1.Down-regulating HIPK2 promotes cisplatin-induced apoptosis of human kidney tubular epithelial cells
Basic & Clinical Medicine 2017;37(7):1031-1036
Objective To explore the effect of HIPK2 on apoptosis of human kidney tubular epithelial cells (HKC) induced by cisplatin.Methods Apoptosis of HKC cells was induced by cisplatin and the expression of HIPK2 was detected by RT-qPCR and Western blot.Two HIPK2 siRNAs were designed according to gene sequence of HIPK2 and cell lines with HIPK2 knockdown were established through transfecting the HIPK2 siRNAs into HKC cells by liposome.The expression of HIPK2 mRNA and protein was detected by RT-qPCR and Western blot after induced by cisplatin.Then cell apoptosis was detected by Annexin V/PI after the HIPK2-knockdown cells were treated with cisplatin.Moreover,the expression of pro-apoptotic protein bax was detected by Western blot after HIPK2 was knockdown.Results The expression of HIPK2 mRNA and protein was down-regulated obviously on the process of HKC apoptosis which induced by dose-dependent cisplatin (P<0.05).The transfection of siRNA could significantly reduce the expression of HIPK2 mRNA and protein in HKC (P<0.05),which promotes the HKC cells apoptosis induced by cisplatin.Conclusions HIPK2 can suppress the HKC cells apoptosis induced by cisplatin.
2.Neutralizing anti-CD44 antibodies suppresses the growth of B16 cells and enhances AKT-mediated glycolytic metabolism in melanoma
Pei WEI ; Zhaohong LIU ; Yaya WU ; Yingming GUO ; Dongdan ZHANG ; Ting OU ; Jiayao ZHU ; Zhiyong WANG
Journal of Medical Postgraduates 2017;30(5):459-463
Objective CD44, a cell surface glycoprotein, plays an important role in tumor growth and glycolysis.The aim of this study was to investigate the effects of neutralizing CD44 antibodies on the growth and glycolytic metabolism of B16 cells in melanoma in vitro.Methods B16 cells were treated with control antibodies (50 μg/mL) or different concentrations of CD44 antibodies (2, 10, and 50 μg/mL) for 24 hours, followed by examination of the activation of the AKT pathway in the B16 cells by Western blot.Then the tumor cells were also treated with control antibodies (50 μg/mL) or CD44 antibodies (50μg/mL) after pretreated with API-2 (4 μmol/L) in a parallel test.After 48 hours of treatment, the expression of lactate dehydrogenase A (LDHA) in the B16 cells and the level of lactate in the culture supernatant were detected by immunofluorescence and colorimetry, respectively.Lastly, the B16 cells were treated with control antibodies (50μg/mL), API-2 (4 μmol/L), CD44 antibodies (50μg/mL), or API-2 + CD44 antibodies for 96 hours, followed by measurement of the proliferation of the cells by MTT and their apoptosis by AO/EB and AnnexinV staining.Results In comparison with the control antibody group, the level of AKT phosphorylation (p-AKT) in the B16 cells showed a concentration-dependent increase in the 2, 10, and 50 μg/mL CD44 antibody groups (1.00±0.25 vs 2.51±0.32, 3.89±0.46, and 4.07±0.42, P<0.01), and the expression of LDHA was increased by (2.13±0.24) times, with the lactate level in the culture supernatant significantly elevated from (35.32±3.24) to (56.34±8.19) mmol/L (P<0.01) after 96 hours of treatment with 50 μg/mL CD44 antibodies.Treatment with API-2+CD44 antibodies, however, suppressed the increase in the LDHA expression and reduced the level of lactate.Compared with the control antibody group, the proliferation rate of the B16 cells was markedly decreased in the API-2, CD44 antibody, and API-2+CD44 antibody groups ([103±12.91] vs [84.87±19.35], [71.35±16.23], and [41.16±9.15]%, P<0.05), while the apoptosis rate remarkably increased ([5.23±0.96] vs [13.65±4.27], [19.21±3.53], and [43.21±7.87]%, P<0.01).Conclusion Neutralizing the function of CD44 in the B16 cells in vitro can inhibit the growth of the cells and promote AKT-mediated glycolytic metabolism, while suppressing the AKT pathway may enhance the antitumor activity of the CD44 antibody.
