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Kumar A, Nader MA, Deep G. Emergence of Extracellular Vesicles as "Liquid Biopsy" for Neurological Disorders: Boom or Bust. Pharmacol Rev 2024; 76:199-227. [PMID: 38351075 PMCID: PMC10877757 DOI: 10.1124/pharmrev.122.000788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 11/11/2023] [Accepted: 11/27/2023] [Indexed: 02/16/2024] Open
Abstract
Extracellular vesicles (EVs) have emerged as an attractive liquid biopsy approach in the diagnosis and prognosis of multiple diseases and disorders. The feasibility of enriching specific subpopulations of EVs from biofluids based on their unique surface markers has opened novel opportunities to gain molecular insight from various tissues and organs, including the brain. Over the past decade, EVs in bodily fluids have been extensively studied for biomarkers associated with various neurological disorders, such as Alzheimer's disease, Parkinson's disease, schizophrenia, bipolar disorder, major depressive disorders, substance use disorders, human immunodeficiency virus-associated neurocognitive disorder, and cancer/treatment-induced neurodegeneration. These studies have focused on the isolation and cargo characterization of either total EVs or brain cells, such as neuron-, astrocyte-, microglia-, oligodendrocyte-, pericyte-, and endothelial-derived EVs from biofluids to achieve early diagnosis and molecular characterization and to predict the treatment and intervention outcomes. The findings of these studies have demonstrated that EVs could serve as a repetitive and less invasive source of valuable molecular information for these neurological disorders, supplementing existing costly neuroimaging techniques and relatively invasive measures, like lumbar puncture. However, the initial excitement surrounding blood-based biomarkers for brain-related diseases has been tempered by challenges, such as lack of central nervous system specificity in EV markers, lengthy protocols, and the absence of standardized procedures for biological sample collection, EV isolation, and characterization. Nevertheless, with rapid advancements in the EV field, supported by improved isolation methods and sensitive assays for cargo characterization, brain cell-derived EVs continue to offer unparallel opportunities with significant translational implications for various neurological disorders. SIGNIFICANCE STATEMENT: Extracellular vesicles present a less invasive liquid biopsy approach in the diagnosis and prognosis of various neurological disorders. Characterizing these vesicles in biofluids holds the potential to yield valuable molecular information, thereby significantly impacting the development of novel biomarkers for various neurological disorders. This paper has reviewed the methodology employed to isolate extracellular vesicles derived from various brain cells in biofluids, their utility in enhancing the molecular understanding of neurodegeneration, and the potential challenges in this research field.
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Affiliation(s)
- Ashish Kumar
- Departments of Cancer Biology (A.K., G.D.), Physiology and Pharmacology (M.A.N.), Radiology (M.A.N.), and Center for Addiction Research (M.A.N., G.D.), Wake Forest University School of Medicine, Winston-Salem, North Carolina; Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina (G.D.); and Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina (G.D.)
| | - Michael A Nader
- Departments of Cancer Biology (A.K., G.D.), Physiology and Pharmacology (M.A.N.), Radiology (M.A.N.), and Center for Addiction Research (M.A.N., G.D.), Wake Forest University School of Medicine, Winston-Salem, North Carolina; Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina (G.D.); and Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina (G.D.)
| | - Gagan Deep
- Departments of Cancer Biology (A.K., G.D.), Physiology and Pharmacology (M.A.N.), Radiology (M.A.N.), and Center for Addiction Research (M.A.N., G.D.), Wake Forest University School of Medicine, Winston-Salem, North Carolina; Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina (G.D.); and Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina (G.D.)
