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Rodríguez Rondón AV, Welling MS, van den Akker ELT, van Rossum EFC, Boon EMJ, van Haelst MM, Delhanty PJD, Visser JA. MC4R Variants Modulate α-MSH and Setmelanotide Induced Cellular Signaling at Multiple Levels. J Clin Endocrinol Metab 2024; 109:2452-2466. [PMID: 38567654 PMCID: PMC11403317 DOI: 10.1210/clinem/dgae210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/10/2024] [Indexed: 04/04/2024]
Abstract
CONTEXT The melanocortin-4 receptor (MC4R) plays an important role in body weight regulation. Pathogenic MC4R variants are the most common cause of monogenic obesity. OBJECTIVE We have identified 17 MC4R variants in adult and pediatric patients with obesity. Here we aimed to functionally characterize these variants by analyzing 4 different aspects of MC4R signaling. In addition, we aimed to analyze the effect of setmelanotide, a potent MC4R agonist, on these MC4R variants. MATERIALS AND METHODS Cell surface expression and α-melanocyte stimulating hormone (α-MSH)- or setmelanotide-induced cAMP response, β-arrestin-2 recruitment, and ERK activation were measured in cells expressing either wild type or variant MC4R. RESULTS We found a large heterogeneity in the function of these variants. We identified variants with a loss of response for all studied MC4R signaling, variants with no cAMP accumulation or ERK activation but normal β-arrestin-2 recruitment, and variants with normal cAMP accumulation and ERK activation but decreased β-arrestin-2 recruitment, indicating disrupted desensitization and signaling mechanisms. Setmelanotide displayed a greater potency and similar efficacy as α-MSH and induced significantly increased maximal cAMP responses of several variants compared to α-MSH. Despite the heterogeneity in functional response, there was no apparent difference in the obesity phenotype in our patients. CONCLUSION We show that these obesity-associated MC4R variants affect MC4R signaling differently yet lead to a comparable clinical phenotype. Our results demonstrate the clinical importance of assessing the effect of MC4R variants on a range of molecular signaling mechanisms to determine their association with obesity, which may aid in improving personalized treatment.
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Affiliation(s)
- Alejandra V Rodríguez Rondón
- Obesity Center CGG and Expertise Center Genetic Obesity, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Mila S Welling
- Obesity Center CGG and Expertise Center Genetic Obesity, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Department of Pediatrics, Division of Endocrinology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Erica L T van den Akker
- Obesity Center CGG and Expertise Center Genetic Obesity, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Department of Pediatrics, Division of Endocrinology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Elisabeth F C van Rossum
- Obesity Center CGG and Expertise Center Genetic Obesity, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Elles M J Boon
- Department of Human Genetics, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Mieke M van Haelst
- Department of Human Genetics, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Patric J D Delhanty
- Obesity Center CGG and Expertise Center Genetic Obesity, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Jenny A Visser
- Obesity Center CGG and Expertise Center Genetic Obesity, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
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Laule C, Sayar-Atasoy N, Aklan I, Kim H, Ates T, Davis D, Atasoy D. Stress integration by an ascending adrenergic-melanocortin circuit. Neuropsychopharmacology 2024; 49:1361-1372. [PMID: 38326456 PMCID: PMC11251172 DOI: 10.1038/s41386-024-01810-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 02/09/2024]
Abstract
Stress is thought to be an important contributing factor for eating disorders; however, neural substrates underlying the complex relationship between stress and appetite are not fully understood. Using in vivo recordings from awake behaving mice, we show that various acute stressors activate catecholaminergic nucleus tractus solitarius (NTSTH) projections in the paraventricular hypothalamus (PVH). Remarkably, the resulting adrenergic tone inhibits MC4R-expressing neurons (PVHMC4R), which are known for their role in feeding suppression. We found that PVHMC4R silencing encodes negative valence in sated mice and is required for avoidance induced by visceral malaise. Collectively, these findings establish PVHMC4R neurons as an effector of stress-activated brainstem adrenergic input in addition to the well-established hypothalamic-pituitary-adrenal axis. Convergent modulation of stress and feeding by PVHMC4R neurons implicates NTSTH → PVHMC4R input in stress-associated appetite disorders.
