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Wang Y, Zhang H, Qiang H, Li M, Cai Y, Zhou X, Xu Y, Yan Z, Dong J, Gao Y, Pan C, Yin X, Gao J, Zhang T, Yu Z. Innovative Biomaterials for Bone Tumor Treatment and Regeneration: Tackling Postoperative Challenges and Charting the Path Forward. Adv Healthc Mater 2024; 13:e2304060. [PMID: 38429938 DOI: 10.1002/adhm.202304060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/24/2024] [Indexed: 03/03/2024]
Abstract
Surgical resection of bone tumors is the primary approach employed in the treatment of bone cancer. Simultaneously, perioperative interventions, particularly postoperative adjuvant anticancer strategies, play a crucial role in achieving satisfactory therapeutic outcomes. However, the occurrence of postoperative bone tumor recurrence, metastasis, extensive bone defects, and infection are significant risks that can result in unfavorable prognoses or even treatment failure. In recent years, there has been significant progress in the development of biomaterials, leading to the emergence of new treatment options for bone tumor therapy and bone regeneration. This progress report aims to comprehensively analyze the strategic development of unique therapeutic biomaterials with inherent healing properties and bioactive capabilities for bone tissue regeneration. These composite biomaterials, classified into metallic, inorganic non-metallic, and organic types, are thoroughly investigated for their responses to external stimuli such as light or magnetic fields, internal interventions including chemotherapy or catalytic therapy, and combination therapy, as well as their role in bone regeneration. Additionally, an overview of self-healing materials for osteogenesis is provided and their potential applications in combating osteosarcoma and promoting bone formation are explored. Furthermore, the safety concerns of integrated materials and current limitations are addressed, while also discussing the challenges and future prospects.
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Affiliation(s)
- Yu Wang
- Department of Orthopedics, Jinshan Hospital, Fudan University, Shanghai, 201508, P. R. China
| | - Huaiyuan Zhang
- Department of Orthopedics, Jinshan Hospital, Fudan University, Shanghai, 201508, P. R. China
| | - Huifen Qiang
- Changhai Clinical Research Unit, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
- Shanghai Key Laboratory of Nautical Medicine and Translation of Drugs and Medical Devices, Shanghai, 200433, P. R. China
| | - Meigui Li
- School of Pharmacy, Henan University, Kaifeng City, Henan, 475004, P. R. China
| | - Yili Cai
- Department of Gastroenterology, Naval Medical Center, Naval Medical University, Shanghai, 200052, P. R. China
| | - Xuan Zhou
- School of Pharmacy, Henan University, Kaifeng City, Henan, 475004, P. R. China
| | - Yanlong Xu
- Department of Orthopedics, Jinshan Hospital, Fudan University, Shanghai, 201508, P. R. China
| | - Zhenzhen Yan
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
| | - Jinhua Dong
- The Women and Children Hospital Affiliated to Jiaxing University, Jiaxing, Zhejiang, 314000, P. R. China
| | - Yuan Gao
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, 200433, P. R. China
| | - Chengye Pan
- Department of Gastroenterology, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
| | - Xiaojing Yin
- Department of Gastroenterology, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
| | - Jie Gao
- Changhai Clinical Research Unit, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
- Shanghai Key Laboratory of Nautical Medicine and Translation of Drugs and Medical Devices, Shanghai, 200433, P. R. China
| | - Tinglin Zhang
- Changhai Clinical Research Unit, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, P. R. China
- Shanghai Key Laboratory of Nautical Medicine and Translation of Drugs and Medical Devices, Shanghai, 200433, P. R. China
| | - Zuochong Yu
- Department of Orthopedics, Jinshan Hospital, Fudan University, Shanghai, 201508, P. R. China
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Du S, Li F, Zhang J, Chen Z, Zhang S, Zhao S, Zhao D, Fan B, Chen K, Liu G. Effects of sintering additives and sintering methods on the mechanical, antimicrobial and optical properties of Si 3N 4 bioceramics. J Mech Behav Biomed Mater 2024; 154:106529. [PMID: 38552335 DOI: 10.1016/j.jmbbm.2024.106529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/19/2024]
Abstract
Si3N4 bioceramics were fabricated using GPS and SPS method with MgO-RE2O3 (RE = La, Nd, Gd, Ho and Lu) sintering additives. The effect of sintering methods and sintering additives on the grain growth, mechanical, antimicrobial properties and color of Si3N4 bioceramics were studied. Samples sintered with GPS are composed of β-Si3N4 and samples sintered with SPS are composed of α-Si3N4 and β-Si3N4. The growth of β-Si3N4 grains in samples sintered with GPS are more adequate. Samples sintered with GPS exhibit a S. aureus inactivation rate up to 98% and a bright color appearance with a hardness of about 13 GPa and a fracture toughness up to 7.5 MPa m1/2, suitable for dental implants. And samples sintered with SPS exhibit a hardness of about 17 GPa and a fracture toughness about 6 MPa m1/2.
