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Mahajan D, Kumar T, Rath PK, Sahoo AK, Mishra BP, Kumar S, Nayak NR, Jena MK. Dendritic Cells and the Establishment of Fetomaternal Tolerance for Successful Human Pregnancy. Arch Immunol Ther Exp (Warsz) 2024; 72:aite-2024-0010. [PMID: 38782369 DOI: 10.2478/aite-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/26/2024] [Indexed: 05/25/2024]
Abstract
Pregnancy is a remarkable event where the semi-allogeneic fetus develops in the mother's uterus, despite genetic and immunological differences. The antigen handling and processing at the maternal-fetal interface during pregnancy appear to be crucial for the adaptation of the maternal immune system and for tolerance to the developing fetus and placenta. Maternal antigen-presenting cells (APCs), such as macrophages (Mφs) and dendritic cells (DCs), are present at the maternal-fetal interface throughout pregnancy and are believed to play a crucial role in this process. Despite numerous studies focusing on the significance of Mφs, there is limited knowledge regarding the contribution of DCs in fetomaternal tolerance during pregnancy, making it a relatively new and growing field of research. This review focuses on how the behavior of DCs at the maternal-fetal interface adapts to pregnancy's unique demands. Moreover, it discusses how DCs interact with other cells in the decidual leukocyte network to regulate uterine and placental homeostasis and the local maternal immune responses to the fetus. The review particularly examines the different cell lineages of DCs with specific surface markers, which have not been critically reviewed in previous publications. Additionally, it emphasizes the impact that even minor disruptions in DC functions can have on pregnancy-related complications and proposes further research into the potential therapeutic benefits of targeting DCs to manage these complications.
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Affiliation(s)
- Deviyani Mahajan
- Department of Biotechnology, School of Bioengineering and Biosciences, Lovely Professional University, Phagwara, Punjab 144411, India
| | - Tarun Kumar
- Department of Veterinary Clinical Complex, Lala Lajpat Rai University of Veterinary and Animal Sciences, Hisar, Haryana 125001, India
| | - Prasana Kumar Rath
- Department of Veterinary Pathology, College of Veterinary Science and AH, Odisha University of Agriculture and Technology, Bhubaneswar, Odisha 751003, India
| | - Anjan Kumar Sahoo
- Department of Veterinary Pathology, College of Veterinary Science and AH, Odisha University of Agriculture and Technology, Bhubaneswar, Odisha 751003, India
- Department of Veterinary Surgery and Radiology, College of Veterinary Science and AH, Odisha University of Agriculture and Technology, Bhubaneswar, Odisha 751003, India
| | - Bidyut Prava Mishra
- Department of Veterinary Pathology, College of Veterinary Science and AH, Odisha University of Agriculture and Technology, Bhubaneswar, Odisha 751003, India
- Department of Livestock Products Technology, College of Veterinary Science and AH, Odisha University of Agriculture and Technology, Bhubaneswar, Odisha 751003, India
| | - Sudarshan Kumar
- Proteomics and Structural Biology Laboratory, Animal Biotechnology Centre, National Dairy Research Institute, Karnal, Haryana 132001, India
| | - Nihar Ranjan Nayak
- Department of Obstetrics and Gynecology, UMKC School of Medicine, Kansas City, MO 64108, USA
| | - Manoj Kumar Jena
- Department of Biotechnology, School of Bioengineering and Biosciences, Lovely Professional University, Phagwara, Punjab 144411, India
