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Zahoor I, Pan G, Cerghet M, Elbayoumi T, Mao-Draayer Y, Giri S, Palaniyandi SS. Current understanding of cardiovascular autonomic dysfunction in multiple sclerosis. Heliyon 2024; 10:e35753. [PMID: 39170118 PMCID: PMC11337049 DOI: 10.1016/j.heliyon.2024.e35753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 08/23/2024] Open
Abstract
Autoimmune diseases, including multiple sclerosis (MS), are proven to increase the likelihood of developing cardiovascular disease (CVD) due to a robust systemic immune response and inflammation. MS can lead to cardiovascular abnormalities that are related to autonomic nervous system dysfunction by causing inflammatory lesions surrounding tracts of the autonomic nervous system in the brain and spinal cord. CVD in MS patients can affect an already damaged brain, thus worsening the disease course by causing brain atrophy and white matter disease. Currently, the true prevalence of cardiovascular dysfunction and associated death rates in patients with MS are mostly unknown and inconsistent. Treating vascular risk factors is recommended to improve the management of this disease. This review provides an updated summary of CVD prevalence in patients with MS, emphasizing the need for more preclinical studies using animal models to understand the pathogenesis of MS better. However, no distinct studies exist that explore the temporal effects and etiopathogenesis of immune/inflammatory cells on cardiac damage and dysfunction associated with MS, particularly in the cardiac myocardium. To this end, a thorough investigation into the clinical presentation and underlying mechanisms of CVD must be conducted in patients with MS and preclinical animal models. Additionally, clinicians should monitor for cardiovascular complications while prescribing medications to MS patients, as some MS drugs cause severe CVD.
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Affiliation(s)
- Insha Zahoor
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Guodong Pan
- Division of Hypertension and Vascular Research, Department of Internal Medicine, Henry Ford Health, Detroit, MI, USA
| | - Mirela Cerghet
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Tamer Elbayoumi
- Department of Pharmaceutical Sciences, College of Pharmacy, Midwestern University, Glendale, AZ, USA
| | - Yang Mao-Draayer
- Multiple Sclerosis Center of Excellence, Autoimmunity Center of Excellence, Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Shailendra Giri
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Suresh Selvaraj Palaniyandi
- Division of Hypertension and Vascular Research, Department of Internal Medicine, Henry Ford Health, Detroit, MI, USA
- Department of Physiology, Wayne State University, Detroit, MI, USA
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von Glehn F, Pochet N, Thapa B, Raheja R, Mazzola MA, Jangi S, Beynon V, Huang J, Farias AS, Paul A, Santos LMB, Gandhi R, Murugaiyan G, Weiner HL, Baecher-Allan CM. Defective Induction of IL-27-Mediated Immunoregulation by Myeloid DCs in Multiple Sclerosis. Int J Mol Sci 2023; 24:ijms24098000. [PMID: 37175706 PMCID: PMC10179146 DOI: 10.3390/ijms24098000] [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: 02/09/2023] [Revised: 03/09/2023] [Accepted: 03/18/2023] [Indexed: 05/15/2023] Open
Abstract
The purpose of this study was to examine whether myeloid dendritic cells (mDCs) from patients with multiple sclerosis (MS) and healthy controls (HCs) become similarly tolerogenic when exposed to IL-27 as this may represent a potential mechanism of autoimmune dysregulation. Our study focused on natural mDCs that were isolated from HCs and MS patient peripheral blood mononuclear cells (PBMCs). After a 24-h treatment with IL-27 ± lipopolysaccharide (LPS), the mDCs were either harvested to identify IL-27-regulated gene expression or co-cultured with naive T-cells to measure how the treated DC affected T-cell proliferation and cytokine secretion. mDCs isolated from HCs but not untreated MS patients became functionally tolerogenic after IL-27 treatment. Although IL-27 induced both HC and untreated MS mDCs to produce similar amounts of IL-10, the tolerogenic HC mDCs expressed PD-L2, IDO1, and SOCS1, while the non-tolerogenic untreated MS mDCs expressed IDO1 and IL-6R. Cytokine and RNA analyses identified two signature blocks: the first identified genes associated with mDC tolerizing responses to IL-27, while the second was associated with the presence of MS. In contrast to mDCs from untreated MS patients, mDCs from HCs and IFNb-treated MS patients became tolerogenic in response to IL-27. The genes differentially expressed in the different donor IL-27-treated mDCs may contain targets that regulate mDC tolerogenic responses.
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Affiliation(s)
- Felipe von Glehn
- Neuroimmunology Unit-Department of Genetics, Microbiology and Immunology-Institute of Biology, University of Campinas, Campinas 13083-970, Brazil
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Nathalie Pochet
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Bibek Thapa
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Radhika Raheja
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Maria A Mazzola
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Sushrut Jangi
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Vanessa Beynon
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Junning Huang
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Alessandro S Farias
- Neuroimmunology Unit-Department of Genetics, Microbiology and Immunology-Institute of Biology, University of Campinas, Campinas 13083-970, Brazil
| | - Anu Paul
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Leonilda M B Santos
- Neuroimmunology Unit-Department of Genetics, Microbiology and Immunology-Institute of Biology, University of Campinas, Campinas 13083-970, Brazil
| | - Roopali Gandhi
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Gopal Murugaiyan
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Howard L Weiner
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Partners Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MS 02115, USA
| | - Clare M Baecher-Allan
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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3
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Leffler J, Trend S, Gorman S, Hart PH. Sex-Specific Environmental Impacts on Initiation and Progression of Multiple Sclerosis. Front Neurol 2022; 13:835162. [PMID: 35185777 PMCID: PMC8850837 DOI: 10.3389/fneur.2022.835162] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/12/2022] [Indexed: 12/28/2022] Open
Abstract
The immunological mechanisms that contribute to multiple sclerosis (MS) differ between males and females. Females are 2–3 times more likely to develop MS compared to males, however the reason for this discrepancy is unknown. Once MS is established, there is a more inflammatory yet milder form of disease in females whereas males generally suffer from more severe disease and faster progression, neural degradation, and disability. Some of these differences relate to genetics, including genetic control of immune regulatory genes on the X-chromosome, as well as immune modulatory properties of sex hormones. Differences in MS development may also relate to how sex interacts with environmental risk factors. There are several environmental risk factors for MS including late-onset Epstein Barr virus infection, low serum vitamin D levels, low UV radiation exposure, smoking, obesity, and lack of physical activity. Most of these risk factors impact males and females differently, either due to biological or immunological processes or through behavioral differences. In this review, we explore these differences further and focus on how the interaction of environmental risk factors with sex hormones may contribute to significantly different prevalence and pathology of MS in males and females.
