Proton pump inhibitors can reverse the YAP mediated paclitaxel resistance in epithelial ovarian cancer
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Several reports indicated that the expression of Yes-associated protein (YAP) was associated with multi-drug resistance. Acidic microenvironment increased by the overexpression of vacuolar-ATPase (V-ATPase) was also observed in tumor growth and drug resistance. We hypothesize that proton pump inhibitors (PPIs), currently used in the anti-acid treatment of peptic disease, could inhibit the acidification of the tumor microenvironment and increase the sensitivity of tumor cells to cytotoxic agents. Thus, our objective is to explore the reversal of drug resistance by the inhibition of YAP through specific PPIs in the epithelial ovarian carcinoma (EOC) cells. .
We found that V-ATPase D1 was a positive regulator of YAP. Sub-lethal doses of the proton pump inhibitor esomeprazole (EMSO) in combination with paclitaxel (PTX) increased the PTX sensitivity in PTX-resistant EOC cells, as compared to PTX single treatments by inhibiting YAP and reserving pH gradient created by the V-ATPase D1. Moreover, sub-lethal doses of EMSO combined with PTX decreased autophagy and improved caspases independent apoptosis of PTX-resistant EOC cells.
These results suggested that sub-lethal doses of esomeprazole reverse YAP-mediated PTX resistance through the inhibiting of both YAP expression and acidic tumor microenvironment created by the V-ATPase D1. Therefore, we think the use of PPIs represents a promising strategy to improve the effectiveness of anti-EOC.
KeywordsVacuolar H + -ATPase YAP Proton pump inhibitors (PPI) Paclitaxel resistance Epithelial ovarian carcinoma (EOC)
Autophagy-related proteins 5
Cell Counting Kit-8
Enzyme-linked immunosorbent assay
Half maximal inhibitory concentration
Proton pump inhibitors
Short hairpin RNA
Scrambled short hairpin RNA
In tumor cells, YAP (Yes-associated protein) is closely associated with tumorigenesis as one of the major transcription activation factors, plays an important role in regulating cell proliferation and organ development . YAP is overexpressed, and is connected with multi-drug resistance [2, 3]. Our previous study  demonstrated that YAP was highly expressed in cisplatin-resistant EOC cancer cells. As a new anti-tubulin drug , paclitaxel (PTX) can raise the binding ability of 14-3-3 protein with YAP while remaining the stability of tublins and maintaining YAP in a phosphorylation status . However, the inhibition of PTX by YAP can be reversed by the up-regulation of YAP .
Cancer cells survival and proliferation in competition with somatic cells and according to the physical and biological properties of their microenvironment. The constant high level of glycolytic activity in tumor cells leads to an increased production of lactic acid and a decreased pH of the extracellular microenvironment. Thus, in tumor cells, V-ATPases maintains an appropriate relatively neutral intracellular pH and an acidic extracellular pH . The acidic microenvironment increased by overexpression of V-ATPases is observed in tumor growth, metastasis and chemoresistance . In addition, several studies have demonstrated that PPIs (proton pump inhibitors), which directly inhibit V-ATPase at the cellular level, has reverted chemoresistance of drug-resistant tumors [10, 11, 12]. YAP/TAZ activation and a shift toward a glycolytic metabolism are commonly observed during tumor progression . YAP is regulated by diverse mechanisms including microenvironmental factors . V-ATPase D1 also known as ATP6V0D1, is the D subunit of the V0 domain. Expressed ubiquitously, V-ATPase D1 acts in concert with other V0 subunits to catalytically acidify a variety of intracellular compartments. V-ATPase D2 has been implicated as a regulator of urine acidification, osteoclast fusion and bone formation. Furthermore, V-ATPase D2 has been identified as a dendritic cell marker. Therefore, we wondered whether the inhibition of V-ATPase D1 through PPI can reserve the PTX resistance caused by the over-expression of YAP, and this may lead to the clinical use of PTX.
In the current study, we find a novel role of V-ATPase D1 in correlation with YAP. PTX resistance of the EOC cancer cells can be reversed by EMSO co-treatment and the YAP inhibition. Furthermore, we uncovered a downloaded of a novel V-ATPase D1/YAP signaling pathway, which may be targeted in EOC treatment. Thus, we have a clinical proof of concept that PPI may well be included in new anti-cancer strategies.
