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Karaman I, Pathak A, Bayik D, Watson DC. Harnessing Bacterial Extracellular Vesicle Immune Effects for Cancer Therapy. Pathog Immun 2024; 9:56-90. [PMID: 38690563 PMCID: PMC11060327 DOI: 10.20411/pai.v9i1.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
There are a growing number of studies linking the composition of the human microbiome to disease states and treatment responses, especially in the context of cancer. This has raised significant interest in developing microbes and microbial products as cancer immunotherapeutics that mimic or recapitulate the beneficial effects of host-microbe interactions. Bacterial extracellular vesicles (bEVs) are nano-sized, membrane-bound particles secreted by essentially all bacteria species and contain a diverse bioactive cargo of the producing cell. They have a fundamental role in facilitating interactions among cells of the same species, different microbial species, and even with multicellular host organisms in the context of colonization (microbiome) and infection. The interaction of bEVs with the immune system has been studied extensively in the context of infection and suggests that bEV effects depend largely on the producing species. They thus provide functional diversity, while also being nonreplicative, having inherent cell-targeting qualities, and potentially overcoming natural barriers. These characteristics make them highly appealing for development as cancer immunotherapeutics. Both natively secreted and engineered bEVs are now being investigated for their application as immunotherapeutics, vaccines, drug delivery vehicles, and combinations of the above, with promising early results. This suggests that both the intrinsic immunomodulatory properties of bEVs and their ability to be modified could be harnessed for the development of next-generation microbe-inspired therapies. Nonetheless, there remain major outstanding questions regarding how the observed preclinical effectiveness will translate from murine models to primates, and humans in particular. Moreover, research into the pharmacology, toxicology, and mass manufacturing of this potential novel therapeutic platform is still at early stages. In this review, we highlight the breadth of bEV interactions with host cells, focusing on immunologic effects as the main mechanism of action of bEVs currently in preclinical development. We review the literature on ongoing efforts to develop natively secreted and engineered bEVs from a variety of bacterial species for cancer therapy and finally discuss efforts to overcome outstanding challenges that remain for clinical translation.
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Affiliation(s)
- Irem Karaman
- Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Asmita Pathak
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Florida
| | - Defne Bayik
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Florida
| | - Dionysios C. Watson
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Florida
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2
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Wu D, Zhao X, Xie J, Yuan R, Li Y, Yang Q, Cheng X, Wu C, Wu J, Zhu N. Physical modulation of mesenchymal stem cell exosomes: A new perspective for regenerative medicine. Cell Prolif 2024:e13630. [PMID: 38462759 DOI: 10.1111/cpr.13630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/29/2024] [Accepted: 02/26/2024] [Indexed: 03/12/2024] Open
Abstract
Mesenchymal stem cell-derived exosomes (MSC-Exo) offer promising therapeutic potential for various refractory diseases, presenting a novel therapeutic strategy. However, their clinical application encounters several obstacles, including low natural secretion, uncontrolled biological functions and inherent heterogeneity. On the one hand, physical stimuli can mimic the microenvironment dynamics where MSC-Exo reside. These factors influence not only their secretion but also, significantly, their biological efficacy. Moreover, physical factors can also serve as techniques for engineering exosomes. Therefore, the realm of physical factors assumes a crucial role in modifying MSC-Exo, ultimately facilitating their clinical translation. This review focuses on the research progress in applying physical factors to MSC-Exo, encompassing ultrasound, electrical stimulation, light irradiation, intrinsic physical properties, ionizing radiation, magnetic field, mechanical forces and temperature. We also discuss the current status and potential of physical stimuli-affected MSC-Exo in clinical applications. Furthermore, we address the limitations of recent studies in this field. Based on this, this review provides novel insights to advance the refinement of MSC-Exo as a therapeutic approach in regenerative medicine.
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Affiliation(s)
- Dan Wu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiansheng Zhao
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiaheng Xie
- Department of Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ruoyue Yuan
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yue Li
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Quyang Yang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiujun Cheng
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Changyue Wu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jinyan Wu
- Department of Dermatology, Chongzhou People's Hospital, Chengdu, China
| | - Ningwen Zhu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Plastic, Reconstructive and Burns Surgery, Huashan Hospital, Fudan University, Shanghai, China
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Spugnini EP, Condello M, Crispi S, Baldi A. Electroporation in Translational Medicine: From Veterinary Experience to Human Oncology. Cancers (Basel) 2024; 16:1067. [PMID: 38473422 DOI: 10.3390/cancers16051067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
Electroporation (EP) is a broadly accepted procedure that, through the application of electric pulses with appropriate amplitudes and waveforms, promotes the delivery of anticancer molecules in various oncology therapies. EP considerably boosts the absorptivity of targeted cells to anticancer molecules of different natures, thus upgrading their effectiveness. Its use in veterinary oncology has been widely explored, and some applications, such as electrochemotherapy (ECT), are currently approved as first-line treatments for several neoplastic conditions. Other applications include irreversible electroporation and EP-based cancer vaccines. In human oncology, EP is still mostly restricted to therapies for cutaneous tumors and the palliation of cutaneous and visceral metastases of malignant tumors. Fields where veterinary experience could help smooth the clinical transition to humans include intraoperative EP, interventional medicine and cancer vaccines. This article recapitulates the state of the art of EP in veterinary and human oncology, recounting the most relevant results to date.
