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Stakišaitis D, Kapočius L, Kilimaitė E, Gečys D, Šlekienė L, Balnytė I, Palubinskienė J, Lesauskaitė V. Preclinical Study in Mouse Thymus and Thymocytes: Effects of Treatment with a Combination of Sodium Dichloroacetate and Sodium Valproate on Infectious Inflammation Pathways. Pharmaceutics 2023; 15:2715. [PMID: 38140056 PMCID: PMC10747708 DOI: 10.3390/pharmaceutics15122715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
The research presents data from a preclinical study on the anti-inflammatory effects of a sodium dichloroacetate and sodium valproate combination (DCA-VPA). The 2-week treatment with a DCA 100 mg/kg/day and VPA 150 mg/kg/day combination solution in drinking water's effects on the thymus weight, its cortex/medulla ratio, Hassall's corpuscles (HCs) number in the thymus medulla, and the expression of inflammatory and immune-response-related genes in thymocytes of male Balb/c mice were studied. Two groups of mice aged 6-7 weeks were investigated: a control (n = 12) and a DCA-VPA-treated group (n = 12). The treatment did not affect the body weight gain (p > 0.05), the thymus weight (p > 0.05), the cortical/medulla ratio (p > 0.05), or the number of HCs (p > 0.05). Treatment significantly increased the Slc5a8 gene expression by 2.1-fold (p < 0.05). Gene sequence analysis revealed a significant effect on the expression of inflammation-related genes in thymocytes by significantly altering the expression of several genes related to the cytokine activity pathway, the inflammatory response pathway, and the Il17 signaling pathway in thymocytes. Data suggest that DCA-VPA exerts an anti-inflammatory effect by inhibiting the inflammatory mechanisms in the mouse thymocytes.
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Affiliation(s)
- Donatas Stakišaitis
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (L.K.); (L.Š.); (I.B.); (J.P.)
- Laboratory of Molecular Oncology, National Cancer Institute, 08660 Vilnius, Lithuania
| | - Linas Kapočius
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (L.K.); (L.Š.); (I.B.); (J.P.)
| | - Evelina Kilimaitė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (L.K.); (L.Š.); (I.B.); (J.P.)
| | - Dovydas Gečys
- Laboratory of Molecular Cardiology, Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu Ave., 50161 Kaunas, Lithuania;
| | - Lina Šlekienė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (L.K.); (L.Š.); (I.B.); (J.P.)
| | - Ingrida Balnytė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (L.K.); (L.Š.); (I.B.); (J.P.)
| | - Jolita Palubinskienė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (L.K.); (L.Š.); (I.B.); (J.P.)
| | - Vaiva Lesauskaitė
- Laboratory of Molecular Cardiology, Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu Ave., 50161 Kaunas, Lithuania;
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Gao Y, Jiang D, Wang C, An G, Zhu L, Cui C. Comprehensive Analysis of Metabolic Changes in Male Mice Exposed to Sodium Valproate Based on GC-MS Analysis. Drug Des Devel Ther 2022; 16:1915-1930. [PMID: 35747443 PMCID: PMC9211130 DOI: 10.2147/dddt.s357530] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 05/31/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Sodium valproate (VPA) is the most widely used broad-spectrum antiepileptic first-line drug in clinical practice and is effective against various types of epilepsy. However, VPA can induce severe cardiotoxicity, nephrotoxicity, hepatotoxicity, and neurotoxicity, which limits its use. Metabolomic studies of VPA-induced toxicity have focused primarily on changes in serum and urine metabolites but have not evaluated changes in major organs or tissues. Methods Central target tissues (intestine, lung, liver, hippocampus, cerebral cortex, inner ear, spleen, kidney, heart, and serum) were analyzed using gas chromatography mass spectrometry to comprehensively evaluate VPA toxicity in mouse models. Results Multivariate analyses, including orthogonal projections of the latent structure and Student’s t test, indicated that depending on the matrix used in the study (the intestine, lung, liver, hippocampus, cerebral cortex, inner ear, spleen, kidney, heart or serum) the number of metabolites differed, the lung being the poorest and the kidney the richest in number. Conclusion These metabolites were closely related and were found to participate in 12 key pathways related to amino acid, fatty acid, and energy metabolism, revealing that the toxic mechanism of VPA may involve oxidative stress, inflammation, amino acid metabolism, lipid metabolism, and energy disorder.