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Affiliation(s)
- Jonatan Leffler
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia
- *Correspondence: Jonatan Leffler
| | - Stephanie Trend
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, University of Western Australia, Perth, WA, Australia
| | - Shelley Gorman
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia
| | - Prue H. Hart
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia
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Pfeil J, Simonetti M, Lauer U, von Thülen B, Durek P, Poulsen C, Pawlowska J, Kröger M, Krähmer R, Leenders F, Hoffmann U, Hamann A. Prevention of EAE by tolerogenic vaccination with PEGylated antigenic peptides. Ther Adv Chronic Dis 2021; 12:20406223211037830. [PMID: 34408824 PMCID: PMC8366199 DOI: 10.1177/20406223211037830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 07/13/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Therapeutic treatment options for chronic autoimmune disorders such as multiple sclerosis (MS) rely largely on the use of non-specific immunosuppressive drugs, which are not able to cure the disease. Presently, approaches to induce antigen-specific tolerance as a therapeutic approach; for example, by peptide-based tolerogenic 'inverse' vaccines have regained great interest. We have previously shown that coupling of peptides to carriers can enhance their capacity to induce regulatory T cells in vivo. METHOD In this present study, we investigated whether the tolerogenic potential of immunodominant myelin T-cell epitopes can be improved by conjugation to the synthetic carrier polyethylene glycol (PEG) in an experimental autoimmune encephalomyelitis (EAE) mouse model for chronic MS (MOG C57BL/6). RESULTS Preventive administration of the PEGylated antigenic peptide could strongly suppress the development of EAE, accompanied by reduced immune cell infiltration in the central nervous system (CNS). Depletion of regulatory T cells (Tregs) abrogated the protective effect indicating that Tregs play a crucial role in induction of antigen-specific tolerance in EAE. Treatment during the acute phase of disease was safe and did not induce immune activation. However, treatment at the peak of disease did not affect the disease course, suggesting that either induction of Tregs does not occur in the highly inflamed situation, or that the immune system is refractory to regulation in this condition. CONCLUSION PEGylation of antigenic peptides is an effective and feasible strategy to improve tolerogenic (Treg-inducing) peptide-based vaccines, but application for immunotherapy of overt disease might require modifications or combination therapies that simultaneously suppress effector mechanisms.
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Affiliation(s)
- Jennifer Pfeil
- Experimental Rheumatology, Deutsches Rheuma-Forschungszentrum, a Leibniz-Institute, Berlin, Germany
| | - Mario Simonetti
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin, Berlin, Germany
| | - Uta Lauer
- Experimental Rheumatology, Deutsches Rheuma-Forschungszentrum, a Leibniz-Institute, Berlin, Germany
| | | | - Pawel Durek
- Experimental Rheumatology, Deutsches Rheuma-Forschungszentrum, a Leibniz-Institute, Berlin, Germany
| | - Christina Poulsen
- Experimental Rheumatology, Deutsches Rheuma-Forschungszentrum, a Leibniz-Institute, Berlin, Germany
| | - Justyna Pawlowska
- Experimental Rheumatology, Deutsches Rheuma-Forschungszentrum, a Leibniz-Institute, Berlin, Germany
| | - Matthias Kröger
- Experimental Rheumatology, Deutsches Rheuma-Forschungszentrum, a Leibniz-Institute, Berlin, Germany
| | | | | | - Ute Hoffmann
- Experimental Rheumatology, Deutsches Rheuma-Forschungszentrum, a Leibniz-Institute, Berlin, Germany
| | - Alf Hamann
- Experimental Rheumatology, Deutsches Rheuma-Forschungszentrum Berlin, Charitéplatz 1, Berlin 10117, Germany
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Recent Advances in Antigen-Specific Immunotherapies for the Treatment of Multiple Sclerosis. Brain Sci 2020; 10:brainsci10060333. [PMID: 32486045 PMCID: PMC7348736 DOI: 10.3390/brainsci10060333] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system and is considered to be the leading non-traumatic cause of neurological disability in young adults. Current treatments for MS comprise long-term immunosuppressant drugs and disease-modifying therapies (DMTs) designed to alter its progress with the enhanced risk of severe side effects. The Holy Grail for the treatment of MS is to specifically suppress the disease while at the same time allow the immune system to be functionally active against infectious diseases and malignancy. This could be achieved via the development of immunotherapies designed to specifically suppress immune responses to self-antigens (e.g., myelin antigens). The present study attempts to highlight the various antigen-specific immunotherapies developed so far for the treatment of multiple sclerosis (e.g., vaccination with myelin-derived peptides/proteins, plasmid DNA encoding myelin epitopes, tolerogenic dendritic cells pulsed with encephalitogenic epitopes of myelin proteins, attenuated autologous T cells specific for myelin antigens, T cell receptor peptides, carriers loaded/conjugated with myelin immunodominant peptides, etc), focusing on the outcome of their recent preclinical and clinical evaluation, and to shed light on the mechanisms involved in the immunopathogenesis and treatment of multiple sclerosis.
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Li Q, Zhou L, Wang L, Li S, Xu G, Gu H, Li D, Liu M, Fang L, Wang Z, Han S, Zheng B. Bcl6 modulates innate immunity by controlling macrophage activity and plays critical role in experimental autoimmune encephalomyelitis. Eur J Immunol 2020; 50:525-536. [DOI: 10.1002/eji.201948299] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/04/2019] [Accepted: 01/16/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Qing Li
- Institute of Biomedical Science East China Normal University Shanghai China
| | - Lei Zhou
- Institute of Biomedical Science East China Normal University Shanghai China
| | - Ling Wang
- Institute of Biomedical Science East China Normal University Shanghai China
| | - Shiqiang Li
- Institute of Biomedical Science East China Normal University Shanghai China
| | - Guiliang Xu
- Institute of Biomedical Science East China Normal University Shanghai China
| | - Haijuan Gu
- Institute of Biomedical Science East China Normal University Shanghai China
| | - Dali Li
- Institute of Biomedical Science East China Normal University Shanghai China
| | - Mingyao Liu
- Institute of Biomedical Science East China Normal University Shanghai China
| | - Lei Fang
- Department of Pathology & Immunology Baylor College of Medicine Houston TX USA
| | - Zhengyi Wang
- Department of Pathology & Immunology Baylor College of Medicine Houston TX USA
| | - Shuhua Han
- Department of Pathology & Immunology Baylor College of Medicine Houston TX USA
| | - Biao Zheng
- Institute of Biomedical Science East China Normal University Shanghai China
- Department of Pathology & Immunology Baylor College of Medicine Houston TX USA
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7
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Melero-Jerez C, Suardíaz M, Lebrón-Galán R, Marín-Bañasco C, Oliver-Martos B, Machín-Díaz I, Fernández Ó, de Castro F, Clemente D. The presence and suppressive activity of myeloid-derived suppressor cells are potentiated after interferon-β treatment in a murine model of multiple sclerosis. Neurobiol Dis 2019; 127:13-31. [PMID: 30798007 DOI: 10.1016/j.nbd.2019.02.014] [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: 05/09/2018] [Revised: 12/13/2018] [Accepted: 02/20/2019] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune demyelinating disease of the human central nervous system (CNS), mainly affecting young adults. Among the immunomodulatory disease modifying treatments approved up to date to treat MS, IFN-β remains to be one of the most widely prescribed for the Relapsing-Remitting (RR) variant of the disease, although its mechanism of action is still partially understood. RR-MS variant is characterized by phases with increasing neurological symptoms (relapses) followed by periods of total or partial recovery (remissions), which implies the existence of immunomodulatory agents to promote the relapsing-to-remitting transition. Among these agents, it has been described the immunosuppressive role of a heterogeneous population of immature myeloid cells, namely the myeloid-derived suppressor cells (MDSCs) during the clinical course of the experimental autoimmune encephalomyelitis (EAE), the most used MS model to study RRMS. However, it is still unknown how the current MS disease modifying treatments, e.g. IFN- β, affects to MDSCs number or activity. Our present results show that a single injection of IFN-β at the onset of the clinical course reduces the severity of the EAE, enhancing the presence of MDSCs within the smaller demyelinated areas. Moreover, the single dose of IFN-β promotes MDSC immunosuppressive activity both in vivo and in vitro, augmenting T cell apoptosis. Finally, we show that IFN-ß preserves MDSC immaturity, preventing their differentiation to mature and less suppressive myeloid cell subsets. Taking together, all these data add new insights into the mechanism of IFN-β treatment in EAE and point to MDSCs as a putative endogenous mediator of its beneficial role in this animal model of MS.
