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Park JS. Clinical importance of immunonutrition in infants: a review of the recent literature. Clin Exp Pediatr 2022; 65:337-343. [PMID: 35176834 PMCID: PMC9263427 DOI: 10.3345/cep.2021.00570] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 12/15/2021] [Indexed: 12/04/2022] Open
Abstract
During the last decades, the role of nutrition has been well elucidated in medicine, especially among critically ill infants and children. Many nutrients have the potential to modulate the immune system. A healthy immune system is essential for the prevention and recovery of many pediatric illnesses. Intervention using specific nutrients for the immune system is called immunonutrition. Immunonutrient supplementation has been attempted to modulate inflammatory or immune responses, leading to an improved clinical course of critically ill patients with prolonged nutritional supplementation parenterally or enterally. This review discusses immunomodulatory nutrients for infants based on the recent literature.
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Affiliation(s)
- Ji Sook Park
- Department of Pediatrics, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
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2
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Shilova O, Shramova E, Proshkina G, Deyev S. Natural and Designed Toxins for Precise Therapy: Modern Approaches in Experimental Oncology. Int J Mol Sci 2021; 22:ijms22094975. [PMID: 34067057 PMCID: PMC8124712 DOI: 10.3390/ijms22094975] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 02/08/2023] Open
Abstract
Cancer cells frequently overexpress specific surface receptors providing tumor growth and survival which can be used for precise therapy. Targeting cancer cell receptors with protein toxins is an attractive approach widely used in contemporary experimental oncology and preclinical studies. Methods of targeted delivery of toxins to cancer cells, different drug carriers based on nanosized materials (liposomes, nanoparticles, polymers), the most promising designed light-activated toxins, as well as mechanisms of the cytotoxic action of the main natural toxins used in modern experimental oncology, are discussed in this review. The prospects of the combined therapy of tumors based on multimodal nanostructures are also discussed.
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Affiliation(s)
- Olga Shilova
- Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry RAS, 117997 Moscow, Russia; (E.S.); (G.P.)
- Correspondence: (O.S.); (S.D.)
| | - Elena Shramova
- Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry RAS, 117997 Moscow, Russia; (E.S.); (G.P.)
| | - Galina Proshkina
- Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry RAS, 117997 Moscow, Russia; (E.S.); (G.P.)
| | - Sergey Deyev
- Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry RAS, 117997 Moscow, Russia; (E.S.); (G.P.)
- Center of Biomedical Engineering, Sechenov University, 119991 Moscow, Russia
- Research Centrum for Oncotheranostics, National Research Tomsk Polytechnic University, 634050 Tomsk, Russia
- Correspondence: (O.S.); (S.D.)
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Carr LE, Virmani MD, Rosa F, Munblit D, Matazel KS, Elolimy AA, Yeruva L. Role of Human Milk Bioactives on Infants' Gut and Immune Health. Front Immunol 2021; 12:604080. [PMID: 33643310 PMCID: PMC7909314 DOI: 10.3389/fimmu.2021.604080] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/22/2021] [Indexed: 12/26/2022] Open
Abstract
Exclusive human milk feeding of the newborn is recommended during the first 6 months of life to promote optimal health outcomes during early life and beyond. Human milk contains a variety of bioactive factors such as hormones, cytokines, leukocytes, immunoglobulins, lactoferrin, lysozyme, stem cells, human milk oligosaccharides (HMOs), microbiota, and microRNAs. Recent findings highlighted the potential importance of adding HMOs into infant formula for their roles in enhancing host defense mechanisms in neonates. Therefore, understanding the roles of human milk bioactive factors on immune function is critical to build the scientific evidence base around breastfeeding recommendations, and to enhance positive health outcomes in formula fed infants through modifications to formulas. However, there are still knowledge gaps concerning the roles of different milk components, the interactions between the different components, and the mechanisms behind health outcomes are poorly understood. This review aims to show the current knowledge about HMOs, milk microbiota, immunoglobulins, lactoferrin, and milk microRNAs (miRNAs) and how these could have similar mechanisms of regulating gut and microbiota function. It will also highlight the knowledge gaps for future research.
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Affiliation(s)
- Laura E. Carr
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Arkansas Children's Nutrition Center, Little Rock, AR, United States
| | - Misty D. Virmani
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Fernanda Rosa
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Arkansas Children's Nutrition Center, Little Rock, AR, United States
| | - Daniel Munblit
- Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Inflammation, Repair and Development Section, Faculty of Medicine, Imperial College London, National Heart and Lung Institute, London, United Kingdom
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | | | - Ahmed A. Elolimy
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Arkansas Children's Nutrition Center, Little Rock, AR, United States
| | - Laxmi Yeruva
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Arkansas Children's Nutrition Center, Little Rock, AR, United States
- Arkansas Children's Research Institute, Little Rock, AR, United States
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Gnanesh Kumar B, Rawal A. Sequence characterization and N-glycoproteomics of secretory immunoglobulin A from donkey milk. Int J Biol Macromol 2020; 155:605-613. [DOI: 10.1016/j.ijbiomac.2020.03.253] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 12/19/2022]
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Abstract
免疫球蛋白A(immunoglobulin A, IgA)在黏膜的免疫功能中起关键作用, 是维持肠道黏膜稳态的重要物质. 分泌型IgA(secretory IgA, SIgA)的分泌组分保护免疫球蛋白不被蛋白水解酶降解, SIgA在肠道内各种免疫因子、免疫细胞以及其他免疫球蛋白的参与下完成肠道内的免疫监视、免疫自稳、免疫调控. 本文主要就肠道中SIgA的结构、合成转运、分泌调节、作用和其相关临床疾病的研究进展作一综述.
