Skip to main content
Erschienen in: Pediatric Cardiology 6/2016

09.05.2016 | Original Article

Identification of Differentially Expressed Genes in Kawasaki Disease Patients as Potential Biomarkers for IVIG Sensitivity by Bioinformatics Analysis

verfasst von: Lan He, Youyu Sheng, Chunyun Huang, Guoying Huang

Erschienen in: Pediatric Cardiology | Ausgabe 6/2016

Einloggen, um Zugang zu erhalten

Abstract

Kawasaki disease (KD) is a leading cause of acquired heart disease predominantly affecting infants and young children. Intravenous immunoglobulin (IVIG) is applied as the most favorable treatment against KD, but IVIG resistant remains exist. Although several clinical scoring systems have been developed to identify children at highest risk of IVIG resistance, there is a need to identify sufficiently sensitive biomarkers for IVIG treatment. Some differentially expressed genes (DEGs) could be the promising potential biomarkers for IVIG-related sensitivity diagnosis. We employed a systematic and integrative bioinformatics framework to identify such kind of genes. The performance of the candidate genes was evaluated by hierarchical clustering, ROC analysis and literature mining. By analyzing three datasets of KD patients, 34 DEGs of the three groups have been found to be associated with IVIG-related sensitivity. A module of 12 genes could predict resistant group patients with high accuracy, and a module of ten genes could predict responsive group patients effectively with accuracy of 96 %. And three of them are most likely to serve as drug targets or diagnostic biomarkers in the future. Compared with unsupervised hierarchical clustering analysis, our modules could distinct IVIG-resistant patients efficiently. Two groups of DEGs could predict IVIG-related sensitivity with high accuracy, which are potential biomarkers for the clinical diagnosis and prediction of IVIG treatment response in KD patients, improving the prognosis of patients.
Anhänge
Nur mit Berechtigung zugänglich
Literatur
4.
Zurück zum Zitat Dajani AS, Taubert KA, Gerber MA, Shulman ST, Ferrieri P, Freed M, Takahashi M, Bierman FZ, Karchmer AW, Wilson W et al (1993) Diagnosis and therapy of Kawasaki disease in children. Circulation 87(5):1776–1780CrossRefPubMed Dajani AS, Taubert KA, Gerber MA, Shulman ST, Ferrieri P, Freed M, Takahashi M, Bierman FZ, Karchmer AW, Wilson W et al (1993) Diagnosis and therapy of Kawasaki disease in children. Circulation 87(5):1776–1780CrossRefPubMed
6.
Zurück zum Zitat Rowley AH, Duffy CE, Shulman ST (1988) Prevention of giant coronary artery aneurysms in Kawasaki disease by intravenous gamma globulin therapy. J Pediatr 113(2):290–294CrossRefPubMed Rowley AH, Duffy CE, Shulman ST (1988) Prevention of giant coronary artery aneurysms in Kawasaki disease by intravenous gamma globulin therapy. J Pediatr 113(2):290–294CrossRefPubMed
9.
Zurück zum Zitat Soltner E, Neel A, Tiab M, Varin S, Cormier G, Maisonneuve H, Maugars Y, Tanguy G, Hamidou M, Berthelot JM (2009) Chronic, eventually fatal, Kawasaki-like disease in an adult with spondylarthropathy responding to IVIG therapy. Joint Bone Spine Revue Rhum 76(5):559–561. doi:10.1016/j.jbspin.2009.01.006 CrossRef Soltner E, Neel A, Tiab M, Varin S, Cormier G, Maisonneuve H, Maugars Y, Tanguy G, Hamidou M, Berthelot JM (2009) Chronic, eventually fatal, Kawasaki-like disease in an adult with spondylarthropathy responding to IVIG therapy. Joint Bone Spine Revue Rhum 76(5):559–561. doi:10.​1016/​j.​jbspin.​2009.​01.​006 CrossRef
