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Background:The optimal sampling points and thresholds for initial serum vancomycin (VCM) concentrations have not been determined in hemodialysis (HD) patients. To clarify this, multiple blood tests were performed, and the correlations between VCM concentrations at several sampling points and the area under the concentration-time curve for 24 hours (AUC24h) were analyzed., Methods:A single-center, prospective observational study was conducted. Patients with end-stage renal failure who received VCM treatment while undergoing chronic maintenance HD were enrolled in this study. HD was performed using a high-flux membrane as the dialyzer. After VCM administration, 7 points were sampled between the first and second HD. The AUC24h after the end of the first HD (AUC0-24) and that before the end of the second HD (AUC24-48) were calculated using the linear trapezoidal method. Correlation analysis and simple regression analysis between AUC24h and serum concentrations were performed at each sampling point., Results:Nine patients were evaluated. Strong correlations were found between AUC24-48 and serum concentrations at 24 hours after the initiation of VCM treatment following the first HD (C24h, R = 0.983 and P < 0.001), between AUC0-24 and C24h (R = 0.967 and P < 0.001), and between AUC24-48 and serum concentration just before the second HD (Cpre(HD2), R = 0.965 and P < 0.001). Regression equations with high coefficients of determination (R2 > 0.9) were obtained, and a C24h of ≥18.0 mg/L and a Cpre(HD2) of ≥16.5 mg/L were required to achieve an AUC24-48 value of ≥400 mg·h/L. In addition, a C24h of ≤23.3 mg/L was estimated to satisfy the AUC0-24 range of ≤600 mg·h/L., Conclusions:C24h and Cpre(HD2) are optimal sampling points for predicting VCM-AUC24h in HD patients.

In recent years, lifestyle-related diseases such as hypertension and diabetes have been on the rise. These conditions can cause serious conditions such as myocardial and cerebral infarctions. Therefore, proper control of blood pressure and blood glucose levels is important issues in preventive medicine. Traditional fermented foods have been shown to have various functions, and their effects on lifestyle-related diseases have attracted particular attention. In this study, we investigated the effects of fermented soybeans and rice bran (OE-1) and supplements containing OE-1 on blood glucose levels and weight changes. We identified an inhibitory effect on elevated blood glucose levels upon administration of OE-1, and this effect was thought to be due to digestive enzyme inhibition. These effects of foods containing OE-1 are expected to have a positive effect on the prevention and improvement of lifestyle-related diseases as health foods.

In this article I attempt to show that grammatical categories such as the adverbs dabei (with it/them) and doch (but, still) in German can be explained as prosodic, syntactic, semantic and pragmatic continuum based on their core meaning. Some classifications described and maintained in the traditional grammar of German, especially represented by the „valency grammar“, i.e. classifications as „sentential adverbs“ or „discourse markers“, therefore should be neutralized and newly considered. The grammatical categories in charge should be understood as crossing over the unit of sentence, and in this respect they are not „Satzglieder“ (sentence constituents), but „Äußerungsglieder“ (utterance constituents) as Darski (2010) claims. In the „adverbial“ area prosodic features and syntactic positions closely correspond to each other and on the other hand semantic contents and pragmatic effects do correspond too. The continuous scale of the elements dabei and doch can be seen as an ample example for demonstrating the „iconic“ relation between prosody/syntax and semantics/pragmatics, i.e. between forms and functions.

We treated a patient with neurosarcoidosis, which caused the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), in whom diagnosis was performed using neuroendoscopy. The patient was a 56-year-old female who was hospitalized for hyponatremia and diagnosed with SIADH based on a detailed examination. During the course, she developed impaired consciousness due to acute hydrocephalus, which improved after ventricular drainage. Head magnetic resonance imaging (MRI) confirmed nodular lesions at the floor of the third ventricle and the cerebral aqueduct. Neuroendoscopic biopsy led to the diagnosis of neurosarcoidosis. Her hyponatremia improved after steroid therapy. Neurosarcoidosis can cause SIADH, and complication of hydrocephalus may lead to a poor prognosis. Neuroendoscopy appears to be effective for the diagnosis of neurosarcoidosis with hydrocephalus and helps in deciding the treatment modality.

