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1.
J Gene Med ; 8(4): 524-31, 2006 Apr.
Article in English | MEDLINE | ID: mdl-16389639

ABSTRACT

BACKGROUND: Direct protein transduction is a recent technique that involves use of peptide vectors. In this study, we demonstrate that adenovirus dodecahedron (Dd), a virus-like particle devoid of DNA and able to penetrate cells with high efficiency, can be used as a vector for protein delivery. METHODS: Taking advantage of Dd interaction with structural domains called WW, we have elaborated a universal adaptor to attach a protein of interest to this vector. RESULTS: A tandem of three WW structural domains derived from the Nedd4 protein enables the formation of stable complexes with Dd, without impairing its endocytosis efficiency. Our protein of interest fused to the triple WW linker is delivered by the dodecahedron in 100% of cells in culture with on average more than ten million molecules per cell. CONCLUSION: These data demonstrate the great potential of adenovirus dodecahedron in combination with WW domains as a protein transduction vector.


Subject(s)
Adenoviridae/genetics , Peptide Fragments/therapeutic use , Proteins/genetics , Biological Transport , Cloning, Molecular , Drug Delivery Systems , Drug Design , Endosomal Sorting Complexes Required for Transport , HeLa Cells , Humans , Nedd4 Ubiquitin Protein Ligases , Ubiquitin-Protein Ligases/genetics
2.
Virology ; 283(1): 1-6, 2001 Apr 25.
Article in English | MEDLINE | ID: mdl-11312656

ABSTRACT

We have analysed the expression and cellular localisation of the matrix protein VP40 from Ebola virus. Full-length VP40 and an N-terminal truncated construct missing the first 31 residues [VP40(31-326)] both locate to the plasma membrane of 293T cells when expressed transiently, while a C-terminal truncation of residues 213 to 326 [VP40(31-212)] shows only expression in the cytoplasm, when analysed by indirect immunofluorescence and plasma membrane preparations. In addition, we find that full-length VP40 [VP40(1-326)] and VP40(31-326) are both released into the cell culture supernatant and float up in sucrose gradients. The efficiency of their release, however, is dependent on the presence of the N-terminal 31 residues. VP40 that is released into the supernatant is resistant to trypsin digestion, a finding that is consistent with the formation of viruslike particles detected by electron microscopy. Together, these results provide strong evidence that Ebola virus VP40 is sufficient for virus assembly and budding from the plasma membrane.


Subject(s)
Cell Membrane/metabolism , Ebolavirus/metabolism , Nucleoproteins/metabolism , Viral Core Proteins/metabolism , Blotting, Western , Cell Line , Centrifugation, Density Gradient , Culture Media , Ebolavirus/growth & development , Fluorescent Antibody Technique , Humans , Microscopy, Electron , Nucleoproteins/genetics , Transfection , Viral Core Proteins/genetics
3.
EMBO J ; 19(24): 6732-41, 2000 Dec 15.
Article in English | MEDLINE | ID: mdl-11118208

ABSTRACT

The matrix protein VP40 from Ebola virus is targeted to the plasma membrane, where it is thought to induce assembly and budding of virions through its association with the lipid bilayer. Ebola virus VP40 is expressed as a monomeric molecule in solution, consisting of two loosely associated domains. Here we show that a C-terminal truncation of seven residues destabilizes the monomeric closed conformation and induces spontaneous hexamerization in solution, as indicated by chemical cross-linking and electron microscopy. Three-dimensional reconstruction of electron microscopy images shows ring-like structures consisting of the N-terminal domain along with evidence for flexibly attached C-terminal domains. In vitro destabilization of the monomer by urea treatment results in similar hexameric molecules in solution. In addition, we demonstrate that membrane association of wild-type VP40 also induces the conformational switch from monomeric to hexameric molecules that may form the building blocks for initiation of virus assembly and budding. Such a conformational change induced by bilayer targeting may be a common feature of many viral matrix proteins and its potential inhibition may result in new anti-viral therapies.


