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Tang XL, Nasr M, Zheng S, Zoubul T, Stephan JK, Uchida S, Singhal R, Khan A, Gumpert A, Bolli R, Wysoczynski M. Bone Marrow and Wharton's Jelly Mesenchymal Stromal Cells are Ineffective for Myocardial Repair in an Immunodeficient Rat Model of Chronic Ischemic Cardiomyopathy. Stem Cell Rev Rep 2023; 19:2429-2446. [PMID: 37500831 PMCID: PMC10579184 DOI: 10.1007/s12015-023-10590-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Although cell therapy provides benefits for outcomes of heart failure, the most optimal cell type to be used clinically remains unknown. Most of the cell products used for therapy in humans require in vitro expansion to obtain a suitable number of cells for treatment; however, the clinical background of the donor and limited starting material may result in the impaired proliferative and reparative capacity of the cells expanded in vitro. Wharton's jelly mesenchymal cells (WJ MSCs) provide a multitude of advantages over adult tissue-derived cell products for therapy. These include large starting tissue material, superior proliferative capacity, and disease-free donors. Thus, WJ MSC if effective would be the most optimal cell source for clinical use. OBJECTIVES This study evaluated the therapeutic efficacy of Wharton's jelly (WJ) and bone marrow (BM) mesenchymal stromal cells (MSCs) in chronic ischemic cardiomyopathy in rats. METHODS Human WJ MSCs and BM MSCs were expanded in vitro, characterized, and evaluated for therapeutic efficacy in a immunodeficient rat model of ischemic cardiomyopathy. Cardiac function was evaluated with hemodynamics and echocardiography. The extent of cardiac fibrosis, hypertrophy, and inflammation was assessed with histological analysis. RESULTS In vitro analysis revealed that WJ MSCs and BM MSCs are morphologically and immunophenotypically indistinguishable. Nevertheless, the functional analysis showed that WJ MSCs have a superior proliferative capacity, less senescent phenotype, and distinct transcriptomic profile compared to BM MSC. WJ MSCs and BM MSC injected in rat hearts chronically after MI produced a small, but not significant improvement in heart structure and function. Histological analysis showed no difference in the scar size, collagen content, cardiomyocyte cross-sectional area, and immune cell count. CONCLUSIONS Human WJ and BM MSC have a small but not significant effect on cardiac structure and function when injected intramyocardially in immunodeficient rats chronically after MI.
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Affiliation(s)
- Xian-Liang Tang
- Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Marjan Nasr
- Center for Cardiometabolic Science, University of Louisville School of Medicine, 580 South Preston St. - Rm 204B, Louisville, KY, 40202, USA
| | - Shirong Zheng
- Center for Cardiometabolic Science, University of Louisville School of Medicine, 580 South Preston St. - Rm 204B, Louisville, KY, 40202, USA
| | - Taylor Zoubul
- Center for Cardiometabolic Science, University of Louisville School of Medicine, 580 South Preston St. - Rm 204B, Louisville, KY, 40202, USA
| | - Jonah K Stephan
- Center for Cardiometabolic Science, University of Louisville School of Medicine, 580 South Preston St. - Rm 204B, Louisville, KY, 40202, USA
| | - Shizuka Uchida
- Center for RNA Medicine, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Richa Singhal
- Center for Cardiometabolic Science, University of Louisville School of Medicine, 580 South Preston St. - Rm 204B, Louisville, KY, 40202, USA
| | - Aisha Khan
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anna Gumpert
- Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Roberto Bolli
- Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Marcin Wysoczynski
- Center for Cardiometabolic Science, University of Louisville School of Medicine, 580 South Preston St. - Rm 204B, Louisville, KY, 40202, USA.
