperatively. The Mann-Whitney U test was used to compare the postoperative stability of the mandible in each group. There were no significant differences between the two groups in changes in the horizontal and vertical positions of point B and pogonion postoperatively, nor were there any significant differences between them in ramal inclination and inclination of the SN plane with point B at the given time points (p=>0.05 in surgical changes in the mandible immediately after surgery and 0.397, 0.616, 0.082, 0.951, 0.901, 0.476 in postoperative changes in the mandible 1 week to 1 year after surgery). Like the conventional four-hole plate, the sliding plate can also be used to achieve stability in the fixation of mandibular bone segments after BSSRO.

Control of interior surface materials for speech privacy in high-speed train cabins.

The effect of interior materials with various absorption coefficients on speech privacy was investigated in a 1:10 scale model of one high-speed train cabin geometry. The speech transmission index (STI) and privacy distance (rP ) were measured in the train cabin to quantify speech privacy. Measurement cases were selected for the ceiling, sidewall, and front and back walls and were classified as high-, medium- and low-absorption coefficient cases. Interior materials with high absorption coefficients yielded a low rP , and the ceiling had the largest impact on both the STI and rP among the interior elements. Combinations of the three cases were measured, and the maximum reduction in rP by the absorptive surfaces was 2.4 m, which exceeds the space between two rows of chairs in the high-speed train. Additionally, the contribution of the interior elements to speech privacy was analyzed using recorded impulse responses and a multiple regression model for rP using the equivalent absorption area. The analysis confirmed that the ceiling was the most important interior element for improving speech privacy. These results can be used to find the relative decrease in rP in the acoustic design of interior materials to improve speech privacy in train cabins.

Clinical impact of tumor volume reduction in rectal cancer following preoperative chemoradiation.

PURPOSE: The purpose of this study was to correlate tumor volumetric analysis obtained using magnetic resonance (MR) imaging with disease-free survival in patients with advanced rectal cancer who underwent preoperative chemoradiotherapy (CRT). PATIENTS AND METHODS: Institutional review board approval was obtained and patient informed consent was waived. This study included 74 patients (47 men, 27 women; mean age, 64 years±10 [SD] years) who underwent preoperative CRT and subsequent rectal surgery between January 2007 and December 2010. Two radiologists who were blinded to the clinical outcome measured tumor volume separately on two sets of MR images obtained before and after CRT. Patients were classified into two groups according to the episode of recurrence and recorded disease-free survival. To assess factors relevant to disease-free survival, univariate and multivariate Cox regression analysis were performed for tumor volume reduction ratio, circumferential resection margin, tumor regression grade, and pathologic staging. RESULTS: Tumor volume reduction ratio (P=0.009), circumferential resection margin (P=0.008) and tumor regression grade (P=0.002) were significantly associated with disease-free survival. At multivariate analysis, tumor volume reduction ratio was the single variable that was associated with disease-free survival (P=0.003). Tumor volume reduction ratio was also a reliable parameter with an excellent interobserver correlation between two readers for pre-CRT volume (ICC=0.939; 95%CI: 0.885-0.979; P<0.001) and post-CRT volume (ICC=0.889; 95%CI: 0.845-0.934; P<0.001). CONCLUSIONS: MR volumetric measurement of rectal cancer helps predict disease-free survival in patients with rectal cancer who underwent preoperative CRT.

Removal ratio of gaseous toluene and xylene transported from air to root zone via the stem by indoor plants.

