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Yau K, Odutayo A, Dash S, Cherney DZI. Biology and Clinical Use of Glucagon-Like Peptide-1 Receptor Agonists in Vascular Protection. Can J Cardiol 2023; 39:1816-1838. [PMID: 37429523 DOI: 10.1016/j.cjca.2023.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/12/2023] Open
Abstract
Glucagon-like peptide-1 receptor agonists (GLP1RA) are incretin agents initially designed for the treatment of type 2 diabetes mellitus but because of pleiotropic actions are now used to reduce cardiovascular disease in people with type 2 diabetes mellitus and in some instances as approved treatments for obesity. In this review we highlight the biology and pharmacology of GLP1RA. We review the evidence for clinical benefit on major adverse cardiovascular outcomes in addition to modulation of cardiometabolic risk factors including reductions in weight, blood pressure, improvement in lipid profiles, and effects on kidney function. Guidance is provided on indications and potential adverse effects to consider. Finally, we describe the evolving landscape of GLP1RA and including novel glucagon-like peptide-1-based dual/polyagonist therapies that are being evaluated for weight loss, type 2 diabetes mellitus, and cardiorenal benefit.
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Affiliation(s)
- Kevin Yau
- Department of Medicine, Division of Nephrology, University Health Network, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ayodele Odutayo
- Department of Medicine, Division of Nephrology, University Health Network, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Satya Dash
- Department of Medicine, Division of Nephrology, University Health Network, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Mohamed EL Kafoury B, Ebrahim AT, Abd-El Hamid Ali MS, Shaker Mehanna N, Ibrahim Ramadan GES, Ezzat Morsy W. Short chain fatty acids and GIT hormones mitigate gut barrier disruption in high fat diet fed rats supplemented by synbiotics. MEDITERRANEAN JOURNAL OF NUTRITION AND METABOLISM 2023; 16:139-163. [DOI: 10.3233/mnm-230026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
High fat diet (HFD) predisposes to many metabolic changes; it may disrupt gut barrier integrity and gut microbiota composition. Synbiotic supplementation may promote host’s metabolic health by selective activation of the healthy microorganisms. This study aimed to probe the interaction between synbiotic supplementation, gut microbiota and gut hormones in HFD states. Twenty-seven adult male albino rats, 3 groups, group I: control, group II: HFD received HFD for 12 weeks and group III: synbiotic-supplemented HFD received synbiotic in the last 6 weeks. The anthropometric measurments were measured. Liver transaminases, lipid profile, parameters of insulin resistance, serum serotonin, glucagon like polypeptide-1 (GLP-1), oxidant/antioxidant markers (MDA/GPx), zonulin levels and quantitative cecal short chain fatty acids (SCFA) were assessed. Samples of liver and colon were employed for histopathological studies. Compared to HFD group, synbiotic led to a significant reduction in anthropometric measurements, liver enzymes, atherogenic index, HOMA-IR and MDA denoting improved dyslipidemia, insulin resistance and oxidative state. Moreover, synbiotic supplementation decreased serum zonulin and increased both serum serotonin, GLP-1 and cecal SCFAs. Synbiotic supplementation ameliorated the metabolic derangements and the disturbed integrity of the intestinal barrier induced by HFD. As synbiotics can increase gut hormones (serum GLP-1&serotonin) and SCFAs.
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Affiliation(s)
| | - Asmaa Tarek Ebrahim
- Assistant Lecturer of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Manal Said Abd-El Hamid Ali
- Assistant Professor of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Assistant Professor of Physiology, Armed Forces College of Medicine, Cairo, Egypt
| | - Nayra Shaker Mehanna
- Professor of Dairy and Food Microbiology, National Research Center, Cairo, Egypt
| | | | - Wessam Ezzat Morsy
- Assistant Professor of Physiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Assistant Professor of Physiology, Armed Forces College of Medicine, Cairo, Egypt
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3
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The protective effects of SGLT-2 inhibitors, GLP-1 receptor agonists, and RAAS blockers against renal injury in patients with type 2 diabetes. Int Urol Nephrol 2023; 55:617-629. [PMID: 36036316 DOI: 10.1007/s11255-022-03355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/21/2022] [Indexed: 10/15/2022]
Abstract
Diabetic kidney disease is one of the most severe complications of type 2 diabetes mellitus. Patients with diabetic kidney disease have a worse prognosis in terms of mortality and morbidity, compared with patients who have diabetes alone. Strict control of blood pressure and blood glucose is the primary method for prevention of initial kidney damage and delaying further progression of existing damage. Other management approaches include the use of exogenous drugs that can effectively protect the kidneys from diabetes, such as sodium-glucose transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and renin-angiotensin-aldosterone system blockers. These drugs may protect against kidney injury through various molecular mechanisms. This review focuses on renal impairment in patients with type 2 diabetes; it discusses the direct and indirect effects of sodium-glucose transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and renin-angiotensin-aldosterone system blockers on diabetic kidney disease. Finally, it discusses the effects of combination treatment with two or three types of drugs in patients with chronic kidney disease.
