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Skirzynska A, Xue C, Shoichet MS. Engineering Biomaterials to Model Immune-Tumor Interactions In Vitro. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2310637. [PMID: 38349174 DOI: 10.1002/adma.202310637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Engineered biomaterial scaffolds are becoming more prominent in research laboratories to study drug efficacy for oncological applications in vitro, but do they have a place in pharmaceutical drug screening pipelines? The low efficacy of cancer drugs in phase II/III clinical trials suggests that there are critical mechanisms not properly accounted for in the pre-clinical evaluation of drug candidates. Immune cells associated with the tumor may account for some of these failures given recent successes with cancer immunotherapies; however, there are few representative platforms to study immune cells in the context of cancer as traditional 2D culture is typically monocultures and humanized animal models have a weakened immune composition. Biomaterials that replicate tumor microenvironmental cues may provide a more relevant model with greater in vitro complexity. In this review, the authors explore the pertinent microenvironmental cues that drive tumor progression in the context of the immune system, discuss how these cues can be incorporated into hydrogel design to culture immune cells, and describe progress toward precision oncological drug screening with engineered tissues.
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Affiliation(s)
- Arianna Skirzynska
- Chemical Engineering and Applied Chemistry, University of Toronto, 200 College Street, Toronto, ON, M5S 3E5, Canada
- Terrence Donnelly Centre for Cellular & Biomolecular Research, University of Toronto, 160 College St, Toronto, ON, M5S 3E1, Canada
| | - Chang Xue
- Terrence Donnelly Centre for Cellular & Biomolecular Research, University of Toronto, 160 College St, Toronto, ON, M5S 3E1, Canada
- Institute for Biomedical Engineering, University of Toronto, 164 College Street, Toronto, ON, M5S 3G9, Canada
| | - Molly S Shoichet
- Chemical Engineering and Applied Chemistry, University of Toronto, 200 College Street, Toronto, ON, M5S 3E5, Canada
- Terrence Donnelly Centre for Cellular & Biomolecular Research, University of Toronto, 160 College St, Toronto, ON, M5S 3E1, Canada
- Institute for Biomedical Engineering, University of Toronto, 164 College Street, Toronto, ON, M5S 3G9, Canada
- Department of Chemistry, University of Toronto, 80 College Street, Toronto, ON, M5S 3H4, Canada
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Nie R, Zhang QY, Feng ZY, Huang K, Zou CY, Fan MH, Zhang YQ, Zhang JY, Li-Ling J, Tan B, Xie HQ. Hydrogel-based immunoregulation of macrophages for tissue repair and regeneration. Int J Biol Macromol 2024; 268:131643. [PMID: 38643918 DOI: 10.1016/j.ijbiomac.2024.131643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/10/2024] [Accepted: 04/14/2024] [Indexed: 04/23/2024]
Abstract
The rational design of hydrogel materials to modulate the immune microenvironment has emerged as a pivotal approach in expediting tissue repair and regeneration. Within the immune microenvironment, an array of immune cells exists, with macrophages gaining prominence in the field of tissue repair and regeneration due to their roles in cytokine regulation to promote regeneration, maintain tissue homeostasis, and facilitate repair. Macrophages can be categorized into two types: classically activated M1 (pro-inflammatory) and alternatively activated M2 (anti-inflammatory and pro-repair). By regulating the physical and chemical properties of hydrogels, the phenotypic transformation and cell behavior of macrophages can be effectively controlled, thereby promoting tissue regeneration and repair. A full understanding of the interaction between hydrogels and macrophages can provide new ideas and methods for future tissue engineering and clinical treatment. Therefore, this paper reviews the effects of hydrogel components, hardness, pore size, and surface morphology on cell behaviors such as macrophage proliferation, migration, and phenotypic polarization, and explores the application of hydrogels based on macrophage immune regulation in skin, bone, cartilage, and nerve tissue repair. Finally, the challenges and future prospects of macrophage-based immunomodulatory hydrogels are discussed.
