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Cufré M, Pastorini M, Martín I, Failde R, Palmero D, Alemán M. Variants of human DECTIN-1 rs16910526 are linked to differential reactive oxygen species production and susceptibility to tuberculosis. J Biomed Sci 2024; 31:77. [PMID: 39103844 DOI: 10.1186/s12929-024-01067-w] [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: 03/05/2024] [Accepted: 07/16/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Dectin-1 is a transmembrane receptor that plays a pivotal role in recognising fungi and Mycobacterium tuberculosis (Mtb). A specific variant, DECTIN-1 rs16910526, results in a truncated receptor that disrupts membrane expression and ligand binding and is clinically associated with recurrent cutaneous mycoses. Previous research has clarified the role of Dectin-1 in boosting immune defenses against mycobacteria by enhancing reactive oxygen species (ROS) production in neutrophils (PMNs). Here, we investigated the association between the rs16910526 variant and Dectin-1 expression in PMNs, as well as intracellular ROS production in response to Mtb. Furthermore, we explored the potential link between the rs16910526 gene variant and TB outcomes in Argentina. METHODS DNA was extracted from blood samples obtained from a cohort of 178 TB patients and healthy subjects (HS) in Argentina. PCR amplification and sequencing were performed to identify the rs16910526 variant. Flow cytometry was utilised to assess Dectin-1 expression on the PMN plasma membrane and to measure intracellular ROS levels, as indicated by the oxidation of DHR123 in response to the Mtb antigen. RESULTS PMNs carrying the rs16910526 variant exhibited diminished Dectin-1 expression and ROS production in response to Mtb (p < 0.0001). In a case‒control study, the rs16910526 variant had an allelic frequency of 0.112 in TB patients and 0.051 in HS. Notably, 10 out of 88 HS and 18 out of 62 TB patients harboured the variant (odds ratio [OR]: 2.55 [95% CI 1.1-5.9, p = 0.03]), indicating a potential association with TB disease. Furthermore, TB patients with the rs16910526 variant exhibited a delayed sputum smear conversion time (p < 0.004) and 100% positivity for acid-fast bacilli smears (p < 0.00001). CONCLUSION Our study identified a significant association between the SNP variant rs16910526 in the DECTIN-1 gene and Dectin-1 expression in the PMN, leading to altered ROS production. The higher frequency of this variant in TB patients compared to HS suggests a possible link with susceptibility to TB disease in Argentina.
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Affiliation(s)
- Mónica Cufré
- Hospital de Infecciosas Francisco Javier Muñiz, Buenos Aires, Argentina
| | - Mercedes Pastorini
- Instituto de Medicina Experimental, IMEX-CONICET-ANM, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina
| | - Ignacio Martín
- Hospital de Infecciosas Francisco Javier Muñiz, Buenos Aires, Argentina
| | - Rodrigo Failde
- Hospital de Infecciosas Francisco Javier Muñiz, Buenos Aires, Argentina
| | - Domingo Palmero
- Hospital de Infecciosas Francisco Javier Muñiz, Buenos Aires, Argentina
| | - Mercedes Alemán
- Instituto de Medicina Experimental, IMEX-CONICET-ANM, Pacheco de Melo 3081, 1425, Buenos Aires, Argentina.
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Liu Y, Zhang L, Wu F, Liu Y, Li Y, Chen Y. Identification and validation of a pyroptosis-related signature in identifying active tuberculosis via a deep learning algorithm. Front Cell Infect Microbiol 2023; 13:1273140. [PMID: 38029270 PMCID: PMC10646574 DOI: 10.3389/fcimb.2023.1273140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Active tuberculosis (ATB), instigated by Mycobacterium tuberculosis (M.tb), rises as a primary instigator of morbidity and mortality within the realm of infectious illnesses. A significant portion of M.tb infections maintain an asymptomatic nature, recognizably termed as latent tuberculosis infections (LTBI). The complexities inherent to its diagnosis significantly hamper the initiatives aimed at its control and eventual eradication. Methodology Utilizing the Gene Expression Omnibus (GEO), we procured two dedicated microarray datasets, labeled GSE39940 and GSE37250. The technique of weighted correlation network analysis was employed to discern the co-expression modules from the differentially expressed genes derived from the first dataset, GSE39940. Consequently, a pyroptosis-related module was garnered, facilitating the identification of a pyroptosis-related signature (PRS) diagnostic model through the application of a neural network algorithm. With the aid of Single Sample Gene Set Enrichment Analysis (ssGSEA), we further examined the immune cells engaged in the pyroptosis process in the context of active ATB. Lastly, dataset GSE37250 played a crucial role as a validating cohort, aimed at evaluating the diagnostic prowess of our model. Results In executing the Weighted Gene Co-expression Network Analysis (WGCNA), a total of nine discrete co-expression modules were lucidly elucidated. Module 1 demonstrated a potent correlation with pyroptosis. A predictive diagnostic paradigm comprising three pyroptosis-related signatures, specifically AIM2, CASP8, and NAIP, was devised accordingly. The established PRS model exhibited outstanding accuracy across both cohorts, with the area under the curve (AUC) being respectively articulated as 0.946 and 0.787. Conclusion The present research succeeded in identifying the pyroptosis-related signature within the pathogenetic framework of ATB. Furthermore, we developed a diagnostic model which exuded a remarkable potential for efficient and accurate diagnosis.
