Mechanism of Action of Potato
Glycoalkaloids against Fusarium solani
Jing He1,2*, Tian-Tian Duo1, Wei
Chen1 and Xiao-Yan Zhang1
1College of Forestry, Gansu
Agricultural University, Lanzhou 730070, China
2Agronomy College,
Gansu Agricultural University, Lanzhou 730070, China
*For correspondence: hejing268@aliyun.com
Received 09 September 2020; Accepted 12 January 2021;
Published 25 March 2021
Abstract
The antifungal mechanism of potato glycoalkaloids was
studied using a sensitive species, Fusarium solani. The effects of
potato glycoalkaloids extract on the
ultrastructure, membrane permeability, contents of reducing sugar, soluble
sugar, soluble protein and mycelial fat of Fusarium solani were
determined. Potato glycoalkaloids significantly affected F. solani mycelial
morphology, resulting in bubbly mycelial cell walls, incomplete outer layer,
discontinuous cell membrane, disorganized structures of mitochondria and other
organelles, and visible leakage of cell contents. Investigation of material
metabolism indicated that potato glycoalkaloids disrupted selective
permeability of mycelial cell membranes; In the treatment group, the soluble
protein content increased from 66.50 g mL-1 to 169.51 g mL-1
for 06 h, the soluble sugar content in extracellular fluid increased from
117.4 g mL-1 to 132.5 g mL-1 for 024 h, which were much
higher than that of the control group, hindered hydrolysis of reducing sugar,
affected nutrient absorption and utilization and inhibited decomposition
metabolism of mycelia. Thus, potato glycoalkaloids altered the morphology of
fungal mycelia, destroyed cell membrane structure, increased mycelial cell
membrane permeability, and caused cell contents leakage, resulting in effective
inhibition of growth and metabolism of plant pathogenic fungus and so could
decrease the occurrence of plant disease. © 2021 Friends Science Publishers
Keywords: Antifungal
mechanism; Fusarium solani; Mycelial morphology; Plant disease; Potato
glycoalkaloids
Introduction
Fusarium is one of the most important fungi in nature, and can
survive in soil and plants during winter and summer, with wide distribution,
diverse hosts, strong resistance, and rapid growth and reproduction (Du 2017). Fusarium
solani is one of the most common Fusarium spp., which infects the host
vascular tissue, destroys its conducting tissue, and produces toxins that harm
crops during growth, development, and metabolism. To date, F. solani is
one of the plant pathogens which are difficult to control in production, and
can cause root diseases in various economic crops worldwide, such as white
mulberry (Zhang 2013), Chinese angelica (Zhao et al. 2012), walnut
(Zheng et al. 2016), medlar (Chen et al. 2017), wild pepper (Li et
al. 2016), and pear (Tang et al. 2017). Fusarium solani can
also cause fruit rot (Rampersad 2010) and deformity (Zhao et al. 2018),
resulting in wilting and death of crops, affecting yield and quality, and
producing huge economic losses. Currently, F. solani control depends on
chemical fungicides such as carbendazim, mancozeb, thiram, cymoxanilmancozeb, xinjunan
acetate, or pyrazole-kresoxim-methyl (Wang et al. 2014; Chen et al. 2017;
Tang et al. 2017). However, long-term usage of chemical fungicides can
result in pesticide residues, environmental pollution, and disease resistance,
leading to a series of adverse effects (Yao et al. 2017). Therefore,
developing alternatives for chemical fungicides using active substances in
plants, such as botanical fungicides, is urgently needed.
Plants produce more than 400,000 kinds of bioactive
components, such as alkaloids, organic acids, flavonoids, phenols, and plant
essential oils, most of which have anthelmintic, insecticidal, antifungal, or
antibacterial activities (Yao et al. 2017). These bioactive compounds
have a broad spectrum of target organisms, are safe for non-target organisms,
and are characterized by low toxicity, low residue, easy degradation, and no
target resistance (He et al. 2006; Yoon et al. 2013; Zhang et
al. 2013a, b). Plant bioactive components are a key research topic for
controlling many plant diseases and developing new botanical pesticides, with
prospects of wide exploitation and utilization (Li 2017; Tang et al. 2018).
Potato glycoalkaloids are steroids produced as secondary
metabolites by potatoes (Guo et al. 2017). The main components of potato
glycoalkaloids are α-solanine and α-chaconine (Zhao et al.
