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Rahaman MH, Thygesen SJ, Maxwell MJ, Kim H, Mudai P, Nanson JD, Jia X, Vajjhala PR, Hedger A, Vetter I, Haselhorst T, Robertson AAB, Dymock B, Ve T, Mobli M, Stacey KJ, Kobe B. o-Vanillin binds covalently to MAL/TIRAP Lys-210 but independently inhibits TLR2. J Enzyme Inhib Med Chem 2024; 39:2313055. [PMID: 38416868 PMCID: PMC10903754 DOI: 10.1080/14756366.2024.2313055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/28/2024] [Indexed: 03/01/2024] Open
Abstract
Toll-like receptor (TLR) innate immunity signalling protects against pathogens, but excessive or prolonged signalling contributes to a range of inflammatory conditions. Structural information on the TLR cytoplasmic TIR (Toll/interleukin-1 receptor) domains and the downstream adaptor proteins can help us develop inhibitors targeting this pathway. The small molecule o-vanillin has previously been reported as an inhibitor of TLR2 signalling. To study its mechanism of action, we tested its binding to the TIR domain of the TLR adaptor MAL/TIRAP (MALTIR). We show that o-vanillin binds to MALTIR and inhibits its higher-order assembly in vitro. Using NMR approaches, we show that o-vanillin forms a covalent bond with lysine 210 of MAL. We confirm in mouse and human cells that o-vanillin inhibits TLR2 but not TLR4 signalling, independently of MAL, suggesting it may covalently modify TLR2 signalling complexes directly. Reactive aldehyde-containing small molecules such as o-vanillin may target multiple proteins in the cell.
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Affiliation(s)
- Md. Habibur Rahaman
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
- Australian Infectious Diseases Research Centre, University of Queensland, Brisbane, Australia
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Sara J. Thygesen
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
| | - Michael J. Maxwell
- Centre for Advanced Imaging, University of Queensland, Brisbane, Australia
| | - Hyoyoung Kim
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
| | - Prerna Mudai
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
| | - Jeffrey D. Nanson
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
- Australian Infectious Diseases Research Centre, University of Queensland, Brisbane, Australia
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Xinying Jia
- Centre for Advanced Imaging, University of Queensland, Brisbane, Australia
| | - Parimala R. Vajjhala
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
| | - Andrew Hedger
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
- Australian Infectious Diseases Research Centre, University of Queensland, Brisbane, Australia
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Irina Vetter
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | | | - Avril A. B. Robertson
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Brian Dymock
- Queensland Emory Drug Discovery Initiative, University of Queensland, Brisbane, Australia
| | - Thomas Ve
- Institute for Glycomics, Griffith University, Southport, Australia
| | - Mehdi Mobli
- Centre for Advanced Imaging, University of Queensland, Brisbane, Australia
| | - Katryn J. Stacey
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
- Australian Infectious Diseases Research Centre, University of Queensland, Brisbane, Australia
| | - Bostjan Kobe
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
- Australian Infectious Diseases Research Centre, University of Queensland, Brisbane, Australia
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
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2
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Toshchakov VY. Peptide-Based Inhibitors of the Induced Signaling Protein Interactions: Current State and Prospects. BIOCHEMISTRY. BIOKHIMIIA 2024; 89:784-798. [PMID: 38880642 DOI: 10.1134/s000629792405002x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 06/18/2024]
Abstract
Formation of the transient protein complexes in response to activation of cellular receptors is a common mechanism by which cells respond to external stimuli. This article presents the concept of blocking interactions of signaling proteins by the peptide inhibitors, and describes the progress achieved to date in the development of signaling inhibitors that act by blocking the signal-dependent protein interactions.
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Affiliation(s)
- Vladimir Y Toshchakov
- Sirius University of Science and Technology, Sirius Federal Territory, Krasnodar Region, 354340, Russia.
