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Mahieu L, Van Moll L, De Vooght L, Delputte P, Cos P. In vitro modelling of bacterial pneumonia: a comparative analysis of widely applied complex cell culture models. FEMS Microbiol Rev 2024; 48:fuae007. [PMID: 38409952 PMCID: PMC10913945 DOI: 10.1093/femsre/fuae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/29/2024] [Accepted: 02/24/2024] [Indexed: 02/28/2024] Open
Abstract
Bacterial pneumonia greatly contributes to the disease burden and mortality of lower respiratory tract infections among all age groups and risk profiles. Therefore, laboratory modelling of bacterial pneumonia remains important for elucidating the complex host-pathogen interactions and to determine drug efficacy and toxicity. In vitro cell culture enables for the creation of high-throughput, specific disease models in a tightly controlled environment. Advanced human cell culture models specifically, can bridge the research gap between the classical two-dimensional cell models and animal models. This review provides an overview of the current status of the development of complex cellular in vitro models to study bacterial pneumonia infections, with a focus on air-liquid interface models, spheroid, organoid, and lung-on-a-chip models. For the wide scale, comparative literature search, we selected six clinically highly relevant bacteria (Pseudomonas aeruginosa, Mycoplasma pneumoniae, Haemophilus influenzae, Mycobacterium tuberculosis, Streptococcus pneumoniae, and Staphylococcus aureus). We reviewed the cell lines that are commonly used, as well as trends and discrepancies in the methodology, ranging from cell infection parameters to assay read-outs. We also highlighted the importance of model validation and data transparency in guiding the research field towards more complex infection models.
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Affiliation(s)
- Laure Mahieu
- Laboratory of Microbiology, Parasitology and Hygiene (LMPH), Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Laurence Van Moll
- Laboratory of Microbiology, Parasitology and Hygiene (LMPH), Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Linda De Vooght
- Laboratory of Microbiology, Parasitology and Hygiene (LMPH), Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Peter Delputte
- Laboratory of Microbiology, Parasitology and Hygiene (LMPH), Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Paul Cos
- Laboratory of Microbiology, Parasitology and Hygiene (LMPH), Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
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Iverson E, Kaler L, Agostino EL, Song D, Duncan GA, Scull MA. Leveraging 3D Model Systems to Understand Viral Interactions with the Respiratory Mucosa. Viruses 2020; 12:E1425. [PMID: 33322395 PMCID: PMC7763686 DOI: 10.3390/v12121425] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/27/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023] Open
Abstract
Respiratory viruses remain a significant cause of morbidity and mortality in the human population, underscoring the importance of ongoing basic research into virus-host interactions. However, many critical aspects of infection are difficult, if not impossible, to probe using standard cell lines, 2D culture formats, or even animal models. In vitro systems such as airway epithelial cultures at air-liquid interface, organoids, or 'on-chip' technologies allow interrogation in human cells and recapitulate emergent properties of the airway epithelium-the primary target for respiratory virus infection. While some of these models have been used for over thirty years, ongoing advancements in both culture techniques and analytical tools continue to provide new opportunities to investigate airway epithelial biology and viral infection phenotypes in both normal and diseased host backgrounds. Here we review these models and their application to studying respiratory viruses. Furthermore, given the ability of these systems to recapitulate the extracellular microenvironment, we evaluate their potential to serve as a platform for studies specifically addressing viral interactions at the mucosal surface and detail techniques that can be employed to expand our understanding.
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Affiliation(s)
- Ethan Iverson
- Department of Cell Biology and Molecular Genetics, Maryland Pathogen Research Institute, University of Maryland, College Park, MD 20742, USA; (E.I.); (E.L.A.)
| | - Logan Kaler
- Biophysics Program, University of Maryland, College Park, MD 20742, USA; (L.K.); (G.A.D.)
| | - Eva L. Agostino
- Department of Cell Biology and Molecular Genetics, Maryland Pathogen Research Institute, University of Maryland, College Park, MD 20742, USA; (E.I.); (E.L.A.)
| | - Daniel Song
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA;
| | - Gregg A. Duncan
- Biophysics Program, University of Maryland, College Park, MD 20742, USA; (L.K.); (G.A.D.)