2013), which represent more than 95% of the total glycoalkaloids (Kodamatani et
al. 2005). Previous studies have shown that potato glycoalkaloids have a
wide range of biological activities (Qiao 2017), and can inhibit infection or
growth of fungi, bacteria, viruses, and other plant pathogenic microorganisms,
prevent insects from feeding or harming plants (Friedman 2004; Liang et al. 2017),
exert protective effects on plants, and possess important medicinal value (Zhao
et al. 2013). Fewell and Roddick (1993) reported that α-solanine
and α-chaconinein potatoes can inhibit the growth of fungi such as Alternaria
brassicicola, Ascobolus crenulatus, Rhizoctonia solani, and Phoma
medicaginis. Furthermore, Zhao et al. (2013) showed that potato
glycoalkaloids have high inhibitory effects on Alternaria porri and Cercosporella
brassicae. Likewise, Ombra et al. (2014) found that potato extract
had antibacterial activity against Bacillus cereus, Escherichia coli,
and Pseudomonas aeruginosa under in vitro conditions.
Currently, potato glycoalkaloids extract has been noted
to have an inhibitory effect on three economic
forest pathogenic fungi: F. solani, Capnodium leaophilum, and Marssonina
juglandis. Notably, the inhibitory effect on F. Solani was the
strongest (Duo et al. 2017). However, the studies on control of F.
solani disease using plant bioactive compounds as well as the antifungal
mechanism of these compounds are limited. Therefore, in the study, the effects
of potato glycoalkaloids extract on the ultrastructure, cell membrane
permeability, and contents of reducing sugar, soluble sugar, soluble protein,
and mycelial fat of F. solani were examined, and the inhibition
mechanism was preliminarily determined. The results could provide a theoretical
basis for prevention and control of economic forest diseases as well as for the
development and utilization of plant-derived fungicides.
The potato is Qingshu variety No.9 being purchased from supermarket.
The fresh potato samples were washed and dried in sunlight for several weeks to
turn the potato skin green and allow germination. Subsequently, the green
potato skin and buds were dried in a vacuum blast drying oven and pulverized
into a powder using a plant pulverizer through an 80-mesh sieve and stored at
04°C until further use.
The test strain of F. solani was isolated from Lycium
barbarum root rot in Gansu Province, China (Fang 1998), and its
pathogenicity was confirmed based on Kochs postulates. After identification,
the strain was stored at 04°C until further use. Potato dextrose broth (PDB)
and potato dextrose agar (PDA) were employed for fungal cultivation. The PDB
comprised 200 g of peeled potato, 20 g of glucose, and 1000 mL of distilled
water (neutral pH). The PDA was prepared by adding 1720 g of agar to the
constituents of PDB. All reagents used were of domestic analytical grade and
purchased from Gansu Zhongrui Chemical Co. Ltd., China.
Potato glycoalkaloids were extracted using an acetic acid
extractionammonia precipitation method with slight modifications (Bo et al.
2012). In brief, 100 g of the potato sample was mixed with 400 mL of 5%
acetic acid, stirred for 60 min (JB-1 magnetic stirrer, Shanghai Leici Xinjing
Instrument Co. Ltd., China), and filtered (SHZ-D III circulating water vacuum
pump, Gongyi Yuhua Instrument Co. Ltd., China). The residue was extracted twice
with 200 mL of 5% acetic acid, and the filtrate was combined, and its pH
adjusted to 11 with ammonia. After extracting three times with 200 mL of
water-saturated n-butanol, the
extracts were combined and dried on a rotary evaporator (RE-3000, Shanghai
Yarong Biochemical Instrument Factory, China), and the residue mixed with 20 mL
of methanol to obtain total glycoalkaloids extract. The mass concentration of
the glycoalkaloids extract was 5 g mL−1.
The F. solani was inoculated onto PDA at a concentration of
0.3036 g mL−1 (EC50), along with 2 g mL−1
potato glycoalkaloid extract, and incubated at 25°C for 48 h. Subsequently,
sterile filter paper strips (0.7 cm Χ 5 cm) were placed around the colony
(covering an area of 5 cm Χ 5 cm) and incubated at 25°C. After 72 h, the edge
of the colony was sampled. The collected sample was fixed by double fixation
with glutaraldehyde and citric acid (Zeng 2012), and observed and photographed
under a transmission electron microscope (JEM2000EX; JEOL, Japan).