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3
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Nilsen KE, Zhang B, Skjesol A, Ryan L, Vagle H, Bøe MH, Orning P, Kim H, Bakke SS, Elamurugan K, Mestvedt IB, Stenvik J, Husebye H, Lien E, Espevik T, Yurchenko M. Peptide derived from SLAMF1 prevents TLR4-mediated inflammation in vitro and in vivo. Life Sci Alliance 2023; 6:e202302164. [PMID: 37788908 PMCID: PMC10547912 DOI: 10.26508/lsa.202302164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/05/2023] Open
Abstract
Inflammation plays a crucial role in the development and progression of many diseases, and is often caused by dysregulation of signalling from pattern recognition receptors, such as TLRs. Inhibition of key protein-protein interactions is an attractive target for treating inflammation. Recently, we demonstrated that the signalling lymphocyte activation molecule family 1 (SLAMF1) positively regulates signalling downstream of TLR4 and identified the interaction interface between SLAMF1 and the TLR4 adaptor protein TRIF-related adapter molecule (TRAM). Based on these findings, we developed a SLAMF1-derived peptide, P7, which is linked to a cell-penetrating peptide for intracellular delivery. We found that P7 peptide inhibits the expression and secretion of IFNβ and pro-inflammatory cytokines (TNF, IL-1β, IL-6) induced by TLR4, and prevents death in mice subjected to LPS shock. The mechanism of action of P7 peptide is based on interference with several intracellular protein-protein interactions, including TRAM-SLAMF1, TRAM-Rab11FIP2, and TIRAP-MyD88 interactions. Overall, P7 peptide has a unique mode of action and demonstrates high efficacy in inhibiting TLR4-mediated signalling in vitro and in vivo.
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Affiliation(s)
- Kaja Elisabeth Nilsen
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Boyao Zhang
- Program in Innate Immunity, Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Astrid Skjesol
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Liv Ryan
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hilde Vagle
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Maren Helene Bøe
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Pontus Orning
- Program in Innate Immunity, Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Hera Kim
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siril Skaret Bakke
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kirusika Elamurugan
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingvild Bergdal Mestvedt
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jørgen Stenvik
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Infectious Diseases, Clinic of Medicine, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - Harald Husebye
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Egil Lien
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Program in Innate Immunity, Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Terje Espevik
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Infectious Diseases, Clinic of Medicine, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - Maria Yurchenko
- https://ror.org/05xg72x27 Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Infectious Diseases, Clinic of Medicine, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
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4
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Rahangdale R, Tender T, Balireddy S, Goswami K, Pasupuleti M, Hariharapura RC. A critical review on antiviral peptides derived from viral glycoproteins and host receptors to decoy herpes simplex virus. Microb Biotechnol 2023; 16:2036-2052. [PMID: 37740682 PMCID: PMC10616652 DOI: 10.1111/1751-7915.14342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 09/25/2023] Open
Abstract
The health of the human population has been continuously challenged by viral infections. Herpes simplex virus (HSV) is one of the common causes of illness and can lead to death in immunocompromised patients. Existing anti-HSV therapies are not completely successful in eliminating the infection due to anti-viral drug resistance, ineffectiveness against the latent virus and high toxicity over prolonged use. There is a need to update our knowledge of the current challenges faced in anti-HSV therapeutics and realize the necessity of developing alternative treatment approaches. Protein therapeutics are now being explored as a novel approach due to their high specificity and low toxicity. This review highlights the significance of HSV viral glycoproteins and host receptors in the pathogenesis of HSV infection. Proteins or peptides derived from HSV glycoproteins gC, gB, gD, gH and host cell receptors (HSPG, nectin and HVEM) that act as decoys to inhibit HSV attachment, entry, or fusion have been discussed. Few researchers have tried to improve the efficacy and stability of the identified peptides by modifying them using a peptidomimetic approach. With these efforts, we think developing an alternative treatment option for immunocompromised patients and drug-resistant organisms is not far off.
