1
|
Foster JA, Hawk GS, Landy DC, Griffin JT, Bernard AC, Oyler DR, Southall WGS, Muhammad M, Sierra-Arce CR, Mounce SD, Borgida JS, Xiang L, Aneja A. Does Scheduled Low-Dose Short-Term NSAID (Ketorolac) Modulate Cytokine Levels After Orthopaedic Polytrauma? A Secondary Analysis of a Randomized Clinical Trial. J Orthop Trauma 2024; 38:358-365. [PMID: 38506517 DOI: 10.1097/bot.0000000000002807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To determine whether scheduled low-dose, short-term ketorolac modulates cytokine concentrations in orthopaedic polytrauma patients. METHODS DESIGN Secondary analysis of a double-blinded, randomized controlled trial. SETTING Single Level I trauma center from August 2018 to October 2022. PATIENT SELECTION CRITERIA Orthopaedic polytrauma patients between 18 and 75 years with a New Injury Severity Score greater than 9 were enrolled. Participants were randomized to receive 15 mg of intravenous ketorolac every 6 hours for up to 5 inpatient days or 2 mL of intravenous saline similarly. OUTCOME MEASURES AND COMPARISONS Daily concentrations of prostaglandin E2 and interleukin (IL)-1a, IL-1b, IL-6, and IL-10. Clinical outcomes included hospital and intensive care unit length of stay, pulmonary complications, and acute kidney injury. RESULTS Seventy orthopaedic polytrauma patients were enrolled, with 35 participants randomized to the ketorolac group and 35 to the placebo group. The overall IL-10 trend over time was significantly different in the ketorolac group ( P = 0.043). IL-6 was 65.8% higher at enrollment compared to day 3 ( P < 0.001) when aggregated over both groups. There was no significant treatment effect for prostaglandin E2, IL-1a, or IL-1b ( P > 0.05). There were no significant differences in clinical outcomes between groups ( P > 0.05). CONCLUSIONS Scheduled low-dose, short-term, intravenous ketorolac was associated with significantly different mean trends in IL-10 concentration in orthopaedic polytrauma patients with no significant differences in prostaglandin E2, IL-1a, IL-1b, or IL-6 levels between groups. The treatment did not have an impact on clinical outcomes of hospital or intensive care unit length of stay, pulmonary complications, or acute kidney injury. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Jeffrey A Foster
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Gregory S Hawk
- Dr Bing Zhang Department of Statistics, University of Kentucky, Lexington, KY
| | | | - Jarod T Griffin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew C Bernard
- Department of Trauma and Acute Care Surgery, University of Kentucky, Lexington, KY
| | - Douglas R Oyler
- Pharmacy Practice & Science Department, University of Kentucky, Lexington, KY
| | - Wyatt G S Southall
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Maaz Muhammad
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Samuel D Mounce
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Jacob S Borgida
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Lusha Xiang
- US Army Institute of Surgical Research, San Antonio, TX
| | - Arun Aneja
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
2
|
Šahinović I, Mandić S, Mihić D, Duvnjak M, Loinjak D, Sabadi D, Majić Z, Perić L, Šerić V. Endocannabinoids, Anandamide and 2-Arachidonoylglycerol, as Prognostic Markers of Sepsis Outcome and Complications. Cannabis Cannabinoid Res 2023; 8:802-811. [PMID: 35649233 PMCID: PMC10589499 DOI: 10.1089/can.2022.0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: One of the major challenges in improving sepsis care is early prediction of sepsis complications. The endocannabinoid system has been intensely studied in recent years; however, little is known about its role in sepsis in humans. This study aimed to assess the prognostic role of endocannabinoids, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), as early predictors of mortality, invasive mechanical ventilation (IMV) requirement, and length of stay (LOS) in patients with sepsis. Materials and Methods: In total, 106 patients with confirmed sepsis were enrolled in this study. The patients were divided into groups according to mortality outcome (survival, N=53; nonsurvival, N=53), IMV requirement (IMV group, N=26; non-IMV group, N=80), and LOS (LOS <10 days, N=59; LOS ≥10 days, N=47). Patients' clinical status was assessed along with laboratory biomarkers as well as AEA and 2-AG concentration measurements early on admission to emergency units. AEA and 2-AG levels were measured by enzyme-linked immunosorbent assay (ELISA) using an ELISA processor, EtiMax 3000 (DiaSorin, Saluggia, Italy). The predictive value of AEA and 2-AG for the studied sepsis outcomes and complications was analyzed using univariate and multivariate analyses and receiver operating characteristic (ROC) curve analysis. Results: Two endocannabinoids showed no significant difference between survivors and nonsurvivors, although an AEA concentration <7.16 μg/L predicted mortality outcome with a sensitivity of 57% (95% confidence interval [CI] 42-71) and specificity of 80% (95% CI 66-91). AEA concentrations ≤17.84 μg/L predicted LOS ≥10 days with sensitivity of 98% (95% CI 89-100) and specificity of 34% (95% CI 22-47). When analyzing IMV requirement, levels of AEA and 2-AG were significantly lower within the IMV group compared with the non-IMV group (5.94 μg/L [2.04-9.44] and 6.70 μg/L [3.50-27.04], p=0.043, and 5.68 μg/L [2.30-8.60] and 9.58 μg/L [4.83-40.05], p=0.002, respectively). The 2-AG showed the best performance for IMV requirement prediction, with both sensitivity and specificity of 69% (p<0.001). Endocannabinoid AEA was an independent risk factor of LOS ≥10 days (odds ratio [OR] 23.59; 95% CI 3.03-183.83; p=0.003) and IMV requirement in sepsis (OR 0.79; 95% CI, 0.67-0.93; p=0.004). Conclusion: Low AEA concentration is a prognostic factor of hospital LOS longer than 10 days. Lower AEA and 2-AG concentrations obtained at the time of admission to the hospital are predictors of IMV requirement.
