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Tavasolian F, Lively S, Pastrello C, Tang M, Lim M, Pacheco A, Qaiyum Z, Yau E, Baskurt Z, Jurisica I, Kapoor M, Inman RD. Proteomic and genomic profiling of plasma exosomes from patients with ankylosing spondylitis. Ann Rheum Dis 2023; 82:1429-1443. [PMID: 37532285 DOI: 10.1136/ard-2022-223791] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Recent advances in understanding the biology of ankylosing spondylitis (AS) using innovative genomic and proteomic approaches offer the opportunity to address current challenges in AS diagnosis and management. Altered expression of genes, microRNAs (miRNAs) or proteins may contribute to immune dysregulation and may play a significant role in the onset and persistence of inflammation in AS. The ability of exosomes to transport miRNAs across cells and alter the phenotype of recipient cells has implicated exosomes in perpetuating inflammation in AS. This study reports the first proteomic and miRNA profiling of plasma-derived exosomes in AS using comprehensive computational biology analysis. METHODS Plasma samples from patients with AS and healthy controls (HC) were isolated via ultracentrifugation and subjected to extracellular vesicle flow cytometry analysis to characterise exosome surface markers by a multiplex immunocapture assay. Cytokine profiling of plasma-derived exosomes and cell culture supernatants was performed. Next-generation sequencing was used to identify miRNA populations in exosomes enriched from plasma fractions. CD4+ T cells were sorted, and the frequency and proliferation of CD4+ T-cell subsets were analysed after treatment with AS-exosomes using flow cytometry. RESULTS The expression of exosome marker proteins CD63 and CD81 was elevated in the patients with AS compared with HC (q<0.05). Cytokine profiling in plasma-derived AS-exosomes demonstrated downregulation of interleukin (IL)-8 and IL-10 (q<0.05). AS-exosomes cocultured with HC CD4+ T cells induced significant upregulation of IFNα2 and IL-33 (q<0.05). Exosomes from patients with AS inhibited the proliferation of regulatory T cells (Treg), suggesting a mechanism for chronically activated T cells in this disease. Culture of CD4+ T cells from healthy individuals in the presence of AS-exosomes reduced the proliferation of FOXP3+ Treg cells and decreased the frequency of FOXP3+IRF4+ Treg cells. miRNA sequencing identified 24 differentially expressed miRNAs found in circulating exosomes of patients with AS compared with HC; 22 of which were upregulated and 2 were downregulated. CONCLUSIONS Individuals with AS have different immunological and genetic profiles, as determined by evaluating the exosomes of these patients. The inhibitory effect of exosomes on Treg in AS suggests a mechanism contributing to chronically activated T cells in this disease.
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Affiliation(s)
- Fataneh Tavasolian
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Starlee Lively
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Chiara Pastrello
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, - Data Science Discovery Centre for Chronic Diseases, University Health Network, Toronto, Ontario, Canada
| | - Michael Tang
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Melissa Lim
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Addison Pacheco
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Zoya Qaiyum
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Enoch Yau
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Zeynep Baskurt
- Department of Biostatistics, Princess Margaret Cancer Center, 610 University Ave, Toronto, Ontario, Canada
| | - Igor Jurisica
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Research Institute, - Data Science Discovery Centre for Chronic Diseases, University Health Network, Toronto, Ontario, Canada
- Departments of Medical Biophysics and Computer Science, and Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
- Institute of Neuroimmunology, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Mohit Kapoor
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Osteoarthritis Research Program, Division of Orthopaedics, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Division of Orthopaedic Surgery and Department of Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Robert D Inman
- Schroeder Arthritis Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Immunology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Spondylitis Program, Division of Rheumatology, Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