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Affiliation(s)
- Yuchen Liu
- Division of Infectious Diseases, Department of Internal Medicine, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
- Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lifan Zhang
- Division of Infectious Diseases, Department of Internal Medicine, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
- Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengying Wu
- Division of Infectious Diseases, Department of Internal Medicine, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
- Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye Liu
- Division of Infectious Diseases, Department of Internal Medicine, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
- Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuanchun Li
- Division of Infectious Diseases, Department of Internal Medicine, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
- Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Chen
- Division of Infectious Diseases, Department of Internal Medicine, State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
- Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Geng X, Wu X, Yang Q, Xin H, Zhang B, Wang D, Liu L, Liu S, Chen Q, Liu Z, Zhang M, Pan S, Zhang X, Gao L, Jin Q. Whole transcriptome sequencing reveals neutrophils’ transcriptional landscape associated with active tuberculosis. Front Immunol 2022; 13:954221. [PMID: 36059536 PMCID: PMC9436479 DOI: 10.3389/fimmu.2022.954221] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Neutrophils have been recognized to play an important role in the pathogenesis of tuberculosis in recent years. Interferon-induced blood transcriptional signatures in ATB are predominantly driven by neutrophils. In this study, we performed global RNA-seq on peripheral blood neutrophils from active tuberculosis patients (ATB, n=15); latent tuberculosis infections (LTBI, n=22); and healthy controls (HC, n=21). The results showed that greater perturbations of gene expression patterns happened in neutrophils from ATB individuals than HC or those with LTBI, and a total of 344 differentially expressed genes (DEGs) were observed. Functional enrichment analysis showed that besides the interferon signaling pathway, multiple pattern recognition receptor pathways were significantly activated in ATB, such as NOD-like receptors and Toll-like receptors. Meanwhile, we also observed that the expression of genes related to endocytosis, secretory granules, and neutrophils degranulation were downregulated. Our data also showed that the NF-κB signaling pathway might be inhibited in patients with ATB, which could increase Mycobacterium tuberculosis survival and lead to active tuberculosis status. Furthermore, we validated the accuracy of some differentially expressed genes in an independent cohort using quantitative PCR, and obtained three novel genes (RBM3, CSRNP1, SRSF5) with the ability to discriminate active tuberculosis from LTBI and HC.
