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The measurement of hypertensive patients' stroke knowledge is an important stroke prevention indicator of health care service quality. The aim of this study was to develop a Chinese version of the Stroke Knowledge Test and examine its psychometric properties, reliability, and validity for hypertensive patients. A sample of 200 hypertensive patients completed the Chinese version of the Stroke Knowledge Test, and 30 of the participants were retested after 2 weeks. The final Chinese version of the Stroke Knowledge Test included 20 items with acceptable content validity (I-CVI = 0.88 ~ 1.00, S-CVI/Ave = 0.97). These items showed satisfactory internal reliability consistency (Kuder Richardson-20 = 0.62) and test–retest reliability was 0.77. The 40% of the difficulty index was in the acceptable range, and 25% was in the difficult range, as well as the 90% items overall values for discrimination were ranged from 0.2 to > 0.4. Known-group validity testing was performed based on the education level, and the result exhibited significant difference (F = 21.21, p < 0.001). The Chinese version of the Stroke Knowledge Test demonstrated acceptable psychometric properties, thus providing a new tool for the future care of hypertensive patients in Taiwan. It also could be as a reference for healthcare providers to educate hypertensive patients on stroke prevention. [ABSTRACT FROM AUTHOR]

The rise in the number of hemodialysis (HD) patients underscores the importance of culturally competent HD nurses. This study aimed to examine the effectiveness of a situated simulation program on HD nurses' cultural competence. This was a quasi-experimental pilot study with a total of 40 participants who met the inclusion criteria from an HD center in northern Taiwan. Participants took part in two separate 3 h education programs. The first program focused on the basic concepts of cultural competence, while the second program involved situated simulations utilizing the Gather–Analyze–Summarize (GAS) method of debriefing. The generalized estimating equations (GEEs) were employed to estimate the intervention effect. The baseline scores were divided into low-score and high-score groups using the median score for subgroup analysis. The subgroup analysis revealed that a significant group-time interaction was identified regarding cultural competence and subscale, verifying the situated simulation's immediate effect. In this study, an integration of the GAS method of debriefing and situated simulation teaching was implemented. The results showed that this approach empowered HD nurses with the ability to foster positive attitudes and demonstrate professional expertise in an organized manner when facing similar clinical scenarios in the future. [ABSTRACT FROM AUTHOR]

Cisplatin is one of the most common therapeutics used in treatments of several types of cancers. To enhance cisplatin lipophilicity and reduce resistance and side effects, a polyfluorinated bipyridine-modified cisplatin analogue, dichloro[4,4'-bis(2,2,3,3-tetrafluoropropoxy)methyl)-2,2'-bipryridine] platinum (TFBPC), was synthesized and therapeutic assessments were performed. TFBPC displayed superior effects in inhibiting the proliferation of several cisplatin-resistant human cancer cell lines, including MDA-MB-231 breast cancers, COLO205 colon cancers and SK-OV-3 ovarian cancers. TFBPC bound to DNA and formed DNA crosslinks that resulted in DNA degradation, triggering the cell death program through the PARP/Bax/Bcl-2 apoptosis and LC3-related autophagy pathway. Moreover, TFBPC significantly inhibited tumor growth in both animal models which include a cell line-derived xenograft model (CDX) of cisplatin-resistant MDA-MB-231, and a patient-derived xenograft (PDX) model of triple-negative breast cancers (TNBCs). Furthermore, the biopsy specimen from TFBPC-treated xenografts revealed decreased expressions of P53, Ki-67 and PD-L1 coupled with higher expression of cleaved caspase 3, suggesting TFBPC treatment was effective and resulted in good prognostic indications. No significant pathological changes were observed in hematological and biochemistry tests in blood and histological examinations from the specimen of major organs. Therefore, TFBPC is a potential candidate for treatments of patients suffering from TNBCs as well as other cisplatin-resistant cancers. [ABSTRACT FROM AUTHOR]

