1
|
Tráj P, Herrmann EM, Sebők C, Vörösházi J, Mackei M, Gálfi P, Kemény Á, Neogrády Z, Mátis G. Protective effects of chicoric acid on polyinosinic-polycytidylic acid exposed chicken hepatic cell culture mimicking viral damage and inflammation. Vet Immunol Immunopathol 2022; 250:110427. [DOI: 10.1016/j.vetimm.2022.110427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
|
2
|
Two Sides to Every Question: Attempts to Activate Chicken Innate Immunity in 2D and 3D Hepatic Cell Cultures. Cells 2021; 10:cells10081910. [PMID: 34440679 PMCID: PMC8394239 DOI: 10.3390/cells10081910] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/20/2021] [Accepted: 07/25/2021] [Indexed: 12/17/2022] Open
Abstract
The liver with resident tissue macrophages is the site of vivid innate immunity, activated also by pathogen-associated molecular patterns (PAMPs) leaking through the intestinal barrier. As gut-derived inflammatory diseases are of outstanding importance in broiler chickens, the present study aimed to establish a proper hepatic inflammatory model by comparing the action of different PAMPs from poultry pathogens on chicken 2D and 3D primary hepatocyte—non-parenchymal cell co-cultures, the latter newly developed with a magnetic bioprinting method. The cultures were challenged by the bacterial endotoxins lipopolysaccharide (LPS) from Escherichia coli, lipoteichoic acid (LTA) from Staphylococcus aureus and by enterotoxin (ETxB) from Escherichia coli, Salmonella Typhimurium derived flagellin, phorbol myristate acetate (PMA) as a model proinflammatory agent and polyinosinic polycytidylic acid (poly I:C) for mimicking viral RNA exposure. Cellular metabolic activity was assessed with the CCK-8 test, membrane damage was monitored with the lactate dehydrogenase (LDH) leakage assay and interleukin-6 and -8 (Il-6 and -8) concentrations were measured in cell culture medium with a chicken specific ELISA. Both LPS and LTA increased the metabolic activity of the 3D cultures, concomitantly decreasing the LDH leakage, while in 2D cultures ETxB stimulated, PMA and poly I:C depressed the metabolic activity. Based on the moderately increased extracellular LDH activity, LTA seemed to diminish cell membrane integrity in 2D and poly I:C in both cell culture models. The applied endotoxins remarkably reduced the IL-8 release of 3D cultured cells, suggesting the effective metabolic adaptation and the presumably initiated anti-inflammatory mechanisms of the 3D spheroids. Notwithstanding that the IL-6 and IL-8 production of 2D cells was mostly not influenced by the endotoxins used, only the higher LTA dose was capable to evoke an IL-8 surge. Flagellin, PMA and poly I:C exerted proinflammatory action in certain concentrations in both 2D and 3D cultures, reflected by the increased cellular IL-6 release. Based on these data, LTA, flagellin, PMA and poly I:C can be considered as potent candidates to induce inflammation in chicken primary hepatic cell cultures, while LPS failed to trigger proinflammatory cytokine production, suggesting the relatively high tolerance of avian liver cells to certain bacterial endotoxins. These results substantiate that the established 3D co-cultures seemed to be proper tools for testing potential proinflammatory molecules; however, the remarkable differences between 2D and 3D models should be addressed and further studied.
Collapse
|
3
|
Fermented Wheat Germ Extract as a Redox Modulator: Alleviating Endotoxin-Triggered Oxidative Stress in Primary Cultured Rat Hepatocytes. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:3181202. [PMID: 33456668 PMCID: PMC7787767 DOI: 10.1155/2020/3181202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 01/19/2023]
Abstract
Bioactive compounds such as benzoquinone derivates presented in fermented wheat germ extract (FWGE) have several positive effects on overall health status of humans and animals alike. Since available data regarding the antioxidant activity of FWGE are limited, the aim of our study was to investigate its effects on the cellular redox homeostasis applying primary hepatocyte cell cultures of rat origin. Cultures were challenged to lipopolysaccharide (LPS) treatment for 2 or 8 hours to trigger inflammatory response. Further, culture media were concomitantly supplemented with or without FWGE (Immunovet®, 0.1% and 1%). In order to monitor the metabolic activity of the cell cultures, CCK-8 test was applied, while reactive oxygen species (ROS) production was measured using Amplex Red method. Malondialdehyde concentration of culture media as a specific marker of lipid peroxidation and the activity of glutathione peroxidase in cell lysates were also determined to monitor the redox status of the cultures. Based on our findings, it can be concluded that FWGE did not show cytotoxic effects in any applied concentration in cell cultures. Furthermore, FWGE efficiently decreased cellular ROS production and lipid peroxidation rate in case of LPS-induced inflammatory response. However, without LPS treatment, higher concentration of FWGE increased the rate of both ROS and malondialdehyde synthesis. This observation may refer to the prooxidant activity of high dose FWGE, which is an important beneficial effect regarding tumor cells. However, in case of noninflamed hepatocytes, considering the results of glutathione peroxidase activity, the application of the product did not result in severe oxidative distress. In accordance with the abovementioned findings, FWGE as a redox modulator, applied in the appropriate concentration, can serve as a promising candidate in the supplementary therapy of patients suffering from various inflammatory diseases, decreasing the free radical generation, thus avoiding the occurrence of cytotoxic effects.