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2
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Lee JW, Lee CS, Son H, Lee J, Kang M, Chai J, Cho HJ, Kim HS. SOX17-mediated LPAR4 expression plays a pivotal role in cardiac development and regeneration after myocardial infarction. Exp Mol Med 2023:10.1038/s12276-023-01025-w. [PMID: 37394586 PMCID: PMC10394006 DOI: 10.1038/s12276-023-01025-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/09/2023] [Accepted: 03/26/2023] [Indexed: 07/04/2023] Open
Abstract
Lysophosphatidic acid receptor 4 (LPAR4) exhibits transient expression at the cardiac progenitor stage during pluripotent stem cell (PSC)-derived cardiac differentiation. Using RNA sequencing, promoter analyses, and a loss-of-function study in human PSCs, we discovered that SRY-box transcription factor 17 (SOX17) is an essential upstream factor of LPAR4 during cardiac differentiation. We conducted mouse embryo analyses to further verify our human PSC in vitro findings and confirmed the transient and sequential expression of SOX17 and LPAR4 during in vivo cardiac development. In an adult bone marrow transplantation model using LPAR4 promoter-driven GFP cells, we observed two LPAR4+ cell types in the heart following myocardial infarction (MI). Cardiac differentiation potential was shown in heart-resident LPAR4+ cells, which are SOX17+, but not bone marrow-derived infiltrated LPAR4+ cells. Furthermore, we tested various strategies to enhance cardiac repair through the regulation of downstream signals of LPAR4. During the early stages following MI, the downstream inhibition of LPAR4 by a p38 mitogen-activated protein kinase (p38 MAPK) blocker improved cardiac function and reduced fibrotic scarring compared to that observed following LPAR4 stimulation. These findings improve our understanding of heart development and suggest novel therapeutic strategies that enhance repair and regeneration after injury by modulating LPAR4 signaling.
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Affiliation(s)
- Jin-Woo Lee
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine or College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Choon-Soo Lee
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - HyunJu Son
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine or College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Jaewon Lee
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Minjun Kang
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine or College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Jinho Chai
- Program in Stem Cell Biology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Hyo-Soo Kim
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine or College of Pharmacy, Seoul National University, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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3
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Soni SS, D'Elia AM, Rodell CB. Control of the post-infarct immune microenvironment through biotherapeutic and biomaterial-based approaches. Drug Deliv Transl Res 2023; 13:1983-2014. [PMID: 36763330 PMCID: PMC9913034 DOI: 10.1007/s13346-023-01290-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
Ischemic heart failure (IHF) is a leading cause of morbidity and mortality worldwide, for which heart transplantation remains the only definitive treatment. IHF manifests from myocardial infarction (MI) that initiates tissue remodeling processes, mediated by mechanical changes in the tissue (loss of contractility, softening of the myocardium) that are interdependent with cellular mechanisms (cardiomyocyte death, inflammatory response). The early remodeling phase is characterized by robust inflammation that is necessary for tissue debridement and the initiation of repair processes. While later transition toward an immunoregenerative function is desirable, functional reorientation from an inflammatory to reparatory environment is often lacking, trapping the heart in a chronically inflamed state that perpetuates cardiomyocyte death, ventricular dilatation, excess fibrosis, and progressive IHF. Therapies can redirect the immune microenvironment, including biotherapeutic and biomaterial-based approaches. In this review, we outline these existing approaches, with a particular focus on the immunomodulatory effects of therapeutics (small molecule drugs, biomolecules, and cell or cell-derived products). Cardioprotective strategies, often focusing on immunosuppression, have shown promise in pre-clinical and clinical trials. However, immunoregenerative therapies are emerging that often benefit from exacerbating early inflammation. Biomaterials can be used to enhance these therapies as a result of their intrinsic immunomodulatory properties, parallel mechanisms of action (e.g., mechanical restraint), or by enabling cell or tissue-targeted delivery. We further discuss translatability and the continued progress of technologies and procedures that contribute to the bench-to-bedside development of these critically needed treatments.
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Affiliation(s)
- Shreya S Soni
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, 19104, USA
| | - Arielle M D'Elia
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, 19104, USA
| | - Christopher B Rodell
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, 19104, USA.