This work was designed to investigate the removal efficiency as well as the ratios of toluene and xylene transported from air to root zone via the stem and by direct diffusion from the air into the medium. Indoor plants (Schefflera actinophylla and Ficus benghalensis) were placed in a sealed test chamber. Shoot or root zone were sealed with a Teflon bag, and gaseous toluene and xylene were exposed. Removal efficiency of toluene and total xylene (m, p, o) was 13.3 and 7.0 µg·m(-3)·m(-2) leaf area over a 24-h period in S. actinophylla, and was 13.0 and 7.3 µg·m(-3)·m(-2) leaf area in F. benghalensis. Gaseous toluene and xylene in a chamber were absorbed through leaf and transported via the stem, and finally reached to root zone, and also transported by direct diffusion from the air into the medium. Toluene and xylene transported via the stem was decreased with time after exposure. Xylene transported via the stem was higher than that by direct diffusion from the air into the medium over a 24-h period. The ratios of toluene transported via the stem versus direct diffusion from the air into the medium were 46.3 and 53.7% in S. actinophylla, and 46.9 and 53.1% in F. benghalensis, for an average of 47 and 53% for both species. The ratios of m,p-xylene transported over 3 to 9 h via the stem versus direct diffusion from the air into the medium was 58.5 and 41.5% in S. actinophylla, and 60.7 and 39.3% in F. benghalensis, for an average of 60 and 40% for both species, whereas the ratios of o-xylene transported via the stem versus direct diffusion from the air into the medium were 61 and 39%. Both S. actinophylla and F. benghalensis removed toluene and xylene from the air. The ratios of toluene and xylene transported from air to root zone via the stem were 47 and 60 %, respectively. This result suggests that root zone is a significant contributor to gaseous toluene and xylene removal, and transported via the stem plays an important role in this process.

Anti-androgen flutamide suppresses hepatocellular carcinoma cell proliferation via the aryl hydrocarbon receptor mediated induction of transforming growth factor-ß1.

The aryl hydrocarbon receptor (AhR) is a ligand-activated transcription factor and a member of the basic helix-loop-helix PER/ARNT/SIM family of chemosensors and developmental regulators. The AhR is widely known as a mediator of dioxin toxicity; however, it also suppresses cancer cell proliferation and recent findings have implicated its role as a tumor suppressor. We conducted a chemical library screen to identify nontoxic AhR ligands with anti-cancer effects and discovered flutamide (Eulexin) as a putative AhR ligand. Flutamide is an androgen receptor (AR) antagonist approved by the United States Food and Drug Administration for the treatment of prostate cancer. We found that flutamide inhibited the growth of several cancer cell lines independent of AR status, and that suppression of AhR expression reversed the anti-proliferative effects of flutamide. We investigated the AhR-dependent mechanism of action of flutamide in human hepatocellular carcinoma cells and identified that transforming growth factor-ß1 (TGF-ß1) is induced by flutamide in an AhR-dependent manner. In contrast, the potent AhR agonist 2,3,7,8-Tetrachlorodibenzo-p-dioxin had no effect on TGF-ß1 expression, indicating the ligand specificity of AhR activation. We also determined that TGF-ß1 induction is required for the AhR-dependent growth inhibitory effects of flutamide. Therefore, flutamide may be effective in AhR-positive cancers that are sensitive to TGF-ß1 signaling, such as hepatocellular carcinoma.

The aryl hydrocarbon receptor mediates raloxifene-induced apoptosis in estrogen receptor-negative hepatoma and breast cancer cells.

Identification of new molecular targets for the treatment of breast cancer is an important clinical goal, especially for triple-negative breast cancer, which is refractory to existing targeted treatments. The aryl hydrocarbon receptor (AhR) is a ligand-activated transcription factor known primarily as the mediator of dioxin toxicity. However, the AhR can also inhibit cellular proliferation in a ligand-dependent manner and act as a tumor suppressor in mice, and thus may be a potential anticancer target. To investigate the AhR as an anticancer target, we conducted a small molecule screen to discover novel AhR ligands with anticancer properties. We identified raloxifene, a selective estrogen receptor (ER) modulator currently used in the clinic for prevention of ER-positive breast cancer and osteoporosis in post-menopausal women, as an AhR activator. Raloxifene directly bound the AhR and induced apoptosis in ER-negative mouse and human hepatoma cells in an AhR-dependent manner, indicating that the AhR is a molecular target of raloxifene and mediates raloxifene-induced apoptosis in the absence of ER. Raloxifene selectively induced apoptosis of triple-negative MDA-MB-231 breast cancer cells compared with non-transformed mammary epithelial cells via the AhR. Combined with recent data showing that raloxifene inhibits triple-negative breast cancer xenografts in vivo (Int J Oncol. 43(3):785-92, 2013), our results support the possibility of repurposing of raloxifene as an AhR-targeted therapeutic for triple-negative breast cancer patients. To this end, we also evaluated the role of AhR expression on survival of patients diagnosed with breast cancer. We found that higher expression of the AhR is significantly associated with increased overall survival and distant metastasis-free survival in both hormone-dependent (ER-positive) and hormone-independent (ER and progesterone receptor (PR)-negative) breast cancers. Together, our data strongly support the possibility of using the AhR as a molecular target for the treatment of hormone-independent breast cancers.

