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Kim JW, Kim HS, Kim HR, Chung KH. Next generation risk assessment of biocides (PHMG-p and CMIT/MIT)-induced pulmonary fibrosis using adverse outcome pathway-based transcriptome analysis. JOURNAL OF HAZARDOUS MATERIALS 2024; 476:134986. [PMID: 38944992 DOI: 10.1016/j.jhazmat.2024.134986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 06/19/2024] [Accepted: 06/19/2024] [Indexed: 07/02/2024]
Abstract
Next-generation risk assessment (NGRA) has emerged as a promising alternative to non-animal studies owing to the increasing demand for the risk assessment of inhaled toxicants. In this study, NGRA was used to assess the inhalation risks of two biocides commonly used as humidifier disinfectants: polyhexamethylene guanidine phosphate (PHMG-p) and chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT). Human bronchial epithelial cell transcriptomic data were processed based on adverse outcome pathways and used to establish transcriptome-based points of departure (tPODs) for each biocide. tPOD values were 0.00500-0.0510 μg/cm2 and 0.0342-0.0544 μg/cm2 for PHMG-p and CMIT/MIT, respectively. tPODs may provide predictive power comparable to that of traditional animal-based PODs (aPODs). The tPOD-based NGRA determined that both PHMG-p and CMIT/MIT present a high inhalation risk. Moreover, the identified PHMG-p posed a higher risk than CMIT/MIT, and children were identified as more susceptible population compared to adults. This finding is consistent with observations from actual exposure events. Our findings suggest that NGRA with transcriptomics offers a reliable approach for risk assessment of specific humidifier disinfectant biocides, while acknowledging the limitations of current models and in vitro systems, particularly regarding uncertainties in pharmacokinetics (PK) and pharmacodynamics (PD).
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Affiliation(s)
- Jun Woo Kim
- School of Pharmacy, Sungkyunkwan University, Suwon 16419, South Korea
| | - Hyung Sik Kim
- School of Pharmacy, Sungkyunkwan University, Suwon 16419, South Korea
| | - Ha Ryong Kim
- College of Pharmacy, Korea University, Sejong 30019, South Korea.
| | - Kyu Hyuck Chung
- School of Pharmacy, Sungkyunkwan University, Suwon 16419, South Korea.
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2
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Park JY, Kim JH, Park CH, Kim SH, Kim IH, Cho WG. Polyhexamethylene guanidine phosphate induces pyroptosis via reactive oxygen species-regulated mitochondrial dysfunction in bronchial epithelial cells. Toxicology 2024; 505:153827. [PMID: 38729513 DOI: 10.1016/j.tox.2024.153827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/24/2024] [Accepted: 05/04/2024] [Indexed: 05/12/2024]
Abstract
Pyroptosis is a form of programmed cell death characterized by gasdermin (GSDM)-mediated pore formation in the cell membrane, resulting in the release of pro-inflammatory cytokines and cellular lysis. Increasing evidence has shown that pyroptosis is responsible for the progression of various pulmonary disorders. The inhalation of polyhexamethylene guanidine (PHMG) causes severe lung inflammation and pulmonary toxicity; however, the underlying mechanisms are unknown. Therefore, in this study, we investigate the role of pyroptosis in PHMG-induced pulmonary toxicity. We exposed bronchial epithelial cells, BEAS-2B, to PHMG phosphate (PHMG-p) and evaluated cell death type, reactive oxygen species (ROS) levels, and relative expression levels of pyroptosis-related proteins. Our data revealed that PHMG-p reduced viability and induced morphological alterations in BEAS-2B cells. Exposure to PHMG-p induced excessive accumulation of mitochondrial ROS (mtROS) in BEAS-2B cells. PHMG-p activated caspase-dependent apoptosis as well as NLRP3/caspase-1/GSDMD-mediated- and caspase-3/GSDME-mediated pyroptosis through mitochondrial oxidative stress in BEAS-2B cells. Notably, PHMG-p reduced mitochondrial respiratory function and induced the translocation of Bax and cleaved GSDM into the mitochondria, leading to mitochondrial dysfunction. Our results enhanced our understanding of PHMG-p-induced lung toxicity by demonstrating that PHMG-p induces pyroptosis via mtROS-induced mitochondrial dysfunction in bronchial epithelial cells.
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Affiliation(s)
- Jun Young Park
- Department of Nuclear Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Ji-Hee Kim
- Department of Occupational Therapy, Soonchunhyang University, 22 Soonchunhyang-ro, Asan-si 35138, Republic of Korea
| | - Chan Ho Park
- Department of Anatomy, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju-si, Gangwon-do 26426, Republic of Korea
| | - Sung-Hwan Kim
- Jeonbuk Branch Institute, Korea Institute of Toxicology, 56212, Republic of Korea
| | - In-Hyeon Kim
- Jeonbuk Branch Institute, Korea Institute of Toxicology, 56212, Republic of Korea
| | - Won Gil Cho
- Department of Anatomy, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju-si, Gangwon-do 26426, Republic of Korea.
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Kang H, Lee S, Jo EK, Yang W, Choi YH. Synergistic interaction of co-exposure to humidifier disinfectant chemicals CMIT/MIT and PHMG in lung injury. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2024; 31:33098-33106. [PMID: 38676862 DOI: 10.1007/s11356-024-33455-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/20/2024] [Indexed: 04/29/2024]
Abstract
A number of biocidal disinfectant chemicals are used as household products to prevent spread of pathogens. People are commonly exposed to multiple chemicals through those disinfectants. However, effects of interactions (e.g., synergism) between disinfectants on human health outcomes have been rarely studied. In this study, we aimed to investigate associations of a mixture of chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT) and polyhexamethylene guanidine (PHMG), which had been used as humidifier disinfectants (HDs) in South Korea, with HD-associated lung injury (HDLI) in a Korean population (n = 4058) with HD exposure through use of HD products. Exposure to HD was retrospectively assessed by an interview-based standardized survey, and HDLI was determined by clinical assessment. After adjusting for covariates, PHMG-specific exposure indices (e.g., amount of use, indoor air concentration, and weekly exposure level) were dose-dependently associated with HDLI (their odds ratios for the comparison of third tertile versus first tertile were 1.95, 1.77, and 2.16, respectively). CMIT/MIT exposure was not observed to have a significant association with HDLI in a single chemical exposure model; however, associations between PHMG exposure and HDLI were strengthened by co-exposure to CMIT/MIT in combined chemical exposure models, where synergistic interactions between CMIT/MIT use and PHMG indices (amount of use and weekly exposure level) were observed (p-interaction in additive scale: 0.02 and 0.03, respectively). Our findings imply that adverse effects of PHMG exposure on lung injury among HD users might be worsened by co-exposure to CMIT/MIT. Given that plenty of household products contain disinfectants on global markets, epidemiological and toxicological investigations are warranted on interaction effects of co-exposure to disinfectants.