Collapse
Affiliation(s)
- Ines Šahinović
- Department of Clinical Laboratory Diagnostics, University Hospital Osijek, Osijek, Croatia
- J.J. Strossmayer University of Osijek, Faculty of Medicine Osijek, Osijek, Croatia
| | - Sanja Mandić
- Department of Clinical Laboratory Diagnostics, University Hospital Osijek, Osijek, Croatia
- J.J. Strossmayer University of Osijek, Faculty of Medicine Osijek, Osijek, Croatia
| | - Damir Mihić
- J.J. Strossmayer University of Osijek, Faculty of Medicine Osijek, Osijek, Croatia
- Department of Pulmonology and Intensive Care, Clinic of Internal Medicine, University Hospital Osijek, Osijek, Croatia
| | - Mario Duvnjak
- J.J. Strossmayer University of Osijek, Faculty of Medicine Osijek, Osijek, Croatia
- Clinic of Infective Diseases, University Hospital Osijek, Osijek, Croatia
| | - Domagoj Loinjak
- J.J. Strossmayer University of Osijek, Faculty of Medicine Osijek, Osijek, Croatia
- Department of Pulmonology and Intensive Care, Clinic of Internal Medicine, University Hospital Osijek, Osijek, Croatia
| | - Dario Sabadi
- J.J. Strossmayer University of Osijek, Faculty of Medicine Osijek, Osijek, Croatia
- Clinic of Infective Diseases, University Hospital Osijek, Osijek, Croatia
| | - Zlatko Majić
- Department of Pulmonology and Intensive Care, Clinic of Internal Medicine, University Hospital Osijek, Osijek, Croatia
| | - Ljiljana Perić
- J.J. Strossmayer University of Osijek, Faculty of Medicine Osijek, Osijek, Croatia
- Clinic of Infective Diseases, University Hospital Osijek, Osijek, Croatia
| | - Vatroslav Šerić
- Department of Clinical Laboratory Diagnostics, University Hospital Osijek, Osijek, Croatia
- J.J. Strossmayer University of Osijek, Faculty of Medicine Osijek, Osijek, Croatia
| |
Collapse
|
3
|
Liang Q, Wang L, Xu J, Lin A, Wu Y, Tao Q, Zhang B, Min H, Song S, Gao Q. A burns and COVID-19 shared stress responding gene network deciphers CD1C-CD141- DCs as the key cellular components in septic prognosis. Cell Death Discov 2023; 9:258. [PMID: 37488118 PMCID: PMC10366195 DOI: 10.1038/s41420-023-01518-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 07/26/2023] Open
Abstract
Differential body responses to various stresses, infectious or noninfectious, govern clinical outcomes ranging from asymptoma to death. However, the common molecular and cellular nature of the stress responsome across different stimuli is not described. In this study, we compared the expression behaviors between burns and COVID-19 infection by choosing the transcriptome of peripheral blood from related patients as the analytic target since the blood cells reflect the systemic landscape of immune status. To this end, we identified an immune co-stimulator (CD86)-centered network, named stress-response core (SRC), which was robustly co-expressed in burns and COVID-19. The enhancement of SRC genes (SRCs) expression indicated favorable prognosis and less severity in both conditions. An independent whole blood single-cell RNA sequencing of COVID-19 patients demonstrated that the monocyte-dendritic cell (Mono-DC) wing was the major cellular source of SRC, among which the higher expression of the SRCs in the monocyte was associated with the asymptomatic COVID-19 patients, while the quantity-restricted and function-defected CD1C-CD141-DCs were recognized as the key signature which linked to bad consequences. Specifically, the proportion of the CD1C-CD141-DCs and their SRCs expression were step-wise reduced along with worse clinic conditions while the subcluster of CD1C-CD141-DCs from the critical COVID-19 patients was characterized of IFN signaling quiescence, high mitochondrial metabolism and immune-communication inactivation. Thus, our study identified an expression-synchronized and function-focused gene network in Mono-DC population whose expression status was prognosis-related and might serve as a new target of diagnosis and therapy.