The mycelia of F. solani were cultured in PDB for 4 days and
washed four times with ultrapure sterile water. Then, the washed mycelia were freeze-dried
to a constant weight (Labconco freeze drier, USA) and 1 g of the mycelia was
transferred into 5 mL of potato glycoalkaloid (EC50) extract and
incubated at 25°C under constant shaking at 120 r min−1.
Subsequently, conductivity of the culture broth was measured (DDB-303A digital
conductivity meter, Shanghai Yidian Scientific Instrument Co. Ltd., China)
hourly during 09 h. Finally, the culture broth was boiled in a water bath
(HH-S6 digital display thermostat water bath, Jintan Medical Instrument
Factory, China) for 10 min and conductivity was determined. The experiment was
repeated thrice, with sterile water and methanol as controls. The permeability
of cell membrane was expressed as relative permeability (%) = (relative time
conductivity value - initial conductivity value) / (kill conductivity value −initial conductivity
value) Χ100% (Shen 2014).
The effect of potato glycoalkaloids on soluble mycoprotein was
determined by Coomassie Brilliant Blue G-250 staining (Song 2010).
In brief, mycelia of F. solani were cultured in PDB for 4 days, and
washed four times with ultrapure sterile water. Then, the washed mycelia were freeze-dried
(Labconco) to a constant weight and 1 g of the mycelia was added to 5 mL of
potato glycoalkaloids (EC50) extract, and sampled at 0, 2, 4, 6, and
8 h. The collected samples were centrifuged (D-37520 centrifuge, Heraeus Biofuge,
Germany), and the absorbance of samples was recorded at 595 nm (Jenway 6505
UV/Vis UV Spectrophotometer; Gaonan Instrument (Shenzhen) Co. Ltd. China). The
protein concentration was calculated according to the protein standard curve,
and the experiment was repeated thrice, with sterile water and methanol as
controls.
The effect of potato glycoalkaloids on soluble sugar in F. solani was
determined by anthrone colorimetry (Yao and Xu 1992). In brief, F. solani mycelia were cultured
in PDB for 4 days, and then washed four times with ultrapure sterile water.
Then, the washed mycelia were freeze-dried (Labconco) to a constant weight and
1 g of mycelia mixed with 5 mL of potato glycoalkaloids (EC50)
extract, and sampled at 0, 1, 2, 4, 6, 8, 10 and 12 h. Subsequently, collected
samples were subjected to centrifugation (6000 rpm; 5 min), heated with
anthrone reagent, and cooled to room temperature, and the absorbance of the
samples measured at 620 nm. The soluble sugar content was calculated according
to the glucose standard curve, and the experiment was repeated thrice, with
sterile water and methanol as controls.
The effect of potato glycoalkaloids on reducing sugar in F. solani was
determined by 3, 5-dinitrosalicylic acid (DNS) method (Chen 2002). In brief, F.
solani mycelia were cultured in PDB for 4 days, and washed four times with
ultrapure sterile water. Then, the washed mycelia were freeze-dried (Labconco)
to a constant weight and 1 g of mycelia was added to 5 mL of potato
glycoalkaloid (EC50) extract, and sampled hourly during 08 h.
Subsequently, 1 mL of the collected samples was respectively subjected to
centrifugation (6000 rpm; 5 min), and 0.5 mL of the supernatant was mixed with
1.5 mL of distilled water and 1.5 mL of DNS reagent to determine the absorbance
at 520 nm. The reducing sugar content was calculated according to the standard
curve, and the experiment was repeated thrice, with sterile water and methanol
as controls.
The oil weight method was employed for sample processing and fat
content determination (Li 1987). The F. solani mycelia were cultured in
PDB for 4 days and washed four times with ultrapure sterile water. Then, the
washed mycelia were freeze-dried (Labconco) to a constant weight and 1 g of the
mycelia was added to 5 mL of potato glycoalkaloids (EC50) extract,
and sampled at 24, 48, and 72 h. Subsequently, the collected samples were
filtered (SHZ-D III circulating water vacuum pump) and rinsed with redistilled
water four times; the obtained wet hyphae were dried at 6080°C for 4 h,
smashed with a mortar and pestle, and filtered through a mesh sieve to obtain
dried powder. The procedure was repeated thrice, and sterile water and methanol
were used as controls. For fat content determination, the Soxhlet extractor was
cleaned, heated in a blast drying oven at 105°C for 20
min, cooled to room temperature, and weighed (m). Then, 12-cm quantitative
filter paper was weighed (m1) and made into a bucket, and 2 g of the
dried sample powder were added to the filter paper bucket and weighed (m2).
