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Talbot K, Song J, Perrier JR, Jackson S, MacGillivray RTA, Pryzdial ELG. Factor V haemostatic diathesis impairing thrombin activation, membrane binding and circulating antigen level due to a novel compound heterozygous mutation, Leu1821Ser and Gly2192Cys. Haemophilia 2024. [PMID: 39118297 DOI: 10.1111/hae.15087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 07/16/2024] [Accepted: 07/19/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION Congenital factor V (FV) deficiency is a rare clotting disorder affecting ∼1 in 1,000,000, with bleeding severity that ranges broadly for poorly understood reasons. AIM To help understand the molecular basis of the observed phenotype in FV deficient patients, the genetics and biochemistry causing a patient's FV deficiency were evaluated. METHODS AND RESULTS A 71-year-old female, who had serious life-long bleeding upon provocation and profound menorrhagia that lead to hysterectomy, was found to have 3% of normal plasma FV antigen with normal electrophoretic mobility. Platelet FV was similarly low, although the banding pattern was less fragmented than normal. Plasma clotting activity was <1% of normal. Familial inheritance and DNA sequence analysis from peripheral blood leukocytes were consistent with novel compound heterozygosity with missense mutations in exon XVII, Leu1821 to Ser (L1821S) and exon XXV, Gly2192 to Cys (G2192C). The respective single-mutation variants were expressed and purified. Explaining why the antigen level and activity were inequivalent, thrombin activation of recombinant (r) FV/L1821S was impaired, and rFV/G2192C was unable to bind to a procoagulant phospholipid membrane. CONCLUSION These findings are consistent with the observed phenotype, highlighting the importance of understanding FV biochemical function to rationalize clinical bleeding severity when the circulating antigen level is discordant.
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Affiliation(s)
- Kimberley Talbot
- Canadian Blood Services, Medical Affairs and Innovation, Vancouver, Canada
- University of British Columbia (UBC), Centre for Blood Research, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, UBC, Vancouver, Canada
| | - Jina Song
- Canadian Blood Services, Medical Affairs and Innovation, Vancouver, Canada
- University of British Columbia (UBC), Centre for Blood Research, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, UBC, Vancouver, Canada
| | - John R Perrier
- Canadian Blood Services, Medical Affairs and Innovation, Vancouver, Canada
- University of British Columbia (UBC), Centre for Blood Research, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, UBC, Vancouver, Canada
| | - Shannon Jackson
- Hematology, St. Paul's Hospital, Providence Health Care, Vancouver, Canada
- Department of Medicine, UBC, Vancouver, Canada
| | - Ross T A MacGillivray
- University of British Columbia (UBC), Centre for Blood Research, Vancouver, Canada
- Department of Biochemistry and Molecular Biology, UBC, Vancouver, Canada
| | - Edward L G Pryzdial
- Canadian Blood Services, Medical Affairs and Innovation, Vancouver, Canada
- University of British Columbia (UBC), Centre for Blood Research, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, UBC, Vancouver, Canada
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Calzavarini S, Villoutreix BO, Lunghi B, Livaja R, Bernardi F, Dahlbäck B. Molecular basis of coagulation factor V deficiency caused by the R1698W inter-domain mutation. Thromb Haemost 2013; 110:31-8. [PMID: 23616041 DOI: 10.1160/th12-10-0780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 03/22/2013] [Indexed: 11/05/2022]
Abstract
Coagulation factor V (FV) deficiency is characterised by variable bleeding phenotypes and heterogeneous mutations. To add new insights into the FV genotype-phenotype relationship, we characterised the R1698W change in the A3 domain, at the poorly investigated interface with the A2 domain. The FV R1698W mutation was responsible for a markedly reduced expression level (10% of FV-WT) and specific activity in thrombin generation (0.39). Interestingly, the FVa1698W showed rapid activity decay upon activation due to increased dissociation rate between the heavy and light chains. The importance of the size and charge of the residue at position 1698 was investigated by three additional recombinant mutants, FVR1698A, FVR1698Q, and FVR1698E. FVR1698A and FVR1698Q expression (30 and 45% of FV-WT), specific activity (both 0.57) and stability were all reduced. Noticeably, FVR1698E showed normal activity and stability despite poor expression (10% of FV-WT). These data indicate the essential role of R1698 for normal biosynthetic process and support local flexibility for positively or negatively charged residues to produce stable and functional A3-A2 domain interactions. Their experimental alteration produces a gradient of FV defects, which help to interpret the wide spectrum of phenotypes in FV-deficient patients.