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Affiliation(s)
- Songmo Du
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China
| | - Fei Li
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China
| | - Jie Zhang
- Advanced Ceramics and Structures Center, Yongjiang Laboratory, Zhenhai District, Ningbo City, Zhejiang Province, China
| | - Zhanglin Chen
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China
| | - Shijia Zhang
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China
| | - Shuo Zhao
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China
| | - Dengke Zhao
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China
| | - Binbin Fan
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China
| | - Kexin Chen
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China
| | - Guanghua Liu
- State Key Laboratory of New Ceramics and Fine Processing, School of Materials Science and Engineering, Tsinghua University, Beijing, 100084, China.
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Huang S, Wen J, Zhang Y, Bai X, Cui ZK. Choosing the right animal model for osteomyelitis research: Considerations and challenges. J Orthop Translat 2023; 43:47-65. [PMID: 38094261 PMCID: PMC10716383 DOI: 10.1016/j.jot.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 03/22/2024] Open
Abstract
Osteomyelitis is a debilitating bone disorder characterized by an inflammatory process involving the bone marrow, bone cortex, periosteum, and surrounding soft tissue, which can ultimately result in bone destruction. The etiology of osteomyelitis can be infectious, caused by various microorganisms, or noninfectious, such as chronic nonbacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO). Researchers have turned to animal models to study the pathophysiology of osteomyelitis. However, selecting an appropriate animal model that accurately recapitulates the human pathology of osteomyelitis while controlling for multiple variables that influence different clinical presentations remains a significant challenge. In this review, we present an overview of various animal models used in osteomyelitis research, including rodent, rabbit, avian/chicken, porcine, minipig, canine, sheep, and goat models. We discuss the characteristics of each animal model and the corresponding clinical scenarios that can provide a basic rationale for experimental selection. This review highlights the importance of selecting an appropriate animal model for osteomyelitis research to improve the accuracy of the results and facilitate the development of novel treatment and management strategies.
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Affiliation(s)
| | | | - Yiqing Zhang
- Guangdong Provincial Key Laboratory of Bone and Joint Degeneration Diseases, Department of Cell Biology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Xiaochun Bai
- Guangdong Provincial Key Laboratory of Bone and Joint Degeneration Diseases, Department of Cell Biology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Zhong-Kai Cui
- Guangdong Provincial Key Laboratory of Bone and Joint Degeneration Diseases, Department of Cell Biology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, China
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Zhai S, Tian Y, Shi X, Liu Y, You J, Yang Z, Wu Y, Chu S. Overview of strategies to improve the antibacterial property of dental implants. Front Bioeng Biotechnol 2023; 11:1267128. [PMID: 37829564 PMCID: PMC10565119 DOI: 10.3389/fbioe.2023.1267128] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/14/2023] [Indexed: 10/14/2023] Open
Abstract
The increasing number of peri-implant diseases and the unsatisfactory results of conventional treatment are causing great concern to patients and medical staff. The effective removal of plaque which is one of the key causes of peri-implant disease from the surface of implants has become one of the main problems to be solved urgently in the field of peri-implant disease prevention and treatment. In recent years, with the advancement of materials science and pharmacology, a lot of research has been conducted to enhance the implant antimicrobial properties, including the addition of antimicrobial coatings on the implant surface, the adjustment of implant surface topography, and the development of new implant materials, and significant progress has been made in various aspects. Antimicrobial materials have shown promising applications in the prevention of peri-implant diseases, but meanwhile, there are some shortcomings, which leads to the lack of clinical widespread use of antimicrobial materials. This paper summarizes the research on antimicrobial materials applied to implants in recent years and presents an outlook on the future development.
