The tyrosine kinase inhibitor nintedanib activates SHP-1 and induces apoptosis in triple-negative breast cancer cells

Chun-Yu Liu,Tzu-Ting Huang,Pei-Yi Chu,Chun-Teng Huang,Chia-Han Lee,Wan-Lun Wang,Ka-Yi Lau,Wen-Chun Tsai,Tzu-I Chao,Jung-Chen Su,Ming-Huang Chen,Chung-Wai Shiau,Ling-Ming Tseng,Kuen-Feng Chen 생화학분자생물학회 2017 Experimental and molecular medicine Vol.49 No.-

Triple-negative breast cancer (TNBC) remains difficult to treat and urgently needs new therapeutic options. Nintedanib, a multikinase inhibitor, has exhibited efficacy in early clinical trials for HER2-negative breast cancer. In this study, we examined a new molecular mechanism of nintedanib in TNBC. The results demonstrated that nintedanib enhanced TNBC cell apoptosis, which was accompanied by a reduction of p-STAT3 and its downstream proteins. STAT3 overexpression suppressed nintedanib-mediated apoptosis and further increased the activity of purified SHP-1 protein. Moreover, treatment with either a specific inhibitor of SHP-1 or SHP-1-targeted siRNA reduced the apoptotic effects of nintedanib, which validates the role of SHP-1 in nintedanib-mediated apoptosis. Furthermore, nintedanib-induced apoptosis was attenuated in TNBC cells expressing SHP-1 mutants with constantly open conformations, suggesting that the autoinhibitory mechanism of SHP-1 attenuated the effects of nintedanib. Importantly, nintedanib significantly inhibited tumor growth via the SHP-1/p-STAT3 pathway. Clinically, SHP-1 levels were downregulated, whereas p-STAT3 was upregulated in tumor tissues, and SHP-1 transcripts were associated with improved disease-free survival in TNBC patients. Our findings revealed that nintedanib induces TNBC apoptosis by acting as a SHP-1 agonist, suggesting that targeting STAT3 by enhancing SHP-1 expression could be a viable therapeutic strategy against TNBC.

TRANSNATIONAL LEISURE INVOLVEMENT AND TRAVEL MOTIVATION OF CONTEMPORARY MIGRANTS

Wei-Jue Huang,Chun-Chu Chen 글로벌지식마케팅경영학회 2018 Global Marketing Conference Vol.2018 No.07