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742, USA;
| | - Margaret A. Scull
- Department of Cell Biology and Molecular Genetics, Maryland Pathogen Research Institute, University of Maryland, College Park, MD 20742, USA; (E.I.); (E.L.A.)
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Bakshani CR, Morales-Garcia AL, Althaus M, Wilcox MD, Pearson JP, Bythell JC, Burgess JG. Evolutionary conservation of the antimicrobial function of mucus: a first defence against infection. NPJ Biofilms Microbiomes 2018; 4:14. [PMID: 30002868 PMCID: PMC6031612 DOI: 10.1038/s41522-018-0057-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/05/2018] [Accepted: 06/06/2018] [Indexed: 02/07/2023] Open
Abstract
Mucus layers often provide a unique and multi-functional hydrogel interface between the epithelial cells of organisms and their external environment. Mucus has exceptional properties including elasticity, changeable rheology and an ability to self-repair by re-annealing, and is therefore an ideal medium for trapping and immobilising pathogens and serving as a barrier to microbial infection. The ability to produce a functional surface mucosa was an important evolutionary step, which evolved first in the Cnidaria, which includes corals, and the Ctenophora. This allowed the exclusion of non-commensal microbes and the subsequent development of the mucus-lined digestive cavity seen in higher metazoans. The fundamental architecture of the constituent glycoprotein mucins is also evolutionarily conserved. Although an understanding of the biochemical interactions between bacteria and the mucus layer are important to the goal of developing new antimicrobial strategies, they remain relatively poorly understood. This review summarises the physicochemical properties and evolutionary importance of mucus, which make it so successful in the prevention of bacterial infection. In addition, the strategies developed by bacteria to counteract the mucus layer are also explored.
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Affiliation(s)
- Cassie R Bakshani
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ana L Morales-Garcia
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Mike Althaus
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Matthew D Wilcox
- Institute for Cell and Molecular Biosciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jeffrey P Pearson
- Institute for Cell and Molecular Biosciences, Newcastle University, Newcastle upon Tyne, UK
| | - John C Bythell
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J Grant Burgess
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, UK
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Epithelial Anion Transport as Modulator of Chemokine Signaling. Mediators Inflamm 2016; 2016:7596531. [PMID: 27382190 PMCID: PMC4921137 DOI: 10.1155/2016/7596531] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 05/03/2016] [Accepted: 05/12/2016] [Indexed: 12/16/2022] Open
Abstract
The pivotal role of epithelial cells is to secrete and absorb ions and water in order to allow the formation of a luminal fluid compartment that is fundamental for the epithelial function as a barrier against environmental factors. Importantly, epithelial cells also take part in the innate immune system. As a first line of defense they detect pathogens and react by secreting and responding to chemokines and cytokines, thus aggravating immune responses or resolving inflammatory states. Loss of epithelial anion transport is well documented in a variety of diseases including cystic fibrosis, chronic obstructive pulmonary disease, asthma, pancreatitis, and cholestatic liver disease. Here we review the effect of aberrant anion secretion with focus on the release of inflammatory mediators by epithelial cells and discuss putative mechanisms linking these transport defects to the augmented epithelial release of chemokines and cytokines. These mechanisms may contribute to the excessive and persistent inflammation in many respiratory and gastrointestinal diseases.
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Cystic fibrosis: NHLBI Workshop on the Primary Prevention of Chronic Lung Diseases. Ann Am Thorac Soc 2015; 11 Suppl 3:S161-8. [PMID: 24754825 DOI: 10.1513/annalsats.201312-444ld] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Cystic fibrosis (CF) is a life-limiting, monogenic disorder characterized by chronic sinopulmonary and gastrointestinal involvement. Progressive pulmonary disease leads to death in the majority of patients. Despite its well-defined molecular basis related to defects in the cystic fibrosis transmembrane conductance regulator anion transport channel, there are large gaps in our understanding of the origin of CF lung disease. Disease has been shown to be present in infancy, and there is mounting evidence that abnormalities begin in utero. Heterogeneity of clinical presentations and severity suggest that many factors involved in lung disease have yet to be fully elucidated. Although new advances in therapeutic treatments have shown promise in delaying disease progression, the prevention of pulmonary disease at its origin (primary prevention) should be a key goal of CF care. The objective of this workshop was to (1) review our understanding of the origins of CF lung disease, (2) determine gaps in the knowledge base that are most significant and most likely to enable prevention of CF lung disease, and (3) prioritize new research questions that will promote pulmonary health in both CF and other childhood lung diseases. The goal of this report is to provide recommendations for future research that will improve our understanding of pulmonary development in health and disease, improve outcome measures and biomarkers for early lung disease, and determine therapeutic targets and strategies to prevent the development of lung disease in children with CF.