3.Preparation and performance characterization of electrospun drug loaded poly (vinyl alcohol)/chitosan nanofibrous membrane.
Yani ZHANG ; Shanwei WU ; Jiayao XU ; Wei CHEN ; Yuanyuan LV
Journal of Zhejiang University. Medical sciences 2013;42(6):644-648
OBJECTIVETo prepare nanofibrous membranes of poly (vinyl alcohol)/chitosan (PVA/CS) loaded with varied salvianic acid A sodium (SAS) contents.
METHODSUltrafine fiber mats were prepared with PVA/CS as matrix and SAS as model drug. The structure and morphology of the nanofibrous membranes were characterized by FT-IR and SEM. Drug-loading amount and drug release profiles of these membranes were determined by UV VIS spectra, and the degradation of the membranes was also investigated.
RESULTSAverage diameters of PVA/CS/SAS nanofibers with different SAS contents were 280 ≊390 nm. Drug-loading amount of these nanofibrous membranes was high and exhibited sustained and controlled release behavior for SAS.
CONCLUSIONThe PVA/CS/SAS nanofibrous membrane prepared in this study loads drug uniformly and has remarkably sustained release behavior, which may offer strategies for the research and development of novel topical drug delivery systems.
Chitosan ; chemical synthesis ; Drug Carriers ; Membranes, Artificial ; Nanofibers ; Polyvinyl Alcohol ; chemical synthesis
4.Comparative Genomics Platform and Phylogenetic Analysis of Fungal Laccases and Multi-Copper Oxidases
Jiayao WU ; Jaeyoung CHOI ; Fred O. ASIEGBU ; Yong-Hwan LEE
Mycobiology 2020;48(5):373-382
Laccases (EC 1.10.3.2), a group of multi-copper oxidases (MCOs), play multiple biological functions and widely exist in many species. Fungal laccases have been extensively studied for their industrial applications, however, there was no database specially focused on fungal laccases. To provide a comparative genomics platform for fungal laccases, we have developed a comparative genomics platform for laccases and MCOs (http://laccase.riceblast.snu.ac.kr/). Based on protein domain profiles of characterized sequences, 3,571 laccases were predicted from 690 genomes including 253 fungi. The number of putative laccases and their properties exhibited dynamic distribution across the taxonomy. A total of 505 laccases from 68 genomes were selected and subjected to phylogenetic analysis. As a result, four clades comprised of nine subclades were phylogenetically grouped by their putative functions and analyzed at the sequence level. Our work would provide a workbench for putative laccases mainly focused on the fungal kingdom as well as a new perspective in the identification and classification of putative laccases and MCOs.
5.Comparison of enhanced thin CT sections with pathologic findings in pulmonary carcinoma, inflammatory, pseudo-tumor and pulmonary tuberculoma.
Zhenfeng ZHANG ; Chenghui ZHANG ; Peihong WU ; Chaomei RUAN ; Lie ZHENG ; Weizhang ZHANG ; Jiayao LI ; Yaopan WU ; Peiqiang CAI
Chinese Journal of Oncology 2002;24(2):173-177
OBJECTIVETo compare quantitatively the enhanced thin CT section with pathologic findings in pulmonary carcinoma, pulmonary inflammatory pseudotumor (IPT) and pulmonary tuberculoma so as to demonstrate the relation of degree of enhancement and the vascular structure within the lesion with special emphasis on pulmonary carcinoma.
METHODSEnhanced thin CT sections were obtained in 35 cases with nodular or patchy lesions in the peripheral lung field which are difficult to differentiate clinically. There were pulmonary carcinoma 21, inflammatory pseudotumor 7 and tuberculoma 7. The number of small vessels (inner diameter 0.02 approximately 0.1 mm), relatively large vessels (inner diameter > 0.1 mm) and their vascular bed areas were analyzed by computed image analyzing system. The relation between CT average attenuation and the number of vessels or the vascular bed areas were statistically evaluated.
RESULTS1. The differences of average attenuation in carcinoma, inflammatory pseudotumor and tuberculoma were statistically significant (P < 0.05). 2. The differences in number of small vessels, relatively large vessels and vascular bed areas among these three types of lesion were also significant (P < 0.05). 3. A positive correlation was found in the average CT affenuation of lung carcinoma and its number of small vessels and relatively large vessels and 4. A positive correlation was found between the average CT attenuation in these three lesions and the relatively large vessels, total vascular amount and vascular bed areas.