Collapse
|
4
|
Effects of Tributyrin Supplementation on Growth Performance, Insulin, Blood Metabolites and Gut Microbiota in Weaned Piglets. Animals (Basel) 2020; 10:ani10040726. [PMID: 32331306 PMCID: PMC7222802 DOI: 10.3390/ani10040726] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 12/20/2022] Open
Abstract
Simple Summary In animal farming, alternatives to antibiotics are required due to the increase of antimicrobial resistance. In this contest, tributyrin showed the ability to promote gut health, to modulate gut microbiota and to improve protein digestibility, leading also to higher growth performance. However, although the mode of action of tributyrin on the intestinal epithelial cells has been partially explained, its effects on lipid and protein metabolism needs to be investigated. This paper provides information about the influence of tributyrin on production traits, blood parameters, faecal microbiota and faecal protein excretion in weaned piglets. Abstract The aim of this study was to investigate the effects of tributyrin supplementation on the production traits, the main metabolic parameters and gut microbiota in weaned piglets. One hundred and twenty crossbred piglets (Large White × Landrace) were randomly divided into two experimental groups (six pens each; 10 piglets per pen): the control group (CTRL), that received a basal diet, and the tributyrin group (TRIB) that received the basal diet supplemented with 0.2% tributyrin. The experimental period lasted 40 days. Production traits were measured at days 14, 28 and 40. A subset composed of 48 animals (n = 4 for each pen; n = 24 per group) was considered for the evaluation of serum metabolic parameters and hair cortisol by enzyme-linked immunosorbent assay (ELISA), and faecal microbiota by real-time polymerase chain reaction (PCR). Our results showed that the treatment significantly increased body weight (BW) at day 28 and day 40 (p = 0.0279 and p = 0.0006, respectively) and average daily gain (ADG) from day 28 to day 40 (p = 0.046). Gain to feed ratio (G:F) was significantly higher throughout the experimental period (p = 0.049). Even if the serum parameters were in the physiological range, albumin, albumin/globulin (A/G) ratio, glucose and high-density lipoproteins (HDL) fraction were significantly higher in the TRIB group. On the contrary, tributyrin significantly decreased the urea blood concentration (p = 0.0026), which was correlated with lean gain and feed efficiency. Moreover, serum insulin concentration, which has a regulatory effect on protein and lipid metabolism, was significantly higher in the TRIB group (p = 0.0187). In conclusion, this study demonstrated that tributyrin can be considered as a valid feed additive for weaned piglets.