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Affiliation(s)
- Carolina Melero-Jerez
- Grupo de Neuroinmuno-Reparación, Hospital Nacional de Parapléjicos, Finca La Peraleda s/n, 45071 Toledo, Spain; Grupo de Neurobiología del Desarrollo-GNDe, Instituto Cajal-CSIC, Avenida Doctor Arce 37, 28002 Madrid, Spain
| | - Margarita Suardíaz
- Unidad de Gestión Clínica Inter-centros de Neurociencias, Laboratorio de Investigación y Servicio de Neurología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Madrid, Spain
| | - Rafael Lebrón-Galán
- Grupo de Neuroinmuno-Reparación, Hospital Nacional de Parapléjicos, Finca La Peraleda s/n, 45071 Toledo, Spain
| | - Carmen Marín-Bañasco
- Unidad de Gestión Clínica Inter-centros de Neurociencias, Laboratorio de Investigación y Servicio de Neurología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Madrid, Spain
| | - Begoña Oliver-Martos
- Unidad de Gestión Clínica Inter-centros de Neurociencias, Laboratorio de Investigación y Servicio de Neurología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Madrid, Spain
| | - Isabel Machín-Díaz
- Grupo de Neuroinmuno-Reparación, Hospital Nacional de Parapléjicos, Finca La Peraleda s/n, 45071 Toledo, Spain
| | - Óscar Fernández
- Unidad de Gestión Clínica Inter-centros de Neurociencias, Laboratorio de Investigación y Servicio de Neurología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Madrid, Spain
| | - Fernando de Castro
- Grupo de Neurobiología del Desarrollo-GNDe, Instituto Cajal-CSIC, Avenida Doctor Arce 37, 28002 Madrid, Spain.
| | - Diego Clemente
- Grupo de Neuroinmuno-Reparación, Hospital Nacional de Parapléjicos, Finca La Peraleda s/n, 45071 Toledo, Spain.
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Zhang N, Nandakumar KS. Recent advances in the development of vaccines for chronic inflammatory autoimmune diseases. Vaccine 2018; 36:3208-3220. [PMID: 29706295 DOI: 10.1016/j.vaccine.2018.04.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/28/2018] [Accepted: 04/19/2018] [Indexed: 12/16/2022]
Abstract
Chronic inflammatory autoimmune diseases leading to target tissue destruction and disability are not only causing increase in patients' suffering but also contribute to huge economic burden for the society. General increase in life expectancy and high prevalence of these diseases both in elderly and younger population emphasize the importance of developing safe and effective vaccines. In this review, at first the possible mechanisms and risk factors associated with chronic inflammatory autoimmune diseases, such as rheumatoid arthritis (RA), multiple sclerosis (MS), systemic lupus erythematosus (SLE) and type 1 diabetes (T1D) are discussed. Current advances in the development of vaccines for such autoimmune diseases, particularly those based on DNA, altered peptide ligands and peptide loaded MHC II complexes are discussed in detail. Finally, strategies for improving the efficacy of potential vaccines are explored.
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Affiliation(s)
- Naru Zhang
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, China; Medical Inflammation Research, Department of Medical Biochemistry and Biophysics, Karolinska Institute, Stockholm, Sweden
| | - Kutty Selva Nandakumar
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, China; Medical Inflammation Research, Department of Medical Biochemistry and Biophysics, Karolinska Institute, Stockholm, Sweden.
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Combined Treatment with Methylprednisolone and Human Bone Marrow-Derived Mesenchymal Stem Cells Ameliorate Experimental Autoimmune Encephalomyelitis. Tissue Eng Regen Med 2018; 15:183-194. [PMID: 30603546 DOI: 10.1007/s13770-017-0101-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/16/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022] Open
Abstract
Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system. Although advances have been made in the treatment of MS, such as the use of IFN-β, glucocorticoids and stem cells, the therapeutic effects of these treatments are not sufficient. In the present study, we evaluated whether the combination of methylprednisolone (MP) and human bone marrow-derived mesenchymal stem cells (BM-MSCs) could enhance the therapeutic effectiveness in experimental autoimmune encephalomyelitis (EAE), a model for MS. EAE was induced by immunizing C57BL/6 mice with myelin oligodendrocyte glycoprotein 35-55 (MOG 35-55). The immunized mice received an intraperitoneal injection of MP (20 mg/kg), an intravenous injection of BM-MSCs (1 × 106 cells) or both on day 14 after immunization. Combination treatment significantly ameliorated the clinical symptoms, along with attenuating inflammatory infiltration and demyelination, compared to either treatment alone. Secretion of pro-inflammatory cytokines (IFN-γ, TNF-α, IL-17) was significantly reduced, and anti-inflammatory cytokines (IL-4, IL-10) was significantly increased by the combination treatment as compared to either treatment alone. Flow cytometry analysis of MOG-reactivated T cells in spleen showed that combination treatment reduced the number of CD4+CD45+ and CD8+ T cells, and increased the number of CD4+CD25+Foxp3+ regulatory T cells. Furthermore, combination treatment enhanced apoptosis in MOG-reactivated CD4+ T cells, a key cellular subset in MS pathogenesis. Combination treatment with MP and BM-MSCs provides a novel treatment protocol for enhancing therapeutic effects in MS.
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10
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Sankowski R, Mader S, Valdés-Ferrer SI. Systemic inflammation and the brain: novel roles of genetic, molecular, and environmental cues as drivers of neurodegeneration. Front Cell Neurosci 2015; 9:28. [PMID: 25698933 PMCID: PMC4313590 DOI: 10.3389/fncel.2015.00028] [Citation(s) in RCA: 226] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 01/15/2015] [Indexed: 12/20/2022] Open
Abstract
The nervous and immune systems have evolved in parallel from the early bilaterians, in which innate immunity and a central nervous system (CNS) coexisted for the first time, to jawed vertebrates and the appearance of adaptive immunity. The CNS feeds from, and integrates efferent signals in response to, somatic and autonomic sensory information. The CNS receives input also from the periphery about inflammation and infection. Cytokines, chemokines, and damage-associated soluble mediators of systemic inflammation can also gain access to the CNS via blood flow. In response to systemic inflammation, those soluble mediators can access directly through the circumventricular organs, as well as open the blood–brain barrier. The resulting translocation of inflammatory mediators can interfere with neuronal and glial well-being, leading to a break of balance in brain homeostasis. This in turn results in cognitive and behavioral manifestations commonly present during acute infections – including anorexia, malaise, depression, and decreased physical activity – collectively known as the sickness behavior (SB). While SB manifestations are transient and self-limited, under states of persistent systemic inflammatory response the cognitive and behavioral changes can become permanent. For example, cognitive decline is almost universal in sepsis survivors, and a common finding in patients with systemic lupus erythematosus. Here, we review recent genetic evidence suggesting an association between neurodegenerative disorders and persistent immune activation; clinical and experimental evidence indicating previously unidentified immune-mediated pathways of neurodegeneration; and novel immunomodulatory targets and their potential relevance for neurodegenerative disorders.