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Feng X, Qiao J, Xu W. Impact of immune regulation and differentiation dysfunction of mesenchymal stem cells on the disease process in ankylosing spondylitis and prospective analysis of stem cell transplantation therapy. Postgrad Med J 2023; 99:1138-1147. [PMID: 37689998 DOI: 10.1093/postmj/qgad073] [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: 05/26/2023] [Revised: 07/19/2023] [Accepted: 08/11/2023] [Indexed: 09/11/2023]
Abstract
Ankylosing spondylitis (AS) is a rheumatic bone and joint disease caused by inflammation, erosion, and pathological bone formation. The pathological features of chronic inflammation, bone destruction, and pathological ossification occur due to the disruption of the body's immune regulation and altered bone remodeling balance. Mesenchymal stem cells (MSCs) have multidirectional differentiation potential and immunomodulatory functions and play an important role in immune regulation and bone formation. The immune regulation and osteogenic capacity of MSCs in AS are altered by factors such as genetic background, internal environment, infection, and mechanical forces that drive disease development. This review further evaluates the role of MSCs dysfunction in inflammation and pathological bone formation by analyzing the effects of the above-mentioned factors on MSCs function and also looks forward to the prospects of MSCs in treating AS, providing some ideas for an in-depth study of inflammation and ectopic ossification. KEY MESSAGES
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Affiliation(s)
- Xinzhe Feng
- Department of Joint Bone Disease Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai 200433, China
| | - Junjie Qiao
- Department of Joint Bone Disease Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai 200433, China
| | - Weidong Xu
- Department of Joint Bone Disease Surgery, Changhai Hospital, Navy Medical University, 168 Changhai Road, Shanghai 200433, China
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Qijiao W, Tao Z, Haimei L, Guomin L, Li S. Identifying circRNA-associated-ceRNA networks in juvenile spondyloarthropathies patients. Pediatr Rheumatol Online J 2023; 21:75. [PMID: 37507775 PMCID: PMC10386608 DOI: 10.1186/s12969-023-00855-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/02/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Juvenile spondyloarthropathies (JSpA) are defined as a heterogeneous group of diseases that start before the age of 16. The study aimed to identify key genes and pathways that are influenced by circRNAs and to screen potential therapeutic agents for JSpA. The study involved the analysis of circRNA expression profiles, identification of circRNA-miRNA-mRNA regulatory networks, and functional annotation of differentially expressed genes. The results of the study may have provided insights into the molecular mechanisms underlying JSpA and potential therapeutic targets for this disease. METHODS In this study, sequencing data of circRNA, miRNA, and mRNA were obtained from the GEO datasets. The data were then analyzed to identify candidates for constructing a circRNA-miRNA-mRNA network based on circRNA-miRNA interactions and miRNA-mRNA interactions. Functional enrichments of genes were performed using the DAVID database. A PPI network was constructed using the STRING database and visualized using Cytoscape software. The MCODE plugin app was used to explore hub genes in the PPI network. The expression changes in immune cells were assessed using the online CIBERSORT algorithm to obtain the proportion of various types of immune cells. Finally, the Connectivity Map L1000 platform was used to identify potential agents for JSpA treatment. Overall, this study aimed to provide a comprehensive understanding of the molecular mechanisms underlying JSpA and to identify potential therapeutic agents for this disease. RESULTS A total of 225 differentially expressed circRNAs (DEcircRNAs), 23 differentially expressed miRNAs (DEmiRNAs) and 1324 differentially expressed mRNAs (DEmRNAs) were identified. We integrated 5 overlapped circRNAs, 7 miRNAs and 299 target mRNAs into a circRNA-miRNA-mRNA network. We next identified 10 hub genes based on the PPI network. KEGG pathway analysis revealed that the DEGs were mainly associated with JAK-STAT signal pathway. We found that neutrophils accounted for the majority of all enriched cells. In addition, we discovered several chemicals as potential treatment options for JSpA. CONCLUSIONS Through this bioinformatics analysis, we suggest a regulatory role for circRNAs in the pathogenesis and treatment of JSpA from the view of a competitive endogenous RNA (ceRNA) network.
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Affiliation(s)
- Wei Qijiao
- Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhang Tao
- Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Liu Haimei
- Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Li Guomin
- Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Sun Li
- Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China.
