MTADV 5-MER peptide suppresses chronic inflammations as well as autoimmune pathologies and unveils a new potential target-Serum Amyloid A
Despite the existence of potent anti-inflammatory biological drugs e.g., anti-TNF and anti IL-6 receptor antibodies, for treating chronic inflammatory and autoimmune diseases, these are costly and not specific. Cheaper oral available drugs remain an unmet need. Expression of the acute phase protein...
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creator | Hemed-Shaked, Maayan Cowman, Mary K. Kim, Jin Ryoun Huang, Xiayun Chau, Edward Ovadia, Haim Amar, Keren-Or Eshkar-Sebban, Lora Melamed, Michal Lev, Libat Bar Kedar, Eli Armengol, Jordi Alemany, Jorge Beyth, Shaul Okon, Eli Kanduc, Darja Elgavish, Sharona Wallach-Dayan, Shulamit B. Cohen, Shmuel Jaffe Naor, David |
description | Despite the existence of potent anti-inflammatory biological drugs e.g., anti-TNF and anti IL-6 receptor antibodies, for treating chronic inflammatory and autoimmune diseases, these are costly and not specific. Cheaper oral available drugs remain an unmet need. Expression of the acute phase protein Serum Amyloid A (SAA) is dependent on release of pro-inflammatory cytokines IL-1, IL-6 and TNF-α during inflammation. Conversely, SAA induces pro-inflammatory cytokine secretion, including Th17, leading to a pathogenic vicious cycle and chronic inflammation. 5- MER peptide (5-MP) MTADV (methionine-threonine-alanine-aspartic acid-valine), also called Amilo-5MER, was originally derived from a sequence of a pro-inflammatory CD44 variant isolated from synovial fluid of a Rheumatoid Arthritis (RA) patient. This human peptide displays an efficient anti-inflammatory effects to ameliorate pathology and clinical symptoms in mouse models of RA, Inflammatory Bowel Disease (IBD) and Multiple Sclerosis (MS). Bioinformatics and qRT-PCR revealed that 5-MP, administrated to encephalomyelytic mice, up-regulates genes contributing to chronic inflammation resistance. Mass spectrometry of proteins that were pulled down from an RA synovial cell extract with biotinylated 5-MP, showed that it binds SAA. 5-MP disrupted SAA assembly, which is correlated with its pro-inflammatory activity. The peptide MTADV (but not scrambled TMVAD) significantly inhibited the release of pro-inflammatory cytokines IL-6 and IL-1β from SAA-activated human fibroblasts, THP-1 monocytes and peripheral blood mononuclear cells. 5-MP suppresses the pro-inflammatory IL-6 release from SAA-activated cells, but not from non-activated cells. 5-MP could not display therapeutic activity in rats, which are SAA deficient, but does inhibit inflammations in animal models of IBD and MS, both are SAA-dependent, as shown by others in SAA knockout mice. In conclusion, 5-MP suppresses chronic inflammation in animal models of RA, IBD and MS, which are SAA-dependent, but not in animal models, which are SAA-independent.