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Affiliation(s)
- Roman Sankowski
- Elmezzi Graduate School of Molecular Medicine , Manhasset, NY , USA ; Feinstein Institute for Medical Research , Manhasset, NY , USA
| | - Simone Mader
- Feinstein Institute for Medical Research , Manhasset, NY , USA
| | - Sergio Iván Valdés-Ferrer
- Elmezzi Graduate School of Molecular Medicine , Manhasset, NY , USA ; Feinstein Institute for Medical Research , Manhasset, NY , USA ; Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , México City , Mexico
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11
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Fernández Hurst N, Bibolini MJ, Roth GA. Diazepam Inhibits Proliferation of Lymph Node Cells Isolated from Rats with Experimental Autoimmune Encephalomyelitis. Neuroimmunomodulation 2015; 22:293-302. [PMID: 25721617 DOI: 10.1159/000369277] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 10/22/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Experimental autoimmune encephalomyelitis (EAE) is an inflammatory demyelinating disease with similarities to human multiple sclerosis involving peripheral activation of autoreactive T cells which infiltrate the central nervous system and react to self antigens leading to damage. In previous studies, we have demonstrated that treatment with diazepam decreases the incidence and histological signs associated with the disease and diminishes immunological responses. The aim of the present work was to evaluate direct effects of diazepam on isolated T cells involved in immune responses during the development of EAE. METHODS Animals were sensitized with whole myelin to induce EAE and sacrificed during the acute phase of the disease. In mononuclear cells isolated from popliteal lymph nodes, cell viability, apoptosis induction, proliferation and cytokine production were evaluated. RESULTS Diazepam did not have a toxic or proapoptotic effect on the cells, at least up to the concentration of 25 μM, but proliferation, CD8+ T-cell activation and proinflammatory cytokine production were dose-dependently decreased. CONCLUSIONS Diazepam has a direct inhibitory effect on the proliferation and activation of T lymphocytes isolated from the main lymphoid organ involved in disease onset and this could be one of the mechanisms that contribute to the beneficial effect previously observed with diazepam in vivo during EAE development.
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Affiliation(s)
- Nicolás Fernández Hurst
- Departamento de Química Biológica, Centro de Investigaciones en Química Biológica de Córdoba (CIQUIBIC, UNC-CONICET), Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina
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12
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Duan X, Zohaib A, Li Y, Zhu B, Ye J, Wan S, Xu Q, Song Y, Chen H, Cao S. miR-206 modulates lipopolysaccharide-mediated inflammatory cytokine production in human astrocytes. Cell Signal 2014; 27:61-8. [PMID: 25452104 DOI: 10.1016/j.cellsig.2014.10.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 10/16/2014] [Indexed: 02/05/2023]
Abstract
Astrocyte-derived inflammation is a common component of acute or chronic injury in the central nervous system. MicroRNAs (miRNAs) are small non-coding RNAs that play important regulatory roles in the inflammatory response. In this study, we found that miR-206 is induced upon stimulation with lipopolysaccharide. Overexpression of miR-206 in astrocytes led to increased expression of inflammatory cytokines (interleukin-6, interleukin-1β, CCL5) upon exposure to lipopolysaccharide, whereas knockdown of miR-206 had completely opposite effects. We used a combination of bioinformatics and experimental techniques to demonstrate that NR4A2, which belongs to the nuclear receptor (NR) 4 family of orphan nuclear receptors, is a direct target of miR-206. Overexpression of miR-206 mimics decreased the activity of a luciferase reporter containing the NR4A2 3'-untranslated region and led to decreased NR4A2 mRNA and protein levels. In contrast, ectopic expression of an miR-206 inhibitor led to elevated NR4A2 expression. We also found that miR-206 modulated the lipopolysaccharide-induced proinflammatory response by targeting NR4A2 and activating nuclear factor-kappa B activity. Finally, we demonstrated that the transcription factor AP-1 plays a critical role in lipopolysaccharide-induced expression of miR-206 and that the extracellular signal-regulated kinase signaling pathway contributes to the regulation of miR-206 level in astrocytes. These data demonstrate that miR-206 positively regulates the lipopolysaccharide-induced inflammatory response in human astrocytes.
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Affiliation(s)
- Xiaodong Duan
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Ali Zohaib
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Yunchun Li
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Bibo Zhu
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Jing Ye
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Shengfeng Wan
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Qiuping Xu
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Yunfeng Song
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Huanchun Chen
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China
| | - Shengbo Cao
- State Key Laboratory of Agricultural Microbiology, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China; Laboratory of Animal Virology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, PR China.
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13
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KIF1B polymorphisms associated with the risk of inflammatory demyelinating disease in Korean population. Genes Genomics 2014. [DOI: 10.1007/s13258-014-0191-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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14
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Alfonso-Loeches S, Ureña-Peralta JR, Morillo-Bargues MJ, Oliver-De La Cruz J, Guerri C. Role of mitochondria ROS generation in ethanol-induced NLRP3 inflammasome activation and cell death in astroglial cells. Front Cell Neurosci 2014; 8:216. [PMID: 25136295 PMCID: PMC4118026 DOI: 10.3389/fncel.2014.00216] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 07/17/2014] [Indexed: 12/30/2022] Open
Abstract
Toll-like receptors (TLRs) and NOD-like receptors (NLRs) are innate immunity sensors that provide an early/effective response to pathogenic or injury conditions. We have reported that ethanol-induced TLR4 activation triggers signaling inflammatory responses in glial cells, causing neuroinflammation and brain damage. However, it is uncertain if ethanol is able to activate NLRs/inflammasome in astroglial cells, which is the mechanism of activation, and whether there is crosstalk between both immune sensors in glial cells. Here we show that chronic ethanol treatment increases the co-localization of caspase-1 with GFAP+ cells, and up-regulates IL-1β and IL-18 in the frontal medial cortex in WT, but not in TLR4 knockout mice. We further show that cultured cortical astrocytes expressed several inflammasomes (NLRP3, AIM2, NLRP1, and IPAF), although NLRP3 mRNA is the predominant form. Ethanol, as ATP and LPS treatments, up-regulates NLRP3 expression, and causes caspase-1 cleavage and the release of IL-1β and IL-18 in astrocytes supernatant. Ethanol-induced NLRP3/caspase-1 activation is mediated by mitochondrial (m) reactive oxygen species (ROS) generation because when using a specific mitochondria ROS scavenger, the mito-TEMPO (500 μM) or NLRP3 blocking peptide (4 μg/ml) or a specific caspase-1 inhibitor, Z-YVAD-FMK (10 μM), abrogates mROS release and reduces the up-regulation of IL-1β and IL-18 induced by ethanol or LPS or ATP. Confocal microscopy studies further confirm that ethanol, ATP or LPS promotes NLRP3/caspase-1 complex recruitment within the mitochondria to promote cell death by caspase-1-mediated pyroptosis, which accounts for ≈73% of total cell death (≈22%) and the remaining (≈25%) die by caspase-3-dependent apoptosis. Suppression of the TLR4 function abrogates most ethanol effects on NLRP3 activation and reduces cell death. These findings suggest that NLRP3 participates, in ethanol-induced neuroinflammation and highlight the NLRP3/TLR4 crosstalk in ethanol-induced brain injury.
