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Kshirsagar SM, Viswaroopan N, Ghosh M, Junaid MSA, Haque S, Khan J, Muzaffar S, Srivastava RK, Athar M, Banga AK. Development of 4-phenylbutyric acid microsponge gel formulations for the treatment of lewisite-mediated skin injury. Drug Deliv Transl Res 2025; 15:638-654. [PMID: 38802678 PMCID: PMC11599469 DOI: 10.1007/s13346-024-01620-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
Lewisite, a chemical warfare agent, causes skin blisters, erythema, edema, and inflammation, requiring mitigation strategies in case of accidental or deliberate exposure. 4-phenyl butyric acid (4-PBA), a chemical chaperone, reduces endoplasmic reticulum stress and skin inflammation. The study aimed to encapsulate 4-PBA in microsponges for effective, sustained delivery against lewisite injury. Porous microsponges in a topical gel would potentially sustain delivery and improve residence time on the skin. Microsponges were developed using the quasi-emulsion solvent diffusion method with Eudragit RS100. Optimized formulation showed 10.58%w/w drug loading was incorporated in a carboxymethylcellulose (CMC) and Carbopol gel for in vitro release and permeation testing using dermatomed human skin. A sustained release was obtained from all vehicles in the release study, and IVPT results showed that compared to the control (41.52 ± 2.54 µg/sq.cm), a sustained permeation profile with a reduced delivery was observed for microsponges in PBS (14.16 ± 1.23 µg/sq.cm) along with Carbopol 980 gel (12.55 ± 1.41 µg/sq.cm), and CMC gel (10.09 ± 1.23 µg/sq.cm) at 24 h. Optimized formulation showed significant protection against lewisite surrogate phenyl arsine oxide (PAO) challenged skin injury in Ptch1+/-/SKH-1 hairless mice at gross and molecular levels. A reduction in Draize score by 29%, a reduction in skin bifold thickness by 8%, a significant reduction in levels of IL-1β, IL6, and GM-CSF by 54%, 30%, and 55%, respectively, and a reduction in apoptosis by 31% was observed. Thus, the translational feasibility of 4-PBA microsponges for effective, sustained delivery against lewisite skin injury is demonstrated.
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Affiliation(s)
- Sharvari M Kshirsagar
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, 3001 Mercer University Drive, Atlanta, GA 30341, USA
| | - Nethra Viswaroopan
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, 3001 Mercer University Drive, Atlanta, GA 30341, USA
| | - Meheli Ghosh
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, 3001 Mercer University Drive, Atlanta, GA 30341, USA
| | - Mohammad Shajid Ashraf Junaid
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, 3001 Mercer University Drive, Atlanta, GA 30341, USA
| | - Safiya Haque
- Department of Dermatology, University of Alabama at Birmingham, UAB Research Center of Excellence in Arsenicals, Birmingham, AL, USA
| | - Jasim Khan
- Department of Dermatology, University of Alabama at Birmingham, UAB Research Center of Excellence in Arsenicals, Birmingham, AL, USA
| | - Suhail Muzaffar
- Department of Dermatology, University of Alabama at Birmingham, UAB Research Center of Excellence in Arsenicals, Birmingham, AL, USA
| | - Ritesh K Srivastava
- Department of Dermatology, University of Alabama at Birmingham, UAB Research Center of Excellence in Arsenicals, Birmingham, AL, USA
| | - Mohammad Athar
- Department of Dermatology, University of Alabama at Birmingham, UAB Research Center of Excellence in Arsenicals, Birmingham, AL, USA
| | - Ajay K Banga
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, 3001 Mercer University Drive, Atlanta, GA 30341, USA.