Introduction Globalization not only increases human mobility, but changes the relationship between international migrants and their country of origin. With improved transportation systems and new technologies, migrants can stay connected to their homeland in multiple ways. In the past, it was costly and time-consuming for migrants to keep in touch with their homeland. Thus, the ability to assimilate into the culture and lifestyle of the mainstream society was important (Alba & Nee, 2003; Portes & Zhou, 1993). At the same time, migrants and minority groups also form ethnic enclaves (e.g., Chinatown, Little Italy) where they can maintain the culture and traditions of home and preserve a part of their cultural identity (Portes & Manning, 1986). Contemporary migrants, however, live in a transnational social field (Louie, 2006). They can easily communicate with their friends and family back home. Even if they reside in rural areas, most goods from the old country can be found in the new country. Migrants can shop online for the groceries, books, fashion, beauty products, kitchenware, etc. from their homeland. They can listen to hit songs in their native language, keep up with the major news events, follow the newest TV series, cheer for their favorite sports teams, watch live election results, and more—almost as if they have never left. Traveling back to the homeland is one important way for migrants to main transnational ties (Haller & Landolt, 2005). This type of travel is commonly known as diaspora tourism (Coles & Timothy, 2004), VFR tourism (Uriely, 2010), and roots tourism (Maruyama & Stronza, 2010). Migrants may visit the homeland for various reasons, including: leisure, business, local food, culture and heritage, quest, retain ties, finding oneself, roots-seeking, personal identity, connection with place, obligation to ancestors, recovery of social identity, and family togetherness (Kluin & Lehtom, 2012; Li & McKercher, 2016; Murdy, Alexander, & Bryce, 2018; Ray & McCain, 2012). Given that contemporary migrants can engage in transnational practices in the host society, and take part in various types of leisure activities that are related to the culture and lifestyle of home, the question is: do migrants still feel the need to visit the homeland in person? Or since everything is readily available, they do not need to go back as often as before. On one hand, participating in transnational leisure activities may strengthen their attachment to the homeland and increase their longing to return. On the other hand, the accessibility of homeland goods, services, culture, and relationships through global networks may decrease the desire and frequency of traveling back to the homeland. Therefore, the purpose of this study is to examine the relationship between transnational leisure activities and motivation to visit the homeland. Specifically, do migrants‘ transnational leisure participation and involvement influence their diaspora tourism motivation? Literature Review Transnationalism refers to the interconnected lifestyle and social experience of immigrants maintaining multiple ties with their home and host societies (Basch, Glick-Schiller, & Blanc, 1994). Transnationalism could be sustained through different types of activities, including economic, political, social, familial, religious, and cultural activities. Although leisure activities have not been a focus of transnationalism research, some cultural transnational practices overlap with leisure activities. The Immigration and Intergenerational Mobility in Metropolitan Los Angeles study (IIMMLA) found that 8.1% of second-generation immigrants participated in organizations associated with their parents‘ country of birth, and 48.7% watched TV or listened to the radio in their parents‘ language at least once a week or more (Rumbaut et al., 2008). The Immigrant Second Generation in New York study (ISGNY) revealed that ethnic music is very important to West Indian immigrants, and they listened to more ethnic music. Chinese-Americans, however, might listen to some Cantonese pop, but usually not traditional Chinese music (Kasinitz et al., 2008). Within leisure research, most studies on the leisure activities of immigrants employ the theory of acculturation. The focus was not on transnational leisure, but on immigrants‘ leisure participation within the mainstream culture of the host society. Many studies examined the effect of acculturation on immigrant leisure, be it participation, perceived benefits, motivations, or constraints. Floyd and Gramann (1993) compared Mexican- and Anglo-Americans to determine if the former‘s outdoor activity patterns and site visitation would be similar to the latter, based on different levels of structural assimilation. Shaull and Gramann (1998) also examined Hispanic- and Anglo-Americans to determine the impact of cultural assimilation on one‘s perceived benefits of outdoor recreation. They found a strong Anglo-conformity pattern in Hispanic-Americans‘ perception of nature-related benefits, while family-related benefits were less prone to the impact of cultural assimilation. Another study by Walker, Deng, and Dieser (2001) compared the motivations of Chinese-Canadians and Euro-North Americans for outdoor recreation. Their findings indicated that acculturation influenced the recreation motivation of Chinese-Canadians, both directly and indirectly through self-construal. The relationship between acculturation and leisure was also examined in Yu and Berryman‘s study (1996) on immigrant adolescents, which revealed a positive relationship between acculturation and recreational activities, and a negative relationship between acculturation and perceived barriers. A similar relationship was found in Scott, Lee, Lee and Kim‘s (2006) study of Korean migrants. They identified some constraints (i.e., lack of English proficiency and fear of discrimination) that varied by one‘s level of acculturation, while the biggest constraint, time, was not influenced by acculturation. Stodolska and Santos (2006) were the first to propose the concept of transnational leisure, and they defined it as leisure that is maintained by transnational migrants to foster their ties with their countries and communities of origin (p. 