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Gouel-Chéron A, Dejoux A, Lamanna E, Bruhns P. Animal Models of IgE Anaphylaxis. BIOLOGY 2023; 12:931. [PMID: 37508362 PMCID: PMC10376466 DOI: 10.3390/biology12070931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023]
Abstract
Allergies and atopy have emerged as significant public health concerns, with a progressively increasing incidence over the last two decades. Anaphylaxis is the most severe form of allergic reactions, characterized by a rapid onset and potentially fatal outcome, even in healthy individuals. Due to the unpredictable nature and potential lethality of anaphylaxis and the wide range of allergens involved, clinical studies in human patients have proven to be challenging. Diagnosis is further complicated by the lack of reliable laboratory biomarkers to confirm clinical suspicion. Thus, animal models have been developed to replicate human anaphylaxis and explore its pathophysiology. Whereas results obtained from animal models may not always be directly translatable to humans, they serve as a foundation for understanding the underlying mechanisms. Animal models are an essential tool for investigating new biomarkers that could be incorporated into the allergy workup for patients, as well as for the development of novel treatments. Two primary pathways have been described in animals and humans: classic, predominantly involving IgE and histamine, and alternative, reliant on IgG and the platelet-activating factor. This review will focus essentially on the former and aims to describe the most utilized IgE-mediated anaphylaxis animal models, including their respective advantages and limitations.
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Affiliation(s)
- Aurélie Gouel-Chéron
- Université Paris Cité, 75010 Paris, France
- Anaesthesiology and Critical Care Medicine Department, DMU Parabol, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France
- Institut Pasteur, Université de Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
| | - Alice Dejoux
- Institut Pasteur, Université de Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- Sorbonne Université, Collège Doctoral, 75005 Paris, France
| | - Emma Lamanna
- Institut Pasteur, Université de Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- Neovacs SA, 92150 Suresnes, France
| | - Pierre Bruhns
- Institut Pasteur, Université de Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
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Arthur GK, Cruse G. Regulation of Trafficking and Signaling of the High Affinity IgE Receptor by FcεRIβ and the Potential Impact of FcεRIβ Splicing in Allergic Inflammation. Int J Mol Sci 2022; 23:ijms23020788. [PMID: 35054974 PMCID: PMC8776166 DOI: 10.3390/ijms23020788] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/06/2022] [Accepted: 01/08/2022] [Indexed: 12/23/2022] Open
Abstract
Mast cells are tissue-resident immune cells that function in both innate and adaptive immunity through the release of both preformed granule-stored mediators, and newly generated proinflammatory mediators that contribute to the generation of both the early and late phases of the allergic inflammatory response. Although mast cells can be activated by a vast array of mediators to contribute to homeostasis and pathophysiology in diverse settings and contexts, in this review, we will focus on the canonical setting of IgE-mediated activation and allergic inflammation. IgE-dependent activation of mast cells occurs through the high affinity IgE receptor, FcεRI, which is a multimeric receptor complex that, once crosslinked by antigen, triggers a cascade of signaling to generate a robust response in mast cells. Here, we discuss FcεRI structure and function, and describe established and emerging roles of the β subunit of FcεRI (FcεRIβ) in regulating mast cell function and FcεRI trafficking and signaling. We discuss current approaches to target IgE and FcεRI signaling and emerging approaches that could target FcεRIβ specifically. We examine how alternative splicing of FcεRIβ alters protein function and how manipulation of splicing could be employed as a therapeutic approach. Targeting FcεRI directly and/or IgE binding to FcεRI are promising approaches to therapeutics for allergic inflammation. The characteristic role of FcεRIβ in both trafficking and signaling of the FcεRI receptor complex, the specificity to IgE-mediated activation pathways, and the preferential expression in mast cells and basophils, makes FcεRIβ an excellent, but challenging, candidate for therapeutic strategies in allergy and asthma, if targeting can be realized.
