Myeloid-derived suppressor cells from tumour-bearing mice induce the population expansion of CD19hiFcγRIIbhi regulatory B cells via PD-L1.

Myeloid-derived suppressor cells (MDSCs) increase in number and gain immunosuppressive functions in tumours and many other pathological conditions. MDSCs are characterized by their strong T-cell immunosuppressive capacity. The effects that MDSCs may have on B cells, especially within the tumour microenvironment, are less well understood. Here, we report that either monocytic MDSCs or polymorphonuclear MDSCs can promote increases in interleukin (IL)-10-expressing CD19hiFcγRIIbhi regulatory B cells in vitro and in vivo. Splenic transitional-1, -2, and -3 cells and marginal zone B cells, but not follicular B cells, differentiate into IL-10-expressing CD19hiFcγRIIbhi regulatory B cells. The adoptive transfer of CD19hiFcγRIIbhi regulatory B cells via tail vein injection can promote subcutaneous 3LL tumour growth in mice. The expression of programmed death-ligand 1 on MDSCs was found to be strongly associated with CD19hiFcγRIIbhi regulatory B cell population expansion. Furthermore, the frequency of circulating CD19+FcγRIIhi regulatory B cells was significantly increased in advanced-stage lung cancer patients. Our results unveil a critical role of MDSCs in regulatory B-cell differentiation and population expansion in lung cancer patients.

Umbilical cord MSC-derived exosomes improve alveolar macrophage function and reduce LPS-induced acute lung injury.

Acute lung injury (ALI) is a severe condition that can progress to acute respiratory distress syndrome (ARDS), with a high mortality rate. Currently, no specific and compelling drug treatment plan exists. Mesenchymal stem cells (MSCs) have shown promising results in preclinical and clinical studies as a potential treatment for ALI and other lung-related conditions due to their immunomodulatory properties and ability to regenerate various cell types. The present study focuses on analyzing the role of umbilical cord MSC (UC-MSC))-derived exosomes in reducing lipopolysaccharide-induced ALI and investigating the mechanism involved. The study demonstrates that UC-MSC-derived exosomes effectively improved the metabolic function of alveolar macrophages and promoted their shift to an anti-inflammatory phenotype, leading to a reduction in ALI. The findings also suggest that creating three-dimensional microspheres from the MSCs first can enhance the effectiveness of the exosomes. Further research is needed to fully understand the mechanism of action and optimize the therapeutic potential of MSCs and their secretome in ALI and other lung-related conditions.

Clinical best practices in interdisciplinary management of human epidermal growth factor receptor 2 antibody-drug conjugates-induced interstitial lung disease/pneumonitis: An expert consensus in China.

Antibody-drug conjugates (ADCs) have demonstrated effectiveness in treating various cancers, particularly exhibiting specificity in targeting human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Recent advancements in phase 3 clinical trials have broadened current understanding of ADCs, especially trastuzumab deruxtecan, in treating other HER2-expressing malignancies. This expansion of knowledge has led to the US Food and Drug Administration's approval of trastuzumab deruxtecan for HER2-positive and HER2-low breast cancer, HER2-positive gastric cancer, and HER2-mutant nonsmall cell lung cancer. Concurrent with the increasing use of ADCs in oncology, there is growing concern among health care professionals regarding the rise in the incidence of interstitial lung disease or pneumonitis (ILD/p), which is associated with anti-HER2 ADC therapy. Studies on anti-HER2 ADCs have reported varying ILD/p mortality rates. Consequently, it is crucial to establish guidelines for the diagnosis and management of ILD/p in patients receiving anti-HER2 ADC therapy. To this end, a panel of Chinese experts was convened to formulate a strategic approach for the identification and management of ILD/p in patients treated with anti-HER2 ADC therapy. This report presents the expert panel's opinions and recommendations, which are intended to guide the management of ILD/p induced by anti-HER2 ADC therapy in clinical practice.

Dual role of pregnancy in breast cancer risk.

