1
|
Matyas JR, Klein C, Ponjevic D, Duncan NA, Kawchuk GN. Repetitive in vivo manual loading of the spine elicits cellular responses in porcine annuli fibrosi. PLoS One 2021; 16:e0248104. [PMID: 33755684 PMCID: PMC7987143 DOI: 10.1371/journal.pone.0248104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 02/21/2021] [Indexed: 11/19/2022] Open
Abstract
Back pain and intervertebral disc degeneration are prevalent, costly, and widely treated by manual therapies, yet the underlying causes of these diseases are indeterminate as are the scientific bases for such treatments. The present studies characterize the effects of repetitive in vivo manual loads on porcine intervertebral disc cell metabolism using RNA deep sequencing. A single session of repetitive manual loading applied to the lumbar spine induced both up- and down-regulation of a variety of genes transcribed by cells in the ventral annuli fibrosi. The effect of manual therapy at the level of loading was greater than at a level distant to the applied load. Gene ontology and molecular pathway analyses categorized biological, molecular, and cellular functions influenced by repetitive manual loading, with over-representation of membrane, transmembrane, and pericellular activities. Weighted Gene Co-expression Network Analysis discerned enrichment in genes in pathways of inflammation and skeletogenesis. The present studies support previous findings of intervertebral disc cell mechanotransduction, and are the first to report comprehensively on the repertoire of gene targets influenced by mechanical loads associated with manual therapy interventions. The present study defines the cellular response of repeated, low-amplitude loads on normal healthy annuli fibrosi and lays the foundation for future work defining how healthy and diseased intervertebral discs respond to single or low-frequency manual loads typical of those applied clinically.
Collapse
Affiliation(s)
- John Robert Matyas
- Department of Comparative Biology & Experimental Medicine, McCaig Institute of Bone and Joint Health, University of Calgary Faculty of Veterinary Medicine, Calgary, Alberta, Canada
- * E-mail:
| | - Claudia Klein
- Department of Clinical and Veterinary Clinical Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dragana Ponjevic
- Department of Comparative Biology & Experimental Medicine, McCaig Institute of Bone and Joint Health, University of Calgary Faculty of Veterinary Medicine, Calgary, Alberta, Canada
| | - Neil A. Duncan
- Department of Civil Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Gregory N. Kawchuk
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
2
|
Modulation of the In Vivo Inflammatory Response by Pro- Versus Anti-Inflammatory Intervertebral Disc Treatments. Int J Mol Sci 2020; 21:ijms21051730. [PMID: 32138314 PMCID: PMC7084831 DOI: 10.3390/ijms21051730] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 12/14/2022] Open
Abstract
Inflammation is central in intervertebral disc (IVD) degeneration/regeneration mechanisms, and its balance is crucial to maintain tissue homeostasis. This work investigates the modulation of local and systemic inflammatory response associated with IVD degeneration/herniation by administration of PRO- versus ANTI-inflammatory treatments. Chitosan/poly-γ-glutamic acid nanocomplexes, known as pro-inflammatory (PRO), and soluble diclofenac, a non-steroidal anti-inflammatory drug (ANTI), were intradiscally administered in a rat IVD injury model, 24 h after lesion. Two weeks after administration, a reduction of disc height accompanied by hernia formation was observed. In the PRO-inflammatory treated group, IL-1β, IL-6 and COX-2 IVD gene expression were upregulated, and loss of nucleus pulposus (NP) structure and composition was observed. Systemically, lower T-cell frequency was observed in the lymph nodes (LN) and spleen (SP) of the PRO group, together with an increase in CD4+ T cells subset in the blood (BL) and LN. In contrast, the ANTI-group had higher proteoglycans/collagen ratio and collagen type 2 content in the NP, while an increase in the frequency of myeloid cells, M1 macrophages and activated macrophages (MHCII+) was observed at the systemic level. Overall, this study illustrates the dynamics of local and systemic inflammatory and immune cell responses associated with intradiscal therapies, which will contribute to designing more successful immunomodulatory treatments for IVD degeneration.
Collapse
|
3
|
Li P, Zhang R, Wang L, Gan Y, Xu Y, Song L, Luo L, Zhao C, Zhang C, Ouyang B, Tu B, Zhou Q. Long-term load duration induces N-cadherin down-regulation and loss of cell phenotype of nucleus pulposus cells in a disc bioreactor culture. Biosci Rep 2017; 37:BSR20160582. [PMID: 28351894 PMCID: PMC5408662 DOI: 10.1042/bsr20160582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/25/2017] [Accepted: 03/27/2017] [Indexed: 12/17/2022] Open
Abstract
Long-term exposure to a mechanical load causes degenerative changes in the disc nucleus pulposus (NP) tissue. A previous study demonstrated that N-cadherin (N-CDH)-mediated signalling can preserve the NP cell phenotype. However, N-CDH expression and the resulting phenotype alteration in NP cells under mechanical compression remain unclear. The present study investigated the effects of the compressive duration on N-CDH expression and on the phenotype of NP cells in an ex vivo disc organ culture. Porcine discs were organ cultured in a self-developed mechanically active bioreactor for 7 days. The discs were subjected to different dynamic compression durations (1 and 8 h at a magnitude of 0.4 MPa and frequency of 1.0 Hz) once per day. Discs that were not compressed were used as controls. The results showed that long-term compression duration (8 h) significantly down-regulated the expression of N-CDH and NP-specific molecule markers (Brachyury, Laminin, Glypican-3 and Keratin 19), attenuated Alcian Blue staining intensity, decreased glycosaminoglycan (GAG) and hydroxyproline (HYP) contents and decreased matrix macromolecule (aggrecan and collagen II) expression compared with the short-term compression duration (1 h). Taken together, these findings demonstrate that long-term load duration can induce N-CDH down-regulation, loss of normal cell phenotype and result in attenuation of NP-related matrix synthesis in NP cells.
