Exosomal Interferon‐Induced Transmembrane Protein 2 Transmitted to Dendritic Cells Inhibits Interferon Alpha Pathway Activation and Blocks Anti–Hepatitis B Virus Efficacy of Exogenous Interferon Alpha
The negative regulators in the interferon (IFN) signaling pathway inhibit intrahepatic immune response, resulting in suboptimal therapeutic response to IFNα treatment in chronic hepatitis B (CHB) patients. Identifying the key negative factors and elucidating the regulating mechanism are essential fo...
Gespeichert in:
Veröffentlicht in: | Hepatology (Baltimore, Md.) Md.), 2019-06, Vol.69 (6), p.2396-2413 |
---|---|
Hauptverfasser: | , , , , , , , , |
Format: | Artikel |
Sprache: | eng |
Schlagworte: | |
Online-Zugang: | Volltext |
Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
container_end_page | 2413 |
---|---|
container_issue | 6 |
container_start_page | 2396 |
container_title | Hepatology (Baltimore, Md.) |
container_volume | 69 |
creator | Shi, Ying Du, Lingyao Lv, Duoduo Li, Hong Shang, Jin Lu, Jiajie Zhou, Lingyun Bai, Lang Tang, Hong |
description | The negative regulators in the interferon (IFN) signaling pathway inhibit intrahepatic immune response, resulting in suboptimal therapeutic response to IFNα treatment in chronic hepatitis B (CHB) patients. Identifying the key negative factors and elucidating the regulating mechanism are essential for improving anti‐HBV (hepatitis B virus) efficacy of IFNα. From the Gene Expression Omnibus (GEO) database, we downloaded and analyzed gene expression profiles of CHB patients with different responses to IFNα (GSE54747), and found that innate immune status was associated with the IFNα‐based therapeutic response in CHB patients. Through PCR array, we found higher baseline level of IFN‐induced transmembrane protein 2 (IFITM2) mRNA and lower baseline level of IFNα mRNA in peripheral blood mononuclear cells (PBMCs) of CHB patients with suboptimal response to IFNα treatment. Increased IFITM2 protein was also found in the serum of IFNα nonresponsive patients. With further experiments, we found that overexpressing IFITM2 in Huh7 cells suppressed endogenous IFNα synthesis by inhibiting phosphorylation of extracellular signal–regulated kinase (ERK), TANK‐binding kinase 1 (TBK1), and interferon regulatory factor 3 (IRF3); knocking out IFITM2 enhanced activation of the endogenous IFNα synthesis pathway, exhibiting better inhibition on HBV replication. We also found that IFITM2 protein was shuttled by exosomes to dendritic cells (DCs), the main source of endogenous IFNα. Exosome‐mediated transport of IFITM2 inhibited synthesis of endogenous IFNα in DCs whereas the inhibitory effect was abolished when IFITM2 was knocked out. Furthermore, we demonstrated that both palmitoylation inhibitor and mutation on 70/71 sites of IFITM2 protein influenced its incorporation into exosomes. Mutated IFITM2 protein increased the effect of IFNα against HBV. Conclusion: Exosome‐mediated transport of IFITM2 to DCs inhibits IFNα pathway activation and blocks anti‐HBV efficacy of exogenous IFNα. The findings provide an explanation to the suboptimal response of CHB patients to IFNα treatment. |
doi_str_mv | 10.1002/hep.30548 |
format | Article |
fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_6593428</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2207165841</sourcerecordid><originalsourceid>FETCH-LOGICAL-c5098-78627634fcf1ce6d5970813facca5f2e7c153e578b96a7ddf1e143db093fd6613</originalsourceid><addsrcrecordid>eNp1kktuFDEQhlsIRIbAggsgS2xg0Ykf_dwgTYaBGSkSswhsLbe7nHbothvbnTC7HAGJa3GKnASHGaIAYmXJ9elzVflPkucEHxGM6XEH4xHDeVY9SGYkp2XKWI4fJjNMS5zWhNUHyRPvLzDGdUarx8kBwyVlNWWz5Mfyq_V2ED1amwBOgbPm5vrb2rSThBadOWH8AEMTT0AbZwNog-j-XocQmWDRWzCt00FLtIC-99HV6UYHf0-K5v3YCbQRobsSWzSXQV-KoGNBmBad9FZ-9mhugr65_r6CMZaC9ugEfdJu8miplJZCbpFVKHZ8DsZO_9qfJo-U6D0825-Hycd3y7PFKj398H69mJ-mMsd1lZZVQcuCZUoqIqFo87rEFWFKSClyRaGUJGeQl1VTF6JsW0WAZKxtcM1UWxSEHSZvdt5xagZoJZjgRM9HpwfhttwKzf-sGN3xc3vJi7xm8Qei4NVe4OyXCXzgg_Yyri5uOQ7GKcUlKfIqu33r5V_ohZ2cieNFipGMsirLIvV6R0lnvXeg7pohmN9mhMeM8F8ZieyL-93fkb9DEYHjHXCle9j-38RXy81O-RO8lMzP</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2231423844</pqid></control><display><type>article</type><title>Exosomal