•Serum Amyloid A, which induces pro-inflammatory cytokines, fuels inflammation.•These cytokines elevate amyloid production, generating uncontrolled vicious cycle.•Binding a laboratory-produced peptide to the amyloid inhibits the cytokine release.•Consequently, the peptide inhibits cytokine-induced inflammations in mouse models.•Our peptide faces unmet needs of chronic inflammations e.g., colitis, arthritis. |
doi_str_mv | 10.1016/j.jaut.2021.102713 |
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•Serum Amyloid A, which induces pro-inflammatory cytokines, fuels inflammation.•These cytokines elevate amyloid production, generating uncontrolled vicious cycle.•Binding a laboratory-produced peptide to the amyloid inhibits the cytokine release.•Consequently, the peptide inhibits cytokine-induced inflammations in mouse models.•Our peptide faces unmet needs of chronic inflammations e.g., colitis, arthritis.</description><identifier>ISSN: 0896-8411</identifier><identifier>EISSN: 1095-9157</identifier><identifier>DOI: 10.1016/j.jaut.2021.102713</identifier><identifier>PMID: 34390919</identifier><language>eng</language><publisher>England: Elsevier Ltd</publisher><subject>Animals ; Anti-Inflammatory Agents - therapeutic use ; Arthritis, Rheumatoid - immunology ; Autoimmunity ; Cells, Cultured ; Computational Biology ; Cytokines ; Cytokines - metabolism ; Disease Models, Animal ; Humans ; Hyaluronan Receptors - genetics ; Inflammation ; Inflammation - immunology ; Inflammation Mediators - metabolism ; Inflammatory Bowel Diseases - immunology ; Mice ; Mice, Knockout ; Multiple Sclerosis - immunology ; Peptide ; Peptides - genetics ; Peptides - therapeutic use ; Serum amyloid A ; Serum Amyloid A Protein - genetics ; Serum Amyloid A Protein - immunology ; Therapy</subject><ispartof>Journal of autoimmunity, 2021-11, Vol.124, p.102713-102713, Article 102713</ispartof><rights>2021 The Authors</rights><rights>Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c307t-9e01a927caad0850d4eb97d2db822240f3fd26322468a11388421d14c75a83f03</cites><orcidid>0000-0003-2111-4608 ; 0000-0001-6970-9390 ; 0000-0002-2965-5399 ; 0000-0001-8741-9784 ; 0000-0001-6156-8730 ; 0000-0003-2714-1666 ; 0000-0002-1781-2916</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://dx.doi.org/10.1016/j.jaut.2021.102713$$EHTML$$P50$$Gelsevier$$Hfree_for_read</linktohtml><link.rule.ids>314,780,784,3550,27924,27925,45995</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/34390919$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Hemed-Shaked, Maayan</creatorcontrib><creatorcontrib>Cowman, Mary K.</creatorcontrib><creatorcontrib>Kim, Jin Ryoun</creatorcontrib><creatorcontrib>Huang, Xiayun</creatorcontrib><creatorcontrib>Chau, Edward</creatorcontrib><creatorcontrib>Ovadia, Haim</creatorcontrib><creatorcontrib>Amar, Keren-Or</creatorcontrib><creatorcontrib>Eshkar-Sebban, Lora</creatorcontrib><creatorcontrib>Melamed, Michal</creatorcontrib><creatorcontrib>Lev, Libat Bar</creatorcontrib><creatorcontrib>Kedar, Eli</creatorcontrib><creatorcontrib>Armengol, Jordi</creatorcontrib><creatorcontrib>Alemany, Jorge</creatorcontrib><creatorcontrib>Beyth, Shaul</creatorcontrib><creatorcontrib>Okon, Eli</creatorcontrib><creatorcontrib>Kanduc, Darja</creatorcontrib><creatorcontrib>Elgavish, Sharona</creatorcontrib><creatorcontrib>Wallach-Dayan, Shulamit B.