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Affiliation(s)
- Yahao Gao
- Clinical Medical School, Jining Medical University, Jining, Shandong, People’s Republic of China
| | - Di Jiang
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Changshui Wang
- Department of Neurosurgery, Affiliated Hospital of Jining Medical University, Jining, People’s Republic of China
| | - Gang An
- Clinical Medical School, Jining Medical University, Jining, Shandong, People’s Republic of China
| | - Li Zhu
- Department of Clinical Pharmacy, Jining First People’s Hospital, Jining Medical University, Jining, Shandong, People’s Republic of China
| | - Changmeng Cui
- Department of Neurosurgery, Affiliated Hospital of Jining Medical University, Jining, People’s Republic of China
- Correspondence: Changmeng Cui, Department of Neurosurgery, Affiliated Hospital of Jining Medical University, 89 Guhuai Road, Jining, Shandong, 272000, People’s Republic of China, Tel +8617805378911, Email
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Juknevičienė M, Balnytė I, Valančiūtė A, Lesauskaitė V, Stanevičiūtė J, Curkūnavičiūtė R, Stakišaitis D. Valproic Acid Inhibits NA-K-2CL Cotransporter RNA Expression in Male But Not in Female Rat Thymocytes. Dose Response 2019; 17:1559325819852444. [PMID: 31210756 PMCID: PMC6545653 DOI: 10.1177/1559325819852444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/12/2019] [Accepted: 04/23/2019] [Indexed: 01/08/2023] Open
Abstract
Objective The NKCC1 is a recognized tumorigenesis marker as it is important for tumor cell proliferation, differentiation, apoptosis, and tumor progression. The study aim was to investigate the effect of sodium valproate (VPA) on thymus NKCC1 RNA expression. Material and Methods Wistar rats, age 4 to 5 weeks, were investigated in the control and VPA-treated male and female gonad-intact and castrated groups. The treatment duration with VPA 300 mg/kg/d was 4 weeks. Rat thymus was weighted; its lobe was taken for the expression of NKCC1 RNA determined by the real-time polymerase chain reaction method. Results The RNA expression of the Slc12a2 gene was found to be significantly higher in the gonad-intact male control compared with the gonad-intact female control (P = .04). There was a gender-related VPA treatment effect on NKCC1 RNA expression in thymus: The Slc12a2 gene RNA expression level was found to be decreased in VPA-treated gonad-intact males (P = .015), and no significant VPA effects were found in the castrated males and in the gonad-intact and castrated females compared with the respective controls (P > .05). Conclusions The study showed a gender-related difference in the NKCC1 RNA expression in rat thymus. The VPA decreases the NKCC1 expression in the thymus only in gonad-intact male rats. The NKCC1 RNA expression downregulation by VPA could be important for further VPA pharmacological studies in oncology.
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Affiliation(s)
- Milda Juknevičienė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ingrida Balnytė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Angelija Valančiūtė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vaiva Lesauskaitė
- Institute of Cardiology of Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jurate Stanevičiūtė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rūta Curkūnavičiūtė
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Donatas Stakišaitis
- Department of Histology and Embryology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Laboratory of Molecular Oncology, National Cancer Institute, Vilnius, Lithuania
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Gender-Related Effect of Sodium Dichloroacetate on the Number of Hassall's Corpuscles and RNA NKCC1 Expression in Rat Thymus. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1602895. [PMID: 31179315 PMCID: PMC6507237 DOI: 10.1155/2019/1602895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 02/26/2019] [Accepted: 04/08/2019] [Indexed: 12/30/2022]
Abstract
The aim was to investigate the effect of dichloroacetate (DCA) on thymus weight, Hassall's corpuscle number (HCs), and NKCC1 RNA expression in Wistar rats aged 4–5 weeks. They were investigated in the controls and DCA-treated gonad-intact and castrated males and females. The treatment lasted 4 weeks with DCA 200 mg/kg/day. At the end of the experiment, rat thymus was weighted, and its lobe was taken for the expression of NKCC1 RNA determined by the PCR method and of Hassall's corpuscles by immunohistochemistry. DCA caused a thymus weight decrease in DCA-treated gonad-intact rats of both genders as compared with their controls (p < 0.05), and no such impact was found in castrated DCA-treated males and females. DCA caused an increase of the HCs in gonad-intact males (p < 0.05), and no such increase in the DCA-treated gonad-intact females was found. There was gender-related difference in the HCs when comparing DCA-treated gonad-intact males and females: males showed significantly higher HCs (p < 0.05); no gender-related differences were found in the castrated DCA-treated groups. The Slc12a2 gene RNA expression level was found to be significantly decreased only in gonad-intact and in castrated DCA-treated males. The authors discuss the gender-related DCA effects on the thymus.