Collapse
Affiliation(s)
- Pei Li
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Ruijie Zhang
- Department of Respiratory Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Liyuan Wang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Yibo Gan
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Yuan Xu
- Department of Orthopedic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400038, China
| | - Lei Song
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Lei Luo
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Chen Zhao
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Chengmin Zhang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Bin Ouyang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Bing Tu
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Qiang Zhou
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| |
Collapse
|
4
|
Chooi WH, Chan SCW, Gantenbein B, Chan BP. Loading-Induced Heat-Shock Response in Bovine Intervertebral Disc Organ Culture. PLoS One 2016; 11:e0161615. [PMID: 27580124 PMCID: PMC5006975 DOI: 10.1371/journal.pone.0161615] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/09/2016] [Indexed: 12/22/2022] Open
Abstract
Mechanical loading has been shown to affect cell viability and matrix maintenance in the intervertebral disc (IVD) but there is no investigation on how cells survive mechanical stress and whether the IVD cells perceive mechanical loading as stress and respond by expression of heat shock proteins. This study investigates the stress response in the IVD in response to compressive loading. Bovine caudal disc organ culture was used to study the effect of physiological range static loading and dynamic loading. Cell activity, gene expression and immunofluorescence staining were used to analyze the cell response. Cell activity and cytoskeleton of the cells did not change significantly after loading. In gene expression analysis, significant up-regulation of heat shock protein-70 (HSP70) was observed in nucleus pulposus after two hours of loading. However, the expression of the matrix remodeling genes did not change significantly after loading. Similarly, expressions of stress response and matrix remodeling genes changed with application and removal of the dynamic loading. The results suggest that stress response was induced by physiological range loading without significantly changing cell activity and upregulating matrix remodeling. This study provides direct evidence on loading induced stress response in IVD cells and contributes to our understanding in the mechanoregulation of intervertebral disc cells.
Collapse
Affiliation(s)
- Wai Hon Chooi
- Tissue Engineering Laboratory, Department of Mechanical Engineering, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Samantha Chun Wai Chan
- Tissue & Organ Mechanobiology, Institute of Surgical Technology and Biomechanics, University of Bern, Bern, Switzerland.,Biointerfaces, Empa, Swiss Federal Laboratories for Materials Science and Technology, St Gallen, Switzerland
| | - Benjamin Gantenbein
- Tissue & Organ Mechanobiology, Institute of Surgical Technology and Biomechanics, University of Bern, Bern, Switzerland
| | - Barbara Pui Chan
- Tissue Engineering Laboratory, Department of Mechanical Engineering, The University of Hong Kong, Hong Kong Special Administrative Region, China
| |
Collapse
|
5
|
Wang Z, Wang G, Zhu X, Geng D, Yang H. Interleukin-2 is upregulated in patients with a prolapsed lumbar intervertebral disc and modulates cell proliferation, apoptosis and extracellular matrix metabolism of human nucleus pulposus cells. Exp Ther Med 2015; 10:2437-2443. [PMID: 26668654 DOI: 10.3892/etm.2015.2809] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 09/25/2015] [Indexed: 12/28/2022] Open
Abstract
Previous studies have demonstrated that the expression levels of cytokines are increased in degenerated intervertebral disc tissues, and several cytokines are associated with the pathogenesis of intervertebral disc degeneration. However, the role of interleukin (IL)-2 in the cellular functions of intervertebral disc tissues remains unreported. The present study aimed to determine the expression levels of IL-2 in the nucleus pulposus (NP) tissues of patients with a prolapsed lumbar intervertebral disc; and to observe the changes in cell proliferation, apoptosis, extracellular matrix (ECM) metabolism and p38 mitogen-activated protein kinase (MAPK) signaling in human NP cells (HNPCs) following treatment with IL-2. The present study demonstrated that IL-2 expression levels were upregulated in the NP tissues of patients with a prolapsed lumbar intervertebral disc; and a subsequent MTT assay demonstrated that IL-2 inhibits the proliferation of HNPCs in a dose-dependent manner. Furthermore, as demonstrated by the increased protein expression levels of Fas cell surface death receptor and the induction of caspase-8 and caspase-3 activity, the death receptor pathway was activated by IL-2 in the HNPCs in order to promote cell apoptosis. In addition, IL-2 promoted ECM degradation in the HNPCs, as demonstrated by an increase in the expression levels of type I collagen, a disintegrin and metalloproteinase with thrombospondin motifs and matrix metalloproteinases, and decreased aggrecan and type II collagen expression levels. Furthermore, phosphorylated-p38 was significantly increased in the HNPCs following IL-2 treatment. In conclusion, the present study demonstrated that IL-2 inhibits cell proliferation, and induces cell apoptosis and ECM degradation, accompanied by the activation of p38 MAPK signaling in HNPCs. Therefore, IL-2 may be a potential therapeutic agent for the treatment of degenerative disc disease.