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Affiliation(s)
- Greer K. Arthur
- Department of Population Health and Pathobiology, College of Veterinary Medicine, NC State University, Raleigh, NC 27607, USA;
| | - Glenn Cruse
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, NC State University, Raleigh, NC 27607, USA
- Correspondence: ; Tel.: +1-919-515-8865
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El Ansari YS, Kanagaratham C, Lewis OL, Oettgen HC. IgE and mast cells: The endogenous adjuvant. Adv Immunol 2020; 148:93-153. [PMID: 33190734 DOI: 10.1016/bs.ai.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mast cells and IgE are most familiar as the effectors of type I hypersensitivity reactions including anaphylaxis. It is becoming clear however that this pair has important immunomodulatory effects on innate and adaptive cells of the immune system. In this purview, they act as endogenous adjuvants to ignite evolving immune responses, promote the transition of allergic disease into chronic illness and disrupt the development of active mechanisms of tolerance to ingested foods. Suppression of IgE-mediated mast cell activation can be exerted by molecules targeting IgE, FcɛRI or signaling kinases including Syk, or by IgG antibodies acting via inhibitory Fcγ receptors. In 2015 we reviewed the evidence for the adjuvant functions of mast cells. This update includes the original text, incorporates some important developments in the field over the past five years and discusses how interventions targeting these pathways might have promise in the development of strategies to treat allergic disease.
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Affiliation(s)
- Yasmeen S El Ansari
- Division of Immunology, Boston Children's Hospital, Boston, MA, United States; Institute of Laboratory Medicine, Philipps University Marburg, Marburg, Germany
| | - Cynthia Kanagaratham
- Division of Immunology, Boston Children's Hospital, Boston, MA, United States; Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Owen L Lewis
- Division of Immunology, Boston Children's Hospital, Boston, MA, United States
| | - Hans C Oettgen
- Division of Immunology, Boston Children's Hospital, Boston, MA, United States; Department of Pediatrics, Harvard Medical School, Boston, MA, United States.
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Vitallé J, Terrén I, Orrantia A, Bilbao A, Gamboa PM, Borrego F, Zenarruzabeitia O. The Expression and Function of CD300 Molecules in the Main Players of Allergic Responses: Mast Cells, Basophils and Eosinophils. Int J Mol Sci 2020; 21:ijms21093173. [PMID: 32365988 PMCID: PMC7247439 DOI: 10.3390/ijms21093173] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/17/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023] Open
Abstract
Allergy is the host immune response against non-infectious substances called allergens. The prevalence of allergic diseases is increasing worldwide. However, while some drugs counteract the symptomatology caused by allergic reactions, no completely effective treatments for allergic diseases have been developed yet. In this sense, the ability of surface activating and inhibitory receptors to modulate the function of the main effector cells of allergic responses makes these molecules potential pharmacological targets. The CD300 receptor family consists of members with activating and inhibitory capabilities mainly expressed on the surface of immune cells. Multiple studies in the last few years have highlighted the importance of CD300 molecules in several pathological conditions. This review summarizes the literature on CD300 receptor expression, regulation and function in mast cells, basophils and eosinophils, the main players of allergic responses. Moreover, we review the involvement of CD300 receptors in the pathogenesis of certain allergic diseases, as well as their prospective use as therapeutic targets for the treatment of IgE-dependent allergic responses.
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Affiliation(s)
- Joana Vitallé
- Immunopathology Group, Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain; (J.V.); (I.T.); (A.O.); (A.B.); (P.M.G.); (F.B.)
| | - Iñigo Terrén
- Immunopathology Group, Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain; (J.V.); (I.T.); (A.O.); (A.B.); (P.M.G.); (F.B.)
| | - Ane Orrantia
- Immunopathology Group, Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain; (J.V.); (I.T.); (A.O.); (A.B.); (P.M.G.); (F.B.)
| | - Agurtzane Bilbao
- Immunopathology Group, Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain; (J.V.); (I.T.); (A.O.); (A.B.); (P.M.G.); (F.B.)
- Pediatrics Service, Cruces University Hospital, 48903 Barakaldo, Spain
| | - Pedro M. Gamboa
- Immunopathology Group, Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain; (J.V.); (I.T.); (A.O.); (A.B.); (P.M.G.); (F.B.)
- Allergology Service, Cruces University Hospital, 48903 Barakaldo, Spain
| | - Francisco Borrego
- Immunopathology Group, Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain; (J.V.); (I.T.); (A.O.); (A.B.); (P.M.G.); (F.B.)
