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Tang Y, Wei Y, Ye Z, Qin C. Th1, Th17, CXCL16 and homocysteine elevated after intracranial and cervical stent implantation. Int J Neurosci 2016; 127:701-708. [PMID: 27669631 DOI: 10.1080/00207454.2016.1241249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The presence of Th1 and Th17 cells has been observed as major inducers in inflammation and immune responses associated stenting. However, there is rare data on the impact of Th1, Th17, CXCL16 and homocysteine after cerebral stent implantation. Here, we performed the statistical analysis to first evaluate the variation of the Th17and Th1 cells and their related cytokines, CXCL16 and homocysteine in the peripheral blood of patients with cerebral stenting. The flow cytometry was used to detect the proportion of Th1 and Th17 cells in peripheral blood mononuclear cells (PBMCs). The enzyme-linked immunosorbent assay was used to measure the serum concentrations of IFN-γ, IL-17 and CXCL16. Plasma homocysteine was examined by immunoturbidimetry. The level of Th1, CXCL16 and homocysteine showed an increase at 3 d, followed by the continuous decrease at 7 d and 3 months. The frequency of Th17 cells increased to a peak at three days, and subsequently decreased with a higher level than baseline. Our data revealed that the variation in Th1, Th17, CXCL16 and homocysteine in peripheral blood of patients with stenting may be implicated in inflammation after intracranial and cervical stent implantation. A better understanding of these factors will provide help for further drug design and clinical therapy.
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Affiliation(s)
- Yanyan Tang
- a Department of Neurology , The First Affiliated Hospital, Guangxi Medical University , Nanning , China
| | - Yunfei Wei
- a Department of Neurology , The First Affiliated Hospital, Guangxi Medical University , Nanning , China
| | - Ziming Ye
- a Department of Neurology , The First Affiliated Hospital, Guangxi Medical University , Nanning , China
| | - Chao Qin
- a Department of Neurology , The First Affiliated Hospital, Guangxi Medical University , Nanning , China
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2
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Smirnova NF, Gayral S, Pedros C, Loirand G, Vaillant N, Malet N, Kassem S, Calise D, Goudounèche D, Wymann MP, Hirsch E, Gadeau AP, Martinez LO, Saoudi A, Laffargue M. Targeting PI3Kγ activity decreases vascular trauma-induced intimal hyperplasia through modulation of the Th1 response. ACTA ACUST UNITED AC 2014; 211:1779-92. [PMID: 25073791 PMCID: PMC4144742 DOI: 10.1084/jem.20131276] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Interventional strategies to treat atherosclerosis, such as transluminal angioplasty and stent implantation, often cause vascular injury. This leads to intimal hyperplasia (IH) formation that induces inflammatory and fibroproliferative processes and ultimately restenosis. We show that phosphoinositide 3-kinase γ (PI3Kγ) is a key player in IH formation and is a valid therapeutic target in its prevention/treatment. PI3Kγ-deficient mice and mice expressing catalytically inactive PI3Kγ (PI3Kγ KD) showed reduced arterial occlusion and accumulation of monocytes and T cells around sites of vascular lesion. The transfer of PI3Kγ KD CD4(+) T cells into Rag2-deficient mice greatly reduced vascular occlusion compared with WT cells, clearly demonstrating the involvement of PI3Kγ in CD4(+) T cells during IH formation. In addition we found that IH is associated with increased levels of Th1 and Th17 cytokines. A specific decrease in the Th1 response was observed in the absence of PI3Kγ activity, leading to decreased CXCL10 and RANTES production by smooth muscle cells. Finally, we show that treatment with the PI3Kγ inhibitor AS-605240 is sufficient to decrease IH in both mouse and rat models, reinforcing the therapeutic potential of PI3Kγ inhibition. Altogether, these findings demonstrate a new role for PI3Kγ activity in Th1-controlled IH development.