Subject(s)
Ebolavirus/physiology , Nucleoproteins/chemistry , Nucleoproteins/physiology , Viral Core Proteins/chemistry , Viral Core Proteins/physiology , Cell Membrane/virology , Crystallography, X-Ray , Image Processing, Computer-Assisted , Liposomes , Microscopy, Electron , Models, Molecular , Nucleoproteins/ultrastructure , Peptide Fragments/chemistry , Protein Conformation , Protein Structure, Secondary , Recombinant Proteins/chemistry , Recombinant Proteins/ultrastructure , Sequence Deletion , Software , Solutions , Urea , Viral Core Proteins/ultrastructure , Virion/physiology
5.
J Immunother ; 22(2): 135-44, 1999 Mar.
Article in English | MEDLINE | ID: mdl-10093038

ABSTRACT

Using three murine tumor models, we compared the antitumor efficacy and certain physiological effects of an in vivo interleukin-12 (IL-12) gene therapy protocol and a systemic IL-12 protein therapy protocol. An IL-12 cDNA gene construct was administered in situ into skin tissue via gene gun delivery, and recombinant IL-12 protein was administered subcutaneously at a dose of 1 microgram/mouse/treatment. Both treatment regimes induced a comparable level of regression of established intradermal MethA sarcomas. In B16 melanoma and P815 mastocytoma models, antitumor efficacy of IL-12 protein therapy appeared to be slightly higher than that of IL-12 gene therapy; however, the protein therapy protocol in this comparative study resulted in a high level of mortality of mice. It was also demonstrated that IL-12 gene therapy, in contrast to the IL-12 protein therapy, was not associated with weight loss, splenomegaly, increased Ly6 antigen expression in the spleen, or visible signs of toxicity, such as fur ruffling and lethargy. Moreover, serum levels of interferon-gamma (IFN-gamma) induced in response to IL-12 gene therapy were 300-1000 times lower than those induced by the systemic IL-12 protein administration. Together, these results suggest that gene gunmediated in vivo delivery of IL-12 cDNA may be considered as a safer alternative to IL-12 protein therapy for certain human cancers.


Subject(s)
Biolistics , Genetic Therapy , Interleukin-12/genetics , Interleukin-12/therapeutic use , Neoplasms, Experimental/therapy , Animals , Antigens, Ly/blood , Female , Interferon-gamma/blood , Mice , Mice, Inbred BALB C , Mice, Inbred C57BL , Mice, Inbred DBA , Splenomegaly , Weight Loss
6.
Br Heart J ; 71(1): 7-15, 1994 Jan.
Article in English | MEDLINE | ID: mdl-8297699

ABSTRACT

OBJECTIVE: To study the effect of epoprostenol (prostacyclin, PGI2) given before, during, and for 36 h after coronary angioplasty on restenosis at six months and to evaluate the transcardiac gradient of platelet aggregation before and after percutaneous transluminal coronary angioplasty (PTCA) in treated and placebo groups. DESIGN: Double blind placebo controlled randomised study. PATIENTS: 135 patients with successful coronary angioplasty. METHODS: Intravenous infusion of PGI2 (4 ng/kg/ml) or buffer was started before balloon angioplasty and continued for 36 hours. Platelet aggregation was measured in blood from the aorta and coronary sinus before and after PTCA in each group. Routine follow up was at six months with repeat angiography and there was quantitative assessment of all angiograms (those undertaken within the follow up period and at routine follow up). PRESENTATION OF RESULTS: Restenosis rates in treated and placebo groups determined according to the National Heart, Lung and Blood Institute definition IV. Comparison at follow up between the effect of treatment on mean absolute luminal diameter and mean absolute follow up diameter in the placebo group. Comparison of acute gain and late loss between groups. RESULTS: Of 125 patients available for assessment 23 were re-admitted because of angina within the follow up period. Quantitative angiography showed restenosis in 15 (10 in the PGI2 group and five in the placebo group). Of 105 patients evaluated at six month angiography there was restenosis in nine more in the PGI2 group and 18 more in the placebo group. Total restenosis rates (for patients) were 29.2% for PGI2 and 38.3% for placebo (NS). The mean absolute gain in luminal diameter was 1.84 (0.76) mm in the PGI2 group and 1.58 (0.56) mm in the placebo group (p = 0.04); the late loss in the PGI2 group was also greater (0.65 (0.94) mm vs 0.62 (0.89) mm (NS) and there was no significant difference in final luminal diameter at follow up between the two groups (1.83 (0.88) mm v 1.59 (0.60) mm). The transcardiac gradient of quantitative platelet aggregation increased after PTCA in both groups, indicating that PGI2 in this dose did not affect angioplasty-induced platelet activation. Mean (SD) platelet activation indices in the PGI2 group were pre PTCA aorta 8.4 (4.1) v coronary sinus 8.8 (4.0) (p = 0.001) and post PTCA aorta 8.9(3.0) v coronary sinus 12.9 (5.7) (p = 0.001). In the placebo group the values were pre PTCA aorta 7.6 (3.3) v coronary sinus 7.4 (3.6) (p = 0.001) and post PTCA aorta 7.6(2.8) v coronary sinus 11.2(4.3) (p = 0.001). CONCLUSION: The dose of PGI2 given was designed to limit side effects and as a short-term infusion did not significantly decrease the six month restenosis rate after PTCA. The sample size, which was determined by the original protocol and chosen because of the potency of the agent being tested, would have detected only a 50% reduction in restenosis rate. There was, however, no effect in the treated patients on the increased platelet aggregation seen in placebo group as a result of angioplasty. Angioplasty is a powerful stimulus to blood factor activation. Powerful agents that prevent local platelet adhesion and aggregation are likely to be required to reduce restenosis.


