Skip to main content
Erschienen in: Angiogenesis 2/2020

01.10.2019 | Original Paper

Glucose withdrawal induces Endothelin 1 release with significant angiogenic effect from first trimester (FTM), but not term human umbilical cord perivascular cells (HUCPVC)

verfasst von: Peter Szaraz, Poonam Mander, Nadav Gasner, Max Librach, Farwah Iqbal, Clifford Librach

Erschienen in: Angiogenesis | Ausgabe 2/2020

Einloggen, um Zugang zu erhalten

Abstract

Background

Perivascular cells (PVC) and their “progeny,” mesenchymal stromal cells (MSC), have high therapeutic potential for ischemic diseases. While hypoxia can increase their angiogenic properties, the other aspect of ischemic conditions—glucose shortage—is deleterious for MSC and limits their therapeutic applicability. Regenerative cells in developing vascular tissues, however, can adapt to varying glucose environment and react in a tissue-protective manner. Placental development and fetal insulin production generate different glucose fluxes in early and late extraembryonic tissues. We hypothesized that FTM HUCPVC, which are isolated from a developing vascular tissue with varying glucose availability react to low-glucose conditions in a pro-angiogenic manner in vitro.

Methods

Xeno-free (Human Platelet Lysate 2.5%) expanded FTM (n = 3) and term (n = 3) HUCPVC lines were cultured in low (2 mM) and regular (4 mM) glucose conditions. After 72 h, the expression (Next Generation Sequencing) and secretion (Proteome Profiler) of angiogenic factors and the functional angiogenic effect (rat aortic ring assay and Matrigel™ plug) of the conditioned media were quantified and statistically compared between all cultures.

Results

Low-glucose conditions had a significant post-transcriptional inductive effect on FTM HUCPVC angiogenic factor secretion, resulting in significantly higher VEGFc and Endothelin 1 release in 3 days compared to term counterparts. Conditioned media from low-glucose FTM HUCPVC cultures had a significantly higher endothelial network enhancing effect compared to all other experimental groups both in vitro aortic ring assay and in subcutan Matrigel™ plugs. Endothelin 1 depletion of the low-glucose FTM HUCPVC conditioned media significantly diminished its angiogenic effect