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Affiliation(s)
- Natalia F Smirnova
- INSERM, UMR1048, F-31300 Toulouse, France Université Toulouse III, Institut de Maladies Métaboliques et Cardiovasculaires, F-31300 Toulouse, France
| | - Stéphanie Gayral
- INSERM, UMR1048, F-31300 Toulouse, France Université Toulouse III, Institut de Maladies Métaboliques et Cardiovasculaires, F-31300 Toulouse, France
| | - Christophe Pedros
- INSERM, UMR1043, F-31300 Toulouse, France UMR CNRS, U5282, F-31300 Toulouse, France Université de Toulouse, UPS, Centre de Physiopathologie de Toulouse Purpan (CPTP), F-31300 Toulouse, France
| | - Gervaise Loirand
- INSERM, UMR1087, F-44007 Nantes, France CNRS 6291, F-44007 Nantes, France
| | - Nathalie Vaillant
- INSERM, UMR1087, F-44007 Nantes, France CNRS 6291, F-44007 Nantes, France
| | - Nicole Malet
- INSERM, UMR1048, F-31300 Toulouse, France Université Toulouse III, Institut de Maladies Métaboliques et Cardiovasculaires, F-31300 Toulouse, France
| | - Sahar Kassem
- INSERM, UMR1043, F-31300 Toulouse, France UMR CNRS, U5282, F-31300 Toulouse, France Université de Toulouse, UPS, Centre de Physiopathologie de Toulouse Purpan (CPTP), F-31300 Toulouse, France
| | - Denis Calise
- INSERM, UMR1048, F-31300 Toulouse, France Université Toulouse III, Institut de Maladies Métaboliques et Cardiovasculaires, F-31300 Toulouse, France
| | - Dominique Goudounèche
- Université Toulouse III, Institut de Maladies Métaboliques et Cardiovasculaires, F-31300 Toulouse, France CMEAB, F-31000 Toulouse, France
| | - Matthias P Wymann
- Institute of Biochemistry and Genetics, University of Basel, 4058 Basel, Switzerland
| | - Emilio Hirsch
- Molecular Biotechnology Center, Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Turin, Italy
| | | | - Laurent O Martinez
- INSERM, UMR1048, F-31300 Toulouse, France Université Toulouse III, Institut de Maladies Métaboliques et Cardiovasculaires, F-31300 Toulouse, France
| | - Abdelhadi Saoudi
- INSERM, UMR1043, F-31300 Toulouse, France UMR CNRS, U5282, F-31300 Toulouse, France Université de Toulouse, UPS, Centre de Physiopathologie de Toulouse Purpan (CPTP), F-31300 Toulouse, France
| | - Muriel Laffargue
- INSERM, UMR1048, F-31300 Toulouse, France Université Toulouse III, Institut de Maladies Métaboliques et Cardiovasculaires, F-31300 Toulouse, France
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3
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Murayama H, Takahashi M, Takamoto M, Shiba Y, Ise H, Koyama J, Tagawa YI, Iwakura Y, Ikeda U. Deficiency of tumour necrosis factor-alpha and interferon-gamma in bone marrow cells synergistically inhibits neointimal formation following vascular injury. Cardiovasc Res 2008; 80:175-80. [PMID: 18791204 DOI: 10.1093/cvr/cvn250] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Neointimal formation after percutaneous coronary intervention (PCI), termed restenosis, limits therapeutic revascularization. Since it is now known that vascular injury involves an inflammatory response, we examined the role of tumour necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) in the neointimal formation after injury. METHODS AND RESULTS Control (BALB/c), TNF-alpha-deficient (Tnf(-/-)), IFN-gamma-deficient (Ifng(-/-)), or double-deficient (Tnf(-/-)Ifng(-/-)) mice were subjected to wire-mediated vascular injury of the right femoral artery. Neointimal formation after injury was significantly reduced after the injury in the Tnf(-/-)Ifng(-/-) mice, compared to that in the control, Tnf(-/-), and Ifng(-/-) mice. Immunohistochemical analysis showed that TNF-alpha and IFN-gamma were expressed in neointimal lesions in the control mice, but not in mice with deficiency of the corresponding cytokine. No significant difference in re-endothelialization was observed among these groups. The number of proliferating cell nuclear antigen in the neointimal lesions was significantly decreased in the Tnf(-/-)Ifng(-/-) mice. Bone marrow transplantation experiments revealed that deficiency of TNF-alpha and IFN-gamma specifically in bone marrow cells significantly inhibited neointimal formation after vascular injury. CONCLUSION The absence of TNF-alpha and IFN-gamma in bone marrow cells synergistically inhibits neointimal formation following vascular injury, and thus, may provide new insights into the mechanisms underlying restenosis after PCI.
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Affiliation(s)
- Hideki Murayama
- Department of Cardiovascular Medicine, Shinshu University Graduate School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
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4
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Slade HB. Monthly Update: Biologicals & Immunologicals: Small molecule cytokine inducers. Expert Opin Investig Drugs 2008. [DOI: 10.1517/13543784.5.6.763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Herbert B Slade
- Immunology Section & Department of Pediatrics, Medical Affairs, Children's Hospital of Philadelphia, 3M Pharmaceuticals
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5
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Abstract
More than 1 million percutaneous coronary interventions (PCIs) are performed yearly worldwide. Restenosis is the recurrent narrowing that can occur within 6 months following an initially successful PCI. Although drug-eluting stents have accomplished remarkable success, restenosis has not been eliminated and optimisation of both the polymers and drugs associated with them is desirable. This article reviews the presently available and potential preventive approaches against restenosis, including the sirolimus and paclitaxel drug-eluting stents.