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4
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Wu Q, Li D, Huang C, Zhang G, Wang Z, Liu J, Yu H, Song B, Zhang N, Li B, Chu X. Glucose control independent mechanisms involved in the cardiovascular benefits of glucagon-like peptide-1 receptor agonists. Biomed Pharmacother 2022; 153:113517. [DOI: 10.1016/j.biopha.2022.113517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022] Open
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Shen Y, Wang XQ, Dai Y, Wang YX, Zhang RY, Lu L, Ding FH, Shen WF. Diabetic dyslipidemia impairs coronary collateral formation: An update. Front Cardiovasc Med 2022; 9:956086. [PMID: 36072863 PMCID: PMC9441638 DOI: 10.3389/fcvm.2022.956086] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary collateralization is substantially impaired in patients with type 2 diabetes and occlusive coronary artery disease, which leads to aggravated myocardial ischemia and a more dismal prognosis. In a diabetic setting, altered serum lipid profiles and profound glycoxidative modification of lipoprotein particles induce endothelial dysfunction, blunt endothelial progenitor cell response, and severely hamper growth and maturation of collateral vessels. The impact of dyslipidemia and lipid-lowering treatments on coronary collateral formation has become a topic of heightened interest. In this review, we summarized the association of triglyceride-based integrative indexes, hypercholesterolemia, increased Lp(a) with its glycoxidative modification, as well as quantity and quality abnormalities of high-density lipoprotein with impaired collateral formation. We also analyzed the influence of innovative lipid-modifying strategies on coronary collateral development. Therefore, clinical management of diabetic dyslipidemia should take into account of its effect on coronary collateralization in patients with occlusive coronary artery disease.
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Affiliation(s)
- Ying Shen
- Department of Cardiovascular Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao Qun Wang
- Department of Cardiovascular Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yang Dai
- Department of Cardiovascular Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Xuan Wang
- Department of Cardiovascular Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Rui Yan Zhang
- Department of Cardiovascular Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Lin Lu
- Department of Cardiovascular Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
- Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Hua Ding
- Department of Cardiovascular Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Feng Hua Ding,
| | - Wei Feng Shen
- Department of Cardiovascular Medicine, School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
- Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Wei Feng Shen,
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Glucagon-Like Peptide 1 Receptor Agonists: A Medication for Obesity Management. Curr Atheroscler Rep 2022; 24:643-654. [PMID: 35624390 DOI: 10.1007/s11883-022-01041-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The burden of obesity worldwide is high and projected to rise. Obesity increases the risk of several cardiovascular diseases and cardiometabolic risk factors; hence, utilizing effective long-term therapies for obesity is of utmost importance. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as effective therapies that achieve substantial weight loss and improve cardiometabolic risk. The purpose of this review is to discuss the role of GLP-1RAs in obesity management. RECENT FINDINGS Two subcutaneous GLP-1RAs, liraglutide and semaglutide, have been evaluated in several clinical trials for weight loss. Liraglutide achieves a mean weight loss of 4-7 kg, and more than 50% of treated individuals achieve 5% or more weight loss. Semaglutide has a greater impact on weight loss, with a mean weight loss of 9-16 kg, and more than 50% of treated individuals achieve 10-15% or more weight loss. These results led to regulatory approval of these agents for weight loss in individuals with obesity, regardless of diabetes status. In addition to weight loss, the benefits of GLP-1RAs extend to other risk factors, such as glycemic control and blood pressure. Gastrointestinal symptoms are the most frequently encountered adverse events with incidences between 5 and 30%. Finally, the cost remains one of the most critical challenges that limit GLP-1RAs use. GLP-1RAs have robust weight loss benefits and are expected to have a critical role in the management of obesity in the coming years. Upcoming studies will evaluate the durability of weight loss achieved with GLP-1RAs and the impact on cardiovascular outcomes.
