1
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Ascenção K, Szabo C. Emerging roles of cystathionine β-synthase in various forms of cancer. Redox Biol 2022; 53:102331. [PMID: 35618601 PMCID: PMC9168780 DOI: 10.1016/j.redox.2022.102331] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 12/12/2022] Open
Abstract
The expression of the reverse transsulfuration enzyme cystathionine-β-synthase (CBS) is markedly increased in many forms of cancer, including colorectal, ovarian, lung, breast and kidney, while in other cancers (liver cancer and glioma) it becomes downregulated. According to the clinical database data in high-CBS-expressor cancers (e.g. colon or ovarian cancer), high CBS expression typically predicts lower survival, while in the low-CBS-expressor cancers (e.g. liver cancer), low CBS expression is associated with lower survival. In the high-CBS expressing tumor cells, CBS, and its product hydrogen sulfide (H2S) serves as a bioenergetic, proliferative, cytoprotective and stemness factor; it also supports angiogenesis and epithelial-to-mesenchymal transition in the cancer microenvironment. The current article reviews the various tumor-cell-supporting roles of the CBS/H2S axis in high-CBS expressor cancers and overviews the anticancer effects of CBS silencing and pharmacological CBS inhibition in various cancer models in vitro and in vivo; it also outlines potential approaches for biomarker identification, to support future targeted cancer therapies based on pharmacological CBS inhibition.
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2
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Gerecke C, Egea Rodrigues C, Homann T, Kleuser B. The Role of Ten-Eleven Translocation Proteins in Inflammation. Front Immunol 2022; 13:861351. [PMID: 35386689 PMCID: PMC8977485 DOI: 10.3389/fimmu.2022.861351] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 12/11/2022] Open
Abstract
Ten-eleven translocation proteins (TET1-3) are dioxygenases that oxidize 5-methyldeoxycytosine, thus taking part in passive and active demethylation. TETs have shown to be involved in immune cell development, affecting from self-renewal of stem cells and lineage commitment to terminal differentiation. In fact, dysfunction of TET proteins have been vastly associated with both myeloid and lymphoid leukemias. Recently, there has been accumulating evidence suggesting that TETs regulate immune cell function during innate and adaptive immune responses, thereby modulating inflammation. In this work, we pursue to review the current and recent evidence on the mechanistic aspects by which TETs regulate immune cell maturation and function. We will also discuss the complex interplay of TET expression and activity by several factors to modulate a multitude of inflammatory processes. Thus, modulating TET enzymes could be a novel pharmacological approach to target inflammation-related diseases and myeloid and lymphoid leukemias, when their activity is dysregulated.
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Affiliation(s)
- Christian Gerecke
- Department of Pharmacology and Toxicology, Institute of Pharmacy, Freie Universität Berlin, Germany
| | - Caue Egea Rodrigues
- Department of Pharmacology and Toxicology, Institute of Pharmacy, Freie Universität Berlin, Germany
| | - Thomas Homann
- Department of Pharmacology and Toxicology, Institute of Pharmacy, Freie Universität Berlin, Germany
| | - Burkhard Kleuser
- Department of Pharmacology and Toxicology, Institute of Pharmacy, Freie Universität Berlin, Germany
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3
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Fueyo-González F, Espinar-Barranco L, Herranz R, Alkorta I, Crovetto L, Fribourg M, Paredes JM, Orte A, González-Vera JA. Self-Assembled Lanthanide Antenna Glutathione Sensor for the Study of Immune Cells. ACS Sens 2022; 7:322-330. [PMID: 35034437 PMCID: PMC8805117 DOI: 10.1021/acssensors.1c02439] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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The small molecule
8-methoxy-2-oxo-1,2,4,5-tetrahydrocyclopenta[de]quinoline-3-carboxylic
acid (2b) behaves as a reactive non-fluorescent Michael
acceptor, which after reaction with thiols becomes fluorescent, and
an efficient Eu3+ antenna, after self-assembling with this
cation in water. This behavior makes 2b a highly selective
GSH biosensor, which has demonstrated high potential for studies in
murine and human cells of the immune system (CD4+ T, CD8+ T, and B cells) using flow cytometry. GSH can be monitored
by the fluorescence of the product of addition to 2b (445
nm) or by the luminescence of Eu3+ (592 nm). 2b was able to capture baseline differences in GSH intracellular levels
among murine and human CD4+ T, CD8+ T, and B
cells. We also successfully used 2b to monitor intracellular
changes in GSH associated with the metabolic variations governing
the induction of CD4+ naïve T cells into regulatory
T cells (TREG).