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Cakebread JA, Humphrey R, Hodgkinson AJ. Immunoglobulin A in Bovine Milk: A Potential Functional Food? JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2015; 63:7311-7316. [PMID: 26165692 DOI: 10.1021/acs.jafc.5b01836] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Immunoglobulin A (IgA) is an anti-inflammatory antibody that plays a critical role in mucosal immunity. It is found in large quantities in human milk, but there are lower amounts in bovine milk. In humans, IgA plays a significant role in providing protection from environmental pathogens at mucosal surfaces and is a key component for the establishment and maintenance of intestinal homeostasis via innate and adaptive immune mechanisms. To date, many of the dairy-based functional foods are derived from bovine colostrum, targeting the benefits of IgG. IgA has a higher pathogenic binding capacity and greater stability against proteolytic degradation when ingested compared with IgG. This provides IgA-based products greater potential in the functional food market that has yet to be realized.
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Affiliation(s)
| | - Rex Humphrey
- AgResearch, Ruakura Research Centre, Hamilton, New Zealand
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Huang J, Guerrero A, Parker E, Strum JS, Smilowitz JT, German JB, Lebrilla CB. Site-specific glycosylation of secretory immunoglobulin A from human colostrum. J Proteome Res 2015; 14:1335-49. [PMID: 25629924 DOI: 10.1021/pr500826q] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Secretory immunoglobulin A (sIgA) is a major glycoprotein in milk and plays a key role in mediating immune protection of the gut mucosa. Although it is a highly glycosylated protein, its site-specific glycosylation and associated glycan micro-heterogeneity have still not been fully elucidated. In this study, the site-specific glycosylation of sIgA isolated from human colostrum (n = 3) was analyzed using a combination of LC-MS and LC-MS/MS and in-house software (Glycopeptide Finder). The majority of the glycans found are biantennary structures with one or more acidic Neu5Ac residues; however, a large fraction belonged to truncated complex structures with terminal GlcNAc. Multiple glycosites were identified with nearly 30 glycan compositions located at seven sites on the secretory component, six compositions at a single site on the J chain, and 16 compositions at five sites on the IgA heavy (H) chain. Site-specific heterogeneity and relative quantitation of each composition and the extent of occupation at each site were determined using nonspecific proteases. Additionally, 54 O-linked glycan compositions located at the IgA1 hinge region (HR) were identified by comparison against a theoretical O-glycopeptide library. This represents the most comprehensive report to date detailing the complexity of glycan micro-heterogeneity with relative quantitation of glycoforms for each glycosylation site on milk sIgA. This strategy further provides a general method for determining site-specific glycosylation in large protein complexes.
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Affiliation(s)
- Jincui Huang
- Department of Chemistry, ‡Foods for Health Institute, §Department of Food Science and Technology, and ∥Department of Biochemistry and Molecular Medicine, University of California , Davis, California 95616, United States
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Ricin crosses polarized human intestinal cells and intestines of ricin-gavaged mice without evident damage and then disseminates to mouse kidneys. PLoS One 2013; 8:e69706. [PMID: 23874986 PMCID: PMC3714305 DOI: 10.1371/journal.pone.0069706] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 06/12/2013] [Indexed: 11/23/2022] Open
Abstract
Ricin is a potent toxin found in the beans of Ricinus communis and is often lethal for animals and humans when aerosolized or injected and causes significant morbidity and occasional death when ingested. Ricin has been proposed as a bioweapon because of its lethal properties, environmental stability, and accessibility. In oral intoxication, the process by which the toxin transits across intestinal mucosa is not completely understood. To address this question, we assessed the impact of ricin on the gastrointestinal tract and organs of mice after dissemination of toxin from the gut. We first showed that ricin adhered in a specific pattern to human small bowel intestinal sections, the site within the mouse gut in which a variable degree of damage has been reported by others. We then monitored the movement of ricin across polarized human HCT-8 intestinal monolayers grown in transwell inserts and in HCT-8 cell organoids. We observed that, in both systems, ricin trafficked through the cells without apparent damage until 24 hours post intoxication. We delivered a lethal dose of purified fluorescently-labeled ricin to mice by oral gavage and followed transit of the toxin from the gastrointestinal tracts to the internal organs by in vivo imaging of whole animals over time and ex vivo imaging of organs at various time points. In addition, we harvested organs from unlabeled ricin-gavaged mice and assessed them for the presence of ricin and for histological damage. Finally, we compared serum chemistry values from buffer-treated versus ricin-intoxicated animals. We conclude that ricin transverses human intestinal cells and mouse intestinal cells in situ prior to any indication of enterocyte damage and that ricin rapidly reaches the kidneys of intoxicated mice. We also propose that mice intoxicated orally with ricin likely die from distributive shock.
