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Jia J, Zoeschg M, Barth H, Pulliainen AT, Ernst K. The Chaperonin TRiC/CCT Inhibitor HSF1A Protects Cells from Intoxication with Pertussis Toxin. Toxins (Basel) 2024; 16:36. [PMID: 38251252 PMCID: PMC10819386 DOI: 10.3390/toxins16010036] [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: 11/02/2023] [Revised: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 01/23/2024] Open
Abstract
Pertussis toxin (PT) is a bacterial AB5-toxin produced by Bordetella pertussis and a major molecular determinant of pertussis, also known as whooping cough, a highly contagious respiratory disease. In this study, we investigate the protective effects of the chaperonin TRiC/CCT inhibitor, HSF1A, against PT-induced cell intoxication. TRiC/CCT is a chaperonin complex that facilitates the correct folding of proteins, preventing misfolding and aggregation, and maintaining cellular protein homeostasis. Previous research has demonstrated the significance of TRiC/CCT in the functionality of the Clostridioides difficile TcdB AB-toxin. Our findings reveal that HSF1A effectively reduces the levels of ADP-ribosylated Gαi, the specific substrate of PT, in PT-treated cells, without interfering with enzyme activity in vitro or the cellular binding of PT. Additionally, our study uncovers a novel interaction between PTS1 and the chaperonin complex subunit CCT5, which correlates with reduced PTS1 signaling in cells upon HSF1A treatment. Importantly, HSF1A mitigates the adverse effects of PT on cAMP signaling in cellular systems. These results provide valuable insights into the mechanisms of PT uptake and suggest a promising starting point for the development of innovative therapeutic strategies to counteract pertussis toxin-mediated pathogenicity.
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Affiliation(s)
- Jinfang Jia
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Manuel Zoeschg
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Holger Barth
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | | | - Katharina Ernst
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
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Li J, Liu B, Wu H, Zhang S, Liang Z, Guo S, Jiang H, Song Y, Lei X, Gao Y, Cheng P, Li D, Wang J, Liu Y, Wang D, Zhan N, Xu J, Wang L, Xiao G, Yang L, Pei G. Sensory nerves directly promote osteoclastogenesis by secreting peptidyl-prolyl cis-trans isomerase D (Cyp40). Bone Res 2023; 11:64. [PMID: 38097598 PMCID: PMC10721806 DOI: 10.1038/s41413-023-00300-w] [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: 04/16/2023] [Revised: 09/13/2023] [Accepted: 10/30/2023] [Indexed: 12/17/2023] Open
Abstract
Given afferent functions, sensory nerves have recently been found to exert efferent effects and directly alter organ physiology. Additionally, several studies have highlighted the indirect but crucial role of sensory nerves in the regulation of the physiological function of osteoclasts. Nonetheless, evidence regarding the direct sensory nerve efferent influence on osteoclasts is lacking. In the current study, we found that high levels of efferent signals were transported directly from the sensory nerves into osteoclasts. Furthermore, sensory hypersensitivity significantly increased osteoclastic bone resorption, and sensory neurons (SNs) directly promoted osteoclastogenesis in an in vitro coculture system. Moreover, we screened a novel neuropeptide, Cyp40, using an isobaric tag for relative and absolute quantitation (iTRAQ). We observed that Cyp40 is the efferent signal from sensory nerves, and it plays a critical role in osteoclastogenesis via the aryl hydrocarbon receptor (AhR)-Ras/Raf-p-Erk-NFATc1 pathway. These findings revealed a novel mechanism regarding the influence of sensory nerves on bone regulation, i.e., a direct promoting effect on osteoclastogenesis by the secretion of Cyp40. Therefore, inhibiting Cyp40 could serve as a strategy to improve bone quality in osteoporosis and promote bone repair after bone injury.