Collapse
Affiliation(s)
- Zhirong Wang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China ; Department of Orthopedic Surgery, Zhangjiagang Hospital of Traditional Chinese Medicine, Zhangjiagang, Jiangsu 215600, P.R. China
| | - Genlin Wang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Xuesong Zhu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Dechun Geng
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Huilin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| |
Collapse
|
6
|
Hartman RA, Yurube T, Ngo K, Merzlak NE, Debski RE, Brown BN, Kang JD, Sowa GA. Biological responses to flexion/extension in spinal segments ex-vivo. J Orthop Res 2015; 33:1255-64. [PMID: 25865090 DOI: 10.1002/jor.22900] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 03/10/2015] [Indexed: 02/04/2023]
Abstract
Mechanical loading is a salient factor in the progression of spinal disorders that contribute to back pain. Biological responses to loading modes like flexion/extension (F/E) in relevant spinal tissues remain unstudied. A novel, multi-axial experimental system was developed to subject viable functional spinal units (FSUs) to complex, in-situ loading. The objective was to determine biological effects of F/E in multiple spinal tissues-annulus fibrosus, nucleus pulposus, facet cartilage, and ligamentum flavum. Rabbit lumbar FSUs were mounted in a bioreactor within a robotic testing system. FSUs underwent small (0.17/0.05 Nm) and large (0.5/0.15 Nm) range-of-motion F/E for 1 or 2 h of cycling. Outcomes in each tissue, compared to unloaded FSUs, included (i) relative mRNA expression of catabolic (MMP-1, 3 and ADAMTS-5), pro-inflammatory (COX-2), and anabolic (ACAN) genes and (ii) immunoblotting of aggrecan degradation. Total energy applied to FSUs increased in groups subject to large range-of-motion and 2-h cycling, and moment relaxation was higher with large range-of-motion. F/E significantly modulated MMP1,-3 and COX-2 in facet cartilage and MMP-3 and ACAN in annulus fibrosus. Large range-of-motion loading increased MMP-mediated aggrecan fragmentation in annulus fibrosus. Biological responses to complex loading ex vivo showed variation among spinal tissues that reflect tissue structure and mechanical loading in F/E.
Collapse
Affiliation(s)
- Robert A Hartman
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 5th Avenue, Pittsburgh, Pennsylvania, 15213.,Department of Bioengineering, University of Pittsburgh, 300 Technology Drive, 360B Center for Bioengineering, Pittsburgh, Pennsylvania, 15219
| | - Takashi Yurube
- Department of Orthopaedic Surgery, University of Pittsburgh, 200 Lothrop Street, E1641 Biomedical Science Tower, Pittsburgh, Pennsylvania, 15261
| | - Kevin Ngo
- Department of Orthopaedic Surgery, University of Pittsburgh, 200 Lothrop Street, E1641 Biomedical Science Tower, Pittsburgh, Pennsylvania, 15261
| | - Nicolas E Merzlak
- Department of Orthopaedic Surgery, University of Pittsburgh, 200 Lothrop Street, E1641 Biomedical Science Tower, Pittsburgh, Pennsylvania, 15261
| | - Richard E Debski
- Department of Bioengineering, University of Pittsburgh, 300 Technology Drive, 360B Center for Bioengineering, Pittsburgh, Pennsylvania, 15219.,Department of Orthopaedic Surgery, University of Pittsburgh, 200 Lothrop Street, E1641 Biomedical Science Tower, Pittsburgh, Pennsylvania, 15261
| | - Bryan N Brown
- Department of Bioengineering, University of Pittsburgh, 300 Technology Drive, 360B Center for Bioengineering, Pittsburgh, Pennsylvania, 15219.,McGowan Institute for Regenerative Medicine, 450 Technology Drive, Suite 300, Pittsburgh, Pennsylvania, 15219
| | - James D Kang
- Department of Orthopaedic Surgery, University of Pittsburgh, 200 Lothrop Street, E1641 Biomedical Science Tower, Pittsburgh, Pennsylvania, 15261
| | - Gwendolyn A Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 5th Avenue, Pittsburgh, Pennsylvania, 15213.,Department of Bioengineering, University of Pittsburgh, 300 Technology Drive, 360B Center for Bioengineering, Pittsburgh, Pennsylvania, 15219.,Department of Orthopaedic Surgery, University of Pittsburgh, 200 Lothrop Street, E1641 Biomedical Science Tower, Pittsburgh, Pennsylvania, 15261
| |
Collapse
|
7
|
Hirata H, Yurube T, Kakutani K, Maeno K, Takada T, Yamamoto J, Kurakawa T, Akisue T, Kuroda R, Kurosaka M, Nishida K. A rat tail temporary static compression model reproduces different stages of intervertebral disc degeneration with decreased notochordal cell phenotype. J Orthop Res 2014; 32:455-63. [PMID: 24285589 DOI: 10.1002/jor.22533] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/07/2013] [Indexed: 02/04/2023]
Abstract
