Ka-Won Noh1, Jihyun Park1, Myung-Soo Kang2. 1. Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul 06351, Korea. 2. Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University; Samsung Biomedical Research Institute (SBRI), Samsung Medical Center, Seoul 06351; BioMembrane Plasticity Research Center (MPRC), Seoul National University College of Medicine, Seoul 03080, Korea.
Abstract
Epstein Barr virus (EBV)-encoded nuclear antigen-1 (EBNA1) plays a pivotal in an EBV episome replication and persistence. Despite considerable attempts, there are no EBV drugs or vaccines. We attempted to eradicate EBV episomes by targeting EBNA1 using the transcription activator-like effector nucleases (TALEN) (E1TN). E1TN-mediated transient knockout (KO) of EBNA1 reduced EBNA1 expression, and caused significant loss of EBV genomes and progressive death of EBV-infected cells. Furthermore, when a mixture of EBV-infected Burkitt's lymphoma (BL) cells and EBV-negative BL cells was targeted by E1TN, EBV-negative cells were counter-selected while most EBV-infected cells died, further substantiating that EBNA1 KO caused selective death of EBV-infected cells. TALEN-mediated transient targeting of EBNA1 attenuated the growth of EBV-infected cells, implicating a possible therapeutic application of E1TN for EBV-associated disorders. [BMB Reports 2016; 49(4): 226-231].
Epstein Barr virus (EBV)-encoded nuclear antigen-1 (EBNA1) plays a pivotal in an EBV episome replication and persistence. Despite considerable attempts, there are no EBV drugs or vaccines. We attempted to eradicate EBV episomes by targeting EBNA1 using the transcription activator-like effector nucleases (TALEN) (E1TN). E1TN-mediated transient knockout (KO) of EBNA1 reduced EBNA1 expression, and caused significant loss of EBV genomes and progressive death of EBV-infected cells. Furthermore, when a mixture of EBV-infected Burkitt's lymphoma (BL) cells and EBV-negative BL cells was targeted by E1TN, EBV-negative cells were counter-selected while most EBV-infected cells died, further substantiating that EBNA1 KO caused selective death of EBV-infected cells. TALEN-mediated transient targeting of EBNA1 attenuated the growth of EBV-infected cells, implicating a possible therapeutic application of E1TN for EBV-associated disorders. [BMB Reports 2016; 49(4): 226-231].
Epstein-Barr virus (EBV) establishes lifelong latency in its hosts by undergoing
latent replication and persistence of viral episomal genomes. EBV infection is
considered a high risk factor and is responsible for > 1% of all humancancers (1). Although the synthesis of viral
genome is initiated by the host replication machinery, efficient replication and
long term persistence require EBV nuclear antigen 1 (EBNA1)-mediated DNA binding
activity (2). In latent infections,
including malignancies, EBV usually persists as a multi-copy episome (3, 4). EBV genome integration is unusual (5, 6). EBNA1 is essential for
EBV episome persistence in dividing cells and enhances episome transcription (7, 8), validating the status of EBNA1 as a reasonable target protein for the
treatment of EBV-associated diseases (9-12). EBV genome has 24
cognate sites in OriP element where EBNA1 binds, enabling EBV genome replication and
transcription. Transcription activator-like effector (TALE)-based nuclease (TALEN)
can introduce frame-shift mutation in specific genomic sites (13). Despite considerable attempts towards developing EBV
drugs (9, 14, 15), there is no
FDA-approved EBV drugs or vaccines (16).
Thus, we have attempted to target EBNA1 in living cells by using TALEN system (E1TN)
to assess the potential therapeutic effect of E1TN on the growth of EBV-infected
gastric cancer (GC), Burkitt's lymphoma (BL), and lymphoblastoid cell line (LCL)
(13, 17-19).