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Affiliation(s)
| | | | | | | | | | | | | | - Shunli Chu
- Jilin Provincial Key Laboratory of Tooth Development and Bone Remodeling, Hospital of Stomatology, Jilin University, Changchun, China
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Yunsheng D, Hui X, Jie W, Tingting Y, Naiqi K, Jiaxing H, Wei C, Yufei L, Qiang Y, Shufang W. Sustained release silicon from 3D bioprinting scaffold using silk/gelatin inks to promote osteogenesis. Int J Biol Macromol 2023; 234:123659. [PMID: 36796557 DOI: 10.1016/j.ijbiomac.2023.123659] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
Repairing extensive bone defects that cannot self-heal has been a clinical challenge. The construction of scaffolds with osteogenic activity through tissue engineering can provide an effective strategy for bone regeneration. This study utilized gelatin, silk fibroin, and Si3N4 as scaffold materials to prepare silicon-functionalized biomacromolecules composite scaffolds using three-dimensional printing (3DP) technology. This system delivered positive outcomes when Si3N4 levels were 1 % (1SNS). The results showed that the scaffold had a porous reticular structure with a pore size of 600-700 μm. The Si3N4 nanoparticles were distributed uniformly in the scaffold. The scaffold could release Si ions for up to 28 days. In vitro experiments showed that the scaffold had good cytocompatibility, promoting the osteogenic differentiation of mesenchymal stem cells (MSCs). In vivo experiments on bone defects in rats showed that the 1SNS group facilitated bone regeneration. Therefore, the composite scaffold system showed potential for application in bone tissue engineering.
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Affiliation(s)
- Dong Yunsheng
- State Key Laboratory of Medicinal Chemical Biology, The Key Laboratory of Bioactive Materials, The College of Life Science, Nankai University, 300071 Tianjin, China
| | - Xiao Hui
- State Key Laboratory of Medicinal Chemical Biology, The Key Laboratory of Bioactive Materials, The College of Life Science, Nankai University, 300071 Tianjin, China
| | - Wang Jie
- State Key Laboratory of Medicinal Chemical Biology, The Key Laboratory of Bioactive Materials, The College of Life Science, Nankai University, 300071 Tianjin, China
| | - Yang Tingting
- State Key Laboratory of Medicinal Chemical Biology, The Key Laboratory of Bioactive Materials, The College of Life Science, Nankai University, 300071 Tianjin, China
| | - Kang Naiqi
- State Key Laboratory of Medicinal Chemical Biology, The Key Laboratory of Bioactive Materials, The College of Life Science, Nankai University, 300071 Tianjin, China
| | - Huang Jiaxing
- State Key Laboratory of Medicinal Chemical Biology, The Key Laboratory of Bioactive Materials, The College of Life Science, Nankai University, 300071 Tianjin, China
| | - Cui Wei
- Qingdao Alticera Advanced Materials Co., Ltd, 266299 Shan Dong, China
| | - Liu Yufei
- State Key Laboratory of Medicinal Chemical Biology, The Key Laboratory of Bioactive Materials, The College of Life Science, Nankai University, 300071 Tianjin, China
| | - Yang Qiang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, 300211 Tianjin, China.
| | - Wang Shufang
- State Key Laboratory of Medicinal Chemical Biology, The Key Laboratory of Bioactive Materials, The College of Life Science, Nankai University, 300071 Tianjin, China.
