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Huang Q, Ding Y, Fang C, Wang H, Kong L. The Emerging Role of Ferroptosis in Sepsis, Opportunity or Challenge? Infect Drug Resist 2023; 16:5551-5562. [PMID: 37641800 PMCID: PMC10460599 DOI: 10.2147/idr.s419993] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/01/2023] [Indexed: 08/31/2023] Open
Abstract
Sepsis is a syndrome in multi-organ dysfunction triggered by a deleterious immunological reaction of the body to a condition caused by infection, surgery, or trauma. Currently, sepsis is thought to be primarily associated with abnormal immune responses resulting in organ microcirculatory disturbances, cellular mitochondrial dysfunction, and induced cell death, although the exact pathogenesis of sepsis is still inconclusive. In recent years, the role of abnormal metabolism of trace nutrients in the pathogenesis of sepsis has been investigated. Ferroptosis is a type of cell death that relies on iron and is characterized by unique morphological, biochemical, and genetic features. Unlike other forms of cell death, such as autophagy, apoptosis, necrosis, and pyroptosis, ferroptosis is primarily driven by lipid peroxidation. Ferroptosis cells may be immunogenic, amplify inflammatory responses, cause more cell death, and ultimately induce multi-organ failure. An increasing number of studies have indicated the significance of ferroptosis in sepsis and its role in reducing inflammation. The effectiveness of sepsis treatment has been demonstrated by the use of drugs that specifically target molecules associated with the ferroptosis pathway, including ferroptosis inhibitors. Nevertheless, there is a scarcity of studies investigating the multi-organ dysfunction caused by ferroptosis in sepsis. This article presents a summary and evaluation of recent progress in the role of ferroptosis through molecularly regulated mechanisms and its potential mechanisms of action in the multi-organ dysfunction associated with sepsis. It also discusses the current challenges and prospects in understanding the connection between sepsis and ferroptosis, and proposes innovative ideas and strategies for the treatment of sepsis.
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Affiliation(s)
- Qigang Huang
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
| | - Yingwei Ding
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
| | - Chao Fang
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
| | - Hao Wang
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
| | - Laifa Kong
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
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Long H, Wu Z. Immunoregulatory effects of Huaier (Trametes robiniophila Murr) and relevant clinical applications. Front Immunol 2023; 14:1147098. [PMID: 37449208 PMCID: PMC10337589 DOI: 10.3389/fimmu.2023.1147098] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Huaier (Trametes robiniophila Murr) is a medicinal fungus of traditional Chinese medicine with more than 1000 years of history of clinical application. Its remarkable anticancer activities has led to its application in treating diverse malignancies. In recent years, the immunomodulatory effects of Huaier have been uncovered and proved to be beneficial in a plethora of immune-related diseases including cancer, nephropathy, asthma, etc. In this review, we comprehensively summarized the active components of Huaier, its regulatory activities on multifaceted aspects of the immune system, its application in various clinical settings as well as toxicologic evidence. Based on currently available literature, Huaier possesses broad-spectrum regulatory activities on various components of the innate and adaptive immune system, including macrophages, dendritic cells, natural killer cells, T and B lymphocytes, etc. Versatile immunologic reactions are under the regulation of Huaier from expression of damage-associated molecular patterns, immune cell activation and maturation to cell proliferation, differentiation, antibody production, expression of cytokines and chemokines and terminal intracellular signal transduction. Moreover, some modulatory activities of Huaier might be context-dependent, typically promoting the restoration toward normal physiological status. With excellent efficacy and minimal side effects, we foresee more extensive application of Huaier for treating immune-related disorders.