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Shrestha N, Karve T, Kipping T, Banga AK. Fabrication of Poly Lactic- co-Glycolic Acid Microneedles for Sustained Delivery of Lipophilic Peptide-Carfilzomib. Mol Pharm 2024; 21:5192-5204. [PMID: 39255036 DOI: 10.1021/acs.molpharmaceut.4c00593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
Transdermal drug delivery (TDD) is an attractive route of administration, providing several advantages, especially over oral and parenteral routes. However, TDD is significantly restricted due to the barrier imposed by the uppermost layer of the skin, the stratum corneum (SC). Microneedles is a physical enhancement technique that efficiently pierces the SC and facilitates the delivery of both lipophilic and hydrophilic molecules. Dissolving microneedles is a commonly used type that is fabricated utilizing various biodegradable and biocompatible polymers, such as polylactic acid, polyglycolic acid, or poly(lactide-co-glycolide) (PLGA). Such polymers also promote the prolonged release of the drug due to the slow degradation of the polymer matrix following its insertion. We selected carfilzomib, a small therapeutic peptide (MW: 719.924 g/mol, log P 4.19), as a model drug to fabricate a microneedle-based sustained delivery system. This study is a proof-of-concept investigation in which we fabricated PLGA microneedles using four types of PLGA (50-2A, 50-5A, 75-5A, and 50-7P) to evaluate the feasibility of long-acting transdermal delivery of carfilzomib. Micromolding technique was used to fabricate the PLGA microneedles and characterization tests, including Fourier transform infrared spectroscopy, insertion capability using the skin simulant Parafilm model, histological evaluation, scanning electron microscopy, and confocal microscopy were conducted. In vitro release and permeation testing were conducted in vertical Franz diffusion cells. N-methyl pyrrolidone was utilized as the organic solvent and microneedles were solidified in controlled conditions, which led to good mechanical strength. Both in vitro release and permeation testing showed sustained profiles of carfilzomib over 7 days. The release and permeation were significantly influenced by the molecular weight of PLGA and the lipophilic properties of carfilzomib.
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Affiliation(s)
- Nisha Shrestha
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, Georgia 30341, United States
| | - Tanvi Karve
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, Georgia 30341, United States
| | - Thomas Kipping
- MilliporeSigma a Business of Merck KGaA, Frankfurter Strasse 250, 64293 Darmstadt, Germany
| | - Ajay K Banga
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, Georgia 30341, United States
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Nguyen-Thi PT, Vo TK, Le HT, Nguyen NTT, Nguyen TT, Van Vo G. Translation from Preclinical Research to Clinical Trials: Transdermal Drug Delivery for Neurodegenerative and Mental Disorders. Pharm Res 2024; 41:1045-1092. [PMID: 38862719 DOI: 10.1007/s11095-024-03718-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/19/2024] [Indexed: 06/13/2024]
Abstract
Neurodegenerative diseases (NDs), particularly dementia, provide significant problems to worldwide healthcare systems. The development of therapeutic materials for various diseases has a severe challenge in the form of the blood-brain barrier (BBB). Transdermal treatment has recently garnered widespread favor as an alternative method of delivering active chemicals to the brain. This approach has several advantages, including low invasiveness, self-administration, avoidance of first-pass metabolism, preservation of steady plasma concentrations, regulated release, safety, efficacy, and better patient compliance. Topics include the transdermal method for therapeutic NDs, their classification, and the mechanisms that allow the medicine to enter the bloodstream through the skin. The paper also discusses the obstacles and potential outcomes of transdermal therapy, emphasizing the benefits and drawbacks of different approaches.
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Affiliation(s)
| | - Tuong Kha Vo
- Department of Sports Medicine, University of Medicine and Pharmacy (VNU-UMP), Vietnam National University Hanoi, Hanoi, 100000, Vietnam
| | - Huong Thuy Le
- Faculty of Pharmacy, Ton Duc Thang University, Ho Chi Minh City, 700000, Vietnam
| | - Nhat Thang Thi Nguyen
- Faculty of Chemical Engineering, Industrial University of Ho Chi Minh City, Ho Chi Minh City, 71420, Vietnam.
| | - Thuy Trang Nguyen
- Faculty of Chemical Engineering, Industrial University of Ho Chi Minh City, Ho Chi Minh City, 71420, Vietnam
| | - Giau Van Vo
- Degenerative Diseases Program, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, 92037, USA.
