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Lobato S, Castillo-Granada AL, Bucio-Pacheco M, Salomón-Soto VM, Álvarez-Valenzuela R, Meza-Inostroza PM, Villegas-Vizcaíno R. PM 2.5, component cause of severe metabolically abnormal obesity: An in silico, observational and analytical study. Heliyon 2024; 10:e28936. [PMID: 38601536 PMCID: PMC11004224 DOI: 10.1016/j.heliyon.2024.e28936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/12/2024] Open
Abstract
Obesity is currently one of the most alarming pathological conditions due to the progressive increase in its prevalence. In the last decade, it has been associated with fine particulate matter suspended in the air (PM2.5). The purpose of this study was to explore the mechanistic interaction of PM2.5 with a high-fat diet (HFD) through the differential regulation of transcriptional signatures, aiming to identify the association of these particles with metabolically abnormal obesity. The research design was observational, using bioinformatic methods and an explanatory approach based on Rothman's causal model. We propose three new transcriptional signatures in murine adipose tissue. The sum of transcriptional differences between the group exposed to an HFD and PM2.5, compared to the control group, were 0.851, 0.265, and -0.047 (p > 0.05). The HFD group increased body mass by 20% with two positive biomarkers of metabolic impact. The group exposed to PM2.5 maintained a similar weight to the control group but exhibited three positive biomarkers. Enriched biological pathways (p < 0.05) included PPAR signaling, small molecule transport, adipogenesis genes, cytokine-cytokine receptor interaction, and HIF-1 signaling. Transcriptional regulation predictions revealed CpG islands and common transcription factors. We propose three new transcriptional signatures: FAT-PM2.5-CEJUS, FAT-PM2.5-UP, and FAT-PM2.5-DN, whose transcriptional regulation profile in adipocytes was statistically similar by dietary intake and HFD and exposure to PM2.5 in mice; suggesting a mechanistic interaction between both factors. However, HFD-exposed murines developed moderate metabolically abnormal obesity, and PM2.5-exposed murines developed severe abnormal metabolism without obesity. Therefore, in Rothman's terms, it is concluded that HFD is a sufficient cause of the development of obesity, and PM2.5 is a component cause of severe abnormal metabolism of obesity. These signatures would be integrated into a systemic biological process that would induce transcriptional regulation in trans, activating obesogenic biological pathways, restricting lipid mobilization pathways, decreasing adaptive thermogenesis and angiogenesis, and altering vascular tone thus inducing a severe metabolically abnormal obesity.
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Affiliation(s)
- Sagrario Lobato
- Departamento de Investigación en Salud, Servicios de Salud del Estado de Puebla, 15 South Street 302, Puebla, Mexico
- Promoción y Educación para la Salud, Universidad Abierta y a Distancia de México. Universidad Avenue 1200, 1st Floor, quadrant 1-2, Xoco, Benito Juarez, 03330, Mexico City, Mexico
- Educación Superior, Centro de Estudios, “Justo Sierra”, Surutato, Badiraguato, Mexico
| | - A. Lourdes Castillo-Granada
- Educación Superior, Centro de Estudios, “Justo Sierra”, Surutato, Badiraguato, Mexico
- Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México, Guelatao Avenue 66, Ejército de Oriente Indeco II ISSSTE, Iztapalapa, 09230, Mexico City, Mexico
| | - Marcos Bucio-Pacheco
- Educación Superior, Centro de Estudios, “Justo Sierra”, Surutato, Badiraguato, Mexico
- Facultad de Biología, Universidad Autónoma de Sinaloa, Americas Avenue, Universitarios Blvd., University City, 80040, Culiacán Rosales, Mexico
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Shinohara M, Gheni G, Hitomi J, Bu G, Sato N. APOE genotypes modify the obesity paradox in dementia. J Neurol Neurosurg Psychiatry 2023; 94:670-680. [PMID: 37414536 PMCID: PMC10695687 DOI: 10.1136/jnnp-2022-331034] [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: 01/04/2023] [Accepted: 06/05/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND While obesity in midlife is a risk factor for dementia, several studies suggested that obesity also protected against dementia, hence so-called obesity paradox. The current study aims to address the relationship between apolipoprotein E (APOE) genotype and obesity in dementia. METHODS Clinical and neuropathological records of the National Alzheimer's Coordinating Center (NACC) in the USA, which longitudinally followed approximately 20 000 subjects with different cognitive statues, APOE genotype and obesity states, were reviewed. RESULTS Obesity was associated with cognitive decline in early elderly cognitively normal individuals without APOE4, especially those with APOE2. Neuropathological analyses adjusted for dementia status showed that APOE2 carriers tended to have more microinfarcts and haemorrhages due to obesity. On the other hand, obesity was associated with a lower frequency of dementia and less cognitive impairment in individuals with mild cognitive impairment or dementia. Such trends were particularly strong in APOE4 carriers. Obesity was associated with fewer Alzheimer's pathologies in individuals with dementia. CONCLUSIONS Obesity may accelerate cognitive decline in middle to early elderly cognitive normal individuals without APOE4 likely by provoking vascular impairments. On the other hand, obesity may ease cognitive impairment in both individuals with dementia and individuals at the predementia stage, especially those with APOE4, through protecting against Alzheimer's pathologies. These results support that APOE genotype modifies the obesity paradox in dementia.