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Affiliation(s)
- Junqin Li
- Southern University of Science and Technology Hospital, No. 6019 Liuxian Street, Xili Avenue, Nanshan District, Shenzhen, 518055, China
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Bin Liu
- Department of Orthopedics, General Hospital of Northern Theater Command, No. 83, Wenhua Road, Shenhe District, Shenyang, 110016, China
| | - Hao Wu
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
- Department of Orthopaedics, Tangdu Hospital, Fourth Military Medical University, 710038, Xi'an, PR China
| | - Shuaishuai Zhang
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Zhuowen Liang
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Shuo Guo
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
- Department of Biomedical Engineering, Fourth Military Medical University, 710032, Xi'an, PR China
| | - Huijie Jiang
- Lingtong Rehabilitation and Recuperation Center, Xi'an, 710600, China
| | - Yue Song
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, 100048, Beijing, PR China
| | - Xing Lei
- Department of Orthopedics, Linyi People's Hospital, LinYi, 276000, China
| | - Yi Gao
- Southern University of Science and Technology Hospital, No. 6019 Liuxian Street, Xili Avenue, Nanshan District, Shenzhen, 518055, China
| | - Pengzhen Cheng
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Donglin Li
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Jimeng Wang
- Department of Orthopedics, 81 Army Hospital of the People's Liberation Army, Zhangjiakou, 075000, China
| | - Yang Liu
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Di Wang
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Nazhi Zhan
- School of Medicine, Southern University of Science and Technology, Shenzhen, 518055, China
| | - Jing Xu
- Southern University of Science and Technology Hospital, No. 6019 Liuxian Street, Xili Avenue, Nanshan District, Shenzhen, 518055, China
| | - Lin Wang
- Southern University of Science and Technology Hospital, No. 6019 Liuxian Street, Xili Avenue, Nanshan District, Shenzhen, 518055, China
| | - Guozhi Xiao
- School of Medicine, Southern University of Science and Technology, Shenzhen, 518055, China
| | - Liu Yang
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China.
| | - GuoXian Pei
- Southern University of Science and Technology Hospital, No. 6019 Liuxian Street, Xili Avenue, Nanshan District, Shenzhen, 518055, China.
- Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China.
- School of Medicine, Southern University of Science and Technology, Shenzhen, 518055, China.
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Jia J, Braune-Yan M, Lietz S, Wahba M, Pulliainen AT, Barth H, Ernst K. Domperidone Inhibits Clostridium botulinum C2 Toxin and Bordetella pertussis Toxin. Toxins (Basel) 2023; 15:412. [PMID: 37505681 PMCID: PMC10467066 DOI: 10.3390/toxins15070412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/29/2023] Open
Abstract
Bordetella pertussis toxin (PT) and Clostridium botulinum C2 toxin are ADP-ribosylating toxins causing severe diseases in humans and animals. They share a common translocation mechanism requiring the cellular chaperones Hsp90 and Hsp70, cyclophilins, and FK506-binding proteins to transport the toxins' enzyme subunits into the cytosol. Inhibitors of chaperone activities have been shown to reduce the amount of transported enzyme subunits into the cytosol of cells, thus protecting cells from intoxication by these toxins. Recently, domperidone, an approved dopamine receptor antagonist drug, was found to inhibit Hsp70 activity. Since Hsp70 is required for cellular toxin uptake, we hypothesized that domperidone also protects cells from intoxication with PT and C2. The inhibition of intoxication by domperidone was demonstrated by analyzing the ADP-ribosylation status of the toxins' specific substrates. Domperidone had no inhibitory effect on the receptor-binding or enzyme activity of the toxins, but it inhibited the pH-driven membrane translocation of the enzyme subunit of the C2 toxin and reduced the amount of PTS1 in cells. Taken together, our results indicate that domperidone is a potent inhibitor of PT and C2 toxins in cells and therefore might have therapeutic potential by repurposing domperidone to treat diseases caused by bacterial toxins that require Hsp70 for their cellular uptake.
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Affiliation(s)
- Jinfang Jia
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Maria Braune-Yan
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Stefanie Lietz
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Mary Wahba
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | | | - Holger Barth
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Katharina Ernst
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
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Braune-Yan M, Jia J, Wahba M, Schmid J, Papatheodorou P, Barth H, Ernst K. Domperidone Protects Cells from Intoxication with Clostridioides difficile Toxins by Inhibiting Hsp70-Assisted Membrane Translocation. Toxins (Basel) 2023; 15:384. [PMID: 37368685 DOI: 10.3390/toxins15060384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Clostridioides difficile infections cause severe symptoms ranging from diarrhea to pseudomembranous colitis due to the secretion of AB-toxins, TcdA and TcdB. Both toxins are taken up into cells through receptor-mediated endocytosis, autoproteolytic processing and translocation of their enzyme domains from acidified endosomes into the cytosol. The enzyme domains glucosylate small GTPases such as Rac1, thereby inhibiting processes such as actin cytoskeleton regulation. Here, we demonstrate that specific pharmacological inhibition of Hsp70 activity protected cells from TcdB intoxication. In particular, the established inhibitor VER-155008 and the antiemetic drug domperidone, which was found to be an Hsp70 inhibitor, reduced the number of cells with TcdB-induced intoxication morphology in HeLa, Vero and intestinal CaCo-2 cells. These drugs also decreased the intracellular glucosylation of Rac1 by TcdB. Domperidone did not inhibit TcdB binding to cells or enzymatic activity but did prevent membrane translocation of TcdB's glucosyltransferase domain into the cytosol. Domperidone also protected cells from intoxication with TcdA as well as CDT toxin produced by hypervirulent strains of Clostridioides difficile. Our results reveal Hsp70 requirement as a new aspect of the cellular uptake mechanism of TcdB and identified Hsp70 as a novel drug target for potential therapeutic strategies required to combat severe Clostridioides difficile infections.