162). Huang, Norman, Ramshaw, and Haller (2015) identified different types of transnational leisure activities by second-generation Chinese-Americans, and categorized them into four types: ethnic events and festivals, ethnic social clubs and organizations, ethnic media and pop culture, and Internet-based activities. As these previous studies were qualitative in nature, there is a need for more quantitative research so as to compare and identify different patterns of transnational leisure (e.g., level of involvement, frequency of participation) and examine how transnational leisure relate to other variables. Methods This study aims to examine the transnational leisure involvement and travel motivation of diaspora tourists. Specifically, overseas Chinese residing in North America (i.e., the USA and Canada) was selected as the target population. The service of a reputable and reliable international online survey company was obtained to reach out to this specific population of interest. Data collection took place from December 2016 to January 2017. A total of 808 responses were gathered. A questionnaire was developed based on previous literature. A list of transnational leisure activities with 19 items was developed based on the work of Huang et al. (2015). The transnational leisure involvement scale was adapted from the works of Kyle, Graefe, Manning, and Bacon (2003) and Kyle, Bricker, Graefe, and Wickham (2004). The scale consists of 14 items and three dimensions: Attraction, Centrality, and Self-expression. As there are many types of transnational leisure activities, respondents were first asked to go through the list and indicate their frequency of participation in each activity. Next, they were asked to think about these activities as they answered the leisure involvement scale. The measures for diaspora tourism motivation was developed based on Poria and colleagues‘ scale for heritage tourism motivation (2004; 2006a; 2006b), Kluin and Lehto‘s (2012) scale for family reunion travel motivations, and Li and McKercher‘s (2016) qualitative study on diaspora tourists. The last section of the questionnaire will be used to collect demographic information. Findings EFA was conducted to explore if transnational leisure activities can be categorized into different types. Three items were removed due to double loading (i.e., Sing Chinese songs in the karaoke, Online shopping for Chinese/Asian items, and Connect with friends and relatives in China through social media). Factor 1 consisted of 3 items that are basic common activities in migrant life, and was labeled Basic transnational leisure (i.e., Eat Chinese food, Shop for Chinese/Asian groceries, and Celebrate Chinese holidays). Factor 2 consisted of 7 items that are related to pop culture and internet-based leisure activities, and was labeled Media-based transnational leisure (e.g., Listen to Chinese songs and music, Watch Chinese drama, Visit websites related to Chinese or Chinese-American culture, and Read/watch the news related to China). Contrary to the individualistic nature of the activities in Factor 2, Factor 3 consisted of 6 items that are more likely to be group activities, and related to social clubs events and activities (e.g., Attend events hosted by Chinese ethnic organizations, Participate in Chinese cultural activities, Play Chinese board or card games, Attend Chinese concerts/performances, and Follow Chinese/Chinese-American sports players or teams). Thus, Factor 3 was labeled Event-based transnational leisure. Respondents‘ participation in these activities was measured on a 5-point scale of frequency, from 1=Never to 5=Always/Everyday. Overall, Basic transnational leisure received the highest mean score (M=3.82), while the means for Media-based (M=2.86) and Event-based activities (M=2.62) were lower. Although the mean scores in Factor 2 and 3 were not high, it should be noted that the nature of these activities are different. Chinese migrants can Eat Chinese food every day, but they cannot Attending Chinese concerts every day. Therefore, the mean scores for Event-based activities were the lowest. Moreover, ANOVA was conducted to compare five migrant generation groups (e.g., first-generation migrants who were born in the old country and relocated to a new country and second-generation migrants are native-born in the new country). The second generation had the lowest level of participation, while the first generation and 4+ generation had the highest level of participation in most types of transnational leisure activities. Correlation analyses further revealed that the frequency of Media-based activities and Event-based activities were positively correlated to the number of homeland trips, while the relationship between Basic transnational leisure and number of homeland trips was not statistically significant. Lastly, CFA was conducted to confirm the underlying dimensions of Transnational Leisure Involvement: Attraction (6 items), Centrality (4 items), and Self-expression (4 items). EFA was conducted to identify the dimensions of diaspora tourism motivation. The 11 items loaded on one of two factors: Chinese Culture (6 items) and Family Heritage (5 items). Multiple regression analyses were conducted, with the three dimensions of transnational leisure involvement as independent variables, and the two dimensions of diaspora tourism motivation as dependent variables. It was found that Attraction and Centrality would influence respondents‘ motivation for Chinese Culture, while Attraction, Centrality, and Self-expression would influence respondents‘ motivation for Personal Heritage. Discussion Results showed that transnational leisure involvement is useful in understanding the activity patterns of different migrant generations. Specifically, the relationships between transnational involvement and diaspora tourism motivation were consistently positive, which provides an effective means of segmenting diaspora tourists. Transnational leisure activities are good opportunities for homeland destinations to connect with diaspora tourists prior to their travel. Other than direct promotional activities, transnational leisure provides an alternative way to increase diaspora tourists‘ level of engagement and frequency of travel to the homeland.

