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Nicolaou A, Mauro C, Urquhart P, Marelli-Berg F. Polyunsaturated Fatty Acid-derived lipid mediators and T cell function. Front Immunol 2014; 5:75. [PMID: 24611066 PMCID: PMC3933826 DOI: 10.3389/fimmu.2014.00075] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/11/2014] [Indexed: 01/10/2023] Open
Abstract
Fatty acids are involved in T cell biology both as nutrients important for energy production as well as signaling molecules. In particular, polyunsaturated fatty acids are known to exhibit a range of immunomodulatory properties that progress through T cell mediated events, although the molecular mechanisms of these actions have not yet been fully elucidated. Some of these immune activities are linked to polyunsaturated fatty acid-induced alteration of the composition of cellular membranes and the consequent changes in signaling pathways linked to membrane raft-associated proteins. However, significant aspects of the polyunsaturated fatty acid bioactivities are mediated through their transformation to specific lipid mediators, products of cyclooxygenase, lipoxygenase, or cytochrome P450 enzymatic reactions. Resulting bioactive metabolites including prostaglandins, leukotrienes, and endocannabinoids are produced by and/or act upon T leukocytes through cell surface receptors and have been shown to alter T cell activation and differentiation, proliferation, cytokine production, motility, and homing events. Detailed appreciation of the mode of action of these lipids presents opportunities for the design and development of therapeutic strategies aimed at regulating T cell function.
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Affiliation(s)
- Anna Nicolaou
- Manchester Pharmacy School, Faculty of Medical and Human Sciences, The University of Manchester , Manchester , UK
| | - Claudio Mauro
- Centre for Biochemical Pharmacology, William Harvey Research Institute, Queen Mary University of London , London , UK
| | - Paula Urquhart
- Manchester Pharmacy School, Faculty of Medical and Human Sciences, The University of Manchester , Manchester , UK
| | - Federica Marelli-Berg
- Centre for Biochemical Pharmacology, William Harvey Research Institute, Queen Mary University of London , London , UK
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Dramane G, Abdoul-Azize S, Hichami A, Vögtle T, Akpona S, Chouabe C, Sadou H, Nieswandt B, Besnard P, Khan NA. STIM1 regulates calcium signaling in taste bud cells and preference for fat in mice. J Clin Invest 2012; 122:2267-82. [PMID: 22546859 DOI: 10.1172/jci59953] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 03/07/2012] [Indexed: 11/17/2022] Open
Abstract
Understanding the mechanisms underlying oro-gustatory detection of dietary fat is critical for the prevention and treatment of obesity. The lipid-binding glycoprotein CD36, which is expressed by circumvallate papillae (CVP) of the mouse tongue, has been implicated in oro-gustatory perception of dietary lipids. Here, we demonstrate that stromal interaction molecule 1 (STIM1), a sensor of Ca(2+) depletion in the endoplasmic reticulum, mediates fatty acid-induced Ca(2+) signaling in the mouse tongue and fat preference. We showed that linoleic acid (LA) induced the production of arachidonic acid (AA) and lysophosphatidylcholine (Lyso-PC) by activating multiple phospholipase A2 isoforms via CD36. This activation triggered Ca(2+) influx in CD36-positive taste bud cells (TBCs) purified from mouse CVP. LA also induced the production of Ca(2+) influx factor (CIF). STIM1 was found to regulate LA-induced CIF production and the opening of multiple store-operated Ca(2+) (SOC) channels. Furthermore, CD36-positive TBCs from Stim1-/- mice failed to release serotonin, and Stim1-/- mice lost the spontaneous preference for fat that was observed in wild-type animals. Our results suggest that fatty acid-induced Ca(2+) signaling, regulated by STIM1 via CD36, might be implicated in oro-gustatory perception of dietary lipids and the spontaneous preference for fat.