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Affiliation(s)
- Rong Nie
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Qing-Yi Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Zi-Yuan Feng
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Kai Huang
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Chen-Yu Zou
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Ming-Hui Fan
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Yue-Qi Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Ji-Ye Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Jesse Li-Ling
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Department of Medical Genetics, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Bo Tan
- Department of Orthopedic Surgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan 611731, PR China
| | - Hui-Qi Xie
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China; Frontier Medical Center, Tianfu Jincheng Laboratory, Chengdu, Sichuan 610212, PR China.
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Li R, Feng D, Han S, Zhai X, Yu X, Fu Y, Jin F. Macrophages and fibroblasts in foreign body reactions: How mechanical cues drive cell functions? Mater Today Bio 2023; 22:100783. [PMID: 37701130 PMCID: PMC10494263 DOI: 10.1016/j.mtbio.2023.100783] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/14/2023] Open
Abstract
Biomaterials, when implanted in the human body, can induce a series of cell- and cytokine-related reactions termed foreign body reactions (FBRs). In the progression of FBRs, macrophages regulate inflammation and healing by polarizing to either a pro-inflammatory or pro-healing phenotype and recruit fibroblasts by secreting cytokines. Stimulated by the biomaterials, fibrotic capsule is formed eventually. The implant, along with its newly formed capsule, introduces various mechanical cues that influence cellular functions. Mechanosensing proteins, such as integrins or ion channels, transduce extracellular mechanical signals into cytoplasm biochemical signals in response to mechanical stimuli. Consequently, the morphology, migration mode, function, and polarization state of the cells are affected. Modulated by different intracellular signaling pathways and their crosstalk, the expression of fibrotic genes increases with fibroblast activation and fibroblast to myofibroblast transition under stiff or force stimuli. However, summarized in most current studies, the outcomes of macrophage polarization in the effect of different mechanical cues are inconsistent. The underlying mechanisms should be investigated with more advanced technology and considering more interfering aspects. Further research is needed to determine how to modulate the progression of fibrotic capsule formation in FBR artificially.
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Affiliation(s)
- Rihan Li
- Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
- Department of Breast and Reconstructive Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
| | - Dongdong Feng
- Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
- Department of Breast and Reconstructive Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
| | - Siyuan Han
- Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
- Department of Breast and Reconstructive Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
| | - Xiaoyue Zhai
- Department of Histology and Embryology, Basic Medical College, China Medical University, Shenyang, Liaoning, 110000, China
| | - Xinmiao Yu
- Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
- Department of Breast and Reconstructive Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
| | - Yuanyuan Fu
- Department of Histology and Embryology, Basic Medical College, China Medical University, Shenyang, Liaoning, 110000, China
| | - Feng Jin
- Department of Breast Surgery, The First Hospital of China Medical University, Shenyang, Liaoning, 110000, China
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Liu Z, Liu J, Li J, Li Y, Sun J, Deng Y, Zhou H. Substrate stiffness can affect the crosstalk between adipose derived mesenchymal stem cells and macrophages in bone tissue engineering. Front Bioeng Biotechnol 2023; 11:1133547. [PMID: 37576988 PMCID: PMC10415109 DOI: 10.3389/fbioe.2023.1133547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 06/15/2023] [Indexed: 08/15/2023] Open
Abstract
