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Wang Q, Huang H, Liang P, Wang L, Zheng J, Zhang Y, Wang H. Development of PD-1 blockade peptide-cell conjugates to enhance cellular therapies for T-cell acute lymphoblastic leukemia. Med Oncol 2023; 41:14. [PMID: 38078948 DOI: 10.1007/s12032-023-02235-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] [Received: 07/22/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023]
Abstract
Blockade of the interaction of the immune checkpoint receptor programmed cell death protein (PD)-1 and its ligand PD-L1 has been found to be a promising cancer treatment. Our previous studies identified that nABPD1 competed with PD-L1 to bind PD-1. The aim of this study was to evaluate the efficacy and safety of anti-tumor immunotherapy of ICIK cells conjugated with peptides in vivo and in vitro. Here, we synthesized the nABPD1 derivatives SBP1 and SBP2 and showed that their binding efficiency to PD-1-positive improving cytokine-induced killer (ICIK) cells was 98 and 82%, respectively. The cytotoxicity of ICIK cells to T-cell acute lymphoblastic leukemia (T-ALL) cells was increased by conjugating with SBP1 or SBP2, which was 2 times higher than that of ICIK cells alone. Furthermore, mice experiments showed that the fluorescence intensity of leukemia cells in T-ALL xenograft models was reduced by more than 95%, indicating that the peptides enhanced the therapeutic effect in vivo, while morphological evaluations showed that the peptides had no toxicity to important organs. Therefore, peptide-cell conjugates (PCCs) may be a novel method to improve the efficacy of cancer immunotherapy by blocking PD-1 in T-ALL patients.
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Affiliation(s)
- Quanxiao Wang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 56 Lingyuan West Road, Guangzhou, 510055, Guangdong, China
| | - Hongxing Huang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 56 Lingyuan West Road, Guangzhou, 510055, Guangdong, China
| | - Peisheng Liang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 56 Lingyuan West Road, Guangzhou, 510055, Guangdong, China
| | - Lili Wang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 56 Lingyuan West Road, Guangzhou, 510055, Guangdong, China
| | - Junheng Zheng
- Guangzhou Yidai Pharmaceutical Co., Ltd, Guangzhou, Guangdong, China
- Zhuhai Taisujian Biotechnology Co., Ltd, Zhuhai, Guangdong, China
- Cheerland Taisujian BioPharm. Co., Ltd, Shenzhen, Guangdong, China
| | - Yan Zhang
- Laboratory of Cancer and Stem Cell Biology, Key Laboratory of Gene Engineering of the Ministry of Education, State Key Laboratory of Biocontrol, School of Life Sciences, Sun Yat-Sen University, Guangzhou Higher Education Mega Center, Guangzhou, China
| | - Hua Wang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 56 Lingyuan West Road, Guangzhou, 510055, Guangdong, China.
- Guangzhou Yidai Pharmaceutical Co., Ltd, Guangzhou, Guangdong, China.
- Zhuhai Taisujian Biotechnology Co., Ltd, Zhuhai, Guangdong, China.
- Cheerland Taisujian BioPharm. Co., Ltd, Shenzhen, Guangdong, China.
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Joshi P, Waghmare S. Molecular signaling in cancer stem cells of tongue squamous cell carcinoma: Therapeutic implications and challenges. World J Stem Cells 2023; 15:438-452. [PMID: 37342225 PMCID: PMC10277967 DOI: 10.4252/wjsc.v15.i5.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/21/2023] [Accepted: 04/07/2023] [Indexed: 05/26/2023] Open
Abstract
Head and neck squamous cell carcinoma is the seventh most common cancer worldwide with high mortality rates. Amongst oral cavity cancers, tongue carcinoma is a very common and aggressive oral cavity carcinoma. Despite the implementation of a multimodality treatment regime including surgical intervention, chemo-radiation as well as targeted therapy, tongue carcinoma shows a poor overall 5-year survival pattern, which is attributed to therapy resistance and recurrence of the disease. The presence of a rare population, i.e., cancer stem cells (CSCs) within the tumor, are involved in therapy resistance, recurrence, and distant metastasis that results in poor survival patterns. Therapeutic agents targeting CSCs have been in clinical trials, although they are unable to reach into therapy stage which is due to their failure in trials. A more detailed understanding of the CSCs is essential for identifying efficient targets. Molecular signaling pathways, which are differentially regulated in the CSCs, are one of the promising targets to manipulate the CSCs that would provide an improved outcome. In this review, we summarize the current understanding of molecular signaling associated with the maintenance and regulation of CSCs in tongue squamous cell carcinoma in order to emphasize the need of the hour to get a deeper understanding to unravel novel targets.
