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Wilbrink R, Neys SF, Hendriks RW, Spoorenberg A, Kroese FG, Corneth OB, Verstappen GM. Aberrant B cell receptor signaling responses in circulating double-negative 2 B cells from radiographic axial spondyloarthritis patients. J Transl Autoimmun 2025; 10:100270. [PMID: 39974741 PMCID: PMC11835616 DOI: 10.1016/j.jtauto.2025.100270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2024] [Revised: 12/24/2024] [Accepted: 01/15/2025] [Indexed: 02/21/2025] Open
Abstract
Objective Radiographic axial spondyloarthritis (r-axSpA) is a chronic rheumatic disease in which innate immune cells and T cells are thought to play a major role. However, recent studies also hint at B cell involvement. Here, we performed an in-depth analysis on alterations within the B-cell compartment from r-axSpA patients. Methods We performed immune gene expression profiling on total peripheral blood B cells from 8 r-axSpA patients and 8 healthy controls (HCs). Next, we explored B cell subset distribution and B-cell receptor (BCR) signaling responses in circulating B cells from 28 r-axSpA patients and 15 HCs, by measuring spleen tyrosine kinase, phosphoinositide 3-kinase and extracellular signal regulated kinase 1/2 phosphorylation upon α-Ig stimulation using phosphoflow cytometry. Results Immune gene expression profiling indicated an elevated pathway score for BCR signaling in total B cells from r-axSpA patients compared with HCs. Flow cytometric analysis revealed an increase in frequency of both total and double-negative 2 (DN2) B cells in r-axSpA patients compared with HCs. In r-axSpA patients, DN2 B cells displayed an isotype shift towards IgA. Remarkably, where DN2 B cells from HCs were hyporesponsive, these cells displayed significant proximal BCR signaling responses in r-axSpA patients. Enhanced BCR signaling responses were also observed in the transitional and naïve B cell population from r-axSpA patients compared with HCs. The enhanced BCR signaling responses in DN2 B cells correlated with clinical disease parameters. Conclusion In r-axSpA patients, circulating DN2 B cells are expanded and, together with transitional and naïve B cells, display significantly enhanced BCR signaling responses upon stimulation. Together, our data suggest B cell involvement in the pathogenesis of r-axSpA.
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Affiliation(s)
- Rick Wilbrink
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan F.H. Neys
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Rudi W. Hendriks
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Anneke Spoorenberg
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frans G.M. Kroese
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Odilia B.J. Corneth
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Gwenny M.P.J. Verstappen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Du X, Li H, Zhao H, Cui S, Sun X, Tan X. Causal relationship between gut microbiota and ankylosing spondylitis and potential mediating role of inflammatory cytokines: A mendelian randomization study. PLoS One 2024; 19:e0306792. [PMID: 39083521 PMCID: PMC11290680 DOI: 10.1371/journal.pone.0306792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/24/2024] [Indexed: 08/02/2024] Open
Abstract
Associations between gut microbiota and ankylosing spondylitis have been discovered in previous studies, but whether these associations reflect a causal relationship remains inconclusive. Aiming to reveal the bidirectional causal associations between gut microbiota and ankylosing spondylitis, we utilized publicly available genome wide association study summary data for 211 gut microbiota (GM) taxa and ankylosing spondylitis (AS) to conduct two sample mendelian randomization analyses. Mediation analysis was performed to explore mediating inflammatory cytokines. We found that genetically predicted higher abundance of Lactobacillaceae family, Rikenellaceae family and Howardella genus had suggestive associations with decreased risk of ankylosing spondylitis while genetic proxied higher abundance of Actinobacteria class and Ruminococcaceae_NK4A214_group genus was associated with increased risk of ankylosing spondylitis. IL23 and IFN-γ were potential mediating cytokines for GM dysbiosis, especially for Actinobacteria class, leading to AS. Our study provided a new exploration direction for the treatment of AS. Lactobacillaceae family, Rikenellaceae family, Howardella genus, Actinobacteria class and Ruminococcaceae_NK4A214_group genus are expected to become new therapeutic targets and monitoring indicators for AS.
