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Lu J, Dong L, Zhang L, Guo Y, Liu H, Liu Y. Analysis of risk factors for acute kidney injury in children with severe wasp stings. Pediatr Nephrol 2024; 39:1927-1935. [PMID: 38196017 PMCID: PMC11026182 DOI: 10.1007/s00467-023-06265-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in children with sepsis, chronic kidney disease, poisoning or other conditions. Wasp stings are recognized as an important etiology. Several retrospective studies have investigated AKI after wasp stings in adults, but research on children remains limited. METHODS The study included 48 children with multiple organ dysfunction syndrome after wasp stings. Demographic data, clinical manifestations, laboratory findings, management and clinical outcomes were collected, and analyzed to identify early indicators or risk factors for AKI. RESULTS 20 children (41.7%) developed AKI, and 28 (58.3%) did not. Serum creatine levels elevated mostly within 24 h from stings in children with AKI (16/20, 80%). Compared with non-AKI group, AKI group exhibited more cases with cola-colored urine, jaundice, and had higher sting numbers/body surface area (BSA) and higher revised sequential organ failure assessment scores (rSOFA) as well as higher levels of C-reactive protein (CRP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), lactate dehydrogenase (LDH), troponin (cTnI), creatine kinase (CK), and longer prothrombin time (PT). Both univariable and multivariable logistic regression analysis identified cola-colored urine as a potential early risk factor for AKI. CONCLUSIONS The AKI group exhibited higher sting numbers/BSA, higher levels of CRP, ALT, AST, TBIL, LDH, cTnI, and CK, as well as longer PT (p < 0.05). Our findings also suggest that cola-colored urine may serve as an early indicator or potential risk factor for AKI after wasp stings in children, which is very easy to identify for first aiders or pediatricians.
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Affiliation(s)
- Jing Lu
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Liqun Dong
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Lijuan Zhang
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yannan Guo
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hanmin Liu
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.
- NHC Key Laboratory of Chronobiology, (Sichuan University), Chengdu, China.
- The Joint Laboratory for Lung Development and Related Diseases of West China Second University HospitalSichuan University and School of Life Sciences of Fudan University, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.
- Sichuan Birth Defects Clinical Research Center, West China Second University Hospital, Sichuan University, Chengdu, China.
| | - Yang Liu
- Department of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.
- NHC Key Laboratory of Chronobiology, (Sichuan University), Chengdu, China.
- The Joint Laboratory for Lung Development and Related Diseases of West China Second University HospitalSichuan University and School of Life Sciences of Fudan University, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.
- Sichuan Birth Defects Clinical Research Center, West China Second University Hospital, Sichuan University, Chengdu, China.
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Lv Y, Lu L, Yu F, Gao Z, Yuan H, Hu F. STING deficiency protects against wasp venom-induced acute kidney injury. Inflamm Res 2023:10.1007/s00011-023-01749-5. [PMID: 37326694 DOI: 10.1007/s00011-023-01749-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/14/2023] [Accepted: 05/21/2023] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVE Recent evidence suggests a key role of the inflammatory responses in wasp venom-induced acute kidney injury (AKI). However, the potential regulatory mechanisms underlying the inflammatory responses in wasp venom-induced AKI remain unclear. STING reportedly plays a critical role in other AKI types and is associated with inflammatory responses and diseases. We aimed to investigate the involvement of STING in inflammatory responses associated with wasp venom-induced AKI. METHODS The role of the STING signaling pathway in wasp venom-induced AKI was studied in vivo using a mouse model of wasp venom-induced AKI with STING knockout or pharmacological inhibition and in vitro using human HK2 cells with STING knockdown. RESULTS STING deficiency or pharmacological inhibition markedly ameliorated renal dysfunction, inflammatory responses, necroptosis, and apoptosis in wasp venom-induced AKI in mice. Moreover, STING knockdown in cultured HK2 cells attenuated the inflammatory response, necroptosis, and apoptosis induced by myoglobin, the major pathogenic factor in wasp venom-induced AKI. Urinary mitochondrial DNA upregulation has also been observed in patients with wasp venom-induced AKI. CONCLUSIONS STING activation mediates the inflammatory response in wasp venom-induced AKI. This may offer a potential therapeutic target for the management of wasp venom-induced AKI.
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Affiliation(s)
- Ying Lv
- School of Medicine, Wuhan University of Science and Technology, Wuhan, 430065, China
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, China
| | - Li Lu
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, China
| | - Fanglin Yu
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, China
| | - Zhao Gao
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, China
| | - Hai Yuan
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, China.
| | - Fengqi Hu
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, China.