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Affiliation(s)
- Habyeong Kang
- Institute of Health Sciences, Korea University, Seoul, 02841, Korea
- School of Health and Environmental Science, Korea University, Anam-Ro 145, Seongbuk-Gu, Seoul, 02841, Korea
| | - Seula Lee
- Center for Humidifier Disinfectant Research, Korean Society of Environmental Health, Seoul, 04376, Korea
| | - Eun-Kyung Jo
- Center for Humidifier Disinfectant Research, Korean Society of Environmental Health, Seoul, 04376, Korea
| | - Wonho Yang
- Department of Occupational Health, Daegu Catholic University, Gyeongsan, 42472, Korea
| | - Yoon-Hyeong Choi
- Institute of Health Sciences, Korea University, Seoul, 02841, Korea.
- School of Health and Environmental Science, Korea University, Anam-Ro 145, Seongbuk-Gu, Seoul, 02841, Korea.
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Cho Y, Jeon S, Kim SH, Kim HY, Kim B, Yang MJ, Rho J, Lee MY, Lee K, Kim MS. Nicotinamide adenine dinucleotide phosphate oxidase 2 deletion attenuates polyhexamethylene guanidine-induced lung injury in mice. Heliyon 2024; 10:e25045. [PMID: 38317961 PMCID: PMC10838801 DOI: 10.1016/j.heliyon.2024.e25045] [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: 07/11/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/07/2024] Open
Abstract
Inhalation of polyhexamethylene guanidine phosphate (PHMG) can cause pulmonary fibrosis. Nicotinamide adenine dinucleotide phosphate (NADPH) oxidases (Nox) are enzymes that produce reactive oxygen species, which may be involved in tissue damage in various lung diseases. To investigate whether the Nox2 isoform of Nox is involved in the progression of PHMG-induced lung damage, we studied the contribution of Nox2 in PHMG-induced lung injury in Nox2-deficient mice. We treated wild-type (WT) and Nox2 knockout mice with a single intratracheal instillation of 1.1 mg/kg PHMG and sacrificed them after 14 days. We analyzed lung histopathology and the number of total and differential cells in the bronchoalveolar lavage fluid. In addition, the expressions of cytokines, chemokines, and profibrogenic genes were analyzed in the lung tissues. Based on our results, Nox2-deficient mice showed less PHMG-induced pulmonary damage than WT mice, as indicated by parameters such as body weight, lung weight, total cell count, cytokine and chemokine levels, fibrogenic mediator expression, and histopathological findings. These findings suggest that Nox2 may have the potential to contribute to PHMG-induced lung injury and serves as an essential signaling molecule in the development of PHMG-induced pulmonary fibrosis by regulating the expression of profibrogenic genes.
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Affiliation(s)
- Yoon Cho
- Inhalation Toxicology Research Group, Korea Institute of Toxicology, Jeongeup-si, Jeollabuk-do, 56212, Republic of Korea
| | - Seulgi Jeon
- Inhalation Toxicology Research Group, Korea Institute of Toxicology, Jeongeup-si, Jeollabuk-do, 56212, Republic of Korea
| | - Sung-Hwan Kim
- Human Health Risk Assessment Center, Korea Institute of Toxicology, Jeongeup-si, Jeollabuk-do, 56212, Republic of Korea
| | - Hyeon-Young Kim
- Human Health Risk Assessment Center, Korea Institute of Toxicology, Jeongeup-si, Jeollabuk-do, 56212, Republic of Korea
| | - Bumseok Kim
- Biosafety Research Institute and Laboratory of Veterinary Pathology, College of Veterinary Medicine, Jeonbuk National University, 79 Gobong-Ro, Iksan-Si, Jeollabuk-Do, 54596, Republic of Korea
| | - Mi-Jin Yang
- Pathology Research Group, Korea Institute of Toxicology, Jeongeup-si, Jeollabuk-do, 56212, Republic of Korea
| | - Jinhyung Rho
- Pathology Research Group, Korea Institute of Toxicology, Jeongeup-si, Jeollabuk-do, 56212, Republic of Korea
| | - Moo-Yeol Lee
- College of Pharmacy, Dongguk University, Goyang-si, Gyeonggi-do, 10326, Republic of Korea
| | - Kyuhong Lee
- Inhalation Toxicology Center for Airborne Risk Factor, Korea Institute of Toxicology, 30 Baehak1-gil, Jeongeup, Jeollabuk-do, 56212, Republic of Korea
- Department of Human and Environmental Toxicology, University of Science & Technology, Daejeon, 34113, Republic of Korea
| | - Min-Seok Kim
- Inhalation Toxicology Research Group, Korea Institute of Toxicology, Jeongeup-si, Jeollabuk-do, 56212, Republic of Korea
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Choi JH, Kim K. Polyhexamethylene Guanidine Phosphate Enhanced Procoagulant Activity through Oxidative-Stress-Mediated Phosphatidylserine Exposure in Platelets. TOXICS 2024; 12:50. [PMID: 38251006 PMCID: PMC10820372 DOI: 10.3390/toxics12010050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 01/23/2024]
Abstract
Polyhexamethylene guanidine phosphate (PHMG-p) is a common biocidal disinfectant that is widely used in industry and household products. However, PHMG-p was misused as a humidifier disinfectant (HD) in South Korea, which had fatal health effects. Various health problems including cardiovascular diseases were observed in HD-exposed groups. However, the potential underlying mechanism of HD-associated cardiovascular diseases is poorly understood. Here, we examined the procoagulant activity of platelets caused by PHMG-p and clarified the underlying mechanism. PHMG-p enhanced phosphatidylserine (PS) exposure through alteration of phospholipid transporters, scramblase, and flippase. Intracellular calcium elevation, intracellular ATP depletion, and caspase-3 activation appeared to underlie phospholipid transporter dysregulation caused by PHMG-p, which was mediated by oxidative stress and mitochondrial dysfunction. Notably, antioxidant enzyme catalase and calcium chelator EGTA reversed PHMG-p-induced PS exposure and thrombin generation, confirming the contributive role of oxidative stress and intracellular calcium in the procoagulant effects of PHMG-p. These series of events led to procoagulant activation of platelets, which was revealed as enhanced thrombin generation. Collectively, PHMG-p triggered procoagulant activation of platelets, which may promote prothrombotic risks and cardiovascular diseases. These findings improve our understanding of HD-associated cardiovascular diseases.