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Sun S, Ji H, Feng Y, Kang Y, Yu J, Liu A. A novel mechanism of tumor-induced thymic atrophy in mice bearing H22 hepatocellular carcinoma. Cancer Manag Res 2018; 10:417-424. [PMID: 29551914 PMCID: PMC5842769 DOI: 10.2147/cmar.s157512] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Thymic atrophy was discovered in tumor-bearing mice in recent years. Methods Flow cytometry was carried out including Annexin V-FITC/PI double staining, PI staining, Terminal dUTP nick-end labeling, CD3-FITC/CD19-PE and CD8-FITC/CD4-PE double staining. Enzyme-linked immunosorbent assay and polymerase chain reaction were also investigated. Results According to our experiments, we demonstrated that no signs of apoptosis in thymocytes were found in H22-bearing mice, while the proportions of CD4+ T cells and CD8+ T cells in thymuses were remarkably increased, the opposite tendency was found in peripheral bloods, and only CD3+CD8+ T cells were discovered in H22 solid tumors. We further discovered that the level of thymosin alpha 1 (Tα1) and the expression of Wnt4 in thymus of H22-bearing mice were significantly improved than control, which indicated the active proliferation and differentiation of thymocytes. Our study revealed that CD8+ T cells could not effectively eliminate H22 cells independently when CD4+ T cells were suppressed by tumors, while the body would only enhance the differentiation and maturation of T cells in thymuses and release them to solid tumor to reinforce antitumor immunocompetence, leading to a vicious cycle which finally led to thymic atrophy. Conclusion Our data propose a novel mechanism of tumor-induced thymic atrophy regulated by abnormal immunoreaction and may provide new ideas for the immunotherapy of tumors.
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Affiliation(s)
- Sujun Sun
- Key Laboratory of Food Nutrition and Safety, Ministry of Education, College of Food Engineering and Biotechnology, Tianjin University of Science and Technology, Tianjin, China
| | - Haiyu Ji
- Key Laboratory of Food Nutrition and Safety, Ministry of Education, College of Food Engineering and Biotechnology, Tianjin University of Science and Technology, Tianjin, China
| | - Yingying Feng
- Key Laboratory of Food Nutrition and Safety, Ministry of Education, College of Food Engineering and Biotechnology, Tianjin University of Science and Technology, Tianjin, China
| | - Yu Kang
- Key Laboratory of Food Nutrition and Safety, Ministry of Education, College of Food Engineering and Biotechnology, Tianjin University of Science and Technology, Tianjin, China
| | - Juan Yu
- Key Laboratory of Food Nutrition and Safety, Ministry of Education, College of Food Engineering and Biotechnology, Tianjin University of Science and Technology, Tianjin, China
| | - Anjun Liu
- Key Laboratory of Food Nutrition and Safety, Ministry of Education, College of Food Engineering and Biotechnology, Tianjin University of Science and Technology, Tianjin, China
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Varga I, Bódi I, Mešťanová V, Kováč M, Klein M. Association between histological alterations in the thymus and sudden infant death syndrome. J Forensic Leg Med 2018; 55:8-13. [PMID: 29438849 DOI: 10.1016/j.jflm.2018.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Sudden infant death syndrome (SIDS) involves the death of an infant during the first year of life and it is among the leading causes of infant mortality worldwide. One hypothesis regarding the pathogenesis of SIDS is that it results from a combination of three independent factors: endogenous vulnerability, a critical time window during postnatal development, and exogenous stressors. This hypothesis is known as the "triple-risk model". METHODS In this study, we used an immunohistological approach to compare the cellular microenvironments of thymuses from 19 infants whose sudden death was classified as SIDS and a control group, which consisted of thymuses from age-matched children undergoing surgery for various congenital heart defects. We hypothesized that morphological signs of stress-related thymic involution would be present. RESULTS Based on our observations, we found evidence that the proliferation and maturation of T-lymphocytes in the thymuses of infants with SIDS were suppressed. We observed enhanced macrophage activity, suggesting an increase in the apoptosis of lymphocytes and decrease in number of thymic dendritic cells and myoid cells. Significant apoptosis of thymic lymphocytes without cell regeneration typically leads to atrophy of the thymus. All cellular events we observed resemble the initial stage of stress-related thymic involution. CONCLUSION These results support the "triple-risk model," suggesting that certain exogenous stressors might be involved in the pathogenesis of SIDS. This was probably not recognized during the autopsies of infants who died suddenly.