Reproductive history is one of the strongest risk factors for breast cancer in women. Pregnancy can promote short-term breast cancer risk, but also reduce a woman's lifetime risk of breast cancer. Changes in hormone levels before and after pregnancy are one of the key factors in breast cancer risk. This article summarizes the changes in hormone levels before and after pregnancy, and the roles of hormones in mammary gland development and breast cancer progression. Other factors, such as changes in breast morphology and mammary gland differentiation, changes in the proportion of mammary stem cells (MaSCs), changes in the immune and inflammatory environment, and changes in lactation before and after pregnancy, also play key roles in the occurrence and development of breast cancer. This review discusses the dual effects and the potential mechanisms of pregnancy on breast cancer risk from the above aspects, which is helpful to understand the complexity of female breast cancer occurrence.

Mesenchymal stem/stromal cell-based cell-free therapy for the treatment of acute lung injury.

Acute lung injury (ALI) is a severe medical condition that causes inflammation and fluid buildup in the lung, resulting in respiratory distress. Moreover, ALI often occurs as a complication of other medical conditions or injuries, including the coronavirus disease of 2019. Mesenchymal stem/stromal cells (MSCs) are being studied extensively for their therapeutic potential in various diseases, including ALI. The results of recent studies suggest that the beneficial effects of MSCs may not be primarily due to the replacement of damaged cells but rather the release of extracellular vesicles (EVs) and other soluble factors through a paracrine mechanism. Furthermore, EVs derived from MSCs preserve the therapeutic action of the parent MSCs and this approach avoids the safety issues associated with live cell therapy. Thus, MSC-based cell-free therapy may be the focus of future clinical treatments.

Immunogenicity of mesenchymal stromal/stem cells.

Mesenchymal stromal/stem cells (MSCs) possess the ability to self-renew and differentiate into other cell types. Because of their anti-inflammatory and immunomodulatory abilities, as well as their more ready availability compared to other stem cell sources, MSCs hold great promise for the treatment of many diseases, such as haematological defects, acute respiratory distress syndrome, autoimmunity, cardiovascular diseases, etc. However, immune rejection remains an important problem. MSCs are considered to have low immunogenicity, but they do not have full immunological privilege. This review analyzes and discusses the safety of MSCs from the perspective of their immunogenicity, with the aim of providing a reference for future research and clinical application.

Successful administration of low-dose almonertinib in a patient with lung adenocarcinoma after osimertinib-induced interstitial lung disease: a case report and literature review.

Osimertinib, the third generation epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), is the standard treatment for nonsmall cell lung cancer with EGFR mutation. However, osimertinib-induced interstitial lung disease (OsiILD) is considered to be a serious adverse event, so some patients will have to discontinue the use of osimertinib due to OsiILD. Almonertinib is a novel third-generation EGFR-TKI. We herein report a patient who developed OsiILD after the use of osimertinib and then switched to almonertinib for further treatment with success. This is the first report of a successfull rechallenge with low-dose almonertinib after OsiILD. We also reviewed the literature to explore the possible risk factors and the subsequent treatment of OsiILD, suggesting that low-dose almonertinib may be an option for follow-up treatment of OsiILD.

Clinical Report of a Rare Mucinous Staphylococcus Aureus Infection.

BACKGROUND: Staphylococcus aureus is the most common pathogen in suppurative infection, which can cause local suppurative infection, pneumonia, etc. A case of double renal calculi complicated with chronic renal insufficiency and mucinous Staphylococcus aureus infection was analyzed and discussed. METHODS: Bacterial culture, identification, and next-generation sequencing. RESULTS: The mucous colony was identified as Staphylococcus aureus, and the condition improved after symptomatic treatment. CONCLUSIONS: Mucinous Staphylococcus is a rare clinical microorganism, which needs to be verified by experiments to avoid false negative results. Genetic sequencing is used to identify strains if necessary.

Awareness of mpox-related knowledge among men who have sex with men in China.