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Affiliation(s)
| | - Keunyoung Kim
- College of Pharmacy, Kangwon National University, Chuncheon 24341, Republic of Korea;
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Yang HS, Yang M, Kang M, Kim B, Lee K. Inhalation toxicity of polyhexamethylene guanidine-phosphate in rats: A 4-week inhalation exposure and 24-week recovery period study. CHEMOSPHERE 2023; 312:137232. [PMID: 36379427 DOI: 10.1016/j.chemosphere.2022.137232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/12/2022] [Accepted: 11/10/2022] [Indexed: 06/16/2023]
Abstract
Humidifier disinfectant (HD) is a causative agent of atypical lung injury reported in 2011 in South Korea, and various diseases caused by HD after exposure cessation have been reported to date. However, there is limited research on most of the reported diseases in terms of their association with HD exposure, and information on the progression of diseases caused by HD exposure is also limited. Therefore, we investigated the effects of HD inhalation on the body in rats. Rats were exposed to 0.15, 0.50, and 1.60 mg/m3 polyhexamethylene guanidine-phosphate (PHMG-p), which is the major component of HDs and most closely related to HD-associated lung injury. We conducted necropsy four times during the recovery period (0, 4, 12, and 24 weeks) and evaluated general systemic toxicities. There were significant changes in the mortality rate, body weight, and food consumption in the PHMG-p-exposed groups. Hematology revealed changes in hemoglobin level, hematocrit, red blood cell, reticulocyte, and white blood cell counts until 12 weeks of the recovery period. PHMG-p induced a delay in prothrombin time until 12 weeks of the recovery period. The aspartate aminotransferase, alanine aminotransferase, total bilirubin, and triglyceride levels were higher in the PHMG-p-exposed groups than in the control group at week 4 of the recovery period, and these parameters normalized after 12 weeks of the recovery period. Histopathological examination in PHMG-p exposed groups revealed several changes in the lungs, including the presence of alveolar macrophages, chronic inflammation, squamous metaplasia, alveolar emphysema, and pulmonary fibrosis. The severity of these symptoms was maintained or exacerbated till 24 weeks. Overall, PHMG-p inhalation can induce irreversible histological changes in the lungs and cause various types of damage throughout the body, even after exposure ends.
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Affiliation(s)
- Hyo-Seon Yang
- Inhalation Toxicology Center for Airborne Risk Factors, Korea Institute of Toxicology, Jeongeup, Jeollabuk-do 56212, Republic of Korea; Biosafety Research Institute and Laboratory of Pathology, College of Veterinary Medicine, Jeonbuk National University, Iksan-si, Jeollabuk do, Republic of Korea.
| | - Mijin Yang
- Jeonbuk Pathology Research Group, Korea Institute of Toxicology, Jeongeup, Jeollabuk-do 56212, Republic of Korea.
| | - Mihyun Kang
- Inhalation Toxicology Center for Airborne Risk Factors, Korea Institute of Toxicology, Jeongeup, Jeollabuk-do 56212, Republic of Korea.
| | - Bumseok Kim
- Biosafety Research Institute and Laboratory of Pathology, College of Veterinary Medicine, Jeonbuk National University, Iksan-si, Jeollabuk do, Republic of Korea.
| | - Kyuhong Lee
- Inhalation Toxicology Center for Airborne Risk Factors, Korea Institute of Toxicology, Jeongeup, Jeollabuk-do 56212, Republic of Korea; Department of Human and Environmental Toxicology, University of Science and Technology, Daejeon 34113, Republic of Korea.
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7
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Sengupta A, Dorn A, Jamshidi M, Schwob M, Hassan W, De Maddalena LL, Hugi A, Stucki AO, Dorn P, Marti TM, Wisser O, Stucki JD, Krebs T, Hobi N, Guenat OT. A multiplex inhalation platform to model in situ like aerosol delivery in a breathing lung-on-chip. Front Pharmacol 2023; 14:1114739. [PMID: 36959848 PMCID: PMC10029733 DOI: 10.3389/fphar.2023.1114739] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/07/2023] [Indexed: 03/08/2023] Open
Abstract
Prolonged exposure to environmental respirable toxicants can lead to the development and worsening of severe respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD) and fibrosis. The limited number of FDA-approved inhaled drugs for these serious lung conditions has led to a shift from in vivo towards the use of alternative in vitro human-relevant models to better predict the toxicity of inhaled particles in preclinical research. While there are several inhalation exposure models for the upper airways, the fragile and dynamic nature of the alveolar microenvironment has limited the development of reproducible exposure models for the distal lung. Here, we present a mechanistic approach using a new generation of exposure systems, the Cloud α AX12. This novel in vitro inhalation tool consists of a cloud-based exposure chamber (VITROCELL) that integrates the breathing AXLung-on-chip system (AlveoliX). The ultrathin and porous membrane of the AX12 plate was used to create a complex multicellular model that enables key physiological culture conditions: the air-liquid interface (ALI) and the three-dimensional cyclic stretch (CS). Human-relevant cellular models were established for a) the distal alveolar-capillary interface using primary cell-derived immortalized alveolar epithelial cells (AXiAECs), macrophages (THP-1) and endothelial (HLMVEC) cells, and b) the upper-airways using Calu3 cells. Primary human alveolar epithelial cells (AXhAEpCs) were used to validate the toxicity results obtained from the immortalized cell lines. To mimic in vivo relevant aerosol exposures with the Cloud α AX12, three different models were established using: a) titanium dioxide (TiO2) and zinc oxide nanoparticles b) polyhexamethylene guanidine a toxic chemical and c) an anti-inflammatory inhaled corticosteroid, fluticasone propionate (FL). Our results suggest an important synergistic effect on the air-blood barrier sensitivity, cytotoxicity and inflammation, when air-liquid interface and cyclic stretch culture conditions are combined. To the best of our knowledge, this is the first time that an in vitro inhalation exposure system for the distal lung has been described with a breathing lung-on-chip technology. The Cloud α AX12 model thus represents a state-of-the-art pre-clinical tool to study inhalation toxicity risks, drug safety and efficacy.
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Affiliation(s)
- Arunima Sengupta
- Organs-on-Chip Technologies, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Aurélien Dorn
- Organs-on-Chip Technologies, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
- AlveoliX AG, Swiss Organs-on-Chip Innovation, Bern, Switzerland
| | - Mohammad Jamshidi
- Organs-on-Chip Technologies, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Magali Schwob
- Organs-on-Chip Technologies, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | - Widad Hassan
- Organs-on-Chip Technologies, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
| | | | - Andreas Hugi
- AlveoliX AG, Swiss Organs-on-Chip Innovation, Bern, Switzerland
| | - Andreas O. Stucki
- Organs-on-Chip Technologies, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
- *Correspondence: Andreas O. Stucki,
| | - Patrick Dorn
- Department of General Thoracic Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Thomas M. Marti
- Department of General Thoracic Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | | | | | | - Nina Hobi
- AlveoliX AG, Swiss Organs-on-Chip Innovation, Bern, Switzerland
| | - Olivier T. Guenat
- Organs-on-Chip Technologies, ARTORG Center for Biomedical Engineering, University of Bern, Bern, Switzerland
- Department of General Thoracic Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
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Kim J, Baek YW, Kim C, Nam YJ, Lee YS, Lee H, Kang JY, Lee H, Choi JY, Park YH, Park SA, Park EK, Jeong SH, Lee JH. Evaluating the comparative MT1B, MT1F, MT1G, and MT1H expression in human pulmonary alveolar epithelial cells treated with polyhexamethylene guanidine-phosphate, chloromethylisothiazolinone/methylisothiazolinone, oligo(2-(2-ethoxy)ethoxyethyl guanidinium chloride, benzalkonium chloride, and sodium dichloroisocyanurate. Mol Cell Toxicol 2022. [DOI: 10.1007/s13273-022-00311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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9
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Gene expression related to lung cancer altered by PHMG-p treatment in PBTE cells. Mol Cell Toxicol 2022. [DOI: 10.1007/s13273-022-00319-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Song JH, Ahn J, Park MY, Park J, Lee YM, Myong JP, Koo JW, Lee J. Health Effects Associated With Humidifier Disinfectant Use: A Systematic Review for Exploration. J Korean Med Sci 2022; 37:e257. [PMID: 35996934 PMCID: PMC9424740 DOI: 10.3346/jkms.2022.37.e257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/29/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND It has been 10 years since the outbreak of lung disease caused by humidifier disinfectants in Korea, but the health effects have not yet been summarized. Therefore, this study aims to systematically examine the health effects of humidifier disinfectants that have been discovered so far. METHODS All literature with humidifier disinfectants and their representative components as the main words were collected based on the web, including PubMed, Research Information Sharing Service, and government publication reports. A total of 902 studies were searched, of which 196 were selected. They were divided into four groups: published human studies (group 1), published animal and cytotoxicology studies (group 2), technical reports (group 3), and gray literature (group 4). RESULTS Out of the 196 studies, 97 (49.5%) were published in peer-reviewed journals as original research. Group 1 consisted of 49 articles (50.5%), while group 2 consisted of 48 articles (49.5%). Overall, respiratory diseases such as humidifier disinfectant associated lung injury, interstitial lung disease, and asthma have a clear correlation, but other effects such as liver, heart, thymus, thyroid, fetal growth, metabolic abnormalities, and eyes are observed in toxicological experimental studies, but have not yet been identified in epidemiologic studies. CONCLUSION The current level of evidence does not completely rule out the effects of humidifier disinfectants on extrapulmonary disease. Based on the toxicological evidence so far, it is required to monitor the population of humidifier disinfectant exposure continuously to see if similar damage occurs.
