1.Protective Effect of Taohong Siwutang on Cerebral Ischemia-reperfusion Injury Based on A1/A2 Phenotype Transformation of Astrocytes Mediated by JAK2/STAT3 Pathway
Huifang WANG ; Xinru CHEN ; Mengyuan CHEN ; Xian ZHOU ; Lan HAN ; Weidong CHEN ; Zhaojie JI
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(7):25-34
ObjectiveTo investigate whether the effect of Taohong Siwutang on cerebral ischemia-reperfusion (CIRI) injury in rats is related to the regulation of astrocyte polarization and explore the related mechanism. MethodsEighty-four male SD rats were randomly assigned to the following groups: A sham operation group, a model group, Taohong Siwutang treatment groups (low dose, medium dose, and high dose), ligustrazine phosphate tablet (LPT) group, and AG490 group. All groups, except for the sham operation group, underwent middle cerebral artery occlusion/reperfusion (MCAO/R) modeling and were treated for seven days. The neurological impairment was evaluated using the Longa score. The volume of cerebral infarction was assessed through 2,3,5-triphenyltetrazolium chloride (TTC) staining. Real-time fluorescent quantitative polymerase chain reaction (Real-time PCR) and Western blot analyses were performed to analyze the mRNA and protein expression levels of cortical complement 3 (C3), S100 calcium-binding protein A10 (S100A10), Janus kinase 2 (JAK2), and signal transducer and activator of transcription 3 (STAT3). Additionally, protein expression levels of vascular endothelial growth factor-A (VEGF-A) were assessed, and the mRNA expression levels of inflammatory factors, including interleukin-6 (IL-6), interleukin-1β (IL-1β), and tumor necrosis factor-α (TNF-α), were evaluated. Glial fibrillary acidic protein (GFAP) and C3, S100A10 and Co-localization was detected via immunofluorescence double staining. Lastly, VEGF expression levels were measured using enzyme-linked immunosorbent assay (ELISA). ResultsCompared with the sham operation group, the model group showed a significant increase in cerebral infarction volume and neurological impairment (P<0.01). C3 protein levels were elevated, while S100A10 levels were decreased. Pathway-related markers were significantly upregulated (P<0.05, P<0.01), and VEGF-A protein levels were significantly reduced (P<0.01). The mRNA expression of inflammatory factors was significantly upregulated (P<0.01). Co-localization analysis showed significantly increased GFAP and C3 fluorescence intensity (P<0.01) and greatly decreased GFAP and S100A10 fluorescence intensity (P<0.01). Additionally, VEGF content was significantly elevated (P<0.01). Compared with the model group, medium- and high-dose Taohong Siwutang and LPT groups exhibited a significant reduction in cerebral infarction volume and neurological impairment (P<0.01). Groups treated with low, medium, and high doses of Taohong Siwutang and LPT group exhibited a decrease in C3 protein expression levels and an increase in S100A10 expression levels (P<0.01). In the high-dose Taohong Siwutang and AG490 groups, both protein and mRNA expression of C3 and pathway-related markers were significantly downregulated (P<0.05, P<0.01), while S100A10 expression and VEGF-A protein levels were significantly increased (P<0.01). Additionally, the mRNA expression levels of inflammatory factors were significantly reduced (P<0.01). The co-localization fluorescence intensity of GFAP and C3 significantly decreased (P<0.01), while that of GFAP and S100A10 greatly increased (P<0.01). Furthermore, VEGF content exhibited a marked elevation (P<0.01). ConclusionTaohong Siwutang exerts a protective effect in rats with cerebral CIRI injury. The underlying mechanism is associated with the downregulation of the JAK2/STAT3 signaling pathway, promotion of A2-type astrocyte polarization, reduction of inflammatory factor release, and enhancement of VEGF production.