Conclusions

FTM HUCPVC isolated from an early extraembryonic tissue show significant pro-angiogenic paracrine reaction in low-glucose conditions at least in part through the excess release of Endothelin 1. This can be a substantial advantage in cell therapy applications for ischemic injuries.
Anhänge
Nur mit Berechtigung zugänglich
Literatur
1.
Zurück zum Zitat Armulik A, Genové G, Mäe M et al (2010) Pericytes regulate the blood–brain barrier. Nature 468(7323):557–561PubMed Armulik A, Genové G, Mäe M et al (2010) Pericytes regulate the blood–brain barrier. Nature 468(7323):557–561PubMed
2.
Zurück zum Zitat da Silva Meirelles L, Caplan AI, Nardi NB (2008) In search of the in vivo identity of mesenchymal stem cells. Stem Cells 26(9):2287–2299 da Silva Meirelles L, Caplan AI, Nardi NB (2008) In search of the in vivo identity of mesenchymal stem cells. Stem Cells 26(9):2287–2299
3.
Zurück zum Zitat Somoza AR, Correa D, Caplan AI (2015) Roles for mesenchymal stem cells as medicinal signaling cells. Nat Protoc 11(1) Somoza AR, Correa D, Caplan AI (2015) Roles for mesenchymal stem cells as medicinal signaling cells. Nat Protoc 11(1)
4.
Zurück zum Zitat Crisan M, Yap S, Casteilla L et al (2008) A perivascular origin for mesenchymal stem cells in multiple human organs. Cell Stem Cell 3(3):301–313PubMed Crisan M, Yap S, Casteilla L et al (2008) A perivascular origin for mesenchymal stem cells in multiple human organs. Cell Stem Cell 3(3):301–313PubMed
5.
Zurück zum Zitat Fu Y, Karbaat L, Wu L et al (2017) Trophic effects of mesenchymal stem cells in tissue regeneration. Tissue Eng 23(6):515–528 Fu Y, Karbaat L, Wu L et al (2017) Trophic effects of mesenchymal stem cells in tissue regeneration. Tissue Eng 23(6):515–528
6.
7.
Zurück zum Zitat Holm A, Heumann T, Augustin HG (2018) Microvascular mural cell organotypic heterogeneity and functional plasticity. Trends Cell Biol 28(4):302–316 Holm A, Heumann T, Augustin HG (2018) Microvascular mural cell organotypic heterogeneity and functional plasticity. Trends Cell Biol 28(4):302–316
8.
Zurück zum Zitat Kato K, Diéguez-Hurtado R, Park DY et al (2018) Pulmonary pericytes regulate lung morphogenesis. Nat Commun 9(1):2448PubMedPubMedCentral Kato K, Diéguez-Hurtado R, Park DY et al (2018) Pulmonary pericytes regulate lung morphogenesis. Nat Commun 9(1):2448PubMedPubMedCentral
9.
Zurück zum Zitat Sundberg C, Friman T, Hecht LE et al (2009) Two different PDGF β-receptor cohorts in human pericytes mediate distinct biological endpoints. Am J Pathol 175(1):171–189PubMedPubMedCentral Sundberg C, Friman T, Hecht LE et al (2009) Two different PDGF β-receptor cohorts in human pericytes mediate distinct biological endpoints. Am J Pathol 175(1):171–189PubMedPubMedCentral
11.
Zurück zum Zitat Webb RC (2003) Smooth muscle contraction and relaxation. Adv Physiol Educ 27:201–206PubMed Webb RC (2003) Smooth muscle contraction and relaxation. Adv Physiol Educ 27:201–206PubMed
12.
Zurück zum Zitat Diehl KJ, Templeton DL, Ma J (2013) Impaired fasting blood glucose is associated with increased endothelin 1 vasoconstrictor tone. Atheroscelosis 229(1):130–133 Diehl KJ, Templeton DL, Ma J (2013) Impaired fasting blood glucose is associated with increased endothelin 1 vasoconstrictor tone. Atheroscelosis 229(1):130–133
13.
Zurück zum Zitat Onogi Y, Wada T, Kamiya C (2017) PDGFβ regulates adipose tissue expansion and glucose metabolism via vascular remodeling in diet-induced obesity. Diabetes 66:1008–1021PubMed Onogi Y, Wada T, Kamiya C (2017) PDGFβ regulates adipose tissue expansion and glucose metabolism via vascular remodeling in diet-induced obesity. Diabetes 66:1008–1021PubMed
14.
Zurück zum Zitat Li W, Liu X, Yanoff M (1996) Cultured retinal capillary pericytes die by apoptosis after an abrupt fluctuation from high to low glucose levels: a comparative study with retinal capillary endothelial cells. Diabetologia 39(5):537–547PubMed Li W, Liu X, Yanoff M (1996) Cultured retinal capillary pericytes die by apoptosis after an abrupt fluctuation from high to low glucose levels: a comparative study with retinal capillary endothelial cells. Diabetologia 39(5):537–547PubMed
15.
Zurück zum Zitat Guimarães-Camboa N, Cattaneo P, Sun Y (2017) Pericytes of multiple organs do not behave as mesenchymal stem cells in vivo. Cell Stem Cell 20(3):345–359PubMedPubMedCentral Guimarães-Camboa N, Cattaneo P, Sun Y (2017) Pericytes of multiple organs do not behave as mesenchymal stem cells in vivo. Cell Stem Cell 20(3):345–359PubMedPubMedCentral
