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Lin YC, Ku CC, Wuputra K, Liu CJ, Wu DC, Satou M, Mitsui Y, Saito S, Yokoyama KK. Possible Strategies to Reduce the Tumorigenic Risk of Reprogrammed Normal and Cancer Cells. Int J Mol Sci 2024; 25:5177. [PMID: 38791215 PMCID: PMC11120835 DOI: 10.3390/ijms25105177] [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: 03/16/2024] [Revised: 04/29/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
The reprogramming of somatic cells to pluripotent stem cells has immense potential for use in regenerating or redeveloping tissues for transplantation, and the future application of this method is one of the most important research topics in regenerative medicine. These cells are generated from normal cells, adult stem cells, or neoplastic cancer cells. They express embryonic stem cell markers, such as OCT4, SOX2, and NANOG, and can differentiate into all tissue types in adults, both in vitro and in vivo. However, tumorigenicity, immunogenicity, and heterogeneity of cell populations may hamper the use of this method in medical therapeutics. The risk of cancer formation is dependent on mutations of these stemness genes during the transformation of pluripotent stem cells to cancer cells and on the alteration of the microenvironments of stem cell niches at genetic and epigenetic levels. Recent reports have shown that the generation of induced pluripotent stem cells (iPSCs) derived from human fibroblasts could be induced using chemicals, which is a safe, easy, and clinical-grade manufacturing strategy for modifying the cell fate of human cells required for regeneration therapies. This strategy is one of the future routes for the clinical application of reprogramming therapy. Therefore, this review highlights the recent progress in research focused on decreasing the tumorigenic risk of iPSCs or iPSC-derived organoids and increasing the safety of iPSC cell preparation and their application for therapeutic benefits.
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Affiliation(s)
- Ying-Chu Lin
- School of Dentistry, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Cha-Chien Ku
- Graduate Institute of Medicine, Department of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-C.K.); (K.W.)
- Regenerative Medicine and Cell Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-J.L.); (D.-C.W.)
- Cell Therapy and Research Center, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
| | - Kenly Wuputra
- Graduate Institute of Medicine, Department of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-C.K.); (K.W.)
- Regenerative Medicine and Cell Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-J.L.); (D.-C.W.)
- Cell Therapy and Research Center, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Waseda Research Institute for Science and Engineering, Waseda University, Tokyo 169-8555, Japan
| | - Chung-Jung Liu
- Regenerative Medicine and Cell Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-J.L.); (D.-C.W.)
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
| | - Deng-Chyang Wu
- Regenerative Medicine and Cell Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-J.L.); (D.-C.W.)
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
| | - Maki Satou
- Research Institute, Horus Co., Ltd., Iruma 358-0032, Saitama, Japan; (M.S.); (Y.M.)
| | - Yukio Mitsui
- Research Institute, Horus Co., Ltd., Iruma 358-0032, Saitama, Japan; (M.S.); (Y.M.)
| | - Shigeo Saito
- Graduate Institute of Medicine, Department of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-C.K.); (K.W.)
- Research Institute, Horus Co., Ltd., Iruma 358-0032, Saitama, Japan; (M.S.); (Y.M.)
- Saito Laboratory of Cell Technology, Yaita 329-1571, Tochigi, Japan
| | - Kazunari K. Yokoyama
- School of Dentistry, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
- Graduate Institute of Medicine, Department of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-C.K.); (K.W.)
- Regenerative Medicine and Cell Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (C.-J.L.); (D.-C.W.)