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Affiliation(s)
- Priyanka Joshi
- Stem Cell Biology Group, Cancer Research Institute, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai 410210, India
| | - Sanjeev Waghmare
- Stem Cell Biology Group, Cancer Research Institute, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai 410210, India
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Chen Y, Huang H, Liu Y, Wang Z, Wang L, Wang Q, Zhang Y, Wang H. Engineering a High-Affinity PD-1 Peptide for Optimized Immune Cell-Mediated Tumor Therapy. Cancer Res Treat 2021; 54:362-374. [PMID: 34352997 PMCID: PMC9016318 DOI: 10.4143/crt.2021.424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/02/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose The purpose of this study was to optimize a peptide (nABP284) that binds to PD-1 by a computer-based protocol in order to increase its affinity. Then, this study aimed to determine the inhibitory effects of this peptide on cancer immune escape by coculturing improving cytokine-induced killer (ICIK) cells with cancer cells. Materials and Methods nABP284 that binds to PD-1 was identified by phage display technology in our previous study. AutoDock and PyMOL were used to optimize the sequence of nABP284 to design a new peptide (nABPD1). Immunofluorescence was used to demonstrate that the peptides bound to PD-1. Surface plasmon resonance (SPR) was used to measure the binding affinity of the peptides. The blocking effect of the peptides on PD-1 was evaluated by a neutralization experiment with human recombinant PD-L1 protein. The inhibition of activated lymphocytes by cancer cells was simulated by coculturing of human acute T lymphocytic leukemia cells (Jurkat T cells) with human tongue squamous cell carcinoma cells (Cal27 cells). The anticancer activities were determined by coculturing ICIK cells with Cal27 cells in vitro. Results A high-affinity peptide (nABPD1, KD=11.9 nM) for PD-1 was obtained by optimizing the nABP284 peptide (KD=11.8 µM). nABPD1 showed better efficacy than nABP284 in terms of increasing the secretion of IL-2 by Jurkat T cells and enhancing the in vitro antitumor activity of ICIK cells. Conclusion nABPD1 possesses higher affinity for PD-1 than nABP284, which significantly enhances its ability to block the PD-1/PD-L1 interaction and to increase ICIK cell-mediated antitumor activity by armoring ICIK cells.
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Affiliation(s)
- Yilei Chen
- Departments Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Hongxing Huang
- Departments Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Yin Liu
- Departments Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Zhanghao Wang
- Departments Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Lili Wang
- Departments Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Quanxiao Wang
- Departments Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Yan Zhang
- Departments Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Hua Wang
- Departments Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
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Feng K, Liu Y, Zhao Y, Yang Q, Dong L, Liu J, Li X, Zhao Z, Mei Q, Han W. Efficacy and biomarker analysis of nivolumab plus gemcitabine and cisplatin in patients with unresectable or metastatic biliary tract cancers: results from a phase II study. J Immunother Cancer 2021; 8:jitc-2019-000367. [PMID: 32487569 PMCID: PMC7269541 DOI: 10.1136/jitc-2019-000367] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2020] [Indexed: 01/05/2023] Open
Abstract
Background The prognosis of patients with unresectable or metastatic biliary tract cancer (BTC) is unacceptably low. This study aimed to determine the efficacy, safety and predictive biomarkers of the immune checkpoint inhibitor nivolumab in combination with chemotherapy in advanced BTCs. Methods In this open-label, single-arm, phase II trial, a chemotherapy and immunotherapy combination consisting of gemcitabine 1000 mg/m2, cisplatin 75 mg/m2 and nivolumab 3 mg/kg was administered every 3 weeks for up to six cycles. Maintenance treatment with gemcitabine plus nivolumab was administered to patients achieving disease control following the combination therapy. The primary outcome was the objective response rate. Secondary outcomes included safety, disease control rate (DCR), progression-free survival (PFS) and overall survival (OS). The exploratory objective was to assess biomarkers for predicting clinical response and prognosis. Results Thirty-two patients with a median age of 60 (range 27–69) years were enrolled. As of September 31, 2019, the median follow-up was 12.8 (95% CI 10.8 to 14.8) months. Twenty-seven response-evaluable patients received a median of 4 (IQR, 3–6) cycles of combination therapy, of whom 15 (55.6%) patients achieved an objective response, including 5 (18.6%) with a complete response (CR), and the DCR was 92.6%. Of the six patients in cohort A who were resistant to gemcitabine-based or cisplatin-based chemotherapy, one achieved CR and one achieved partial response. Thirteen of 21 chemotherapy-naive patients (61.9%) in cohort B achieved an objective response. The median PFS of all patients in cohorts A+B was 6.1 months. The median OS was 8.5 months, with a 33.3% 12-month OS rate. The most frequent grade 3 or higher adverse events were thrombocytopenia (56%) and neutropenia (22%). Fitness might be a biomarker for predicting clinical response. On-therapy changes in serum soluble FasL, MCP-1 and interferon-γ were correlated with prognosis. Conclusions Nivolumab in combination with gemcitabine and cisplatin offers promising efficacy and a manageable safety profile for patients with advanced BTCs. Trial registration number NCT03311789