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Taskinen MR, Matikainen N, Björnson E, Söderlund S, Ainola M, Hakkarainen A, Lundbom N, Sihlbom C, Thorsell A, Andersson L, Adiels M, Hartmann B, Deacon CF, Holst JJ, Packard CJ, Borén J. Role of endogenous incretins in the regulation of postprandial lipoprotein metabolism. Eur J Endocrinol 2022; 187:75-84. [PMID: 35521766 DOI: 10.1530/eje-21-1187] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/22/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Incretins are known to influence lipid metabolism in the intestine when administered as pharmacologic agents. The aggregate influence of endogenous incretins on chylomicron production and clearance is less clear, particularly in light of opposing effects of co-secreted hormones. Here, we tested the hypothesis that physiological levels of incretins may impact on production or clearances rates of chylomicrons and VLDL. DESIGN AND METHODS A group of 22 overweight/obese men was studied to determine associations between plasma levels of glucagon-like peptides 1 and 2 (GLP-1 and GLP-2) and glucose-dependent insulinotropic polypeptide (GIP) after a fat-rich meal and the production and clearance rates of apoB48- and apoB100-containing triglyceride-rich lipoproteins. Subjects were stratified by above- and below-median incretin response (area under the curve). RESULTS Stratification yielded subgroups that differed about two-fold in incretin response. There were neither differences in apoB48 production rates in chylomicrons or VLDL fractions nor in apoB100 or triglyceride kinetics in VLDL between men with above- vs below-median incretin responses. The men with above-median GLP-1 and GLP-2 responses exhibited higher postprandial plasma and chylomicron triglyceride levels, but this could not be related to altered kinetic parameters. No differences were found between incretin response subgroups and particle clearance rates. CONCLUSION We found no evidence for a regulatory effect of endogenous incretins on contemporaneous chylomicron or VLDL metabolism following a standardised fat-rich meal. The actions of incretins at pharmacological doses may not be reflected at physiological levels of these hormones.
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Affiliation(s)
- Marja-Riitta Taskinen
- Research Programs Unit, Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - Niina Matikainen
- Research Programs Unit, Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Elias Björnson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Sanni Söderlund
- Research Programs Unit, Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Mari Ainola
- Research Programs Unit, Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - Antti Hakkarainen
- HUS Medical Imaging Center, Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nina Lundbom
- HUS Medical Imaging Center, Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Carina Sihlbom
- Proteomics Facility, University of Gothenburg, Gothenburg, Sweden
| | - Annika Thorsell
- Proteomics Facility, University of Gothenburg, Gothenburg, Sweden
| | - Linda Andersson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Martin Adiels
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Bolette Hartmann
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Carolyn F Deacon
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- School of Biomedical Sciences, Ulster University, Coleraine, UK
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Chris J Packard
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jan Borén
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska University Hospital, Gothenburg, Sweden
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Abstract
Hypertriglyceridemia is a common lipid disorder encountered in clinical practice. Plasma triglycerides are a marker for the concentration of triglycerides carried in chylomicrons and very low-density lipoprotein particles. A fasting triglyceride level <150 mg/dL is accepted widely as the upper limit of normal range. Guidelines for hypertriglyceridemia are variable without a global consensus on classification and goals for triglyceride levels. A general classification of hypertriglyceridemia is mild < 200 mg/dL, moderate = 200 to 500 mg/dL, moderate to severe = 500 to 1000 mg/dL, and severe > 1000 mg/dL. Because moderate hypertriglyceridemia does increase atherosclerotic cardiovascular disease risk, it is important to determine the underlying etiology to guide appropriate and timely management. This article provides stepwise recommendations on the diagnosis and management of moderate hypertriglyceridemia, based on 3 common scenarios encountered in clinical practice. Initial steps in management include evaluating for secondary contributors, especially diabetes mellitus. Based on patient characteristics, appropriate management decisions include lifestyle adjustments aimed at weight loss and decreasing alcohol consumption and use of statin and nonstatin therapies.