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Crabbé A, Ledesma MA, Nickerson CA. Mimicking the host and its microenvironment in vitro for studying mucosal infections by Pseudomonas aeruginosa. Pathog Dis 2014; 71:1-19. [PMID: 24737619 DOI: 10.1111/2049-632x.12180] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/09/2014] [Accepted: 04/09/2014] [Indexed: 02/01/2023] Open
Abstract
Why is a healthy person protected from Pseudomonas aeruginosa infections, while individuals with cystic fibrosis or damaged epithelium are particularly susceptible to this opportunistic pathogen? To address this question, it is essential to thoroughly understand the dynamic interplay between the host microenvironment and P. aeruginosa. Therefore, using model systems that represent key aspects of human mucosal tissues in health and disease allows recreating in vivo host-pathogen interactions in a physiologically relevant manner. In this review, we discuss how factors of mucosal tissues, such as apical-basolateral polarity, junctional complexes, extracellular matrix proteins, mucus, multicellular complexity (including indigenous microbiota), and other physicochemical factors affect P. aeruginosa pathogenesis and are thus important to mimic in vitro. We highlight in vitro cell and tissue culture model systems of increasing complexity that have been used over the past 35 years to study the infectious disease process of P. aeruginosa, mainly focusing on lung models, and their respective advantages and limitations. Continued improvements of in vitro models based on our expanding knowledge of host microenvironmental factors that participate in P. aeruginosa pathogenesis will help advance fundamental understanding of pathogenic mechanisms and increase the translational potential of research findings from bench to the patient's bedside.
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Affiliation(s)
- Aurélie Crabbé
- The Biodesign Institute, Center for Infectious Diseases and Vaccinology, Arizona State University, Tempe, AZ, USA
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Applications of mouse airway epithelial cell culture for asthma research. Methods Mol Biol 2014; 1032:91-107. [PMID: 23943446 DOI: 10.1007/978-1-62703-496-8_7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Primary airway epithelial cell culture provides a valuable tool for studying cell differentiation, cell-cell interactions, and the role of immune system factors in asthma pathogenesis. In this chapter, we discuss the application of mouse tracheal epithelial cell cultures for the study of asthma biology. A major advantage of this system is the ability to use airway epithelial cells from mice with defined genetic backgrounds. The in vitro proliferation and differentiation of mouse airway epithelial cells uses the air-liquid interface condition to generate well-differentiated epithelia with characteristics of native airways. Protocols are provided for manipulation of differentiation, induction of mucous cell metaplasia, genetic modification, and cell and pathogen coculture. Assays for the assessment of gene expression, responses of cells, and analysis of specific cell subpopulations within the airway epithelium are included.