The intervertebral disc nucleus pulposus (NP) has two phenotypically distinct cell types-notochordal cells (NCs) and non-notochordal chondrocyte-like cells. In human discs, NCs are lost during adolescence, which is also when discs begin to show degenerative signs. However, little evidence exists regarding the link between NC disappearance and the pathogenesis of disc degeneration. To clarify this, a rat tail disc degeneration model induced by static compression at 1.3 MPa for 0, 1, or 7 days was designed and assessed for up to 56 postoperative days. Radiography, MRI, and histomorphology showed degenerative disc findings in response to the compression period. Immunofluorescence displayed that the number of DAPI-positive NP cells decreased with compression; particularly, the decrease was notable in larger, vacuolated, cytokeratin-8- and galectin-3-co-positive cells, identified as NCs. The proportion of TUNEL-positive cells, which predominantly comprised non-NCs, increased with compression. Quantitative PCR demonstrated isolated mRNA up-regulation of ADAMTS-5 in the 1-day loaded group and MMP-3 in the 7-day loaded group. Aggrecan-1 and collagen type 2α-1 mRNA levels were down-regulated in both groups. This rat tail temporary static compression model, which exhibits decreased NC phenotype, increased apoptotic cell death, and imbalanced catabolic and anabolic gene expression, reproduces different stages of intervertebral disc degeneration.
Collapse
Affiliation(s)
- Hiroaki Hirata
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Cell sources for nucleus pulposus regeneration. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23 Suppl 3:S364-74. [PMID: 24297331 DOI: 10.1007/s00586-013-3106-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 11/07/2013] [Accepted: 11/07/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE There is increasing interest in the development of cell therapy as a possible approach for the treatment of degenerative disc disease. To regenerate nucleus pulposus tissue, the cells must produce an appropriate proteoglycan-rich matrix, as this is essential for the functioning of the intervertebral disc. The natural environment within the disc is very challenging to implanted cells, particularly if they have been subcultured in normal laboratory conditions. The purpose of this work is to discuss parameters relevant to translating different proposed cell therapies of IVD into clinical use. RESULTS Several sources of cells have been proposed, including nucleus pulposus cells, chondrocytes and mesenchymal stem cells derived from bone marrow or adipose tissue. There are some clinical trials and reports of attempts to regenerate nucleus pulposus utilising either autologous or allogenic cells. While the published results of clinical applications of these cell therapies do not indicate any safety issues, additional evidence will be needed to prove their long-term efficacy. CONCLUSION This article discusses parameters relevant for successful translation of research on different cell sources into clinically applicable cell therapies: the influence of the intervertebral disc microenvironment on the cell phenotype, issues associated with cell culture and technical preparation of cell products, as well as discussing current regulatory requirements. There are advantages and disadvantages of each proposed cell type, but no strong evidence to favour any one particular cell source at the moment.
Collapse
|
9
|
Gilbert HTJ, Nagra NS, Freemont AJ, Millward-Sadler SJ, Hoyland JA. Integrin - dependent mechanotransduction in mechanically stimulated human annulus fibrosus cells: evidence for an alternative mechanotransduction pathway operating with degeneration. PLoS One 2013; 8:e72994. [PMID: 24039840 PMCID: PMC3764176 DOI: 10.1371/journal.pone.0072994] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 07/23/2013] [Indexed: 12/11/2022] Open
Abstract
Intervertebral disc (IVD) cells derived from degenerate tissue respond aberrantly to mechanical stimuli, potentially due to altered mechanotransduction pathways. Elucidation of the altered, or alternative, mechanotransduction pathways operating with degeneration could yield novel targets for the treatment of IVD disease. Our aim here was to investigate the involvement of RGD-recognising integrins and associated signalling molecules in the response to cyclic tensile strain (CTS) of human annulus fibrosus (AF) cells derived from non-degenerate and degenerate IVDs. AF cells from non-degenerate and degenerate human IVDs were cyclically strained with and without function blocking RGD – peptides with 10% strain, 1.0 Hz for 20 minutes using a Flexercell® strain device. QRT-PCR and Western blotting were performed to analyse gene expression of type I collagen and ADAMTS -4, and phosphorylation of focal adhesion kinase (FAK), respectively. The response to 1.0 Hz CTS differed between the two groups of AF cells, with decreased ADAMTS -4 gene expression and decreased type I collagen gene expression post load in AF cells derived from non-degenerate and degenerate IVDs, respectively. Pre-treatment of non-degenerate AF cells with RGD peptides prevented the CTS-induced decrease in ADAMTS -4 gene expression, but caused an increase in expression at 24 hours, a response not observed in degenerate AF cells where RGD pre-treatment failed to inhibit the mechano-response. In addition, FAK phosphorylation increased in CTS stimulated AF cells derived from non-degenerate, but not degenerate IVDs, with RGD pre-treatment inhibiting the CTS – dependent increase in phosphorylated FAK. Our findings suggest that RGD -integrins are involved in the 1.0 Hz CTS – induced mechano-response observed in AF cells derived from non-degenerate, but not degenerate IVDs. This data supports our previous work, suggesting an alternative mechanotransduction pathway may be operating in degenerate AF cells.