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Fang Y, Ni J, Wang YS, Zhao Y, Jiang LQ, Chen C, Zhang RD, Fang X, Wang P, Pan HF. Exosomes as biomarkers and therapeutic delivery for autoimmune diseases: Opportunities and challenges. Autoimmun Rev 2023; 22:103260. [PMID: 36565798 DOI: 10.1016/j.autrev.2022.103260] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Exosomes are spherical lipid bilayer vesicles composed of lipids, proteins and nucleic acids that deliver signaling molecules through a vesicular transport system to regulate the function and morphology of target cells, thereby involving in a variety of biological processes, such as cell apoptosis or proliferation, and cytokine production. In the past decades, there are emerging evidence that exosomes play pivotal roles in the pathological mechanisms of several autoimmune diseases (ADs), including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), type 1 diabetes mellitus (T1DM), Sjogren's syndrome (SS), multiple sclerosis (MS), inflammatory bowel disease (IBD). systemic sclerosis (SSc), etc. Several publications have shown that exosomes are involved in the pathogenesis of ADs mainly through intercellular communication and by influencing the response of immune cells. The level of exosomes and the expression of nucleic acids can reflect the degree of disease progression and are excellent biomarkers for ADs. In addition, exosomes have the potential to be used as drug carriers thanks to their biocompatibility and stability. In this review, we briefly summarized the current researches regarding the biological functions of exosomes in ADs, and provided an insight into the potential of exosomes as biomarkers and therapeutic delivery for these diseases.
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Affiliation(s)
- Yang Fang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China; Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China
| | - Jing Ni
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China; Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China
| | - Yun-Sheng Wang
- Department of Endocrinology, the Second People's Hospital of Hefei, the Affiliated Hefei Hospital of Anhui Medical University, Hefei 230011, Anhui, China
| | - Yan Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China; Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China
| | - Ling-Qiong Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China; Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China
| | - Cong Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China; Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China
| | - Ruo-Di Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China; Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China
| | - Xi Fang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China; Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China
| | - Peng Wang
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China; Teaching Center for Preventive Medicine, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China.
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui, China; Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, The Second Hospital of Anhui Medical University, China.
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Abbas AA, Abdulkader HA, Giordo R, Ashour HM, Erre GL, Pintus G, Zayed H. Implications and theragnostic potentials of circular RNAs in rheumatic diseases. Int J Biol Macromol 2023; 235:123783. [PMID: 36822282 DOI: 10.1016/j.ijbiomac.2023.123783] [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: 10/11/2022] [Accepted: 02/16/2023] [Indexed: 02/25/2023]
Abstract
Circular RNAs (circRNAs), a class of non-coding RNAs (ncRNAs), are highly stable and ubiquitous molecules that exhibit tissue-specific expression. Accumulating evidence has shown that aberrant expression of circRNAs can play a role in the pathogenesis of several diseases. Rheumatic diseases are a varied group of autoimmune and inflammatory disorders affecting mainly the musculoskeletal system. Notably, circRNAs, which are essential immune system gene modulators, are strongly linked to the occurrence and progression of autoimmune disorders. Here, we present and discuss the current findings concerning the roles, implications and theragnostic potentials of circRNAs in common rheumatic diseases, including ankylosing spondylitis (AS), osteoarthritis (OA), osteoporosis (OP), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Crohn's disease (CD), and gout. This review aims to provide new insights to support the development of novel diagnostic and therapeutic strategies for these disabling diseases.
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Affiliation(s)
- Alaa Ahmed Abbas
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Hadil Adnan Abdulkader
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Roberta Giordo
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, 505055 Dubai, United Arab Emirates
| | - Hossam M Ashour
- Department of Integrative Biology, College of Arts and Sciences, University of South Florida, St. Petersburg, FL 33701, USA
| | - Gian Luca Erre
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University Hospital (AOUSS) and University of Sassari, 07100 Sassari, Italy
| | - Gianfranco Pintus
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43B, 07100 Sassari, Italy; Department of Medical Laboratory Sciences, College of Health Sciences and Sharjah Institute for Medical Research, University of Sharjah, University City Rd, Sharjah 27272, United Arab Emirates.
| | - Hatem Zayed
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, P.O. Box 2713, Doha, Qatar.