Purpose: This study aimed to explore the effect of biomaterials with different stiffness on Adipose Derived Mesenchymal Stem Cells (ADSC)-macrophage crosstalk in bone tissue engineering and its role in bone repair. Methods: Biomaterials with Young's modulus of 64 and 0.2 kPa were selected, and the crosstalk between ADSCs and macrophages was investigated by means of conditioned medium treatment and cell co-culture, respectively. Polymerase chain reaction (PCR) and flow cytometry were used to evaluate the polarization of macrophages. Alkaline phosphatase (ALP) and alizarin red staining (ARS) solutions were used to evaluate the osteogenic differentiation of ADSCs. Transwell assay was used to evaluate the chemotaxis of ADSCs and macrophages. Moreover, mass spectrometry proteomics was used to analyze the secreted protein profile of ADSCs of different substrates and macrophages in different polarization states. Results: On exploring the influence of biomaterials on macrophages from ADSCs on different substrates, we found that CD163 and CD206 expression levels in macrophages were significantly higher in the 64-kPa group than in the 0.2-kPa group in conditioned medium treatment and cell co-culture. Flow cytometry showed that more cells became CD163+ or CD206+ cells in the 64-kPa group under conditioned medium treatment or cell co-culture. The Transwell assay showed that more macrophages migrated to the lower chamber in the 64-kPa group. The proteomic analysis found that ADSCs in the 64-kPa group secreted more immunomodulatory proteins, such as LBP and RBP4, to improve the repair microenvironment. On exploring the influence of biomaterials on ADSCs from macrophages in different polarization states, we found that ALP and ARS levels in ADSCs were significantly higher in the M2 group than in the other three groups (NC, M0, and M1 groups) in both conditioned medium treatment and cell co-culture. The Transwell assay showed that more ADSCs migrated to the lower chamber in the M2 group. The proteomic analysis found that M2 macrophages secreted more extracellular remodeling proteins, such as LRP1, to promote bone repair. Conclusion: In bone tissue engineering, the stiffness of repair biomaterials can affect the crosstalk between ADSCs and macrophages, thereby regulating local repair immunity and affecting bone repair.
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Affiliation(s)
- Zeyang Liu
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jin Liu
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jipeng Li
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yinwei Li
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Sun
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Deng
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Huifang Zhou
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Bomb K, Pradhan L, Zhang Q, Jarai BM, Bhattacharjee A, Burris DL, Kloxin AM, Fromen CA. Destructive fibrotic teamwork: how both microenvironment stiffness and profibrotic interleukin 13 impair alveolar macrophage phenotype and function. Biomater Sci 2022; 10:5689-5706. [PMID: 36018297 PMCID: PMC9632634 DOI: 10.1039/d2bm00828a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The pulmonary fibrotic microenvironment is characterized by increased stiffness of lung tissue and enhanced secretion of profibrotic soluble cues contributing to a feedback loop that leads to dysregulated wound healing and lung failure. Pinpointing the individual and tandem effects of profibrotic stimuli in impairing immune cell response remains difficult and is needed for improved therapeutic strategies. We utilized a statistical design of experiment (DOE) to investigate how microenvironment stiffness and interleukin 13 (IL13), a profibrotic soluble factor linked with disease severity, contribute to the impaired macrophage response commonly observed in pulmonary fibrosis. We used engineered bioinspired hydrogels of different stiffness, ranging from healthy to fibrotic lung tissue, and cultured murine alveolar macrophages (MH-S cells) with or without IL13 to quantify cell response and analyze independent and synergistic effects. We found that, while both stiffness and IL13 independently influence macrophage morphology, phenotype, phagocytosis and efferocytosis, these factors work synergistically to exacerbate impaired macrophage phenotype and efferocytosis. These unique findings provide insights into how macrophages in fibrotic conditions are not as effective in clearing debris, contributing to fibrosis initiation/progression, and more broadly inform how underlying drivers of fibrosis modulate immune cell response to facilitate therapeutic strategies.
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Affiliation(s)
- Kartik Bomb
- Chemical and Biomolecular Engineering, University of Delaware, Newark, DE, USA.
| | - Lina Pradhan
- Chemical and Biomolecular Engineering, University of Delaware, Newark, DE, USA.
| | - Qi Zhang
- Chemical and Biomolecular Engineering, University of Delaware, Newark, DE, USA.
| | - Bader M Jarai
- Chemical and Biomolecular Engineering, University of Delaware, Newark, DE, USA.
| | | | - David L Burris
- Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - April M Kloxin
- Chemical and Biomolecular Engineering, University of Delaware, Newark, DE, USA.
- Material Science and Engineering, University of Delaware, Newark, DE, USA
| | - Catherine A Fromen
- Chemical and Biomolecular Engineering, University of Delaware, Newark, DE, USA.