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Affiliation(s)
- Connor Laule
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Nilufer Sayar-Atasoy
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Iltan Aklan
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Hyojin Kim
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Tayfun Ates
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Debbie Davis
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Deniz Atasoy
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
- Iowa Neuroscience Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
- Fraternal Order of Eagles Diabetes Research Center (FOEDRC), Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
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3
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Feng R, Xu T, Xie X, Zhang ZK, Liu C, Zhan XX. A hyper-distance-based method for hypernetwork comparison. CHAOS (WOODBURY, N.Y.) 2024; 34:083120. [PMID: 39146451 DOI: 10.1063/5.0221267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/23/2024] [Indexed: 08/17/2024]
Abstract
Hypernetwork is a useful way to depict multiple connections between nodes, making it an ideal tool for representing complex relationships in network science. In recent years, there has been a marked increase in studies on hypernetworks; however, the comparison of the difference between two hypernetworks has received less attention. This paper proposes a hyper-distance (HD)-based method for comparing hypernetworks. The method is based on higher-order information, i.e, the higher-order distance between nodes and Jensen-Shannon divergence. Experiments carried out on synthetic hypernetworks have shown that HD is capable of distinguishing between hypernetworks generated with different parameters, and it is successful in the classification of hypernetworks. Furthermore, HD outperforms current state-of-the-art baselines to distinguish empirical hypernetworks when hyperedges are randomly perturbed.
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Affiliation(s)
- Ruonan Feng
- Alibaba Research Center for Complexity Sciences, Hangzhou Normal University, Hangzhou 311121, People's Republic of China
| | - Tao Xu
- Alibaba Research Center for Complexity Sciences, Hangzhou Normal University, Hangzhou 311121, People's Republic of China
| | - Xiaowen Xie
- Alibaba Research Center for Complexity Sciences, Hangzhou Normal University, Hangzhou 311121, People's Republic of China
| | - Zi-Ke Zhang
- College of Media and International Culture, Zhejiang University, Hangzhou 310058, People's Republic of China
| | - Chuang Liu
- Alibaba Research Center for Complexity Sciences, Hangzhou Normal University, Hangzhou 311121, People's Republic of China
| | - Xiu-Xiu Zhan
- Alibaba Research Center for Complexity Sciences, Hangzhou Normal University, Hangzhou 311121, People's Republic of China
- College of Media and International Culture, Zhejiang University, Hangzhou 310058, People's Republic of China
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Cho D, O'Berry K, Possa-Paranhos IC, Butts J, Palanikumar N, Sweeney P. Paraventricular Thalamic MC3R Circuits Link Energy Homeostasis with Anxiety-Related Behavior. J Neurosci 2023; 43:6280-6296. [PMID: 37591737 PMCID: PMC10490510 DOI: 10.1523/jneurosci.0704-23.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/19/2023] Open
Abstract
The hypothalamic melanocortin system is critically involved in sensing stored energy and communicating this information throughout the brain, including to brain regions controlling motivation and emotion. This system consists of first-order agouti-related peptide (AgRP) and pro-opiomelanocortin (POMC) neurons located in the hypothalamic arcuate nucleus and downstream neurons containing the melanocortin-3 (MC3R) and melanocortin-4 receptor (MC4R). Although extensive work has characterized the function of downstream MC4R neurons, the identity and function of MC3R-containing neurons are poorly understood. Here, we used neuroanatomical and circuit manipulation approaches in mice to identify a novel pathway linking hypothalamic melanocortin neurons to melanocortin-3 receptor neurons located in the paraventricular thalamus (PVT) in male and female mice. MC3R neurons in PVT are innervated by hypothalamic AgRP and POMC neurons and are activated by anorexigenic and aversive stimuli. Consistently, chemogenetic activation of PVT MC3R neurons increases anxiety-related behavior and reduces feeding in hungry mice, whereas inhibition of PVT MC3R neurons reduces anxiety-related behavior. These studies position PVT MC3R neurons as important cellular substrates linking energy status with neural circuitry regulating anxiety-related behavior and represent a promising potential target for diseases at the intersection of metabolism and anxiety-related behavior such as anorexia nervosa.SIGNIFICANCE STATEMENT Animals must constantly adapt their behavior to changing internal and external challenges, and impairments in appropriately responding to these challenges are a hallmark of many neuropsychiatric disorders. Here, we demonstrate that paraventricular thalamic neurons containing the melanocortin-3 receptor respond to energy-state-related information and external challenges to regulate anxiety-related behavior in mice. Thus, these neurons represent a potential target for understanding the neurobiology of disorders at the intersection of metabolism and psychiatry such as anorexia nervosa.