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Corthésy B. Multi-faceted functions of secretory IgA at mucosal surfaces. Front Immunol 2013; 4:185. [PMID: 23874333 PMCID: PMC3709412 DOI: 10.3389/fimmu.2013.00185] [Citation(s) in RCA: 363] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 06/24/2013] [Indexed: 01/06/2023] Open
Abstract
Secretory IgA (SIgA) plays an important role in the protection and homeostatic regulation of intestinal, respiratory, and urogenital mucosal epithelia separating the outside environment from the inside of the body. This primary function of SIgA is referred to as immune exclusion, a process that limits the access of numerous microorganisms and mucosal antigens to these thin and vulnerable mucosal barriers. SIgA has been shown to be involved in avoiding opportunistic pathogens to enter and disseminate in the systemic compartment, as well as tightly controlling the necessary symbiotic relationship existing between commensals and the host. Clearance by peristalsis appears thus as one of the numerous mechanisms whereby SIgA fulfills its function at mucosal surfaces. Sampling of antigen-SIgA complexes by microfold (M) cells, intimate contact occurring with Peyer’s patch dendritic cells (DC), down-regulation of inflammatory processes, modulation of epithelial, and DC responsiveness are some of the recently identified processes to which the contribution of SIgA has been underscored. This review aims at presenting, with emphasis at the biochemical level, how the molecular complexity of SIgA can serve these multiple and non-redundant modes of action.
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Affiliation(s)
- Blaise Corthésy
- R&D Laboratory, Department of Immunology and Allergy, University State Hospital Lausanne (CHUV) , Lausanne , Switzerland
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Asai T, Morrison SL. The SRC family tyrosine kinase HCK and the ETS family transcription factors SPIB and EHF regulate transcytosis across a human follicle-associated epithelium model. J Biol Chem 2013; 288:10395-405. [PMID: 23439650 DOI: 10.1074/jbc.m112.437475] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A critical step in the induction of adaptive mucosal immunity is antigen transcytosis, in which luminal antigens are transported to organized lymphoid tissues across the follicle-associated epithelium (FAE) of Peyer's patches. However, virtually nothing is known about intracellular signaling proteins and transcription factors that regulate apical-to-basolateral transcytosis. The FAE can transcytose a variety of luminal contents, including inert particles, in the absence of specific opsonins. Furthermore, it expresses receptors for secretory immunoglobulin A (SIgA), the main antibody in mucosal secretions, and uses them to efficiently transcytose SIgA-opsonized particles present in the lumen. Using a human FAE model, we show that the tyrosine kinase HCK regulates apical-to-basolateral transcytosis of non-opsonized and SIgA-opsonized particles. We also show that, in cultured intestinal epithelial cells, ectopic expression of the transcription factor SPIB or EHF is sufficient to activate HCK-dependent apical-to-basolateral transcytosis of these particles. Our results provide the first molecular insights into the intracellular regulation of antigen sampling at mucosal surfaces.
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Affiliation(s)
- Tsuneaki Asai
- Department of Microbiology, Immunology and Molecular Genetics, UCLA, Los Angeles, California 90095, USA.
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12
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Mantis NJ, Rol N, Corthésy B. Secretory IgA's complex roles in immunity and mucosal homeostasis in the gut. Mucosal Immunol 2011; 4:603-11. [PMID: 21975936 PMCID: PMC3774538 DOI: 10.1038/mi.2011.41] [Citation(s) in RCA: 779] [Impact Index Per Article: 59.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Secretory IgA (SIgA) serves as the first line of defense in protecting the intestinal epithelium from enteric toxins and pathogenic microorganisms. Through a process known as immune exclusion, SIgA promotes the clearance of antigens and pathogenic microorganisms from the intestinal lumen by blocking their access to epithelial receptors, entrapping them in mucus, and facilitating their removal by peristaltic and mucociliary activities. In addition, SIgA functions in mucosal immunity and intestinal homeostasis through mechanisms that have only recently been revealed. In just the past several years, SIgA has been identified as having the capacity to directly quench bacterial virulence factors, influence composition of the intestinal microbiota by Fab-dependent and Fab-independent mechanisms, promote retro-transport of antigens across the intestinal epithelium to dendritic cell subsets in gut-associated lymphoid tissue, and, finally, to downregulate proinflammatory responses normally associated with the uptake of highly pathogenic bacteria and potentially allergenic antigens. This review summarizes the intrinsic biological activities now associated with SIgA and their relationships with immunity and intestinal homeostasis.
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Affiliation(s)
- Nicholas J. Mantis
- Division of Infectious Diseases, Wadsworth Center, New York State Department of Health, Albany, NY 12208,Biomedical Sciences Program, University at Albany School of Public Health, Albany, NY 12201,To whom correspondence should be addressed: and
| | | | - Blaise Corthésy
- R&D Laboratory of the Division of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland,To whom correspondence should be addressed: and
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Pincus SH, Smallshaw JE, Song K, Berry J, Vitetta ES. Passive and active vaccination strategies to prevent ricin poisoning. Toxins (Basel) 2011; 3:1163-84. [PMID: 22069761 PMCID: PMC3202875 DOI: 10.3390/toxins3091163] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 08/17/2011] [Accepted: 09/05/2011] [Indexed: 11/16/2022] Open
Abstract
Ricin toxin (RT) is derived from castor beans, produced by the plant Ricinus communis. RT and its toxic A chain (RTA) have been used therapeutically to arm ligands that target disease-causing cells. In most cases these ligands are cell-binding monoclonal antibodies (MAbs). These ligand-toxin conjugates or immunotoxins (ITs) have shown success in clinical trials [1]. Ricin is also of concern in biodefense and has been classified by the CDC as a Class B biothreat. Virtually all reports of RT poisoning have been due to ingestion of castor beans, since they grow abundantly throughout the world and are readily available. RT is easily purified and stable, and is not difficult to weaponize. RT must be considered during any "white powder" incident and there have been documented cases of its use in espionage [2,3]. The clinical syndrome resulting from ricin intoxication is dependent upon the route of exposure. Countermeasures to prevent ricin poisoning are being developed and their use will depend upon whether military or civilian populations are at risk of exposure. In this review we will discuss ricin toxin, its cellular mode of action, the clinical syndromes that occur following exposure and the development of pre- and post-exposure approaches to prevent of intoxication.
