An Antifungal Polycyclic Tetramate Macrolactam, Heat-Stable Antifungal Factor (HSAF), Is a Novel Oxidative Stress Modulator in Lysobacter enzymogenes

Polycyclic tetramate macrolactams (PoTeMs) are a fast-growing family of antibiotic natural products found in phylogenetically diverse microorganisms. Surprisingly, none of the PoTeMs have been investigated for potential physiological functions in their producers. Here, we used heat-stable antifungal...

Ausführliche Beschreibung

Gespeichert in:
Bibliographische Detailangaben
Veröffentlicht in:Applied and environmental microbiology 2021-04, Vol.87 (10)
Hauptverfasser: Yu, Lingjun, Li, Hui, Zhou, Zaichun, Liu, Fengquan, Du, Liangcheng
Format: Artikel
Sprache:eng
Schlagworte:
Online-Zugang:Volltext
Tags: Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
container_end_page
container_issue 10
container_start_page
container_title Applied and environmental microbiology
container_volume 87
creator Yu, Lingjun
Li, Hui
Zhou, Zaichun
Liu, Fengquan
Du, Liangcheng
description Polycyclic tetramate macrolactams (PoTeMs) are a fast-growing family of antibiotic natural products found in phylogenetically diverse microorganisms. Surprisingly, none of the PoTeMs have been investigated for potential physiological functions in their producers. Here, we used heat-stable antifungal factor (HSAF), an antifungal PoTeM from , as a model to show that PoTeMs form complexes with iron ions, with an association constant ( ) of 2.71 × 10 M The and data showed formation of 2:1 and 3:1 complexes between HSAF and iron ions, which were confirmed by molecular mechanical and quantum mechanical calculations. HSAF protected DNA from degradation in high concentrations of iron and H O or under UV radiation. HSAF mutants of barely survived under oxidative stress and exhibited markedly increased production of reactive oxygen species (ROS). Exogenous addition of HSAF into the mutants significantly prevented ROS production and restored normal growth in the mutants under the oxidative stress. The results reveal that the function of HSAF is to protect the producer microorganism from oxidative damage rather than as an iron-acquisition siderophore. The characteristic structure of PoTeMs, a 2,4-pyrrolidinedione-embedded macrolactam, may represent a new iron-chelating scaffold of microbial metabolites. The study demonstrated a previously unrecognized strategy for microorganisms to modulate oxidative damage to the cells. PoTeMs are a family of structurally distinct metabolites that have been found in a large number of bacteria. Although PoTeMs exhibit diverse therapeutic properties, the physiological function of PoTeMs in the producer microorganisms had not been investigated. HSAF from is an antifungal PoTeM that has been subjected to extensive studies for mechanisms of biosynthesis, regulation, and antifungal activity. Using HSAF as a model system, we here showed that the characteristic structure of PoTeMs, a 2,4-pyrrolidinedione-embedded macrolactam, may represent a new iron-chelating scaffold of microbial metabolites. In , HSAF functions as a small-molecule modulator for oxidative damage caused by iron, H O , and UV light. Together, the study demonstrated a previously unrecognized strategy for microorganisms to modulate oxidative damage to the cells. HSAF represents the first member of the fast-growing PoTeM family of microbial metabolites whose potential biological function has been studied.