Correlation of antibiotic prophylaxis and difficulty of extraction with postoperative inflammatory complications in the lower third molar surgery.

Our aim was to investigate the correlation among antibiotic prophylaxis, difficulty of extraction, and postoperative complications in the removal of lower 3rd molars. A total of 1222 such extractions in 890 patients between January 2010 and January 2012 were analysed retrospectively. The difficulty of extraction measured by Pederson's index, antibiotic prophylaxis with cefditoren, and postoperative complications were recorded. The difficulty of extraction was significantly associated with postoperative complications (p=0.03). There were no significant associations between antibiotic prophylaxis and postoperative complications in groups of equal difficulty ("easy" group (class I) p=1.00; "moderate" group (class II) p=1.00; and "difficult" group (class III) p=0.65). There was a small but insignificant increase in the number of dry sockets and infections in class III cases. In conclusion, this study provides further evidence that antibiotic prophylaxis for the prevention of postoperative inflammatory complications is unnecessary for extraction of 3rd molars.

Advantage of 3D volumetric dosemeter in delivery quality assurance of dynamic arc therapy: comparison of pencil beam and Monte Carlo calculations.

OBJECTIVE: To evaluate the accuracy of pencil beam calculation (PBC) and Monte Carlo calculation (MCC) for dynamic arc therapy (DAT) in a cylindrically shaped homogenous phantom, by comparing the two plans with an ion chamber, a film and a three-dimensional (3D) volumetric dosemeter. METHODS: For this study, an in-house phantom was constructed, and the PBC and MCC plans for DAT were performed using iPlan® RT (BrainLAB®, Heimstetten, Germany). The A16 micro ion chamber (Standard Imaging, Middleton, WI), Gafchromic® EBT2 film (International Specialty Products, Wayne, NJ) and ArcCHECK™ (Sun Nuclear, Melbourne, FL) were used for measurements. For comparison with each plan, two-dimensional (2D) and 3D gamma analyses were performed using 3%/3 mm and 2%/2 mm criteria. RESULTS: The difference between the PBC and MCC plans using 2D and 3D gamma analyses was found to be 7.85% and 28.8%, respectively. The ion chamber and 2D dose distribution measurements did not exhibit this difference revealed by the comparison between the PBC and MCC plans. However, the 3D assessment showed a significant difference between the PBC and MCC (62.7% for PBC vs 93.4% for MCC, p = 0.034). CONCLUSION: Evaluation using a 3D volumetric dosemeter can be clinically useful for delivery quality assurance (QA), and the MCC should be used to achieve the most reliable dose calculation for DAT. ADVANCES IN KNOWLEDGE: (1) The DAT plan calculated using the PBC has a limitation in the calculation methods, and a 3D volumetric dosemeter was found to be an adequate tool for delivery QA of DAT. (2) The MCC was superior to PBC in terms of the accuracy in dose calculation for DAT even in the homogenous condition.

An outbreak of lymphomas in a layer chicken flock previously infected with fowlpox virus containing integrated reticuloendotheliosis virus.