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Affiliation(s)
- Francisco Fueyo-González
- Instituto de Química Médica (CSIC), Juan de la Cierva 3, 28006 Madrid, Spain
- Department of Medicine, Translational Transplant Research Center, Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York 10029, United States
| | - Laura Espinar-Barranco
- Nanoscopy Laboratory, Departamento de Fisicoquímica, Unidad de Excelencia de Química Aplicada a Biomedicina y Medioambiente, Facultad de Farmacia, Universidad de Granada, Campus Cartuja, 18071 Granada, Spain
| | - Rosario Herranz
- Instituto de Química Médica (CSIC), Juan de la Cierva 3, 28006 Madrid, Spain
| | - Ibon Alkorta
- Instituto de Química Médica (CSIC), Juan de la Cierva 3, 28006 Madrid, Spain
| | - Luis Crovetto
- Nanoscopy Laboratory, Departamento de Fisicoquímica, Unidad de Excelencia de Química Aplicada a Biomedicina y Medioambiente, Facultad de Farmacia, Universidad de Granada, Campus Cartuja, 18071 Granada, Spain
| | - Miguel Fribourg
- Department of Medicine, Translational Transplant Research Center, Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, New York 10029, United States
| | - Jose Manuel Paredes
- Nanoscopy Laboratory, Departamento de Fisicoquímica, Unidad de Excelencia de Química Aplicada a Biomedicina y Medioambiente, Facultad de Farmacia, Universidad de Granada, Campus Cartuja, 18071 Granada, Spain
| | - Angel Orte
- Nanoscopy Laboratory, Departamento de Fisicoquímica, Unidad de Excelencia de Química Aplicada a Biomedicina y Medioambiente, Facultad de Farmacia, Universidad de Granada, Campus Cartuja, 18071 Granada, Spain
| | - Juan A. González-Vera
- Instituto de Química Médica (CSIC), Juan de la Cierva 3, 28006 Madrid, Spain
- Nanoscopy Laboratory, Departamento de Fisicoquímica, Unidad de Excelencia de Química Aplicada a Biomedicina y Medioambiente, Facultad de Farmacia, Universidad de Granada, Campus Cartuja, 18071 Granada, Spain
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4
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Lutter L, van der Wal MM, Brand EC, Maschmeyer P, Vastert S, Mashreghi M, van Loosdregt J, van Wijk F. Human regulatory T cells locally differentiate and are functionally heterogeneous within the inflamed arthritic joint. Clin Transl Immunology 2022; 11:e1420. [PMID: 36204213 PMCID: PMC9525321 DOI: 10.1002/cti2.1420] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 08/27/2022] [Accepted: 09/19/2022] [Indexed: 11/12/2022] Open
Abstract
Objective Tregs are crucial for immune regulation, and environment‐driven adaptation of effector (e)Tregs is essential for local functioning. However, the extent of human Treg heterogeneity in inflammatory settings is unclear. Methods We combined single‐cell RNA‐ and TCR‐sequencing on Tregs derived from three to six patients with juvenile idiopathic arthritis (JIA) to investigate the functional heterogeneity of human synovial fluid (SF)‐derived Tregs from inflamed joints. Confirmation and suppressive function of the identified Treg clusters was assessed by flow cytometry. Results Four Treg clusters were identified; incoming, activated eTregs with either a dominant suppressive or cytotoxic profile, and GPR56+CD161+CXCL13+ Tregs. Pseudotime analysis showed differentiation towards either classical eTreg profiles or GPR56+CD161+CXCL13+ Tregs supported by TCR data. Despite its most differentiated phenotype, GPR56+CD161+CXCL13+ Tregs were shown to be suppressive. Furthermore, BATF was identified as an overarching eTreg regulator, with the novel Treg‐associated regulon BHLHE40 driving differentiation towards GPR56+CD161+CXCL13+ Tregs, and JAZF1 towards classical eTregs. Conclusion Our study reveals a heterogeneous population of Tregs at the site of inflammation in JIA. SF Treg differentiate to a classical eTreg profile with a more dominant suppressive or cytotoxic profile that share a similar TCR repertoire, or towards GPR56+CD161+CXCL13+ Tregs with a more distinct TCR repertoire. Genes characterising GPR56+CD161+CXCL13+ Tregs were also mirrored in other T‐cell subsets in both the tumor and the autoimmune setting. Finally, the identified key regulators driving SF Treg adaptation may be interesting targets for autoimmunity or tumor interventions.