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Luo T, Tan B, Zhu L, Wang Y, Liao J. A Review on the Design of Hydrogels With Different Stiffness and Their Effects on Tissue Repair. Front Bioeng Biotechnol 2022; 10:817391. [PMID: 35145958 PMCID: PMC8822157 DOI: 10.3389/fbioe.2022.817391] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/07/2022] [Indexed: 12/20/2022] Open
Abstract
Tissue repair after trauma and infection has always been a difficult problem in regenerative medicine. Hydrogels have become one of the most important scaffolds for tissue engineering due to their biocompatibility, biodegradability and water solubility. Especially, the stiffness of hydrogels is a key factor, which influence the morphology of mesenchymal stem cells (MSCs) and their differentiation. The researches on this point are meaningful to the field of tissue engineering. Herein, this review focus on the design of hydrogels with different stiffness and their effects on the behavior of MSCs. In addition, the effect of hydrogel stiffness on the phenotype of macrophages is introduced, and then the relationship between the phenotype changes of macrophages on inflammatory response and tissue repair is discussed. Finally, the future application of hydrogels with a certain stiffness in regenerative medicine and tissue engineering has been prospected.
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Affiliation(s)
- Tianyi Luo
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Bowen Tan
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Lengjing Zhu
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Yating Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Jinfeng Liao
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- *Correspondence: Jinfeng Liao,
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Qiang N, Lin W, Zhou X, Liu Z, Lu M, Qiu S, Tang S, Zhu J. Electrospun Fibers Derived from Peptide Coupled Amphiphilic Copolymers for Dorsal Root Ganglion (DRG) Outgrowth. Gels 2021; 7:196. [PMID: 34842696 PMCID: PMC8628770 DOI: 10.3390/gels7040196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/27/2021] [Accepted: 10/30/2021] [Indexed: 12/22/2022] Open
Abstract
Developing scaffolds with appropriate mechanical/structural features as well as tunable bioactivities are indispensable in the field of tissue engineering. This study focused on one such attempt to electrospin the copolymer of L-lactic acid (L-LA) and functional monomer (3(S)- [(benzyloxycarbony)methyl]-1,4-dioxane-2,5-dione, BMD) with small peptide modifications for the purpose of neural tissue engineering. Scanning Electron Microscopy (SEM) micrographs showed fabricated electrospun copolymer as porous and uniform nanofibrous materials with diameter in the range of 800-1000 nm. In addition, the modified scaffolds displayed a lower contact angle than poly(L-lactide) (PLLA) indicating higher hydrophilicity. To further incorporate the bioactive functions, the nanofibers were chemically coupled with small peptide (isoleucine-lysine-valine-alanine-valine, IKVAV). The incorporation of IKVAV onto the electrospun fiber was confirmed by X-ray photoelectron spectroscopy (XPS) and such incorporation did not affect the surface morphology or fiber diameters. To demonstrate the potential of applying the designed scaffolds for nerve regeneration, dorsal root ganglion (DRG) neurons were cultured on the nanofibers to examine the impact on neurite outgrowth of DRGs. The results indicated that the fabricated nanofibrous matrix with small peptide might be a potential candidate for neural tissue engineering.
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Affiliation(s)
- Na Qiang
- School of Chemistry and Materials Engineering, Huizhou University, Huizhou 516007, China; (N.Q.); (Z.L.); (M.L.); (S.Q.)
| | - Wensheng Lin
- Department of Biomedical Engineering, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China;
| | - Xingwu Zhou
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Zhu Liu
- School of Chemistry and Materials Engineering, Huizhou University, Huizhou 516007, China; (N.Q.); (Z.L.); (M.L.); (S.Q.)
| | - Ming Lu
- School of Chemistry and Materials Engineering, Huizhou University, Huizhou 516007, China; (N.Q.); (Z.L.); (M.L.); (S.Q.)
| | - Si Qiu
- School of Chemistry and Materials Engineering, Huizhou University, Huizhou 516007, China; (N.Q.); (Z.L.); (M.L.); (S.Q.)
| | - Shuo Tang
- Department of Orthopaedics, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen 517000, China
| | - Jixiang Zhu
- Department of Biomedical Engineering, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China;
- The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan 511518, China
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