- Ikerbasque, Basque Foundation for Science, 48013 Bilbao, Spain
| | - Olatz Zenarruzabeitia
- Immunopathology Group, Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain; (J.V.); (I.T.); (A.O.); (A.B.); (P.M.G.); (F.B.)
- Correspondence: ; Tel.: +34-699-227-735
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Moñino-Romero S, Erkert L, Schmidthaler K, Diesner SC, Sallis BF, Pennington L, Jardetzky T, Oettgen HC, Bohle B, Fiebiger E, Szépfalusi Z. The soluble isoform of human FcɛRI is an endogenous inhibitor of IgE-mediated mast cell responses. Allergy 2019; 74:236-245. [PMID: 30030936 DOI: 10.1111/all.13567] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/01/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The soluble isoform of FcɛRI, the high-affinity IgE receptor (sFcεRI), is a protein of the IgE network with poorly defined functions. OBJECTIVE To define cellular sources and signals that result in the production of human sFcεRI and study its in vivo functions. METHODS FcεRI-transfected human cell lines (MelJuso), human monocyte-derived dendritic cells (moDCs), and murine bone marrow-derived mast cells (MC) were stimulated by FcεRI cross-linking and release of sFcεRI was analyzed (ELISA, Western Blot). Lysosomal-associated membrane protein 1 degranulation assays and human basophil activation tests (BATs) were used to study IgE-dependent activation. Recombinant sFcεRI (rsFcεRI) was used to assess its role in murine models of anaphylaxis with WT (wild-type) and IgE-/- (IgE-deficient) mice. RESULTS Antigen-specific cross-linking of IgE-loaded FcɛRI on MelJuso cells that express the trimeric or tetrameric receptor isoform induced the production of sFcεRI. Using MCs and moDCs, we confirmed that IgE/FcɛRI activation induces sFcɛRI release. We demonstrated that generation of sFcɛRI requires Src phosphorylation and endo/lysosomal acidification. In experimental mouse models, sFcɛRI diminishes the severity of IgE-mediated anaphylaxis. BATs confirmed that, comparable to the anti-IgE monoclonal antibody omalizumab, sFcɛRI is an inhibitor of the human innate IgE effector axis, implying that sFcɛRI and omalizumab potentially inhibit each other in vivo. CONCLUSION sFcɛRI is produced after antigen-specific IgE/FcɛRI-mediated activation signals and functions as an endogenous inhibitor of IgE loading to FcɛRI and IgE-mediated activation. Our results imply, therefore, that sFcɛRI contributes to a negative regulatory feedback loop that aims at preventing overshooting responses after IgE-mediated immune activation.
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Affiliation(s)
- S. Moñino-Romero
- Department of Pediatrics and Adolescent Medicine; Medical University Vienna; Vienna Austria
- Division of Gastroenterology, Hepatology and Nutrition; Department of Medicine; Boston Children's Hospital; Boston Massachusetts
| | - L. Erkert
- Division of Gastroenterology, Hepatology and Nutrition; Department of Medicine; Boston Children's Hospital; Boston Massachusetts
| | - K. Schmidthaler
- Department of Pediatrics and Adolescent Medicine; Medical University Vienna; Vienna Austria
| | - S. C. Diesner
- Department of Pediatrics and Adolescent Medicine; Medical University Vienna; Vienna Austria
| | - B. F. Sallis
- Division of Gastroenterology, Hepatology and Nutrition; Department of Medicine; Boston Children's Hospital; Boston Massachusetts
- Department of Pediatrics; Harvard Medical School; Boston Massachusetts
| | - L. Pennington
- Department of Structural Biology; School of Medicine; Stanford University; Stanford California
| | - T. Jardetzky
- Department of Structural Biology; School of Medicine; Stanford University; Stanford California
| | - H. C. Oettgen
- Department of Pediatrics; Harvard Medical School; Boston Massachusetts
- Division of Immunology; Department of Medicine; Boston Children's Hospital; Boston Massachusetts
| | - B. Bohle
- Department of Pathophysiology and Allergy Research; Medical University of Vienna; Vienna Austria
| | - E. Fiebiger
- Division of Gastroenterology, Hepatology and Nutrition; Department of Medicine; Boston Children's Hospital; Boston Massachusetts
- Department of Pediatrics; Harvard Medical School; Boston Massachusetts