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Affiliation(s)
- Silvia Alfonso-Loeches
- Molecular and Cellular Pathology of Alcohol Laboratory, Prince Felipe Research Center Valencia, Spain
| | - Juan R Ureña-Peralta
- Molecular and Cellular Pathology of Alcohol Laboratory, Prince Felipe Research Center Valencia, Spain
| | | | - Jorge Oliver-De La Cruz
- Molecular and Cellular Pathology of Alcohol Laboratory, Prince Felipe Research Center Valencia, Spain
| | - Consuelo Guerri
- Molecular and Cellular Pathology of Alcohol Laboratory, Prince Felipe Research Center Valencia, Spain
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15
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Schreiner B, Bailey SL, Miller SD. T-cell response dynamics in animal models of multiple sclerosis: implications for immunotherapies. Expert Rev Clin Immunol 2014; 3:57-72. [DOI: 10.1586/1744666x.3.1.57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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16
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Aharoni R. New findings and old controversies in the research of multiple sclerosis and its model experimental autoimmune encephalomyelitis. Expert Rev Clin Immunol 2014; 9:423-40. [DOI: 10.1586/eci.13.21] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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17
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Brain pericyte plasticity as a potential drug target in CNS repair. Drug Discov Today 2012; 18:456-63. [PMID: 23266366 DOI: 10.1016/j.drudis.2012.12.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 11/23/2012] [Accepted: 12/11/2012] [Indexed: 01/09/2023]
Abstract
Brain pericytes (BrPCs) are essential cellular components of the central nervous system neurovascular unit involved in the regulation of blood flow, blood-brain barrier function, as well as in the stabilization of the vessel architecture. More recently, it became evident that BrPCs, besides their regulatory activities in brain vessel function and homeostasis, have pleiotropic functions in the adult CNS ranging from stromal and regeneration promoting activities to stem cell properties. This special characteristic confers BrPC cell plasticity, being able to display features of other cells within the organism. BrPCs might also be causally involved in certain brain diseases. Due to these properties BrPCs might be potential drug targets for future therapies of neurological disorders. This review summarizes BrPC properties, disorders in which this cell type might be involved, and provides suggestions for future therapeutic developments targeting BrPCs.
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18
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Jadasz JJ, Aigner L, Rivera FJ, Küry P. The remyelination Philosopher's Stone: stem and progenitor cell therapies for multiple sclerosis. Cell Tissue Res 2012; 349:331-47. [PMID: 22322424 DOI: 10.1007/s00441-012-1331-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 01/16/2012] [Indexed: 12/12/2022]
Abstract
Multiple sclerosis (MS) is an autoimmune disease that leads to oligodendrocyte loss and subsequent demyelination of the adult central nervous system (CNS). The pathology is characterized by transient phases of recovery during which remyelination can occur as a result of resident oligodendroglial precursor and stem/progenitor cell activation. However, myelin repair efficiency remains low urging the development of new therapeutical approaches that promote remyelination activities. Current MS treatments target primarily the immune system in order to reduce the relapse rate and the formation of inflammatory lesions, whereas no therapies exist in order to regenerate damaged myelin sheaths. During the last few years, several transplantation studies have been conducted with adult neural stem/progenitor cells and glial precursor cells to evaluate their potential to generate mature oligodendrocytes that can remyelinate axons. In parallel, modulation of the endogenous progenitor niche by neural and mesenchymal stem cell transplantation with the aim of promoting CNS progenitor differentiation and myelination has been studied. Here, we summarize these findings and discuss the properties and consequences of the various molecular and cell-mediated remyelination approaches. Moreover, we address age-associated intrinsic cellular changes that might influence the regenerative outcome. We also evaluate the extent to which these experimental treatments might increase the regeneration capacity of the demyelinated human CNS and hence be turned into future therapies.
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Affiliation(s)
- Janusz J Jadasz
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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19
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Abstract
The fundamental role of inflammatory immune processes in the pathology of multiple sclerosis (MS) provides the rationale for immunomodulatory therapies that attempt to shift the immune system from pro-inflammatory to anti-inflammatory pathways and induce regulatory mechanisms. Growing understanding of immune cellular and molecular mechanisms together with modern biotechnology engendered promising immunomodulatory treatment strategies, with novel mechanisms of actions and different levels of specificity. These include inhibitory molecules, monoclonal antibodies, cell therapies and agents that are administered orally or by infrequent infusions. Several of these treatments have demonstrated impressive efficacy in Phase II and III clinical trials by reducing disease activity and accumulation of disability. However, with the advent of potent therapies, rare but severe adverse effects, such as CNS infections and malignancies, have occurred. This article describes current and upcoming immunomodulatory strategies for MS therapy. The potential of immunomodulatory treatments to counteract the inflammatory characteristics of MS and support neuroprotective processes is discussed.
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Affiliation(s)
- Rina Aharoni
- The Department of Immunology, The Weizmann Institute of Science, Rehovot, Israel.
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20
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Common CYP7A1 promoter polymorphism associated with risk of neuromyelitis optica. Neurobiol Dis 2010; 37:349-55. [DOI: 10.1016/j.nbd.2009.10.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 09/30/2009] [Accepted: 10/10/2009] [Indexed: 11/21/2022] Open
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21
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Customized Cell-Based Treatment Options to Combat Autoimmunity and Restore β-Cell Function in Type 1 Diabetes Mellitus: Current Protocols and Future Perspectives. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2010; 654:641-65. [DOI: 10.1007/978-90-481-3271-3_28] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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22
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Bayas A, Stasiolek M, Kruse N, Toyka KV, Selmaj K, Gold R. Altered innate immune response of plasmacytoid dendritic cells in multiple sclerosis. Clin Exp Immunol 2009; 157:332-42. [PMID: 19664140 DOI: 10.1111/j.1365-2249.2009.03964.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Plasmacytoid dendritic cells (pDCs) are of crucial importance in immune regulation and response to microbial factors. In multiple sclerosis (MS), pDCs from peripheral blood showed an immature phenotype, but its role in susceptibility to MS is not determined. Because infectious diseases are established triggers of exacerbations in MS, in this study we have characterized the expression of Toll-like receptors (TLR) and the maturation and functional properties of peripheral blood pDCs from clinically stable, untreated MS patients in response to signals of innate immunity. After stimulation of TLR-9, interferon (IFN)-alpha production by pDCs was significantly lower in MS (n = 12) compared to healthy controls (n = 9). In an allogenic two-step co-culture assay we found an impaired effect of TLR-9 stimulation on IFN-gamma expression of autologous naive T cells in MS patients (n = 4). In peripheral blood mononuclear cells, TLR-9 stimulation with type A CpG ODN resulted in a higher expression of TLR-1, -2, -4, -5 and -8 in MS patients (n = 7) compared with healthy controls (n = 11). These findings suggest an altered innate immune response to microbial stimuli in MS patients and may help understanding of why common infectious agents trigger MS attacks.
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Affiliation(s)
- A Bayas
- Department of Neurology, University of Würzburg, Würzburg, Poland.
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23
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Mannie MD, Abbott DJ, Blanchfield JL. Experimental autoimmune encephalomyelitis in Lewis rats: IFN-beta acts as a tolerogenic adjuvant for induction of neuroantigen-dependent tolerance. THE JOURNAL OF IMMUNOLOGY 2009; 182:5331-41. [PMID: 19380780 DOI: 10.4049/jimmunol.0803756] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cytokine-Ag fusion proteins represent a novel approach for induction of Ag-specific tolerance and may constitute an efficient therapy for autoimmune disease. This study addressed whether a fusion protein containing rat IFN-beta and the encephalitogenic 73-87 determinant of myelin basic protein (i.e., the neuroantigen, or NAg) could prevent or treat experimental autoimmune encephalomyelitis (EAE) in Lewis rats. The optimal structure of the fusion protein was comprised of the rat IFN-beta cytokine as the N-terminal domain with an enterokinase (EK) linker to the NAg domain. Both cytokine and NAg domains had full biological activity. Subcutaneous administration of 1 nmol of IFNbeta-NAg fusion protein in saline on days -21, -14, and -7 before encephalitogenic challenge on day 0 resulted in a substantial attenuation of EAE. In contrast, administration of IFN-beta or NAg alone did not affect susceptibility to EAE. The covalent attachment of IFN-beta and NAg was not necessary, because separate injections of IFN-beta and NAg at adjacent sites were as effective as injection of IFNbeta-NAg for prevention of disease. When treatment was initiated after disease onset, the rank order of inhibitory activity was as follows: the IFNbeta-NAg fusion protein > or = a mixture of IFN-beta plus NAg > IFN-beta > NAg. The novel finding that IFN-beta acts as a tolerogenic adjuvant as well as a tolerogenic fusion partner may have significance for development of tolerogenic vaccines.