2.Protective Effect of Taohong Siwutang on Cerebral Ischemia-reperfusion Injury Based on A1/A2 Phenotype Transformation of Astrocytes Mediated by JAK2/STAT3 Pathway
Huifang WANG ; Xinru CHEN ; Mengyuan CHEN ; Xian ZHOU ; Lan HAN ; Weidong CHEN ; Zhaojie JI
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(7):25-34
ObjectiveTo investigate whether the effect of Taohong Siwutang on cerebral ischemia-reperfusion (CIRI) injury in rats is related to the regulation of astrocyte polarization and explore the related mechanism. MethodsEighty-four male SD rats were randomly assigned to the following groups: A sham operation group, a model group, Taohong Siwutang treatment groups (low dose, medium dose, and high dose), ligustrazine phosphate tablet (LPT) group, and AG490 group. All groups, except for the sham operation group, underwent middle cerebral artery occlusion/reperfusion (MCAO/R) modeling and were treated for seven days. The neurological impairment was evaluated using the Longa score. The volume of cerebral infarction was assessed through 2,3,5-triphenyltetrazolium chloride (TTC) staining. Real-time fluorescent quantitative polymerase chain reaction (Real-time PCR) and Western blot analyses were performed to analyze the mRNA and protein expression levels of cortical complement 3 (C3), S100 calcium-binding protein A10 (S100A10), Janus kinase 2 (JAK2), and signal transducer and activator of transcription 3 (STAT3). Additionally, protein expression levels of vascular endothelial growth factor-A (VEGF-A) were assessed, and the mRNA expression levels of inflammatory factors, including interleukin-6 (IL-6), interleukin-1β (IL-1β), and tumor necrosis factor-α (TNF-α), were evaluated. Glial fibrillary acidic protein (GFAP) and C3, S100A10 and Co-localization was detected via immunofluorescence double staining. Lastly, VEGF expression levels were measured using enzyme-linked immunosorbent assay (ELISA). ResultsCompared with the sham operation group, the model group showed a significant increase in cerebral infarction volume and neurological impairment (P<0.01). C3 protein levels were elevated, while S100A10 levels were decreased. Pathway-related markers were significantly upregulated (P<0.05, P<0.01), and VEGF-A protein levels were significantly reduced (P<0.01). The mRNA expression of inflammatory factors was significantly upregulated (P<0.01). Co-localization analysis showed significantly increased GFAP and C3 fluorescence intensity (P<0.01) and greatly decreased GFAP and S100A10 fluorescence intensity (P<0.01). Additionally, VEGF content was significantly elevated (P<0.01). Compared with the model group, medium- and high-dose Taohong Siwutang and LPT groups exhibited a significant reduction in cerebral infarction volume and neurological impairment (P<0.01). Groups treated with low, medium, and high doses of Taohong Siwutang and LPT group exhibited a decrease in C3 protein expression levels and an increase in S100A10 expression levels (P<0.01). In the high-dose Taohong Siwutang and AG490 groups, both protein and mRNA expression of C3 and pathway-related markers were significantly downregulated (P<0.05, P<0.01), while S100A10 expression and VEGF-A protein levels were significantly increased (P<0.01). Additionally, the mRNA expression levels of inflammatory factors were significantly reduced (P<0.01). The co-localization fluorescence intensity of GFAP and C3 significantly decreased (P<0.01), while that of GFAP and S100A10 greatly increased (P<0.01). Furthermore, VEGF content exhibited a marked elevation (P<0.01). ConclusionTaohong Siwutang exerts a protective effect in rats with cerebral CIRI injury. The underlying mechanism is associated with the downregulation of the JAK2/STAT3 signaling pathway, promotion of A2-type astrocyte polarization, reduction of inflammatory factor release, and enhancement of VEGF production.
3.Influence of Outdoor Light at Night on Early Reproductive Outcomes of In Vitro Fertilization and Its Threshold Effect: Evidence from a Couple-Based Preconception Cohort Study.