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Affiliation(s)
- Sara Calzavarini
- Sara Calzavarini, PhD, Service and Central Laboratory of Hematology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
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A modulator domain controlling thermal stability in the Group II chaperonins of Archaea. Arch Biochem Biophys 2011; 512:111-8. [PMID: 21600187 DOI: 10.1016/j.abb.2011.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 04/22/2011] [Accepted: 04/24/2011] [Indexed: 11/22/2022]
Abstract
Archaeal Group II chaperonins (Cpns) are strongly conserved, considering that their growth temperatures range from 23 to 122°C. The C-terminal 15-25 residues are hypervariable, and highly charged in thermophilic species. Our hypothesis is that the C-terminal is a key determinant of stabilization of the Cpn complex. The C-terminus of the Cpn from the hyperthermophile Pyrococcus furiosus was mutated to test this hypothesis. C-terminal deletions and replacement of charged residues resulted in destabilization. The stability of ATPase activity declined in proportion to the reduction in charged residues with Ala or Gly. An EK-rich motif ((528)EKEKEKEGEK5(37)) proved to be a key domain for stabilization at or near 100°C. Mutations "tuned" the Cpn for optimal protein folding at lower optimal temperatures, and Glu substitution was more potent than Lys replacement. Pf Cpn stability was enhanced by Ca(2+), especially in the mutant Cpn lacking C-terminal Lys residues. This suggests that Glu-Glu interactions between C termini might be mediated by Ca(2+). The C-terminal of a Cpn from the psychrophilic archaeon Methanococcoides burtonii was replaced by a domain from the hyperthermophile, resulting in increased thermostability and thermoactivity. We conclude that localized evolutionary variation in the C-terminus modulates the temperature range of archaeal Cpns.
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Differential contributions of Glu96, Asp102 and Asp111 to coagulation Factor V/Va metal ion binding and subunit stability. Biochem J 2009; 422:257-64. [DOI: 10.1042/bj20090405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Blood coagulation FV (Factor V) is activated by thrombin-mediated excision of the B domain, resulting in a non-covalent heterodimer, FVa (activated FV). Previous studies implicated Glu96, Asp102 and Asp111 in the essential Ca2+-dependent FVa subunit interaction. In the present study, FV E96A, D102A and D111A were purified and evaluated for function, subunit dissociation and metal ion binding. Chromogenic and clotting assays in the presence of procoagulant vesicles showed that each variant was inhibited (∼20–40%). D111A was further inhibited (>90%) after cleavage by thrombin. Comparable function was observed on activated platelets. D111A inhibition correlated to spontaneous subunit dissociation and severely impaired Ca2+ binding. The Cu2+ interaction was also inhibited, suggesting interdependent Ca2+ and Cu2+ binding to FV. The parental FV (FV-810; wild-type human FV missing residues 811–1491) used here is fully active without proteolysis because the B domain is truncated. Therefore, a FVa-like functional configuration exists for intact D111A independent of normal metal ion interactions. Unlike D111A, the thrombin-mediated FVa derived from E96A and D102A had only moderately enhanced subunit dissociation upon chelation and had normal metal ion binding. For FV-810-, E96A- and D102A-derived FVa, loss of function after chelation significantly preceded subunit dissociation. This study defines the highly conserved segment spanning Glu96–Asp111 in FV as multifunctional. Of the three amino acids evaluated, Asp111 is essential and probably functions through direct and indirect effects on Ca2+ and Cu2+ interactions. Glu96 and Asp102 individually influence FV/FVa by more subtle effects, possibly at the metal ion-dependent subunit interface.
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Stoilova-McPhie S, Parmenter CDJ, Segers K, Villoutreix BO, Nicolaes GAF. Defining the structure of membrane-bound human blood coagulation factor Va. J Thromb Haemost 2008; 6:76-82. [PMID: 17949476 DOI: 10.1111/j.1538-7836.2007.02810.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Blood coagulation factor (F) Va is the essential protein cofactor to the serine protease FXa. Factor Va stimulates the thrombin-to-prothrombin conversion by the prothrombinase complex, by at least five orders of magnitude. Factor Va binds with very high affinity to phosphatidylserine containing phospholipid membranes, which allows the visualization of its membrane-bound state by transmission electron microscopy (EM). METHODS In this paper we present an averaged three-dimensional structure of FVa molecules attached to phosphatidylserine containing lipid tubes, as determined by EM and single particle analysis. The low-resolution FVa three-dimensional structure is compared with the available atomic models for FVa. RESULTS The experimental data are combined with the most suitable atomic model and a membrane-bound FVaEM model is proposed that best fits the protein density defined by EM. In the FVaEM model, the C1 and C2 membrane-binding domains are juxtaposed onto the membrane surface and the model geometries indicate a deeper insertion of both C domains into the lipid bilayer than has been previously suggested. CONCLUSION The present structure is a first step towards a higher-resolution experimental structure of a human FVa molecule in its membrane-bound conformation, allowing the visualization of individual domains within FVa and its association with the membrane.
