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Durrer I, Ackermann D, Klossner R, Grössl M, Vögel C, Du Toit T, Vogt B, Jamin H, Mohaupt MG, Gennari-Moser C. No extra-adrenal aldosterone production in various human cell lines. J Mol Endocrinol 2024; 72:e230100. [PMID: 38175924 PMCID: PMC10895282 DOI: 10.1530/jme-23-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/04/2024] [Indexed: 01/06/2024]
Abstract
Extra-adrenal de novo aldosterone (Aldo) production has been described inconsistently. Systematic data based upon state-of-the-art technology including validated controls are sparse. We hypothesized that aldosterone synthase (CYP11B2) expression and de novo Aldo production are absent in nonadrenal human cell lines, either immortalized cell lines or commercially available primary cell lines, including peripheral blood mononuclear cells (PBMCs) of individuals without and with primary hyperaldosteronism (PA). CYP11B2-transfected COS-7 and endogenous CYP11B2 expressing adrenal H295R cells served as positive controls. Various well-characterized, purchased, immortalized (BeWo, HEK293, HTR-8/SVneo, JEG-3) and primary (HAEC, HLEC, HRGEC, HRMC, HUAEC, HUVEC, PBMC) cell lines as well as self-isolated PBMCs from PA patients (n = 5) were incubated with the steroid hormone substrates progesterone, deoxycorticosterone, corticosterone or 18-OH-corticosterone with and without Ang II for 24 h to assess CYP11B2 enzymatic activity. CYP11B2 expression was analyzed by real-time PCR and liquid chromatography-mass spectrometry was used to quantify Aldo production. Pronounced CYP11B2 mRNA expression and Aldo production were observed in both positive controls, which followed an incremental time course. Neither substrates alone nor coincubation with Ang II significantly stimulated CYP11B2 expression or Aldo production in various immortalized and primary cell lines and PBMCs of PA patients. These results strongly support the absence of relevant de novo extra-adrenal Aldo production in nonadrenal cells, including blood mononuclear cells, irrespective of the absence or presence of autonomous adrenal Aldo production.
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Affiliation(s)
- Isabelle Durrer
- Department of Nephrology and Hypertension University of Bern, Berne, Switzerland
| | - Daniel Ackermann
- Department of Nephrology and Hypertension University of Bern, Berne, Switzerland
| | - Rahel Klossner
- Department of Nephrology and Hypertension University of Bern, Berne, Switzerland
- Department of Internal Medicine, Sonnenhof, Lindenhofgruppe, Berne, Switzerland
| | - Michael Grössl
- Department of Nephrology and Hypertension University of Bern, Berne, Switzerland
| | - Clarissa Vögel
- Department of Nephrology and Hypertension University of Bern, Berne, Switzerland
| | - Therina Du Toit
- Department for BioMedical Research University of Bern, Berne, Switzerland
| | - Bruno Vogt
- Department of Nephrology and Hypertension University of Bern, Berne, Switzerland
| | - Heidi Jamin
- Department of Nephrology and Hypertension University of Bern, Berne, Switzerland
- Department for BioMedical Research University of Bern, Berne, Switzerland
| | - Markus G Mohaupt
- Department of Internal Medicine, Sonnenhof, Lindenhofgruppe, Berne, Switzerland
- Department for BioMedical Research University of Bern, Berne, Switzerland
| | - Carine Gennari-Moser
- Department of Nephrology and Hypertension University of Bern, Berne, Switzerland
- Department for BioMedical Research University of Bern, Berne, Switzerland
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2
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Pang Z, Launonen H, Korpela R, Vapaatalo H. Local aldosterone synthesis in the large intestine of mouse: An ex vivo incubation study. J Int Med Res 2022; 50:3000605221105163. [PMID: 35748030 PMCID: PMC9248050 DOI: 10.1177/03000605221105163] [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] [Indexed: 11/25/2022] Open
Abstract
Objective To investigate the regulation of local aldosterone synthesis by physiological
stimulants in the murine gut. Methods Male mice were fed for 14 days with normal, high (1.6%) or low (0.01%) sodium
diets. Tissue liver receptor homolog-1 and aldosterone in the colon and
caecum were detected using an enzyme-linked immunosorbent assay (ELISA).