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Affiliation(s)
- Hongrong Long
- Department of cardiac function, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhongcai Wu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Liu Q, Liu J, Du Y, Guo W, Mi J, Guo Y. Network Pharmacology and Molecular Docking Analysis to Explore the Mechanism of Huaiqihuang-Mediated Alleviation of Henoch–Schönlein Purpura Nephritis. BioMed Research International 2022; 2022:1-13. [PMID: 36389115 PMCID: PMC9652090 DOI: 10.1155/2022/2798217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022]
Abstract
Objective Henoch–Schönlein purpura nephritis (HSPN) is considered a major cause of chronic renal failure and is the most common secondary glomerular disease in children. Huaiqihuang (HQH), a traditional Chinese herbal formula, exhibits therapeutic effects against HSPN in clinical practice. However, the potential molecular targets and mechanisms underlying HSPN treatment remain unclear. Methods By constructing a protein-protein interaction (PPI) network, core targets related to HQH and HSPN were identified. Gene Ontology enrichment and Kyoto Encyclopedia of Genes and Genomes pathways were analyzed to identify the main pathways related to HSPN based on the core targets. To screen the main active ingredients of HQH against HSPN, an ingredient-target-pathway network was constructed using the top 10 main pathways associated with HSPN. Then, molecular docking was performed to explore the interactions and binding patterns between molecules and proteins. Results Clinical data showed that HQH combined with conventional medicine significantly reduced 24-hour urine protein excretion, urine microalbumin levels, and erythrocyte counts in the urine sediment of HSPN patients. By constructing PPI models, 15 potential core targets were identified. The top 10 main pathways showed higher enrichment ratios, including the cytokine–cytokine receptor interaction and signaling pathways related to NOD-like receptor, IL-17, etc. Through the ingredient-target-pathway network and molecular docking, we revealed that five active ingredients of HQH had good affinities with three core targets, AKT1, MMP9, and SERPINE1, which may be vital in treating HSPN. Conclusions The study preliminarily explored the active ingredients, targets, and pathways involved in HQH therapy for HSPN. The mechanism of HQH therapy may be attributed to the modulation of inflammatory response, immune response, and oxidative stress. Combined with clinical data, our results indicate that HQH is highly effective in treating HSPN.
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Yang G, Yang H, Cui S, Shan J, Rajakani K. Effect of Huaiqihuang Granules Combined with Comprehensive Nursing on Children with Primary Nephrotic Syndrome. Journal of Healthcare Engineering 2022; 2022:1-7. [PMID: 35075385 PMCID: PMC8783717 DOI: 10.1155/2022/3279503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 12/30/2021] [Accepted: 12/31/2021] [Indexed: 11/22/2022]
Abstract
Background To observe the effect of Huaiqihuang granules combined with comprehensive nursing intervention on children with primary nephrotic syndrome (PNS) and its effect on renal function index. Methods A total of 104 patients were included, and the patients were randomly divided into two groups, with 52 cases in each group. The control group was treated with glucocorticoid, and the study group was treated with Huaiqihuang granules. The clinical efficacy of the two groups was observed. The levels of TG, TC, EGFR, 24 h UTP, BUN, Scr, IgA, IgG, IgM, IFN-γ and TNF-α were compared between two groups before and after treatment. The incidence of adverse reactions and recurrence rate after treatment were compared between the two groups. Results The effective rate of the study group (94.23%) was significantly higher than that of the control group (78.85%). Before treatment, there was no significant difference in TG and TC levels between the two groups. After treatment, the levels of TG and TC in both groups were decreased, and the decrease was more obvious in the study group. Compared with before treatment, the levels of 24 h UTP, BUN, Scr, IFN-γ, and TNF-α in both groups were significantly decreased after treatment, while EGFR, IgA, IgG, and IgM levels were significantly increased. Compared with the control group, the changes of each index in the study group were more obvious after treatment. After treatment, the incidence of adverse reactions and recurrence rate in the study group were significantly lower than those in the control group. Conclusions Huaiqihuang granules combined with comprehensive nursing treatment in children with PNS can reduce the occurrence of recent recurrence and adverse reactions and improve the cellular immune function and renal function.