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Schiera G, Di Liegro CM, Schirò G, Sorbello G, Di Liegro I. Involvement of Astrocytes in the Formation, Maintenance, and Function of the Blood-Brain Barrier. Cells 2024; 13:150. [PMID: 38247841 PMCID: PMC10813980 DOI: 10.3390/cells13020150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
The blood-brain barrier (BBB) is a fundamental structure that protects the composition of the brain by determining which ions, metabolites, and nutrients are allowed to enter the brain from the blood or to leave it towards the circulation. The BBB is structurally composed of a layer of brain capillary endothelial cells (BCECs) bound to each other through tight junctions (TJs). However, its development as well as maintenance and properties are controlled by the other brain cells that contact the BCECs: pericytes, glial cells, and even neurons themselves. Astrocytes seem, in particular, to have a very important role in determining and controlling most properties of the BBB. Here, we will focus on these latter cells, since the comprehension of their roles in brain physiology has been continuously expanding, even including the ability to participate in neurotransmission and in complex functions such as learning and memory. Accordingly, pathological conditions that alter astrocytic functions can alter the BBB's integrity, thus compromising many brain activities. In this review, we will also refer to different kinds of in vitro BBB models used to study the BBB's properties, evidencing its modifications under pathological conditions.
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Affiliation(s)
- Gabriella Schiera
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (Dipartimento di Scienzee Tecnologie Biologiche, Chimiche e Farmaceutiche) (STEBICEF), University of Palermo, 90128 Palermo, Italy; (G.S.); (C.M.D.L.)
| | - Carlo Maria Di Liegro
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (Dipartimento di Scienzee Tecnologie Biologiche, Chimiche e Farmaceutiche) (STEBICEF), University of Palermo, 90128 Palermo, Italy; (G.S.); (C.M.D.L.)
| | - Giuseppe Schirò
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (G.S.); (G.S.)
- Neurology and Multiple Sclerosis Center, Unità Operativa Complessa (UOC), Foundation Institute “G. Giglio”, 90015 Cefalù, Italy
| | - Gabriele Sorbello
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (G.S.); (G.S.)
| | - Italia Di Liegro
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (G.S.); (G.S.)
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Shi J, Huang S. Comparative Insight into Microglia/Macrophages-Associated Pathways in Glioblastoma and Alzheimer's Disease. Int J Mol Sci 2023; 25:16. [PMID: 38203185 PMCID: PMC10778632 DOI: 10.3390/ijms25010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/09/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Microglia and macrophages are pivotal to the brain's innate immune response and have garnered considerable attention in the context of glioblastoma (GBM) and Alzheimer's disease (AD) research. This review delineates the complex roles of these cells within the neuropathological landscape, focusing on a range of signaling pathways-namely, NF-κB, microRNAs (miRNAs), and TREM2-that regulate the behavior of tumor-associated macrophages (TAMs) in GBM and disease-associated microglia (DAMs) in AD. These pathways are critical to the processes of neuroinflammation, angiogenesis, and apoptosis, which are hallmarks of GBM and AD. We concentrate on the multifaceted regulation of TAMs by NF-κB signaling in GBM, the influence of TREM2 on DAMs' responses to amyloid-beta deposition, and the modulation of both TAMs and DAMs by GBM- and AD-related miRNAs. Incorporating recent advancements in molecular biology, immunology, and AI techniques, through a detailed exploration of these molecular mechanisms, we aim to shed light on their distinct and overlapping regulatory functions in GBM and AD. The review culminates with a discussion on how insights into NF-κB, miRNAs, and TREM2 signaling may inform novel therapeutic approaches targeting microglia and macrophages in these neurodegenerative and neoplastic conditions. This comparative analysis underscores the potential for new, targeted treatments, offering a roadmap for future research aimed at mitigating the progression of these complex diseases.
