Biomedical subjects

T F Orntoft

Publications and source records attributed to T F Orntoft.

At least 37 records · Page 2Linked to original sources

PubMed1999

Proteomics and immunohistochemistry define some of the steps involved in the squamous differentiation of the bladder transitional epithelium: a novel strategy for identifying metaplastic lesions.

Here, we present a novel strategy for dissecting some of the steps involved in the squamous differentiation of the bladder urothelium leading to squamous cell carcinomas (SCCs). First, we used proteomic technologies and databases (http://biobase.dk/cgi-bin/celis) to reveal proteins that were expressed specifically by fresh normal urothelium and three SCCs showing no urothelial components. Thereafter, antibodies against some of the differentially expressed proteins as well as a few known keratinocyte markers were used to stain serial cryostat sections (immunowalking) of biopsies obtained from bladder cystectomies of two of the SCC-bearing patients (884-1 and 864-1). Because bladder cancer is a field disease, we surmised that the urothelium of these patients may exhibit a spectrum of abnormalities ranging from early metaplastic stages to invasive disease. Immunohistochemical analysis revealed three types of non-keratinizing metaplastic lesions (types 1-3) that did not express keratins 7, 8, 18, and 20 (expressed by normal urothelium) and could be distinguished based on their staining with keratin 19 antibodies. Type 1 lesions showed staining of all cell layers in the epithelium (with differences in the staining intensity of the basal compartment), whereas type 2 lesions exhibited mainly basal cell staining. Type 3 lesions did not stain with keratin 19 antibodies. In cystectomy 884-1, type 3 lesions exhibited the same immunophenotype as the SCC and may be regarded as precursors to the tumor. Basal cells in these lesions did not express keratin 13, suggesting that the tumor, which was also keratin 13 negative, may have arisen from the expansion of these cells. Similar results were observed with cystectomy 864-1, which showed carcinoma in situ of the SCC type. SCC 864-1 exhibited both keratin 19-negative and -positive cells, implying that the tumor arose from the expansion of the basal cell compartment of type 2 and 3 lesions. Besides providing with a novel strategy for revealing metaplastic lesions, our studies have shown that it is feasible to apply powerful proteomic technologies to the analysis of complex biological samples under conditions that are as close as possible to the in vivo situation.

Biomarkers, Tumor↗

PubMed1999

A comprehensive protein resource for the study of bladder cancer: http://biobase.dk/cgi-bin/celis.

In our laboratories we are exploring the possibility of using proteome expression profiles of fresh bladder tumors (transitional cell carcinomas, TCCs; squamous cell carcinomas, SCCs) and random biopsies as fingerprints to subclassify histopathological types and as a starting point to search for protein markers that may form the basis for diagnosis, prognosis, and treatment. Ultimately, the goal of these studies is to identify signaling pathways and components that are affected at various stages of bladder cancer progression and that may provide novel leads in drug discovery. Here we present our ongoing efforts to establish comprehensive two-dimensional polyacrylamide gel electrophoresis (2-D PAGE) databases of TCCs and SCCs which are being constructed based on the proteomic and immunohistochemical analysis of hundreds of fresh tumors, random biopsies and cystectomies received shortly after operation (http://biobase.dk/cgi-bin/celis).

Animals↗

PubMed1999

Psoriasin (S100A7): a putative urinary marker for the follow-up of patients with bladder squamous cell carcinomas.

To search for bladder squamous cell carcinoma markers that are released to the urine a blind and systematic analysis of the protein profiles of fresh tumors, their secreted proteins, as well as the patient's urine was carried out using state-of-the-art proteomic technology. We review the data concerning the putative marker psoriasin (S100A7), which, alone or in combination with other biomarkers, may be valuable for the noninvasive follow-up of patients bearing these tumors.

Biomarkers, Tumor↗

PubMed1999

Clinical aspects of altered glycosylation of glycoproteins in cancer.

Alteration of the expression of carbohydrate structures is frequently observed in tumor cells. This review summarizes the different changes of O- and N-linked glycoproteins observed in cancer cells, the impact of the tumor-related carbohydrate phenotypes on the clinical outcome of the cancer disease, and the various ways in which carbohydrate structures can interact with different carbohydrate-detecting adhesion molecules, selectins, and sialoadhesins. Various ways of inhibiting the formation of cell adhesion-engaged carbohydrates on the cell surface, or inhibiting the binding are discussed. Carbohydrate structures which are in clinical use as circulating tumor markers and the effect of genotypes on tumor marker concentrations are reviewed.