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Affiliation(s)
- Ji-Hun Song
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joonho Ahn
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Young Park
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaeyoung Park
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Min Lee
- Department of Occupational and Environmental Medicine, Severance Hospital, College of Medicine, Yonsei University, Seoul, Korea
| | - Jun-Pyo Myong
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Wan Koo
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jongin Lee
- Department of Occupational and Environmental Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Kang MS, Kim SH, Yang MJ, Kim HY, Kim IH, Kang JW, Choi HS, Jin SW, Park EJ. Polyhexamethylene guanidine phosphate-induced necrosis may be linked to pulmonary fibrosis. Toxicol Lett 2022; 362:1-16. [DOI: 10.1016/j.toxlet.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/05/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
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12
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Das B, Sahoo S, Mallick B. HIWI2 induces G2/M cell cycle arrest and apoptosis in human fibrosarcoma via the ROS/DNA damage/p53 axis. Life Sci 2022; 293:120353. [PMID: 35074406 DOI: 10.1016/j.lfs.2022.120353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/13/2022] [Accepted: 01/18/2022] [Indexed: 12/14/2022]
Abstract
AIMS Piwi, like RNA-mediated gene silencing 4 (PIWIL4) or HIWI2, are seen deregulated in human cancers and possibly play critical roles in tumorigenesis. It is unknown what role HIWI2 plays in the regulation of fibrosarcoma, an early metastatic lethal type of soft tissue sarcoma (STS). The present study aimed to investigate the role of HIWI2 in the tumorigenesis of fibrosarcoma. MAIN METHODS The expression of HIWI2 in HT1080 fibrosarcoma cells was determined by qRT-PCR and western blotting. The MTT assay, colony formation assay, cell cycle, and PE-AnnexinV/7AAD apoptosis assay using flow cytometry, DNA laddering assay, comet assay, and γH2AX accumulation assay were performed to study the effect of HIWI2 overexpression in HT1080 cells. Further, the effect of silencing of HIWI2 was determined by cell viability assay, transwell migration, and invasion assay. KEY FINDINGS HIWI2 is under-expressed in STS cell lines and tissues, which is associated with poor disease-free survival, disease-specific survival, and progression-free survival of the patients. Overexpression of HIWI2 in HT1080 cells causes DNA damage by increasing intracellular ROS by inhibiting the expression of antioxidant genes (SOD1, SOD2, GPX1, GPX4, and CAT). Furthermore, an increase in H2AX phosphorylation was observed, which activates p53 that promotes p21 expression and caspase-3 activation, leading to G2/M phase cell cycle arrest and apoptosis. HIWI2 silencing, on the contrary, promotes cell growth, migration, and invasion by activating MMP2 and MMP9. SIGNIFICANCE These results are the first to show that HIWI2 acts as a tumor suppressor in fibrosarcoma by modulating the ROS/DNA damage/p53 pathway.
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Affiliation(s)
- Basudeb Das
- RNAi and Functional Genomics Lab., Department of Life Science, National Institute of Technology, Rourkela 769008, Odisha, India
| | - Swapnil Sahoo
- RNAi and Functional Genomics Lab., Department of Life Science, National Institute of Technology, Rourkela 769008, Odisha, India
| | - Bibekanand Mallick
- RNAi and Functional Genomics Lab., Department of Life Science, National Institute of Technology, Rourkela 769008, Odisha, India.
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Lee J, Choi SJ, Jeong JS, Kim SY, Lee SJ, Baek SK, Kwon N, Lee SH, Kim W, Cho JW, Koh EM, Lee K, Jeong EJ, Nam SY, Yu WJ. Adverse postnatal developmental effects in offspring from humidifier disinfectant biocide inhaled pregnant rats. CHEMOSPHERE 2022; 286:131636. [PMID: 34358894 DOI: 10.1016/j.chemosphere.2021.131636] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 06/13/2023]
Abstract
Inhalation exposure to polyhexamethylene guanidine phosphate (PHMG-P), one of the primary biocides used in humidifier disinfectants, caused a fatal pulmonary disease in Korea. Pregnant women were also exposed to PHMG-P, and subsequent studies showed that PHMG-P inhalation during pregnancy adversely affects their health and embryo-fetal development. However, the postnatal developmental effects after birth on prenatally PHMG-P-exposed offspring have not yet been investigated. Therefore, in this study, we aimed to examine the postnatal development of prenatally PHMG-P-exposed offspring. Pregnant rats (22 or 24 females per group) were exposed to PHMG-P during pregnancy in a whole-body inhalation chamber at the target concentrations of 0, 0.14, 1.60, and 3.20 mg/m3. After parturition, the prenatally exposed offspring were transferred to non-exposed surrogate mothers to minimize the secondary effects of severe maternal toxicities. Postnatal development of offspring was then examined with a modified extended one-generation reproductive toxicity study design. At 3.20 mg/m3 PHMG-P, increased perinatal death rates and decreased viability index (postnatal survival of offspring between birth and postnatal day 4) were observed. In addition, F1 offspring had lower body weight at birth that persisted throughout the study. PHMG-P-exposed pregnant rats also had severe systemic toxicities and increased gestation period. At 1.60 mg/m3 PHMG-P, a decreased viability index was also observed with systemic toxicities of PHMG-P-exposed pregnant rats. These results indicate that prenatal PHMG-P exposure adversely affects the offspring's future health and could be used for human risk assessment.
