1.Dual rheumatoid factor and anti-cyclic citrullinated peptide antibody positivity affects the manifestations of rheumatoid arthritis.
Li Huan Angela Marie CHAN ; Khai Pang LEONG ; Justina Wei Lynn TAN ; Xiao GAO ; Wei Qiang SEE ; Ee Tzun KOH
Singapore medical journal 2025;66(9):486-491
INTRODUCTION:
Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) are used in the diagnosis and prognostication of rheumatoid arthritis (RA). We wanted to determine the specific contributions of RF and ACPA to the biological nature of RA and whether they act synergistically.
METHODS:
We identified 731 patients from our prospective multi-ethnic RA cohort and categorised them into four groups: ACPA-positive, RF-positive, doubly positive and doubly negative. We compared the demographics, Disease Activity Score-28, Health Assessment Questionnaire score, quality of life using Short Form 36 and the use of prednisolone and disease-modifying antirheumatic drugs (DMARDs) of these patient groups.
RESULTS:
Four hundred and ninety-one patients (67.2%) were ACPA+RF+, 54 (7.4%) were ACPA+RF-, 82 (11.2%) were ACPA-RF+ and 104 (14.2%) were ACPA-RF-. Mean disease duration before the study entry was not different in the four groups. Patients with older age of onset were less likely to be positive for RF and ACPA. Fewer ACPA+RF+ patients were in remission compared to those in the other groups ( P < 0.05). Erythrocyte sedimentation rate (ESR) was higher at study entry in the ACPA+RF+ group (40.4 mm/h vs. 30.6-30.9 mm/h, P < 0.05). Prednisolone and number of DMARDs used were higher in the ACPA+RF+ group compared to the doubly negative group. There were no differences in the functional status and quality of life.
CONCLUSIONS
RA patients who were positive for both ACPA and RF had lower remission rate, higher baseline ESR and required more corticosteroid and DMARD treatment compared to those who were singly positive or doubly negative. Being doubly positive confers a worse outcome to RA patients.
Humans
;
Arthritis, Rheumatoid/diagnosis*
;
Male
;
Female
;
Middle Aged
;
Rheumatoid Factor/blood*
;
Anti-Citrullinated Protein Antibodies/blood*
;
Adult
;
Quality of Life
;
Prospective Studies
;
Antirheumatic Agents/therapeutic use*
;
Aged
;
Peptides, Cyclic/immunology*
;
Prednisolone/therapeutic use*
;
Surveys and Questionnaires
;
Severity of Illness Index
;
Prognosis
2.The IL-23p19 monoclonal antibody significantly alleviates nephritis in MRL/lpr lupus mice by modulating the Th17/Treg balance.
Wei CHENG ; Saizhe SONG ; Yu SHEN ; Cuiping LIU ; Xin CHANG ; Jian WU
Chinese Journal of Cellular and Molecular Immunology 2025;41(7):620-628
Objective To investigate the therapeutic effects of interleukin 23p19(IL-23p19) monoclonal antibody in the MRL/lpr lupus-like mouse model. Methods A total of 36 female MRL/lpr mice aged 8 weeks were randomly divided into 6 groups: PBS group (blank control), IgG group (isotype IgG), dexamethasone (DEX) group (positive control), and three IL-23p19 monoclonal antibody treatment groups with different dose gradients: low dose (LD, 1 mg/kg), medium dose (MD, 3 mg/kg), and high dose (HD, 10 mg/kg). Drug intervention began at 12 weeks of age via tail vein injection. Urine protein levels were measured using urine protein test strips; serum anti-dsDNA antibody levels were detected by ELISA; serum creatinine and blood urea nitrogen levels were measured using an automatic biochemical analyzer; renal histopathological changes were analyzed by H&E and PAS staining; immunofluorescence was used to assess IgG and C3 immune complex deposition in kidney tissues; flow cytometry was employed to examine the expression of T helper 1(Th1), Th2, Th17, T follicular helper (Tfh), and regulatory T cells(Treg) cell subsets in the spleen; and RT-qPCR was used to detect the expression of related transcription factors in the spleen. Results IL-23p19 monoclonal antibody reduced urine protein levels, alleviated splenomegaly, improved renal function, and decreased anti-dsDNA antibody levels in MRL/lpr mice. It also mitigated glomerulonephritis and reduced renal immune complex deposition. Furthermore, IL-23p19 monoclonal antibody significantly suppressed the proportion of Th1 and Th17 cells while upregulating Treg cell proportion in the spleen. Additionally, it downregulated T-bet and retinoic acid receptor-related orphan receptor γt (RORγt) mRNA levels and upregulated forkhead box P3(FOXP3) mRNA levels in the spleen. Conclusions IL-23p19 monoclonal antibody demonstrates significant therapeutic effects in MRL/lpr mice, likely through modulation of the Th17/Treg cell balance.