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Affiliation(s)
| | | | - Stefania Crispi
- Institute of Biosciences and BioResources-UOS Naples CNR, Via P. Castellino 111, 80131 Naples, Italy
| | - Alfonso Baldi
- Biopulse Srl, 00144 Rome, Italy
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, Campania University "Luigi Vanvitelli", 81100 Caserta, Italy
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Sun M, Zhang H, Liu J, Chen J, Cui Y, Wang S, Zhang X, Yang Z. Extracellular Vesicles: A New Star for Gene Drug Delivery. Int J Nanomedicine 2024; 19:2241-2264. [PMID: 38465204 PMCID: PMC10924919 DOI: 10.2147/ijn.s446224] [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: 10/24/2023] [Accepted: 02/20/2024] [Indexed: 03/12/2024] Open
Abstract
Recently, gene therapy has become a subject of considerable research and has been widely evaluated in various disease models. Though it is considered as a stand-alone agent for COVID-19 vaccination, gene therapy is still suffering from the following drawbacks during its translation from the bench to the bedside: the high sensitivity of exogenous nucleic acids to enzymatic degradation; the severe side effects induced either by exogenous nucleic acids or components in the formulation; and the difficulty to cross the barriers before reaching the therapeutic target. Therefore, for the successful application of gene therapy, a safe and reliable transport vector is urgently needed. Extracellular vesicles (EVs) are the ideal candidate for the delivery of gene drugs owing to their low immunogenicity, good biocompatibility and low toxicity. To better understand the properties of EVs and their advantages as gene drug delivery vehicles, this review covers from the origin of EVs to the methods of EVs generation, as well as the common methods of isolation and purification in research, with their pros and cons discussed. Meanwhile, the engineering of EVs for gene drugs is also highlighted. In addition, this paper also presents the progress in the EVs-mediated delivery of microRNAs, small interfering RNAs, messenger RNAs, plasmids, and antisense oligonucleotides. We believe this review will provide a theoretical basis for the development of gene drugs.
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Affiliation(s)
- Man Sun
- School of Life Sciences, Jilin University, Changchun, 130012, People’s Republic of China
| | - Huan Zhang
- School of Life Sciences, Jilin University, Changchun, 130012, People’s Republic of China
| | - Jiayi Liu
- School of Life Sciences, Jilin University, Changchun, 130012, People’s Republic of China
| | - Jiayi Chen
- School of Life Sciences, Jilin University, Changchun, 130012, People’s Republic of China
| | - Yaxin Cui
- School of Life Sciences, Jilin University, Changchun, 130012, People’s Republic of China
| | - Simiao Wang
- School of Life Sciences, Jilin University, Changchun, 130012, People’s Republic of China
| | - Xiangyu Zhang
- Department of General Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, 310020, People’s Republic of China
| | - Zhaogang Yang
- School of Life Sciences, Jilin University, Changchun, 130012, People’s Republic of China
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Harris DD, Sabe SA, Broadwin M, Xu C, Stone C, Kanuparthy M, Malhotra A, Abid MR, Sellke FW. Intramyocardial Injection of Hypoxia-Conditioned Extracellular Vesicles Modulates Response to Oxidative Stress in the Chronically Ischemic Myocardium. Bioengineering (Basel) 2024; 11:125. [PMID: 38391611 PMCID: PMC10886197 DOI: 10.3390/bioengineering11020125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION Patients with advanced coronary artery disease (CAD) who are not eligible for stenting or surgical bypass procedures have limited treatment options. Extracellular vesicles (EVs) have emerged as a potential therapeutic target for the treatment of advanced CAD. These EVs can be conditioned to modify their contents. In our previous research, we demonstrated increased perfusion, decreased inflammation, and reduced apoptosis with intramyocardial injection of hypoxia-conditioned EVs (HEVs). The goal of this study is to further understand the function of HEVs by examining their impact on oxidative stress using our clinically relevant and extensively validated swine model of chronic myocardial ischemia. METHODS Fourteen Yorkshire swine underwent a left thoracotomy for the placement of an ameroid constrictor on the left circumflex coronary artery to model chronic myocardial ischemia. After two weeks of recovery, the swine underwent a redo thoracotomy with injection of either HEVs (n = 7) or a saline control (CON, n = 7) into the ischemic myocardium. Five weeks after injection, the swine were subjected to terminal harvest. Protein expression was measured using immunoblotting. OxyBlot analysis and 3-nitrotyrosine staining were used to quantify total oxidative stress. RESULTS There was a significant increase in myocardial expression of the antioxidants SOD 2, GPX-1, HSF-1, UCP-2, catalase, and HO-1 (all p ≤ 0.05) in the HEV group when compared to control animals. The HEVs also exhibited a significant increase in pro-oxidant NADPH oxidase (NOX) 1, NOX 