10.
Zurück zum Zitat Ogihara Y, Ogata S, Nomoto K, Ebato T, Sato K, Kokubo K, Kobayashi H, Ishii M (2014) Transcriptional regulation by infliximab therapy in Kawasaki disease patients with immunoglobulin resistance. Pediatr Res 76(3):287–293. doi:10.1038/pr.2014.92 CrossRefPubMed Ogihara Y, Ogata S, Nomoto K, Ebato T, Sato K, Kokubo K, Kobayashi H, Ishii M (2014) Transcriptional regulation by infliximab therapy in Kawasaki disease patients with immunoglobulin resistance. Pediatr Res 76(3):287–293. doi:10.​1038/​pr.​2014.​92 CrossRefPubMed
11.
Zurück zum Zitat Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, Shulman ST, Bolger AF, Ferrieri P, Baltimore RS, Wilson WR, Baddour LM, Levison ME, Pallasch TJ, Falace DA, Taubert KA (2004) Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 110(17):2747–2771. doi:10.1161/01.cir.0000145143.19711.78 CrossRefPubMed Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, Shulman ST, Bolger AF, Ferrieri P, Baltimore RS, Wilson WR, Baddour LM, Levison ME, Pallasch TJ, Falace DA, Taubert KA (2004) Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 110(17):2747–2771. doi:10.​1161/​01.​cir.​0000145143.​19711.​78 CrossRefPubMed
17.
Zurück zum Zitat Sano T, Kurotobi S, Matsuzaki K, Yamamoto T, Maki I, Miki K, Kogaki S, Hara J (2007) Prediction of non-responsiveness to standard high-dose gamma-globulin therapy in patients with acute Kawasaki disease before starting initial treatment. Eur J Pediatr 166(2):131–137. doi:10.1007/s00431-006-0223-z CrossRefPubMed Sano T, Kurotobi S, Matsuzaki K, Yamamoto T, Maki I, Miki K, Kogaki S, Hara J (2007) Prediction of non-responsiveness to standard high-dose gamma-globulin therapy in patients with acute Kawasaki disease before starting initial treatment. Eur J Pediatr 166(2):131–137. doi:10.​1007/​s00431-006-0223-z CrossRefPubMed
18.
Zurück zum Zitat Sleeper LA, Minich LL, McCrindle BM, Li JS, Mason W, Colan SD, Atz AM, Printz BF, Baker A, Vetter VL, Newburger JW (2011) Evaluation of Kawasaki disease risk-scoring systems for intravenous immunoglobulin resistance. J Pediatr 158(5):831.e833–835.e833. doi:10.1016/j.jpeds.2010.10.031 CrossRef Sleeper LA, Minich LL, McCrindle BM, Li JS, Mason W, Colan SD, Atz AM, Printz BF, Baker A, Vetter VL, Newburger JW (2011) Evaluation of Kawasaki disease risk-scoring systems for intravenous immunoglobulin resistance. J Pediatr 158(5):831.e833–835.e833. doi:10.​1016/​j.​jpeds.​2010.​10.​031 CrossRef
19.
Zurück zum Zitat Seki M, Kobayashi T, Kobayashi T, Morikawa A, Otani T, Takeuchi K, Ayusawa M, Tsuchiya K, Yasuda K, Suzuki T, Shimoyama S, Ikeda K, Ishii Y, Arakawa H (2011) External validation of a risk score to predict intravenous immunoglobulin resistance in patients with Kawasaki disease. Pediatr Infect Dis J 30(2):145–147. doi:10.1097/INF.0b013e3181f386db CrossRefPubMed Seki M, Kobayashi T, Kobayashi T, Morikawa A, Otani T, Takeuchi K, Ayusawa M, Tsuchiya K, Yasuda K, Suzuki T, Shimoyama S, Ikeda K, Ishii Y, Arakawa H (2011) External validation of a risk score to predict intravenous immunoglobulin resistance in patients with Kawasaki disease. Pediatr Infect Dis J 30(2):145–147. doi:10.​1097/​INF.​0b013e3181f386db​ CrossRefPubMed