Antigens, Neoplasm↗

PubMed1999

Comparison of three methods of microsatellite detection.

Examination of microsatellites is frequent in the diagnosis of cancer. Microsatellites are repeat DNA sequences scattered throughout the human genome. These repeat regions are very frequent and highly polymorphic elements. In this study we focus on dinucleotide repeats. We compared three different methods for the detection of microsatellites: use of the ABI Prism 377 fluorescence sequencer, autoradiography and silver-stained gels. DNA was extracted from various clinical samples and amplified by different polymerase chain reaction (PCR) protocols. DNA from normal and tumor tissues was analysed using each method. The fluorescence method was more sensitive than the two other methods; however, this technology is very expensive. It seems possible, when examining microsatellites on a low budget, to avoid radioactivity by using silver-stained gels as an alternative. In conclusion, we observed identical results when comparing autoradiography with the fluorescence technique. However, we observed variability in the results when interpreting a single locus comparing silver staining with autoradiography and the fluorescence technique. Classification of the tumors based on several microsatellite loci was always identical.

Autoradiography↗

PubMed1999

Lewis antigen mediated adhesion of freshly removed human bladder tumors to E-selectin.

PURPOSE: Twenty fresh surgical specimens of human bladder tumors were tested for their ability to adhere to recombinant P and E-selectin. The adhesion was correlated to immunological detection of carbohydrate structures. MATERIALS AND METHODS: A static titertray assay with immobilized selectins and appropriate controls was used for bladder tumor cell adhesion. On the same tumors expression of carbohydrate structures was examined by immunohistochemistry and Western blotting. RESULTS: No tumor bound to P-selectin. Nine tumors showed a high number of cells binding to E-selectin, 5 showed intermediate binding, and 6 showed only rare binding. The specificity of the binding was verified by inhibition with EDTA, by blocking antibodies to E-selectin, and by an acrylamide based sLe(x) (Galbeta1-4 [Fucalpha1-3]GlcNAc-) polymer. The binding was significantly more frequent (p <0.045) in superficial tumors than in invasive tumors. The binding property was correlated to the detection of carbohydrate structures in Western blots and tissue sections of the same tumors, using six different monoclonal antibodies: anti-sLe(a), anti-sLe(x), anti-Le(a), anti-Le(x) (two different clones) and anti-Le(b). Most blot-stainings were smeared indicating a mucin-type carrier molecule, but 115, 55 and 40 kDa bands carrying Le(a) and/or Le(b) epitopes were present in all tumors that bound. The Le(a) structure, as detected by blotting, was the only structure necessary for binding in the center of the wells (p <0.001), and was correlated to number of bound cells (p <0.006). A weaker correlation was found between Le(b) and number of bound cells (p <0.032), whereas it was remarkable that no correlation was found with Le(x) or sLe(x). Immunohistological staining of Le(a) on cell membranes correlated with frequent binding (p <0.003), whereas no correlation was found to secretor and Lewis genotypes. CONCLUSIONS: These data on clinical specimens indicate that Lewis antigen mediated E-selectin adhesion may play a role in the human bladder cancer disease.

Blotting, Western↗

PubMed1999

Reference values and biological variation for tumor marker CA 19-9 in serum for different Lewis and secretor genotypes and evaluation of secretor and Lewis genotyping in a Caucasian population.

The concentration of the tumor marker CA 19-9 is influenced by the patient's secretor status and Lewis genotype. The aim of this study was to establish novel reference intervals for CA 19-9 in serum based on secretor and Lewis genotypes, to investigate the biological variation of CA 19-9, and to evaluate the utility of Lewis and secretor genotyping on a group of individuals with serologically defined Lewis phenotypes. CA 19-9 was measured in serum of 500 healthy individuals. Secretor and Lewis genotypes were determined by sequencing and PCR-cleavage methods. Significant differences were found between subgroups with different Lewis and secretor genotypes. Genotype-based reference intervals for CA 19-9 are presented. The upper reference limit for all individuals was 28.7 kilounits/L; for secretors and nonsecretors, the upper reference limits were 12.4 and 61.2 kilounits/L, respectively. The analytical imprecision (CVA) was 9.8%, the within-subject variability (CVI) was 15.8%, and the between-subject variability (CVG) was 102.2%. Good agreement was found between Lewis and secretor genotyping and conventional blood grouping. Genotype-based reference intervals may be a way to increase the clinical utility of CA 19-9. On the basis of the calculation of a critical difference for sequential values (significant at P </=0.05) of 51.5%, a 40-50% change in marker concentration is suggested as the limit for significant change when the marker is used for follow up. PCR-based genotyping is a reliable method for secretor and Lewis histo-blood grouping.

