1
|
Mesenchymal Stem Cell-Derived Extracellular Vesicles as Idiopathic Pulmonary Fibrosis Microenvironment Targeted Delivery. Cells 2022; 11:cells11152322. [PMID: 35954166 PMCID: PMC9367455 DOI: 10.3390/cells11152322] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) affects an increasing number of people globally, yet treatment options remain limited. At present, conventional treatments depending on drug therapy do not show an ideal effect in reversing the lung damage or extending the lives of IPF patients. In recent years, more and more attention has focused on extracellular vesicles (EVs) which show extraordinary therapeutic effects in inflammation, fibrosis disease, and tissue damage repair in many kinds of disease therapy. More importantly, EVs can be modified or used as a drug or cytokine delivery tool, targeting injury sites to enhance treatment efficiency. In light of this, the treatment strategy of mesenchymal stem cell-extracellular vesicles (MSC-EVs) targeting the pulmonary microenvironment for IPF provides a new idea for the treatment of IPF. In this review, we summarized the inflammation, immune dysregulation, and extracellular matrix microenvironment (ECM) disorders in the IPF microenvironment in order to reveal the treatment strategy of MSC-EVs targeting the pulmonary microenvironment for IPF.
Collapse
|
2
|
Ortiz-Zapater E, Signes-Costa J, Montero P, Roger I. Lung Fibrosis and Fibrosis in the Lungs: Is It All about Myofibroblasts? Biomedicines 2022; 10:biomedicines10061423. [PMID: 35740444 PMCID: PMC9220162 DOI: 10.3390/biomedicines10061423] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 12/15/2022] Open
Abstract
In the lungs, fibrosis is a growing clinical problem that results in shortness of breath and can end up in respiratory failure. Even though the main fibrotic disease affecting the lung is idiopathic pulmonary fibrosis (IPF), which affects the interstitial space, there are many fibrotic events that have high and dangerous consequences for the lungs. Asthma, chronic obstructive pulmonary disease (COPD), excessive allergies, clearance of infection or COVID-19, all are frequent diseases that show lung fibrosis. In this review, we describe the different kinds of fibrosis and analyse the main types of cells involved-myofibroblasts and other cells, like macrophages-and review the main fibrotic mechanisms. Finally, we analyse present treatments for fibrosis in the lungs and highlight potential targets for anti-fibrotic therapies.
Collapse
Affiliation(s)
- Elena Ortiz-Zapater
- Department of Biochemistry and Molecular Biology, Faculty of Medicine-IIS INCLIVA, University of Valencia, 46010 Valencia, Spain
- Correspondence:
| | | | - Paula Montero
- Department of Pharmacology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (P.M.); (I.R.)
| | - Inés Roger
- Department of Pharmacology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain; (P.M.); (I.R.)
- Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Health Institute Carlos III, 28029 Madrid, Spain
| |
Collapse
|
3
|
Botelho FM, Rodrigues R, Guerette J, Wong S, Fritz DK, Richards CD. Extracellular Matrix and Fibrocyte Accumulation in BALB/c Mouse Lung upon Transient Overexpression of Oncostatin M. Cells 2019; 8:cells8020126. [PMID: 30764496 PMCID: PMC6406700 DOI: 10.3390/cells8020126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/24/2019] [Accepted: 01/27/2019] [Indexed: 02/06/2023] Open
Abstract
The accumulation of extracellular matrix in lung diseases involves numerous factors, including cytokines and chemokines that participate in cell activation in lung tissues and the circulation of fibrocytes that contribute to local fibrotic responses. The transient overexpression of the gp130 cytokine Oncostatin M can induce extracellular matrix (ECM) accumulation in mouse lungs, and here, we assess a role for IL-13 in this activity using gene deficient mice. The endotracheal administration of an adenovirus vector encoding Oncostatin M (AdOSM) caused increases in parenchymal lung collagen accumulation, neutrophil numbers, and CXCL1/KC chemokine elevation in bronchioalveolar lavage fluids. These effects were similar in IL-13-/- mice at day 7; however, the ECM matrix induced by Oncostatin M (OSM) was reduced at day 14 in the IL-13-/- mice. CD45+col1+ fibrocyte numbers were elevated at day 7 due to AdOSM whereas macrophages were not. Day 14 levels of CD45+col1+ fibrocytes were maintained in the wildtype mice treated with AdOSM but were reduced in IL-13-/- mice. The expression of the fibrocyte chemotactic factor CXCL12/SDF-1 was suppressed marginally by AdOSM in vivo and significantly in vitro in mouse lung fibroblast cell cultures. Thus, Oncostatin M can stimulate inflammation in an IL-13-independent manner in BALB/c lungs; however, the ECM remodeling and fibrocyte accumulation is reduced in IL-13 deficiency.