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Noonin C, Peerapen P, Thongboonkerd V. Contamination of bacterial extracellular vesicles (bEVs) in human urinary extracellular vesicles (uEVs) samples and their effects on uEVs study. JOURNAL OF EXTRACELLULAR BIOLOGY 2022; 1:e69. [PMID: 38938597 PMCID: PMC11080850 DOI: 10.1002/jex2.69] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 06/29/2024]
Abstract
Bacterial overgrowth is common for improperly stored urine. However, its effects on human urinary extracellular vesicles (uEVs) study had not been previously examined nor documented. This study investigated the presence of bacterial EVs (bEVs) contaminated in uEVs samples and their effects on uEVs study. Nanoscale uEVs were isolated from normal human urine immediately after collection (0-h) or after 25°C-storage with/without preservative (10 mM NaN3) for up to 24-h. Turbidity, bacterial count and total uEVs proteins abnormally increased in the 8-h and 24-h-stored urine without NaN3. NanoLC-ESI-LTQ-Orbitrap MS/MS identified 6-13 bacterial proteins in these contaminated uEVs samples. PCR also detected bacterial DNAs in these contaminated uEVs samples. Besides, uEVs derived from 8-h and 24-h urine without NaN3 induced macrophage activation (CD11b and phagocytosis) and secretion of cytokines (IFN-α, IL-8, and TGF-β) from macrophages and renal cells (HEK-293, HK-2, and MDCK). All of these effects induced by bacterial contamination were partially/completely prevented by NaN3. Interestingly, macrophage activation and cytokine secretion were also induced by bEVs purified from Escherichia coli. This study clearly shows evidence of bEVs contamination and their effects on human uEVs study when the urine samples were inappropriately stored, whereas NaN3 can partially/completely prevent such effects from the contaminated bEVs.
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Affiliation(s)
- Chadanat Noonin
- Medical Proteomics Unit, Office for Research and Development, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Paleerath Peerapen
- Medical Proteomics Unit, Office for Research and Development, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Visith Thongboonkerd
- Medical Proteomics Unit, Office for Research and Development, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
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Wang S, Chen F, Zeng C, Gu H, Wang Z, Yu W, Wu Y, Shen H. RNA Sequencing Reveals the Expression Profiles of circRNAs and Indicates Hsa_circ_0070562 as a Pro-osteogenic Factor in Bone Marrow-Derived Mesenchymal Stem Cells of Patients With Ankylosing Spondylitis. Front Genet 2022; 13:947120. [PMID: 35873481 PMCID: PMC9299369 DOI: 10.3389/fgene.2022.947120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Recent studies have reported that circular RNAs (circRNAs) play a crucial regulatory role in a variety of human diseases. However, the roles of circRNAs in pathological osteogenesis in ankylosing spondylitis (AS) remain unclear. We conducted circRNA and miRNA expression profiling of osteogenically differentiated bone marrow-derived mesenchymal stem cells (BMSCs) of patients with AS compared with those of healthy donors (HDs) by RNA sequencing (RNA-seq). Results showed that a total of 31806 circRNAs were detected in the BMSC samples, of which 418 circRNAs were significantly differentially expressed (DE) with a fold change ≥2 and p value <0.05. Among these, 204 circRNAs were upregulated, and 214 were downregulated. GO and KEGG analyses demonstrated that the DE circRNAs were mainly involved in the regulation of biological processes of the cell matrix adhesion and the TGF-beta signaling pathway, which are closely related to AS. circRNA-miRNA interaction networks related to the TGF-beta signaling pathway were established. The results of qRT-PCR showed that has_circ_0070562 was significantly up-regulated in AS-MSCs. In vitro experiments showed that silencing of has_circ_0070562 weakened osteogenesis of AS-BMSCs. In conclusion, we identified numerous circRNAs that were dysregulated in AS-BMSCs compared with HD-BMSCs. Bioinformatic analyses suggested that these dysregulated circRNAs might play important functional roles in AS-BMSCs osteogenesis. Circ_0070562 functioned as a pro-ostegenic factor and might serve as a potential biomarker and a therapeutic target for AS.
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Affiliation(s)
- Shan Wang
- Center for Biotherapy, Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Fenglei Chen
- Department of Orthopedics, Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Chenying Zeng
- Center for Biotherapy, Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Huimin Gu
- Center for Biotherapy, Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Ziming Wang
- Department of Orthopedics, Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Wenhui Yu
- Department of Orthopedics, Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Yanfeng Wu
- Center for Biotherapy, Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Huiyong Shen
- Department of Orthopedics, Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
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