The difference between the two masses indicated the quality of the dried sample
powder (m2-m1). Subsequently, the dried sample was soaked
in petroleum ether overnight, and heated in a thermostat water bath for 65°C.
Reflux extraction was performed for 12 h using a Soxhlet fat extractor, and
then the extract was heated at 100°C for 8 h, cooled to room temperature, and
weighed (m′). Crude fat was calculated as follows: crude fat (%) =
(m′−m)/(m2−m1) Χ100%.
All the above measurements were repeated at least three times. The
results were expressed as mean value ±standard errors calculated by Microsoft Excel 2007. The variance was
examined using SPSS 19.0 and the difference investigated by employing Duncans
new complex range method (Zhang 2013).
Once the cell wall or cell membrane is destroyed, the cell cannot
maintain its inherent structure in morphology, and the mycelium will be
twisted, deformed, or even broken. In this study, the controls without potato
glycoalkaloids treatment presented thin and uniform cell walls, complete
structure, hyphae surrounded by a continuous outer layer, intact internal
tissue structure, no extravasation of cell contents, normal development, and
clearly visible vacuoles, mitochondria, and other organelles (Fig. 1A). However,
after treatment with EC50 potato glycoalkaloids, the fungal cell
walls became thinner and irregular, cell internal structure was disrupted, and
some membrane structures were incomplete (Fig. 1B). Furthermore, after
treatment with 2 g mL−1 potato glycoalkaloids, cell walls of
mycelia had a bubble shape, outer layer components were altered, cell wall
structure was incomplete, the outer cell membrane was discontinuous, structure
of mitochondria and other organelles was not obvious, and
extracellular inclusions were exuded (Fig. 1C). In contrast, following
treatment with methanol, the cell wall structure was clear, mitochondria and
ribosomes were clearly visible, and the vacuolar structure was intact,
indicating that methanol did not affect antibacterial activity of potato
glycoalkaloids (Fig. 1D). These findings indicated that potato glycoalkaloids
destroyed the cell surface morphology of F. solani, severely damaging
the cytoplasm, mitochondria, and other organelles, as well as increasing the cell membrane permeability and so causing leakage of
cell contents.
Selective permeability is the most basic function of the cell membrane.
If the cell loses this function, the cell will die. In this study, the Fig. 2
shows the effects of potato glycoalkaloids on the cell membrane permeability of
F. solani. The relative cell membrane permeability increased with time
in both the control and treatment groups. However, the relative cell membrane
permeability was significantly higher for the treatment compared with the
control group. In both the control and treatment groups, the relative cell
membrane permeability rapidly increased during 14 h, with a greater increase
for the treatment than the control group. After 4 h, the difference in relative
cell membrane permeability quickly broadened between the two groups, indicating
that the F. solani cell membrane damage caused by potato glycoalkaloids
at EC50 concentration intensified at 4 h. Subsequently, the relative
cell membrane permeability of the control group gradually decreased during 49 h,
whereas that of the treatment group increased by 25.2% at 9 h, and remained
stable at 8 and 9 h.
Material metabolism is divided into anabolism and catabolism, both of
which maintain dynamic balance in normal life activities. When this balance is
broken, it will cause diseases of the organism and even death. In this study,
the soluble protein leakage in the treatment group exhibited an upward trend
with time, which significantly differed from that in the control group (Fig.
3). During 06 h, soluble protein leakage in the treatment group increased from
66.50 to 169.51 μgmL−1, which was much higher than that
in the control group. However, during 624 h, the soluble protein leakage in
the treatment group gradually decreased with time, possibly due to consumption
of soluble proteins by newly formed cells of F. Solani for growth. After
24 h, the soluble protein leakage in the treatment and control groups gradually
increased and stabilized.