Collapse
|
5
|
Mackei M, Molnár A, Nagy S, Pál L, Kővágó C, Gálfi P, Dublecz K, Husvéth F, Neogrády Z, Mátis G. Effects of Acute Heat Stress on a Newly Established Chicken Hepatocyte-Nonparenchymal Cell Co-Culture Model. Animals (Basel) 2020; 10:ani10030409. [PMID: 32121577 PMCID: PMC7142495 DOI: 10.3390/ani10030409] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 01/22/2023] Open
Abstract
Heat stress is one of the most important issues in broiler flocks impairing animal health and productivity. On a cellular level, excess heat exposure can trigger heat shock response acting for the restoration of cell homeostasis by several mechanisms, such as affecting heat shock protein synthesis, redox homeostasis and pro-inflammatory cytokine production. The major aim of this study was to establish a novel avian hepatocyte-nonparenchymal cell co-culture as a model for investigating the cellular effects of heat stress and its interaction with inflammation in chicken liver. Cell fractions were isolated by differential centrifugation from a freshly perfused chicken liver, and hepatocyte mono-cultures as well as hepatocyte-nonparenchymal cell co-cultures (with cell ratio 6:1, hepatocytes to nonparenchymal cells, mimicking a milder hepatic inflammation) were prepared. Isolated and cultured cells were characterized by flow cytometry and immunocytochemistry applying hepatocyte- and macrophage-specific antibodies. Confluent cell cultures were exposed to 43 °C temperature for 1 or 2 h, while controls were cultured at 38.5 °C. The metabolic activity, LDH enzyme activity, reactive oxygen species (H2O2) production, extracellular concentration of heat shock protein 70 (HSP70), and that of the pro-inflammatory cytokines interleukin (IL-)6 and IL-8 were assessed. Shorter heat stress applied for 1 h could strongly influence liver cell function by significantly increasing catabolic metabolism and extracellular H2O2 release, and by significantly decreasing HSP70, IL-6, and IL-8 production on both cell culture models. However, all these alterations were restored after 2 h heat exposure, indicating a fast recovery of liver cells. Hepatocyte mono-cultures and hepatocyte-nonparenchymal cell co-cultures responded to heat stress in a similar manner, but the higher metabolic rate of co-cultured cells may have contributed to a better capability of inflamed liver cells for accommodation to stress conditions. In conclusion, the established new primary cell culture models provide suitable tools for studying the hepatic inflammatory and stress response. The results of this study highlight the impact of short-term heat stress on the liver in chickens, underline the mediatory role of oxidative stress in acute stress response, and suggest a fast cellular adaptation potential in liver cells.
Collapse
Affiliation(s)
- Máté Mackei
- Department of Physiology and Biochemistry, Division of Biochemistry, University of Veterinary Medicine, István utca 2, H-1078 Budapest, Hungary; (Z.N.); (G.M.)
- Correspondence: ; Tel.: +36-(1)-478-4157
| | - Andor Molnár
- Department of Animal Science, Georgikon Faculty, University of Pannonia, Deák Ferenc utca 16, H-8360 Keszthely, Hungary; (A.M.); (S.N.); (L.P.); (K.D.); (F.H.)
| | - Szabolcs Nagy
- Department of Animal Science, Georgikon Faculty, University of Pannonia, Deák Ferenc utca 16, H-8360 Keszthely, Hungary; (A.M.); (S.N.); (L.P.); (K.D.); (F.H.)
| | - László Pál
- Department of Animal Science, Georgikon Faculty, University of Pannonia, Deák Ferenc utca 16, H-8360 Keszthely, Hungary; (A.M.); (S.N.); (L.P.); (K.D.); (F.H.)
| | - Csaba Kővágó
- Department of Pharmacology and Toxicology, University of Veterinary Medicine, István utca 2, H-1078 Budapest, Hungary; (C.K.); (P.G.)
| | - Péter Gálfi
- Department of Pharmacology and Toxicology, University of Veterinary Medicine, István utca 2, H-1078 Budapest, Hungary; (C.K.); (P.G.)
| | - Károly Dublecz
- Department of Animal Science, Georgikon Faculty, University of Pannonia, Deák Ferenc utca 16, H-8360 Keszthely, Hungary; (A.M.); (S.N.); (L.P.); (K.D.); (F.H.)
| | - Ferenc Husvéth
- Department of Animal Science, Georgikon Faculty, University of Pannonia, Deák Ferenc utca 16, H-8360 Keszthely, Hungary; (A.M.); (S.N.); (L.P.); (K.D.); (F.H.)
| | - Zsuzsanna Neogrády
- Department of Physiology and Biochemistry, Division of Biochemistry, University of Veterinary Medicine, István utca 2, H-1078 Budapest, Hungary; (Z.N.); (G.M.)
| | - Gábor Mátis
- Department of Physiology and Biochemistry, Division of Biochemistry, University of Veterinary Medicine, István utca 2, H-1078 Budapest, Hungary; (Z.N.); (G.M.)