Background N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in patients with acute coronary syndrome (ACS), and is a powerful predictor of long-term mortality. Differences in the clinical utility and pathophysiological implication of NT-proBNP and conventional cardiac markers in patients with ST elevation (STE) vs non-STE (NSTE) ACS were investigated in the present study. Methods and Results Ninety consecutive patients admitted with acute chest pain and a diagnosis of unstable angina or acute myocardial infarction were analyzed. Patients with ≥Killip class II were excluded to focus on the effect of myocardial ischemia on the release of cardiac markers. The markers were measured on admission and analyzed according to the time from onset. Conventional cytosolic marker (creatine kinase-MB) and myofibril marker (troponin T: TnT) were both significantly higher in STE-ACS patients compared with NSTE-ACS patients. Conversely, NT-proBNP was significantly higher in NSTE-ACS patients than STE-ACS especially within 3 h of onset, suggesting a larger ischemic insult despite the smaller extent of myocardial necrosis compared with STE-ACS patients. There was no significant correlation between NT-proBNP level and left ventricular ejection fraction (LVEF) obtained at acute-phase echocardiography in either NSTE-ACS patients (LVEF 57.7±11.2%) or STE-ACS patients (LVEF 55.1±12.7%). Comparison between NT-proBNP and TnT levels revealed a marked difference of elevations, with significantly augmented elevation of NT-proBNP (p

症例は51歳の男性. 7年前に他院で盲腸癌に対して結腸右半切除術(D3)を施行された. por, se, n1 (+), stage III aであった. 2004年11月頃より肛門部掻痒感を主訴に近医を受診した.直腸診で下部直腸前壁に可動性不良の粘膜下腫瘍を触知したため精査となった.直腸・前立腺に浸潤する40×50mmの腫瘍を認めた.経直腸生検では低分化腺癌であった. PET検査では他に遠隔転移は認めなかった.盲腸癌が孤立性転移をしたものと考え骨盤内臓器全摘術を施行した.術中ダグラス窩部腹膜にひきつれを認めたが腫瘍は腹腔内に露出していなかった.他に転移は認めなかった.術後4カ月目に陰茎転移が判明した.その後,再発は認めていない.骨盤内臓器全摘術は過大な侵襲を伴い慎重な手術適応の判断が必要となるが,本症のように根治切除可能なものに対しては積極的外科治療を行うべきと考えられた.

後腹膜に原発する黄色肉芽腫は比較的稀な疾患である.今回,われわれは左坐骨神経に癒着していた後腹膜黄色肉芽腫の1例を経験したので報告する.症例は56歳,女性である.子宮癌検診で骨盤内に腫瘍を指摘され,当院婦人科に入院した.術前診断は有茎性子宮筋腫または卵巣腫瘍であった.開腹所見で骨盤内に8×7×5 cmの後腹膜に存在する腫瘍を認め,直腸を右方に圧排していた.腫瘍は仙骨と左坐骨神経に癒着していたが,剥離は可能で完全摘出した.病理組織学的には黄色肉芽腫であった.術後1年5カ月を経過した現在再発所見は認めていない.

症例は61歳の男性. 平成11年6月右下腹部痛を主訴に近医より当院紹介受診した. 右下腹部に有痛性の腫瘤を触知し急性虫垂炎の術前診断にて同日虫垂切除術を施行した. 病理組織学的には悪性リンパ腫 (diffuse large cell type) であった.腫大した体表リンパ節は触知せず術前の胸部単純X線写真, 他の消化管精査, 腹部CTにても異常所見認めず, 虫垂原発悪性リンパ腫と診断された. 術後化学療法追加した.虫垂原発悪性リンパ腫の本邦報告例は自験例を含め32例で, 文献的考察を含め報告する.

A 60-year-old man was admitted to the hospital because of constipation in July, 1993. With a diagnosis of rectal cancer (Rs) with synchronous multiple liver metastases (H3), an abdominal resection of the rectum, a right hepatic lobectomy and partial liver resections of the segment 3 and 4 were performed. After while, partial liver resections were performed twice for recurrences in the segment 4 of the liver in June, 1994 and September, 1995. In September, 1997, a left lateral segmentectomy of the liver and a partial resection of the gastric wall were performed for recurrence in the residual liver which directly invaded the stomach. At that time, No. 6 lymph node metastasis was observed. Histologically, the surgical margin of the stomach was positive, and a distal gastrectomy with D1 lymph nodes dissection was carried out in October, 1997. It is rare that metastatic tumor directly invades the stomach. We report the patient who is surviving for 5 years after the initial operation with aggressive liver resection.