Wen Bin FANG ; Ying TANG ; Ya Ning SUN ; Yan Lan TANG ; Yin Yin CHEN ; Ya Wen CAO ; Ji Qi FANG ; Kun Jing HE ; Yu Shan LI ; Ya Ning DAI ; Shuang Shuang BAO ; Peng ZHU ; Shan Shan SHAO ; Fang Biao TAO ; Gui Xia PAN
Biomedical and Environmental Sciences 2025;38(8):1009-1015
4.Mechanism of Dingkun Dan in Promoting Ovarian Granulosa Cell Proliferation in Polycystic Ovary Syndrome via microRNA-30d-5p-Mediated Targeting of Smad2
Lan CHEN ; Xiaojing YAN ; Yuanpei LIAN ; Li ZHU ; Shikang ZHOU ; Dijun WANG ; Jiali CAI ; Chunyan YIN ; Ji CAO
Journal of Guangzhou University of Traditional Chinese Medicine 2025;42(7):1750-1756
Objective To investigate the therapeutic mechanism of Dingkun Dan(DKD)in polycystic ovary syndrome(PCOS)by examining the effects of microRNA-30d-5p on ovarian granulosa cells(GCs).Methods A PCOS rat model was established using dehydroepiandrosterone(DHEA).Normal rat GCs and PCOS rat GCs were cultured in vitro and divided into four groups:blank control group,model group,low-dose DKD group,and high-dose DKD group.After grouping,GCs viability was assessed using the methyl thiazolyl tetrazolium(MTT)assay,GCs apoptosis was analyzed by flow cytometry,and the gene expression of transforming growth factor β1(TGF-β1),Smad2,Smad3,and microRNA-30d-5p in GCs was measured by real-time polymerase chain reaction(RT-PCR),protein expression of TGF-β1,Smad2,and Smad3 in GCs was detected by Western Blot.Results Compared with the blank control group,the model group exhibited significantly decreased GCs viability,increased GCs apoptosis,upregulated mRNA and protein expression of TGF-β1,Smad2,and Smad3,and downregulated microRNA-30d-5p expression,the differences were statistically significant(P<0.01).Compared with the model group,both low-and high-dose DKD groups showed increased GCs viability,reduced GCs apoptosis,downregulated mRNA and protein levels of TGF-β1 Smad2 and Smad3,elevated microRNA-30d-5p expression,and the differences were statistically significant(P<0.05 or P<0.01).Conclusion DKD promotes GCs proliferation by targeting Smad2 via microRNA-30d-5p,suggesting a potential therapeutic role in PCOS-related ovulatory dysfunction.
5.Effect of sodium cantharidinate and vitamin B6 injection on human hepatocellular carcinoma cells and its mechanism
Lan-Lan SI ; Wen XU ; Le LI ; Dong JI ; Xue-Yuan CHEN ; Jiu-Zeng DAI ; Zeng-Tao YAO ; Wei-Wei CHEN ; Yan LIU
Medical Journal of Chinese People's Liberation Army 2025;50(6):747-755
Objective To analyze the effect of sodium cantharidinate and vitamin B6 injection(SCV)on four human hepatocellular carcinoma(HCC)cell lines(SMMC-7721,Bel-7402,Huh7,and HepG2)and explore its mechanism.Methods Normal hepatic cell line L02 was treated with SCV at concentrations of 0 μmol/L(control),0.5,1,2,4,8,16,and 32 μmol/L,and the cytotoxicity of SCV on L02 cells was detected using CCK-8 assay.Human HCC cell lines(SMMC-7721,Bel-7402,Huh7,and HepG2)were cultured.SCV-untreated control group(0 μmol/L)and 2,4,and 8 μmol/L SCV-treated groups were set up.CCK-8 assay,plate cloning formation assay,Transwell assay,wound healing assay,and flow cytometry were used to detect the effects of SCV on the growth and proliferation capacity,colony formation ability,invasion and migration capabilities,cell cycle,and apoptosis of the four hepatocellular carcinoma cell lines,respectively.Western blotting was performed to detect the expression levels of apoptosis-related proteins,including nuclear factor kappa-B subunit p65(p65),B-cell lymphoma 2(Bcl-2),and Caspase-3,and to preliminarily explore the underlying mechanism.Results The CCK-8 assay showed that SCV at 0.5,1,2,4,and 8 μmol/L had no significant cytotoxic effect on L02 cells compared with untreated control group,so 2,4,and 8 μmol/L SCV were selected for subsequent experiments.Compared with the untreated control group(0 μmol/L),SCV at different concentrations(2,4,and 8 μmol/L)significantly inhibited the proliferation of the four HCC cell lines(P<0.001).The plate cloning formation assay showed that SCV at different concentrations(2,4,and 8 μmol/L)significantly reduced the colony formation ability of the four HCC cell lines(P<0.05 or P<0.01 or P<0.001).In addition,Transwell and wound healing assays revealed that SCV at different concentrations(2,4,and 8 μmol/L)significantly inhibited the invasion and migration of HCC cells(P<0.05 or P<0.01 or P<0.001).In the above results,the inhibitory effect of SCV was concentration-dependent.Flow cytometry analysis indicated that SCV arrested cells in the G2/M phase(P<0.05 or P<0.01 or P<0.001)and significantly promoted cell apoptosis(P<0.05 or P<0.01 or P<0.001).Western blotting showed that SCV significantly down-regulated the expression of p65(P<0.05 or P<0.01)and Bcl-2(P<0.05),and up-regulated the expression of Caspase-3(P<0.05 or P<0.01).Conclusions SCV can significantly inhibit the proliferation,colony formation,invasion,and migration of multiple human HCC cell lines and arrest the cell cycle.SCV may inhibit the expression of p65 and Bcl-2,thereby lifting their inhibitory effect on the apoptotic pathway and activating Caspase-3 to promote apoptosis.