Collapse
Affiliation(s)
- Qiao Liang
- Center for Translational Medicine and Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, Jiangsu Province, China
| | - Lei Wang
- Department of Clinical Laboratory, Jiangsu Provincial Hospital of Integrated Chinese and Western Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, 210028, China
| | - Jing Xu
- Center for Translational Medicine and Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, Jiangsu Province, China
| | - Anqi Lin
- Center for Translational Medicine and Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, Jiangsu Province, China
| | - Yongzheng Wu
- Center for Translational Medicine and Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, Jiangsu Province, China
| | - Qing Tao
- Center for Translational Medicine and Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, Jiangsu Province, China
| | - Bin Zhang
- Center for Translational Medicine and Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, Jiangsu Province, China
- Central Laboratory, Nanjing Chest Hospital, Nanjing Medical University, Nanjing, 210028, China
| | - Haiyan Min
- Central Laboratory, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210028, China
| | - Shiyu Song
- Center for Translational Medicine and Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, Jiangsu Province, China.
| | - Qian Gao
- Center for Translational Medicine and Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, Jiangsu Province, China.
| |
Collapse
|
4
|
Cui Z, Wang L, Li H, Feng M. Study on immune status alterations in patients with sepsis. Int Immunopharmacol 2023; 118:110048. [PMID: 36989895 DOI: 10.1016/j.intimp.2023.110048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023]
Abstract
Sepsis, characterized by cytokine-mediated hyper-inflammation and a consistent decline in immune responsiveness, is associated with a high risk of death in the intensive care unit (ICU). Here, we for the first time investigated the changes in immune and inflammatory responses to understand the interactions between immune and inflammatory biomarkers and their association with patient outcomes. The cytokine and lymphocyte subset levels were analyzed in healthy donors (HD) and patients with sepsis upon admission to the ICU (D0), D3, D7, D14, and D28 using flow cytometry. The primary endpoint was mortality on day 90. The trends in lymphocyte subsets and cytokine levels in all patients (n = 47), HD (n = 27), and patient subgroups (surviving, n = 30; dead, n = 17) were analyzed using an independent sample t-test and principal component analysis. Age, steroids (steroids used > 48 h), secondary infection, acute heart failure, acute kidney injury, coagulopathy, hypohepatia, organ transplant and septic shock (when transferred to the ICU) were associated with mortality. Absolute lymphocyte counts and lymphocyte subsets levels were reduced in most patients with sepsis. The proportion of Tregs in the patients increased with disease progression and was associated with immunosuppression. In conclusion, sepsis downregulated adaptive immunity, and induced the transition of the patients to prolonged immune suppression. The study suggests that while cellular immunity recovered within 2 weeks of admission, humoral and innate immunity recovery takes longer. These findings may assist in developing appropriate therapeutic approaches to improve the immune responses in patients with sepsis.
Collapse
|
5
|
Alves GF, Stoppa I, Aimaretti E, Monge C, Mastrocola R, Porchietto E, Einaudi G, Collotta D, Bertocchi I, Boggio E, Gigliotti CL, Clemente N, Aragno M, Fernandes D, Cifani C, Thiemermann C, Dianzani C, Dianzani U, Collino M. ICOS-Fc as innovative immunomodulatory approach to counteract inflammation and organ injury in sepsis. Front Immunol 2022; 13:992614. [PMID: 36119089 PMCID: PMC9479331 DOI: 10.3389/fimmu.2022.992614] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Inducible T cell co-stimulator (ICOS), an immune checkpoint protein expressed on activated T cells and its unique ligand, ICOSL, which is expressed on antigen-presenting cells and non-hematopoietic cells, have been extensively investigated in the immune response. Recent findings showed that a soluble recombinant form of ICOS (ICOS-Fc) can act as an innovative immunomodulatory drug as both antagonist of ICOS and agonist of ICOSL, modulating cytokine release and cell migration to inflamed tissues. Although the ICOS-ICOSL pathway has been poorly investigated in the septic context, a few studies have reported that septic patients have reduced ICOS expression in whole blood and increased serum levels of osteopontin (OPN), that is another ligand of ICOSL. Thus, we investigated the pathological role of the ICOS-ICOSL axis in the context of sepsis and the potential protective effects of its immunomodulation by administering ICOS-Fc in a murine model of sepsis. Polymicrobial sepsis was induced by cecal ligation and puncture (CLP) in five-month-old male wild-type (WT) C57BL/6, ICOS-/-, ICOSL-/- and OPN-/- mice. One hour after the surgical procedure, either CLP or Sham (control) mice were randomly assigned to receive once ICOS-Fc, F119SICOS-Fc, a mutated form uncapable to bind ICOSL, or vehicle intravenously. Organs and plasma were collected 24 h after surgery for analyses. When compared to Sham mice, WT mice that underwent CLP developed within 24 h a higher clinical severity score, a reduced body temperature, an increase in plasma cytokines (TNF-α, IL-1β, IL-6, IFN-γ and IL-10), liver injury (AST and ALT) and kidney (creatinine and urea) dysfunction. Administration of ICOS-Fc to WT CLP mice reduced all of these abnormalities caused by sepsis. Similar beneficial effects were not seen in CLP-mice treated with F119SICOS-Fc. Treatment of CLP-mice with ICOS-Fc also attenuated the sepsis-induced local activation of FAK, P38 MAPK and NLRP3 inflammasome. ICOS-Fc seemed to act at both sides of the ICOS-ICOSL interaction, as the protective effect was lost in septic knockout mice for the ICOS or ICOSL genes, whereas it was maintained in OPN knockout mice. Collectively, our data show the beneficial effects of pharmacological modulation of the ICOS-ICOSL pathway in counteracting the sepsis-induced inflammation and organ dysfunction.