| |
Collapse
|
6
|
Flow-Based Three-Dimensional Co-Culture Model for Long-Term Hepatotoxicity Prediction. MICROMACHINES 2019; 11:mi11010036. [PMID: 31892214 PMCID: PMC7019533 DOI: 10.3390/mi11010036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/13/2019] [Accepted: 12/25/2019] [Indexed: 12/30/2022]
Abstract
We developed concave microwell arrays to establish a size-controllable 3-D co-culture liver model for in vitro drug toxicity testing, to predict hepatotoxicity. The interaction of hepatocytes with hepatic stellate cells (HSCs) was investigated by co-culturing primary 3-D hepatocyte spheroids and HSCs (heterosphere), using 3-D liver-on-a-chip. The effect of HSCs was investigated during spheroid formation; they were involved in controlling the organization of spheroidal aggregates and the formation of tight cell–cell contacts. Scanning electron microscopy (SEM) images showed that co-cultured spheroids with smoother surfaces in the flow chip aggregated more tightly and rapidly, compared to mono-cultured spheroids, until 13 days. Metabolic function analysis revealed that heterospheres secreted 40% more albumin and urea than hepatospheres on day 13. Additionally, an acetaminophen (AAP) and isoniazid (INH) concentration-dependent increase in CYP3A4 expression was detected in the 3-D cultures, and an increase in Lactate dehydrogenase (LDH) release after AAP and INH treatment was observed. CYP1A2, Mrp1 and UGT1A5 mRNA expression levels in the heterospheres and hepatospheres were evaluated from days 3 to 13. To examine the potential for toxicity testing in the flow-conditioned culture of the heterospheres, we evaluated cytotoxicity using the endpoint LDH release in the heterospheres and hepatospheres. IC50 values for AAP and INH after 24 h of exposure were calculated from the dose–response curves of the compounds. Flow-conditioned heterosphere culture results suggest that it may be suitable for long-term culture and cytotoxicity testing. Thus, our co-culture system closely resembles the in vivo environment and allows long-term in vitro hepatotoxicity prediction.
Collapse
|
7
|
Pászti-Gere E, Szombath G, Gütschow M, Steinmetzer T, Székács A. 3-Amidinophenylalanine-derived matriptase inhibitors can modulate hepcidin production in vitro. Naunyn Schmiedebergs Arch Pharmacol 2019; 393:511-520. [PMID: 31659405 PMCID: PMC7280348 DOI: 10.1007/s00210-019-01743-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023]
Abstract
Matriptase-2 (MT-2) is a type II transmembrane serine protease and predominantly attached to the surface of hepatocytes. MT-2 decreases the production of hepcidin, a key regulator of iron homeostasis. In this study, the effects of four 3-amidinophenylalanine-derived combined matriptase-1/matriptase-2 (MT-1/2) inhibitors (MI-432, MI-441, MI-460, and MI-461) on hepcidin production were investigated in hepatocyte mono- and hepatocyte-Kupffer cell co-cultures. In MI-461-treated cell cultures, the extracellular hydrogen peroxide contents and the interleukin-6 and -8 (IL-6 and IL-8) levels were determined and compared to controls. Hepcidin overproduction was observed in hepatocytes upon treatment with MI-432, MI-441 and MI-461 at 50 μM. In contrast, extracellular hydrogen peroxide levels were not elevated significantly after matriptase inhibition with MI-461. Furthermore, MI-461 did not induce increases in IL-6 and IL-8 levels in these hepatic models. A model of the binding mode of inhibitor MI-461 in complex with MT-2 revealed numerous polar contacts contributing to the nanomolar potency of this compound. Based on the in vitro data on hepcidin regulation, treatment with MI-461 might be valuable in pathological states of iron metabolism without causing excessive oxidative stress.
Collapse
Affiliation(s)
- Erzsébet Pászti-Gere
- Department of Pharmacology and Toxicology, University of Veterinary Medicine, Budapest, Hungary.