6.Characteristics of changes in HBsAg,HBV DNA and ALT after cessation of nucleos(t)ide analogue therapy in patients with HBeAg-negative chronic hepatitis B
Qiao-Lan LYU ; Li LIU ; Song QING ; Ying-Jie JI ; Yan LIU ; Chao ZHANG ; Fu-Sheng WANG ; Yong-Qian CHEN
Medical Journal of Chinese People's Liberation Army 2025;50(9):1076-1082
Objective To investigate the characteristics of changes in hepatitis B surface antigen(HBsAg),hepatitis B virus(HBV)deoxyribonucleic acid(DNA),and alanine aminotransferase(ALT)levels following the cessation of nucleos(t)ide analogues(NAs)therapy in hepatitis B e antigen(HBeAg)-negative chronic hepatitis B(CHB)patients with baseline HBsAg levels<1000 IU/ml.Methods This retrospective cohort study analyzed 73 HBeAg-negative CHB patients treated at the Fifth Medical Centre of Chinese PLA General Hospital from January 2020 to June 2023.Patients were divided into 3 groups according to baseline HBsAg level and discontinuation strategy:HBsAg-negative discontinuation group(n=14),HBsAg-positive discontinuation group(n=25),and HBsAg-positive continuation group(n=34).All patients were followed for 48 weeks.Baseline clinical characteristics and changes in virological and hepatic biochemical indicators during follow-up were compared among the 3 groups.Univariate logistic regression analysis was performed to assess the correlation between clinical indicators and HBV DNA reappearance in HBsAg-positive discontinuation group,and between clinical indicators and HBsAg decline>0.5 log IU/ml in this group.Results There were no significant differences in the baseline levels of gender,age,albumin,and total bilirubin among the 3 groups(P>0.05).The baseline direct bilirubin level was significantly higher in HBsAg-positive discontinuation group than that in other groups(P<0.05),while the lymphocyte counts were significantly higher in HBsAg-negative discontinuation group(P<0.05).During the 48-week follow-up period,the HBV DNA reappearance rate in HBsAg-positive discontinuation group(72.0%)was significantly higher than that in other groups(P<0.001).There was no significant difference in the incidence of ALT elevation among the three groups(P=0.260).The proportion of patients with HBsAg decline>0.5 log IU/ml in HBsAg-positive discontinuation group(24.0%)was significantly higher than that in HBsAg-positive continuation group(5.9%,P<0.05).The proportion of patients with HBsAg increase>0.5 log IU/ml in HBsAg-positive discontinuation group(12.0%)was also significantly higher than that in HBsAg-positive continuation group(0%,P<0.05).Univariate logistic regression analysis revealed no significant association between the analyzed clinical indicators and HBsAg decline(P>0.05).Conclusions Discontinuation of NAs therapy in HBsAg-negative patients demonstrates high safety,with sustained HBsAg negativity post-cessation and low risks of viral relapse and liver function abnormalities.For HBsAg-positive patients,discontinuation may promote HBsAg decline in some individuals but is associated with risks of HBV DNA reappearance and HBsAg elevation.The decision to discontinue therapy should be comprehensively evaluated based on patients'baseline HBsAg levels and clinical characteristics.
