1
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Bierling TEH, Gumann A, Ottmann SR, Schulz SR, Weckwerth L, Thomas J, Gessner A, Wichert M, Kuwert F, Rost F, Hauke M, Freudenreich T, Mielenz D, Jäck HM, Pracht K. GLUT1-mediated glucose import in B cells is critical for anaplerotic balance and humoral immunity. Cell Rep 2024; 43:113739. [PMID: 38340319 DOI: 10.1016/j.celrep.2024.113739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/14/2023] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Glucose uptake increases during B cell activation and antibody-secreting cell (ASC) differentiation, but conflicting findings prevent a clear metabolic profile at different stages of B cell activation. Deletion of the glucose transporter type 1 (GLUT1) gene in mature B cells (GLUT1-cKO) results in normal B cell development, but it reduces germinal center B cells and ASCs. GLUT1-cKO mice show decreased antigen-specific antibody titers after vaccination. In vitro, GLUT1-deficient B cells show impaired activation, whereas established plasmablasts abolish glycolysis, relying on mitochondrial activity and fatty acids. Transcriptomics and metabolomics reveal an altered anaplerotic balance in GLUT1-deficient ASCs. Despite attempts to compensate for glucose deprivation by increasing mitochondrial mass and gene expression associated with glycolysis, the tricarboxylic acid cycle, and hexosamine synthesis, GLUT1-deficient ASCs lack the metabolites for energy production and mitochondrial respiration, limiting protein synthesis. We identify GLUT1 as a critical metabolic player defining the germinal center response and humoral immunity.
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Affiliation(s)
- Theresa E H Bierling
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Amelie Gumann
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Shannon R Ottmann
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian R Schulz
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Leonie Weckwerth
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Jana Thomas
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Arne Gessner
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Magdalena Wichert
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Frederic Kuwert
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Franziska Rost
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Manuela Hauke
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Tatjana Freudenreich
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Dirk Mielenz
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Hans-Martin Jäck
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Katharina Pracht
- Division of Molecular Immunology, Internal Medicine III, University Hospital Erlangen, Nikolaus-Fiebiger Center, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.
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2
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Urbanczyk S, Baris OR, Hofmann J, Taudte RV, Guegen N, Golombek F, Castiglione K, Meng X, Bozec A, Thomas J, Weckwerth L, Mougiakakos D, Schulz SR, Schuh W, Schlötzer-Schrehardt U, Steinmetz TD, Brodesser S, Wiesner RJ, Mielenz D. Mitochondrial respiration in B lymphocytes is essential for humoral immunity by controlling the flux of the TCA cycle. Cell Rep 2022; 39:110912. [PMID: 35675769 DOI: 10.1016/j.celrep.2022.110912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 12/28/2021] [Accepted: 05/12/2022] [Indexed: 11/03/2022] Open
Abstract
To elucidate the function of oxidative phosphorylation (OxPhos) during B cell differentiation, we employ CD23Cre-driven expression of the dominant-negative K320E mutant of the mitochondrial helicase Twinkle (DNT). DNT-expression depletes mitochondrial DNA during B cell maturation, reduces the abundance of respiratory chain protein subunits encoded by mitochondrial DNA, and, consequently, respiratory chain super-complexes in activated B cells. Whereas B cell development in DNT mice is normal, B cell proliferation, germinal centers, class switch to IgG, plasma cell maturation, and T cell-dependent as well as T cell-independent humoral immunity are diminished. DNT expression dampens OxPhos but increases glycolysis in lipopolysaccharide and B cell receptor-activated cells. Lipopolysaccharide-activated DNT-B cells exhibit altered metabolites of glycolysis, the pentose phosphate pathway, and the tricarboxylic acid cycle and a lower amount of phosphatidic acid. Consequently, mTORC1 activity and BLIMP1 induction are curtailed, whereas HIF1α is stabilized. Hence, mitochondrial DNA controls the metabolism of activated B cells via OxPhos to foster humoral immunity.
