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Kodali NA, Janarthanan R, Sazoglu B, Demir Z, Dirican O, Zor F, Kulahci Y, Gorantla VS. A World Update of Progress in Lower Extremity Transplantation: What's Hot and What's Not. Ann Plast Surg 2024; 93:107-114. [PMID: 38885168 DOI: 10.1097/sap.0000000000004035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
ABSTRACT The field of vascularized composite allotransplantation (VCA) is the new frontier of solid organ transplantation (SOT). VCA spans life-enhancing/life-changing procedures such as upper extremity, craniofacial (including eye), laryngeal, tracheal, abdominal wall, penis, and lower extremity transplants. VCAs such as uterus transplants are life giving unlike any other SOT. Of all VCAs that have shown successful intermediate- to long-term graft survival with functional and immunologic outcomes, lower extremity VCAs have remained largely underexplored. Lower extremity transplantation (LET) can offer patients with improved function compared to the use of conventional prostheses, reducing concerns of phantom limb pain and stump complications, and offer an option for eligible amputees that either fail prosthetic rehabilitation or do not adapt to prosthetics. Nevertheless, these benefits must be carefully weighed against the risks of VCA, which are not trivial, including the adverse effects of lifelong immunosuppression, extremely challenging perioperative care, and delayed nerve regeneration. There have been 5 lower extremity transplants to date, ranging from unilateral or bilateral to quadrimembral, progressively increasing in risk that resulted in fatalities in 3 of the 5 cases, emphasizing the inherent risks. The advantages of LET over prosthetics must be carefully weighed, demanding rigorous candidate selection for optimal outcomes.
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Affiliation(s)
- Naga Anvesh Kodali
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Ramu Janarthanan
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Bedreddin Sazoglu
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Zeynep Demir
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Omer Dirican
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Fatih Zor
- Department of Plastic Surgery, Indiana University, Indianapolis, IN
| | - Yalcin Kulahci
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Vijay S Gorantla
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
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2
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Qi JP, Jiang H, Wu T, Zhang Y, Huang W, Li YX, Wang J, Zhang J, Ying ZH. Difficult-to-treat rheumatoid arthritis treated with Abatacept combined with Baricitinib: A case report. World J Clin Cases 2023; 11:2474-2481. [PMID: 37123310 PMCID: PMC10130995 DOI: 10.12998/wjcc.v11.i11.2474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/19/2023] [Accepted: 03/20/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Sporadic cases of rheumatoid arthritis (RA) due to unsatisfactory responses to Abatacept (ABT) have been reported; however, the rescue therapy has not been finalized. Here, we present a case with difficult-to-treat RA (D2T RA) that was resistant to either a single ABT or a Janus kinase (JAK) inhibitor (Tofacitinib), but improved with a combination of ABT and JAK inhibitor (Baricitinib, BAT).
CASE SUMMARY A 46-year-old Chinese woman who had RA for ten years that was resistant to Tocilizumab, Etanercept, Adalimumab, and ABT. According to the European League Against Rheumatism definition, the patient was diagnosed with D2T RA. It was then improved with a combination of ABT and a JAK inhibitor BAT.
CONCLUSION ABT combined with BAT may be an acceptable strategy for treating D2T RA.
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Affiliation(s)
- Jia-Ping Qi
- Graduate School, Bengbu Medical College, Bengbu 233030, Anhui Province, China
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
| | - Huan Jiang
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Teng Wu
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Yuan Zhang
- Graduate School, Bengbu Medical College, Bengbu 233030, Anhui Province, China
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
| | - Wei Huang
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
| | - Yi-Xuan Li
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Jing Wang
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Ju Zhang
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
| | - Zhen-Hua Ying
- Graduate School, Bengbu Medical College, Bengbu 233030, Anhui Province, China
- Center for General Practice Medicine, Department of Rheumatology and Immunology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou 310000, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
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3
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Iglesias M, Brennan DC, Larsen CP, Raimondi G. Targeting inflammation and immune activation to improve CTLA4-Ig-based modulation of transplant rejection. Front Immunol 2022; 13:926648. [PMID: 36119093 PMCID: PMC9478663 DOI: 10.3389/fimmu.2022.926648] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
For the last few decades, Calcineurin inhibitors (CNI)-based therapy has been the pillar of immunosuppression for prevention of organ transplant rejection. However, despite exerting effective control of acute rejection in the first year post-transplant, prolonged CNI use is associated with significant side effects and is not well suited for long term allograft survival. The implementation of Costimulation Blockade (CoB) therapies, based on the interruption of T cell costimulatory signals as strategy to control allo-responses, has proven potential for better management of transplant recipients compared to CNI-based therapies. The use of the biologic cytotoxic T-lymphocyte associated protein 4 (CTLA4)-Ig is the most successful approach to date in this arena. Following evaluation of the BENEFIT trials, Belatacept, a high-affinity version of CTLA4-Ig, has been FDA approved for use in kidney transplant recipients. Despite its benefits, the use of CTLA4-Ig as a monotherapy has proved to be insufficient to induce long-term allograft acceptance in several settings. Multiple studies have demonstrated that events that induce an acute inflammatory response with the consequent release of proinflammatory cytokines, and an abundance of allograft-reactive memory cells in the recipient, can prevent the induction of or break established immunomodulation induced with CoB regimens. This review highlights advances in our understanding of the factors and mechanisms that limit CoB regimens efficacy. We also discuss recent successes in experimentally designing complementary therapies that favor CTLA4-Ig effect, affording a better control of transplant rejection and supporting their clinical applicability.