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Affiliation(s)
- S Stoilova-McPhie
- Department of Biological Sciences, University of Warwick, Coventry, UK.
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Derry MC, Sutherland MR, Restall CM, Waisman DM, Pryzdial ELG. Annexin 2-mediated enhancement of cytomegalovirus infection opposes inhibition by annexin 1 or annexin 5. J Gen Virol 2007; 88:19-27. [PMID: 17170432 DOI: 10.1099/vir.0.82294-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Biochemical studies have suggested that annexin 2 (A2) may participate in cytomegalovirus (CMV) infection. In the current work, effects of A2 monomer (p36) and heterotetramer (A2t; p36(2)p11(2)) were investigated. Demonstrating a role for endogenous A2, the four stages of infection that were followed were each inhibited by anti-p36 or anti-p11 at 37 degrees C. Immuno-inhibition was attenuated when the virus and cells were pre-incubated at 4 degrees C to coordinate virus entry initiated afterwards at 37 degrees C, reconciling controversy in the literature. As an explanation, CMV-induced phosphorylation of p36 was prevented by the 4 degrees C treatment. Supporting these immuno-inhibition data, purified A2t or p11 increased CMV infectious-progeny generation and CMV gene expression. A specific role for A2t was indicated by purified p36 having no effect. Unlike other steps, primary plaque formation was not enhanced by purified A2t or p11, possibly because of undetectable phosphorylation. As annexins 1 (A1) and 5 (A5) interact with A2, their effect on CMV was also tested. Both purified proteins inhibited CMV infection. In each experiment, the concentration of A1 required for half-maximal inhibition was five- to 10-fold lower than that of A5. Addition of A2 opposed A1- or A5-mediated inhibition of CMV, as did certain A2-specific antibodies that had no effect in the absence of added A1 or A5. Transfection of the p36-deficient cell line HepG2 increased CMV infection and was required for inhibition by the other annexins. These data suggest that CMV exploits A2t at physiological temperature to oppose the protection of cells conferred by A1 or A5.
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Affiliation(s)
- Mélanie C Derry
- Department of Pathology and Laboratory Medicine, University of British Columbia/Centre for Blood Research, 2350 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada
- Research and Development Department, Canadian Blood Services, Ottawa, ON, Canada
| | - Michael R Sutherland
- Department of Pathology and Laboratory Medicine, University of British Columbia/Centre for Blood Research, 2350 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- Research and Development Department, Canadian Blood Services, Ottawa, ON, Canada
| | - Christina M Restall
- Research and Development Department, Canadian Blood Services, Ottawa, ON, Canada
| | - David M Waisman
- Department of Medical Biochemistry, University of Calgary, Calgary, AB, Canada
| | - Edward L G Pryzdial
- Department of Pathology and Laboratory Medicine, University of British Columbia/Centre for Blood Research, 2350 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- Research and Development Department, Canadian Blood Services, Ottawa, ON, Canada
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Orban T, Kalafatis M, Gogonea V. Completed Three-Dimensional Model of Human Coagulation Factor Va. Molecular Dynamics Simulations and Structural Analyses. Biochemistry 2005; 44:13082-90. [PMID: 16185076 DOI: 10.1021/bi050891t] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Factor Va is the critical cofactor for prothrombinase assembly required for timely and efficient prothrombin activation. In the absence of a complete crystal structure for the cofactor, Pellequer et al. [(2000) Thromb. Haemostasis 84, 849-857] proposed an incomplete homology model of factor Va (it lacks 46 amino acids from the carboxyl terminus of the heavy chain), which is a static model in a vacuum. A recently published X-ray structure of activated protein C (APC) inactivated bovine factor Va(i) (without the A2 domain) suggests a completely new arrangement of the C1 and C2 domains as compared with the previously published structure of the recombinant C1 and C2 domains. Our aims were (a) to exchange the C1 and C2 domains of the homology model with the modified bovine C1 and C2 domains using the X-ray structure as a template, (b) to determine by computation the three-dimensional model for the carboxyl-terminal peptide of the factor Va heavy chain (Ser(664)-Arg(709)) and incorporate it into the incomplete model, (c) to obtain a complete model of the cofactor folded in solution that might account for its physiological functions and interactions with other components of prothrombinase, and (d) to use the model in order to understand the mechanism of factor Va inactivation by