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Affiliation(s)
- Jian Shi
- Department of Neurology, Department of Veterans Affairs Medical Center, University of California, San Francisco, CA 94121, USA
| | - Shiwei Huang
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN 55455, USA
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Li Z, Wang X, Wang X, Yi X, Wong YK, Wu J, Xie F, Hu D, Wang Q, Wang J, Zhong T. Research progress on the role of extracellular vesicles in neurodegenerative diseases. Transl Neurodegener 2023; 12:43. [PMID: 37697342 PMCID: PMC10494410 DOI: 10.1186/s40035-023-00375-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 08/23/2023] [Indexed: 09/13/2023] Open
Abstract
Neurodegenerative diseases, such as Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, and Huntington's disease, affect millions of people worldwide. Tremendous efforts have been put into disease-related research, but few breakthroughs have been made in diagnostic and therapeutic approaches. Extracellular vesicles (EVs) are heterogeneous cell-derived membrane structures that arise from the endosomal system or are directly separated from the plasma membrane. EVs contain many biomolecules, including proteins, nucleic acids, and lipids, which can be transferred between different cells, tissues, or organs, thereby regulating cross-organ communication between cells during normal and pathological processes. Recently, EVs have been shown to participate in various aspects of neurodegenerative diseases. Abnormal secretion and levels of EVs are closely related to the pathogenesis of neurodegenerative diseases and contribute to disease progression. Numerous studies have proposed EVs as therapeutic targets or biomarkers for neurodegenerative diseases. In this review, we summarize and discuss the advanced research progress on EVs in the pathological processes of several neurodegenerative diseases. Moreover, we outline the latest research on the roles of EVs in neurodegenerative diseases and their therapeutic potential for the diseases.
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Affiliation(s)
- Zhengzhe Li
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, 341000, China
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Xiaoling Wang
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Xiaoxing Wang
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, 341000, China
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Xiaomei Yi
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, 341000, China
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Yin Kwan Wong
- Department of Nephrology, Shenzhen Key Laboratory of Kidney Diseases, and Shenzhen Clinical Research Centre for Geriatrics, Shenzhen People's Hospital, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, 518020, China
| | - Jiyang Wu
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, 341000, China
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Fangfang Xie
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Die Hu
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - Qi Wang
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, 341000, China
| | - Jigang Wang
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China.
- Department of Nephrology, Shenzhen Key Laboratory of Kidney Diseases, and Shenzhen Clinical Research Centre for Geriatrics, Shenzhen People's Hospital, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, 518020, China.
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China.
| | - Tianyu Zhong
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, 341000, China.
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China.
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Couch Y. Challenges associated with using extracellular vesicles as biomarkers in neurodegenerative disease. Expert Rev Mol Diagn 2023; 23:1091-1105. [PMID: 37916853 DOI: 10.1080/14737159.2023.2277373] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION The hunt for new biomarkers - for the diagnosis of subcategories of disease, or for the monitoring of the efficacy of novel therapeutics - is an increasingly relevant challenge in the current era of precision medicine. In neurodegenerative research, the aim is to look for simple tools which can predict cognitive or motor decline early, and to determine whether these can also be used to test the efficacy of new interventions. Extracellular vesicles (EVs) are thought to play an important role in intercellular communication and have been shown to play a vital role in a number of diseases. AREAS COVERED The aim of this review is to examine what we know about EVs in neurodegeneration and to discuss their potential to be diagnostic and prognostic biomarkers in the future. It will cover the techniques used to isolate and study EVs and what is currently known about their presence in neurodegenerative diseases. In particular, we will discuss what is required for standardization in biomarker research, and the challenges associated with using EVs within this framework. EXPERT OPINION The technical challenges associated with isolating EVs consistently, combined with the complex techniques required for their efficient analysis, might preclude 'pure' EV populations from being used as effective biomarkers. Whilst biomarker discovery is important for more effective diagnosis, monitoring, prediction and prognosis in neurodegenerative disease, reproducibility and ease-of-use should be the priorities.