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Affiliation(s)
- Mark D Mannie
- Department of Microbiology and Immunology, East Carolina University, Brody School of Medicine, Greenville, NC 27834, USA
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24
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Das A, Guyton MK, Matzelle DD, Ray SK, Banik NL. Time-dependent increases in protease activities for neuronal apoptosis in spinal cords of Lewis rats during development of acute experimental autoimmune encephalomyelitis. J Neurosci Res 2008; 86:2992-3001. [PMID: 18521931 PMCID: PMC2614291 DOI: 10.1002/jnr.21737] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Multiple sclerosis (MS) is characterized by axonal demyelination and neurodegeneration, the latter having been inadequately explored in the MS animal model experimental autoimmune encephalomyelitis (EAE). The purpose of this study was to examine the time-dependent correlation between increased calpain and caspase activities and neurodegeneration in spinal cord tissues from Lewis rats with acute EAE. An increase in TUNEL-positive neurons and internucleosomal DNA fragmentation in EAE spinal cords suggested that neuronal death was a result of apoptosis on days 8-10 following induction of EAE. Increases in calpain expression in EAE correlated with activation of pro-apoptotic proteases, leading to apoptotic cell death beginning on day 8 of EAE, which occurred before the appearance of visible clinical symptoms. Increases in calcineurin expression and decreases in phospho-Bad (p-Bad) suggested Bad activation in apoptosis during acute EAE. Increases in the Bax:Bcl-2 ratio and activation of caspase-9 showed the involvement of mitochondria in apoptosis. Further, caspase-8 activation suggested induction of the death receptor-mediated pathway for apoptosis. Endoplasmic reticulum stress leading to caspase-3 activation was also observed, indicating that multiple apoptotic pathways were activated following EAE induction. In contrast, cell death was mostly a result of necrosis on the later day (day 11), when EAE entered a severe stage. From these findings, we conclude that increases in calpain and caspase activities play crucial roles in neuronal apoptosis during the development of acute EAE.
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Affiliation(s)
- Arabinda Das
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - M. Kelly Guyton
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina
| | - Denise D. Matzelle
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Swapan K. Ray
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, South Carolina
| | - Naren L. Banik
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
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25
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Lutterotti A, Sospedra M, Martin R. Antigen-specific therapies in MS - Current concepts and novel approaches. J Neurol Sci 2008; 274:18-22. [PMID: 18599087 DOI: 10.1016/j.jns.2008.05.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 05/16/2008] [Accepted: 05/27/2008] [Indexed: 11/27/2022]
Abstract
Induction of antigen-specific tolerance is a promising therapeutic approach for autoimmune diseases. Despite many successes in animal models, translation to the clinic has been hampered by lack of efficacy, disease exacerbation and hypersensitivity reactions. Novel approaches aim at inducing tolerance to several immunodominant antigens at the same time. Besides several key issues like the route of administration, dose of antigen and nature of antigen, antigen-specific therapies should be performed early in the disease course in order to block the diversification of autoreactive specificities and thereby prevent disease progression. It is essential that clinical trials are accompanied by appropriate immunologic analyses to be used either as a parameter to monitor safety and efficacy, but also to get a better understanding of the mechanisms of disease and the respective treatment approach. Here we will discuss the mechanisms of tolerance, the experience with trials in MS and present novel approaches.
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Affiliation(s)
- Andreas Lutterotti
- Institute for Neuroimmunology and Clinical MS Research (inims), Center for Molecular Neurobiology Hamburg, University Medical Center Eppendorf, Hamburg, Germany.
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26
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Talora C, Campese AF, Bellavia D, Felli MP, Vacca A, Gulino A, Screpanti I. Notch signaling and diseases: an evolutionary journey from a simple beginning to complex outcomes. Biochim Biophys Acta Mol Basis Dis 2008; 1782:489-97. [PMID: 18625307 DOI: 10.1016/j.bbadis.2008.06.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 06/10/2008] [Accepted: 06/10/2008] [Indexed: 10/21/2022]
Abstract
Notch signaling pathway regulates a wide variety of cellular processes during development and it also plays a crucial role in human diseases. This important link is firmly established in cancer, since a rare T-ALL-associated genetic lesion has been initially reported to result in deletion of Notch1 ectodomain and constitutive activation of its intracellular region. Interestingly, the cellular response to Notch signaling can be extremely variable depending on the cell type and activation context. Notch signaling triggers signals implicated in promoting carcinogenesis and autoimmune diseases, whereas it can also sustain responses that are critical to suppress carcinogenesis and to negatively regulate immune response. However, Notch signaling induces all these effects via an apparently simple signal transduction pathway, diversified into a complex network along evolution from Drosophila to mammals. Indeed, an explanation of this paradox comes from a number of evidences accumulated during the last few years, which dissected the intrinsic canonical and non-canonical components of the Notch pathway as well as several modulatory extrinsic signaling events. The identification of these signals has shed light onto the mechanisms whereby Notch and other pathways collaborate to induce a particular cellular phenotype. In this article, we review the role of Notch signaling in cells as diverse as T lymphocytes and epithelial cells of the epidermis, with the main focus on understanding the mechanisms of Notch versatility.
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Affiliation(s)
- Claudio Talora
- Department of Experimental Medicine, Sapienza University of Rome, Roma, Italy
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27
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Gaupp S, Cannella B, Raine CS. Amelioration of experimental autoimmune encephalomyelitis in IL-4Ralpha-/- mice implicates compensatory up-regulation of Th2-type cytokines. THE AMERICAN JOURNAL OF PATHOLOGY 2008; 173:119-29. [PMID: 18535177 DOI: 10.2353/ajpath.2008.071156] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The cytokine receptor interleukin (IL)-4R, expressed by lymphocytes, is well known for its role in immunomodulatory signaling and has also been documented on oligodendrocytes, suggesting involvement in glial cell interactions. In the present study, we investigated the clinical course and pathology of experimental autoimmune encephalomyelitis in mice demonstrating deletion of IL-4R and found a correlation with cytokine expression during acute and chronic disease. Wild-type (WT) littermates served as controls. Although IL-4R(-/-) mice displayed a milder course throughout, they showed comparable pathology to WT in the acute phase. However, during the chronic phase, IL-4R(-/-) mice exhibited extensive remyelination and an apparent increase in oligodendrocytes. Cytokine patterns were examined by immunocytochemistry, fluorescence-activated cell sorting, and enzyme-linked immunosorbent assay and were strongly proinflammatory within the central nervous system during the acute phase in WT mice whereas IL-4R(-/-) animals expressed higher levels of IL-6 and IL-10 that became more pronounced with time. The milder experimental autoimmune encephalomyelitis and enhanced remyelination in IL-4R(-/-) mice appeared to be related to a shift toward a Th-2 pattern involving mainly IL-6 and IL-10. These data suggest that IL-4R exerts a negative regulatory role on oligodendrocytes that when deleted results in enhanced myelin repair.
