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Li Q, Chen N, Liu C, Zhao Z, Huang M, Li J, Yang G. Staphylococcus aureus β-hemolysin impairs oxygen transport without causing hemolysis. Virulence 2025; 16:2490208. [PMID: 40202859 PMCID: PMC11988224 DOI: 10.1080/21505594.2025.2490208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Revised: 01/27/2025] [Accepted: 04/02/2025] [Indexed: 04/11/2025] Open
Abstract
Staphylococcus aureus (S. aureus) infection can lead to the occurrence of hypoxia, however, the underlying mechanisms have not been fully elucidated. β-hemolysin (Hlb) induced hemolysis of red blood cells (RBCs) requires a temperature transition from "hot" to "cold," a phenomenon not observed under physiological conditions. In this study, we discovered that RBCs treated with Hlb exhibited a high level of intracellular Ca2+ and underwent a shape transformation from biconcave discoid to spherical, which was contingent upon the degradation of sphingomyelin of the cell membrane and led to impaired oxygen transport. The increase in intracellular Ca2+ levels induced by Hlb was dependent on the activation of the ion channel N-methyl-D-aspartate receptor. Furthermore, we found that Hlb-induced Ca2+ influx increased the cytoplasmic pH and subsequently attenuated the oxygen release from RBCs, which were also observed in both hlb transgenic mice and a murine model with S. aureus challenge. Our findings reveal a novel role for Hlb as sphingomyelinase in impairing RBC function under non-lytic conditions, shedding light on the mechanism behind hypoxia associated with S. aureus infection.
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Affiliation(s)
- Qi Li
- Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Nan Chen
- Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chenghua Liu
- Beijing Institute of Pharmacology and Toxicology, Academy of Military Medical Sciences, Academy of Military Science of the Chinese People’s Liberation Army, Beijing, China
| | - Zhen Zhao
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Minjun Huang
- Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jingjing Li
- Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Guang Yang
- Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Rasquel-Oliveira FS, Ribeiro JM, Martelossi-Cebinelli G, Costa FB, Nakazato G, Casagrande R, Verri WA. Staphylococcus aureus in Inflammation and Pain: Update on Pathologic Mechanisms. Pathogens 2025; 14:185. [PMID: 40005560 PMCID: PMC11858194 DOI: 10.3390/pathogens14020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2025] [Revised: 01/23/2025] [Accepted: 02/10/2025] [Indexed: 02/27/2025] Open
Abstract
Staphylococcus aureus (S. aureus) is a Gram-positive bacterium of significant clinical importance, known for its versatility and ability to cause a wide array of infections, such as osteoarticular, pulmonary, cardiovascular, device-related, and hospital-acquired infections. This review describes the most recent evidence of the pathogenic potential of S. aureus, which is commonly part of the human microbiota but can lead to severe infections. The prevalence of pathogenic S. aureus in hospital and community settings contributes to substantial morbidity and mortality, particularly in individuals with compromised immune systems. The immunopathogenesis of S. aureus infections involves intricate interactions with the host immune and non-immune cells, characterized by various virulence factors that facilitate adherence, invasion, and evasion of the host's defenses. This review highlights the complexity of S. aureus infections, ranging from mild to life-threatening conditions, and underscores the growing public health concern posed by multidrug-resistant strains, including methicillin-resistant S. aureus (MRSA). This article aims to provide an updated perspective on S. aureus-related infections, highlighting the main diseases linked to this pathogen, how the different cell types, virulence factors, and signaling molecules are involved in the immunopathogenesis, and the future perspectives to overcome the current challenges to treat the affected individuals.