Animals
;
Female
;
Mice, Inbred MRL lpr
;
T-Lymphocytes, Regulatory/drug effects*
;
Th17 Cells/drug effects*
;
Antibodies, Monoclonal/therapeutic use*
;
Interleukin-23 Subunit p19/immunology*
;
Mice
;
Lupus Nephritis/drug therapy*
;
Kidney/drug effects*
;
Antibodies, Antinuclear/blood*
3.A Retrospective Analysis of Irregular Erythrocyte Antibodies in the Blood Transfusion Department of People's Hospital of Xinjiang Uygur Autonomous Region from 2011 to 2022.
Ru-Bin WANG ; Hui-Jun LI ; Fei LI ; Wei CHEN
Journal of Experimental Hematology 2025;33(1):211-216
OBJECTIVE:
The distribution of irregular erythrocyte antibodies in the blood transfusion department of the People's Hospital of Xinjiang Uygur Autonomous Region from 2011 to 2022 and the relationship between irregular erythrocyte antibodies and ethnicity, gender, pregnancy history, blood transfusion history were retrospectively analyzed.
METHODS:
The irregular antibody screening data of patients who were proposed to receive blood transfusions in the clinical blood transfusion safety and blood management software of our hospital from 2011 to 2022 were collected for a retrospective study, and the distribution of irregular erythrocyte antibodies from 2011 to 2022 was analyzed. The relationship between ethnicity, gender, pregnancy history, blood transfusion history and the detection rate of irregular erythrocyte antibodies was further analyzed.
RESULTS:
From 2011 to 2022, the positive detection rate of irregular erythrocyte antibodies in 329 270 samples was 0.77%. Rh blood group (43.72%), Lewis blood group (9.90%) and MNS blood group (6.44%) accounted for the highest proportion of irregular erythrocyte antibody positive samples. In Rh blood group, the proportion of anti-D and anti-E in positive samples was the highest, with 19.09% and 16.06%, respectively. In MNS blood group, the proportion of anti-M in positive samples was the highest (5.46%). In Lewis blood group, the proportion of anti-Lea in positive samples was the highest (8.80%). Compared with other ethnic groups, the detection rates of irregular erythrocyte antibodies were significantly higher in Han, Hui and Uyghur ethnic groups (P < 0.001). Irregular erythrocyte antibody positive samples in Rh blood group system were concentrated in Han and Uygur ethnic groups. Compared to males and patients without a history of blood transfusion and pregnancy, female patients and patients with a history of blood transfusion and pregnancy had significantly higher detection rates of irregulart erythrocyte antibodies (P < 0.01).
CONCLUSION
The results of irregular antibody screening before blood transfusion showed that Rh blood group system antibodies were the main type of irregular antibodies, and the screening of various Rh blood group antigens should be strengthened. And the screening should be focused on female, patients with blood transfusion history and pregnancy history, as well as ethnic minority patients.
Humans
;
Retrospective Studies
;
Female
;
Blood Transfusion
;
China
;
Rh-Hr Blood-Group System/immunology*
;
Male
;
Erythrocytes/immunology*
;
Pregnancy
;
Isoantibodies/blood*
;
Blood Grouping and Crossmatching
;
Antibodies
;
Adult
;
Blood Group Antigens/immunology*
4.Screening of High-Titer IgG Antibodies to 2019-nCoV among Voluntary Blood Donors in Zunyi.
Liang-Xue WEN ; Li SU ; Sheng-Jun ZENG ; Lan-Yi ZHANG ; Si-Hai HUANG
Journal of Experimental Hematology 2025;33(2):526-529
OBJECTIVE:
To investigate the serological prevalence of high-titer IgG antibodies against 2019-nCoV among voluntary blood donors in Zunyi.