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Affiliation(s)
- Seth H. Pincus
- Children’s Hospital and LSU Health Sciences Center, New Orleans, LA 70118, USA;
| | - Joan E. Smallshaw
- Cancer Immunobiology Center and Department of Microbiology, University of Texas, Southwestern Medical Center, Dallas, TX 75235, USA;
| | - Kejing Song
- Children’s Hospital, New Orleans, LA 70118, USA;
| | - Jody Berry
- Cangene Corporation, Winnipeg, MB R3T 5Y3, Canada;
| | - Ellen S. Vitetta
- Cancer Immunobiology Center, Departments Of Immunology and Microbiology, University of Texas Southwestern Medical Center, Dallas, TX 75230, USA
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Roy CJ, Song K, Sivasubramani SK, Gardner DJ, Pincus SH. Animal models of ricin toxicosis. Curr Top Microbiol Immunol 2011; 357:243-57. [PMID: 21956160 DOI: 10.1007/82_2011_173] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Animal models of ricin toxicosis are necessary for testing the efficacy of therapeutic measures, as well studying the mechanisms by which ricin exerts its toxicity in intact animals. Because ricin can serve as a particularly well-characterized model of tissue damage, and the host response to that damage, studies of the mechanisms of ricin toxicity may have more general applicability. For example, our studies of the molecular mechanisms underlying the development of ricin-induced hypoglycemia may help elucidate the relationship of type II diabetes, insulin resistance, and inflammation. Studies in non-human primates are most relevant for testing and developing agents having clinical utility. But these animals are expensive and limited in quantity, and so rodents are used for most mechanistic studies.
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Affiliation(s)
- Chad J Roy
- Tulane National Primate Research Center, Tulane School of Medicine, New Orleans, LA 70112, USA.
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Mantis NJ, Forbes SJ. Secretory IgA: arresting microbial pathogens at epithelial borders. Immunol Invest 2010; 39:383-406. [PMID: 20450284 DOI: 10.3109/08820131003622635] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Secretory IgA (SIgA) is the predominant class of antibody found in intestinal secretions. Although SIgA's role in protecting the intestinal epithelium from the enteric pathogens and toxins has long been recognized, surprisingly little is known about the molecular mechanisms by which this is achieved. The present review summarizes the current understanding of how SIgA functions to prevent microbial pathogens and toxins from gaining access to the intestinal epithelium. We also discuss recent work from our laboratory examining the interaction of a particular protective monoclonal IgA with Salmonella and propose, based on this work, that SIgA has a previously unrecognized capacity to directly interfere with microbial virulence at mucosal surfaces.
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Affiliation(s)
- Nicholas J Mantis
- Division of Infectious Diseases, Wadsworth Center, New York State Department of Health, University at Albany School of Public Health, Albany, New York 12208, USA.
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Corthésy B. Role of secretory immunoglobulin A and secretory component in the protection of mucosal surfaces. Future Microbiol 2010; 5:817-29. [PMID: 20441552 DOI: 10.2217/fmb.10.39] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The contribution of secretory immunoglobulin A (SIgA) antibodies in the defense of mucosal epithelia plays an important role in preventing pathogen adhesion to host cells, therefore blocking dissemination and further infection. This mechanism, referred to as immune exclusion, represents the dominant mode of action of the antibody. However, SIgA antibodies combine multiple facets, which together confer properties extending from intracellular and serosal neutralization of antigens, activation of non-inflammatory pathways and homeostatic control of the endogenous microbiota. The sum of these features suggests that future opportunities for translational application from research-based knowledge to clinics include the mucosal delivery of bioactive antibodies capable of preserving immunoreactivity in the lung, gastrointestinal tract, the genito-urinary tract for the treatment of infections. This article covers topics dealing with the structure of SIgA, the dissection of its mode of action in epithelia lining different mucosal surfaces and its potential in immunotherapy against infectious pathogens.