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Affiliation(s)
- Fernanda S. Rasquel-Oliveira
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Immunology, Parasitology and General Pathology, Center of Biological Sciences, Londrina State University, Londrina 86057-970, PR, Brazil; (F.S.R.-O.)
| | - Jhonatan Macedo Ribeiro
- Department of Microbiology, Center of Biological Sciences, Londrina State University, Londrina 86057-970, PR, Brazil (G.N.)
| | - Geovana Martelossi-Cebinelli
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Immunology, Parasitology and General Pathology, Center of Biological Sciences, Londrina State University, Londrina 86057-970, PR, Brazil; (F.S.R.-O.)
| | - Fernanda Barbosa Costa
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Immunology, Parasitology and General Pathology, Center of Biological Sciences, Londrina State University, Londrina 86057-970, PR, Brazil; (F.S.R.-O.)
| | - Gerson Nakazato
- Department of Microbiology, Center of Biological Sciences, Londrina State University, Londrina 86057-970, PR, Brazil (G.N.)
| | - Rubia Casagrande
- Department of Pharmaceutical Sciences, Center of Health Science, Londrina State University, Londrina 86038-440, PR, Brazil
| | - Waldiceu A. Verri
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Immunology, Parasitology and General Pathology, Center of Biological Sciences, Londrina State University, Londrina 86057-970, PR, Brazil; (F.S.R.-O.)
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Esnaashari F, Zahmatkesh H. Antivirulence activities of Rutin-loaded chitosan nanoparticles against pathogenic Staphylococcus aureus. BMC Microbiol 2024; 24:328. [PMID: 39244527 PMCID: PMC11380343 DOI: 10.1186/s12866-024-03446-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 07/26/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Staphylococcus aureus is an infectious bacterium that is frequently found in healthcare settings and the community. This study aimed to prepare rutin-loaded chitosan nanoparticles (Rut-CS NPs) and assess their antibacterial activity against pathogenic strains of S. aureus. RESULTS The synthesized Rut-CS NPs exhibited an amorphous morphology with a size ranging from 160 to 240 nm and a zeta potential of 37.3 mV. Rut-CS NPs demonstrated significant antibacterial activity against S. aureus strains. Following exposure to Rut-CS NPs, the production of staphyloxanthin pigment decreased by 43.31-89.63%, leading to increased susceptibility of S. aureus to hydrogen peroxide. Additionally, visual inspection of cell morphology indicated changes in membrane integrity and permeability upon Rut-CS NPs exposure, leading to a substantial increase (107.07-191.08%) in cytoplasmic DNA leakage in the strains. Furthermore, ½ MIC of Rut-CS NPs effectively inhibited the biofilm formation (22.5-37.5%) and hemolytic activity (69-82.59%) in the S. aureus strains. CONCLUSIONS Our study showcases that Rut-CS NPs can serve as a novel treatment agent to combat S. aureus infections by altering cell morphology and inhibiting virulence factors of S. aureus.
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Affiliation(s)
- Fatemeh Esnaashari
- Department of Biology, Lahijan Branch, Islamic Azad University, Lahijan, Iran
| | - Hossein Zahmatkesh
- Department of Microbiology, Lahijan Branch, Islamic Azad University, Lahijan, Iran.
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Vadakkan K, Sathishkumar K, Kuttiyachan Urumbil S, Ponnenkunnathu Govindankutty S, Kumar Ngangbam A, Devi Nongmaithem B. A review of chemical signaling mechanisms underlying quorum sensing and its inhibition in Staphylococcus aureus. Bioorg Chem 2024; 148:107465. [PMID: 38761705 DOI: 10.1016/j.bioorg.2024.107465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 05/20/2024]
Abstract
Staphylococcus aureus is a significant bacterium responsible for multiple infections and is a primary cause of fatalities among patients in hospital environments. The advent of pathogenic bacteria such as methicillin-resistant S. aureus revealed the shortcomings of employing antibiotics to treat bacterial infectious diseases. Quorum sensing enhances S. aureus's survivability through signaling processes. Targeting the key components of quorum sensing has drawn much interest nowadays as a promising strategy for combating infections caused by bacteria. Concentrating on the accessory gene regulator quorum-sensing mechanism is the most commonly suggested anti-virulence approach for S.aureus. Quorum quenching is a common strategy for controlling illnesses triggered by microorganisms since it reduces the pathogenicity of bacteria and improves bacterial biofilm susceptibility to antibiotics, thus providing an intriguing prospect for drug discovery. Quorum sensing inhibition reduces selective stresses and constrains the emergence of antibiotic resistance while limiting bacterial pathogenicity. This review examines the quorum sensing mechanisms involved in S. aureus, quorum sensing targets and gene regulation, environmental factors affecting quorum sensing, quorum sensing inhibition, natural products as quorum sensing inhibitory agents and novel therapeutical strategies to target quorum sensing in S. aureus as drug developing technique to augment conventional antibiotic approaches.