APC. In the first step a sequence alignment of the human and bovine C1 and C2 domains was performed followed by amino acid changes in the three-dimensional structure where the sequences were not identical. The new model of the C1 and C2 domains was then attached to the homology model. The analysis of the MD simulation data revealed that several domains of the cofactor were significantly displaced during simulation. Using our completed model of human factor Va, we are also demonstrating for the first time that cleavage of membrane-bound normal factor Va as well as membrane-bound factor V(LEIDEN) by APC at Arg(306) is required for the dissociation of the A2 domain from the rest of the molecule. Thus, differences in the inactivation rates of the two cofactor molecules are due to differences in the rate of cleavage at Arg(306). The data demonstrate that our model represents the foundation for the establishment of a complete prothrombinase complex model, which might be successful in describing accurately the ternary protein-protein interaction and thus accounts for experimental observations.
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Affiliation(s)
- Tivadar Orban
- Department of Chemistry, Cleveland State University, Ohio 44195, USA
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Adams TE, Hockin MF, Mann KG, Everse SJ. The crystal structure of activated protein C-inactivated bovine factor Va: Implications for cofactor function. Proc Natl Acad Sci U S A 2004; 101:8918-23. [PMID: 15184653 PMCID: PMC428447 DOI: 10.1073/pnas.0403072101] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2004] [Indexed: 11/18/2022] Open
Abstract
In vertebrate hemostasis, factor Va serves as the cofactor in the prothrombinase complex that results in a 300,000-fold increase in the rate of thrombin generation compared with factor Xa alone. Structurally, little is known about the mechanism by which factor Va alters catalysis within this complex. Here, we report a crystal structure of protein C inactivated factor Va (A1.A3-C1-C2) that depicts a previously uncharacterized domain arrangement. This orientation has implications for binding to membranes essential for function. A high-affinity calcium-binding site and a copper-binding site have both been identified. Surprisingly, neither shows a direct involvement in chain association. This structure represents the largest physiologically relevant fragment of factor Va solved to date and provides a new scaffold for the future generation of models of coagulation cofactors.
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Affiliation(s)
- Ty E Adams
- Department of Biochemistry, College of Medicine, University of Vermont, 89 Beaumont Avenue, Burlington, VT 05405, USA
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van der Neut Kolfschoten M, Dirven RJ, Poort SR, van Wijk R, Vos HL, Rosendaal FR, Bertina RM. Characterization of an immunologic polymorphism (D79H) in the heavy chain of factor V. J Thromb Haemost 2004; 2:910-7. [PMID: 15140126 DOI: 10.1046/j.1538-7836.2004.00713.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND During the study of a family with hereditary factor (F)V deficiency (FV Amersfoort, 1102 A > T in exon 7) we identified an individual with 5% FV heavy chain antigen (FV(HC)) and 50% FV light chain antigen (FV(LC)). Further testing revealed that apart from the FV Amersfoort allele a second variant FV allele was segregating in this family, which encodes for a FV molecule with a reduced affinity for mAb V-23 used in the FV heavy chain ELISA (ELISA(HC)). OBJECTIVE Identification and characterization of the molecular basis responsible for the reduced affinity of the variant FV for mAb V-23. METHODS Family members of the proband were screened for mutations in the exons coding for the heavy chain of FV, after which the recombinant variant FV could be generated and characterized. Next, the cases and controls of the Leiden Thrombophilia Study (LETS) were genotyped for carriership of the variant FV. RESULTS In the variant FV allele a polymorphism in exon 3 (409G > C) was identified, which predicts the replacement of aspartic acid 79 by histidin (D79H). Introduction of this mutation in recombinant FV confirmed that it reduces the affinity for binding to mAb V-23. The substitution has no effect on FV(a) stability and Xa-cofactor activity. In Caucasians the frequency of the FV-79H allele is approximately 5%. Analysis of the LETS revealed that the FV-79H allele is not associated with FV levels (FV(LC)), activated protein C sensitivity (using an activated partial thromboplastin time-based test) or risk of venous thrombosis (OR 1.07, CI 95: 0.7-1.7). CONCLUSION The D79H substitution in FV should be considered as a neutral polymorphism. The monoclonal antibody V-23, which has a strongly reduced affinity for FV-79H, is not suitable for application in diagnostic tests.