YAP is highly expressed in EOC and is directly regulated by V-ATPase D1 expression
Association of V-ATPase D1 expression with clinicopathological factors in epithelial ovarian carcinoma patients
Association of YAP expression with clinicopathological factors in epithelial ovarian carcinoma patients
YAP-TEAD1 confers PTX-resistance to EOC cells
TEAD family members are YAP downstream co-activators. Multiple genes strongly correlated with tumorigenesis were regulated by TEAD family, including CTGF and Cyr61. Our results showed that Cyr61 and CTGF were highly induced by YAP expression in A2780/T cells, compared to A2780 cells (Fig. 1g). In ovarian cancer initiated cells, TEAD1 and TEAD4 were found to be expressed at significantly higher levels than in differentiated ovarian cancer cells. In this study, we focused on YAP downstream co-activators TEAD1. As shown in Fig. 2f, the expression of TEAD1 was overexpressed in the A2780/T cells, compared with the A2780 cells. Next, we cloned the CTGF promoter into a basic luciferase reporter and found that it was potently activated by YAP but not by YAP-S94A, and the activation was further enhanced by TEAD1 co-expression (Fig. 2g). Expression of the dominant-negative TEAD1-C, but not the TEAD1-C-AD (in which the C-terminal YAP-binding domain was replaced by the YAP transactivation domain), blocked the activation of CTGF reporter by YAP (Fig. 2h). These results indicate that YAP activates the CTGF promoter through TEAD1.
Effects of acidic pHe on V-ATPase D1 change
PPI reduced PTX resistance in EOC cells through the inhibition of YAP. Synergetic effects of the combination of PPI and PTX resulted in the inhibition of YAP and cytotoxicity to PTX-resistant EOC cells
Paclitaxel and EMSO Combination Index (CI) against A2780 and A2780/T Cells
A2780+ PTX(0.05) + EMSO(50)
A2780+ PTX(0.25) + EMSO(100)
A2780+ PTX(1.25) + EMSO(130)
A2780/T+ PTX(0.04) + EMSO(50)
A2780/T + PTX(0.90)
A2780/T + PTX(0.90) + EMSO(100)
A2780/T + PTX(5.0)
A2780/T + PTX(5.0) + EMSO(150)
We also demonstrated the specific and significant inhibition of PTX-resistance related mRNA and protein expression in A2780 and A2780/T exposed to PTX (0.25 and 2 μM), EMSO (130 and 150 μM) alone or to the combination with PTX. MDR1 expression was very high in the A2780/T cells, but nearly absent in the parental A2780 cells. The levels YAP and cyr61 expression in the A2780/T cells co-treated with EMSO+PTX were significantly decreased, compared to EMSO and PTX alone treatment. However, statistical significance was not achieved neither for YAP nor cyr61 expression in A2780 cells using the same treatment combination (Fig. 4c). As shown in Fig. 4d-e, compared to YAP expression, p-gp expression was very high in the A2780/T cells, but nearly absent in the parental A2780 cells. Q-PCR and confocal analysis revealed that YAP and its downstream target Cyr61 was inhibited by combination therapy with sub-lethal doses of EMSO and PTX in the A2780/T cells, compared to EMSO and PTX alone (Fig. 4d-e). Moreover, the increase of p-YAP expression and decrease of p-gp and TEAD1 expression in the two ovarian cancer cells were reversed by a co-treatment with EMSO+PTX (Fig. 4d).
It has been well documented that the PI3K/AKT pathway is essential for the proliferation and invasion of tumor cells, and activation of the PI3K/AKT signaling pathway is regulated by YAP. Western blots of two cell lysates showed that a combination treatment with PTX + EMSO did affect the phosphorylation status of Akt (Fig. 4f). Therefore, co-treatment with PTX + EMSO may decrease YAP nuclear localization and activity and causes more sensitivity to PTX in the two ovarian cancer cells.
PPI-mediated apoptosis was revealed using a caspase-independent apoptotic-like cytotoxicity upon PTX treatment of EOC cells
We next examined the possible mechanisms responsible for the apoptotic effects of sub-lethal doses of EMSO combined with PTX, we evaluated its effects based on the activation of caspases. Morphological analysis showed that sub-lethal doses of EMSO combined with PTX had no significant effect on caspase-3 and caspase-8 activities in the two EOC cell lines (Fig. 5c). To confirm the role of caspases in sub-lethal doses of EMSO combination with PTX-induced cell death, the pan-caspases inhibitor z-VAD-fmk was used at 20 μM (Fig. 5d). We observed that preincubation with z-VAD-fmk, had no significant effect on co-treatment PTX + EMSO-induced apoptosis in the two EOC cells. This suggests that activated caspases are not instrumental for the combination of EMSO with PTX-induced apoptosis in the EOC cells.