Subject(s)
Angioplasty, Balloon, Coronary , Coronary Disease/prevention & control , Epoprostenol/therapeutic use , Coronary Disease/therapy , Double-Blind Method , Female , Follow-Up Studies , Humans , Male , Middle Aged , Platelet Aggregation/drug effects , Postoperative Period , Recurrence , Treatment Failure
7.
Health Visit ; 63(11): 378, 1990 Nov.
Article in English | MEDLINE | ID: mdl-2266018

ABSTRACT

Large numbers of babies are given gripe water for no valid reason or for only trivial symptoms, write Cynthia Illingworth and John Timmins. When a health visitor survey of Sheffield mothers and babies showed how widespread was the practice of giving gripe water, they decided to seek information about the nature of gripe water, the conditions which it is supposed to treat and its use by a representative number of women.


Subject(s)
Antifoaming Agents/therapeutic use , Colic/drug therapy , Gastrointestinal Diseases/drug therapy , Infant Care , Mothers , Self Medication , Antifoaming Agents/adverse effects , Community Health Nursing , Humans , Infant, Newborn , Surveys and Questionnaires
8.
J Pediatr Gastroenterol Nutr ; 8(4): 491-5, 1989 May.
Article in English | MEDLINE | ID: mdl-2498499

ABSTRACT

Over a 2-month period, white deposits were found in infusion sets delivering parenteral nutrition mixtures that included a lipid emulsion. When components of the infusion were mixed in the laboratory, separation (creaming) of the emulsion could be demonstrated, and this enabled us to predict the concentrations of the prescribed infusates that were likely to cream. Further investigations showed that creaming occurred when the lipid emulsion was mixed with heparin and calcium ions at concentrations above 1 U/ml and 1 mumol/ml, respectively.


Subject(s)
Calcium , Fat Emulsions, Intravenous , Heparin , Excipients , Parenteral Nutrition, Total
9.
Am J Vet Res ; 49(6): 860-4, 1988 Jun.
Article in English | MEDLINE | ID: mdl-2840843

ABSTRACT

Hybridomas were selected for secretion of monoclonal antibodies directed against pseudorabies virus (PRV) glycoproteins. Each monoclonal antibody was capable of neutralizing PRV in vitro in the presence of complement. This panel of antibodies was used in passive immunization studies to protect mice and swine from PRV-induced mortality. The most protective antibody in mice was 3A4, specific for PRV glycoprotein gp50, which afforded as high as 100% protection. Although antibody 3A4 was partially protective in swine, antibody 3D11, which is specific for PRV glycoprotein glll, afforded greater protection--83% protection when ascitic fluid was used and 100% protection when immunoglobulin concentrated from cell cultures was used at a dose of 150 mg/pig. These studies demonstrated that monoclonal antibodies may be useful for short-term prophylaxis against PRV-induced disease and that antibody directed against either PRV glycoprotein glll or gp50 is sufficient to protect animals from PRV-induced mortality.


