Gut microbiota: a superior operator for dietary phytochemicals to improve atherosclerosis.

Mounting evidence implicates the gut microbiota as a possible key susceptibility factor for atherosclerosis (AS). The employment of dietary phytochemicals that strive to target the gut microbiota has gained scientific support for treating AS. This study conducted a general overview of the links between the gut microbiota and AS, and summarized available evidence that dietary phytochemicals improve AS via manipulating gut microbiota. Then, the microbial metabolism of several dietary phytochemicals was summarized, along with a discussion on the metabolites formed and the biotransformation pathways involving key gut bacteria and enzymes. This study additionally focused on the anti-atherosclerotic potential of representative metabolites from dietary phytochemicals, and investigated their underlying molecular mechanisms. In summary, microbiota-dependent dietary phytochemical therapy is a promising strategy for AS management, and knowledge of "phytochemical-microbiota-biotransformation" may be a breakthrough in the search for novel anti-atherogenic agents.

ADP-dependent glucokinase controls metabolic fitness in prostate cancer progression.

BACKGROUND: Cell metabolism plays a pivotal role in tumor progression, and targeting cancer metabolism might effectively kill cancer cells. We aimed to investigate the role of hexokinases in prostate cancer (PCa) and identify a crucial target for PCa treatment. METHODS: The Cancer Genome Atlas (TCGA) database, online tools and clinical samples were used to assess the expression and prognostic role of ADP-dependent glucokinase (ADPGK) in PCa. The effect of ADPGK expression on PCa cell malignant phenotypes was validated in vitro and in vivo. Quantitative proteomics, metabolomics, and extracellular acidification rate (ECAR) and oxygen consumption rate (OCR) tests were performed to evaluate the impact of ADPGK on PCa metabolism. The underlying mechanisms were explored through ADPGK overexpression and knockdown, co-immunoprecipitation (Co-IP), ECAR analysis and cell counting kit-8 (CCK-8) assays. RESULTS: ADPGK was the only glucokinase that was both upregulated and predicted worse overall survival (OS) in prostate adenocarcinoma (PRAD). Clinical sample analysis demonstrated that ADPGK was markedly upregulated in PCa tissues vs. non-PCa tissues. High ADPGK expression indicates worse survival outcomes, and ADPGK serves as an independent factor of biochemical recurrence. In vitro and in vivo experiments showed that ADPGK overexpression promoted PCa cell proliferation and migration, and ADPGK inhibition suppressed malignant phenotypes. Metabolomics, proteomics, and ECAR and OCR tests revealed that ADPGK significantly accelerated glycolysis in PCa. Mechanistically, ADPGK binds aldolase C (ALDOC) to promote glycolysis via AMP-activated protein kinase (AMPK) phosphorylation. ALDOC was positively correlated with ADPGK, and high ALDOC expression was associated with worse survival outcomes in PCa. CONCLUSIONS: In summary, ADPGK is a driving factor in PCa progression, and its high expression contributes to a poor prognosis in PCa patients. ADPGK accelerates PCa glycolysis and progression by activating ALDOC-AMPK signaling, suggesting that ADPGK might be an effective target and marker for PCa treatment and prognosis evaluation.

The effect of bladder function on the efficacy of transurethral prostatectomy in patients with benign prostatic hyperplasia: a retrospective, single-center study.

We investigated the impact and predictive value of bladder function in patients with benign prostatic hyperplasia (BPH) on the efficacy of transurethral prostatectomy. Symptomatic, imaging, and urodynamic data of patients who underwent transurethral prostatectomy at West China Hospital of Sichuan University (Chengdu, China) from July 2019 to December 2021 were collected. Follow-up data included the quality of life (QoL), International Prostate Symptom Score (IPSS), and IPSS storage and voiding (IPSS-s and IPSS-v). Moreover, urinary creatinine (Cr), nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and prostaglandin estradiol (PGE2) were measured in 30 patients with BPH and 30 healthy participants. Perioperative indicators were determined by subgroup analyses and receiver operating characteristic (ROC) curve analysis. Among the 313 patients with BPH included, patients with severe micturition problems had more improvements but higher micturition grades postoperatively than those with moderate symptoms. Similarly, good bladder sensation, compliance, and detrusor contractility (DC) were predictors of low postoperative IPSS and QoL. The urinary concentrations of BDNF/Cr, NGF/Cr, and PGE2/Cr in patients were significantly higher than those in healthy participants (all P < 0.001). After evaluation, only DC was significantly related to both urinary indicators and postoperative recovery of patients. Patients with good DC, as predicted by urinary indicators, had lower IPSS and IPSS-v than those with reduced DC at the 1st month postoperatively (both P < 0.05). In summary, patients with impaired bladder function had poor recovery. The combined levels of urinary BDNF/Cr, NGF/Cr, and PGE2/Cr in patients with BPH may be valid predictors of preoperative bladder function and postoperative recovery.