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Affiliation(s)
- Gado Dramane
- Unité Propre de L’Enseignement Supérieure Lipides and Signalisation Cellulaire Equipe d’Accueil 4183, Faculté des sciences de la vie, terre et environnement, Dijon, France
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Akhtar Khan N. Polyunsaturated fatty acids in the modulation of T-cell signalling. Prostaglandins Leukot Essent Fatty Acids 2010; 82:179-87. [PMID: 20189788 DOI: 10.1016/j.plefa.2010.02.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Indexed: 11/25/2022]
Abstract
n-3 polyunsaturated fatty acids (PUFA) have been shown to modulate immune responses. These agents, being considered as adjuvant immunosuppressants, have been used in the treatment of various inflammatory and autoimmune diseases. However, the molecular mechanisms of action of n-3 PUFA-induced immunosuppressive effects are not well-understood. Since exogenous n-3 PUFA, under in vitro and in vivo conditions, are efficiently incorporated into T-cell plasma membranes, a number of recent studies have demonstrated that these agents may modulate T-cell signalling. In this review, the interactions of n-3 PUFA with the second messenger cascade initiated during early and late events of T-cell activation are discussed. We particularly focus on how these fatty acids can modulate the production of diacylglycerol and the activation of protein kinase C, mitogen activated protein kinase, calcium signalling and translocation of transcriptional factors, implicated in the regulation of gene transcription in T-cells.
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Affiliation(s)
- Naim Akhtar Khan
- University of Burgundy, Department of Physiology, UPRES EA4183 Lipids and Cell Signalling, Faculty of Life Sciences, Dijon, France.
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Kim W, Khan NA, McMurray DN, Prior IA, Wang N, Chapkin RS. Regulatory activity of polyunsaturated fatty acids in T-cell signaling. Prog Lipid Res 2010; 49:250-61. [PMID: 20176053 DOI: 10.1016/j.plipres.2010.01.002] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 01/06/2010] [Accepted: 01/19/2010] [Indexed: 12/25/2022]
Abstract
n-3 Polyunsaturated fatty acids (PUFA) are considered to be authentic immunosuppressors and appear to exert beneficial effects with respect to certain immune-mediated diseases. In addition to promoting T-helper 1 (Th1) cell to T-helper 2 (Th2) cell effector T-cell differentiation, n-3 PUFA may also exert anti-inflammatory actions by inducing apoptosis in Th1 cells. With respect to mechanisms of action, effects range from the modulation of membrane receptors to gene transcription via perturbation of a number of second messenger cascades. In this review, the putative targets of anti-inflammatory n-3 PUFA, activated during early and late events of T-cell activation will be discussed. Studies have demonstrated that these fatty acids alter plasma membrane micro-organization (lipid rafts) at the immunological synapse, the site where T-cells and antigen-presenting cells (APC) form a physical contact for antigen initiated T-cell signaling. In addition, the production of diacylglycerol and the activation of different isoforms of protein kinase C (PKC), mitogen-activated protein kinase (MAPK), calcium signaling, and nuclear translocation/activation of transcriptional factors, can be modulated by n-3 PUFA. Advantages and limitations of diverse methodologies to study the membrane lipid raft hypothesis, as well as apparent contradictions regarding the effect of n-3 PUFA on lipid rafts will be critically presented.
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Affiliation(s)
- Wooki Kim
- Program in Integrative Nutrition and Complex Diseases, Center for Environmental and Rural Health, Texas A&M University, USA
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Itagaki K, Menconi M, Antoniu B, Zhang Q, Gonnella P, Soybel D, Hauser C, Hasselgren PO. Dexamethasone stimulates store-operated calcium entry and protein degradation in cultured L6 myotubes through a phospholipase A(2)-dependent mechanism. Am J Physiol Cell Physiol 2010; 298:C1127-39. [PMID: 20107037 DOI: 10.1152/ajpcell.00309.2009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Muscle wasting in various catabolic conditions is at least in part regulated by glucocorticoids. Increased calcium levels have been reported in atrophying muscle. Mechanisms regulating calcium homeostasis in muscle wasting, in particular the role of glucocorticoids, are poorly understood. Here we tested the hypothesis that glucocorticoids increase intracellular calcium concentrations in skeletal muscle and stimulate store-operated calcium entry (SOCE) and that these effects of glucocorticoids may at least in part be responsible for glucocorticoid-induced protein degradation. Treatment of cultured myotubes with dexamethasone, a frequently used in vitro model of muscle wasting, resulted in increased intracellular calcium concentrations determined by fura-2 AM fluorescence measurements. When SOCE was measured by using calcium "add-back" to muscle cells after depletion of intracellular calcium stores, results showed that SOCE was increased 15-25% by dexamethasone and that this response to dexamethasone was inhibited by the store-operated calcium channel blocker BTP2. Dexamethasone treatment stimulated the activity of calcium-independent phospholipase A(2) (iPLA(2)), and dexamethasone-induced increase in SOCE was reduced by the iPLA(2) inhibitor bromoenol lactone (BEL). In additional experiments, treatment of myotubes with the store-operated calcium channel inhibitor gadolinium ion or BEL reduced dexamethasone-induced increase in protein degradation. Taken together, the results suggest that glucocorticoids increase calcium concentrations in myocytes and stimulate iPLA(2)-dependent SOCE and that glucocorticoid-induced muscle protein degradation may at least in part be regulated by increased iPLA(2) activity, SOCE, and cellular calcium levels.