Collapse
Affiliation(s)
- Fernando M Botelho
- McMaster Immunology Research Centre, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
| | | | | | | | | | | |
Collapse
|
4
|
Tsou LK, Huang YH, Song JS, Ke YY, Huang JK, Shia KS. Harnessing CXCR4 antagonists in stem cell mobilization, HIV infection, ischemic diseases, and oncology. Med Res Rev 2017; 38:1188-1234. [PMID: 28768055 DOI: 10.1002/med.21464] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/13/2017] [Accepted: 07/16/2017] [Indexed: 12/12/2022]
Abstract
CXCR4 antagonists (e.g., PlerixaforTM ) have been successfully validated as stem cell mobilizers for peripheral blood stem cell transplantation. Applications of the CXCR4 antagonists have heralded the era of cell-based therapy and opened a potential therapeutic horizon for many unmet medical needs such as kidney injury, ischemic stroke, cancer, and myocardial infarction. In this review, we first introduce the central role of CXCR4 in diverse cellular signaling pathways and discuss its involvement in several disease progressions. We then highlight the molecular design and optimization strategies for targeting CXCR4 from a large number of case studies, concluding that polyamines are the preferred CXCR4-binding ligands compared to other structural options, presumably by mimicking the highly positively charged natural ligand CXCL12. These results could be further justified with computer-aided docking into the CXCR4 crystal structure wherein both major and minor subpockets of the binding cavity are considered functionally important. Finally, from the clinical point of view, CXCR4 antagonists could mobilize hematopoietic stem/progenitor cells with long-term repopulating capacity to the peripheral blood, promising to replace surgically obtained bone marrow cells as a preferred source for stem cell transplantation.
Collapse
Affiliation(s)
- Lun Kelvin Tsou
- Institute of Biotechnology and Pharmaceutical Research, National Health Research Institutes, Miaoli County, Taiwan, ROC
| | | | - Jen-Shin Song
- Institute of Biotechnology and Pharmaceutical Research, National Health Research Institutes, Miaoli County, Taiwan, ROC
| | - Yi-Yu Ke
- Institute of Biotechnology and Pharmaceutical Research, National Health Research Institutes, Miaoli County, Taiwan, ROC
| | - Jing-Kai Huang
- Institute of Biotechnology and Pharmaceutical Research, National Health Research Institutes, Miaoli County, Taiwan, ROC
| | - Kak-Shan Shia
- Institute of Biotechnology and Pharmaceutical Research, National Health Research Institutes, Miaoli County, Taiwan, ROC
| |
Collapse
|
5
|
Leukocytes: The Double-Edged Sword in Fibrosis. Mediators Inflamm 2015; 2015:652035. [PMID: 26568664 PMCID: PMC4629055 DOI: 10.1155/2015/652035] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
Skin tissue scar formation and fibrosis are often characterized by the increased production and deposition of extracellular matrix components, accompanied by the accumulation of a vast number of myofibroblasts. Scaring is strongly associated with inflammation and wound healing to regain tissue integrity in response to skin tissue injury. However, increased and uncontrolled inflammation, repetitive injury, and individual predisposition might lead to fibrosis, a severe disorder resulting in the formation of dense and stiff tissue that loses the physical properties and physiological functions of normal tissue. Fibrosis is an extremely complicated and multistage process in which bone marrow-derived leukocytes act as both pro- and antifibrotic agents, and therefore, few, if any, effective therapies are available for the most severe and lethal forms of fibrosis. Herein, we discuss the current knowledge on the multidimensional impact of leukocytes on the induction of fibrosis, focusing on skin fibrosis.