17.
Zurück zum Zitat Zhu H, Sun A, Zou Y, Ge J (2014) Inducible metabolic adaptation promotes mesenchymal stem cell therapy for ischemia A hypoxia-induced and glycogen-based energy pre-storage strategy. Arterioscler Thromb Vasc Biol 34(4):870–876PubMed Zhu H, Sun A, Zou Y, Ge J (2014) Inducible metabolic adaptation promotes mesenchymal stem cell therapy for ischemia A hypoxia-induced and glycogen-based energy pre-storage strategy. Arterioscler Thromb Vasc Biol 34(4):870–876PubMed
18.
Zurück zum Zitat Nuschke A, Rodrigues M, Wells AW (2016) Mesenchymal stem cells/multipotent stromal cells (MSCs) are glycolytic and thus glucose is a limiting factor of in vitro models of MSC starvation. Stem Cell Res Ther 7(1):179PubMedPubMedCentral Nuschke A, Rodrigues M, Wells AW (2016) Mesenchymal stem cells/multipotent stromal cells (MSCs) are glycolytic and thus glucose is a limiting factor of in vitro models of MSC starvation. Stem Cell Res Ther 7(1):179PubMedPubMedCentral
19.
Zurück zum Zitat Moya A, Paquet J, Deschepper M (2018) Human mesenchymal stem cell failure to adapt to glucose shortage and rapidly use intracellular energy reserves through glycolysis explains poor cell survival after implantation. Stem Cells 36(3):363–376PubMed Moya A, Paquet J, Deschepper M (2018) Human mesenchymal stem cell failure to adapt to glucose shortage and rapidly use intracellular energy reserves through glycolysis explains poor cell survival after implantation. Stem Cells 36(3):363–376PubMed
20.
Zurück zum Zitat Deschepper M, Oudina K, David B (2011) Survival and function of mesenchymal stem cells (MSCs) depend on glucose to overcome exposure to long-term, severe and continuous hypoxia. J Cell Mol Med 15(7):1505–1514PubMedPubMedCentral Deschepper M, Oudina K, David B (2011) Survival and function of mesenchymal stem cells (MSCs) depend on glucose to overcome exposure to long-term, severe and continuous hypoxia. J Cell Mol Med 15(7):1505–1514PubMedPubMedCentral
21.
Zurück zum Zitat Yong KW, Choi JR, Mohammadi M (2018) Mesenchymal stem cell therapy for ischemic tissues. Stem Cells Int 2018:8179075PubMedPubMedCentral Yong KW, Choi JR, Mohammadi M (2018) Mesenchymal stem cell therapy for ischemic tissues. Stem Cells Int 2018:8179075PubMedPubMedCentral
22.
Zurück zum Zitat Phelps J, Sanati-Nezhad A, Ungrin M (2018) Bioprocessing of mesenchymal stem cells and their derivatives: toward cell-free therapeutics. Stem Cells Int 2018:9415367PubMedPubMedCentral Phelps J, Sanati-Nezhad A, Ungrin M (2018) Bioprocessing of mesenchymal stem cells and their derivatives: toward cell-free therapeutics. Stem Cells Int 2018:9415367PubMedPubMedCentral
23.
Zurück zum Zitat Velegrakis A, Sfakiotaki M, Sifakis S (2017) Human placental growth hormone in normal and abnormal fetal growth. Biomed Rep 7(2):115–122PubMedPubMedCentral Velegrakis A, Sfakiotaki M, Sifakis S (2017) Human placental growth hormone in normal and abnormal fetal growth. Biomed Rep 7(2):115–122PubMedPubMedCentral
24.
Zurück zum Zitat Desoye G, Nolan CJ (2016) The fetal glucose steal: an underappreciated phenomenon in diabetic pregnancy. Diabetologia 59(6):1089–1094PubMedPubMedCentral Desoye G, Nolan CJ (2016) The fetal glucose steal: an underappreciated phenomenon in diabetic pregnancy. Diabetologia 59(6):1089–1094PubMedPubMedCentral
25.
Zurück zum Zitat Hay WW Jr (2006) Placental-fetal glucose exchange and fetal glucose metabolism. Trans Am Clin Climatol Assoc 117:321–339PubMedPubMedCentral Hay WW Jr (2006) Placental-fetal glucose exchange and fetal glucose metabolism. Trans Am Clin Climatol Assoc 117:321–339PubMedPubMedCentral
26.
Zurück zum Zitat Avolio E, Rodriguez-Arabaolaza I, Spencer HL (2015) Expansion and characterization of neonatal cardiac pericytes provides a novel cellular option for tissue engineering in congenital heart disease. J Am Heart Assoc 4(6):e002043PubMedPubMedCentral Avolio E, Rodriguez-Arabaolaza I, Spencer HL (2015) Expansion and characterization of neonatal cardiac pericytes provides a novel cellular option for tissue engineering in congenital heart disease. J Am Heart Assoc 4(6):e002043PubMedPubMedCentral
27.
Zurück zum Zitat Chen WC, Baily JE, Corselli M (2015) Human myocardial pericytes: multipotent mesodermal precursors exhibiting cardiac specificity. Stem Cells 33(2):557–573PubMedPubMedCentral Chen WC, Baily JE, Corselli M (2015) Human myocardial pericytes: multipotent mesodermal precursors exhibiting cardiac specificity. Stem Cells 33(2):557–573PubMedPubMedCentral