RESULTS
Transient EBNA1 KO caused selective cell death in EBV-infected cells
Given that EBNA1 is essential for EBV extra-chromosomal genome replication and
persistence and that EBV genome endurance is usually required for EBV-infected
cell growth, we hypothesized that targeted transient disruption of EBNA1 by E1TN
pair will cause a selective death or attenuation of EBV-infected cells but not
EBV-negatives in vitro. To this end, we transiently targeted
EBNA1 by transfecting EBV-infected cells (therefore EBNA1-postive) with pair of
EBNA1 targeting E1TN vectors and surrogate EBNA1 marker reporter of red
fluorescence protein / green fluorescence protein
(RFP+/GFP-@EBNA1) at 1:1:2 ratio, sorted double
negative and double positive for RFP/GFP, plated in a 96-well plate at various
densities (1, 10, 20, 50, 100, 200, 500 cells per well depending on cell types),
and scored the number of wells where cells outgrew at 2 weeks post plating
(Table S1, Fig. 1A, B). Those
RFP+/GFP+ cells were assumed to have gone through E1TN
pair-induced frame shift mutation(s) on targeting site in surrogate
RFP+/GFP-@EBNA1 reporter at least (likely also on
endogenous EBNA1 site) while RFP-/GFP- cells were ones
where reporter was un-transfected (Fig.
1B). The RFP+/GFP-@EBNA1 reporter plasmid
constitutively expresses RFP when the GFP sequence is bound to the RFP sequence
out of frame. GFP expression is recovered by frame shift mutation via
error-prone non homologous end joining (NHEJ) only when the potential target
site is disrupted.
Fig. 1.
Transient knock-out (KO) of EBNA1 in EBV-infected cancer cells caused
substantial cell death. (A) Experimental scheme of TALEN-mediated KO of
EBNA1. RFP/GFP double positive cells were sorted by FACS at 48 hr-post
transfection and plated in 96 well plates at various cell densities of
1, 10, 100, 1000 cells/well. Three weeks after plating, the number of
outgrown wells was scored. (B) Approximately 6.1% and 3.4% cells showed
double positivity in EBNA1-targeted RAJIE1TN and
SNU-719E1TN cells. The percentage of strong RFP+GFP+
cells was usually less than that observed by the fluorescent microscope.
(C) Single transfection of the E1TN pair induced a death of EBV-positive
RAJI Burkitt’s lymphoma (BL), SNU-719 gastric carcinoma (GC) and
SNU-265 lymphoblastoid cell line (LCL) cells but not in EBV-negative
BJAB BL cells. Double-positive or double-negative cells were plated at
10 cells of BAJB bad RAJI per well or 100 cells of SNU-719 and SNU-265
per wells for SNU-719 and SNU-265. E1TN pair did not show significant
toxicity as observed from similar cell plating efficiency. E1TN pair
mediated transient KO of EBNA1 in EBV-infected RAJI BL and SNU-719 GC
cell line induced progressive cell death. P value by Student’s
t-test (*P < .0001). (D) Second transfection of E1TN pair
resulted in a significant decrease in the plating efficiency of RAJI
cells, likely inducing progressive cell death. Upon first round of
transfection (denoted as 1 in the number of E1TN pair transfection), all
double negative cells (non-transfected) grew rapidly while double
positive cells died at a rate of 20%. Upon second and third rounds of
transfections into selected and outgrown colonies of RAJI cells from the
first round, cells in most wells (85% and 95%, respectively) died when
plated at a density of 100 cells/well.
In support of the hypotheses, plating RFP+/GFP+ RAJI at 1,
10, and 100 cells/well upon EBNA1 transient disruption resulted in 100, 68, and
20% of cell death, respectively. In contrast, plating the
RFP-/GFP- RAJI BL control fraction at 1, 10 and 100
cells/well gave rise to 90, 28, 0% of cell death in total wells, respectively,
as expected; this was indicative of the significantly higher rate of cell death
in EBNA1-targeted cells (RFP+/GFP+) than in EBNA1-non-targeted cells (RFP-/GFP-)
(P < .0001) (Fig. 1C, D, Table
S1). The effect was even more striking in the adherent SNU-719 cells, a
naturally EBV-infected GC cell line, as plating RFP+/GFP+ cells at less than or
equal to 100 cells per well resulted in no or almost no outgrowth. For 500
cells/well, only 20% grew from all the wells (Table S1, Fig. 1C). We have observed essentially similar results
from the SNU-265 cell line, a naturally EBV infected LCL; Plating of
EBNA1-targeted, hence RFP+/GFP+, SNU-265 LCL cells at a
density of < 50 cells/well gave rise to no outgrowth. The possibility
that E1TN pair is toxic to cells was ruled out in the experiment using
EBV-negative BJAB cells. Transfection of the E1TN pair into BJAB BL (hence
EBNA1-negative) did not affect cell growth in the aforementioned experiment
(Table S1, Fig. 1C). These results
indicate that E1TN-mediated transient KO of EBNA1 in EBV-infected cells is
sufficient for the attenuation or death of EBV-positive cells with no
discernible toxicity.