Clinical benefit and safety associated with mRNA vaccines for advanced solid tumors: A meta-analysis.

Tumor mRNA vaccines have been developed for over 20 years. Whether mRNA vaccines could promote a clinical benefit to advanced cancer patients is highly unknown. PubMed and Embase were retrieved from January 1, 2000 to January 4, 2023. Random effects models were employed. Clinical benefit (objective response rate [ORR], disease control rate [DCR], 1-year/2-year progression-free survival [PFS], and overall survival [OS]) and safety (vaccine-related grade 3-5 adverse events [AEs]) were evaluated. Overall, 984 patients (32 trials) were enrolled. The most typical cancer types were melanoma (13 trials), non-small cell lung cancer (5 trials), renal cell carcinoma (4 trials), and prostate adenocarcinoma (4 trials). The pooled ORR and DCR estimates were 10.0% (95%CI, 4.6-17.0%) and 34.6% (95%CI, 24.1-45.9%). The estimates for 1-year and 2-year PFS were 38.4% (95%CI, 24.8-53.0%) and 20.0% (95%CI, 10.4-31.7%), respectively. The estimates for 1-year and 2-year OS were 75.3% (95%CI, 62.4-86.3%) and 45.5% (95%CI, 34.0-57.2%), respectively. The estimate for vaccine-related grade 3-5 AEs was 1.0% (95%CI, 0.2-2.4%). Conclusively, mRNA vaccines seem to demonstrate modest clinical response rates, with acceptable survival rates and rare grade 3-5 AEs.

Insight into mixed chlorine/chloramines conversion and associated water quality variability in drinking water distribution systems.

Mixed chlorine/chloramines are common in drinking water distribution systems (DWDSs); however, their transformation and impact on chemical and microbial characteristics are not well understood. We systematically investigated water quality parameters associated with mixed chlorine/chloramine species conversion in 192 samples (including raw, finished, and tap water) collected throughout the year in a city in East China. Various chlorine/chloramine species (free chlorine, monochloramine [NH2Cl], dichloramine [NHCl2], and organic chloramines [OC]) were detected in both chlorinated and chloraminated DWDSs. NHCl2 + OC increased with transport distance along the pipeline network. The maximum proportion of NHCl2 + OC in over total chlorine in tap water reached 66 % and 38 % from chlorinated and chloraminated DWDSs, respectively. Both free chlorine and NH2Cl showed a rapid decay in the water pipe systems, but NHCl2 and OC were more persistent. Correlations between chlorine/chloramine species and physicochemical parameters were established. Models for predicting the sum of chloroform/TCM, bromodichloromethane/BDCM, chlorodibromomethane/CBDM, and bromoform/TBM (THM4) (R2 = 0.56) and haloacetic acids (HAAs) (R2 = 0.65) exhibited greater accuracy based on machine learning tuned with chlorine/chloramine species, particularly NHCl2 + OC. The predominant bacterial communities in mixed chlorine/chloramine systems were those resistant to chlorine or chloramine such as proteobacteria. NH2Cl was the most significant explanatory factor (28.1 %) for the variation in microbial community assemblage in chloraminated DWDSs. Although residual free chlorine and NHCl2 + OC, accounted for a smaller proportion of chlorine species in chloraminated DWDSs, they played an essential role (12.4 % and 9.1 %, respectively) in the microbial community structure.

YAP/Smad3 promotes pathological extracellular matrix microenviroment-induced bladder smooth muscle proliferation in bladder fibrosis progression.