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Affiliation(s)
- Pierre-Frédéric Keller
- Montreal Heart Institute, Department of Medicine, 5000 Belanger Street, Montreal, Canada
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6
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Gabeler EEE, van Hillegersberg R, Statius van Eps RG, Sluiter W, Mulder P, van Urk H. Endovascular photodynamic therapy with aminolaevulinic acid prevents balloon induced intimal hyperplasia and constrictive remodelling. Eur J Vasc Endovasc Surg 2002; 24:322-31. [PMID: 12323175 DOI: 10.1053/ejvs.2002.1723] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVE intimal hyperplasia (IH) and constrictive remodelling are important causes of restenosis following endovascular interventions, such as percutaneous transluminal angioplasty. Photodynamic therapy (PDT) with 5-aminolaevulinic (ALA) may prevent restenosis by cellular depletion and the elimination of cholinergic innervation. STUDY DESIGN/MATERIALS AND METHODS rats (n=90) were subdivided into 4 main groups. In the experimental group (n=36: 3 replications x 4 doses x 3 examination time-points), ALA was administered (200mg/kg i.v.) 2-3h before balloon injury (BI) of the common iliac artery followed by endovascular illumination with 633nm at either 12.5, 25, 50 or 100J/cm diffuser length (dl BI+PDT group). As control groups served the BI+Light only (LO) group (n=36) that received no ALA, the BI only group (n=9) (BI), and a group (n=9) that received a Sham procedure (Sham group). RESULTS planimetric analysis showed IH of 0.28+/-0.12mm(2) (BI), 0.27+/-0.12mm(2) (BI+LO at 100J/cmdl) in contrast to 0.02+/-0.02mm(2) after BI+PDT at 100J/cmdl at 16 weeks (p<0.05). In the BI+PDT groups, a light-dose increase of a factor 2 led to an IH decrease of 17% (p<0.05). In the BI and BI+LO groups constrictive remodelling was found, in contrast to BI+PDT treated groups at 16 weeks. The staining of cholinergic innervation of the tunic media of the blood vessel wall in BI+PDT showed no damage at the highest fluence. CONCLUSION endovascular ALA-PDT prevents IH and constrictive remodelling after BI without damage of cholinergic innervation of the tunica media. The effective light fluence rate in the rat is 50-100J/cmdl.
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Affiliation(s)
- E E E Gabeler
- Department of Surgery, University Hospital Rotterdam-Dijkzigt, Erasmus MC, Room H928, Dr Molewaterplein 40, 3015 GE Rotterdam, The Netherlands
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7
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Kipshidze N, Moussa I, Nikolaychik V, Chekanov V, Khanna A, Colombo A, Leon MB, Moses J. Influence of Class I interferons on performance of vascular cells on stent material in vitro. CARDIOVASCULAR RADIATION MEDICINE 2002; 3:82-90. [PMID: 12699837 DOI: 10.1016/s1522-1865(02)00155-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Numerous reports suggest that Class 1 interferons (IFNs), particularly IFN-gamma, inhibit migration and proliferation of different types of human cells. The objective of the present study was to determine the effect of Class I IFNs on viability and growth characteristics of human aortic endothelial cells (ECs), smooth muscle cells (SMC) and fibroblasts (FBs) in vitro. METHODS Stainless-steel (316-l) disks were coated with fibrin meshwork containing IFN-gamma or IFN-alpha. The discs and IFN embedded meshwork were incubated with human EC, SMC and FB, and then cultured, whereas control cells were seeded onto uncoated surfaces or plain fibrin meshwork. Concentrations of recombinant IFN varied from 5 to 20 ng/cm(2). Assessment of effect on cell viability, growth and attachment was performed utilizing Alamar Blue (AB) assay. Cell morphology was assessed by scanning electron microscopy (SEM). RESULTS We have now shown inhibitory capacity of IFN-gamma on all three types of unstimulated cells. The growth-inhibitory effect was maximal with SMC, while it was minimal with FB and EC. IFN-gamma abrogated mitogenic responses of SMC but not EC and partially FB to VEGF and FGF stimulation. IFN-alpha was able to inhibit EC growth and, to a lesser extent, FB, and did influence growth rates of SMC. Biochemical analysis of lactate dehydrogenase activity suggested that IFN was not toxic to vascular cells. We also measured the expression of cell adhesive molecules: P- and E-selections, PECAM and ICAM-1. These molecules were upregulated by IFN in EC. Media derived from quiescent human SMC displayed low immunoreactive elastase activity, while conditional media after IFN-gamma treatment but not IFN-alpha treatment had approximately a threefold greater activity. CONCLUSION These data suggest that IFN-gamma significantly inhibits SMC growth in the absence of significant endothelial toxicity and is dose-dependent; however, animal experiments are needed to further explore the antirestenotic effects of IFNs.