BACKGROUND: With the rapid spread of the mpox epidemic, cases have emerged in multiple countries, mainly among men who have sex with men. Because of the connectedness of today's world, countries have to be prepared to face risks in advance. Therefore, this study aimed to investigate awareness of mpox-related knowledge among men who have sex with men in China. METHODS: With the assistance of the social organizations of men who have sex with men, a cross-sectional survey of men who have sex with men in China was conducted through an online questionnaire between July 1 and July 18, 2022. A nationwide sample of Chinese men who have sex with men (N = 3,257) was recruited. RESULTS: Only 36.9% of participants had mpox-related knowledge. Awareness of mpox-related knowledge among respondents was positively associated with those in older age groups (33 to 42 years and 51 years or older) (adjusted odds ratio [AOR] = 1.31; 95% confidence interval [CI]: 1.03-1.67, AOR = 1.61; 95% CI: 1.16-2.24; respectively), married (AOR = 1.55; 95% CI: 1.09-2.19), and those with a graduate degree or above (AOR = 2.14; 95% CI: 1.11-4.13), while negatively associated with those living in the western parts of China (AOR = 0.74; 95% CI: 0.60-0.92), and those who were unsure of their history of Human Immunodeficiency Virus (HIV) status (AOR = 0.44; 95% CI: 0.30-0.63). CONCLUSION: Mpox-related knowledge is fairly low among men who have sex with men in China. China needs to spread knowledge to the public through multiple channels, especially in key populations (men who have sex with men, HIV-infected, etc.), and take preventive measures to effectively avoid outbreaks of mpox.

Identification and Characterization of Neocosmospora silvicola Causing Canker Disease on Pinus armandii in China.

Chinese white pine, Pinus armandii, is a source of high-quality timber and an afforestation tree in China, which plays an important ecological and social role in water and soil conservation. Recently, a new canker disease has been reported in Longnan City, Gansu Province, where P. armandii is mainly distributed. In this study, the causal agent was isolated from diseased samples and identified as a fungal pathogen, Neocosmospora silvicola, based on morphological characteristics and molecular analyses (internal transcribed spacer, large subunit, RNA polymerase II, and translation elongation factor-1α). Pathogenicity tests on P. armandii revealed that N. silvicola isolates caused a 60% average mortality rate in artificially inoculated 2-year-old seedlings. The pathogenicity of these isolates was also observed on the branches of 10-year-old P. armandii trees with a 100% mortality rate. These results agree with the isolation of N. silvicola from diseased plants, suggesting the possible role of this fungus in the decline of P. armandii plants. Mycelial growth of N. silvicola was fastest on potato dextrose agar medium, and growth occurred at pH values ranging from 4.0 to 11.0 with temperatures between 5 and 40°C. The fungus also grew rapidly in complete darkness compared with other light conditions. Of the eight carbon and seven nitrogen sources tested, starch and sodium nitrate, respectively, were highly efficient in supporting the mycelial growth of N. silvicola. The ability of N. silvicola to grow at low temperatures (5°C) may explain its occurrence in the Longnan area of Gansu Province. This article is the first report of N. silvicola as an important fungal pathogen causing branch and stem cankers on Pinus tree species, which remains a threat to the forests.

Toxicity evaluation of polycyclic aromatic hydrocarbons (PAHs) in soils of coal chemical industry areas, North China.

Objectives of this study were to investigate the concentrations, distributions, toxicities, and risk assessment of 16 polycyclic aromatic hydrocarbons in surface soils surrounding a coal chemical industrial zone in the southeast of Shanxi province, China. A total of 52 topsoil samples were collected from different land-use areas: cereal agriculture, roadsides, and parkland. Results show that the total PAHs (∑16PAHs) ranged from 3.87 × 103 to 116 × 103 µg kg-1 and that the total carcinogenicity PAHs (∑BPAHs) ranged from 3.11 × 103 to 94.2 × 103 µg kg-1, with the highest concentration of ∑16PAHs noted in the RS samples, followed by PS and AS. The entire risk quotient of all PAH maximum permissible concentrations (RQ∑PAHMPCi) was greater than 1.0, and the minimum concentration entire risk quotient (RQ∑PAHNCi) of 84.3% of all samples was higher than 800. The value of the total toxicity equivalent concentration of PAH (PAHBapeq) for areas surrounding the coal chemical industrial zone was higher than the value of the standard level, and the incremental lifetime cancer risk (ILCR) far exceeds the U.S. EPA's risk standard. The toxic properties of PAHs indicated that the soils in the survey areas have a high risk to human health and the environment.

Sporoderm-broken spores of Ganoderma lucidum alleviates liver injury induced by DBP and BaP co-exposure in rat.