Interferon‐Induced Transmembrane Protein 2 Transmitted to Dendritic Cells Inhibits Interferon Alpha Pathway Activation and Blocks Anti–Hepatitis B Virus Efficacy of Exogenous Interferon Alpha</title><source>Wiley Online Library Journals Frontfile Complete</source><source>EZB-FREE-00999 freely available EZB journals</source><creator>Shi, Ying ; Du, Lingyao ; Lv, Duoduo ; Li, Hong ; Shang, Jin ; Lu, Jiajie ; Zhou, Lingyun ; Bai, Lang ; Tang, Hong</creator><creatorcontrib>Shi, Ying ; Du, Lingyao ; Lv, Duoduo ; Li, Hong ; Shang, Jin ; Lu, Jiajie ; Zhou, Lingyun ; Bai, Lang ; Tang, Hong</creatorcontrib><description>The negative regulators in the interferon (IFN) signaling pathway inhibit intrahepatic immune response, resulting in suboptimal therapeutic response to IFNα treatment in chronic hepatitis B (CHB) patients. Identifying the key negative factors and elucidating the regulating mechanism are essential for improving anti‐HBV (hepatitis B virus) efficacy of IFNα. From the Gene Expression Omnibus (GEO) database, we downloaded and analyzed gene expression profiles of CHB patients with different responses to IFNα (GSE54747), and found that innate immune status was associated with the IFNα‐based therapeutic response in CHB patients. Through PCR array, we found higher baseline level of IFN‐induced transmembrane protein 2 (IFITM2) mRNA and lower baseline level of IFNα mRNA in peripheral blood mononuclear cells (PBMCs) of CHB patients with suboptimal response to IFNα treatment. Increased IFITM2 protein was also found in the serum of IFNα nonresponsive patients. With further experiments, we found that overexpressing IFITM2 in Huh7 cells suppressed endogenous IFNα synthesis by inhibiting phosphorylation of extracellular signal–regulated kinase (ERK), TANK‐binding kinase 1 (TBK1), and interferon regulatory factor 3 (IRF3); knocking out IFITM2 enhanced activation of the endogenous IFNα synthesis pathway, exhibiting better inhibition on HBV replication. We also found that IFITM2 protein was shuttled by exosomes to dendritic cells (DCs), the main source of endogenous IFNα. Exosome‐mediated transport of IFITM2 inhibited synthesis of endogenous IFNα in DCs whereas the inhibitory effect was abolished when IFITM2 was knocked out. Furthermore, we demonstrated that both palmitoylation inhibitor and mutation on 70/71 sites of IFITM2 protein influenced its incorporation into exosomes. Mutated IFITM2 protein increased the effect of IFNα against HBV. Conclusion: Exosome‐mediated transport of IFITM2 to DCs inhibits IFNα pathway activation and blocks anti‐HBV efficacy of exogenous IFNα. The findings provide an explanation to the suboptimal response of CHB patients to IFNα treatment.</description><identifier>ISSN: 0270-9139</identifier><identifier>EISSN: 1527-3350</identifier><identifier>DOI: 10.1002/hep.30548</identifier><identifier>PMID: 30723923</identifier><language>eng</language><publisher>United States: Wolters Kluwer Health, Inc</publisher><subject>Cell activation ; Dendritic cells ; Exosomes ; Extracellular signal-regulated kinase ; Gene expression ; Hepatitis ; Hepatitis B ; Hepatology ; Immune status ; Interferon ; Interferon regulatory factor ; Interferon regulatory factor 3 ; Kinases ; Leukocytes (mononuclear) ; Original ; Palmitoylation ; Peripheral blood mononuclear cells ; Phosphorylation ; Proteins ; Signal transduction ; Transmembrane proteins ; α-Interferon</subject><ispartof>Hepatology (Baltimore, Md.), 2019-06, Vol.69 (6), p.2396-2413</ispartof><rights>2019 The Authors. Hepatology published by Wiley Periodicals, Inc., on behalf of American Association for the Study of Liver Diseases.</rights><rights>2019 by the American Association for the Study of Liver Diseases.