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Affiliation(s)
- Kayeen Vadakkan
- Department of Biotechnology, St. Mary's College (Autonomous), Thrissur, Kerala 680020, India; Manipur International University, Imphal, Manipur 795140, India.
| | - Kuppusamy Sathishkumar
- Center for Global Health Research, Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Thandalam, Chennai, Tamil Nadu 602105, India
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Jia Y, Guan Z, Liu C, Huang M, Li J, Feng J, Shen B, Yang G. Staphylococcus aureus β-hemolysin causes skin inflammation by acting as an agonist of epidermal growth factor receptor. Microbiol Spectr 2024; 12:e0222723. [PMID: 38059627 PMCID: PMC10783061 DOI: 10.1128/spectrum.02227-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 11/08/2023] [Indexed: 12/08/2023] Open
Abstract
IMPORTANCE Staphylococcus aureus is a Gram-positive opportunistic bacterium that is responsible for the majority of skin infections in humans. Our study provides important molecular insights into the pathogenesis of S. aureus skin infections and identifies a potential therapeutic target for the treatment of these infections. Our findings also indicate that β-hemolysin (Hlb) secreted by colonized S. aureus is a risk factor for epidermal growth factor receptor (EGFR)-related diseases by acting as an agonist of EGFR. The neutralized monoclonal antibody we have developed for the first time will provide a functional inhibitor of Hlb. This study provides important insights to better understand the relationship between the skin colonization of S. aureus and inflammatory skin diseases.
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Affiliation(s)
- Yonggen Jia
- Beijing Institute of Tropical Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhangchun Guan
- Beijing Institute of Pharmacology and Toxicology, Beijing, China
- Cancer Institute, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Chenghua Liu
- Beijing Institute of Pharmacology and Toxicology, Beijing, China
| | - Minjun Huang
- Beijing Institute of Tropical Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jingjing Li
- Beijing Institute of Tropical Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jiannan Feng
- Beijing Institute of Pharmacology and Toxicology, Beijing, China
| | - Beifen Shen
- Beijing Institute of Pharmacology and Toxicology, Beijing, China
| | - Guang Yang
- Beijing Institute of Tropical Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Pharmacology and Toxicology, Beijing, China
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Jin M, He B, Cai X, Lei Z, Sun T. Research progress of nanoparticle targeting delivery systems in bacterial infections. Colloids Surf B Biointerfaces 2023; 229:113444. [PMID: 37453264 DOI: 10.1016/j.colsurfb.2023.113444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Bacterial infection is a huge threat to the health of human beings and animals. The abuse of antibiotics have led to the occurrence of bacterial multidrug resistance, which have become a difficult problem in the treatment of clinical infections. Given the outstanding advantages of nanodrug delivery systems in cancer treatment, many scholars have begun to pay attention to their application in bacterial infections. However, due to the similarity of the microenvironment between bacterial infection lesions and cancer sites, the targeting and accuracy of traditional microenvironment-responsive nanocarriers are questionable. Therefore, finding new specific targets has become a new development direction of nanocarriers in bacterial prevention and treatment. This article reviews the infectious microenvironment induced by bacteria and a series of virulence factors of common pathogenic bacteria and their physiological functions, which may be used as potential targets to improve the targeting accuracy of nanocarriers in lesions.
