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Ruiz-Vargas A, Ivorra A, Arkwright JW. Design, Construction and Validation of an Electrical Impedance Probe with Contact Force and Temperature Sensors Suitable for in-vivo Measurements. Sci Rep 2018; 8:14818. [PMID: 30287842 PMCID: PMC6172255 DOI: 10.1038/s41598-018-33221-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 09/19/2018] [Indexed: 12/31/2022] Open
Abstract
Bioimpedance spectroscopy measurements can be used for tissue characterization. These measurements can be performed in soft tissues by direct contact of a non-invasive probe consisting of two or four electrodes. The amount of force applied by users can be quite different, and the measurements can vary as a result. To compensate for this, we have built an electrical impedance probe (diameter 3.2 mm) with fibre optic contact-force and temperature sensors built in it. The different sensors of the probe were tested individually. The errors in magnitude and phase angle of the probe are <0.9% and <4°, respectively, for a 0.9% NaCl solution. The linear dynamic range of the force sensor was from 0 to 100 grams. An ex-vivo experiment on a section of proximal colon from a guinea-pig was performed. Twenty bioimpedance measurements were taken in a frequency range of 5 kHz to 1 MHz, while simultaneously recording the force applied. For an increase in contact pressure applied to tissue from 0 to 15.4 kPa, the maximum change in resistivity was 33% at 5 kHz and the minimum was 6.6% at 142 kHz. The probe is small enough to be introduced via the instrument port of an endoscope.
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Affiliation(s)
- Albert Ruiz-Vargas
- The Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide, Australia.
| | - Antoni Ivorra
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
- Serra Húnter Programme, Universitat Pompeu Fabra, Barcelona, Spain
| | - John William Arkwright
- The Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide, Australia
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Matsumura T, Arai M, Ishigami H, Fujie M, Ishikawa K, Akizue N, Taida T, Ohta Y, Hamanaka S, Okimoto K, Saito K, Maruoka D, Nakagawa T, Kato N. Evaluation of Esophageal Mucosal Integrity in Patients with Gastroesophageal Reflux Disease. Digestion 2018; 97:31-37. [PMID: 29393167 DOI: 10.1159/000484106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Impaired esophageal mucosal integrity plays a role in causing symptoms of gastroesophageal reflux disease (GERD). Recently, the assessment of esophageal baseline impedance (BI) using the multichannel intraluminal impedance-pH (MII-pH) test was suggested as a surrogate technique for the study of esophageal mucosal integrity and was reported to be useful in distinguishing GERD from non-GERD. However, measuring BI requires a 24-h testing period, is complicated, and causes considerable patient discomfort. SUMMARY Recently, endoscopy-guided catheters that can measure mucosal impedance (MI) and mucosal admittance (MA), which is the inverse of impedance, were developed, and their usefulness in measuring MI and MA for the diagnosis of GERD has been reported. In these studies, esophageal MI values were significantly lower in patients with GERD than in those without GERD. In contrast, esophageal MA was significantly higher in patients with GERD than in those without. Furthermore, we reported that MA is inversely correlated with BI and correlated with acid exposure time. Key Messages: Endoscopy-guided real-time measurement of MI and MA may allow the estimation of mucosal integrity and may be a useful diagnostic tool for patients with GERD in a manner similar to 24-h MII-pH monitoring.
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Affiliation(s)
- Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Arai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideaki Ishigami
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mai Fujie
- Department of Clinical Engineering Center, Chiba University Hospital, Chiba, Japan
| | - Kentaro Ishikawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shinsaku Hamanaka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keiko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoo Nakagawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Ruiz-Vargas A, Ivorra A, Arkwright JW. Monitoring the Effect of Contact Pressure on Bioimpedance Measurements. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2018:4949-4952. [PMID: 30441453 DOI: 10.1109/embc.2018.8513173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This paper presents preliminary results on the effect of contact pressure on bioimpedance measurements in an excised section of human colon tissue. The impedance measurements were performed with a small diameter probe suitable for in-vivo use, which is capable of measuring contact force. Force measurements are performed by fiber optic sensor which consisted of a Fiber Bragg Grating. The obtained results highlight the importance on limiting the applied pressure during bioimpedance measurements.