Collapse
|
6
|
Inhibitors of CXC chemokine receptor type 4: putative therapeutic approaches in inflammatory diseases. Curr Opin Hematol 2014; 21:29-36. [PMID: 24275689 DOI: 10.1097/moh.0000000000000002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The CXC chemokine receptor type 4 (CXCR4), which is a G-protein coupled receptor, and its ligand CXCL12 play an important role in neutrophil homeostasis and inflammation. This review focuses on involvement of the CXCL12/CXCR4 axis in inflammation and different inflammatory diseases and depicts that blocking CXCR4 is an attractive therapeutic strategy. RECENT FINDINGS Binding of CXCL12 to CXCR4 retains immature neutrophils in the bone marrow and also participates in leukocyte recruitment into inflamed tissue. The CXCL12/CXCR4 axis is also involved in several inflammatory processes and diseases including the WHIM (warts, hypogammaglobulinemia, infections and myelokathexis) syndrome, HIV, autoimmune disorders, ischemic injury, and pulmonary fibrosis. SUMMARY Based on these findings, blocking CXCR4 seems to be a therapeutic strategy in inflammatory diseases. Several promising CXCR4 antagonists are in different stages of development and clinical trials. Currently, only plerixafor (AMD3100) has been approved for short-term application.
Collapse
|
7
|
Royce SG, Moodley Y, Samuel CS. Novel therapeutic strategies for lung disorders associated with airway remodelling and fibrosis. Pharmacol Ther 2013; 141:250-60. [PMID: 24513131 DOI: 10.1016/j.pharmthera.2013.10.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/01/2013] [Indexed: 01/11/2023]
Abstract
Inflammatory cell infiltration, cytokine release, epithelial damage, airway/lung remodelling and fibrosis are central features of inflammatory lung disorders, which include asthma, chronic obstructive pulmonary disease, acute respiratory distress syndrome and idiopathic pulmonary fibrosis. Although the lung has some ability to repair itself from acute injury, in the presence of ongoing pathological stimuli and/or insults that lead to chronic disease, it no longer retains the capacity to heal, resulting in fibrosis, the final common pathway that causes an irreversible loss of lung function. Despite inflammation, genetic predisposition/factors, epithelial-mesenchymal transition and mechanotransduction being able to independently contribute to airway remodelling and fibrosis, current therapies for inflammatory lung diseases are limited by their ability to only target the inflammatory component of the disease without having any marked effects on remodelling (epithelial damage and fibrosis) that can cause lung dysfunction independently of inflammation. Furthermore, as subsets of patients suffering from these diseases are resistant to currently available therapies (such as corticosteroids), novel therapeutic approaches are required to combat all aspects of disease pathology. This review discusses emerging therapeutic approaches, such as trefoil factors, relaxin, histone deacetylase inhibitors and stem cells, amongst others that have been able to target airway inflammation and airway remodelling while improving related lung dysfunction. A better understanding of the mode of action of these therapies and their possible combined effects may lead to the identification of their clinical potential in the setting of lung disease, either as adjunct or alternative therapies to currently available treatments.
Collapse
Affiliation(s)
- Simon G Royce
- Fibrosis Laboratory, Department of Pharmacology, Monash University, Clayton, Victoria 3800, Australia; Departments of Pathology and Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria 3010, Australia.
| | - Yuben Moodley
- Department of Respiratory and Sleep Medicine, School of Medicine and Pharmacology, Royal Perth Hospital, University of Western Australia, Perth 6000, Western Australia, Australia
| | - Chrishan S Samuel
- Fibrosis Laboratory, Department of Pharmacology, Monash University, Clayton, Victoria 3800, Australia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria 3010, Australia; Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria 3010, Australia.
| |
Collapse
|
8
|
Wolters PJ, Collard HR, Jones KD. Pathogenesis of idiopathic pulmonary fibrosis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2013; 9:157-79. [PMID: 24050627 DOI: 10.1146/annurev-pathol-012513-104706] [Citation(s) in RCA: 556] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a fibrosing interstitial lung disease associated with aging that is characterized by the histopathological pattern of usual interstitial pneumonia. Although an understanding of the pathogenesis of IPF is incomplete, recent advances delineating specific clinical and pathologic features of IPF have led to better definition of the molecular pathways that are pathologically activated in the disease. In this review we highlight several of these advances, with a focus on genetic predisposition to IPF and how genetic changes, which occur primarily in epithelial cells, lead to activation of profibrotic pathways in epithelial cells. We then discuss the pathologic changes within IPF fibroblasts and the extracellular matrix, and we conclude with a summary of how these profibrotic pathways may be interrelated.