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Karve T, Banga AK. Comparative evaluation of physical and chemical enhancement techniques for transdermal delivery of linagliptin. Int J Pharm 2024; 654:123992. [PMID: 38479485 DOI: 10.1016/j.ijpharm.2024.123992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/20/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
Linagliptin is a dipeptidyl peptidase-4 inhibitor used for the management of type-2 diabetes. US FDA-approved products are available exclusively as oral tablets. The inherent drawbacks of the oral administration route necessitate exploring delivery strategies via other routes. In this study, we investigated the feasibility of transdermal administration of linagliptin through various approaches. We compared chemical penetration enhancers (oleic acid, oleyl alcohol, and isopropyl myristate) and physical enhancement techniques (iontophoresis, sonophoresis, microneedles, laser, and microdermabrasion) to understand their potential to improve transdermal delivery of linagliptin. To our knowledge, this is the first reported comparison of chemical and physical enhancement techniques for the transdermal delivery of a moderately lipophilic molecule. All physical enhancement techniques caused a significant reduction in the transepithelial electrical resistance of the skin samples. Disruption of the skin's structure post-treatment with physical enhancement techniques was further confirmed using characterization techniques such as dye binding, histology, and confocal microscopy. In vitro permeation testing (IVPT) demonstrated that the passive delivery of linagliptin across the skin was < 5 µg/sq.cm. Two penetration enhancers - oleic acid (93.39 ± 8.34 µg/sq.cm.) and oleyl alcohol (424.73 ± 42.86 µg/sq.cm.), and three physical techniques - iontophoresis (53.05 ± 0.79 µg/sq.cm.), sonophoresis (141.13 ± 34.22 µg/sq.cm.), and laser (555.11 ± 78.97 µg/sq.cm.) exceeded the desired target delivery for therapeutic effect. This study established that linagliptin is an excellent candidate for transdermal delivery and thoroughly compared chemical penetration and physical transdermal delivery strategies.
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Affiliation(s)
- Tanvi Karve
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, USA
| | - Ajay K Banga
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA 30341, USA.
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Datta D, Noor A, Rathee A, Singh S, Kohli K. Hypothesizing the Oleic Acid-Mediated Enhanced and Sustained Transdermal Codelivery of Pregabalin and Diclofenac Adhesive Nanogel: A Proof of Concept. Curr Mol Med 2024; 24:1317-1328. [PMID: 38847251 DOI: 10.2174/0115665240291343240306054318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/29/2024] [Accepted: 02/22/2024] [Indexed: 10/19/2024]
Abstract
Pregabalin (PG) and diclofenac diethylamine (DEE) are anti-inflammatory molecules that are effective in relieving inflammation and pain associated with musculoskeletal disorders, arthritis, and post-traumatic pain, among others. Intravenous and oral delivery of these two molecules has their limitations. However, the transdermal route is believed to be an alternate viable option for the delivery of therapeutic molecules with desired physicochemical properties. To this end, it is vital to understand the physicochemical properties of these drugs, dosage, and strategies to enhance permeation, thereby surmounting the associated constraints and concurrently attaining a sustained release of these therapeutic molecules when administered in combination. The present work hypothesizes the enhanced permeation and sustained release of pregabalin and diclofenac diethylamine across the skin, entrapped in the adhesive nano-organogel formulation, including permeation enhancers. The solubility studies of pregabalin and diclofenac diethylamine in combination were performed in different permeation enhancers. Oleic acid was optimized as the best permeation enhancer based on in vitro studies. Pluronic organogel containing pregabalin and