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Affiliation(s)
- Blaise Corthésy
- R&D Laboratory of the Department of Immunology & Allergy, University State Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
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Recognition of secretory IgA by DC-SIGN: implications for immune surveillance in the intestine. Immunol Lett 2010; 131:59-66. [PMID: 20362001 DOI: 10.1016/j.imlet.2010.03.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 03/20/2010] [Accepted: 03/22/2010] [Indexed: 12/19/2022]
Abstract
Secretory IgA (SIgA), the predominant class of antibody in intestinal secretions, serves as the first line of defense against enteric infections. SIgA has also been proposed to function in immune surveillance, given that both SIgA and SIgA-antigen complexes are actively transported by Peyer's patch M cells from the intestinal lumen to sub-epithelial dendritic cells (DCs). The goal of the present study was to identify the receptor(s) potentially utilized by mucosal DCs to recognize and internalize SIgA. We demonstrate that human colostral SIgA is recognized by purified recombinant human DC-specific ICAM-3 grabbing nonintegrin (DC-SIGN) in a solid phase binding assay, as well as by DC-SIGN ectopically expressed on the surface of Chinese hamster ovary (CHO-S) cells. The interaction between SIgA and DC-SIGN was specific, given that it was Ca(2+)-dependent and inhibited by mannan. Moreover, SIgA bound to, and was internalized by, endogenous DC-SIGN expressed on THP-1 cells following monocyte to macrophage-like cell differentiation by stimulation with phorbol ester and interleukin-4. These data identify DC-SIGN as a putative receptor for SIgA, and reveal a mechanism by which DCs could collaborate with M cells in immune surveillance at mucosal surfaces.
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Arnold JN, Wormald MR, Sim RB, Rudd PM, Dwek RA. The impact of glycosylation on the biological function and structure of human immunoglobulins. Annu Rev Immunol 2007; 25:21-50. [PMID: 17029568 DOI: 10.1146/annurev.immunol.25.022106.141702] [Citation(s) in RCA: 964] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immunoglobulins are the major secretory products of the adaptive immune system. Each is characterized by a distinctive set of glycoforms that reflects the wide variation in the number, type, and location of their oligosaccharides. In a given physiological state, glycoform populations are reproducible; therefore, disease-associated alterations provide diagnostic biomarkers (e.g., for rheumatoid arthritis) and contribute to disease pathogenesis. The oligosaccharides provide important recognition epitopes that engage with lectins, endowing the immunoglobulins with an expanded functional repertoire. The sugars play specific structural roles, maintaining and modulating effector functions that are physiologically relevant and can be manipulated to optimize the properties of therapeutic antibodies. New molecular models of all the immunoglobulins are included to provide a basis for informed and critical discussion. The models were constructed by combining glycan sequencing data with oligosaccharide linkage and dynamics information from the Glycobiology Institute experimental database and protein structural data from "The Protein Data Bank."
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Affiliation(s)
- James N Arnold
- Oxford Glycobiology Institute, Department of Biochemistry, University of Oxford, South Parks Road, Oxford OX1 3QU, United Kingdom.
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Carra JH, Wannemacher RW, Tammariello RF, Lindsey CY, Dinterman RE, Schokman RD, Smith LA. Improved formulation of a recombinant ricin A-chain vaccine increases its stability and effective antigenicity. Vaccine 2007; 25:4149-58. [PMID: 17408819 DOI: 10.1016/j.vaccine.2007.03.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 02/28/2007] [Accepted: 03/05/2007] [Indexed: 12/22/2022]
Abstract
Ricin is a potent toxin associated with bioterrorism for which no vaccine or specific countermeasures are currently available. A stable, non-toxic and immunogenic recombinant ricin A-chain vaccine (RTA 1-33/44-198) has been developed by protein engineering. We identified optimal formulation conditions for this vaccine under which it remained stable and potent in storage for up to 18 months, and resisted multiple rounds of freeze-thawing without stabilizing co-solvents. Reformulation from phosphate buffer to succinate buffer increased adherence of the protein to aluminum hydroxide adjuvant from 15 to 91%, with a concomitant increase of nearly threefold in effective antigenicity in a mouse model. Using Fourier-transform infrared spectroscopy, we examined the secondary structure of the protein while it was adhered to aluminum hydroxide. Adjuvant adsorption produced only a small apparent change in secondary structure, while significantly stabilizing the protein to thermal denaturation. The vaccine therefore may be safely stored in the presence of adjuvant. Our results suggest that optimization of adherence of a protein antigen to aluminum adjuvant can be a useful route to increasing both stability and effectiveness, and support a role for a "depot effect" of adjuvant.
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Affiliation(s)
- John H Carra
- Integrated Toxicology Division, U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, MD 21702-5011, United States
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Corthésy B. Roundtrip ticket for secretory IgA: role in mucosal homeostasis? THE JOURNAL OF IMMUNOLOGY 2007; 178:27-32. [PMID: 17182536 DOI: 10.4049/jimmunol.178.1.27] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
An important activity of mucosal surfaces is the production of Ab referred to as secretory IgA (SIgA). SIgA serves as the first line of defense against microorganisms through a mechanism called immune exclusion. In addition, SIgA adheres selectively to M cells in intestinal Peyer's patches, thus mediating the transepithelial transport of the Ab molecule from the intestinal lumen to underlying gut-associated organized lymphoid tissue. In Peyer's patches, SIgA binds and is internalized by dendritic cells in the subepithelial dome region. When used as carrier for Ags in oral immunization, SIgA induces mucosal and systemic responses associated with production of anti-inflammatory cytokines and limits activation of dendritic cells. In terms of humoral immunity at mucosal surfaces, SIgA appears thus to combine properties of a neutralizing agent (immune exclusion) and of a mucosal immunopotentiator inducing effector immune responses in a noninflammatory context favorable to preserve local homeostasis of the gastrointestinal tract.