Clinical Practice of Blood Transfusion in Orthotopic Organ Transplantation: A Single Institution Experience

Tsai, Huang-Wen,Hsieh, Fu-Chien,Chang, Chih-Chun,Su, Ming-Jang,Chu, Fang-Yeh,Chen, Kuo-Hsin,Jeng, Kuo-Shyang,Chen, Yun Asian Pacific Journal of Cancer Prevention 2015 Asian Pacific journal of cancer prevention Vol.16 No.17

Background: Orthotopic organ transplantation, a treatment option for irreversible organ dysfunction according to organ failure, severe damaged organ or malignancy in situ, was usually accompanied with massive blood loss thus transfusion was required. We aimed to evaluate the adverse impact of blood transfusion on solid organ transplantation. Materials and Methods: From January, 2009 to December, 2014, patients who received orthotopic organ transplantation at Far Eastern Memorial Hospital medical center were enrolled. Clinical data regarding anemia status and red blood cell (RBC) transfusion before, during and after operation, as well as patient outcomes were collected for further univariate analysis. Results: A total of 105 patients who underwent orthotopic transplantation, including liver, kidney and small intestine were registered. The mean hemoglobin (Hb) level upon admission and before operation were $11.6{\pm}1.8g/dL$ and $11.7{\pm}1.7g/dL$, respectively; and the nadir Hb level post operation and the final Hb level before discharge were $8.3{\pm}1.6g/dL$ and $10.2{\pm}1.6g/dL$, respectively. The median units (interquartile range) of RBC transfusion in pre-operative, peri-operative and post-operative periods were 0 (0-0), 2 (0-12), and 2 (0-6) units, respectively. Furthermore, the median (interquartile range) length of hospital stay (LHS) from admission to discharge and from operation to discharge were 28 (17-44) and 24 (16-37) days, respectively. Both peri-operative and post-operative RBC transfusion were associated with longer LHS from admission to discharge and from operation to discharge. Furthermore, it increased the risk of post-operative septicemia. While peri-operative RBC transfusion elevated the risk of acute graft rejection in patients who received orthotopic transplantation. Conclusions: Worse outcome could be anticipated in those who had received massive RBC transfusion in transplantation operation. Hence, peri-operative RBC transfusion should be avoided as much as possible.

Creatine Kinase (CK)-MB-to-Total-CK Ratio: a Laboratory Indicator for Primary Cancer Screening

Chang, Chih-Chun,Liou, Ching-Biau,Su, Ming-Jang,Lee, Yi-Chen,Liang, Chai-Ting,Ho, Jung-Li,Tsai, Huang-Wen,Yen, Tzung-Hai,Chu, Fang-Yeh Asian Pacific Journal of Cancer Prevention 2015 Asian Pacific journal of cancer prevention Vol.16 No.15

Background: For the determination of creatine kinase (CK)-MB, the immunoinhibition method is utilized most commonly. However, the estimated CK-MB activity may be influenced by the presence of CK isoenzymes in some conditions like cancer. Thus, a CK-MB-to-total-CK ratio more than 1.0 could be found in such a situation. The study aimed to explore the relationship of cancer to high CK-MB-to-total-CK ratio. Materials and Methods: From January 2011 to December 2014, laboratory data on all CK-MB and total CK test requests were extracted at Far Eastern Memorial Hospital (88,415 requests). Patients with a CK-MB-to-total-CK ratio more than 1.0 were registered in this study. Clinical data including tumor location, tumor TNM stage and metastatic status were also collected. Results: A total of 846 patients were identified with a CK-MB-to-total-CK ratio more than 1.0. Of these, 339 (40.1%) were diagnosed with malignancies. The mean CK-MB-to-total-CK ratio was significantly higher in malignancy than in non-malignancy ($1.35{\pm}0.28$ vs $1.25{\pm}0.23$, p<0.001) groups. The most frequent malignancy with a CK-MB-to-total-CK ratio more than 1.0 was colorectal cancer ($1.42{\pm}0.28$, 16.5%, n=56), followed by lung cancer ($1.38{\pm}0.24$, 15.9%, n=54) and hepatocellular carcinoma (14.5%, n=49). Higher CK-MB-to-total-CK ratios in hematological malignancies ($1.44{\pm}0.41$)were also noted. Additionally, the CK-MB-to-total-CK ratio was markedly higher in advanced stage malignancy than in early stage ($1.37{\pm}0.26$ vs. $1.29{\pm}0.31$, p=0.014) and significantly higher in liver metastasis than in non-liver metastasis ($1.48{\pm}0.30$ vs. $1.30{\pm}0.21$, p<0.001). Conclusions: The CK-MB-to-total-CK ratio is an easily available indicator and could be clinically utilized as a primary screening tool for cancer. Higher ratio of CK-MB-to-total-CK was specifically associated with certain malignancies, like colorectal cancer, lung cancer and hepatocellular carcinoma, as well as some cancer-associated status factors such as advanced stage and liver metastasis.