Collapse
Affiliation(s)
- Hamish T. J. Gilbert
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Navraj S. Nagra
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Anthony J. Freemont
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Sarah J. Millward-Sadler
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
| | - Judith A. Hoyland
- Centre for Regenerative Medicine, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester, United Kingdom
- * E-mail:
| |
Collapse
|
10
|
McCann MR, Patel P, Beaucage KL, Xiao Y, Bacher C, Siqueira WL, Holdsworth DW, Dixon SJ, Séguin CA. Acute vibration induces transient expression of anabolic genes in the murine intervertebral disc. ACTA ACUST UNITED AC 2013; 65:1853-64. [PMID: 23661269 DOI: 10.1002/art.37979] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 04/11/2013] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Low-amplitude whole-body vibration has been adopted for the treatment of back pain and spinal disorders. However, there is limited knowledge of the impact of vibration on the intervertebral disc (IVD). This study was undertaken to examine the effects of acute vibration on anabolic and catabolic pathways in the IVD and to characterize the dependence of these changes on time and frequency. METHODS Custom-designed platforms were developed to apply acute vibration to ex vivo and in vivo mouse models. Spinal segments (ex vivo) or mice (in vivo) were subjected to vibration (for 30 minutes at 15-90 Hz with peak acceleration at 0.3g), and IVDs were examined at specific time points after vibration. Gene expression was quantified using real-time polymerase chain reaction, and protein levels were examined by quantitative mass spectrometry and immunofluorescence. RESULTS In the ex vivo model, acute vibration at 15 Hz induced expression of anabolic genes (aggrecan, biglycan, decorin, type I collagen, and Sox9) and suppressed expression of Mmp13, with the most pronounced changes detected 6 hours following vibration. These beneficial effects were frequency dependent and were no longer evident between 45 and 90 Hz. In vivo, the effects on anabolic gene expression were even more robust and were accompanied by decreased expression of Adamts4, Adamts5, and Mmp3. Moreover, significant increases in the protein levels of aggrecan, biglycan, decorin, and type I collagen were detected in vivo. CONCLUSION These findings demonstrate dramatic anabolic effects of acute vibration on IVD tissue, responses that are dependent on frequency. The similarity of the in vivo and ex vivo responses indicates that at least some effects of vibration are tissue autonomous.
Collapse
Affiliation(s)
- Matthew R McCann
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Rastogi A, Kim H, Twomey JD, Hsieh AH. MMP-2 mediates local degradation and remodeling of collagen by annulus fibrosus cells of the intervertebral disc. Arthritis Res Ther 2013; 15:R57. [PMID: 23621950 PMCID: PMC4060574 DOI: 10.1186/ar4224] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 04/27/2013] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Degeneration of the intervertebral disc (IVD) is characterized by marked degradation and restructuring of the annulus fibrosus (AF). Although several matrix metalloproteinases (MMPs) have been found to be more prevalent in degenerate discs, their coordination and function within the context of the disease process are still not well understood. In this study, we sought to determine whether MMP-2 is associated with degenerative changes in the AF and to identify the manner by which AF cells use MMP-2. METHODS Two established animal models of disc degeneration, static compression and transannular needle puncture of rodent caudal discs, were examined for MMP-2 immunopositivity. With lentiviral transduction of an shRNA expression cassette, we screened and identified an effective shRNA sequence for generating stable RNA interference to silence MMP-2 expression in primary rat AF cells. Gelatin films were used to compare gelatinase activity and spatial patterns of degradation between transduced cells, and both noninfected and nonsense shRNA controls. The functional significance of MMP-2 was determined by assessing the ability for cells to remodel collagen gels. RESULTS Both static compression and 18-g annular puncture of rodent caudal discs stimulated an increase in MMP-2 activity with concurrent lamellar disorganization in the AF, whereas 22-g and 26-g needle injuries did not. To investigate the functional role of MMP-2, we established lentivirus-mediated RNAi to induce stable knockdown of transcript levels by as much as 88%, and protein levels by as much as 95% over a 10-day period. Culturing transduced cells on gelatin films confirmed that MMP-2 is the primary functional gelatinase in AF cells, and that MMP-2 is used locally in regions immediately around AF cells. In collagen gels, transduced cells demonstrated an inability to remodel collagen matrices. CONCLUSIONS Our study indicates that increases in MMP-2 observed in human degenerate discs are mirrored in experimentally induced degenerative changes in rodent animal models. AF cells appear to use MMP-2 in a very directed fashion for local matrix degradation and collagen remodeling. This suggests that MMP-2 may have a functionally significant role in the etiology of degenerative disc disease and could be a potential therapeutic target.