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Affiliation(s)
- Savitha Subramanian
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle WA, USA
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9
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Borén J, Taskinen MR, Björnson E, Packard CJ. Metabolism of triglyceride-rich lipoproteins in health and dyslipidaemia. Nat Rev Cardiol 2022; 19:577-592. [PMID: 35318466 DOI: 10.1038/s41569-022-00676-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 02/07/2023]
Abstract
Accumulating evidence points to the causal role of triglyceride-rich lipoproteins and their cholesterol-enriched remnants in atherogenesis. Genetic studies in particular have not only revealed a relationship between plasma triglyceride levels and the risk of atherosclerotic cardiovascular disease, but have also identified key proteins responsible for the regulation of triglyceride transport. Kinetic studies in humans using stable isotope tracers have been especially useful in delineating the function of these proteins and revealing the hitherto unappreciated complexity of triglyceride-rich lipoprotein metabolism. Given that triglyceride is an essential energy source for mammals, triglyceride transport is regulated by numerous mechanisms that balance availability with the energy demands of the body. Ongoing investigations are focused on determining the consequences of dysregulation as a result of either dietary imprudence or genetic variation that increases the risk of atherosclerosis and pancreatitis. The identification of molecular control mechanisms involved in triglyceride metabolism has laid the groundwork for a 'precision-medicine' approach to therapy. Novel pharmacological agents under development have specific molecular targets within a regulatory framework, and their deployment heralds a new era in lipid-lowering-mediated prevention of disease. In this Review, we outline what is known about the dysregulation of triglyceride transport in human hypertriglyceridaemia.
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Affiliation(s)
- Jan Borén
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Marja-Riitta Taskinen
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Elias Björnson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Chris J Packard
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Muzurović EM, Volčanšek Š, Tomšić KZ, Janež A, Mikhailidis DP, Rizzo M, Mantzoros CS. Glucagon-Like Peptide-1 Receptor Agonists and Dual Glucose-Dependent Insulinotropic Polypeptide/Glucagon-Like Peptide-1 Receptor Agonists in the Treatment of Obesity/Metabolic Syndrome, Prediabetes/Diabetes and Non-Alcoholic Fatty Liver Disease-Current Evidence. J Cardiovasc Pharmacol Ther 2022; 27:10742484221146371. [PMID: 36546652 DOI: 10.1177/10742484221146371] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The obesity pandemic is accompanied by increased risk of developing metabolic syndrome (MetS) and related conditions: non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH), type 2 diabetes mellitus (T2DM) and cardiovascular (CV) disease (CVD). Lifestyle, as well as an imbalance of energy intake/expenditure, genetic predisposition, and epigenetics could lead to a dysmetabolic milieu, which is the cornerstone for the development of cardiometabolic complications. Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RAs promote positive effects on most components of the "cardiometabolic continuum" and consequently help reduce the need for polypharmacy. In this review, we highlight the main pathophysiological mechanisms and risk factors (RFs), that could be controlled by GLP-1 and dual GIP/GLP-1 RAs independently or through synergism or differences in their mode of action. We also address the evidence on the use of GLP-1 and dual GIP/GLP-1 RAs in the treatment of obesity, MetS and its related conditions (prediabetes, T2DM and NAFLD/NASH). In conclusion, GLP-1 RAs have already been established for the treatment of T2DM, obesity and cardioprotection in T2DM patients, while dual GIP/GLP-1 RAs appear to have the potential to possibly surpass them for the same indications. However, their use in the prevention of T2DM and the treatment of complex cardiometabolic metabolic diseases, such as NAFLD/NASH or other metabolic disorders, would benefit from more evidence and a thorough clinical patient-centered approach. There is a need to identify those patients in whom the metabolic component predominates, and whether the benefits outweigh any potential harm.
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Affiliation(s)
- Emir M Muzurović
- Department of Internal Medicine, Endocrinology Section, Clinical Center of Montenegro, Podgorica, Montenegro.,Faculty of Medicine, University of Montenegro, Podgorica, Montenegro
| | - Špela Volčanšek
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia.,Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Karin Zibar Tomšić
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Andrej Janež
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia.,Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom.,Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Manfredi Rizzo
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates.,Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Christos S Mantzoros
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Boston VA Healthcare System, Harvard Medical School, Boston, MA, USA
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