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Sun T, Huang J, Zhang W, Zheng X, Wang H, Liu J, Leng H, Yuan W, Song C. Simvastatin-hydroxyapatite coatings prevent biofilm formation and improve bone formation in implant-associated infections. Bioact Mater 2023; 21:44-56. [PMID: 36017072 PMCID: PMC9395756 DOI: 10.1016/j.bioactmat.2022.07.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 11/29/2022] Open
Abstract
Implant-associated infections (IAIs) caused by biofilm formation are the most devastating complications of orthopedic surgery. Statins have been commonly and safely used drugs for hypercholesterolemia for many years. Here, we report that simvastatin-hydroxyapatite-coated titanium alloy prevents biofilm-associated infections. The antibacterial properties of simvastatin against Staphylococcus aureus and Staphylococcus epidermidis biofilms in vitro was confirmed by crystal violet staining and live-dead bacterial staining. We developed a simvastatin-and hydroxyapatite (Sim-HA)-coated titanium alloy via electrochemical deposition. Sim-HA coatings inhibited Staphylococcus aureus biofilm formation and improved the biocompatibility of the titanium alloy. Sim-HA coatings effectively prevented Staphylococcus aureus IAI in rat femurs, as confirmed by radiological assessment and histological examination. The antibacterial effects of the Sim-HA coatings were attributed to their inhibitory effects on biofilm formation, as verified by scanning electron microscopic observations and bacterial spread plate analysis. In addition, the Sim-HA coatings enhanced osteogenesis and osteointegration, as verified by micro-CT, histological evaluation, and biomechanical pull-out tests. In summary, Sim-HA coatings are promising implant materials for protection against biofilm-associated infections. Simvastatin-hydroxyapatite coatings were prepared on Ti6Al4V by electrochemical deposition process. The Simvastatin-hydroxyapatite coatings inhibited S. aureus biofilm formation and improved biocompatibility in vitro. The coatings exhibited antibacterial effects and improved bone formation in a rat femur IAI model. Simvastatin coatings are promising for application in orthopedic implants.
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Liu Y, Zhang B, Liu F, Qiu Y, Mu W, Chen L, Ma C, Ye T, Wang Y. Strontium doped electrospinning fiber membrane with antibacterial and osteogenic properties prepared by pulse electrochemical method. ENGINEERED REGENERATION 2022. [DOI: 10.1016/j.engreg.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Pinna M, Signorelli A, Binda G, Dossi C, Rampazzi L, Spanu D, Recchia S. How to Clean and Safely Remove HF from Acid Digestion Solutions for Ultra-Trace Analysis: A Microwave-Assisted Vessel-Inside-Vessel Protocol. Methods Protoc 2022; 5:mps5020030. [PMID: 35448695 PMCID: PMC9029609 DOI: 10.3390/mps5020030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/16/2022] Open
Abstract
The complete dissolution of silicate-containing materials, often necessary for elemental determination, is generally performed by microwave-assisted digestion involving the forced use of hydrofluoric acid (HF). Although highly efficient in dissolving silicates, this acid exhibits many detrimental effects (e.g., formation of precipitates, corrosiveness to glassware) that make its removal after digestion essential. The displacement of HF is normally achieved by evaporation in open-vessel systems: atmospheric contamination or loss of analytes can occur when fuming-off HF owing to the non-ultraclean conditions necessarily adopted for safety reasons. This aspect strongly hinders determination at the ultra-trace level. To overcome this issue, we propose a clean and safe microwave-assisted procedure to induce the evaporative migration of HF inside a sealed “vessel-inside-vessel” system: up to 99.9% of HF can be removed by performing two additional microwave cycles after sample dissolution. HF migrates from the digestion solution to a scavenger (ultrapure H2O) via a simple physical mechanism, and then, it can be safely dismissed/recycled. The procedure was validated by a soil reference material (NIST 2710), and no external or cross-contamination was observed for the 27 trace elements studied. The results demonstrate the suitability of this protocol for ultra-trace analysis when the utilization of HF is mandatory.