Visceral lymphomas occurred in a 236-day-old layer flock previously diagnosed with reticuloendotheliosis virus (REV)-integrated fowlpox virus (FPV) infection at the age of 77 days. Common pathologic lesions were multiple neoplastic nodules of homogeneous lymphocytes in the livers and spleens of all submitted chickens. All neoplastic tissues were positive for the REV envelope (env) gene by PCR. In a retrospective molecular study of FPV-infected 77-day-old chickens from the same flock, we identified nearly full-length REV provirus integrated into the genome of FPV as well as the REV env gene in trachea samples, whereas only the REV LTR region was present in the FPV strain used to vaccinate this flock. The 622-bp REV env gene nucleotide sequence derived from the trachea and neoplastic tissues was identical. Commercial ELISA of serum samples revealed that all chickens aged between 17 and 263 days in this flock were positive for REV but not for avian leukosis virus. Taken together, the evidence suggests that the visceral lymphomas were caused by a REV-integrated FPV field strain. FPV infections of commercial chickens should be followed up by careful monitoring for manifestations of REV infection, including lymphomas and immune depression, considering the ease with which the REV provirus appears to be able to integrate into the FPV genome.

Biotemplated silica and titania nanowires: synthesis, characterization and potential applications.

A simple biotemplating method for the synthesis of silica (SiO2) and titania (TiO2) nanowires was designed on a fibrillar protein (alpha-synuclein) template. The diameter of SiO2 and TiO2 nanowires could be varied, between 20-100 nm, by varying the processing conditions. The nanowires were characterized by energy dispersive spectroscopy (EDS) and electron energy loss spectroscopy (EELS). Due to their high surface area and porosity, the nanowires were tested for potential applications in enzymatic biosensor design.

Supine linac treatment versus tomotherapy in craniospinal irradiation: planning comparison and dosimetric evaluation.

Craniospinal irradiation (CSI) is the standard treatment of primary intracranial tumour with risk of leptomeningeal dissemination. However, supine setup field-in-field technique does not need inter-fractional junction shift. Recently, the studies of CSI with tomotherapy showed excellent target coverage and tolerable normal organ dose in paediatric patients. The planning comparison and dosimetric difference between conventional radiotherapy and tomotherapy are presented. Three patients with central nervous system germinoma received supine CSI treatment. Normal tissue complication probability calculation was performed for parotid gland, kidney, lens, small bowel, ovary and testis. Homogenous vertebral body coverage for tomotherapy compared with conformal radiotherapy was found. The mean dose to each parotid gland decreased by 7.3 and 10 Gy, respectively, with tomotherapy. The volume of oesophagus and small bowel receiving >10 Gy was significantly lower. The V2, V5, V10 and V20 of the lungs are 81.6, 12.4, 2.3 and 0 % with tomotherapy. Tomotherapy showed excellent homogenous dose distribution through the craniospinal axis (PTV) and higher conformity index.

Improvement of transmittance by fabricating broadband subwavelength anti-reflection structures for polycarbonate.

We report on how to increase transmittance of a 0.2 mm thick polycarbonate (PC) film by periodic subwavelength anti-reflection structures in the visible spectral range. Subwavelength anti-reflection structures like moth-eyes are fabricated into the polycarbonate substrate itself by thermal nano-imprinting lithography (TH-NIL), which uses silicon stamps that have periodic structures such as gratings (lines and spaces) and pillared dots, and are fabricated by laser interference lithography (LIL) and transformer coupled plasma etching. To increase transmittance of a polycarbonate film, we control the periods and shapes of patterns, the number of patterned surfaces, and the overlapping direction of patterns that are fabricated into its surfaces. As a result of this, we show that average transmittance improves as the pattern period gets shorter and as both surfaces of the film are patterned. We also show that the spectrum range gets larger as the pattern period gets shorter and is determined by the longer pattern period in the case of designing a film to have different pattern period on its surfaces. The maximum average transmittance of a polycarbonate film increases up to approximately 6% compared to a bare sample in the 470-800 nm spectral range.

A novel chimeric promoter that is highly responsive to hypoxia and metals.