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Affiliation(s)
- Blaise Corthésy
- R&D Laboratory of the Division of Immunology and Allergy, State University Hospital (Centré Hospitalìer Universitaire Vandois), Rue du Bugnon, BH 19-650, 1011 Lausanne, Switzerland.
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Yoder JM, Aslam RU, Mantis NJ. Evidence for widespread epithelial damage and coincident production of monocyte chemotactic protein 1 in a murine model of intestinal ricin intoxication. Infect Immun 2007; 75:1745-50. [PMID: 17283086 PMCID: PMC1865717 DOI: 10.1128/iai.01528-06] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The development of small-animal models is necessary to understand host responses and immunity to emerging infectious diseases and potential bioterrorism agents. In this report we have characterized a murine model of intestinal ricin intoxication. Ricin administered intragastrically (i.g.) to BALB/c mice at doses ranging from 1 to 10 mg/kg of body weight induced dose-dependent morphological changes in the proximal small intestine (i.e., duodenum), including widespread villus atrophy and epithelial damage. Coincident with epithelial damage was a localized increase in monocyte chemotactic protein 1, a chemokine known to be associated with inflammation of the intestinal mucosa. Immunity to intestinal ricin intoxication was achieved by immunizing mice i.g. with ricin toxoid and correlated with elevated levels of antitoxin mucosal immunoglobulin A (IgA) and serum IgG antibodies. We expect that this model will serve as a valuable tool in identifying the inflammatory pathways and protective immune responses that are elicited in the intestinal mucosa following ricin exposure and will prove useful in the evaluation of antitoxin vaccines and therapeutics.
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Affiliation(s)
- J Marina Yoder
- Division of Infectious Disease, Wadsworth Center, New York State Department of Health, 120 New Scotland Avenue, Albany, NY 12208, USA
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Matsumura T, Fujinaga Y, Jin Y, Kabumoto Y, Oguma K. Human milk SIgA binds to botulinum type B 16S toxin and limits toxin adherence on T84 cells. Biochem Biophys Res Commun 2007; 352:867-72. [PMID: 17156748 DOI: 10.1016/j.bbrc.2006.11.095] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 11/17/2006] [Indexed: 12/21/2022]
Abstract
Botulinum neurotoxin produced by Clostridium botulinum type B is in the form of a complex of 12S and 16S toxins. Food-borne botulism is caused by these complex toxins which are ingested orally and absorbed from the digestive tract. Here, we show that the human milk SIgA binds to the type B16S toxin. The binding of SIgA to 16S toxin and HA was inhibited by carbohydrates such as galactose, suggesting that the interaction of carbohydrate side chain of the SIgA with the HA of the 16S toxin is important for SIgA-16S complex formation. We also demonstrate that SIgA inhibits the attachment of 16S toxin to intestinal epithelial cells. These data suggest that the interaction of antigen nonspecific SIgA with 16S toxin has a large influence on the absorption of 16S toxin from the intestinal epithelium, and that SIgA may provide insight into developing a therapeutic agent for type B food-borne botulism.
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Affiliation(s)
- Takuhiro Matsumura
- Laboratory for Infection Cell Biology, International Research Center for Infectious Diseases, Research Institute for Microbial Diseases, Osaka University, Yamada-oka 3-1, Suita, Osaka 565-0871, Japan
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Kaetzel CS, Chintalacharuvu KR, Morrison SL. Recombinant IgA Antibodies. MUCOSAL IMMUNE DEFENSE: IMMUNOGLOBULIN A 2007. [PMCID: PMC7121033 DOI: 10.1007/978-0-387-72232-0_15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The production of monoclonal antibodies and the development of recombinant antibody technology have made antibodies one of the largest classes of drugs in development for prophylactic, therapeutic and diagnostic purposes. Currently, all of the Food and Drug Administration (FDA)- approved antibodies are immunoglobulin Gs (IgGs). However, more than 95%of the infections are initiated at the mucosal surfaces, where IgA is the primary immune effector antibody.
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Mantis NJ, McGuinness CR, Sonuyi O, Edwards G, Farrant SA. Immunoglobulin A antibodies against ricin A and B subunits protect epithelial cells from ricin intoxication. Infect Immun 2006; 74:3455-62. [PMID: 16714576 PMCID: PMC1479255 DOI: 10.1128/iai.02088-05] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Epithelial cells of the respiratory and gastrointestinal tracts are extremely vulnerable to the cytotoxic effects of ricin, a Shiga-like toxin with ribosome-inactivating properties. While mucosal immunity to ricin correlates with secretory immunoglobulin A (IgA) antibody levels in vivo, the potential of IgA to protect epithelial cells from ricin in vitro has not been examined due to the unavailability of well-defined antitoxin IgA antibodies. Here we report the characterization of four monoclonal IgA antibodies (IgA MAbs) produced from the Peyer's patches and mesenteric lymph nodes of BALB/c mice immunized intragastrically with ricin toxoid. Two IgA MAbs (33G2 and 35H6) were active against ricin's lectin subunit (RTB), and two (23D7 and 25A4) reacted with the toxin's enzymatic subunit (RTA). All four IgA MAbs neutralized ricin in a Vero cell cytotoxicity assay, blocked toxin-induced interleukin-8 release by the human monocyte/macrophage cell line 28SC, and protected polarized epithelial cell monolayers from ricin-mediated protein synthesis inhibition. 33G2 and 35H6 reduced ricin binding to the luminal surfaces of human intestinal epithelial cells to undetectable levels in tissue section overlay assays, whereas 23D7 had no effect on toxin attachment. 23D7 and 25A4 did, however, reduce ricin transcytosis across MDCK II cell monolayers, possibly by interfering with intracellular toxin transport. We conclude that IgA antibodies against RTA and RTB can protect mucosal epithelial cells from ricin intoxication.