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Xue X, Liu XH, Lu CL, Jin XY, Liu Q, Wang XQ, Liu JP. Chinese patent herbal medicine Huaiqihuang for Henoch-Schonlein purpura nephritis in children: a systematic review of randomized controlled trials. BMC Complement Med Ther 2021; 21:278. [PMID: 34743723 PMCID: PMC8573979 DOI: 10.1186/s12906-021-03415-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 09/20/2021] [Indexed: 01/06/2023] Open
Abstract
Background Henoch-Schönlein purpura nephritis (HSPN) is listed as the most common secondary glomerular diseases among children. Approximately 15 to 20% of children eventually could develop into chronic renal failure. Chinese patent herbal medicine Huaiqihuang (HQH) has been widely used in children with HSPN. This study aimed to evaluate the effectiveness and safety of HQH for HSPN in children, so as to provide evidence for clinical use. Methods Randomized controlled trials (RCTs) on HQH for HSPN in children were searched in eight Chinese and English databases from their inception to December 2020. We included children with HSPN received HQH combined with conventional medicine. Cochrane “Risk of bias” tool was used to assess methodological quality, and “Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach” to summarize the certainty of evidence for main findings. Effect estimates were presented as risk ratio (RR), mean difference (MD) or standardized mean difference (SMD) with 95% confidence interval (CI) in meta-analyses using RevMan 5.3. Data not suitable for statistical pooling were synthesized qualitatively. Results In total seven RCTs were identified. Compared with conventional medicine alone, HQH plus conventional medicine showed the better effect in improving clinical cure rate (RR 1.58; 95%CI 1.17 to 2.14; n = 6) and total effective rate (RR 1.34; 1.16 to 1.54; n = 6); reducing urine sediment erythrocyte count (MD -9.23; − 10.76 to − 7.69; n = 3) and urine β2 micro-globulin level (MD -0.09; − 0.12 to − 0.06; n = 2). No serious adverse event was recorded in all included trials. Conclusions Limited evidence showed HQH combined with conventional medicine had a beneficial effect for children with HSPN, and the side effects were mild. HQH may be a promising complementary therapy. However, long term follow-up, high quality and multicenter RCTs are required to confirm the findings.
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Affiliation(s)
- Xue Xue
- Hubei University of Traditional Chinese Medicine, The first clinical college and affiliated hospital, Wuhan, 430061, Hubei, China.,Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, 100029, China
| | - Xue-Han Liu
- Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, 100029, China
| | - Chun-Li Lu
- Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, 100029, China
| | - Xin-Yan Jin
- Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, 100029, China
| | - Qiang Liu
- Hubei University of Traditional Chinese Medicine, The first clinical college and affiliated hospital, Wuhan, 430061, Hubei, China
| | - Xiao-Qin Wang
- Hubei University of Traditional Chinese Medicine, The first clinical college and affiliated hospital, Wuhan, 430061, Hubei, China
| | - Jian-Ping Liu
- Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, 100029, China.
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Abstract
Ferroptosis is an iron-dependent cell death pathway and participates in various diseases. Current evidence suggests that ferroptosis can obviously affect the function of blood cells. This paper aims to elaborate the role of ferroptosis in blood cells and related diseases. First, abnormal ferroptosis damages the developing red blood cells by breaking systemic iron homeostasis, leading to erythropoiesis suppression and anaemia. Ferroptosis mediates neutrophils recruitment and neutrophil extracellular trap formation (NETosis). In T-cells, ferroptosis induces a novel point of synergy between immunotherapy and radiotherapy. Additionally, ferroptosis may mediate B cells differentiation, antibody responses and lymphoma. Nevertheless, increased ferroptosis can ameliorate acute myeloid leukaemia and T-cell leukaemia/lymphoma by inducing iron-dependent cancer cells death. Besides, ferroptosis activates platelets by increasing P-selectin, thus causing thromboembolism. Ferroptosis mediates virus infection and parasite infection by driving T-cell death and preventing T-cell immunity. Interestingly, ferroptosis is also considered as a critical player in COVID-19 infections, while targetting ferroptosis may also improve thromboembolism and prognosis in patients with COVID-19 infection. Overall, the crucial role of ferroptosis in blood cells will show a new therapeutic potential in blood cell-related diseases.HighlightsFerroptosis shows a new therapeutic potential for blood cell-related diseases.Ferroptosis damages erythropoiesis and thus induces anaemia.Ferroptosis induces platelet activation and leads to thromboembolism.Ferroptosis regulates T-cell and B-cell immunity, which participant in infectious diseases.Inversely, ferroptosis ameliorates acute myeloid leukaemia and T-cell leukaemia.