METHODS:
The blood plasma specimens were diluted at 1∶160 or 1∶320, then tested for the presence of 2019-nCoV IgG antibodies by using an indirect enzyme-linked immunosorbent assay(ELISA). The differences of antibody reactive rate among different genders, ages, and blood types were analyzed.
RESULTS:
1 523 reactive specimens were identified in 5 378 specimens which were diluted at a ratio of 1∶160. Similarly, 329 reactive specimens were identified in 2 988 diluted at 1∶320. The overall reactive rate for antibodies was 22.1%. It was observed that females, individuals over the age of 40, and those with blood type AB exhibited higher high-titer antibody reactive rate.
CONCLUSION
After entering a new stage of 2019-nCoV infection prevention and control, there is a relatively high detection rate of high-titer 2019-nCoV IgG antibodies among voluntary blood donors in Zunyi. The reactive rate of antibodies varies among different genders, ages, and blood types.
Humans
;
Blood Donors
;
Immunoglobulin G/blood*
;
Antibodies, Viral/blood*
;
SARS-CoV-2/immunology*
;
COVID-19
;
Female
;
Enzyme-Linked Immunosorbent Assay
;
Adult
;
China
;
Male
;
Middle Aged
5.Investigation of Infection in HBV-Reactive Blood Donors in Wuhan.
Hao YANG ; Qin YU ; Ting-Ting XU ; Lei ZHAO
Journal of Experimental Hematology 2025;33(3):875-880
OBJECTIVE:
To investigate the pattern of hepatitis B virus (HBV) infection and the prevalence of hepatitis D virus (HDV) infection among voluntary blood donors who tested reactive for HBV in Wuhan, and to provide data support for the prevention and treatment of HBV and HDV infections.
METHODS:
Electrochemiluminescence (ECL) method was used to detect hepatitis B serological markers in the samples with HBsAg and/or HBV DNA reactivity, and the HBV infection in different groups was statistically analyzed. The HDV IgM and IgG antibodies were screened by ELISA, and the prevalence of HDV infection in the retained samples was analyzed.
RESULTS:
In 351 ELISA and/or nucleic acid test (NAT) reactive samples, the serological tests for hepatitis B revealed that 4 cases (1.1%) were positive for HBsAg, HBeAg, and anti-HBc, 182 cases (51.9%) were positive for HBsAg, anti-HBe, and anti-HBc, and 55 cases (15.7%) were negative for HBsAg but positive for anti-HBc. Among them, the HBsAg ELISA dual reagent reactive group (HBsAg R&R group) and the HBsAg ELISA single reagent reactive/HBV DNA reactive group (HBsAg R&NR/HBV DNA R group) had the highest rates of HBsAg(+), anti-HBe(+), and anti-HBc(+), accounting for more than 90% and 65%, respectively, followed by low activity of HBV acute infection or chronic carriers, accounting for about 5% and 20%, respectively. In the HBsAg R&NR/HBV DNA NR group, the combined proportion of individuals with anti-HBs single positive and all hepatitis B serological markers negative accounted for 78%, and those who were HBsAg negative but anti-HBc positive accounted for approximately 20%. In the HBsAg NR&NR/HBV DNA R group, there was nearly 9% of HBsAg(+), anti-HBe(+), and anti-HBc(+), the remaining were all HBsAg negative but anti-HBc positive, with a 100% anti-HBc positivity rate in this group. No HDV IgM or IgG antibodies were detected in the retained samples.
CONCLUSION
Blood donors with HBV-reactive results in blood screening exhibit multiple patterns of infection indicators. The prevalence rate of HDV infection among blood donors in Wuhan is extremely low. However, the risk of asymptomatic occult hepatitis B infection (OBI) blood donors being co-infected with HDV should not be overlooked in areas with high prevalence of HBV.
Humans
;
Blood Donors
;
Hepatitis B/blood*
;
China/epidemiology*
;
Adult
;
Male
;
Female
;
Hepatitis D/epidemiology*
;
Middle Aged
;
Hepatitis B virus/immunology*
;
Hepatitis B Antibodies/blood*
;
Young Adult
;
DNA, Viral/blood*
;
Hepatitis B Surface Antigens/blood*
;
Prevalence
;
Adolescent
6.Anti-early antigen Epstein-Barr virus titer and atherosclerosis in relation to vascular endothelial growth factor (VEGF) polymorphism rs3025039 among older Japanese individuals.