</creatorcontrib><creatorcontrib>Cohen, Shmuel Jaffe</creatorcontrib><creatorcontrib>Naor, David</creatorcontrib><title>MTADV 5-MER peptide suppresses chronic inflammations as well as autoimmune pathologies and unveils a new potential target-Serum Amyloid A</title><title>Journal of autoimmunity</title><addtitle>J Autoimmun</addtitle><description>Despite the existence of potent anti-inflammatory biological drugs e.g., anti-TNF and anti IL-6 receptor antibodies, for treating chronic inflammatory and autoimmune diseases, these are costly and not specific. Cheaper oral available drugs remain an unmet need. Expression of the acute phase protein Serum Amyloid A (SAA) is dependent on release of pro-inflammatory cytokines IL-1, IL-6 and TNF-α during inflammation. Conversely, SAA induces pro-inflammatory cytokine secretion, including Th17, leading to a pathogenic vicious cycle and chronic inflammation. 5- MER peptide (5-MP) MTADV (methionine-threonine-alanine-aspartic acid-valine), also called Amilo-5MER, was originally derived from a sequence of a pro-inflammatory CD44 variant isolated from synovial fluid of a Rheumatoid Arthritis (RA) patient. This human peptide displays an efficient anti-inflammatory effects to ameliorate pathology and clinical symptoms in mouse models of RA, Inflammatory Bowel Disease (IBD) and Multiple Sclerosis (MS). Bioinformatics and qRT-PCR revealed that 5-MP, administrated to encephalomyelytic mice, up-regulates genes contributing to chronic inflammation resistance. Mass spectrometry of proteins that were pulled down from an RA synovial cell extract with biotinylated 5-MP, showed that it binds SAA. 5-MP disrupted SAA assembly, which is correlated with its pro-inflammatory activity. The peptide MTADV (but not scrambled TMVAD) significantly inhibited the release of pro-inflammatory cytokines IL-6 and IL-1β from SAA-activated human fibroblasts, THP-1 monocytes and peripheral blood mononuclear cells. 5-MP suppresses the pro-inflammatory IL-6 release from SAA-activated cells, but not from non-activated cells. 5-MP could not display therapeutic activity in rats, which are SAA deficient, but does inhibit inflammations in animal models of IBD and MS, both are SAA-dependent, as shown by others in SAA knockout mice. In conclusion, 5-MP suppresses chronic inflammation in animal models of RA, IBD and MS, which are SAA-dependent, but not in animal models, which are SAA-independent.
•Serum Amyloid A, which induces pro-inflammatory cytokines, fuels inflammation.•These cytokines elevate amyloid production, generating uncontrolled vicious cycle.•Binding a laboratory-produced peptide to the amyloid inhibits the cytokine release.•Consequently, the peptide inhibits cytokine-induced inflammations in mouse models.•Our peptide faces unmet needs of chronic inflammations e.g., colitis, arthritis.</description><subject>Animals</subject><subject>Anti-Inflammatory Agents - therapeutic use</subject><subject>Arthritis, Rheumatoid - immunology</subject><subject>Autoimmunity</subject><subject>Cells, Cultured</subject><subject>Computational Biology</subject><subject>Cytokines</subject><subject>Cytokines - metabolism</subject><subject>Disease Models, Animal</subject><subject>Humans</subject><subject>Hyaluronan Receptors - genetics</subject><subject>Inflammation</subject><subject>Inflammation - immunology</subject><subject>Inflammation Mediators - metabolism</subject><subject>Inflammatory Bowel Diseases - immunology</subject><subject>Mice</subject><subject>Mice, Knockout</subject><subject>Multiple Sclerosis - immunology</subject><subject>Peptide</subject><subject>Peptides - genetics</subject><subject>Peptides - therapeutic use</subject><subject>Serum amyloid A</subject><subject>Serum Amyloid A Protein - genetics</subject><subject>Serum Amyloid A Protein - immunology</subject><subject>Therapy</subject><issn>0896-8411</issn><issn>1095-9157</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2021</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9UctuFDEQtBCILAs_wAH5yGUWtz0vS1xWIQSkREhJ4Gp57Z7Eqxl7sD2J8gn8dbzawJFTl1pVpa4uQt4D2wCD9tN-s9dL3nDGoSx4B-IFWQGTTSWh6V6SFetlW_U1wAl5k9KeMYCmaV6TE1ELySTIFflzebP98os21eXZFZ1xzs4iTcs8R0wJEzV3MXhnqPPDqKdJZxd8ojrRBxzHwywXBDdNi0c663wXxnDrik57Sxd_j24smHp8oHPI6LPTI8063mKurjEuE91Oj2Nwlm7fkleDHhO-e55r8vPr2c3pt-rix_n30-1FZQTrciWRgZa8M1pb1jfM1riTneV213POazaIwfJWFNj2GkD0fc3BQm26RvdiYGJNPh595xh-L5iymlwyJY32GJakeNNCLVldTNaEH6kmhpQiDmqObtLxUQFThwrUXh0qUIcK1LGCIvrw7L_sJrT_JH9_XgifjwQsKe8dRpWMQ2_QuogmKxvc__yfAOlRmEk</recordid><startdate>202111</startdate><enddate>202111</enddate><creator>Hemed-Shaked, Maayan</creator><creator>Cowman, Mary K.