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Chai W, Zhang J, Zhu Z, Liu W, Pan D, Li Y, Chen B. Pyocyanin from Pseudomonas induces IL-8 production through the PKC and NF-κB pathways in U937 cells. Mol Med Rep 2013; 8:1404-10. [PMID: 24002221 DOI: 10.3892/mmr.2013.1662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 08/15/2013] [Indexed: 11/06/2022] Open
Abstract
Pyocyanin, an extracellular product of Pseudomonas aeruginosa (P. aeruginosa), is important in invasive pulmonary infection. Pseudomonas infections are characterized by a marked influx of polymorphonuclear cells (neutrophils). An increased release of interleukin-8 (IL-8), a potent neutrophil chemoattractant, in response to pyocyanin may contribute to the marked infiltration of neutrophils and subsequent neutrophil-mediated tissue damage observed in Pseudomonas-associated lung diseases. In order to explore the pathogenesis of pyocyanin on macrophages, we treated phorbol-12-myristate-13-acetate (PMA)-differentiated U937 cells with pyocyanin in vitro and explored the expression of IL-8 using reverse transcription polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). In the present study, we also investigated the activation of protein kinase C (PKC) and nuclear factor (NF)-κB in PMA-differentiated U937 cells by western blotting and immunohistochemical methods. It was found that pyocyanin increased IL-8 release and mRNA expression in differentiated U937 cells in a concentration- and time-dependent manner. Calphostin C (Cal C), a protein kinase C (PKC) inhibitor, and pyrrolidine dithiocarbamate (PDTC) , an NF-κB inhibitor, blocked IL-8 expression in a concentration-dependent manner in pyocyanin-induced U937 cells. We concluded that pyocyanin promotes IL-8 secretion and mRNA expression in a concentration- and time-dependent manner and furthermore, that the PKC and NF-κΒ signaling pathways may be involved in the expression of IL-8 in pyocyanin-infected PMA-differentiated U937 cells.
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Affiliation(s)
- Wenshu Chai
- Department of Respiratory Diseases, The First Affiliated Hospital, Liaoning Medical University, Jinzhou, Liaoning 121001, P.R. China
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Preciado D, Burgett K, Ghimbovschi S, Rose M. NTHi induction of Cxcl2 and middle ear mucosal metaplasia in mice. Laryngoscope 2013; 123:E66-71. [PMID: 23553435 DOI: 10.1002/lary.24097] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 02/05/2013] [Accepted: 02/15/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Chronic otitis media (COM) develops after sustained inflammation and is characterized by secretory middle ear epithelial metaplasia and effusion, most frequently mucoid. Nontypeable Haemophilus influenzae (NTHi), the most common acute otitis media (OM) pathogen, is known to activate inflammation and mucin expression in vitro and in animal models of OM. The goals of this study were to examine histopathological and expression profiling epithelial effects of NTHi challenge in murine middle ears. STUDY DESIGN In vitro and in vivo murine model of OM. METHODS Weekly transtympanic inoculation of Balb/c mice with 300 μg/ml of NTHi lysates versus saline was performed. Histopathologic analysis was carried out at 4 weeks. Expression microarray analysis was performed at 1 and 7 days. Microarray findings were validated in independent animal samples and in a cultured murine middle ear epithelial cell (mMEEC) line. RESULTS Histopathologic analyses revealed middle ear mucosal thickening after NTHi exposure. Microarray analyses of inflammatory response genes which changed significantly demonstrated that the chemokine Cxcl2 had the largest fold-change, with significantly increased expression at 1 and 7 days after NTHi injection compared to either saline or no-injection (P <0.01). Validation by real-time qPCR revealed similar significantly increased relative mRNA levels for Cxcl2. NTHi lysates were also found to significantly upregulate the transcription of Cxcl2 in mMEEC in a time- and dose-dependent manner (P <0.05). CONCLUSIONS Middle ear NTHi challenge in mice leads to chronic epithelial mucosal metaplasia and overexpression of inflammatory mediators, most notably Cxcl2. This finding is parallel to NTHi-mediated pulmonary mucosal metaplasia where Cxcl2 has been identified as an important inflammatory mediator.