28.
Zurück zum Zitat Epshtein A, Rachi E, Sakhneny L (2017) Neonatal pancreatic pericytes support β-cell proliferation. Mol Metab 6(10):1330–1338PubMedPubMedCentral Epshtein A, Rachi E, Sakhneny L (2017) Neonatal pancreatic pericytes support β-cell proliferation. Mol Metab 6(10):1330–1338PubMedPubMedCentral
29.
Zurück zum Zitat Gauthier-Fisher A, Szaraz P, Librach CL (2019) Pericytes in the umbilical cord. Adv Exp Med Biol 1122:211–233PubMed Gauthier-Fisher A, Szaraz P, Librach CL (2019) Pericytes in the umbilical cord. Adv Exp Med Biol 1122:211–233PubMed
30.
Zurück zum Zitat Hong SH, Maghen L, Kenigsberg S, Teichert AM, Rammeloo AW, Shlush E, Szaraz P et al (2013) Ontogeny of human umbilical cord perivascular cells: molecular and fate potential changes during gestation. Stem Cells Dev 22(17):2425–2439PubMed Hong SH, Maghen L, Kenigsberg S, Teichert AM, Rammeloo AW, Shlush E, Szaraz P et al (2013) Ontogeny of human umbilical cord perivascular cells: molecular and fate potential changes during gestation. Stem Cells Dev 22(17):2425–2439PubMed
31.
Zurück zum Zitat Davies JE, Walker JT, Keating A (2017) Concise review: Wharton’s Jelly: the Rich, but enigmatic, source of mesenchymal stromal cells. Stem Cells Transl Med 6(7):1620–1630PubMedPubMedCentral Davies JE, Walker JT, Keating A (2017) Concise review: Wharton’s Jelly: the Rich, but enigmatic, source of mesenchymal stromal cells. Stem Cells Transl Med 6(7):1620–1630PubMedPubMedCentral
32.
33.
Zurück zum Zitat Sarugaser R, Lickorish D, Baksh D et al (2005) Human umbilical cord perivascular (HUCPV) cells: a source of mesenchymal progenitors. Stem Cells 23(2):220–229PubMed Sarugaser R, Lickorish D, Baksh D et al (2005) Human umbilical cord perivascular (HUCPV) cells: a source of mesenchymal progenitors. Stem Cells 23(2):220–229PubMed
34.
Zurück zum Zitat Baksh D, Yao R, Tuan RS (2007) Comparison of proliferative and multilineage differentiation potential of human mesenchymal stem cells derived from umbilical cord and bone marrow. Stem Cells 25(6):1384–1392PubMed Baksh D, Yao R, Tuan RS (2007) Comparison of proliferative and multilineage differentiation potential of human mesenchymal stem cells derived from umbilical cord and bone marrow. Stem Cells 25(6):1384–1392PubMed
35.
Zurück zum Zitat Schugar RC, Chirieleison SM, Wescoe KE (2009) High harvest yield, high expansion, and phenotype stability of CD146 mesenchymal stromal cells from whole primitive human umbilical cord tissue. J Biomed Biotechnol 2009:789526PubMedPubMedCentral Schugar RC, Chirieleison SM, Wescoe KE (2009) High harvest yield, high expansion, and phenotype stability of CD146 mesenchymal stromal cells from whole primitive human umbilical cord tissue. J Biomed Biotechnol 2009:789526PubMedPubMedCentral
36.
Zurück zum Zitat Montemurro T, Andriolo G, Montelatici E (2011) Differentiation and migration properties of human foetal umbilical cord perivascular cells: potential for lung repair. J Cell Mol Med 15(4):796–808PubMed Montemurro T, Andriolo G, Montelatici E (2011) Differentiation and migration properties of human foetal umbilical cord perivascular cells: potential for lung repair. J Cell Mol Med 15(4):796–808PubMed
37.
Zurück zum Zitat Szaraz P, Librach M, Maghen L et al (2016) In vitro differentiation of first trimester human umbilical cord perivascular cells into contracting cardiomyocyte-like cells. Stem Cells Int 2016:7513252PubMedPubMedCentral Szaraz P, Librach M, Maghen L et al (2016) In vitro differentiation of first trimester human umbilical cord perivascular cells into contracting cardiomyocyte-like cells. Stem Cells Int 2016:7513252PubMedPubMedCentral
38.
Zurück zum Zitat Shlush E, Maghen L, Swanson S et al (2017) In vitro generation of Sertoli-like and haploid spermatid-like cells from human umbilical cord perivascular cells. Stem Cell Res Ther 8(1):37PubMedPubMedCentral Shlush E, Maghen L, Swanson S et al (2017) In vitro generation of Sertoli-like and haploid spermatid-like cells from human umbilical cord perivascular cells. Stem Cell Res Ther 8(1):37PubMedPubMedCentral
39.
Zurück zum Zitat Iqbal F, Szaraz P, Librach M et al (2017) Angiogenic potency evaluation of cell therapy candidates by a novel application of the in vitro aortic ring assay. Stem Cell Res Ther 8(1):184PubMedPubMedCentral Iqbal F, Szaraz P, Librach M et al (2017) Angiogenic potency evaluation of cell therapy candidates by a novel application of the in vitro aortic ring assay. Stem Cell Res Ther 8(1):184PubMedPubMedCentral