Repeated, transient transfection of E1TN pair induced progressive EBV+ RAJI
cell death and transient EBNA1 KO caused decrease in EBNA1 level and EBV genome
copy number
To substantiate the negative role of E1TN pair in EBV-infected cell growth,
RFP/GFP double positive cells from the first transfected RAJI were grown until
all cells were verified to no longer carry E1TN by fluorescence-activated cell
sorting (FACS) analyses (note that the reporter plasmid and E1TN pair plasmids
do not carry antibiotics-resistance markers). The subpopulations were brought up
transfected, plated at a density of 300 cells/well in 96-well plate, and scored
for cell survival as described above during 2 weeks post plating. As a result,
further KO by the second transfection of E1TN resulted in progressive cell death
in 87 of 96 wells (Table S2, Fig. 1D).
Western blotting analyses to EBNA1 monoclonal antibody verified the decrease in
EBNA1 from first (Fig. 2A, B, single
transfection) and successive second rounds of E1TN pair transfection (Fig. 2C, 3 rounds of transfection) in type
III latent RAJI and type I latent SNU-719, both of which are naturally
EBV-infected cancer cells. In RAJI cells showing type III EBV latency in which
EBNA2 and LMP1 are also expressed from episomal EBV genomes, EBNA1 targeting
resulted in concomitant decrease in the EBNA2 but less robustly in LMP1 (Fig. 2A, C). Surviving colonies
(RAJIE1TN-5, SNU-719E1TN-4) were verified to have a
“cut and rejoin in the target site”, which likely resulted from a
frame shift event as shown by T7E1 assay (Fig.
2D); therefore, lower level of EBNA1 was noted. Although insertion or
deletions (indels) cannot be observed with the naked eye, the faded bands after
T7E1 treatment imply that TALEN worked and did partially delete EBNA1.
RAJIE1TN-5 cells were further propagated, re-transfected, plated
at 300 cells/well in 96-well plate, and scored for cell survival in 2 weeks
after plating in the same way. This repeated KO of EBNA1 then again induced
progressive cell death in 96% of wells. However, ultimately no derivation of
EBV-eliminated RAJI cells suggests that the persistence of EBV episome by the
virtue of functional EBNA1 is essential for prolonged growth of EBV-infected
cells in vitro (Table S2). EBNA1 expression was significantly
lower in several clones that survived from multiple rounds of E1TN pair
transfection (RAJIE1TN in Fig.
2A and SNU-719E1TN in Fig.
2B). In accordance with the hypothesis, E1TN-targeted
EBVlow (therefore EBNA1low) clones grew at a much
slower rate between 10% and 50% in vitro (Fig. 2A, B, see the relative cell growth (RCG) under panel
pictures).
Fig. 2.
Repeated, transient transfection of E1TN pair caused the decrease in
EBNA1 level and growth attenuation of EBV-infected cells. (A, B) Western
blotting (WB) to EBNA1, EBNA2, LMP1 and β-actin in the clones
(shown in Fig. 1C or D) of RAJI
cells with type III latency (A) and to EBNA1 in SNU-719 cells with type
I latency (B). Note there was more robust knock-down (KD) in EBNA1 by
the second round (E1TNx2) than by the first round targeting (E1TNx1) in
both RAJI and SNU-719. The relative cell growth (RCG) of EBVlow
(therefore EBNA1low) clones was typically between 10% and at
most 50% in vitro (denoted as .1 to .5) (see RCG). (C)
Third round and repeated transfection of E1TN (RAJIE1TNx3)
caused more significant, but incomplete, loss of EBNA1. Note the low
expression of EBNA2 and LMP1 in RAJI in panel A and C likely results
from unusual experimental deviation. (D) The target region of EBNA1 was
PCR-amplified, denatured, annealed, and digested with T7 endonuclease 1
(T7E1).The appearance of shorter bands or disappearance of expected DNA
bands indicates E1TN pair–mediated occurrence of deletion or
frame-shift mutation in the target site of EBNA1. (E) In vitro cell
growth attenuation in EBNA1low cells (RAJIE1TN8,
RAJIE1TN11) and SNU-719E1TN4
SNU-719E1TN9 compared to their parental cells
(RAJIPT, SNU-719PT).