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Affiliation(s)
- Jinsoo Lee
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea; College of Veterinary Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Seong-Jin Choi
- Department of Chemical Assessment, Korea Environment Corporation, Incheon, Republic of Korea
| | - Ji-Seong Jeong
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Sang Yun Kim
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Seung-Jin Lee
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Sang-Ki Baek
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Nayun Kwon
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Sang-Hyub Lee
- Department of Chemical Assessment, Korea Environment Corporation, Incheon, Republic of Korea
| | - Woojin Kim
- Toxicologic Pathology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Jae-Woo Cho
- Toxicologic Pathology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Eun Mi Koh
- Bioanalytical and Immunoanalytical Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Kyuhong Lee
- Inhalation Toxicology Research Group, Korea Institute of Toxicology, Jeongeup, Republic of Korea; Department of Human and Environmental Toxicology, University of Science & Technology, Daejeon, Republic of Korea
| | - Eun Ju Jeong
- Chemical Risk Assessment Research Committee, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Sang-Yoon Nam
- College of Veterinary Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Wook-Joon Yu
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea.
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14
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Choi S, Choi S, Choi Y, Cho N, Kim SY, Lee CH, Park HJ, Oh WK, Kim KK, Kim EM. Polyhexamethylene guanidine phosphate increases stress granule formation in human 3D lung organoids under respiratory syncytial virus infection. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2022; 229:113094. [PMID: 34942421 DOI: 10.1016/j.ecoenv.2021.113094] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Abstract
Polyhexamethylene guanidine phosphate (PHMG-p), a humidifier disinfectant, is known to cause lung toxicity, including inflammation and pulmonary fibrosis. In this study, we aimed to investigate the effect of PHMG-p on human lung tissue models (2D epithelial cells and 3D organoids) under conditions of oxidative stress and viral infection. The effect of PHMG-p was studied by evaluating the formation of stress granules (SGs), which play a pivotal role in cellular adaptation to various stress conditions. Under oxidative stress and respiratory syncytial virus (RSV) infection, exposure to PHMG-p remarkably increased eIF2α phosphorylation, which is essential for SG-related signalling, and significantly increased SG formation. Furthermore, PHMG-p induced fibrotic gene expression and caused cell death due to severe DNA damage, which was further increased under oxidative stress and RSV infection, indicating that PHMG-p induces severe lung toxicity under stress conditions. Taken together, toxicity evaluation under various stressful conditions is necessary to accurately predict potential lung toxicity of chemicals affecting the respiratory tract.
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Affiliation(s)
- Seri Choi
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea; Korea Bioactive Natural Material Bank, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul 08826, South Korea
| | - Sunkyung Choi
- Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea
| | - Yeongsoo Choi
- Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea
| | - Namjoon Cho
- Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea
| | - Seung-Yeon Kim
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea; Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea
| | - Chang Hyun Lee
- Institute of Radiation Medicine, Seoul National University Hospital and College of Medicine, Seoul National University, Seoul 08826, South Korea; Department of Radiology, Seoul National University College of Medicine and Hospital, Seoul National University, Seoul 03080, South Korea
| | - Han-Jin Park
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea
| | - Won Keun Oh
- Korea Bioactive Natural Material Bank, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul 08826, South Korea
| | - Kee K Kim
- Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea.
| | - Eun-Mi Kim
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea.
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15
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Tao MT, Zhang J, Luo ZZ, Zhou NN, Song CC. Dynamic and quantitative characterization of antagonism within disinfectant mixtures by a modified area-concentration ratio method. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2021; 221:112455. [PMID: 34174735 DOI: 10.1016/j.ecoenv.2021.112455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/31/2021] [Accepted: 06/21/2021] [Indexed: 06/13/2023]
Abstract
The coexistence of various typical disinfectant pollutants has the potential to produce toxicity interaction towards organisms in the environment. A suitable model is necessary to evaluate the interaction quantitatively. Hence, the area-concentration ratio (ACR) method was modified (MACR) by combing confidence intervals to dynamically and quantitatively evaluate the toxicity interactions within disinfectant mixture pollutants. Disinfectant mixtures were designed by the direct equipartition design ray method using three guanidine disinfectants, chlorhexidine diacetate (CD), chlorhexidine (CHL), and polyhexamethylene biguanidine (POL) and one chlorine-containing disinfectant calcium hypochlorite (CAL). The toxicities of the four disinfectants and their mixtures towards Vibrio qinghaiensis sp.-Q67 (Q67) were determined by the time-dependent toxicity microplate analysis method. And the toxicity mechanism was analyzed by determining the effects of four disinfectants and their binary mixtures on the structure of cell, DNA and proteins (Pro) for Q67. The results show that the toxicities of CD and CHL to Q67vary little with time, but POL and CAL show the obvious time-dependent toxicity. The toxicities of CD, CHL and POL to Q67 are significantly stronger than that of CAL at the same exposure time. The toxicities of three binary mixture systems don't have significant difference in different exposure time. MACR can dynamically, quantitatively and accurately characterize toxicity interactions compared with ACR. According to MACR, the antagonism intensity dynamically changes with the prolongation of exposure time for binary mixture rays of three guanidine disinfectants and CAL, and linearly correlates with the components' concentration ratios. Four disinfectants all can destroy cell membrane and cause desaturation DNA of test organism, and CAL even can destroy the structure of DNA and protein. The probably reason for the antagonism within binary mixtures is the reaction between guanidine group and ClO-, which is called chemical antaogism.
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Affiliation(s)
- Meng-Ting Tao
- Anhui Provincial Key Laboratory of Environmental Pollution Control and Resource Reuse, College of Environment and Energy Engineering, Anhui Jianzhu University, Hefei, China
| | - Jin Zhang
- Anhui Provincial Key Laboratory of Environmental Pollution Control and Resource Reuse, College of Environment and Energy Engineering, Anhui Jianzhu University, Hefei, China.
| | - Zong-Zong Luo
- Anhui Provincial Key Laboratory of Environmental Pollution Control and Resource Reuse, College of Environment and Energy Engineering, Anhui Jianzhu University, Hefei, China
| | - Na-Na Zhou
- Anhui Provincial Key Laboratory of Environmental Pollution Control and Resource Reuse, College of Environment and Energy Engineering, Anhui Jianzhu University, Hefei, China
| | - Cong-Cong Song
- Anhui Provincial Key Laboratory of Environmental Pollution Control and Resource Reuse, College of Environment and Energy Engineering, Anhui Jianzhu University, Hefei, China
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16
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Kim C, Jeong SH, Kim J, Kang JY, Nam YJ, Togloom A, Cha J, Lee KY, Lee CH, Park EK, Lee JH. Evaluation of the long-term effect of polyhexamethylene guanidine phosphate in a rat lung model using conventional chest computed tomography with histopathologic analysis. PLoS One 2021; 16:e0256756. [PMID: 34492061 PMCID: PMC8423271 DOI: 10.1371/journal.pone.0256756] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 08/15/2021] [Indexed: 12/26/2022] Open
Abstract
There have been no studies on the effects of polyhexamethylene guanidine phosphate (PHMG) after a long period of exposure in the rodent model. We aimed to evaluate long-term lung damage after PHMG exposure using conventional chest computed tomography (CT) and histopathologic analysis in a rat model. A PHMG solution was intratracheally administrated to 24 male rats. At 8, 26, and 52 weeks after PHMG instillation, conventional chest CT was performed in all rats and both lungs were extracted for histopathologic evaluation. At 52 weeks after PHMG instillation, four carcinomas had developed in three of the eight rats (37.5%). Bronchiolo-alveolar hyperplasia and adenoma were found in rats at 8, 26, and 52 weeks post-instillation. The number of bronchiolo-alveolar hyperplasia significantly increased over time (P-value for trend< 0.001). The severity of lung fibrosis and fibrosis scores significantly increased over time (P-values for trend = 0.002 and 0.023, respectively). Conventional chest CT analysis showed that bronchiectasis and linear density scores suggestive of fibrosis significantly increased over time (P-value for trend < 0.001). Our study revealed that one instillation of PHMG in a rat model resulted in lung carcinomas and progressive and irreversible fibrosis one year later based on conventional chest CT and histopathologic analysis. PHMG may be a lung carcinogen in the rat model.