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Affiliation(s)
- Mitsuru Shinohara
- Department of Aging Neurobiology, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
- Department of Neuroscience, Mayo Clinic, Jacksonville, Florida, USA
- Department of Aging Neurobiology, Osaka University, Suita, Osaka, Japan
| | - Ghupurjan Gheni
- Department of Aging Neurobiology, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Junichi Hitomi
- Department of Aging Neurobiology, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Guojun Bu
- Department of Neuroscience, Mayo Clinic, Jacksonville, Florida, USA
| | - Naoyuki Sato
- Department of Aging Neurobiology, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
- Department of Aging Neurobiology, Osaka University, Suita, Osaka, Japan
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Calderón-Garcidueñas L, Hernández-Luna J, Aiello-Mora M, Brito-Aguilar R, Evelson PA, Villarreal-Ríos R, Torres-Jardón R, Ayala A, Mukherjee PS. APOE Peripheral and Brain Impact: APOE4 Carriers Accelerate Their Alzheimer Continuum and Have a High Risk of Suicide in PM 2.5 Polluted Cities. Biomolecules 2023; 13:927. [PMID: 37371506 DOI: 10.3390/biom13060927] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
This Review emphasizes the impact of APOE4-the most significant genetic risk factor for Alzheimer's disease (AD)-on peripheral and neural effects starting in childhood. We discuss major mechanistic players associated with the APOE alleles' effects in humans to understand their impact from conception through all life stages and the importance of detrimental, synergistic environmental exposures. APOE4 influences AD pathogenesis, and exposure to fine particulate matter (PM2.5), manufactured nanoparticles (NPs), and ultrafine particles (UFPs) associated with combustion and friction processes appear to be major contributors to cerebrovascular dysfunction, neuroinflammation, and oxidative stress. In the context of outdoor and indoor PM pollution burden-as well as Fe, Ti, and Al alloys; Hg, Cu, Ca, Sn, and Si UFPs/NPs-in placenta and fetal brain tissues, urban APOE3 and APOE4 carriers are developing AD biological disease hallmarks (hyperphosphorylated-tau (P-tau) and amyloid beta 42 plaques (Aβ42)). Strikingly, for Metropolitan Mexico City (MMC) young residents ≤ 40 y, APOE4 carriers have 4.92 times higher suicide odds and 23.6 times higher odds of reaching Braak NFT V stage versus APOE4 non-carriers. The National Institute on Aging and Alzheimer's Association (NIA-AA) framework could serve to test the hypothesis that UFPs and NPs are key players for oxidative stress, neuroinflammation, protein aggregation and misfolding, faulty complex protein quality control, and early damage to cell membranes and organelles of neural and vascular cells. Noninvasive biomarkers indicative of the P-tau and Aβ42 abnormal protein deposits are needed across the disease continuum starting in childhood. Among the 21.8 million MMC residents, we have potentially 4 million APOE4 carriers at accelerated AD progression. These APOE4 individuals are prime candidates for early neuroprotective interventional trials. APOE4 is key in the development of AD evolving from childhood in highly polluted urban centers dominated by anthropogenic and industrial sources of pollution. APOE4 subjects are at higher early risk of AD development, and neuroprotection ought to be implemented. Effective reductions of PM2.5, UFP, and NP emissions from all sources are urgently needed. Alzheimer's Disease prevention ought to be at the core of the public health response and physicians-scientist minority research be supported.