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Affiliation(s)
- Xinyu Du
- Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western Medicine, Tianjin Hospital, Tianjin, China
| | - Haibo Li
- Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western Medicine, Tianjin Hospital, Tianjin, China
| | - Hongzhou Zhao
- Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western Medicine, Tianjin Hospital, Tianjin, China
| | - Shuangshuang Cui
- Orthopedics Institute, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Xiaozhuo Sun
- Preventive Treatment of Disease Department, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xiaochan Tan
- Acupuncture Department, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, China
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Fang P, Liu X, Qiu Y, Wang Y, Wang D, Zhao J, Ding H, Bao N. Exploring causal correlations between inflammatory cytokines and ankylosing spondylitis: a bidirectional mendelian-randomization study. Front Immunol 2023; 14:1285106. [PMID: 38054001 PMCID: PMC10694192 DOI: 10.3389/fimmu.2023.1285106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/31/2023] [Indexed: 12/07/2023] Open
Abstract
Background The impact of inflammatory factors on the development of Ankylosing Spondylitis (AS) is widely recognized, but the exact causal relationship remains unclear. Methods The bidirectional mendelian-randomization study utilized genetic data from a genome-wide association study (GWAS) of 186 AS cases and 456,162 controls of European ancestry. Inflammatory cytokines were obtained from a GWAS summary of 8,293 healthy participants. Causal associations were primarily investigated using the inverse variance-weighted method, supplemented by MR Egger, weighted median and weighted mode analyses. Heterogeneity in the results was assessed using the Cochrane Q test. Horizontal pleiotropy was evaluated through the MR-Egger intercept test and the MR pleiotropy residual sum and outliers (MR-PRESSO) test. Sensitivity analysis was conducted through leave-one-out analysis. Results The results suggest a genetically predicted potential association between beta-nerve growth factor (βNGF), Interleukin-1-beta (IL-1β), and TNF-related apoptosis inducing ligand (TRAIL) with the risk of AS (OR: 2.17, 95% CI: 1.13-4.16; OR: 0.41, 95% CI: 0.18-0.95,; OR: 1.47, 95% CI: 1.02-2.13).Additionally, Interleukin-12p70 (IL-12p70), Interleukin-17 (IL-17), Interleukin-6 (IL-6), Interleukin-4 (IL-4), Stromal-cell-derived factor 1 alpha (SDF-1α), Macrophage inflammatory protein 1β (MIP1β), Monocyte chemoattractant protein-3 (MCP-3), Platelet-derived growth factor bb (PDGFbb), Granulocyte-colony stimulating factor (GCSF), Fibroblast growth factor basic (bFGF), TNF-related apoptosis inducing ligand (TRAIL), and Interferon-gamma (IFN -γ) are suggested as consequences of AS in genetically prediction.No evidence of horizontal pleiotropy or heterogeneity between the genetic variants was found (P>0.05), and a leave-one-out test confirmed the stability and robustness of this association. Conclusion These findings suggest that βNGF, IL-1β, and TRAIL may play a crucial role in the pathogenesis of AS. Additionally, AS may impact the expression of cytokines such as IL-12p70, IL-17, IL-6, IL-4, SDF-1α, MIP1β, MCP-3, PDGFbb,GCSF, bFGF,TRAIL,and IFN-γ. Further investigations are warranted to determine whether these biomarkers can be utilized for the prevention or treatment of AS.
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Affiliation(s)
| | | | | | | | | | | | - Hao Ding
- Department of Orthopedics, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Nirong Bao
- Department of Orthopedics, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Zhang J, Peng C, Xu S, Zhao Y, Zhang X, Zhang S, Guo Z. Mitochondrial displacement loop region single nucleotide polymorphisms and mitochondrial DNA copy number associated with risk of ankylosing spondylitis. Int J Rheum Dis 2023; 26:2157-2162. [PMID: 37592897 DOI: 10.1111/1756-185x.14876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 07/03/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023]
Abstract
AIM The pathogenesis of ankylosing spondylitis (AS) seems to be associated with genetics, the environment, heredity, and oxidative stress. Single nucleotide polymorphisms (SNPs) in the displacement loop (D-loop) region of mitochondrial DNA (mtDNA) and mtDNA copy number were investigated for their correlation with AS patients. METHODS This study included 83 AS patients and 100 healthy controls from the Second Hospital of Hebei Medical University. DNAs were extracted from blood samples for polymerase chain reaction analysis and quantitative real-time polymerase chain reaction analysis. Plasma reactive oxygen species (ROS) levels were measured by fluorescent probe technology. RESULTS The distribution frequencies of the minor alleles of nucleotides 16304C (p = .037), 16311C (p = .027), and 152C (p = .034) were remarkably higher in AS patients than in healthy controls, which indicated that the16304C, 16311C, and 152C alleles were correlated with an increased risk of AS. Simultaneously, mtDNA copy number was statistically higher in patients with AS compared with controls (1.450 ± 0.876 versus 0.835 ± 0.626, p < .001). We also observed an increased ROS generation in AS patients compared with controls (27 066.169 ± 18 364.819 versus 14 758.330 ± 5854.946, p < .001) subsequently. In addition, the AS susceptible SNP 16311C is associated with high ROS levels (35 065.177 ± 26 999.934 vs. 25 005.818 ± 14 999.495, p = .043). CONCLUSION Our study demonstrated that SNPs in the mtDNA D-loop could be AS risk biomarkers with the potential to promote oxidative stress levels; mtDNA copy number-induced mitochondrial dysfunction may also be involved in AS pathogenesis.