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Affiliation(s)
- Ivan Varga
- Institute of Histology and Embryology, Faculty of Medicine, Comenius University, Bratislava, Slovakia.
| | - Ildikó Bódi
- Department of Anatomy, Histology, and Embryology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Veronika Mešťanová
- Institute of Histology and Embryology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Martin Kováč
- Department of Forensic Medicine, Health Care Surveillance Authority, Prešov, Slovakia
| | - Martin Klein
- Institute of Histology and Embryology, Faculty of Medicine, Comenius University, Bratislava, Slovakia
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Mikušová R, Mešťanová V, Polák Š, Varga I. What do we know about the structure of human thymic Hassall’s corpuscles? A histochemical, immunohistochemical, and electron microscopic study. Ann Anat 2017; 211:140-148. [DOI: 10.1016/j.aanat.2017.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 02/08/2017] [Accepted: 02/23/2017] [Indexed: 10/20/2022]
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Mešťanová V, Varga I. Morphological view on the evolution of the immunity and lymphoid organs of vertebrates, focused on thymus. Biologia (Bratisl) 2016. [DOI: 10.1515/biolog-2016-0137] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Stanevičiūtė J, Urbonienė D, Valančiūtė A, Balnytė I, Vitkauskienė A, Grigalevičienė B, Stakišaitis D. The effect of dichloroacetate on male rat thymus and on thymocyte cell cycle. Int J Immunopathol Pharmacol 2016; 29:818-822. [PMID: 27742881 DOI: 10.1177/0394632016674019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 09/21/2016] [Indexed: 11/16/2022] Open
Abstract
The study aim was to investigate the effect of dichloroacetate (DCA) on thymus and the thymocyte cycle in rats. Wistar male gonad-intact and castrated rats (4-5 weeks) were investigated in the following groups: (1) control; (2) treated with DCA; and (3) treated with the DCA and sodium valproate (NaVP) combination. Rats were treated for 4 weeks with DCA 200 mg/kg/day alone and 300 mg/kg/day of NaVP plus 200 mg/kg/day of DCA (every second week, beginning with NaVP). After the experiment, the thymus was weighted, and the thymus lobe was taken for thymocyte flow cytometry. In gonad-intact rats, the thymus weight of the control was higher than in rats treated with DCA (P <0.001) or with the NaVP-DCA combination (P <0.04); a comparison of thymus weight between DCA- and NaVP-DCA-treated groups revealed a higher thymus weight loss in the DCA-treated group (P <0.03). Flow cytometry shows that DCA treatment increased the percentage of cells in the G2-M phase (P <0.03) and reduced in G1-G0 (P <0.02). The DCA treatment effect was determined only in gonad-intact but not in castrated rats. The authors discuss the possible DCA and NaVP interaction mechanisms.