Yuji SHIMIZU ; Hirotomo YAMANASHI ; Shin-Ya KAWASHIRI ; Yuko NOGUCHI ; Nagisa SASAKI ; Seiko NAKAMICHI ; Kazuhiko ARIMA ; Yasuhiro NAGATA ; Takahiro MAEDA
Environmental Health and Preventive Medicine 2025;30():83-83
BACKGROUND:
Epstein-Barr (EB) virus infection stimulates the production of vascular endothelial growth factor (VEGF), which contributes to the progression of angiogenesis. Angiogenesis plays an important role in the development of atherosclerosis. Since serum anti-early antigen EB virus IgG (EBV EA-IgG) titer is a sign of active EB virus infection, EBV EA-IgG titer could be associated with atherosclerosis. The number of minor (T) alleles in VEGF polymorphism rs3025039 has been reported to be inversely associated with serum VEGF concentration, suggesting that rs3025039 might have a strong influence on the association between EBV EA-IgG titer and atherosclerosis. By focusing on the role of VEGF in the development of atherosclerosis, this study aimed to investigate the association between active EB virus infection and atherosclerosis.
METHODS:
A cross-sectional study of 2,661 older Japanese individuals aged 60-89 years who participated in annual health check-ups during 2017-2019 was conducted. Logistic regression was used to evaluate the association between EBV EA-IgG titer and atherosclerosis in relation to rs3025039 genotype. The influence of rs3025039 (T) allele carrier status on the association between EBV EA-IgG titer and atherosclerosis was also evaluated by using logistic regression.
RESULTS:
Among rs3025039 CC-homozygotes, with the lowest EBV EA-IgG titer tertile as the reference, the multivariable odds ratio (95% confidence interval) was 1.11 (0.82, 1.50) for the medium tertile and 1.07 (0.78, 1.47) for the high tertile. Among rs3025039 (T) allele carriers, the corresponding values were 1.44 (0.88, 2.36) and 1.88 (1.15, 3.05), respectively. There was a significant interaction between rs3025039 (T) allele carrier status and the association between EBV EA-IgG titer and atherosclerosis (adjusted p = 0.0497).
CONCLUSION
EBV EA-IgG titer was significantly positively associated with atherosclerosis only among participants who are genetically less likely to have progressive angiogenesis. An angiogenesis-related genetic factor was revealed as a determinant of the association between EBV EA-IgG titer and atherosclerosis. These findings introduce a novel concept that could explain the association between viral infection and atherosclerosis.
Humans
;
Aged
;
Male
;
Middle Aged
;
Female
;
Japan/epidemiology*
;
Atherosclerosis/virology*
;
Aged, 80 and over
;
Vascular Endothelial Growth Factor A/genetics*
;
Epstein-Barr Virus Infections/virology*
;
Polymorphism, Single Nucleotide
;
Cross-Sectional Studies
;
Herpesvirus 4, Human
;
Antigens, Viral/immunology*
;
Antibodies, Viral/blood*
;
Immunoglobulin G/blood*
;
Genotype
;
East Asian People
7.Process parameter optimization and immunogenicity evaluation of calcium phosphate-coated foot-and-mouth disease virus-like particles.
Lihua REN ; Wei GUO ; Qianqian XIE ; Ruipeng LIU ; Shiqi SUN ; Hu DONG ; Yun ZHANG ; Manyuan BAI ; Huichen GUO ; Zhidong TENG
Chinese Journal of Biotechnology 2025;41(7):2672-2681
Bio-mineralization has emerged as a promising strategy to enhance vaccine immunogenicity. This study optimized the calcium phosphate (CaP) mineralization process of foot-and-mouth disease virus-like particles (FMD VLPs) to achieve high mineralization efficiency and scalability. Key parameters, including concentrations of Ca2+, HPO42-, NaCl, and VLPs, as well as stirring speed, were systematically optimized. Stability of the scaled-up reaction system and immunogenicity of the mineralized vaccine were evaluated. Optimal conditions [25.50 mmol/L Ca(NO3)2, 15 mmol/L Na2HPO4, 300 mmol/L NaCl, 0.75 mg/mL VLPs, and 1 500 r/min] yielded CaP-mineralized VLPs (VLPs-CaP) with high mineralization efficiency, uniform morphology, and a favorable particle size. Scaling up the reaction by 25 folds maintained consistent mineralization efficiency and particle characteristics. Immunization in mice demonstrated that VLPs-CaP induced higher titers of specific antibodies and neutralizing antibodies than unmineralized VLPs (P < 0.05). Higher IgG2a/IgG1 ratio and enhanced IFN-γ secretion (P < 0.05) further indicated robust cellular immune responses. We establish a stable and scalable protocol for VLPs-CaP, providing a theoretical and technical foundation for developing high-efficacy VLPs-CaP vaccines.