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Affiliation(s)
- Nicholas J Mantis
- Division of Infectious Disease, Wadsworth Center, N.Y. State Department of Health, 120 New Scotland Avenue, Albany, NY 12208, USA.
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Perrier C, Sprenger N, Corthésy B. Glycans on secretory component participate in innate protection against mucosal pathogens. J Biol Chem 2006; 281:14280-7. [PMID: 16543244 DOI: 10.1074/jbc.m512958200] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In mucosal secretions, secretory component (SC) is found either free or bound to polymeric IgA within the secretory IgA complex. SC displays numerous and various glycans, which are potential ligands for bacterial compounds. We first established that human SC (hSC) purified from colostrum (hSCcol) or produced in Chinese hamster ovary cells (hSCrec) exhibits the same lectin reactivity. Both forms bind to Clostridium difficile toxin A and functionally protect polarized Caco-2 cell monolayers from the cytopathic effect of the toxin. The interaction is mediated by glycans present on hSC and involves galactose and sialic acid residues. hSCcol and hSCrec were also shown to bind enteropathogenic Escherichia coli adhesin intimin and to inhibit its infectivity on HEp-2 cells in a glycan-dependent manner as well. SC remained operative in the context of the whole secretory IgA molecule and can therefore enhance its Fab-mediated neutralizing properties. On the contrary, hSC did not interact with three different strains of rotavirus (RF, RRV, and SA11). Accordingly, infection of target MA104 cells with these rotavirus strains was not reduced in the presence of either form of hSC tested. Although not a universal mechanism, these findings identify hSC as a microbial scavenger contributing to the antipathogenic arsenal that protects the body epithelial surfaces.
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Affiliation(s)
- Clémentine Perrier
- R & D Laboratory of the Division of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
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26
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Lavelle EC. Lectins and microparticles for enhanced oral vaccination. Methods 2006; 38:84-9. [PMID: 16406570 DOI: 10.1016/j.ymeth.2005.09.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Accepted: 09/16/2005] [Indexed: 12/25/2022] Open
Abstract
Oral administration is an attractive means of vaccination since it alleviates the need for injection and trained personnel. Furthermore, effective oral vaccination induces immune responses locally in the gastrointestinal tract, the site of colonisation and infection by many pathogens. However, since most proteins and peptides are degraded in the gut, do not interact specifically with the epithelium, or induce strong immune responses, this route of delivery is generally inefficient. Two of the most promising potential approaches are the use of lectins to target vaccines to the epithelium and the association of vaccines with biodegradable microparticles. This paper describes methods to assess the stability of vaccines and targeting molecules in the gastrointestinal tract, interaction with the mucosa, uptake into internal organs and induction of mucosal antibody responses.
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Affiliation(s)
- E C Lavelle
- Adjuvant Research Group, Department of Biochemistry, Trinity College, Dublin 2, Ireland.
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Lewis MJ, Pleass RJ, Batten MR, Atkin JD, Woof JM. Structural Requirements for the Interaction of Human IgA with the Human Polymeric Ig Receptor. THE JOURNAL OF IMMUNOLOGY 2005; 175:6694-701. [PMID: 16272325 DOI: 10.4049/jimmunol.175.10.6694] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Transport of polymeric IgA onto mucosal surfaces to become secretory IgA is mediated by the polymeric Ig receptor (pIgR). To study the interaction of human dimeric IgA (dIgA) (the predominant form of IgA polymer) with the human pIgR (hpIgR), we generated recombinant wild-type dIgA1 and dIgA2m(1) and various mutant dIgA1 and analyzed their interaction with a recombinant human secretory component and membrane-expressed hpIgR. We found that wild-type dIgA1 and dIgA2m(1) bound to recombinant human secretory component with similar affinity and were transcytosed by the hpIgR to the same extent. Mutation of the IgA Calpha2 domain residue Cys311 to Ser reduced binding to hpIgR, possibly through disruption of noncovalent interactions between the Calpha2 domain and domain 5 of the receptor. Within the Calpha3 domain of IgA1, we found that combined mutation of residues Phe411, Val413, and Thr414, which lie close to residues previously implicated in hpIgR binding, abolished interaction with the receptor. Mutation of residue Lys377, located very close to this same region, perturbed receptor interaction. In addition, 4 aa (Pro440-Phe443), which lie on a loop at the domain interface and form part of the binding site for human FcalphaRI, appear to contribute to hpIgR binding. Lastly, use of a monomeric IgA1 mutant lacking the tailpiece revealed that the tailpiece does not occlude hpIgR-binding residues in IgA1 monomers. This directed mutagenesis approach has thus identified motifs lying principally across the upper surface of the Calpha3 domain (i.e., that closest to Calpha2) critical for human pIgR binding and transcytosis.