Collapse
Affiliation(s)
- Paul J Wolters
- Department of Medicine, School of Medicine, University of California, San Francisco, California 94143; ,
| | | | | |
Collapse
|
9
|
Extracellular matrix microenvironment contributes actively to pulmonary fibrosis. Curr Opin Pulm Med 2013; 19:446-52. [DOI: 10.1097/mcp.0b013e328363f4de] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
10
|
Borie R, Quesnel C, Phin S, Debray MP, Marchal-Somme J, Tiev K, Bonay M, Fabre A, Soler P, Dehoux M, Crestani B. Detection of alveolar fibrocytes in idiopathic pulmonary fibrosis and systemic sclerosis. PLoS One 2013; 8:e53736. [PMID: 23341987 PMCID: PMC3547062 DOI: 10.1371/journal.pone.0053736] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 12/04/2012] [Indexed: 12/22/2022] Open
Abstract
Background Fibrocytes are circulating precursors for fibroblasts. Blood fibrocytes are increased in patients with idiopathic pulmonary fibrosis (IPF). The aim of this study was to determine whether alveolar fibrocytes are detected in broncho-alveolar lavage (BAL), to identify their prognostic value, and their potential association with culture of fibroblasts from BAL. Methods We quantified fibrocytes in BAL from 26 patients with IPF, 9 patients with Systemic Sclerosis(SSc)-interstitial lung disease (ILD), and 11 controls. BAL cells were cultured to isolate alveolar fibroblasts. Results Fibrocytes were detected in BAL in 14/26 IPF (54%) and 5/9 SSc patients (55%), and never in controls. Fibrocytes were in median 2.5% [0.4–19.7] and 3.0% [2.7–3.7] of BAL cells in IPF and SSc-ILD patients respectively. In IPF patients, the number of alveolar fibrocytes was correlated with the number of alveolar macrophages and was associated with a less severe disease but not with a better outcome. Fibroblasts were cultured from BAL in 12/26 IPF (46%), 5/9 SSc-ILD (65%) and never in controls. The detection of BAL fibrocytes did not predict a positive culture of fibroblasts. Conclusion Fibrocytes were detected in BAL fluid in about half of the patients with IPF and SSc-ILD. Their number was associated with less severe disease in IPF patients and did not associate with the capacity to grow fibroblasts from BAL fluid.
Collapse
Affiliation(s)
- Raphael Borie
- Assistance Publique-Hopitaux de Paris, Service de Pneumologie A, Centre de Compétences Maladies Rares Pulmonaires, Hôpital Bichat, Paris, France
- INSERM, Unité 700, Faculté Bichat, Université Paris 7, Paris, France
| | - Christophe Quesnel
- INSERM, Unité 700, Faculté Bichat, Université Paris 7, Paris, France
- Assistance Publique-Hopitaux de Paris, Service d’Anesthésie et de Réanimation Chirurgicale, Hôpital Tenon, Paris, France
| | - Sophie Phin
- INSERM, Unité 700, Faculté Bichat, Université Paris 7, Paris, France
| | - Marie-Pierre Debray
- Assistance Publique-Hopitaux de Paris, Service de Radiologie, Hôpital Bichat, Paris, France
| | | | - Kiet Tiev
- Assistance Publique-Hopitaux de Paris, Service de Médecine Interne, Hôpital Saint Antoine, Paris, France
| | - Marcel Bonay
- INSERM, Unité 700, Faculté Bichat, Université Paris 7, Paris, France
- Assistance Publique-Hopitaux de Paris, Service d'Explorations Fonctionnelles, Hôpital Saint Antoine, Paris, France
- Université Paris Diderot Paris 7, PRES Sorbonne Paris Cité, Paris, France
| | - Aurélie Fabre
- INSERM, Unité 700, Faculté Bichat, Université Paris 7, Paris, France
- Université Paris Diderot Paris 7, PRES Sorbonne Paris Cité, Paris, France
- Assistance Publique-Hopitaux de Paris, Service d'Anatomopathologie, Hôpital Bichat, Paris, France
| | - Paul Soler
- INSERM, Unité 700, Faculté Bichat, Université Paris 7, Paris, France
| | - Monique Dehoux
- INSERM, Unité 700, Faculté Bichat, Université Paris 7, Paris, France
- Assistance Publique-Hopitaux de Paris, Service de Biochimie, Hôpital Bichat, Paris, France
| | - Bruno Crestani
- Assistance Publique-Hopitaux de Paris, Service de Pneumologie A, Centre de Compétences Maladies Rares Pulmonaires, Hôpital Bichat, Paris, France
- INSERM, Unité 700, Faculté Bichat, Université Paris 7, Paris, France
- Université Paris Diderot Paris 7, PRES Sorbonne Paris Cité, Paris, France
- * E-mail:
| |
Collapse
|
11
|