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Affiliation(s)
- Cherry Kim
- Department of Radiology, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
| | - Sang Hoon Jeong
- Medical Science Research Center, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
| | - Jaeyoung Kim
- Medical Science Research Center, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
| | - Ja Young Kang
- Medical Science Research Center, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
| | - Yoon Jeong Nam
- Medical Science Research Center, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
| | - Ariunaa Togloom
- Medical Science Research Center, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
| | - Jaehyung Cha
- Medical Science Research Center, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
| | - Ki Yeol Lee
- Department of Radiology, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
| | - Chang Hyun Lee
- Department of Radiology, College of Medicine, Seoul National University, Seoul National University Hospital, Seoul, South Korea
| | - Eun-Kee Park
- Department of Medical Humanities and Social Medicine, College of Medicine, Kosin University, Busan, South Korea
| | - Ju-Han Lee
- Department of Pathology, Ansan Hospital, Korea University College of Medicine, Danwon-gu, Ansan-si, Gyeonggi, South Korea
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17
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MTF1 Is Essential for the Expression of MT1B, MT1F, MT1G, and MT1H Induced by PHMG, but Not CMIT, in the Human Pulmonary Alveolar Epithelial Cells. TOXICS 2021; 9:toxics9090203. [PMID: 34564354 PMCID: PMC8472727 DOI: 10.3390/toxics9090203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/14/2021] [Accepted: 08/27/2021] [Indexed: 11/24/2022]
Abstract
The inhalation of humidifier disinfectants (HDs) is linked to HD-associated lung injury (HDLI). Polyhexamethylene guanidine (PHMG) is significantly involved in HDLI, but the correlation between chloromethylisothiazolinone (CMIT) and HDLI remains ambiguous. Additionally, the differences in the molecular responses to PHMG and CMIT are poorly understood. In this study, RNA sequencing (RNA-seq) data showed that the expression levels of metallothionein-1 (MT1) isoforms, including MT1B, MT1E, MT1F, MT1G, MT1H, MT1M, and MT1X, were increased in human pulmonary alveolar epithelial cells (HPAEpiCs) that were treated with PHMG but not in those treated with CMIT. Moreover, upregulation of MT1B, MT1F, MT1G, and MT1H was observed only in PHMG-treated HPAEpiCs. The protein expression level of metal regulatory transcription factor 1 (MTF1), which binds to the promoters of MT1 isoforms, was increased in PHMG-treated HPAEpiCs but not in CMIT-treated HPAEpiCs. However, the expression of early growth response 1 (EGR1) and nuclear receptor superfamily 3, group C, member 1 (NR3C1), other transcriptional regulators involved in MT1 isomers, were increased regardless of treatment with PHMG or CMIT. These results suggest that MTF1 is an essential transcription factor for the induction of MT1B, MT1F, MT1G, and MT1H by PHMG but not by CMIT.
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18
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Lee H, Park J, Park K. Fibrosis as a result of polyhexamethylene guanide exposure in cultured Statens Seruminstitut Rabbit Cornea (SIRC) cells. Environ Anal Health Toxicol 2021; 36:e2021009-0. [PMID: 34130374 PMCID: PMC8421752 DOI: 10.5620/eaht.2021009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/29/2021] [Indexed: 12/26/2022] Open
Abstract
Previous research studies on the toxicity of polyhexamethylene guanidine (PHMG) as a humidifier disinfectant majorly focused on lung fibrosis. Considering that disinfectants in humidifiers are released in aerosol form, the eyes are directly exposed and highly vulnerable to the detrimental effects of the PHMG. Therefore, in the present study we investigated the adverse effects of PHMG on the eyes; considering fibrosis as a manifestation of PHMG toxicity in the eye, we evaluated fibrosis-related biomarkers in cultured Statens Seruminstitut Rabbit Cornea (SIRC) cells. Cell viability was measured using 3-(4,5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay, fibrosis-related biomarkers were evaluated through polymerase chain reaction (PCR) and immunoblotting, and oxidative stress was evaluated using 2',7'-dichlorodihydrofluorescein diacetate (H2DCFDA). Polyhexamethylene guanidine showed cytotoxicity in a time and concentration-dependent manner. Fibrosis related biomarkers including transforming growth factor-β (TGF-β), α-smooth muscle actin (α-SMA), matrix metalloproteinase (MMP), tissue inhibitor of metalloproteinase (TIMP) and hemeoxygenase-1 (HO-1) increased in both gene and protein levels. Oxidative stress also increased in the PHMG-treated cultured cells. The findings of the present study suggest that PHMG could cause toxicity in the eye as manifested by fibrosis.
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Affiliation(s)
- Handule Lee
- College of Pharmacy, Dongduk Women's University, Seoul 02748, Korea
| | - Juyoung Park
- College of Pharmacy, Dongduk Women's University, Seoul 02748, Korea
| | - Kwangsik Park
- College of Pharmacy, Dongduk Women's University, Seoul 02748, Korea
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19
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Evaluation of polyhexamethylene guanidine-induced lung injuries by chest CT, pathologic examination, and RNA sequencing in a rat model. Sci Rep 2021; 11:6318. [PMID: 33737587 PMCID: PMC7973781 DOI: 10.1038/s41598-021-85662-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/04/2021] [Indexed: 12/19/2022] Open
Abstract
Our aim was to correlate chest CT and pathologic findings of polyhexamethylene guanidine phosphate (PHMG)-induced lung injuries in a rat model, to determine whether PHMG exposure causes lung tumors, and to explore genetic alterations according to PHMG exposure under the guidance of CT. A PHMG solution was intratracheally administrated to 40 male rats. Chest CT was carried out in all rats and both lungs were collected for histopathologic evaluation. At 4- and 8-weeks post-instillation, one lobe of the right lung from 3 rats was subjected to RNA sequencing. At least one abnormal CT finding was found in all rats at all weeks. The major CT findings were inflammation, fibrosis, and tumors in the pathologic analysis, where significant changes were observed over time. The lung lesions remained persistent after 8 weeks of PHMG exposure. In the pathologic analysis, the extent/severity of inflammation did not show statistically significant changes over time, whereas the extent/severity of fibrosis increased continuously up to 6 weeks after PHMG exposure and then decreased significantly at 8 weeks. Bronchiolar-alveolar adenomas which have malignant potential were found in 50% of rats at 6 and 8 weeks after PHMG exposure. Also, several genes associated with lung cancer, acute lung injury, and pulmonary fibrosis were detected. Our study revealed that PHMG-induced lung injury and its changes according to the number of weeks after exposure were demonstrated using chest CT and pathologic evaluation. In addition, we showed that PHMG exposure caused lung tumors and genetic alterations according to PHMG exposure under the guidance of CT.