20.
Zurück zum Zitat Ogawa S (2014) Biomarker. Jpn J Clin Med 72(9):1578–1584 Ogawa S (2014) Biomarker. Jpn J Clin Med 72(9):1578–1584
21.
Zurück zum Zitat Abe J, Matsuda A (2013) [Biomarkers associated with unresponsiveness to IVIG in children with Kawasaki disease]. Nihon Rinsho Men’eki Gakkai kaishi = Japanese. J Clin Immunol 36(1):27–34CrossRef Abe J, Matsuda A (2013) [Biomarkers associated with unresponsiveness to IVIG in children with Kawasaki disease]. Nihon Rinsho Men’eki Gakkai kaishi = Japanese. J Clin Immunol 36(1):27–34CrossRef
24.
Zurück zum Zitat Ogata S, Ogihara Y, Nomoto K, Akiyama K, Nakahata Y, Sato K, Minoura K, Kokubo K, Kobayashi H, Ishii M (2009) Clinical score and transcript abundance patterns identify Kawasaki disease patients who may benefit from addition of methylprednisolone. Pediatr Res 66(5):577–584. doi:10.1203/PDR.0b013e3181baa3c2 CrossRefPubMed Ogata S, Ogihara Y, Nomoto K, Akiyama K, Nakahata Y, Sato K, Minoura K, Kokubo K, Kobayashi H, Ishii M (2009) Clinical score and transcript abundance patterns identify Kawasaki disease patients who may benefit from addition of methylprednisolone. Pediatr Res 66(5):577–584. doi:10.​1203/​PDR.​0b013e3181baa3c2​ CrossRefPubMed
26.
Zurück zum Zitat Diboun I, Wernisch L, Orengo CA, Koltzenburg M (2006) Microarray analysis after RNA amplification can detect pronounced differences in gene expression using limma. BMC Genome 7:252. doi:10.1186/1471-2164-7-252 CrossRef Diboun I, Wernisch L, Orengo CA, Koltzenburg M (2006) Microarray analysis after RNA amplification can detect pronounced differences in gene expression using limma. BMC Genome 7:252. doi:10.​1186/​1471-2164-7-252 CrossRef
29.
Zurück zum Zitat da Huang W, Sherman BT, Lempicki RA (2009) Bioinformatics enrichment tools: paths toward the comprehensive functional analysis of large gene lists. Nucl Acids Res 37(1):1–13. doi:10.1093/nar/gkn923 CrossRef da Huang W, Sherman BT, Lempicki RA (2009) Bioinformatics enrichment tools: paths toward the comprehensive functional analysis of large gene lists. Nucl Acids Res 37(1):1–13. doi:10.​1093/​nar/​gkn923 CrossRef
30.
Zurück zum Zitat Joyseeree R, Abou Sabha R, Mueller H (2015) Applying machine learning to gait analysis data for disease identification. Stud Health Technol Inform 210:850–854PubMed Joyseeree R, Abou Sabha R, Mueller H (2015) Applying machine learning to gait analysis data for disease identification. Stud Health Technol Inform 210:850–854PubMed
32.
Zurück zum Zitat Chang EJ, Kim HJ, Ha J, Kim HJ, Ryu J, Park KH, Kim UH, Lee ZH, Kim HM, Fisher DE, Kim HH (2007) Hyaluronan inhibits osteoclast differentiation via Toll-like receptor 4. J Cell Sci 120(Pt 1):166–176. doi:10.1242/jcs.03310 PubMed Chang EJ, Kim HJ, Ha J, Kim HJ, Ryu J, Park KH, Kim UH, Lee ZH, Kim HM, Fisher DE, Kim HH (2007) Hyaluronan inhibits osteoclast differentiation via Toll-like receptor 4. J Cell Sci 120(Pt 1):166–176. doi:10.​1242/​jcs.​03310 PubMed