Adult↗

PubMed1998

Pronounced microsatellite instability in transitional cell carcinomas from young patients with bladder cancer.

Microsatellites may show loss of heterozygosity as well as instability of the repeats. We examined 22 different microsatellites in 14 bladder tumours (7 grade II non-invasive, 7 grade III/IV invasive) and found altered CA repeat length compared with leukocytes, indicating instability, in several microsatellites in all tumours. Instability was significantly more frequent in low stage tumours compared with high stage tumours. The number of new bands occuring was also significantly higher in low stage tumours (median 7.2) compared with high stage tumours (median 3.3). Furthermore, patients with a disease course > or = 1 year had significantly more unstable microsatellites (10.83) than those with a disease course < 1 year (mean 8.88). Examination of biopsies from normal bladder mucosa showed no instability. In 2 cases in which selected site biopsies were taken, alterations differed from the tumours, pointing at a different clonal development. LOH was most frequent in 9p markers in low stage tumours. In a group of markers located at 2p, 17p (p53), 9q, 5q and 10p, LOH was significantly more frequent in high stage tumours. Microsatellites placed at MSH2 and MLH1 loci showed LOH in several cases, indicating that the profound microsatellite instability could partly be an effect of damage to these genes.

Adult↗

PubMed1998

Association of IgM type anti-GM1 antibodies and muscle strength in chronic acquired demyelinating polyneuropathy.

The pathogenetic role of anti-GM1 in chronic acquired demyelinating polyneuropathy (CADP) is uncertain. An association between antibodies and disease activity has not yet been established. In 8 patients with CADP followed longitudinally, anti-GM1 antibodies were monitored with a standardized enzyme-linked immunosorbent assay technique and muscle performance with isokinetic dynamometry. During a mean observation period of 24 months, strength improved in 6 of 8 patients by a median value of 54.5%, and anti-GM1 fell in all 6 patients; the reduction being 43%. In 2 patients, muscle performance deteriorated by 30 and 8%, whereas anti-GM1 titers increased by 10 and 9%, respectively. The relative change in anti-GM1 was inversely related to muscle performance. Clinical scoring of muscle performance according to the Medical Research Council scale failed to show an association with anti-GM1. It is concluded that anti-GM1 antibodies are closely related to disease activity, and that the close association indicates a role of anti-GM1 in the pathogenesis of CADP.

Adult↗

PubMed1998

Glycoproteins in the urothelium and in the urine of the epidermal growth factor induced growing urinary tract in rats.

Systemic treatment with epidermal growth factor (EGF) induces growth of all wall layers of the urinary tract in pigs and rats. We have previously described that the EGF stimulated urothelium in Goettingen minipigs accumulates glycoproteins. The aim of the present study was to examine and partly characterize glycoproteins in the urothelium and in the urine from rats treated with EGF. Seventy-two female Wistar rats were allocated into five groups receiving EGF treatment (150 microg/kg per day) for 0 (controls), 1, 2, 3 and 4 weeks before being killed. Glycoconjugates were characterized by means of lectins on tissue sections, and using Western blotting, in bladder extracts and in urine. The characterization mostly focused on the expression of the mucin-type core structures T and Tn using the lectins peanut agglutinin (PNA) and Vicia villosa (VVA) and specific monoclonal antibodies. The thickened EGF-stimulated urothelium retained the normal differentiation pattern as judged from the appearance on electron microscopy and from the expression of carbohydrate structures. Within the urothelium and in the urine there was increased expression of mucin-type glycoproteins suggesting increased urothelial production and excretion of mucin-type glycoproteins. In conclusion, the EGF stimulated hyperplastic urothelium most probably excretes increased amounts of mucin-type glycoproteins to the urine but it retains the normal pattern of differentiation as assessed by lectin characterization.