Collapse
Affiliation(s)
| | - Ian Stoppa
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Eleonora Aimaretti
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Chiara Monge
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Raffaella Mastrocola
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Elisa Porchietto
- Pharmacology Unit, School of Pharmacy, University of Camerino, Camerino, Italy
| | - Giacomo Einaudi
- Pharmacology Unit, School of Pharmacy, University of Camerino, Camerino, Italy
| | - Debora Collotta
- Department of Neurosciences (Rita Levi Montalcini), University of Turin, Turin, Italy
| | - Ilaria Bertocchi
- Department of Neurosciences (Rita Levi Montalcini), University of Turin, Turin, Italy
| | - Elena Boggio
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | | | - Nausicaa Clemente
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Manuela Aragno
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Daniel Fernandes
- Department of Pharmacology, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Carlo Cifani
- Pharmacology Unit, School of Pharmacy, University of Camerino, Camerino, Italy
| | - Christoph Thiemermann
- William Harvey Research Institute, Bart’s and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Chiara Dianzani
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Umberto Dianzani
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Massimo Collino
- Department of Neurosciences (Rita Levi Montalcini), University of Turin, Turin, Italy
- *Correspondence: Massimo Collino,
| |
Collapse
|
6
|
Senousy SR, Ahmed ASF, Abdelhafeez DA, Khalifa MMA, Abourehab MAS, El-Daly M. Alpha-Chymotrypsin Protects Against Acute Lung, Kidney, and Liver Injuries and Increases Survival in CLP-Induced Sepsis in Rats Through Inhibition of TLR4/NF-κB Pathway. Drug Des Devel Ther 2022; 16:3023-3039. [PMID: 36105322 PMCID: PMC9467300 DOI: 10.2147/dddt.s370460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
Abstract Inflammation and oxidative stress play a major role in the development of sepsis and its associated complications, leading to multiple organ failure and death. The lungs, liver, and kidneys are among the early affected organs correlated with mortality in sepsis. Alpha-chymotrypsin (α-ch) is a serine protease that exerts anti-inflammatory, anti-edematous, and anti-oxidant properties. Purpose This study was undertaken to elucidate if the anti-inflammatory and anti-oxidant effects of α-ch observed in previous studies can alleviate lung, liver, and kidney injuries in a cecal ligation and puncture (CLP)-induced sepsis model, and thus decrease mortality. Materials and Methods Septic animals were given α-ch 2 h post CLP procedure. Sepsis outcomes were assessed in the lungs, liver, and kidneys. Separate animal groups were investigated for a survival study. Results CLP resulted in 0% survival, while α-chymotrypsin post-treatment led to 50% survival at the end of the study. Administration of α-chymotrypsin resulted in a significant attenuation of sepsis-induced elevated malonaldehyde (MDA) and total nitrite/nitrate (NOx) levels. In addition, there was a significant increase in reduced glutathione (GSH) content and superoxide dismutase (SOD) activity in the lungs, liver, and kidneys. Administration of α-ch reduced elevated tissue expression of toll-like receptor-4 (TLR4), nuclear factor kappa-B (NF-κB), myeloperoxidase (MPO), and inducible nitric oxide synthase (iNOS). Alpha-chymotrypsin resulted in a significant reduction in serum levels of tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6). Alpha-chymotrypsin attenuated the rise in serum creatinine, cystatin C, blood urea nitrogen (BUN), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels that was observed in the septic group. In addition, α-ch significantly reduced the lung wet/dry weight ratio, total protein content, and leukocytic counts in bronchoalveolar lavage fluid (BALF). Histopathological examination of the lungs, liver, and kidneys confirmed the protective effects of α-ch on those organs. Conclusion α-ch has protective potential against sepsis through lowering tissue expression of TLR4, NF-κB, MPO, and iNOS leading to decreased oxidative stress and inflammatory signals induced by sepsis. This effect appeared to alleviate the damage to the lungs, liver, and kidneys and increase survival in rats subjected to sepsis.