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Affiliation(s)
- Xingzhu Geng
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaolin Wu
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qianting Yang
- Guangdong Key Laboratory for Emerging Infectious Diseases, Shenzhen Key Laboratory of Infection & Immunity, Shenzhen Third People’s Hospital, Shenzhen, China
| | - Henan Xin
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Zhang
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
| | - Dakuan Wang
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
| | - Liguo Liu
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Song Liu
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Chen
- Guangdong Key Laboratory for Emerging Infectious Diseases, Shenzhen Key Laboratory of Infection & Immunity, Shenzhen Third People’s Hospital, Shenzhen, China
| | - Zisen Liu
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
| | - Mingxia Zhang
- Guangdong Key Laboratory for Emerging Infectious Diseases, Shenzhen Key Laboratory of Infection & Immunity, Shenzhen Third People’s Hospital, Shenzhen, China
| | - Shouguo Pan
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
| | - Xiaobing Zhang
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Qi Jin, ; Xiaobing Zhang, ; Lei Gao,
| | - Lei Gao
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Qi Jin, ; Xiaobing Zhang, ; Lei Gao,
| | - Qi Jin
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Qi Jin, ; Xiaobing Zhang, ; Lei Gao,
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Li C, He K, Yin M, Zhang Q, Lin J, Niu Y, Wang Q, Xu Q, Jiang N, Zhao G. LOX-1 Regulates Neutrophil Apoptosis and Fungal Load in A. Fumigatus Keratitis. Curr Eye Res 2021; 46:1800-1811. [PMID: 34264144 DOI: 10.1080/02713683.2021.1948063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine whether LOX-1 regulates neutrophil apoptosis and fungal load in A. fumigatus keratitis. METHODS Fas, FasL, CASP3, CASP8, CASP9 and BCL2 were tested in normal and infected corneas of C57BL/6 mice. Mice corneas were infected with A. fumigatus with or without pretreatment of LOX-1 neutralizing antibody or inhibitor (Poly I). Clinical score was recored and HE staining was tested. Fungal load in mice corneas was observed by plate counting. Poly morphonuclear neutrophilic leukocytes (PMNs) were stimulated with 75% ethanol-killed A. fumigatus with or without pretreatment of LOX-1 neutralizing antibody or Poly I. PCR, western blot and immunostaining tested expression of Fas, FasL, CASP3, CASP8, CASP9, BCL2 and cleaved caspase-3. PMNs infiltration and TUNEL-positive cells were assessed by immunofluorescent staining. Flow cytometry assay tested the percentage of apoptosis neutrophils. RESULTS Fas, Fas ligand, caspase-8, caspase-9 and caspase-3 mRNA levels were significantly higher in C57BL/6 mice corneas infected with A. fumigatus than normal corneas. Poly I treatment alleviated the severity and decreased clinical score at 3, 5 and 7 days post infecrion (p.i.). HE staining showed less infiltration in corneal tissue after LOX-1 inhibition. Plate counting experiment showed that number of viable fungus in corneas of Poly I treated group was significantly less than control group. LOX-1 neutralizing antibody or Poly I treatment significantly decreased neutrophil infiltration, the quantity of TUNEL-positive cells, the expression of Fas, Fas ligand, caspase-8, caspase-9, caspase-3, cleaved caspase-3 and the percentage of apoptosis neutrophils compared with control corneas. LOX-1 neutralizing antibody treatment significantly decreased Fas, FasL, CASP3, CASP8, CASP9 and cleaved caspase-3 expression in neutrophils. CONCLUSION LOX-1 inhibition decrease neutrophil apoptosis and fungal load in A. fumigatus keratitis.
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Affiliation(s)
- Cui Li
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Kun He
- Department of Ophthalmology, Zhejiang Quhua Hospital Quzhou, Zhejiang, China
| | - Min Yin
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Qiuqiu Zhang
- Department of Ophthalmology, Zaozhuang Municipal Hospital, Zaozhuang, Shandong, China
| | - Jing Lin
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yawen Niu
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Qian Wang
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Qiang Xu
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Nan Jiang
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Guiqiu Zhao
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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Kielbik M, Szulc-Kielbik I, Klink M. IRAK1 and IRAK4 signaling proteins are dispensable in the response of human neutrophils to Mycobacterium tuberculosis infection. FEMS Microbiol Lett 2019; 366:5614973. [PMID: 31702785 DOI: 10.1093/femsle/fnz226] [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: 08/02/2019] [Accepted: 11/07/2019] [Indexed: 11/13/2022] Open
Abstract
The involvement of neutrophils in the host response to Mycobacterium tuberculosis (Mtb) infection is not as well recognized as the involvement of macrophages and dendritic cells. Thus, this study gives more insight on the impact of the virulent Mtb H37Rv strain on proapoptotic and proinflammatory functions of human neutrophils in vitro. We found that neutrophils are not able to kill Mtb during the infection process, probably due to the lack of reactive oxygen species and nitric oxide production in response to bacteria. However, infected neutrophils effectively released cytokines, chemoattractant interleukin (IL) 8 and proinflammatory IL-1β. Moreover, Mtb enhanced the early apoptosis of neutrophils at 2 h postinfection. Additionally, this proapoptotic and proinflammatory response of neutrophils to Mtb infection occurred in an IRAK1- and IRAK4-independent manner. We also found that Mtb did not affect the surface expression of Toll-like receptor (TLR) 2 and slightly enhanced the surface expression of TLR4, but did not influence mRNA levels of both TLRs during the infection process. In conclusion, we show that the inhibition of signaling proteins activated by MyD88-dependent pathway did not participate in the biological activity of neutrophils against Mtb.