- Cell Therapy and Research Center, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
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Price K, Yang WH, Cardoso L, Wang CM, Yang RH, Yang WH. Jun Dimerization Protein 2 (JDP2) Increases p53 Transactivation by Decreasing MDM2. Cancers (Basel) 2024; 16:1000. [PMID: 38473360 DOI: 10.3390/cancers16051000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
The AP-1 protein complex primarily consists of several proteins from the c-Fos, c-Jun, activating transcription factor (ATF), and Jun dimerization protein (JDP) families. JDP2 has been shown to interact with the cAMP response element (CRE) site present in many cis-elements of downstream target genes. JDP2 has also demonstrates important roles in cell-cycle regulation, cancer development and progression, inhibition of adipocyte differentiation, and the regulation of antibacterial immunity and bone homeostasis. JDP2 and ATF3 exhibit significant similarity in their C-terminal domains, sharing 60-65% identities. Previous studies have demonstrated that ATF3 is able to influence both the transcriptional activity and p53 stability via a p53-ATF3 interaction. While some studies have shown that JDP2 suppresses p53 transcriptional activity and in turn, p53 represses JDP2 promoter activity, the direct interaction between JDP2 and p53 and the regulatory role of JDP2 in p53 transactivation have not been explored. In the current study, we provide evidence, for the first time, that JDP2 interacts with p53 and regulates p53 transactivation. First, we demonstrated that JDP2 binds to p53 and the C-terminal domain of JDP2 is crucial for the interaction. Second, in p53-null H1299 cells, JDP2 shows a robust increase of p53 transactivation in the presence of p53 using p53 (14X)RE-Luc. Furthermore, JDP2 and ATF3 together additively enhance p53 transactivation in the presence of p53. While JDP2 can increase p53 transactivation in the presence of WT p53, JDP2 fails to enhance transactivation of hotspot mutant p53. Moreover, in CHX chase experiments, we showed that JDP2 slightly enhances p53 stability. Finally, our findings indicate that JDP2 has the ability to reverse MDM2-induced p53 repression, likely due to decreased levels of MDM2 by JDP2. In summary, our results provide evidence that JDP2 directly interacts with p53 and decreases MDM2 levels to enhance p53 transactivation, suggesting that JDP2 is a novel regulator of p53 and MDM2.
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Affiliation(s)
- Kasey Price
- Department of Biomedical Sciences, School of Medicine, Mercer University, Savannah, GA 31404, USA
| | - William H Yang
- Department of Biomedical Sciences, School of Medicine, Mercer University, Savannah, GA 31404, USA
| | - Leticia Cardoso
- Department of Biomedical Sciences, School of Medicine, Mercer University, Savannah, GA 31404, USA
| | - Chiung-Min Wang
- Department of Biomedical Sciences, School of Medicine, Mercer University, Savannah, GA 31404, USA
| | - Richard H Yang
- Department of Biomedical Sciences, School of Medicine, Mercer University, Savannah, GA 31404, USA
| | - Wei-Hsiung Yang
- Department of Biomedical Sciences, School of Medicine, Mercer University, Savannah, GA 31404, USA
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Wagner KD, Wagner N. The Senescence Markers p16INK4A, p14ARF/p19ARF, and p21 in Organ Development and Homeostasis. Cells 2022; 11:cells11121966. [PMID: 35741095 PMCID: PMC9221567 DOI: 10.3390/cells11121966] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/15/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023] Open
Abstract
It is widely accepted that senescent cells accumulate with aging. They are characterized by replicative arrest and the release of a myriad of factors commonly called the senescence-associated secretory phenotype. Despite the replicative cell cycle arrest, these cells are metabolically active and functional. The release of SASP factors is mostly thought to cause tissue dysfunction and to induce senescence in surrounding cells. As major markers for aging and senescence, p16INK4, p14ARF/p19ARF, and p21 are established. Importantly, senescence is also implicated in development, cancer, and tissue homeostasis. While many markers of senescence have been identified, none are able to unambiguously identify all senescent cells. However, increased levels of the cyclin-dependent kinase inhibitors p16INK4A and p21 are often used to identify cells with senescence-associated phenotypes. We review here the knowledge of senescence, p16INK4A, p14ARF/p19ARF, and p21 in embryonic and postnatal development and potential functions in pathophysiology and homeostasis. The establishment of senolytic therapies with the ultimate goal to improve healthy aging requires care and detailed knowledge about the involvement of senescence and senescence-associated proteins in developmental processes and homeostatic mechanism. The review contributes to these topics, summarizes open questions, and provides some directions for future research.