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Affiliation(s)
- Ming Jin
- School of Chemistry, Chemical Engineering and Life Science, Wuhan University of Technology, 122 Luoshi Road, Wuhan 430070, China; Hubei Key Laboratory of Nanomedicine for Neurodegenerative Diseases, Wuhan University of Technology, 122 Luoshi Road, Wuhan 430070, China
| | - Bin He
- Institute of Animal Husbandry and Veterinary, Wuhan Academy of Agricultural Sciences, China
| | - Xiaoli Cai
- School of Chemistry, Chemical Engineering and Life Science, Wuhan University of Technology, 122 Luoshi Road, Wuhan 430070, China; Hubei Key Laboratory of Nanomedicine for Neurodegenerative Diseases, Wuhan University of Technology, 122 Luoshi Road, Wuhan 430070, China
| | - Zhixin Lei
- School of Chemistry, Chemical Engineering and Life Science, Wuhan University of Technology, 122 Luoshi Road, Wuhan 430070, China; Hubei Key Laboratory of Nanomedicine for Neurodegenerative Diseases, Wuhan University of Technology, 122 Luoshi Road, Wuhan 430070, China.
| | - Taolei Sun
- School of Chemistry, Chemical Engineering and Life Science, Wuhan University of Technology, 122 Luoshi Road, Wuhan 430070, China; Hubei Key Laboratory of Nanomedicine for Neurodegenerative Diseases, Wuhan University of Technology, 122 Luoshi Road, Wuhan 430070, China.
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Phenotypic and Genomic Comparison of Staphylococcus aureus Highlight Virulence and Host Adaptation Favoring the Success of Epidemic Clones. mSystems 2022; 7:e0083122. [PMID: 36409083 PMCID: PMC9765012 DOI: 10.1128/msystems.00831-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) of the sequence type 59 (ST59) and ST398 lineages has emerged in hospitals and displayed a higher virulent potential than its counterparts ST5 and ST239. However, the mechanism of the host cell-pathogen interaction and specific determinates that contribute to the success of epidemic clones remain incompletely understood. In the present study, 142 S. aureus strains (ST59, ST398, ST239, and ST5) were selected from our 7-year national surveillance of S. aureus bloodstream infections (n = 983). We revealed that ST59 and ST398 had a higher prevalence of the protease-associated genes hysAVSaβ, paiB, and cfim and enhanced proteolytic activity than the other lineages. ST59 and ST398 showed a higher expression of RNAIII and psmα and greater proficiency at causing cell lysis than other lineages. Furthermore, ST59 and ST398 were strongly recognized by human neutrophils and caused more cell apoptosis and neutrophil extracellular trap degradation than the other lineages. In addition, these strains differed substantially in their repertoire and composition of intact adhesion genes. Moreover, ST398 displayed higher adaptability to human epidermal keratinocytes and a unique genetic arrangement inside the oligopeptide ABC transport system, indicating functional variations. Overall, our study revealed some potential genomic traits associated with virulence and fitness that might account for the success of epidemic clones. IMPORTANCE Considerable efforts have been exerted to identify factors contributing to the success of epidemic Staphylococcus aureus clones, however, comparative phenotypic studies lack representation owing to the small number of strains. Large-scale strain collections focused on the description of genomic characteristics. Moreover, methicillin-resistant S. aureus infections constitute 30% to 40% of S. aureus bloodstream infections, and recent research has elucidated highly virulent methicillin-susceptible S. aureus strains. However, comprehensive research on the factors contributing to the success of epidemic S. aureus clones is lacking. In this study, 142 S. aureus strains were selected from our 7-year national surveillance of S. aureus bloodstream infections (n = 983) accompanied by a rigorous strain selection process. A combination of host cell-pathogen interactions and genomic analyses was applied to the represented strains. We revealed some potential genomic traits associated with virulence and fitness that might account for the success of epidemic clones.