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4
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Schary Y, Rotem I, Caller T, Lewis N, Shaihov-Teper O, Brzezinski RY, Lendengolts D, Raanani E, Sternik L, Naftali-Shani N, Leor J. CRISPR-Cas9 editing of TLR4 to improve the outcome of cardiac cell therapy. Sci Rep 2023; 13:4481. [PMID: 36934130 PMCID: PMC10024743 DOI: 10.1038/s41598-023-31286-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 03/09/2023] [Indexed: 03/20/2023] Open
Abstract
Inflammation and fibrosis limit the reparative properties of human mesenchymal stromal cells (hMSCs). We hypothesized that disrupting the toll-like receptor 4 (TLR4) gene would switch hMSCs toward a reparative phenotype and improve the outcome of cell therapy for infarct repair. We developed and optimized an improved electroporation protocol for CRISPR-Cas9 gene editing. This protocol achieved a 68% success rate when applied to isolated hMSCs from the heart and epicardial fat of patients with ischemic heart disease. While cell editing lowered TLR4 expression in hMSCs, it did not affect classical markers of hMSCs, proliferation, and migration rate. Protein mass spectrometry analysis revealed that edited cells secreted fewer proteins involved in inflammation. Analysis of biological processes revealed that TLR4 editing reduced processes linked to inflammation and extracellular organization. Furthermore, edited cells expressed less NF-ƙB and secreted lower amounts of extracellular vesicles and pro-inflammatory and pro-fibrotic cytokines than unedited hMSCs. Cell therapy with both edited and unedited hMSCs improved survival, left ventricular remodeling, and cardiac function after myocardial infarction (MI) in mice. Postmortem histologic analysis revealed clusters of edited cells that survived in the scar tissue 28 days after MI. Morphometric analysis showed that implantation of edited cells increased the area of myocardial islands in the scar tissue, reduced the occurrence of transmural scar, increased scar thickness, and decreased expansion index. We show, for the first time, that CRISPR-Cas9-based disruption of the TLR4-gene reduces pro-inflammatory polarization of hMSCs and improves infarct healing and remodeling in mice. Our results provide a new approach to improving the outcomes of cell therapy for cardiovascular diseases.
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Affiliation(s)
- Yeshai Schary
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Itai Rotem
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Tal Caller
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Nir Lewis
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Olga Shaihov-Teper
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Rafael Y Brzezinski
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Daria Lendengolts
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Ehud Raanani
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid Sternik
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nili Naftali-Shani
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Jonathan Leor
- Neufeld and Tamman Cardiovascular Research Institutes, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Heart Center, Sheba Medical Center, 52621, Tel-Hashomer, Israel.
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5
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Mu L, Dong R, Guo B. Biomaterials-Based Cell Therapy for Myocardial Tissue Regeneration. Adv Healthc Mater 2022; 12:e2202699. [PMID: 36572412 DOI: 10.1002/adhm.202202699] [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: 10/19/2022] [Revised: 12/11/2022] [Indexed: 12/28/2022]
Abstract
Cardiovascular diseases (CVDs) have been the leading cause of death worldwide during the past several decades. Cell loss is the main problem that results in cardiac dysfunction and further mortality. Cell therapy aiming to replenish the lost cells is proposed to treat CVDs especially ischemic heart diseases which lead to a big portion of cell loss. Due to the direct injection's low cell retention and survival ratio, cell therapy using biomaterials as cell carriers has attracted more and more attention because of their promotion of cell delivery and maintenance at the aiming sites. In this review, the three main factors involved in cell therapy for myocardial tissue regeneration: cell sources (somatic cells, stem cells, and engineered cells), chemical components of cell carriers (natural materials, synthetic materials, and electroactive materials), and categories of cell delivery materials (patches, microspheres, injectable hydrogels, nanofiber and microneedles, etc.) are systematically summarized. An introduction of the methods including magnetic resonance/radionuclide/photoacoustic and fluorescence imaging for tracking the behavior of transplanted cells in vivo is also included. Current challenges of biomaterials-based cell therapy and their future directions are provided to give both beginners and professionals a clear view of the development and future trends in this area.
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Affiliation(s)
- Lei Mu
- Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Ruonan Dong
- Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Baolin Guo
- Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi'an Jiaotong University, Xi'an, 710049, China.,State Key Laboratory for Mechanical Behavior of Materials, and Frontier Institute of Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
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6
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Foglio E, Pellegrini L, Russo MA, Limana F. HMGB1-Mediated Activation of the Inflammatory-Reparative Response Following Myocardial Infarction. Cells 2022; 11:cells11020216. [PMID: 35053332 PMCID: PMC8773872 DOI: 10.3390/cells11020216] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/04/2022] [Accepted: 01/08/2022] [Indexed: 02/06/2023] Open
Abstract
Different cell types belonging to the innate and adaptive immune system play mutually non-exclusive roles during the different phases of the inflammatory-reparative response that occurs following myocardial infarction. A timely and finely regulation of their action is fundamental for the process to properly proceed. The high-mobility group box 1 (HMGB1), a highly conserved nuclear protein that in the extracellular space can act as a damage-associated molecular pattern (DAMP) involved in a large variety of different processes, such as inflammation, migration, invasion, proliferation, differentiation, and tissue regeneration, has recently emerged as a possible regulator of the activity of different immune cell types in the distinct phases of the inflammatory reparative process. Moreover, by activating endogenous stem cells, inducing endothelial cells, and by modulating cardiac fibroblast activity, HMGB1 could represent a master regulator of the inflammatory and reparative responses following MI. In this review, we will provide an overview of cellular effectors involved in these processes and how HMGB1 intervenes in regulating each of them. Moreover, we will summarize HMGB1 roles in regulating other cell types that are involved in the different phases of the inflammatory-reparative response, discussing how its redox status could affect its activity.