To develop a potent hypoxia-inducible promoter, we evaluated the usefulness of chimeric combinations of the (Egr-1)-binding site (EBS) from the Egr-1 gene, the metal-response element (MRE) from the metallothionein gene, and the hypoxia-response element (HRE) from the phosphoglycerate kinase 1 gene. In transient transfection assays, combining three copies of HRE (3 x HRE) with either EBS or MRE significantly increased hypoxia responsiveness. When a three-enhancer combination was tested, the EBS-MRE-3 x HRE (E-M-H) gave a hypoxia induction ratio of 69. The expression induced from E-M-H-pGL3 was 2.4-fold higher than that induced from H-pGL3 and even surpassed the expression from a human cytomegalovirus promoter-driven vector. The high inducibility of E-M-H was confirmed by validation studies in different cells and by expressing other cDNAs. Gel shift assays together with functional overexpression studies suggested that increased levels of hypoxia-inducible factor 1alpha, metal transcription factor-1 and Egr-1 may be associated with the high inducibility of the E-M-H chimeric promoter. E-M-H was also induced by hypoxia mimetics such as Co2+ and deferoxamine (DFX) and by hydrogen peroxide. Gene expression from the E-M-H was reversible as shown by the reduced expression of the transgene upon removal of inducers such as hypoxia and DFX. In vivo evaluation of the E-M-H in ischemic muscle revealed that erythropoietin secretion and luciferase and LacZ expression were significantly higher in the E-M-H group than in a control or H group. With its high induction capacity and versatile means of modulation, this novel chimeric promoter should find wide application in the treatment of ischemic diseases and cancer.

Phorbol ester up-regulates aldose reductase expression in A549 cells: a potential role for aldose reductase in cell cycle modulation.

Over-expression of aldose reductase (AR) has been observed in many cancer cells. To clarify the role of AR in tumor cells, we investigated the pathways mediating expression of the AR gene induced by 12-O-tetradecanoylphorbol-13-acetate (TPA), a potent tumor promoter. In A549 human lung adenocarcinoma cells, TPA elicited a dose- and time-dependent increase in AR mRNA level with an elevated enzyme activity. The TPA-induced increase in mRNA level and promoter activity of the AR gene was significantly attenuated in the presence of an inhibitor of protein kinase C, tyrosine kinase, or nuclear factor kappaB (NF-kappaB). TPA augmented the NF-kappaB-dependent gene transcription, indicating the involvement of NF-kappaB in this regulation. Accumulation of TPA-treated cells in S phase was almost completely abolished in the presence of ethyl 1-benzyl-3-hydroxy-2(5H)-oxopyrrole-4-carboxylate, an AR inhibitor. Taken together, TPA augmented the promoter activity of the AR gene via the activation of protein kinase and NF-kappaB. The inhibition of AR may assist in the chemotherapy of malignant tumors by suppressing the rapid growth of cancer cells.

Genetic basis of hearing loss associated with enlarged vestibular aqueducts in Koreans.

Sensorineural hearing loss associated with enlargement of the vestibular aqueduct (EVA) can be associated with mutations of the SLC26A4 gene. In western populations, less than one-half of the affected individuals with EVA have two mutant SLC26A4 alleles, and EVA is frequently caused by unknown genetic or environmental factors alone or in combination with a single SLC26A4 mutation as part of a complex trait. In this study, we ascertained 26 Korean probands with EVA and performed nucleotide sequence analysis to detect SLC26A4 mutations. All subjects had bilateral EVA, and 20 of 26 were sporadic (simplex) cases. Fourteen different mutations were identified, including nine novel mutations. Five mutations were recurrent and accounted for 80% of all mutant alleles, providing a basis for the design and interpretation of cost-efficient mutation detection algorithms. Two mutant alleles were identified in 21 (81%), one mutant allele was detected in three (11%), and zero mutant allele was detected in two (8%) of 26 probands. The high proportion of Korean probands with two SLC26A4 mutations may reflect a reduced frequency of other genetic or environmental factors causing EVA in comparison to western populations.