doi_str_mv 10.1128/AEM.03105-20
format Article
fullrecord <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_8117748</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2535885329</sourcerecordid><originalsourceid>FETCH-LOGICAL-a446t-1d9a544fedb778aa4224f19ae003d9881ddae1ee5caf54423ffbe59cb26e2c303</originalsourceid><addsrcrecordid>eNp1ks1u1DAUhSMEokNhxxpZYtNKk-Kf_DgbpKjqMJVmKNKUtXXj3AypHLvEyYj0Pfq-eJhSChIrL-53j_z5OIreMnrGGJcfyov1GRWMpjGnz6IZo4WMUyGy59GM0qKIOU_oUfTK-xtKaUIz-TI6EiJnPOF8Ft2XlpR2aJvRbsGQL85MetKm1eQahx46GJCsQffOgB6gm5MlwhBvBqgMPl1chLHryclyUy5O5-TSEyCf3Q4NufrR1jC0OySboUfvydrVo4E93Vqymryrwi72BO3d1LktWvSvoxcNGI9vHs7j6Ovi4vp8Ga-uPl2el6sYkiQbYlYXkCZJg3WV5xIgGCUNKwApFXUhJatrQIaYamgCx0XTVJgWuuIZci2oOI4-HnJvx6rDWqMNzkbd9m0H_aQctOrviW2_qa3bKclYnicyBJw8BPTu-4h-UF3rNRoDFt3oFU8p4xnLkzyg7_9Bb9zY26AXKJFKmQpeBGp-oMKTe99j83gZRtW-bxX6Vr_6VnwvcHrAwXf8T-B_2HdPZR-Df38G8RN0brRh</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2535885329</pqid></control><display><type>article</type><title>An Antifungal Polycyclic Tetramate Macrolactam, Heat-Stable Antifungal Factor (HSAF), Is a Novel Oxidative Stress Modulator in Lysobacter enzymogenes</title><source>American Society for Microbiology</source><source>PubMed Central</source><source>Alma/SFX Local Collection</source><creator>Yu, Lingjun ; Li, Hui ; Zhou, Zaichun ; Liu, Fengquan ; Du, Liangcheng</creator><contributor>Zhou, Ning-Yi</contributor><creatorcontrib>Yu, Lingjun ; Li, Hui ; Zhou, Zaichun ; Liu, Fengquan ; Du, Liangcheng ; Zhou, Ning-Yi</creatorcontrib><description>Polycyclic tetramate macrolactams (PoTeMs) are a fast-growing family of antibiotic natural products found in phylogenetically diverse microorganisms. Surprisingly, none of the PoTeMs have been investigated for potential physiological functions in their producers. Here, we used heat-stable antifungal factor (HSAF), an antifungal PoTeM from , as a model to show that PoTeMs form complexes with iron ions, with an association constant ( ) of 2.71 × 10 M The and data showed formation of 2:1 and 3:1 complexes between HSAF and iron ions, which were confirmed by molecular mechanical and quantum mechanical calculations. HSAF protected DNA from degradation in high concentrations of iron and H O or under UV radiation. HSAF mutants of barely survived under oxidative stress and exhibited markedly increased production of reactive oxygen species (ROS). Exogenous addition of HSAF into the mutants significantly prevented ROS production and restored normal growth in the mutants under the oxidative stress. The results reveal that the function of HSAF is to protect the producer microorganism from oxidative damage rather than as an iron-acquisition siderophore. The characteristic structure of PoTeMs, a 2,4-pyrrolidinedione-embedded macrolactam, may represent a new iron-chelating scaffold of microbial metabolites. The study demonstrated a previously unrecognized strategy for microorganisms to modulate oxidative damage to the cells. PoTeMs are a family of structurally distinct metabolites that have been found in a large number of bacteria. Although PoTeMs exhibit diverse therapeutic properties, the physiological function of PoTeMs in the producer microorganisms had not been investigated. HSAF from is an antifungal PoTeM that has been subjected to extensive studies for mechanisms of biosynthesis, regulation, and antifungal activity. Using HSAF as a model system, we here showed that the characteristic structure of PoTeMs, a 2,4-pyrrolidinedione-embedded macrolactam, may represent a new iron-chelating scaffold of microbial metabolites. In , HSAF functions as a small-molecule modulator for oxidative damage caused by iron, H O , and UV light. Together, the study demonstrated a previously unrecognized strategy for microorganisms to modulate oxidative damage to the cells. HSAF represents the first member of the fast-growing PoTeM family of microbial metabolites whose potential biological function has been studied.</description><identifier>ISSN: 0099-2240</identifier><identifier>EISSN: 1098-5336</identifier><identifier>DOI: 10.1128/AEM.03105-20</identifier><identifier>PMID: 33712422</identifier><language>eng</language><publisher>United States: American Society for Microbiology</publisher><subject>Antibiotics ; Antifungal activity ; Antifungal agents ; Biodegradation ; Biosynthesis ; Chelation ; Coordination compounds ; Damage ; Environmental Microbiology ; Fungicides ; Hydrogen peroxide ; Ions ; Iron ; Lysobacter enzymogenes ; Metabolites ; Microorganisms ; Mutants ; Natural products ; Oxidative stress ; Phylogeny ; Physiological effects ; Physiology ; Quantum mechanics ; Reactive oxygen species ; Scaffolds ; Thermal stability ; Ultraviolet radiation</subject><ispartof>Applied and environmental microbiology, 2021-04, Vol.87 (10)</ispartof><rights>Copyright © 2021 American Society for Microbiology.