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Affiliation(s)
- Nicholas Kipshidze
- Lenox Hill Heart and Vascular Institute and Cardiovascular Research Foundation, New York, NY 10021, USA.
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8
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Meuwissen M, Piek JJ, van der Wal AC, Chamuleau SA, Koch KT, Teeling P, van der Loos CM, Tijssen JG, Becker AE. Recurrent unstable angina after directional coronary atherectomy is related to the extent of initial coronary plaque inflammation. J Am Coll Cardiol 2001; 37:1271-6. [PMID: 11300434 DOI: 10.1016/s0735-1097(01)01133-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study was performed to evaluate the relationship between plaque inflammation of the initial culprit lesion and the incidence of recurrent angina for one year after directional coronary atherectomy (DCA). BACKGROUND A positive correlation between coronary plaque inflammation and angiographic restenosis has been reported. METHODS A total of 110 patients underwent DCA. Cryostat sections were immunohistochemically stained with monoclonal antibodies CD68 (macrophages), CD-3 (T lymphocytes) and alpha-actin (smooth muscle cells [SMCs]). The SMC and macrophage contents were planimetrically quantified as a percentage of the total tissue area. T lymphocytes were counted as the number of cells/mm2. The patients were followed for one year to document recurrent unstable angina pectoris (UAP) or stable angina pectoris (SAP). RESULTS Recurrent UAP developed in 16 patients, whereas recurrent SAP developed in 17 patients. The percent macrophage areas were larger in patients with recurrent UAP (27 +/- 12%) than in patients with recurrent SAP (8 +/- 4%; p = 0.0001) and those without recurrent angina (18 +/- 14%; p = 0.03). The number of T lymphocytes was also greater in patients with recurrent UAP (25 +/- 14 cells/mm2) than in patients with recurrent SAP (14 +/- 8 cells/mm2; p = 0.02) and those without recurrent angina (14 +/- 12 cells/mm2; p = 0.002). Multiple stepwise logistic regression analysis identified macrophage areas and T lymphocytes as independent predictors for recurrent UAP. CONCLUSIONS There is a positive association between the extent of initial coronary plaque inflammation and the recurrence of unstable angina during long-term follow-up after DCA. These results underline the role of ongoing smoldering plaque inflammation in the recurrence of unstable angina after coronary interventions.
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Affiliation(s)
- M Meuwissen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, The Netherlands
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9
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DEV NAGENDUB, HOFMANN GÜNTERA, DEV SUKHENDUB, RABUSSAY DIETMARP. Intravascular Electroporation Markedly Attenuates Neointima Formation After Balloon Injury of the Carotid Artery in the Rat. J Interv Cardiol 2000. [DOI: 10.1111/j.1540-8183.2000.tb00311.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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10
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Tellides G, Tereb DA, Kirkiles-Smith NC, Kim RW, Wilson JH, Schechner JS, Lorber MI, Pober JS. Interferon-gamma elicits arteriosclerosis in the absence of leukocytes. Nature 2000; 403:207-11. [PMID: 10646607 DOI: 10.1038/35003221] [Citation(s) in RCA: 313] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atherosclerosis and post-transplant graft arteriosclerosis are both characterized by expansion of the arterial intima as a result of the infiltration of mononuclear leukocytes, the proliferation of vascular smooth muscle cells (VSMCs) and the accumulation of extracellular matrix. They are also associated with the presence of the immunomodulatory cytokine interferon-gamma (IFN-gamma). Moreover, in mouse models of atheroma formation or allogeneic transplantation, the serological neutralization or genetic absence of IFN-gamma markedly reduces the extent of intimal expansion. However, other studies have found that exogenous IFN-gamma inhibits cultured VSMC proliferation and matrix synthesis, and reduces intimal expansion in response to mechanical injury. This discrepancy is generally explained by the idea that IFN-gamma either directly activates macrophages, or, by increasing antigen presentation, indirectly activates T cells within the lesions of atherosclerosis and graft arteriosclerosis. These activated leukocytes are thought to express the VSMC-activating cytokines and cell-surface molecules that cause the observed arteriosclerotic responses. Here we have inserted pig and human arteries into the aorta of immunodeficient mice, and we show that IFN-gamma can induce arteriosclerotic changes in the absence of detectable immunocytes by acting on VSMCs to potentiate growth-factor-induced mitogenesis.