Animals↗

PubMed1998

Molecular alterations in bladder cancer.

In recent years, significant information has been accumulated on the molecular alterations that take place during development of transitional cell carcinoma (TCC). A number of studies aimed at defining loss of heterozygosity have shown a general chromosomal instability in TCC with loss of parts of chromosome 9 at early stages of papillomas, and of chromosomes 11, 13, 3, 4, 8, 17 and 18 during further development of the tumor. Oncogenes are activated, exemplified by mutations in the ras gene family and overexpression of the c-erbB-2 gene, in a minor fraction of tumors. Alterations of tumor suppressors (involved in control of the cell cycle, DNA quality control and activation of apoptosis) seem to be frequently involved. Among these p53 has a key role, and one p53 allele is frequently lost in TCC followed by mutation of the remaining allele.These alterations are correlated with survival, disease progression, invasion and recurrence. Also frequently lost are the cell cycle control genes p16 and p15. The predictive value of this has not yet been determined. Studies of glycosylation genes have shown downregulation of the ABO gene, followed by loss of ABO blood group structures and accumulation of the Lewis cell adhesion molecules in high grade tumors. Functional proteome analysis has furthermore identified biomarkers that are correlated with grade and stage. Molecular models for TCC development can now be built, and clinical testing of these is urgently needed.

Blood Group Antigens↗

PubMed1998

Increased concentrations of genotype-interpreted Ca 19-9 in urine of bladder cancer patients mark diffuse atypia of the urothelium.

We investigated the use of genotype-interpreted measurements of the tumor marker Ca 19-9 in the urine of bladder cancer patients as a marker of the extent of urothelial disease. Ca 19-9 in urine (sialyl-Le(a)/creatinine ratio) was measured in 81 bladder cancer patients and correlated to T-category, histologic grade, and presence of urothelial dysplasia. As reference group, Ca 19-9 ratio was measured in urine from 21 apparently healthy individuals. The amount of sialyl-Le(a) expressed is influenced by the Lewis genotype and secretor status. Accordingly, secretor status was determined in urine by a novel ELISA method, and the Lewis genotypes of all of the individuals were determined by PCR cleavage methods. Ca 19-9 concentrations in urine were higher (P < 0.01) in bladder cancer patients than in healthy individuals and significantly (P = 0.02) higher in cancer patients with concomitant urothelial dysplasia than in those with normal urothelium. For individuals Lewis-genotyped as homozygous wild-type, Ca 19-9 concentrations in urine were higher, both in cancer patients (P = 0.06) and in healthy individuals (P = 0.004), than in the heterozygous individuals. Furthermore, nonsecretor cancer patients had higher (P < 0.01) Ca 19-9 concentrations in urine. Attention is drawn to the possibility of a general genotype interpretation of a result in clinical chemistry.

Adult↗

PubMed1997

Proteome profiling of bladder squamous cell carcinomas: identification of markers that define their degree of differentiation.

One hundred fifty fresh bladder tumors were analyzed blindly by two-dimensional PAGE in combination with proteome identification techniques (microsequencing and mass spectrometry) and immunofluorescence of cryostat sections. Of these, six showed protein expression patterns corresponding to squamous cell carcinomas (SCCs). All tumors were already invasive at the time of presentation, and in most cases, the histopathological grade could not be determined with certainty. The more differentiated of the tumors included SCC 589-1, a lesion showing extensive keratinization, and 536-1, a pure SCC that resembled normal skin growing invasively into the muscle. Both tumors expressed keratins 5, 6, 10, 14, 16, 17, and 20, as well as the differentiation-associated proteins psoriasin, psoriasis-associated fatty acid-binding protein (PA-FABP), and galectin 7. SCC 589-1, however, exhibited higher levels of keratin 10, PA-FABP, and galectin 7 and, in addition, expressed keratins 13, 15, and 19, which were not detected in the pure SCC. Involucrin, glutathione S-transferase pi, stratifin (14-3-3 sigma), and the SCC antigen 1, on the other hand, were less abundant in SCC 589-1. In comparison, less-differentiated tumors did not express keratin 10 and were characterized by a decreased expression of keratin 14, psoriasin, PA-FABP, galectin 7, and stratifin (14-3-3 sigma). Indeed, two of these lesions (553-1 and 651-1) could be readily lined up in order of decreasing degree of differentiation based on the expression of these markers. The degree of differentiation of the other two SCCs could not be assessed with certainty because they may represent special cases (SCC 646-1, solid tumor; SCC 485-1, special differentiation pattern). All six SCCs externalized psoriasin to the urine, supporting the contention that this protein, alone or in combination with other polypeptides, may represent a useful marker for the early detection of these lesions.