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Affiliation(s)
- Lisanne Lutter
- Center for Translational Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht Utrecht University Utrecht The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht Utrecht University Utrecht The Netherlands
| | - M Marlot van der Wal
- Center for Translational Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht Utrecht University Utrecht The Netherlands
| | - Eelco C Brand
- Center for Translational Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht Utrecht University Utrecht The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht Utrecht University Utrecht The Netherlands
| | - Patrick Maschmeyer
- Therapeutic Gene Regulation Deutsches Rheuma‐Forschungszentrum (DRFZ), an Institute of the Leibniz Association Berlin Germany
| | - Sebastiaan Vastert
- Center for Translational Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht Utrecht University Utrecht The Netherlands
| | - Mir‐Farzin Mashreghi
- Therapeutic Gene Regulation Deutsches Rheuma‐Forschungszentrum (DRFZ), an Institute of the Leibniz Association Berlin Germany
- BIH Center for Regenerative Therapies (BCRT) Berlin Institute of Health at Charité – Universitätsmedizin Berlin Charitéplatz 1 Berlin Germany
| | - Jorg van Loosdregt
- Center for Translational Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht Utrecht University Utrecht The Netherlands
| | - Femke van Wijk
- Center for Translational Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht Utrecht University Utrecht The Netherlands
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5
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Kuschman HP, Palczewski MB, Thomas DD. Nitric oxide and hydrogen sulfide: Sibling rivalry in the family of epigenetic regulators. Free Radic Biol Med 2021; 170:34-43. [PMID: 33482335 DOI: 10.1016/j.freeradbiomed.2021.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/16/2020] [Accepted: 01/06/2021] [Indexed: 01/12/2023]
Abstract
Nitric oxide (NO) and hydrogen sulfide (H2S) were previously only known for their toxic properties. Now they are regarded as potent gaseous messenger molecules (gasotransmitters) that rapidly transverse cell membranes and transduce cellular signals through their chemical reactions and modifications to protein targets. Both are known to regulate numerous physiological functions including angiogenesis, vascular tone, and immune response, to name a few. NO and H2S often work synergistically and in competition to regulate each other's synthesis, target protein activity via posttranslational modifications (PTMs), and chemical interactions. In addition to their canonical modes of action, increasing evidence has demonstrated that NO and H2S share another signaling mechanism: epigenetic regulation. This review will compare and contrast biosynthesis and metabolism of NO and H2S, their individual and shared interactions, and the growing body of evidence for their roles as endogenous epigenetic regulatory molecules.
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Affiliation(s)
- Hannah Petraitis Kuschman
- University of Illinois at Chicago, Department of Pharmaceutical Sciences, University of Illinois at Chicago, Chicago, IL, 60612, United States
| | - Marianne B Palczewski
- University of Illinois at Chicago, Department of Pharmaceutical Sciences, University of Illinois at Chicago, Chicago, IL, 60612, United States
| | - Douglas D Thomas
- University of Illinois at Chicago, Department of Pharmaceutical Sciences, University of Illinois at Chicago, Chicago, IL, 60612, United States.