Collapse
|
12
|
Mietsch A, Neidlinger-Wilke C, Schrezenmeier H, Mauer UM, Friemert B, Wilke HJ, Ignatius A. Evaluation of platelet-rich plasma and hydrostatic pressure regarding cell differentiation in nucleus pulposus tissue engineering. J Tissue Eng Regen Med 2011; 7:244-52. [DOI: 10.1002/term.524] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 05/17/2011] [Accepted: 09/21/2011] [Indexed: 01/24/2023]
Affiliation(s)
- Antje Mietsch
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research; Ulm University; Germany
| | - Cornelia Neidlinger-Wilke
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research; Ulm University; Germany
| | - Hubert Schrezenmeier
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm; German Red Cross Blood Transfusion Service Baden-Württemberg, Center of Musculoskeletal Research; Ulm University; Germany
| | - Uwe Max Mauer
- Department of Neurosurgery; German Armed Forces Hospital of Ulm; Germany
| | - Benedikt Friemert
- Department of Trauma Surgery and Orthopaedics; German Armed Forces Hospital of Ulm; Germany
| | - Hans-Joachim Wilke
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research; Ulm University; Germany
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research; Ulm University; Germany
| |
Collapse
|
13
|
Abstract
Degenerative changes in the material properties of nucleus pulposus and anulus fibrosus promote changes in viscoelastic properties of the whole disc. Volume, pressure and hydration loss in the nucleus pulposus, disk height decreases and fissures in the anulus fibrosus, are some of the signs of the degenerative cascade that advances with age and affect, among others, spinal function and its stability. Much remains to be learned about how these changes affect the function of the motion segment and relate to symptoms such as low back pain and altered spinal biomechanics.
Collapse
Affiliation(s)
- Nozomu Inoue
- Department of Orthopedic Surgery and Director of Spine Biomechanics Laboratory, Rush University Medical Center, Chicago, IL
| | | |
Collapse
|
14
|
Yurube T, Takada T, Hirata H, Kakutani K, Maeno K, Zhang Z, Yamamoto J, Doita M, Kurosaka M, Nishida K. Modified house-keeping gene expression in a rat tail compression loading-induced disc degeneration model. J Orthop Res 2011; 29:1284-90. [PMID: 21387398 DOI: 10.1002/jor.21406] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 02/15/2011] [Indexed: 02/04/2023]
Abstract
House-keeping genes (HKGs) are generally used as endogenous controls for molecular normalization in quantitative PCR analysis. However, whether all the so-called HKGs are useful for intervertebral disc research is controversial. Our objective was, using a prevalidated rat tail static compression loading-induced disc degeneration model, to clarify the feasibility of common HKGs for gene-quantification in the nucleus pulposus cells. In real-time RT-PCR for five HKGs [β-actin, β-glucuronidase, β-2 microglobulin, glyceraldehyde 3-phosphate dehydrogenase (GAPDH), and lactate dehydrogenase A (LDHA)], static compression at 1.3 MPa for up to 56 days demonstrated messenger RNA (mRNA) expression levels of consistent β-2 microglobulin and GAPDH, slightly up-regulated β-glucuronidase, and fairly down-regulated β-actin and LDHA. Especially, β-actin had a drastic suppression to 0.15-fold in the loaded relative to unloaded discs at 7 days. In immunofluorescence, β-actin showed a significant down-regulation to almost undetectable levels from 28 days, while GAPDH was constantly detected throughout. β-Actin mRNA and protein-distribution are thought to be affected by the loading treatment, however, GAPDH mRNA and protein-distribution can retain relatively stable expressions. Under prolonged static compression, β-actin and probably LDHA are inappropriate, and GAPDH is a feasible HKG as internal references in the disc cells.
Collapse
Affiliation(s)
- Takashi Yurube
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
STUDY DESIGN In vitro and in vivo rat tail model to assess effects of torsion on intervertebral disc biomechanics and gene expression. OBJECTIVE Investigate effects of torsion on promoting biosynthesis and producing injury in rat caudal intervertebral discs. SUMMARY OF BACKGROUND DATA Torsion is an important loading mode in the disc and increased torsional range of motion is associated with clinical symptoms from disc disruption. Altered elastin content is implicated in disc degeneration, but its effects on torsional loading are unknown. Although effects of compression have been studied, the effect of torsion on intervertebral disc gene expression is unknown. METHODS In vitro biomechanical tests were performed in torsion on rat tail motion segments subjected to 4 treatments: elastase, collagenase, genipin, control. In vivo tests were performed on rats with Ilizarov-type fixators implanted to caudal motion segments with five 90 minute loading groups: 1 Hz cyclic torsion to ± 5 ± 15° and ± 30°, static torsion to + 30°, and sham. Anulus and nucleus tissues were separately analyzed using qRT-PCR for gene expression of anabolic, catabolic, and proinflammatory cytokine markers. RESULTS In vitro tests showed decreased torsional stiffness following elastase treatment and no changes in stiffness with frequency. In vivo tests showed no significant changes in dynamic stiffness with time. Cyclic torsion upregulated elastin expression in the anulus fibrosus. Up regulation of TNF-α and IL-1β was measured at ±30°. CONCLUSION We conclude that strong differences in the disc response to cyclic torsion and compression are apparent with torsion increasing elastin expression and compression resulting in a more substantial increase in disc metabolism in the nucleus pulposus. Results highlight the importance of elastin in torsional loading and suggest that elastin remodels in response to shearing. Torsional loading can cause injury to the disc at excessive amplitudes that are detectable biologically before they are biomechanically.