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Affiliation(s)
- Diego Preciado
- Center for Genetic Medicine Research, Children's National Medical Center, Washington, DC, U.S.A; Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's National Medical Center, Washington, DC, U.S.A
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Tamang DL, Pirzai W, Priebe GP, Traficante DC, Pier GB, Falck JR, Morisseau C, Hammock BD, McCormick BA, Gronert K, Hurley BP. Hepoxilin A(3) facilitates neutrophilic breach of lipoxygenase-expressing airway epithelial barriers. THE JOURNAL OF IMMUNOLOGY 2012; 189:4960-9. [PMID: 23045615 DOI: 10.4049/jimmunol.1201922] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A feature shared by many inflammatory lung diseases is excessive neutrophilic infiltration. Neutrophil homing to airspaces involve multiple factors produced by several distinct cell types. Hepoxilin A(3) is a neutrophil chemoattractant produced by pathogen-infected epithelial cells that is hypothesized to facilitate neutrophil breach of mucosal barriers. Using a Transwell model of lung epithelial barriers infected with Pseudomonas aeruginosa, we explored the role of hepoxilin A(3) in neutrophil transepithelial migration. Pharmacological inhibitors of the enzymatic pathways necessary to generate hepoxilin A(3), including phospholipase A(2) and 12-lipoxygenase, potently interfere with P. aeruginosa-induced neutrophil transepithelial migration. Both transformed and primary human lung epithelial cells infected with P. aeruginosa generate hepoxilin A(3) precursor arachidonic acid. All four known lipoxygenase enzymes capable of synthesizing hepoxilin A(3) are expressed in lung epithelial cell lines, primary small airway epithelial cells, and human bronchial epithelial cells. Lung epithelial cells produce increased hepoxilin A(3) and lipid-derived neutrophil chemotactic activity in response to P. aeruginosa infection. Lipid-derived chemotactic activity is soluble epoxide hydrolase sensitive, consistent with hepoxilin A(3) serving a chemotactic role. Stable inhibitory structural analogs of hepoxilin A(3) are capable of impeding P. aeruginosa-induced neutrophil transepithelial migration. Finally, intranasal infection of mice with P. aeruginosa promotes enhanced cellular infiltrate into the airspace, as well as increased concentration of the 12-lipoxygenase metabolites hepoxilin A(3) and 12-hydroxyeicosa-5Z,8Z,10E,14Z-tetraenoic acid. Data generated from multiple models in this study provide further evidence that hepoxilin A(3) is produced in response to lung pathogenic bacteria and functions to drive neutrophils across epithelial barriers.
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Affiliation(s)
- David L Tamang
- Mucosal Immunology Laboratory, Massachusetts General Hospital, Charlestown, MA 02129, USA
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Chen C, Fang X, Wang Y, Li Y, Wang D, Zhao X, Bai C, Wang X. Preventive and therapeutic effects of phosphoinositide 3-kinase inhibitors on acute lung injury. Chest 2011; 140:391-400. [PMID: 21636664 DOI: 10.1378/chest.10-3060] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Phosphoinositide 3-kinases (PI3Ks) are involved in a number of biologic responses. Recent preclinical studies demonstrated that the PI3K-dominant signal pathway could play an important role in the development of acute lung injury, although the mechanism remains unclear. METHODS CD-1 mice were administered different PI3K inhibitors either intranasally or intragastrically once a day for 3 days before intratracheal instillation of lipopolysaccharide at 4 h and 24 h. Effects of SHBM1009 on lipopolysaccharide-induced capillary permeability, leukocyte distribution and activation, and epithelial cell function were measured. Therapeutic effects of SHBM1009 on pancreatic elastase-induced lung injury were evaluated in rats. RESULTS The data demonstrated that the local delivery of PI3K inhibitors played more effective roles in the prevention of endotoxin-induced lung injury than the systemic delivery. The preventive effects of PI3K inhibitors varied most likely because of chemical properties, targeting sites, and pharmacokinetics. The local PI3K inhibitors prevented both endotoxin- and elastase-induced lung injury in mice and rats, possibly through directly inhibiting or inactivating the function of airway epithelial cells, which could not produce chemoattractant factors to activate neutrophils and macrophages. CONCLUSIONS PI3K may be a therapeutic target for lung injury, and local delivery of PI3K inhibitors may be one of the optimal approaches for the therapy.
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Affiliation(s)
- Chengshui Chen
- Department of Respiratory Medicine, The First Hospital, Wenzhou Medical College, Zhejiang, China
| | - Xiaocong Fang
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yaoli Wang
- Intensive Care Unit, Daping Hospital, The Third Military Medical University, Chongqing, China
| | - Yuping Li
- Department of Respiratory Medicine, The First Hospital, Wenzhou Medical College, Zhejiang, China
| | - Diane Wang
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xia Zhao
- Biomedical Center, Lund University, Lund, Sweden
| | - Chunxue Bai
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiangdong Wang
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai, China.
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