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Lai D, Tian Y, Ji CF, Zang Y, Fu YS, Weng CF. Wasp-stung rat model translationally expresses the coagulopathy manifestations of human wasp patients. Hum Exp Toxicol 2023; 42:9603271221149013. [PMID: 36623279 DOI: 10.1177/09603271221149013] [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: 01/10/2023]
Abstract
Two over 80 wasp stings male victims appeared severe abnormal coagulation were consecutively examined by thromboelastography (TEG) guided with heparinase during hospitalization. However, the cause of coagulopathy remains unsolved. Rats were applied to establish a wasp-stung animal model highly resembled the manifestations of wasp-stung patients. According body surface area conversion, Sprague-Dawley rats were stung based on wasp sting numbers (0, 4, 8, 12 stings; n = 6 each) with various exposure times (0, 1, 3, 6 h) to determine the simulation of coagulopathy. The blood R, K values, and angle degree of wasp-stung rats were measured by TEG. The TEG profiles of stung rats were found to be concomitant with that of wasp-stung patients. Data showed that the endogenous heparinization of rats was time-dependent. Compared to the TEG profile of eight stings given rat, the coagulation time of 2 mm clot formation at 3 h (R value) was longer than that at 0 h. The coagulation time was prolonged with increasing sting numbers when compared to the various stings at 1, 3, and 6 h exposed. Interestingly, there was observed the peak coagulation at 3 h of eight stings. The Ck-standard and Ck-heparinase at 3 h after 8 stings given were R: 9.6-4.4 min; K: 3.8-1.8 min; angle degree: 49.8-68.0, respectively. The original data of R, K values and angle degree in two wasp-stung victims were 11.7-13.6 min, 4.3-5.5 min, and 41.2-32.8° in CK-standard, respectively; whereas those of the CK-heparinase groups were 5.6-6.7 min, 2.4-2.5 min, and 59.5-58.8°, correspondingly. Conclusively, this massive wasp-stung animal model can be applied to the investigations of pathogenesis and provides a clinical strategy or guideline for clinical intervention.
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Affiliation(s)
- Dong Lai
- Medical Research Center, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China.,Intensive Care Unit, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Yan Tian
- Medical Research Center, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China.,Intensive Care Unit, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Chang-Fu Ji
- Medical Research Center, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China.,Intensive Care Unit, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Yuan Zang
- Medical Research Center, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China.,Intensive Care Unit, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Yaw-Syan Fu
- Medical Research Center, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China.,Department of Physiology, School of Basic Medical Science, 519884Xiamen Medical College, Xiamen, China
| | - Ching-Feng Weng
- Medical Research Center, 519884The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China.,Department of Physiology, School of Basic Medical Science, 519884Xiamen Medical College, Xiamen, China
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Han J, Cui L, Yu F, Wang R, Yuan H, Hu F. Megalin blockade with cilastatin ameliorates multiple wasp sting-induced acute kidney injury in rats. Toxicon 2022; 220:106960. [DOI: 10.1016/j.toxicon.2022.106960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/17/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
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Cai ZY, Xu BP, Zhang WH, Peng HW, Xu Q, Yu HB, Chu QG, Zhou SS. Acute respiratory distress syndrome following multiple wasp stings treated with extracorporeal membrane oxygenation: A case report. World J Clin Cases 2022; 10:11122-11127. [PMID: 36338203 PMCID: PMC9631122 DOI: 10.12998/wjcc.v10.i30.11122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/07/2022] [Accepted: 09/16/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND It is necessary for clinicians to be aware of a rare but possible acute respiratory distress syndrome (ARDS) complication caused by multiple wasp stings. Severe ARDS has a high mortality rate but no specific pharmacotherapies have been identified to date. This case study presents the first case of severe ARDS caused by multiple wasp stings, treated successfully with extracorporeal membrane oxygenation (ECMO). It also emphasizes the effectiveness of early ECMO treatment for severe ARDS with persistent hypoxemia.
CASE SUMMARY A 24-year-old woman was admitted to the emergency department after being stung by more than 10 wasps within a 30-min period, with clinical symptoms of multiple rashes, dizziness, chest tightness, nausea, and vomiting. On the 2nd day of admission, the patient developed progressive dyspnea. The patient was diagnosed with ARDS based on clinical manifestations and lung computed tomography (CT) scan. Because of the progressive dyspnea, the intensive care unit physician performed endotracheal intubation and continued to provide ventilator support, but the patient’s respiratory distress worsened, as indicated by the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen. Veno-venous ECMO was initiated for 6 d. On day 7 of admission, ECMO was stopped. On the 11th day of admission, CT scan of the lungs revealed significant reduction of ground-glass opacities and consolidations. After about 2 wk, the patient recovered completely from ARDS and was discharged to home. At the 2-mo follow-up, the patient was in good health with no recurrence of dyspnea nor chest tightness.