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Affiliation(s)
- Jingjing Zhang
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chenxing Peng
- Department of Immunology and Rheumatology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shuo Xu
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yufei Zhao
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoyun Zhang
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shasha Zhang
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhanjun Guo
- Department of Immunology and Rheumatology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Jin Q, Liu Y, Zhang Z, Wen X, Chen Z, Tian H, Kang Z, Wu X, Xu H. MYC promotes fibroblast osteogenesis by regulating ALP and BMP2 to participate in ectopic ossification of ankylosing spondylitis. Arthritis Res Ther 2023; 25:28. [PMID: 36803548 PMCID: PMC9942334 DOI: 10.1186/s13075-023-03011-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/09/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Ectopic ossification is an important cause of disability in patients with ankylosing spondylitis (AS). Whether fibroblasts can transdifferentiate into osteoblasts and contribute to ossification remains unknown. This study aims to investigate the role of stem cell transcription factors (POU5F1, SOX2, KLF4, MYC, etc.) of fibroblasts in ectopic ossification in patients with AS. METHODS Primary fibroblasts were isolated from the ligaments of patients with AS or osteoarthritis (OA). In an in vitro study, primary fibroblasts were cultured in osteogenic differentiation medium (ODM) to induce ossification. The level of mineralization was assessed by mineralization assay. The mRNA and protein levels of stem cell transcription factors were measured by real-time quantitative PCR (q-PCR) and western blotting. MYC was knocked down by infecting primary fibroblasts with lentivirus. The interactions between stem cell transcription factors and osteogenic genes were analysed by chromatin immunoprecipitation (ChIP). Recombinant human cytokines were added to the osteogenic model in vitro to evaluate their role in ossification. RESULTS We found that MYC was elevated significantly in the process of inducing primary fibroblasts to differentiate into osteoblasts. In addition, the level of MYC was remarkably higher in AS ligaments than in OA ligaments. When MYC was knocked down, the expression of the osteogenic genes alkaline phosphatase (ALP) and bone morphogenic protein 2 (BMP2) was decreased, and the level of mineralization was reduced significantly. In addition, the ALP and BMP2 were confirmed to be the direct target genes of MYC. Furthermore, interferon-γ (IFN-γ), which showed high expression in AS ligaments, was found to promote the expression of MYC in fibroblasts in the process of ossification in vitro. CONCLUSIONS This study demonstrates the role of MYC in ectopic ossification. MYC may act as the critical bridge that links inflammation with ossification in AS, thus providing new insights into the molecular mechanisms of ectopic ossification in AS.
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Affiliation(s)
- Qianmei Jin
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Yaoyang Liu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Zhiguo Zhang
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Xingzhu Wen
- Department of General Surgery, 72nd Group Army Hospital, Huzhou University, Huzhou, 313000, Zhejiang, China
| | - Ziqiang Chen
- Department of Orthopaedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Haijun Tian
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Zijian Kang
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Xin Wu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Huji Xu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, China.
- School of Medicine, Tsinghua University, Beijing, 100084, China.
- Peking-Tsinghua Center for Life Sciences, Tsinghua University, Beijing, 100084, China.
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Sun R, Wang X, Sun X, Zhao B, Zhang X, Gong X, Wong SH, Chan MTV, Wu WKK. Emerging Roles of Long Non-Coding RNAs in Ankylosing Spondylitis. Front Immunol 2022; 13:790924. [PMID: 35222376 PMCID: PMC8866863 DOI: 10.3389/fimmu.2022.790924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/19/2022] [Indexed: 12/16/2022] Open
Abstract
Ankylosing spondylitis (AS) is a chronic systemic autoimmune disease characterized by inflammation, bone erosion, spur formation of the spine and the sacroiliac joints. However, the etiology and molecular pathogenesis of AS remain largely unclear. Recently, a growing number of studies showed that long non-coding RNAs (lncRNAs) played critical roles in the development and progression of autoimmune and orthopedic conditions, including AS. Studies demonstrated that a myriad of lncRNAs (e.g. H19, MEG3, LOC645166) pertinent to regulation of inflammatory signals were deregulated in AS. A number of lncRNAs might also serve as new biomarkers for the diagnosis and predicting the outcomes of AS. In this review, we summarize lncRNA profiling studies on AS and the functional roles and mechanism of key lncRNAs relevant to AS pathogenesis. We also discuss their potential values as biomarkers and druggable targets for this potentially disabling condition.