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Network based systems biology approach to identify diseasome and comorbidity associations of Systemic Sclerosis with cancers. Heliyon 2022; 8:e08892. [PMID: 35198765 PMCID: PMC8841363 DOI: 10.1016/j.heliyon.2022.e08892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/04/2021] [Accepted: 01/29/2022] [Indexed: 01/11/2023] Open
Abstract
Systemic Sclerosis (SSc) is an autoimmune disease associated with changes in the skin's structure in which the immune system attacks the body. A recent meta-analysis has reported a high incidence of cancer prognosis including lung cancer (LC), leukemia (LK), and lymphoma (LP) in patients with SSc as comorbidity but its underlying mechanistic details are yet to be revealed. To address this research gap, bioinformatics methodologies were developed to explore the comorbidity interactions between a pair of diseases. Firstly, appropriate gene expression datasets from different repositories on SSc and its comorbidities were collected. Then the interconnection between SSc and its cancer comorbidities was identified by applying the developed pipelines. The pipeline was designed as a generic workflow to demonstrate a premise comorbid condition that integrate regarding gene expression data, tissue/organ meta-data, Gene Ontology (GO), Molecular pathways, and other online resources, and analyze them with Gene Set Enrichment Analysis (GSEA), Pathway enrichment and Semantic Similarity (SS). The pipeline was implemented in R and can be accessed through our Github repository: https://github.com/hiddenntreasure/comorbidity. Our result suggests that SSc and its cancer comorbidities share differentially expressed genes, functional terms (gene ontology), and pathways. The findings have led to a better understanding of disease pathways and our developed methodologies may be applied to any set of diseases for finding any association between them. This research may be used by physicians, researchers, biologists, and others.
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JDP2, a Novel Molecular Key in Heart Failure and Atrial Fibrillation? Int J Mol Sci 2021; 22:ijms22084110. [PMID: 33923401 PMCID: PMC8074072 DOI: 10.3390/ijms22084110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 11/17/2022] Open
Abstract
Heart failure (HF) and atrial fibrillation (AF) are two major life-threatening diseases worldwide. Causes and mechanisms are incompletely understood, yet current therapies are unable to stop disease progression. In this review, we focus on the contribution of the transcriptional modulator, Jun dimerization protein 2 (JDP2), and on HF and AF development. In recent years, JDP2 has been identified as a potential prognostic marker for HF development after myocardial infarction. This close correlation to the disease development suggests that JDP2 may be involved in initiation and progression of HF as well as in cardiac dysfunction. Although no studies have been done in humans yet, studies on genetically modified mice impressively show involvement of JDP2 in HF and AF, making it an interesting therapeutic target.
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Yu W, Deng W, Zhao Q, Zhuang H, Zhang C, Jian Z. miR-501 acts as an independent prognostic factor that promotes the epithelial-mesenchymal transition through targeting JDP2 in hepatocellular carcinoma. Hum Cell 2019; 32:343-351. [PMID: 30877624 DOI: 10.1007/s13577-019-00243-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/21/2019] [Indexed: 12/11/2022]
Abstract
Hepatocellular carcinoma (HCC), the second common cancer, was a kind of primary liver cancer with high incidence. miR-501, identified as a novel regulator, was acted as a potential biomarker in several diseases. JDP2, acted as a repressor of AP-1 complex, was a member of the basic leucine zipper (bZIP) transcription factor family. RT-qPCR was applied to evaluate miR-501 and JDP2 expression level and we found that miR-501 was upregulated in HCC tissues and cells. miR-501 ectopic expression promoted HCC cell invasion and epithelial-mesenchymal transition (EMT), while low expression present the opposite results. JDP2 was downregulated in HCC tissues and cells, and overexpressed JDP2 facilitated HCC cell invasion and EMT. Furthermore, luciferase reporter assay indicated that JDP2 was a target of miR-501 and altered miR-501 expression the JPD2 mRNA may changed. The expression of miR-501 and JDP2 had negative connection in HCC tissues. In addition, Kaplan-Meier method revealed that miR-501 upregulation or JDP2 downregulation predicted poor prognosis in HCC patients. miR-501 promoted cell invasion and EMT by regulated JDP2 in hepatocellular carcinoma. The newly identified miR-501/JDP2 axis provides novel insight into the pathogenesis of hepatocellular carcinoma.