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Affiliation(s)
- Maria Braune-Yan
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Jinfang Jia
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Mary Wahba
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Johannes Schmid
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Panagiotis Papatheodorou
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Holger Barth
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
| | - Katharina Ernst
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University Medical Center, 89081 Ulm, Germany
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Ernst K. Requirement of Peptidyl-Prolyl Cis/Trans isomerases and chaperones for cellular uptake of bacterial AB-type toxins. Front Cell Infect Microbiol 2022; 12:938015. [PMID: 35992160 PMCID: PMC9387773 DOI: 10.3389/fcimb.2022.938015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
Bacterial AB-type toxins are proteins released by the producing bacteria and are the causative agents for several severe diseases including cholera, whooping cough, diphtheria or enteric diseases. Their unique AB-type structure enables their uptake into mammalian cells via sophisticated mechanisms exploiting cellular uptake and transport pathways. The binding/translocation B-subunit facilitates binding of the toxin to a specific receptor on the cell surface. This is followed by receptor-mediated endocytosis. Then the enzymatically active A-subunit either escapes from endosomes in a pH-dependent manner or the toxin is further transported through the Golgi to the endoplasmic reticulum from where the A-subunit translocates into the cytosol. In the cytosol, the A-subunits enzymatically modify a specific substrate which leads to cellular reactions resulting in clinical symptoms that can be life-threatening. Both intracellular uptake routes require the A-subunit to unfold to either fit through a pore formed by the B-subunit into the endosomal membrane or to be recognized by the ER-associated degradation pathway. This led to the hypothesis that folding helper enzymes such as chaperones and peptidyl-prolyl cis/trans isomerases are required to assist the translocation of the A-subunit into the cytosol and/or facilitate their refolding into an enzymatically active conformation. This review article gives an overview about the role of heat shock proteins Hsp90 and Hsp70 as well as of peptidyl-prolyl cis/trans isomerases of the cyclophilin and FK506 binding protein families during uptake of bacterial AB-type toxins with a focus on clostridial binary toxins Clostridium botulinum C2 toxin, Clostridium perfringens iota toxin, Clostridioides difficile CDT toxin, as well as diphtheria toxin, pertussis toxin and cholera toxin.
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Novel Strategies to Inhibit Pertussis Toxin. Toxins (Basel) 2022; 14:toxins14030187. [PMID: 35324684 PMCID: PMC8951090 DOI: 10.3390/toxins14030187] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/25/2022] Open
Abstract
Pertussis, also known as whooping cough, is a respiratory disease caused by infection with Bordetella pertussis, which releases several virulence factors, including the AB-type pertussis toxin (PT). The characteristic symptom is severe, long-lasting paroxysmal coughing. Especially in newborns and infants, pertussis symptoms, such as leukocytosis, can become life-threatening. Despite an available vaccination, increasing case numbers have been reported worldwide, including Western countries such as Germany and the USA. Antibiotic treatment is available and important to prevent further transmission. However, antibiotics only reduce symptoms if administered in early stages, which rarely occurs due to a late diagnosis. Thus, no causative treatments against symptoms of whooping cough are currently available. The AB-type protein toxin PT is a main virulence factor and consists of a binding subunit that facilitates transport of an enzyme subunit into the cytosol of target cells. There, the enzyme subunit ADP-ribosylates inhibitory α-subunits of G-protein coupled receptors resulting in disturbed cAMP signaling. As an important virulence factor associated with severe symptoms, such as leukocytosis, and poor outcomes, PT represents an attractive drug target to develop novel therapeutic strategies. In this review, chaperone inhibitors, human peptides, small molecule inhibitors, and humanized antibodies are discussed as novel strategies to inhibit PT.