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c5098-78627634fcf1ce6d5970813facca5f2e7c153e578b96a7ddf1e143db093fd6613</citedby><cites>FETCH-LOGICAL-c5098-78627634fcf1ce6d5970813facca5f2e7c153e578b96a7ddf1e143db093fd6613</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>230,314,776,780,881,1411,27901,27902</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30723923$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Shi, Ying</creatorcontrib><creatorcontrib>Du, Lingyao</creatorcontrib><creatorcontrib>Lv, Duoduo</creatorcontrib><creatorcontrib>Li, Hong</creatorcontrib><creatorcontrib>Shang, Jin</creatorcontrib><creatorcontrib>Lu, Jiajie</creatorcontrib><creatorcontrib>Zhou, Lingyun</creatorcontrib><creatorcontrib>Bai, Lang</creatorcontrib><creatorcontrib>Tang, Hong</creatorcontrib><title>Exosomal Interferon‐Induced Transmembrane Protein 2 Transmitted to Dendritic Cells Inhibits Interferon Alpha Pathway Activation and Blocks Anti–Hepatitis B Virus Efficacy of Exogenous Interferon Alpha</title><title>Hepatology (Baltimore, Md.)</title><addtitle>Hepatology</addtitle><description>The negative regulators in the interferon (IFN) signaling pathway inhibit intrahepatic immune response, resulting in suboptimal therapeutic response to IFNα treatment in chronic hepatitis B (CHB) patients. Identifying the key negative factors and elucidating the regulating mechanism are essential for improving anti‐HBV (hepatitis B virus) efficacy of IFNα. From the Gene Expression Omnibus (GEO) database, we downloaded and analyzed gene expression profiles of CHB patients with different responses to IFNα (GSE54747), and found that innate immune status was associated with the IFNα‐based therapeutic response in CHB patients. Through PCR array, we found higher baseline level of IFN‐induced transmembrane protein 2 (IFITM2) mRNA and lower baseline level of IFNα mRNA in peripheral blood mononuclear cells (PBMCs) of CHB patients with suboptimal response to IFNα treatment. Increased IFITM2 protein was also found in the serum of IFNα nonresponsive patients. With further experiments, we found that overexpressing IFITM2 in Huh7 cells suppressed endogenous IFNα synthesis by inhibiting phosphorylation of extracellular signal–regulated kinase (ERK), TANK‐binding kinase 1 (TBK1), and interferon regulatory factor 3 (IRF3); knocking out IFITM2 enhanced activation of the endogenous IFNα synthesis pathway, exhibiting better inhibition on HBV replication. We also found that IFITM2 protein was shuttled by exosomes to dendritic cells (DCs), the main source of endogenous IFNα. Exosome‐mediated transport of IFITM2 inhibited synthesis of endogenous IFNα in DCs whereas the inhibitory effect was abolished when IFITM2 was knocked out. Furthermore, we demonstrated that both palmitoylation inhibitor and mutation on 70/71 sites of IFITM2 protein influenced its incorporation into exosomes. Mutated IFITM2 protein increased the effect of IFNα against HBV. Conclusion: Exosome‐mediated transport of IFITM2 to DCs inhibits IFNα pathway activation and blocks anti‐HBV efficacy of exogenous IFNα. The findings provide an explanation to the suboptimal response of CHB patients to IFNα treatment.</description><subject>Cell activation</subject><subject>Dendritic cells</subject><subject>Exosomes</subject><subject>Extracellular signal-regulated kinase</subject><subject>Gene expression</subject><subject>Hepatitis</subject><subject>Hepatitis B</subject><subject>Hepatology</subject><subject>Immune status</subject><subject>Interferon</subject><subject>Interferon regulatory factor</subject><subject>Interferon regulatory factor 3</subject><subject>Kinases</subject><subject>Leukocytes (mononuclear)</subject><subject>Original</subject><subject>Palmitoylation</subject><subject>Peripheral blood mononuclear cells</subject><subject>Phosphorylation</subject><subject>Proteins</subject><subject>Signal transduction</subject><subject>Transmembrane