EBNA1 KO counter-selected EBV-negative cells from the pre-mixtures of
EBV-negative and EBV-infected cells
The failure to derive EBV-eliminated yet live cells validates the requirement of
EBV genome for cell growth and survival. Therefore, we performed spike
experiments in an attempt to check whether transient EBNA1 KO can counter select
EBVnegative cells from a mixture of EBV-negative and infected cells. To support
this idea, we premixed EBV-negative BJAB and EBV-infected RAJI cells at
1:103, 102 and 10 ratios, which were then followed by
the transfection of RFP+/GFP−@EBNA1 reporter
and E1TN pair in the same method as mentioned in Fig. 3A. These resulting surviving clones were propagated and 12
randomly selected clones were subjected to FGA short tandem repeat analyses
using BJAB and RAJI as the references. As a result, the higher number of spiked
BJAB cells, the more BJAB cells were counter-selected (Table S3, Fig. 3B); Two, six and nine clones of 12
randomly selected clones from 1:1000, 1:100 and 1:10 spiked ratio, respectively,
were identified as BJAB cells. A spike ration of 1:1000 of BJAB: RAJI induced
the survival ratio of 84 from 88 wells and short tandem repeats (STR) analyses
with 12 randomly selected clones revealed 2 BJAB cell line (Table S3) (STR data
not shown). In the next spiking experiment where 10-fold BJAB cells were
premixed with RAJI cells (BJAB: RAJI at 1:100 ratio), 23 of 30 wells were
selected (77%) and STR analyses for randomly selected 12 colonies verified that
a higher number of BJAB (6/12, 50%), and a concomitantly less number of RAJI
(5/12, 42%) cells, were selected as expected (Fig. 3C). Identity was further verified by comprehensive STR
analyses using 16 markers (Fig. 3D).
Furthermore, spiking of BJAB with RAJI cells at a ratio of 1:10 resulted in
partial growth in 52 wells out of 96 plated wells. STR analysis of randomly
selected 12 wells showed that majority of the survived colonies (9/12, 75%) were
BJAB cells and only 2 of them (2/12, 17%) were RAJI with significant EBNA1 KD
shown (Table S3, Fig. 4A, B). Their
identities were further verified by comprehensive STR analyses using 16 markers.
One representative clone (BJAB:RAJI E1TN-selected-1 [BJRJST-1]) was
presumed to be BJAB from the STR. As presumed, this clone was found to be BJAB
from the comprehensive STR analyses (Fig.
4C). In addition, EBV negativity in BJRJST-1 was shown
through EBER in situ staining (Fig. 4D). EBNA1 KD was collinear to EBNA2 and LMP1 KD in
representative clones (Fig. 3E). These
spike experiments indicate that transient EBNA1 KO can selectively attenuate
EBV-infected cells and counter select more EBV-negative cells in
vitro via selectively targeting EBV+ RAJI cells.
Fig. 3.
Transient KO of EBNA1 in spiked cells counter-selected most
EBV-negative BJAB cells. (A) Experimental scheme of TALEN-mediated KO of
EBNA1. EBVnegative BJAB and EBV-infected RAJI cells were mixed at a
ratio of 1:3-103 ratios, transiently transfected, sorted, and
selected as described above (B) Higher counter-selection of EBV-negative
BJAB cells from the cell mixture with higher BJAB to RAJI. (C, D)
Western blotting analysis (C) to EBNA1 and beta-actin antibody and short
tandem repeat (STR) analyses (D) for the randomly selected 12 clones
from the 1:100 BJAB:RAJI spiked experiment. WB revealed that two clones
(clone 3 and 10) were RAJI cells and therefore these two were not
subjected to STR.
Fig. 4.