A 50-year-old woman was admitted to the hospital because of an abnormal shadow detected incidentally by a routine chest X-ray, examination 4 years previously, when she was asymptomatic. The tumor gradually increased in size in those years. After admission, a partial resection of the lung including the tumor was performed. The tumor was attached to the visceral pleura of right lower lobe by a pedicle. Pathologically the tumor was solitary fibrous tumor of the pleura (localized fibrous mesothelioma). The histogenesis of solitary fibrous tumor is still controversial, but the mesencymal origin is preferred on the basis of immunohistochemical findings including CD34 positivity. In this case tumor cells also demonstrated positive for CD34.

A sulfated glycoglycerolipid, 1-O-(6′-sulfo-α-d-glucopyranosyl)-2,3-di-O-phytanyl-sn-glycerol (KN-208), a derivative of the polar lipid isolated from an archaebacterium, strongly inhibited DNA polymerase (pol) α and pol β in vitro among 5 eukaryotic DNA polymerases (α, β, γ, δ, and ϵ). It also inhibited Escherichia coli DNA polymerase I Klenow fragment (E. coli pol I) and human immunodeficiency virus reverse transcriptase (HIV RT). The mode of inhibition of these polymerases was competitive with the DNA template primer and was non-competitive with the substrate dTTP. KN-208 inhibited pol β most strongly, with a Ki value of 0.05 μM, 10-fold lower than that for pol α (0.5 μM) and 60- or 140-fold lower than that for HIV RT (3 μM) or for E. coli pol I (7 μM), respectively. The loss of sulfate on the 6′-position of glucopyranoside of this compound completely abrogated inhibition. However, the hydrophilic part of KN-208, glucose 6-sulfate alone, showed no inhibition. Other sulfated compounds containing different hydrophobic structures, such as dodecyl sulfate and cholesterol sulfate, exhibited a much weaker inhibition. Our results suggest that the whole molecular structure of KN-208 is required for inhibition. KN-208 was shown to be modestly cytotoxic for the human leukemic cell line K562. Interestingly, a subcytotoxic dose of KN-208 increased the sensitivity of the human leukemic cells to an alkylating agent, methyl methanesulfonate, while it did not potentiate the effects of ultraviolet light or of cisplatin. Int. J. Cancer 76:512–518, 1998.© 1998 Wiley-Liss, Inc.

Lithocholic acid (LCA), one of the major components in secondary bile acids, promotes carcinogenesis in rat colon epithelial cells induced by N-methyl-N'-nitro-N-nitrosoguanidine (MNNG), which methylates DNA. Base-excision repair of DNA lesions caused by the DNA methylating agents requires DNA polymerase beta (pol beta). In the present study, we examined 17 kinds of bile acids with respect to inhibition of mammalian DNA polymerases in vitro. Among them, only LCA and its derivatives inhibited DNA polymerases, while other bile acids were not inhibitory. Among eukaryotic DNA polymerases alpha, beta, delta, epsilon, and gamma, pol beta was the most sensitive to inhibition by LCA. The inhibition mode of pol beta was non-competitive with respect to the DNA template-primer and was competitive with the substrate, dTTP, with the Ki value of 10 microM. Chemical structures at the C-7 and C-12 positions in the sterol skeleton are important for the inhibitory activity of LCA. This inhibition could contribute to the tumor-promoting activity of LCA.