Collapse
|
16
|
latridis JC, Godburn K, Wuertz K, Alini M, Roughley PJ. Region-dependent aggrecan degradation patterns in the rat intervertebral disc are affected by mechanical loading in vivo. Spine (Phila Pa 1976) 2011; 36:203-9. [PMID: 20714280 PMCID: PMC2988868 DOI: 10.1097/brs.0b013e3181cec247] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Immunoblotting study to evaluate aggrecan degradation patterns in rat intervertebral discs (IVDs) subjected to mechanical overload. OBJECTIVE To evaluate the effects of in vivo dynamic compression overloading on aggrecan degradation products associated with matrix metalloproteinase (MMP) and aggrecanase activity in different regions of the IVD. SUMMARY OF BACKGROUND DATA Aggrecan cleavage at the MMP and aggrecanase sites is an important event in human IVD aging, with distinct cleavage patterns in the anulus and nucleus regions.No such information is available on regional variations in rat IVDs, nor on how such cleavage is affected by mechanical loading. METHODS Sprague-Dawley rats were instrumented with an Ilizarov-type device and subjected to dynamic compression (1 MPa and 1 Hz for 8 hours per day for 8 weeks). Control, sham, and overloaded IVDs were separated by disc region and analyzed for aggrecan degradation products using immunoblotting techniques, with antibodies specific for the aggrecanase and MMP cleavage sites in the interglobular domain of aggrecan. RESULTS Control IVDs exhibited strong regional variation in aggrecan degradation patterns with minimal degradation products being present in the nucleus pulposus, degradation products associated with aggrecanase cleavage predominating in the inner anulus fibrosus (AF), and degradation products associated with MMP cleavage predominating in the outer AF. Dynamic compression overloading increased the amount of aggrecan degradation products associated with MMP cleavage not only in the AF but also in the nucleus pulposus. Degradation profiles of sham IVDs were similar to control. CONCLUSION Aggrecan G1 regions resulting from proteolysis were found to have a strong regionally specific pattern in the rat IVD, which was altered under excessive loading. The shift from aggrecanase to MMP-induced degradation products with dynamic compression overloading suggests that protein degradation and loss can precede major structural disruption in the IVD, and that MMP-induced aggrecan degradation may be a marker of mechanically induced disc degeneration.
Collapse
Affiliation(s)
- James C latridis
- School of Engineering, University of Vermont, Burlington, VT 05405, USA.
| | | | | | | | | |
Collapse
|
17
|
Yurube T, Nishida K, Suzuki T, Kaneyama S, Zhang Z, Kakutani K, Maeno K, Takada T, Fujii M, Kurosaka M, Doita M. Matrix metalloproteinase (MMP)-3 gene up-regulation in a rat tail compression loading-induced disc degeneration model. J Orthop Res 2010; 28:1026-32. [PMID: 20162718 DOI: 10.1002/jor.21116] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The rodent static compression loading-induced disc degeneration model still has important gaps among the radiographic, magnetic resonance imaging (MRI), and histological schemes and the acute and chronic expression of catabolic genes such as matrix metalloproteinase (MMP)-3. Our objectives were to assess the validity of a rat tail two-disc static compression model and to elucidate a representative catabolic marker, MMP-3 gene alterations, throughout the degenerative process. Static compression at 1.3 MPa for up to 56 days produced progressive disc height loss in radiographs, lower nucleus intensity on T2-weighted MRIs, and histomorphological degeneration. Real-time RT-PCR mRNA quantification showed significant MMP-3 up-regulation in nucleus pulposus cells from 7 days and a significantly progressive increase as the loading duration lengthened, with high correlations to radiological degenerative scores. Immunohistochemistry demonstrated progressively increased positive staining for MMP-3. These results validate this animal model for disc degeneration research. Progressive mRNA and protein-distributional up-regulations indicate the significant role of MMP-3 and its feasibility as a disc degenerative marker. This model should prove useful for investigating the pathomechanism and for evaluating molecular therapies for degenerative disc disease.