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Jarquín-Yáñez K, Herrera-Enriquez MÁ, Lemini C, Melendez-Moreno E, Villena-López P, Ávila ME, Hernández-Téllez B, Piñón-Zárate G, Sampedro-Carrillo EA, Castell-Rodríguez AE. Epicutaneous Administration of 17β-Estradiol Induces Langerhans Cells Depletion. Immunol Invest 2021; 51:1561-1581. [PMID: 34569394 DOI: 10.1080/08820139.2021.1975738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Langerhans cells (LC) number and function in mouse vaginal mucosa are affected by 17β-estradiol (E2) application; nonetheless, its effect on epidermal LC has not been studied. The purpose of this study was to evaluate the effect of topical administration of E2 on the number, phenotype, and migratory ability of LC in mouse skin. METHODS Ears of adult CD1 male mice were topically treated once with several doses. Immunohistochemical staining for CD207 and TUNEL staining were performed. LC migration to lymph nodes and the effect on the expression of costimulatory molecules on cultured dendritic cells (DC) were also evaluated. RESULTS E2 decreased the number of CD207+ LC in a dose-dependent manner. One hour after treatment, 1 and 10 µg/mL E2 significantly reduced the LC number by 21% and 26%, respectively, after two hours, the reduction was 23% and 41%, respectively. After 48 hours, LC recovered, and after 96 hours of treatment, the CD207+/MHCII+ DC numbers were increased in regional lymph nodes. However, CD86 and CD40 molecules were expressed at lower levels than in positive control. The TUNEL assay did not show apoptotic cells. Furthermore, in cultured DC, E2 promoted a decrease in CD40 and CD86 expression and an increase in CD273, CD274, MHCII, and CCR7. CONCLUSIONS The topical administration of E2 induced a transitory local diminution of LC population and a tolerogenic phenotype. This decrease in epidermal LC suggests that E2 may affect skin immune responses, inducing an inhibitory response, which should be considered when prescribing topical E2 medications.
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Affiliation(s)
- Katia Jarquín-Yáñez
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
| | | | - Cristina Lemini
- Pharmacology, Medicine School, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Edith Melendez-Moreno
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Paulina Villena-López
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Maria Estela Ávila
- Pharmacology, Medicine School, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Beatriz Hernández-Téllez
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Gabriela Piñón-Zárate
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
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Peralta MB, Cainelli S, Stassi AF, Angeli E, Renna MS, Signorini ML, Gareis NC, Durante L, Rey F, Ortega HH, Salvetti NR, Velázquez MML. Association between phagocytic activity of monocytes and days to conception after parturition in dairy cows when considering the hormonal and metabolic milieu. Anim Reprod Sci 2021; 232:106818. [PMID: 34343817 DOI: 10.1016/j.anireprosci.2021.106818] [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] [Received: 11/18/2020] [Revised: 07/22/2021] [Accepted: 07/24/2021] [Indexed: 02/04/2023]
Abstract
The nutritional conditions and immune status of dairy cows affect reproductive performance. This study was conducted with the aim to analyze the phagocytic activity (PA) and phagocytic capacity (PC) of circulating monocytes after the period of transition from pregnancy to lactation, to evaluate possible associations with duration of time period to conception following parturition. Results indicated PA was not associated with duration of time period to conception following parturition. In contrast, cows with a lesser PC conceived earlier (98 ± 9 days in milk, DIM) than those with a greater PC (168 ± 15 DIM). Based on these results, to analyze the association of the hormonal and metabolic milieu with the PA and PC, the animals were grouped considering the days to conception following parturition. In the group with the greater number of days to conception (>168 DIM), the PA was associated with concentrations of progesterone and beta-hydroxybutyrate (BHB) at 90 DIM and glucose at 120 DIM, whereas PC was associated with the concentrations of progesterone, cortisol and glucose at 90 DIM, non-esterified fatty acids (NEFA) at 120 DIM, 17β-estradiol at 150 DIM, and 17β-estradiol and BHB at 180 DIM. Overall, these results represent a new perspective related to the reproductive performance of dairy cows. The modifications of cellular functions may be useful for predicting the onset of health complications in dairy cows and to manage cows in ways that result in an enhanced fertility during the subsequent lactational period.