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MESH Headings
- Adult
- Animals
- Arteriosclerosis/etiology
- Arteriosclerosis/immunology
- Cell Division/physiology
- Cells, Cultured
- Coronary Vessels/transplantation
- Histocompatibility Antigens/biosynthesis
- Humans
- Image Processing, Computer-Assisted
- Immunohistochemistry
- Interferon-gamma/physiology
- Leukocytes/immunology
- Leukocytes/physiology
- Mice
- Mice, SCID
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/physiology
- Platelet-Derived Growth Factor/biosynthesis
- Platelet-Derived Growth Factor/physiology
- Receptor, Platelet-Derived Growth Factor beta/biosynthesis
- Receptor, Platelet-Derived Growth Factor beta/physiology
- Swine
- Transplantation, Heterologous
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Affiliation(s)
- G Tellides
- Interdepartmental Program in Vascular Biology and Transplantation, Boyer Center for Molecular Medicine, and the Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06510, USA.
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11
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Autieri MV, Agrawal N. IRT-1, a novel interferon-gamma-responsive transcript encoding a growth-suppressing basic leucine zipper protein. J Biol Chem 1998; 273:14731-7. [PMID: 9614071 DOI: 10.1074/jbc.273.24.14731] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Interferon-gamma (IFN-gamma) inhibits proliferation of vascular smooth muscle cells (VSMCs) in culture and reduces arterial restenosis post-balloon angioplasty. The identification and characterization of IFN-gamma-specific transcripts in VSMCs are an important approach to discern the molecular mechanisms underlying vascular proliferative disease. In this report, we describe IRT-1, a novel mRNA transcript constitutively expressed in a number of human tissues, but expressed in human VSMCs only when they are stimulated with IFN-gamma. This mRNA expression is induced >200-fold 72 h after IFN-gamma treatment. IRT-1 mRNA is also acutely expressed in rat carotid arteries that are injured by balloon angioplasty. The IRT-1 cDNA transcript encodes a basic protein that contains a leucine zipper motif, a core nuclear localization sequence, and a single strongly hydrophobic region. Constitutive IRT-1 mRNA expression in human peripheral blood lymphocytes is reduced when these cells are stimulated to proliferate. Overexpression of IRT-1 protein in VSMCs alters their morphology and dramatically reduces their proliferative capacity. This study suggests that IRT-1 is an IFN-gamma-inducible factor that may regulate the progression of vascular proliferative diseases.
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Affiliation(s)
- M V Autieri
- Department of Molecular Biology, Deborah Heart and Lung Research Institute, Browns Mills, New Jersey 08015, USA
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12
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Keiser JA, Uprichard AC. Restenosis: is there a pharmacologic fix in the pipeline? ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 1997; 39:313-51. [PMID: 9160119 DOI: 10.1016/s1054-3589(08)60075-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
One of the most frustrating aspects of restenosis is that it is the result of advances in medical care (there was no restenosis before the days of balloon angioplasty), yet it seems to be resistant to all that science has to offer. Still we believe there is reason to be optimistic. We are at last beginning to see some promise from clinical trials, and data being generated confirm some of the hypotheses previously generated from animal experiments. Thus the effects seen with the GP IIb/IIIa antibody 7E3 suggest that thrombosis may be as important in its long-term sequelae as it is for acute reocclusion. The jury is still out on whether antiproliferative approaches will be a therapeutic option, but local delivery paradigms using novel formulations delivered by catheter or impregnated in stents may allow the concept to be tested without the risk of systemic toxicity. Plans are also underway for gene therapy trials, although we may have to wait for better vector technology before taking these into the coronary bed. Perhaps we should move away from the "single pill" approach and accept that, like many infections, malignancies, or even heart failure, a multifaceted approach with combination therapy will provide the first glimmer of that brighter tomorrow.
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Affiliation(s)
- J A Keiser
- Parke-Davis Pharmaceutical Research, Warner Lambert Company, Ann Arbor, Michigan 48105, USA
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