Vaccines, Virus-Like Particle/immunology*
;
Immunogenicity, Vaccine
;
Calcium Phosphates/chemistry*
;
Foot-and-Mouth Disease Virus
;
Biomineralization
;
Particle Size
;
Animals
;
Mice
;
Antibodies, Neutralizing/blood*
;
Antibodies, Viral/blood*
;
Immunity, Cellular
8.Immunogenic evaluation of pseudorabies virus gB protein expressed in the baculovirus-insect cell system.
Jin WANG ; Kai WANG ; Ying ZHANG ; Shuzhen TAN ; Shiqi SUN ; Huichen GUO ; Shuanghui YIN ; Jiaqiang NIU
Chinese Journal of Biotechnology 2025;41(7):2694-2706
Pseudorabies (PR) is an infectious disease caused by the pseudorabies virus (PRV), affecting various domesticated and wild animals. Since pigs are the only natural hosts of PRV, PR poses a serious threat to the pig farming industry. Currently, PR is primarily prevented through vaccination with inactivated vaccines or genetically modified attenuated live vaccines. Developing safe and effective genetically engineered vaccines would facilitate the eradication and control of PR. In this study, the PRV vaccine strain Bartha-K61 was used as the reference strain. The gB protein was expressed via the baculovirus-insect cell expression system. Non-denaturing gel electrophoresis confirmed that the gB protein could form a trimeric structure. The purified gB protein was used to immunize mice, and the immune effect was evaluated by a challenge test. The results showed that the gB antigen induced a strong immune response in mice, with the serum-neutralizing antibody titer above 1:70. The lymphocyte stimulation index reached more than 1.29, and the level of (interferon gamma, IFN-γ) release was higher than 100 pg/mL. After immunization, mice were challenged with the virus at a dose of 104 TCID₅₀/mL, 200 μL per mouse, and the clinical protection rate was 100%. Immunohistochemistry, histopathological section, and tissue viral load results showed that the pathological damage and viral load in the gB-immunized group were significantly lower than those in the PBS group. In summary, the gB protein obtained in this study induced strong humoral and cellular immune responses in mice, laying a foundation for developing a recombinant gB protein subunit vaccine.
Animals
;
Mice
;
Baculoviridae/metabolism*
;
Viral Envelope Proteins/biosynthesis*
;
Herpesvirus 1, Suid/genetics*
;
Pseudorabies/immunology*
;
Swine
;
Pseudorabies Vaccines/genetics*
;
Antibodies, Viral/blood*
;
Insecta/cytology*
;
Mice, Inbred BALB C
;
Female
;
Viral Vaccines/immunology*
9.Development and immunogenicity evaluation in mice of a novel mRNA vaccine expressing herpes simplex virus type 2 envelope glycoprotein gD.