Transient transfection of E1TN pair induced progressive loss of EBV
episome from EBV-infected BL cells. (A, B) Short tandem repeat (STR)
analyses (A) and Western blotting analysis (B) for randomly selected 12
clones from 1:10 BJAB:RAJI spiked experiment. While 50% the surviving
clones were identified as BJAB from the 1:100 (BJAB: RAJI) spiked cells,
75% were identified as BJAB from the 1:10 spiked experiment, indicating
that the higher number of BJAB cells were spiked with less RAJI
admixture, the higher the counter selection of BJAB cells. (C) STR
analyses of two representative clones selected from the BJAB:RAJI
mixture (BJRJST-1 and BJRJST-10 presumed as BJAB
and RAJI, respectively, from the mini STR. The comprehensive STR results
for 16 STR markers were in accordance to the results of FGA STR in (A)
and EBNA1 WB in (B). (D) EBV negativity in BJRJST-1 as shown
by EBER in situ staining. Note that the negative control BJAB cells and
positive control RAJI cells stained as expected, (E) EBNA1 KD was
collinear to EBNA2 and LMP1 KD in clones 2, 3, 7 shown in Fig. 3C and Fig. 4B. (F) Single transient transfection of the
E1TN pair induced progressive loss of EBV episome from EBV-infected BL
cells. EBV+ BJAB cells carrying latent EBVGFP genomes were
transfected once with the RFP+/GFP-@EBNA1 reporter and E1TN pair. The
progressive loss of EBV was presented with the loss of GFP. Note that
the transient single transfection induced EBV loss by 39% to
32%.
E1TN induced progressive loss of EBV episome from EBV-infected BL
cells
We next attempted to determine the efficiency of E1TN pair to eliminate EBV
episomes from the transformed BL cells whose growth depends on the presence of
EBV. In support of this idea (20), we
infected BJAB cells with green EBV BAC virus, in which the GFP represents the
persistence of EBV episome persistence. We then transfected
RFP+/GFP-@EBNA1 reporter into BJAB-EBVGFP
cells along with or without the E1TN pair. The RFP+/GFP+
cells were FACS-sorted and plated, and the EBVGFP+ cell fraction was
determined by flow cytometry. Single transient transfection of E1TN pair induced
progressive loss of EBV episome from the EBV-infected BJAB BL cells (Fig. 4F). The progressive loss of EBV was
presented with GFP (Note that transient single transfection induced EBV loss by
39% to 32% over 2 weeks upon transient KD of EBNA and the cells were not
subjected to selection, as the E1TN pair carries no antibiotics resistance
markers).
DISCUSSION
We attempted to eradicate EBV episome from EBV-infected GC, BL, and LCL cells by
targeting EBNA1, an essential protein for latent viral replication and persistence.
Our results showed that targeted transient disruption of EBNA1 by E1TN could induce
selective death of naturally EBV-infected cells, but not EBV-negative cells, thereby
resulting in no derivation of EBV-eliminated daughter cells from EBV-infected
parental cells. These results strongly support the hypothesis that EBNA1-mediated
EBV latent episome persistence is necessary for persistent growth of EBV-infected
cells. The requirement of EBNA1 for EBV persistence was further substantiated in the
subsequent spike experiments; the pre-mixture of EBV-infected RAJI cells with
EBV-negative BJAB cells and subsequent targeted transient disruption of EBNA1
counter-selected mostly EBV-negative BJAB cells.Knocking out multiple alleles of EBNA1 that are likely present in polyploidy cells
would be highly difficult. Therefore, we have attempted multiple rounds of KO by
repeated transfection of the E1TN pair. However, this was inadequate to acclaim any
negative derivatives. From multiple rounds of E1TN pair transfection into several
different EBV-infected cell lines in this study, more than 14 RAJI colonies managed
to grow but none of them showed complete lack of EBV episomes or knockout of EBNA1,
suggesting that cell death is followed by EBNA1 KO, because of the defects in EBV
genome replication or persistence. Similar results were observed in SNU-265 and
SNU-719 cells, supporting that whichever cells containing nuclease-induced mutations
most likely died out.To the best of our knowledge, this is the first report that TALEN-mediated transient
targeting of EBNA1 can efficiently attenuate the growth of EBV-infected cells,
implicating possible therapeutic application of E1TN when the E1TN pair was
effectively delivered by concentrated nasal spray containing E1TN, in particularly
to the nasopharyngeal epithelial mucosa in nasopharyngeal carcinomapatients.
Because a TALEN system requires two TALEN vectors, use of lentivirus or adenovirus
is not feasible to deliver two TALEN vectors in a single viral vector which has a
small maximum cloning capacity. In summary, transient, targeted-disruption of EBNA1
induced death and growth attenuation of EBV-infected cells.