Collapse
Affiliation(s)
- Shaymaa Ramzy Senousy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Al-Shaimaa F Ahmed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
- Correspondence: Al-Shaimaa F Ahmed, Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, Egypt, Tel +20 1020018842, Email
| | - Dalia A Abdelhafeez
- Department of Pathology, Faculty of Medicine, Minia University, Minia, Egypt
| | | | - Mohammed A S Abourehab
- Department of Pharmaceutics, Faculty of Pharmacy, Umm Al-Qura University, Makkah, 21955, Saudi Arabia
| | - Mahmoud El-Daly
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| |
Collapse
|
7
|
Shapiro L, Scherger S, Franco-Paredes C, Gharamti AA, Fraulino D, Henao-Martinez AF. Chasing the Ghost: Hyperinflammation Does Not Cause Sepsis. Front Pharmacol 2022; 13:910516. [PMID: 35814227 PMCID: PMC9260244 DOI: 10.3389/fphar.2022.910516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/23/2022] [Indexed: 12/15/2022] Open
Abstract
Sepsis is infection sufficient to cause illness in the infected host, and more severe forms of sepsis can result in organ malfunction or death. Severe forms of Coronavirus disease-2019 (COVID-19), or disease following infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are examples of sepsis. Following infection, sepsis is thought to result from excessive inflammation generated in the infected host, also referred to as a cytokine storm. Sepsis can result in organ malfunction or death. Since COVID-19 is an example of sepsis, the hyperinflammation concept has influenced scientific investigation and treatment approaches to COVID-19. However, decades of laboratory study and more than 100 clinical trials designed to quell inflammation have failed to reduce sepsis mortality. We examine theoretical support underlying widespread belief that hyperinflammation or cytokine storm causes sepsis. Our analysis shows substantial weakness of the hyperinflammation approach to sepsis that includes conceptual confusion and failure to establish a cause-and-effect relationship between hyperinflammation and sepsis. We conclude that anti-inflammation approaches to sepsis therapy have little chance of future success. Therefore, anti-inflammation approaches to treat COVID-19 are likewise at high risk for failure. We find persistence of the cytokine storm concept in sepsis perplexing. Although treatment approaches based on the hyperinflammation concept of pathogenesis have failed, the concept has shown remarkable resilience and appears to be unfalsifiable. An approach to understanding this resilience is to consider the hyperinflammation or cytokine storm concept an example of a scientific paradigm. Thomas Kuhn developed the idea that paradigms generate rules of investigation that both shape and restrict scientific progress. Intrinsic features of scientific paradigms include resistance to falsification in the face of contradictory data and inability of experimentation to generate alternatives to a failing paradigm. We call for rejection of the concept that hyperinflammation or cytokine storm causes sepsis. Using the hyperinflammation or cytokine storm paradigm to guide COVID-19 treatments is likewise unlikely to provide progress. Resources should be redirected to more promising avenues of investigation and treatment.
Collapse
Affiliation(s)
- Leland Shapiro
- Division of Infectious Diseases, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- *Correspondence: Leland Shapiro,
| | - Sias Scherger
- Division of Infectious Diseases, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
| | - Carlos Franco-Paredes
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Hospital Infantil de México, Federico Gomez, Mexico City, Mexico
| | - Amal A. Gharamti
- Department of Internal Medicine, Yale University, Waterbury, CT, United States
| | - David Fraulino
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Andrés F. Henao-Martinez
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| |
Collapse
|
8
|
Future Drug Targets in Periodontal Personalised Medicine—A Narrative Review. J Pers Med 2022; 12:jpm12030371. [PMID: 35330371 PMCID: PMC8955099 DOI: 10.3390/jpm12030371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/22/2022] [Accepted: 02/26/2022] [Indexed: 02/08/2023] Open
Abstract
Periodontal disease is an infection-driven inflammatory disease characterized by the destruction of tooth-supporting tissues. The establishment of chronic inflammation will result in progressive destruction of bone and soft tissue changes. Severe periodontitis can lead to tooth loss. The disease has complex pathogenesis with an interplay between genetic, environmental, and host factors and pathogens. Effective management consists of plaque control and non-surgical interventions, along with adjuvant strategies to control inflammation and disrupt the pathogenic subgingival biofilms. Recent studies have examined novel approaches for managing periodontal diseases such as modulating microbial signaling mechanisms, tissue engineering, and molecular targeting of host inflammatory substances. Mounting evidence suggests the need to integrate omics-based approaches with traditional therapy to address the disease. This article discusses the various evolving and future drug targets, including proteomics, gene therapeutics, vaccines, and nanotechnology in personalized periodontal medicine for the effective management of periodontal diseases.