proteins</subject><subject>α-Interferon</subject><issn>0270-9139</issn><issn>1527-3350</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>24P</sourceid><sourceid>WIN</sourceid><recordid>eNp1kktuFDEQhlsIRIbAggsgS2xg0Ykf_dwgTYaBGSkSswhsLbe7nHbothvbnTC7HAGJa3GKnASHGaIAYmXJ9elzVflPkucEHxGM6XEH4xHDeVY9SGYkp2XKWI4fJjNMS5zWhNUHyRPvLzDGdUarx8kBwyVlNWWz5Mfyq_V2ED1amwBOgbPm5vrb2rSThBadOWH8AEMTT0AbZwNog-j-XocQmWDRWzCt00FLtIC-99HV6UYHf0-K5v3YCbQRobsSWzSXQV-KoGNBmBad9FZ-9mhugr65_r6CMZaC9ugEfdJu8miplJZCbpFVKHZ8DsZO_9qfJo-U6D0825-Hycd3y7PFKj398H69mJ-mMsd1lZZVQcuCZUoqIqFo87rEFWFKSClyRaGUJGeQl1VTF6JsW0WAZKxtcM1UWxSEHSZvdt5xagZoJZjgRM9HpwfhttwKzf-sGN3xc3vJi7xm8Qei4NVe4OyXCXzgg_Yyri5uOQ7GKcUlKfIqu33r5V_ohZ2cieNFipGMsirLIvV6R0lnvXeg7pohmN9mhMeM8F8ZieyL-93fkb9DEYHjHXCle9j-38RXy81O-RO8lMzP</recordid><startdate>201906</startdate><enddate>201906</enddate><creator>Shi, Ying</creator><creator>Du, Lingyao</creator><creator>Lv, Duoduo</creator><creator>Li, Hong</creator><creator>Shang, Jin</creator><creator>Lu, Jiajie</creator><creator>Zhou, Lingyun</creator><creator>Bai, Lang</creator><creator>Tang, Hong</creator><general>Wolters Kluwer Health, Inc</general><general>John Wiley and Sons Inc</general><scope>24P</scope><scope>WIN</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7T5</scope><scope>7TM</scope><scope>7TO</scope><scope>7U9</scope><scope>H94</scope><scope>K9.</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>201906</creationdate><title>Exosomal Interferon‐Induced Transmembrane Protein 2 Transmitted to Dendritic Cells Inhibits Interferon Alpha Pathway Activation and Blocks Anti–Hepatitis B Virus Efficacy of Exogenous Interferon Alpha</title><author>Shi, Ying ; Du, Lingyao ; Lv, Duoduo ; Li, Hong ; Shang, Jin ; Lu, Jiajie ; Zhou, Lingyun ; Bai, Lang ; Tang, Hong</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c5098-78627634fcf1ce6d5970813facca5f2e7c153e578b96a7ddf1e143db093fd6613</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Cell activation</topic><topic>Dendritic cells</topic><topic>Exosomes</topic><topic>Extracellular signal-regulated kinase</topic><topic>Gene expression</topic><topic>Hepatitis</topic><topic>Hepatitis B</topic><topic>Hepatology</topic><topic>Immune status</topic><topic>Interferon</topic><topic>Interferon regulatory factor</topic><topic>Interferon regulatory factor 3</topic><topic>Kinases</topic><topic>Leukocytes (mononuclear)</topic><topic>Original</topic><topic>Palmitoylation</topic><topic>Peripheral blood mononuclear cells</topic><topic>Phosphorylation</topic><topic>Proteins</topic><topic>Signal transduction</topic><topic>Transmembrane proteins</topic><topic>α-Interferon</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Shi, Ying</creatorcontrib><creatorcontrib>Du, Lingyao</creatorcontrib><creatorcontrib>Lv, Duoduo</creatorcontrib><creatorcontrib>Li, Hong</creatorcontrib><creatorcontrib>Shang, Jin</creatorcontrib><creatorcontrib>Lu, Jiajie</creatorcontrib><creatorcontrib>Zhou, Lingyun</creatorcontrib><creatorcontrib>Bai, Lang</creatorcontrib><creatorcontrib>Tang, Hong</creatorcontrib><collection>Wiley Online Library Open Access</collection><collection>Wiley Free Content</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Immunology Abstracts</collection><collection>Nucleic Acids Abstracts</collection><collection>Oncogenes and Growth Factors Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Hepatology (Baltimore, Md.)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Shi, Ying</au><au>Du, Lingyao</au><au>Lv, Duoduo</au><au>Li, Hong</au><au>Shang, Jin</au><au>Lu, Jiajie</au><au>Zhou, Lingyun</au><au>Bai, Lang</au><au>Tang, Hong</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Exosomal Interferon‐Induced Transmembrane Protein 2 Transmitted to Dendritic Cells Inhibits Interferon Alpha Pathway Activation and Blocks Anti–Hepatitis B Virus Efficacy of Exogenous Interferon Alpha</atitle><jtitle>Hepatology (Baltimore, Md.)