3, p47phox, and p67phox (all p ≤ 0.05). However, no change was observed in the expression of NFkB, KEAP 1, and PRDX1 (all p > 0.05) between the HEV and CON groups. There were no significant differences in total oxidative stress as determined by OxyBlot and 3-nitrotyrosine staining (p = 0.64, p = 0.32) between the groups. CONCLUSIONS Administration of HEVs in ischemic myocardium induces a significant increase in pro- and antioxidant proteins without a net change in total oxidative stress. These findings suggest that HEV-induced changes in redox signaling pathways may play a role in increased perfusion, decreased inflammation, and reduced apoptosis in ischemic myocardium. Further studies are required to determine if HEVs alter the net oxidative stress in ischemic myocardium at an earlier time point of HEV administration.
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Affiliation(s)
- Dwight D Harris
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Sharif A Sabe
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Mark Broadwin
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Cynthia Xu
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Christopher Stone
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Meghamsh Kanuparthy
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Akshay Malhotra
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - M Ruhul Abid
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI 02903, USA
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Aloi N, Drago G, Ruggieri S, Cibella F, Colombo P, Longo V. Extracellular Vesicles and Immunity: At the Crossroads of Cell Communication. Int J Mol Sci 2024; 25:1205. [PMID: 38256278 PMCID: PMC10816988 DOI: 10.3390/ijms25021205] [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: 12/28/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open
Abstract
Extracellular vesicles (EVs), comprising exosomes and microvesicles, are small membranous structures secreted by nearly all cell types. They have emerged as crucial mediators in intercellular communication, playing pivotal roles in diverse physiological and pathological processes, notably within the realm of immunity. These roles go beyond mere cellular interactions, as extracellular vesicles stand as versatile and dynamic components of immune regulation, impacting both innate and adaptive immunity. Their multifaceted involvement includes immune cell activation, antigen presentation, and immunomodulation, emphasising their significance in maintaining immune homeostasis and contributing to the pathogenesis of immune-related disorders. Extracellular vesicles participate in immunomodulation by delivering a wide array of bioactive molecules, including proteins, lipids, and nucleic acids, thereby influencing gene expression in target cells. This manuscript presents a comprehensive review that encompasses in vitro and in vivo studies aimed at elucidating the mechanisms through which EVs modulate human immunity. Understanding the intricate interplay between extracellular vesicles and immunity is imperative for unveiling novel therapeutic targets and diagnostic tools applicable to various immunological disorders, including autoimmune diseases, infectious diseases, and cancer. Furthermore, recognising the potential of EVs as versatile drug delivery vehicles holds significant promise for the future of immunotherapies.
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Affiliation(s)
| | | | | | | | - Paolo Colombo
- Institute for Biomedical Research and Innovation, National Research Council of Italy (IRIB-CNR), Via Ugo La Malfa 153, 90146 Palermo, Italy; (N.A.); (G.D.); (S.R.); (F.C.); (V.L.)
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Kovács KD, Visnovitz T, Gerecsei T, Peter B, Kurunczi S, Koncz A, Németh K, Lenzinger D, Vukman KV, Balogh A, Rajmon I, Lőrincz P, Székács I, Buzás EI, Horvath R. Nanoinjection of extracellular vesicles to single live cells by robotic fluidic force microscopy. J Extracell Vesicles 2023; 12:e12388. [PMID: 38032323 PMCID: PMC10688506 DOI: 10.1002/jev2.12388] [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: 01/31/2022] [Revised: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
In the past decade, extracellular vesicles (EVs) have attracted substantial interest in biomedicine. With progress in the field, we have an increasing understanding of cellular responses to EVs. In this Technical Report, we describe the direct nanoinjection of EVs into the cytoplasm of single cells of different cell lines. By using robotic fluidic force microscopy (robotic FluidFM), nanoinjection of GFP positive EVs and EV-like particles into single live HeLa, H9c2, MDA-MB-231 and LCLC-103H cells proved to be feasible. This injection platform offered the advantage of high cell selectivity and efficiency. The nanoinjected EVs were initially localized in concentrated spot-like regions within the cytoplasm. Later, they were transported towards the periphery of the cells. Based on our proof-of-principle data, robotic FluidFM is suitable for targeting single living cells by EVs and may lead to information about intracellular EV cargo delivery at a single-cell level.