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Affiliation(s)
- Marcos Iglesias
- Vascularized and Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Giorgio Raimondi, ; Marcos Iglesias,
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Christian P. Larsen
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Giorgio Raimondi
- Vascularized and Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Giorgio Raimondi, ; Marcos Iglesias,
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Iglesias M, Khalifian S, Oh BC, Zhang Y, Miller D, Beck S, Brandacher G, Raimondi G. A short course of tofacitinib sustains the immunoregulatory effect of CTLA4-Ig in the presence of inflammatory cytokines and promotes long-term survival of murine cardiac allografts. Am J Transplant 2021; 21:2675-2687. [PMID: 33331121 DOI: 10.1111/ajt.16456] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/07/2020] [Accepted: 12/11/2020] [Indexed: 01/25/2023]
Abstract
Costimulation blockade-based regimens are a promising strategy for management of transplant recipients. However, maintenance immunosuppression via CTLA4-Ig monotherapy is characterized by high frequency of rejection episodes. Recent evidence suggests that inflammatory cytokines contribute to alloreactive T cell activation in a CD28-independent manner, a reasonable contributor to the limited efficacy of CTLA4-Ig. In this study, we investigated the possible synergism of a combined short-term inhibition of cytokine signaling and CD28 engagement on the modulation of rejection. Our results demonstrate that the JAK/STAT inhibitor tofacitinib restored the immunomodulatory effect of CTLA4-Ig on mouse alloreactive T cells in the presence of inflammatory cytokines. Tofacitinib exposure conferred dendritic cells with a tolerogenic phenotype reducing their cytokine secretion and costimulatory molecules expression. JAK inhibition also directly affected T cell activation. In vivo, the combination of CTLA4-Ig and tofacitinib induced long-term survival of heart allografts and, importantly, it was equally effective when using grafts subjected to prolonged ischemia. Transplant survival correlated with a reduction in effector T cells and intragraft accumulation of regulatory T cells. Collectively, our studies demonstrate a powerful synergism between CTLA4-Ig and tofacitinib and suggest their combined use is a promising strategy for improved management of transplanted patients.
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Affiliation(s)
- Marcos Iglesias
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Saami Khalifian
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Byoung C Oh
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yichuan Zhang
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Devin Miller
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sarah Beck
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Giorgio Raimondi
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Majumder P, Zhang Y, Iglesias M, Fan L, Kelley JA, Andrews C, Patel N, Stagno JR, Oh BC, Furtmüller GJ, Lai CC, Wang YX, Brandacher G, Raimondi G, Schneider JP. Multiphase Assembly of Small Molecule Microcrystalline Peptide Hydrogel Allows Immunomodulatory Combination Therapy for Long-Term Heart Transplant Survival. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2020; 16:e2002791. [PMID: 32812339 PMCID: PMC7686956 DOI: 10.1002/smll.202002791] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/02/2020] [Indexed: 06/11/2023]
Abstract
Combination therapies that target multiple pathways involved in immune rejection of transplants hold promise for patients in need of restorative surgery. Herein, a noninteracting multiphase molecular assembly approach is developed to crystallize tofacitinib, a potent JAK1/3 inhibitor, within a shear-thinning self-assembled fibrillar peptide hydrogel network. The resulting microcrystalline tofacitinib hydrogel (MTH) can be syringe-injected directly to the grafting site during surgery to locally deliver the small molecule. The rate of drug delivered from MTH is largely controlled by the dissolution of the encapsulated microcrystals. A single application of MTH, in combination with systemically delivered CTLA4-Ig, a co-stimulation inhibitor, affords significant graft survival in mice receiving heterotopic heart transplants. Locoregional studies indicate that the local delivery of tofacitinib at the graft site enabled by MTH is required for the observed enhanced graft survival.