</jtitle><addtitle>Hepatology</addtitle><date>2019-06</date><risdate>2019</risdate><volume>69</volume><issue>6</issue><spage>2396</spage><epage>2413</epage><pages>2396-2413</pages><issn>0270-9139</issn><eissn>1527-3350</eissn><abstract>The negative regulators in the interferon (IFN) signaling pathway inhibit intrahepatic immune response, resulting in suboptimal therapeutic response to IFNα treatment in chronic hepatitis B (CHB) patients. Identifying the key negative factors and elucidating the regulating mechanism are essential for improving anti‐HBV (hepatitis B virus) efficacy of IFNα. From the Gene Expression Omnibus (GEO) database, we downloaded and analyzed gene expression profiles of CHB patients with different responses to IFNα (GSE54747), and found that innate immune status was associated with the IFNα‐based therapeutic response in CHB patients. Through PCR array, we found higher baseline level of IFN‐induced transmembrane protein 2 (IFITM2) mRNA and lower baseline level of IFNα mRNA in peripheral blood mononuclear cells (PBMCs) of CHB patients with suboptimal response to IFNα treatment. Increased IFITM2 protein was also found in the serum of IFNα nonresponsive patients. With further experiments, we found that overexpressing IFITM2 in Huh7 cells suppressed endogenous IFNα synthesis by inhibiting phosphorylation of extracellular signal–regulated kinase (ERK), TANK‐binding kinase 1 (TBK1), and interferon regulatory factor 3 (IRF3); knocking out IFITM2 enhanced activation of the endogenous IFNα synthesis pathway, exhibiting better inhibition on HBV replication. We also found that IFITM2 protein was shuttled by exosomes to dendritic cells (DCs), the main source of endogenous IFNα. Exosome‐mediated transport of IFITM2 inhibited synthesis of endogenous IFNα in DCs whereas the inhibitory effect was abolished when IFITM2 was knocked out. Furthermore, we demonstrated that both palmitoylation inhibitor and mutation on 70/71 sites of IFITM2 protein influenced its incorporation into exosomes. Mutated IFITM2 protein increased the effect of IFNα against HBV. Conclusion: Exosome‐mediated transport of IFITM2 to DCs inhibits IFNα pathway activation and blocks anti‐HBV efficacy of exogenous IFNα. The findings provide an explanation to the suboptimal response of CHB patients to IFNα treatment.</abstract><cop>United States</cop><pub>Wolters Kluwer Health, Inc</pub><pmid>30723923</pmid><doi>10.1002/hep.30548</doi><tpages>18</tpages><oa>free_for_read</oa></addata></record> |
fulltext | fulltext |
identifier | ISSN: 0270-9139 |
ispartof | Hepatology (Baltimore, Md.), 2019-06, Vol.69 (6), p.2396-2413 |
issn | 0270-9139 1527-3350 |
language | eng |
recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_6593428 |
source | Wiley Online Library Journals Frontfile Complete; EZB-FREE-00999 freely available EZB journals |
subjects | Cell activation Dendritic cells Exosomes Extracellular signal-regulated kinase Gene expression Hepatitis Hepatitis B Hepatology Immune status Interferon Interferon regulatory factor Interferon regulatory factor 3 Kinases Leukocytes (mononuclear) Original Palmitoylation Peripheral blood mononuclear cells Phosphorylation Proteins Signal transduction Transmembrane proteins α-Interferon |
title | Exosomal Interferon‐Induced Transmembrane Protein 2 Transmitted to Dendritic Cells Inhibits Interferon Alpha Pathway Activation and Blocks Anti–Hepatitis B Virus Efficacy of Exogenous Interferon Alpha |
url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-09T12%3A03%3A19IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Exosomal%20Interferon%E2%80%90Induced%20Transmembrane%20Protein%202%20Transmitted%20to%20Dendritic%20Cells%20Inhibits%20Interferon%20Alpha%20Pathway%20Activation%20and%20Blocks%20Anti%E2%80%93Hepatitis%20B%20Virus%20Efficacy%20of%20Exogenous%20Interferon%20Alpha&rft.jtitle=Hepatology%20(Baltimore,%20Md.)&rft.au=Shi,%20Ying&rft.date=2019-06&rft.volume=69&rft.issue=6&rft.spage=2396&rft.epage=2413&rft.pages=2396-2413&rft.issn=0270-9139&rft.eissn=1527-3350&rft_id=info:doi/10.1002/hep.30548&rft_dat=%3Cproquest_pubme%3E2207165841%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2231423844&rft_id=info:pmid/30723923&rfr_iscdi=true |