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Affiliation(s)
- Melanie J Lewis
- Division of Pathology and Neurosciences, University of Dundee Medical School, Ninewells Hospital, Dundee, United Kingdom
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Kaetzel CS. The polymeric immunoglobulin receptor: bridging innate and adaptive immune responses at mucosal surfaces. Immunol Rev 2005; 206:83-99. [PMID: 16048543 DOI: 10.1111/j.0105-2896.2005.00278.x] [Citation(s) in RCA: 410] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Secretory antibodies of the immunoglobulin A (IgA) class form the first line of antigen-specific immune protection against inhaled, ingested, and sexually transmitted pathogens and antigens at mucosal surfaces. Epithelial transcytosis of polymeric IgA (pIgA) is mediated by the polymeric immunoglobulin receptor (pIgR). At the apical surface, the extracellular ligand-binding region of pIgR, known as secretory component (SC), is cleaved and released in free form or as a component of secretory IgA (SIgA). SC has innate anti-microbial properties, and it protects SIgA from proteolytic degradation. Expression of pIgR is regulated by microbial products through Toll-like receptor signaling and by host factors such as cytokines and hormones. Recent studies of the structure of the extracellular ligand-binding domain of pIgR have revealed mechanisms by which it binds pIgA and other ligands. During transcytosis, pIgA has been shown to neutralize pathogens and antigens within intracellular vesicular compartments. The recent identification of disease-associated polymorphisms in human pIgR near the cleavage site may help to unravel the mystery of how pIgR is cleaved to SC. The identification of novel functions for SC and SIgA has expanded our view of the immunobiology of pIgR, a key component of the mucosal immune system that bridges innate and adaptive immune defense.
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Affiliation(s)
- Charlotte S Kaetzel
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, KY 40536, USA.
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Liu DY, Liu P. Changes of IgA and sIgA and its clinical significant in hepatic diseases. Shijie Huaren Xiaohua Zazhi 2005; 13:2275-2277. [DOI: 10.11569/wcjd.v13.i18.2275] [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] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the values of IgA and sIgA detection in the clinical diagnosis of hepatic diseases.
METHODS: Patients with acute hepatitis (AH, n = 35), chronic severe hepatitis (CSH, n = 9), chronic hepatitis (CH, n = 67) and liver cirrhosis (LC, n = 57) were involved. The level of IgA was assayed by rate nephelometry, and the level of sIgA was detected by radioimmunoassay.
RESULTS: The levels of fecal IgA and sIgA were notably elevated in patients with AH, CSH, CH and LC as compared with those in the controls (IgA: 100±47, 251±178, 80±24, 145±164 mg/L vs <67 mg/L, P < 0.01; sIgA: 88±96, 326±237, 88±121, 104±109 mg/L vs 13±10 mg/L, P < 0.01). IgA was positively correlated with sIgA(r = 0.4371, P < 0.01). The levels of serum IgA and sIgA were markedly increased in patients with AH, CSH, CH and LC as compared with those in the controls (IgA: 3.1±1.1, 3.4±1.8, 3.3±1.7, 4.9±3.3 g/L vs 1.6±0.2 g/L, P < 0.01; sIgA: 31.1±25.8, 80.3±25.4, 30.5±24.1, 50.0±20.5 µg/L vs 23.4±8.2 µg/L, P<0.01 or P < 0.05). The fecal IgA and sIgA were not correlated with serum IgA and sIgA, and serum IgA was not correlated with serum sIgA (P >0.05). In patients with CH, CSH and LC, serum sIgA was significantly correlated with alkaline phosphatase (r = 0.523 0, P < 0.01) and total bilirubin (r = 0.4 581, P < 0.01). In patients with AH, serum sIgA level was correlated with alanine aminotransferase (r = 0.4 692, P < 0.01), total bilirubin (r = 0.4 265, P < 0.01).
CONCLUSION: The detection of IgA and sIgA can be used in the clinical diagnosis of hepatic diseases.
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Mantis NJ. Vaccines against the category B toxins: Staphylococcal enterotoxin B, epsilon toxin and ricin. Adv Drug Deliv Rev 2005; 57:1424-39. [PMID: 15935880 DOI: 10.1016/j.addr.2005.01.017] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Accepted: 01/25/2005] [Indexed: 01/15/2023]
Abstract
The threat of bioterrorism worldwide has accelerated the demand for the development of therapies and vaccines against the Category B toxins: staphylococcal enterotoxin B (SEB), epsilon toxin (ETX) produced by Clostridium perfringens types B and D, and ricin, a natural product of the castor bean. The diverse and unique nature of these toxins poses a challenge to vaccinologists. While formalin-inactivated toxins can successfully induce antibody-mediated protection in animals, their usefulness in humans is limited because of potential safety concerns. For this reason, research is now aimed at developing recombinant, attenuated vaccines based on a detailed understanding of the molecular mechanisms by which these toxins function. Vaccine development is further complicated by the fact that as bioterrorism agents, SEB, ETX and ricin would most likely be disseminated as aerosols or in food/water supplies. Our understanding of the mechanisms by which these toxins cross mucosal surfaces, and importance of mucosal immunity in preventing toxin uptake is only rudimentary.
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Affiliation(s)
- Nicholas J Mantis
- Division of Infectious Disease, Wadsworth Center, New York State Department of Health, Albany, NY 12208, USA.
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