Fibrosis is a chronic inflammation process with excess extracellular matrix (ECM) deposition that cannot be reversed. Patients suffer from bladder dysfunction caused by bladder fibrosis. Moreover, the interactive mechanisms between ECM and bladder fibrosis are still obscure. Hence, we assessed the pivotal effect of Yes-associated protein (YAP) on the proliferation of bladder smooth muscle in fibrosis process. We identified that stiff ECM increased the expression and translocation of YAP in the nucleus of human bladder smooth muscle cell (hBdSMC). Sequencings and proteomics revealed that YAP bound to Smad3 and promoted the proliferation of hBdSMC via MAPK/ERK signaling pathway in stiff ECM. Moreover, CUT and TAG sequencing and dual-luciferase assays demonstrated that Smad3 inhibited the transcription of JUN. The YAP inhibitor CA3 was used in a partial bladder outlet obstruction (pBOO) rat model. The results showed that CA3 attenuated bladder smooth muscle proliferation. Collectively, YAP binding with Smad3 in the nucleus inhibited the transcription of JUN, and promoted the proliferation of bladder smooth muscle through the MAPK/ERK signaling pathway. The current study identified a novel mechanism of mechanical force induced bladder fibrosis that provided insights in YAP-associated organ fibrosis.

Structural Characterization and In Vitro Fermentation Characteristics of Enzymatically Extracted Black Mulberry Polysaccharides.

In this study, we systematically investigated the structural characterization and in vitro fermentation patterns of crude black mulberry fruit polysaccharides (BMPs), either extracted by water (BMP) or by enzymatic treatment. Different enzymatic treatments were pectinase-extracted (PE)-BMP, pectin lyase-extracted (PL)-BMP, cellulase-extracted (CE)-BMP, and compound enzymes-extracted (M)-BMP (pectinase:pectin lyase:cellulase = 1:1:1). Our results show that enzymatic treatment improved the polysaccharide yield and led to a different chemical composition and structure for the polysaccharides. Change dynamics during the in vitro fermentation indicated that BMPs could indeed be degraded and consumed by human fecal microbiota and that different BMPs showed different degrees of fermentability. In addition, BMPs stimulated the growth of Bacteroidetes and Firmicutes, inhibited the growth of Fusobacteria and Proteobacteria (except for CE-BMP), and induced the production of short-chain fatty acids (SCFAs). Furthermore, we found that BMP and PL-BMP exhibited better fermentability and prebiotic potential than the other polysaccharides.

Neoadjuvant chemotherapy for patients with locally advanced penile cancer: an updated evidence.

Neoadjuvant chemotherapy (NAC) has shown promising results in patients with locally advanced penile cancer. However, no consensus exists on its applications for locally advanced penile cancer. Thus, it is unclear which kind of chemotherapy regimen is the best choice. Consequently, a systematic search of PubMed, Web of Science, and EMBASE was performed in March 2021 to assess the efficacy and safety of NAC for the treatment of patients with locally advanced penile cancer. The Newcastle-Ottawa Scale was used to assess the risk of bias in each study. This study synthesized 14 published studies. The study revealed that patients who achieved an objective response to NAC obtained a better survival outcome compared with those who did not achieve an objective response. In addition, the objective response rates (ORRs) and pathological complete response (pCR) rates were 0.57 and 0.11, respectively. The incidence of grade ≥3 toxicity was 0.36. Subgroup analysis found that the ORR and pCR of the taxane-platinum (TP) regimen group performed better than those of the nontaxane-platinum (NTP) regimen group (0.57 vs 0.54 and 0.14 vs 0.07, respectively). Moreover, the TP regimen group had more frequent toxicity than the NTP regimen group (0.41 vs 0.26). However, further studies were warranted to confirm the findings.

Dietary Fiber Modulates the Fermentation Patterns of Cyanidin-3-O-Glucoside in a Fiber-Type Dependent Manner.