Jialuo BING ; Liye JIN ; Yao DENG ; Shucai SUN ; Xiaotian HAN ; Xueting CHENG ; Zhenyong QI ; Tangqi WANG ; Ruiwen HAN ; Desheng ZHAI ; Wenjie TAN
Chinese Journal of Biotechnology 2025;41(8):3241-3251
Human alphaherpesvirus 2 (HSV-2) is the main pathogen resulting human genital herpes, which poses a major threat to the socio-economic development, while there is no effective vaccine. In this study, we developed a novel lipopolyplex (LPP)-delivered mRNA vaccine expressing the HSV-2 envelope glycoprotein gD and evaluated its immunogenicity in mice. The mRNA vaccine was prepared from the genetically modified gD mRNA synthesized in vitro combined with the LPP delivery platform and it was named gD-ORI mRNA. The expression of gD antigen in the mRNA vaccine was validated in vitro by Western blotting and indirect immunofluorescence assay, then the immune responses induced by this mRNA vaccine in mice were evaluated. The immunization with gD mRNA alone induced strong humoral and cellular immune responses in mice. Robust and long-lasting gD-specific IgG antibodies were detected in the mouse serum after booster immunization with gD-ORI mRNA. The immunized mice exhibited a Th1/Th2 balanced IgG response and robust neutralizing antibodies against HSV-2, and a clear dose-response relationship was observed. The gD-specific IgG antibodies were maintained in mice for a long time, up to 18 weeks post-booster immunization. At the same time, multifunctional gD-specific CD4+ and CD8+ T cells in vaccinated mice were detected by intracellular cytokine staining (ICS). This novel gD-expressing mRNA vaccine delivered by LPP induces strong and long-lasting immune responses in mice post booster immunization and has a promising prospect for development and application. This study provides scientific evidence and reference for the development of a new mRNA vaccine for HSV-2.
Animals
;
Herpesvirus 2, Human/genetics*
;
Viral Envelope Proteins/genetics*
;
Mice
;
Herpes Genitalis/immunology*
;
RNA, Messenger/immunology*
;
Female
;
Mice, Inbred BALB C
;
Antibodies, Viral/blood*
;
mRNA Vaccines/immunology*
;
Antibodies, Neutralizing/blood*
;
Humans
10.Clinical significance of antiphospholipid antibodies in Behcet disease with thrombosis.
Yukai LI ; Hongyan WANG ; Liang LUO ; Yun LI ; Chun LI
Journal of Peking University(Health Sciences) 2024;56(6):1036-1040
OBJECTIVE:
To investigate the distribution and clinical significance of antiphospholipid antibody (aPL) in patients with Behcet disease (BD).
METHODS:
A total of 222 BD patients admitted to the Department of Rheumatology and Immunology in Peking University People' s Hospital from February 2008 to July 2024 were selected retrospectively. General data of the patients including age and gender were collec-ted. Clinical manifestations (including oral ulcers, genital ulcers, and thrombosis) and laboratory indexes (including aPL, human leukocyte antigen-B51, and anti-endothelial cell antibody) were collec-ted. The recurrence of thrombosis in the BD patients with thrombosis was followed up. Chi-square test was used to compare the clinical symptoms and laboratory indicators between aPL positive group and aPL negative group. Log-rank test was used to compare the recurrence rates of the aPL positive group and the aPL negative group, and P correction was performed by Two-stage method. Finally, Graphpad prism was used for plotting.
RESULTS:
The prevalence of single aPL, double aPL and triple aPL positivity in the BD patients were 22.1%, 0.5% and 1.4%, respectively. The positive rates of anti-cardiolipin antibody, anti-β2 glycoprotein Ⅰ antibody and lupus anticoagulant (LAC) were 10.4%, 1.8% and 13.1%, respectively. The incidence of thrombosis in the aPL positive group was significantly higher than that in the aPL negative group (44.9% vs. 16.9%, P < 0.001). The erythrocyte sedimentation rate [(20.78±4.91) mm/h vs. (15.85±4.29) mm/h, P=0.005], C-reactive protein [(12.97±5.17) mg/L vs. (7.49± 4.22) mg/L, P=0.010] and IgM [(1.55±0.95) g/L vs. (1.12±0.72) g/L, P < 0.001] in the aPL positive group were significantly higher than those in the aPL negative group. LAC positivity was an independent risk factor for thrombosis in the BD patients (OR=8.51, 95%CI: 2.71-26.72, P < 0.001). The recurrence rate of the aPL positive group was higher than that of the aPL negative group, but there was no statistical difference (69.23% vs. 52.17%, P=0.932).
CONCLUSION
Positive LAC and aneurysm are independent risk factors for thrombosis in BD patients. At the same time, positive antiphospholipid antibody can also significantly increase the risk of thrombosis in BD patients, which has important significance for guiding the treatment of BD.
Humans
;
Behcet Syndrome/blood*
;
Antibodies, Antiphospholipid/blood*
;
Thrombosis/immunology*
;
Male
;
Female
;
Retrospective Studies
;
Adult
;
Recurrence
;
Antibodies, Anticardiolipin/blood*
;
Clinical Relevance

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