| | - Z. Szépfalusi
- Department of Pediatrics and Adolescent Medicine; Medical University Vienna; Vienna Austria
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Lozano-Ojalvo D, López-Fandiño R. Immunomodulating peptides for food allergy prevention and treatment. Crit Rev Food Sci Nutr 2017; 58:1629-1649. [PMID: 28102702 DOI: 10.1080/10408398.2016.1275519] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Among the most promising strategies currently assayed against IgE-mediated allergic diseases stands the possibility of using immunomodulating peptides to induce oral tolerance toward offending food allergens or even to prevent allergic sensitization. This review focuses on the beneficial effects of food derived immunomodulating peptides on food allergy, which can be directly exerted in the intestinal tract or once being absorbed through the intestinal epithelial barrier to interact with immune cells. Food peptides influence intestinal homeostasis by maintaining and reinforcing barrier function or affecting intestinal cell-signalling to nearby immune cells and mucus secretion. In addition, they can stimulate cells of the innate and adaptive immune system while supressing inflammatory responses. Peptides represent an attractive alternative to whole allergens to enhance the safety and efficacy of immunotherapy treatments. The conclusions drawn from curative and preventive experiments in murine models are promising, although there is a need for more pre-clinical studies to further explore the immunomodulating strategy and its mechanisms and for a deeper knowledge of the peptide sequence and structural requirements that determine the immunoregulatory function.
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Affiliation(s)
- Daniel Lozano-Ojalvo
- a Instituto de Investigación en Ciencias de la Alimentación (CIAL, CSIC-UAM) , Madrid , Spain
| | - Rosina López-Fandiño
- a Instituto de Investigación en Ciencias de la Alimentación (CIAL, CSIC-UAM) , Madrid , Spain
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Oettgen HC. Fifty years later: Emerging functions of IgE antibodies in host defense, immune regulation, and allergic diseases. J Allergy Clin Immunol 2017; 137:1631-1645. [PMID: 27263999 DOI: 10.1016/j.jaci.2016.04.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 04/22/2016] [Accepted: 04/22/2016] [Indexed: 01/15/2023]
Abstract
Fifty years ago, after a long search, IgE emerged as the circulating factor responsible for triggering allergic reactions. Its extremely low concentration in plasma created significant hurdles for scientists working to reveal its identity. We now know that IgE levels are invariably increased in patients affected by atopic conditions and that IgE provides the critical link between the antigen recognition role of the adaptive immune system and the effector functions of mast cells and basophils at mucosal and cutaneous sites of environmental exposure. This review discusses the established mechanisms of action of IgE in pathologic immediate hypersensitivity, as well as its multifaceted roles in protective immunity, control of mast cell homeostasis, and its more recently revealed immunomodulatory functions.
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Affiliation(s)
- Hans C Oettgen
- Division of Immunology, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, Mass.
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Gangwar RS, Landolina N, Arpinati L, Levi-Schaffer F. Mast cell and eosinophil surface receptors as targets for anti-allergic therapy. Pharmacol Ther 2016; 170:37-63. [PMID: 27773785 DOI: 10.1016/j.pharmthera.2016.10.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Roopesh Singh Gangwar
- Pharmacology & Experimental Therapeutics Unit, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Nadine Landolina
- Pharmacology & Experimental Therapeutics Unit, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Ludovica Arpinati
- Pharmacology & Experimental Therapeutics Unit, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Israel
| | - Francesca Levi-Schaffer
- Pharmacology & Experimental Therapeutics Unit, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Israel.