35.
Zurück zum Zitat Mori M, Tomono N, Yokota S (1995) [Coronary arteritis of Kawasaki disease unresponsive to high-dose intravenous gammaglobulin successfully treated with plasmapheresis]. Nihon Rinsho Men’eki Gakkai kaishi = Japanese. J Clin Immunol 18(3):282–288CrossRef Mori M, Tomono N, Yokota S (1995) [Coronary arteritis of Kawasaki disease unresponsive to high-dose intravenous gammaglobulin successfully treated with plasmapheresis]. Nihon Rinsho Men’eki Gakkai kaishi = Japanese. J Clin Immunol 18(3):282–288CrossRef
36.
Zurück zum Zitat Wang Y, Wang W, Gong F, Fu S, Zhang Q, Hu J, Qi Y, Xie C, Zhang Y (2013) Evaluation of intravenous immunoglobulin resistance and coronary artery lesions in relation to Th1/Th2 cytokine profiles in patients with Kawasaki disease. Arthr Rheum 65(3):805–814. doi:10.1002/art.37815 CrossRef Wang Y, Wang W, Gong F, Fu S, Zhang Q, Hu J, Qi Y, Xie C, Zhang Y (2013) Evaluation of intravenous immunoglobulin resistance and coronary artery lesions in relation to Th1/Th2 cytokine profiles in patients with Kawasaki disease. Arthr Rheum 65(3):805–814. doi:10.​1002/​art.​37815 CrossRef
37.
Zurück zum Zitat Shangguan W, Du Z, Yang H, Zhang Y, Song M, Dong W (2014) Effects of intravenous immunoglobulin upon the overexpression and over-activation of nuclear factor-kappaB and matrix metalloproteinase-9 in murine model of Kawasaki disease. Zhonghua yi xue za zhi 94(12):938–943PubMed Shangguan W, Du Z, Yang H, Zhang Y, Song M, Dong W (2014) Effects of intravenous immunoglobulin upon the overexpression and over-activation of nuclear factor-kappaB and matrix metalloproteinase-9 in murine model of Kawasaki disease. Zhonghua yi xue za zhi 94(12):938–943PubMed
38.
Zurück zum Zitat Wang CL, Wu YT, Liu CA, Kuo HC, Yang KD (2005) Kawasaki disease: infection, immunity and genetics. Pediatr Infect Dis J 24(11):998–1004CrossRefPubMed Wang CL, Wu YT, Liu CA, Kuo HC, Yang KD (2005) Kawasaki disease: infection, immunity and genetics. Pediatr Infect Dis J 24(11):998–1004CrossRefPubMed
39.
Zurück zum Zitat Guo MM, Tseng WN, Ko CH, Pan HM, Hsieh KS, Kuo HC (2015) Th17- and Treg-related cytokine and mRNA expression are associated with acute and resolving Kawasaki disease. Allergy 70(3):310–318. doi:10.1111/all.12558 CrossRefPubMed Guo MM, Tseng WN, Ko CH, Pan HM, Hsieh KS, Kuo HC (2015) Th17- and Treg-related cytokine and mRNA expression are associated with acute and resolving Kawasaki disease. Allergy 70(3):310–318. doi:10.​1111/​all.​12558 CrossRefPubMed
42.
Zurück zum Zitat Liu R, He B, Gao F, Liu Q, Yi Q (2012) Association of the resistin gene promoter region polymorphism with Kawasaki disease in Chinese children. Med Inflamm 2012:356362. doi:10.1155/2012/356362 Liu R, He B, Gao F, Liu Q, Yi Q (2012) Association of the resistin gene promoter region polymorphism with Kawasaki disease in Chinese children. Med Inflamm 2012:356362. doi:10.​1155/​2012/​356362
43.