Cultural competence refers to a healthcare provider's ability to consider cultural factors that affect an individual's health and attitudes toward disease and disability. Nurse practitioners (NPs) are increasingly important in healthcare, practicing culturally competent care strategies to improve the quality of patient care. The aim of this study was to explore cultural competence and its related factors among NPs. A cross sectional study design with a structured questionnaire survey was used. Purposive sampling was employed, for which 86 NPs were recruited from a medical center in northern Taiwan. A T-test, one-way ANOVA, and Pearson's product-moment correlation coefficient were used for data analysis. The results were as follows: (1) overall, the total score for cultural competence was above-average, with a score of 3.75; (2) years of experience as a NP was found to have a statistically significant correlation with overall clinical competence, with r = 0.23, p < 0.05; (3) there were significant differences in clinical awareness and cultural sensitivity related to the clinical ladder system (t = −2.42, p = 0.01; t = −2.04, p = 0.04). The findings of this study can provide information for directors of medical institutions to design an in-service educational program for NPs to enhance their cultural competence and nursing quality. [ABSTRACT FROM AUTHOR]

Sleep disturbance is considered one of the hallmarks of the common symptoms experienced by women during and after menopause. This study aimed to compare the effectiveness of two different multiple-component, sleep-promoting interventions on the sleep quality of menopausal women. A quasi-experimental study and repeated measured design, with a four-week sleep-promoting intervention, was conducted. A total of 123 eligible participants were recruited from a health center in northern Taiwan and divided into the progressive muscle relaxation plus sleep hygiene (PMRS), the meditative movement relaxation plus sleep hygiene (MMRS), or control group at a 1:1:1 ratio. The Chinese version of Pittsburgh sleep quality index and actigraphy were used to assess the sleep disturbances of menopausal women. The subjective sleep data was collected before, immediately after the intervention, 8 weeks, and 12 weeks after the intervention. The results showed that the global score of subjective sleep quality and its components were significantly improved after both interventions. Additionally, the MMRS was superior to the PMRS for subjective sleep quality. Moreover, the objective sleep indices indicated that sleep latency was reduced after both the interventions. These findings can serve as a reference for nurses when caring for menopausal women with sleep disturbance. [ABSTRACT FROM AUTHOR]

Background: Shared decision-making (SDM) is significantly associated with promoting the quality of end-of-life (EOL). The attitude of nurses toward the end of life can affect EOL care, but there are few SDM-related clinical learning programs focused on EOL. In this study, therefore, we evaluated the effectiveness of an EOL-simulation education program on attitudes toward SDM among nurses, using an objective structured clinical examination (OSCE). Methods: We used a quasi-experimental study design to evaluate nurses working at a medical center in Taiwan. We recruited 100 nurses and assigned them to an experimental group (n = 50) and a control group (n = 50). The experimental group received the SDM attitude (SDMA) cultivation program, and the control group did not. After the intervention, all participants were examined in an OSCE to assess the efficacy of their learning. A p value of.05 was considered statistically significant. Results: The average score of the experimental group was higher than that of the control group in the dimensions "empathic communication" and "mastery learning", but these differences were not significant. SDMA score is significantly and positively correlated with SDMA global score, standardized patient survey (SPS) score, and SPS global score (r =.92,.56, and.50, respectively; p <.01). Conclusions: Simulations concerning EOL care that incorporate SDM components would be effective for training clinical nurses. This study can serve as a reference for nursing-administration managers who may consider designing SDM-related education programs to improve the quality of clinical nursing care. [ABSTRACT FROM AUTHOR]

Background: Shared decision making (SDM) is a patient-centered nursing concept that emphasizes the autonomy of patients. SDM is a co-operative process that involves information exchange and communication between medical staff and patients for making treatment decisions. In this study, we explored the experiences of clinical nursing staff participating in SDM. Methods: This study adopted a qualitative research design. Semistructured interviews were conducted with 21 nurses at a medical center in northern Taiwan. All interview recordings were transcribed verbatim. Content analysis was performed to analyze the data. Results: The findings yielded the following three themes covering seven categories: knowledge regarding SDM, trigger discussion and coordination, and respect of sociocultural factors. Conclusions: The results of this study describe the experiences of clinical nursing staff participating in SDM and can be used as a reference for nursing education and nursing administrative supervisors wishing to plan and enhance professional nursing SDM in nursing education. [ABSTRACT FROM AUTHOR]