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Affiliation(s)
- Weixuan Yu
- Department of Surgical Oncology, Tungwah Hospital of Sun Yat-Sen University, Dongguan, 523110, Guangdong, China
| | - Wen Deng
- Biotherapy Department, Sun Yat-sen Memorial Hospital, Guangzhou, 510120, Guangdong, China
| | - Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
| | - Hongkai Zhuang
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Chuanzhao Zhang
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhongshan Er Road, Guangzhou, 510080, China.
| | - Zhixiang Jian
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhongshan Er Road, Guangzhou, 510080, China.
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Chen YL, Chan SH, Lin PY, Chu PY. The expression of a tumor suppressor gene JDP2 and its prognostic value in hepatocellular carcinoma patients. Hum Pathol 2017; 63:212-216. [DOI: 10.1016/j.humpath.2017.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/26/2017] [Accepted: 03/02/2017] [Indexed: 02/07/2023]
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Tsai MH, Wuputra K, Lin YC, Lin CS, Yokoyama KK. Multiple functions of the histone chaperone Jun dimerization protein 2. Gene 2016; 590:193-200. [PMID: 27041241 DOI: 10.1016/j.gene.2016.03.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/12/2016] [Accepted: 03/22/2016] [Indexed: 11/25/2022]
Abstract
The Jun dimerization protein 2 (JDP2) is part of the family of stress-responsible transcription factors such as the activation protein-1, and binds the 12-O-tetradecanoylphorbol-13-acetateresponse element and the cAMP response element. It also plays a role as a histone chaperone and participates in diverse processes, such as cell-cycle arrest, cell differentiation, apoptosis, senescence, and metastatic spread, and functions as an oncogene and anti-oncogene, and as a cellular reprogramming factor. However, the molecular mechanisms underlying these multiple functions of JDP2 have not been clarified. This review summarizes the structure and function of JDP2, highlighting the specific role of JDP2 in cellular-stress regulation and prevention.
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Affiliation(s)
- Ming-Ho Tsai
- Graduated Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kenly Wuputra
- Graduated Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yin-Chu Lin
- School of Dentistry, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chang-Shen Lin
- Graduated Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Kazunari K Yokoyama
- Graduated Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Science and Engineering, Tokushima Bunri University, Sanuki, Japan; Department of Molecular Preventive Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Nagamine T, Nomada S, Onouchi T, Kameshita I, Sueyoshi N. Nuclear translocation of doublecortin-like protein kinase and phosphorylation of a transcription factor JDP2. Biochem Biophys Res Commun 2014; 446:73-8. [DOI: 10.1016/j.bbrc.2014.02.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
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Singh H, Giridharan N, Bhonde R, Venkatesan V. Deriving at candidate genes of metabolic stress from pancreas of WNIN/GR-Ob mutant rats. Islets 2013; 5:133-8. [PMID: 24131929 DOI: 10.4161/isl.25520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Development of appropriate animal model systems have greatly helped our understanding of the basic mechanism(s) of several degenerative diseases. WNIN/GR-Ob?a mutant rat strain developed at the National Center for Laboratory Animal Sciences facility of National Institute of Nutrition, is a new animal model ideal to study the metabolic syndrome since it is obese with impaired glucose tolerance and also exhibits several secondary complications. The present study was performed in the pancreas of this mutant model to assess the global gene expression (microarray) to assess the transcriptome level changes in situ depicting inflammation, obesity, insulin resistance, and diabetes in these animals. Our findings suggest an interplay of several confounding factors in pancreas which include inflammation /macrophage infiltration/apoptosis/oxidative and endoplasmic reticulum stress, all contributing for the shift toward pro-inflammation. We were able to phenotypically correlate the metabolic alterations vis-a-vis candidate genes (array analyses) compared between mutants and its age matched, parental controls. We advocate that the data reported here would provide a suitable insight in to the pathophysiology of metabolic syndrome .