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Affiliation(s)
- Rakesh Rahangdale
- Department of Pharmaceutical Biotechnology, Manipal College of Pharmaceutical SciencesManipal Academy of Higher EducationManipalKarnatakaIndia
| | - Tenzin Tender
- Department of Pharmaceutical Biotechnology, Manipal College of Pharmaceutical SciencesManipal Academy of Higher EducationManipalKarnatakaIndia
| | - Sridevi Balireddy
- Department of Pharmaceutical Biotechnology, Manipal College of Pharmaceutical SciencesManipal Academy of Higher EducationManipalKarnatakaIndia
| | - Kamini Goswami
- Microbiology Division, Council of Scientific and Industrial ResearchCentral Drug Research InstituteLucknowUttar PradeshIndia
| | - Mukesh Pasupuleti
- Microbiology Division, Council of Scientific and Industrial ResearchCentral Drug Research InstituteLucknowUttar PradeshIndia
- Academy of Scientific and Innovative Research (AcSIR)GhaziabadIndia
| | - Raghu Chandrashekar Hariharapura
- Department of Pharmaceutical Biotechnology, Manipal College of Pharmaceutical SciencesManipal Academy of Higher EducationManipalKarnatakaIndia
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5
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Javmen A, Zou J, Nallar SC, Szmacinski H, Lakowicz JR, Gewirtz AT, Toshchakov VY. TLR5-Derived, TIR-Interacting Decoy Peptides to Inhibit TLR Signaling. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 210:1419-1427. [PMID: 36946775 PMCID: PMC10121880 DOI: 10.4049/jimmunol.2200394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 02/22/2023] [Indexed: 03/23/2023]
Abstract
TLR5, which is activated by flagellin, plays an important role in initiating immune response to a broad spectrum of motile bacterial pathogens. TLRs induce intracellular signaling via dimerization of their TIR domains followed by adapter recruitment through multiple interactions of receptor and adapter TIRs. Here, a library of cell-permeable decoy peptides derived from the TLR5 TIR was screened for TLR5 signaling inhibition in the HEK-Blue-mTLR5 reporter cell line. The peptide demonstrating the strongest inhibition, 5R667, corresponded to the second helix of the region between the third and fourth β-strands (helix C″). In addition to the TLR5-induced cytokine expression, 5R667 inhibited cytokine expression elicited by TLR4, TLR2, and TLR9. 5R667 also suppressed the systemic cytokine induction elicited by LPS administration in mice. 5R667 binding specificity was studied by time-resolved fluorescence spectroscopy in a cell-based assay. 5R667 demonstrated a multispecific binding pattern with respect to TIR domains: It bound TIRs of TLR adapters of the MyD88-dependent pathway, Toll/interleukin-1 receptor domain-containing adapter protein/MyD88 adapter-like (TIRAP) and MyD88, and also the TIR of TLR5. TR667, the peptide derived from the TIRAP region, which is structurally homologous to 5R667, demonstrated binding and inhibitory properties similar to that of 5R667. The surface-exposed residues within TIR regions represented by 5R667 and TR667 form motifs, which are nearly 90% conserved in vertebrate evolution and are distinctive of TLR5 and TIRAP TIR domains. Thus, we have identified an evolutionary conserved adapter recruitment motif within TLR5 TIR, the function of which can be inhibited by selective cell-permeable decoy peptides, which can serve as pan-specific TLR inhibitors.
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Affiliation(s)
- Artur Javmen
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Jun Zou
- Institute for Biomedical Sciences, Georgia State University, Atlanta, Georgia, United States of America
| | - Shreeram C. Nallar
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Henryk Szmacinski
- Center for Fluorescence Spectroscopy, Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Joseph R. Lakowicz
- Center for Fluorescence Spectroscopy, Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Andrew T. Gewirtz
- Institute for Biomedical Sciences, Georgia State University, Atlanta, Georgia, United States of America
| | - Vladimir Y. Toshchakov
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201
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6
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Sidletskaya K, Vitkina T, Denisenko Y. The Role of Toll-Like Receptors 2 and 4 in the Pathogenesis of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:1481-1493. [PMID: 32606656 PMCID: PMC7320879 DOI: 10.2147/copd.s249131] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/24/2020] [Indexed: 12/14/2022] Open
Abstract
Currently, chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. The determination of immune mechanisms of inflammation in the disease presents an important challenge for fundamental medical research. According to modern views, Toll-like receptors (TLRs), among which TLR2 and TLR4 play a key role, are one of the essential components of inflammatory process in COPD. This review focuses on following aspects: the role of TLR2 and TLR4 in the initiation of inflammatory process in COPD; the mechanisms of influence of various exogenous factors (cigarette smoke, suspended particulate matter, and bacteria) on the expression of TLR2 and TLR4; the contribution of these TLRs to the T-helper (Th) immune response development in COPD, in particular to the Th17 immune response, which contributes to the progression of the disease and therapeutic implications of TLR2 and TLR4 in COPD.