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Affiliation(s)
- Lilian Calderón-Garcidueñas
- College of Health, The University of Montana, Missoula, MT 59812, USA
- Universidad del Valle de México, Mexico City 14370, Mexico
| | | | - Mario Aiello-Mora
- Otorrinolaryngology Department, Instituto Nacional de Cardiología, Mexico City 14080, Mexico
| | | | - Pablo A Evelson
- Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Buenos Aires C1113 AAD, Argentina
| | | | - Ricardo Torres-Jardón
- Instituto de Ciencias de la Atmósfera y Cambio Climático, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Alberto Ayala
- Sacramento Metropolitan Air Quality Management District, Sacramento, CA 95814, USA
- West Virginia University, Morgantown, WV 26506, USA
| | - Partha S Mukherjee
- Interdisciplinary Statistical Research Unit, Indian Statistical Institute, Kolkata 700108, India
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Li A, Du J, Cai Y, Chen X, Sun K, Guo T. Body Mass Index Decrease Has a Distinct Association with Alzheimer's Disease Pathophysiology in APOE ɛ4 Carriers and Non-Carriers. J Alzheimers Dis 2023; 96:643-655. [PMID: 37840490 DOI: 10.3233/jad-230446] [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] [Indexed: 10/17/2023]
Abstract
BACKGROUND Body mass index (BMI) changes may be related to Alzheimer's disease (AD) alterations, but it is unclear how the apolipoprotein E ɛ4 (APOE ɛ4) allele affects their association. OBJECTIVE To explore the association of BMI changes with AD pathologies in APOE ɛ4 carriers and non-carriers. METHODS In 862 non-demented ADNI participants with≥2 BMI measurements, we investigated the relationships between BMI slopes and longitudinal changes in amyloid-β (Aβ) accumulation, neurodegeneration and cognition, and follow-up tau deposition in different Aβ and APOE ɛ4 statuses. RESULTS In Aβ+ APOE ɛ4 non-carriers, faster BMI declines were associated with faster rates of Aβ accumulation (standardized β (βstd) = -0.29, p = 0.001), AD meta regions of interest (metaROI) hypometabolism (βstd = 0.23, p = 0.026), memory declines (βstd = 0.17, p = 0.029), executive function declines (βstd = 0.19, p = 0.011), and marginally faster Temporal-metaROI cortical thinning (βstd = 0.15, p = 0.067) and higher follow-up Temporal-metaROI tau deposition (βstd = -0.17, p = 0.059). Among Aβ- individuals, faster BMI decreases were related to faster Aβ accumulation (βstd = -0.25, p = 0.023) in APOE ɛ4 carriers, whereas predicted faster declines in memory and executive function in both APOE ɛ4 carriers (βstd = 0.25, p = 0.008; βstd = 0.32, p = 0.001) and APOE ɛ4 non-carriers (βstd = 0.11, p = 0.030; βstd = 0.12, p = 0.026). CONCLUSIONS This study highlights the significance of tracking BMI data in older adults by providing novel insights into how body weight fluctuations and APOE ɛ4 interact with AD pathology and cognitive decline.
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Affiliation(s)
- Anqi Li
- Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen, China
| | - Jing Du
- Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen, China
| | - Yue Cai
- Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen, China
| | - Xuhui Chen
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Kun Sun
- Institute of Cancer Research, Shenzhen Bay Laboratory, Shenzhen, China
| | - Tengfei Guo
- Institute of Biomedical Engineering, Shenzhen Bay Laboratory, Shenzhen, China
- Institute of Cancer Research, Shenzhen Bay Laboratory, Shenzhen, China
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Zhao YL, Ou YN, Ma YH, Huang YY, Bi YL, Tan L, Yu JT. Association between Life’s Simple 7 and cerebrospinal fluid biomarkers of Alzheimer’s disease pathology in cognitively intact adults: the CABLE study. Alzheimers Res Ther 2022; 14:74. [PMID: 35619174 PMCID: PMC9134665 DOI: 10.1186/s13195-022-01019-2] [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] [Received: 01/14/2022] [Accepted: 05/16/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Introduction
This study sought to explore the association between Life’s Simple 7 (LS7) and cerebrospinal fluid (CSF) Alzheimer’s disease (AD) pathological biomarkers in the cognitively normal northern Chinese population.