</creator><creator>Kim, Jin Ryoun</creator><creator>Huang, Xiayun</creator><creator>Chau, Edward</creator><creator>Ovadia, Haim</creator><creator>Amar, Keren-Or</creator><creator>Eshkar-Sebban, Lora</creator><creator>Melamed, Michal</creator><creator>Lev, Libat Bar</creator><creator>Kedar, Eli</creator><creator>Armengol, Jordi</creator><creator>Alemany, Jorge</creator><creator>Beyth, Shaul</creator><creator>Okon, Eli</creator><creator>Kanduc, Darja</creator><creator>Elgavish, Sharona</creator><creator>Wallach-Dayan, Shulamit B.</creator><creator>Cohen, Shmuel Jaffe</creator><creator>Naor, David</creator><general>Elsevier Ltd</general><scope>6I.</scope><scope>AAFTH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0003-2111-4608</orcidid><orcidid>https://orcid.org/0000-0001-6970-9390</orcidid><orcidid>https://orcid.org/0000-0002-2965-5399</orcidid><orcidid>https://orcid.org/0000-0001-8741-9784</orcidid><orcidid>https://orcid.org/0000-0001-6156-8730</orcidid><orcidid>https://orcid.org/0000-0003-2714-1666</orcidid><orcidid>https://orcid.org/0000-0002-1781-2916</orcidid></search><sort><creationdate>202111</creationdate><title>MTADV 5-MER peptide suppresses chronic inflammations as well as autoimmune pathologies and unveils a new potential target-Serum Amyloid A</title><author>Hemed-Shaked, Maayan ; Cowman, Mary K. ; Kim, Jin Ryoun ; Huang, Xiayun ; Chau, Edward ; Ovadia, Haim ; Amar, Keren-Or ; Eshkar-Sebban, Lora ; Melamed, Michal ; Lev, Libat Bar ; Kedar, Eli ; Armengol, Jordi ; Alemany, Jorge ; Beyth, Shaul ; Okon, Eli ; Kanduc, Darja ; Elgavish, Sharona ; Wallach-Dayan, Shulamit B. ; Cohen, Shmuel Jaffe ; Naor, David</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c307t-9e01a927caad0850d4eb97d2db822240f3fd26322468a11388421d14c75a83f03</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2021</creationdate><topic>Animals</topic><topic>Anti-Inflammatory Agents - therapeutic use</topic><topic>Arthritis, Rheumatoid - immunology</topic><topic>Autoimmunity</topic><topic>Cells, Cultured</topic><topic>Computational Biology</topic><topic>Cytokines</topic><topic>Cytokines - metabolism</topic><topic>Disease Models, Animal</topic><topic>Humans</topic><topic>Hyaluronan Receptors - genetics</topic><topic>Inflammation</topic><topic>Inflammation - immunology</topic><topic>Inflammation Mediators - metabolism</topic><topic>Inflammatory Bowel Diseases - immunology</topic><topic>Mice</topic><topic>Mice, Knockout</topic><topic>Multiple Sclerosis - immunology</topic><topic>Peptide</topic><topic>Peptides - genetics</topic><topic>Peptides - therapeutic use</topic><topic>Serum amyloid A</topic><topic>Serum Amyloid A Protein - genetics</topic><topic>Serum Amyloid A Protein - immunology</topic><topic>Therapy</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Hemed-Shaked, Maayan</creatorcontrib><creatorcontrib>Cowman, Mary K.