Released corticosterone and aldosterone in tissue incubation experiments
after stimulation with angiotensin II (Ang II) and dibutyryl-cAMP (DBA; the
second messenger of adrenocorticotropic hormone) were assayed using an
ELISA. Tissue aldosterone synthase (CYP11B2) protein levels were measured
using an ELISA and Western blots. Results In incubated colon tissues, aldosterone synthase levels were increased by a
low-sodium diet; and by Ang II and DBA in the normal diet group. Release of
aldosterone into the incubation buffer was increased from the colon by a
low-sodium diet and decreased by a high-sodium diet in parallel with changes
in aldosterone synthase levels. In mice fed a normal diet, colon incubation
with both Ang II and DBA increased the release of aldosterone as well as its
precursor corticosterone. Conclusion Local aldosterone synthesis in the large intestine is stimulated by a
low-sodium diet, dibutyryl-cAMP and Ang II similar to the adrenal
glands.
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Affiliation(s)
- Zan Pang
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Hanna Launonen
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Riitta Korpela
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Human Microbiome Research Programme, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Heikki Vapaatalo
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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3
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Beck L, Su J, Comerma-Steffensen S, Pinilla E, Carlsson R, Hernanz R, Sheykhzade M, Danielsen CC, Simonsen U. Endothelial Dysfunction and Passive Changes in the Aorta and Coronary Arteries of Diabetic db/db Mice. Front Physiol 2020; 11:667. [PMID: 32655412 PMCID: PMC7324802 DOI: 10.3389/fphys.2020.00667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 05/25/2020] [Indexed: 12/19/2022] Open
Abstract
Endothelial cell dysfunction and vessel stiffening are associated with a worsened prognosis in diabetic patients with cardiovascular diseases. The present study hypothesized that sex impacts endothelial dysfunction and structural changes in arteries from diabetic mice. In diabetic (db/db) and normoglycaemic (db/db+) mice, the mechanical properties were investigated in pressurized isolated left anterior descending coronary arteries and aorta segments that were subjected to tensile testing. Functional studies were performed on wire-mounted vascular segments. The male and female db/db mice were hyperglycaemic and had markedly increased body weight. In isolated aorta segments without the contribution of smooth muscle cells, load to rupture, viscoelasticity, and collagen content were decreased suggesting larger distensibility of the arterial wall in both male and female db/db mice. In male db/db aorta segments with smooth muscle cell contribution, lumen diameter was smaller and the passive stretch-tension curve was leftward-shifted, while they were unaltered in female db/db aorta segments versus control db/db+ mice. In contrast to female db/db mice, coronary arteries from male db/db mice had altered stress-strain relationships and increased distensibility. Transthoracic echocardiography revealed a dilated left ventricle with unaltered cardiac output, while aortic flow velocity was decreased in male db/db mice. Impairment of acetylcholine relaxation was aggravated in aorta from female db/db compared to control and male db/db mice, while impairment of sodium nitroprusside relaxations was only observed in aorta from male db/db mice. The remodeling in the coronary arteries and aorta suggests an adaptation of the arterial wall to the reduced flow velocity with sex-specific differences in the passive properties of aorta and coronary arteries. The findings of less distensible arteries and more pronounced endothelial dysfunction in female compared to male diabetic mice may have implications for the observed higher incidence of macrovascular complications in diabetic women.