Dibutyl phthalate (DBP) and Benzo(a)pyrene (BaP) are ubiquitous contaminants in environment and foodstuffs, which increase the chance of their combined exposure to humans in daily life. However, the combined effects of DBP and BaP on liver and the underlying mechanisms are still unclear. In this study, we explored the combined effects of DBP and BaP on liver and the potential mechanisms in a rat model. We found that DBP and BaP co-exposure activated the MyD88/NF-κB pathway through increasing TLR4 acetylation (TLR4ac) level, leading to the imbalance of pro-inflammatory factors (CXCL-13, IL-6 and TNF-α) and anti-inflammatory factors (IL-10), ultimately resulting in liver tissue damage and functional changes. Sporoderm-broken spores of Ganoderma lucidum (SSGL) had strong alleviating effects on liver injury induced by DBP and BaP co-exposure. Our study found that SSGL suppressed TLR4ac-regulated MyD88/NF-κB signaling to reduce the release of pro-inflammatory factors, and promote the secretion of IL-10, thus alleviating liver injury caused by DBP and BaP co-exposure. In conclusion, SSGL contributed to liver protection against DBP and BaP-induced liver injury in rats via suppressing the TLR4ac-regulated MyD88/NF-κB signaling.

miR-122-5p regulates hepatocytes damage caused by BaP and DBP co-exposure through SOCS1/STAT3 signaling in vitro.

BaP and DBP are ubiquitously and contemporaneously present in the environment. However, Current studies largely concentrate on the effects of a single pollutant (BaP or DBP). The liver is vital for biogenic activities. The effects of BaP and DBP co-exposure on liver remain unclear. Thus, we treated human normal liver cell (L02 cell) with BaP or/and DBP. We found that compared to individual exposure, co-exposure to BaP and DBP induced further increased levels of AST and ALT. BaP and DBP co-exposure caused further increased levels of IL-2, IL-6, and TNF-α, decreased IL-10 level, and a higher percentage of apoptotic cells and S-phase arrest cells. BaP and DBP co-exposure worsen the decrease of miR-122-5p level and chaos of SOCS1/STAT3 signaling. Dual-luciferase reporter gene assays showed that SOCS1 was a validated target of miR-122-5p. miR-122-5p overexpression alleviated the increased SOCS1 expression, decreased phospho-STAT3 expression, decreased IL-10 level, increased TNF-α levels, increased percentage of apoptosis and S-phase arrest, and cytotoxicity induced by BaP and DBP co-exposure in hepatocytes. These results suggested that miR-122-5p negatively regulated the synergistic effects on apoptosis and disorder of inflammatory factor secretion involved in hepatocyte injury caused by BaP and DBP co-exposure through targeting SOCS1/STAT3 signaling.

Asymmetric Synthesis of Tetrahydroisoquinoline Derivatives through 1,3-Dipolar Cycloaddition of C,N-Cyclic Azomethine Imines with Allyl Alkyl Ketones.

A [3 + 2] 1,3-Dipolar cycloaddition of C,N-cyclic azomethine imines with allyl alkyl ketones has been achieved. The reaction proceeds under mild conditions and tolerates a wide range of functional groups. An array of tetrahydroisoquinoline derivatives is generally constructed with good diastereoselectivities and enantioselectivities (up to >25:1 dr, >95% ee). Moreover, the absolute configuration of the product was previously determined by using the quantum electronic circular dichroism calculation and ECD spectrum method.

Inhibition of Human UGT1A1-Mediated Bilirubin Glucuronidation by Polyphenolic Acids Impact Safety of Popular Salvianolic Acid A/B-Containing Drugs and Herbal Products.