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Affiliation(s)
- Kiyoshi Itagaki
- Dept. of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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McElroy SP, Drummond RM, Gurney AM. Regulation of store-operated Ca2+ entry in pulmonary artery smooth muscle cells. Cell Calcium 2009; 46:99-106. [DOI: 10.1016/j.ceca.2009.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 05/05/2009] [Accepted: 05/31/2009] [Indexed: 11/25/2022]
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Aires V, Hichami A, Boulay G, Khan NA. Activation of TRPC6 calcium channels by diacylglycerol (DAG)-containing arachidonic acid: A comparative study with DAG-containing docosahexaenoic acid. Biochimie 2007; 89:926-37. [PMID: 17532549 DOI: 10.1016/j.biochi.2006.10.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2006] [Accepted: 10/27/2006] [Indexed: 11/29/2022]
Abstract
We synthesized a diacylglycerol (DAG)-containing arachidonic acid, i.e., 1-stearoyl-2-arachidonyl-sn-glycerol (SAG), and studied its implication in the modulation of canonical transient receptor potential sub-type 6 (TRPC6) channels in stably-transfected HEK-293 cells. SAG induced the influx of Ca(2+), and also of other bivalent cations like Ba(2+) and Sr(2+), in these cells. SAG-evoked Ca(2+) influx was not due to its metabolites as inhibitors of DAG-lipase (RHC80267) and DAG-kinase (R50922) failed to inhibit the response of the same. To emphasise that SAG exerts its action via its DAG configuration, but not due to the presence of stearic acid at sn-1 position, we synthesized 1-palmitoyl-2-arachidonyl-sn-glycerol (PAG). PAG-induced increases in [Ca(2+)](i) were not significantly different from those induced by SAG. For the comparative studies, we also synthesized the DAG-containing docosahexaenoic acid, i.e., 1-stearoyl-2-docosahexaenoyl-sn-glycerol (SDG). We observed that SDG and 1,2-dioctanoyl-sn-glycerol (DOG), a DAG analogue, also evoked increases in [Ca(2+)](i), which were lesser than those evoked by SAG. However, activation of TRPC6 channels by all the DAG molecular species (SAG, DOG and SDG) required Src kinases as the tyrosine kinase inhibitors, PP2 and SU6656, significantly attenuated the increases in [Ca(2+)](i) evoked by these agents. Moreover, disruption of lipid rafts with methyl-beta-cyclodextrin completely abolished SAG-, DOG- and SDG-induced increases in [Ca(2+)](i). The present study shows that SAG as well as SDG and DOG stimulate Ca(2+) influx through the activation of TRPC6 calcium channels which are regulated by Src kinases and intact lipid raft domains.
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Affiliation(s)
- Virginie Aires
- Département de Physiologie, UPRES Lipides and Nutrition, Université de Bourgogne, Faculté des Sciences de la Vie, 6 Boulevard Gabriel, 2100 Dijon, France
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Boittin FX, Petermann O, Hirn C, Mittaud P, Dorchies OM, Roulet E, Ruegg UT. Ca2+-independent phospholipase A2 enhances store-operated Ca2+ entry in dystrophic skeletal muscle fibers. J Cell Sci 2006; 119:3733-42. [PMID: 16926189 DOI: 10.1242/jcs.03184] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Duchenne muscular dystrophy is caused by deficiency of dystrophin and leads to progressive weakness. It has been proposed that the muscle degeneration occurring in this disease is caused by increased Ca2+ influx due to enhanced activity of cationic channels that are activated either by stretch of the plasma membrane (stretch-activated channels) or by Ca2+-store depletion (store-operated channels). Using both cytosolic Ca2+ measurements with Fura-2 and the manganese quench method, we show here that store-operated Ca2+ entry is greatly enhanced in dystrophic skeletal flexor digitorum brevis fibers isolated from mdx5cv mice, a mouse model of Duchenne muscular dystrophy. Moreover, we show for the first time that store-operated Ca2+ entry in these fibers is under the control of the Ca2+-independent phospholipase A2 and that the exaggerated Ca2+ influx can be completely attenuated by inhibitors of this enzyme. Enhanced store-operated Ca2+ entry in dystrophic fibers is likely to be due to a near twofold overexpression of Ca2+-independent phospholipase A2. The Ca2+-independent phospholipase A2 pathway therefore appears as an attractive target to reduce excessive Ca2+ influx and subsequent degeneration occurring in dystrophic fibers.