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Affiliation(s)
- Lilliana Beck
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Faculty of Health Aarhus University, Aarhus, Denmark
| | - Junjing Su
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Faculty of Health Aarhus University, Aarhus, Denmark
| | - Simon Comerma-Steffensen
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Faculty of Health Aarhus University, Aarhus, Denmark.,Department of Biomedical Sciences/Animal Physiology, Veterinary Faculty, Central University of Venezuela, Maracay, Venezuela
| | - Estéfano Pinilla
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Faculty of Health Aarhus University, Aarhus, Denmark
| | - Rune Carlsson
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Faculty of Health Aarhus University, Aarhus, Denmark
| | - Raquel Hernanz
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Faculty of Health Aarhus University, Aarhus, Denmark.,Departamento de Ciencias Básicas de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Majid Sheykhzade
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Carl Christian Danielsen
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Faculty of Health Aarhus University, Aarhus, Denmark
| | - Ulf Simonsen
- Department of Biomedicine, Pulmonary and Cardiovascular Pharmacology, Faculty of Health Aarhus University, Aarhus, Denmark
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4
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Lu Q, Davel AP, McGraw AP, Rao SP, Newfell BG, Jaffe IZ. PKCδ Mediates Mineralocorticoid Receptor Activation by Angiotensin II to Modulate Smooth Muscle Cell Function. Endocrinology 2019; 160:2101-2114. [PMID: 31373631 PMCID: PMC6735772 DOI: 10.1210/en.2019-00258] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/28/2019] [Indexed: 01/30/2023]
Abstract
Angiotensin II (AngII) and the mineralocorticoid receptor (MR) ligand aldosterone both contribute to cardiovascular disorders, including hypertension and adverse vascular remodeling. We previously demonstrated that AngII activates MR-mediated gene transcription in human vascular smooth muscle cells (SMCs), yet the mechanism and the impact on SMC function are unknown. Using an MR-responsive element-driven transcriptional reporter assay, we confirm that AngII induces MR transcriptional activity in vascular SMCs and endothelial cells, but not in Cos1 or human embryonic kidney-293 cells. AngII activation of MR was blocked by the MR antagonist spironolactone or eplerenone and the protein kinase C-δ (PKCδ) inhibitor rottlerin, implicating both in the mechanism. Similarly, small interfering RNA knockdown of PKCδ in SMCs prevented AngII-mediated MR activation, whereas knocking down of MR blocked both aldosterone- and AngII-induced MR function. Coimmunoprecipitation studies reveal that endogenous MR and PKCδ form a complex in SMCs that is enhanced by AngII treatment in association with increased serine phosphorylation of the MR N terminus. AngII increased mRNA expression of the SMC-MR target gene, FKBP51, via an MR-responsive element in intron 5 of the FKBP51 gene. The impact of AngII on FKBP51 reporter activity and gene expression in SMCs was inhibited by spironolactone and rottlerin. Finally, the AngII-induced increase in SMC number was also blocked by the MR antagonist spironolactone and the PKCδ inhibitor rottlerin. These data demonstrate that AngII activates MR transcriptional regulatory activity, target gene regulation, and SMC proliferation in a PKCδ-dependent manner. This new mechanism may contribute to synergy between MR and AngII in driving SMC dysfunction and to the cardiovascular benefits of MR and AngII receptor blockade in humans.
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Affiliation(s)
- Qing Lu
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Ana P Davel
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, São Paulo, Brazil
| | - Adam P McGraw
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Sitara P Rao
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Brenna G Newfell
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
| | - Iris Z Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts
- Correspondence: Iris Z. Jaffe, MD, PhD, Tufts Medical Center, Molecular Cardiology Research Institute, 800 Washington Street, Box 80, Boston, Massachusetts 02111. E-mail:
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5
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Lang F, Leibrock C, Pelzl L, Gawaz M, Pieske B, Alesutan I, Voelkl J. Therapeutic Interference With Vascular Calcification-Lessons From Klotho-Hypomorphic Mice and Beyond. Front Endocrinol (Lausanne) 2018; 9:207. [PMID: 29780355 PMCID: PMC5945862 DOI: 10.3389/fendo.2018.00207] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/13/2018] [Indexed: 12/13/2022] Open
Abstract
Medial vascular calcification, a major pathophysiological process associated with cardiovascular disease and mortality, involves osteo-/chondrogenic transdifferentiation of vascular smooth muscle cells (VSMCs). In chronic kidney disease (CKD), osteo-/chondrogenic transdifferentiation of VSMCs and, thus, vascular calcification is mainly driven by hyperphosphatemia, resulting from impaired elimination of phosphate by the diseased kidneys. Hyperphosphatemia with subsequent vascular calcification is a hallmark of klotho-hypomorphic mice, which are characterized by rapid development of multiple age-related disorders and early death. In those animals, hyperphosphatemia results from unrestrained formation of 1,25(OH)2D3 with subsequent retention of calcium and phosphate. Analysis of klotho-hypomorphic mice and mice with vitamin D3 overload uncovered several pathophysiological mechanisms participating in the orchestration of vascular calcification and several therapeutic opportunities to delay or even halt vascular calcification. The present brief review addresses the beneficial effects of bicarbonate, carbonic anhydrase inhibition, magnesium supplementation, mineralocorticoid receptor (MR) blockage, and ammonium salts. The case is made that bicarbonate is mainly effective by decreasing intestinal phosphate absorption, and that carbonic anhydrase inhibition leads to metabolic acidosis, which counteracts calcium-phosphate precipitation and VSMC transdifferentiation. Magnesium supplementation, MR blockage and ammonium salts are mainly effective by interference with osteo-/chondrogenic signaling in VSMCs. It should be pointed out that the, by far, most efficient substances are ammonium salts, which may virtually prevent vascular calcification. Future research will probably uncover further therapeutic options and, most importantly, reveal whether these observations in mice can be translated into treatment of patients suffering from vascular calcification, such as patients with CKD.