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Polyhexamethylene Guanidine Phosphate Induces Apoptosis through Endoplasmic Reticulum Stress in Lung Epithelial Cells. Int J Mol Sci 2021; 22:ijms22031215. [PMID: 33530568 PMCID: PMC7865558 DOI: 10.3390/ijms22031215] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/11/2021] [Accepted: 01/21/2021] [Indexed: 12/17/2022] Open
Abstract
Airway epithelial cell death contributes to the pathogenesis of lung fibrosis. Polyhexamethylene guanidine phosphate (PHMG-p), commonly used as a disinfectant, has been shown to be strongly associated with lung fibrosis in epidemiological and toxicological studies. However, the molecular mechanism underlying PHMG-p-induced epithelial cell death is currently unclear. We synthesized a PHMG-p–fluorescein isothiocyanate (FITC) conjugate and assessed its uptake into lung epithelial A549 cells. To examine intracellular localization, the cells were treated with PHMG-p–FITC; then, the cytoplasmic organelles were counterstained and observed with confocal microscopy. Additionally, the organelle-specific cell death pathway was investigated in cells treated with PHMG-p. PHMG-p–FITC co-localized with the endoplasmic reticulum (ER), and PHMG-p induced ER stress in A549 cells and mice. The ER stress inhibitor tauroursodeoxycholic acid (TUDCA) was used as a pre-treatment to verify the role of ER stress in PHMG-p-induced cytotoxicity. The cells treated with PHMG-p showed apoptosis, which was inhibited by TUDCA. Our results indicate that PHMG-p is rapidly located in the ER and causes ER-stress-mediated apoptosis, which is an initial step in PHMG-p-induced lung fibrosis.
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Chatterjee N, Lee H, Kim J, Kim D, Lee S, Choi J. Critical window of exposure of CMIT/MIT with respect to developmental effects on zebrafish embryos: Multi-level endpoint and proteomics analysis. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2021; 268:115784. [PMID: 33120346 DOI: 10.1016/j.envpol.2020.115784] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 07/29/2020] [Accepted: 10/03/2020] [Indexed: 05/08/2023]
Abstract
Systemic toxicity, particularly, developmental defects of humidifier disinfectant chemicals that have caused lung injuries in Korean children, remains to be elucidated. This study evaluated the mechanisms of the adverse effects of 5-chloro-2-methyl-4-isothiazoline-3-one/2methyl-4-isothiazolin-3-one (CMIT/MIT), one of the main biocides of the Korean tragedy, and identify the most susceptible developmental stage when exposed in early life. To this end, the study was designed to analyze several endpoints (morphology, heart rate, behavior, global DNA methylation, gene expressions of DNA methyl-transferases (dnmts) and protein profiling) in exposed zebrafish (Danio rerio) embryos at various developmental stages. The results showed that CMIT/MIT exposure causes bent tail, pericardial edema, altered heart rates, global DNA hypermethylation and significant alterations in the locomotion behavior. Consistent with the morphological and physiological endpoints, proteomics profiling with bioinformatics analysis suggested that the suppression of cardiac muscle contractions and energy metabolism (oxidative phosphorylation) were possible pivotal underlying mechanisms of the CMIT/MIT mediated adverse effects. Briefly, multi-level endpoint analysis indicated the most susceptible window of exposure to be ≤ 6 hpf followed by ≤ 48 hpf for CMIT/MIT. These results could potentially be translated to a risk assessment of the developmental exposure effects to the humidifier disinfectants.
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Affiliation(s)
- Nivedita Chatterjee
- School of Environmental Engineering, University of Seoul, 163 Seoulsiripdae-ro, Dongdaemun-gu, Seoul, 02504, Republic of Korea
| | - Hyunho Lee
- School of Environmental Engineering, University of Seoul, 163 Seoulsiripdae-ro, Dongdaemun-gu, Seoul, 02504, Republic of Korea
| | - Jiwan Kim
- School of Environmental Engineering, University of Seoul, 163 Seoulsiripdae-ro, Dongdaemun-gu, Seoul, 02504, Republic of Korea
| | - Doeun Kim
- BK21 Plus KNU Multi-Omics Based Creative Drug Research Team, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, 41566, Republic of Korea
| | - Sangkyu Lee
- BK21 Plus KNU Multi-Omics Based Creative Drug Research Team, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, 41566, Republic of Korea
| | - Jinhee Choi
- School of Environmental Engineering, University of Seoul, 163 Seoulsiripdae-ro, Dongdaemun-gu, Seoul, 02504, Republic of Korea.
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22
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p53: A Key Protein That Regulates Pulmonary Fibrosis. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:6635794. [PMID: 33312337 PMCID: PMC7721501 DOI: 10.1155/2020/6635794] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/05/2020] [Accepted: 11/20/2020] [Indexed: 02/06/2023]
Abstract
Pulmonary fibrosis is a progressively aggravating lethal disease that is a serious public health concern. Although the incidence of this disease is increasing, there is a lack of effective therapies. In recent years, the pathogenesis of pulmonary fibrosis has become a research hotspot. p53 is a tumor suppressor gene with crucial roles in cell cycle, apoptosis, tumorigenesis, and malignant transformation. Previous studies on p53 have predominantly focused on its role in neoplastic disease. Following in-depth investigation, several studies have linked it to pulmonary fibrosis. This review covers the association between p53 and pulmonary fibrosis, with the aim of providing novel ideas to improve the clinical diagnosis, treatment, and prognosis of pulmonary fibrosis.
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23
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Yang SC, Tsai YF, Pan YL, Hwang TL. Understanding the role of neutrophils in acute respiratory distress syndrome. Biomed J 2020; 44:439-446. [PMID: 33087299 PMCID: PMC7481802 DOI: 10.1016/j.bj.2020.09.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 12/12/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is difficult to treat and is associated with a high mortality rate. The most severe form of coronavirus disease 2019 (COVID-19) also leads to life-threatening ARDS. Neutrophil counts are positively correlated with disease severity in ARDS. Neutrophil activation not only plays a significant role in immune defense against infections, but also causes tissue damage and leads to inflammatory diseases. Activated neutrophils rapidly migrate to inflamed lung tissue, releasing toxic granular contents and generating neutrophil extracellular traps. In the last few decades, it has become apparent that neutrophils occupy a central role in ARDS pathology. In this review, we summarize the neutrophil inflammatory responses and their relationships to ARDS. According to the current literature, understanding the function of neutrophils may be helpful in the treatment of ARDS.
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Affiliation(s)
- Shun-Chin Yang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan; Graduate Institute of Natural Products, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yen-Lin Pan
- Department of Pharmacy, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Tsong-Long Hwang
- Graduate Institute of Natural Products, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Research Center for Chinese Herbal Medicine, Research Center for Food and Cosmetic Safety, and Graduate Institute of Health Industry Technology, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan; Department of Chemical Engineering, Ming Chi University of Technology, New Taipei City, Taiwan.