7.Establishment of quantitative analysis model for quality control indexes of Farfarae Flos based on NIRS
Tao GENG ; Wenhui JIANG ; Jialun LIU ; Songping LAN ; Liuying WANG ; Peilin CHEN ; Hanjing YAN ; Shengguo JI
China Pharmacy 2024;35(9):1057-1063
OBJECTIVE To establish a quantitative analysis model for the contents of tussilagone, moisture, ethanol-soluble extract and total ash in Farfarae Flos based on near-infrared spectroscopy (NIRS), providing a new idea for the rapid quality evaluation of Farfarae Flos and its preparations. METHODS Referring to the 2020 edition of the Chinese Pharmacopoeia, the contents of the main quality control indexes tussilagone, moisture, ethanol-soluble extract and total ash in 130 batches of Farfarae Flos from 19 producing areas were determined by HPLC, drying method, hot dip method and ash assay, respectively. The NIRS data information of the medicinal herbs of Farfarae Flos was collected, and then NIRS combined with the partial least squares method was used to establish the individual quantitative analysis models of the above quality control indexes in the samples, and the predictive model of the NIRS content was obtained after sample validation with validation set. RESULTS The range for the contents of tussilagone, moisture, ethanol-soluble extract and total ash in 130 batches of Farfarae Flos were 0.051 4%-0.103 5%, 7.75%-10.93%, 20.17%-31.12%, and 7.68%-12.10%, respectively. The internal cross-validation coefficients of determination (R2) of the established models for the quantitative analysis of tussilagone, moisture, ethanol-soluble extract and total ash in Farfarae Flos were 0.985 8, 0.968 4, 0.973 4, 0.988 0, respectively; the root mean square errors of calibration (RMSEC) were 0.001 54, 0.187, 0.478, 0.127, respectively; the root mean square errors of prediction (RMSEP) were 0.001 81, 0.212, 0.543, 0.149, respectively; RMSEP/RMSEC were 1.175 3, 1.133 7, 1.136 0 and 1.173 2, respectively, which were all within a reasonable range (1<RMSEP/RMSEC≤1.2). The mean absolute errors between the true and model-predicted values of the above four quality control indexes in the validation set of samples were -0.000 36, 0.061 43, 0.144 00, and 0.010 43, respectively,and the mean predicted recoveries were 99.65%, 100.72%,100.66%, and 100.15%, respectively. CONCLUSIONS The established NIRS quantitative analysis model has high stability and reliable results, which can be used for the rapid batch prediction of the content of relevant quality control indexes in Farfarae Flos.
8.The correlation between YAP nuclear expression and tumor size with prognosis of epithelial ovarian cancer
Zelian LI ; Lan XIAO ; Yu JIANG ; Weixue JI ; Ying CHEN ; Yuanyuan YANG ; Yunxia CAO
Acta Universitatis Medicinalis Anhui 2024;59(2):298-304
Objective To investigate the correlation between Yes-associated protein(YAP)nuclear expression and tumor size with prognosis of patients with epithelial ovarian cancer(EOC)and to study the role of YAP in EOC.Methods 120 patients with EOC were selected as the experimental group,including 38 patients with early stage(Ⅰ+Ⅱ)EOC and 8 2 patients with advanced stage(Ⅲ+Ⅳ)EOC.3 0 normal ovarian tissues obtained from patients with uterine leiomyoma were enrolled as the control group.Immunohistochemical(IHC)assay was em-ployed to determine YAP expression and sub-location.The relationship between YAP expression and the pathologi-cal parameters of the 120 patients with EOC was analyzed,so as to the prognosis of these patients.EOC cells(C13K and OV2008)were cultured with varying initial cell volumes.Ki67 expression and cell proliferation were tested by immunofluorescence and cloning assay respectively.YAP expression at mRNA and protein levels were de-tected by q-PCR and Western blot respectively when the cell conference of EOC cells reached to low(60%)and high(90%)cell density.Results The YAP nuclear expression was significantly higher in the EOC group com-pared to the control group(P<0.05).The average diameter of stage Ⅰ+Ⅱ EOC was larger than that of stage Ⅲ+Ⅳ EOC(P<0.01).The high nuclear expression of YAP was positively associated with pathological grade,clinical stage and the level of Ca125>1 000 IU/ml,while negatively correlated with tumor size(all P<0.05).Survival analyses showed that smaller tumor size(<10 cm)and higher YAP nuclear expression were negatively as-sociated with the 3-year overall survival rate of EOC patients(P<0.01).C13K and OV2008 cells cultured in the low density group exhibited a high number of clone formation,high Ki67 and YAP expression(P<0.01).The down-regulation of YAP expression could decrease the cell viability of EOC cells in the low-and high-density groups(P<0.05).Conclusion Higher level of YAP nuclear expression and smaller tumour size are inversely associated with the clinical prognosis of patients with EOC.Inhibiting YAP nuclear expression leads to a decrease in the prolif-eration capacity of EOC cells.