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Affiliation(s)
- Florian Lang
- Department of Physiology I, Eberhard Karls-University, Tübingen, Germany
- *Correspondence: Florian Lang,
| | - Christina Leibrock
- Department of Physiology I, Eberhard Karls-University, Tübingen, Germany
- Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany
| | - Lisann Pelzl
- Department of Physiology I, Eberhard Karls-University, Tübingen, Germany
| | - Meinrad Gawaz
- Department of Internal Medicine III, Eberhard Karls-University, Tübingen, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité-Universität Medizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Partner Site Berlin, German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Ioana Alesutan
- Department of Internal Medicine and Cardiology, Charité-Universität Medizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Partner Site Berlin, German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Jakob Voelkl
- Department of Internal Medicine and Cardiology, Charité-Universität Medizin Berlin, Berlin, Germany
- Partner Site Berlin, German Centre for Cardiovascular Research (DZHK), Berlin, Germany
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6
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Alesutan I, Voelkl J, Feger M, Kratschmar DV, Castor T, Mia S, Sacherer M, Viereck R, Borst O, Leibrock C, Gawaz M, Kuro-O M, Pilz S, Tomaschitz A, Odermatt A, Pieske B, Wagner CA, Lang F. Involvement Of Vascular Aldosterone Synthase In Phosphate-Induced Osteogenic Transformation Of Vascular Smooth Muscle Cells. Sci Rep 2017; 7:2059. [PMID: 28515448 PMCID: PMC5435689 DOI: 10.1038/s41598-017-01882-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 04/04/2017] [Indexed: 02/07/2023] Open
Abstract
Vascular calcification resulting from hyperphosphatemia is a major determinant of mortality in chronic kidney disease (CKD). Vascular calcification is driven by aldosterone-sensitive osteogenic transformation of vascular smooth muscle cells (VSMCs). We show that even in absence of exogenous aldosterone, silencing and pharmacological inhibition (spironolactone, eplerenone) of the mineralocorticoid receptor (MR) ameliorated phosphate-induced osteo-/chondrogenic transformation of primary human aortic smooth muscle cells (HAoSMCs). High phosphate concentrations up-regulated aldosterone synthase (CYP11B2) expression in HAoSMCs. Silencing and deficiency of CYP11B2 in VSMCs ameliorated phosphate-induced osteogenic reprogramming and calcification. Phosphate treatment was followed by nuclear export of APEX1, a CYP11B2 transcriptional repressor. APEX1 silencing up-regulated CYP11B2 expression and stimulated osteo-/chondrogenic transformation. APEX1 overexpression blunted the phosphate-induced osteo-/chondrogenic transformation and calcification of HAoSMCs. Cyp11b2 expression was higher in aortic tissue of hyperphosphatemic klotho-hypomorphic (kl/kl) mice than in wild-type mice. In adrenalectomized kl/kl mice, spironolactone treatment still significantly ameliorated aortic osteoinductive reprogramming. Our findings suggest that VSMCs express aldosterone synthase, which is up-regulated by phosphate-induced disruption of APEX1-dependent gene suppression. Vascular CYP11B2 may contribute to stimulation of VSMCs osteo-/chondrogenic transformation during hyperphosphatemia.