MATERIALS AND METHODS
EBNA1 TALEN design
To disrupt EBNA1, two EBNA1_TALEN nucleases (E1TN_L1 and E1TN_R1) were
constructed: E1TN_L1 and E1TN_R1 recognize EBNA1 nucleotide (nt) 41 to 59 from
the start codon and nt 72 to 90, respectively. Six different DNA binding domain
(DBD) modules each of which recognizes 3 bases from the EBNA1 sequence nt 41 to
59 were selected, arrayed, and fused to the catalytic domain of type II
restriction enzyme FokI to induce specific cleavage of EBNA1 site (E1TN_L1).
Similarly, 6 additional DBD modules that recognize 3 bases each from the nt 72
to 90 were fused to FokI as well (E1TN_R1) (17, 18). Additionally, a
RFP+/GFP-@EBNA1 reporter plasmid that harbors two
reporter genes(constitutively expressing the monomericred fluorescence protein
(RFP) open reading frame (ORF) and conditionally expressing the inducible
enhanced green fluorescence protein (EGFP) ORF) with the target site (EBNA1 nt
40 to 90) fused to the GFP ORF out-of-frame was constructed. Constitutive RFP
indicates transfection efficiency while EGFP expression implies that a potential
target site was disrupted. EGFP only becomes expressed when the E1TN pair
mediates in-frame correction from the out-of-frame site at upstream of GFP ORF.
The most efficiently working target sites by EBNA1 TALEN were as follows; left
TALEN (E1TN L) 19 bases target sequence is 5’-TAG GAC AGA AGG AAG ACT
C-3’ and right TALEN (E1TN R) 19 base target sequence is 5’-TCC ACT
GCC GCC GGA GCC T-3’. In human, no such 19 base sequence with 100%
identical to EBNA1 are found. The RFP+/GFP-@EBNA1 reporter
plasmid contains an EBNA1 oligo sequence, that is 5’-CTA GGA CAG AAG GAA
GAC TCA ACA GGA CCA GAA GGC TCC GGC GGC AGT GGA (A)-3’.
Cell culture, transfection, sorting and selection of targeted cells,
verification of gene disruption and rate of EBV genome loss upon E1TN
introduction
EBNA1 gene disruption was verified by T7E1 assay as described (17, 18, 20) (detail in SI).
Spike experiments
EBV-negative BJAB cells were mixed with EBV-positive RAJI cells with at a ratio
of 1:10, 1:100 and 1:1000 and transfected with a pair of TALEN plasmids (2
μg each) and RFP+/GFP-@EBNA1 reporter plasmid (4
μg). Two days later, double positive (RFP+GFP+ cells) cells were sorted and
plated at 10 or 102 cells/well, and the number of surviving colonies
was scored. EBNA1 KO was tested by T7E1 and western blotting, whilst the
identity of overgrown colonies was verified by short tandem repeats (STR)
profiling. For mini-STR, FGA STR marker was amplified using primer set of
forward 5’-GGCTGCAGGGCATAA CATTA-3’ and reverse
5’-ATTCTATGACTTTGCGCTTCAGGA-3’ and separated on 10%
polyacrylamide/1XTAE gel. Complete DNA fingerprinting for 16 STR markers was
undertaken at the Korea Cell Line Bank, a World Intellectual Property
Organization (WIPO)-accredited international cell line repository institute
(Seoul, Korea).
Authors: Jeffrey C Miller; Siyuan Tan; Guijuan Qiao; Kyle A Barlow; Jianbin Wang; Danny F Xia; Xiangdong Meng; David E Paschon; Elo Leung; Sarah J Hinkley; Gladys P Dulay; Kevin L Hua; Irina Ankoudinova; Gregory J Cost; Fyodor D Urnov; H Steve Zhang; Michael C Holmes; Lei Zhang; Philip D Gregory; Edward J Rebar Journal: Nat Biotechnol Date: 2010-12-22 Impact factor: 54.908
Authors: Lan Yu; Xun Tian; Chun Gao; Ping Wu; Liming Wang; Bei Feng; Xiaomin Li; Hui Wang; Ding Ma; Zheng Hu Journal: Front Med Date: 2018-04-12 Impact factor: 4.592