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Liu Y, Li Z, Qi Y, Wen X, Zhang L. Metagenomic Analysis Reveals a Changing Microbiome Associated With the Depth of Invasion of Oral Squamous Cell Carcinoma. Front Microbiol 2022; 13:795777. [PMID: 35222330 PMCID: PMC8863607 DOI: 10.3389/fmicb.2022.795777] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/17/2022] [Indexed: 12/15/2022] Open
Abstract
The relationship between oral squamous cell carcinoma (OSCC) development and the microbiome has attracted increasing attention. The depth of invasion (DOI) is an important indicator of tumor progression, staging and prognosis, and the change in the oral microbiome based on the DOI is unclear. This report describes the use of metagenomic analyses to investigate the relationship between the oral microbiome and the DOI. Forty patients in different DOI categories were recruited; 10 healthy people served as the control group. Swab samples collected from the participants were subjected to metagenomic analyses, and the oral microbial communities and their functions were investigated. The abundances of Fusobacterium nucleatum, Capnocytophaga sputigena, Porphyromonas endodontalis, and Gemella haemolysans were significantly increased in the patients compared with the controls. The abundances of some bacteria exhibited a stage-related trend. The abundances of P. endodontalis, Gemella morbillorum and G. haemolysans increased with increasing DOI. In contrast, the abundances of Prevotella melaninogenica, Haemophilus parainfluenzae and Neisseria flavescens decreased with increasing DOI. Based on receiver operating characteristic (ROC) curve analysis, eight species were found to have predictive value: Rothia mucilaginosa, P. melaninogenica, H. parainfluenzae, and N. flavescens in the healthy control group and P. endodontalis, G. morbillorum, G. haemolysans and Fusobacterium periodonticum in the high DOI group. In the functional analysis, several metabolic pathways were decreased, whereas flagellar assembly and bacterial chemotaxis showed an increasing trend as the disease progressed. Biofilm formation, flagella, lipopolysaccharide (LPS) and other virulence factors exhibited staging-related changes. These pathogenic pathways and factors had a clear correlation with specific pathogens. In particular, when OSCC progressed to the late stage, microbial diversity and functional potential changed greatly.
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Affiliation(s)
- Yuan Liu
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, Shanghai, China
- National Center for Stomatology & National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Zhengrui Li
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, Shanghai, China
- National Center for Stomatology & National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Yanxu Qi
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong University, Shandong, China
- Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Shandong University, Shandong, China
| | - Xutao Wen
- Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Guangxi Medical University, Nanning, Guangxi, China
| | - Ling Zhang
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, Shanghai, China
- National Center for Stomatology & National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Shanghai, China
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Raineri EJM, Altulea D, van Dijl JM. Staphylococcal trafficking and infection - from 'nose to gut' and back. FEMS Microbiol Rev 2021; 46:6321165. [PMID: 34259843 PMCID: PMC8767451 DOI: 10.1093/femsre/fuab041] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/11/2021] [Indexed: 12/12/2022] Open
Abstract
Staphylococcus aureus is an opportunistic human pathogen, which is a leading cause of infections worldwide. The challenge in treating S. aureus infection is linked to the development of multidrug-resistant strains and the mechanisms employed by this pathogen to evade the human immune defenses. In addition, S. aureus can hide asymptomatically in particular ‘protective’ niches of the human body for prolonged periods of time. In the present review, we highlight recently gained insights in the role of the human gut as an endogenous S. aureus reservoir next to the nasopharynx and oral cavity. In addition, we address the contribution of these ecological niches to staphylococcal transmission, including the roles of particular triggers as modulators of the bacterial dissemination. In this context, we present recent advances concerning the interactions between S. aureus and immune cells to understand their possible roles as vehicles of dissemination from the gut to other body sites. Lastly, we discuss the factors that contribute to the switch from colonization to infection. Altogether, we conclude that an important key to uncovering the pathogenesis of S. aureus infection lies hidden in the endogenous staphylococcal reservoirs, the trafficking of this bacterium through the human body and the subsequent immune responses.
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Affiliation(s)
- Elisa J M Raineri
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dania Altulea
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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