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6
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Sun F, Luo JH, Yue TT, Wang FX, Yang CL, Zhang S, Wang XQ, Wang CY. The role of hydrogen sulphide signalling in macrophage activation. Immunology 2020; 162:3-10. [PMID: 32876334 PMCID: PMC7730026 DOI: 10.1111/imm.13253] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 01/05/2023] Open
Abstract
Hydrogen sulphide (H2S) is the latest identified small gaseous mediator enabled by its lipophilic nature to freely permeate the biological membranes. Initially, H2S was recognized by its roles in neuronal activity and vascular relaxation, which makes it an important molecule involved in paracrine signalling pathways. Recently, the immune regulatory function of gasotransmitters, H2S in particular, is increasingly being appreciated. Endogenous H2S level has been linked to macrophage activation, polarization and inflammasome formation. Mechanistically, H2S‐induced protein S‐sulphydration suppresses several inflammatory pathways including NF‐κB and JNK signalling. Moreover, H2S serves as a potent cellular redox regulator to modulate epigenetic alterations and to promote mitochondrial biogenesis in macrophages. Here in this review, we intend to summarize the recent advancements of H2S studies in macrophages, and to discuss with focus on the therapeutic potential of H2S donors by targeting macrophages. The feasibility of H2S signalling component as a macrophage biomarker under disease conditions would be also discussed.
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Affiliation(s)
- Fei Sun
- The Center for Biomedical Research, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
| | - Jia-Hui Luo
- The Center for Biomedical Research, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
| | - Tian-Tian Yue
- The Center for Biomedical Research, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
| | - Fa-Xi Wang
- The Center for Biomedical Research, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
| | - Chun-Liang Yang
- The Center for Biomedical Research, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
| | - Shu Zhang
- The Center for Biomedical Research, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
| | - Xin-Qiang Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
| | - Cong-Yi Wang
- The Center for Biomedical Research, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China.,Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China.,Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
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7
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Behera J, Tyagi SC, Tyagi N. Role of hydrogen sulfide in the musculoskeletal system. Bone 2019; 124:33-39. [PMID: 30928641 PMCID: PMC6570498 DOI: 10.1016/j.bone.2019.03.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/26/2019] [Accepted: 03/26/2019] [Indexed: 01/09/2023]
Abstract
Hydrogen sulfide (H2S) has been known as a gasotransmitter, and it contributes to various physiological and pathological processes. Multiple enzymes such as cystathionine-β-synthase (CBS), cystathionine-γ-lyase (CSE) and 3-Mercaptopyruvate sulfurtransferase (MST) produce endogenous H2S, and these are differentially expressed in the various tissue systems including the skeletal system. However, abnormal H2S production is associated with deregulation of the signaling cascade and imbalanced tissue homeostasis. Several studies have previously provided evidence showing the essential regulatory action of H2S in skeletal homeostasis. In this review, we have emphasized the novel function of H2S in both bone and skeletal muscle anabolism, in particular. Additionally, we also reviewed the molecular and epigenetic basis of H2S signaling in bone development and skeletal muscle function.
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Affiliation(s)
- Jyotirmaya Behera
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Suresh C Tyagi
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Neetu Tyagi
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA.
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8
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Hydrogen sulfide maintains dental pulp stem cell function via TRPV1-mediated calcium influx. Cell Death Discov 2018; 4:1. [PMID: 30062050 PMCID: PMC6060166 DOI: 10.1038/s41420-018-0071-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 02/17/2018] [Accepted: 02/20/2018] [Indexed: 12/21/2022] Open
Abstract
Hydrogen sulfide (H2S), an endogenous gasotransmitter, mediated a variety of biological processes through multiple signaling pathways, and aberrant H2S metabolism has been associated with mesenchymal stem cell (MSC) dysfunction. Here we employed the small interfering RNA treatment for cystathionine β-synthase (CBS), cystathionine γ-lyase, the main enzymes to synthesize H2S, and CBS-knockout mice to analyze the effect of H2S on dental pulp homeostasis. We showed that H2S deficiency attenuated dental pulp stem cell (DPSC) osteogenic/dentinogenic differentiation in vitro and in vivo with enhanced cell proliferation. Mechanically, H2S facilitated the transient receptor potential action channel subfamily V member 1-mediated calcium (Ca2+) influx, which subsequently activated the β-catenin pathway. While H2S deficiency decreased Ca2+, resulting in glycogen synthase kinase-3β-mediated β-catenin degradation, which controls proliferation and differentiation of DPSCs. Consistently, H2S-deficient mice displayed disturbed pattern of dental pulp and less dentin formation. In this study, we identified a previously unknown mechanism by which H2S regulates DPSC lineage determination and dental pulp homeostasis.