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Affiliation(s)
- Michal Kielbik
- Institute of Medical Biology, Polish Academy of Sciences, Lodz, Poland
| | | | - Magdalena Klink
- Institute of Medical Biology, Polish Academy of Sciences, Lodz, Poland
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Faridgohar M, Nikoueinejad H. New findings of Toll-like receptors involved in Mycobacterium tuberculosis infection. Pathog Glob Health 2017; 111:256-264. [PMID: 28715935 DOI: 10.1080/20477724.2017.1351080] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB), an important issue in the present age, affects millions of people each year. The infectious agent of TB, Mycobacterium tuberculosis (Mtb), interacts with the immune system which prevents the development of this bacterium as much as possible. In fact, the receptors on the surface of immune cells identify the bacteria, one of which is Toll-like receptors (TLRs). Different TLRs including 2, 4, 9 and 8 play critical roles in tuberculosis infection. In this paper, we focused on the role of TLRs which interact with different components of Mtb and, consequently, prevent the entrance and influence of bacteria on the body.
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Affiliation(s)
- Majid Faridgohar
- a Molecular Biology Research Center , Baqiyatallah University of Medical Sciences , Tehran , Iran
| | - Hassan Nikoueinejad
- b Nephrology and Urology Research Center , Baqiyatallah University of Medical Sciences , Tehran , Iran
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Källenius G, Correia-Neves M, Buteme H, Hamasur B, Svenson SB. Lipoarabinomannan, and its related glycolipids, induce divergent and opposing immune responses to Mycobacterium tuberculosis depending on structural diversity and experimental variations. Tuberculosis (Edinb) 2015; 96:120-30. [PMID: 26586646 DOI: 10.1016/j.tube.2015.09.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/16/2015] [Indexed: 01/04/2023]
Abstract
Exposure to Mycobacterium tuberculosis (Mtb) may lead to active or latent tuberculosis, or clearance of Mtb, depending essentially on the quality of the host's immune response. This response is initiated through the interaction of Mtb cell wall surface components, mostly glycolipids, with cells of the innate immune system, particularly macrophages (Mφs) and dendritic cells (DCs). The way Mφs and DC alter their cytokine secretome, activate or inhibit different microbicidal mechanisms and present antigens and consequently trigger the T cell-mediated immune response impacts the host immune response against Mtb. Lipoarabinomannan (LAM) is one of the major cell wall components of Mtb. Mannosyl-capped LAM (ManLAM), and its related cell wall-associated types of glycolipids/lipoglycans, namely phosphatidylinositol mannosides (PIMs) and lipomannan (LM), exhibit important and distinct immunomodulatory properties. The structure, internal heterogeneity and abundance of these molecules vary between Mtb strains exhibiting distinct degrees of virulence. Thus ManLAM, LM and PIMs may be considered crucial Mtb-associated virulence factors in the pathogenesis of tuberculosis. Of particular relevance for this review, there is controversy about the specific immunomodulatory properties of these distinct glycolipids, particularly when tested as purified molecules in vitro. In addition to the variability in the glycolipid composition conflicting reports may also result from differences in the protocols used for glycolipid isolation and for in vitro experiments including immune cell types and procedures to generate them. Understanding the immunomodulatory properties of these cell wall glycolipids, how they differ between distinct Mtb strains, and how they influence the degree of Mtb virulence, is of utmost relevance to understand how the host mounts a protective or otherwise pathologic immune response. This is essential for the design of preventive strategies against tuberculosis. Thus, since clarifying the controversy on this matter is crucial we here review, summarize and discuss reported data from in vitro stimulation with the three major Mtb complex cell wall glycolipids (ManLAM, PIMs and LM) in an attempt to conciliate the conflicting findings.
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Affiliation(s)
- Gunilla Källenius
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, 118 83 Stockholm, Sweden.
| | - Margarida Correia-Neves
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, 118 83 Stockholm, Sweden; Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal; ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Helen Buteme
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, 118 83 Stockholm, Sweden; Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Beston Hamasur
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, 118 83 Stockholm, Sweden
| | - Stefan B Svenson
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, 118 83 Stockholm, Sweden
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