Autophagy flux inhibited by the combinations of PTX with sub-lethal doses of EMSO
We also found that PTX treatment preferentially induced GFP-LC3B puncta in the A2780/T cells but not in the A2780 cells. There was also an increased accumulation of LC3B in the presence of a sub-lethal dose of EMSO combined with PTX with a strongly enhanced the presence of punctuate fluorescence in A2780/T cells (Fig. 6c-d), indicating ESOM partially reduced autophagic flux.
These findings suggest that co-treatment with a sub-lethal dose of EMSO likely causes the accumulation of autophagosomes and slows down the autophagic flux.
Acidic microenvironment increased by overexpression of V-ATPases has been observed in malignant tissues. It was also found that higher expression of V-ATPase mRNA was associated with a significant poor survival . Our results revealed that V-ATPase D1 silencing cells exhibited 2.25 -fold inhibition in YAP protein level. The inhibition of V-ATPase D1 reduces YAP activities in A2780/T cells. Knocking down the expression of V-ATPase D1 in A2780/T cells prevented the expression of target proteins downstream of YAP. Overall, our studies have provided a novel mechanism in PTX-resistance ovarian cancer cells through the activating of YAP transcriptional activity by V-ATPase D1.
Previous research has reported that over-expression of YAP promotes PTX-resistance in ovarian cancer cells . The precise mechanisms by which YAP enhances drug resistance remain unclear. In the present study, we found that YAP was significantly elevated in A2780/T cells, compared with A2780 cells. To further confirm the relationship between YAP and PTX resistance, over-expression of YAP by stable transfection enhanced the expression level of YAP and contributed to PTX -resistance in the A2780 cells. Correspondingly, suppression of YAP by siRNA effectively inhibited YAP expression, resulting in PTX-sensitivity in A2780/T cells. Our immunostaining results also showed that TEAD1 was positively correlated with YAP expression, suggested that TEAD1was a direct binding partner of YAP. Therefore, we speculate that modulating YAP and TEAD1 activities may be an effective strategy to prevent the PTX-resistance in ovarian cancers.
Treatment using PPIs has been proposed as a valid and feasible approach because of the relatively low toxicity and potential selectivity of these drugs. It has been reported that PPIs are chemosensitizing as well as cytotoxic drugs, active against several human tumor cells, such as osteosarcoma [19, 20], melanoma [21, 22], gastric carcinoma [23, 24, 25], pancreatic cancer  and breast cancer [27, 28, 29]. In this context, we hypothesized that the V-ATPase blocker PPI could reverse the YAP-mediated PTX-resistance in EOC cells. Our results demonstrated that a sub-lethal dose of EMSO affected the membrane V-ATPase D1 expression, as well as regulated the transmembrane pH gradient in EOC cells, suggesting that V-ATPase D1 mediated the acidic tumor microenvironment formation. These data are in agreement with one study demonstrating in MCF-7 breast carcinoma cell line that a low extracellular pH induces higher resistance to PTX .
When used in combination, the PPIs improve the efficacy of the anti-cancer drugs. This study further supports these previous observations. In a lung cancer study, it has been proven that the combination of EMSO with chemotherapeutics results in a more pronounced cytotoxic effect . In our study, apparent and statistically significant cytotoxic effects were observed in a combinated treatment with a sub-lethal dose of EMSO and PTX. We also found that PTX combined with sub-lethal doses of EMSO generated strong synergism effect. A sub-lethal dose of EMSO could effectively inhibit YAP protein and its down-stream proteins. Moreover, our results showed that the down-regulation of MDR1/P-gp protein expression. In addition, we observed that the decrease in phosphor-AKT levels was accompanied by lower cell survival rates and PTX-sensitivity in A2780 and A2780/T cells exposed to a PTX + EMSO co- treatment. Thus, our results indicated a substantial reversal in PTX-resistance cells, was YAP-mediated in EOC cells.