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Ernst K, Mittler AK, Winkelmann V, Kling C, Eberhardt N, Anastasia A, Sonnabend M, Lochbaum R, Wirsching J, Sakari M, Pulliainen AT, Skerry C, Carbonetti NH, Frick M, Barth H. Pharmacological targeting of host chaperones protects from pertussis toxin in vitro and in vivo. Sci Rep 2021; 11:5429. [PMID: 33686161 PMCID: PMC7940712 DOI: 10.1038/s41598-021-84817-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/16/2021] [Indexed: 01/05/2023] Open
Abstract
Whooping cough is caused by Bordetella pertussis that releases pertussis toxin (PT) which comprises enzyme A-subunit PTS1 and binding/transport B-subunit. After receptor-mediated endocytosis, PT reaches the endoplasmic reticulum from where unfolded PTS1 is transported to the cytosol. PTS1 ADP-ribosylates G-protein α-subunits resulting in increased cAMP signaling. Here, a role of target cell chaperones Hsp90, Hsp70, cyclophilins and FK506-binding proteins for cytosolic PTS1-uptake is demonstrated. PTS1 specifically and directly interacts with chaperones in vitro and in cells. Specific pharmacological chaperone inhibition protects CHO-K1, human primary airway basal cells and a fully differentiated airway epithelium from PT-intoxication by reducing intracellular PTS1-amounts without affecting cell binding or enzyme activity. PT is internalized by human airway epithelium secretory but not ciliated cells and leads to increase of apical surface liquid. Cyclophilin-inhibitors reduced leukocytosis in infant mouse model of pertussis, indicating their promising potential for developing novel therapeutic strategies against whooping cough.
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Affiliation(s)
- Katharina Ernst
- Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Ulm, Germany.
| | - Ann-Katrin Mittler
- Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Ulm, Germany
| | | | - Carolin Kling
- Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Ulm, Germany
| | - Nina Eberhardt
- Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Ulm, Germany
| | - Anna Anastasia
- Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Ulm, Germany
| | - Michael Sonnabend
- Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Ulm, Germany
| | - Robin Lochbaum
- Institute of General Physiology, University of Ulm, Ulm, Germany
| | - Jan Wirsching
- Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Ulm, Germany
| | - Moona Sakari
- Institute of Biomedicine, Research Unit for Infection and Immunity, University of Turku, Turku, Finland
| | - Arto T Pulliainen
- Institute of Biomedicine, Research Unit for Infection and Immunity, University of Turku, Turku, Finland
| | - Ciaran Skerry
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicholas H Carbonetti
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Manfred Frick
- Institute of General Physiology, University of Ulm, Ulm, Germany
| | - Holger Barth
- Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Ulm, Germany.
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Ernst K, Sailer J, Braune M, Barth H. Intoxication of mammalian cells with binary clostridial enterotoxins is inhibited by the combination of pharmacological chaperone inhibitors. Naunyn Schmiedebergs Arch Pharmacol 2020; 394:941-954. [PMID: 33284399 PMCID: PMC8102464 DOI: 10.1007/s00210-020-02029-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 11/18/2020] [Indexed: 01/05/2023]
Abstract
Binary enterotoxins Clostridioides difficile CDT toxin, Clostridium botulinum C2 toxin, and Clostridium perfringens iota toxin consist of two separate protein components. The B-components facilitate receptor-mediated uptake into mammalian cells and form pores into endosomal membranes through which the enzymatic active A-components translocate into the cytosol. Here, the A-components ADP-ribosylate G-actin which leads to F-actin depolymerization followed by rounding of cells which causes clinical symptoms. The protein folding helper enzymes Hsp90, Hsp70, and peptidyl-prolyl cis/trans isomerases of the cyclophilin (Cyp) and FK506 binding protein (FKBP) families are required for translocation of A-components of CDT, C2, and iota toxins from endosomes to the cytosol. Here, we demonstrated that simultaneous inhibition of these folding helpers by specific pharmacological inhibitors protects mammalian, including human, cells from intoxication with CDT, C2, and iota toxins, and that the inhibitor combination displayed an enhanced effect compared to application of the individual inhibitors. Moreover, combination of inhibitors allowed a concentration reduction of the individual compounds as well as decreasing of the incubation time with inhibitors to achieve a protective effect. These results potentially have implications for possible future therapeutic applications to relieve clinical symptoms caused by bacterial toxins that depend on Hsp90, Hsp70, Cyps, and FKBPs for their membrane translocation into the cytosol of target cells.
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Affiliation(s)
- Katharina Ernst
- Institute of Pharmacology and Toxicology, Ulm University Medical Center, 89081, Ulm, Germany.
| | - Judith Sailer
- Institute of Pharmacology and Toxicology, Ulm University Medical Center, 89081, Ulm, Germany
| | - Maria Braune
- Institute of Pharmacology and Toxicology, Ulm University Medical Center, 89081, Ulm, Germany
| | - Holger Barth
- Institute of Pharmacology and Toxicology, Ulm University Medical Center, 89081, Ulm, Germany.
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