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Affiliation(s)
- Poulami Majumder
- Chemical Biology Laboratory, National Cancer Institute, National Institutes of Health, Building 376, Boyles St, Frederick, MD, 21702, USA
| | - Yichuan Zhang
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA
| | - Marcos Iglesias
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA
| | - Lixin Fan
- Basic Science Program, Frederick National Laboratory for Cancer Research, SAXS Core Facility of the National Cancer Institute, Frederick, MD, 21702, USA
| | - James A Kelley
- Chemical Biology Laboratory, National Cancer Institute, National Institutes of Health, Building 376, Boyles St, Frederick, MD, 21702, USA
| | - Caroline Andrews
- Cancer and Inflammation Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, 21702, USA
| | - Nimit Patel
- Small Animal Imaging Program, Frederick National Laboratory for Cancer Research, Frederick, MD, 21702, USA
| | - Jason R Stagno
- Structural Biophysics Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, 21702, USA
| | - Byoung Chol Oh
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA
| | - Georg J Furtmüller
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA
| | - Christopher C Lai
- Chemical Biology Laboratory, National Cancer Institute, National Institutes of Health, Building 376, Boyles St, Frederick, MD, 21702, USA
| | - Yun-Xing Wang
- Structural Biophysics Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, 21702, USA
| | - Gerald Brandacher
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA
| | - Giorgio Raimondi
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA
| | - Joel P Schneider
- Chemical Biology Laboratory, National Cancer Institute, National Institutes of Health, Building 376, Boyles St, Frederick, MD, 21702, USA
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6
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Lund ME, Greer J, Dixit A, Alvarado R, McCauley-Winter P, To J, Tanaka A, Hutchinson AT, Robinson MW, Simpson AM, O'Brien BA, Dalton JP, Donnelly S. A parasite-derived 68-mer peptide ameliorates autoimmune disease in murine models of Type 1 diabetes and multiple sclerosis. Sci Rep 2016; 6:37789. [PMID: 27883079 PMCID: PMC5121616 DOI: 10.1038/srep37789] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 11/02/2016] [Indexed: 12/16/2022] Open
Abstract
Helminth parasites secrete molecules that potently modulate the immune responses of their hosts and, therefore, have potential for the treatment of immune-mediated human diseases. FhHDM-1, a 68-mer peptide secreted by the helminth parasite Fasciola hepatica, ameliorated disease in two different murine models of autoimmunity, type 1 diabetes and relapsing-remitting immune-mediated demyelination. Unexpectedly, FhHDM-1 treatment did not affect the proliferation of auto-antigen specific T cells or their production of cytokines. However, in both conditions, the reduction in clinical symptoms was associated with the absence of immune cell infiltrates in the target organ (islets and the brain tissue). Furthermore, after parenteral administration, the FhHDM-1 peptide interacted with macrophages and reduced their capacity to secrete pro-inflammatory cytokines, such as TNF and IL-6. We propose this inhibition of innate pro-inflammatory immune responses, which are central to the initiation of autoimmunity in both diseases, prevented the trafficking of autoreactive lymphocytes from the periphery to the site of autoimmunity (as opposed to directly modulating their function per se), and thus prevented tissue destruction. The ability of FhHDM-1 to modulate macrophage function, combined with its efficacy in disease prevention in multiple models, suggests that FhHDM-1 has considerable potential as a treatment for autoimmune diseases.
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Affiliation(s)
- Maria E Lund
- The School of Life Sciences, University of Technology Sydney, New South Wales, Australia
| | - Judith Greer
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Aakanksha Dixit
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Raquel Alvarado
- The School of Life Sciences, University of Technology Sydney, New South Wales, Australia
| | | | - Joyce To
- The School of Life Sciences, University of Technology Sydney, New South Wales, Australia
| | - Akane Tanaka
- The School of Life Sciences, University of Technology Sydney, New South Wales, Australia
| | - Andrew T Hutchinson
- The School of Life Sciences, University of Technology Sydney, New South Wales, Australia.,The Centre for Health Technology, University of Technology Sydney, New South Wales, Australia
| | - Mark W Robinson
- Medical Biology Center, School of Biological Sciences, Queen's University, Belfast, Northern Ireland, United Kingdom
| | - Ann M Simpson
- The School of Life Sciences, University of Technology Sydney, New South Wales, Australia.,The Centre for Health Technology, University of Technology Sydney, New South Wales, Australia
| | - Bronwyn A O'Brien
- The School of Life Sciences, University of Technology Sydney, New South Wales, Australia.,The Centre for Health Technology, University of Technology Sydney, New South Wales, Australia
| | - John P Dalton
- Medical Biology Center, School of Biological Sciences, Queen's University, Belfast, Northern Ireland, United Kingdom
| | - Sheila Donnelly
- The School of Life Sciences, University of Technology Sydney, New South Wales, Australia
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