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Warners MJ, van Rhijn BD, Verheij J, Smout AJPM, Bredenoord AJ. Disease activity in eosinophilic esophagitis is associated with impaired esophageal barrier integrity. Am J Physiol Gastrointest Liver Physiol 2017; 313:G230-G238. [PMID: 28546282 DOI: 10.1152/ajpgi.00058.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/19/2017] [Accepted: 05/19/2017] [Indexed: 01/31/2023]
Abstract
In eosinophilic esophagitis (EoE), the esophageal barrier integrity is impaired. Integrity can be assessed with different techniques. To assess the correlations between esophageal eosinophilia and various measures of mucosal integrity and to evaluate whether endoscopic impedance measurements can predict disease activity, endoscopies and mucosal integrity measurements were performed in adult EoE patients with active disease (≥15 eosinophils/high-power field) at baseline (n = 32) and after fluticasone (n = 15) and elemental dietary treatment (n = 14) and in controls (n = 19). Mucosal integrity was evaluated during endoscopy using electrical tissue spectroscopy (ETIS) measuring mucosal impedance and transepithelial electrical resistance (TER) and transepithelial molecule-flux through biopsy specimens in Ussing chambers. We included 61 measurements; 32 of patients at baseline and 29 after treatment, 3 patients dropped out. After treatment, 20 patients were in remission (≤15 eosinophils/high-power field) and these measurements were compared with 41 measurements of patients with active disease (at baseline or after failed treatment). All four mucosal integrity measures showed significant impairment in active EoE compared with remission. Eosinophilia was negatively correlated with ETIS and TER and positively with transepithelial molecule flux (P ≤ 0.001). The optimal ETIS cutoff to predict disease activity was 6,000 Ω·m with a sensitivity of 79% [95% confidence interval (CI) 54-94%], specificity of 84% (95% CI 69-94%), positive predictive values of 89% (95% CI 77-95%) and negative predictive values of 71% (95% CI 54-84%). In EoE patients, markers of mucosal integrity correlate with esophageal eosinophilia. Additionally, endoscopic mucosal impedance measurements can predict disease activity.NEW & NOTEWORTHY In adult patients with eosinophilic esophagitis (EoE), the mucosal integrity, measured by making use of four different parameters, correlates strongly with esophageal eosinophilia. The accuracy of endoscopically measured mucosal impedance to distinguish active disease from remission was acceptable with moderate specificity and sensitivity. Mucosal impedance measurements can predict disease activity in adult EoE patients.
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Affiliation(s)
- Marijn J Warners
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands; .,Tytgat Institute for Liver and GI Research, Academic Medical Centre, Amsterdam, The Netherlands
| | - Bram D van Rhijn
- Department of Dermatology and Allergology, University Medical Centre, Utrecht, The Netherlands; and
| | - Joanne Verheij
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Andreas J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
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van Hoeij FB, Weijenborg PW, van den Bergh Weerman MA, van den Wijngaard RMJGJ, Verheij J, Smout AJPM, Bredenoord AJ. Mucosal integrity and sensitivity to acid in the proximal esophagus in patients with gastroesophageal reflux disease. Am J Physiol Gastrointest Liver Physiol 2016; 311:G117-22. [PMID: 27198192 DOI: 10.1152/ajpgi.00134.2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 05/15/2016] [Indexed: 01/31/2023]
Abstract
Acid reflux episodes that extend to the proximal esophagus are more likely to be perceived. This suggests that the proximal esophagus is more sensitive to acid than the distal esophagus, which could be caused by impaired mucosal integrity in the proximal esophagus. Our aim was to explore sensitivity to acid and mucosal integrity in different segments of the esophagus. We used a prospective observational study, including 12 patients with gastroesophageal reflux disease (GERD). After stopping acid secretion-inhibiting medication, two procedures were performed: an acid perfusion test and an upper endoscopy with electrical tissue impedance spectroscopy and esophageal biopsies. Proximal and distal sensitivity to acid and tissue impedance were measured in vivo, and mucosal permeability and epithelial intercellular spaces at different esophageal levels were measured in vitro. Mean lag time to heartburn perception was much shorter after proximal acid perfusion (0.8 min) than after distal acid perfusion (3.9 min) (P = 0.02). Median in vivo tissue impedance was significantly lower in the distal esophagus (4,563 Ω·m) compared with the proximal esophagus (8,170 Ω·m) (P = 0.002). Transepithelial permeability, as measured by the median fluorescein flux was significantly higher in the distal (2,051 nmol·cm(-2)·h(-1)) than in the proximal segment (368 nmol·cm(-2)·h(-1)) (P = 0.033). Intercellular space ratio and maximum heartburn intensity were not significantly different between the proximal and distal esophagus. In GERD patients off acid secretion-inhibiting medication, acid exposure in the proximal segment of the esophagus provokes symptoms earlier than acid exposure in the distal esophagus, whereas mucosal integrity is impaired more in the distal esophagus. These findings indicate that the enhanced sensitivity to proximal reflux episodes is not explained by increased mucosal permeability.