Lung cancer is the most commonly diagnosed cancer worldwide, and metastasis in lung cancer is the leading cause of cancer‐related deaths. Thus, understanding the mechanism of lung cancer metastasis will improve the diagnosis and treatment of lung cancer patients. Herein, we found that expression of cluster of differentiation 109 (CD109) was correlated with the invasive and metastatic capacities of lung adenocarcinoma cells. CD109 is upregulated in tumorous tissues, and CD109 overexpression was associated with tumor progression, distant metastasis, and a poor prognosis in patient with lung adenocarcinoma. Mechanistically, expression of CD109 regulates protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signaling via its association with the epidermal growth factor receptor (EGFR). Inhibition of CD109 decreases EGFR phosphorylation, diminishes EGF‐elicited activation of AKT/mTOR, and sensitizes tumor cells to an EGFR inhibitor. Taken together, our results show that CD109 is a potential diagnostic and therapeutic target in lung cancer patients. [ABSTRACT FROM AUTHOR]

Background: Musculoskeletal disorder (MSD) is currently recognized as one of the most common occupational injuries for which nursing personnel in the medical service industry have been identified as a high-risk group. In this study, we explore the prevalence of MSD in various body parts as well as their risk factors among hospital nurses. Methods: A cross-sectional descriptive design with stratified cluster sampling was used to collect data from 1,803 nurses. The survey included a demographic questionnaire, and Nordic Musculoskeletal Questionnaire. Results: The results showed that the greatest prevalence of MSD symptoms by body regions were in the right shoulder (85.8%), the left shoulder (80.9%), the neck (62.4%), the right wrist (62.2%) and the lower back (60.4%). Risk factors for shoulder discomfort includes department type, exercise habits, and age (p <.05). Risk factors for neck discomfort includes seniority in the current unit, "job title, and "history of MDS (p <.05). Risk factors for upper back discomfort includes age and seniority in the current unit (p <.05). Risk factors for lower back discomfort including seniority in the current unit, department type, and number of days worked per week (p <.05). Conclusions: The results of this study can serve as a reference for nursing administration managers and decision-makers for reducing musculoskeletal discomfort among nurses and thereby achieving superior quality in clinical care. [ABSTRACT FROM AUTHOR]

Background: Culture influences personal health habits and behavior, and healthcare personnel possess different views of cultural perspectives. Currently, an appropriate instrument to assess cultural competence in clinical practice is limited. The present study aimed to develop and examine the psychometric properties of the Nursing Cultural Competence Scale (NCCS) for clinical nurses. Methods: Developing and assessing the scale was carried out in two phases: Phase I involved a qualitative research to explore the themes of nurses’ cultural competence and instrument development; Phase II established construct validity of the scale using a sample of 246 nurses in Taiwan. Data from the questionnaire were analyzed using exploratory factor analysis, confirmatory factor analysis, internal consistency and test-retest reliability. Analysis results were used to determine the reliability and validity of the developed scale. Results: The results showed four factors including cultural awareness ability, cultural action ability, cultural resources application ability, and self-learning cultural ability were generated by exploratory factor analysis, and these factors explained 62.0% of total variance. Cronbach’s α of the Nursing Cultural Competence Scale was .88, and test-retest reliability correlation was .70. Conclusions: The establishment of the tool will facilitate accurate monitoring of the cultural competence among nurses and nursing managers, which can inform the construction of nursing policies aimed at pledge cultural competence expansion. [ABSTRACT FROM AUTHOR]

In multiple myeloma (MM), homeostasis is largely maintained by misfolded protein clearance via the proteasomal and aggresomal pathways. Histone deacetylase 6 (HDAC6) binds polyubiquitinated proteins and dynein motors and transports this protein cargo to the aggresome for further degradation. Accordingly, a combination of an HDAC6 inhibitor and bortezomib (BTZ) could increase ubiquitinated protein accumulation, leading to further apoptosis. Here we evaluated the anti-MM activity of MPT0G413, a novel specific HDAC6 inhibitor, using in vitro and in vivo models. MPT0G413 treatment more significantly inhibited cell growth in MM cells than in normal bone marrow cells. Furthermore, the combination of MPT0G413 and BTZ enhanced polyubiquitinated protein accumulation and synergistically reduced MM viability, increased caspase-3, caspase-8, caspase-9 levels, and cleaved poly (ADP) ribosome polymerase and also inhibited adherence of MM cells to bone marrow stromal cells (BMSC) and reduced VEGF and IL-6 levels and cell growth in a co-culture system. The combination treatment disturbed the bone marrow microenvironment and induced synergic, caspase-dependent apoptosis. Xenograft tumor growth significantly decreased in combination-treated SCID mice. In conclusion, MPT0G413 and BTZ synergistically inhibit MM viability, providing a framework for the clinical evaluation of combined therapies for MM. [ABSTRACT FROM AUTHOR]