</creatorcontrib><creatorcontrib>Kim, Jin Ryoun</creatorcontrib><creatorcontrib>Huang, Xiayun</creatorcontrib><creatorcontrib>Chau, Edward</creatorcontrib><creatorcontrib>Ovadia, Haim</creatorcontrib><creatorcontrib>Amar, Keren-Or</creatorcontrib><creatorcontrib>Eshkar-Sebban, Lora</creatorcontrib><creatorcontrib>Melamed, Michal</creatorcontrib><creatorcontrib>Lev, Libat Bar</creatorcontrib><creatorcontrib>Kedar, Eli</creatorcontrib><creatorcontrib>Armengol, Jordi</creatorcontrib><creatorcontrib>Alemany, Jorge</creatorcontrib><creatorcontrib>Beyth, Shaul</creatorcontrib><creatorcontrib>Okon, Eli</creatorcontrib><creatorcontrib>Kanduc, Darja</creatorcontrib><creatorcontrib>Elgavish, Sharona</creatorcontrib><creatorcontrib>Wallach-Dayan, Shulamit B.</creatorcontrib><creatorcontrib>Cohen, Shmuel Jaffe</creatorcontrib><creatorcontrib>Naor, David</creatorcontrib><collection>ScienceDirect Open Access Titles</collection><collection>Elsevier:ScienceDirect:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of autoimmunity</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Hemed-Shaked, Maayan</au><au>Cowman, Mary K.</au><au>Kim, Jin Ryoun</au><au>Huang, Xiayun</au><au>Chau, Edward</au><au>Ovadia, Haim</au><au>Amar, Keren-Or</au><au>Eshkar-Sebban, Lora</au><au>Melamed, Michal</au><au>Lev, Libat Bar</au><au>Kedar, Eli</au><au>Armengol, Jordi</au><au>Alemany, Jorge</au><au>Beyth, Shaul</au><au>Okon, Eli</au><au>Kanduc, Darja</au><au>Elgavish, Sharona</au><au>Wallach-Dayan, Shulamit B.</au><au>Cohen, Shmuel Jaffe</au><au>Naor, David</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>MTADV 5-MER peptide suppresses chronic inflammations as well as autoimmune pathologies and unveils a new potential target-Serum Amyloid A</atitle><jtitle>Journal of autoimmunity</jtitle><addtitle>J Autoimmun</addtitle><date>2021-11</date><risdate>2021</risdate><volume>124</volume><spage>102713</spage><epage>102713</epage><pages>102713-102713</pages><artnum>102713</artnum><issn>0896-8411</issn><eissn>1095-9157</eissn><abstract>Despite the existence of potent anti-inflammatory biological drugs e.g., anti-TNF and anti IL-6 receptor antibodies, for treating chronic inflammatory and autoimmune diseases, these are costly and not specific. Cheaper oral available drugs remain an unmet need. Expression of the acute phase protein Serum Amyloid A (SAA) is dependent on release of pro-inflammatory cytokines IL-1, IL-6 and TNF-α during inflammation. Conversely, SAA induces pro-inflammatory cytokine secretion, including Th17, leading to a pathogenic vicious cycle and chronic inflammation. 5- MER peptide (5-MP) MTADV (methionine-threonine-alanine-aspartic acid-valine), also called Amilo-5MER, was originally derived from a sequence of a pro-inflammatory CD44 variant isolated from synovial fluid of a Rheumatoid Arthritis (RA) patient. This human peptide displays an efficient anti-inflammatory effects to ameliorate pathology and clinical symptoms in mouse models of RA, Inflammatory Bowel Disease (IBD) and Multiple Sclerosis (MS). Bioinformatics and qRT-PCR revealed that 5-MP, administrated to encephalomyelytic mice, up-regulates genes contributing to chronic inflammation resistance. Mass spectrometry of proteins that were pulled down from an RA synovial cell extract with biotinylated 5-MP, showed that it binds SAA. 5-MP disrupted SAA assembly, which is correlated with its pro-inflammatory activity. The peptide MTADV (but not scrambled TMVAD) significantly inhibited the release of pro-inflammatory cytokines IL-6 and IL-1β from SAA-activated human fibroblasts, THP-1 monocytes and peripheral blood mononuclear cells. 5-MP suppresses the pro-inflammatory IL-6 release from SAA-activated cells, but not from non-activated cells. 5-MP could not display therapeutic activity in rats, which are SAA deficient, but does inhibit inflammations in animal models of IBD and MS, both are SAA-dependent, as shown by others in SAA knockout mice. In conclusion, 5-MP suppresses chronic inflammation in animal models of RA, IBD and MS, which are SAA-dependent, but not in animal models, which are SAA-independent.