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Affiliation(s)
- Marco Pinna
- Department of Science and High Technology, University of Insubria, Via Valleggio 11, 22100 Como, Italy; (M.P.); (A.S.)
| | - Arianna Signorelli
- Department of Science and High Technology, University of Insubria, Via Valleggio 11, 22100 Como, Italy; (M.P.); (A.S.)
| | - Gilberto Binda
- Norwegian Institute for Water Research (NIVA), Gaustadalléen 21, 0349 Oslo, Norway;
| | - Carlo Dossi
- Department of Theoretical and Applied Sciences, University of Insubria, Via Dunant 3, 22100 Varese, Italy;
| | - Laura Rampazzi
- Department of Human Sciences and Innovation for the Territory, University of Insubria, Via Sant’Abbondio 12, 22100 Como, Italy;
| | - Davide Spanu
- Department of Science and High Technology, University of Insubria, Via Valleggio 11, 22100 Como, Italy; (M.P.); (A.S.)
- Correspondence: (D.S.); (S.R.); Tel.: +39-0312-386-428 (D.S.); +39-0312-386-450 (S.R.)
| | - Sandro Recchia
- Department of Science and High Technology, University of Insubria, Via Valleggio 11, 22100 Como, Italy; (M.P.); (A.S.)
- Correspondence: (D.S.); (S.R.); Tel.: +39-0312-386-428 (D.S.); +39-0312-386-450 (S.R.)
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Hu G, Zhu Y, Xu F, Ye J, Guan J, Jiang Y, Di M, Li Z, Guan H, Yao X. Comparison of surface properties, cell behaviors, bone regeneration and osseointegration between nano tantalum/PEEK composite and nano silicon nitride/PEEK composite. JOURNAL OF BIOMATERIALS SCIENCE. POLYMER EDITION 2022; 33:35-56. [PMID: 34464239 DOI: 10.1080/09205063.2021.1974812] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
Both tantalum (Ta) and silicon nitride (SN) exhibit osteogenic bioactivity and antibacterial property. In addition, as a biomaterial for bone repair, polyetheretherketone (PEEK) has outstanding biocompatibility and mechanical performances while it is biologically inert. In this study, by blending PEEK with Ta and SN nanoparticles, respectively, Ta/PEEK composite (TPC) and SN/PEEK composite (SPC) were fabricated for load-bearing bone repair. The surface roughness, hydrophilicity and surface energy of TPC containing Ta nanoparticles were higher than SPC containing SN nanoparticles and PEEK. In addition, TPC with Ta nanoparticles exhibited low antibacterial property while SPC with SN nanoparticles showed high bacterial property. Moreover, the MC3T3-E1 cells responses (e.g. proliferation and differentiation) to TPC was the highest while PEEK was the lowest in vitro. Furthermore, new bone formation and osseointegration for TPC was the highest while PEEK was the lowest in vivo. In conclusion, compared with PEEK, addition of Ta and SN nanoparticles into PEEK fabricated bioactive composites of TPC and SPC with optimized surface property, which played crucial roles in inducing cellular response/bone regeneration. Although the osteogenic activity of SPC was lower than TPC, SPC exhibited osteogenic activity and good antibacterial property, which could prevent infection from bacterial. Therefore, SPC would have better potential for bone substitute.
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Affiliation(s)
- Gangfeng Hu
- Department of Orthopedics, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Yuan Zhu
- Department of Orthopedics, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Fangqi Xu
- Department of Orthopedics, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Jiakuan Ye
- Department of Orthopedics, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Jie Guan
- Department of Orthopedics, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Yiqian Jiang
- Department of Orthopedics, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Meijuan Di
- Department of Orthopedics, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
| | - Zhennan Li
- The Second Clinical Medicine College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Hong Guan
- The Second Clinical Medicine College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xiaocong Yao
- Department of Orthopedics, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China
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