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Affiliation(s)
- Zhe Chen
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hunan Provincial Key Laboratory of Tumor Microenvironment Responsive Drug Research, Hengyang Medical School, University of South China, Hengyang, China
| | - Jinyong Jiang
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hunan Provincial Key Laboratory of Tumor Microenvironment Responsive Drug Research, Hengyang Medical School, University of South China, Hengyang, China
| | - Nian Fu
- Department of Gastroenterology, Affiliated Nanhua Hospital, University of South China, Hengyang, China
| | - Linxi Chen
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hunan Provincial Key Laboratory of Tumor Microenvironment Responsive Drug Research, Hengyang Medical School, University of South China, Hengyang, China
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Liu Y, Chen DQ, Han JX, Zhao TT, Li SJ. A Review of Traditional Chinese Medicine in Treating Renal Interstitial Fibrosis via Endoplasmic Reticulum Stress-Mediated Apoptosis. Biomed Res Int 2021; 2021:6667791. [PMID: 34055995 DOI: 10.1155/2021/6667791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 04/23/2021] [Accepted: 05/07/2021] [Indexed: 01/07/2023]
Abstract
Renal interstitial fibrosis (RIF) is the main pathological manifestation of end-stage renal disease. Recent studies have shown that endoplasmic reticulum (ER) stress is involved in the pathogenesis and development of RIF. Traditional Chinese medicine (TCM), as an effective treatment for kidney diseases, can improve kidney damage by affecting the apoptotic signaling pathway mediated by ER stress. This article reviews the apoptotic pathways mediated by ER stress, including the three major signaling pathways of unfolded protein response, the main functions of the transcription factor C/EBP homologous protein. We also present current research on TCM treatment of RIF, focusing on medicines that regulate ER stress. A new understanding of using TCM to treat kidney disease by regulating ER stress will promote clinical application of Chinese medicine and discovery of new drugs for the treatment of RIF.
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Wu Y, Song X, Qin S, Chen P, Huang L, Wang Q, Shan T, Liang F, Liao X, Liu Q, Huang Y, Wang Y. Subacute toxicological evaluation of AT-533 and AT-533 gel in Sprague-Dawley rats. Exp Ther Med 2021; 21:632. [PMID: 33968163 PMCID: PMC8097234 DOI: 10.3892/etm.2021.10064] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 03/17/2021] [Indexed: 11/05/2022] Open
Abstract
As a novel heat shock protein 90 inhibitor, AT-533 exhibits various biological activities in vitro, including anti-viral, anti-tumor and anti-inflammatory activities. Moreover, AT-533 gel, a gel dosage form of AT-533, has been suggested to have anti-keratitis and herpes simplex virus type-1 infection-induced effects on the skin lesions of animals. However, the safety evaluation of AT-533 and AT-533 gel has, to the best of our knowledge, not been examined in in vivo toxicological tests. Therefore, these toxicological tests were carried out in the present study. A 30-day subacute toxicity test for AT-533 was conducted at doses of 1, 2 and 4 mg/kg in Sprague-Dawley rats, while that for AT-533 gel was conducted using a single dose of 5 g/kg. The toxicological tests showed that a high-dose of AT-533 caused lethality and side effects in Sprague-Dawley rats. However, no mortality, loss of appetite and body weight, adverse reactions, or toxicologically relevant alterations in hematology, biochemistry and macroscopic findings (except for skin) occurred in rats exposed to low-dose AT-533 and single-dose AT-533 gel (5 g/kg) during a 30-day subacute dermic toxicity study. The aforementioned results suggested that AT-533 gel is non-toxic for Sprague-Dawley rats, as shown by a dermic subacute toxicity test and that except for slight skin irritation, AT-533 gel had almost no side effects when administered percutaneously for 30 days.