The effect of simulated borer infested shoot pruning on yield parameters of eggplant

R. Srinivasan,Chun-Chu Huang 한국응용곤충학회 2009 Journal of Asia-Pacific Entomology Vol.12 No.1

Pruning and prompt disposal of pest-damaged eggplant shoots at regular intervals up to the first harvest is an important component in the eggplant fruit and shoot borer (EFSB) IPM strategy. However, the impact of pruning on yield parameters remains unknown. We conducted field experiments during 2005–2007 to analyze the impact of pruning on the yield of an EFSB-susceptible accession (EG075) and a commercial cultivar (‘Pingtung long’) through simulated studies. Shoot pruning did not have any significant effect on the mean number of fruits per plant in both varieties. However, significant differences in mean fruit length of ‘Pingtung long’ occurred among the treatments; the longest fruit length (25.22 cm) was recorded with 30% shoot pruning. The mean fruit diameter and fruit weight did not differ significantly in ‘Pingtung long’ or EG075, and there was no significant yield reduction due to shoot pruning in either variety. Pruning and prompt disposal of pest-damaged eggplant shoots at regular intervals up to the first harvest is an important component in the eggplant fruit and shoot borer (EFSB) IPM strategy. However, the impact of pruning on yield parameters remains unknown. We conducted field experiments during 2005–2007 to analyze the impact of pruning on the yield of an EFSB-susceptible accession (EG075) and a commercial cultivar (‘Pingtung long’) through simulated studies. Shoot pruning did not have any significant effect on the mean number of fruits per plant in both varieties. However, significant differences in mean fruit length of ‘Pingtung long’ occurred among the treatments; the longest fruit length (25.22 cm) was recorded with 30% shoot pruning. The mean fruit diameter and fruit weight did not differ significantly in ‘Pingtung long’ or EG075, and there was no significant yield reduction due to shoot pruning in either variety.

Diagnostic Role of Serum Free-to-Total Prostate Specific Antigen (PSA) Ratio in Prostate Cancer with Serum Total Concentration of PSA below 4 ng/mL

Chang, Chih-Chun,Lee, Yi-Chen,Tsai, Huang-Wen,Yii, Shyi-Chun,Yen, Tzung-Hai,Chu, Fang-Yeh Asian Pacific Journal of Cancer Prevention 2015 Asian Pacific journal of cancer prevention Vol.16 No.13

Purpose: To examine the effectiveness of serum free-to-total prostate specific antigen ratio (%fPSA) for the detection of prostate cancer (PCa) in men with different serum total PSA (tPSA) categories. Materials and Methods: From January 2010 to December 2013, a total of 225 patients with lower urinary tract symptoms (LUTS) underwent tPSA and %fPSA measurements. Histological examination with calculation of Gleason score and whole body bone scans were performed in identified cases of PCa. Results: PCa was diagnosed in 44 (19.6%) patients and the remaining 181 patients had benign prostate disease. PCa was detected in 5 (23.8%), 13 (8.7%) and 26 (47.3%) cases with tPSA level ranges ${\leq}4ng/ml$, 4 to 10 ng/ml and >10 ng/ml, respectively. The average Gleason score was $7.2{\pm}0.2$. Some 6 (13.6%) out of 44 PCa patients had bone metastases. The sensitivity was 80% and specificity was 81.3% at the cut-off %fPSA of 15% in PCa patients with a tPSA level below 4 ng/mL. A lower %fPSA was associated with PCa patients with Gleason score ${\geq}7$ than those with Gleason score ${\leq}6$ ($11.7{\pm}0.98$ vs. $16.5{\pm}2.25%$, P=0.029). No obvious relation of %fPSA to the incidence of bone metastasis was apparent in this study. Conclusions: The clinical application of %fPSA could help to discriminate PCa from benign prostate disease in men with a tPSA concentration below 4 ng/mL.