Biomarkers, Tumor↗

PubMed1997

IgM anti-GM1 antibodies in the Guillain-Barré syndrome: a serological predictor of the clinical course.

It has been suggested that antibodies against GM1 are involved in the pathogenesis of the Guillain-Barré syndrome (GBS). Recently, we have developed a standardized ELISA assay for anti-GM1 antibodies of IgM type well-suited for longitudinal patient studies. The relationship between serum antibodies against GM1 and Campylobacter jejuni was investigated in patients with GBS and in patients with C. jejuni infection. Patients with a short-lasting anti-GM1 elevation had a fast recovery, whereas patients with slow recovery had a long-lasting anti-GM1 elevation. A linear relationship was found between significant clinical recovery and the time until the anti-GM1 peak was halved (R = 0.9, p < 0.01). The absolute level of anti-GM1 did not predict the length of the recovery nor was the level of anti-GM1 related to the clinical disability at its nadir. Our data indicate that monitoring of the IgM anti-GM1 level can predict clinical recovery in GBS patients.

Adolescent↗

PubMed1997

A two-site lectinoenzymatic assay for determination of tumour marker glycoproteins in rectal secretions.

A method is described for a titre-tray based two-site lectinoenzymatic assay of glycoproteins. WGA lectin, reacting with the core-part of glycans, was combined with lectins PNA and DBA, the latter two reacting with terminal parts of glycans. A standard curve was obtained with bovine submaxillary gland asialomucin, and measurements of human rectal secretion were calibrated against this curve. The assay showed an intra-assay reproducibility of 2.4-7.5%, and inter-assay reproducibility of 3.9-20.8%. Recovery tests showed a linearity close to predicted values. The selected standard was ideal as inhibition of lectin binding by monosaccharides showed similar inhibition profiles for human rectal secretion and for asialomucin standard. Neuraminidase treatment dramatically increased the PNA binding to human rectal secretion immobilized on WGA. Western blotting of human rectal secretion demonstrated a large range of lectin-reactive glycoproteins, the main fraction reacting with all lectins being approximately 250 kDa. The assay described is well suited for studies of the glycan part of tumour marker glycoproteins, and changes occurring in these. It has a high sensitivity by ignoring that the glycans may be present on different molecules. Examination of rectal secretions from various cancer patients showed significantly increased PNA binding, as well as an increased PNA/DBA binding ratio, in patients with colorectal cancer (p<3x10(-3)) and, unexpectedly, in patients with other cancers (p<5x10(-3)).

Animals↗

PubMed1996

Influence of Lewis alpha1-3/4-L-fucosyltransferase (FUT3) gene mutations on enzyme activity, erythrocyte phenotyping, and circulating tumor marker sialyl-Lewis a levels.

Fucosylated glycoproteins carrying alpha1-4 fucose residues are of importance for cell adhesion and as tumor markers. The Lewis gene, FUT3, encodes the only known alpha1-4-fucosyltransferase (FucT), and individuals who are deficient in this enzyme type as Lewis-negative on erythrocytes. We examined the mutational spectrum of the Lewis gene in Denmark and found 6 different mutations. Five, T59G, T202C, C314T, G508A, and T1067A, were frequent, and one, C445A, was only detected in one out of 40 individuals. Allele-specific polymerase chain reaction as well as cloning of FUT3 alleles showed that the 202 and 314 mutations were co-located on the same allele. COS7 cells transfected with an allele having the 202/314 mutations lacked enzyme activity. Polymerase chain reaction-cleavage assays were established for the genotyping of healthy individuals as well as 20 genuine Lewis-negative cancer patients and 10 non-genuine. The latter have Lewis-negative erythrocytes but saliva alpha1-4FucT activity. The genuine Lewis-negative individuals had mutations on both FUT3 alleles. In 66 healthy individuals, a gene dosage effect was detected as FUT3 heterozygous individuals had a lower alpha1-4FucT activity in saliva than did homozygous wild-type individuals. The lower enzyme level in heterozygous individuals resulted in a significantly (p < 0.04) lower level of circulating sialyl-Lewis a structure in serum. This has the clinical impact that cut-off levels in tumor marker assays should be defined on the basis of genotyping. In the group of non-genuine Lewis-negative cancer patients, whose erythrocytes convert from Lewis-positive to Lewis-negative during the disease, FUT3 heterozygosity was significantly (p < 0.05) more common.