CONCLUSION ARDS complication caused by multiple wasp stings may be fatal when mechanical ventilation becomes dangerous due to persistent hypoxemia and despite optimization of ARDS management. We propose that the early implementation of ECMO is a relatively effective treatment, although the evidence is relatively limited.
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Affiliation(s)
- Zheng-Yin Cai
- Department of Critical Care Medicine, Traditional Chinese Hospital of Lu'an Affiliated to Anhui University of Traditional Chinese Medicine, Lu'an 237000, Anhui Province, China
| | - Bao-Ping Xu
- Department of Critical Care Medicine, Traditional Chinese Hospital of Lu'an Affiliated to Anhui University of Traditional Chinese Medicine, Lu'an 237000, Anhui Province, China
| | - Wei-Hao Zhang
- Department of Critical Care Medicine, Traditional Chinese Hospital of Lu'an Affiliated to Anhui University of Traditional Chinese Medicine, Lu'an 237000, Anhui Province, China
| | - Huai-Wen Peng
- Department of Critical Care Medicine, Traditional Chinese Hospital of Lu'an Affiliated to Anhui University of Traditional Chinese Medicine, Lu'an 237000, Anhui Province, China
| | - Qing Xu
- Department of Critical Care Medicine, Traditional Chinese Hospital of Lu'an Affiliated to Anhui University of Traditional Chinese Medicine, Lu'an 237000, Anhui Province, China
| | - Huai-Bin Yu
- Department of Critical Care Medicine, Traditional Chinese Hospital of Lu'an Affiliated to Anhui University of Traditional Chinese Medicine, Lu'an 237000, Anhui Province, China
| | - Quan-Gen Chu
- Department of Chinese Medicine, Anhui University of Traditional Chinese Medicine, Hefei 230031, Anhui Province, China
| | - Shu-Sheng Zhou
- Department of Intensive Care Unit, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230001, Anhui Province, China
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A rat model of acute kidney injury caused by multiple subcutaneous injections of Asian giant hornet (Vespa mandarina Smith) venom. Toxicon 2022; 213:23-26. [DOI: 10.1016/j.toxicon.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/12/2022] [Accepted: 04/11/2022] [Indexed: 12/20/2022]
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Wang J, Xu G, Jin H, Chai Y, Yang X, Liu Z, Hou S, Fan H. Ulinastatin Alleviates Rhabdomyolysis-Induced Acute Kidney Injury by Suppressing Inflammation and Apoptosis via Inhibiting TLR4/NF-κB Signaling Pathway. Inflammation 2022; 45:2052-2065. [PMID: 35668155 DOI: 10.1007/s10753-022-01675-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/02/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022]
Abstract
Acute kidney injury (AKI) is an important complication of rhabdomyolysis (RM), but there is lack of effective treatments. Ulinastatin (UTI) is a broad-spectrum serine protease inhibitor isolated and purified from human urine with strong anti-inflammatory and cytoprotective actions. The aim of this research was to investigate the effect and potential mechanism of UTI on RM-induced AKI (RM-AKI). We established RM-induced AKI model and myoglobin (Mb)-stimulated NRK-52E cell model. In vivo, twenty-four rats were randomly divided into three groups (n = 8): control, RM-AKI, and RM-AKI + UTI. In vitro, the NRK-52E cells were divided into six groups according to the different treatment method. Mb-stimulated NRK-52E cells were treated with UTI or si-TLR4 transfection to characterize the mechanisms of UTI in RM-AKI. Indicators of the kidney injury, cell viability, cell cycle, oxidative stress, inflammation, apoptosis, and TLR4/NF-κB signaling pathway were assessed. In vivo and in vitro, UTI significantly decreased the expression of TLR4 and p65. In vivo, UTI significantly improved renal function and reduced inflammatory reaction and kidney injury. In vitro, UTI protected NRK-52E cells from Mb stimulation by suppressing cell cytotoxicity, cell cycle inhibition, overproduction of ROS, inflammation, and apoptosis. Additionally, UTI played a protective role by downregulating the TLR4 expression. The results indicate that UTI alleviates RM-AKI by suppressing the inflammatory response and apoptosis via inhibiting TLR4/NF-κB signaling pathway. Our study provides a new mechanism for the protective effect of UTI on RM-AKI.