9.Rapid Determination of 32 Kinds of Veterinary Drug Residues in Eggs Using Modified QuEChERS Based on Reduced Graphene Oxide-coated Melamine Sponge by Ultra-High Liquid Chromatography-Tandem Mass Spectrometry
Xu XU ; Jia LYU ; Lan-Rui YANG ; Zhu-Chen HOU ; Bao-Cheng JI ; Yan-Hong BAI
Chinese Journal of Analytical Chemistry 2024;52(1):121-129,中插38-中插43
A rapid analytical method for simultaneous determination of 32 kinds of multi-residue veterinary drugs in eggs was developed using a modified QuEChERS technique based on a reduced graphene oxide-coated melamine sponge(r-GO@MeS)by ultra-high performance liquid chromatography-tandem mass spectrometry(UPLC-MS/MS).The influences of graphene oxide(GO)concentrations,sponge dosages,and purification modes on drug recoveries were investigated during the purification process.The optimal purification conditions involved using a GO concentration of 0.5 mg/mL,a sponge dosage of 6.0 cm3/mL,and a dynamic purification mode of 5 extrusion cycles.Separation was achieved using an Agilent Eclipse Plus C18 RRHD column(100 mm×2.1 mm,1.8 μm),and quantitative analysis was performed by the external standard method using an electrospray ionization source(ESI)in multiple reaction monitoring(MRM)mode.The results showed that all 32 kinds of veterinary drugs exhibited good linear correlation with coefficients greater than 0.999,and matrix effects(MEs)ranging from?7.8%to 18.9%.The limits of detection(LODs)and quantification(LOQs)ranged from 0.2 to 10.2 μg/kg and from 0.6 to 28.0 μg/kg,respectively.The recoveries for the three spiked levels were in the range of 66.5%?117.5%,with intra-day and inter-day precision(Relative standard deviation)below 13.3%and 16.3%,respectively.The synthetic r-GO@MeS exhibited efficient matrix purification without the need of high-speed centrifugation or strong magnetic field assistance.This significantly shorted the sample pretreatment time and improved the convenience of the matrix purification process.Combined with UPLC-MS/MS,the method was suitable for the rapid determination of multi-residue veterinary drugs in eggs.
10.A Case Report of Multidisciplinary Diagnosis and Treatment of a Patient with Tuberous Sclerosis Complex and Multi-Organ Involvement
Hua ZHENG ; Yunfei ZHI ; Lujing YING ; Lan ZHU ; Mingliang JI ; Ze LIANG ; Jiangshan WANG ; Haifeng SHI ; Weihong ZHANG ; Mengsu XIAO ; Yushi ZHANG ; Kaifeng XU ; Zhaohui LU ; Yaping LIU ; Ruiyi XU ; Huijuan ZHU ; Li WEN ; Yan ZHANG ; Gang CHEN ; Limeng CHEN
JOURNAL OF RARE DISEASES 2024;3(1):79-86
Tuberous sclerosis complex(TSC)is a rare genetic disease that can lead to benign dysplasia in multiple organs such as the skin, brain, eyes, oral cavity, heart, lungs, kidneys, liver, and bones. Its main symptoms include epilepsy, intellectual disabilities, skin depigmentation, and facial angiofibromas, whilst incidence is approximately 1 in 10 000 to 1 in 6000 newborns. This case presents a middle-aged woman who initially manifested with epilepsy and nodular depigmentation. Later, she developed a lower abdominal mass, elevated creatinine, and severe anemia. Based on clinical features and whole exome sequencing, the primary diagnosis was confirmed as TSC. Laboratory and imaging examinations revealed that the lower abdominal mass originated from the uterus. CT-guided biopsy pathology and surgical pathology suggested a combination of leiomyoma and abscess. With the involvement of multiple organs and various complications beyond the main diagnosis, the diagnostic and therapeutic process for this patient highlights the importance of rigorous clinical thinking and multidisciplinary collaboration in the diagnosis and treatment of rare and challenging diseases.

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