Methods
From the Chinese Alzheimer’s Biomarker and LifestylE (CABLE) study, 1106 cognitively normal participants were enrolled. The mean age was 62.34 years, and 39.6% were female. LS7 scores were summed with each metric assigned 0, 1, or 2 scores. The multiple linear regression models were used to investigate the association between LS7 scores and CSF AD biomarkers.
Results
We found that LS7 scores were significantly associated with CSF AD pathologies, including Aβ42/40 (β = 0.034, P = .041), p-tau181 (β = − 0.043, P = .006), and t-tau (β = − 0.044, P = .003). In subscales, the biological metrics (blood pressure, cholesterol, glucose) were significantly related to CSF tau-related biomarkers. These associations were observed in the APOE ε4 allele non-carriers, yet not in carriers. The relationship of behavior metrics was found in the middle age and males.
Conclusion
Improving LS7 scores might do a favor to alleviate the pathology of AD in the preclinical stage, especially among the APOE ε4 allele non-carriers.
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Li M, Ma Y, Fu Y, Liu J, Hu H, Zhao Y, Huang L, Tan L. Association between air pollution and
CSF sTREM2
in cognitively normal older adults: The
CABLE
study. Ann Clin Transl Neurol 2022; 9:1752-1763. [PMID: 36317226 PMCID: PMC9639632 DOI: 10.1002/acn3.51671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/04/2022] [Accepted: 09/16/2022] [Indexed: 11/06/2022] Open
Abstract
Objectives Ambient air pollution aggravates the process of Alzheimer's disease (AD) pathology. Currently, the exact inflammatory mechanisms underlying these links from clinical research remain largely unclear. Methods This study included 1,131 cognitively intact individuals from the Chinese Alzheimer's Biomarker and LifestylE database with data provided on cerebrospinal fluid (CSF) AD biomarkers (amyloid beta‐peptide 42 [Aβ42], total tau [t‐tau], and phosphorylated tau [p‐tau]), neuroinflammatory (CSF sTREM2), and systemic inflammatory markers (high sensitivity C‐reactive protein and peripheral immune cells). The 2‐year averaged levels of ambient fine particulate matter with diameter <2.5 μm (PM2.5), nitrogen dioxide (NO2), and ozone (O3) were estimated at each participant's residence. Multiple‐adjusted models were approached to detect associations of air pollution with inflammatory markers and AD‐related proteins. Results Ambient 2‐year averaged exposure of PM2.5 was associated with changes of neuroinflammatory markers, that is, CSF sTREM2 (β = −0.116, p = 0.0002). Similar results were found for O3 exposure among the elderly (β = −0.111, p = 0.0280) or urban population (β = −0.090, p = 0.0144). No significant evidence supported NO2 related to CSF sTREM2. For potentially causal associations with accumulated AD pathologies, the total effects of PM2.5 on CSF amyloid‐related protein (CSF Aβ42 and p‐tau/Aβ42) were partly mediated by CSF sTREM2, with proportions of 14.22% and 47.15%, respectively. Additional analyses found inverse associations between peripheral inflammatory markers with PM2.5 and NO2, but a positive correlation with O3. Interpretation These findings demonstrated a strong link between PM2.5 exposure and microglial dysfunction. Furthermore, CSF sTREM2 as a key mediator modulated the influences of PM2.5 exposure on AD amyloid pathologies.