The differences of basic attributes, health promotion behaviors, and quality of life between elderly males and females in Taiwan were compared. Several scales were used to examine the gender differences and the factors associated with quality of life. Regression analysis revealed that gender, education level, depression level, and healthy diet were key factors influencing the overall quality of life. The education level of females was lower, and their depression level was higher; however, females had healthier diets. With regards to their satisfaction in the quality of life, elderly males scored higher than females in both the physical and psychological domains. [ABSTRACT FROM AUTHOR]

Aims and objectives: To investigate the distribution and risk factors associated with undiagnosed obstructive sleep apnoea among hypertensive patients. Background: Obstructive sleep Apnoea has been deemed a cardinal risk factor affecting cardiovascular event, and the condition is still frequently overlooked clinically. The lack of advanced diagnosis often causes hypertensive patients with obstructive sleep apnoea to miss opportunities for preventing chronic diseases. Design: A cross‐sectional design. Methods: A total of 215 hypertensive participants were recruited from the cardiovascular outpatients of medical centre in northern and middle Taiwan. The Chinese version of Pittsburgh Sleep Quality Index, the Chinese version of the Epworth Sleep Scale and a portable sleep monitoring device were used for data collection. Logistic regression analysis was conducted to identify the factors affecting hypertensive patients with obstructive sleep apnoea, and a multinomial logistic regression analysis was used to examine the major influence factors for each obstructive sleep apnoea severity level. Results: 81.9% of the hypertensive participants were found having obstructive sleep apnoea. Concerning to the obstructive sleep apnoea severity, 50.0% of participants had mild obstructive sleep apnoea. After controlling the confounding variables, the supine position (odds ratio, 1.04; 95% CI, 1.01–1.07), SO2 (odds ratio, 0.58; 95% CI, 0.38–0.89) and oxygen desaturation index (odds ratio, 2.70; 95% CI, 1.18–6.18) were significantly associated with obstructive sleep apnoea. Furthermore, severe obstructive sleep apnoea was significantly correlated with gender (odds ratio, 0.04; 95% CI, 0.00–0.66), excessive daytime sleepiness (odds ratio, 20.27; 95% CI, 1.58–26.97) and oxygen desaturation index (odds ratio, 4.05; 95% CI, 1.86–8.81). Conclusions: Nearly 82% of the hypertensive participants were found having undiagnosed obstructive sleep apnoea, and 80% of them were mild or moderate severity. Oxygen desaturation index, SO2 and the supine position were found to be major predictors for obstructive sleep apnoea. Remarkably, oxygen desaturation index was the most significant predictor for mild, moderate and severe obstructive sleep apnoea. Relevance to clinical practice: Healthcare providers should enhance their sensitivities to hypertensive patients at a high risk for obstructive sleep apnoea by actively assessing common obstructive sleep apnoea symptoms and providing strategies to alleviate obstructive sleep apnoea symptoms. [ABSTRACT FROM AUTHOR]

Aims and objectives. To examine the psychometric properties of the Menopausal Symptoms Distress Affecting Sleep Quality Scale. Background. Sleep disturbances are an extensive and common problem among menopausal women. However, no unique and specific scale has yet been developed to detect the inductive symptoms distresses that cause poor sleep quality for menopausal women. Design. A cross-sectional design. Methods. The Menopausal Symptoms Distress Affecting Sleep Quality Scale was based on in-depth interviews with menopausal women and literature review. Convenience sampling was employed. One hundred and fifty three women participated in this study. Exploratory factor analysis, concurrent validity and contrasting group validity were used to examine the validity of the Menopausal Symptoms Distress Affecting Sleep Quality Scale. Cronbach's a was conducted to test the reliability. The accuracy of the scale was analysed with the receiver operating characteristic from MED CALC version 10.4.8.0 software. The scale's sensitivity, specificity, positive and negative predictive value were analysed to locate the best cut-off point. Results. One factor was generated by Exploratory factor analysis, and this factor explained 49-07% of total variance. In addition, the Menopausal Symptoms Distress Affecting Sleep Quality Scale had significant positive correlations with the Greene Climacteric Scale and the self-evaluation of menopausal symptoms scale. Cronbach's a of the Menopausal Symptoms Distress Affecting Sleep Quality Scale was 0-89. Moreover, the diagnostic accuracy probability of the scale's receiver operating characteristic curve was 0-85. The best cut-off point was three with a sensitivity of 76% and a specificity of 87%. Conclusions. The Menopausal Symptoms Distress Affecting Sleep Quality Scale had good reliability and validity, as well as refined indicators for assessing the tool's accuracy. Relevance to clinical Practice. The Menopausal Symptoms Distress Affecting Sleep Quality Scale is easy to use, can quickly detect the sleep conditions of menopausal women who suffer from menopausal symptom distress, and provide efficient nursing interventions to relieve menopausal symptom distresses, and then improve sleep quality. [ABSTRACT FROM AUTHOR]