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Affiliation(s)
- M B Peralta
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina
| | - S Cainelli
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina
| | - A F Stassi
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina
| | - E Angeli
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina
| | - M S Renna
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina
| | - M L Signorini
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Instituto Nacional de Tecnología Agropecuaria EEA Rafaela, Ruta 34 Km 227, Rafaela, Santa Fe, Argentina
| | - N C Gareis
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina
| | - L Durante
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina
| | - F Rey
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina
| | - H H Ortega
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina
| | - N R Salvetti
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina
| | - M M L Velázquez
- Laboratorio de Biología Celular y Molecular Aplicada, Instituto de Ciencias Veterinarias del Litoral (ICiVet-Litoral), Universidad Nacional del Litoral (UNL)/Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Esperanza, Santa Fe, Argentina; Facultad de Ciencias Veterinarias del Litoral, Universidad Nacional del Litoral (UNL), Esperanza, Santa Fe, Argentina.
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Souza CLSE, Barbosa CD, Coelho HILN, Santos Júnior MN, Barbosa EN, Queiroz ÉC, Teles MF, Dos Santos DC, Bittencourt RS, Soares TDJ, Oliveira MV, Timenetsky J, Campos GB, Marques LM. Effects of 17β-Estradiol on Monocyte/Macrophage Response to Staphylococcus aureus: An In Vitro Study. Front Cell Infect Microbiol 2021; 11:701391. [PMID: 34336722 PMCID: PMC8317603 DOI: 10.3389/fcimb.2021.701391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/29/2021] [Indexed: 01/23/2023] Open
Abstract
To describe how 17β-estradiol (E2) influence in the monocyte/macrophage response induced by S. aureus in in vitro models of murine peritoneal macrophages (MPMs) and human peripheral blood monocytes (HPBM). MPMs (2 x 105/ml) were isolated from sham (n=3) and ovariectomized (OVX) females (n = 3) and males (n = 3) after induction by thioglycolate. The MPMs obtained from OVX females and males were treated for 24 hours with 17β-estradiol (E2) (10-7 M), and after that, inoculation with S. aureus was carried out for 6 hours. The macrophages were collected and destined to evaluate the relative gene expression of TNF-α, IL-1β, IL-6, IL-8 and TLR2. For the in vitro model of HPBMs, six men and six women of childbearing age were selected and HPBMs were isolated from samples of the volunteers’ peripheral blood. In women, blood was collected both during menstruation and in the periovulatory period. HPBMs were inoculated with S. aureus for 6 hours and the supernatant was collected for analysis of cytokines by Luminex and the HPBMs were removed for analysis of 84 genes involved in the host’s response to bacterial infections by RT-PCR array. Previous treatment with E2 decreased the gene expression and production of proinflammatory cytokines, such as TNF-α, IL-1β and IL-6 and decreased the expression of TLR2 tanto em MPMs quanto em HPBMs. The analysis of gene expression shows that E2 inhibited the NFκB pathway. It is suggested that 17β-estradiol acts as an immunoprotective in the monocyte/macrophage response induced by S. aureus.
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Affiliation(s)
- Clarissa Leal Silva E Souza
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil.,Santo Agostinho School of Health (FASA), Santo Agostinho Colleges, Afya Educational, Vitória da Conquista, Brazil
| | - Camila Dutra Barbosa
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil
| | - Hanna I L N Coelho
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil
| | - Manoel N Santos Júnior
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil.,University of Santa Cruz (UESC), Ilhéus, Brazil
| | - Elaine Novaes Barbosa
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil
| | - Éllunny Chaves Queiroz
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil
| | - Mauro Fernandes Teles
- Santo Agostinho School of Health (FASA), Santo Agostinho Colleges, Afya Educational, Vitória da Conquista, Brazil
| | - Déborah Cruz Dos Santos
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil
| | - Rafaela Souza Bittencourt
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil
| | - Telma de Jesus Soares
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil
| | | | - Jorge Timenetsky
- Department of Microbiology, Institute of Biomedical Science, University of São Paulo, São Paulo, Brazil
| | - Guilherme Barreto Campos
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil
| | - Lucas Miranda Marques
- Multidisciplinary Institute of Health, Federal University of Bahia (UFBA), Vitória da Conquista, Brazil.,University of Santa Cruz (UESC), Ilhéus, Brazil.,Department of Microbiology, Institute of Biomedical Science, University of São Paulo, São Paulo, Brazil