Wie ist ein Plagiat als solches schlüssig zu definieren und welche Instanzen befinden darüber? Durch die jüngsten Plagiat-Affären in(Deutschland und Österreich, Ungarn und Rumänien, in die ranghohe Politikerinnen und Politiker verwickelt waren, gewann der Begriff des Plagiats mit seinen Voraussetzungen und Konsequenzen neue und brisante Aktualität. Die seither in öffentlichen, kontrovers geführten Debatten aufgeworfenen Fragen werden im vorliegenden Band einer interdisziplinären Betrachtung unterzogen, an der Wissenschaftlerinnen und Wissenschaftler aus Literatur-, und Kulturwissenschaft, der Rechts- und Sozialwissenschaften sowie den Technik- und Biowissenschaften beteiligt sind. Auch synonyme und bedeutungsverwandte Begriffe wie Fälschung, Imitation, Kopie, Parodie, Kryptomnesie, Ideendiebstahl, Produkt- und Patentpiraterie werden berücksichtigt, insbesondere auch das Verhältnis von Urheberrecht und Plagiat: Nicht jedes Plagiat stellt eine Urheberrechtsverletzung dar und nicht jede Urheberrechtsverletzung ein Plagiat. In den einzelnen Beiträgen werden u. a. die historische Herausbildung von Urheberrechten, die Auffassung von Originalität und geistigem Eigentum sowie die postmoderne, literarische Infragestellung von Autor- und Urheberschaft behandelt. Anhand von konkreten Beispielen werden sowohl die aktuellen Verfahrensweisen des Plagiierens im Internet-Zeitalter dargestellt wie auch Methoden, Plagiate zu kontrollieren, ihnen vorzubeugen und sie zu verhindern.

A case of carcinoma of the pancreatic head associated with situs inversus (SI) and polycystic liver (PCL) is presented. The patient was a 71-year-old male with complaints of jaundice and general fatigue. Percutaneous transhepatic biliary drainage (PTBD) revealed complete obstruction of the lower end of the common bile duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis of the main pancreatic duct (MPD) in the head of the pancreas. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated multiple cysts in the liver as well as SI. Pylorus-preserving-pancreatoduodenectomy (PPPD) was performed by an operator who took his usual position on the patient's right side. We had no particular difficulty during surgery, although we had to charge several procedures. We consider it reliable to take the usual positions during surgery, even in cases of SI.

HMG-CoA還元酵素阻害剤であるsimvastatin (リポバス®) を脂質異常を呈する透析患者に投与し, その効果と安全性について検討した. 血清総コレステロール (TC) 200mg/dl以上または高比重リポ蛋白コレステロール (HDL-C) 35mg/dl以下を呈する透析患者38例, 男性20例, 女性18例, 平均年齢58.7歳を対象とし, simvastatin 1日5mgを投与し, 投与前より投与後6か月までの血清脂質, アポ蛋白, lipoprotein (a) (Lp (a)), 過酸化脂質 (MDA) を測定した. また, 超遠心法にてリポ蛋白を分離し各リポ蛋白内の脂質成分もそれぞれ測定した.simvastatin投与前後においてTCは, 25.7% (232.4±47.2mg/dl→172.6±32.9mg/dl), 低比重リポ蛋白コレステロール (LDL-C) は, 33.6% (151.0±36.9mg/dl→100.3±29.3mg/dl) と有意に低下したが, HDL-C, 中性脂肪には有意な変化は認められなかった. アポ蛋白は, アポB 24.5% (115.4±20.6mg/dl→87.1±20.5mg/dl), アポE 30.0% (6.9±2.8mg/dl→4.9±3.0mg/dl) と有意に低下したが, 他のアポ蛋白には有意な変化は少なかった. MDAも有意に低下したが, Lp (a) には変化は認められなかった. リポ蛋白の分画では超低比重リポ蛋白コレステロール (VLDL-C), 中間型リポ蛋白コレステロール (IDL-C), LDL1-C, LDL2-Cに有意な低下が認められたが, その他のリポ蛋白分画の脂質成分にはそれほど大きな変化は認められなかった. 安全性については, simvastatin投与12か月間において, 特記すべき副作用はほとんど認められなかった.以上のことよりsimvastatinは透析患者の高コレステロール血症に対して有効であり, かつ安全に使用できることが示された.

A case of esophageal leiomyoma with remarkable calcification is presented. A 65-year-old man was admitted to the hospital, because esophagography on a health screening demonstrated extraesophageal compression and deformity of the esophagus. Endoscopy showed a protruding lesion, 3cm in diameter, in the anterior wall of the esophagus under the bifurcation of the trachea. Esophagography and computed tomography showed a massive calcification in the lesion. With endoscopic ultrasonography a tumor originating from the proper muscular layer of the esophagus was suspected. Enucleation of the tumor was performed. The resected specimen was a hard and saddle-like tumor, 4×3×1.5cm in size. Histological findings revealed leiomyoma. Nine of 20 cases of calcified leiomyoma of the esophagus reported in Japan were characterized by the location in the anterior wall of the esophagus near the bifurcation of the trachea.