Subject(s)
Antibodies, Monoclonal/therapeutic use , Herpesvirus 1, Suid/immunology , Immunization, Passive , Pseudorabies/prevention & control , Swine Diseases/prevention & control , Animals , Female , Glycoproteins/immunology , Hybridomas , Mice , Mice, Inbred BALB C , Nasopharynx/microbiology , Neutralization Tests , Swine
10.
J Virol ; 61(12): 3977-82, 1987 Dec.
Article in English | MEDLINE | ID: mdl-2824827

ABSTRACT

Pseudorabies virus (PRV) is an alphaherpesvirus which causes an economically important disease of swine. One of the PRV glycoproteins, gp50, was previously identified as the sequence homolog of herpes simplex virus glycoprotein gD (E.A. Petrovskis, J.G. Timmins, M.A. Armentrout, C.C. Marchioli, R.J. Yancey, Jr., and L.E. Post, J. Virol. 59:216-223, 1986). gp50 was evaluated as a PRV subunit vaccine candidate. gp50 protected mice from PRV-induced mortality either when delivered via infection with a recombinant vaccinia virus or when administered as a subunit vaccine produced in a eucaryotic cell line, Chinese hamster ovary (CHO) cells. In addition, gp50 synthesized in CHO cells protected pigs from lethal infection with PRV. This result demonstrates that a single viral glycoprotein could induce a protective immune response in the natural host of a herpesvirus infection.


Subject(s)
Antigens , Herpesvirus 1, Suid/immunology , Pseudorabies/prevention & control , Vaccines, Synthetic , Viral Envelope Proteins , Viral Proteins/immunology , Viral Vaccines , Animals , Antibodies, Viral/biosynthesis , Cell Line , Immunization/veterinary , Mice , Swine , Swine Diseases/prevention & control , Vaccinia virus/genetics , Vaccinia virus/immunology , Viral Proteins/genetics
11.
J Virol ; 60(3): 1166-9, 1986 Dec.
Article in English | MEDLINE | ID: mdl-3023669

ABSTRACT

The pseudorabies virus vaccine strains Norden and Bartha each have been reported to have deletions in the small unique component of the genome (B. Lomniczi, M. L. Blankenship, and T. Ben-Porat, J. Virol. 49:970-979, 1984). The deletion in Norden was shown to delete the entire coding region for gI but not any of the coding sequences for gp63. However, gp63 in Norden-infected cells was only 36 kilodaltons, and a 44-kilodalton form of gp63 was released into the medium. In Bartha, the deletion removed the coding region for all but 89 amino acids of gp63, and no gp63 was detected in either Bartha-infected cells or medium.


Subject(s)
Herpesvirus 1, Suid/immunology , Viral Proteins/genetics , Viral Vaccines , Base Sequence , Chromosome Deletion , Chromosome Mapping , DNA, Viral/genetics , Glycoproteins/genetics , Herpesvirus 1, Suid/genetics
12.
Virology ; 155(2): 707-15, 1986 Dec.
Article in English | MEDLINE | ID: mdl-3024408

ABSTRACT

Pseudorabies virus (PRV) produces a glycoprotein, gX, that accumulates in the medium of infected cells. The gX gene was expressed in Chinese hamster ovary cells (CHOgX cells) using the cytomegalovirus Towne major immediate early promoter. Like PRV-infected cells, CHOgX cells produced gX and exported it into the medium. Tunicamycin reduced the molecular weight of the gX in the medium to 89 kDa, compared with 99 kDa for gX made in the absence of drug. In the presence of tunicamycin gX produced by both PRV-infected cells and CHOgX cells was still glycosylated, as indicated by incorporation of [14C]glucosamine. The most likely form of this glycosylation is O-linked. In a pulse-chase experiment, gX first appeared in a 90-kDa form, then a 115-kDa form. This 115-kDa form is probably cleaved to give the 99-kDa form of gX that is released into the medium. The 115-kDa form was much more persistent in the PRV-infected Vero cells than in the CHOgX cells. In both cell types, gX was labeled by [35S]sulfate in the presence and absence of tunicamycin.