diclofenac diethylamine with oleic acid was fabricated. Duro-Tak® (87-2196) was added to the organogel formulation as a pressure-sensitive adhesive to sustain the release profile of these two therapeutic molecules. The adhesive organogel was characterized for particle size, scanning electron microscopy, and contact angle measurement. The HPLC method developed for the quantification of the dual drug showed a retention time of 3.84 minutes and 9.69 minutes for pregabalin and diclofenac, respectively. The fabricated nanogel adhesive formulation showed the desired results with particle size and contact angle of 282 ± 57 nm and ≥120⁰, respectively. In vitro studies showed the percentage cumulative release of 24.90 ± 4.65% and 33.29 ± 4.81% for pregabalin and diclofenac, respectively. In order to accomplish transdermal permeation, the suggested hypothesis of fabricating PG and DEE nano-organogel in combination with permeation enhancers will be a viable drug delivery method. In comparison to a traditional gel formulation, oleic acid as a permeation enhancer increased the penetration of both PG and DEE from the organogel formulation. Notably, the studies showed that the use of pressure-sensitive adhesives enabled the sustained release of both PG and DEE.Therefore, the results anticipated the hypothesis that the transdermal delivery of adhesive PG and DEEbased nanogel across the human skin can be achieved to inhibit inflammation and pain.
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Affiliation(s)
- Deepanjan Datta
- Department of Pharmaceutics, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal 576104, Karnataka State, India
| | - Afeefa Noor
- Department of Pharmacy, Lloyd Institute of Management and Technology, Plot No.11, Knowledge Park-II, Greater Noida 201306, Uttar Pradesh, India
| | - Anjali Rathee
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Snigdha Singh
- Department of Pharmacy, Lloyd Institute of Management and Technology, Plot No.11, Knowledge Park-II, Greater Noida 201306, Uttar Pradesh, India
| | - Kanchan Kohli
- Department of Pharmacy, Lloyd Institute of Management and Technology, Plot No.11, Knowledge Park-II, Greater Noida 201306, Uttar Pradesh, India
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
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Kshirsagar S, Dandekar A, Srivastava RK, Khan J, Muzaffar S, Athar M, Banga AK. Microneedle-mediated transdermal delivery of N-acetyl cysteine as a potential antidote for lewisite injury. Int J Pharm 2023; 647:123547. [PMID: 37884214 PMCID: PMC10872459 DOI: 10.1016/j.ijpharm.2023.123547] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 10/28/2023]
Abstract
Lewisite is a chemical warfare agent intended for use in World War and a potential threat to the civilian population due to presence in stockpiles or accidental exposure. Lewisite-mediated skin injury is characterized by acute erythema, pain, and blister formation. N-acetyl cysteine (NAC) is an FDA-approved drug for acetaminophen toxicity, identified as a potential antidote against lewisite. In the present study, we have explored the feasibility of rapid NAC delivery through transdermal route for potentially treating chemical warfare toxicity. NAC is a small, hydrophilic molecule with limited passive delivery through the skin. Using skin microporation with dissolving microneedles significantly enhanced the delivery of NAC into and across dermatomed human skin in our studies. Microporation followed by application of solution (poke-and-solution) resulted in the highest in vitro delivery (509.84 ± 155.04 µg/sq·cm) as compared to poke-and-gel approach (474.91 ± 70.09 µg/sq·cm) and drug-loaded microneedles (226.89 ± 33.41 µg/sq·cm). The lag time for NAC delivery through poke-and-solution approach (0.23 ± 0.04 h) was close to gel application (0.25 ± 0.02 h), with the highest for drug-loaded microneedles (1.27 ± 1.16 h). Thus, we successfully demonstrated the feasibility of rapid NAC delivery using various skin microporation approaches for potential treatment against lewisite-mediated skin toxicity.