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Affiliation(s)
- Sophia Urbanczyk
- Division of Molecular Immunology, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Olivier R Baris
- MitoVasc, University of Angers, UMR CNRS 6015/INSERM U1083, Angers, France
| | - Jörg Hofmann
- Chair of Biochemistry, Department Biology, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - R Verena Taudte
- Institute of Experimental and Clinical Pharmacology and Toxicology, Universitätsklinikum Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Naïg Guegen
- MitoVasc, University of Angers, UMR CNRS 6015/INSERM U1083, Angers, France; Department of Biochemistry and Genetics, University Hospital, Angers, France
| | - Florian Golombek
- Chair of Bioprocess Engineering, Technical Faculty, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Kathrin Castiglione
- Chair of Bioprocess Engineering, Technical Faculty, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Xianyi Meng
- Deparment of Internal Medicine III, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Aline Bozec
- Deparment of Internal Medicine III, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Jana Thomas
- Division of Molecular Immunology, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Leonie Weckwerth
- Division of Molecular Immunology, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Dimitrios Mougiakakos
- Deparment of Internal Medicine V, Universitätsklinikum Erlangen, Translational Research Center, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian R Schulz
- Division of Molecular Immunology, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Wolfgang Schuh
- Division of Molecular Immunology, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany
| | | | - Tobit D Steinmetz
- Division of Molecular Immunology, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Brodesser
- University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cluster of Excellence Cellular Stress Responses in Aging-associated Diseases (CECAD), Cologne, Germany
| | - Rudolf J Wiesner
- University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cluster of Excellence Cellular Stress Responses in Aging-associated Diseases (CECAD), Cologne, Germany; Center for Physiology and Pathophysiology, Institute of Vegetative Physiology and Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Dirk Mielenz
- Division of Molecular Immunology, Universitätsklinikum Erlangen, Nikolaus-Fiebiger-Zentrum, FAU Erlangen-Nürnberg, Erlangen, Germany.
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3
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Schuh W, Baus L, Steinmetz T, Schulz SR, Weckwerth L, Roth E, Hauke M, Krause S, Morhart P, Rauh M, Hoffmann M, Vesper N, Reth M, Schneider H, Jäck H, Mielenz D. A surrogate cell-based SARS-CoV-2 spike blocking assay. Eur J Immunol 2021; 51:2665-2676. [PMID: 34547822 PMCID: PMC8646767 DOI: 10.1002/eji.202149302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/29/2021] [Accepted: 09/17/2021] [Indexed: 01/08/2023]
Abstract
To monitor infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and successful vaccination against coronavirus disease 2019 (COVID-19), the kinetics of neutralizing or blocking anti-SARS-CoV-2 antibody titers need to be assessed. Here, we report the development of a quick and inexpensive surrogate SARS-CoV-2 blocking assay (SUBA) using immobilized recombinant human angiotensin-converting enzyme 2 (hACE2) and human cells expressing the native form of surface SARS-CoV-2 spike protein. Spike protein-expressing cells bound to hACE2 in the absence or presence of blocking antibodies were quantified by measuring the optical density of cell-associated crystal violet in a spectrophotometer. The advantages are that SUBA is a fast and inexpensive assay, which does not require biosafety level 2- or 3-approved laboratories. Most importantly, SUBA detects blocking antibodies against the native trimeric cell-bound SARS-CoV-2 spike protein and can be rapidly adjusted to quickly pre-screen already approved therapeutic antibodies or sera from vaccinated individuals for their ACE2 blocking activities against any emerging SARS-CoV-2 variants.