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Affiliation(s)
- Eleonora Foglio
- Technoscience, Parco Scientifico e Tecnologico Pontino, 04100 Latina, Italy;
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy;
| | - Laura Pellegrini
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy;
| | - Matteo Antonio Russo
- IRCCS San Raffaele Roma and MEBIC Consortium, 00166 Rome, Italy;
- San Raffaele University of Rome, 00166 Rome, Italy
| | - Federica Limana
- San Raffaele University of Rome, 00166 Rome, Italy
- Laboratory of Cellular and Molecular Pathology, IRCCS San Raffaele Roma, 00166 Rome, Italy
- Correspondence:
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7
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Nath AV, Ajit S, Sekar AJ, P R AK, Muthusamy S. MicroRNA-200c/429 mediated regulation of Zeb1 augments N-Cadherin in mouse cardiac mesenchymal cells. Cell Biol Int 2021; 46:222-233. [PMID: 34747544 DOI: 10.1002/cbin.11724] [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: 05/17/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/10/2022]
Abstract
Cardiac mesenchymal cells (CMCs) are a promising cell type that showed therapeutic potential in heart failure models. The analysis of the underlying mechanisms by which the CMCs improve cardiac function is on track. This study aimed to investigate the expression of N-Cadherin, a transmembrane protein that enhances cell adhesion, and recently gained attention for differentiation and augmentation of stem cell function. The mouse CMCs were isolated and analyzed for the mesenchymal markers using flow cytometry. Quantitative real-time polymerase chain reaction (qRT-PCR) and western blot analysis were used to assess the expression of N-Cadherin along with its counteracting molecule E-Cadherin and their regulator Zeb1 in CMCs and dermal fibroblast. The expression level of miR-200c and miR-429 was analyzed using miRNA assays. Transient transfection of miR-200c followed by qRT-PCR, western blot analysis, and immunostaining was done in CMCs to analyze the expression of Zeb1, N-Cadherin, and E-Cadherin. Flow cytometry analysis showed that CMCs possess mesenchymal markers and absence for hematopoietic and immune cell markers. Increased expression of N-Cadherin and Zeb1 in CMCs was observed in CMCs at both RNA and protein levels compared to fibroblast. We found significant downregulation of miR-200c and miR-429 in CMCs. The ectopic expression of miR-200c in CMCs significantly downregulated Zeb1 and N-Cadherin expression. Our findings suggest that the significant downregulation of miR-200c/429 in CMCs maintains the expression of N-Cadherin, which may be important for its functional integrity.
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Affiliation(s)
- Asha V Nath
- TIMED, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Shilpa Ajit
- Department of Applied Biology, Division of Tissue Culture, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Anupama J Sekar
- Department of Applied Biology, Division of Tissue Culture, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Anil Kumar P R
- Department of Applied Biology, Division of Tissue Culture, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Senthilkumar Muthusamy
- Department of Applied Biology, Division of Tissue Culture, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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8
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Moore JB, Wysoczynski M. Immunomodulatory Effects of Cell Therapy after Myocardial Infarction. JOURNAL OF CELLULAR IMMUNOLOGY 2021; 3:85-90. [PMID: 33959728 PMCID: PMC8098722 DOI: 10.33696/immunology.3.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Joseph B Moore
- Diabetes and Obesity Center, University of Louisville School of Medicine, Louisville, KY, USA
| | - Marcin Wysoczynski
- Diabetes and Obesity Center, University of Louisville School of Medicine, Louisville, KY, USA
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