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Affiliation(s)
- Ruifu Sun
- Department Spinal of Qingdao Hospital Central, Qingdao Hospital Central, Qingdao, China
| | - Xuesong Wang
- Department Spinal of Qingdao Hospital Central, Qingdao Hospital Central, Qingdao, China
| | - Xiaohong Sun
- Department Obstetrics and Gynecology of Qingdao Hospital Central, Central Qingdao Hospital, Qingdao, China
| | - Bing Zhao
- Department Spinal of Qingdao Hospital Central, Qingdao Hospital Central, Qingdao, China
| | - Xiugong Zhang
- Department Spinal of Qingdao Hospital Central, Qingdao Hospital Central, Qingdao, China
| | - Xiaojin Gong
- Department Spinal of Qingdao Hospital Central, Qingdao Hospital Central, Qingdao, China
| | - Sunny Hei Wong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- State Key Laboratory of Digestive Disease and LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Matthew Tak Vai Chan
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - William Ka Kei Wu
- State Key Laboratory of Digestive Disease and LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
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B Cell Involvement in the Pathogenesis of Ankylosing Spondylitis. Int J Mol Sci 2021; 22:ijms222413325. [PMID: 34948121 PMCID: PMC8703482 DOI: 10.3390/ijms222413325] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 12/25/2022] Open
Abstract
Extensive research into ankylosing spondylitis (AS) has suggested the major role of genetics, immune reactions, and the joint-gut axis in its etiology, although an ultimate consensus does not yet exist. The available evidence indicates that both autoinflammation and T-cell-mediated autoimmune processes are actively involved in the disease process of AS. So far, B cells have received relatively little attention in AS pathogenesis; this is largely due to a lack of conventional disease-defining autoantibodies. However, against prevailing dogma, there is a growing body of evidence suggestive of B cell involvement. This is illustrated by disturbances in circulating B cell populations and the formation of auto-reactive and non-autoreactive antibodies, along with B cell infiltrates within the axial skeleton of AS patients. Furthermore, the depletion of B cells, using rituximab, displayed beneficial results in a subgroup of patients with AS. This review provides an overview of our current knowledge of B cells in AS, and discusses their potential role in its pathogenesis. An overarching picture portrays increased B cell activation in AS, although it is unclear whether B cells directly affect pathogenesis, or are merely bystanders in the disease process.
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Liu Y, Zhang G, Guan Y, Zhao X, Wang Q, Li H, Qi J. Association of IFN-γ polymorphisms with ankylosing spondylitis risk. J Cell Mol Med 2020; 24:10615-10620. [PMID: 32729668 PMCID: PMC7521230 DOI: 10.1111/jcmm.15680] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 01/14/2023] Open
Abstract
The case‐control study was designed to investigate the genetic effects of interferon‐gamma (IFN‐γ) rs2069727 and rs1861494 polymorphisms on ankylosing spondylitis (AS) susceptibility in a Chinese Han population. Blood samples were collected from 108 AS patients and 110 healthy controls. IFN‐γ polymorphisms were genotyped by polymerase chain reaction‐restriction fragment length polymorphism (PCR‐RFLP). Hardy‐Weinberg equilibrium (HWE) test was performed in control group. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated using chi‐square test to evaluate the association between AS susceptibility and IFN‐γ polymorphisms, and the results were adjusted by logistic regressive analysis. The frequency of rs2069727 CC genotype was much higher in cases than that in controls, suggested its significant association with increased AS risk (adjusted OR = 5.899, 95% CI = 1.563‐22.261; P = .009). In addition, C allele also showed close association with increased risk of AS (adjusted OR = 2.052, 95% CI = 1.286‐1.704, P = 0 .003). While the genotype and allele frequencies of IFN‐γ rs1861494 polymorphism were not significantly different between patients and controls (P > 0.05 for all), IFN‐γ rs2069727 polymorphism is significantly associated with increased AS risk in a Chinese Han Population.
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Affiliation(s)
- Yanhui Liu
- Department of Orthopedics, Harrison International Peace Hospital, The People's Hospital of Hengshui City, Hengshui, China
| | - Guohui Zhang
- Department of Orthopedics, Harrison International Peace Hospital, The People's Hospital of Hengshui City, Hengshui, China
| | - Yulong Guan
- Department of Orthopedics, Harrison International Peace Hospital, The People's Hospital of Hengshui City, Hengshui, China
| | - Xiaoliang Zhao
- Department of Orthopedics, Harrison International Peace Hospital, The People's Hospital of Hengshui City, Hengshui, China
| | - Quan Wang
- Department of Orthopedics, Harrison International Peace Hospital, The People's Hospital of Hengshui City, Hengshui, China
| | - Hua Li
- Department of Orthopedics, Harrison International Peace Hospital, The People's Hospital of Hengshui City, Hengshui, China
| | - Jinhong Qi
- Department of Orthopedics, Harrison International Peace Hospital, The People's Hospital of Hengshui City, Hengshui, China
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