This cross-sectional study explored the relationship between professional commitment and job satisfaction among nurses. A total of 132 registered nurses were recruited from a hospital in northern Taiwan. A self-reported structured questionnaire was used to collect data. Findings revealed significant differences among nurses in willingness to make an effort and their marital status, appraisal in continuing their careers, job level, and goals and values related to working shifts. Significant differences were found between inner satisfaction and work sector and marital status. Nurses’ professional commitment was strongly related to job satisfaction; aspects of professional commitment explained 32% of the variance in job satisfaction. Study results may inform health care institutions about the importance of nurses’ job satisfaction and professional commitment so hospital administration can improve these aspects of organizational environment. [ABSTRACT FROM AUTHOR]

Various acidic anhydrides including cantharidin were converted into corresponding aminobenzylcantharidinimide 3a and analogous imides 3b∼k (at the ortho, meta, and para positions) with 35%∼87% yields by reacting with aminobenzylamines and triethylamine. The two methyl side chains of cantharidinimides 3ao, 3am, and 3ap, and related imides had more than two chiral centers; the lone pair of electrons of nitrogen displayed a different chemical shift and coupling constant in H-NMR spectra when the amino group of benzylamine was in the ortho position. These cantharidinimides had parent aniline, pyridine, and naphthalene plane structures, and the primary amine nucleophilicity and basicity might reflect the inductive electron's negative effect on chemical shifts. We prepared cantharidinimides by heating the reactants cantharidin 1a, aliphatic and aromatic acid anhydrides, primary benzylic amines, and aniline derivatives to ca. 200 °C with 3 mL of dry toluene, and 1∼2 mL of triethylamine in high-pressure sealed tubes (Buchi glasuster 0032) to produce cantharidinimides and their analogues in good yields. The para-aminobenzylic imides showed greater inhibition of nitric oxide (NO) synthesis by NO synthase (NOS) than did ortho- and meta-aminobenzylic imides. Compound 3fp, para-aminobenzylic norbonane-imide, had the most potent effect on inducible NOS among the tested compounds and showed 35% inhibition. [ABSTRACT FROM AUTHOR]

The professional nursing competence ladder system can effectively inspire nurses' work morale, improve quality of life, and avoid the issue of senior staff leaving the clinical setting. The aim of this study was to explore the willingness to participate in the professional nursing competence ladder system and its related factors among nurses. A cross-sectional study design with a structured questionnaire was used. Purposive sampling was employed, and 696 nurses who qualified to be promoted as N2 were recruited from a medical center in southern Taiwan. The results showed most nurses were willing to participate in the nursing ladder system. There were significant differences between willingness to participate in the ladder system and age, education level, as well as promotion experience. This study emphasizes the importance of intensifying internal encouraging factors and strengthening external encouraging factors to improve participation rates. Healthcare institutions could provide instruction on case report writing to increase nurses' willingness to participate in the clinical ladder program. [ABSTRACT FROM AUTHOR]

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Background: The professional nursing clinical ladder program can effectively enhance the professional morale of nursing staff and help retain the best senior nurses in clinical settings. Hence, it is important to explore factors that influence nurse staff intentions to participate in the clinical ladder. Purpose: This study examined factors that affect nurse staff intention to participate in the N3 nurse clinical ladder program. Methods: We used a cross sectional study design and a structured questionnaire survey. We employed purposive sampling to recruit 389 nurse staffs qualified for promotion to the N3 level from a medical center in southern Taiwan. Results: Findings showed: (1) Nearly two-thirds (233, 59.9%) of participants intended to participate in clinical ladder; (2) The factors of age, years of nursing experience, years in current position, project/research experience, promotion experience, and intention all significantly affected intent to participate in the ladder; (3) A significant difference between willingness to participate in the ladder program and each of the following variables- motivation, satisfaction, professional capacity, and sense of achievement; (4) Logistic regression analysis identified only motivation as a valid predictor of willingness to participate the ladder program (95% CI: 1.21-3.78). Conclusion / Implications for practice: Results provide a useful reference to nursing administrators for planning on-the-job training and increasing nurse staff participation in the ladder. The authors hope results can help promote better human resource management and achievements. [ABSTRACT FROM AUTHOR]