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Affiliation(s)
- Jinxiang Wang
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, Zhejiang, 325000, China.
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, China.
| | - Guowu Xu
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, Zhejiang, 325000, China
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Heng Jin
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, Zhejiang, 325000, China
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Yanfen Chai
- Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Xinyue Yang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, 300072, China
| | - Ziquan Liu
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, Zhejiang, 325000, China
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, 300072, China
| | - Shike Hou
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, Zhejiang, 325000, China
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, 300072, China
| | - Haojun Fan
- Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou, Zhejiang, 325000, China.
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, 300072, China.
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Kaisbain N, Rajappan M, Lim WJ, Chang CY. Acute Liver Injury, Rhabdomyolysis, and Acute Kidney Injury Following Mass Envenomation by Wasps in Malaysia. Cureus 2022; 14:e24369. [PMID: 35611044 PMCID: PMC9124431 DOI: 10.7759/cureus.24369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/16/2022] Open
Abstract
A wasp sting is not uncommon in rural areas, especially in developing countries. While severe allergic reactions to wasp sting are well known, many are unaware of its dangerous systemic toxic reactions. In addition, these systemic toxic reactions occur more gradually as compared to anaphylaxis reactions, which occur rapidly. These deadly systemic reactions can be deceiving, as the local reactions may seem benign and harmless. In an untrained eye with a low index of suspicion, these systemic toxic reactions may be missed without repeated laboratory evaluations and may prove fatal without the timely institution of supportive treatments.
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Yuan H, Gao Z, Chen G, Peng C, Sun Y, Jiang B, Zhou H, Cheng Y, Hu F, Zhang Q. An integrative proteomics metabolomics based strategy reveals the mechanisms involved in wasp sting induced acute kidney injury. Toxicon 2021; 205:1-10. [PMID: 34773816 DOI: 10.1016/j.toxicon.2021.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 01/06/2023]
Abstract
The pathophysiological mechanisms involved in wasp-sting-induced acute kidney injury (AKI) remain largely unknown. Here, we combined proteomics and metabolomics to investigate the mechanisms behind multiple wasp sting-induced AKI. Interestingly, we found many differentially abundant proteins in the serum of AKI group compared with that of the non-AKI and control groups, involved in several metabolic pathways and the regulation of cellular processes. In addition, we also detected differentially abundant metabolites in the AKI group; among them many were involved in the glycerophospholipid metabolic pathway (the key pathway in the context of AKI): 50 metabolites, all downregulated in the AKI group. Importantly, the convergent analysis of metabolomics and proteomics data revealed that biomarkers of rhabdomyolysis (CA 3, MYL3, and LDH) and hemolysis (ALT and LDH) were integrated into a regulatory network with phospholipid metabolism products in the AKI group, indicating that wasp sting-induced AKI is secondary to rhabdomyolysis and intravascular hemolysis. Of note, such a phenotype suggests the disruption of the membrane of skeletal muscle cells and red blood cells mediated by the phospholipase A1 (PLA1), PLA2, and mastoparan in the wasp venom, via the disruption of membrane glycerophospholipids. Overall, our results highlight a potential new mechanism behind wasp sting-induced AKI and suggest that PLA inhibitors may be potential agents for the treatment of this condition.
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Affiliation(s)
- Hai Yuan
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, Hubei, China.
| | - Zhao Gao
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, Hubei, China.
| | - Guang Chen
- Department of Clinical Laboratory, People's Hospital of Weifang, Weifang, 261000, Shandong, China.
| | - Changkun Peng
- Department of Nephrology, People's Hospital of Baokang, Xiangyang, 441000, Hubei, China.
| | - Yujun Sun
- Department of Nephrology, Nanzhang Hospital of Traditional Chinese Medicine, Xiangyang, 441000, Hubei, China.
| | - Binbin Jiang
- Department of Nephrology, Baokang Hospital of Traditional Chinese Medicine, Xiangyang, 441000, Hubei, China.
| | - Hongyu Zhou
- Department of Nephrology, People's Hospital of Gucheng, Xiangyang, 441000, Hubei, China.
| | - Yong Cheng
- Department of Nephrology, People's Hospital of Nanzhang, Xiangyang, 441000, Hubei, China.
| | - Fengqi Hu
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, Hubei, China.
| | - Qi Zhang
- Department of Oncology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, Hubei, China.
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