| | - Gergely Szombath
- Department of Pharmacology and Toxicology, University of Veterinary Medicine, Budapest, Hungary
| | | | - Torsten Steinmetzer
- Institute of Pharmaceutical Chemistry, Philipps-University Marburg, Marburg, Germany
| | - András Székács
- Agro-Environmental Research Institute, National Agricultural Research and Innovation Centre, Budapest, Hungary
| |
Collapse
|
8
|
Wang G, Zheng Y, Wang Y, Cai Z, Liao N, Liu J, Zhang W. Co-culture system of hepatocytes and endothelial cells: two in vitro approaches for enhancing liver-specific functions of hepatocytes. Cytotechnology 2018; 70:1279-1290. [PMID: 29675734 DOI: 10.1007/s10616-018-0219-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 04/09/2018] [Indexed: 01/16/2023] Open
Abstract
Although hepatocyte transplantation and bioartificial liver support system provide new promising opportunities for those patients waiting for liver transplantation, hepatocytes are easily losing liver-specific functions by using the common in vitro cultured methods. The co-culture strategies with mimicking the in vivo microenvironment would facilitate the maintenance of liver-specific functions of hepatocytes. Considering that hepatocytes and endothelial cells (ECs) account for 80-90% of total cell populations in the liver, hepatocytes and ECs were directly co-cultured with hepatic stellate cells (HSCs) or adipose tissue-derived stem cells (ADSCs) at a ratio of 700:150:3 or 14:3:3 in the present study, and the liver-specific functions were carefully analyzed. Our results showed that the two co-culture systems presented the enhanced liver-specific functions through promoting secretion of urea and ALB and increasing the expressions of ALB, CYP3A4 and HNF4α, and the vessel-like structure in the co-culture system consisted of hepatocytes, ECs and ADSCs. Hence, our results suggested that the directly co-culture of hepatocytes and ECs with HSCs or ADSCs could significantly improve liver-specific functions of hepatocytes, and the co-culture system could further promote angiogenesis of ECs at a later stage. Therefore, this study provides potential interesting in vitro strategies for enhancing liver-specific functions of hepatocytes.
Collapse
Affiliation(s)
- Gaoxiong Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, People's Republic of China
| | - Youshi Zheng
- The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, 350025, People's Republic of China
- The Liver Center of Fujian Province, Fujian Medical University, Fuzhou, 350025, People's Republic of China
| | - Yingchao Wang
- The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, 350025, People's Republic of China
- The Liver Center of Fujian Province, Fujian Medical University, Fuzhou, 350025, People's Republic of China
| | - Zhixiong Cai
- The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, 350025, People's Republic of China
- The Liver Center of Fujian Province, Fujian Medical University, Fuzhou, 350025, People's Republic of China
| | - Naishun Liao
- The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, 350025, People's Republic of China.
- The Liver Center of Fujian Province, Fujian Medical University, Fuzhou, 350025, People's Republic of China.
| | - Jingfeng Liu
- The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, 350025, People's Republic of China
- The Liver Center of Fujian Province, Fujian Medical University, Fuzhou, 350025, People's Republic of China
- Liver Disease Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350007, People's Republic of China
| | - Wenmin Zhang
- Department of Pathology, Fujian Medical University, Fuzhou, 350004, People's Republic of China.
| |
Collapse
|
9
|
The Impact of Acute Matriptase Inhibition in Hepatic Inflammatory Models. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6306984. [PMID: 27642598 PMCID: PMC5013213 DOI: 10.1155/2016/6306984] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 08/01/2016] [Indexed: 12/20/2022]
Abstract
Purpose. Dysfunction of matriptase-2 can be involved in iron regulatory disorder via downregulation of hepcidin expression. In the present study, we investigated the effects of 3-amidinophenylalanine-derived matriptase inhibitors on porcine hepatic inflammatory cell models. Methods. Hepatocyte-Kupffer cell cocultures (ratio of 2 : 1 and 6 : 1) were treated with four structurally related matriptase inhibitors at 50 μM. Cell cytotoxicity and relative expressions of IL-6 and IL-8 and the levels of hepcidin were determined by MTS and porcine-specific ELISA. The extracellular H2O2 contents were analyzed by Amplex Red method. Results. Matriptase inhibitors at 50 µM for 24 h did not increase cell death rate. The elevated ROS production observed after short-term application of inhibitor MI-441 could be correlated with lowered hepcidin expression. MI-460 could significantly enhance hepcidin levels in the supernatants of cocultures (by 62.21 ± 26.8% in hepatocyte-Kupffer cell, 2 : 1, and by 42.6 ± 14.3% in hepatocyte-Kupffer cell, 6 : 1, cocultures, resp.). No significant changes were found in IL-6 and IL-8 levels in cocultures exposed to matriptase inhibitors. Conclusions. Based on in vitro findings, administration of MI-460 via modulation of hepcidin expression without cytotoxic and oxidative stress inducing properties might be a reliable alternative to treat iron overload in human and veterinary clinical practice.
Collapse
|