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Affiliation(s)
- Himadri Singh
- Biochemistry/Stem Cell Research; National Institute of Nutrition (ICMR); Tarnaka, Hyderabad, India
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Maruyama K, Fukasaka M, Vandenbon A, Saitoh T, Kawasaki T, Kondo T, Yokoyama KK, Kidoya H, Takakura N, Standley D, Takeuchi O, Akira S. The transcription factor Jdp2 controls bone homeostasis and antibacterial immunity by regulating osteoclast and neutrophil differentiation. Immunity 2012. [PMID: 23200825 DOI: 10.1016/j.immuni.2012.08.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Jdp2 is an AP-1 family transcription factor that regulates the epigenetic status of histones. Previous in vitro studies revealed that Jdp2 is involved in osteoclastogenesis. However, the roles of Jdp2 in vivo and its pleiotropic functions are largely unknown. Here we generated Jdp2(-/-) mice and discovered its crucial roles not only in bone metabolism but also in differentiation of neutrophils. Jdp2(-/-) mice exhibited osteopetrosis resulting from impaired osteoclastogenesis. Jdp2(-/-) neutrophils were morphologically normal but had impaired surface expression of Ly6G, bactericidal function, and apoptosis. We also found that ATF3 was an inhibitor of neutrophil differentiation and that Jdp2 directly suppresses its expression via inhibition of histone acetylation. Strikingly, Jdp2(-/-) mice were highly susceptible to Staphylococcus aureus and Candida albicans infection. Thus, Jdp2 plays pivotal roles in in vivo bone homeostasis and host defense by regulating osteoclast and neutrophil differentiation.
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Affiliation(s)
- Kenta Maruyama
- Laboratory of Host Defense, Osaka University, Osaka, Japan
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Rayess H, Wang MB, Srivatsan ES. Cellular senescence and tumor suppressor gene p16. Int J Cancer 2011; 130:1715-25. [PMID: 22025288 DOI: 10.1002/ijc.27316] [Citation(s) in RCA: 507] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 10/14/2011] [Indexed: 12/14/2022]
Abstract
Cellular senescence is an irreversible arrest of cell growth. Biochemical and morphological changes occur during cellular senescence, including the formation of a unique cellular morphology such as flattened cytoplasm. Function of mitochondria, endoplasmic reticulum and lysosomes are affected resulting in the inhibition of lysosomal and proteosomal pathways. Cellular senescence can be triggered by a number of factors including, aging, DNA damage, oncogene activation and oxidative stress. While the molecular mechanism of senescence involves p16 and p53 tumor suppressor genes and telomere shortening, this review is focused on the mechanism of p16 control. The p16-mediated senescence acts through the retinoblastoma (Rb) pathway inhibiting the action of the cyclin dependant kinases leading to G1 cell cycle arrest. Rb is maintained in a hypophosphorylated state resulting in the inhibition of transcription factor E2F1. Regulation of p16 expression is complex and involves epigenetic control and multiple transcription factors. PRC1 (Pombe repressor complex (1) and PRC2 (Pombe repressor complex (2) proteins and histone deacetylases play an important role in the promoter hypermethylation for suppressing p16 expression. While transcription factors YY1 and Id1 suppress p16 expression, transcription factors CTCF, Sp1 and Ets family members activate p16 transcription. Senescence occurs with the inactivation of suppressor elements leading to the enhanced expression of p16.
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Affiliation(s)
- Hani Rayess
- Department of Surgery, VA Greater Los Angeles Healthcare system, West Los Angeles, CA, USA
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