The interactions between cell-wall polysaccharides and polyphenols in the gastrointestinal tract have attracted extensive attention. We hypothesized that dietary fiber modulates the fermentation patterns of cyanidin-3-O-glucoside (C3G) in a fiber-type-dependent manner. In the present study, the effects of four dietary fibers (fructose-oligosaccharides, pectin, ß-glucan and arabinoxylan) on the modulation of C3G fermentation patterns were investigated through in vitro fermentation inoculated with human feces. The changes in gas volume, pH, total carbohydrate content, metabolites of C3G, antioxidant activity, and microbial community distribution during in vitro fermentation were analyzed. After 24 h of fermentation, the gas volume and total carbohydrate contents of the four dietary-fiber-supplemented groups respectively increased and decreased to varying degrees. The results showed that the C3G metabolites after in vitro fermentation mainly included cyanidin, protocatechuic acid, 2,4,6-trihydroxybenzoic acid, and 2,4,6-trihydroxybenzaldehyde. Supplementation of dietary fibers changed the proportions of C3G metabolites depending on the structures. Dietary fibers increased the production of short-chain fatty acids and the relative abundance of gut microbiota Bifidobacterium and Lactobacillus, thus potentially maintaining colonic health to a certain extent. In conclusion, the used dietary fibers modulate the fermentation patterns of C3G in a fiber-type-dependent manner.

Using untargeted metabolomics to profile the changes in roselle (Hibiscus sabdariffa L.) anthocyanins during wine fermentation.

In this study, an UHPLC-QE-MS approach in combination with multivariate statistical analyses was used to investigate the metabolic profiles, especially the anthocyanin profiles, during the fermentation of roselle wine. Overall, a large number of different metabolites (e.g., phenols, lipids, carbohydrates, amino acids and peptides, and others) were identified in the fermentation processes. Eight anthocyanin metabolites were identified in roselle wine for the first time, of which six were identified in the main fermentation process and two in the post-fermentation process. In addition, we identified several metabolic pathways during the fermentation process, and the metabolic pathways of anthocyanins in roselle wine are mainly related to flavonoid biosynthesis and to anthocyanin biosynthesis. These findings are expected to be useful for further studies on wine chemistry and yeast metabolism.

Recent advances on bioactive polysaccharides from mulberry.

Mulberry (Moraceae family), commonly considered as a folk remedy, has a long history of usage in many regions of the world. Polysaccharides regarded as one of the major components in mulberry plants, and they possess antioxidant, antidiabetic, hepatoprotective, prebiotic, immunomodulatory and antitumor properties, among others. In recent decades, mulberry polysaccharides have been widely studied for their multiple health benefits and potential economic value. However, there are few reviews providing updated information on polysaccharides from mulberry. In this review, recent advances in the study of isolation, purification, structural characterization, biological activity and the structure-activity relationship of mulberry polysaccharides are summarized and discussed. Furthermore, a thorough analysis of the current trends and perspectives on mulberry polysaccharides is also proposed. Hopefully, these findings can provide a useful reference value for the development and application of natural polysaccharides in the field of functional food and medicine in the future.

Tuina for periarthritis of shoulder: A systematic review protocol.

BACKGROUND: Periarthritis of shoulder (PAS) symptom is one of the leading causes prompting many patients to seek treatment. Tuina is a common treatment for PAS in China. But at present, there is no systematic evaluation report on its therapeutic effectiveness and safety. This protocol aims to reveal the efficacy and safety of Tuina for treating PAS. METHODS: The following databases will be searched by electronic methods: PubMed, EBASE, WHO International Clinical Trials Registry Platform, Embase, the Chinese Biomedical Literature Database (CBM), Wan-fang Data (WANFANG), the China National Knowledge Infrastructure (CNKI), and other sources from inception to December 2019. Bias risk, subgroup analysis, data synthesis, and meta-analyses will be assessed with RevMan V.5.3 software if the data is met inclusion conditions. RESULTS: This study will present a quality evidence of Tuina for the treatment of PAS patients. CONCLUSION: The systematic review will present reliable evidence to judge whether or not Tuina is a safe and effective intervention for PAS patients. PROSPERO REGISTRATION NUMBER: CRD42019147445.

Pretreatment elevated fibrinogen level predicts worse oncologic outcomes in upper tract urothelial carcinoma.