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Affiliation(s)
- Froukje B van Hoeij
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and
| | - Pim W Weijenborg
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and
| | | | - René M J G J van den Wijngaard
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and
| | - J Verheij
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands;
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Kia L, Pandolfino JE, Kahrilas PJ. Biomarkers of Reflux Disease. Clin Gastroenterol Hepatol 2016; 14:790-797. [PMID: 26404867 PMCID: PMC4808459 DOI: 10.1016/j.cgh.2015.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/28/2015] [Accepted: 09/11/2015] [Indexed: 02/06/2023]
Abstract
Gastroesophageal reflux disease (GERD) encompasses an array of disorders unified by the reflux of gastric contents. Because there are many potential disease manifestations, esophageal and extraesophageal, there is no single biomarker of the entire disease spectrum; a set of GERD biomarkers that each quantifies specific aspects of GERD-related pathology might be needed. We review recent reports of biomarkers of GERD, specifically in relation to endoscopically negative esophageal disease and excluding conventional pH-impedance monitoring. We consider histopathologic biomarkers, baseline impedance, and serologic assays to determine that most markers are based on manifestations of impaired esophageal mucosal integrity, which is based on increased ionic and molecular permeability, and/or destruction of tight junctions. Impaired mucosal integrity quantified by baseline mucosal impedance, proteolytic fragments of junctional proteins, or histopathologic features has emerged as a promising GERD biomarker.
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Affiliation(s)
| | | | - Peter J Kahrilas
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
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Weijenborg PW, Smout AJPM, Verseijden C, van Veen HA, Verheij J, de Jonge WJ, Bredenoord AJ. Hypersensitivity to acid is associated with impaired esophageal mucosal integrity in patients with gastroesophageal reflux disease with and without esophagitis. Am J Physiol Gastrointest Liver Physiol 2014; 307:G323-9. [PMID: 24924748 DOI: 10.1152/ajpgi.00345.2013] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Increased esophageal sensitivity and impaired mucosal integrity have both been described in patients with gastroesophageal reflux disease, but the relationship between hypersensitivity and mucosal integrity is unclear. The aim of the present study was to investigate acid sensitivity in patients with erosive and nonerosive reflux disease and control subjects to determine the relation with functional esophageal mucosal integrity changes as well as to investigate cellular mechanisms of impaired mucosal integrity in these patients. In this prospective experimental study, 12 patients with nonerosive reflux disease, 12 patients with esophagitis grade A or B, and 11 healthy control subjects underwent an acid perfusion test and upper endoscopy. Mucosal integrity was measured during endoscopy by electrical tissue impedance spectroscopy and biopsy specimens were analyzed in Ussing chambers for transepithelial electrical resistance, transepithelial permeability and gene expression of tight junction proteins and filaggrin. Patients with nonerosive reflux disease and esophagitis were more sensitive to acid perfusion compared with control subjects, having a shorter time to perception of heartburn and higher perceived intensity of heartburn. In reflux patients, enhanced acid sensitivity was associated with impairment of in vivo and vitro esophageal mucosal integrity. Mucosal integrity was significantly impaired in patients with esophagitis, displaying higher transepithelial permeability and lower extracellular impedance. Although no significant differences in the expression of tight junction proteins were found in biopsies among patient groups, mucosal integrity parameters in reflux patients correlated negatively with the expression of filaggrin. In conclusion, sensitivity to acid is enhanced in patients with gastroesophageal reflux disease, irrespective of the presence of erosions, and is associated with impaired esophageal mucosal integrity. Mucosal integrity of the esophagus is associated with the expression of filaggrin.