To improve treatment efficacy, it is crucial to investigate the precise molecular mechanism of PPIs in EOC, which may occur through: (i) inhibition of drug extrusion from cells via P-glycoprotein or other MDR-related mechanisms ; (ii) increase in anti-apoptotic molecules ; and (iii) acidic endosomes, which are an important step in the maturation of autophagosomes and PPIs which inhibit autophagy . Some human cancers, including ovarian, gastrointestinal, prostate and breast cancers [34, 35, 36, 37] exhibit high levels of autophagic activity. Studies have described the induction of autophagy in response to therapeutic agents . For example, cisplatin and PTX were able to induce autophagy in A549 lung cancer cells . Increasing evidence suggests that inhibition of autophagy augments cytotoxicity caused by anticancer drugs in preclinical models . Inhibitors of autophagy that can be used in vivo include CQ (chloroquine), HCQ (hydroxychloroquine) and PPIs. Co-treatment with pantoprazole was able to inhibit autophagy and enhance cytotoxicity in vivo .
On the search for cellular mechanisms that mediate the effect of EMSO in EOC cell PTX-resistance, our data are consistent with other recent studies indicating that resistance to PTX is associated with up-regulation of autophagy in EOC cells. The administration of EMSO can augment the activity of PTX, but only at sub-lethal doses. EMSO combination of PTX has been shown to be feasible with a good toxicity profile. An increase in cell death was observed when PTX was combinated with sub-lethal doses of EMSO. We also showed that sub-lethal doses of EMSO exerts their cytotoxic action through a caspase-independent apoptotic-like cell death.
Despite our important findings, our study has several limitations. This analysis was limited to two selected EOC cells and one basic anticancer drug. We also did not perform an in vivo study to assess the potential clinical relevance of the in vitro results.
Clinical and experimental approaches were combined to demonstrate that V-ATPase D1 regulated YAP expression mediated PTX-resistance in EOC. To this end, drugs targeting the V-ATPase D1/YAP signaling pathway can be specifically developed to overcome the occurrence of tumor resistance in EOC. Thus, EMSO may be useful as a chemosensitizer in the treatment of patients with PTX-resistance EOC.
Patients and tissue specimens
Tumor samples from patients with ovarian cancer were acquired from the First Affiliated Hospital of An Hui Medical University (PJ2017-0704) and a written informed consent was approved by the First Affiliated Hospital of An Hui Medical University Institutional Review Board. Twelve normal ovarian specimens were obtained during surgery from women with myoma of uterus. A single gynecologic pathologist (I-G Do) examined the specimens using hematoxylin and eosin staining. Specimens were selected in analysis if they comprised more than 90% tumor cells. Data was collected from electronic and paper medical records.
Esomeprazole sodium was purchased from AstraZeneca (Sweden) and dissolved to 10 mmol/L in saline before use. PTX injection was purchased from Aosaikang Co., Ltd. (Jiangsu, China). Z-VAD-FMK was purchased from Calbiochem (USA).
Cell lines and culture
Human EOC cell lines (A2780 and A2780/Taxol) were purchased from Hui Ying Biological Technology Co., Ltd., China. PTX-sensitive A2780 Cells was maintained in complete DMEM, high glucose (Hyclone, USA) supplemented with 10% fetal bovine serum. PTX-resistant A2780/Taxol (A2780/T) cells were cultured in RPMI 1640 supplemented with 10% fetal bovine-serum medium, first the A2780/T cells were exposed to 100 nM PTX for 24 h, then the medium was changed to fresh one without PTX. When cells reached almost 80% confluency, the cells were incubated with increasing concentrations of PTX to finally obtain the cells resistant to 1200 nM PTX. For maintenance of PTX-resistance phenotype, 250 nM PTX was added into the normal medium. The drug resistant cells were cultured in PTX-free medium for at least 2 weeks prior to being used in experiments. All cells were cultured at 37 °C in a humidified atmosphere incubator with 5% CO2.
Immunohistochemical studies were carried out on formalin-fixed, paraffin- embedded, 4 μm thick tissue sections and stained with hemoxylin and eosin. After deparaffinization and antigens retrieval, slides were washes, blocked and incubated with V-ATPase D1(Santa Cruz, USA) and YAP (Santa Cruz, USA) at 4 °C overnight, followed by 1 h incubation with biotinylated goat-anti-mouse or biotinylated goat-anti-rabbit secondary antibody. Immunostaining was performed with diaminobenzidine (DAB) using the streptavidin-biotin complex/horseradish peroxidase (sABC-HRP) method. Sections were counterstained with hematoxylin, and then mounted in medium. For each sample four microscopic fields (× 200) in three different sections were counted. The intensity of staining was graded on a semi quantitative scale from 0 to 3, where 0 = no staining, 1+ = weak staining, 2+ = moderate staining, and 3+ = strong staining. The range of possible scores was between 0 and 250.