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Affiliation(s)
- Wolfgang Schuh
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Lena Baus
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Tobit Steinmetz
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Sebastian R. Schulz
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Leonie Weckwerth
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Edith Roth
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Manuela Hauke
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Sara Krause
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Patrick Morhart
- Division of Molecular Pediatrics, Department of PediatricsFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Manfred Rauh
- Division of Molecular Pediatrics, Department of PediatricsFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Markus Hoffmann
- Infection Biology UnitGerman Primate Center‐Leibniz Institute for Primate ResearchGöttingenGermany
- Faculty of Biology and PsychologyUniversity of GöttingenGöttingenGermany
| | - Niklas Vesper
- Institute of Biology III (Molecular Immunology)University of FreiburgFreiburgGermany
| | - Michael Reth
- Institute of Biology III (Molecular Immunology)University of FreiburgFreiburgGermany
| | - Holm Schneider
- Division of Molecular Pediatrics, Department of PediatricsFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Hans‐Martin Jäck
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
| | - Dirk Mielenz
- Division of Molecular Immunology, Department of Internal Medicine 3, Nikolaus‐Fiebiger‐ZentrumFriedrich‐Alexander‐Universität (FAU) Erlangen‐NürnbergErlangenGermany
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4
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Simon D, Tascilar K, Schmidt K, Manger B, Weckwerth L, Sokolova M, Bucci L, Fagni F, Manger K, Schuch F, Ronneberger M, Hueber A, Steffen U, Mielenz D, Herrmann M, Harrer T, Kleyer A, Krönke G, Schett G. Brief Report: Humoral and cellular immune responses to SARS-CoV-2 infection and vaccination in B cell depleted autoimmune patients. Arthritis Rheumatol 2021; 74:33-37. [PMID: 34196506 PMCID: PMC8427106 DOI: 10.1002/art.41914] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/29/2021] [Indexed: 12/04/2022]
Abstract
Objective B cell depletion is an established therapeutic principle in a wide range of autoimmune diseases. However, B cells are also critical for inducing protective immunity after infection and vaccination. We undertook this study to assess humoral and cellular immune responses after infection with or vaccination against SARS–CoV‐2 in patients with B cell depletion and controls who are B cell–competent. Methods Antibody responses (tested using enzyme‐linked immunosorbent assay) and T cell responses (tested using interferon‐γ enzyme‐linked immunospot assay) against the SARS–CoV‐2 spike S1 and nucleocapsid proteins were assessed in a limited number of previously infected (n = 6) and vaccinated (n = 8) autoimmune disease patients with B cell depletion, as well as previously infected (n = 30) and vaccinated (n = 30) healthy controls. Results As expected, B cell and T cell responses to the nucleocapsid protein were observed only after infection, while respective responses to SARS–CoV‐2 spike S1 were found after both infection and vaccination. A SARS–CoV‐2 antibody response was observed in all vaccinated controls (30 of 30 [100%]) but in none of the vaccinated patients with B cell depletion (0 of 8). In contrast, after SARS–CoV‐2 infection, both the patients with B cell depletion (spike S1, 5 of 6 [83%]; nucleocapsid, 3 of 6 [50%]) and healthy controls (spike S1, 28 of 30 [93%]; nucleocapsid, 28 of 30 [93%]) developed antibodies. T cell responses against the spike S1 and nucleocapsid proteins were found in both infected and vaccinated patients with B cell depletion and in the controls. Conclusion These data show that B cell depletion completely blocks humoral but not T cell SARS–CoV‐2 vaccination response. Furthermore, limited humoral immune responses are found after SARS–CoV‐2 infection in patients with B cell depletion.
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Affiliation(s)
- David Simon
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Koray Tascilar
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Katja Schmidt
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Leonie Weckwerth
- Division of Molecular Immunology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Maria Sokolova
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Laura Bucci
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Filippo Fagni
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | | | - Axel Hueber
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Ulrike Steffen
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Dirk Mielenz
- Division of Molecular Immunology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Martin Herrmann
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Thomas Harrer
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Arnd Kleyer
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Gerhard Krönke
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.,Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
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5
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Ottenbacher K, Malter R, Weckwerth L. A toilet seat arrangement for children with neuromotor dysfunction. Am J Occup Ther 1979; 33:193. [PMID: 474335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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