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Affiliation(s)
- Dajin Cho
- Department of Molecular and Integrative Physiology, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
- Neuroscience Program, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
| | - Kyle O'Berry
- Department of Molecular and Integrative Physiology, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
- Neuroscience Program, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
| | - Ingrid Camila Possa-Paranhos
- Department of Molecular and Integrative Physiology, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
| | - Jared Butts
- Department of Molecular and Integrative Physiology, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
- Neuroscience Program, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
| | - Naraen Palanikumar
- Department of Molecular and Integrative Physiology, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
| | - Patrick Sweeney
- Department of Molecular and Integrative Physiology, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
- Neuroscience Program, University of Illinois Urbana-Champaign, Urbana, Illinois 61801
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Zhang SX, Kim A, Madara JC, Zhu PK, Christenson LF, Lutas A, Kalugin PN, Jin Y, Pal A, Tian L, Lowell BB, Andermann ML. Competition between stochastic neuropeptide signals calibrates the rate of satiation. RESEARCH SQUARE 2023:rs.3.rs-3185572. [PMID: 37546985 PMCID: PMC10402269 DOI: 10.21203/rs.3.rs-3185572/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
We investigated how transmission of hunger- and satiety-promoting neuropeptides, NPY and αMSH, is integrated at the level of intracellular signaling to control feeding. Receptors for these peptides use the second messenger cAMP. How cAMP integrates opposing peptide signals to regulate energy balance, and the in vivo spatiotemporal dynamics of endogenous peptidergic signaling, remain largely unknown. We show that AgRP axon stimulation in the paraventricular hypothalamus evokes probabilistic NPY release that triggers stochastic cAMP decrements in downstream MC4R-expressing neurons (PVHMC4R). Meanwhile, POMC axon stimulation triggers stochastic, αMSH-dependent cAMP increments. Release of either peptide impacts a ~100 μm diameter region, and when these peptide signals overlap, they compete to control cAMP. The competition is reflected by hunger-state-dependent differences in the amplitude and persistence of cAMP transients: hunger peptides are more efficacious in the fasted state, satiety peptides in the fed state. Feeding resolves the competition by simultaneously elevating αMSH release and suppressing NPY release, thereby sustaining elevated cAMP in PVHMC4R neurons. In turn, cAMP potentiates feeding-related excitatory inputs and promotes satiation across minutes. Our findings highlight how biochemical integration of opposing, quantal peptide signals during energy intake orchestrates a gradual transition between stable states of hunger and satiety.