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Sørensen KW, Nicolaes GAF, Villoutreix BO, Yamazaki T, Tans G, Rosing J, Dahlbäck B. Functional Properties of Recombinant Factor V Mutated in a Potential Calcium-Binding Site. Biochemistry 2004; 43:5803-10. [PMID: 15134454 DOI: 10.1021/bi0361362] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Activated coagulation factor V (FVa) is a cofactor of activated factor X (FXa) in prothrombin activation. FVa is composed of a light chain (LC) and a heavy chain (HC) that are noncovalently associated in a calcium-dependent manner. We constructed a recombinant FV Asp111Asn/Asp112Asn mutant (rFV-NN) to abolish calcium binding to a potential calcium-binding site in FVa in order to study the specific role of these residues in the expression of FVa activity. Whereas thrombin-activated recombinant FV wild type (rFV-wt) presented with stable FVa activity, incubation of rFV-NN with thrombin resulted in a temporary increase in FVa activity, which was rapidly lost upon prolonged incubation. Loss of FVa activity was most likely due to dissociation of HC and LC since, upon chromatography of rFVa-NN on a SP-Sepharose column, the HC did not bind significantly to the resin whereas the LC bound and could be eluted at high ionic strength. In contrast, rFVa-wt adhered to the column, and both the HC and LC coeluted at high ionic strength. In the presence of phospholipid vesicles, the loss of rFVa-NN activity was partially prevented by FXa, active site inhibited FXa, and prothombin in a dose-dependent manner. We conclude that the introduced amino acid substitutions result in a loss of the high-affinity (calcium-dependent) interaction of the HC and LC of FVa. We propose that the introduced substitutions disrupt the calcium-binding site in FV, thereby yielding a FV molecule that rapidly loses activity following thrombin-catalyzed activation most likely via dissociation of the HC and LC.
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Affiliation(s)
- Kristoffer W Sørensen
- Department of Clinical Chemistry, Lund University, Malmö University Hospital, Malmö, Sweden
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Wakabayashi H, Freas J, Zhou Q, Fay PJ. Residues 110-126 in the A1 domain of factor VIII contain a Ca2+ binding site required for cofactor activity. J Biol Chem 2004; 279:12677-84. [PMID: 14722121 DOI: 10.1074/jbc.m311042200] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Generation of factor VIII cofactor activity requires divalent metal ions such as Ca2+ or Mn2+. Evaluation of cofactor reconstitution from isolated factor VIIIa subunits revealed the presence of a functional Ca2+ binding site within the A1 subunit. Isothermal titration calorimetry demonstrated at least two Ca2+ binding sites of similar affinity (K(d) = 0.74 microm) within the A1 subunit. Mutagenesis of an acidic residue-rich region in the A1 domain (residues 110-126) homologous to a putative Ca2+ binding site in factor V (Zeibdawi, A. R., and Pryzdial, E. L. (2001) J. Biol. Chem. 276, 19929-19936) and expression of B-domainless factor VIII molecules yielded reagents to probe Ca2+ and Mn2+ binding in a functional assay. Basal activity observed for wild type factor VIII in a metal ion-free buffer was enhanced approximately 2-fold with saturating Ca2+ or Mn2+ and yielded functional K(d) values of 1.2 and 1.40 microm, respectively. Ca2+ binding affinity was greatly reduced (or lost) in several mutants including E110A, E110D, D116A, E122A, D125A, and D126A. Alternatively, E113A, D115A, and E124A showed wild type-like activity with little or no reduction in Ca2+ affinity. However, Mn2+ affinity was minimally altered except for mutant D125A (and D116A). These results are consistent with region 110-126 serving a critical role for Ca2+ coordination with selected residues capable of contributing to a partially overlapping site for Mn2+, and that occupancy of either site is required for maximal cofactor activity.
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Affiliation(s)
- Hironao Wakabayashi
- Department of Biochemistry and Biophysics, University of Rochester School of Medicine, 601 Elmwood Avenue, Rochester, NY 14642, USA
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