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Affiliation(s)
- Kaichao Feng
- Department of Bio-therapeutic, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yang Liu
- Department of Bio-therapeutic, the First Medical Center, Chinese PLA General Hospital, Beijing, China.,Department of Geriatric Hematology, the Second Medical Center, Chinese PLA General Hospital, Beijing, China
| | | | - Qingming Yang
- Department of Bio-therapeutic, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Liang Dong
- Department of Bio-therapeutic, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiejie Liu
- Department of Bio-therapeutic, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiang Li
- Department of Bio-therapeutic, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhikun Zhao
- YuceBio Technology Co., Ltd, Shenzhen, China
| | - Qian Mei
- Department of Bio-therapeutic, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Weidong Han
- Department of Bio-therapeutic, the First Medical Center, Chinese PLA General Hospital, Beijing, China
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Kubina R, Iriti M, Kabała-Dzik A. Anticancer Potential of Selected Flavonols: Fisetin, Kaempferol, and Quercetin on Head and Neck Cancers. Nutrients 2021; 13:nu13030845. [PMID: 33807530 PMCID: PMC7998948 DOI: 10.3390/nu13030845] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
Flavonols are ones of the most common phytochemicals found in diets rich in fruit and vegetables. Research suggests that molecular functions of flavonoids may bring a number of health benefits to people, including the following: decrease inflammation, change disease activity, and alleviate resistance to antibiotics as well as chemotherapeutics. Their antiproliferative, antioxidant, anti-inflammatory, and antineoplastic activity has been proved. They may act as antioxidants, while preventing DNA damage by scavenging reactive oxygen radicals, reinforcing DNA repair, disrupting chemical damages by induction of phase II enzymes, and modifying signal transduction pathways. One of such research areas is a potential effect of flavonoids on the risk of developing cancer. The aim of our paper is to present a systematic review of antineoplastic activity of flavonols in general. Special attention was paid to selected flavonols: fisetin, kaempferol, and quercetin in preclinical and in vitro studies. Study results prove antiproliferative and proapoptotic properties of flavonols with regard to head and neck cancer. However, few study papers evaluate specific activities during various processes associated with cancer progression. Moreover, an attempt was made to collect the majority of substantive studies on bioactive potential of the selected flavonols, especially with regard to modulation of a range of signal transduction pathways that participate in cancer development.
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Affiliation(s)
- Robert Kubina
- Department of Pathology, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, 40-055 Katowice, Poland;
- Correspondence: ; Tel.: +48-32-364-13-54
| | - Marcello Iriti
- Department of Agricultural and Environmental Sciences, Milan State University, via G. Celoria 2, 20133 Milan, Italy;
| | - Agata Kabała-Dzik
- Department of Pathology, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, 40-055 Katowice, Poland;
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Zhao L, Li P, Zhao L, Wang M, Tong D, Meng Z, Zhang Q, Li Q, Zhang F. Expression and clinical value of PD‐L1 which is regulated by BRD4 in tongue squamous cell carcinoma. J Cell Biochem 2019; 121:1855-1869. [DOI: 10.1002/jcb.29420] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/08/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Lu Zhao
- Shandong Provincial Key Laboratory of Oral Tissue Regeneration, School of Stomatology Shandong University Jinan Shandong China
- Department of Oral and Maxillofacial Surgery, School of Stomatology Shandong University Jinan Shandong China
- Department of Stomatology Binzhou People's Hospital Binzhou Shandong China
| | - Pengchong Li
- Department of Stomatology Binzhou People's Hospital Binzhou Shandong China
| | - Li Zhao
- Department of Periodontology Dongguan Dental Hospital Dongguan Guangdong China
| | - Miao Wang