40.
Zurück zum Zitat Szaraz P, Banhegyi G, Benedetti A (2010) Altered redox state of luminal pyridine nucleotides facilitates the sensitivity towards oxidative injury and leads to endoplasmic reticulum stress dependent autophagy in HepG2 cells. Int J Biochem Cell Biol 42(1):157–166PubMed Szaraz P, Banhegyi G, Benedetti A (2010) Altered redox state of luminal pyridine nucleotides facilitates the sensitivity towards oxidative injury and leads to endoplasmic reticulum stress dependent autophagy in HepG2 cells. Int J Biochem Cell Biol 42(1):157–166PubMed
41.
Zurück zum Zitat Badiola N, Penas C, Miñano-Molina A et al (2011) Induction of ER stress in response to oxygen-glucose deprivation of cortical cultures involves the activation of the PERK and IRE-1 pathways and of caspase-12. Cell Death Dis 2:e149PubMedPubMedCentral Badiola N, Penas C, Miñano-Molina A et al (2011) Induction of ER stress in response to oxygen-glucose deprivation of cortical cultures involves the activation of the PERK and IRE-1 pathways and of caspase-12. Cell Death Dis 2:e149PubMedPubMedCentral
42.
Zurück zum Zitat de la Cadena SG, Hernández-Fonseca K, Camacho-Arroyo I, Massieu L (2014) Glucose deprivation induces reticulum stress by the PERK pathway and caspase-7- and calpain- mediated caspase-12 activation. Apoptosis 19(3):414–427PubMed de la Cadena SG, Hernández-Fonseca K, Camacho-Arroyo I, Massieu L (2014) Glucose deprivation induces reticulum stress by the PERK pathway and caspase-7- and calpain- mediated caspase-12 activation. Apoptosis 19(3):414–427PubMed
43.
Zurück zum Zitat Salani D, Taraboletti G, Rosanò L et al (2000) Endothelin 1 induces an angiogenic phenotype in cultured endothelial cells and stimulates neo- vascularization in vivo. Am J Pathol 157(5):1703–1711PubMedPubMedCentral Salani D, Taraboletti G, Rosanò L et al (2000) Endothelin 1 induces an angiogenic phenotype in cultured endothelial cells and stimulates neo- vascularization in vivo. Am J Pathol 157(5):1703–1711PubMedPubMedCentral
44.
Zurück zum Zitat Wu MH, Huang CY, Lin JA et al (2014) Endothelin 1 promotes vascular endothelial growth factor-dependent angiogenesis in human chondrosarcoma cells. Oncogene 33(13):1725–1735PubMed Wu MH, Huang CY, Lin JA et al (2014) Endothelin 1 promotes vascular endothelial growth factor-dependent angiogenesis in human chondrosarcoma cells. Oncogene 33(13):1725–1735PubMed
45.
Zurück zum Zitat Valentijn Karine M, Evan Sadler J, Valentijn Jack A, Voorberg Jan, Eikenboom Jeroen (2011) Functional architecture of Weibel-Palade bodies. Blood 117:5033–5043PubMedPubMedCentral Valentijn Karine M, Evan Sadler J, Valentijn Jack A, Voorberg Jan, Eikenboom Jeroen (2011) Functional architecture of Weibel-Palade bodies. Blood 117:5033–5043PubMedPubMedCentral
46.
Zurück zum Zitat Labusca L, Herea DD, Mashayekhi K (2018) Stem cells as delivery vehicles for regenerative medicine-challenges and perspectives. World J Stem Cells 10(5):43–56PubMedPubMedCentral Labusca L, Herea DD, Mashayekhi K (2018) Stem cells as delivery vehicles for regenerative medicine-challenges and perspectives. World J Stem Cells 10(5):43–56PubMedPubMedCentral
47.
Zurück zum Zitat Luk F, de Witte SF, Korevaar SS et al (2016) Inactivated mesenchymal stem cells maintain immunomodulatory capacity. Stem Cells Dev 25(18):1342–1354PubMed Luk F, de Witte SF, Korevaar SS et al (2016) Inactivated mesenchymal stem cells maintain immunomodulatory capacity. Stem Cells Dev 25(18):1342–1354PubMed
48.
Zurück zum Zitat Kilkenny C, Browne WJ, Cuthill IC (2010) Improving bioscience research reporting: the ARRIVE guidelines for reporting animal research. PLoS ONE 8(6):e1000412 Kilkenny C, Browne WJ, Cuthill IC (2010) Improving bioscience research reporting: the ARRIVE guidelines for reporting animal research. PLoS ONE 8(6):e1000412
Metadaten
Titel
Glucose withdrawal induces Endothelin 1 release with significant angiogenic effect from first trimester (FTM), but not term human umbilical cord perivascular cells (HUCPVC)
verfasst von
Peter Szaraz
Poonam Mander
Nadav Gasner
Max Librach
Farwah Iqbal
Clifford Librach
Publikationsdatum
01.10.2019
Verlag
Springer Netherlands
Erschienen in
Angiogenesis / Ausgabe 2/2020
Print ISSN: 0969-6970
Elektronische ISSN: 1573-7209
DOI
https://doi.org/10.1007/s10456-019-09682-0