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Affiliation(s)
- Yanting Wu
- Institute of Biomedicine, College of Life Science and Technology, Jinan University, Guangzhou, Guangdong 510632, P.R. China.,Guangzhou (Jinan) Biomedicine Research and Development Center Co. Ltd, Guangzhou, Guangdong 510632, P.R. China
| | - Xiaowei Song
- College of Pharmacy, Jinan University, Guangzhou, Guangdong 510632, P.R. China
| | - Shurong Qin
- College of Pharmacy, Jinan University, Guangzhou, Guangdong 510632, P.R. China
| | - Pengxiao Chen
- Guangzhou (Jinan) Biomedicine Research and Development Center Co. Ltd, Guangzhou, Guangdong 510632, P.R. China
| | - Lianzhou Huang
- College of Pharmacy, Jinan University, Guangzhou, Guangdong 510632, P.R. China
| | - Qiaoli Wang
- Guangzhou (Jinan) Biomedicine Research and Development Center Co. Ltd, Guangzhou, Guangdong 510632, P.R. China
| | - Tianhao Shan
- Institute of Biomedicine, College of Life Science and Technology, Jinan University, Guangzhou, Guangdong 510632, P.R. China
| | - Feng Liang
- Guangzhou (Jinan) Biomedicine Research and Development Center Co. Ltd, Guangzhou, Guangdong 510632, P.R. China
| | - Xiaofeng Liao
- Guangzhou (Jinan) Biomedicine Research and Development Center Co. Ltd, Guangzhou, Guangdong 510632, P.R. China
| | - Qiuying Liu
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, Guangdong 510006, P.R. China
| | - Yunsheng Huang
- Guangdong Medical University, Dongguan, Guangdong 523808, P.R. China
| | - Yifei Wang
- Institute of Biomedicine, College of Life Science and Technology, Jinan University, Guangzhou, Guangdong 510632, P.R. China.,Guangzhou (Jinan) Biomedicine Research and Development Center Co. Ltd, Guangzhou, Guangdong 510632, P.R. China.,College of Pharmacy, Jinan University, Guangzhou, Guangdong 510632, P.R. China
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Dai Y, Zhao M, Qiu F, Yan X, Fan Y, Sun C. Investigation of the effect of Huaiqihuang granules via adjuvant treatment in children with relapsed systemic lupus erythematosus. Am J Transl Res 2021; 13:3222-3229. [PMID: 34017492 PMCID: PMC8129345] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To investigate the therapeutic effect of Huaiqihuang granules in children with relapsed systemic lupus erythematosus (SLE), and analyze its impact on the regulation of inflammatory factors, immune function, and recurrence rate. METHODS Seventy-six children with relapsed SLE were evenly divided into two groups, the control group with conventional SLE treatment and the observation group which was treated with Huaiqihuang granules on the basis of the conventional treatment. After 8 weeks of treatment, the positive rate of antinuclear antibody (ANA) titer, 24-hour urine protein (24 h Upro), serum inflammatory factors, monocyte chemoattractant protein 1 (MCP-1), receptor for advanced glycation end products (RAGE) level and systemic lupus erythematosus disease activity index (SLEDAI) score were compared. The recurrence rate of SLE between the two groups was also analyzed at the 6-month follow-up. RESULTS Compared with before treatment, the positive rate of ANA titer, 24 h Upro, and serum interleukin-10 (IL-10) and tumor necrosis factor family B cell activating factor (BAFF) levels in the two groups of children were decreased after treatment; in addition, levels of these parameters in the observation group were significantly lower than those of the control group. The interleukin-2 (IL-2) level of both groups was significantly increased after treatment, and the observation group showed a significantly higher level of IL-2 than that of the control group (all P<0.05). After treatment, serum MCP-1 and RAGE levels of the two groups were considerably lower compared with that before treatment, which were significantly lower in the observation group than those of the control group (all P<0.05). SLEDAI scores of the two groups were significantly decreased after treatment, which were notably lower in the observation group than those of the control group (all P<0.05). The six-month follow-up demonstrated that the recurrence rate of SLE in the observation group was remarkably lower than that of the control group (P<0.05). CONCLUSION The adjuvant treatment by Huaiqihuang granules can effectively reduce the inflammatory response, decrease the disease activity of SLE, and lower the recurrence rate in children with SLE relapse, which is worthy of clinical application.
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Affiliation(s)
- Yongjun Dai
- Department of Pediatrics, The Affiliated Municipal Hospital of Taizhou UniversityTaizhou, Zhejiang Province, China
| | - Min Zhao
- Department of Pharmacy, Yidu Central Hospital of WeifangWeifang, Shandong Province, China
| | - Fuli Qiu
- Department of Pediatrics, Pingyi County Hospital of Traditional Chinese MedicineLinyi, Shandong Province, China
| | - Xue Yan
- Department of Pediatrics, Pingyi County Hospital of Traditional Chinese MedicineLinyi, Shandong Province, China
| | - Yong Fan
- Department of Neonatology, Shouguang City Maternal and Child Health Care HospitalShouguang, Shandong Province, China
| | - Cuifeng Sun
- Department of General Practice, School Hospital of Shandong Normal UniversityJi’nan, Shandong Province, China
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