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Affiliation(s)
- Meng Li
- Department of Neurology Qingdao Municipal Hospital, Qingdao University Qingdao China
| | - Ya‐Hui Ma
- Department of Neurology Qingdao Municipal Hospital, Qingdao University Qingdao China
| | - Yan Fu
- Department of Neurology Qingdao Municipal Hospital, Qingdao University Qingdao China
| | - Jia‐Yao Liu
- Department of Neurology Qingdao Municipal Hospital, Qingdao University Qingdao China
| | - He‐Ying Hu
- Department of Neurology Qingdao Municipal Hospital, Qingdao University Qingdao China
| | - Yong‐Li Zhao
- Department of Neurology Qingdao Municipal Hospital, Qingdao University Qingdao China
| | - Liang‐Yu Huang
- Department of Neurology Qingdao Municipal Hospital, Qingdao University Qingdao China
| | - Lan Tan
- Department of Neurology Qingdao Municipal Hospital, Qingdao University Qingdao China
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Blood-Based Biomarkers for Alzheimer's Disease Diagnosis and Progression: An Overview. Cells 2022; 11:cells11081367. [PMID: 35456047 PMCID: PMC9044750 DOI: 10.3390/cells11081367] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/12/2022] [Accepted: 04/15/2022] [Indexed: 01/10/2023] Open
Abstract
Alzheimer’s Disease (AD) is a progressive neurodegenerative disease characterized by amyloid-β (Aβ) plaque deposition and neurofibrillary tangle accumulation in the brain. Although several studies have been conducted to unravel the complex and interconnected pathophysiology of AD, clinical trial failure rates have been high, and no disease-modifying therapies are presently available. Fluid biomarker discovery for AD is a rapidly expanding field of research aimed at anticipating disease diagnosis and following disease progression over time. Currently, Aβ1–42, phosphorylated tau, and total tau levels in the cerebrospinal fluid are the best-studied fluid biomarkers for AD, but the need for novel, cheap, less-invasive, easily detectable, and more-accessible markers has recently led to the search for new blood-based molecules. However, despite considerable research activity, a comprehensive and up-to-date overview of the main blood-based biomarker candidates is still lacking. In this narrative review, we discuss the role of proteins, lipids, metabolites, oxidative-stress-related molecules, and cytokines as possible disease biomarkers. Furthermore, we highlight the potential of the emerging miRNAs and long non-coding RNAs (lncRNAs) as diagnostic tools, and we briefly present the role of vitamins and gut-microbiome-related molecules as novel candidates for AD detection and monitoring, thus offering new insights into the diagnosis and progression of this devastating disease.
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Ruan W, Shen S, Xu Y, Ran N, Zhang H. Mechanistic insights into procyanidins as therapies for Alzheimer's disease: A review. J Funct Foods 2021. [DOI: 10.1016/j.jff.2021.104683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Huang Z, Zhang M, He D, Song P, Mo C, Cheng X, Song T, Li Y, Zhang X, Liao M. Serum metabolomics of Bama miniature pigs bitten by Bungarus multicinctus. Toxicol Lett 2021; 350:225-239. [PMID: 34343594 DOI: 10.1016/j.toxlet.2021.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
Bungarus multicinctus is one of the top ten venomous snakes in China, and its bite causes acute and severe diseases, but its pathophysiology remains poorly elucidated. Thus, an animal model of Bungarus multicinctus bite was established by intramuscular injection of 30μg/kg of Bungarus multicinctus venom, and then the serum metabolites were subsequently screened, identified and validated by ultra-performance liquid chromatography-quadrupole-time of flight-mass spectrometry (UPLC-Q-TOF-MS) methods to explore the potential biomakers and possible metabolic pathways. Untargeted metabolomics analysis showed that 36 and 38 endogenous metabolites levels changed in ESI+ and ESI-, respectively, KEGG pathway analysis showed that 5 metabolic pathways, including mineral absorption, central carbon metabolism in cancer, protein digestion and absorption, aminoacyl-tRNA biosynthesis and ABC transporters might be closely related to Bungarus multicinctus bite. Targeted metabolomics analysis showed that there were significant differences in serum D-proline, L-leucine and L-glutamine after Bungarus multicinctus bite (P < 0.05). In addition, receiver operating characteristic (ROC) analysis showed that the diagnostic efficiency of L-Glutamine was superior to other potential biomarkers and the AUC value was 0.944. Moreover, we found evidence for differences in the pathophysiology of glutamine between Bungarus multicinctus bite group and normal group, specifically with the content of glutamine synthetase (GS) and glutaminase (GLS). Taken together, the current study has successfully established an animal model of Bungarus multicinctus bite, and further identified the links between the metabolic perturbations and the pathophysiology and the potential diagnostic biomakers of Bungarus multicinctus bite, which provided valuable insights for studying the mechanism of Bungarus multicinctus bite.
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Affiliation(s)
- Zhi Huang
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, PR China; Guangxi Medical University, Nanning, 530021, PR China
| | - Meng Zhang
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, PR China
| | - Dongling He
- Guangxi Medical University, Nanning, 530021, PR China
| | - Pengshu Song
- Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, 530003, PR China
| | - Caifeng Mo
- Guangxi Medical University, Nanning, 530021, PR China
| | | | - Tianlin Song
- Guangxi Medical University, Nanning, 530021, PR China
| | - Yalan Li
- Guangxi Medical University, Nanning, 530021, PR China
| | - Xuerong Zhang
- Guangxi Medical University, Nanning, 530021, PR China
| | - Ming Liao
- Guangxi Medical University, Nanning, 530021, PR China.
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