To figure out if YAP directly regulated by V-ATPase expression, we generated stable V-ATPase D1 knockdown YAP-high/PTX-resistant A2780/T cells by transfection of V-ATPase D1 shRNA plasmid (Santa Cruz, USA). Stable clones were selected with G418 (Gibco, USA). To investigate the relationship between YAP and PTX resistance, YAP plasmids and siYAP-RNA were transfected, respectively, into YAP-low/PTX-sensitive A2780 cells or YAP-high/PTX-resistant A2780/T cells, using Lipofectamine 2000 transfection reagent (Invitrogen, USA) as per manufacturer’s instructions. After incubation for 48 h, the transfected cells were used for the following experiments.
Human YAP cDNA was inserted into the expression vector pCL3-based verctos, resulting in the Flag-tagged YAP (Flag-YAP). YAP wild type or S94A mutant, and TEAD1 shRNAs were designed in a region identical in TEAD1, then stably co-transfected with a Renila luciferase expression plasmid into cells. Luciferase activities were analyzed using a dual-luciferase reporter kit (Promega, USA). Transfections were performed in triplicate and repeated three times to ensure reproducibility.
Measurement of intracellular pH levels
BCECF-AM (Beyotime Biotechnology, China) is the most widely used fluorescent indicator for intracellular pH. The BCECF-AM was excited at 488 nm with emission collected at 535 nm. Cells (1 × 105 cells) were seeded in a 35-mm confocal dish in RPMI1640 and high glucose DMEM with 10% FBS. The next day, cells were exposed to EMSO in serum free RPMI 1640 and high glucose DMEM. After 48 h, the cells were treated with 1 μmol/L BCECF-AM solution, incubated at 37 °C for 40 min and analyzed by fluorescence microscopy.
Cells were grown on round glass coverslips (Thermo Fisher Scientific, USA) in 35 mm cell culture dishes. Following a 7-9 min fixation with 4% pre-chilled paraformaldehyde, the coverslips were washed with PBS, permeabilized with 0.5% Triton X-100-PBS for 5-10 min, and blocked with 5% bovine serum albumin-PBS for 60 min. The YAP antibody was incubated with the cells overnight at 4 °C. After incubation with the appropriate secondary fluorescent antibody Alexa green 488 nm (Molecular Probes, Life Technologies, USA), nuclei were stained with DAPI (Beyotime Biotechnology, China) and the cell were immediately observed under a fluorescence microscope. For the co-localization analysis of V-ATPase D1 with plasma membrane, cells were washed and fixed as described above, but not permeabilized. After the immunofluorescence stain for the V-ATPase D1, cells were also stained with a pan-cadherin (Abcam, UK) that bind of the cell membrane.
Cytotoxicity of a single and combined drug in PTX sensitive and resistant EOC cells
Cell cytotoxicity was analyzed with Cell Counting Kit-8 (CCK-8) assay kit (Beyotime Biotechnology, China). Briefly, cells were seeded into flat-bottomed 96-well plates at a density of 8000 per well and incubated overnight. After cellular adhesion, the A2780/T cells were exposed to various doses of PTX (0.04, 0.2, 0.9, 5, 23 μM) and in the absence or presence of EMSO (150 μM), the A2780 cells were exposed to various doses of PTX (0.01, 0.05, 0.25, 1.25, 7.5 μM) in the absence or presence of EMSO (130 μM) for 48 h followed by treatment with 10 μl of CCK-8 solution for an additional 1 h at 37 °C, and the absorbance was measured at 450 nm using a microplate reader (Perkin Elmer, USA). At least three independent experiments were performed.
Cell apoptosis detection
Apoptosis was induced by PTX (0.25 and 2 μM) with or without EMSO (130 and 150 μM) co-treatment for 48 h each. Apoptosis detection was carried out with Annexin V-FITC and Propidium Iodide (PI) double staining assay kit (KeyGen Biotech, China), following the manufacturer’s instruction. Apoptotic cells were uncovered using flow cytometry (BD Bioscience, USA). Data acquisition and analysis were done with CellQuest V3.3 (BD Bioscience, USA).