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24
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Leem JH, Kim HC. Mitochondria disease due to humidifier disinfectants: diagnostic criteria and its evidences. Environ Anal Health Toxicol 2020; 35:e2020007. [PMID: 32693559 PMCID: PMC7374188 DOI: 10.5620/eaht.e2020007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/13/2020] [Indexed: 12/15/2022] Open
Abstract
Humidifier disinfectant damages caused by the misuse of humidifier disinfects, such as polyhexamethylene guanidine (PHMG), resulted in chemical disasters in South Korea in 2011. About four million people were exposed to humidifier disinfectants (HDs) in the 17 years between 1994 and 2011. Although fatal lung damage was initially reported, investigations into the victims’ injuries revealed that the damage was not limited to the lungs, but that systemic damage was also confirmed. Considering the spread of HD from the lungs to the whole body, the toxic effects of PHMG from reactive oxygen species (ROS), NOTCH signaling pathways, and mitochondrial dysfunction resulted in endothelial damage in the lungs, blood vessels, liver, kidneys, bone marrow, nerves, and muscles. The main toxic mechanisms involved in HD damage may be the NOTCH pathway and mitochondrial damage. There are many case reports which include neurologic disorders (ADHD, depression, posttraumatic stress disorder), muscular disorder (exercise intolerance, myalgia), energy metabolism disorder (chronic fatigue syndrome), and immunologic disorder (rheumatoid arthritis) in HDs victims. These case reports involve multi-system involvement in HDs victims. Further well-designed study is needed to clarify whether mitochondrial dysfunction is associated with multi-organs involvement in HDs victims.
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Affiliation(s)
- Jong Han Leem
- Department of Occupational and Environmental Medicine, Inha University, Incheon, Korea
| | - Hwan-Cheol Kim
- Department of Occupational and Environmental Medicine, Inha University, Incheon, Korea
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Lee E, Lee SY, Hong SJ. The past, present, and future of humidifier disinfectant-associated interstitial lung diseases in children. Clin Exp Pediatr 2020; 63:251-258. [PMID: 32024320 PMCID: PMC7374007 DOI: 10.3345/cep.2019.01326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022] Open
Abstract
Exposure to environmental factors can cause interstitial lung diseases (ILDs); however, such types of ILDs are rare. From 2007 to 2011, an ILD epidemic occurred in South Korea owing to inhalational exposure to toxic chemicals in humidifier disinfectants (HDs). HD-associated ILDs (HD-ILDs) are characterized by rapidly progressing respiratory failure with pulmonary fibrosis and a high mortality rate of 43.8%-58.0%. Although 18.1%-31.1% of the general population used HDs, only a small proportion of HD users were diagnosed with HD-ILDs. This finding suggests that investigation of the pathophysiologies underlying HD-ILDs is needed in addition to the identification of susceptibility to HD-ILDs. Further, there have been several concerns regarding the diverse health effects of exposure to toxic chemicals in HDs, including those that have not been identified, and long-term prognoses in terms of pulmonary function and residual pulmonary lesions observed on follow-up chest images. In this review, we summarize the clinical features, pathologic findings, and changes in radiologic findings over time in patients with HD-ILDs and the results of previous experimental research on the mechanisms underlying the effects of toxic chemicals in HDs. Studies are currently underway to identify the pathophysiologies of HD-ILDs and possible health effects of exposure to HDs along with the development of targeted therapeutic strategies. The experience of identification of HD-ILDs has encouraged stricter control of safe chemicals in everyday life.
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Affiliation(s)
- Eun Lee
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - So-Yeon Lee
- Department of Pediatrics, Childhood Asthma Atopy Center, Humidifier Disinfectant Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo-Jong Hong
- Department of Pediatrics, Childhood Asthma Atopy Center, Humidifier Disinfectant Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ma Q, Liao H, Xu L, Li Q, Zou J, Sun R, Xiao D, Liu C, Pu W, Cheng J, Zhou X, Huang G, Yao L, Zhong X, Guo X. Autophagy-dependent cell cycle arrest in esophageal cancer cells exposed to dihydroartemisinin. Chin Med 2020; 15:37. [PMID: 32351616 PMCID: PMC7183693 DOI: 10.1186/s13020-020-00318-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/14/2020] [Indexed: 12/19/2022] Open
Abstract
Background Dihydroartemisinin (DHA), a derivate of artemisinin, is an effective antimalarial agent. DHA has been shown to exert anticancer activities to numerous cancer cells in the past few years, while the exact molecular mechanisms remain to be elucidated, especially in esophageal cancer. Methods Crystal violet assay was conducted to determine the cell viability of human esophageal cancer cell line Eca109 treated with DHA. Tumor-bearing nude mice were employed to evaluate the anticancer effect of DHA in vivo. Soft agar and crystal violet assays were used to measure the tumorigenicity of Eca109 cells. Flow cytometry was performed to evaluate ROS or cell cycle distribution. GFP-LC3 plasmids were delivered into Eca109 cells to visualize autophagy induced by DHA under a fluorescence microscope. The mRNA and protein levels of each gene were tested by qRT-PCR and western blot, respectively. Results Our results proved that DHA significantly reduced the viability of Eca109 cells in a dose- and time-dependent manner. Further investigation showed that DHA evidently induced cell cycle arrest at the G2/M phase in Eca109 cells. Mechanistically, DHA induced intracellular ROS generation and autophagy in Eca109 cells, while blocking ROS by an antioxidant NAC obviously inhibited autophagy. Furthermore, we found that telomere shelterin component TRF2 was down-regulated in Eca109 cells exposed to DHA through autophagy-dependent degradation, which could be rescued after autophagy was blocked by ROS inhibition. Moreover, the DNA damage response (DDR) was induced obviously in DHA treated cells. To further explore whether ROS or autophagy played a vital role in DHA induced cell cycle arrest, the cell cycle distribution of Eca109 cells was evaluated after ROS or autophagy blocking, and the results showed that autophagy, but not ROS, was essential for cell cycle arrest in DHA treated cells. Conclusion Taken together, DHA showed anticancer effect on esophageal cancer cells through autophagy-dependent cell cycle arrest at the G2/M phase, which unveiled a novel mechanism of DHA as a chemotherapeutic agent, and the degradation of TRF2 followed by DDR might be responsible for this cell phenotype.
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Affiliation(s)
- Qiang Ma
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Hebin Liao
- 2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Lei Xu
- 2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Qingrong Li
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Jiang Zou
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Ru Sun
- 3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,4Department of Blood Transfusion, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Dan Xiao
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Chang Liu
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Wenjie Pu
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Jibing Cheng
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Xi Zhou
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Guangcheng Huang
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Lihua Yao
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Xiaowu Zhong
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
| | - Xiaolan Guo
- 1Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,2Translational Medicine Research Center, North Sichuan Medical College, Nanchong, 637000 People's Republic of China.,3Department of Laboratory Medicine, North Sichuan Medical College, Nanchong, 637000 People's Republic of China
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