Discussions about topic-prominent language verus subject-prominent language are old but still of current interest. According to the now classic work of Li and Thompson (1976), topic-prominent languages possess the following characteristics: the topic is coded on the surface, that is morphologically and/or syntactically; passive constructions either do not or only marginally exist or carry a special meaning; there are no dummy or empty subjects; double subject constructions are available; it is not the subject but the topic that controls coreferential constituent deletion; verb-final languages tend to be topic-prominent; there are no constraints on what kind of constituent may be the topic; and topic-comment sentences are basic. The traditional grammar of Japanese distinguishes between two types of postpositional particles: kaku-joshi (case particles) on the one hand and kakari-joshi (relating/charging particles) on the other hand. Japanese reveals a relatively free word order, while maintaining a rigid verb-final position. This article sketches synchronic and diachronic case-drop phenomena, and exemplifies some other typologically related as well as unrelated languages for their functional parallelism.

SummaryBackgroundThe expanding role of cardiac markers – cytosolic [heart-type fatty acid-binding protein (H-FABP) and creatine kinase MB (CK-MB)], myofibril [troponin T (TnT)], and cardio-endocrine [N-terminal pro-B-type natriuretic peptide (NT-proBNP)] – has been clarified in patients with acute coronary syndrome and those with heart failure. However, these applications for early risk stratification in the cardiac emergency, and the influence of renal function on these evaluations have not been fully investigated.Patients and methodsWe investigated the prognostic value of these representative cardiac markers and influence of renal function on these evaluations in 165 consecutive patients who were admitted for cardiac emergency because of chest pain or dyspnea.ResultsThere were significant correlations between TnT and CK-MB (r=0.512, p

A 19-year-old man was admitted for severe traumatic tricuspid regurgitation (TR) 4 months after a traffic accident. Transthoracic echocardiography revealed severe TR, with an abnormal chordal structure. Three-dimensional echocardiography showed widely lacerated right ventricular endocardium involving many subvalvular components. In this case of traumatic TR, three-dimensional echocardiography was useful not only for its diagnosis but also in providing important information for surgical decision making.

The question of how the spin degrees of freedom in the nucleon are organized has not yet been fully answered. Forward hadron production in transversely polarized p+p collisions provides a unique way of probing the spin structure of the nucleon. Large (10% or more) single transverse spin asymmetries (AN) were measured at a wide range of collision energy. The STAR collaboration has previously measured π0 production with the Forward Pion Detector (FPD) at RHIC, and reported that large AN persists up to s = 200 GeV. A Pb‐glass electromagnetic calorimeter detector named the Forward Meson Spectrometer (FMS) has been built and installed at STAR. The FMS covers the pseudo‐rapidity region of 2.5

The topic of this article is the measurement of the transverse spin dependent Collins and dihadron interference fragmentation functions at the Belle experiment. Recent results and projections for future measurements will be presented.

We describe a case of gastroduodenal ulcer in which pyloric vestibular stenosis exacerbated in a short time and we had difficulties in differentiation from advanced gastric cancer.The case was a 71-year-old male who had had head injury and was being medicated for sustaining headache. On October 16, 1989, the patient was admitted to our hospital because of melena. Upper gastrointestinal series revealed a probable advanced gastric cancer. Borrmann type 4. Biopsy cytology, however, showed no malignant findings. Because of markedly exacerbated stenosis at the pyloric vestibule, pyloric-side gastrectomy and duodenectomy were carried out on November 22. In the excised specimen, giant girdle ulcer (Ul-II) in 3 lines at the lesser curvature, anterior and posterior wall of lower body of stomach, and a whole-circumference stenosis 7 cm in length reaching to the duodenal bulb at the anal-side were observed. Histopathological findings included mild inflammatory findings at mucous membrane, submucosal proliferation of collagen fiber, and marked hypertrophy of intrinsic muscle layer at the whole-circumference stenosis site. This pyloric vestibular stenosis might be due to repeated chronic inflammation. Possible factors causing exacerbation can be medication and circulatory disturbance.