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Affiliation(s)
- Karolina Sidletskaya
- Vladivostok Branch of Federal State Budgetary Science Institution "Far Eastern Scientific Center of Physiology and Pathology of Respiration" - Institute of Medical Climatology and Rehabilitative Treatment, Vladivostok, Russia
| | - Tatyana Vitkina
- Vladivostok Branch of Federal State Budgetary Science Institution "Far Eastern Scientific Center of Physiology and Pathology of Respiration" - Institute of Medical Climatology and Rehabilitative Treatment, Vladivostok, Russia
| | - Yulia Denisenko
- Vladivostok Branch of Federal State Budgetary Science Institution "Far Eastern Scientific Center of Physiology and Pathology of Respiration" - Institute of Medical Climatology and Rehabilitative Treatment, Vladivostok, Russia
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7
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Toshchakov VY, Neuwald AF. A survey of TIR domain sequence and structure divergence. Immunogenetics 2020; 72:181-203. [PMID: 32002590 PMCID: PMC7075850 DOI: 10.1007/s00251-020-01157-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/20/2020] [Indexed: 12/31/2022]
Abstract
Toll-interleukin-1R resistance (TIR) domains are ubiquitously present in all forms of cellular life. They are most commonly found in signaling proteins, as units responsible for signal-dependent formation of protein complexes that enable amplification and spatial propagation of the signal. A less common function of TIR domains is their ability to catalyze nicotinamide adenine dinucleotide degradation. This survey analyzes 26,414 TIR domains, automatically classified based on group-specific sequence patterns presumably determining biological function, using a statistical approach termed Bayesian partitioning with pattern selection (BPPS). We examine these groups and patterns in the light of available structures and biochemical analyses. Proteins within each of thirteen eukaryotic groups (10 metazoans and 3 plants) typically appear to perform similar functions, whereas proteins within each prokaryotic group typically exhibit diverse domain architectures, suggesting divergent functions. Groups are often uniquely characterized by structural fold variations associated with group-specific sequence patterns and by herein identified sequence motifs defining TIR domain functional divergence. For example, BPPS identifies, in helices C and D of TIRAP and MyD88 orthologs, conserved surface-exposed residues apparently responsible for specificity of TIR domain interactions. In addition, BPPS clarifies the functional significance of the previously described Box 2 and Box 3 motifs, each of which is a part of a larger, group-specific block of conserved, intramolecularly interacting residues.
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Affiliation(s)
- Vladimir Y Toshchakov
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | - Andrew F Neuwald
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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8
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Javmen A, Szmacinski H, Lakowicz JR, Toshchakov VY. Frontline Science: Targeting the TLR7 signalosome assembly. J Leukoc Biol 2019; 108:1697-1706. [PMID: 31642126 DOI: 10.1002/jlb.2hi0819-180r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/31/2019] [Accepted: 10/07/2019] [Indexed: 02/06/2023] Open
Abstract
TLRs sense a broad range of microbial molecules and initiate antimicrobial immune response. The members of the TLR family use cytoplasmic Toll/interleukin-1R homology (TIR) domain to initiate intracellular signaling. The activated TLRs dimerize their TIRs and recruit adapter proteins to the dimer, through multiple interactions of receptor and adapter TIR domains. Although TLRs play an essential role in innate immunity, the aberrant TLR signaling may cause pathogenic inflammation. This study has screened a library of cell-permeable decoy peptides (CPDPs) derived from the TLR7 TIR for interference with TLR7 signaling and identified new CPDPs that target the TLR7 signalosome assembly. Peptides 7R1, 7R6, 7R9, and 7R11 inhibited the TLR7-induced signaling in murine and human macrophages. The most potent inhibitory peptide of the four, 7R11, significantly reduced the systemic cytokine levels elicited by administration of a TLR7 agonist to mice. TLR7 TIR surface regions that correspond to inhibitory peptides generally corresponded to four TIR sites that mediate signalosome assembly for other TLRs. The cell-based Förster resonance energy transfer/fluorescence lifetime imaging confirmed that 7R9 and 7R11 interact with adapter TIRs. These findings clarify the molecular mechanisms that trigger the adapter recruitment to activated TLR7 and suggest that 7R9 and 7R11 have a significant translational potential as candidate or lead therapeutics for treatment of TLR7-related inflammatory diseases.
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Affiliation(s)
- Artur Javmen
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Henryk Szmacinski
- Department of Biochemistry and Molecular Biology and Center for Fluorescence Spectroscopy, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph R Lakowicz
- Department of Biochemistry and Molecular Biology and Center for Fluorescence Spectroscopy, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Vladimir Y Toshchakov
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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