Background: Culture serves as an adhesive to bind the lives of people. There are no objective, useful tools to assess cultural competence and practice. In this study, we evaluated whether the cultural competence of nurses was strengthened through the Cultural Competence Cultivation Programme. Methods: A quasi-experimental research design was used to evaluate nurses working at a medical centre in Taiwan. They were randomly allocated into an experimental group (n = 47), which received the Cultural Competence Cultivation Programme, or a control group (n = 50), which did not receive the educational programme. After the intervention, learning efficacy of the participants was assessed using an Objective Structured Clinical Examination (OSCE). The research data were statistically analysed on SPSS. Results: The average score of the experimental group was significantly higher in the 'communication ability and skill' category. Furthermore, OSCE scores and Standardised Patient Survey assessment and total scores were significantly and positively correlated. Conclusion: The findings of this study can serve as a reference for designing future clinical education programmes. [ABSTRACT FROM AUTHOR]

Background: There are some limitations of standard chemotherapy for acute leukemia. Vincristine and doxorubicin are commonly used for acute leukemia, but they may induce serious side effects such as cardiomyopathy and neurotoxicity. Furthermore, chemotherapy resistance occurs more and more frequently. Therefore, effective treatment strategies are needed. Histone deacetylase 6 inhibition is considered as a potential therapeutic strategy for acute leukemia, since it is observed that HDAC6 is overexpressed in acute leukemia and regulates tumor survival. Combination therapy for cancer is used to minimize adverse drug effects, reduce drug dosage, enhance efficacy, and prevent drug resistance. In order to improve efficacy of chemotherapy agents of acute leukemia, this study will investigate the effects of combination MPT0G211, a novel histone deacetylase 6 inhibitor, with doxorubicin or vincristine on human acute leukemia cells. Results: MPT0G211 combined with doxorubicin induces DNA damage response on human acute myeloid leukemia cells. MPT0G211 can additionally increase Ku70 acetylation and release BAX to mitochondria. Ectopic expression of HDAC6 successively reversed the apoptosis triggered by the combined treatment. Moreover, co-treatment of MPT0G211 and vincristine may alter microtubule dynamics, triggering acute lymphoblastic leukemia cells arrest in mitotic phase followed by induction of the apoptotic pathway. Finally, MPT0G211 plus doxorubicin or vincristine can significantly improve the tumor growth delay in a tumor xenograft model. Conclusions: Collectively, our data highlighted that MPT0G211 in combination with chemotherapy drugs has significant anticancer activity, suggesting a novel strategy for the treatment of acute leukemia. [ABSTRACT FROM AUTHOR]

Elevated soluble (s) CD163 and free hemoglobin (Hb) levels predict fatty liver progression; however, the molecular mechanisms underlying Hb metabolism and liver injury remain undefined. We investigated the effects of endoplasmic reticular (ER) stress on red blood cell (RBC) rheology and free Hb recycling pathways. ER stress was induced in Sprague-Dawley rats by an intraperitoneal injection of tunicamycin (TM) (50, 100, and 200 μg/100 g body weight (BW)) or an intravenous injection of Hb (5 mg/100 g BW). A TM injection increased sCD163 levels, attenuated free Hb uptake, and maintained RBC aggregability. An Hb injection increased serum LVV-hemorphin-7 and total bilirubin levels, but this effect was suppressed by TM. A Western blot analysis showed that ER stress suppressed Hb degradation in the liver through downregulation of globin degradation proteins cathepsin D and glyoxalase-1, as well as heme degradation protein heme oxyganase-1 and keap-1 expression. An ER stress activator also increased the translocation of nuclear factor (NF)-κB (p65) and nuclear factor-erythroid 2-related factor 2 (Nrf2) to nuclei. In conclusion, ER stress triggers ineffective Hb metabolism via altering globin and heme iron degradation pathways. Inability to recycle and metabolize free Hb may underlie the association between iron dysfunction and liver injury. [ABSTRACT FROM AUTHOR]