Collapse
|
9
|
Gandhirajan A, Roychowdhury S, Vachharajani V. Sirtuins and Sepsis: Cross Talk between Redox and Epigenetic Pathways. Antioxidants (Basel) 2021; 11:antiox11010003. [PMID: 35052507 PMCID: PMC8772830 DOI: 10.3390/antiox11010003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 12/19/2022] Open
Abstract
Sepsis and septic shock are the leading causes of death among hospitalized patients in the US. The immune response in sepsis transitions from a pro-inflammatory and pro-oxidant hyper-inflammation to an anti-inflammatory and cytoprotective hypo-inflammatory phase. While 1/3rd sepsis-related deaths occur during hyper-, a vast majority of sepsis-mortality occurs during the hypo-inflammation. Hyper-inflammation is cytotoxic for the immune cells and cannot be sustained. As a compensatory mechanism, the immune cells transition from cytotoxic hyper-inflammation to a cytoprotective hypo-inflammation with anti-inflammatory/immunosuppressive phase. However, the hypo-inflammation is associated with an inability to clear invading pathogens, leaving the host susceptible to secondary infections. Thus, the maladaptive immune response leads to a marked departure from homeostasis during sepsis-phases. The transition from hyper- to hypo-inflammation occurs via epigenetic programming. Sirtuins, a highly conserved family of histone deacetylators and guardians of homeostasis, are integral to the epigenetic programming in sepsis. Through their anti-inflammatory and anti-oxidant properties, the sirtuins modulate the immune response in sepsis. We review the role of sirtuins in orchestrating the interplay between the oxidative stress and epigenetic programming during sepsis.
Collapse
Affiliation(s)
- Anugraha Gandhirajan
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (A.G.); (S.R.)
| | - Sanjoy Roychowdhury
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (A.G.); (S.R.)
| | - Vidula Vachharajani
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (A.G.); (S.R.)
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Correspondence:
| |
Collapse
|
10
|
Han HS, Kim SY, Shin JS, Lee HH, Chung KS, Rhee YK, Cho CW, Hong HD, Lee KT. Polysaccharide fraction isolated from the leaves of Hordeum vulgare L. protects against colonic inflammation of systemic immune responses. J Funct Foods 2021. [DOI: 10.1016/j.jff.2021.104765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
|
11
|
Tong-Minh K, Welten I, Endeman H, Hagenaars T, Ramakers C, Gommers D, van Gorp E, van der Does Y. Predicting mortality in adult patients with sepsis in the emergency department by using combinations of biomarkers and clinical scoring systems: a systematic review. BMC Emerg Med 2021; 21:70. [PMID: 34120605 PMCID: PMC8201689 DOI: 10.1186/s12873-021-00461-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/20/2021] [Indexed: 11/18/2022] Open
Abstract
Background Sepsis can be detected in an early stage in the emergency department (ED) by biomarkers and clinical scoring systems. A combination of multiple biomarkers or biomarker with clinical scoring system might result in a higher predictive value on mortality. The goal of this systematic review is to evaluate the available literature on combinations of biomarkers and clinical scoring systems on 1-month mortality in patients with sepsis in the ED. Methods We performed a systematic search using MEDLINE, EMBASE and Google Scholar. Articles were included if they evaluated at least one biomarker combined with another biomarker or clinical scoring system and reported the prognostic accuracy on 28 or 30 day mortality by area under the curve (AUC) in patients with sepsis. We did not define biomarker cut-off values in advance. Results We included 18 articles in which a total of 35 combinations of biomarkers and clinical scoring systems were studied, of which 33 unique combinations. In total, seven different clinical scoring systems and 21 different biomarkers were investigated. The combination of procalcitonin (PCT), lactate, interleukin-6 (IL-6) and Simplified Acute Physiology Score-2 (SAPS-2) resulted in the highest AUC on 1-month mortality. Conclusion The studies we found in this systematic review were too heterogeneous to conclude that a certain combination it should be used in the ED to predict 1-month mortality in patients with sepsis. Future studies should focus on clinical scoring systems which require a limited amount of clinical parameters, such as the qSOFA score in combination with a biomarker that is already routinely available in the ED. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00461-z.