ABO Blood-Group System↗

PubMed1996

Loss of adipocyte-type fatty acid binding protein and other protein biomarkers is associated with progression of human bladder transitional cell carcinomas.

Multifocal recurrent papillary tumors provide a unique model system to study the molecular mechanisms underlying the steps involved in transitional cell carcinoma progression and offer a valuable source of material to search for biomarkers that may form the basis for diagnosis, prognosis, and treatment. We have examined the protein expression profiles of normal bladder urothelium and of 63 transitional cell carcinomas of various histopathological grades and T stages using high-resolution, two-dimensional gel electrophoresis, microsequencing, mass spectrometry, and a two-dimensional gel protein database approach for polypeptide identification (http://biobase.dk/cgi-bin/celis). In general, the results revealed a striking similarity between the overall qualitative expression patterns of papillary tumors of all grades, as well as of papillary and solid tumors of grade III. With few exceptions, tumors of grades I-III expressed, albeit at different levels, all of the keratins (7, 8, 13, 17, 18, 19, and 20) found in the normal urothelium. Grade IV tumors lacked or expressed reduced levels of keratin 13 but most resembled low-grade tumors. One invasive grade IV tumor, however, expressed a fibroblast-like protein phenotype. Four proteins that were expressed by normal urothelium and were lost at various stages of progression were identified as glutathione S-transferase mu, prostaglandin dehydrogenase (PGDH), a fatty acid binding protein with homology to the adipocyte isoform (A-FABP), and keratin 13. The percentage of tumors expressing A-FABP was very high in low-grade lesions but decreased drastically (P = 0.0006) in grade III and IV neoplasms. In addition, low-grade tumors contained more A-FABP than their high-grade counterparts. The stage of the disease was also statistically (P = 0.0269) related to the presence or absence of A-FABP in grade III tumors. Similar analysis of glutathione S-transferase mu and PGDH showed a statistically significant decrease of these proteins in high-grade (grades III and IV) tumors (P = 0.0026 and P = 0.0044, respectively). Only PGDH showed a suggestive correlation (P = 0.0775) with the stage of the disease in grade III tumors. Keratin 13 showed a drastic decrease in grade IV tumors. In addition to identifying biomarkers that may have prognostic value, our studies have suggested that A-FABP is an important component of the pathway(s) leading to bladder cancer development.

Biomarkers, Tumor↗

PubMed1996

The blood group ABO gene transcript is down-regulated in human bladder tumors and growth-stimulated urothelial cell lines.

The molecular mechanism that in human bladder tumors leads to the loss of blood group ABO glycosyltransferase activity and, thereby, the loss of ABO antigens was investigated. In 15 tumors and 3 normal biopsies from blood group AB individuals and 7 tumors and 3 normal biopsies from blood group O individuals, mRNA was detected by a reverse transcription PCR (RT-PCR) assay, and the ABO blood group structure was determined by immunohistology. The RT-PCR spanned several introns in the ABO gene to exclude DNA contamination, and the RT-PCR product was shown to reflect the ABO gene message by dideoxy sequencing. The ABO mRNA was present in normal urothelium and low-grade tumors but disappeared from high grade tumors. This correlation to tumor grade was significant (P<0.04). Immunohistochemistry with monoclonal anti-blood group antibodies showed a complete correlation between the presence of mRNA and the presence of AB carbohydrate structures on cell surfaces. In two urothelial cell lines, genotyped as A/- and A/A, growth stimulation with the cholera toxin B subunit led to a total loss of ABO mRNA, and epidermal growth factor stimulation had an identical effect on one of the cell lines. We conclude that the ABO glycosylation in normal and malignant urothelium is regulated at the mRNA level, and that a mechanism associated with cell proliferation may trigger down-regulation of ABO mRNA.

ABO Blood-Group System↗