</rights><rights>Copyright American Society for Microbiology May 2021</rights><rights>Copyright © 2021 American Society for Microbiology. 2021 American Society for Microbiology</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-a446t-1d9a544fedb778aa4224f19ae003d9881ddae1ee5caf54423ffbe59cb26e2c303</citedby><cites>FETCH-LOGICAL-a446t-1d9a544fedb778aa4224f19ae003d9881ddae1ee5caf54423ffbe59cb26e2c303</cites><orcidid>0000-0003-4048-1008</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://journals.asm.org/doi/pdf/10.1128/AEM.03105-20$$EPDF$$P50$$Gasm2$$H</linktopdf><linktohtml>$$Uhttps://journals.asm.org/doi/full/10.1128/AEM.03105-20$$EHTML$$P50$$Gasm2$$H</linktohtml><link.rule.ids>230,314,723,776,780,881,3175,27901,27902,52726,52727,52728,53766,53768</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/33712422$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><contributor>Zhou, Ning-Yi</contributor><creatorcontrib>Yu, Lingjun</creatorcontrib><creatorcontrib>Li, Hui</creatorcontrib><creatorcontrib>Zhou, Zaichun</creatorcontrib><creatorcontrib>Liu, Fengquan</creatorcontrib><creatorcontrib>Du, Liangcheng</creatorcontrib><title>An Antifungal Polycyclic Tetramate Macrolactam, Heat-Stable Antifungal Factor (HSAF), Is a Novel Oxidative Stress Modulator in Lysobacter enzymogenes</title><title>Applied and environmental microbiology</title><addtitle>Appl Environ Microbiol</addtitle><addtitle>Appl Environ Microbiol</addtitle><description>Polycyclic tetramate macrolactams (PoTeMs) are a fast-growing family of antibiotic natural products found in phylogenetically diverse microorganisms. Surprisingly, none of the PoTeMs have been investigated for potential physiological functions in their producers. Here, we used heat-stable antifungal factor (HSAF), an antifungal PoTeM from , as a model to show that PoTeMs form complexes with iron ions, with an association constant ( ) of 2.71 × 10 M The and data showed formation of 2:1 and 3:1 complexes between HSAF and iron ions, which were confirmed by molecular mechanical and quantum mechanical calculations. HSAF protected DNA from degradation in high concentrations of iron and H O or under UV radiation. HSAF mutants of barely survived under oxidative stress and exhibited markedly increased production of reactive oxygen species (ROS). Exogenous addition of HSAF into the mutants significantly prevented ROS production and restored normal growth in the mutants under the oxidative stress. The results reveal that the function of HSAF is to protect the producer microorganism from oxidative damage rather than as an iron-acquisition siderophore. The characteristic structure of PoTeMs, a 2,4-pyrrolidinedione-embedded macrolactam, may represent a new iron-chelating scaffold of microbial metabolites. The study demonstrated a previously unrecognized strategy for microorganisms to modulate oxidative damage to the cells. PoTeMs are a family of structurally distinct metabolites that have been found in a large number of bacteria. Although PoTeMs exhibit diverse therapeutic properties, the physiological function of PoTeMs in the producer microorganisms had not been investigated. HSAF from is an antifungal PoTeM that has been subjected to extensive studies for mechanisms of biosynthesis, regulation, and antifungal activity. Using HSAF as a model system, we here showed that the characteristic structure of PoTeMs, a 2,4-pyrrolidinedione-embedded macrolactam, may represent a new iron-chelating scaffold of microbial metabolites. In , HSAF functions as a small-molecule modulator for oxidative damage caused by iron, H O , and UV light. Together, the study demonstrated a previously unrecognized strategy for microorganisms to modulate oxidative damage to the cells. HSAF represents the first member of the fast-growing PoTeM family of microbial metabolites whose potential biological function has been studied.