This study aimed to further validate the prognostic role of fibrinogen in upper tract urothelial carcinoma (UTUC) in a large Chinese cohort. A total of 703 patients who underwent radical nephroureterectomy were retrospectively identified. Fibrinogen levels of ≥4.025 g l-1 were defined as elevated. Logistic regression analysis was performed to determine the association between fibrinogen and adverse pathological features. Kaplan-Meier analysis and Cox regression models were used to assess the associations of fibrinogen with cancer-specific survival (CSS), disease recurrence-free survival (RFS), and overall survival (OS). Harrell c-index and decision curve analysis were used to assess the clinical utility of multivariate models. The median follow-up duration was 42 (range: 1-168) months. Logistic regression analysis revealed that elevated fibrinogen was associated with higher tumor stage and grade, lymph node involvement, lymphovascular invasion, sessile carcinoma, concomitant variant histology, and positive surgical margins (all P < 0.05). Multivariate Cox regression analysis demonstrated that elevated fibrinogen was independently associated with decreased CSS (hazard ratio [HR]: 2.33; P < 0.001), RFS (HR: 2.09; P < 0.001), and OS (HR: 2.09; P < 0.001). The predictive accuracies of the multivariate models were improved by 3.2%, 2.0%, and 2.8% for CSS, RFS, and OS, respectively, when fibrinogen was added. Decision curve analysis showed an added benefit for CSS prediction when fibrinogen was added to the model. Preoperative fibrinogen may be a strong independent predictor of worse oncologic outcomes in UTUC; therefore, it may be valuable to apply this marker to the current risk stratification in UTUC.

IL-8 protects prostate cancer cells from GSK-3ß-induced oxidative stress by activating the mTOR signaling pathway.

INTRODUCTION: Both oxidative stress and inflammation play important roles in prostate cancer cell apoptosis or proliferation; however, the mechanisms underlying these processes remain unclear. Thus, we selected interleukin-8 (IL-8) as the bridge between inflammation and cancer cell oxidative stress-induced death and aimed to confirm its connection with mTOR and Glycogen synthase kinase-3 beta (GSK-3ß). METHODS: We overexpressed GSK-3ß and observed its effect on reactive oxygen species (ROS) and oxidative stress-induced cell death. IL-8 was then upregulated or downregulated to determine its impact on preventing cell damage due to GSK-3ß-induced oxidative stress. In addition, we overexpressed or knocked down mTOR to confirm its role in this process. Real-time PCR, Western blotting, transcription, Cell Counting Kit 8 (CCK-8), and flow cytometry analyses were performed in addition to the use of other techniques. RESULTS: IL-8 promotes prostate cancer cell proliferation and decreases apoptosis, whereas GSK-3ß activates the caspase-3 signaling pathway by increasing ROS and thereby induces oxidative stress-mediated cell death. In addition, mTOR can also decrease activation of the caspase-3 signaling pathway by inhibiting GSK-3 and thus decreasing ROS production. Moreover, the inhibitory effect of IL-8 on GSK-3ß occurs through the regulation of mTOR. CONCLUSION: The results of this study highlight the importance of GSK-3ß, which increases the production of ROS and thereby induces oxidative stress in tumor cells, whereas IL-8 and mTOR attenuate oxidative stress to protect prostate cancer cells through inhibition of GSK-3ß.

The preoperative serum cystatin-C as an independent prognostic factor for survival in upper tract urothelial carcinoma.

Cystatin-C (Cys-C) has been reported as a valuable prognostic biomarker in various malignancies. However, its effect on upper tract urothelial carcinoma (UTUC) patients has not been investigated before. Thus, to explore the impact of Cys-C on survival outcomes in patients undergoing radical nephroureterectomy (RNU), a total of 538 patients with UTUC who underwent RNU between 2005 and 2014 in our center (West China Hospital, Chengdu, China) were included in this study. Kaplan-Meier method and Cox regression analyses were performed to assess the relationship between Cys-C and survival outcomes using SPSS version 22.0. The cutoff value of Cys-C was set as 1.4 mg l-1 using the receiver operating characteristic (ROC) curves and Youden index. The mean age of patients included was 66.1 ± 11.1 years, and the median follow-up duration was 38 (interquartile range: 19-56) months. Overall, 162 (30.1%) patients had elevated Cys-C, and they were much older and had worse renal function than those with Cys-C <1.4 mg l-1 (both P < 0.001). Meanwhile, Kaplan-Meier analysis revealed that the group with elevated Cys-C had worse cancer-specific survival (CSS, P = 0.001), disease recurrence-free survival (RFS, P = 0.003), and overall survival (OS, P < 0.001). Multivariable Cox analysis suggested that the elevated Cys-C was identified as an independent prognostic predictor of CSS (hazard ratio [HR]: 1.997, 95% confidential interval [CI]: 1.331-2.996), RFS (HR: 1.429, 95% CI: 1.009-2.023), and OS (HR: 1.989, 95% CI: 1.366-2.896). In conclusion, our result revealed that the elevated preoperative serum Cys-C was significantly associated with worse outcomes in UTUC patients undergoing RNU.