Collapse
Affiliation(s)
- Takashi Yurube
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Noailly J, Planell JA, Lacroix D. On the collagen criss-cross angles in the annuli fibrosi of lumbar spine finite element models. Biomech Model Mechanobiol 2010; 10:203-19. [DOI: 10.1007/s10237-010-0227-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 05/17/2010] [Indexed: 11/28/2022]
|
19
|
Potier E, Noailly J, Ito K. Directing bone marrow-derived stromal cell function with mechanics. J Biomech 2009; 43:807-17. [PMID: 19962149 DOI: 10.1016/j.jbiomech.2009.11.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Revised: 11/13/2009] [Accepted: 11/16/2009] [Indexed: 01/12/2023]
Abstract
Because bone marrow-derived stromal cells (BMSCs) are able to generate many cell types, they are envisioned as source of regenerative cells to repair numerous tissues, including bone, cartilage, and ligaments. Success of BMSC-based therapies, however, relies on a number of methodological improvements, among which better understanding and control of the BMSC differentiation pathways. Since many years, the biochemical environment is known to govern BMSC differentiation, but more recent evidences show that the biomechanical environment is also directing cell functions. Using in vitro systems that aim to reproduce selected components of the in vivo mechanical environment, it was demonstrated that mechanical loadings can affect BMSC proliferation and improve the osteogenic, chondrogenic, or myogenic phenotype of BMSCs. These effects, however, seem to be modulated by parameters other than mechanics, such as substrate nature or soluble biochemical environment. This paper reviews and discusses recent experimental data showing that despite some knowledge limitation, mechanical stimulation already constitutes an additional and efficient tool to drive BMSC differentiation.
Collapse
Affiliation(s)
- E Potier
- Biomedical Engineering, Eindhoven University of Technology, Postbus 513, 5600 MB Eindhoven, The Netherlands
| | | | | |
Collapse
|
20
|
Adenovirus-mediated tissue inhibitor of metalloproteinase-3 gene transfection inhibits rabbit intervertebral disc degeneration in vivo. ACTA ACUST UNITED AC 2009. [DOI: 10.1007/s11684-009-0072-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
21
|
Wuertz K, Godburn K, MacLean JJ, Barbir A, Donnelly JS, Roughley PJ, Alini M, Iatridis JC. In vivo remodeling of intervertebral discs in response to short- and long-term dynamic compression. J Orthop Res 2009; 27:1235-42. [PMID: 19274755 PMCID: PMC2757138 DOI: 10.1002/jor.20867] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 01/27/2009] [Indexed: 02/04/2023]
Abstract
This study evaluated how dynamic compression induced changes in gene expression, tissue composition, and structural properties of the intervertebral disc using a rat tail model. We hypothesized that daily exposure to dynamic compression for short durations would result in anabolic remodeling with increased matrix protein expression and proteoglycan content, and that increased daily load exposure time and experiment duration would retain these changes but also accumulate changes representative of mild degeneration. Sprague-Dawley rats (n = 100) were instrumented with an Ilizarov-type device and divided into three dynamic compression (2 week-1.5 h/day, 2 week-8 h/day, 8 week-8 h/day at 1 MPa and 1 Hz) and two sham (2 week, 8 week) groups. Dynamic compression resulted in anabolic remodeling with increased matrix mRNA expression, minimal changes in catabolic genes or disc structure and stiffness, and increased glysosaminoglycans (GAG) content in the nucleus pulposus. Some accumulation of mild degeneration with 8 week-8 h included loss of annulus fibrosus GAG and disc height although 8-week shams also had loss of disc height, water content, and minor structural alterations. We conclude that dynamic compression is consistent with a notion of "healthy" loading that is able to maintain or promote matrix biosynthesis without substantially disrupting disc structural integrity. A slow accumulation of changes similar to human disc degeneration occurred when dynamic compression was applied for excessive durations, but this degenerative shift was mild when compared to static compression, bending, or other interventions that create greater structural disruption.
Collapse
Affiliation(s)
- Karin Wuertz
- Spine Bioengineering Lab, School of Engineering, University of Vermont, 33 Colchester Avenue, 201 Perkins Hall, Burlington, Vermont 05405
- Spine Research Unit, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Karolyn Godburn
- Spine Bioengineering Lab, School of Engineering, University of Vermont, 33 Colchester Avenue, 201 Perkins Hall, Burlington, Vermont 05405
| | - Jeffrey J. MacLean
- Spine Bioengineering Lab, School of Engineering, University of Vermont, 33 Colchester Avenue, 201 Perkins Hall, Burlington, Vermont 05405
| | - Ana Barbir
- Spine Bioengineering Lab, School of Engineering, University of Vermont, 33 Colchester Avenue, 201 Perkins Hall, Burlington, Vermont 05405
| | - Justin Stinnett Donnelly
- Spine Bioengineering Lab, School of Engineering, University of Vermont, 33 Colchester Avenue, 201 Perkins Hall, Burlington, Vermont 05405
| | - Peter J. Roughley
- Genetics Unit, Shriners Hospital for Children, Montreal, Quebec, Canada
| | - Mauro Alini
- AO Research Institute, Davos Platz, Switzerland
| | - James C. Iatridis
- Spine Bioengineering Lab, School of Engineering, University of Vermont, 33 Colchester Avenue, 201 Perkins Hall, Burlington, Vermont 05405
| |
Collapse
|
22
|
Le Maitre CL, Frain J, Millward-Sadler J, Fotheringham AP, Freemont AJ, Hoyland JA. Altered integrin mechanotransduction in human nucleus pulposus cells derived from degenerated discs. ACTA ACUST UNITED AC 2009; 60:460-9. [DOI: 10.1002/art.24248] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|