</description><subject>Antibiotics</subject><subject>Antifungal activity</subject><subject>Antifungal agents</subject><subject>Biodegradation</subject><subject>Biosynthesis</subject><subject>Chelation</subject><subject>Coordination compounds</subject><subject>Damage</subject><subject>Environmental Microbiology</subject><subject>Fungicides</subject><subject>Hydrogen peroxide</subject><subject>Ions</subject><subject>Iron</subject><subject>Lysobacter enzymogenes</subject><subject>Metabolites</subject><subject>Microorganisms</subject><subject>Mutants</subject><subject>Natural products</subject><subject>Oxidative stress</subject><subject>Phylogeny</subject><subject>Physiological effects</subject><subject>Physiology</subject><subject>Quantum mechanics</subject><subject>Reactive oxygen species</subject><subject>Scaffolds</subject><subject>Thermal stability</subject><subject>Ultraviolet radiation</subject><issn>0099-2240</issn><issn>1098-5336</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2021</creationdate><recordtype>article</recordtype><recordid>eNp1ks1u1DAUhSMEokNhxxpZYtNKk-Kf_DgbpKjqMJVmKNKUtXXj3AypHLvEyYj0Pfq-eJhSChIrL-53j_z5OIreMnrGGJcfyov1GRWMpjGnz6IZo4WMUyGy59GM0qKIOU_oUfTK-xtKaUIz-TI6EiJnPOF8Ft2XlpR2aJvRbsGQL85MetKm1eQahx46GJCsQffOgB6gm5MlwhBvBqgMPl1chLHryclyUy5O5-TSEyCf3Q4NufrR1jC0OySboUfvydrVo4E93Vqymryrwi72BO3d1LktWvSvoxcNGI9vHs7j6Ovi4vp8Ga-uPl2el6sYkiQbYlYXkCZJg3WV5xIgGCUNKwApFXUhJatrQIaYamgCx0XTVJgWuuIZci2oOI4-HnJvx6rDWqMNzkbd9m0H_aQctOrviW2_qa3bKclYnicyBJw8BPTu-4h-UF3rNRoDFt3oFU8p4xnLkzyg7_9Bb9zY26AXKJFKmQpeBGp-oMKTe99j83gZRtW-bxX6Vr_6VnwvcHrAwXf8T-B_2HdPZR-Df38G8RN0brRh</recordid><startdate>20210427</startdate><enddate>20210427</enddate><creator>Yu, Lingjun</creator><creator>Li, Hui</creator><creator>Zhou, Zaichun</creator><creator>Liu, Fengquan</creator><creator>Du, Liangcheng</creator><general>American Society for Microbiology</general><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7QL</scope><scope>7QO</scope><scope>7SN</scope><scope>7SS</scope><scope>7ST</scope><scope>7T7</scope><scope>7TM</scope><scope>7U9</scope><scope>8FD</scope><scope>C1K</scope><scope>FR3</scope><scope>H94</scope><scope>M7N</scope><scope>P64</scope><scope>RC3</scope><scope>SOI</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0003-4048-1008</orcidid></search><sort><creationdate>20210427</creationdate><title>An Antifungal Polycyclic Tetramate Macrolactam, Heat-Stable Antifungal Factor (HSAF), Is a Novel Oxidative Stress Modulator in Lysobacter enzymogenes</title><author>Yu, Lingjun ; Li, Hui ; Zhou, Zaichun ; Liu, Fengquan ; Du, Liangcheng</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-a446t-1d9a544fedb778aa4224f19ae003d9881ddae1ee5caf54423ffbe59cb26e2c303</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2021</creationdate><topic>Antibiotics</topic><topic>Antifungal activity</topic><topic>Antifungal agents</topic><topic>Biodegradation</topic><topic>Biosynthesis</topic><topic>Chelation</topic><topic>Coordination compounds</topic><topic>Damage</topic><topic>Environmental Microbiology</topic><topic>Fungicides</topic><topic>Hydrogen peroxide</topic><topic>Ions</topic><topic>Iron</topic><topic>Lysobacter enzymogenes</topic><topic>Metabolites</topic><topic>Microorganisms</topic><topic>Mutants</topic><topic>Natural products</topic><topic>Oxidative stress</topic><topic>Phylogeny</topic><topic>Physiological effects</topic><topic>Physiology</topic><topic>Quantum mechanics</topic><topic>Reactive oxygen species</topic><topic>Scaffolds</topic><topic>Thermal stability</topic><topic>Ultraviolet radiation</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Yu, Lingjun</creatorcontrib><creatorcontrib>Li, Hui</creatorcontrib><creatorcontrib>Zhou, Zaichun</creatorcontrib><creatorcontrib>Liu, Fengquan</creatorcontrib><creatorcontrib>Du, Liangcheng</creatorcontrib><collection>PubMed</collection><collection>CrossRef</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Biotechnology Research Abstracts</collection><collection>Ecology Abstracts</collection><collection>Entomology Abstracts (Full archive)</collection><collection>Environment Abstracts</collection><collection>Industrial and Applied Microbiology Abstracts (Microbiology A)</collection><collection>Nucleic Acids Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>Technology Research Database</collection><collection>Environmental Sciences and Pollution Management</collection><collection>Engineering Research Database</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>Genetics Abstracts</collection><collection>Environment Abstracts</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Applied and environmental microbiology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Yu, Lingjun</au><au>Li, Hui</au><au>Zhou, Zaichun</au><au>Liu, Fengquan</au><au>Du, Liangcheng</au><au>Zhou, Ning-Yi</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>An Antifungal Polycyclic Tetramate Macrolactam, Heat-Stable Antifungal Factor (HSAF), Is a Novel Oxidative Stress Modulator in Lysobacter enzymogenes</atitle><jtitle>Applied and environmental microbiology</jtitle><stitle>Appl Environ Microbiol</stitle><addtitle>Appl Environ Microbiol</addtitle><date>2021-04-27</date><risdate>2021</risdate><volume>87</volume><issue>10</issue><issn>0099-2240</issn><eissn>1098-5336</eissn><abstract>Polycyclic tetramate macrolactams (PoTeMs) are a fast-growing family of antibiotic natural products found in phylogenetically diverse microorganisms. Surprisingly, none of the PoTeMs have been investigated for potential physiological functions in their producers. Here, we used heat-stable antifungal factor (HSAF), an antifungal PoTeM from , as a model to show that PoTeMs form complexes with iron ions, with an association constant ( ) of 2.71 × 10 M The and data showed formation of 2:1 and 3:1 complexes between HSAF and iron ions, which were confirmed by molecular mechanical and quantum mechanical calculations. HSAF protected DNA from degradation in high concentrations of iron and H O or under UV radiation. HSAF mutants of barely survived under oxidative stress and exhibited markedly increased production of reactive oxygen species (ROS). Exogenous addition of HSAF into the mutants significantly prevented ROS production and restored normal growth in the mutants under the oxidative stress. The results reveal that the function of HSAF is to protect the producer microorganism from oxidative damage rather than as an iron-acquisition siderophore. The characteristic structure of PoTeMs, a 2,4-pyrrolidinedione-embedded macrolactam, may represent a new iron-chelating scaffold of microbial metabolites. The study demonstrated a previously unrecognized strategy for microorganisms to modulate oxidative damage to the cells. PoTeMs are a family of structurally distinct metabolites that have been found in a large number of bacteria. Although PoTeMs exhibit diverse therapeutic properties, the physiological function of PoTeMs in the producer microorganisms had not been investigated. HSAF from is an antifungal PoTeM that has been subjected to extensive studies for mechanisms of biosynthesis, regulation, and antifungal activity. Using HSAF as a model system, we here showed that the characteristic structure of PoTeMs, a 2,4-pyrrolidinedione-embedded macrolactam, may represent a new iron-chelating scaffold of microbial metabolites. In , HSAF functions as a small-molecule modulator for oxidative damage caused by iron, H O , and UV light. Together, the study demonstrated a previously unrecognized strategy for microorganisms to modulate oxidative damage to the cells. HSAF represents the first member of the fast-growing PoTeM family of microbial metabolites whose potential biological function has been studied.</abstract><cop>United States</cop><pub>American Society for Microbiology</pub><pmid>33712422</pmid><doi>10.1128/AEM.03105-20</doi><tpages>16</tpages><orcidid>https://orcid.org/0000-0003-4048-1008</orcidid><oa>free_for_read</oa></addata></record>
fulltext fulltext
identifier ISSN: 0099-2240
ispartof Applied and environmental microbiology, 2021-04, Vol.87 (10)
issn 0099-2240
1098-5336
language eng
recordid cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_8117748
source American Society for Microbiology; PubMed Central; Alma/SFX Local Collection
subjects Antibiotics
Antifungal activity
Antifungal agents
Biodegradation
Biosynthesis
Chelation
Coordination compounds
Damage
Environmental Microbiology
Fungicides
Hydrogen peroxide
Ions
Iron
Lysobacter enzymogenes
Metabolites
Microorganisms
Mutants
Natural products
Oxidative stress
Phylogeny
Physiological effects
Physiology
Quantum mechanics
Reactive oxygen species
Scaffolds
Thermal stability
Ultraviolet radiation
title An Antifungal Polycyclic Tetramate Macrolactam, Heat-Stable Antifungal Factor (HSAF), Is a Novel Oxidative Stress Modulator in Lysobacter enzymogenes
url https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-15T18%3A12%3A46IST&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=An%20Antifungal%20Polycyclic%20Tetramate%20Macrolactam,%20Heat-Stable%20Antifungal%20Factor%20(HSAF),%20Is%20a%20Novel%20Oxidative%20Stress%20Modulator%20in%20Lysobacter%20enzymogenes&rft.jtitle=Applied%20and%20environmental%20microbiology&rft.au=Yu,%20Lingjun&rft.date=2021-04-27&rft.volume=87&rft.issue=10&rft.issn=0099-2240&rft.eissn=1098-5336&rft_id=info:doi/10.1128/AEM.03105-20&rft_dat=%3Cproquest_pubme%3E2535885329%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=2535885329&rft_id=info:pmid/33712422&rfr_iscdi=true