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Affiliation(s)
- Yvonne Couch
- Acute Stroke Program, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Abstract
Alzheimer's disease (AD) is a neurodegenerative disease with dysfunction of memory, language and thinking. More than 55 million people were diagnosed with AD or other dementia around the world in 2020. The pathology of AD is still unclear and there are no applicable therapies for AD. MicroRNAs (miRNAs) play key roles in AD pathology and have great potential for the diagnosis and treatment of AD. Extracellular vesicles (EVs) widely exist in body fluids such as blood and cerebrospinal fluid (CSF) and contain miRNAs that are involved in cell-to-cell communication. We summarized the dysregulated miRNAs in EVs derived from the different body fluids of AD patients, as well as their potential function and application in AD. We also compared these dysregulated miRNAs in EVs to those in the brain tissues of AD patients aiming to provide a comprehensive view of miRNAs in AD. After careful comparisons, we found that miR-125b-5p and miR-132-3p were upregulated and downregulated in several different brain tissues of AD and EVs of AD, respectively, suggesting their value in AD diagnosis based on EV miRNAs. Furthermore, miR-9-5p was dysregulated in EVs and different brain tissues of AD patients and had also been tested as a potential therapy for AD in mice and human cell models, suggesting that miR-9-5p could be used to design new therapies for AD.
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Affiliation(s)
- Wanran Li
- State Key Laboratory of Primate Biomedical Research, Institute of Primate Translational Medicine, Kunming University of Science and Technology, Kunming 650500, China
| | - Yun Zheng
- College of Landscape and Horticulture, Yunnan Agricultural University, Kunming 650201, China
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Fan S, Poetsch A. Proteomic Research of Extracellular Vesicles in Clinical Biofluid. Proteomes 2023; 11:proteomes11020018. [PMID: 37218923 DOI: 10.3390/proteomes11020018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/24/2023] Open
Abstract
Extracellular vesicles (EVs), the lipid bilayer membranous structures of particles, are produced and released from almost all cells, including eukaryotes and prokaryotes. The versatility of EVs has been investigated in various pathologies, including development, coagulation, inflammation, immune response modulation, and cell-cell communication. Proteomics technologies have revolutionized EV studies by enabling high-throughput analysis of their biomolecules to deliver comprehensive identification and quantification with rich structural information (PTMs, proteoforms). Extensive research has highlighted variations in EV cargo depending on vesicle size, origin, disease, and other features. This fact has sparked activities to use EVs for diagnosis and treatment to ultimately achieve clinical translation with recent endeavors summarized and critically reviewed in this publication. Notably, successful application and translation require a constant improvement of methods for sample preparation and analysis and their standardization, both of which are areas of active research. This review summarizes the characteristics, isolation, and identification approaches for EVs and the recent advances in EVs for clinical biofluid analysis to gain novel knowledge by employing proteomics. In addition, the current and predicted future challenges and technical barriers are also reviewed and discussed.
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Affiliation(s)
- Shipan Fan
- School of Basic Medical Sciences, Nanchang University, Nanchang 330021, China
| | - Ansgar Poetsch
- Queen Mary School, Medical College, Nanchang University, Nanchang 330021, China
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Zhou W, Zhao L, Mao Z, Wang Z, Zhang Z, Li M. Bidirectional Communication Between the Brain and Other Organs: The Role of Extracellular Vesicles. Cell Mol Neurobiol 2023:10.1007/s10571-023-01345-5. [PMID: 37067749 PMCID: PMC10106324 DOI: 10.1007/s10571-023-01345-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/03/2023] [Indexed: 04/18/2023]
Abstract
A number of substances released by the brain under physiological and pathological conditions exert effects on other organs. In turn, substances produced primarily by organs such as bone marrow, adipose tissue, or the heart may have an impact on the metabolism and function and metabolism of the healthy and diseased brain. Despite a mounting amount of evidence supports such bidirectional communication between the brain and other organs, research on the function of molecular mediators carried by extracellular vesicles (EVs) is in the early stages. In addition to being able to target or reach practically any organ, EVs have the ability to cross the blood-brain barrier to transport a range of substances (lipids, peptides, proteins, and nucleic acids) to recipient cells, exerting biological effects. Here, we review the function of EVs in bidirectional communication between the brain and other organs. In a small number of cases, the role has been explicitly proven; yet, in most cases, it relies on indirect evidence from EVs in cell culture or animal models. There is a dearth of research currently available on the function of EVs-carrying mediators in the bidirectional communication between the brain and bone marrow, adipose tissue, liver, heart, lungs, and gut. Therefore, more studies are needed to determine how EVs facilitate communication between the brain and other organs.