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Affiliation(s)
- Kinga Dóra Kovács
- Nanobiosensorics LaboratoryInstitute of Technical Physics and Materials Science, HUN‐REN Centre for Energy ResearchBudapestHungary
- Department of Biological PhysicsEötvös UniversityBudapestHungary
| | - Tamás Visnovitz
- Department of Genetics, Cell‐ and ImmunobiologySemmelweis UniversityBudapestHungary
- Department of Plant Physiology and Molecular Plant BiologyEötvös Loránd UniversityBudapestHungary
| | - Tamás Gerecsei
- Nanobiosensorics LaboratoryInstitute of Technical Physics and Materials Science, HUN‐REN Centre for Energy ResearchBudapestHungary
| | - Beatrix Peter
- Nanobiosensorics LaboratoryInstitute of Technical Physics and Materials Science, HUN‐REN Centre for Energy ResearchBudapestHungary
| | - Sándor Kurunczi
- Nanobiosensorics LaboratoryInstitute of Technical Physics and Materials Science, HUN‐REN Centre for Energy ResearchBudapestHungary
| | - Anna Koncz
- Department of Genetics, Cell‐ and ImmunobiologySemmelweis UniversityBudapestHungary
- HUN‐REN‐SU Translational Extracellular Vesicle Research GroupBudapestHungary
| | - Krisztina Németh
- Department of Genetics, Cell‐ and ImmunobiologySemmelweis UniversityBudapestHungary
- HUN‐REN‐SU Translational Extracellular Vesicle Research GroupBudapestHungary
| | - Dorina Lenzinger
- Department of Genetics, Cell‐ and ImmunobiologySemmelweis UniversityBudapestHungary
| | - Krisztina V. Vukman
- Department of Genetics, Cell‐ and ImmunobiologySemmelweis UniversityBudapestHungary
| | - Anna Balogh
- Nanobiosensorics LaboratoryInstitute of Technical Physics and Materials Science, HUN‐REN Centre for Energy ResearchBudapestHungary
| | - Imola Rajmon
- Nanobiosensorics LaboratoryInstitute of Technical Physics and Materials Science, HUN‐REN Centre for Energy ResearchBudapestHungary
| | - Péter Lőrincz
- Department of Anatomy, Cell and Developmental BiologyEötvös Loránd UniversityBudapestHungary
| | - Inna Székács
- Nanobiosensorics LaboratoryInstitute of Technical Physics and Materials Science, HUN‐REN Centre for Energy ResearchBudapestHungary
| | - Edit I. Buzás
- Department of Genetics, Cell‐ and ImmunobiologySemmelweis UniversityBudapestHungary
- HUN‐REN‐SU Translational Extracellular Vesicle Research GroupBudapestHungary
- HCEMM‐SU Extracellular Vesicle Research GroupBudapestHungary
| | - Robert Horvath
- Nanobiosensorics LaboratoryInstitute of Technical Physics and Materials Science, HUN‐REN Centre for Energy ResearchBudapestHungary
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Zhu S, Wang J, Suo M, Huang H, Liu X, Wang J, Li Z. Can extracellular vesicles be considered as a potential frontier in the treatment of intervertebral disc disease? Ageing Res Rev 2023; 92:102094. [PMID: 37863436 DOI: 10.1016/j.arr.2023.102094] [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] [Received: 08/20/2023] [Revised: 10/04/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
As a global public health problem, low back pain (LBP) caused by intervertebral disc degeneration (IDD) seriously affects patients' quality of life. In addition, the prevalence of IDD tends to be younger, which brings a huge burden to individuals and society economically. Current treatments do not delay or reverse the progression of IDD. The emergence of biologic therapies has brought new hope for the treatment of IDD. Among them, extracellular vesicles (EVs), as nanoscale bioactive substances that mediate cellular communication, have now produced many surprising results in the research of the treatment of IDD. This article reviews the mechanisms and roles of EVs in delaying IDD and describes the prospects and challenges of EVs.
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Affiliation(s)
- Shengxu Zhu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Junlin Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China
| | - Moran Suo
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Huagui Huang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Xin Liu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Jinzuo Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China
| | - Zhonghai Li
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, the People's Republic of China; Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, the People's Republic of China.
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