•Serum Amyloid A, which induces pro-inflammatory cytokines, fuels inflammation.•These cytokines elevate amyloid production, generating uncontrolled vicious cycle.•Binding a laboratory-produced peptide to the amyloid inhibits the cytokine release.•Consequently, the peptide inhibits cytokine-induced inflammations in mouse models.•Our peptide faces unmet needs of chronic inflammations e.g., colitis, arthritis.</abstract><cop>England</cop><pub>Elsevier Ltd</pub><pmid>34390919</pmid><doi>10.1016/j.jaut.2021.102713</doi><tpages>1</tpages><orcidid>https://orcid.org/0000-0003-2111-4608</orcidid><orcidid>https://orcid.org/0000-0001-6970-9390</orcidid><orcidid>https://orcid.org/0000-0002-2965-5399</orcidid><orcidid>https://orcid.org/0000-0001-8741-9784</orcidid><orcidid>https://orcid.org/0000-0001-6156-8730</orcidid><orcidid>https://orcid.org/0000-0003-2714-1666</orcidid><orcidid>https://orcid.org/0000-0002-1781-2916</orcidid><oa>free_for_read</oa></addata></record> |
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subjects | Animals Anti-Inflammatory Agents - therapeutic use Arthritis, Rheumatoid - immunology Autoimmunity Cells, Cultured Computational Biology Cytokines Cytokines - metabolism Disease Models, Animal Humans Hyaluronan Receptors - genetics Inflammation Inflammation - immunology Inflammation Mediators - metabolism Inflammatory Bowel Diseases - immunology Mice Mice, Knockout Multiple Sclerosis - immunology Peptide Peptides - genetics Peptides - therapeutic use Serum amyloid A Serum Amyloid A Protein - genetics Serum Amyloid A Protein - immunology Therapy |
title | MTADV 5-MER peptide suppresses chronic inflammations as well as autoimmune pathologies and unveils a new potential target-Serum Amyloid A |
url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2024-12-27T01%3A54%3A49IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=MTADV%205-MER%20peptide%20suppresses%20chronic%20inflammations%20as%20well%20as%20autoimmune%20pathologies%20and%20unveils%20a%20new%20potential%20target-Serum%20Amyloid%20A&rft.jtitle=Journal%20of%20autoimmunity&rft.au=Hemed-Shaked,%20Maayan&rft.date=2021-11&rft.volume=124&rft.spage=102713&rft.epage=102713&rft.pages=102713-102713&rft.artnum=102713&rft.issn=0896-8411&rft.eissn=1095-9157&rft_id=info:doi/10.1016/j.jaut.2021.102713&rft_dat=%3Cproquest_cross%3E2561490426%3C/proquest_cross%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2561490426&rft_id=info:pmid/34390919&rft_els_id=S0896841121001219&rfr_iscdi=true |