Bilirubin-related adverse reactions (ADR, e.g., jaundice and hyperbilirubinemia) induced by herbs rich in certain polyphenolic acids are widely reported. However, the causes and the mechanisms underlying these ADR are not well understood. The purpose of this article is to determine the mechanism by which certain polyphenolic acids inhibit UGT1A1-mediated bilirubin glucuronidation, leading to jaundice or hyperbilirubinemia. We investigated in vitro inhibitory effects on bilirubin glucuronidation of salvianolic acid A (SAA), salvianolic acid B (SAB), danshensu (DSS), protocatechuic aldehyde (PA), and rosmarinic acid (RA), as well as two Salvia miltiorrhiza injections (DSI and CDI) rich in polyphenolic acids. The results showed that average formation rates of three bilirubin glucuronides displayed a significant difference (p < 0.05) and the formation of monoglucuronide was favored regardless if an inhibitor was present or not. SAA, SAB, DSI, and CDI, but not DSS, PA, and RA, significantly inhibited human UGT1A1-mediated bilirubin glucuronidation via a mixed-type inhibitory mechanism. Average IC50 values of SAA, SAB, DSI, and CDI-mediated inhibition of bilirubin glucuronidation were bilirubin concentration-dependent, and their values (against total bilirubin glucuronidation) were in the range 0.44 ± 0.02 to 0.86 ± 0.04 µg/mL (for SAA), 4.22 ± 0.30 to 12.50 ± 0.93 µg/mL (for SAB), 9.29 ± 0.76 to 18.82 ± 0.63 µg/mL (for DSI), and 9.18 ± 2.00 to 22.36 ± 1.39 µg/mL (for CDI), respectively. In conclusion, SAA and its analog SAB are the main ingredients responsible for inhibition of bilirubin glucuronidation by DSI and CDI, whose use is associated with many high bilirubin-related ADR.

Immune complex negatively regulates toll-like receptor 3-triggered tumour necrosis factor α production in B cells.

Inappropriate activation of toll-like receptor 3 (TLR3) has been implicated in the pathogenesis of autoimmune diseases, so the negative regulation of TLR3-triggered immune response has received increasing attention. Nonpathogenic immune complex (IC) has been used as treatment for many inflammatory and autoimmune diseases. However, the role of IC in the regulation of TLR3-triggered immune responses and the underlying mechanisms need to be investigated. In this study we demonstrate that IC or intravenous immunoglobulin (Ig) stimulation of B cells attenuates polyinosinic:polycytidylic acid (poly I:C)-induced CD40 expression; IC, but not Ig, can significantly inhibit poly I:C-induced pro-inflammatory tumour necrosis factor α (TNF-α) production by B cells. Moreover, IC/Ig stimulation does not alter the expression of TLR3 in B cells. Further experiments suggest that receptor for the Fc portion of IgGIIb (FcγRIIb) is involved in the suppressive effect of IC on TLR3-mediated TNF-α production, but not CD40 expression. Thus, we provide a new means of negative regulation of TLR3-triggered immune responses in B cells via FcγRIIb, and we provide a new mechanistic explanation of the therapeutic effect of nonpathogenic IC on inflammatory or autoimmune diseases.

Immune complex negatively regulates Toll-like receptor 9-mediated immune responses in B cells through the inhibitory Fc-gamma receptor IIb.

Because inappropriate activation of Toll-like receptor 9 (TLR9) may induce pathological damage, negative regulation of the TLR9-triggered immune response has attracted considerable attention. Nonpathogenic immune complex (IC) has been demonstrated to have beneficial therapeutic effects in some kinds of autoimmune diseases. However, the role of IC in the regulation of TLR9-triggered immune responses and the underlying mechanisms remain unclear. In this study, it was demonstrated that IC stimulation of B cells not only suppresses CpG-oligodeoxynucleotide (CpG-ODN)-induced pro-inflammatory IL-6 and IgM κ production, but also attenuates CD40 and CD80 expression. Furthermore, our results suggest that the receptor for the Fc portion of IgG (FcγR) IIb is involved in the suppressive effect of IC on TLR9-mediated CD40, CD80 and IL-6 expression. Finally, it was found that IC down-regulates TLR9 expression in CpG-ODN activated B cells. Our results provide an outline of a new pathway for the negative regulation of TLR9-triggered immune responses in B cells via FcγRIIb. A new mechanistic explanation of the therapeutic effect of nonpathogenic IC on inflammatory and autoimmune diseases is also provided.

Analyzing the differentially expressed genes and pathway cross-talk in aggressive breast cancer.