The Antimuscarinic Agent Tolterodine Regulates Bladder Extracellular Matrix in Partial Bladder Outlet Obstruction in Rats.

BACKGROUND/AIMS: Antimuscarinic agents can delay the progression of bladder dysfunction caused by bladder outlet obstruction (BOO). To date, the relationship between muscarinic receptor activity and the bladder extracellular matrix (ECM) remains unclear. Thus, an animal model of partial BOO (PBOO) in female rats was established to explore the variation in bladder wall ECM proteins under PBOO conditions with antimuscarinic agent administration. METHODS: Rats were randomly divided into three groups: sham, PBOO, and PBOO plus tolterodine. Picrosirius red staining was used to examine the smooth muscle and collagen content of bladder samples. Gene microarray and RT-PCR were performed to survey the expression of ECM proteins, receptors, and metabolism regulators in the rat bladder. Positive results were further evaluated by immunohistochemistry. RESULTS: Picrosirius red staining showed that smooth muscle volume significantly increased in the PBOO and PBOO plus tolterodine groups (p < 0.05), while collagen significantly increased in the PBOO group (p < 0.05) but not in the PBOO plus tolterodine group. Gene microarray and RT-PCR revealed that none of the collagen subtypes exhibited significant changes after PBOO establishment and tolterodine administration. However, matrix metalloproteinases (MMPs) increased significantly in the PBOO plus tolterodine group (p < 0.05). Additionally, PBOO inhibited the expression of non-collagen ECM proteins in the rat bladder wall, while tolterodine induced the expression of non-collagen ECM proteins and ECM receptors. CONCLUSIONS: Tolterodine decreased the volume of collagen in PBOO rat bladder wall, possibly via MMPs, and regulated the expression of ECM proteins and receptors.

Baicalin is an inhibitor of subgroup J avian leukosis virus infection.

Avian leukosis virus subgroup J (ALV-J) can cause great economic losses to the poultry industry worldwide. Baicalin, one of the flavonoids present in S.baicalensis Georgi, has been shown to have antiviral activities. To investigate whether baicalin has antiviral effects on the infection of ALV-J in DF-1 cells, the cells were treated with baicalin at different time points. We found that baicalin could inhibit viral mRNA, protein levels and overall virus infection in a dose- and time-dependent manner using a variety of assays. Baicalin specifically targeted virus internalization and reduced the infectivity of ALV-J particles, but had no effect on the levels of major ALV-J receptor and virus binding to DF-1 cells. Collectively, these results suggest that baicalin might have potential to be developed as a novel antiviral agent for ALV-J infection.

Analgesic effects of Chinese Tuina massage in a rat model of pain.

Previous clinical trials have suggested that the Chinese Tuina massage may exert transient analgesic effects. However, further investigation regarding the underlying mechanism has been hindered by the lack of a suitable animal model of pain. The present study established a rat model of hind leg pain by injecting 5.8% hypertonic saline solution (HSS) into the left gastrocnemius muscle. The effects of various Tuina massages on the pain thresholds of the rats were then measured. In addition, the effects of ipsilateral and contralateral Tuina massages on C-fiber-evoked field potentials following electrical stimulation of the left sciatic nerve were determined. Alterations in the gastrocnemius muscle tissues following various Tuina applications were investigated using hematoxylin and eosin, and desmin staining, as well as malondialdehyde and superoxide dismutase assays. Heavy hand pressure transiently reduced the pain sensitivity of both posterior limbs, despite HSS only being injected into the left hind leg. Tuina massage treatments that lasted for 15 min were associated with the best results and an absence of local tissue changes. The results of electrical sciatic nerve stimulation demonstrated that ipsilateral and contralateral Tuina massage may decrease the level of peripheral nociceptive C-fiber activity. In the present study, the Chinese Tuina massage exerted analgesic effects in a rat model of pain, which did not involve tissue damage, following a 15 min massage. Therefore, the rat model of pain used in the present study may provide a novel approach for investigating the molecular and physiological mechanisms underlying the therapeutic effects of Tuina massage.