Weitere Artikel der Ausgabe 2/2020

Angiogenesis 2/2020 Zur Ausgabe

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag

Chronisches Koronarsyndrom: Gefahr von Hospitalisierung wegen Herzinsuffizienz

06.05.2024 Herzinsuffizienz Nachrichten

Obwohl ein rezidivierender Herzinfarkt bei chronischem Koronarsyndrom wahrscheinlich die Hauptsorge sowohl der Patienten als auch der Ärzte ist, sind andere Ereignisse womöglich gefährlicher. Laut einer französischen Studie stellt eine Hospitalisation wegen Herzinsuffizienz eine größere Gefahr dar.

Vorhofflimmern bei Jüngeren gefährlicher als gedacht

06.05.2024 Vorhofflimmern Nachrichten

Immer mehr jüngere Menschen leiden unter Vorhofflimmern. Betroffene unter 65 Jahren haben viele Risikofaktoren und ein signifikant erhöhtes Sterberisiko verglichen mit Gleichaltrigen ohne die Erkrankung.

„Restriktion auf vier Wochen Therapie bei Schlaflosigkeit ist absurd!“

06.05.2024 Insomnie Nachrichten

Chronische Insomnie als eigenständiges Krankheitsbild ernst nehmen und adäquat nach dem aktuellen Forschungsstand behandeln: Das forderte der Schlafmediziner Dr. Dieter Kunz von der Berliner Charité beim Praxis Update.

GLP-1-Rezeptoragonisten und SGLT-2-Hemmer: zusammen besser

06.05.2024 Typ-2-Diabetes Nachrichten

Immer häufiger wird ein Typ-2-Diabetes sowohl mit einem GLP-1-Rezeptor-Agonisten als auch mit einem SGLT-2-Inhibitor behandelt. Wie sich das verglichen mit den Einzeltherapien auf kardiovaskuläre und renale Komplikationen auswirkt, wurde anhand von Praxisdaten aus Großbritannien untersucht.

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.