Subject(s)
Glycoproteins/metabolism , Herpesvirus 1, Suid/metabolism , Viral Proteins/metabolism , Animals , Cell Line , Cricetinae , Glycosylation , Kinetics , Molecular Weight , Protein Processing, Post-Translational/drug effects , Sulfates/metabolism , Tunicamycin/pharmacology
13.
J Virol ; 60(1): 185-93, 1986 Oct.
Article in English | MEDLINE | ID: mdl-3018284

ABSTRACT

A library of pseudorabies virus (PRV) DNA fragments was constructed in the expression cloning vector lambda gt11. The library was screened with antisera which reacted with mixtures of PRV proteins to isolate recombinant bacteriophages expressing PRV proteins. By the nature of the lambda gt11 vector, the cloned proteins were expressed in Escherichia coli as beta-galactosidase fusion proteins. The fusion proteins from 35 of these phages were purified and injected into mice to raise antisera. The antisera were screened by several different assays, including immunoprecipitation of [14C]glucosamine-labeled PRV proteins. This method identified phages expressing three different PRV glycoproteins: the secreted glycoprotein, gX; gI; and a glycoprotein that had not been previously identified, which we designate gp63. The gp63 and gI genes map adjacent to each other in the small unique region of the PRV genome. The DNA sequence was determined for the region of the genome encoding gp63 and gI. It was found that gp63 has a region of homology with a herpes simplex virus type 1 (HSV-1) protein, encoded by US7, and also with varicella-zoster virus (VZV) gpIV. The gI protein sequence has a region of homology with HSV-1 gE and VZV gpI. It is concluded that PRV, HSV, and VZV all have a cluster of homologous glycoprotein genes in the small unique components of their genomes and that the organization of these genes is conserved.


Subject(s)
Genes, Viral , Glycoproteins/isolation & purification , Herpesvirus 1, Suid/genetics , Viral Proteins/isolation & purification , Bacteriophage lambda/genetics , Base Sequence , DNA, Recombinant , Genes , Herpesvirus 3, Human/genetics , Recombinant Proteins/genetics , Sequence Homology, Nucleic Acid , Simplexvirus/genetics
14.
J Virol ; 59(2): 216-23, 1986 Aug.
Article in English | MEDLINE | ID: mdl-3016293

ABSTRACT

The DNA sequence was determined for a region of the pseudorabies virus (PRV) genome to which a mutation defining resistance to a monoclonal antibody has been mapped (M. W. Wathen and L. M. K. Wathen, J. Virol., 51:57-62, 1984). This sequence was found to contain an open reading frame that did not include an amino acid sequence directing N-linked glycosylation. This open reading frame was expressed in uninfected Chinese hamster ovary cells to produce the PRV glycoprotein gp50. When PRV-infected Vero cells were incubated in the presence of tunicamycin, the gp50 that was produced had an identical molecular weight to that produced in the absence of drug. When infected cells were incubated in the presence of monensin, the molecular weight of gp50 was reduced from 60,000 to 45,000, but was not sensitive to endo-beta-N-acetylglucosaminidase H. These observations led to the conclusion that gp50 does not contain N-linked carbohydrate, as predicted from the DNA sequence. A region of the amino acid sequence and the positions of the cysteine residues of PRV gp50 are homologous to glycoprotein D of herpes simplex virus.


Subject(s)
DNA, Viral/genetics , Genes, Viral , Glycoproteins/genetics , Herpesvirus 1, Suid/genetics , Viral Envelope Proteins , Viral Proteins/genetics , Amino Acid Sequence , Animals , Antibodies, Monoclonal , Antibodies, Viral/immunology , Base Sequence , Cell Line , Cricetinae , Glycoproteins/immunology , Protein Processing, Post-Translational , Viral Proteins/immunology
15.
J Virol ; 54(1): 21-9, 1985 Apr.
Article in English | MEDLINE | ID: mdl-2983115

ABSTRACT

RNA from pseudorabies virus (PRV)-infected cells was translated in a reticulocyte lysate with and without the addition of dog pancreas microsomes. Upon addition of the microsomes to the translation reaction, an additional prominent protein product was observed that was not present when microsomes were omitted. The gene coding for this processed protein and its lower-molecular-weight precursor was mapped within the small unique region of the genome by hybridization of mRNA to cloned fragments of PRV DNA and translation of the selected mRNAs. A fragment of the coding region of this gene was inserted into an open reading frame cloning vector to express part of this gene as a hybrid protein in Escherichia coli. This hybrid protein was injected into mice to raise an antiserum which was found to precipitate the glycoprotein which accumulates in the medium of PRV-infected cells. This allows us to conclude that the gene for the "excreted" glycoprotein (gX) maps to the small unique region of the genome, and that the precursor of this glycoprotein is readily processed by dog pancreas microsomes. The region of the PRV genome which codes for this glycoprotein was sequenced and found to include an open reading frame coding for 498 amino acids, flanked by sequences which contain features common to eucaryotic promoters and polyadenylation signals. The predicted protein sequence includes a hydrophobic sequence at the N-terminus which could be a signal sequence, and a hydrophobic sequence followed by a hydrophilic sequence at the C-terminus.