CONCLUSIONS1. The average degree of attenuation, being divided into four degrees, is of practical value in the differentiation of lung carcinoma, inflammatory pseudotumor and tuberculoma. 2. The average CT attenuation of lung carcinoma, inflammatory pseudotumor and tuberculoma is in direct proportion to the number of vessels and vessel bed areas and 3. The characteristic CT enhancement in lung carcinoma reflexes the condition of vessels and blood supply within the tumor.
Adult ; Aged ; Female ; Humans ; Lung ; blood supply ; diagnostic imaging ; pathology ; Lung Neoplasms ; diagnostic imaging ; pathology ; Male ; Middle Aged ; Plasma Cell Granuloma, Pulmonary ; diagnostic imaging ; pathology ; Tomography, X-Ray Computed ; methods ; Tuberculoma ; diagnostic imaging ; pathology ; Tuberculosis, Pulmonary ; diagnostic imaging ; pathology
6.Analysis of the trend of medication use in patients with ulcerative colitis in a single center from 2010 to 2019
Xianmin XUE ; Song SU ; He ZHOU ; Yujie ZHANG ; Jiayao WANG ; Yirong JIN ; Yongquan SHI ; Kaichun WU ; Jie LIANG
Chinese Journal of Digestion 2021;41(9):624-628
Objective:To analyze the trend of medication use in patients with ulcerative colitis (UC) in recent ten years in at Xijing Hospital, Air Force Military Medical University.Methods:From 2010 to 2019, the clinical data of 1 425 patients diagnosed with UC in the Department of Gastroenterology at Xijing Hospital, Air Force Medical University, were retrospectively collected. According to the period of medication, the UC patients were divided into year 2010 to 2014 group and year 2015 to 2019 group. The general information and the medication trend of year 2010 to 2014 group and year 2015 to 2019 group were analyzed. And then according to gender and age (<40 years old and ≥40 years old), patients were divided into subgroups and analyzed. Independent sample t test and chi-square test were used for statistical analysis. Results:The number of UC patients of year 2010 to 2014 group and year 2015 to 2019 group was 369 and 1 056, respectively. The percentages of patients in remission of the two groups were 9.5% (35/369) and 12.0% (127/1 056), respectively; the percentages of mild patients were 40.4% (149/369) and 41.6% (439/1 056), respectively; the percentages of moderate patients were 37.4% (138/369) and 28.9% (305/1 056), respectively; the percentages of severe patients were 12.7% (47/369) and 17.5% (185/1 056), respectively. There was no significant difference in the proportion of UC patients with different degrees between year 2010 to 2014 group and year 2015 to 2019 group ( P>0.05). There were no significant differences in the age and proportion of female between the year 2010 to 2014 group and year 2015 to 2019 group ((46.2±15.3) years old vs. (44.6±30.6) years old; 45.8%, 169/369 vs. 44.8%, 473/1 056; both P>0.05). The utilization rates of 5-aminosalicylic acid (5-ASA), glucocorticoid, immunosuppressants, and biological agents of the year 2015 to 2019 group were all higher than those of the year 2010 to 2014 group (96.8%, 1 022/1 056 vs. 90.0%, 332/369; 29.9%, 316/1 056 vs. 14.6%, 54/369; 8.4%, 89/1 056 vs. 2.4%, 9/369; 4.8%, 51/1 056 vs. 0.5%, 2/369, respectively), and the differences were all statistically significant ( χ2=26.766, 33.256, 15.315 and 14.038, all P<0.01). Within each of the year 2010 to 2014 group and the year 2015 to 2019 group, there were no significant differences between the female and male in the age, utilization rates of 5-ASA, glucocorticoid, immunosuppressants and biological agents ((47.2±13.6) years old vs. (45.3±16.5) years old, (43.1±12.9) years old vs. (45.8±39.5) years old, 88.8%, 150/169 vs. 91.0%, 182/200; 96.8%, 458/473 vs. 96.7%, 564/583; 13.6%, 23/169 vs. 15.5%, 31/200; 28.3%, 134/473 vs. 31.2%, 182/583; 2.4%, 4/169 vs. 2.5%, 5/200; 7.0%, 33/473 vs. 9.6%, 56/583; 0 vs. 1.0%, 2/200; 5.3%, 25/473 vs. 4.5%, 26/583; all P>0.05). In the patients aged≥40 years old of the year 2010 to 2014 group, the proportion of females was higher than that of the patients aged <40 years old (50.2%, 121/241 vs. 37.5%, 48/128), and the utilization rate of 5-ASA in patients aged ≥40 years old was lower than that of patients aged <40 years old (85.9%, 207/241 vs. 97.7%, 125/128), and the differences were statistically significant ( χ2=5.438 and 12.824, P=0.020 and P<0.01). In the year 2010 to 2014 group, there were no statistically significant differences in the utilization rates of glucocorticoid, immunosuppressants and biological agents between patients aged ≥40 years old and patients aged <40 years old (13.7%, 33/241 vs. 16.4%, 21/128; 2.1%, 5/241 vs. 3.1%, 4/128; 0 vs. 1.6%, 2/128; all P>0.05). In the year 2015 to 2019 group, the utilization rate of biological agents in patients aged≥40 years old was lower than that in patients aged<40 years old (3.7%, 23/630 vs. 46.5%, 198/426), and the difference was statistically significant ( χ2=4.721, P=0.030). In the year 2015 to 2019 group, there were no statistically significant differences in female proportion, utilization rates of 5-ASA, glucocorticoid, immunosuppressants and biological agents between patients aged≥40 years old and patients aged <40 years old (43.7%, 275/630 vs. 46.5%, 198/426; 96.0%, 605/630 vs. 97.9%, 417/426; 29.7%, 187/630 vs. 30.3%, 129/426; 8.6%, 54/630 vs. 8.2%, 35/426; all P>0.05). Conclusions:Compared with year 2010 to 2014, the number of UC patients remarkably increased in the year 2015 to 2019 in the Department of Gastroenterology, Xijing Hospiatal, Air Force Medical University. The utilization rates of 5-ASA, glucocorticoid, immunosuppressants and biological agents all increased in UC patients. The medication trends of UC patients with different gender were almost the same. The medication trends of UC patients with different age were different.
7.Application progress of machine learning in orthopedic diagnosis and treatment
Tongtong HUO ; Jiayao ZHANG ; Honglin WANG ; Jiaming YANG ; Wei WU ; Zhewei YE
International Journal of Biomedical Engineering 2023;46(4):355-359
In recent years, artificial intelligence-related technologies have been deeply combined with many medical fields, and the intersection of medicine and engineering has become a hot topic. There are problems with heavy data and difficulty making decisions in orthopedic disease diagnosis and treatment. Machine learning is an important method of artificial intelligence. Since it can automatically analyze and predict medical big data, it is widely used in the field of orthopedics. It also assists physicians in completing disease diagnosis and treatment efficiently. In this review paper, the application and progress of machine learning in preoperative, intraoperative, and postoperative diagnosis and treatment in orthopedics are reviewed, providing new ways for exploring more rational diagnosis and treatment strategies.
8.A real-world study of first-line albumin-bound paclitaxel in the treatment of advanced pancreatic cancer in China
Juan DU ; Xin QIU ; Jiayao NI ; Qiaoli WANG ; Fan TONG ; Huizi SHA ; Yahui ZHU ; Liang QI ; Wei CAI ; Chao GAO ; Xiaowei WEI ; Minbin CHEN ; Zhuyin QIAN ; Maohuai CAI ; Min TAO ; Cailian WANG ; Guocan ZHENG ; Hua JIANG ; Anwei DAI ; Jun WU ; Minghong ZHAO ; Xiaoqin LI ; Bin LU ; Chunbin WANG ; Baorui LIU
Chinese Journal of Oncology 2024;46(11):1038-1048
Objective:To observe and evaluate the clinical efficacy and safety of albumin-bound paclitaxel as first-line treatment for patients with advanced pancreatic cancer in China, and to explore the prognosis-related molecules in pancreatic cancer based on next-generation sequencing (NGS) of tumor tissues.Methods:From December 2018 to December 2020, patients with locally advanced or metastatic pancreatic cancer were recruited to accept albumin-bound paclitaxel as first-line treatment in the oncology departments of 24 hospitals in East China. The primary endpoints were overall survival (OS) and treatment related adverse events, and the secondary endpoint was progression-free survival (PFS). Adverse effects were graded using Common Terminology Criteria for Adverse Events 5.0 (CTCAE 