- Department of Oral and Maxillofacial Surgery, School of Stomatology Shandong University Jinan Shandong China
| | - Dongdong Tong
- Department of Oral and Maxillofacial Surgery, School of Stomatology Shandong University Jinan Shandong China
| | - Zilin Meng
- School of Resources and Environmental Engineering Shandong University of Technology Zibo Shandong China
| | - Qian Zhang
- School of Resources and Environmental Engineering Shandong University of Technology Zibo Shandong China
| | - Qing Li
- Shandong Provincial Key Laboratory of Oral Tissue Regeneration, School of Stomatology Shandong University Jinan Shandong China
- Department of Oral and Maxillofacial Surgery, School of Stomatology Shandong University Jinan Shandong China
| | - Fenghe Zhang
- Shandong Provincial Key Laboratory of Oral Tissue Regeneration, School of Stomatology Shandong University Jinan Shandong China
- Department of Oral and Maxillofacial Surgery, School of Stomatology Shandong University Jinan Shandong China
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Arjunan P, Meghil MM, Pi W, Xu J, Lang L, El-Awady A, Sullivan W, Rajendran M, Rabelo MS, Wang T, Tawfik OK, Kunde-Ramamoorthy G, Singh N, Muthusamy T, Susin C, Teng Y, Arce RM, Cutler CW. Oral Pathobiont Activates Anti-Apoptotic Pathway, Promoting both Immune Suppression and Oncogenic Cell Proliferation. Sci Rep 2018; 8:16607. [PMID: 30413788 PMCID: PMC6226501 DOI: 10.1038/s41598-018-35126-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/30/2018] [Indexed: 12/25/2022] Open
Abstract
Chronic periodontitis (CP) is a microbial dysbiotic disease linked to increased risk of oral squamous cell carcinomas (OSCCs). To address the underlying mechanisms, mouse and human cell infection models and human biopsy samples were employed. We show that the ‘keystone’ pathogen Porphyromonas gingivalis, disrupts immune surveillance by generating myeloid-derived dendritic suppressor cells (MDDSCs) from monocytes. MDDSCs inhibit CTLs and induce FOXP3 + Tregs through an anti-apoptotic pathway. This pathway, involving pAKT1, pFOXO1, FOXP3, IDO1 and BIM, is activated in humans with CP and in mice orally infected with Mfa1 expressing P. gingivalis strains. Mechanistically, activation of this pathway, demonstrating FOXP3 as a direct FOXO1-target gene, was demonstrated by ChIP-assay in human CP gingiva. Expression of oncogenic but not tumor suppressor markers is consistent with tumor cell proliferation demonstrated in OSCC-P. gingivalis cocultures. Importantly, FimA + P. gingivalis strain MFI invades OSCCs, inducing inflammatory/angiogenic/oncogenic proteins stimulating OSCCs proliferation through CXCR4. Inhibition of CXCR4 abolished Pg-MFI-induced OSCCs proliferation and reduced expression of oncogenic proteins SDF-1/CXCR4, plus pAKT1-pFOXO1. Conclusively, P. gingivalis, through Mfa1 and FimA fimbriae, promotes immunosuppression and oncogenic cell proliferation, respectively, through a two-hit receptor-ligand process involving DC-SIGN+hi/CXCR4+hi, activating a pAKT+hipFOXO1+hiBIM−lowFOXP3+hi and IDO+hi- driven pathway, likely to impact the prognosis of oral cancers in patients with periodontitis.
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Affiliation(s)
- Pachiappan Arjunan
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America.
| | - Mohamed M Meghil
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America.,Department of Oral Biology, Augusta University, Augusta, Georgia, United States of America
| | - Wenhu Pi
- Department of Radiation Oncology, Indiana University, Indianapolis, Indiana, United States of America
| | - Jinxian Xu
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | - Liwei Lang
- Department of Oral Biology, Augusta University, Augusta, Georgia, United States of America
| | - Ahmed El-Awady
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | - William Sullivan
- Department of Energy, Joint Genome Institute, California, United States of America
| | - Mythilypriya Rajendran
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | - Mariana Sousa Rabelo
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America.,Department of Periodontics, University of São Paulo, Sao Paulo, Brazil
| | - Tong Wang
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | - Omnia K Tawfik
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | | | - Nagendra Singh
- Department of Biochemistry & Molecular Biology, Cancer Research Center, Augusta University, Augusta, Georgia, United States of America
| | - Thangaraju Muthusamy
- Department of Biochemistry & Molecular Biology, Cancer Research Center, Augusta University, Augusta, Georgia, United States of America
| | - Cristiano Susin
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | - Yong Teng
- Department of Oral Biology, Augusta University, Augusta, Georgia, United States of America
| | - Roger M Arce
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | - Christopher W Cutler
- Department of Periodontics, Dental College of Georgia, Augusta University, Augusta, Georgia, United States of America.
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