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Affiliation(s)
- Stephen X Zhang
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- Co-corresponding authors
| | - Angela Kim
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Joseph C Madara
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Paula K Zhu
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Lauren F Christenson
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Andrew Lutas
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- Present address: Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Peter N Kalugin
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- Program in Neuroscience, Harvard University, Cambridge, MA 02138, USA
| | - Yihan Jin
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California, Davis, Sacramento, CA 95817, USA
| | - Akash Pal
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California, Davis, Sacramento, CA 95817, USA
| | - Lin Tian
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California, Davis, Sacramento, CA 95817, USA
| | - Bradford B Lowell
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Mark L Andermann
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- Program in Neuroscience, Harvard University, Cambridge, MA 02138, USA
- Department of Neurobiology, Harvard Medical School, Boston, MA 02115, USA
- Co-corresponding authors
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Zhang SX, Kim A, Madara JC, Zhu PK, Christenson LF, Lutas A, Kalugin PN, Jin Y, Pal A, Tian L, Lowell BB, Andermann ML. Competition between stochastic neuropeptide signals calibrates the rate of satiation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.11.548551. [PMID: 37503012 PMCID: PMC10369917 DOI: 10.1101/2023.07.11.548551] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
We investigated how transmission of hunger- and satiety-promoting neuropeptides, NPY and αMSH, is integrated at the level of intracellular signaling to control feeding. Receptors for these peptides use the second messenger cAMP, but the messenger's spatiotemporal dynamics and role in energy balance are controversial. We show that AgRP axon stimulation in the paraventricular hypothalamus evokes probabilistic and spatially restricted NPY release that triggers stochastic cAMP decrements in downstream MC4R-expressing neurons (PVH MC4R ). Meanwhile, POMC axon stimulation triggers stochastic, αMSH-dependent cAMP increments. NPY and αMSH competitively control cAMP, as reflected by hunger-state-dependent differences in the amplitude and persistence of cAMP transients evoked by each peptide. During feeding bouts, elevated αMSH release and suppressed NPY release cooperatively sustain elevated cAMP in PVH MC4R neurons, thereby potentiating feeding-related excitatory inputs and promoting satiation across minutes. Our findings highlight how state-dependent integration of opposing, quantal peptidergic events by a common biochemical target calibrates energy intake.
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Pickard J, Chen C, Salman R, Stansbury C, Kim S, Surana A, Bloch A, Rajapakse I. HAT: Hypergraph analysis toolbox. PLoS Comput Biol 2023; 19:e1011190. [PMID: 37276238 DOI: 10.1371/journal.pcbi.1011190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/16/2023] [Indexed: 06/07/2023] Open
Abstract
Recent advances in biological technologies, such as multi-way chromosome conformation capture (3C), require development of methods for analysis of multi-way interactions. Hypergraphs are mathematically tractable objects that can be utilized to precisely represent and analyze multi-way interactions. Here we present the Hypergraph Analysis Toolbox (HAT), a software package for visualization and analysis of multi-way interactions in complex systems.
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Affiliation(s)
- Joshua Pickard
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, United States of America
- iReprogram, Inc., Ann Arbor, Michigan, United States of America
| | - Can Chen
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rahmy Salman
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Cooper Stansbury
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Sion Kim
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Amit Surana
- Raytheon Technologies Research Center, East Hartford, Connecticut, United States of America
| | - Anthony Bloch
- Department of Mathematics, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Indika Rajapakse
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, United States of America
- iReprogram, Inc., Ann Arbor, Michigan, United States of America
- Department of Mathematics, University of Michigan, Ann Arbor, Michigan, United States of America
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Alcantara IC, Tapia APM, Aponte Y, Krashes MJ. Acts of appetite: neural circuits governing the appetitive, consummatory, and terminating phases of feeding. Nat Metab 2022; 4:836-847. [PMID: 35879462 PMCID: PMC10852214 DOI: 10.1038/s42255-022-00611-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 06/16/2022] [Indexed: 12/11/2022]
Abstract
The overconsumption of highly caloric and palatable foods has caused a surge in obesity rates in the past half century, thereby posing a healthcare challenge due to the array of comorbidities linked to heightened body fat accrual. Developing treatments to manage body weight requires a grasp of the neurobiological basis of appetite. In this Review, we discuss advances in neuroscience that have identified brain regions and neural circuits that coordinate distinct phases of eating: food procurement, food consumption, and meal termination. While pioneering work identified several hypothalamic nuclei to be involved in feeding, more recent studies have explored how neuronal populations beyond the hypothalamus, such as the mesolimbic pathway and nodes in the hindbrain, interconnect to modulate appetite. We also examine how long-term exposure to a calorically dense diet rewires feeding circuits and alters the response of motivational systems to food. Understanding how the nervous system regulates eating behaviour will bolster the development of medical strategies that will help individuals to maintain a healthy body weight.
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Affiliation(s)
- Ivan C Alcantara
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA
- Department of Neuroscience, Brown University, Providence, RI, USA
| | | | - Yeka Aponte
- National Institute on Drug Abuse (NIDA), National Institutes of Health, Baltimore, MD, USA.
- The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Michael J Krashes
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA.
- National Institute on Drug Abuse (NIDA), National Institutes of Health, Baltimore, MD, USA.
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