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Affiliation(s)
- Wu Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, China
| | - Lihong Zhao
- Department of Radiotherapy, Jilin Cancer Hospital, 1018 Huguang Street, Changchun, 130012, Jilin, China
| | - Zelu Mao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, China
| | - Zhihua Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, China
| | - Zhixiong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, China
| | - Meihua Li
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yongwai Street, Nanchang, 330006, Jiangxi, China.
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Abstract
PURPOSE OF REVIEW Dementia is a syndrome with several possible pathologies. To date, definitive methods for diagnosis and treatment of sub-types of dementia have not been established. Emerging evidence suggests that exosomes can provide important information for the diagnosis and treatment of several subtypes of dementia. This article reviews recent studies on the application of exosomes in dementia. RECENT FINDINGS Exosomes are involved in the pathogenesis of Alzheimer's disease (AD) and Parkinson's disease (PD) through transporting toxic proteins such as amyloid beta (Aβ), tau, and α-synuclein. Exosomal microRNAs (miR) and proteins reflect the disease state, and therefore, exosomes can be used as diagnostic markers for diseases such as AD, PD, Huntington's disease (HD), vascular dementia (VaD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD). Mesenchymal stem cell (MSC)-derived exosomes have been shown to ameliorate disease pathology, and improve cognitive function in AD, PD, and VAD. SUMMARY Recent studies have shown that exosomes could be novel diagnostic agents for dementia because they contain molecules that could be potential biomarker candidates indicative of the type and stage of dementia. Therapeutic application of exosomes in dementia has revealed that exosomes only, or exosomes loaded with an active pharmaceutical ingredient (API), ameliorate disease phenotype of dementia. Further work is needed to exploit this potential.
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Affiliation(s)
- Hyeon Su Joo
- School of Life Science, Handong Global University, Pohang
| | - Ha Yeong Jeon
- School of Life Science, Handong Global University, Pohang
| | - Eun Be Hong
- INEXOPLAT, Inc. M2704, 32, Songdogwahak-ro, Yeonsu-gu, Incheon, Republic of Korea
| | - Ha Young Kim
- School of Life Science, Handong Global University, Pohang
| | - Jung Min Lee
- School of Life Science, Handong Global University, Pohang
- INEXOPLAT, Inc. M2704, 32, Songdogwahak-ro, Yeonsu-gu, Incheon, Republic of Korea
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Abstract
Aging induces a series of immune related changes, which is called immunosenescence, playing important roles in many age-related diseases, especially neurodegenerative diseases, tumors, cardiovascular diseases, autoimmune diseases and coronavirus disease 2019(COVID-19). However, the mechanism of immunosenescence, the association with aging and successful aging, and the effects on diseases are not revealed obviously. In order to provide theoretical basis for preventing or controlling diseases effectively and achieve successful aging, we conducted the review and found that changes of aging-related phenotypes, deterioration of immune organ function and alterations of immune cell subsets participated in the process of immunosenescence, which had great effects on the occurrence and development of age-related diseases.
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Affiliation(s)
- Yunan Wang
- Department of Rheumatology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Chen Dong
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yudian Han
- Information Center, The First People’s Hospital of Nantong City, Nantong, China
| | - Zhifeng Gu
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong, China
- *Correspondence: Zhifeng Gu, ; Chi Sun,
| | - Chi Sun
- Department of Geriatrics, Affiliated Hospital of Nantong University, Nantong, China
- *Correspondence: Zhifeng Gu, ; Chi Sun,
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