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Affiliation(s)
- François-Xavier Boittin
- Laboratory of Pharmacology, Geneva-Lausanne School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, 1211 Geneva 4, Switzerland
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Hichami A, Morin C, Rousseau E, Khan NA. Diacylglycerol-Containing Docosahexaenoic Acid in Acyl Chain Modulates Airway Smooth Muscle Tone. Am J Respir Cell Mol Biol 2005; 33:378-86. [PMID: 15961724 DOI: 10.1165/rcmb.2005-0136oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We synthesized and assessed the role of a diacylglycerol (DAG)-containing docosahexaenoic acid (DHA), that is, 1-stearoyl-2-docosahexaenoyl-sn-glycerol (SDHG), in the contraction of guinea pig airway smooth muscle (ASM). We compared its action with 1-stearoyl-2-arachidonoyl-sn-glycerol (SAG) and 1,2-dioctanoyl-sn-glycerol (1,2-DiC8), a stable DAG analog. The three DAGs (SAG, SDHG, and 1,2-DiC8) induced reversible concentration-dependent contraction of ASM. SDHG induced higher guinea pig ASM contraction than did SAG and 1,2-DiC8. The effects of SDHG were blocked, to different extents, by nifedipine (L-type Ca2+ channel blocker). By employing GF-109203X (protein kinase C [PKC] inhibitor) and lanthanum (La3+), a nonselective cation channel blocker, we observed that SDHG evoked ASM contractile response via PKC-dependent and PKC-independent (but Ca2+-dependent) pathways. Interestingly, SAG exerted its action only by increasing [Ca2+]i and did not require PKC activation. To probe the implication of calcium mobilization, we employed thapsigargin (TG), which also induced ASM contraction in a calcium-dependent manner. SDHG and 1,2-DiC8, in a PKC-dependent manner, induced the phosphorylation of CPI-17 (myosin light chain phosphatase inhibitor of 17 kD). Furthermore, SAG and TG failed to phosphorylate CPI-17 in ASM cells. Our results suggest that different DAG species, produced during a dietary supplementation with fatty acids, could modulate the reactivity of airway smooth muscles in a PKC-dependent and -independent manner, and hence, may play a critical role in health and disease.
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Affiliation(s)
- Aziz Hichami
- Département-Physiologie, Immunologie et Neurosciences, UPRES Lipides et Nutrition, Faculté des Sciences de la Vie, 21000 Dijon, France
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Denys A, Hichami A, Khan NA. n-3 PUFAs modulate T-cell activation via protein kinase C-α and -ε and the NF-κB signaling pathway. J Lipid Res 2005; 46:752-8. [PMID: 15627650 DOI: 10.1194/jlr.m400444-jlr200] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We elucidated the mechanisms of action of two n-3 PUFAs, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), in Jurkat T-cells. Both DHA and EPA were principally incorporated into phospholipids in the following order: phosphatidylcholine < phosphatidylethanolamine < phosphatidylinositol/phosphatidylserine. Furthermore, two isoforms of phospholipase A(2) (i.e., calcium-dependent and calcium-independent) were implicated in the release of DHA and EPA, respectively, during activation of these cells. The two fatty acids inhibited the phorbol 12-myristate 13-acetate (PMA)-induced plasma membrane translocation of protein kinase C (PKC)-alpha and -epsilon. The two n-3 PUFAs also inhibited the nuclear translocation of nuclear factor kappaB (NF-kappaB) and the transcription of the interleukin-2 (IL-2) gene in PMA-activated Jurkat T-cells. Together, these results demonstrate that DHA and EPA, being released by two isoforms of phospholipase A(2), modulate IL-2 gene expression by exerting their action on two PKC isoforms and NF-kappaB in Jurkat T-cells.