Collapse
Affiliation(s)
- Kirby Tong-Minh
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Postbus 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Iris Welten
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Postbus 2040, 3000, CA, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tjebbe Hagenaars
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Postbus 2040, 3000, CA, Rotterdam, The Netherlands
| | - Christian Ramakers
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eric van Gorp
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Viroscience, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Yuri van der Does
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Postbus 2040, 3000, CA, Rotterdam, The Netherlands
| |
Collapse
|
12
|
Tindal EW, Armstead BE, Monaghan SF, Heffernan DS, Ayala A. Emerging therapeutic targets for sepsis. Expert Opin Ther Targets 2021; 25:175-189. [PMID: 33641552 PMCID: PMC8122062 DOI: 10.1080/14728222.2021.1897107] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/25/2021] [Indexed: 12/11/2022]
Abstract
Introduction: Sepsis is characterized by a dysregulated host response to infection. Sepsis-associated morbidity/mortality demands concerted research efforts toward therapeutic interventions which are reliable, broadly effective, and etiologically based. More intensive and extensive investigations on alterations in cellular signaling pathways, gene targeting as a means of modifying the characteristic hyper and/or hypo-immune responses, prevention through optimization of the microbiome, and the molecular pathways underlying the septic immune response could improve outcomes.] Areas covered: The authors discuss key experimental mammalian models and clinical trials. They provide an evaluation of evolving therapeutics in sepsis and how they have built upon past and current treatments. Relevant literature was derived from a PubMed search spanning 1987-2020.Expert opinion: Given the complex nature of sepsis and the elicited immune response, it is not surprising that a single cure-all therapeutic intervention, which is capable of effectively and reliably improving patient outcomes has failed to emerge. Innovative approaches seek to address not only the disease process but modify underlying patient factors. A true improvement in sepsis-associated morbidity/mortality will require a combination of unique therapeutic modalities.
Collapse
Affiliation(s)
- Elizabeth W Tindal
- Division of Surgical Research, Department of Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Brandon E Armstead
- Division of Surgical Research, Department of Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Sean F Monaghan
- Division of Surgical Research, Department of Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Daithi S Heffernan
- Division of Surgical Research, Department of Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Alfred Ayala
- Division of Surgical Research, Department of Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA
| |
Collapse
|
13
|
Meletiadis J, Tsiodras S, Tsirigotis P. Interleukin-6 Blocking vs. JAK-STAT Inhibition for Prevention of Lung Injury in Patients with COVID-19. Infect Dis Ther 2020; 9:707-713. [PMID: 32789663 PMCID: PMC7680461 DOI: 10.1007/s40121-020-00326-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Indexed: 12/25/2022] Open
Abstract
The severe respiratory insufficiency observed during COVID-19 infection may not be directly related to a cytopathogenic effect induced by the virus itself, but to an exaggerated and inappropriate immune response. In an effort to reduce the severity of organ dysfunction, including respiratory insufficiency, monoclonal antibodies (Mabs) that block the interleukin-6 receptor, such as tocilizumab, sarilumab, and siltuximab, are under investigation for the treatment of COVID-19. However, blocking of just one of the many cytokines involved in the inflammatory reaction may not slow down the magnitude of the process. Since timing is important, the immune deficiency induced by IL6 blockade at the late immunodeficiency phase of sepsis that follows the initial inflammatory response may be detrimental. Finally, monitoring the degree and duration of IL6 blockade may be challenging because of the long half-life of Mabs (2-3 weeks). Pro- and anti-inflammatory cytokines act through a common JAK-STAT signaling pathway, which can be inhibited by JAK-STAT inhibitors. Ruxolitinib, a tyrosine kinase inhibitor selective for JAK1, 2, blocks many pro- and anti-inflammatory cytokines including IL6. Ruxolitinib has favorable pharmacodynamics and an acceptable safety profile. The short half-life (4-6 h) of the drug offers the opportunity for ideal monitoring of the degree and duration of cytokine blocking, simply by the adjusting dose and duration of therapy. From a theoretical point of view, the balanced control of cytokine blockade throughout the course of the septic process should be the cornerstone of modern management. According to this hypothesis, maximization of blocking should be attempted at the phase of hyper-inflammation for preventing severe organ damage, while pro-inflammatory blockade should be minimized at the late phase of immunoparalysis for prevention of secondary infections. Based on the above considerations, we consider that the efficacy and safety of this drug deserves testing in the context of a controlled randomized trial.
Collapse
Affiliation(s)
- Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Sotirios Tsiodras
- Forth Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Tsirigotis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
14
|
Clere-Jehl R, Mariotte A, Meziani F, Bahram S, Georgel P, Helms J. JAK-STAT Targeting Offers Novel Therapeutic Opportunities in Sepsis. Trends Mol Med 2020; 26:987-1002. [PMID: 32631717 DOI: 10.1016/j.molmed.2020.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/21/2020] [Accepted: 06/10/2020] [Indexed: 12/13/2022]
Abstract
Sepsis is a life-threatening condition caused by exaggerated host responses to infections taking place in two phases: (i) a systemic (hyper)inflammatory response syndrome (SIRS), participating in multiple organ failure (MOF), a major complication of septic shock, followed by (ii) a compensatory anti-inflammatory response syndrome (CARS), leading to sepsis-induced immunosuppression and resulting in late infections and long-term mortality. The Janus kinase-signal transducer and activator of transcription (JAK-STAT)-dependent signaling pathway is involved in both manifestations, hence playing a key role during sepsis. It is also involved in emergency myelopoiesis, which participates in host defense. The aim of this review is to highlight and refine the recent implications of this signaling pathway in sepsis and illustrate why its central position makes it a potential biomarker and therapeutic target.