5.0). NGS sequencing on the primary or metastatic tissue samples of pancreatic cancer obtained through surgical resection or biopsy was performed.Results:This study recruited 229 patients, including 70 patients with locally advanced pancreatic cancer (LAPC) and 159 patients with metastatic pancreatic cancer (mPC). The disease control rate was 79.9% and the objective response rate is 36.3%.The common adverse effects during treatment were anaemia (159 cases), leucopenia (170 cases), neutropenia (169 cases), increased aminotransferases (110 cases), and thrombocytopenia (95 cases), and the incidence of grade 3-4 neutropenia is 12.2% (28/229). The median follow-up time was 21.2 months (95% CI: 18.5-23.1 months). The median PFS (mPFS) was 5.3 months (95% CI: 4.37-4.07 months) and the median OS (mOS) was 11.2 months (95% CI: 9.5-12.9 months). The mPFS of patients with LAPC was 7.4 months (95% CI: 6.6-11.2 months), and their mOS was 15.5 months (95% CI: 12.6-NA months). The mPFS of patients with mPC was 3.9 months (95% CI: 3.4-5.1 months), and their mOS was 9.3 months (95% CI: 8.0-10.8 months). Multivariate Cox regression analysis showed that clinical stage ( HR=1.47, 95% CI: 1.06-2.04), primary tumor site ( HR=0.64, 95% CI: 0.48-0.86), Eastern Cooperative Oncology Group Performance Status (ECOG PS) score ( HR=2.66, 95% CI: 1.53-4.65), and whether to combine radiotherapy ( HR=0.65, 95% CI: 0.42-1.00) were independent influencing factors for the PFS of these patients. The primary tumor site ( HR=0.68, 95% CI: 0.48-0.95), ECOG score ( HR=5.82, 95% CI: 3.14-10.82), and whether to combine radiotherapy ( HR=0.58, 95% CI: 0.35-0.96) were independent influencing factors of the OS of these patients. The most frequent gene mutations in these advanced stage pancreatic patients were KRAS (89.66%), TP53 (77.01%), CDKN2A (32.18%), and SMAD4 (21.84%) by NGS of tumor tissues from 87 pancreatic cancer patients with sufficient specimens. Further analysis revealed that mutations in CDKN2B, PTEN, FGF6, and RBBP8 genes were significantly associated with an increased risk of death ( P<0.05). Conclusion:Albumin-bound paclitaxel as first-line treatment demonstrated feasible anti-tumor efficacy and manageable safety for patients with advanced pancreatic cancer in China.
9.A real-world study of first-line albumin-bound paclitaxel in the treatment of advanced pancreatic cancer in China
Juan DU ; Xin QIU ; Jiayao NI ; Qiaoli WANG ; Fan TONG ; Huizi SHA ; Yahui ZHU ; Liang QI ; Wei CAI ; Chao GAO ; Xiaowei WEI ; Minbin CHEN ; Zhuyin QIAN ; Maohuai CAI ; Min TAO ; Cailian WANG ; Guocan ZHENG ; Hua JIANG ; Anwei DAI ; Jun WU ; Minghong ZHAO ; Xiaoqin LI ; Bin LU ; Chunbin WANG ; Baorui LIU
Chinese Journal of Oncology 2024;46(11):1038-1048
Objective:To observe and evaluate the clinical efficacy and safety of albumin-bound paclitaxel as first-line treatment for patients with advanced pancreatic cancer in China, and to explore the prognosis-related molecules in pancreatic cancer based on next-generation sequencing (NGS) of tumor tissues.Methods:From December 2018 to December 2020, patients with locally advanced or metastatic pancreatic cancer were recruited to accept albumin-bound paclitaxel as first-line treatment in the oncology departments of 24 hospitals in East China. The primary endpoints were overall survival (OS) and treatment related adverse events, and the secondary endpoint was progression-free survival (PFS). Adverse effects were graded using Common Terminology Criteria for Adverse Events 5.0 (CTCAE 5.0). NGS sequencing on the primary or metastatic tissue samples of pancreatic cancer obtained through surgical resection or biopsy was performed.Results:This study recruited 229 patients, including 70 patients with locally advanced pancreatic cancer (LAPC) and 159 patients with metastatic pancreatic cancer (mPC). The disease control rate was 79.9% and the objective response rate is 36.3%.The common adverse effects during treatment were anaemia (159 cases), leucopenia (170 cases), neutropenia (169 cases), increased aminotransferases (110 cases), and thrombocytopenia (95 cases), and the incidence of grade 3-4 neutropenia is 12.2% (28/229). The median follow-up time was 21.2 months (95% CI: 18.5-23.1 months). The median PFS (mPFS) was 5.3 months (95% CI: 4.37-4.07 months) and the median OS (mOS) was 11.2 months (95% CI: 9.5-12.9 months). The mPFS of patients with LAPC was 7.4 months (95% CI: 6.6-11.2 months), and their mOS was 15.5 months (95% CI: 12.6-NA months). The mPFS of patients with mPC was 3.9 months (95% CI: 3.4-5.1 months), and their mOS was 9.3 months (95% CI: 8.0-10.8 months). Multivariate Cox regression analysis showed that clinical stage ( HR=1.47, 95% CI: 1.06-2.04), primary tumor site ( HR=0.64, 95% CI: 0.48-0.86), Eastern Cooperative Oncology Group Performance Status (ECOG PS) score ( HR=2.66, 95% CI: 1.53-4.65), and whether to combine radiotherapy ( HR=0.65, 95% CI: 0.42-1.00) were independent influencing factors for the PFS of these patients. The primary tumor site ( HR=0.68, 95% CI: 0.48-0.95), ECOG score ( HR=5.82, 95% CI: 3.14-10.82), and whether to combine radiotherapy ( HR=0.58, 95% CI: 0.35-0.96) were independent influencing factors of the OS of these patients. The most frequent gene mutations in these advanced stage pancreatic patients were KRAS (89.66%), TP53 (77.01%), CDKN2A (32.18%), and SMAD4 (21.84%) by NGS of tumor tissues from 87 pancreatic cancer patients with sufficient specimens. Further analysis revealed that mutations in CDKN2B, PTEN, FGF6, and RBBP8 genes were significantly associated with an increased risk of death ( P<0.05). Conclusion:Albumin-bound paclitaxel as first-line treatment demonstrated feasible anti-tumor efficacy and manageable safety for patients with advanced pancreatic cancer in China.
10.Construction of evaluation system for clinical effectiveness of Drug Selection Guideline for Medical Institutions
Bin HAN ; Jiayao WU ; Dong XIE ; Lu YU ; Weilong ZHONG ; Rong DUAN ; Zhengxiang LI
China Pharmacy 2022;33(5):524-529
OBJECTIVE To establish an evaluation syste m of clinical effec tiveness of Drug Selection Guideline for Medical Institutions,and to provide reference for drug selection in medical institution. METHODS Retrieved from relevant Chinese government websites ,PubMed,Embase,CBM and CNKI ,etc.,from the inception to Sept. 14th 2021,related contents of clinical effectiveness related to three secondary indicators ,such as “recommended level and strength of guideline ”“clinical pathway ”and “evidence and level of efficacy ”were extracted respectively ;evaluation system was construction for the clinical effectiveness. RESULTS A total of 5,4 and 17 policy documents or literatures were included according to “recommended level and strength of guideline”“clinical pathway ”and“evidence and level of efficacy ”,respectively.“The recommended level and strength of drug guideline”could reflect the clinical effectiveness of drugs ,and the evaluation content referred to the recommended level and strength of the selected drugs in the guidelines for corresponding indications. “Clinical pathway ”was the embodiment of drug effectiveness, and the evaluation content referred to the clinical path of whether the selected drugs were included in the corresponding indications. The evaluation contents of “evidence and level of efficacy ”were different between chemical medicine/ biological agent and Chinese patent medicine ;evidence and quality level of efficacy research for chemical medicine/biological agent referred to GRADE system ,while those for Chinese patent medicine referred to classic works or clinical experience inheritance. Therefore,the evaluation contents of this index system were the evidence and quality level of the efficacy research related to selected drugs. CONCLUSIONS The evaluation system of clinical effectiveness of drugs constructed from the perspective of drug selection in medical institutions can lay the foundation of evaluation system for the construction of Drug Selection Guideline for Medical Institutions ,and also provide reference for drug selection in medical institutions.