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Affiliation(s)
- Ioana Alesutan
- Department of Physiology, University of Tübingen, Tübingen, Germany
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Jakob Voelkl
- Department of Physiology, University of Tübingen, Tübingen, Germany
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Berlin, Germany
| | - Martina Feger
- Department of Physiology, University of Tübingen, Tübingen, Germany
| | - Denise V Kratschmar
- Department of Pharmaceutical Sciences, and the National Center for Excellence in Research NCCR Kidney.CH, University of Basel, Basel, Switzerland
| | - Tatsiana Castor
- Department of Physiology, University of Tübingen, Tübingen, Germany
| | - Sobuj Mia
- Department of Physiology, University of Tübingen, Tübingen, Germany
| | - Michael Sacherer
- Div. of Cardiology, Medical University of Graz and Ludwig Boltzmann Institute for Translational Heart Failure Research, Graz, Austria
| | - Robert Viereck
- Department of Physiology, University of Tübingen, Tübingen, Germany
| | - Oliver Borst
- Department of Physiology, University of Tübingen, Tübingen, Germany
- Department of Cardiology and Cardiovascular Medicine, University of Tübingen, Tübingen, Germany
| | | | - Meinrad Gawaz
- Department of Cardiology and Cardiovascular Medicine, University of Tübingen, Tübingen, Germany
| | - Makoto Kuro-O
- Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
| | - Andreas Tomaschitz
- Div. of Cardiology, Medical University of Graz and Ludwig Boltzmann Institute for Translational Heart Failure Research, Graz, Austria
- Bad Gleichenberg Clinic, Bad Gleichenberg, Austria
| | - Alex Odermatt
- Department of Pharmaceutical Sciences, and the National Center for Excellence in Research NCCR Kidney.CH, University of Basel, Basel, Switzerland
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow-Klinikum, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Department of Cardiology, University of Graz, Graz, Austria; Department of Internal Medicine and Cardiology, German Heart Center Berlin (DHZB), Berlin, Germany
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, and the National Center for Excellence in Research NCCR Kidney, Zurich, Switzerland
| | - Florian Lang
- Department of Physiology, University of Tübingen, Tübingen, Germany.
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7
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Prossnitz ER, Barton M. Estrogen biology: new insights into GPER function and clinical opportunities. Mol Cell Endocrinol 2014; 389:71-83. [PMID: 24530924 PMCID: PMC4040308 DOI: 10.1016/j.mce.2014.02.002] [Citation(s) in RCA: 285] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 02/04/2014] [Indexed: 12/16/2022]
Abstract
Estrogens play an important role in the regulation of normal physiology, aging and many disease states. Although the nuclear estrogen receptors have classically been described to function as ligand-activated transcription factors mediating genomic effects in hormonally regulated tissues, more recent studies reveal that estrogens also mediate rapid signaling events traditionally associated with G protein-coupled receptors. The G protein-coupled estrogen receptor GPER (formerly GPR30) has now become recognized as a major mediator of estrogen's rapid cellular effects throughout the body. With the discovery of selective synthetic ligands for GPER, both agonists and antagonists, as well as the use of GPER knockout mice, significant advances have been made in our understanding of GPER function at the cellular, tissue and organismal levels. In many instances, the protective/beneficial effects of estrogen are mimicked by selective GPER agonism and are absent or reduced in GPER knockout mice, suggesting an essential or at least parallel role for GPER in the actions of estrogen. In this review, we will discuss recent advances and our current understanding of the role of GPER and the activity of clinically used drugs, such as SERMs and SERDs, in physiology and disease. We will also highlight novel opportunities for clinical development towards GPER-targeted therapeutics, for molecular imaging, as well as for theranostic approaches and personalized medicine.
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Affiliation(s)
- Eric R Prossnitz
- Department of Cell Biology and Physiology, UNM Cancer Center, University of New Mexico Health Sciences Center, Albuquerque, NM 87120, USA.
| | - Matthias Barton
- Molecular Internal Medicine, University of Zurich, Switzerland.
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