Fig. 1: Effect of potato
glycoalkaloids on ultrastructure of F. solani (2550Χ)
A: Control 1 (sterile water); B: Treatment 1 (EC50); C: Treatment 2 (2 g mL−1); D: Control 2 (methanol).
CW: Cell wall; V: Vacuole; M: Mitochondrion
Fig. 2: Effect of potato
glycoalkaloids on cell membrane permeability of F. solani
Soluble sugar leakage in the treatment group significantly differed
from that in the control with time (Fig. 4). During 024 h, soluble sugar
leakage in the treatment group increased from 117.4 to 132.5 μg mL−1, which was
much higher than that in the control group. However, after 24 h, leakage in the
treatment group decreased with time owing to consumption of soluble sugar in
the extracellular fluid by newly formed F. solani cells for growth.
The reducing sugar content in the extracellular fluid significantly
differed between the treatment and control group with time (Fig. 5). In both
groups, the reducing sugar content in the extracellular fluid sharply decreased
during 02 h, but gradually reduced during 272 h, indicating that potato
glycoalkaloids significantly decreased the absorption and utilization of
reducing sugar by F. solani.
The fat content in the extracellular fluid of both the treatment and
control groups increased during 048 h, with significantly higher fat leakage
for the treatment compared with the control group (Fig. 6). The fat content in
the extracellular fluid of the treatment group increased by 54.20 and 52.07%,
compared with sterile water and methanol control groups at 48 h, respectively,
indicating that potato glycoalkaloids damaged the cell structure and caused fat
content leakage from F. solani plasma membrane. However, after 48 h, fat
content in the extracellular fluid of both treatment and control groups showed
a downward trend, possibly resulting from a weakening effect of potato
glycoalkaloids or a self-remediation mechanism of F. solani.
Plant bioactive substances mainly target the cell membrane of fungi by
altering membrane stability and causing damage to the membrane structure and
extravasation of inclusions, ultimately resulting in fungicidal or fungistatic
effect (Zhou et al. 2014). Previous studies have shown that
glycoalkaloids predominantly combine with sterols in the fungal cell membrane,
forming a complex that destroys membrane integrity and causes loss of normal
membrane function (Sun 2014). In the present study, transmission electron
microscopy showed that F. solani morphology was distorted after potato
glycoalkaloids treatment, and that some cell walls were blurred or even lost.
Additionally, structure of the cell and vacuolar membranes was destroyed and
the organelles distorted. These observations indicated that potato
glycoalkaloids can affect the surface morphology of F. solani, leading
to incomplete membrane structure and causing serious damage to cytoplasm and
mitochondria, consistent with the effect of pyrolin on Monilinia fructicola (Wu
et al. 2009), ethyl acetate extract of amaranth on Xanthomonas citri (Liao
et al. 2017), and water-soluble chitosan on the ultrastructure of Fusarium
(Jia et al. 2016).
Fig. 3: Effect of potato
glycoalkaloids on soluble protein leakage of F. solani
Fig. 4: Effect of potato
glycoalkaloids on soluble sugar leakage of F. solani
Electrical conductivity can indirectly reflect cell
membrane permeability, and a higher electrical conductivity of a
culture broth signifies enhanced electrolyte leakage and increased damage to
cell membranes (Shang 2017). Peng et al. (2017) showed that extract of Cynanchum
atratum could enhance the cell membrane permeability of Penicillium
italium, while Zhang et al. (2008) revealed that the extract of Xanthium
sibiricum induced changes in membrane permeability of Botrytis cinerea,
resulting in increased conductivity of the culture broth. Furthermore, Liu et al. (2018a) found that the total saponins and total
ginsenoside from ginseng stem and leaf can induce changes in the permeability
of the mycelium membrane of F. solani, respectively, leading to
increased conductivity of the culture broth. Liu et al. (2018b) showed
that limonene can increase the cell membrane permeability of Pseudomonas
aeruginosa and destroy its cell morphology and integrity, thus effectively
inhibiting its growth. Similarly, in the present study, the cell membrane
permeability of F. solani increased after treatment with potato
glycoalkaloids, and transmission electron microscopy revealed leakage of
intracellular contents and destruction of cell membrane structure. These
results showed that the cell
membrane and integrity of F. solani were destroyed by potato
glycoalkaloids, which directly affected the physiological functions of the cell
membrane, such as exchange of intracellular and extracellular substances and
regulation of cell growth, leading to disturbance infungal metabolism.