Subject(s)
Genes, Viral , Herpesvirus 1, Suid/genetics , Viral Proteins/genetics , Amino Acid Sequence , Base Sequence , Chromosome Mapping , Genes , Glycoproteins/genetics , Membrane Proteins/genetics , Molecular Weight , Protein Biosynthesis , Protein Processing, Post-Translational
16.
Prostate ; 6(4): 395-402, 1985.
Article in English | MEDLINE | ID: mdl-2418427

ABSTRACT

Two-dimensional electrophoretic analysis of human prostate fluid reveals an abundant protein migrating to a molecular weight of 15 kD and an isoelectric point of 5.5. Polyclonal antibodies were raised specifically to microgram quantities of electrophoresed, excised, and eluted PSP15 (prostate secretory protein). Western immunoblot analysis using these antibodies showed they not only react to PSP15, but cross-react with simian prostate and human seminal fluid proteins of similar molecular weights. Two-dimensional gel immunoblots strongly suggest that the seminal protein and PSP15 are the same, thereby providing a more accessible source of the protein. The antibody to the human PSP15 cross-reacted with neither prostate fluid from the ventral lobe of the rat prostate nor the prostate fluid from the beagle dog.


Subject(s)
Carrier Proteins/immunology , Epitopes , Prostate/metabolism , Prostatic Secretory Proteins , Animals , Autoradiography , Body Fluids/immunology , Electrophoresis , Humans , Macaca mulatta , Male , Molecular Weight , Prospective Studies , Species Specificity
17.
Gene ; 39(1): 89-93, 1985.
Article in English | MEDLINE | ID: mdl-3000894

ABSTRACT

Experience with cloning pseudorabies virus (PRV) DNA in the lambda gt11 phage vector has shown that there are special requirements for the antisera used in screening the libraries, in addition to the requirement that the antisera recognize proteins on a Western blot. Initial screening of a lambda gt11 library of sheared PRV DNA fragments in Escherichia coli for expression of PRV antigens using PRV hyperimmune antisera was unsuccessful. It was only after screening the library with antisera raised against PRV proteins eluted from sodium dodecyl sulfate (SDS)-polyacrylamide (PA) gels that positive results were obtained. These "gel-slice" antisera (GSA) were equivalent in potency to hyperimmune antisera in standard immunoassays (including ELISA, immunoprecipitation, Western blots, and neutralization of virus), but only the GSA could recognize PRV fusion proteins expressed by recombinant lambda gt11 phage. This difference was seen despite the fact that hyperimmune antisera performed satisfactorily on Western blots of denatured PRV-infected cell extracts. These results show that the efficiency of screening expression libraries in E. coli can be improved if antibodies are raised against denatured proteins.


Subject(s)
Antibodies, Viral , Bacteriophage lambda/genetics , Genes, Viral , Viral Proteins/genetics , Acetone , Chemical Precipitation , Cloning, Molecular , Herpesvirus 1, Suid/genetics , Herpesvirus 1, Suid/immunology , Protein Denaturation , Viral Proteins/immunology , Viral Proteins/isolation & purification
18.
Cortex ; 16(3): 493-9, 1980 Oct.
Article in English | MEDLINE | ID: mdl-7214933

ABSTRACT

A patient with Dyke-Davidoff-Masson Syndrome had a lifelong history of spatial disorientation and visual-spatial cognitive defects demonstrated by psychological tests. We suggest that the abnormalities of behavior and test performance may be related atrophic lesions demonstrated by pneumoencephalography and computerized axial tomography. We consider several explanations to account for the lack of compensation for these cognitive defects.


Subject(s)
Brain/abnormalities , Cognition Disorders/diagnosis , Face/abnormalities , Orientation , Space Perception , Abnormalities, Multiple/diagnosis , Aged , Atrophy , Bone and Bones/abnormalities , Humans , Male , Syndrome
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