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Affiliation(s)
- Pim W Weijenborg
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Caroline Verseijden
- Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Henk A van Veen
- Van Leeuwenhoek Center for Advanced Microscopy, Department of Cell Biology, Academic Medical Center, Amsterdam, The Netherlands; and
| | - Joanne Verheij
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Wouter J de Jonge
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands; Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands;
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Weijenborg PW, Rohof WOA, Akkermans LMA, Verheij J, Smout AJPM, Bredenoord AJ. Electrical tissue impedance spectroscopy: a novel device to measure esophageal mucosal integrity changes during endoscopy. Neurogastroenterol Motil 2013; 25:574-8, e457-8. [PMID: 23607721 DOI: 10.1111/nmo.12106] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 02/02/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with gastroesophageal reflux disease (GERD) have impaired esophageal mucosal integrity. Measurement of the mucosal integrity is complex and time-consuming. Electrical tissue impedance spectroscopy (ETIS) is a device that measures impedance of tissue in vivo during endoscopy. In this study, we aimed to validate ETIS as a measure of esophageal mucosal integrity. METHODS Electrical tissue impedance spectroscopy measurements were performed during upper endoscopy in 12 GERD patients and 11 healthy controls after cessation of proton pump inhibition. During endoscopy biopsies of the distal esophagus were obtained for transmission electron microscopy to determine dilation of intercellular spaces (DIS) and for Ussing chamber experiments to determine transepithelial permeability and transepithelial electrical resistance. KEY RESULTS Extracellular impedance measured in vivo by ETIS was significantly lower in GERD patients compared to controls [mean (SD) 5621 (3299) Ω.m and 8834 (2542) Ω.m, respectively, P < 0.05]. We found a strong inverse relation between extracellular impedance determined by ETIS and DIS (r = -0.76, P < 0.05), and between extracellular resistance in vivo and transepithelial permeability of esophageal biopsies (r = -0.65, P < 0.01). CONCLUSIONS & INFERENCES Electrical tissue impedance spectroscopy is a new tool that can be used to evaluate esophageal mucosal integrity changes during endoscopy.
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Affiliation(s)
- P W Weijenborg
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Zhong C, Duan L, Wang K, Xu Z, Ge Y, Yang C, Han Y. Esophageal intraluminal baseline impedance is associated with severity of acid reflux and epithelial structural abnormalities in patients with gastroesophageal reflux disease. J Gastroenterol 2013; 48:601-10. [PMID: 23076541 PMCID: PMC3654188 DOI: 10.1007/s00535-012-0689-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 09/13/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND The esophageal intraluminal baseline impedance may be used to evaluate the status of mucosa integrity. Esophageal acid exposure decreases the baseline impedance. We aimed to compare baseline impedance in patients with various reflux events and with different acid-related parameters, and investigate the relationships between epithelial histopathologic abnormalities and baseline impedance. METHODS A total of 229 GERD patients and 34 controls underwent 24-h multichannel intraluminal impedance and pH monitoring (MII-pH monitoring), gastroendoscopy, and completed a GERD questionnaire (GerdQ). We quantified epithelial intercellular spaces (ICSs) and expression of tight junction (TJ) proteins by histologic techniques. RESULTS Mean baseline values in reflux esophagitis (RE) (1752 ± 1018 Ω) and non-erosive reflux disease (NERD) (2640 ± 1143 Ω) were significantly lower than in controls (3360 ± 1258 Ω; p < 0.001 and p = 0.001, respectively). Among NERD subgroups, mean baselines in the acid reflux group (2510 ± 1239 Ω) and mixed acid/weakly acidic reflux group (2393 ± 1009 Ω) were much lower than in controls (3360 ± 1258 Ω; p = 0.020 and p < 0.001, respectively). The mean baseline in severe RE patients was significantly lower than in mild RE patients (LA-C/D vs. LA-A/B: 970 ± 505 Ω vs. 1921 ± 1024 Ω, p < 0.001). There was a significant negative correlation between baseline value and acid exposure time (AET) (r = -0.41, p < 0.001), and a weak but significant correlation (r = -0.20, p = 0.007) between baseline value and weakly AET. Negative correlations were observed between ICS and the baseline impedance (r = -0.637, p < 0.001) and claudin-1 and the baseline impedance (r = -0.648, p < 0.001). CONCLUSIONS Patients with dominant acid reflux events and with longer AET have low baseline impedance. Baseline values are correlated with esophageal mucosal histopathologic changes such as dilated ICS and TJ alteration.
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Affiliation(s)
- Chanjuan Zhong
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191 People’s Republic of China
| | - Liping Duan
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191 People’s Republic of China
| | - Kun Wang
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191 People’s Republic of China
| | - Zhijie Xu
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191 People’s Republic of China
| | - Ying Ge
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191 People’s Republic of China
| | - Changqing Yang
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191 People’s Republic of China
| | - Yajing Han
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191 People’s Republic of China
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