Zurück zum Zitat Mahachie John JM, Baurecht H, Rodriguez E, Naumann A, Wagenpfeil S, Klopp N, Mempel M, Novak N, Bieber T, Wichmann HE, Ring J, Illig T, Cattaert T, Van Steen K, Weidinger S (2010) Analysis of the high affinity IgE receptor genes reveals epistatic effects of FCER1A variants on eczema risk. Allergy 65(7):875–882. doi:10.1111/j.1398-9995.2009.02297.x CrossRefPubMed Mahachie John JM, Baurecht H, Rodriguez E, Naumann A, Wagenpfeil S, Klopp N, Mempel M, Novak N, Bieber T, Wichmann HE, Ring J, Illig T, Cattaert T, Van Steen K, Weidinger S (2010) Analysis of the high affinity IgE receptor genes reveals epistatic effects of FCER1A variants on eczema risk. Allergy 65(7):875–882. doi:10.​1111/​j.​1398-9995.​2009.​02297.​x CrossRefPubMed
45.
Zurück zum Zitat Khor CC, Davila S, Breunis WB, Lee YC, Shimizu C, Wright VJ, Yeung RS, Tan DE, Sim KS, Wang JJ, Wong TY, Pang J, Mitchell P, Cimaz R, Dahdah N, Cheung YF, Huang GY, Yang W, Park IS, Lee JK, Wu JY, Levin M, Burns JC, Burgner D, Kuijpers TW, Hibberd ML (2011) Genome-wide association study identifies FCGR2A as a susceptibility locus for Kawasaki disease. Nat Genet 43(12):1241–1246. doi:10.1038/ng.981 CrossRefPubMed Khor CC, Davila S, Breunis WB, Lee YC, Shimizu C, Wright VJ, Yeung RS, Tan DE, Sim KS, Wang JJ, Wong TY, Pang J, Mitchell P, Cimaz R, Dahdah N, Cheung YF, Huang GY, Yang W, Park IS, Lee JK, Wu JY, Levin M, Burns JC, Burgner D, Kuijpers TW, Hibberd ML (2011) Genome-wide association study identifies FCGR2A as a susceptibility locus for Kawasaki disease. Nat Genet 43(12):1241–1246. doi:10.​1038/​ng.​981 CrossRefPubMed
46.
Zurück zum Zitat Kuo HC, Chao MC, Hsu YW, Lin YC, Huang YH, Yu HR, Hou MF, Liang CD, Yang KD, Chang WC, Wang CL (2012) CD40 Gene polymorphisms associated with susceptibility and coronary artery lesions of Kawasaki disease in the Taiwanese population. Sci World J 2012:520865. doi:10.1100/2012/520865 CrossRef Kuo HC, Chao MC, Hsu YW, Lin YC, Huang YH, Yu HR, Hou MF, Liang CD, Yang KD, Chang WC, Wang CL (2012) CD40 Gene polymorphisms associated with susceptibility and coronary artery lesions of Kawasaki disease in the Taiwanese population. Sci World J 2012:520865. doi:10.​1100/​2012/​520865 CrossRef
47.
Zurück zum Zitat Onouchi Y, Gunji T, Burns JC, Shimizu C, Newburger JW, Yashiro M, Nakamura Y, Yanagawa H, Wakui K, Fukushima Y, Kishi F, Hamamoto K, Terai M, Sato Y, Ouchi K, Saji T, Nariai A, Kaburagi Y, Yoshikawa T, Suzuki K, Tanaka T, Nagai T, Cho H, Fujino A, Sekine A, Nakamichi R, Tsunoda T, Kawasaki T, Nakamura Y, Hata A (2008) ITPKC functional polymorphism associated with Kawasaki disease susceptibility and formation of coronary artery aneurysms. Nat Genet 40(1):35–42. doi:10.1038/ng.2007.59 CrossRefPubMed Onouchi Y, Gunji T, Burns JC, Shimizu C, Newburger JW, Yashiro M, Nakamura Y, Yanagawa H, Wakui K, Fukushima Y, Kishi F, Hamamoto K, Terai M, Sato Y, Ouchi K, Saji T, Nariai A, Kaburagi Y, Yoshikawa T, Suzuki K, Tanaka T, Nagai T, Cho H, Fujino A, Sekine A, Nakamichi R, Tsunoda T, Kawasaki T, Nakamura Y, Hata A (2008) ITPKC functional polymorphism associated with Kawasaki disease susceptibility and formation of coronary artery aneurysms. Nat Genet 40(1):35–42. doi:10.​1038/​ng.​2007.​59 CrossRefPubMed
48.