AIM: The aim of this study was to explore the genes and pathways involved in the aggressive breast cancer cells. METHODS: The gene expression profiles of GSE40057, including four aggressive breast cell lines and six less aggressive cell lines, were downloaded from the Gene Expression Omnibus (GEO) database. The gene differential expression analysis was carried out with limma software with the method of Bayes for multiple tests. The gene ontology (GO) term enrichment and pathway cross-talk analysis were performed with the online tool of DAVID and Cytoscape software. RESULTS: A total of 401 differentially expressed genes (DEG), such as pentraxin 3 (PTX3), snail family zinc finger 2 (SNAI2), interleukin-8/6 (IL-8/6), osteonectin (SPARC), matrix metallopeptidase-1 (MMP-1) and Ras-related protein Rab-25 (Rab 25), were identified between aggressive and less aggressive cell lines. They were mainly enriched in the GO terms of response to wounding, negative regulation of cell proliferation and calcium binding. Pathways in cancer dysfunctionally interacted with glyoxylate and dicarboxylate metabolism (P < 0.0001), basal transcription factors (P < 0.0001), tyrosine metabolism (P < 0.0001), calcium signaling pathway (P = 0.0021), FcγR-mediated phagocytosis (P = 0.0022), metabolism of xenobiotics by cytochrome P450 (P = 0.0097) and phagosome (P = 0.0102). CONCLUSION: The screened aggressive cancer-associated DEG (PTX3, SNAI2, IL-8/6, SPARC, MMP-1 and Rab25) and significant pathways (calcium signaling pathway, tyrosine metabolism, alanine, aspartate and glutamate metabolism) give us new insights into the mechanism of aggressive breast cancer cells, and these DEG may become promising target genes in the treatment of metastatic breast cancer.

[Study on the hemodynamic changes in solid thyroid nodules by ultrasound contrast quantitative analysis].

OBJECTIVE: To compare the difference between the different perfusional regions in solid thyroid nodules. METHODS: From October 2013 to May 2015, CEUS was performed in 59 patients who hospitalizated in Zhoushan Hospital with solid thyroid nodules before operation. The time-intensity curve (TIC) of normal thyroid tissue, tumor edge and tumor center was drawn to collect perfusion index like the peak intensity (PI), time to peak (TP), area under the curve (AUC), mean transit time (MTT). After surgery, immunohistochemical staining was performed to evaluate the MVD in surgical specimens.Quantitative parameters and MVD were assessed by the Spearman correlation analysis. RESULTS: There were 31 thyroid papillary carcinomas and 28 nodular goiters. In malignant tumor group, the PI of normal thyroid tissue, tumor edge and tumor center were 28% ± 6%, 21% ± 7% and 14% ± 5%, respectively, while the AUC and MVD of the same regions were (1 865 ± 1 079)%S, (1 376 ± 595)%S, (805 ± 412)%S and(33 ± 6), (27 ± 6)/HP, (17 ± 6)/HP, respectively. The differences were statistically significant. However, in benign tumor group, there was no obvious statistic difference in the quantitative parameters and MVD between the three regions. The PI values of thyroid carcinomas and nodular goiters all were positively correlated with MVD (r=0.819, r=0.838, P<0.05). CONCLUSIONS: The variance of perfusion parameters were valuable diagnostic basis in differential diagnosis between benign and malignant thyroid nodules. They were associated with MVD, which might reflect the microvessel distributional characteristics of neoplasm and might be one of bases used to evaluate neoplasm angiogenesis.

[Sensitivity and specificity of noninvasive prenatal fetal RhD genotesting: a meta-analysis].

OBJECTIVE: To explore the sensitivity, specificity and clinical validity of fetal Rh genotyping from maternal blood. METHODS: A comprehensive literature search of PubMed, Embase and Web of Science was performed for describing fetal RhD determination from maternal blood. The inclusion criteria were established based on the validity criteria for diagnostic research. And the eligible entries were collected and analyzed with MetaDisc4.0. RESULTS: This meta-analysis included 55 studies with a total of 17 138 samples. The random-effect model was used for analysis because of heterogeneity. The pooled sensitivity and specificity were 98.5% and 97.3% respectively. The SROC curve was plotted and the area under the curve (AUC) calculated (AUC = 0.994). The subgroup and sensitivity analyses were performed. The sensitivity of 25 studies with samples<100 (94.6%) was significantly lower than those of 19 studies with samples 100-300 (98.5%) and 11 studies with samples>300 (99.0%) (χ² = 36.800, 106.062, P < 0.05). The sensitivity of 19 studies with samples 100-300 (98.5%) was not different from that of 11 studies with samples >300 (99.0%)( χ² = 3.068, P > 0.05). CONCLUSIONS: Noninvasive prenatal diagnosis of fetal RhD status from maternal blood represents a significant achievement in the application of research with high sensitivity and specificity. It may be applied for screening testing of all RhD⁻ negative pregnant women.