It must be noted that plant bioactive compounds also affect the
morphology and structure of fungal mycelia, causing deformity, kinking,
swelling, and lysis. As a result, the mycelial soluble protein and soluble
sugar can leak into the culture medium (Zhou et al. 2011; Fan et al. 2015;
Zhang et al. 2016). In fungi, soluble protein mainly comprises various
enzymes involved in metabolism. During growth, the fungi secrete proteins that
penetrate the cell membrane into the thallus fluid through osmosis. Thus,
changes in the content of these proteins reflect alteration in the total
cellular metabolism (Liu et al. 2016). Sugar catabolism provides the
energy needed for fungal growth, and inhibition of the absorption and
utilization of sugar could lead to lack of energy required by the fungi,
affecting growth and propagation of the thallus (Liu et al. 2016). The
total lipid content in the fungal cell membrane affects cell membrane fluidity,
and a decrease in the total lipid content may lead to a reduction in cell
membrane fluidity (Shang 2017). Thus, one approaches to achieve fungicidal or fungistatic effect is to inhibit fungal metabolism (Zhou
et al. 2014). In the present study, the contents of total sugar,
protein, and fat in F. solani
Fig. 5: Effect of potato
glycoalkaloids on reducing sugar content of F. solani
Fig. 6: Effect of potato glycoalkaloids on fat content of F. solani
initially increased and then decreased with time after
treatment with potato glycoalkaloids. However, the content of reducing sugar
decreased in F. solani treated with potato glycoalkaloids, but
significantly increased in control cells without glycoalkaloids treatment.
Similar findings were also reported by Wu (2008), who showed that the contents
of total sugar, reducing sugar, protein, and fat in B. cinerea treated
with propamidine were significantly higher than those in control B. cinerea
without treatment, indicating that plant bioactive compounds inhibited
catabolism in fungi. Biological catabolic systems are complex, and disturbance
in a certain catabolic link can obstruct the entire catabolic process,
threatening life of the organism. However, self-remedial mechanisms can
overcome the blocked metabolic processes to continue life activities (Zeng
2012). Therefore, it is possible that self-remedial mechanisms of F. solani allowed
the fungal cells to thrive after treatment with potato glycoalkaloids,
resulting in an initial increase and subsequent decrease in contents of total
sugar, protein, and fat with treatment duration.
Results in the present study showed that potato glycoalkaloids
significantly affected the morphological structure of F. solani.
Treatment with potato glycoalkaloids resulted in bubbly and undulated mycelial
cell walls, incomplete outer structure, discontinuous cell membrane, disordered
structure of mitochondria and other organelles, and visible extracellular
contents. The material metabolism analysis demonstrated that potato glycoalkaloids
destroyed the selective permeability of fungal cell membranes and causing
extravasation of large quantities of internal lipids, proteins, and sugars.
This hindered the hydrolysis of reducing sugars, affecting the absorption and
utilization of nutrients, and ultimately inhibiting catabolism in fungi.
However, knowledge of the specific antifungal mechanism of potato
glycoalkaloids is limited. Therefore, further research on the effects of potato
glycoalkaloids on fungal respiratory metabolism (e.g., related enzymes activities) and energy metabolism (e.g., inhibition of electron transport
and oxidative phosphorylation, and information expression of nucleic acids and
other molecular substances) is necessary for a better understanding of the
antifungal mechanism of these compounds and for acquiring comprehensive and
systematic theoretical support for the development and utilization of botanical
pesticides.
Acknowledgements
The work was supported by grants from the National Natural Science
Foundation of China (32060341), Special Funds for Discipline Construction of
Gansu Agricultural University (GAU-XKJS-2018-096), and Supporting Funds for
Youth Mentor of Gansu Agricultural University (GAU-QDFC-2018-07) and
Postdoctoral Research Projects (2015GSZYZZ002). We thank International Science
Editing (http://www.internationalscienceediting.com) for editing this
manuscript.
Author Contributions
JH planned the experiments, JH and TTD
interpreted the results, JH, TTD and WC contributed to writing and XYZ statistically
analyzed the data and prepared illustrations.
Conflicts of Interes
The authors declare that they
have no conflict of interest.
Data Availability
The data will be made avaialble
on acceptable requests to the corresponding author.
Ethics Approval
Not applicable.
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