The Lymphotoxin-α 252 A>G Polymorphism and Breast Cancer: A Meta-analysis

Zhou, Ping,Huang, Wei,Chu, Xing,Du, Liang-Feng,Li, Jian-Ping,Zhang, Chun Asian Pacific Journal of Cancer Prevention 2012 Asian Pacific journal of cancer prevention Vol.13 No.5

Objective: The aim of this meta-analysis is to evaluate associations between LTA-252 A>G and breast cancer (BC). Methods: Electronic searches of several databases were conducted for all online publications. A total of 7 studies involving 4,625 BC patients and 4,373 controls were identified. Results: This meta-analysis showed no significant association between the LTA-252 A>G polymorphism and BC in overall or Caucasian populations. However, a positive association was found limited to Asian populations. Conclusion: Although there was no significant association found between the LTA-252 A>G polymorphism and BC overall, a positive association was found in Asian populations.

Genetic Dissection for Intra-and Intercellular Small Interfering RNA Pathways in Arabidopsis by Activation Tagging

Munawar Ahmad,Chun Lin Shi,Mohammad Nazim Uddin,Won Kyong Cho,Yeong Gil Rim,Hyo Sub Chu,Li Jun Huang,Jae Yean Kim 한국응용생명화학회 2008 Applied Biological Chemistry (Appl Biol Chem) Vol.51 No.5

Design Customization of Respiratory Mask based on 3D Face Anthropometric Data

Chih-Hsing Chu,Szu-Hao Huang,Chih-Kai Yang,Chun-Yang Tseng 한국정밀공학회 2015 International Journal of Precision Engineering and Vol. No.

This study presents a machine learning based method for design customization of a 3D respiratory mask. A parametric model of a3D human face was constructed from an anthropometric database consisting of 495 facial models. An AdaBoost.R algorithm wasapplied to identify a set of measurable parameters most related to the facial geometry. The correlation between parameters wasestimated using principal component analysis and linear regression. With those parameter values as input, the parametric modelgenerates 3D meshes of a human face that serve as a design reference for the construction of a customized respiratory mask of agood fit. We conducted a series of experiments with 10-fold cross-validation to validate the effectiveness of the proposed method.

The Immunotyping Distribution of Serum Monoclonal Paraprotein and Environmental Impact on Multiple Myeloma (MM) and Monoclonal Gammopathy of Uncertain Significance (MGUS) in Taiwan: A Medical Center-Based Experience

Chang, Chih-Chun,Su, Ming-Jang,Lee, Shu-Jene,Tsai, Yu-Hui,Kuo, Lin-Yin,Lin, I-Hsin,Huang, Hui-Ling,Yen, Tzung-Hai,Chu, Fang-Yeh Asian Pacific Journal of Cancer Prevention 2016 Asian Pacific journal of cancer prevention Vol.17 No.1

Background: Whether ambient exposure to environmental pollutants leads to hematopoietic malignancies such as multiple myeloma (MM) remains to be ascertained. Therefore, we aimed to investigate the immunotyping distribution of serum monoclonal paraprotein and the environmental influence on MM and monoclonal gammopathy of uncertain significance (MGUS) in the Taiwanese population. Materials and Methods: Serum protein electrophoresis with immunosubtraction by the capillary zone electrophoresis method was performed as primary screening for MM and MGUS. Clinical, pathological, and residence data of patients were also obtained. Results: From August, 2013 to June, 2015, a total of 327 patients underwent serum protein electrophoresis with immunosubtraction. Among these, 281 demonstrated no remarkable findings or non-malignant oligoclonal gammopathy, 23 were detected to have MGUS, 18 were identified as MM, and a further 5 were found as other malignancies. The most frequent immunotyping distribution of serum monoclonal paraprotein was IgG kappa (54.3%, n=25), followed by IgA lambda (15.2%, n=7) and IgG lambda (10.9%, n=5) in subjects with gammopathy. Additionally, it was shown that the elderly (OR: 4.61, 95% CI: 1.88-11.30, P<0.01) and males (OR: 2.04, 95% CI: 1.04-4.02, P=0.04) had significantly higher risk of developing MM and MGUS. There was no obvious impact of environmental factors on the health risk of MM and MGUS evolution (OR: 0.77, 95% CI: 0.40-1.50, P=0.49). Conclusions: The most frequent immunotyping distribution of serum monoclonal paraprotein included IgG kappa, IgA lambda and IgG lambda in MM and MGUS in the Taiwanese population. The elderly and male subjects are at significantly higher risk of MM and MGUS development, but there was no obvious impact of environmental factors on risk.