Karsdal MA, Nielsen MJ, Sand JM, Henriksen K, Genovese F, Bay-Jensen AC, Smith V, Adamkewicz JI, Christiansen C, Leeming DJ. Extracellular matrix remodeling: the common denominator in connective tissue diseases. Possibilities for evaluation and current understanding of the matrix as more than a passive architecture, but a key player in tissue failure. Assay Drug Dev Technol 2012; 11:70-92. [PMID: 23046407 DOI: 10.1089/adt.2012.474] [Citation(s) in RCA: 187] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Increased attention is paid to the structural components of tissues. These components are mostly collagens and various proteoglycans. Emerging evidence suggests that altered components and noncoded modifications of the matrix may be both initiators and drivers of disease, exemplified by excessive tissue remodeling leading to tissue stiffness, as well as by changes in the signaling potential of both intact matrix and fragments thereof. Although tissue structure until recently was viewed as a simple architecture anchoring cells and proteins, this complex grid may contain essential information enabling the maintenance of the structure and normal functioning of tissue. The aims of this review are to (1) discuss the structural components of the matrix and the relevance of their mutations to the pathology of diseases such as fibrosis and cancer, (2) introduce the possibility that post-translational modifications (PTMs), such as protease cleavage, citrullination, cross-linking, nitrosylation, glycosylation, and isomerization, generated during pathology, may be unique, disease-specific biochemical markers, (3) list and review the range of simple enzyme-linked immunosorbent assays (ELISAs) that have been developed for assessing the extracellular matrix (ECM) and detecting abnormal ECM remodeling, and (4) discuss whether some PTMs are the cause or consequence of disease. New evidence clearly suggests that the ECM at some point in the pathogenesis becomes a driver of disease. These pathological modified ECM proteins may allow insights into complicated pathologies in which the end stage is excessive tissue remodeling, and provide unique and more pathology-specific biochemical markers.
Collapse
|
12
|
Fujiwara A, Kobayashi H, Masuya M, Maruyama M, Nakamura S, Ibata H, Fujimoto H, Ohnishi M, Urawa M, Naito M, Takagi T, Kobayashi T, Gabazza EC, Takei Y, Taguchi O. Correlation between circulating fibrocytes, and activity and progression of interstitial lung diseases. Respirology 2012; 17:693-8. [PMID: 22404428 DOI: 10.1111/j.1440-1843.2012.02167.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Interstitial lung diseases (ILD) are characterized by progressive interstitial pulmonary fibrosis and a decline in lung function. Fibrocytes are bone marrow-derived mesenchymal progenitor cells that may play a role in the pathogenesis of pulmonary fibrosis. Circulating fibrocyte numbers have been correlated with the prognosis of patients with idiopathic pulmonary fibrosis. The aim of the present study was to evaluate the relationship between circulating fibrocytes, and parameters of disease activity and progression in several groups of patients with ILD. METHODS The study population comprised 41 patients with ILD and seven healthy control subjects. Circulating CD45(+) collagen-I(+) fibrocytes were evaluated by flow cytometry. RESULTS The number of circulating fibrocytes was significantly increased in all patients with ILD and particularly in patients with idiopathic interstitial pneumonitis and interstitial pneumonitis associated with collagen vascular disease as compared with healthy control subjects. The numbers of circulating fibrocytes were significantly correlated with pulmonary function test parameters and with serum levels of sialylated carbohydrate antigen, a marker of disease activity. Temporal changes in circulating fibrocyte numbers were evaluated in two patients, and the results suggested that these changes correlated with the activity of ILD. CONCLUSIONS The results from this study provide further evidence for the role of circulating fibrocytes in fibrotic lung diseases.
Collapse
Affiliation(s)
- Atsushi Fujiwara
- Divisions of Pulmonary and Critical Care Medicine, Mie University School of Medicine, Mie Chuo Medical Center, Tsu, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|