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5
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Li Y, Cao L, Qian Z, Guo Q, Niu X, Huang L. Mifepristone regulates Tregs function mediated by dendritic cells through suppressing the expression of TGF-β. Immunopharmacol Immunotoxicol 2021; 43:85-93. [PMID: 33406939 DOI: 10.1080/08923973.2020.1867998] [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: 12/15/2022]
Abstract
BACKGROUND Previous studies have demonstrated that mifepristone in the daily low-dose affects the function of endometrium. These researches also implied an alteration of endometrium immune balance, which might be involved in regulating endometrial function. However, the detailed mechanisms remain to be further explored. METHODS In this study, the expressions of CD80, CD86, and ICAM-1 in dendritic cells (DCs), which were stimulated with different concentrations of mifepristone (20, 65, and 200 nM), were detected by FACS. After that, we further evaluated the expression of Forkhead box P3 (FOXP3) and IL-10 in Tregs, which co-cultured with mifepristone treated DCs. In mechanism, we compared the indoleamine 2,3-dioxygenase (IDO) and TGF-β expression with enzyme-linked immunosorbent assay (ELISA). RESULTS The results indicated that mifepristone promoted the expressions of CD80, CD86, and ICAM-1 in a dosage dependent manner. Reversely, FOXP3 and IL-10 expression levels in Tregs co-cultured with mifepristone-treated DCs were significantly decreased compared with those co-cultured with nontreated DC. Furthermore, a significant reduce in IDO and TGF-β expression was observed in DCs treated with mifepristone. By using the IDO inhibitor (1-methyl tryptophan, 1-MT) or TGF-b supplement, we confirmed that TGF-β, but not IDO could rescue the downregulation of FOXP3 and IL-10 in Tregs co-cultured with mifepristone treated DCs. All of these results suggest that mifepristone may regulate DC function by decreasing TGF-β expression, which further results in the downregulations of FOXP3 and IL-10 in Tregs. CONCLUSION Therefore, our research provides a theoretical basis for a potentially clinical application of mifepristone as a novel contraceptive.
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Affiliation(s)
- Yinghua Li
- Hangzhou Women's Hospital, Hangzhou, China.,Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lili Cao
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhida Qian
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qingyun Guo
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaocen Niu
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lili Huang
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Wei R, Lai N, Zhao L, Zhang Z, Zhu X, Guo Q, Chu C, Fu X, Li X. Dendritic cells in pregnancy and pregnancy-associated diseases. Biomed Pharmacother 2020; 133:110921. [PMID: 33378991 DOI: 10.1016/j.biopha.2020.110921] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 12/20/2022] Open
Abstract
Dendritic cells (DCs) play a critical immuno-modulating role in pregnancy, which requires the maternal immune system to tolerate semiallogeneic fetus and at the same time to maintain adequate defense against pathogens. DCs interact closely with other immune components such as T cells, natural killer cells and macrophages, as well as the endocrine system to keep a pregnancy-friendly environment. Aberrant DC activities have been related to various pregnancy-associated diseases such as recurrent spontaneous abortion, preterm birth, pre-eclampsia, peripartum cardiomyopathy and infectious pregnancy complications. These findings make DCs an attractive candidate for prevention or therapy on the pregnancy-associated diseases. Here, we review recent findings that provide new insights into the roles of DCs in pregnancy and the related diseases. We also discuss the medical potentials to manipulate DCs in clinics. Whereas this is an emerging area with much work remaining, we anticipate that a better understanding of the role of DCs in maternal-fetal immunotolerance and a therapeutic manipulation of DCs will help women suffering from the pregnancy-associated diseases.
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Affiliation(s)
- Ran Wei
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Nannan Lai
- Scientific Research Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, PR China
| | - Lin Zhao
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Zhen Zhang
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Xiaoxiao Zhu
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Qiang Guo
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Chu Chu
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Xiaoxiao Fu
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Xia Li
- Laboratory for Molecular Immunology, Institute of Basic Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China.
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