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Affiliation(s)
- Jurate Stanevičiūtė
- Lithuanian University of Health Sciences, Department of Histology and Embryology, Medical Academy, Kaunas, Lithuania
| | - Daiva Urbonienė
- Lithuanian University of Health Sciences, Department of Laboratory Medicine, Medical Academy, Kaunas, Lithuania
| | - Angelija Valančiūtė
- Lithuanian University of Health Sciences, Department of Histology and Embryology, Medical Academy, Kaunas, Lithuania
| | - Ingrida Balnytė
- Lithuanian University of Health Sciences, Department of Histology and Embryology, Medical Academy, Kaunas, Lithuania
| | - Astra Vitkauskienė
- Lithuanian University of Health Sciences, Department of Laboratory Medicine, Medical Academy, Kaunas, Lithuania
| | - Brigita Grigalevičienė
- Lithuanian University of Health Sciences, Department of Non-Infectious Diseases, Faculty of Veterinary Medicine, Veterinary Academy, Kaunas, Lithuania
| | - Donatas Stakišaitis
- Lithuanian University of Health Sciences, Department of Histology and Embryology, Medical Academy, Kaunas, Lithuania .,Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius University, Vilnius, Lithuania
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Stakisaitis D, Mozuraite R, Juodziukyniene N, Didziapetriene J, Uleckiene S, Matusevicius P, Valanciute A. Sodium Valproate Enhances the Urethane-Induced Lung Adenomas and Suppresses Malignization of Adenomas in Ovariectomized Female Mice. Int J Endocrinol 2015; 2015:218219. [PMID: 26491438 PMCID: PMC4600510 DOI: 10.1155/2015/218219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/12/2015] [Accepted: 05/20/2015] [Indexed: 12/11/2022] Open
Abstract
In the present study, the possible effect of sodium valproate (NaVP) on urethane-induced lung tumors in female mice has been evaluated. BALB/c mice (n = 60; 4-6 weeks old, females) were used in the following groups: (1) urethane-treated; (2) urethane-NaVP-treated; (3) only NaVP-treated; (4) control. In the same groups, ovariectomized female mice (n = 60) were investigated. Urethane was given intraperitoneally, with a total dose of 50 mg/mouse. In NaVP-treated mice groups, 0.4% aqueous solution of NaVP was offered to mice ad libitum. The duration of the experiment was 6 months. The number of tumors per mouse in ovariectomized mice and in those treated with urethane and NaVP was significantly higher than in mice treated with urethane only (8.29 ± 0.58 versus 6.0 ± 0.63, p < 0.02). No significant difference in the number of tumors per mouse was revealed while comparing the nonovariectomized urethane- and urethane-NaVP-treated groups (p = 0.13). A significant decrease of adenocarcinoma number in ovariectomized mice treated with a urethane-NaVP as compared with ovariectomized mice treated with urethane only was found (p = 0.031). NaVP together with low estrogen may have a protective effect on the malignization of adenomas in ovariectomized mice.
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Affiliation(s)
- Donatas Stakisaitis
- Laboratory of Carcinogenesis and Tumor Pathophysiology, National Cancer Institute, Vilnius University, Santariskiu 1, LT-08660 Vilnius, Lithuania
| | - Raminta Mozuraite
- Department of Histology and Embryology, Lithuanian University of Health Sciences, Mickeviciaus 9, LT-44307 Kaunas, Lithuania
| | - Nomeda Juodziukyniene
- Department of Histology and Embryology, Lithuanian University of Health Sciences, Mickeviciaus 9, LT-44307 Kaunas, Lithuania
- Veterinary Academy, Lithuanian University of Health Sciences, Tilzes 18, LT-47181 Kaunas, Lithuania
| | - Janina Didziapetriene
- Laboratory of Carcinogenesis and Tumor Pathophysiology, National Cancer Institute, Vilnius University, Santariskiu 1, LT-08660 Vilnius, Lithuania
| | - Saule Uleckiene
- Laboratory of Carcinogenesis and Tumor Pathophysiology, National Cancer Institute, Vilnius University, Santariskiu 1, LT-08660 Vilnius, Lithuania
| | - Paulius Matusevicius
- Veterinary Academy, Lithuanian University of Health Sciences, Tilzes 18, LT-47181 Kaunas, Lithuania
| | - Angelija Valanciute
- Department of Histology and Embryology, Lithuanian University of Health Sciences, Mickeviciaus 9, LT-44307 Kaunas, Lithuania
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