Zurück zum Zitat Onouchi Y, Ozaki K, Burns JC, Shimizu C, Terai M, Hamada H, Honda T, Suzuki H, Suenaga T, Takeuchi T, Yoshikawa N, Suzuki Y, Yasukawa K, Ebata R, Higashi K, Saji T, Kemmotsu Y, Takatsuki S, Ouchi K, Kishi F, Yoshikawa T, Nagai T, Hamamoto K, Sato Y, Honda A, Kobayashi H, Sato J, Shibuta S, Miyawaki M, Oishi K, Yamaga H, Aoyagi N, Iwahashi S, Miyashita R, Murata Y, Sasago K, Takahashi A, Kamatani N, Kubo M, Tsunoda T, Hata A, Nakamura Y, Tanaka T (2012) A genome-wide association study identifies three new risk loci for Kawasaki disease. Nat Genet 44(5):517–521. doi:10.1038/ng.2220 CrossRefPubMed Onouchi Y, Ozaki K, Burns JC, Shimizu C, Terai M, Hamada H, Honda T, Suzuki H, Suenaga T, Takeuchi T, Yoshikawa N, Suzuki Y, Yasukawa K, Ebata R, Higashi K, Saji T, Kemmotsu Y, Takatsuki S, Ouchi K, Kishi F, Yoshikawa T, Nagai T, Hamamoto K, Sato Y, Honda A, Kobayashi H, Sato J, Shibuta S, Miyawaki M, Oishi K, Yamaga H, Aoyagi N, Iwahashi S, Miyashita R, Murata Y, Sasago K, Takahashi A, Kamatani N, Kubo M, Tsunoda T, Hata A, Nakamura Y, Tanaka T (2012) A genome-wide association study identifies three new risk loci for Kawasaki disease. Nat Genet 44(5):517–521. doi:10.​1038/​ng.​2220 CrossRefPubMed
49.
Zurück zum Zitat Kuo HC, Yu HR, Juo SH, Yang KD, Wang YS, Liang CD, Chen WC, Chang WP, Huang CF, Lee CP, Lin LY, Liu YC, Guo YC, Chiu CC, Chang WC (2011) CASP3 gene single-nucleotide polymorphism (rs72689236) and Kawasaki disease in Taiwanese children. J Hum Genet 56(2):161–165. doi:10.1038/jhg.2010.154 CrossRefPubMed Kuo HC, Yu HR, Juo SH, Yang KD, Wang YS, Liang CD, Chen WC, Chang WP, Huang CF, Lee CP, Lin LY, Liu YC, Guo YC, Chiu CC, Chang WC (2011) CASP3 gene single-nucleotide polymorphism (rs72689236) and Kawasaki disease in Taiwanese children. J Hum Genet 56(2):161–165. doi:10.​1038/​jhg.​2010.​154 CrossRefPubMed
50.
Zurück zum Zitat Onouchi Y, Suzuki Y, Suzuki H, Terai M, Yasukawa K, Hamada H, Suenaga T, Honda T, Honda A, Kobayashi H, Takeuchi T, Yoshikawa N, Sato J, Shibuta S, Miyawaki M, Oishi K, Yamaga H, Aoyagi N, Iwahashi S, Miyashita R, Murata Y, Ebata R, Higashi K, Ozaki K, Sasago K, Tanaka T, Hata A (2013) ITPKC and CASP3 polymorphisms and risks for IVIG unresponsiveness and coronary artery lesion formation in Kawasaki disease. Pharmacogenomics J 13(1):52–59. doi:10.1038/tpj.2011.45 CrossRefPubMed Onouchi Y, Suzuki Y, Suzuki H, Terai M, Yasukawa K, Hamada H, Suenaga T, Honda T, Honda A, Kobayashi H, Takeuchi T, Yoshikawa N, Sato J, Shibuta S, Miyawaki M, Oishi K, Yamaga H, Aoyagi N, Iwahashi S, Miyashita R, Murata Y, Ebata R, Higashi K, Ozaki K, Sasago K, Tanaka T, Hata A (2013) ITPKC and CASP3 polymorphisms and risks for IVIG unresponsiveness and coronary artery lesion formation in Kawasaki disease. Pharmacogenomics J 13(1):52–59. doi:10.​1038/​tpj.​2011.​45 CrossRefPubMed
Metadaten
Titel
Identification of Differentially Expressed Genes in Kawasaki Disease Patients as Potential Biomarkers for IVIG Sensitivity by Bioinformatics Analysis
verfasst von
Lan He
Youyu Sheng
Chunyun Huang
Guoying Huang
Publikationsdatum
09.05.2016
Verlag
Springer US
Erschienen in
Pediatric Cardiology / Ausgabe 6/2016
Print ISSN: 0172-0643
Elektronische ISSN: 1432-1971
DOI
https://doi.org/10.1007/s00246-016-1381-z

Weitere Artikel der Ausgabe 6/2016

Pediatric Cardiology 6/2016 Zur Ausgabe

Update Kardiologie

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