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Affiliation(s)
- Sharvari Kshirsagar
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, USA
| | - Amruta Dandekar
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, USA
| | - Ritesh K Srivastava
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jasim Khan
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Suhail Muzaffar
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mohammad Athar
- UAB Research Center of Excellence in Arsenicals, Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ajay K Banga
- Center for Drug Delivery Research, Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, USA.
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Hartmann AK, Bartneck J, Pielenhofer J, Meiser SL, Arnold-Schild D, Klein M, Stassen M, Schild H, Muth S, Probst HC, Langguth P, Grabbe S, Radsak MP. Optimized dithranol-imiquimod-based transcutaneous immunization enables tumor rejection. Front Immunol 2023; 14:1238861. [PMID: 37727790 PMCID: PMC10505723 DOI: 10.3389/fimmu.2023.1238861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/11/2023] [Indexed: 09/21/2023] Open
Abstract
Introduction Transcutaneous immunization (TCI) is a non-invasive vaccination method promoting strong cellular immune responses, crucial for the immunological rejection of cancer. Previously, we reported on the combined application of the TLR7 agonist imiquimod (IMQ) together with the anti-psoriatic drug dithranol as novel TCI platform DIVA (dithranol/IMQ based vaccination). In extension of this work, we further optimized DIVA in terms of drug dose, application pattern and established a new IMQ formulation. Methods C57BL/6 mice were treated on the ear skin with dithranol and IMQ-containing ointments together with ovalbumin-derived peptides. T cell responses were determined by flow cytometry and IFN-ɤ ELISpot assay, local skin inflammation was characterized by ear swelling. Results Applying the adjuvants on separate skin sites, a reduced number of specific CD8+ T cells with effector function was detectable, indicating that the local concurrence of adjuvants and peptide antigens is required for optimal vaccination. Likewise, changing the order of dithranol and IMQ resulted in an increased skin inflammatory reaction, but lower frequencies of antigen-specific CD8+ T cells indicating that dithranol is essential for superior T cell priming upon DIVA. Dispersing nanocrystalline IMQ in a spreadable formulation (IMI-Sol+) facilitated storage and application rendering comparable immune responses. DIVA applied one or two weeks after the first immunization resulted in a massive increase in antigen-specific T cells and up to a ten-fold increased memory response. Finally, in a prophylactic tumor setting, double but no single DIVA treatment enabled complete control of tumor growth, resulting in full tumor protection. Discussion Taken together, the described optimized transcutaneous vaccination method leads to the generation of a strong cellular immune response enabling the effective control of tumor growth and has the potential for clinical development as a novel non-invasive vaccination method for peptide-based cancer vaccines in humans.
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Affiliation(s)
- Ann-Kathrin Hartmann
- IIIrd Department of Medicine – Hematology and Oncology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Joschka Bartneck
- IIIrd Department of Medicine – Hematology and Oncology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jonas Pielenhofer
- Biopharmaceutics and Pharmaceutical Technology, Institute of Pharmacy and Biochemistry, Johannes Gutenberg-University, Mainz, Germany
| | - Sophie Luise Meiser
- Biopharmaceutics and Pharmaceutical Technology, Institute of Pharmacy and Biochemistry, Johannes Gutenberg-University, Mainz, Germany
| | - Danielle Arnold-Schild
- Institute of Immunology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Matthias Klein
- Institute of Immunology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Michael Stassen
- Institute of Immunology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Hansjörg Schild
- Institute of Immunology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Mainz Research School of Translational Biomedicine (TransMed), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Sabine Muth
- Institute of Immunology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Hans Christian Probst
- Institute of Immunology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter Langguth
- Biopharmaceutics and Pharmaceutical Technology, Institute of Pharmacy and Biochemistry, Johannes Gutenberg-University, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Stephan Grabbe
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Mainz Research School of Translational Biomedicine (TransMed), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Markus P. Radsak
- IIIrd Department of Medicine – Hematology and Oncology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Mainz Research School of Translational Biomedicine (TransMed), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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