Morphological detection of apoptosis by Hoechst-33342 assay
Cells were harvested and washed in ice-cold PBS and fixed with 3.7% paraformaldehyde in PBS for 10 min at room temperature. Fixed cells were permeabilized with saponin and stained with Hoechst-33342 solution (Beyotime Biotechnology, China) for 10 min at room temperature. Nuclear morphology of cells was examined by fluorescence microscopy. The percentage of apoptosis was calculated by counting the condensed and fragmented nuclei in cells. The experiment was repeated three times.
Green fluorescent protein-LC3 translocation
Ad-mCherry-GFP-LC3B (Beyotime Biotechnology, China) was used to detect autophagy. Cells were transfected with Ad-mCherry-GFP-LC3B using Lipofectamine 2000 in serum-free medium for 240 min after which the medium was changed to a complete medium. After 24 h, the transfected cells were exposed to PTX (0.25 and 2 μM) in the absence or presence of EMSO (130 and 150 μM) for 48 h. The distribution and the fluorescence of mCherry-GFP-LC3B were visualized by fluorescence microscopy.
Real-time reverse transcription PCR
Total RNA was extracted with Trizol Reagent (Invitrogen, USA) and quantified by a spectrophotometer. cDNA synthesis was carried out using M-MLV reverse transcriptase (Invitrogen, USA). Quantitative PCR experiments were performed on the 7500 Real-time PCR system (Applied Biosystems, USA) by using the SYBR Green PCR reagents (Takara, Japan). The levels of mRNA were calculated using the equation 2-∆∆CT and normalized to human 18 s mRNA levels.
Western blotting analysis
The total protein was extracted using RIPA lysis buffer (Beyotime Biotechnology, China) supplemented with protease inhibitors cocktail (Roche, USA). The proteins were quantified using BCATM Protein Assay Kit (Pierce, Appleton, USA). The western blot was performed according to the standard protocol.
Enzyme-linked immunosorbent assay
For the analysis of active caspase-3 and caspase-8 expression, cells were lysed in PRO-PRE Protein Extraction Solution (Intron Biotechnology, Korea). The protein concentration was determined using a BCA protein kit (Thermo Scientific, USA). The concentrations of active caspase-3 and caspase-8 (Invitrogen, USA) were determined using an Enzyme-linked immunosorbent assay (ELISA) kits used according to the manufacturer’s instructions. All samples were measured in triplicate.
The correlation between YAP and V-ATPase D1 was evaluated using Spearman’s rank correlation coefficient test. The results are expressed as the mean + standard error (SE) or standard deviation (SD) of the raw data. The Student’s t test was used to determine the statistical significance of differences between the control and test groups. A p value of < 0.05 was considered statistically significant.
Combination index (CI) values were calculated using CalcuSyn Version 2.1 according to the Chou-Talalay method for drug combinations (Chou, 2010). CI is a parameter that gives information about the effectiveness of drug combinations. Combination effects are defined as very strong synergism (CI < 0.1), strong synergism (0.1 < CI < 0.3), synergism (0.3 < CI < 0.7), moderate synergism (0.70 < CI < 0.85), slight synergism (0.85 < CI < 0.90), nearly additive (0.9 < CI < 1.1), or antagonistic (CI > 1.1) (Chou, 2006).
The authors gratefully acknowledge all the volunteers who generously providing tissue samples for this study.
XL and YSJ designed the project; HJ, SXY, LZM, LZL performed the experiments; CY, PXH interpreted and analyzed the data; XL drafted the manuscript. All the authors have approved the submitted version and have agreed to be personally accountable for the contributions and for ensuring that questions related to the accuracy or integrity of any part of the work are answered.
This work was partially supported by grants from the National Natural Science Foundation of China (grant number: 81603138), the Special Fund for Guiding Local Science and Technology Development awarded by the Central Government of Anhui Province (grant number: 2017070802d149). The funding bodies represents government’s fulfillment of their duty in maximizing the benefits from public research output in China.
Ethics approval and consent to participate
This study was approved by the Institutional Ethics Committee of The First Affiliated Hospital of An Hui Medical University and according to the Declaration of Helsinki. Informed consent was also obtained from each participants.
Consent for publication
The authors declare that they have no competing interests.
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