A hot-cathode Penning-discharge sputtering (HC-PDS) apparatus has been newly developed, which normally operates at an Ar gas pressure of 10−4 Torr and provides a high-density ion flux even at low target voltages below −0.10 kV. As one performance test, we tried sputter-depositions from Mo, W, and Ta refractory metals. By means of PIXE analysis, it was found that argon was incorporated, but its concentration was estimated to be less than 2 at%, while other impurities coming from the construction materials of the HC-PDS apparatus could be reduced to as low as 1 at%. An attempt was made to fabricate a high-Tc superconducting Y Ba Cu O film from a single target. A film close to the nominal composition ratio of the target was obtained at lower pressures of around 1 × 10−3 Torr.

Two cases of adenoid cystic carcinoma in buccal mucosa were reported. The first case was a 56-years old woman having a buccal tumor since 20 years ago. The tumor was removed and neck dissection was performed. Her cheek was reconstructed by using a temporal flap prepared from the forehead. Tumor was 3×3×2cm in size, and histopathological study revealed a cribriform of adenoid cystic carcinoma. The other case was a 62 years old woman, who noticed a painless tumor at the cheek one year ago. Surgical procedure was performed, but margine positive was showed by histopathological sutdy. She rejected the additional surgery, it is unavoidable, and chemotherapy with Cisplatin was done. Recently only five cases have been reported in Japan. It seems that the prognosis relates with the histopathological type, and careful surgical resection is the best treatment.

To assess the feasibility and potential impact of routine three-dimensional (3D) echocardiographic assessment of left ventricular (LV) ejection fraction and volumes on clinical decision-making.Patients referred to three hospital-based echocardiography laboratories underwent 2D echocardiography (2DE) and 3D echocardiography (3DE). Feasibility was assessed in a group of 168 unselected patients and decision-making assessed within an expanded group of 220 patients. The time for acquisition and measurement was obtained. Feasibility was defined by ability to measure LV parameters. The potential of 3DE to alter clinical decisions based on 2DE was evaluated by the ability to identify four clinically relevant measurement thresholds: (1) LV end-systolic volume (LVESV)50 ml/m(2) (indication for surgery in regurgitant valve disease); (2) LVESV30 ml/m(2) (prognosis after infarction); (3) LV ejection fraction (LVEF)35% (indication for implantable defibrillator); and (4) LVEF40% (indication for heart failure treatment).3DE was technically feasible in 83% of unselected patients. The additional time for 3D acquisition and measurement was available in 184 patients and was 5.4 (SD 2.0) minutes. The use of 3DE changed categorisation in between 6-11% of patients. Within threshold categories, 3D reallocated 17.5% (11/63) of patients with LVEF35%, 16.1% (13/81) for LVEF40%, 12.4% (13/105) for LVESV30 ml/m(2) and 8.5% (5/59) for LVESV50 ml/m(2). Most of the impact of 3D was within 10 ml/m(2) of selected volume thresholds (or=75%) and 10% of EF thresholds (80%).Measurement of LV volumes and EF by 3DE is clinically feasible and has the potential to significantly alter clinical decision-making.

High-risk acute coronary syndrome is characterized by vulnerable-plaque with subocclusive thrombus and down-stream microemboli spreading minor myocardial damage, resulting in non-ST-elevation myocardial infarction. Advances in the understanding of the pathogenesis and consequences of acute coronary syndrome have stimulated development of novel biomarkers, and expanded their role in the different spectrum of the underlying pathophysiology, namely multi-biomarker strategy; consisted of biomarkers for 1) myocardial necrosis(membrane damage to myofibril necrosis), 2) plaque destabilization, 3) myocardial stress(ischemic stress per se and end-diastolic atrial or ventricular wall stress), 4) myocardial ischemia, and 5) inflammatory process. In this article, we review clinical importance of novel biomarkers referring our previous clinical investigation and other reports, especially troponin T for detection of minor myocardial damage associated with vulnerable plaque with thrombus/embolus, heart-type fatty acid -binding protein for earlier detection of myocardial damage and it's role for the rule-out triage, N-terminal pro-BNP for earlier risk stratification in cardiac emergency, and soluble CD40 ligand for earlier identification of plaque destabilization with platelet activation in non-ST-elevation acute coronary syndrome.