Collapse
Affiliation(s)
- Raphaël Clere-Jehl
- Université de Strasbourg, Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive et Réanimation, Nouvel Hôpital Civil, Strasbourg, France; ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, Centre de Recherche d'Immunologie et d'Hématologie, Faculté de Médecine, Fédération Hospitalo-Universitaire (FHU) OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Alexandre Mariotte
- ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, Centre de Recherche d'Immunologie et d'Hématologie, Faculté de Médecine, Fédération Hospitalo-Universitaire (FHU) OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Ferhat Meziani
- Université de Strasbourg, Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive et Réanimation, Nouvel Hôpital Civil, Strasbourg, France
| | - Seiamak Bahram
- ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, Centre de Recherche d'Immunologie et d'Hématologie, Faculté de Médecine, Fédération Hospitalo-Universitaire (FHU) OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Philippe Georgel
- ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, Centre de Recherche d'Immunologie et d'Hématologie, Faculté de Médecine, Fédération Hospitalo-Universitaire (FHU) OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France.
| | - Julie Helms
- Université de Strasbourg, Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive et Réanimation, Nouvel Hôpital Civil, Strasbourg, France; ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, Centre de Recherche d'Immunologie et d'Hématologie, Faculté de Médecine, Fédération Hospitalo-Universitaire (FHU) OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France.
| |
Collapse
|
15
|
Qin K, Han C, Zhang H, Li T, Li N, Cao X. NAD + dependent deacetylase Sirtuin 5 rescues the innate inflammatory response of endotoxin tolerant macrophages by promoting acetylation of p65. J Autoimmun 2017; 81:120-129. [PMID: 28461090 DOI: 10.1016/j.jaut.2017.04.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 12/19/2022]
Abstract
The induction and persistence of a hypo-inflammatory and immunosuppressive state in severe sepsis is commonly associated with increased risks of secondary infections and mortality. Toll-like receptor (TLR)-triggered inflammatory response of macrophages/monocytes plays an important role in determining the outcome of hyper-inflammation during the acute phase and the hypo-inflammation during immunosuppressive phase of sepsis. However, the mechanisms for controlling hypo-inflammatory response in endotoxin tolerant macrophages remain to be fully understood. Considering that metabolic control of inflammation is an emerging field and the balance between AMP/ATP and oxidized NAD+/reduced NADH is associated with inflammation and metabolism, we analyzed the level of NAD+ in TLR-triggered innate inflammatory response, and found that the decreased level of NAD+ was significantly related to the increased inflammatory cytokine production both in vivo and in vitro. By screening the expression and function of NAD+ dependent type III deacetylase Sirtuin family members, we found that SIRT5 and SIRT1/2 had opposite expression patterns and functions in macrophages. SIRT5 deficiency decreased TLR-triggered inflammation in both acute and immunosuppressive phases of sepsis. Interestingly, cytoplasmic SIRT5 counteracted the inhibitory effects of SIRT2 and enhanced the innate inflammatory responses in macrophages and even in endotoxin-tolerant macrophages by promoting acetylation of p65 and activation of NF-κB pathway. Mechanistically, SIRT5 competed with SIRT2 to interact with NF-κB p65, in a deacetylase activity-independent way, to block the deacetylation of p65 by SIRT2, which consequently led to increased acetylation of p65 and the activation of NF-κB pathway and its downstream cytokines. Our study discovered the new functions of different Sirtuin members in sepsis, indicating that targeting of Sirtuin family members at different sepsis phases can be helpful to precisely control the progression of sepsis.
Collapse
Affiliation(s)
- Kewei Qin
- National Key Laboratory of Medical Immunology & Institute of Immunology, Second Military Medical University, Shanghai 200433, China
| | - Chaofeng Han
- National Key Laboratory of Medical Immunology & Institute of Immunology, Second Military Medical University, Shanghai 200433, China
| | - Hua Zhang
- National Key Laboratory of Medical Immunology & Institute of Immunology, Second Military Medical University, Shanghai 200433, China
| | - Tianliang Li
- National Key Laboratory of Medical Immunology & Institute of Immunology, Second Military Medical University, Shanghai 200433, China
| | - Nan Li
- National Key Laboratory of Medical Immunology & Institute of Immunology, Second Military Medical University, Shanghai 200433, China
| | - Xuetao Cao
- National Key Laboratory of Medical Immunology & Institute of Immunology, Second Military Medical University, Shanghai 200433, China; Department of Immunology & Center for Immunotherapy, Institute of Basic Medical Sciences, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100005, China.
| |
Collapse
|