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Affiliation(s)
- Anne Denys
- University of Burgundy, Department of Physiology, Unité Propre de Recherche et de l'Enseignement Supérieur (UPRES) Lipids and Nutrition, Faculty of Life Sciences, Dijon 21000, France
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Denys A, Aires V, Hichami A, Khan NA. Thapsigargin-stimulated MAP kinase phosphorylation via CRAC channels and PLD activation: inhibitory action of docosahexaenoic acid. FEBS Lett 2004; 564:177-82. [PMID: 15094063 DOI: 10.1016/s0014-5793(04)00361-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Revised: 03/09/2004] [Accepted: 03/11/2004] [Indexed: 11/17/2022]
Abstract
This study was conducted on human Jurkat T-cells to investigate the role of depletion of intracellular Ca(2+) stores in the phosphorylation of two mitogen-activated protein kinases (MAPKs), i.e. extracellular signal-regulated kinase (ERK) 1 and ERK2, and their modulation by a polyunsaturated fatty acid, docosahexaenoic acid (DHA). We observed that thapsigargin (TG) stimulated MAPK activation by store-operated calcium (SOC) influx via opening of calcium release-activated calcium (CRAC) channels as tyrphostin-A9, a CRAC channel blocker, and two SOC influx inhibitors, econazole and SKF-96365, diminished the action of the former. TG-stimulated ERK1/ERK2 phosphorylation was also diminished in buffer containing EGTA, a calcium chelator, further suggesting the implication of calcium influx in MAPK activation in these cells. Moreover, TG stimulated the production of diacylglycerol (DAG) by activating phospholipase D (PLD) as propranolol (PROP) (a PLD inhibitor), but not U73122 (a phospholipase C inhibitor), inhibited TG-evoked DAG production in these cells. DAG production and protein kinase C (PKC) activation were involved upstream of MAPK activation as PROP and GF109203X, a PKC inhibitor, abolished the action of TG on ERK1/ERK2 phosphorylation. Furthermore, DHA seems to act by inhibiting PKC activation as this fatty acid diminished TG- and phorbol 12-myristate 13-acetate-induced ERK1/ERK2 phosphorylation in these cells. Together these results suggest that Ca(2+) influx via CRAC channels is implicated in PLD/PKC/MAPK activation which may be a target of physiological agents such as DHA.
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Affiliation(s)
- Anne Denys
- Département de Physiologie, UPRES Lipides et Nutrition, Université de Bourgogne, Faculté des Sciences de la Vie, 6 Boulevard Gabriel, 21000 Dijon, France
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Su X, Mancuso DJ, Bickel PE, Jenkins CM, Gross RW. Small interfering RNA knockdown of calcium-independent phospholipases A2 beta or gamma inhibits the hormone-induced differentiation of 3T3-L1 preadipocytes. J Biol Chem 2004; 279:21740-8. [PMID: 15024020 DOI: 10.1074/jbc.m314166200] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Alterations in lipid secondary messenger generation and lipid metabolic flux are essential in promoting the differentiation of adipocytes. To determine whether specific subtypes of intracellular phospholipases A(2) (PLA(2)s) facilitate hormone-induced differentiation of 3T3-L1 cells into adipocytes, we examined alterations in the mRNA level, protein mass, and activity of three previously characterized mammalian intracellular PLA(2)s. Hormone-induced differentiation of 3T3-L1 cells resulted in 7.3 +/- 0.5- and 7.4 +/- 1.4-fold increases of mRNA encoding the calcium-independent phospholipases, iPLA(2)beta and iPLA(2)gamma, respectively. In contrast, the temporally coordinated loss of at least 90% of cPLA(2)alpha mRNA was manifest. Western analysis demonstrated the near absence of both iPLA(2)beta and iPLA(2)gamma protein mass in resting 3T3-L1 cells that increased dramatically during differentiation. In vitro measurement of PLA(2) activities demonstrated an increase in both iPLA(2)beta and iPLA(2)gamma activities that were discriminated using the chiral mechanism based inhibitors (S)- and (R)-BEL, respectively. Remarkably, treatment of 3T3-L1 cells with small interfering RNA directed against either iPLA(2)beta or iPLA(2)gamma prevented hormone-induced differentiation. Moreover, analysis of the temporally programmed expression of transcription factors demonstrated that the small interfering RNA knockdown of iPLA(2)beta or iPLA(2)gamma resulted in down-regulation of the expression of peroxisome proliferator-activated receptor gamma and the CCAAT enhancer-binding protein alpha (C/EBPalpha). No alterations in the expression of the early stage transcription factors C/EBPbeta and C/EBPdelta were observed. Collectively, these results demonstrate prominent alterations in intracellular PLA(2)s during 3T3-L1 cell differentiation into adipocytes and identify the requirement of iPLA(2)beta and iPLA(2)gamma for the adipogenic program that drives resting 3T3-L1 cells into adipocytes after hormone stimulation.
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Affiliation(s)
- Xiong Su
- Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA
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