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Affiliation(s)
- Stefanie Gaupp
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
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28
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Svejgaard A. The immunogenetics of multiple sclerosis. Immunogenetics 2008; 60:275-86. [PMID: 18461312 DOI: 10.1007/s00251-008-0295-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 03/31/2008] [Indexed: 12/26/2022]
Abstract
The discoveries in the 1970s of strong associations between various diseases and certain human leukocyte antigen (HLA) factors were a revolution within genetic epidemiology in the last century by demonstrating for the first time how genetic markers can help unravel the genetics of disorders with complex genetic backgrounds. HLA controls immune response genes and HLA associations indicate the involvement of autoimmunity. Multiple sclerosis (MS) was one of the first conditions proven to be HLA associated involving primarily HLA class II factors. We review how HLA studies give fundamental information on the genetics of the susceptibility to MS, on the importance of linkage disequilibrium in association studies, and on the pathogenesis of MS. The HLA-DRB1*1501 molecule may explain about 50% of MS cases and its role in the pathogenesis is supported by studies of transgenic mice. Studies of polymorphic non-HLA genetic markers are discussed based on linkage studies and candidate gene approaches including complete genome scans. No other markers have so far rivaled the importance of HLA in the genetic susceptibility to MS. Recently, large international collaborations provided strong evidence for the involvement of polymorphism of two cytokine receptor genes in the pathogenesis of MS: the interleukin 7 receptor alpha chain gene (IL7RA) on chromosome 5p13 and the interleukin 2 receptor alpha chain gene (IL2RA (=CD25)) on chromosome 10p15. It is estimated that the C allele of a single nucleotide polymorphism, rs6897932, within the alternative spliced exon 6 of IL7RA is involved in about 30% of MS cases.
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Affiliation(s)
- Arne Svejgaard
- Department of Clinical Immunology, Section 7631, University Hospital of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
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29
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Bell JJ, Divekar RD, Ellis JS, Cascio JA, Haymaker CL, Jain R, Tartar DM, Hoeman CM, Hardaway JC, Zaghouani H. In trans T cell tolerance diminishes autoantibody responses and exacerbates experimental allergic encephalomyelitis. THE JOURNAL OF IMMUNOLOGY 2008; 180:1508-16. [PMID: 18209046 DOI: 10.4049/jimmunol.180.3.1508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A number of Ag-specific approaches have been developed that ameliorate experimental allergic encephalomyelitis (EAE), an animal model for the human autoimmune disease multiple sclerosis. Translation to humans, however, remains a consideration, justifying the search for more insight into the mechanism underlying restoration of self-tolerance. Ig-proteolipid protein (PLP) 1 and Ig-myelin oligodendrocyte glycoprotein (MOG) are Ig chimeras carrying the encephalitogenic PLP 139-151 and MOG 35-55 amino acid sequence, respectively. Ig-PLP1 ameliorates EAE in SJL/J (H-2(s)) mice while Ig-MOG modulates the disease in C57BL/6 (H-2(b)) animals. In this study, we asked whether the chimeras would suppress EAE in F(1) mice expressing both parental MHC alleles and representing a polymorphism with more relevance to human circumstances. The results show that Ig-MOG modulates both PLP1 and MOG peptide-induced EAE in the F(1) mice, whereas Ig-PLP1 counters PLP1 EAE but exacerbates MOG-induced disease. This in trans aggravation of MOG EAE by Ig-PLP1 operates through induction of PLP1-specific T cells producing IL-5 that sustained inhibition of MOG-specific Abs leading to exacerbation of EAE. Thus, in trans T cell tolerance, which should be operative in polymorphic systems, can aggravate rather than ameliorate autoimmunity. This phenomenon possibly takes place through interference with protective humoral immunity.
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Affiliation(s)
- J Jeremiah Bell
- Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia, MO 65212, USA
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30
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Multiple sclerosis therapy: An update on recently finished trials. J Neurol 2007; 254:1473-90. [DOI: 10.1007/s00415-007-0684-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Revised: 06/14/2007] [Accepted: 06/19/2007] [Indexed: 10/22/2022]
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31
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Abstract
During the last few years, the concept of multiple sclerosis (MS) as a pure inflammatory disease mediated by myelin reactive T cells has been challenged. Neither the specificity nor the mechanisms triggering or perpetuating the immune response are understood. Genetic studies have so far not identified therapeutic targets outside the HLA complex, but epidemiological and immunological studies have suggested putative pathogenetic factors which may be important in therapy or prevention, including the Epstein-Barr virus and vitamin D. Advances in the treatment of MS have been reached by manipulating the immune response where the pathogenesis of MS intersects experimental autoimmune encephalomyelitis, most recently by blocking T-cell migration through the blood-brain barrier. Antigen-specific approaches are effective in experimental models driven by a focused immune response against defined autoantigens, but MS may not fit into this concept. Novel candidate autoantigens which are not constitutively expressed in the brain, such as protein alpha-B crystallin or IgG V-region idiotopes, as well as evidence of pathogenetic heterogeneity and complexity, suggest that treating MS by tolerizing the immune system against an universal MS antigen may be a fata morgana. Further characterization of MS subtypes may lead to individualized treatment. However, shared immunological features, such as intrathecal production of oligoclonal IgG, suggest that potential therapeutic targets may be shared by most MS patients.
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Affiliation(s)
- T Holmøy
- Institute of Immunology, Faculty of Medicine, Rikshospitalet-Radiumhospitalet Medical Center, University of Oslo, Oslo, Norway.
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Mannie MD, Abbott DJ. A fusion protein consisting of IL-16 and the encephalitogenic peptide of myelin basic protein constitutes an antigen-specific tolerogenic vaccine that inhibits experimental autoimmune encephalomyelitis. THE JOURNAL OF IMMUNOLOGY 2007; 179:1458-65. [PMID: 17641011 DOI: 10.4049/jimmunol.179.3.1458] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
To test a novel concept for the generation of tolerogenic vaccines, fusion proteins were constructed encompassing a tolerogenic or biasing cytokine and the major encephalitogenic peptide of guinea pig myelin basic protein (GPMBP; i.e., neuroantigen or NAg). The cytokine domain was predicted to condition APC while simultaneously targeting the covalently linked encephalitogenic peptide to the MHC class II Ag processing pathway of those conditioned APC. Rats were given three s.c. injections of cytokine-NAg in saline 1-2 wk apart and then at least 1 wk later were challenged with NAg in CFA. The rank order of tolerogenic activity in the Lewis rat model of EAE was NAgIL16 > IL2NAg > IL1RA-NAg, IL13NAg >or= IL10NAg, GPMBP, GP69-88, and saline. NAgIL16 was also an effective inhibitor of experimental autoimmune encephalomyelitis when administered after an encephalitogenic challenge during the onset of clinical signs. Covalent linkage of the NAg and IL-16 was required for inhibition of experimental autoimmune encephalomyelitis. These data identify IL-16 as an optimal cytokine partner for the generation of tolerogenic vaccines and indicate that such vaccines may serve as Ag-specific tolerogens for the treatment of autoimmune disease.