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Blank U, Charles N, Benhamou M. The high-affinity immunoglobulin E receptor as pharmacological target. Eur J Pharmacol 2016; 778:24-32. [DOI: 10.1016/j.ejphar.2015.05.070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 04/29/2015] [Accepted: 05/17/2015] [Indexed: 01/02/2023]
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Li X, Wang J, Shi H, Gao L, Wang X. Inhibition of three novel Radix Scutellariae extracts on immediate hypersensitivity. AFRICAN JOURNAL OF TRADITIONAL, COMPLEMENTARY, AND ALTERNATIVE MEDICINES 2014; 11:54-60. [PMID: 25395705 DOI: 10.4314/ajtcam.v11i5.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Radix Scutellariae, a few papers reported its pharmacology activities including alleviate small intestines smooth muscles spasm, sedation, antihypertensive effect. However, the inhibition of its different organic extracts on immediate hypersensitivity has not bee researched. MATERIALS AND METHODS To investigate the anti-immediate hypersensitivity of three extracts including ethanol extracts, acetone extracts, ethyl acetate extracts from Radix Scutellariae, four pharmacological screening model were chose, such as 4-Aminopyridine induced pruritus model, histamine-induced mouse paw edema model, PCA(passive cutaneous anaphylaxis) in ear of mouse, activie cutaneous anaphylaxismouse (mouse ear edema test), furthermore, total IgE level in the sensitized mice serum was evaluated deeply. RESULTS Ethanol group at 1.42 g/kg and 0.71 g/kg could greatly decrease the licking number to 1.2 and 12.7 respectively; also keep mice paw swelling at 0.29 ml and 0.51 ml at 15 min after injection of histamine. Both ear passive cutaneous allergic reaction and active cutaneous anaphylaxis-ear swelling test demonstrated that ethanol group exhibit great inhibition on immediate hypersensitivity.Low IgE level was found in ethanol group, but high in other two groups. CONCLUSION The ethanol extracts exhibits obvious strong inhibition, however, the acetone ones and ethyl acetate showed a little.
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Affiliation(s)
- Xiaorong Li
- Central Laboratory, The Luhe Teaching Hospital of the Capital Medical University, Beijing, China
| | - Jiangning Wang
- Reparative and reconstructive Sugery, Beijing Shijitan Hospital, Capital Medical University Beijing, China
| | - Haiyun Shi
- Department of Allergy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lei Gao
- Plastic Surgery, The Luhe Teaching Hospital of the Capital Medical University, Beijing, China
| | - Xueyan Wang
- Department of Allergy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Redhu NS, Shan L, Al-Subait D, Ashdown HL, Movassagh H, Lamkhioued B, Gounni AS. IgE induces proliferation in human airway smooth muscle cells: role of MAPK and STAT3 pathways. Allergy Asthma Clin Immunol 2013; 9:41. [PMID: 24499258 PMCID: PMC3842672 DOI: 10.1186/1710-1492-9-41] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/01/2013] [Indexed: 12/27/2022] Open
Abstract
Airway remodeling is not specifically targeted by current asthma medications, partly owing to the lack of understanding of remodeling mechanisms, altogether posing great challenges in asthma treatment. Increased airway smooth muscle (ASM) mass due to hyperplasia/hypertrophy contributes significantly to overall airway remodeling and correlates with decline in lung function. Recent evidence suggests that IgE sensitization can enhance the survival and mediator release in inflammatory cells. Human ASM (HASM) cells express both low affinity (FcεRII/CD23) and high affinity IgE Fc receptors (FcεRI), and IgE can modulate the contractile and synthetic function of HASM cells. IgE was recently shown to induce HASM cell proliferation but the detailed mechanisms remain unknown. We report here that IgE sensitization induces HASM cell proliferation, as measured by 3H-thymidine, EdU incorporation, and manual cell counting. As an upstream signature component of FcεRI signaling, inhibition of spleen tyrosine kinase (Syk) abrogated the IgE-induced HASM proliferation. Further analysis of IgE-induced signaling depicted an IgE-mediated activation of Erk 1/2, p38, JNK MAPK, and Akt kinases. Lastly, lentiviral-shRNA-mediated STAT3 silencing completely abolished the IgE-mediated HASM cell proliferation. Collectively, our data provide mechanisms of a novel function of IgE which may contribute, at least in part, to airway remodeling observed in allergic asthma by directly inducing HASM cell proliferation.
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Affiliation(s)
| | | | | | | | | | | | - Abdelilah S Gounni
- Department of Immunology, Faculty of Medicine, University of Manitoba, 419 Apotex Centre- 750 McDermot Ave, Winnipeg, MB R3E 0T5, Canada.
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