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9
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Liu Y, Peng W, Qu K, Lin X, Zeng Z, Chen J, Wei D, Wang Z. TET2: A Novel Epigenetic Regulator and Potential Intervention Target for Atherosclerosis. DNA Cell Biol 2018; 37:517-523. [PMID: 29653065 DOI: 10.1089/dna.2017.4118] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Atherosclerosis is the underlying cause of cardio-cerebrovascular disease. However, the mechanisms of atherosclerosis are still unclear. The modification of DNA methylation has an important role in atherosclerosis development. As a member of the Ten-eleven translocation (TET) family, TET methylcytosine dioxygenase 2 (TET2) can modify DNA methylation by catalyzing 5-methylcytosine to 5-hydroxymethylcytosine and mediate DNA demethylation. Recent findings suggest that TET2 is related to the phenotype transformation of vascular smooth muscle cells, endothelial dysfunction, and inflammation of macrophage, the key factors of atherosclerosis. Therefore, TET2 may be a potential target for atherosclerosis treatment. This review will elaborate the recent findings that suggest the role of TET2 in atherosclerosis.
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Affiliation(s)
- Yami Liu
- 1 Key Laboratory for Atherosclerology of Hunan Province, Institute of Cardiovascular Disease, University of South China , Hengyang, China
| | - Wen Peng
- 2 Department of Spine Surgery, The First Affiliated Hospital, University of South China , Hengyang, China
| | - Kai Qu
- 3 College of Bioengineering, Chongqing University , Chongqing, China
| | - Xiaolong Lin
- 4 Department of Pathology, The Third People's Hospital of Huizhou , Huizhou, China
| | - Zhaolin Zeng
- 1 Key Laboratory for Atherosclerology of Hunan Province, Institute of Cardiovascular Disease, University of South China , Hengyang, China
| | - Jiaojiao Chen
- 1 Key Laboratory for Atherosclerology of Hunan Province, Institute of Cardiovascular Disease, University of South China , Hengyang, China
| | - Dangheng Wei
- 1 Key Laboratory for Atherosclerology of Hunan Province, Institute of Cardiovascular Disease, University of South China , Hengyang, China
| | - Zuo Wang
- 1 Key Laboratory for Atherosclerology of Hunan Province, Institute of Cardiovascular Disease, University of South China , Hengyang, China
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10
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Yang R, Liu Y, Shi S. Hydrogen Sulfide Regulates Homeostasis of Mesenchymal Stem Cells and Regulatory T Cells. J Dent Res 2016; 95:1445-1451. [PMID: 27432317 DOI: 10.1177/0022034516659041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hydrogen sulfide (H2S) has long been known as a toxic gas. However, recently accumulated evidence suggests that H2S contributes to a variety of physiologic and pathologic processes. Endogenous H2S production is regulated by multiple enzymes that are differentially expressed in the cardiovascular, neuronal, immune, renal, respiratory, gastrointestinal, reproductive, liver, and endocrine systems. Alteration of H2S metabolism may affect multiple signaling pathways and tissue homeostasis. The growing number of diverse targets for which H2S serves as a gasotransmitter has been extensively reviewed elsewhere. In this review, the authors discuss current emerging evidence that H2S regulates mesenchymal stem cell and T-cell functions.
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Affiliation(s)
- R Yang
- Department of Anatomy and Cell Biology, University of Pennsylvania, School of Dental Medicine, Philadelphia, PA, USA.,Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, China
| | - Y Liu
- Laboratory of Tissue Regeneration and Immunology and Department of Periodontics, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, Capital Medical University School of Stomatology, Beijing, China
| | - S Shi
- Department of Anatomy and Cell Biology, University of Pennsylvania, School of Dental Medicine, Philadelphia, PA, USA
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