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MESH Headings
- Amino Acid Sequence
- Animals
- Cell Line
- Encephalomyelitis, Autoimmune, Experimental/genetics
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Encephalomyelitis, Autoimmune, Experimental/prevention & control
- Epitopes/administration & dosage
- Epitopes/genetics
- Epitopes/immunology
- Guinea Pigs
- Immune Tolerance/genetics
- Interleukin-16/administration & dosage
- Interleukin-16/genetics
- Interleukin-16/immunology
- Molecular Sequence Data
- Myelin Basic Protein/administration & dosage
- Myelin Basic Protein/genetics
- Myelin Basic Protein/immunology
- Peptide Fragments/administration & dosage
- Peptide Fragments/genetics
- Peptide Fragments/immunology
- Rats
- Rats, Inbred Lew
- Recombinant Fusion Proteins/administration & dosage
- Recombinant Fusion Proteins/genetics
- Recombinant Fusion Proteins/immunology
- Vaccines, DNA/administration & dosage
- Vaccines, DNA/genetics
- Vaccines, DNA/immunology
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Affiliation(s)
- Mark D Mannie
- Department of Microbiology and Immunology, The Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
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Chatenoud L, Bluestone JA. CD3-specific antibodies: a portal to the treatment of autoimmunity. Nat Rev Immunol 2007; 7:622-32. [PMID: 17641665 DOI: 10.1038/nri2134] [Citation(s) in RCA: 271] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Targeted immunotherapies hold great promise for the treatment and cure of autoimmune diseases. The efficacy of CD3-specific monoclonal antibody therapy in mice and humans stems from its ability to re-establish immune homeostasis in treated individuals. This occurs through modulation of the T-cell receptor (TCR)-CD3 complex (also termed antigenic modulation) and/or induction of apoptosis of activated autoreactive T cells, which leaves behind 'space' for homeostatic reconstitution that favours selective induction, survival and expansion of adaptive regulatory T cells, which establishes long-term tolerance. This Review summarizes the pre-clinical and clinical studies of CD3-specific monoclonal antibody therapy and highlights future opportunities to enhance the efficacy of this potent immunotherapeutic.
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Affiliation(s)
- Lucienne Chatenoud
- Université René Descartes, Paris 5, Institut National de la Santé et de la Recherche Médicale, Unité 580, Hôpital Necker - Enfants Malades, 161 rue de Sèvres 75743 Paris CEDEX 15, France.
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34
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Kleinschnitz C, Meuth SG, Kieseier BC, Wiendl H. [Update on pathophysiologic and immunotherapeutic approaches for the treatment of multiple sclerosis]. DER NERVENARZT 2007; 78:883-911. [PMID: 17551708 DOI: 10.1007/s00115-007-2261-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple sclerosis (MS) is a chronic disabling disease with significant implications for patients and society. The individual disease course is difficult to predict due to the heterogeneity of clinical presentation and of radiologic and pathologic findings. Although its etiology still remains unknown, the last decade has brought considerable understanding of the underlying pathophysiology of MS. In addition to its acceptance as a prototypic inflammatory autoimmune disorder, recent data reveal the importance of primary and secondary neurodegenerative mechanisms such as oligodendrocyte death, axonal loss, and ion channel dysfunction. The deepened understanding of its immunopathogenesis and the limited effectiveness of currently approved disease-modifying therapies have led to a tremendous number of trials investigating potential new drugs. Emerging treatments take into account the different immunopathological mechanisms and strategies, to protect against axonal damage and promote remyelination. This review provides a compilation of novel immunotherapeutic strategies and recently uncovered aspects of known immunotherapeutic agents. The pathogenetic rationale of these novel drugs for the treatment of MS and accompanying preclinical and clinical data are highlighted.
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Affiliation(s)
- C Kleinschnitz
- Neurologische Klinik und Poliklinik, Universitätsklinikum, Josef-Schneider-Strasse 11, 97080, Würzburg, Germany
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Chatenoud L. Une étape vers la restauration de la tolérance immunitaire au soi dans les maladies auto-immunes humaines. Med Sci (Paris) 2007; 23:167-71. [PMID: 17291426 DOI: 10.1051/medsci/2007232167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
In developed countries the incidence of autoimmune insulin-dependent or type 1 diabetes as the one of all autoimmune diseases has steadily increased over the last decades. Conventional therapy of type 1 diabetes is essentially palliative namely, chronic delivery of exogenous insulin that is associated with major constraints (multiple daily parenteral administration, serious risks linked to hypoglycemic episodes) and incomplete effectiveness in preventing severe degenerative complications. This explains the growing attention on modern therapeutic strategies using biological agents such as CD3 monoclonal antibodies that allow 'reprogramming' the immune system to restore self-tolerance to pancreatic beta cell antigens. This strategy which proved successful in the experimental setting has recently been translated to the clinic with very encouraging results. CD3 antibodies may represent a new category of drugs affording a real cure for autoimmunity namely, inhibiting the pathogenic immune response while preserving the host reactivity to unrelated antigens.
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MESH Headings
- Adult
- Animals
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Autoantibodies/biosynthesis
- Autoantibodies/immunology
- Autoantigens/immunology
- Autoantigens/therapeutic use
- Autoimmune Diseases/immunology
- Autoimmune Diseases/therapy
- Autoimmunity/immunology
- CD3 Complex/immunology
- Chaperonin 60/immunology
- Chaperonin 60/therapeutic use
- Clinical Trials, Phase I as Topic
- Clinical Trials, Phase II as Topic
- Clonal Deletion
- Diabetes Mellitus, Type 1/immunology
- Diabetes Mellitus, Type 1/therapy
- Glutamate Decarboxylase/immunology
- Glutamate Decarboxylase/therapeutic use
- Humans
- Immunoglobulin G/immunology
- Immunoglobulin G/therapeutic use
- Immunotherapy/methods
- Infant, Newborn
- Insulin/immunology
- Insulin/therapeutic use
- Islets of Langerhans/immunology
- Mice
- Mice, Inbred NOD
- Muromonab-CD3/immunology
- Muromonab-CD3/therapeutic use
- Randomized Controlled Trials as Topic
- Self Tolerance/immunology
- T-Lymphocyte Subsets/immunology
- Thymectomy/adverse effects
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Affiliation(s)
- Lucienne Chatenoud
- Inserm U580, Faculté René-Descartes Paris 5, Hôpital Necker- Enfants-Malades, 161, rue de Sèvres 75015, Paris, France.
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Dhib-Jalbut S, Arnold DL, Cleveland DW, Fisher M, Friedlander RM, Mouradian MM, Przedborski S, Trapp BD, Wyss-Coray T, Yong VW. Neurodegeneration and neuroprotection in multiple sclerosis and other neurodegenerative diseases. J Neuroimmunol 2006; 176:198-215. [PMID: 16983747 DOI: 10.1016/j.jneuroim.2006.03.027] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Multiple sclerosis is considered a disease of myelin destruction; Parkinson's disease (PD), one of dopaminergic neuron depletion; ALS, a disease of motor neuron death; and Alzheimer's, a disease of plaques and tangles. Although these disorders differ in important ways, they also have common pathogenic features, including inflammation, genetic mutations, inappropriate protein aggregates (e.g., Lewy bodies, amyloid plaques), and biochemical defects leading to apoptosis, such as oxidative stress and mitochondrial dysfunction. In most disorders, it remains uncertain whether inflammation and protein aggregation are neurotoxic or neuroprotective. Elucidating the mechanisms that orchestrate neuronal diseases should facilitate development of neuroprotective and neurorestorative strategies.
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Affiliation(s)
- Suhayl Dhib-Jalbut
- UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, and The Cleveland Clinic, OH, USA.
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